Journal of pain and symptom management最新文献

Context: Patients with hematologic neoplasms after Chimeric antigen receptor T-cell (CAR-T) therapy have multiple syndromes, with corresponding symptoms.

Objectives: The review aimed to integrate the severity and incidences of symptoms in these patients, and to investigate the difference of the symptoms among different geographic locations, types of hematological tumors, evaluating instruments, and evaluating time, to provide a theoretical basis for symptom management.

Methods: A literature search of PubMed, Web of Science, Embase, the Cochrane Library, China National Knowledge Internet, SinoMed, VIP, and WANFANG DATA was performed for studies reporting symptom scores or symptom incidences of these patients published before November 9, 2023. Heterogeneity between studies was assessed by Higgins' I². A random effects model was used for studies with I² > 50%. Methodological quality of included studies was assessed using the Joanna Briggs Institute Critical Appraisal Checklist.

Results: Eight studies were included. Among the reported symptoms, sleep disturbance, fatigue and depression were of higher severity, with the standardized scores exceeding 50. Sadness, problem with concentration, problem with memory, cough and nausea were the top five symptoms in incidence, which exceeded 50%. The symptom scores and incidences assessed by the patient-reported outcomes were higher. Within 90 days of CAR-T infusion, these patients reported a significantly higher severity and incidence of multiple symptoms.

Conclusion: Patients with hematologic neoplasms treated by CAR-T suffer from multiple symptoms, including depression, fatigue, and so on. Instruments used to evaluate symptoms and the evaluating time may influence the outcome of symptom assessment.

While Comfort Feeding Only is appropriate for patients with advanced dementia, its emphasis on assiduous hand-feeding that may prolong life for years fails to accommodate the preferences of those who do not want to continue living with this illness. Some have proposed advance directives to completely halt the provision of oral nutrition and hydration once a person has reached an advanced stage of dementia. However, these directives may fail to address patients' discomfort, caregivers' obligations, or current care and regulatory standards when patients reside in facilities. In response to these dilemmas, we introduce Minimal Comfort Feeding (MCF). Rather than offering food and liquids proactively as with Comfort Feeding Only, caregivers provide nutrition and hydration only in response to signs of hunger and thirst. While further study is required to define and negotiate challenges in operationalizing this approach, MCF provides a framework that resolves competing ethical and clinical considerations in caring for those with advanced dementia.

Context: Many general pediatrics residents lack sufficient opportunities to conduct difficult conversations with families, particularly about end-of-life care. Simulation learning is an effective means of practicing professional skills. A pediatric palliative care (PPC) physician is uniquely suited to mentor residents and fellows learning to lead difficult conversations through simulation. Co-facilitation of the simulated difficult conversation by a bereaved parent or family member enhances the learning experience.

Objectives: To report 11-years' experience simulating difficult conversations with bereaved parent-actors.

Methods: PPC physicians developed two simulations to teach difficult conversations to clinical learners at a midwestern quaternary pediatric medical center. Bereaved parents and hospital chaplains co-facilitated the simulation. The first portrayed the death of an infant following emergency resuscitation, and the second, a goals-of-care conversation with the parent of a child with a degenerative condition. A de-novo evaluation rubric was prepared using the six Accreditation Council for Graduate Medical Education (ACGME) Core Competencies to evaluate the participant's performance in the simulation.

Results: For the first simulated scenario (N=194 residents; N=16 fellows), residents improved significantly on 16/21 ACGME-based criteria between encounters; for the second (N=118 residents; N=14 fellows), residents improved significantly on 10/21 criteria. Fellows' performance did not improve significantly in either scenario, but they presented with high baseline scores.

Conclusions: Simulations with bereaved parent actors improved general pediatrics residents' performance and comfort during difficult conversations and are transportable to diverse settings.

Purpose: Serious illness conversations (SICs) are discussions between clinicians and cancer patients about illness understanding, information preferences, and goals of care. Interventions to prompt SICs increase SIC rates and improve care delivery near the end of life. This embedded sub-study examined SIC barriers and facilitators among "refractory" patients without an SIC despite enrollment in an SIC clinical trial.

Design, setting, and population: We recruited advanced cancer patients with no documented SIC 60 days after randomization in a clinical trial of patient- and clinician-nudges to engage in SICs. We conducted semi-structured interviews with patients and their caregivers if present and brief email surveys with patients' oncologists. We used qualitative content analysis to identify themes related to SIC barriers and facilitators and to identify strategies to improve SICs.

Results: Of 44 participants, 19 were patients, 10 were caregivers, and 15 were oncologists. Themes of SIC barriers and facilitators included (1) how patients coped with their illness, which shaped their readiness for SICs; (2) clinician communication style, which shaped ease of having an SIC; (3) prognostic uncertainty and disease stability, which could prompt or justify delaying an SIC; and (4) family members' presence, which could instigate an SIC. Regarding ways to improve SIC nudges, patients and caregivers had mixed perspectives but often highlighted a preference for interventions with personal touches.

Conclusions: Patient readiness remains an important barrier even after targeted SIC interventions. Future SIC interventions should consider approaches tailored to patient communication preferences and interventions involving personal interactions.

Context: Opioids are the mainstay therapy for patients affected by cancer pain. However, about 10-20% of patients do not benefit from the received analgesic treatment or experience side effects. Genetic variability might account for the variation in individual responses to opioids, both in terms of efficacy and toxicity.

Objectives: The aim of this genome-wide association study (GWAS) was to identify genetic markers of opioid toxicity, in terms of nausea-vomiting.

Methods: Cancer patients receiving morphine, oxycodone, buprenorphine, and fentanyl were recruited from different European countries. Data about toxicity (nausea-vomiting score, NVS) and other relevant clinical information were collected, as well as genotyping data. Regression analysis between genotypes of 2,052 patients and NVS was performed, using appropriate covariates, with REGENIE software.

Results: We found 65 variants associated with NVS (P-value < 1.0×10^-5). Of note, 14 intronic variants on chromosome 2 were in NPAS2 gene, encoding a circadian transcription factor reported to play a role in another opioid side effect, the alteration of sleep. Some of these variants were previously identified as splicing quantitative trait loci of the NPAS2 gene.

Conclusions: This is the first GWAS, performed in more than two thousand individually genotyped patients treated with opioids for cancer pain, that investigated the genetic bases of opioid-induced nausea-vomiting. Although further studies are needed to confirm our findings and to characterize the functional role of the identified variants, our results emphasize the importance of performing large pharmacogenomic studies to identify germline variants associated with opioid response, with the ultimate goal of tailoring cancer pain therapies.