Current Opinion in Supportive and Palliative Care最新文献

Purpose of the review: The number of patients with end-stage chronic obstructive pulmonary disease (COPD) treated with chronic non-invasive ventilation (NIV) has greatly increased. In this review, the authors summarize the evidence for nocturnal NIV and NIV during exercise. The authors discuss the multidisciplinary and advanced care of patients with end-stage COPD treated with NIV.

Recent findings: Nocturnal NIV improves gas exchange, health-related quality of life and survival in stable hypercapnic COPD patients. Improvements in care delivery have been achieved by relocating care from the hospital to home based; home initiation of chronic NIV is feasible, non-inferior regarding efficacy and cost-effective compared to in-hospital initiation. However, the effect of NIV on symptoms is variable, and applying optimal NIV for end-stage COPD is complex. While exercise-induced dyspnoea is a prominent complaint in end-stage COPD, nocturnal NIV will not change this. However, NIV applied solely during exercise might improve exercise tolerance and dyspnoea. While chronic NIV is often a long-standing treatment, patient expectations should be discussed early and be managed continuously during the treatment. Further, integration of advance care planning requires a multidisciplinary approach.

Summary: Although chronic NIV is an effective treatment in end-stage COPD with persistent hypercapnia, there are still important questions that need to be answered to improve care of these severely ill patients.

Purpose of the review: Effective education enables people to modify the distress and impact of breathlessness by integrating evidence-informed breathlessness-related behaviours (knowledge, skill, attitude) into everyday life. This review considers recent studies of educational approaches focussed on chronic breathlessness as a modifiable, noxious and debilitating multidimensional experience.

Recent findings: Systematic assessments of text-based patient education materials and mobile phone applications specific to breathlessness indicate that while these resources are readily available, issues continue to persist with quality, readability, usefulness and availability of non-English language versions. Various forms of educational interventions for breathlessness have proven feasible and valued by people living with breathlessness and their significant others (uptake/completion, personal benefit, ripple effect on health professionals). Health professional knowledge about the impact of chronic breathlessness and effective management can be altered through structured, educational interventions.

Summary: Empiric studies of patient education for breathlessness are scarce despite persistent calls for better breathlessness education for people living with or providing care for someone living with this noxious symptom. In clinical practice, it is highly likely that there are effective and ineffective educational practices, both of which, if publicly disseminated, would inform future educational strategies to advance breathlessness self-management.

Purpose of review: To render holistic overview on community-based end-of-life care in the context of Singapore, with analysis of nursing care implications for older adults requiring end-of-life care services.

Recent findings: Healthcare professionals caring for older adults with life-limiting conditions had to play an active role in the constantly evolving healthcare landscape during the coronavirus disease 2019 (COVID-19) pandemic. Usual meetings and community-based end-of-life care interventions were converted to online mode, utilizing digital technology. In order to provide value-based and culturally relevant care, further studies are warranted to evaluate healthcare professionals, patients and family caregivers' preferences whilst utilizing digital technology. As a result of COVID-19 pandemic restrictions to minimize infection transmissions, animal-assisted volunteering activities were conducted virtually. Regular healthcare professionals' engagement in wellness interventions is necessary to boost morale and prevent potential psychological distress.

Summary: To strengthen the delivery of end-of-life community care services, the following recommendations are proposed: active youth engagement via inter-collaborations and connectedness of community organizations; improving support for vulnerable older adults in need of end-of-life care services; and enhancing healthcare professionals well-being through the implementation of timely support interventions.

Purpose of review: Chronic pain is poorly treated with many developing disabling comorbidities such as anxiety, depression and insomnia. Considerable evidence supports the idea that pain and anxiodepressive disorders share a common neurobiology and can mutually reinforce, which has significant long-term implications as the development of comorbidities leads to poorer treatment outcomes for both pain and mood disorders. This article will review recent advances in the understanding of the circuit basis for comorbidities in chronic pain.

Recent findings: A growing number of studies have aimed to determine the mechanisms underlying chronic pain and comorbid mood disorders by using modern viral tracing tools for precise circuit manipulation with optogenetics and chemogenetics. These have revealed critical ascending and descending circuits, which advance the understanding of the interconnected pathways that modulate the sensory dimension of pain and the long-term emotional consequences of chronic pain.

Summary: Comorbid pain and mood disorders can produce circuit-specific maladaptive plasticity; however, several translational issues require addressing to maximise future therapeutic potential. These include the validity of preclinical models, the translatability of endpoints and expanding analysis to the molecular and system levels.

Purpose of review: To explore the current evidence relating to the practical management of cancer cachexia in palliative care.

Recent findings: The authors found a growing evidence base including the publication of several expert guidelines since 2020. Guidelines identified the need for individualised nutritional and physical exercise support as the mainstay of cachexia management. Dietician and allied health professional referrals are recommended for the best patient outcomes. Limitations of nutritional support and exercise are acknowledged. Patient outcomes from multimodal anti-cachexia therapy are awaited at this time. Communication about the mechanisms of cachexia and nutritional counselling are identified as ways to reduce distress. Evidence supporting the use of pharmacological agents remains insufficient to make recommendations. Corticosteroids and progestins may be offered for symptom relief in refractory cachexia, taking into consideration well-documented side effects. Emphasis is placed on adequately managing nutritional impact symptoms. A specific role for palliative care clinicians and the use of existing palliative care guidelines in managing cancer cachexia were not identified.

Summary: Current evidence recognises the inherently palliative nature of cancer cachexia management, and practical guidance correlates with the tenets of palliative care. Individualised approaches to support nutritional intake, physical exercise and alleviate symptoms that accelerate cachexia processes are currently recommended.

Purpose of review: The prison population is growing and ageing, and many people will die from natural causes while incarcerated. This article provides a contemporary review of key issues related to palliative and end-of-life care in prisons.

Recent findings: Few countries have integrated prison hospices. Palliative care needs may go unrecognised in prison. Older offenders may not trust the prison to care for them and may benefit from segregation. Cancer remains a major cause of death. Training staff remains a priority, and technology can help facilitate this. The coronavirus disease 2019 (COVID-19) had a significant impact on prisons, less is known about its impact on palliative care. Compassionate release is underutilised, and the issue of medically assisted dying adds complexity to decisions around end-of-life care. Peer carers can provide reliable symptom assessment. Family members are often absent when someone dies in prison.

Summary: Palliative and end-of-life care in prisons requires a joined-up approach, and staff must understand the challenges of both this and custodial care in general. The relational network both inside and outside of the prison should be involved, and when possible and appropriate, we should consider alternatives to dying whilst incarcerated, such as compassionate release.

Purpose of review: The notion of a 'good death' is central to hospice and palliative care philosophy. This review interrogates social imaginaries of the 'good death' in the context of current global, health and sociopolitical challenges.

Recent findings: Research literature and policy documents across fields continue to place emphasis on the 'good death'. As part of the equity turn in palliative care, there is a growing body of work highlighting the diverse perspectives of people whose voices were heretofore not understood. Inequities are evident not only in terms of who has access to a 'good death' but also related to the effects of the dominant 'good death' script itself.

Summary: There is increasing evidence that pursuit of the 'good death' narrative may be counter to supporting people as they are living and dying. The authors instead argue for a research, policy and practice shift to 'matters of care'.

Purpose of review: Neuromodulation techniques are being increasingly used to alleviate pain and enhance quality of life. Non-invasive cortical stimulation was originally intended to predict the efficacy of invasive (neurosurgical) techniques, but has now gained a place as an analgesic procedure in its own right.

Recent findings: Repetitive transcranial magnetic stimulation (rTMS): Evidence from 14 randomised, placebo-controlled trials (~750 patients) supports a significant analgesic effect of high-frequency motor cortex rTMS in neuropathic pain. Dorsolateral frontal stimulation has not proven efficacious so far. The posterior operculo-insular cortex is an attractive target but evidence remains insufficient. Short-term efficacy can be achieved with NNT (numbers needed to treat) ~2-3, but long-lasting efficacy remains a challenge.Like rTMS, transcranial direct-current stimulation (tDCS) induces activity changes in distributed brain networks and can influence various aspects of pain. Lower cost relative to rTMS, few safety issues and availability of home-based protocols are practical advantages. The limited quality of many published reports lowers the level of evidence, which will remain uncertain until more prospective controlled studies are available.

Summary: Both rTMS and tDCS act preferentially upon abnormal hyperexcitable states of pain, rather than acute or experimental pain. For both techniques, M1 appears to be the best target for chronic pain relief, and repeated sessions over relatively long periods of time may be required to obtain clinically significant benefits. Patients responsive to tDCS may differ from those improved by rTMS.

Current Opinion in Supportive and Palliative Care was launched in 2007. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The fields of supportive and palliative care are divided into 12 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Section Editors for this issue.