Annals of palliative medicine最新文献

Background: Reactivation of the varicella zoster virus (VZV) results in herpes zoster (HZ), which is a painful unilateral rash with a typical dermatomal distribution. HZ may be followed by postherpetic neuralgia (PHN), vasculopathy, myelopathy, retinal necrosis, and cerebellitis. Vasculopathy can cause ischemic stroke, aneurysms, arterial dissection, transient ischemic attack, and rarely, peripheral arterial disease (PAD). The possible mechanism is that the VZV travels to the arteries through the sensory ganglia, leading to inflammation and pathological vascular remodeling, which result in vasculopathy.

Case description: Here, we describe a rare case of femoral artery occlusion induced vasculopathy 5 years after HZ. A 65-year-old woman visited our pain clinic with persistent pain following HZ that occurred 3 months earlier. She had several rash scars on the right thigh along with a continuous throbbing, shooting, and sharp pain. The patient was diagnosed with PHN and prescribed with medications that relieved the leg pain. The symptoms remained stationary for almost 5 years. She presented again with complaints of a paroxysmal tingling sensation in the right thigh and claudication due to increased pain, which had begun 6 months prior. She reported leg pain after walking for 10 minutes. Lumbar spine magnetic resonance imaging (MRI) revealed foraminal stenosis at the level of right L2, with no abnormality below L2. Subsequently, the patient was evaluated for vascular diseases. Lower extremity ultrasonography and computed tomography (CT) angiography revealed stenosis and thrombotic occlusions in the right superficial femoral and tibial arteries as well as the left middle femoral and tibial arteries. Surgical revascularization via percutaneous angioplasty was performed bilaterally. The leg pain was relieved after the procedure and the claudication improved.

Conclusions: Peripheral artery occlusion is a rare phenomenon following HZ. In cases involving changes in HZ symptoms, further evaluation is required for potential vasculopathy.

Background and objective: In locally advanced cancer, bleeding is a common clinical presentation and radiotherapy (RT) provides a noninvasive, well-tolerated, cost-effective treatment. However, the choice for fractionation dose and schedule seem to merely depend on physician's preference rather than specific guidelines. We reviewed the available literature on palliative hemostatic RT for response rate (RR) and bleeding duration in relation with the given dose.

Methods: The PubMed database was used to search for articles, which were assessed by predetermined inclusion and exclusion criteria. A total of 54 articles, published over the last 20 years until December 2023 were analyzed for dose and/or fractionation regimen and their relation to the RR.

Key content and findings: A variety of fractionation schedules are used for palliative symptom control, including hemostasis. Research focusing on hemostatic irradiation specifically and prospective studies are rare. Moreover, to our knowledge, there are no specific (prospective) studies ongoing. Both external beam radiotherapy (EBRT) and brachytherapy lead to bleeding control and daily or weekly hypofractionated irradiation is safe and effective for both high and low biological equivalent dose (BED) regimens. If feasible, based on patient condition, some studies favor higher BED regimens to obtain more durable tumor/higher bleeding response. Higher radiation dose for thoracic irradiation may be indicative for simultaneous presentation of obstruction and/or dysphagia. Brachytherapy may be used solely or in combination with EBRT or in the setting of re-irradiation. Short-course regimens are preferred in patients in with low performance index scores. For future studies, multivariate analysis, including BED, can be important to assess efficacy of different fractionation schedules for a variety of tumor etiologies.

Conclusions: Hemostatic RT, both by EBRT and brachytherapy, appears to be a safe and effective palliative treatment that clinically and statistically significantly reduces bleeding in cancer patients. The available literature is limited regarding prospective and uniform evaluation of hemostatic RT, including fractionation schedules. BED seems to be indicative for a better RR for specific indications. Current evidence suggests that treatment decisions should be tailored according to the patients' condition, tumor etiology and other clinical symptoms. More (prospective) research focusing on hemostasis is necessary to develop clear guidelines.

Chronic breathlessness (CB) or dyspnea is prevalent in fibrotic interstitial lung diseases (F-ILD). It is the main driver of a poor health-related quality of life (HRQOL). Timely and accurate assessment and management of CB are paramount in F-ILD care. This is reflected in latest American and European guidelines that recommend early integration of symptom-targeted therapies. Despite calls for improved CB care, evidence indicates that it remains under recognized and under treated. This narrative review focuses on the current evidence for CB assessment and management in F-ILD and proposes an algorithm for patient-centered management of CB in an outpatient setting. An overview of CB assessment tools is provided along with recommendations from guidelines and experts. The limited evidence base for CB interventions in ILD is reviewed; existing dyspnea guidelines recommend a hierarchical approach to therapies starting with the implementation of nonpharmacologic interventions (NPI). Pulmonary rehabilitation is the most common NPI in F-ILD, that improves function, dyspnea, and HRQOL. Oxygen can be prescribed to treat CB associated with exertional hypoxemia early in the course of F-ILD, with evidence suggesting short-term improvements in CB and HRQOL. For patients with severe, persistent CB despite optimization of NPI and oxygen, opioids can be prescribed, initially as short-acting, low-dose oral morphine with prophylactic doses for exertion and as needed for crises. Self-management education and written action plans may help improve patient confidence and control. Development of competency in symptom management and fostering a professional and institutional culture prioritizing CB will advance patient care and should be a priority for F-ILD patients.

Heart disease is the number one cause of death in the United States. Advanced cardiac conditions, such as heart failure, are characterized by severe symptoms, recurrent hospitalizations, limited/uncertain prognosis, decreased quality of life, and high levels of caregiver burden. The burden of heart failure is highest in older adults, for whom cardiovascular symptoms are layered on existing age-related problems such as geriatric syndromes, polypharmacy, depression, frailty, inadequate social support, decreased representation in clinical trials, and aging caregivers. Deliberate integration of outpatient and interdisciplinary geriatrics, palliative care, and cardiovascular care are essential for this special population. Life-prolonging and quality of life-focused approaches to managing cardiovascular disease are not mutually exclusive; many cardiology medications and treatments prolong life while also improving symptom burden. Symptom management, a cornerstone of palliative care, is therefore not only complementary to life-prolonging cardiology treatments, but also integral to optimized daily cardiovascular care. In this review, we aim to summarize relevant literature and provide practical tools that can be used by primary care clinicians, geriatricians, cardiologists and palliative care clinicians to optimize holistic outpatient care for adults who are aging with heart disease. While palliative care is appropriate for any age or stage of illness, we will focus on older adults with heart disease, and the nuances of managing their symptoms, goals of care, and quality of life.

Radiofrequency ablation (RFA) of the articular branches of the femoral and obturator nerves (the innervation of the anterior capsule of the hip) is an emerging treatment for chronic hip pain. Body mass index (BMI) greater than 30, older age, large acetabular/femoral head bone marrow lesions, chronic widespread pain, depression, and female sex increase the risk of developing hip pain. Chronic hip pain is a common condition with a wide range of etiologies, including hip osteoarthritis (OA), labral tears, osteonecrosis, post total hip arthroplasty (THA), post-operative dislocation/fracture, and cancer. The most common and well studied is hip OA. Management of chronic hip pain includes conservative measures (pharmacotherapy and exercise), surgery, and percutaneous procedures such as RFA. While surgery is effective, those whose medical comorbidities preclude surgery, those who do not wish to have surgery, and those whose pain persists after surgery (11-36% of patients) could benefit from RFA. Because of the aforementioned circumstances, hip RFA is often a palliative intervention. Hip RFA is an effective treatment, one recent retrospective study of 138 patients found 69% had >50% pain relief at 6 months. The most frequent adverse event reported for hip RFA is pain from needle placement. No serious bleeding events have been reported, despite the valid concern of the procedure's proximity to vasculature. This descriptive review details the pathophysiology of hip pain, its etiologies, its clinical presentation, conservative management, the anatomy/technique of hip RFA, hip RFA efficacy, and RFA adverse events.

Radiofrequency ablation (RFA), a minimally invasive procedure for pain reduction, is increasingly used for managing chronic neck pain and headaches. This article offers a concise overview of cervical spine RFA. In the context of RFA, heat is applied to specific nerve tissues to interrupt pain signals. Wallarian degeneration occurs as a result of the thermal injury to the nerve. The heat generated by the RFA procedure can damage the nerve fibers, initiating the degenerative process. Wallarian degeneration is a process that occurs in a nerve axon due to the thermal injury, leading to the breakdown and eventual degradation of the axon and its myelin sheath. However, nerves have regeneration capacity, especially the peripheral nerves, which are often the target of RFA for pain management. After Wallarian degeneration takes place, the nerve sheath, or the connective tissue surrounding the nerve, can serve as a scaffold for the growth of new nerve fibers. Over time, these new fibers can regenerate and re-establish connections, potentially restoring nerve function. Three common types are traditional thermal, water-cooled, and pulsed radio frequency ablation. Given the regenerative potential of nerves, these procedures are typically effective for 1 to 2 years, with some variability. Despite a 112% increase in Medicare claims for RFA from 2009 to 2018, it's recommended for patients who respond positively to diagnostic medial branch blocks, with recent guidelines suggesting a single block may be sufficient. Although generally effective, the procedure carries risks, including nerve and tissue injury. Notably, the procedure's increased utilization notably surpasses the most commonly reported prevalence rates of conditions it aims to treat. Moreover, diagnostic blocks performed before cervical RFA also have their risks, such as inadvertent vascular injections leading to seizures or paralysis. In summary, the risks and benefits of cervical RFA must be considered with regards to the patient's comorbidities and specific pain issues. The skill and experience of the practitioner plays a significant role in minimizing these risks. Detailed discussions with healthcare providers about the risks, benefits, and alternatives can help in making an informed decision about the procedure.

Bone metastases are a common and debilitating consequence of advanced cancer, often necessitating palliative radiation therapy (RT) for pain relief. Reirradiation (reRT) of bone metastases is often considered after lack of pain relief following an initial course of RT, after a partial but unsatisfying pain response to an initial course of radiotherapy, or after pain recurrence following a complete or partial pain response to an initial course of RT. The NCIC CTG SC.20 trial, a landmark multicenter, randomized, non-blinded, controlled non-inferiority trial, addressed the critical question of optimal dose fractionation for reRT in this patient population. This trial compared the efficacy and toxicity of a single 8 Gy fraction to multiple fractions totaling 20 Gy in 850 patients with painful bone metastases requiring reRT. The primary endpoint was overall pain response at 2 months, with secondary endpoints of quality of life (QoL) measures, functional interference, and toxicity profiles assessed using patient-reported questionnaires and the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30. The intention-to-treat analysis revealed no significant difference in pain response between the two arms, meeting the pre-specified non-inferiority criteria. The per-protocol analysis suggested a potential benefit for a subset of patients receiving multiple fractions, although this was not statistically robust. Acute toxicities were more prevalent in the multiple fractions arm, with implications for patient comfort and healthcare utilization. Importantly, responders to reRT reported significant improvements in functional interference and QoL. The trial's findings support the use of a patient-centric approach to palliative RT, highlighting the viability of a single 8 Gy fraction as a less toxic and more convenient treatment option, albeit with consideration for individual patient circumstances. These results have significant implications for clinical practice, potentially reducing healthcare burdens while optimizing patient convenience during palliative care for painful bone metastases.

For those who have kidney failure and are managed conservatively without dialysis, symptoms are often prevalent, multiple, and troublesome. They interfere with quality of life, reduce wellbeing, and can affect family carers too. Symptoms can sometimes be difficult to manage, and-for professionals-they are often hard to assess and not always amenable to management with medications appropriate for use in kidney failure. Fatigue is one of the most common symptoms; alongside a general overview of symptoms in this population, we include a more detailed discussion of this often-neglected symptom. The solutions to the main symptoms experienced by those with kidney failure managed conservatively without dialysis lie in detailed assessment and monitoring of symptoms, working as a multi-disciplinary team to the maximum to draw on the full range of skills and expertise, and use of non-pharmacological, as well as pharmacological, approaches. Both nephrology and palliative care skills and expertise are important to optimise the recognition, assessment, and management of symptoms. There are few published descriptions of models of conservative kidney management (CKM) or supportive kidney care and there is a lack of evidence to suggest which model is most effective. We therefore consider the evidence on optimal models of CKM and make suggestions for best practice.

Background: Radiofrequency ablation (RFA) is a treatment modality that has been increasingly used for the management of chronic shoulder pain. Serious conditions that can identified as the cause of chronic shoulder pain include rotator cuff disorders, adhesive capsulitis, osteoarthritis, glenohumeral instability, and acromioclavicular joint disorders. Treatment of chronic shoulder pain typically consists of physical therapy, oral and topical medications, intra-articular corticosteroid injections, and even surgery. The aim of this study was to examine the most recent primary and secondary outcomes of RFA for chronic shoulder pain.

Methods: A systematic review was conducted using three different databases including PubMed, MEDLINE, and the Cochrane Database. The key concepts of "radiofrequency ablation" and "shoulder pain" were used. The search took place in June 2023, and it included articles from the past 20 years.

Results: Of the 396 articles found, 29 were included in the review. Most studies focused on reduction in pain scores, duration of relief, function, and patient satisfaction. In several studies, RFA was compared to conservative options such as physical therapy or corticosteroid injections.

Conclusions: Overall, RFA shows positive outcomes in terms of the management of chronic shoulder pain. Therefore, RFA can serve as another treatment option for patients who fail conservative management or are not strong surgical candidates. Understanding the outcomes of RFA for chronic shoulder pain can provide patients and clinicians with evidence for the most appropriate treatment.