Annals of palliative medicine最新文献

Background: Delirium derived from dementia with Lewy bodies (DLB), and the risk of drug hypersensitivity derived from DLB is not well recognized in oncology. To avoid severe side effects caused by antipsychotics, these risks need to be carefully considered by health care providers involved in cancer treatment. The objective of this study is to report the presence of DLB-derived delirium, which is often mixed with ordinary delirium, and its associated hidden risk in cancer treatment.

Case description: A male in his 80s presented with no history of psychiatric disorders. Although he had experienced visual hallucinations such as animals or persons, and the gradual progression of Parkinsonism for several years, he was not undergoing treatment by a psychiatrist. When hospitalized for endoscopy examination, he became agitated with delusions and hallucinations, and was diagnosed with delirium. The examination was postponed. After 2 months, he was diagnosed with DLB, and the delirium he experienced was regarded as a part of DLB. After treatment with donepezil, lemborexant, and yokukansan (a Japanese herbal medicine), his mental status stabilized, and the surgery was conducted safely after drug hypersensitivity with DLB was carefully considered.

Conclusions: In the cancer perioperative period, delirium derived from DLB may occur mixed with ordinary delirium. Oncologists need to be aware of the risk of hidden DLB with delirium and remain updated regarding this topic. In addition, these patients may well be treated with psychotropics that, in principle, do not exacerbate extrapyramidal symptoms, such as donepezil, yokukansan, and lemborexant.

Radical esophagectomy remains the cornerstone of curative treatment for esophageal cancer, but is frequently complicated by postoperative events, most notably anastomotic leakage. Anastomotic leakage, occurring in up to 30% of cases, is multifactorial in origin and significantly increases morbidity and mortality. This review aims to summarize current management strategies, highlight emerging therapies, and identify persistent clinical challenges related to this complication. Relevant studies were identified through targeted literature searches of articles focusing on clinical management, therapeutic innovation, and reported outcomes related to anastomotic leakage, with an emphasis on recent and high-impact publications. This review synthesizes current strategies for the detection, prevention, and management of anastomotic leakage and evaluates emerging interventions. Early diagnosis through contrast-enhanced computed tomography (CT) and esophagography is critical for improving outcomes. Conservative measures such as broad-spectrum antibiotics, nutritional support, and image-guided drainage remain the first-line approach, while surgical revision and endoscopic techniques like stenting and vacuum therapy are increasingly employed in complex cases. Novel therapies, including tissue-engineered constructs and biodegradable stents, are under development but lack large-scale clinical validation. Despite these advancements, major clinical challenges persist, including limited predictive tools for risk stratification, variability in treatment algorithms across institutions, and unclear long-term efficacy of newer interventions. Furthermore, most novel strategies are supported by small cohort studies or preclinical data, limiting their immediate clinical application. Therefore, improved multidisciplinary collaboration, standardized treatment protocols, and integration of predictive diagnostics are essential for optimizing outcomes. Future research should focus on validating emerging therapies through randomized clinical trials and developing personalized management algorithms based on patient-specific risk factors and leak characteristics.

Background: Delirium is a common condition at the end of life and causes significant distress in patients and their loved ones. A precipitant factor can be found in less than half of the patients and the management interventions are limited.

Case description: A patient in his late sixties with low English proficiency with a metastatic neuroendocrine tumor was transferred to a palliative care unit on non-invasive bilevel ventilation. He appeared to become delirious and agitated, trying to remove the face mask, wriggling in bed, and tapping the bedrails. Haloperidol and lorazepam were required when non pharmacological interventions failed to calm him down. The following morning, the patient was able to explain that the positive-pressure facemask was suffocating him and that he could not breathe. So, he was transitioned to high-flow oxygen via nasal cannula, and within a few hours, his respiratory distress significantly improved, and he regained his previous self.

Conclusions: In this report, we highlight the challenges faced by clinical teams diagnosing and managing delirium, in particular when a language barrier is present. Non-invasive bilevel ventilation is generally avoided in patients at the end of life (unless it offers comfort and it is aligned with the patient's wishes), but if used should be considered as a cause of agitation and worsening shortness of breath, especially when it can be easily tested by removing the facemask.

Background: Although aggressive care at the end of life (ACEOL) for advanced gastrointestinal cancer can impose a significant burden on patients and healthcare systems, its prevalence and underlying determinants remain poorly understood. This study aimed to quantify the frequency of ACEOL and identify risk factors associated with such care in a Japanese population.

Methods: We retrospectively reviewed 275 patients with advanced gastrointestinal cancer who initiated first-line palliative chemotherapy at Osaka Medical and Pharmaceutical University between 2017 and 2022. ACEOL was defined according to established indicators, including prolonged hospitalization, multiple emergency department visits or hospital admissions, initiation of a new chemotherapy regimen, intensive care unit admission, and death in an acute care hospital during the last month of life. Logistic regression analyses were performed to explore factors predictive of ACEOL.

Results: Overall, 57.8% of patients (159/275) received at least one indicator of ACEOL. The most common factors were death in an acute hospital (38.5%) and prolonged hospitalization (>14 days; 33.8%). Patients receiving ACEOL had significantly shorter overall survival (OS) than those not receiving ACEOL (8.5 vs. 12.9 months, P=0.02). Younger age [odds ratio (OR) 2.01] and opioid use at the start of chemotherapy (OR 3.39) were identified as independent predictors.

Conclusions: More than half of these patients with advanced gastrointestinal cancer received ACEOL, partly driven by younger age and opioid use at baseline. These findings highlight the need for early identification of high-risk patients and proactive integration of palliative care services to decrease ACEOL.

Background: Patients with symptomatic bone metastases often require urgent palliative radiotherapy, yet conventional treatment planning workflows involving computed tomography (CT) simulation can delay the treatment planning. The purpose of this study is to utilize diagnostic CT for palliative radiotherapy treatment planning in patients with bone metastases in order to reduce the time between physician consultation and treatment planning.

Methods: We retrospectively collected data from 27 eligible patients treated for bone metastases at Mount Sinai Hospital between April 2020 and May 2023. From the original treatment plans, contours, beam arrangements, and administered monitor units (MUs) were transferred from the planning CT to the diagnostic CT for dose calculation. Plan quality was evaluated using target volume coverage metrics, including planning target volume (PTV) V95%, PTV mean dose, and global hotspots.

Results: Out of all the patients in our database, four patients were excluded due to absence of a prior diagnostic CT scan, and three patients were excluded since the entire target volume was not within the diagnostic CT field of view. In total, 26 treatment plans from 20 patients were compared with the original plans. The potential reduction in wait time was estimated by subtracting the average time from initial consult to CT simulation, which was approximately 6.5±1.2 days in this cohort. For all 26 diagnostic CT plans, the mean PTV V95% was 95.3%±0.2%. Compared to the original plans, mean V95% decreased by 1.3%±0.7% and global hotspots increased by 1.80%±0.004% in the diagnostic CT plans.

Conclusions: Our study demonstrated that treatment planning with diagnostic CT is feasible in the palliative radiotherapy setting for patients with bone metastases. This approach may reduce the time between physician consultation and treatment planning, thereby enabling timely relief for patients with symptomatic bone metastases.

Background and objective: The coronavirus disease 2019 (COVID-19) pandemic resulted in an historic disruption and transformation of the healthcare system, including the management of individuals with serious illness. Rehabilitation for patients facing serious or life-threatening illness is underutilized and poorly understood, resulting in unwarranted suffering, disability, and poorly coordinated care. This narrative review aims to describe the impact of the COVID-19 pandemic on the role and scope of rehabilitation within the context of serious illness and palliative care.

Methods: A focused review of the literature included selected articles identified from three databases published from January 2020 to January 2025. Findings were synthesized narratively, with a focus on identifying themes and gaps in the literature related to two main topics: (I) the evidence related to rehabilitation for those with serious or life-threatening COVID-19 during the pandemic and (II) how rehabilitation for patients with serious illness has been transformed after emerging from the pandemic (including non-COVID diagnoses such as cancer, neurologic conditions, etc.).

Key content and findings: The key themes identified during the COVID-19 pandemic emphasized the need for early rehabilitation, interdisciplinary care, and an emphasis on cardiopulmonary principles for rehabilitation. Themes identified during the pandemic also included the emerging role of telerehabilitation, and need for evidence and clinical guidelines for serious illnesses (including long COVID). Themes related to the transformative effect on palliative rehabilitation after the pandemic included an increased importance and focus on coordination of care and interdisciplinary care for those with serious illness and increased focus on mental health and social determinants of health (SDOH). Additionally, there appears to be increased infrastructure and activity related to research, advocacy, and awareness for palliative rehabilitation.

Conclusions: The COVID-19 global pandemic highlighted the need for high quality, coordinated palliative care, including rehabilitation services, for patients facing a serious or life-threatening illness. Due to the benefits to a person's quality of life (QoL), dignity, and comfort, there is increasing evidence of the importance of seamless, ongoing access to rehabilitation services for patients with serious illness.