BMJ Supportive & Palliative Care最新文献

Background: The aim of this systematic review and meta-analysis is to compare the complication rates of enteral nutrition (EN) (oral or tube feeding (TF)) and parenteral nutrition (PN) in patients with any cancer.

Methods: A systematic review of the literature until 2024 was conducted, including randomised controlled trials comparing EN and PN with respect to one or more of four endpoints: (1) infection, (2) nutrition support complications, (3) major complications and (4) mortality. A meta-analysis was conducted to generate summary effect estimates. Analysis was stratified by paediatric (≤21 years old) versus adults (>21 years old) patients. Subgroup analyses were conducted, based on including patients with (vs without) protein-energy malnutrition (PEM) and type of EN. Cumulative meta-analysis and leave-one-out analysis was conducted. Type I error was set at 0.05.

Results: 49 studies reporting on 6361 patients were included: 41 reported on adults and 8 on children. Among adults, the infection rate was higher for PN compared with EN (risk ratio=1.07, 95% CI: 1.00 to 1.14), with no differences in rates of nutrition support complications, major complications or mortality. Among children, there were no differences in all four endpoints. On cumulative meta-analysis, EN was overall marginally superior to PN for infection, although results fluctuated over time between superiority and no difference. Subgroup analysis found no differences in effects among patients with (vs without) PEM and patients provided with EN options of standard care versus TF.

Discussion: From the perspective of complications, EN and PN are equivalent, with EN demonstrating marginal superiority for infection among adults.

Background: Patients with life-limiting conditions are often cared for at home by family, typically without adequate training to carry out the challenging tasks performed. This systematic review assessed the efficacy of interventions designed to help family caregivers manage pain and other symptoms in adults and children with life-limiting conditions at home.

Methods: A systematic search was performed on seven databases. A narrative synthesis was conducted, along with a meta-analysis comparing outcomes in those who received an intervention to those who did not, or to preintervention scores.

Results: 84 eligible studies were identified. Significant improvements in pain and fatigue in patients with cancer were found compared with patients in the control group and baseline. Caregivers of patients with cancer receiving an intervention, compared with the control group caregivers, showed significant improvements in self-efficacy and active coping and lower avoidant coping. This group also showed significant improvements in burden, self-efficacy, anxiety and depression, and decreases in avoidant coping pre- to post intervention. Patients with dementia whose caregivers received an intervention showed significantly reduced pain intensity and improvements in quality of life pre- to post intervention. Caregivers of patients with dementia showed significantly reduced distress pre- to post intervention. No beneficial effects were found for caregivers of patients with Parkinson's disease or heart failure, although only limited analyses could be performed.

Conclusions: Interventions targeting family caregivers can improve both patient symptoms and caregiver outcomes, as demonstrated in cancer and dementia care. Future mixed-methods research should collect data from caregiver and patient dyads, identifying key intervention components. There is also need for more studies on caregivers of paediatric patients.

Resilience-building in palliative care professionals: scoping review BACKGROUND: Burnout, demoralisation and compassion fatigue are common among palliative care professionals. Practising palliative care necessitates a quality of resilience in order to ensure constant and optimal patient care. However, there is no universal approach to prevent burnout or raise resilience among palliative care professionals. This study aims to provide an overview of interventions and explore their effectiveness in building resilience in palliative care professionals.

Methods: The search was conducted in four databases: MEDLINE, Embase, CINAHL, PsycINFO and Cochrane Database. Two independent investigators reviewed eligibility, with conflicts resolved by a third investigator. One reviewer performed data extraction, later reviewed by a second investigator. All eligible studies were manually re-reviewed. Quantitative and qualitative data synthesis were conducted.

Results: The search initially revealed 11 470 potentially eligible citations. 12 studies were included in the analysis. Most studies had a small number of participants. The studies varied in sample size, interventions and assessment tools, making it challenging to identify the most effective resilience-building interventions. However, our analysis revealed commonly found elements among these interventions: five essential elements (regularity, self-care, mindfulness, reflective practice and cognitive-behavioural therapy) and three supporting elements (peer support, educational sessions and organisational support).

Discussion: While the effectiveness of specific interventions remains inconclusive, this review highlights essential and supporting elements that should be considered in designing resilience-building programmes for palliative care professionals. Future research should focus on developing assessment tools specific to palliative care, conducting well-designed studies, and creating replicable, standardised interventions.

Objectives: The study evaluates the fifth cohort of the palliative care cancer treatment centres (CTC) educational programme in India with the aim of refining the course on the basis of participant feedback thereby improving palliative care services at cancer centres.

Methods: The intervention included participation in the CTC 5 teaching and training programme, which encompassed foundation course, refresher course, access to palliative care training modules, clinical training and mentorship under palliative care experts. The feedback was taken from all 57 participants (29 doctors and 28 nurses) of CTC 5 programme representing 14 hospitals across nine regions in India. The assessment tools included Likert scale ratings and free-text comments. 3-point and 5-point Likert scale ratings were used to gauge the usefulness of course topics, quality of content and delivery. A mixed methods approach was used for a comprehensive evaluation by taking both quantitative measures of participant inputs and qualitative insights into their experiences and suggestions. The knowledge gained by the participants was analysed using pre-training and post-training assessments.

Results: The feedback obtained from the participants highlighted both strengths and scope for improvement. The foundation course received positive feedback for its sessions, especially on communication skills and pain management. The refresher course received positive feedback for team presentations but lacked sufficient case discussions. The interactive nature of sessions was well-received. Following the CTC 5 programme, participants showed a 30.38% knowledge gain. Overall, the programme exceeded expectations for 62% of participants, highlighting its impact on personal development and clinical practices in palliative care.

Conclusion: The study provides useful insights for designing future palliative care educational courses to address the needs of health professionals. The CTC programme has promising potential to bring about positive changes in both the personal and professional development of participants ultimately improving palliative care services across India.

Objective: Improper use of human albumin (HA) is now common in clinical settings. This study aims to explore the feasibility of the plan-do-check-act (PDCA) cycle in promoting the rational use of HA.

Methods: The differences between the control and observation groups (after the PDCA cycle) in terms of serum albumin detection rate, serum albumin values, HA usage, and rationality were analysed and compared using a before-and-after control method.

Results: A total of 372 patients were recruited, including 186 in each of the control and observation groups. On comparison, it was observed that the overall use of HA improved after the PDCA cycle compared with the preintervention period, and the rational rate of HA prescriptions increased from 68.3% to 96.2%. The serum albumin detection rate before applying for HA increased from 83.9% to 98.9%, and the median values decreased from 26.7 (22.8-30.9) g/L to 24.7 (22.7-27.2) g/L. Regarding the use of HA, the median amount of HA used was reduced by 20 g compared with the preintervention period, meanwhile, the median duration was shortened by 2 days.

Conclusion: The PDCA cycle is desirable when employed to promote the rational use of HA.

Objectives: Palliative care phases (stable, unstable, deteriorating, terminal and bereavement) are useful in describing the palliative care situation of patients/relatives and their care needs as well as the suitability of care plans. Little is known about care setting-specific differences of the phases and their association with burden of symptoms/problems and functional status. We aimed to describe the presence and association of symptom/problem burden and functional status with the palliative care phase at the beginning of care episodes in specialist palliative care units, specialist home care teams and advisory services.

Methods: This study is a secondary analysis of a prospective, cross-sectional, multicentre study collecting data on patients' complexity in Germany. Analyses using the palliative care phase, symptom/problem burden measured by the Integrated Palliative care Outcome Scale (IPOS), functional status measured by the Australian-modified Karnofsky Performance Status (AKPS), severity of confusion and agitation, age and gender were conducted, including descriptive statistics, non-parametric tests and multinomial logistic regression.

Results: 3115 phases from three settings were included, with an average age of 72 years (SD±13.3) and 49% male. The distribution of phases at episode start varied among settings: data showed in palliative care units 20.3% stable, 43.4% unstable, 31.5% deteriorating and 4.8% terminal; in palliative care advisory, 26% stable, 33.9% unstable, 32.8% deteriorating and 7.3% terminal; and in specialist palliative home care, 42.4% stable, 21.3% unstable, 29.1% deteriorating and 7.2% terminal phases. Multinomial logistic regression showed that besides functional status, in palliative care units and specialist palliative home care, high physical symptom burden and palliative care advisory, high emotional burden increased the odds of being in an unstable phase.

Conclusions: Setting-specific differences in patient characteristics and symptom and problem burden associated with palliative care phases lead towards different demands on the teams providing patient care.

Purpose: Malnutrition severely impacts tolerance to anticancer therapies, but any relationship with overall survival (OS) at the time of solid tumour diagnosis in outpatients in the USA remains unclear.

Methods: This retrospective study evaluated 3562 patients who completed the Malnutrition Screening Tool (MST) at diagnosis, identifying the relationship between MST risk, a validated tool evaluating anorexia and weight loss, and OS. MST score of ≥2 of 5 was classified as high malnutrition risk (H-MST). Kaplan-Meier techniques and Cox proportional hazards models were used to analyse OS in H-MST versus low malnutrition risk (L-MST).

Results: In the unadjusted models, MST risk was individually associated with OS. Multivariable regression confirmed that MST risk remained independently prognostic for OS after controlling for key confounding variables, HR=1.51 (95% CI: 1.33 to 1.72). The H-MST group had shorter OS (50-month survival rates: 69% L-MST vs 60% H-MST).

Conclusion: MST risk at diagnosis is an independent prognostic factor for OS. H-MST risk is associated with shorter survival in a broad cohort of solid tumour oncology outpatients.

Objectives: This study investigates the status of end-of-life (EOL) care and palliative care (PC) training in Spanish medical schools and assesses students' perspectives.

Methods: The research employs a quantitative cross-sectional survey and a systematic review of curricula including schools to which the respondent students belonged to.

Results: A systematic review reveals that only 12 out of 39 universities offer mandatory PC or EOL care subjects, often integrated with other areas. Optional courses exist in nine universities but with minimal emphasis. Survey responses from 368 senior medical students indicate limited exposure to EOL or PC training, with significant deficits reported in communicative attitudes, ethics, administrative procedures and self-care. Most students lack confidence in EOL care and PC skills, often relying on imitation or personal experience for learning. Nearly half have sought training outside their regular curriculum, and the majority express a desire for additional education in these areas.

Conclusions: The study underscores the urgent need to enhance PC and EOL care teaching in Spanish medical schools, addressing gaps in physiological understanding, communication, ethics, administrative processes and self-care for healthcare professionals dealing with EOL situations.

Objectives: To assess the incidence of neutropenia, febrile neutropenia, documented infection with neutropenia and fever associated with early-stage breast cancer (BC) in a real-life setting.

Methods: A retrospective study that includes 88 women with BC who received a first dose of Epirubicin plus Cyclophosphamide with or without 5-Fluorouracil, in the county hospital of Ryhov, Sweden. The patients were included continuously from May 2017 to November 2020 and were ≥18 years old. All data was collected in a form and the G-CSF prophylaxis was checked to ensure that it was given during the treatments.

Results: The median age among the patients was 59 (min 27-82max) years. 79 patients were treated with primary prophylaxis with Granulocyte-colony stimulating factor (G-CSF) support. Seven (8.0%) patients were affected by a neutropenic episode, including one (1.1%) patient with FN and two (2.3%) patients with documented infection (online supplemental table 1).

Conclusion: The incidence of neutropenic events in this study is relatively low. A higher incidence of neutropenic episodes is observed in patients ≥ 60 years old compared with younger patients, despite lower doses of chemotherapy for the elderly. The use of G-CSF in the elderly, regardless of the dose of chemotherapy, may be needed to decrease the incidence of neutropenia and its consequences. The adverse effects of G-CSF and its cost-effectiveness are important perspectives which should be included in the treatment.