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Background: Implantation of a permanent pacemaker and atrioventricular (AV) node ablation (pace-and-ablate) is an established approach for rate and symptom control in elderly patients with symptomatic atrial fibrillation (AF). Left bundle branch area pacing (LBBAP) is a physiological pacing strategy that might overcome right ventricular pacing-induced dyssynchrony. In this study, the feasibility and safety of performing LBBAP and AV node ablation in a single procedure in the elderly was investigated. Methods: Consecutive patients with symptomatic AF referred for pace-and-ablate underwent the treatment in a single procedure. Data on procedure-related complications and lead stability were collected at regular follow-up at one day, ten days and six weeks after the procedure and continued every six months thereafter. Results: 25 patients (mean age 79.2 ± 4.2 years) were included and underwent successful LBBAP. In 22 (88%) patients, AV node ablation and LBBAP were performed in the same procedure. AV node ablation was postponed in two patients due to lead-stability concerns and in one patient on their own request. No complications related to the single-procedure approach were observed with no lead-stability issues at follow-up. Conclusions: LBBAP combined with AV node ablation in a single procedure is feasible and safe in elderly patients with symptomatic AF.

Background: Implantation of a permanent pacemaker and atrioventricular (AV) node ablation (pace-and-ablate) is an established approach for rate and symptom control in elderly patients with symptomatic atrial fibrillation (AF). Left bundle branch area pacing (LBBAP) is a physiological pacing strategy that might overcome right ventricular pacing-induced dyssynchrony. In this study, the feasibility and safety of performing LBBAP and AV node ablation in a single procedure in the elderly was investigated. Methods: Consecutive patients with symptomatic AF referred for pace-and-ablate underwent the treatment in a single procedure. Data on procedure-related complications and lead stability were collected at regular follow-up at one day, ten days and six weeks after the procedure and continued every six months thereafter. Results: 25 patients (mean age 79.2 ± 4.2 years) were included and underwent successful LBBAP. In 22 (88%) patients, AV node ablation and LBBAP were performed in the same procedure. AV node ablation was postponed in two patients due to lead-stability concerns and in one patient on their own request. No complications related to the single-procedure approach were observed with no lead-stability issues at follow-up. Conclusions: LBBAP combined with AV node ablation in a single procedure is feasible and safe in elderly patients with symptomatic AF.

Bakgrund: Livets slutskede är en del i den palliativa vården som syftar främst till att lindra patientens besvärliga symtom och göra livet så hanterbart som möjligt inför döden. Genom en djupare förståelse av hur det är att befinna sig i livets sista tid kan omvårdnaden anpassas därefter. Syfte: Att beskriva patienters upplevelser av att befinna sig i livets slutskede. Metod: En litteraturöversikt bestående av tolv vetenskapliga artiklar av kvalitativ design. Dataanalys har genomförts enligt Fribergs fem steg. Resultat: Resultatet presenteras i två teman; att konfronteras med det okända och en känsla av meningsfullhet. Resultatet visar att de upplevelser som uppstår i livets slutskede är olika för varje patient och de bör bemötas utifrån sin egen livsvärld. Resultatet visar också att det finns behov av trygghet och symtomkontroll vilket kan vara av betydelse för patienternas upplevelse av livskvalitet den sista tiden i livet. Slutsats: Resultatet visar att patienter i livets slutskede ofta upplevde rädsla och oro vid konfrontation med det okända. De ville inte försvinna från livet och gå miste om framtiden. Trygghet var ett tydligt behov hos patienterna som befinn sig i livets slutskede. Anhöriga och den andliga världen beskrivs kunna ge denna trygghet. Det visade sig också att hoppet är det sista som överger människan., Background: The final stage of life is part of palliative care and aims primarily to relieve the patient's troublesome symptoms and make life as manageable as possible before death. Through a deeper understanding of what it is like to be in the last days of life, care can be adapted accordingly. Aim: To describe patients experience of existing in the end of life. Method: A literature study based on twelve articles with qualitative design. The five steps of Friberg were used for the data analysis. Results: The result are presented in two themes; to be confronted with the unknown and a sense of meaning. The result show that the experiences that arise at the end of life are different between patients and should be treated based on their own life world. The result also shows that there is need for security as well as symptom control which can be of importance for the patients experience of quality of life in the final time in life. Conclusion: The result show that patients in the final stages of life often experienced fear and anxiety when confronted with the unknown. They did not want to disappear from life and miss out on the future. Security was a prominent need for the patients in the end of life. Relatives and the spiritual world were found providing this security. It was also shown that hope is the last thing leaving the human.

Bakgrund: Livets slutskede är en del i den palliativa vården som syftar främst till att lindra patientens besvärliga symtom och göra livet så hanterbart som möjligt inför döden. Genom en djupare förståelse av hur det är att befinna sig i livets sista tid kan omvårdnaden anpassas därefter. Syfte: Att beskriva patienters upplevelser av att befinna sig i livets slutskede. Metod: En litteraturöversikt bestående av tolv vetenskapliga artiklar av kvalitativ design. Dataanalys har genomförts enligt Fribergs fem steg. Resultat: Resultatet presenteras i två teman; att konfronteras med det okända och en känsla av meningsfullhet. Resultatet visar att de upplevelser som uppstår i livets slutskede är olika för varje patient och de bör bemötas utifrån sin egen livsvärld. Resultatet visar också att det finns behov av trygghet och symtomkontroll vilket kan vara av betydelse för patienternas upplevelse av livskvalitet den sista tiden i livet. Slutsats: Resultatet visar att patienter i livets slutskede ofta upplevde rädsla och oro vid konfrontation med det okända. De ville inte försvinna från livet och gå miste om framtiden. Trygghet var ett tydligt behov hos patienterna som befinn sig i livets slutskede. Anhöriga och den andliga världen beskrivs kunna ge denna trygghet. Det visade sig också att hoppet är det sista som överger människan., Background: The final stage of life is part of palliative care and aims primarily to relieve the patient's troublesome symptoms and make life as manageable as possible before death. Through a deeper understanding of what it is like to be in the last days of life, care can be adapted accordingly. Aim: To describe patients experience of existing in the end of life. Method: A literature study based on twelve articles with qualitative design. The five steps of Friberg were used for the data analysis. Results: The result are presented in two themes; to be confronted with the unknown and a sense of meaning. The result show that the experiences that arise at the end of life are different between patients and should be treated based on their own life world. The result also shows that there is need for security as well as symptom control which can be of importance for the patients experience of quality of life in the final time in life. Conclusion: The result show that patients in the final stages of life often experienced fear and anxiety when confronted with the unknown. They did not want to disappear from life and miss out on the future. Security was a prominent need for the patients in the end of life. Relatives and the spiritual world were found providing this security. It was also shown that hope is the last thing leaving the human.

Background: Despite improvements in medical care, patients with advanced cancer still experience substantial symptom distress. There is increasing interest in the use of medicinal cannabinoids but little high-quality evidence to guide clinicians. This study aims to define the role of a 1:1 delta-9-tetrahydrocannabinol/cannabidiol (THC/CBD) cannabinoid preparation in the management of symptom burden in patients with advanced cancer undergoing standard palliative care. Methods and design: One hundred fifty participants will be recruited from five sites within the Queensland Palliative Care Research Group (QPCRG) and randomly assigned to an active treatment or placebo group. This study is a pragmatic multicentre, randomised, placebo-controlled, two-arm trial of escalating doses of an oral 1:1 THC/CBD cannabinoid preparation. It will compare efficacy and safety outcomes of a titrated dose (10 mg/10 mg/mL oral solution formulation, dose range 2.5 mg/2.5 mg-30 mg/30 mg/day) against placebo. There is a 2-week patient-determined titration phase, using escalating doses of 1:1 THC/CBD or placebo, to reach a dose that achieves symptom relief with tolerable side effects. This is then followed by a further 2-week assessment period on the stable dose determined in collaboration with clinicians. The primary objective is to assess the effect of escalating doses of a 1:1 THC/CBD cannabinoid preparation against placebo on change in total symptom score, with secondary objectives including establishing a patient-determined effective dose, the change in total physical and emotional sores, global impression of change, anxiety and depression, opioid use, quality of life and adverse effects. Discussion: This will be the first placebo-controlled clinical trial to rigorously evaluate the efficacy, safety and acceptability of 1:1 THC/CBD for symptom relief in advanced cancer patients. This study will allow the medical community to have some evid

The purpose of this Evidence-Based Project is to determine the effectiveness of using “teach-back” method in giving education to patients receiving chemotherapy and how this method can increase patient satisfaction with understanding of medication action and side effects. Teach-back method is a way of checking patient’s understanding by asking them to state in their own words the information about their health. It is a way to confirm that the explanations given by their provider is understood. Teach-back method can improve patient’s understanding and adherence, decrease call backs and cancelled appointments. This project was developed to improve the organization’s patient satisfaction survey released in October of 2019 which showed only 61% of patients reported that staff “always” explained about medicines before giving it to them. The organization received a 2 out of 5 stars rating for this particular measure. Providing effective chemotherapy education can be challenging especially in a busy outpatient hospital oncology setting however patient education is essential to promote patient safety, optimal dosing, and adherence to the treatment plan. Participants of this project were exclusive to patients who have Medicare. Chemotherapy education utilizing the teach-back method was conducted. Four weeks after the intervention follow up patient satisfaction survey was completed (N=35) and the results were compared to the results of the previous patient satisfaction survey.

Background: Despite improvements in medical care, patients with advanced cancer still experience substantial symptom distress. There is increasing interest in the use of medicinal cannabinoids, but there is little high quality evidence to guide clinicians. This study aims to define the role of cannabidiol (CBD) in the management of symptom burden in patients with advanced cancer undergoing standard palliative care. Methods and design: This study is a multicentre, randomised, placebo controlled, two arm, parallel trial of escalating doses of oral CBD. It will compare efficacy and safety outcomes of a titrated dose of CBD (100 mg/mL formulation, dose range 50 mg to 600 mg per day) against placebo. There is a 2-week patient determined titration phase, using escalating doses of CBD or placebo to reach a dose that achieves symptom relief with tolerable side effects. This is then followed by a further 2-week assessment period on the stable dose determined in collaboration with clinicians. Discussion: A major strength of this study is that it will target symptom burden as a whole, rather than just individual symptoms, in an attempt to describe the general improvement in wellbeing previously reported by some patients in open label, non controlled trials of medicinal cannabis. Randomisation with placebo is essential because of the well-documented over reporting of benefit in uncontrolled trials and high placebo response rates in cancer pain trials. This will be the first placebo controlled clinical trial to evaluate rigorously the efficacy, safety and acceptability of CBD for symptom relief in advanced cancer patients. This study will provide the medical community with evidence to present to patients wishing to access medicinal cannabis for their cancer related symptoms. Trial registration number: ALCTRN12618001220257 Registered 20/07/2018.

Background: Alleviating symptoms, fulfilling psychosocial needs, and the inclusion of family are among the criteria that determine care quality in palliative treatment. The care quality is especially inadequate for people with dementia (PwD) at the end of life. To improve this, it is necessary to understand the process of nurses’ clinical decision-making in symptom management in the terminal phase of PwD. Aim: The aim of the study was to examine the decision-making process of symptom management for PwD in nursing homes in their terminal phase of life. Design: A qualitative design was chosen with a constructivist approach. Individual interviews were conducted with nurses (n=32) in four Swiss nursing homes. Results: ‘Recount and reflect’ plays a vital role in the care of PwD in terminal phase, enabling symptom recognition and facilitating symptom management. A process of thinking during the course of action enables nursing staff members to understand what, when, and how symptom changes have taken place. Conclusion: Highly-trained nurses need to support health care assistants through counselling, coaching, and leadership to help reduce the symptom burden experienced by PwD. Relatives are necessary to maintain an exchange of ideas regarding the appropriate treatment to reduce symptom burden.

Background: Alleviating symptoms, fulfilling psychosocial needs, and the inclusion of family are among the criteria that determine care quality in palliative treatment. The care quality is especially inadequate for people with dementia (PwD) at the end of life. To improve this, it is necessary to understand the process of nurses’ clinical decision-making in symptom management in the terminal phase of PwD. Aim: The aim of the study was to examine the decision-making process of symptom management for PwD in nursing homes in their terminal phase of life. Design: A qualitative design was chosen with a constructivist approach. Individual interviews were conducted with nurses (n=32) in four Swiss nursing homes. Results: ‘Recount and reflect’ plays a vital role in the care of PwD in terminal phase, enabling symptom recognition and facilitating symptom management. A process of thinking during the course of action enables nursing staff members to understand what, when, and how symptom changes have taken place. Conclusion: Highly-trained nurses need to support health care assistants through counselling, coaching, and leadership to help reduce the symptom burden experienced by PwD. Relatives are necessary to maintain an exchange of ideas regarding the appropriate treatment to reduce symptom burden.

Introduction: Asthma is a global health problem that negatively affects various aspects of the quality of a person's life. The aim of the study was to examine the quality of life in children and adolescents with asthma and the correlation between the degree of asthma control and the quality of life.Methods: The cross-sectional study included 100 children and adolescents with asthma over a six-month period in 2015. The study used: Standardized Pediatric Asthma Quality of Life Questionnaire (PAQLQ(S)) for the assessment quality of life and the questionnaires for the assessment of asthma control for two age groups: Asthma Control Test (ACT) for adolescents and Childhood Asthma Control Test (C-ACT).Results: 62 boys and 38 girls aged 7−17, whose average age was 11.2 (s = 2.7) years were included in the study. The overall PAQLQ(S) score ranged between 3.30 and 7.00 with an average mean value of 5.95. The findings have showed that most children with asthma estimated their overall PAQLQ(S) on the positive end of the scale. The children reported more impairment in the domain of 'Emotion' (x = 5.84) than in 'Activities' and 'Symptoms'. The percentage of adolescents in the category of poor control (12.5 %) was significantly lower than in the group of children (25.0 %). In both groups of children, the sub-scale 'Symptoms' was in highest correlation with the degree of asthma control (r = 0.915, p < 0.01).Discussion and conclusion: In this study the children and adolescents with asthma showed an overall good quality of life. Control of asthma symptoms in children and adolescents positively influenced their quality of life., Uvod: Astma je globalni zdravstveni problem, ki negativno vpliva na različne vidike kakovosti življenja. Cilj raziskave je bil preučiti kakovost življenja pri otrocih in mladostnikih z astmo ter povezavo med stopnjo nadzora astme in kakovostjo življenja.Metode: Presečna študija je vključevala 100 otrok in mladostnikov z astmo v šestmesečnem obdobju leta 2015. V raziskavi so bili uporabljeni: standardiziran vprašalnik o kakovosti življenja otrok z astmo (PAQLQ(S)) za oceno kakovosti življenja in vprašalnika za oceno krmiljenja astme za dve starostni skupini: test za kontrolo astme za mladostnike (ACT) in test za kontrolo astme pri otrocih (C-ACT).Rezultati: Vključenih je bilo 62 fantov in 38 deklic, starih od 7 do 17 let, katerih povprečna starost je bila 11,2 (s = 2,7) leta. Skupni rezultati v oceni PAQLQ(S) so se gibali med 3,30 in 7,00 s povprečno vrednostjo 5,95. Ugotovitve kažejo, da je večina otrok z astmo umestila svojo splošno PAQLQ(S) proti pozitivnemu koncu lestvice. Otroci so poročali o večji oslabelosti na področju »Čustva« (x = 5,84) kot na področjih »Dejavnosti« in »Simptomi«. Odstotek mladostnikov, ki spadajo v kategorijo slabega nadzora (12,5 %), je bil znatno nižji kot v skupini otrok (25,0 %). V obeh skupinah otrok je bila lestvica »Simptomi« v največji povezavi s stopnjo nadzora astme (r = 0,915, p < 0,01).Diskusija in zaključek: V raziskavi so otroci in mladostniki z astmo pokazali splošno dobro kakovost življenja. Nadzor simptomov astme pri otrocih in mladostnikih je pozitivno vplival na njihovo kakovost življenja.

Introduction: Asthma is a global health problem that negatively affects various aspects of the quality of a person's life. The aim of the study was to examine the quality of life in children and adolescents with asthma and the correlation between the degree of asthma control and the quality of life.Methods: The cross-sectional study included 100 children and adolescents with asthma over a six-month period in 2015. The study used: Standardized Pediatric Asthma Quality of Life Questionnaire (PAQLQ(S)) for the assessment quality of life and the questionnaires for the assessment of asthma control for two age groups: Asthma Control Test (ACT) for adolescents and Childhood Asthma Control Test (C-ACT).Results: 62 boys and 38 girls aged 7−17, whose average age was 11.2 (s = 2.7) years were included in the study. The overall PAQLQ(S) score ranged between 3.30 and 7.00 with an average mean value of 5.95. The findings have showed that most children with asthma estimated their overall PAQLQ(S) on the positive end of the scale. The children reported more impairment in the domain of 'Emotion' (x = 5.84) than in 'Activities' and 'Symptoms'. The percentage of adolescents in the category of poor control (12.5 %) was significantly lower than in the group of children (25.0 %). In both groups of children, the sub-scale 'Symptoms' was in highest correlation with the degree of asthma control (r = 0.915, p < 0.01).Discussion and conclusion: In this study the children and adolescents with asthma showed an overall good quality of life. Control of asthma symptoms in children and adolescents positively influenced their quality of life., Uvod: Astma je globalni zdravstveni problem, ki negativno vpliva na različne vidike kakovosti življenja. Cilj raziskave je bil preučiti kakovost življenja pri otrocih in mladostnikih z astmo ter povezavo med stopnjo nadzora astme in kakovostjo življenja.Metode: Presečna študija je vključevala 100 otrok in mladostnikov z astmo v šestmesečnem obdobju leta 2015. V raziskavi so bili uporabljeni: standardiziran vprašalnik o kakovosti življenja otrok z astmo (PAQLQ(S)) za oceno kakovosti življenja in vprašalnika za oceno krmiljenja astme za dve starostni skupini: test za kontrolo astme za mladostnike (ACT) in test za kontrolo astme pri otrocih (C-ACT).Rezultati: Vključenih je bilo 62 fantov in 38 deklic, starih od 7 do 17 let, katerih povprečna starost je bila 11,2 (s = 2,7) leta. Skupni rezultati v oceni PAQLQ(S) so se gibali med 3,30 in 7,00 s povprečno vrednostjo 5,95. Ugotovitve kažejo, da je večina otrok z astmo umestila svojo splošno PAQLQ(S) proti pozitivnemu koncu lestvice. Otroci so poročali o večji oslabelosti na področju »Čustva« (x = 5,84) kot na področjih »Dejavnosti« in »Simptomi«. Odstotek mladostnikov, ki spadajo v kategorijo slabega nadzora (12,5 %), je bil znatno nižji kot v skupini otrok (25,0 %). V obeh skupinah otrok je bila lestvica »Simptomi« v največji povezavi s stopnjo nadzora astme (r = 0,915, p < 0,01).Diskusija in zaključek: V raziskavi so otroci in mladostniki z astmo pokazali splošno dobro kakovost življenja. Nadzor simptomov astme pri otrocih in mladostnikih je pozitivno vplival na njihovo kakovost življenja.

In a randomized, double-blind, Phase III study, we compared pasireotide long-acting release (pasireotide LAR) with octreotide long-acting repeatable (octreotide LAR) in managing carcinoid symptoms refractory to first-generation somatostatin analogues. Adults with carcinoid tumors of the digestive tract were randomly assigned (1:1) to receive pasireotide LAR (60 mg) or octreotide LAR (40 mg) every 28 days. Primary outcome was symptom control based on frequency of bowel movements and flushing episodes. Objective tumor response was a secondary outcome. Progression-free survival (PFS) was calculated in a post hoc analysis. Adverse events were recorded. At the time of a planned interim analysis, the data monitoring committee recommended halting the study because of a low predictive probability of showing superiority of pasireotide over octreotide for symptom control (n=43 pasireotide LAR, 20.9%; n=45 octreotide LAR, 26.7%; odds ratio, 0.73; 95% confidence interval [CI], 0.27-1.97; P=0.53). Tumor control rate at month 6 was 62.7% with pasireotide and 46.2% with octreotide (odds ratio, 1.96; 95% CI, 0.89-4.32; P=0.09). Median (95% CI) PFS was 11.8 months (11.0 - not reached) with pasireotide versus 6.8 months (5.6 - not reached) with octreotide (hazard ratio, 0.46; 95% CI, 0.20-0.98; P=0.045). The most frequent drug-related adverse events (pasireotide vs octreotide) included hyperglycemia (28.3% vs 5.3%), fatigue (11.3% vs 3.5%), and nausea (9.4% vs 0%). We conclude that, among patients with carcinoid symptoms refractory to available somatostatin analogues, similar proportions of patients receiving pasireotide LAR or octreotide LAR achieved symptom control at month 6. Pasireotide LAR showed a trend toward higher tumor control rate at month 6, although it was statistically not significant, and was associated with a longer PFS than octreotide LAR.

In a randomized, double-blind, Phase III study, we compared pasireotide long-acting release (pasireotide LAR) with octreotide long-acting repeatable (octreotide LAR) in managing carcinoid symptoms refractory to first-generation somatostatin analogues. Adults with carcinoid tumors of the digestive tract were randomly assigned (1:1) to receive pasireotide LAR (60 mg) or octreotide LAR (40 mg) every 28 days. Primary outcome was symptom control based on frequency of bowel movements and flushing episodes. Objective tumor response was a secondary outcome. Progression-free survival (PFS) was calculated in a post hoc analysis. Adverse events were recorded. At the time of a planned interim analysis, the data monitoring committee recommended halting the study because of a low predictive probability of showing superiority of pasireotide over octreotide for symptom control (n=43 pasireotide LAR, 20.9%; n=45 octreotide LAR, 26.7%; odds ratio, 0.73; 95% confidence interval [CI], 0.27-1.97; P=0.53). Tumor control rate at month 6 was 62.7% with pasireotide and 46.2% with octreotide (odds ratio, 1.96; 95% CI, 0.89-4.32; P=0.09). Median (95% CI) PFS was 11.8 months (11.0 - not reached) with pasireotide versus 6.8 months (5.6 - not reached) with octreotide (hazard ratio, 0.46; 95% CI, 0.20-0.98; P=0.045). The most frequent drug-related adverse events (pasireotide vs octreotide) included hyperglycemia (28.3% vs 5.3%), fatigue (11.3% vs 3.5%), and nausea (9.4% vs 0%). We conclude that, among patients with carcinoid symptoms refractory to available somatostatin analogues, similar proportions of patients receiving pasireotide LAR or octreotide LAR achieved symptom control at month 6. Pasireotide LAR showed a trend toward higher tumor control rate at month 6, although it was statistically not significant, and was associated with a longer PFS than octreotide LAR.

In a randomized, double-blind, Phase III study, we compared pasireotide long-acting release (pasireotide LAR) with octreotide long-acting repeatable (octreotide LAR) in managing carcinoid symptoms refractory to first-generation somatostatin analogues. Adults with carcinoid tumors of the digestive tract were randomly assigned (1:1) to receive pasireotide LAR (60 mg) or octreotide LAR (40 mg) every 28 days. Primary outcome was symptom control based on frequency of bowel movements and flushing episodes. Objective tumor response was a secondary outcome. Progression-free survival (PFS) was calculated in a post hoc analysis. Adverse events were recorded. At the time of a planned interim analysis, the data monitoring committee recommended halting the study because of a low predictive probability of showing superiority of pasireotide over octreotide for symptom control (n=43 pasireotide LAR, 20.9%; n=45 octreotide LAR, 26.7%; odds ratio, 0.73; 95% confidence interval [CI], 0.27-1.97; P=0.53). Tumor control rate at month 6 was 62.7% with pasireotide and 46.2% with octreotide (odds ratio, 1.96; 95% CI, 0.89-4.32; P=0.09). Median (95% CI) PFS was 11.8 months (11.0 - not reached) with pasireotide versus 6.8 months (5.6 - not reached) with octreotide (hazard ratio, 0.46; 95% CI, 0.20-0.98; P=0.045). The most frequent drug-related adverse events (pasireotide vs octreotide) included hyperglycemia (28.3% vs 5.3%), fatigue (11.3% vs 3.5%), and nausea (9.4% vs 0%). We conclude that, among patients with carcinoid symptoms refractory to available somatostatin analogues, similar proportions of patients receiving pasireotide LAR or octreotide LAR achieved symptom control at month 6. Pasireotide LAR showed a trend toward higher tumor control rate at month 6, although it was statistically not significant, and was associated with a longer PFS than octreotide LAR.

In a randomized, double-blind, Phase III study, we compared pasireotide long-acting release (pasireotide LAR) with octreotide long-acting repeatable (octreotide LAR) in managing carcinoid symptoms refractory to first-generation somatostatin analogues. Adults with carcinoid tumors of the digestive tract were randomly assigned (1:1) to receive pasireotide LAR (60 mg) or octreotide LAR (40 mg) every 28 days. Primary outcome was symptom control based on frequency of bowel movements and flushing episodes. Objective tumor response was a secondary outcome. Progression-free survival (PFS) was calculated in a post hoc analysis. Adverse events were recorded. At the time of a planned interim analysis, the data monitoring committee recommended halting the study because of a low predictive probability of showing superiority of pasireotide over octreotide for symptom control (n=43 pasireotide LAR, 20.9%; n=45 octreotide LAR, 26.7%; odds ratio, 0.73; 95% confidence interval [CI], 0.27-1.97; P=0.53). Tumor control rate at month 6 was 62.7% with pasireotide and 46.2% with octreotide (odds ratio, 1.96; 95% CI, 0.89-4.32; P=0.09). Median (95% CI) PFS was 11.8 months (11.0 - not reached) with pasireotide versus 6.8 months (5.6 - not reached) with octreotide (hazard ratio, 0.46; 95% CI, 0.20-0.98; P=0.045). The most frequent drug-related adverse events (pasireotide vs octreotide) included hyperglycemia (28.3% vs 5.3%), fatigue (11.3% vs 3.5%), and nausea (9.4% vs 0%). We conclude that, among patients with carcinoid symptoms refractory to available somatostatin analogues, similar proportions of patients receiving pasireotide LAR or octreotide LAR achieved symptom control at month 6. Pasireotide LAR showed a trend toward higher tumor control rate at month 6, although it was statistically not significant, and was associated with a longer PFS than octreotide LAR.

PURPOSE Every health care sector including hospice/palliative care needs to systematically improve services using patient-defined outcomes. Data from the national Australian Palliative Care Outcomes Collaboration aims to define whether hospice/palliative care patients' outcomes and the consistency of these outcomes have improved in the last 3 years. METHODS Data were analysed by clinical phase (stable, unstable, deteriorating, terminal). Patient-level data included the Symptom Assessment Scale and the Palliative Care Problem Severity Score. Nationally collected point-of-care data were anchored for the period July-December 2008 and subsequently compared to this baseline in six 6-month reporting cycles for all services that submitted data in every time period (n = 30) using individual longitudinal multi-level random coefficient models. RESULTS Data were analysed for 19,747 patients (46 % female; 85 % cancer; 27,928 episodes of care; 65,463 phases). There were significant improvements across all domains (symptom control, family care, psychological and spiritual care) except pain. Simultaneously, the interquartile ranges decreased, jointly indicating that better and more consistent patient outcomes were being achieved. CONCLUSION These are the first national hospice/palliative care symptom control performance data to demonstrate improvements in clinical outcomes at a service level as a result of routine data collection and systematic feedback.

In a randomized, double-blind, Phase III study, we compared pasireotide long-acting release (pasireotide LAR) with octreotide long-acting repeatable (octreotide LAR) in managing carcinoid symptoms refractory to first-generation somatostatin analogues. Adults with carcinoid tumors of the digestive tract were randomly assigned (1:1) to receive pasireotide LAR (60 mg) or octreotide LAR (40 mg) every 28 days. Primary outcome was symptom control based on frequency of bowel movements and flushing episodes. Objective tumor response was a secondary outcome. Progression-free survival (PFS) was calculated in a post hoc analysis. Adverse events were recorded. At the time of a planned interim analysis, the data monitoring committee recommended halting the study because of a low predictive probability of showing superiority of pasireotide over octreotide for symptom control (n=43 pasireotide LAR, 20.9%; n=45 octreotide LAR, 26.7%; odds ratio, 0.73; 95% confidence interval [CI], 0.27-1.97; P=0.53). Tumor control rate at month 6 was 62.7% with pasireotide and 46.2% with octreotide (odds ratio, 1.96; 95% CI, 0.89-4.32; P=0.09). Median (95% CI) PFS was 11.8 months (11.0 - not reached) with pasireotide versus 6.8 months (5.6 - not reached) with octreotide (hazard ratio, 0.46; 95% CI, 0.20-0.98; P=0.045). The most frequent drug-related adverse events (pasireotide vs octreotide) included hyperglycemia (28.3% vs 5.3%), fatigue (11.3% vs 3.5%), and nausea (9.4% vs 0%). We conclude that, among patients with carcinoid symptoms refractory to available somatostatin analogues, similar proportions of patients receiving pasireotide LAR or octreotide LAR achieved symptom control at month 6. Pasireotide LAR showed a trend toward higher tumor control rate at month 6, although it was statistically not significant, and was associated with a longer PFS than octreotide LAR.

In a randomized, double-blind, Phase III study, we compared pasireotide long-acting release (pasireotide LAR) with octreotide long-acting repeatable (octreotide LAR) in managing carcinoid symptoms refractory to first-generation somatostatin analogues. Adults with carcinoid tumors of the digestive tract were randomly assigned (1:1) to receive pasireotide LAR (60 mg) or octreotide LAR (40 mg) every 28 days. Primary outcome was symptom control based on frequency of bowel movements and flushing episodes. Objective tumor response was a secondary outcome. Progression-free survival (PFS) was calculated in a post hoc analysis. Adverse events were recorded. At the time of a planned interim analysis, the data monitoring committee recommended halting the study because of a low predictive probability of showing superiority of pasireotide over octreotide for symptom control (n=43 pasireotide LAR, 20.9%; n=45 octreotide LAR, 26.7%; odds ratio, 0.73; 95% confidence interval [CI], 0.27-1.97; P=0.53). Tumor control rate at month 6 was 62.7% with pasireotide and 46.2% with octreotide (odds ratio, 1.96; 95% CI, 0.89-4.32; P=0.09). Median (95% CI) PFS was 11.8 months (11.0 - not reached) with pasireotide versus 6.8 months (5.6 - not reached) with octreotide (hazard ratio, 0.46; 95% CI, 0.20-0.98; P=0.045). The most frequent drug-related adverse events (pasireotide vs octreotide) included hyperglycemia (28.3% vs 5.3%), fatigue (11.3% vs 3.5%), and nausea (9.4% vs 0%). We conclude that, among patients with carcinoid symptoms refractory to available somatostatin analogues, similar proportions of patients receiving pasireotide LAR or octreotide LAR achieved symptom control at month 6. Pasireotide LAR showed a trend toward higher tumor control rate at month 6, although it was statistically not significant, and was associated with a longer PFS than octreotide LAR.

Fatigue is experienced by cancer patients in all stages of the disease trajectory: from before diagnosis to years after completing treatment and also in advanced cancer. Fatigue has a greater negative influence on quality of life and daily activities than any other cancer-related symptom. Although both national and international guidelines have been developed to enhance the management of cancer-related fatigue, cancer-related fatigue is still poorly understood. This thesis describes research that has been performed in order to clarify some aspects of the multidimensional nature, pathogenesis, assessment and treatment of cancer-related fatigue. Concerning the multidimensional nature of fatigue, we investigated in a systematic review whether the physical and mental senses of fatigue are expressions of one symptom (multidimensional concept) or expressions of several phenomena which are all called fatigue but actually are separate symptoms (multiple symptom concept). We found some circumstantial evidence supporting the multiple symptom concept, for example a different trajectory during anti-tumor therapy. We also investigated in a cross-sectional study whether cancer patients in various stages of the disease trajectory have different fatigue experiences. We found that fatigue is more intense and that especially physical fatigue is more prominent in advanced cancer patients than in cancer survivors. With respect to the pathogenesis of fatigue, we found that several inflammatory markers were correlated to physical fatigue, but not to mental fatigue in advanced cancer patients, whereas no consistent association could be found between inflammation and fatigue in cancer survivors. On the assessment of fatigue, we investigated in a systematic review which the optimal cut points are on 0 to 10 Numeric Rating Scales for fatigue and other symptoms. Overall, using a score ≥4 for all symptoms as a trigger for a more comprehensive assessment seems to be justified in daily clinical

Palliative care for patients with advanced and progressive diseases has recently become an integrated and compulsory part of undergraduate training in Germany. Up until now, undergraduate teaching in this cross-disciplinary medical field varied and therefore problems during the implementation process with regard to formal aspects and teaching content are to be expected. This contribution summarizes the new legislative framework for palliative care as an independent specialty in undergraduate medical training and describes format, content and problems of the current implementation process at the University Medical School Göttingen, in order to provide advice and support for other faculties., Die palliativmedizinische Versorgung schwerst- und sterbenskranker Patienten wurde mit letzter Novellierung der Ärztlichen Approbationsordnung (07/2009) als Querschnittsfach 13 in das studentische Curriculum aufgenommen. Die formale Implementierung als Pflichtlehr- und Prüfungsfach innerhalb der vorgeschriebenen Umsetzungsfrist dürfte eingedenk der Heterogenität bisheriger palliativmedizinischer Ausbildung an den einzelnen Fakultäten Herausforderungen in Hinblick auf strukturelle und insbesondere inhaltliche Fragen mit sich bringen. Dieser Beitrag skizziert die neuen rechtlichen Rahmenbedingungen für das Querschnittsfach 13 und den bisherigen Stand der Lehre im Fachbereich Palliativmedizin in Deutschland. Der Beitrag möchte anhand des bisherigen, noch nicht abgeschlossenen Implementierungsprozesses an der Universitätsmedizin Göttingen die damit verbundenen Probleme aufzeigen sowie konzeptuelle und curriculare Anregungen und Hilfestellungen für die Umsetzung an anderen Fakultäten geben.

Les récentes contributions théoriques et cliniques sur le couple âgé dont l’un des membres est dépendant de l’alcool soulignent l’importance d’une approche à la fois pragmatique-interactive et sémantique-symbolique de la situation. En particulier, la dépendance à l’alcool doit être comprise à la lumière des tâches développementales spécifiques, des ressources et des contraintes qui correspondent au cycle de vie du couple âgé. Le présent article propose à titre illustratif le parcours psychothérapeutique d’un couple dont l’un des membres est alcoolique, qui s’est déroulé selon les phases suivantes :contrôle du symptôme alcoolique, récit de l’histoire individuelle et familiale et renégociation/reformulation des espaces/temps du couple. La dissolution progressive du symptôme a permis de relancer le projet individuel, de couple et familial :une dimension essentielle pour améliorer la qualité de la vie du couple âgé., Recent theoretical and clinical contributions on old age couples with one alcohol-dependent member underline the need for a pragmatic-interactive and semantic-symbolic approach of the issue. In particular, alcohol dependence should be read in the light of specific developmental tasks, resources and constraints corresponding to old age couples’ lifecycle. This paper proposes the example of a psychotherapeutic work of a couple with one alcohol-dependent member, through the following stages :control of the alcoholic symptom, account of personal and family history, renegotiation/reformulation of the couple’s spaces/times. Thanks to the progressive dissolution of the symptom, the individual, couple and family’s project has been re-launched :an essential point to better the old-aged couple’s quality of life., info:eu-repo/semantics/published

Most terminally-ill patients pass through a phase of deterioration that precedes, by a few days, their death. Making the diagnosis of dying phase is key to ensuring that the patient and his or her family receives the best possible care and eventually experiences a good death. Care of the families should be a central activity of health teams in this phase. We should inform clearly of the situation, trying to anticipate symptoms and time, as well as circumstances, to death. We should encourage an active attitude of the family and adequate emotional support. Care plan should include non-pharmacological and pharmacological approach to achieve symptom control. Usually subcutaneous route is the best route to administrate drugs in this phase. Nutrition and fluids should not be offered to imminently dying patients unless it is considered likely that the benefit will outweigh the harm. Sometimes, when is no possible to relieve symptoms in the last days of life with available drugs, we can use palliative sedation therapy. Palliative sedation is defined as the use of specific sedative medications to relieve intolerable suffering from refractory symptoms by a reduction in patient consciousness. The indication of palliative sedation should follow systematic and inclusive processes that include ethical considerations, drug selection and monitoring of patients., La mayoría de los pacientes en situación terminal pasan por una fase de deterioro que precede en unos días a su fallecimiento y se denomina agonía. El reconocimiento de que una persona está entrando en esta fase es fundamental para adecuar el plan de cuidados del enfermo y su familia, enfatizando en el confort y los cuidados esenciales. La atención a los familiares debe ser una actividad central de la asistencia en esta fase de la enfermedad. Debemos informar claramente de la situación, tratando de anticipar la probable sintomatología que puede tener el paciente, y como y cuando se va a producir la muerte. Se debe fomentar una actitud activa de los familiares y facilitar apoyo emocional. El plan de cuidados en esta fase debe incluir las medidas ambientales y físicas y el tratamiento farmacológico necesario para controlar adecuadamente la sintomatología. El resto de los tratamientos farmacológicos deben ser retirados. Generalmente la vía de elección en la administración de fármacos es la subcutánea. La nutrición e hidratación no están generalmente indicadas en esta fase salvo consideraciones especiales. En algunas ocasiones la sintomatología del paciente en la fase agónica no puede controlarse con los tratamientos habituales y debemos recurrir a la sedación. La sedación paliativa se define como “el uso de fármacos específicamente sedantes para reducir un sufrimiento intolerable, derivado de síntomas refractarios, mediante la disminución del nivel de consciencia del paciente”. La indicación de sedación paliativa debe cumplir una serie de garantías éticas y una adecuada realización y monitorización del tratamiento.

Describes the case of a patient diagnosed with squamous cell carcinoma of the head neck, which joins the palliative care unit of the Hospital Virgen de la Poveda for symptomatic control and family to care claudication. The patient presented at admission an acute confusional syndrome, which runs with ideas and attempts to escape, in addition to other symptoms changing. In the primary caregiver there is a grieving process advance “maladjusted” and multiple cognitive biases and misconceptions about the process of the disease. The objectives of the interdisciplinary team went to symptomatic control, improved communication, maladjusted early resolution of mourning and farewell. The patient remained joined thirty-two days at our center; this time aimed at symptomatic control was achieved in full, until death. The primary caregiver was emotionally tied to her husband. They were able to say goodbye., Se expone el caso de un enfermo diagnosticado de cáncer epidermoide de cabeza cuello, que ingresa en la unidad de cuidados paliativos del Hospital Virgen de la Poveda para control sintomático y por claudicación familiar ante los cuidados. El enfermo presenta al ingreso un síndrome confusional agudo (SCA), que cursa con ideas e intentos de fuga; además de otros síntomas cambiantes. En la cuidadora principal se aprecia un proceso de duelo anticipado “desadaptativo”, y múltiples sesgos cognitivos y concepciones erróneas sobre el proceso de la enfermedad. Los objetivos del equipo interdisciplinar se dirigieron al control sintomático, mejora de la comunicación, resolución de duelo anticipado desadaptativo y despedida. El paciente permaneció ingresado treinta y dos días en nuestro centro, en este tiempo el objetivo de control sintomático se alcanzó en su totalidad, hasta el éxitus. La cuidadora principal consiguió vincularse afectivamente con su esposo. Pudieron despedirse.

Most terminally-ill patients pass through a phase of deterioration that precedes, by a few days, their death. Making the diagnosis of dying phase is key to ensuring that the patient and his or her family receives the best possible care and eventually experiences a good death. Care of the families should be a central activity of health teams in this phase. We should inform clearly of the situation, trying to anticipate symptoms and time, as well as circumstances, to death. We should encourage an active attitude of the family and adequate emotional support. Care plan should include non-pharmacological and pharmacological approach to achieve symptom control. Usually subcutaneous route is the best route to administrate drugs in this phase. Nutrition and fluids should not be offered to imminently dying patients unless it is considered likely that the benefit will outweigh the harm. Sometimes, when is no possible to relieve symptoms in the last days of life with available drugs, we can use palliative sedation therapy. Palliative sedation is defined as the use of specific sedative medications to relieve intolerable suffering from refractory symptoms by a reduction in patient consciousness. The indication of palliative sedation should follow systematic and inclusive processes that include ethical considerations, drug selection and monitoring of patients., La mayoría de los pacientes en situación terminal pasan por una fase de deterioro que precede en unos días a su fallecimiento y se denomina agonía. El reconocimiento de que una persona está entrando en esta fase es fundamental para adecuar el plan de cuidados del enfermo y su familia, enfatizando en el confort y los cuidados esenciales. La atención a los familiares debe ser una actividad central de la asistencia en esta fase de la enfermedad. Debemos informar claramente de la situación, tratando de anticipar la probable sintomatología que puede tener el paciente, y como y cuando se va a producir la muerte. Se debe fomentar una actitud activa de los familiares y facilitar apoyo emocional. El plan de cuidados en esta fase debe incluir las medidas ambientales y físicas y el tratamiento farmacológico necesario para controlar adecuadamente la sintomatología. El resto de los tratamientos farmacológicos deben ser retirados. Generalmente la vía de elección en la administración de fármacos es la subcutánea. La nutrición e hidratación no están generalmente indicadas en esta fase salvo consideraciones especiales. En algunas ocasiones la sintomatología del paciente en la fase agónica no puede controlarse con los tratamientos habituales y debemos recurrir a la sedación. La sedación paliativa se define como “el uso de fármacos específicamente sedantes para reducir un sufrimiento intolerable, derivado de síntomas refractarios, mediante la disminución del nivel de consciencia del paciente”. La indicación de sedación paliativa debe cumplir una serie de garantías éticas y una adecuada realización y monitorización del tratamiento.

Describes the case of a patient diagnosed with squamous cell carcinoma of the head neck, which joins the palliative care unit of the Hospital Virgen de la Poveda for symptomatic control and family to care claudication. The patient presented at admission an acute confusional syndrome, which runs with ideas and attempts to escape, in addition to other symptoms changing. In the primary caregiver there is a grieving process advance “maladjusted” and multiple cognitive biases and misconceptions about the process of the disease. The objectives of the interdisciplinary team went to symptomatic control, improved communication, maladjusted early resolution of mourning and farewell. The patient remained joined thirty-two days at our center; this time aimed at symptomatic control was achieved in full, until death. The primary caregiver was emotionally tied to her husband. They were able to say goodbye., Se expone el caso de un enfermo diagnosticado de cáncer epidermoide de cabeza cuello, que ingresa en la unidad de cuidados paliativos del Hospital Virgen de la Poveda para control sintomático y por claudicación familiar ante los cuidados. El enfermo presenta al ingreso un síndrome confusional agudo (SCA), que cursa con ideas e intentos de fuga; además de otros síntomas cambiantes. En la cuidadora principal se aprecia un proceso de duelo anticipado “desadaptativo”, y múltiples sesgos cognitivos y concepciones erróneas sobre el proceso de la enfermedad. Los objetivos del equipo interdisciplinar se dirigieron al control sintomático, mejora de la comunicación, resolución de duelo anticipado desadaptativo y despedida. El paciente permaneció ingresado treinta y dos días en nuestro centro, en este tiempo el objetivo de control sintomático se alcanzó en su totalidad, hasta el éxitus. La cuidadora principal consiguió vincularse afectivamente con su esposo. Pudieron despedirse.

Palliative care seeks to enhance quality of life in the face of death by addressing the physical, psychological, social, and spiritual needs of patients with advanced disease. The purpose of this paper is to explore whether palliative patients needs, nursing actions, and evaluation can be identified in the nursing documentation. Data consisted of reviews of patients' case records in a palliative care unit. Data were analyzed using content analysis and counting frequency of keywords used from the Well-being Integrity Prevention and Safety (VIPS) model, followed by an inductive analysis of the case record documentation aiming to identify palliative care components. The result shows that the documentation revealed physical care, especially pain, more frequently than other needs. Nursing documentation focuses on identification more than on nursing actions and evaluation.

Background: The modest improvement in median survival of advanced non-small-cell lung cancer (NSCLC) by cisplatin-based chemotherapy has led to the current opinion that clinical benefit for the patient is at least as important an end-point as objective response rate (ORR) or survival. Clinical benefit response was the primary end-point of this prospective randomised trial in symptomatic, advanced stage IIIB/IV NSCLC, comparing single agent gemcitabine (GEM) to cisplatin-based chemotherapy. Patients and methods: Patients received either GEM (1000 mg/m(2), days 1, 8 and 15) or cisplatin (100 mg/m(2), day 1) plus Vindesine (3 mg/m(2), days 1 and 15) (PV), both every four weeks. Clinical benefit was measured by a simple metric based on changes in a visual analogue symptom score list, the Karnofsky performance status and the weight. Results: One hundred sixty-nine patients were randomised (84 GEM, 85 PV). Prognostic factors and baseline symptoms were well balanced between the two arms. Most of the the objective responders and about half of the patients with disease stabilisation experienced clinical benefit. Compared to PV, a significantly larger number of GEM-treated patients experienced a clinical benefit (48.1 vs. 28.9%, P = 0.03) that lasted significantly longer (median duration 16 vs. 10 weeks, P = 0.01). No important differences in ORR, time-to-progression or median survival were observed. Grade 3 + 4 toxicity was significantly higher in the PV-group for leukopenia (P = 0.0003), neutropenia (P < 0.0001), nausea/vomiting (P = 0.0006), alopecia (P < 0.0001), and neurotoxicity (P = 0.04). Some severe pulmonary toxicity to GEM was noted. Conclusion: Comparison of GEM with cisplatin-based therapy in symptomatic, advanced NSCLC demonstrates that GEM produces significantly a stronger and longer-lasting clinical benefit, probably due to its equal effectiveness in terms of ORR, time-to-progression or survival, combined with significantly less severe therapy-related toxicity

RésuméLes récentes contributions théoriques et cliniques sur le couple âgé dont l’un des membres est dépendant de l’alcool soulignent l’importance d’une approche à la fois pragmatique-interactive et sémantique-symbolique de la situation. En particulier, la dépendance à l’alcool doit être comprise à la lumière des tâches développementales spécifiques, des ressources et des contraintes qui correspondent au cycle de vie du couple âgé. Le présent article propose à titre illustratif le parcours psychothérapeutique d’un couple dont l’un des membres est alcoolique, qui s’est déroulé selon les phases suivantes : contrôle du symptôme alcoolique, récit de l’histoire individuelle et familiale et renégociation/reformulation des espaces/temps du couple. La dissolution progressive du symptôme a permis de relancer le projet individuel, de couple et familial : une dimension essentielle pour améliorer la qualité de la vie du couple âgé., Alcohol and empty nestRecent theoretical and clinical contributions on old age couples with one alcohol-dependent member underline the need for a pragmatic-interactive and semantic-symbolic approach of the issue. In particular, alcohol dependence should be read in the light of specific developmental tasks, resources and constraints corresponding to old age couples’ lifecycle. This paper proposes the example of a psychotherapeutic work of a couple with one alcohol-dependent member, through the following stages : control of the alcoholic symptom, account of personal and family history, renegotiation/reformulation of the couple’s spaces/times. Thanks to the progressive dissolution of the symptom, the individual, couple and family’s project has been re-launched : an essential point to better the old-aged couple’s quality of life.