Search

Allergic reactions may result in central symptoms of dizziness, including nonspecific chronic imbalance, Meniere's disease, and autoimmune inner ear disease. Excepting first-generation antihistamines, and short-term use of steroids, most pharmacotherapies used to treat allergic rhinitis have limited benefit in treating allergically induced or related dizziness. Allergy immunotherapy and/or an elimination diet for diagnosed food allergies have been found to be effective treatments. Individuals diagnosed with autoimmune inner ear disease remain challenging to treat and may require high-dose, long-term steroid treatment, biologics, or immunomodulators for symptom control.

Musculoskeletal diseases are a group of clinical conditions affecting the body's movement and remain a common source of pain affecting the quality of life. The aetio-pathological reasons for pain associated with musculoskeletal diseases can be varied and complex. Conventional medicine can treat or modify pain due to musculoskeletal diseases; however, these may be associated with some side effects and at times may not be able to relieve pain completely. These treatment modalities also have ceiling effects like doses of analgesics, the number of nerve blocks, etc. Complementary and Alternative Medicine (CAM) provides a supplementary, unconventional modality to alleviate discomfort and disability associated with these mostly chronic conditions to manage activities of daily living. These modalities have been variedly combined with conventional management for symptom control and thus improve day-to-day activities. We assess the role of commonly used CAM modalities in the management of pain arising from Musculoskeletal diseases.

Background In order to better characterize outcomes of palliative surgery (PS), we evaluated patients that experienced top quartile survival to elucidate predictors of high impact PS. Methods All PS performed on advanced cancer patients from 2003 to 2017 were identified from a PS database. Results 167 patients were identified. Multivariate analysis demonstrated the ability to rise from a chair was independently associated with top quartile survival (HR 7.61, 95% CI 2.12–48.82, p=0.008) as was the need for re-operation (HR 2.81, 95% CI 1.26–6.30, p=0.0012). Patients who were able to rise from a chair had significantly prolonged overall survival (320 vs 87 days, p Conclusions Although not the primary goal, long-term survival can be achieved following PS and is associated with re-operation and the ability to rise from a chair. These patients experience the benefits of PS for a longer period of time, which in turn maximizes value and positive impact. Summary Long-term survival and symptom control can be achieved in highly selected advanced cancer patients following palliative surgery. The ability of the patient to independently rise from a chair and the provider to offer a re-operation when indicated are associated with long-term survival following a palliative operation.

With the advent of biologic and small molecule therapies, there has been a substantial change in the treatment of inflammatory bowel disease. These advances have had a great impact in preventing disease progression, intestinal damage and, therefore, have contributed to a better quality of life. Discordance between symptom control and mucosal healing has been demonstrated. This has led to the search for new disease control targets. The treat to target strategy, based on expert recommendations and now a randomized controlled trial, has determined that clinical and endoscopic remission should be the goal of therapy. Biomarkers (fecal calprotectin) can be a surrogate target. Although histological healing has shown benefits, there is inadequate evidence and inadequate therapy for that to be a fixed goal at this time. This review will focus on therapeutic goals, according to the evidence currently available, and evaluate strategies to achieve them.

I am a radiation oncologist with a busy clinical practice in Pennsylvania. I am credentialed to certify patients for medical marijuana and recommend that my patients try medical marijuana when symptom control with other options is suboptimal. This invited contribution is a brief summary of information that may help radiation oncologists understand their potential role in getting patients access to medical marijuana and my perspective on its potential value in the care of our patients.

Radiotherapy (RT) can be used to palliate cancer-related symptoms and improve quality of life (QoL). Patient Reported Outcome Measures (PROMs) could be a reliable, minimally invasive method to monitor patients after palliative radiotherapy. This review was performed to provide an overview of the way PROMs are currently used in follow-up after palliative RT, regarding the goal of the PROM, the type of PROMs, PROM selection, PROM completion as well as the follow-up schemes and patient adherence and attrition. Pubmed, EMBASE and the Cochrane Library were systematically searched for articles published between 2008 and 2020. Titles and abstracts were reviewed to find relevant studies, which were advanced to full-text review. The reference lists of review articles were screened for correctness of the search and additional studies. No meta-analysis was performed. This search strategy identified 5733 studies, with 94 ultimately selected for inclusion in this topical review. We discovered a great variety of studies that used PROMs after palliative RT. We found no articles describing PROMs in routine clinical care. PROMs were exclusively used as a benchmarking tool and never to improve symptom control or QoL for individual patients. The selection process for the questionnaires, completion method and/or follow-up scheme was seldom described. We did not find any studies referencing patients' experience on PROMs. Although clear guidelines on the use of PROMs in palliative RT may be difficult to establish, more attention should be paid to the PROM aspect when writing study protocols. Furthermore, efforts should be made to introduce PROMs in routine clinical care in the context of palliative RT. ispartof: RADIOTHERAPY AND ONCOLOGY vol:149 pages:94-103 ispartof: location:Ireland status: published

BACKGROUND: Many depressed patients are not able to achieve or sustain symptom remission despite serial treatment trials - often termed "treatment resistant depression". A broader, perhaps more empathic concept of "difficult-to-treat depression" (DTD) was considered. METHODS: A consensus group discussed the definition, clinical recognition, assessment and management implications of the DTD heuristic. RESULTS: The group proposed that DTD be defined as "depression that continues to cause significant burden despite usual treatment efforts". All depression management should include a thorough initial assessment. When DTD is recognized, a regular reassessment that employs a multi-dimensional framework to identify addressable barriers to successful treatment (including patient-, illness- and treatment-related factors) is advised, along with specific recommendations for addressing these factors. The emphasis of treatment, in the first instance, shifts from a goal of remission to optimal symptom control, daily psychosocial functional and quality of life, based on a patient-centred approach with shared decision-making to enhance the timely consideration of all treatment options (including pharmacotherapy, psychotherapy, neurostimulation, etc.) to optimize outcomes when sustained remission is elusive. LIMITATIONS: The recommended definition and management of DTD is based largely on expert consensus. While DTD would seem to have clinical utility, its specificity and objectivity may be insufficient to define clinical populations for regulatory trial purposes, though DTD could define populations for service provision or phase 4 trials. CONCLUSIONS: DTD provides a clinically useful conceptualization that implies a search for and remediation of specific patient-, illness- and treatment obstacles to optimizing outcomes of relevance to patients. ispartof: Journal of Affective Disorders vol:267 pages:264-282 ispartof: location:Netherlands status: published

Pain management in acute orthopedic injury needs to be tailored to the presentation and patient. Subjective and objective assessment, in conjunction with pathophysiology, should be used to provide symptom control. Ideally, treatment should be administered in an escalating fashion, attempting to manage pain with the lowest dose of the safest medication available. There are also adjunctive therapies, including those that are nonpharmacologic, that can provide additional relief.

The burden of nonpain symptoms such as anorexia, constipation, nausea, and vomiting contribute to patient suffering throughout the course of advanced illness. It is important to address symptom control throughout the disease trajectory, and especially at the end of life. Primary care clinicians must recognize these symptoms early, provide ongoing assessment, and keep abreast of evidence-based management strategies, including valid clinical protocols.

Background Objectives were to describe the proportion of bothersome symptoms self-reported using the Symptom Screening in Pediatrics Tool (SSPedi) documented in the medical records and associated with an intervention. Methods Eligible respondents were inpatients aged 8–18 years receiving cancer treatments and expected to be in hospital or clinic three days later. Children self-reported symptom bother using SSPedi. We evaluated symptom documentation and interventions in the medical records proximal to SSPedi administration. Results There were 168 children included. Symptoms rated as at least ‘a lot’ bother were documented in the medical record less than 60% of the time for 12 of 15 symptoms. Of these symptoms, the most infrequently documented symptoms were problems with thinking or remembering things (0%), changes in how your body or face look (4.8%), changes in taste (7.7%) and tingly or numb hands or feet (11.1%). Intervention provision for symptoms rated as ‘a lot’ bother occurred less than 60% of the time for 10 of 15 symptoms. Of these symptoms, the most infrequently treated were thinking or remembering things (0%), changes in how your body or face look (0%), tingly or numb hands or feet (0%), changes in taste (0%), diarrhoea (0%) and feeling tired (1.6%). Conclusions Documentation of symptoms and intervention provision were generally infrequent. Symptoms that were almost never documented or treated included problems with cognition, body image, taste changes and peripheral neuropathy. Future efforts should incorporate symptom screening into routine care and facilitate symptom management by improving access to evidence-based clinical practice guidelines.

1) Investigate incidence and predictors of readmissions after tonsillectomy with or without adenoidectomy (TA) in children. 2) Identify factors that may predict readmission.Nationwide cross-sectional survey of US hospital admissions.and Methods: The 2013 Nationwide Readmission Database (NRD) was used to examine all-cause readmissions within 30 days of TA in children (age18 years). Logistic regression was used to analyze the associations of demographics, diagnosis, insurance status, length of index stay, and median household income with readmission.9079 children undergoing TA resulted in 327 (3.6%) patients requiring readmission. The average age of children readmitted were 5.0 years and they were 51% female. The most common readmission diagnoses were dehydration (47%), hemorrhage (26%), and pain (16%). The average time to readmission was 7.3 days. The average times to readmission for hemorrhage, pain and dehydration were 6.3, 4.5 and 4.1 days, respectively. Children who needed respiratory intubation (OR = 4.0), had a medical or surgical complication (OR = 3.3), or prolonged hospital stay (OR = 1.03) during the index admission were more likely to be readmitted. Age, gender, payer and socioeconomic status and diagnosis of obstructive sleep apnea (OSA) did not increase the odds of readmission.Readmissions in children after TA were primarily due to dehydration, hemorrhage, and pain. Adequate symptom control in children has the greatest potential to reduce readmission rates following TA.

During the past 25 years, many developmental steps have occurred in Hungary in palliative care. Further education and service development is needed to provide a quality palliative care for all the Hungarian people. Hungary has a universal health care system with a developed infrastructure. The first Hungarian hospice team started in 1991. At that time, the concept of hospice care was unknown. Symptom control and psychosocial support for the dying patient was inadequate. The regulatory framework was based on the 1997 Health Care Act which was followed by significant palliative care legislation including documents on the legal requirements for palliative care (2004). National guidelines were developed in 2002. Home and inpatient hospice care are reimbursed by the National Insurance Fund. Patients and families pay nothing. The multidisciplinary team provides care for patients and families and hospice home care is widely available across the country. Inpatient units are still lacking in Hungary. Strong opioids are readily available in the country and can be prescribed for cancer and noncancer patients. Palliative care is taught in medical and nursing undergraduate and postgraduate education. From 2014, physicians in Hungary can take a one-year course to qualify for a license in palliative medicine.

Aims and objectives To understand the influence of family caregivers' perceptions about patients' dying and death quality on their grief intensity. Background Dying patients and their family caregivers face life-limiting illness together, and they work jointly to negotiate shared understandings and mutual adaptation to losses. Design Cross-sectional data were collected via an online survey. The manuscript followed the STROBE report guideline. Methods Family caregivers of patients who had died within 8–365 days prior were recruited. The Quality of Dying and Death Questionnaire (QDDQ) (translated into Mandarin) and the Chinese Grief Reaction Assessment Form (GRAF) were used to measure the two key variables. Multivariate linear regression was performed to explore the links between the two variables while controlling for potential confounders. Results Data were collected from 170 bereaved Chinese caregivers, and 150 cases were involved in the analysis. The four-factor structure of the QDDQ was appropriate for Chinese participants. After controlling whether end-of-life care was provided and families' satisfaction with physicians' and nurses' services, regressions revealed that more intense grief of the bereaved caregivers was associated with better symptom control for and worse transcendence of the deceased patient. Moreover, those who believed that the deceased had fulfilled his or her family duties before death experienced less intense grief, and the participant's relationship with the deceased also made a difference. Conclusion Two aspects of patients' dying and death quality perceived by family caregivers, namely symptom control and transcendence, have opposite influences on caregivers' grief intensity.

Management of agitated patients presents a challenge with regard to balancing appropriate diagnostic plans and treatment aimed at controlling symptoms with an interest in prioritizing patient and staff safety and preserving patient dignity. This article will discuss a tiered approach to caring for the agitated patient, including early recognition of escalating behavior, verbal de-escalation techniques, the use and choice of medication and route for symptom control, and concepts related to physical restraint, special populations, and bias.

Objective: Patients with breast cancer receiving chemotherapy experience many symptoms. This study set out to determine the effect of the mobile application-based symptom monitoring process on symptom control and quality of life in breast cancer patients. Data Sources: The research sample consisted of 57 patients who applied to an outpatient chemotherapy unit of a university hospital. The patients in the intervention group reported symptoms starting from the first day when they received chemotherapy with Msemptom and until the 15th day after chemotherapy. After evaluation of the daily symptom reports of the patients, the patients were instructed via text message to report symptoms as moderate, severe, or very severe symptoms. After the application, the median of the Memorial Symptom Assessment Scale (MSAS)-physical subscale score of the patients in the control group was found to be statistically significantly higher than in the intervention group (P = .028). It was also found that after application, the medians of the European Organization for Research and Treatment of Cancer-Quality of Life (EORTC-QLQC30), symptom scale and nausea-vomiting score (P = .012), QLQ-BR23 Module sexual function (P = .024), and sexual pleasure subscale score (P = .026) were statistically significantly higher than patients in the intervention group. Conclusion: The process of symptom monitoring with mobile applications is especially effective in controlling physical symptoms. Implications for Nursing Practice: It is recommended to expand mobile application-based symptom monitoring process in breast cancer patients and to support the patients in using this application-based process. (c) 2021 Elsevier Inc. All rights reserved.

BackgroundDisease-related symptoms impair the quality of life of patients with chronic lymphocytic leukaemia (CLL) who do not require systemic therapy. Available therapies are not specifically aimed at symptom control. Because stimulation of the B-cell receptor activates JAK2 in CLL cells and the JAK2 inhibitor ruxolitinib improves symptoms in patients with myelofibrosis, we postulated that ruxolitinib would improve disease-related symptoms in patients with CLL. We did a phase 2 trial of ruxolitinib to test this hypothesis.MethodsSymptomatic patients with CLL who did not require systemic therapy were enrolled at MD Anderson Cancer Center (Houston, TX, USA) between Sept 15, 2014, and Sept 20, 2015. Participants were given 10 mg ruxolitinib orally twice a day. Scores on the Brief Fatigue Inventory (BFI), CLL module of the MD Anderson Symptom Inventory (MDASI) and symptom-associated interference in daily activities, were assessed before treatment and after 3 months. This trial is ongoing and is registered at ClinicalTrials.gov (NCT02131584).Findings41 patients (25 previously untreated for CLL and 16 previously treated) were enrolled. At 3 months, the mean percentage change from baseline in BFI score was 44·3% (SD 35·0, p

Globally, the number of patients undergoing maintenance dialysis is increasing, yet throughout the world there is significant variability in the practice of initiating dialysis. Factors such as availability of resources, reasons for starting dialysis, timing of dialysis initiation, patient education and preparedness, dialysis modality and access, as well as varied "country-specific" factors significantly affect patient experiences and outcomes. As the burden of end-stage kidney disease (ESKD) has increased globally, there has also been a growing recognition of the importance of patient involvement in determining the goals of care and decisions regarding treatment. In January 2018, KDIGO (Kidney Disease: Improving Global Outcomes) convened a Controversies Conference focused on dialysis initiation, including modality choice, access, and prescription. Here we present a summary of the conference discussions, including identified knowledge gaps, areas of controversy, and priorities for research. A major novel theme represented during the conference was the need to move away from a "one-size-fits-all" approach to dialysis and provide more individualized care that incorporates patient goals and preferences while still maintaining best practices for quality and safety. Identifying and including patient-centered goals that can be validated as quality indicators in the context of diverse health care systems to achieve equity of outcomes will require alignment of goals and incentives between patients, providers, regulators, and payers that will vary across health care jurisdictions.

Summary Background Malignant pleural mesothelioma incidence continues to rise, with few available evidence-based therapeutic options. Results of previous non-randomised studies suggested that video-assisted thoracoscopic partial pleurectomy (VAT-PP) might improve symptom control and survival. We aimed to compare efficacy in terms of overall survival, and cost, of VAT-PP and talc pleurodesis in patients with malignant pleural mesothelioma. Methods We undertook an open-label, parallel-group, randomised, controlled trial in patients aged 18 years or older with any subtype of confirmed or suspected mesothelioma with pleural effusion, recruited from 12 hospitals in the UK. Eligible patients were randomly assigned (1:1) to either VAT-PP or talc pleurodesis by computer-generated random numbers, stratified by European Organisation for Research and Treatment of Cancer risk category (high vs low). The primary outcome was overall survival at 1 year, analysed by intention to treat (all patients randomly assigned to a treatment group with a final diagnosis of mesothelioma). This trial is registered with ClinicalTrials.gov, number NCT00821860. Findings Between Oct 24, 2003, and Jan 24, 2012, we randomly assigned 196 patients, of whom 175 (88 assigned to talc pleurodesis, 87 assigned to VAT-PP) had confirmed mesothelioma. Overall survival at 1 year was 52% (95% CI 41–62) in the VAT-PP group and 57% (46–66) in the talc pleurodesis group (hazard ratio 1·04 [95% CI 0·76–1·42]; p=0·81). Surgical complications were significantly more common after VAT-PP than after talc pleurodesis, occurring in 24 (31%) of 78 patients who completed VAT-PP versus ten (14%) of 73 patients who completed talc pleurodesis (p=0·019), as were respiratory complications (19 [24%] vs 11 [15%]; p=0·22) and air-leak beyond 10 days (five [6%] vs one [1%]; p=0·21), although not significantly so. Median hospital stay was longer at 7 days (IQR 5–11) in patients who received VAT-PP compared with 3 days (2–5) for those who received talc pleurodesis (p Interpretation VAT-PP is not recommended to improve overall survival in patients with pleural effusion due to malignant pleural mesothelioma, and talc pleurodesis might be preferable considering the fewer complications and shorter hospital stay associated with this treatment. Funding BUPA Foundation.

Arteriovenous malformations (AVMs) are vascular lesions that are thought to arise from congenital errors during development of vessels resulting in abnormal connections between arteries and veins. Though most AVMs develop in the brain or spinal cord, they can occur anywhere in the body. These extracranial or peripheral AVMs have a predilection for the head, neck, and limbs. Since these malformations infiltrate normal soft tissue, management requires selective treatment with preservation of normal surrounding architecture. Therefore, they are best addressed through a staged multimodal and multidisciplinary approach, using a combination of different laser, interstitial, intravascular and surgical techniques to specifically target anomalous vessels. The goal of treatment is overall disease improvement and symptom control with interventions that do not result in outcomes worse than the disease itself. Recently, the discovery of somatic and germline mutations in peripheral AVMs have contributed to a better understanding of the pathophysiology, resulting in promising new pharmacologic treatments. Recent evidence suggests that adjuvant medical therapy can enhance and sustain interventional and/or surgical outcomes. Herein we describe how a new understanding of the etiology and physiology of extracranial AVM provides guidance to current treatment approaches.

The prevalence of allergic rhinitis (AR) has been estimated at 10% to 40%, and its economic burden is substantial. AR patients develop specific immunoglobulin E (IgE) antibody responses to indoor and outdoor environmental allergens with exposure over time. These specific IgE antibodies bind to high-affinity IgE receptors on mast cells and basophils. Key outcome measures of therapeutic interventions include rhinitis symptom control, rescue medication requirements, and quality-of-life measures. A comprehensive multiple modality treatment plan customized to the individual patient can optimize outcomes.

Vomiting and abdominal pain are common in patients in the emergency department. This article focuses on small bowel obstruction (SBO), cyclic vomiting, and gastroparesis. Through early diagnosis and appropriate management, the morbidity and mortality associated with SBOs can be significantly reduced. Management of SBOs involves correction of physiologic and electrolyte disturbances, bowel rest and removing the source of the obstruction. Treatment of acute cyclic vomiting is primarily directed at symptom control, volume and electrolyte repletion, and appropriate specialist follow-up. The mainstay of therapy for gastroparesis is metoclopramide.

Purpose To describe educational features in palliative and end-of-life care (PEOLC) in pulmonary/critical care fellowships and identify the features associated with perceptions of trainee competence in PEOLC. Methods A survey of educational features in 102 training programs and the perceived skill and comfort level of trainees in 6 PEOLC domains: communication, symptom control, ethical/legal, community/institutional resources, specific syndromes, and ventilator withdrawal. We evaluated associations between perceived trainee competence/comfort in PEOLC and training program features, using regression analyses. Results Fifty-five percent of program directors (PDs) reported faculty with training in PEOLC; 30% had a written PEOLC curriculum. Neither feature was associated with trainee competence/comfort. Program directors and trainees rated bedside PEOLC teaching highly. Only 20% offered PEOLC rotations; most trainees judged these valuable. Most PDs and trainees reported that didactic teaching was insufficient in communication, although sufficient teaching of this was associated with perceived trainee competence in communication. Perceived trainee competence in managing institutional resources was rated poorly. Program directors reporting significant barriers to PEOLC education also judged trainees less competent in PEOLC. Time constraint was the greatest barrier. Conclusion This survey of PEOLC education in US pulmonary/critical care fellowships identified associations between certain program features and perceived trainee skill in PEOLC. These results generate hypotheses for further study.

This study was conducted to find out the effect of yoga applied to asthma patients on the patients' respiratory functions, symptom control and quality of life.The sample of the study consisted of a total of randomly chosen 112 asthma patients, 56 in the experimental group and 56 in the control group, who met the research criteria and who agreed to participate in the study. A total of 12 yoga sessions, 2 sessions a week for 6 weeks, was applied to the patients in the experimental group. The patients in the control group did not receive any intervention.In the intragroup comparison of average pre-test and post-test scores of respiratory function and Asthma Control Test (ACT) and Asthma Quality of Life Scale (AQLQ) total and sub-dimension scores of the patients in the experimental and control group, the difference was found to be statistically significant (p 0.05). In addition, post-test score averages were found to increase in the experimental group, while they were found to decrease in the control group.It was found that yoga influenced respiratory functions, symptom control and quality of life positively in asthma patients. The clinical trial registration number is NCT04107415/https://clinicaltrials.gov/ct2/show/NCT04107415.

ResumenLa calidad de vida constituye un concepto multidimensional y evaluar al paciente representa un reto debido a la necesidad de mostrar su carácter multifacético.Medir la calidad de vida con un solo instrumento refleja la calidad de vida global y esto se considera adecuado para pacientes en entornos paliativos debido a sus condiciones generales, además de que es sumamente útil para el seguimiento. Se recomienda la aplicación de instrumentos validados, sencillos y fáciles de interpretar por el paciente y por el propio equipo de profesionales sanitarios.Las evaluaciones individualizadas reflejan mejor los dominios relevantes de la calidad de vida de cada paciente y los cambios que puede experimentar en las enfermedades crónicas o potencialmente mortales. Esta es una experiencia individual y así se debe considerar.Cuando el paciente no pueda realizar la autoevaluación, se sugiere que el cuidador principal informe acerca de los síntomas, la función y el desempeño.AbstractQuality of life is a multidimensional concept, and assessing the patient represents a challenge due to the need to demonstrate its multi-faceted nature.Measuring quality of life with a single tool reflects quality of life at a global scale, and this is considered appropriate for patients in palliative settings, due to their general status, as well as being very useful for monitoring purposes. It is recommended to use validated tools that are simple and easy to interpret for the patient and the medical team.Individualised assessments reflect more adequately relevant quality of life domains of each patient and possible changes that may occur in chronic or potentially fatal diseases. This is an individual experience and must be regarded accordingly.When the patient is unable perform the self-assessment, it is suggested that the primary caregiver should provide information on the patient's symptoms, function and performance.

ResumenSe destaca el área de oportunidad en el cuidado paliativo del adulto en edad avanzada, planteando una gama de posibilidades para implementar los cuidados por situación vital con base en sus necesidades y teniendo como objetivo la conservación de la calidad de vida, la dignidad de la persona, su rehabilitación y la de su familia. Para esto, se debe considerar que el adulto en edad avanzada se enfrenta una declinación gradual y progresiva a medida que envejece y enferma, y que necesita este tipo de cuidados que prodiguen la atención en el control de síntomas físicos, psicológicos, sociales y espirituales, Asimismo, se deben enfrentar los retos para llevar a cabo este tipo de acciones en el domicilio con medidas de promoción, prevención y fomento. Es necesario asegurar que los adultos de edad avanzada y sus familiares reciban asesoría por el personal multidisciplinario de la salud para el cuidado en casa.AbstractAn important area for improvement in palliative care for the elderly is highlighted, with a range of possibilities proposed to implement care according to the patient's life situation. This is based on the patient's needs and aims to preserve the quality of life, dignity and rehabilitation of the patient, as well as to reduce the burden for the family. For this, consideration should be given to the fact that the elderly are faced with a gradual and progressive decline as they get older and sicker, and that they need this type of care to provide control of the physical, psychological, social and spiritual symptoms. Furthermore, challenges must be met to develop these actions with promotion, prevention and encouragement. It is necessary to ensure that the elderly and their families receive home-based care and multidisciplinary advice.

Palliative medicine/palliative care is a speciality aimed at symptom control in patients with life-limiting illnesses. Palliative medicine no longer focuses on care of the dying only but is an integral part of the management of patients with a life-limiting illness. It approaches symptom control in a holistic manner addressing a patient's physical, psychological, social and spiritual needs. This article aims to give an overview of the principles of palliative medicine and guidance on management of particular, frequently seen symptoms, emergencies and end of life care.

Introduction DBS is a therapeutic option for patients with Parkinson disease (PD), tremor and dystonia. In patients who experience suboptimal clinical results with conventional programming (monopolar, double monopolar or bipolar settings), interleaved pulses can sometimes be used to provide differential therapeutic benefits with the possibility of fewer side effects. Interleaving allows a clinician to define two “programs” that automatically alternate. The goal of this paper is to 1) present clinical scenarios where DBS interleaving was used across two clinics to provide improved symptom control in three patients with suboptimal results from conventional programming; 2) address the potential mechanisms of interleaving; and 3) provide practical tips on the use of interleaving. Methods Three patients were formally compared for therapeutic benefit on interleaved and conventional parameter settings. Results Interleaving is most likely to be useful in two clinical scenarios: 1) different contacts are beneficial for specific symptoms, but each at a different stimulation amplitude; or 2) symptoms are resolved incompletely, and further voltage increase is limited by side effects. The factors underpinning the differences in outcomes with interleaving are unknown but may be highly dependent on specific symptoms and to electrode positioning. Interleaving is a relatively new programming platform and there is no data to demonstrate long-term benefits. Conclusions Interleaving is a tool that may augment outcomes, and possibly obviate the need for surgical revisions, although in our experience across two large centers it has been effective for only a small number of patients.

Pelvic floor disorders, which include rectal prolapse (RP) and faecal incontinence (FI), are benign conditions, which are not life threatening but affect the quality of life. This is usually a disease of elderly, mostly frail patients. Management is multidisciplinary based on the symptoms, co-morbidities and patient's expectations. Neuromodulation with sacral nerve stimulation provides good symptom control in well-motivated patients with FI. The modern management of RP in suitable patients is ventral mesh rectopexy where the rectovaginal septum is reconstituted; however perineal approaches still have a major role.

Objectives Rechargeable (RC) implantable pulse generators (IPGs) for deep brain stimulation (DBS) in movement disorders have recently become available. No guidelines exist for parameter adjustment after conversion of non-RC to RC IPGs, or reports of patient satisfaction with RC IPGs when used as initial DBS device or after conversion from non-RC IPGs. Materials and Methods Patients who underwent placement of Activa RC IPG (Medtronic, Inc.) were surveyed by phone about device satisfaction. Their charts were retrospectively reviewed and DBS settings were analyzed. The stimulation settings before and after conversion to RC were compared. Results Thirty-one patients (age 15–90; 18 male) with movement disorders (nine Parkinson's disease, nine dystonia, eight essential tremor, five others) were identified. Twelve subjects had initial RC IPG implantation; 19 were converted from non-RC IPGs (Soletra; Medtronic, Inc.) 2–14 years after initial DBS implant (mean 6.3 ± 3.44 years). Twenty-six patients (17 conversions) were surveyed an average of 12.1 months since RC IPG implantation. Overall satisfaction with RC was high. Patients converted to RC were more likely to choose it again than those with initial RC. Patients denied differences in symptom control after conversion. Mean amplitude, pulse width, and frequency were slightly lower after conversion regardless of diagnosis and remained lower after three postconversion reprogramming with slow drift of amplitude back to preconversion settings, more in the GPi group. Conclusions RC IPGs in DBS for movement disorders are well received by patients as initial therapy and after conversion. Mild reduction in stimulation parameters might be allowed after conversion to RC IPG.

Durable left ventricular assist devices (LVADs) have not only enhanced longevity but also conferred sustained improvements in quality of life, symptom control, and functional capacity in patients with medically refractory advanced heart failure. Problems with device-related infection, bleeding, neurologic events, right-sided heart failure, and device malfunction have dominated the clinical care of patients living on mechanical support. Even as adoption of durable LVADs accelerated globally, we began to encounter a growing dilemma of pump malfunction caused by thrombosis. In early 2011, clinicians began to notice a spike in the incidence of pump thrombosis with the HeartMate II (Thoratec Corp, Pleasanton, CA) LVAD. By 2012, the problem of thrombosis in LVADs began to consume most of the scientific direction as centers and collaborative groups began to dissect this nascent phenomenon. In this perspective, we describe the magnitude and implications of pump thrombosis, discuss secular and management trends in this unique population, attempt to dissect the problem at its root, offer guidance on surveillance and therapeutic principles, and outline issues that deserve our immediate and collaborative attention.

Fribrodysplasia ossificans progressiva (FOP) is a rare genetic disease characterized by progressive heterotopic ossification of connective tissues, episodic flare-ups and bilateral deformities of the great toe (hallux valgus). As faulty tissue repair processes progressively calcify tissue, patients suffer from swelling and limited mobility in that area. We present a case of a 66-year-old woman who had initially presented at age 54 without the hallux valgus deformity or classic-type flare-ups. As there is currently no cure for FOP, management is mainly symptom control. Physicians should still consider FOP if imaging indicates progressive heterotopic ossification in the absence of hallux valgus in an older patient., Highlights • Fibrodysplasia ossificans progressiva can present after age 50. • Patients can present without great toe deformity. • Atypical flare-ups include flu-like symptoms and stiffness. • Imaging is vital in diagnosis of atypical cases.

There is increasing evidence that patient self-management strategies, used as adjuncts to traditional pharmacological interventions, can improve symptom control for people living with lung cancer. While it is acknowledged that the specialist lung cancer nurse (SLCN) is well positioned in the multidisciplinary team to facilitate patient self-management education (PSME), limited guidance is available to SLCNs on this role.

ObjectiveTo observe the therapeutic effect of percutaneous kyphoplasty (PKP) and oral Zishengukang (ZSGK) for the treatment of osteoporotic vertebral compression fractures (OVCFs).MethodsSeventy patients were randomly divided into a control group (PKP group) and an experimental group (PKP plus ZSGK group). The 35 patients in the experimental group were prescribed 6 g oral ZSGK three times a day for 90 days after PKP. Visual analog pain scale (VAS), Oswestry functional score, vertebral height and Cobb's angle were recorded and compared before treatment and at one week, one month and three months after treatment.ResultsVertebral height and Cobb's angle significantly improved and VAS and Oswestry functional score were significantly lower in both groups after PKP than pre-operatively (P0.05).ConclusionPKP combined with oral ZSGK provide superior short-term and long-term symptom control after OVCF than PKP alone.