Successful use of Rectal Pregabalin for the Treatment of Chemotherapy-Induced Neuropathic Pain-a Case Report

INTRODUCTION

A 65-year-old female patient could no longer take oral food or medications due to a duodenal occlusion associated with metastatic urothelial carcinoma. Her pre-existing chemotherapy-induced polyneuropathy had been well treated with pregabalin orally.

METHODS

Since only preparations for oral use of pregabalin are available, pregabalin suppositories were compounded by the hospital pharmacy for rectal use in this patient.

RESULTS

With the rectal administration, the treatment was successfully continued; we measured a good increase in serum levels and the symptoms improved significantly.

DISCUSSION

Cancer patients often need to be treated with co-analgesics. At the end of life, treatment often cannot be continued due to lack of other than oral administration. Our case adds to the low evidence of pregabalin administered rectally.

Preliminary results regarding automated identification of patients with a limited six-month survival prognosis using nursing assessment in uro-oncology patients

INTRODUCTION

Contrary to current recommendations, palliative co-management of tumor patients often occurs late in daily clinical practice. Palliative care specialist (PCS) co-management should be considered at the latest after a 6-month prognosis has been presumed. Therefore, identifying patients with a limited prognosis is a reasonable measure.

METHODS

Patients were identified using a screening tool for limited prognosis, which combined their tumor stage and data from the nursing anamnesis. In this retrospective study, a monocentric cohort of patients with urological malignancies-UICC (Union for International Cancer Control) stages III and IV - were enrolled from March to December 2019, with a 6-month follow-up period ending in May 2020.

RESULTS

Most patients were male and suffered from prostate cancer. Patients with uro-oncological tumors dying within 6 months correlated significantly with the presence of repeated hospitalizations within three months, pain on admission, malnutrition, impaired breathing and reduced mobility (P < 0.001). The test was fair in quality (AUC 0.727) at a cut-point of five; a sensitivity of 97% and a specificity of 25% were obtained. The PPV was 0.64 and NPV was 0.82.

DISCUSSION/CONCLUSION

We specifically identified the predictors of limited prognosis in urological cancer patients across several entities using an automated scoring system based on tumor stage and data from the nursing anamnesis. Therefore, we recognized hospitalization as an important transition point and determined nurses to be valuable partners in identifying unmet palliative care needs without additional technical, personnel or financial effort.

[Generalist palliative care in hospitals during the first wave of the COVID-19 pandemic]

BACKGROUND

In the research network of German university palliative care centers (PallPan), as part of Network University Medicine (NUM), recommendations for action were developed in regard to the care provided for seriously ill and dying patients during a pandemic. For this purpose, the experiences and needs of hospital staff working closely with patients outside of specialized palliative care units during the first wave of the COVID-19 pandemic were also examined.

MATERIALS AND METHODS

Nationwide online survey of 8,882 physicians, nurses and therapists working in acute inpatient care in the period from December 2020 to January 2021 by means of a newly developed and piloted questionnaire on changes, burdens and cooperation with specialized palliative care. Grouping based on the changes in the number of seriously ill and dying people in the first wave of the pandemic. Due to the exploratory character of the survey, the data were analyzed descriptively.

RESULTS

505/8882 completed questionnaires were evaluated (5.7 %). 167/505 (33.1 %) of the respondents reported a lower quality of care for the critically ill and dying. 464/505 (91.8 %) reported exemptions in place for visiting the dying. The most frequently mentioned stress factor was the perceived loneliness of the seriously ill and dying 437/505 (86.5 %), followed by stricter hygiene rules 409/505 (81 %), increased workload 372/505 (73.3 %) and perceived psychological stress on relatives and survivors 395/505 (78.2 %). 141/505 (27.9 %) of respondents used Tablet PCs to support patient-family communication. 310/505 (61.4 %) involved palliative care professionals in patient care, and 356/505 (70.5 %) of respondents found other palliative care services helpful.

CONCLUSION

Experiences and suggestions for improving palliative care in pandemic times are integrated into the PallPan recommendations for action. Family visits should be allowed and supplemented by digital offers. Palliative Care should also be integrated into both pandemic and contingency plans.

Inpatient generalist palliative care during the SARS-CoV-2 pandemic - experiences, challenges and potential solutions from the perspective of health care workers

BACKGROUND

The SARS-CoV-2 pandemic has presented major challenges to the health system. Despite high acute case numbers, patients without Covid-19 still need to be cared for. Due to the severity of the disease and a possible stressful overall situation, patients with palliative care needs also require comprehensive care during pandemic times. In addition to specialized palliative care facilities, this also takes place in non palliative care wards. In order to ensure this general palliative care also in pandemic times, the experience of the staff should be used. The aim of this paper is to examine challenges and possible solutions for general palliative care inpatients in relation to the care of seriously ill and dying patients and their relatives.

METHODS

Qualitative semi-structured focus groups were conducted online for the study. Participants were staff from intensive care or isolation wards or from units where vulnerable patients (e.g. with cognitive impairment) are cared for. The focus groups were recorded and subsequently transcribed. The data material was analysed with the content structuring content analysis according to Kuckartz.

RESULTS

Five focus groups with four to eight health care professionals with various backgrounds were conducted. Fifteen main categories with two to eight subcategories were identified. Based on frequency and the importance expressed by the focus groups, six categories were extracted as central aspects: visiting regulations, communication with relatives, hygiene measures, cooperation, determination of the patients will and the possibility to say good bye.

CONCLUSION

The pandemic situation produced several challenges needing specific solutions in order to manage the care of seriously ill and dying patients. Especially visiting needs regulation to prevent social isolation and dying alone. Finding alternative communication ways as well as interprofessional and interdisciplinary cooperation is a precondition for individualised care of seriously ill and dying patients and their relatives. Measures preventing infections should be transparently communicated in hospitals.

National strategy for palliative care of severely ill and dying people and their relatives in pandemics (PallPan) in Germany - study protocol of a mixed-methods project

Background

In the SARS-CoV-2 pandemic, general and specialist Palliative Care (PC) plays an essential role in health care, contributing to symptom control, psycho-social support, and providing support in complex decision making. Numbers of COVID-19 related deaths have recently increased demanding more palliative care input. Also, the pandemic impacts on palliative care for non-COVID-19 patients. Strategies on the care for seriously ill and dying people in pandemic times are lacking. Therefore, the program ‘Palliative care in Pandemics’ (PallPan) aims to develop and consent a national pandemic plan for the care of seriously ill and dying adults and their informal carers in pandemics including (a) guidance for generalist and specialist palliative care of patients with and without SARS-CoV-2 infections on the micro, meso and macro level, (b) collection and development of information material for an online platform, and (c) identification of variables and research questions on palliative care in pandemics for the national pandemic cohort network (NAPKON).

Methods

Mixed-methods project including ten work packages conducting (online) surveys and qualitative interviews to explore and describe i) experiences and burden of patients (with/without SARS-CoV-2 infection) and their relatives, ii) experiences, challenges and potential solutions of health care professionals, stakeholders and decision makers during the SARS-CoV-2 pandemic. The work package results inform the development of a consensus-based guidance. In addition, best practice examples and relevant literature will be collected and variables for data collection identified.

Discussion

For a future “pandemic preparedness” national and international recommendations and concepts for the care of severely ill and dying people are necessary considering both generalist and specialist palliative care in the home care and inpatient setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00898-w.

Admission of a Terminally Ill Lung Cancer Patient With the Accidental Diagnosis of SARS-CoV-2 to a Palliative Care Unit Resulting in a SARS-CoV-2 Outbreak

The COVID-19 pandemic poses challenges for palliative care. Terminal patients cannot wear masks and may demonstrate unspecific symptoms reminiscent of those caused by COVID-19. This report is about a terminally ill patient with lung cancer who displayed fever, cough, and fatigue. During hospital admission screening, the patient tested negative for SARS-CoV-2. When admitting his wife to stay with him, she also had to test for SARS-CoV-2 and displayed a positive test result. Until the positive results were reported, six staff members were infected with SARS-CoV-2, even though they were routinely wearing respirators. This resulted in the palliative care unit having to be closed. Hospitals need strict and adequate testing and re-testing strategies even for intra-hospital transfers. Workers must strictly adhere to recommended respirator practices. Ventilation of patient rooms is essential due to the possible enrichment of particle aerosols containing viruses, as negative pressure rooms are not recommended in all countries.

Screening for Palliative Care Needs: Pilot Data From German Comprehensive Cancer Centers

PURPOSE

Guidelines recommend several screening tools to identify patients with complex palliative needs. This diversity and lack of structural recommendations offer a wide scope for implementing screening. Against this background, the current status of implementation at German Comprehensive Cancer Centers (CCCs) funded by the German Cancer Aid has not yet been investigated.

METHODS

e-mail survey of the 17 hospital sites of the 13 CCCs. The questionnaire asked for structural characteristics of the centers as well as preconditions of the screening process. Structurally established screening procedures (one item) and standardized workflows, modes of performance, screening tools (four items), modes of training how to screen, and responsibilities (two items) were assessed.

RESULTS

In a 2-month period, 15 hospital sites responded; seven hospital sites conducted a palliative care needs (PCN) screening. Only one hospital site carried out PCN screening in almost all oncology departments, but only with the distress thermometer. Other hospital sites determined palliative needs by assessing physical symptoms using the Integrated Palliative Care Outcome Scale or the Minimal Documentation System, and two hospital sites combined tools to determine both physical and psychological stress. The type of screening varied from paper-pencil-based to tablet computer-based documentation. The main barriers to implementation were identified as a lack of human resources and a lack of structural conditions.

CONCLUSION

There is a lack of consensus among palliative care specialists and oncologists in the CCCs supported by the German Cancer Aid in PCN screening as well as of structured guidelines and the professional association. Structural requirements should be adapted to these needs, which include both technical and human resources. A combined psycho-oncologic and palliative care screening might help to formulate best practice recommendations.

[Needs and burdens of palliative care patients with advanced and/or metastatic head and neck tumors]

Hintergrund

Neue Therapieformen ermöglichen auch bei Patienten mit fortgeschrittenen und metastasierten Kopf-Hals-Tumoren gute Behandlungsansätze. Gespräche über das Lebensende, vorausschauende Versorgungsplanung und auch palliativmedizinische Konzepte geraten dadurch oft in den Hintergrund.

Ziel der Arbeit

Analyse von Symptomen, Belastungen sowie dem Vorliegen von Vorsorgedokumenten, von stationär palliativmedizinisch mitbetreuten Patienten durch Selbsteinschätzung. Erhebung der Integration der spezialisierten Palliativversorgung in die Versorgung stationär verstorbener Patienten anhand des Qualitätsindikators nach Earle.

Material und Methoden

Retrospektive Analyse der vom Palliativdienst mitbetreuten Patienten mit Kopf-Hals-Tumoren durch Nutzung des standardisierten IPOS Fragebogens.

Ergebnisse

Die häufigsten physischen Symptome waren „Schwäche“ (77 %), „Appetitlosigkeit“ (65 %) und „eingeschränkte Mobilität“ (65 %). „Schmerzen“ wurden von 42 % der Patienten angegeben. Die häufigsten emotionalen und psychosozialen Belastungen waren „Traurigkeit“ (97 %) und „Sorgen des Patienten“ (94 %), die „fehlende Möglichkeit Gefühle“ zu teilen (77 %), „unzureichende Informiertheit“ (85 %) und „organisatorische Probleme“ (77 %). Bei 23 % der Patienten lagen Vorsorgedokumente vor. Das Qualitätsziel nach Earle wurde nicht erreicht.

Diskussion

Die Patienten berichten in der Auswertung in hohem Maß Symptome und Belastungen, am häufigsten im emotionalen Bereich und bezüglich kommunikativer und praktischer Bedürfnisse. Hier zeigt sich möglicherweise auch ein Gesprächsbedarf über Wünsche und Vorstellungen im Hinblick auf das Lebensende. Palliativdienste sollten deshalb besonders auf die psychosozialen Bedürfnisse einzugehen.

Utility of the integrated palliative care outcome scale (IPOS): a cross-sectional study in hospitalised patients with heart failure

AIM

The aim of this study was to evaluate the suitability and comprehensibility of the integrated palliative care outcome scale for the evaluation of palliative care needs in patients with heart failure.

METHODS AND RESULTS

This cross-sectional study investigated 100 heart failure patients (40 women, 60 men; median age 79 years) within the first few days of their hospitalisation by applying the integrated palliative care outcome scale (3-day recall period) and two additional self-developed questions about the suitability and comprehensibility of the integrated palliative care outcome scale. Clinically relevant somatic and psycho-emotional symptoms were reported very frequently (approximately 75% each), followed by communicational needs or practical issues. Ninety-five per cent of patients thought the integrated palliative care outcome scale very easy to understand, and 91% judged the integrated palliative care outcome scale suitable to assess palliative care needs.

CONCLUSION

The integrated palliative care outcome scale was well accepted by hospitalised patients with heart failure and identified a high burden of both physical and psycho-emotional symptoms. Screening for palliative care has to consider patients and their relatives alike, and should be part of a comprehensive care concept jointly integrated into clinical routine by primary and specialised palliative care teams.

Utility of the integrated palliative care outcome scale (IPOS): a cross-sectional study in hospitalised patients with heart failure

AIM

The aim of this study was to evaluate the suitability and comprehensibility of the integrated palliative care outcome scale for the evaluation of palliative care needs in patients with heart failure.

METHODS AND RESULTS

This cross-sectional study investigated 100 heart failure patients (40 women, 60 men; median age 79 years) within the first few days of their hospitalisation by applying the integrated palliative care outcome scale (3-day recall period) and two additional self-developed questions about the suitability and comprehensibility of the integrated palliative care outcome scale. Clinically relevant somatic and psycho-emotional symptoms were reported very frequently (approximately 75% each), followed by communicational needs or practical issues. Ninety-five per cent of patients thought the integrated palliative care outcome scale very easy to understand, and 91% judged the integrated palliative care outcome scale suitable to assess palliative care needs.

CONCLUSION

The integrated palliative care outcome scale was well accepted by hospitalised patients with heart failure and identified a high burden of both physical and psycho-emotional symptoms. Screening for palliative care has to consider patients and their relatives alike, and should be part of a comprehensive care concept jointly integrated into clinical routine by primary and specialised palliative care teams.

Human xylosyltransferase-I - a new marker for myofibroblast differentiation in skin fibrosis

Skin fibrosis is a severe type of fibrotic disorder emerging in terms of hypertrophic scars or systemic sclerosis. Key event of fibrogenesis is the transition of fibroblasts to matrix-producing myofibroblasts. In the presence of fibrotic triggers, for instance secretion of profibrotic growth factors like transforming growth factor-β1 (TGF-β1) or mechanical strain, myofibroblasts persist. Current research focuses on discovering innovative myofibroblast biomarkers which are regulated in fibrotic development and accessible for antifibrotic inhibition. Here, we consider the suitability of xylosyltransferase-I (XT-I) as a myofibroblast biomarker in skin fibrosis. XT-I catalyzes the initial step of glycosaminoglycan biosynthesis. Its increase in enzymatic activity is known to refer only to manifested diseases which are characterized by an abnormal rate of proteoglycan biosynthesis. In this study, treatment of normal human dermal fibroblasts (NHDF) with TGF-β1 was followed by increased relative XYLT1 mRNA expression. Remarkably, this upregulation was strongly dependent on myofibroblast content, increasing during fibrogenesis. Moreover, XT activity increased time-dependently in response to progressive myofibroblast transformation. XYLT1 expression was inhibited by TGF-β receptor I (ALK5) inhibitor SB431542. In contrast, XYLT2 expression was only marginally affected by TGF-β1 as well as ALK5 inhibition. Our results strengthen the significance of XT expression and activity in fibrotic remodeling. Therefore, we propose XT activity, in addition to α-SMA expression, as a new biomarker for myofibroblast differentiation and fibrotic development. Further studies are now needed to evaluate the option to control and inhibit fibrotic remodeling by interfering with XT expression.

[Shortage of physicians in anaesthesiology and intensive care medicine - Causes, consequences and solutions]

74% of all hospitals had vacant positions in 2011, also departments of anaesthesiology and intensive care medicine. More than 50% of these departments work with locums. There are couple of reasons for the shortage of physicians. The consequences in anaesthesiology and intensive care medicine can result in qualitative and financial loss. To solve the shortage of physicians one has to solve the reasons. Main reasons are increasing feminization of medical profession and part-time-work, work-life-balance and a poor specialised education.

[Regional anesthesia as a useful alternative to general anesthesia? Overview of the current data]

Neuromuscular disorders are rare and often not very well diagnosed diseases. They can be separated in prejunctional, junctional or postjunctional diseases. General anesthesia is connected with a higher risk, therefore regional anesthesia could often be regarded with favour and could be a safe alternative. Because of the lack of systematically studies and guidelines the decision choosing a regional anesthesia is always a risk-benefit-analysis. This and also the detailed preoperative neurological status must, because of forensic reason, exactly be documented.

Detection of late epilepsy by the texture analysis of MR brain images in the lithium-pilocarpine rat model

The aim of the study was to detect by texture analysis non easily visible anomalies of magnetic resonance (MR) images of piriform and entorhinal cortices relevant to the lithium-pilocarpine (Li-Pilo) model of temporal lobe epilepsy in rats. Status epilepticus was induced by Li-Pilo in twenty male rats 21 day-old. T(2)-weighted MR images of their brain, were obtained before injection of Li-Pilo and one day after status epilepticus. An hyperintense signal was found in the piriform and entorhinal cortices of six rats, which developed chronic epilepsy after a latent period of one to three months. Among the 14 other rats which displayed images similar to those obtained before injection, four remained healthy but 10 rats developed late epileptic symptoms, raising the problem of hidden cortical damage which may be too subtle to be detected by classic MRI examination. A numeric treatment of digital images was then undertaken by texture analysis, to derive image information from a purely computational point of view. The combined texture and discriminant analyses based on pixels pattern anomalies, selected 3 texture parameters derived from co-occurrence matrix which characterized structural abnormalities relevant to the hyperintense signal, not only in the modified images of 6 rats but also in images of 10 rats with apparently non modified images. These three texture's parameters allowed to classify the twenty rats of our experiment as follows: sixteen epileptic rats were effectively classified with cortical lesions, two non epileptic were correctly classified with healthy cortex, but two healthy rats were not correctly classified. This misclassification is discussed on the basis of the time dependence of the onset of seizure in the Li-Pilo model. These promising results suggest to apply this method to MRI examinations for an improvement of the early diagnostic of human epilepsy.

Automatic learning strategies and their application to electrophoresis analysis

Automatic learning plays an important role in image analysis and pattern recognition. A taxonomy of automatic learning strategies is presented; this categorization is based on the amount of inferences the learning element must perform to bridge the gap between environmental and system knowledge representation level. Four main categories are identified and described: rote learning, learning by deduction, learning by induction, and learning by analogy. An application of learning by induction to medical image analysis is then exposed. It consists in the classification of two-dimensional gel electrophoretograms into meaningful distinct classes, as well in their conceptual description.

Automatic classification of two-dimensional gel electrophoresis pictures by heuristic clustering analysis: a step toward machine learning

The interpretation of two-dimensional gel electrophoresis (2-DGE) profiles can be facilitated by artificial intelligence and machine learning programs. We have incorporated into our 2-DGE computer analysis system (termed MELANIE-Medical Electrophoresis Analysis Interactive Expert system) a program which automatically classifies 2-DGE patterns using heuristic clustering analysis. This program is a step toward machine learning. In this publication, we describe the classification method and the preliminary results obtained with liver biopsy electrophoretograms. Heuristic clustering is also compared to other classification techniques.