ABSTRACT
BACKGROUND: The elderly admitted to nursing homes have especially suffered the havoc of the COVID-19 pandemic since most of them are not prepared to face such health problems. METHODS: An innovative coordinated on-site medicalization program (MP) in response to a sizeable COVID-19 outbreak in three consecutive waves was deployed, sharing coordination and resources among primary care, the referral hospital, and the eleven residences. The objectives were providing the best possible medical care to residents in their environment, avoiding dehumanization and loneliness of hospital admission, and reducing the saturation of hospitals and the risk of spreading the infection. The main outcomes were a composite endpoint of survival or optimal palliative care (SOPC), survival, and referral to the hospital. RESULTS: 587 of 1199 (49%) residents were infected, of whom 123 (21%) died. Patients diagnosed before the start of the MP presented SOPC, survival, and referrals to the hospital of 83%, 74%, and 22.4%, opposite to 96%, 84%, and 10.6% of patients diagnosed while the MP was set up. The SOPC was independently associated with an MP (OR 3.4 [1.6-7.2]). CONCLUSION: During the COVID-19 outbreak, a coordinated MP successfully obtained a better rate of SOPC while simultaneously reducing the need for hospital admissions, combining optimal medical management with a more compassionate and humanistic approach in older people.
ABSTRACT
PURPOSE: The main aim of the study was to assess the impact of individualized management of breakthrough cancer pain (BTcP) on quality of life (QoL) of patients with advanced cancer in clinical practice. METHODS: A prospective, observational, multicenter study was conducted in patients with advanced cancer that were assisted by palliative care units. QoL was assessed with the EORTC QLQ-C30 questionnaire at baseline (V0) and after 28 days (V28) of individualized BTcP therapy. Data on background pain, BTcP, comorbidities, and frailty were also recorded. RESULTS: Ninety-three patients completed the study. Intensity, duration, and number of BTcP episodes were reduced (p < 0.001) at V28 with individualized therapy. Transmucosal fentanyl was used in 93.8% of patients, mainly by sublingual route. Fentanyl titration was initiated at low doses (78.3% of patients received doses of 67 µg, 100 µg, or 133 µg) according to physician evaluation. At V28, mean perception of global health status had increased from 31.1 to 53.1 (p < 0.001). All scales of EORTC QLQ-C30 significantly improved (p < 0.001) except physical functioning, diarrhea, and financial difficulties. Pain scale improved from 73.6 ± 22.6 to 35.7 ± 22.3 (p < 0.001). Moreover, 85.9% of patients reported pain improvement. Probability of no ≥ 25% improvement in QoL was significantly higher in patients ≥ 65 years old (OR 1.39; 95% CI 1.001-1.079) and patients hospitalized at baseline (OR 4.126; 95% CI 1.227-13.873). CONCLUSION: Individualized BTcP therapy improved QoL of patients with advanced cancer. Transmucosal fentanyl at low doses was the most used drug. TRIAL REGISTRATION: This study was registered at ClinicalTrials.gov database (NCT02840500) on July 19, 2016.
Subject(s)
Breakthrough Pain/drug therapy , Cancer Pain/drug therapy , Neoplasms/complications , Neoplasms/drug therapy , Pain Management/methods , Quality of Life/psychology , Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Prospective StudiesABSTRACT
Pneumocystis jirovecii is an atypical fungus exhibiting pulmonary tropism and a highly defined host specificity. It is generally regarded as an opportunistic microorganism causing serious pneumonia in AIDS patients. However, with the currently rising number of patients receiving immunosuppressive therapies for malignancies, allogeneic organ transplantations and autoimmune diseases, Pneumocystis pneumonia is becoming more and more recognized in non-HIV immunosuppressed individuals. The clinical presentation in HIV-infected patients may differ from that in other immunocompromised patients and its diagnosis continues to be challenging as there are no specific symptoms or signs. Cotrimoxazole is the drug of choice for prophylaxis and therapy of any form or severity of Pneumocystis pneumonia, but there are only a few options for other alternative treatments. The management of this pneumonia remains a major challenge for all physicians caring for immunosuppressed patients.
