Palliative care in Hospitalized Middle-Aged and Older Adults With COVID-19.

CONTEXT: As COVID-19 overwhelms health systems worldwide, palliative care strategies may ensure rational use of resources while safeguarding patient comfort and dignity. OBJECTIVE: To describe palliative care practices in hospitalized middle-aged and older adults in two of the largest COVID-19 treatment centers in Sao Paulo, Brazil. METHODS: Retrospective cohort. Eligible patients were those aged 50 years or older hospitalized between March and May 2020 with a laboratory confirmation of SARS-CoV-2 infection. Palliative care implementation was defined as present if medical notes indicated a decision to limit escalation of life support measures, or when opioids or sedatives were prescribed for palliative management of symptoms. RESULTS: We included 1162 participants (57% male, median 65 years). Overall, 21% were frail and 54% were treated in intensive care units, but only 17% received palliative care. Stepwise logistic regression demonstrated that age ≥80 years, dementia, history of stroke or cancer, frailty, having a PaO2/FiO2<200 or a C-reactive protein ≥150mg/dL at admission predicted palliative care implementation. Patients placed under palliative care stayed longer (13 vs.11 days) and were more likely to die in hospital (86 vs.27%). They also spent more days in ICU and received vasoactive drugs, hemodialysis, and invasive ventilation more frequently. CONCLUSIONS: One in five middle-aged and older adults hospitalized with COVID-19 received palliative care in our cohort. Patients who were very old, multimorbid, frail, and had severe COVID-19 were more likely to receive palliative care. However, it was often delayed until advanced and invasive life support measures had already been implemented.

Clinical outcomes and quality of life of COVID-19 survivors: A follow-up of 3 months post hospital discharge.

BACKGROUND: Over 66 million people worldwide have been diagnosed with COVID-19. Therefore, understanding their clinical evolution beyond hospital discharge is essential not only from an individual standpoint, but from a populational level. OBJECTIVES: Our primary aim was to assess the impact of COVID-19 on health-related quality of life (HRQoL) 3 months after hospital discharge. Additionally, we screened for anxiety and depression and assessed important clinical outcomes. METHODS: This was a single-center cohort study performed in Sao Paulo (Brazil), in which participants were contacted by telephone to answer a short survey. EQ-5D-3L was used to assess HRQoL and clinical data from patients' index admission were retrieved from medical records. RESULTS: We contacted 251 participants (59.8% males, mean age 53 years old), 69.7% of which had presented with severe COVID-19. At 3 months of follow-up, 6 patients had died, 51 (20.3%) had visited the emergency department again and 17 (6.8%) had been readmitted to hospital. Seventy patients (27.9%) persisted with increased dyspnoea and 81 had a positive screening for anxiety/depression. Similarly, patients reported an overall worsening of EQ-5D-3L single summary index at 3 months compared to before the onset of COVID-19 symptoms (0.8012 (0.7368 - 1.0) vs. 1.0(0.7368 - 1.0), p < 0.001). This affected all 5 domains, but especially pain/discomfort and anxiety/depression. Only female sex and intensive care requirement were independently associated with worsening of HRQoL. CONCLUSION: Patients hospitalized for COVID-19 frequently face persistent clinical and mental health problems up to 3 months following hospital discharge, with significant impact on patients' HRQoL.

Methadone as first-line opioid treatment for cancer pain in a developing country palliative care unit.

PURPOSE: The use of methadone for cancer pain is limited by the need of expertise and close titration due to variable half-life. Yet, it is a helpful palliative strategy in low-resources countries given its long-acting effect at low cost and worth additional study. Our aim was to describe the prescription and outcomes of methadone as a first-line treatment for cancer pain in a tertiary palliative care unit (PCU) in Argentina. METHODS: Retrospective review of medical records of patients with moderate to severe cancer pain seen at the PCU in 1-year period, who initiated strong opioids at the first consultation. Data collected during the first month of treatment included disease and pain characteristics, initial and final opioid type and dose and need for opioid rotation. RESULTS: Methadone was the most frequent opioid both at the initial and last assessment (71 and 66 % of the prescriptions). In all, treatment with strong opioids provided considerable decrease in pain intensity (p < 0.001) with low and stable opioid dose. Median and interquartile range (IR) of oral morphine equivalent daily dose (OMEDD) was 26 (16-32) and 39 (32-55) mg for initial and final assessments, respectively (p = 0.3). In patients initiated with methadone, the median (IR) daily methadone dose was 5 (4-6) mg at first and 7.5 (6-10) mg at final assessment, and the median (IR) index of opioid escalation was 0 (0-4) mg; (p < 0.05). Patients on methadone underwent less percentage of opioid rotation (15 versus 50 %; p < 0.001) and longer time to rotation (20.6 ± 4.4 versus 9.0 ± 2.7 days; p < 0.001) than patients on other opioids. CONCLUSIONS: Results indicate the preference of methadone as first-line strong opioid treatment in a PCU, providing good pain relief at low doses with low need for rotation. Several considerations about the costs of strong opioids in the region are given.

Evaluación subjetiva de la calidad de recuperación postoperatoria de pacientes operadas de cesárea con anestesia general o regional / Subjective assessment of the quality of postoperative recovery of patients operated by caesarean section with general or spinal anesthesia

Introducción: La elección de la técnica anestésica puede influir en la recuperación postoperatoria, Si bien la anestesia general ha sido la técnica tradicional en la operación cesárea, la anestesia raquídea está siendo usada cada vez con mayor frecuencia. Sin embargo aún no se sabe si la misma se asocia a una mejor calidad de recuperación. Objetivos: Comparar la recuperación de la anestesia general versus espinal para la operación cesárea con especial enfoque en la calidad subjetiva, la capacidad materna de cuidar al recién nacido y la satisfacción materna Métodos: Se estudiaron prospectivamente mujeres (≥ 18 años) operadas de cesárea entre agosto y octubre de 2005 en un hospital general. Se utilizó el escore QoR40 para evaluar la calidad de la recuperación. La capacidad materna de cuidar al recién nacido y la satisfacción se estudiaron con una escala visual análoga (EVA) y con un escore categórico de tres niveles. Los datos se expresaron como: (mediana; rango). Resultados: Se estudiaron sesenta y tres pacientes: 22 operadas con anestesia general y 41 con anestesia subaracnoidea. La calidad de la recuperación de la anestesia espinal (193: 181197) fue significativamente mejor que con anestesia general (189; 174-193), (p =0,047); siendo la sensación de bienestar, las mialgias y la odinofagia los tres elementos determinantes de esa diferencia. La capacidad materna para tomar en brazos al recién nacido, lactancia y cambio de pañales, así como la satisfacción materna fueron similares en ambos grupos. Conclusiones: Si bien la anestesia espinal se asoció a una mejor calidad subjetiva de recuperación, esto parece deberse sobre todo a una menor incidencia de odinofagia, y la capacidad de cuidar del recién nacido así como la satisfacción parecen no estar afectadas. La identificación de diferencias en efectos adversos importantes -pero muy raros- que afecten la calidad de la recuperación requiere de estudios prospectivos y randomizados con mayor número de pacientes.

Background: The choice of anesthesia may influence postoperative recovery. While general anesthesia is the traditional choice for caesarian section, spinal anesthesia is increasingly used. However it is not known whether spinal anesthesia is associated with superior recovery. Objective: To compare recovery from spinal vs. general anesthesia following caesarian section, focusing on quality of recovery, maternal capacity for newborn care, and maternal satisfaction. Methods: we prospectively studied women (≥18 years old) undergoing a caesarean section between August-October 2005, at larger general hospital. The QoR-40 score was used to evaluate quality of recovery. Maternal capacity for newborn care, as well as maternal satisfaction, were both studied with a visual analogue scale (VAS) and three-level categorical score. Data are expressed as (median: inter-quartile range). Results: Sixty three patients were studied: 22 underwent spinal anesthesia. Quality of recovery from spinal anesthesia (193: 181-197) was significantly better than general anesthesia (189; 174-193) (p=0,047); however, the elements that accounted for this difference were a feeling of "well being", the presence of myalgias and a "sore throat". The mother's capacity to hold the newborn, breast feed and change diapers, as well as maternal satisfaction were similar in both groups. Conclusion: Although spinal anesthesia for cesarean section is associated with better subjective quality of recovery, this may be due predominantly to a lower incidence of sore throat, and the capacity of mothers to care for their children, as well as maternal satisfaction, appears to be unaffected. Detection of potential differences in important -but very rare- adverse effects associated with either technique would require a very large prospective randomized study.

Preliminary report on tumor stem cell/B cell hybridoma vaccine for recurrent glioblastoma multiforme.

BACKGROUND: Glioblastoma multiforme (GBM), the most aggressive glioma, presents with a rapid evolution and relapse within the first year, which is attributed to the persistence of tumor stem cells (TSC) and the escape of immune surveillance. Mixed leukocyte culture (MLC) cytoimplant has been shown to function as a powerful intratumor pro-inflammatory cytokine pump. Tumor B-cell hybridoma (TBH) vaccines have been shown to function as antigen-presenting cells. We evaluated the toxicity and efficiency of each treatment alone and in combination. PATIENTS AND METHODS: In an open study, 12 consecutive patients were evenly divided into 3 groups, each group receiving 3 different treatments. Patients in Group 1 were treated, after diagnosis, with debulking surgery (DS)+radiotherapy (Rx), and after the first relapse underwent DS+MLC treatment. Patients in Group 2 were similarly treated but after the first relapse underwent DS+MLC+TBH. Finally, patients in Group 3 were similarly treated but after the first relapse underwent DS+TBH. Nestin PAP stain assessed TSC participation in TBH. RESULTS: Treatment with MLC had strong and rapid therapeutic effects, but was limited in duration and induced various degrees of brain inflammation. Treatment with MLC+TBH acted synergistically, provoking a rapid, strong and lasting therapeutic response but also generating different degrees of brain inflammation. A lasting therapeutic effect without generating high degrees of brain inflammation occurred in patients treated with TBH vaccine alone. CONCLUSION: TSC vaccine consisting of TBH alone seems to have potent adjuvant reactions overcoming both persistence of tumor stem cells and immune escape of GBM without provoking an encephalitic reaction.