Management of analgosedation during noninvasive respiratory support: an expert Delphi consensus document developed by the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI).

BACKGROUND: Discomfort can be the cause of noninvasive respiratory support (NRS) failure in up to 50% of treated patients. Several studies have shown how analgosedation during NRS can reduce the rate of delirium, endotracheal intubation, and hospital length of stay in patients with acute respiratory failure. The purpose of this project was to explore consensus on which medications are currently available as analgosedatives during NRS, which types of patients may benefit from analgosedation while on NRS, and which clinical settings might be appropriate for the implementation of analgosedation during NRS. METHODS: The Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) selected a panel of experts and asked them to define key aspects of the use of analgesics and sedatives during NRS treatment. The methodology applied is in line with the principles of the modified Delphi and RAND-UCLA methods. The experts developed statements and supportive rationales which were then subjected to blind votes for consensus. RESULTS: The use of an analgosedation strategy in adult patients with acute respiratory failure of different origins may be useful where there is a need to manage discomfort. This strategy should be considered after careful assessment of other potential factors associated with respiratory failure or inappropriate noninvasive respiratory support settings, which may, in turn, be responsible for NRS failure. Several drugs can be used, each of them specifically targeted to the main component of discomfort to treat. In addition, analgosedation during NRS treatment should always be combined with close cardiorespiratory monitoring in an appropriate clinical setting. CONCLUSIONS: The use of analgosedation during NRS has been studied in several clinical trials. However, its successful application relies on a thorough understanding of the pharmacological aspects of the sedative drugs used, the clinical conditions for which NRS is applied, and a careful selection of the appropriate clinical setting.

Risk factors for PPCs in laparoscopic non-robotic vs. laparoscopic robotic abdominal surgery (LapRas): rationale and protocol for a patient-level analysis of LAS VEGAS and AVATaR.

INTRODUCTION: Postoperative pulmonary complications (PPCs) vary amongst different surgical techniques. We aim to compare the incidence of PPCs after laparoscopic non-robotic versus laparoscopic robotic abdominal surgery. METHODS AND ANALYSIS: LapRas (Risk Factors for PPCs in Laparoscopic Non-robotic vs Laparoscopic robotic abdominal surgery) incorporates harmonized data from 2 observational studies on abdominal surgery patients and PPCs: 'Local ASsessment of VEntilatory management during General Anaesthesia for Surgery' (LAS VEGAS), and 'Assessment of Ventilation during general AnesThesia for Robotic surgery' (AVATaR). The primary endpoint is the occurrence of one or more PPCs in the first five postoperative days. Secondary endpoints include the occurrence of each individual PPC, hospital length of stay and in-hospital mortality. Logistic regression models will be used to identify risk factors for PPCs in laparoscopic non-robotic versus laparoscopic robotic abdominal surgery. We will investigate whether differences in the occurrence of PPCs between the two groups are driven by differences in duration of anesthesia and/or the intensity of mechanical ventilation. ETHICS AND DISSEMINATION: This analysis will address a clinically relevant research question comparing laparoscopic and robotic assisted surgery. No additional ethical committee approval is required for this metanalysis. Data will be shared with the scientific community by abstracts and original articles submitted to peer-reviewed journals. REGISTRATION: The registration of this post-hoc analysis is pending; individual studies that were merged into the used database were registered at clinicaltrials.gov: LAS VEGAS with identifier NCT01601223, AVATaR with identifier NCT02989415.

Video vs. direct laryngoscopy for adult surgical and intensive care unit patients requiring tracheal intubation: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: This systematic review and meta-analysis aimed to determine whether a specific videolaryngoscopy technique is superior to standard direct laryngoscopy using a Macintosh blade to reduce the risk of difficult intubation in surgical and intensive care unit patients. MATERIALS AND METHODS: We identified all randomized controlled trials comparing videolaryngoscopes (VLSs) to direct laryngoscopy in the Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE (from inception to April 2020). The primary outcome was difficult intubation in adult surgical and intensive care unit patients. Secondary outcomes were successful intubation at the first attempt, airway trauma, sore throat, hoarseness, hypoxia, and mortality. RESULTS: We included 97 randomized controlled trials to evaluate 12775 patients. A high risk of bias was found in at least 50% of the included studies for each outcome. VLSs reduced the risk of difficult intubation compared to direct Macintosh laryngoscopy (RR 0.48, 95% CI from 0.35 to 0.65). VLSs increased the rate of successful intubation at the first attempt when compared to direct Macintosh laryngoscopy (RR 1.03, 95% CI from 1.00 to 1.07). Lower risks of airway trauma were found with VLSs (RR 0.69, 95% CI from 0.55 to 0.86). A decreased risk of hoarseness was associated with the use of VLSs (RR 0.67, 95% CI from 0.54 to 0.83). In addition, VLSs did not significantly reduce the risk of hypoxia compared with direct laryngoscopy (RR 0.83, 95% CI from 0.60 to 1.16). CONCLUSIONS: In this systematic review and meta-analysis, we found that the use of VLSs reduced the risk of difficult intubation and slightly increased the ratio of successful intubation at the first attempt among adult patients.

Digital disruption of dietetics: are we ready?

Digital health is transforming the delivery of health care around the world to meet the growing challenges presented by ageing populations with multiple chronic conditions. Digital health technologies can support the delivery of personalised nutrition care through the standardised Nutrition Care Process (NCP) by using personal data and technology-supported delivery modalities. The digital disruption of traditional dietetic services is occurring worldwide, supporting responsive and high-quality nutrition care. These disruptive technologies include integrated electronic and personal health records, mobile apps, wearables, artificial intelligence and machine learning, conversation agents, chatbots, and social robots. Here, we outline how digital health is disrupting the traditional model of nutrition care delivery and outline the potential for dietitians to not only embrace digital disruption, but also take ownership in shaping it, aiming to enhance patient care. An overview is provided of digital health concepts and disruptive technologies according to the four steps in the NCP: nutrition assessment, diagnosis, intervention, and monitoring and evaluation. It is imperative that dietitians stay abreast of these technological developments and be the leaders of the disruption, not simply subject to it. By doing so, dietitians now, as well as in the future, will maximise their impact and continue to champion evidence-based nutrition practice.

Reevaluación de los efectos de PEEP alta con maniobras de reclutamiento vs. PEEP baja sin maniobras de reclutamiento durante la anestesia general para cirugía: protocolo y plan de análisis estadístico para un metaanálisis de los datos de pacientes individuales de PROVHILO, iPROVE y PROBESE / Re-evaluation of the effects of high PEEP with recruitment manoeuvres versus low PEEP without recruitment manoeuvres during general anaesthesia for surgery -Protocol and statistical analysis plan for an individual patient data meta-analysis of PROVHILO, iPROVE and PROBESE

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Replicating group-based education interventions for the management of type 2 diabetes: a review of intervention reporting.

AIMS: To assess the completeness of reporting of group-based education interventions for the management of type 2 diabetes. METHODS: A previous systematic review of group-based education programmes for adults with type 2 diabetes identified eligible intervention studies. Data were extracted and assessed using the Template for Intervention Description and Replication ('TIDieR') checklist. Missing data were sourced from other published material, or by contacting authors. RESULTS: Fifty-three publications describing 47 studies were included. No publications sufficiently described all items. Authors of 43 of the 47 included studies (91%) were contacted via e-mail to obtain missing data in order to complete the TIDieR checklist. Seven (16%) did not respond. Additional data were obtained for 33/47 studies (70%). Most studies (45/47, 96%) described the intervention duration and frequency, detailed the procedures and rationale (40/47, 85%), provided a brief intervention name and explained any individual tailoring (38/47, 81%), defined whether providers received training and adequately described how the programme was delivered (37/47, 79%). However, few described any modifications (28/47, 60%), whether the intervention was delivered as planned (27/47, 57%), where it was delivered (21/47, 45%), whether materials were provided (19/47, 40%), and who delivered the intervention (13/47, 28%). CONCLUSIONS: Group-based education interventions for the management of type 2 diabetes are poorly reported. To translate effective research into practice, practitioners need sufficient detail to implement evidence-based interventions. Researcher adoption of the TIDieR checklist will assist the translation and replication of published interventions.

Dietitians' perspectives of the barriers and enablers to delivering patient-centred care.

BACKGROUND: Patient-centred care (PCC) is widely recognised as being important with respect to the delivery of quality health care. However, limited research has explored PCC in the dietetic context. In particular, dietitians' views of the barriers and enablers to delivering a patient-centred approach have not been investigated. Therefore, the present study aimed to explore primary care dietitians' perspectives of the barriers and enablers to delivering PCC. METHODS: The present study was situated in a constructivist-interpretivist paradigm and used qualitative methods. Both convenience and snowball sampling were used to recruit Australian Accredited Practising Dietitians (APD) who were working in primary care. Individual semi-structured interviews explored dietitians' perspectives of the barriers and enablers to delivering PCC. Data were analysed thematically. RESULTS: Twelve APDs were interviewed between March and April 2018. Seven themes were discovered: (i) challenges in defining PCC; (ii) valuing PCC; (iii) enacting PCC; (iv) requiring additional education in PCC; (v) evaluating one's own practice; (vi) workplace pressures and constraints; and (vii) keeping up with expectations. CONCLUSIONS: These findings suggest that: (i) the meaning of PCC in dietetics should be clarified to ensure it is being practiced consistently; (ii) undergraduate curricula require a greater emphasis on PCC so that dietitians graduate with the necessary knowledge and skills; (iii) there is a need for more professional development training to facilitate uptake of PCC in practice; and (iv) quantitative measurement of PCC using validated instruments is needed to evaluate PCC in the dietetic setting. Addressing some of these factors may assist dietitians to adopt these practices.

Development and psychometric testing of an inventory to measure patient-centred care in dietetic practice - dietitian version.

BACKGROUND: The lack of a valid instrument to measure patient-centred care (PCC) in dietetic practice makes it challenging to evaluate how patient-centred dietitians are. The present study aimed to develop and psychometrically test a dietitian-reported inventory to measure PCC in dietetic practice. METHODS: The inventory was compiled based on a literature review of existing validated scales that measured the dimensions of PCC. Next, the inventory was distributed as a cross-sectional survey to 180 Australian Accredited Practicing Dietitians who worked in primary care. Exploratory factor analysis was performed using principal factor analysis with Promax rotation. Cronbach's alpha (criteria ≥0.80), inter-item correlations and corrected item-total correlations (criteria 0.30-0.70) were computed to evaluate the internal consistency of each scale. RESULTS: Five factors were extracted accounting for 56.9% of the variance. Most variables had strong loadings on only one factor. Factors were labelled as: shared decision-making; holistic and individualised care; patient-dietitian communication; knowing the patient; and caring patient-dietitian relationships. Cronbach's alpha was 0.94 for the total inventory and ranged from 0.73 to 0.91 for the individual factors. Inter-item correlations and corrected item-total correlations mostly fell in the desired range. CONCLUSIONS: The present study offers a preliminary, conceptually grounded dietitian-reported inventory, which is the first instrument developed and tested to measure PCC in dietetic practice. These findings illustrate the underlying factor structure of the inventory and support the reliability of the scales. With further testing, this inventory may provide useful to clinicians and researchers working to better understand and improve dietetic practice.

Association between night-time surgery and occurrence of intraoperative adverse events and postoperative pulmonary complications.

BACKGROUND: The aim of this post hoc analysis of a large cohort study was to evaluate the association between night-time surgery and the occurrence of intraoperative adverse events (AEs) and postoperative pulmonary complications (PPCs). METHODS: LAS VEGAS (Local Assessment of Ventilatory Management During General Anesthesia for Surgery) was a prospective international 1-week study that enrolled adult patients undergoing surgical procedures with general anaesthesia and mechanical ventilation in 146 hospitals across 29 countries. Surgeries were defined as occurring during 'daytime' when induction of anaesthesia was between 8:00 AM and 7:59 PM, and as 'night-time' when induction was between 8:00 PM and 7:59 AM. RESULTS: Of 9861 included patients, 555 (5.6%) underwent surgery during night-time. The proportion of patients who developed intraoperative AEs was higher during night-time surgery in unmatched (43.6% vs 34.1%; P<0.001) and propensity-matched analyses (43.7% vs 36.8%; P=0.029). PPCs also occurred more often in patients who underwent night-time surgery (14% vs 10%; P=0.004) in an unmatched cohort analysis, although not in a propensity-matched analysis (13.8% vs 11.8%; P=0.39). In a multivariable regression model, including patient characteristics and types of surgery and anaesthesia, night-time surgery was independently associated with a higher incidence of intraoperative AEs (odds ratio: 1.44; 95% confidence interval: 1.09-1.90; P=0.01), but not with a higher incidence of PPCs (odds ratio: 1.32; 95% confidence interval: 0.89-1.90; P=0.15). CONCLUSIONS: Intraoperative adverse events and postoperative pulmonary complications occurred more often in patients undergoing night-time surgery. Imbalances in patients' clinical characteristics, types of surgery, and intraoperative management at night-time partially explained the higher incidence of postoperative pulmonary complications, but not the higher incidence of adverse events. CLINICAL TRIAL REGISTRATION: NCT01601223.

The tension between efficiency and effectiveness: a study of dietetic practice in primary care.

BACKGROUND: Primary healthcare dietitians have a vital role to play in the prevention and management of chronic disease. Working in primary care requires efficient and effective management of practice to ensure client and practitioner needs are met. The present study aimed to explore the way in which primary care dietitians in Australia view the constructs of efficiency and effectiveness within the context of their practice. METHODS: The study used an exploratory qualitative design within a pragmatist framework. Individual semi-structured telephone interviews were conducted with Australian primary care dietitians. All interviews were audio-recorded, transcribed verbatim and analysed using an inductive thematic approach. RESULTS: Twenty dietitians (17 females) working as private practitioners in primary care from three Australian states participated in the present study. Three themes emerged from the data. The first theme revealed that seeking efficiency and especially effectiveness were important to primary care dietitians and that there was a tension between the two. The second theme identified that efficiency and effectiveness are influenced by personal and structural factors. The final theme explored how dietitians are actively seeking ways to be more efficient and effective, including supportive networks, as well as the utilisation of technology. CONCLUSIONS: Achieving a balance between efficiency and effectiveness in primary care dietetics is challenging to practitioners, who may require further training and support to enhance productivity, time management and resource utilisation. Structured issues exist for the workface. Further studies are required to quantify these findings and to explore whether it is possible to optimise efficiency and effectiveness and achieve sustainability of the dietetic workforce in primary care.

Intraoperative ventilation settings and their associations with postoperative pulmonary complications in obese patients.

BACKGROUND: There is limited information concerning the current practice of intraoperative mechanical ventilation in obese patients, and the optimal ventilator settings for these patients are debated. We investigated intraoperative ventilation parameters and their associations with the development of postoperative pulmonary complications (PPCs) in obese patients. METHODS: We performed a secondary analysis of the international multicentre Local ASsessment of VEntilatory management during General Anesthesia for Surgery' (LAS VEGAS) study, restricted to obese patients, with a predefined composite outcome of PPCs as primary end-point. RESULTS: We analysed 2012 obese patients from 135 hospitals across 29 countries in Europe, North America, North Africa, and the Middle East. Tidal volume was 8.8 [25th-75th percentiles: 7.8-9.9] ml kg-1 predicted body weight, PEEP was 4 [1-5] cm H2O, and recruitment manoeuvres were performed in 7.7% of patients. PPCs occurred in 11.7% of patients and were independently associated with age (P<0.001), body mass index ≥40 kg m-2 (P=0.033), obstructive sleep apnoea (P=0.002), duration of anaesthesia (P<0.001), peak airway pressure (P<0.001), use of rescue recruitment manoeuvres (P<0.05) and routine recruitment manoeuvres performed by bag squeezing (P=0.021). PPCs were associated with an increased length of hospital stay (P<0.001). CONCLUSIONS: Obese patients are frequently ventilated with high tidal volume and low PEEP, and seldom receive recruitment manoeuvres. PPCs increase hospital stay, and are associated with preoperative conditions, duration of anaesthesia and intraoperative ventilation settings. Randomised trials are warranted to clarify the role of different ventilatory parameters in obese patients. CLINICAL TRIAL REGISTRATION: NCT01601223.

The fragility of statistically significant findings in randomised controlled anaesthesiology trials: systematic review of the medical literature.

The fragility index (FI), the number of events the statistical significance a result depends on, and the number of patients lost to follow-up are important parameters for interpreting randomised clinical trial results. We evaluated these two parameters in randomised controlled trials in anaesthesiology. For this, we performed a systematic search of the medical literature, seeking articles reporting on anaesthesiology trials with a statistically significant difference in the primary outcome and published in the top five general medicine journals, or the top 15 anaesthesiology journals. We restricted the analysis to trials reporting clinically important primary outcome measures. The search identified 139 articles, 35 published in general medicine journals and 104 in anaesthesiology journals. The median (inter-quartile range) sample size was 150 (70-300) patients. The FI was 4 (2-17) and 3 (2-7), and the number of patients lost to follow-up was 0 (0-18) and 0 (0-6) patients in trials published in general medicine and anaesthesiology journals, respectively. The number of patients lost to follow-up exceeded the FI in 41 and 27% in trials in general medicine journals and anaesthesiology journals, respectively. The FI positively correlated with sample size and number of primary outcome events, and negatively correlated with the reported P-values. The results of this systematic review suggest that statistically significant differences in randomised controlled anaesthesiology trials are regularly fragile, implying that the primary outcome status of patients lost to follow-up could possibly have changed the reported effect.

Variable versus conventional lung protective mechanical ventilation during open abdominal surgery (PROVAR): a randomised controlled trial.

BACKGROUND: Experimental studies showed that controlled variable ventilation (CVV) yielded better pulmonary function compared to non-variable ventilation (CNV) in injured lungs. We hypothesized that CVV improves intraoperative and postoperative respiratory function in patients undergoing open abdominal surgery. METHODS: Fifty patients planned for open abdominal surgery lasting >3 h were randomly assigned to receive either CVV or CNV. Mean tidal volumes and PEEP were set at 8 ml kg-1 (predicted body weight) and 5 cm H2O, respectively. In CVV, tidal volumes varied randomly, following a normal distribution, on a breath-by-breath basis. The primary endpoint was the forced vital capacity (FVC) on postoperative Day 1. Secondary endpoints were oxygenation, non-aerated lung volume, distribution of ventilation, and pulmonary and extrapulmonary complications until postoperative Day 5. RESULTS: FVC did not differ significantly between CVV and CNV on postoperative Day 1, 61.5 (standard deviation 22.1) % vs 61.9 (23.6) %, respectively; mean [95% confidence interval (CI)] difference, -0.4 (-13.2-14.0), P=0.95. Intraoperatively, CVV did not result in improved respiratory function, haemodynamics, or redistribution of ventilation compared to CNV. Postoperatively, FVC, forced expiratory volume at the first second (FEV1), and FEV1/FVC deteriorated, while atelectasis volume and plasma levels of interleukin-6 and interleukin-8 increased, but values did not differ between groups. The incidence of postoperative pulmonary and extrapulmonary complications was comparable in CVV and CNV. CONCLUSIONS: In patients undergoing open abdominal surgery, CVV did not improve intraoperative and postoperative respiratory function compared with CNV. CLINICAL TRIAL REGISTRATION: NCT 01683578.

Quality of development and reporting of dietetic intervention studies in primary care: a systematic review of randomised controlled trials.

BACKGROUND: High-quality research methodologies and clear reporting of studies are essential to facilitate confidence in research findings. The aim of the present study was to conduct an in-depth examination of the methodological quality and reporting of studies included in a recent systematic review of dietitians' effectiveness at providing individualised nutrition care to adult patients. METHODS: The methodological quality and reporting of 27 Randomised Controlled Trials (RCTs) were appraised using the UK Medical Research Council (MRC) Guidelines for complex interventions and the CONSORT checklist for reporting RCTs. A quality appraisal checklist was developed for each guideline/assessment tool aiming to evaluate the extent to which each study met the designated criteria. Excerpts from studies that best addressed criteria were collated to provide exemplary accounts of how criteria may be achieved in future studies. RESULTS: None of the reviewed studies met more than half of the MRC Guidance criteria, indicating that there is clear room for improvement in reporting the methodological underpinnings of these studies. Similarly, no studies met all criteria of the CONSORT checklist, suggesting that there is also room for improvement in the design and reporting of studies in this field. CONCLUSIONS: Dietitians, researchers and journal editors are encouraged to use the results and exemplary accounts from this review to identify key aspects of studies that could be improved in future research. Improving future research will enhance the quality of the evidence-base that investigates the outcomes of dietary interventions involving dietitians.

Patients' perceptions and experiences of patient-centred care in dietetic consultations.

BACKGROUND: Patient-centred care (PCC) is essential to quality healthcare. However, there is a paucity of research on PCC in dietetics, particularly regarding patients' experiences and perspectives of PCC. We aimed to enhance our understanding of PCC in dietetics by exploring patients' perceptions and experiences of PCC in individual dietetic consultations. METHODS: The present study used qualitative methods, situated in a constructivist-interpretivist paradigm. Maximum variation purposive sampling was used to recruit English speaking adult participants who had participated in ≥1 dietetic consultations for nutrition care. Individual semi-structured interviews explored participants' perceptions and experiences of PCC in dietetic consultations. Data were analysed thematically. RESULTS: Eleven patients were interviewed between September and November 2016. Four overarching themes emerged: (i) fostering and maintaining caring relationships; (ii) delivering individualised care; (iii) enabling patient involvement; and (iv) taking control of one's own health. CONCLUSIONS: PCC is important to patients. Thus, there is opportunity for dietitians to enhance the care they provide by adopting patient-centred practices. As the first study of its kind, these findings can inform future dietetic practice, education and research by contributing patients' perspectives of PCC. By understanding patients' unique needs and preferences, dietitians can better align their practice with a patient-centred approach. Furthermore, these findings are useful for informing future dietetic research and education.

Assessing Option B+ retention and infant follow-up in Lilongwe, Malawi.

Malawi launched Option B+, a program for all pregnant or breastfeeding HIV-positive women to begin lifelong combination antiretroviral therapy (cART), in July 2011. This study characterises a portion of the continuum of care within an antenatal setting in Lilongwe. Women testing HIV-positive and having a cART initiation record at Bwaila Antenatal Clinic from July 2013 to January 2014 were included. Using logistic regression models, we analysed relationships between maternal characteristics and return for infant testing. Among 490 HIV-positive women with a cART initiation record, 360 (73%) were retained at three months. Of these, 203 (56%) were adherent. Records of infant testing were located for 204 women (42%). Women who were not retained were less likely to have an early infant diagnosis record (aOR = 0.20; 95% CI: 0.10, 0.41). Among the women retained, there was a non-significant association between maternal adherence and infant testing (OR = 1.35; 95% CI: 0.89, 2.06). Women lost at earlier continuum stages, who are at higher risk for mother-to-child-transmission, were less likely to bring infants for testing. Even with a test-and-treat program, many women did not remain in care or bring their infant for testing. Facilitating strategies to improve these measures remains an important unmet need.

Permanent diffuse alopecia after haematopoietic stem cell transplantation in childhood.

Permanent alopecia after haematopoietic stem cell transplantation (HSCT) is distressing and few studies have investigated this late effect. The aim of the study was to assess the percentage of patients with alopecia and investigate risk factors for alopecia. Patients who underwent allogeneic HSCT before age 19 years, from January 1990 to January 2013, who were at least 2 years after transplant and in follow-up in our clinic were included. Alopecia was defined as clinically apparent decreased hair density. Possible risk factors considered for alopecia after HSCT included: gender, age, diagnosis, donor type, conditioning regimen: cranial irradiation (TBI/cranial radiotherapy) and/or chemotherapy, which chemotherapeutic agents were used and acute/chronic GvHD. The percentage of permanent alopecia in our cohort was 15.6% (41/263 patients). All patients had diffuse alopecia except for one with alopecia totalis. In multivariate analysis, a conditioning regimen with busulphan and busulphan plus fludarabine (odds ratio (OR) 5.7 (confidence interval (CI): 2.5-12.7) and OR 7.4 (CI: 3.3-16.2), respectively, was the main risk factor and associated with alopecia independent of acute/chronic GvHD. Neither TBI nor other alkylating chemotherapy, including treosulfan, was associated with alopecia. In conclusion, permanent alopecia after HSCT is associated with busulphan and GvHD and occurs in 16% of patients.

[Paediatric palliative care: multidisciplinary and pro-active]. / Kinderpalliatieve zorg: multidisciplinair en proactief.

Every child with a life-limiting or threatening illness, and his or her family, has a right to palliative care. Palliative care is not limited to end-of-life care, but starts from the moment of diagnosis and is independent of whether there are curative options. To optimise quality of life of both the child and the family, the emphasis of care should be on both somatic and psychosocial and spiritual aspects from the very start, and goals should be set together with the child and the family. A multidisciplinary and pro-active approach is essential if this is to be achieved. It is, therefore, strongly recommended that at least every academic hospital should have a multidisciplinary paediatric palliative care team.