Paniculitis mesentérica: ¿es algo de lo que nos tenemos que preocupar? / Mesenteric panniculitis: is it something that we should worry about?

La paniculitis mesentérica es una entidad poco frecuente, y menos aún detectada salvo de modo incidental. Sin embargo, puede estar asociada a sintomatología muy prevalente en cuidados paliativos. Presentamos un caso que ilustra esta problemática, a modo de reflexión. (AU)

Mesenteric panniculitis is a rare condition that is even rarer to detect except incidentally. However, it may be associated with very prevalent symptoms in the setting of palliative care. We report a case that illustrates this problem in order to invite reflection. (AU)

Influencia de la localización del tumor en la sobrecarga del cuidador principal en pacientes hospitalizados con cáncer avanzado / Influence of tumor location on primary caregiver burden in hospitalized patients with advanced cancer

Introducción: La sobrecarga del cuidador/a aumenta el sufrimiento de pacientes y familiares. Se han realizado pocos trabajos sobre los factores relacionados con ello, incluidos los clínicos o biográficos. Objetivo: Analizar el impacto de la localización de la neoplasia y otros factores sobre la sobrecarga del cuidador/a. Métodos: Estudio descriptivo analítico transversal en una unidad de cuidados paliativos para pacientes con cáncer avanzado. Criterios de inclusión: mayores de 18 años con diagnóstico de cáncer avanzado, con un cuidador/a identificable. Se recogieron variables tanto del paciente como del cuidador/a, incluidos elementos biográficos y clínicos. La sobrecarga se midió mediante la escala de Zarit (EZ) de 22 y 7 ítems, así como una escala 0-10 para sobrecarga autopercibida y la Hospital Anxiety and Depression Scale (HADS) del cuidador/a. Resultados: Se incluyeron 38/65 casos (58 %). La edad media fue de 75 y 58 años para pacientes y cuidadores (50 % hijas), con la localización digestiva del tumor como la más frecuente. La mayoría de los cuidadores trabajaban también fuera de casa, con un 58 % cuidando más de 6 meses. Medias: EZ22 = 46 (DE = 15); EZ7 = 16 (DE = 6). La ubicación digestiva mostró menos carga en las escalas EZ22, EZ7 y 0-10 (p = 0,048), y la ubicación pulmonar se asoció con puntuaciones más altas en la HADS-Ansiedad. Los pacientes con delirium, antecedentes de salud mental o inestabilidad clínica se asociaron con puntuaciones EZ22 más altas (p < 0,05). En aquellos con EZ22 > 46, la HADS-Ansiedad y la HADS global fueron más altas (p = 0,006 y p = 0,014). (AU)

Background: Caregiver burden increases the suffering of patients and their relatives. Few studies have focused on burden-associated factors, including clinical or biographical characteristics. Aim: To analyze the impact of tumor location and other factors on caregiver burden. Methods: An analytic, descriptive, cross-sectional study was conducted in a palliative care unit for advanced cancer patients. Inclusion criteria included: patients older than 18 years with advanced cancer diagnosis, with a recognizable caregiver, who signed an informed consent. Variables of both patients and caregivers were collected, including biographical items and clinical characteristics. Burden was defined by more than 46 or 15 points in Zarit’s Scale (ZS) of 22 items (ZS22) or 7 (ZS7) items, respectively. We also used a 0-10 scale for self-perceived burden. Caregivers’ HADS scores were also recorded, with more than 10 points in subscales and 16 points in overall score as breakpoints for anxiety or depression. Results: A total of 38/65 cases were included (58 %). Mean age was 75 and 58 years for patients and caregivers (50 % offspring), respectively, with tumor location in the digestive system being most common. Most caregivers also worked out of home, and 58 % had been caring for more than 6 months. Means: ZS22 = 46 (DS = 15); ZS7 = 16 (DS = 6). A digestive location obtained a lower burden score in the ZS22, ZS7, and 0-10 scales (p = 0.048), and a lung location was associated with higher HADS-A scores. Patients with delirium, mental disorders, or clinical instability were associated with higher ZS22 scores (p < 0.05). In those with ZS22 > 46, HADS-A scores and overall scores were higher (p = 0.006 and p = 0.014). (AU)

Pain Standards for Accredited Healthcare Organizations (ACDON Project): A Mixed Methods Study.

Up to 50% of cancer patients and up to 90% of those in terminal stages experience pain associated with disease progression, poor quality of life, and social impact on caregivers. This study aimed to establish standards for the accreditation of oncological pain management in healthcare organizations. A mixed methods approach was used. First, a pragmatic literature review was conducted. Second, consensus between professionals and patients was reached using the Nominal Group and Delphi technique in a step that involved anesthesiologists, oncologists, family physicians, nurses, psychologists, patient representatives, and caregivers. Third, eight hospitals participated in a pilot assessment of the level of fulfillment of each standard. A total of 37 standards were extracted. The Nominal Group produced additional standards, of which 60 were included in Questionnaire 0 that was used in the Delphi Technique. Two Delphi voting rounds were performed to reach a high level of consensus, and involved 64 and 62 participants with response rates of 90% and 87%, respectively. Finally, 39 standards for the management of cancer pain were agreed upon. In the self-evaluation, the average range of compliance was between 56.4% and 100%. The consensus standards of the ACDON Project might improve the monitoring of cancer pain management. These standards satisfied the demands of professionals and patients and could be used for the accreditation of approaches in cancer pain management.

Supervivencia tras delirium en pacientes oncológicos avanzados tratados por profesionales específicos de cuidados paliativos en ámbito hospitalario: ¿hay alguna diferencia? / Survival after delirium in advanced cancer patients treated by specifi c palliative care professionals at the hospital: Is there any difference?

INTRODUCCIÓN: El delirium es un factor pronóstico negativo en población geriátrica y de enfermedad avanzada. No hay trabajos que focalicen en la población atendida por equipos específicos de cuidados paliativos. OBJETIVO: Analizar la supervivencia de los pacientes que debutan con un cuadro de delirium durante su estancia en una Unidad de Hospitalización de Cuidados Paliativos. METODOLOGÍA: Estudio descriptivo retrospectivo de supervivencia. Se incluyeron pacientes ingresados en la UCP del HSJD de Pamplona durante el semestre abril-septiembre 2012. Variables: datos demográficos, tipo de neoplasia, deterioro cognitivo, ECOG y supervivencia desde el ingreso. Se registró la presencia de delirium según criterios DSM IV al ingreso y durante el ingreso. De este último subgrupo se registraron las variables: factores precipitantes-contribuyentes, subtipo de delirium, reversibilidad del cuadro y supervivencia desde el diagnóstico. Se calcularon funciones de supervivencia mediante el método de Kaplan-Meier. Se comparó supervivencia respecto a presentar o no delirium mediante la prueba de Mantel-Haenszel (log-rank). RESULTADOS: Prevalencia de delirium del 50 % (26 % al ingreso) con incidencia del 25 %. Mediana supervivencia: 11 días (IC 7,54-14,45) en los pacientes con delirium y de 22 días (IC 11,41-32,58) en el resto. En los que debutaron durante el ingreso, la mediana de supervivencia fue 16 días y 5 desde el diagnóstico de delirium. Existen diferencias estadísticamente significativas entre la supervivencia del grupo que ingresa con delirium frente a los que no lo presentan en ningún momento, así como la suma del total de pacientes con delirium. No hubo diferencias significativas entre los que debutan durante el ingreso y los que no presentan delirium. CONCLUSIONES: El delirium ha demostrado ser un factor pronóstico a nivel global. Sin embargo, en poblaciones con mayor fragilidad y en seguimiento continuo por personal entrenado en el manejo del mismo, su influencia diferencial sobre la supervivencia no ha quedado tan claramente establecida

INTRODUCTION: Delirium is a negative prognostic factor in the geriatric population and in advanced disease. There is no research that focuses on the population attended to by specific palliative care teams. OBJECTIVE: To analyze the survival of patients who develop delirium during their stay in a palliative care hospitalization unit. METHODOLOGY: A descriptive retrospective study of survival. Patients admitted to the PCU of Hospital San Juan de Dios, Pamplona, Spain, between April and September 2012 were included. Variables: demographic data, type of neoplasia, cognitive impairment, ECOG, and survival from admission. Delirium was recorded according to DSM IV criteria at admission and during hospitalization. In the latter subgroup, the variables recorded were: precipitating-contributing factors, delirium subtype, reversibility of the condition, and survival from diagnosis. Survival functions were calculated using the Kaplan-Meier method. Survival was compared with the presence or absence of delirium using the Mantel-Haenszel test (log-rank). RESULTS: The prevalence of delirium was almost 50 % (26 % at admission) with an incidence of 25 %. Median survival was 11 days (CI: 7.54-14.45) in the patients who presented with delirium, and 22 days (CI: 11.41-32.58) in the rest. Within the subgroup of patients who presented with delirium during admission, median survival was 16 days from admission and 5 from the diagnosis of delirium. There are statistically significant differences in survival between the group that arrived with delirium and those who did not develop it at any time, as well as with the sum of the total number of patients with delirium. In contrast, there are no significant differences between those who debuted during admission and those without delirium. CONCLUSIONS: Delirium has proven to be a prognostic factor globally. However, in populations with greater fragility and in continuous monitoring by personnel trained in its management, its differential impact on survival has not been so clearly established

Valor de una herramienta de cribado de una sola pregunta en el despistaje de delirium por parte de enfermería en pacientes con cáncer en un servicio de oncología / Value of a single-question screening tool for delirium screening by a nurse team in cancer patients at an oncology service

INTRODUCCIÓN: El papel de enfermería en el cribado del delirium resulta fundamental. Pocos trabajos analizan la validez de herramientas de pregunta única. OBJETIVOS: Comprobar la validez de una «pregunta única» como herramienta de cribado de delirium en una unidad de hospitalización de oncología médica y analizar los factores relacionados con la presencia de cribado positivo. METODOLOGÍA: Estudio descriptivo transversal de validez de una prueba de cribado. CRITERIOS DE INCLUSIÓN: mayores de 18 años, con presencia de un tumor sólido y que estuvieran ingresados al menos 3 días. Se comparó una pregunta única por parte de enfermería con un patrón oro a través del CAM y los criterios de DSM-IV por parte de medicina, midiendo la relación con otras variables. RESULTADOS: Incluidos 42 pacientes. Varón de 61 años con localización digestiva con intención paliativa como más frecuente. Prevalencia de un 14% de delirium según CAM (26% cribado positivo), con alta concordancia, sensibilidad, especificidad y valor predictivo negativo. Asociación con uso de opioides. CONCLUSIÓN: Una herramienta de «pregunta única» sería útil para el cribado del delirium

INTRODUCTION: The role of nursing in the process of delirium screening is fundamental. Few studies analyze the validity of the single question tool. OBJECTIVES: To verify the validity of the single question as a delirium screening tool in a Medical Oncology inpatient unit and analyze the factors linked to the presence of a positive screening. METHODOLOGY: Cross-sectional descriptive study of the single question screening validity. Inclusion criteria: Older than 18 years old, with presence of a solid tumour and hospitalized for at least 3 days. The single question by the nursing team was compared with a gold standard through CAM and DMS-IV criteria by the medical team, measuring the relation to other variables. RESULTS: 42 patients included. Sixty-one-year-old male with a digestive tract location treated with palliative intention as the most frequent. Prevalence of 14% of delirium by CAM (26% positive screening), with high concordance, sensitivity, specificity and negative predictive value. Association with opioid usage. CONCLUSIONS: A single question tool would be useful in the delirium screening

«Chemical coping» o la compensación con sustancias químicas: ¿tenemos claro lo que tenemos que hacer? / Chemical coping: Are we sure about what we have to do?

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El pronóstico en pacientes con cáncer avanzado en domicilio: ¿es la Palliative Performance Scale la respuesta que esperábamos? / Prognosis in advanced cancer patients at home: ¿Is the Palliative Performance Scale the answer we were waiting for?

OBJETIVO: El estatus funcional ha demostrado valor pronóstico en múltiples ámbitos. Hay pocos trabajos en población atendida en domicilio. Nos preguntamos si la Palliative Performance Scale (PPS) nos sirve como herramienta para estimar la supervivencia en pacientes con cáncer avanzado en el domicilio.como objetivos secundarios se analizó la interacción de otras variables en su capacidad estimatoria, como el delirium. MÉTODO: Estudio retrospectivo de supervivencia. Pacientes en atención domiciliaria por equipos específicos durante 2013. CRITERIOS DE INCLUSIÓN: mayores de 18 años que recibieron primera visita por un Equipo de Soporte de Atención Domiciliaria, con cáncer avanzado. Variables: sociodemográficas (edad, sexo) y clínicas (PPS, localización del tumor primario, supervivencia, lugar de fallecimiento y delirium. Análisis estadístico con curvas de Kaplan-Meier y regresión de Cox. RESULTADOS: Trescientos ochenta y tres pacientes de 473 quedaron incluidos. El paciente tipo fue un varón de 74 años con localización primaria en el aparato digestivo, una mediana de PPS y un supervivencia de 50% y 30 días, respectivamente, falleciendo el 53% en el domicilio. La PPS mostró asociación estadísticamente significativa con la supervivencia, mostrando que, por cada 10% de descenso de la PPS, aumenta el riesgo de mortalidad en un 3,1% (p < 0,000). El delirium apareció en el 12,5% y se etiquetó como variable de interacción en la regresión de Cox. Los pacientes con mejor estatus funcional en nuestra primera visita fallecieron más en el hospital que en el domicilio (p < 0,000). Y los menores de 60 años presentaron más frecuentemente un estatus funcional mejor (PPS>40, p < 0,012). CONCLUSIONES: Este estudio confirma la validez como herramienta pronóstica de la PPS también en el ámbito domiciliario en poblaciones atendidas por Equipo de Soporte de Atención Domiciliaria. El delirium evidencia un valor pronóstico que interacciona negativamente con la PPS

OBJECTIVE: Performance status has shown to have a prognostic value in multiple settings. There is little research on patients cared for at home. This study set out to determine whether the Palliative Performance Scale (PPS) is also useful as a prognostic tool also in patients with advanced cancer receiving care at home. As secondary objectives, an analysis was also carried out on the influence of other variables, such as delirium, on its prognostic ability. METHOD: A retrospective survival study was conducted on patients in a home-care setting attended by palliative care teams during 2013. Inclusion criteria: older than 18 years old and who received a first visit by a Palliative Home Care Team, with advanced cancer. Variables: demographic (age, gender) and clinical (PPS, primary location of cancer, survival, place of death, and delirium). Statistical analysis was performed with Kaplan-Meier curves and Cox-regression. RESULTS: The study finally included 383/473 PATIENTS: The most frequent patient type was a 74 year-old male with the digestive system as primary location, a median PPS and survival of 50%, and 30 days, respectively, and 53% died at home. PPS showed a statistically significant association with survival, showing that, per each 10% less PPS, the mortality risk increased by 3.1%. Delirium was present in 12.5% of the patients, and appeared to be an interaction variable in the Cox-regression. Patients with a better performance status in the first visit died more often in the hospital (P<.000). Those younger than 60 years old had a better performance status than older ones (PPS>40, P<.012). CONCLUSIONS: This study confirms that the PPS is also a prognostic tool in a home care setting in a population attended by Palliative Home Care Team. Delirium suggests a prognostic value that negatively interacts with the PPS estimation

Cuidados paliativos en las urgencias extra-hospitalarias: una urgencia formativa / Palliative care in outpatient emergencies: An educational urgency

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La sedación paliativa por sufrimiento existencial en atención primaria: una delgada línea roja / Palliative sedation for existential suffering in primary care: A thin red line

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Assessment of the impact of comorbidity on the survival of cancer patients treated by palliative care teams.

OBJECTIVE: The usefulness of the age-adjusted Charlson Comorbidity Index (ACCI) as a gauge of the impact of comorbidity on survival is known in the geriatric population. In palliative care, there is little research studying the correlation between comorbidity and survival in the advanced stages of oncological disease. The aim of our study was to explore the impact of comorbidity, measured with the ACCI, on survival in our patients. Our hypothesis was that higher ACCI scores would be associated with lower survival rates after the first visit. METHOD: We conducted a prospective observational study over one year. Patients were attended by palliative home care teams. The main variables were: survival from metastatic disease after the first visit and ACCI score on the first visit. We also employed a descriptive analysis and a Kaplan-Meier survival analysis, including different ranges of ACCI scores. RESULTS: The final sample included 66 subjects. The standard patient was a 76-year-old man with lung cancer who had received chemotherapy. The overall average ACCI score was 10.45. Significant differences were found between the different locations of metastatic disease (greater survivals in breast, ovary, and prostate; p = 0.005) and some treatments (hormone and radiotherapy; p = 0.001 for each), but not from the first visit. We found lower survival rates among lung cancer patients with higher comorbidity (ACCI ≥ 11, p = 0.047), with no differences on other primary locations or overall values. SIGNIFICANCE OF RESULTS: The data show that comorbidity measured by the ACCI may be an interesting prognostic factor during the late stages of disease, as we have found in lung cancer. More research is certainly needed.

Palliative sedation for cancer patients included in a home care program: a retrospective study.

OBJECTIVE: Palliative sedation is a common treatment in palliative care. The home is a difficult environment for research, and there are few studies about sedation at home. Our aim was to analyze this practice in a home setting. METHOD: We conducted a retrospective cross-sectional descriptive study in a home cohort during 2011. The inclusion criteria were as follows: 18 years or older and enrolled in the Palliative Home Care Program (PHCP) with advanced cancer. The variables employed were: sex, age, primary tumor location, and place of death. We also registered indication, type, drug and dose, awareness of diagnosis and prognosis, consent, survival, presence or absence of rales, painful mouth, and ulcers in patients sedated at home. We also collected the opinions of family members and professionals about the suffering of sedated patients. RESULTS: A total of 446 patients (56% at home) of the 617 admitted to the PHCP between January and December of 2011 passed away. The typical patient in our population was a 70-year-old man with a lung tumor. Some 35 (14%) home patients required sedation, compared to 93 (49%) at the hospital. The most frequent indication was delirium (70%), with midazolam the most common drug (mean dose, 40 mg). Survival was around three days. Rales were frequent (57%) as well as awareness of diagnosis and prognosis (77 and 71%, respectively). Perception of suffering after sedation was rare among relatives (17%) and professionals (8%). In most cases, the decision was made jointly by professionals and family members. SIGNIFICANCE OF RESULTS: Our study confirmed the role of palliative sedation as an appropriate therapeutic tool in the home environment.

Encuesta a profesionales de cuidados paliativos sobre la vivencia de la sexualidad de sus pacientes: ¿por qué no preguntamos sobre ello? / A survey of palliative care professionals on the sex life of their patients: why don’t we ask about it?

Objetivo: La prevalencia de disfunción sexual en nuestros pacientes es elevada, así como el deseo de poder hablar de ello con sus cuidadores. Nuestra praxis, sin embargo, es deficitaria a este respecto. Nos preguntamos si se pueden detectar condicionantes para ello en nuestra opinión, experiencia y percepción de competencia. Método: Estudio prospectivo descriptivo mediante encuesta anónima consistente en 10 preguntas. Se incluyó potencialmente a todo el personal sanitario de las unidades de ingreso y de atención domiciliaria de cuidados paliativos del Hospital San Juan de Dios en Navarra, con preguntas cerradas. El sexo, el rango de edad y la profesión se controlaron como variables independientes. Los datos se analizaron mediante valores porcentuales. Resultados: De la muestra potencial (n = 42, solo 3 varones), respondieron 37, la mayoría mujeres (35), enfermeras o auxiliares (81%). La mayoría (100%) cree que la enfermedad afecta en la vivencia, aunque solo la mitad (48%) que se debería preguntar por ello, y afirma necesitar formación (78%). La percepción de cualificación va creciendo con la edad (18% en < 30 años, 58%en > 41), así como la convicción de que es necesario preguntar (36% en < 30 años, 72% en > 41).Se solicita más ayuda a quien menos cualificado se percibe (0% a psicólogas, 30% a enfermeras y 72% a médicos). La propia vivencia (78%) no se percibe como condicionante. Conclusiones: La falta de consenso en la necesidad de abordar esta esfera en nuestra práctica clínica aparece como posible condicionante de nuestra praxis actual. Así mismo, en nuestra muestra, se le solicita ayuda a los que se perciben menos cualificados, lo cual seguramente contribuye a dificultar más nuestro abordaje. Una adecuada formación podría cambiar la dinámica divergente entre las necesidades de nuestros pacientes y nuestra respuesta insuficiente (AU)

Objective: the prevalence of sexual dysfunction in our patients is high, as is the wish to be able to talk about it with their carers. Our praxis, however, lacks in this respect. We ask ourselves is it possible to detect conditioning factors regarding this from our opinions, experiences and perception of our own competence. Method: A prospective study using an anonymous questionnaire consisting of 10 questions. This included almost all health care professionals in the admissions and homecare areas in palliative are in the hospital of San Juan de Dios in Navarra (Spain) using a closed question technique. The sex, age range and profession were used as independent variables. The data was then analysed using percentage values. Results: From the potential sample (n=42, only 3 men), 37 answered, the majority women (35),registered nurses and auxiliaries (81%). Everyone (100%) felt that the illness affects their sex life, however only half of these (48%) felt that they should ask about this, and all agreed that we need more professional development (78%). The idea that we need a professional development in this area increases with age (18% in <30 year old, 72% in >41). Those who ask for more help are those who feel less qualified (0% psychologists, 30% nurses and 72% doctors). The participants did not see their own life experience as a conditioning factor (78%).Conclusions: The lack of consensus over the need of asking about this problem appears to be aconditioning factor for our clinical practice. From our study it was seen that those who are less qualified see the need for support, which surely contributes to the way in which we deal with this. Good professional development could change this diverging dynamic within the needs of our patients and our poor response (AU)