Palliative care in kidney transplant recipients with graft failure.

Kidney transplantation is the best renal replacement therapy for patients with end stage kidney disease. It provides longer patient survival and better quality of life than dialysis. The clinical course after kidney transplantation could be complex and variable. Patients may develop various complications or even kidney graft failure. Symptom burden related to uraemia in patients with graft failure, and the side-effects of immunosuppression, cause psychological distress and adversely affect the quality of life of patients. Treatment decisions in patients with graft failure can be challenging to patients and their caregivers. Renal palliative care is an emerging field, but its adoption remains relatively low among kidney transplant recipients with progressive graft failure. In this context, timely consideration and referral for palliative care can improve symptom burden, reduce stress in patients and their caregivers, and facilitate treatment goal setting and advanced care planning. Common barriers to bring palliative care to suitable patients include: (I) misconception in patients, caregivers and healthcare providers that palliative care means abandonment of life sustaining treatment; (II) over-optimistic prognostic assessment and over-aggressive management approach; (III) insufficient awareness and training in palliative care of healthcare professionals; (IV) inadequate access to and insufficient resources in palliative care. Enhanced training and awareness, and further studies, would be needed to optimize the decision process and delineate the benefit of palliative care, and to guide evidence-based practice in the transplant population.

Management of Anemia in Renal Palliative Care Clinic: A Patient-Centered Approach.

BACKGROUND: Despite the growing needs in nondialytic alternatives for conservative kidney management, few studies have examined the management of anemia in palliative care (PC) outpatient clinics, which represent the key point of entry for timely access to PC. OBJECTIVE: A retrospective study to review for a patient-centered approach in anemia management and symptom control. RESULTS: Over the study period from July 2020 to March 2023, a total of 158 patients were seen at our renal PC clinic, 47 were included in data analysis. Patients had a mean age and glomerular filtration rate of 81.3 (9.5) years and 8.6 (5.3) mL/min/1.73 m2, and 68.1% and 44.7% were receiving erythropoiesis-stimulating agents (ESAs) and iron supplements respectively, with only 4.3% of patients required transfusion over past six months. Mean hemoglobin was maintained at 9.8 (1.4) g/dL, with a mean POS-S renal score of 4.7 (3.2). Majority of patients (93.6%) had satisfactory rating on "weakness and lack of energy" item. CONCLUSION: A patient-centered approach in anemia management at renal PC outpatient clinics may alleviate symptom burden and minimize transfusion requirement.

Rethinking Palliative Care in Psychiatry.

This Viewpoint describes specific issues related to severe mental illnesses for palliative care.

Incorporating transitional palliative care in a bone marrow transplant unit by serious illness conversation: a case report.

Background: Transplant professionals are specialized in providing lifesaving organs to patients in whom organ failure including bone marrow, in a way that gives strong hope to patients and families. We should be aware of that patients with advanced medical conditions must have an advanced care planning (ACP) in place, though it is difficult to balance possible outcomes and hope. Case Description: This case report showed our serious illness conversation program (SICP) could transit gradually a patient with bone marrow transplant (BMT) and palliative care (PC) needs to hospice care. Initially, she had difficulty in accepting the relapse of her hematological disease, with the main focus on disease treatment and blood parameters. After the transition, this patient's symptoms got better, she felt more stable emotionally, her muscle strength improved, and her hope was reignited because she wanted to go to her daughter's wedding. All these have been facilitated by the PC team. Conclusions: In this case, use of SIC can be regarded as a tool to facilitate better communication and so lead to faster and smoother transition to PC and subsequently hospice care. The use of chemotherapy (e.g., vidaza), on the other hand, had important palliative roles including for symptom control, maintaining patient's mobility and quality of life. Despite her condition being gradually deteriorated, her grief could be largely resolved if most of the wishes fulfilled.

Underwater Impact and Intention-Behaviour Gap of Scuba Divers on Coral Communities in Hong Kong SAR, China.

Recreational diving, under the continual growth of the scuba diving industry, may escalate coral reef damage as one of the substantial anthropogenic impacts and is of pressing concern. Besides unregulated and excessive diving activities, accidental contact with corals by inexperienced divers can cause recurring physical damage and heighten the pressure on coral communities. Understanding the ecological impacts of underwater contact with marine biota will thus be crucial to develop more sustainable scuba diving practices in Hong Kong. To probe the scuba diving impacts of divers' contact with coral communities, WWF-Hong Kong started a citizen science monitoring programme and invited 52 advanced divers to conduct direct underwater observations. Questionnaires were also developed to examine and address the research gap between the associated attitudes and the perceived contact rate of divers. Results from analysing the underwater behaviours of 102 recreational divers showed inconsistent perceived and actual contact rates. It was revealed that recreational divers might often overlook the ecological effects of their activities underwater on coral communities. The questionnaire findings will be utilised to improve the framework of the dive-training programmes and enhance divers' awareness to minimise their influence on the marine environment.

Rheumatology and palliative care: needs and opportunities.

Palliative care (PC) has expanded to medical conditions beyond its conventional scope of terminal malignancy and end-stage organ failure. This editorial showed our opinion in care model for the integration of PC into rheumatology and the growing needs of both rheumatology and PC services in view of increasing comorbidities and novel therapies. We anticipate an escalating demand for PC in this special group of patients who have concomitant long-standing systemic rheumatic diseases and age-related comorbidities. In addition, patients with advanced malignancy who develop rheumatological problems and require PC is also an emerging area of service need.

Comparison of the effects of sufentanil-dominant anaesthesia/analgesia and epidural anaesthesia/analgesia on postoperative immunological alterations, stress responses and prognosis in open hepatectomy: a randomized trial.

Background: Both in vitro and in animal studies have shown immunosuppressive effects of opioids which might provoke tumour growth and metastasis, while no definite results were shown in previous clinical studies. To find out the effects between general anaesthesia combined with sufentanil target-controlled infusion (SGA) and general anaesthesia combined with epidural anaesthesia (EGA) on immunological alterations, stress responses and prognosis in patients undergoing open hepatectomy, a prospective, non-inferiority, randomized-controlled study was performed. Methods: Patients with liver neoplasms undergoing open hepatectomy were randomly assigned to either SGA (n=81) or EGA (n=81) group. The primary outcome was the ratio of interferon (IFN)-γ/interleukin (IL)-4 at 24 h after surgery (T3). The secondary outcomes included immune-related cytokines, circulating immune cells, stress-related cytokines, cortisol and blood glucose, visual analogue scale scores. Plasma was sampled at five-time points [baseline/before surgery (T0), 5 min after portal block release (T1), 1 h after surgery (T2), T3, and on a postoperative day (POD)5 (T4)]. Cancer-related outcomes, including recurrence, metastasis and survival, were followed up at 3 months and 1 year after surgery. Results: The IFN-γ/IL-4 ratios were comparable between both groups at T3 {median [interquartile range (IQR)]: 20.78 (12.73-29.18) vs. 19.52 (13.98-29.29), P=0.607}. At T3, the proportions of circulating T cells were decreased, while those of B and natural killer cells were increased. The plasma level of tumour necrosis factor (TNF)-α at T2 was significantly higher in the SGA group [median (IQR): 7.45 (6.20-9.80) vs. 5.95 (4.95-7.45) pg/mL, P<0.001]. Patient-controlled intravenous analgesia was less effective than epidural analgesia on POD0 and POD2. For hepatocellular carcinoma (HCC)-related outcomes, no significant differences were found in either short- or long-term follow-ups. Conclusions: Although the levels of TNF-α were higher in the SGA group, the tumour-related immunological alterations and follow-ups showed no difference between groups. SGA appears not to be inferior to EGA regarding tumour-related immunity and prognosis. Intravenous opioid use appears not to be inferior to epidural anaesthesia, and can be used safely in HCC patients without worsening patients' prognosis. Trial Registration: Chinese Clinical Trial Registry (No. ChiCTR2000035299).

Supportive care and symptom management in patients with advanced hematological malignancies: a literature review.

BACKGROUND AND OBJECTIVE: Recent advances have led to cure or long-term disease control for patients with hematological malignancy (HM). Unfortunately, some of them still have poor prognoses and are often associated with significant symptom burden and poor quality of life for patients and families. These patients usually require supportive care including red blood cell and platelet transfusion, due to disease itself and the oncological treatment, apart from their symptom management. However, there is currently lack of the literatures review in these aspects. The objective of this review is to summarize practical supportive care recommendations for physicians or nurses practicing in palliative care (PC)/hematology-oncology unit, starting with core approaches in use of blood products for anemia and thrombocytopenia, management of tumor lysis syndrome, PC and oncology nursing care. METHODS: Evidence for this review was obtained from a search of the Cochrane database, PubMed, guidelines of European Society of Medical Oncology, British society of Hematology, American Society of Clinical Oncology, National Comprehensive Cancer Network and peer-reviewed journal articles. KEY CONTENT AND FINDINGS: For asymptomatic cancer patients who are anaemic, a threshold of haemoglobin level of 7 g/dL is considered to be safe and generally favored for blood transfusion. 'Single-unit' red cell transfusion is safer and at least as effective as 'double-unit' transfusion. Prophylactic platelet transfusion should be given to stable patients without bleeding and with platelet count less than 10×109/L. In febrile patients, the threshold is lifted to 20×109/L. There are also recommendations for the use of blood products during COVID-19 pandemic. In general, HM patients were more prone to painful infections when compared with solid cancer patients. Thus, antibiotics to treat underlying infections should be applied whenever possible and as required to control pain. CONCLUSIONS: This narrative review showed the recent literatures in the supportive care and symptom management of advanced HM patients. However, it is limited by some of the 'evidence-based' recommendations for interventions (including symptom management) based on early phase of HM populations rather than those receiving end-of-life care.

Effects of high-dose opioid analgesia on survival, pain relief, quality of life and adverse drug reactions in cancer and neuropathic pain patients: a retrospective cohort study in real-world clinical practice.

Background: Pain is a common symptom among cancer patients and directly affects their prognosis. As the leading drug for pain management, opioids are widely prescribed. So it is necessary to get people a correct understanding and application of opioids. In order to examine whether the use of high-dose opioids might affect survival and quality of life, this retrospective cohort study was performed to explore the outcomes of patients receiving high-dose opioids for pain management in a first-class tertiary hospital in China. Methods: We retrospectively searched medical records of inpatients and outpatients with pain who were treated with opioids in The First Affiliated Hospital, Zhejiang University School of Medicine from July to December 2021. Forty-three cases who were treated with high-dose opioids meeting inclusion criteria. Among these patients, 37 had cancer pain and 6 had neuropathic pain. All patients had regular follow-up when readmission until to April 7, 2022. Medical records of patients on high-dose opioids (equivalent to morphine ≥300 mg/d) was collected, including numerical rating scale (NRS), Karnofsky performance score (KPS), survival and adverse drug reactions (ADRs). Pain relief, quality of life, survival, and ADRs of patients after pain treatment were analyzed and evaluated. Results: The NRS score was significantly reduced and pain was relieved after high-dose opioid treatment. The before and after average NRS score of cancer pain was 5.2±1.6 vs. 2.2±1.1 points (P<0.001), neuropathic pain was 5.0±2.2 vs. 1.3±1.2 points (P<0.05), respectively. Although there is no statistical difference, quality of life showed a trend of improvement compared with before treatment. The before and after average KPS scores of cancer pain patients was 55.7±17.3 vs. 62.4±20.0, and neuropathic pain patients was 71.7±9.0 vs. 83.3±4.7. There were no intolerable ADRs. The median survival time was 238 days and 83 days in patients with cancer pain who received high-dose opioids and ultra-high dose opioids (equivalent to morphine ≥600 mg/d). Conclusions: Multimodal high-dose opioid pain treatments are important approaches to effectively relieve moderate to severe pain and improve the quality of life of patients. This study provides a clinical basis for future pain treatment with high-dose opioids.

Choosing the best way for urinary decompression and developing a novel predictive model for septic shock using SOFA in these patients.

OBJECTIVES: To identify predictive factors for the development of sepsis/septic shock postdecompression of calculi-related ureteric obstruction using the Sequential Organ Failure Assessment (SOFA) score and to compare clinical outcomes and odd risk ratios of patients developing sepsis/septic shock following the insertion of percutaneous nephrostomy (PCN) versus insertion of retrograde ureteral stenting (RUS). METHODS: Clinico-epidemiological data of patients who underwent PCN and/or RUS in two institutions for calculi-related ureteric obstruction were retrospectively collected from January 2014 to December 2020. RESULTS: 537 patients (244 patients in PCN group, 293 patients in RUS group) from both institutions were eligible for analysis based on inclusion and exclusion criteria. Patients with PCN were generally older, had poorer Eastern Cooperative Oncology Group status, and larger obstructive ureteral calculi compared to patients with RUS. Patients with PCN had longer durations of fever, the persistence of elevated total white cell and creatinine, and longer hospitalization stays compared with patients who had undergone RUS. RUS up-front has more unsuccessful interventions compared with PCN. There were no significant differences in the change in SOFA score postintervention between the two interventions. In multivariate analysis, the higher temperature just prior to the intervention (adjusted odds ratio [OR]: 2.039, p = 0.003) and Cardiovascular SOFA score of 1 (adjusted OR:4.037, p = 0.012) were significant independent prognostic factors for the development of septic shock postdecompression of ureteral obstruction. CONCLUSIONS: Our study reveals that both interventions have similar overall risk of urosepsis, septic shock and mortality rate. Despite a marginally higher risk of failure, RUS should be considered in patients with lower procedural risk. Patients going for PCN should be counseled for a longer stay. Post-HDU/-ICU monitoring, inotrope support postdecompression should be considered for patients with elevated temperature within 1 h preintervention and cardiovascular SOFA score of 1.

Incorporating emotion coaching into behavioral parent training program: evaluation of its effectiveness.

Disruptive behaviors in childhood yield negative mental health outcomes. Both behavioral management and emotion coaching parenting programs were effective in reducing children's disruptive behaviors. This randomized control trial (RCT) study evaluated the effectiveness of a community clinic-based, parent training program that incorporated emotion coaching into behavioral training (BPEC) for 119 parents who expressed difficulty in handling their elementary school-aged children's disruptive behaviors. These parents were randomly assigned to the treatment group or waitlist control. Pre-tests, post-tests, and 3-month delayed post-tests were administered. Compared to those in the waitlist control group, participants in the BPEC group reported significantly (a) fewer child oppositional behaviors and ADHD symptoms and (b) more positive aspects of the parent-child relationship. Significant short-term effects were maintained after 3-month for parent-reported, child oppositional behaviors. Thus, BPEC effectively reduced the disruptive behaviors of children.

Impact of enhanced haematology palliative care services in patients with myelodysplastic syndrome and acute myeloid leukaemia: study protocol for a randomized controlled trial.

BACKGROUND: Patients with acute myeloid leukaemia (AML) and myelodysplastic syndrome (MDS) suffer from a significant symptom burden and psychological, spiritual, social needs comparable to patients with solid metastatic malignancy. Referral to palliative care services for these haematological patients remains limited or often confined to the last days of life. We pioneered a palliative care (PC) program integrated with standard haematological care. The purpose of this trial will study the interventions by the PC team and preliminary results in the clinical outcomes. METHODS: This project is a non-blinded, randomized, controlled trial. In this study, we examine the clinical outcomes of the integrated PC program for MDS/AML patients when the 2nd lines disease treatment failed and in the presence of prognostic indicators. In group 1, patients will receive standard haematological care associated with PC (i.e., intervention group). In contrast, in group 2, patients will receive standard haematological care only (i.e., control group) with PC service only on a request basis. Patients who join the program would have to complete a standardized questionnaire to assess their quality of life and their psychological and physical symptoms. RESULTS: This is to exam the impact of the early integrated palliative care with enhanced psychosocial interventions to both advanced MDS/AML patients and their primary family members in Hong Kong. DISCUSSION: This protocol will not display any result. If future results demonstrate that the enhanced PC interventions are effective, they will provide a quality treatment plan for patients with MDS/AML. TRIAL REGISTRATION: The Hong Kong University/Hospital Authority Hong Kong West Institutional Review Board (HKU/HA HKW IRB). The registration number is UW 19-824.

Early integrated palliative care for haematology cancer patients-the impact on symptom burden in Hong Kong.

BACKGROUND: Evidence showed that early palliative care could have many benefits in clinical outcomes for patients living with advanced medical illnesses. In fact, most of these studies have not involved patients with advanced haematologic cancer (HC), which are known to be associated with significant physical and psychological symptoms. In Hong Kong, an Early Integrated Palliative Care (EIPC) collaboration involving both Heamatology unit of Queen Mary Hospital (QMH) and the Palliative Medical Unit of Grantham Hospital (GH) has been started since early 2018 as a better way to improve the service gap. The HC patients failed 2 or more lines of cancer treatment are identified during the joint round and hematology clinic. Some of these patients will be referred to our PC services. Our joint PC clinic has multidisciplinary input from palliative care physicians, hematologists, and clinical psychologists. The clinic program is well coordinated and structured. The HC patients are initially seen by the parent team for disease treatment and then by GH PC team for symptom control and psychosocial care. METHODS: This was a retrospective study with a review of the clinical charts and electronic healthcare records of all patients who attended the Hematology PC clinic from June 2018 to September 2020. For the inclusion criteria, patients were found eligible if they had prospectively completed Edmonton Symptom Assessment Scale (ESAS) assessments for at least the initial and follow-up visits within a range of ≥7 days and ≤60 days of the first visit. RESULTS: Thirty-eight patients ultimately agreed to the referral. The mean age was 70.5 (12.5) years old. Twenty-five patients (66%) had myelodysplastic syndrome (MDS); 10 (26%) had acute myeloid leukemia (AML). Around 50-60% of patients reported significant symptoms of fatigue, anxiety, drowsiness, and anorexia; 42% of patients had significantly depressed moods while 37% had pain. There were significant symptom improvements for pain, depression, and anxiety after follow-up visits. CONCLUSIONS: The study showed that our EIPC program resulted in a significant reduction in some of the important symptom item scores, including pain, anorexia, anxiety, and depression, after the follow-up visits.