How to conduct research in palliative care? A perspective from Italy.

BACKGROUND: In western countries, the increasing life expectancy and the growing number of individuals with advanced chronic conditions have resulted in a greater demand for palliative care. Specifically, Italy has witnessed substantial growth in the palliative care field, marked by the establishment of Palliative Care Networks and an academic fellowship program in 2022. To further enhance this field, it is crucial to conduct high-quality scientific research that produces results applicable in clinical practice. AIM: This article explores challenges and potential solutions in conducting effective palliative care research, considering sample definition, research settings, outcomes, and ethical concerns. While focusing on the Italian context, the presented research framework can be applied to other contexts and regions. RESULTS: Palliative care research is complex and challenging due to its holistic approach, which encompasses various vital dimensions of patients and their families, including physical, emotional, and social needs. The Italian and worldwide experience provides insights into managing these challenges and enhancing the methodological rigor of studies and the practical application of research findings. CONCLUSIONS: This article emphasizes the importance of developing protocols tailored to palliative care's unique characteristics, and the necessity of dedicated funding for palliative care research, calling for increased support and recognition. The article advocates for improvement of the quality and relevance of palliative care studies, promoting better patient outcomes and enhanced caregiving.

Causes of deaths in long-term care and hospice care facilities during the first year of COVID-19 pandemic: a snapshot of Italy during 2020.

BACKGROUND: Older adults living in long-term care facilities (LTCF) have been severely affected by COVID-19. Hospice care (HC) facilities and palliative care are essential in treating patients dying from COVID-19. In Italy, little is known about the impact of COVID-19 on deaths in LTCF and the care provided in HC to COVID-19 patients. AIM: To assess overall and case-specific mortality in 2020 in LTC and HC facilities in comparison to the previous five years (2015-2019). METHODS: We performed a descriptive study using data derived from the Italian national "Cause of Death" registry-managed by the Italian National Institute of Statistics-on deaths occurred in LTC and HC facilities during 2020 and the period 2015-2019. RESULTS: Number of deaths significantly increased in 2020 compared with 2015-2019 in LTCF (83,062 deaths vs. 59,200) and slightly decreased in hospices (38,788 vs. 39,652). COVID-19 caused 12.5% of deaths in LTCF and only 2% in hospices. Other than COVID-19, in 2020, cancer accounted for 77% of all deaths that occurred in HC, while cardiovascular diseases (35.6%) and psychotic and behavioral disorders (10%) were the most common causes of death in LTCF. Overall, 22% of the excess mortality registered in Italy during 2020 is represented by the deaths that occurred in LTCF. DISCUSSION AND CONCLUSION: LTCF were disproportionally affected by COVID-19, while the response to the pandemic in HC was limited. These data can help plan strategies to limit the impact of future epidemics and to better understand residential care response to COVID-19 epidemic.

Impact of the Covid-19 pandemic on palliative care provision by a hospital-based unit: results from an observational study.

Background Palliative care is a key approach in improving the quality of life of patients and their families facing the end-of-life care process. It is widely regarded as a public-health concern, especially considering the rapidly increasing end-of-life care needs worldwide. Its provision has been highly challenged by the COVID-19 pandemic emergency. Objective This study aims to analyse whether and to what extent the provision of Palliative Care to non-COVID patients provided by a hospital-based unit has changed during the COVID-19 pandemic. Material and methods A retrospective observational study was performed. All non-COVID patients admitted from October 1, 2019 to September 30, 2020 and evaluated by the hospital-based Palliative Care team were considered. Three time periods were considered: pre-lockdown, lockdown and post-lockdown. A trend analysis and multiple linear and logistic regressions to study and quantify the statistical significance of the associations were performed. Results A statistically significant positive linear trend of the number of hospitalized patients in need of Palliative Care was found over the study period. Compared to pre-lockdown, the rest of the study period presented more female and elderly patients, the length of stay and the number of patients discharged to a Hospice setting were significantly reduced. The waiting time did not change in lockdown but decreased in post-lockdown and the mortality rate was not significantly different. Also, the average number of Palliative Care consultations per patient significantly increased in the lockdown and post-lockdown. Discussion First, the significant admissions drop between the start of the pandemic and the following study period is in line with recent literature. The consequent rebound registered may be attributed to the high pressure from outside requiring admission and care. Second, the significantly older age of patients found during the lockdown than before the lockdown could be attributed to a "selection effect" of young patients, more able to delay hospitalization than the elderly, also in line with recent literature. Third, the shorter waiting time for Palliative Care activation the post-lockdown compared to the pre-lockdown period could be due to both increased hospital efficiency and to the greater pressure to discharge patients during the post-lockdown period. Also, the significant reduction in the lockdown and post-lockdown of the length of stay after Palliative Care activation could be explained considering both the greater receptivity of healthcare services outside the hospital, such as Hospices, and the greater pressure on hospital wards to discharge. Fourth, the unchanged in-hospital mortality rate remained over the entire period could be an indication of the high quality of care provided by this hospital setting to fragile patients, which is to be noted especially considering the average mortality rate registered during pandemic context in healthcare facilities. Conclusions The study aimed to quantify the impact of the COVID-19 on the provision of Palliative Care by a hospital-based team. We believe it might represent an innovative contribution and we hope similar research will be produced in order build the evidence for future challenges in this field.

Neurosurgical Defeats: Critically Ill Patients and the Role of Palliative Care Service.

The onco-functional balance in neuro-oncology requires maximizing tumor removal while rigorously preserving patients' neurological status. When postoperative worsening prevents the implementation of oncologic treatments, palliative care service offers an individualized path for symptom and psychosocial distress relief. Here, we report on a series of 25 patients operated on for malignant brain tumor who did not undergo adjuvant treatments after neurosurgery; they represented 3.9% of the whole institutional surgical series. These patients were significantly older and had a lower preoperative Karnofsky performance status than the whole cohort. Importantly, in 22 out of 25 (88%) cases, a surgical complication occurred, leading to clinical worsening in 21 patients. For the end of life, the majority of patients chose a hospice care facility (72%). While a careful selection of brain tumor patients candidate to neurosurgery is required, palliative care service provided invaluable help in coping with patients' and caregivers' needs.

The "develOpment of metabolic and functional markers of Dementia IN Older people" (ODINO) Study: Rationale, Design and Methods.

Mild cognitive impairment (MCI), also termed mild neurocognitive disorder, includes a heterogeneous group of conditions characterized by declines in one or more cognitive domains greater than that expected during "normal" aging but not severe enough to impair functional abilities. MCI has been associated with an increased risk of developing dementia and even considered an early stage of it. Therefore, noninvasively accessible biomarkers of MCI are highly sought after for early identification of the condition. Systemic inflammation, metabolic perturbations, and declining physical performance have been described in people with MCI. However, whether biological and functional parameters differ across MCI neuropsychological subtypes is presently debated. Likewise, the predictive value of existing biomarkers toward MCI conversion into dementia is unclear. The "develOpment of metabolic and functional markers of Dementia IN Older people" (ODINO) study was conceived as a multi-dimensional investigation in which multi-marker discovery will be coupled with innovative statistical approaches to characterize patterns of systemic inflammation, metabolic perturbations, and physical performance in older adults with MCI. The ultimate aim of ODINO is to identify potential biomarkers specific for MCI subtypes and predictive of MCI conversion into Alzheimer's disease or other forms of dementia over a three-year follow-up. Here, we describe the rationale, design, and methods of ODINO.

Simplified low-cost production of O-antigen from Salmonella Typhimurium Generalized Modules for Membrane Antigens (GMMA).

The Novartis Vaccines Institute for Global Health is developing vaccines using outer membrane particles, known as Generalized Modules for Membrane Antigens (GMMA). These are blebs of outer membrane and periplasm, shed from the surface of living Gram-negative bacteria following the targeted deletion of proteins involved in maintaining the integrity of the inner and outer membranes. The current study investigates the use of GMMA as starting material for extraction of membrane components, focusing on the O-antigen polysaccharide portion of lipopolysaccharide from Salmonella Typhimurium. We show that the amount of O-antigen extracted from GMMA by acid hydrolysis is comparable to the quantity extracted from whole wild type bacteria, but with less protein and DNA contaminants. Compared to conventional purification, GMMA enabled a reduction in the number of purification steps required to obtain the O-antigen polysaccharide with the same purity. Purification processes from GMMA and bacteria were characterised by similar final yields. Use of GMMA as starting material provides the possibility to simplify the purification process of O-antigen, with a consequent decrease in manufacturing costs of O-antigen-based glyconjugate vaccines against Salmonella strains and potentially other Gram-negative bacteria.

Dopaminergic agents and nutritional status in Parkinson's disease.

BACKGROUND: Malnutrition has been found in up to 24% of patients with Parkinson's disease; dopaminergic drugs might impair nutritional status. We evaluated the association of nutritional status with the use of dopaminergic agents. METHODS: We analyzed data from 75 elderly patients with Parkinson's disease attending a geriatric day hospital. Nutritional status was assessed by the Mini Nutritional Assessment (MNA). Dopaminergic drugs were normalized for weight. RESULTS: In linear regression, total levodopa (l-dopa) equivalent daily dose (LEDD) was associated with worse MNA (B = -0.14, 95% CI = -0.26--0.02; P = 0.019). This association remained significant only for l-dopa (B = -0.19, 95% CI = -0.32--0.52; P = 0.007), but not dopaminergic agent dosages. Increasing l-dopa dosages were associated with increasing probability of risk of malnutrition (P for trend = 0.049). CONCLUSIONS: In our population, LEDD was associated with worse nutritional status and risk of malnutrition; this association was limited to use of l-dopa.

Association of sarcopenia with short- and long-term mortality in older adults admitted to acute care wards: results from the CRIME study.

BACKGROUND: Sarcopenia is a common condition in older and frail populations, and it has been associated with adverse health outcomes. However, impact of sarcopenia on mortality in hospitalized older adults has rarely been evaluated. Aim of the present study was to investigate the association between sarcopenia and mortality during hospital stay and at 1 year after discharge in older individuals admitted to acute care wards. METHODS: This is a multicentre observational study involving 770 in-hospital patients. Muscle mass was quantified with the bioelectrical impedance analysis. The diagnosis of sarcopenia was based on the algorithm proposed by the European Working Group on Sarcopenia in Older People (EWGSOP). After discharge, participants were followed for 1 year. Mortality was assessed during hospital stay and during 1-year follow-up. RESULTS: Within the 770 participants (mean age: 81 ± 7 years, 56% women), sarcopenia was present in 214 (28%) of them, 22 participants died during hospital stay, and 113 in the year after discharge. Participants with sarcopenia had a significantly higher in-hospital (6% vs 2%; p = .007) and 1-year mortality (26% vs 14%; p < .001) as compared with participants without sarcopenia. After adjusting for potential confounders, sarcopenia resulted significantly associated with in-hospital (hazard ratio: 3.45; 95% CI: 1.35-8.86) and 1-year mortality (hazard ratio: 1.59; 95% CI: 1.10-2.41). CONCLUSIONS: Sarcopenia is a prevalent condition among older adults admitted to acute care wards and it is associated with increased short- and long-term mortality in hospitalized older adults.