Factors influencing length of survival in ambulatory palliative care - a cross sectional study based on secondary data.

BACKGROUND: Quality of life and patient self-determination are key elements in successful palliative care. To achieve these goals, a robust prediction of the remaining survival time is useful as it can provide patients and their relatives with information for individual goal setting including appropriate priorities. The Aim of our study was to assess factors that influence survival after enrollment into ambulatory palliative care. METHODS: In this cross-sectional, multicenter study (n = 14 study centers) clinical records of all palliative care patients who were treated in 2017 were extracted and underwent statistical analysis. The main outcome criterion was the association of survival time with clinical characteristics such as age, type of disease, symptoms and performance status. RESULTS: A total of 6282 cases were evaluated. Median time of survival was 26 days (95 % CI: 25-27 days). The strongest association for an increased hazard ratio was found for the following characteristics: moderate/severe weakness (aHR: 1.91; 95 % CI: 1.27-2.86) Karnofsky score 10-30 (aHR: 1.80; 95 % CI: 1.67-1.95), and age > 85 (aHR: 1.50; 95 % CI: 1.37-1.64). Surprisingly, type of disease (cancer vs. non-cancer) was not associated with a change in survival time (aHR: 1.03; 95 % CI: 0.96-1.10). CONCLUSIONS: In this cross-sectional study, the most relevant predictor for a short survival time in specialized ambulatory palliative care was the performance status while type of disease was irrelevant to survival.

[Specialized Outpatient Palliative Care: Results of a Cross-Sectional Study]. / Spezialisierte ambulante Palliativversorgung (SAPV) ­ Querschnittsanalyse von Symptomlast, Diagnosen und Sterbeort über 7 Jahre an einem Standort in NRW.

OBJECTIVE: Specialized outpatient palliative care (SAPV) is an important component in the care of people in their final days of life in Germany. The analysis of a representative cohort allows important conclusions to be drawn for improving the situation of people in palliative care in Germany. METHODS: We analyzed the routine data of 2691 palliative patients collected during the care of an SAPV team. Statistical analyses were performed using SPSS version 24. RESULTS: In SAPV, approximately three-fourths of patients died in their homes. Of the total of 2691 patients, 1972 suffered from a malignancy and 719 patients had a non-malignant, chronic disease. The age at first contact with SAPV was significantly higher in patients without malignancy. Patients with or without malignancy did not differ from each other in terms of quality of life (Karnofsky's score) or symptom frequency. Only disorientation was documented significantly more frequently in non-tumor patients and was also more pronounced. CONCLUSION: SAPV enables the fulfilment of the wish of most patients to die in their homes.

Specialized Outpatient Palliative Care­Clinical Course and Predictors for Living at Home Until Death

BACKGROUND: Specialized outpatient palliative care (SOPC) is an important component of the palliative medicine care concept in Germany. Its purpose is to improve the out-of-hospital care of patients who cannot be adequately cared for by their primary care physicians and in the setting of general outpatient palliative care (GOPC). METHODS: In this retrospective analysis of anonymized routine treatment data, we analyzed the characteristics of SOPC patients overall and with specific diseases, and depicted them both numerically and graphically. We also carried out a regression analysis of the factors affecting whether or not patients will be able to die in a home environment. RESULTS: The analysis included data from 14 460 patients who were treated by 14 different SOPC teams in the North Rhine area of Germany in 2017 and 2018. The majority of patients who died were able to live at home until death (85.9%); only a small percentage died as inpatients (7.7%). The symptom burden shortly before death was less than at the beginning of treatment. The factors displaying a statistically significant association with dying at home were: more advanced age (aOR 0.96; 95% CI: [0.95; 0.96]), female sex (aOR 0.85; 95% CI: [0.74; 0.98]), and house calls at night (aOR 0.60; 95% CI: [0.51; 0.71]). CONCLUSION: SOPC met its declared objectives of limiting distressing symptoms and enabling patients to live at home until death.

Living donor and split-liver transplants in hepatitis C recipients: does liver regeneration increase the risk for recurrence?

Concern exists that partial liver transplants (either a living donor [LD] or deceased donor [DD] in hepatitis C virus (HCV)-positive recipients may be associated with an increased risk for recurrence. From 1999 to 2003, at our institution, 51 HCV-positive recipients underwent liver transplants: 32 whole-liver (WL) transplants, 12 LD transplants and 7 DD split transplants. Donor characteristics differed in that WL donors were older, and LD livers had lower ischemic times. Recipient characteristics were similar except that mean MELD scores in LD recipients were lower (p < 0.05). With a mean follow-up of 28.3 months, 46 (90%) recipients are alive: three died from HCV recurrent liver disease and two from tumor recurrence. Based on 1-year protocol biopsies, the incidence of histologic recurrence in the three groups is as follows: WL, 81%; LD, 50% and DD split, 86% (p = 0.06 for LD versus WL). The mean grade of inflammation on the biopsy specimens was: WL, 1.31; LD, 0.33 and DD split, 1.2 (p = 0.002 for LD versus WL; p = 0.03 for LD versus DD split). Mean stage of fibrosis was: WL, 0.96; LD, 0.22 and DD split, 0.60 (p = 0.07 for LD versus WL). Liver regeneration does not seem to affect hepatitis C recurrence as much, perhaps, as factors such as DD status, donor age and cold ischemic time.

A comparison of surgical outcomes and quality of life surveys in right lobe vs. left lateral segment liver donors.

Concern remains regarding the possibly higher risk to living liver donors of the right lobe (RL), as compared with the left lateral segment (LLS). We studied outcomes and responses to quality of life (QOL) surveys in the two groups. From 1997 to 2004, we performed 49 living donor liver transplants (LDLTs): 33 RL and 16 LLS. Notable differences included a higher proportion of female and unrelated donors in the RL group. A significantly larger liver mass was resected in RL (vs. LLS) donors: 720 (vs. 310) g, p = 0.01; RL donors also had greater blood loss (398 vs. 240 mL, p = 0.04) and operative times (7.2 vs. 5.7 h, p = 0.05). However, those findings did not translate into significant differences in donor morbidity. The complication rate was 12.5% in LLS donors and 9.1% in RL donors (p = ns). Per a QOL survey at 6 months postdonation, no significant differences were noted in SF-12 scores for the two groups. Recovery times were somewhat longer for RL donors. Mean time off work was 61.0 days for RL donors and 32.4 days for LLS donors (p = 0.004). RL donation is associated with greater operative stress for donors, but not necessarily with a more complicated recovery or differences in QOL.

[Time factor and repopulation during fractionated radiotherapy. Comparison between two xenografted human squamous cell carcinoma]. / Zeitfaktor und Tumorrepopulierung während einer fraktionierten Radiotherapie. Vergleich zweier xenotransplantierter Plattenepithelkarzinome.

BACKGROUND: A series of experiments were performed to determine the local tumour control of two human squamous cell carcinoma lines in nude mice. An accelerated-fractionated radiation therapy regime is compared to a conventional-fractionated therapy regime. MATERIAL AND METHODS: KB is a well established human nasopharyngeal squamous cell carcinoma line (ATCC CCL 17). In nude mice KB grows as an low differentiated carcinoma. PEC MB is an undifferentiated squamous cell carcinoma of the maxillary sinus, which was successfully established in nude mice by our group 1993. Both tumors were serially passaged in nude mice. Local irradiation was given without anaesthesia under ambient conditions to air breathing animals using 18 MeV electrons of an linear accelerator (Mevatron 77, Siemens, Munich). Each dose level group consists of six to eight animals. The radiation treatments were given in ten equals fractions using graded dose levels of 2, 3, 4.5, 6 and 8 Gy. The interfraction time interval was 6 hours in the accelerated-fractionated group and 24 hours in the conventional-fractionated group (Figure 1). In the conventional-fractionated group a therapy break was given after 5 fractions for 72 h. The endpoint of the experiments was the dose, which was necessary to control 50% of the tumors (TCD(50)). The TCD(50) values were calculated after 60 days (Tables 1a and 1b). RESULTS: The experiments show, that with increasing overall treatment time of 8 3/4 days using the same number of fractions under ambient conditions the tumor control dose of the tumor KB increases from 36.3 Gy (95% CI 30.9...42.7) to 44.3 Gy (38.3...51.2) (Figure 2a). For the tumor PEC MB the tumor control dose increases from 39.5 Gy (33.4...46.7) to 45.5 Gy (37.0...56.0 (Figure 2b). CONCLUSION: This observed increase of the dose necessary to control the squamous cell carcinoma KB and PEC MB can be caused by repopulation of clonogenic tumors cells, however, other mechanism such as an increasing fraction of hypoxic tumor cells can not be ruled out.

Simulator verification of the accuracy of patient repositioning after virtual simulation. Is physical simulation still needed?

PURPOSE: To evaluate the frequency and amount of displacements after repositioning a patient on the physical simulator following virtual simulation. MATERIAL AND METHODS: After laser marking at the CT scanner and virtual simulation, patients were repositioned on the simulator. The isocenter obtained from the calculated table movements was checked by fluoroscopically measuring the distances to standardized anatomic landmarks and comparing them to the treatment plan. RESULTS: In 86% of patients, displacements were < or = 0.5 cm. There was no significant difference between the supine and prone position, diagnosis categories or CT reconstruction indices. The use of immobilization devices and cranial versus body stem localization did make a significant difference. Rates of exact repositioning were high in brain and head and neck patients and comparatively low in abdominal tumors and breast cancer. CONCLUSIONS: Immobilization devices play an important role for the precision of radiotherapy. Whenever precise positioning is possible (e. g. with a head mask), virtual simulation alone might be sufficient. Patients with abdominal and breast tumors, were repositioning precision is often suboptimal, might profit from an additional physical simulation.

Radiation-induced changes of telomerase activity in a human Ewing xenograft tumor.

AIM: The effect of ionizing irradiation on telomerase activity and further associated biological factors was evaluated in a human Ewing tumor xenograft model on nude mice. MATERIAL AND METHODS: The human Ewing tumor cell line STA-ET-1 was established in a nude mouse model. Initially, the dose-response relationship for the tumor model was established. For the radiation experiments two dose levels were chosen: 5 Gy and 30 Gy. After 5 Gy, there was no significant growth delay whereas after 30 Gy there was a marked growth delay without the induction of a complete remission. Tumors were examined 6, 12, 24, 48, 72, and 96 hours post irradiation. After irradiation with 30 Gy further time points were 6, 9, 12 and 15 days. For each dose and time group, three tumors were evaluated. RESULTS: There was a reduction of telomerase activity after 5 Gy to 50% (not statistically significant) after 3 days; however, after 30 Gy there was a reduction of telomerase activity to 23% of the initial value after 6 days (p = 0.001). Telomerase activity correlated with the expression of human telomerase reverse transcriptase (hTERT), but not with the expression of telomerase-associated protein (TP1) and human telomerase RNA (hTR). The maximal amounts of necrosis or apoptosis after 30 Gy were 19% and 6.9%, respectively. CONCLUSIONS: Ionizing radiation reduces telomerase activity and the expression of hTERT which cannot be explained by the induction of necrosis or apoptosis alone. The reduction of telomerase activity may contribute to delayed cell death after radiotherapy. The combined use of radiation and specific telomerase inhibitors may be a potentially synergistic treatment strategy.