Predicting 60-Day Mortality in a Home-Care Service: Development of a New Inter-RAI 49-Frailty Index in Patients with Chronic Disease and without a Cancer Diagnosis.

OBJECTIVE: Frailty Index (FI) is used to define the level of frailty in various clinical settings. Fifteen- and 26-item FIs have been demonstrated to predict 1-year mortality and intensity of care in home care (HC) and palliative home care (PHC). The objective of this study was to develop a new FI to predict the 60-day risk of death or transition to a PHC service after the initiation of an HC service in patients with chronic disease and without a cancer diagnosis. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Patients 18 years and older followed in an HC service of a "Frailty Department-Local Palliative Care Network" from January 1, 2017, to October 31, 2021. METHODS: A 49-item FI (FI-49) was developed selecting variables within the standardized international Residential Assessment Instrument assessments (interRAI-HC) and compared to existing FIs with 15 and 26 variables. RESULTS: A total of 2099 patients were included in the study with a median age of 80.0 years (IQR: 72.0-86.0) and a predominantly female population (62.4%). Among these patients, 8% died or were transferred to PHC within the 60-day follow-up. The FI-49 demonstrated a higher ability to predict 60-day mortality (C index 0.8165, 95% CI 0.7848-0.8481) compared to the 26- and 15-item FI. An FI-49 cutoff of 0.33 was also selected to provide clinicians with a more practical approach (C-index of 0.7044, 95% CI 0.6796-0.7292). CONCLUSION AND IMPLICATION: The FI-49 is a good predictor of short-term mortality or transition to palliative care among older patients referred to an HC service. The automatic calculation of this tool could facilitate more appropriate care planning and the correct allocation of healthcare resources, especially considering the rapid ageing of the population.

Prognostic Role of NECPAL CCOMS-ICO Tool on One-Year Mortality in a Hospitalized Older Population.

Background: It is essential to establish both the appropriateness of palliative care (PC) and the prognosis in daily clinical practice to guide decision making in the management of older people with multiple advanced chronic diseases. Objectives: We assessed patients who were appropriate for PC using the NECPAL tool in a hospitalized older population and then we investigated its predictive validity on one-year mortality compared with the multidimensional prognostic index (MPI), a validated geriatric prognostic tool. Design: Prospective cohort study. Setting/Subjects: We enrolled 103 older adults hospitalized for acute medical and surgical conditions in a geriatric hospital in Italy. Measurements: The variables of interest were obtained at baseline through interviews of the ward medical staff and by consulting the computerized medical records. Long-term mortality (one-year) was assessed through the analysis of data acquired from hospital or territorial databases or through telephone contact with caregivers. Results: Mean age was 86.8 ± 7.2 years, with a female prevalence of 54.4%. Prevalence of NECPAL+ patients was 65.1%. MPI low risk: 30.1%; moderate risk: 41.7%; severe risk: 28.2%. Patients deceased during follow-up were 54.4%. NECPAL+ patients were more likely to die, even after adjusting for age, sex, and MPI score (hazard ratio [HR] 2.7, p = 0.020). All the NECPAL categories were associated with one-year mortality. MPI showed a better predictive power than NECPAL (area under the curve [AUC] 0.85 vs. 0.75, p = 0.030). After the exclusion of "Comorbidity: ≥2 concurrent diseases" item from NECPAL, its AUC increased to 0.78 with no statistically significant differences from MPI (p = 0.122). Conclusions: NECPAL is useful to identify the appropriateness of PC in hospitalized older adults, also allowing to predict long-term mortality with a performance similar to that of a validated geriatric prognostic tool.

Assessing the Costs of Home Palliative Care in Italy: Results for a Demetra Multicentre Study.

BACKGROUND: The sustainability of palliative care services is nowadays crucial inasmuch as resources for palliative care are internationally scarce, the funding environment is competitive, and the potential population is growing. METHODS: The DEMETRA study is a multicentre prospective observational study, describing the intensity of care and the related costs of palliative home care pathways. RESULTS: 475 patients were enrolled as recipients of specialized palliative home care. The majority of recipients were cancer patients (89.4%). The mean duration of palliative care pathways was 46.6 days and mean home care intensity coefficient equal to 0.6. The average daily cost of the model with the reference variables is 96.26 euros. Factors statistically significantly associated with an increase in mean daily costs were greater dependence and extreme frailty (p < 0.05). Otherwise, a longer duration of treatment course was associated with a significant decrease in mean daily costs (p < 0.001). CONCLUSIONS: In terms of clinical and organizational management, considering the close association with the intensity and cost of the path, frailty should be systematically assessed by all facilities that potentially refer patients to home palliative care teams, and it should be carefully recorded in a standardized payment rate perspective.

The Relationship between Practitioners and Caregivers during a Treatment of Palliative Care: A Grounded Theory of a Challenging Collaborative Process.

The possibility of coming to a "good death" is a challenging issue that crosses ethical and religious beliefs, cultural assumptions, as well as medical expertise. The provision of palliative care for relieving patients' pain is a practice that reshapes the path to the event of death and gives form to a particular context of awareness, recalling the notion proposed by Glaser and Strauss. This decision redesigns the relationships between patients, practitioners and caregivers and introduces a new pattern of collaboration between them. Our study focuses on the implications of the collaboration between practitioners and caregivers, starting from the assumption that the latter may provide support to their loved ones and to the practitioners, but need to be supported too. We provide a qualitative analysis of this collaboration based on an empirical research that took place in four different settings of provision of palliative care, reporting the contrast between the affective engagement of caregivers and the professional approach of practitioners. We claim that this ambivalent collaboration, while embedded in contingent and incommensurable experiences, brings to the fore the broader understanding of the path to a "good death," outlining its societal representation as a collective challenge.

An update on antithrombotic therapy in atrial fibrillation patients in long-term ambulatory setting after percutaneous coronary intervention: where do we go from here?

INTRODUCTION: In the treatment of patients with atrial fibrillation (AF) who undergo percutaneous coronary intervention (PCI), it is unclear which combination of antithrombotic drugs is preferable and which is the optimal duration of treatment. AREAS COVERED: The authors review the available evidence in this area resulting from single studies and meta-analyses. In the absence of direct head-to-head comparisons between different non-vitamin K oral anticoagulants (NOAC), the authors review the available studies with NOACS in these patients and derived indirect comparisons. EXPERT OPINION: In patients with AF who undergo PCI, a dual antithrombotic strategy which includes a NOAC plus single antiplatelet therapy with a P2Y12 inhibitor (preferably clopidogrel) should be considered as the preferred treatment option in most cases. Oral anticoagulation associated with dual antiplatelet therapy (triple antithrombotic therapy) should be offered for no longer than 30 days to patients with very high thrombotic and low hemorrhagic risk. It is unclear whether the dual antithrombotic strategy should be continued beyond 12 months in patients at high risk of thrombotic events. Additional data from adequately powered controlled studies are needed to support the long-term efficacy of this strategy and to establish the best patient-tailored approach in this complex scenario.

Ablation of atrial tachycardia in the setting of prior mitral valve surgery.

BACKGROUND: Data regarding catheter ablation of post-surgical atrial tachycardia occurring after mitral valve surgery are scarce. Through a search of the literature, this study aimed to assess the feasibility of catheter ablation and the characteristics of atrial arrhythmias ablated in these patients. METHODS: Studies assessing the main procedure parameters and the electrophysiologic findings of the investigated atrial tachycardia were selected. The electrophysiologic mechanism (focal vs. re-entrant arrhythmias), site of arrhythmia origin (left atrium vs. right atrium) and their anatomic correlation with specific surgical access and/or prior Cox-Maze IV procedure were all addressed. RESULTS: Eleven studies including 206 patients undergoing catheter ablation of 297 post-surgical arrhythmia morphologies occurring after mitral valve surgery were considered. Major complications were observed in 2 patients only (0.9%). Restoration of sinus rhythm was achieved in 96% of patients. Macro-reentrant arrhythmia was mostly observed (90.4%) with a non-negligible proportion of focal arrhythmia (9.6%). Left-sided arrhythmia was common (54.4%,) but cavotricuspid isthmus-dependent arrhythmia was frequently reported (33%). Although specific atriotomies showed trends towards peculiar locations of the investigated arrhythmia, Cox-Maze IV procedure was the only independent predictor for left-sided arrhythmia (OR=17.3; 95% CI 7.2-41.2; P<0.0001). CONCLUSIONS: Catheter ablation of post-surgical arrhythmia occurring after mitral valve surgery is feasible, and, in this setting, the vast majority of the arrhythmia morphologies are based on macro-reentry and in about one third of cases show cavotricuspid isthmus-dependent arrhythmia. Prior Cox-Maze-IV associated with mitral valve surgery is an independent predictor of left-sided arrhythmia possibly due to non-transmural surgical lesions.

Impact of Palliative Care in Evaluating and Relieving Symptoms in Patients with Advanced Cancer. Results from the DEMETRA Study.

Background: Cancer patients experience multiple symptoms throughout the course of the disease. We aimed to provide a comprehensive analysis of the symptom burden in patients with advanced cancer at admission to specialist palliative care (PC) services and seven days later to estimate the immediate impact of PC intervention. Patient and methods: The analysis was based on an observational, prospective, multicenter study (named DEMETRA) conducted in Italy on new patients accessing network specialist PC centers during the period May 2017-November 2017. The prevalence and intensity of symptoms were assessed at baseline and after seven days using three tools including the Edmonton Symptom Assessment System (ESAS). Results: Five PC centers recruited 865 cancer patients. Thirty-three different symptoms were observed at the baseline, the most frequent being asthenia (84.9%) and poor well-being (71%). The intensity of the most frequent symptoms according to ESAS ranged from 5.5 for asthenia to 3.9 for nausea. The presence and intensity of physical symptoms increased with increasing levels of anxiety and depression. After seven days, prevalence of nausea and breathlessness as well as intensity of almost all symptoms significantly decreased. Conclusions: The study confirmed the considerable symptom burden of patients with advanced cancer. PC intervention has significantly reduced the severity of symptoms, despite the patients' advanced disease and short survival.

COVID-19 emergency and palliative medicine: an intervention model'.

OBJECTIVES: The aim of this work is to describe the multidisciplinary model of intervention applied and the characteristics of some COVID-19 patients assisted by the hospital palliative care unit (UCP-H) of an Italian hospital in Lombardy, the Italian region most affected by the COVID-19 pandemic. METHODS: A retrospective study was conducted on patients admitted to the A. Manzoni Hospital (Lecco, Lombardy Region, Italy) and referred to the UCP-H between 11 March 2020 and 18 April 2020, the period of maximum spread of COVID-19 in this area. Data were collected on the type of hospitalisation, triage process, modality of palliative care and psychological support provided. RESULTS: 146 COVID-10 patients were referred to the UCP-H. Of these, 120 died during the observation time (82%) while 15 (10.2%) improved and were discharged from the UCP-H care. 93 had less favourable characteristics (rapid deterioration of respiratory function, old age, multiple comorbidities) and an intensive clinical approach was considered contraindicated, while 48 patients had more favourable presentations. Mean follow-up was 4.8 days. A mean of 4.3 assessments per patient were performed. As to respiratory support, 94 patients were treated with oxygen only (at different volumes) and 45 with Continuous Positive Airway Pressure (CPAP). CONCLUSION: The ongoing pandemic highlighted the need for dedicated palliative care teams and units for dying patients. This work highlights how palliative medicine specialist can make a fundamental contribution thanks to their ability and work experience in an organised multiprofessional context.

Clinical Care Conditions and Needs of Palliative Care Patients from Five Italian Regions: Preliminary Data of the DEMETRA Project.

In order to plan the right palliative care for patients and their families, it is essential to have detailed information about patients' needs. To gain insight into these needs, we analyzed five Italian local palliative care networks and assessed the clinical care conditions of patients facing the complexities of advanced and chronic disease. A longitudinal, observational, noninterventional study was carried out in five Italian regions from May 2017 to November 2018. Patients who accessed the palliative care networks were monitored for 12 months. Sociodemographic, clinical, and symptom information was collected with several tools, including the Necesidades Paliativas CCOMS-ICO (NECPAL) tool, the Edmonton Symptom Assessment System (ESAS), and interRAI Palliative Care (interRAI-PC). There were 1013 patients in the study. The majority (51.7%) were recruited at home palliative care units. Cancer was the most frequent diagnosis (85.4%), and most patients had at least one comorbidity (58.8%). Cancer patients reported emotional stress with severe symptoms (38.7% vs. 24.3% in noncancer patients; p = 0.001) and were less likely to have clinical frailty (13.3% vs. 43.9%; p < 0.001). Our study confirms that many patients face the last few months of life with comorbidities or extreme frailty. This study contributes to increasing the general knowledge on palliative care needs in a high-income country.

Catheter ablation of atrial tachycardias after mitral valve surgery: A systematic review and meta-analysis.

INTRODUCTION: Data regarding catheter ablation (CA) of atrial tachycardias (ATs) occurring after mitral valve surgery (MVS) are scarce. The aim of this study was to assess the safety and efficacy of CA of ATs in this surgical population through a systematic review of the literature and meta-analysis. METHODS: A systematic search on PubMed/MEDLINE, EMBASE, and Web of Science was performed considering patients undergoing CA for ATs occurring after MVS. Periprocedural thromboembolic and hemorrhagic complications were assessed. The acute success and maintenance of sinus rhythm (SR) at a mid (<24 months) and long-term follow-up (FU) after CA were investigated along with the burden of arrhythmic recurrence at FU. RESULTS: Fourteen studies for a total of 227 patients were considered. Three-dimensional (3D) mapping systems were used in all studies. Only two major bleedings were recorded with a pooled estimate of periprocedural major complications of 0%. The acute success after CA was 95% with a clear improvement over time. Although maintenance of SR was 71% at a midterm FU, long-term efficacy was as low as 47% due to an increased burden of atrial fibrillation (AF) recurrence despite multiple procedures/patient. CONCLUSION: In this meta-analysis, CA of postsurgical ATs after MVS proved safe and effective but with still a significant burden of AF recurrence at more than 24 months of FU due to a progressive atrial substrate deterioration. The improvement of procedural success over time might suggest a learning curve in optimizing the use of 3D mapping systems.

Factors influencing outcomes of rheolytic thrombectomy on thrombosed dialysis access grafts: Door to angiographic bed time and what else?

BACKGROUND: The aim of this study was to investigate the effect of the time interval from clinical presentation of arteriovenous graft thrombosis and the thrombectomy procedure by the AngioJet system in terms of technical and clinical success and to identify factors influencing success. METHODS: A total of 60 consecutive patients (35 men and 25 women; mean age = 52 ± 7.89 years) who had undergone percutaneous thrombectomy by the AngioJet device from 2016 to 2019 were retrospectively enrolled. Demographics and fistula data, previous treatments, time from clinical onset of thrombosis to intervention, procedural details and complications were recorded. Technical and clinical success and primary and secondary patency rates were calculated. One-way analysis of variance was performed to test any correlation between patient-related and fistula/procedure-related variables and technical/clinical success. Odds ratio and relative risk were also calculated when necessary. RESULTS: Technical success and clinical success were 95% and 91.7%, respectively. Post-interventional primary and secondary patency rates at 1 year were 72.5% and 84.3%, respectively. Complication rate was 6.7%. One-way analysis of variance showed that clinical success was higher in patients with no previous treatment (p = 0.015). Furthermore, clinical success was significantly associated with door to angiographic bed time (p = 0.002): p-value for the 24-h and the 72-h cut-off was 0.012 and 0.006, respectively. CONCLUSION: Percutaneous rheolytic thrombectomy is safe and effective for thrombosed arteriovenous grafts, with acceptable primary and secondary patency rates. Higher clinical success was found in patients never treated before and when the procedure was carried out within 24 h from the clinical onset of thrombosis.

Predicting care intensity in geriatric home care patients: a comparison of different measures.

BACKGROUND: Dependency in older ages is increasing. Many older persons receive care while living in the community. We aimed to identify the predictive value of four clinical measurements to predict home care intensity in older patients following discharge from hospital to home care over 90 days. METHODS: We included 425 inpatients from the "Frailty Department-Local Palliative Care Network" of the local social health authority (ASST) Lecco, Italy (mean age 75.4 years, SD 14.5; female 75.5%). Changes in Health, End-stage disease, and Signs and Symptoms, light version (CHESS-Lite), activities of daily living (ADL), frailty, and the Service Urgency Algorithm. Receiver operative curves were used to calculate the area under the curve (AUC) for predicting Home Care Intensity coefficient (ratio of the number of days when any home care was provided 90 days post-discharge). The interRAI Contact Assessment Instrument was used to calculate these measures. RESULTS: Analysis was stratified using six different home care intensity score cut-offs. CHESS-Lite had a higher AUC for predicting home care intensity at all cut-off levels but was best for predicting the highest level of home care intensity (≥ 0.8) where the AUC was 0.71 (0.64-0.79). The frailty index also had an acceptable AUC. ADL had the lowest AUC. CONCLUSIONS: Health instability measured with CHESS-Lite has a high predictive value for identifying home care intensity in geriatric patients after discharge from hospital to home, especially in persons with higher home care intensity scores. Geriatric patients with high health instability should be focused on at discharge to prioritize assessment and initiate timely services for home care support.

Challenges in Narrow QRS Complex Tachycardia Interpretation.

Several arrhythmogenic substrates may generate narrow QRS complex tachycardia, frequently encountered in clinical practice. Some narrow QRS complex tachycardias, however, are sustained by an uncommon arrhythmogenic mechanism. Although rare, these forms should be taken into account in the differential diagnosis to avoid misdiagnosis and improper patient management. Dual atrioventricular node physiology can be responsible for different uncommon forms of narrow QRS complex tachycardia, also nonreentrant in mechanism. A ventricular origin also is possible, if the tachycardia site is located in the upper ventricular septum with fast ventricular propagation to the specific conduction system and narrowing of the QRS complex.

In-stent restenosis associated with dual-layer Roadsaver carotid artery stent: a retrospective single-center study.

AIM: To evaluate the incidence of in-stent restenosis (ISR) at 12-month follow-up, in patients treated with new dual-layer Roadsaver (Terumo Corp, Tokyo, Japan) carotid artery stent (CAS). MATERIALS AND METHODS: Thirteen patients underwent CAS and received a Roadsaver. Neurological examination was performed in all patients. Carotid stenosis was revealed by Doppler ultrasound (DUS) and multidetector CT (MDCT) scan. Four patients presented a peak systolic velocity (PSV) between 130 and 150 cm/s, six a PSV between 150 and 180 cm/s, and three a PSV > 180 cm/s. MDCT gave further anatomic information. Direct stenting was performed in 11 (84.6%) cases, whereas in 2 (15.4%) cases predilatation was required. In all cases postdilatation was performed. Technical and clinical success and safety were evaluated. Stent patency was evaluated during the 12-month follow-up. RESULTS: Technical success was achieved in all cases. In three patients a nonsignificant residual stenosis < 30% has been reported. No major complications during or after the procedure occurred. One patient (7.7%) showed a transitory bradycardia during angioplasty. One (7.7%) local bleeding at the puncture site treated conservatively occurred. All the neurological examinations performed 24 h and 30 days after the procedure were negative. No significant ISR was registered. In 2 patients, < 30% ISR was revealed at DUS performed after 6 months and confirmed at 12 months. In both patients CEUS and MDCT denied the presence of significant stenosis. CONCLUSIONS: Roadsaver stent seems to be durable. Further studies with longer-term outcome are necessary to confirm our results.

Investigation on Dabigatran Etexilate and Worsening of Renal Function in Patients with Atrial fibrillation: The IDEA Study.

BACKGROUND AND OBJECTIVES: Warfarin-related nephropathy is an unexplained acute kidney injury, and may occur in patients with supratherapeutic INR, in the absence of overt bleeding. Similar findings have been observed in rats treated with dabigatran etexilate. We conducted a prospective study in dabigatran etexilate-treated patients to assess the incidence of dabigatran-related nephropathy and to investigate the possible correlation between dabigatran plasma concentration (DPC) and worsening renal function. METHOD: One hundred and seven patients treated long term with dabigatran etexilate for non-valvular atrial fibrillation (NVAF) were followed up for 90 days. DPC, serum creatinine (SCr) and serum cystatin C were prospectively measured. Ninety five patients had complete follow-up data and were evaluable for primary endpoint. RESULTS: Eleven patients had supratherapeutic DPC, defined as DPC higher than 200 ng/ml at study enrolment, but at the end of follow-up no patient showed a persistent increase in SCr. No patients experienced acute kidney injury. CONCLUSIONS: Our study shows that no persistent renal detrimental effect is associated with dabigatran treatment. An increase in SCr during dabigatran treatment is reversible and it seems to be unrelated to dabigatran itself.

Monitoring the Italian Home Palliative Care Services.

BACKGROUND: In Italy, there currently is a lack of reliable and consistent data on home palliative care provided to people near death. OBJECTIVES: Monitoring the activities of the Italian Home Palliative Care Services, according to the 2014 national data collection program entitled "Observatory of Best Practices in Palliative Care" and providing process/outcome measures on a subsample (Best Practice Panel), on regulatory standards and on complete/reliable activity data. DESIGN: A data collection web portal using two voluntary internet-based questionnaires in order to retrospectively identify the main care activity data provided within the year 2013 by Home care units. In the Best Practice Panel and International best practices, eligibility and quality measures refer to the national standards of the NL 38/2010. Setting/Subject: Home Palliative Care Services (HPCSs) that provided care from January to December 2013. RESULTS: 118 Home care units were monitored, globally accounting for 40,955 assisted patients within the year 2013 (38,384 cancer patients); 56 (47.5% of 118) were admitted in the Best Practice Panel. Non-cancer (5%) and pediatric (0.4%) patients represented negligible percentages of frail care patients, and a majority of patients died at home (respectively nearly 75% and 80% of cancer and non-cancer patients). CONCLUSION: The study demonstrated the feasibility of the collection of certified data from Home care services through a web-based system. Only 80% of the facilities met the requirements provided by the Italian NL 38/2010. Moreover, the extension of the palliative care services provided to frail non-cancer and pediatric patients, affected by complex and advanced chronic conditions, is still inadequate in Italy.

"Before I die I want to ": An experience of death education among university students of social service and psychology.

The censorship of death and dying has removed the "memento mori" practices, and in order to reintroduce this practice, some "Before I die" projects have been increasingly implemented. Running in parallel, in the syllabi of social service and psychology students, some experiences of death education has commenced. This study illustrates the results of a qualitative research conducted on the "Before I die I want to …" Polaroid® Project (BIDIWT), which is divided into two phases. The first phase entails an analysis of the wishes collected from the United States, Japan, India, and Italy. The second phase refers to the analysis of the captions of the BIDIWT realized from two groups of undergraduates, with regard to the effect of such experience on their religiosity, representation of death, and fear of death.

Perioperative Safety and Efficacy of Different Anticoagulation Strategies With Direct Oral Anticoagulants in Pulmonary Vein Isolation: A Meta-Analysis.

OBJECTIVES: The purpose of this study was to evaluate the safety and efficacy of uninterrupted and interrupted direct oral anticoagulant (DOAC) administration in patients undergoing pulmonary vein isolation (PVI). BACKGROUND: The optimal periprocedural management of DOACs in patients undergoing PVI is not well defined, and different strategies are used. METHODS: A systematic search of PubMed/MEDLINE, Ovid/MEDLINE, and EMBASE was performed. Three strategies for periprocedural DOAC administration were considered: uninterrupted, mildly interrupted (<12 h), and interrupted (≥12 h). Primary endpoints were major bleeding (MB) and thromboembolic (TE) complications; pooled weighted mean incidence (WMI) was calculated using a random-effects model. A secondary endpoint was the WMI of overall bleeding (OB). RESULTS: The analysis included 43 studies for a total of 8,362 patients. DOACs showed similar safety and efficacy in the 3 subgroups. The WMI of MB was 1.02%, 1.49%, and 1.17% for the uninterrupted, mildly interrupted, and interrupted strategy, respectively; the WMI of TE complications was 0.16%, 0.46%, and 0.49% for the uninterrupted, mildly interrupted, and interrupted strategy, respectively, with no heterogeneity. OB appeared to be higher in uninterrupted (6.33%) and mildly interrupted (8.62%) groups compared with the interrupted (3.53%), with substantial heterogeneity among studies. No interaction was found between the incidence of MB and TE complications and different DOACs. CONCLUSIONS: In patients undergoing PVI, these 3 anticoagulation strategies may have similar safety and efficacy in terms of MB and TE complications. OB appears to be higher in uninterrupted and mildly interrupted strategies compared with the interrupted strategy. No substantial differences were observed among DOACs regarding the incidence of MB and TE complications.