Circadian rhythm disorders in patients with advanced cancer: a scoping review.

Circadian rhythms can be demonstrated in several biomarkers and behavioural activities, with rhythmical patterns occurring roughly over a 24-h period. Circadian disorders occur in patients with cancer and may be associated with poor clinical outcomes. This scoping review aimed to identify circadian rhythm research and reporting practices, circadian rhythm patterns, circadian rhythm disorders, and relevant associations of circadian rhythm disorders in patients with advanced cancer. Studies involved adult patients with locally advanced or metastatic cancer and used objective measures of circadian rhythmicity. Two independent authors completed initial screening of title and abstracts, full text reviews, data extraction, and data checking. A total of 98 articles were highlighted in the scoping review, which utilised physical activity measures (actigraphy and polysomnography), biomarkers (cortisol and melatonin), or a combination. Several circadian rhythms are commonly disordered amongst patients with advanced cancer and have significant implications for symptom burden, quality of life, and survival. It remains unclear which patients are most at risk of a circadian rhythm disorder. Significant heterogeneity exists in research and reporting practices. Standardising this approach may address discrepancies in the current literature and allow for research to focus on the most relevant parameters and approaches to improving circadian rhythmicity.

Vital Signs in Palliative Care: A Scoping Review.

Vital signs are routinely measured in secondary healthcare settings and can be used to detect clinical problems, guide treatment, and monitor response to treatment. Vital signs are less frequently measured in palliative care settings. Reasons for this are unclear. This scoping review aimed to assess the generic use of vital signs in palliative care, and its role in prognostication for adult patients with cancer receiving palliative care. Medline, Embase, and CINAHL were searched for articles involving adult patients with advanced cancer receiving palliative care who had their vital signs measured. Twenty-six articles were identified in which one or a combination of vital signs, with or without other clinical parameters, was used to prognosticate for patients. An additional three articles investigated the generic use of vital signs in patients with advanced cancer. There was significant heterogeneity between identified studies, with some indication that changes in vital signs may indicate that a patient is close to death. However, other studies suggested that patients may maintain normal vital signs until the time of death. Further studies are needed to explore whether abnormal vital signs may be used as a prognostic indicator for patients with cancer receiving palliative care.

Advance care planning for patients with chronic obstructive pulmonary disease on home non-invasive ventilation: A qualitative study exploring barriers, facilitators and patients' and healthcare professionals' recommendations.

BACKGROUND: Although home non-invasive ventilation for patients with chronic obstructive pulmonary disease and persisting hypercapnia prolongs time to hospital readmission and prognosis, they retain a poor long-term prognosis. Requiring non-invasive ventilation in this population should trigger advance care planning, yet only 50% of patients are engaged in such discussions. AIM: This study aimed to explore the barriers and facilitators to advance care planning for patients with chronic obstructive pulmonary disease on home non-invasive ventilation and generate recommendations for improving practice. STUDY DESIGN: A cross-sectional interview study took place with 10 patients with chronic obstructive pulmonary disease on home non-invasive ventilation and 12 North East Assisted Ventilation Service healthcare professionals from the North East of England. RESULTS: Three themes ('overlooked', 'disjointed care' and 'awareness and expertise') were identified. Patients with chronic obstructive pulmonary disease are a 'forgotten about' population, exacerbated by prejudice and unpredictable disease trajectories. Recognition as a distinct and underserved population may improve care and advance care planning. All participants recognised a lack of care continuity, including limited collaboration and communication between services, as a significant barrier to advanced care planning. Additionally, lacking understanding of the rationale and positive impacts of advance care planning, exacerbated by a lack of expertise in difficult conversations, was a barrier to advance care planning. CONCLUSIONS: Patients and healthcare professionals highlighted the need for individualised and ongoing advance care planning, particularly around prognosis and care preferences. Discussions should be initiated by familiar clinicians. Effective communication between services, clear agreements and protocols and upskilling healthcare professionals may ensure continuity of care.

International e-Delphi Consensus Recommendations for the Assessment and Diagnosis of Circadian rest-Activity Rhythm Disorders (CARDs) in Patients with Cancer.

PURPOSE: Circadian rest-Activity Rhythm Disorders (CARDs) are common in patients with cancer, particularly in advanced disease. CARDs are associated with increased symptom burden, poorer quality of life, and shorter survival. Research and reporting practices lack standardization, and formal diagnostic criteria do not exist. This electronic Delphi (e-Delphi) study aimed to formulate international recommendations for the assessment and diagnosis of CARDs in patients with cancer. METHODS: An international e-Delphi was performed using an online platform (Welphi). Round 1 developed statements regarding circadian rest-activity rhythms, diagnostic criteria, and assessment techniques. Rounds 2 and 3 involved participants rating their level of agreement with the statements and providing comments until consensus (defined internally as 67%) and stability between rounds were achieved. Recommendations were then created and distributed to participants for comments before being finalized. RESULTS: Sixteen participants from nine different clinical specialties and seven different countries, with 5-35 years of relevant research experience, were recruited, and thirteen participants completed all three rounds. Of the 164 generated statements, 66% achieved consensus, and responses were stable between the final two rounds. CONCLUSIONS: The e-Delphi resulted in international recommendations for assessing and diagnosing CARDs in patients with cancer. These recommendations should ensure standardized research and reporting practices in future studies.

Specialist Palliative Care for Patients with Cancer: More Than End-of-Life Care.

Palliative care has traditionally focused on end-of-life care for patients with advanced cancer. This has since expanded to include symptom management and quality-of-life improvement from the moment of cancer diagnosis. Specialist palliative care teams work across community and inpatient settings and focus on dealing with complex problems whilst supporting healthcare colleagues in providing generalist palliative care. This article will outline the principles of palliative care, models of palliative care delivery, the distinctions between palliative care and supportive care, and the role of specialist palliative care in cancer survivorship.

Palliative care simulation for internal medicine trainees: development and pilot study.

OBJECTIVES: Shape of training has recognised that 'Managing End-of-Life and Applying Palliative Care Skills' is a key competency for internal medicine trainees. It provides the opportunity and challenge to improve palliative care training for generalist physicians. Simulation has been recognised internationally as a holistic teaching and assessment method. This study aimed to produce a palliative medicine simulation training package for internal medicine trainees for delivery by palliative medicine trainees providing the former opportunity to practice assessment and management of patients with life-limiting illness and the latter teaching and management opportunities. METHODS: A regional group of palliative medicine trainees were trained in simulation and debrief. Nominal and focus group techniques designed a simulation training package. Learning outcomes were mapped to the internal medicine curriculum descriptors. RESULTS: Palliative simulation for internal medicine trainees (PALL-SIM-IMT) is a training package meeting internal medicine trainees' curriculum requirements. Regional pilots have demonstrated feasibility for delivery by palliative medicine trainees and improvement in recipients' confidence in all curriculum descriptors. CONCLUSIONS: PALL-SIM-IMT can aid competency achievement for the provision of generalist palliative care by internal medicine trainees. It allows reciprocal development of palliative medicine trainees' leadership and teaching skills. National adoption and evaluation is ongoing.

Denosumab-induced hypocalcaemia in metastatic gastric cancer.

Hypocalcaemia in malignancy is infrequently reported and the underlying cause is often multifactorial. Denosumab, an antiresorptive medication, can be used to treat a number of cancer-related complications including hypercalcaemia, metastatic bone pain and to reduce fracture-events. We present a case of a hospice inpatient with profound and recurring hypocalcaemia following a single denosumab infusion which required repeated hospitalisation, for intravenous calcium, alongside a prolonged course of vitamin D and electrolyte replacement. The case highlights the risk of hypocalcaemia with denosumab use, together with the need to identify and treat vitamin D deficiency in both the prevention and management of such a complication.

BET 2: prophylactic antiemetic use in immobilised adult trauma patients.

A short-cut review was carried out to establish whether prophylactic antiemetic agents reduce the incidence of vomiting in immobilised patients who have suffered trauma. A total of 137 papers were found using the reported searches, of which two presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. It is concluded that prophylactic use of antiemetic agents in trauma patients may reduce the likelihood of vomiting some 5-12-fold.