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For the global-scale multimedia live streaming services, both of the cost-efficiency at the service provider side and the Quality of Experience (QoE) satisfaction at the viewer side need to be achieved. This is a difficult challenge because the request patterns of global live-streaming services are highly dynamic. In this paper, we solve this issue by cloud-based adaptive resource allocation. We first present a cloud-based multi-tier architecture, called MaaS (Media as a Service), which consists of four types of modules. The main issue that we focus on is the deployment of properly dimensioned MaaS modules in proper geographical regions. We take the QoE of the Dynamic Adaptive Streaming over HTTP viewers into account for this decision. We propose a combination of deep-learning based demand prediction scheme and a dynamic-programming based heuristic to make a good tradeoff between viewers' QoE and the cloud resource cost. Extensive evaluation shows that the proposed scheme clearly outperforms the existing schemes. [ABSTRACT FROM AUTHOR]

Key points: There is a lack of data on the self‐perceived burden (SPB) of terminal cancer patients at their very end of life.In this multicenter Korean study, terminal cancer patients perceived their burdensomeness from their family caregiver perspective.To relieve patients' SPB, physicians should pay attention to dyads with the features identified in this study. [ABSTRACT FROM AUTHOR]

Aim: The presence of periodontal disease (PD) at a single time point has been suggested as a predictor of diabetes risk, but whether changes in PD status are associated with altered risk of diabetes is yet to be reported on a population scale. This study investigated whether recovery from or development of PD in a population is associated with an altered risk of diabetes occurrence. Materials and Methods: Data of subjects who received health screening from 2002 to 2007 were obtained from the National Health Insurance Service–National Health Screening cohort database of Korea. Patients with a history of diabetes were excluded. Changes in PD status were determined from the first two health screenings. Study subjects were divided into four groups according to the changes in PD status: PD‐free, PD‐recovered, PD‐developed, and PD‐chronic. The outcome was the occurrence of diabetes. Results: Overall, 111,611 subjects were included for analysis. During a median follow‐up of 9.10 years, diabetes developed in 6102 subjects. The adjusted hazard ratios (HRs) for incident diabetes across various PD change groups (in reference to the PD‐free group) were as follows: PD‐chronic group = 1.096 (95% confidence interval [CI] 1.026–1.170, p =.006); PD‐developed group = 1.073 (95% CI 0.993–1.159, p =.075); and PD‐recovered group = 1.019 (95% CI 0.945–1.100, p =.622). The subjects who recovered from PD had a lower diabetes risk than those who had consistent PD (adjusted HR 0.930, 95% CI 0.865–1.000, p =.050), whereas those who developed PD had a higher risk of diabetes than those who remained PD‐free. Conclusion: The longitudinal change in PD status is associated with incident diabetes risk. Future intervention studies are necessary to determine whether PD treatment can prevent incident diabetes. [ABSTRACT FROM AUTHOR]

The article discusses palliative care education in the Asia Pacific. Topics discussed include need to further develop and promote access to quality hospice and palliative care in the Asia Pacific; online palliative care education resource for multidisciplinary healthcare students and educators; and landscape of palliative care education in Australia.

Background: Well detection of the symptoms and signs of dying patients is essential for providing proper palliative care. Our goal is to evaluate the predominant symptoms and compare the changes in dying patients with digestive tract cancer in Japan, South Korea, and Taiwan.Methods: A total of 1057 cancer patients aged 18 years or older admitted in palliative care units with locally advanced or metastatic gastroesophageal, colorectal, and pancreaticobiliary cancer were enrolled from January 2017 to March 2019. The severity of physical and psychological symptoms and signs assessed by physicians and/or nurses upon admission, 1 week after admission, and within 3 days of death, was compared according to cancer type and country of origin.Results: Among the 338 gastroesophageal, 358 pancreaticobiliary, and 361 colorectal cancer patients, 894 (93.1%) died during the observation period. Fatigue was the most severe symptom in all cancer groups before dying. Dyspnea, fatigue, drowsiness, and ascites improved after hospitalization albeit they worsened prior to death. In particular, ascites was a marked symptom in patients with pancreaticobiliary cancer. Delirium and hallucination gradually worsened during the period leading to death. Differences in manifestations with respect to the country of origin were not significant.Conclusion: We identified the most prevalent signs and symptoms in patients from East Asia who were dying from digestive tract cancers. Proper management, based on these prevalent signs and symptoms during the dying period, plays a vital role in providing adequate palliative care. [ABSTRACT FROM AUTHOR]

Background: Limited data are available on how the timing and setting of palliative care (PC) referral can affect end-of-life care. In this retrospective cohort study, the authors examined how the timing and setting of PC referral were associated with the quality of end-of-life care.Methods: All adult patients residing in the Houston area who died of advanced cancer between September 1, 2009 and February 28, 2010 and had a PC consultation were included. Data were retrieved on PC referral and quality of end-of-life care indicators.Results: Among 366 decedents, 120 (33%) had an early PC referral (>3 months before death), and 169 (46%) were first seen as outpatients. Earlier PC referral was associated with fewer emergency room visits (39% vs 68%; P<.001), fewer hospitalizations (48% vs 81%; P<.003), and fewer hospital deaths (17% vs 31%; P5.004) in the last 30 days of life. Similarly, outpatient PC referral was associated with fewer emergency room visits (48% vs 68%; P<.001), fewer hospital admissions (52% vs 86%; P<.001), fewer hospital deaths (18% vs 34%; P5.001), and fewer intensive care unit admissions (4% vs 14%; P5.001). In multivariate analysis, outpatient PC referral (odds ratio [OR], 0.42; 95% confidence interval [CI], 0.28-0.66; P<.001) was independently associated with less aggressive end-of-life care. Men (OR, 1.63; 95% CI, 1.06-2.50; P5.03) and hematologic malignancies (OR, 2.57; 95% CI, 1.18-5.59; P5.02) were associated with more aggressive end-of-life care.Conclusions: Patients who were referred to outpatient PC had improved end-of-life care compared with those who received inpatient PC. The current findings support the need to increase the availability of PC clinics and to streamline the process of early referral. [ABSTRACT FROM AUTHOR]

BACKGROUND Limited data are available on how the timing and setting of palliative care (PC) referral can affect end-of-life care. In this retrospective cohort study, the authors examined how the timing and setting of PC referral were associated with the quality of end-of-life care. METHODS All adult patients residing in the Houston area who died of advanced cancer between September 1, 2009 and February 28, 2010 and had a PC consultation were included. Data were retrieved on PC referral and quality of end-of-life care indicators. RESULTS Among 366 decedents, 120 (33%) had an early PC referral (>3 months before death), and 169 (46%) were first seen as outpatients. Earlier PC referral was associated with fewer emergency room visits (39% vs 68%; P < .001), fewer hospitalizations (48% vs 81%; P < .003), and fewer hospital deaths (17% vs 31%; P = .004) in the last 30 days of life. Similarly, outpatient PC referral was associated with fewer emergency room visits (48% vs 68%; P < .001), fewer hospital admissions (52% vs 86%; P < .001), fewer hospital deaths (18% vs 34%; P = .001), and fewer intensive care unit admissions (4% vs 14%; P = .001). In multivariate analysis, outpatient PC referral (odds ratio [OR], 0.42; 95% confidence interval [CI], 0.28-0.66; P < .001) was independently associated with less aggressive end-of-life care. Men (OR, 1.63; 95% CI, 1.06-2.50; P = .03) and hematologic malignancies (OR, 2.57; 95% CI, 1.18-5.59; P = .02) were associated with more aggressive end-of-life care. CONCLUSIONS Patients who were referred to outpatient PC had improved end-of-life care compared with those who received inpatient PC. The current findings support the need to increase the availability of PC clinics and to streamline the process of early referral. Cancer 2014;120:1743-1749. © 2014 American Cancer Society. [ABSTRACT FROM AUTHOR]

Abstract: A method based on PCR-restriction fragment length polymorphism analysis (PRA) using a novel region of the hsp65 gene was developed for the rapid and exact identification of mycobacteria to the species level. A 644 bp region of hsp65 in 62 mycobacteria reference strains, and 4 related bacterial strains were amplified, and the amplified DNAs were subsequently digested with restriction enzymes, namely, AvaII, HphI, and HpaII. Most of the mycobacteria species were easily differentiated at the species level by the developed method. In particular, the method enabled the separation of M. avium, M. intracellulare and M. tuberculosis to the species level by AvaII digestion alone. An algorithm was constructed based on the results and a blind test was successfully performed on 251 clinical isolates, which had been characterized by conventional biochemical testing. Our results suggest that this novel PRA offers a simple, rapid, and accurate method for the identification of mycobacteria culture isolates at the species level. [Copyright &y& Elsevier]

Purpose: Recent guidelines for prognostic evaluation recommend clinicians’ prediction of survival (CPS) for survival prediction in patients with advanced cancer. However, CPS is often inaccurate and optimistic. Studies on factors associated with overestimation or underestimation of CPS are limited. We aimed to investigate the factors associated with the overestimation and underestimation of CPS in patients with far-advanced cancer. Methods: The current study was a secondary analysis of an international multicenter prospective cohort study, which enrolled newly admitted patients with advanced cancer in palliative care units (PCUs) in Japan, Korea, and Taiwan from 2017 to 2018. We obtained the temporal CPS at enrollment and performed multivariate logistic regression analysis to identify the factors associated with “underestimation (less than 33% of actual survival)” and “overestimation (more than 33% of actual survival).” Results: A total of 2571 patients were assessed and admitted in 37 PCUs between January 2017 and September 2018. Older age (adjusted odds ratio [aOR] 1.01; 95% confidence interval [CI] 1.01–1.02; P < 0.01) and reduced oral intake (aOR 0.68; 95% CI 0.51–0.89; P < 0.01) were identified as significant factors associated with underestimation. Dyspnea (aOR 1.28; 95% CI 1.06–1.54; P = 0.01) and hyperactive delirium (aOR 1.34; 95% CI 1.05–1.72; P = 0.02) were identified as significant factors associated with overestimation. Conclusion: Older age was related to underestimation, while dyspnea and hyperactive delirium were related to overestimation of CPS for patients with weeks of survival. However, reduced oral intake was less likely to lead to underestimation. [ABSTRACT FROM AUTHOR]

Context: Spiritual well-being (SWB) is significant for patients with life-limiting illnesses. Thus, shortened versions of questions would be helpful in approaching SWB.Objectives: Our goal was to develop a one-item screening question to assess the SWB of advanced cancer inpatients.Methods: This was a cross-sectional, multicenter study involving adult advanced cancer inpatients from seven palliative care units in South Korea. The candidate one-item questions were three questions scored using numeric rating scales from 0 to 10: feeling at peace (Are you at peace?), self-rated spirituality (Do you think of yourself as a spiritual person?), and self-rated religiosity (Do you think of yourself as a religious person?). The Functional Assessment of Chronic Illness Therapy-Spirituality 12 (FACIT-Sp-12) comprised of two subscales Meaning/Peace and Faith was used to assess SWB. Pearson's correlation test was conducted to determine the relationship between the three questions, the total FACIT-Sp-12 score, and its subscales.Results: A total of 202 patients were enrolled. A strong correlation was observed between self-rated spirituality (r = 0.732 and 0.790; P < 0.001 and < 0.001 respectively) and religiosity (r = 0.708 and 0.758; P < 0.001 and < 0.001 respectively) with the total FACIT-Sp-12 scores and faith subscale scores. Feeling at peace showed a moderate correlation with the total of FACIT-Sp-12 scores (r = 0.505, P < 0.01). All three questions had a moderate correlation with the meaning/peace subscale.Conclusion: Self-rated spirituality and religiosity showed better convergence validity than feeling at peace. Therefore, we recommend self-rated spirituality or religiosity as a one-item question for screening SWB in inpatients with advanced cancer. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study was to evaluate the effectiveness of the intraoral use of subperiosteally placed self-inflating tissue expanders for subsequent bone augmentation and implant integrity. Material and methods: A prospective, multicenter, randomized controlled trial was performed on patients requiring alveolar bone graft for dental implant insertion. Patients were assigned to three groups: tissue expansion and tunneling graft (TET group), tissue expansion and conventional bone graft (TEG), and control group without tissue expansion. Dimensional changes of soft tissue and radiographic vertical bone gain, retention, and peri-implant marginal bone changes were evaluated and secondary outcomes; clinical complications and thickness changes of expanded overlying tissue were assessed. Results: Among 75 patients screened, a total of 57 patients were included in the final analysis. Most patients showed uneventful soft tissue expansion without any inflammatory sign or symptoms. Ultrasonographic measurements of overlying gingiva revealed no thinning after tissue expansion (p > 0.05). Mean soft vertical and horizontal tissue measurements at the end of its expansion were 5.62 and 6.03 mm, respectively. Significantly higher vertical bone gain was shown in the TEG (5.71 ± 1.99 mm) compared with that in the control patients (4.32 ± 0.97 mm; p < 0.05). Hard tissue retention— measured by bone resorption after 6 months—showed that control group showed higher amount of vertical (2.06 ± 1.00 mm) and horizontal bone resorption (1.69 ± 0.81 mm) compared to that of the TEG group (p < 0.05). Conclusion: The self-inflating tissue expander effectively augmented soft tissue volume and both conventional bone graft and tunneling techniques confirmed their effectiveness in bone augmentation. With greater amount of bone gain and better 6 month hard tissue integrity, the TEG group compared to the control group—without tissue expansion—showed that the combined modality of tissue expander use and guided bone regeneration (GBR) technique may improve the outcome and predictability of hard tissue augmentation. [ABSTRACT FROM AUTHOR]

Background: Some factors associated with spiritual well-being in dying patients have previously been reported. However, there has been no cross-cultural study comparing factors related to spiritual well-being. The current investigation may shed light on this under-investigated area through a comparison of diverse factors. Aim: We aimed to (1) examine factors associated with spiritual well-being in the last days and (2) compare those factors across three East Asian countries. Design: This is an international multicenter prospective cohort study. Setting/participants: Newly admitted inpatients with far advanced cancer in palliative care units in Japan, Korea and Taiwan were enrolled. Each patient was classified into one of two groups based on spiritual well-being score in the last days of life. Univariate and multivariate analyses were performed to identify the factors related to better spiritual well-being score in each country. Results: A total of 1761 patients treated at 37 palliative care units from January 2017 to September 2018 were analyzed. Seven variables were significant in Japan, three in Korea, and five in Taiwan. "Good death scale [acceptance]," "fatigue" and "expressed wish for hastened death" were unique in Japan. "Visit from a pastoral care worker within 48 h of death" was unique in Korea. "Patient's preferences for place of death," "dyspnea" and "continuous deep sedation" were unique in Taiwan. Conclusions: This study found novel factors related to spiritual well-being in the last days of life, several of which differed according to country. Recognition of factors associated with spiritual well-being can improve the quality of palliative care. [ABSTRACT FROM AUTHOR]

The surprise question screening tool ("Would I be surprised if this person died within the next 12 months?") was initially developed to identify possible palliative care needs. One controversial topic regarding the surprise question is whether it should be used as a prognostic tool (predicting survival) for patients with life-limiting illnesses. In this "Controversies in Palliative Care" article, three groups of expert clinicians independently answered this question. All experts provide an overview of current literature, practical advice, and opportunities for future research. All experts reported on the inconsistency of the prognostic capabilities of the surprise question. Two of the three expert groups felt that the surprise question should not be used as a prognostic tool due to these inconsistencies. The third expert group felt that the surprise question should be used as a prognostic tool, particularly for shorter time frames. The experts all highlighted that the original rationale for the surprise question was to trigger a further conversation about future treatment and a potential shift in the focus of the care, identifying patients who many benefit from specialist palliative care or advance care planning; however, many clinicians find this discussion a difficult one to initiate. The experts agreed that the benefit of the surprise question comes from its simplicity: a one-question tool that requires no specific information about the patient's condition. More research is needed to better support the application of this tool in routine practice, particularly in noncancer populations. [ABSTRACT FROM AUTHOR]

Background: The objective prognostic score (OPS) needs to be modified to reflect practical palliative care circumstances. Objectives: We aimed to validate modified models of OPS with few or no laboratory tests for patients with advanced cancer. Design: An observational study was performed. Setting/Subjects: A secondary analysis of an international, multicenter cohort study of patients in East Asia was performed. The subjects were inpatients with advanced cancer in the palliative care unit. Measurements: We developed two modified OPS (mOPS) models to predict two-week survival: mOPS-A consisted of two symptoms, two objective signs, and three laboratory results, while mOPS-B consisted of three symptoms, two signs, and no laboratory data. We compared the accuracy of the prognostic models using sensitivity, specificity, and area under the receiver operating characteristic curve (AUROC). Calibration plots for two-week survival and net reclassification indices (NRIs) were compared for the two models. Survival differences between higher and lower score groups of each model were identified by the log-rank test. Results: We included a total of 1796 subjects having median survival of 19.0 days. We found that mOPS-A had higher specificity (0.805–0.836) and higher AUROCs (0.791–0.797). In contrast, mOPS-B showed higher sensitivity (0.721–0.725) and acceptable AUROCs (0.740–0.751) for prediction of two-week survival. Two mOPSs showed good concordance in calibration plots. Considering NRIs, replacing the original OPS with mOPSs improved overall reclassification (absolute NRI: 0.47–4.15%). Higher score groups of mOPS-A and mOPS-B showed poorer survival than those of lower score groups (p < 0.001). Conclusions: mOPSs used reduced laboratory data and had relatively good accuracy for predicting survival in advanced cancer patients receiving palliative care. [ABSTRACT FROM AUTHOR]

Context: Spiritual well-being (SWB) is very important in palliative care patients.Objectives: The aim of this study was to investigate the SWB among palliative care patients in Korea with different religious affiliations and to identify the correlates of SWB.Methods: This study is a cross-sectional, multicenter study involving hospitalized patients seen by palliative care teams. We collected data on basic clinicodemographic characteristics, factors related to religion (meaningful religious events, religious activities such as attending worship, individual spiritual activities such as prayer), overall quality of life, and SWB. SWB was measured using Functional Assessment of Chronic Illness Therapy-Spirituality 12. We examined the differences in SWB among patients who reported themselves as Protestants, Catholics, Buddhists, and having no religious affiliations.Results: Among the 202 patients enrolled, 69 (34.2%), 48 (23.8%), 43 (21.3%), and 42 (20.8%) persons were Protestants, were Catholics, were Buddhists, and had no religious affiliation, respectively. The Functional Assessment of Chronic Illness Therapy-Spirituality 12 was highest among Protestants, followed by Catholics, Buddhists, and those without religious affiliation (29.8 vs. 27.0 vs. 23.2 vs. 16.3, P < 0.001). The faith subscale (12.4 vs. 10.4 vs. 7.7 vs. 2.5, P < 0.001) showed similar distributions. Christians reported higher SWB in the meaning and the peace subscale than patients without a religious affiliation. In the multivariate analysis, religious affiliation (P < 0.001), individual spiritual activities (P < 0.001), and quality of life (P < 0.001) were significantly related to a greater SWB. Age was inversely associated with the meaning subscale (P = 0.002).Conclusion: Although faith practices may be particularly helpful to improve spiritual well-being among Christians, further research is needed to determine what individual spiritual activities can support non-Christians. [ABSTRACT FROM AUTHOR]

Background: Little is known about accuracy and confidence of clinicians' prediction of survival (CPS) in East-Asian countries. Objective: We aimed to examine accuracy of CPS for 7-, 21-, and 42-day survival in palliative inpatients and its association with prognostic confidence. Design: An international prospective cohort study in Japan (JP), Korea (KR), and Taiwan (TW). Setting/Subjects: Subjects were inpatients with advanced cancer admitted to 37 palliative care units in three countries. Measurements: Discrimination of CPS was investigated through sensitivity, specificity, overall accuracy, and area under the receiver operating characteristics curves (AUROCs) according to 7-, 21-, and 42-day survival. The accuracies of CPS were compared with those of Performance Status-based Palliative Prognostic Index (PS-PPI). Clinicians were instructed to rate confidence level on a 0–10-point scale. Results: A total of 2571 patients were analyzed. The specificity was highest at 93.2–100.0% for the 7-day CPS, and sensitivity was highest at 71.5–86.8% for the 42-day CPS. The AUROCs of the seven-day CPS were 0.88, 0.94, and 0.89, while those of PS-PPI were 0.77, 0.69, and 0.69 for JP, KR, and TW, respectively. As for 42-day prediction, sensitivities of PS-PPI were higher than those of CPS. Clinicians' confidence was strongly associated with the accuracy of prediction in all three countries (all p-values <0.01). Conclusions: CPS accuracies were highest (0.88–0.94) for the seven-day survival prediction. CPS was more accurate than PS-PPI in all timeframe prediction except 42-day prediction in KR. Prognostic confidence was significantly associated with the accuracy of CPS. [ABSTRACT FROM AUTHOR]

Purpose: Few large-scale studies have focused on the prevalence of symptoms and signs during the last days of patients diagnosed with advanced cancer. Identifying the patterns of specific symptoms according to cancer type is helpful to provide end-of-life care for patients with advanced cancer. We investigated the prevalence and severity of symptoms and signs associated with impending death in patients with advanced cancer.Methods: In this secondary analysis of an international multicenter cohort study conducted in three East Asian countries, we compared the severity of symptoms and signs among dying patients in the last 3 days of life according to the type of primary cancer using one-way analysis of variance (ANOVA). Post hoc analysis was conducted for multiple comparisons of each symptom according to the type of primary cancer.Results: We analyzed 2131 patients from Japan, Korea, and Taiwan. The prevalence of most symptoms and signs were relatively stable from 1 week after admission to the last 3 days of life. According to cancer type, edema of the lower extremities was the most common symptom and fatigue/ ascites were the most severe symptoms in digestive tract cancer. For lung cancer, respiratory secretion was the most prevalent and dyspnea/respiratory secretion were the most severe symptoms.Conclusion: We demonstrated the prevalence and severity of symptoms and signs associated with the impending death of patients with advanced cancer in East Asia. Our study can enable clinicians to recognize the specific symptoms and signs at the very end of life. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the prevalence of Toxoplasma gondii and Toxocara canis in patients with uveitis. Methods: Patients with uveitis were examined. Serum antibodies to T. gondii and T. canis were tested by using the enzyme-linked immunosorbent assay. Polymerase chain reaction (PCR) was done using blood and aqueous humor (AH). Results: Ninety-eight patients were enrolled. Mean age was 43.5 ± 13.2 years. Six patients were seropositive for T. gondii with the following pattern: anterior uveitis, 1; posterior uveitis with retinitis, 2; pan uveitis, 2. One patient had a positive PCR result for T. gondii in AH, who showed panuveitis. Twenty-three patients were positive to serum IgG for T. canis with the following clinical manifestation: granuloma, 6; pigmented scar, 3; vitritis, 6-but none were PCR positive. Conclusions: T. gondii and T. canis are still important causes of uveitis. Ocular toxocariasis is not an uncommon cause of uveitis, even in adults. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the prevalence of Toxoplasma gondii and Toxocara canis in patients with uveitis. Method: Patients with uveitis were examined. Serum antibodies to T. gondii and T. canis were tested by using enzyme-linked immunosorbent assay (ELISA). Polymerase chain reaction (PCR) was done using blood and aqueous humor (AH). Results: 98 patients were enrolled. Mean age was 43.5 ± 13.2 years. Six patients were seropositive for T. gondii with the following pattern-anterior uveitis: 1; posterior uveitis with retinitis: 2; pan uveitis: 2. One patient had a positive result of PCR for T.gondii in AH, who showed pan uveitis. 23 patients were positive to serum IgG for T. canis with the following clinical manifestation-granuloma: 6; pigmented scar: 3; virtrits: 6-but none were PCR positive. Conclusion: T.gondii and T.canis are still one of the important causes of uveitis. Ocular toxocariasis is not an uncommon cause of uveitis even in adult. [ABSTRACT FROM AUTHOR]

Background: Artificial hydration (AH) is a challenging issue in terminally ill patients with cancer, because it influences patients' symptoms control, quality of life, and quality of dying (QOD). To date, it is not clear how much AH supply is proper for imminently dying patients. This study aimed to investigate the association between the amount of AH and QOD. Methods: This study is part of the East Asian Collaborative Cross‐Cultural Study to Elucidate the Dying Process (EASED) conducted in Japan, Korea, and Taiwan from January 2017 to September 2018. Patients' demographics, symptoms, and managements on admission to palliative care units (PCUs) and before death were recorded. The AH amount was classified into different groups by 250‐mL intervals to compare their difference. The Good Death Scale (GDS) was used to measure QOD, with patients classified into higher or lower QOD groups using GDS = 12 as the cutoff point. We used logistic regression analysis to assess the association between AH amount and QOD. Results: In total, 1530 patients were included in the analysis. Country, religion, spiritual well‐being, fatigue, delirium, dyspnea, AH, and antibiotics use before death were significantly associated with QOD. After conducting regression analysis, patients administered with 250 to 499 mL AH had significantly better QOD (odds ratio, 2.251; 95% confidence interval, 1.072‐4.730; P =.032) than those without AH. Conclusions: AH use impacts the QOD of terminally ill patients with cancer admitted to PCUs. Communication with patients and their families on appropriate AH use has a positive effect on QOD. Lay Summary: Our prospective cross‐cultural multicenter study aims to investigate the relationship between artificial hydration (AH) amount and quality of dying among terminally ill patients with cancer.The findings reveal that country, religion, spiritual well‐being, fatigue, delirium, dyspnea, AH, and antibiotics use before death were significantly associated with quality of death (QOD).After multivariable logistic regression, patients administered with AH amount 250 to 499 mL had significantly better QOD (odds ratio, 2.251; 95% confidence interval, 1.072‐4.730; P =.032) than those without AH.Communication with patients and their families regarding AH is recommended as it may help them be better prepared for the end‐of‐life stage and achieve a good death. Artificial hydration (AH) use affects the quality of death (QOD) of terminally ill patients with cancer cared for in palliative care units. Patients administered 250 to 499 mL of AH have significantly better QOD (odds ratio, 2.251; 95% confidence interval, 1.072‐4.730; P =.032) than those without AH. [ABSTRACT FROM AUTHOR]

Background: Symptoms are not typically part of established various prognostic factors and scoring systems but are among the most frequently assessed issues in patient care. Objectives: To evaluate that, changes in symptoms can provide additional useful prognostic information. Design: A secondary analysis of an international cohort study in Japan, Korea, and Taiwan. Setting/Subjects: Subjects were adult patients with advanced cancer (n = 2074) who were admitted to 37 palliative care units (PCUs) in 3 countries from January 2017 to September 2018. Measurements: Symptoms (dyspnea, fatigue, dry mouth, and drowsiness) were assessed at admission and one-week later. Dyspnea was assessed by the presence of resting and exertional dyspnea, whereas other symptoms were assessed using the Integrated Palliative care Outcome Scales (IPOS) (range 0–4). For analysis, we grouped patients by symptom change, as either Improved, Stable, or Worsened (by having at least a one increment decrease, no change, or at least a one increment increase, respectively). Results: Worsened groups had the shortest survival (median survival 15–21 days) compared with those with Improved (median survival 23–31 days) and Stable symptoms (median survival 27–29 days) across all four symptoms (dyspnea, fatigue, dry mouth, and drowsiness). Survival differences were statistically significantly different across all three groups for all symptoms (all p < 0.001). Interestingly, Improved symptoms were associated with similar survival compared with Stable groups, with no statistical differences. Conclusions: Worsened symptoms at one week after admission were useful predictors of survival for patients with advanced cancer in PCUs during the final weeks of life. Longitudinal assessments are needed to reflect passage of time as well as impact of treatments. [ABSTRACT FROM AUTHOR]

Purpose: No study has been conducted to compare the clinicians' prediction of survival (CPS) with Palliative Prognostic Scores (PaP) across countries. We aimed to compare the performance of the CPS in PaP (PaP-CPS), the PaP without the CPS, and the PaP total scores in patients with advanced cancer in three East Asian countries.Methods: We compared the discriminative accuracy of the three predictive models (the PaP-CPS [the score of the categorical CPS of PaP], the PaP without the CPS [sum of the scores of only the objective variables of PaP], and the PaP total score) in patients admitted to palliative care units (PCUs) in Japan, Korea, and Taiwan. We calculated the area under the receiver operating characteristic curve (AUROC) for 30-day survival to compare the discriminative accuracy of these three models.Results: We analyzed 2,072 patients from three countries. The AUROC for the PaP total scores was 0.84 in patients in Japan, 0.76 in Korea, and 0.79 in Taiwan. The AUROC of the PaP-CPS was 0.82 in patients in Japan, 0.75 in Korea, and 0.78 in Taiwan. The AUROC of the PaP without the CPS was 0.75 in patients in Japan, 0.66 in Korea, and 0.67 in Taiwan.Conclusion: The PaP total scores and the PaP-CPS consistently showed similar discriminative accuracy in predicting 30-day survival in patients admitted to PCUs in Japan, Korea, and Taiwan. It may be sufficient for experienced clinicians to use the CPS alone for estimating the short-term survival (less than one month) of patients with far-advanced cancer. The PaP may help to improve prognostic confidence and further reduce subjective variations. [ABSTRACT FROM AUTHOR]

Background: Clinicians typically rely on their own or the nurses' clinical impression (NI) of symptoms rather than patient self-reports. It is unclear whether these means of assessment yield similar results. Objective: To prospectively compare patient-reported symptoms on a modified Edmonton Symptom Assessment System (ESAS) with NI scores. Methods: Consecutive patients with advanced cancer admitted to our acute palliative care unit between April and July 2010 were studied. We collected the results of the ESAS on the day of admission (D1) to the unit and 2 days later (D3). We also collected the NI of each patient's physical and psychological distress on D1 and D3. Results: One hundred eighteen patients completed the ESAS on D1 and 116 on D3. On D1 there was no significant association between NI score and ESAS assessment except for dyspnea, which was weakly correlated with NI score for physical distress ( r=0.22, p=0.02). The median ESAS physical and psychosocial scores were 31 and 12 in patients with NI of low or no physical distress, versus 34 ( p=0.07) and 15 ( p=0.18) in patients with NI of moderate or severe distress, respectively. On D3, we found a significant association between ESAS and NI only for pain ( r=0.32, p<0.001) and anxiety ( r=0.30, p=0.001). Sensitivity and specificity of the NIs for ESAS scores were low on both days. Conclusion: The clinical impression of highly trained palliative care nurses showed poor association with patient-reported symptom intensity. Validated symptom assessment tools are needed for bedside clinical assessment. [ABSTRACT FROM AUTHOR]

Summary Mutations in the E3 ubiquitin ligase Parkin have been linked to familial Parkinson’s disease. Parkin has also been implicated in mitosis through mechanisms that are unclear. Here we show that Parkin interacts with anaphase promoting complex/cyclosome (APC/C) coactivators Cdc20 and Cdh1 to mediate the degradation of several key mitotic regulators independent of APC/C. We demonstrate that ordered progression through mitosis is orchestrated by two distinct E3 ligases through the shared use of Cdc20 and Cdh1. Furthermore, Parkin is phosphorylated and activated by polo-like kinase 1 (Plk1) during mitosis. Parkin deficiency results in overexpression of its substrates, mitotic defects, genomic instability, and tumorigenesis. These results suggest that the Parkin-Cdc20/Cdh1 complex is an important regulator of mitosis. [ABSTRACT FROM AUTHOR]

Context: The terms "actively dying," "end of life," "terminally ill," "terminal care," and "transition of care" are commonly used but rarely and inconsistently defined.Objectives: We conducted a systematic review to examine the concepts and definitions for these terms.Methods: We searched MEDLINE, PsycINFO, Embase, and CINAHL for published peer-reviewed articles from 1948 to 2012 that conceptualized, defined, or examined these terms. Two researchers independently reviewed each citation for inclusion and then extracted the concepts/definitions when available. We also searched 10 dictionaries, four palliative care textbooks, and 13 organization Web sites, including the U.S. Federal Code.Results: One of 16, three of 134, three of 44, two of 93, and four of 17 articles defined or conceptualized actively dying, end of life, terminally ill, terminal care, and transition of care, respectively. Actively dying was defined as "hours or days of survival." We identified two key defining features for end of life, terminally ill, and terminal care: life-limiting disease with irreversible decline and expected survival in terms of months or less. Transition of care was discussed in relation to changes in 1) place of care (e.g., hospital to home), 2) level of professions providing the care (e.g., acute care to hospice), and 3) goals of care (e.g., curative to palliative). Definitions for these five terms were rarely found in dictionaries, textbooks, and organizational Web sites. However, when available, the definitions were generally consistent with the concepts discussed previously.Conclusion: We identified unifying concepts for five commonly used terms in palliative care and developed a preliminary conceptual framework toward building standardized definitions. [ABSTRACT FROM AUTHOR]

Abstract: Context: The terms “actively dying,” “end of life,” “terminally ill,” “terminal care,” and “transition of care” are commonly used but rarely and inconsistently defined. Objectives: We conducted a systematic review to examine the concepts and definitions for these terms. Methods: We searched MEDLINE, PsycINFO, Embase, and CINAHL for published peer-reviewed articles from 1948 to 2012 that conceptualized, defined, or examined these terms. Two researchers independently reviewed each citation for inclusion and then extracted the concepts/definitions when available. We also searched 10 dictionaries, four palliative care textbooks, and 13 organization Web sites, including the U.S. Federal Code. Results: One of 16, three of 134, three of 44, two of 93, and four of 17 articles defined or conceptualized actively dying, end of life, terminally ill, terminal care, and transition of care, respectively. Actively dying was defined as “hours or days of survival.” We identified two key defining features for end of life, terminally ill, and terminal care: life-limiting disease with irreversible decline and expected survival in terms of months or less. Transition of care was discussed in relation to changes in 1) place of care (e.g., hospital to home), 2) level of professions providing the care (e.g., acute care to hospice), and 3) goals of care (e.g., curative to palliative). Definitions for these five terms were rarely found in dictionaries, textbooks, and organizational Web sites. However, when available, the definitions were generally consistent with the concepts discussed previously. Conclusion: We identified unifying concepts for five commonly used terms in palliative care and developed a preliminary conceptual framework toward building standardized definitions. [Copyright &y& Elsevier]

Bone-anchored maxillary protraction (BAMP) is effective for skeletal Class III malocclusion. However, infection, screw and plate loosening, and device failures occur with conventional plates. This pilot prospective study analyzed the feasibility of individualized BAMP using preoperative simulation and 3D titanium printing in patients referred by the orthodontic department for four BAMP miniplates. Preoperative cone beam computed tomography data were analyzed using CAD/CAM software to fabricate the individualized 3D-printed BAMP device. The customized plates were printed using selective laser sintering and inserted onto the bone through an adjunct transfer jig. The accuracy of preoperative simulation and actual placement of the BAMP device were tested by superimposing simulated positioned digital images and postoperative computed tomography data. The growth modification effect depended on superimposition of lateral cephalograms and comparative changes in SNA, SNB, ANB, and Wits. Two male patients were finally included in the study. BAMP decreased the ANB difference (−4.56 to −1.09) and Wits appraisal (−7.52 to −3.26) after 2 years. Normal measurement indices for sagittal and vertical growth indicated successful growth modification. The mean accuracy between preoperative simulation and actual surgery was 0.1081 ± 0.5074 mm. This treatment modality involving preoperative simulation and 3D titanium printing for fabricating and placing customized BAMP devices precisely at planned locations is effective for treating skeletal Class III malocclusion. [ABSTRACT FROM AUTHOR]

Abstract: Context: The use of targeted therapy at the end of life has not been well characterized. Objectives: To determine the frequency and predictors of targeted therapy use in the last days of life. Methods: All adult patients residing in the Houston area who died of advanced cancer between September 1, 2009 and February 28, 2010 and had contact with our institution within the last three months of life were included. We collected baseline demographics and data on chemotherapy and targeted agents. Results: Eight hundred sixteen patients were included: average age 62 years (range 21–97), female 48% and white 61%. The median interval between the last treatment and death was 47 (interquartile range [IQR] 21–97) days for targeted agents and 57 (IQR 26–118) days for chemotherapeutic agents. Within the last 30 days of life, 116 (14%) patients received targeted agents and 147 (18%) received chemotherapy. Regimens given in the last 30 days of life included a median of one (IQR 1–2) chemotherapeutic or targeted agent and 43 (5%) patients receiving targeted agents had concurrent chemotherapy. The most common targeted agents in the last 30 days of life were erlotinib (n = 25), bevacizumab (n = 20), rituximab (n = 11), gemtuzumab (n = 8), and temsirolimus (n = 8). On multivariate analysis, younger age (odds ratio [OR] 0.98 per year, P = 0.01), hematologic malignancy (OR = 6.1, P < 0.001), and lung malignancy (OR = 2.6, P = 0.05) were associated with increased targeted agent use in the last 30 days of life. Conclusion: Targeted agents were used as often as chemotherapy at the end of life, particularly among younger patients and those with hematologic malignancies. Guidelines on targeted therapy use at the end of life are needed. [Copyright &y& Elsevier]

Purpose: Commonly used terms such as "supportive care," "best supportive care," "palliative care," and "hospice care" were rarely and inconsistently defined in the palliative oncology literature. We conducted a systematic review of the literature to further identify concepts and definitions for these terms.Methods: We searched MEDLINE, PsycInfo, EMBASE, and CINAHL for published peer-reviewed articles from 1948 to 2011 that conceptualized, defined, or examined these terms. Two researchers independently reviewed each citation for inclusion and then extracted the concepts/definitions when available. Dictionaries/textbooks were also searched.Results: Nine of 32 "SC/BSC," 25 of 182 "PC," and 12 of 42 "HC" articles focused on providing a conceptual framework/definition. Common concepts for all three terms were symptom control and quality-of-life for patients with life-limiting illness. "SC" focused more on patients on active treatment compared to other categories (9/9 vs. 8/37) and less often involved interdisciplinary care (4/9 vs. 31/37). In contrast, "HC" focused more on volunteers (6/12 vs. 6/34), bereavement care (9/12 vs. 7/34), and community care (9/12 vs. 6/34). Both "PC" and "SC/BSC" were applicable earlier in the disease trajectory (16/34 vs. 0/9). We found 13, 24, and 17 different definitions for "SC/BSC," "PC," and "HC," respectively. "SC/BSC" was the most variably defined, ranging from symptom management during cancer therapy to survivorship care. Dictionaries/textbooks showed similar findings.Conclusion: We identified defining concepts for "SC/BSC," "PC," and "HC" and developed a preliminary conceptual framework unifying these terms along the continuum of care to help build consensus toward standardized definitions. [ABSTRACT FROM AUTHOR]

Abstract: Context: There is limited published data regarding the outcomes of palliative care consult on cancer pain treatment at the first follow-up visit. Objectives: The primary aim of this study was to determine pain treatment response to an outpatient palliative care consultation at the first follow-up visit for patients with cancer pain. Methods: Data from consecutive patients (n =1612) who were referred to the outpatient Supportive Care Center at The University of Texas M. D. Anderson Cancer Center and completed the Edmonton Symptom Assessment System at their initial and subsequent visits from January 2003 to December 2010 were reviewed. All patients received interdisciplinary care led by palliative care specialists following an institutional protocol. Pain treatment response was defined as a ≥2 point or ≥30% reduction from baseline. Using logistic regression models, predictive factors associated with pain treatment response were assessed. Results: The mean (SD) baseline pain was 5.36 (2.9). Of the 1612 patients, 462 (29%) rated their pain as mild (numeric rating scale [NRS] score 0–3), 511 (32%) as moderate (NRS score 4–6), and 639 (39%) as severe (NRS score 7–10). Almost half (728 of 1612 [45%]) of the patients achieved pain treatment response. However, 228 of 728 (31%) responding patients still had pain ≥4 at the first follow-up visit in 15 days on average. Of the 462 patients with mild pain at baseline, 147 (32%) had worse pain at the first follow-up visit. Factors associated with clinical response were baseline pain intensity (odds ratio [OR] per point 1.4; P <0.01), fatigue (OR per point 1.01; P =0.014), and Edmonton Symptom Assessment System symptom burden (OR per point 1.01; P =0.039). Conclusion: More than half of the patients with moderate/severe pain were nonresponders, and about one-third of the patients with mild pain had an increase in pain severity to moderate/severe levels at the first follow-up. More frequent follow-up visits, phone calls, and interdisciplinary clinics may improve pain control. [Copyright &y& Elsevier]

Abstract: Context: Multiple organizations have raised concerns about the lack of standard definitions for terminology in the supportive and palliative oncology literature. Objectives: We aimed to determine 1) the frequency of 10 commonly used terms in the supportive and palliative oncology literature, 2) the proportion of articles that provided definitions for each term, and 3) how each term was defined. Methods: We systematically searched MEDLINE, PubMed, PsycINFO, the Cochrane Library, Embase, ISI Web of Science, and Cumulative Index to Nursing and Allied Health Literature for original studies, review articles, and systematic reviews related to palliative care and cancer in the first six months of 2004 and 2009. We counted the number of occurrences for “palliative care,” “supportive care,” “best supportive care,” “hospice care,” “terminal care,” “end-of-life,” “terminally ill,” “goals of care,” “actively dying,” and “transition of care” in each article, reviewed them for the presence of definitions, and documented the journal characteristics. Results: Among the 1213 articles found, 678 (56%) were from 2009. “Palliative care” and “end-of-life” were the most frequently used terms. “Palliative care,” “end-of-life,” and “terminally ill” appeared more frequently in palliative care journals, whereas “supportive care” and “best supportive care” were used more often in oncology journals (P <0.001). Among 35 of 601 (6%) articles with a definition for “palliative care,” there were 16 different variations (21 of 35 articles used the World Health Organization definition). “Hospice care” had 13 definitions among 13 of 151 (9%) articles. “Supportive care” and other terms were rarely defined (less than 5% of articles that used the term). Conclusion: Our findings highlight the lack of definitional clarity for many important terms in the supportive and palliative oncology literature. Standard definitions are needed to improve administrative, clinical, and research operations. [Copyright &y& Elsevier]

Objective: This nested case–control study aimed to investigate the effects of VEGFA polymorphisms on the development of bisphosphonate-related osteonecrosis of the jaw (BRONJ) in women with osteoporosis. Methods: Eleven single nucleotide polymorphisms (SNPs) of the VEGFA were assessed in a total of 125 patients. Logistic regression was performed for multivariable analysis. Machine learning algorithms, namely, fivefold cross-validated multivariate logistic regression, elastic net, random forest, and support vector machine, were developed to predict risk factors for BRONJ occurrence. Area under the receiver-operating curve (AUROC) analysis was conducted to assess clinical performance. Results: The VEGFA rs881858 was significantly associated with BRONJ development. The odds of BRONJ development were 6.45 times (95% CI, 1.69–24.65) higher among carriers of the wild-type rs881858 allele compared with variant homozygote carriers after adjusting for covariates. Additionally, variant homozygote (GG) carriers of rs10434 had higher odds than those with wild-type allele (OR, 3.16). Age ≥ 65 years (OR, 16.05) and bisphosphonate exposure ≥ 36 months (OR, 3.67) were also significant risk factors for BRONJ occurrence. AUROC values were higher than 0.78 for all machine learning methods employed in this study. Conclusion: Our study showed that the BRONJ occurrence was associated with VEGFA polymorphisms in osteoporotic women. [ABSTRACT FROM AUTHOR]

Background: The characteristics of physician communication with patients at the end of life (EOL) in East Asia have not been well studied. We investigated physicians' communications with imminently dying patients with cancer and their families in palliative care units (PCUs) in Japan, South Korea, and Taiwan.Methods: This observational study included patients with cancer newly admitted and deceased during their first admission to 39 PCUs in three countries. We evaluated 1) the prevalence and timing of informing patients and families of patients' impending death and 2) the prevalence of communication to assure the families of the patient's comfort.Results: We analyzed 2138 patients (Japan: 1633, South Korea: 256, Taiwan: 249). Fewer Japanese (4.8%: 95% confidence interval [95% CI], 3.8%-5.9%) and South Korean (19.6%: 95% CI, 15.2%-25.0%) patients were informed of their impending death, whereas 66.4% (95% CI, 60.2%-72.1%) of Taiwanese were informed; among all three countries, ≥90% of families were informed. Although most patients in all three countries and the families in South Korea and Taiwan were informed of the impending death greater than or equal to four days before death, 62.1% (95% CI, 59.6%-64.6%) of Japanese families were informed less than or equal to three days prior. Most families in all three countries received assurance that the patient would remain comfortable (could hear until death, no distress with death rattle or respiration with mandibular movement).Conclusions: Physicians in Taiwan communicated about patient's impending death most frequently, and physicians in all three countries generally provided assurance to families that the patients would remain comfortable. Further studies should explore the reasons for these differences and the effects of such communications in East Asia. [ABSTRACT FROM AUTHOR]

Background: The purpose of the current study was to investigate the association between cardiorespiratory fitness (CRF), measured by a simple step test, and the prevalence of metabolic syndrome among Korean adults, in a cross sectional design.Methods: A total of 1,007 Korean adults (488 men and 519 women) who underwent routine health checkups were recruited. CRF was measured by Tecumseh step test. The National Cholesterol Education Program's Adult Treatment Panel III guideline was used to determine the prevalence of metabolic syndrome. A logistic regression was performed to reveal possible associations.Results: The results of the study showed that a lower level of CRF was significantly associated with a higher prevalence of metabolic syndrome in men, but not in women. On the other hand, higher BMI was associated with a higher prevalence of metabolic syndrome in both men and women. However, BMI was not associated with fasting glucose nor hemoglobinA1c in men. When the combined impact of BMI and CRF on the prevalence of metabolic syndrome was analyzed, a significantly increased prevalence of metabolic syndrome was found in both men (odds ratio [OR]: 18.8, 95% Confidence Interval [CI]: 5.0-70.5) and women (OR: 8.1, 95% CI: 2.8-23.9) who had high BMI and low cardiorespiratory fitness. On the other hand, the prevalence of metabolic syndrome was only increased 7.9 times (95% CI: 2.0-31.2) in men and 5.4 times (95% CI: 1.9-15.9) in women who had high level of CRF and high BMI.Conclusion: In conclusion, the current study demonstrated the low CRF and obesity was a predictor for metabolic syndrome in Korean adults. [ABSTRACT FROM AUTHOR]