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In elderly patients, failure to thrive describes a state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments. Manifestations of this condition include weight loss, decreased appetite, poor nutrition, and inactivity. Four syndromes are prevalent and predictive of adverse outcomes in patients with failure to thrive: impaired physical function, malnutrition, depression, and cognitive impairment. Initial assessments should include information on physical and psychologic health, functional ability, socioenvironmental factors, and nutrition. Laboratory and radiologic evaluations initially are limited to a complete blood count, chemistry panel, thyroid-stimulating hormone level, urinalysis, and other studies that are appropriate for an individual patient. A medication review should ensure that side effects or drug interactions are not a contributing factor to failure to thrive. The impact of existing chronic diseases should be assessed. Interventions should be directed toward easily treatable causes of failure to thrive, with the goal of maintaining or improving overall functional status. Physicians should recognize the diagnosis of failure to thrive as a key decision point in the care of an elderly person. The diagnosis should prompt discussion of end-of-life care options to prevent needless interventions that may prolong suffering. [ABSTRACT FROM AUTHOR]

Severe pain is highly prevalent, with rates of 40% to 70% in patients with advanced cancer, liver disease, heart failure, human immunodeficiency virus, and renal failure. Wide variations in pain assessment and reporting methods and the measurement of multiple symptoms should be addressed in future studies. Regarding psychological approaches, determining whether hypnotherapy or other individual psychotherapeutic interventions reduce pain and/or psychological distress in a palliative care population is difficult. Interest is increasing in the concept of demoralization syndromes and the role of posttraumatic stress disorder in modulating responses to pain at the end of life. We review evidence from multiple studies that the use of rehabilitative therapy improves functional status and pain control among patients with advanced cancer, and we raise the possibility that rehabilitation therapy will be helpful in patients with other advanced diseases. We summarize ongoing clinical trials of electronic order sets, clinical care pathways, and care management pathways to improve pain management in palliative care. Wagner's Chronic Illness Model provides a way of analyzing how healthcare systems can be changed to provide adequate and continuing pain management in palliative care. Much work remains to ensure that pain is recognized, treated, and monitored effectively. [ABSTRACT FROM AUTHOR]

Objectives: There were two quality improvement goals for this project: (1) to evaluate the outcomes of an 8-week geriatric-focused mindfulness-based group therapy program for chronic pain management called "Mindfulness-based Chronic Pain Care" offered at a senior community center affiliated with a geriatric primary care clinic, and (2) to obtain feedback from participants to make relevant modifications for future groups., Methods: The program consisted of eight 150-minute weekly sessions. Thirteen community-dwelling older adults aged 60 and older participated in the program. The study utilized a non-randomized control-group pretest-posttest design. Participants completed pre- and post-program evaluations measuring pain and related psychosocial outcomes and were also asked to evaluate the importance of the group. Intervention and control groups were compared by t-test, chi-square likelihood ratio, Fischer's exact test, and multivariate analysis of variance with repeated measures., Results: There were statistically significant improvements in three areas: 1) increased activity level, 2) increased "pain willingness," and 3) decreased generalized anxiety symptoms. Qualitative analysis highlighted how this intervention was important to participants., Conclusions: The results of this pilot program indicate promising outcomes for older adults suffering from chronic pain., Clinical Implications: The Mindfulness-based Chronic Pain Care program was a practical, feasible, and acceptable approach for pain management among program participants.

Patients with Acute Myeloid Leukemia (AML) have a complex disease trajectory characterized by high symptom and psychosocial burden, a high rate of hospitalization and intensive care unit admission at the end-of-life (EOL), and frequent use of chemotherapy near the EOL. In addition, palliative and hospice care are underutilized in patients with AML despite their poor prognosis. Clinicians providing care to patients with end-stage AML frequently encounter multiple challenges, particularly surrounding the frequent administration of blood products near the EOL. We present a case of a patient with end-stage AML whose desire for transfusions causes significant patient and caregiver distress at the EOL. Balancing patient autonomy with the potentially inappropriate use of blood transfusions at the EOL and having good communication and collaboration among healthcare teams are important considerations when delivering optimal EOL care to patients with AML.

Background/aim: Liquid biopsy (LB) is a promising non-invasive tool to detect cancer. Over the last few years, exosomes recruited from LB have attracted the attention of researchers for their involvement in cancer. We focused on the role of LB exosomes in gastric cancer (GC)., Materials and Methods: We investigated the world literature on exosome-encapsulated functional biomarkers (non-coding RNAs and DNAs) taken from GC patients' LBs. Only the studies exploring serum, intraperitoneal fluid or gastric lavage were included., Results: As of 2022, fifty articles with an overall count of 3552 GC patients were investigated. Given the statistically significant associations with the clinicopathological categories of tumor depth, lymph node metastasis, staging class and tumor size, most exosome-mediated microRNAs, long non-coding RNAs and circular RNAs proved to exert a potentially important bioclinical role in terms of diagnosis, screening, prognosis and therapeutic targets., Conclusion: In the future, resorting to exosomal biomarkers taken from LB of affected patients could revolutionize the non-invasive fight against GC., (Copyright © 2022 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Purpose: We describe the development and the psychometric properties of an instrument to assess self-perceived EOL care competencies for healthcare professionals: The End-of-Life Care Questionnaire (EOL-Q)., Methods: The EOL-Q consists of 28 questions assessing knowledge, attitudes and behaviors with subscale items addressing seven domains of care: decision-making, communication, continuity of care, emotional support for patients/families, symptom management, spiritual support for patients/families, and support for clinicians. The EOL-Q was used to assess competencies of 1,197 healthcare professionals from multiple work units at a large medical center. Cronbach's alpha coefficients were calculated for the survey and subscales. A factor analysis was also conducted., Results: Internal consistency reliability was for was high for the total scale (0.93) and for the subscales addressing knowledge, behaviors, decision-making, communication, emotional support and symptom management (0.84-0.92); and moderate (>0.68) for the attitudes and continuity of care subscales. The factor analysis demonstrated robust consolidation of the communication and continuity of care subscales (eigenvalue 9.47), decision-making subscale (eigenvalue 3.38), symptom management subscale (eigenvalue 1.51), and emotional and spiritual support subscales (eigenvalue 1.13)., Conclusion: Analysis of the psychometric properties of the EOL-Q care across settings supports its reliability and validity as a measure of self-perceived EOL care competencies in the domains of communication and continuity of care, decision-making, symptom management, and emotional and spiritual support. The EOL-Q displays promise as a tool for use in a variety of educational, research, and program development initiatives in EOL care.

As people live longer with chronic disease and serious illness in the U.S., palliative care teams are called upon to support patients and their families. Social workers are an integral part of the palliative care interprofessional team, and yet there are disproportionately few training programs for social workers who wish to specialize in this area. The curriculum of a post-graduate palliative care training program for social workers should be based on the current standards for palliative care and social work, as described by the National Association of Social Workers (NASW), Council for Social Work Education (CSWE) and the Center to Advance Palliative Care (CAPC). Trainees should develop skills to care for patients who have chronic or life-limiting illness, patients who are nearing their end of life, patients who are in the active dying phase and their families around end of life planning, medical decision making, grief and bereavement. A post-graduate social work training program that aims to prepare social workers to work in the field of palliative care should consist of clinical rotations at multiple sites, robust didactic curriculum and clinical supervision. Interprofessional learning is necessary and training should include opportunities for scholarly work, quality improvement activities, leadership, and teaching. Post-graduate training programs in palliative care will prepare future social workers to be experts in a sub-specialty skill set to meet the needs of people living with chronic disease. These needs and opportunities call on the social work profession to take action to develop post-graduate training programs in palliative care.

Background: In the last decade, analysis of malignant cells and flora in gastric lavage (GL) has provided interesting data on pathogenesis of gastric cancer (GC). For this study, combining such two aspects into one cyto-microbiologic category, we tested the prognostic role of the presence/absence of cancer cells (GL1/GL0) and bacterial microbiota (MB1/MB0) in our GC population., Material and Methods: Between April 2012 and August 2019, 79 surgical patients with GC were prospectively investigated with the determination of GL MB., Results: Compared with GL1 MB0, GL1 MB1 strongly correlated with advanced GC, portended poorer overall survival (OS) (45.8 months vs 20.5 months, P = 0.049), and resulted a significant ( P = 0.008) and an independent ( P = 0.013) prognostic factor unfavorable for OS., Conclusion: In the light of our results, the cyto-microbiologic parameter of GL MB should be used to gain a better prognosis of GC patients. Administration of antimicrobial treatment for MB1 subjects should be entertained because it could reduce the risk of oncogenesis., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Journal of Cytology.)

Background/aim: As of 2020, carbohydrate antigen 72.4 (Ca 72.4) has been rarely investigated in the gastric juice (GJ) of patients with gastric cancer (GC). Our aim was to analyze the significance and role of this tumor antigen in the GJ of our GC population., Patients and Methods: Between April 2012 and July 2013, 37 patients with operable GC were prospectively investigated to determine the GJ Ca 72.4 levels before surgical manipulation., Results: GJ Ca 72.4 ≥6.49 ng/ml strongly correlated with the traditional categories of aggressive cancer (advanced tumor depth and stage, lymph node invasion and metastatic lymphatic ratio, indication to adjuvant treatment). It also associated with shorter survival (p=0.049) and is, thus, suggested as an independent factor of poor prognosis in GC patients (p=0.047)., Conclusion: The GJ Ca 72.4 parameter should be considered an indicator of an aggressive tumor phenotype and should be used in the prognostic assessment of GC patients., (Copyright© 2020, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

An interprofessional conference that addressed basic palliative care knowledge and skills was implemented annually at a large, academic healthcare institution. The conference significantly influenced participant's self-perceived competencies in the delivery of quality palliative care. This conference led to a sustainable program of palliative care initiatives consisting of a yearly workshop for nurses focused on palliative care core competencies and a biennial interprofessional conference designed to facilitate networking and address significant topics in palliative care.

Introduction/objective: Differently from other digestive malignancies, gastric cancer (GC) pathobiology is still little known and understood. Recently, cytopathology and molecular biology on gastric juice/gastric lavage (GJ/GL) of GC patients have provided novel and interesting results in terms of screening, diagnosis, prognosis, and therapy. However, entertaining cytologic examination and molecular test as a unified solo-run test is previously unreported. Our aim was to assess the new parameter "GL Ca 72.4" for GC patients., Methods: Between April 2012 and July 2013, GJ/GL obtained from 37 surgical GC patients were tested for the presence/absence (GL1/GL0) of exfoliated malignant cells along with the intragastric concentration of Ca 72.4 (normal value <6.49 ng/mL: Ca 72.4n; elevated level ≥6.49 ng/mL: Ca 72.4+)., Results: At a median follow-up of 79.3 months, all the GC alive patients were "GL0 Ca 72.4n." The "GL1 Ca 72.4+" parameter, in comparison with GL0 Ca 72.4n, strongly correlated with deeper tumor invasion (p = 0.027), severe nodal metastasis (p = 0.012), worst metastatic node ratio (p = 0.041), higher number of metastatic lymph nodes (30 vs. 20 nodes, p = 0.014), angiolymphatic invasion (p = 0.044), advanced stage (p = 0.034), and adjuvant therapy (p = 0.044). The Kaplan-Meier model showed that GL1 Ca 72.4+ subjects had shorter overall survival (OS) than GL0 Ca 72.4n cases (9.7 vs. 43.2 months, respectively, p = 0.042). At univariate analysis, the GL1 Ca 72.4+ parameter resulted a significant prognostic factor for OS (p = 0.023)., Conclusions: The combined cyto-molecular parameter "GL1 Ca 72.4+" appears to be a strong indicator of aggressive tumor behavior and a significant prognostic factor of poor survival for GC patients., (© 2020 S. Karger AG, Basel.)

Historically, analysis of intragastric exfoliative cytology (IEC) of gastric cancer (GC) was used with a diagnostic intent only. With the successful advent of endoscopic biopsy, the rate of detection of GC has improved worldwide and, as a consequence, IEC has been progressively abandoned. Today, however, there is a renewed interest in this field of research, as witnessed by several pertinent publications. As discussed in this review, in fact, currently the importance of analyzing IEC in patients with early and advanced GC seems to reside in its clinicopathological and prognostic significance. In fact, compared to non-sloughing tumors, GC exhibiting intragastric exfoliation was recently associated with an aggressive tumor phenotype (characterized by deeper infiltration of the gastric wall, lymph nodal or distant metastases, angiolymphatic and perineural invasion) and poorer prognosis. Adoption of IEC examination in routine practice might help identify patients at higher risk of developing local recurrence and peritoneal metastasis from early and advanced GC, optimizing their treatment and improving quality of life and life expectancy., (Copyright© 2019, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Many of America's Veterans have unique medical and psychosocial needs related to their military service. Since most medical care received by Veterans occurs outside of the Department of Veterans Affairs (VA) health care system, it is imperative that all medical providers have a working understanding of the unique needs of Veterans and some of the many programs and services available to Veterans through the VA. This article, created by an interdisciplinary team of palliative care and hospice providers who care for Veterans throughout the country, seeks to improve the comfort with which non-VA clinicians care for Veterans while increasing knowledge about programs for which Veterans might qualify through the VA.

Background:: The Institute of Medicine identifies that quality palliative/end-of-life (EOL) care should be provided to patients with serious, life-limiting illnesses and their families by competently prepared health professionals., Purpose:: This study assessed perceived concerns of health professionals pertaining to the delivery of palliative/EOL care in the hospital setting. The specific aim was to determine thematic concerns in the delivery of palliative/EOL care which emerged from respondents' impressions of a memorable palliative/EOL patient experience., Methods:: Interdisciplinary health professionals at a large academic health system in the Midwest were surveyed to reflect upon a memorable palliative/EOL life care patient situation (positive or negative). A Thematic Analysis approach was used to code qualitative responses to 4 open-ended questions and then extract themes and subthemes from the coded data., Results:: Concerns identified by participants (N = 425) emerged around 7 themes including communication (97%), decision-making/care planning (75%), education needs (60%), EOL care (48%), ethics (24%), satisfaction with care (9%), and spiritual/cultural sensitivity (6%)., Conclusion:: Challenges exist in the delivery of quality palliative/EOL care in the hospital setting which may be addressed through educational initiatives that focus on recognition of cultural influences on care preferences, improving communication between patients/families and providers, education about the differences between palliative and EOL care, and increased competency of health providers in having EOL/goals-of-care discussions. Health professionals must recognize the benefit of collaborative palliative care in order to meet patient and family needs holistically and comprehensively.

Background/aim: Although reckoned necessary for survival benefit, neoadjuvant chemotherapy (NAC) of gastric cancer (GC) patients has so far provided questionable results. Consequently, searching for new and clearer systems of response to NAC, post-NAC re-evaluation and prognostic prediction appears essential. The purpose of this study was to examine endogastric cytopathology and hemoglobin level count as new features, potentially useful for GC patients after NAC., Patients and Methods: Between April 2012 and October 2018, 21 of 116 patients with resectable GC received NAC and were investigated for the presence of free-floating malignant cells in their gastric lavage (yGL1) and the development of hypohemoglobinia (yAnemia)., Results: yGL1 and yAnemia were found in 11 and 12 patients, respectively. yGL1 correlated with the traditional parameters of tumor regression (p=0.0424). Both yGL1 and yAnemia were found to be independent predictive factors of overall and progression-free survival (p≤0.0364)., Conclusion: In the light of our results, the yGL1 and yAnemia appear two promising, simple and interesting clinicopathological features which should always be examined for better clarifying GC patients' response to NAC., (Copyright© 2019, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: In the United States, most deaths occur in hospitals, with approximately 25% of hospitalized patients having palliative care needs. Therefore, the provision of good end-of-life (EOL) care to these patients is a priority. However, research assessing staff preparedness for the provision of EOL care to hospitalized patients is lacking., Objective: To assess health-care professionals' self-perceived competencies regarding the provision of EOL care in hospitalized patients., Methods: Descriptive study of self-perceived EOL care competencies among health-care professionals. The study instrument (End-of-Life Questionnaire) contains 28 questions assessing knowledge, attitudes, and behaviors related to the provision of EOL care. Health-care professionals (nursing, medicine, social work, psychology, physical, occupational and respiratory therapist, and spiritual care) at a large academic medical center participated in the study. Means were calculated for each item, and comparisons of mean scores were conducted via t tests. Analysis of variance was used to identify differences among groups., Results: A total of 1197 questionnaires was completed. The greatest self-perceived competency was in providing emotional support for patients/families, and the least self-perceived competency was in providing continuity of care. When compared to nurses, physicians had higher scores on EOL care attitudes, behaviors, and communication. Physicians and nurses had higher scores on most subscales than other health-care providers., Conclusions: Differences in self-perceived EOL care competencies were identified among disciplines, particularly between physicians and nurses. The results provide evidence for assessing health-care providers to identify their specific training needs before implementing educational programs on EOL care.

Differently from other digestive malignancies, gastric cancer (GC) carcinogenesis seems more heterogeneous and unclear. This entails failing in identification of reliable serum tumor markers for screening early GC (EGC) as well as persisting ominous prognosis of this disease. Recently, investigation of human noncoding genome, especially long noncoding molecules (lncRNAs), has provided promising data. As for GC, however, since the current information on GC-specific lncRNAs is still scarce and comes largely from analyses performed on tissue or serum of affected patients, we decided to review the current literature dealing with expression of such molecules in the gastric juice (GJ) of GC patients. In the case of GC, in fact, several cytological and molecular works have already demonstrated GJ to be an interesting biological material for improving clinicopathologic and prognostic knowledge of this cancer. For this review, we burrowed into the literature on lncRNAs expressed in GJ of GC patients. PubMed, Science Direct, Scopus, Web of Science, Google Scholar and ResearchGate were the search engines entertained. As of 2018, only seven studies have been reported. LINC00152, AA174084, UCA1, RMRP, ABHD11-AS1, LINC00982 and H19 were the GJ lncRNAs examined. Following our review, we can conclude that, due to their high specificity and reliability, GJ lncRNAs should deserve a prominent role in the field of GC research: importantly, they could be used for screening EGC, ameliorating the existing methods of staging (which are still far from being completely accurate), improving the prognostic capacity of the current diagnostic armamentarium and, finally, providing new and valuable therapeutic targets., (Copyright © 2018 Elsevier GmbH. All rights reserved.)

In addition to classical metastatic pathways, recently gastric cancer was described having an alternative route called "endoluminal exfoliation". Provisional analyses demonstrated, in fact, this kind of shedding is associated with several clinico-pathological features indicative of aggressive behavior and resulted to be an independent prognostic factor entailing poor prognosis. Compared with non-sowing counterparts, in fact, patients affected with exfoliating early and advanced gastric carcinomas met with shorter overall survival, disease free survival, progression free survival and time to tumor progression. In spite of these interesting results, however, the clinico-pathological and oncological significance of this unconventional metastatic route is still to be clarified. Such an investigation is further urged by the increasing widespread employment of minimally invasive treatments for gastric cancer which include a wide spectrum of intragastric interventions and maneuvers. Indeed, endoscopic mucosal resection, endoscopic submucosal dissection, endoscopic full-thickness resection, intragastric laparoscopic surgery and hybrid procedures all take place inside of the stomach. However, iatrogenic perforations can occur during execution of these treatments leading to spillage of malignant cells from gastric to the peritoneal cavity or trocar insertion sites. Furthermore, many other gastric conditions and interventions can collide with endogastric presence of floating cancer cells: spontaneous ulceration or perforation, laparotomy surgery, gastrointestinal occlusion, diverticula. Viability, migration and intraluminal transportability of the intragastric floating cancer cells represents another original and intriguing topic. All these considerations led us to entertain the hypothesis that removing the exfoliated cancer cells from the gastric lumen could save patients from the dreaded potential risk of spillage. Performing gastric lavage before starting any kind of tumor intervention could be the most appropriate procedure to adopt with prophylactic intent. Should our speculation prove to be clinically significant, preoperative gastric lavage should be pointed out as a simple but cogent method useful for preventing oncological mishaps such as spillage of gastric cancer cells and development of related recurrences or metastases., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background/aim: Although there is an increasing number of studies on laparoscopic resection of early gastric cancer (EGC), as of 2018 no standardized strategy exists. We reviewed available literature dealing with laparoscopic intragastric (intraluminal) surgery (LIGS) conducted for patients with EGC to better define indications, benefits and limitations of this particular minimally invasive technique., Materials and Methods: PubMed, MEDLINE, Science Direct, Scopus, Web of Science, Google Scholar and ResearchGate were the search engines investigated. Only LIGS for EGC was entertained; studies conducted for other gastric diseases were excluded. Suitable articles written in all languages were included in the review., Results: As of 2018, we found 19 studies dealing with LIGS for EGC: studies on 72 humans and four pigs were identified. Among 72 human participants, there were 59 mucosal, five submucosal and one subserosal cancer., Conclusion: Based on our review, LIGS appears as a cogent option to endoscopic resection for treating superficial EGC., (Copyright© 2018, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background/aim: Detecting free tumor cells in the peritoneal lavage fluid of gastric cancer patients permits to assess a more accurate prognosis, predict peritoneal recurrence and select cases for a more aggressive treatment. Currently, cytology and molecular biology comprise the two most popular methods of detection that are under constant study by researchers., Materials and Methods: We burrowed into the available literature comparing cytological with molecular detection of free intraperitoneal gastric cancer cells. PubMed, Science Direct, Scopus and Google Scholar were the search engines investigated., Results: As of 2017, 51 dedicated studies have been published. Messenger RNA of carcinoembryonic antigen was the genetic target most frequently described. The genetic technique is usually superior to cytology in sensitivity (38-100% vs. 12.3-67% respectively), whereas cytological examination tends to show a slight pre-eminence in specificity (approximately 100%)., Conclusion: So far, given the imperfection of each method, employment of both cytology and molecular examination seem to be mandatory., (Copyright© 2018, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Correction: The authors would like to correct errors in the original article [1] that may have lead readers to misinterpret the scope, evidence base and target population of VHA Handbook 1004.03 "Life-Sustaining Treatment (LST) Decisions: Eliciting, Documenting, and Honoring Patients' Values, Goals, and Preferences".

Background/aim: To date, the combination of gastroscopy with biopsy remains the only test validated for screening gastric cancer (GC). Currently, analysis of circulating microRNAs (miRNAs or miRs) is providing interesting information on GC prognosis, but since these molecules are shared by several types of cancer, its clinical use could be questionable and difficult. MicroRNAs in gastric juice (GJ) could represent a cogent alternative to screening GC by biopsy., Materials and Methods: We investigated the pertinent literature dealing with GC GJ microRNAs through four popular search engines (PubMed, Science Direct, Scopus and Google Scholar)., Results: As of 2017, only four studies had been published and were all from Chinese experience. MiR-421, miR-129, miR-21, miR-106a and miR-133a were the five molecules studied in the GJ of the enrolled patients., Conclusion: The GJ miRNA test is reliable and reproducible. The discussed GJ miRNAs appear to be new potential biomarkers for the screening of GC., (Copyright© 2018, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background/aim: Concerning gastric cancer (GC), nasogastric tube (NGT) is routinely employed for peri-operative decompression and palliative enteral nutrition. Additionally, we believe to have found a further application., Patients and Methods: Between April 2012 and April 2017, 96 GC patients received preoperative nasogastric lavage (GL). All samples were cytologically examined to detect the presence (GL1) or absence (GL0) of malignant cells. Data were analyzed with classificatory, staging and prognostic purpose., Results: GL1 was detected in 46 GC patients: association with tumor depth, lymph node and distant metastasis, lymphovascular and peri-neural invasion, diffuse type and signet-ring cells was significant (respectively p=0.0274, 0.0324, 0.0446, 0.0287, <0.0001, 0.0413, <0.0001). GL1 entailed significantly poorer overall (OS), progression-free, disease-free survival and tumor progression (18 vs. 32 months). At multivariate analysis, GL1 was an independent prognostic factor for worse OS (p=0.0287)., Conclusion: NGT seems an economic oncologic measure useful for obtaining information on GC staging and prognosis., (Copyright© 2018, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background/aim: Early gastric cancer (EGC) is usually associated with excellent prognosis. Some cases, however, entail a poorer survival. Our aim was to assess if EGC exfoliating into gastric lavage (GL) has a more aggressive behavior than the non-exfoliative counterpart., Patients and Methods: Between April 2012 and April 2017, 96 gastric cancer patients were prospectively submitted to preoperative GL to detect the presence (GL1) or absence (GL0) of exfoliated malignant cells., Results: A total of 16 patients had EGC. T1b cases had significantly poorer overall (OS), progression-free (PFS) and disease-free survival (DFS) than their GL0 counterpart (16.3 vs. 61 months, p=0.0032). Similarly, the entire T1 class (T1a plus T1b EGCs) showed worse OS, PFS, DFS (15.5 vs. 61 months, p=0.0008) and time-to-tumor progression (17 vs. 61 months, p=0.0103)., Conclusion: In the case of EGC, the GL0-GL1 classification should become a routine clinical practice to identify the aggressive tumor phenotypes requiring for closer follow-up or additional treatment., (Copyright© 2017, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: Educating nurses about palliative and end-of-life (EOL) care is a high priority in health care settings. The purpose of this study was to assess nurses' perceived competency regarding the provision of palliative and EOL care to hospitalized patients., Method: This study surveyed nurses from 25 pediatric and adult acute and intensive care units (ICU; N = 583) Quantitative data analysis was descriptive and correlational. Qualitative data analysis identified themes of participant concerns., Results: Data analysis revealed that perceived competency in palliative and EOL care is significantly higher in the ICU nurses (p <.0001). Mean scores were significantly higher when nurses had more than 10 years of experience (p <.0001). Open-ended responses indicated concerns regarding improved communication behaviors, decision making, and facilitation of continuity of care., Conclusion: The results provide guidance for development of palliative and EOL care nursing education programs tailored to address specific unit needs according to staff characteristics, patient population focus of care, and acuity level of care. J Contin Educ Nurs. 2017;48(7):329-336., (Copyright 2017, SLACK Incorporated.)

As of 2017, no serum tumor marker has shown high levels of sensitivity or specificity for early detection, classification, staging, prediction and prognosis of patients affected by gastric cancer. In this regard, since 1975 several authors have investigated the gastric juice or gastric lavage of patients with gastric adenocarcinoma in order to determine the concentrations of intragastric tumor markers and discover the perfect antigen for this cancer. To date, however, a systematic review of the literature on intragastric tumor markers is still unreported. After a thorough search, we found important as well as unimportant findings and have come to clearly defined conclusions. We believe that describing the current state of knowledge achieved by the scientific community in this particular field of research could augment information on the complex pathobiology of gastric cancer and entail a deeper understanding of its unpredictable malignant behavior., (Copyright© 2017, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: The program "Implementing Goals of Care Conversations with Veterans in VA LTC Settings" is proposed in partnership with the US Veterans Health Administration (VA) National Center for Ethics in Health Care and the Geriatrics and Extended Care Program Offices, together with the VA Office of Nursing Services. The three projects in this program are designed to support a new system-wide mandate requiring providers to conduct and systematically record conversations with veterans about their preferences for care, particularly life-sustaining treatments. These treatments include cardiac resuscitation, mechanical ventilation, and other forms of life support. However, veteran preferences for care go beyond whether or not they receive life-sustaining treatments to include issues such as whether or not they want to be hospitalized if they are acutely ill, and what kinds of comfort care they would like to receive., Methods: Three projects, all focused on improving the provision of veteran-centered care, are proposed. The projects will be conducted in Community Living Centers (VA-owned nursing homes) and VA Home-Based Primary Care programs in five regional networks in the Veterans Health Administration. In all the projects, we will use data from context and barrier and facilitator assessments to design feedback reports for staff to help them understand how well they are meeting the requirement to have conversations with veterans about their preferences and to document them appropriately. We will also use learning collaboratives-meetings in which staff teams come together and problem-solve issues they encounter in how to get veterans' preferences expressed and documented, and acted on-to support action planning to improve performance., Discussion: We will use data over time to track implementation success, measured as the proportions of veterans in Community Living Centers (CLCs) and Home-Based Primary Care (HBPC) who have a documented goals of care conversation soon after admission. We will work with our operational partners to spread approaches that work throughout the Veterans Health Administration.

Although decreasing in the incidence over the last years, currently gastric adenocarcinoma represents the second cause of cancer related-death worldwide. Further knowledge and novel therapies are desperately needed in order to make the prognosis of these patients more acceptable. Infact, even though in recent years numerous staging parameters have been largely studied and unanimously recognized for their clinical and prognostic value, today too many shadows still exist around the capacity to predict exactly the natural history or post-treatment behavior of this cancer even among patients of the same stage. This study has identified the presence of isolated cancer cells as well as tumor markers (CEA, Ca 19.9, Ca 72.4 and Ca 50) from the gastric lavage of patients affected by gastric adenocarcinoma. Such findings led to the hypothesis that endoluminal exfoliation of neoplastic cells and the release of their products (tumor markers) into the gastric juice might be an expression of neoplastic behavior as well as aggressive malignancy. Should this hypothesis become a reality, some important progress could be made in the knowledge, staging, prediction as well as management and follow-up of this inauspicious type of cancer., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objectives: To investigate gastric lavage (GL) cytopathology and immunometric analysis as novel clinicopathologic and prognostic parameters for gastric cancer (GC)., Study Design: In 38 patients with gastric adenocarcinoma, we performed a cytopathologic analysis and an immunometric assay of GL using four tumor markers (CEA, CA 19.9, CA 72.4, and CA 50). The intragastric tumor marker levels were compared with a control group consisting of 41 non-GC patients to determine a statistically significant cutoff value., Results: GL cytopathology demonstrated the presence of cancer cells in 13 (34.2%) of the 38 GC patients: such a finding correlated to the parameters pT and pN with a statistically significant validity (p < 0.0267 and p < 0.0306, respectively). Measurement of intragastric CA 19.9 and CA 50 attained a statistically significant cutoff value (p < 0.002 and p < 0.0096, respectively), which was invalidated by the low sensitivity of the ROC curve analysis., Conclusions: In contrast to determination of its tumor markers, GL cytopathology correlated well with pT and pN staging parameters. Should this and other features be corroborated by future studies, the GL cytology test could be routinely used to detect aggressive types of GC even at early stages and result in important progress in the knowledge, staging, prediction, as well as management and follow-up of this inauspicious type of cancer., (© 2016 S. Karger AG, Basel.)

Often thought of as a benign and self-limited condition, hiccups can become persistent or intractable, and thus be associated with substantial morbidity and distress. In such cases, an underlying etiology is often present, and may be overlooked. Debilitating hiccups can present a major challenge to optimal symptom management. Various causes of protracted hiccups have been identified including metabolic abnormalities, central nervous system pathology, malignancy, medications, and disorders attributed to cardiac, pulmonary and gastrointestinal etiologies. We present a case of intractable hiccups in a patient with an advanced hematological malignancy and review specific therapies for the management of persistent hiccups.

Aims: To describe the integration of massage therapy into a palliative care service and to examine the relationship between massage and symptoms in patients with advanced illnesses., Methods: Between April 1, 2009, and July 31, 2010, 153 patients received massage at the VA Ann Arbor Health Care System. Data on pain, anxiety, dyspnea, relaxation, and inner peace were collected pre and post massage. Diagnoses, chronic pain, and social support were also abstracted. Analysis of covariance was used to examine changes over time., Results: All short-term changes in symptoms showed improvement and all were statistically significant. Pain intensity decreased by 1.65 (0-10 scale, P < .001), anxiety decreased by 1.52 (0-10 scale, P < .001), patients' sense of relaxation increased by 2.92 (0-10 scale, P < .001), and inner peace improved by 1.80 (0-10 scale, P < .001)., Conclusion: Massage is a useful tool for improving symptom management and reducing suffering in palliative care patients.

Objectives: Comprehensive health care for older adults is complex, involving multiple comorbidities and functional impairments of varying degrees and numbers. In response to this complexity and associated barriers to care, home-based care models have become prevalent. The home-based primary care (HBPC) model, based at a Michigan Department of Veterans Affairs Medical Center, and the Michigan Waiver Program (MWP) that includes home-based care are 2 of these. Although both models are formatted to address barriers to effective and efficient health care, there are differences in disease prevalence and functional performance between groups. The objective of this study was to explore the differences between the 2 groups, to shed some light on potential trends that could suggest areas for resource allocation by service providers., Design: Using a retrospective analysis of data collected using the interRAI-home care, we examined a cross-sectional representation of clients enrolled in HBPC and MWP in 2008., Participants: The HBPC sample had 89 participants. The MWP database contained 9324 participants from across the State of Michigan and were weighted to be comparable to the HBPC population in sex and age, and to simulate the HBPC sample size., Results: Veterans were more independent in basic activities of daily living performance, but there was no difference in the rate of reported falls between the 2 groups. Veterans had more pain and a higher prevalence of coronary artery disease (z = 7.0; P < .001), Chronic obstructive pulmonary disease (z = 3.9; P < .001), and cancer (z = 8.5; P < .001). There was no statistically significant difference between the 2 groups in terms of the prevalence of geriatric syndromes. Scores on subscales of the interRAI-home care indicated a lower risk of serious health decline and adverse outcomes for MWP compared with HBPC clients (1.4 ± 1.1 vs 0.9 ± 0.1; z = 2.5; P = .012). Veterans receiving home-based care through the Veterans Affairs Medical Center were more burdened by chronic disease and had higher degrees of loneliness than their MWP counterparts- factors, which may increase their likelihood of hospitalizations. MWP participants had more cases of cerebrovascular accident (z = 2.1; P = .039), as well as a higher rate of diagnosed dementias (z = 2.7; P = .006). Though not different, stress among caregivers in both groups, and depression in clients of both groups were substantial. Overall, sleep, pain, coronary artery disease, chronic obstructive pulmonary disease, and cancer are significant issues for Veteran clients, and clients treated through MWP home-care in Michigan have higher than national average rates of dementias, diabetes, hypertension, and coronary artery disease., Conclusion: With expanded home care models of service on the horizon, comparisons such as the one presented here could identify more efficient and effective service, with potential for improved client health outcomes., (Copyright © 2013. Published by Elsevier Inc.)

It is expected that the American geriatric population will have an increased need for hospice and palliative care services over the next few decades. We surveyed 187 community dwelling older adults about several aspects related to end-of-life (EOL) care. Participants were much more familiar with the term hospice than palliative care. In general, they had positive attitudes towards hospice and palliative care. Although experience caring for a dying relative was common, it wasn't associated with better attitudes towards hospice and palliative care or better familiarity with these terms. Familiarity with the term palliative care was associated with better attitudes towards EOL care. Our findings highlight the need for enhanced end-of-life care education among older adults, and reinforce the need for further research in this area.

Neuropathic cancer pain is common, very disabling and difficult to treat. It can be related to tumor invasion of neural structures and neuronal damage by surgery, chemotherapy and radiation therapy. Adjuvant analgesics are often used with opioids to control neuropathic pain in cancer patients. Methadone, a synthetic opioid with multiple mechanisms of action, is gaining increasing importance as an effective agent in the treatment of cancer related neuropathic pain. This case illustrates the challenges of managing severe pain in a patient with head and neck cancer while undergoing anti-tumor treatment. A review of the adjuvant analgesics and opioids, particularly methadone, in the management of neuropathic pain is also included.

Bleeding malignant wounds in palliative care patients can be anxiety-provoking for patients, their caregivers, and healthcare providers, and can be difficult to manage. We present the case of a 60-year-old man with a bleeding neck wound due to squamous cell carcinoma of the hypopharynx admitted to our inpatient palliative care unit. Management of bleeding included local wound care measures and psychosocial support for the patient and his wife. We review therapeutic approaches to managing bleeding malignant wounds with the aim of providing clinically useful information.

To examine medical residents' perceived competence in caring for patients with dementia we conducted an online survey of all 120 second, third and fourth-year residents in Internal Medicine, Medicine/Pediatrics, and Family Medicine at University of Michigan. A structured survey elicited residents' training, experience, confidence, and perceived career needs for skills in estimating prognosis, symptom management, and communication in caring for patients with dementia, compared to patients with metastatic cancer. Among the 61 (51 %) respondents, a majority report lower confidence in assessing prognosis and eliciting treatment wishes in patients with dementia (vs. metastatic cancer), and in performing skills integral to the care of patients with dementia, including the ability to assess caregiver needs, decisional capacity, advise on place of care, and manage agitation, despite viewing these skills as important to their future careers. These findings support the need for enhanced education on optimal care of patients with advanced dementia.

Hypertrophic pulmonary osteoarthropathy (HOA) is a condition associated with lung cancer and many other diseases. Pain associated with HOA can be disabling, unremitting, and refractory to conventional analgesic medications. We present a challenging case of HOA in a patient with nonsmall cell lung cancer and review specific therapies for management of HOA-related pain.

Background: The need for improved (end-of-life) EOL care in the intensive care unit (ICU) has gained attention in the medical literature over the last 10 years. The purpose of this study is to describe ICU health care providers' self-perceived knowledge, attitudes, and behaviors related to the provision of EOL care as a first step in planning educational interventions for ICU staff., Methods and Results: One hundred eighty-five ICU staff members of an academic affiliated tertiary medical center in Milwaukee, Wisconsin received the survey, the Scale of End-of-Life Care in the ICU (EOLC-ICU), a new questionnaire developed for this study. The response rate was 50.3%., Conclusion: We found that having previous EOL care education was common among ICU staff. However, several deficiencies in self-perceived EOL competencies were identified among staff, particularly in the areas of communication, continuity of care, and decision-making process. Nursing and medical staff also had different perceptions on how certain EOL behaviors were carried out in the ICU. Educational interventions will be implemented in our ICU in an effort to improve staff preparedness for the provision of quality EOL care.

Patients with chronic pain on daily opioid therapy are frequently burdened with symptoms of constipation. Opioid-induced constipation (OIC) contributes to an overall negative impact on the quality of life and may result in poor pain management outcomes. Laxative agents are crucial in opioid-related pain management. Following a careful assessment, a stepwise approach to OIC may provide comfort and relief to patients. This article reviews the pathophysiology, assessment, and pharmacological treatment of OIC. Novel approaches for OIC such as the peripheral opioid receptor antagonists and selective serotonin antagonists are also discussed.

Clinically significant depression is a common psychiatric disorder in patients with advanced and terminal diseases. Depression is often unrecognized and untreated and it causes major suffering to patients and families. Having adequate knowledge and skills to properly recognize depression in patients with advanced illnesses is essential for providing comprehensive end-of-life care. The objective of this paper is to review the key elements of the assessment of depression in palliative care patients. We also discuss the challenges of making the diagnosis, review the risk factors associated with depression and describe the features of the most common assessment tools that have been studied in this population. Finally, we highlight how to differentiate depression from normal grief, as the overlap between these conditions imposes a diagnostic challenge.