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Delirium is a common neuropsychiatric complication in patients with advanced cancer. Central nervous system (CNS)-active medications are established risk factors for delirium; however, these patients often require polypharmacy for symptom management, resulting in a high medication burden and increased risk of drug-drug interactions (DDIs). The impact of CNS medication burden and DDIs on delirium remains unclear. This multicenter, prospective observational study examined the association between CNS medication burden, measured using the CNS standardized daily dose (SDD), DDIs, and delirium incidence, duration, and mortality in hospitalized patients with advanced cancer. Among 190 patients, 20% developed delirium. CNS SDD was associated with delirium risk (adjusted OR [aOR]: 1.04, 95% CI: 1.0004–1.08). In categorical analyses, patients with a CNS SDD ≥ 10 had a significantly higher risk of delirium (aOR: 4.29, 95% CI: 1.33–15.47). Potential DDIs increasing exposure to delirium-risk medications had an aOR of 4.14 (95% CI: 0.96–17.41). Although neither CNS SDD nor DDIs affected delirium duration, opioid burden was associated with increased mortality. CNS medication burden and DDIs may be important factors for delirium and clinical outcomes. These findings underscore the need for medication optimization and proactive DDI monitoring to reduce the risk of delirium and improve patient outcomes.

This study aimed to examine the impact of the COVID-19 pandemic on the emergency department (ED) visits of cardiovascular disease (CVD) patients. The customized data of the National Health Insurance Service (NHIS) from 2017 to 2020 were analyzed. CVD patients were defined by the code ‘V192’ based on the NHIS coverage benefit expansion policy. The number of ED visits of CVD patients, as well as executed procedures in 2020 (during the pandemic), were compared to the corresponding average numbers in 2018 and 2019 (prepandemic). Stratification by age group, residential area and hospital location was performed. The number of ED visits of newly diagnosed CVD patients decreased by 2.1% nationwide in 2020 (2018–2019: 97,041; 2020: 95,038) and decreased the most (by 14.1%) in March (2018–2019: 8539; 2020: 7334). However, the number of executed procedures increased by 1.1% nationwide in 2020 (2018–2019: 74,696; 2020: 75,520), while it decreased by 11.9% in April (2018–2019: 6603; 2020: 5819). The most notable decreases in the number of newly diagnosed CVD patients (31.7%) and procedures (29.2%) in March 2020 were observed in the Daegu·Gyeongbuk area. CVD patients living in the epicenter of the COVID-19 pandemic may experience difficulty accessing healthcare facilities and receiving proper treatment.

We aimed to investigate the demographic characteristics, common chief complaints, and diagnosis of geriatric cancer-related emergency department (ED) visits and trends of ED outcomes. This retrospective observational study included all ED visits in South Korea between 2016 and 2020. The study population was older people ≥ 65 years living with cancer who visited ED with cancer-related problems. The demographics, common diagnoses, and ED outcomes were investigated. A multivariate logistic regression analysis was conducted to investigate factors associated with mortality. Geriatric cancer-related ED (GCED) visits were 746,416 cases over 5 years. The proportion of older adults among cancer-related ED visits increased from 50.1% in 2016 to 55.3% in 2020. The proportion of the “oldest old” (≥ 85 years) increased from 9.6 to 12.1%. For GCED, the ward admission rate after ED treatment was 60.2% and in-hospital mortality rate was 11.8%. Both of these increased with age group (“young old” (65–74), “middle old” (75–84), and “oldest old” (≥ 85 years) groups admission rates: 56.1%, 62.8%, and 68.0%; and mortality rates: 10.0%, 12.7%, and 15.7%, respectively). The most common diagnosis was pneumonia (4.9%). Old age and ambulance use were also associated with mortality. Older adults account for more than half of cancer-related ED visits, and their number is increasing every year. GCED visits are associated with high hospitalization and mortality, especially among the oldest old. It is important to prepare for a rise in GCED visits is necessary.

This study aimed to present a new approach to predict to delirium admitted to the acute palliative care unit. To achieve this, this study employed machine learning model to predict delirium in patients in palliative care and identified the significant features that influenced the model. A multicenter, patient-based registry cohort study in South Korea between January 1, 2019, and December 31, 2020. Delirium was identified by reviewing the medical records based on the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. The study dataset included 165 patients with delirium among 2314 patients with advanced cancer admitted to the acute palliative care unit. Seven machine learning models, including extreme gradient boosting, adaptive boosting, gradient boosting, light gradient boosting, logistic regression, support vector machine, and random forest, were evaluated to predict delirium in patients with advanced cancer admitted to the acute palliative care unit. An ensemble approach was adopted to determine the optimal model. For k-fold cross-validation, the combination of extreme gradient boosting and random forest provided the best performance, achieving the following accuracy metrics: 68.83% sensitivity, 70.85% specificity, 69.84% balanced accuracy, and 74.55% area under the receiver operating characteristic curve. The performance of the isolated testing dataset was also validated, and the machine learning model was successfully deployed on a public website ( http://ai-wm.khu.ac.kr/Delirium/ ) to provide public access to delirium prediction results in patients with advanced cancer. Furthermore, using feature importance analysis, sex was determined to be the top contributor in predicting delirium, followed by a history of delirium, chemotherapy, smoking status, alcohol consumption, and living with family. Based on a large-scale, multicenter, patient-based registry cohort, a machine learning prediction model for delirium in patients with advanced cancer was developed in South Korea. We believe that this model will assist healthcare providers in treating patients with delirium and advanced cancer.

The prevalent use of opioids for pain management in patients with advanced cancer underscores the need for research on their neuropsychiatric impacts, particularly delirium. Therefore, we aimed to investigate the potential association between opioid use and the risk of delirium in patients with advanced cancer admitted to the acute palliative care unit. We conducted a retrospective observational study utilizing a multicenter, patient-based registry cohort by collecting the data from January 1, 2019, to December 31, 2020, in South Korea. All data regarding exposures, outcomes, and covariates were obtained through retrospective chart reviews by a team of specialized medical professionals with expertise in oncology. Full unmatched and 1:1 propensity-score matched cohorts were formed, and stratification analysis was conducted. The primary outcome, delirium, was defined and diagnosed by the DSM-IV. Of the 2,066 patients with advanced cancer, we identified 42.8% (mean [SD] age, 64.4 [13.3] years; 60.8% male) non-opioid users and 57.2% (62.8 [12.5] years; 55.9% male) opioid users, respectively. Opioid use was significantly associated with an increased occurrence of delirium in patients with advanced cancer (OR, 2.02 [95% CI 1.22–3.35]). The risk of delirium in patients with advanced cancer showed increasing trends in a dose-dependent manner. High-dose opioid users showed an increased risk of delirium in patients with advanced cancer compared to non-opioid users (low-dose user: OR, 2.21 [95% CI 1.27–3.84]; high-dose user: OR, 5.75 [95% CI 2.81–11.77]; ratio of OR, 2.60 [95% CI 1.05–6.44]). Patients with old age, male sex, absence of chemotherapy during hospitalization, and non-obese status were more susceptible to increased risk of delirium in patients with cancer. In this multicenter patient-based registry cohort study, we found a significant, dose-dependent association between opioid use and increased risk of delirium in patients with advanced cancer. We also identified specific patient groups more susceptible to delirium. These findings highlight the importance of opioid prescription in these patients with advanced cancer, balancing effective doses for pain management and adverse dose-inducing delirium.

Advancements in the treatment and management of patients with cancer have extended their survival period. To honor such patients’ desire to live in their own homes, home-based supportive care programs have become an important medical practice. This study aims to investigate the effects of a multidimensional and integrated home-based supportive care program on patients with advanced cancer. SupporTive Care At Home Research is a cluster non-randomized controlled trial for patients with advanced cancer. This study tests the effects of the home-based supportive care program we developed versus standard oncology care. The home-based supportive care program is based on a specialized home-based medical team approach that includes (1) initial assessment and education for patients and their family caregivers, (2) home visits by nurses, (3) biweekly regular check-ups/evaluation and management, (4) telephone communication via a daytime access line, and (5) monthly multidisciplinary team meetings. The primary outcome measure is unplanned hospitalization within 6 months following enrollment. Healthcare service use; quality of life; pain and symptom control; emotional status; satisfaction with services; end-of-life care; advance planning; family caregivers’ quality of life, care burden, and preparedness for caregiving; and medical expenses will be surveyed. We plan to recruit a total of 396 patients with advanced cancer from six institutions. Patients recruited from three institutions will constitute the intervention group, whereas those recruited from the other three institutions will comprise the control group.

IntroductionCritically ill patients in intensive care units (ICUs) receive life-sustaining treatments aimed at restoring or maintaining organ function. ICU admission often involves substantial multidimensional suffering that can burden patients, their families and surrogates. Multidisciplinary palliative care support can help alleviate their sufferings. In South Korea, however, palliative care has not yet been integrated into critical care settings, highlighting the need to explore the feasibility of its implementation within the ICU.Methods and analysisThis study aims to test the feasibility of a consultation-based palliative care intervention in the ICU. The study will include 20 patients admitted to the ICU of a tertiary hospital due to sudden severe acute brain injury or progressive organ failure, along with their family caregivers. A palliative care team, comprising a social worker and a palliative care physician, will provide consultations to the ICU healthcare professionals based on the palliative care needs, following family counselling. Additional family meetings will be held if necessary. The primary outcomes will include participation rates, family counselling rates and study completion rates. The intervention’s potential impact will be assessed by changes in surrogate decision-making conflict, self-efficacy, depression and anxiety, post-decision regret and the experience of patient-centred and family-centred care. The demand and acceptability of the intervention will be assessed through semi-structured interviews with family surrogates, followed by qualitative analysis.Ethics and disseminationThis study will be conducted in accordance with the Declaration of Helsinki and applicable national laws and regulations. The clinical study protocol, along with any protocol amendments and the informed consent form, has been approved by the Institutional Review Board of the Hospital (2404-111-1532). We plan to submit the study results for presentation at conferences and for publication in international peer-reviewed journals. Data will also be made available on request to participants, funding agencies and interested researchers.Trial registration numberNCT06490835.

Although immune checkpoint inhibitors (ICIs) can induce durable responses in non-small-cell lung cancer (NSCLC) patients, a significant proportion of responders still experience progressive disease after a period of response. Limited data are available on the clinical patterns of acquired resistance (AR) to ICIs. Clinical and radiologic data from 125 NSCLC patients treated with anti-PD-1 or PD-L1 antibodies between 2011 and 2018 at two tertiary academic institutions were retrospectively reviewed. Overall, 63 (50.4%) patients experienced AR after ICI treatment in a median of 10.7 months. Among the 13 patients with a partial response with ICI, 12 (32.4%) had only lymph node progression. Most patients (n = 52, 82.5%) had one or two sites with progression (oligo-progression). The median overall survival (OS) after progression was significantly longer in the extrathoracic group than in the thoracic and liver progression groups (30.2 months [95% confidence interval (CI), 13.4 to not reached (NR)], 11.7 months [95% CI, 9.5-21.1], and 5.4 months [95% CI, 2.6-NR], respectively, P < 0.001). Patients with oligo-progression had significantly longer OS after AR than did the multi-progression patients (18.9 months [95% CI, 10.6-NR] vs. 8.8 months [95% CI, 5.7-NR], P = 0.04). No significant difference in progression-free survival was observed between the subsequent chemotherapy and the ICI after AR groups (P = 0.723). Patients with AR after ICI treatment had a unique progression pattern with oligo-progression and high rates of progression only in the lymph nodes. Local treatment and/or continuation of ICIs beyond AR might be an effective option.

Background Few studies have focused on high‐flow nasal cannula (HFNC) usage in the last few weeks of life. The aim of this study was to identify the status of HFNC use in patients with cancer at the end of life and the relevant clinical factors. Methods We performed a retrospective cohort study in a tertiary hospital in the Republic of Korea. Among patients with cancer who died between 2018 and 2020, those who initiated HFNC within 14 days before death were included. Patients were categorized based on the time from HFNC initiation to death as imminent (<4 days) and non‐imminent (≥4 days). Results Among the 2191 deceased patients with terminal cancer, 329 (15.0%) were analyzed. The median age of the patients was 66 years, and 62.9% were male. The leading cause of respiratory failure was pneumonia (70.2%), followed by pleural effusion (30.7%) and aggravation of lung neoplasms (18.8%). Most patients were conscious (79.3%) and had resting dyspnea (76.3%) at HFNC initiation. Patients received HFNC therapy for a mean of 3.4 days in the last 2 weeks of life, and 62.6% initiated it within 4 days before death. Furthermore, female sex, no palliative care consultation, no advance statements in person on life‐sustaining treatment, and no resting dyspnea were independently associated with the imminent use of HFNC. Conclusions Many patients with cancer started HFNC therapy at the point of imminent death. However, efforts toward goal‐directed use of HFNC at the end‐of‐life stage are required. This study illustrates the status of high‐flow nasal cannula use in patients with terminal cancer at the end of life. Efforts to communicate patients' stated goals of care may help enhance goal‐concordant use of high‐flow nasal cannula at the end of life and reduce initiating in an imminently dying state.

Although metabolic intratumoral heterogeneity (ITH) gives important value on treatment responses and prognoses, its association with treatment outcomes have not been reported in gastric cancer (GC). We aimed to evaluate temporal changes in metabolic ITH and the associations with treatment responses, progression-free survival (PFS), and overall survival (OS) in advanced GC patients. Eighty-five patients with unresectable, locally advanced, or metastatic GC were prospectively enrolled before the first-line palliative chemotherapy and underwent [ 18 F]FDG PET at baseline (TP1) and the first response follow-up evaluation (TP2). Standardized uptake values (SUVs), volumetric parameters, and textural features were evaluated in primary gastric tumor at TP1 and TP2. Of 85 patients, 44 had partial response, 33 had stable disease, and 8 progressed. From TP1 to TP2, metabolic ITH was significantly reduced ( P  < 0.01), and the degree of the decrease was greater in responders than in non-responders ( P  < 0.01). Using multiple Cox regression analyses, a low SUV max at TP2, a high kurtosis at TP2 and larger decreases in the coefficient of variance were associated with better PFS. A low SUV max at TP2, larger decreases in the metabolic tumor volume and larger decreased in the energy were associated with better OS. Age older than 60 years and responders also showed better OS. An early reduction in metabolic ITH is useful to predict treatment outcomes in advanced GC patients.