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IntroductionSelf-expanding metal stents (SEMS) are widely used in the palliative management of oesophageal malignancy to relieve progressive dysphagia. However, complications such as stent migration, chest pain, and procedural failure pose significant challenges. This retrospective study aimed to compare the procedural burden and outcomes of partially covered Ultraflex stents versus Niti-S ‘double-type’ stents over a four-year period at a district general hospital.MethodsData was retrospectively obtained from the Medilogik online reporting tool and Nervecenter electronic records from January 2021 to December 2024. Information was collected on patient demographics, stent indication, histological subtype, and type of SEMS used. Procedural complications (e.g., bleeding, perforation), 30-day mortality, 8-day readmission rates, and the need for repeat procedures were analysed. This comparison focused on partially covered Boston Scientific Corporation Ultraflex SEMS and Taewoong Medical Co., Ltd. Niti-S Double type SEMS. Fully covered stents were excluded. Three operators performed the procedures.Results91 patients underwent oesophageal stenting during the study period; 31 females and 60 males, with a mean age of 73.7 years (range 51–91). The primary indication for stenting was oesophageal malignancy. The majority of patients received partially covered Ultraflex stent (n=50) and the Niti-S Double type stent (n=25).Stent migration occurred in 22% of patients with Ultraflex stents (n=11) compared to 4% with Niti-S stents (n=1), showing a significant difference (p=0.039). Readmissions within 8 days of discharge were noted in 12% of Ultraflex stented patients (n=6) and 24% of Niti-S stented patients (n=6), with no statistically significant difference observed (p=0.243). The 30-day mortality rate was 12% (n=6) in the Ultraflex group compared to 4% (n=1) in the Niti-S group; this difference was not statistically significant (p=0.421).Abstract P166 Figure 1Comparison of procedure burden and adverse outcomes: ultraflex Vs Niti-S stents[Figure omitted. See PDF]ConclusionsThe Niti-S double-type stent outperformed the Ultraflex stent, with lower migration rates, likely due to its design that reduces migration and improves deployment. Patients with Ultraflex stents had higher complication rates and re-scoping needs within 12 months.Although the Niti-S stent costs £750 compared to £640 for the Ultraflex, its ability to reduce migration and avoid repeat procedures enhances overall cost-effectiveness. These findings emphasize the value of newer stent designs in improving patient outcomes and reducing procedural burden in oesophageal malignancy.

The oligometastatic paradigm suggests that some patients with a limited number of metastases might be cured if all lesions are eradicated. Evidence from randomised controlled trials to support this paradigm is scarce. We aimed to assess the effect of stereotactic ablative radiotherapy (SABR) on survival, oncological outcomes, toxicity, and quality of life in patients with a controlled primary tumour and one to five oligometastatic lesions. This randomised, open-label phase 2 study was done at 10 hospitals in Canada, the Netherlands, Scotland, and Australia. Patients aged 18 or older with a controlled primary tumour and one to five metastatic lesions, Eastern Cooperative Oncology Group score of 0–1, and a life expectancy of at least 6 months were eligible. After stratifying by the number of metastases (1–3 vs 4–5), we randomly assigned patients (1:2) to receive either palliative standard of care treatments alone (control group), or standard of care plus SABR to all metastatic lesions (SABR group), using a computer-generated randomisation list with permuted blocks of nine. Neither patients nor physicians were masked to treatment allocation. The primary endpoint was overall survival. We used a randomised phase 2 screening design with a two-sided α of 0·20 (wherein p<0·20 designates a positive trial). All analyses were intention to treat. This study is registered with ClinicalTrials.gov, number NCT01446744. 99 patients were randomised between Feb 10, 2012, and Aug 30, 2016. Of 99 patients, 33 (33%) were assigned to the control group and 66 (67%) to the SABR group. Two (3%) patients in the SABR group did not receive allocated treatment and withdrew from the trial; two (6%) patients in the control group also withdrew from the trial. Median follow-up was 25 months (IQR 19–54) in the control group versus 26 months (23–37) in the SABR group. Median overall survival was 28 months (95% CI 19–33) in the control group versus 41 months (26–not reached) in the SABR group (hazard ratio 0·57, 95% CI 0·30–1·10; p=0·090). Adverse events of grade 2 or worse occurred in three (9%) of 33 controls and 19 (29%) of 66 patients in the SABR group (p=0·026), an absolute increase of 20% (95% CI 5–34). Treatment-related deaths occurred in three (4·5%) of 66 patients after SABR, compared with none in the control group. SABR was associated with an improvement in overall survival, meeting the primary endpoint of this trial, but three (4·5%) of 66 patients in the SABR group had treatment-related death. Phase 3 trials are needed to conclusively show an overall survival benefit, and to determine the maximum number of metastatic lesions wherein SABR provides a benefit. Ontario Institute for Cancer Research and London Regional Cancer Program Catalyst Grant.

IntroductionThere are currently only a limited number of studies evaluating factors predictive of early mortality for patients undergoing endoscopy retrograde cholangiopancreatography (ERCP) for malignant biliary strictures. As ERCP is an invasive procedure with a risk of significant complications, it is important that is performed in appropriate circumstances, where the benefits outweigh the risks. Our objective was to evaluate predictive factors for mortality in patients with malignant (or suspected malignant) obstruction to aid decision making and inform prognosis in this group of patients.MethodsThe endoscopy database at Royal Sussex County Hospital was retrospectively searched to identify ERCPs carried out in 2017, 2019, 2022 and 2023. Patients who underwent ERCP for suspected malignant biliary obstruction were identified and case records reviewed. Demographic and laboratory data were collected and analysed to evaluate predictors of 30-day mortality.ResultsA total of 1016 ERCPs were carried out in the study period. 83 patients in this cohort were identified as having suspected malignant obstructions with a mean age of 72. 27 (33%) patients died within 30-days of ERCP. Admission INR was significantly higher in the 30-day mortality group compared with the non-mortality group (2 vs 1.34, p=0.035). On review of the mortality cases, post-ERCP bleeding was not the cause of death. Albumin was significantly lower in the mortality group (33.6 g/L vs 37.0 g/L, p = 0.010). There was no significant difference in any of the other variables analysed (table 1).Abstract P157 Table 1Variables analysed in 30-daysurvival and mortality groups post ERCPVariable Died Survived p ALP 831 (27) 805.7 (56) 0.833 ALT 165.22 (27) 244.8 (56) 0.051 Age 73.59 (27) 71.21 (56) 0.432 Albumin 33.63 (27) 37.02 (56) 0.010 Bilirubin 248.7 (27) 185.89 (56) 0.095 CRP 56.04 (27) 63.77 (56) 0.616 Creatinine 101.41 (27) 77.11 (56) 0.095 Hb 114.67 (27) 118.12 (56) 0.469 INR 2 (27) 1.34 (56) 0.035 Sodium 132.96 (27) 134.3 (56) 0.262 ConclusionsOur study demonstrates that admission INR and Albumin are predictive of 30-day mortality in patients undergoing ERCP for malignant biliary obstruction. Clearly in a palliative setting, performing an invasive procedure may be futile if survival is expected to be less than 30 days unless the is an expectation of a significant improvement in quality of life. Therefore, patient selection for intervention should take into consideration both objective markers and clinical judgement of patient’s frailty. Larger scale studies are needed to confirm our findings and identify other variables predictive of short-term mortality to assist in selecting patients who are most likely to benefit from palliative biliary stenting.

IntroductionPatients with advanced liver disease are often referred late to palliative care services or experience healthcare that does not meet their end of life needs. The IPOS is a robust, widely-used patient reported outcome measure that has been validated in advanced disease. It captures the main symptoms and concerns of the patient from a bio-psycho-social-spiritual perspective and is brief enough to be used clinically at end of life. The IPOS utilises Likert scales and free-text questions, allowing patients to report symptoms and their impact over a set time period. We collated national IPOS data to establish the physical, psychological, emotional and practical symptoms, needs or concerns that matter most to patients with advanced liver disease to support both hepatology and palliative care services, working to reduce these health inequalities.MethodsHepatology and palliative care services across England shared fully anonymised, routinely collected IPOS data from adult patients with advanced liver disease. Advanced liver disease (irrespective of the underlying aetiology) included those with compensated or decompensated cirrhosis unsuitable for curative treatment, and/or felt to be within their last year of life. Secondary analysis using descriptive statistics of the IPOS’ closed questions identified the main symptoms and their level of impact.ResultsResults (n=323) demonstrate a median age of 71 years (range 34 to 95) and median deprivation decile of 4 (range 1–10). Of reported ICD-10 codes (n=227), 8% (n=19) were liver disease related to alcohol, 30% (n=68) were due to malignant diseae and 57% (n=130) were liver disease with an unspecified aetiology.Within the IPOS physical subscale, 68.7% (n=222) were moderately, severely or overwhelmingly affected by weakness or lack of energy, with 40.6% (n=131) severely or overwhelmingly affected. Problems with mobility were the next most frequently reported symptom affecting 35.3% (n=114) at a severe to overwhelming level. Among the psychological concerns, family anxiety was reported ‘most of the time’ to ‘always’ for 44.3% (n=143). Being able to share feeling as wished with family or friends was reported by 13.9% (n=45) as only occasionally, or not at all, making this the most unmet need in the IPOS communication/practical issues subscale.ConclusionsAlthough final conclusions can only be drawn after full statistical analysis of the entire dataset, interim analysis suggests there are gaps in symptom management that should be explored further. These include rehabilitation as well as patient/family support needs. Knowledge of the symptoms and concerns which affect patients most will support ongoing work improving access and quality of supportive and palliative care for those with advanced liver disease.

Over the past decade, a large body of evidence has accumulated supporting the integration of palliative care into oncology practice for patients with advanced cancer. The question is no longer whether palliative care should be offered, but what is the optimal model of delivery, when is the ideal time to refer, who is in greatest need of a referral, and how much palliative care should oncologists themselves be providing. These questions are particularly relevant given the scarcity of palliative care resources internationally. In this state‐of‐the‐science review directed at the practicing cancer clinician, the authors first discuss the contemporary literature examining the impact of specialist palliative care on various health outcomes. Then, conceptual models are provided to support team‐based, timely, and targeted palliative care. Team‐based palliative care allows the interdisciplinary members to address comprehensively the multidimensional care needs of patients and their caregivers. Timely palliative care, at its best, is preventive care to minimize crises at the end of life. Targeted palliative care involves identifying the patients most likely to benefit from specialist palliative care interventions, akin to the concept of targeted cancer therapies. Finally, the strengths and weaknesses of innovative care models, such as outpatient clinics, embedded clinics, nurse‐led palliative care, primary palliative care provided by oncology teams, and automatic referral, are summarized. Moving forward, more research is needed to determine how different health systems can best personalize palliative care to provide the right level of intervention, for the right patient, in the right setting, at the right time.

The elderly may represent a specific cluster of high-risk patients for developing COVID-19 with rapidly progressive clinical deterioration. Indeed, in older individuals, immunosenescence and comorbid disorders are more likely to promote viral-induced cytokine storm resulting in life-threatening respiratory failure and multisystemic involvement. Early diagnosis and individualized therapeutic management should be developed for elderly subjects based on personal medical history and polypharmacotherapy. Our review examines the pathogenesis and clinical implications of ageing in COVID-19 patients; finally, we discuss the evidence and controversies in the management in the long-stay residential care homes and aspects of end-of-life care for elderly patients with COVID-19.

Full integration of oncology and palliative care relies on the specific knowledge and skills of two modes of care: the tumour-directed approach, the main focus of which is on treating the disease; and the host-directed approach, which focuses on the patient with the disease. This Commission addresses how to combine these two paradigms to achieve the best outcome of patient care. Randomised clinical trials on integration of oncology and palliative care point to health gains: improved survival and symptom control, less anxiety and depression, reduced use of futile chemotherapy at the end of life, improved family satisfaction and quality of life, and improved use of health-care resources. Early delivery of patient-directed care by specialist palliative care teams alongside tumour-directed treatment promotes patient-centred care. Systematic assessment and use of patient-reported outcomes and active patient involvement in the decisions about cancer care result in better symptom control, improved physical and mental health, and better use of health-care resources. The absence of international agreements on the content and standards of the organisation, education, and research of palliative care in oncology are major barriers to successful integration. Other barriers include the common misconception that palliative care is end-of-life care only, stigmatisation of death and dying, and insufficient infrastructure and funding. The absence of established priorities might also hinder integration more widely. This Commission proposes the use of standardised care pathways and multidisciplinary teams to promote integration of oncology and palliative care, and calls for changes at the system level to coordinate the activities of professionals, and for the development and implementation of new and improved education programmes, with the overall goal of improving patient care. Integration raises new research questions, all of which contribute to improved clinical care. When and how should palliative care be delivered? What is the optimal model for integrated care? What is the biological and clinical effect of living with advanced cancer for years after diagnosis? Successful integration must challenge the dualistic perspective of either the tumour or the host, and instead focus on a merged approach that places the patient's perspective at the centre. To succeed, integration must be anchored by management and policy makers at all levels of health care, followed by adequate resource allocation, a willingness to prioritise goals and needs, and sustained enthusiasm to help generate support for better integration. This integrated model must be reflected in international and national cancer plans, and be followed by developments of new care models, education and research programmes, all of which should be adapted to the specific cultural contexts within which they are situated. Patient-centred care should be an integrated part of oncology care independent of patient prognosis and treatment intention. To achieve this goal it must be based on changes in professional cultures and priorities in health care.