Elena Ruggiero’s research while affiliated with University-Hospital of Padova and other places

Background Bereavement is a crucial physiological process in palliative care; grief-processing disorders can be diagnosed at least 6 months after death and can have severe clinical or psychological consequences. This study aims to verify how adequate management of anticipatory mourning and condolence conversations can be protective in the early stages of grief. Methods Patients and caregivers are supported by a multidisciplinary team through semi-structured interviews. In condolence conversations within one month of the death, we identify signs of psychological fragility that require support for adequate processing of the loss. Results From the condolence conversations, only 2–4% of caregivers who had received psychological support during the hospital stay and showed a good level of acceptance of their relative’s end of life exhibited grief problems within 1 month of death; none showed excessive avoidance of memories, difficulties with trust, or feelings of emotional loneliness. Conclusions Despite the limitations, the preliminary data of our study clearly suggest the protective potential of multidisciplinary support, particularly in reducing the risk of developing grief processing disorders. These considerations encourage us to implement our model of clinical and psychological support systems and develop pathways dedicated to caregivers experiencing greater difficulty.

Glucocorticoids (GCs) have been widely used in symptomatic patients for the treatment of COVID-19. The risk for adrenal insufficiency must be considered after GC withdrawal given that it is a life-threatening condition if left unrecognized and untreated. Our study aimed to diagnose adrenal insufficiency early on through a GC reduction schedule in patients with COVID-19 infection. From November 2021 to May 2022, 233 patients were admitted to the Geriatric Division of the University Hospital of Padova with COVID-19 infection. A total of 122 patients were treated with dexamethasone, after which the GC tapering was performed according to a structured schedule. It consists of step-by-step GC tapering with prednisone, from 25 mg to 2.5 mg over 2 weeks. Morning serum sodium, potassium, and cortisol levels were assessed 3 days after the last dose of prednisone. At the end of GC withdrawal, no adrenal crisis or signs/symptoms of acute adrenal insufficiency were reported. Median serum cortisol, sodium, and potassium levels after GC discontinuation were, respectively, 427 nmol/L, 140 nmol/L, and 4 nmol/L (interquartile range 395–479, 138–142, and 3.7–4.3). A morning serum cortisol level below the selected threshold of 270 nmol/L was observed in two asymptomatic cases (respectively, 173 and 239 nmol/L, reference range 138–690 nmol/L). Mild hyponatremia (serum sodium 132 to 134 nmol/L, reference range 135–145 nmol/L) was detected in five patients, without being related to cortisol levels. A structured schedule for the tapering of GC treatment used in patients with severe COVID-19 can reduce the risk of adrenal crisis and acute adrenal insufficiency.

Background Bereavement is a physiological process of great importance in palliative care; grief-processing disorders can be diagnosed after at least 6 months after death and have severe clinical or psychological consequences. Aim of the study is to verify how adequate management of anticipatory mourning and condolence conversation in the early grief stages can be protective. Methods Patients and caregivers are supported by the multidisciplinary team by semi structured interviews. In condolence conversation within 1 month of the death, we identify elements of suspicion of psychological fragility that require support for an adequate processing of the loss. Results From condolence conversation, only 3% of the caregivers who had been psychologically supported during the hospital stay and demonstrated a good level of acceptance of their relative's end of life, showed problems in grieving within 1 month of death; none showed excessive avoidance of memories, difficulties with trust and feelings of emotional loneliness. Conclusions Despite the limitations, the preliminary data of our study clearly suggests the protective potential of multidisciplinary support, particularly in the risk of developing grief processing disorders. These considerations encourage us to implement our model of clinical and psychological support system and develop paths dedicated to caregivers in greater difficulty.

Pain is one of the predominant and troublesome symptoms that burden cancer patients during their whole disease trajectory: adequate pain management is a fundamental component of cancer care. Opioid are the cornerstone of cancer pain relief therapy and their skillful management must be owned by physicians approaching cancer pain patients. In light of the increased survival of cancer patients due to advances in therapy, deprescription should be considered as a part of the opioid prescribing regime, from therapy initiation, dose titration, and changing or adding drugs, to switching or ceasing. In clinical practice, opioid tapering after pain remission could be challenging due to withdrawal symptoms’ onset. Animal models and observations in patients with opioid addiction suggested that somatic and motivational symptoms accompanying opioid withdrawal are secondary to the activation of stress-related process (mainly cortisol and catecholamines mediated). In this narrative review, we highlight how the lack of validated guidelines and tools for cancer patients can lead to a lower diagnostic awareness of opioid-related disorders, increasing the risk of developing withdrawal symptoms. We also described an experience-based approach to opioid withdrawal, starting from a case-report of a symptomatic patient with a history of metastatic pheochromocytoma-paraganglioma.

The prognosis of patients with advanced adrenocortical carcinoma (ACC) is often poor: in the case of metastatic disease, five-year survival is reduced. Advanced disease is not a non-curable disease and, in referral centers, the multidisciplinary approach is the standard of care: if a shared decision regarding several treatments is available, including the correct timing for the performance of each one, overall survival is increased. However, many patients with advanced ACC experience severe psychological and physical symptoms secondary to the disease and the cancer treatments. These symptoms, combined with existential issues, debase the quality of the remaining life. Recent strong evidence from cancer research supports the early integration of palliative care principles and skills into the advanced cancer patient’s trajectory, even when asymptomatic. A patient with ACC risks quickly suffering from symptoms/effects alongside the disease; therefore, early palliative care, in some cases concurrent with oncological treatment (simultaneous care), is suggested. The aims of this paper are to review current, advanced ACC approaches, highlight appropriate forms of ACC symptom management and suggest when and how palliative care can be incorporated into the ACC standard of care.