End of life treatments and events in ovarian cancer: A comparison of short versus long-term outcomes

5096

Background: To identify the aggressiveness of treatment and events in ovarian cancer patients during the last year of life based on survival time. Methods: Patient charts of deceased epithelial ovarian cancer patients were retrospectively reviewed from 2000–2005. All patients included had debulking surgery and received adjuvant chemotherapy. Patients were separated into groups based on survival quartiles. Aggressiveness of care was measured by chemotherapy regimens, ER visits and hospitalizations. Significant clinical events (SCE) were defined as ascites, bowel obstruction, and pleural effusion. Comparison of quartiles was done using chi-square and t-test statistic. Multiple regression analysis was done using survival duration as a dependent variable. Results: 97 patients with epithelial ovarian cancer were reviewed. There was no difference in patterns of hospitalizations and SCE between the top and bottom survival quartiles. Patients with a shorter survival time received more chemotherapy during their last 3 months of life and had increased overall aggressiveness of care measures (Table). In patients who had a remission, regression analysis revealed length of initial remission time was significant in predicting survival (p < 0.01). Time to 2nd relapse was also significant in predicting survival time (p < 0.01). Number of SCE during the last year of life events trended for predicting survival (p = 0.10). Conclusions: Duration of ovarian cancer remission is predictive of survival. Those patients with a short trajectory of disease receive more aggressive care, chemotherapy at the end of life, less hospice care; however, they die similarly to those with longer survival duration. Those patients with short remissions and / or SCE during recurrence should receive less aggressive care at the end-of-life.

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No significant financial relationships to disclose.

Cetuximab, paclitaxel, carboplatin and radiation for esophageal and gastric cancer

4029

Background: Cetuximab is an IgG1, chimerized, monoclonal antibody that binds specifically to the epidermal growth factor receptor. Cetuximab improves survival when combined with radiation for patients with locally advanced head and neck cancer. We evaluated the safety and efficacy of the addition of cetuximab to concurrent chemoradiation for patients with esophageal and gastric cancer. Methods: Patients with adenocarcinoma or squamous cell cancer of the esophagus or stomach without distant organ metastases were eligible. Patients with locally advanced disease from mediastinal, celiac, portal and gastric lymphadenopathy were eligible. Surgical resection was not required. Clinical complete response was defined as no tumor on postreatment endoscopic biopsy. Patients received cetuximab, 400mg/m2 week #1 then 250 mg/m2/week for 5 weeks, paclitaxel, 50 mg/m2/week, and carboplatin, AUC =2 weekly for 6 weeks, with concurrent 50.4 Gy radiation. Results: Thirty-seven patients have been entered. The median age was 61 (range of 30–87). Thirty-four have esophageal cancer and 3 have gastric cancer. Of the patients with esophageal cancer, twenty-five have adenocarcinoma and nine have squamous cell cancer. Thus far, 30 patients have completed treatment and are evaluable for toxicity. There have been no grade 4 non-hematologic toxicities and 1 pt had grade 4 neutropenia (3%). Six patients (20%) had grade 3 esophagitis. Other grade 3 toxicities included dehydration (n=5), rash (n=9), and paclitaxel/cetuximab hypersensitivity reactions (n=2). Eighteen of 27 patients (67%) have had clinical complete response. Seven pts out of 16 (43%) who have gone to surgery have had a pathologic CR. Conclusions: Cetuximab can be safely administered with chemoradiation for patients with esophageal cancer. Consistent with the data in head and neck cancer, cetuximab increases cutaneous toxicity but does not increase mucositis/esophagitis when combined with chemoradiation. Further evaluation is ongoing.

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Genetic and environmental effects on the muscle structure response post-mortem

This paper reviewed the mechanisms by which glycolytic rate and pre-rigor stretching of muscle impact on meat quality. If muscle is free to shorten during the rigor process extremes in glycolytic rate can impact negatively on meat quality by inducing either cold or rigor shortening. Factors that contribute to variation in glycolytic rate include the glycogen concentration at slaughter and fibre type of the muscle. Glycolysis is highly sensitive to temperature, which is an important factor in heavy grain fed carcasses. An alternative solution to controlling glycolysis is to stretch the muscle pre-rigor so that it cannot shorten, thus providing an insurance against extremes in processing conditions. Results are presented which show a large reduction in variance (both additive and phenotypic) in tenderness caused by pre-rigor stretching. Whilst this did not impact on the heritability of shear force, it did reduce genotype differences. The implications of these results on the magnitude of genotype effects on tenderness is discussed.

Undergraduate and postgraduate dental students' 'reflection on learning': a qualitative study

The aim of this study was to explore undergraduate and postgraduate dental students' understanding of a good learning experience by using 'reflection on learning' as described by Schon. Four groups of Year 4 BDS students and one group of postgraduate students in dental public health took part in a series of focus group discussions. The responses were grouped into four broad themes (a) active, practical and positive learning; (b) interactive/together learning; (c) personal learning; (d) theory into practice. Six educational models of good learning proposed by the students are described.

Low birth weight and cardiovascular risk factors in Auckland adolescents: a retrospective cohort study

AIMS

To determine whether birth weight is inversely associated with cardiovascular risk factors in a multiethnic sample of New Zealand adolescents.

METHODS

A retrospective cohort with birth weight collected from hospital records of 855 (68%) out of 1260 Auckland-born students who had blood pressure, fasting blood lipids, and glucose measured while in Year 11-13 at high school.

RESULTS

After controlling for sex, age, and ethnicity, none of the following cardiovascular risk factors were associated with birth weight (p>0.05): systolic and diastolic blood pressure, total cholesterol, HDL cholesterol, triglycerides, and glucose. Serum cholesterol came closest to statistical significance: regression coefficient being--0.10 mmol/L (SE=0.06, p value=0.11). In contrast (after controlling for age, sex, and ethnicity), current Body Mass Index (BMI) was significantly (p<0.05) related to all above cardiovascular risk factors. The proportion of students with elevated serum cholesterol levels (top 20%) attributable to elevated BMI (>30 kg/m2) was 18%, and that attributable to low birth weight (<2.5 kg) was 2%.

CONCLUSIONS

These results do not support for the 'fetal origins' hypothesis. The very low proportion of adolescents with elevated coronary risk factors attributed to low birth weight suggests that the focus of cardiovascular disease prevention should remain in adolescence and adulthood, rather than in pregnancy.

Predictors of life satisfaction of Korean nurses

AIM

This paper reports a study to identify the levels of work satisfaction, burnout and life satisfaction among Korean hospital nurses and the relative importance of negative and positive work outcomes (burnout and work satisfaction) in explaining the variance of life satisfaction of nurses.

BACKGROUND

Previous research has demonstrated that work outcomes such as job satisfaction and burnout can affect overall life satisfaction. It is not yet known, however, whether positive and negative aspects of work outcomes exert equally strong or varying degrees of effect, nor whether the relationships demonstrated primarily in Western cultures also are present in other cultures. Given the widespread shortage of nurses, it is important to identify areas for organizational interventions that have the greatest potential for improving both recruitment and retention of nurses.

METHODS

A cross-sectional correlational design was used. A survey was undertaken with 194 nurses from general hospitals of 300 beds or more in southern Korea between May 1999 and March 2000. Paper and pencil self-rating questionnaires were used to gather information. Data were analysed using descriptive statistics, Pearson correlations and multiple regressions.

RESULTS

Korean nurses reported moderate levels of life satisfaction, with low levels of work satisfaction and high levels of burnout. Burnout explained more variance in life satisfaction than work satisfaction. Those who experienced higher personal accomplishment and lower emotional exhaustion and who were satisfied with their professional status and did not work at night reported higher life satisfaction.

CONCLUSIONS

This study highlights the relative importance of negative work outcomes on nurses' overall well-being. Strategies to reduce emotional exhaustion, enhance nurses' personal accomplishment and satisfaction with professional status, and accommodate shift preferences for work scheduling were suggested. Replicating this study with nurses from other geographic areas using random selection will be needed to increase the generalizability of the findings.

A comprehensive model for predicting burnout in Korean nurses

BACKGROUND

Although burnout among nurses has been studied in a great deal, this work has not included Korean nurses. Furthermore, the role of personal resources such as empathy and empowerment in predicting the variance in burnout has never been examined.

AIM

The purpose of this study was to understand the phenomenon of burnout among Korean nurses. A comprehensive model of burnout was examined to identify significant predictors among individual characteristics, job stress and personal resource, with the intention of providing a basis for individual and organizational interventions to reduce levels of burnout experienced by Korean nurses.

METHODS

A cross-sectional correlational design was used. A sample of 178 nurses from general hospitals in southern Korea was surveyed from May 1999 to March 2000. The data were collected using paper and pencil self-rating questionnaires and analysed using descriptive statistics, Pearson correlations, and hierarchical multiple regression.

RESULTS

Korean nurses reported higher levels of burnout than nurses in western countries such as Germany, Canada, the United Kingdom and the United States of America. Nurses who experienced higher job stress, showed lower cognitive empathy and empowerment, and worked in night shifts at tertiary hospitals were more likely to experience burnout.

CONCLUSIONS

Identifying a comprehensive model of burnout among Korean nurses is an essential step to develop effective managerial strategies to reduce the problem. Suggestions to reduce the level of burnout include enhancing nurses' cognitive empathy and perceived power, providing clear job descriptions and work expectations, and exploring nurses' shift preferences, especially at tertiary hospitals. In future research we recommend recruiting nurses from broader geographical areas using random selection in order to increase the generalizability of the findings.

Prevention. Part 1: smoking cessation advice within the general dental practice

Smoking remains the largest single preventable cause of death and disability in the UK and costs the NHS 1.7 billion pound each year. More than 120,000 people die prematurely due to smoking related diseases. Worldwide smoking is the single most important public health problem. The detrimental effects of smoking and tobacco use on oral health are well recognised. Oral cancers and pre-cancers, periodontal diseases and poor wound healing are the most significant and serious effects of smoking on the mouth. In addition, staining of the teeth, soft tissue changes and halitosis are aesthetic and social impacts of smoking directly related to oral health.

Determination of plasma trace elements in tumor-bearing animals by proton-induced X-ray emission spectroscopy

Although altered levels of circulating essential trace elements are known to accompany malignant disease, the lack of sensitivity of conventional detection methods has generally limited their study to clinical conditions involving extensive disease (i.e., significant tumor burden). As such, the application of altered trace element levels as potential prognostic guides or as response indicators subsequent to treatment has been of limited use. During this study, proton-induced X-ray emission spectroscopy was evaluated as a tool to determine trace element imbalances in a murine tumor model. Using plasma from C57B1/6 mice bearing the syngeneic Lewis lung carcinoma (LLCa), levels of Fe, Cu, and Zn, as well as changes in the Cu /Zn ratio, were measured in animals carrying an increasing primary tumor burden. The plasma levels of Fe, Cu, and Zn were found to decrease significantly 7 d following implants of LLCa cells with no significant change observed in the Cu/Zn ratio. By d 21, however, an increase in the Cu/Zn ratio was found to accompany increased growth of the LLCa tumor; the plasma levels of Cu had returned to normal levels, whereas both the Fe and Zn plasma levels remained lowered. Collectively, the results suggest that although a net change in individual plasma trace element concentrations might not be accurately associated with tumor growth, a clear relationship was established between the Cu/Zn ratio and tumor size.

The effect of age, gender, risk level and glycosylated hemoglobin in predicting foot amputation in HMO patients with diabetes

PURPOSE

To determine if age, gender, risk level and glucosylated hemoglobin could predict foot amputations in HMO patients with diabetes.

DATA SOURCES

A retrospective chart review of a non-random sample of 27 patients with amputation and 110 randomly selected patients without amputation during the same time period. Chi-square, t-tests and logistic regression were used to analyze the data.

CONCLUSIONS

There was no significant difference between the group with amputation and those without amputation in age or gender. However, there was a significant difference between the two groups in the risk stratification (p = .005) and glycosylated hemoglobin levels (p = .058).

IMPLICATIONS FOR PRACTICE

Nurse practitioners can effectively screen for amputation risk factors and closely monitor glycosylated hemoglobin levels of diabetic patients to reduce the incidence of vascular complications and related lower extremity amputation.

Outcomes-based trial of an inpatient nurse practitioner service for general medical patients

Although teaching hospitals are increasingly using nurse practitioners (NPs) to provide inpatient care, few studies have compared care delivered by NPs and housestaff or the ability of NPs to admit and manage unselected general medical patients. In a Midwest academic teaching hospital 381 patients were randomized to general medical wards staffed either by NPs and a medical director or medical housestaff. Data were obtained from medical records, interviews and hospital databases. Outcomes were compared on both an intention to treat (i.e. wards to which patients were randomized) and actual treatment (i.e. wards to which patients were admitted) basis. At admission, patients assigned randomly to NP-based care (n = 193) and housestaff care (n= 188) were similar with respect to demographics, comorbidity, severity of illness and functional parameters. Outcomes at discharge and at 6 weeks after discharge were similar (P>0.10) in the two groups, including: length of stay; charges; costs; consultations; complications; transfers to intensive care; 30-day mortality; patient assessments of care; and changes in activities of daily living, SF-36 scores and symptom severity. However, after randomization, 90 of 193 patients (47%) assigned to the NP ward were actually admitted to housestaff wards, largely because of attending physicians and NP requests. None the less, outcomes of patients admitted to NP and housestaff wards were similar (P>0.1). NP-based care can be implemented successfully in teaching hospitals and, compared to housestaff care, may be associated with similar costs and clinical and functional outcomes. However, there may be important obstacles to increasing the number of patients cared for by NPs, including physician concerns about NPs' capabilities and NPs' limited flexibility in managing varying numbers of patients and accepting off-hours admissions.

Carotid artery injuries and their management

BACKGROUND

Major vascular injuries in the region of the neck are most frequently the result of penetrating trauma. Evaluation and management of patients with injury to Zone II of the neck remains highly controversial. Most studies involve small number of patients with a lack of standardization of the nature of the injury in reporting outcome. It is the purpose of this study to propose a grading scale for vascular injuries in the neck that would allow for more uniform reporting of such injuries.

METHODS

EXPERIMENTAL DESIGN

A retrospective review of all patients treated for penetrating trauma to the neck was performed and the subset of patients with major vascular injuries identified. Data from this group of patients are presented.

SETTING

Level II urban trauma center.

PATIENTS AND INTERVENTIONS

During the period July 1984 to June 1994, 107 patients were treated for penetrating neck trauma. Injuries to the major arteries of the neck were present in 18 of the 107 patients (16.8%). All injuries were graded on the developed scale. Management protocol was based on the grade of the injury. Grade 1 injuries were managed non-operatively with systemic anticoagulation and low molecular weight dextran. Grade 2 injuries were treated with primary repair. Injuries of Grades 3 and 4 were treated by primary repair or interposition graft. Exceptions were isolated injuries of the external carotid artery, which were treated by ligation alone.

RESULTS

Of the 18 patients with carotid artery injuries, 2 had injuries of the external carotid artery, treated with ligation alone. The internal carotid artery was injured in 7 cases. An interposition saphenous vein/PTFE graft was used in all cases. In 9 cases the common carotid artery was injured. Repair was accomplished by a combination of either a primary repair or interposition graft. Overall mortality was 3/16 (16.6%). No new or worsening of neurologic deficit occurred in any patient.

CONCLUSIONS

Carotid artery injuries occur in about 17% of patients with penetrating neck trauma. Data regarding management and prognosis in these patients are at best concflicting, in part, due to lack of a standardized classification system. The proposed grading scale is designed to overcome this problem.

Liver and bone window settings for soft-copy interpretation of chest and abdominal CT

OBJECTIVE

We evaluated whether the use of multiple window and level settings on a soft-copy workstation improves diagnostic accuracy on chest and abdominal CT. We hypothesized that routinely using window and level settings during soft-copy interpretation would beneficially affect the final diagnosis without compromising efficiency.

MATERIALS AND METHODS

Two hundred three randomly selected abdominal and chest CT scans were interpreted by three radiologists using a four-monitor soft-copy workstation (images per screen, nine; resolution, 2K). After the initial interpretations, all scans were reevaluated by the same radiologists using additional liver and bone window and level settings. Differences in conspicuity and characterization of abnormalities were graded on a three-point scale.

RESULTS

Conspicuity and characterization of abnormalities were improved in 67% of abnormal findings (81/121; p = 0.01). Improvement (a finding that substantially affected the final diagnosis) was present in 18% of abnormal findings (22/121; p = 0.04). On average, the evaluation of images at multiple window and level settings required an additional 40 sec per case.

CONCLUSION

The use of multiple window and level settings during soft-copy interpretation resulted in improved lesion detectability and characterization with greater diagnostic efficacy. Using soft-copy workstations, radiologists can evaluate images using multiple settings without compromising efficiency.

Predicting the occurrence of diabetes mellitus in recipients of heart transplants

AIMS

To establish the incidence of post-transplant diabetes mellitus (PTDM) and factors predictive of its development.

METHODS

This was a retrospective review (using hospital records and transplant database) of 97 consecutive adult patients who underwent cardiac transplantation at St Vincent's Hospital, Sydney, Australia.

RESULTS

Mean follow-up was 27 months. Excluding five patients who had pre-existing diabetes, the cumulative incidence of PTDM was 15.7%. Pre-transplant random blood glucose (5.6 +/- 0.8 vs. 5.2 +/- 0.6 mmol/l, P<0.05), family history (46% vs. 15%, P<0.05) and a continuing requirement for insulin on the second post-transplant day (54% vs. 15%, P< 0.01) differed in those who developed PTDM as opposed to those who remained free of diabetes. Patients who developed PTDM had received slightly higher mean doses of prednisolone at three months (0.21 +/- 0.03 vs. 0.19 +/- 0.03 mg. kg(-1)/day(-1), P<0.01). Of the factors identifiable prior to initial hospital discharge, only family history of diabetes mellitus and second post-transplant day insulin requirement independently predicted the occurrence of PTDM.

CONCLUSIONS

A family history of diabetes and the need for insulin beyond the first 24 h after transplantation are factors identifiable prior to hospital discharge, which predict patients at risk of developing PTDM. In such patients, consideration to minimizing the dose of glucocorticoids should be given where possible.

Imaging features of posttransplantation lymphoproliferative disorder in pancreas transplant recipients

OBJECTIVE

The purpose of this study was to describe the imaging features of posttransplant lymphoproliferative disorder (PTLD) in pancreas transplant recipients.

CONCLUSION

The prominent image finding of PTLD in pancreas transplant recipients is diffuse allograft enlargement, an appearance that may be indistinguishable from the image findings of acute pancreatitis or transplant rejection. However, failure of response to immunosuppressive therapy, presence of intraallograft or extraallograft focal masses, or organomegaly may suggest the diagnosis of PTLD.

Percutaneous abdominal and pelvic interventional procedures using CT fluoroscopy guidance

OBJECTIVE

The purpose of our study was to assess the use of low-milliamperage CT fluoroscopy guidance for percutaneous abdominopelvic biopsy and therapeutic procedures.

MATERIALS AND METHODS

We reviewed the clinical records and relevant imaging studies of 97 patients who underwent 119 percutaneous CT fluoroscopy-guided abdominal or pelvic procedures: fluid collection aspiration or drainage catheter insertion (n = 59), biopsy (n = 49), hepatocellular carcinoma ethanol ablation (n = 6), chemoneurolysis (n = 4), and brachytherapy catheter insertion (n = 1). These procedures were guided using a helical CT scanner providing real-time fluoroscopy reconstruction at six frames per second. A control panel and video monitor beside the gantry allowed direct operator control during all interventional procedures.

RESULTS

One hundred twelve (94.1%) procedures were successfully performed using either a stand-off needle holder and continuous real-time CT fluoroscopy guidance or incremental manual insertion and intermittent CT fluoroscopy to confirm position. Image quality using low milliamperage was adequate for needle or drainage tube placement in all but two low-contrast liver lesions. Two hematomas were accessed but yielded no fluid on aspiration; one drainage procedure was abandoned after the patient developed endotoxic shock. Imaging of ethanol distribution during injection facilitated tumor ablation and neurolytic procedures. CT fluoroscopy allowed rapid assessment of needle, guidewire, dilator, and catheter placement, especially in nonaxial planes. Average CT fluoroscopy time for biopsy and therapeutic procedures was 133 sec (range, 35-336 sec) and 186 sec (range, 20-660 sec), respectively.

CONCLUSION

CT fluoroscopy is a practical clinical tool that facilitates effective performance of percutaneous abdominal and pelvic interventional procedures.

Elderly patients' understanding of advance directives

Growing evidence suggests that advance directives (ADs) are often ineffective. Further explanation of how these documents are viewed by the public, the expectations of how decisions about treatment are made, and, in particular, patients' understanding of how ADs are actually used in the clinical setting, are warranted. This article details a descriptive study in which patients were interviewed, during hospital stays, about their beliefs and understanding of advanced directives, as well as the processes used in completing them. The study was undertaken in a community hospital located in a rural area in the Midwest. Findings show that many patients were able to clearly articulate what an AD means in terms of making their choices known. However, misconceptions were found in patients' understanding of ADs and only 46% reported discussing their ADs with a physician. Strategies for effective implementation of education programs related to ADs are detailed here.

Bacterial loss from biofilms exposed to free chlorine

Previous studies have demonstrated the increased resistance of biofilm bacteria to biocides when compared with freely suspended planktonic cells, but there have been few investigations of sloughing and losses from biofilms in response to biocide activity. A model biofilm system was used to demonstrate that the loss of sloughed bacteria (including Escherichia coli as a pathogen indicator organism) from actively growing biofilm reached levels of 10(6)-10(7) CFU ml-1 of eluted medium. The sloughing response was examined in response to a range of free chlorine concentrations from 0.6 to 5.0 mg l-1. While chlorine treatment greatly reduced bacterial sloughing, significant bacterial loss into the planktonic phase still occurred with free chlorine concentrations below 3.0 mg l-1, indicating active growth and sloughing of biofilm organisms. Exposure of the biofilm to higher levels of free chlorine resulted in inhibition of bacterial loss, though biocide removal was accompanied by a rapid, almost immediate, recovery of sloughing ability. This work demonstrates the endurance and speed of biofilm recovery upon quenching of chlorine residuals, highlighting a potentially significant public health risk from biofilm recovery and the sloughing of pathogenic organisms associated with the biofilm.