Strategies to embed palliative care into a culture of cancer care

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Background: In 2012, the 3 hospital Lifespan Health System launched a palliative care initiative. The hospitals and medical oncologists knew this was critical for patient centered and value-based cancer care, but recognized many barriers: physician practice patterns, lack of dedicated resources and systems, patient and family education gaps, and limited return on investment in the current environment. A multi-level inpatient and outpatient strategy was implemented and tracked over four years. Methods: External benchmarking data from a Medicare claims analysis of Vizient (academic health system consortium) member organizations and from ASCO QOPI data were used in the analysis. Internal data analysis included a study on symptom management for lung cancer patients, hospital reports on palliative care service utilization, ED visits and hospital admission trends for cancer patients. Multi-level interventions were employed: hospital investment in staff and systems, partnership with a community-based hospice and palliative care provider, a medical oncology physician champion with Board certification in palliative care, a palliative care inpatient consult service and daily ICU rounds, an oncology medical home, medical oncologist Saturday hours, electronic prompts for consults, and a cancer call triage center. Results: A Medicare claims analysis for 2012 to 2014 on cancer decedents with ICU stays in the last 30 days in the Vizient national study of health systems showed that Lifespan was at the 11th percentile, making them the 4th lowest (days in ICU) in performance (pre/post data requested). QOPI data on appropriate referrals to hospice or palliative care prior to death improved from 58% in 2010, which was below the QOPI benchmark of 61%, to 94% in 2016 which is above the QOPI benchmark of 74%. Other QOPI and hospital data will be included in the presentation. Conclusions: Palliative care, a crucial tool for the delivery of future cancer care, is challenging to implement effectively. This study shows that a hospital/medical oncology partnership can drive change to embed palliative care into the culture of cancer care and these strategies offer a roadmap for others to follow as they strive to offer patient centered and value-based cancer care.

The association between physical activity and cognition in men with and without HIV infection

OBJECTIVES

HIV-associated neurocognitive disorders are highly prevalent, and physical activity (PA) is a modifiable behaviour that may affect neurocognitive function. Our objective was to determine the association between PA and neurocognitive function and the effect of HIV on this association.

METHODS

PA was assessed in the Multicenter AIDS Cohort Study with the International Physical Activity Questionnaire. A neuropsychological test battery assessed global impairment and domain-specific impairment (executive function, speed of processing, working memory, learning, memory, and motor function) every 2 years. Semiannually, the Symbol Digit Modalities Test and Trail Making Test Parts A and B were performed. Adjusted logistic regression models were used to assess the PA-neurocognitive function association. Using longitudinal data, we also assessed the PA category-decline of neurocognitive function association with multivariate simple regression.

RESULTS

Of 601 men, 44% were HIV-infected. Low, moderate, and high PA was reported in 27%, 25%, and 48% of the HIV-infected men vs. 19%, 32% and 49% of the HIV-uninfected men, respectively. High PA was associated with lower odds of impairment of learning, memory, and motor function [odds ratio (OR) ranging from 0.52 to 0.57; P < 0.05 for all]. The high PA-global impairment association OR was 0.63 [95% confidence interval (CI) 0.39, 1.02]. Among HIV-infected men only, across multiple domains, the high PA-impairment association was even more pronounced (OR from 0.27 to 0.49). Baseline high/moderate PA was not associated with decline of any domain score over time. HIV infection was marginally associated with a higher speed of decline in motor function.

CONCLUSIONS

A protective effect of high PA on impairment in neurocognitive domains was observed cross-sectionally. Longitudinal PA measurements are needed to elucidate the PA-neurocognitive function relationship over time.

Two-photon controlled sol–gel condensation for the microfabrication of silica based microstructures. The role of photoacids and photobases

Two-photon excitation of photobases is used to induce pH changes and control the condensation step of the sol–gel process at the focal point of a laser beam in a confocal configuration.

Aminophosphine ligands as a privileged platform for development of antitumoral ruthenium(ii) arene complexes

The potential utility of aminophosphine ligands in both high-throughput testing and rational design of new anticancer metallodrugs.

New oral targeted therapies for metastatic breast cancer disrupt the traditional patients' management-A healthcare providers' view

Although a cure still cannot be expected for metastatic breast cancer, thanks to progressive advances in treatments, life expectancy has been increasing over the past 15 years. This study aims to present the impact on the organisation of patients' management of newly released oral targeted therapies dedicated to metastatic breast cancer and the obstacles to their diffusion. Our work is based on the analysis of 40 semi-structured interviews, conducted with oncology healthcare professionals in three regions of France (2015-2016). It shows three main results. First, the prescription of an oral targeted therapy requires greater collaboration between healthcare professionals than traditional intravenous oncology drugs, which may be challenging. Second, there remain many barriers to the dissemination of oral targeted therapies. Third, taking an oral targeted therapy keeps the patient away from the hospital facility and asks for a strong therapeutic alliance. The management of oral targeted therapies is time-consuming for medical oncologists and disrupts the traditional care pathway. The multiplication of actors involved in patients' management reinforces the slowdown in the deployment and acceptance of therapeutic innovations. More players equal a higher risk of slowdown. Questioning and re-designing hospital organisation and management modalities towards this type of care are critical.

Palliative Care Consultations in Nursing Homes and End-of-Life Hospitalizations

CONTEXT

Although specialty palliative care in hospital and outpatient settings is associated with lower acute care use, its impact in U.S. nursing homes (NHs) is unknown.

OBJECTIVES

To understand how NH use of palliative care consults is associated with end-of-life hospitalizations.

METHODS

Seven consult providers in four states and 24 counties shared data on the number of consult visits and residents served (per NH) in study years 2000-2010. All NHs in the 24 counties were studied (n = 286). An NH-level longitudinal file included consult data, aggregated Medicare resident assessment and claims data, and NH characteristics. Consult introduction was "yes" when 1% of residents received consults. Volume was the number of consult visits per 100 residents, annually. Panel multivariate regression with NH fixed effects examined whether rates of hospital deaths and hospitalizations in the last 30 days of life differentially changed for NHs introducing consults, or increasing consult volume.

RESULTS

One hundred seventy (59%) of the 286 NHs introduced consults by 2010. NHs with consults, compared to others, had residents with higher acuity and functional impairment, and lower nurse but higher nursing assistant staffing. Controlling for covariate differences and compared to NHs without consults, NHs introducing consults had a 1% (95% CI -0.021, 0.002) greater reduction in hospital death rates and a 1.6% (95% CI -0.031, -0.002) greater reduction in hospitalizations in the last 30 days of life. No statistically significant associations between volume and study outcomes were observed.

CONCLUSION

The introduction of specialty palliative care consults in NHs is associated with overall reductions in end-of-life hospitalizations.

Palliative Care Consultations in Nursing Homes and Reductions in Acute Care Use and Potentially Burdensome End-of-Life Transitions

OBJECTIVES

To evaluate how receipt and timing of nursing home (NH) palliative care consultations (primarily by nurse practitioners with palliative care expertise) are associated with end-of-life care transitions and acute care use DESIGN: Propensity score-matched retrospective cohort study.

SETTING

Forty-six NHs in two states.

PARTICIPANTS

Nursing home residents who died from 2006 to 2010 stratified according to days between initial consultation and death (≤7, 8-30, 31-60, 61-180). Propensity score matching identified three controls (n = 1,174) according to strata for each consultation recipient (n = 477).

MEASUREMENTS

Outcomes were hospitalizations in the last 7, 30, and 60 days of life; emergency department (ED) visits in the last 30 and 60 days; and any potentially burdensome care transition, defined as hospitalization or hospice admission within 3 days of death or two or more hospitalizations or ED visits within 30 days. Weighted multivariate logistic regression analyses were used to evaluate outcomes.

RESULTS

Residents with consultations had lower rates of hospitalization than controls, with rates lowest when initial consultations were furthest from death. For instance, in residents with initial consultations 8 to 30 days before death, the adjusted hospitalization rate in the last 7 days of life was 11.1% (95% confidence interval (CI) = 9.8-12.4%), vs 22.0% (95% CI = 20.6-23.4%) in controls, although in those with initial consultations 61 to 180 days before death, rates were 6.9% (95% CI = 5.5-8.4%), vs 22.9% (95% CI = 20.5-25.4%). Potentially burdensome transition rates were lower when consultations were 61 to 180 days before death (16.2%, 95% CI = 13.7-18.6%), vs 28.2% (95% CI = 25.8-30.6%) for controls.

CONCLUSION

Palliative care consultations improve end-of-life NH care by reducing acute care use and potentially burdensome care transitions.

Factors Affecting Resilience in Children Exposed to Violence

Exposure to violence puts children at risk for developing a variety of problems, including depression, anxiety, and conduct problems. The extent to which children's individual, family, school, and peer group characteristics influence resilient responses to violence exposure was investigated amongst Grade 6 students living in a high-violence community in Cape Town. The majority (68.44%) reported both witnessing and being a victim of violence. Both witnessing and victimisation by violence were found to be positively associated with anxiety and depression, but only victimisation was positively associated with conduct problems. Peer delinquency was positively associated with both depression and conduct problems. Involvement in conventional after-school activities was negatively associated with anxiety, and school support was negatively associated with both depression and conduct problems. No association was identified between parent support and any of anxiety, depression, or conduct problems. However, this latter finding may be related to measurement problems, or to participants' reports that they were most likely to be victimised in their homes (rather than at school or in the neighbourhood). While this study is limited by its cross-sectional nature, it implies that key sites for intervention are after-school activities, school support, peer delinquency, and home life.

[Non-metastatic triple-negative breast cancer in 2016: Definitions and management]

Triple-negative breast cancer (TN), as defined by the triple negativity in immunohistochemistry: the absence of estrogen receptor, progesterone receptor and the absence of overexpression or amplification of HER2, corresponds to 15 % of invasive breast cancers. This is a very heterogeneous group of tumors both at the genomic and transcriptomic level and at morphological, clinical and prognostic level. Although there are some good prognosis forms, the majority of TN tumors is characterized by a poor prognosis with a greater frequency of visceral metastases and a maximum risk of relapse in the first two years after diagnosis. Systemic adjuvant treatment with chemotherapy is almost always indicated. The surgical treatment and radiotherapy treatment should be comparable to the other subtypes and obey the same rules of oncologic surgery. TN tumors are not associated with a higher risk of locoregional relapse after conservative treatment and adjuvant radiotherapy. Optimization of systemic therapies is currently and for the last decade a challenge. A number of targeted therapies and efficiency biomarkers identification of these targeted therapies is essential to allow significant progress in optimizing systemic therapy for these tumors.

Association between Rome III Diagnostic Criteria and Treatment Failure in Children Brought for Emergency Department Care

BACKGROUND: Many children diagnosed with functional constipation (FC) in the ED in fact meet Rome III criteria for irritable bowel syndrome constipaion subtype (IBS-C). The frequency of this misdiagnosis and its relation to outcomes is unknown.

OBJECTIVES: To determine if treatment failure frequency differs based on Rome III diagnostic criteria classification in a cohort of ED children diagnosed by treating physicians as having constipation.

DESIGN/METHODS: We performed a prospective cohort study of children 1 month – 18 years of age who were diagnosed with or were treated as FC in a pediatric ED. ED chart data was abstracted and a follow-up call was performed 7 days post-ED visit to enable the completion of the ROME III functional intestinal disorder questionnaire, confirm treatments administered, and enable symptom resolution assessment. 'Adequate therapy' was defined in accordance with ESPGHAN/NASPGHAN consensus guidelines. Treatment failure was defined by ≥2 of the following: persistence of presenting symptom(s), bowel movement frequency &lt;1 every other day, pain or difficulty passing stools, abdominal pain between bowel movements, and/or persistence of the ED chief complaint.

RESULTS: 929 potentially eligible children were identified; 237 were excluded. We failed to contact 162 patients and 17 refused consent. 513 (74%) completed day 7 follow up – 227 (44%) met FC ROME III criteria, 119 (23%) met IBS-C criteria and 167 (33%) did not meet IBS-C or FC criteria and were classified as ‘other’. Mean age was 6.1±3.9 years. Treatment failure occurred in 69 (30%) FC patients, 50 (43%) of those with IBS-C, and 41 (25%) of ‘other’ group; P=0.007. These differences persisted when only those receiving ‘adequate therapy’ (n=308) were included: 41 (28%) of FC and 16 (22%) of those in the ‘other’ group had persistent symptoms compared to 37 (43%) of IBS-C patients; P=0.008. Kaplan-Meier analysis revealed greater symptom persistence in children with IBS-C compared to those with FC (P&lt;0.001). Those classified as FC were more likely to have abdominal distension (P=0.05) and tenderness (P=0.04) compared to the IBS-C.

CONCLUSION: Children diagnosed with constipation in an ED who fulfill ROME III irritable bowel syndrome (constipation subtype) criteria have a higher treatment failure rate at day 7 compared to functional constipation even when including only those who received adequate functinal constipation therapy. ROME III criteria can be employed to identify children with irritable bowel syndrome; such children might benefit from diagnosis specific therapy.

Greatly reduced risk of EBV reactivation in rituximab-experienced recipients of alemtuzumab-conditioned allogeneic HSCT

EBV-associated post-transplant lymphoproliferative disease (PTLD) remains an important complication of allogeneic haematopoietic stem cell transplantation (allo-HSCT). We retrospectively analysed the incidence and risk factors for EBV reactivation in 186 adult patients undergoing consecutive allo-HSCT with alemtuzumab T-cell depletion at a single centre. The cumulative incidence of EBV reactivation was 48% (confidence interval (CI) 41-55%) by 1 year, with an incidence of high-level EBV reactivation of 18% (CI 13-24%); 8 patients were concurrently diagnosed with PTLD. Amongst patients with high-level reactivation 31/38 (82%) developed this within only 2 weeks of first EBV qPCR positivity. In univariate analysis age⩾50 years was associated with significantly increased risk of EBV reactivation (hazard ratio (HR) 1.54, CI 1.02-2.31; P=0.039). Furthermore, a diagnosis of non-Hodgkin lymphoma (NHL) was associated with greatly reduced risk of reactivation (HR 0.10, CI 0.03-0.33; P=0.0001) and this was confirmed in multivariate testing. Importantly, rituximab therapy within 6 months prior to allo-HSCT was also highly predictive for lack of EBV reactivation (HR 0.18, CI 0.07-0.48; P=0.001) although confounding with NHL was apparent. Our data emphasise the risk of PTLD associated with alemtuzumab. Furthermore, we report the clinically important observation that rituximab, administered in the peri-transplant period, may provide effective prophylaxis for PTLD.

Isolation of a Wickerhamomyces anomalus yeast strain from the sandfly Phlebotomus perniciosus, displaying the killer phenotype

The yeast Wickerhamomyces anomalus has been studied for its wide biotechnological potential, mainly for applications in the food industry. Different strains of W. anomalus have been isolated from diverse habitats and recently from insects, including mosquitoes of medical importance. This paper reports the isolation and phylogenetic characterization of W. anomalus from laboratory-reared adults and larvae of Phlebotomus perniciosus (Diptera: Psychodidae), a main phlebotomine vector of human and canine leishmaniasis. Of 65 yeast strains isolated from P. perniciosus, 15 strains were identified as W. anomalus; one of these was tested for the killer phenotype and demonstrated inhibitory activity against four yeast sensitive strains, as reported for mosquito-isolated strains. The association between P. perniciosus and W. anomalus deserves further investigation in order to explore the possibility that this yeast may exert inhibitory/killing activity against Leishmania spp.

Disrupted nitric oxide signaling due to GUCY1A3 mutations increases risk for moyamoya disease, achalasia and hypertension

Moyamoya disease (MMD) is a progressive vasculopathy characterized by occlusion of the terminal portion of the internal carotid arteries and its branches, and the formation of compensatory moyamoya collateral vessels. Homozygous mutations in GUCY1A3 have been reported as a cause of MMD and achalasia. Probands (n = 96) from unrelated families underwent sequencing of GUCY1A3. Functional studies were performed to confirm the pathogenicity of identified GUCY1A3 variants. Two affected individuals from the unrelated families were found to have compound heterozygous mutations in GUCY1A3. MM041 was diagnosed with achalasia at 4 years of age, hypertension and MMD at 18 years of age. MM149 was diagnosed with MMD and hypertension at the age of 20 months. Both individuals carry one allele that is predicted to lead to haploinsufficiency and a second allele that is predicted to produce a mutated protein. Biochemical studies of one of these alleles, GUCY1A3 Cys517Tyr, showed that the mutant protein (a subunit of soluble guanylate cyclase) has a significantly blunted signaling response with exposure to nitric oxide (NO). GUCY1A3 missense and haploinsufficiency mutations disrupt NO signaling leading to MMD and hypertension, with or without achalasia.