Primary care usage at the end of life: a retrospective cohort study of cancer patients using linked primary and hospital care data

PURPOSE

Health service use is most intensive in the final year of a person's life, with 80% of this expenditure occurring in hospital. Close involvement of primary care services has been promoted to enhance quality end-of-life care that is appropriate to the needs of patients. However, the relationship between primary care involvement and patients' use of hospital care is not well described. This study aims to examine primary care use in the last year of life for cancer patients and its relationship to hospital usage.

METHODS

Retrospective cohort study in Victoria, Australia, using linked routine care data from primary care, hospital and death certificates. Patients were included who died related to cancer between 2008 and 2017.

RESULTS

A total of 758 patients were included, of whom 88% (n = 667) visited primary care during the last 6 months (median 9.1 consultations). In the last month of life, 45% of patients were prescribed opioids, and 3% had imaging requested. Patients who received home visits (13%) or anticipatory medications (15%) had less than half the median bed days in the last 3 months (4 vs 9 days, p < 0.001, 5 vs 10 days, p = 0.001) and 1 month of life (0 vs 2 days, p = 0.002, 0 vs 3 days, p < 0.001), and reduced emergency department presentations (32% vs 46%, p = 0.006, 31% vs 47% p < 0.001) in the final month.

CONCLUSION

This study identifies two important primary care processes-home visits and anticipatory medication-associated with reduced hospital usage and intervention at the end of life.

The association of histopathologic features after neoadjuvant chemo-immunotherapy with clinical outcome: Sub-analyses from the randomized double-blinded, placebo-controlled, Phase III IMagyn050/GOG3015/ENGOT-ov39 study

OBJECTIVE

Histopathologic characteristics after neoadjuvant chemotherapy (NACT) may correlate with outcome. This study evaluates histopathologic features after immunotherapy and NACT/bevacizumab, and associated clinical outcomes.

METHODS

Evaluable tissue from IMagyn050/GOG3015/ENGOT-ov39 patients from prespecified anatomic sites from interval cytoreductive surgery (ICS) after NACT/bevacizumab plus atezolizumab/placebo underwent central histopathologic scoring and analyzed with clinical outcomes.

RESULTS

The predefined population had 243 evaluable NACT patients, with 48.1% tumors being PD-L1-positive. No statistically significant differences in PFS (16.9 months vs. 19.2 months, p = 0.21) or OS (41.5 months vs. 45.1 months, p = 0.67) between treatment arms were seen. Substantial residual tumor (RT) (3+) was identified in 26% atezolizumab vs. 24% placebo arms (p = 0.94). Most showed no (1+) necrosis (82% vs. 96%, respectively, p = 0.69), moderate (2+) to severe (3+) fibrosis (71% vs. 75%, respectively, p = 0.82), and extensive (2+) inflammation (53% vs. 47% respectively, p = 0.48). No significant histopathologic differences were identified by tissue site or by arm. Multivariate analyses showed increased risk for progression with moderate and substantial RT (13.6 mon vs. 21.1 mon, hazard ratio 2.0, p < 0.01; 13.6 mon vs. 21.1 mon, HR 1.9, p < 0.01, respectively); but decreased risk for death with extensive inflammation (46.9 mon vs. 36.3 mon, HR 0.65, p = 0.02). Inflammation also correlated with greater likelihood of response to NACT/bevacizumab plus immunotherapy (odds ratio 2.9, p < 0.01). Modeling showed inflammation as a consistent but modest predictor for OS.

CONCLUSIONS

Detailed histologic assessment of ICS specimens appear to identify characteristics, such as inflammation and residual tumor, that may provide insight to certain clinical outcomes. Future work potentially leveraging emerging tools may provide further insight into outcomes.

Patient perceptions regarding alcohol use after bariatric surgery

INTRODUCTION

Patients who have undergone bariatric surgery are at increased risk of an alcohol use disorder. Though patients understand this risk, the majority engage in post-surgical alcohol use. This suggests that education alone is not sufficient to reduce post-surgical drinking. To prevent development of post-surgical alcohol use disorders, we need better understanding of the reasons patients use alcohol following surgery. The purpose of this study was to identify factors associated with post-surgical alcohol use.

METHOD

Patients (N = 20) who were 1-3 years post-bariatric surgery and were consuming alcohol at least twice monthly participated in a 60-min interview. Participants responded about their knowledge regarding risk of post-surgical alcohol use and reasons why patients may start drinking. Deductive and inductive coding were completed by two independent raters.

RESULTS

Although nearly all participants were aware of the risks associated with post-surgical alcohol use, most believed that lifelong abstinence from alcohol was unrealistic. Common reasons identified for using alcohol after bariatric surgery included social gatherings, resuming pre-surgical use, and addiction transfer. Inductive coding identified three themes: participants consumed alcohol in different ways compared to prior to surgery; the effect of alcohol was substantially stronger than pre-surgery; and beliefs about why patients develop problematic alcohol use following surgery.

CONCLUSION

Patients consume alcohol after bariatric surgery for a variety of reasons and they do not believe recommending abstinence is useful. Understanding patient perceptions can inform interventions to minimize alcohol use after bariatric surgery. Modifications to traditional alcohol relapse prevention strategies may provide a more robust solution to decreasing negative outcomes experienced by individuals undergoing bariatric surgery.

Decision strategies while intoxicated relate to alcohol-impaired driving attitudes and intentions

OBJECTIVE

Approximately 28 million individuals engage in alcohol-impaired driving (AID) every year. This study investigated individuals' AID decision making strategies under intoxication, their variability across the breath alcohol concentration (BrAC) curve, and the association between strategy and AID attitudes, intentions, and behavior.

METHOD

Seventy-nine adults (mean 23.9 years, 57% female) who drank alcohol ≥2 days per week and lived >2 miles away from their typical drinking locations completed an alcohol administration protocol and AID decision making task. AID attitudes, intentions, and behaviors were assessed repeatedly across the BrAC curve. Bayesian cognitive modeling identified decision strategies used by individuals on the AID decision making task, revealing whether alcohol consumption level and/or ride service cost factored into individuals' decisions to drive while impaired or obtain a ride. Additional analyses tested whether AID attitudes and intentions were related to individuals' decision strategies.

RESULTS

Two decision strategies were examined on the ascending and descending limbs of the BrAC curve: compensatory (both consumption level and ride service cost factored into AID decisions) and non-compensatory (only consumption level factored into AID decisions). Switching to a compensatory strategy on the descending limb was associated with lower perceived intoxication, perceiving AID as less dangerous, and being willing to drive above the legal BrAC limit.

CONCLUSIONS

Results suggest that risk for engaging in AID is higher for those using a cost-sensitive, compensatory strategy when making AID decisions under intoxication. Future research is needed to test whether AID countermeasures (e.g., subsidized ride services) are differentially effective according to decision strategy type. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Sustainable micropollutant bioremediation via stormwater biofiltration system

Waters contaminated with micropollutants are of environmental and public health concern globally. Stormwater is a significant source of anthropogenic micropollutants to receiving waters. Hence, sustainable stormwater remediation is needed to reduce contamination of waterways. Yet designing sustainable bioremediation solutions, including those targeted to remove micropollutants, is a major scientific challenge. This study aimed to adapt the design of stormwater biofiltration systems, to improve the removal of micropollutants and understand the role of the micropollutant-degrading bacteria in this bioremediation process. We investigated the atrazine removal performance of a prototype biofiltration system, in which the filter media was supplemented with Granulated Activated Carbon (GAC). The prototype biofiltration system completely removed atrazine to below detectable limits, significantly exceeding the GAC's adsorption capacity alone, suggesting other biological processes were present. We showed that atrazine degradation capacity, measured by the kinetics of the trzN gene abundance, was accelerated in the prototype system compared to the standard system (which had no added GAC; 0.8 vs. 0.37 week-1, respectively). Notably, this high level of atrazine removal did not come at the expense of the removal performance of other typical stormwater macropollutants (e.g., nutrients, suspended solids). The prototype biofiltration system showed a proof-of-concept of sustaining microbial remediation of a model micropollutant alongside stormwater macropollutants, which could be used to reduce impacts on receiving waterways and protect our ecosystems and human health.

High prevalence of vertebral fractures in seizure patients with normal bone density receiving chronic anti-epileptic drugs

People with epilepsy who take certain medications are at risk for developing osteoporosis and fractures of the vertebrae that commonly go undiagnosed. By using technology available in a bone density scan, we observed at least one fracture in many subjects with bone density in the normal and osteopenic range.

PURPOSE/INTRODUCTION

Chronic use of antiepileptic drugs (AEDs), both enzyme-inducing (phenytoin, phenobarbital, carbamazepine, and primidone) and non-enzyme-inducing (i.e., valproate), is recognized as a cause of secondary osteoporosis. Vertebral compression fractures (VF) are the most common type of osteoporotic fractures and may confer an increased risk of future hip, wrist, and vertebral fractures. Vertebral compression fractures in the general population are frequently asymptomatic, and under-diagnosed. The purpose of this study is to describe the prevalence of VF in a cohort of male veterans with epilepsy on chronic AEDs.

METHODS

The cohort for this study consisted of 146 male veterans who carried a diagnosis of epilepsy and were chronic users of AEDs known to cause osteoporosis (phenobarbital, phenytoin, carbamazepine, primidone, and valproate). Chronic AED use was defined as receiving an AED for at least 2 years. Subjects were previously seen in the osteoporosis clinic and had been evaluated by a dual-energy X-Ray absormetry (DXA) instrument including morphometric studies following a standard vertebral fracture assessment (VFA) protocol during the same DXA imaging acquisition session.

RESULTS

The mean age was 63 years. Low bone mineral density defined as osteoporosis or osteopenia was observed in 29% and 43% respectively. We observed at least one VF in 41 % of the subjects who had normal BMD, 54% in the osteopenic range, and 75% in the osteoporotic range.

CONCLUSIONS

By performing a VFA in addition to standard bone densitometric studies, we disclosed a large prevalence of compression fractures in individuals with epilepsy chronically treated with AEDs who had BMDs in the normal and osteopenic ranges. The addition of VFA or other imaging methods to evaluate VF should be included in the evaluation of bone health in individuals with epilepsy receiving AEDs since it may modify treatment recommendations to prevent future osteoporotic fractures.

Giant Gastric Ulcers: An Unusual Culprit

Mycophenolate Mofetil (MMF) is routinely used immunosuppressant in solid organ transplantation is commonly associated with several gastrointestinal (GI) side effects. Here we present a case of giant gastric ulcer of 5 cm from MMF use post cardiac transplant. CASE DESCRIPTION: A 56-year-old male with history of severe ischemic cardiomyopathy post heart transplant was on immunosuppression with MMF, tacrolimus and prednisone for 5 months. He presented with severe epigastric pain and intermittent episodes of melena for 1 month. His pain radiated to back that is worsened with eating. Associated with loss of appetite, vomiting and 16-pound weight loss in 3 months. He never smoked, drank alcohol or used over the counter pain medications. He was profoundly anemic requiring blood transfusions. EGD performed demonstrated very large clean-based ulcer of 5 cm diameter in the body, smaller ulcer of 8 mm diameter in pre-pyloric region and 5-10 small aphthous ulcers in the gastric body and fundus. Gastric biopsies taken from the ulcer were negative for Helicobacter pylori, cytomegalovirus and malignancy. Flexible sigmoidoscopy revealed non-bleeding inflamed internal hemorrhoids. Consequently, MMF was discontinued and switched to azathioprine. He was treated with twice daily proton pump inhibitor therapy with resolution of abdominal pain, improved appetite and weight gain. DISCUSSION: MMF is well known for common GI side-effects such as nausea, diarrhea, vomiting, ulcers, abdominal pain and rarely gastrointestinal bleeding. Few studies reported 3 to 8% incidence of ulcer perforation and GI bleeding within 6 months. Risk of gastroduodenal erosions is nearly 1.83 times for MMF, with the highest lesions associated with MMF-tacrolimus-corticosteroid combination treatment as seen in our patient. Hypothesis is that GI tract is vulnerable because of dependence of enterocytes on de novo synthesis of purines, which is disrupted by MMF. Typically, upper GI mucosal injuries of mucosal irritation leading to esophagitis, gastritis and/or ulcers are seen. Endoscopy is both diagnostic and therapeutic if bleeding gastric ulcers are noted. Minor complications improve with reduction of drug dose or use of enteric coated preparation if feasible. Discontinuation of the drug is main stay in the management of MMF related ulcer disease. Simple medical treatment with either H2-receptor antagonists, proton-pump inhibitors, coating agents, prostaglandins or combination has proven effective in most cases. Considering excellent results with medical management of ulcer, role of surgery is limited.

A Longitudinal Examination of Decisions to Ride and Decline Rides with Drinking Drivers

BACKGROUND

Riding with a drinking driver (RWDD) is a serious concern that leads to numerous preventable deaths every year. There is a significant gap in research on empirically tested predictors of RWDD that could be implemented in prevention efforts. College students are in need of such prevention efforts, as they have some of the highest rates of alcohol-related crash fatalities and may engage in RWDD more than their noncollege peers. This study utilized behavioral decision-making approach to examine predictors of RWDD and declining a ride from a drinking driver (Decline) in older college students.

METHODS

Students (n = 791) in their third year of college were enrolled from 3 large and diverse universities. Psychosocial (e.g., expectancies, norms) and decision-making variables (willingness to RWDD and intentions to use alternatives) were assessed in the fall of their third year. One year later, RWDD and Decline behaviors were assessed. Zero-inflated Poisson analyses were used to assess how decision-making variables predicted RWDD and Decline behavior. Associations between psychosocial and decision-making variables were also assessed.

RESULTS

Thirteen percent of students reported RWDD and ~28% reported Decline behavior. Willingness to RWDD and typical weekly drinking were both associated with increases in RWDD (odds ratio [OR] = 1.58 and 1.40, respectively), whereas intentions to use alternatives, sex, and ethnicity were not associated with RWDD. Only weekly drinking was associated with Decline, with an increase in drinking associated with increased Decline (OR = 1.48). All psychosocial variables were significantly associated with the decision-making variables except positive expectancies.

CONCLUSIONS

Results provide evidence that willingness to RWDD is a predictor of future RWDD, even if students intend to use safe alternatives. Future research is needed to better understand decision-making factors that influence Decline. Results also suggest prevention and interventions efforts, such as brief motivational intervention, Parent-Based Interventions, and normative feedback interventions could be adapted to reduce RWDD.

Investigation of the HotDog patient warming system: detection of thermal gradients

OBJECTIVE

To assess the performance of an active patient-warming device.

MATERIALS AND METHODS

Temperatures of an active patient-warming device (HotDog system) were measured at various time points using an infrared thermometer. The study was conducted in two phases: Phase 1 compared temperatures among four different areas of the warming blanket. Phase 2 compared conditions simulating different scenarios using a weighted patient simulator.

RESULTS

Phase 1: Three out of four positions on the warming blanket had significantly different temperature measurements. Phase 2: Temperature output by the warming blanket was reduced: (1) in the absence of the patient simulator placed across the blanket (-1·9°C, P=0·013); (2) if the patient simulator was placed away from the blanket sensor (-2·0°C, P=0·009); and (3) if there was fluid between the patient simulator and warming blanket (-2·2°C, P=0·004). In a majority of measurements (95%), the set temperature of 43°C on the control unit was not reached (range, 29·8 to 42·9°C) and 2·3% of measurements were higher (range, 43·1 to 45·8°C) than the control unit set temperature of 43°C.

CLINICAL SIGNIFICANCE

Measured temperatures on the active warming blanket did not reflect control unit settings. This could result in the potential for hyperthermic injury, ineffectual heating and uneven heat distribution.

Peptide and nucleic acid-directed self-assembly of cationic nanovehicles through giant unilamellar vesicle modification: Targetable nanocomplexes for in vivo nucleic acid delivery

One of the greatest challenges for the development of genetic therapies is the efficient targeted delivery of therapeutic nucleic acids. Towards this goal, we have introduced a new engineering initiative in self-assembly of biologically safe and stable nanovesicle complexes (∼90 to 140nm) derived from giant unilamellar vesicle (GUV) precursors and comprising plasmid DNA or siRNA and targeting peptide ligands. The biological performance of the engineered nanovesicle complexes were studied both in vitro and in vivo and compared with cationic liposome-based lipopolyplexes. Compared with cationic lipopolyplexes, nanovesicle complexes did not show advantages in transfection and cell uptake. However, nanovesicle complexes neither displayed significant cytotoxicity nor activated the complement system, which are advantageous for intravenous injection and tumour therapy. On intravenous administration into a neuroblastoma xenograft mouse model, nanovesicle complexes were found to distribute throughout the tumour interstitium, thus providing an alternative safer approach for future development of tumour-specific therapeutic nucleic acid interventions. On oropharyngeal instillation, nanovesicle complexes displayed better transfection efficiency than cationic lipopolyplexes. The technological advantages of nanovesicle complexes, originating from GUVs, over traditional cationic liposome-based lipopolyplexes are discussed.

STATEMENT OF SIGNIFICANCE

The efficient targeted delivery of nucleic acids in vivo provides some of the greatest challenges to the development of genetic therapies. Giant unilamellar lipid vesicles (GUVs) have been used mainly as cell and tissue mimics and are instrumental in studying lipid bilayers and interactions. Here, the GUVs have been modified into smaller nanovesicles. We have then developed novel nanovesicle complexes comprising self-assembling mixtures of the nanovesicles, plasmid DNA or siRNA, and targeting peptide ligands. Their biophysical properties were studied and their transfection efficiency was investigated. They transfected cells efficiently without any associated cytotoxicity and with targeting specificity, and in vivo they resulted in very high and tumour-specific uptake and in addition, efficiently transfected the lung. The peptide-targeted nanovesicle complexes allow for the specific targeted enhancement of nucleic acid delivery with improved biosafety over liposomal formulations and represent a promising tool to improve our arsenal of safe, non-viral vectors to deliver therapeutic cargos in a variety of disorders.

Comparative summer dynamics of surface cyanobacterial communities in two connected lakes from the west of Ireland

The eutrophication of lakes is typically associated with high biomass proliferations of potentially toxic cyanobacteria. At a regional level, the sustainable management of water resources necessitates an approach that recognises the interconnectivity of multiple water systems within river catchments. This study examined the dynamics in summer diversity of planktonic cyanobacterial communities and microcystin toxin concentrations in two inter-connected lakes from the west of Ireland prone to nutrient enrichment. DGGE analysis of 16S rRNA gene amplicons of genotype-I cyanobacteria (typically spherical) showed changes in the communities of both Lough Corrib and Ballyquirke Lough throughout the summer, and identified cyanobacterial genotypes both unique and shared to both lakes. Microcystin concentrations, estimated via the protein phosphatase 2A inhibition assay, were greater in August than in July and June in both lakes. This was concomitant to the increased occurrence of Microcystis as evidenced by DGGE band excision and subsequent sequencing and BLAST analysis. RFLP analysis of PCR amplified mcy-A/E genes clustered together the August samples of both lakes, highlighting a potential change in microcystin producers across the two lakes. Finally, the multiple factor analysis of the combined environmental data set for the two lakes highlighted the expected pattern opposing greater water temperature and chlorophyll concentration against macronutrient concentrations, but also indicated a negative relationship between microcystin concentration and cyanobacterial diversity, possibly underlining allelopathic interactions. Despite some element of connectivity, the dissimilarity in the composition of the cyanobacterial assemblages and the timing of community change in the two lakes likely were a reflexion of niche differences determined by meteorologically-forced variation in physico-chemical parameters in the two water bodies.

A review of recent advances in optical fibre sensors for in vivo dosimetry during radiotherapy

This article presents an overview of the recent developments and requirements in radiotherapy dosimetry, with particular emphasis on the development of optical fibre dosemeters for radiotherapy applications, focusing particularly on in vivo applications. Optical fibres offer considerable advantages over conventional techniques for radiotherapy dosimetry, owing to their small size, immunity to electromagnetic interferences, and suitability for remote monitoring and multiplexing. The small dimensions of optical fibre-based dosemeters, together with being lightweight and flexible, mean that they are minimally invasive and thus particularly suited to in vivo dosimetry. This means that the sensor can be placed directly inside a patient, for example, for brachytherapy treatments, the optical fibres could be placed in the tumour itself or into nearby critical tissues requiring monitoring, via the same applicators or needles used for the treatment delivery thereby providing real-time dosimetric information. The article outlines the principal sensor design systems along with some of the main strengths and weaknesses associated with the development of these techniques. The successful demonstration of these sensors in a range of different clinical environments is also presented.

Progress toward developing a cataract classification system

A cataract classification system is being developed based on a set of standard photographs. The system uses an ordinal scale ranging from 0 (no opacities) to 2 (definite opacities) to classify cataractous changes in the nuclear, cortical, and posterior subcapsular lens zones. The reproducibility of slitlamp-derived and photo-derived classifications using the system was evaluated. The reproducibility between 2 observers for slitlamp-derived classifications was very high (n = 60). The reproducibility within and among 4 photography readers was also good for photo-derived classifications (n = 100). Discrepancies were found between ratings derived from slitlamp examinations and from photographs; such discrepancies were most frequent for gradings of cortical opacities.

Multiphoton luminescence imaging of chemically functionalized multi-walled carbon nanotubes in cells and solid tumors

A simplified scheme showing the non-linear photoluminescence properties of f-MWNTs and their potential use as imaging tools in cells and tumors.

Sewage pollution in urban stormwater runoff as evident from the widespread presence of multiple microbial and chemical source tracking markers

The concurrence of human sewage contamination in urban stormwater runoff (n=23) from six urban catchments across Australia was assessed by using both microbial source tracking (MST) and chemical source tracking (CST) markers. Out of 23 stormwater samples human adenovirus (HAv), human polyomavirus (HPv) and the sewage-associated markers; Methanobrevibacter smithii nifH and Bacteroides HF183 were detected in 91%, 56%, 43% and 96% of samples, respectively. Similarly, CST markers paracetamol (87%), salicylic acid (78%) acesulfame (96%) and caffeine (91%) were frequently detected. Twenty one samples (91%) were positive for six to eight sewage related MST and CST markers and remaining two samples were positive for five and four markers, respectively. A very good consensus (>91%) observed between the concurrence of the HF183, HAv, acesulfame and caffeine suggests good predictability of the presence of HAv in samples positive for one of the three markers. High prevalence of HAv (91%) also suggests that other enteric viruses may also be present in the stormwater samples which may pose significant health risks. This study underscores the benefits of employing a set of MST and CST markers which could include monitoring for HF183, adenovirus, caffeine and paracetamol to accurately detect human sewage contamination along with credible information on the presence of human enteric viruses, which could be used for more reliable public health risk assessments. Based on the results obtained in this study, it is recommended that some degree of treatment of captured stormwater would be required if it were to be used for non-potable purposes.