Retrospective Outcomes of a New Acupuncture Service at a Comprehensive Cancer Center

Introduction: Among cancer centers, patients' interest in acupuncture is growing, in addition to clinical research in the intervention. Their National Cancer Institute-designated comprehensive cancer center piloted an acupuncture service. Their aim was to assess whether acupuncture impacted patient self-reported symptoms as delivered clinically and discuss their implementation strategy. Methods: Patients undergoing acupuncture at a comprehensive cancer center from June 2019 to March 2020 were asked to complete a modified Edmonton Symptom Assessment Scale (ESAS) before and after each session. The authors evaluated symptom changes after acupuncture in both outpatient and inpatient settings. A change of ≥1 U, on the 0-10 scale, was considered clinically significant. Results: Three hundred and nine outpatient and 394 inpatient acupuncture sessions were provided to patients at the comprehensive cancer center during this period, of which surveys from 186 outpatient (34 patients) and 124 inpatient (57 patients) sessions were available for analysis. The highest pretreatment symptoms reported by outpatients were neuropathy (5.78), pain (5.58), and tiredness (5.59). Outpatients receiving acupuncture reported clinically significant improvements in pain (ESAS score change of -2.97), neuropathy (-2.68), decreased lack of well-being (-2.60), tiredness (-1.85), nausea (-1.83), anxiety (-1.56), activities of daily living issues (-1.32), depression (-1.23), anorexia (-1.19), insomnia (-1.14), and shortness of breath (-1.14). The most severe pretreatment symptoms reported by inpatients were pain (6.90), insomnia (6.16), and constipation (5.44). Inpatients receiving acupuncture reported clinically significant improvements in anxiety (-3.69), nausea (-3.61), insomnia (-3.26), depression (-2.98), pain (-2.77), neuropathy (-2.68), anorexia (-2.20), constipation (-1.95), and diarrhea (-1.26). Conclusion: Both outpatient and inpatient participants in this pilot acupuncture program reported clinically significant improvements in symptoms after a single acupuncture treatment. Some differences between the outpatient and inpatient settings warrant further investigation.

Loss to Follow-up in Head and Neck Cancer: A Systematic Review of Randomized Controlled Trials

OBJECTIVE

To evaluate the reporting and rates of loss to follow-up (LTFU) in head and neck cancer (HNC) randomized controlled trials based in the United States.

DATA SOURCES

Pubmed/MEDLINE, Cochrane, Scopus databases.

REVIEW METHODS

A systematic review of titles in Pubmed/MEDLINE, Scopus, and Cochrane Library was performed. Inclusion criteria were US-based randomized controlled trials focused on the diagnosis, treatment, or prevention of HNC. Retrospective analyses and pilot studies were excluded. The mean age, patients randomized, publication details, trial sites, funding, and LTFU data were recorded. Reporting of participants through each stage of the trial was documented. Binary logistic regression was performed to evaluate associations between study characteristics and reporting LTFU.

RESULTS

A total of 3255 titles were reviewed. Of these, 128 studies met the inclusion criteria for analysis. A total of 22,016 patients were randomized. The mean age of participants was 58.6 years. Overall, 35 studies (27.3%) reported LTFU, and the mean LTFU rate was 4.37%. With the exception of 2 statistical outliers, study characteristics including publication year, number of trial sites, journal discipline, funding source, and intervention type did not predict the odds of reporting LTFU. Compared to 95% of trials reporting participants at eligibility and 100% reporting randomization, only 47% and 57% reported on withdrawal and details of the analysis, respectively.

CONCLUSION

The majority of clinical trials in HNC in the United States do not report LTFU, which inhibits the evaluation of attrition bias that may impact the interpretation of significant findings. Standardized reporting is needed to evaluate the generalizability of trial results to clinical practice.

Associations between symptoms with healthcare utilization and death in advanced cancer patients

INTRODUCTION

There is limited data about assessments that are associated with increased utilization of medical services among advanced oncology patients (AOPs). We aimed to identify factors related to healthcare utilization and death in AOP.

METHODS

AOPs at a comprehensive cancer center were enrolled in a Center for Medicare and Medicaid Innovation program. Participants completed the Edmonton Symptom Assessment Scale (ESAS) and the Functional Assessment of Cancer Therapy-General (FACT-G) scale. We examined factors associated with palliative care (PC), acute care (AC), emergency room (ER), hospital admissions (HA), and death.

RESULTS

In all, 817 AOPs were included in these analyses with a median age of 69. They were generally female (58.7%), white (61.4%), stage IV (51.6%), and represented common cancers (31.5% GI, 25.2% thoracic, 14.3% gynecologic). ESAS pain, anxiety, and total score were related to more PC visits (B=0.31, 95% CI [0.21, 0.40], p<0.001; B=0.24 [0.12, 0.36], p<0.001; and B=0.038 [0.02, 0.06], p=0.001, respectively). Total FACT-G score and physical subscale were related to total PC visits (B=-0.021 [-0.037, -0.006], p=0.008 and B=-0.181 [-0.246, -0.117], p<0.001, respectively). Lower FACT-G social subscale scores were related to more ER visits (B=-0.03 [-0.53, -0.004], p=0.024), while increased tiredness was associated with fewer AC visits (B=-0.039 [-0.073, -0.006], p=0.023). Higher total ESAS scores were related to death within 30 days (OR=0.87 [0.76, 0.98], p=0.027).

CONCLUSIONS

The ESAS and FACT-G assessments were linked to PC and AC visits and death. These assessments may be useful for identifying AOPs that would benefit from routine PC.

The perspectives of oncology healthcare providers on the role of palliative care in a comprehensive cancer center

BACKGROUND

Palliative care (PC) is an essential part of oncologic care, but its optimal role within a cancer center remains unclear. This study examines oncology healthcare providers' perspectives about the role of PC at a comprehensive cancer center (CCC).

METHODS

Physicians, nurses, and other oncology healthcare providers at a CCC were surveyed for their opinions about the role of inpatient and outpatient PC, preferences for PC services, and barriers to referral. Chi-squared tests and multiple regression analyses were performed to explore associations.

RESULTS

We received 137/221 completed questionnaires (61% response rate). Respondents were generally female (78%), had ≤ 10 years of service (69%), and included physicians (32%), nurses (32%), and advanced practice providers (17%). Most respondents (82%) agreed that more patients could benefit from PC. They also agreed that PC is beneficial for both outpatient and inpatient management of complex pain (96 and 88%), complex symptoms (84 and 74%), and advanced cancer patients (80 and 64%). Transition to hospice (64 vs. 42%, p = 0.007) and goals of care (62 vs. 49%, p = 0.011) provided by PC services were more valued by respondents for the inpatient than for the outpatient setting. Barriers to utilizing PC included lack of availability, unsure of when to refer, and poor communication. The majority of respondents (83%) preferred a cancer focused PC team to provide high-quality care.

CONCLUSIONS

Overall, the majority of oncology health care providers believe that more patients could benefit from PC, but opinions vary regarding the roles of inpatient and outpatient PC. Barriers and areas for improvement include availability, referral process, and improved communication.

Outcomes from 18 years of cervical spine surgery in MPS IVA: a single centre's experience

PURPOSE

This study examines the long-term outcomes of paediatric Morquio (MPS IVA) patients undergoing cervical spine surgery and evaluates the factors that impacting this.

METHODS

A retrospective review was performed on all MPS IVA patients undergoing cervical spine surgery, since the introduction of standardised neuroradiological screening. The impact of preoperative neurological status, growth, genotype and radiological status on outcome is assessed, whilst long-term surgical, radiological and neurological outcomes are documented.

RESULTS

Twenty-six of the eighty-two MPS IVA patients (31%) reviewed underwent cervical spine surgery at a median age of 6.1 years (range, 1.45 to 15.24). Preoperatively, cord signal change was seen in 11 patients with 5 being myelopathic; however, 6 clinically manifesting patients had no overt cord signal change. Postoperatively, none of the 14 preoperatively clinically asymptomatic patients followed long term progressed neurologically during a median follow-up of 77.5 months (range = 18-161). Of the ten preoperatively clinically symptomatic patients who were followed up for the same duration, seven continued to deteriorate, two initially improved and one remained stable. Radiological follow-up performed for a median duration of 7 years (range = 0.5-16) has shown a degree of stenosis at the level immediately caudal to the termination of the graft in 76% of patients, though only one has become clinically symptomatic and required revision.

CONCLUSIONS

Once clinically elicitable neurological signs become evident in patients with MPS IVA, they tend to progress despite surgical intervention. Referring clinicians should also not be falsely reassured by the lack of T2 spinal cord signal change but should consider surgical intervention in the face of new clinical symptomology or radiological signs of progressive canal stenosis or instability.

465 nm laser sources by intracavity frequency doubling using a 49-edge-emitters laser bar

A compact blue laser was generated by intracavity frequency doubling based on quasi-phase-matched second-harmonic generation (SHG) in a MgO-doped periodically poled lithium niobate bulk crystal. A 49 single-transverse-mode edge-emitters laser bar with antireflective coating was used as a pump source. An optical output power of 1.2 W SHG of blue lights at 465 nm is generated at 45 A injection current, equivalent to an overall wall-plug efficiency of 1.33%.

Congenital renal tubular dysplasia and skull ossification defects similar to teratogenic effects of angiotensin converting enzyme (ACE) inhibitors

An apparently autosomal recessive syndrome of congenital renal tubular dysplasia and skull ossification defects is described in five infants from two separate, consanguineous, Pakistani Muslim kindreds. The clinical, pathological, and radiological features are similar to the phenotype associated with fetal exposure to angiotensin converting enzyme (ACE) inhibitors: intrauterine growth retardation, skull ossification defects, and fetal/ neonatal anuric renal failure associated with renal tubular dysplasia. There was no fetal exposure to ACE inhibitors in the affected infants. Phenotypic similarities between these familial cases and those associated with ACE inhibition suggest an abnormality of the "renin-angiotensin-aldosterone" system (RAS). It is postulated that the molecular pathology in this uncommon autosomal recessive proximal renal tubular dysgenesis could be related to mutations of the gene systems governing the RAS.

Raising the outcome standards for conventional open cholecystectomy

BACKGROUND

Postcholecystectomy length of stay declined after the introduction of laparoscopy in 1987. Technology deserves some credit for reducing iatrogenic trauma. However, the improved outcome primarily resulted from setting higher surgical standards. What goals were (and are) achievable with the conventional "open" technique?

METHODS

One surgeon performed 160 consecutive open cholecystectomies from 1983 to 1987. The patients averaged 46 years of age (range 13 to 100), 62% were female, and 20% presented acutely. Five (3.1%) had common bile duct exploration. Each patient was prepared to accept early discharge. Prompt ambulation followed minimal tissue handling and use of long-acting local anesthesia. Enteral feeding at 300 kcal plus 12 g AAs/ hour began immediately, with swallowed air and potential excess removed automatically by efficient more proximal aspiration.

RESULTS

160 patients were discharged the next day, 158 of 160 (99%) without receiving any narcotics. They absorbed (on average) 3,350 kcal plus 130 g AAs the initial 8 to 16 hours. Serum branched-chain amino acids (BCAA) levels rose above basal within 4 hours. Three patients (1.9%) were readmitted. One (0.6%) had a sterile biloma drained percutaneously. A single acute cholecystitis patient developed sepsis (0.6%), a subphrenic abscess that resolved after drainage. The sole mortality (0.6%) was caused suddenly 27 days postoperatively by a pulmonary embolus.

CONCLUSIONS

Laparoscopy is a valuable surgical tool whose actual incremental benefits are yet to be determined. Shorter length of stay after cholecystectomy may primarily reflect the altered expectations and overall improved surgical performance associated with this innovation.

Patents in the public interest

The UK High Court has granted an injunction allowing Chiron Corporation a monopoly in selling hepatitis C virus test kits. The decision will be welcomed by the pharmaceutical and biotechnology industries.

Time to abandon Brussels' bid on patents

After six years of debate, the European Commission's attempts to harmonize biotechnology legislation still face opposition over the patenting of genes. Recent legal experience suggests that its efforts are unnecessary.

Postoperative enteral hyperalimentation results in earlier elevation of serum branched-chain amino acid levels

To objectively document the immediate maintenance and successful exploitation of postoperative gastrointestinal (GI) function, elemental diet was infused into the more distal duodenum of 30 cholecystectomy patients at 300 kcal per hour, beginning on arrival at the recovery room. Approximately 4,600 kcal and 190 grams of amino acids were absorbed during the initial 16 hours. Serum branched-chain amino acids (BCAAs) had risen above basal levels at 4 hours, statistically significant only for leucine (+64%). The higher concentrations had reached statistical significance for all BCAAs by 6 hours, when leucine had risen by 83%, isoleucine by 54%, and valine by 47%. The elevated BCAA and glucose levels sustained throughout the hyperalimentation period objectively verify that postoperative GI function can be safely exploited, and may contribute to improved wound healing and sepsis resistance.

Delusional infestation associated with post-herpetic neuralgia and EEG abnormalities

An 80-year-old widow with delusional infestation in association with post-herpetic neuralgia and EEG abnormalities in the left anterior parietal lobe responded to combined pimozide and carbamazepine. Aetiological factors are reviewed in relation to the literature.

Nasogastric tube "suction-buster holes" release mucosal occlusion despite high suction

Aspiration devices can persistently malfunction if moderate (not just high) suction causes mucosal occlusion of every opening. The standard pattern of uniformly large orifices was modified by supplementing half the nasal tubes with smaller (one tenth of the area) openings. Ten pairs of postoperative patients sipped water while suction applied to their nasal tubes varied from 40 to 300 mm Hg. Unmodified tubes consistently functioned only when applied vacuum was below 60 mm Hg. At 60 mm Hg, 20% (2/10) of tubes malfunctioned, with swallows failing to return on three consecutive attempts even at this gentle level. The failure rate rose with increasing applied suction. All 10 devices evidenced persistent occlusion when the vacuum exceeded 90 mm Hg. Each adverse result was confirmed by continued malfunction when suction was increased by another 10 mm Hg. The brisk flow through large esophageal openings dramatically differs from restricted inflow. Supplementing the standard set of uniform, large-bore aspiration orifices with additional small openings results in unimpeded function over the full range of available hospital vacuum. The additional small openings permitted the turbulent evacuation characteristic of large-bore patency. No device with accessory "suction-buster" orifices malfunctioned at even the highest available suction (300 mm Hg).

Human immunodeficiency virus type 1 infection in women attending a sexually transmitted diseases clinic in Kenya

A cross-sectional study was conducted among women attending a sexually transmitted diseases clinic in Nairobi, kenya, to determine the prevalence of and associated risk factors for human immunodeficiency virus (HIV) type 1 infection. HIV-1 antibody was detected in 13.8% of 600 women. This virus was found most frequently in prostitutes (odds ratio [OR], 7.2), in women reporting a history of genital ulcers (OR, 2.3), and in those with a current diagnosis of genital ulcers (OR, 5.1). Lifetime duration of oral contraceptive use was significantly greater in HIV-1-positive women. Multivariate analysis revealed an association between genital ulcers and HIV-1 infection (OR, 3.8). The strongest association for HIV-1 infection, however, occurred with genital ulcers in combination with the use of oral contraceptives (OR, 25.7).

Accelerated erythropoiesis: the hidden benefit of autologous donation

The risks associated with the administration of blood products have increased efforts to avoid homologous transfusions. Preoperative autologous donation has received renewed interest as a method of decreasing homologous transfusion requirements. Autologous donations may also stimulate postoperative erythropoiesis. The purpose of this study is to evaluate the effect of an aggressive autologous donation program on postoperative erythropoiesis. Ten adult male baboons were divided into two groups. The autologous group (n = 5) donated an average of 2 units of blood per week for 5 weeks before operation. The control group (n = 5) had no preoperative treatment. All animals then underwent a laparotomy and exchange transfusion with hetastarch to a final hematocrit of 15 percent. The time required to recover to hematocrits of 20 percent (3.3 vs. 5.7 days, p less than 0.01), 25 percent (7.0 vs. 8.8 days, p less than 0.05), and 30 percent (11.1 vs. 17.7 days, p less than 0.01) was shorter in the autologous group. The autologous group had more intense reticulocytosis during the first 4 postoperative days (p less than 0.03). The data show that participation in an aggressive autologous donation program improves the erythropoietic response to anemia in the postoperative setting. This represents a hidden benefit of preoperative autologous donations and suggests that more aggressive donation schedules may be clinically beneficial. Recognition of that acceleration of erythropoiesis by autologous donation could further reduce the need for transfusion of homologous blood.

Physiologic effects of acute anemia: implications for a reduced transfusion trigger

The risks of transfusion-associated infectious disease have led to a reassessment of transfusion practice, which in turn has resulted in a trend toward the reduction of homologous transfusion. This reduction is primarily due to the initiation of hemotherapy at more severe levels of anemia. The optimum threshold for the initiation of transfusion therapy, or the transfusion trigger (TT), is unknown. The purpose of this study is to evaluate the effects of withholding transfusion or lowering the TT to a hematocrit (Hct) of 15 percent in unanesthetized animals. Nineteen adult baboons underwent a laparotomy to simulate surgical stress. Upon their recovery from anesthesia, hemodynamic measurements were obtained, and the animals underwent an exchange transfusion (ET) with 6-percent hetastarch to a final Hct of 15 percent. After ET, hemodynamic measurements were repeated, and the animals were followed for 2 months. There was no morbidity after ET or during the 2-month observation period. After ET, there was a significant increase in both the cardiac output (3.3 vs. 2.5 L/min, p less than 0.001) and the oxygen extraction ratio (59.9 vs. 38.2%, p less than 0.0001). Oxygen delivery fell after ET (18.9 vs. 11.1 cc/kg/min, p less than 0.001), but there was no significant change in oxygen consumption after ET. The unanesthetized animals adapted well to severe anemia and experienced no adverse effects on their long-term survival in this setting, which suggests that the reduction of the TT to a Hct of 15 percent in normal animals is safe. Adoption of this TT could result in a significant reduction in the requirements for homologous transfusion with its attendant risks.

Growth of fresh-frozen pulmonary allograft conduit in growing lambs

To investigate the fate of cryopreserved pulmonary conduit allografts, an experimental model was used in lambs. The lambs underwent resection of the pulmonary trunk and valve to the level of the bifurcation of the pulmonary arteries and then were replaced by cryopreserved (CryoLife, Incorporated, Laboratories) pulmonary conduit allografts obtained from lambs of similar size. Lambs were operated on at 4 weeks of age and followed up with cardiac catheterization and cineangiography every 3 months for a period of 18 months. Lambs were electively sacrificed in the following order: two at 1 month, two at 3 months, one at 6 months, two at 12 months, and five at 18 months. To assess the structure of the conduit tissue, sections for light microscopy were obtained from the proximal, midportion, and distal ends of the conduit. While the lambs grew from a weight of 11.7 kg at the time of implant to more than 70 kg at 18 months, the diameter of the pulmonary conduit distended from 16 mm at the time of implant to 17.7, 19.1, 24.9, 34.3, and 33.7 mm at 1, 3, 6, 12, and 18 months, respectively. The length of the conduit also extended from an original inner length of 25 mm and an original outer length of 32 mm to the following dimensions: inner lengths of 27.9, 32.7, 38.8, 43.6, and 45.3 mm, respectively, at 1, 3, 6, 12, and 18 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Mycotic intracranial abscesses during induction treatment for acute lymphoblastic leukaemia

A boy with newly diagnosed acute lymphoblastic leukaemia developed mycotic cerebral abscesses despite treatment with amphotericin. He survived this episode on combination antifungal treatment.

An analysis of the transfusion medicine content of the test of the National Board of Medical Examiners

A two-year (1984-1985) review of 3,764 questions appearing on Part I and Part II of the National Board of Medical Examiners (NBME) indicated 140 (4%) were transfusion medicine (TM)-related. Fewer questions on TM appeared on Part II than Part I (45 vs. 95, P less than 0.001). Unexpectedly, the lowest proportion of questions (excluding psychiatry) in the Part II examination was in the surgery section. Part I NBME appears to adequately reflect and assess the TM content of the medical school curricula, but the number and distribution of questions in Part II of the NBME does not reflect recent changes in the clinical transfusion medicine curricula of many United States medical schools.

Postoperative enteral hyperalimentation for cryptosporidial acute cholecystitis associated with AIDS and enteritis

A homosexual youth presented with undiagnosed acute cryptosporidial cholecystitis, a fever of 102.8 degrees F and a WBC of 3500/mm3. This was preceded by several months of watery diarrhea and 20% weight loss. Following cholecystectomy, G-I function was maintained by efficient esophageal aspiration of swallowed air, with simultaneous immediate duodenal feeding of elemental diet. He absorbed 160 g amino acids and 4200 kcal, and was safely self-sufficient when discharged 26 hours postoperatively. Reappearance of the persistent cryptosporidial enteritis was followed by diagnoses of the offending organism and the associated AIDS. He failed to respond to specific spiramycin therapy, and 8 months after cholecystectomy he succumbed to pneumocystis carinii pneumonia. For this malnourished and particularly vulnerable patient, preservation of postoperative G-I function and its exploitation for enteral support may have been essential to enhance "immune competence" and lead to a remarkably smooth and rapid recovery.

Discharge within 24 hours of elective cholecystectomy. The first 100 patients

Discharge with 24 hours of elective cholecystectomy has proved to be an attainable goal for the vast majority of patients, without increasing risk. The clinical courses of the first 100 subjects (of 109 consecutive patients) to reach this goal were examined critically. Preservation of gastrointestinal function and immediate full enteral nutrition were major steps toward reduction of hospital dependency. Pain and the need for narcotics were reduced by careful patient instruction and wound infiltration with a long-acting local anesthetic. Preoperative hospitalization was eliminated by outpatient testing and admission for 29 subjects, who were admitted the day of surgery. This group's entire stay was only one day. Patients and family found the total regimen acceptable by independent review. Significant cost savings were realized as a fringe benefit.

Reducing postoperative pain, narcotics, and length of hospitalization

Bupivacaine wound infiltration together with efficient esophagogastric decompression and immediate elemental feeding in 43 consecutive, well-instructed patients who had undergone cholecystectomy reduced their postoperative analgesia requirements to an average of 17 (+/- 46, SD) mg of meperidine during the initial 24 hours. No analgesics were requested by 35/43 patients (81%) and 40/43 were discharged within 24 hours of surgery. All 86 conventionally treated control patients required narcotics, averaging 4.4 (+/- 0.3, SD) doses and amounting to 290 (+/- 25, SD) mg of meperidine or its equivalent during their first postoperative day and were discharged in 6.5 (+/- 0.7, SD) days. None were discharged in less than 3 days. Home interview by a visiting nurse was carried out for a block of 19 treated patients and their families. Six patients were interviewed prospectively within 33 to 64 hours of surgery, with a repeat visit 1 to 2 months later. Retrospectively studied patients were only seen 1 to 4 months after surgery. These interviews confirmed the patients' and their families' satisfaction with their bodily functions, their limited discomfort, and their independence from the hospital. Wound infiltration with a long-acting local anesthetic, efficient removal of swallowed air, and immediate, full enteral nutrition contribute to reduced postoperative pain and narcotic use in well-instructed patients, thus leading to safe and satisfactory early discharge.

Manometrically guided colon insufflation during double-contrast barium enemas

The double-contrast enema's potential for high accuracy depends in part on consistently good inflation of the colon. However, optimal inflation is often not obtained because of deflation during filming, underinflation because of fear of perforating the colon, or patient discomfort. To help meet the dual requirements of ensuring consistently good bowel inflation while avoiding over-inflation, we have designed a modified insufflator which incorporates a manometer and allows accurate readings of intraluminal large-bowel pressures during or following insufflation. In more than 3000 examinations using this method we have experienced no complications.

Efficient gastroduodenal decompression with simultaneous full enteral nutrition: a new gastrostomy catheter technique

A gastrostomy tube was designed that provides efficient supplemental aspiration of the proximal duodenum to remove gas that escapes gastric removal, utilizing an extension of the gastric suction channel. A separate lumen delivers elemental diet 7.5 cm more distally, for safe postoperative feeding. On clinical testing, patients consistently achieved immediately postoperative enteral absorption of 3000 kcal/day and positive protein balance. Supplemental insulin was required for optimum utilization, maintaining plasma glucose within the physiologic range. Oral barium motility study during the second 24 hr demonstrated prompt gastric emptying and spontaneous anastomotic passage. We noted decreased clogging with mucus, attributable to "self-cleansing" by the aspirated duodenal juices. This was returned with the feedings to prevent depletion. There were no complications attributable to this regimen. Patients were discharged uneventfully as early as 48 hr following colectomy.