Palliative Care and Mental Health among Pancreatic Cancer Patients in the United States: An Examination of Service Utilization and Health Outcomes

INTRODUCTION

Palliative care (PC) utilization remains low among pancreatic cancer patients. This study explores the association of PC with mental health service and pharmacotherapy utilization among pancreatic cancer patients.

METHODS

Retrospective analysis was conducted on a sample of patients in the United States with newly diagnosed pancreatic cancer using Electronic Health Record data from Optum's Integrated Claims-Clinical data set. Subsequent diagnoses of anxiety and depression and PC consultation encounters were determined using ICD-9/10 codes. Adjusted associations of mental health treatments with PC and patient characteristics were quantified using multiple logistic regression.

RESULTS

Among newly diagnosed pancreatic cancer patients (n = 4029), those with PC consultations exhibited a higher prevalence of anxiety (33.9% vs. 22.8%) and depression (36.2% vs. 23.2%). Mental health service use and pharmacotherapy varied, with the highest utilization among patients having both anxiety and depression. Treatment pattern was also influenced by age (aOR 1.832 for age <55 vs. 65-70 years). Notably, PC consultations showed no significant effect on the likelihood of documented treatment.

DISCUSSION

Our study emphasizes underutilization of PC and MH treatment for pancreatic cancer patients. These findings imply a crucial need for further investigation into palliative care's role in addressing mental health concerns among pancreatic cancer patients.

Prevalence and Predictors of Depression in Women with Osteoarthritis: Cross-Sectional Analysis of Nationally Representative Survey Data

Osteoarthritis (OA) is the most common joint disease in the US and can increase the risk of depression. Both depression and OA disproportionately affect women, yet this study is one of few on depression prevalence, treatment across age groups, and predictors in women with OA. Data were extracted from the 2011-March 2020 National Health and Nutrition Examination Survey (NHANES). Women aged ≥ 45 years with self-reported osteo- or degenerative arthritis were included. Outcomes were depression (assessed with PHQ-9) and treatment (self-reported pharmacotherapy and mental health services). Logistic regression was used to examine associations between age group, covariates, and outcomes. Overall, depression prevalence was 8%, with higher proportions among those 45-64 years old. Aging was associated with reduced odds of depression (Age 65-79: OR 0.68 (95% CI: 0.52-0.89); Age 80+: OR 0.49 (95% CI: 0.33-0.74); vs. Age 45-54). Of those with a positive depression screen, 21.6% documented some form of treatment. Age group was not statistically different between those treated and those not treated. Women aged 45-64 with osteoarthritis may be at increased risk of depression, and most are not treated. As depression is related to increased pain and risk of rehospitalization, future research should prioritize interventions to increase uptake of depression treatment.

Propofol Versus Dexmedetomidine for Procedural Sedation in a Pediatric Population

OBJECTIVES

Frequently, infants and children require sedation to facilitate noninvasive procedures and imaging studies. Propofol and dexmedetomidine are used to achieve deep procedural sedation in children. The objective of this study was to compare the clinical safety and efficacy of propofol versus dexmedetomidine in pediatric patients undergoing sedation in a pediatric sedation unit.

METHODS

A retrospective analysis of patients sedated with either propofol or dexmedetomidine in a pediatric sedation unit by pediatric emergency physicians was performed. Both medications were dosed per protocol with propofol 2 mg/kg induction and 150 μg · kg^-1 · min^-1 maintenance and dexmedetomidine 3 μg/kg induction for 10 minutes and 2 μg · kg^-1 · h^-1maintenance. The variables collected included drug dose, sedation time (time that the drug was given to the completion of the procedure), recovery time (end of the study to the return to the presedation sedation score for 15 minutes), need for dose rate changes, airway management, and adverse events.

RESULTS

A total of 2432 children were included- 1503 who received propofol and 929 who received dexmedetomidine. Propofol and dexmedetomidine resulted in successful completion of the study in 98.8% and 99.7%, respectively (P = 0.02). The mean recovery time for propofol was 34.3 minutes, compared with 65.6 minutes for dexmedetomidine (P < 0.001). The need for unexpected airway management was 9.7% for propofol and 2.2% for dexmedetomidine (P < 0.001). Adverse events occurred in 8.6% and 6% of patients in the propofol and dexmedetomidine groups, respectively (P = 0.02).

CONCLUSIONS

Propofol use led to significantly shorter recovery times, with an increased need for airway management, but rates of bag-mask ventilation (2.3%), airway obstruction (1.1%), and desaturation (1.6%) were low. No patients required intubation. Propofol is a reasonable alternative to dexmedetomidine, with a clinically acceptable safety profile.

Fever phobia: a survey of caregivers of children seen in a pediatric emergency department

BACKGROUND

Fever continues to be the most common complaint of children seen in a Pediatric Emergency Department (PED). Previous studies have assessed the prevalence of fever phobia in various populations. This study aims to document the incidence of fever phobia in a PED.

METHODS

Through convenience sampling, caregivers of children seen in a PED were surveyed using a research-assistant-administered questionnaire. The survey contained 28 questions pertaining to caregivers' perceptions, attitudes, and behaviors regarding fever in children.

RESULTS

In all, 230 caregivers were surveyed. The median temperature considered to be a fever was 37.8 degrees C (100.0 degrees F), with a range of 36.1 degrees C (97 degrees F) to 40.6 degrees C (105 degrees F), whereas the median temperature considered to result in harmful consequences was 40.6 degrees C (105 degrees F), with a range of 37.8 degrees C (100 degrees F) to 43.3 degrees C (110 degrees F). The median temperature at which antipyretics would be administered was 37.8 degrees C (100 degrees F), with a range of 36.1 degrees C (97 degrees F) to 39.4 degrees C (103 degrees F). More than one third of caregivers reported that they would administer antipyretics inappropriately. The median temperature at which a child would be taken to the PED was 39.4 degrees C (103 degrees F), with a range of 36.7 degrees C (98 degrees F) to 40.8 degrees C (105.4 degrees F). There was also a relationship between level of education and level of fever concern.

CONCLUSION

Fever phobia and inappropriate treatment for febrile children is present among caregivers of patients seen in a PED. Level of education may be a factor in fever knowledge and practices. Overly zealous, potentially harmful home practices and unnecessary PED visits for the assessment and treatment of fever in children is widespread among caregivers surveyed in the PED.

Biologic and chemical terrorism in children: an assessment of residents' knowledge

This study was conducted to determine the baseline fund of knowledge of pediatric and emergency medicine residents at a single institution in the medical management of pediatric victims of biologic and chemical terrorism. A test covering essential content was developed and validated by experts. The test was given anonymously to volunteer pediatric and emergency medicine residents at a single institution. The test was readministered 5 months after a lecture on the content. The 34 pediatric residents and 15 emergency medicine residents scored a median of 65% and 73%, respectively (P = .03). Residents from both specialties combined scored a median of 70% correct versus those residents who did not attend the lecture. Pediatric and emergency medicine residents are significantly unprepared to manage pediatric victims of biologic and chemical terrorism. Education curriculums on this topic must be incorporated into these residencies. The traditional lecture format may not be the most effective technique.

Prudent layperson definition of an emergent pediatric medical condition

This study was designed to assess how well parents rated pediatric medical conditions based on their perceived degree of urgency so as to determine if the "Prudent Layperson Standard'' is reasonable. A self-administered, supervised survey was given to a convenience sample of 340 caregivers in the emergency department of an urban children's hospital. Respondents were asked to rank the urgency of 15 scenarios. A caregiver response within 1 point of the physician score was considered concordant with medical opinion. A 2-week-old infant with a rectal temperature of 103.7 degrees F was the only emergent scenario underestimated by caregivers. A 1 1/2-yr-old child with an upper respiratory tract infection, a 7-year-old child with ringworm, an 8-month-old infant with a simple forehead contusion, and a 4-year-old child with conjunctivitis were the non-urgent scenarios overestimated by caregivers. Laypeople are able to identify cases constructed to represent obvious pediatric medical emergencies. Several patient subgroups frequently overestimate medical urgency.

Near strangulation as a result of hair tourniquet syndrome

Hair tourniquet syndrome has been a recognized clinical entity for many decades. In this syndrome, hair becomes tightly wrapped around an appendage, usually that of an infant. Body parts involved include the finger, toe, penis, clitoris, and uvula. The end result of necrosis is also well documented. In this report, an 11-month-old girl with hair tourniquet syndrome causing signs and symptoms of an acute strangulation is presented.

A prospective study of the "two-bag system'' in diabetic ketoacidosis management

The "two-bag'' system, an adaptation of the euglycemic clamp technique, consists of simultaneous administration of 2 intravenous (IV) fluid bags of differing dextrose concentrations. Individualized therapy is dictated by adjustment of the infusion rate of each bag. We sought to assess the benefits of the two-bag system in the initial acute emergency department management of children in diabetic ketoacidosis (DKA). Thirty-three children presenting to an urban pediatric emergency department in DKA were randomized into 2 groups: patients managed with the two-bag system and patients managed with the traditional "one-bag'' system. Other aspects of the management were standardized. Outcome measures included rate of decline in serum glucose, rate of bicarbonate correction, time on IV insulin therapy, and response time for IV fluid changes. Study period was defined as time on IV insulin therapy. There were no differences between the 2 groups in demographic parameters, initial baseline metabolic parameters, or total time on IV insulin therapy. There were no differences between the groups in average rates of serum glucose decline: two-bag 33.1 mg/dL/hr (s.e. 5.57, 95% CI 22.2, 44), one-bag 30.2 mg/dL/hr (s.e. 5.72, 95% CI 19, 41.4); average rate of serum bicarbonate correction: two-bag 1.19 mEq/L/hr, one-bag 1.27 mEq/L/hr; or the average number of IV fluid bags used: two-bag 4.1 bags, one-bag 3.2 bags. However, there was a difference between the groups in regard to elapsed total time to make changes in the IV fluids: two-bag 1 minute, one-bag 42 minutes, (p < 0.001). The "two-bag'' system enables a faster response time in making IV fluid therapy changes. This efficiency makes this system ideal for use in the emergency department.

Factors used by pediatric emergency medicine program directors to select their fellows

BACKGROUND

Pediatric emergency medicine (PEM) recently has become a highly competitive subspecialty with twice the number of applicants for positions available. Little information exists on the characteristics that PEM programs desire in their applicants. We sought to assess the factors used by PEM program directors when ranking PEM fellow applicants in the National Resident Match Program (NRMP).

METHODS

A 47-item questionnaire (adapted from a previously published questionnaire) was designed to assess the relative importance of various factors in the ranking of PEM fellow applicants in the NRMP. The questionnaire was mailed to all 43 PEM program directors that participated in the 2001 NRMP. The program directors were asked to grade selection factors based on a five-point Likert scale: 1, unimportant; 2, somewhat important; 3, important; 4, very important; 5, critical. The factors addressed in the questionnaire included academic criteria, letters of recommendation, applicant characteristics, and aspects of the interview. In addition, we asked 10 yes-or-no questions pertaining to specific aspects of each program. Responses were tabulated and means and standard deviations reported.

RESULTS

A program response rate of 93% (40/43) was obtained. The most important factors in granting an interview were recommendations from colleagues in PEM (4.21 +/- 0.78), research potential (3.81 +/- 1.10), and reputation of the applicant's pediatric program (3.51 +/- 0.91). The least important factors in granting an interview were reputation of the applicant's undergraduate institution (1.76 +/- 0.86), medical school grades (1.83 +/- 0.87), and board scores (2.11 +/- 0.91). Letters from division chiefs of PEM (4.15 +/- 0.78) and clinical faculty in PEM (4.06 +/- 0.82) were considered the most important letters of recommendation, whereas letters from basic science faculty were considered the least important (1.89 +/- 0.96). Ability to work with a team (4.66 +/- 0.42), compatibility with the program (4.65 +/- 0.35), commitment to hard work (4.55 +/- 0.45), ability to grow in knowledge (4.41 +/- 0.58), ability to solve problems (4.36 +/- 0.63), ability to listen (4.34 +/- 0.65), and ability to articulate thoughts (4.32 +/- 0.59) were the most important characteristics in the final ranking of candidates. Thirty percent (12/40) of the program directors stated that it was important for the program to "match" its top choice. The majority of programs have a selection committee that contributes to the final ranking of applicants.

CONCLUSIONS

The results of this study suggest that a rather subjective but uniform prioritization of criteria is used in evaluating PEM program applicants. Awareness of these factors would enable applicants to make a critical self-analysis of their strengths and weaknesses prior to the submission of their applications.

Comparative efficacy of oral dexamethasone versus oral prednisone in acute pediatric asthma

OBJECTIVE

The objective was to determine whether 2 days of oral dexamethasone (DEX) is more effective than 5 days of oral prednisone/prednisolone (PRED) in improving symptoms and preventing relapse in children with acute asthma.

STUDY DESIGN

This was a prospective randomized trial of children (2 to 18 years old) who presented to the emergency department with acute asthma. PRED 2 mg/kg, maximum 60 mg (odd days) or DEX 0.6 mg/kg, maximum 16 mg (even days) was used. At discharge children in the PRED group were prescribed 4 daily doses (1 mg/kg/d, maximum 60 mg); children in the DEX group received a prepackaged dose (0.6 mg/kg, maximum 16 mg) to take the next day. The primary outcome was relapse within 10 days.

RESULTS

When DEX was compared with PRED, relapse rates (7.4% of 272 vs 6.9% of 261), hospitalization rates from the emergency department (11% vs 12%) or after relapse (20% vs 17%), and symptom persistence at 10 days (22% vs 21%) were similar. In the PRED group more children were excluded for vomiting in the emergency department (3% vs 0.3%; P =.008), more parents were noncompliant (4% vs. 0.4%; P =.004), and more children missed > or =2 days of school (19.5% vs. 13.2%; P =.05).

CONCLUSION

In children with acute asthma, 2 doses of dexamethasone provide similar efficacy with improved compliance and fewer side effects than 5 doses of prednisone.

Sports-related concussions

Concussion is the most common head injury occurring in sports participation. Concussions range from a brief period of neural dysfunction to a prolonged period of unconsciousness with retrograde amnesia. It is imperative that the pediatric emergency medicine specialist be familiar with the proper initial assessment of the child or adolescent athlete who has sustained a sports-related concussion, the latest grading scales of concussions, and the current recommendations for returning the athlete to competition. A systematic approach to the athlete who has suffered a concussion will minimize the risk of further injury or mortality.

Evaluation of an ambu-bag valve with a self-contained, colorimetric end-tidal CO2 system in the detection of airway mishaps: an animal trial

OBJECTIVE

Capno-Flo (Kirk Specialty Systems, Carrouton, TX) is a portable pulmonary resuscitator (self inflating ambu-bag--valve system) with a self-contained, colorimetric end-tidal CO2 detector that has the ability to provide continuous CO2 monitoring for up to 2 hours. The purpose of this study is to determine the accuracy and time interval for the Capno-Flo monitor to detect acute airway obstructions and hypopharyngeal extubations in an intubated animal model.

SUBJECTS

Five anesthetized, non-paralyzed, mechanically ventilated Yorkshire minipigs.

METHODS

Complete and partial airway obstruction was simulated with complete and partial cross-clamping of the endotracheal (ET) tube. Placement of the ET tube into the hypopharynx was performed to simulate accidental extubation. In addition to the Capno-Flo colorimetric indicator, both sidestream (SS) and mainstream (MS) capnography were used to monitor end-tidal CO2 and comparison. The time intervals for the capnograph wave to flatten and for the monitor to display "zero" were recorded after each airway alteration. Each experiment was carried out for 180 seconds, and a total of 25 trials was performed.

RESULTS

Complete obstruction produced a color change in the Capno-Flo monitor in 9+/-2 seconds and flattening of the SS and MS waveform in 8+/-2 seconds and 6+/-2 seconds, respectively. The SS and MS monitors displayed zero in 49+/-7 seconds and 19+/-1 seconds, respectively. Partial obstruction did not produce color change, a flattening of the wave, or a monitor display of zero. Hypopharyngeal extubation produced a color change in 10+/-2 seconds, flattening of the SS and MS waveform in 7+/-2 seconds and 7+/-1 seconds, respectively. The SS and MS monitors displayed "zero" in 76+/-16 seconds and 18+/-3 seconds, respectively.

CONCLUSION

The Capno-Flo identified all complete airway obstructions and hypopharyngeal extubations rapidly. The CF monitor performed comparable to the SS and MS capnographs. Neither the Capno-Flo, nor the sidestream, nor the mainstream capnographs detected partial airway obstruction. The clinical application of this portable inexpensive capnometer in the continuous monitoring of the intubated patient, especially the transport patient, should be investigated further.

Tick paralysis syndrome in a 5-year-old girl

Tick paralysis syndrome (TPS) is an uncommon cause of ascending paralysis in children. Familiarity with its clinical features is important, since prompt diagnosis and removal of the tick is curative. We report the case of a 5-year-old girl with TPS manifested as lower extremity ataxia and paralysis and briefly discuss the salient features of TPS.

Pediatric emergency department nurses' perspectives on fever in children

BACKGROUND

Fever is the most common complaint of children seen in a Pediatric Emergency Department (PED). Since pediatric emergency nurses commonly educate parents on fever management, this study sought to examine their knowledge base regarding fever in children.

METHODS

Through convenience sampling, pediatric emergency registered nurses working at one of four PEDs were surveyed using a self-administered questionnaire containing 10 open-ended questions pertaining to fever in children.

RESULTS

Eighty-eight pediatric emergency registered nurses (median experience 8.0 years, range 3 months to 28 years) were surveyed. The median temperature considered by pediatric emergency nurses to be a fever was 38.0 degrees C (100.4 degrees F) with a range of 37.2 degrees C (99.0 degrees F) to 38.9 degrees C (102.0 degrees F), while the median temperature considered to be dangerous to a child was 40.6 degrees C (105.0 degrees F) with a range of 38.0 degrees C (100.4 degrees F) to 41.8 degrees C (107.0 degrees F). Eleven percent was not sure what temperature constituted a fever while 31% was not sure what temperature would be dangerous to a child. Fifty-seven percent considered seizures the primary danger to a febrile child while 29% stated permanent brain injury or death could occur from a high fever. Sixty percent chose acetaminophen as first line treatment while 7% stated alcohol or tepid water baths were also acceptable treatment options. Thirty-eight percent stated that a different medication should be added if a child was still febrile 1 hour after initial treatment while 31% would not use additional medication. Eighteen percent stated it was dangerous for a child to leave the PED if still febrile.

CONCLUSION

Fever phobia and inconsistent treatment approaches occur among experienced pediatric emergency registered nurses. These phobias and inconsistencies subsequently could be conveyed to parents. In order to assure accurate parental education, PEDs should educate their medical team regarding the management of fever in children.

Peripherally inserted central venous catheter fracture and embolization to the lung

We report an adolescent patient with a peripherally inserted central venous catheter fracture and subsequent migration of the catheter fragment through the heart and into the lower lobe of the right lung. Physical findings were unremarkable for indications of this pulmonary embolization. With the increasing use of such devices for prolonged venous access, the practicing pediatric emergency physician should be aware of this potential complication.

Utility of monitoring capnography, pulse oximetry, and vital signs in the detection of airway mishaps: a hyperoxemic animal model

This study was undertaken to determine the time interval for changes in end-tidal CO2, oxygen saturation (SaO2), heart rate (HR), and blood pressure (BP) in response to an acute airway obstruction or hypopharyngeal extubation in a hyperoxemic model. Complete and partial airway obstructions were simulated with complete and partial cross-clamping of an endotracheal (ET) tube in five anesthetized, nonparalyzed, mechanically ventilated Yorkshire minipigs with initial PAo2 of > 400 mm Hg. Placement of the ET tube into the hypopharynx was performed to simulate accidental extubation. Both sidestream (SS) and mainstream (MS) capnography were used. Continuous pulse oximetry monitored SaO2, femoral arterial catheter monitored systolic BP, and electrocardiograph monitored HR. The time intervals for the capnograph wave to flatten and for the monitor to display zero were recorded after each airway alteration. The time interval to a change in the initial HR of 10 beats/min, a change of initial systolic BP of 10 mm Hg, and a change of initial SaO2 of 5% were recorded. Experiments were carried out for 180 seconds, and 25 trials were performed. HR, systolic BP, and SaO2 did not change for the 180-second duration of the trials. Complete obstruction produced a flattening of the SS and MS waveform in 8 +/- 2 seconds and 6 +/- 2 seconds, respectively. The SS and MS monitors displayed zero in 19 +/- 1 seconds and 68 +/- 7 seconds, respectively. Partial obstruction did not produce flattening of the wave or a monitor displaying zero. Hypopharyngeal extubation produced a flattening of the SS and MS waveform in 7 +/- 1 seconds and 7 +/- 2 seconds, respectively. The SS and MS monitors displayed zero in 18 +/- 3 seconds and 76 +/- 16 seconds, respectively. Continuous end-tidal CO2 capnography detects acute airway obstruction and hypopharyngeal extubation more rapidly than does pulse oximetry or vital sign monitoring in a hyperoxemic porcine model.

Use of thiocyanate elution to estimate relative avidity of allergen specific IgE antibodies

Although several methods for estimating avidity of antigen-antibody reactions are available, most are impractical for the study of human IgE antibodies because of a requirement for pure allergen and antibody in relatively large amounts. To determine the relative avidity of specific IgE antibodies for Dermatophagoides pteronyssinus allergens, seven concentrations of the chaotropic thiocyanate ion were used to disrupt epitope-antibody binding in a specific IgE immunoassay system, using sera from 16 allergic patients with marked skin test reactivity to a standardized D. pteronyssinus extract. Relative avidity, the molarity of thiocyanate required to produce a 50% decrement in binding, ranged from 0.29-3.1. Within assay coefficient of variation (CV) was 9.9% and between assay CV was 13%. D. pteronyssinus specific IgE levels ranged from 0.66-141 kUa/L, not correlating with relative avidity (rho = -0.12). Thiocyanate elution appears to be a useful method for estimating relative avidity of specific IgE antibodies for the myriad epitopes of the allergenic proteins in an allergen extract. It could be used to study the immunochemistry of specific IgE assays; avidity maturation in allergen immunotherapy and in asymptomatic but sensitized patients; and preseasonal versus postseasonal changes in avidity within individuals. With a suitable solid phase, it could be modified to examine avidity at the epitope level.

Vocal cord dysfunction presenting as acute asthma in a pediatric patient

We report a pediatric patient with an acute onset of paradoxical vocal cord movement which presented as his first episode of wheezing. History and physical examination suggested the diagnosis of vocal cord dysfunction, which was confirmed by a flexible fiberoptic nasophayrngoscopic examination. This is the first report of paradoxical vocal cord movement being made on initial presentation of wheezing in the emergency department and supports earlier reports that this diagnosis can be made in the pediatric population. The practicing pediatric emergency physician should consider the diagnosis of paradoxical vocal cord dysfunction in the differential diagnosis of wheezing in the pediatric patient, especially if the patient does not have the typical historical and physical findings associated with reactive airway disease.