bluuebunny/crossref_metadata_2025 huggingface dataset:
Communicating Oncologic Prognosis with Empathy (COPE).
Authors: Phillips Farya , Goodgame Boone W , Jones Barbara L
Published: November 2018

38

Background: Clear communication between patients and providers is imperative to maximize patient outcomes, particularly for patients with incurable cancer who require prompt engagement in decision-making. In response to the need to engage in quality patient-centered communication, an interprofessional team, representing medicine, nursing, social work, and spiritual care developed a simple, single-page tool that summarizes the prognosis and treatment plan for patients with incurable cancers. This pilot study evaluates the communication guide, Communicating Oncologic Prognosis with Empathy (COPE), for discussing prognosis and treatment options for cancer patients. Methods: A pilot test of 30 participants with incurable cancer was completed at an oncology clinic. The communication guide was evaluated using a pre- and post-test design, participants completed a prognosis and treatment perception survey (PTPQ) prior to their first oncology appointment. Patients then met with their oncologist and the COPE guide was used to guide the discussion and patients received a copy of the COPE guide. The COPE guide was placed in the patient chart and other members of the healthcare team were able to use the tool to provide the patient with support and explore the patient’s response to information received. Patients completed the post-test PTPQ at 4 week follow up and completed exit interviews to assess patient reported impact on communication with medical team, caregivers, and quality of life. Results: Key findings revealed participants prefer receiving detailed information about prognosis and have differing perceptions about goals of treatment compared to the oncology team. The tool seemed to facilitate mostly accurate information recall regarding prognosis and treatment options. Conclusions: Despite the high value patients placed on knowing about prognosis and quality of communication with their medical team, the majority reported incongruent goals of treatment and likelihood of cure compared with their oncologist, highlighting major gaps in patients’ understanding of their prognosis. The COPE guide serves as a promising mechanism to enhance patient-centered communication about prognosis and treatment for patients with incurable cancer.
When should anti-cancer treatment be ended? Why and when to discontinue palliative chemotherapy.
Authors: Kondo Yuurin , Nakajima Maria Michiko , Nakajima Go , Hayashi Kazuhiko
Published: November 2018

41

Background: Currently, palliative chemotherapy (PC) near the end of life is frequently discussed. It is important to know when it is appropriate to end PC to maintain the best quality of life. The criteria for discontinuation of anti-cancer therapy are often “exacerbation of patient’s condition,” “problems with toxicity,” or “patient refusal.” However, there is no clear agreement regarding when to end PC. Ending treatment is one of the most difficult decisions for oncologists. The purpose of this study was to determine clear reasons for the discontinuation of PC and to gain an understanding of the current situation regarding explanation of prognosis in clinical practice. Methods: This retrospective study included 144 patients with incurable cancer who had received PC and died between January 2014 and November 2016. We examined the reasons for discontinuation of PC and whether patients had completed end-of-life discussions, including a discussion of life expectancy, when their PC was terminated. Results: Causes of discontinuation of PC were as follows: 8.3% patient’s desire, progressive disease (PD) in 48.5%, poor performance status (PS) in 20.1%, and toxicity in 17.4%. In patients who chose to end anticancer therapy voluntarily, all patients received a clear explanation of their prognosis, including life expectancy. Among 67 patients with PD, 45 (67.1%) received information regarding their prognosis; 17 of 29 patients (58.6%) with poor PS received similar information. Among patients who ended PC due to toxicity, only 8 of 25 patients (32%) completed end-of-life discussions, including a discussion of life expectancy. In addition, death within 1 month from the discontinuation of PC occurred in 0 cases where treatment was discontinued due to patient’s desire, 10 cases (15%) due to PD, 10 cases (34.4%) due to PS, and 7 cases (28%) due to toxicity. Conclusions: This study shows that patients who discontinued treatment due to poor PS or toxicity had a shorter interval between the final PC and death. Moreover, it indicated that the details of the end-of-life discussion might be influenced by the reason for discontinuation of PC, including or excluding a discussion of life expectancy.
Adding shared laughter to optimise shared medicine.
Authors: Buiting Hilde M. , de Bree Remco , Brom Linda , Mack Jennifer W. , van den Brekel Michiel
Published: November 2018

43

Background: Most people are familiar with the expression "laughter is the best medicine". By triggering endorphin release and strengthening relationships, it can be considered a perfect holistic care-approach. We explored the occurrence, acceptability, and functions of humor and laughter in patients with incurable cancer. Methods: We performed 16 in-depth interviews with patients with incurable cancer at the day-care unit of a Dutch comprehensive cancer hospital. We further performed and online questionnaire-study among 33 oncologists (41% of 81 approached) about experiences with humour and laughter in breast, lung, head and neck, or urological cancer. Results: Nearly all oncologists reported using humour (97%), and all reported to sometimes laugh during consultations; 83% reported experiencing a positive effect of laughter. These results were in line with patients’ experiences: Patients noted that humor always stayed alive, despite having incurable cancer. Apart from this human aspect, patients also used humor to broach difficult topics and to downplay challenges. Some patients explicated that the appreciation of humor was dependent on the type of humor, since humor is rather personal. Patients and oncologists acknowledged that using humor is delicate, and sometimes inappropriate, partly because they did not always share the same type of humor. Laughter, in contrast, was regarded as ‘lighter’ than humor, and could, accordingly, more easily be implemented. However, both patients and specialists cautioned against patients using laughter to avoid uncertainty or broach difficult topics. Conclusions: Our results suggest that patients and healthcare professionals can benefit from humour or laughter. Many conversations were joyful, even in the midst of medical challenges. Although humor is personal, laughter can be applied more easily. Healthcare professionals therefore need to have a basic comprehension of the impact of laughter to facilitate discussions, improve the doctor-patient relationship, and identify underlying wishes. If applied appropriately, shared laughter will possibly add to optimise shared medicine.
Frustration and distress during treatment for advanced renal cell carcinoma.
Authors: Bergerot Cristiane Decat , Battle Dena , Bergerot Paulo Gustavo , George Daniel J. , Hammers Hans J. , Jonasch Eric , Ljungberg Borje , Bex Axel , Dizman Nazli , Staehler Michael D. , Pal Sumanta K.
Published: November 2018

47

Background: Treatment strategies for advanced renal cell carcinoma (aRCC) have improved over the past 15 years. Durable responses are now achievable, giving rise to the possibility of cure in a small proportion of this population. However, it is not clear how patients are coping with more protracted courses of treatment. We sought to determine sources of frustration among patients diagnosed with aRCC. Methods: We performed a cross-sectional analysis of data derived from an online survey distributed via social media from April to June, 2017. We assessed source of frustration using an open-ended question: “In your own words, what has frustrated you most about your medical care related to your diagnosis?”. We assessed distress using the Distress Thermometer. Qualitative content analysis was performed to characterize responses related to frustration. Descriptive statistics was generated and the Kruskal-Wallis test was used to explore the relationship between clinical characteristics and sources of frustration. Results: We enrolled 217 patients with aRCC. The majority were male (52.3%), and white (93.5%). Clear cell histology (84.2%) was the most common diagnosis. Patients reported high levels of distress (M = 6.4; SD = 2.8). Sources of frustration were documented in 71.9% of patients, and were most commonly related to distrust of the cancer care system (12.4%), fear of progression (11.5%), lack of information (11.1%), financial concerns (9.7%), communication between patient and physician (7.8%), treatment side effects (4.6%), lack of available research (4.1%), mistrust of physician’s knowledge (4.1%), and access to supportive care (2.8%). Higher levels of frustration were associated with higher levels of distress (P = 0.01). Patients with non-clear cell RCC more commonly reported an emotional source of frustration (P = 0.02). Conclusions: Patients with aRCC report high levels of distress and frustration with their diagnosis and treatment. The most frequent drivers of frustration can suggest opportunities to maximize support to patients and their families. A better understanding of their disease and prognosis, addressing financial concerns and offering psychosocial support may alleviate frustration amongst patients with aRCC.
Opioid prescribing upon discharge for patients with solid malignancies.
Authors: Lal Ashima , LaFollette Jennifer Ann , Terrell Constance
Published: November 2018

50

Background: Pain is a common symptom associated with cancer resulting in increased health care utilization. We aim to study patients admitted with uncontrolled pain and review their discharge medications after development of an effective pain regimen while hospitalized. Anecdotally, we observe patients are being discharged with suboptimal regimens resulting in increased Emergency Department (ED) visits or readmissions. By identifying suboptimal opioid prescriptions we hope to improve care and patient satisfaction and minimize ED visits or readmission rates. The primary objective is to identify opportunities for improvement of opioid prescribing upon discharge for medical oncology patients. Methods: Retrospective study exempt from IRB review. We reviewed admitted patients with a solid tumor cancer diagnosis and consult to inpatient medical oncology at a safety-net hospital in an urban Southeastern population from June to November 2017 with data collected on 29 patients. Data was analyzed using descriptive statistics. Potential health-system cost avoidance was calculated. Results: 51% of patients were discharged with a lower daily oral morphine equivalent (DOME) than received while inpatient, with a median of 12 days until scheduled follow-up appointment. While 75% of patients were prescribed an adequate supply for long acting opioids, only 39% received an adequate supply of short acting opioids. 12 patients (41%) returned to the ED or urgent clinic within 30 days. 4 events were associated with a lower DOME and/or inadequate supply compared to their inpatient regimen. The total amount billed for missed opportunities showed the hospital was reimbursed only 25%. Conclusions: Opportunities to prevent discrepancies in discharge regimens exist. Pain regimens should be assessed for accuracy and supply at discharge and appointments. Patients should be discharged with a sufficient amount of opioids until their follow up, including ensuring insurance coverage of medication prescribed, with emphasis on patients maintaining their outpatient appointments. We plan to continue analysis post continuous QI initiative to improve clinical practice in pain management for patients with solid tumor malignancy.
Comparability of the Cancer Supportive Care Clinical Studies Collaborative (CSCCSC) study population to national referrals to other specialist palliative care services.
Authors: Currow David Christopher , Matsuoka Hiromichi , Allingham Samuel , Fazekas Belinda , Brown Linda , Vandersman Zac , Clark Katherine , Agar Meera
Published: November 2018

63

Background: There are no agreed national nor international criteria for referral to palliative care. Key population characteristics have been defined to aid the generalizability of research findings in palliative care clinical studies. To codify differences in key demographic factors between patients with cancer participating in the Australian national Cancer Supportive Care Clinical Studies Collaborative (CSCCSC) phase III symptom control studies and the population referred to other Australian palliative care services. Methods: This study compares two contemporaneous consecutive cohorts generated through clinical trial participation and the national palliative care clinical quality improvement registry in Australia. Age, sex, cancer diagnosis, language, and socio-economic status were compared. Results: Cohorts were people with cancer: enrolled in CSCCSC phase III clinical studies (n=902; 17 sites); and registered by the Australian national Palliative Care Outcomes Collaboration (PCOC; n=75,240; 117 sites). Participants in CSCCSC studies were younger than those of PCOC (median 71 (IQR 62, 79) versus median 73 (IQR 63, 81); p=0.003 respectively). There was no significant difference in sex (p=0.483). Patients who spoke English accounted 95.0% of enrollees in the CSCCSC group and 92.2% in the PCOC group (p = 0.004). Clinical study participants had higher socioeconomic status that the PCOC group (p=0.022). Conclusions: Overall, the slightly different demographic patterns are reflective of the differences often seen between phase III trials and the populations to whom the results will be applied. Age differences particularly need to be taken into account when considering the best way to apply each study’s findings.
Polypharmacy and medication costs at end of life among commercially insured adults age 65 and older with cancer.
Authors: McDermott Cara L. , Fedorenko Catherine R. , Sun Qin , Curtis J. Randall , Kreizenbeck Karma L. , Conklin Ted , Smith Bruce , Lyman Gary H. , Ramsey Scott David
Published: November 2018

65

Background: Polypharmacy, or the concurrent use of multiple medications, may expose patients to drug-drug interactions and excessive costs. There are limited data on polypharmacy for commercially insured older adults, primarily Medicare Advantage patients, that may have better access to medication management services than Medicare fee-for-service patients. We characterized medication use and out-of-pocket (OOP) medication costs in the last month of life among patients age 65+ who did not enroll in hospice to examine medication use in this population. Methods: We linked enrollment and claims records from two regional commercial insurers to Surveillance, Epidemiology, and End Results (SEER) Cancer Surveillance System and Washington State Cancer Registry records for patients diagnosed with a stage IV malignancy in Washington State between January 1, 2007-December 31, 2016. We calculated OOP costs as the difference between allowed and paid claim amounts and adjusted OOP costs (aOOP) for inflation to 2017 dollars. Results: Among 345 patients with medication claims in their last month, 156 (45%) had a chemotherapy claim. Average age was 74 years (range 65-95), 55% (n = 190) were male, and 150 had lung cancer (44%). Patients averaged 7.7 medication claims (range 1-50); 151 (44%) had 1-4, 99 (29%) had 5-9, and 95 (27%) had 10+. Common symptom-related medications were opioids, benzodiazepines, anti-emetics. Chemotherapy was associated with higher odds of 10+ prescriptions (OR 1.38, 95% CI 1.26-1.51). Excluding four patients with aOOP chemotherapy costs > $14,000, average aOOP costs were $101 for chemotherapy claims (range $0-$8957) and $33 for non-chemotherapy claims ($0-$1993). Costs for those in the highest quartile ranged from $320-$8957 for chemotherapy claims and $100-1993 for non-chemotherapy claims. Conclusions: Most subjects had at least five medication claims in their last 30 days. One-quarter had 10+ claims, which was associated with chemotherapy receipt. Hospice enrollment could reduce OOP costs, as hospice provides symptom-related medications. Interventions facilitating hospice enrollment and reducing chemotherapy use may minimize polypharmacy and cost burden for patients and families.
Factors associated with receipt of palliative-only care among survivors with head and neck cancer.
Authors: Osazuwa-Peters Nosayaba , Bukatko Aleksandr R , Simpson Matthew C , Gaubatz Matthew , Polednik Katherine M. , Adjei Boakye Eric
Published: November 2018

73

Background: Head and neck cancer (HNC) survivors with end-stage disease may receive multimodal treatment with non-curative intent. However, besides clinical indications for palliative care, there is a paucity of data describing nonclinical factors associated with receipt of palliative care. This study aimed at characterizing sociodemographic factors associated with HNC survivors receiving palliative-only care. Methods: We used data from the National Cancer Database from 2004-2014, restricting our cohort to adult HNC survivors receiving palliative-only care. Multivariate logistic regression estimated association between sociodemographic factors and receiving palliative-only care. Survival of palliative-only patients was assessed via Cox proportional hazards model. Final regression models were adjusted for clinical/nonclinical covariates, including: age, comorbidity score, tumor site, cancer stage, histology, HPV status, and population density/urbanization. Results: Out of 325,489 HNC survivors, 2,404 received palliative-only treatment. Mean age was 69.1 years, and median survival was 4.9 months. Sociodemographic factors associated with receiving palliative-only care were gender: (female aOR=1.11; 95% CI 1.02, 1.22), race/ethnicity: [(Hispanic aOR=0.77; 95% CI 0.62, 0.97), (Non-Hispanic Black aOR=1.35; 95% CI 1.20, 1.52)], insurance status: [(uninsured aOR=2.59; 95% CI 2.13, 3.14), (Medicaid aOR=3.11; 95% CI 2.67, 3.61), (Medicare aOR=1.71; 95% CI 1.50, 1.95)], travel distance for care: (≥50 miles aOR=0.64; 95% CI 0.55, 0.74). Additionally, survivors receiving palliative-only care who were uninsured (aHR=1.34; 95% CI 1.08, 1.65), under Medicaid (aHR=1.29; 95%CI 1.10, 1.52), or Medicare (aHR=1.16; 95%CI 1.01, 1.33) were significantly more likely to die compared with those privately insured. Conclusions: Females, blacks, and those uninsured, under Medicaid/Medicare disproportionately contribute to the palliative-only population among HNC survivors. Disparities persist even at end-stage disease among HNC survivors and impact disease outcome.
A single-center randomized clinical trial of palliative rehabilitation versus standard care alone in patients with newly diagnosed non-resectable cancer.
Authors: Nottelmann Lise , Groenvold Mogens , Petersen Morten Aagard , Vejlgaard Tove , Jensen Lars Henrik
Published: November 2018

75

Background: Palliative care and rehabilitation may both improve quality of life, but research on their combination and early integration into oncology care is sparse. Methods: Adults diagnosed with non-resectable cancers within the last 8 weeks were randomized to standard oncology care alone or an additional offer of individually tailored palliative rehabilitation. Two mandatory consultations and a 12 week open contact with a specialized palliative care team were offered. An additional opportunity was participation in a multidisciplinary group program combining a patient/caregiver school with physical exercise, individual consultations, or both. Participants were assessed at baseline and after 6 and 12 weeks with an extended version of the EORTC QLQ-C30 questionnaire using the item banks for computer-adaptive testing to obtain improved measurement. At baseline participants were asked to choose what they needed help with the most from a list of possible 'primary problems' corresponding to 12 of the 15 QLQ-C30 scales. The primary outcome was the change in that "primary problem" scale measured as area under the curve across the 12 weeks. Group differences were tested in an adjusted linear regression model. Results: 301 patients with lung- (40%), gastrointestinal- (27%), prostatic- (18%), and various other solid tumors (15%) were included. 139 patients were allocated to the intervention group and 149 to the standard care group. The palliative rehabilitation intervention was received by 132. Of those, 26 received the two mandatory consultations only, 59 additionally participated in a group program, and 47 additionally received individual consultations without participation in a group. The intervention showed an effect for the primary outcome with an absolute between-group difference of 3.0 (0.0;6.0) p = 0.047. The result was confirmed by a sensitivity analysis of the change from baseline to 12 weeks showing an absolute difference of 3.3 (1.0; 5.6) p = 0.005. Conclusions: A palliative rehabilitation intervention initiated soon after diagnosis and integrated in the standard oncology treatment improved quality of life. Clinical trial information: NCT02332317.
A randomized controlled trial of a novel artificial-intelligence based smartphone application to optimize the management of cancer-related pain.
Authors: Kamdar Mihir M. , Centi Amanda Jayne , Fischer Nils , Jethwani Kamal
Published: November 2018

76

Background: Cancer pain affects 70-90% of advanced malignancy patients, resulting in impaired quality of life and increased healthcare utilization. Novel care delivery models are needed to optimize care for patients dealing with cancer-related pain in between clinic visits. ePAL is a smartphone application(app) that regularly monitors pain and uses artificial intelligence(AI) to differentiate urgent from non-urgent issues to intercede in real time. The purpose of this randomized controlled trial was to determine ePAL's impact on pain severity, attitudes toward cancer treatment, and healthcare utilization in patients with cancer pain. Methods: MGH Palliative Care Clinic Patients with pain from metastatic, solid-organ cancer (n=112) were recruited and randomized to either a control group (n=56) that received usual care or an intervention group (n=56) that used the ePAL app in addition to usual care for 8 weeks. The app assessed pain 3 times/week and questionnaires about pain (BPI), attitudes towards cancer treatment(BQ-II), and general anxiety(GAD-7) were given at 0, 4, and 8 weeks. A repeated measures mixed model approach assessed how outcome measures changed over time. Models controlled for baseline differences at enrollment and random slopes in addition to baseline depression score, age and sex(alpha=0.05). Results: Pain severity (BPI) and negative attitudes toward cancer pain treatment (BQ-II) decreased significantly for those using the app compared to controls(coeff. -0.09, 95% CI: -0.17, -0.007, p=0.034 and coeff. -0.037, 95% CI: -0.072, -0.001, p=0.042 respectively). Anxiety scores increased for those using ePAL compared to controls (coeff. 0.21, 95% CI: 0.039, 0.37, p=0.015). Over 8-weeks, ePAL users had 40% fewer inpatient hospital admissions compared to controls (n=15 vs. n=25, p=0.048). Conclusions: To our knowledge, this is the first mobile app to utilize AI and clinical algorithms to significantly decrease pain and reduce overall inpatient hospitalizations in patients with cancer-related pain. Clinical trial information: NCT02069743.
Palliative radiotherapy education in hospice and palliative medicine fellowship: A national needs assessment.
Authors: Martin Emily Jean , Jones Joshua Adam
Published: November 2018

87

Background: Educational deficiencies among hospice and palliative medicine (HPM) physicians are thought to contribute to sub-optimal utilization of palliative radiotherapy (PRT) for patients with advanced cancer. We conducted a national survey of HPM fellowship program directors and fellows to assess the need for increased PRT education in HPM fellowship. Methods: A 17-item, anonymous, electronic survey was distributed via email in May 2018 to the directors of all US Accreditation Council for Graduate Medical Education-accredited HPM fellowship programs with at least one enrolled fellow. A similar 19-item survey was emailed to the coordinators of these programs for distribution to enrolled fellows. Three reminder emails were sent over a one-month period. Results: Eighty-one (68%) of 120 eligible program directors and 114 (34%) of 338 eligible fellows completed the surveys. Nearly all respondents (98% of program directors and 99% of fellows) agreed that HPM physicians should be familiar with the principles of PRT and 95% of both groups agreed that this topic should be taught in HPM fellowship. Thirty percent of programs, however, lacked any PRT curriculum and 57% of programs provided only 1 or 2 hours of didactic PRT education. The minority of fellows felt confident in their ability to identify radiation oncology emergencies (43%) or to manage symptoms associated with radiotherapy toxicities (42%) and only 56% felt confident in their ability to assess which patients should be referred to radiation oncology for possible PRT. Notably, the majority of fellows reported that if they were more knowledgeable about PRT they would be more likely to consider referral to radiation oncology (78%), to collaborate with the radiation oncologists involved in their patients’ care (76%), and to advocate for shorter fractionation schedules or possible omission of radiation therapy altogether based on a patient’s prognosis or goals of care (78%). Conclusions: HPM fellowship program directors and fellows agree that that there is a need for increased education in PRT in HPM fellowship. Curricular interventions that address this need may result in more appropriate utilization of PRT.
Disentangled: A single institutional analysis comparing differences in end-of-life patterns and resource utilization in acute leukemia and bone marrow transplant units.
Authors: Decastro Gene , Anandan Samuel , Ginsberg Adam , Lopez Santiago
Published: November 2018

90

Background: The impact of palliative medicine in patients with hematologic malignancies is a growing area of investigation. Over the last year, the Palliative Medicine service at North Shore University Hospital (NSUH) has developed and sustained a co-management model for patients admitted to the acute leukemia (ALU) or bone marrow transplant (BMTU) units. Methods: The primary outcome measure was the time from admission to initial consult. The secondary outcome measure was length of stay in a goal concordant setting to receive end of life (EOL) care, namely our inpatient palliative care unit (PCU). Results: There were 106 new consults in twelve months (45 acute leukemia/lymphoma consults and 61 bone marrow transplant consults). The principal diagnosis seen on the ALU was acute myeloid leukemia (56%), whereas on the BMTU it was multiple myeloma (28%). The average time to consult for the ALU decreased from 18.8 days at 6 months to 8.8 days at 12 months. For the BMTU, time to consult decreased from 10.2 days at 6 months to 4.6 days at 12 months. The mortality rate of patients seen from the ALU and BMTU was 40% and 12%, respectively. Of the ALU population deaths, 83% were 65 or older, compared to 29% of the BMTU deaths. Mortality events in the ICU were greater for BMTU patients (43%) relative to ALU patients (11%). Fifty percent of the ALU inpatient expirations were able to receive EOL care in our PCU. The remaining deaths were in the ALU (39%) or ICU (11%). For BMT patients, 57% died on the BMTU, and 43% in the MICU. Despite comparable numbers of PCU transfers during the pre- and post-intervention period, our initiative increased the average LOS in the PCU from 1.1 to 5.7 days. Of the ALU patients electing DNR prior to death (83%), the average DNR-to-death days was 10.6 days, whereas BMTU patients who elected DNR prior to death (50%) had an average of 6.5 DNR-to-death days. Conclusions: This partnership allowed for recognition of differences in EOL care patterns across these populations. It has demonstrated a benefit by accelerating time to consult and enhancing transitions to goal concordant settings for patients with hematologic malignancies at the end of their lives.
Emergent palliative radiotherapy: Dedicated personnel resources to improve workflow.
Authors: Wu Susan Y. , Boreta Lauren , Chan Jason , Chapman Christopher H. , Yee Emily , Braunstein Steve E.
Published: November 2018

93

Background: Approximately half of patients undergoing radiotherapy (RT) do so with palliative intent. Urgent indications for RT may include neurologic compromise, pain, or bleeding. While some practices have a dedicated palliative RT team, the majority utilize an “on-call” system with a rotating outpatient radiation oncologist. We report our experience with a dedicated nurse practitioner (NP) to assist with palliative RT workflow, with the goal of expediting patient care. Methods: 226 inpatients treated with RT to a site of metastatic disease from May 2012 to May 2018 were included. Since August 2017, an NP has helped expedite emergent RT referrals. Mann-Whitney U tests were used to compare days between steps in the treatment planning process before and after integration of an NP. Results: The median age at RT was 60 years (IQR 49–69). The most common primary sites were lung (26%) and breast (12%). The most common indication for RT was symptomatic brain metastases (SBM, 33% of patients), followed by pain (27%) and spinal cord compression or cauda equina syndrome (SCC) (21%). The median time from referral (defined as initial contact by the primary team) to consultation was one day (IQR 0-2), and from referral to RT was four days (IQR 2-6). Median time from referral to RT was shorter for SCC (two days, IQR 1-4.5) and SBM (three days, IQR 1–6), than pain (five days, IQR 2–8) (p = 0.001 and p = 0.015, respectively). 68% of patients with SCC (32/47) and 35% of patients with SBM (26/74) started RT within one day of consultation. With an NP, patients were more likely to undergo simulation (sim) the same day as consultation (74% vs. 58%, p = 0.03). Same day sim was more common in patients with neurologic deficits (SCC+SBM) than those without (87% vs. 62%, p = 0.02). In those with neurologic deficits, time from consultation to sim decreased from 0.85 to 0.23 days (p = 0.04) and time from sim to RT decreased from 2.7 to 1.8 days (approaching significance, p = 0.06). In patients treated for pain, time from consultation to RT was reduced from 6.3 to 2.1 days (p = 0.02). Conclusions: For practices without a dedicated palliative RT team, involvement of an NP can improve workflow and expedite urgent RT. Further research is needed to rigorously explore quality improvement in the delivery of palliative RT.
Integration and delivery of palliative and supportive care.
Authors: Okinyi Fredrick Otieno , Dower Joshua , Serubuga Makory Germaine , Orndorff Christy , Gallegos Jarred , Indalo Edwin , Musau Helena , Adhiambo Catharine , Wangechi Catherine , Rochford Rosemary , Sirengo Brigid , Remick Scot C. , Mwanda Walter
Published: November 2018

97

Background: Pediatric palliative care (PC) and end-of-life (EoL) planning and support for children, families, and providers are under-developed in Kenya. PC providers in Kenya want to build advocacy and teams to support children with life-threatening or limiting diseases and their families. Methods: KEHPCA in collaboration with UoN/KNH and US pediatric PC providers solicited applications from across the country to participate in a weeklong “train-the-trainer” workshop. The program was entirely devoted to pediatric PC and EoL care and is the “first-like” workshop to our knowledge. The program incorporated a variety of teaching and training tools that were used to support children, their families and caregivers suitable for the Kenyan setting. The cases of 7 children (7 mos. to 11 yrs) served as the focal point for training including extensive role-play scenarios. Results: The workshop convened 9-13th July 2018 in Nairobi. KEHPCA selected 31 providers from among 130 across Kenya to participate and included medical officers, nurses, pharmacists, psychosocial workers, spiritual care, and a school teacher. Expectations were identified by participants at the start, pre- and post-conference surveys were completed, and the identical survey was submitted twice to more than 5,000 physicians listed in the Kenya Board of Medicine directory. There is a lack of awareness of the importance of PC by physicians listed in the directory responding to the same survey. The workshop was well received and ways forward identified. Conclusions: There is consensus among participants that there are five critical gaps in pediatric PC in Kenya: 1) PC requires an interdisciplinary team; 2) interdisciplinary family visits are seldom done; 3) there is a need to facilitate EoL and serious illness conversations with families/guardians and children as appropriate (adolescents in particular); 4) identify ways to support the legacy of infants and young children who pass away; and 5) a clear desire to support the healthcare team. These observations will form a solid departure point for developing programs and ways forward for Kenyan children with life-threatening illnesses. [Supported in part by: KEHPCA and NIH grant nos.: D43 TW009333.]
A Carboxy-Terminal Monoleucine-Based Motif Participates in the Basolateral Targeting of the Na+/I− Symporter
Authors: Martín Mariano , Modenutti Carlos Pablo , Peyret Victoria , Geysels Romina Celeste , Darrouzet Elisabeth , Pourcher Thierry , Masini-Repiso Ana María , Martí Marcelo Adrián , Carrasco Nancy , Nicola Juan Pablo
Published: November 2018

The Na+/iodide (I−) symporter (NIS), a glycoprotein expressed at the basolateral plasma membrane of thyroid follicular cells, mediates I− accumulation for thyroid hormonogenesis and radioiodide therapy for differentiated thyroid carcinoma. However, differentiated thyroid tumors often exhibit lower I− transport than normal thyroid tissue (or even undetectable I− transport). Paradoxically, the majority of differentiated thyroid cancers show intracellular NIS expression, suggesting abnormal targeting to the plasma membrane. Therefore, a thorough understanding of the mechanisms that regulate NIS plasma membrane transport would have multiple implications for radioiodide therapy. In this study, we show that the intracellularly facing carboxy-terminus of NIS is required for the transport of the protein to the plasma membrane. Moreover, the carboxy-terminus contains dominant basolateral information. Using internal deletions and site-directed mutagenesis at the carboxy-terminus, we identified a highly conserved monoleucine-based sorting motif that determines NIS basolateral expression. Furthermore, in clathrin adaptor protein (AP)-1B–deficient cells, NIS sorting to the basolateral plasma membrane is compromised, causing the protein to also be expressed at the apical plasma membrane. Computer simulations suggest that the AP-1B subunit σ1 recognizes the monoleucine-based sorting motif in NIS carboxy-terminus. Although the mechanisms by which NIS is intracellularly retained in thyroid cancer remain elusive, our findings may open up avenues for identifying molecular targets that can be used to treat radioiodide-refractory thyroid tumors that express NIS intracellularly.
Ovulation: Parallels With Inflammatory Processes
Authors: Duffy Diane M , Ko CheMyong , Jo Misung , Brannstrom Mats , Curry Thomas E
Published: November 2018

The midcycle surge of LH sets in motion interconnected networks of signaling cascades to bring about rupture of the follicle and release of the oocyte during ovulation. Many mediators of these LH-induced signaling cascades are associated with inflammation, leading to the postulate that ovulation is similar to an inflammatory response. First responders to the LH surge are granulosa and theca cells, which produce steroids, prostaglandins, chemokines, and cytokines, which are also mediators of inflammatory processes. These mediators, in turn, activate both nonimmune ovarian cells as well as resident immune cells within the ovary; additional immune cells are also attracted to the ovary. Collectively, these cells regulate proteolytic pathways to reorganize the follicular stroma, disrupt the granulosa cell basal lamina, and facilitate invasion of vascular endothelial cells. LH-induced mediators initiate cumulus expansion and cumulus oocyte complex detachment, whereas the follicular apex undergoes extensive extracellular matrix remodeling and a loss of the surface epithelium. The remainder of the follicle undergoes rapid angiogenesis and functional differentiation of granulosa and theca cells. Ultimately, these functional and structural changes culminate in follicular rupture and oocyte release. Throughout the ovulatory process, the importance of inflammatory responses is highlighted by the commonalities and similarities between many of these events associated with ovulation and inflammation. However, ovulation includes processes that are distinct from inflammation, such as regulation of steroid action, oocyte maturation, and the eventual release of the oocyte. This review focuses on the commonalities between inflammatory responses and the process of ovulation.
Prepregnancy Fat Free Mass and Associations to Glucose Metabolism Before and During Pregnancy
Authors: Diaz Eva Carolina , Børsheim Elisabet , Shankar Kartik , Cleves Mario Alberto , Andres Aline
Published: November 2018

Objective

Our aim was to quantify the individual contribution of prepregnancy (PP) fat-free mass (FFM), expressed as [PP-FFM index (PP-FFMI) = FFM (kg)/height (m2)], on markers of glucose homeostasis before and during pregnancy.

Methods

Body composition was assessed in 43 women before pregnancy using air-displacement plethysmography. Blood was drawn at PP and gestational weeks ∼8 and 30. Relationships between body composition (independent) variables and glucose homeostasis (dependent) variables were assessed using adjusted correlations and simple and multiple linear regression analyses.

Results

PP-FFMI was the strongest predictor of plasma insulin concentration [squared partial correlation (Pr2) = 17, P = 0.007] and homeostasis model assessment of insulin resistance (HOMA2-IR) (Pr2 = 16, P = 0.010). At gestation week 30, PP-FFMI and gestational weight gain (GWG) were the strongest predictors of insulin concentration (PP-FFMI: Pr2 = 20, P = 0.010; GWG: Pr2 = 12, P = 0.052) and HOMA2-IR (PP-FFMI: Pr2 = 19, P = 0.012; GWG: Pr2 = 13, P = 0.045). After accounting for PP fat mass index (PP-FMI), PP-FFMI and GWG were independently associated with first-phase insulin response (PP-FFMI: Pr2 = 20, P = 0.009; GWG: Pr2 = 15, P = 0.025) and second-phase insulin response (PP-FFMI: Pr2 = 19, P = 0.011; GWG: Pr2 = 17, P = 0.016). PP-FMI was the strongest predictor of an oral glucose tolerance test‒derived estimated metabolic clearance rate of glucose (PP-FMI: Pr2 = 14, P = 0.037) and estimated insulin sensitivity index (PP-FMI: Pr2 = 13, P = 0.047).

Conclusions

PP-FFMI was a predictor of markers of glucose homeostasis before and during pregnancy. Studies assessing the effect of skeletal muscle quality on metabolic regulation during pregnancy are warranted.
C. elegans PTEN and AMPK block neuroblast divisions by inhibiting a BMP-insulin-PP2A-MAPK pathway
Authors: Zheng Shanqing , Qu Zhi , Zanetti Michael , Lam Brandon , Chin-Sang Ian
Published: November 2018

Caenorhabditis elegans that hatch in the absence of food stop their postembryonic development in a process called L1 arrest. Intriguingly, we find that the postembryonic Q neuroblasts divide and migrate during L1 arrest in mutants that have lost the energy sensor AMP-activated protein kinase (AMPK) or the insulin/IGF-1 signaling (IIS) negative regulator DAF-18/PTEN. We report that DBL-1/BMP works upstream of IIS to promote agonistic insulin-like peptides during L1 arrest. However, the abnormal Q cell divisions that occur during L1 arrest use a novel branch of the IIS pathway that is independent of the terminal transcription factor DAF-16/FOXO. Using genetic epistasis and drug interactions we show that AMPK functions downstream of, or in parallel with DAF-18/PTEN and IIS to inhibit PP2A function. Further, we show that PP2A regulates the abnormal Q cell divisions by activating the MPK-1/ERK signaling pathway via LIN-45/RAF, independently of LET-60/RAS. PP2A acts as a tumor suppressor in many oncogenic signaling cascades. Our work demonstrates a new role for PP2A that is needed to induce neuroblast divisions during starvation and is regulated by both insulin and AMPK.
Mechanism and physiological significance of autoregulation of the Escherichia coli hfq gene
Authors: Morita Teppei , Aiba Hiroji
Published: November 2018

The RNA chaperone Hfq plays a critical role in sRNA-mediated gene regulation in enteric bacteria. The major role of Hfq is to stimulate base-pairing between sRNAs and target mRNAs by binding both RNAs through three RNA-binding surfaces. To understand the post-transcriptional network exerted by Hfq and its associated sRNAs, it is important to know how the cellular concentration of Hfq is regulated. While an early study showed that hfq translation is repressed by Hfq, the detailed mechanism and biological significance of the hfq autoregulation remain to be studied. Here, we show that the synthesis of Hfq is strictly autoregulated to maintain the cellular concentration of Hfq within a limited range even when the hfq mRNA is overexpressed from a plasmid-borne hfq gene. Mutational and biochemical studies demonstrate that Hfq represses its own translation primarily by binding to the hfq mRNA through the distal face. The growth of cells harboring the hfq plasmid is markedly inhibited due to an increased Hfq level when the distal face of Hfq is mutated or the 5′-UTR of hfq is mutated. A mutation in the rim suppresses the growth inhibition caused by the distal face mutation, suggesting that the interaction of Hfq with undefined RNAs through the rim is responsible for the growth inhibition by the increased Hfq level. In addition, the data suggest that the hfq autoregulation operates not only in cells harboring a multicopy hfq gene but also in the wild-type cells.
ВЛИЯНИЕ РЕАБИЛИТАЦИИ НА КАЧЕСТВО ЖИЗНИ БОЛЬНЫХ, ПЕРЕНЕСШИХ ОСТРЫЙ КОРОНАРНЫЙ СИНДРОМ С ЭКСТРЕННОЙ ЧТКА И СТЕНТИРОВАНИЕМ КОРОНАРНЫХ АРТЕРИЙ (г. КРАСНОЯРСК)
Authors: Aksyutina Natalya Valeryevna , Shulman Vladimir Abramovich , Nikulina Svetlana Yurievna , Bespalov Andrey Vladimirovich , Knyazeva Irina Sergeevna , Mordovsky Basiliy Sergeyevich , Aldanova Elena Evgenevna , Zlakazov Oleg Vladimirovich , Chuhlomin Nikita Vasilyevich , Krasulya Ivan Vladimirovich , Kokourov Anton Olegovich , Chinyakov Dmitry Anatolyevich , Gvozdeva Anastasia Vladimirovna , Kuznetsova Oksana Olegovna , Sevostyanova Irina Igorevna
Published: November 2018

Цель. Изучить изменение качества жизни больных, перенесших острый коронарный синдром (ОКС) c экстренной реваскуляризацией посредством ЧТКА и стентирования коронарных артерий (КА).Материалы и методы. Включено 150 пациентов с ОКС, ЧТКА и стентированием КА. 1 группа – 65 человек, направленных на 2 этап кардиореабилитации; 2 группа – 85 человек, отказавшихся от проведения 2 этапа кардиореабилитации. Пациенты прошли стандартное обследование и дополнительно тестирование по тесту-опроснику Бека и SF-36.Результаты. Пациенты с полным курсом кардиореабилитации имели статический значимый прирост показателей здоровья (физический компонент здоровья после выписки 42,30 [38,25; 44,35] относительно через 6 месяцев 56,30 [51,85; 58,10], р<0,001; психологический компонент после выписки 42,80 [39,75; 50,20] относительно через 6 месяцев 56,70 [51,85; 57,20], р<0,001). Во 2 группе такой закономерности нет. Подтверждено отрицательное влияние табакокурения на физический (r = - 0,629, p<0,05) и психологический (r = - 0,621, p<0,05) компоненты здоровья, и повышенного уровня холестерина на физический (r = - 0,424, p<0,05) и психологический (r = - 0,405, p<0,05) компоненты здоровья.Заключение. Выявлена высокая значимость реабилитационных мероприятий у пациентов после стационарного лечения по поводу ОКС, ЧТКА и стентирования КА. При этом, из имеющихся факторов риска на качество реабилитационных мероприятий отрицательно влияет повышенный уровень холестерина и курение.
Puppet power!
Authors: Benham Kim
Published: November 2018

Puppets can be a tremendous tool for story telling and are great for engaging the attention of a large group of children. However you decide to use your puppets, you don't have to be a ventriloquist – children's imaginations will do it all, says Kim Benham, senior manager at Sparkles Pre-School in Croydon.
Working in Harmony
Authors: Faux Karen
Published: November 2018

Karen Faux finds out how an outstanding nursery embarked on an exciting journey when it brought in an outdoor learning expert to deliver training. Practice across all areas has been enriched as a result.
Communication breakdown
Authors: Bergin Joelle
Published: November 2018

What is the best strategy to adopt when temper tantrums appear to be linked to speech and language delay? SENCO Joelle Bergin suggests an Antecendent, Behaviour, Consequence observation chart as a starting point.
Make a fresh start
Authors: Chapman Ailsa
Published: November 2018

Out with the old and in with the new…In the case of Ailsa Chapman's nursery and pre-school this means getting rid of the clutter and favouring new resources in natural materials such as metal and wood.
Monster maths!
Authors: Hewson Claire
Published: November 2018

Roll up your sleeves and prepare to get messy with some Halloween-themed maths! As children engage in monster maths encourage them to make predictions and then test their own ideas.
Learning to care
Authors: Harries Judith
Published: November 2018

The books of Mick Inkpen, which feature characters such as Kipper, Wibbly Pig and Penguin Small are a great starting point for observing animals and understanding their environments and needs.
Blown away
Authors: Hart Karen
Published: November 2018

Experiencing the wind outdoors and expressing what it feels like in artworks is a great way to encourage children to use different art media, mix colours and explore relationships between shape and texture.
Effectiveness of fascial closure technique following percutaneous endovascular aneurysm repair
Authors: Majid K , Anwar MA , Shepherd A , Malina M , Hussain T
Published: November 2018

Introduction

Percutaneous access and closure is commonly performed for patients undergoing endovascular aneurysm repair (EVAR). It has proven to be a safe and successful method of closure associated with fewer complications when compared with the traditional open technique. Fascial closure is an alternative technique that can be used for closure reducing the risks associated with the open technique. The aim of this study was to assess the safety and durability of fascial closure for failed percutaneous closure device following EVAR.

Materials and methods

Over a 12-month period, 49 patients who had undergone EVAR were identified via our EVAR register. Retrospective analysis of the clinical records was undertaken. We identified all the patients who had fascial closure of the groins following a failed percutaneous closure device. Patients had a computed tomography angiogram one month postoperatively, with duplex imaging and clinic follow-up three months later.

Results

Fascial closure was performed in 14 groins. It failed in three groins and these patients had traditional open repair. Fascial closure was successful in 11 groins (7 patients). Of these seven patients, one was female (6%). The mean age was 80 years (range 68–92 years). Two patients died and one was lost to follow-up. One pseudoaneurysms were seen on computed tomography angiogram, which was managed conservatively and had resolved on follow-up imaging.

Conclusions

Fascial closure is a very good alternative to open repair after failure of the closure device.