bluuebunny/crossref_metadata_2025 huggingface dataset:
Body composition of children with moderate and severe undernutrition and after treatment: a narrative review
Authors: Wells Jonathan C. K.
Published: November 2019

Background

Until recently, undernourished children were usually assessed using simple anthropometric measurements, which provide global assessments of nutritional status. There is increasing interest in obtaining more direct data on body composition to assess the effects of undernutrition on fat-free mass (FFM) and its constituents, such as muscle and organs, and on fat mass (FM) and its regional distribution.

Main text

Recent studies show that severe-acute undernutrition, categorised as ‘wasting’, is associated with major deficits in both FFM and FM that may persist in the long-term. Fat distribution appears more central, but this is more associated with the loss of peripheral fat than with the elevation of central fat. Chronic undernutrition, categorised as ‘stunting’, is associated with deficits in FFM and in specific components, such as organ size. However, the magnitude of these deficits is reduced, or – in some cases – disappears, after adjustment for height. This suggests that FFM is largely reduced in proportion to linear growth. Stunted children vary in their FM – in some cases remaining thin throughout childhood, but in other cases developing higher levels of FM. The causes of this heterogeneity remain unclear. Several different pathways may underlie longitudinal associations between early stunting and later body composition. Importantly, recent studies suggest that short children are not at risk of excess fat deposition in the short term when given nutritional supplementation.

Conclusion

The short- and long-term functional significance of FFM and FM for survival, physical capacity and non-communicable disease risk means that both tissues merit further attention in research on child undernutrition.
Withaferin A ameliorates ovarian cancer-induced cachexia and proinflammatory signaling
Authors: Straughn Alex R. , Kakar Sham S.
Published: November 2019

Background

Ovarian cancer is the fifth leading cause of cancer-related deaths amongst women in the United States. Cachexia is the primary cause of death in approximately 30% of cancer patients, and is often evidenced in ovarian cancer patients. We tested the steroidal lactone Withaferin A to examine if it could ameliorate ovarian cancer-induced cachexia.

Methods

Six-week-old severely immunodeficient female mice were xenografted with the ovarian cancer cell line A2780 followed by treatment with Withaferin A or vehicle. Changes in functional grip strength were assessed on a weekly basis. Postmortem, H&E staining was performed on skeletal muscle sections and immunofluorescent immunohistochemistry was performed on skeletal muscle and tumor sections. The levels of NF-κB-related proinflammatory cytokines were assessed in the xenografted tumors and in resident host skeletal muscle.

Results

Xenografting of the A2780 cell line resulted in a significant rate of mortality, which was attenuated by a therapeutic dosage of Withaferin A. Mice that received vehicle treatment following xenografting exhibited functional muscle decline over the course of the study. The therapeutic dosage Withaferin A treatment attenuated this reduction in grip strength, whereas the supratherapeutic dosage of Withaferin A was found to be toxic/lethal and demonstrated a further decline in functional muscle strength and an increased rate of mortality on par with vehicle treatment. At a histological level, the vehicle treated tumor-bearing mice exhibited a profound reduction in myofibrillar cross-sectional area compared to the vehicle treated tumor-free control group. The atrophic changes induced by the xenografted tumor were significantly ameliorated by treatment with Withaferin A. The combination of functional muscle weakening and induction of myofibrillar atrophy corroborate a cachectic phenotype, which was functionally rescued by Withaferin A. Further, treatment completely abolished the slow-to-fast myofiber type conversion observed in the settings of cancer-induced cachexia. In both host resident skeletal muscle and the xenografted tumors, we report an increase in NF-κB-related proinflammatory cytokines that was reversed by Withaferin A treatment. Finally, we demonstrated that Withaferin A significantly downregulates cytosolic and nuclear levels of phospho-p65, the active canonical NF-κB transcription factor, in xenografted tumors.

Conclusions

Cumulatively, our results demonstrate a previously overlooked role of Withaferin A in a xenograft model of ovarian cancer. We propose mechanisms by which Withaferin A reduces NF-κB-dependent pro-inflammatory cytokine production leading to an attenuation of the cachectic phenotype in an i.p. xenograft model of ovarian cancer.
Association between decreased HDL levels and cognitive deficits in patients with bipolar disorder: a pilot study
Authors: Hui Li , Yin Xiao Li , Chen Jie , Yin Xu Yuan , Zhu Hong Liang , Li Jin , Yin Guang Zhong , Xu Xiao Wen , Yang Xiao Nan , Qian Zheng Kang , Jiang Cai Xia , Tang Zhen , Yang Hai Bing , Cheung Eric F. C. , Chan Raymond C. K. , Jia Qiu Fang
Published: November 2019

Background

Cognitive deficits are common in patients with bipolar disorder (BD). Abnormal high density lipoprotein (HDL) levels have been implicated in cognitive deficits associated with ageing and neurodegenerative disorders. The present study aimed to investigate serum HDL levels, cognitive deficits and their association in patients with BD.

Methods

Thirty-seven patients with BD and 37 gender- and age-matched healthy controls (HCs) were recruited in a case–control study. Cognition was assessed using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), and serum HDL levels were measured using enzymatic colourimetry.

Results

There was no difference in serum HDL levels between patients with BD and HCs after adjusting for gender, age, education and body mass index (BMI). Cognitive test scores in patients with BD were significantly lower than those in HCs except for the visuospatial/constructional index after adjusting for confounding variables. Serum HDL levels were positively correlated with RBANS total score and language score in patients with BD. Stepwise multiple regression analysis showed that serum HDL levels were significantly correlated with RBANS total score and subscale scores on immediate memory and language in patients with BD after adjusting for confounding factors.

Conclusions

Our findings suggest that patients with BD had poorer cognitive performance than HCs except for the visuospatial/constructional domain, and decreased serum HDL levels were correlated with cognitive deficits, especially in immediate memory and language domains in patients with BD.
Developing student 21st Century skills in selected exemplary inclusive STEM high schools
Authors: Stehle Stephanie M. , Peters-Burton Erin E.
Published: November 2019

Background

There is a need to arm students with noncognitive, or 21stCentury, skills to prepare them for a more STEM-based job market. As STEM schools are created in a response to this call to action, research is needed to better understand how exemplary STEM schools successfully accomplish this goal. This conversion mixed method study analyzed student work samples and teacher lesson plans from seven exemplary inclusive STEM high schools to better understand at what level teachers at these schools are engaging and developing student 21stCentury skills.

Results

We found of the 67 lesson plans collected at the inclusive STEM high schools, 50 included instruction on 21stCentury skills. Most of these lesson plans designed instruction for 21stCentury skills at an introductory level. Few lesson plans encouraged multiple 21stCentury skills and addressed higher levels of those skills. Although there was not a significant difference between levels of 21stCentury skills by grade level, there was an overall trend of higher levels of 21stCentury skills demonstrated in lesson plans designed for grades 11 and 12. We also found that lesson plans that lasted three or more days had higher levels of 21stCentury skills.

Conclusions

These findings suggest that inclusive STEM high schools provide environments that support the development of 21stCentury skills. Yet, more can be done in the area of teacher professional development to improve instruction of high levels of 21stCentury skills.
Correlation between exercise, personal income level and health-related quality of life in patients with newly diagnosed stable angina
Authors: Wang Yi , Huang Lei , Zhou Lai-Xin
Published: November 2019

Background

Stable angina is one of the most common clinical types of coronary artery disease (CAD) and associated with poor health-related quality of life (HRQL). However, few studies have evaluated the risk factors associated with HRQL in patients with newly diagnosed stable angina.

Methods

A cross-sectional survey was conducted with 342 consecutive outpatients with newly diagnosed stable angina from October 2017 to January 2018 at the Second Affiliated Hospital of Army Medical University, Chongqing, China. Eight dimensions of HRQL were evaluated via the 36-item Short-Form Health Survey, including physical functioning, role limitation due to physical problems, bodily pain, general health, vitality, social functioning, role limitation due to emotional problems, and mental health. Physical and mental component summaries were calculated. Multiple stepwise regression was performed to determine the factors associated with HRQL.

Results

Patients who were older, were females, did not exercise, had lower educational levels, had lower monthly incomes, had smoking/drinking habits, and had diabetes, hypertension, or hyperlipemia showed lower physical HRQL scores, while those who were older with lower educational levels and lower monthly incomes showed lower mental HRQL scores. The results of the multiple stepwise regression analyses showed that physical and mental HRQL were positively correlated with exercise and monthly income and negatively associated with age. Patients with monthly income ≥5000 Yuan showed higher HRQL scores than those with monthly income < 5000 Yuan. Sleep quality and drinking were negatively associated with physical, but not mental HRQL.

Conclusions

Our findings indicated that exercise and personal income level, both modifiable factors, were positively associated with physical and mental HRQL. These findings could have implications for clinical suggestions and strategies to improve HRQL in patients with stable angina.
Anesthetic management of a patient with sodium-channel myotonia: a case report
Authors: Matsumoto Naohisa , Nishimoto Rei , Matsuoka Yoshikazu , Takeda Yoshimasa , Morimatsu Hiroshi
Published: November 2019

Background

Sodium-channel myotonia (SCM) is a nondystrophic myotonia, characterized by pure myotonia without muscle weakness or paramyotonia. The prevalence of skeletal muscle channelopathies is approximately 1 in 100,000, and the prevalence of SCM is much lower. To our knowledge, this is the first report on anesthetic management of a patient with SCM.

Case presentation

A 23-year-old woman with congenital nasal dysplasia and SCM was scheduled to undergo rhinoplasty with autologous costal cartilage. Total intravenous anesthesia without muscle relaxants was administered followed by continuous intercostal nerve block. Although transient elevation of potassium level in the blood was observed during surgery, the patient did not show exacerbation of myotonic or paralytic symptoms in the postoperative period.

Conclusion

Total intravenous anesthesia and peripheral nerve block can be administered safely to a patient with SCM. However, careful monitoring of the symptoms and electrolytes is recommended.
The authentic balut: history, culture, and economy of a Philippine food icon
Authors: Alejandria Maria Carinnes P. , De Vergara Tisha Isabelle M. , Colmenar Karla Patricia M.
Published: November 2019

The practice of making and eating fertilized duck eggs is a widely known practice in Asia. In the Philippines, “balut” is a popularly known Filipino delicacy which is made by incubating duck eggs for about 18 days. However, criticisms against its authenticity and the unstable demand for balut in the market pose challenges to the development of the Philippine balut industry. Consequently, this research aims to trace the history of balut production and consumption in the Philippines by specifically looking into the following. First, it explores the factors that contribute to the discovery and patronage of balut. Second, it identifies the localities that popularized the balut industry. Third, this includes the key industries that started the large scale production of balut. Fourth, it discusses the local ways of balut-making practices in the country. Lastly, it also provides an account of the ways of balut consumption. Through content analysis of secondary data, this research argues that balut remains an authentic Filipino food despite shared patronage in several Asian countries through the localized meanings associated with its consumption, preparation, and distribution.
Evaluating patient out-of-pocket (OOP) costs associated with attendance at a prostate cancer supportive care program.
Authors: Wu Eugenia , Hedden Lindsay , Bryan Sterling , Arsovska Olga , Vivar Michaela , Sundar Monita , Goldenberg Larry , Higano Celestia S.
Published: November 2019

108

Background: The Prostate Cancer Supportive Care (PCSC) Program at the Vancouver Prostate Centre (VPC) services address the physical and psychological needs of men and their partners from the time of PC diagnosis onwards. The study objective was to assess the level of patient out-of-pocket (OOP) expenditure associated with attending the PCSC services, which are otherwise free of charge, and determine whether OPP varies by specific clinical or sociodemographic characteristics. Methods: All men with PC seen at the VPC are invited to enroll in this study. Before or after any clinic and/or education appointment, pts completed a cost evaluation survey. Demographic data was collected from the PCSC Program registration forms and VPC electronic medical records. Results: Between 16-Apr-18 and 06-Sep-18, 207 men enrolled in the study and completed the survey. OOP expenses were highly skewed, with the majority of study participants spending less than $20 for each visit to the program, median (median $10, SD 80.0). Majority (93.6%) experienced either no or minimal financial burden, while 5.3% experienced moderate and 1.1% experienced substantial financial burden associated with their attendance at the program. Forty-four participants (22.1%) had to take time away from work to attend a PCSC service, on average this was 275 minutes, and 13.6% of them (2.9% of the total study sample) considered not participating because of difficulty getting the necessary time off. The average travel time (72.9 minutes) associated with a visit to the program was also highly skewed (median 45.0, SD 210.6). Using a simple linear regression, longer travel was associated with higher cost (t=8.30, p<0.0001), however, longer travel was unrelated to cost burden (F=0.35, p=0.79). Conclusions: OOP expenditure as well as associated burden is very minimal for the majority of participants. From a programmatic standpoint, a reasonable number of participants (22%) had to take time away from work. Bi-variate results show no relationship with personal income, OOP expenditure and financial burden.
Antiemetic efficacy of intravenous (IV) NEPA in patients with breast cancer (BC) receiving anthracycline/cyclophosphamide (AC) chemotherapy.
Authors: Schwartzberg Lee S. , Aapro Matti S.
Published: November 2019

115

Background: The complexity of administering multi-agent prophylactic antiemetic combinations required to prevent chemotherapy-induced nausea and vomiting (CINV) may contribute to poor guideline adherence seen in multiple studies. NEPA, a combination antiemetic of an NK1 receptor antagonist (RA) [netupitant (oral)/fosnetupitant (IV)] and 5-HT3RA, palonosetron, offers 5-day CINV prevention with a single dose. Unlike other IV NK1RAs, the fosnetupitant solution does not require a surfactant, emulsifier, or solubility enhancer and contains no allergenic excipients, thereby minimizing infusion-related toxicities that have been reported with other NK1RAs. This study previously reported the safety of IV NEPA in BC patients receiving repeat cycles of AC; there were no infusion-site or hypersensitivity reactions related to IV NEPA reported. The efficacy results of this study are the focus of this presentation. Methods: This was a Phase 3b, double-blind safety study in females with BC naïve to highly/moderately emetogenic chemotherapy. Patients were randomized 1:1 to receive a single 30-min infusion of IV NEPA or a single oral NEPA capsule on Day 1 prior to AC. Oral dexamethasone was also given to all patients before AC on Day 1 only. Complete response (CR: no emesis, no rescue) and no significant nausea (NSN: < 25mm on 100mm VAS scale) rates were calculated daily during the 5 days (0-120 h) post-AC in Cycle 1. No formal statistical comparison between groups was planned. Results: 402 total patients were included in the analysis. Most patients were white (93%) with ECOG status of 0 (75%); the mean age was 55 years. Comparable CR and NSN rates were seen for IV and oral NEPA during each of the 5 days post-AC. Conclusions: As a simplified single-dose formulation, IV NEPA showed high response rates in BC patients receiving AC, with favorable safety as no treatment-related infusion-site/hypersensitivity reactions were reported. Clinical trial information: NCT03403712. [Table: see text]
The efficacy and the incidence of drowsiness with different modified administrations of olanzapine in preventing chemotherapy induced nausea and vomiting.
Authors: Qian Yu , Wang Jun , Wu Yuan , Dong Shuang , Hu Sheng , Luo Chenggang , Wei Shaozhong , RAN Fengming
Published: November 2019

121

Background: Olanzapine is now widely used for preventing chemotherapy-induced nausea and vomiting (CINV). The recommended oral administration is 10 mg at bedtime. However, drowsiness is one of common side effects of olanzapine. Several modified administrations of olanzapine, such as dose reduction and early taken are being tried in clinical practice to avoid drowsiness. Methods: We retrospectively reviewed 500 patients who used olanzapine for CINV from January 2018 to January 2019 in our department. Eligible criteria include patients who used the constant administration of olanzapine for at least four days to prevent acute and delayed CINV. Patients were grouped into three groups according to three different administrations of olanzapine as full dose (10mg), half dose (5 mg), and early taken (10 mg, six hours before bedtime). Eligible patients were randomly selected in each group as a ratio of 1:1:1. The frequency of CINV, the incidence of drowsiness and the duration of olanzapine administration were collected and compared. Results: There are 267 patients met the criteria and 48 patients in each group. The median frequency of CINV per day in all 144 patients was 3, 1, 1 on day 1 to 3 after chemotherapy respectively. The frequency of CINV was not different among three groups. The incidence of drowsiness was 38%, 20%, and 23% in full dose, half dose and early taken groups (P < 0.05). The median days of administration were 5, 10 and 6 days in full dose, half dose and early taken group, respectively. Conclusions: Modified administration of olanzapine, both by dose reduction and early taken, could have similar effect in preventing CINV but reduced the incidence of the side effect as drowsiness. Further study should be done to explore the proper administration of olanzapine in preventing CINV.
Treatment of neoplastic fever and sweats in two cancer patients with oxybutynin.
Authors: Smith Thomas J. , Yarchoan Mark , Leon-Ferre Roberto Antonio , Tucker Wendy , Loprinzi Charles L.
Published: November 2019

128

Background: Treatment for neoplastic fevers and sweating (NFS) is usually accomplished successfully with non-steroidal drugs (NSAIDs) such as naproxen, but such therapies may be contraindicated in some patients due to drug interactions, bleeding diathesis, renal disease, or cirrhosis. Options for treating NFS in such patients are limited. Methods: We report the first use of oxybutynin (OxyB), commonly used for hyperhidrosis and increasingly used for hormonally mediated hot flashes (Smith TJ, NEJM 2018; Leon-Ferre R, SABCS 2018, under review in JNCI Cancer Spectrum, for NFS in NSAID-ineligible or refractory patients. Results: Two patients with NFS were treated. The first was a 70 year old (yo) woman with cholangiocarcinoma with 3 months of NFS for whom naproxen was ineffective and who was starting chemotherapy. Within 2 hours after 2.5 mg OxyB q12h her sweating was gone, and her fever, which had been up to 100.4F, never resumed. The second was a 52 yo male with cirrhosis and hepatocellular carcinoma who was prescribed 2.5 mg q12h OxyB with lysis of his fever within hours and cessation of his sweating. To date, over one month has passed with no reduction in efficacy. Conclusions: OxyB may be a successful treatment modality for patients with NFS who cannot be treated with or are refractory to NSAIDs. Further research is warranted to ensure stability of results over time and to monitor for side effects.
The efficacy of palliative radiation therapy in the treatment of recurrent and metastatic ovarian cancer.
Authors: Butala Anish , Patel Roshal , Jones Joshua Adam , Taunk Neil
Published: November 2019

129

Background: Ovarian cancer is the 2nd most common gynecologic malignancy with surgery and platinum-based chemotherapy as the mainstay of initial treatment. However, ovarian cancer has generally high rates of recurrence and metastasis after primary therapy. For patients with progressive or symptomatic disease, radiation therapy (RT) can be utilized as an effective option for palliation. Methods: A retrospective review was conducted of patients treated with palliative RT for symptomatic or recurrent ovarian cancer between 2015-2019 at a single institution. 17 women were identified who received 20 courses of RT. Response was classified as complete response (CR), partial response (PR), and progressive disease (PD). Overall response rate (ORR) was the sum of CR and PR. Results: Median age at RT was 57 (range 36-76). Histologic subtypes were high grade serous (65%), low grade serous (12%), clear cell (12%), and other (12%). The most common indications were pain (65%), bleeding (30%), and asymptomatic progression (20%). 18 of 20 RT courses were delivered to soft tissue or nodal metastases. RT techniques included 2D/3D (60%), IMRT (30%), and SBRT (10%). Dose ranged from 20-60 Gy in 3-28 fractions. 20 Gy in 5 fractions (25%) and 30-31 Gy in 10 fractions (25%) were most common. Of the 16 RT courses for symptomatic disease, clinical ORR was 87.5% within 3 months of RT (50% PR and 37.5% CR). 3 treatments had sustained response beyond 3 months. 2 developed PD. Of 11 RT courses with follow-up imaging, radiographic ORR was 36.1% (27% PR and 9.1% CR) within 3 months of RT. 1 had sustained PR beyond 3 months. Of the 10 RT courses for symptomatic high grade serous histology, PR and CR was seen in 50% and 40% of patients within 3 months (90% ORR). Conclusions: Palliative RT offers high rates of clinical response for symptomatic patients with metastatic ovarian cancer within 3 months of treatment delivery. Rapid clinical response rates were particularly favorable for those with high grade serous histology. RT should be considered as a standard palliative option for patients with symptomatic ovarian cancer metastases. Further prospective studies are warranted to establish the optimal timing, dose, and relation to chemosensitivity in this setting.
Opioid usage patterns among Medicare pancreatic cancer patients according to palliative care utilization.
Authors: Lu Zhanni , Ganduglia Cazaban Cecilia M , LeonNovelo Luis G. , Yennu Sriram , Giordano Sharon H. , Zhao Hui
Published: November 2019

14

Background: Opioid pharmacotherapy is used to manage moderate and severe pain in palliative care (PC). Pain affects 80% pancreatic cancer patients older than 65 years. We assessed the opioid utilization patterns in Medicare patients with pancreatic cancer whom did not use PC (NPC), used community-based PC (CBPC) or used hospital-based PC (HBPC). Methods: We assessed opioid use, types, dispensed days, opioid uptake rates, doses (measured by morphine equivalent doses (MEDs)), and related adverse events (AEs) after pancreatic cancer diagnosis in Medicare beneficiaries selected from the SEER-Medicare database between 2007 and 2013 using the log-binomial, generalized linear mixed, and Cox proportional hazards modeling. Results: 16,106 patients were identified (median age: 78 years; female: 55.2%), of whom 8.3% used CBPC and 19.6% used HBPC. PC users were more likely to use opioids (CBPC: 72.2% vs. HBPC: 63.4% vs. NPC: 56.3%, P<.001). The most commonly prescribed opioid type in NPC, HBPC and CBPC users was fentanyl (54.1%), hydromorphone (27.7%) and morphine (26.1%). Compared to other study patients, CBPC users had shorter median dispensed days per prescription (CBPC: 3 days vs. HBPC: 4 days vs. NPC: 4 days, P<.001) but higher median MEDs per prescription (CBPC: 25 mg vs. HBPC: 25 mg vs. NPC: 0.13 mg, P<.001). Adjusting for demographic and clinical factors, no significantly different uptake rates of opioids were determined in PC users compared to NPC users (CBPC: RR, 1.02, P=.057; HBPC: RR, 1.002, P=.783). HBPC users had higher adjusted daily MEDs than CBPC and NPC users 3 months after diagnosis (135.1 mg/d vs. 126.5 mg/d vs. 65.7 mg/d, P<.001). CBPC users had higher adjusted daily MEDs than HBPC and NPC users 3 months before death (164.3mg/d vs. 155.6 mg/d vs. 92.1 mg/d, P=.0002). CBPC users had lower but HBPC users had higher adjusted hazard ratios of delirium (CBPC: HR, 0.95, HBPC: HR, 1.26, P<.001) and drowsiness (CBPC: HR, 0.94, HBPC: HR, 1.53, P<.001) than NPC users. Conclusions: Older pancreatic cancer patients using PC tended to use opioids and consumed higher opioid doses. CBPC users had lower risks of opioid-related delirium and drowsiness. The factors of the opioid use variations need to be assessed.
Serious illness communication practices in glioblastoma care at an academic medical center.
Authors: Reed-Guy Lauren , Alexander Tyler D. , Biggiani Gregory , Miranda Stephen P. , O'Connor Nina
Published: November 2019

28

Background: Glioblastoma (GBM) is an aggressive primary brain tumor with a disease course marked by both cognitive and physical decline. Early conversations about end-of-life (EOL) preferences are important given the average life expectancy of 14 months. Little is known about patterns of communication in GBM. Objective: To describe current practices surrounding EOL conversations in GBM patients at an academic medical center. Methods: We reviewed the medical records of 240 patients treated for GBM at the University of Pennsylvania who died between 2017 and 2019. We systematically identified and characterized EOL conversations, as defined by documented discussions of prognosis, goals of care, EOL planning and/or code status. Results: Patients in this study were predominantly male, white, privately insured and had relatively high performance status (median KPS 80 at initiation of therapy). Median survival was 487 days and 96% of patients received both chemotherapy and radiation. Nearly all patients (96%) had at least one EOL conversation documented. The median number of documented conversations per patient was 4. The first EOL conversation occurred at a median of 24 days after diagnosis (range 0 to 3,883) and 362 days before death (0 to 2,401). The last EOL conversation occurred at a median of 32 days before death (0 to 1,514). EOL conversations took place earlier among older patients, with each additional year of age at diagnosis associated with a first conversation 8 days earlier (95% CI: -12 to -4 days; p<0.01). At least one EOL conversation occurred at an outpatient visit for 89% of patients; 33% had conversations during hospital admissions; and 38% had EOL conversations via telephone. Medical oncology was the most common specialty to document EOL conversations (89% of patients), followed by palliative care (19%), radiation oncology (13%) and neurosurgery (10%). Conclusions: EOL conversations appear to have occurred relatively early and often, but further work is needed to evaluate the quality of documented discussions and to determine whether this pattern is unique to this single center or widespread. The variety in provider specialty and conversation setting reflects the complexity of the care environment in GBM.
Motivation to engage in communication skills training by oncology specialty.
Authors: Portman Diane , Otto Amy , Thirlwell Sarah , Lubrano di Ciccone Barbara , Reblin Maija
Published: November 2019

29

Background: The present study aimed to assess oncology fellows’ motivation to participate in communication skills training by specialty. Methods: Oncology fellows attending communication skills training were invited to participate in program-evaluation research. Before each workshop, participants provided demographic information and completed subjective communications skills and motivation questionnaires. Following the workshop, the subjective communication skills survey was repeated. Results: Fifty physician trainees participated. Half were female. Most were first-year fellows (81%), White/Caucasian (56%), non-Hispanic (92%). Mean age was 32 years ( SD= 3.63). Motivation for attending the workshop was most commonly external regulation (e.g., required participation; M= 5.66, SD= 1.38), followed by identified regulation (e.g., belief the workshop will be helpful; M= 4.30, SD= 1.26) and intrinsic motivation (e.g., interest in topic; M= 3.76, SD= 1.15). Amotivation was less common ( M= 2.47, SD= 1.35). All scales rated 1-7. A one-way ANOVA revealed significant differences in levels of identified regulation ( F(4,44) = 3.26, p= .020) and external regulation ( F(4,45) = 3.47, p= .015) between fellows of different specialties. Post-hoc comparisons revealed that Hematology Oncology fellows reported significantly lower levels of identified regulation than Hospice & Palliative Medicine fellows ( M difference = -1.35, p= .024). Hematology Oncology ( M difference = 1.60, p= .012) and Surgical Oncology fellows ( M difference = 1.67, p= .043) both reported significantly higher levels of external regulation than Hospice & Palliative Medicine fellows. However, there were no significant differences between specialties with regard to post-workshop preparedness or pre-post change in preparedness ( ps > .05). Conclusions: There is opportunity to create targeted interventions to improve physician motivation to participate in communication skills education by matching messaging to each specialty’s motivation type.
Genomic profiling: Shared decision making and emotional well-being among patients with metastatic genitourinary cancers.
Authors: Bergerot Cristiane Decat , Bergerot Paulo Gustavo , Philip Errol James , Salgia Meghan , Salgia Nicholas , Dizman Nazli , Hsu Joann , Pal Sumanta K.
Published: November 2019

31

Background: Little is known regarding patients’ beliefs concerning genomic profiling (GP) and its potential association with emotional well-being. We examined essential components of shared decision-making in the context of GP and their relationship to symptoms of anxiety (SAnx) and of depression (SDep) among patients with metastatic genitourinary cancers. Methods: Patients were recruited from a single institution after receiving a standardized dialogue about GP from their oncologist. Patients were included if they had received GP in the context of routine clinical care, and assessed across a range of perceptions related to GP (e.g., communication, expectations, risks associated, reasons and hopes), SAnx (PROMIS-Anxiety) and SDep (PROMIS-Depression). The Kruskal-Wallis test was used. Results: Seventy patients with incurable genitourinary cancers (60% kidney, 21% prostate and 18% bladder cancers) were surveyed. Patients reported that information about GP was presented clearly (95%), comprehensively (94%), accurately (92%), and compassionately (98%), and most felt they possessed a good understanding of GP (78%). No significant differences emerged between patients with or without SAnx or SDep. Patients reported similar reasons for pursuing GP, including to help guide treatment decision making and to follow their physician’s suggestion. Notably, those with SAnx or SDep were more likely to report a desire for information that could help predict their disease outcome (20% and 33%) compared to patients without SAnx or SDep (0%) (P < 0.05). Those with SDep tended to report a desire for GP to improve their treatment response compared to those without SDep (42% vs. 21%, P = 0.04). Compared to those without SDep, patients with SDep were more likely to report a belief that GP could reveal a cure to their disease (73% vs. 50%, P = 0.01). Conclusions: Our findings reinforce the importance of effective counselling in the context of complex medical decision-making. SAnx and SDep may be associated with erroneous beliefs or expectations the role of GP in treatment. Given the complexity of GP, interventions are needed to enhance patients' understanding of these tests and therapeutic implications.
Timing is everything: Improving the frequency, timeliness, and effectiveness of goals of care conversations for oncology patients in Manitoba.
Authors: Carpenter-Kellett Tara , Gingerich Joel Roger , Czaykowski Piotr , Loader Alissa , Bucher Oliver
Published: November 2019

4

Background: Advanced care planning (ACP) in oncology requires effective communication and coordination. Early and regular ACP discussions are endorsed by ESMO and can help facilitate quality, patient-centered care. Methods: An ACP curriculum was created at CancerCare Manitoba that included health care provider (HCP) engagement, HCP and patient education, improved ACP clinical workflow, and improved ease of ACP documentation in the medical record. We evaluated the occurrence and frequency of ACP discussions before implementation of the ACP curriculum using a random sample of 100 adult patients diagnosed with stage IV solid tumors in Manitoba, Canada during 2014. We compared this group to a similar group of patients from 2017 after ACP curriculum implementation. Differences between the two cohorts were tested using Chi-square and Fisher’s Exact tests. The time from a patient’s first clinic visit with an oncologist to their first ACP conversation was described using cumulative incidence curves with K-sample tests used to test for significant differences between the 2014 and 2017 cohorts. Results: Of the 200 patients selected, 153 were assessed at our provincial cancer center (76 in 2014 and 77 in 2017). The median age for this group was 68. 59% were male. 56% received at least 1 line of chemotherapy. ACP documentation increased from 29% in 2014 to 42% in 2017 (p = 0.10). Between 2014 and 2017, initial ACP discussions occurred at: Initial visit (18% vs. 41%), disease progression (27% vs. 31%) and referral to palliative care (55% vs. 28%). After curriculum implementation ACP documentation occurred earlier in the patient’s cancer journey (p = 0.04). Conclusions: After implementation of an ACP curriculum at our cancer center, ACP discussions occurred more often and earlier, but the difference was only significant for earlier ACP discussions. Even after ACP curriculum implementation, a significant proportion of patients did not have ACP documented in their patient record. Understanding and overcoming barriers related to ACP at our institution will be critical for further ACP documentation improvement.
Outcomes of in-hospital cardiopulmonary resuscitation (ICPR) for cardiac arrest in adult patients with metastatic solid cancers: A nationwide inpatient sample (NIS) database analysis from 2012 to 2014.
Authors: Malapati Sindhu Janarthanam , Singh Sunny R K , Kumar Rohit , Ahmed Jibran , Vohra Ishaan , Katiyar Vatsala , Kafri Zyad
Published: November 2019

44

Background: Cardiopulmonary arrest is known to have a poor prognosis which is further worsened by existing co-morbidities. The prevalence of metastatic malignancy is rapidly increasing with improved cancer treatments and yet the outcomes of ICPR are not well studied in these patients. We aim to study the epidemiology, associations and outcomes in this subpopulation. Methods: Retrospective cohort analysis of the 2012 to 2014 NIS database. We included patients ≥ 18 years with the International Classification of Diseases, 9th Revision, Clinical Modification procedure codes for ICPR and diagnosis codes for solid metastatic cancers. Primary diagnosis of cardiopulmonary arrest was excluded (represents out‐of‐hospital arrest.) Primary outcome was inpatient mortality following ICPR and the factors associated were analyzed using logistic regression. Results: Amongst 1,432,240 admissions of adults with metastatic solid cancers, 0.6% (n = 8840) received ICPR, of which 82% (n = 7245) died in the same admission. Inpatient mortality following ICPR in adults without metastatic solid cancers was 68.7%. For adults with metastatic solid cancers receiving ICPR, mean age was 65.9 years, 57.7% were males and 60.6% Caucasian. Also, 11.5% of them had an inpatient palliative care encounter. On multivariate logistic regression analysis, African Americans had higher mortality than Caucasians (OR 1.5, p 0.01) while elective admission and age < 50 years had lower mortality (OR 0.5, p < 0.05 and OR 0.5, p 0.01 respectively.) There was no difference in mortality based on site of primary tumor, gender, day of admission, Charlson Comorbidity Index, insurance status and hospital teaching status, location or size. Conclusions: Amongst adult patients with metastatic solid cancers receiving ICPR, 82% died within the same admission. Race, age and admission type predicted mortality. Despite known poor prognosis, only 11.5% had a palliative care encounter. [Table: see text]
Performance status, survival, and end-of-life care in adults with non-small cell lung cancer (NSCLC) treated with immunotherapy.
Authors: Petrillo Laura A. , El-Jawahri Areej , Nipp Ryan David , Lichtenstein Morgan , Reynolds Kerry Lynn , Greer Joseph , Temel Jennifer S. , Gainor Justin F.
Published: November 2019

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Background: Immune checkpoint inhibitors (ICI) improve survival for adults with metastatic NSCLC. Despite limited data on ICI efficacy in adults with poor performance status (PS), oncologists often elect to treat this population with ICI given their relatively favorable toxicity profile and potential for durable response. We aimed to describe the timing of ICI and patients’ survival based on PS, and explore the effect of late ICI use on end-of-life (EOL) care. Methods: Retrospective study of 235 adults with metastatic NSCLC at a single academic center who initiated ICI from 2015-2017. We compared overall survival (OS) among adults with Eastern Cooperative Oncology Group (ECOG) PS ≥ 2 at ICI start to those with ECOG PS < 2, using the log-rank test and Cox regression, adjusted for age, sex, comorbidity, time from diagnosis and line of therapy. We used logistic regression to analyze the association between ICI in the last 30 days of life and EOL care. Results: The median age at ICI start was 67 (range 37-91), and 83/235 (35%) had ECOG PS ≥ 2. Patients received ICI as first- (19%), second-line (56%) or later (25%) therapy. Median OS was 4.0 months in adults with ECOG PS ≥ 2 and 14.3 months in ECOG PS < 2 (p < 0.0001; HR = 2.5 [95% CI 1.8–3.5]). Among adults who died (n = 165), 17% of those with ECOG PS ≥ 2 started ICI in last 30 days of life and 24% started or continued ICI in their last 30 days, compared to 4% and 7% of ECOG PS < 2 (p = 0.005, p = 0.001, respectively). Receipt of ICI in last 30 days of life was associated with decreased hospice referral (OR 0.29, p = 0.006), decreased odds of hospice stay > 7 days (OR 0.15, p < 0.001), and increased in-hospital death (OR 6.8, p = 0.001). Conclusions: Adults with metastatic NSCLC and ECOG PS ≥ 2 experience significantly shorter survival than those with ECOG PS < 2 and more often receive ICI near the end of life, and late ICI use is associated with decreased hospice use and increased in-hospital death. Clinicians should thus use caution in extrapolating data from clinical trials, which are limited to ECOG PS < 2, to inform the care of adults with ECOG PS ≥ 2. Further, these results highlight potential tradeoffs of ICI and underscore the need for efforts to improve communication about ICI risks and benefits.
Symptom burden and characteristics of patients who die in the acute palliative care unit of a tertiary cancer center.
Authors: Kim YuJung , Ahn Grace S. , Kim Hak Ro , Kang Beodeul , Hur Sung Soun , Kim Ji-Won , Kim Se Hyun , Kim Jin Won , Lee Jeong-Ok , Lee Keun-Wook , Kim Jee Hyun , Bang Soo-Mee , Lee Jong Seok
Published: November 2019

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Background: Acute Palliative Care Units (ACPUs) are novel inpatient programs in tertiary care centers that provide aggressive symptom management and assist transition to hospice. However, patients often die in the APCU before successfully transferring to hospice. The aim of this study was to evaluate the symptom burden and characteristics of advanced cancer patients who die in the APCU. Methods: We retrospectively reviewed the medical records of all advanced cancer patients admitted to the APCU between April, 2015 and March, 2016 at a tertiary cancer center in Korea. Basic characteristics and symptom burden assessed by the Edmonton Symptom Assessment System (ESAS) were obtained from consultation upon APCU admission. Statistical analyses were conducted to compare patients who died in the APCU with those who were discharged alive. Results: Of the 267 patients analyzed, 87 patients (33%) died in the APCU. The median age of patients was 66 (range, 23-97). Patients who died in the APCU had higher ESAS scores of drowsiness (6 vs 5, P = 0.002), dyspnea (4 vs 2, P = 0.001), anorexia (8 vs 6, P = 0.014) and insomnia (6 vs 4, P = 0.001) compared to patients who discharged alive. Total symptom distress scores (SDS) were also significantly higher (47 vs 40, P = 0.001). Patients who died in the APCU were more likely to be male (odds ratio [OR] for female patients 0.38, 95% confidence interval [CI] 0.22-0.67, P < 0.001) and have higher ESAS scores of drowsiness (OR 2.08, 95% CI, 1.08-3.99, P = 0.029) and dyspnea (OR 2.19, 95% CI 1.26-3.80, P = 0.005). These patients showed significantly shorter survival after APCU admission (7 days vs 31 days, P < 0.001). Conclusions: Advanced cancer patients who die in the APCU are more likely to be male and have significantly higher symptom burden that include drowsiness and dyspnea. These patients show rapid clinical deterioration after APCU admission. More proactive and timely end-of-life care is needed for these patients.
Patterns of palliative care among patients receiving palliative radiotherapy.
Authors: Chen Jie Jane , Rawal Bhupendra , Krishnan Monica Shalini , Hertan Lauren Michelle , Shi Diana D. , Roldan Claudia Sofia , Huynh Mai Anh , Spektor Alexander , Balboni Tracy A.
Published: November 2019

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Background: Few studies have examined how palliative care (PC) delivered by a dedicated PC team is integrated at the time of radiotherapy (RT) consultation. We aimed to characterize patterns of PC in relation to RT, predictors of PC, and outcomes based on PC integration. Methods: We retrospectively reviewed 162 patients with metastatic cancer who received palliative RT at a single institution (7/2017-2/2018). PC integration was defined as: no PC, concurrent PC (PC initiated +/- 4 weeks within RT consult), established PC (any PC visit in the 6 months prior to RT consult), and subsequent PC (PC initiated > 4 weeks after RT consult). Logistic regression analyses determined predictors of receiving any PC. Cox proportional hazards regression identified predictors of OS. Results: Median follow-up was 7.8 months (range: 0.3-20.6). Patients (56% female; 84% white; median age: 64 years (range: 22-94)) had a median of 2 metastatic sites (range: 1-6) and 2 prior courses of palliative chemotherapy (range: 0-7). Of the 74 patients (46%) with any PC, 24 (32%) had concurrent PC, 21 (28%) had established PC, and 29 (39%) had subsequent PC. The most common reasons for PC initiation were pain (58%) and goals of care/end-of-life care management (20%). Nearly half (49%) of PC consults occurred in an inpatient setting; a minority (22%) of RT consults were inpatient. On multivariate analysis, receiving any PC significantly differed by race (non-white vs white, OR = 6.40 [95% CI 1.98-20.69], p = 0.002), cancer type (lung vs non-breast other histology, OR = 0.15 [95% CI 0.06-0.35], p < 0.001), and RT consult setting (inpatient vs outpatient, OR = 3.32 [95% CI 1.36-8.13], p = 0.009). On multivariate analysis, male sex (HR = 1.51 [95% CI 1.01-2.27], p = 0.046) and ECOG 2-4 (HR = 2.22 [95% CI 1.47-3.36], p < 0.001) predicted worse OS. Age, marital status, language, insurance type, metastatic burden, prior palliative chemotherapy, and PC integration were not independent predictors of OS. Conclusions: At our institution, dedicated PC occurred in < 50% of patients receiving palliative RT for metastatic cancer. We need initiatives to increase PC for all palliative RT patients, especially in the outpatient setting and for those with lung cancer who were less likely to receive dedicated PC.
OCM community oncology palliative care program: Opioid analgesic utilization.
Authors: Akhtar Adil Jamal , Sheth Karna , Margolis Jeffrey H. , Muskovitz Andrew A. , Zekman Richard Philip , Howard George , Folbe Mitchell , Qamruzzaman Yusuf , Ballouz Samer , Scott-Barney Tammy , Maxwell Karma , Ibrahim Mohammed , Stortz Lexi , Fabbiano Maria
Published: November 2019

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Background: Oncology Division of Michigan Health Professionals participates in Oncology Care Model (OCM ). A community oncology program for early and timely involvement of palliative care (PC) was launched in September 2017 to improve cancer pain management. Under-treatment of cancer pain leads to continued patient suffering and impaired quality of life. Appropriate dosing, rotation and frequent assessments are essential for better pain control. This study aims to see the effect of PC on opioid analgesic utilization. Methods: Retrospective claims review was performed with PC patients referred from September 2017 – December 2018 with an opioid class (as defined by CDC) Part D claim (within OCM data). Opioid utilization across agents was measured in morphine-milligram-equivalents (MME). MME per patient per opioid month (PPM) was compared between PC-referred and PC-not referred patients, pre- and post- PC start. Average MME PPM was compared between PC-Engaged and PC declined or unable to reach patients. Within these 2 cohorts, Long-Acting (LA) vs. Short-Acting (SA) opioid utilization was calculated. Results: PC-not referred patients appear to have little monthly variation in opioid dosing. PC-referred patients showed wide variation in opioid dosing before PC. After PC start, opioid dosing stabilized. PC-Engaged patients had more than double MME PPM vs PC declined or unable to reach (2481 MME PPM vs 1198 MME PPM respectively). PC-Engaged patients utilized a higher percentage of LA (43%) whereas PC declined or unable to reach used much less LA (8%). Conclusions: In patients with uncontrolled pain, PC-referral led to decreased variation in opioid dosing and better pain control. Better pain control may be the result of higher utilization of both SA & LA opioids. Patients who do not engage in PC may be at-risk for under-treatment. Study was limited by OCM claims available as of June 2019. Results may be refreshed as more data becomes available.