Recent Publications by CFE Educators

BACKGROUND

Seriously ill patients frequently receive care in hospitals, and palliative care is a core competency for hospitalists. We aimed to summarize and critique recent research that has the potential to impact the clinical practice of palliative care in the hospital.

METHODS

We reviewed articles published between January 2012 and May 2013, identified through a hand-search of leading journals and PubMed. The authors collectively selected 9 articles based on their scientific rigor and relevance to hospital practice. We review their findings, strengths, and limitations and make recommendations for practice.

RESULTS

Key findings include: indwelling pleural catheters and talc pleurodesis provide similar relief of dyspnea in patients with malignant pleural effusions; oxygen many not be needed to prevent dyspnea in many dying patients; docusate may not be needed in addition to sennosides to treat opioid-induced constipation; atropine is no more effective than placebo in treating respiratory rattles in dying patients; many older adult survivors of in-hospital cardiopulmonary resuscitation (CPR) are alive up to 1 year after discharge; observing CPR may decrease family post-traumatic stress; surrogates of intensive care unit patients often interpret prognostic information optimistically; many patients with metastatic cancer feel that chemotherapy may cure their disease; viewing a goals-of-care video may decrease preference for CPR in patients being admitted to skilled nursing facilities.

CONCLUSIONS

Recent research provides important insights into the effectiveness of medications and interventions for symptom management, outcomes of CPR for patients and families, and Journal of Hospital Medicine 2013;8:715-720. © 2013 Society of Hospital Medicine.

PURPOSE

To minimize feature loss in T1- and T2-weighted MRI by merging multiple MR images acquired at different TR and TE to generate an image with increased dynamic range.

MATERIALS AND METHODS

High Dynamic Range (HDR) processing techniques from the field of photography were applied to a series of acquired MR images. Specifically, a method to parameterize the algorithm for MRI data was developed and tested. T1- and T2-weighted images of a number of contrast agent phantoms and a live mouse were acquired with varying TR and TE parameters. The images were computationally merged to produce HDR-MR images. All acquisitions were performed on a 7.05 T Bruker PharmaScan with a multi-echo spin echo pulse sequence.

RESULTS

HDR-MRI delineated bright and dark features that were either saturated or indistinguishable from background in standard T1- and T2-weighted MRI. The increased dynamic range preserved intensity gradation over a larger range of T1 and T2 in phantoms and revealed more anatomical features in vivo.

CONCLUSIONS

We have developed and tested a method to apply HDR processing to MR images. The increased dynamic range of HDR-MR images as compared to standard T1- and T2-weighted images minimizes feature loss caused by magnetization recovery or low SNR.

Hepatocerebral mitochondrial DNA depletion syndromes are classically considered diseases of early childhood, typically affecting the liver, peripheral, and central nervous systems with a rapidly progressive course. Evidence is emerging that initial symptom onset can extend into adulthood, though few such cases have been reported. We describe a 25-year-old woman who presented initially with secondary amenorrhea, followed by a megaloblastic anemia, lactic acidosis, leukoencephalopathy, progressive peripheral neuropathy, and liver cirrhosis. An apparently homozygous P98L mutation was identified in MPV17, a gene associated with a lethal infantile neurohepatopathy. Homozygosity for the same allele was recently reported in a man with a similar hepatic and neurologic phenotype. This is the first clinical report of an adult female with this disorder, and the first to describe amenorrhea and megaloblastic anemia as likely associated symptoms.

Tumor associated macrophages (TAMs) are recruited from the circulation to the tumor site, and can undergo a spectrum of phenotypic changes, with two contrasting activation states described in the literature: the M1 and M2 phenotypes. We previously identified a population of TAMs that express proliferating cell nuclear antigen (PCNA) and are associated with high grade, hormone receptor negative breast cancers and poor outcomes. In the present exploratory study we again found that high PCNA(+) TAM counts in pre-treatment tumor biopsies (102 invasive breast cancer cases from the I-SPY 1 Trial, a prospective neoadjuvant trial with serial core biopsies and gene array data) were associated with high grade, hormone receptor negativity, and decreased recurrence free survival. We explored the association of these PCNA(+) TAMs with the expression of M1 and M2 related genes and, contrary to expectation, observed that high PCNA(+) TAM levels were associated with more M1- than M2-related genes. An immune gene signature, derived from cytotoxic T cell and MHC Class II genes (Tc/ClassII), was developed and we found that high PCNA(+) TAM counts, in the context of a low Tc/ClassII signature score, were associated with significantly worse recurrence free survival in all cases and in hormone receptor negative only cases. We observed similar results using a gene signature-proxy for PCNA(+) TAMs in a larger independent set of 425 neoadjuvant-treated breast cancer cases. The results of this exploratory study indicate that high numbers of PCNA(+) TAMs, in the absence of an anti-tumor immune microenvironment (as indicated by a low Tc/ClassII signature score), are associated with poor outcomes in breast cancer patients treated with neoadjuvant chemotherapy. This, along with the observation that PCNA(+) TAMs were associated predominantly with M1-related genes, may provide new insights into the role of the immune microenvironment in breast cancer.

PURPOSE

We characterized the natural history of symptoms with time in patients with bladder cancer undergoing cystectomy.

MATERIALS AND METHODS

For 6 months we followed 33 participants treated with muscle invasive bladder cancer treatment with cystectomy in this prospective cohort study. Patients and family caregivers completed validated symptom assessment and satisfaction surveys at baseline, and 2, 4 and 6 months later. Primary outcomes were the change from baseline in pain, fatigue, depression, anxiety, quality of life and spiritual well-being. Secondary outcomes included posttraumatic growth, patient satisfaction and family caregiver burden.

RESULTS

Pain increased after radical cystectomy and remained increased 6 months postoperatively based on Brief Pain Inventory scores (baseline and 6-month scores 4.0, 95% CI 0-8.0 and 9.8, 95% CI 1.9-17.6, respectively, p = 0.03). Posttraumatic growth showed a trend toward an increase at 2 months (p = 0.06). Fatigue peaked at 4 months but did not change significantly with time (p = 0.12). There was similarly no significant change with time in depression, anxiety, quality of life, spiritual well-being or satisfaction. Neither family caregiver burden nor satisfaction showed a statistically significant change with time postoperatively.

CONCLUSIONS

Pain increased after radical cystectomy and remained increased 6 months postoperatively. There was a trend toward increased posttraumatic growth at 2 months. Otherwise, by 6 months cystectomy was associated with no improvement in preoperative symptoms of fatigue, quality of life, spiritual well-being, depression or anxiety. After cystectomy pain should be assessed and treated more aggressively in patients with bladder cancer and efforts should be made to improve postoperative symptoms.

BACKGROUND

There is wide variability in the degree of adherence to guideline recommendations among caregivers. Our aim was to determine the clinical impact of the 2006 guidelines from the American Thyroid Association (ATA) on the management of differentiated thyroid cancer (DTC) in the United States.

METHODS

The Surveillance, Epidemiology and End Results (SEER) database (2004-2009) was employed. Patients were divided into two groups based on receipt of care before (DTC 04-06) and after (DTC 07-09) the release of the 2006 ATA guidelines. Adherence was determined with a chi-square test and binary logistic regression. Survival was analyzed with the Kaplan-Meier method and log-rank test.

RESULTS

A total of 12,816 patients with DTC were identified between 2004 and 2006, and 14,514 between 2007 and 2009 (DTC 07-09). Adherence to Recommendation 26 (surgery) tended to increase in DTC 07-09 (82.2% vs. 83.2%, p=0.083). Factors associated with discordant practice among the DTC 07-09 group were older age, treatment in the Northeast, having more than one primary cancer, tumor size >4 cm, and follicular and Hürthle cell histologies. Factors associated with accordance were treatment in the Midwest, level II-VI metastases, having lymph nodes examined, AJCC Stage III, and presenting with distant metastases. Patients treated in accordance with Recommendation 26 showed prolonged disease-specific survival (p0.001). A trend toward more adherence to Recommendation 27 (lymphadenectomy) was observed over time (68.4% vs. 69.7%, p=0.065). Adherence to Recommendation 27 was not associated with disease-specific survival (p=0.539). Less discordance from guidelines was seen for cancers that were 2.1-4 cm, extrathyroidal, and greater than Stage I. Overall accordance with Recommendation 32 (radioactive iodine [RAI] ablation) increased in DTC 07-09 compared to DTC 04-06 (61.7% vs. 57.5% respectively, p0.001), and this was associated with improved disease-specific survival in DTC 07-09 (p0.001). Predictors of care discordant with guidelines were patient age ≥ 65 years, living in the Northeast, and not undergoing total thyroidectomy. Factors associated with RAI use in accordance with guidelines were married status, treatment in the South, and having more than one lymph node examined.

CONCLUSIONS

Care in accordance with evidence-based guidelines for DTC is associated with improved patient outcomes. Ongoing efforts should be undertaken to propagate guidelines to reduce variation in care and improve overall quality of care.