Changes in employment and household income during the 24 months following a cancer diagnosis

Goals of work  The purpose of the study was to describe the changes in employment and household income following a cancer diagnosis. Materials and Methods  Participants were 68 recent cancer survivors (6–24 months since diagnosis) aged 18 years or older who were employed full- or part-time prior to receiving a cancer diagnosis. Data were both quantitative and qualitative. Participants completed a mailed questionnaire about various issues faced by cancer survivors, including 36 questions about work, finances, and income. In addition, space was provided for participants to write optional narrative details about work experiences. Main Results  Before cancer, all 68 participants were employed, 45 full-time and 23 part-time. After completion of primary cancer treatment, 49 (72%) were employed (29 full-time and 20 part-time). A decrease in household income after cancer diagnosis was reported by 37% of participants. Of those who were the main income earners in their households prior to cancer, 26% were no longer the main earners after cancer. The qualitative data about work difficulties fell broadly into two areas: physical difficulties and attitudes of employers. Conclusions  Though limited by a comparatively small sample size, this study is the first to focus on employment in the very early survivorship period, using both questionnaire and qualitative data. The findings show that many individuals continue to work during and after treatment, though reduction of work hours or quitting work is not uncommon. The complex factors associated with work decisions are not easily assessed with questionnaires, and in-depth qualitative studies of recent cancer survivors are warranted.     

Washing hands before and after performing massages? Changes in bacterial survival count on skin of a massage therapist and a client during massage therapy

OBJECTIVE: Massage therapy involves direct contact between the therapist and the client in a clinical setting, which can result in the transfer of bacteria. The purpose of this study was to determine the degree of bacteria transfer between a therapist and a client during a massage session and differences between types of lubricants used. DESIGN: Medium cultures were taken from the therapist's palms and the client's skin before, during, and after the massage session. Experiments proceeded with the following settings: use of three different types of lubricants, without the use of a lubricant, and without massage as control. After each massage session, the therapist washed his or her hands and a bacterial sample was again taken. MAIN OUTCOME MEASURES: Changes in bacteria count. RESULTS: (1) Bacteria count on the therapist's palms increased during and after massage with and without the use of lubricant. There was no change in the case of no massage. (2) Bacteria count on the client's skin decreased during and after massage with the use of three different kinds of lubricants compared to the no-massage control. However, an increase was evident when no lubricant was used. (3) After hand washing with water for 20 seconds after each massage session, there were still bacteria on the therapist's palms. However, bacteria count differed with the type of lubricant used. CONCLUSION: Bacteria from the client's skin transferred to the therapist's hands during massage therapy. Bacteria count when no lubricant was used was greater than massage sessions using lubricants.     

Assessment of regional lung recruitment and derecruitment during a PEEP trial based on electrical impedance tomography

Objective To investigate whether electrical impedance tomography (EIT) is capable of monitoring regional lung recruitment and lung collapse during a positive end-expiratory pressure (PEEP) trial. Design Experimental animal study of acute lung injury. Subject Six pigs with saline-lavage-induced acute lung injury. Interventions An incremental and decremental PEEP trial at ten pressure levels was performed. Ventilatory, gas exchange, and hemodynamic parameters were automatically recorded. EIT and computed tomography (CT) scans of the same slice were simultaneously taken at each PEEP level. Measurements and results A significant correlation between EIT and CT analyses of end-expiratory gas volumes (r = 0.98 up to 0.99) and tidal volumes (r = 0.55 up to r = 0.88) could be demonstrated. Changes in global and regional tidal volumes and arterial oxygenation (PaO₂/FiO₂) demonstrated recruitment/derecruitment during the trial, but at different onsets. During the decremental trial, derecruitment first occurred in dependent lung areas. This was indicated by lowered regional tidal volumes measured in this area and by a decrease of PaO₂/FiO₂. At the same time, the global tidal volume still continued to increase, because the increase of ventilation of the non-dependent areas was higher than the loss in the dependent areas. This indicates that opposing regional changes might cancel each other out when combined in a global parameter. Conclusions EIT is suitable for monitoring the dynamic effects of PEEP variations on the regional change of tidal volume. It is superior to global ventilation parameters in assessing the beginning of alveolar recruitment and lung collapse.     

Changes in weight and metabolic parameters during treatment with antipsychotics and metformin: do the data inform as to potential guideline development? A systematic review of clinical studies

Background: Changes in weight and metabolic parameters have been commonly reported in patients with schizophrenia. Metformin has been evaluated in clinical studies to prevent or reduce weight gain and changes in metabolic parameters in non‐diabetic subjects. We undertook a systematic review of the efficacy and safety of metformin in reducing weight gain and metabolic abnormalities in non‐diabetic subjects with schizophrenia or bipolar disorder taking antipsychotic medication to establish if these data could potentially drive guideline development. Methods: Medical databases were searched using terms including ‘antipsychotic’, ‘atypical antipsychotic agent’, ‘antipsychotic agents’, ‘antipsychotic‐drug’ and ‘metformin’ and ‘weight’. Studies reporting weight and/or metabolic outcomes in non‐diabetic subjects with schizophrenia and bipolar disorder were included regardless of methodological type and subject age. Results: Nine randomised double‐blind studies and two open cohort studies evaluating metformin and changes in weight in trials up to 16 weeks were identified. In all, 495 participants received antipsychotics (mostly olanzapine), and three studies were in subjects aged < 18 years. The adult studies predominantly utilised non‐Caucasian subjects with chronic schizophrenia. Weight and lifestyle intervention programmes were provided to all cohorts in eight studies, which confounded interpretation of the data. In ten studies, the addition of metformin to antipsychotic treatment was associated with either significantly attenuated weight gain or weight loss compared with control groups. Nine studies measured various glucose parameters. In four studies, subjects prescribed metformin had significantly improved glucose parameters relative to controls. The two studies of metformin in patients with first‐episode schizophrenia demonstrated the largest improvement in weight and glucose parameters. Conclusions: Metformin may have some value in reducing or preventing weight gain and changes in metabolic parameters during treatment with antipsychotic medication particularly in first‐episode psychosis; however, it has been predominantly studied short‐term and in non‐Caucasian populations. A number of new trials are due to report data 2009–2013 to aid definitive interpretation of the role of metformin. Further longer‐term studies are warranted before definitive guidelines can be established.     

Cancer of unknown primary: addressing the communicative,ethical and medical challenges in clinical practice – a perspective from palliative care and supportive oncology

Abstract

Cancer of unknown primary (CUP) constitutes approximately 3–5% of all cancers and is the fourth leading cause of cancer death in females and males in developed countries. Despite its frequency, it remains a poorly understood entity in terms of its behaviour, investigation, management and prognosis. Physicians and allied professionals, especially those in palliative care, face unique ethical, communicative and medical challenges in the context of CUP. These challenges have not been specifically explored in the literature to date. This article illustrates these challenges in the form of a case report and discussion.     

Management of blood glucose in the critically ill in Australia and New Zealand: a practice survey and inception cohort study

Objective To document current management of blood glucose in Australian and New Zealand intensive care units (ICUs) and to investigate the association between insulin administration, blood glucose concentration and hospital outcome.Design and setting Practice survey and inception cohort study in closed multi-disciplinary ICUs in Australia and New Zealand.Patients Twenty-nine ICU directors and 939 consecutive admissions to 29 ICUs during a 2-week period.Measurement and results Data collected included unit approaches to blood glucose management, patient characteristics, blood glucose concentrations, insulin administration and patient outcomes. Ten percent of the ICU directors reported using an intensive insulin regimen in all their patients. In 861 patients (91.7%) blood glucose concentration was greater than 6.1 mmol/l, 287 (31.1%) received insulin, and the median blood glucose concentration triggering insulin administration was 11.5 (IQR 9.4–14) mmol/l. Univariate analysis demonstrated that non-survivors had a higher maximum daily blood glucose concentration (12 mmol/l, 9.4–14.8, vs. 9.5, 7.6–12.2) and were more likely to receive insulin (47% vs. 28%). Multiple logistic regression analysis showed age (OR per 5-year decrease 0.93, 95% CI 0.87–1.00) and APACHE II (OR per point decrease 0.87, 95% CI 0.84–0.90) to be independently associated with hospital mortality. After controlling for age and APACHE II both daily highest blood glucose (OR 0.95, 95% CI 0.90–1.00) and administration of insulin (OR 0.62, 95% CI 0.39–1.00) were independently associated when added to the model alone; neither was independently associated when they were simultaneously included in the model.Conclusion Few Australian and New Zealand ICUs have adopted intensive insulin therapy. In this study, insulin administration and highest daily blood glucose concentration could not be separated in their association with hospital mortality.Electronic supplementary material The electronic reference of this article is . The online full-text version of this article includes electronic supplementary material. This material is available to authorised users and can be accessed by means of the ESM button beneath the abstract or in the structured full-text article. To cite or link to this article you can use the above reference.     

Outcome research in palliative care: could it represent a new dimension of clinical research or clinical practice?

Outcome research is a new dimension of clinical research, and all fields of clinical medicine are involved in this kind of analysis. Overall survival and quality of life are the main outcomes identified in clinical oncology. The former must be the main outcome whenever possible; the latter has to be the main outcome when an improvement of overall survival cannot be expected. It follows that quality of life is the main outcome of palliative care, in which the patient instead of the disease represents the target of the clinical approach. In our critical paper, we review the meaning of clinical outcomes in palliative care, classifying the outcomes as main and surrogate outcomes, and the results of the trials as indexes of activity and efficacy of a treatment. We also review the main randomized clinical trials on the treatment of cancer cachexia, trying to define the role of the treatments in cachexia-related symptom control and quality of life improvement. Strictly related to outcome analysis is the dimension of pharmacoeconomic evaluation. The models of the different designs of pharmacoeconomic analysis are revisited in an attempt to conjugate the pharmacoeconomic evaluation with the particular dimension of palliative care.     

Chemotherapy-induced nausea and vomiting in clinical practice: impact on patients’ quality of life

Background

Chemotherapy-induced nausea and vomiting (CINV) in cancer patients are common symptoms most feared by patients. The aim of this study was to analyze the impact of CINV associated to moderate/highly emetogenous chemotherapy regimens on patients’ quality of life (QoL).

Patients and methods

Open, multicenter, prospective observational study was performed. Each patient filled out a patient diary for each cycle from the day before chemotherapy and for the next 5?days that included the number of emetic episodes, the intensity of nausea, and QoL evaluation (functional living index-emesis questionnaire).

Results

Data from 202 consecutive patients from nine university hospitals were collected, but only data from 160 were analyzed (79.2?%). Most of the participants (70?%) were women with a mean age of 50?years (SD 1.2?years). The most frequent cancer site was breast (44?%) followed by lung (16?%) and 76.3?% were receiving highly emetogenous chemotherapy. Despite the use of antiemetic prophylaxis, patients experienced significant nausea and vomiting during 31?% (3.2?% during acute, 15.0?% during delayed phase, and 13.2?% during both phases) and 45.1?% (5.1?% only during the acute phase, 23.5?% only during the delayed phase and 16.5?% during both phases) of the cycles, respectively, having 44.5?% (nausea) and 39.3?% (emesis) of the cycles an impact on patients’ QoL.

Conclusions

The results of the study confirm the detrimental effect of CINV on patients’ QoL despite the use of antiemetic prophylaxis (5HT₃ receptor antagonist, steroids, and dopamine receptor antagonists). It is mandatory to intensify the detection of CINV in order to improve the management of these important, albeit frequent, side effects of cancer treatments.     

The combination of a heat and moisture exchanger and a Booster TM: a clinical and bacteriological evaluation over 96 h

OBJECTIVE: To determine whether the combination with a new device (Booster ) for active humidification improves the efficacy of a hydrophobic heat and moisture exchanger (HME). DESIGN AND SETTING: Prospective, interventional study in the ICU of a university hospital. PATIENTS: Consecutive patients requiring controlled mechanical ventilation INTERVENTIONS: Patients were ventilated with a HME, and a Booster was added for 96 h to the ventilatory circuit. MEASUREMENTS AND RESULTS: During the inspiration phase the following factors were measured: peak and mean airway pressures, maximal (beginning of inspiration), minimal (end of inspiration), and mean values of temperature of inspired gases, and relative and absolute humidity of inspired gases. Microbiological samples were obtained from the Booster, the ventilator side of the HME, and the tracheal secretions on days 1 and 4. Minimal and mean temperatures were increased as soon as the Booster was used and this increase was maintained for 96 h until the Booster was withdrawn. Then the temperature returned to baseline values. Absolute humidity values followed the same course. There was also some indirect evidence of very little, if any, changes in the HME resistance. The ventilatory side of the HMEs remained sterile in each patient, and the Booster was colonized by the same bacteria as those in the tracheal secretions. CONCLUSIONS: Adding the Booster to a hydrophobic HME improved the heat and water preservation of ventilatory gas.     

Dehydroepiandrosterone: a modulator of cellular immunity and heat shock protein 70 production during polymicrobial sepsis

Objective DHEA is an immunomodulatory steroid hormone that improves survival during systemic inflammation. A DHEA-induced modulation of heat shock protein response may be an alternative mechanism contributing to the beneficial effects of this hormone. We investigated the effect of DHEA administration on survival, cellular immune functions, and HSP-70 production in septic mice. Design and setting Randomized animal study, level I trauma center, university research laboratory. Subjects Male NMRI mice. Interventions Mice were subjected to sham operation (laparotomy, LAP) or sepsis (cecal ligation and puncture, CLP) with or without administration of either saline 0.9% (LAP, CLP) or 20 mg/kg DHEA subcutaneously (LAP/DHEA, CLP/DHEA). Survival was monitored over a 48-h period. Splenocyte apoptosis rate (AnnexinV binding), splenocyte proliferation ([³H]thymidine incorporation), TNF-α plasma concentration (ELISA), and HSP-70 concentration (ELISA) in tissue extracts from liver, lung, and spleen were monitored 48 h after onset of sepsis. Results DHEA administration improved the survival of septic mice (78% vs. 50%). This effect was paralleled by increased splenocyte proliferation, decreased cellular apoptosis rate of splenocytes, and attenuation of TNF-α release. Furthermore, an increased HSP-70 concentration was observed in lungs and spleens of DHEA-treated septic animals. Conclusions DHEA-treatment decreased the mortality rate of septic mice. This was accompanied by improved cellular immune functions and an augmented heat shock response (HSP-70) of lungs and spleens. Further studies are required to demonstrate a direct relationship between the improved survival and the observed alterations in the immune system in DHEA-treated animals.     

Withholding and withdrawing life support from the critically ill: how does it work in clinical practice?

Withholding and withdrawing life support from the critically ill commonly occurs in clinical practice. Sedatives and analgesics are frequently given during this process to patients who are not so deeply comatose that they cannot benefit from them. The withholding and withdrawal of life support is compatible with several judicial decisions, including the recent Cruzan decision of the U.S. Supreme Court. Recent studies are providing insights into how, why, and under what circumstances the withholding and withdrawal of life support take place, and how drugs are administered during these processes. Additional studies are needed to further elucidate these processes and to contribute to the shaping of realistic and humane standards of terminal care.     

Epidemiology of sepsis in Germany: results from a national prospective multicenter study

Objective To determine the prevalence and mortality of ICU patients with severe sepsis in Germany, with consideration of hospital size. Design Prospective, observational, cross-sectional 1-day point-prevalence study. Setting 454 ICUs from a representative nationwide sample of 310 hospitals stratified by size. Data were collected via 1-day on-site audits by trained external study physicians. Visits were randomly distributed over 1 year (2003). Patients Inflammatory response of all ICU patients was assessed using the ACCP/SCCM consensus conference criteria. Patients with severe sepsis were followed up after 3 months for hospital mortality and length of ICU stay. Measurements and results Main outcome measures were prevalence and mortality. A total of 3,877 patients were screened. Prevalence was 12.4% (95% CI, 10.9–13.8%) for sepsis and 11.0% (95% CI, 9.7–12.2%) for severe sepsis including septic shock. The ICU and hospital mortality of patients with severe sepsis was 48.4 and 55.2%, respectively, without significant differences between hospital size. Prevalence and mean length of ICU stay of patients with severe sepsis were significantly higher in larger hospitals and universities (≤ 200 beds: 6% and 11.5 days, universities: 19% and 19.2 days, respectively). Conclusions The expected number of newly diagnosed cases with severe sepsis in Germany amounts to 76–110 per 100,000 adult inhabitants. To allow better comparison between countries, future epidemiological studies should use standardized study methodologies with respect to sepsis definitions, hospital size, and daily and monthly variability. The named authors wrote this article on behalf of the German Competence Network Sepsis (SepNet) C. Engel and F. M. Brunkhorst contributed equally to this work     

Disparity between skin perfusion and sublingual microcirculatory alterations in severe sepsis and septic shock: a prospective observational study

OBJECTIVE: Measurement of central-to-toe temperature difference has been advocated as an index of severity of shock and as a guide for circulatory therapy in critically ill patients. However, septic shock, in contrast to other forms of shock, is associated with a distributive malfunction resulting in a disparity between vascular compartments. Although this disparity has been established between systemic and microcirculatory parameters, it is unclear whether such disparity exists between skin perfusion and microcirculation. To test this hypothesis of disparity, we simultaneously measured parameters of the two vascular compartments, in the early phase of sepsis. DESIGN: Prospective observational study in patients with severe sepsis/septic shock in the first 6 h of ICU admission. Simultaneous measurements of central-to-toe temperature difference and sublingual microcirculatory orthogonal polarization spectral imaging, together with parameters of systemic hemodynamics. SETTING: 22 bed mixed-ICU in a tertiary teaching hospital. PATIENTS: 35 consecutive patients in a 12-month period. MEASUREMENTS AND RESULTS: In 35 septic patients and a median APACHE II score of 20, no correlation between central-to-toe temperature gradient and microvascular flow index was observed (r (s) = -0.08, p =0.65). Also no significant correlation between temperature gradient/microvascular flow index and systemic hemodynamic parameters could be demonstrated. CONCLUSIONS: During the early phase of resuscitated severe sepsis and septic shock there appears to be no correlation between sublingual microcirculatory alterations and the central-to-toe temperature difference. This finding adds to the concept of a dispersive nature of blood flow under conditions of sepsis between microcirculatory and systemic hemodynamics.