Predictors of quality of life in head and neck cancer survivors up to 5 years after end of treatment: a cross-sectional survey

Purpose

This study aimed to assess quality of life (QoL) in head and neck cancer (HNC) survivors and determine factors predictive of poor QoL in the first 5 years after the end of treatment.

Methods

A cross-sectional survey, including the Quality of Life in Adult Cancer Survivors (QLACS) measure, was sent to HNC survivors in three Scottish health regions, with responses linked to routinely collected clinical data. Independent sample t tests, ANOVAs, Pearson correlations and multiple hierarchical regressions were used to explore associations between and to determine the contribution made by demographic, lifestyle and clinical factors to predicting ‘generic’ and ‘cancer-specific’ quality of life.

Results

Two hundred eighty patients (65 %) returned questionnaires. After adjustment, multivariate analysis showed that younger age, lower socio-economic status, unemployment and self-reported comorbidity independently contributed to poorer generic and cancer-specific quality of life. In addition to these factors, having had a feeding tube or a diagnosis of oral cavity cancer were independently predictive of poorer cancer-specific quality of life.

Conclusions

Socio-economic factors and comorbidity are important predictors of QoL in HNC survivors. These factors and the detrimental long-term effects of feeding tubes need further attention in research and practice.

     

Role of oncologists and primary care physicians in providing follow-up care to non-Hodgkin lymphoma survivors within 5 years of diagnosis: a population-based study

Purpose

The growing population of non-Hodgkin lymphoma (NHL) survivors living longer with high physical and psychological treatment burden, in combination with the projected shortage of medical professionals, necessitates redesigning cancer follow-up care. This study examined follow-up care patterns, factors associated with follow-up care, and attitudes towards follow-up care among NHL survivors.

Methods

We surveyed survivors of aggressive NHL 2 to 5 years post-diagnosis (N?=?363) using a population-based sample from the Los Angeles County Surveillance Epidemiology and End Results registry.

Results

Most survivors (82 %) received cancer-related follow-up care in the past year from an oncologist. History of recurrence, more comorbidities, more symptoms, and a shorter survivor–oncologist relationship were associated with high-frequency care with the oncologist [(≥5 visits in the past year), p?<?0.05]. Many survivors followed up by oncologists (71 %) also saw a primary care provider (PCP) and 47 % also saw both a PCP and other specialists. Factors associated with seeing a PCP in addition to an oncologist included more symptoms, more health information needs, no history of recurrence, perceived excellent quality of cancer follow-up care, and fewer visits with the oncologist (p?<?0.05). Survivors generally reported high reassurance from, and low negative anticipation towards, follow-up care.

Conclusions

The high proportion of NHL survivors receiving care from multiple physicians, and the sizable proportion (～30 %) who have not recently seen a PCP, suggests that coordinating care across specialties is critical to ensure comprehensive, non-duplicative care. Understanding factors associated with cancer-related follow-up is a first step towards more effective, efficient, patient-centered care.     

Subacute Cutaneous Lupus Erythematosus: Clinical Characteristics,Disease Associations,Treatments, and Outcomes in a Series of 90 Patients at Mayo Clinic, 1996-2011

Objective

To characterize the clinical presentation, laboratory studies, disease associations, and treatments of subacute cutaneous lupus erythematosus (SCLE).

Approach to Complications of Ventricular Assist Devices: A Clinical Review for the Emergency Provider

BackgroundHeart failure is a major public health problem in the United States. Increasingly, patients with advanced heart failure that fail medical therapy are being treated with implanted ventricular assist devices (VADs).ObjectiveThis review provides an evidence-based summary of the current data for the evaluation and management of implanted VAD complications in an emergency department context.DiscussionWith a prevalence of >5.8 million individuals and >550,000 new cases diagnosed each year, heart failure is a major public health problem in the United States. Increasingly, patients with advanced heart failure that fail medical therapy are being treated with implanted VADs. As the prevalence of patients with VADs continues to grow, they will sporadically present to the emergency department, regardless of whether the facility is a designated VAD center. As a result, all emergency physicians must be familiar with the basic principles of VAD function, as well as the diagnosis and initial management of VAD-related complications. In this review, we address these topics, with a focus on contemporary third-generation continuous flow VADs. This review will help supplement the critical care skills of emergency physicians in managing this complex patient population.ConclusionsThe cornerstone of managing the unstable VAD patient is rapid initiation of high-quality supportive care and recognition of device-related complications, as well as the identification and use of specialist VAD teams and other resources for support. Emergency physicians must understand VADs so that they may optimally manage these complex patients.     

Using Neuroleptics to Treat Delirium in Dying Cancer Patients at a Cancer Center in Saudi Arabia

Neuroleptics are commonly used for treating delirium as a common problem in terminally ill cancer patients. However, prescribing patterns are believed to substantially vary among health professionals. The aim of this study is to determine the pattern of prescribing neuroleptics for treating delirium in cancer patients dying in a palliative care unit in Saudi Arabia. We reviewed the medical records of adults with advanced cancer who died in the palliative care unit over 23 months. In addition to patients’ demographics, data collection included the pattern of prescribing neuroleptics for the treatment of delirium during the last week of life. For the 271 patients included (57.6% females), the median age was 54 years. Although 62% of patients were on around-the-clock (ATC) neuroleptics to treat delirium, about two thirds of these were requiring rescue doses (PRN [pro re nata]) as well. The ATC neuroleptics included haloperidol alone (89.3%), levomepromazine alone (2.4%), or both (8.3%). All neuroleptics were administered via the parenteral route. On average, the maximum daily doses of the ATC neuroleptics were 4 mg for haloperidol and 15.5 mg for levomepromazine. Patients with primary or metastatic brain cancers were less likely to be on neuroleptics (P < .0001). The authors conclude that in their palliative care unit, haloperidol is by far the most commonly used neuroleptic, followed by levomepromazine, to treat the common problem of delirium in patients dying with advanced cancer. The generally low doses of neuroleptics required may be attributed to several factors in this population, including cultural motives.     

Safety and efficacy of the LAP-BAND AP® adjustable gastric band in the treatment of obesity: results at 2 years

Background: The objective of this analysis is to report interim, 2-year results for morbidly obese patients who have undergone laparoscopic adjustable gastric banding in the LAP-BAND AP? EXperience (APEX) trial. Methods: The APEX trial is an ongoing, multicenter, prospective, open-label, 5-year study of the LAP-BAND AP? System (LBAP) in 517 morbidly obese patients at 50 clinical centers in the United States. Last observation carried forward was used in the analyses of change in body weight and comorbid conditions, and observed data were analyzed for the Obesity and Weight-Loss Quality of Life (OWLQOL) questionnaire. Changes in body weight, percent weight loss, percent excess weight loss, body mass index (BMI), OWLQOL score, remission or improvement in obesity-related comorbid conditions, and adverse events were reported. Results: At baseline, 81.5% of patients were female, and 85.8% were white. The mean age was 42.5 years, and the mean BMI was 44.0 kg/m2. More than 85% of patients had ≥ 1 obesity-related comorbidity. At 2 years, the mean BMI change was -8.5 kg/m2, and the mean percent weight loss was -19.3%. Responses to all questions on the OWLQOL questionnaire had a mean improvement of 54% (range, 26%-67%) at 2 years. Obesity-related comorbid conditions were remitted or improved in the majority of patients at 2 years, including type 2 diabetes mellitus (96%), hypertension (91%), gastroesophageal reflux disease (91%), hyperlipidemia (77%), obstructive sleep apnea (86%), depression (75%), and osteoarthritis (93%). The LBAP and its implantation were well tolerated, with 19.1% and 6.0% of patients reporting device-related adverse events or serious device-related adverse events, respectively. Conclusion: The LBAP safely and effectively facilitated weight loss in morbidly obese patients, with clinically meaningful improvements in quality of life and obesity-related comorbidities. The durability of these results will be further described with additional follow-up through 5 years. Trial registration: www.ClinicalTrials.gov identifier NCT00501085.     

Measuring the Psychosocial Dimensions of Quality of Life in Patients With Advanced Cancer: Psychometrics of the German Quality of Life at the End of Life-Cancer-Psychosocial Questionnaire

Context

Quality of life (QoL) is a central focus of care in advanced cancer. Specialized instruments, such as the Quality of Life at the End of Life-Cancer (QUAL-EC), may be useful to assess psychosocial issues associated with QoL unique to this population.

Single-session alcohol sclerotherapy of symptomatic liver cysts using 10–20 min of ethanol exposure: no recurrence at 2–16 years of follow-up

Purpose

To assess long-term results after single-session alcohol sclerotherapy of symptomatic benign liver cysts performed with maximum 20 min of exposure to alcohol.

Methods

We included 47 patients aged 32–88 years (42 women, 5 men) with 51 benign non-parasitic liver cysts that were exposed to ethanol for 7–20 min in a single sclerotherapy session and were followed for at least 24 months. Each cyst was emptied before injecting ethanol (10% of cyst volume, but maximum 100 mL) into it. The patient rotated from side to side to facilitate contact between ethanol and the whole cyst wall. Pre-treatment cyst volume was defined as the volume of aspirated cyst fluid after complete emptying of the cyst. Follow-up cyst volume was estimated based on computed tomography images.

Results

Cyst volumes were 30–4900 (median 520) mL at pre-treatment and 0–230 (median 1) mL at 24–193 (median 56) months follow-up, a reduction of 83–100% (median 99.7%). No cyst required repeated treatment during the follow-up. Median volume reduction was 99.7% at median 49 months of follow-up for 35 cysts exposed to ethanol for 7–10 min vs. 99.6% at median 75 months of follow-up for 16 cysts exposed for 20 min (p = 0.83, Mann–Whitney test). Ethanol intoxication occurred in one patient. There were no other complications except for pain.

Conclusion

Long-term results of single-session alcohol sclerotherapy performed with maximum 20 min of exposure to ethanol were satisfactory with no sign of recurrence of cyst fluid.

     

Clinical Characteristics and Outcomes of “Silent” and “Non-Silent” Peritonitis in Patients on Peritoneal Dialysis

♦ Objectives: We compared the clinical characteristics and outcomes of “silent” peritonitis (meaning episodes without fever and abdominal pain) and “non-silent” peritonitis in patients on peritoneal dialysis (PD).♦ Methods: Our cohort study collected data about all peritonitis episodes occurring between January 2008 and April 2010. Disease severity score, demographics, and biochemistry and nutrition data were recorded at baseline. Effluent cell counts were examined at regular intervals, and the organisms cultured were examined. Treatment failure was defined as peritonitis-associated death or transfer to hemodialysis.♦ Results: Of 248 episodes of peritonitis occurring in 161 PD patients, 20.9% led to treatment failure. Of the 248 episodes, 51 (20.6%) were not accompanied by fever and abdominal pain. Patients with these silent peritonitis episodes tended to be older (p = 0.003). The baseline values for body mass index, triglycerides, and daily energy intake were significantly lower before silent peritonitis episodes than before non-silent episodes (p = 0.01, 0.003, and 0.001 respectively). Although silent peritonitis episodes were more often culture-negative and less often caused by gram-negative organisms, and although they presented with low effluent white cell counts on days 1 and 3, the risk for treatment failure in those episodes was not lower (adjusted odds ratio: 1.33; 95% confidence interval: 0.75 to 2.36; p = 0.33).♦ Conclusions: Silent peritonitis is not a rare phenomenon, especially in older patients on PD. Although these episodes were more often culture-negative, silent presentation was not associated with a better outcome.Key words: Peritonitis, outcomesPeritonitis, a common complication of peritoneal dialysis (PD), contributes to treatment failure, hospitalization, and death. It is important to diagnose PD-associated peritonitis and to initiate empiric antibiotic therapy as early as possible to prevent those serious consequences (1). Peritonitis is defined based on the presentation of symptoms, peritoneal effluent cell count, and culture of micro-organisms. Patients have to recognize their symptoms—including cloudy effluent, fever, and abdominal pain—early in the onset of peritonitis. Awareness of the symptoms of peritonitis is a key precondition for obtaining an effluent cell count and culture to promptly make the diagnosis, especially for patients who live far from the hospital and who cannot easily send dialysate samples to a lab.In fact, the symptoms of peritonitis vary in severity across the PD population. In pediatric PD patients, disease severity scores (DSSs) at the onset of peritonitis are calculated as a points total for pain and fever (2-5). The range shows that some patients might present with cloudy effluent alone, and some might complain of severe abdominal pain or high fever, or both.In most PD centers, DSS is not a routine measurement tool for PD-related peritonitis in adults. The DSS range for the adult PD population is not known, but we recognized that abdominal pain and fever might be absent at the onset of some peritonitis episodes. Here, we refer to those peritonitis episodes as “silent” peritonitis episodes. We coined the term silent peritonitis for this phenomenon because patients do not complain of fever or abdominal pain, and yet they have peritonitis. By contrast, we refer to peritonitis episodes with varying extents of fever and abdominal pain as “non-silent”peritonitis.Because previous studies reported that an absence of fever in bacteremic community-acquired pneumonia predicts a worse outcome in elderly individuals (6,7), comparisons of the clinical characteristics and outcomes in silent and non-silent peritonitis in the PD population are of interest. In the present study, we addressed that issue in a single-center cohort of patients presenting with incident episodes of peritonitis. Specifically, we set out to determine the clinical characteristics (including demographics, biochemical and nutrition indices, effluent cell counts, and causative organisms) and final outcomes associated with these two types of peritonitis.     

Multicenter Evaluation of the Clinical Outcomes of Daptomycin with and without Concomitant β-Lactams in Patients with Staphylococcus aureus Bacteremia and Mild to Moderate Renal Impairment

Patients with underlying renal disease may be vulnerable to vancomycin-mediated nephrotoxicity and Staphylococcus aureus bacteremia treatment failure. In light of recent data demonstrating the successful use of β-lactam plus daptomycin in very difficult cases of S. aureus bacteremia, we examined safety and clinical outcomes for patients who received daptomycin with or without concomitant β-lactams. We identified 106 patients who received daptomycin for S. aureus bacteremia, had mild or moderate renal insufficiency according to FDA criteria, and enrolled in the Cubicin Outcomes Registry and Experience (CORE), a multicenter registry, from 2005 to 2009. Daptomycin treatment success was 81%. Overall treatment efficacy was slightly enhanced with the addition of a β-lactam (87% versus 78%; P = 0.336), but this trend was most pronounced for bacteremia associated with endocarditis or bone/joint infection or bacteremia from an unknown source (90% versus 57%; P = 0.061). Factors associated with reduced daptomycin efficacy (by logistic regression) were an unknown source of bacteremia (odds ratio [OR] = 7.59; 95% confidence interval [CI] = 1.55 to 37.2), moderate renal impairment (OR = 9.11; 95% CI = 1.46 to 56.8), and prior vancomycin failure (OR = 11.2; 95% CI = 1.95 to 64.5). Two patients experienced an increase in creatine phosphokinase (CPK) that resolved after stopping daptomycin. No patients developed worsening renal insufficiency related to daptomycin. In conclusion, daptomycin appeared to be effective and well tolerated in patients with S. aureus bacteremia and mild to moderate renal insufficiency. Daptomycin treatment efficacy might be enhanced with β-lactam combination therapy in primary endovascular and bone/joint infections. Additional studies will be necessary to confirm these findings.     

Treatment Effect in Earlier Trials of Patients With Chronic Medical Conditions: A Meta-Epidemiologic Study

Objective

To determine whether the early trials in chronic medical conditions demonstrate an effect size that is larger than that in subsequent trials.

Prognosis of patients aged 80 years and over admitted in medical intensive care unit

Objective To determine the prognostic indicators of long-term survival after admission to a medical intensive care unit (MICU) for patients aged 80 years and over.Design Prospective cohort study.Setting A 14-bed MICU in a 970-bed, acute care, tertiary, university hospital in Paris, France.Patients A total of 233 patients aged 80 years and over discharged from a MICU during a 2-year period.Measurements and main results Severity at admission was estimated using the Simplified Acute Physiology Score. The underlying condition was classified using the MacCabe classification. The functional status was assessed using the Knaus classification. The outcome after MICU discharge was determined after a median 2-year follow-up. The functional outcome was assessed by telephone interviews, employing the Instrumental Activities of Daily Living (IADL). The in-MICU mortality was 19.5% including death occurring during the 2 days following discharge. The long-term survival rates for patients admitted to the MICU were 59% at 2 months, 33% at 2 years, and 29% at 3 years. The multivariate analysis identified two prognostic factors of death after discharge: presence of an underlying fatal disease (HR 1.7; 95% CI 1.1–2.6) and severe functional limitation (HR 1.7; 95% CI 1.2–2.6). The IADL was excellent or good for 56% of the surviving patients.Conclusion Long-term survival after MICU is mainly related to the underlying condition, whereas known factors for in-MICU survival do not influence long-term prognosis.