Mirtazapine improves sleep and lowers anxiety and depression in cancer patients: superiority over imipramine

Goals of the work  This study aimed to compare the effectiveness of mirtazapine and imipramine on not only the distressing symptoms of cancer patients such as pain, nausea, vomiting, appetite loss, and sleep disturbances but also depressive and anxiety symptoms. Materials and methods  Fifty-three patients with cancer who were diagnosed with major depressive disorder, anxiety disorder, or adjustment disorder were included. Twenty patients on mirtazapine, 13 patients on imipramine, and 20 patients in the control group without medication were interviewed during three visits (baseline, third week, and sixth week). Pain, nausea, vomiting, appetite loss, and sleep disturbances were evaluated with self-assessment single-symptom scales during each visit. The patients were also asked to complete the Hospital Anxiety Depression Scale (HADS) during each visit. Main results  There were no significant differences among the three visits in the mirtazapine, imipramine, or control groups in terms of pain, nausea, vomiting, or appetite loss. For the initial, middle, and late insomnia, only the mirtazapine group showed improvements (p = 0.001, p = 0.001, p = 0.003). There were also significant differences in the mean total (p = 0.03), anxiety (p = 0.003), and depression (p = 0.025) scores of HADS among the three visits for patients taking mirtazapine. There were no significant differences for HADS scores from the baseline to the end point for patients taking imipramine or control group patients. Conclusion  Our findings suggest that mirtazapine is effective for resolving insomnia as well as anxiety and depressive symptoms in cancer patients. However, more systematic research, such as placebo-controlled studies, is needed.     

The symptom experience in the first 100 days following allogeneic hematopoietic stem cell transplantation (HSCT)

Goals of work  Despite advances in allogeneic hematopoietic stem cell transplantation (HSCT), post-transplant complications are common, and patients’ symptom experience has not been well documented. Purpose  To characterize the symptom experience of adult patients pre-transplantation and days 0, 30, and 100 after allogeneic HSCT. Methods  Data from 76 participants enrolled in a prospective health-related quality of life (HRQL) study were used. Symptom occurrence, distress, and clusters were determined based on the 11 symptoms of the Symptom Distress Scale (SDS). Results  Participants were on average 40 years old (SD ± 13.5). The majority (54%) received reduced intensity conditioning. Prevalent symptoms included fatigue (68%) and worry (68%) at baseline, appetite change (88%) at day 0, and fatigue at days 30 (90%) and 100 (81%). Participants reported the following symptoms as severely distressing: worry (16%) [baseline], insomnia (32%) [day 0], appetite change (22%) [day 30], and fatigue (11%) [day 100]. The total SDS score was highest at day 0 (M = 26.6 ± 7.6) when the highest number of symptoms were reported [median = 8 (1–11)]. Symptoms formed clusters comprised of fatigue, appearance change, and worry at baseline, and fatigue, insomnia, and bowel changes at days 0 and 30. Compared to those with low symptom distress, participants with moderate/severe symptom distress reported poorer HRQL. Conclusion  Allogeneic HSCT patients present for transplantation with low symptom distress yet experience multiple symptoms and high symptom distress after HSCT conditioning. Understanding the symptom experience of allogeneic HSCT patients can guide management strategies and improve HRQL.     

Needs of developing the skills of palliative care at the oncology ward

Background To clarify the prevalence and severity of the symptoms, 203 consecutive patients with breast, prostate and other cancers treated mainly for palliation were surveyed. Materials and methods The series includes 116 men and 87 women with the mean age of 65 years (range 27–86 years). The patients filled-up the Edmonton Symptom Assessment System (ESAS) questionnaire with 11 items describing cancer-related symptoms in the visual analogue scale (VAS). Results Altogether, 98% of the patients reported at least 1 of the 10 symptoms. There was a significant difference in the score frequencies between the 10 symptoms (p = 0.0001), fatigue receiving the highest frequency (50.8%) of the high scores. Fatigue was also the single most frequent symptom reported by 86.3% of the patients, followed by pain at effort (71.5%), sleeplessness (71.1%) and depression (59.0%). The most disturbing syndrome was pain (n = 48, 23.9%), followed by fatigue (n = 28, 13.9%), depression (9.5%) and dyspnoea (6.0%). Altogether, 75% had more than 5 symptoms and 10% reported all 10 symptoms. The total number of symptoms was not significantly associated with sex (p = 0.781) or age (p = 0.062), but it was associated with the diagnostic group; patients with breast cancer (n = 41) and those with prostate cancer (n = 44) reported fewer symptoms than the patients with other cancers (n = 116)(p = 0.023, Kruskal–Wallis). Conclusions Symptoms related to cancer are common among patients treated with palliative indication, but if not specifically surveyed, may remain un-detected and un-treated. ESAS as a clinical tool brings more symptoms to the attention of the physicians and helps in getting a comprehensive insight into the patient’s problems.     

Performance of Integrated FDG-PET/CT for Differentiating Benign and Malignant Lung Lesions -Results from a Large Prospective Clinical Trial

Purpose The purpose of the study was to evaluate prospectively whether integrated 2-deoxy-2-[¹⁸F]fluoro-d-glucose positron emission tomography/computed tomography (FDG-PET/CT) is more accurate for determination of malignancy in newly diagnosed pulmonary lesions compared to separate interpretation of CT and FDG-PET. Procedures Two hundred and seventy-six patients with newly diagnosed lung lesions underwent FDG-PET/CT. Helical CT, FDG-PET, and FDG-PET/CT were interpreted separately to determine the performance of each imaging modality. Histopathology served as reference in all patients, and in further 60 patients, a benign lesion was verified at follow-up (mean follow-up of 1,040 days). Results Histology revealed malignant lung tumors in 216 of 276 patients. With PET and PET/CT, a significantly lower number of lesions were classified as equivocal compared to CT alone (p < 0.001). Assuming that equivocal lesions are benign, performance of diagnostic tests was as follows: sensitivity, specificity, and accuracy for CT was 94, 75, and 90%, for PET 97, 83, and 94% (p = 0.021), and for PET/CT 96, 87, and 94% (p = 0.010). Assuming that equivocal lesions are malignant, sensitivity, specificity, and accuracy for CT was 99, 37, and 86%, for PET 99, 77, and 94% (p < 0.001), and for PET/CT 98, 68, and 92% (p = 0.002). PET and PET/CT showed the highest concordance (K = 0.912; confidence interval 0.866–0.958). In lesions less than or equal to 3 cm, there was a significant difference in the performance of PET alone and multidetector row CT as well as PET/CT and multidetector row CT (p = 0.007), irrespective if equivocal findings were judged as malignant or benign. Conclusion For differentiation of benign from malignant lung lesions, integrated FDG-PET/CT imaging was significantly more accurate than CT but not FDG-PET. The addition of metabolic imaging (FDG-PET) to morphological imaging (CT) leads to an increase in specificity and significantly reduced equivocal findings and is therefore recommended to further specify newly diagnosed lung lesions. Sandra Pauls and Andreas K. Buck equally contributed. An erratum to this article can be found at     

Introduction to the Proceedings of the 2nd World Molecular Imaging Congress

Purpose  To demonstrate the presence of endothelial dysfunction (ED) in asymptomatic patients with type 2 diabetes mellitus (DM) by using ¹³N-ammonia–positron emission tomography (PET). PET can identify ED by quantifying myocardial blood flow (MBF) during rest, cold pressor test (CPT), and pharmacologic stress. The endothelial-dependent vasodilation index (EDVI), myocardial flow reserve (MFR), and the percentage of the change between rest and CPT (%ΔMBF) are markers of endothelial function. Procedures  Thirty-nine subjects were studied (19 women and 20 men); 22 recently diagnosed type 2 diabetic patients and 17 healthy controls (HC). A three-phase ¹³N-ammonia–PET was performed. Results  Mean EDVI was 1.208 ± 0.34 vs. 1.55 ± 0.37 (diabetic vs. HC group, respectively) (p = 0.002), MFR was 2.803 ± 1.39 vs. 3.27 ± 0.72 (p = NS), and the %ΔMBF was 20 ± 34% vs. 55 ± 37% (p = 0.002). Rest MBF and CPT MBF were normalized to the rate pressure product (RPP). EDVI′ and %ΔMBF′ were calculated using the corrected values for the RPP. Mean EDVI′ was (0.864 ± 0.250 vs. 1.110 ± 0.238, p = 0.004) and mean %ΔMBF′ was (−8.2 ± 14.7% vs. 4.5 ± 12.1%, p = 0.005). Conclusions  Asymptomatic, recently diagnosed type 2 diabetes patients present ED that can be quantified by ¹³N-ammonia–PET.     

Ampicillin/sulbactam for children hospitalized with community-acquired pneumonia

Childhood community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality worldwide, but studies on the treatment of children hospitalized with CAP are limited. Although ampicillin/sulbactam is frequently used to treat the pediatric population there are very limited data about the effect of the parenteral form for childhood CAP. Hence, a retrospective study was conducted to assess clinical response to empirical parenteral ampicillin/sulbactam among children hospitalized with CAP. A total of 501 children with presumed bacterial etiology and treated with intravenous ampicillin/sulbactam were included in the study. Treatment was defined as failure if the initial ampicillin/sulbactam therapy was changed because of no clinical improvement 72 h or more after its use or clinical worsening at any time. Thirty-one (6.2%) children needed treatment change whereas 470 (93.8%) were treated successfully with ampicillin/sulbactam. In multivariate analysis, male gender [OR (95%CI): 3.32 (1.37–8.04), p = 0.008], CRP levels [OR (95%CI) 1.04 (1.01–1.08), p = 0.024], and existence of pleural effusion [OR (95%CI) 5.74 (2.17–15.15), p = 0.0001] were found to be significantly associated with treatment failure for the whole study group. For the subgroup of children between 3 and 60 months of age; respiratory rate [OR (95%CI) 1.06 (1.02–1.10), p = 0.0006] was also found to be an additional risk factor. In conclusion, this is the largest study showing that empiric parenteral ampicillin/sulbactam is effective, safe, and well tolerated for treatment of children hospitalized with CAP. However, pleural effusion was found to be the main factor associated with treatment failure.     

Associations between quality of life, fatigue, and cytokine levels in patients aged 50+ with acute myeloid leukemia

Goals of work  Quality of life (QOL) is significantly impaired in patients with acute myeloid leukemia (AML), and fatigue is the most common and disabling symptom; effective treatment measures have yet to be found. Cytokines, biomarkers of inflammation, may moderate both health outcomes, but published data are limited. We looked at the role of cytokines in modulating QOL and fatigue in an older AML population. Patients and methods  We recruited 34 English-speaking patients (23 men, 11 women) aged 50 or older with AML within 1 year of diagnosis. QOL and fatigue were assessed with validated questionnaires. Blood was simultaneously drawn for quantitative measurement of a 13-cytokine panel. Repeat measurements were done 4–6 weeks later (n = 28 patients). Spearman correlations between health measures and cytokine levels were examined at baseline, as were changes in variables between time points. A potentially clinically important correlation was defined as an r ≥ 0.30. Results  At baseline, potentially clinically important correlations were noted between global QOL and interferon (IFN)-γ (r = −0.376, p = 0.031), interleukin (IL)-2 (r = −0.340, p = 0.053), IL-5 (r = −0.368, p = 0.035), IL-8 (r = −0.312, p = 0.077), and TNF-α (r = −0.326, p = 0.064). A similar correlation was observed between IL-6 and fatigue (r = 0.332, p = 0.059). Between time points, there were no potentially important correlations between changes in global QOL and any cytokine. However, potentially important correlations with fatigue were seen with both IL-5 (r = 0.344, p = 0.073) and IL-10 (r = 0.326, p = 0.091) between time points. Conclusions  These preliminary data provide support for a larger controlled study of cytokines, fatigue, and QOL in patients with AML.     

Effect of hydromorphone on ventilation in palliative care patients with dyspnea

Goals This study assessed the effect of hydromorphone treatment on ventilation and the intensity of dyspnea in palliative care patients. The assessments measured changes in peripheral oxygen saturation (SaO₂), transcutaneous arterial pressure of carbon dioxide (tcpaCO₂), respiratory rate (f), and pulse frequency (PF) during the titration phase with hydromorphone for symptomatic therapy of dyspnea. The aims of the study were to verify the efficacy of hydromorphone for the management of dyspnea and assess its effect on ventilation. Materials and methods Fourteen patients admitted to our palliative care unit were included in this prospective, nonrandomized trial. At admission, all patients suffered from dyspnea. TcpaCO₂, SaO₂, and PF were measured transcutaneously by means of a SenTec Digital Monitor (SenTec AG, Switzerland). Main results As early as 30 min after the first hydromorphone application, mean respiratory rate decreased from 38.8 ± 4.9 breaths/min (range 30.0–45.0 breaths/min) to 34.6 ± 4.2 breaths/min (29.0–41.0 breaths/min); after 120 min to 29.0 ± 3.1 breaths/min (range 24.0–33.0 breaths/min) (p = 0.001). The other monitored respiratory parameter, however, showed no significant changes. A significant improvement was shown in the intensity of dyspnea [numeric rating scale 0–10: 5.2 ± 1.5 (4–8)/6.4 ± 2.1 (4–10) vs 1.1 ± 0.9 (0–3)/2.3 ± 1.3 (1–5); p = 0.001]. Conclusions Neither was there a significant decrease in SaO₂ nor a significant increase in tcpaCO₂ after the initial hydromorphone application, i.e., there was no hydromorphone-induced respiratory depression. The first hydromorphone application, however, resulted in a significant decrease in the intensity of dyspnea and respiratory rate.     

Safety of ondansetron loading doses in children with cancer

Introduction In highly emetogenic chemotherapy, the recommended dose of the serotonin-receptor antagonist ondansetron (5 mg/m² q8h) may be insufficient to prevent chemotherapy-induced nausea and vomiting. In adults, ondansetron-loading doses (OLD) of 32 mg are safe. We aimed to evaluate in children the safety of an OLD of 16 mg/m² (top, 24 mg) i.v., followed by two doses of 5 mg/m² q8h. Materials and methods This retrospective single-center study included all pediatric oncology patients having received ≥1 OLD between 2002 and 2005. Adverse events (AE) definitely, probably, or possibly related to OLD were studied, excluding AE not or unlikely related to the OLD. Associations between potential predictors and at least moderate AE were analyzed by mixed logistic regression. Results Of 167 patients treated with chemotherapy, 37 (22%) received 543 OLD. The most common AE were hypotension, fatigue, injection site reaction, headache, hot flashes/flushes, and dizziness. At least mild AE were described in 139 OLD (26%), at least moderate AE in 23 (4.2%), and severe AE in 5 (0.9%; exact 95% confidence interval [CI], 0.4–2.1). Life-threatening or lethal AE were not observed (0.0%; 0.0–0.6). At least moderate AE were significantly more frequent in female patients (odds ratio [OR] 3.5; 95% CI 1.4–8.8; p = 0.010), after erroneously given second OLD (17.0; 1.9–154; p = 0.012) and higher 24 h cumulative surface corrected dose (1.26 per mg/m²; 1.06–1.51; p = 0.009). OLD given to infants below 2 years were not associated with more frequent AE. Conclusions Ondansetron-loading doses of 16 mg/m² (top, 24 mg) i.v. seem to be safe in infants, children, and adolescents. Results presented in part at the 20th Symposium of the Multinational Association of Supportive Care in Cancer, St. Gallen, Switzerland, June 27–30, 2007.     

Increasing Uptake Time in FDG-PET: Standardized Uptake Values in Normal Tissues at 1 versus 3 h

Objective  Positron emission tomography (PET) imaging at more than 1 h after 2-deoxy-2-[¹⁸F]fluoro-d-glucose (FDG) administration may result in less blood pool activity and possibly decreased normal FDG uptake in tissues such as liver. Lower normal background activity could be an important component of improved image contrast on delayed imaging. Increasing FDG uptake in normal organs, however, may mitigate the beneficial effects of blood pool clearance. The purpose of this study is to determine the normal tissue and blood pool FDG uptake at 1 and 3 h after injection. Subjects and methods  Ninety-nine patients with known or suspected malignancy referred for FDG-PET–computed tomography (CT) were retrospectively evaluated. PET imaging was performed at either 1 h (60 ± 15 min; n = 50) or at 3 h (180 ± 15 min; n = 49) after FDG administration. Normal tissue FDG uptake without involvement by malignancy or influenced by artifact (misregistration, “brown fat,” focal muscle uptake, focal atherosclerotic disease) was confirmed by inspection of both the PET and CT scans. Aortic blood pool, adipose tissue, bone marrow, cerebellum, liver, lungs, muscle, and spleen were quantitatively evaluated by CT-guided region of interest analysis in three contiguous slices. Mean standardized uptake values (SUVs) were analyzed using one-way analysis of variance. Results  Mean SUVs on the 3- versus 1-h images were significantly lower for aortic blood pool 13% (p < 0.0001) and adipose tissue 20% (p < 0.008). FDG uptake showed significant increases at 3 h compared to 1-h imaging in the cerebellum 40% (p < 0.0001), bone marrow 25% (p = 0.003), muscle 21% (p = 0.0004), and spleen 13% (p = 0.01). The liver and lung showed no significant differences (1%, p = 0.85; −2%, p = 0.62, respectively). Conclusions  On FDG imaging at 3 h compared to 1 h, significant changes were apparent, but the magnitude of changes was modest overall. Three-hour delayed imaging demonstrated significantly lower aortic blood pool and adipose tissue activity and significantly higher cerebellum, muscle, spleen, and bone marrow activity. Hepatic and lung activities were not significantly different. These results suggest that previously reported improvements in tumor image contrast with delayed imaging may be primarily due to cumulative FDG uptake within the tumor rather than reduction in normal background activity.     

Disease-Specific Depression and Outcomes in Chronic Heart Failure: A Propensity Score Analysis

Depression is common in heart failure and is associated with increased mortality. Yet, it is often underdiagnosed and inadequately treated. Lack of disease-specific and easy-to-administer screening tools is one of the reasons for underdiagnosis of depression in heart failure. We examined the effect of depression, as diagnosed by a single question about depression caused by heart failure symptoms and affecting quality of life, in a propensity score-matched cohort of heart failure patients. Of the 581 patients enrolled in the quality-of-life sub-study of the Digitalis Investigation Group trial, 298 (51%) reported that their heart failure prevented them from living as they wanted during the last month by making them feel depressed. Seventy patients (23%) who reported that they felt “much” or “very much” depressed were considered depressed for the purpose of this study. We matched 47 (67%) of these depressed patients with 47 patients from among the 283 patients without depression. Kaplan–Meier and matched Cox regression analyses were used to estimate associations of depression with mortality and hospitalizations during a median follow up of 33 months. Compared with 8 (17%) deaths in patients in the non-depressed group, 19 (40%) of those in the depressed group died from all causes [unadjusted hazard ratio (HR), 1.55; 95% confidence interval (CI), 1.004–2.39; p = 0.048]. Adjustment for propensity scores (adjusted HR, 1.77; 95% CI, 1.04–3.00; p = 0.034) or other covariates (adjusted HR, 1.85; 95% CI, 1.12–3.04; p = 0.016) did not alter the association between depression and mortality. The association, however, became marginally significant in the matched cohort (HR, 2.50; 95% CI, 0.97–6.44; p = 0.058). There was no significant association between depression and hospitalization. Baseline depression, identified by a single disease-specific question, was associated with increased mortality among ambulatory chronic heart failure patients.     

A patient-reported outcome instrument to assess the impact of oropharyngeal mucositis on health-related quality of life: a longitudinal psychometric evaluation

Goals of work  An oropharyngeal mucositis (OM)-specific health-related quality of life measure (OMQoL) has been developed to assess the impact of OM from the perspective of patients. The current paper describes the convergent, concurrent, and known-group validities and responsiveness in relation to clinical and health outcomes. Materials and methods  A multicenter approach was used, and 137 patients treated with different cancer therapies completed the OMQoL and the European Organization for Research and Treatment of Cancer Quality of Life questionnaire [EORTC QLQ-C30 (Ch)] twice over a 4-week period or weekly over a 7-week period, along with concurrent measures of OM and its related symptoms. Main results  The OM-related symptom scores correlated highly with the OMQoL, confirming its convergent validity (r = −0.724–−0.971, p < 0.01). Moderate correlations between the subscales of the OMQoL and EORTC QLQ-C30 (Ch) were indicative of good concurrent validity (r = 0.450–0.724, p < 0.01). The OMQoL was able to distinguish between patients with different severities of OM (p < 0.01) and types of cancer therapy (p < 0.01), providing evidence of good known-group validity. The changes in effects sizes corresponding to changes in OM curves indicate that the OMQoL is responsive to changes in OM status. Conclusions  These findings suggest that the OMQoL has very good psychometric properties and can be used as a health-related quality of life assessment for cancer patients with OM. Much work is still needed in strengthening the psychometric qualities and interpretability of the OMQoL by demonstrating its ability to detect outcome changes over time.     

Factors associated with poor general health after stem-cell transplantation

Aims To describe functional status (FS), general health (GH) and symptom distress (SD) from admission to 1 year post-SCT and to identify medical, demographic, and/or patient-reported outcome variables associated with patient-perceived GH. Material and methods Forty-one patients (27 women) with a median age of 44 (18–65) years answered three questionnaires (SIP, SWED-QUAL, and SFID-SCT) from admission to 1 year post-SCT. Results At discharge, 59% of the patients reported poor FS and GH, and 24% reported >10 simultaneous symptoms. After 1 year post-SCT, 22% still reported poor FS, 32% poor GH, and 12% >10 simultaneous symptoms. Compared with admission, significantly larger proportions of the patients reported poor GH at discharge (20 vs 59%, p = .001), poor FS at 6 months (24 vs 59%, p = .004), and poor GH [The number of symptoms was found to be significantly associated with poor GH at discharge (OR 1.330, p = .009) and at 1 year post-SCT (OR 2.000, p = .010)]. Patients reporting “poor GH” at discharge and at 1 year post-SCT reported a median of 7 and 10 symptoms, respectively. Patients with “good GH” reported a median of three symptoms both at T1 and T4. “Tiredness”, “anxiety”, “mouth dryness”, “loss of appetite”, and “diarrhoea” were reported by a larger proportion of the patients reporting “poor GH”. Conclusions The results confirm that some patients who have undergone a SCT have a negatively affected life situation. The study indicates that actively asking for symptoms and applying the best treatment for symptom alleviation are among the most important measures that SCT teams can take to help the patients perceive better general health and an improved life situation.     

Maintenance of effects of a home-based physical activity program among breast cancer survivors

Purpose  Although physical activity (PA) adoption improves fitness and psychological well-being among cancer survivors, PA maintenance has not been examined. This paper presents follow-up of a home-based PA program for women treated for early-stage breast cancer. Materials and methods  Eighty-six sedentary women (mean age = 53.14 years, SD = 9.70) were randomly assigned to a PA or contact control group. The PA group received a 12-week telephone counseling program to adopt PA. Assessments were conducted at baseline, end-of-intervention (12 weeks), 6, and 9 months post-baseline. Results  When comparing change from end-of-intervention (12 weeks) between groups, a significant reduction was observed in minutes of PA at 6 months (t = −2.10, p < 0.05), but there was no decrease in intervention effect at 9 months (t = −0.19, p = 0.84). Similarly, post-intervention reductions in fatigue were lost at 6 months (t = 3.27, p < 0.01), but remained present at 9 months (t = 1.65, p = 0.10). PA group’s fitness improvements were maintained at both follow-ups (t = 1.04, p = 0.30 and t = 0.05, p = 0.96). The previously significant intervention effect on vigor was maintained at 6 months (t = 1.32, p = 0.19) but was significantly reduced at 9 months (t = −2.15, p < 0.05). PA participants were more likely to progress in motivational readiness at 6 (OR = 5.95, 95% CI = 2.30, 15.36) and 9 months (OR = 4.09, 95% CI = 1.69, 9.87); however, group differences in meeting PA guidelines were not maintained. Conclusion  Some positive effects of a home-based PA intervention for breast cancer patients were maintained at 6 and 9 months.     

Long-term adverse effects of hematopoietic stem cell transplantation on dental development in children

Purpose  The purpose of this study was to assess late effects of cytotoxic therapy with hematopoietic stem cell transplantation (HCT) on dental development in survivors of childhood cancer. Materials and methods  Forty children who underwent allogeneic HCT for a variety of hematological malignancies were evaluated at a minimum of 2 years after transplantation. We obtained information on oral symptoms, exposed panoramic radiographs (PRG), and performed an oral examination. PRGs were scored for agenesis and root and/or crown abnormalities. The root–crown ratio was calculated, and dental age was assessed using Demirjian’ s method. Main results  The studied group showed a significantly higher prevalence of tooth agenesis compared to normative data for first and second premolars in both the maxilla and mandible, as well as the second molars in the mandible (all p values <0.001). Children who were <3 years old at the time of cancer treatment had significantly more missing teeth than older children, F(2,37) = 7.58, p < 0.002. Root–crown ratios were lower in the study sample than those from normative data. In addition, the mean dental age was higher (as a result of earlier apical root closure) than the mean chronological age, t(28) = 2.47, p < 0.020. Conclusions  Nearly all children examined had dental development disturbances, including agenesis, short roots, and arrested root development. An oral/dental evaluation and preventative oral supportive care regimens should be part of programs monitoring late effects in long-term survivors of childhood cancer. This paper has been presented as an invited lecture at the 2008 MASCC/ISOO Symposium in Houston, Texas, USA.     

Quality of end-of-life treatment for cancer patients in general wards and the palliative care unit at a regional cancer center in Japan: a retrospective chart review

Goals In Japan, most cancer patients die in the hospital. The aim of this study was to assess the quality of end-of-life treatment for dying cancer patients in general wards and palliative care unit (PCU). Materials and methods A retrospective chart review study was conducted. The following data on cancer patients who died in general wards (N = 104) and PCU (N = 201) at a regional cancer center were collected: do-not-resuscitate (DNR) decisions, treatments in the last 48 h of life, and aggressiveness of cancer care for dying patients. Main results DNR orders were documented for most patients (94% in general wards, 98% in PCU, p = 0.067) and families usually consented (97%, 97%, p = 0.307). Comparison of general wards with PCU showed that, in the last 48 h of life, significantly more patients in general wards received life-sustaining treatment (resuscitation, 3.8%, 0%, p = 0.001; mechanical ventilation, 4.8%, 0%, p = 0.004), large volume hydration (>1,000 ml/day, 67%, 10%, p < 0.001) with continuous administration (83%, 5%, p = 0.002) and fewer palliative care drugs (strong opioids, 68%, 92%, p < 0.001; corticosteroids, 49%, 70%, p < 0.001; nonsteroidal anti-inflammatory drugs, 34%, 85%, p < 0.001). Regarding aggressiveness of cancer care, patients received a new chemotherapy regimen within 30 days of death (3.0%), chemotherapy within 14 days of death (4.3%), and intensive care unit admission in the last month of life (3.3%). Conclusion We found that families, not patients, consented to DNR, and life-sustaining treatments were appropriately withheld; however, patients on general wards received excessive hydration, and the use of palliative care drugs could be improved. Application of our findings can be used to improve clinical care in general wards.     

A non-randomized comparison of mindfulness-based stress reduction and healing arts programs for facilitating post-traumatic growth and spirituality in cancer outpatients

Goals of work The aim of this study was to compare a mindfulness-based stress reduction (MBSR) program and a healing through the creative arts (HA) program on measures of post-traumatic growth (PTGI-R), spirituality (FACIT-Sp), stress (SOSI), and mood disturbance (POMS) in cancer patients. Materials and methods A sample of cancer outpatients (MBSR, n = 60; HA, n = 44) with a variety of diagnoses chose to attend either an 8-week MBSR program or a 6-week HA program and were assessed pre- and post-intervention. The majority of participants were female, married, and had breast cancer. Main results Repeated measures analysis of variance indicated that participants in both groups improved significantly over time on overall post-traumatic growth (p = 0.015). Participants in the MBSR group improved on measures of spirituality more than those in the HA group (p = 0.029). Participants in the MBSR group also showed more improvement than those in HA on measures of anxiety (POMS, p = 0.038), anger (POMS, p = 0.004), overall stress symptoms (SOSI, p = 0.041), and mood disturbance (POMS, p = 0.023). Several main effects of time were also observed in both groups. These results were found despite attrition in both groups. Conclusions Both programs may improve facilitation of positive growth after traumatic life experiences for those who choose to participate. MBSR may be more helpful than HA in enhancing spirituality and reducing stress, depression, and anger.     

Impact of mild hypoxemia on renal function and renal resistive index during mechanical ventilation

Rationale  Short-term hypoxemia affects diuresis and natriuresis in healthy individuals. No data are available on the impact of the mild hypoxemia levels usually tolerated in critically ill patients receiving mechanical ventilation. Objectives  To assess the renal effects of mild hypoxemia during mechanical ventilation for acute lung injury (ALI). Methods  Prospective, physiological study in 12 mechanically ventilated patients with ALI. Patients were studied at baseline with an arterial saturation (SaO₂) of 96% [94–98] then a comparison was performed between SaO₂ values of 88–90% (mild hypoxemia) and 98–99% (high oxygenation). Main results  FiO₂ was set at 0.25 [0.23–0.32] and 0.7 [0.63–0.8], respectively, to obtain SaO₂ of 89 [89–90] and 99% [98–99]. Hemodynamic or respiratory parameters were not significantly affected by FiO₂ levels. Compared with high oxygenation level, mild hypoxemia using low FiO₂ was associated with increase in diuresis (median [interquartile range], 67 [55–105] vs. 55 [45–60] ml/h; P = 0.003) and in doppler-based renal resistive index (RI) (0.78 [0.66–0.85] vs. 0.72 [0.60–0.78]; P = 0.003). The 2-h calculated creatinine clearance also increased (63 [46–103] vs. 35 [30–85] ml/min; P = 0.005) without change in urinary creatinine (P = 0.13). No significant change in natriuresis was observed. Half of the patients were under norepinephrine infusion and the renal response did not differ according to the presence of vasopressors. Conclusion  In patients with ALI, mild hypoxemia related to short-term low FiO₂ induce increases in diuresis and in renal RI. This latter point suggests intra-renal mechanisms that need to be further investigated. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.