Intensity of integrated cancer palliative care plans and end‐of‐life acute medical hospitalisation among cancer patient in Northern Italy

A high hospital utilisation at the end of life (EOL) is an indicator of suboptimal quality of health care. We evaluated the impact of the intensity of different Integrated Cancer Palliative Care (ICPC) plans on EOL acute medical hospitalisation among cancer decedents. Decedents of cancer aged 18–84 years, who were residents in two Italian regions, were investigated through integrated administrative data. Outcomes considered were prolonged hospital stay for medical reasons, 2+ hospitalisations during the last month of life and hospital death. The ICPC plans instituted 90 to 31 days before death represented the main exposure of interest. Other variables considered were gender, age class at death, marital status, recent hospitalisation and primary cancer site. Among 6,698 patients included in ICPC plans, 44.3% presented at least one critical outcome indicator; among these, 76.5% died in hospital, 60.3% had a prolonged (12+ days) medical hospitalisation, 19.1% had 2+ hospitalisations at the EOL. These outcomes showed a strong dose–response effect with the intensity of the ICPC plans, which is already evident at levels of moderate intensity. A well‐ICPC approach can be very effective—beginning at low levels of intensity of care—in reducing the percentage of patients spending many days or dying in hospital.     

Pegylated Filgrastim Versus Filgrastim for Stem Cell Mobilization in Multiple Myeloma After Novel Agent Induction

Background

The current standard of care for transplant-eligible myeloma patients is novel agent-based induction, followed by high-dose chemotherapy and autologous stem cell rescue. Chemo-mobilization of peripheral blood CD34⁺ stem cells (PBSCs) with pegylated filgrastim (pegfilgrastim), a sustained-duration formulation of filgrastim, has been used as an alternative to filgrastim in several studies involving heterogeneous cohorts of lymphoma and multiple myeloma (MM) patients and shown to be equivalent in PBSC yield and cost-effectiveness. The present study focused on the efficacy of pegfilgrastim in PBSC mobilization compared with filgrastim exclusively after novel agent-based induction in a homogeneous group of MM patients.

Preferences for the Provision of Smoking Cessation Education Among Cancer Patients

Many individuals who use tobacco will continue to smoke after a cancer diagnosis and throughout treatment. This study aims to better understand cancer patient preferences to learn about smoking cessation. All new patients seen at Princess Margaret Cancer Centre between 1 January 2014 and 30 June 2015 were asked to complete the Combined Tobacco History Survey as part of standard new patient assessments. Smoking status, second hand smoke exposure, years smoked, family support, cessation preferences, demographic and tumour details were collected. Multivariable regression assessed factors associated with smoking cessation educational preferences. Nine thousand and one hundred ten patients completed the survey. One thousand and six hundred ninety-one were current smokers (17 %) of which 43 % were female and median age was 57 years (range 18–95). One thousand and two hundred thirty-eight (73 %) were willing to consider quitting and 953 (56 %) reported a readiness to quit next month. Patients were most interested in pamphlets (45 %) followed by telephone support (39 %), speaking with a healthcare professional (29 %), website (15 %), support group (11 %) and speaking with successful former smokers (9 %). Younger patients (≤45 years) preferred receiving smoking cessation education over the telephone (50 %; p?<?0.001), while older patients (46–65 years and >65 years) preferred smoking education to be provided in pamphlets (43 and 51 %, respectively; p?=?0.07). In multivariable analyses, older patients were more likely to prefer pamphlets than younger patients OR 1.11 (95 % CI 1.01–1.23; p?=?0.03). Older cancer patients preferred to receive smoking cessation education through pamphlets and younger patients preferred the telephone. Tailored provision of cessation education resources for cancer patients is warranted.     

A regional evaluation of variation in low-severity hospital admissions

Objective

Determine patient and hospital-level variation in proportions of low-severity admissions.

Design

Retrospective cohort study.

Setting

Thirty hospitals in a large metropolitan region.

Patients

A total of 43,209 consecutive eligible patients discharged in 1991 through 1993 with congestive heart failure (n=25.213) or pneumonia (n=17,996).

Measurements and main results

Admission severity of illness was measured from validated multivariable models that estimated the risk of in-hospital death; models were based on clinical data abstracted from patients' medical based on clinical data abstracted from patients' medical records. Admissions were categorized as “low severity” if the predicted risk of death was less than 1%. Nearly 15% of patients (n=6,382) were categorized as low-severity admissions. Compared with other patients, low-severity admissions were more likely (p<.001) to be nonwhite and to have Medicaid or be uninsured. Low-severity admissions had shorter median length of stay (4 vs 7 days; p<.001), but accounted for 10% of the total number of hospital days. For congestive heart failure, proportions of low-severity admissions across hospitals ranged from 10% to 25%; 12 hospitals had rates that were significantly different (p<.01) than the overall rate of 17%. For pneumonia, proportions ranged from 3% to 22%; 12 hospitals had rates different from the overall rate of 12%. Variation across hospitals remained after adjusting for patient sociodemographic factors.

Conclusions

Rates of low-severity admissions for congestive heart failure and pneumonia varied across hospitals and were higher among nonwhite and poorly insured patients. Although the current study does not identify causes of this variability, possible explanations include differences in access to ambulatory services, decisions to admit patients for clinical indications unrelated to the risk of hospital mortality, and variability in admission practices of individual physicians and hospitals. The development of protocols for ambulatory management of low-severity patients and improvement of access to outpatient care would most likely decrease the utilization of more costly hospital services.     

Early Extubation following Cardiac Surgery in a Veterans Population

Background: Early tracheal extubation is an important component of the "fast track" cardiac surgery pathway. Factors associated with time to extubation in the Department of Veterans Affairs (DVA) population are unknown. The authors determined associations of preoperative risk and intraoperative clinical process variables with time to extubation in this population.

Methods: Three hundred four consecutive patients undergoing coronary artery bypass graft, valve surgery, or both on a fast track clinical pathway between October 1, 1993 and September 30, 1995 at a university-affiliated DVA medical center were studied retrospectively. After univariate screening of a battery of preoperative risk and intraoperative clinical process variables, stepwise logistic regression was used to determine associations with tracheal extubation 10 h (late) after surgery. Postoperative lengths of stay, complications, and 30-day and 6-month mortality rates were compared between the two groups.

Results: One hundred forty-six patients (48.3%) were extubated early; one patient required emergent reintubation (0.7%). Of the preoperative risk variables considered, only age (odds ratio, 1.80 per 10-yr increment) and preoperative intra-aortic balloon pump (odds ratio, 7.88) were multivariately associated with time to extubation (model R) ("late" association is indicated by an odds ratio >1.00; "early" association is indicated by an odds ratio <1.00). Entry of these risk variables into a second regression model, followed by univariately significant intraoperative clinical process variables, yielded the following associations (model R-P): age (odds ratio, 1.86 per 10-yr increment), sufentanil dose (odds ratio, 1.54 per 1-[micro sign]g/kg increment), major inotrope use (odds ratio, 5.73), platelet transfusion (odds ratio, 10.03), use of an arterial graft (odds ratio, 0.32), and fentanyl dose (odds ratio, 1.45 per 10-[micro sign]g/kg increment). Time of arrival in the intensive care unit after surgery was also significant (odds ratio, 1.42 per 1-h increment). Intraoperative clinical process variables added significantly to model performance (P < 0.001 by the likelihood ratio test).     

Genetic model of multi-step breast carcinogenesis involving the epithelium and stroma: clues to tumour-microenvironment interactions

Although numerous studies have reported that high frequencies of loss of heterozygosity (LOH) at various chromosomal arms have been identified in breast cancer, differential LOH in the neoplastic epithelial and surrounding stromal compartments has not been well examined. Using laser capture microdissection, which enables separation of neoplastic epithelium from surrounding stroma, we microdissected each compartment of 41 sporadic invasive adenocarcinomas of the breast. Frequent LOH was identified in both neoplastic epithelial and/or stromal compartments, ranging from 25 to 69% in the neoplastic epithelial cells, and from 17 to 61% in the surrounding stromal cells, respectively. The great majority of markers showed a higher frequency of LOH in the neoplastic epithelial compartment than in the stroma, suggesting that LOH in neoplastic epithelial cells might precede LOH in surrounding stromal cells. Furthermore, we sought to examine pair-wise associations of particular genetic alterations in either epithelial or stromal compartments. Seventeen pairs of markers showed statistically significant associations. We also propose a genetic model of multi-step carcinogenesis for the breast involving the epithelial and stromal compartments and note that genetic alterations occur in the epithelial compartments as the earlier steps followed by LOH in the stromal compartments. Our study strongly suggests that interactions between breast epithelial and stromal compartments might play a critical role in breast carcinogenesis and several genetic alterations in both epithelial and stromal compartments are required for breast tumour growth and progression.     

Development of the renal corpuscle during metamorphosis in the lamprey

The renal corpuscle of the adult lamprey, Petromyzon marnus L., is formed during the programmed period of metamorphosis. Development is initiated early in this metamorphic period and is marked by the synchronous formation and growth of rudimentary nephron units (RNU) from a longitudinal cord of nephrogenic tissue extending from the posterior tip of the degenerating larval kidney to the cloaca and connected to the peritoneal epithelium. Detachment of the RNU from the peritoneum involves autolysis and cell death and is accompanied by their branching into five or six hexagonally-arranged nephrons which radiate from the original point of attachment. Differentiation of the epithelial cells at the proximal ends of the nephrons is preceded by the widening of lateral intercellular spaces, the formation of tubular lumina (primitive urinary spaces), the loss of apical cell junctions, and the development of a capillary network with its associated mesangium. With the extension of the capillaries and mesangium between the proximal ends of adjacent undifferentiated nephrons, visceral epithelial cells (podocytes), with long cell processes (trabeculae) and slit membranes, make their appearance. The urinary spaces resulting from this form of development are lined by the epithelium of the dilated ends of the nephrons (nephric capsules). The cells of these capsules differentiate mainly into podocytes, but a few parietal cells connect to the draining tubule. This method of development explains the unique form of the renal corpuscle in the adult lamprey. Despite the type of morphogenesis, this renal corpuscle possesses the fine-structural features seen in the renal corpuscles of other vertebrates.