Prognostic disclosure to patients with cancer near the end of life.

BACKGROUND: Patients' understanding of their prognosis informs numerous medical and nonmedical decisions, but patients with cancer and their physicians often have disparate prognostic expectations. OBJECTIVE: To determine whether physician behavior might contribute to the disparity between patients' and physicians' prognostic expectations. DESIGN: Prospective cohort study. SETTING: Five hospices in Chicago, Illinois. PATIENTS: 326 patients with cancer. INTERVENTION: Physicians formulated survival estimates and also indicated the survival estimates that they would communicate to their patients if the patients insisted. MEASUREMENTS: Comparison of the formulated and communicated prognoses. RESULTS: For 300 of 311 evaluable patients (96.5%), physicians were able to formulate prognoses. Physicians reported that they would not communicate any survival estimate 22.7% (95% CI, 17.9% to 27.4%) of the time, would communicate the same survival estimate they formulated 37% (CI, 31.5% to 42.5%) of the time, and would communicate a survival estimate different from the one they formulated 40.3% (CI, 34.8% to 45.9%) of the time. Of the discrepant survival estimates, most (70.2%) were optimistically discrepant. Multivariate analysis revealed that older patients were more likely to receive frank survival estimates, that the most experienced physicians and the physicians who were least confident about their prognoses were more likely to favor no disclosure over frank disclosure, and that female physicians were less likely to favor frank disclosure over pessimistically discrepant disclosure. CONCLUSIONS: Physicians reported that even if patients with cancer requested survival estimates, they would provide a frank estimate only 37% of the time and would provide no estimate, a conscious overestimate, or a conscious underestimate most of the time (63%). This pattern may contribute to the observed disparities between physicians' and patients' estimates of survival.     

Accelerated myocardial metabolic recovery with terminal warm blood cardioplegia

Although blood cardioplegia provides excellent protection, myocardial metabolic recovery is delayed. To evaluate the benefits of a terminal warm cardioplegic infusion after cold blood cardioplegia, we performed a prospective randomized trial in 20 patients undergoing elective coronary bypass grafting. Eleven patients received cold blood cardioplegia and nine patients received cold blood cardioplegia and warm blood cardioplegia before cross-clamp removal (hot shot). The hot shot provided oxygen and removed excess lactate from the arrested heart. After the hot shot lactate was extracted by the heart and tissue adenosine triphosphate and glycogen concentrations were preserved. Atrial pacing and volume loading 3 and 4 hours postoperatively decreased myocardial lactate extraction after cold blood cardioplegia but increased lactate extraction after the hot shot. Left atrial pressures were higher at similar end-diastolic volumes (by nuclear ventriculography), which suggested decreased diastolic compliance after cold blood cardioplegia. Terminal warm blood cardioplegia accelerated myocardial metabolic recovery, preserved high-energy phosphates, improved the metabolic response to postoperative hemodynamic stresses, and reduced left atrial pressures.     

Diltiazem cardioplegia. A balance of risk and benefit

Calcium channel blockers may prevent myocardial injury during cardioplegia and reperfusion. A prospective, randomized trial was instituted to evaluate the hemodynamic and myocardial metabolic recovery in 40 patients undergoing elective aorta-coronary bypass with either diltiazem in crystalloid potassium cardioplegia (n = 20) or crystalloid potassium cardioplegia (n = 20). In a preliminary trial, doses between 150 and 250 micrograms/kg reduced the period of heart block after cross-clamp removal (90 +/- 110 minutes) from that found with higher doses and improved myocardial metabolism. In the randomized trial, diltiazem cardioplegia (150 micrograms/kg) produced coronary vasodilatation during cardioplegia and produced less reactive hyperemia during reperfusion. Myocardial oxygen extraction was lower and myocardial lactate production was less after diltiazem cardioplegia during reperfusion. Tissue adenosine triphosphate and creatine phosphate concentrations were preserved better after diltiazem cardioplegia. The postoperative creatine kinase MB levels were less (p less than 0.05) after diltiazem cardioplegia, which indicated less myocardial injury. Postoperative volume loading demonstrated that systolic function (the relation between systolic blood pressure and end-systolic volume index) was depressed after diltiazem cardioplegia compared to crystalloid cardioplegia, but cardiac index was higher because afterload (mean arterial pressure) was lower and preload (end-diastolic volume index) was higher. Diltiazem cardioplegia preserved high-energy phosphates, improved postoperative myocardial metabolism, and reduced ischemic injury after elective coronary bypass. However, diltiazem was a potent negative inotrope and produced prolonged periods of electromechanical arrest. Diltiazem cardioplegia may be of value in patients with severe ischemia but should be used with caution in patients with ventricular dysfunction, and a dose-response relation must be established at each institution before clinical use.     

Reducing the risk of urgent revascularization for unstable angina: a randomized clinical trial

A prospective, randomized trial was instituted to determine whether blood cardioplegia (BC) could reduce the morbidity and mortality for patients undergoing urgent coronary bypass for unstable angina. One hundred forty patients who came to the hospital with prolonged angina at rest and who required urgent revascularization because their symptoms were resistant to medical therapy were randomized to receive BC (n = 70) or crystalloid cardioplegia (CC) (n = 70). The operative mortality rate was 2.8%, the incidence of myocardial infarction was 8.6%, the incidence of low output syndrome was 18% and morbidity (myocardial infraction or low output syndrome) was 23%. Patients who received BC had a significantly lower mortality rate (BC, 0%; CC, 5%; p less than 0.05) and incidence of myocardial infarction (BC, 4%; CC, 13.5%; p less than 0.05) or low output syndrome (BC, 10%; CC, 19%; p less than 0.05). The highest postoperative CK-MB level was less after BC (BC, 31 +/- 17 U/L; CC, 56 +/- 13 U/L; p less than 0.05). Preoperative predictors of postoperative morbidity in addition to the type of cardioplegia included the response to medical therapy, persistent ischemic electrocardiographic changes, left ventricular ejection fraction, and age. A multivariate analysis identified the type of cardioplegic protection (p = 0.008) and age (p = 0.05) as significant independent predictors of postoperative morbidity. BC reduced the risk of urgent revascularization for unstable angina.     

MRI‐compatible breast/rib phantom for evaluating ultrasonic thermal exposures

Introduction

The target of this study was the development of a magnetic resonance imaging (MRI) compatible breast phantom for focused ultrasound which includes plastic (ABS) ribs. The objective of the current study was the evaluation of a focused ultrasound procedure using the proposed phantom that eliminates rib heating.

Material and Methods

The proposed phantom was evaluated using two different focused ultrasound exposures. The surrounding breast tissue was mimicked using an agar–silica–evaporation milk gel (2% w/v – 2% w/v – 40% v/v).

Results

The attenuation of the ABS was similar to that of ribs. MR thermometry of focused ultrasound exposures were acquired using the breast/rib phantom. In one exposure focused ultrasound was applied with far‐field targeting of the ribs. In the other exposure, the transducer was positioned laterally, thus avoiding exposure of the rib to focused ultrasound.

Conclusions

Due to growing interest in using MRI guided focused ultrasound (MRgFUS) for patients with breast cancer, the proposed breast/rib phantom can be utilized as a very useful tool for evaluating ultrasonic protocols.     

Sonographically guided ilioinguinal nerve block.

OBJECTIVE: The aim of this study was to describe a sonographically guided ilioinguinal nerve block in adults. METHODS: We developed a useful step-by-step technique of sonographically guided ilioinguinal nerve block based on visualization of abdominal muscles, fascial planes, and the branch of the deep circumflex iliac artery. RESULTS: We performed 9 sonographic examinations with subsequent blockade of the ilioinguinal nerve. All injections resulted in a clinically successful sensory block. CONCLUSIONS: This technique is reliable and reproducible. The block is achievable by a low-volume local anesthetic injection. Visualization of the intestines and blood vessels in the abdominal wall may help prevent an inadvertent injury.     

Hypochromic erythrocytes (%): a reliable marker for recognizing iron-restricted erythropoiesis and predicting response to erythropoietin in anemic patients with myeloma and lymphoma

The aim of the study was to evaluate the role of hypochromic erythrocytes (HYPO%) compared to “traditional” and novel markers of iron status and erythropoiesis in recognizing iron-restricted erythropoiesis (IRE) and predicting response to erythropoietin (rHuEPO) in anemic patients with myeloma and lymphoma. Forty-one newly diagnosed patients who received epoetin-beta at a subcutaneous weekly dose of 30,000 IU for 6 weeks were studied. Response to rHuEPO was observed in 27 patients (65.8%). Twelve non-responders received, additionally, 200 mg of IV iron sucrose, weekly, for 4 weeks. Evaluation of markers was performed at baseline and on weeks 1, 2 and 6 for all patients and also on weeks 7–10 for non-responders to rHuEPO. Baseline HYPO%, at a cut-off value of <5%, and an increment in reticulocyte absolute number (RETICS-AB) ≥ 50,000/μl and reticulocyte hematocrit (RETICS-Hct) ≥ 50%, between baseline and week 2, were independent predictive factors for response to rHuEPO. We found that these markers had superior predictive value for response to rHuEPO than four widely used predictive models. Furthermore, a baseline HYPO% count of above 5% proved superior over serum ferritin < 100 ng/ml and transferrin saturation < 20% in recognizing IRE. In conclusion, baseline HYPO% either alone or in combination with RETICS-AB or RETICS-Hct after 2 weeks of rHuEPO treatment could be reliably used in predicting response to rHuEPO. Additionally, HYPO% has proved a reliable marker for recognizing IRE before rHuEPO treatment and, thus, could be used for identifying patients who will benefit from IV iron supplementation.     

Measuring clinically significant chemotherapy-related toxicities using Medicare claims from Cancer and Leukemia Group B (CALGB) trial participants

BACKGROUND: Because the elderly are underrepresented on clinical trials, physicians have few sources of information to estimate the risks (ie, toxicities) and benefits of chemotherapy administration to the elderly. OBJECTIVE: Our goal was to determine whether the standard measures of toxicity used in clinical trials could be captured from observational Medicare claims data. METHODS: We identified 175 elderly clinical trial patients treated on 2 Cancer and Leukemia Group B (CALGB) trials (9344, adjuvant breast study and 9730, advanced lung cancer study) and merged participants' CALGB data with their Medicare data. From CALGB data, we identified the most frequent Extended Clinical Toxicity Critieria grade III/IV toxicities. We reviewed diagnostic and procedure codes from Medicare manuals, developed algorithms to measure the toxicities, and then finalized the algorithms after empiric review of patients' codes. We compared results of Medicare algorithms to gold standard CALGB toxicity information to calculate test characteristics. RESULTS: CALGB data documented that 15 grade III/IV chemotherapy-related toxicities occurred in > or =3% of the 175 patients: white blood cell, hemoglobin, platelets, anorexia, nausea, vomiting, diarrhea, stomatitis, sensory neuropathy, motor neuropathy, motor or sensory neuropathy, dyspnea, hyperglycemia, infection, and malaise. Vomiting was the only toxicity identified by the Medicare-based algorithm with a sensitivity, specificity, and area under the receiver operator curve of > or =80%. CONCLUSIONS: The results of this preliminary study suggest that Medicare diagnostic and procedure codes may be of only limited value in measuring clinically significant chemotherapy-related toxicities in elderly Medicare beneficiaries. Future research includes confirming these findings in a larger and more diverse sample.