Surveillance With Serial Imaging and CA 19-9 Tumor Marker Testing After Resection of Pancreatic Cancer: A Single-Center Retrospective Study.

OBJECTIVES: Most patients receiving curative-intent surgery for pancreatic cancer will experience cancer recurrence. However, evidence that postoperative surveillance testing improves survival or quality of life is lacking. We evaluated the use and characteristics of surveillance with serial imaging and CA 19-9 tumor marker testing at an NCI-designated comprehensive cancer center. METHODS: We conducted a retrospective cohort study of patients who entered surveillance after curative-intent resection of pancreatic adenocarcinoma. We abstracted information from the electronic medical record about oncology office visits, surveillance testing (cross-sectional imaging and CA 19-9 tumor marker testing), and pancreatic cancer recurrence, with follow-up through 2 years after pancreatectomy. We conducted analyses to describe the use of surveillance testing and to characterize the sensitivity and specificity of CA 19-9 tumor marker testing for the identification of cancer recurrence. RESULTS: We identified 90 patients entering surveillance after pancreatectomy. CA 19-9 was the most frequently used surveillance test, followed by CT imaging. Forty-seven patients (52.2%) experienced recurrence within two years of pancreatectomy. Recurrence risk was 58.8% versus 31.8% in patients with elevated versus normal CA 19-9 at diagnosis ( P =0.03). Elevated CA 19-9 at any point during surveillance was significantly associated with 2-year recurrence risk ( P <0.001). Elevated CA 19-9 had a sensitivity of 83% (95% CI 0.72-0.95) and specificity of 87% (0.76-0.98) for identification of recurrence within 2 years of pancreatectomy. CONCLUSIONS: CA 19-9 demonstrates clinical validity for identifying recurrence of pancreatic cancer during surveillance. Surveillance approaches with reduced reliance on imaging should be prospectively evaluated.

From active treatment to surveillance: how the barriers and facilitators of implementing survivorship care planning could be an opportunity for telehealth in oncology care for rural patients.

PURPOSE: Cancer survivorship care planning is a recognized yet underutilized aspect of care delivery, and the opportunity for telehealth in cancer survivorship is examined. METHODS: We conducted a mixed-methods study in Vermont and New Hampshire to characterize perceptions of rural cancer providers and survivors regarding survivorship transitions in care, consisting of (a) key informant interviews with primary care and oncology clinicians, (b) a broader survey of clinicians, and (c) surveys and focus group discussions with cancer survivors. In these interactions, we also explored the use of a shared telehealth survivorship care planning appointment between oncology clinicians, primary care clinicians, and survivors. RESULTS: Results from surveys and interviews clustered around several themes, namely (1) infrequent care transitioning back to primary care, (2) lack of mental health services, (3) lack of side effect education, (4) low perceived utility of survivorship care plans, (5) clinicians exclusively communicate using the EMR and finding it imperfect, and (6) clinicians and survivors reported conflicting perceptions regarding survivors' access to telehealth options. CONCLUSIONS: Our results suggest that telehealth has the potential to augment the delivery of survivorship care planning; however, key technical and logistical concerns need to be addressed, particularly enhanced coordination across clinician scheduling and ensuring payment parity for various telehealth implementation strategies. IMPLICATIONS FOR CANCER SURVIVORS: Cancer survivorship care planning is a recognized yet underutilized aspect of care delivery. There is an opportunity for the application of telehealth for supportive care in survivorship care planning, which should be a focus of further research.

From active treatment to surveillance: How the barriers and facilitators of implementing survivorship care planning could be an opportunity for telehealth in oncology care for rural patients.

Purpose: Cancer survivorship care planning is a recognized yet underutilized aspect of care delivery and the opportunity for telehealth in cancer survivorship is examined. Methods: We conducted a mixed-methods study in Vermont and New Hampshire to characterize perceptions of rural cancer providers and survivors regarding survivorship transitions in care, consisting of: a) key informant interviews with primary care and oncology clinicians, b) a broader survey of clinicians, and c) surveys and focus group discussions with cancer survivors. In these interactions, we also explored the use of a shared telehealth survivorship care planning appointment between oncology clinicians, primary care clinicians, and survivors. Results: Results from surveys and interviews clustered around several themes, namely: 1) infrequent care transitioning back to primary care; 2) lack of mental health services; 3) lack of side effect education; 4) low perceived utility of survivorship care plans; 5) clinicians exclusively communicate using the EMR and finding it imperfect; and 6) clinicians and survivors reported conflicting perceptions regarding survivors' access to telehealth options. Conclusions: Our results suggest that telehealth has potential to augment the delivery of survivorship care planning; however, key technical and logistical concerns need to be addressed, particularly enhanced coordination across clinician scheduling and ensuring payment parity for various telehealth implementation strategies. Implications for Cancer Survivors: Cancer survivorship care planning is a recognized yet underutilized aspect of care delivery. There is an opportunity for the application of telehealth for supportive care in survivorship care planning, which should be a focus of further research.

A Survey of Hospice and Palliative Care Nurses' and Holistic Nurses' Perceptions of Spirituality and Spiritual Care.

The provision of spiritual care is referred to in professional practice guidelines and mandated in nurses' ethical codes. Still, a gap exists regarding essential training in spiritual conversation and assessment, leaving some health care providers feeling uncomfortable when assessing spiritual support needs. The purpose of this study was to assess hospice and palliative nurses' and holistic nurses' perceptions of spirituality and spiritual care. It was assumed that the standards of care for hospice and palliative nurses and holistic nurses stipulate that spiritualty is addressed within the framework of their specialties and provide education for spiritual care, thus making these nurses proficient in providing spiritual care. This exploratory, descriptive study utilized a web-based survey to measure perception of spirituality and spiritual care giving using a modified Spirituality and Spiritual Care Rating Scale. A convenience sample was recruited from members of the Hospice and Palliative Nurses Association and the American Holistic Nurses Association (n = 250). Descriptive statistics summarized data as well as qualitative analysis of written narratives. Content analysis of open-ended survey questions was used to identify themes until saturation. This study found that given adequate resources and education, nurses can be positioned to address the spiritual needs of patients and provide appropriate care. This study adds to an emerging body of evidence suggesting that training in spiritual care should be an important component of the foundational nursing curriculum.

Virtual monitoring of suicide risk in the general hospital and emergency department.

OBJECTIVE: To determine whether continuous virtual monitoring, an intervention that facilitates patient observation through video technology, can be used to monitor suicide risk in the general hospital and emergency department (ED). METHOD: This was a retrospective analysis of a protocol in which select patients on suicide precautions in the general hospital and ED received virtual monitoring between June 2017 and March 2018. The primary outcome was the number of adverse events among patients who received virtual monitoring for suicide risk. Secondary outcomes were the percentage of patients for whom virtual monitoring was discontinued for behavioral reasons and the preference for observation type among nurses. RESULTS: 39 patients on suicide precautions received virtual monitoring. There were 0 adverse events (95% confidence interval (CI) = 0.000-0.090). Virtual monitoring was discontinued for behavioral reasons in 4/38 cases for which the reason for terminating was recorded (0.105, 95%CI = 0.029-0.248). We were unable to draw conclusions regarding preference for observation type among nurses due to a low response rate to our survey. CONCLUSIONS: Suicide risk can feasibly be monitored virtually in the general hospital or ED when their providers carefully select patients for low impulsivity risk.

The Integration of Survivorship Care Planning at a Comprehensive Cancer Center.

Research has demonstrated that cancer survivors who receive a survivorship care plan (SCP) have better coordinated follow-up care, higher overall satisfaction, and report significantly fewer posttreatment emotional concerns. The Commission on Cancer, a program of the American College of Surgeons, has developed a standard of care in which 100% of eligible patients are to receive an SCP by the end of 2019. Nurse practitioners at a National Cancer Institute (NCI)-designated academic medical center worked to develop a standardized process to deliver SCPs to all eligible patients. The primary objective of the project was to standardize how SCPs were completed and embed them into the electronic medical record (EMR) using a templated note created for the EMR. Through an interdisciplinary steering committee, survivorship priorities were established and aligned with LIVESTRONG and American Society of Clinical Oncology guidelines. In addition, survivorship care planning was identified as an essential service to be provided by all cancer disease management groups (DMG) at the cancer center. A cancer SCP subcommittee was formed to explore methods to expand the delivery of SCPs and standardize the SCP process. Prior to this project, SCPs were being done by less than 10% of the providers and only for a few diagnoses, and no standardized method of documentation existed prior to this quality improvement initiative. The standardization of the SCP has increased both participation of other DMGs as well as increased the rate of completion to 34%. We believe that continuous reassessment and process improvement will help us reach the Commission on Cancer goal of providing SCPs to all eligible patients.

Report of wood decay fungus Inonotus tropicalis (phylum Basidiomycota) from a dog with a granulomatous mediastinal mass.

A 75.9-kg, 3.5-year-old male Irish Wolfhound dog with a 2-3-week history of gagging and eating difficulties was referred to the University of Florida Veterinary Medical Hospital (Gainesville, Florida) for evaluation of a large cranial mediastinal mass suspected to be a thymoma or lymphosarcoma. The patient had 4 months of nearly 10 kg progressive weight loss with severe flank sensitivity and radiographically apparent lumbar vertebral changes interpreted as discospondylitis. Lab work revealed hyperglobulinemia, mild proteinuria, normal T4, negative Brucella canis titer, and negative blood and urine bacterial cultures. A thoracotomy revealed a nonresectable, destructive, space-occupying mediastinal mass resulting in euthanasia without surgical recovery. Biopsies from the mass were collected during surgery for histology. Microscopic examination revealed extensive granulomatous cellulitis and lymphadenitis characterized by central cavitated necrotic areas containing debris and degenerate neutrophils, intermediate zones of fibrovascular proliferation with marked mixed inflammation, peripheral fibrosis, frequent multinucleated macrophages, and scattered mineralization. The necrotic material contained dense mats of 2 µm wide by 8-15 µm long fungal hyphae with parallel walls, acute angle branching, frequent septae, and occasional bulb-like dilations. DNA sequencing and phylogenetic analysis of the internal transcribed spacer region confirmed the presence of a fungus in the Inonotus tropicalis group. Inonotus tropicalis is primarily a wood decay fungus that is found on dead wood from angiosperms in tropical and subtropical habitats. Isolates of the I. tropicalis group have been detected a few times from immunosuppressed human beings with X-linked granulomatous disease.