Prediction of survival time after terminal extubation: the balance between critical care unit utilization and hospice medicine in the COVID-19 pandemic era.

BACKGROUND: We established 1-h and 1-day survival models after terminal extubation to optimize ventilator use and achieve a balance between critical care for COVID-19 and hospice medicine. METHODS: Data were obtained from patients with end-of-life status at terminal extubation from 2015 to 2020. The associations between APACHE II scores and parameters with survival time were analyzed. Parameters with a p-value ≤ 0.2 in univariate analysis were included in multivariate models. Cox proportional hazards regression analysis was used for the multivariate analysis of survival time at 1 h and 1 day. RESULTS: Of the 140 enrolled patients, 76 (54.3%) died within 1 h and 35 (25%) survived beyond 24 h. No spontaneous breathing trial (SBT) within the past 24 h, minute ventilation (MV) ≥ 12 L/min, and APACHE II score ≥ 25 were associated with shorter survival in the 1 h regression model. Lower MV, SpO2 ≥ 96% and SBT were related to longer survival in the 1-day model. Hospice medications did not influence survival time. CONCLUSION: An APACHE II score of ≥ 25 at 1 h and SpO2 ≥ 96% at 1 day were strong predictors of disposition of patients to intensivists. These factors can help to objectively tailor pathways for post-extubation transition and rapidly allocate intensive care unit resources without sacrificing the quality of palliative care in the era of COVID-19. Trial registration They study was retrospectively registered. IRB No.: 202101929B0.

Body Mass Index-Adjusted Body Weight Loss Grading Predicts Overall Survival in Esophageal Squamous Cell Carcinoma Patients.

PURPOSE: Various malnutrition and inflammation criteria were associated with prognosis of esophageal squamous cell carcinoma (ESCC) patients. Nonetheless, the interplay of clinicopathological features, malnutrition, and inflammation criteria with overall survival in ESCC patients remains unclear. METHODS: We retrospectively reviewed medical records of 205 patients diagnosed with ESCC between 2007 and 2012, and evaluated the status of participant malnutrition and inflammation, including body mass index < 18.5 kg/m2, body weight loss > 5.0%, serum albumin level < 3.5 g/dl, neutrophil-to-lymphocyte ratio > 3.5, platelet-to-lymphocyte ratio > 20, prognostic nutrition index < 40, blood total lymphocyte count < 1600 cells/mm3, and grades of body mass index-adjusted body weight loss (combined BMI-BWL). We assessed the association of clinicopathological features, nutritional status, and inflammation condition with overall survival using univariate and multivariate Cox regression analyses. RESULTS: The mean overall survival of ESCC patients was 28.8 mo,. The multivariate logistic regression model after adjustment for clinicopathological variables, malnutrition status, inflammation condition, and co-morbid status found that tumor stage and grades of combined BMI-BML served as equally important prognostic factors for overall survival. CONCLUSIONS: Advanced tumor stage and high grades of combined BMI-BWL were independent prognostic factors for overall survival in ESCC patients.

Determining Malnutrition Assessment Criteria to Predict One-Year Mortality for Locally Advanced Head and Neck Cancer Patients Undergoing Concurrent Chemoradiotherapy.

Study on the impact of pretreatment malnutrition on treatment outcomes in locally advanced head and neck cancer (LAHNC) patients is still lacking. We prospectively collected various malnutrition assessment methods including nutrition indexes, inflammatory biomarkers, and lean body mass index (LBMI) data before treatments. The one year mortality rate was assessed, and the factors associated with this outcome were investigated. Furthermore, the association between malnutrition assessment methods was examined. A total of 113 patients were enrolled. By prognostic stratification based on the prognostic nutritional index (PNI) and platelet-to-lymphocyte ratio (PLR) combination, the low PNI/high PLR group had highest and the high PNI/low PLR group had the lowest mortality rate. Furthermore, the PNI was positively correlated with the LBMI, and the PLR was inversely correlated with the LBMI. PNI and PLR were found to be independent prognostic factors of one year mortality and also associated with the loss of muscle.

Prognostic nutritional index relevance in chemoradiotherapy for advanced oral cavity, oropharyngeal and hypopharyngeal cancer.

BACKGROUND AND OBJECTIVES: This study was designed to evaluate the impact of the prognostic nutritional index (PNI) on treatment-related toxicities and tolerance in patients with advanced head and neck cancers who were undergoing concurrent chemoradiotherapy (CCRT). METHODS AND STUDY DESIGN: We retrospectively analyzed and compared the clinical characteristic, toxicities and survival of 143 patients with stage III, IVA, and IVB head and neck cancer who were treated with CCRT according to their PNI between 2007 and 2010. RESULTS: Low PNI was correlated with T classification and advanced tumor stage. Patients with low PNI were less likely to tolerate CCRT, required tube feeding support more frequently and had higher percentages of grade 3/4 hematological toxicities, sepsis and toxic death. CONCLUSIONS: Pretreatment PNI predicts treatment-tolerance and toxicity in patients with advanced head and neck cancer undergoing CCRT.

Prognostic Significance of Low Body Mass Index and Betel-Quid Use in the 5-Year Survival Rates of Esophageal Squamous Cell Carcinoma Patients.

AIM: This study aimed to examine the relationship between clinicopathological features, varied malnutrition criteria, and survival in esophageal squamous cell carcinoma (ESCC) patients. METHODS: Six malnutrition criteria (body mass index (BMI) < 18.5 kg/m2, serum albumin level < 3.5 g/dL, neutrophil-to-lymphocyte ratio (NLR) > 3.5, platelet-to-lymphocyte ratio (PLR) > 17, prognostic nutrition index (PNI) < 40, and blood total lymphocyte count (TLC) < 1,600 cells/mm3) were measured in 205 ESCC patients at the time of diagnosis. Malnutrition status and clinicopathological features were tested for prognostic effects on the 5-year survival rate. RESULTS: Malnutrition rates vary according to nutrition assessment tools, ranging from 21.5% based on BMI < 18.5 kg/m2 to 67.8% based on PNI < 40. These rates are associated with increased inflammation, but they showed no difference among various tumor stages. After adjustment of demographic variables and comorbid status, advanced tumor stage, low BMI at diagnosis, and betel quid use showed prognostic significance in the 5-year survival rate based on a multivariate logistic regression analysis. CONCLUSIONS: Different nutrition assessment criteria produced different malnutrition rates. Advanced tumor stage, low BMI at diagnosis, and betel quid use were independent prognostic factors for worse survival of ESCC patients.

Body mass index above 24 is beneficial for the 6-month survival rate in hepatocellular carcinoma patients with extrahepatic metastases.

BACKGROUND AND OBJECTIVES: To investigate the effect of overweight status on the 6-month survival rate in patients with extrahepatic hepatocellular carcinoma (HCC). METHODS AND STUDY DESIGN: We retrospectively analyzed the records of 51 patients with hepatocellular carcinoma and extrahepatic metastases between 2007 and 2010 before treatment. The associations among overweight status (body mass index [BMI] >24 kg/m2), demographic variables, and survival outcome were analyzed by univariate and multivariate analysis. RESULTS: BMI>24 kg/m2 was significantly associated with the 6-month survival rate (p=0.042). Gender (p=0.149), Child Pugh classification (p=0.149), Okuda staging (p=0.093), and albumin concentration >3.5 mg/dL (p=0.082) showed marginal survival benefits in univariate analysis. Multivariate analysis confirmed that BMI >24 kg/m2 was an independent prognostic factor for the 6-month survival rate (p=0.03). CONCLUSIONS: BMI >24 kg/m2 was associated with an improved 6-month survival rate in patients with extrahepatic metastatic hepatocellular carcinoma.

Truth telling in Taiwanese cancer care: patients' and families' preferences and their experiences of doctors' practices.

OBJECTIVE: Despite the significant role played by cancer patients' families in medical decision-making in Asian countries, inconsistencies have hitherto not been evaluated between patients' and families' preferences and doctors' actual practices with regard to cancer truth telling. METHODS: For this quantitative comparative study of cancer patients' and families' truth-telling preferences and their experiences of doctors' practices, 532 patients, 551 family members, and 127 doctors (N = 1 210) were enrolled from five hospitals across Taiwan over 2 years. Truth telling was assessed using the Taiwanese version of a modified Japanese truth-telling scale. RESULTS: Patients' truth-telling preferences and their experiences of doctors' truth-telling practices differed significantly in scores on the overall truth-telling scale and each subscale, including method of disclosure, emotional support, additional information, and setting (P < .001). Similar findings were obtained for families' preferences and doctors' actual practices (P < .001). Patients' and families' truth-telling preference scores were higher than doctors' actual practice scores. Multiple regression analysis revealed a dose-dependent effect of doctors' monthly truth-telling frequency on their truth-telling preferences, but this effect was only borderline significant (P = .08). This multiple regression model explained 30% of the total variance in doctors' truth-telling preferences (F = 1.38, P = .22). CONCLUSIONS: Taiwanese medical educational policies need to be revised to better equip doctors to practice truth telling in accordance with the preferences of cancer patients and families. Communication skills training should be prioritized for doctors who refrain from truth telling in actual practice.

Dasatinib-related chylothorax.

Dasatinib is a potent second-generation tyrosine kinase inhibitor for the treatment of chronic myeloid leukemia. The most common adverse event associated with dasatinib therapy is fluid retention, including pleural effusion. Dasatinib-related chylothorax has rarely been reported. The clinical manifestations, pathophysiology, management, and prognosis are not fully understood. Here we report a 40-year-old woman presenting with chylothorax following dasatinib use. We propose the hypothesis of its mechanism as well as offering a review of the relevant literature.

The Charlson Comorbidity Index is an Independent Prognostic Factor for Treatment-Naïve Hepatocellular Carcinoma Patients with Extrahepatic Metastases.

BACKGROUND/AIMS: This study aimed to investigate the association between comorbidity, anti-cancer treatment, and overall survival in patients with hepatocellular carcinoma (HCC) with extrahepatic metastases. METHODOLOGY: We retrospectively analyzed data from 57 patients diagnosed as having treatment-naïve stage IV HCC with extrahepatic metastases between 2007 and 2010. Comorbidity was assessed using two scoring systems, the Charlson comorbidity index (CCI) and the Kaplan-Feinstein index. Associations between comorbidity, demographic variables, treatment modality, and overall survival were analyzed. RESULTS: Univariate analysis showed that a CCI of ≥ 2 (P = 0.017), an Okuda score of II/III (P = 0.026), and the use of anti-cancer therapy (P = 0.039) was associated with overall survival. Fewer patients with a CCI of ≥ 2 received treatment (P < 0.001), and anti-cancer treatment of any modality did not show a survival benefit in these patients (P = 0.174). The multivariate analysis showed that a CCI of ≥ 2 was the only independent prognostic factor for overall survival (P = 0.043). CONCLUSIONS: The pre-treatment comorbidity status played an important role in overall survival because of its association with the administration of anti-cancer therapy. Therefore, comprehensive evaluation of comorbidities before treatment is recommended for HCC patients with extrahepatic metastases.

A retrospective review of the prognostic value of ALDH-1, Bmi-1 and Nanog stem cell markers in esophageal squamous cell carcinoma.

Stem cell markers are upregulated in various cancers and have potential as prognostic indicators. The objective of this study was to determine the expression of three stem cell markers, aldehyde dehydrogenase 1 (ALDH-1), B cell-specific Moloney murine leukemia virus integration site 1 (Bmi-1), and Nanog, in esophageal squamous cell carcinoma (ESCC) tissues. Immunohistochemistry was used to measure the expression of ALDH-1, Bmi-1, and Nanog in ESCC tissues from 41 patients who received pre-operative chemoradiation. We evaluated the relationship between expression of these markers, and clinicopathological features, tumor regression grade (TRG), and 5-year overall survival (OS). There were no significant associations of ALDH-1 or Bmi-1 expression with age, gender, clinical stage, and treatments (p>0.05). However, patients with Nanog-positive tumors were significantly older than those whose tumors were Nanog-negative (p = 0.033). TRG after treatment was significantly associated with expression of ALDH-1 (p = 0.001), Bmi-1 (p = 0.004), and Nanog (p<0.001). Although OS was significantly better in patients with low TRGs (p = 0.001), there were no significant correlations between ALDH-1, Bmi-1, or Nanog with OS. Expression of ALDH-1, Bmi-1, and Nanog correlated with TRG, but not OS. Further large studies are necessary to fully elucidate the prognostic value of these stem cell markers for ESCC patients.

Omega-3 fatty acid-, micronutrient-, and probiotic-enriched nutrition helps body weight stabilization in head and neck cancer cachexia.

OBJECTIVE: To evaluate whether an oral nutritional supplement enriched with omega-3 fatty acids, micronutrients, and probiotics affected body weight (BW) changes, serum albumin and prealbumin levels in patients with head and neck cancer (HNC) cachexia. STUDY DESIGN: Sixty-eight HNC patients were randomly assigned to receive either an Ethanwell/Ethanzyme (EE) regimen enriched with omega-3 fatty acids, micronutrients, and probiotics, or control (Isocal) for a 3-month period. Analysis of covariance was used to examine the association between BW change and variables. RESULTS: Patients with body mass index (BMI) <19 and those receiving the EE regimen consumed fewer daily calories but showed significantly increased BW and maintained higher serum albumin and prealbumin levels than other patients (P<.05). Their BW changes were significantly associated with changes in serum albumin and prealbumin levels. CONCLUSIONS: EE regimen improved BW as well as serum albumin and prealbumin levels in HNC patients with BMI <19.

Pretreatment performance status and nutrition are associated with early mortality of locally advanced head and neck cancer patients undergoing concurrent chemoradiation.

Unexpected fatal events in patients with head and neck cancers undergoing concurrent chemoradiation therapy are a clinical concern. Malnutrition, which is reported frequently in head and neck cancer patients, are associated with immunity derangement. The purpose of this study was to identify risk factors for early death of patients undergoing chemoradiation. We retrospectively analyzed the records of 194 stage III, IVA, and IVB head and neck cancer patients who were treated with chemoradiation between 2007 and 2009. We defined early death as death while receiving chemoradiation or within 60 days of treatment completion. Risk factors for early death were tested using univariate and multivariate analyses. Fourteen patients (7.2 %) experienced early death, 78.6 % of whom died of infection. Univariate analysis revealed significant correlations between early death and several pretreatment variables, including Eastern Cooperative Oncology Group performance status (PS) >1, hemoglobin <10 g/dL, albumin <3 g/dL, body mass index (BMI) <19 kg/m(2), and peripheral blood total lymphocyte count <700/µL. Multivariate analysis showed that PS >1, BMI <19 kg/m(2), and peripheral blood total lymphocyte count <700/µL were independent variables associated with early death. Poor performance status and malnutrition before chemoradiation independently predict early death in locally advanced head and neck cancer patients undergoing chemoradiation. Cautious management of head and neck cancer patients with these risk factors is required throughout chemoradiation period.

Low body mass index at 3 months following adjuvant chemoradiation affects survival of postoperative locally advanced oral cavity cancer patients.

OBJECTIVES/HYPOTHESIS: To investigate the association between body mass index and outcomes such as recurrence and survival in postoperative locally advanced oral cavity cancer patients who underwent adjuvant chemoradiation. STUDY DESIGN: Retrospective analysis of patient data and outcomes. METHODS: We retrospectively analyzed the records of 61 stage III, IVA, and IVB oral cavity cancer patients who were treated with curative surgery and adjuvant chemoradiation between 2007 and 2009. Each patient's body mass index was recorded throughout the treatment duration and after its completion. The associations between demographic variables, body mass index, and survival outcomes were determined by univariate and multivariate analyses. RESULTS: Overall, body mass index decreased throughout the chemoradiation period and reached the nadir at 3 months after completion of therapy. Univariate analysis showed that patients with body mass index <18.5 kg/m(2) at 3 months after chemoradiation had significantly higher recurrence and decreased survival rates. Multivariate analysis confirmed that body mass index <18.5 kg/m(2) at this time point is an independent predictor for recurrence (P = .039) and overall survival (P = .043). CONCLUSIONS: Early recurrence can be predicted by malnourished status 3 months after treatment completion. Malnourishment has significant negative effects on overall survival in locally advanced postoperative oral cavity cancer patients who are undergoing adjuvant chemoradiation. After therapy is completed, nutritional guidance and care should be continued for patients with this advanced disease.

Decreasing dosage of irinotecan, 5-flurouracil (5-FU) and leucovorin (LV) in the treatment of advanced and/or metastatic colorectal cancer: a phase II study.

BACKGROUND: In this study, we attempted to determine the efficacy and toxicity of decreasing dosage of irinotecan plus 5-fluorouracil (5-FU) and leucovorin (LV) in the treatment of advanced colorectal cancer. METHODS: A total of 250 mg/m2 Irinotecan (CPT-11) intravenous infusion for 90 minutes was administered every 3 weeks. A 24-hour intravenous infusion with 2000 mg/m2 5-FU and 200 mg/m2 LV was administered through a port-A catheter system weekly for 2 consecutive weeks. Each treatment cycle was repeated every 3 weeks. Progression-free survival and survival curves were drawn according to Kaplan-Meier method. Tumor responses were determined according to the RECIST guidelines. Toxicities were evaluated using the WHO criteria. RESULTS: Thirty-eight patients were enrolled from September 2001 through October 2004. The median number of treatment courses was 8.1 (range, 1-14). Based on the intent-to-treat principle, the response rate was 39.5% (95% CI: 25.4-54.4%) which included 5.3% complete response (CR) and 34.2% partial response (PR). The time to tumor progression was 8.4 months (range, 2-12 months). The median time of survival was 18.4 months (range, 4-26 months). The major toxicities were grade 1 neutropenia and grade 2 diarrhea. Toxic death was not found in this study. The efficacy of this regimen was compatible with the reports of the clinical trials in the United States and European countries but fewer incidence of toxicity was found in our results. CONCLUSION: The results revealed that our combination regimen of 5-FU/LV + CPT-11 is a highly effective and acceptable protocol. This treatment is easily performed in an outpatient clinic. The biggest advantage is that all patients were intensively cared by the physicians to maintain a quality of life, and only 26.3% of patients showed progressive disease. Therefore, this regimen may be considered to be used in the treatment of patients with terminal cancer. A further randomized study comparing this regimen with oral fluoropyrimidines plus irinotecan is warranted.

The relationship between parental concerns and professional assessment in developmental delay in infants and children--a hospital-based study.

BACKGROUND: Developmental delay (DD) in infants and children is one of the chief complaints of parents. It has been established that the concerns of parents are as accurate as quality screening tests. Some kinds of concerns are particularly useful in the early detection of associated developmental problems. The purpose of this study was to investigate the relationship between the main parental concerns and the final diagnosis based on professional assessment of children who are suspected to have DD. METHODS: One-hundred and 1 infants or children were recruited into this study. The major concerns of parents were elicited and categorized by various developmental domains: speech, motor, behavioral, cognitive, global, and non-specific developmental problems. All children underwent comprehensive combined assessments by professionals in the hospital, and were classified into 6 subtypes: speech, motor, behavioral, cognitive, and global DD, and normal development. RESULTS: Our results revealed that parental concerns about speech, motor, and behavioral development yielded a high sensitivity to the final diagnosis of the same developmental domain (77-89%). However, concerns about cognitive and global DD had limited sensitivity (15-36%). On the other hand, concerns about global, speech, and motor DD had relatively higher positive predictive values (55-77%). Comparatively, cognitive or behavioral concerns had lower positive predictive values (25-33%). CONCLUSIONS: Such results indicate that parents play an important role in detecting speech, motor and behavioral DD in children. Parental concerns about cognition and behavior should be questioned in terms of their association with the real problem. This information may be useful in establishing trends in understanding the discrepancy or relationship between parental concerns and professional assessments in DD.

A randomized trial comparing intravesical instillations of mitoxantrone and doxorubicin in patients with superficial bladder cancer.

BACKGROUND: This randomized trial was conducted to compare the efficacy and side effects of intravesical mitoxantrone instillation with those of doxorubicin in superficial bladder cancer following transurethral resection. METHODS: Sixty-three patients were randomized into mitoxantrone and doxorubicin groups. Most of the patients enrolled were elderly people (mean age, 71 years). The instilled doses of doxorubicin and mitoxantrone were 30 and 14 mg, respectively. Disease recurrence and side effects were compared using Fisher's exact test. The interval to recurrence was shown by Kaplan-Meier survivorship curves, and the log-rank test was used to compare the time to recurrence. RESULTS: The median follow-up period was 36 months. Thirty-three patients received mitoxantrone, whereas 30 patients used doxorubicin. The recurrence rate in the doxorubicin group was 30% (95% CI: 19.8%-38.8%), while it was 27.3% (95% CI: 17.5%-36.8%) in the mitoxantrone group. The median recurrence-free survival in the mitoxantrone group and in the doxorubicin group was 22 and 20 months, respectively (p=0.580). Higher recurrence rates were found for Grade III and multiple primary tumors. There was no significant difference in response rates (p=0.784). The incidence of side effects was 20% in the doxorubicin group and 21.2% in the mitoxantrone group. However, the difference was not significant (p>0.99). CONCLUSIONS: The results revealed that the efficacy and side effects of mitoxantrone were similar to those of doxorubicin. Especially for patients with pulmonary tuberculosis or aged patients with primary bladder tumors, mitoxantrone and doxorubicin may be the tolerable and effective intravesical agents.

Primary malignant melanoma of the nasal cavity.

Malignant melanoma is a highly lethal melanocytic neoplasm, usually affecting the skin. Primary malignant melanoma of the nasal cavity is rarely seen. Clinically, most patients display initial nonspecific symptoms of unilateral nasal obstruction or epistaxis. The prognosis is generally poor, with a mean survival time of 3.5 years. Extensive local invasion and distant metastasis to other organs may occur. The usual treatment of choice is radical excision. Radiotherapy and chemotherapy appear to have little effect. We report a fatal case of intranasal cavity malignant melanoma in which the patient initially presented with blood-tinged sputum, productive cough, and intermittent fever. Preoperative hepatic metastasis was found. Palliative surgery was performed to excise the nasal cavity tumor. Then, 6 courses of chemotherapy were further administered. Unfortunately, regional cervical nodal involvement and pancreatic head metastases occurred 1.5 years after the diagnosis. The patient's condition rapidly deteriorated, followed by death. We have chosen to discuss this aggressive condition because of its rarity and also to emphasize the importance of its early detection through vigilant attention to nonspecific nasal symptoms. A review of the literature concerning intranasal malignant melanoma is presented. We further discuss its possible etiology, site of origin, incidence, clinical presentations, principles of management, and outcome.