Acute care hospitalization near the end of life for cancer patients who die in hospital in Canada.

Acute care hospitals have a role in managing the health care needs of people affected by cancer when they are at the end of life. However, there is a need to provide end-of-life care in other settings, including at home or in hospice, when such settings are more appropriate. Using data from 9 provinces, we examined indicators that describe the current landscape of acute care hospital use at the end of life for patients who died of cancer in hospital in Canada. Interprovincial variation was observed in acute care hospital deaths, length of stay in hospital, readmission to hospital, and intensive care unit use at the end of life. High rates of acute care hospital use near the end of life might suggest that community and home-based end-of-life care might not be suiting patient needs.

Global threats to human water security and river biodiversity.

Protecting the world's freshwater resources requires diagnosing threats over a broad range of scales, from global to local. Here we present the first worldwide synthesis to jointly consider human and biodiversity perspectives on water security using a spatial framework that quantifies multiple stressors and accounts for downstream impacts. We find that nearly 80% of the world's population is exposed to high levels of threat to water security. Massive investment in water technology enables rich nations to offset high stressor levels without remedying their underlying causes, whereas less wealthy nations remain vulnerable. A similar lack of precautionary investment jeopardizes biodiversity, with habitats associated with 65% of continental discharge classified as moderately to highly threatened. The cumulative threat framework offers a tool for prioritizing policy and management responses to this crisis, and underscores the necessity of limiting threats at their source instead of through costly remediation of symptoms in order to assure global water security for both humans and freshwater biodiversity.

Does routine symptom screening with ESAS decrease ED visits in breast cancer patients undergoing adjuvant chemotherapy?

BACKGROUND: In 2007, the provincial cancer agency in Ontario, Canada initiated a wide-scale program to screen for symptoms in the cancer population using the Edmonton Symptom Assessment Scale (ESAS). The purpose of this study is to evaluate the impact of screening with ESAS on emergency department (ED) visit rates in women with breast cancer receiving adjuvant chemotherapy. PATIENTS AND METHODS: This retrospective cohort study used linked administrative health care data from across the province of Ontario, Canada. The cohort included all women aged ≥18 who were diagnosed with stage I-III breast cancer between January 2007 and December 2009 and received adjuvant chemotherapy within 6 months of diagnosis. Using an adjusted recurrent event model, we examined the association of screening with ESAS at a clinic visit on the ED visit rate. RESULTS: The relative rate of ED visits was 0.57 when prior ESAS screening occurred compared to when it did not. The relative rate of ED visits was 0.83 when the prior number of ESAS screens was modeled as a continuous variable. Alternatively stated, the rate of ED visits was 43 % lower among patients previously screened with ESAS compared to those not previously screened. For each additional prior ESAS assessment, there was a 17 % decreased rate of ED visits. CONCLUSIONS: Our results demonstrate that screening with ESAS is associated with decreased ED visits. To our knowledge, this is the first report on the effectiveness of routinely documenting a patient reported outcome on ED visits, in a real-world setting.

Asian river fishes in the Anthropocene: threats and conservation challenges in an era of rapid environmental change.

This review compares and contrasts the environmental changes that have influenced, or will influence, fishes and fisheries in the Yangtze and Mekong Rivers. These two rivers have been chosen because they differ markedly in the type and intensity of prevailing threats. The Mekong is relatively pristine, whereas the Three Gorges Dam on the Yangtze is the world's largest dam representing the apotheosis of environmental alteration of Asian rivers thus far. Moreover, it is situated at the foot of a planned cascade of at least 12 new dams on the upper Yangtze. Anthropogenic effects of dams and pollution of Yangtze fishes will be exacerbated by plans to divert water northwards along three transfer routes, in part to supplement the flow of the Yellow River. Adaptation to climate change will undoubtedly stimulate more dam construction and flow regulation, potentially causing perfect storm conditions for fishes in the Yangtze. China has already built dams along the upper course of the Mekong, and there are plans for as many as 11 mainstream dams in People's Democratic Republic (Laos) and Cambodia in the lower Mekong Basin. If built, they could have profound consequences for biodiversity, fisheries and human livelihoods, and such concerns have stalled dam construction. Potential effects of dams proposed for other rivers (such as Nujiang-Salween) are also cause for concern. Conservation or restoration measures to sustain some semblance of the rich fish biodiversity of Asian rivers can be identified, but their implementation may prove problematic in a context of increasing Anthropocene alteration of these ecosystems.

Palliative care for cancer patients near end of life in acute-care hospitals across Canada: a look at the inpatient palliative care code.

Hospitals play an important role in the care of patients with advanced cancer: nearly half of all cancer deaths occur in acute-care settings. The need for increasing access to palliative care and related support services for patients with cancer in acute-care hospitals is therefore growing. Here, we examine how often and how early in their illness patients with cancer might be receiving palliative care services in the 2 years before their death in an acute-care hospital in Canada. The palliative care code from inpatient administrative databases was used as a proxy for receiving, or being referred for, palliative care. Currently, the palliative care code is the only data element routinely collected from patient charts that allows for the tracking of palliative care activity at a pan-Canadian level. Our findings suggest that most patients with cancer who die in an acute-care hospital receive a palliative designation; however, many of those patients are identified as palliative only in their final admission before death. Of the patients who received a palliative designation before their final admission, nearly half were identified as palliative less than 2 months before death. Findings signal that delivery of services within and between jurisdictions is not consistent, that the palliative care needs of some patients are being missed by physicians, and that palliative care is still largely seen as end-of-life care and is not recognized as an integral component of cancer care. Measuring the provision of system-wide palliative care remains a challenge because comprehensive national data about palliative care are not currently reported from all sectors. To advance measurement and reporting of palliative care in Canada, attention should be focused on collecting comparable data from regional and provincial palliative care programs that individually capture data about palliative care delivery in all health care sectors.

Mechanisms of exertional dyspnea in patients with cancer.

Exertional dyspnea is an important symptom in cancer patients, and, in many cases, its cause remains unexplained after careful clinical assessment. To determine mechanisms of exertional dyspnea in a variety of cancer types, we evaluated cancer outpatients with clinically important unexplained dyspnea (CD) at rest and during exercise and compared the results with age-, sex-, and cancer stage-matched control cancer (CC) patients and age- and sex-matched healthy control participants (HC). Participants (n = 20/group) were screened to exclude clinical cardiopulmonary disease and then completed dyspnea questionnaires, anthropometric measurements, muscle strength testing, pulmonary function testing, and incremental cardiopulmonary treadmill exercise testing. Dyspnea intensity was greater in the CD group at peak exercise and for a given ventilation and oxygen uptake (P < 0.05). Peak oxygen uptake was reduced in CD compared with HC (P < 0.05), and breathing pattern was more rapid and shallow in CD than in the other groups (P < 0.05). Reduced tidal volume expansion during exercise correlated with reduced inspiratory capacity, which, in turn, correlated with reduced inspiratory muscle strength. Patients with cancer had a relatively reduced diffusing capacity of the lung for carbon monoxide, reduced skeletal muscle strength, and lower ventilatory thresholds during exercise compared with HC (P < 0.05). There were no significant between-group differences in measurements of airway function, pulmonary gas exchange, or cardiovascular function during exercise. In the absence of evidence of airway obstruction or restrictive interstitial lung disease, the shallow breathing pattern suggests ventilatory muscle weakness as one possible explanation for increased dyspnea intensity at a given ventilation in CD patients.

The surgical management of pediatric breast masses.

Information regarding the surgical management of breast masses in the pediatric age group is sparse and is primarily directed at unusual neoplasms. We have reviewed the surgical treatment of 50 patients with inflammatory and neoplastic breast masses occurring in a 15-year period (1957 to 1973) at the Children's Hospital of Los Angeles. There were 42 girls and 8 boys, ranging in age from 12 days to 18 years. All patients had either surgical excision or incision and drainage of the masses with a subsequent histologic diagnosis. A variety of pathologic entities were encountered, but there were no primary malignancies. There were 33 patients with fibroadenomas, including four patients with multiple masses. Thirteen patients, six of whom were male, had cellulitis with an underlying breast abscess. The offending organism was gram-negative in one third of these abscesses. While none of the masses in this series were malignant, surgery was indicated to (1) establish diagnosis, (2) allay fears of patient, family, and referring physician, and (3) correct an obvious cosmetic deformity. Surgical drainage encouraged resolution of the inflammatory process, aided in the recovery of the organism, and assured appropriate drug therapy.

Pediatric lipoblastomatosis: two unusual cases.

Lipoblastomatosis is a rare, fatty tumor of childhood that is usually located in the limbs. Two pediatric patients were seen with tumors that originated in the mediastinum and retroperitoneal area. The mediastinal tumor was the infiltrating form of lipoblastomatosis while the retroperitoneal tumor was the noninfiltrating type. Neither form is malignant but local recurrences are common. Both were surgically excised without sacrifice of important contiguous structures that were surrounded by tumor. There has been no recurrence 21/2 and 6 years after operation. Conservative excision of this malignant-appearing but histologically benign tumor is emphasized.

Bronchiectasis in pediatric patients resulting from aspirated grass inflorescences.

A grass inflorescence (flowering head) aspirated by a child is difficult to diagnose, and frequently cannot be retrieved by bronchoscopy. Of four pediatric patients with aspirated grass inflorescences, two had severe hemoptysis and the other two were septic at the time of diagnosis. Their chronic debilitation and bronchiectasis necessitated an eventual pulmonary resection, with full recovery in all four patients.

Diagnosis and management of congenital vascular rings: a 22-year experience.

Between 1968 and 1990, we operatively treated 39 patients (19 boys, 20 girls) with congenital aortic arch anomalies. Median age was 7 months (range, 1.5 months to 23 years). Thirty-seven patients (95%) had respiratory symptoms. Barium swallow was diagnostic in 95%. Right arch with aberrant left subclavian artery and double aortic arch were the most common types (11 each). Treatment of an aortic diverticulum was documented in 19 patients; the aortic diverticulum was excised (9), managed by aortopexy (7), or left in situ (3). Postoperative recovery was rapid, with a median intensive care unit stay of 2 days, time to oral feeding of 1 day, and postoperative time to discharge of 7 days. Two deaths occurred: 1 infant had undergone emergent operation for control of hemorrhage from an aortotracheal fistula due to tracheostomy tube erosion, and the other had multiple associated congenital heart defects. Postoperative complications included bleeding (1), pneumonia (5), and chylothorax (4). One boy had persistent severe symptoms due to an untreated aortic diverticulum and underwent subsequent excision of the aortic diverticulum with complete relief of symptoms. Median length of follow-up was 12.5 months, with at least 97% of survivors completely or nearly completely free of symptoms from the vascular ring. These results suggest that early repair of congenital aortic vascular rings, including fixating or excising an associated serious aortic diverticulum, is safe and effective and allows for normal tracheal growth.

Pneumothorax in the Marfan syndrome: prevalence and therapy.

At least twenty-four reports of pneumothorax associated with the Marfan syndrome have appeared in the medical literature, but the frequency and optimal method of treatment remain unclear. We conducted a retrospective review of medical records from one genetics clinic and found that the frequency of spontaneous pneumothorax in patients older than 12 years with Marfan's syndrome was 4.4% (11 out of 249). Men were more commonly, but no more severely, affected than women. Seven patients had recurrent or bilateral pneumothorax. In 9 of the 11 patients, apical bullae were present and detectable on chest radiograph. Pneumothorax frequently recurred if not treated by resection of the offending bullae. We recommend that all adolescent and adult patients with the Marfan syndrome undergo chest radiography for ascertainment of the gross pathological condition of the lung. Definitive surgical treatment should be performed at the first occurrence of pneumothorax because of the high rate of recurrence after treatment with a chest tube, with or without pleurodesis.

Management of dyspnea and cough in patients with cancer.

The understanding and treatment of dyspnea in the cancer patient are where the science of pain management was 15 or 20 years ago. Very few studies have examined the pathophysiologic mechanisms that cause dyspnea in cancer patients, and few investigators have evaluated therapeutic strategies to control dyspnea in this patient group. The optimal therapy for dyspnea is treatment of the underlying cause. When this is not possible, opioids and phenothiazines provide effective symptomatic relief in most cases, but many unanswered questions remain. Are these the optimal drugs, and what are their optimal doses? What are the effects of chronic dosing? Which is the best route of administration? How serious are the risks of respiratory depression? A clear consensus supports the aggressive treatment of pain in terminally ill cancer patients, even if death is hastened as an unintended consequence. No such position has yet been reached in the management of dyspnea in the same population. As a result, dyspnea is addressed only very late in the course of the disease, perhaps reducing the patient's quality of life and function at earlier stages and resulting in a very small "therapeutic window" in the terminal phase. Clearly, a need exists for more research to determine the most effective management of this common and very distressing symptom.

Dyspnea in the advanced cancer patient.

Optimal management of dyspnea in terminal cancer patients requires an understanding of the responsible pathophysiological mechanisms. This prospective study assessed visual analogue scales (VAS) of shortness of breath (SOB) and anxiety, bedside spirometry, maximum inspiratory pressure (MIP), chest radiography, arterial blood gases, hemoglobin, and electrocardiogram, if indicated, in 100 terminally ill cancer patients. Forty-nine percent of the patients had lung cancer. The median VAS scores for SOB and anxiety were 53 mm and 29 mm, respectively. Spirometry was abnormal in 93% of patients, with 5% having obstructive, 41% restrictive, and 47% mixed patterns. The median MIP was 16 cm H2O. Sixty-five percent of the patients had parenchymal or pleural involvement on chest radiograph. Twenty-nine percent had evidence of cardiac ischemia, recent or current myocardial infarction or atrial fibrillation. Patients had a median of five different abnormalities that could have contributed to their shortness of breath. Only anxiety (p = 0.001), a history of smoking (p = 0.02), and pCO2 levels were statistically significantly correlated with SOB VAS scores. The potentially correctable causes of dyspnea included hypoxia (40%), anemia (20%), and bronchospasm (52%). The finding of very low MIPs suggests severe respiratory muscle weakness may contribute significantly to dyspnea in this patient population. Further studies are needed to confirm this finding and characterize the underlying pathophysiology.

The short-form McGill Pain Questionnaire in chronic cancer pain.

A short form of the McGill Pain Questionnaire (SF-MPQ) was previously developed. It was found to correlate highly with and demonstrate differences due to treatment in a manner similar to the long form of the McGill Pain Questionnaire (LF-MPQ). The LF-MPQ was previously found to be a valid measurement of pain in the cancer population. The present study demonstrated that the sensory, affective, and total scores of the SF-MPQ correlated highly with the LF-MPQ on three administrations, each 3-4 wk apart in 24 patients with chronic pain due to cancer. Both the long and short total scores correlated highly with the visual analogue scale (VAS) and present pain intensity (PPI) scale. The SF-MPQ demonstrated changes over time in a manner similar to the LF-MPQ in this patient group. These observations support the value of the SF-MPQ as a tool for studying interventions in patients with chronic pain due to cancer.

Physiological changes and clinical correlations of dyspnea in cancer outpatients.

The purposes of this cross-sectional study of 75 outpatients of a general oncology clinic were to assess the subjective and objective factors associated with dyspnea in cancer patients and to characterize factors that might contribute to respiratory muscle weakness demonstrated in a previous study. Patients with moderate to severe shortness of breath completed visual analogue scales (VAS) of shortness of breath (SOB) and anxiety; other data were acquired from pulmonary function tests, including maximum inspiratory pressure (MIP) and expiratory pressures; chest radiography; arterial blood gases; measurement of hemoglobin, serum potassium, phosphate, calcium, albumin, and magnesium; and ultrasound study of the diaphragm for thickness and excursion. The correlation coefficient between SOB VAS and anxiety VAS was 0.26 (P = 0.03). In stepwise multiple regression analyses, only the regression coefficient for anxiety remained significant at P < 0.05 in the multivariate model with SOB VAS as the dependent variable. The multivariate model using MIP (a measure of respiratory muscle strength) as the dependent variable, found significance for total diaphragmatic excursion, hemoglobin, phosphate, residual volume over total lung volume, vital capacity, percent predicted total lung capacity, oxygen saturation, and forced vital capacity. The regression coefficients for these variables were significant at P < 0.05 and the model accounted for 58% of the variance of MIP.

A Canadian survey of issues in cancer pain management.

We report the analysis of a cancer management survey mailed to a representative group of health professionals in 1994. The goals of the study were to gather information on cancer pain treatment practices, and to obtain health professional views on obstacles to ideal pain management. The survey, designed by a working party of pharmacists, nurses and physicians, was distributed to 14,628 physicians. A total of 2,686 physicians responded to the survey, including 39% of medical or radiation oncologists, and 18.19% of physicians who listed their primary interest as Family Medicine. Reflecting the modest emphasis placed on palliative care and cancer pain management in the current Canadian milieu, 67% of physicians rated their past teaching experience as only "fair" or "poor." Lack of exposure to pain education was reflected in the response to a series of hypothetical case scenarios exploring physician choices in managing severe cancer pain. For example, in the initial management of a cancer patient with severe pain, 50% of physicians would not use a strong opioid in the absence of other contraindications to opioid use. A wide variety of analgesics and non-pharmacologic techniques is available to Canadian physicians to assist patients with pain. Few physicians identified the unavailability of analgesics or analgesic techniques as limiting factors in pain management. We conclude that greater emphasis should be placed on pain education in our training programmes. We suggest that further surveys of this type, sponsored by our provincial colleges and medical organizations, can provide feedback which will enhance the adherence by Canadian physicians to published guidelines for pain management.

Dyspnea in cancer patients: prevalence and associated factors.

The objectives of this study were to determine the prevalence of dyspnea in the general cancer population, the intensity of the symptom as perceived by the patient, and the patient characteristics associated with the presence of dyspnea. Nine hundred and twenty-three cancer outpatients completed visual analogue scales (VAS) and verbal rating scales (VRS-D) to assess the intensity of their dyspnea. Baseline data included variables that were known covariates of dyspnea. Forty-six percent of the patients had some shortness of breath. Only 4% had a diagnosis of lung cancer and 5.4% lung metastases. Risk factors found to be significantly related to the presence of dyspnea were history of smoking; asthma or chronic obstructive pulmonary disease (COPD); lung irradiation; or a history of exposure to asbestos, coal dust, cotton dust or grain dust (P values from 0.001 to 0.038). The prevalence of dyspnea was strongly related to the number of risk factors a patient had (P < 0.0001). The VAS and VRS-D were significantly correlated, establishing concurrent validity for the VRS-D.

Differential palatability of leaf litter to four sympatric isopods in a Hong Kong forest.

The feeding behaviour of four sympatric isopods from a Hong Kong forest has been investigated. The study included two armadillids (Formosillo raffaelei and Orodillo maculatus) and two philosciids (Burmoniscus ocellatus and Burmoniscus sp.). When given a choice of eight types of litter, all isopod species showed significant dietary selection, and food preferences were similar. Berchemia racemosa (Rhamnaceae) was most readily consumed, followed by Celtis sinensis (Ulmaceac), while feeding rates on Cinnamomum camphora (Lauraceae) were low. The armadillids exhibited a narrower dietary spectrum than the philosciids. All isopods showed significant differences in consumption rates when each litter type was presented separately to them. Cinnamomum camphora was eaten the slowest, while Celtis sinensis and Berchemia racemosa were the top-ranked species. Although patterns of litter ranking based on percentage eaten or feeding rates were similar, all isopods ate more food when given a mixture of leaves than when presented with a single litter type. Assimilation rates were, in general, positively related to feeding rates. On this basis, it appears that assimilation may influence food preference. There were no clear relationships between food preference or feeding rates and ash, calcium, copper, soluble tannin or energy content of the litter. This finding may indicate the benefits of isopods maintaining a mixed diet, consuming certain litter species to meet their calcium or copper requirements and then switching to others so as to meet daily energy needs and to avoid excessive injection of tannins or plant allelochemicals.

Multipurpose central venous access in the immunocompromised pediatric patient.

During a 21-month period, 50 consecutive pediatric oncology patients undergoing bone marrow transplantation and/or cytoreductive chemotherapy had 61 silastic central venous catheters placed to facilitate their therapy. All catheters were used for medications, routine blood sampling, and transfusions, with 45% also used for hyperalimentation and 57% used for bone marrow transplantation. Catheters were utilized during both inpatient and outpatient therapy periods. Total catheter days numbered 8455, an average of 139 days per catheter. Forty-seven catheters (77%) were removed electively or were in place at time of patient death. Seven were removed for mechanical complications (1/1409 catheter days). Four additional episodes of presumed catheter sepsis were managed with antibiotics and did not require catheter removal (40% of septic episodes). One catheter is still in place after 585 days. Complication rates were not influenced by this multiple use protocol. With standardized catheter care and surveillance, multipurpose, long-term central venous access can be safely utilized in the immunosuppressed pediatric patient.

The effects of gastric hyperosmotic glucose feedings on regional perfusion in the neonatal piglet.

Regional blood flow and intestinal wall perfusion were studied in 13 anesthetized 1-5 day old neonatal piglets before and after gastric glucose infusion. The radionuclide labeled microsphere technique was used with 15 +/- 3 mu microspheres (85Sr, 141Ce) given in two separate left atrial infections. The 10% glucose with a patent blue dye marker did not affect CO but produced significant increases in blood flow to the adrenals bilaterally, to all layers of the proximal small intestine and to the mucosa of the distal small intestine. The glucose also caused a significant reduction in the animals' arterial pH, PaO2, and total CO2 with an increase in the blood glucose level. This response to gastric glucose infusion is different from adult animals since lower glucose concentrations produced blood flow changes in all layers of the exposed small intestine and the adrenals in our neonatal animals.