High-protein compared with standard parenteral nutrition in palliative cancer care.

OBJECTIVES: High-protein parenteral nutrition (PN) has been developed to counteract muscle loss in patients with cancer treated with PN. Nevertheless, it is not clear if high-protein PN is as safe as standard PN in patients with palliative cancer. Our primary aim was to compare the proportion of patients with elevated liver enzymes between high-protein and standard PN in patients with palliative cancer enrolled to Medical Home Care. Our secondary aim was to compare the two treatments with regard to weight and albumin levels during treatment. METHODS: Medical records from 2016 to 2018 were retrospectively reviewed to identify palliative cancer patients that had received PN for more than 3 weeks. Data on weight, height, albumin, liver enzymes, socioeconomic factors and dietitian consultations were collected at baseline and after 3-8 weeks of PN treatment. The odds of having elevated liver enzymes or having a maintained weight and/or stable albumin levels were calculated using logistic regression. RESULTS: 20 patients treated with high-protein PN were compared with 104 patients treated with standard PN. Patients treated with high-protein PN had a significantly higher weight at follow-up compared with patients treated with standard PN (p<0.05). There was no significant difference in the proportion of patients with elevated liver enzymes (OR 0.20; 95% CI 0.02 to 1.86), or maintained weight and/or albumin levels (OR 1.62; 95% CI 0.46 to 5.76) between high-protein and standard PN. CONCLUSION: High-protein PN was as safe, and at least as effective, as standard PN to patients with palliative cancer.

Equal effect of vancomycin lock with or without heparin in treatment of central venous catheter related blood stream infections - an observational study in palliative home care.

BACKGROUND: Catheter related blood stream infections is a complication in patients with central venous catheter. The aim of this study was to compare vancomycin-heparin-lock and non-heparin, high-dose vancomycin-lock as treatment in patients admitted to palliative home care. With non-heparin, high-dose vancomycin-lock a high concentration of 5 mg/mL vancomycin is attained instead of only 500 ug/mL when dissolved in heparin. The non-heparin method also has the advantage of being easier and cheaper but might entail an increased risk of clotting. METHODS: Medical records from patients enrolled at a palliative home care unit in Stockholm between 2016 and 2018 were reviewed retrospectively. Three divisions used vancomycin-heparin-lock and the other 3 divisions used non-heparin, high-dose vancomycin-lock. Inclusion criteria were a central venous catheter related blood stream infection treated with one of the two methods for >7 days and a follow-up blood culture at the end of treatment. RESULTS: Twenty-five patients fulfilled the inclusion criteria, 12 treated with vancomycin-heparin-lock and 13 with non-heparin, high-dose vancomycin-lock. There was no significant difference in resolved infections between the two treatments, 6 of 12 for vancomycin-heparin-lock and 10 of 13 for non-heparin, high-dose vancomycin-lock (p = .23). In the non-heparin group one central venous catheter was removed due to clotting although the infection had resolved. Overall, removal of central venous catheter was similar in the two groups (6 of 12 and 4 of 13, p = .43). CONCLUSION: The current study does not support superiority of one treatment over the other. However, larger, randomized studies are needed, before firm conclusions can be drawn.

Catheter-related bloodstream infections in palliative care patients receiving parenteral nutrition by medical home care.

BACKGROUND: Catheter-related bloodstream infections (CRBSIs) constitute a major complication associated with the use of central venous lines (CVL). The aim of this study was to investigate the incidence proportion and risk factors of CRSBI in palliative care patients with CVL receiving home parenteral nutrition (HPN). METHODS: Medical records from patients admitted to a medical home care unit in stockholm, Sweden, during 2017 were reviewed (n=1022) and 454 palliative care patients with a CVL were identified. Data on CRBSI cases, HPN exposure time, type of parenteral nutrition (PN), age, diagnosis and type of CVL were collected. RESULTS: Twenty-nine of 143 patients receiving HPN through a CVL were diagnosed with a CRBSI (20%). Nine of 311 patients with CVL without exposure for HPN developed CRBSI (3%). The risk of a CRBSI was significantly higher in patients receiving HPN compared with those not receiving HPN, OR 8.5 (95% CI 4.0 to 18.7). For those receiving HPN six to seven times a week the risk was even higher, OR 13 (95% CI 5.1 to 30.3). The highest incidence proportion of CRBSI (31%) was found in a home care team where patients had been trained to disconnect themselves from the PN drip. Sex, cancer versus non-cancer, type of CVL or protein content in the PN, did not differ between patients that developed CRBSI versus those that did not develop the outcome. CONCLUSION: HPN entails a high risk of CRBSI. A high frequency of PN and incautious handling of the disconnection of the drip, seem to be the most important risk factors.

Cognitive, psychosocial, somatic and treatment factors predicting return to work after breast cancer treatment.

BACKGROUND: Breast cancer (BC) may affect the ability to work. In this study, we want to identify any associations between cognitive, psychosocial, somatic and treatment factors with time to return to work (RTW) among women treated for BC. METHODS AND PARTICIPANTS: At eight (baseline) and 11(follow-up) months after BC diagnosis, women who had received adjuvant treatment for early BC at Stockholm South General Hospital completed the Headminder neuropsychological tests to obtain the Cognitive Stability Index (CSI), the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire and its Breast Cancer Module. At both time points, we compared the scores from women who had returned to work with those who had not. We also reviewed the medical certificates of women still on sick leave at 8, 11 and 18 months after diagnosis to determine why they had not returned to work. RESULTS: At baseline, 29 of 45 enroled women were working and 15 were not (one dropped out after baseline testing). The 14 women still not working 11 months after BC diagnosis had more advanced BC (OR = 3.64, 95% CI 2.01-7.31), lymph-node involvement (OR = 18.80, 95% CI 5.32-90.69) and Her 2-positive tumours (OR = 10.42,95% CI 2.19-65.32) than did working women. None of the scores for the four cognitive domains changed significantly at follow-up in either group. Comments on the medical certificates generally supported these findings. Independently of any adjuvant cancer therapy, overall quality of life improved and most women did RTW 18 months after BC diagnosis. CONCLUSIONS: Chemotherapy is associated with longer periods of sick leave. Cognitive functions do not predict RTW. Independently of any adjuvant therapy, most women eventually RTW in a few months. The ability to predict RTW after BC treatment should help prepare higher-risk patients for delayed RTW and allow earlier interventions to restore their social relations and quality of life.

Effects of adjuvant treatment on cognitive function in women with early breast cancer.

PURPOSE: Whether adjuvant therapy impairs cognitive function in women with breast cancer (BC) is unclear. We determined the effects of adjuvant therapy on cognitive function in women with early BC. METHODS: We consecutively and prospectively enrolled women aged 40-69 years who had a positive radiographic finding from the mammography screening program at Stockholm South General Hospital. All women completed the Headminder Web-based neuropsychological battery Cognitive Stability Index (CSI) for response speed, processing speed, memory, and attention before diagnosis (T1), after surgery and before adjuvant treatment (T2), 6 months after start of adjuvant treatment (T3), and after another 3 months of follow-up (T4). Women with BC were divided into those receiving chemotherapy, hormone therapy, or no adjuvant medical therapy. Women without a diagnosis of BC served as healthy controls. RESULTS: Of the 146 women enrolled, 77 had BC of whom 18 received chemotherapy; 45, hormone therapy, and 14, no adjuvant medical therapy; 69 were healthy controls. Memory scores for women with BC were significantly lower than those for controls over time, even after controlling for age and education. Memory and response speed scores were lower after chemotherapy than before (P<0.01 for both). Processing speed and attention improved significantly over time in all groups, a result consistent with a practice effect. CONCLUSION: Our results indicate subtle changes related to time course and treatment. Especially, that chemotherapy may impair memory and response speed in women with BC, consistent with those reported by BC survivors after adjuvant medical treatment.

The effects of breast cancer diagnosis and surgery on cognitive functions.

BACKGROUND: Women with breast cancer (BC) report cognitive impairment. Receiving a BC diagnosis may have a negative psychological impact. We sought to determine whether a diagnosis of BC and subsequent surgical treatment reduced cognitive function. MATERIAL AND METHODS: We recruited women, who had a positive radiographic finding, consecutively from the mammography screening program at Stockholm South General Hospital. All subjects completed the Headminder Web-based neuropsychological battery Cognitive Stability Index (CSI) for response speed, processing speed, memory, and attention at enrolment (T1, Baseline). CSI was administered again, after BC was ruled out, or after sector resection or mastectomy, if BC was confirmed by cytology or biopsy (T2, Retest). RESULTS AND CONCLUSION: Of the 148 women approached, 146 were enrolled; 69 were healthy and 77 had BC. Comparison between groups at baseline, according to independent t-test, showed significant differences in response speed and processing speed. Cognitive abilities did not decline in either group on any of the measured domains. Our results suggest that a diagnosis of BC and subsequent surgery is not associated with substantial cognitive decline at retest. However, the lack of improvement in attention at retest among BC patients may be suggestive of a decline.

What are the qualities of dilemmas experienced when prescribing opioids in general practice?

The decision process preceding prescribing analgesics is complex and the physician is often struggling to balance several disparate considerations in order to work out what is rational. Several factors--medical, intellectual, emotional and logistic--influence the decision whether or not to prescribe, and the decision itself influences how the physicians feel about themselves. In this study the 'critical incident technique' was used for exploring the qualities of dilemmas among general physicians prior to prescribing analgesics to patients in primary health care. The study displayed two main types of problems in connection with prescription of opioids. The first main problem was a concern about abuse and addiction with no proper indication for the drug. The second main type of problem was related to the appropriateness of the drug, although the indication as such might be correct, i.e. acute or chronic pain. An important consequence of the dilemmas experienced influenced the physicians' self-esteem negatively, including failures in the patient-physician relationship. This results in emotional strain and is often experienced as a personal defeat. Only a few physicians denied prescription despite the experience of a dilemma, which might indicate an ambivalence or lack of knowledge among physicians with regard to proper indications for opioid prescription. However, it may also suggest that physicians need more training in saying no, or skills in deciding proper indications for opioids, which needs to be addressed during educational programmes.