Post-operative radiation improves survival in children younger than 3 years with intracranial ependymoma.

Concerns regarding long-term toxicities have led to the avoidance of post-operative radiation (PORT) in young children with intracranial ependymoma. We investigated the association between post-operative radiation therapy and overall survival (OS) in children younger than 3 years and compared their survival to other age groups. The study sample from the SEER database included 804 patients with intracranial ependymoma, grades 2-3, and diagnosed between 1988 and 2005. OS was estimated using the Kaplan-Meier method, and hazard ratios (HR) and 95% confidence limits (CL) were calculated based on multivariable Cox proportional hazards models. A total of 804 patients were selected and PORT was administered to 35% of patients younger than 3 years. With a median follow-up of 3 years (range 0.1-18 years), the 3 year OS was 61% for children younger than 3 years, 83% for those ages 3-20 years, and 69% for patients older than 20 years (P < 0.001). In multivariable analysis, OS was significantly improved for patients receiving PORT (HR 0.8, 95% CL 0.6-0.9), and gross total resection (HR 0.6, 95% CL 0.5-0.8). Among children younger than 3 years, the 3 year OS was significantly greater among those who received PORT compared to those who did not (81% vs. 56%, respectively, P = 0.005). The majority of children younger than 3 years with intracranial ependymoma did not receive PORT. Children younger than 3 years who did not receive PORT had a relatively poor outcome, while those who received radiation therapy had a survival similar to older patients.

Frequent manual repositioning and incidence of pressure ulcers among bed-bound elderly hip fracture patients.

Frequent manual repositioning is an established part of pressure ulcer prevention, but there is little evidence for its effectiveness. This study examined the association between repositioning and pressure ulcer incidence among bed-bound elderly hip fracture patients, using data from a 2004-2007 cohort study in nine Maryland and Pennsylvania hospitals. Eligible patients (n=269) were age ≥ 65 years, underwent hip fracture surgery, and were bed-bound at index study visits (during the first 5 days of hospitalization). Information about repositioning on the days of index visits was collected from patient charts; study nurses assessed presence of stage 2+ pressure ulcers 2 days later. The association between frequent manual repositioning and pressure ulcer incidence was estimated, adjusting for pressure ulcer risk factors using generalized estimating equations and weighted estimating equations. Patients were frequently repositioned (at least every 2 hours) on only 53% (187/354) of index visit days. New pressure ulcers developed at 12% of visits following frequent repositioning vs. 10% following less frequent repositioning; the incidence rate of pressure ulcers per person-day did not differ between the two groups (incidence rate ratio 1.1, 95% confidence interval 0.5-2.4). No association was found between frequent repositioning of bed-bound patients and lower pressure ulcer incidence, calling into question the allocation of resources for repositioning.

Trends in self-reported health care provider recommendations for colorectal cancer screening by race.

OBJECTIVE: To examine whether a racial difference exists in self-reported recommendations for colorectal cancer screening from a health care provider, and whether this difference has changed over time. METHOD: Secondary analysis of the 2002, 2004, 2006, and 2008 Maryland Cancer Surveys, cross-sectional population-based random-digit-dial surveys on cancer screening. Participants were 11,368 White and 2495 Black Maryland residents age ≥ 50 years. RESULTS: For each race, recommendations for colonoscopy/sigmoidoscopy increased over time (67%-83% for Whites, 57%-74% for Blacks; p<0.001 for both), but the race difference remained approximately 10% at each survey. Among respondents without a colonoscopy in the last 10 years (n=5081), recommendations for fecal occult blood test (FOBT) in the past year decreased over time for Whites (37%-24%, p<0.001) and for Blacks (36-28%, p=0.05), with no difference by race in any year. In multivariable analysis, the effect of race on the odds of reporting a provider recommendation did not vary significantly across time for either test (p=0.80 for colonoscopy/sigmoidoscopy, p=0.24 for FOBT for effect modification by year). CONCLUSION: Whites were more likely than Blacks to report ever receiving a provider recommendation for colonoscopy/sigmoidoscopy. Although the proportion of patients receiving recommendations for colonoscopy/sigmoidoscopy increased over time, the gap between races remained unchanged.

Differences in services provided by hospices based on home health agency certification status.

BACKGROUND: Similar patient populations and favorable regulations have led many home health agencies to become Medicare and/or Medicaid certified as hospice agencies (mixed), but home health and hospice programs differ in focus and scope. Little research has been performed examining the differences between mixed hospices and those agencies only certified as hospices (nonmixed). OBJECTIVES: To describe the differences in agency characteristics between mixed and nonmixed agencies; and to compare frequencies of service provision by mixed and nonmixed agencies. RESEARCH DESIGN: Cross-sectional study using data from the 2000 National Home and Hospice Care Survey. SUBJECTS: A total of 760 Medicare and/or Medicaid certified hospice agencies providing services during the survey, including 393 mixed agencies (52% of sample) and 367 nonmixed hospices. MEASURES: Survey responses by administrators about services provided by agency. RESULTS: Nonmixed agencies were significantly more likely than mixed agencies to provide many types of services, including: volunteers [96.1% vs. 77.4%, respectively; odds ratio (OR): 7.27; 95% confidence interval (CI): 5.26-10.05], social services (96.1% vs. 93.5%; OR: 1.70; 95% CI: 1.20-2.40), spiritual care (95.1% vs. 77.8%; OR: 5.53; 95% CI: 4.13-7.41), bereavement care (93.5% vs. 79.8%; OR: 3.63; 95% CI: 2.80-4.72), counseling (89.5% vs. 70.2%; OR: 3.62; 95% CI: 2.92-4.48), and physician services (87.2% vs. 52.0%; OR: 6.30; 95% CI: 5.18-7.66). In logistic regression models, these differences remained significant after adjustment for census region, operation by a hospital, number of patients and number of hospice patients, and Medicare and Medicaid hospice certification status. CONCLUSIONS: Mixed agencies provide a narrower range of services to hospice patients than nonmixed agencies, including fewer services considered cornerstones of hospice treatment.

Pressure ulcer preventive device use among elderly patients early in the hospital stay.

BACKGROUND: Clinical guidelines for the prevention of pressure ulcers advise that pressure-reducing devices should be used for all patients at risk of or with pressure ulcers and that all pressure ulcers should be documented in the patient record. Adherence to these guidelines among elderly hospital patients early in the hospital stay has not been examined in prior studies. OBJECTIVE: The objective of this study was to examine adherence to guidelines by determining the frequency and correlates of use of preventive devices early in the hospital stay of elderly patients and by determining the frequency and correlates of recording pressure ulcers in the patient record. METHODS: This was a cross-sectional study of 792 patients aged 65 years or older admitted through the emergency department to the inpatient medical service at two teaching hospitals in Philadelphia, Pennsylvania, between 1998 and 2001. Patients were examined by a research nurse on Hospital Day 3 (median of 48 hours after admission) to determine the use of preventive devices, presence of pressure ulcers, and risk of pressure ulcers (by Norton scale). Data on additional risk factors were obtained from the admission nursing assessment in the patient record. Data on documentation of pressure ulcers were obtained by chart abstraction. RESULTS: Only 15% of patients had any preventive devices in use at the time of the examination. Among patients considered at risk of pressure ulcers (Norton score < or =14), only 51% had a preventive device. In multivariable analyses, high risk of pressure ulcers was associated with use of preventive devices (odds ratio = 41.8, 95% confidence interval = 14.0-124.6), whereas the type and stage of pressure ulcer were not. Documentation of a pressure ulcer was present for only 68% of patients who had a pressure ulcer according to the research examination. DISCUSSION: Use of preventive devices and documentation of pressure ulcers are suboptimal even among patients at high risk.

Communication skill frameworks: applications in radiation oncology.

Communication is an important part of high-quality care at every step. Communication skills can be learned, practiced, and improved. In this review, we outline the basic frameworks for communication skills training, describe their components, and demonstrate their utility in the context of vignettes. We discuss specific evidence-based roadmaps for approaching the various communication tasks a radiation oncologist might encounter. Each is summarized with an easy to remember mnemonic. These include responding to emotion using NURSE statements, delivering serious news using SPIKES, discussing prognosis using ADAPT, and discussing goals of care using REMAP. To tie it all together, we offer a simplified general approach to all communication tasks with the mnemonic ACE (Assess, Communicate, Empathize).

Bleeding in cancer patients and its treatment: a review.

Bleeding is a common problem in cancer patients, related to local tumor invasion, tumor angiogenesis, systemic effects of the cancer, or anti-cancer treatments. Existing bleeds can also be exacerbated by medications such as bevacizumab, nonsteroidal anti-inflammatory drugs (NSAIDs), and anticoagulants. Patients may develop acute catastrophic bleeding, episodic major bleeding, or low-volume oozing. Bleeding may present as bruising, petechiae, epistaxis, hemoptysis, hematemesis, hematochezia, melena, hematuria, or vaginal bleeding. Therapeutic intervention for bleeding should start by establishing goals of care, and treatment choice should be guided by life expectancy and quality of life. Careful thought should be given to discontinuation of medications and reversal of anticoagulation. Interventions to stop or slow bleeding may include systemic agents or transfusion of blood products. Noninvasive local treatment options include applied pressure, dressings, packing, and radiation therapy. Invasive local treatments include percutaneous embolization, endoscopic procedures, and surgical treatment.

Update of the systematic review of palliative radiation therapy fractionation for bone metastases.

PURPOSE: Radiation therapy is an effective modality for pain management of symptomatic bone metastases. We update the previous meta-analyses of randomized trials comparing single fraction to multiple fractions of radiation therapy in patients with uncomplicated bone metastases. METHODS: A literature search was conducted in Ovid Medline, Embase, and Cochrane Central Register. Ten new randomized trials were identified since 2010, five with adequate and appropriate data for inclusion, resulting in a total of 29 trials that were analyzed. Forest plots based on each study's odds ratios were computed using a random effects model and the Mantel-Haenszel statistic. RESULTS: In intention-to-treat analysis, the overall response rate was similar in patients for single fraction treatments (61%; 1867/3059) and those for multiple fraction treatments (62%; 1890/3040). Similarly, complete response rates were nearly identical in both groups (23% vs 24%, respectively). Re-treatment was significantly more frequent in the single fraction treatment arm, with 20% receiving additional treatment to the same site versus 8% in the multiple fraction treatment arm (p < 0.01). No significant difference was seen in the risk of pathological fracture at the treatment site, rate of spinal cord compression at the index site, or in the rate of acute toxicity. CONCLUSION: Single fraction and multiple fraction radiation treatment regimens continue to demonstrate similar outcomes in pain control and toxicities, but re-treatment is more common for single fraction treatment patients.

Top 10 Tips Palliative Care Clinicians Should Know About Radiation Oncology.

As palliative care (PC) moves upstream in the course of advanced illness, it is critical that PC providers have a broad understanding of curative and palliative treatments for serious diseases. Possessing a working knowledge of radiation therapy (RT), one of the three pillars of cancer care, is crucial to PC providers given RT's role in both the curative and palliative settings. This article provides PC providers with a primer on the vocabulary of RT; the team of people involved in the planning of RT; and common indications, benefits, and side effects of treatment.

A systematic review of the methods used to assess the association between appropriate antibiotic therapy and mortality in bacteremic patients.

Studies of the association between inappropriate antibiotic therapy and mortality among bacteremic patients have generated conflicting findings. We systematically reviewed these studies to identify methodological heterogeneity that may explain the lack of agreement. We identified 51 articles that met the inclusion criteria, and we extracted the following data: study design, definition and measurement of variables, and statistical methods. Only 8 studies (16%) defined inappropriate antibiotic therapy as that which was inactive in vitro against the isolated organism(s) and not consistent with current clinical practice recommendations and distinguished between empiric and definitive treatment. Thirty-four studies (67%) measured the severity of illness, but only 6 (12%) specified the time at which it was measured. The methodological recommendations suggested in this article are intended to improve the validity and generalizability of future research. In brief, future studies should define "inappropriate" therapy on the basis of in vitro susceptibility data, should separately evaluate empiric and definitive therapy, and should control for the baseline severity of illness.

Palliative radiation therapy for bone metastases: Update of an ASTRO Evidence-Based Guideline.

PURPOSE: The purpose is to provide an update the Bone Metastases Guideline published in 2011 based on evidence complemented by expert opinion. The update will discuss new high-quality literature for the 8 key questions from the original guideline and implications for practice. METHODS AND MATERIALS: A systematic PubMed search from the last date included in the original Guideline yielded 414 relevant articles. Ultimately, 20 randomized controlled trials, 32 prospective nonrandomized studies, and 4 meta-analyses/pooled analyses were selected and abstracted into evidence tables. The authors synthesized the evidence and reached consensus on the included recommendations. RESULTS: Available literature continues to support pain relief equivalency between single and multiple fraction regimens for bone metastases. High-quality data confirm single fraction radiation therapy may be delivered to spine lesions with acceptable late toxicity. One prospective, randomized trial confirms both peripheral and spine-based painful metastases can be successfully and safely palliated with retreatment for recurrence pain with adherence to published dosing constraints. Advanced radiation therapy techniques such as stereotactic body radiation therapy lack high-quality data, leading the panel to favor its use on a clinical trial or when results will be collected in a registry. The panel's conclusion remains that surgery, radionuclides, bisphosphonates, and kyphoplasty/vertebroplasty do not obviate the need for external beam radiation therapy. CONCLUSION: Updated data analysis confirms that radiation therapy provides excellent palliation for painful bone metastases and that retreatment is safe and effective. Although adherence to evidence-based medicine is critical, thorough expert radiation oncology physician judgment and discretion regarding number of fractions and advanced techniques are also essential to optimize outcomes when considering the patient's overall health, life expectancy, comorbidities, tumor biology, anatomy, previous treatment including prior radiation at or near current site of treatment, tumor and normal tissue response history to local and systemic therapies, and other factors related to the patient, tumor characteristics, or treatment.

Outcomes of Definitive Radiation Therapy for Primary Vaginal Carcinoma.

OBJECTIVE(S): The aim of this study was to review treatment and outcomes of patients with primary vaginal cancer treated with definitive radiotherapy. MATERIALS AND METHODS: We retrospectively reviewed medical records of 71 patients with primary vaginal adenocarcinoma or squamous cell carcinoma treated with definitive radiotherapy with at least 2 years of follow-up (median follow-up, 6.24 y). RESULTS: Ninety-three percent of patients were treated with external-beam radiotherapy plus brachytherapy (median dose, 7540 cGy); 4 patients with stage I disease and 1 patient with stage II disease were treated with brachytherapy alone (median dose, 6000 cGy). The cause-specific 5- and 10-year survival rates, respectively, were 96% and 96% for stage I patients, 75% and 68% for stage II patients, 69% and 64% for stage III patients, and 53% and 53% for stage IVA patients. The 5- and 10-year local-regional control rates for all patients were 79% and 75%, respectively. The 5- and 10-year distant metastasis-free survival rates for all patients were 87% and 85%, respectively. Sixteen patients had tumors involving the distal one third of the vagina. Of the 7 who received elective inguinal node irradiation, 0 failed in the inguinal nodes. Of the 9 who did not receive elective inguinal node irradiation, 2 failed in the inguinal nodes. Severe complications (grades 3 to 4) occurred in 16 patients (23%). CONCLUSIONS: Radiotherapy provides excellent results as definitive treatment for primary vaginal cancer, although the risk of severe complications is high. Generally, treatment should consist of both external-beam radiation therapy and brachytherapy. Inguinal nodes should be irradiated electively when the primary tumor involves the distal one third of the vagina.

Declining use of radiotherapy in stage I and II Hodgkin's disease and its effect on survival and secondary malignancies.

PURPOSE: Concerns regarding long-term toxicities have led some to withhold radiotherapy (RT) for the treatment of Stage I and II Hodgkin's disease (HD). The present study was undertaken to assess the use of RT for HD and its effect on overall survival and the development of secondary malignancies. METHODS AND MATERIALS: The present study included data from the Surveillance, Epidemiology, and End Results database from patients aged ≥ 20 years who had been diagnosed with Stage I or II HD between 1988 and 2006. Overall survival was estimated using the Kaplan-Meier method, and the Cox multivariate regression model was used to analyze trends. RESULTS: A total of 12,247 patients were selected, and 51.5% had received RT. The median follow-up for the present cohort was 4.9 years, with 21% of the cohort having >10 years of follow-up. Between 1988 and 1991, 62.9% had undergone RT, but between 2004 and 2006, only 43.7% had undergone RT (p < .001). The 5-year overall survival rate was 76% for patients who had not received RT and 87% for those who had (p < .001). The hazard ratio adjusted for other variables in the regression model showed that patients who had not undergone RT (hazard ratio, 1.72; 95% confidence interval, 1.72-2.02) was associated with significantly worse survival compared with patients who had received RT. The actuarial rate of developing a second malignancy was 14.6% vs. 15.0% at 15 years for those who had and had not undergone RT, respectively (p = .089). CONCLUSIONS: The present study is one of the largest studies to examine the role of RT for Stage I and II HD. Our results revealed a survival benefit with the addition of RT with no increase in the development of secondary malignancies compared with patients who had not received RT. Furthermore, the present nationwide study revealed a >20% absolute decrease in the use of RT from 1988 to 2006.

Care-related risk factors for hospital-acquired pressure ulcers in elderly adults with hip fracture.

OBJECTIVES: To identify care-related factors associated with hospital-acquired pressure ulcers (HAPUs). DESIGN: Prospective cohort study. SETTING: Nine hospitals in Baltimore Hip Studies network. PARTICIPANTS: Six hundred fifty-eight individuals aged 65 and older who underwent surgery for hip fracture. MEASUREMENTS: Skin examinations at baseline and on alternating days until hospital discharge. Participants were deemed to have a HAPU if they developed one or more new Stage 2 or higher pressure ulcers (PUs) during the hospital stay. RESULTS: Longer emergency department stays were associated with lower HAPU incidence (>4-6 hours: adjusted incidence rate ratio (aIRR) = 0.68, 95% confidence interval (CI) = 0.48-0.96; >6 hours: aIRR = 0.68, 95% CI = 0.46-0.99, both vs ≤ 4 hours). Participants with 24 hours or longer between admission and surgery had a higher postsurgery HAPU rate than those with less than 24 hours (aIRR = 1.62, 95% CI = 1.24-2.11). Surgery with general anesthesia had a lower postsurgery HAPU rate than surgery with other types of anesthesia (aIRR = 0.66, 95% CI = 0.49-0.88). There was no significant association between HAPU incidence and timing of transport to the hospital, type of transport to the hospital, or surgery duration. CONCLUSION: Most of the factors hypothesized to be associated with higher PU incidence were associated with lower incidence or were not significantly associated, suggesting that HAPU development may not be as sensitive to care-related factors as commonly believed. Rigorous studies of innovative preventive interventions are needed to inform policy and practice.