Assessing Efficacy and Use Patterns of Medical Cannabis for Symptom Management in Elderly Cancer Patients.

OBJECTIVES: Our study sought to further characterize patterns of medical cannabis use in elderly cancer patients. Furthermore, we sought to assess efficacy of medical cannabis for the treatment of pain, nausea, anorexia, insomnia and anxiety in elderly cancer patients. BACKGROUND: Medical cannabis use is growing for symptom management in cancer patients, but limited data exists on the safety or efficacy of use in elderly patients. METHODS: A retrospective chart review assessing changes in numerical symptom scores reported at clinic visits before and after medical cannabis initiation. RESULTS: There was no statistically significant difference in pain, nausea, appetite, insomnia or anxiety scores reported before and after initiation of medical cannabis. Oil was the most common form used, followed by vape, and the most common ratios used were high tetrahydrocannabinol (THC) to cannabidiol (CBD) and equal parts THC/CBD products. CONCLUSION: This study did not find a statistically significant change in symptom scores with medical cannabis use, although further study is warranted given the limitations of the present study. Elderly patients most commonly are using equal parts THC/CBD or high THC ratio products initially.

Hospice Emergency Planning and COVID-19.

Objectives: Centers for Medicare and Medicaid Services requirements for Emergency Preparedness Planning (EPP) by hospice organizations significantly increased in 2017. This study seeks to assess the involvement of various hospice personnel in EPP before and since the onset of the novel coronavirus disease COVID-19 pandemic. Methods: A link to an anonymous online survey was sent to members of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association, targeting members involved in hospice care in the United States. A descriptive analysis of the data was performed. Results: Prior to the pandemic, 39.8% of respondents were "moderately" or "very" involved with the development and revisions of the Emergency Preparedness Plan. Since the beginning of the pandemic, this increased to 59%, which largely occurred among physicians. Clinical Nurse and Nurse Practitioner involvement in development/revisions remained low. Approximately 30% of respondents desired more involvement across the areas of EPP. Conclusion: The involvement of personnel of various disciplines is varied and the involvement of physicians appears to have increased with the onset of the COVID-19 pandemic. A notable portion of personnel desired more involvement across all aspects of EPP. More research is needed in this important but little-understood area.

COVID-19 Pandemic Impacts on U.S. Hospice Agencies: A National Survey of Hospice Nurses and Physicians.

BACKGROUND: Hospice agencies face unique challenges during times of widespread public health emergencies. The pandemic of novel coronavirus disease COVID-19 is widely affecting global healthcare systems. AIM: This study assesses effects of the COVID-19 pandemic on U.S. hospice agencies, staff, and patients as reported by hospice agency staff. DESIGN: An anonymous electronic survey was developed. Free-text comments were assessed for impacts on hospice agencies, staff, and patients and their families. SETTING/PARTICIPANTS: The target audience was members of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association who self-identified as being active with hospice agencies in the United States. RESULTS: Reported impacts include inadequate supplies of personal protective equipment, changes in hospice services, and decreased access by hospice personnel to patients in long term care facilities. Flow of patients through hospice care settings was impeded. Agencies experienced changes in workforce availability and increased emotional support needs of staff. Patient and families experienced increased bereavement needs. Nearly one-third of respondents reported negative effects on patient outcomes, such as inadequate symptom management and negative psychosocial effects. CONCLUSION: Respondents indicate that the COVID-19 pandemic had negative effects on both hospice patient care and hospice agency functioning. Hospice agencies appear to face challenges unique among U.S. healthcare agencies due to their service delivery model and focus on interdisciplinary care. There is need for further exploration of the effects that the COVID-19 pandemic has on hospice agencies in order to improve care for their patient population during public health emergencies.

Dexmedetomidine as an Option for Opioid Refractory Pain in the Hospice Setting.

Background: Opioid refractory pain is a common problem in pain management. Dexmedetomidine is suggested to have opioid-sparing effects, with well-described use in surgical and intensive care unit settings. Some authors advocate its benefit in reducing delirium. Its effects are thought to be exhibited through agonism of pre- and postsynpatic α2-receptors in the central nervous system. It is more selective on α2-receptors than clonidine, accounting for its relatively lower incidence of hypotension. Its use in sedation is favored because it does not depress the respiratory system. The main side effects reported include bradycardia. Case Description: Twenty-eight-year-old woman with triple negative left breast cancer and a locally destructive tumor was admitted to hospice after exhausting her disease-directed therapy options. Her chief complaint was a throbbing, burning pain to the left chest wall, lower back, and bilateral lower extremities, rated 8/10 on a 10-point verbal scale. Multiple pharmacologic agents for pain, including patient-controlled analgesia infusions with adjuvant methadone and steroids, had failed to provide consistent pain management. Symptoms were difficult to control in the home setting, and she required multiple admissions to our inpatient hospice unit for pain management. She also developed episodes of delirium shortly after hospice admission. We attributed her symptoms to rapid disease progression. After failed pain control with opioids, ketamine, and lidocaine, we trialed a dexmedetomidine infusion. While on the infusion, her pain rating decreased to 0/10 and she had no delirium. Pain recurred soon after cessation of the infusion, initially rated 6/10. Conclusion: Dexmedetomidine is safe for opioid refractory pain in the hospice inpatient setting. However, its effects may not be sustained. There is potential for use in end-of-life care, with added benefit for possible control of delirium.

Myxedema Coma Complicated by Pancytopenia.

Hypothyroidism is common, with an extreme manifestation of myxedema coma if untreated. Hematologic consequences of myxedema coma include mild leukopenia and anemia, rarely pancytopenia. We present a patient with typical symptoms of myxedema coma, but found to be pancytopenic, with sustained response to levothyroxine and blood transfusion for anemia.

Cardiac Involvement by HIV-Associated DLBCL.

Non-Hodgkin's lymphoma (NHL) is a common AIDS-defining malignancy among people living with HIV. Of the different types of NHLs, diffuse large B-cell lymphoma (DLBCL) is the most common. Prognosis of DLBCL has improved over the years in the general population but remains relatively poor in HIV-positive individuals. Almost any organ system can be affected by DLBCL; however, cardiac involvement remains rare and suggests aggressive disease. We present a case of DLBCL in an HIV-positive patient, who had cardiac involvement, with the only clue to cardiac involvement being symptom being tachycardia and dysphagia.

Unilateral upper extremity lymphedema in metastatic prostate cancer.

Upper extremity lymphedema and cutaneous spread are atypical behavior of prostate disease and should be kept in the differential for selected patients. This presentation in these patients may be underdiagnosed and potentially an ominous sign. Our case adds to our continued learning of possible prostate malignancy behavior.