Creating a Palliative Care Clinic for Patients with Cancer Pain and Substance Use Disorder.

BACKGROUND: Opioids are a first-line treatment for severe cancer pain. However, clinicians may be reluctant to prescribe opioids for patients with concurrent substance use disorders (SUD) or clinical concerns about non-prescribed substance use. MEASURES: Patient volume, 60-day retention rate, and use of sublingual buprenorphine to treat opioid use disorder. INTERVENTION: We created the Palliative Harm Reduction and Resiliency Clinic, a palliative care clinic founded on harm reduction principles and including formal collaboration with addiction psychiatry. OUTCOMES: During the first 18 months, patient volume increased steadily; 70% of patients had at least one subsequent visit within 60 days of the initial appointment; and buprenorphine was prescribed for 55% of patients with opioid use disorder. CONCLUSIONS/LESSONS LEARNED: The formal collaboration with addiction psychiatry and the integration of harm reduction principles and practices into ambulatory palliative care improved our ability to provide treatment to a previously underserved patient population with high symptom burden.

Limitations and Complications in Treating Femoral Neck Fractures with the Femoral Neck System: A Case Report.

Introduction: The femoral neck system (FNS) represents an emerging fixation system designed for the management of femoral neck fractures. This innovative system combines the mechanical benefits of compression and anti-rotation properties in internal fixation. Biomechanical studies have demonstrated the superior axial and rotational stability of the FNS implant when compared to traditional cannulated screws and dynamic hip screw. Despite these promising mechanical advantages, there is currently a limited body of literature addressing the factors contributing to FNS failure. A thorough assessment of the safety and outcomes associated with this novel implant is essential. Case Report: In this context, we present three cases wherein FNS failure occurred, aiming to elucidate the potential causes behind these failures, and had to undergo either an implant removal or bipolar hemiarthroplasty. Conclusion: While considering the femoral neck system as the implant of choice, we should consider the age, injury to surgery time, and the location of the fracture line. However, we cannot conclusively ascertain whether age contributes independently to the risk of failure.

Case of Infected Non-Union of Distal Femur Treated with Ilizarov Fixator Assisted Knee Arthrodesis and Limb Lengthening Surgery.

Introduction: Femoral fractures in adults are around 3-6% and 0.4% of all the fractures are usually distal femoral fractures, frequently consisting of high-energy injuries which are associated with compound trauma. Conventionally, femoral-tibial fusion remains one of the last treatment choices for the recurrent septic failure. Case Report: We report a unique case where a 52-year-old male had presented with a post-operative infected non-union of distal femur and patella with discharging sinus and distal femur plate in situ. The patient presented to our outpatient department with complaints of pain and swelling over right knee with discharging sinus with fixed flexion deformity of 20° for 1-year post trauma and post-surgery. The discharging sinus was over lateral aspect of knee with purulent discharge. His blood parameters were suggestive of high erythrocyte sedimentation rate, and C-reactive protein levels and a Gram staining were suggestive of Gram-negative bacilli. X-ray showed non-union of distal femur and osteomyelitic changes and knee subluxation with distal femur plate and encirclage with K-wire for patella in situ. The patient underwents three-stage procedure of debridement with implant removal, followed by knee arthrodesis and ultimately limb lengthening surgery. Conclusion: Our case report is unique and distinctive as it shows that, when a case of infected non-union of distal femur comes with stiff and non-salvageable knee with severe arthritic changes and financial constraints, we should consider for knee arthrodesis with ilizarov ring fixator and limb lengthening surgery. Although it yielded stiff knee but with functioning limb without limb length discrepancy.

Does preoperative 3D CT planning helps in predicting the component size determination and alignment in automatic robotic total knee arthroplasty (RA-TKA).

Purpose: Image-based Robotic Total knee Arthroplasty (RA-TKA)was developed with the purpose of enhancing the accuracy in determining the component sizes preoperatively and helping surgeons in minimizing errors and improve patient outcomes. The research aims to find the reliability of robotic-assisted TKR based on images in determining the correct component sizes using preoperative three-dimensional (3D) computer tomography. Method: After ethical approval, we conducted a prospective study from March 2022 to December 2022. A total of 100 knees underwent image-based RA-TKA having grade 4 Osteoarthritis knee (Kellegren Lawrence classification). A single senior surgeon performed on all patients. Postoperative implant sizes and fit were assessed by five radiographic markers by an independent observer. Results: In our study, we found the mean age was (64.96 ± 7.3) years, with female to male ratio of 43:22. The preoperative 3D CT accuracy is 100% for femoral component sizing and 97% for the tibial component. There was a statistically significant improvement in varus deformity from preoperative 7.370 ± 3.70° to 1.24 0 ± 0.910° after surgery., p = 0.001. Improvement in flexion deformity correction was from preoperative 6.50 ± 6.30 to postoperative 1.640 ± 1.770, p = 0.001. Conclusion: Our study concludes that the use of pre-operative 3D CT helps in predicting the component sizes, minimizes surgical time, and enhances implant position accuracy, as well as improves postoperative limb alignment in the coronal and sagittal planes.

Patient Experiences After Aborted Cancer Surgery: A Qualitative Study.

BACKGROUND: Surgical resection is a necessary component of curative-intent treatment for most solid-organ cancers but is occasionally aborted, most often due to occult metastatic disease or unanticipated unresectability. Despite its frequency, little research has been performed on the experiences, care needs, and treatment preferences of patients who experience an aborted cancer surgery. METHODS: Semistructured interviews of patients who had previously experienced an aborted cancer surgery were conducted, focusing on their recalled experiences and stated preferences. All interviews were audio recorded, transcribed, and coded by two independent researchers by using NVivo 12. An integrative approach to qualitative analysis was used-both inductive and deductive methods-and iteratively identifying themes until saturation was reached. RESULTS: Fifteen patients with an aborted cancer surgery participated in the interviews. Cancer types included pancreatic (n = 9), cholangiocarcinoma (n = 3), hepatocellular carcinoma (n = 1), gallbladder (n = 1), and neuroendocrine (n = 1). The most common reasons for aborting surgery included local tumor unresectability (n = 8) and occult metastatic disease (n = 7). Five subthemes that characterized the patient experience following an aborted cancer surgery emerged, including physical symptoms, emotional responses, impact on social and life factors, coping mechanisms, and support received. CONCLUSIONS: This qualitative study characterizes the impact of aborted cancer surgery on multiple domains of quality of life: physical, emotional, social, and existential. These results highlight the importance of developing patient-centered interventions that focus on enhancing quality of life after aborted cancer surgery.

Whether M.D. Pathology curriculum is sufficient to meet pathology practice requirements in India? A survey of newly qualified pathologists.

Background and Objectives: Pathology is a broad subject consisting of various branches, such as hematology, clinical pathology, biochemistry, histopathology, cytology, blood banking, and others. All the subspecialties are difficult to cover in depth in a 3-year MD Pathology course and curriculum. Hence, it was decided to investigate whether the MD Pathology curriculum is able to meet the challenges of today's laboratory medicine practice. So, a survey was conducted among newly qualified pathologists who have passed their exam within last 5 years. Purpose was to know their views about MD Pathology curriculum with special emphasis on challenges they face during their day-to-day practice. Materials and Methods: Study is designed as cross-sectional survey conducted via web-based Google forms questionnaire. Study population is pathologists qualified within last 5 years. A convenience sample of eligible pathologists was taken by sending a web-based Google form to various pathology groups on social media apps. Data were collected in the Google spreadsheet software and various responses were summarized as percentages, graphs, and pie-charts as necessary. Chi square test was used to find the significance of difference in responses from government, private, and deemed university respondents. Results: Different numbers of responses were received to different survey questions. Out of 187 respondents, 65 (34.8%) worked in a hospital-based laboratory, 61 (32.6%) did jobs in a private laboratory, 49 (26.2%) worked in a medical college, and 37 (19.8%) worked in their own private laboratories. Out of 193 respondents, 158 (81.9%) were working in hematology, 149 (77.2%) in clinical pathology, 139 (72%) in cytopathology, 118 (61.7%) in histopathology, whereas 103 (53.4%) worked in clinical biochemistry, and least number of respondents, i.e., 38 (19.7%) were working in blood bank. Almost all the respondents had overlapping work in hematology and other areas. The level of confidence rated by the respondents was best in hematology, followed by clinical pathology; it was least for clinical biochemistry and blood bank. Out of 192 respondents, 64.1% (123) felt that the curriculum does not equip them for lab management and administration, 21.9% (42) felt that the curriculum somewhat equipped them; whereas only 14.1% (27) felt that curriculum equips them for this task. There were 191 responses to the question regarding satisfaction with MD Pathology curriculum; out of which, 51.8% (99) were not satisfied, 24.6% (47) said they may be satisfied, whereas 23.6% (45) were satisfied with the curriculum. There was no significant difference in responses from government, private, and deemed university respondents. Conclusions: The graduating MD Pathology students expressed confidence in reporting routine cases of hematology, clinical pathology, routine cytology, and histopathology. However, there is difficulty in clinical biochemistry, blood banking, and reporting of malignancies. The laboratory management and administration, communication skills, and quality assurance are also other areas of weakness. MD Pathology program needs more focus on these weaknesses, so that newly qualified graduate would feel confident in day-to-day laboratory working.

Top Ten Tips Palliative Care Clinicians Should Know About Buprenorphine.

Pain management in palliative care (PC) is becoming more complex as patients survive longer with life-limiting illnesses and population-wide trends involving opioid misuse become more common in serious illness. Buprenorphine, a generally safe partial mu-opioid receptor agonist, has been shown to be effective for both pain management and opioid use disorder. It is critical that PC clinicians become comfortable with indications for its use, strategies for initiation while understanding risks and benefits. This article, written by a team of PC and addiction-trained specialists, including physicians, nurse practitioners, social workers, and a pharmacist, offers 10 tips to demystify buprenorphine use in serious illness.

Psychological Distress in Young Adults with Acute Myeloid Leukemia Undergoing Induction Chemotherapy.

Young adults (YAs), aged 18-39 years, with acute myeloid leukemia (AML) navigate life disruptions amid an unpredictable illness trajectory. We conducted a secondary analysis of patient-reported outcomes for hospitalized YAs with high-risk AML receiving intensive chemotherapy, collected during a multisite randomized clinical trial. Of the 160 patients, 14 (8.8%) were YAs. At week 2 of hospitalization, YAs demonstrated significant worse quality of life (ß = -18.27; p = 0.036), higher anxiety (ß = 2.72; p = 0.048), and higher post-traumatic stress disorder (PTSD; ß = 10.34; p = 0.007) compared with older adults. Our analysis demonstrated a longitudinal presence of anxiety and PTSD, suggesting persistent unmet psychological needs for YAs with AML.

Defining the psychiatric and financial burden of mental and substance use disorders in cancer patients.

PURPOSE: To identify the proportion of Emergency Department (ED) visits in cancer patients associated with a mental and substance use disorder (MSUD) and the subsequent healthcare costs. METHODS: Nationally representative data on ED visits from 2009 to 2018 was obtained from the Nationwide Emergency Department Sample (NEDS). We identified cancer-related visits with or without a MSUD using the Clinical Classifications Software diagnoses documented during the ED visit. Survey-adjusted frequencies and proportions of ED visits among adult cancer patients with or without a MSUD was evaluated. Survey-adjusted multivariable logistic regression models were used to examine demographic and clinical predictors of the presence of an MSUD and the likelihood of hospital admission for patients with a primary MSUD. RESULTS: Among 54,004,462 ED visits with a cancer diagnosis between 2009 and 2018, 11,803,966 (22%) were associated with a MSUD. Compared to a primary diagnosis of cancer, patients who presented to the ED with a chief complaint of MSUD were more likely to be female (54% vs. 49%), younger (median: 58 vs. 66), more likely to have Medicaid insurance, and more likely to be discharged home. The three most common MSUD diagnoses among cancer patients were alcohol-related disorders, anxiety disorders, and depressive disorders. The total costs associated with a primary MSUD from 2009 to 2018 was $3,133,432,103, of which alcohol-related disorders claimed the largest majority. Younger age (OR per 10-year increase: 0.86, 95% CI: 0.85, 0.86) and female sex (OR: 1.34, 95% CI: 1.33-1.35) were associated with higher odds of having an MSUD. CONCLUSIONS: Our findings demonstrate a high burden of psychiatric and substance use illness in the cancer population and provide the rationale for early psychosocial intervention to support these patients.

A Unique Case of Recurrent Osteochondroma Enclosing Brachial Artery in a 13-Year-Old Female.

Introduction: Osteochondromas (OCEs) are benign chondrogenic lesions arising on the external surface of the bone with aberrant cartilage (exostosis) from the perichondral ring that may contain a marrow cavity also. In few cases, depending on the anatomical site affected, different degrees of edema, redness, paresthesia, or paresis can take place due to simple contact or friction. Furthermore, depending on their closeness to neurovascular structures, the procedure of excision becomes crucial to avoid recurrence. We report a unique case of recurrent OCE of the proximal humerus enclosing the brachial artery which makes for an important case and procedure to ensure that no relapse occurs. Case Report: We report a unique case of a 13-year-old female who had presented with a history of pain and recurrent swelling for 5 years. The swelling size was 4.4 cm × 3.7 cm × 4 cm with a previous history of swelling at the same site operated in 2018. Conclusion: This case report demonstrates that when presented with a case of recurrent OCE of the proximal humerus, doing proper excision of the tumor is crucial to prevent its relapse.

Ilizarov Ankle Arthrodesis: A Simple Salvage Solution for Failed and Neglected Ankle Fractures.

Background: Infection around the ankle joint after fracture fixation, or septic arthritis with active discharging sinuses is often challenging to manage with conventional procedures of arthrodesis. The Ilizarov method of arthrodesis gives a better alternative for salvage in such cases. Methods: This was a retrospective study including 20 patients who were subjected to tibiotalar arthrodesis with Ilizarov method. The major pathologies included internal fixation of ankle fractures complicated by infection, posttraumatic infected ankle arthritis, and osteomyelitis. The patients were evaluated on the basis of Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria. The aim of the surgery was to achieve plantigrade, stable, and painless foot with no signs of infection. Results: A total of 20 patients were operated and reviewed at our institute. The study comprised of 15 male and 5 female patients with a mean age of 43.9 years (range 33-55 years). Out of 20 patients, 4 patients had complications of pin-tract infection and one had wire breakage of the forefoot ring. According to the ASAMI criteria, 17 patients had excellent bone scores and 18 patients had good functional scores. Union was achieved in all patients with resolution of infection and the mean limb length discrepancy was 1.92 cm (range 1-2.5 cm). Conclusions: The Ilizarov fixator for ankle arthrodesis provides an excellent way for strong bone fusion, infection eradication, early weight-bearing, and the added benefits of compression at the arthrodesis site post-operatively.

Recurrent Giant Cell Tumor of the Distal End of the Femur.

Introduction: The aim of the study was a case report of a right-sided recurrent giant cell tumor of the distal end of the femur. Methodology: A case of a 25-year-old male patient with a history of recurrent giant cell tumor of the right distal femur who presented with chief complaints of pain over right distal femur and stiffness in the right knee for 2 years with restricted knee movement and is unable to walk. He was diagnosed with recurrent giant cell tumor of the right of the distal femur and was treated with wide excision with mega prosthesis reconstruction. Result: Wide excision with mega prosthesis reconstruction showed a good functional range of motion with early rehabilitation, stability, and mobility of joints. Conclusion: We recommend wide excision and reconstruction with mega prosthesis is an effective method compared to sandwich technique and nailing and can be successfully done in the case of recurrent giant cell tumor of the distal femur with a good outcome, functional range of motion, stability, and mobility of the joint with early rehabilitation though it is a technically demanding surgery. The knee joint could have been salvaged and the need for more extensive surgery could have been prevented, had the diagnosis of recurrent giant cell tumor was made earlier.

Osteochondroma Presenting Clinically with Carpal Tunnel Syndrome in a 12-Year-old Boy.

INTRODUCTION: An exostosis is a benign growth of bone, which when capped with cartilage is called osteochondroma, which can appear as solitary or multiple, mostly affecting the long bones, pelvis, and shoulder region. The prevalence of known solitary exostosis is 1-2% in the general population. They are slow growing lesions with rare malignant transformation. In patients with a solitary exostosis, the chance of developing a chondrosarcoma out of an exostosis is around 1%. CASE REPORT: A 12-year-old boy presented to our outpatient department with complaints of pain, and swelling at the right wrist since 1 year and tingling numbness on and around palmar aspect of index and middle finger since 6 months. The swelling was of size 3 cm × 2 cm, Tinel's sign was positive. His blood parameters were normal. X-ray showed exostoses. Magnetic resonance imaging was suggestive of osteochondroma. Nerve conduction study was normal. Excision biopsy confirmed the diagnosis and also relieved all symptoms. CONCLUSION: Our case report is unique in its own way as it reminds us that when presented with a case of osteochondroma of the distal radius in children, carpal tunnel syndrome can also occur.

Transdermal Buprenorphine Use for Pain Management in Palliative Care.

Cancer related pain is prevalent among patients with a cancer diagnosis, occurring from the tumor itself or as a result of treatment. Many patients require opioid therapy to manage pain and providers must balance efficacy with side effects. Transdermal buprenorphine (TDB) has shown promise for pain management, however, the maximum dose available in the US is considered low, resulting in doubts of efficacy. This study set out to assess if the patch strengths available in the US (5-20 mcg/hour) are able to provide analgesia for patients with cancer in a palliative medicine clinic. This retrospective chart review analyzed patient charts for outpatient TDB use within a palliative medicine clinic in the United States. Patients had to have a follow up visit with the clinic in order to be included. Sixty-eight patients were included for analysis with 54 (79%) continuing at least 28 days and 37 (54%) continuing for at least 84 days. The median change in pain score was 0, though 25 (46%) of patients reported a decrease of 1 or more points at the first follow up. TDB is a viable option for cancer related pain for select patients, demonstrated by duration of use and stable reporting of pain.

Aggressive Vertebral Hemangioma Causing Recurring Myelopathy -A Rare Case Report and Review of Literature.

Introduction: Vertebral hemangiomas although benign vascular lesions few of these may be ag-gressive causing osseous, extra-osseous and/or epidural expansions with recurrence rate as low as 3%. It should be considered as one of the important differentials while dealing with lytic lesions in the dorsal spine causing compressive myelopathy. Case Report: A 16-year-old female came with an acute history of paraparesis with bladder in-volvement. She was diagnosed of vertebral hemangioma of D9 for which she underwent surgical decompression and fixation. At present, she had paraparesis with a sensory level of D10 on exami-nation. After radiological investigations (X-ray and MRI) she had high intensity signals in the extra osseous portion of D9 with significant neural compression indicating recurrence of vertebral he-mangioma. She underwent decompression with long segment instrumentation with prior arterial embolization. Histopathology features were suggestive of hemangioma and our diagnosis of recur-rence was confirmed. At 2 weeks, the patient had improved neurology with partial sensory recovery and Grade 2 power in the right lower limb and Grade 1 power in the left lower limb. Histopathology report confirmed the diagnosis of hemangioma indicating recurrence. At 6 months follow-up after aggressive rehabilitation, the patient was spastic and improved to Grade 3 power in the left lower limb and Grade 4 power in the right lower limb. The sphincteric control was also found to be fair at 1 year follow-up. Discussion: Vertebral hemangiomas when causing progressive neurological deficit warrant surgical decompression. The choice of intervention depends on location and extent of the tumor. Due to their high vascularity, it is advisable for to preoperatively carry out arterial embolization. Conclusion: Although commonly asymptomatic, vertebral hemangiomas may present as compressive myelopathy. Therefore, they should be detected early, intervened and followed up regularly to detect recurrence to prevent worsening of neurology and function.

Dengue and Zika virus infections are enhanced by live attenuated dengue vaccine but not by recombinant DSV4 vaccine candidate in mouse models.

BACKGROUND: A tetravalent live attenuated dengue vaccine, Dengvaxia, sensitised naïve recipients to severe dengue illness upon a subsequent natural dengue infection and is suspected to be due to antibody-dependent enhancement (ADE). ADE has also been implicated in the severe neurological outcomes of Zika virus (ZIKV) infection. It has become evident that cross-reactive antibodies targeting the viral pre-membrane protein and fusion-loop epitope are ADE-competent. A pre-clinical tetravalent dengue sub-unit vaccine candidate, DSV4, eliminates these ADE-competent epitopes. METHODS: We compared protective efficacy and ADE-competence of murine polyclonal antibodies induced by DSV4, Dengvaxia and an 'in house' tetravalent mixture of all four laboratory DENV strains, TV DENV, using established mouse models. FINDINGS: DSV4-induced antibodies, known to be predominantly type-specific, provided significant protection against lethal DENV challenge, but did not promote ADE of either DENV or ZIKV infection in vivo. Antibodies elicited by Dengvaxia and TV DENV, which are predominantly cross-reactive, not only failed to offer protection against lethal DENV challenge, but also promoted ADE of both DENV and ZIKV infection in vivo. INTERPRETATION: Protective efficacy against DENV infection may be linked to the induction of neutralising antibodies which are type-specific rather than cross-reactive. Whole virus-based dengue vaccines may be associated with ADE risk, despite their potent virus-neutralising capacity. Vaccines designed to eliminate ADE-competent epitopes may help eliminate/minimise ADE risk. FUNDING: This study was supported partly by ICGEB, India, the National Biopharma Mission, DBT, Government of India, Sun Pharmaceutical Industries Limited, India, and NIAID, NIH, USA.

Evaluation of QTc Interval Prolongation Among Patients With Cancer Using Enteral Methadone.

CONTEXT:: The effect of methadone on corrected QT interval (QTc) in patients with cancer pain is not well-known. OBJECTIVES:: To describe and characterize the effect of low-, moderate-, and high-dose enteral methadone on QTc interval in patients with cancer. METHODS:: Retrospective cohort study including patients prescribed enteral methadone during the 27-month study period. Participants were divided into 3 methadone daily dose groups: <30 (low dose), 30 to 59 (moderate dose), ≥60 (high dose) mg. The primary outcome was the incidence of QTc prolongation (>450 ms for females and >430 ms for males). Secondary outcomes included the magnitude of change in QTc after starting methadone, the incidence of clinically significant QTc prolongation (>500 ms) and the prevalence of torsades de pointes and syncope. RESULTS:: Two hundred three patients met study inclusion criteria: 91 (45%) low dose, 52 (26%) moderate dose, and 60 (29%) high dose. Incidence of QTc prolongation for low-, moderate-, and high-dose groups was 50 (55%), 37 (71%), and 43 (72%), respectively ( P = .039, low vs high dose). Incidence of clinically significant QTc prolongation was 10 (11%), 4 (8%), and 7 (12%) for low-, moderate-, and high-dose groups. For patients without QTc prolongation prior to initiating methadone, 62% of moderate-dose patients and 67% of high-dose patients had QTc prolongation, while taking methadone. CONCLUSION:: This study found a notably high incidence of QTc prolongation in patients with cancer using enteral methadone. Future studies should aim to determine the risk of adverse cardiac effects in the cancer population and determine appropriate monitoring of methadone for pain management.

Giant Cell Tumor Presenting as A Spindle Shaped Tumor Arising From the Costovertebral Junction at D7, d8, d9 Levels.

INTRODUCTION: Giant cell tumor accounts for 5 to 9 percent of all primary bony tumors. Giant cell tumors are usually found in the long bones, most often the distal femur, proximal tibia, distal radius and rarely arising from the ribs. In this paper, we describe a case of giant cell tumor presented at an unusual location of the costovertebral junction as a dumbbell shaped tumor. CASE REPORT: Authors report a case of a 27 year old male patient with a giant cell tumor arising from the costovertebral junction at D7, D8, and D9 levels compressing the cord. Well-defined osteolysis with nonsclerotic borders were visualized on radiographs and CT scan images. Intermediate signal intensity on T1 sequences and central high signal and peripheral intermediate signal intensity on T2 sequences was visualized on MRI images. CT guided biopsy was reported as a moderately vascular lesion with spindle cell neoplasm suggestive of schwannoma. The cord was decompressed, tumor mass was surgically resected and stabilization with instrumentation was done. Histopatholgy was suggestive of giant cell tumor. CONCLUSION: Giant cell tumor may be included in the differential diagnosis in a well-defined lytic lesion when involving the costovertebral junction presenting as a spindle cell tumor on biopsy reports.