A human health assessment of hazardous air pollutants in Portland, OR.

Ambient air samples collected from five monitoring sites in Portland, OR during July 1999 to August 2000 were analyzed for 43 hazardous air pollutants (HAP). HAP concentrations were compared to carcinogenic and non-carcinogenic benchmark levels. Carcinogenic benchmark concentrations were set at a risk level of one-in-one-million (1x10(-6)). Hazard ratios of 1.0 were used when comparing HAP concentrations to non-carcinogenic benchmarks. Emission sources (point, area, and mobile) were identified and a cumulative cancer risk and total hazard index were calculated for HAPs exceeding these health benchmark levels. Seventeen HAPs exceeded a cancer risk level of 1x10(-6) at all five monitoring sites. Nineteen HAPs exceeded this level at one or more site. Carbon tetrachloride, 1,3-butadiene, formaldehyde, and 1,1,2,2-tetrachloroethane contributed more than 50% to the upper-bound lifetime cumulative cancer risk of 2.47x10(-4). Acrolein was the only non-carcinogenic HAP with hazard ratios that exceeded 1.0 at all five sites. Mobile sources contributed the greatest percentage (68%) of HAP emissions. Additional monitoring and health assessments for HAPs in Portland, OR are warranted, including addressing issues that may have overestimated or underestimated risks in this study. Abatement strategies for HAPs that exceeded health benchmarks should be implemented to reduce potential adverse health risks.

Daily journal club: an education tool in palliative care.

Journal clubs are a valuable tool for medical education. This paper describes a unique daily journal club format utilized by our palliative care programme and presents the results of a questionnaire sent to trainees exploring satisfaction with its educational value. We reviewed the number and type of articles presented at the journal club over 1 year. A questionnaire was mailed to participating family medicine residents and palliative care fellows. The number of articles presented over 1 year was 252. Pain and symptom control, psychosocial issues and drugs other than opioids were topics accounting for 72% of the presentations. Half were given by attending physician staff, 38% by trainees and 12% by multidisciplinary visitors. Palliative care fellows indicated significantly higher levels of satisfaction than family medicine residents, particularly in the areas of clinical applicability, acceptability of the daily schedule and overall educational value. The increased emphasis on evidence-based practice in palliative care suggests that a journal club could be a useful educational tool. The results from our experience could be applied to other palliative care programmes.

A dose reconstruction of 60Co-contaminated window frames in a Taiwanese school.

Since 1992, hundreds of buildings in Taiwan were discovered to have 60Co contamination in the structural rebar. The contamination resulted from improper handling of 60Co-contaminated scrap metal in 1982 and 1983, which subsequently was recycled and used throughout Taiwan. Hsin-hsin Kindergarten school enrolled about 600 students over the 10-y period before the contamination was discovered. Hsin-hsin Kindergarten had three 60Co-contaminated steel window frames with measured dose rates on contact up to 150 microSv h(-1). In this study, a range of potential doses received by the Hsin-hsin Kindergarten students were estimated using ISOSHLD dose modeling software. ISOSHLD is a rapid, inexpensive screening tool to reconstruct dose ranges. To assess the potential risks to habitants of the school for the first year after construction, calculated dose rate ranges of 0.08 microSv h(-1) to 75.38 microSv h(-1) were then applied to the International Commission [corrected] on Radiation Protection 60 nominal detriment coefficients for stochastic effects. Risk estimates ranged from 1.46 x 10(-4) to 7.42 x 10(-4) excess fatal cancers per lifetime.

Multidisciplinary symptom control clinic in a cancer center: a retrospective study.

Our objective in this study was to review the characteristics, symptom intensity and satisfaction of patients referred to a half-day symptom control clinic (SCC) for advanced cancer patients. This was a retrospective study. The setting was a multidisciplinary symptom control clinic in a cancer centre. Those taking part were 166 consecutive advanced cancer patients referred to the half-day multidisciplinary SCC because of symptom distress. Patients referred to the clinic were assessed in a private room by a physician, a nurse, a pharmacist, a psychologist, and social, rehabilitation, nutrition, respiratory and pastoral care workers. Symptom distress (multiple visual analogue scales), cognition, and CAGE (alcoholism) were determined. Recommendations were given to the patient and sent to the oncologist, family physician and home care nurse. For 110 patients a second assessment was carried out 1 week later, and 64 patients underwent a telephone assessment 2 weeks after the second visit. Symptom intensity was determined during initial and follow-up visits, as well as during two follow-up telephone assessments. In addition, demographics and patient satisfaction with the SCC were determined. Overall symptom distress, depression, anxiety and sensation of wellbeing improved significantly from the first (n = 166) to the second clinic visit (n = 110). Further significant improvement was observed in overall symptom distress, pain, anxiety, sense of wellbeing and depression at the 2- (n = 64) and 4-week (n = 38) telephone follow-up assessments. Mean satisfaction with the SCC (0-10) was 7.7 +/- 2. Our findings suggest that the work of the SCC results in long-term effectiveness in symptom control and high levels of patient satisfaction. The SCC allows for better integration of care between a cancer center and community-based physicians and nurses. It also allows patients access to multiple disciplines that are not available outside tertiary centers.

Impact of the Edmonton Labeled Visual Information System on physician recall of metastatic cancer patient histories. a randomized controlled trial.

The Edmonton Labeled Visual Information System (ELVIS) is a novel method of documenting clinical information because it is a pictorial method of representing cancer burden and treatment. This randomized, crossover, multiperiod trial involved 16 physicians who each reviewed two ELVIS and two control (text) cancer patient cases (total 32 ELVIS and 32 text cases). Short-answer questionnaires were administered immediately and 18--24 hours following. Mean (+/- SD) recall of basic disease and treatment information was superior immediately following the ELVIS cases (83% +/- 14%) versus text cases (60% +/- 14%, P < 0.0001) and 18--24 hours later (ELVIS cases 65% +/- 21% versus text cases 43% +/- 21%, P < 0.0001). Mean (+/- SD) time required to memorize information was reduced in the ELVIS cases (4 +/- 2 min) versus text cases (13 +/- 6 min, P < 0.0001). Ratings of overall physician preference strongly favored the ELVIS over text. The data indicate that ELVIS aids the process of learning complex cancer patient histories.

Attitudes and beliefs of palliative care physicians regarding communication with terminally ill cancer patients.

The subject of communication between palliative care physicians and their patients regarding their diagnosis and prognosis has not been extensively researched. The purpose of this survey was to compare the attitudes and beliefs of palliative care specialists regarding communication with the terminally ill in Europe, South America, and Canada. A sample of palliative care physicians from South America (Argentina and Brazil), French-speaking Europe, and Canada were identified, and posted a questionnaire. Physicians who stated that they practised palliative care at least 30% of their time were considered evaluable as palliative care specialists. Of a total of 272 questionnaires, 228 were returned (84%); and 182/228 (81%) respondents were considered to be palliative care specialists. Palliative care physicians in all three regions believed that cancer patients should be informed of their diagnosis and the terminal nature of their illness. Physicians reported that at least 60% of their patients knew their diagnosis and the terminal stage of their illness in 52% and 24% of cases in South America, and 69% and 38% of cases in Europe, respectively. All physicians agreed that 'do not resuscitate' orders should be present, and should be discussed with the patient in all cases. While 93% of Canadian physicians stated that at least 60% of their patients wanted to know about the terminal stage of their illness, only 18% of South American, and 26% of European physicians said this (P < 0.001). Similar results were found when the physicians were asked the percentage of families who want patients to know the terminal stage of their illness. However, almost all of the physicians agreed that if they had terminal cancer they would like to know. There was a significant association between patient based decision-making and female sex (P = 0.007), older age (P = 0.04), and physicians from Canada and South America (P < 0.001). Finally, in their daily decision making, South American physicians were significantly more likely to support beneficence and justice as compared with autonomy. Canadian physicians were more likely to support autonomy as compared with beneficence. In summary, our findings suggest that there are major regional differences in the attitudes and beliefs of physicians regarding communication at the end of life. More research is badly needed on the attitudes and beliefs of patients, families, and health care professionals in different regions of the world.

Communication between primary care physicians and radiation oncologists regarding patients with cancer treated with palliative radiotherapy.

PURPOSE: The purpose of this study was to assess the satisfaction and information needs of primary care physicians (PCPs) regarding communication with radiation oncologists (ROs), with respect to patients who receive palliative radiotherapy (RT). A selected objective was to evaluate the agreement between PCPs' expectations and the content of the RO letter sent after completion of RT. PCPs' knowledge of the role of palliative RT and their awareness of available patient support services were also determined. METHODS: The PCPs of patients discharged from the Cross Cancer Institute after receiving palliative RT were surveyed using a mail-out questionnaire. Questions regarding communication, RT knowledge, and awareness of support services were asked. The corresponding RO letter was reviewed. RESULTS: A total of 148 PCPs were identified and were mailed questionnaires, with 114 (77%) responding. Overall, 80% (87 of 109) of PCPs found the RO letter to be useful in patient management. However, there was poor (< 53%) agreement between PCPs' expectations and the actual content of the RO letter. Knowledge of the indications and effectiveness of palliative RT was limited, with PCPs obtaining a median score of 4 of a possible 8. Only 27% (31 of 114) of PCPs were aware of all five of the patient support services listed. CONCLUSION: Results show that although the majority of PCPs found the RO letter useful, they believed that the letter lacked important information while containing unnecessary details. Communication between PCPs and ROs needs improvement, especially considering that PCPs seem to have limited knowledge of palliative RT.

The frequency and correlates of dyspnea in patients with advanced cancer.

Dyspnea is a devastating symptom in patients with advanced cancer. Unfortunately, very limited research has been done on the frequency and correlates of dyspnea in this particular patient population. The purpose of this prospective study was to assess the frequency of moderate to severe dyspnea and the correlates of dyspnea in a population of ambulatory terminally ill cancer patients. One hundred thirty-five consecutive patients attending a multidisciplinary pain clinic were tested for respiratory function (vital capacity, peak flow, maximal inspiratory pressure, and oxygen saturation). All patients gave their rating of dyspnea, anxiety, and fatigue/tiredness using visual analogue scales (VAS). Lung involvement by the tumor (primary or metastatic) was determined from the patient's chart. Moderate dyspnea occurred in 74/135 (55%) patients with terminal cancer. Lung involvement (r = 0.285, P = 0. 0009), anxiety (r = 0.306, P = 0.0003), fatigue/tiredness (r = 0.211, P = 0.0146), and vital capacity (r = -0.189, P = 0.0444) were significantly correlated with the intensity of dyspnea. Multivariate analysis demonstrated that lung involvement (P = 0.0016) and anxiety (P = 0.0027) were independently correlated with the intensity of dyspnea. In the subgroup of patients with moderate to severe dyspnea, multivariate analysis found anxiety (P = 0.0318) and maximal inspiratory pressure (P = 0.0187) to be independent correlates of the intensity of dyspnea. Dyspnea is a frequent symptom in patients with advanced cancer. The presence of cancer in the lungs, anxiety, and maximal inspiratory pressure are correlates of the intensity of dyspnea in this patient population. Possible treatments addressing low maximal inspiratory pressure and anxiety are needed, as well as further research in finding new correlates of dyspnea in advanced cancer patients.

Predictors of home death in palliative care cancer patients.

With recent changes in health care there is greater emphasis on providing care at home, including the support of families to enable more home deaths. Since a home death may not be practical or desirable in every family situation, there is a need for an objective way to assess the viability of a home death in each individual family situation. The purpose of this study was to describe the relative role of predictors of home death in a cohort of palliative care patients with advanced cancer. A questionnaire was created as a means of assessing the viability of a home death. Five questions were included. Ninety questionnaires were administered by home care coordinators. A follow-up questionnaire was administered to record the place of death. Of the 73 evaluable patients, 34 (47%) died at home and 39 (53%) died in hospital or hospice. The desire for a home death by both the patient and the caregiver, support of a family physician, and presence of more than one caregiver were all significantly associated with a home death. Logistic regression identified a desire for home death by both the patient and the caregiver as the main predictive factor for a home death. The presence of more than one caregiver was also predictive of home death. The questionnaire is simple and, if our results are confirmed, it can be used for predicting those who will not have a home death.

Opioid type and other clinical predictors of laxative dose in advanced cancer patients: a retrospective study.

BACKGROUND: Constipation is a frequent and underdiagnosed complication in patients with advanced cancer. Constipation in this population is multifactorial, but the use of opioids is one of the main causes. The purpose of this retrospective study was to establish the association between opioid type and laxative dose, as well as the contribution of other clinical factors in advanced cancer patients admitted to a palliative care unit. METHODS: The records of consecutive patients admitted to the Acute Palliative Care Unit at the Grey Nuns Hospital between December 1995 and January 1997 were reviewed. Criteria of eligibility were the presence of cancer pain treated by opioids (oral and subcutaneous morphine and hydromorphone, oral methadone), oral laxative treatment capable of achieving at least one bowel movement every 3 days, and the absence of bowel obstruction or colostomy. During period(s) of stable analgesic doses, the charts were reviewed for demographic and clinical characteristics, average number of bowel movements, daily laxative doses, doses and type of opioid, laxative/opioid dose ratio (LOR) (calculated by dividing the total laxative dose by the total opioid dose), functional and cognitive status, food intake, and level of calcium, albumin, and potassium. RESULTS: Forty-nine evaluable patients were identified. The LOR in patients receiving oral opioids was 0.15 +/- 0.19 vs. 0.18 +/- 0.17 in patients on parenteral opioids (p > 0.2). The LOR in patients receiving methadone was 0.025 +/- 0.027 as compared to 0.24 +/- 0.23 in patients receiving morphine and 0.17 +/- 0.13 in patients on hydromorphone (p < 0.0001). We found a strong association between LOR and abdominal involvement (p < 0.0006), opioid type (p < 0.0001), age (p < 0.0001), and female gender (p < 0.034). There were no significant correlation between LOR and functional status, cognitive status, food intake, and level of calcium or potassium. CONCLUSION: We conclude that laxative dose needs to be titrated on an individualized basis. The LOR is lower in patients receiving methadone and in those of male gender, younger age, and absence of abdominal involvement.

The impact of a regional palliative care program on the cost of palliative care delivery.

In July 1995 the Edmonton Regional Palliative Care Program (ERPCP) was established in the City of Edmonton to increase the access of patients with terminal cancer to palliative care services, decrease the number of cancer deaths in acute-care facilities, and increase the participation of family physicians in the care of terminally ill patients. The objective of this retrospective study was to determine the cost of implementation of the ERPCP and savings in acute-care facility costs after its implementation. We did this by comparing the cost of care for patients during 1992-93 (prior to the ERPCP) and 1996-97 (with the ERPCP). The main outcome measures were the cost of care and the total hospital stay in days for all patients during their last acute-care hospital admission. The increased funding for the ERPCP was offset by a significant decrease in the overall cost of palliative care in the acute-care facilities. There was a substantial decrease in the palliative care costs in acute facilities from 11,963,846 dollars in 1992/93 to 3,449,055 dollars in 1996/97. This can be explained by the significant decrease in the number of palliative care patient days in acute-care facilities from 22,608 during 1992/93 to 6085 during 1996/97. Physician billings were slightly higher for 1996 as compared to 1992. In 1992, 90% (195,117/427,780) of the billings were made by the specialists (internists, surgeons, and other specialists), while in 1996/97 67% (359,869/537,342) of the payments were made to primary care practitioners (p < 0.0001). Overall, there were estimated saving of 1,650,689 dollars for palliative care costs in 1996/97 as compared to 1992/93. Our results suggest that the establishment of an integrated palliative care program reduced the cost of care. Prospective cost measurement studies are required.

The addition of an audiocassette recording of a consultation to written recommendations for patients with advanced cancer: A randomized, controlled trial.

BACKGROUND: Communication between physicians and advanced cancer patients is frequently difficult. Patients often report poor levels of satisfaction with communication. The purpose of this study was to assess the impact on patients' recall of and overall satisfaction with their consultation by the addition of an audiocassette recording of a consultation to written recommendations. METHODS: Sixty patients with advanced cancer were randomized to either receive a tape recording of their consultation or receive no tape in addition to written recommendations in this randomized, double-blind trial. Patients gave their global ratings of the clinic, were tested for their recall of information given, and responded to questions about the utilization and role of the cassette in influencing family communication. RESULTS: The addition of the audiocassette to written communications significantly increased patient satisfaction with the clinic (8.7 +/- 1.7 vs. 7.7 +/- 2.0 on a scale of 0-10; P = 0.04) and significantly improved recall of the information given during the consultation (88% +/- 8.7% vs. 80% +/- 15.5%; P = 0.02). Patients expressed a high level of satisfaction with the audiocassette. Patients listened to the tape a median of 2 (range 1-4) times, whereas family members and friends listened to the cassette a median of 2 (range 1-3) times. CONCLUSIONS: The addition of an audiocassette recording of an outpatient consultation to written recommendations for patients with advanced cancer is capable of increasing both the overall patient recall of the visit and satisfaction with the outpatient clinical setting. Patients expressed a high level of satisfaction with the audiocassette.

A randomized controlled trial of local injections of hyaluronidase versus placebo in cancer patients receiving subcutaneous hydration.

BACKGROUND: Most cancer patients develop reduced oral intake or dehydration before death. Subcutaneous hydration (SCH) can be safe and effective. SCH is frequently administered using hyaluronidase to improve fluid absorption. The objective of this study was to determine the effects of hyaluronidase on patient comfort during bolus SCH. PATIENTS AND METHODS: Twenty-one cancer patients requiring parenteral hydration were administered a 500 cc bolus of two-thirds dextrose (5%) and one-third normal saline solution subcutaneously at 08:00 and 16:00 hours during day 1 and day 2. On day 1 patients were randomized on a double-blind basis to receive 150 units of hyaluronidase versus placebo as a bolus into the site of infusion immediately before starting each one-hour infusion. During day 2 patients were crossed over to receive the alternate treatment at a new infusion site. Visual analogue scales (0 = best, 100 = worst) for pain and swelling at the infusion site were completed by each patient. In addition, investigators blindly assessed the site of infusion for the presence of edema, rash, and leakage. RESULTS: No significant differences were observed for pain, swelling, edema, rash or leakage between the placebo and the hyaluronidase scores. After completion of the two days of the study, patients blindly chose hyaluronidase in 1 (5%) case, placebo in 5 (24%) cases, and no preference in 15 (71%) cases (P < 0.01). There was no treatment or interaction effect for pain, except for a period effect (P = 0.045) for the morning bolus administration. There were no treatment, period, or interaction effects for any of the other variables. CONCLUSIONS: Our results suggest that hyaluronidase is not necessary for routine bolus SCH. It may still be useful for a minority of patients who are not able to tolerate infusion well due to swelling or pain.

Temporal distribution of deaths in cancer patients admitted to a palliative care unit.

The timing of death has received much attention, particularly in the area of sudden cardiac death. Many studies have demonstrated that sudden cardiac death and other sudden deaths follow a circadian pattern. Deaths have also been reported to vary around dates that are especially meaningful to patients and families. To test these reported observations in a cancer palliative care population, we reviewed the date and time of death of 626 consecutive patients admitted to the palliative care unit of a western Canadian hospital. All patients were adults with advanced metastatic or locally recurrent cancer. A circadian distribution in the time of deaths was observed; 225 deaths occurred between 20:00 and 06:00 (261 deaths expected) versus 401 deaths between 06:00 and 20:00 (365 deaths expected) (p = 0.0037). The distribution of deaths did not change significantly according to day of the week or month of the year. Based on patient birthday, 41 deaths occurred during the three weeks before a birthday (33.5 deaths expected) versus 26 deaths during the three weeks after a birthday (33.5 deaths expected) (p = 0.067). There appear to be fewer deaths during the evening and night; there does not appear to be a decline in deaths before the patient's birthday; and any temporal distribution of deaths in this population appears to be minimal.

Role of methadone in the management of pain in cancer patients.

In most cancer patients who are treated with opioid analgesics for pain control, the type of opioid needs to be changed at least once because of the presence of side effects or the need to escalate analgesic doses to toxic levels. Methadone may be an excellent alternative in such patients due to its lack of known active metabolites, high lipid solubility, excellent absorption following oral and rectal delivery, and extremely low cost. However, it has unique problems, such as a long, unpredictable half-life and greater potency than previously assumed. At present, methadone is viewed as a second-line opioid for chronic cancer pain. Better pharmacokinetic and clinical studies are required to establish the role of methadone in this setting. Issues to be explored include a potential role in treating patients who have poorly responsive pain syndromes, such as neuropathic pain, or who develop a rapid tolerance to other opioids; the possibility of extending dosing intervals to every 12 or 24 hours; and its possible use as a first-line opioid.

Respective limits of palliative care and oncology in the supportive care of cancer patients.

Advanced cancer patients develop a number of devastating physical and psychosocial symptoms before death. In recent years, there have been great advances in our knowledge on the appropriate assessment and management of many of the physical and psychosocial symptoms. There is also increasing understanding on the need for patients and families to receive appropriate follow-up and to have access to multiple settings for optimal care. Unfortunately, both models developed on the basis of palliative care/hospice and those developed on the basis of supportive care/oncology have failed to achieve these goals. Future models for the delivery of supportive cancer care will have to consider the need to ensure that patients receive a consistent level of assessment and management up to the time of death, that there is appropriate flexibility, to allow patients to access multiple levels of care in the trajectory of their illness, and that there is a significant contribution to the body of knowledge and future education of health care professionals. These programs will need to develop individually for each country with due consideration for the structure of the health care system, the structure of the academic system, and the financing of health care in different regions of the world.

Edmonton Regional Palliative Care Program: impact on patterns of terminal cancer care.

The Edmonton Regional Palliative Care Program was established in July 1995 to measure the access of patients with terminal cancer to palliative care services, decrease the number of cancer-related deaths in acute care facilities and increase the participation of family physicians in the care of terminally ill patients. In this retrospective study the authors compared the pattern of care and site of deaths before establishment of the program (1992/93) and during its second year of operation (1996/97). Significantly more cancer-related deaths occurred in acute care facilities in 1992/93 than in 1996/97 (86% [1119/1304] v. 49% [633/1279]) (p < or = 0.001). The number of inpatient days decreased, from 24,566 in 1992/93 to 6960 in 1996/97. More cancer patients saw a palliative care consult team in 1996/97 than in 1992/93 (82% v. 22%). The shift from deaths in acute care facilities to palliative hospices suggests that the establishment of an integrated palliative care program has increased access of patients with terminal cancer to palliative care.

Twice-daily versus once-daily morphine sulphate controlled-release suppositories for the treatment of cancer pain. A randomized controlled trial.

We evaluated the safety and efficacy of controlled-release morphine sulphate suppositories administered 12-hourly and once daily in patients with chronic cancer in a randomized double-blind crossover trial. Pain was assessed using a 100-mm VAS pain scale and a five-point ordinal pain scale. The VAS pain intensity score was 17.5+/-17.2 after suppositories every 12 h, versus 16.2+/-13.4 after suppositories every 24 h (difference not significant). The difference between the mean VAS pain scores with 12-hourly and once-daily dosing was 1.3 mm (not significant). The mean ordinal pain scores were 1.0+/-0.7 versus 1.0+/-0.6 for 12-hourly and once-a-day dosing, respectively (not significant). A retrospective power analysis indicated that a difference of 5.9 mm was detectable, even with only 6 patients. Adverse events noted were constipation, nausea, anorexia, and dry mouth. The use of once-a-day controlled-release morphine suppository is a more convenient and equally effective alternative to twice a day dosing.

Bus rounds for medical congresses on palliative care.

Three 4-hour bus rounds were organized as part of an international palliative care congress, to promote patient-based education both at home and in acute care hospitals. Patient cases were presented and discussed en route to and from each visit. A total of 23 medical specialists visited 16 patients (10 in three different hospitals and 6 at home). A mean of 5.3 cases were presented during each round. A total of nine journal club articles were presented, a mean of three (2-4) articles per round. A questionnaire was filled out anonymously by all 23 participants. On a scale of 1 (worst) to 5 (best) they gave the rounds an overall rating of 5 (range 4-5). These findings suggest bus rounds provide an opportunity for intensive exposure to patient-based learning, both in acute care hospitals and at home.