Perspectives on death and dying: a study of resident comfort with End-of-life care.

BACKGROUND: Despite the benefits to early palliative care in the treatment of terminal illness, barriers to timely hospice referrals exist. Physicians who are more comfortable having end-of-life (EOL) conversations are more likely to refer to hospice. However, very little is known about what factors influence comfort with EOL care. METHODS: An anonymous survey was sent to all the residents and fellows at a single institution. Self-reported education, experience and comfort with EOL care was assessed. Using multivariate logistic regression analysis, variables that influenced comfort with EOL conversations were analyzed. RESULTS: Most residents (88.1%) reported little to no classroom training on EOL care during residency. EOL conversations during residency were frequent (50.6% reported > 10) and mostly unsupervised (61.9%). In contrast, EOL conversations during medical school were infrequent (3.7% reported >10) and mostly supervised (78.6%). Most (54.3%) reported little to no classroom training on EOL care during medical school. Physicians that reported receiving education on EOL conversations during residency and those who had frequent EOL conversations during residency had significantly higher comfort levels having EOL conversations (p = 0.017 and p = 0.003, respectively). Likewise, residents that felt adequately prepared to have EOL conversations when graduating from medical school were more likely to feel comfortable (p = 0.030). CONCLUSIONS: Most residents had inadequate education in EOL conversation skills during medical school and residency. Despite the lack of training, EOL conversations during residency are common and often unsupervised. Those who reported more classroom training during residency on EOL skills had greater comfort with EOL conversations. Training programs should provide palliative care education to all physicians during residency and fellowship, especially for those specialties that are most likely to encounter patients with advanced terminal disease.

Severe neutropenia following a prolonged course of vancomycin that progressed to agranulocytosis with drug reexposure.

OBJECTIVE: To report a case of severe neutropenia after discontinuing prolonged treatment with vancomycin that progressed to agranulocytosis with vancomycin reexposure. CASE SUMMARY: A 78-year-old woman presented with severe neutropenia (absolute neutrophil count [ANC] 37 cells/µL) and hypocellular bone marrow with absence of myeloid elements 8 weeks after discontinuing a 3-week treatment course of vancomycin 750 mg every 12 hours. Filgrastim 300 µg daily was started for neutropenia and vancomycin 750 mg every 12 hours and aztreonam 1 g every 8 hours were initiated for catheter-related acute thrombophlebitis of the upper extremity. The patient's ANC decreased to 10 cells/µL within 3 days of starting vancomycin. We suspected an autoimmune process, potentially related to vancomycin exposure, and began treatment with methylprednisolone 1 mg/kg daily. The ANC precipitously dropped to 0 cells/µL despite treatment with steroids and an increased filgrastim dose of 480 µg/day. All antibiotics were discontinued on the fifth day of hospitalization. Within 48 hours, her neutrophil count showed recovery (white blood cell count 500 cells/µL; 10% neutrophils). DISCUSSION: Idiosyncratic drug-induced agranulocytosis is an uncommon phenomenon but is often associated with serious consequences such as sepsis. We believe this case is unique because of the unusually late neutropenia discovered several weeks after finishing a prolonged course of vancomycin. Furthermore, agranulocytosis developed after unintentional rechallenge with vancomycin. According to the Naranjo probability scale, this case illustrates a probable adverse event caused by vancomycin. CONCLUSIONS: This case demonstrates a serious adverse event potentially associated with vancomycin use, and calls attention to the safety of rechallenging with vancomycin during a possible drug-induced neutropenia.

Survival trends of metastatic small intestinal neuroendocrine tumor: a population-based analysis of SEER database.

BACKGROUND: Incidence of small intestinal neuroendocrine tumors (SNETs) is increasing and they now comprise the most common types of small intestinal cancer. SNETs frequently present with distant metastasis. Significant uncertainty prevails with regards to the surgical management strategies in metastatic SNETs. Therefore, we aim to analyze survival trends in metastatic SNET patients stratified by type of surgical treatment. METHODS: We analyzed the data from the SEER database: Incidence - SEER 18 Regs Research Data + Hurricane Katrina Impacted Louisiana Cases, Nov 2016 Sub (1973-2014 varying). Relative survival rates (RSRs) and hazard ratios (HRs) were measured for patients diagnosed with metastatic SNET between 2000 and 2014. Treatment received was divided into two broad categories; surgical resection and no surgery and further subcategorized into local resection (LR) (surgery of the primary tumor only) and radical resection (RR) (surgery for primary tumor and metastasectomy). RESULTS: We identified 1,138 metastatic SNET cases. Median age was 61 years. Median survival was 41 months and 5 year RSR was 72%. Age >50 years (HR 2.10, P<0.001), poorly differentiated histology (HR 3.50, P<0.001) and tumor size >2 cm (HR 1.27, P=0.07), showed poor outcome. The group which did not receive any tumor directed surgery showed the worst survival (5 years RSR 45.30% vs. 76%, respectively for no surgery vs. surgery group, P<0.001). We found no significant difference in survival between LR and RR (HR 1.01, 95% CI: 0.73-1.40, P=0.92). Upon further stratification, surgery significantly improved survival on patients who were >50 years (HR 0.37), and for primary tumor location in the duodenum (HR 0.13). CONCLUSIONS: Surgery for the primary tumor (LR or RR) significantly improved 5-year survival even in the presence of distant metastasis irrespective of primary tumor size, grade, or histology. Poor prognostic factors include, age >50 years, duodenal primary, tumor size >2 cm, and poorly differentiated histology.

Impact of Palliative Chemotherapy and Travel Distance on Hospice Referral in Patients With Stage IV Pancreatic Cancer: A Retrospective Analysis Within a Veterans Administration Medical Center.

BACKGROUND: Metastatic pancreatic ductal adenocarcinoma (mPDAC) has a poor prognosis despite chemotherapy advancements. Although hospice utilization has increased, timing of referral is not always optimal. AIM: To investigate whether palliative chemotherapy and travel distance to the treatment center impact hospice referral patterns in veterans of the US military in order to identify potential areas for improving referral timing. DESIGN: Demographic and clinical data were collected retrospectively according to the timing of hospice referral. Settings/Participants: Patients with mPDAC within a Veterans Administration Medical Center from 2005 to 2014. RESULTS: Of 58 patients identified, 52 were referred to hospice. The median time from diagnosis to referral and referral to death was 2.4 and 3.1 weeks, respectively. Palliative chemotherapy was administered to 22 (42.3%) patients, with 30 (57.7%) patients not treated due to poor functional status (n = 16, 53.3%) or patient refusal (n = 14, 46.7%). Subset analysis for those travelling >60 miles versus <60 miles to the treatment center showed the median time to hospice referral was 1.7 versus 4.7 weeks. With no significant differences between groups, univariate analysis demonstrated that those referred to hospice >2.4 weeks from diagnosis more often received chemotherapy ( P < .001) and lived <60 miles from the treatment center ( P = .05). CONCLUSION: Receipt of palliative chemotherapy and proximity to the treatment center appear to delay referral to hospice in patients with mPDAC. Increasing physician awareness of such factors that may impact the decision to involve hospice is necessary for delivering optimal oncology care.

Delayed Imaging Presentation of a Symptomatic Insulinoma After Bariatric Surgery.

Many reports exist on hyperinsulinemic hypoglycemia after bariatric surgery, which can result in persistence of the metabolic syndrome in patients who have undergone these procedures. While the noninsulinoma pancreatogenous hypoglycemia syndrome, or nesidioblastosis, has garnered increased attention in these patients, its presentation is similar to patients with an insulinoma and this entity must therefore be evaluated and ruled out. Herein, we present a patient who developed symptoms of hypoglycemia 7 years after Roux-en-Y gastric bypass surgery. While a diagnosis of insulinoma was entertained, his laboratory values were indeterminate and imaging localization was inconclusive. Because of significant medical comorbidities, he was managed symptomatically until imaging ultimately localized a lesion in the pancreatic uncinate process consistent with an insulinoma. He subsequently underwent resection and remains disease and symptom free 1 year after surgery. This case demonstrates the diagnostic and imaging dilemma in patients with hypoglycemia after bariatric surgery and should be of interest to anyone who cares for these patients.

Infusion Room-Based Transition to Practice Model for Teaching Cancer Systemic Therapy Management.

PURPOSE: Oncology training requirements mandate that fellows demonstrate competence in delivery of cancer therapeutics, understand clinical indications for treatment, and manage toxicities by completion of training. An academic training environment may hinder fellows' engagement in prescribing, monitoring, and adjusting cancer therapy; thus, trainees may complete their fellowship with limited experience in developing such critical skills. To provide hands-on experience in cancer systemic therapy management, we created a novel infusion room-based rotation in the final year of training; here we report the structure, logistics, and evaluation of this innovative program. METHODS: In 2004, The University of Florida Hematology Oncology Fellowship Program created an outpatient infusion room rotation called Transition to Practice (TTP). We surveyed 20 graduates of the program to assess the ability of the rotation to teach skills necessary for systemic therapy management and identify which fellowship rotations had an impact on their readiness to practice independently. RESULTS: Nineteen graduates completed the survey. TTP was rated highest for promoting independence in making decisions related to therapy and adjustment to the treatment plan. It was less valuable in teaching the financial aspects of cancer therapy encounters. The Veterans Affairs Medical Center continuity clinic and the TTP rotation were highly regarded for preparing graduates to practice oncology independently. CONCLUSION: We consider the TTP model an effective learning environment for oncology trainees to develop the essential skill set for managing cancer systemic therapy on the basis of this single-institution analysis of recent graduates. This model could be applied to training other oncology professionals, such as advanced practice providers, who are new to the field.

Adequacy of published oncology randomized controlled trials to provide therapeutic details needed for clinical application.

BACKGROUND: Randomized controlled trials (RCTs) improve clinical care through evidence-based results. Guidelines exist for RCT result reporting, but specific details of therapeutic administration promote clinical application and reproduction of the trial design. We assess the reporting methodology in RCTs published in major oncology journals. METHODS: Ten essential elements of RCT reporting were identified and included drug name, dose, route, cycle length, maximum number of cycles, premedication, growth factor support, patient monitoring parameters, and dosing adjustments for hematologic and organ-specific toxicity. All therapy-based oncology RCTs published between 2005 and 2008 in the New England Journal of Medicine (NEJM), Journal of Clinical Oncology (JCO), Journal of the National Cancer Institute (JNCI), Blood, and Cancer were analyzed for inclusion of these 10 elements. RESULTS: Of 339 identified articles, 262 were included in the final analysis (165 from JCO, 31 from NEJM, 27 from Cancer, 20 from JNCI, and 19 from Blood). Premedication, growth factor support, and dose adjustments for toxicities were each reported less than half of the time. Only 30 articles (11%) met the main objective of complete data reporting (ie, all 10 essential elements) and was highest in JNCI (5/20; 25%), followed by Cancer (5/27; 18%), JCO (18/165; 11%), Blood (1/19; 5%), and NEJM (1/31; 3%). The presence of an online appendix did not substantially improve complete reporting. CONCLUSIONS: RCTs published in major oncology journals do not consistently report essential therapeutic details necessary for translation of the trial findings to clinical practice. Potential solutions to improve reporting include modification of submission guidelines, use of online appendices, and providing open access to trial protocols.