Comparison of Health Care Providers Attitudes and Beliefs Regarding Medical Marijuana and Cannabidiol in the Management of Pain and Other Symptoms in Cancer Patients.

Background: Medical marijuana (MM) and cannabidiol (CBD) have received increasing attention to manage pain and other symptoms even with limited scientific evidence. Objectives: We examined the attitudes and beliefs of health care providers toward MM and CBD compared to standard treatments for cancer-associated pain and various symptoms. Design: Two sets of anonymous surveys (MM and CBD) containing similar items were completed by clinicians of four symptom-focused specialties. Results: A minority of respondents preferred recommending MM (9%) and CBD (13%), respectively, over opioids for cancer pain, while 11% and 22% felt that MM and CBD, respectively, would be useful to combine with opioids to treat cancer pain. Respondents did not favor MM or CBD over common treatment options for nonpain symptoms. Conclusion: MM and CBD were not preferred over current standard treatments for pain and other symptoms. Responses from the four specialties aligned with unique aspects of their clinical practice.

Hospitalization characteristics and outcomes of patients with cancer and COVID-19 at a comprehensive cancer center.

PURPOSE: Several studies have confirmed increased mortality among patients with both COVID-19 and cancer. It remains important to continue to report observations of morbidity and mortality from COVID-19 in this vulnerable population. The purpose of this study is to describe the hospitalization characteristics and outcomes of patients with both cancer and COVID-19 admitted to our comprehensive cancer center. METHODS: This was a descriptive study of the first COVID-19-related hospitalization among adult patients with cancer admitted to our institution. Descriptive statistics were used to summarize patient demographics, clinical as well as hospitalization characteristics. Overall survival (OS) was estimated using the Kaplan-Meier method. RESULTS: A total of 212 patients were included in our cohort with a mean age of 59 years. Fifty-four percent of patients had history of solid tumor malignancy and 46% had hematologic malignancies. Eighty-five percent of our cohort had active malignancy. The mean length of stay (LOS) for hospitalization was 11.2 days (median LOS of 6 days). Twenty-five percent had severe disease and 10.8% died during their initial hospitalization. Those who had severe disease had worse survival at the end of the observation period. CONCLUSIONS: COVID-19 among cancer patients causes significant morbidity and mortality as well as repeat hospitalizations. Continued study of COVID-19 in this vulnerable population is essential in order to better inform evolving treatment algorithms, public health policies, and infection control protocols, especially for institutions caring for patients with cancer.

Comparison of LACE and HOSPITAL Readmission Risk Scores for CMS Target and Nontarget Conditions.

This study evaluated the utility and performance of the LACE index and HOSPITAL score with consideration of the type of diagnoses and assessed the accuracy of these models for predicting readmission risks in patient cohorts from 2 large academic medical centers. Admissions to 2 hospitals from 2011 to 2015, derived from the Vizient Clinical Data Base and regional health information exchange, were included in this study (291 886 encounters). Models were assessed using Bayesian information criterion and area under the receiver operating characteristic curve. They were compared in CMS diagnosis-based cohorts and in 2 non-CMS cancer diagnosis-based cohorts. Overall, both models for readmission risk performed well, with LACE performing slightly better (area under the receiver operating characteristic curve 0.73 versus 0.69; P ≤ 0.001). HOSPITAL consistently outperformed LACE among 4 CMS target diagnoses, lung cancer, and colon cancer. Both LACE and HOSPITAL predict readmission risks well in the overall population, but performance varies by salient, diagnosis-based risk factors.

Derivation and Validation of the Cancer READMIT Score: A Readmission Risk Scoring System for Patients With Solid Tumor Malignancies.

PURPOSE: Readmissions for the medical treatment of cancer have traditionally been excluded from readmission measures under the Hospital Readmissions Reduction Program. Patients with cancer often have higher readmission rates and may need heightened support to ensure effective care transitions after hospitalization. Estimating readmission risk before discharge may assist in discharge planning efforts and help promote care coordination at time of discharge. PATIENTS AND METHODS: We developed and validated a readmission risk scoring system among a cohort of adult cancer patients with solid tumor admitted at a comprehensive cancer center. Multivariate logistic regression analysis was used to develop the model. The model's discriminative capacity was evaluated through a receiver operating characteristic curve analysis. We further compared the performance of the developed score with existing risk scores for 30-day readmission. RESULTS: The 30-day unplanned readmission rate in the total cohort was 16.0% (n = 1,078 of 6,720). After multivariate analysis, Cancer site, Recent emergency room visit within 30 days, non-English primary language, Anemia defined as hemoglobin < 10 g/dL, > 4 Days length of stay during the index admission, unmarried Marital status, Increased white blood cell count > 11 × 109/L, and distant Tumor spread were significantly associated with risk of unplanned 30-day readmission. The derived score, which we call the Cancer READMIT score, had modest discriminatory performance in predicting readmissions (area under the curve for the model receiver operating characteristic curve = 0.647). CONCLUSION: The Cancer READMIT score was able to predict 30-day unplanned readmissions to our institution with fairly modest performance. External validation of our derived risk scoring system is recommended.

Safety and efficacy of percutaneous transabdominal and transesophageal decompression gastric catheters for palliation of malignant bowel obstruction.

PURPOSE: To evaluate the safety and primary technical success rate of gastric decompression via percutaneous transabdominal gastrostomy (PTAG) or percutaneous transesophageal gastric (PTEG) catheter placement for management of malignant bowel obstruction (MBO). A secondary purpose was to evaluate the safety and success rate for PTAG catheter placement in patients with both MBO and ascites. METHODS: A single-institution retrospective review of 385 patients who underwent attempted decompression gastric catheter placement from March 2013 to August 2018 was performed. Medical records and imaging studies were reviewed. A subgroup of patients with concomitant MBO and ascites were identified. The primary outcome measures were procedural technical success and procedural complications. RESULTS: 394 decompression gastrostomy catheters were attempted from 2013 to 2018, n = 353 PTAG and n = 41 PTEG. The success rate was 95.5% (n = 337 of 353) for PTAG and 97.6% (n = 40 of 41) for PTEG. There were 63 total complications involving 47 (13.9%) patients following PTAG and 13 total complications involving 9 (22.5%) patients following PTEG, P = 0.16. For the subgroup of patients with MBO and ascites, the success rate was 94.8% (n = 182 of 192 patients), and there were 20 complications involving 17 (12.9%) of 132 patients. CONCLUSION: Gastric decompression for patients with MBO via PTAG or PTEG catheter placement is associated with high success rates and low complications.

Evaluation of Cancer Patients With Suspected Pulmonary Embolism: Performance of the American College of Physicians Guideline.

BACKGROUND: Accurate risk stratification of pulmonary embolism (PE) can reduce unnecessary imaging. We investigated the extent to which the American College of Physicians (ACP) guideline for evaluation of patients with suspected PE could be applied to cancer patients in the emergency department of a comprehensive cancer center. MATERIALS AND METHODS: Data from cancer patients who underwent CT pulmonary angiography (CTPA) between August 1, 2015, and October 31, 2015, were collected. We assessed each patient's diagnostic workup for its adherence to the ACP guideline in terms of clinical risk stratification and age-adjusted d-dimer level and the degree to which these factors were associated with PE. RESULTS: Of the 380 patients identified, 213 (56%) underwent CTPA indicated per the ACP guideline, and 78 (21%) underwent CTPA not indicated per the guideline. Only one of the patients who underwent nonindicated CTPA had a PE. Fifty-seven patients underwent unnecessary d-dimer evaluation, and 71 patients with negative d-dimer test results underwent nonindicated CTPA. PEs were found in 6 of 108 (6%) low-risk patients, 22 of 219 (10%) intermediate-risk patients, and 13 of 53 (25%) high-risk patients. The ACP guideline had negative predictive value of 99% (95% confidence interval: 93%-100%) and sensitivity of 97% (95% confidence interval: 86%-100%) in predicting PE. CONCLUSION: The ACP guideline has good sensitivity for detecting PE in cancer patients and thus can be applied in this population. Compliance with the ACP guideline when evaluating cancer patients with suspected PE could reduce the use of unnecessary imaging and laboratory studies.

Demonstrating value: association of cost and quality outcomes with implementation of a value-driven oncology-hospitalist inpatient collaboration for patients with lung cancer.

The hospitalist model of care has gained favour in many hospital systems for the value, cost-effectiveness and quality of care that hospitalists provide. Hospitalists are experts in high-acuity medical problems of patients and they are intimately knowledgeable about hospital operations that enable efficiency of patient care. This results in tremendous cost-savings for institutions especially since hospitalists are also obligated to be involved in quality and practice improvement initiatives. The University of Texas MD Anderson Cancer Center employs oncology-hospitalists for many of their patients with cancer needing inpatient services. This physician team has expertise in both cancer-related and comorbidity-related reasons for hospitalisation. In September 2015, the thoracic and head and neck medical oncology team started a collaboration with the Oncology Hospitalist team whereby a proportion of patients with thoracic malignancies were directly admitted to hospitalists for inpatient care. To determine the value of this collaboration, a pre- and post- implementation study was done to compare quality outcomes such as readmission rates and length of stay (LOS) between the two groups. Adjusted outcomes showed that readmission rates were similar for both physician groups both at baseline and after implementation of the collaborative (p=0.680 and p=0.840, respectively). Median LOS was similar for both groups at baseline (4 days) and was not significantly different post-implementation (4vs5 days, p=0.07). The adjusted cost of a hospitalisation was also similar for hospitalist encounters and thoracic oncology encounters. This initial study showed that quality of care remained comparable for patients with lung cancer who were admitted to either service. With possibly shorter LOS but comparable readmission outcomes and adjusted cost for patients discharged from the hospitalist service, there is a strong value benefit for the implemented Thoracic Oncology-Hospitalist inpatient collaborative.

Unplanned 30-Day Readmissions in a General Internal Medicine Hospitalist Service at a Comprehensive Cancer Center.

PURPOSE: Hospital readmissions are considered by the Centers for Medicare and Medicaid as a metric for quality of health care delivery. Robust data on the readmission profile of patients with cancer are currently insufficient to determine whether this measure is applicable to cancer hospitals as well. To address this knowledge gap, we estimated the unplanned readmission rate and identified factors influencing unplanned readmissions in a hospitalist service at a comprehensive cancer center. METHODS: We retrospectively analyzed unplanned 30-day readmission of patients discharged from the General Internal Medicine Hospitalist Service at a comprehensive cancer center between April 1, 2012, and September 30, 2012. Multiple independent variables were studied using univariable and multivariable logistic regression models, with generalized estimating equations to identify risk factors associated with readmissions. RESULTS: We observed a readmission rate of 22.6% in our cohort. The median time to unplanned readmission was 10 days. Unplanned readmission was more likely in patients with metastatic cancer and those with three or more comorbidities. Patients discharged to hospice were less likely to be readmitted (all P values < .01). CONCLUSION: We observed a high unplanned readmission rate among our population of patients with cancer. The risk factors identified appear to be related to severity of illness and open up opportunities for improving coordination with primary care physicians, oncologists, and other specialists to manage comorbidities, or perhaps transition appropriate patients to palliative care. Our findings will be instrumental for developing targeted interventions to help reduce readmissions at our hospital. Our data also provide direction for appropriate application of readmission quality measures in cancer hospitals.

Risk of oral and gastrointestinal mucosal injury among patients receiving selected targeted agents: a meta-analysis.

PURPOSE: The purpose of this study was to estimate the risk and severity of oral and gastrointestinal mucosal toxicities associated with selected targeted agents. METHODS: We searched the English-language literature in February 2011 for reports of randomized clinical trials comparing a FDA-approved targeted agent to a standard of care regimens. Long-term follow-up and secondary reports of trials were excluded, leaving 85 studies for analysis. Using meta-analytic methods, we calculated the relative risks of oral and gastrointestinal toxicities, adjusting for sample size using the inverse variance technique. For each targeted agent and each side effect, we calculated the number needed to harm, the number of patients that, if treated with the more toxic regimen, would produce one additional episode of the toxicity. RESULTS: Oral mucositis was significantly more frequent among patients treated with bevacizumab, erlotinib, sorafenib, or sunitinib, although this difference was confined to low-grade mucositis. The clinical significance of these findings is unclear given its low incidence and mild severity. In contrast, diarrhea was significantly more frequent with most of the targeted agents studied, with adjusted relative risks between 1.5 and 4.5. An additional patient with diarrhea will be observed for every three to five patients treated with these targeted agents, compared with conventional regimens. CONCLUSIONS: Oral mucosal toxicities occasionally complicate treatment with these targeted agents, but the clinical significance of this finding is not clear. Diarrhea is a hallmark of treatment with these targeted agents; this side effect should be carefully ascertained to permit early intervention and control.

Physical activity recommendation for hypertension management: does healthcare provider advice make a difference?

BACKGROUND: Achieving normal blood pressure with antihypertensive medication remains an achievable goal for only approximately equal to 31% of hypertensive patients. Physical activity is a primary lifestyle measure required to lower blood pressure in hypertensive patients, and the US Preventative Services Task force (USPSTF) recommends counseling by health care providers to promote regular physical activity. Surveys of patients suggest, however, that few healthcare providers follow the USPSTF recommendation on physical activity counseling. METHOD: This article examined data on the rate of healthcare provider counseling, compliance with recommendations and the blood pressure difference associated with following recommendations to increase physical activity. Data are from the National Health and Nutritional Examination Survey III 1988-1994 (NHANES-III) of adults with hypertension. We compared the results of compliance with recommendation from the NHANES-III data to five recent clinical trials on physical activity conducted between 1991 and 2001. RESULTS: A third of the NHANES-III hypertensive patients received counseling to engage in physical activity to manage their hypertension, and 71% (n=669) followed the recommendations and had a systolic blood pressure that was an average of approximately equal to 3-4 mm Hg lower than those who did not follow recommendations. CONCLUSION: This study shows that fewer patients are receiving exercise counseling to help lower blood pressure and improve health outcomes. However, patients seem to follow the advice when given. Given the magnitude of poorly controlled hypertension, these findings should alert healthcare providers to find innovative means of physical activity recommendation to improve health outcomes.

Lead poisoning in an adult: lead mobilization by pregnancy?

We report a case of acute lead poisoning in an adult female who had last been exposed to lead 7 years ago. She presented with abdominal pain, knee pain, and neurological symptoms, hypertension, chronic kidney disease, and anemia with basophilic stippling and lead gum lines. Compared to during her recent pregnancy, her lead level had almost tripled in 5 months to 81 mcg/dL. Chelation therapy was initiated and improved the patient's symptoms and lead level significantly. In the absence of any new lead exposure or other reasons for increased bone turnover, this acute lead increase was likely due to skeletal mobilization caused by increased resorption from mineralized tissue during and after her pregnancy. This case report illustrates the seriousness of long-term health effects associated with lead poisoning at a multi-organ level, even years after the initial exposure. Thus, patient care should not be limited to the acute treatment of increased lead levels, but also include prevention of increased mobilization and bone turnover and appropriate patient education. In this context, we review various aspects of lead toxicity, especially during pregnancy and lactation.