Accelerated transcranial magnetic stimulation for psychological distress in advanced cancer: A phase 2a feasibility and preliminary efficacy clinical trial.

BACKGROUND: Psychological and existential suffering affects many people with advanced illness, and current therapeutic options have limited effectiveness. Repetitive transcranial magnetic stimulation (rTMS) is a safe and effective therapy for refractory depression, but no previous study has used rTMS to treat psychological or existential distress in the palliative setting. AIM: To determine whether a 5-day course of "accelerated" rTMS is feasible and can improve psychological and/or existential distress in a palliative care setting. DESIGN: Open-label, single arm, feasibility, and preliminary efficacy study of intermittent theta-burst stimulation to the left dorsolateral prefrontal cortex, 600 pulses/session, 8 sessions/day (once per hour) for 5 days. The outcomes were the rates of recruitment, completion of intervention, and follow-up (Feasibility); and the proportion of participants achieving 50% improvement on the Hamilton Depression Rating Scale (HDRS) or Hospital Anxiety and Depression Scale (HADS) 2 weeks post-treatment (Preliminary Efficacy). SETTING/PARTICIPANTS: Adults admitted to our academic Palliative Care Unit with advanced illness, life expectancy >1 month and psychological distress. RESULTS: Due to COVID-19 pandemic-related interruptions, a total of nine participants were enrolled between August 2021 and April 2023. Two withdrew before starting rTMS, one stopped due to clinical deterioration unrelated to rTMS, and six completed the rTMS treatment. Five of six participants had a >50% improvement in HDRS, HADS-Anxiety, or both between baseline and the 2 week follow up; the sixth died prior to the 2-week follow-up. In this small sample, mean depression scores decreased from baseline to 2 weeks post-treatment (HDRS 18 vs 7, p = 0.03). Side effects of rTMS included transient mild scalp discomfort. CONCLUSIONS: Accelerated rTMS improved symptoms of depression, anxiety, or both in this small feasibility and preliminary efficacy study. A larger, sham-controlled study is warranted to determine whether rTMS could be an effective, acceptable, and scalable treatment in the palliative setting. TRIAL REGISTRATION: NCT04257227.

Implementation of the Richmond Agitation-Sedation Scale (palliative version) on an inpatient palliative care unit.

BACKGROUND: The Richmond Agitation-Sedation Scale - Palliative version (RASS-PAL) tool is a brief observational tool to quantify a patient's level of agitation or sedation. The objective of this study was to implement the RASS-PAL tool on an inpatient palliative care unit and evaluate the implementation process. METHODS: Quality improvement implementation project using a short online RASS-PAL self-learning module and point-of-care tool. Participants were staff working on a 31-bed inpatient palliative care unit who completed the RASS-PAL self-learning module and online evaluation survey. RESULTS: The self-learning module was completed by 49/50 (98%) of regular palliative care unit staff (nurses, physicians, allied health, and other palliative care unit staff). The completion rate of the self-learning module by both regular and casual palliative care unit staff was 63/77 (82%). The follow-up online evaluation survey was completed by 23/50 (46%) of respondents who regularly worked on the palliative care unit. Respondents agreed (14/26; 54%) or strongly agreed (10/26; 38%) that the self-learning module was implemented successfully, with 100% agreement that it was effective for their educational needs. CONCLUSION: Using an online self-learning module is an effective method to engage and educate interprofessional staff on the RASS-PAL tool as part of an implementation strategy.

Bilateral necrobiotic xanthogranuloma of the eyelids followed by a diagnosis of multiple myeloma 20 years later.

A uniquely indolent case of necrobiotic xanthogranuloma with bilateral, periorbital involvement was presented. This patient presented with cutaneous eyelid lesions of 20 years' duration. Although symptomless, the patient underwent testing for hematologic malignancy, which led to a diagnosis of multiple myeloma. A review of the literature revealed that this is the longest interval between the onset of the skin manifestations and the diagnosis of the systemic malignancy in this rare disease.

Iatrogenic risk factors for cytomegalovirus retinitis.

BACKGROUND: To determine the iatrogenic risk factors for cytomegalovirus (CMV) retinitis in patients with the acquired immunodeficiency syndrome (AIDS). METHODS: The case-control study included 120 patients with CMV retinitis and 159 patients without CMV retinitis, all of whom had AIDS and CD4 counts less than 50 cells/microL at the time of diagnosis of retinitis or at the defined corresponding date in the controls. Iatrogenic risk factors studied were corticosteroid use, treatment with chemotherapy, treatment with radiotherapy, and blood transfusions. RESULTS: Among the risk factors studied, only steroid use was predictive of CMV retinitis (odds ratio 6.41, 95% confidence interval 2.35-17.51). Based on this study, the use of steroids systemically elevated the risk of CMV retinitis.

Clinical risk factors for cytomegalovirus retinitis in patients with AIDS.

PURPOSE: To determine the clinical risk factors for cytomegalovirus (CMV) retinitis in patients with AIDS. DESIGN: A case-control study. PARTICIPANTS: The study included 120 patients in whom CMV retinitis had been diagnosed from 1990 through 1999 (cases) and 159 patients without CMV retinitis from the same period (controls). All individuals had AIDS and CD4 counts less than 50 cells/microl at the time of diagnosis of retinitis in the cases or on the corresponding date for the controls. METHODS: Clinical risk factors were determined by history or physical examination. Confounders controlled for included CD4 count, hospital center, and a series of variables to control for confounding by drug treatment. Statistical analysis was performed by multivariate logistic regression. A systematic model-building strategy was developed from assumption testing to model building to model checking. MAIN VARIABLES MEASURED: Presence of visual symptoms, retinal microinfarctions (cotton-wool spots), history of opportunistic infections, and risk factors for human immunodeficiency virus acquisition were determined and compared in both groups. RESULTS: The following clinical risk factors were significant predictors of CMV retinitis: flashing lights or floaters (odds ratio [OR], 11.42; 95% confidence interval [CI], 3.43 to 38.01), cotton-wool spots (OR, 2.90; 95% CI, 1.01 to 8.29), number of previous opportunistic infections (OR, 1.81; 95% CI, 1.24 to 2.64), previous nonocular CMV infection (OR, 82.99; 95% CI, 6.86 to 1004.58), previous Mycobacterium infection (OR, 3.41; 95% CI, 0.99 to 11.85), and homosexuality (OR, 2.83; 95% CI, 1.13 to 7.12). CONCLUSIONS: Based on this study, clinical variables have been identified that elevate the risk of CMV retinitis. These findings may be useful to clinicians and health policy experts in developing rational guidelines for screening, examination frequency, and targeted prophylaxis for CMV retinitis in patients with AIDS.

Clinical utility of a Legionella pneumophila urinary antigen test in a large university teaching hospital.

OBJECTIVE: To determine the clinical utility of diagnosing Legionella pneumonia by urinary antigen testing (LPUAT) in a low prevalence centre. DESIGN: The results of LPUATs were abstracted and analyzed from the authors' laboratory information system. Medical records were reviewed in detail for all positive tests and a random sample of 50 negative tests. SETTING: The Queen Elizabeth II Health Sciences Centre, a large university hospital complex. POPULATION STUDIED: Patients who were admitted from the emergency room with pneumonia or who had developed pneumonia in hospital and who had a LPUAT performed between April 1998 and October 2000. MAIN RESULTS: One thousand one hundred fifty-four tests were performed on 1007 patients. Seven patients had nine positive LPUATs. Three of these patients had confirmed Legionella pneumophila pneumonia. Three others had probable or possible L pneumophila pneumonia. There was one probable false positive. Six of the seven patients were already on empirical anti-L pneumophila therapy. Of the 50 negative tests reviewed in detail, 31 patients were on one of the antibiotics of choice for L pneumophila at the time the test was ordered; in 21 (68%) of these patients the negative result did not lead to a change in therapy. CONCLUSIONS: The cost to diagnose each case of Legionella pneumonia by LPUAT was approximately $5,770 and most patients were already on appropriate antibiotics. In patients with negative tests, antibiotics were often not changed in response to the test result. Rigorous screening of patients is required to increase pretest probability for LPUAT to be justified.