Comparing Symptom Burden in Patients with Metastatic and Nonmetastatic Cancer.

BACKGROUND: Symptoms of patients with advanced cancer have been extensively studied, but less attention has been paid to the symptomatology of patients with localized disease. We compared the symptom burden of outpatients with cancer, either metastatic or localized disease, seen in a palliative care comanagement clinic. METHODS: We conducted a retrospective, cross-sectional study assessing patient symptoms with multiple patient surveys, including a modified Edmonton Symptom Assessment Survey (to assess pain, fatigue, anxiety, depression, and nausea), along with a spiritual well-being screen and questions about relationships and quality of life. Consecutive patients at a comprehensive cancer center completed the surveys prior to their first visit to an outpatient palliative care clinic providing palliative care concurrently with the patients' oncologic treatments. Patients were referred by their oncologist, radiation oncologist, oncologic surgeon, or primary care physician without respect to their stage or prognosis. Statistical analyses used were χ(2), Fisher's exact test, Student's t test, and multivariate linear regression. Significance was taken as p<0.05. RESULTS: Two hundred and five patients were included in this study. One hundred and twenty-seven patients (62%) had metastatic cancer and 78 (38%) had nonmetastatic cancer. The characteristics of the two study groups were similar with regard to age, sex, ethnicity, language, religion, partnership status, and insurance status. Patients with metastatic disease and localized disease had similar mean symptom burden and mean individual symptom intensity for all symptoms evaluated except for nausea, which was worse in patients with metastatic disease (3.4 versus 2.5, p=0.0028). Nausea was also worse in younger patients. CONCLUSION: Among patients referred to a cancer center outpatient palliative care clinic, symptom burden is similar in patients with localized and metastatic disease. Even patients with relatively good prognoses may nevertheless have significant symptom burdens in physical, emotional, and existential domains. The palliative care needs of all patients must be assessed, regardless of stage or prognosis.

Use of gabapentin in the treatment of behavioural and psychological symptoms of dementia: a review of the evidence.

Behavioural and psychological symptoms of dementia (BPSD) have been defined as a heterogeneous range of psychological reactions, psychiatric symptoms and behaviours that may be unsafe, disruptive and impair the care of a patient in a given environment. To date, there are no US FDA-approved drugs or clear standards of pharmacological care for the treatment of BPSD. The novel antiepileptic agent gabapentin is being increasingly considered for use in the geriatric population because of its relatively favourable safety profile compared with other classes of psychiatric medications. Gabapentin has been administered to several geriatric patients with bipolar disorder and patients with dementia. It has also been reported to be successful in the treatment of a 13-year-old boy with behavioural dyscontrol, a finding that suggested a possible role for gabapentin in the treatment of other behavioural disorders. The purpose of this review was to find evidence for the use of gabapentin in the treatment of BPSD. To this end, a search was performed for case reports, case series, controlled trials and reviews of gabapentin in the treatment of this condition. The key words 'dementia', 'Alzheimer's disease' and 'gabapentin' were used. Searches were performed in PubMed, PsycINFO, Ovid MEDLINE, Cochrane Library and ClinicalTrials.gov. The search revealed that there are limited data on the efficacy of gabapentin for BPSD in the form of 11 case reports, 3 case series and 1 retrospective chart review; no controlled studies appear to have been published to date on this topic. In most of the reviewed cases, gabapentin was reported to be a well tolerated and effective treatment for BPSD. However, two case reports in which gabapentin was used in the context of agitation in dementia with Lewy bodies questioned the appropriateness of gabapentin for all types of dementia-related agitation. The dearth of available data limits support for the off-label use of gabapentin for the treatment of BPSD. Furthermore, controlled studies should be conducted before gabapentin can be clinically indicated for the successful treatment of BPSD.

Use of ultrasound measurement of the inferior vena cava diameter as an objective tool in the assessment of children with clinical dehydration.

OBJECTIVES: Bedside ultrasonography (US) measurement of the inferior vena cava (IVC) and aorta (Ao) may be useful in objectively assessing children with dehydration. The objectives of this study were 1) to compare the IVC and Ao diameters (IVC/Ao) ratio of dehydrated children with controls and 2) to compare the IVC/Ao ratio before and after intravenous (i.v.) rehydration in children with dehydration. METHODS: This prospective observational study was performed in an urban pediatric emergency department. Children between 6 months and 16 years of age with clinical evidence of dehydration were enrolled. Bedside US measurements of the IVC and Ao were taken before and immediately after i.v. fluids were administered. An age-, gender-, and weight-matched control without dehydration was enrolled for each subject. The IVC/Ao ratios of subjects and controls were compared using Wilcoxon signed rank test, as were the ratios before and after i.v. hydration for each subject. RESULTS: Thirty-six pairs of subjects and matched controls were enrolled. The IVC/Ao ratios in the subjects were lower as compared with controls (mean of 0.75 vs. 1.01), with a mean difference of 0.26 (95% confidence interval = 0.18 to 0.35). In subjects, the IVC/Ao ratios were significantly lower before i.v. hydration (mean of 0.75 vs. 1.09), with a mean difference of 0.34 (95% confidence interval = 0.29 to 0.39). CONCLUSIONS: As measured by bedside US measurement, the IVC/Ao ratio is lower in children clinically assessed to be dehydrated. Furthermore, it increases with administration of i.v. fluid boluses.

Diagnosis and guided reduction of forearm fractures in children using bedside ultrasound.

BACKGROUND: Forearm fractures are common injuries in children. Displaced and angulated fractures usually require reduction. Ultrasound diagnosis and guided reduction offer several potential advantages: (1) the procedure does not involve ionizing radiation; (2) compared with fluoroscopy units, the newer ultrasound units are more portable; and (3) repeated studies can be obtained easily and quickly. OBJECTIVE: The primary objective was to investigate the accuracy of emergency department (ED) physician-performed ultrasound in the diagnosis and guided reduction of forearm fractures in children. METHODS: Children suspected of having forearm fractures were enrolled prospectively in an urban pediatric ED from June 2004 to November 2004. A bedside ultrasound of the forearm bones was performed by a pediatric emergency medicine physician. Ultrasound findings were compared with radiograph findings. Reductions were performed under ultrasound guidance. Postreduction radiographs were performed. Any need for further reduction was recorded. RESULTS: During the study period, 68 patients were enrolled. Radiographs revealed forearm fractures in 48 patients. Twenty-nine subjects had fractures of the radius alone; 17 had fractures of both the radius and the ulna, and 2 had fractures of the ulna alone. Ultrasound revealed the correct type and location of the fracture in 46 patients. The sensitivity for the detection of forearm fractures was 97% (95% confidence interval [CI], 89%-100%) using ultrasound. The specificity was 100% (95% CI, 83%-100%). Twenty-six subjects underwent reduction of their fractures in the ED. Two subjects required rereduction after the initial reduction. The initial success rate of ultrasound-guided reduction was 92% (95% CI, 75%-99%). CONCLUSIONS: Bedside ultrasound performed by pediatric emergency medicine physicians is a reliable and convenient method of diagnosing forearm fractures in children. It is also useful in guiding the reduction of these fractures.

Role of phospholipase D signaling in ethanol-induced inhibition of carbachol-stimulated DNA synthesis of 1321N1 astrocytoma cells.

Inhibition of astrocyte proliferation has been suggested to be an important event in the developmental neurotoxicity associated with ethanol. We have previously shown that the acetylcholine analog carbachol induces astroglial cell proliferation through activation of muscarinic M3 receptors, and that ethanol strongly inhibits this effect by inhibiting activation of protein kinase C (PKC) zeta and its down-stream effector 70-kDa ribosomal S6 kinase (p70S6K). In this study, we investigated whether inhibition by ethanol of this signal transduction pathway in 1321N1 human astrocytoma cells may be due, at least in part, to inhibition of the formation of the PKC zeta activator phosphatidic acid (PA), which is formed by hydrolysis of phosphatidylcholine by phospholipase D (PLD). 1-Butanol, which is a substrate for PLD and inhibits PA formation, inhibited carbachol-induced cell proliferation and the underlying intracellular signaling, whereas its analog tert-butanol, which is a poor substrate for PLD, was much less effective. In addition, exogenous PAs were able to increase DNA synthesis and to activate PKC zeta and p70S6K. Furthermore, in carbachol-stimulated cells, ethanol increased the formation of phosphatidylethanol and inhibited the formation of PA. Taken together, these results indicate that PLD activation plays an important role in carbachol-induced astroglial cell proliferation by generating the second messenger PA, which activates PKC zeta. Moreover, the effect of ethanol on carbachol-induced proliferation appears to be mediated, at least in part, by its ability to interact with PLD leading to a decreased synthesis of PA.