Application errors associated with topical treatment of scabies: an observational study.

BACKGROUND: In recent years, there has been a significant increase in scabies infestations throughout German-speaking countries. Given the high frequency of treatment failures, the question arises as to whether topical permethrin treatment is always performed correctly. PATIENTS AND METHODS: Our department uses a fluorescent test cream to teach patients on how to correctly apply topical permethrin. In the context of a prospective observational study of 21 patients, we systematically assessed and analyzed potential application errors. RESULTS: None of the participants succeeded in adequately applying the cream to the entire skin as previously instructed. The median number of regions left untreated was six (minimum: 2; maximum: 18), which included a median body surface area of 6 % (minimum: 2 %; maximum: 30 %). With regard to predilection sites of scabies, the ankles were left untreated in 62 % of cases, followed by the interdigital spaces (toes) (33 %) and the sacral region (24 %). All patients considered the pretreatment training to be very useful. CONCLUSIONS: The present findings clearly demonstrate potential shortcomings when it comes to the application of topical antiscabies treatment. This may provide a (potentially underestimated) explanation for the large number of reports on treatment failures in this regard, which falsely suggest potential treatment resistance.

Telemedically augmented palliative care : Empowerment for patients with advanced cancer and their family caregivers.

BACKGROUND: Studies have shown that initiating early palliative care of patients with end-stage cancer can improve their quality of life and decrease symptoms of depression. The challenge is to find an effective way to care for these patients while minimizing the burden on healthcare resources. Telemedicine can play a vital role in solving this problem. METHODS: A user-friendly telemedical device enabling patients encountering medical problems to send a direct request to a palliative care team was developed. A controlled feasibility study was conducted by assigning 15 patients with advanced cancer and their family caregivers to receive either standard palliative care or telemedically augmented palliative care. Th quality of life (QoL) was assessed using standardized validated questionnaires as well as frequency and duration of hospital admissions and user satisfaction. The primary goal of this study was to increase the QoL of patients and their family caregivers. The secondary goal of this study was to decrease the frequency and duration of hospital admissions. RESULTS: This study showed a good feasibility despite the low overall willingness to participate in a relatively "technical" trial. The hospital anxiety and depression scale (HADS) was significantly lower in the intervention group, suggesting an improved quality of life. Although a decrease in the number of hospital admissions could not be shown, the user satisfaction was very good. CONCLUSION: Telemedicine could be a useful tool to enhance the general well-being of palliative oncology patients. Now that the feasibility of this approach has been confirmed, larger studies are needed to verify its positive impact on the QoL.

Migrate your mind: the role of palliative care in transcultural cancer treatment : A qualitative analysis.

BACKGROUND: In increasingly multi-ethnic societies fostering cultural awareness and integration of immigrants is not only a political duty but also an obligation for social and healthcare systems. Importantly, cultural beliefs and needs strongly impact on the quality of life of cancer patients and may become even more crucial at the end of life. However, to date, ethnic and cultural aspects of palliative care are insufficiently researched. METHODS: This qualitative study at the Medical University of Vienna included 21 staff members from different disciplines in oncology and palliative care working with patients with various cultural backgrounds at the end of life. Semi-structured interviews were performed to gain insights into specific aspects of palliative care that are important in the clinical encounter with terminally ill cancer patients with migrant backgrounds and their relatives. RESULTS: Interviews revealed specific aspects of palliative care, which fell into four fundamental categories and were all perceived as beneficial in the clinical encounter with migrant clients: (A) structural and (B) personal conditions of the palliative care setting, (C) specific care and treatment intentions and (D) personnel requirements and attitudes. CONCLUSION: This study revealed first insights into possibilities and prospects of transcultural palliative care for migrants and their relatives. The results might have important implications for the end of life care in this growing population.

Personalized RNA mutanome vaccines mobilize poly-specific therapeutic immunity against cancer.

T cells directed against mutant neo-epitopes drive cancer immunity. However, spontaneous immune recognition of mutations is inefficient. We recently introduced the concept of individualized mutanome vaccines and implemented an RNA-based poly-neo-epitope approach to mobilize immunity against a spectrum of cancer mutations. Here we report the first-in-human application of this concept in melanoma. We set up a process comprising comprehensive identification of individual mutations, computational prediction of neo-epitopes, and design and manufacturing of a vaccine unique for each patient. All patients developed T cell responses against multiple vaccine neo-epitopes at up to high single-digit percentages. Vaccine-induced T cell infiltration and neo-epitope-specific killing of autologous tumour cells were shown in post-vaccination resected metastases from two patients. The cumulative rate of metastatic events was highly significantly reduced after the start of vaccination, resulting in a sustained progression-free survival. Two of the five patients with metastatic disease experienced vaccine-related objective responses. One of these patients had a late relapse owing to outgrowth of ß2-microglobulin-deficient melanoma cells as an acquired resistance mechanism. A third patient developed a complete response to vaccination in combination with PD-1 blockade therapy. Our study demonstrates that individual mutations can be exploited, thereby opening a path to personalized immunotherapy for patients with cancer.

Palliative care units in lung cancer in the real-world setting: a single institution's experience and its implications.

OBJECTIVE: Palliative care plays a crucial role in the overall management of patients with advanced lung cancer and was shown to lead to clinically meaningful improvement in quality of life, less aggressive endof-life care, and potentially prolonged survival. Here we summarize our single institution experience on palliative care in patients with lung cancer. METHODS: The data of patients with lung cancer treated at the palliative care unit of the Medical University of Vienna between June 2010 and March 2013 were retrospectively reviewed. Patient characteristics, reasons for admissions, treatment as well as interventions during hospitalization, and clinical outcomes were determined. RESULTS: The study enrolled 91 lung cancer patients, who represented 19.8% of the 460 patients admitted to the palliative care unit. They had the following clinical characteristics: 39% females, 61% males; median age 62 years; median Karnofsky performance status 50%, 92% metastatic disease, 74% non-small cell lung cancer (NSCLC), 19% small-cell lung cancer (SCLC), 7% neuroendocrine carcinomas of the lung. Primary reasons for admission were deterioration of performance status in 40%, uncontrolled cancer-related pain in 38%, dyspnea in 13%, and psychosocial factors in 8% of the patients. Median duration of hospitalization was 16 days (range, 1-101 days). Improvement or stabilisation of tumor-related symptoms was achieved in 25% of the patients. Seventy-five percent of all patients died during their first admission. Their median survival from primary diagnosis until death was 16 months (95% confidence interval, 13.7-18.3 months). CONCLUSIONS: Patients with lung cancer admitted to the palliative care unit had late-stage disease. In order to provide early palliative care, the management of lung cancer patients should guarantee access to ambulatory care, inpatient care and home care as well as cooperation and communication between oncologists and palliative care physicians.

Coming and going: predicting the discharge of cancer patients admitted to a palliative care unit: easier than thought?

PURPOSE: Discharging a patient admitted to an inpatient palliative care unit (PCU) is a major challenge. A predictor of the feasibility of home discharge at the time of admission would be very useful. We tried to identify such predictors in a prospective observational study. METHODS: Sixty patients with advanced cancer admitted to a PCU were enrolled. Sociodemographic data were recorded and a panel of laboratory tests performed. The Karnofsky performance status scale (KPS) and the palliative performance scale (PPS) were determined. A palliative care physician and nurse independently predicted whether the patient would die at the ward. The association of these variables with home discharge or death at the PCU was determined. RESULTS: Sixty patients (26 men and 34 women) with advanced cancer were included in the study. Discharge was achieved in 45 % of patients, while 55 % of patients died at the PCU. The median stay of discharged patients was 15.2 days, and the median stay of deceased patients 13.6 days. Median KPS and PPS on admission was 56.2 % for the entire group and significantly higher for discharged patients (60.7 %) compared to deceased patients (52.4 %). Median BMI on admission was 22.8 in the entire group and was similar in discharged and deceased patients. No correlation was found between a panel of sociodemographic variables and laboratory tests with regard to discharge or death. In a binary logistic regression model, the probability of discharge as estimated by the nurse/physician and the KPS and PPS were highly significant (p = 0.008). CONCLUSION: Estimation by a nurse and a physician were highly significant predictors of the likelihood of discharge and remained significant in a multivariate logistic regression model including KPS and PPS. Other variables, such as a panel of laboratory tests or sociodemographic variables, were not associated with discharge or death.

Distal gastrectomy in pancreaticoduodenectomy is associated with accelerated gastric emptying, enhanced postprandial release of GLP-1, and improved insulin sensitivity.

OBJECTIVE: This study aims to investigate the relationship between gastric emptying, postprandial GLP-1 and insulin sensitivity after pancreaticoduodenectomy (PD). BACKGROUND: Abnormal glucose regulation is highly prevalent in patients with pancreatic neoplasm and resolves in some after PD, the cause of which is unclear. The procedure is carried out with pylorus preservation (PPPD) or with distal gastrectomy (Whipple procedure). Accelerated gastric emptying and ensuing enhanced release of glucagon-like peptide-1 (GLP-1) conceivably play a role in glucose metabolism after PD. It was the purpose of this study to shed light on the relationship between gastric emptying, GLP-1 and glycemic control after PPPD and the Whipple procedure. METHODS: A 75-g oral glucose tolerance test was carried out in 13 patients having undergone PPPD and in 13 after the Whipple procedure, median age 61 (range, 32-70) years, following an interval of 23 (range, 5-199) months. Gastric emptying was measured by the paracetamol absorption method. Plasma concentrations of glucose, insulin, GLP-1 and paracetamol were measured at baseline, 10, 20, 30 60, 90, 120, 150 and 180 min. Homeostasis model assessment-estimated insulin resistance (HOMA-IR) and oral glucose insulin sensitivity were calculated from glucose and insulin concentrations. RESULTS: Patients with Whipple procedure as compared to PPPD had accelerated gastric emptying (p = 0.01) which correlated with early (0-30 min) integrated GLP-1 (AUC30; r (2) = 0.61; p = 0.02) and insulin sensitivity (r (2) = 0.41; p = 0.026) and inversely with HOMA-IR (r (2) = 0.17; p = 0.033). Two of 13 Whipple patients (15 %) as compared to seven of 13 after PPPD (54 %) had postload glucose concentrations (i.e. 120 min postmeal) ≥200 mg/dl (p < 0.05). None of 13 (0 %) after Whipple procedure but four of 13 patients (31 %) after PPPD had fasting glucose concentrations ≥126 mg/dl (p < 0.05) CONCLUSIONS: Gastric emptying was accelerated after Whipple procedure as compared to patients who have undergone PPPD, resulting in higher postprandial GLP-1 concentrations and insulin sensitivity and improved glycemic control.

Predicting discharge of palliative care inpatients by measuring their heart rate variability.

OBJECTIVES: Home discharge after hospital admission to an inpatient palliative care unit (PCU) is a major challenge. Dysfunction of the autonomic nervous system is commonly observed in patients with advanced cancer in this setting. The aim of this prospective observational study was to determine whether the measurement of heart rate variability (HRV) by assessing parameters of the autonomic nervous system on a 24-h-ECG at the time of admission to the PCU was correlated with the likelihood of discharge. METHODS: Sixty hospitalized patients with advanced cancer of distinct origin, admitted to a PCU, were enrolled consecutively. The Karnofsky performance status scale (KPS) and the palliative performance scale (PPS) were obtained. HRV was measured over one day (20-24 hours) using a portable five-point ECG. The aim of the study was to compare HRV measurements in patients who could be discharged and those who died. The association of these variables with home discharge or death at the PCU was calculated. RESULTS: Discharge was achieved in 45% of patients while 55% of patients died. Median KPS and median PPS on admission were significantly higher in discharged patients than in those who died (P=0.001). Patients who were discharged tended to have a higher HRV, although the difference was not significant. CONCLUSIONS: KPS and PPS were significant predictors of the likelihood of discharge while HRV did not predict discharge.

The application of the V-Loc closure device for gastrointestinal sutures: a preliminary study.

BACKGROUND: Leakage is one of the major complications in gastrointestinal surgery. This preliminary study compared a new barbed absorbable thread for gastrointestinal sutures with monofil suture material in a cadaver model. METHODS: In this study, mechanical experiments were performed in 20 recently deceased individuals. Incisions were made in the small intestine, colon, and stomach, and then sutures were created with the V-Loc closure device and monofil suture material. Intestinal bursting pressure was measured by inserting a balloon and slowly filling it with air until there was a dehiscence, or wall or suture rupture. RESULTS: The bursting pressures differed significantly between the two sutures in the small intestine, showing the advantage of the V-Loc closure device, which had a mean bursting pressure of 116.2 mmHg compared with 110 mmHg for the monofil suture (p = 0.003). The mean bursting pressure did not differ significantly between the two sutures in the colon and the stomach. The mean bursting pressures for the V-Loc closure device were 141.3 mmHg (stomach) and 137.2 mmHg (colon) compared with the monofil suture material bursting pressures of 133 mmHg (stomach) and 134.8 mmHg (colon). CONCLUSIONS: Because the bursting strength of the sutures created with monofil suture material differs significantly from that of the V-Loc closure device, the V-Loc suture material should be used for gastrointestinal sutures. Although the two sutures did not differ significantly in the colon or the stomach, the V-Loc closure device should be used for these as well because its advantages may overrule those of the monofil suture. No knot tying is required, and the operating time can be shorter. Especially for laparoscopic surgery, the V-Loc closure device is recommended.

Three-dimensional multiphoton/optical coherence tomography for diagnostic applications in dermatology.

A preliminary clinical trial using state-of-the-art multiphoton tomography (MPT) and optical coherence tomography (OCT) for three-dimensional (3D) multimodal in vivo imaging of normal skin, nevi, scars and pathologic skin lesions has been conducted. MPT enabled visualization of sub-cellular details with axial and transverse resolutions of <2 µm and <0.5 µm, respectively, from a volume of 0.35 × 0.35 × 0.2 mm(3) at a frame rate of 0.14 Hz (512 × 512 pixels). State-of-the-art OCT, operating at a center wavelength of 1300 nm, was capable of acquiring 3D images depicting the layered architecture of skin with axial and transverse resolutions ~8 µm and ~20 µm, respectively, from a volume of 7 × 3.5 × 1.5 mm(3) at a frame rate of 46 Hz (1024 × 1024 pixels). This study demonstrates the clinical diagnostic potential of MPT/OCT for pre-screening relatively large areas of skin using 3D OCT to identify suspicious regions at microscopic level and subsequently using high resolution MPT to obtain zoomed in, sub-cellular level information of the respective regions.