Optimizing transitions of care antimicrobial prescribing at a community teaching hospital.

Objective: Antibiotic prescribing at hospital discharge is an important focus for antimicrobial stewardship efforts. This study set out to determine the impact of a pharmacist-led intervention at hospital discharge on appropriate antimicrobial prescribing. Design: This was a pre-/post-study evaluating the impact of a pharmacist-led review on antibiotic prescribing at hospital discharge. Pharmacists evaluated antibiotic prescriptions at discharge for appropriate duration, spectrum of activity, frequency, and strength of dose. Each of these criteria needed to be met for an antibiotic regimen to be considered appropriate. Setting: Moses Cone Hospital is a 535-bed community teaching hospital in Greensboro, North Carolina. Patients or Participants: Patients ≥18 years of age discharged from the hospital with an antibiotic prescription were included. Exclusion criteria included patients discharged against medical advice, discharged to a skilled nursing facility, or prescribed indefinite prophylactic antimicrobial therapy. Interventions: A review of patients discharged with antibiotics in 2020 was performed. Patients discharged with antibiotic prescriptions from January 2021 to April 2022 were evaluated prior to discharge by pharmacists. The pharmacist made recommendations to providers based on their evaluations. Results: 162 retrospective patients were screened, and 136 patients were screened at discharge from the hospital in the prospective cohort. 76/162 (47%) retrospective patients received appropriate antibiotic therapy at discharge, while 92/136 (68%) of prospective patients received appropriate discharge therapy (p = 0.001). Conclusions: In this study examining the efficacy of stewardship pharmacist intervention at hospital discharge, pharmacist review and recommendations were associated with an increased rate of appropriate antimicrobial prescribing. Ethics statement: This study was conducted under the approval of the Institutional Review Board of the Moses H. Cone Health System. The approval protocol number was 1483117-1 and took effect on September 2nd, 2019. As the research was either retrospective in nature or part of the standard of care recommendations, the project was granted expedited review.

Radiation for below the knee skin cancers: a single institution experience.

Background: Historically, radiation to skin cancers for the lower legs has been avoided due to the perceived increased risk of radiation toxicity (poor wound healing, radiation necrosis). However, there is a paucity of published data regarding this perceived risk.Purpose: The objective was to review the risk of poor wound healing/radiation necrosis occurring post radiation and to determine rates of complete response (CR), partial response (PR), and progressive disease after radiation therapyMaterials and methods: A retrospective review of patients treated with radiation for skin cancer below the knee was undertaken from January 1, 2013 to May 31, 2018.Results: A total of 25 patients with 39 below the knee skin sites were treated with radiation. Mean follow-up time was 19 months (range 3 months-7.2 years). Crude CR, PR and progression rates for the treated lesions were 65%, 19%, and 16% respectively. Four out of 23 (17%) patients developed Grade 3 skin toxicity. There were no grades 4 or 5 toxicities.Conclusions: For patients not eligible for surgery, radiation therapy is an option with a moderate chance of complete response (65%) and a 17% risk of poor wound healing/radiation necrosis.

Radiation therapy for the treatment of skin Kaposi sarcoma.

OBJECTIVE: Kaposi sarcoma (KS) lesions are purplish, reddish blue or dark brown/black macules, plaques or nodules which involve the skin and occasionally internal organs. Most patients with KS have a long indolent chronic course. METHODS: A retrospective review was undertaken for all KS skin patients treated with radiotherapy at a tertiary cancer centre from Jan. 2, 1999 to Dec. 31, 2014 (inclusive). RESULTS: A total of 47 patients with KS (43 classical, 0 African, 1 iatrogenic, 3 AIDS related) were seen in the multidisciplinary clinic. Out of this group, 17 patients (5 females and 12 males, 14 classical, 0 African, 0 iatrogenic, 3 AIDS related) with 97 KS skin sites were treated with local external beam radiotherapy. An additional 18 skin sites were treated with repeat radiotherapy. The radiotherapy dose ranged from 6 Gy in 1 fraction to 30 Gy in 10 fractions with the most common dose fractionation scheme being 8 Gy in 1 fraction or 20 Gy in 5 daily fractions. For the previously untreated KS sites, 87% responded to radiation [30% complete response (CR) and 57% partial response (PR)]. Thirteen percent of KS sites treated with radiation progressed. For the skin sites which were treated with repeat radiotherapy, 0% showed CRs, 50% PRs and 50% had continued progression. CONCLUSIONS: The majority of KS skin lesions (87%) responded to radiotherapy. Patients experience minimal side effects from the palliative radiation regimens used. KS skin lesions which progress despite radiation are unlikely to show CR with repeat radiotherapy. In our experience 50% of skin KS will have partial regression with repeat radiotherapy and 50% will have continued progression.

A multicenter assessment of the adequacy of cancer pain treatment using the pain management index.

PURPOSES: Determine adequacy of management of pain secondary to bone metastases by physicians referring to specialized outpatient palliative radiotherapy (RT) clinics in Canada; compare geographic differences in adequacy of pain management and pain severity between these cohorts; compare results with published international literature. METHODS: Prospectively collected data from three participating centers were used to calculate the Pain Management Index (PMI) by subtracting the patient-rated pain score at time of initial clinic visit from the analgesic score. Scores were 0, 1, 2, and 3 when patients reported no pain (0), mild (1-4), moderate (5-6), or severe pain (7-10), respectively, on the Edmonton Symptom Assessment System or Brief Pain Inventory. Analgesic scores of 0, 1, 2, and 3 were assigned for no pain medication, nonopioids, weak opioids, and strong opioids respectively. A negative PMI suggests inadequate pain management. RESULTS: Overall incidence of negative PMI and moderate to severe pain was 25.1% and 70.9% respectively for 2011 patients. Comparing the three participating centers, the incidence of negative PMI was 31.0%, 20.0%, and 16.8% (p < 0.0001), and severe pain was 55.5%, 48.2% and 43.4% (p < 0.0001), these correlated with a negative PMI. Patients referred to our clinics were less likely to be undertreated for their pain when compared to study results from international countries. CONCLUSION: Geographic differences in adequacy of analgesic management for painful bone metastases exist between Canadian specialized outpatient palliative RT clinics and between centers globally. Investigating reasons for these differences may provide insight into solutions to improve quality of life for these patients.

Retrospective assessment of cancer pain management in an outpatient palliative radiotherapy clinic using the Pain Management Index.

CONTEXT: The Pain Management Index (PMI) is a simple index linking the usual severity of cancer pain with the category of medication prescribed to treat it. Medication categories are derived from the World Health Organization's "analgesic ladder" approach to cancer pain, and the PMI is an indicator of the extent to which the medication prescribed corresponds to the recommended categories for mild, moderate, and severe pain. OBJECTIVES: The aim of this study was to assess prevalence of inadequate pain management in an outpatient palliative radiotherapy clinic using the PMI. METHODS: All patients with bone metastases referred for palliative radiotherapy from 1999 to 2006 were retrospectively analyzed for patient-rated pain scores (0-10 scale) and analgesic consumption. Pain scores were assigned 0, 1, 2, and 3 when patients reported no pain (0), mild (1-4), moderate (5-6), or severe pain (7-10), respectively. Analgesic scores of 0, 1, 2, and 3 were assigned when patients were prescribed no pain medication, nonopioids, "weak" opioids, and "strong" opioids, respectively. The PMI score was calculated by subtracting the pain score from the analgesic score. A negative PMI score was considered an indicator of potentially inadequate pain management by the prescriber. Descriptive statistics, Pearson's r correlation, and univariate and multivariate logistic regression analysis were used to determine the relationship of PMI over time, and the relationship with predictive factors. RESULTS: One thousand patients were included from January 1999 to December 2006. A negative PMI was calculated for 25.8% of patients at initial consultation. Prevalence of negative PMI significantly increased over years (P<0.0001). Higher Karnofsky Performance Status (P<0.0001) and breast primary cancer site (P<0.0001) were significantly associated with negative PMI after adjusting for year variable. CONCLUSION: Despite publication of numerous cancer pain management guidelines, undermedication appears to be a persistent problem for patients with painful bone metastases referred for radiotherapy.

Elderly patients with painful bone metastases should be offered palliative radiotherapy.

PURPOSE: To investigate the efficacy of palliative radiotherapy (RT) in relieving metastatic bone pain in elderly patients. METHODS AND MATERIALS: The response to RT for palliation of metastatic bone pain was evaluated from a prospective database of 558 patients between 1999 and 2008. The pain scores and analgesic intake were used to calculate the response according to the International Bone Metastases Consensus Working Party palliative RT endpoints. Subgroup analyses for age and other demographic information were performed. RESULTS: No significant difference was found in the response rate in patients aged >or=65, >or=70, and >or=75 years compared with younger patients at 1, 2, or 3 months after RT. The response was found to be significantly related to the performance status. CONCLUSION: Age alone did not affect the response to palliative RT for bone metastases. Elderly patients should be referred for palliative RT for their painful bone metastases, regardless of age, because they receive equal benefit from the treatment.

Neurosurgical rescue of bradycardia induced by intracerebral hypertension: a case report and review of the literature.

Brain metastases usually occur secondary to lung, breast, unknown primary, melanoma, and colon cancers. A growing tumor in the brain is commonly associated with edema and increased intracranial pressure (ICP). Common signs and symptoms due to increased ICP or brain edema include headache, nausea, and vomiting. One of the main treatment modalities in the management of brain metastases is whole-brain radiation. However, increased ICP may lead to acute deterioration of the neurologic status due to development of radiation-induced edema. Therefore, alternative management options should be considered for these patients to avoid complications from whole-brain radiation treatment. We discuss the case of a brain metastases patient who presented with bradycardia induced by brain edema.

Immediate pain relief and improved structural stability after percutaneous vertebroplasty for a severely destructive vertebral compression fracture.

Approximately 10% to 30% of patients with cancer have metastases to the spine that require treatment. Spinal metastases can cause acute and chronic pain, compression fractures, spinal instability, and neurologic deficits. Vertebral compression fractures can be a significant cause of pain and impaired function. Radiation therapy is the standard treatment for patients with spinal metastases. However, this may not be the optimal treatment by itself for some patients when immediate pain relief is desirable. Percutaneous vertebroplasty is a mildly invasive treatment which involves the injection of cement, polymethylmethacrylate (PMMA) into a diseased vertebral body. We report a patient who presented with a severely destructive lesion and compression fracture at T9 with severe pain and impaired mobility. Percutaneous vertebroplasty provided immediate pain relief and restored structural stability of the diseased vertebra.

The role of plain radiographs in management of bone metastases.

Approximately 50% of patients with cancer will develop skeletal metastases, which often lead to significant pain. When a patient complains of pain, a bone scan and/or plain x-rays are ordered as investigations. X-rays necessitate a 1-cm diameter mass and 50% bone mineral loss at minimum for detection. Up to 40% of lesions will be unidentified by x-rays, presenting false-negative results. Computed tomography (CT) scans can recognize a bony metastatic lesion up to 6 months earlier than an x-ray. However, plain x-rays can also lead to rare false-positive results. We present a case with a false-positive result in a patient with lung cancer.

Symptoms and quality of life in cancer patients with brain metastases following palliative radiotherapy.

PURPOSE: To examine prospectively patient self-rated symptoms and quality of life (QOL) indicators in patients with brain metastases following whole brain radiotherapy (WBRT). METHODS AND MATERIALS: Consecutive patients with brain metastases referred for WBRT were approached for this study. Patients were asked to rate their symptoms and QOL using the Spitzer Quality of Life Index questionnaire. Follow-up was at 1, 2, and 3 months following WBRT. Linear regression analysis was used to determine the change in symptom severity over time. RESULTS: Between August 2005 to October 2007, 129 patients with brain metastases were enrolled. The majority of patients (88%) received 20 Gy in five fractions. Median age was 64 years, and median Karnofsky Performance Status at baseline was 70. The most commonly experienced symptoms at baseline were headaches, weakness, balance problems, and fatigue. Thirty-five percent of patients rated neurological functional (NF) status as 1, indicating moderate neurological symptoms and need for assistance. Forty-three percent of patients had stable or decreased fatigue, and 47% had a stable or improved NF status over time (p = 0.0040). Although certain QOL domains improved over time, all other QOL domains and symptom items did not change significantly following WBRT. CONCLUSION: WBRT may have contributed to symptom stabilization in our study. An alternative goal of WBRT may be the prevention of symptom progression and QOL deterioration. Further research is required to select the most appropriate group of patients with brain metastases who would benefit most from WBRT.

Continued success of the rapid response radiotherapy program: a review of 2004-2008.

PURPOSE: To update the clinical activity of the Rapid Response Radiotherapy Program (RRRP). MATERIALS AND METHODS: We conducted a retrospective review of our clinic database from January 2004 until July 2008. The number of patients referred to the RRRP, relevant demographic data, diagnosis and treatment dispositions were recorded. Time interval between referral to consultation and consultation to simulation were also calculated. RESULTS: During the study period, 3,267 patients were seen in the RRRP. Forty-five percent (1,494) of the patients were new to the clinic. Of the 3,267 patients seen, 1,548 (47.4%) were female and 1,719 (52.6%) were male. The median age was 69.2 years (range, 22-101 years). The most common primary sites were lung (34.2%), breast (21.2%) and prostate (17.0%). The majority of patients were referred for palliative treatment of bone metastases (52.4%) or treatment for brain metastases (20.7%). Of the patients referred, 2,311 (70.5%) patients received palliative radiotherapy. The median duration from referral to consultation was 4 days. The majority (82.3%) of patients were simulated and treated within the first 7 days following consultation. CONCLUSION: The number of patients referred to the RRRP from January 2004-July 2008 remains comparable to our previous report (1996-2003). The overall median interval from referral to consultation for the analysed time period was 4 days. Therefore, we are continuing to meet our goal of providing rapid access to palliative radiation treatment for symptomatic cancer patients. Further information relating to progression and advancements within the clinic aimed at improving our patients' quality of life are explored.

Would larger radiation fields lead to a faster onset of pain relief in the palliation of bone metastases?

PURPOSE: Hemibody irradiation has been shown to relieve bony metastatic pain within 24-48 hours of treatment, whereas for local external beam radiation, onset of pain relief is 1-4 weeks after radiation. The primary objective of this study is to examine whether there is a relationship between the areas of radiation treatment and onset of pain relief. METHODS AND MATERIALS: From Jan 1999 to Jan 2002, a total of 653 patients with symptomatic bone metastases were treated with external beam radiation. Pain scores and analgesic consumption were recorded at baseline and Weeks 1, 2, 4, 8, and 12. The areas of radiation treatment for all patients were calculated, then correlated with the response and analyzed in various ways. We first compared pain score alone with mean radiation field size. Second, we combined pain score and analgesic consumption. Last, we implemented the International Consensus end points for pain score and analgesic intake. RESULTS: Assessment of 653 patients showed no significant correlation comparing pain scores alone with radiation field area, with the exception of Week 4 for partial responders. Again, no significant correlation was found when combining both analgesic intake and pain score against radiation field size. Even when implementing the International Consensus end point definitions for radiation response, the only significant correlation between radiation field size and response was observed in Week 2 for partial response. CONCLUSION: There was no statistical significance between mean areas of radiation treatment with the onset of pain relief.

Determining the incidence of pain flare following palliative radiotherapy for symptomatic bone metastases: results from three canadian cancer centers.

PURPOSE: To determine the incidence of pain flare following radiotherapy (RT) for painful bone metastases. MATERIALS AND METHODS: Patients with bone metastases treated with RT were eligible. Worst pain scores and analgesic consumption were collected before, daily during, and for 10 days after treatment. Pain flare was defined as a 2-point increase in the worst pain score (0-10) compared to baseline with no decrease in analgesic intake, or a 25% increase in analgesic intake with no decrease in worst pain score. Pain flare was distinguished from progression of pain by requiring the worst pain score and analgesic intake return to baseline levels after the increase/flare (within the 10-day follow-up period). RESULTS: A total of 111 patients from three cancer centers were evaluable. There were 50 male and 61 female patients with a median age of 62 years (range, 40-89 years). The primary cancers were mainly breast, lung, and prostate. Most patients received a single 8 Gy (64%) or 20 Gy in five fractions (25%). The overall pain flare incidence was 44/111 (40%) during RT and within 10 days following the completion of RT. Patients treated with a single 8 Gy reported a pain flare incidence of 39% (27/70) and, with multiple fractions, 41% (17/41). CONCLUSION: More than one third of the enrolled patients experienced a pain flare. Identifying at-risk individuals and managing potential pain flares is crucial to achieve an optimal level of care.

Has pain management in cancer patients with bone metastases improved? A seven-year review at an outpatient palliative radiotherapy clinic.

The primary objective of this study was to determine the prevalence of underdosage of analgesics for pain associated with bone metastases in outpatients referred to the Rapid Response Radiotherapy Program at the Odette Cancer Centre from 1999 to 2006. A prospective database containing data for all patients with bone metastases who were referred to the Rapid Response Radiotherapy Program for palliative radiotherapy from 1999 to 2006 was analyzed. The database included patient demographic information, including age at referral for radiation to the bone, gender, primary cancer site, and Karnofsky Performance Status; information on treatment-related factors, such as worst pain ratings and analgesic consumption in the past 24 hours (recorded as oral morphine equivalent doses); pain intensity ratings (none [rating=0], mild [rating=1-4], moderate [rating=5-6] or severe [rating=7-10]; and analgesic consumption (rated as none, nonopioids, weak opioids [e.g., codeine] and strong opioids [e.g., morphine and hydromorphone]). Patients who experienced moderate or severe pain and were prescribed no pain medication, nonopioids, or weak opioids were considered to be undermedicated. Between January 1999 and December 2006, 1,038 patients were included in the study database. Approximately 56% of patients were male and 44% were female. The median age was 68 years (range 28-95) and the median Karnofsky Performance Status was 70 (range 10-100). The percentages of undermedicated patients were 40% in 1999, 34% in 2000, 29% in 2001, 37% in 2003, 39% in 2004, 36% in 2005, and 48% in 2006. No appreciable decline was noted in the proportion of patients with moderate-to-severe pain who received no pain medication, nonopioids, or weak opioids during the study period. Despite the publication of pain management guidelines and the dissemination of data regarding the proportion of patients with bone metastases who are being prescribed inadequate analgesics, our findings suggest that a significant proportion of patients continue to be undermedicated.

The palliative performance scale: examining its inter-rater reliability in an outpatient palliative radiation oncology clinic.

INTRODUCTION: The Palliative Performance Scale (PPS) was developed by the Victoria Hospice Society in 1996 to modernize the Karnofsky Performance Scale. Currently, it is being used to measure palliative patient performance status in a variety of settings. Despite its widespread use, only one study has examined the inter-rater reliability of the PPS. PURPOSE: To examine the inter-rater reliability of the PPS in measuring performance status in patients seen in an outpatient palliative radiation oncology clinic METHODS: Performance status for 102 consecutive patients was assessed by an oncologist (MD), a radiation therapist (RT), and a research assistant (RA) in the Rapid Response Radiotherapy Program at the Odette Cancer Centre in Toronto, Ontario, Canada. Raters' scores were analyzed for correlation and compared to evaluate the inter-rater reliability of the PPS tool. RESULTS: Excellent correlation was found between the scores rated by the MD and RA (r = 0.86); good correlation was observed between scores rated by the MD and RT (r = 0.69) and the RT and RA (r = 0.77). Scores between all three raters, as well as between rater pairs, were also found to have good reliability as measured by the Chronbach's alpha coefficient. Significant results were obtained for the range of PPS scores in which the majority of our patients fell: 40-80%. CONCLUSION: PPS was shown to have good overall inter-rater reliability in an outpatient palliative setting, but more research is needed to establish the validity and reliability of the tool in a variety of different palliative settings.

Rare bone metastases of the olecranon.

Abstract Bone metastases are prevalent in patients with cancer, especially with primary lung, breast, renal cell, thyroid, and prostate carcinomas. When looking specifically at primary renal cell carcinoma, approximately 40% of patients will develop bone metastases during the course of their disease. However, distal bony involvement to the appendicular skeleton occurs less frequently, developing below the elbow and knee in approximately 7% of metastatic renal cell carcinoma patients. The incidence of olecranon metastasis is extremely rare in all cancers and so far only two cases have been reported in literature. We report the third case of an olecranon metastasis in a patient with renal cell carcinoma.

Rapid improvement in pain and functional level in a patient with metastatic renal cell carcinoma: a case report and review of the literature.

Renal cell carcinoma (RCC) represents approximately 3% of all adult cancers and is more common in males. Systemic treatment for RCC has improved following the introduction of sunitinib. Bone metastases are present in up to 50% of RCC patients. We report a case of rapid improvement in metastatic bone lesions, recorded by nuclear bone scan, in a male patient receiving localized palliative radiotherapy in addition to systemic sunitinib and zoledronic acid. Concurrently, quality of life and performance status improved dramatically. Although we are unsure of the exact mechanism for such rapid improvement in metastatic bone lesions, the swiftness this improvement deserves reporting.

Is response to radiotherapy in patients related to the severity of pretreatment pain?

PURPOSE: The primary objective of this study was to determine whether there is a relationship between the severity of pretreatment pain and response to palliative radiotherapy (RT) for painful bone metastases. METHODS AND MATERIALS: The database for patients with bone metastases seen at the Rapid Response Radiotherapy Program at the Odette Cancer Center from 1999 to 2006 was analyzed. The proportion of patients with mild (scores 1-4), moderate (scores 5-6), or severe (scores 7-10) pain at baseline who experienced a complete response, partial response, stable response, or progressive response after palliative RT was determined according to International Bone Metastases Consensus definitions. RESULTS: During the 7-year study period 1,053 patients received palliative radiation for bone metastases. The median age was 68 years and the median Karnofsky performance status was 70. Of the patients, 53% had a complete or partial response at 1 month, 52% at 2 months, and 54% at 3 months post-RT. CONCLUSIONS: There was no significant difference in terms of the proportion of responders (patients with complete or partial response) and nonresponders in terms of painful bone metastases among patients presenting with mild, moderate, or severe pain. Patients with moderate pain should be referred for palliative RT.

Has the pattern of practice in the prescription of radiotherapy for the palliation of thoracic symptoms changed between 1999 and 2006 at the rapid response radiotherapy program?

PURPOSE: Eleven randomized controlled trials (RCT) comparing various radiotherapy (RT) schedules for locally advanced lung cancer published since 1991 found no difference in palliation of intrathoracic symptoms. The most commonly prescribed schedule by Canadian Radiation Oncologists (RO) (20 Gy in five fractions [20 Gy/5]), when first evaluated versus 10 Gy/1 in a 2002 RCT, showed a significant survival benefit. A subsequent RCT assessing 20 Gy/5 found worse survival versus 16 Gy/2. This study examines whether the RT prescription for lung cancer palliation in the Rapid Response Radiotherapy Program (RRRP) has changed over time. METHODS AND MATERIALS: Chart review was conducted for patients treated with palliative thoracic RT across three periods (1999-2006). Patient demographics, tumor, treatment, and organizational factors were analyzed descriptively. Chi-square test was used to detect differences in proportions between unordered categorical variables. Continuous variables were tested using analysis of variance. Multivariate logistic regression was used to identify independent predictors of RT schedule prescribed. RESULTS: A total of 117 patients received 121 courses of palliative thoracic RT. The most common dose (20 Gy/5) comprised 65% of courses in 1999, 68% in 2003, and 60% in 2005-2006 (p = 0.76). The next most common dose was 30 Gy/10 (13%). Overall, the median survival was 14.9 months, independent of RT schedule (p = 0.68). Multivariate analysis indicated palliative chemotherapy and certification year of RO were significant predictors of prescription of 20 Gy/5. CONCLUSION: RT schedule for palliation of intrathoracic symptoms did not mirror the results of sequential, conflicting RCTs, suggesting that factors other than the literature influenced practice patterns in palliative thoracic RT.