Palliative care needs of cancer patients in U.S. nursing homes.

BACKGROUND: Increasingly, nursing homes are the place of care for older Americans with cancer. Yet, few studies has characterized the quality of care for this growing population. OBJECTIVE: Characterize the scope and quality of cancer care in U.S. nursing homes. DESIGN: Secondary analysis of the national repository of the Minimum Data Set (MDS) SETTING AND SUBJECTS: Nursing home residents noted to have cancer diagnosis on the MDS. RESULTS: Of the 190,769 New Hampshire residents (8.8%) with a cancer diagnosis, 1 in 4 had weight loss (23.4%), received intravenous medications (27.7%), or used oxygen (25.4%). Overall, 45.3% had a do-not-resuscitate (DNR) order, with state variations ranging from 17.8% (New Jersey) to 70.5% (Wisconsin). More than 1 in 10 (12.0%) were defined as terminally ill, although only 29.3% of these received hospice services. Among patients with pain, half of those who survived to a second assessment had persistent, severe pain (51.3%), which also varied by state, ranging from 43.3% (Iowa) to 65.8% (Nevada). Active treatment was rare; less than 5% received chemotherapy or radiotherapy. However, 15.5% had parenteral and/or tube feedings for nutrition. Approximately, 1 in 10 New Hampshire residents had advanced cancer. CONCLUSION: Our findings suggest important opportunities to improve the quality of cancer care for older adults.

Acute right atrial strain: regression in normal as well as abnormal P-wave amplitudes with treatment of obstructive pulmonary disease.

OBJECTIVE: To evaluate right atrial (RA) "strain" as reflected by changes in P-wave amplitude and vector in patients with COPD immediately before and immediately after beginning treatment of exacerbations. BACKGROUND: P-pulmonale (frequently temporary, reflecting acute RA strain) occurs under a variety of circumstances, including COPD. Emergency room (ED) ECGs in patients with acute exacerbations of COPD have suggested that P-pulmonale (P waves > or = 2.5 in leads II, III, and aVF) tends to resolve subsequent to acute treatment. RA strain is defined as a response to RA stress (probably transient pressure rise and/or acute RA enlargement) in patients with COPD. Since P-pulmonale occurs in a small minority of patients with COPD, we investigated dynamic changes in size and mean vector (axis) of all frontal plane P waves in the ED vs the immediate subsequent ward ECG in patients with acute exacerbations of COPD. METHODS: We prospectively compared P-wave amplitude in the ED with the first in-patient ECG in 50 consecutive patients with acute exacerbations of COPD and in 20 consecutive nonpulmonary control patients, analyzing only ECGs showing sinus rhythm and in which P waves were clearly recorded. Despite using a calibrated magnifying graticule, it was difficult to interpret a dynamic change if the initial ED ECG had P-wave amplitude < 1.5 mm in leads II and aVF. We selected lead II because it usually has the largest frontal plane P waves and also aVF to reflect the relative verticality of the mean P vector (axis). We performed a matched-pair analysis to compare the equality of means. RESULTS: Of the patients with COPD, only seven patients (14%) had classical P-pulmonale on the ED ECG. Forty-eight of 50 consecutive patients (96%) demonstrated a decrease in P-wave amplitude between ED and subsequent ward ECGs. Two patients showed no change. The mean differences of P-wave amplitude between ED and ward ECGs in lead II was 0.78 mm, and that in lead aVF was 0.8 mm. The difference of the mean P-axis between ED and ward ECGs was - 5.24 degrees (p < 0.0001 for all three measurements). There was no P-wave amplitude change in the control group between ED and ward ECGs. CONCLUSIONS: P-wave amplitude in patients with COPD decreases once an acute exacerbation subsides. Thus, P-wave amplitude and vector are dynamic and could reflect reduced RA strain. We question the traditional (1935) absolute cutoff of 2.5 mm for P-pulmonale as of limited value due to insensitivity, hence inappropriate for what this investigation demonstrates to be a continuous variable.