Do discussions of financial burdens decrease long-term financial toxicity in adolescent and young adult cancer survivors?

PURPOSE

This study aims to evaluate the associations between patient-provider cost discussions with patient-reported out-of-pocket (OOP) spending and long-term financial toxicity (FT) among adolescent and young adult (AYA; 15-39 years old) cancer survivors.

METHODS

Using a cross-sectional survey, we assessed the themes and quality of patient discussions with providers about financial needs and general survivorship preparation, quantified patients' levels of FT, and evaluated patient-reported OOP spending. We determined the association between cancer treatment cost discussion and FT using multivariable analysis. In a subset of survivors (n = 18), we conducted qualitative interviews and used thematic analysis to characterize responses.

RESULTS

Two hundred forty-seven AYA survivors completed the survey at a mean of 7 years post treatment and with a median COST score of 13. 70% of AYA survivors did not recall having any cost discussion about their cancer treatment with a provider. Having any cost discussion with a provider was associated with decreased FT (β = 3.00; p = 0.02) but not associated with reduced OOP spending (χ2 = 3.77; p = 0.44). In a second adjusted model, with OOP spending included as a covariate, OOP spending was a significant predictor of FT (β =  - 1.40; p = 0.002). Key qualitative themes included survivors' frustration about the lack of communication related to financial issues throughout treatment and in survivorship, feeling unprepared, and reluctance to seek help.

CONCLUSION

AYA patients are not fully informed about the costs of cancer care and FT; the dearth of cost discussions between patients and providers may represent a missed opportunity to reduce costs.

So Many Ways to Be Wrong: Completeness and Accuracy in a Prospective Study of OR-to-ICU Handoff Standardization

BACKGROUND

Studies focused on improving handoffs often measure the quality of information exchange using information completeness without reporting on accuracy. The present investigation aimed to characterize changes in the accuracy of transmitted patient information after standardization of operating room (OR)-to-ICU handoffs.

METHODS

Handoffs and Transitions in Critical Care (HATRICC) was a mixed methods study conducted in two US ICUs. From 2014 to 2016, trained observers captured the nature and content of information transmitted during OR-to-ICU handoffs, comparing this to the electronic medical record. Inconsistencies were compared before and after handoff standardization. Semistructured interviews initially conducted for implementation were reanalyzed to contextualize quantitative findings.

RESULTS

A total of 160 OR-to-ICU handoffs were observed-63 before and 97 after standardization. Across seven categories of information, including allergies, past surgical history, and IV fluids, two types of inaccuracy were observed: incomplete information (for example, providing only a partial list of allergies) and incorrect information. Before standardization, an average of 3.5 information elements per handoff were incomplete, and 0.11 were incorrect. After standardization, the number of incomplete information elements per handoff decreased to 2.4 (-1.1, p < 0.001), and the number of incorrect items was similar, at 0.16 (p = 0.54). Interviews revealed that the familiarity of a transporting OR provider (for example, surgeon, anesthetist) with the patient's case was considered an important factor affecting information exchange.

CONCLUSION

Handoff accuracy improved after standardizing OR-to-ICU handoffs in a two-ICU study. The improvement in accuracy was due to improved completeness rather than a change in the transmission of inaccurate information.

Clinical experience with 99mTc-MIBI scintimammography in patients with breast microcalcifications

The aim of this study was to evaluate whether 99mTc-MIBI scintimammography can improve the diagnostic value of mammography for the differentiation of benign and malignant breast microcalcifications. In 41 women presenting 45 clusters of microcalcifications, a 99mTc-MIBI scintimammography was performed before open biopsy. There were 24 malignant lesions (53%). The sensitivity (SE) and specificity (SP) of 99mTc-MIBI scintimammography were 58.3% and 81%, and the positive and negative predictive values (PPV, NPV) were 78% and 63%, respectively. SE and PPV increased for lesions over 10 mm and for the younger patients (under 50 years). No correlation was found between true positive uptake and breast cancer invasiveness: 69% (9/13) for invasive lesions and 45% (5/11) for noninvasive lesions (P = 0.48). 99mTc-MIBI scintimammography was more often positive in high grade than in low- or intermediate-grade ductal carcinoma in situ (P = 0.03). The results were analysed according to the morphologic aspect of the microcalcifications. 99mTc-MIBI scintimammography could not be used for routine evaluation of all the microcalcifications detected by mammography.

[Value of tissue harmonic imaging in biliary lithiasis]

AIM OF THE STUDY

To define the role of harmonic imaging in the study of biliary lithiasis.

SUBJECTS AND METHODS

We included 50 consecutive patients with suspected biliary lithiasis. Three independent observers compared results of harmonic imaging and conventional ultrasonography.

RESULTS

This study showed a better interobserver agreement with harmonic imaging for acoustic shadow (kappa=0.87 vs 0.68) and intra-hepatic biliary stones (kappa=0.79 vs 0.49). More stones and more lithiasic gallbladders were seen with harmonic imaging (27 vs 24) and visualization of gallbladder sludge and the acoustic shadow from stones (P=0.01) was better. Ultrasound examination appears to be easier and faster and the diagnosis is more certain with harmonic imaging than with conventional ultrasonography (P=0.005).

CONCLUSION

Harmonic imaging provides more information on biliary lithiasis and a more certain diagnosis.

[Percutaneous cholecystostomy in non-surgical patients]

PURPOSE

To assess the efficacy and complications of percutaneous cholecystostomy (PC) in the treatment of acute cholecystitis in non-surgical patients.

MATERIALS AND METHODS

Retrospective study of 25 cases (16 males and 9 females) of PC. The average age was 82 years (range: 59-95). Eight had acute acalculous cholecystitis (AAC) and 17 had acute calculous cholecystitis (ACC). US-guided percutaneous cholecystostomy was performed in most cases; CT-guidance was required in 5 cases.

RESULTS

One technical failure and one complication (abdominal wall hematoma) occurred. PC was successful for sepsis control in 21 patients (5 AAC and 16 ACC): delayed cholecystectomy was performed in one patient, and one patient had recurrent acute cholecystitis at one month that responded to medical management. For the 4 remaining patients: 1 corresponded to the technical failure, and failure of sepsis control was observed in the 3 others patients (2 AAC, 1 ACC). PC was the definitive treatment or resulted in sepsis control in 84% of cases. PC was the definitive treatment, without recurrence, in 76% of cases.

CONCLUSION

US or CT guided percutaneous cholecystostomy is an effective treatment, with a low rate of complication, in elderly or critically ill patients. PC can be used as a definitive treatment or as a temporizing measure in critically ill patients allowing for delayed definitive surgical/endoscopic management.

[Preoperative evaluation of choledochal cyst with MR cholangiopancreatography]

The choledochal cyst is a rare congenital disorder usually diagnosed in childhood. It requires a complete surgical resection to prevent complications, particularly the risk of malignant changes. At present, the preoperative examination requires a direct opacification of the biliary tree, but this is an invasive technique with a high risk of infection, especially in pediatric patients.

CASE REPORT

A choledochal cyst was diagnosed in a five-year-old girl with recurrent abdominal pain. Diagnosis was made by ultrasound and preoperative evaluation by magnetic resonance-cholangiopancreatography using single-shot fast-spin echo sequences. A complete correlation was observed between surgical, preoperative cholangiography and MRCP data.

CONCLUSION

Recent improvement in MRCP techniques provide a complete anatomic analysis of choledochal cysts, enabling one to diagnose an anomalous junction of the pancreaticobiliary duct, even the presence of stones within the biliary tree. This short and noninvasive examination should in the future replace direct opacification of the biliary tree for the preoperative assessment of choledochal cysts.

Recombinant adenovirus-mediated gene transfer into the adult rat retina

PURPOSE

The present study was designed to evaluate the feasibility of gene transfer into the retina of adult rats, using a recombinant replication-defective adenovirus vector expressing a reporter gene.

METHODS

Purified recombinant adenovirus expressing beta-galactosidase (lacZ) (Ad5.hCMV.lacZ) at doses ranging from 1.4 x 10(2) to 1.4 x 10(6) plaque-forming units (pfu) were injected into the subretinal space of adult Lewis rats. The presence of lacZ was determined by histochemical assay and reverse transcription and polymerase chain reaction analysis (RT PCR) of total RNA extracted from eyes injected with recombinant adenovirus expressing lacZ.

RESULTS

As assessed by biomicroscopy, the expression of lacZ was highest in the retinal pigment epithelium in a localized area corresponding to the site of injection. The level of lacZ expression was correlated with the amount of virus delivered to the subretinal space. Persistent but decreasing expression of lacZ was noted over time. RT PCR revealed the expression of messenger RNA for at least sixty days.

CONCLUSIONS

The results of this study demonstrate that efficient and stable transfer of genetic material into the subretinal space of adult rats may be achieved using a recombinant adenoviral vector. The use of such vectors should prove useful in developing novel applications and approaches to the study of recombinant protein expression in vivo.

Identification and characterization of P2Y2 nucleotide receptors in human retinal pigment epithelial cells

P2 nucleotide receptor expression in cultured human retinal pigment epithelial (RPE) cells was investigated using the photoaffinity ATP analog BzATP, polymerase chain reaction of reverse-transcribed RNA (RT-PCR) and fura-2 fluorescence measurement of changes in intracellular free calcium concentration ([Ca2+]i). In experiments carried out in RPE cells at passage 10-15, addition of micromolar concentrations of ATP, UTP, and ATPgammaS to RPE cells resulted in a rapid, transient 3.5-fold increase in [Ca2+]i followed by a prolonged elevation that was twofold above the original baseline. Similar results were obtained from cells at passage 2. Characteristics of nucleotide-stimulated calcium mobilization in RPE cells, including partial inhibition by pertussis toxin, suggest that a G protein-coupled receptor mediates this response. Consistent with the expression of a P2Y2 nucleotide receptor subtype in RPE cells, [alpha-32P]BzATP labeled a 53-kDa protein in plasma membranes, and RT-PCR revealed the presence of P2Y2 receptor RNA. Adenosine had no effect on [Ca2+]i in RPE cells, indicating that the A2 subtype of P1 receptor described previously in human RPE is not involved in the response to nucleotides. Together the results indicate that human RPE cells express functional P2Y2 nucleotide receptors.

Interleukin-10 immunoadhesin production by a replication-defective adenovirus

The present study examined the use of replication-defective adenovirus for in vitro production of an immunoadhesin. A recombinant adenovirus, rendered replication defective by deletion of the E1 gene, was constructed to contain the murine interleukin-10 gene fused in frame with the hinge, CH2, and CH3 domains of the murine immunoglobulin gamma 1 heavy chain constant region gene under the control of the human cytomegalovirus promoter. The resultant recombinant virus, Ad5.hCMV.mIL-10:HFc, was used to transduce several cell types. The expressed protein, mIL-10:HFc, is secreted as a disulfide-bonded homodimer. In vitro, a murine pro-B-cell line expressing transfected recombinant murine interleukin-10 receptor proliferated in response to purified mIL-10:HFc. The results obtained demonstrate the relative ease of production of an immunoadhesin using replication-defective adenovirus.

Adenovirus-mediated gene transfer of ornithine aminotransferase in cultured human retinal pigment epithelium

PURPOSE

To evaluate the efficacy of adenovirus mediated transfer of ornithine delta-aminotransferase (OAT) into human retinal pigment epithelial (RPE) cells.

METHODS

Adenovirus-mediated gene transfer into primary cultures of human RPE was evaluated by measurement of enzyme activity in whole cell extracts and by Western blot analysis. To assess mitochondrial integrity, succinate dehydrogenase activity was measured in transduced RPE cells. Expression of adenovirus early genes was evaluated using reverse transcription-polymerase chain reaction.

RESULTS

OAT activity, which was 65 nmol/mg.hour in untransduced cells, could be increased to levels in excess of 20,000 nmol/mg.hour using an adenovirus vector carrying the OAT cDNA. There was, however, a significant reduction in succinate dehydrogenase activity associated with OAT activity greater than 12,000 nmol/mg.hour. Transduced human RPE displayed an altered morphology that appears to be a response to the vector because similar changes could be induced by an adenovirus vector that does not carry the OAT cDNA. Adenovirus early gene expression was detected in transduced RPE.

CONCLUSIONS

This study represents a first step in the development of intraocular gene replacement therapy for the treatment of gyrate atrophy. The authors demonstrate that adenovirus is an efficient vehicle for the delivery of OAT into human RPE and that RPE will tolerate greater than a 150-fold increase in OAT-specific activity. Evidence for disruption of mitochondria when OAT activity exceeds 12,000 nmol/mg.hour and vector-induced toxicity indicate that more controlled transgene expression and refinement of the vector systems is needed.

The diagnosis and management of uveitis

The diagnosis and management of uveitis is complicated and challenging. The protean signs and symptoms seen in patients with uveitis may lead to a diagnostic dilemma. A carefully taken history with particular attention to demographic factors and meticulous physical examination are crucial to guiding diagnostic testing. Tailoring the diagnostic approach in patients with uveitis frequently yields useful data in contrast to blanketing every possible uveitic entity. It is also important to distinguish among various aetiologies, including infectious and neoplastic causes which may respond to specific therapy. Medical treatment of noninfectious uveitis must have clear objectives including reduction of inflammation, relief of symptoms and restoration of visual functioning. Familiarity with possible symptoms and signs of adverse drug reactions is essential early in the course of treatment so that their effects may be minimised. Appropriate therapy of presumed autoimmune uveitis is based on disease severity, presence or absence of bilateral disease and the health status of the patient.

Recoverin is highly uveitogenic in Lewis rats

PURPOSE

Recoverin, a calcium-binding protein that selectively localizes to the retina and pineal gland, has been identified as the target for the putative pathogenic autoimmune process of cancer-associated retinopathy (CAR). The present study was aimed at testing the capacity of recoverin to induce experimental autoimmune uveoretinitis and pinealitis in Lewis rats.

METHODS

Lewis rats were immunized against recombinant myristoylated recoverin by a single footpad injection of the protein, at various doses, emulsified in complete Freund's adjuvant. Development of uveoretinitis was monitored by clinical and histologic examinations, whereas pinealitis was detected by histologic examination.

RESULTS

Immunization with recoverin induced severe panuveitic changes that closely resemble those induced by S-antigen (arrestin). The effect was dose-dependent, with 10 micrograms/rat the lowest immunopathogenic dose. Rats immunized with recoverin also developed pineal inflammation.

CONCLUSION

Recoverin is highly immunopathogenic in Lewis rats. Although the ocular changes induced in rats differ from those seen in CAR, the data recorded here are in line with the concept that recoverin can initiate pathogenic autoimmune processes in the eye.