Palliative Care as a Component of High Value and Cost-Saving Care During Hospitalization for Metastatic Cancer

PURPOSE/OBJECTIVE(S)

Randomized controlled trials have demonstrated that palliative care can improve both quality of life and survival for outpatients with advanced cancer, but there is limited population-based data on the value of inpatient palliative care. We assessed palliative care as a component of high-value care among a nationally representative sample of inpatients with metastatic cancer. We further identified care, patient, and hospital characteristics significantly associated with high costs.

MATERIALS/METHODS

This study analyzed hospitalizations of patients ≥18 years with a primary diagnosis of metastatic cancer from the National Inpatient Sample (covering 97% of the U.S. population) from 2010-2019. We utilized multivariable mixed-effects logistic regression to assess medical services (receipt of palliative care, invasive medical ventilation [IMV], systemic therapy), patient demographics, and hospital characteristics that were associated with high charges billed to insurance and hospital costs. We utilized generalized linear mixed-effects models to determine cost savings associated with provision of palliative care.

RESULTS

Among 397,691 hospitalizations from 2010 to 2019, the median charge per admission increased by 24.9%, from $44,904 in 2010 to $56,098 in 2019, while the median cost remained stable at $14,300. Receipt of inpatient palliative care was associated with significantly lower charges (Odds Ratio [OR], 0.62; 95% CI, 0.61-0.64; P <.001) and costs (OR, 0.59; 95% CI, 0.58-0.61; P<.001). Factors associated with high charges were receipt of invasive medical ventilation (P<.001) or systemic therapy (P<.001), Hispanic patients (P<.001), and young age (18-49 years, P<.001). For-profit hospitals were more likely to bill high charges (OR, 5.05; 95% CI, 4.78-5.33, P<.001) but less likely to incur high hospital costs (OR, 0.51; 95% CI, 0.48-0.54, P<.001) than public hospitals. In adjusted generalized linear mixed effects regression, palliative care provision was associated with a $1,293 (-13.4%, P<.001) reduction in costs per hospitalization compared to no palliative care, independent of receipt of invasive care and age. Significant interactions were observed between receipt of palliative care and patient age group (-9.6% for 18-49 years; -14.7% for ≥70 years), receipt of IMV (-6.4% for IMV receipt; -14.0% for no IMV), hospital ownership (-19.6% for for-profit; -10.5% for public), and year of hospitalization (-15.4% for 2010; -8.9% for 2019).

CONCLUSION

Inpatient palliative care is associated with reduced hospital costs for patients with metastatic cancer, irrespective of age and receipt of aggressive interventions. Assuming inpatient palliative care receipt increases by 50%, we estimate $4,045,000 in annual national savings. Integration of inpatient palliative care may de-escalate costs incurred through low-value inpatient interventions.

Effect of Licorice Essential Oil (Glycyrrhizaglabraglabra) on Performance and Some Biochemical Parameters of Broiler Chickens

Due to its beneficial components, such as glycyrrhizin, licorice is regarded a medicinal and fragrant plant. This research was designed to investigate the efficacy of licorice essential oil as an alternative to chemical antibiotics on broiler production, carcass features, cellular and humoral safety, and numerous biochemical variables in broiler blood serum. A total of 160 day-old broiler chicks were assigned to four treatment groups using a totally randomized approach. Each treatment consisted of 4 replicates, with 10 chicks in each replication. The experimental treatments included a control group, a group receiving an elemental diet containing 0.1% licorice essential oil, a group receiving an elemental diet containing 0.2% licorice essential oil, and a group receiving an elemental diet containing 0.3% licorice essential oil. Broilers had ad libitum access to feed and water in accordance with a three-phase feeding schedule consisting of a starter, grower, and finisher diet. There was no statistically significant difference (P>0.05) in body weight, feed intake, or feed conversion ratio between birds given the control or essential oil licorice at various stages of the experiment. However, birds receiving 0.1% licorice essential oil had a lower gallbladder relative weight and 0.3% licorice essential oil had less abdominal fat than the control group (P<0.05). Blood glucose, cholesterol, and LDL concentrations all fell considerably in licorice essential oil-treated birds relative to controls (P<0.05). The cellular immune response of birds fed licorice-containing diets did not differ from that of control birds (P>0.05), however there was a significant difference in the humoral immune response at 0.1% licorice essential oil compared to the control group (P<0.05). In overall, the results of this experiment demonstrated that incorporating licorice essential oil into a bird's diet improves its health and safety.

Diagnostic performance of prostate health index (PHI) in predicting prostate cancer on prostate biopsy

INTRODUCTION

Prostate health index (PHI) has been shown to have better diagnostic accuracy in predicting prostate cancer (PCa) in men with total prostate-specific antigen (PSA) levels between 4-10ng/ml. However, little is known of its value in men with elevated PSA beyond this range. This study aimed to evaluate the diagnostic performance of PHI in Malaysian men with elevated PSA values ≤ 20ng/ml.

MATERIALS AND METHODS

From March 2015 to August 2016, all men consecutively undergoing transrectal ultrasound (TRUS)-guided prostate biopsy with total PSA values ≤ 20ng/ ml were recruited. Blood samples were taken immediately before undergoing prostate biopsy. The performance of total PSA, %fPSA, %p2PSA and PHI in determining the presence of PCa on prostate biopsy were compared.

RESULTS

PCa was diagnosed in 25 of 84 patients (29.7%). %p2PSA and PHI values were significantly higher (p<0.05) in patients with PCa than those without PCa. The areas under the receiver operating characteristic curves for total PSA, %fPSA, %p2PSA and PHI were 0.558, 0.560, 0.734 and 0.746, respectively. At 90% sensitivity, the specificity of PHI (42.4%) was five times better than total PSA (8.5%) and two times better than %fPSA (20.3%). By utilising PHI cut-off >22.52, 27 of 84 (32.1%) patients could have avoided undergoing biopsy.

CONCLUSION

Findings of our study support the potential clinical effectiveness of PHI in predicting PCa in a wider concentration range of total PSA up to 20ng/ml.

Is Procalcitonin more superior to hs-CRP in the diagnosis of infection in diabetic foot ulcer?

INTRODUCTION

Procalcitonin (PCT) has recently emerged as a marker for diagnosing infection. This study aimed to compare the performance of PCT and other infection markers in diagnosing infected diabetic foot ulcer (IDFU).

MATERIALS AND METHODS

A total of 128 diabetic patients with foot ulcers were recruited and divided into two groups, consisting of 73 patients in the IDFU group and 55 in the non-infected diabetic foot ulcer (NIDFU). The severity of infection in IDFU patients was graded based on the Infectious Disease Society of America-International Working Group on the Diabetic Foot classification. Blood samples from all the patients were collected for measurement of PCT, high sensitivity C-reactive protein (hs-CRP) and white cell count (WBC). The area under the receiver operating curves (AUC) were then constructed and analysed.

RESULTS

PCT, hs-CRP and WBC levels were significantly higher in the IDFU group compared to NIDFU with hs-CRP demonstrated the highest AUC (0.91; p <0.001) followed by PCT (0.814; p < 0.001) and lastly WBC (0.775; p < 0.001). The best cut off value, sensitivity and specificity for the presence of infection in diabetic foot, were 3.47 mg/dL, 80% and 89% for hs-CRP, 0.11 ng/ml, 70% and 87% for PCT and 11.8x109/L, 60% and 90% for WBC. All the infection markers showed significant positive correlations with infection severity of DFU.

CONCLUSION

This study showed that hs-CRP is a more sensitive marker for diagnosing IDFU. Although PCT is useful in differentiating IDFU from NIDFU, the use of PCT is not necessary as it adds little value to the current practice.

Retraction: Randomized controlled trial of vitamin D supplementation in children with autism spectrum disorder

The above article, published in print in the Jan 2018 issue of the Journal of Child Psychology & Psychiatry and online in Wiley Online Library (wileyonlinelibrary.com), has been retracted by the JCPP Editor-in-Chief, Edmund Sonuga-Barke, and John Wiley & Sons. Following a series of communications from readers highlighting concerns about the paper (now published on the journal website), the journal editors requested that the authors send them the raw data from the trial. In response the authors informed the editors that; (i) the electronic data base had been lost following a computer outage and (ii) that they could send only 95 out of 120 hard-copy participant data sheets as one site had closed and was no longer contactable. The substantial data loss in and of itself posed a serious difficulty in verifying the correctness of the data presented in the paper. The JCPP then analysed the data from the 95 cases itself. A number of significant discrepancies emerged between the re-analysis and the findings reported in the paper both in terms of means and standard deviations of key outcome variables across the trial. These involved very substantial differences that we judged to be extremely unlikely to have arisen due to variations in composition of the original and re-analysed samples. We also discovered previously unidentified/reported problems with missing data and recording irregularities regarding changes in treatment regimen and subject identifiers. As a result of these issues the Editors no longer have confidence in the findings reported in the original paper. Based on all these matters combined and following published guidance from the Committee on Publishing Ethics (COPE) and Wiley's Best Practice Guidelines on Publishing Ethics, we have decided that the only course of action available to us is to retract the paper.

Switching from sulphonylurea to a sodium-glucose cotransporter2 inhibitor in the fasting month of Ramadan is associated with a reduction in hypoglycaemia

The aim of the present study was to assess the hypoglycaemia risk and safety of dapagliflozin compared with sulphonylurea during the fasting month of Ramadan. In this 12-week, randomized, open-label, two-arm parallel group study, 110 patients with type 2 diabetes who were receiving sulphonylurea and metformin were randomized either to receive 10 mg (n = 58) of dapagliflozin daily or to continue receiving sulphonylurea (n = 52). The primary outcome was to compare the effects of dapagliflozin and sulphonylurea on the proportions of patients with at least one episode of hypoglycaemia during Ramadan, as well as to assess the safety of dapagliflozin when used to treat patients observing Ramadan. A lower proportion of patients had reported or documented hypoglycaemia in the dapagliflozin group than in the sulphonylurea group: 4 (6.9%) versus 15 (28.8%); p = 0.002. The relative risk of any reported or documented hypoglycaemia in the 4th week of Ramadan was significantly lower in the dapagliflozin group: RR=0.24, 95%CI: 0.09, 0.68; p=0.002. No significance differences were observed between the two groups regarding postural hypotension (13.8 vs 3.8%; p = 0.210) or urinary tract infections (10.3 vs 3.8%; p = 0.277). In conclusion, fewer patients exhibited hypoglycaemia in the dapagliflozin group than in the sulphonylurea group.

Conventional versus Doxorubicin-Eluting Beads Transarterial Chemoembolization for Unresectable Hepatocellular Carcinoma: a Tertiary Medical Centre Experience in Malaysia

BACKGROUND

Hepatocellular carcinoma (HCC) is a common cancer that is frequently diagnosed at an advanced stage. Transarterial chemoembolisation (TACE) is an effective palliative treatment for patients who are not eligible for curative treatment. The two main methods for performing TACE are conventional (c-TACE) or with drug eluting beads (DEB-TACE). We sought to compare survival rates and tumour response between patients undergoing c-TACE and DEB-TACE at our centre.

MATERIALS AND METHODS

A retrospective cohort study of patients undergoing either treatment was carried out from January 2009 to December 2014. Tumour response to the procedures was evaluated according to the modified Response Evaluation Criteria in Solid Tumors (mRECIST). Kaplan-Meier analysis was used to assess and compare the overall survival in the two groups.

RESULTS

A total of 79 patients were analysed (34 had c-TACE, 45 had DEB-TACE) with a median follow-up of 11.8 months. A total of 20 patients in the c-TACE group (80%) and 12 patients in the DEB-TACE group (44%) died during the follow up period. The median survival durations in the c-TACE and DEB-TACE groups were 4.9 ± 3.2 months and 8.3 ± 2.0 months respectively (p=0.008). There was no statistically significant difference noted among the two groups with respect to mRECIST criteria.

CONCLUSIONS

DEB-TACE demonstrated a significant improvement in overall survival rates for patients with unresectable HCC when compared to c-TACE. It is a safe and promising approach and should potentially be considered as a standard of care in the management of unresectable HCC.

[Snake venom Kunitz/BPTI family: Structure, classification and pharmacological potential]

Snake venoms are rich sources of serine proteinase inhibitors that are members of the KunitzBPTI (bovine pancreatic trypsin inhibitor) family. Generally, these inhibitors are formed by 60 amino acids approximately. Their folding is characterised by a canonical loop that binds in a complementary manner to the active site of serine protease. Some variants from snake venoms show only weak inhibitory activity against proteases while others are neurotoxic. Moreover, proteases inhibitors are involved in various physiological prdcesses, such as blood coagulation, fibrinolysis, and inflammation. Also, these molecules showed an anti-tumoralpotent and anti-metastatic effect. Interestingly, KunitzBPTI peptides can have exquisite binding specificities and possess high potency for their targets making them excellent therapeutic candidates.

The Effectiveness of Trypsin Modulating Oostatic Factor (TMOF) and Combination of TMOF with Bacillus thuringiensis Against Aedes aegypti Larvae in the Laboratory

BACKGROUND

Trypsin Modulating Oostatic Factor (TMOF) terminates trypsin biosynthesis in adult and larval mosquito gut. It will inhibit the growth and development of mosquito larvae feeding on it resulting in death by starvation. The objective of this study is to determine the effective dose of Pichia-TMOF and the combination of Pichia-TMOF with Bacillus thuringiensis (Bt) as larvicide on Ae. aegypti larvae.

METHODS

Aedes aegypti first-instar larvae were exposed to various doses of Pichia-TMOF, Bt and combination of Pichia-TMOF and Bt. The development of the larvae were observed and recorded daily during the bioassay larval test until the adult emergence.

RESULTS

The results showed that 400 ppm Pichia-TMOF and 300 ppm Pichia-TMOF were able to cause 100% and 67% cumulative mortality on Ae. aegypti larvae on 8(th) day respectively. At 200 ppm, 100 ppm and 50 ppm concentration Pichia-TMOF showed obvious stunted effect on Ae. aegypti larvae. Moreover, the combination of 400 ppm Pichia-TMOF with 0.1 ppm Bt showed synergistic effect on Ae. aegypti.

CONCLUSION

Pichia-TMOF inhibited trypsin biosynthesis is potential to act in larval gut causing stunted growth and larval development and causing mortality. The combination of Pichia-TMOF and Bt increased the effectiveness in causing larval mortality.

Evaluation of Piper aduncum Linn. Essential Oil (Fam:Piperaceae) against Periplaneta americana (L.)

BACKGROUND

The efficacy of Piper aduncum essential oil was evaluated against Periplaneta americana adults and nymphs in the laboratory.

METHODS

The plant essential oil at varying concentrations ranging between 10,000 to 80,000 ppm were placed inside glass beakers, rolled horizontally to ensure the essential oil covers all sides of the beakers and exposed to adults and nymphs of P. americana. Resigen (R) 1ppm was used as positive control and distilled water as negative control. The LT50 and LT90 was obtained using Log Probit programme.

RESULTS

Exposure of essential oil to females P. americana at concentrations between 10,000 to 80,000 ppm indicated the LT50 and LT90 values between 5.31 h-189.19 h and 14.90 h-2105.31 h, respectively. Treatment with the same concentrations against males P. americana ,the LT50 and LT90 were 2.08 h-181.73 h and 5.4 h-8460.51 h, respectively. Treatment against the nymphal stage with the same range of concentrations indicated the LT50 and LT 90 of 4.68 h-381.02 h and 28.71 h-5313.36 h, respectively.The nymphs and males were more susceptible than the females cockroaches. Treatment with Resigen (R) at 1ppm indicated much lower LT 50 and LT 90 values of 2.54 h-9.47 h for the females, 1.47 h-4.22 h for the males and 4.69 h-8.92 h for the nymphs.The negative control indicated no mortality for all stages of the cockroach.

CONCLUSION

Piper aduncum essential oil can be used as an alternative natural product for controlling the cockroach Peripatetic americana.

Investigation of the stability of medicinal additives in animal feedingstuffs to prepare reference feeds

The stability of several medicinal additives in cattle, pig and poultry feeds has been monitored. The feeds were stored at various temperatures under different conditions; processes such as freeze-drying, gamma-irradiation and pelletization were also applied. The medicinal additives appeared to be more stable in the feeds stored at reduced temperatures and under conditions that totally exclude light. Processing of feeds and storage at elevated temperature appeared to reduce the content of the medicinal additives examined.

Effect of ibuprofen and indomethacin on human plasma melatonin

Ibuprofen reduced human plasma melatonin (MT) after 2 h when administered orally (400 mg) at 2400 h. Increasing plasma concentrations correlated well with increasing inhibition of serum MT levels during this time. Maximum plasma ibuprofen coincided with minimum plasma MT in 3 out of 4 volunteers. Although two volunteers exhibited a partial recovery in MT levels, concentrations after 6 h were significantly less than 0600 h values in drug-free volunteers. Administration of ibuprofen (400 mg) at 1800 h delayed the nocturnal surge of plasma MT. When a slow release preparation of indomethacin (75 mg) was administered at 1800 h, the dark phase rise of plasma MT was completely prevented. Thus the longer acting cyclooxygenase inhibitor exhibited a longer lasting inhibition of plasma MT concentration.