Interdisciplinary Approach to Expedited Outpatient Gastrostomy Tube Placement in Head and Neck Cancer Patients: A Single Center Retrospective Study

RATIONALE AND OBJECTIVE

Treatment for head and neck cancer (HNC) can lead to decreased oral intake which often requires gastrostomy tube (g-tube) placement to provide nutritional support. A multidisciplinary team (MDT) consisting of interventional radiology (IR), HNC oncology and surgery, nutrition, and speech language pathology departments implemented an expedited outpatient g-tube placement pathway to reduce hospital stays and associated costs, initiate feeds sooner, and improve communication between care teams. This single center study investigates differences in complications, time to procedure and costs savings with implementing this pathway.

METHODS

142 patients with HNC who underwent elective image guided g-tube placement by IR from 2015 to 2022 were identified retrospectively. 52 patients underwent the traditional pathway, and 90 patients underwent the expedited pathway. Patient demographics, procedure characteristics, periprocedural costs and 90-day complication rates were collected and compared statistically.

RESULTS

The 90-day complication rate was comparable between groups (traditional=32.7%; expedited=22.2%; p-value=0.17). The expedited pathway decreased the time from consult to procedure by 11.1 days (95% CI 7.6 - 14.6; p < 0.001) and decreased charge per procedure by $2940 (95% CI $989-$4891; p < 0.001).

CONCLUSION

A MDT for the treatment of patients with HNC successfully provided enteral nutrition support faster, with fewer associated costs, and in a more patient centered approach than previously done at this institution.

Treatment of Hepatocellular Carcinoma by Multimodal In Situ Vaccination Using Cryoablation and a Plant Virus Immunostimulant

PURPOSE

To test the hypothesis that cryoablation combined with intratumoral immunomodulating nanoparticles from cowpea mosaic virus (CPMV) as an in situ vaccination approach induces systemic antitumoral immunity in a murine model of hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Mice with bilateral, subcutaneous RIL-175 cell-derived HCCs were randomized to 4 groups: (a) phosphate-buffered saline (control), (b) cryoablation only (Cryo), (c) CPMV-treated only (CPMV), and (d) cryoablation plus CPMV-treated (Cryo + CPMV) (N = 11-14 per group). Intratumoral CPMV was administered every 3 days for 4 doses, with cryoablation performed on the third day. Contralateral tumors were monitored. Tumor growth and systemic chemokine/cytokine levels were measured. A subset of tumors and spleens were harvested for immunohistochemistry (IHC) and flow cytometry. One- or 2-way analysis of variance was performed for statistical comparisons. A P value of <.05 was used as the threshold for statistical significance.

RESULTS

At 2 weeks after treatment, the Cryo and CPMV groups, alone or combined, outperformed the control group in the treated tumor; however, the Cryo + CPMV group showed the strongest reduction and lowest variance (1.6-fold ± 0.9 vs 6.3-fold ± 0.5, P < .0001). For the untreated tumor, only Cryo + CPMV significantly reduced tumor growth compared with control (9.2-fold ± 0.9 vs 17.8-fold ± 2.1, P = .01). The Cryo + CPMV group exhibited a transient increase in interleukin-10 and persistently decreased CXCL1. Flow cytometry revealed natural killer cell enrichment in the untreated tumor and increased PD-1 expression in the spleen. Tumor-infiltrating lymphocytes increased in Cryo + CPMV-treated tumors by IHC.

CONCLUSIONS

Cryoablation and intratumoral CPMV, alone or combined, demonstrated potent efficacy against treated HCC tumors; however, only cryoablation combined with CPMV slowed the growth of untreated tumors, consistent with an abscopal effect.

Identifying enhancement-based staging markers on baseline MRI in patients with colorectal cancer liver metastases undergoing intra-arterial tumor therapy

OBJECTIVES

To determine if three-dimensional whole liver and baseline tumor enhancement features on MRI can serve as staging biomarkers and help predict survival of patients with colorectal cancer liver metastases (CRCLM) more accurately than one-dimensional and non-enhancement-based features.

METHODS

This retrospective study included 88 patients with CRCLM, treated with transarterial chemoembolization or Y90 transarterial radioembolization between 2001 and 2014. Semi-automated segmentations of up to three dominant lesions were performed on pre-treatment MRI to calculate total tumor volume (TTV) and total liver volumes (TLV). Quantitative 3D analysis was performed to calculate enhancing tumor volume (ETV), enhancing tumor burden (ETB, calculated as ETV/TLV), enhancing liver volume (ELV), and enhancing liver burden (ELB, calculated as ELV/TLV). Overall and enhancing tumor diameters were also measured. A modified Kaplan-Meier method was used to determine appropriate cutoff values for each metric. The predictive value of each parameter was assessed by Kaplan-Meier survival curves and univariable and multivariable cox proportional hazard models.

RESULTS

All methods except whole liver (ELB, ELV) and one-dimensional/non-enhancement-based methods were independent predictors of survival. Multivariable analysis showed a HR of 2.1 (95% CI 1.3-3.4, p = 0.004) for enhancing tumor diameter, HR 1.7 (95% CI 1.1-2.8, p = 0.04) for TTV, HR 2.3 (95% CI 1.4-3.9, p < 0.001) for ETV, and HR 2.4 (95% CI 1.4-4.0, p = 0.001) for ETB.

CONCLUSIONS

Tumor enhancement of CRCLM on baseline MRI is strongly associated with patient survival after intra-arterial therapy, suggesting that enhancing tumor volume and enhancing tumor burden are better prognostic indicators than non-enhancement-based and one-dimensional-based markers.

KEY POINTS

• Tumor enhancement of colorectal cancer liver metastases on MRI prior to treatment with intra-arterial therapies is strongly associated with patient survival. • Three-dimensional, enhancement-based imaging biomarkers such as enhancing tumor volume and enhancing tumor burden may serve as the basis of a novel prognostic staging system for patients with liver-dominant colorectal cancer metastases.

Effects of different combinations of N, P and K at different time interval on vegetative, reproductive, yield and quality traits of mango (Mangifera Indica. L) cv. Dusehri

The experiment was carried out on mango cv. Dusehri to investigate the effect of N, P and K fertilizers on vegetative, reproductive growth, yield and fruit quality. Eight different fertilizer combinations such as T1 (control), T2 (N), T3 (P), T4 (K), T5 (NP), T6 (NK), T7 (PK) and T8 (NPK) were used. Individual or combine fertilizer application of N (1000 g), P (750 g) and K (750 g) were applied during growing season in February and August. All the treatments significantly influenced on vegetative growth, flowering, fruiting, yield and other physiochemical attributes of mango as compared to control. Least effect was observed with individual fertilizer application while combine fertilizer treatments enhanced most of the investigated parameters. Especially, qualitative traits showed non-significant differences between treated and untreated mango trees. However, among the different treatments T8 (NPK) showed significance for fruiting aspects such as maximum size of growth flushes (177.51 mm), total number of panicles/tree (845), total number of flowers/panicle (974), sex ratio (69.18%), fruit retention (13.85%), total number of fruits/tree (379), yield (82 kg/tree), fruit weight (197.5 g), pulp weight (135.5 g) and physiochemical parameters namely TSS (24.53), Vit. C (57.63 mg/100 mL) and total sugar (20.84%). In general, combine application of NPK (T8) were the most effective in enhancing fruiting aspects, yield, physiochemical characteristics as well as improved fruit quality of mango trees.

Assessment of an Innovative Voluntary Substance Abuse Treatment Program Designed to Replace Compulsory Drug Detention Centers in Malaysia

BACKGROUND

As part of an ongoing initiative by the Malaysian government to implement alternative approaches to involuntary detention of people who use drugs, the National Anti-Drug Agency has created new voluntary drug treatment programs known as Cure and Care (C&C) Centers that provide free access to addiction treatment services, including methadone maintenance therapy, integrated with social and health services.

OBJECTIVES

We evaluated early treatment outcomes and client satisfaction among patients accessing C&C treatment and ancillary services at Malaysia's second C&C Center located in Kota Bharu, Kelantan.

METHODS

In June-July 2012, a cross-sectional convenience survey of 96 C&C inpatients and outpatients who entered treatment >30 days previously was conducted to assess drug use, criminal justice experience, medical co-morbidities, motivation for seeking treatment, and attitudes towards the C&C. Drug use was compared for the 30-day-period before C&C entry and the 30-day-period before the interview.

RESULTS

Self-reported drug use levels decreased significantly among both inpatient and outpatient clients after enrolling in C&C treatment. Higher levels of past drug use, lower levels of social support, and more severe mental health issues were reported by participants who were previously imprisoned. Self-reported satisfaction with C&C treatment services was high. Conclusions/Importance: Preliminary evidence of reduced drug use and high levels of client satisfaction among C&C clients provide support for Malaysia's ongoing transition from compulsory drug detention centers (CDDCs) to these voluntary drug treatment centers. If C&C centers are successful, Malaysia plans to gradually transition away from CDDCs entirely.

Getting PrEPared for HIV Prevention Navigation: Young Black Gay Men Talk About HIV Prevention in the Biomedical Era

Biomedical HIV prevention strategies, such as pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP), represent new opportunities to reduce critically high HIV infection rates among young black men who have sex with men (YBMSM). We report results of 24 dyadic qualitative interviews (N=48), conducted in Los Angeles, CA, exploring how YBMSM and their friends view PrEP and PEP. Interviews were analyzed using a grounded theory approach. Participants had widely divergent levels of knowledge about these prevention methods. Misconceptions and mistrust regarding PrEP were common, and concerns were expressed about PrEP-related stigma and the potential for gossip among peers who might assume a person on PrEP was HIV-positive. Yet participants also framed PrEP and PEP as valuable new options within an expanded "tool kit" of HIV prevention strategies that created possibilities for preventing new HIV infections, dating men with a different HIV status, and decreased anxiety about exposure to HIV. We organized themes around four main areas: (1) information and misinformation about biomedical HIV prevention; (2) expectations about PrEP, sexual behavior, and stigma; (3) gossip, disclosure, and "spreading the word" about PrEP and PEP; and (4) the roles of PrEP and PEP in an expanded HIV prevention tool kit. The findings suggest a need for guidance in navigating the increasingly complex array of HIV-prevention options available to YBMSM. Such "prevention navigation" could counter misconceptions and address barriers, such as stigma and mistrust, while helping YBMSM make informed selections from among expanded HIV prevention options.

An exploratory qualitative assessment of self-reported treatment outcomes and satisfaction among patients accessing an innovative voluntary drug treatment centre in Malaysia

BACKGROUND

In Malaysia, compulsory drug detention centres (CDDCs) hold suspected drug users for two years without adjudication. Acute detoxification without healthcare access has been documented. CDDCs are criticized globally due to ineffectiveness in treating addiction and human rights violations. In response, the Malaysian government began transitioning these facilities into voluntary drug treatment centres known as "Cure and Care" (C&C) centres that embrace a holistic treatment-based approach to drug addiction rehabilitation.

METHODS

An explorative qualitative study was undertaken to explore patient perspectives and satisfaction regarding treatment and services at the new Cure and Care centre in Kota Bharu, Malaysia. A convenience sample of 20 patients was recruited to participate in semi-structured in-depth interviews. Content analysis was used to identify the salient themes.

RESULTS

Patients identified methadone treatment, psychosocial programs, religious instruction, and recreational activities as important factors contributing to treatment success for addressing both health and addiction needs. Though many had previously been in a CDDC, adherence to treatment in the C&C centre was perceived to be facilitated by the degree of social support, the voluntary nature and the array of new programs available for selection.

CONCLUSION

C&Cs represents a dramatic shift in the Malaysian government's approach to drug addiction. Our findings demonstrate positive patient experiences associated with the holistic treatment-based approach of these centres. This exploratory study provides additional evidence to document this ongoing policy transition and may guide continued expansion of new holistic drug treatment programs across the country.

Transcatheter technique now standard for Secundum ASD Closure, A case report of our first experience

DOI: http://dx.doi.org/10.3329/pulse.v4i1.6963Pulse Vol.4 January 2010 p.32-33

Kallmann syndrome: a case of hypogonadotropic hypogonadism

An eighteen years old boy hailing from Nandail, Mymensingh was complaining of small external genitalia, small testes, and gradual enlargement of breast, weight gain, absence of facial, axillary and public hair, absence of sense of smell. His height was 162 cm, weight 59 kg, BMI-22.52 kg/m2 with eunuchoid body habitus. His stretch penile length was 5 cm, testicular volume < 5 ml, stage B3 development of breast and absence of facial, axillary and public hair. He was found anosmic of standard odors. Patient was clinically and biochemically in euthyroid state with low level of testosterone, LH and FSH and normal serum prolactin level. He was diagnosed as a case of hypogonadotropic hypogonadism due to Kallmann syndrome.

Clinical and sociodemographic features of acute carbamate and organophosphate poisoning: a study of 70 adult patients in north Jordan

OBJECTIVE

To define the sociodemographic and clinical aspects of organic phosphate and carbamate poisoning.

DESIGN

The records of 70 adults (33 males and 37 females) with carbamate or organophosphate intoxication admitted to a North Jordan Teaching Hospital over a five-year period were reviewed retrospectively. These patients represented 10% of all drug overdoses admitted over the same period.

RESULTS

The most cases occurred in the 15-19 year-old age group and the female to male ratio was 1.1:1. Carbamate intoxication was more than twice as common as organophosphate intoxication. Two thirds (64%) of the patients intended to commit suicide, 26% were due to accidental ingestion and the remaining 10% were from occupational exposure. Muscarinic manifestations were the predominant clinical feature followed by central nervous system and then nicotinic manifestations. Low grade fever, not related to infection, was observed in 49% of the patients and respiratory difficulty in 47%, of which 11% required assisted ventilation. Twenty-nine percent of the patients presented with coma. Three patients died for a hospital mortality of 4%.

CONCLUSIONS

The widespread use of carbamates and organophosphates as household pesticides and the lack of adequate regulations controlling their sale and application has encouraged teenagers to prefer them as a modality of attempted suicide. This source of poisoning has become a major health problem in some developing countries.

Locked intramedullary nailing for complex non-union of the tibia

Ten patients with complex non-union of the tibia were treated by locked intramedullary nailing. These patients had scarred skin as a result of initial severe open fractures, multiple debridement or fasciotomies with external fixators and skin grafts applied. Seven of the patients also had previous osteomyelitis or pin track infections. Fully pain-free walking was achieved in all patients and radiological union in nine patients without the need for a bone graft. Four patients developed infection after nailing, of which three resolved with treatment.

Ketamine infusion for postoperative analgesia: a prospective cohort study in asthmatics

Ketamine, most often used as an anaesthetic agent can provide adequate post operative analgesia when delivered in the form of infusion, replacing narcotics, which can cause bronchospasm in susceptible individuals. This cohort study was undertaken to assess the feasibility of providing complete post operative analgesia in asthmatics with ketamine delivered in sub-anaesthetic doses (6.10-6.41 ugm./kg.-1/min-1). Diazepam (0.97-1.02 ugm./kg.-1/min-1) was delivered from the same infusion to eliminate the unwanted effects of ketamine. Ketamine induced little alteration in blood pressure while tachycardia was significant (P < 0.05). Respiratory functions observed, were favourable for asthmatics. Diazepam helped in reducing ketamine induced side effects, but after infusion over long periods tendency of cumulation was observed. Complications encountered were minimum with more than 93% patient acceptability for this method of analgesia.