Pediatric Undifferentiated Pleomorphic Sarcoma of the Cecum.

Background: Undifferentiated pleomorphic sarcoma (UPS) is a high-grade neoplasm typically diagnosed in older adults and localized to the extremities or retroperitoneum. Because of poor response to therapy and high rates of recurrence, this neoplasm is associated with a poor prognosis. Case Report: A 12-year-old female presented with weight loss, abdominal pain, fatigue, and diarrhea. She was profoundly anemic with occult blood-positive stools. On endoscopy, a fungating cecal mass was biopsied and diagnosed as malignant sarcomatoid neoplasm. The neoplasm was resected with clear margins during subsequent surgery, and on final pathology was diagnosed as UPS. A suspicious lung nodule was also removed via video-assisted thoracoscopic surgery and found to be a granuloma positive for Histoplasma capsulatum for which the patient received antifungal therapy. The patient did not receive additional chemotherapy or radiotherapy and was doing well without signs of recurrence at 12 months postresection. Conclusion: This report of cecal UPS in a 12-year-old is rare because of the patient's age and tumor location. We have identified only 2 other case reports of pediatric gastrointestinal UPS. This case illustrates the need for a broad differential and prompt workup in pediatric patients presenting with weight loss and abdominal complaints. More information regarding the management and outcomes in cases of gastrointestinal UPS is needed to assist providers in determining the best treatment course and to allow for better prognostication.

I've Got the Power: Nurses' Moral Distress and Perceptions of Empowerment.

BACKGROUND: Nurses experience moral distress when they feel disempowered or impeded in taking the ethically right course of action. Research suggests an inverse relationship between moral distress and empowerment. In the intensive care unit, providing palliative care services may reduce moral distress because palliative care is often provided in situations that give rise to moral distress. OBJECTIVE: To evaluate the effect of nurses' use of a palliative care screening tool on their moral distress and perceptions of empowerment. METHODS: A pretest-posttest pilot study was conducted involving day-shift medical intensive care unit nurses. The nurses administered a palliative care screening tool to their assigned patients daily for 8 weeks and communicated the results to an attending physician or fellow. Demographic information was collected, along with data on nurses' moral distress and perceptions of structural and workplace empowerment before and after the intervention. Moral distress was evaluated using the Moral Distress Scale-Revised. Perceptions of structural and workplace empowerment were quantified using the Conditions for Work Effectiveness Questionnaire-II and the Global Empowerment Scale, respectively. RESULTS: Preintervention and postintervention surveys were completed by 17 nurses. Paired-sample t tests revealed a significant decrease in the frequency of moral distress (t16 = -2.22, P = .04) and a significant increase in workplace empowerment (t16 = -2.75, P = .01). No significant changes in moral distress intensity or structural empowerment were found. CONCLUSION: Nurses' sense of empowerment and the frequency of moral distress are favorably affected by active participation in assessing and communicating patients' palliative care needs.

A randomized controlled trial of buprenorphine taper duration among opioid-dependent adolescents and young adults.

BACKGROUND AND AIMS: Few randomized controlled trials have evaluated buprenorphine treatment interventions for opioid-dependent youth. Consequently, optimal administration strategies for this cohort are unclear. Our aim was to evaluate the relative efficacy of two different buprenorphine taper lengths in promoting abstinence from illicit opioids and treatment retention among opioid-dependent youth. DESIGN: A double-blind, placebo controlled, multicenter randomized controlled trial. SETTING: Two hospital-based research clinics (Manhattan and Brooklyn) in New York City, USA from 2005 to 2010. PARTICIPANTS: Volunteer sample of 53 primarily Caucasian participants between the ages of 16 and 24 (n = 11 under age 18) who met DSM-IV opioid dependence criteria. INTERVENTION: Participants were assigned randomly to either a 28-day buprenorphine taper (n = 28) or 56-day buprenorphine taper (n = 25) via a parallel-groups design during a 63-day period. Both groups received behavioral counseling and opioid abstinence incentives. Both taper conditions had a minimum of 1 week of placebo dosing at the end of the taper. MEASUREMENTS: The primary outcome was opioid abstinence measured as a percentage of scheduled urine toxicology tests documented to be negative for opioids. The secondary outcome was treatment retention, measured as number of days attended scheduled visits. FINDINGS: Intent-to-treat analyses revealed that participants who received a 56-day buprenorphine taper had a significantly higher percentage of opioid-negative scheduled urine tests compared with participants who received a 28-day buprenorphine taper [35 versus 17%, P = 0.039; Cohen's d = 0.57, 95% confidence interval (CI) = 0.02, 1.13]. Participants who received a 56-day buprenorphine taper were retained in treatment significantly longer than participants who received a 28-day buprenorphine taper (37.5 versus 26.4 days, P = 0.027; Cohen's d = 0.63, 95% CI = 0.06, 1.19). Daily attendance requirement was associated with decreased abstinence and shorter retention compared with a two to three times weekly attendance requirement, independent of taper duration. Follow-up data were insufficient to report. CONCLUSION: Longer (56-day) buprenorphine taper produces better opioid abstinence and retention outcomes than shorter (28-day) buprenorphine taper for opioid-dependent youth.

Report of an HIV clinic-based pain management program and utilization of health status and health service by HIV patients.

CONTEXT: Current reports on human immunodeficiency virus (HIV) pain are limited to epidemiological data on neuropathic pain in HIV and most studies were conducted before the availability of highly active antiretroviral therapy. Complex pain was reported to be highly prevalent and associated with advanced disease. OBJECTIVES: The authors conducted a retrospective review of the medical records of 81 patients from the Center for Positive Living (CPL) at Montefiore Medical Center who were newly referred to a pain management program in 2006 to identify the potential benefits of integrating a pain management team into the care of persons living with HIV and etiologies of pain. METHODS: A standardized chart abstraction tool was used to capture clinical data. Data related to health service utilization and viral outcomes were obtained from the clinical information systems. RESULTS: The most common pain diagnoses were multiple syndromes, degenerative disc disease or spinal stenosis, and neuropathy. There was a decrease in emergency room utilization in the 12 months following an initial pain management appointment (p < 0.0001) and an increase in use of primary care (p = 0.0017). The use of adjuvant medications increased after intake into the pain clinic (p < 0.0001). Having an opioid dose in excess of 200 mg/d oral morphine equivalents and maintenance of each palliative care and infectious disease clinic appointment were inversely associated with viral loads in excess of 75 copies: odds ratio (OR) = 0.21 (95% confidence interval/CI], 0.11-0.44), OR = 0.77 (95% CI, 0.68-0.86), and 0.94 (95% CI, 0.93-0.99), respectively. CONCLUSIONS: The decrease in emergency room visits and increase in use of adjuvant analgesics and compliance with primary care and nonmedication approaches for the management of pain in the 12 months subsequent to initial palliative/pain clinic appointments highlight potential improved quality of care associated with the integration of a pain management team into the primary care of persons living with HIV disease.