Financial-legal navigation reduces financial toxicity of pediatric, adolescent, and young adult cancers.

BACKGROUND: Pediatric, adolescent, and young adult patients with cancer and their caregivers are at high risk of financial toxicity, and few evidence-based oncology financial and legal navigation programs exist to address it. We tested the feasibility, acceptability, and preliminary effectiveness of Financial and Insurance Navigation Assistance, a novel interdisciplinary financial and legal navigation intervention for pediatric, adolescent and young adult patients and their caregivers. METHODS: We used a single-arm feasibility and acceptability trial design in a pediatric hematology and oncology clinic and collected preintervention and postintervention surveys to assess changes in financial toxicity (3 domains: psychological response/Comprehensive Score for Financial Toxicity [COST], material conditions, and coping behaviors); health-related quality of life (Patient-Reported Outcomes Measurement Information System Physical and Mental Health, Anxiety, Depression, and Parent Proxy scales); and perceived feasibility, acceptability, and appropriateness. RESULTS: In total, 45 participants received financial navigation, 6 received legal navigation, and 10 received both. Among 15 adult patients, significant improvements in FACIT-COST (P = .041) and physical health (P = .036) were noted. Among 46 caregivers, significant improvements were noted for FACIT-COST (P < .001), the total financial toxicity score (P = .001), and the parent proxy global health score (P = .0037). We were able to secure roughly $335 323 in financial benefits for 48 participants. The intervention was rated highly for feasibility, acceptability, and appropriateness. CONCLUSIONS: Integrating financial and legal navigation through Financial and Insurance Navigation Assistance was feasible and acceptable and underscores the benefit of a multidisciplinary approach to addressing financial toxicity. CLINICALTRIALS.GOV REGISTRATION: NCT05876325.

Neurotoxicity of Inhalation Anesthetics in the Neonatal Rat Brain: Effects on Behavior and Neurodegeneration in the Piriform Cortex.

There is concern that clinical use of anesthetic drugs may cause neurotoxicity in the developing brain and subsequent abnormal neurobehavior. We therefore evaluated neurotoxic effects of inhalation anesthetics in the neonatal rat brain, using in vivo histological and neurobehavioral outcomes. Wistar rats (n=79, postnatal day 15) were subjected to a clinically relevant single exposure of urethane, isoflurane, sevoflurane, or placebo, without surgery. At 48 h and 96 h, behavioral parameters were recorded and the animals were sacrificed. In cryosectioned brains, total cells and dying cells in layer II of the piriform cortex were counted using unbiased stereology. At 48 h, cell numbers in layer II of the piriform cortex of all drug-treated animals were reduced versus controls (p=0.01). The effect persisted at 96 h in isoflurane- and urethane-exposed animals. Piriform cortical layer II neurons undergoing degeneration, detected histologically by pyknotic nuclei and eosinophilic cytoplasm, were increased in the animals treated with isoflurane (1.9 ± 0.7 at 96 h) and urethane (2.4 ± 0.8 at 96 h) versus sevoflurane (0.8 ± 0.3 at 96 h) and controls (0.9 ± 0.2 at 96 h). Sevoflurane- and isoflurane-treated animals exhibited increased activity and decreased suckling compared with controls, and sevoflurane-exposed animals also displayed increased rearing behavior at both timepoints.

The clinical utility of an index of global oxygenation for guiding red blood cell transfusion in cardiac surgery.

BACKGROUND: This observational study explored the potential utility of oxygen extraction ratio (O2ER) as an adjunct to the hemoglobin (Hb) concentration for guiding red blood cell (RBC) transfusion decisions after cardiac surgery with cardiopulmonary bypass (CPB). STUDY DESIGN AND METHODS: Hb and O2ER measures were obtained before as well as 15 and 120 minutes after RBC transfusion episodes (defined as 1-2 RBC units given in succession after CPB, within 24 hr. of surgery). Changes related to RBC transfusions among patients with normal (30%) and elevated(>30%) pretransfusion O2ERs were analyzed. RESULTS: Of the 176 patients enrolled, 74 received RBC transfusions. Of these, 50 had data available for 62 transfusion episodes. Pretransfusion episode O2ER values were elevated in 27 cases and normal in 35(56%) cases. Among those who received transfusion for low Hb concentration, 43 percent (27/62) had normal pretransfusion O2ER values. While the posttransfusion O2ER values did not change in patients with normal pretransfusion O2ER values, they did decrease inpatients with elevated pretransfusion O2ER values (% change [+/-SD] at 15 and 120 min after transfusion was -5.2 +/- 7.8 and -3.8 +/- 8.0%, respectively; p < 0.05). CONCLUSION: If a normal O2ER in anemic patients with no evidence of organ dysfunction indicates adequate tissue oxygen delivery, then our findings suggest that incorporating O2ER into the transfusion decision will substantially reduce post-cardiac surgery RBC transfusions by allowing us to safely avoid transfusing this group of patients. Future studies are needed to assess the validity of this conclusion.

Prediction of massive blood transfusion in cardiac surgery.

PURPOSE: In cardiac surgery with cardiopulmonary bypass (CPB), excessive blood loss requiring the transfusion of multiple red blood cell (RBC) units is a common complication that is associated with significant morbidity and mortality. The objective of this study was to develop a prediction rule for massive blood transfusion (MBT) that could be used to optimize the management of, and research on, at-risk patients. METHODS: Data were collected prospectively over the period from 2000 to 2005, on patients who underwent surgery with CPB at one hospital. Patients who received > or = five units of RBC within one day of surgery were classified as MBT. Logistic regression was used to appropriately select and weigh perioperative variables in the prediction rule, which was developed on the initial 60% of the sample and validated on the remaining 40%. RESULTS: Of the 10,667 patients included, 925 (8.7%) had MBT. The clinical prediction rule included 12 variables (listed in order of predictive value: CPB duration, preoperative hemoglobin concentration, body surface area, nadir CPB hematocrit, previous sternotomy, preoperative shock, preoperative platelet count, urgency of surgery, age, surgeon, deep hypothermic circulatory arrest, and type of procedure) and was highly discriminative (c-index = 0.88). In the validation set, those classified as low-, moderate-, and high-risk by a simple risk score derived from the prediction rule had a 5%, 27%, and 58% chance of MBT, respectively. CONCLUSION: A clinical prediction rule was developed that accurately identified patients at low-risk or high-risk for MBT. Studies are needed to determine the external generalizability and clinical utility of the prediction rule.