Estimating survival in advanced cancer: a comparison of estimates made by oncologists and patients.

PURPOSE: To compare estimates of expected survival time (EST) made by patients with advanced cancer and their oncologists. METHODS: At enrolment patients recorded their "understanding of how long you may have to live" in best-case, most-likely, and worst-case scenarios. Oncologists estimated survival time for each of their patients as the "median survival of a group of identical patients". We hypothesized that oncologists' estimates of EST would be unbiased (~ 50% longer or shorter than the observed survival time [OST]), imprecise (< 33% within 0.67 to 1.33 times OST), associated with OST, and more accurate than patients' estimates of their own survival. RESULTS: Twenty-six oncologists estimated EST for 179 patients. The median estimate of EST was 6.0 months, and the median OST was 6.2 months. Oncologists' estimates were unbiased (56% longer than OST), imprecise (27% within 0.67 to 1.33 times OST), and significantly associated with OST (HR 0.88, 95% CI 0.82 to 0.93, p < 0.01). Only 41 patients (23%) provided a numerical estimate of their survival with 107 patients (60%) responding "I don't know". The median estimate by patients for their most-likely scenario was 12 months. Patient estimates of their most-likely scenario were less precise (17% within 0.67 to 1.33 times OST) and more likely to overestimate survival (85% longer than OST) than oncologist estimates. CONCLUSION: Oncologists' estimates were unbiased and significantly associated with survival. Most patients with advanced cancer did not know their EST or overestimated their survival time compared to their oncologist, highlighting the need for improved prognosis communication training. Trial registration ACTRN1261300128871.

Assessing knowledge and attitudes about end of life: Evaluation of three instruments designed for adults with intellectual disability.

BACKGROUND: This paper examines the development and psychometric characteristics of three instruments about end of life, designed for use with adults with intellectual disability (ID). Respectively, the instruments assess understanding of the concept of death, end-of-life planning, and fear of death. METHODS: Part 1: instruments were developed or adapted, and pilot tested with 11 adults with ID and 2 disability staff. Part 2: 39 adults with ID and 40 disability staff were assessed on all three instruments. RESULTS: We evaluated comprehensibility, internal consistency, inter-rater reliability, subscale: total score correlations, missing data, and withdrawal. Psychometric findings were mostly good. Overall, 23% of participants with ID withdrew at some point. This outcome may have been as much due to assessment fatigue as to sensitive content. There were no adverse events. CONCLUSIONS: People with ID can reliably complete assessments about end-of-life. Generally, each instrument was found to be comprehensible, reliable and valid.

Single-centre cross-sectional analysis of advance care planning among elderly inpatients.

BACKGROUND: Advance care planning (ACP) has been shown to provide beneficial outcomes for elderly patients; however, it may not be commonly implemented. AIMS: To assess prevalence of advance care directives (ACD) and documented medical orders about end-of-life care for elderly inpatients; to explore the feasibility of an ACP screening interview. METHODS: A single-centre cross-sectional analysis of 100 consecutive patients aged ≥80 years admitted for ≥48 h to a tertiary referral hospital, conducted between 16 and 18 January 2013. Medical records were reviewed for presence of (i) an ACD, (ii) resuscitation/end-of-life care intervention orders (REOL) and (iii) documented substitute decision-maker (SDM). If patients were able and willing to participate they completed an ACP screening interview exploring (i) their views on ACP and (ii) if an ACD was previously documented. RESULTS: In 100 medical records, there were: zero ACD, 17 REOL and 8 with clear documentation of patients' preferred SDM. Out of 100 patients, 33 completed the interview: 32 (97%) were able to identify their preferred SDM, in 9 (27%) the nominated SDM was different from their 'next of kin'. Out of 33, 7 (21%) reported having an enduring guardian, 4/33 (12%) an ACD. Out of 29, 23 (79%) interviewees without an ACD were interested in discussing ACP further. Out of 30, 8 (27%) interviewees without REOL said that they would not wish to have aggressive life-prolonging measures. No patients reported discomfort with the screening interview. CONCLUSIONS: ACD and correct documentation of SDM were uncommon in the medical records in this sample of elderly inpatients. The ACP screening interview appears feasible and acceptable and may be a useful tool for identifying patients' preferred SDM and willingness to discuss ACP further.

Percutaneous chemical myotomy using botulium neurtoxin A under local anaesthesia in the treatment of cricopharyngeal dysphagia following laryngectomy.

OBJECTIVE: The purpose of this study was to evaluate the outcome of the use of percutaneous injection of botulinum neurotoxin A under local anaesthesia in the management of cricophayngeus dysphagia in post-laryngectomy patients. METHODS: Fifteen post-laryngectomy patients (6 males, 9 females, age range 48-72 years) with surgery performed not less than five years with post-operative radiotherapy were recruited. Under video-fluoroscopic control and the attachment of a metal safety pin to the neck as a topographical marker for the cricopharyngeus muscle, botulinum neurotoxin was injected after local anaesthesia infiltration. Patients were followed up for a 4 months period with repeated video-fluoroscopy and telephone self-assessment and weight change. RESULTS: Eighty seven percent of patients noticed some improvement in their dysphagia. One patient reported an adverse reaction of pain at the site of injection. CONCLUSION: Percutaneous local injection of botulinum neurotoxin A is a simple, safe and cost-effective means of improving cricopharyngeal dysphagia in post-laryngectomy patients when general anaesthesia is contra-indicated.

Protective vaccination with a recombinant fragment of Clostridium botulinum neurotoxin serotype A expressed from a synthetic gene in Escherichia coli.

A completely synthetic gene encoding fragment C, a approximately 50-kDa fragment, of botulinum neurotoxin serotype A was constructed from oligonucleotides. The gene was expressed in Escherichia coli, and full-sized product was produced as judged by Western blot (immunoblot) analysis. Crude extracts of E. coli expressing the gene were used to vaccinate mice and evaluate their survival against challenge with active toxin. Mice given three subcutaneous vaccinations were protected against an intraperitoneal administration of 10(6) 50% lethal doses (ID50) of serotype A toxin. The same mice survived when challenged with 3 LD50 of botulinum toxin serotype E but died when challenged with 10 LD50 of serotype E or 3 LD50 of serotype B. Purified fragment C was compared with the botulinum toxoid vaccine in a vaccination and challenge study. Fragment C was as efficacious in protecting against challenge with active botulinum neurotoxin serotype A as the toxoid vaccine. This recombinant protein product has many properties that make it a good candidate for human use to protect against botulinum toxin.

Aspirin dosage for infants and children.

The labeled dosage schedule that has long been on pediatric aspirin preparations is at variance with the recommendation in authoritative medical references, studies demonstrating antipyretic effectiveness in children, and the prescribing habits of pediatricians as revealed by a poll conducted by the authors. Aspirin pharmacokinetics are influenced by a number of physiologic factors, as well as by dosage, and complicate the problem of assuring safe and effective pediatric use. Basic pharmacokinetic considerations indicate that the increase in size of individual doses needed to assure therapeutic salicyate blood levels, thereby removing the temptation of parents to administer the drug too often, is made permissible (i.e., safe while effective) by expanding the interdose interval to four hours instead of three. A revised pediatric aspirin disage schedule is presented that better meets the practices of the pediatric community and the needs of consumers.

Xenon-133 determination of muscle blood flow in electrical injury.

Xe-133 washout determination of muscle blood flow (MBF) was used to detect muscle ischemia in electrical injury of an experimental animal model and three patients. The control MBF of rabbit hindlimbs, which averaged 11.29 +/- 1.07 cc/min/100 gm, was significantly reduced by electrical injury, to 5.82 +/- 1.49 cc/min/100 gm (p less than 0.001). An electrical injury of 4,000 watt-seconds or greater was associated with uniform MBF less than 1.00 cc/min/100 gm and with histopathologic alterations of muscle necrosis. Thenar MBF less than 1.00 cc/min/100 gm in two patients was associated with muscle necrosis requiring distal arm amputation. The remaining patient with sequential muscle blood flows above this level had uneventful healing of hand electrical injuries. Xe-133 determination of MBF may be a useful objective technique to determine the extent of electrical injury in muscle.

Sequential circulatory changes in the circumferentially burned limb.

To assess the hemodynamic alterations in the circumferentially burned extremity, Doppler arterial examinations and Xenon-133 washout determinations of muscle blood flow (MBF) were obtained in 27 limbs. In this laboratory normal resting MBF was 2.82+/-0.86 cc/min/100 gm (mean +/- S.E.M., N=26) with no value less than 1.60 cc/min/100 gm. In 27 circumferentially burned limbs, the maximum decrement in MBF occurred by 36 hours following thermal injury. The lowest MBF value in the 11 extremities not requiring escharotomy was 1.50cc/min/100gm. Escharotomy was done in 16 extremities. Mean MBF immediately prior to escharotomy was 1.30+/-0.26cc/min/100gm and improved to 4.43+/-0.52cc/min/100gm following escharotomy (p less than 0.01). Correlation between MBF and Doppler examinations was present in 63% of all studies and in 88% of studies performed immediately before or after escharotomy. The diagnostic sensitivity of Doppler examination required audible recognition of abnormal velocity signals as well as absent velocity signals. Because the intial MBF determination or Doppler examination is not helpful in predicting which extremities will eventually require escharotomy, sequential studies should be done during the first 36-48 hours following thermal injury.