Psychosocial practice trends in pediatric oncology.

Children with cancer are now living longer lives. As a result, the focus on care has shifted to include psychosocial components to help promote healthy adjustment to the diagnosis of cancer. In addition, the focus extends to the systems that encompass the patient and family. This ranges from cultural needs to comfort care and how the medical team and institutions address these issues. Through well-defined psychosocial practices, children and families are better prepared to cope with cancer and become well-adjusted survivors. However, regardless of the eventual outcome of the disease, providing psychosocial services can add to the quality of life. Many common practices have emerged over the last 25 years, and many more will continue to arise as outcome studies continue to address the impact of psychosocial services and interventions. This report explores some current trends and common psychosocial practices in working with children with cancer and their families.

Preoperative pulmonary evaluation. Identifying patients at increased risk for complications.

During surgical procedures, multiple physiologic changes affect the pulmonary system and its defense mechanisms. The presence of basic risk factors (eg, smoking, chronic obstructive pulmonary disease, severe obesity) can affect whether these physiologic changes result in pulmonary complications or even death. Therefore, the presence of risk factors should be ascertained in all patients before abdominal or thoracic surgery. The degree of risk can be further determined preoperatively by additional evaluation, such as pulmonary function testing, newer assessment of cardiorespiratory status, history taking, and physical examination. The presence of risk factors and the type of operation to be performed should guide decisions about whether to perform a procedure or to use prophylactic measures before and after surgery. New operative techniques may allow some procedures that were prohibited in the past to be performed in high-risk patients.

The use of erythropoietin in the management of Jehovah's Witnesses who have revision total hip arthroplasty.

Five Jehovah's Witnesses (one man and four women) were managed with revision total hip arthroplasty. The average age of the patients at the time of the index operation was 66.4 years (range, fifty-eight to seventy-eight years). All of the patients received subcutaneous injections of recombinant human erythropoietin before the operation, at an initial dose of 100 international units per kilogram of body weight three times a week. The duration of preoperative treatment was determined by the hematocrit at the time of presentation. The hematocrit was monitored weekly, beginning with the second week of treatment, and the dose was adjusted accordingly until the time of the operation. Erythropoietin therapy was discontinued if the hematocrit exceeded 0.45 at any time. The hematocrit before the erythropoietin therapy was begun, at the time of admission to the hospital (one or two days preoperatively), immediately postoperatively, and at the time that the patient was discharged were recorded for this study. All five revision total hip arthroplasties were performed successfully without a blood transfusion. No patient had any complications associated with an excessive loss of blood or a low hematocrit. The average hematocrit was 0.395 (range, 0.317 to 0.447) before the erythropoietin therapy was begun and was 0.476 (range, 0.431 to 0.509) after treatment with erythropoietin and before the operation (that is, at the time of admission to the hospital). The average duration of erythropoietin therapy was twenty-six days preoperatively and 3.6 days postoperatively. The average hematocrit was 0.368 (range, 0.272 to 0.424) immediately after the operation and was 0.308 (range, 0.294 to 0.327) at the time of discharge from the hospital. No patient had evidence of deep venous thrombosis. This study illustrates that it is possible and apparently safe to optimize the hematocrit, by use of erythropoietin, in a patient who is scheduled for an operation. This may be particularly beneficial to a patient with anemia who has failure of a total hip arthroplasty. A relatively high hematocrit (0.45 to 0.50) preoperatively provides a relative margin of safety to a procedure that frequently involves a great deal of intraoperative blood loss. The use of erythropoietin preoperatively is particularly suited to joint replacements and revisions because of their elective nature and the moderately flexible timing associated with these procedures.

Is anticoagulation indicated for asymptomatic postoperative calf vein thrombosis?

The purpose of this study was to determine the effect of anticoagulation on the incidence of thrombotic propagation and pulmonary embolism in patients with calf vein thrombosis after total hip or total knee arthroplasty. Patients undergoing arthroplasties had prospective surveillance for postoperative deep vein thrombosis by both bilateral contrast venography and venous duplex scanning. Calf vein thrombosis was documented by venography in 42 patients (50 limbs), including 29 of 253 patients undergoing total hip arthroplasty (11.4%) and 13 of 99 patients undergoing total knee arthroplasty (13%). Of patients on whom follow-up duplex scans were performed, heparin followed by warfarin anticoagulation was used in 11 (13 limbs) and withheld in 21 (25 limbs). Propagation of thrombosis to the popliteal or superficial femoral vein or both was detected by serial duplex scanning in 3 of 13 treated limbs (23%) and 2 of 25 untreated limbs (8%), (p = 0.43). All thrombus propagations were detected within 2 weeks of the operative procedure. There were no pulmonary emboli or deaths. Propagation of asymptomatic calf vein thrombosis after arthroplasty was not influenced by anticoagulation, suggesting that postoperative calf vein thrombosis need not be routinely treated. Serial venous duplex scanning is useful to identify the occasional patient in whom thrombotic propagation requiring anticoagulation develops.

Duplex scanning versus venography as a screening examination in total hip arthroplasty patients.

Combined B-mode/Doppler (duplex) scanning and venography were compared in routine perioperative screening for proximal deep vein thrombosis (DVT) in 158 total hip arthroplasty (THA) patients. Preoperative scans were performed in the first 60 patients; the low preoperative prevalence of 2% for proximal DVT was thought not to warrant routine preoperative scanning. Postoperatively, duplex scanning had a sensitivity of 79%, a specificity of 98%, and an accuracy of 97% when venography was considered as the gold standard. The postoperative incidence of proximal DVT was 12% in this group of THA patients treated with mechanical and pharmacologic prophylaxis. Including calf vein thrombosis, 30% had DVT postoperatively. This study demonstrates the efficacy of duplex scanning for diagnosing proximal DVT and describes an effective noninvasive method of screening THA patients for the presence of proximal DVT.

Milk-induced malabsorption in malnourished African patients.

Fifty malnourished rural African patients were randomly assigned to whole milk (50 g lactose/L), acidified milk (24 g lactose/L), or a commercial lactose-free diet (LFD) as a constant nasogastric infusion for 3 d, starting at 2 L/d and increasing to 3 L/d if tolerated. During the first 2 d mild symptoms of intolerance developed in 63% of patients on whole milk, 37% on acidified milk, and 54% on LFD whereas severe intolerance, necessitating withdrawal, was encountered in 22% receiving whole milk and none receiving LFD. Stool weights and fat excretion on day 3 were greater (P less than 0.02) in the remaining milk-fed patients whereas nitrogen balance remained strongly positive in all three groups. Eighty-seven percent of patients were methane producers, and high excretion rates were associated with better milk tolerance. The results suggest that although undiluted cow milk will not form a suitable tube feed for malnourished African patients, products such as acidified milk may prove cost effective.

Duplex scanning in orthopaedic patients.

Duplex scanning with a combination of real-time and Doppler ultrasound is a noninvasive procedure used for the detection of deep vein thrombosis. The technique is described, its use in orthopaedic patients is discussed, and a plan of treatment based on duplex results is reported.

Acute postoperative confusion and hallucinations in Parkinson disease.

STUDY OBJECTIVE: To determine whether patients with Parkinson disease are at an increased risk for postoperative confusion. DESIGN: Retrospective chart review of patients with Parkinson disease who remained in the hospital at least 48 hours after their surgery. Current data were compared with published historical controls. SETTING: Recent medical records of a university-affiliated hospital, Veterans Administration hospital, and community hospital. PATIENTS: Available charts of patients with Parkinson disease who had had surgery in the last 2 years. Patients were excluded if they were disoriented at admission or had serious metabolic disturbances. MEASUREMENTS AND MAIN RESULTS: Fifteen of twenty-five postoperative patients with Parkinson disease (60%; CI, 39% to 78%) suffered significant acute confusion, and 9 of these patients had documented hallucinations. Neuropsychiatric changes were frequently delayed after surgery. The acute confusional state lasted an average 2.5 days; several patients, however, were discharged before resolution. These disturbances did not appear to be related to type of anti-parkinsonian medication or anesthetic. CONCLUSION: In comparison with historical controls, the relative risk of patients with Parkinson disease having an acute postoperative confusional state is between 2.8 and 8.1. These patients may need environmental supports during the postoperative period.

The plight of modern Bushmen.

The nutritional status of 51 adult Bushmen in northeast Namibia, who have been forced to abandon their traditional hunter/gatherer lifestyle and merge with pastural/urbanized Hereros of Bantu origin, was assessed. Controls were 23 local medical staff and investigators. The diet was very unbalanced, consisting of little more than refined maize meal. Any money earned was usually spent on alcoholic beverages which, at such times, replaced normal food intake. Although short stature is thought to be genetic in origin (Bushmen were on average 15 cm shorter than Hereros), body mass corrected for height was severely diminished in 30% of adults, fat stores were depleted in 70%, and arm muscle was reduced in 75%. In general, women were more depleted than men. Blood tests showed low plasma vitamin C, folic acid, and vitamin A and E concentrations compared with controls. Plasma protein concentrations suggested a high frequency of chronic liver or enteric diseases. Examination of 44 hospital patients showed that 85% had pulmonary tuberculosis, and nutritional depletion was universal. The results raise serious doubts about the survival of Bushmen as an independent ethnic group.

Preoperative cardiac consultations in a teaching hospital.

Perioperative consultations may play a major role in the care of surgical patients in an era of prospective payments. Since insurance reimbursement policy favors limitations in the number of consultants on a case, general medicine ("holistic") consultation services may become preferred perioperative consultants in the future. To focus curriculum planning for perioperative consultants, we reviewed the content of 60 consecutive perioperative consultations by noncardiac surgery services to a university cardiology consultation team. Clinical descriptions of the patients' exercise tolerance showed that 95% of the patients belonged in functional classes I and II. One fourth of the requests were for routine preoperative clearance. The most frequent cardiac conditions for evaluation were congestive heart failure, old myocardial infarctions, murmurs, abnormal electrocardiograms, angina, and previous histories of coronary artery bypass surgery. Few patients needed management of arrhythmias. Physicians involved in perioperative care should assess their abilities in managing these cardiac conditions.

Perioperative asymptomatic venous thrombosis: role of duplex scanning versus venography.

We compared combined B-mode/Doppler (duplex ultrasonic scanning and venography in routine preoperative and postoperative screening for major proximal deep vein thrombosis in 78 patients undergoing total hip or knee arthroplasty. Of 309 extremity examinations, duplex scanning had an overall sensitivity of 85.7% (12/14) and a specificity of 97.3% (287/295). The preoperative prevalence and postoperative incidence of major deep vein thrombosis were 2.5% and 14.1% of patients, respectively, despite intensive mechanical and pharmacologic prophylaxis. In addition, venography documented a preoperative prevalence and postoperative incidence of isolated calf deep vein thrombosis in 2.5% and 16.7% of patients, respectively. Whereas such disease extended proximally even in the absence of anticoagulation in only 18% of patients studied by serial duplex scans, calf deep vein thrombosis accounted for the only two instances of pulmonary embolism in this study. There were no deaths related to pulmonary embolism. This study suggests that duplex scanning is useful in screening for perioperative deep vein thrombosis in patients undergoing total hip or knee arthroplasty, which carries a significant risk of venous thromboembolism despite routine prophylaxis.

Financial unbundling reduces outpatient laboratory use.

Previous studies have examined methods of reducing laboratory use, without great success. We studied the effects of the financial unbundling of clinical biochemistry determinations in a university outpatient clinic. After eliminating the charge structure that promoted panel use, the ordering of chemistry 19 panels fell dramatically, accompanied by an increase in orders for electrolyte and chemistry 6 panels. The total number of biochemical assay determinations fell by one third after this administrative intervention. Only orders for potassium and creatinine measurements remained relatively unchanged and eventually increased. The ordering of five analytes of the chemistry 19 profile was reduced by at least 50%. Reassessment of the intervention six months later demonstrated the sustained decline in laboratory use. We conclude that physicians are attuned to price inefficiencies in basic laboratory testing and can alter their ordering behavior accordingly. Facilities can change patterns of use by altering charge structures alone. The decline in laboratory testing also indicates that physicians receive unnecessary clinical data when they order biochemical profiles. Financially bundled chemistry profiles could be replaced by physiologically based test groupings.

Efficacy of propoxur insecticide strip use in a laboratory animal facility.

A non-fumigant, controlled-release, impregnated strip (insecticide strip) was evaluated for effectiveness against cockroaches (Blatella germanica) in a conventional animal facility. A substantial initial roach mortality was observed in treated rooms. Continued use of the insecticide strip assisted in the control of the cockroach population and did not affect plasma cholinesterase levels of exposed laboratory animals.