Non-oncology Population Research Articles

In-person prospective audit and feedback on an oncology ward: development of an immunocompromised antimicrobial stewardship program.

To describe clinical syndromes, opportunities for antimicrobial optimization, and acceptance of recommendations made by an immunocompromised antimicrobial stewardship program performing in-person prospective audit and feedback (IPPAF) on inpatient oncology services. Retrospective cohort study. Three inpatient oncology services including patients with solid tumor malignancies in an academic cancer center. Hospitalized adults with oncologic malignancies receive antimicrobials for any indication. We reviewed all patients receiving antimicrobials on inpatient oncology services who were included in IPPAF and prospectively documented clinical syndromes represented, most common recommendations, and acceptance rate. We also examined the standardized antimicrobial administration ratio (SAAR) for oncology units over the study period. Over 34 weeks, we performed 154 interventions for 138 patients. Metastatic malignancy was common (52%) and 90-day mortality was high (43%). Diagnostic uncertainty was common (33/154, 21%), as were cases of intra-abdominal pathology (30/154, 19%), pneumonia (25/154, 16%), and urinary tract infection (12/154, 8%). The most common recommendations were changes in duration (63/154, 41%) and stopping antimicrobials for syndromes determined to be noninfectious (29/154, 19%). Acceptance of interventions was high (77% overall) and several SAARs on the primary oncology unit significantly decreased after starting IPPAF. We identified numerous opportunities for antimicrobial optimization among solid tumor malignancy patients. Most clinical syndromes were ones also encountered frequently in non-oncology populations, but several were unique and represented opportunities for targeted education.

10. Breast Implant-associated Anaplastic Large Cell Lymphoma (BIA-ALCL) Prevalence in a Cohort of 1,508 Patients from a Private Cosmetic Practice

PURPOSE: The highest Incidence Rate (IR) reported for BIA-ALCL of 1:300, was prospectively assessed in large oncologic populations. Objectives: to estimate the cumulative IR in non-oncologic breast augmentation patients, and to calculate the implant-specific IR (ISIR). METHODS: We conducted a prospective observational study featuring 1,508 breast augmentation patients between 2006-2016. Patients were monitored yearly since implant placement and any implant-related complication, including BIA-ALCL, was recorded. All cases were identified by cross-checking clinical, pathology and external records data. Cumulative IR was evaluated with reverse Kaplan-Meier method. Patients were subdivided by implant manufacturer/characteristics, and IRs was calculated dividing the number of cases by the total follow-up years among them. RESULTS: All patients received either macro or microtextured implants bilaterally. Mean follow-up was of 3.2 years (range: 1 months to 16.4 years). Overall, 216 patients (14,3%) received 257 revisional surgeries. BIA-ALCL occurred 6 times, after a median exposure of 10.7 years (range: 2.9 - 16.3). Cumulative IR was 4 cases/1000 individuals (1:250), the person-IR was 0.25 cases/1000 person-years. Implant-specific IR was 8.6 cases/1000 individuals with Allergan Biocell® devices and 1.3/1000 individuals with Mentor Siltex® devices. CONCLUSION: An IR similar to the highest was confirmed also in a non-oncologic population, whose reliability seems linked to having in common the accuracy and length of follow-up, independently of potential oncological predisposition. Allergan Biocell® surface confirmed the higher implant-specific IR

Adaptations within Palliative Care Delivery Models Due to the COVID-19 Pandemic at a Tertiary Care Hospital.

Background: Since the onset of the COVID-19 pandemic, all facets of palliative care provision for patients with serious illness have faced unparalleled challenges. Methods: We describe our palliative care program's response to the increased clinical volume associated with the pandemic by adapting workflows for inpatient and outpatient palliative care teams caring for oncology and nononcology populations. Results: During the initial surge, the demand for palliative care consultation for patients affected by SARS-CoV-2 was high, accounting for 75% of all inpatient palliative care referral requests for oncology and nononcology patients. Furthermore, our ambulatory clinic experienced a 40% increase in visits for complex oncology patients between February and December of 2020. Discussion: This article highlights transformations in palliative care delivery implemented in response to the pandemic and reflects on how these transformations have shaped our current care delivery models. We further delineate our intentional reliance on key population health principles to drive ongoing innovation in palliative care provision across our clinical teams.

Estimation of the demand for palliative care in non-oncologic patients in Chile

BackgroundAccess to palliative care is an emerging global public health challenge. In Chile, a palliative care law was recently enacted to extend palliative care coverage to the non-oncologic population. Thus, a reliable and legitimate estimate of the demand for palliative care is needed for proper health policy planning.ObjectiveTo estimate the demand for Palliative Care in Chile.MethodologyDiseases likely to require palliative care were identified according to literature and expert judgement. Annual deaths of diseases identified were estimated for the periods 2018–2020. Demand estimation corresponds to the identification of the proportion of deceased patients requiring palliative care based on the burden of severe health-related suffering. Finally, patient-years were estimated based on the expected survival adjustment.ResultsThe estimated demand for palliative care varies between 25,650 and 21,679 patients depending on the approximation used. In terms of annual demand, this varies between 1,442 and 10,964 patient-years. The estimated need has a minor variation between 2018 and 2019 of 0.85% on average, while 2020 shows a slightly higher decrease (7.26%).ConclusionThis is a replicable method for estimating the demand of palliative care in other jurisdictions. Future studies could approach the demand based on the decedent population and living one for a more precise estimation and better-informed health planning. It is hoped that our methodological approach will serve as an input for implementing the palliative care law in Chile, and as an example of estimating the demand for palliative care in other jurisdictions.

Mechanisms of Myocardial Ischemia in Cancer Patients: A State-of-the-Art Review of Obstructive Versus Non-Obstructive Causes.

In patients with cancer, myocardial infarction (MI) has distinct features and mechanisms compared to the non-oncology population. Triggers of myocardial ischemia specific to the oncology population have been increasingly identified. Coronary plaque disruption, coronary vasospasm, coronary microvascular dysfunction, spontaneous coronary artery dissection, and coronary oxygen supply-demand mismatch are all causes of MI that have been shown to have specific triggers related to either the treatments or complications of cancer. MI can occur in the presence or absence of atherosclerotic coronary artery disease (CAD). MI with nonobstructive CAD (MINOCA) is a heterogeneous syndrome that has distinct pathophysiology and different epidemiology from MI with significant CAD (MI-CAD). Recognition and differentiation of MI-CAD and MINOCA is essential in the oncology population, due to unique etiology and impact on diagnosis, management, and overall outcomes. There are currently no reports in the literature concerning MINOCA as a unified syndrome in oncology patients. The purpose of this review is to analyze the literature for studies related to known triggers of myocardial ischemia in cancer patients, with a focus on MINOCA. We propose that certain cancer treatments can induce MINOCA-like states, and further research is warranted to investigate mechanisms that may be unique to certain cancer states and types of treatment.

Adverse drug reactions of the SARS-CoV-2 mRNA-1273 vaccine in a cohort of cancer patients of a tertiary hospital in Madrid, Spain.

e24072 Background: SARS-CoV-2 vaccines efficacy and safety have been tested in phase 3 studies which did not include cancer patients. Information is scarce regarding COVID-19 vaccines safety in this population. Methods: The objective of this study is to evaluate the safety profile of the mRNA-1273 vaccine across cancer patients and its relationship to patients’ demographics. This cross sectional study included patients 18-years or older with solid malignancies receiving active treatment in Hospital Clínico San Carlos (Madrid, Spain) who had received the three dose schedule of the mRNA9 1273 vaccine. Patient electronic medical records were reviewed retrospectively to collect data between April 19, 2021 and December 31, 2021. Patients with documented previous infection by SARS-Cov-2 were excluded. Results: 93 patients met inclusion criteria. 31 patients (33%) were male and 62 patients (66%) were female. Mean age was 61 [SD 8]. 33% of the study population had metastatic disease. The majority of patients (60%) had ECOG 0 whereas 32% and 8% of the population had ECOG 1 and 2 respectively. Most common tumors were breast (33%) and gastrointestinal (17%). Treatment modalities included chemotherapy (37%), targeted therapy (23%), immunotherapy (12%) and combined therapy (28%). Local adverse effects at the site of injection and systemic adverse reactions had different trends, local adverse reactions were reported more frequently after the first and second dose than after the third (42%, 50% and 36% respectively), while systemic adverse reactions were reported less frequently after the first and second dose than after the third (16%, 35% and 53% respectively). Most common systemic adverse effect was fever followed by malaise and myalgia. No grade 4 or 5 adverse events were reported. We found a statistically significant association between sex and systemic adverse reactions after the third dose with a moderate correlation assessed by Cramer’s V. Cochran-Armitage test showed a statistically significant linear trend, p = 0.012, with higher ECOG score associated with a lower proportion of patients suffering from systemic side effects. A logistic regression showed that females had 5.79 times higher odds to exhibit systemic adverse events after the third dose (p = 0.01) compared to males. Increasing age was associated with a decreased likelihood of exhibiting adverse events (p = 0.016). ECOG scores didn’t show a statistically significant association. Conclusions: mRNA-1273 vaccine shows a tolerable safety profile, which is similar to the non-oncologic population. The likelihood of adverse reactions appears to be associated with gender and age. Its association with ECOG scores is less evident. Further studies are needed to elucidate the safety profile of COVID-19 vaccines in cancer patients.

Mental state of demoralisation across diverse clinical settings: A systematic review, meta-analysis and proposal for its use as a ‘specifier’ in mental illness

Demoralisation is a state of poor coping characterised by low morale, hopelessness, subjective incompetence, and loss of meaning and purpose in life. While studied extensively in oncology and palliative care, there has been recent exploration in broader medical and mental health settings. The aim was to investigate the prevalence of demoralisation and associated sociodemographic and psychological factors across these clinical settings. Six electronic databases were used to locate articles from January 2014 to March 2020. A pre-publication update of non-oncology populations was completed in September 2021. The review has been reported following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Pooled prevalence of demoralisation was determined through % prevalence and mean demoralisation score; this was synthesised through meta-analysis of single means to determine pooled mean prevalence of Demoralisation Scale scores using the 'R' statistical software. Demoralisation has been examined in 52 studies (n = 11,670) and found to be prevalent in 24-35% of oncology and non-oncology, including mental health, populations. The mean score on the Demoralisation Scale was 24.3 (95% confidence interval, CI = [21.3, 27.3]). There was evidence of divergent validity in addition to significant comorbidity between depression, demoralisation and suicidal ideation. Burdensome physical symptoms, and psychological and demographic factors are strongly correlated with demoralisation. There remains a need to recognise demoralisation in various clinical and cultural settings and to strongly consider its inclusion as a 'specifier' within formal nosological systems for adjustment and depressive disorders. This is important to initiate targeted interventions and prevent significant morbidity.

The Correlation Between Changes in Cardiac Biomarkers and Cardiac Events in Patients With Non-Small Cell Lung Cancer (NSCLC) Treated With Stereotactic Body Radiation Therapy (SBRT) — Exploratory Analysis of a Phase II Study

Heart dose in patients receiving thoracic radiotherapy (RT) correlates with cardiovascular events (CVE) and outcomes, but there are currently no established cardiac biomarkers predictive of RT-induced cardiotoxicity. A cardiac risk score (CRS) (10-point score: 0- < 4 = low risk (LR), 4- < 7 = intermediate risk (IR), 7-10 = high risk (HR)) determined by a validated cardiac biomarker panel of 4 proteins (NT-proBNP, osteopontin, KIM-1 and TIMP-1) has been previously shown to predict for CVE in a non-oncology population. We assessed RT-induced changes in the CRS before, during and after RT and hypothesize that biomarker elevations following SBRT correlate with CVE (MI, stroke, CV death, heart failure, arrythmia, valvular surgery), and with heart dose.Patients with NSCLC were treated with SBRT on an IRB-approved prospective phase II study on dose escalation in patients with large (T1b-T4N0-N1M0) primary NSCLC. Consecutive patients treated from 2013 to 2018 with a history of a prior CVE, a CVE after SBRT, or a mean heart dose (MHD) > 5 Gy were selected for CRS analysis. Patient samples were obtained pre-treatment, on the last day of SBRT and in follow-up (1, 3 and 6 months after SBRT). Two-sample t-tests were performed to compare CRS over time. Subset analyses were performed in patients with or without MHD > 5 Gy and in patients with or without a CVE during follow-up.A total of 62 samples from 17 patients were analyzed for CRS. The median age was 79 years and 53% were male. Patients were AJCC 8th edition stage IB (29%), IIA (12%), IIB (41%) and IIIA (18%). RT doses were 40 to 45 Gy in 5 fractions (18%), 50 Gy in 5 fractions (70%) or 60 Gy in 8 fractions (12%). Eight (47%) patients had a MHD > 5 Gy. At a median follow-up of 21 months, 11 (65%) patients experienced a CVE after RT. Baseline CRS were LR (41%), IR (41%), HR (12%) or not evaluable (6%). CRS increased from baseline to the last day of SBRT (mean difference (MD) in score was +0.52, P = 0.06). On subgroup analysis, patients who experienced a CVE in follow-up had a greater increase in CRS (MD: +1.101, P = 0.008). There was also a trend of increase in CRS in patients with MHD > 5 Gy (MD: +0.592, P = 0.1). There were no significant changes in the CRS during the follow-up period.Our results from this exploratory prospective analysis demonstrate a significant correlation between an increase in CRS during SBRT and the development of CVE in follow-up after SBRT. Additionally, a trend in association between an increase in CRS during SBRT and MHD was identified, which could indicate an underlying relationship between CRS change during RT and MHD. These findings should be further explored in a larger patient population.

Impact of active cancer on COVID-19 survival: a matched-analysis on 557 consecutive patients at an Academic Hospital in Lombardy, Italy.

BackgroundThe impact of active cancer in COVID-19 patients is poorly defined; however, most studies showed a poorer outcome in cancer patients compared to the general population.MethodsWe analysed clinical data from 557 consecutive COVID-19 patients. Uni-multivariable analysis was performed to identify prognostic factors of COVID-19 survival; propensity score matching was used to estimate the impact of cancer.ResultsOf 557 consecutive COVID-19 patients, 46 had active cancer (8%). Comorbidities included diabetes (n = 137, 25%), hypertension (n = 284, 51%), coronary artery disease (n = 114, 20%) and dyslipidaemia (n = 122, 22%). Oncologic patients were older (mean age 71 vs 65, p = 0.012), more often smokers (20% vs 8%, p = 0.009), with higher neutrophil-to-lymphocyte ratio (13.3 vs 8.2, p = 0.046). Fatality rate was 50% (CI 95%: 34.9;65.1) in cancer patients and 20.2% (CI 95%: 16.8;23.9) in the non-oncologic population. Multivariable analysis showed active cancer (HRactive: 2.26, p = 0.001), age (HRage>65years: 1.08, p < 0.001), as well as lactate dehydrogenase (HRLDH>248mU/mL: 2.42, p = 0.007), PaO2/FiO2 (HRcontinuous: 1.00, p < 0.001), procalcitonin (HRPCT>0.5ng/mL: 2.21, p < 0.001), coronary artery disease (HRyes: 1.67, p = 0.010), cigarette smoking (HRyes: 1.65, p = 0.041) to be independent statistically significant predictors of outcome. Propensity score matching showed a 1.92× risk of death in active cancer patients compared to non-oncologic patients (p = 0.013), adjusted for ICU-related bias. We observed a median OS of 14 days for cancer patients vs 35 days for other patients.ConclusionA near-doubled death rate between cancer and non-cancer COVID-19 patients was reported. Active cancer has a negative impact on clinical outcome regardless of pre-existing clinical comorbidities.

Low Incidence of SARS-CoV-2 in Patients with Solid Tumours on Active Treatment: An Observational Study at a Tertiary Cancer Centre in Lombardy, Italy.

Background: The incidence and prognosis of SARS-CoV-2-positive cancer patients on active oncologic treatment remain unknown. Retrospective data from China reported higher incidence and poorer outcomes with respect to the general population. We aimed to describe the real-word incidence of SARS-CoV-2 in cancer patients and the impact of oncologic therapies on the infection. Materials & Methods: In this study, we analysed all consecutive cancer patients with solid tumours undergoing active intravenous treatment (chemotherapy, immunotherapy, targeted therapy, alone or in combination) between 21 February and 30 April 2020, in a high-volume cancer centre in Lombardy, Italy. We focused on SARS-CoV-2-positive patients, reporting on the clinical characteristics of the cancer and the infection. Results: We registered 17 SARS-CoV-2-positive patients among 1267 cancer patients on active treatment, resulting in an incidence of 1.3%. The median age was 69.5 years (range 43–79). Fourteen patients (82%) required hospitalisation for COVID-19 with a median in-hospital stay of 11.5 days (range 3–58). Fourteen of the seventeen (82%) were treated for locally advanced or metastatic disease. We could not demonstrate any correlation between SARS-CoV-2 infection and tumour or treatment type. The COVID-19-related fatality rate was 29% (5/17), which was higher than that of the general population cared for in our centre (20%). Conclusions: Active oncologic treatments do not represent a risk factor for SARS-CoV-2 infection in cancer patients. However, the prognosis of infected cancer patients appears to be worse compared with that of the non-oncologic population. Given the low number of SARS-CoV-2-positive cases and the uncertainties in risk factors that may have an impact on the prognosis, we advocate for the continuum of cancer care even during the current pandemic.

Acute Neurological Complications of Brain Tumors and Immune Therapies, a Guideline for the Neuro-hospitalist.

Patients with brain tumors presenting to the emergency room with acute neurologic complications may warrant urgent investigations and emergent management. As the neuro-hospitalist will likely encounter this complex patient population, an understanding of the acute neurologic issues will have value. We discuss updated information and management regarding various acute neurologic complications among neuro-oncology patients and neurologic complications of immunotherapy. Understanding of the acute neurologic complications associated with central nervous system tumors and with common contemporary cancer treatments will facilitate the neuro-hospitalist management of these patient populations. While there are aspects analogous to the diagnosis and management in the non-oncologic population, a number of unique features discussed in this review should be considered.

Incidence and economic burden of infections in cancer patients receiving immune checkpoint inhibitors.

e19365 Background: Along with antitumor effects, Immune Checkpoint Inhibitors (ICPI) have shown great potential in treating chronic infections such as HIV, Hepatitis B, and malaria, in ex-vivo studies. However, several case reports and case series suggested increased infection risk in cancer patients receiving ICPI. The purpose of our study is to assess the risk of infections in cancer patients receiving ICPI. We also attempted to evaluate the role of a multidisciplinary approach (Oncology and Infectious disease specialists) and the cost associated with treatment. Methods: Records on all cancer patients over age ≥18 years old who had received at least one dose of ICPI from 2015 to 2018 at two major community teaching hospitals in the Central Massachusetts region were reviewed. Several risk factors associated with infection were identified. Two-tailed unpaired t-test was used to analyze the association between risk factors and infection. We calculated the average length of stay (LOS) and cost per admission with a multidisciplinary vs. non-multidisciplinary approach. The calculated total average cost per admission was compared with a random set of non-oncologic population admitted with similar infections noted in our study to estimate the economic burden. Results: Thirty-seven (21.8%) patients developed sixty-two episodes of infection. Microbiological confirmation was available in 13 episodes. Risk factors like COPD (P = 0.01), prior chemotherapy (P = 0.03), and steroid use (P = 0.003) were significantly associated with infections. An infection-associated mortality rate was noted to be 2.3%. With the involvement of multidisciplinary team, the average LOS increased from 5.9 to 8.1 days. Yet, the average cost per admission approximately remained the same (52,047$ vs. 54,510$). Upon comparison with a non-oncologic patient, the average cost per admission for an infection in cancer patients receiving ICPI increased from 11,527$ to 35,484$. Conclusions: Surprisingly, a significant incidence of infections and associated health care resource utilization continue to prevail in cancer patients despite the utility of ICPI. Although the economic burden due to the infections in this set of patients is remarkably high when compared to the general population, the multidisciplinary approach did not increase the hospital costs.

Inferior and Intra-/Peri-Articular Superior Sacroiliac Joint Injection Approaches Under Ultrasound Guidance to Treat Metastasis-Related Posterior Pelvic Bone Pain.

Numerous mechanical and pathologic variables contribute to sacroiliac joint (SIJ) pain. The oncologic population has additional considerations, including tumor burden causing fracture, nerve compression, joint instability, and periosteal inflammation. Post-treatment changes may also restrict joint mobility, causing transitional pain. Currently, fluoroscopically guided SIJ injections, aimed at the inferior one third of the SIJ, are the gold standard for treatment but have only been described in the nononcologic population. Ultrasound (US) guidance may confer several benefits, including positioning, ease of procedure, lower costs, and, importantly, guidance to avoid neovascularization, metastatic disease, and other soft tissue structures. We aim to describe the advantages of US-guided SIJ injections for refractory malignant SIJ pain from extra-articular tumors. We then describe our technique and decision framework for accessing the superior or inferior SIJ in patients with metastatic sacroiliac pain. A retrospective review was performed on 5 patients with refractory malignant SIJ pain who underwent US-guided superior or inferior approach SIJ injection. Using imaging and outcomes, we developed a decision framework. Patients received either inferior or superior approach SIJ injections depending on location of tumor, extent of tumor invasion, and stability of the SIJ as per our framework. All patients reported improvement in pain and function without complications. We propose a decision framework for inferior vs. superior approach US-guided SIJ injections in the oncologic population with SIJ pain from metastases to the pelvis or sacrum. Having multiple techniques to approach the SIJ is important in the oncologic population, in whom metastatic tumor burden poses a technical challenge to performing these injections.

Rationale and design of the Children's Oncology Group (COG) study ALTE1621: a randomized, placebo-controlled trial to determine if low-dose carvedilol can prevent anthracycline-related left ventricular remodeling in childhood cancer survivors at high risk for developing heart failure.

BackgroundAnthracyclines are widely used in the treatment of childhood cancer. One of the well-recognized side-effects of anthracycline therapy is dose-dependent cardiomyopathy that may progress to heart failure (HF) years after completion of cancer-directed therapy. This study will evaluate the efficacy of low-dose beta-blocker (carvedilol) for HF risk reduction in childhood cancer survivors at highest risk for HF. The proposed intervention has the potential to significantly reduce chronic cardiac injury via interruption of neurohormonal systems responsible for left ventricular (LV) remodeling, resulting in improved cardiac function and decreased risk of HF. The intervention is informed by previous studies demonstrating efficacy in pediatric and adult non-oncology populations, yet remains unstudied in the pediatric oncology population.Methods/DesignThe primary objective of the trial is to determine impact of the intervention on echocardiographic markers of cardiac remodeling and HF risk, including: LV wall thickness/ dimension ratio (LVWT/D; primary endpoint), as well as LV ejection fraction, volume, and blood biomarkers (natriuretic peptides, galectin-3) associated with HF risk. Secondary objectives are to establish safety and tolerability of the 2-year course of carvedilol using: 1) objective measures: hepatic and cardiovascular toxicity, treatment adherence, and 2) subjective measures: participant self-reported outcomes. Two hundred and fifty survivors of childhood cancer (diagnosed <21 years of age), and previously treated with high-dose (≥300 mg/m2) anthracyclines will be enrolled in a randomized, double-blind, placebo controlled trial. After baseline assessments, participants will be randomized in a 1:1 ratio to low-dose carvedilol (maximum dose: 12.5 mg/day) or placebo. Carvedilol or placebo is up-titrated (starting dose: 3.125 mg/day) according to tolerability.DiscussionWhen completed, this study will provide much-needed information regarding a physiologically plausible pharmacological risk-reduction strategy for childhood cancer survivors at high risk for developing anthracycline-related HF.Trial registrationClinicalTrials.gov; NCT02717507

Screening and intervention for treatment-related cardiac dysfunction in childhood cancer survivors.

10.2217/FON.15.108 © 2015 Future Medicine Ltd During the past four decades, marked advances have been made in the treatment of childhood cancers, such that long-term survival is an expected outcome for many children diagnosed with cancer today [1]. However, improvements in outcome have come at a cost. It is estimated that nearly a third of all childhood cancer survivors will develop a severe or life-threatening health condition years after completion of cancerdirected therapy [2]; these include second cancers, endocrinopathies, neurosensory impairment and cardiovascular disease [2]. Outcomes following onset of cardiovascular disease are especially poor; 5-year overall survival is less than 50% [3], emphasizing the need to develop early screening and prevention strategies in survivors at highest risk of developing cardiovascular disease. Research on survivorship issues has revealed a clear association between certain therapeutic exposures such as anthracycline chemotherapy and/or mediastinal radiation and risk of cardiovascular complications such as heart failure [4]. In these survivors, there is often a long latency between initial exposure to cardiotoxic therapies and onset of clinically overt heart disease [4]. This period is characterized by the development of asymptomatic systolic and/or diastolic cardiomyopathy that can be detected using a variety of imaging modalities [4,5]. Radionuclide angiography (multigated acquisition scan and radionuclide ventriculography) was historically considered the gold standard for assessment of cardiac function [4,5]. However, exposure to ionizing radiation, along with a limited ability to detect structural abnormalities and early cardiac dysfunction, has limited its use in childhood cancer survivors [4,5]. 2D echocardiography offers a readily available assessment of both structure and function without exposure to radiation, and has therefore been widely used to follow childhood cancer survivors. [4,5] Frequently measured echocardiographic parameters of cardiac function include ejection fraction, shortening fraction, velocity of fiber shortening corrected for heart rate, stress–velocity index, left ventricular end-systolic wall stress and more subtle measures of diastolic function [4–6]. More recently, cardiac MRI has emerged as a sensitive and reproducible alternative to echocardiography in nononcology populations and cancer survivors [7,8]. However, despite its diagnostic advantages, higher cost and limited availability impede its use for routine screening. Consequently, current guidelines continue to recommend 2D echocardiography as the screening modality of choice for childhood cancer survivors [6]. COMMENTARY Special Focus Issue: Cardio-oncology

Clostridium difficile infection in hospitalized cancer patients.

e20707 Background: The incidence and severity of Clostridium difficileinfection (CDI) has significantly increased over the past decade. Although the epidemiology and treatment of CDI is well elucidated in the non-oncology population, it is poorly understood among cancer patients. CDI prevention is particularly important for patients with cancer, because diarrhea often results in dose reductions or delays of chemotherapy or radiotherapy. Methods: We performed a retrospective study to assess the incidence and severity of C. difficile infection among adult cancer patients admitted to the Oncology Service at “12 de Octubre” University Hospital, from January 2009 to March 2013. All inpatients with diarrhea underwent testing for the presence of C. difficile (enzyme immunoassay for toxins A and B). Chemotherapy administered, and antibiotics used before the development of CDI symptoms, was noted. Results: Of the 230 admitted patients during the 4-year study period, the overall incidence of CDI was 9.6% (N=22). Of these, 8 (36.4%) and 14 patients (63.6%) were deemed to have mild and moderate CDI, respectively. Patients with CDI (N=5, 22.7%) suffered more severe complications than patients with other enteric infections (N=2, 15.4%). There was a slight trend between previous use of antibiotics and CDI (P= 0.09), however we found no relationship between CDI and previous administration of corticosteroids or proton pump inhibitors. With regards to outcome of chemotherapy, patients with platinum-based therapy were more affected by CDI (N=19, 86.3%), and four of them died. Conclusions: Despite a potential decrease in the incidence of CDI in the last years, this infection still contributes substantially to morbidity and possibly mortality in this vulnerable patient population. There was no relationship between gastrointestinal cancer and CDI. Use of carboplatin chemotherapy was significantly associated with CDI, and CDI was more frequent in gynecologic cancer patients, as these patients are more frequently treated with this therapy. Our study supports the possibility of platinum-based chemotherapy as a risk factor for CDI although the reason for the effect is not clear.

Bone Health Care for Patients With Prostate Cancer Receiving Androgen Deprivation Therapy

Patients with prostate cancer often receive androgen deprivation therapy (ADT) as part of their treatment regimen. However, treatment with ADT causes multiple side effects, including reduced bone mineral density (BMD), lower lean body mass, and a higher risk for fractures. Several organizations provide clinical practice guidelines for osteoporosis screening, prevention, and treatment in this population, but adherence to these guidelines remains low. Areas for improvement in provider adherence include baseline and follow-up BMD testing, as well as counseling regarding healthy bone behaviors such as calcium/vitamin D intake, lifestyle changes, and physical exercise. Comparison of osteoporosis care in breast cancer and non-oncology populations shows that suboptimal bone health care is not isolated to prostate cancer. A summary of the literature examining improvements in patient adherence and provider delivery of bone health care is included in this review, but high-quality studies are lacking. Patients may be the most receptive to written educational information delivered at or near the time of ADT initiation. Involvement of a primary care practitioner and oncologist in care delivery is associated with higher BMD test use. Institution-level programs that automatically initiate osteoporosis screening and management may be effective at reducing the incidence of hip fracture. Lastly, suggestions are provided for future approaches to knowledge translation and quality of care studies to improve bone health.

A retrospective review of metronidazole and vancomycin in the management of Clostridium difficile infection in patients with hematologic malignancies

The incidence and severity of Clostridium difficile infection has significantly increased over the past decade. Although the epidemiology and treatment of C. difficile infection is well elucidated in the non-oncology population, it is poorly understood among cancer patients. This illustrates great concern as the majority of these patients are immunosuppressed, which puts them at higher risk for developing severe disease. Furthermore, suboptimal treatment of C. difficile infection can compromise care of underlying malignancy. Due to limited amount of data, we conducted this study to better ascertain the epidemiology and treatment outcomes of C. difficile infection in a subset of oncology patients at our institution. The primary objective was to assess the incidence and severity of C. difficile infection in patients with hematologic malignancies, including those undergoing hematopoietic stem cell transplant for a hematologic condition. The secondary objectives were to assess: (a) the outcome of C. difficile infection after therapy with metronidazole and/or vancomycin and (b) mortality following C. difficile infection. We performed a retrospective study to assess the incidence and severity of C. difficile infection and to evaluate outcomes of therapy with metronidazole and/or vancomycin among adult patients admitted to the Malignant Hematology/Blood and Marrow Transplantation service at our center from January 2009 to 2012. Of the 390 admitted patients during the 3-year study period, the overall incidence of C. difficile infection was 18.7% (n = 73). Forty-six patients (63.0%) were deemed to have mild-moderate C. difficile infection. With regards to outcome of therapy, less exposure to antimicrobial agents was significantly associated with a higher resolution rate (p = 0.0029). Response rates to metronidazole were 53.7%, vancomycin 50%, and combination therapy 38.5%, although no difference in achievement of resolution was found among the three treatment modalities (p = 0.5533). Older patients were more likely to experience recurrent C. difficile infection (p = 0.0007). It was found that 55 patients (75.3%) were alive at 6 months. These results highlight the high incidence of C. difficile infection in a subset of cancer patients at our institution. Although most patients presented with mild-moderate disease, severity of C. difficile infection in cancer patients may be underestimated due to the frequent presence of neutropenia. This study is the first analysis conducted, which directly compares outcomes of C. difficile infection after therapy with metronidazole, vancomycin, or combination therapy exclusively in patients with hematologic malignancies, including those undergoing hematopoietic stem cell transplant for a hematologic condition. We found no difference in treatment outcomes among metronidazole, vancomycin, or combination therapy. The recommendation from the literature to use metronidazole as the initial drug of choice for mild-moderate C. difficile infection is a reasonable option, although the rate of cure is low. This study highlights the critical need for better treatment options, due to suboptimal response rates to current therapy. Larger scale studies are needed to better understand the epidemiology and management of C. difficile infection in this patient population.

Neuromodulation of Cancer Pain

Managing cancer-related chronic pain is challenging to health care professionals as well as cancer patients and survivors. The management of cancer-related pain has largely consisted of pharmacological treatments, which has caused researchers to focus on neurotransmitter activity as a mediator of patients' perception of pain rather than the electrical activity during neurobiological processes of cancer-related pain. Consequently, brain-based pain treatment has focused mainly on neurotransmitters and not electrical neuromodulation. Neuroimaging research has revealed that brain activity is associated with patients' perceptions of symptoms across various diagnoses. The brain modulates internally generated neural activity and adjusts perceptions according to sensory input from the peripheral nervous system. Cancer-related pain may result not only from changes in the peripheral nervous system but also from changes in cortical activity over time. Thus, cortical reorganization by way of the brain's natural, plastic ability (neuroplasticity) may be used to manage pain symptoms. Physical and psychological distress could be modulated by giving patients tools to regulate neural activity in symptom-specific regions of interest. Initial research in nononcology populations suggests that encouraging neuroplasticity through a learning paradigm can be a useful technique to help treat chronic pain. Here we review evidence that indicates a measurable link between brain activity and patient-reported psychological and physical distress. We also summarize findings regarding both the neuroelectrical and neuroanatomical experience of symptoms, review research examining the mechanisms of the brain's ability to modify its own activity, and propose a brain-computer interface as a learning paradigm to augment neuroplasticity for pain management.

Implementation of the American Society of Clinical Oncology and Oncology Nursing Society Chemotherapy Safety Standards

Chemotherapy involves an intricate, high-risk, multidisciplinary process of prescribing, dispensing, and administering complex multimedication regimens with narrow therapeutic indices. Chemotherapeutic agents also require safe-handling precautions for patients and healthcare providers. In addition, a number of chemotherapy and targeted therapies have expanded to nononcology populations. This complexity demands standardization of chemotherapy practice for all healthcare providers to ensure safe outcomes. This article describes one organization's multidisciplinary effort to standardize chemotherapy practice according to the American Society of Clinical Oncology and Oncology Nursing Society's 31 safety standards for chemotherapy administration. The article also describes how the organization integrated and developed standards of practice using interdisciplinary approaches. The educational processes used during implementation and the lessons learned are discussed to assist healthcare providers involved in standardizing chemotherapy administration. The article equips healthcare professionals with a multidisciplinary process for high-quality clinical standards of practice that may reduce errors and ensure safety.