Risk of critical illness among patients with solid cancers: a population-based observational study of 118,541 adults

Importance: Critical illness may be a potential determinant of cancer outcomes and geographic variations, but its role has not been described before. Objective: To determine the incidence of admission to intensive care units (ICUs) within 2 years following cancer diagnosis. Design, Setting, and Participants: This was a retrospective observational study using cancer registry data in 4 datasets from 2000 to 2009 with linked ICU admission data from 2000 to 2011, in the West of Scotland region of the United Kingdom (population, 2.4 million; all 16 ICUs within the region). All 118 541 patients (≥16 years) diagnosed as having solid (nonhematological) cancers. Their median age was 69 years, and 52.0% were women. Main Outcomes and Measures: Demographic and clinical variables associated with admission to an ICU and death in an ICU. Results: A total of 118 541 patients met the study criteria. Overall, 6116 patients (5.2% [95% CI, 5.0%-5.3%]) developed a critical illness and were admitted to an ICU within 2 years. Risk of critical illness was highest at ages 60 to 69 years and higher in men. The cumulative incidence of critical illness was greatest for small intestinal (17.2% [95% CI, 13.3%-21.8%]) and colorectal cancers (16.5% [95% CI, 15.9%-17.1%]). The risk following breast cancer was low (0.8% [95% CI, 0.7%-1.0%]). The percentage who died in ICUs was 14.1% (95% CI, 13.3%-15.0%), and during the hospital stay, 24.6% (95% CI, 23.5%-25.7%). Mortality was greatest among emergency medical admissions and lowest among elective surgical patients. The risk of critical illness did not vary by socioeconomic circumstances, but mortality was higher among patients from deprived areas. Conclusions and Relevance: In this study, about 1 in 20 patients experienced a critical illness resulting in ICU admission within 2 years of cancer diagnosis. The associated high mortality rate may make a significant contribution to overall cancer outcomes

The utility of scoring systems in critically ill cirrhotic patients admitted to a general intensive care unit

Purpose: This study aimed to establish which prognostic scoring tool provides the greatest discriminative ability when assessing critically ill cirrhotic patients in a general intensive care unit (ICU) setting.<p></p> Methods: This was a 12-month, single-centered prospective cohort study performed in a general, nontransplant ICU. Forty clinical and demographic variables were collected on admission to calculate 8 prospective scoring tools. Patients were followed up to obtain ICU and inhospital mortality. Receiver operating characteristic curve analysis was used to determine the discriminative ability of the scores. Univariate and multivariate analyses were used to identify any independent predictors of mortality in these patients. The incorporation of any significant variables into the scoring tools was assessed.<p></p> Results: Fifty-nine cirrhotic patients were admitted over the study period, with an ICU mortality of 31%. All scores other than the renal-specific Acute Kidney Injury Network score had similar discriminative abilities, producing area under the curves of between 0.70 and 0.76. None reached the clinically applicable level of 0.8. The Sequential Organ Failure Assessment score was the best performing score. Lactate and ascites were individual predictors of ICU mortality with statistically significant odds ratios of 1.69 and 5.91, respectively. When lactate was incorporated into the Child-Pugh score, its prognostic accuracy increased to a clinically applicable level (area under the curve, 0.86).<p></p> Conclusions: This investigation suggests that established prognostic scoring systems should be used with caution when applied to the general, nontransplant ICU as compared to specialist centers. Our data suggest that serum arterial lactate may improve the prognostic ability of these scores

The utility of trans thoracic echocardiograhic measures of right ventricular systolic function in a lung resection cohort

Right ventricular (RV) dysfunction occurs following lung resection and is associated with post-operative complications and long-term functional morbidity. Accurate peri-operative assessment of RV function would have utility in this population. The difficulties of transthoracic echocardiographic (TTE) assessment of RV function may be compounded following lung resection surgery, and no parameters have been validated in this patient group. This study compares conventional TTE methods for assessing RV systolic function to a reference method in a lung resection population. Right ventricular index of myocardial performance (RIMP), fractional area change (FAC), tricuspid annular plane systolic excursion (TAPSE) and S′ wave velocity at the tricuspid annulus (S′), along with speckle tracked global and free wall longitudinal strain (RV-GPLS and RV-FWPLS respectively) are compared with RV ejection fraction obtained by cardiovascular magnetic resonance (RVEFCMR). Twenty-seven patients undergoing lung resection underwent contemporaneous CMR and TTE imaging; pre-operatively, on post-operative day two and at 2 months. Ability of each of the parameters to predict RV dysfunction (RVEFCMR <45%) was assessed using the area under the receiver operating characteristic curve (AUROCC). RIMP, FAC and S′ demonstrated no predictive value for poor RV function (AUROCC <0.61, P > 0.05). TAPSE performed marginally better with an AUROCC of 0.65 (P = 0.04). RV-GPLS and RV-FWPLS demonstrated good predictive ability with AUROCC’s of 0.74 and 0.76 respectively (P < 0.01 for both). This study demonstrates that the conventional TTE parameters of RV systolic function are inadequate following lung resection. Longitudinal strain performs better and offers some ability to determine poor RV function in this challenging population

Characteristics and outcomes of surgical patients with solid cancers admitted to the intensive care unit

Within the surgical population admitted to intensive care units (ICUs), cancer is a common condition. However, clinicians can be reluctant to admit patients with cancer to ICUs owing to concerns about survival. To compare the clinical characteristics and outcomes of surgical patients with and without cancer who are admitted to ICUs. An observational retrospective cohort study using ICU audit records linked to hospitalization discharge summaries, cancer registrations, and death records of all 16 general adult ICUs in the West of Scotland was conducted. All 25 017 surgical ICU admissions between January 1, 2000, and December 31, 2011, were included, and data analysis was conducted during that time. Patients were dichotomized based on a diagnosis of a solid malignant tumor as determined by its documentation in the Scottish Cancer Registry within the 2 years prior to ICU admission. Intensive care unit patients with cancer were compared with ICU patients without cancer in terms of patient characteristics (age, sex, severity of illness, reason for admission, and organ support) and survival (ICU, hospital, 6 months, and 4 years). Within the 25 017 surgical ICU patients, 13 684 (54.7%) were male, the median (interquartile range [IQR]) age was 64 (50-74), and 5462 (21.8%) had an underlying solid tumor diagnosis. Patients with cancer were older (median [IQR] age, 68 [60-76] vs 62 [45-74] years; P < .001) with a higher proportion of elective hospitalizations (60.5% vs 19.8%; P < .001), similar Acute Physiology and Chronic Health Evaluation II scores (median for both, 17), but lower use of multiorgan support (57.9% vs 66.7%; P < .001). Intensive care unit and hospital mortality were lower for the cancer group, at 12.2% (95% CI, 11.3%-13.1%) vs 16.8% (95% CI, 16.3%-17.4%) (P < .001) and 22.9% (95% CI, 21.8%-24.1%) vs 28.1% (27.4%-28.7%) (P < .001). Patients with cancer had an adjusted odds ratio for hospital mortality of 1.09 (95% CI, 1.00-1.19). By 6 months, mortality in the cancer group was higher than that in the noncancer group at 31.3% compared with 28.2% (P < .001). Four years after ICU admission, mortality for those with and without cancer was 60.9% vs 39.7% (P < .001) respectively. Cancer is a common diagnosis among surgical ICU patients and this study suggests that initial outcomes compare favorably with those of ICU patients with other conditions. Consideration that a diagnosis of cancer should not preclude admission to the ICU in patients with surgical disease is suggested

The feasibility of nurse-delivered, low-intensity cognitive behavioural therapy for irritable bowel syndrome.

Introduction: This study assessed the feasibility of nurse-delivered cognitive behavioural therapy (CBT) for the treatment of irritable bowel syndrome (IBS). Methods and analysis: A mixed-method design was used, and 20 participants were randomly allocated to high-intensity CBT (n=5), guided self-help (n=5), self-help only (n=5) or treatment as usual (n=5). Ten intervention participants completed semi-structured interviews. Quantitative data were analysed using descriptive statistics; qualitative data were analysed using group thematic analysis. Results: Barriers to the interventions were lack of therapist contact, negative preconceptions about treatment and factors relating to supporting materials. Treatment facilitators included therapist-facilitated relaxation, narratives located within self-help materials and social support mechanisms. Conclusion: Further development of the low-intensity interventions in collaboration with service users is required to improve intervention acceptability and relevance.N/

B-type natriuretic peptide predicts deterioration in functional capacity following lung resection

OBJECTIVES Following lung resection, there is a decrease in the functional capacity and quality of life, which is not fully explained by changes in pulmonary function. Previous work demonstrates that B-type natriuretic peptide (BNP) is associated with short- and long-term complications following lung resection, leading to the suggestion that cardiac dysfunction may contribute to functional deterioration. Our aim was to investigate any relationship between BNP and subjective and objective indices of functional deterioration following lung resection surgery. METHODS Twenty-seven patients undergoing lung resection had serum BNP measured preoperatively, on postoperative day (POD)1 and POD2, and at 2 months postoperatively. The functional deterioration was assessed using 6-min walk tests and the Medical Research Council dyspnoea scale. ‘Deterioration in functional capacity’ was defined as either an increase in the Medical Research Council dyspnoea score or a significant decrease in the 6-min walk test distance. RESULTS BNP increased over time (P < 0.01) and was significantly elevated on POD1 and POD2 (P < 0.02 for both). Seventeen patients demonstrated functional deterioration 2 months postoperatively. At all perioperative time points, BNP was significantly higher in patients showing deterioration (P < 0.05 for all). Preoperative BNP was predictive of functional deterioration at 2 months with an area under the receiver-operating characteristic curve of 0.82 (P = 0.01, 95% confidence interval 0.65–0.99). CONCLUSIONS This study has demonstrated, using subjective and objective measures, that preoperative BNP is a predictor of functional deterioration following lung resection. BNP may have a role in preoperative risk stratification in this population, allowing therapy in future to be targeted towards high-risk patients with the aim of preventing postoperative cardiac dysfunction. Clinical trial registration number: NCT01892800

Reflective practice in speech-language pathology: relevance for practice and education = La pratique réflexive en orthophonie : pertinence pour la pratique et l’enseignement

As a profession, speech-language pathology appears to have become interested in reflection and reflective practice as important components of clinical practice and education. However, little systematic consideration of the potential value of reflective practice within the field has been undertaken. The purpose of this paper seeks to consider how reflective practice is relevant to contemporary speech-language pathology practice. Drawing on comprehensive and diverse theoretical literature, we suggest that reflective practice is a framework worthy of consideration because of its potential to: (1) foster the generation of knowledge from practice, (2) balance and contextualize science with patient care, (3) facilitate the integration of theory and practice, (4) link evidence-based practice with clinical expertise, and finally, (5) contribute to the cultivation of ethical practice. © 2016, Canadian Association of Speech-Language Pathologists and Audiologists. All Rights Reserved

The right ventricular response to lung resection

Objectives: Lung cancer is a leading cause of cancer death and in suitable cases the best chance of cure is offered by surgery. Lung resection is associated with significant postoperative cardiorespiratory morbidity, with dyspnea and reduced functional capacity as dominant features. These changes are poorly associated with deterioration in pulmonary function and a potential role of right ventricular (RV) dysfunction has been hypothesized. Cardiovascular magnetic resonance imaging is a reference method for noninvasive assessment of RV function and has not previously been applied to this population. Methods: We used cardiovascular magnetic resonance imaging to assess the RV response to lung resection. Cardiovascular magnetic resonance imaging with volume and flow analysis was performed on 27 patients preoperatively, on postoperative day 2 and at 2 months. Left ventricular ejection fraction and RV ejection fraction, the ratio of stroke volume to end systolic volume, pulmonary artery acceleration time, and distensibility of main and branch pulmonary arteries were studied. Results: Mean ± standard deviation RV ejection fraction deteriorated from 50.5% ± 6.9% preoperatively to 45.6% ± 4.5% on postoperative day 2 and remained depressed at 44.9% ± 7.7% by 2 months (P = .003). The ratio of stroke volume to end systolic volume deteriorated from median 1.0 (quartile 1, quartile 3, 0.9, 1.2) preoperatively to median 0.8 (quartile 1, quartile 3, 0.7, 1.0) on postoperative day 2 (P = .011). On postoperative day 2 there was a decrease in pulmonary artery acceleration time and operative pulmonary artery distensibility (P < .030 for both). There were no changes in left ventricular ejection fraction during the study period (P = .621). Conclusions: These findings suggest RV dysfunction occurs following lung resection and persists 2 months after surgery. The deterioration in the ratio of stroke volume to end systolic volume suggests a mismatch between afterload and contractility. There is an increase in indices of pulsatile afterload resulting from the operative pulmonary artery

Effect of soy protein isolate on the functional, pasting, and sensory acceptability of cassava starch-based custard

Open Access JournalFortification of custard powder (CP) with protein from cheap sources such as soybean could potentially improve its nutritive value but may alter its functional and sensory properties. This study was therefore conducted to determine the effect of soy protein isolate (SPI) inclusion (0%–20%) on some functional and sensory properties of cassava starch-based CP. Functional, pasting, and sensory acceptability were determined using standard methods. Increase in soy protein isolate significantly (p < .05) decreased dispersibility, packed bulk density, swelling power, peak, trough, breakdown, final, and setback viscosities, but increased least gelation concentration, water absorption capacity, and solubility index. This study further showed that despite increasing addition of SPI up to 20%, sensory acceptability of the cassava starch-based CP formulations did not differ significantly, and most of them had very similar acceptability when compared to that of corn starch-based CP