Is there scope to discontinue non-essential medication in patients with advanced lung cancer?

Focal Points 1. Patients with advanced lung cancer take many ‘non-essential’ medicines 2. A simple audit tool could be used to identify ‘non-essential’ medicines that could be discontinued 3. Pharmacists have a potential role in identifying and reviewing ‘non-essential’ medicines Background Lung cancer patients can present with complex medical histories often taking medications to manage existing conditions and prevent future morbidity e.g. antihypertensives and antiplatelets. Guidelines for discontinuing these medications in life-limiting illnesses, such as advanced lung cancer, have not been produced despite the potential to reduce burden, in terms of cost and, more importantly, discomfort to the patient.1 The objectives of this work was to audit the number of medications in patients taking erlotinib for the treatment of advanced lung cancer; and, develop a draft tool that can be used to identify non-essential medications which could, potentially, be discontinued. Methods This clinical audit was undertaken at an acute NHS Trust in April 2011. A clinical audit tool was used to extract data from medical notes of patients receiving erlotinib for non-small cell lung cancer (NSCLC) and compared to a set of criteria to establish if the medicine is essential, non-essential or uncertain. These criteria were based on a study that defined unnecessary medication as where there is no anticipated short-term benefit to patients with respect to survival, quality of life or symptom control.2 All patients who had received erlotinib in the Trust for the treatment of NSCLC within 18 months were selected for the audit. A consensus group (consultant pharmacist, lung nurse specialist and consultant oncologist) reviewed results and considered which medications they would have stopped. Results Of the 20 patients audited, 19 were taking at least one medication that could have been discontinued. The mean number of medications taken was 8 (range 1–16). Seventeen patients were taking essential medications (e.g. analgesics) necessary for symptom control in cancer. Non-essential medicines were regarded as those which provided no short term benefit to the patients with respect to survival, quality of life or symptom control or any medicine which had potential to cause harm. The focus group concurred that the majority of non-essential medications identified by the criteria could have been discontinued. Medications classified as uncertain were taken by 7 patients. These medications need to be further reviewed. Discussion For patients undergoing treatment for terminal lung cancer the issue of discontinuing medications is not an immediate priority. However, at some point in their treatment pathway a discussion regarding their medications should be instigated. The focus group revealed that timing of this discussion is crucial. The futile use of medication in terminally ill cancer patients has been reported in the literature and this work is in agreement with this by showing that patients with NSCLC taking erlotinib are taking unnecessary medications.2 Patients take medications such as statins and antihypertensives with the belief that they will be taking them for the rest of their lives, therefore if an appropriate explanation for discontinuation is not given the patients and/or their families may misconceive this as a death-hastening intervention. This work also showed that a significant number of patients who are taking erlotinib also take a proton pump inhibitor (PPI) despite the fact there is a clinically significant drug interaction between erlotinib and PPIs where the absorption of erlotinib is reduced.3 In conclusion, patients taking erlotinib for the treatment of advanced NSCLC take many unnecessary medications and written guidelines on what can be withdrawn are needed. There is the potential for pharmacists to become involved in the review of patients with terminal cancer to facilitate discontinuing potentially unnecessary medicines

Dispersion Features of Conducting Sheath Helix Embedded Elliptical and Circular Fibers with Chiral Nihility Core

Discussions have been made of the electromagnetic wave propagation through optical fibers of elliptical and circular cross-sections with the loadings of conducting sheath helix at the core-clad interface with particular orientations. In both geometrical situations, the core section of fiber is assumed to be composed of chiral nihility medium, and the clad remains linear, homogeneous, isotropic, and nonmagnetic dielectric. Dispersion relations are deduced for both fiber structures, followed by the analysis of dispersion features considering a few low-order EH modes. Furthermore, the effects of conducting helix pitch angle on the features of wave propagation are also discussed

Waves in Microstructured Conducting Sheath Helix Embedded Optical Guides with Chiral Nihility and Chiral Materials

The paper deals with the sustainment of electromagnetic waves in circularly cylindrical optical guide with chiral nihility and chiral materials in the core and the clad sections, respectively. A perfectly conducting tightly wound helix is introduced at the core-clad interface. The eigenvalue relation for such a complex optical microstructured guide is deduced by applying suitable boundary conditions at the core-clad interface, and the dispersion behavior is analyzed by varying the pitch angle of helix. The sustainment of energy flux density in such optical guides is estimated under various structural conditions, and the density patterns in core-clad sections are anatomized analytically

Substituted organotin complexes of 4-methoxybenzoic acid for reduction of poly(vinyl chloride) photodegradation

Poly(vinyl chloride) suffers from degradation through oxidation and decomposition when exposed to radiation and high temperatures. Stabilizers are added to polymeric materials to inhibit their degradation and enable their use for a longer duration in harsh environments. The design of new additives to stabilize poly(vinyl chloride) is therefore desirable. The current study includes the synthesis of new tin complexes of 4-methoxybenzoic acid and investigates their potential as photostabilizers for poly(vinyl chloride). The reaction of 4-methoxybenzoic acid and substituted tin chlorides gave the corresponding substituted tin complexes in good yields. The structures of the complexes were confirmed using analytical and spectroscopic methods. Poly(vinyl chloride) was doped with a small quantity (0.5%) of the tin complexes and homogenous thin films were made. The effects of the additives on the stability of the polymeric material on irradiation with ultraviolet light were assessed using different methods. Weight loss, production of small polymeric fragments, and drops in molecular weight were lower in the presence of the additives. The surface of poly(vinyl chloride), after irradiation, showed less damage in the films containing additives. The additives, in particular those containing aromatic (phenyl groups) substitutes, inhibited the photodegradation of polymeric films significantly. Such additives act as efficient ultraviolet absorbers, peroxide quenchers, and hydrogen chloride scavengers

Modeling of single mode optical fiber having a complicated refractive index profile by using modified scalar finite element method

A numerical method based on modified scalar finite element method (SC-FEM) is presented and programmed on MATLAB platform for optical fiber modeling purpose. We have estimated the dispersion graph, mode cut off condition, and group delay and waveguide dispersion for highly complicated chirped type refractive index profile fiber. The convergence study of our FEM formulation is carried out with respect to the number of division in core. It has been found that the numerical error becomes less than 2 % when the number of divisions in the core is more then 30. To predict the accurate waveguide dispersion characteristics, we need to compute expression (d^2 (Vb))/(dV^2 ) numerically by the FEM method. For that the normalized propagation constant b (in terms of β) should be an accurate enough up to around 6 decimal points. To achieve this target, we have used 1 million sampling points in our FEM simulations. Further to validate our results we have derived the higher order polynomial expression for each case. Comparison with other methods in calculation of normalized propagation constant is found to be satisfactory. In traditional FEM analysis a spurious solution is generated because the functional does not satisfy the boundary conditions in the original waveguide problem, However in our analysis a new term that compensate the missing boundary condition has been added in the functional to eliminate the spurious solutions. Our study will be useful for the analysis of optical fiber having varying refractive index profile

Supporting shared decision making for older people with multiple health and social care needs: a realist synthesis

Background: Health care systems are increasingly moving towards more integrated approaches. Shared decision making (SDM) is central to these models but may be complicated by the need to negotiate and communicate decisions between multiple providers, as well as patients and their family carers; particularly for older people with complex needs. The aim of this review was to provide a context relevant understanding of how interventions to facilitate SDM might work for older people with multiple health and care needs, and how they might be applied in integrated care models. Methods: Iterative, stakeholder driven, realist synthesis following RAMESES publication standards. It involved: 1) scoping literature and stakeholder interviews (n-13) to develop initial programme theory/ies, 2) systematic searches for evidence to test and develop the theories, and 3) validation of programme theory/ies with stakeholders (n=11). We searched PubMed, The Cochrane Library, Scopus, Google, Google Scholar, and undertook lateral searches. All types of evidence were included. Results: We included 88 papers; 29 focused on older people or people with complex needs. We identified four context-mechanism-outcome configurations that together provide an account of what needs to be in place for SDM to work for older people with complex needs. This includes: understanding and assessing patient and carer values and capacity to access and use care, organising systems to support and prioritise SDM, supporting and preparing patients and family carers to engage in SDM and a person-centred culture of which SDM is a part. Programmes likely to be successful in promoting SDM are those that allow older people to feel that they are respected and understood, and that engender confidence to engage in SDM. Conclusions: To embed SDM in practice requires a radical shift from a biomedical focus to a more person-centred ethos. Service providers will need support to change their professional behaviour and to better organise and deliver services. Face to face interactions, permission and space to discuss options, and continuity of patient-professional relationships are key in supporting older people with complex needs to engage in SDM. Future research needs to focus on inter-professional approaches to SDM and how families and carers are involved