This study represents the most recent estimate to date of the prevalence of hospital palliative care in the United States. There is wide geographic variation in access to palliative care services although factors predicting hospital palliative care have not changed since 2005. Overall, medical students have high rates of access to hospital palliative care although complete penetration into academic settings has not occurred. The association between hospital palliative care penetration and lower Medicare costs is intriguing and deserving of further study.
The prevalence of Prolonged Grief Disorder (PGD) in non-Whites is currently unknown. This study was performed to explore the prevalence of PGD in African Americans (AAs). Multivariable analysis of two studies of recently bereaved individuals found AAs to have significantly higher rates of PGD than Whites (21% [14 of 66] vs. 12% [55 of 471], respectively; p = 0.03). Experiencing a loved one's death as sudden or unexpected was also significantly associated with PGD over and above the effects of race/ethnicity. AAs may be at increased risk for the development of PGD. The development of effective interventions to treat PGD highlights the need to identify high-risk individuals and refer them to therapy and suggests the potential need for such therapies to adopt culturally sensitive approaches to care.
A 48-year-old man presented in 1999 with a mass on his right thumb. Biopsy revealed aggressive digital papillary adenoma. He underwent partial amputation; pathology revealed a 1.5-cm aggressive digital papillary adenocarcinoma (ADPCa) with widely negative margins. The final pathology was described previously by Jih et al. 1 There was no evidence of metastatic disease on cross-sectional imaging at the time. The patient was followed with routine physical examination and cross-sectional imaging for 5 years without evidence of recurrence or spread.The patient was treated for pneumonia in late 2009. A follow-up computed tomography scan in early 2010 showed a subcentimeter mass in the lingula for which 6-month follow-up was recommended. In June 2010, the patient presented with substernal chest pain and was treated for non-ST elevation myocardial infarction with a bare metal stent in the proximal right circumflex artery. A postprocedure chest x-ray in June 2010 revealed a left lower lobe lung nodule. Subsequent computed tomography imaging of the chest, abdomen, and pelvis revealed a 2.5-cm mass at the left lung base, a 3-cm lingular mass abutting the chest wall, multiple liver hypodensities, a lytic lesion in the left pubic ramus, and several subcutaneous nodules, the largest in the left chest wall measuring 2 cm. There was also stranding with enhancement of the left gluteus and adductor musculature. Magnetic resonance imaging of the brain demonstrated no intracranial pathology. A subcentimeter mass was noted along the right thenar eminence at the base of the right thumb, the site of initial diagnosis. Three biopsies were performed in the following areas: the left chest wall and underlying lingular mass, the left gluteus maximus muscle, and the right thenar eminence. All revealed ADPCa that was consistent with the primary lesion, now presenting as metastatic disease 11 years after initial treatment.The patient reported difficulty walking because of pain in his left buttock that extended into his left thigh. He also reported pain in the right hand that extended from the area of initial amputation of the right thumb to the mass at the base of the first finger. There was exquisite point tenderness in the anterolateral sole of each foot; each was associated with a subcentimeter nodule. These lesions (left buttock, right hand, and bilateral feet) grew rapidly over the course of 2 weeks. The patient had a decreased appetite and lost 20 pounds over 3 months.The patient did not have any medical history of immune deficiency. Medications at the time of referral included aspirin, atorvastatin, clopidogrel, lisinopril, metoprolol, extended-release morphine (15 mg every 8 hours), and hydromorphone (2 mg every 3 hours) as e386
Purpose-Complex radiotherapy (RT) planning is increasingly common in the treatment of lung cancer though it remains unclear if these treatments are associated with better outcomes. We evaluated the association between the complexity of RT planning simulation with survival among elderly Stage IIIB non-small cell lung cancer (NSCLC) patients.Methods-We included all patients aged >65 years with histologically confirmed Stage IIIB NSCLC diagnosed between 1992 and 2002 receiving chemotherapy and RT from the Surveillance, Epidemiology, and End Results registry linked to Medicare claims. Patients were divided into simple, intermediate, and complex RT planning groups using Medicare physician codes. KaplanMeier curves and Cox regression were used to compare overall and lung cancer-specific survival rates across groups.Results-We identified 1,733 patients: 148 (8%), 1,138 (66%), and 447 (26%) were classified as having received simple, intermediate and complex RT planning, respectively. Baseline characteristics were similar across groups. Increasing complexity of RT planning was significantly associated with better overall survival (p=0.0002). Multivariate analyses showed that intermediate (HR: 0.75, 95% CI: 0.62 to 0.91) and complex planning (HR: 0.69, 95% CI: 0.55 to 0.86) were associated with better overall survival compared to simple RT planning. Similar results were observed for lung cancer-specific survival analyses. Toxicities were comparable across groups.Conclusions-The use of more complex RT planning and simulation methods is associated with better survival in elderly patients with Stage IIIB NSCLC. Although these results should be further validated in prospective clinical trials, this data suggests that complex planning may improve the outcomes of these patients.
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