Current transfusion practices and survival rates of MT patients vary widely among trauma centers. Conventional MT guidelines may underestimate the optimal plasma and platelet to RBC ratios. Survival in civilian MT patients is associated with increased plasma and platelet ratios. Massive transfusion practice guidelines should aim for a 1:1:1 ratio of plasma:platelets:RBCs.

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Background Limited data is available on how the timing and setting of palliative care referral can affect end-of-life care. In this retrospective cohort study, we examined how the timing and setting of palliative care (PC) referral were associated with the quality of end-of-life care. Methods All adult patients residing in the Houston area who died of advanced cancer between 9/1/2009 and 2/28/2010 and had a PC consultation were included. We retrieved data on PC referral and quality of end-of-life care indicators. Results Among 366 decedents, 120 (33%) had early PC referral (>3 months before death) and 169 (46%) were first seen as outpatients. Earlier PC referral was associated with fewer emergency room visits (39% vs. 68%, P<0.001), hospitalizations (48% vs. 81%, P<0.003), and hospital deaths (17% vs. 31%, P=0.004) in the last 30 days of life. Similarly, outpatient PC referral was associated with fewer emergency room visits (48% vs. 68%, P<0.001), hospital admissions (52% vs. 86%, P<0.001), hospital deaths (18% vs. 34%, P=0.001) and intensive care unit admissions (4% vs. 14%, P=0.001). In multivariate analysis, outpatient PC referral (odds ratio [OR]=0.42, 95% confidence interval [CI] 0.28-0.66; P<0.001) was independently associated with less aggressive end-of-life care. Male sex (OR=1.63, 95%CI 1.06-2.50; P=0.03) and hematologic malignancy (OR=2.57, 95%CI 1.18-5.59; P=0.02) were associated with more aggressive end-of-life care. Conclusion Patients referred to outpatient PC had improved end-of-life care compared to inpatient PC. Our findings support the need to increase the availability of PC clinics and to streamline the process of early referral.

Background Limited data is available on the quality of end-of-life care for patients with hematologic malignancies. In this retrospective cohort study, we compared the quality of end-of-life care between patients with hematologic malignancies and those with solid tumors. Methods All adult patients who died of advanced cancer between 9/1/2009 and 2/28/2010 while under the care of our institution were included. We collected baseline demographics and end-of-life care indicators, including emergency room visits, hospitalization, intensive care unit admissions, and systemic cancer therapy use within the last 30 days of life. Results 113/816 (14%) decedents had hematologic malignancies. In the last 30 days of life, hematologic patients were more likely to have emergency room visits (54% vs. 43%, P=0.03), hospital admissions (81% vs. 47%, P<0.001), >=2 admissions (23% vs. 10%, P<0.001), >14 days of hospitalization (38% vs. 8%, P<0.001), intensive care unit admissions (39% vs. 8%, P<0.001) and death (33% vs. 4%, P<0.001), chemotherapy use (43% vs. 14%, P<0.001), and targeted therapy use (34% vs. 11%, P<0.001) compared to patients with solid tumors. Patients with hematologic malignancies were also less likely to have palliative care unit admissions (8% vs. 17%, P=0.02). The composite score for aggressiveness of care (0=best, 6=worst) was significantly higher among patients with hematologic malignancies than those with solid tumors (median 2 vs. 0, P<0.001). In multivariate analysis, hematologic malignancy was a significant factor associated with aggressive end-of-life care (odds ratio 6.6, 95% confidence interval 4.1–10.7, P<0.001). Conclusions Patients with hematologic malignancies received more aggressive care at the end-of-life.

To assess the joint relationships among body mass index, menopausal status, and breast cancer according to breast cancer subtype and estrogen-progestin medication use, we conducted a meta-analysis of 89 epidemiologic reports published in English during 1980-2012 identified through a systematic search of bibliographic databases. Pooled analysis yielded a summary risk ratio of 0.78 (95% confidence interval (CI): 0.67, 0.92) for hormone receptor-positive premenopausal breast cancer associated with obesity (body mass index (weight (kg)/height (m)(2)) ≥30 compared with <25). Obesity was associated with a summary risk ratio of 1.39 (95% CI: 1.14, 1.70) for receptor-positive postmenopausal breast cancer. For receptor-negative breast cancer, the summary risk ratios of 1.06 (95% CI: 0.70, 1.60) and 0.98 (95% CI: 0.78, 1.22) associated with obesity were null for both premenopausal and postmenopausal women, respectively. Elevated postmenopausal breast cancer risk ratios associated with obesity were limited to women who never took estrogen-progestin therapy, with risk ratios of 1.42 (95% CI: 1.30, 1.55) among never users and 1.18 (95% CI: 0.98, 1.42) among users; too few studies were available to examine this relationship according to receptor subtype. Future research is needed to confirm whether obesity is unrelated to receptor-negative breast cancer in populations of postmenopausal women with low prevalence of hormone medication use.

Background Controversy persists about optimal mammography screening strategies. Objective To evaluate mammography strategies considering screening and treatment advances. Design Collaboration of six simulation models. Data Sources National data on incidence, risk, breast density, digital mammography performance, treatment effects, and other-cause mortality. Target Population An average-risk cohort. Time Horizon Lifetime. Perspective Societal. Interventions Mammograms from age 40, 45 or 50 to 74 at annual or biennial intervals, or annually from 40 or 45 to 49 then biennially to 74, assuming 100% screening and treatment adherence. Outcome Measures Screening benefits (vs. no screening) include percent breast cancer mortality reduction, deaths averted, and life-years gained. Harms include number of mammograms, false-positives, benign biopsies, and overdiagnosis. Results for Average-Risk Women Biennial strategies maintain 79.8%-81.3% (range across strategies and models: 68.3–98.9%) of annual screening benefits with almost half the false-positives and fewer overdiagnoses. Screening biennially from ages 50–74 achieves a median 25.8% (range: 24.1%-31.8%) breast cancer mortality reduction; annual screening from ages 40–74 years reduces mortality an additional 12.0% (range: 5.7%-17.2%) vs. no screening, but yields 1988 more false-positives and 7 more overdiagnoses per 1000 women screened. Annual screening from ages 50–74 had similar benefits as other strategies but more harms, so would not be recommended. Sub-population Results Annual screening starting at age 40 for women who have a two- to four-fold increase in risk has a similar balance of harms and benefits as biennial screening of average-risk women from 50–74. Limitations We do not consider other imaging technologies, polygenic risk, or non-adherence. Conclusion These results suggest that biennial screening is efficient for average-risk groups, but decisions on strategies depend on the weight given to the balance of harms and benefits. Primary Funding Source National Institutes of Health

Background Attrition is common among supportive/palliative oncology clinical trials. Few studies have documented the reasons and predictors for dropout. We aimed to determine the rate, reasons and factors associated with attrition both before reaching the primary endpoint and the end of study. Methods We conducted a review of all prospective interventional supportive/palliative oncology trials in the Department of Palliative Care and Rehabilitation Medicine at MD Anderson Cancer Center between 1999–2011. Patient and study characteristics and attrition data were extracted. Results 1214 patients were included in 18 clinical trials. The median age was 60, 41% had performance status ≥3, median fatigue 7/10 and median dyspnea 2/10. The attrition rate was 26% (95% confidence interval [CI] 23%-28%) for the primary endpoint and 44% (95% CI 41%-47%) for the end of study. Common reasons for primary endpoint dropout were symptom burden (21%), patient preference (15%), hospitalization (10%) and death (6%). Primary endpoint attrition was associated with higher baseline intensity of fatigue (odds ratio [OR]=1.10 per point, P=0.01) and longer study duration (P=0.04). End of study attrition was associated with higher baseline levels of dyspnea (OR=1.06, P=0.01), fatigue (OR=1.08, P=0.01), Hispanic race (OR=1.87, P=0.002), higher education (P=0.02), longer study duration (P=0.01) and outpatient studies (P=0.05). Conclusions The attrition rate was high in supportive/palliative oncology clinical trials, and was associated with various patient characteristics and high baseline symptom burden. These findings have implications for future clinical trial design including eligibility criteria and sample size calculation.

Background. The physical signs of impending death have not been well characterized in cancer patients. A better understanding of these signs may improve the ability of clinicians to diagnose impending death. We examined the frequency and onset of 10 bedside physical signs and their diagnostic performance for impending death. Methods. We systematically documented 10 physical signs every 12 hours from admission to death or discharge in 357 consecutive patients with advanced cancer admitted to two acute palliative care units. We examined the frequency and median onset of each sign from death backward and calculated their likelihood ratios (LRs) associated with death within 3 days. Results. In total, 203 of 357 patients (52 of 151 in the U.S., 151 of 206 in Brazil) died. Decreased level of consciousness, Palliative Performance Scale #20%, and dysphagia of liquids appeared at high frequency and .3 days before death and had