“Improving the Management of Pain in Hospitalized Adults” by R. Sean Morrison, MD, Diane E. Meier, MD, Daniel Fischberg, MD, and others.
Pain management can be improved through better documentation of pain followed by the prescribing of appropriate analgesics, this study reports. Use of an enhanced pain scale significantly increased the prescribing of World Health Organization Step 2 or 3 analgesics for patients with moderate or severe pain compared with a one-item scale. The increased prescription of analgesics did not reduce pain severity, however.
In this controlled study, pain documentation improved over 80% with the combined use of an enhanced pain-assessment instrument and either audit or feedback or a computerized support system. The enhanced pain assessment included more comprehensive information that was used to guide the prescription of analgesia more effectively.
The simpler assessment tool asked patients to rate their pain on a four-point scale. The enhanced tool asked for an assessment of current pain and worst pain as well as assessment of pain relief, and whether the level of pain was acceptable. The enhanced tool also used a four-point scale.
Patients in hospital units that used the enhanced pain scale were more likely to have their pain assessed than patients in units using the simpler scale. Similar findings emerged for patients using audit and feedback of pain results compared with units without these features.
Units in which a clinical decision support system was added had increased pain assessment compared with units without audit and feedback, but not compared with units that had audit and feedback.
Use of the enhanced pain scale and a clinical decision support system increased the number of patients who received at least one pain assessment a day to 79.3% from the 32.1% use with the standard pain assessment. Units using audit and feedback improved the percentage of patients assessed to 80%.
The findings came from assessing more than 3,900 adults from nine medical/surgical units with similar baseline patient demographics and pain scores in a large teaching hospital.
Arch Intern Med 2006;166:1033–1039.
“Impact of Sentinel Node Status and Other Risk Factors on the Clinical Outcome of Head and Neck Melanoma Patients” by Stanley P. L. Leong, MD, Neil A. Accortt, PhD, Richard Essner, MD, and others.
Recurrence and/or overall survival in patients with melanoma of the head and neck are affected by sentinel node status and several other factors, this multicenter study reports. Pooled data from the San Francisco-based Sentinel Lymph Node Working Group showed that tumor site was predictive of recurrence. Tumor site and thickness emerged as significantly predictive of overall survival.
Sentinel lymph node status was found to be the strongest independent predictor of mortality by univariate analysis, but not by multivariate analysis. Instead, tumor site, particularly the scalp, was significantly associated with mortality. Tumors from the scalp were associated with a more than three-fold greater mortality compared with tumors on the face. The multivariate analysis also showed tumor thickness to be an independent predictor of overall survival.
At a median follow-up of 3.3 years, the overall mortality from head and neck melanoma was 10%, and the rate for developing at least one recurrence was 20%. The authors said this indicates that mortality will probably rise with longer follow-up.
Sentinel lymph node status was the most robust predictor of disease-free survival in the multivariate model. Positive sentinel lymph node status correlated with significantly thicker tumors, which were more likely to have tumor ulceration—a significant predictor of time to recurrence or disease-free survival.
The results of this study are consistent with those of other studies, and the authors said they hope such information—when combined with further classification of subtypes by molecular signatures—will help target adjuvant therapy and spare patients with a more favorable prognosis from exposure to regimens with toxicities.
Arch Otolaryngol Head Neck Surg 2006;132:370–373
“Smoking Affects Treatment Outcome in Patients with Advanced Non-Small-Cell Lung Cancer” by Anne S. Tsao, MD, Dian Kiu, J. Jack Lee, PhD, and others.
In this retrospective review, patients with non-small-cell lung cancer (NSCLC) who had never smoked had an improved outcome compared with NSCLC patients who were smokers when treated with chemotherapy. Smoking status appeared to have no prognostic effect on treatment response or overall survival rates in NSCLC patients who received chemoradiation, which was surprising to the authors.
This retrospective review was based on patients' medical records from January 1993 to December 2002 at the University of Texas M. D. Anderson Cancer Center. Of the 873 patients who received chemotherapy, the response rates were 19% for never smokers, 8% for former smokers, and 12% for current smokers.
The median survival times were 1.37, 0.86, and 0.83 years, respectively. The overall survival rates at one year were 62.6% for never smokers, 41.8% for former smokers, and 42.7% for current smokers.
Continuing to smoke did not correlate with adverse outcomes for patients with advanced disease, but the value of a smoking-cessation program for patients with early-stage disease who can achieve curative outcomes remains clear, the authors state. The lack of adverse effects of continued smoking seen in this study contrasts with previous retrospective reviews.
The results of this study also differed from previous studies by not showing adverse effects of continued smoking in NSCLC patients who received chemoradiation. In the current study, the patients who did worse were those who quit smoking just before the initiation of chemoradiation.
The authors attribute this finding to patients becoming too ill to continue smoking; better survival rates were seen in patients who quit smoking from more than two weeks to less than one year prior to treatment compared with patients who continued to smoke during therapy.
“Mesoblastic Nephroma—A Report from the Gesellschaft fur Pädiatrische Onkologie und Hämatologie (GPOH)” by Rhoikos Furtwaengler, MD, Harald Reinhard, MD, Ivo Leuschner, MD, and others.
This study confirms that radical nephrectomy with accurate surgical-pathological staging should be the standard of care for children with mesoblastic nephroma, the most frequently occurring solid kidney tumor in newborns. However, patients with Stage III mesoblastic nephroma who are three months of age or older are more likely to develop recurrences and therefore may benefit from adjuvant treatment.
In this retrospective evaluation of outcomes from two databases, the entire group (45 patients) had excellent results at a median follow-up of 4.2 years: overall survival was 95%, and event-free survival was 94%.
Classic mesoblastic nephroma was found in 29 tumors and cellular mesoblastic nephroma in 21. Of the nine patients with Stage III mesoblastic nephroma, five had tumor ruptures and eight had positive surgical margins. Following nephrectomy, five patients received further treatment.
Two of the three patients who developed recurrent disease died. All three were at least three months old. Although no significant differences in overall survival emerged in any of the groups, the patients who died both had cellular mesoblastic nephroma and were at least six months old.
Mesoblastic nephroma occurred approximately twice as frequently in males as in females. Cellular mesoblastic nephroma was associated with significantly larger tumors and older patients than classic mesoblastic nephroma. In contrast to previous studies, fewer patients had the cellular form in this study (42% vs 63%).
Based on their results, the authors said they believe that adjuvant treatment constitutes overtreatment of patients with Stage III and classic subtypes of mesoblastic nephroma. They suggest that these patients be spared exposure to probably inefficient chemotherapy and bemonitored for a longer time.
Adjuvant therapy is recommended in the subgroup of patients with three risk factors: cellular mesoblastic nephroma, local Stage III disease, and being at least three months old at diagnosis.
“Medical Academia is Failing Patients and Clinicians by Neglecting Basic Observational Clinical Research” by Peter M. Rothwell.
Basic observational research has the potential to improve clinical outcomes, yet represents a neglected area of clinical research, the author of this editorial warns. From his point of view, the current makeup and funding of academia in Britain is a barrier to addressing the most important issues to patients and clinicians.
The author, Peter M. Rothwell, Professor of Clinical Neurology at Radcliffe Infirmary in Oxford, UK, believes the failure to emphasize research that would elucidate basic diagnosis and prognosis is endemic. He draws examples from neurology, his own specialty, to support his claim that many patients have been hurt by incorrect diagnoses and delayed or inappropriate treatment.
Citing transient ischemic attacks (TIA), Professor Rothwell claims that little is known concerning the reliability of its clinical diagnosis, and almost nothing at all about the prognosis of several TIA-like presentations.
Clinicians who treat these presentations as TIA may expose their patients to potentially dangerous interventions, like carotid surgery. On the other hand, clinicians who fail to diagnose TIA correctly may miss an important opportunity to prevent stroke.
The author cites several possible causes that may have contributed to the problem, including not enough practicing physicians in decision-making roles in academia, underestimation of the need by non-clinical or non-practicing researchers, and lack of appreciation for the immediate improvements such research can bring.
Prof. Rothwell said he believes it is imperative that medical academia improve its quantity and quality of basic observational research. If change doesn't come from within academia, politicians may force academia to prioritize appropriately, he states.
“Examining the Need for Neck Dissection in the Era of Chemoradiation Therapy for Advanced Head and Neck Cancer” by Laura A. Goguen, MD, Marshall R. Posner, MD, Roy B. Tischler, MD, and others.
Based on this review of cases at Dana-Farber Cancer Institute, neck dissection is not recommended for patients with Stage III or IV N2 head and neck cancer who have a complete clinical response after sequential chemoradiotherapy.
There was no improvement in survival if patients with N2 disease were assessed as having a complete clinical response based on physical examination, imaging studies, and positron emission tomography. These combined clinical evaluations provide accurate prediction of no residual neck disease on neck dissection.
Patients with N3 disease, however, are at high risk for residual neck metastasis following sequential chemoradiotherapy.
No benefit in overall survival and progression-free survival was found in patients with N2 disease who attained a complete clinical response who had neck dissection compared with patients assessed to have less than a complete clinical response. Pathologic complete response was confirmed by neck dissection in patients with a complete clinical response.
Patient with initial N3 disease had the greatest risk for residual neck disease after sequential chemoradiotherapy. Neck dissection revealed that almost half of these patients had residual positive neck disease.
The findings emerged from a review of 52 patients (40 with N2 disease and 12 with N3 disease). Complete clinical response was seen in 20 patients and was determined by all available clinical data after sequential chemoradiotherapy. Based on these findings, the authors believe that neck dissection is not required for patients with N2 disease.
Arch Otolaryngol Head Neck Surg 2006;132:526–531.