Music as an aid for postoperative recovery in adults: a systematic review and meta-analysis

Hole J (2015) The Lancet (Link to abstract)                                            

This study is a systematic review of RCTs looking at the use of music in the intraoperative and postoperative period to reduce post-operative pain. The authors ended up with 72 studies that had a control group (white noise, headphones, regular noise, and some others) with varying degrees of quality. Overall the use of music decreased pain, decreased analgesia use, and decreased anxiety regardless of the procedure, whether GA was used or not and whether or not the patient was allowed to choose the music. Limitations include heterogeneity of the quality of included studies and possible publication bias based on the funnel plot.

* Likely we can think of music as another form of distraction. We know that distraction is important in controlling children’s’ pain and perhaps this is another form of distraction that we can use. It hasn’t been as well evaluated in children but given the minimal risk profile there is no reason not to use music for patients who request it. 

Risk of Subsequent Neoplasms During the Fifth and Sixth Decades of Life in the Childhood Cancer Study Cohort

Turcotte L (2015), Journal of Clinical Oncology (Link to abstract)

This is a paper from the Childhood Cancer Survivorship Study, which is a retrospective cohort with ongoing longitudinal observation.  This report focuses on 14,364 survivors diagnosed between 1970 and 1986 who were 40 years or older at last contact.  It reports the cumulative incidence of new subsequent neoplasms occurring after the age of 40 as 34.6 % with survivors being twice as likely as the general population to receive a diagnosis of subsequent malignant neoplasm after this age.  Survivors were at particular risk for breast, renal, thyroid and soft tissue sarcomas.  Female sex and therapeutic radiation were identified as risk factors.

* Make sure our survivors are aware that their increased risk of second cancer is truly lifelong.  Think strategically about screening options. 

Prescription Opioids in Adolescence and Future Opioid Misuse

Miech R (2015), Pediatrics (Link to abstract)                                                            

This is a prospective study investigating the impact of medically prescribed opioids on the risk that adolescents and young adults will misuse opioids in the future. The study found that there was a threefold increase in the rate of misuse in the group of participants who were judged to be at lowest initial risk of opioid misuse (as designated by previous experiences with illegal substances and attitudes toward drug use), and a 33% increase in risk of misuse overall. Interestingly, no independent increase in the risk was identified in the groups stratified to be at higher risk of opioid misuse initially. Recommendations from this study include using non-opioid pain control measures prior to opioids in an effort to minimize their use, and to carefully counsel adolescents who receive opioids around the risks of opioid misuse and abuse.

* Contrary to common teaching, there is actually an increased risk of future opioid misuse in young adults who are appropriately prescribed opioids prior to the end of high school.

Genome-Wide Identification and Characterization of Novel Factors Conferring Resistance to Topoisomerase II Poisons in Cancer

Wijdeven R, 2015, Cancer Research (Link to abstract)

The authors created a panel of knockout haploid cells using CRISPR and tested them systematically to identify gene products related to resistance to topoisomerase II inhibitors. They confirmed that ABCB1 confers resistance and identified 4 new genes that when knocked out lead to resistance to topoisomerase II inhibitors: C9orf82, SMARCB1, SMARCE1, and Keap1. All of these genes are related to repair of double stranded DNA breaks. For the most part, these deletions do not make cells resistant to topo I inhibitors.

*Given the major toxicities of doxorubicin and etoposide it would be useful to select patients whose tumors will be resistant to these agents. This panel identifies the genes that could help us make thischoice. We will now have to investigate these in animal and human studies.

Complications of Central Venous Access Devices: A Systematic Review

Ullman AJ (2015), Pediatrics (Link to abstract)                                            

This study is a systematic review looking at the proportion and rate of central venous access device (CVAD) failure and complications in pediatrics across CVAD types. It was found that 25% of all CVADs fail or have significant complications (i.e. become a source of infection or be obstructed from clots). PICCs had a high rate of failure and complications, approximately equal to umbilical catheters in neonates, while, as expected, totally implanted devices were found to have the lowest rates. Many of the causes of the failures were found to be preventable, as quality improvement initiatives in various studies did show improvement in the CVAD survival and function. This study advocates for the careful use of CVADs, which aren’t without their risks, and continued quality improvement initiatives to decrease the rates of failure and complications.

* Central venous access devices, including PICCs and ports, have significant rates of failure and complications, many of which are due to preventable factors.

Sensitivity of the Automated Auditory Brainstem Response in Neonatal Hearing Screening

Levit et al, 2015 Pediatrics                                          

Link to abstract:

This article investigated the sensitivity of the auditory brainstem response (ABR) test to identify hearing loss. A cohort of infants who failed the initial screening otoacoustic emissions test (TEOAE), or were admitted to the NICU for more than 5 days, were referred for further testing with the ABR. 24% of the infants who passed the ABR were later diagnosed with hearing loss, which represented more than 50% infants in the cohort who were diagnosed with hearing loss.

*This study highlights the need for regular auditory testing and need for continued improvement of the sensitivity of the ABR.

Journal of Clinical Oncology Special Series Issue on collaborative efforts in childhood cancers and survivorship

September 2015 Journal of Clinical Oncology                                                     

Link to abstract:

The Journal of Clinical Oncology September 20, 2015 is a MUST read.  This special edition details the collaborative efforts that have contributed to the advances in survival for childhood cancers:

  • Childhood Acute Lymphoblastic Leukemia: Progress Through Collaboration
  • Collaborative Efforts Driving Progress in Pediatric Acute Myeloid Leukemia
  • Non-Hodgkin Lymphoma in Children and Adolescents: Progress Through Effective Collaboration, Current Knowledge, and Challenges Ahead
  • Pediatric Hodgkin Lymphoma
  • Pediatric Brain Tumors: Innovative Genomic Information Is Transforming the Diagnostic and Clinical Landscape
  • Advances in Wilms Tumor Treatment and Biology: Progress Through International Collaboration
  • Advances in Risk Classification and Treatment Strategies for Neuroblastoma
  • Pediatric and Adolescent Extracranial Germ Cell Tumors: The Road to Collaboration
  • Osteosarcoma: Current Treatment and a Collaborative Pathway to Success
  • Ewing Sarcoma: Current Management and Future Approaches Through Collaboration
  • Rare Tumors in Children: Progress Through Collaboration
  • Collaborative Research in Childhood Cancer Survivorship: The Current Landscape
  • Toward the Cure of All Children With Cancer Through Collaborative Efforts: Pediatric Oncology As a Global Challenge

Cardiometabolic Risks and Severity of Obesity in Children & Young Adults

Skinner et al (2015) New England Journal of Medicine

Link to abstract:

This is a cross-sectional analysis of data from a US population based study - the National Health and Nutrition Examination Survey between 1999 and 2012.  They looked at the relationship between obesity and a number of cardiometabolic risk factors. 8579 children and young adults in this survey were overweight or obese. Within this group, the more obese, the higher the risks of negative cardiometabolic risk factors like high BP, negative cholesterol and lipid profiles.

*This is a general population study – not specific to childhood cancer survivors.

Alignment of Do-Not-Resuscitate Status With Patients’ Likelihood of Favorable Neurological Survival After In-Hospital Cardiac Arrest

Fendler et al (2015) Journal of the American Medical Association (JAMA)                                                               

Link to abstract:

This study involved 26327 adult patients who had recovery of circulation after in-hospital cardiac arrests at 406 US hospitals between April 2006 and September 2012. The authors used a validated prognostic tool to calculate each patient’s likelihood of survival without severe neurological disability. They looked at the association between good neurological survival and having a post-arrest Do-Not-Resuscitate (DNR) order written.

22.6% [95% CI, 22.1%-23.1%] of the patients had a DNR order written within 12 hours of return of circulation.  These were older and sicker patients, and were more likely to have a worse neurological prognosis. However, even amongst the patients with the poorest prognosis (less than a 10% chance of a favorable neurological survival) only 1/3 had a DNR order, reasons were not assessed.

*Interestingly, patients with a good prognosis who somehow ended up with a DNR, ended up using lower levels of resources and had worse outcomes in the long term than those with a good prognosis who didn’t get a DNR.

The utility of computed tomography in the management of fever and neutropenia in pediatric oncology

Rao et al, 2015 Pediatric Blood and Cancer                                                         

Link to abstract:

Retrospective cohort study including oncology patients admitted with F&N from 2003-2009, ≤21 years. Median duration of admission was 5 days (range 0-79), 22% of patients had a CT scan (139 scans in 93 individuals).  21% of those who had a scan had multiple scans during the admission.  68% of scans included chest, 69% included abdomen, 41% included head, & 55% pan-scans (>1 body part).

Risk factors for having a scan: older age (≥7 years), longer admission (≥7 days), positive culture from non-blood source, findings on CXR, additional disease burden (“sicker” patients, not well defined) or symptoms in addition to F&N at presentation. 

Pan-scans more likely in younger patients (<7 years), pts with hematologic malignancy, history of fungal infection, +ve blood cultures or +ve viral PCR, pts without additional symptoms beyond F&N. 

66% of scans identified possible source of infection – sinusitis (27%), pulmonary infiltrate (27%), possible fungal lesions (17%).  Factors associated with finding infection: African American  race, hypotension, chest CT alone, head CT alone or included in pan-scan, scan done ≥7 days after admission. 

*In 41%, CT led to a change in management, most often change in antibiotic (53%) or antiviral/antifungal (42%).  Pan-scans seemed not more effective, abdominal scan were good at ruling out infection but not good to identify infection (i.e. usually not helpful). 

Intestinal Obstruction in Survivors of Childhood Cancer: A Report From the Childhood Cancer Survivor Study

Madenci A et al, 2015 Journal of Clinical Oncology                                                           

Link to abstract:

This report from the Childhood Cancer Survivorship (retrospective cohort) study looked at the cumulative incidence of intestinal obstruction requiring surgery occurring 5 or more years from cancer diagnosis in 12,316 5-year survivors (2,002 with and 10,314 without abdominopelvic tumors) and compared this to 4,023 sibling participants.  They found the cumulative incidence to be 5.8% among survivors with abdomino-pelvic tumors, 1.0% among those without abdomino-pelvic tumors, and 0.3% among siblings. They also found that developing late intestinal obstruction increased subsequent mortality among survivors.

*Take home message: we need to promote awareness of this complication among patients in our long term follow up service, particularly those with abdomino-pelvic tumors.