Publications by authors named "Suresh Reddy"

86 Publications

Economics of Biofuel Production: A Case of Sorghum and Pearl Millet in India.

Methods Mol Biol 2021 ;2290:287-316

Division for Sustainable Development Studies (DSDS), Centre for Economic and Social Studies(CESS), Hyderabad, Telangana, India.

Reduction of fossil fuels at an alarming rate has attracted increasing attention to blending biofuels worldwide. India's energy demand is expected to grow at an annual rate of 4-5 times over the next couple of decades. With self-sufficiency levels in crude oil becoming a distant dream, there is growing interest to look out for alternative fuels and the biofuels are an important option for policy makers in India. In this context, this paper reviews the experiences in India in the last two decades with respect to biofuel cultivation and its impact on land use, environment, and the livelihoods of rural communities. The objective of this paper is to assess the economics of biofuel production using Sorghum and Pearl millet feedstocks in India using a Life Cycle Analysis (LCA) approach. Baseline study was conducted during the year 2013 in the Madhya Pradesh state of India covering five districts and 333 sample farmers to understand the farmers perception about the various issues related to the production of biofuels using Indian staple food crops Sorghum and Pearl millet. Empirical data from the multi-locational trials conducted during the years 2014-2015 and 2015-2016 in farmers' fields was used to conduct the LCA analysis. Sorghum and Pearl millet feedstocks which are rain-fed crops are considered for bioethanol production with different pretreatment methods. Net Energy Ratio (NER), Net Energy Balance (NEB), Net Carbon Balance (NCB), and % Carbon reduction were some of the key parameters used for analysis and the results are evaluated based on the environmental impacts through the Life Cycle Assessment at 5% blending. Findings reveal that, dilute alkali pretreatment process is most energy intensive due to consumption of alkali consumption. Whereas dilute acid pretreatment has higher conversion efficiency than the other pretreatment processes which is due to higher glucan and xylan conversion efficiencies.The study concludes that Sorghum feedstock is more energy intensive than Pearl millet feedstock due to higher water requirement and yield. Biofuels, either conventional or advanced, should not been couraged without a comprehensive outlook on the overall impact that will ultimately have on the society, environment, or on the countries' energy security. Efforts should be made toward encouragement of research and development in the field as well as in formulating a comprehensive and effective biofuel policy for India.
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http://dx.doi.org/10.1007/978-1-0716-1323-8_19DOI Listing
June 2021

Frequency of and Factors Associated With Nonmedical Opioid Use Behavior Among Patients With Cancer Receiving Opioids for Cancer Pain.

JAMA Oncol 2021 Mar;7(3):404-411

Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston.

Importance: One of the main aims of research on nonmedical opioid use (NMOU) is to reduce the frequency of NMOU behaviors through interventions such as universal screening, reduced opioid exposure, and more intense follow-up of patients with elevated risk. The absence of data on the frequency of NMOU behavior is the major barrier to conducting research on NMOU.

Objective: To determine the overall frequency of and the independent predictors for NMOU behavior.

Design, Setting, And Participants: In this prognostic study, 3615 patients with cancer were referred to the supportive care center at MD Anderson Cancer Center from March 18, 2016, to June 6, 2018. Patients were eligible for inclusion if they had cancer and were taking opioids for cancer pain for at least 1 week. Patients were excluded if they had no follow-up within 3 months of initial consultation, did not complete the appropriate questionnaire, or did not have scheduled opioid treatments. After exclusion, a total of 1554 consecutive patients were assessed for NMOU behavior using established diagnostic criteria. All patients were assessed using the Edmonton Symptom Assessment Scale, the Screener and Opioid Assessment for Patients with Pain (SOAPP), and the Cut Down, Annoyed, Guilty, Eye Opener-Adapted to Include Drugs (CAGE-AID) survey. Data were analyzed from January 6 to September 25, 2020.

Results: A total of 1554 patients (median [interquartile range (IQR)] age, 61 [IQR, 52-69] years; 816 women [52.5%]; 1124 White patients [72.3%]) were evaluable for the study, and 299 patients (19.2%) had 1 or more NMOU behaviors. The median (IQR) number of NMOU behaviors per patient was 1 (IQR, 1-3). A total of 576 of 745 NMOU behaviors (77%) occurred by the first 2 follow-up visits. The most frequent NMOU behavior was unscheduled clinic visits for inappropriate refills (218 of 745 [29%]). Eighty-eight of 299 patients (29.4%) scored 7 or higher on SOAPP, and 48 (16.6%) scored at least 2 out of 4 points on the CAGE-AID survey. Results from the multivariate model suggest that marital status (single, hazard ratio [HR], 1.58; 95% CI, 1.15-2.18; P = .005; divorced, HR, 1.43; 95% CI, 1.01-2.03; P = .04), SOAPP score (positive vs negative, HR, 1.35; 95% CI, 1.04-1.74; P = .02), morphine equivalent daily dose (MEDD) (HR, 1.003; 95% CI, 1.002-1.004; P < .001), and Edmonton Symptom Assessment Scale pain level (HR, 1.11; 95% CI, 1.06-1.16; P < .001) were independently associated with the presence of NMOU behavior. In recursive partition analysis, single marital status, MEDD greater than 50 mg, and SOAPP scores greater than 7 were associated with a higher risk (56%) for the presence of NMOU behavior.

Conclusions And Relevance: This prognostic study of patients with cancer taking opioids for cancer pain found that 19% of patients developed NMOU behavior within a median duration of 8 weeks after initial supportive care clinic consultation. Marital status (single or divorced), SOAPP score greater than 7, higher levels of pain severity, and MEDD level were independently associated with NMOU behavior. This information will assist clinicians and investigators designing clinical and research programs in this important field.
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http://dx.doi.org/10.1001/jamaoncol.2020.6789DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7791402PMC
March 2021

Photo-Electrochemical Water Splitting Behavior of Directionally Aligned CdSe Quantum Dots on Copper(II) Benzene-1,3,5-Tricarboxylate Metal-Organic Frameworks (MOFs).

J Nanosci Nanotechnol 2021 Mar;21(3):1623-1635

Electroplating and Metal Finishing Division, CSIR-Central Electrochemical Research Institute, Karaikudi 630003, Tamilnadu, India.

Herein, a facile synthesis protocol for the development of directional alignment of CdSe quantum dots (QDs) on the surface of Copper benzene-1, 3, 5-tricarboxylate (CuBTC) metal-organic frameworks (MOFs) was proposed. The sensitization of CdSe QDs with MOFs offered enhancement of light-harvesting properties in the visible region of the solar spectrum due to the broad absorption band of CdSe QDs. As a photo-anode, it has generated current density of ˜20 mA/cm² at 1.70 V (vs. Reversible hydrogen electrode (RHE)) during the photo-electrochemical water splitting in 1 M Na₂S electrolyte. The present investigation demonstrates the directional attachment of CdSe QDs on CuBTC is beneficial in facilitating light-harvesting and photo-electrochemical properties of CuBTC MOFs.
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http://dx.doi.org/10.1166/jnn.2021.19030DOI Listing
March 2021

The Utility of Using Preoperative MRI as a Predictor for Intraoperative Pituitary Adenoma Consistency and Surgical Resection Technique.

J Neurol Surg B Skull Base 2020 Dec 2;81(6):651-658. Epub 2019 Aug 2.

Loyola University Chicago Stritch School of Medicine, Maywood, Illinois, United States.

 Most pituitary adenomas are of soft consistency and can be resected during surgery with routine suction instruments. However, fibrous adenomas may require more aggressive techniques. The ability to predict consistency on magnetic resonance imaging (MRI) would improve preoperative preparation and may have implications on the extent of resection.  A retrospective review of MRI and tumor histology of 50 consecutive patients who underwent endoscopic endonasal resection for nonfunctional adenomas was performed.  An intensity ratio was calculated based on quantitative MRI signal intensity of the adenoma and pons. Intraoperatively, a sequentially graded technique required for resection ranged from suction (R1) for softer tumors, curettes (R2) for tumors with intermediate consistency, and aspirators and/or other microinstruments (R3) for firmer tumors. Fibrotic content was determined from histologic collagen percentage, and rates of gross total resection (GTR) were calculated from postoperative imaging. Statistical analyses were performed to determine if resection classification could be predicted by intensity ratio or collagen percentage, calculate ratio of cut-off points for clinical use, and assess for correlation between intensity ratios and collagen percentage.  Tumors with ratios < 1.6 on the T2-weighted coronal image and collagen content > 5.3% were likely to have required a more aggressive resection technique. Statistically significant lower rates of GTR and higher rates of perioperative complications were seen with such tumors.  Preoperative MRI analyses can be helpful but not definitive in predicting adenoma consistency. Fibrous adenomas, associated with higher collagen content, are more difficult to resect and have higher rates of subtotal resection.
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http://dx.doi.org/10.1055/s-0039-1694049DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7755513PMC
December 2020

Morphology, Activation, and Metal Substitution Effects of AlPO-5 for CO Pressure Swing Adsorption.

Front Chem 2020 6;8:568669. Epub 2020 Oct 6.

Department of Chemical Engineering, Khalifa University, Abu Dhabi, United Arab Emirates.

Aluminophosphate, AlPO-5, an AFI zeotype framework consisting of one-dimensional parallel micropores, and metal-substituted AlPO-5 were prepared and studied for CO adsorption. Preparation of AlPO-5 by using different activation methods (calcination and pyrolysis), incorporation of different metals/ions (Fe, Mg, Co, and Si) into the framework using various concentrations, and manipulation of the reaction mixture dilution rate and resulting crystal morphology were examined in relation to the CO adsorption performance. Among the various metal-substituted analogs, FeAPO-5 was found to exhibit the highest CO capacity at all pressures tested (up to 4 bar). Among the Fe-substituted samples, xFeAPO-5, with x being the Fe/AlO molar ratio in the synthesis mixture (range of 2.5:100-10:100), 5FeAPO-5 exhibited the highest capacity (1.8 mmol/g at 4 bar, 25°C) with an isosteric heat of adsorption of 23 kJ/mol for 0.08-0.36 mmol/g of CO loading. This sample also contained the minimum portion of extra-framework or clustered iron and the highest mesoporosity. Low water content in the synthesis gel led to the formation of spherical agglomerates of small 2D-like crystallites that exhibited higher adsorption capacity compared to columnar-like crystals produced by employing more dilute mixtures. CO adsorption kinetics was found to follow a pseudo-first-order model. The robust nature of AlPO-5-based adsorbents, their unique one-dimensional pore configuration, fast kinetics, and low heat of adsorption make them promising for pressure swing adsorption of CO at industrial scale.
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http://dx.doi.org/10.3389/fchem.2020.568669DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7573157PMC
October 2020

Finding common ground in Kashmir.

Lancet 2020 09;396(10255):e51

The American Association of Physicians of Indian Origin, Oak Brook, IL 60523, USA.

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http://dx.doi.org/10.1016/S0140-6736(19)32561-9DOI Listing
September 2020

The development of a nomogram to determine the frequency of elevated risk for non-medical opioid use in cancer patients.

Palliat Support Care 2021 02;19(1):3-10

Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.

Objective: Non-medical opioid use (NMOU) is a growing crisis. Cancer patients at elevated risk of NMOU (+risk) are frequently underdiagnosed. The aim of this paper was to develop a nomogram to predict the probability of +risk among cancer patients receiving outpatient supportive care consultation at a comprehensive cancer center.

Method: 3,588 consecutive patients referred to a supportive care clinic were reviewed. All patients had a diagnosis of cancer and were on opioids for pain. All patients were assessed using the Edmonton Symptom Assessment Scale (ESAS), Screener and Opioid Assessment for Patients with Pain (SOAPP-14), and CAGE-AID (Cut Down-Annoyed-Guilty-Eye Opener) questionnaires. "+risk" was defined as an SOAPP-14 score of ≥7. A nomogram was devised based on the risk factors determined by the multivariate logistic regression model to estimate the probability of +risk.

Results: 731/3,588 consults were +risk. +risk was significantly associated with gender, race, marital status, smoking status, depression, anxiety, financial distress, MEDD (morphine equivalent daily dose), and CAGE-AID score. The C-index was 0.8. A nomogram was developed and can be accessed at https://is.gd/soappnomogram. For example, for a male Hispanic patient, married, never smoked, with ESAS scores for depression = 3, anxiety = 3, financial distress = 7, a CAGE score of 0, and an MEDD score of 20, the total score is 9 + 9+0 + 0+6 + 10 + 23 + 0+1 = 58. A nomogram score of 58 indicates the probability of +risk of 0.1.

Significance Of Results: We established a practical nomogram to assess the +risk. The application of a nomogram based on routinely collected clinical data can help clinicians establish patients with +risk and positively impact care planning.
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http://dx.doi.org/10.1017/S1478951520000322DOI Listing
February 2021

Metal Organic Framework - Based Mixed Matrix Membranes for Carbon Dioxide Separation: Recent Advances and Future Directions.

Front Chem 2020 3;8:534. Epub 2020 Jul 3.

Department of Chemical Engineering, Khalifa University, Abu Dhabi, United Arab Emirates.

Gas separation and purification using polymeric membranes is a promising technology that constitutes an energy-efficient and eco-friendly process for large scale integration. However, pristine polymeric membranes typically suffer from the trade-off between permeability and selectivity represented by the Robeson's upper bound. Mixed matrix membranes (MMMs) synthesized by the addition of porous nano-fillers into polymer matrices, can enable a simultaneous increase in selectivity and permeability. Among the various porous fillers, metal-organic frameworks (MOFs) are recognized in recent days as a promising filler material for the fabrication of MMMs. In this article, we review representative examples of MMMs prepared by dispersion of MOFs into polymer matrices or by deposition on the surface of polymeric membranes. Addition of MOFs into other continuous phases, such as ionic liquids, are also included. CO separation from hydrocarbons, H, N, and the like is emphasized. Hybrid fillers based on composites of MOFs with other nanomaterials, e.g., of MOF/GO, MOF/CNTs, and functionalized MOFs, are also presented and discussed. Synergetic effects and the result of interactions between filler/matrix and filler/filler are reviewed, and the impact of filler and matrix types and compositions, filler loading, surface area, porosity, pore sizes, and surface functionalities on tuning permeability are discoursed. Finally, selectivity, thermal, chemical, and mechanical stability of the resulting MMMs are analyzed. The review concludes with a perspective of up-scaling of such systems for CO separation, including an overview of the most promising MMM systems.
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http://dx.doi.org/10.3389/fchem.2020.00534DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7350925PMC
July 2020

Frequency of Burnout Among Palliative Care Physicians Participating in a Continuing Medical Education Course.

J Pain Symptom Manage 2020 07 25;60(1):80-86.e2. Epub 2020 Feb 25.

Department of Palliative, Integrative and Rehabilitation Medicine, The University of Texas, MD Anderson Cancer Center, Houston, Texas, USA.

Context: Palliative care (PC) physicians are vulnerable for burnout given the nature of practice. The burnout frequency may be variable and reported between 24% and 38% across different countries.

Objective: The main objective of our study was to determine the frequency of burnout among PC physicians participating in PC continuing medical education course.

Methods: A survey including the Maslach Burnout Inventory-General along with 41 custom questions were administered to determine the frequency of burnout among physicians attending the 2018 Hospice and Palliative Medicine Board review course.

Results: Of 110 physicians, 91 (83%) completed the survey. The median age was 48 years with 65% being females, 81% married, 46% in community practice, 38% in practice for 6-15 years. PC was practiced ≥50% of the time by 62%, and 76% were doing clinical work. About 73 (80%) reported that PC is appreciated at their work, 58 (64%) reported insurance to be a burden, and 58 (64%) reported that the electronic medical record was a burden. About 82 (90%) felt optimistic about continuing PC in future. Maslach Burnout Inventory results suggest that 35 (38%) participants reported at least one symptom of burnout. Only being single/separated showed trend toward significance with burnout (P = 0.056).

Conclusion: Burnout among PC physicians who attended a board review course was 38%. Being single/separated showed trend toward association with burnout. Physicians who choose to attend continuing medical education may have unique motivating characteristics allowing them to better cope with stress and avoid burnout.
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http://dx.doi.org/10.1016/j.jpainsymman.2020.02.013DOI Listing
July 2020

Chronic Non-Malignant Pain in Patients with Cancer Seen at a Timely Outpatient Palliative Care Clinic.

Cancers (Basel) 2020 Jan 15;12(1). Epub 2020 Jan 15.

Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA.

Palliative care is seeing cancer patients earlier in the disease trajectory with a multitude of chronic issues. Chronic non-malignant pain (CNMP) in cancer patients is under-studied. In this prospective study, we examined the prevalence and management of CNMP in cancer patients seen at our supportive care clinic for consultation. We systematically characterized each pain type with the Brief Pain Inventory (BPI) and documented current treatments. The attending physician made the pain diagnoses according to the International Association for the Study of Pain (IASP) task force classification. Among 200 patients (mean age 60 years, 69% metastatic disease, 1-year survival of 77%), the median number of pain diagnosis was 2 (IQR 1-2); 67 (34%, 95% CI 28-41%) had a diagnosis of CNMP; 133 (67%) had cancer-related pain; and 52 (26%) had treatment-related pain. In total, 12/31 (39%) patients with only CNMP and 21/36 (58%) patients with CNMP and other pain diagnoses were on opioids. There was a total of 94 CNMP diagnoses among 67 patients, including 37 (39%) osteoarthritis and 20 (21%) lower back pain; 30 (32%) were treated with opioids. In summary, CNMP was common in the timely palliative care setting and many patients were on opioids. Our findings highlight the need to develop clinical guidelines for CNMP in cancer patients to standardize its management.
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http://dx.doi.org/10.3390/cancers12010214DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7016539PMC
January 2020

Extension for Community Healthcare Outcomes-Palliative Care in Africa Program: Improving Access to Quality Palliative Care.

J Glob Oncol 2019 07;5:1-8

University of Texas MD Anderson Cancer Center, Houston, TX.

Purpose: There is limited access to quality palliative care (PC) for patients with advanced cancer in sub-Saharan Africa. Our aim was to describe the development of the Project Extension for Community Healthcare Outcomes-Palliative Care in Africa (ECHO-PACA) program and describe a preliminary evaluation of attitudes and knowledge of participants regarding the ability of the program to deliver quality PC.

Methods: An interdisciplinary team at the MD Anderson Cancer Center, guided by experts in PC in sub-Saharan Africa, adapted a standardized curriculum based on PC needs in the region. Participants were then recruited, and monthly telementoring sessions were held for 16 months. The monthly telementoring sessions consisted of case presentations, discussions, and didactic lectures. Program participants came from 14 clinics and teaching hospitals in Ghana, Kenya, Nigeria, South Africa, and Zambia. Participants were surveyed at the beginning, midpoint, and end of the 16-month program to evaluate changes in attitudes and knowledge of PC.

Results: The median number of participants per session was 30. Thirty-three (83%) of 40 initial participants completed the feedback survey. Health care providers' self-reported confidence in providing PC increased with participation in the Project ECHO-PACA clinic. There was significant improvement in the participants' attitudes and knowledge, especially in titrating opioids for pain control ( = .042), appropriate use of non-opioid analgesics ( = .012), and identifying and addressing communication issues related to end-of-life care ( = .014).

Conclusion: Project ECHO-PACA was a successful approach for disseminating knowledge about PC. The participants were adherent to ECHO PACA clinics and the completion of feedback surveys. Future studies should evaluate the impact of Project ECHO-PACA on changes in provider practice as well as patient outcomes.
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http://dx.doi.org/10.1200/JGO.19.00128DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6776016PMC
July 2019

Prophylactic Fentanyl Sublingual Spray for Episodic Exertional Dyspnea in Cancer Patients: A Pilot Double-Blind Randomized Controlled Trial.

J Pain Symptom Manage 2019 10 2;58(4):605-613. Epub 2019 Jul 2.

Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA.

Context: The optimal dose of fentanyl sublingual spray (FSS) for exertional dyspnea has not been determined.

Objectives: We examined the effect of two doses of prophylactic FSS on exertional dyspnea.

Methods: In this parallel, dose-finding, double-blind randomized clinical trial, opioid-tolerant cancer patients completed a shuttle walk test at baseline. Patients completed a second shuttle walk test 10 minutes after a single dose of FSS equivalent to either 35%-45% (high dose) or 15%-25% (low dose) of the total daily opioid dose. The primary outcome was change in modified dyspnea Borg scale (0-10) between the first and second shuttle walk tests. Secondary outcomes included adverse events as well as changes in walk distance, vital signs, and neurocognitive function.

Results: Thirty of the 50 enrolled patients completed the study. High-dose FSS (n = 13) resulted in significantly lower dyspnea (mean change -1.42; 95% CI -2.37, -0.48; P = 0.007) and greater walk distance (mean change 44 m; P = 0.001) compared to baseline. Low-dose FSS (n = 17) resulted in a nonsignificant reduction in dyspnea (mean change -0.47; 95% CI -1.26, 0.32; P = 0.24) and significant increase in walk distance (mean change 24 m; P = 0.01) compared to baseline. Global evaluation showed high-dose group was more likely to report at least somewhat better improvement (64% vs. 24%; P = 0.06). No significant adverse events or detriment to vital signs or neurocognitive function was detected.

Conclusion: Prophylactic FSS was well tolerated and demonstrated a dose-response relationship in improving both dyspnea and walk distance. High-dose FSS should be tested in confirmatory trials.
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http://dx.doi.org/10.1016/j.jpainsymman.2019.06.024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6754768PMC
October 2019

Integration of a Mandatory Palliative Care Education Into Hematology-Oncology Fellowship Training in a Comprehensive Cancer Center: A Survey of Hematology Oncology Fellows.

J Oncol Pract 2019 11 3;15(11):e934-e941. Epub 2019 Jul 3.

The University of Texas, MD Anderson Cancer Center, Houston, TX.

Purpose: The primary aim of this study was to determine the attitudes and beliefs of hematology and medical oncology (HMO) fellows regarding palliative care (PC) after they completed a 4-week mandatory PC rotation.

Methods: The PC rotation included a 4-week standardized curriculum covering all PC domains. HMO fellows were provided educational materials and attended all didactic sessions. All had clinical rotation in an acute PC unit and an outpatient clinic. All HMO fellows from 2004 to 2017 were asked to complete a 32-item survey on oncology trainee perception of PC.

Results: Of 105 HMO fellows, 77 (73%) completed the survey. HMO fellows reported that PC rotation improved assessment and management of symptoms (98%); opioid prescription (89%), opioid rotation (78%), and identification of opioid adverse effects (87%); communication with patients and families (91%), including advance care planning discussion (88%) and do-not-resuscitate discussion (88%); and they reported comfort with discussing ethical issues (74%). Participants reported improvement in knowledge of symptom assessment and management (n = 76; 98%) as compared with efficacy in ethics (n = 57 [74%]; = .0001) and for coping with stress of terminal illness (n = 45 [58%]; = .0001). The PC rotation educational experience was considered either far better or better (53%) or the same (45%) as other oncology rotations. Most respondents (98%) would recommend PC rotations to other HMO fellows, and 95% felt rotation should be mandatory.

Conclusion: HMO fellows reported PC rotation improved their attitudes and knowledge in all PC domains. PC rotation was considered better than other oncology rotations and should be mandatory.
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http://dx.doi.org/10.1200/JOP.19.00056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7846059PMC
November 2019

Minimally Invasive Cordotomy for Refractory Cancer Pain: A Randomized Controlled Trial.

Oncologist 2019 07 22;24(7):e590-e596. Epub 2019 Feb 22.

Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.

Background: Up to 30% of patients with cancer continue to suffer from pain despite aggressive supportive care. The present study aimed to determine whether cordotomy can improve cancer pain refractory to interdisciplinary palliative care.

Materials And Methods: In this randomized controlled trial, we recruited patients with refractory unilateral somatic pain, defined as a pain intensity (PI) ≥4, after more than three palliative care evaluations. Patients were randomized to percutaneous computed tomography-guided cordotomy or continued interdisciplinary palliative care. The primary outcome was 33% improvement in PI at 1 week after cordotomy or study enrollment as measured by the Edmonton Symptom Assessment Scale.

Results: Sixteen patients were enrolled (nine female, median age 58 years). Six of seven patients (85.7%) randomized to cordotomy experienced >33% reduction in PI (median preprocedure PI = 7, range 6-10; 1 week after cordotomy median PI = 1, range 0-6; = .022). Zero of nine patients randomized to palliative care achieved a 33% reduction in PI. Seven patients (77.8%) randomized to palliative care elected to undergo cordotomy after 1 week. All of these patients experienced >33% reduction in PI (median preprocedure PI = 8, range 4-10; 1 week after cordotomy median PI = 0, range 0-1; = .022). No patients were withdrawn from the study because of adverse effects of the intervention.

Conclusion: These data support the use of cordotomy for pain refractory to optimal palliative care. The findings of this study justify a large-scale randomized controlled trial of percutaneous cordotomy.

Implications For Practice: This prospective clinical trial was designed to determine the improvement in pain intensity in patients randomized to either undergo cordotomy or comprehensive palliative care for medically refractory cancer pain. This study shows that cordotomy is effective in reducing pain for medically refractory cancer pain, and these results can be used to design a large-scale comparative randomized controlled trial that could provide the evidence needed to include cordotomy as a treatment modality in the guidelines for cancer pain management.
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http://dx.doi.org/10.1634/theoncologist.2018-0570DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6656471PMC
July 2019

Patterns of Opioid Prescription, Use, and Costs Among Patients With Advanced Cancer and Inpatient Palliative Care Between 2008 and 2014.

J Oncol Pract 2019 01 29;15(1):e74-e83. Epub 2018 Nov 29.

1 The University of Texas MD Anderson Cancer Center, Houston, TX.

Purpose: An understanding of opioid prescription and cost patterns is important to optimize pain management for patients with advanced cancer. This study aimed to determine opioid prescription and cost patterns and to identify opioid prescription predictors in patients with advanced cancer who received inpatient palliative care (IPC).

Materials And Methods: We reviewed data from 807 consecutive patients with cancer who received IPC in each October from 2008 through 2014. Patient characteristics; opioid types; morphine equivalent daily dose (MEDD) in milligrams per day of scheduled opioids before, during, and after hospitalization; and in-admission opioid cost per patient were assessed. We determined symptom changes between baseline and follow-up palliative care visits and the in-admission opioid prescription predictors.

Results: A total of 714 (88%) of the 807 patients were evaluable. The median MEDD per patient decreased from 150 mg/d in 2008 to 83 mg/d in 2014 ( P < .001). The median opioid cost per patient decreased and then increased from $22.97 to $40.35 over the 7 years ( P = .03). The median MEDDs increased from IPC to discharge by 67% ( P < .001). The median Edmonton Symptom Assessment Scale pain improvement at follow-up was 1 ( P < .001). Younger patients with advanced cancer (odds ratio [OR[, 0.95; P < . 001) were prescribed higher preadmission MEDDs (OR, 1.01; P < .001) more often in the earlier study years (2014 v 2009: OR, 0.18 [ P = .004] v 0.30 [ P = .02]) and tended to use high MEDDs (> 75 mg/d) during hospitalization.

Conclusion: The MEDD per person decreased from 2008 to 2014. The opioid cost per patient decreased from 2008 to 2011 and then increased from 2012 to 2014. Age, prescription year, and preadmission opioid doses were significantly associated with opioid doses prescribed to patients with advanced cancer who received IPC.
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http://dx.doi.org/10.1200/JOP.18.00205DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6333384PMC
January 2019

Pharmacokinetic and pharmacodynamic studies of etodolac loaded vesicular gels on rats by transdermal delivery.

Daru 2018 Sep 11. Epub 2018 Sep 11.

Department of Pharmaceutical Technology, A.U. College of Pharmaceutical Sciences, Andhra University, Visakhapatnam, Andhra Pradesh, 530003, India.

Background: The present study includes the development of liposomal and ethosomal gels for transdermal delivery to overcome the side effects associated with oral route.

Methods: The liposomes and ethosomes were prepared by 3 factorial design using film hydration and cold methods, respectively. Different concentrations of liposomal (ETO-LG) and ethosomal (ETO-EG) gels were prepared at 1%, 2 and 3% (w/v) using carbopol 940 NF. 1%w/v ETO-LG & ETO-EG were optimized upon rheological studies of prepared gels. The optimized gels were further characterized for various physicochemical properties and biophysical studies using FTIR, pharmacokinetic (PK) and pharmacodynamic (PD) studies. The pharmacodynamic activity was performed using carrageenan paw oedema model. The prepared vesicular gels were compared with 45% v/v ethanolic ETO-solution and marketed gel PROXYM® in all the characteristic parameters.

Results: The pharmacokinetic study reveals that the half life of etodolac in ETO-EG was 1.56 folds whereas ETO-LG showed 1.31 folds higher than PROXYM®. The mean residence time (MRT) of etodolac in ETO-EG and ETO-LG is increased in 1.57 and 1.25 folds, respectively, when compared to PROXYM®. The ETO-EG showed higher percentage reduction in oedema (81.67%) compared to other test products.

Conclusion: The pharmacokinetic and pharmacodynamic studies indicated that the vesicular gels show better results compared to PROXYM®. The correlation coefficient value between PK and PD was found to be 0.9635. Graphical abstract ᅟ.
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http://dx.doi.org/10.1007/s40199-018-0214-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6154486PMC
September 2018

Predicting the risk for aberrant opioid use behavior in patients receiving outpatient supportive care consultation at a comprehensive cancer center.

Cancer 2018 10 7;124(19):3942-3949. Epub 2018 Sep 7.

Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.

Background: Opioid misuse is a growing crisis. Patients with cancer who are at risk of aberrant drug behaviors are frequently underdiagnosed. The primary objective of this study was to determine the frequency and factors predicting a risk for aberrant opioid and drug use behaviors (ADB) among patients who received an outpatient supportive care consultation at a comprehensive cancer center. In addition, the screening performance of the Cut Down-Annoyed-Guilty-Eye Opener (CAGE) questionnaire adapted to include drug use (CAGE-AID) was compared with that of the 14-item Screener and Opioid Assessment for Patients With Pain (SOAPP-14) tool as instruments for identifying patients at risk for ADB.

Methods: In total, 751 consecutive patients with cancer who were referred to a supportive care clinic were reviewed. Patients were eligible if they had diagnosis of cancer and had received opioids for pain for at least 1 week. All patients were assessed using the Edmonton Symptom Assessment Scale (ESAS), the SOAPP-14, and the CAGE-AID. SOAPP scores ≥7 (SOAPP-positive) were used to identify patients who were at risk of ADB.

Results: Among the 729 of 751 (97%) evaluable consults, 143 (19.6%) were SOAPP-positive, and 73 (10.5%) were CAGE-AID-positive. Multivariate analysis revealed that the odds ratio of a positive SOAPP score was 2.3 for patients who had positive CAGE-AID scores (P < .0001), 2.08 for men (P = .0013), 1.10 per point for ESAS pain (P = .014), 1.13 per point for ESAS anxiety (P = .0015), and 1.09 per point for ESAS financial distress (P = .012). A CAGE-AID cutoff score of 1 in 4 had 43.3% sensitivity and 90.93% specificity for screening patients with a high risk of ADB.

Conclusions: The current results indicate a high frequency of an elevated risk of ADB among patients with cancer. Men and patients who have anxiety, financial distress, and a prior history of alcoholism/illicit drug use are at increased risk of ADB.
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http://dx.doi.org/10.1002/cncr.31670DOI Listing
October 2018

Efficacy and safety of sofosbuvir-based antiviral therapy to treat hepatitis C virus infection after kidney transplantation.

Clin Kidney J 2018 Jun 30;11(3):429-433. Epub 2017 Oct 30.

Department of Nephrology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.

Background: The objectives of this pilot study were to assess the efficacy and safety of an interferon-free sofosbuvir and ribavirin combination regimen to treat chronic hepatitis C virus (HCV) infection in kidney transplant recipients and to study the impact of sofosbuvir on calcineurin inhibitor (CNI) drug levels.

Methods: A total of 10 kidney transplant recipients with chronic HCV infection were included in the study. All received sofosbuvir and ribavirin combination therapy. The virological response to therapy and the adverse effects of the drugs were studied. The area under the curve (AUC) and pharmacokinetic data of levels of CNI were compared while the patients were receiving sofosbuvir and ribavirin drugs and when they were no longer on these drugs.

Results: In all, 9 of 10 patients (90%) achieved rapid virological response (RVR) with undetectable HCV RNA at 4 weeks and the remaining patient achieved undetectable HCV RNA at 8 weeks. A sustained virological response was seen at 3, 6 and 12 months and was maintained in all 10 patients (100%). The important aspect of the study is the effect of treatment with the sofosbuvir-ribavirin combination regimen on the CNI AUC levels, which resulted in a reduction in the CNI AUC. While used as part of triple-drug immunosuppression, no change in the dose of CNI (tacrolimus and cyclosporine) was required based on measurement of C0 levels.

Conclusions: The sofosbuvir and ribavirin combination therapy is effective and safe to treat HCV infection in the post-renal transplant setting. There is a need for close CNI level monitoring while these patients are on sofosbuvir therapy. With therapy and viral clearance, there could be reduction in CNI levels due to increased clearance of CNI drugs, which is shown by the AUC measurements. This could be important for patients at high risk for rejection.
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http://dx.doi.org/10.1093/ckj/sfx112DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6007709PMC
June 2018

The minimal clinically important difference of the Richmond Agitation-Sedation Scale in patients with cancer with agitated delirium.

Cancer 2018 05 22;124(10):2246-2252. Epub 2018 Feb 22.

Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.

Background: The Richmond Agitation-Sedation Scale (RASS) is commonly used to assess psychomotor activity; however, to the authors' knowledge, its minimal clinically important difference (MCID) has not been determined to date. The objective of the current study was to identify the MCID for RASS using 2 anchor-based approaches.

Methods: The current study was a secondary analysis of a randomized controlled trial to compare the effect of lorazepam versus placebo as an adjuvant to haloperidol for persistent agitation in patients with delirium. The primary outcome was change in RASS (10-point numeric rating scale ranging from -5 [unarousable] to +4 [combative]) from baseline to 8 hours after treatment administration. The sensitivity-specificity and within-patient change methods were used to identify the MCID, with the anchor being patient comfort after the study intervention as perceived by caregivers and nurses.

Results: A total of 90 patients were randomized and 58 (64%) received the study medication for restlessness/agitation (mean baseline RASS, 1.6). A total of 23 caregivers (61%) and 23 nurses (55%) perceived that the patient was more comfortable after treatment. Using the sensitivity-specificity method, the optimal RASS reduction was ≥4 points according to both caregivers (sensitivity of 61% and specificity of 80%; area under the curve, 0.71) and nurses (sensitivity of 73% and specificity of 84%; area under the curve, 0.78). The RASS cutoff value based on the within-patient change method was similar (-4.2 for caregivers and -4.0 for nurses).

Conclusions: For patients with persistent restlessness/agitation, a reduction of ≥4 points in RASS was considered to be the MCID for both nurses and caregivers. These preliminary findings may have implications for sample size calculation and the interpretation of treatment effect in future delirium trials. Cancer 2018;124:2246-52. © 2018 American Cancer Society.
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http://dx.doi.org/10.1002/cncr.31312DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5935554PMC
May 2018

Decisional control preferences among patients with advanced cancer: An international multicenter cross-sectional survey.

Palliat Med 2018 04 13;32(4):870-880. Epub 2017 Dec 13.

1 Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.

Background: Understanding patients' decision control preferences is important in providing quality cancer care. Patients' decisional control preference can be either active (patients prefer to make decisions themselves), shared (collaborative between patient, their physician, and/or family), or passive (patients prefer that the decisions are made by either the physician and/or their family).

Aim: To determine the frequency and predictors of passive decision control preferences among advanced cancer patients. We also determined the concordance between actual decision-making and decision control preferences and its association with patient satisfaction.

Design: In this cross-sectional survey of advanced cancer patients referred to palliative care across 11 countries, we evaluated sociodemographic variables, Control Preference Scale, and satisfaction with the decisions and care.

Results: A total of 1490 participants were evaluable. Shared, active, and passive decision control preferences were 33%, 44%, and 23%, respectively. Passive decision control preferences (odds ratio, p value) was more frequent in India (4.34, <0.001), Jordan (3.41, <0.001), and France (3.27, <0.001). Concordance between the actual decision-making and decision control preferences was highest in the United States ( k = 0.74) and lowest in Brazil (0.34). Passive decision control preference was significantly associated with (odds ratio per point, p value) better performance status (0.99/point, 0.017), higher education (0.64, 0.001), and country of origin (Brazil (0.26, <0.0001), Singapore (0.25, 0.0003), South Africa (0.32, 0.0002), and Jordan (2.33, 0.0037)).

Conclusion: Passive decision control preferences were less common (23%) than shared and active decision control preference even among developing countries. Significant predictors of passive decision control preferences were performance status, education, and country of origin.
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http://dx.doi.org/10.1177/0269216317747442DOI Listing
April 2018

Perception of Curability Among Advanced Cancer Patients: An International Collaborative Study.

Oncologist 2018 04 20;23(4):501-506. Epub 2017 Nov 20.

Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Barretos, Brazil.

Background: There are limited data on illness understanding and perception of cure among advanced cancer patients around the world. The aim of the study was to determine the frequency and factors associated with inaccurate perception of curability among advanced cancer patients receiving palliative care across the globe.

Materials And Methods: Secondary analysis of a study to understand the core concepts in end-of-life care among advanced cancer patients receiving palliative care from 11 countries across the world. Advanced cancer patients were surveyed using a Patient Illness Understanding survey and Control Preference Scale. Descriptive statistics and multicovariate logistic regression analysis were performed.

Results: Fifty-five percent (763/1,390) of patients receiving palliative care inaccurately reported that their cancer is curable. The median age was 58, 55% were female, 59% were married or had a partner, 48% were Catholic, and 35% were college educated. Sixty-eight percent perceived that the goal of therapy was "to get rid of their cancer," and 47% perceived themselves as "seriously ill." Multicovariate logistic regression analysis shows that accurate perception of curability was associated with female gender (odds ratio [OR] 0.73,  = .027), higher education (OR 0.37,  < .0001), unemployment status (OR 0.69,  = .02), and being from France (OR 0.26,  < .0001) and South Africa (OR 0.52,  = .034); inaccurate perception of curability was associated with better Karnofsky performance status (OR 1.02 per point,  = .0005), and being from Philippines (OR 15.49,  < .0001), Jordan (OR 8.43,  < .0001), Brazil (OR 2.17,  = .0037), and India (OR 2.47,  = .039).

Conclusion: Inaccurate perception of curability in advanced cancer patients is 55% and significantly differs by gender, education, performance status, employment status, and country of origin. Further studies are needed to develop strategies to reduce this misperception of curability in advanced cancer patients.

Implications For Practice: The findings of this study indicate that inaccurate perception of curability among advanced cancer patients is 55%. Inaccurate perception of curability significantly differs by gender, education, performance status, employment status, and country of origin. There is great need to facilitate improved patient-physician communication so as to improve health care outcomes and patient satisfaction.
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http://dx.doi.org/10.1634/theoncologist.2017-0264DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5896700PMC
April 2018

Palliative radiation therapy in the last 30 days of life: A systematic review.

Radiother Oncol 2017 11 16;125(2):193-199. Epub 2017 Oct 16.

Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, USA. Electronic address:

Purpose: To investigate the utilization of palliative radiation therapy (RT), predictors for the use of RT, and symptom palliation following RT during the last 30 days of life through systemic review of literature.

Materials/methods: A systematic search of available medical literature databases was performed on patients receiving palliative RT in the last 30 days of life. A total of 18 studies were evaluated.

Results: The overall palliative RT utilization rates during the last month of life were in the range of 5-10% among patients who died of cancer and 9-15.3% of patients who received palliative RT. The most commonly used regimen was 30 Gy in 10 fractions (36-90%). Single fraction RT utilization ranged from 0% to 59%. ECOG performance status 3-4 was significantly associated with patients receiving RT in the last 30 days of life and shorter survival. Twenty-six percent of patients who survived less than 1 month were reported to show symptom palliation following RT.

Conclusion: Palliative RT was performed in approximately 10% of patients who died of cancer near their end of life, with the most commonly used regimen of 30 Gy in 10 fractions. This study suggests that greater use of shorter or single fraction regimens may be beneficial, especially in patients with poor performance status.
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http://dx.doi.org/10.1016/j.radonc.2017.09.016DOI Listing
November 2017

Outcomes of a Specialized Interdisciplinary Approach for Patients with Cancer with Aberrant Opioid-Related Behavior.

Oncologist 2018 02 11;23(2):263-270. Epub 2017 Oct 11.

Department of Palliative Care and Rehabilitation Medicine, Houston, Texas, USA.

Background: Data on the development and outcomes of effective interventions to address aberrant opioid-related behavior (AB) in patients with cancer are lacking. Our outpatient supportive care clinic developed and implemented a specialized interdisciplinary team approach to manage patients with AB. The purpose of this study was to report clinical outcomes of this novel intervention.

Materials And Methods: The medical records of 30 consecutive patients with evidence of AB who received the intervention and a random control group of 70 patients without evidence of AB between January 1, 2015, and August 31, 2016, were reviewed.

Results: At baseline, pain intensity ( = .002) and opioid dose ( = .001) were significantly higher among patients with AB. During the course of the study, the median number of ABs per month significantly decreased from three preintervention to 0.4 postintervention ( < .0001). The median morphine equivalent daily dose decreased from 165 mg/day at the first intervention visit to 112 mg/day at the last follow-up ( = .018), although pain intensity did not significantly change ( = .984). "Request for opioid medication refills in the clinic earlier than the expected time" was the AB with the highest frequency prior to the intervention and the greatest improvement during the study period. Younger age ( < .0001) and higher Edmonton Symptom Assessment System anxiety score ( = .005) were independent predictors of the presence of AB.

Conclusion: The intervention was associated with a reduction in the frequency of AB and opioid utilization among patients with cancer receiving chronic opioid therapy. More research is needed to further characterize the clinical effectiveness of this intervention.

Implications For Practice: There are currently no well-defined and evidence-based strategies to manage cancer patients on chronic opioid therapy who demonstrate aberrant opioid-related behavior. The findings of this study offer a promising starting point for the creation of a standardized strategy for clinicians and provides valuable information to guide their practice regarding these patients. The study results will also help clinicians to better understand the types and frequencies of the most common aberrant behaviors observed among patients with cancer who are receiving chronic opioid therapy. This will enhance the process of timely patient identification, management, or referral to the appropriate specialist teams.
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http://dx.doi.org/10.1634/theoncologist.2017-0248DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5813743PMC
February 2018

Global disparities in cancer pain management and palliative care.

J Surg Oncol 2017 Apr 23;115(5):637-641. Epub 2017 Feb 23.

Division of Cancer Medicine, Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.

Palliative care and pain management constitute an integral part of the multi-disciplinary approach to treating patients with cancer. There are major disparities in the global presence of sustainable palliative care models and universal availability of effective pain medications, especially in low and middle income countries with the highest predicted future burden of cancer. Active intervention is needed to improve the availability of palliative care and effective pain control worldwide.
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http://dx.doi.org/10.1002/jso.24585DOI Listing
April 2017

Post-Discharge Survival Outcomes of Patients with Advanced Cancer from the University of Texas MD Anderson Cancer Center Investigational Cancer Therapeutics (Phase I Trials) Inpatient Unit.

Oncology 2017 2;92(1):14-20. Epub 2016 Nov 2.

Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.

Background: Patients with advanced cancer who progress on standard therapy are potential candidates for phase I clinical trials. Due to their aggressive disease and complex comorbid conditions, these patients often need inpatient admission. This study assessed the outcomes of such patients after they were discharged to hospice care.

Patients And Methods: We performed a retrospective analysis of patients with solid tumor malignancies who were discharged to hospice care from the inpatient service.

Results: One hundred thirty-three patients were included in the study cohort. All patients had metastatic disease and an Eastern Cooperative Oncology Group performance status ≥3. The median survival after discharge to hospice from an inpatient setting was 16 days, with a survival rate of 5% at 3 months after discharge. The median survival after the last cancer treatment was 46 days, with survival of 17% at 3 months, and 5% at 6 months. Patients with lactate dehydrogenase (LDH) >618 IU/L had a median post-discharge survival of 11 days versus 20 days for patients with LDH ≤618 IU/L.

Conclusions: Patients with metastatic cancer participating in phase I trials who have poor performance status and require inpatient admission have a very short survival after discharge to hospice. A high LDH level predicts an even shorter survival.
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http://dx.doi.org/10.1159/000449505DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5308283PMC
January 2017

Frequency, predictors, and outcomes of urine drug testing among patients with advanced cancer on chronic opioid therapy at an outpatient supportive care clinic.

Cancer 2016 Dec 10;122(23):3732-3739. Epub 2016 Aug 10.

Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer, Houston, Texas.

Background: Data are limited on the use and outcomes of urine drug tests (UDTs) among patients with advanced cancer. The main objective of this study was to determine the factors associated with UDT ordering and results in outpatients with advanced cancer.

Methods: A retrospective chart review was conducted of 1058 patients who attended an outpatient supportive care clinic from March 2014 to November 2015. Sixty-one patients who were receiving chronic opioid therapy and underwent UDTs were identified. A control group of 120 patients who did not undergo UDTs was selected for comparison.

Results: Sixty-one of 1058 patients (6%) underwent UDTs, and 33 of 61 patients (54%) had abnormal results. Multivariate analysis indicated that the odds ratio for UDT ordering was 3.9 in patients who had positive Cut Down, Annoyed, Guilty, and Eye Opener (CAGE) questionnaire results (P = .002), 4.41 in patients aged < 45 years (P < .001), 5.58 in patients who had moderate-to-severe pain (Edmonton Symptom Assessment Scale pain scores ≥4; P < .001), 0.27 in patients with advanced-stage cancer, (P = .008), and 0.25 in patients who had moderate-to-severe fatigue (P = .001). Among 52 abnormal UDT results in 33 patients, the most common opioid findings were prescribed opioids absent in urine (14 of 52 tests; 27%) and unprescribed opioids in urine (13 of 52 tests; 25%).

Conclusions: UDTs were used infrequently among outpatients with advanced cancer who were receiving chronic opioid therapy. Younger age, positive CAGE questionnaire results, early stage cancer or no evidence of disease status, higher pain intensity, and lower fatigue scores were significant predictors of UDT ordering. More than 50% of UDT results were abnormal. More research is necessary to better characterize aberrant opioid use in patients with advanced cancer. Cancer 2016;122:3732-9. © 2016 American Cancer Society.
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http://dx.doi.org/10.1002/cncr.30240DOI Listing
December 2016

Aberrant Opioid Use and Urine Drug Testing in Outpatient Palliative Care.

J Palliat Med 2016 07 12;19(7):778-82. Epub 2016 May 12.

1 Department of Palliative Care and Rehabilitation Medicine, University of Texas at MD Anderson Cancer Center , Houston, Texas.

Aberrant opioid use is a public health issue, which has not been adequately described in the palliative care literature. With the increasing integration of palliative care into oncologic care, palliative care clinicians are seeing patients earlier in the disease trajectory, and therefore, more outpatients with chronic pain requiring chronic opioid therapy. This may have resulted in a concomitant rise in the number of patients with aberrant opioid use. In this article, we report on two patients with aberrant opioid-related behavior seen at our palliative care clinic. A high suspicion of opioid abuse, misuse, or diversion based on certain behavioral cues necessitated the ordering of a urine drug test (UDT). The tests helped the medical team to confirm an already existing pattern of maladaptive opioid use. In both cases, we provided ample opioid education and implemented effective strategies to address their aberrant opioid use. These cases suggest the need for palliative care clinicians to develop strategies to effectively address this issue in our field of medicine. It also highlights the usefulness of UDT in the outpatient palliative care setting.
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http://dx.doi.org/10.1089/jpm.2015.0335DOI Listing
July 2016

The Opioid Rotation Ratio From Transdermal Fentanyl to "Strong" Opioids in Patients With Cancer Pain.

J Pain Symptom Manage 2016 06 28;51(6):1040-5. Epub 2016 Jan 28.

Department of Palliative Care and Rehabilitation Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA.

Context: One-third of cancer patients require opioid rotation (OR) to treat uncontrolled pain or opioid-induced neurotoxicity. Although fentanyl is the most frequently rotated opioid in cancer patients, the accurate opioid rotation ratio (ORR) from transdermal fentanyl (TDF) to other so-called "strong" opioids is unknown.

Objectives: We aimed to determine the ORR of TDF to strong opioids, as measured by morphine equivalent daily dose (MEDD).

Methods: We reviewed 2471 consecutive patient visits (938 patients) to our supportive care center for an OR from TDF to strong opioids. Information regarding demographics, symptoms, and MEDD was collected in patients who followed up within six weeks. Linear regression analysis was used to estimate the ORR between TDF dose and net MEDD (MEDD after OR minus MEDD of the breakthrough opioid used along with TDF before OR).

Results: Among 47 eligible patients, the median age was 54 years, 53% were male, and 77% had advanced cancer. The median time to follow-up was 14 days. Uncontrolled pain (83%) was the most common reason for OR. In patients with OR and no worsening of pain at follow-up (n = 41), the median ORR (range) from TDF mg/day to net MEDD mg/day was 100 (12.5-217) and from TDF mcg/hour to net MEDD was 2.4 (0.3-5.2); the correlation of TDF dose to net MEDD was 0.60 (P < 0.0001).

Conclusion: The median ORR from TDF mg/day to MEDD is 100 and from TDF mcg/hour to MEDD is 2.4, suggesting that TDF 100 mcg/hour is equivalent to an MEDD of 240 mg.
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http://dx.doi.org/10.1016/j.jpainsymman.2015.12.312DOI Listing
June 2016

Patient Home Visits: Measuring Outcomes of a Community Model for Palliative Care Education.

J Palliat Med 2016 Mar 14;19(3):271-8. Epub 2015 Dec 14.

1 Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center , Houston, Texas.

Background: Health care professionals may have limited exposure to home-based care. There is no published literature that has described the experiences and satisfaction of participation in patient home visits (PHV).

Objective: The objective of this article is to describe the characteristics of PHV, our approach, and evaluation by participants over a nine-year period.

Methods: We conducted a review of surveys completed by participants in PHV from 2005-2013. All participants anonymously completed the evaluation questionnaires at the end of PHVs. Different PHV assessment forms were used for the 2005-2010 and 2011-2013 time periods.

Results: A total of 34 PHVs were conducted with 106 patients and approximately 750 participants with a mean of 3 patients and 22 participants per PHV between 2005 and 2013. For 18 PHVs there are 317 surveys completed with 353 participants, making it a 90% response rate. Responding participants were physicians 125/543 (23%) and other professionals 418/543 (77%). In both time periods of 2005-2010 and 2011-2013 a survey with a 1 (completely agree) to 5 (completely disagree) scale was used. Agreeing that PHV was an effective teaching tool during 2005-2010 were 335/341 (98%); during 2011-2013, 191/202 (95%) agreed that PHV provided increased understanding and sharing of best practices in palliative care.

Conclusions: PHV was perceived by participants as an effective way of providing interactive community education. A broad range of themes were addressed, and the participants reported high levels of learning in all domains of palliative care. There were no cases of patient or relative expression of distress as a result of PHV.
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http://dx.doi.org/10.1089/jpm.2015.0275DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4779281PMC
March 2016

Synthesis and biological evaluation of benzimidazole-oxindole conjugates as microtubule-targeting agents.

Bioorg Chem 2015 Dec 8;63:72-84. Epub 2015 Oct 8.

Department of Chemistry Sri Venkateswara University, Tirupati 517 502, India.

A series of benzimidazole-oxindole conjugates were synthesized and evaluated for their cytotoxic activity. The cytotoxicity assay results suggest that conjugates 5c and 5p exhibit promising cytotoxicity against human breast cancer cell line (MCF-7). The Cell cycle analysis revealed that these conjugates induced cell cycle arrest at G2/M phase in MCF-7 cells. The tubulin polymerization assay results suggested that these conjugates inhibit tubulin polymerization with IC50 values 1.12 and 1.59μM respectively. Immunofluorescence analysis also suggested that these conjugates effectively inhibited the microtubule assembly in MCF-7 cells. Further, molecular docking studies indicated that these conjugates 5c and 5p interact and binds efficiently with the tubulin protein. By and large, the results demonstrated that these benzimidazole-oxindole conjugates possess cytotoxic property by inhibiting the tubulin polymerization.
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http://dx.doi.org/10.1016/j.bioorg.2015.09.003DOI Listing
December 2015