Article:

Nutritional Interventions during Chemotherapy for Pancreatic Cancer: A Systematic Review of Prospective Studies.

Cintoni M, Grassi F, Palombaro M, Rinninella E, Pulcini G, Di Donato A, Salvatore L, Quero G, Tortora G, Alfieri S, Gasbarrini A, Mele MC.Nutrients. 2023 Feb 1;15(3):727. doi: 10.3390/nu15030727.PMID: 36771433 Free PMC article. Review.

Abstract:

Background: Pancreatic cancer incidence is growing, but the prognosis for survival is still poor. Patients with pancreatic cancer often suffer from malnutrition and sarcopenia, two clinical conditions that negatively impact oncological clinical outcomes. The aim of this systematic review was to analyze the impact of different nutritional interventions on clinical outcomes in patients with pancreatic cancer during chemotherapy.

Methods: A systematic review of MedLine, EMBASE, and Web of Science was carried out in December 2022, identifying 5704 articles. Titles and abstracts of all records were screened for eligibility based on inclusion criteria, and nine articles were included.

Results: All nine articles included were prospective studies, but a meta-analysis could not be performed due to heterogenicity in nutritional intervention. This Systematic Review shows an improvement in Quality of Life, nutritional status, body composition, oral intake, and Karnofsky Performance Status, following nutritional interventions.

Conclusions: This Systematic Review in pancreatic cancer patients during chemotherapies does not allow one to draw firm conclusions. However, nutritional support in pancreatic cancer patients is advisable to ameliorate oncological care. Further well-designed prospective studies are needed to identify nutritional support’s real impact and to establish a reliable way to improve nutritional status of pancreatic cancer patients during chemotherapy.

Type of Study: Systematic Review

Why I selected this article: I selected this article because one of my patients is a 62 y/o F on palliative care for advanced localized pancreatic cancer. She had a stent in place that became clogged and suffered an iatrogenic tear of the jejunum during a replacement procedure. The patient underwent a procedure where passive drains were placed, and she was NPO for approximately two weeks. She was recently given methylene blue to ingest, and it was determined that it was safe for her to advance to clear liquids.

Summary:

                  Pancreatic cancer is among the most lethal of cancers due to its initial asymptomatic presentation. Signs and symptoms of pancreatic cancer present much later in disease progression, at which point the cancer has advanced. Because of this, pancreatic cancer bears poor prognosis even when managed with surgical resection and/or chemotherapy. Extensive chemotherapy coupled with the burden of disease makes patients susceptible to becoming malnourished which may contribute to worse overall outcomes. One way to mitigate these adverse outcomes is by providing nutritional support. According to the article I selected, nutritional support in pancreatic cancer has demonstrated increase in overall survival. In one study, patients who received oral L-carnitine vs placebo for 12 weeks lived a median of 469-569 days compared to 356-456. Another study revealed that patients who received nutritional interventions had better quality of life (as per the QLQ-C30 global scale), improved cognitive function and reduced gastrointestinal symptoms. The QLQ-C30 global scale is a questionnaire that measures the physical, psychological, and social functions of cancer patients. Additionally, authors of this systematic review selected studies which focused on the Karnofsky performance scale. This KPS scale is an assessment tool that providers can employ to determine a patient’s functional status. Namely, their ability to performs ADLs. Studies showed that patients who received nutritional therapy had better functional capacity and improved ability to resist the adverse effects of therapy. Authors also recommended adjunct pancreatic enzyme replacement therapy since reduction of pancreatic secretions associated with pancreatic cancer lead to maldigestion and malabsorption, thus contributing to malnutrition.

PA-Port 1

PA-Port 2

PA-Port 3

Psychiatry was my fourth rotation during my clinical year. Similar to our other rotations, we had one mid-site evaluation, and one final site evaluation. Prior to meeting with our site evaluator, we were given instructions on what material to bring and how to prepare it. Although we were tasked with submitting the same usual documents, there were extra factors that we had to keep in mind. For example, our drug cards required an article demonstrating the evidence of efficacy of each drug. Although I was initially a overwhelmed with having to find ten articles, I believe that it helped me develop a deeper understanding for how these drugs work, which allowed me to determine what interventions were better for different psychiatric conditions. Another difference between the psychiatry site evaluations and our other site evaluations is that for our H&Ps, our mental status exam replaced our physical exam. For our first site evaluation, we met with our site evaluator in person. We went in alphabetical order (based on last name) answering questions about our cases and helping each other with questions that were more difficult. We did not necessarily present the case to one another but I believe this method of evaluation is more effective for learning. We basically had an hour-long conversation about our patients and I enjoyed interacting with my classmates in this way as opposed to the usual monotonous reading 5-6 pages worth of an H&P.

For our final site evaluation, the structure was similar but we convened over zoom. We were allowed to submit any journal article of our liking so long as it was within the realm of psychiatry and behavioral health. Usually, we have to submit an article pertaining to one of our H&Ps. Because our site evaluator asked us questions pertaining to our case, I made sure to know my case inside and out so that I would be prepared to answer any questions that came my way. I made sure to review my differentials, medications, and assessment/plan extensively. I think it made a big difference compared to my first evaluation because I was more confident answering questions and I had a better idea of what to focus on for the final evaluation.

My rotation in psychiatry is one of the best experiences I’ve had during my clinical year. I was given the opportunity to work closely with my preceptor, multiple residents, and developed unique relationships with the patients I met in the inpatient unit.  In complete honesty, I wasn’t looking forward to this rotation because psychiatry did not interest me; it felt like a specialty I would never consider. After these five weeks, however, I am considering inpatient psychiatry as a field to practice in.  A typical day during this rotation consisted of me arriving early and following my assigned resident while they rounded on their patients. During my first week, I observed and took notes on the different interview techniques they implemented. Because I needed to conduct some interviews for my procedure log, I wanted to understand which questions were pertinent and why. I was initially worried about interviewing patients because, typically, there is an order in which questions must be asked. If the conversation deviated (and it always did), the interviewer was responsible for redirecting the patient. This was something that I felt required a certain level of skill that I was not yet confident in. Once rounds ended, I talked with my resident about the patient, about questions that were asked, and went over differential diagnosis. This method of teaching was extremely conducive to my learning, and I feel like I have a very strong foundation in inpatient psychiatric conditions because residents were able to dedicate time to answering any questions I had. By the second week, I was able to ask questions during interviews, translate during interviews, and eventually conducted entire interviews by myself.

Patients that were difficult to deal with were those that were acutely psychotic or manic, especially if they were aggressive or sexually preoccupied. These were patients I usually observed from a distance with multiple members of the treatment team. The most important thing I learned about dealing with these patients is to ensure that they are not blocking the entrance to the door, and to never approach them alone while they are experiencing psychosis or mania. Once these patients were medicated, they were more agreeable and conducting interviews was easier. One patient in particular who was labile and aggressive upon admission, became more linear, calm, and able to interact with his peers with appropriate intervention. We were able to converse about jobs he had in his youth and his family by the time I left, and I was extremely proud of his progress. This is a patient that I am certain will stick with me for the remainder of my career. Overall, I believe this rotation helped me understand patients better. Sometimes when patients present with unusual behavior, they may have underlying issues such as psychiatric conditions, personal life challenges, or other factors entirely. I think this perspective is necessary to provide the best possible care, and I am grateful to the team I worked with for providing this perspective that I will carry with me not only during my future rotations, but for the rest of my career.

Ambulatory Care is one of the rotations I was looking forward to the most because I worked as a medical scribe for about two years before attending PA school. For this rotation, our mid-site evaluator tasked us with preparing one H&P and creating 5 drug cards. While I was confident in my presentation, certain aspects of my H&P such as the assessment and plan were lacking. My site evaluator taught me that I need to flesh out the plan more extensively and focus on not only managing the history of present illness but making sure that chronic medical conditions are being addressed as well. For example, the patient in my first H&P had a history of uncontrolled hypertension but presented to the clinic for perichondritis. Although I understand her blood pressure is something that requires management, I did not include it in my plan because I was focused on addressing the issue at hand which was the infected right ear. The site evaluator also explained that this patient may not have been the best person to choose for an H&P as she was in significant pain and may have been brushing off certain questions for the provider to come in sooner.  During the final site evaluation, we were tasked with providing two H&Ps, a journal article with a summary, and 5 more drug cards. I presented the case of a patient with suspected hypertensive urgency and was able to develop an assessment and plan that addressed the issue at hand while also focusing on how to manage her stress and inability to follow up with a primary care provider. Additionally, I adjusted my assessment to include the pertinent history, physical exam findings, and any positive results that we acquired in the lab on the day of the visit (ie: urinalysis). For my first H&P, my assessment was not as detailed because it was difficult to get a history from the patient while she was in pain. I felt more confident in this history and physical after taking my site evaluators’ comments into consideration. My classmates and I answered questions for each other’s cases and conversed with our site evaluator about the best course of action for each patient. Moving forward, I will be fleshing out my plan the way I did for this rotation as it is more comprehensive.  

For my ambulatory care rotation, I worked with different providers during every shift. Each provider supplied me with different skills that I used to flesh out my history of present illness, develop a list of differential diagnosis, and create an appropriate assessment and plan. Across the board, all the providers I worked with emphasized the importance of documentation to rule out “the serious stuff . For example, one patient presented to the clinic with bilateral conjunctival injection and lacrimation. Upon further investigation, the patient stated he has a history of seasonal allergies and had been experiencing some rhinorrhea for a couple of day. On physical exam the patient had edematous, pale turbinates and his visual acuity was normal. This sounded like a classic case of allergic rhinitis but because he presented with  conjunctival injection, my preceptor informed me that we need to rule out ophthalmologic emergencies like orbital cellulitis. She taught me to refer to WikEM or Up To Date to help me figure out what questions I can ask. For this patient, we wanted to ask if he had any changes in vision or painful eye movements. We also examined the eye carefully to make sure there was no chemosis or proptosis. The last step was to document our findings. I enjoyed this way of working up the patient and found it to be helpful for developing my differential diagnosis so I think that I will continue evaluating my patients this way for my future rotations.

Prior to this rotation, I was not confident in providing patient education. Providing patient education is extremely important to me so this is something I worked on during every shift. The more I studied for the ambulatory care end of rotation exam, the more information I was able to relay to my patients. I supplemented my studying with slides and PANCE prep pearls instead of doing Rosh questions. By the time the 5 weeks were up, I felt like my patient education flowed like a conversation and I was able to speak to patients with confidence and answer their questions. My preceptors agreed with my counseling and were able to jump in at the end if they felt like I missed anything important. That being said, one thing I wish I had the opportunity to practice was IV placement. I was able to perform a decent number of procedures (venipuncture, urinalysis, cerumen removal, etc) but I did not get to place an IV in any patient. Typically, if the disposition is that the patient requires an IV, urgent care providers send them to the emergency room. I am hoping that I can develop this skill in other rotations like Emergency Medicine. Overall, I feel grateful that I was able to provide care in my community for 5 weeks and I learned that urgent care can play a role in mitigating health discrepancies in underserved neighborhoods.