In total, the EPA offers approximately $1 million in annual funding for pollution prevention support programs and resource conservation activities. This $1 million is parceled out evenly among the EPA’s Pollution Prevention Regional Program Offices. Additionally, an estimated $800,000 is available in grants via the Pollution Prevention Information Network (PPIN). This Network is dedicated to providing services that foster awareness of P2 practices.

Beyond regional and business support, federal grant money is also available to states, tribes and intertribal consortia. Available funds per year are approximately $4 million and are reserved primarily for state regulatory programs.

For more information on grants and funding, please visit the EPA’s official site for pollution prevention: http://www.epa.gov/p2/pubs/grants/index.htm.

• Modifying production processes
• Encouraging the use of non-toxic or less-toxic substances
• Executing effective conservation techniques
• Re-using and recycling materials rather than dumping them in the waste stream

Pollution Prevention As Government Policy

On October 25, 1990, the U.S. government passed the Pollution Prevention Act. The P2 Act has served as the guiding document for both government and private efforts towards pollution prevention. In regards to all water, air and land pollutants, the P2 Act mandates that:

• All attempts should be made to prevent or reduce pollution at the source
• Where prevention is not possible, pollution should be recycled in an environmentally safe manner
• Where prevention and recycling are not possible, pollution should be treated as environmentally friendly as possible
• Pollution disposal or release into the environment should be reserved only as a final option and must be done so in an environmentally friendly manner

Who Promotes Pollution Prevention?

The Environmental Protection Agency (EPA) is the chief federal agency in charge of promoting pollution prevention. However, a number of other federal agencies provide supplemental support. At the state level, state departments of environmental management also uphold P2 policies and promotion.

The top priority for all government agencies regarding pollution prevention is education. This involves partnering with the general public to teach individuals about the importance of P2. The government has placed special emphasis on educating children, in the hopes of planting seeds for improved pollution prevention measures in the future.

Beyond the general public, the EPA is also intent on raising awareness and building partnerships among business entities, consumer groups, colleges and other sectors. Specialized partnership efforts are also targeted at the health community, with an emphasis on reducing disease susceptibility through pollution prevention. Additionally, the EPA is responsible for advancing P2 as a priority among the international community.

While thoracentesis or closed pleural biopsy can usually help confirm the diagnosis of pleural malignancy, enough tissue may not be obtained to make a differentiation between mesothelioma and lung adenocarcinoma. Moreover, negative results do not imply the absence of mesothelioma. Although used rarely, surgical procedures (via open thoracotomy or video thoracoscopic biopsy) have shown to provide higher diagnostic yield.

The challenges faced while confirming a diagnosis of mesothelioma have been illustrated through a study involving 188 successive patients examined between 1973 and 1990. In 98 percent of cases, diagnosis was established using video-assisted thoracoscopic (VATS) biopsy, in comparison to 39 percent for closed pleural biopsy and fluid cytology combined and 26 for thoracentesis alone. The VATS procedures were performed using local anesthesia in an endoscopy suite and had minimal complications or morbidity.

Around 10% of patients who go through diagnostic procedures for mesothelioma end up seeding the biopsy site with tumor cells which later leads to recurrance in the chest wall. Radiation therapy is often used for the treatment of patients diagnosed with symptomatic, recurrent disease occurring at the site of biopsy. Such complications can be avoided if prophylactic radiation therapy is administered to the surgical scar or thoracentesis site.

Symptoms and signs

Symptoms most commonly associated with epithelial pleural mesothelioma include dyspnea and nonpleuritic chest pain. In rare cases, asymptomatic patients experience a unilateral pleural effusion which can be detected during routine chest radiography.

At the time of diagnosis, the most common physical findings range from unilateral dullness to percussion at the lung base, scoliosis towards the side where the malignancy has occurred and palpable chest wall masses.

Paraneoplastic syndromes

There are several different paraneoplastic syndromes associated with epithelioid mesothelioma. Some of these are given below:

• Migratory thrombophlebitis
• Disseminated intravascular coagulation
• Coombs-positive hemolytic anemia
• Hypoglycemia
• Thrombocytosis
• Hypercalcemia linked with discharge of a parathyroid hormone-like peptide

The findings highlight the potentially substantial patient benefits that result from hospice care:

• Patients who disenrolled from hospice care were admitted to an emergency hospital department at a rate of 33.9 percent. In comparison, hospice patients were admitted to similar facilities at a rate of only 3.1 percent.
• Patients who disenrolled from hospice were admitted as an inpatient to a hospital at a rate of 39.8 percent. In comparison, hospice patients were admitted as an inpatient at a rate of 1.6 percent.
• On average, disenrolled patients spent 19.3 days in the hospital. In contrast, hospice patients spent an average of 6.7 days in the hospital.
• Disenrolled patients died in the hospital an estimated 9.6 percent of the time. In contrast, hospice patients died in the hospital an estimated 0.2 percent of the time.
• Treatment costs incurred by disenrolled hospice patients were nearly five times higher than costs incurred by hospice patients.

Previous academic studies have found that hospice care improves patient quality of life and reduces depression. When patients are surrounded by loved ones at home, the trauma of death and patient suffering may be minimized.

What can we do about this? Well, healthcare providers can take additional measures to ensure patients and caregivers understand the full benefits of hospice care. Doctors and nurses can help patients investigate outpatient treatment options. Considering that outpatient care can provide adequate treatment support while improving the patient’s all-around quality of life, we should do all we can to enable cancer patients to get hospice care.

Also, this is interesting: The first volume of a “book of cancer knowledge” has been published – BBC

Imaging studies – These are commonly used for the evaluation of patients with suspected resectable malignant mesothelioma. Potential options available include CT, MRI, PET, and integrated PET/CT.

Chest CT – This is useful in identifying invasion of the ribs, chest wall and mediastinal structures. Potential indicators of tumor invasion include gross extension into mediastinal fat, loss of normal fat planes, and tumor which surrounds more than 50% of mediastinal structures. However, it has limited ability to accurately detect the involvement of intrathoracic lymph nodes.

MR imaging – For specific patients with suspected resectable disease, some physicians recommend Magnetic Resonance (MR) imaging in order to further examine the local extent of disease. In particular, coronal MRI may help identify the spread of pleural mesothelioma via the diaphragm into the peritoneal cavity.

PET scan – PET scans that make use of 18-fluorodeoxyglucose (FDG) have been helpful in detecting extrathoracic disease. However, in cases where only PET was used, a number of false negatives and false positives were reported during evaluation of mediastinal lymph nodes.

Integrated PET-CT – This type of imaging technique has proved most reliable for initial assessment of the patient. Below are three single institutional series that demonstrate the results obtained using the above technique:

• In the first series, 42 successive patients without any signs of T4 or M1 disease (based on CT) were evaluated using PET-CT. 12 patients (29%) were reclassified as terminal cases, based on the existence of a T4 lesion or distant metastasis (29% and 14% respectively).
• In the second series, 54 patients with suspected resectable mesothelioma (stage II/III) were evaluated using PET-CT. Surgical procedures were used to establish the imaging findings among 52 patients whereas two patients who had distant metastases were followed. It was noted that PET-CT was considerably more accurate than MRI, CT or PET alone for both stage II and stage III disease.
• In the third series, a comparison between PET-CT and CT in 35 patients was carried out. Based on the PET-CT findings, surgical resection was not indicated in 14 of the 35 cases (40%). This was usually due to the increase in the staging of the primary tumor.

Surgical staging – Extended surgical staging is recommended in cases where extrapleural pneumonectomy (EPP) is still being considered an option after imaging studies. In a series of 118 successive patients, surgical staging involved laparoscopy with peritoneal lavage in order to detect subdiaphragmatic involvement. This was followed by mediastinoscopy. This procedure helped avoid inappropriate interventions in 16 patients (14%).

Other studies – There are many other types of studies that can provide clinically useful ancillary information.

• Mediastinoscopy has shown to be increasingly effective in mesothelioma diagnosis and staging. This is based on recent studies that have shown considerable negative prognostic effects of mediastinal nodal invasion.
• Usually, pulmonary function tests have shown a restrictive pattern, resulting from chest wall involvement and/or encasement of the lung.

Medicines: Generally, social workers and psychologists work with psychiatrists who are able to prescribe medicines in order to help control your distress. At times, a drug is required to manage distress resulting from cancer, or distress caused by a specific medicine used in cancer treatment or another serious symptom. For instance, steroids such as Decadron® and prednisone can lead to mood swings. At higher doses, opioid pain medicines such as Dilaudid®, morphine, or fentanyl can induce confused thinking. Specific medicines may be required to control these symptoms.

Medicines used to treat depression (anti-depressants) or those that are used to treat anxiety (anti-anxiety medicines) can be administered to control distress and manage symptoms like poor appetite and sleep. Certain patients are afraid to take these medicines thinking that – “I might get addicted”, or “I will become a zombie”. Often, these concerns are exaggerated, quite similar to the unreasonable fear of taking narcotics to reduce cancer pain. There are many people who also fear that visiting a psychiatrist would imply that they are “weak” or “crazy”. However, similar to other health professionals, psychiatrists too are usually able to reduce severe distress levels by providing effective counseling and helping select the best medicines.

Pastoral services

During a crisis, (for instance when you or one of your family members has been diagnosed with cancer), many individuals prefer to discuss issues with a person belonging to their religious or spiritual group. Nowadays, many clergy have received proper training in pastoral counseling for cancer patients. They are usually available to the cancer care team and they usually see patients who may not be having their own clergy or religious counselor.

There is a great deal of significance attached to pastoral services because knowing that you have cancer can result in a crisis of belief or faith. Some people may start questioning their life’s purpose or wonder why God chose them to be cancer victims. Other individuals may treat the cancer diagnosis as a punishment from God or an indication that God has left them. Cancer patients can rely on their spiritual and religious resources to deal with their illness and find answers to these questions.

Clergy can help you deal with concerns such as:

• Grief
• Concerns related to death and the afterlife
• Internal conflict or dented belief systems
• Loss of faith
• Concerns related to the meaning or purpose of life
• Concerns related to the relationship with a holy being or God
• Guilt
• Hopelessness
• Isolation from the religious community
• Conflict between existing beliefs and recommended treatment
• Need for specific types of rituals

Special issues

Specific situations require special skills, for instance grief counseling and sexual counseling.

For grief counseling, you will find the Association for Death Education and Counseling quite useful. They have plenty of resources for individuals who need help or for those who may want to provide support to another person trying to cope with a loss.

If you need the services of a trained professional who specializes in sexual counseling and sex therapy, you can get help from the American Association of Sex Educators, Counselors, and Therapists.

How to choose the right counselor

In case you wish to get help from a counselor, it makes sense to find one who may have proper training and experience in providing care to cancer patients. Your cancer care team can be your best resource for seeking referrals to providers in your locality. The Psychosocial Oncology Society (APOS) is another good resource. Within 2 business days, they will help you get in touch with someone through their toll-free service at 1-866-276-7443. Using their services, you will be able to find a trained professional in your local area who can provide counseling to cancer patients. You need to make a call and ask for other professionals in case you don’t feel safe talking to or are not comfortable with the first one.

Previous post on this topic.

Nausea and Vomiting: Their Relationship with Brain Signals

What causes nausea and vomiting? Directly or indirectly, the brain controls all bodily functions and the same applies to stomach upset and vomiting. The act of vomiting is controlled by a specific region within the brain, generally referred to as the vomiting center. This site lies on the floor of the fourth ventricle, a location within the brain called the area postrema. This neurological center comprises of an array of receptor cells that can result in nausea and vomiting when stimulated. Also called a circumventricular organ, the area postrema is located outside the blood brain barrier. This implies that it can receive stimulation from blood-borne cytotoxic agents among other things. Along with stimulation received from chemotherapies, the area postrema can also lead to side-effects (induce vomiting) due to signals received from other anatomical sites such as:

• The cerebral chemoreceptive trigger zone (CTZ) which can be stimulated by drugs, chemicals, or foreign matter present in the bloodstream
• Organs in the digestive tract and nerves that respond to disease or chemotherapeutic discomfort
• Limbic system receptor sites and cerebral cortex that are stimulated by pain, emotional discomfort, odors, sight and taste sensations
• Internal ear receptors that react to motion

Stimulations and reactions associated with the vomiting center occur when receptor cells come in contact with specific chemical compositions called neurotransmitters. These neurotransmitters travel to the area postrema carrying several different instructions that can induce varied types of nausea and vomiting symptoms such as:

• Breakthrough vomiting – This refers to chronic nausea and vomiting that prevails even after antiemetic (anti-nausea) drugs and other therapies have been administered
• Acute nausea and vomiting – This relates to stomach discomfort and vomiting that occurs within a few hours after chemotherapy is administered
• Delayed nausea and vomiting – These side-effects take 24 hours or more to manifest after chemotherapy is administered
• Anticipatory vomiting – This refers to a general behavior noticed among some patients who experience nausea and vomiting just prior to the start of the chemotherapy session

At certain places, the social worker may be the only resource, who may be handling all psychosocial, psychological and practical problems. Services like these are normally included as a part of your total care. Information about community resources is also available with social workers. That way they can refer you to other types of local help resources, apart from providing counseling.

Practical problems: These types of problems can vary from everyday requirements, for instance food and clothing, to professional requirements, for example job issues. Here are a few examples of the most common practical problems that you or your family members may face, and which may require you to get help from a social worker.

• Concerns related to the illness, for instance, how to reach the treatment facility everyday, how to arrange for parking costs, and which place to stay for overnight hospital visits that happen at out-of-town locations.

• Concerns about finance

• Concerns about the job

• School-related concerns

• Food costs and how to prepare

• Help with everyday activities

• Language or cultural differences (when your culture or language may not be the same as that of people around you)

• Arranging help for family members and caregivers

To deal with problems that may only be leading to mild distress, the social worker can provide patient and family education, initiate support group sessions, and make available resource lists. In case the distress is severe due to practical problems, patient and family counseling may be provided by the social worker. Other services provided by a social worker can include referring people to community resources, teaching effective approaches to problem-solving, helping you get the required care, and initiating education and support group sessions.

Mental health

Generally, mental health services deal with the evaluation and treatment of your distress in the moderate to severe range (4 or more when evaluated using the distress scale). This type of distress can be due to emotional or psychiatric problems that the individual may have had faced before the diagnosis of cancer. Certain problems that can make coping a lot more difficult include the following:

• Severe depression

• Dementia

• Panic attacks

• Anxiety

• Substance abuse

• Mood disorders

• Adjustment disorders

• Personality disorders

All the above may worsen due to the distress resulting from cancer diagnosis.

Usually, mental health services are offered by psychiatric nurses, psychiatrists, psychologists, and psychiatric social workers. Often, social workers and oncology nurses are also highly skilled and experienced in these specific areas. Normally, one of these members will be a part of your cancer care team. To help you cope, mental health professional rely on a wide variety of counseling and therapy approaches. They usually begin by helping you identify ways or approaches that may have proved effective for you earlier. These professionals will respect your individual coping style and attempt to strengthen it even more. They can make it possible for you to understand how past experiences or problems might be making it difficult for you to cope with the cancer. They can also teach you specific techniques such as meditation and relaxation to help you cope with your distress.