Emetogenicity of multiday chemotherapy regimens: Drug and patient factors affecting control of CINV

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Background: Multi-day chemo regimens have particular advantages in increasing tolerability and maintaining dose intensity of combination cytotoxic therapy. However repeated daily insults of therapy can make control of CINV challenging. Increased knowledge of factors affecting poor control of multi-day chemo, under current CINV prevention conditions, would be beneficial. Methods: A dataset of 621 patients treated in a blinded, randomised non-inferiority study (Grunberg SM, Gabrial NY, Clark G, MASCC 2007, Abstract # 18) of a granisetron transdermal patch (TDS, Sancuso) and oral granisetron, was analysed. As TDS was shown to be non-inferior to oral granisetron, data from both arms were used. All patients had received 3–5 days of moderately or highly emetogenic chemotherapy. Total Control of CINV over Day 1 and Days 1–3 was used as the efficacy endpoint. Stepwise logistic regression analysis was used to assess the predictive performance of patient and chemotherapy factors. Wald chi-squared statistics and Akaike criteria were used to measure significance of predictive factors and model fit, respectively. Results: The simple sum of emetogenicity scores of each cytotoxic (Grunberg SM,(2005) Evaluation of new antiemetic agents_an update. Support Care Cancer (2005) 13: 80–84) provided best overall prediction of emetogenicity of the multiday regimen. Cisplatin was more emetogenic and doxorubicin less so compared to established scoring (Grunberg SM,(2005) Evaluation of new antiemetic agents_an update. Support Care Cancer (2005) 13: 80–84). Age and gender were significant in predicting control: females <60 and males <40years being at risk. A genitourinary site of cancer was also an independent risk factor. Smoking, alcohol use, previous chemotherapy and performance score had no significant effect on risk of CINV. Conclusions: Established emetogenicity scores, derived from historical data on untreated patients, are relevant to multi-day chemo but could be revised to improve prediction of CINV. Cisplatin has a stronger impact on poor control in multi-day than single-agent scoring predicts. Age and gender factors remain important; but with different age breaks for male and female. These and tumour site factors should be taken into account when designing clinical trials or analysing data relating to antiemetics and CINV.

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Effects of developmental age, ambient temperature, and dietary alterations on delta(12) desaturase activity in the house cricket, Acheta domesticus

Double bond formation in polyunsaturated fatty acids (PUFA) is mediated by desaturase enzymes. Certain insect species have been found to possess a Delta(12) desaturase, previously thought to occur exclusively in plants. We have begun to characterize this enzyme to determine its relatedness to those found in plants and animals. Desaturase activity can be altered significantly by a number of environmental factors in protozoa, cyanobacteria, plants, fish, and rats. We present evidence here that Delta(12) desaturase activity in Acheta domesticus is affected by developmental stage, starvation, dietary alterations, and fluctuations in ambient temperature. Highest activity is observed during the middle of the penultimate instar and 3 to 6 days after adult emergence. Starvation markedly decreases Delta(12) activity, whereas resumption of feeding on fat-free or low fat diets increases activity.

Intra-arterial 5-fluorouracil and intravenous folinic acid in the treatment of liver metastases from colorectal cancer

OBJECTIVE

To compare two regimens of intra-arterial chemotherapy for the treatment of hepatic metastases from colorectal cancer.

DESIGN

Open study.

SETTING

Teaching hospital, UK SUBJECT: 57 patients with unresectable metastases confined to the liver, and an indwelling catheter in the hepatic artery.

INTERVENTIONS

The first 33 patients had a 24-hour intra-arterial infusion of 5-fluorouracil (5-FU) 1500 mg/m2, together with folinic acid 200 mg/m2 intravenously for the first and last two hours of the 5-FU infusion. This was repeated at weekly intervals for six weeks followed by a two-week gap before the next cycle. The remaining 24 patients had a two-weekly regimen in which folinic acid 200 mg/m2 was infused intravenously over 2 hours followed by an intra-arterial loading dose of 5-FU 400 mg/m2 over 15 minutes; 5-FU 1600 mg/m2 was then given by intra-arterial infusion over 22 hours. This was repeated on day 2 and then at two-weekly intervals.

MAIN OUTCOME MEASURES

Response rate and toxicity.

RESULTS

Median follow-up was 21 months, and estimated median survival 19 months. 29 patients (51%) have responded, 5 completely. There are no significant differences between the groups. Sites of progression were liver alone 26 (53%), lung alone 9 (18%), liver and lung 3 (6%), and the remainder in local or regional nodes (n = 7) or bone (n = 4). Six patients experienced WHO grade 3 or 4 toxicity.

CONCLUSION

The two regimens have high response rates and cause little systemic toxicity. Intra-arterial chemotherapy for hepatic metastases from colorectal cancer is currently being compared with conventional systemic chemotherapy in a randomised controlled trial.

The physician's role in a world of technology

Technology has come to dominate the medical world over the past 100 years. Some of this technology has come from science and some has been imported from the world of business. Some technology exists in the form of physical objects; other technology takes the form of systems and organization. Technology to manage information has played a particularly critical role in changing how medicine is practiced. Those who choose to apply the latest technologies to patient care do so in ways that are not merely a reflection of some "objective" set of scientific data. Rather, the use of technology transforms both the clinical encounter and the technology itself, and in so doing reflects the values of those who created and those who use the technology. Despite the many ways that technology has come to be used for medical care over the course of the past century, the role of the physician has remained central.

Evaluation of a follow-up programme after curative resection for colorectal cancer

Frequent liver imaging can detect liver metastases from colorectal cancer at an asymptomatic stage.

Making a medical practice in an uneasy world: some thoughts from a century ago

A century ago medical trainees in the United States faced many of the same sorts of issues that confront trainees today. For practical advice in setting up their practices, many of those trainees turned to a book by physician David Cathell called The Physician Himself, which was first published in 1882 and was reprinted many times thereafter. This paper explores the advice Cathell offered in his book as well as parallels with events of the recent past, discussing Cathell's opinions on physician overcrowding, medical education, new technology such as the telephone and the automobile, and the sensitive ethical issues that physicians must deal with. The paper concludes that because being an excellent physician in both Cathell's time and today requires more than good science, Cathell's book helps to remind us of the social world in which medicine is practiced.

Infusion pumps for systemic and intra-arterial chemotherapy of colorectal liver metastases

Over a 12 month period, we prospectively evaluated the use of an ambulatory infusion pump for intra-arterial and intravenous chemotherapy in patients with colorectal liver metastases. In all, 274 separate infusions were given with minor complications occurring on six occasions. Administering treatment on an outpatient basis rather than as an inpatient has resulted in savings of over Pounds 17000 in the first year.

A phase II study of regional 2-weekly 5-fluorouracil infusion with intravenous folinic acid in the treatment of colorectal liver metastases

Forty patients with unresectable colorectal metastases confined to the liver were evaluated in a phase II study. 5-Fluorouracil (5-FU) was delivered via a surgically placed hepatic artery catheter. Patients received folinic acid (200 mg m-2) intravenously over 2 h followed by a loading dose of intra-arterial 5-FU (400 mg m-2) over 15 min, then 5-FU (1600 mg m-2) by intra-arterial infusion over the following 22 h. This was repeated on day 2 and the whole schedule was repeated every 2 weeks. Response was assessed after six treatments. The median follow-up was 17 months. Overall response rate was 46% with 8% complete response. Estimated median survival is 19 months. Site of progression was the liver alone in 55%, liver and lung in another 16% and 29% in other sites. Eight patients experienced grade 3 or 4 toxicity. The response rate of this regimen compares favourably with reported trials of intra-arterial FUDR, and our schedule is currently being compared with a similar schedule of intravenous 5-FU and folinic acid in a randomized Medical Research Council trial (CR05).

Creating university hospitals: rationales and realities

This article analyzes the reasons given for the founding of three early university hospitals: those at the University of Michigan, the University of Pennsylvania, and Johns Hopkins University. The hospital at the University of Michigan was founded to ensure medical students' access to clinical instruction. The University of Pennsylvania's desire to have not only access to but control over hospital affairs provided the impetus to build a university hospital. Johns Hopkins University, building upon the examples of Michigan and Pennsylvania, firmly joined the hospital and medical school and introduced research as a link between these institutions. The early histories of these three institutions demonstrate how each created a different mission for its university hospital. Today, as in the past, university hospitals must choose which of their multiple roles to emphasize. The meaning of "university hospital" has always been ambiguous, and this ambiguity can provide useful flexibility to institutions responding to a changing environment.

Medical history in the undergraduate medical curriculum

History has long played a role in the education of American physicians, but the uses of medicine's past have changed over time. In the late nineteenth century, some physicians taught medical history to their students to supply a sense of continuity with professional traditions in times of rapid and bewildering change. Other physicians believed that instruction in medical history would impart a sense of refinement to medical practitioners. In the late twentieth century, medical history is increasingly viewed as a significant dimension of the professional, intellectual, and humanistic development of medical students. Further, it is one of the principal means by which recent, radical changes in health care can be given needed perspective. The knowledge that medicine and the medical sciences are fundamentally social enterprises is an important lesson for medical students. Through exposure to the history of health care, students also learn that medical knowledge is itself subject to change and is acquired in specific contexts. In the 1990s, medical history is taught in a variety of settings. In some schools, history is integrated into the teaching of medical humanities. Where medical history is institutionally distinct from the humanities, courses in medical history may be either elective or required. In order to reach students at every stage of their medical education, historians and clinicians can join forces to teach history in innovative and flexible programs.

Histories of academic medical education

The author discusses the ways in which the history of medicine has changed in recent times, from an emphasis on celebrating past events to a focus on elucidating the nature of changes in medical care. Characteristic historical methodologies are described, including a tendency to use multiple types of sources. The importance of education in medical history and the potential utility of the study of history for contemporary medical practice are emphasized. The author gives examples of the many ways in which the history of medical education might be conceptualized.

Septic arthritis of the hip complicating pregnancy

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Resident-patient interactions: the humanistic qualities of internal medicine residents assessed by patients, attending physicians, program supervisors, and nurses

BACKGROUND

The patient-physician relationship is central to medical practice. Increasingly, educators and certifying bodies seek to assess trainees' humanistic qualities.

METHOD

The humanistic qualities of first-year internal medicine residents were rated in 1987-88 and 1988-89 by patients hospitalized on the general internal medicine and pulmonary services of the University of Michigan Hospital. Attending physicians (for 1988-89 only), program supervisors (program directors and chief residents), and nurses (for 1988-89 only) rated the same residents, and these ratings were compared with those of the patients.

RESULTS

A total of 625 patient questionnaires for 70 residents were analyzed, with a mean of nine patient evaluations per resident and a range from four to 24. Analysis showed that more than 50 patients would need to rate each resident to achieve desired levels of reproducibility. Large numbers of attending physicians (20 to 50) would also be required to obtain a reproducible assessment; the attending physicians' ratings correlated only moderated well (r = .26) with the patients' ratings. Ratings from smaller numbers of program supervisors (five to ten) and nurses (ten to 20) would be needed for reproducible assessments. However, only the nurses' ratings showed a moderately strong relationship (r = .35) with the patients' ratings.

CONCLUSIONS

Patients, attending physicians, program supervisors, and nurses view differently the humanistic attributes of residents as they interact with patients. Large numbers of patients and attending physicians would be needed to obtain reproducible ratings. Nurses' and program supervisors' ratings are much more reproducible, but nurses' perceptions correlate more closely to those of patients.

The storage of tetanus vaccine in accident and emergency departments: a postal survey

The aim of this study was to assess the quality of storage of tetanus vaccine in accident and emergency (A&E) departments and also of the awareness of Department of Health guidelines. A postal questionnaire was sent to 50 randomly selected major A&E departments in the British Isles, enquiring about awareness of Department of Health guidelines (Department of Health, 1990). Forty (80%) A&E departments responded. Only 14 were aware of the Department of Health guidelines and in only 18 was there a member of staff taking responsibility for vaccine storage. The study found that safe storage of vaccine, and therefore guarantee of efficacy, is not occurring in the majority of A&E departments. Unnoticed failure of refrigerators could be exposing patients to the risk of tetanus infection.

Patterns of alcohol use and abuse among aging Civil War veterans, 1865-1920

Given the extent of alcoholism among elderly people, it is remarkable how little is known about the biomedical and social dimensions of alcohol use and abuse in late life. In the absence of compelling longitudinal data drawn from contemporary sources, a historical perspective may help to illuminate the incidence and consequences of alcohol abuse among the elderly. Based on a study of 370 case histories drawn from the National Military Home in Dayton, Ohio, which around the turn of the century was the nation's largest old-age home, it appears that alcohol's social ramifications were more important than its pathological or physiological manifestations in late 19th-century America. Drinking habits among aging Civil War veterans varied considerably: moderate consumption was acceptable; too much of a good thing caused problems.

Regional variation in 1917 health care expenditures

In 1917, the Bureau of Labor Statistics surveyed 11,946 white households nationwide, recording demographic variables and yearly expenses on physicians, medicines, nurses, and hospitals. There was significant variation in these medical expenses among the nine census bureau regions. Using a multivariate analysis, we demonstrated that some of the variation could be explained by household variables, such as household income and size, some of the variability could be explained by the availability of physicians and hospital beds, and some could be explained by interactions between the different types of health care. However, after accounting for these possible explanatory variables, significant regional variation remained. We conclude that regional variation in health care expenditures is not new, and that studying how regional variation has changed during the twentieth century is likely to help explain why that variation exists today.

Progression of hydrocephalus during corticosteroid therapy for neurosarcoidosis

We describe a patient with sarcoid meningitis and hydrocephalus who improved rapidly after initiation of oral prednisone therapy, but who later decompensated acutely and required an emergency ventriculoperitoneal shunt. Hydrocephalus associated with neurosarcoidosis may progress despite steroid treatment, even when symptoms have improved. If hydrocephalus associated with neurosarcoidosis is treated with corticosteroids and without a shunt procedure we suggest that the corticosteroids should be continued at high doses for a prolonged period.

The invention and development of American internal medicine

During the early twentieth century American physicians considered several different ways to identify medical specialists. The first autonomous specialty board was incorporated in 1924, and over the next few decades the board system became the accepted system for credentialing specialists. In 1936 the American Board of Internal Medicine (ABIM) became the twelfth specialty board. It was intended to recognize only a few outstanding internists, for the ABIM's founders believed that general practitioners should continue to deliver the vast majority of care. However, World War II greatly increased the importance of the ABIM and of the specialty boards system. The army medical services emphasized the importance of board certification, thus encouraging physicians to receive residency training and to sit for a specialty board. After the war, the expanding VA hospital system provided them a place to do so. Specialty training and board certification became the norm, not the exception. Also, the national exigencies of World War II forced Congress to devise a new system to distribute federal funds for biomedical research to universities. That system, continued as the National Institutes of Health, supported the subsequent growth of internal medicine in general, as well as its subspecialties. Both the ABIM and the other specialty boards were formed at a particular time and place in response to the specific interests of individuals and organizations, and their histories reflect both the ideals of their founders and the long-term structural effects of war.

One hundred years of clinical preventive medicine in America

The history of clinical preventive medicine has been shaped by the interactions of biomedical knowledge and sociopolitical forces. In the late nineteenth century, medical thinking shifted from the belief that diseases were caused by general bodily imbalances to the belief that diseases were caused by specific agents, and that they might be amenable to specific preventive and therapeutic approaches. During the twentieth century, preventive medicine moved from advocating a public health, community-based approach toward preventing specific diseases in individual patients. The establishment of preventive medicine as a discipline has been fostered both by recent concerns that medical care emphasizes cure, rather than care, and by efforts to reduce health care costs.

The humanities, humanistic behavior, and the humane physician: a cautionary note

Efforts to teach and evaluate humanistic qualities in physicians in residency training are marred by ambiguous goals. The humane physician can be characterized by four distinct qualities: technical competence, humanistic attitude, knowledge of humanistic concepts, and humanistic behavior. Education in the humanities can foster humanistic attitudes, but it cannot promise to lead to changes in behavior. Likewise, although formal training in communication teaches the skills necessary for humanistic behavior, without an understanding of humanistic concepts these skills may not serve medical or moral ends. Evaluation of the humane physician must also include modalities that test attitude, knowledge, and behavior. Testing one characteristic does not ensure competence in other areas; knowledge of the requirements for informed consent, for example, does not guarantee one's ability to discuss this concept effectively with patients. In this article, we suggest ways to combine the humanities and communication skills in the clinical setting and we emphasize both the training and the evaluation of humane physicians.

The changing face of twentieth-century American cardiology

The meaning of American cardiology has been transformed over the past century. During that time, cardiology has been defined by several organizations: by the American Board of Internal Medicine through subspecialty certifications; by the two major American cardiology societies, the American Heart Association and the American College of Cardiology; and by the four major cardiology journals. These organizations have sometimes cooperated, sometimes competed. Cardiology has also had to negotiate relationships with several external interest groups, including pediatrics, surgery, hospitals, and internal medicine. Throughout the 20th century, the word cardiology has had no meaning save its definition within a larger web of organizations, relationships, and ideas. The meaning, like the meaning of all specialties and subspecialties, is historically mediated and constantly changing.

Perceptions of ethical problems by nurses and doctors

To identify how nurses and physicians perceive ethical problems in clinical medicine, we conducted structured interviews with 26 nurses and 24 physicians who work in acute-care units. Both groups thought that they frequently encounter ethical problems, although there was significant variation within each group about how often members of each group perceived such problems. Members of the health-care team often disagreed about ethical decisions. Nurses often described conflicts with physicians, but physicians rarely recognized disagreements with nurses. Clinical ethicists need to be aware of this heterogeneous perception in order to communicate effectively about ethical problems.

"Soldier's heart": the redefinition of heart disease and specialty formation in early twentieth-century Great Britain

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