Association of Arts Event Attendance With Cognitive Function Among Older Adults Enrolled in the Health and Retirement Study

Background and Objectives

Among the cognitively impaired, arts engagement is associated with improved neurocognitive symptoms. Less is known about arts engagement as a potentially modifiable lifestyle factor to prevent or slow cognitive decline. Our aim was to evaluate the association between arts event attendance and cognition.

Research Design and Methods

We used data from the 2014 and 2016 waves of the Health and Retirement Study to evaluate the association between arts event attendance and cognition using multivariable linear regressions. Arts event attendance in 2014 was our exposure of interest and included visiting an art museum or art gallery; attending an arts or crafts fair; attending a live performance (concert, play, or reading); and/or going to a movie theater. Cognitive function in 2016 measured on a 27-point scale by the Telephone Interview for Cognitive Status was our main outcome of interest.

Results

Of the 1,149 participants included in the final analysis, 70.7% attended an arts event. The mean baseline cognitive score was higher among those who attended art events (16.8 [standard deviation {SD}, ±3.8] vs 13.8 [SD, ±5.0]; p < .001). In our multivariable regressions, those who attended arts events in 2014 exhibited higher cognitive scores in 2016 after controlling for demographic, socioeconomic, health, and baseline cognitive covariates (β, 1.07 [95% confidence interval {CI}, 0.50-1.64]; p < .001). This association was primarily observed in those with lower baseline cognitive function (β, 1.19 [95% CI, 0.33-2.06]; p = .008).

Discussion and Implications

Arts event attendance may be associated with better cognitive function. Given concerns for residual confounding and reverse causality, this association warrants further study.

From Individualized Interactions to Standardized Schedules: A History of Time Organization in U.S. Outpatient Medicine

Many outpatient physicians and patients feel that current scheduling systems do not afford enough time for direct patient-physician interaction, leaving patients feeling unheard and physicians feeling demoralized. This dissatisfaction degrades patients' trust in the health care system and contributes to workforce moral injury and burnout. In the hopes of understanding the roots of this time stress and helping to guide future decisions about how to organize physicians' time, this article describes changes in the organization of U.S. outpatient physicians' time, starting from care at home in the late 19th century. It discusses the origins of the appointment system, which was invented to be highly personalized, with assistants adjusting appointment durations to accommodate clinical activities, specific patient needs, and individual physician proclivities. The article then describes how centralization of appointment scheduling became more common as U.S. medicine became increasingly consolidated into larger and larger groups and health systems. This distanced schedulers from the people and care they were organizing and necessitated standardized appointment durations, which did not accommodate individual patient and physician needs. With the rise of managerialism, schedulers became increasingly accountable to administrators rather than patients and physicians. Whereas early appointment systems depended on personal connection between schedulers and the physicians and patients they supported, today's schedulers have few such interactions. The widespread shift to centralized scheduling and standardized time slots has contributed to misalignment among time allocation, patient care, and health care workforce well-being and is likely exacerbating ongoing tensions among patients, physicians, and administrators.

Design, implementation, and reflections on a two-week virtual visual arts and medicine course for third- and fourth-year medical students

BACKGROUND

Medical humanities courses that incorporate the visual arts traditionally require in-person instruction and visits to museums. The COVID-19 pandemic afforded medical educators a unique opportunity to implement and evaluate virtual visual arts programming.

METHODS

A two-week, 7-module visual arts and medicine elective course for third and fourth-year medical students was conducted virtually in the Spring of 2021. The course included traditional didactic components as well as a range of hands-on creative art activities including painting, graphic medicine, photovoice, and Kintsugi (Japanese craft). Digital tools including Canvas, Google Jamboard, and Zoom facilitated student engagement. Student feedback was collected through anonymous post-course surveys.

RESULTS

We successfully conducted a virtual visual arts and medicine elective which integrated hands-on creative art activities. Most students "strongly agreed" that remote instruction was sufficient to meet course objectives. However, all students also "agreed" that in-person instruction may promote more in-depth engagement with the visual arts. The hands-on creative art activities were appreciated by all students.

CONCLUSION

Visual arts-based medical humanities courses can be delivered virtually and can include hands-on creative art activities such as painting. Future visual arts and medicine courses may benefit from incorporating a range of pedagogical methodologies, digital tools, control groups, and pre-/post-course assessments.

Entanglements of Eugenics, Public Health, and Academic Medicine: Reckoning with the Life and Legacies of Victor C. Vaughan

Victor C. Vaughan (1851-1929) was a noted medical educator, microbiologist, and active proponent for the idea of eugenics. Vaughan spent his career at the University of Michigan, where he served as Medical School Dean for many years. He lectured widely on the importance of "race betterment" and actively supported passage of state legislation that led to over 3,000 sterilizations in the state of Michigan. After his death, Vaughan's name was applied to student organizations, endowed chairs, buildings, and more. This paper considers how the use of Vaughan's name not only reflected Vaughan's support of eugenics but also gendered and racialized ideas about what it means to be a physician. We conclude that the use of any name from the past carries meanings about what our values are in the present and that, if there was ever a moment to celebrate the life of Victor Vaughan, that moment has passed.

The evolution of prenatal care delivery guidelines in the United States

The coronavirus disease 2019 pandemic led to some of the most drastic changes in clinical care delivery ever seen in the United States. Almost overnight, providers of prenatal care adopted virtual visits and reduced visit schedules. These changes stood in stark contrast to the 12 to 14 in-person prenatal visit schedule that had been previously recommended for almost a century. As maternity care providers consider what prenatal care delivery changes we should maintain following the acute pandemic, we may gain insight from understanding the evolution of prenatal care delivery guidelines. In this paper, we start by sketching out the relatively unstructured beginnings of prenatal care in the 19th century. Most medical care fell within the domain of laypeople, and childbirth was a central feature of female domestic culture. We explore how early discoveries about "toxemia" created the groundwork for future prenatal care interventions, including screening of urine and blood pressure-which in turn created a need for routine prenatal care visits. We then discuss the organization of the medical profession, including the field of obstetrics and gynecology. In the early 20th century, new data increasingly revealed high rates of both infant and maternal mortalities, leading to a greater emphasis on prenatal care. These discoveries culminated in the first codification of a prenatal visit schedule in 1930 by the Children's Bureau. Surprisingly, this schedule remained essentially unchanged for almost a century. Through the founding of the American College of Obstetricians and Gynecologists, significant technological advancements in laboratory testing and ultrasonography, and calls of the National Institutes of Health Task Force for changes in prenatal care delivery in 1989, prenatal care recommendations continued to be the same as they had been in 1930-monthly visits until 28 weeks' gestation, bimonthly visits until 36 weeks' gestation, and weekly visits until delivery. However, coronavirus disease 2019 forced us to change, to reconsider both the need for in-person visits and frequency of visits. Currently, as we transition from the acute pandemic, we should consider how to use what we have learned in this unprecedented time to shape future prenatal care. Lessons from a century of prenatal care provide valuable insights to inform the next generation of prenatal care delivery.

Visual arts in the clinical clerkship: a pilot cluster-randomized, controlled trial

BACKGROUND

Arts exposure is associated with positive psychological constructs. To date, no randomized, controlled studies have integrated art into clinical medical education or measured its effects on positive psychological constructs or educational outcomes. In this study, we assessed the possibility and potential benefits of integrating visual arts education into a required internal medicine (IM) clinical clerkship.

METHODS

We conducted a controlled trial in an academic healthcare system with an affiliated art museum. IM students were assigned to one of three interventions: museum-based arts (n = 11), hospital-based arts (n = 10), or hospital-based conventional education (n = 13). Arts groups explored empathy, resilience, and compassion in works of art during facilitator-guided discussions. We assessed pre- and post-intervention measures of empathy, mindfulness, tolerance of ambiguity, and grit and tracked National Board of Medical Examiners IM shelf exam performance to capture changes in educational outcomes. Focus group discussions with participants in the arts-based interventions were performed at the study's conclusion.

RESULTS

Arts education was successfully integrated into a busy clinical clerkship in both hospital and art museum settings. Focus group participants reported increased implicit bias cognizance and time for reflection, but no significant differences in psychometric or educational outcomes were identified. While most students felt positively toward the experience; some experienced distress from missed clinical time.

CONCLUSIONS

This pilot study demonstrates the feasibility of integrating visual arts education into the clerkship. Although observable quantitative differences in measures of positive psychological constructs and educational outcomes were not found, qualitative assessment suggested benefits as well as the feasibility of bringing fine arts instruction into the clinical space. A larger, multi-center study is warranted.

Paradoxes of professional autonomy: a qualitative study of U.S. neonatologists from 1978-2017

The professional autonomy of physicians often requires they take responsibility for life and death decisions, but they must also find ways to avoid bearing the full weight of such decisions. We conducted in-person, semi-structured interviews with neonatologists (n = 20) in four waves between 1978 and 2017 in a single Midwestern U.S. city. Using open coding analysis, we found over time that neonatologists described changes in their sense of professional autonomy and responsibility for decisions with life and death consequences. Through the early 1990s, as neonatology consolidated as a profession, physicians simultaneously enjoyed high levels of professional discretion and responsibility and were often constrained by bioethics and the law. By 2010s, high involvement of parents and collaboration with multiple subspecialties diffused the burden felt by individual practitioners, but neonatology's professional autonomy was correlatively diminished. Decision-making in the NICU over four decades reveal a complex relationship between the professional autonomy of neonatologist and the burden they bear, with some instances of ceding autonomy as a protective measure and other situations of unwelcomed erosion of professional autonomy that neonatologists see as complicating provision of care.

The Empirical Foundations of Telemedicine Interventions in Primary Care

INTRODUCTION

This article presents the scientific evidence for the merits of telemedicine interventions in primary care. Although there is no uniform and consistent definition of primary care, most agree that it occupies a central role in the healthcare system as first contact for patients seeking care, as well as gatekeeper and coordinator of care. It enables and supports patient-centered care, the medical home, managed care, accountable care, and population health. Increasing concerns about sustainability and the anticipated shortages of primary care physicians have sparked interest in exploring the potential of telemedicine in addressing many of the challenges facing primary care in the United States and the world.

MATERIALS AND METHODS

The findings are based on a systematic review of scientific studies published from 2005 through 2015. The initial search yielded 2,308 articles, with 86 meeting the inclusion criteria. Evidence is organized and evaluated according to feasibility/acceptance, intermediate outcomes, health outcomes, and cost.

RESULTS

The majority of studies support the feasibility/acceptance of telemedicine for use in primary care, although it varies significantly by demographic variables, such as gender, age, and socioeconomic status, and telemedicine has often been found more acceptable by patients than healthcare providers. Outcomes data are limited but overall suggest that telemedicine interventions are generally at least as effective as traditional care. Cost analyses vary, but telemedicine in primary care is increasingly demonstrated to be cost-effective.

CONCLUSIONS

Telemedicine has significant potential to address many of the challenges facing primary care in today's healthcare environment. Challenges still remain in validating its impact on clinical outcomes with scientific rigor, as well as in standardizing methods to assess cost, but patient and provider acceptance is increasingly making telemedicine a viable and integral component of primary care around the world.

War, Medicine, and Cultural Diplomacy in the Americas: Frank Wilson and Brazilian cardiology

American cultural diplomacy played a key role in the institutionalization of Brazilian cardiology. In 1942, Frank Wilson, an internationally recognized pioneer in electrocardiography, made an extended wartime visit to Rio de Janeiro and São Paulo. The visit was sponsored by the United States Department of State as part of Roosevelt's Good Neighbor Policy and brought Wilson together with a group of physicians who would establish the specialty of cardiology in Brazil. This US cultural and diplomatic initiative strengthened an academic network that was already evolving and would eventually prove to be of benefit to both sides. Latin American physicians began in the 1920s to visit Wilson's laboratory at the University of Michigan, where they established the relationships on which Wilson would build. While affiliation with the "Wilson school" advanced the cause of Brazilian cardiologists who sought to establish themselves as specialists, cooperation with Latin American physicians benefitted Wilson in his pursuit of wider recognition for his innovations in the use of electrocardiography (ECG). Wilson's identity as a scientific ambassador to Latin America helped in legitimating his approach to the clinical application of the ECG. A close examination of Wilson's relationship to Brazilian cardiology demonstrates the role played by science and medicine as a part of wartime cultural diplomacy, as well as the dynamics of the transnational circulation of scientific knowledge and practices.

Visceral Vistas: Basil Hirschowitz and the Birth of Fiberoptic Endoscopy

Fiberoptic endoscopy was developed at the University of Michigan in the 1950s by gastroenterology fellow Basil Hirschowitz and 2 physicists. Previous methods to visualize the gastrointestinal lumen used rigid instruments that relied on rudimentary optical systems. They were limited in reach and caused patients considerable discomfort. Fiberoptic technology dramatically changed endoscopic practice. The fiberoptic endoscope, or fiberscope, was a flexible instrument that allowed direct inspection of the gastrointestinal lumen. Although many practicing endoscopists initially resisted its adoption, the fiberscope ultimately held sway. Studying the period from the fiberscope's first introduction in the late 1950s to its more widespread acceptance in the late 1960s may help us understand how a new technology makes its way into routine clinical practice.

The heartfelt music of Ludwig van Beethoven

Musicologists, historians, and physicians have speculated that Beethoven experienced cardiac arrhythmias, and that they manifest in specific compositions. Based on what is known about Beethoven's medical issues, this seems a reasonable assumption to make. This essay strengthens the hypothesis that Beethoven suffered from cardiac arrhythmias by placing Beethoven's music in its historical context, and by identifying several compositions that may reflect Beethoven's experience of an arrhythmia.

The changing meaning of a health care workforce

In this commentary, the author describes how the meaning of the health care workforce has changed, focusing on the physician workforce. Some questions have been asked consistently over the years: How many should we have? What type? Where should they work? In 1830 there were no licensing laws, and every literate American could be a member of the health care workforce by following detailed instructions in a popular handbook. Subsequent years saw the initiation of state licensing laws and the reform of medical education. Medical specialties and specialty boards were created, although it was not until after World War II that the dominance of the general practitioner gave way to specialists. For over a century, estimates of physician supply have swung between "too many" and "too few." Rural and economically disadvantaged communities have long struggled with access to health care providers. The author also identifies some issues that have only been considered fairly recently, such as the ethnic and gender diversity of the workforce. Wars have played a major role in changing ideas about the workforce, often in ways that long outlast the actual dates of the conflict. The meaning of the health care workforce has always been deeply embedded in a specific social, political, and economic context.

An international health elective in Haiti: a case for osteopathic medicine

As global health education becomes increasingly important, more physicians are participating in international health electives (IHEs). Haiti is a favorable site for an IHE because of its substantial health care needs and rich culture. Although both osteopathic and allopathic physicians can provide effective health care to Haitians, osteopathic physicians may be particularly well suited to serve in Haiti because of their training in osteopathic manipulative treatment (OMT). Because OMT's laying of the hands (high touch) is similar to the touch inherent to Haiti's traditional ethnomedical practices, osteopathic physicians' use of OMT can enhance trust among Haitians and increase Haitians' willingness to work with westernized medical practitioners. In addition, an IHE in a low-resource country such as Haiti can provide osteopathic physicians with a global outlook on medicine and a range of critical communication and clinical skills. The authors advocate for the development of an IHE in Haiti for osteopathic physicians.

Reflections on the past and future of primary care

Medical care and primary care were at one time synonymous. All health care was primary. The concept and terminology of primary care came into widespread use during the 1960s, reflecting a specific policy agenda: bolstering the role of the generalist physician, which had changed dramatically following World War II. This essay describes the transformation of the nineteenth-century physician making house calls on horseback into the twenty-first-century primary care physician contemplating the electronic records of her patient population. The essential point is that "primary care" was born out of tension with other forms of medical care. In the future, primary care will be reinvented, and changes will be caused by the sorts of external social, political, and economic forces that previously led to systemic transformation.

Maintaining connections: some thoughts on the value of intensive care unit rounding for general medicine ward teams

When established ward patients are unexpectedly transferred to an intensive care unit (ICU), the ward team should continue to follow them. Although there may be reasons not to do so, the advantages outweigh the obstacles. Great pedagogic value can be gained from following patients after acute decompensation, but a more important reason is that by following patients into the ICU, the ward team can enact for both patients and their families the twin virtues of caring and continuity. Doing so also demonstrates the highest ideals of medicine-that we are focused not on defined areas of turf, but on our patient's well-being. It shows that we are not merely doing narrowly defined "shift work," but that we truly care about our patients. Rounding on established patients who have been transferred into the ICU is the sort of behavior that undergirds the fundamental bases of professionalism. It takes a few minutes from a busy day, but it can be incredibly beneficial for families, patients, and the ideals of medicine.

Coronary heart disease and heart attacks, 1912-2010

This paper was originally written for a conference entitled ‘The Future of Medical History. Now it ought to be clear – certainly to historians – that the future of anything is hard to predict; but at least in the short term, any future for medical history seems likely to include the history of disease, and the history of coronary heart disease (CHD) provides an excellent example of what the history of disease has to offer to a wide range of audiences.

Implementation science: how to jump‐start infection prevention

Implementing evidence&#x2010;based infection prevention practices is challenging. Implementation science, which is the study of methods promoting the uptake of evidence into practice, addresses the gap between theory and practice. Just as healthcare epidemiology has emerged as a paradigm for patient safety, infection prevention may serve as a clinical model for implementation researchers.

Teaching community-based participatory research principles to physicians enrolled in a health services research fellowship

To improve health and reduce inequities through health services research, investigators are increasingly actively involving individuals and institutions who would be affected by the research. In one such approach, community-based participatory research (CBPR), community members participate in every aspect of designing and implementing research with the expectation that this process will enhance the translation of research into practice in communities. Because few physician researchers have expertise in such community-based approaches to research, the Robert Wood Johnson Foundation leadership expanded the mission of the Robert Wood Johnson Clinical Scholars Program (RWJCSP), which historically focused on health services and clinical research, to include training and mentored experiences in CBPR.The authors discuss the three years of experience (2005-2008) implementing the new community research curricula at the four RWJCSP sites: University of California, Los Angeles; University of Pennsylvania in Philadelphia; University of Michigan in Ann Arbor; and Yale University in New Haven. Three common goals and objectives are identified across sites: teaching the principles of CBPR, providing opportunities for conducting CBPR, and making an impact on the health of the communities served. Each site's different approaches to teaching CBPR based on the nature of the existing community and academic environments are described. The authors use illustrative quotes to exemplify three key challenges that training programs face when integrating community-partnered approaches into traditional research training: relationship building, balancing goals of education/scholarship/relationships/product, and sustainability. Finally, the authors offer insights and implications for those who may wish to integrate CBPR training into their research training curricula.

A history of the American Society for Clinical Investigation

One hundred years ago, in 1909, the American Society for Clinical Investigation (ASCI) held its first annual meeting. The founding members based this new society on a revolutionary approach to research that emphasized newer physiological methods. In 1924 the ASCI started a new journal, the Journal of Clinical Investigation. The ASCI has also held an annual meeting almost every year. The society has long debated who could be a member, with discussions about whether members must be physicians, what sorts of research they could do, and the role of women within the society. The ASCI has also grappled with what else the society should do, especially whether it ought to take a stand on policy issues. ASCI history has reflected changing social, political, and economic contexts, including several wars, concerns about the ethics of biomedical research, massive increases in federal research funding, and an increasingly large and specialized medical environment.

Where should hospitalists sit within the academic medical center?

One of the most significant changes in US hospitals over the past decade has been the emergence of hospitalists as key providers of inpatient care. The number of hospitalists in both community and teaching hospitals is growing rapidly, and as the field burgeons, many are questioning where hospitalists should reside within the academic medical center (AMC). Should they be a distinct division or department, or should they be incorporated into existing divisions? We describe hospital medicine's current trajectory and provide recommendations for hospital medicine's place in the AMC. Local social and economic factors are most likely to determine whether hospital medicine programs will become independent divisions at most AMCs. We believe that in many large AMCs, separate divisions of hospital medicine are less likely to form soon, and in our opinion should not form until they are able to fulfill the tripartite mission traditionally carried out by independent specialist divisions. At community hospitals and less research-oriented AMCs, hospital medicine programs may soon be ready to become separate divisions.

Tall girls: the social shaping of a medical therapy

During the latter half of the 20th century, estrogen therapy was administered to prevent otherwise healthy girls with tall stature from becoming tall adults by inhibiting further linear growth. We explore how decisions to treat tall girls with estrogen were influenced by both scientific knowledge and sociologic norms. Estrogen therapy represented the logical application of scientific knowledge regarding the role of estrogen for closure of the growth plates, but it also reflected prevailing societal and political beliefs about what it meant to be a tall girl. We discuss the rise and fall in popularity of this therapy and suggest that insight into the present-day treatment of short stature can be gained by comparing the use of estrogen therapy for tall girls with the use of growth hormone therapy for short boys. We suggest that this case study illustrates how scientific knowledge is always created and applied within a particular social context.

Medical news for the public to use? What's on local TV news

BACKGROUND

Local television news is the number 1 source of information for most Americans, and media health reporting has increased significantly during the past 10 years.

OBJECTIVE

To evaluate the health topics and reporting characteristics of health stories on local television news across the United States.

STUDY DESIGN

Content analysis of full-length broadcasts of local television news from a representative sample of the top 50 US media markets (122 stations).

METHODS

Two trained coders evaluated all health stories for topics and reporting characteristics. Any discrepancies were resolved by a third independent coder.

RESULTS

Among 2795 broadcasts reviewed, 1799 health stories were aired. Seventy-six percent of all stories were about medical conditions. The median story airtime was 33 seconds. Breast cancer and West Nile virus were the 2 most common topics reported on. Among 1371 stories about disease, few gave recommendations, cited specific data sources, or discussed prevalence. Egregious errors were identified that could harm viewers who relied on the information.

CONCLUSIONS

Local television news devotes significant airtime to health stories, yet few newscasts provide useful information, and some stories with factually incorrect information and potentially dangerous advice were aired. Regularly reaching 165 million people, local television news has the power to provide health information to most Americans. It is crucial that television reporting of health news be improved and that reporting errors be eliminated.

Making history: lessons from the great moments series of pharmaceutical advertisements

The authors shed light on present-day pharmaceutical advertisements by looking back to an important early chapter in pharmaceutical company-sponsored promotion: the Great Moments in Medicine and Great Moments in Pharmacy, a series of commercial paintings produced by Parke, Davis & Company between 1948 and 1964. Beginning in the early 1950s, Parke-Davis delivered reproductions of the Great Moments images to physicians and pharmacies throughout the United States and Canada and funded monthly pullout facsimiles in key national magazines. The images also appeared in calendars, popular magazines, and "educational" brochures. By the mid-1960s, articles in both the popular and the medical press lauded the Great Moments for "changing the face of the American doctor's office" while describing the painter, Robert Thom, as the "Norman Rockwell" of medicine. The authors' brief analysis uses source material including popular articles about the Great Moments, existing scholarship, previously unexamined artist's notes, and, ultimately, the images themselves to explain why these seemingly kitschy paintings attained such widespread acclaim. They show how the Great Moments tapped into a 1950s medical climate when doctors were thought of as powerfully independent practitioners, pharmaceutical companies begged the doctor's good graces, and HMOs and health plans were nowhere to be seen. The authors conclude by suggesting that the images offer important lessons for thinking about the many pharmaceutical advertisements that confront present-day doctors, patients, and other consumers.

The history of eugenics and the future of gene therapy

In this commentary, I shall provide an overview of some recent histories of eugenics and suggest some lessons that this history may have for today. This commentary is not an argument against gene therapy. Rather, it is a plea for historical understanding of what has been done,..."in the name of eugenics."... There is a temptation to parody misgivings about gene therapy. I suggest that there are justified reasons to think about the social consequences of gene therapy. I do not hold that we ought to stop the program now, but I do believe that scientists, physicians, and the public ought to be aware of the slippery slope on which we as a society -- and we are all members of society -- have embarked.

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.