Clinical Predictors of Survival for Patients with Stage IV Cancer Referred to Radiation Oncology

BackgroundThere is an urgent need for a robust, clinically useful predictive model for survival in a heterogeneous group of patients with metastatic cancer referred to radiation oncology.MethodsFrom May 2012 to August 2013, 143 consecutive patients with stage IV cancer were prospectively evaluated by a single radiation oncologist. We retrospectively analyzed the effect of 29 patient, laboratory and tumor-related prognostic factors on overall survival using univariate analysis. Variables that were statistically significant on univariate analysis were entered into a multivariable Cox regression to identify independent predictors of overall survival.ResultsThe median overall survival was 5.5 months. Four prognostic factors significantly predicted survival on multivariable analysis including ECOG performance status (0–1 vs. 2 vs. 3–4), number of active tumors (1 to 5 vs. ≥6), albumin levels (≥3.4 vs. 2.4 to 3.3 vs. <2.4 and primary tumor site (Breast, Kidney or Prostate vs. Other). Risk group stratification was performed by assigning points for adverse prognostic factors resulting in very low, low, intermediate and high risk groups. The median survival was >31.4 months for very low risk patients compared to 14.5 months for low risk, 4.1 months for intermediate risk and 1.2 months for high risk (p<0.001).ConclusionsThese data suggest that a model that considers performance status, extent of disease, primary tumor site and serum albumin represents a simple model to accurately predict survival for patients with stage IV cancer who are potential candidates for radiation therapy.     

Levels of State and Trait Anxiety in Patients Referred to Ophthalmology by Primary Care Clinicians: A Cross Sectional Study

Purpose

There is a high level of over-referral from primary eye care leading to significant numbers of people without ocular pathology (false positives) being referred to secondary eye care. The present study used a psychometric instrument to determine whether there is a psychological burden on patients due to referral to secondary eye care, and used Rasch analysis to convert the data from an ordinal to an interval scale.

Design

Cross sectional study.

Participants and Controls

322 participants and 80 control participants.

Methods

State (i.e. current) and trait (i.e. propensity to) anxiety were measured in a group of patients referred to a hospital eye department in the UK and in a control group who have had a sight test but were not referred. Response category analysis plus infit and outfit Rasch statistics and person separation indices were used to determine the usefulness of individual items and the response categories. Principal components analysis was used to determine dimensionality.

Main Outcome Measure

Levels of state and trait anxiety measured using the State-Trait Anxiety Inventory.

Results

State anxiety scores were significantly higher in the patients referred to secondary eye care than the controls (p<0.04), but similar for trait anxiety (p>0.1). Rasch analysis highlighted that the questionnaire results needed to be split into “anxiety-absent” and “anxiety-present” items for both state and trait anxiety, but both subscales showed the same profile of results between patients and controls.

Conclusions

State anxiety was shown to be higher in patients referred to secondary eye care than the controls, and at similar levels to people with moderate to high perceived susceptibility to breast cancer. This suggests that referral from primary to secondary eye care can result in a significant psychological burden on some patients.     

Treatment in England of Canadian Patients Addicted to Narcotic Drugs

The method of treatment and the results obtained from the treatment of 50 Canadian patients addicted to narcotic drugs who went to England are recorded. These patients were first stabilized on the minimal dose of narcotic drug which permitted them to work, and to acquire security and self-respect. Then, after psychiatric treatment dealing with the basic problem of their personality disorder, complete withdrawal treatment of the narcotic drug was undertaken.Nine of 10 patients aged between 20 and 30, of good social and cultural background, have been relieved of dependence on drugs for over two years.The other 40 patients came from a different background. Nearly all had been imprisoned for drug offences and they had come to England to obtain treatment and to avoid further prison sentences in Canada.The 31 patients whose prison sentences had been directly connected with drug offences are working steadily and leading an apparently normal life.The remaining nine patients had been convicted of criminal acts before becoming addicted to narcotic drugs and, with two exceptions, the results of their treatment compare unfavourably with the other patients, seven having been convicted and imprisoned in London.     

Referred Sensations Elicited by Video-Mediated Mirroring of Hands

Humans readily perceive ownership of a limb even when it is artificially induced as in the case of using a mirror reflection. However, mirror reflections are very constrained perceptions which do not allow transformations and varied contexts as often occurs in real life. The extent to which perceived limb ownership occurs with video-mediated manipulations is not known, particularly given the perception would no longer be a precise copy (reflection) of a person’s own limb. The present study directly compared referred sensations of the limbs with the use of a mirror reflection to those obtained with a new video-mediated setup to assess perceived ownership. Manipulations that could not be performed with a standard mirror reflection, such as reversal of the spatial positions of the limbs, were also investigated to examine how far the perceived ownership effects could be pushed. Across a series of experiments, data on the quality, intensity and location of referred sensations were collected and analyzed together with measures of hand ownership and participants’ experience of the two setups. Results reveal that participants felt referred sensations in both the optical and the video-mediated setup, and that video-mediated manipulations of hand-position reversals produced equal to stronger effects of ownership compared with the mirror reflection. These findings open up new possibilities for scientific experimentation and therapy that are discussed in the paper.     

What Do We Most Need to Learn about Food Intake Regulation?

Many mechanisms are known to contribute to the regulation of food intake. This notwithstanding, variations in food intake from day to day and deviations from daily energy balance are substantial and very readily tolerated. Yet, despite this very loose short-term adjustment of food intake to energy expenditure, most adults maintain stable body compositions during long periods of their lives. This is particularly puzzling when it occurs in the face of an ubiquitous supply of appealing foods and under circumstances that, in many ways, promote food consumption. Thus, the question arises as to why people in affluent societies eat substantially less on most days, than the amounts that they can so readily consume on high-intake days? In addition to conscious decisions, physiological phenomena restraining food consumption must be presumed to play an important role in limiting weight. But what are the phenomena that cause spontaneous reduction in food intake after a few days of overeating? Our ignorance about the nature and impact of these effects stands in the way of a better understanding of body weight regulation and of the factors responsible for the induction and maintenance of obesity.     

Higher Seroprevalence of Hepatitis B Virus Antigen in Patients with Cystic Hydatid Disease than in Patients Referred to Internal Medicine Clinics in Turkey

Turkey remains an intermediate area for prevalence of hepatitis B virus (HBV) surface antigenemia. The sheep-raising areas of Turkey also pose a high risk for cystic hydatid disease (CHD). Both HBV infection and CHD are major public health issues particularly in eastern parts of Turkey; however, there is no data regarding HBV infection in patients who have had CHD. The aims of this study were to evaluate the association between HBV infection and CHD and suggest ways to reduce HBV infection which is still widespread in Turkey. A retrospective study was conducted with 94 adult patients with active CHD referred to the hepatology department, Yuzuncuyil University School of Medicine from December 2010 to December 2012. All subjects came from rural areas of the region and underwent ultrasonography of abdomen which detected CHD of the liver. All the patients were serologically positive for Echinococcus granulosus. The control group consisted of 500 patients (300 men and 200 women) referred to the internal medicine clinics for other reasons. The patients with CHD and in the control group were tested for the existence of HBs antigen according to the standard procedures. The seroprevalence of HBs antigen was significantly higher in patients with active CHD than those in the control group (12.7% vs 5.2%; P=0.0017). Our data indicate that there is significant association between HBV infection and CHD. All patients with CHD should be screened for HBV infection.     

Differences in Clinical Outcomes According to Weaning Classifications in Medical Intensive Care Units

Background

Although the weaning classification based on the difficulty and duration of the weaning process has been evaluated in the different type of intensive care units (ICUs), little is known about clinical outcomes and validity among the three groups in medical ICU. The objectives of this study were to evaluate the clinical relevance of weaning classification and its association with hospital mortality in a medical ICU with a protocol-based weaning program.

Methods

All consecutive patients admitted to the medical ICU and requiring mechanical ventilation (MV) for more than 24 hours were prospectively registered and screened for weaning readiness by a standardized weaning program between July 2010 and June 2013. Baseline characteristics and outcomes were compared across weaning classifications.

Results

During the study period, a total of 680 patients were weaned according to the standardized weaning protocol. Of these, 457 (67%) were classified as simple weaning, 136 (20%) as difficult weaning, and 87 (13%) as prolonged weaning. Ventilator-free days within 28 days decreased significantly from simple to difficult to prolonged weaning groups (P < 0.001, test for trends). In addition, reintubation within 48 hours after extubation (P < 0.001) and need for tracheostomy during the weaning process (P < 0.001) increased significantly across weaning groups. Finally, ICU (P < 0.001), post-ICU (P = 0.001), and hospital (P < 0.001) mortalities significantly increased across weaning groups. In a multiple logistic regression model, prolonged weaning but not difficult weaning was still independently associated with ICU (adjusted OR 8.265, 95% CI 3.484–19.605, P < 0.001), and post-ICU (adjusted OR 3.180, 95% CI 1.349–7.497, P = 0.005), and hospital (adjusted OR 5.528, 95% CI 2.801–10.910, P < 0.001) mortalities.

Conclusions

Weaning classification based on the difficulty and duration of the weaning process may provide prognostic information for mechanically ventilated patients who undergo the weaning process.     

New Ideas about the Solubility of Drugs

Methods are described for detecting precipitation of ionisable drugs under conditions of changing pH, estimating kinetic solubility from the onset of precipitation, and measuring solubility by chasing equilibrium. Definitions are presented for kinetic, equilibrium, and intrinsic solubility of ionisable drugs, supersaturation and subsaturation, and for chasers and non‐chasers, which are two classes of ionisable drug with significantly different solubility properties. The use of Bjerrum Curves and Neutral‐Species Concentration Profiles to depict solubility properties are described and illustrated with case studies showing super‐dissolving behaviour, conversion between crystalline forms and enhancement of solubility through supersaturation, and the use of additives and simulated gastrointestinal fluids.     

Acceptance and Perception of Nigerian Patients to Medical Photography

The aim of the study was to determine the acceptance and perception of Nigerian patients to medical photography. A self‐administered questionnaire was distributed among Nigerian patients attending oral and maxillofacial surgery and plastic surgery clinics of 3 tertiary health institutions. Information requested included patients' opinion about consent process, capturing equipment, distribution and accessibility of medical photographs. The use of non‐identifiable medical photographs was more acceptable than identifiable to respondents for all purposes (P = 0.003). Most respondents were favourably disposed to photographs being taken for inclusion in the case note, but opposed to identifiable photographs being used for other purposes most especially in medical websites and medical journals. Female respondents preferred non‐identifiable medical photographs to identifiable ones (P = 0.001). Most respondents (78%) indicated that their consent be sought for each of the outline needs for medical photography. Half of the respondents indicated that identifiable photographs may have a negative effect on their persons; and the most commonly mentioned effects were social stigmatization, bad publicity and emotional/psychological effects. Most of the respondents preferred the use of hospital‐owned camera to personal camera/personal camera‐phone for their medical photographs. Most respondents (67.8%) indicated that they would like to be informed about the use of their photographs on every occasion, and 74% indicated that they would like to be informed of the specific journal in which their medical photographs are to be published. In conclusion, non‐identifiable rather than identifiable medical photography is acceptable to most patients in the studied Nigerian environment. The use of personal camera/personal camera‐phone should be discouraged as its acceptance by respondents is very low. Judicious use of medical photography is therefore advocated to avoid breach of principle of privacy and confidentiality in medical practice.     

Quality of Care of Hospitalized Internal Medicine Patients Bedspaced to Non-Internal Medicine Inpatient Units

Background

When the number of patients requiring hospital admission exceeds the number of available department-allotted beds, patients are often placed on a different specialty''s inpatient ward, a practice known as “bedspacing”. Whether bedspacing affects quality of patient care has not been previously studied.

Methods

We reviewed consecutive general internal medicine (GIM) admissions for congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and pneumonia at St. Michael''s Hospital in Toronto, Canada, from 2007 to 2011 and examined whether quality of care differs between bedspaced and nonbedspaced patients. We matched each bedspaced patient with a GIM ward patient admitted on the same call shift with the same diagnosis. The primary outcome was the ratio of the actual to the estimated length of stay (ELOS). General and disease specific measures for CHF, COPD, and pneumonia (e.g. fluid restriction) were evaluated, as well as 30-day Emergency Department (ED) and hospital readmissions.

Results

Overall, 1639 consecutive admissions were reviewed, and 39 matched pairs for CHF, COPD and pneumonia were studied. Differences in both general and disease specific care measures were not detected between groups. For many disease-specific comparisons, ordering and adherence to quality of care indicators was low in both groups.

Conclusions

We were unable to detect differences in quality of care between bedspaced and nonbedspaced patients. As high patient volumes and hospital overcrowding remains, bedspacing will likely continue. More research is required in order to determine if quality of care is compromised by this ongoing practice.     

由传统病历向电子病历平稳过渡的探讨

随着现代化科学技术的飞跃发展,计算机及网络广泛地应用于社会各个领域,医院管理的信息化不断加强,传统病历已不能满足医学发展的需要。从传统病历向电子病历过渡是否顺利,将影响到很长一段时间内的医疗质量和医疗安全。结合北京天坛医院电子病历的使用情况,从电子病历使用者的角度探讨了如何实现由传统病历向电子病历的平稳过渡。     

Medical Application of Synthetic Phospholipids as Liposomes and Drugs

Abstract

Synthetic phospholipids or analogues having well-defined purities are useful and stable carriers of drugs for a variety of medical therapies. Synthetic phospholipids possess the additional quality of being powerful drugs in the therapy of cancer and protozoaen diseases. In the last decade we have developed several different strategies for the large scale synthesis of phospholipids (50 to 100 kg). Here we describe methods involving the recombination of nonpolar and polar regions of phospholipid molecules which permit the creation of an unlimited variety of well-defined and characterizable phospholipids and of analogues. As an example for medical application we describe hexadecylphosphocholine (HePC) which in 1992 was approved and registered as a drug by the German Bundesgesundheitsamt. Recent studies have provided compelling evidence that erucylphosphocholine (ErPC) is an even more selective drug than HePC for systemic i.v. treatment of cancer.     

儿科抗癫痫药物应用研究进展

儿童癫痫为小儿神经科的常见疾病,临床表现以抽搐为主。近年来,随着医疗技术的发展,以及人们对儿童癫痫的重视,国内外文献对儿科癫痫的治疗报道越来越多,目前,药物治疗仍然是抗癫痫的首选方法,除了运用新型抗癫痫药物外,也有采用中药治疗癫痫的报道,现就近年来儿童癫痫的药物治疗研究作一综述。