Ablative radioiodine therapy for hyperthyroidism: long term follow up study.

A total of 225 patients were treated for hyperthyroidism with 555 MBq (15 mCi) radioiodine to ablate the thyroid and induce early hypothyroidism. The efficacy of this treatment in eradicating hyperthyroidism and problems of follow up were assessed one to six years later from case records and questionnaires. Information was received from 197 out of 219 live patients (90%) and from 160 doctors concerning 207 patients (92%). Only three patients were not traced and six had died since treatment. The modal time to hypothyroidism was three months, and 64% of patients were hypothyroid at one year; 5.6% had failed to become euthyroid within one year. Ninety five per cent of patients had been seen by the doctor and 82% had had a thyroid test done within the past two years. Most doctors preferred patients to be returned to their care once thyroxine treatment was stabilised. An ablative dose of 131I is recommended as an effective means of treatment which has clear advantages over conventional methods. Good communications and effective follow up should ensure success.     

Hormone replacement therapy: one-year follow up of DNA damage

Although hormone replacement therapy (HRT) may offer considerable benefits for menopausal women, the potential cancer risk may limit its use. This work aimed at assessing whether HRT is able to induce DNA damage in postmenopausal women monitored by the micronucleus (MN) test, which provides a reliable biomarker of genotoxicity and cancer risk assessment. A group of 16 healthy women (non-smokers) in spontaneous menopause were given oral estradiol (2 mg oral micronized 17-beta estradiol daily) for 1 month, followed by a 30-day wash-out period and a transdermal treatment with 17-beta estradiol (1.5 mg gel daily) during 1 month. Oral intake of dihydrogesterone (10 mg/day for 12 days/month) was cyclically combined with oral or transdermal estradiol during the next 9 months. Venous blood samples were collected before the treatment, and after 1, 3, 6 and 12 months of therapy. Slides were scored blind and MN frequency was evaluated as number of micronuclei per 1000 binucleated cells. The baseline plasma levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH) and estradiol (E2) were simultaneously measured. The means of MN frequency were 18.2+/-1.6, 18.6+/-2.1, 14.8+/-1.5, 15.9+/-1.0 and 17.7+/-1.3 for samples collected before and at 1, 3, 6 and 12 months, respectively. The MN frequencies at every sampling time did not statistically differ from the basal values. In addition, no statistically significant associations between MN values and hormone levels of E2 and FSH were observed throughout the entire study. This study shows the absence of any significant increase of MN frequencies in women undergoing oral and/or transdermal HRT, sequentially monitored for up to 12 months of therapy.     

Nurse led follow up and conventional medical follow up in management of patients with lung cancer: randomised trial

ObjectiveTo assess the effectiveness of nurse led follow up in the management of patients with lung cancer.DesignRandomised controlled trial.SettingSpecialist cancer hospital and three cancer units in southeastern England.Participants203 patients with lung cancer who had completed their initial treatment and were expected to survive for at least 3 months.InterventionNurse led follow up of outpatients compared with conventional medical follow up.ResultsPatient acceptability of nurse led follow up was high: 75% (203/271) of eligible patients consented to participate. Patients who received the intervention had less severe dyspnoea at 3 months (P=0.03) and had better scores for emotional functioning (P=0.03) and less peripheral neuropathy (P=0.05) at 12 months. Intervention group patients scored significantly better in most satisfaction subscales at 3, 6, and 12 months (P<0.01 for all subscales at 3 months). No significant differences in general practitioners'' overall satisfaction were seen between the two groups. No differences were seen in survival or rates of objective progression, although nurses recorded progression of symptoms sooner than doctors (P=0.01). Intervention patients were more likely to die at home rather than in a hospital or hospice (P=0.04), attended fewer consultations with a hospital doctor during the first 3 months (P=0.004), had fewer radiographs during the first 6 months (P=0.04), and had more radiotherapy within the first 3 months (P=0.01). No other differences were seen between the two groups in terms of the use of resources.ConclusionNurse led follow up was acceptable to lung cancer patients and general practitioners and led to positive outcomes.

What is already known on this topic

Most patients with cancer are routinely seen in outpatient clinics for many years despite lack of evidence of effectivenessDoctors and nurses often fail to detect patients'' emotional distress, and patients have little time to raise concerns

What this study adds

Follow up of patients with lung cancer by clinical nurse specialists is safe, acceptable, and cost effectiveBoth patients and general practitioners were highly satisfied with the nurse led model of follow up     

Long-term follow up of patients with common variable immunodeficiency treated with intravenous immunoglobulin: Reevaluation of intravenous immunoglobulin replacement therapy

Five patients with common variable immunodeficiency treated in our hospital between December 1979 and December 1990 were given six kinds of intravenous immunoglobulin preparations (pepsin treated, S-sulfonated, polyethylene glycol treated, pH4 treated, alkylated, and pH4.25 formulation preparation) for replacement therapy. Duration of the therapy ranged from 7.6 to 11 years. Incidences of fever and acute infections were variable among patients, but no significant differences were seen in the incidences among periods given each preparation. Three cases revealed abnormal pulmonary functions in tests. Adverse reactions were rarely seen in our study periods, and no severe reactions were observed. No significant differences were seen in incidences of adverse reactions. Postinfusion levels of serum complement slightly decreased from preinfusion levels. However, the decrease in complement was not related to any adverse reaction. No long-term complications such as transmission of hepatitis have been observed. Our data suggest that no obvious differences exist between the efficacy and safety of each IVIG preparation. Differences of efficacy of IVIG replacement therapy may be due to the variable pathophysiology of each patient.Abbreviations CVID common variable immunodeficiency - IVIG intravenous immunoglobulin     

Influence of intrinsic myocardial conduction on paced QRS morphology during cardiac resynchronization therapy follow up

We report two cases of patients of cardiac resynchronization therapy (CRT) whose ECGs, during follow up, showed different paced QRS morphology as compared to those of immediate post-device implantation. Parameters of leads, including sensitivity and capture thresholds, were unchanged. There was no lead dislodgement confirmed on fluoroscopy. The ECGs obtained in device off mode showed different intrinsic QRS morphology as compared to those of pre-implant morphology. These changes were attributable to electrolyte imbalance in one patient and progressive intraventricular conduction defect in the other. These cases demonstrate that intrinsic myocardial conduction pattern influences paced QRS morphology. Irreversible change in paced QRS morphology may indicate poor prognosis.     

Proposal for changes in cystoscopic follow up of patients with bladder cancer and adjuvant intravesical chemotherapy.

A famous surgeon observed that the most important instrument for the management of superficial bladder cancer was a typewriter because it facilitated the organisation of the regular follow up examinations that are so important in controlling this disease. Cystoscopic follow up must be lifelong, and the cost, in the broadest sense, to both patient and health service is considerable. A recent study has suggested that the conventional frequency of bladder examinations may not be necessary and that most patients could be spared many cystoscopies. Instillation of cytotoxic drugs in the bladder has been shown to reduce the recurrence of tumours destroyed endoscopically and the development of new tumours elsewhere in the bladder. Because intravesical instillations are inconvenient, expensive, and may be toxic they have been reserved for patients thought to be at greatest risk of recurrence. However, two clinical trials have shown that a single cytotoxic instillation may be beneficial for low risk patients. If this is verified in everyday practice, the routine use of intravesical chemotherapy for all patients at the time of initial treatment could reduce the need for cystoscopies even further. Such changes should improve the quality of life of the 7000 new patients with superficial bladder cancer each year in England and Wales and allow savings to be made in the NHS.     

Long term follow up of severely ill patients who underwent urgent cardiac transplantation.

OBJECTIVE--To assess long term survival (> 5 years) and quality of life in severely ill patients referred for urgent cardiac transplantation. SETTING--Tertiary referral centres: before transplantation at the National Heart Hospital (late 1984 to end 1986); after transplantation at Harefield Hospital. SUBJECTS--Eighteen patients (15 men; three women) who had required intensive support in hospital before cardiac transplantation and were alive at short term follow up. INTERVENTIONS--Intravenous infusions of cardiac drugs (mean 2.2 infusions), intravenous diuretics (17 patients), and many other drugs before transplantation. Intra-aortic balloon counterpulsation (four patients), temporary pacing (two), and resuscitation from cardiac arrest (three). Patients had specialised nursing care on a medical intensive care unit in almost every case. MAIN OUTCOME MEASURES--Long term survival in patients after urgent cardiac transplantation and perceived quality of life. RESULTS--Of 18 patients who were alive at short term follow up (mean (range) 19.4 (10-33) months), 14 were still alive in 1992 (69 (61-83) months). Ten still worked full time, and 11 reported no restrictions in their daily activities. Three of four patients who died in the intervening period survived > 5 years after transplantation. Overall, 17 of 18 patients survived at least 5 years. CONCLUSIONS--In severely ill patients who undergo urgent cardiac transplantation and survive in the short term, long term (5-7 year) survival and quality of life seem good.     

Slater revisited: 6 year follow up study of patients with medically unexplained motor symptoms

Objective: To investigate psychiatric and neurological morbidity, diagnostic stability, and indicators of prognosis in patients previously identified as having medically unexplained motor symptoms. Design: Follow up study. Setting: National Hospital for Neurology and Neurosurgery, London—a secondary and tertiary referral hospital for neurological disorders. Subjects: 73 patients with medically unexplained motor symptoms admitted consecutively in 1989-91. 35 (48%) patients had absence of motor function (for example, hemiplegia) and 38 (52%) had abnormal motor activity (for example, tremor, dystonia, or ataxia). Main outcome measures: Neurological clinical diagnosis at face to face reassessment by a neurologist and a psychiatric diagnosis after a standardised assessment interview—the schedule for affective disorders and schizophrenia—conducted by a psychiatrist. Results: Good follow up data were available for 64 subjects (88%). Only three subjects had new organic neurological disorders at follow up that fully or partly explained their previous symptoms. 44/59 (75%) subjects had had psychiatric disorders; in 33 (75%) patients, the psychiatric diagnosis coincided with their unexplained motor symptoms. 31/59 (45%) patients had a personality disorder. Three subjects had developed new psychiatric illnesses at follow up, but in only one did the diagnosis account for the previous motor symptoms. Resolution of physical symptoms was associated with short length of symptoms, comorbid psychiatric disorder, and a change in marital status during follow up. Conclusions: Unlike Slater’s study of 1965, a low incidence of physical or psychiatric diagnoses which explained these patients’ symptoms or disability was found. However, a high level of psychiatric comorbidity existed.

Key messages

• Motor symptoms that remain unexplained medically despite thorough investigation are a common clinical problem, but the emergence of a subsequent organic explanation for these symptoms is rare
• The prevalence of coexistent affective and anxiety disorders is high and many patients also have a personality disorder
• Patients with a shorter duration of symptoms and coexistent anxiety or depression are likely to do better at follow up
• Reinvestigation of these patients is both expensive and potentially dangerous and should be avoided where no clear clinical indication exists

     

Proposed follow up programme after curative resection for lower third oesophageal cancer

Cyclins are indispensable elements of the cell cycle and derangement of their function can lead to cancer formation. Recent studies have also revealed more mechanisms through which cyclins can express their oncogenic potential. This review focuses on the aberrant expression of G1/S cyclins and especially cyclin D and cyclin E; the pathways through which they lead to tumour formation and their involvement in different types of cancer. These elements indicate the mechanisms that could act as targets for cancer therapy.