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Biomedical subjects

L G Walker

Publications and source records attributed to L G Walker.

At least 37 records · Page 2Linked to original sources
PubMed1999

The effects of the participation of patients with cancer in teaching communication skills to medical undergraduates: a randomised study with follow-up after 2 years.

The importance of good doctor-patient communication is widely recognised. The aims of this study were to evaluate the immediate effects of the participation of patients with cancer on the attitudes and skills of undergraduate medical students receiving an interview skills training programme, and to assess the effects of the participation of patients with cancer on the attitudes and interview performance of students 2 years later. It was hypothesised that the participation of cancer patients would have specific beneficial effects on attitudes and interview performance. Before participating in a 6-session interview methods course in third year, students were randomised to be taught with patients who had cancer (experimental group) or with patients with other diagnoses (control group). Before and after participating in the course, 233 students (94% response rate) completed an Attitudes Questionnaire. When they reached their fifth year, 54 students again completed the Attitudes Questionnaire and, in addition, made a video recording of an interview with a patient who had gynaecological cancer. These recordings were rated independently by two researchers using the Interview Rating Instrument. Immediately after the course, a number of differences were found between the two groups. For example, students in the experimental group were more likely to consider the ability to listen an extremely important characteristic of hospital doctors and to consider more strongly that trust is an essential part of the doctor-patient relationship. 2 years after the course, the ability of hospital doctors to communicate with patients, and the need for clinical decisions to reflect patients' wishes, were considered to be more important by students in the experimental group, although even 96% of controls felt both these issues were very or extremely important. As hypothesised, the experimental group had better ratings in terms of responding empathically, showing regard and concern for the patient, and assessing the impact of the symptoms on the patient's life. The participation of patients with cancer has beneficial and enduring effects on the attitudes and interview performance of medical undergraduates. Medical schools should consider how best patients with cancer can make an important contribution to communication skills training.

Clinical Competence↗
PubMed1999

Psychological factors can predict the response to primary chemotherapy in patients with locally advanced breast cancer.

This study evaluated the possible value of psychological variables in predicting clinical and pathological response to primary chemotherapy. 96 women with newly diagnosed large, or locally advanced, breast cancer (T2 > 4 cm, T3, T4, N2 and M0) participated in a prospective, randomised trial to evaluate the effects of relaxation training with guided imagery and L-arginine on response to primary chemotherapy. Before the first of six cycles of primary chemotherapy, women were assessed using the Hospital Anxiety and Depression Scale (HADS) and the Eysenck Personality Questionnaire (EPQ). The primary outcomes were clinical response (evaluated using standard International Union Against Cancer (UICC) criteria) and pathological response (graded by means of a previously published 5-point scale) following primary chemotherapy. Stepwise linear regressions were used to estimate the predictive value of age, menopausal status, clinical nodal status, tumour size at diagnosis, oestrogen receptor status, dietary supplementation (L-arginine versus placebo), personality (EPQ-L scores), mood (HADS scores) and a psychological intervention. HADS depression score was a significant independent predictor of pathological response to chemotherapy. HADS anxiety score was a significant independent predictor of clinical response. Because the original tumour size before chemotherapy (also a significant predictor of clinical and pathological responses) was taken into account in the analyses, the results cannot be explained in terms of psychobiological factors related to tumour size. This study supports the importance of psychological factors as independent predictors of response to primary chemotherapy in patients with breast cancer. If they can be replicated, these findings have major implications for the management of women with breast cancer. Psychological factors need to be assessed and evaluated in future trials of chemotherapy.

Adult↗
PubMed1999

Testing complementary and alternative therapies within a research protocol.

In patients with cancer, the demand for complementary and alternative medicine (CAM) is considerable. Unfortunately, however, for many of these interventions there is a lack of evidence for efficacy, effectiveness and safety in patients with cancer. This review focuses on the prospective, randomised, controlled trial (RCT) as a tool for evaluating CAM. Although a number of difficulties and limitations are acknowledged, the RCT will continue to be the gold standard for evaluating the efficacy, effectiveness and safety of CAM. Developments in clinical trial methodology and in psychosocial oncology have made it more appropriate and feasible to evaluate CAM using RCT methodology. Two different kinds of RCTs are now accepted as valid, namely explanatory and pragmatic trials. The latter does not necessarily require that the patient or the therapist is 'blind' to the treatment being given. Furthermore, pragmatic trials can be designed to take patient preferences into account. A number of practical issues are discussed, including the choice of comparator or control interventions, ways of assessing the effects of individual differences, minimising therapist variability, the problem of finding acceptable inclusion-exclusion criteria and the assessment of treatment outcome. A number of randomised, controlled trials have demonstrated the efficacy, effectiveness and safety of various complementary and alternative interventions (the Cochrane Data Base has now established a CAM field). The publication of positive results from randomised trials of complementary interventions that have not yet been studied using this methodology would do a great deal to alleviate the scepticism of conventional practitioners towards these types of CAM and would facilitate further the integration of complementary and conventional interventions.

Complementary Therapies↗
PubMed1999

Predicting a second hip fracture.

In an attempt to identify a high-risk cohort of patients, who could be offered preventive therapy, we assessed patients who had suffered one hip fracture. A total of 394 patients were prospectively followed to determine those who had suffered a second fracture. Entry bone mass of the unfractured hip and total body was examined by dual X-ray absorptiometry (DXA) and of the os calcis, by quantitative ultrasound (QUS), along with various clinical parameters. The relative risks in the QUS parameters did not reach significance, except for broadband ultrasound attentuation as measured by the McCue CUBA Clinical, whereas femoral neck and total body bone mineral density also reached significance. Lowest quartile body weight was also a significant risk factor as were occurrence of a new fall and poor mobility score. Using Receiver Operator Characteristic curves, we found no significant differences between DXA trochanter or for the Mini Mental State Examination score in predicting those who sustained a second hip fracture. In this elderly group risk factors are almost as good as bone mass at predicting those who will sustain a second hip fracture. Low body weight and poor mobility could be used as triggers for the use of preventive therapy without the use of bone mass measurements and to target expensive preventive therapy to reduce fracture risk.

Absorptiometry, Photon↗
PubMed1999

Psychological, clinical and pathological effects of relaxation training and guided imagery during primary chemotherapy.

The diagnosis and treatment of breast cancer are stressful, and stress may be associated with a poorer response to chemotherapy. There is a need, therefore, to develop and evaluate interventions that might enhance quality of life and, possibly, improve treatment response. The effects of relaxation combined with guided imagery (visualizing host defences destroying tumour cells) on quality of life and response to primary chemotherapy, to date, have not been adequately evaluated. Ninety-six women with newly diagnosed large or locally advanced breast cancer (T2 > 4 cm, T3, T4, or TxN2 and M0) took part in a prospective, randomized controlled trial. Patients were randomized following diagnosis to a control condition (standard care) or to the experimental condition (standard care plus relaxation training and imagery). Psychometric tests to evaluate mood and quality of life were carried out before each of the six cycles of chemotherapy and 3 weeks after cycle 6: tests of personality and coping strategy were carried out prior to cycles one and six. Clinical response to chemotherapy was evaluated after six cycles of chemotherapy using standard UICC criteria and pathological response was assessed from the tissue removed at surgery. As hypothesized, patients in the experimental group were more relaxed and easy going during the study (Mood Rating Scale). Quality of life was better in the experimental group (Global Self-assessment and Rotterdam Symptom Checklist). The intervention also reduced emotional suppression (Courtauld Emotional Control Scale). The incidence of clinically significant mood disturbance was very low and the incidence in the two groups was similar. Finally, although the groups did not differ for clinical or pathological response to chemotherapy, imagery ratings were correlated with clinical response. These simple, inexpensive and beneficial interventions should be offered to patients wishing to improve quality of life during primary chemotherapy.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1999

Enteral nutritional supplementation with key nutrients in patients with critical illness and cancer: a meta-analysis of randomized controlled clinical trials.

OBJECTIVE: To conduct a meta-analysis of 11 randomized controlled trials comparing enteral nutritional support supplemented with key nutrients versus standard enteral nutritional support to determine effects on morbidity and mortality rates and hospital stay. BACKGROUND DATA: Recent studies have shown that malnutrition occurs in up to 30% of patients undergoing gastrointestinal surgery, resulting in an increased risk of postoperative complications and death. With the realization that key nutrients can modulate inflammatory, metabolic, and immune processes, enteral nutritional regimens (supplemented with large amounts of key nutrients) have been developed for clinical use. METHODS: Eleven prospective, randomized controlled trials evaluating 1009 patients treated with combinations of key nutrients (Impact, Immun-Aid) were evaluated. Outcome measures examined were the incidences of pneumonia, infectious complications, and death, and length of hospital stay. Meta-analyses were undertaken to obtain the odds ratio and 95% confidence interval for incidences of infectious complications, pneumonia, and death, and the weighted mean difference and 95% confidence interval for length of hospital stay. RESULTS: The provision of nutritional support supplemented with key nutrients to patients with critical illness resulted in a decrease in infectious complications when compared with patients receiving standard nutritional support and a significant reduction in overall hospital stay. Similar results were documented in patients with gastrointestinal cancer. However, there were no differences between patient groups for either pneumonia or death. CONCLUSIONS: This meta-analysis has demonstrated that nutritional support supplemented with key nutrients results in a significant reduction in the risk of developing infectious complications and reduces the overall hospital stay in patients with critical illness and in patients with gastrointestinal cancer. However, there is no effect on death. These data have important implications for the management of such patients.

Abdominal Abscess↗
PubMed1998

Treatment of large and locally advanced breast cancers using neoadjuvant chemotherapy.

BACKGROUND: Neoadjuvant (primary) chemotherapy is being used increasingly in the treatment of patients with large and locally advanced breast cancer with the aim of reducing the size of the primary tumor and eliminating micrometastatic disease. Response rates to, compliance with, and survival of patients following neoadjuvant chemotherapy have been variable. We report the results of a consecutive series of 77 patients with breast cancer who received neoadjuvant chemotherapy. METHODS: Seventy-seven patients with locally advanced breast cancers were treated with multimodality therapy comprising up to six cycles of chemotherapy (cyclophosphamide, vincristine, doxorubicin, and prednisolone), radiotherapy, and then surgery. The median follow-up was 54 months. Clinical response rates to therapy and overall survival have been documented. In addition, prognostic factors for survival were identified using the Cox proportional hazards model. RESULTS: The overall objective response rate of the primary tumor to chemotherapy alone was 87% (25% complete and 62% partial responses, UICC criteria). Following radiotherapy the response rate was 90% (52% complete and 38% partial responses). The overall 5-year survival for all patients was 0.48. However, the probability of survival at 5 years was 0.74 in those with a complete response, and 0.36 if there was a partial clinical response, but no patients who had either stasis of disease or progression survived for 5 years. Independent predictors of better survival that were identified were a complete histopathological response after chemotherapy and radiotherapy, a complete clinical response to chemotherapy, and five or six cycles of chemotherapy versus four or less. CONCLUSIONS: Neoadjuvant chemotherapy in patients with large and locally advanced breast cancers can result in satisfactory local control and overall survival rates, especially in patients with a complete clinical or histopathological response after treatment.

Adult↗
PubMed1998

Psychosocial aspects of cancer in the elderly.

A number of studies have shown that older people are less distressed by the diagnosis of cancer than their younger counterparts. This may be because older people have fewer dependants and they are less likely to suffer financial difficulties and to experience disruption to their daily routine following the diagnosis. It is surprising, therefore, that many elderly patients do not receive the biologically optimal treatment of their disease, even when comorbid medical conditions are taken into account. This appears to reflect an age bias amongst professionals involved in the management of cancer. There is a paucity of studies examining the perspective of elderly patients themselves regarding factors they consider important in their management. Elderly patients with cancer are not an homogeneous group in terms of their views about management. The vast majority of elderly patients, in common with younger patients, consider that giving the most effective treatment for breast cancer is just as important for older patients as it is for younger patients and that, in making a decision about the best treatment for them, the surgeon should only take account of the biological aspects of the disease. Clinicians, therefore, should avoid making assumptions about what patients wish simply on the basis of the age of the patient. Although there is a recent trend towards more elderly patients participating in oncology treatment trials, there is a great dearth of information about the acceptability and effectiveness of psychosocial interventions in elderly patients.

Adaptation, Psychological↗
PubMed1998

Breast screening: the psychological sequelae of false-positive recall in women with and without a family history of breast cancer.

The psychological effects of false-positive mammography were evaluated in 124 women who had taken part in the U.K. National Health Service Breast Screening Programme. In addition, the effects of recall on women with and without a family history were compared. These women were asked to complete the Hospital Anxiety and Depression Scale (HADS) before being invited to attend for screening, at recall and 5 weeks and 4 months after recall. At screening and at recall, the women were asked to complete the Health Questionnaire (HQ) which measures stress-related behaviour changes in the previous week. In the week before screening, compared with women who did not have a family history of breast cancer, women with a family history had lower scores on HADS depression and reported fewer stress-related behaviour changes. At recall, regardless of family history, the women were more likely to have borderline or clinically significant anxiety than at baseline or screening. Nevertheless, for most women, recall-induced anxiety was relatively transient (less than 5 weeks). Compared with women without a family history, women with a family history were more anxious 4 months after recall, although their anxiety scores tended to be lower (P < 0.06) than at baseline. A strength of the present study is that the initial baseline measure was uncontaminated by the screening process. Women who did not complete questionnaires at one or more of the subsequent time points scored higher on HADS depression at baseline, indicating that the results are likely to have underestimated the effects of recall. Screening appears to be less stressful for women with a family history than for those without a history. However, for both groups recall causes short term distress. Breast screening programmes should ensure that steps are taken to minimise the number of women who are recalled for unnecessary investigations.

Anxiety↗
PubMed1998

Potentiation of the response to chemotherapy in patients with breast cancer by dietary supplementation with L-arginine: results of a randomised controlled trial.

Patients with large primary breast cancers are being treated with neo-adjuvant chemotherapy. Studies in animals have shown that responses to chemotherapy can be increased by dietary manipulation of tumour cell metabolism. Also dietary supplementation with the amino acid L-arginine, resulted in an increase in tumour metabolic activity expression of the nuclear activation antigen, Ki67, in patients with breast cancer. Therefore, we have carried out a randomised, double blind, placebo controlled trial to determine if L-arginine supplementation is beneficial in patients with breast cancer, undergoing neo-adjuvant chemotherapy. 96 patients were randomised to receive L-arginine (30 g/day) for three days (n = 48) or placebo (n = 48) prior to undergoing chemotherapy (doxorubicin, cyclophosphamide, vincristine, prednisolone), 6 pulses at 21-day intervals. Clinical and pathological responses were assessed in both groups of patients following completion of chemotherapy. The clinical response rate was 77% (23% complete and 54% partial responses) in the L-arginine treated group, compared with 71% (15% complete and 56% partial) in the placebo group of patients (p = ns). However, in patients with tumours less than 6 cm in initial diameter, there was a significant increase in the better histopathological responses in the L-arginine group, when compared with the placebo group of patients (88% vs 52%, p = 0.04). This may have important implications for clinical practice.

Adenocarcinoma↗
PubMed1998

Acute phase proteins in patients with large and locally advanced breast cancer treated with neo-adjuvant chemotherapy: response and survival.

Seventy-seven patients with locally advanced breast cancer were treated with multimodality therapy comprising of six pulses of neo-adjuvant chemotherapy (doxorubicin, cyclophosphamide, vincristine and prednisolone) at 21-day intervals, followed by surgery (breast conservation or mastectomy) with appropriate axillary surgery, radiotherapy and adjuvant tamoxifen. The serum concentrations of acute phase proteins, C-reactive protein (CRP), á-1-anti-trypsin, albumin and transferrin were measured in serum taken prior to commencement of treatment. Patients were followed up for a median of 31 months and their clinical and histological responses and overall survival recorded. Univariate analyses revealed that tumour stage (p=0.01), clinical lymph node status (p=0. 02) and pre-treatment levels of serum albumin (p=0.002) and á-1-anti-trypsin (p=0.06) predicted overall survival. Using the Cox proportional hazards model reduced pre-treatment levels of serum albumin (p<0.00001), progressive lymph node involvement with tumour (p<0.005), and advancing tumour stage (p<0.01) were independent prognostic indicators for a poorer survival in patients with locally advanced breast cancer receiving neo-adjuvant chemotherapy.

Acute-Phase Proteins↗
PubMed1998

Serum albumin: a prognostic indicator in patients with colorectal cancer.

Various prognostic factors for survival have been identified in patients with colorectal cancer. However, although it has been suggested that the pre-treatment serum albumin concentration is a prognostic indicator in certain malignant diseases (melanoma, prostate cancer, leukaemia), its value in patients with colorectal cancer remains unclear. This study investigated the prognostic value of serum albumin in this patient group. A total of 431 patients presenting to the Professorial Surgical Unit between 1972 and 1985 were analysed in this study. Using the Cox proportional hazard model, age, tumour stage (Dukes' stage) and tumour differentiation were shown to be independent prognostic factors for survival in patients with localized colorectal cancer. In addition, the pre-treatment serum albumin concentration was found to be an independent prognostic indicator. This is the first such documentation for patients with 'curable' colorectal cancer.

Adult↗
PubMed1997

The psychological and psychiatric effects of rIL-2 therapy: a controlled clinical trial.

It has been suggested that recombinant interleukin-2 (rIL-2) may cause pyschological and psychiatric problems, although the effects of rIL-2 on its own have not been well documented. To evaluate these effects, 17 patients with advanced colorectal cancer took part in a randomised, parallel group study of rIL-2 with chemotherapy (5-fluorouracil and leucovorin) versus chemotherapy alone. Patients were assessed regularly by means of various psychometric tests including the Hospital Anxiety and Depression Scale, the Mood Rating Scale, the Mini-Mental State Examination, the Digit Symbol Substitution Test, the Trail-Making Test and the Benton Revised Visual Retention Test. Rigorous discontinuation criteria were applied to ensure that the effect of time-related variables did not influence the results. Compared with patients who were given chemotherapy alone, patients receiving immunochemotherapy reported reduced energy, impaired confidence, higher depressed mood and more confusion. Immunochemotherapy was rated as more distressing than chemotherapy alone and patients reported a greater incidence of appetite impairment, weight loss, poor concentration and fever. Cognitive assessments indicated that brain dysfunction can be caused by rIL-2. Compared with the control group, patients receiving immunochemotherapy showed significant impairment on Trail Making Test B and the Digit Symbol Substitution Test. One patient developed repeated transient psychotic episodes associated with rIL-2 infusions and another regularly became confused. These effects were not due to sleep deprivation or pyrexia. Treatment with rIL-2 should not be discarded on psychosocial grounds, although in each case the psychological morbidity and adverse effects on quality of life need to be balanced carefully against potential therapeutic benefits.

Antimetabolites, Antineoplastic↗
PubMed1997

The value of peri-operative nutrition in the sick patient.

In summary, therefore, the provision of TPN to malnourished patients in the pre-operative period reduces the incidence of post-operative complications, but does not affect post-operative mortality. It is likely that the provision of nutrition by the enteral route is as effective as that by the parenteral route, and may have the extra benefit of resulting in a reduction in infectious complications when compared with patients receiving TPN. Furthermore, the use of enteral nutritional support in the post-operative period may also reduce both septic and major complications, but does not alter mortality. The use of specific combinations of nutrients appears to offer the greatest promise in the use of peri-operative nutritional support. The initial studies reported to date demonstrate reductions in post-operative morbidity, but again there are no benefits on mortality. However, further studies to determine the optimal combinations of nutrients for use in patients in the peri-operative period are urgently required.

Enteral Nutrition↗
PubMed1997

Cognitive performance and mood after a weekend on call in a surgical unit.

BACKGROUND: Considerable interest and concern have been expressed about junior doctors' hours. This study was carried out to evaluate the emotional and cognitive effects of a weekend on call in a surgical ward. METHODS: Ten surgical house officers were assessed, in counterbalanced design, on four Monday mornings, twice after a weekend off duty and twice after a weekend on call. Cognitive functioning was assessed using the Cognitive Drug Research computerized cognitive assessment system, and emotional state was evaluated by means of the Aberdeen Mood Rating Scale. RESULTS: Following a weekend on call, significant impairment in concentration, speed and power was observed, and the doctors felt less confident, less energetic and more confused. Impaired attention, working memory, long-term memory and confusion were most closely correlated with number of hours worked on Sunday, and tiredness and confusion were related to number of hours slept. CONCLUSION: A weekend on call has significant deleterious effects on cognitive performance and mood. The findings have implications for staffing levels and the design of duty rosters.

Affect↗
PubMed1997

Expression of growth factor receptors is not a prognostic indicator in young patients with colorectal cancer.

Growth factor receptor expression has been shown to be of prognostic significance in certain cancers, but its relevance in young patients with colorectal cancer is unknown. The aim of this study, therefore, is to determine the prognostic relevance of growth factor receptor expression [c-erbB-2, epidermal growth factor receptor (EGFR) and transforming growth factor beta receptor (TGF beta R)] in such patients. Ninety-two patients were evaluated. They were staged using the Jass staging system and the presence of metastases. The expression of EGFR and TGF beta R and the protein production of c-erbB-2 were detected using standard immunohistochemical techniques. The expression of EGFR and TGF beta R and the presence of the c-erbB-2 protein product were not identified as independent prognostic factors for survival. Furthermore, their expression did not correlate with established prognostic indicators such as Jass staging, the presence of extramural vascular invasion and the degree of tumour differentiation.

Biomarkers, Tumor↗