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A single institutional subset analysis of the WJLCG study comparing concurrent and sequential chemoradiotherapy for stage III non-small-cell lung cancer.

PURPOSE: To supplement findings of the West Japan Lung Cancer Group (WJLCG) study, treatment outcomes in our institution were reviewed from the perspective of radiation oncology. MATERIALS AND METHODS: Chemotherapy consisted of cisplatin (80 mg/m2 on days 1 and 29), vindesine (3 mg/m2 on days 1, 8, 29, and 36), and mitomycin (8 mg/m2 on days 1 and 29). In the concurrent arm, radiation therapy began on day 2 with a dose of 56 Gy in 28 fractions over 6.8 weeks, with an interval of 10 days at 28 Gy. In the sequential arm, radiation therapy began on day 50 with a dose of 56 Gy in 28 fractions over 5.6 weeks, without an interval. RESULTS: Twenty-four patients in the concurrent arm and 25 patients in the sequential arm in our institution were eligible for the WJLCG study. In the concurrent arm, three patients could not receive the full dose of radiation therapy and 12 patients required interruption of radiation therapy for more than 4 days. The median survival time among per-protocol patients and in those with interruption or with incomplete radiation therapy was 28.9 months and 14.1 months, respectively (p = 0.02). In the sequential arm, one patient could not receive the full dose of radiation therapy and none of the patients required such interruption. Local relapse and distant metastases as the first site of relapse occurred in 12 (11 in-field, 1 marginal) and five patients, respectively, in the concurrent arm, and in eight (7 in-field, 1 marginal) and 11 patients, respectively, in the sequential arm. CONCLUSION: In the concurrent regimen, noncompletion or interruption of radiation therapy was frequent, and the prognosis of such patients was poor.

Adult↗

PubMed2001

Peer influences on college drinking: a review of the research.

Peer pressure is consistently implicated in the excessive drinking of college students. However, both theory and empirical findings suggest that peer pressure is a combination of three distinct influences: overt offers of alcohol, modeling, and social norms. Overt offers of alcohol can range from polite gestures to intense goading or commands to drink. Modeling occurs when the student's behavior corresponds to another student's concurrent drinking behavior. Perceived social norms can serve to make excessive alcohol use appear common and acceptable to the student. This review critically examines the literature on each form of peer influence and provides suggestions for future research.

Adult↗

PubMed1986

Evaluating the impact of education by a clinical pharmacist on antibiotic prescribing and administration in an acute care state psychiatric hospital.

An antibiotic utilization review program was implemented by a clinical pharmacist in an acute care state psychiatric facility. Antibiotic utilization was concurrently audited in 61 antibiotic orders, written for 48 patients, in order to determine antibiotic prescribing and administration practices and problems. Interventions, consisting of educational presentations, problem-solving meetings, and distribution of written educational materials, were provided by a clinical pharmacist to improve antibiotic prescribing and administration practices. A second audit of 68 antibiotic orders written for 47 patients was concurrently audited after completion of the interventions. When prescribing problems were detected, the clinical pharmacist made recommendations to the prescribing physician. Statistically significant changes in the use of culture and sensitivity tests, appropriate dosage regimens, correct antibiotic administration, and selection of cost-effective therapy were found after all educational interventions were provided. A positive trend not resulting in statistical significance was noted for documentation of infectious disease and selection of appropriate antibiotic agents. This study demonstrates a drug utilization review role for clinical pharmacist's involvement in the acute care psychiatric facility, and illustrates one method by which clinical pharmacists can provide educational programs to improve nonpsychotropic drug prescribing and administration in this setting.

Adolescent↗

PubMed2000

Concurrent measurement of antigen- and antibody-dependent oxidative burst and phagocytosis in monocytes and neutrophils.

The current study aims to review flow cytometric (FCM) parameters for the quantification of phagocytosis. A limitation of existing methods is their difficulty with accurate quantification of the phagocytic index, i.e., number of beads per phagocyte, in individual cell lines in mixed cell suspensions. We have quantified phagocytosis and the oxidative burst simultaneously using fluorescent beads coated with meningococcal outer membrane vesicles (OMV beads) by the conversion of dihydrorhodamine 123 (DHR-123) to rhodamine 123 (R-123). Both these processes depend on specific serum opsonins. After the incubation, staining with a fluorescent anti-CD14 monoclonal antibody succeeded in discriminating phagocytosing monocytes from neutrophils. The spectral overlaps between OMV beads, R-123, and anti-CD14 could be completely compensated. Percentage of phagocytosis and the phagocytic index were similar in monocytes and neutrophils, but the oxidative burst behaved differently. Two monocyte subpopulations were observed. Both subpopulations spontaneously converted some DHR-123 into R-123, whereas the reaction was triggered by phagocytosis in neutrophils. The total oxidative response increased with increasing phagocytic index in both cell types, but the oxidative burst in monocytes was about twice that of neutrophils. The oxidative ratio (mean R-123 fluorescence value divided by the phagocytic index) declined with time in monocytes, but increased in neutrophils. Our results demonstrate the need for careful attention to technical details. This single-laser, three-color FCM method facilitates the comparative research of phagocytosis and the oxidative burst in monocytes and neutrophils and provides a basis for a number of applications in hematology, infectious medicine, and immunology.

Antibodies, Monoclonal↗

PubMed1984

The role of utilization management under PPS.

Under PPS an effective utilization management system is essential and the implementation of such systems presents a new challenge for hospital managers. An effective utilization management system must have the following characteristics: a process for establishing expected resource levels for each DRG; the ability to assign a working DRG at admission; a review schedule for each DRG; a method of identifying consistent patterns of high utilization; a focused review plan which targets selected DRG and physicians; a method of predicting the clinical treatment requirements of each patient; a review process which evaluates the need for continued hospitalization and identifies the reasons for any misutilization, and a feedback process which modifies the focused review plan on an ongoing basis. By operating a utilization management system with these attributes on a concurrent basis, a hospital will achieve the monitoring and control over its resources so critical under PPS. Hospitals that are able to successfully implement a utilization management system will have accomplished one of the essential components necessary to respond to PPS.

Ancillary Services, Hospital↗

PubMed1997

[Chemoradiotherapy for patients with advanced head and neck cancer].

At diagnosis of head and neck cancer, over half of all patients show advanced stages. Cure rates for patients with advanced head and neck carcinomas remain low. Because of the poor outcome of unresectable patients with head and neck cancer after radiation therapy alone, concomitant chemoradiotherapy has been used for these advanced cases in order to improve locoregional and systemic tumor control. On the other hand, a recent treatment modality for resectable head and neck cancer has a new goal to preserve organ functions, i.e., speech, swallowing and appearance, which are affected by surgical resection. For both of these reasons, various concomitant administrations of chemotherapy and radiotherapy have been applied for advanced tumors. In this paper, the clinical results of the past and present reports are reviewed and summarized in terms of chemoradiotherapy using single and combination chemotherapeutic drug therapy. In conclusion, some aggressive concurrent chemoradiotherapy trials suggest an improved locoregional control rate, prolonged disease-free interval and a better overall survival rate.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed2002

Teaching interdisciplinary geriatrics team care.

OBJECTIVES: Addressing the current fragmentation and lack of coordination of health care requires that health professionals be skilled and motivated towards interdisciplinary team care. The objectives of our program are to (1) enhance attitudes towards team health care and (2) improve group interaction skills among interdisciplinary health care learners. DESCRIPTION: We nested an educational intervention focusing on skills and attitudes in interdisciplinary team care within a one-month rotation in an interdisciplinary geriatrics clinic. One day each week, a morning is devoted to small-group seminars, and learners participate as members of an interdisciplinary geriatrics clinical team in the afternoon. Learners are from four disciplines and include an internal medicine resident, a nurse practitioner, a social worker, and pharmacy students. During the small-group seminars, eight hours are spent focusing on team care through facilitated discussions with assigned readings that include (1) motivational information and personal stories regarding the fragmented nature of current health care and personal attitudes and experiences with team care (2 hours), (2) a review of selected effective group communication skills (e.g., querying another learner about reasoning behind a statement before responding with a counter-opinion) (one hour), (3) case studies with team care planning and debriefing on group process behaviors (four hours), and (4) exploration of the potential relevance of team care to learners' own career paths (1 hour). The remaining seminars are devoted to topics in clinical geriatrics and managed care, and to reviewing patient files for the afternoon clinic. In the interdisciplinary clinic, learners spend an additional 18 hours seeing patients with a team that includes faculty from each of the four disciplines. Patients are seen jointly, and care plans are developed and implemented collaboratively. The primary outcome measures are pre- and post-rotation attitudes regarding interdisciplinary team care. Concurrent controls who do not participate in the program are also assessed. Additional measures include faculty observation of communication behaviors, review of written interdisciplinary care plans, and learner perceptions of the value of the rotation. After a one-year planning and pilot period, the educational program is now in its third month of operation. DISCUSSION: Previous team-care training programs for health professionals have demonstrated difficulty in fostering effective attitudes and skills. During the planning and pilot year, we identified barriers to success that included (1) negative baseline attitudes toward interdisciplinary team care, especially among medical residents, (2) unrecognized assumptions and behaviors by learners regarding authority and power relationships within the team, and (3) specific concerns by learners regarding the effectiveness and efficiency of health care teams. We hope to demonstrate success through a program that includes direct examination of learners' attitudes and their origins in a safe environment, immediate feedback regarding group behaviors, case-based learning, and direct role exposure to a well-functioning interdisciplinary team.

Attitude of Health Personnel↗

PubMed1999

An update of combined modality therapy for patients with muscle invading bladder cancer using selective bladder preservation or cystectomy.

PURPOSE: We update the results of tri-modality treatment for patients with muscle invading bladder tumors with selection for bladder preservation based on tumor response to induction therapy. MATERIAL AND METHODS: We reviewed the literature on modern tri-modality bladder preserving approaches using transurethral resection, radiation and concurrent chemotherapy followed by either bladder conservation with careful surveillance for complete responding patients or prompt cystectomy in those whose tumors persist after induction therapy. RESULTS: The published experiences from 3 centers and 2 prospective trials done by the Radiation Therapy Oncology Group were evaluated for 5-year overall survival of patients selected for bladder preservation or prompt cystectomy (49 to 63%) and for those with a conserved bladder (38 to 43%). The overall 5-year survival rates were comparable to other series of immediate cystectomy based approaches in patients of similar age and presenting with tumors of similar clinical stage. Of patients treated with the bladder preserving approach 20 to 30% cured of muscle invading cancer will subsequently have a new superficial tumor. The superficial tumors have responded well to intravesical drug therapy. Modern bladder preserving treatments usually result in a well functioning bladder without incontinence or significant hematuria. However, concurrent systemic chemotherapy and radiation have the potential for acute morbidity. Presently the ideal candidate for bladder preservation has primary clinical stage T2 tumor, no associated ureteral obstruction, visibly complete transurethral resection and complete response after induction chemoradiation based on endoscopic evaluation including re-biopsy and cytology. CONCLUSIONS: It is recommended that tri-modality treatment be administered by dedicated multimodality teams. In this country this approach to treatment is available at many of the institutions participating in the Radiation Therapy Oncology Group study. This treatment may be considered a reasonable alternative in patients who are deemed medically unfit for cystectomy and for those who are seeking an alternative to radical cystectomy.

Combined Modality Therapy↗

PubMed1982

Althesin infusions for maintenance of anaesthesia.

The intravenous anaesthetic Althesin may be administered by continuous intravenous infusion for maintenance of general anaesthesia, sedation in patients in intensive care units or during investigational procedures. Published reports of experience with this technique are reviewed, with particular attention to the rates of administration employed and the influence of other anaesthetics and analgesic agents used concurrently.

Adolescent↗

PubMed1986

Effect of warfarin on the activated partial thromboplastin time.

Outpatients followed in an anticoagulation clinic were studied retrospectively to determine the effect of warfarin on the activated partial thromboplastin time (APTT). Twenty-nine patients were studied in part 1 of the trial to determine whether their APTT values were elevated when their prothrombin time (PT) was within 1.5 to 2.5 times the control PT. Part 2 was carried out using the data of 32 patients to determine whether a correlation existed between the degree of elevation of the patients' PT values due to warfarin and the concurrent degree of elevation of their APTT results. Baseline PT and APTT values and a minimum of three concurrent PT and APTT values determined during anticoagulation therapy with warfarin were used. Data were collected by chart review and review of Hematology Department records. Results indicated that a statistically significant difference was evident between the baseline APTT (30.79 sec) and the mean APTT (55.10 sec) when the PT was within the therapeutic range of 1.5 to 2.5 times the control while on warfarin therapy. Good linear correlation was evident (r = 0.821) between the degree of elevation of the PT and the degree of elevation of the APTT for the group. In most cases, a good linear correlation was also evident for individual patients. Routine ordering of concurrent APTT and PT tests for patients receiving warfarin therapy is not needed since the PT alone can be monitored under most circumstances.

Blood Coagulation Tests↗

PubMed2006

Music for pain relief.

BACKGROUND: The efficacy of music for the treatment of pain has not been established. OBJECTIVES: To evaluate the effect of music on acute, chronic or cancer pain intensity, pain relief, and analgesic requirements. SEARCH STRATEGY: We searched The Cochrane Library, MEDLINE, EMBASE, PsycINFO, LILACS and the references in retrieved manuscripts. There was no language restriction. SELECTION CRITERIA: We included randomized controlled trials that evaluated the effect of music on any type of pain in children or adults. We excluded trials that reported results of concurrent non-pharmacological therapies. DATA COLLECTION AND ANALYSIS: Data was extracted by two independent review authors. We calculated the mean difference in pain intensity levels, percentage of patients with at least 50% pain relief, and opioid requirements. We converted opioid consumption to morphine equivalents. To explore heterogeneity, studies that evaluated adults, children, acute, chronic, malignant, labor, procedural, or experimental pain were evaluated separately, as well as those studies in which patients chose the type of music. MAIN RESULTS: Fifty-one studies involving 1867 subjects exposed to music and 1796 controls met inclusion criteria. In the 31 studies evaluating mean pain intensity there was a considerable variation in the effect of music, indicating statistical heterogeneity ( I(2) = 85.3%). After grouping the studies according to the pain model, this heterogeneity remained, with the exception of the studies that evaluated acute postoperative pain. In this last group, patients exposed to music had pain intensity that was 0.5 units lower on a zero to ten scale than unexposed subjects (95% CI: -0.9 to -0.2). Studies that permitted patients to select the music did not reveal a benefit from music; the decline in pain intensity was 0.2 units, 95% CI (-0.7 to 0.2). Four studies reported the proportion of subjects with at least 50% pain relief; subjects exposed to music had a 70% higher likelihood of having pain relief than unexposed subjects (95% CI: 1.21 to 2.37). NNT = 5 (95% CI: 4 to 13). Three studies evaluated opioid requirements two hours after surgery: subjects exposed to music required 1.0 mg (18.4%) less morphine (95% CI: -2.0 to -0.2) than unexposed subjects. Five studies assessed requirements 24 hours after surgery: the music group required 5.7 mg (15.4%) less morphine than the unexposed group (95% CI: -8.8 to -2.6). Five studies evaluated requirements during painful procedures: the difference in requirements showed a trend towards favoring the music group (-0.7 mg, 95% CI: -1.8 to 0.4). AUTHORS' CONCLUSIONS: Listening to music reduces pain intensity levels and opioid requirements, but the magnitude of these benefits is small and, therefore, its clinical importance unclear.

Analgesics, Opioid↗

PubMed2005

Virtual laboratory manual for microscopic anatomy.

Using digital technology, we have assembled a virtual laboratory manual (VLM) that is a Web-based copy of our traditional laboratory manual. The VLM is used to enhance traditional laboratory instruction in histology. For each reference in the VLM to either a histological slide or an electron micrograph (EM), hyperlinks are included that download digital images derived from the students' glass slide sets or scanned EMs. The VLM serves as an atlas of digital images for concurrent study of similar sections by light microscopy during laboratory sessions. In addition, students can review the images from the VLM at remote locations. We have encouraged continued use of light microscopes in laboratories by basing the majority of practical examination identifications on analysis of marked histological slides that require students to use their own microscopes. The VLM provides the convenience of a Web-based resource with high-quality images, yet allows retention of the many excellent traditional aspects of our course. An example of a VLM laboratory on epithelium is available online (http://users.von.uc.edu/michaeje/VLM-Epithelium/exLab4.pdf).

Computer-Assisted Instruction↗

PubMed2004

ASC-US and HPV testing in women aged 40 years and over.

High-risk human papillomavirus (HPV) DNA triage is commonly performed for cervical cytology specimens interpreted as atypical squamous cells of undetermined significance (ASC-US), but little is known about testing results in women > or =40 yr of age. The extent to which clinical follow-up after HPV testing reflects the most recent management guidelines is unknown also. Data from 108 patients > or =40 yr of age with concurrent (93 patients) or recent (15 patients) ASC-US interpretations and HPV testing were reviewed. Twenty-five (23.1%) of these patients were positive for high-risk HPV. The HPV(+) rate was higher in women with a current interpretation of ASC-US (26.9%) compared with those with a previous ASC-US result (0%). Many patients were not managed exactly according to the "2001 Consensus Guidelines for the Management of Women with Cervical Cytologic Abnormalities." The majority (52.6%) of women with HPV(+) ASC-US did not receive colposcopy in our institution, and 41.3% of women with HPV(-) ASC-US received follow-up testing within 8 mo. These results show the potential for inadequate evaluation of women with HPV(+) ASC-US, as well as unnecessary early repeat cytology in HPV(-) ASC-US patients. Therefore, additional clinician education and reminders to correlate cytology and HPV test results may be warranted to optimize patient care.

Adult↗

PubMed1987

Association of congenital megacalycosis and ipsilateral segmental megaureter.

Four cases of congenital megacalycosis associated with ipsilateral segmental megaureter in children are presented. This association has not been emphasized, although review of the English and French literature revealed eight such cases. In all cases, the concurrent entities are unilateral, with a left-sided predominance and a male prevalence. The diagnosis of megacalycosis is presumed in four of the cases by normal function and prompt emptying of the calyceal systems on diuretic renography and/or urography. The presence of normal caliber renal pelvis interposed between the dilated collecting system and the distal dilated ureter without evidence of vesicoureteral reflux implies the coexistence of ipsilateral idiopathic megaureter. The patients usually present because of urinary tract infection and/or calculus formation, but respond well to conservative therapy.

Adolescent↗

PubMed1981

Breast cancer concurrent with hyperthyroidism: a case report.

A case of breast cancer concurrent with hyperthyroidism was reported and the relation between breast cancer and thyroid dysfunction was reviewed. It has been frequently suggested that the incidence of breast cancer is decreased in patients with hyperthyroidism and breast cancer coincidental with hyperthyroidism is rare.

Adult↗

PubMed2004

Genital lentigines and melanocytic nevi with superimposed lichen sclerosus: a diagnostic challenge.

BACKGROUND: Benign pigmented lesions of the genitalia, such as genital lentigines and melanocytic nevi, often show clinical and histopathologic features highly suggestive of malignant melanoma (MM). Superimposed changes of lichen sclerosus (LS) may cause real concern and lead to an erroneous diagnosis of MM. OBJECTIVE: This study was performed to assess clinicopathologic characteristics of genital lentigines and melanocytic nevi with associated LS. METHODS: We performed a retrospective review of 5 cases. RESULTS: Histopathologic sections of the 2 cases of genital lentigines with concurrent changes of LS showed a lichenoid lymphocytic infiltrate and pigment incontinence with melanophages in a fibrosed papillary dermis, features reminiscent of completely regressed MM. The 3 cases of genital melanocytic nevi and superimposed LS were sharply circumscribed, relatively symmetric, but revealed confluent nests varying in size and shape and pagetoid upward spread of melanocytic nests and single melanocytes. Changes of LS extended beyond the melanocytic proliferation. CONCLUSION: Genital lentigines and melanocytic nevi with associated LS may show features that mimic MM.

Adult↗

PubMed2001

Dosimetric predictors of radiation esophagitis in patients treated for non-small-cell lung cancer with carboplatin/paclitaxel/radiotherapy.

PURPOSE: To establish dosimetric predictors of radiation esophagitis (RE) in patients treated with a combination of carboplatin, paclitaxel, and radiotherapy. METHODS AND MATERIALS: Three-dimensional radiotherapy plans of 26 patients with non-small-cell lung cancer who received 50-60 Gy of radiotherapy concurrently with weekly administration of carboplatin (AUC 2) and paclitaxel (40-45 mg/m(2)) were reviewed in conjunction with RE. The factors analyzed included the following: percentages of organ volumes receiving >40 Gy (V40), >45 Gy (V45), >50 Gy (V50), and >55 Gy (V55); the length of esophagus (total circumference) treated with >40 Gy (LETT40), >45 Gy (LETT45), >50 Gy (LETT50), and >55 Gy (LETT55); the maximum dose in the esophagus (Dmax); and the mean dose in the esophagus (Dmean). Data were obtained on the basis of superposition algorithm. RESULTS: All factors except Dmax showed statistical correlation with RE. Good correlations were shown between RE and LETT45 (rho = 0.714) and V45 (rho = 0.686). CONCLUSIONS: LETT45 and V45 appear to be useful dosimetric predictors of RE. It is also suggested that Dmax does not predict RE.

Adult↗

PubMed2000

Histologic examination of bone marrow core biopsy specimens has limited value in the diagnosis of mycobacterial and fungal infections in patients with the acquired immunodeficiency syndrome.

Bone marrow cultures and biopsy specimens are commonly obtained to rule out disseminated infections, especially in persons with the acquired immunodeficiency syndrome (AIDS) and cytopenias. Using culture as the gold standard, we reviewed 130 consecutive bone marrow cores obtained from 114 AIDS patients along with results of concurrent blood and/or bone marrow aspirate cultures to determine the usefulness of histologic examination for diagnosis of mycobacterial and fungal infections. We also compared the ability of Ziehl-Neelsen, auramine-rhodamine (AR), polyclonal antibody to Mycobacterium bovis (Ab), and Gomori's methenamine silver staining to detect infections. Twenty-seven patients had mycobacterial infection (25 Mycobacterium avium-intracellulare complex cases and two Mycobacterium tuberculosis cases) detected by blood and/or bone marrow cultures. The maximum sensitivity of histology was 50% when the auramine-rhodamine stain and the polyclonal antibody to M bovis were used in combination. The single best stain was auramine-rhodamine, with a sensitivity of 44%, followed by the polyclonal antibody to M bovis (35%). Granulomas were observed in nine cases of mycobacterial infection and did not correlate with the presence of stainable organisms. Of seven patients with positive fungal cultures of bone marrow, four had granulomas and a positive Gomori's methenamine silver stain, one had only a positive stain, and two had neither granulomas nor a diagnostic stain. Overall, granulomas were not sensitive for the detection of infections when culture-proven mycobacterial and fungal cases were evaluated together. We conclude that bone marrow examination has a limited value in the routine evaluation of common opportunistic infections in AIDS patients and recommend that less-invasive tests, such as blood cultures, be obtained initially in most circumstances.

AIDS-Related Opportunistic Infections↗