Home care: what is it?

The oft quoted phrase, "There's no place like home," has no greater meaning than when long-term care decisions are being made. In the midst of ongoing late life changes, one's home is often the only anchor. Through carefully selected home care and nursing and care management services, living at home remains a viable option for older adults and their families. Physicians can serve as a vital link between older adults and the home care system by educating the patient where services can be obtained. Physician input into referral and collaboration with other care managers can help determine the best approach to home care.

Comparison of single versus multiple lifestyle interventions: are the antihypertensive effects of exercise training and diet-induced weight loss additive?

Although aerobic exercise training and diet-induced weight loss each have been shown to individually lower elevated blood pressure (BP), it is currently not known whether their combined use produces an additive antihypertensive effect. In this randomized clinical trial we therefore compared the effect on resting BP of exercise training only and dietary modification only with that of exercise training plus dietary modification in 55 sedentary, overweight patients with high normal BP or stage 1 or 2 hypertension. After baseline testing, patients were randomized to 1 of the following 3 interventions for 12 weeks: exercise training only (aerobic exercise; 30 to 45 minutes; 3 to 5 days/week; 60% to 85% of maximal heart rate), dietary modification only (aimed primarily at weight loss via restriction of energy intake and dietary fat), or exercise training plus dietary modification. Forty-eight patients completed the study. In these patients, exercise training plus dietary modification elicited a greater reduction (p < or = 0.001) in body weight (-7.1 +/- 2.9 vs -1.0 +/- 1.8 kg) than exercise training only, and a greater increase (p < or = 0.05) in maximal oxygen uptake (4.3 +/- 2.6 vs 1.9 +/- 2.0 ml/kg/min) versus dietary modification only. However, the reduction in BP with exercise training plus dietary modification (-12.5 +/- 6.3/7.9 +/- 4.3 mm Hg) did not differ significantly from that with exercise training only (-9.9 +/- 6.4/5.9 +/- 4.6 mm Hg) or dietary modification only (-11.3 +/- 12.1/7.5 +/- 4.3 mm Hg). These data indicate that the antihypertensive effects of exercise training and diet-induced weight loss are not additive. This finding has important public health and clinical implications for the millions of overweight persons with high normal BP or stage 1 or 2 hypertension.

Interpreting energy expenditure for anaerobic exercise and recovery: an anaerobic hypothesis

Energy expenditure during and after exercise is composed of aerobic and anaerobic bioenergetics and the energy demands of aerobic recovery. Current attempts to measure energy expenditure include an exercise oxygen uptake + oxygen debt (EPOC) measurement or, an oxygen deficit + exercise oxygen uptake measurement. This investigation illustrates how oxygen debt and oxygen deficit interpretation can effect a total energy expenditure measurement. It was hypothesized that the total energy expenditure for several intermittent bouts of exercise and recovery would be greater than for one bout of continuous exercise and recovery when equivalent work was compared. Exercise was performed under low-intensity and high-intensity conditions. Both oxygen debt and oxygen deficit methodology resulted in similar energy expenditure measurements for both intermittent and continuous exercise. This implies little to no recovery energy demand or considerable methodology errors. Differences in total energy expenditure were found when the oxygen deficit and parts of the oxygen debt (EPOC) were considered separate and independent (p < 0.05). These differences can be accounted for when the data are interpreted utilizing thermodynamic (2nd law) and engineering (in-series efficiency) concepts rather than the heat equivalent of carbohydrate oxidation (20.9 kJ equals one liter of O2). It is suggested that while oxygen uptake provides an excellent representation of aerobic metabolism during exercise and recovery, oxygen uptake may be an inadequate measure of the energetics of lactate production (fermentation). In application, energy expenditure differences appear realistic only for high-intensity, intermittent exercise rather than lower intensity exercise.

A model emerges for the community-based nurse care management of older adults

Changes in the demographics of older adults and the structure and financing of the health care delivery system have created a need to develop alternative models of care delivery for the elderly. The nurse care management model is a potentially cost-effective solution for provision of comprehensive care to this population. By providing timely health promotion and illness prevention education, as well as coordinating community resources, nurses can reduce the health care costs of this growing segment of the population. Funding this model, however, remains a challenge as such services are not directly reimbursed by third-party payers.

Physical urticaria: a common misdiagnosis

The incidence of urticaria, a symptom that accompanies many allergic disorders, is frequently reported to be low. However, an accurate estimate is difficult to determine as the condition is often unreported or misdiagnosed. Because the associated discomfort of urticaria is disproportionate to the seriousness of the condition, the lay public and health professionals alike tend to dismiss or overlook the need for a diagnostic workup and treatment options. Urticaria, however, can have a tremendous impact on the everyday life of the sufferer, and the significance of this condition warrants attention. In this paper, a brief overview of urticaria and its physiology is provided, followed by a discussion of the different types of physical urticarias. Assessment and diagnosis, cautions, guidelines, and techniques for the primary care provider are discussed.

Preference of sheep for foods varying in flavors and nutrients

Our objective was to better understand the importance of flavor and nutrients in food preferences of lambs. Three foods differing in flavor and nutritional quality were created by grinding and mixing grape pomace, barley, alfalfa pellets, and soybean meal in different proportions. food 1 (2.21 Mcal/kg DE, 8.1% DP), food 2 (2.42 Mcal/kg DE, 11.0% DP), and food 3 (2.68 Mcal/kg DE, 13.8% DP). Intake of each food, offered singly and together, was assessed when foods 2 and 3 were flavored with 1% onion or 1% oregano. Lambs (n = 24) preferred food 3 > 2 > 1, regardless of flavor (P < .05), and they continued to prefer food 3 > 2 > 1, even when they received the toxin LiCl after eating one of the three foods (P < .05). When offered a choice, lambs always ate substantial amounts of all three foods, even though they might have been expected to eat food 3 exclusively. We hypothesize selection of a varied diet resulted from a decrease in preference for food just eaten as a result of sensory input (taste, odor, texture, i.e., a food's flavor) and postingestive feedback (effects of nutrients and toxins on chemo-, osmo-, and mechano-receptors) unique to each food. Thus, we submit that offering different foods of similar nutritional value, offering foods of different nutritional value, and offering the same food in different flavors are all means of enhancing food preference and intake.

Human monocytes are unable to bind to or phagocytize IgA and IgG immune complexes formed with influenza virus in vitro

An in vitro model system was used to investigate how human monocytes recognize influenza A/WSN(H1N1)-infected epithelial cells, and the role that anti-influenza IgA and IgG Abs play in this interaction. Pretreatment of the monocytes with neuraminidase or F(ab')2 fragments of a mAb against the Ca1 epitope on the hemagglutinin (HA) molecule inhibited monocyte adherence to the infected cells. This suggested that monocytes bound to the sialic acid binding site on the HA molecule and not to other viral or epithelial cell Ags. In the presence of neutralizing concentrations of intact Abs (human serum IgA, secretory IgA, IgG, or mouse anti-HA mAb), monocytes were unable to bind to influenza-infected epithelium or to phagocytize the IgA or IgG immune complexes formed with influenza virus, even though they could use these same Abs to attach to or phagocytize inert particles. Under conditions of Ag excess and low concentrations of Ab, monocytes bound primarily to the viral HA molecule, but showed some recognition of the viral immune complexes. This dual binding did not increase monocyte adherence to the infected epithelium above that observed with virus alone. These findings indicate that neutralizing concentrations of IgA or IgG Abs, the predominant Abs found in the upper and lower respiratory tract, respectively, do not augment and can prevent monocyte recognition of influenza virus. This suggests that in vivo monocytes must use a non-Fc-mediated mechanism to adhere to and phagocytize these immune complexes.

Human monocytes are unable to bind to or phagocytize IgA and IgG immune complexes formed with influenza virus in vitro

An in vitro model system was used to investigate how human monocytes recognize influenza A/WSN(H1N1)-infected epithelial cells, and the role that anti-influenza IgA and IgG Abs play in this interaction. Pretreatment of the monocytes with neuraminidase or F(ab')2 fragments of a mAb against the Ca1 epitope on the hemagglutinin (HA) molecule inhibited monocyte adherence to the infected cells. This suggested that monocytes bound to the sialic acid binding site on the HA molecule and not to other viral or epithelial cell Ags. In the presence of neutralizing concentrations of intact Abs (human serum IgA, secretory IgA, IgG, or mouse anti-HA mAb), monocytes were unable to bind to influenza-infected epithelium or to phagocytize the IgA or IgG immune complexes formed with influenza virus, even though they could use these same Abs to attach to or phagocytize inert particles. Under conditions of Ag excess and low concentrations of Ab, monocytes bound primarily to the viral HA molecule, but showed some recognition of the viral immune complexes. This dual binding did not increase monocyte adherence to the infected epithelium above that observed with virus alone. These findings indicate that neutralizing concentrations of IgA or IgG Abs, the predominant Abs found in the upper and lower respiratory tract, respectively, do not augment and can prevent monocyte recognition of influenza virus. This suggests that in vivo monocytes must use a non-Fc-mediated mechanism to adhere to and phagocytize these immune complexes.

A phase I/II study to evaluate radiation therapy and hyperthermia for deep-seated tumours: a report of RTOG 89-08

The purpose of this paper is to evaluate the safety and efficacy of deep hyperthermia in conjunction with radiation therapy. This study employed 'second generation' electromagnetic devices which were felt to be better able to confine heating and spare normal tissue than the devices evaluated in a previous study (RTOG 84-01). Sixty six patients at six institutions were enrolled on a prospective Phase I/II study. Eligible deep seated tumours were treated with a combination of external hyperthermia and radiation therapy. Radiation consisted of 1.7-2 Gy per fraction, 4-5 fractions per week, to > 20 Gy (previously irradiated lesions) or > 50 Gy (no previous radiation). Deep hyperthermia was delivered with electromagnetic devices: BSD 2000 for 92% of cases, Thermotron for 5% of cases, other low frequency electromagnetic for 4% of cases. Hyperthermia was delivered < or = twice weekly. Overall complete and partial response rates were 34% and 16% respectively. Response was not correlated with maximum tumour temperature or disease site. There was, however, a strong association with radiation dose: 54% CR with > or = 45 Gy versus 7% with < 45 Gy (p < 0.0001). The achieved temperatures were less than ideal. Although the average maximum tumor temperature was 41.9 degrees C (range 35.7 degrees C-46.7 degrees C), the minimum tumour temperatures were low. The average minimum tumour temperature was 38.5 degrees C and was never > 41.8 degrees C. Treatment was well tolerated with no fatalities. There were four acute grade 3 or 4 toxicities (6% of patients). Patient discomfort resulted in interruption or discontinuation of sessions in 30% of the sessions. In 12 cases (18% of patients) the planned course of hyperthermia was discontinued due to acute discomfort. The devices used in this study were better tolerated than the devices used in the previous Phase I/II deep hyperthermia trial (RTOG 84-01) with less patient discomfort and no problems with severe systemic cardiovascular stress. In the previous study 68% of the hyperthermia courses were prematurely terminated primarily due to patient discomfort and toxicity; in the present study 18% were prematurely terminated. However, as indicated by the low minimum tumour temperature, fundamental problems with achieving acceptable temperature distributions remain.

Final report of a phase I/II trial of hyperfractionated and accelerated hyperfractionated radiation therapy with carmustine for adults with supratentorial malignant gliomas. Radiation Therapy Oncology Group Study 83-02

BACKGROUND

Efforts to improve local control and survival by increasing the dose of once-daily radiation therapy beyond 70 Gray (Gy) for patients with malignant gliomas has yet been unsuccessful. Hyperfractionated radiation therapy (HF) should allow for delivery of a higher total dose without increasing normal tissue late effects, whereas accelerated hyperfractionated radiation therapy (AHF) may minimize tumor repopulation by shortening overall treatment time. The Radiation Therapy Oncology Group (RTOG) conducted a randomized Phase I/II study of escalating doses of HF and AHF either carmustine (bis-chlorethyl nitrosourea [BCNU]) fro adults with supratentorial glioblastoma multiforme (GBM) or anaplastic astrocytoma (AA). Primary study endpoints were overall survival and acute and chronic treatment-related toxicity.

METHODS

From 1983 to 1989, 786 patients with supratentorial gliomas (81% with GBM and 19% with AA) were stratified by histology, age, and performance status and randomized to receive partial brain irradiation, utilizing either HF (1.2 Gy twice daily to doses of 64.8, 72, 76.8, or 81.6 Gy) of AHF (1.6 Gy twice daily to doses of 48 or 54.4 Gy). All patients received carmustine. The distinction of pronistic factors was similar on all arms.

RESULTS

There were 747 eligible and analyzable patients among 786 enrolled patients (95%). Two patients had a Grade 5 and 65 patients had a Grade 4 chemotherapy toxicity. Two patients in the 81.6 Gy arm experienced late Grade 4 radiation toxicity and there was 1 late radiation-associated death in the 54.4 Gy arm. The rate of Grade 3 of worse radiation toxicity at 5 years, calculated by the delivered does level, was 3% in the lowest total dose arms (48 and 54.4 Gy), 4% in the intermediate dose arms (64.8 and 72 Gy), and 5% in the highest dose arms (76.8 and 81.6 Gy) (p = 0.54). Survival rates at 2 and 5 years were: 21% and 11%, and 4%, respectively, for GBM patients. There were no significant differences between the treatment arms with regard to median survival time (MST), when analyzed by the originally assigned dose. The MST for all patients varied between 10.8 months and 12.7 months (P = 0.59); between 9.6 months and 11 months for patients with GBM (P = 0.43); and between 30.4 months and 85.8 months for patients with AA (P = 0.78). Analysis of the survival rates for all patients by dose received rather than by dose assigned revealed a 14% 5-year survival rate for the lower HF doses (64.8 and 73 Gy), 11% for the higher doses (76.8 and 81.6 Gy), and 10% for the AHF doses (48 and 54.4 Gy) (P = 0.1). The subgroup a AA patients had a better MST (49.9 months) in the lower received HF doses than in the higher HF doses (34.6 months) (P = 0.35). In contrast, GM patients who received the higher HF doses had survival superior to the patients in the AHF arms (MST of 11.6 months and 10.2 months, respectively, P = 0.04).

CONCLUSIONS

The use of HF with BCNU and dose escalation up to 81.6 Gy is both feasible and tolerable, although late toxicity increases slightly with increasing dose. The best MST with the least toxicity were observed for AA in the lower received HF doses (72 and 64.8 Gy). Accordingly, 72 Gy in two 1.2 Gy fractions was used as the investigational arm of a completed Phase III trial (RTOG 90-06). In contrast, for GBM patients, longer survival times were noted in the higher received HF doses (78.6 and 81.6 Gy), suggesting the role for further dose escalation. The low toxicity rate with AHF arms suggest that further dose escalation is possible and is currently occurring in RTOG 94-11.

Race and prognosis of brain tumor patients entering multicenter clinical trials. A report from the Radiation Therapy Oncology Group

We investigated the possible influence of race on the survival of patients with malignant gliomas enrolled in three consecutive trials of the Radiation Therapy Oncology Group (RTOG) retrospectively using the group's statistical database. There were no statistical differences between the survival rates for black patients with glioblastoma multiforme (GBM) and those for the white patients. The limited influence of therapy on this disease may be responsible in part for this result.

Results of a randomized comparison of radiotherapy and bromodeoxyuridine with radiotherapy alone for brain metastases: report of RTOG trial 89-05

PURPOSE

To determine if the addition of bromodeoxyuridine (BrdUrd) to radiotherapy prolongs survival when compared to radiotherapy alone in patients with brain metastases.

METHODS AND MATERIALS

Seventy-two patients with brain metastases were randomized to 37.5 Gy in 15 fractions of 2.5 Gy or to the same dose with BrdUrd 0.8 g/m2 per day for 4 days of each of 3 weeks. Drug treatment was begun on Thursday or Friday before the first week of radiotherapy. Patients had a Karnofsky performance score of at least 70, a neurological function classification of 1 or 2, and any primary tumor except central nervous system (CNS), leukemia, or lymphoma. The primary was absent, controlled, or under active radiotherapy. Patients were free of other metastases. They were stratified by primary site (breast, lung or other), number of metastases (single or multiple) and age (< 60 vs. > 60).

RESULTS

There was no significant difference between the two treatment arms (p = 0.904). The study was open from October 1989 to March 1993 and accrued 72 patients. Only one patient in the RT only arm remains alive. The two treatment arms were balanced with respect to all stratification variables. Toxicity due to radiotherapy was similar in both arms. BrdUrd caused significant Grade 4 and 5 hematologic and skin toxicity in five patients. Two patients died due to hematologic toxicity and one from a Stevens-Johnson type skin reaction. Phenytoin played a role in the skin reactions and ranitidine was associated with the hematologic deaths. Ranitidine was eliminated, BrdUrd was discontinued after any hematologic toxicity, and no further Grade 4 or 5 toxicities were seen. The median survival was 6.12 months in the radiotherapy group and 4.3 in the BrdUrd group (p = 0.904). Patients with solitary brain metastases had significantly better survival (p = 0.031).

CONCLUSIONS

BrdUrd did not enhance the efficacy of the radiotherapy regimen tested, in spite of the fact that brain metastases have shown high labeling indices. The toxicity of this schedule of BrdUrd administration was apparently increased by ranitidine and phenytoin.

Perceptions of senior residents about a community-based nursing center

This phenomenological study explored the meaning of nursing services provided in a community-based nursing center for older adults. A systematic, randomly selected sample of 27 residents, ranging in age from 56 to 86 and predominantly female, participated in one of four focus-group sessions. Residents' perceptions were elicited using open-ended questions. Themes were organized using common phenomena from group sessions. Contextual factors identified were beliefs about aging, future concerns, and views about health care. Three major themes were feeling valued and respected; opening doors to self care; and decreasing self-care costs. The findings offer an understanding of the value of community-based nursing centers to older adults and lend strong support for care management provided by nurses.

Central pathology review in clinical trials for patients with malignant glioma. A Report of Radiation Therapy Oncology Group 83-02

BACKGROUND

Confounding biologic factors, including histologic grade, may influence the outcome of adult patients with malignant gliomas more than may modifications in therapeutic approach. Any clinical trial design for malignant gliomas in adults must account for such biologic factors, including the accurate identification of the two histologic subgroups astrocytoma with anaplastic foci (AAF) or glioblastoma multiforme (GBM), which are associated with distinctly different survival outcomes. This paper examines the need for a central pathology review before entry of patients in cooperative group clinical trials stratified by histologic grade.

METHODS

Pathology slides from Radiation Therapy Oncology Group (RTOG) trial 83-02, a randomized Phase II study of hyperfractionated and accelerated hyperfractionated radiation therapy and carmustine for malignant gliomas, provided 747 analyzable cases, with 680 (91%) available for central pathology review. This review was performed by a single pathologist according to RTOG/Eastern Cooperative Oncology Group histopathologic criteria. The kappa statistic was used to measure agreement between the institutional and central classification of AAF and GBM. The influence of misclassification was examined using computer simulation of varying clinical trial sizes (n = 25, 50, or 200). The effect on the statistical power of trials (n = 200) with varying mixtures of AAF and GBM tumors was investigated using computer simulations.

RESULTS

Of 159 tumors classified as AAF by institutional pathology review, only 66% (105) were classified as AAF (AAF/AAF) by central review, and 54 of these cases (34%) were classified as GBM (GBM/AAF), whereas 96% (501) of 521 institutionally classified as GBM (GBM/GBM) were similarly classified by central review. Computer simulations demonstrated a 59% underestimation in the median survival (1.82 vs. 4.49 years) for trials of patients with institutionally defined AAF compared to patients with centrally defined AAF in studies of 200 patients, resulting from the addition of poor prognosis of GBM in the trial. Misclassification can also substantially reduce the statistical power of a clinical trial. In one of the simulation studies, statistical power was reduced from 65% to 14% if 50% of the patients were to receive an inaccurate histologic classification. Even greater losses in power are possible in many plausible clinical settings.

CONCLUSIONS

This examination of a central versus an institutional pathology review demonstrates a low level of agreement on AAF classification and a high level of concordance on GBM classification. The results indicate the need to adjust sample size for trials of both AAF and GBM tumors to have adequate statistical power. A central pathology review remains essential for trial entry for patients with AAF and could be omitted for trials enrolling patients with GBM only.

Anticipatory coping in the elderly

1. Concerns about the future are a major source of stress for older adults. 2. Contrary to popular opinion, older adults are capable of coping with threats to their well-being. 3. Health care providers can assist older adults in identifying the issues of concern to them and planning strategies to either prevent or minimize the losses they expect to occur in the future.

Concurrent hyperfractionated irradiation and chemotherapy for unresectable nonsmall cell lung cancer. Results of Radiation Therapy Oncology Group 90-15

BACKGROUND

Clinical trials of hyperfractionated radiation therapy and induction chemotherapy followed by standard radiation therapy have shown improved survival in patients with unresectable nonsmall cell lung cancer (NSCLC). Radiosensitization may improve local tumor control when chemotherapy is given concurrently with hyperfractionated radiation therapy, but also may increase toxicity. A Phase I/II trial, Radiation Therapy Oncology Group 90-15, was designed to evaluate whether this strategy could improve survival with acceptable toxicity and be part of a Phase III trial of chemoradiation sequencing.

METHODS

Vinblastine (5 mg/M2 weekly x 5 weeks) and cisplatin (75 mg/M2 days 1, 29, and 50) were given during twice-daily irradiation (1.2 Gy, 6 hours apart) to 69.6 Gy in 58 fractions in 6 weeks. Eligible patients had American Joint Committee on Cancer (AJCC) Stage II (unresected) or IIIA-B NSCLC and Karnofsky performance status 70 or greater; there were no weight loss restrictions.

RESULTS

Of 42 eligible patients, 76% had greater than 5% weight loss, 45% had T4 primary tumors, and 62% were Stage IIIB. All protocol treatment was completed in 53%. Acute toxicity was predominantly hematologic with 19 of 42 (45%) having Grade 4 toxicity or higher, three (7%) with septic death. Ten of 42 (24%) had Grade 3 or higher esophagitis. There were two (4.7%) patients with Grade 3 or higher (1 lung and 1 esophagus) and two (4.7%) with Grade 4 or higher (1 lung and 1 hematologic) late toxicities. Median survival time was 12.2 months, with an overall 1-year survival of 54%, an estimated 2 year survival of 28% and a 1-year progression free survival of 38%.

CONCLUSIONS

For patients with unresectable nonsmall cell lung cancer, who were not selected on the basis of weight loss, concurrent hyperfractionated irradiation and chemotherapy had more intense acute toxicity than hyperfractionation alone, but late toxicity was acceptable. One and 2-year survival rates were 54 and 28%, respectively.

White matter changes are correlated significantly with radiation dose. Observations from a randomized dose-escalation trial for malignant glioma (Radiation Therapy Oncology Group 83-02)

BACKGROUND

A Phase I/II randomized dose-seeking trial was performed to document the severity, time course, and significance of white matter changes seen on serial imaging scans (magnetic resonance imaging, computed tomography) associated with bis-chlorethyl nitrosourea (BCNU) and hyperfractionated cranial irradiation.

METHODS

Long term survivors (> or = 18 months) were identified from a prospective randomized dose-escalation Phase I/II trial designed to evaluate twice-daily radiotherapy for supratentorial high grade malignant gliomas. All scans were reviewed by a neuroradiologist who had no information about the prescribed dose and fractionation. In the trial, patients were assigned to receive 64.8 Gy, 72.0 Gy, 76.8 Gy, or 81.4 Gy (all fractionated as 1.2 Gy twice a day [bid]), or 48.0 Gy or 54.4 Gy (both in 1.6-Gy bid fractions). Bis-chlorethyl nitrosourea was administered every 8 weeks for 1 year. Of 747 randomized patients, 177 had analyzable scans. The scans reviewed were those acquired preoperatively, immediately postoperatively, 3, 6, 12, and 18 months after radiotherapy. Radiographic endpoints included no white matter change (Grade 0), minimal patchy white matter foci (Grade 1), start of confluence of white matter disease (Grade 2), large confluent areas (Grade 3), confluence with cortical/subcortical involvement (Grade 4), leukoencephalopathy (Grade 5), and possible necrosis (Grade 6) according to the classification of F. Fazekas et al. The effects were scored relative to the baseline preoperative scans. The dose pairs of 48 Gy and 54.4 Gy, 64.8 Gy and 72 Gy, and 76.8 Gy and 81.4 Gy were grouped together for analysis (low, intermediate, and high dose, respectively). Toxicity was analyzed in three ways: Grade 2 or worse, Grade 3 or worse, and Grade 6.

RESULTS

Grade 2 or worse changes were observed in 26.6, 27.6, and 40.4% of patients in the low, intermediate, and high dose groups, respectively. Grade 3 or worse changes were observed in 8.3, 20.0, and 36.5% of patients in the low, intermediate, and high dose groups, respectively. Grade 6 changes were observed in 1.6, 4.6, and 19.2% of patients in the low, intermediate, and high dose groups, respectively. No statistically significant differences were observed among treatment groups when toxicity was evaluated as Grade 2 or worse. For toxicity of Grade 3 or worse, an chi-square test revealed P values of 0.04 (low vs. intermediate dose), 0.09 (intermediate vs. high dose), and 0.0005 (low vs. high dose). With the endpoint of possible necrosis (Grade 6), P values were 0.21 (low vs. intermediate dose), 0.05 (intermediate vs. high dose), and 0.003 (low vs. high dose). The median time to radiographic appearance of an effect (15 months) was not influenced by total dose or fraction size.

CONCLUSIONS

A well described toxicity scale for white matter injury was applied successfully to patients with malignant glioma treated with definitive irradiation. Severe white matter changes continued to increase significantly as the total dose of hyperfractionated cranial irradiation was escalated. The time to onset of the white matter abnormalities appeared to be independent of dose. An ongoing Radiation Therapy Oncology Group study will allow correlation of white matter injury with prospective neuropsychometric testing.

Antiemetic drugs attenuate food aversions in sheep

Ruminants learn to avoid many foods that contain toxins by associating the flavor of the foods with aversive postingestive feedback. We hypothesized the emetic system is a cause of aversive feedback, and three experiments were conducted to determine whether antiemetic drugs (diphenhydramine, metoclopramide, dexamethasone) would attenuate food aversions caused by the toxicant lithium chloride (LiCl). Lambs were assigned to one of four treatments: antiemetics plus LiCl (A + L), antiemetics alone (A), LiCl alone (L), or neither antiemetics nor LiCl (C). The LiCl was administered immediately after sheep ate oats, wheat, and milo in Exp. 1, 2, and 3, respectively. The antiemetics were given 1 h before and at the time LiCl was administered to sheep. Lambs that received antiemetics (A and A + L) consistently ate more grain than lambs that did not receive the drugs (C and L) (Exp. 1, P < .08; Exp. 2, P < .05; Exp. 3, P < .08), and there was no interaction between antiemetics and LiCl. Thus, the results of all three experiments were consistent with the hypothesis that antiemetic drugs attenuate food aversions caused by the toxicant LiCl because sheep receiving antiemetic drugs (Group A + L) ate more grain than sheep not receiving the drugs (Group L). In addition, we suggest aversive postingestive feedback limited intake of grain because sheep receiving antiemetic drugs (Group A) ate somewhat more grain than sheep not receiving the drugs (Group C).

Surgical reporting instrument designed to improve outcome data in head and neck cancer trials

Precise reporting of surgical staging and operative data in multi-institutional protocol studies could provide a number of benefits: 1) fewer cases would be discarded because of inadequate data, 2) staff review time would be reduced, 3) there would be assurance that participating surgeons were performing similar operations on similar tumors, 4) the resulting precision in stratification should improve the likelihood of achieving accurate comparison of the treatment options under study, and 5) by comparing the surgical parameters with local-regional control of disease, the specific factors that have a statistically significant correlation with outcome could be identified. This paper presents a computer-based, anatomically oriented reporting instrument that should improve the reliability of surgical data available to multi-institutional protocols.

Radiation Therapy Oncology Group quality of life assessment: design, analysis, and data management issues

The Radiation Therapy Oncology Group (RTOG) has embarked on seven phase II or phase III multicentre clinical trials involving a quality of life component. Each quality of life trial used questionnaires or examinations that have been tested for reliability and validity by independent investigators. Each trial includes questionnaires that examine the patient's physical, functional, social, and emotional status, and that measure a specific quality of life issue pertinent to the patient's diagnosis or treatment. Two trial designs have been implemented for studies with quality of life endpoints. One design involves companion trials to the primary treatment study pertaining solely to the quality of life endpoint. The second design integrates the quality of life component into the primary trial design. The RTOG has found a need for education of individuals and institutions expected to administer and obtain the quality of life data. Once the data have been collected several methods for the analysis of the quality of life data are available. However, there is no one best method for analysing quality of life data, thus more than one method should be used in order to provide insight into the data.