Validation of symptom clusters in patients with metastatic bone pain

Purpose

Symptom clusters (scs) are a dynamic construct. They consist of at least 2 or 3 interrelated symptoms that may be a significant predictor of patient morbidity. In a previous study, we identified 2 scs in patients with bone metastases:

These scs may be clinically important in the pain and symptom management of patients with metastatic bone pain. It is therefore important to validate the reported scs to determine if they hold true across similar patient populations.

Patients and Methods

From February to September 2007, our study accrued 52 patients with bone metastases [29 men (56%), 23 women (44%); median age: 68.5 years (range: 39–87 years)] who were referred for palliative radiotherapy (rt). Prostate (31%), breast (29%), and lung (19%) were the most common primary cancer sites. Treatment arms ranged from single to multiple fractions, with most patients receiving a single 8-Gy fraction (77%) or 20 Gy in 5 fractions (21%). The most prevalent sites for rt were spine (42%), hips (17%), and pelvis (14%). Worst pain at the site of rt and functional interference scores were assessed using the Brief Pain Inventory (bpi), a multidimensional pain instrument that uses 11-point numeric rating scales. Patients provided their symptom severity scores on the bpi at baseline and at 4, 8, and 12 weeks post rt. At all time points, a principal component analysis with varimax rotation was performed on 8 items (worst pain and 7 functional interference items) to determine relationships between symptoms before and after rt for bone pain.

Results

Two scs were identified. Cluster 1 included worst pain and interference with general activity, normal work, and walking ability; cluster 2 consisted of interference with mood, sleep, enjoyment of life, and relations with others. Our statistical analysis produced varied results for the 2 clusters found in our previous investigation. These differences may be an indicator for the instability of scs or may be a result of the fewer number of patients accrued in the present validation study.

Conclusions

The scs in our two studies were not identical for patients receiving palliative rt for symptomatic bone metastases. Another sc validation study should be conducted with a larger sample before a conclusion is drawn about the existence of an unstable phenomenon in sc research.

Retrospective analysis of the treatment of psoriasis of the palms and soles

In this retrospective analysis, the effect of currently used treatments in 26 patients with psoriasis of the palms and soles were analyzed. In general, patients are treated initially with topical medications including superpotent topical corticosteroids in combination with calcipotriene ointment or tazarotene gel or both. If satisfactory improvement is not achieved in 4-8 weeks, systemic retinoids are added, formerly etretinate and currently acitretin, except in women of childbearing potential. If the latter regimen is not effective within two months, soak PUVA is added to the regimen of oral retinoids and topical medications. If improvement is inadequate, or if the treatment regimen is not tolerated, methotrexate or cyclosporine have been added in the past. The availability of the excimer laser has recently modified our approach so that this therapy is used in combination with acitretin before soak PUVA. With the availability of biologic agents, methotrexate is avoided because of its hepatotoxicity and bone marrow toxicity and cyclosporine is avoided because of its nephrotoxicity. If oral acitretin plus topical therapy is not adequate to control the disease and the excimer laser is not an option because of its limited availability, alefacept, etanercept and infliximab are added when possible. Other biologic agents are likely to be added to this list in the future.

After radiotherapy, do bone metastases from gastrointestinal cancers show response rates similar to those of bone metastases from other primary cancers?

PURPOSE

Reports investigating whether the response rates to palliative radiation therapy (RT) for painful bone metastases from gastrointestinal (GI) cancers are similar to rates for bone metastases from other primary cancer sites have been limited. The present study evaluated response rates for symptomatic bone metastases from gi cancers after palliative outpatient rt in the Rapid Response Radiotherapy Program (RRRP).

PATIENTS AND METHODS

We identified 69 patients with bone metastases from gi primaries who received palliative rt in the RRRP clinic during 1999-2006. We extracted records for 31 of these patients during 1999-2003 from an RRRP database that used the Edmonton Symptom Assessment Scale (ESAS). Record for the remaining 38 patients during 2003-2006 were extracted from an RRRP database that used the Brief Pain Inventory (BPI). Eligibility criteria for encryption in the two RRRP databases and for collection of patient demographic information (age, sex, primary cancer site, and Karnofsky performance status) were identical. Response rates for this cohort of metastatic gi patients were then compared to rates for 479 patients receiving palliative RT for bone metastases from other primary cancer sites. Pain scores from the ESAS and BPI and data on analgesic consumption were collected at baseline and by telephone follow-up at 4, 8, and 12 weeks after RT for all patients. Complete (CR), partial (PR), and overall (CR+PR) responses were evaluated according to International Consensus Endpoints.

RESULTS

Assessment of the 69 patients with metastatic GI cancers revealed CR, PR, and CR+PR rates of 18%, 42%, and 61% at 4 weeks; 22%, 35%, and 57% at 8 weeks; and 50%, 21%, and 71% at 12 weeks for evaluable patients. The 479 evaluable patients with metastatic cancer from other primary cancer sites had CR, PR, and CR+PR rates of 25%, 27%, and 51% at 4 weeks; 26%, 22%, and 48% at 8 weeks; and 22%, 29%, and 51% at 12 weeks. No statistically significant differences were observed in RT response rates for bone metastases from GI cancers than from other primary cancer sites.

CONCLUSIONS

After palliative RT, bone metastases from gi cancers demonstrate response rates that are similar to rates for metastases from other primary cancer sites. Patients with symptomatic bone metastases from GI malignancies should be referred for palliative RT as readily as patients with osseous metastases from other primary cancer sites.

Symptom clusters in cancer patients with brain metastases

AIM

To explore the presence of symptom clusters in patients with brain metastases.

MATERIALS AND METHODS

Patients with brain metastases referred to an outpatient palliative radiotherapy clinic were asked to rate their symptom distress using the Edmonton Symptom Assessment Scale (ESAS). Baseline demographic data were obtained. To determine interrelationships between symptoms, a principal component analysis with 'varimax rotation' was carried out on the nine ESAS items. Follow-up was carried out by telephone 1, 2, 4, 8 and 12 weeks after radiation.

RESULTS

Between January 1999 and January 2002, 170 patients with brain metastases provided complete baseline data on the ESAS. The most common primary cancer sites were lung, breast and gastrointestinal. Fatigue was the highest scored symptom, followed by a poor sense of well-being, anxiety, drowsiness and poor appetite. The four most prevalent symptoms were fatigue (91.7%), a poor sense of well-being (88.1%), drowsiness (82.2%) and anxiety (82.1%). Three symptom clusters were found at baseline. Cluster 1 included fatigue, drowsiness, shortness of breath and pain. Cluster 2 included anxiety and depression. Cluster 3 included poor appetite, nausea and a poor sense of well-being. Fatigue, nausea, drowsiness and poor appetite showed an overall increase in symptom severity over time; whereas fatigue, drowsiness and poor appetite were experienced to some extent by a greater proportion of patients at week 12 compared with baseline. Symptom clusters emerged in all weeks of follow-up, but consisted of different symptoms in each week.

CONCLUSION

Symptom clusters seemed to exist in patients with brain metastases before and after whole brain radiotherapy. However, different symptoms clustered at various time points. The effectiveness of whole brain radiotherapy in providing palliative relief to patients with brain metastases needs to be explored with regards to symptom clusters.

Medicolegal impact of the new hurt laws in Pakistan

The penal laws in Pakistan went through sweeping reforms in 1979 with intent to bring them in line with the Islamic Jurisprudence. The introduction of these laws repealed the definitions as well as punishments of various types of injuries. Besides that these laws also redefined and reclassified the crime of murder. The laws required that the injuries be identified and documented by an authorized physician. The new classification of injuries and deaths, lack of proper forensic training of the emergency room physicians, performance of medicolegal work by doctors at the earliest stages of their careers and theoretical methods of undergraduate teaching in forensic medicine are matters of concern as they adversely affect the quality of medicolegal work performed in the country. This article gives an overview of the medicolegal system of Pakistan. It also reviews the current laws, their impact on the medical and legal systems of the country and offers some recommendations to correct the existing situation of forensic training and work standards.

Factors associated with bone regrowth following diabetes-related partial amputation of the foot

BACKGROUND

The formation of hypertrophic bone after partial resection of metatarsal bone has the potential to cause abnormal foci of high pressure in people who have diabetes mellitus; this may increase the risk of reulceration and reamputation. However, we are not aware of previous studies evaluating the risk factors for this entity.

METHODS

The records of ninety-two adults (mean age, 54+/-10.1 years; range, thirty to seventy-four years) with diabetes who had had an isolated partial amputation of a ray were abstracted. Repeat radiographs were made for all of these subjects at a mean of 22+/-6.1 months (range, thirteen to thirty-five months) after the initial procedure. The formation of hypertrophic bone was defined as more than three millimeters of regrowth.

RESULTS

A total of forty-one (45 percent) of the subjects had formation of hypertrophic bone at the time of radiographic analysis after isolated partial amputation of a ray. On multivariate analysis, the factors that were significantly associated with this regrowth of bone were male gender (88 percent [thirty-six] of the forty-one patients who had bone regrowth were male compared with 51 percent [twenty-six] of the fifty-one patients who did not have bone regrowth; p<0.01, odds ratio = 5.7, 95 percent confidence interval = 1.8 to 18.9), the use of manual bone-cutting instruments (used in 56 percent [twenty-three] of the forty-one patients who had bone regrowth compared with 16 percent [eight] of the fifty-one who did not; p<0.01, odds ratio = 4.7, 95 percent confidence interval = 1.6 to 13.8), and a resection made distal to the surgical neck of the metatarsal (used in 34 percent [fourteen] of the forty-one patients who had bone regrowth compared with 12 percent [six] of the fifty-one who did not; p<0.03, odds ratio = 4.5, 95 percent confidence interval = 1.2 to 16.9). The patients who had regrowth of bone were approximately eight times more likely to have reulceration at the site of the amputation than were those who did not have regrowth (24 percent [ten] of the patients with regrowth had reulceration compared with 4 percent [two] of the patients without regrowth; p<0.01, chi square = 8.4, odds ratio = 7.9, 95 percent confidence interval = 1.6 to 38.5).

CONCLUSIONS

Overgrowth of the bone of a transected metatarsal predisposes patients to ulceration. Male gender, the use of manual bone-cutting instruments, and metaphyseal amputation may be associated with long-term regrowth of bone following isolated partial amputation of a ray. The use of power instruments during these procedures may lead to a lower prevalence of this reaction, thereby potentially reducing the risk of ulceration, infection, and reamputation.

Evidence that HLA-B*2706 is not protective against spondyloarthropathy

OBJECTIVE

Studies in Southeast Asia showed that HLA-B*2704 is positively associated with spondyloarthropathy (SpA), while B*2706 does not occur in such patients. In view of the absence of an association between B*2706 and SpA it was suggested that B*2706 protects against the disease, while it is supposed that B*2704 presents pathogenetic peptides. We studied families in which both B*2704 and B*2706 occurred to see whether in B*2704/B*2706 heterozygotes the effect of one of the subtypes shows a preponderance over the other.

METHODS

Two families of mixed Chinese/Indonesian origin were studied. HLA-B27 subtyping was performed by polymerase chain reaction in combination with sequence specific oligonucleotide probes.

RESULTS

In one family, members with B*2704, B*2706, or both occurred. In the other family B*2704, B*2706, and B*2708 were present. In both families SpA was seen only in B*2704 positive members, while the B*2706 and B*2708 positive members were healthy, except some B*2704/B*2706 or B*2704/B2708 heterozygotes.

CONCLUSION

The pathogenic influence of B*2704 is thus dominant over the supposed protective influence of B*2706. It is probable that B*2704 can present pathogenetic peptides, while a protective influence of B*2706 does not exist. B*2708, which was until now described in only a few cases, behaved in this study as B*2706 and is probably not associated with SpA.

Limb salvage with Chopart's amputation and tendon balancing

For several decades, Chopart's amputation has met with some skepticism owing to reports of significant equinus deformity developing soon after the procedure is performed. However, with appropriate tendon balancing, which generally includes anterior tibial tendon transfer and tendo Achillis lengthening, this level of amputation is often more functional than slightly more distal amputations, such as Lisfranc or short transmetatarsal amputations. The authors offer a rationale for this observation, which includes a discussion of the longitudinal and transverse arch concept of the foot. This concept dictates that the shorter the midfoot-level amputation, the more likely the patient is to develop an equinovarus deformity, thus exposing the fifth metatarsal base and cuboid to weightbearing stress and a high risk of ulceration. Chopart's amputation, in eliminating the cuboid, often obviates the potential varus deformity and thus can have a more acceptable long-term result.

Clinical and immunological studies in vitiligo in the United Arab Emirates

OBJECTIVE

To determine the clinical and immunological changes encountered in patients with vitiligo in Al-Ain population, United Arab Emirates (UAE).

DESIGN

This is a prospective descriptive hospital-based study.

SETTING

Al-Ain Medical District, Al-Ain Hospital, United Arab Emirates.

SUBJECTS

Patients who were seen at Al-Ain hospital for skin diseases during 1996.

RESULTS

The study was based on 65 patients. The sample consisted 32 (49%) males and 33 (51%) females. The mean and standard deviation of age for males were 38.6 +/- 13.5 years and for females were 35.1 +/- 15.9 years. Most of the patients were UAE, Omani and Pakistani nationals. Positive family history of vitiligo was found in 19% of the patients. Association with other immune diseases was found in 6% of the patients while one or more organ specific antibodies, all of whom were females, most of them had positive history of autoimmune diseases.

CONCLUSION

Vitiligo is more common among UAE nationals since the UAE community including a multi-national society.

Production of sodium-chloride-tolerant Brassica juncea plants by in vitro selection at the somatic embryo level

Somatic embryos, developed from hypocotyl segments of light-grown seedlings of Brassica juncea cv RLM198, were subjected to selection at varying concentrations of sodium chloride (NaCl). Plants were developed from proliferated somatic embryos selected on NaCl-containing medium. The selections were characterized for salt tolerance, esterase isozyme pattern, and proline accumulation. It has been found that: (i) selected tolerant lines showed better root growth, shoot growth, and fresh weight accumulation on salt-containing medium when compared to the control; (ii) salt tolerance was transmitted to the next generation in seed progeny of tolerant plants grown in the absence of exposure to salt; (iii) both the starting material and the tolerant selections accumulated proline, even when grown in salt-free medium. On salt-containing medium, however, the differences in accumulated proline between the control and tolerant lines became more pronounced, and (iv) the patterns of esterase isozymes of two tolerant selections were similar but distinctly different from that of the parental control.

Clinical investigation of ranitidine in patients with gastritis

A double-blind clinical investigation was conducted to study the effectiveness of ranitidine therapy in 52 patients with gastritis that had been confirmed by panendoscopy. Subjective weekly assessment of symptoms showed that patients receiving 300 mg of ranitidine daily for four weeks improved considerably more than those receiving placebo. In the ranitidine-treated group, symptoms completely disappeared in 20 (80%) of 25 patients and significantly improved in the other five; in the placebo group, only nine (45%) of 20 patients improved, with the remaining 11 staying unchanged (seven patients--one in the ranitidine-treated group and six in the placebo-treated group--did not return to the hospital and so were withdrawn from the study). Panendoscopy repeated in 41 patients at the end of the four-week treatment period confirmed the assessment of symptoms. No significant adverse effects were observed in patients taking ranitidine. This investigation found ranitidine to be an effective short-term treatment for patients with endoscopically proved gastritis.

The effect of topical retinoic acid (Airol) in the treatment of tinea versicolor

A clinical trial with retinoic acid (Airol) cream 0.05% applied topically was carried out on 50 patients suffering from tinea versicolor allocated to a random procedure. The results, judged in terms of cure rate, incidence of relapse and tolerance were very satisfactory. As regards the above mentioned criteria for a successful treatment, there was no significant difference between the lotion and cream groups. Repigmentation of the affected skin after retinoic acid occurred in a relatively shorter period compared with other anti-fungal preparations, especially when simultaneously exposed to sunlight. The therapeutic action on dermatophytes was discussed. It was pointed out that patients suffering from tinea versicolor are predisposed to dermatophyte infections and that cleanliness of the skin is a simple but essential way of preventing contamination with Malassezia furfur.