Reflection on the application of the Consolidated Framework for Implementation Research to a national policy to improve inclusion of people with disabilities

People with disabilities face many barriers in the built environment impacting their mobility, health, and social participation. In the US, under the Americans with Disabilities Act (ADA), municipalities were required to develop and implement barrier-removal plans for pedestrian infrastructure, called ADA transition plans, but very few have done so. Many communities know they need a plan but do not know how to get it done because of a lack of understanding of the many different implementation considerations. Implementation science offers a useful approach for understanding complex policy implementation such as ADA plans. This paper provides a reflection on the adaptation of the Consolidated Framework for Implementation Research (CFIR) to evaluate the implementation of ADA transition planning. To apply the CFIR, we tailored the construct definitions and modified them to fit the specific context of the ADA transition planning process. We documented the constructs that were more challenging to apply, those that were not relevant, and those that were particularly useful. This paper can serve as a valuable example that other researchers can use when considering adapting the CFIR or other implementation frameworks for the evaluation of complex social policy beyond the ADA.

Carboplatin in Combination with Bendamustine in Previously Untreated Patients with Extensive-Stage Small Cell Lung Cancer (SCLC)

BACKGROUND AND OBJECTIVE

Bendamustine is an alkylating agent with high efficacy in non-Hodgkin's lymphoma and multiple myeloma. Even in solid tumours, monotherapy with bendamustine has resulted in subjective remissions and has been associated with a low rate of side effects. The current dose-finding study was designed to determine the maximum tolerated dose (MTD) of combined carboplatin/bendamustine in previously untreated patients with extensive-stage small cell lung cancer (SCLC).

PATIENTS AND METHODS

Carboplatin was administered as a 1-hour infusion on day 1 at increasing dose levels, and bendamustine was administered as a short infusion on days 1 and 2 at increasing dose levels (80-120 mg/m(2)). The regimen was administered every 3 weeks. Four dose levels were planned, starting with 80 mg/m(2) bendamustine and carboplatin area under the curve (AUC) 5 (dose level I). The other dose levels were 100 mg/m(2) bendamustine and carboplatin AUC 5 (dose level II), 100 mg/m(2) bendamustine and carboplatin AUC 6 (dose level III), and 120 mg/m(2) bendamustine and carboplatin AUC 6 (dose level IV). A minimum of three patients were enrolled at each dose level.

RESULTS

Dose-limiting toxicities, which included fatigue, infection and tachyarrhythmia, were observed at dose level III. The recommended dose for phase II studies was therefore established at dose level II. The majority of haematological and non-haematological toxicities observed were only mild (grade 1 or 2) in patients at dose levels I and II. None of the patients developed severe alopecia. Objective responses were observed in eight of the ten patients involved in this trial.

CONCLUSION

Because of its acceptable toxicity and favourable preliminary antitumour efficacy, the combination of carboplatin and bendamustine appears to be a potentially useful chemotherapeutic option in patients with extensive SCLC.

Diagnostic management of orthostatic intolerance in the workplace

OBJECTIVE

Orthostatic intolerance (OI) is a syndrome that is characterised by headache, concentration difficulties, palpitation of the heart, dizziness associated with postural tachycardia and plasma norepinephrine concentrations that are disproportionately high when the sufferer is in the upright posture. In contrast to other forms of orthostatic dysregulation - orthostatic hypotension (OH) and postural orthostatic tachycardia syndrome (POTS) - OI, hitherto, could be diagnosed only by a tilt table examination, with high expenditure. In this paper we examine the reliability and validity of a questionnaire as a screening instrument for OI.

METHODS

We studied 138 young men (mean age 21.6 years) who were undergoing military service. After a medical check and filling in the questionnaire, the participants underwent a tilt table test including monitoring of blood pressure, heart rate and plasma catecholamines, in the supine position and during 30 min of standing. The questionnaire consisted of ten items registering presence and frequency of typical OI symptoms.

RESULTS

Probands (104) showed normal tilt table test results. OI was diagnosed in 14 probands, OH in 6 and POTS in 14. The OI participants scored significantly higher in the questionnaire than the healthy subjects did: the mean score of the OI group was 22.6, the healthy participants had a mean score of 3.9. Participants with POTS had a mean score of 13.5 and subjects with OH had a mean score of 17.0. Reliability analysis showed a Cronbach's alpha of 0.888. Validity analysis showed that 93.5% of the probands with any kind of orthostatic dysregulation can be detected.

CONCLUSIONS

We were able to establish a short questionnaire as a reliable and valid screening instrument for OI. Usage of this questionnaire can simplify enormously the diagnostic management of patients with suspected OI.

Efficacy and toxicity of bendamustine in patients with relapsed low-grade non-Hodgkin's lymphomas

Low-grade non-Hodgkin's lymphomas (NHL) are very sensitive to a broad range of chemotherapeutic and biological agents. Relapses, however, occur even after aggressive cytostatic combinations in first-line therapy. Therefore, effective and well-tolerated salvage therapies are very important. In this single-institution trial, the efficacy and toxicity of bendamustine in the treatment of relapsed low-grade NHL was investigated. Fifty-eight patients with low-grade NHL pretreated with different cytostatic regimens were included. All patients received bendamustine at 120 mg/m(2) as a 1-h infusion on 2 consecutive days. The treatment was repeated every 3 weeks until complete remission (CR), partial remission (PR) or stable disease (SD) was confirmed on two consecutive cycles. Efficacy and toxicity were evaluated in 52 patients: CR was induced in 11%, PR in 62% and SD in another 10% of the patients. No response to treatment was seen in 17%. The median duration of remission was 16 months and the median survival time was 36 months. Side effects were generally mild, and restricted to myelosuppression, gastrointestinal toxicity and allergic reactions. Bendamustine proved to be very effective and was well tolerated in pretreated patients with relapsed or primary resistant low-grade NHL.

Genotyping of measles virus isolates from central Europe and Russia

Sequence analysis of 285 nucleotides located on the variable part of the N gene was undertaken on measles virus (MV) samples collected from acutely infected patients in Germany, the Czech Republic, Denmark, Poland, and Russia. Two distinct genotypes (C2 and D6) have circulated in Germany between 1993 and 1996. Isolates of genotype C2 were related to strains reported in Germany before 1993. This genotype was also found in the Czech Republic in 1992 and in Denmark in 1997. The occurrence of genotype D6 in Germany is described below for the first time. In 1998, this genotype was identified in Poland. Genotypes C2 and D6 were also reported in Spain and in the United Kingdom between 1992 and 1996. Therefore, it is concluded that these genotypes are widely distributed over Europe. The analysis of the isolates from Russia revealed that genotype A was present in 1988 in the European part of the country and in 1996 in Siberia. An isolate identified in 1997 in Siberia belonged to genotype D6, which had never been found previously in Russia. We also analysed MV obtained from a case of subacute sclerosing panencephalitis (SSPE) in 1995 in Turkey. A comparison of this sequence with published sequences implied that this SSPE case was associated with a new genetic lineage of MV.

Comparative investigation of the long non-coding M-F genome region of wild-type and vaccine measles viruses

The sequence of the 300 nucleotides region of the measles virus genome was determined that includes a part of the 3'-untranslated region of the matrix (M) gene, the intergenic region and a part of the 5'-untranslated region of the fusion (F) gene [M-F region] for vaccine strain Leningrad-16 and 14 wild-type isolates. The data obtained demonstrate the variability of this long non-coding M-F region. No mutations in this region of the genome were found which seem to be specific for vaccine strains of measles virus (MV).

Hypersensitivity reactions to parenteral lipid solutions

In cancer patients, hypersensitivity reactions to adjunctive medications are easily mistaken for cytostatic toxicities. We report on three patients with systemic reactions (flush, dyspnea, tachycardia, hypotension, back pain) to a lipid emulsion containing long chain fatty acids (LCT). Reexposure to LCT and exposure to MCT (medium chain fatty acids) solutions of slightly different composition--no soybean lecithin used as an emulsifier--were well tolerated. These data suggest that traces of soybean proteins are the allergenic agents. Therefore, hypersensitivity to concomitant medications, including parenteral nutrition, has to be considered in oncologic patients demonstrating severe systemic reactions to intravenous therapy.

Phase II study of paclitaxel and cisplatin in patients with non-small cell lung cancer

Few cytotoxic agents tested in adequate phase II trials involving patients with non-small cell lung cancer have produced single-agent response rates greater than 15%. Paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) is one of them, with reported response rates ranging from 21% to 36%. Platinum-based regimens have been key to the development of the most effective combination therapies for NSCLC. We are currently investigating the efficacy and toxicity of combining paclitaxel (175 mg/m2) given by 3-hour infusion, followed by cisplatin (75 mg/m2) via 1-hour infusion, on a 21-day schedule for the treatment of 75 chemotherapy-naive patients with stage IIIB (17.3%) or stage IV (82.6%) non-small cell lung cancer. Patient characteristics include a median age of 58 years (age range, 28 to 75 years) and a median Eastern Cooperative Oncology Group performance status of 2; 19 patients (25.3%) are women and 56 (74.7%) are men. All patients received standard prophylactic premedication as well as adequate hydration. To date, 75 subjects and 328 courses are evaluable for toxicity. Hematologic toxicities have been moderate; grade 3 or 4 neutropenia occurred in 37% of cycles (50% of patients), and grade 3 or 4 thrombocytopenia was observed in only 2% of cycles (2% of patients). Other notable toxicities were World Health Organization grade 2 or 3 alopecia and nausea/vomiting. Grade 1 or 2 peripheral neuropathy occurred in 26% and grade 3 or 4 in only 1% of all courses. Of 67 patients evaluable for response, complete remission was noted in three (5%) patients, partial remission in 25 (37%) patients, stable disease in 22 (33%) patients, and progressive disease in 17 (25%) patients. These results suggest that combination paclitaxel/cisplatin is active and well tolerated in the treatment of non-small cell lung cancer.

Paclitaxel and cisplatin in patients with non-small cell lung cancer: results of a phase II trial

We performed a clinical phase II trial of the combination of paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) and cisplatin in patients with locally advanced (stage IIIB) or metastatic non-small cell lung cancer (NSCLC), using a 3-hour infusion of paclitaxel followed by a 1-hour infusion of cisplatin. Treatment was repeated every 21 days, for a maximum of six cycles. The patients received paclitaxel 175 mg/m2 followed by cisplatin 75 mg/m2. At present, 52 chemotherapy-naive patients with stage IIIB (17.3%) or stage IV (82.7%) NSCLC have been entered into this ongoing trial. Ten (19%) of the patients are women and 42 (81%) are men. With 197 courses of chemotherapy given, all 52 patients are evaluable for toxicity. Hematologic toxicities were moderate: World Health Organization (WHO) grade 3 or 4 neutropenia occurred in 38.7% of the cycles (47.7% of patients), and WHO grade 3 or 4 thrombocytopenia was observed in 1.5% of cycles (3.8% of patients). Other toxicities consisted mainly of WHO grade 2 or 3 alopecia and nausea/vomiting. World Health Organization grade 1 or 2 polyneuropathy occurred in 30.4% and grade 3 or 4 only in 1% of all courses. Of 40 patients evaluable for response, a complete remission was noted in one patient, a partial remission occurred in 13 patients (32.5%), stable disease was seen in 14 patients (35%), and disease progressed in 12 patients (30%). These results suggest that the combination of paclitaxel and cisplatin is active and tolerable in the treatment of NSCLC. The efficacy of the combination seems high in this poor-prognosis population.

[Hypersalivation as a leading symptom of neoplastic meningiosis in highly malignant non-Hodgkin's lymphoma]

Partial remission of a centroblastic non-Hodgkin's lymphoma, clinical stage IV A, in a 79-year-old man was achieved by six courses of chemotherapy with epirubicin, cyclophosphamide and vincristine. The only residual finding was a palpable small cervical lymphoma. After a treatment pause of about 6 weeks increasing hypersalivation set in which ultimately made food intake impossible and led to a breakdown in the patient's general state. Findings in the region of the head, neck, throat and the base of the skull were unremarkable, but cerebrospinal fluid contained 1300/3 cells, almost all of them lymphoblasts. After five intrathecal injections of at first 15 mg methotrexate and 4 mg dexamethasone each, followed by five more with 40 mg cytarabine added to them, the CSF cell count became normal. At the same time salivation clearly decreased and food intake became once again possible. The patient died 5 months later from hypercalcaemia due to osseous infiltrations. Until his death there was no recurrence of the hypersalivation as the cardinal sign of meningeal carcinomatosis.