On the Opioid Crisis: An Interview with Vincent Lam

Vincent Lam, the author of the best-selling novels Bloodletting & Miraculous Cures (Lam 2006) and The Headmaster's Wager (Lam 2012), recently spoke with the editors of Healthcare Quarterly (HQ), Neil Stuart and Anne Wojtak, about his new novel On the Ravine (Lam 2023). The novel explores the nuances of substance abuse and its impacts on patients and the people in their lives.

From the Editors

Some of us may recall a time in healthcare when it seemed that the summer months were a bit quieter, providing an opportunity to catch our breath before the onslaught of fall and the ramp-up to flu season. Yet, with the increasing demand on our health systems, the sense of downtime has all but disappeared. This may suggest that we collectively have less time available for review, reflection and learning - all of which are critical elements for improvement and transformation. As an editorial team, our contribution is to continue synthesizing and presenting leading practices and innovative concepts to our readers, enabling them to access knowledge and ideas more easily. It is how we can help build capacity in our system to deliver better healthcare at a time when renewal is needed more than ever.

From the Editors

As we consider the current pressures on healthcare, the options for where to focus our policy and leadership efforts are numerous and, at times, overwhelming. From health human resources capacity to access to mental health and preventative care to intermittent closures of emergency departments - the outlook is alarming. To help make sense of the situation, our Healthcare Quarterly (HQ) editorial team carefully considers a few areas to focus on in each edition. Over the past few issues, we have highlighted the importance of health equity and the challenges faced by different populations in gaining access to appropriate care and support. We continue to welcome submissions on this topic as we start to shift our focus toward other system priorities, including the mental health crisis in Canada. We are currently exploring a special focus edition on this long-neglected area of the health system and will be inviting submissions on this topic over the coming months.

Shadows and Light: An Interview with Heather Patterson

The editors of Healthcare Quarterly (HQ) recently had the opportunity to speak with Heather Patterson - emergency physician, photographer and author of the recently released book Shadows and Light (Patterson 2022). Through the photographs she took at Calgary-area hospitals during the height of the COVID-19 pandemic, Patterson created a poignant record of how the pandemic affected hospital staff, patients and their families. The book has struck a chord with many Canadians as it offers both an honest appraisal of the dreadful toll of the pandemic while also demonstrating the grace and compassion of healthcare workers.

From the Editors

The recent winter months were particularly brutal for the healthcare system and its patients as we grappled with an onslaught of infectious diseases, healthcare backlogs and critical shortages of health human resources. We subsequently watched as Canada's federal and provincial leaders sought agreement on additional investments for several of our most precarious sectors, including long-term care, primary care and mental healthcare. Spring 2023 offers some optimism in that we will have new resources to make much-needed improvements to our depleted health sectors and services. While we can anticipate ongoing tensions as to how these investments will be used and how political leaders are held accountable, our healthcare leaders are gearing up to increase capacity and shore up our systems.

From the Editors

As we launch into 2023, the third year of the COVID-19 pandemic, the state of Canadian healthcare remains deeply concerning. Over the fall and winter months, our systems have experienced crippling levels of hospitalizations due to waves of infectious diseases, including influenza, respiratory syncytial virus infection and COVID-19. We have been particularly distressed by the impact to paediatric care, the insufficient capacity in mental health services and the continued strain on our healthcare workforce as well as on patients and families.

Lessons from the COVID-19 Pandemic for Long-Term Care: Where Do We Go Next?

Even before the COVID-19 pandemic, I would often hear colleagues who are intimately familiar with our health and social care system remark that they would never allow themselves or those closest to them to end up in long-term care. Sadly, the conversation often progressed to an acknowledgment that more desirable alternatives to long-term care for the most part lie outside our publicly supported care system and are only accessible to those with the means. And then we had the pandemic. For too many it turned what was often dreary and uninspiring care into a modern hell - so awful that two Canadian provinces called in the military to restore care in their worst-hit homes (Howlett 2021). There can be no doubt that the challenges that we face in providing dignified, respectful care to all our seniors have been decades in the making. It would be wrong to simply blame the long-term care homes, and it would be a travesty to lay the blame on individual care providers. On the contrary, those working in long-term care have continued to do their best, against the odds. In the early stages of the pandemic, they were not given the support that they deserved, and many paid a high personal price for their service.

From the Editors

It would be a vast understatement to say that our healthcare systems are facing extraordinary pressure. The COVID-19 pandemic has pushed our people and our systems to their limits. We observe with trepidation that the current state of healthcare has not looked more precarious at any time in recent memory. Patients and families are feeling it. Providers, clinicians and leaders in the system are feeling it. And all of us recognize that it will take incredible political will and system-wide commitment to make the changes that are needed to renew and strengthen our front-line teams, structures and capacity. As editors for Healthcare Quarterly (HQ), we see the opportunity to contribute to the daunting task ahead by shining a light on leading practices and lessons learned from implementing change across Canada and beyond. Our commitment is to continue to showcase healthcare leadership in all forms and share opportunities for post-pandemic recovery and the future of healthcare.

From the Editors

Although we do not yet know how or when the story of COVID-19 ends, Canadians are welcoming the summer of 2022 with the anticipation of the first prolonged period of near normalcy in two-and-a-half years. This sense of renewal coincides with the start of our roles as the new co-editors-in-chief of Healthcare Quarterly (HQ). Building on HQ's 25 years of excellence in sharing leading practices in health services delivery and policy, we are looking forward to taking the journal in new directions. Although both of us of have had long careers in healthcare and have experienced many cycles of change, this particular point in time feels different. Despite the devastating aftermath of this global pandemic, the disruption comes with an extraordinary level of opportunity. It is in thinking about the future state that we have embraced our new leadership roles with HQ.

Leadership Perspective: Addressing Canada's Opioid Crisis - Reducing the Harm of Leadership

While the COVID-19 pandemic has been the major focus for healthcare leaders since early 2020, the opioid crisis has been growing in the background. Confronting this emerging problem will require new thinking. Guest editors Anne Wojtak and Neil Stuart spoke with Scott Elliott, executive director, and Patrick McDougall, director of Knowledge Translation and Evaluation, at the Dr. Peter AIDS Foundation in Vancouver to gain their insights into how leaders can respond effectively.

Leadership Perspective: Partnering with Patients to Co-Design Healthcare Systems

The ability to partner with patients to design healthcare systems is an increasingly critical skill for healthcare leaders. Guest editors Anne Wojtak and Neil Stuart spoke with Vincent Dumez, co-director of the Montreal-based Centre of Excellence on Partnership with Patients and the Public, to gain an understanding of what true patient partnership looks like and how healthcare system design can be transformed.

Resetting the Future of Healthcare Leadership

There is no doubt that the events of the past two years will leave an indelible mark on human history. The tragic loss of so many lives during the COVID-19 pandemic, the long-term health and psychological impacts for many more and the economic and societal changes will reverberate for years to come. While the pandemic is not yet over, we are starting to appreciate how different our new future looks and feels. It is within this context that Longwoods Publishing and the Canadian College of Health Leaders (CCHL) have collaborated, for the first time, in a shared reflection on the future of leadership in Canada's healthcare system.

An imaging refractometer for density fluctuation measurements in high energy density plasmas

We report on a recently developed laser-probing diagnostic, which allows direct measurements of ray-deflection angles in one axis while retaining imaging capabilities in the other axis. This allows us to measure the spectrum of angular deflections from a laser beam, which passes through a turbulent high-energy-density plasma. This spectrum contains information about the density fluctuations within the plasma, which deflect the probing laser over a range of angles. We create synthetic diagnostics using ray-tracing to compare this new diagnostic with standard shadowgraphy and schlieren imaging approaches, which demonstrates the enhanced sensitivity of this new diagnostic over standard techniques. We present experimental data from turbulence behind a reverse shock in a plasma and demonstrate that this technique can measure angular deflections between 0.06 and 34 mrad, corresponding to a dynamic range of over 500.

Environmental Sustainability Must Be on Our Agenda for Healthcare

I am increasingly alarmed by climate change and environmental degradation. Many of you share my concerns, no doubt. I worry that we are not dealing with these issues in a manner that promises meaningful or timely results, and I believe we must reorder our priorities. There is also a fundamental unfairness that runs through what is happening. Environmental harm compounds existing inequities within and among our communities, inequities between richer and poorer nations and, most insidiously, generational inequity - deferring the consequences of our inaction to a future generation. Adding to these concerns is the realization that in my own professional field, healthcare, we have given little thought to the sector's role in and responsibility for environmental sustainability. To date, these issues have not been part of the mainstream healthcare conversation.

Estimating policy-relevant health effects of ambient heat exposures using spatially contiguous reanalysis data

BACKGROUND

Regional National Weather Service (NWS) heat advisory criteria in New York State (NYS) were based on frequency of heat events estimated by sparse monitoring data. These may not accurately reflect temperatures at which specific health risks occur in large geographic regions. The objectives of the study were to use spatially resolved temperature data to characterize health risks related to summertime heat exposure and estimate the temperatures at which excessive risk of heat-related adverse health occurs in NYS. We also evaluated the need to adjust current heat advisory threshold and messaging based on threshold temperatures of multiple health outcomes.

METHODS

We assessed the effect of multi-day lag exposure for maximum near-surface air temperature (T_max) and maximum Heat Index derived from the gridded National Land Data Assimilation System (NLDAS) reanalysis dataset on emergency department (ED) visits/ hospitalizations for heat stress, dehydration, acute kidney failure (AKF) and cardiovascular diseases (CVD) using a case-crossover analysis during summers of 2008-2012. We assessed effect modification using interaction terms and stratified analysis. Thresholds were estimated using piecewise spline regression.

RESULTS

We observed an increased risk of heat stress (Risk ratio (RR) = 1.366, 95% confidence interval (CI): 1.347, 1.386) and dehydration (RR = 1.024, 95% CI: 1.021, 1.028) for every 1 °C increase in T_max on the day of exposure. The highest risk for AKF (RR = 1.017, 95% CI: 1.014, 1.021) and CVD (RR = 1.001, 95% CI: 1.000, 1.002) were at lag 1 and 4 respectively. The increased risk of heat-health effects persists up to 6 days. Rural areas of NYS are at as high a risk of heat-health effects as urban areas. Heat-health risks start increasing at temperatures much lower than the current NWS criteria.

CONCLUSION

Reanalysis data provide refined exposure-response functions for health research, in areas with sparse monitor observations. Based on this research, rural areas in NYS had similar risk for health effects of heat. Heat advisories in New York City (NYC) had been reviewed and lowered previously. As such, the current NWS heat advisory threshold was lowered for the upstate region of New York and surrounding areas. Enhanced outreach materials were also developed and disseminated to local health departments and the public.

Are the current thresholds, indicators, and time window for cold warning effective enough to protect cardiovascular health?

More extreme cold weather and larger weather variations have raised concerns regarding their effects on public health. Although prior studies assessed the effects of cold air temperature on health, especially mortality, limited studies evaluated wind chill temperatures on morbidity, and health effects under the current cold warning threshold. This study identified the thresholds, lag periods, and best indicators of extreme cold on cardiovascular disease (CVD) by comparing effects of wind chill temperatures and cold air temperatures on CVD emergency department (ED) visits in winter and winter transition months. Information was collected on 662,625 CVD ED visits from statewide hospital discharge dataset in New York State. Meteorological factors, including air temperature, wind speed, and barometric pressure were collected from National Oceanic and Atmospheric Administration. A case-crossover approach was used to assess the extreme cold-CVD relationship in winter (December-February) and transition months (November and March) after controlling for PM_2.5. Conditional logistic regression models were employed to analyze the association between cold weather factors and CVD ED visits. We observed CVD effects occurred when wind chill temperatures were as high as -3.8 °C (25 °F), warmer than current wind chill warning standard (≤-28.8 °C or ≤-20 °F). Wind chill temperature was a more sensitive indicator of CVD ED visits during winter with temperatures ≤ -3.8 °C (25 °F) with delay effect (lag 6); however, air temperature was better during transition months for temperatures ≤ 7.2 °C (45 °F) at earlier lag days (1-3). Among all CVD subtypes, hypertension ED visit had the strongest negative association with both wind chill temperature and air temperature. This study recommends modifying the current cold warning temperature threshold given larger proportions of CVD cases are occurring at considerably higher temperatures than the current criteria. We also recommend issuing cold warnings in winter transitional months.

Anomalous Heating and Plasmoid Formation in a Driven Magnetic Reconnection Experiment

We present a detailed study of magnetic reconnection in a quasi-two-dimensional pulsed-power driven laboratory experiment. Oppositely directed magnetic fields (B=3  T), advected by supersonic, sub-Alfvénic carbon plasma flows (V_{in}=50  km/s), are brought together and mutually annihilate inside a thin current layer (δ=0.6  mm). Temporally and spatially resolved optical diagnostics, including interferometry, Faraday rotation imaging, and Thomson scattering, allow us to determine the structure and dynamics of this layer, the nature of the inflows and outflows, and the detailed energy partition during the reconnection process. We measure high electron and ion temperatures (T_{e}=100  eV, T_{i}=600  eV), far in excess of what can be attributed to classical (Spitzer) resistive and viscous dissipation. We observe the repeated formation and ejection of plasmoids, consistent with the predictions from semicollisional plasmoid theory.

A spatial fuzzy logic approach to urban multi-hazard impact assessment in Concepción, Chile

Even though most cities are exposed to more than one hazard, local planners and decision-makers still have a limited understanding of the exposure and sensitivity to and the spatial distribution of hazards. We examine the impact of multiple hazards in the Concepción Metropolitan Area (CMA), Chile. A flexible methodology based on spatial fuzzy logic modelling was developed to explore the impact of weather-related hazards, including coastal flooding, fluvial flooding, water scarcity, heat stress, and wildfire. 32 indicators were standardised and then aggregated through a stepwise approach into a multi-hazard impact index. We find that all the municipalities in the CMA increased their level of impact between 1992 and 2002, due to a larger increase in the exposure rather than the modest decrease in sensitivity. Municipal sensitivity was driven mostly by changes in the population's age structure. Wildfires and water scarcity appeared to have the largest impact on all municipalities. Fuzzy modelling offered high flexibility in the standardisation and aggregation of indicators with diverse characteristics, while also providing a means to explore how the interaction of numerous indicators influenced the index. The resulting maps can help identify indicators, components, and hazards or combinations of hazards that most influence the impact on municipalities. The results can be used to improve and promote dialogue among policy-makers and stakeholders regarding prioritisation of resources for urban development in ways that can also reduce exposure and sensitivity and lower vulnerability to climate change. The methods presented can be adapted to other cities.

Assessing urban adaptive capacity to climate change

Despite the growing number of studies focusing on urban vulnerability to climate change, adaptive capacity, which is a key component of the IPCC definition of vulnerability, is rarely assessed quantitatively. We examine the capacity of adaptation in the Concepción Metropolitan Area, Chile. A flexible methodology based on spatial fuzzy modelling was developed to standardise and aggregate, through a stepwise approach, seventeen indicators derived from widely available census statistical data into an adaptive capacity index. The results indicate that all the municipalities in the CMA increased their level of adaptive capacity between 1992 and 2002. However, the relative differences between municipalities did not change significantly over the studied timeframe. Fuzzy overlay allowed us to standardise and to effectively aggregate indicators with differing ranges and granularities of attribute values into an overall index. It also provided a conceptually sound and reproducible means of exploring the interplay of many indicators that individually influence adaptive capacity. Furthermore, it captured the complex, aggregated and continued nature of the adaptive capacity, favouring to deal with gaps of data and knowledge associated with the concept of adaptive capacity. The resulting maps can help identify municipalities where adaptive capacity is weak and identify which components of adaptive capacity need strengthening. Identification of these capacity conditions can stimulate dialogue amongst policymakers and stakeholders regarding how to manage urban areas and how to prioritise resources for urban development in ways that can also improve adaptive capacity and thus reduce vulnerability to climate change.

Structure of a Magnetic Flux Annihilation Layer Formed by the Collision of Supersonic, Magnetized Plasma Flows

We present experiments characterizing the detailed structure of a current layer, generated by the collision of two counterstreaming, supersonic and magnetized aluminum plasma flows. The antiparallel magnetic fields advected by the flows are found to be mutually annihilated inside the layer, giving rise to a bifurcated current structure-two narrow current sheets running along the outside surfaces of the layer. Measurements with Thomson scattering show a fast outflow of plasma along the layer and a high ion temperature (T_{i}∼Z[over ¯]T_{e}, with average ionization Z[over ¯]=7). Analysis of the spatially resolved plasma parameters indicates that the advection and subsequent annihilation of the inflowing magnetic flux determines the structure of the layer, while the ion heating could be due to the development of kinetic, current-driven instabilities.

Is increased time to diagnosis and treatment in symptomatic cancer associated with poorer outcomes? Systematic review

BACKGROUND

It is unclear whether more timely cancer diagnosis brings favourable outcomes, with much of the previous evidence, in some cancers, being equivocal. We set out to determine whether there is an association between time to diagnosis, treatment and clinical outcomes, across all cancers for symptomatic presentations.

METHODS

Systematic review of the literature and narrative synthesis.

RESULTS

We included 177 articles reporting 209 studies. These studies varied in study design, the time intervals assessed and the outcomes reported. Study quality was variable, with a small number of higher-quality studies. Heterogeneity precluded definitive findings. The cancers with more reports of an association between shorter times to diagnosis and more favourable outcomes were breast, colorectal, head and neck, testicular and melanoma.

CONCLUSIONS

This is the first review encompassing many cancer types, and we have demonstrated those cancers in which more evidence of an association between shorter times to diagnosis and more favourable outcomes exists, and where it is lacking. We believe that it is reasonable to assume that efforts to expedite the diagnosis of symptomatic cancer are likely to have benefits for patients in terms of improved survival, earlier-stage diagnosis and improved quality of life, although these benefits vary between cancers.

Clinicians' attitudes towards clinical trials of cancer therapy

Background:

Patient accrual into cancer clinical trials remains at low levels. This survey elicited attitudes and practices of cancer clinicians towards clinical trials.

Method:

The 43-item Clinicians Attitudes to Clinical Trials Questionnaire was completed by participants in an intervention study aimed at improving multi-disciplinary involvement in randomised trials. Responses from 13 items were summed to form a research-orientation score.

Results:

Eighty-seven clinicians (78%) returned questionnaires. Physicians, more often than surgeons, chose to prioritise prolonging a patient's life, recruited ⩾50% of patients into trials and attended more research-focussed conferences. Clinicians at specialist centres were more positive about trials with no-treatment arms than those at district general hospitals, more likely to believe clinician, rather than patient reluctance to participate was the greater obstacle to trial accrual, and preferred national and international to local recognition. Clinicians belonging to breast and colorectal teams were less disappointed about not enrolling patients in trials and more accepting of no-treatment arm trials. Research orientation was higher in physicians than surgeons and higher in specialist centres than district hospitals.

Conclusions:

This study provides greater understanding of clinicians’ attitudes to trials. Results have been used to inform training interventions for clinicians targeting the problem of low and selective accrual.

Comparison of different critical load approaches for assessing streamwater acid-sensitivity to broadleaf woodland expansion

Due to its potential adverse effects on freshwater acidification, risk assessments of the impacts of forest expansion on surface waters are required. The critical load methodology is the standard way of assessing these risks and the two most widely used models are the Steady-State Water Chemistry (SSWC) and First-order Acidity Balance (FAB) models. In the UK the recommended risk assessment procedure for assessing the impact of forest expansion on freshwater acidification uses the SSWC model, whilst the FAB model is used for guiding emission policy. This study compared the two models for assessing the sensitivity of streamwater to acidification in 14 catchments with different proportions of broadleaf woodland cover in acid-sensitive areas in the UK. Both models predicted the exceedance of streamwater critical loads in the same catchments, but the magnitudes of exceedance varied due to the different treatment of nitrogen processes. The FAB model failed to account for high nitrogen leaching to streamwater, attributed to nitrogen deposition and/or fixation of nitrogen by alder trees in some study catchments, while both models underestimated the influence of high seasalt deposition. Critical load exceedance in most catchments was not sensitive to the use of different acid neutralising capacity thresholds or runoff estimates, probably due to the large difference between critical load values and acidic deposition loadings. However, the assessments were more sensitive to differences in calculation procedure in catchments where nitrogen deposition was similar to the availability of base cations from weathering and/or where critical load exceedance values were <1keqH(+)ha(-1)yr(-1). Critical load exceedance values from both models agreed with assessments of acid-sensitivity based on indicator macroinvertebrates sampled from the study catchments. Thus the methodology currently used in the UK appears to be robust for assessing the risk of broadleaf woodland expansion on surface water acidification and ecological status.

Effects of broadleaf woodland cover on streamwater chemistry and risk assessments of streamwater acidification in acid-sensitive catchments in the UK

Streamwater was sampled at high flows from 14 catchments with different (0-78%) percentages of broadleaf woodland cover in acid-sensitive areas in the UK to investigate whether woodland cover affects streamwater acidification. Significant positive correlations were found between broadleaf woodland cover and streamwater NO3 and Al concentrations. Streamwater NO3 concentrations exceeded non-marine SO4 in three catchments with broadleaf woodland cover>or=50% indicating that NO3 was the principal excess acidifying ion in the catchments dominated by woodland. Comparison of calculated streamwater critical loads with acid deposition totals showed that 11 of the study catchments were not subject to acidification by acidic deposition. Critical loads were exceeded in three catchments, two of which were due to high NO3 concentrations in drainage from areas with large proportions of broadleaved woodland. The results suggest that the current risk assessment methodology should protect acid-sensitive catchments from potential acidification associated with broadleaf woodland expansion.

The sustainability of Canada's healthcare system: a framework for advancing the debate

The debate of whether Canada's healthcare system is sustainable is mired in ideology. This paper offers a framework that takes us beyond the ideological standoff with a process to deal ethically with the issue of the sustainability of publicly funded healthcare.

Analysis of a panel of antibodies to APC reveals consistent activity towards an unidentified protein

Acquisition of truncating mutations in the adenomatous polyposis coli (APC) protein underlies the progression of the majority of sporadic and familial colorectal cancers. As such, the localisation patterns and interacting partners of APC have been extensively studied in a range of systems, relying on the use of a broad panel of antibodies. Until recently, antibodies to APC have been used largely unchecked. However, several recent reports have been invaluable in clarifying the use of a number of antibodies commonly used to detect APC. Here, we analyse the specificity of a further subset of antibodies to APC. We used a panel of six commercially available antibodies (directed to the amino and carboxy termini of APC) and confirm the detection of full-length APC by immunoblotting. We demonstrate that a 150 kDa protein, also reproducibly detected by this panel of antibodies, is unlikely to be APC. We present data for the immunological staining patterns of the APC antibodies and validate the results through RNAi. Using this approach, we confirm that the apical staining pattern, observed by immunofluorescence and previously reported in cell systems, is unlikely to be APC. Finally, we present our data as a summary of APC-antibody specificities for APC.

Survival and safety of exemestane versus tamoxifen after 2-3 years' tamoxifen treatment (Intergroup Exemestane Study): a randomised controlled trial

BACKGROUND

Early improvements in disease-free survival have been noted when an aromatase inhibitor is given either instead of or sequentially after tamoxifen in postmenopausal women with oestrogen-receptor-positive early breast cancer. However, little information exists on the long-term effects of aromatase inhibitors after treatment, and whether these early improvements lead to real gains in survival.

METHODS

4724 postmenopausal patients with unilateral invasive, oestrogen-receptor-positive or oestrogen-receptor-unknown breast cancer who were disease-free on 2-3 years of tamoxifen, were randomly assigned to switch to exemestane (n=2352) or to continue tamoxifen (n=2372) for the remainder of a 5-year endocrine treatment period. The primary endpoint was disease-free survival; overall survival was a secondary endpoint. Efficacy analyses were intention-to-treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN11883920.

RESULTS

After a median follow-up of 55.7 months (range 0-89.7), 809 events contributing to the analysis of disease-free survival had been reported (354 exemestane, 455 tamoxifen); unadjusted hazard ratio 0.76 (95% CI 0.66-0.88, p=0.0001) in favour of exemestane, absolute benefit 3.3% (95% CI 1.6-4.9) by end of treatment (ie, 2.5 years after randomisation). 222 deaths occurred in the exemestane group compared with 261 deaths in the tamoxifen group; unadjusted hazard ratio 0.85 (95% CI 0.71-1.02, p=0.08), 0.83 (0.69-1.00, p=0.05) when 122 patients with oestrogen-receptor-negative disease were excluded.

CONCLUSIONS

Our results suggest that early improvements in disease-free survival noted in patients who switch to exemestane after 2-3 years on tamoxifen persist after treatment, and translate into a modest improvement in overall survival.

Bendamustine prolongs progression-free survival in metastatic breast cancer (MBC): a phase III prospective, randomized, multicenter trial of bendamustine hydrochloride, methotrexate and 5-fluorouracil (BMF) versus cyclophosphamide, methotrexate and 5-fluorouracil (CMF) as first-line treatment of MBC

Two i.v. regimens, bendamustine, methotrexate and 5-fluorouracil (BMF) and cyclophosphamide, methotrexate and 5-fluorouracil (CMF) were compared as first-line therapy in a randomized, open, multicenter phase III trial including 364 patients with metastatic breast cancer (MBC). Bendamustine is an anti-neoplastic agent with alkylating, but also additional, so far unclear, mechanisms of action. We wanted to show the superiority of BMF over CMF in terms of time to progression (TTP) (primary endpoint), overall response, response duration, toxicity and quality of life (QoL). TTP was significantly longer in the BMF group (8.2 versus 6.7 months for CMF) (p=0.0071). The effect of BMF on TTP was more pronounced in the stratum 'prior adjuvant therapy, no visceral metastases' (p=0.034). Overall response rates and QoL did not significantly differ between the regimens. BMF caused more mucositis and leukopenias. Thus, bendamustine, when replacing cyclophosphamide in the CMF combination, can be expected to produce longer progression-free survival in first-line treatment of MBC.

The level of haemoglobin in anaemic cancer patients correlates positively with quality of life

The aim of this study was to assess the relationship between haemoglobin level and quality-of-life in anaemic cancer patients. Patients, diagnosed with one of four cancers, were recruited if their haemoglobin level was <12 g dl(-1) (female) or <13 g dl(-1) (male). The condition-specific Functional Assessment of Cancer Therapy-Anaemia and the generic SF-36 were used to assess quality-of-life. Thirty-six per cent of the 179 recruited patients had breast cancer, 28% ovarian cancer, 25% lung cancer, and 11% multiple myeloma. Their mean (s.d.) haemoglobin level was 10.66 (1.04) g dl(-1). Partial correlations controlling for the potentially confounding effects of age, gender, and time since diagnosis found significant positive relationships between haemoglobin and all domains of the Functional Assessment of Cancer Therapy-Anaemia, and with all but two of the SF-36 domains. On linear regression controlling for the same factors, each unit haemoglobin rise equalled an average 8.19 Functional Assessment of Cancer Therapy-Anaemia, and an average 6.88 Functional Assessment of Cancer Therapy-Fatigue, increase. Haemoglobin accounted for a similar amount of variability (8%) in SF-36 scores. In conclusion, quality-of-life has been found to be significantly positively related to haemoglobin level in anaemic cancer patients. This suggests that normalisation of haemoglobin in cancer patients is likely to increase their quality-of-life. The greater sensitivity of the condition-specific Functional Assessment of Cancer Therapy-Anaemia compared with the generic SF-36 suggests that the Functional Assessment of Cancer Therapy-Anaemia can be used alone to assess quality-of life in this patient group.

A multicentre phase II pilot study of epirubicin and Taxol (paclitaxel) in patients with advanced breast cancer

Anthracyclines are the gold standard monotherapy for metastatic breast cancer. Higher response rates are seen with drug combinations, especially with newer agents such as taxanes. The purpose of this study was to evaluate the toxicity and activity of the combination of paclitaxel and epirubicin in patients with advanced breast cancer. Thirty-five women with locally advanced or metastatic breast cancer (first and second relapse) were treated with epirubicin 75 mg/m2 and paclitaxel 200 mg/m2 3-weekly. Six centres recruited 35 patients; 34 (97%) were assessable for response. Eighteen had undergone prior chemotherapy, including six (17%) with anthracycline-containing regimens. Grade 4 neutropenia was found in 33 patients (94%), which was of 4 days' average duration; however, infective complications were rare, with only nine cycles (6%) complicated by neutropenic sepsis. There were two sepsis-related deaths. Symptomatic cardiotoxicity was infrequent, although a >15% decline in cardiac function was recorded in five patients (14%). Grade 3 peripheral neuropathy occurred in three patients (9%). The overall response rate was 50% (95% confidence interval 33-67) (complete response 12%; partial response 38%), with a median duration of response of 31 weeks. The median time to progression was 27 weeks, with a median survival of 48 weeks. This regimen appears to be a relatively safe, tolerable and effective treatment for advanced breast cancer. A United Kingdom Co-ordinating Committee for Cancer Research Phase III trial (AB-01) comparing this combination of epirubicin and paclitaxel with cyclophosphamide and paclitaxel completed accrual in November 1999.

Healthcare: the new economy's last frontier?

The New Economy is transforming large parts of the business world and the public sector. New Internet technologies are being used to increase efficiency and add value. But the most distinctive contribution of the Internet is the added reach that it is giving to producers and service providers who had previously been confined by geography and by travel time and costs. Now they are able to connect with much larger markets and reach more communities and do so with a much greater immediacy. The Internet is also facilitating much more responsive and tailored services/products. This is giving rise to new and expanded demand, as these Internet-enabled services become more attractive to buyers/consumers.

An evaluation of program management: the West Park Hospital experience

Program management as a way to structure hospital management has been attracting growing interest. Numerous hospitals are introducing it. West Park Hospital was one of the first hospitals to adopt program management in 1991 and mount a rigorous evaluation of the new approach, one which relied on external evaluators. This article reviews the emergence of program management in the hospital sector and reports on the evaluation of West Park's experience.

Angiogenesis, assessed by platelet/endothelial cell adhesion molecule antibodies, as indicator of node metastases and survival in breast cancer

Animal models suggest a role for new vessel formation (angiogenesis) in tumours with metastatic potential, and there is some evidence that this is true for human tumours. What is needed is a sensitive and specific label for endothelial cells, and one candidate would be a monoclonal antibody to platelet/endothelial cell adhesion molecule (PECAM). We have counted microvessels in 103 primary breast cancers using the JC70 antibody to PECAM (or CD31). We compared our findings with various pathological indicators (lymph node status and tumour grade, size, and type and markers (oestrogen receptor, and c-erbB-2 expression and detection of mutant p53). Tumours showed significantly higher vascularisation than normal breast tissue and the number of blood vessels/mm2 was significantly associated with node metastasis. Only 2 out of 50 tumours with 99 vessel/mm2 or less were node positive whereas 31 out of 39 tumours with counts above 140/mm2 were positive (p < 0.0001). Tumour size and grade also correlated with node metastasis and vascularisation also increased with the size of the primary and with poor differentiation. However, within each subgroup of size or differentiation tumours without node involvement had much lower vascular counts, and multivariate analysis showed that vascular count alone explains the association of size and grade with node metastasis. Other markers, conventional or novel, did not correlate with vascularisation. Even with the short follow-up in this series, vascular counts correlated with early death. These results suggest that angiogenesis is closely linked to metastasis, that it is acquired at a critical density of vessels, and that this process occurs as tumours enlarge or become more poorly differentiated. Counting of newly formed microvessels stained with endothelium-specific antibodies may prove to be a useful tool in the early detection of metastatic potential and in the selection of patients for whom anti-angiogenesis drugs might be beneficial.

Genealogical analysis of cystic fibrosis families and chromosome 7q RFLP haplotypes in the Hutterite Brethren

In the 100-year period 1880-1980 the Hutterite population increased from about 442 to 23,000 individuals in North America. There are three endogamous subdivisions in this Caucasian genetic isolate. A total of 11 cystic fibrosis (CF) families from Canada and the United States were investigated, including at least two families from each of the three subdivisions, the Dariusleut, Lehrerleut, and Schmiedeleut. A study of RFLPs for the loci D7S8, D7S23, MET, and D7S18 (also called D7S16) in the region of the CF gene in 10 families shows considerable genetic variability. There were three different extended CF gene-region haplotypes on CF chromosomes (CF haplotypes), and there were 13 different extended CF gene-region haplotypes on normal chromosomes (normal haplotypes). The three CF haplotypes have different D7S23 and MET haplotypes. Parents who have the same CF haplotype are, on the average, more closely related than parents who have different haplotypes, but only within the same subdivision. A marriage node graph of 11 families illustrates the complexity of Hutterite genealogies. The frequency distribution of CF haplotypes in the Hutterite sample differs notably from those of larger agglomerates of family data from collaborative studies, with respect to D7S8, MET haplotypes, and D7S23 haplotypes. We propose that there were at least three CF carriers among the founders of the Hutterite population and that copies of a particular CF haplotype in current individuals are identical by descent. The alternative that one or more genetically distinguishable CF haplotypes resulted from recombination since the founding of the population is considered to be less likely.

Phase II study of combination 4'-epidoxorubicin and mitomycin C in recurrent epithelial ovarian cancer

Thirty-three evaluable patients who had epithelial ovarian cancer that had not responded to treatment were entered into a phase II study of combination epirubicin and mitomycin C. Epirubicin (65 mg/m2) and mitomycin C (4 mg/m2) were administered separately, each as an i.v. bolus every 4 weeks. Ten patients (30%) had a complete or partial responses. The median duration of response was 20 weeks (range, 9-53). The regimen was well tolerated. Myelotoxicity occurred in four patients requiring hospitalization for septicaemia. Eleven patients had a blood transfusion. Alopecia was common, and nausea and vomiting, though frequent, usually mild. Cardiological toxicity was observed in one patient only. She developed congestive cardiac failure after an acute myocardial infarction. This regimen is active in advanced ovarian cancer that has not responded to prior treatment and warrants further study combination with other active drugs as a first-line regimen for ovarian cancer.

Plasminogen activator inhibitor type 1 gene is located at region q21.3-q22 of chromosome 7 and genetically linked with cystic fibrosis

The regional chromosomal location of the human gene for plasminogen activator inhibitor type 1 (PAI1) was determined by three independent methods of gene mapping. PAI1 was localized first to 7cen-q32 and then to 7q21.3-q22 by Southern blot hybridization analysis of a panel of human and mouse somatic cell hybrids with a PAI1 cDNA probe and in situ hybridization, respectively. We identified a frequent HindIII restriction fragment length polymorphism (RFLP) of the PAI1 gene with an information content of 0.369. In family studies using this polymorphism, genetic linkage was found between PAI1 and the loci for erythropoietin (EPO), paraoxonase (PON), the met protooncogene (MET), and cystic fibrosis (CF), all previously assigned to the middle part of the long arm of chromosome 7. The linkage with EPO was closest with an estimated genetic distance of 3 centimorgans, whereas that to CF was 20 centimorgans. A three-point genetic linkage analysis and data from previous studies showed that the most likely order of these loci is EPO, PAI1, PON, (MET, CF), with PAI1 being located centromeric to CF. The PAI1 RFLP may prove to be valuable in ordering genetic markers in the CF-linkage group and may also be valuable in genetic analysis of plasminogen activation-related diseases, such as certain thromboembolic disorders and cancer.