Addressing the mother-infant relationship in displaced communities

Delivering appropriate care to refugee families requires complex care systems and models that take account of the social, cultural, and political dimensions as well as the psychologic dimension. Children born into these families are exposed to consequences of their own past experiences and also may be subject to the transmission of the traumas experienced by their parents. This exposure can lead to alterations in these children's individual creative resources. Early, tailored care should be provided for these families, so that the transmission of the trauma and its consequences can be managed or ameliorated.

American Society of Clinical Oncology clinical practice guidelines for the use of chemotherapy and radiotherapy protectants

PURPOSE

Because toxicities associated with chemotherapy and radiotherapy can adversely affect short- and long-term patient quality of life, can limit the dose and duration of treatment, and may be life-threatening, specific agents designed to ameliorate or eliminate certain chemotherapy and radiotherapy toxicities have been developed. Variability in interpretation of the available data pertaining to the efficacy of the three United States Food and Drug Administration-approved agents that have potential chemotherapy- and radiotherapy-protectant activity-dexrazoxane, mesna, and amifostine-and questions about the role of these protectant agents in cancer care led to concern about the appropriate use of these agents. The American Society of Clinical Oncology sought to establish evidence-based, clinical practice guidelines for the use of dexrazoxane, mesna, and amifostine in patients who are not enrolled on clinical treatment trials.

METHODS

A multidisciplinary Expert Panel reviewed the clinical data regarding the activity of dexrazoxane, mesna, and amifostine. A computerized literature search was performed using MEDLINE. In addition to reports collected by individual Panel members, all articles published in the English-speaking literature from June 1997 through December 1998 were collected for review by the Panel chairpersons, and appropriate articles were distributed to the entire Panel for review. Guidelines for use, levels of evidence, and grades of recommendation were reviewed and approved by the Panel. Outcomes considered in evaluating the benefit of a chemotherapy- or radiotherapy-protectant agent included amelioration of short- and long-term chemotherapy- or radiotherapy-related toxicities, risk of tumor protection by the agent, toxicity of the protectant agent itself, quality of life, and economic impact. To the extent that these data were available, the Panel placed the greatest value on lesser toxicity that did not carry a concomitant risk of tumor protection.

RESULTS AND CONCLUSION

Mesna: (1) Mesna, dosed as detailed in these guidelines, is recommended to decrease the incidence of standard-dose ifosfamide-associated urothelial toxicity. (2) There is insufficient evidence on which to base a guideline for the use of mesna to prevent urothelial toxicity with ifosfamide doses that exceed 2.5 g/m(2)/d. (3) Either mesna or forced saline diuresis is recommended to decrease the incidence of urothelial toxicity associated with high-dose cyclophosphamide use in the stem-cell transplantation setting. Dexrazoxane: (1) The use of dexrazoxane is not routinely recommended for patients with metastatic breast cancer who receive initial doxorubicin-based chemotherapy. (2) The use of dexrazoxane may be considered for patients with metastatic breast cancer who have received a cumulative dosage of 300 mg/m(2) or greater of doxorubicin in the metastatic setting and who may benefit from continued doxorubicin-containing therapy. (3) The use of dexrazoxane in the adjuvant setting is not recommended outside of a clinical trial. (4) The use of dexrazoxane can be considered in adult patients who have received more than 300 mg/m(2) of doxorubicin-based therapy for tumors other than breast cancer, although caution should be used in settings in which doxorubicin-based therapy has been shown to improve survival because of concerns of tumor protection by dexrazoxane. (5) There is insufficient evidence to make a guideline for the use of dexrazoxane in the treatment of pediatric malignancies, with epirubicin-based regimens, or with high-dose anthracycline-containing regimens. Similarly, there is insufficient evidence on which to base a guideline for the use of dexrazoxane in patients with cardiac risk factors or underlying cardiac disease. (6) Patients receiving dexrazoxane should continue to be monitored for cardiac toxicity. Amifostine: (1) Amifostine may be considered for the reduction of nephrotoxicity in patients receiving cisplatin-based chemoth

CT staging of esophageal carcinoma in patients treated by primary radiation therapy and chemotherapy

Primary radiation therapy with concurrent chemotherapy is under study as definitive and palliative therapy for patients with esophageal carcinoma. To evaluate the correlation between CT staging and outcome, we retrospectively reviewed the CT scans of 48 patients treated with primary radiation therapy and concurrent chemotherapy and correlated CT staging with disease-free survival, overall survival, and site of relapse. Excluding one patient who was understaged and six patients who died of problems unrelated to esophageal carcinoma, mean survival of CT stage I, II, and III patients was 14.7, 21.3, and 5.2 months, respectively. When the CT stage is modified by the presence of nodal involvement on CT, the mean survival of stage IIn and IIIn (nodes greater than 1.5 cm in diameter) and stage IV patients (distant metastases) was 16.4, 19.2, and 10.6 months, respectively. Despite thickening of the esophageal wall greater than 3.0 cm in five patients with stage IIn cancer, mean survival was still 19.2 months. Patients with pericardial effusion had the worst survival of only 4.3 months. Stage II patients had a significantly longer (p less than 0.05) disease-free period than all other groups and the difference between stage II and III patients was highly significant (p less than 0.01). Stage II patients were also more likely to be disease-free at the time of death or last follow-up (p less than 0.05). Computed tomographic staging of esophageal carcinoma is useful in radiation therapy treatment planning and predicting outcome of patients managed with a nonsurgical technique of concurrent radiation and chemotherapy.

Diagnosis of osteomyelitis by MR imaging

Bone scans are highly sensitive for the diagnosis of acute osteomyelitis, but the difficulty of separating bone-marrow processes from soft-tissue disease limits the specificity and accuracy. A diagnostic technique capable of distinguishing bone-marrow processes from soft-tissue disease would improve the diagnostic accuracy of osteomyelitis. To evaluate the use of MR in the diagnosis of osteomyelitis, MR examinations were performed in 35 patients with suspected acute osteomyelitis. Twelve of these were proved to have osteomyelitis either by surgery (nine patients) or by clinical follow-up (three patients). In the other 23, osteomyelitis was excluded by surgery (12 patients) or by the clinical course (11 patients). Evidence of osteomyelitis on MR consisted of abnormalities of the bone marrow with decreased signal intensity on the T1-weighted images and increased signal intensity on the T2-weighted or short-T1 inversion recovery (STIR) images. MR and bone scintigraphy were interpreted by two radiologists who were given no clinical information other than to rule out osteomyelitis. The sensitivities of MR and static bone scan were 100% for bone-marrow abnormality. Because bone-marrow abnormality in osteomyelitis associated with healing fractures was incorrectly diagnosed by MR (one case) and bone scintigraphy (two cases), the sensitivities of MR and scintigraphy for the diagnosis of osteomyelitis were 92% and 82%, respectively. The specificities of MR and scintigraphy were 96% and 65%, respectively (p less than .05). The overall accuracy for the diagnosis of osteomyelitis was 94% for MR and 71% for bone scan (p less than .05). Because of its ability to separate soft-tissue disease from underlying bone marrow, MR may be used to evaluate patients with positive bone scintigraphy to improve the specificity and accuracy of diagnosis for osteomyelitis.

Phonocardiographic method of assessing changes in left ventricular function after Starr-Edwards replacement of aortic valve

A phonocardiographic method is described for measuring the time taken by the ball of a Starr-Edwards prosthesis to move to the apex of the cage at the onset of left ventricular ejection, and from this its acceleration can be derived. The acceleration is conspicuously increased in post-ectopic beats and in exercise, but is unaffected by posture and tachycardia induced by atropine or ventricular pacing. It is suggested that the acceleration of the ball is related to the initial acceleration of blood into the ascending aorta.