Implementation of podiatry telephone appointments for people with rheumatic and musculoskeletal diseases

BACKGROUND

Foot health problems are common in the general population, and particularly so in people with rheumatic and musculoskeletal disorders (RMD). Several clinical guidelines state that people with RMDs should have access to foot health services, although service capacity is often limited. The current COVID-19 pandemic has increased the need for alternative ways to provide patient care. The aim of this clinical audit was to review a newly implemented telephone follow-up appointment service conducted within the Rheumatology Podiatry Department in Leeds, UK.

METHODS

Fifty-eight patients attending the Rheumatology Podiatry Department at Leeds Teaching Hospitals NHS Trust were contacted by telephone approximately 6-8 weeks following initial intervention. During the telephone consultation, all patients were asked pre-defined questions relating to their symptoms, intervention efficacy, the need for further appointments and their preference for the type of consultation. To assess the cost of the telephone consultation the number of attempts needed in order to make successful contact, the duration of the call and the number of telephone follow-up appointments completed in a working day were also recorded.

RESULTS

Twenty-five patients (43%) were successfully contacted within the 6-8 weeks stipulated time frame and were included in the analysis. Of the 25 contacted, twelve (48%) patients were successfully contacted on the first attempt. Ten (40%) were successfully contacted on the second attempt. The remaining three patients (12%) required 3 or more attempts to make successful contact. Telephone consultations were estimated not to last longer than 10 min, including notes screening and documentation. Eleven patients (44%) reported an improvement in their symptoms, thirteen (52%) reported no change and one patient (4%) reported their symptoms to be worse.

CONCLUSION

Telephone follow-up consultations may be a potentially cost-effective alternative to face-to-face appointments when implemented in a Rheumatology Podiatry Department, and provide an alternative way of providing care, especially when capacity for face-to-face contact is limited. The potential cost saving and efficiency benefits of this service are likely to be enhanced when telephone consultations are pre-arranged with patients.

A Mechanical and Histological Comparison of Bone Healing Using Titanium Bone Plates with Porous Surfaced Titanium Screws versus Smooth Surfaced Titanium Screws

Bilateral midshaft femoral osteotomies were stabilized with a 3 mm fracture gap in 12 dogs using titanium bone plates and either smooth surfaced (SS) or porous surfaced (PS) titanium screws. Mechanical studies demonstrated that PS screws required a significantly greater torque to remove than the SS screws at both 8 and 16 weeks. At 16 weeks, screw removal torque increased by a factor of 1.3 over the insertion torque for PS screws and decreased by a factor of 2.9 for SS screws. Histologically, the amount of new bone formation and porosity, over the entire length of the femur, was significantly greater in the femora stabilized with PS screws; indicative of greater overall fixation rigidity. At both time periods, there was an increase in torsional stiffness in the osteotomies stabilized with SS screws. Radiographically, there was no difference in the osteotomy callus area for either screw type. From this study, there appears to be advantages to using PS bone screws instead of SS screws when subjected to dynamic loading such as gap fixation.

Hyponatraemia in cancer patients on an inpatient rehabilitation unit

This study identifies the incidence of hyponatraemia in cancer patients on an inpatient rehabilitation unit and examines the association between admission hyponatraemia and rehabilitation length of stay (LOS), functional outcome, and survival. After institutional review committee's approval, we retrospectively reviewed medical records of 295 consecutive patients who were admitted to this inpatient cancer rehabilitation unit between 27 January 2009 through 31 July 2010 in a tertiary cancer centre. The incidence of hyponatraemia in cancer patients admitted to our inpatient rehabilitation unit was 41.4%. Median rehabilitation LOS for patients with mild (Na 130-134 mEq/L) and moderate-severe (Na < 130 mEq/L) hyponatraemia was 11 and 15 days, respectively, which was significantly longer than patients with eunatraemia (10 days; P = 0.03). Functional Independence Measure gain for ambulation and transfers during inpatient rehabilitation stay was not significantly different between three different patient groups. We concluded that large portion of patients who require acute inpatient rehabilitation presented with hyponatraemia, which is associated with prolonged rehabilitation LOS. Whether aggressive management of hyponatraemia will shorten rehabilitation stay needs further study.

Tibetan sound meditation for cognitive dysfunction: results of a randomized controlled pilot trial

OBJECTIVE

Although chemotherapy-induced cognitive impairment is common among breast cancer patients, evidence for effective interventions addressing cognitive deficits is limited. This randomized controlled trial examined the feasibility and preliminary efficacy of a Tibetan Sound Meditation (TSM) program to improve cognitive function and quality of life in breast cancer patients.

METHODS

Forty-seven breast cancer patients (mean age 56.3 years), who were staged I-III at diagnosis, 6-60 months post-chemotherapy, and reported cognitive impairment at study entry were recruited. Participants were randomized to either two weekly TSM sessions for 6 weeks or a wait list control group. Neuropsychological assessments were completed at baseline and 1 month post-treatment. Self-report measures of cognitive function (Functional Assessment of Cancer Therapy (FACT)-Cog), quality of life (SF-36), depressive symptoms (Center for Epidemiologic Studies Depression Scale), sleep disturbance (Pittsburgh Sleep Quality Index), fatigue (Brief Fatigue Inventory), and spirituality (FACT-Sp) were completed at baseline, the end of treatment, and 1 month later.

RESULTS

Relative to the control group, women in the TSM group performed better on the verbal memory test (Rey Auditory Verbal Learning Test trial 1) (p = 0.06) and the short-term memory and processing speed task (Digit Symbol) (p = 0.09) and reported improved cognitive function (p = 0.06), cognitive abilities (p = 0.08), mental health (p = 0.04), and spirituality (p = 0.05) at the end of treatment but not 1 month later.

CONCLUSIONS

This randomized controlled trial revealed that TSM program appears to be a feasible and acceptable intervention and may be associated with short-term improvements in objective and subjective cognitive function as well as mental health and spirituality in breast cancer patients.

Heart rate variability as a measure of autonomic dysfunction in men with advanced cancer

Autonomic dysfunction is common in patients with cancer and may have considerable negative effects on quality of life and mortality. This study retrospectively compared heart rate variability measured by the standard deviation of normal-to-normal intervals (SDNN) to Ewing test score, a composite score from a battery of five defined autonomic tests, in detection of autonomic dysfunction in 47 men with advanced cancer. The Ewing test score has been validated for diagnosis of autonomic dysfunction but is time-consuming and requires considerable patient co-operation; we hypothesised that SDNN, a much simpler test, is a useful alternative. The patients were categorised into three groups according to Ewing score: ≤ 2 (mild or no autonomic dysfunction), 2.5-3 (moderate) and ≥ 3.5 (severe). The SDNN (mean ± SD) for the three groups were 57.1 ± 26.9 ms 62.3 ± 22.4 ms and 37.7 ± 20.3 ms respectively. A significant negative correlation was found between Ewing score and SDNN (r = -0.40, P = 0.005). A SDNN of ≤ 40 ms had 63% sensitivity and 75% specificity in the diagnosis of severe autonomic dysfunction (i.e. Ewing score ≥ 3.5). The positive predictive value of SDNN ≤ 40 ms in predicting moderate/severe autonomic dysfunction was 89%.

Clinical findings and recommendations made during home visits by a palliative care specialist physician

Little has been reported regarding the nature of home visits by palliative care specialist physicians to assist in the management of complex cases. We determined the characteristics, actionable clinical findings and recommendations made during consecutive home visits conducted by a specialist physician for patients registered with a community palliative care service. Patient demographic information and clinical records were reviewed. Ninety-one patients received a total of 104 home and residential facility visits. Median patient age was 59 (Q1-Q3, 43-72). Ten children (under the age of 14) received a total of 15 visits. Seventy-three patients (80%) had a cancer diagnosis. Median visit duration was 60 min (Q1-Q3, 45-60). The major actionable clinical findings were pain (120), gastrointestinal (115), neuropsychiatric (58), mouth and skin (33) and respiratory (29). One-third of recommendations involved changes in analgesia regimen (opioids 67, adjuvants 44). The specialist physician home visit resulted in multiple patient care recommendations. This information may help palliative care programmes improve their care for patients and families in the community.

Single- versus multiple-item assessment of quality of life in patients with advanced cancer

e20528

Background: The main objective of palliative cancer care is to improve quality of life (QOL). As multiple dimensions impact on the construct of QOL, multi-dimensional instruments are usually used in its measurement. These are time consuming and burdensome for repeated use. Recent authors have suggested that brief single-item global assessments can provide a reliable measure of QOL. We assessed the performance of the Edmonton Symptom Assessment System ‘feeling of well-being’ item (ESAS WB) using the Functional Assessment of Cancer Therapy - General (FACT-G) instrument as a gold standard. Methods: After obtaining IRB approval, we reviewed the data from 213 advanced cancer patients who had participated in six studies from March 2006 to June 2008 and determined the level of association between baseline ESAS WB and FACT-G total score and subscale domains (Physical (Pwb), Social/Family (Swb), Emotional (Ewb), and Functional (Fwb) Well-Being) and also the 9 ESAS symptom intensity scores using Spearman correlation coefficients. We also calculated the change between the baseline (T1) and second (T2) observations of ESAS WB and of FACT-G total score and determined their level of association using a Pearson correlation coefficient. In addition, we predicted the change in FACT-G as predicted by the change in ESAS WB score using regression analysis. Results: Mean age was 60 (SD 12) years and 48% were female. At T1, the Spearman correlation coefficient of ESAS WB and FACT-G was -0.48 (p<0.0001). Spearman correlation coefficients for ESAS WB and FACT-G subscale domains and ESAS symptom intensity scores were also highly significant (p<0.0001) for all physical and emotional symptoms (other than p=0.003 for nausea) except for FACT Swb (p=0.08). The Pearson correlation coefficient for difference between T1 and T2 in ESAS WB and FACT-G for 146 patients was -0.36 (p<0.0001). The regression analysis was highly significant (p<0.0001). The change in ESAS WB corresponding to FACT-G published minimally important difference (MID) was -0.24 for 3, -1.55 for 5, and -2.87 for 7, respectively. Conclusions: ESAS WB is a practical instrument for clinical use and best reflects the Pwb, Ewb and Fwb domains of FACT-G as compared to Swb.

No significant financial relationships to disclose.

Utilization of antineoplastic therapy (ANT) in advanced cancer patients admitted to an acute palliative care unit (APCU) at a comprehensive cancer center

9590

Background: Cancer patients admitted to a palliative care unit generally have a poor prognosis. The role of ANT (chemotherapy and targeted agents) in these patients is unclear. We examined the frequency, trends, factors and survival associated with ANT use in hospitalized patients who required an APCU stay. Methods: All patients admitted to APCU between September 1, 2003 and August 31, 2008 were included. Demographics, cancer diagnosis and ANTs utilization from day of hospitalization to discharge, and survival information were retrieved retrospectively. Results: 2604 cancer patients had the following characteristics: median age 59 (range 18–101), male 51%, hematologic malignancy 11%, median hospital stay 11 (Q1-Q3 8–17) days, median APCU stay 7 (Q1-Q3 4–10) days and median survival 22 days. During hospitalization, 393 patients (15%) received ANTs, including chemotherapy (N=297, 11%) and targeted therapy (N=155, 6%). No significant change in frequency of ANTs was detected over the 5 year period. Multivariate logistic regression analysis ( Table ) revealed that younger age, cancer primaries and longer admissions were associated with ANT use. Patients with hematologic malignancies received more chemotherapy (38% vs. 8%, p<0.001) and targeted agents (18% vs. 4%, p<0.001) compared to patients with solid tumors. ANT use was associated with longer overall survival in univariate analysis (median 25 days vs. 21 days, p=0.001); however, this was no longer significant in multivariate Cox regression analysis. Conclusions: The use of ANT during hospitalization that included an APCU stay was limited to a highly selected group of patients, and did not increase overtime. ANT use was associated with younger age, specific cancer primaries, longer admissions, and no significant improvement in survival. The APCU at our cancer center facilitates simultaneous care where patients access palliative care while on ANT. [Table: see text]

No significant financial relationships to disclose.

The association between autonomic dysfunction and survival in advanced cancer: A preliminary report

e20534

Background: Autonomic nervous system dysfunction (AD) is a common syndrome in patients with advanced cancer. It is associated with decreased survival in several patient populations including diabetes mellitus, heart failure and neurological diseases. Based on this available evidence, we hypothesized that autonomic dysfunction is associated with reduced survival in patients with advanced cancer. The objective of this preliminary study was to test the association between AD as measured by the standardized Ewing test and Heart Variability (HRV) measures and survival in patients with advanced cancer. Methods: We examined the relationship between survival and parameters of AD in male patients with advanced cancer who participated in a prospective study of autonomic dysfunction and hypogonadism. Eligibility criteria were defined based on the prospective study protocol. We collected demographic information, date of study entry and Ewing and HRV scores. Date of death was obtained from the online Social Security Death Index database. We defined survival as the interval between study entry and date of death. A survival analysis was used to test the association between survival (days) and Ewing test (0–5) and measures of heart rate variability (HRV), including time domain (SDNN) and frequency domain (Ultra low, Very low, Low, and High frequency) parameters.A spearman correlation test was also performed. Results: 47 male patients were included in this study. Median age was 59 (20–79) and 63% were caucasians. Autonomic dysfunction (AD), defined as Ewing score >2, was present in 80% (38/47) of the patients. Median Ewing score was 3 (1–5), indicating moderate to severe AD. Spearman correlation for Ewing and SDNN HRV was 0.44 (p=0.002). There was a significant association between abnormal Ewing score and survival (p<0.0001), and abnormal SDNN HRV and survival (p=0.056). Spearman correlation for Ewing score and survival and SDNN HRV and survival were r = -0.27620 (p=0.0602) and r =0.24198 (p= 0.1013) respectively. Conclusions: Autonomic dysfunction is associated with shorter survival in male patients with advanced cancer. Further longitudinal research in a larger cohort is justified based on these findings.

No significant financial relationships to disclose.

Reliability and validity of the Functional Assessment of Cancer Therapy-melanoma (FACT-M)

8554

Background: Our group has developed a disease-specific module for the Functional Assessment of Cancer Therapy (FACT) instrument to assess quality of life (QOL) in melanoma patients. The purpose of this study was to assess the reliability and validity of the melanoma subscale (MS) and melanoma surgery subscales (MSS) as well as the total FACT-M, which includes the FACT combined with the MS and MSS. Methods: 273 melanoma patients (stages I-IV) attending an outpatient melanoma clinic completed a battery of questionnaires at baseline assessment. The scores from the MS, MSS, and total FACT-M were compared to patient performance status (ECOG and Karnofsky scales), disease stage, treatment status, and other instruments with related domains including the Profile of Mood States, Marlowe-Crowne Social Desirability Scale, and the EORTC Quality of Life Questionnaire - melanoma module. Patients were assessed 1 week after baseline to assess test-retest reliability, and 163 patients completed assessments at 3 months to evaluate the responsiveness to change in performance status. Results: Internal consistency and test-retest reliability for the MS (Cronbach's a = 0.85, r = 0.81), MSS (a = 0.85, r = 0.82), and the total FACT-M (a = 0.95, r = 0.90) were excellent. Overall, the scales correlated with other measures and correlations were in the hypothesized direction. As predicted, FACT-M, MS, and MSS scores were lower for patients with advanced (stage III/IV) melanoma, patients with poor performance status, and patients who were receiving active treatment. In addition, total FACT-M, MS, and MSS scores were highly sensitive to changes in performance status (p = 0.0012, 0.0004, and 0.0006, respectively). Conclusions: The FACT-M is a reliable and valid QOL assessment tool for patients with melanoma. This disease-specific instrument should be utilized for melanoma QOL assessment in clinical trials.

No significant financial relationships to disclose.

Understanding of informed consent by demented individuals

BACKGROUND

The informed consent process is central to the conduct of research but may be difficult for cognitively impaired participants to understand. The authors developed a brief test addressing the elements of informed consent for a specific minimum-risk nontreatment research protocol.

OBJECTIVE

To evaluate and document understanding of informed consent by elderly research participants across a range of dementia severity.

METHODS

The elements of informed consent regarding participation in a longitudinal study of healthy aging and dementia were reviewed with both demented (n = 250) and nondemented (n = 165) participants who then completed a short test requiring yes-no responses to assess understanding of these elements. Demented participants had very mild, mild, or moderate dementia as staged by the Clinical Dementia Rating.

RESULTS

After adjusting for education, performance on the test varied with dementia severity in mean differences and by correlation. All nondemented and very mildly demented participants and 92% of mildly demented participants provided correct answers for at least 8 of 10 true-false items, whereas only 67% of the moderately demented participants achieved this level of accuracy.

CONCLUSIONS

Demented individuals, very mild and mild, understood informed consent information for this nontreatment research study. Understanding notably declined in the moderate stage of dementia. Brief tests may be useful as one method to assess understanding of the consent process for specific studies.

Sex and age differences in the pharmacokinetics of alosetron

AIMS

To determine the effects of sex and age on the pharmacokinetics of alosetron.

METHODS

Single oral and intravenous 2 mg doses of alosetron were administered on separate occasions to 48 healthy, young and elderly, males and females. Serum was sampled for 12 h post-dose to measure alosetron concentrations.

RESULTS

Serum concentrations of alosetron were higher in females than in males, resulting from a sex difference in clearance by metabolism. Mean clearance values were 504 vs 677 ml min(-1) in young females vs males (mean ratio 0.75), and 461 vs 670 ml min(-1) in elderly females vs males (mean ratio 0.69). The sex difference in alosetron pharmacokinetics achieved statistical significance in the elderly, but not in the young. Irrespective of sex, alosetron clearance was increased by smoking. Serum concentrations tended to be higher in the elderly, although the effect of age was generally not significant. Volume of distribution was smaller in females (approximately 63 l) compared with males (approximately 84 l), regardless of age or the sex difference in body weight.

CONCLUSIONS

A significant difference in clearance by metabolism of alosetron between the sexes, and possibly between the young and elderly was observed.

An interaction between the cytochrome P450 probe substrates chlorzoxazone (CYP2E1) and midazolam (CYP3A)

AIMS

The use of multiple probe substrates to evaluate the activity of drug metabolizing enzymes requires that there are no inter-substrate interactions. As part of a series of studies to develop a clinically useful collection of probe substrates that could be given alone or in any combination, we observed an interaction between midazolam (MDZ) and another component of the six-drug cocktail. Published data indicated that the interacting component was likely to be chlorzoxazone. This was investigated as part of a second study. The data relating to the interaction from both studies are reported here.

METHODS

Both studies were performed in 16 healthy subjects. All treatments were given orally after an overnight fast. In study 1, which was performed to a four-period, open, crossover design, subjects received on separate occasions MDZ 5 mg, diclofenac 25 mg, a four drug cocktail (caffeine 100 mg, mephenytoin 100 mg, debrisoquine 10 mg and chlorzoxazone 250 mg) and a six drug cocktail (caffeine 100 mg, mephenytoin 100 mg, debrisoquine 10 mg, chlorzoxazone 250 mg, diclofenac 25 mg and MDZ 5 mg). In study 2, which was performed to a two-period, open, crossover design, subjects received a five drug cocktail (as the six drug cocktail in the first study, but without chlorzoxazone and with diclofenac dose increased to 50 mg) and a six drug cocktail (as five drug cocktail, with chlorzoxazone 250 mg). In both studies, blood samples were taken for measurement of plasma MDZ and 1-hydroxy MDZ (1-OH MDZ) concentrations. In study 1, blood samples were taken up to 12 h post-dose while in study 2 a single sample was taken 2 h after dosing. In study 1, the potential interaction between MDZ and the other components of the six drug cocktail was assessed by comparing AUClast ratios (1-OH MDZ/MDZ) between the two treatments. Additionally, a single sampling timepoint of 2 h post-dose for determination of concentration, rather than AUC, ratios was established. The 2 h plasma concentration ratios from studies 1 and 2 were combined and a pooled analysis performed to compare ratios within each study (to determine the change in ratio when MDZ was dosed with and without chlorzoxazone) and between studies (to determine the consistency of the ratios when MDZ was given either as part of the two six drug cocktails or when given alone and as part of the five drug cocktail).

RESULTS

In study 1, both the AUClast ratio and the 2 h post-dose plasma concentration ratio were reduced when MDZ was given as part of the six drug cocktail in comparison with those for MDZ alone. This was the result of an increase in MDZ, rather than decrease in 1-OH MDZ, concentrations and was considered to result from a reduction in first pass metabolism of MDZ. The geometric mean AUClast values (with 95% CI) for MDZ were 95.6 (79.0, 115.7) and 160.4 (133.6, 192.6) microg l(-1) h when given alone and as part of the six drug cocktail, respectively. The corresponding values for 1-OH MDZ were 789.6 (697.6, 893.6) and 791.4 (701.7, 892.6) microg l(-1) h. The ratio of adjusted geometric mean AUClast ratios for the two treatments was 1.82 (90% CI 1.48, 2.23, P < 0.001). The pooled plasma 1-OH MDZ/MDZ ratio data from both studies showed that the differences in MDZ metabolism observed in study 1 were replicated in study 2. The adjusted geometric mean 1-OH MDZ/MDZ ratios when MDZ was given alone and as part of the six drug cocktail were 7.79 and 4.59, respectively, for study 1 (ratio 1.70, 95% CI 1.36, 2.11, P < 0.001) and 7.64 and 4.60 for study 2 (ratio 1.66, 95% CI 1.34, 2.06, P < 0.001). These data indicate that when given orally chlorzoxazone interacts with MDZ, increasing plasma MDZ concentrations. In contrast, there was no difference between the plasma 1-OH MDZ/MDZ ratios when MDZ was given alone and as part of the five drug cocktail indicating that there were no interactions between MDZ and any of the other components of that cocktail.

CONCLUSIONS

Chlorzoxazone appears to significantly influence the pharmacokinetics of oral MDZ, probably through inhibition of first pass metabolism by CYP3A in the GI tract. Data from these studies and literature evidence showing a further interaction between chlorzoxazone and CYP1A2 substrates and questions concerning the specificity of chlorzoxazone as a probe substrate for CYP2E1, indicate that the use of chlorzoxazone in multisubstrate probe cocktails should be avoided.

Synovial fluid cytokines and eicosanoids as markers of joint disease in horses

OBJECTIVE

To evaluate the value of various synovial fluid cytokines and eicosanoids to diagnose joint disease or categories of joint disease.

STUDY DESIGN

Prospective acquisition of clinicopathologic data.

ANIMALS OR SAMPLE POPULATION

Client-owned or donated horses: 50 joints with no evidence of disease; 28 joints with acute disease; 32 joints with chronic disease; 9 joints with cartilage damage and no other signs of joint disease.

METHODS

Concentrations of tumor necrosis factor-alpha (TNF-alpha), interleukin-1beta (IL-1beta), interleukin-6 (IL-6), prostaglandin E(2) (PGE(2)), thromboxane B(2) (TXB(2)), prostaglandin F1-alpha (PGF(1)-alpha), and leukotriene B(4) (LTB(4)), were measured in equine synovial fluid by immunoassay and categorized according to duration and degree of joint disease. Any test value for a given category that was different from normal was further analyzed for sensitivity (S), specificity (Sp), and operating point (most valid test cutoff value). Likelihood ratios and predictive values were calculated at the operating point. Mediator concentrations were correlated to synovial fluid white blood cell count. Tests were reported as poor, fair, good, or excellent based on predictive values of <.25,.25-.5,.5-.75, or >.75, respectively.

RESULTS

TNF synovial fluid concentration as a predictor of joint disease was good, and the value of TNF (maximum S and Sp) indicating joint disease was >36 pg/mL. IL-1beta as a predictor of joint disease was good, and the value of IL-1beta indicating joint disease was >4.5 pg/mL. IL-6 concentration was an excellent predictor of joint disease. Any IL-6 in synovial fluid indicated joint disease and correlated highly with synovial fluid white blood cell count (P <.0001). PGE(2) was a good-excellent predictor of disease (positive predictive value [PPV] = 0.75), and the concentration indicating joint disease was >22.5 pg/mL. The diagnostic PGF(1)-alpha concentration indicating severe chronic joint disease was identified to be >16.5 pg/mL with very high sensitivity (S = 1) and specificity (Sp =.89). PGF(1)-alpha concentrations > 9.5 pg/mL had a good PPV (.69) and NPV (.6) for any joint disease. TBX(2) concentrations below 31.5 pg/mL (S =.57; Sp =.61) were a very good predictor of joint disease (PPV =.72). LTB(4) concentration appeared to be greater in severe acute joint disease than normal joints; this was not significant (P =.15) and correlated highly with synovial fluid white blood cell count (P =.0001).

CONCLUSIONS

The ability of a single value from a joint in an adult horse predicting the presence of joint disease was often good (.5-.75), and was excellent (> or =.75) for IL-6 and PGE(2). TNF-alpha and IL-1beta were no more effective than white blood cell count in screening for joint disease. IL-6 was the most sensitive and specific for joint disease and could be an excellent screening test for the presence of joint disease when lameness is difficult to identify or is intermittent. PGE(2) would be a functional screening test for the presence of any joint disease and offers a differentiating feature because values were not influenced by white blood cell count. PGF(1)-alpha values > 16.5 pg/mL identified chronic severe joint disease and may be clinically useful when there are minimal radiographic changes but substantial articular cartilage degradation.

Paclitaxel plus topotecan treatment for patients with relapsed or refractory aggressive non-Hodgkin's lymphoma

BACKGROUND

Used as single agents, paclitaxel and topotecan have demonstrated promising activity in treating patients with relapsed aggressive non-Hodgkin's lymphoma (NHL). We conducted a phase II clinical trial to investigate the activity and tolerability of the combination of both drugs.

PATIENTS AND METHODS

Patients with refractory or relapsed aggressive NHL who had previously been treated with a maximum of two prior chemotherapeutic regimens were given intravenous infusions of paclitaxel 200 mg/m2 over three hours on day one and topotecan 1 mg/m2 over 30 minutes daily from days one to five. All patients received daily subcutaneous injections of filgrastim (granulocyte colony-stimulating factor) 5 microg/kg starting 24 hours after the last dose of chemotherapy until neutrophil recovery. Treatments were repeated every three weeks for a maximum of six courses. Patients who achieved partial remission or complete remission (CR) after at least two courses were offered stem cell transplantation, if eligible.

RESULTS

Of the 71 patients eligible for this trial, 66 (93%) were evaluable for treatment response. The median age was 53 years (range 23 to 74 years). Thirty-six percent of the patients had previously been treated with ara-C/platinum-based regimens, and 48% failed to achieve CR after primary induction therapy. Sixty-seven percent of the patients had elevated lactate dehydrogenase levels at the time of treatment initiation. The overall response rate was 48% (95% confidence interval (95% CI): 36%-61%). Patients who had primary refractory disease had a response rate of 31%, compared with 65% for patients who did not. Similarly, the response rate of patients who failed to achieve CR after their most recent previous therapy was 37%, compared with a 65% response rate in patients who relapsed from a first or second CR. The median duration of response was six months. A total of 199 courses were given, with a median of three courses per patient. Neutropenia at levels < or = 500 leukocytes per microliter was observed after 32% of the courses, and thrombocytopenia at levels < or = 20,000 platelets per microliter was observed after 17% of the courses. Grade 3-4 neutropenic fever occurred after 6% of the courses. Non-hematologic toxic effects were predominantly grade 1-2.

CONCLUSION

The combination of paclitaxel and topotecan is an effective first or second line salvage therapy for patients with relapsed or refractory aggressive NHL who had prior anthracycline- or platinum-based chemotherapy.

Lack of effect of ondansetron on the pharmacokinetics and analgesic effects of morphine and metabolites after single-dose morphine administration in healthy volunteers

AIMS

The purpose of this investigation was to study the influence of ondansetron on the single-dose pharmacokinetics and the analgesic effects elicited by morphine and the 3- and 6-glucuronide metabolites of morphine in healthy volunteers.

METHODS

This was a randomized, double-blind, placebo-controlled, two-way crossover study in which six male and six female subjects were administered a single 10 mg intravenous dose of morphine sulphate, followed 30 min later by a single 16 mg intravenous dose of ondansetron hydrochloride or placebo. Serum and urine concentrations of morphine, morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G) samples were quantified over 48 h using high performance liquid chromatography with detection by mass spectrometry. Analgesia was assessed in the volunteers with a contact thermode device to provide a thermal pain stimulus. Four analgesic response variables were measured including thermal pain threshold, thermal pain tolerance, temporal summation of pain and mood state.

RESULTS

The two treatments appeared to be equivalent based on the 90% confidence intervals (0.6, 1.67) of the least squares means ratio. All least squares means ratio confidence intervals for each parameter, for each analyte fell within the specified range, demonstrating a lack of an interaction.

CONCLUSIONS

The results of this study suggest that administration of ondansetron (16 mg i.v.) does not alter the pharmacokinetics of morphine and its 3- or 6-glucuronide metabolites to a clinically significant extent, nor does it affect the overall analgesic response to morphine as measured by the contact thermode system.

Radiographic appearance of the chest following therapy for Hodgkin disease

This study was carried out to define the post-treatment appearance of the chest radiographs in 44 consecutive patients with Hodgkin disease who received mantle irradiation with or without chemotherapy and to determine how the incidence and severity of post-treatment abnormalities relate to the radiation parameters and chemotherapeutic regimens. Radiographs of the chest in 44 patients, computed tomograms of the chest in 31 patients and of the abdomen of 35 patients were reviewed, prior to and following treatment, for mediastinal contours, pericardial status, cardiac size and pulmonary fibrosis. All patients were followed for a minimum of 1 year and 27 were followed for more than 5 years. Stable post-treatment imaging studies were correlated with the initial extent of disease, radiation parameters, and chemotherapeutic regimens. Stable post-treatment findings were categorised as follows: the chest radiograph was normal or showed subtle vascular reorientation; moderate paramediastinal fibrosis was present; severe pulmonary fibrosis had occurred with narrowing of the cardiomediastinal silhouette in some patients. In general, the severity of the fibrosis was dependent on (1) the size of the radiation fields and on whether or not the coverage of the hila included a 1- to 2-cm margin; (2) the amounts of chemotherapy and particularly bleomycin containing regimens and (3) individual susceptibility of normal tissue irradiation. Therapy for Hodgkin disease is not necessarily associated with radiographic sequelae regardless of the initial status of the mediastinum or the treatment. However, the post-treatment appearance of the chest radiographs in this study was related strongly to (1) the initial extent of disease and particularly the status of the hila, both of which influenced the amounts of lung parenchyma that were included in the treatment fields; (2) the use of bleomycin in chemotherapy regimens and (3) individual normal tissue radiosensitivity.

Comparison of the neurokinin-1 antagonist GR205171, alone and in combination with the 5-HT3 antagonist ondansetron, hyoscine and placebo in the prevention of motion-induced nausea in man

AIMS

In man a neurokinin-1 (NK1) receptor antagonist has previously been shown to be ineffective in the prevention of motion-induced nausea. The antiemetic efficacy of NK1 receptor antagonists against chemotherapy-induced emesis is, however, enhanced when combined with a 5-HT3 receptor antagonist. Hence the efficacy of the NK1 antagonist GR205171 in combination with the 5-HT3 antagonist ondansetron (Zofrantrade mark) was assessed in motion-induced nausea.

METHODS

GR205171 25 mg i.v., with and without concomitant administration of ondansetron 8 mg i.v., and hyoscine hydrobromide 0. 6 mg orally (positive control) were compared with placebo in a model of motion-induced nausea. The study was performed to a four-period, randomized, balanced, double-blind, crossover design in 16 healthy subjects. The end-point was the exposure to the motion stimulus required to produce moderate nausea in the subjects.

RESULTS

The motion stimulus required to produce moderate nausea was significantly greater for the positive control than placebo (P < 0. 001). There was no significant difference between either GR205171 or GR205171 plus ondansetron and placebo (P = 0.648 and 0.342, respectively).

CONCLUSIONS

The enhancement of NK1 receptor antagonist antiemetic activity through combination with a 5-HT3 receptor antagonist is not replicated in motion-induced nausea.

Complementary/alternative medicine use in a comprehensive cancer center and the implications for oncology

PURPOSE

Oncologists are aware that their patients use complementary/alternative medicine (CAM). As cancer incidence rates and survival time increase, use of CAM will likely increase. This study assessed the prevalence and predictors of CAM use in a comprehensive cancer center.

SUBJECTS AND METHODS

Subjects were English-speaking cancer patients at least 18 years of age, attending one of eight outpatient clinics at The University of Texas M.D. Anderson Cancer Center, Houston, TX, between December 1997 and June 1998. After giving written informed consent, participants completed a self-administered questionnaire. Differences between CAM users and nonusers were assessed by chi(2) and univariate logistic regression analysis. A multivariate logistic regression model identified the simultaneous impact of demographic, clinical, and treatment variables on CAM use; P values were two-sided.

RESULTS

Of the 453 participants (response rate, 51.4%), 99.3% had heard of CAM. Of those, 83.3% had used at least one CAM approach. Use was greatest for spiritual practices (80.5%), vitamins and herbs (62.6%), and movement and physical therapies (59.2%) and predicted (P <.001) by sex (female), younger age, indigent pay status, and surgery. After excluding spiritual practices and psychotherapy, 95.8% of participants were aware of CAM and 68.7% of those had used CAM. Use was predicted (P <.0001) by sex (female), education, and chemotherapy.

CONCLUSION

In most categories, CAM use was common among outpatients. Given the number of patients combining vitamins and herbs with conventional treatments, the oncology community must improve patient-provider communication, offer reliable information to patients, and initiate research to determine possible drug-herb-vitamin interactions.

Therapeutic and prognostic implications of peripheral blood lymphopenia in patients with Hodgkin's disease

Patients with Hodgkin's disease (HD) are known to have peripheral blood lymphopenia, but the prognostic significance of this observation and its implication on immune therapy remain controversial. We determined the peripheral blood lymphocyte (PBL) counts and their subsets of 238 newly diagnosed patients with HD referred to our institution, and the quantitative changes of B, T, and natural killer cells were correlated with the patients' clinical variables. The mean white blood cell count increased steadily with advancing disease stage. In contrast, the mean absolute PBL count and its CD4, CD8, and CD3-/CD56+/CD16+ subsets, after an initial increase in stage I, steadily decreased with advanced HD stages. The mean CD20 lymphocyte count decreased steadily with advancing stage without an initial increase. Prognostic factor analysis was determined in 196 patients adequately treated with modern therapies. Neither the absolute PBL count, nor CD4, CD8, or CD20 counts correlated with shorter disease free survival. In this study, the decline in total PBL count or in its subsets in HD patients did not correlate with shorter disease free survival. Because peripheral blood lymphopenia of HD correlated with advanced clinical stage but had no independent prognostic significance, we propose that this peripheral blood lymphopenia is likely to be due to lymphocyte trafficking and homing to the diseased nodes rather than due to an absolute quantitative deficiency. Thus, strategies to improve lymphocyte functions in HD patients should continue to be explored therapeutically.

Heterogeneity in systemic availability of ondansetron and granisetron following oral administration

This open-label, randomized, two-way crossover study compared the relative heterogeneity in systemic availability of oral ondansetron and granisetron. It was conducted in 10 healthy male and 10 healthy female subjects aged 18 to 50 years. Following an overnight fast, each subject received 8 mg ondansetron and 1 mg granisetron. Treatments were separated by 7 days. Blood samples for drug assay were collected over a period of 36 h and variability in pharmacokinetic parameter estimates were assessed following standardization by their respective means. Granisetron showed significantly more variability than ondansetron in the three primary endpoints of the area under the curve extrapolated to infinite time, the area under the curve to the last quantifiable time point, and maximal concentration (p =.0032,.0037, and.0042, respectively). In one subject, concentrations of granisetron were detectable but below the lower limit of quantitation at any time point. The impact this variability may have on therapeutic efficacy is not clear. An apparent bimodal distribution in granisetron AUC infinite, which appeared to be related to smoking was observed. Because granisetron has been reported to be metabolized primarily by the cytochrome P-450 (CYP) 3A isozyme family in humans, it is possible that cigarette smoke could be an inducer of CYP3A or that CYP1A2, also implicated in the metabolism of granisetron and known to be induced by smoking, is more important in the biotransformation of granisetron than previously thought.