Totally implanted system for intravenous chemotherapy in patients with cancer

A totally implanted system for improved central venous access has been investigated in 20 patients with cancer (six with solid tumors, four with leukemia, and 10 with lymphomas) who were treated with aggressive chemotherapy regimens and who lacked peripheral venous sites. The system is implanted using local anesthesia and consists of a subcutaneous injection port connected to a Silastic catheter threaded through the subclavian vein into the superior vena cava. Injections and continuous infusions (for up to three weeks) of virtually all classes of antineoplastic agents, antibiotics, blood components, and intravenous solutions were administered through the system. The system was filled with heparinized saline and not otherwise flushed between uses. The system has remained functional for periods exceeding 450 days (mean 235 days). There was no significant local irritation and no system became infected. None of 18 large-bore catheters (0.63 mm lumen) became occluded (seven to 300 days), whereas five of six small-bore catheters (0.38 mm lumen) became occluded (90 to 420 days). Three of the occluded systems were replaced. Acceptance has been excellent, and patients have had no impediment to normal activities. This system appears to be an alternate means of safe and reliable central venous access with improved convenience and cosmetic acceptability.

Communication skills training, communication skills training with family and cognitive behavioral mood management training for alcoholics

To evaluate three promising social learning approaches to the treatment of alcoholism, 69 male alcoholics in standard inpatient treatment participated in either a communication skills training group (CST), a communication skills training group with family participation (CSTF) or a cognitive behavioral mood management training group (CBMMT). Alcoholics who received CST or CSTF drank significantly less alcohol per drinking day during 6-month follow-up than those in CBMMT. The groups did not differ in abstinence rates or latency to relapse. All groups improved in skill and anxiety on the extensive battery of process measures, including role-play tests of general and alcohol-specific coping skills, but those in CST improved most in skill in alcohol-specific high-risk role plays and in ability to relax after the role plays. Alcoholics' skill, response latency, anxiety and urge to drink during alcohol-specific role plays were highly correlated with treatment outcome, demonstrating the importance of including comprehensive process measures in treatment outcome research. Implications for patient-treatment matching and future research are discussed.

The treatment of chronic lymphocytic leukemia with COP chemotherapy

Since single drug therapy of chronic lymphocytic leukemia (CLL) has not resulted in prolonged remissions of advanced disease, we initiated a program of combination chemotherapy, COP (cycloposphamide, vincristine sulfate, prednisone) for CLL patients with increasing adenopathy, spenomegaly, and/or signs of marrow failure defined as either anemia or thrombocytopenia. Thirty-six patients received COP either as initial therapy or following progression of disease on single agent therapy. The response rate was 72% with 26 patients responding (16 complete remissions, and 10 good partial remissions). The responses lasted from 8 to 50+ months. Sixteen of the responding patients remain in remission, 2 have active disease and 8 have died. Median survival has not yet been reached but the two-year survival from initiation of COP of the responding patients (complete and good partial response) is 90%. Ten patients had either poor partial or no response with median survival of 18 months. The median survival of the entire group of 36 patients is 35 months. COP is an effective and well tolerated therapy for advanced chronic lymphocytic leukemia.

Detecting symptoms of alcohol abuse in primary care settings

BACKGROUND

Studies on alcohol abuse are frequently based on patients who meet minimum diagnostic criteria, thus ignoring patients with individual symptoms of harmful or hazardous use. Consequently, we are unable to characterize alcohol-abusing patients with sufficient clarity to effectively focus screening for primary prevention.

OBJECTIVE

To determine the prevalence of harmful and hazardous use of alcohol, assess screening instruments for detecting alcohol abuse or dependence, and assess the impact of alcohol use on other diagnoses treated in outpatient settings.

DESIGN

Survey (cross-sectional study).

SETTING

Hospital-based outpatient clinic.

PARTICIPANTS

Three hundred randomly selected adults (aged 18 years and older).

MAIN OUTCOME MEASURE

Diagnosis of alcohol abuse or dependence based on the Diagnostic Interview Schedule (DIS).

RESULTS

About 18% met DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) criteria of abuse or dependence while almost 50% had at least one symptom of harmful or hazardous use. The T-ACE questionnaire, a modified version of the CAGE questionnaire, was the most effective screening instrument for both men and women. Selected diagnoses, personal characteristics such as family history of alcohol abuse, and self-reported patterns of alcohol use could identify patients likely to meet diagnostic criteria.

CONCLUSIONS

Many symptoms of substance use disorders are not adequately addressed in outpatient practice. Little is known about how alcohol use in varying quantities affects health care utilization and treatment of conditions commonly seen in outpatient medicine. Consequently, we lack a full appreciation of the burden of disease borne by alcohol use and have yet to achieve a universally accepted method of approaching primary and secondary prevention of alcohol-related problems.

Safety and efficacy of long-term oral anticoagulation in cancer patients

The course of long-term oral anticoagulation in 25 patients (186 patient-months) with cancer managed in an outpatient anticoagulation clinic was analyzed to determine the frequency of complications. Major and minor hemorrhagic complications occurred in 10.7% and 32% of treatment courses, respectively, for an incidence of 1.6% and 4.8%, respectively, per patient-month. Recurrent thromboembolism occurred in 14% of treatment courses. These results are better than previous reports in the literature, but worse than our overall anticoagulation clinic experience. Patients with cancer requiring anticoagulation are at a higher risk of hemorrhagic and thrombotic complications. Accordingly, we recommend that such patients be monitored closely, preferably by physicians experienced with such therapy, as in an anticoagulation clinic, to avoid an excessive degree of morbidity.

Detoxification of alcoholics: improving care by symptom-triggered sedation

This study evaluated a staff training program on alcohol detoxification. Training consisted of didactic presentations on the pathophysiology of alcohol withdrawal syndrome and information on use of the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-A). Treatment course was assessed on 100 patients admitted before or after the training. Whereas 73% of patients were given drug therapy before, only 13% of patients received drug therapy after. Significantly more benzodiazepine was administered before training (M = 108.48 mg) than after training (M = 42.97 mg). After excluding those who received no drug therapy, patients who received benzodiazepine after the training received significantly higher amounts of benzodiazepine (M = 252.50 mg) than those who received drug before (M = 144.64 mg). The average number of hours from the first benzodiazepine dose to the last was reduced from 13 to 5 hr. Clinical implications of matching patient symptomatology with appropriate drug therapy, thus preventing both over- and under-treatment for alcohol withdrawal symptoms, are discussed.

Attitudes toward risk factor behavior of relatives of cancer patients

BACKGROUND

Targeted health promotion requires an identifiable subpopulation which is accessible, at increased risk, receptive to input, and receptive to change. Relatives of recently diagnosed cancer patients may meet these criteria and have not previously been investigated as recipients of preventive education regarding smoking and diet.

METHODS

This study investigates these factors, beliefs regarding perceived susceptibility to cancer, and attitudes toward behavior change in 101 relatives of 50 patients with smoking-related cancers, breast cancer, and other diet-related cancers. Congruence of attitudes between patients and relatives, another possible factor in changing health behaviors, also was assessed.

RESULTS

Access to relatives of patients was very high, as was their willingness to discuss these issues (99% of relatives contacted participated in the survey). Relatives' ratings of relevant risk factors were generally higher than those of patients; ratings of their own vulnerability were moderate. Within diagnostic groups, there was high concordance of belief between patients and relatives for certain types of risk, such as heredity for breast cancer (r = 0.81) and smoking for smoking-related cancers (r = 0.52), but not for dietary factors.

CONCLUSIONS

The high level of access suggests that relatives may be receptive to discussing issues of behavior risk and change. They are at least as aware as patients of cancer risk factors. Spontaneous behavior change was very low. They may therefore be good candidates for targeted health promotion regarding cancer risk.

Evaluation of a program designed to help family and significant others to motivate resistant alcoholics into recovery

Little empirical work has been done in the alcohol field on the issue of motivating reticent people into treatment. This study explored the impact of a program that involved counseling an alcoholic's social network to eventually confront the alcoholic in urging him or her to seek treatment. Twenty-four social networks (relatives plus significant others) participated in this study and of these, seven formally confronted the alcoholic. Social networks were not randomized to confronting vs nonconfronting conditions, although the comparison groups were equivalent on several important dimensions. Results indicate that alcoholics who were confronted were significantly more likely to enter an alcohol detox or rehabilitation program and to remain continuously abstinent than were nonconfronted alcoholics. This study suggests that the alcoholic's social network can be helped to become highly influential in motivating the alcoholic to seek treatment.

Interdigitating reticulum-cell sarcoma of the intestine: a case report and review of the literature

Dendritic cells are immune accessory cells which are widely distributed in many tissues. Those which are present within lymphoid follicle centers are classified as follicular dendritic cells. Those which are found outside germinal centers may be referred to as interdigitating reticulum cells, or Langerhans cells when they occur in the skin. Abnormal proliferations of dendritic cells are best known as the group of disorders comprising Langerhans-cell histiocytosis, which occurs primarily in children and teenagers. There are increasing reports of malignant proliferations of both types of dendritic cells in adults. However, there is only one previous description of the cytologic features of a dendritic cell sarcoma based on imprint cytology of a resected jejunal mass. The current report provides a detailed description of the cytologic features of a fine-needle aspirate of a recurrence of an interdigitating reticulum-cell sarcoma of the cecum.

Patient-treatment matching for alcoholic men in communication skills versus cognitive-behavioral mood management training

It would be helpful to be able to predict which alcoholics will be more likely to benefit from specific forms of treatment in order to optimize treatment resources. Certain hypothesized patient-treatment matching predictions were investigated with 52 alcoholics who received either communication skills training or cognitive behavioral mood management training in addition to a standard Veterans Administration inpatient alcoholism treatment program. Significant interaction effects showed that alcoholics had worse treatment outcomes in mood management training if they had higher initial anxiety or urge to drink in high-risk role plays or lower had higher initial anxiety or urge to drink in high-risk role plays or lower education. No significant interaction of treatment with irrational beliefs or marital status was found. Communication skills training seemed to be equally effective for alcoholics at any educational level, irrespective of initial coping skill, anxiety, urge to drink, alcohol dependence, or marital status. Thus, although mood management training seems to be as effective as communication skills training for alcoholics with higher education, less anxiety, and less urge to drink, communication skills training benefits a broader spectrum of patients, regardless of initial level of education, alcohol dependence, skill, anxiety, or beliefs.

Preirradiation chemotherapy of supratentorial malignant primary brain tumors with intracarotid cis-platinum (CDDP) and i.v. BCNU. A phase II trial

Thirty patients with histologically verified malignant supratentorial gliomas were treated with a preirradiation chemotherapy protocol consisting of two courses of intracarotid (i.c.) CDDP, 90 mg/m2, followed by i.v. BCNU, 200 mg/m2. Side effects from therapy were mild and self-limiting; no irreversible retinal or neurologic toxicity could be attributed to i.c. chemotherapy. Of the 27 patients who completed the chemotherapy portion of the protocol, tumor size on postchemotherapy computed tomography (CT) was decreased by greater than 50% in 13% as compared to the postoperative CT scan; in only 4% was the CT scan unequivocally increased in size. Twenty-five (83%) patients completed the entire protocol. Median time to tumor progression and survival in patients who completed the protocol was 53 (range of 13-130+) and 61 (range of 29-130+) weeks, respectively. Twenty-four percent of patients still have not demonstrated tumor progression at intervals greater than 1 year after diagnosis as judged by clinical and radiographic criteria. Tumor recurrences were always contiguous to the original tumor bed. We conclude that preirradiation chemotherapy may be administered safely and with low morbidity. Further study to determine an optimal timing between chemotherapy and radiation therapy is warranted.

Emergency Department Use in the Perinatal Period: An Opportunity for Early Intervention

STUDY OBJECTIVE

We characterize emergency department (ED) utilization among perinatal women and identify differences in risk factors and outcomes between women who use versus do not use the ED during the perinatal period.

METHODS

This is a retrospective cross-sectional study comparing patients who used the ED versus did not use the ED during the perinatal period. Patient data were collected from medical chart review and postpartum interviews.

RESULTS

Of the 678 participants, 218 (33%) had at least 1 perinatal ED visit. Women who used the ED were more likely than those who did not to be adolescent (relative risk [RR] 2.23; 95% confidence interval [CI] 1.38 to 3.63), of minority race (RR 1.94; 95% CI 1.46 to 2.57), and Medicaid insured (RR 2.14; 95% CI 1.71 to 2.67). They were more likely to smoke prenatally (RR 3.42; 95% CI 2.34 to 4.99), to use recreational drugs prenatally (RR 3.53; 95% CI 1.78 to 7.03), and to have experienced domestic abuse (RR 1.78; 95% CI 1.12 to 2.83). They were more likely to have delayed entry to prenatal care (RR 2.01; 95% CI 1.46 to 2.77) and to experience postpartum depression (RR 2.97; 95% CI 1.90 to 4.64). Their infants were nearly twice as likely to be born prematurely (RR 1.92; 95% CI 1.07 to 3.47).

CONCLUSION

Results highlight that pregnant patients using the ED are a high-risk, vulnerable population. Routine ED screening and linkage of this vulnerable population to early prenatal care and psychosocial interventions should be considered as a public health strategy worth investigating.

Development of a behavior analytically derived alcohol-specific role-play assessment instrument

Social learning theory postulates that chronic alcohol abusers may have deficits in ability to cope with stressful situations, and these deficits may be associated with relapse after treatment. Attempts to study the hypothesized deficits have been hampered by methodological problems. Therefore, a behavior analytic procedure was used to develop 10 categories of situations based on over 600 drinking situations elicited from alcoholics. Role plays were developed for each of these categories, and samples of alcoholics in treatment were asked to respond as if they were trying not to drink. Videotaped responses were behaviorally rated by trained judges for skill and anxiety, and subjects completed self-report ratings of urge to drink, anxiety, difficulty and skill after each role play. Good interrater reliabilities and internal consistency were found across three samples of alcoholics, with virtually no gender differences. Previous and current investigations show the validity and utility of this instrument. The Alcohol Specific Role Play Test therefore shows promise as a means of assessing alcoholics' reactions to high-risk situations.

Tillotson C, Choi D, Robinson J, Calsyn DA, Mandler RN, Jenkins LM, Thompson LL, Dempsey CL, Liepman MR, McCarty D. Reducing HIV-related risk behaviors among injection drug users in residential detoxification

This study of 632 drug injectors enrolled in eight residential detoxification centers within the National Drug Abuse Treatment Clinical Trials Network tested three interventions to reduce drug and sex risk behaviors. Participants were randomized to: (a) a two-session, HIV/HCV counseling and education (C&E) model added to treatment as usual (TAU), (b) a one-session, therapeutic alliance (TA) intervention conducted by outpatient counselors to facilitate treatment entry plus TAU, or (c) TAU. Significant reductions in drug and sex risk behaviors occurred for all three conditions over a 6-month follow-up period. C&E participants reported significantly greater rates of attending an HIV testing appointment, but this was not associated with better risk reduction outcomes. Reporting treatment participation within 2 months after detoxification and self-efficacy to practice safer injection behavior predicted reductions in injection risk behaviors. Findings indicate that participation in detoxification was followed by significant decreases in drug injection and risk behaviors for up to 6-months; interventions added to standard treatment offered no improvement in risk behavior outcomes.

The Michigan Alcoholism Screening Test: false positives in a college student sample

The Michigan Alcoholism Screening Test (MAST), designed and validated by Selzer (1971), is widely used to screen for persons with alcohol problems. The most recent version of the MAST includes the question "Have you ever attended a meeting of Alcoholics Anonymous (AA)?" This question may contribute to false positive identifications, as it does not specify whether attendance is for the subject's own problem drinking. In the current research, 114 college students completed the MAST along with an additional question: "Have you ever attended a meeting of Alcoholics Anonymous because of your own problem drinking?" The results indicated that seven of 114 subjects (6.1%) attained inflated MAST scores because they had attended an Alcoholics Anonymous meeting, but not for their own problem drinking. It is suggested that the wording to the Alcoholics Anonymous question on the MAST be changed to reduce the number of false positive identifications produced by this instrument.

Intimate Partner Violence Associated with Postpartum Depression, Regardless of Socioeconomic Status

Objective This study examined whether socioeconomic status moderated the association between intimate partner violence (IPV) and postpartum depression among a community-based sample of women. Defining the role of poverty in the risk of postpartum depression for IPV victims enables prioritization of health promotion efforts to maximize the effectiveness of existing maternal-infant resources. Methods This cross-sectional telephone-survey study interviewed 301 postpartum women 2 months after delivery, screening them for IPV and depression [using Edinburgh Postnatal Depression Scale (EPDS)]. Socioeconomic status was defined by insurance (Medicaid-paid-delivery or not). This analysis controlled for the following covariates, collected through interview and medical-record review: demographics, obstetric history, prenatal health and additional psychosocial risk factors. After adjusting for significant covariates, multiple linear regression was conducted to test whether socioeconomic status confounded or moderated IPV's relationship with EPDS-score. Results Ten percent of participants screened positive for postpartum depression, 21.3 % screened positive for current or previous adult emotional or physical abuse by a partner, and 32.2 % met poverty criteria. IPV and poverty were positively associated with each other (χ(2) (1) = 11.76, p < .001) and with EPDS score (IPV: beta 3.2 (CI 2.0, 4.5) p < .001, poverty: beta 1.3 (CI 0.2, 2.4) p = .017). In the multiple linear regression, IPV remained significantly associated, but poverty did not (IPV: adjusted beta 3.1 (CI 1.8, 4.3) p < .001, poverty: adjusted beta 0.8 (CI -0.3, 1.9) p = .141), and no statistically significant interaction between IPV and poverty was found. Conclusions Study findings illustrated that IPV was strongly associated with postpartum depression, outweighing the influence of socioeconomic status upon depression for postpartum women.

Improving the transition from residential to outpatient addiction treatment: gender differences in response to supportive telephone calls

Substance use relapse rates are often high in the first months after discharge from inpatient substance abuse treatment, and patient adherence to aftercare plans is often low. Four residential addiction treatment centers participated in a feasibility study designed to estimate the efficacy of a post-discharge telephone intervention intended to encourage compliance with aftercare. A total of 282 participants (100 women, 182 men) with substance use disorders were included in this secondary analysis. The findings revealed that women were more likely than men to attend aftercare. This "gender effect" persisted after adjustment for a number of potential mediators.

Alcohol abusers' and social drinkers' responses to alcohol-relevant and general situations

Responses of alcohol abusers and social drinkers were compared on general and alcohol-specific problem situations using role-play methodology. Multiple responses were assessed including behavioral observational ratings, self-reports and psychophysiologic measures. There were few differences between groups in responses to the general situations. Alcohol abusers had higher urges to drink than did the social drinkers in both the general and the alcohol-specific situations. However, in response to the alcohol-specific situations, the alcohol abusers, compared to the social drinkers, were rated by judges as significantly less skillful, and they displayed more self-reported anxiety, had a higher frequency of occurrence of problem situations in the natural environment and reported greater perceived realism of the alcohol-specific situations. Psychophysiologic measures did not differentiate between the groups. Results are discussed with respect to the importance of situation specificity in understanding the precipitants of drinking and their treatment implications.

Irrational beliefs, urges to drink and drinking among alcoholics

The relationship of various irrational beliefs to alcohol dependence, urges to drink, anxiety and drinking after treatment was investigated for 63 male alcoholics, using Jones' Irrational Beliefs Test (IBT). Alcohol dependence was most strongly associated with problem avoidance. Urges to drink, anxiety and difficulty during alcohol-related role-plays were strongly correlated with problem avoidance and dwelling on negative events. The IBT was unrelated to pretreatment drinking measures but did predict 6-month posttreatment drinking (n = 48) which suggests these beliefs can mediate treatment response. Feeling doomed by the past was the best predictor of both frequency of drinking and average quantity consumed during follow-up. Treatment implications include targeting specific beliefs for intervention.