Biomedical subjects
Publications and source records attributed to R Joss.
This review gives an overview over the diagnostic and pharmacological approach to pain in cancer patients. The work-up and the pharmaceutical treatment is detailed and several important points in the use of opiates are highlighted.
Type 2 diabetes mellitus is often associated with other risk factors for atherosclerotic disease, resulting in a marked increase in cardiovascular events and deaths. Combined treatment of hyperglycaemia, dyslipidaemia and hypertension significantly decreases the frequency and severity of diabetic microvascular and macrovascular complications. In a prospective cohort study including 356 type 2 diabetic patients (= 14% of all in-patients during a 6 months' period) the prevalence and treatment of cardiovascular risk factors were determined. Hypertension was diagnosed in 54% of the diabetic patients, albuminuria in 53% and dyslipidaemia in 47%; there were 40 smokers (17%). On admission the mean HbA1c was 7.7 +/- 2.0%, the mean fasting plasma glucose 10.0 +/- 4.2 mmol/l (and 8.9 +/- 3.9 mmol/l, p = 0.03, when discharged), the mean systolic blood pressure was 144 +/- 28 mm Hg (and 131 +/- 20, p < 0.0001, when discharged), and the triglycerides were 2.6 +/- 0.4 mmol/l. 34% of the hypertensive diabetic patients were treated with a combination of anti-hypertensive drugs, 44% of the dyslipidaemic diabetic patients were treated with statins, and 58% of all diabetic patients received aspirin or oral anticoagulation. 23% of the diabetic patients were treated by diet alone, 36% with insulin, 25% with sulfonylureas and 5% with metformin, while 11% were given a combination of antihyperglycaemic medication. In-hospital mortality was 11%. The diabetic patients were discharged on 2.9 +/- 1.7 different drugs. The prevalence of associated cardiovascular risk factors is high in type 2 diabetic patients, and thus a combination of drugs is often warranted. The rate of admissions and in-hospital mortality is high in type 2 diabetic patients.
BACKGROUND: The term "Castleman's disease" (angiofollicular lymph node hyperplasia) comprises a heterogeneous clinicopathologic entity among lymphoproliferative disorders. CASE REPORT: We present a rare case with retroperitoneal manifestations, and discuss several aspects of diagnosis, differential diagnosis, the clinical course and therapy of the disease. Finally, we summarize the actual knowledge about the pathogenesis of Castleman's disease.
After 2 weeks' treatment with sulfasalazine (SASP) and mesalazine enema, a 32-year-old female with recently diagnosed ulcerative colitis developed bilateral pulmonary infiltrates with peripheral eosinophilia. Both drugs were discontinued. In view of a high-positive antibody titre (1:4096) against Legionella pneumophila serogroups 1-5, legionnaires' disease was assumed and empirical antilegionella therapy with macrolid antibiotic was started. The patient's condition improved within days. Three months later SASP was given again in view of exacerbation of the inflammatory bowel disease. Three days after initiation of therapy acute pulmonary symptoms again developed with bilateral, confluent opacities and blood eosinophilia. The abnormalities resolved completely after the drug was discontinued and prophylactic antibiotic therapy was given. Peripheral lung infiltrates with blood eosinophilia are a rare side effect of SASP therapy. The prognosis of the illness after the drug has been discontinued is generally good, usually with complete recovery of pulmonary function. The risk factors for sulfasalazine pulmonary toxicity are not well known. We describe the first case of SASP-induced hypersensitivity lung disease with simultaneous Legionella pneumophila infection.
After a short introduction to recent developments in the field of tobacco control, the non-surgical treatment of small cell and non-small cell lung cancer is summarised with special reference to practical aspects. The promising results obtained with newer cytostatic agents are reviewed. In small cell lung cancer, modern chemotherapy prolongs survival five-fold to an average of one year and 5-10% of all patients achieve long-term disease-free survival. In non-small cell lung cancer combination chemotherapy prolongs median survival and improves the quality of life. Newer cytostatic agents such as the taxanes, vinorelbine and gemcitabine are highly active. These agents are currently incorporated into new, highly active combination chemotherapies. Whether these newer polychemotherapies will bring a significant improvement awaits the results of future randomised trials.
Modern medicine offers to patients and physicians an ever increasing multitude of diagnostic and therapeutic possibilities. Depending upon the individual viewpoint of the patient and the caregivers there may be different opinions about the "right" choice. This article reviews some of the potential problems and conflicts, which may arise from multiple diagnostic and therapeutic options. We feel, that it is of utmost importance, that the informed patient is involved in the decision process.
In the last decade six new chemotherapeutic agents including the vinca alcaloid vinorelbine, the taxanes paclitaxel and docetaxel, the antimetabolite gemcitabine and the two topoisomerase I-inhibitors irinotecan and topotecan were shown to be active in several phase II- and randomized phase III-trials. This article reviews their mode of action, their efficacy, their side effects and their indications. Their state of registration and reimbursement by insurance companies in Switzerland are summarized. Finally, their costs and cost-effectiveness in a time of increasing financial restraint in health care budgets are analyzed.
A case history of a breast cancer patient is used to exemplify ethical dilemmas in medical oncology: information of a cancer patient and his family, ethical problems with genetic testing, ethical issues with do-not-resuscitate-orders, ethical dilemmas with limited resources, problems with insurance companies, ethical issues in clinical trials and questions in dying patients including physician-assisted suicide and active euthanasia. Medical oncologists have to develop skills in recognizing ethical dilemmas in patient care and must prepare to cope with the many and complex ethical issues in the care of oncology patients.
This review summarizes some of our current knowledge on the burn-out syndrome and details factors contributing to the high rate of emotional melt-down in health professionals. Possible coping strategies are detailed, and some personal thoughts how to prevent emotional exhaustion are given.
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A three-year evaluation of total quality management (TQM) at NHS demonstration sites shows there are clear factors which predict successful implementation of TQM. The intention is to raise awareness at both TQM and non-TQM sites of the need to have a structured, pre-planned approach to TQM, based on a thorough understanding of alternative approaches.
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"Fatigue and malaise" (FM) is a frequent, non-specific symptom of cancer patients caused by the disease, its treatment and psychological distress. Since comprehensive quality of life assessment is often not feasible in multicentre clinical trials, short, but clinically relevant, quality of life indicators have to be defined. In a representative subsample of 127 patients in a phase-III randomized small-cell lung cancer trial comparing two different regimens of combination chemotherapy, quality of life was assessed at the beginning of each of the six treatment cycles with a self-rating questionnaire including an early version of the EORTC questionnaire, a mood adjective check list (Bf-S) and a single linear-analogue self-assessment scale (LASA) measuring general well-being. FM, measured with a five-item Likert subscale of the EORTC questionnaire, showed moderate to high intercorrelations with other EORTC subscales assessing disease symptoms, toxicity of treatment, role functioning, personal functioning, restriction of social activity, psychological distress, emotional (Bf-S) and general well-being (LASA). At baseline, FM was one of the most pronounced symptoms. Over the six cycles 43%-31% of the patients complained of moderate to severe fatigue. Over the first two cycles FM tended to decrease, slightly increasing during cycles 3 and 4 and decreasing again before cycle 6. In a multiple regression analysis over the six cycles, 53% of the variance of FM was explained by patient-rated symptoms of disease and toxicity (disease alone: 43%; toxicity alone: 35%). Initial performance status, previous weight loss, treatment arm, cycle number and age predicted the scores of FM over the six cycles.(ABSTRACT TRUNCATED AT 250 WORDS)
Between 1985 and 1990 the Swiss Group for Clinical Cancer Research (SAKK) for the first time assessed quality of life (QL) variables in 188 patients in a multicenter small-cell lung cancer trial that compared two different regimens of combination chemotherapy. QL-assessment was scheduled at the beginning of each of the six treatment cycles. The self-rating QL questionnaire included an early version of the EORTC QL questionnaire, a mood adjective checklist (Bf-S) and a single linear analogue scale (LASA) measuring general well-being. Compliance with completion of the scheduled questionnaires varied between 37% and 58% over the six cycles, and between 21% and 68% among the 7 participating institutions. Mean compliance was 49%. The institution was found the only significant factor predicting compliance (p < 0.001). Patient age, sex, education and biological prognostic factors at randomization were not predictors of compliance. Although compliance was poor, the data received was of high quality. We suggest practical guidelines for improving compliance with QL data collection in multicenter clinical trials.
Eighty-three previously untreated patients with aggressive non-Hodgkin's lymphomas were treated with either MACOP-B (23 patients) or VACOP-B (60 patients) as originally described by Klimo and Conners [1, 2]. Their median age was 46 years. Thirty-seven patients had stage I or II and 46 stage III or IV disease. The tumor histopathology was reviewed in all cases. Sixty-five patients had intermediate grade and 18 high-grade non-Hodgkin's lymphomas according to the International Working Formulation. The rate of complete response was 74% for MACOP-B and 76% for VACOP-B. At the time of analysis the duration of follow-up was 50 months for the MACOP-B and 22 months for the VACOP-B group. The actuarial three-year progression-free survival was 35 +/- 10% for the MACOP-B group, 48 +/- 11% for the VACOP-B group, and 46 +/- 7% for all patients. Treatment mortality was 6%. A univariate and a multivariate analysis of selected pretreatment parameters and of regimen demonstrated that stage III or IV, high-grade lymphoma, and elevated serum LDH, but not the type of regimen, are significantly associated with poor progression-free survival in our patient population.
During the last two decades the treatment strategy in operable breast cancer has been revolutionized by the introduction of adjuvant systemic therapies. This article reviews the basis for the use of adjuvant systemic therapy and summarizes the results achieved so far. Practical guidelines are formulated.
Phase II studies on ifosfamide and mesna in pancreatic cancer have mostly been inconclusive. In all of these studies ifosfamide was administered as an i.v. bolus or by short infusions. Since dose fractionation of ifosfamide over several days increases its therapeutic index, we chose to maximize the dose fractioning by selecting a continuous-infusion schedule (1.75 g/m2 on days 1-5 every 21-28 days, with mesna 60%-100% of the ifosfamide dose up to 12 h after ifosfamide). Since 1987 29 patients (performance status less than or equal to 2) with advanced inoperable adenocarcinoma of the pancreas were studied (8 women and 21 men; median age 58 years: 36-73 years). A total of 25 patients are evaluable for response (1 ineligible; 3 inevaluable: 2 early deaths due to disseminated intravascular coagulation, 1 refusal). One female patient with a complete response on computed tomography scan (after five cycles) but residual liver metastases on surgical exploration survived for 473 days. Three male patients with partial response survived for 205, 335 and 355 days. Six more patients with minor response (3) or no change (3) but significant decrease of tumour marker CA 19-9 had a median survival of 213 days (106-243). Responders seemed to benefit in terms of pain relief and general well-being. The median overall survival of all patients was 148 days (21-473). Haematotoxicity was rarely dose-limiting [median nadirs: white blood cells = 2.1 x 10(9)/l (0.45-6.4), Hb = 10.7 g/dl (7.5-13), platelets = 137 x 10(9)/l (21-411)]. Nausea and vomiting were mild with prophylactic oral metoclopramide. No central nervous system toxicity or urotoxicity was observed. Alopecia was seen in all patients who had received at least two cycles. Continuous infusion of ifosfamide was generally well tolerated and useful for palliation in 10 of 25 patients. A higher dose intensity is recommended.