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A 72-year-old man presented to the emergency department with shortness of breath. He had a history of left ventricular failure, hypertension, treated esophageal carcinoma and recurrent deep vein thromboses. His [...]

The Miller School of Medicine of the University of Miami and Project Medishare, an affiliated not-for-profit organization, provided a large-scale relief effort in Haiti after the earthquake of 12 January 2010. Their experience demonstrates that academic medical centers in proximity to natural disasters can help deliver effective medical care through a coordinated process involving mobilization of their own resources, establishment of focused management teams at home and on the ground with formal organizational oversight, and partnership with governmental and nongovernmental relief agencies. Proximity to the disaster area allows for prompt arrival of medical personnel and equipment. The recruitment and organized deployment of large numbers of local and national volunteers are indispensable parts of this effort. Multidisciplinary teams on short rotations can form the core of the medical response.

Background and Purpose Therapy-related changes in limb volumes often are estimated using summated segmental volumes based on adjacent circumference measurements. The purposes of this study were: (1) to determine the effect of different segment lengths on calculated volume reductions after complete decongestive therapy and (2) to determine the effect of excluding posttherapy control limb volumes on calculated reductions in edema volume in patients with unilateral limb lymphedema. Subjects This two-part retrospective study was conducted using data from patients with bilateral leg lymphedema (n=70) and data from patients with unilateral arm lymphedema (n=75) and patients with unilateral leg lymphedema (n=45). Methods For the bilateral leg lymphedema group, pretreatment to posttreatment changes in limb volume were determined using segment lengths of 4, 8, and 12 cm. For the unilateral lymphedema group, pretreatment to posttreatment changes in edema volume were determined and compared using or not using posttreatment control limb volumes. Results Bilateral leg volume changes were similar for all segment lengths but not significantly different from each other. Unilateral edema volume changes were significantly overestimated in both arms and legs when posttherapy control limb volumes were not used. Discussion and Conclusion The results indicate that segment lengths of 4 cm generally are not needed to obtain adequate estimates of leg volume changes. Both limb volumes should be measured to properly assess therapeutic outcomes in patients with unilateral limb lymphedema., Treatment outcomes of therapy for limb edema and lymphedema with respect to changes in edema volume often are assessed in the clinic based on limb circumferences, which are used to [...]

Background: Previous studies have demonstrated that African-Americans with colon cancer have worse overall and stage-specific survival rates than Caucasians. Such differences could reflect variation in access to health care, in tumor biology, or in treatment efficacy. Little is known about potential differences in chemotherapy-related toxicities between African-Americans and Caucasians. In this study, we examined survival and toxic effects among African-American and Caucasian patients enrolled in a large, randomized phase III trial of adjuvant chemotherapy for resected colon cancer. Methods: We analyzed data on 3380 patients (344 African-Americans and 3036 Caucasians) enrolled in a randomized trial of adjuvant 5-fluorouracil-based chemotherapy in patients with stage II (high risk) and stage III colon cancer to evaluate differences in outcomes and toxicity. We compared disease-free survival (DFS) and overall survival (OS) between African-Americans and Caucasians by the Kaplan-Meier method, computed Cox proportional hazards by multivariable analysis, and compared treatment-related toxicity rates by Fisher's exact test. All statistical tests were two-sided. Results: We found no differences in DFS or OS between African-American and Caucasian patients. Five-year DFS was 57% (95% confidence interval [CI] = 52% to 62%) for African-Americans and 58% (95% CI = 56% to 60%) for Caucasians (P = .15), and 5-year OS was 65% (95% CI = 60% to 70%) for African-Americans and 66% (95% CI = 64% to 68%) for Caucasians (P = .38). On multivariable analysis, no statistically significant difference in disease recurrence or death was detected between the racial/ethnic groups (hazard ratios for African-Americans versus Caucasians: disease recurrence = 1.1, 95% CI = 0.9 to 1.3; death = 1.1, 95% CI = 0.9 to 1.3). Treatment-related toxicity differed between the African-American and Caucasian patients, with African-Americans experiencing statistically significantly lower rates of diarrhea (P

Background: The incidence of second primary colorectal cancer in patients with a history of colon cancer, compared with patients with a history of adenomatous polyps, is unknown. It is unclear whether guidelines for colonoscopy screening in patients with polyps are appropriate for patients with previous colon cancer. Objective: To determine the incidence of second primary colorectal cancer after treatment for localized colon cancer and to compare this incidence with that of first primary colorectal cancer in both the general population and high-risk patients. Design: Historical cohort study. Setting: An international, multi-institutional trial of adjuvant 5-fluorouracil-based chemotherapy for localized colon cancer. Patients: 3278 patients with resected stage II and stage III colon cancer. Measurements: Occurrence of endoscopic or radiologic colon surveillance and incidence of second primary colorectal cancer. Results: Forty-two cases of second primary invasive colon cancer were found over 15 345 person-years of follow-up, yielding an incidence rate of 274 per 100 000 person-years (95% CI, 196 to 369 per 100 000 person-years) and a cumulative incidence of 1.5% (CI, 1.1% to 2.0%) at 5 years. This rate was compared with rates of first colon cancer in two reference groups: the general population and patients who had undergone frequent colonoscopy and polypectomy because of a history of adenomatous polyps; standardized incidence ratios were 1.6 (CI, 1.2 to 2.2) and 6.8 (CI, 2.7 to 22.0), respectively. Conclusion: The incidence of second primary colorectal cancer remains high despite intensive surveillance strategies.

Background: Follow-up testing after surgery for colon cancer is recommended principally to identify resectable recurrences, but data on the efficacy of, outcomes of, and optimal strategies for this testing are limited. Objectives: To determine the relation between follow-up tests and salvage surgery, assess outcomes, and document surgical mortality. Design: Retrospective cohort, study. Setting: A North American multi-institutional trial comparing postoperative chemotherapy plus follow-up with follow-up alone. Patients: 1247 patients with resected stage II and stage III colon cancer. Intervention: The protocol mandated follow-up testing that could be supplemented at the discretion of treating physicians. Indications of recurrent disease were documented. Measurements: Recurrence, resectable recurrence, surgical mortality, and survival were studied. Results: 548 patients had recurrence of colon cancer. Salvage surgery was attempted in 222 patients (41%). In 109 patients (20%), curative-intent surgery was done for hepatic recurrence (28 patients), pulmonary metastasis (20 patients), local recurrence (24 patients), or recurrence at other sites (37 patients). Most curative-intent surgical procedures were motivated by follow-up testing (36 patients), elevated carcinoembryonic antigen level (41 patients), or symptoms (27 patients). The median follow-up time after curative-intent surgery exceeded 5 years; the estimated 5-year disease-free survival rate was 23%. A solitary lesion was a favorable prognostic factor. The surgical mortality rate was 2%. Curative-intent resections were done in 15 patients with second primary colorectal cancer; 12 of these patients have survived disease-free. Conclusions: Second operations for colon cancer that are triggered, by follow-up testing or symptoms are common and can result in long-term disease-free survival., Follow-up testing and surgical treatment of recurrent cancer after colon cancer surgery appear to be common and effective. Researchers studied 1,247 who had undergone surgery for colon cancer. Cancer recurred in 548 patients, 41% of whom had a second surgery. Follow-up testing for cancer recurrence identified most of the tumors for which a second surgery intended to cure the disease was undertaken. Colonoscopy and other diagnostic screening methods conducted annually during the first 3-5 years after colon cancer surgery may be cost-effective.

Introduction of tumor markers into routine clinical practice has been poorLY controlled, with few criteria or guidelines as to how such markers should be used. We propose a Tumor Marker Utility Grading System (TMUGS) to evaluate the clinical utility of tumor markers and to establish an investigational agenda for evaluation of new tumor markers. A Tumor Marker Utility Grading Worksheet has been designed. The initial portion of this worksheet is used to clarify the precise characteristics of the marker in question. These characteristics include the marker designation, the molecule and/or substance and the relevant alteration from normalcy the assay format and reagents, the specimen type, and the neoplastic disease for which the marker is being evaluated. To determine the clinical utility of each marker, one of several potential uses must be designated, including risk assessment, screening, differential diagnosis, prognosis, and monitoring clinical course. For each of these uses, associations between marker assay results and expected biologic process and end points must be determined. However, knowledge of tumor marker data should contribute to a decision in practice that results in a more favorable clinical outcome for the patient, including increased overall survival, increased disease-free survival, improvement in quality of life, or reduction in cost of care. Semiquantitative utility scales have been developed for each end point. The only markers recommended for use in routine clinical practice are those that are assigned utility scores of '++ or '+++' on a 6-point scale (ranging from 0 to +++) in the categories relative to more favorable clinical outcomes. Each utility score assignment should be supported by documentation of the level of evidence used to evaluate the marker. TMUGS will establish a standardized analytic technique to evaluate clinical utility of known and future tumor markers. It should result in improved patient outcomes and more cost-efficient investigation and application of tumor markers. [J Natl Cancer Inst 1996;88:1456-66

Background. The biochemical modulation of 5-fluorouracil (5-FU) by the reduced folate folinic acid (FA) in the treatment of patients with advanced gastric cancer was examined. Methods. The Southwest Oncology Group performed parallel randomized Phase II trials of two schedules of 5-FU and FA in 80 patients with advanced gastric cancer. Of 76 analyzable patients, 36 were randomized to receive bolus FA (200 mg/[m.sup.2], days 1-4) along with continuous infusion 5-FU (1000 mg/[m.sup.2], days 1-4) and 40 were randomized to receive bolus FA (200 mg/[m.sup.2], days 1-5) before the bolus 5-FU (375 mg/[m.sup.2], days 1-5). Results. There were three (8%) partial responses (95% confidence interval [CI] 2%-22%) on the continuous infusion arm. The bolus arm had two (5%) complete responses and six (15%) partial responses for an overall response rate of 20% (95% CI 9%-36%). The median duration of response was 4.6 months for the infusion patients and 16.6 months for the bolus patients. Survival was poor, with median survival of 5 months on both regimens. Gastrointestinal toxicity was substantial, with Grade 3 mucositis observed in 36% of patients on the continuous infusion regimen versus only 10% of patients on the bolus regimen. Grade 3 or higher hematologic toxicity occurred more often in the bolus arm than in the continuous infusion arm (28% vs. 14%, respectively). Two toxic deaths occurred, one related to sepsis the other secondary to coronary insufficiency. Conclusions. Biochemical modulation of 5-FU by FA using the dose and schedules tested has only modest activity in the treatment of advanced gastric cancer. Cancer 1995; 76:715-9. Key words: stomach neoplasms, leucovorin, fluorouracil, antineoplastic agents.

* Objective: To determine the effectiveness of two adjuvant therapy regimens in improving surgical cure rates in stage III (Dukes stage C) colon cancer. * Design: Randomized, concurrently controlled clinical trial. * Setting: Major cancer centers, universities, and community clinics affiliated with the North Cancer Treatment Group, the Southwest Oncology Group, and the Eastern Cooperative Oncology Group. * Patients: Those who had had curative-intent resections of stage III colon cancer in the previous 1 to 5 weeks. * Intervention: Patients were assigned to observation only, to levamisole alone (50 mg orally three times/d for 3 days, repeated every 2 weeks for 1 year), or to this regimen of levamisole plus fluorouracil (450 mg/[m.sup.2] body surface area intravenously daily for 5 days and then, beginning at 28 days, weekly for 48 weeks). * Measurements: Rates of cancer recurrence and death. Early- and late-treatment side effects. * Results: With all 929 eligible patients able to be followed for 5 years or more (median follow-up, 6.5 years), fluorouracil plus levamisole reduced the recurrence rate by 40% (P < 0.0001) and the death rate by 33% (P = 0.0007). Levamisole reduced the recurrence rate by only 2% and the death rate by only 6%. With few exceptions, toxicity was mild and patient compliance was excellent. No evidence of late side effects was seen. * Conclusion: Fluorouracil plus levamisole is tolerable adjuvant therapy to surgery; it has been confirmed to substantially increase cure rates for patients with high-risk (stage III) colon cancer. It should be considered standard treatment for all such patients not entered into clinical trials., A combination of the drugs fluorouracil and levamisole may prevent recurrence of colon cancer that has been surgically removed. Recurrance rate improved by 40% and the death rate by 33% in a five-year follow up study of 929 patients who had undergone surgical removal of stage III (high risk) colon cancer and who had subsequently taken fluorouracil plus levamisole as chemotherapy. Side effects were reported to be manageable, and 70% of patients complied with the treatment regimen. This study is a follow up to a 1990 study which recommended fluorouracil plus levamisole following surgical removal of stage III colon cancer. The National Institutes of Health recommended this approach as standard therapy for patients with surgically treated stage III colon cancer after the 1990 study was published. The chemotherapeutic effect of fluorouracil may be enhanced by levamisole, which may explain why they work together well. Future research may show that fluorouracil plus leucovorin do equally well.

Background. The use of chemotherapy in patients with metastatic carcinoid tumors has been of limited value, and investigation of new agents is necessary. Previous reports have suggested that dimethyltriazenoimidazole carboxamide (DTIC) may have antitumor activity. Methods. A Phase II trial to investigate the clinical response rate to DTIC in patients with metastatic carcinoid tumors was performed. DTIC was administered at low (650 mg/[m.sup.2]) or high (850 Mg/[m.sup.2]) doses every 28 days. Results. Sixty-three patients were entered into the study, and 56 were evaluable for toxicity and response. Toxicity was moderate, with the most common side effect being nausea and vomiting (88%). Nine patients (16%; 95% confidence interval, 8-28%) had partial responses, 5 of 25 receiving 850 mg/[m.sup.2] and 4 of 31 receiving 650 Mg/[m.sup.2] of DTIC. Median survival time of all patients was 20 months. Conclusions. DTIC has minimal activity in patients with metastatic carcinoid tumors. Cancer 1994; 73: 1505-8.

Background. Pancreatic carcinoma responds poorly to conventional chemotherapy. To identify potentially useful agents, a sequence of clinical trials were done. Methods. A series of Phase II randomized trials were done by the Southwest Oncology Group in which patients with metastatic or advanced pancreatic cancer were randomized to receive single agents (methyl-glyoxal-bis-guanylhydrazone [MGBG], dihydroxyanthracenedione [DHAD], and aziridinylbenzoquinone [AZQ]) or a combined regimen of 5-fluorouracil, doxorubicin, mitomycin C, and streptozotocin (FAM-S). Toxicity, response, and survival were determined. Results. Seventy-one patients received FAM-S and 82, the Phase II single agents. Response rates (95% confidence intervals) for the various treatments were: FAM-S, 11% (0%, 21%); MGBG, 6% (0.8%,21%); DHAD, 0% (0%, 12%); and AZQ, 0% (0%, 16%). The median survival times were: FAM-S Group, 4.8 months and Phase II agent Group, 3.4 months. Conclusions. The FAM-S regimen and the Phase II agents tested did not have substantial antitumor activity in pancreatic cancer. The use of new agents as initial therapy is reasonable. Cancer 1993; 71:322-5.

Early detection remains a pipe dream when society's dollars dictate screening practice, but radical lymph node dissection and new chemotherapy combinations improve survival. EXPRESS STOP Suspecting stomach cancer: Although overall [...]

Etoposide has been repeatedly shown to be active against small cell lung cancer. Since etoposide and cisplatin combine for synergistic activity, this combination is often used in the treatment of small cell lung cancer, where overall response rates of 64 to 88 percent are observed among previously untreated patients and rates of 27 to 58 percent are observed among patients who have failed previous therapy. Research on animals has established that the effectiveness of etoposide is strongly dependent upon the level and schedule of dosage; many current regimens administer the drug over a three- to five-day period. A study was undertaken to determine the effectiveness of an oral regimen of etoposide in the treatment of small cell lung cancer. A total of 83 patients were stratified according to extent of disease, age, sex, and performance status; they were then randomly assigned to groups receiving either cisplatin plus oral etoposide or cisplatin plus intravenous etoposide. The overall response rate for the patients receiving the oral drug was 50 percent while the overall response rate for the intravenous group was 59 percent. This difference was not statistically significant, although it should be mentioned that with the small number of patients in this study, any difference less than 25 percent is unlikely to be truly meaningful. The median duration of the response was 6.1 months and 6.9 months for the oral and the intravenous groups, respectively. The toxic side effects of the chemotherapy were generally comparable between the two groups, although moderate to severe anemia was more common among the patients receiving intravenous treatment, and this group therefore required more transfused blood. The results of the study indicated that until the results of larger studies indicate otherwise, oral etoposide may be used as an effective substitute when intravenous etoposide may not be suitable. (Consumer Summary produced by Reliance Medical Information, Inc.)

The development of an effective health policy for men is being impeded by limited clinical perspectives as well as the prevailing cultural norms and habitual health service towards them. A social determinants of health approach would help Australia and Australian medical fraternity move away from policies and practices that perpetrate negative views of men and ignore the complexity of their health problems, which would result in improved health outcomes.

The 6th National Men's Health Conference, which was held in Melbourne in October 2005, incorporated the 4th National Aboriginal and Torres Strait Islander Male Health Convention. One of the main underlying themes of the conference was to question the assertion that poor health outcomes of men are due to the lack of their inclination to consult doctors at the proper time and to shift the focus to making health services more available to and appropriate for Australian men.

The 2005 flea control guidelines have been compiled by a group of specialists to assist veterinarians in making the difficult choices associated with effective flea control in dogs and cats. [...]

The telephone rang one evening. 'Robert, I haven't seen you since your hospital retiral do. You've had hiccups for 10 days--that must be really grim, My bright ideas? Well, have [...]

Action on clinical effectiveness is showing that success in implementing evidence based practice is achieved only when there are real local partnerships between clinicians and managers. The challenge is not [...]

What happenbs to the airways at night? Waking at night struggling for breath, wheezing, and coughing can be a terrifying experience. To have doctors write off these scaring episodes as [...]