Managing what you measure: Creating outcome-driven systems of care for youth with serious emotional disturbances

This article presents the California System of Care Model for youth with severe emotional disturbances as an illustration of how ongoing assessment of the costs and outcomes of service delivery can be an integral part of a service delivery model. The core of this model, developed initially in Ventura County, California, is a five-step planning process that guides care system development and implementation. The implications of each stage of the planning process for evaluation and feedback at the child, family, and system levels are highlighted. A set of principles for selecting outcome measures deriving from the planning process are also presented that, in conjunction with the planning model, serve as guidelines for establishing outcome measures within care systems. The resulting specific plan for measuring system- and client-level outcomes deriving from this process, along with challenges to the implementation of the outcome management plan, is described.     

Acupuncture prophylaxis of cancer chemotherapy-induced sickness.

In a multi-facet study we evaluated the efficacy of P6 electroacupuncture (10 Hz applied for 5 min) as an antiemetic in patients receiving a variety of cancer chemotherapy drugs. The study involved 130 (15 in an open pilot study, 10 in a randomized placebo controlled crossover study and 105 in a definitive study) patients who had a history of distressing sickness after previous treatment, and who, on the basis of a previous survey, would be expected to have a 96% chance of this with subsequent therapy. Sickness was either completely absent or reduced considerably in 97% of patients and no side effects were encountered. The limited crossover study, using a 'dummy' acupuncture (ACP) point showed that the beneficial effects were limited to the P6 point. Logistic and ethical considerations excluded the possibility of carrying out a larger placebo-controlled study. While in our hands P6 ACP was an effective antiemetic in patients having cancer chemotherapy, because of the time involved and the brevity of the action (8 h) an alternative approach to electro-ACP is required before this technique is adopted clinically.     

Patterns and predictors of early recurrence in postmenopausal women with estrogen receptor-positive early breast cancer

Previous studies suggest that disease recurrence peaks at around 2 years in patients with early stage breast cancer (EBC), but provide no data regarding recurrence type. This retrospective analysis aimed to identify early recurrence types and risk factors in estrogen receptor-positive (ER+) EBC patients treated with adjuvant tamoxifen following breast cancer surgery. Postmenopausal women diagnosed with ER+ EBC from 1995 to 2004 were evaluated. Annual hazard ratios (HR) for recurrence at different sites were calculated. Time-dependent Cox regression analysis was used to identify predictors of recurrence within 2.5 years of diagnosis, including factors that were more strongly predictive of early than later recurrence. Of 3,614 patients evaluated, 476 developed recurrence during the 5-year median follow-up. Cumulative recurrence rates at 2.5 years (95% confidence interval) were: overall 6.3% (5.5–7.1), locoregional 1.1% (0.7–1.5), contralateral 0.5% (0.3–0.7), and distant 4.8% (4.0–5.6). The annual HR of overall recurrence peaked at 2 years (4.3% per annum). The majority of this peak represented distant recurrence (3.4% per annum). In Cox regression analysis, tumor size and grade, lymph node involvement, lymphovascular invasion, and symptomatic presentation were significant independent predictors of early recurrence. Age at diagnosis was independently predictive of recurrence within 2.5 years of diagnosis but not later recurrence. This study identified an early recurrence peak at 2 years, most of which were distant recurrences. Implementing an aromatase inhibitor after an initial 2–3 years of tamoxifen fails to address this early peak of distant recurrence and the potential breast cancer-associated mortality.     

Bronchial artery embolization: monitoring with somatosensory evoked potentials. Work in progress

Surgery remains the treatment of choice for massive and recurrent hemoptysis. In some instances, however, immediate surgical intervention is contraindicated. In these situations, bronchial artery embolization (BAE) has proved to be a successful definitive treatment for non-surgical candidates and a palliative therapy in patients requiring hemodynamic stabilization prior to surgery. The most serious complication of BAE is spinal cord ischemia. This relates directly to the potential anastomotic connections between the bronchial circulation and the anterior spinal artery. Somatosensory evoked potentials (SSEPs) have been used in the past to monitor spinal cord ischemia during procedures that threaten the vascularity of the spinal cord. The authors report two cases in which SSEPs were employed to monitor spinal cord ischemia during bronchial artery embolization.     

Breast-conserving surgery and radiotherapy in early-stage breast cancer: the importance of local control

Breast-conserving therapy is a successful, well-studied, and scientifically validated treatment of early-stage breast carcinoma. This approach has enormously improved the quality of life and cosmetic outcome for appropriately selected and treated patients while achieving the same long-term survival rates as mastectomy. This article reviews the evidence showing the importance of achieving initial local control to maximize breast cancer-specific survival rates, the impact of systemic therapy on the local control rates achieved with breast-conserving therapy, the integration of chemotherapy with radiation therapy, and the role of breast magnetic resonance imaging in breast-conserving therapy.