Feasibility and Preliminary Effectiveness of Varenicline for Treating Co-Occurring Cannabis and Tobacco Use

Few studies have evaluated treatment for co-occurring cannabis and tobacco use. The objective of this pilot study was to evaluate the feasibility and preliminary effectiveness of varenicline for co-occurring cannabis and tobacco use. Participants who reported cannabis use on ≥5 days per week were recruited from an urban, outpatient opioid treatment program (OTP). Participants were randomized to either four weeks of standard OTP clinical care (SCC; medication-assisted treatment for opioid use disorder and individual behavioral counseling), followed by four weeks of SCC plus varenicline (SCC+VT), or to four weeks of SCC+VT followed by four weeks of SCC. All participants contributed feasibility and outcome data during both study phases. Of 193 persons screened, seven were enrolled. Retention at eight weeks was 100%. No adverse effects prompted varenicline discontinuation. Participants reported lower cannabis craving during the SCC+VT phase compared to baseline, and lower frequencies and quantities of cannabis use compared to both baseline and the SCC alone phase. In the SCC+VT phase, participants also reported fewer cigarettes per day. Among persons with co-occurring cannabis and tobacco use, varenicline is well-tolerated and may reduce cannabis craving, cannabis use, and tobacco use.     

The Evaluation of Esophageal Adenocarcinoma Using Dynamic Contrast-Enhanced Magnetic Resonance Imaging

Although neoadjuvant chemoradiation eradicates esophageal adenocarcinoma in a substantial proportion of patients, conventional imaging techniques cannot accurately detect this response. Dynamic contrast-enhanced magnetic resonance imaging is an emerging approach that may be well suited to fill this role. This pilot study evaluates the ability of this method to discriminate adenocarcinoma from normal esophageal tissue. Patients with esophageal adenocarcinoma and control subjects underwent scanning. Patients treated with neoadjuvant therapy underwent pre- and postchemoradiation scans. Parameters were extracted for each pixel were K ^trans (equilibrium rate for transfer of contrast reagent across the vascular wall), v _e (volume fraction of interstitial space), and τ _i (mean intracellular water lifetime). Five esophageal adenocarcinoma patients and two tumor-free control subjects underwent scanning. The mean K ^trans value was 5.7 times greater in esophageal adenocarcinoma, and τ _i is 2.0 times smaller, than in the control subjects. K ^trans decreased by 11.4-fold after chemoradiation. Parametric maps qualitatively demonstrate a difference in K ^trans. DCE MRI of the esophagus is feasible. K ^trans, a parameter that has demonstrated discriminative ability in other malignancies, also shows promise in differentiating esophageal adenocarcinoma from benign tissue. The determination of K ^trans represents an in vivo assay for endothelial permeability and thus may serve as a quantitative measure of response to induction chemoradiation. Presented at the 20th World Congress of the International Society for Digestive Surgery November, 2006, Rome, Italy.     

Controversies in the management of stage III non-small-cell lung cancer

Lung cancer remains the leading cause of death in the USA and is the most common cancer both in incidence and in mortality globally (1.35 million deaths annually). Non-small-cell lung cancer accounts for >80% of all lung cancers . About 35–45% of non-small-cell lung cancer patients present with locally advanced non-metastatic stage III disease. However, confirmed stage III disease represents a very heterogeneous group ranging from borderline surgical candidate with minimal mediastinal involvement to bulky mediastinal nodes or contralateral nodal involvement with significant controversy regarding optimal management in these various situations. This article specifically addresses the role of surgery, radiotherapy and chemotherapy in multimodal approach to treat stage III patients with N2/N3 involvement and controversies surrounding these recommendations.     

A study of concurrent radiochemotherapy with paclitaxel in glioblastoma multiforme

Despite advances in neurosurgery and radiotherapy, the prognosis of patients with glioblastoma multiforme remains poor. Reports in the literature about the radiosensitizing properties of paclitaxel stimulated the authors to conduct a study using paclitaxel concurrently with radiation in a group of 18 patients who had residual disease postoperatively. Paclitaxel was delivered weekly as an intravenous infusion in a dose of 60 mg/m ² along with radiation to the primary lesion. A total of 108 cycles of paclitaxel was given. All the patients tolerated the treatment well. The main side effects were haematological, and neuropathy which was self-limiting. The overall 1-year survival rate was 70%, with 12 patients alive at 13 months. The median survival has not yet been reached although it is more than 13 months. Thus, paclitaxel can be safely delivered concomitantly with radiation in patients with glioblastoma multiforme. Larger, randomized trials are required to establish the comparative efficacy of paclitaxel as a radiosensitizer in glioblastoma multiforme.     

OESOPHAGECTOMY

The mortality and morbidity of oesophagectomy are examined in this retrospective review of 128 patients with benign and malignant oesophageal disease. There were 11 deaths in hospital. The operative mortality was not influenced by age, sex, or the approach to oesophagectomy, but was significantly greater in patients given chemoradiation therapy before surgery. Complications were frequent in the early postoperative period and some were due to avoidable errors in technique or selection of operative approach. Follow-up was complete in over 90% of survivors. Late complications included aspiration pneumonia secondary to gastric stasis following total oesophagectomy and anastomotic recurrence after the one-stage procedure of gastro-oesophagectomy. When the whole stomach is used to replace the oesophagus a pyloroplasty is advised. The one-stage operation is not recommended for squamous cancer of the distal oesophagus and adenocarcinoma of the cardia.     

Influence of co‐occurring mental and substance use disorders on the prevalence of problem gambling in Canada

Context/background Research has shown that problem gambling (PG) is associated with substance use disorders (SUD) and also with other mental disorders (MD). Nevertheless, evidence about the relative contribution of each type of disorder for the risk of gambling in the population is very limited. Objective Study the association of SUD, alone and in combination with MD, with the prevalence and severity of PG. Design Cross‐sectional national survey (Canadian Community Health Survey—Mental Health and Well‐Being) data collected through a multi‐stage stratified cluster design. Setting Population‐based household survey. Participants This analysis includes data on 36 885 participants (99.7% of the survey sample). Main outcome measures The prevalence and severity of PG were measured using the Canadian Problem Gambling Index. Prevalence of MD (mood and anxiety disorders) and SUD were defined according to the World Mental Health Survey Initiative Composite International Diagnostic Interview, following definitions of the DSM‐IV. Results Compared to the population, higher prevalence rates of PG are observed when the severity of SUD is higher, but are not impacted by the co‐occurrence of MD. For individuals with low risk and moderate risk/problem gambling, the prevalence rate difference (prevalence rate in the subgroup minus prevalence rate in the population) observed among substance dependents was reduced when MD co‐occurred (from a prevalence rate difference of 2.5; 99% confidence interval 1.6–3.8 to 1.6; 99% confidence interval 1.2–2.2 for low risk gamblers and from 3.7; 99% confidence interval 1.6–5.5 to 2.9; 99% confidence interval 2.0–4.3 for moderate risk/problem gamblers). Estimates were not statistically different. Conclusions Prevalence of all levels of PG increased with SUD severity, but the pattern did not appear to be affected by MD co‐occurrence. Results suggest particular attention be given to SUD in treatment‐seeking clients with co‐occurring disorders.     

Short-and Long-term Efficacy of Electroconvulsive Therapy for Late-life Depression: A Pilot Study

Background : Electroconvulsive therapy (ECT) is often administered among the elderly, who are particularly likely to have concurrent medical conditions and medication intolerance. Objective : To examine the short‐and long‐term efficacy of ECT for late‐life depression, we performed a two‐phase, prospective, naturalistic follow‐up study that compared treatment outcome in old‐aged with that in middle‐aged subjects. Methods : Phase I study: Twenty‐one subjects who were consecutively referred for ECT, aged at least 50 years, and met the DSM‐IV criteria for a major depressive episode were enrolled. Before ECT, severity of concurrent medical conditions was assessed with the cumulative illness rating scale (CIRS). Before and after a course of ECT, the severity of depressive symptoms was evaluated with the 17‐item Hamilton rating scale for depression (HAM‐D). Phase II study: Seventeen subjects who responded to an acute ECT course in the phase I study were enrolled. Various continuation medications were administered, and symptoms were monitored and evaluated with the HAM‐D for 24 weeks or until relapse. Results : Overall the subjects had an 81 % short‐term response rate and a 47% relapse rate within 24 weeks after ECT. Response and relapse rates were not significantly different between the middle‐and old‐aged groups (response rates: 91% vs. 70%; relapse rates: 40% vs. 57%). However, the old‐aged patients had higher post‐ECT HAM‐D scores than the middle‐aged patients did (P<0.05), and CIRS scores positively correlated with post‐ECT HAM‐D scores (P<0.05). Relapsers tended to have higher CIRS scores than non‐relapsers did (P=0.06). Conclusion : In late‐life depression, the short‐term response rate to ECT is considerably good, but the relapse rate was relatively high. Clinicians need to take into consideration the age of patient and any concurrent medical conditions, when planning long‐term management of residual depressive symptoms and prevention of relapse after an initial good response to ECT.     

Significance of Concurrent Chemoradiotherapy as Primary Treatment in Patients with Metastatic Cervical Cancer

(1) This study investigated the prognostic impact of tumor size in patients with metastatic cervical cancer. (2) Methods: Seventy-three cervical cancer patients in our institute were stratified into two groups based on distant metastasis: para-aortic lymph node metastasis alone (IIIC2) or spread to distant visceral organs with or without para-aortic lymph node metastasis (IVB) to identify primary tumor size and concurrent chemoradiotherapy. (3) Results: The overall survival (OS) for patients with a tumor >6.9 cm in size was significantly poorer than that for patients with a tumor ≤6.9 cm in the IVB group (p = 0.0028); the corresponding five-year OS rates in patients with a tumor ≤6.9 and >6.9 cm were 53.3% and 13.4%, respectively. In the multivariate analysis, tumor size and primary treatment were significantly associated with survival in metastatic cervical cancer. (4) Conclusions: Tumor size ≤6.9 cm and concurrent chemoradiotherapy as the primary treatment were favorable prognostic factors for patients with metastatic cervical cancer.     

Accelerated Radiation Therapy Using Weekend Boost with Concurrent Cisplatin in Head and Neck Squamous Cell Cancers: An Indian Institutional Experience

PurposeThe purpose of the study was to evaluate the feasibility and efficacy of an accelerated radiotherapy schedule using weekend boost in terms of tumor response, compliance, and acute toxicities for head and neck squamous cell carcinoma, and to report long-term clinical outcomes.Materials and MethodsTwenty-six patients with stages III-IV head and neck squamous cell carcinoma receiving radical chemoradiotherapy were accrued prospectively into the study. External beam radiation therapy to a total dose of 66–70 Gy in 33–35 fractions, 1.8–2.0 Gy per fraction along with concurrent weekly cisplatin was planned. Radiation regimen included delivery of six fractions per week, with boost field delivered as the sixth fraction on the weekend. The compliance, tumor response, and toxicities were recorded. Survival curves were estimated using the Kaplan–Meier method.ResultsTwenty-one of 26 patients (81%) completed treatment as planned and five patients died during the course of treatment. Sixteen patients (62%) completed treatment in less than 44 days and, at the end of 3 months’ follow-up, 18 patients (69%) showed complete response and two patients (8%) showed partial response. The 2- and 5-year actuarial disease-free survival were 90% and 65%, respectively, and 2- and 5-year actuarial overall survival were 60% and 38%, respectively.ConclusionAccelerated fractionation using weekend boost, along with concurrent weekly concurrent cisplatin, is an effective and promising approach with favorable impact on initial tumor response, comparable results, and acceptable toxicities.