Cancer symptom management in the elderly

Clear and concise written guidelines must designate accountability for coordination of the persons involved. As might be assumed by the preceding discussion, the process takes considerable time and effort. The development of clear guidelines is a long term venture and usually does not occur quickly. In some cases a nearby agency may have developed a useful protocol that when shared with area providers, is quickly accepted. However, one to two years is not uncommon to developing a complex plan of care or protocol which can be used effectively and is specific to the conditions in a particular setting. Written guides, when developed correctly, should save all providers' time, and ensure better client care. Clear directions regarding the care to be provided and well-established lines of communication can save health care providers time and increase the likelihood of better health outcomes for the client. The coordination of planning within the home care agency, and across professional, agency and geographic boundaries is a prerequisite for successful cancer symptom management. The central aim in planning is to enhance the family's ability to manage independently and to facilitate continuity of care in the use of health care services. For the client to have the greatest potential for symptom amelioration, the home care agency must assume a major role in the coordination of care providers in the delivery of care.     

Home intravenous therapy: Part II--Resource guide

Part II of the paper is a resource guide which lists resources that agencies may use to develop a home intravenous therapy program. In the first section, national organizations and journals and books concerned with intravenous therapy are listed as well as journal articles, guidelines and guidebooks and client and provider educational materials. National and regional product and service representatives of intravenous therapy related companies are also listed. In the second section, addresses for the State Boards of Nursing are given for Alaska, Idaho, Montana, Oregon and Washington. Each state section includes a list of those agencies who indicated in the 1988 survey that they would be willing to share materials. In addition, product and service vendors of intravenous therapy supplies and equipment are listed for the State of Washington.     

The medical "brain drain" and health priorities in Latin America.

This analysis of the medical brain drain places the problem in the context of the health care infrastructure in the developing world. It emphasizes Latin American social realities as a corrective to the self-interest which characterizes much of the current debate in the United States. It is argued that the same factors constituting emigration "push" factors in Latin America simultaneously underscore the relative unimportance of medical manpower migration compared to other obstacles to health progress. That conclusion is supported by a comparison of the relative damage caused by the brain drain by itself and the damage caused by factors which the brain drain concomitantly symbolizes and flows from: elitist objectives, misdirected priorities, unrealistic policies, and inadequate planning on the part of most Latin American nations. In the absence of urgently needed change in traditional structures, merely closing the gates on foreign medical graduates will not serve to ameliorate health conditions in the region. Those who seek real health improvements for developing nations must address greater challenges than the brain drain.     

Causes of albuminuria in patients with type 2 diabetes without diabetic retinopathy

BACKGROUND: The causes of albuminuria in patients with type 2 diabetes are heterogeneous and are scantily investigated, particularly if the patient has a lack of diabetic retinopathy. Therefore, we evaluated the structural background of albuminuria in a large consecutive group of Caucasian patients with type 2 diabetes without retinopathy. METHODS: Three hundred forty-seven consecutive patients with type 2 diabetes with persistent albuminuria (>300 mg/24 h) were recorded. Fundus photo (80%) and ophthalmoscopy were performed. Ninety-three (27%) had no retinopathy, and a kidney biopsy was performed in 52 (56%) of these patients. An insufficient tissue sample was obtained in one patient. The biopsies were evaluated by three masked nephropathologists. RESULTS: The biopsies revealed diabetic glomerulopathy in 69% of the patients (28 males and 7 females), while the remaining 31% (95% CI, 18 to 44) had either nondiabetic glomerulopathies such as glomerulonephritis (N = 7, 6 males and 1 female, 13%) or normal glomerular structure (N = 9, 7 males and 2 females, 18%). No significant differences in sex, age (56 +/- 8 vs. 53 +/- 10 years, mean SD), body mass index (30 +/- 4 vs. 31 +/- 8 kg/m2), known duration of diabetes (6 +/- 6 vs. 4 +/- 3 years), GFR (95 +/- 29 vs. 89 +/- 31 mL/min/1.73 m2), albuminuria (1304 +/- 169 to 4731 vs. 1050 +/- 181 to 5176 mg/24 hours), blood pressure (150/87 +/- 16/9 vs. 145/89 +/- 16/9 mm Hg), prevalence of hypertension (89 vs. 100%), hemoglobin A1c (8.2 +/- 1.6% vs. 9.0 +/- 2.5%), and serum total cholesterol (7.1 +/- 2.4 vs. 6.3 +/- 1.6 mmol/L) were found between patients with and without diabetic glomerulopathy. CONCLUSIONS: Albuminuric patients with type 2 diabetes without diabetic retinopathy have a prevalence of biopsies with normal glomerular structure or nondiabetic kidney diseases of approximately 30%. A separation between diabetic and nondiabetic glomerular lesions was not possible based on demographic, clinical, or laboratory data. Consequently, such patients may require further evaluation, including a kidney biopsy.     

Neural cell adhesion molecules, CaM kinase II and long-term memory in the chick

The intermediate and medial hyperstriatum ventrale (IMHV) of the chick brain is a site of recognition memory for filial imprinting. Previous results have demonstrated learning-related changes in the amounts of the three major isoforms of neural cell adhesion molecule (NCAM) in the left IMHV. The increases were present 24 h after training. The present study enquired whether the increases persisted and were present 48 h after training. The brain regions analysed were the left and right IMHV and the left and right hyperstriatum accessorium (HA), a visual projection area. The alpha-subunit of calcium/calmodulin protein kinase II (CaMKIIalpha) was also assayed. There were significant correlations between a measure of the strength of learning and the amount of NCAM 180 in the right IMHV (r = +0.65; p = 0.012) but not in the left, and in the left HA (r = -0.61; p = 0.02), but not in the right. There were no learning-related changes for CaMKIIalpha. We conclude that in IMHV the effects of imprinting on NCAM 180 are expressed mainly in the left IMHV 24 h after training, but 48 h after training are expressed mainly in the right IMHV.     

Continuous monitoring of regional cerebral blood flow: experimental and clinical validation of a novel thermal diffusion microprobe

OBJECT: Current clinical neuromonitoring techniques lack adequate surveillance of cerebral perfusion. In this article, a novel thermal diffusion (TD) microprobe is evaluated for the continuous and quantitative assessment of intraparenchymal regional cerebral blood flow (rCBF). METHODS: To characterize the temporal resolution of this new technique, rCBF measured using the TD microprobe (TD-rCBF) was compared with rCBF levels measured by laser Doppler (LD) flowmetry during standardized variations of CBF in a sheep model. For validation of absolute values, the microprobe was implanted subcortically (20 mm below the level of dura) into 16 brain-injured patients, and TD-rCBF was compared with simultaneous rCBF measurements obtained using stable xenon-enhanced computerized tomography scanning (sXe-rCBF). The two techniques were compared using linear regression analysis as well as the Bland and Altman method. Stable TD-rCBF measurements could be obtained throughout all 3- to 5-hour sheep experiments. During hypercapnia, TD-rCBF increased from 49.3+/-15.8 ml/100 g/min (mean +/- standard deviation) to 119.6+/-47.3 ml/100 g/ min, whereas hypocapnia produced a decline in TD-rCBF from 51.2+/-12.8 ml/100 g/min to 39.3+/-5.6 m/100 g/min. Variations in mean arterial blood pressure revealed an intact autoregulation with pressure limits of approximately 65 mm Hg and approximately 170 mm Hg. After cardiac arrest TD-rCBF declined rapidly to 0 ml/100 g/min. The dynamics of changes in TD-rCBF corresponded well to the dynamics of the LD readings. A comparison of TD-rCBF and sXe-rCBF revealed a good correlation (r = 0.89; p < 0.0001) and a mean difference of 1.1+/-5.2 ml/100 g/min between the two techniques. CONCLUSIONS: The novel TD microprobe provides a sensitive, continuous, and real-time assessment of intraparenchymal rCBF in absolute flow values that are in good agreement with sXe-rCBF measurements. This study provides the basis for the integration of TD-rCBF into multimodal monitoring of patients who are at risk for secondary brain injury.     

TP53 mutation and survival in aggressive B cell lymphoma

TP53 is mutated in 20–25% of aggressive B‐cell lymphoma (B‐NHL). To date, no studies have addressed the impact of TP53 mutations in prospective clinical trial cohorts. To evaluate the impact of TP53 mutation to current risk models in aggressive B‐NHL, we investigated TP53 gene mutations within the RICOVER‐60 trial. Of 1,222 elderly patients (aged 61–80 years) enrolled in the study and randomized to six or eight cycles of CHOP‐14 with or without Rituximab (NCT00052936), 265 patients were analyzed for TP53 mutations. TP53 mutations were demonstrated in 63 of 265 patients (23.8%). TP53 mutation was associated with higher LDH (65% vs. 37%; p < 0.001), higher international prognostic index‐Scores (IPI 4/5 27% vs. 12%; p = 0.025) and B‐symptoms (41% vs. 24%; p = 0.011). Patients with TP53 mutation were less likely to obtain a complete remission CR/CRu (CR unconfirmed) 61.9% (mut) vs. 79.7% (wt) (p = 0.007). TP53 mutations were associated with decreased event‐free (EFS), progression‐free (PFS) and overall survival (OS) (median observation time of 40.2 months): the 3 year EFS, PFS and OS were 42% (vs. 60%; p = 0.012), 42% (vs. 67.5%; p < 0.001) and 50% (vs. 76%; p < 0.001) for the TP53 mutation group. In a Cox proportional hazard analysis adjusting for IPI‐factors and treatment arms, TP53 mutation was shown to be an independent predictor of EFS (HR 1.5), PFS (HR 2.0) and OS (HR 2.3; p < 0.001). TP53 mutations are independent predictors of survival in untreated patients with aggressive CD20+ lymphoma. TP53 mutations should be considered for risk models in DLBCL and strategies to improve outcome for patients with mutant TP53 must be developed.