Management of molecular-targeted therapy for chronic myelogenous leukemia

PURPOSE: To provide primary care providers with guidelines on the evaluation and management of treatment for patients with chronic myelogenous leukemia (CML) with emphasis on the molecular-targeted therapy imatinib mesylate. DATA SOURCES: Research-based articles in the medical literature, review articles, and clinical practice guidelines. CONCLUSIONS: CML is a clonal stem cell disorder causing 5,000 new cases annually. Research on molecular-targeted therapy confirms that specific protein kinases have broad consequences for the development of future drugs to treat CML. The most recent discovery is a new compound, imatinib mesylate, which has become commercially available. Currently, the standard of care for CML is this agent. This therapy has changed management strategies for treatment of patients with the diagnosis of CML. IMPLICATIONS FOR PRACTICE: Long-term observations and evaluations are needed for final determination of treatment effectiveness; thus, primary care providers will follow patients with CML in the community. Unforeseen toxicity may surface, requiring accurate assessment and evaluation. Primary care providers will be actively involved with providing symptom management for these patients.     

Presumed prevalence analysis on suspected and highly suspected breast cancer lesions in S?o Paulo using BIRADS criteria.

CONTEXT AND OBJECTIVE: Breast cancer screening programs are critical for early detection of breast cancer. Early detection is essential for diagnosing, treating and possibly curing breast cancer. Since there are no data on the incidence of breast cancer, nationally or regionally in Brazil, our aim was to assess women by means of mammography, to determine the prevalence of this disease. DESIGN AND SETTING: The study protocol was designed in collaboration between the Department of Diagnostic Imaging (DDI), Institute of Diagnostic Imaging (IDI) and S?o Paulo Municipal Health Program. METHODS: A total of 139,945 Brazilian women were assessed by means of mammography between April 2002 and September 2004. Using the American College of Radiology (ACR) criteria (Breast Imaging Reporting and Data System, BIRADS), the prevalence of suspected and highly suspected breast lesions were determined. RESULTS: The prevalence of suspected (BIRADS 4) and highly suspected (BIRADS 5) lesions increased with age, especially after the fourth decade. Accordingly, BIRADS 4 and BIRADS 5 lesions were more prevalent in the fourth, fifth, sixth and seventh decades. CONCLUSION: The presumed prevalence of suspected and highly suspected breast cancer lesions in the population of S?o Paulo was 0.6% and it is similar to the prevalence of breast cancer observed in other populations.     

Evaluating medication-related services in a hospital setting using the disconfirmation of expectations model of satisfaction

BACKGROUND: Patient satisfaction is considered an important outcome measure of services and associated with behavioral intentions. The appraisal process commonly used in satisfaction models is the disconfirmation of expectations. A patient compares his or her experience to preexisting expectations. The resulting satisfaction from this comparison is dependent on whether the patient's expectations are superior, inferior, or just as expected. OBJECTIVES: The aims of this study were to (1) determine the relationship between disconfirmation of expectations with medication-related services and patient satisfaction with medical care; and (2) determine if patient satisfaction is related to the likelihood to say good things about the medical care provided at the hospital to family and friends. METHODS: A cross-sectional, nonexperimental study design was implemented to test the disconfirmation of expectations model. Patients on warfarin therapy and recently discharged from an acute care hospital to their homes were surveyed by mail. The survey asked about how well the hospital services related to medication therapy met patient expectations. Satisfaction with medical care and the likelihood of positive word of mouth regarding the medical care were also measured. Structural equation modeling (SEM) was used to test the model. RESULTS: The survey response rate was 34% (n=187). Factor analysis of the 7 disconfirmation of expectation items resulted in a 2-factor solution: (1) medication counseling and (2) discharge medication services. The SEM demonstrated that the model was significant; however, the disconfirmation of expectation items did not significantly relate to the 1-item satisfaction measure. Patient satisfaction and the behavioral intentions measures were significantly related. A post hoc analysis using SEM demonstrated that the disconfirmation of expectations factors did significantly relate to a higher-order latent construct. This construct also related to patient satisfaction. CONCLUSION: The disconfirmation of expectations has a role in a postservice experience response expressed by the patient, but not as a direct antecedent to patient satisfaction. Opportunities to improve the model are the use of a multi-item satisfaction measure and the inclusion of patient affect.     

Vasculitis and Leukemia

Vasculitis may accompany neoplasias and be of paraneoplastic type or associated with drugs used in patient treatment. We evaluated skin biopsies of twenty-eight cases with vasculitis accompanying leukemias reviewed and clinical outcome was evaluated. Eleven of the 28 cases had paraneoplastic vasculitis and 17 had vasculitis associated with various drugs including chemotherapy, cytokines and antibacterial agents. Paraneoplastic vasculitis was seen in 3 cases with chronic myelocytic leukemia in blastic phase, 5 patients with acute myeloblasts leukemia, and 3 with myelodysplastic syndrome. Drugs responsible for the 17 cases of vasculitis included hydroxyurea, vincristine, cytosine-arabinoside, methotrexate, all-trans retinoic acid, granulocyte-colony stimulating factor, interferon and antibiotics.

Paraneoplastic vasculitis is not rare in leukemias and may be a manifestation of the blastic phase of chronic myeloid leukemia. Furthermore paraneoplastic vasculitis can be fatal in myelodysplastic syndromes and may be present clinically before the specific diagnosis is made. Drugs used in routine therapy may be the cause of the vasculitis, thus skin biopsy should be performed in all cutaneous lesions in patients with hemopoietic neoplasias.     

The effect of salts on the micellization temperature of aqueous poly(ethylene oxide)-b-poly(propylene oxide)-b-poly(ethylene oxide) solutions and the dissolution rate and water diffusion coefficient in their corresponding gels.

Studies were performed to examine the effect of ionic salts on phase transitions, dissolution rates, and diffusion coefficients of water in gels of poly(ethylene oxide)-b-poly(propylene oxide)-b-poly(ethylene oxide) with polymer concentrations ranging from 22 to 32% w/w and salt concentrations ranging from 0 to 1.5% w/w. Salts tested include Na(3)PO(4), Na(2)SO(4), Na(2)HPO(4), NaH(2)PO(4), NaCH(3)CO(2), NaCl, and KI. Micellization transition temperatures were obtained using differential scanning calorimetry. The dissolution rates were obtained by measurement of the surface erosion rates, and diffusion coefficients were obtained by using a method to analyze the intrusion of water into the aqueous gels. It was found that salts had no effect on the dissolution rate of the polymer gels into deionized water. However, when the salt concentration in the aqueous dissolution media was adjusted to match the concentration in the gels, the dissolution rate of the polymer gel decreased with increasing salt concentration. The salts also had a profound effect on the critical micellization temperature (CMT) and the diffusion coefficient of water within the gel. The diffusion coefficient and CMT decreased in the presence of salts. The magnitude of these effects was comparable to their placement on the Hofmeister, or lyotropic series for salts. The effects of polymer and salt concentrations on the CMT were quantified, and a single correlation was proposed to predict the micellization temperatures for a wide range of salt and polymer concentrations.     

In vivo antiplaque activity of a sanguinarine-containing dentifrice: Comparison with conventional toothpastes

This study was undertaken to investigate the effect of a sanguinarine-containing dentifrice on supragingival and subgingival plaque in response to suggestions that sanguinarine extract has antiplaque activity. Volunteer dental students were randomly assigned to a control or an experimental group. During an initial examination, plaque scores and samples of subgingival plaque were obtained. The students were given oral hygiene instructions and were told to floss once and brush twice daily, using either the experimental (sanguinarine-containing) or control (any other) dentifrice for a period of 1 month, following which they were once more examined. Plaque scores and samples of subgingival plaque were again obtained. Examination of subgingival plaque was performed using a phase-contrast microscope to determine the distribution of bacterial morphotypes. Comparison of the data from the initial examination with that at the completion of the study showed a significant reduction of supragingival plaque within each group. However, there was no significant difference in the amount of supragingival plaque between groups. There were no significant between-group differences for any bacterial morpho-type. It was concluded that sanguinarine extract had no detectable antiplaque activity when used in a dentifrice.     

Road traffic accidents and the elderly

Aim:   To identify and evaluate the causes and characteristics of road traffic accidents (RTA) and to analyze injury patterns in elderly road traffic victims in order to apply appropriate measures for the prevention of RTA in the elderly.
Methods:   Two hundred and fifty-eight elderly road traffic victims admitted to the Emergency and Traumatology Departments of our institution were enrolled. Complete data about the circumstances surrounding the accident, mechanism of injury, specific injury, comorbid conditions and drug history were recorded. All subjects underwent a physical and mental function examination.
Results:   The majority of road traffic victims were pedestrians. Most elderly pedestrian accidents were due to falls. Accidents by elderly car drivers occurred frequently at intersections. Craniocerebral and extremity injuries formed the majority of the injuries in pedestrian and cyclist victims whereas chest injuries were commoner in car accident victims. Medical problems and medication usage was common among RTA victims.
Conclusion:   The fragility of elderly car occupants and pedestrians should be taken into consideration and strategies aimed at the road-user safety including periodic medical screening, improvement of road structure and facilities, and the improved design of motor vehicles should be implemented.     

Differences in Characteristics and Outcome of Patients with Penetrating Injuries in the USA and the Netherlands: A Multi-institutional Comparison

Introduction

The incidence and nature of penetrating injuries differ between countries. The aim of this study was to analyze characteristics and clinical outcomes of patients with penetrating injuries treated at urban Level-1 trauma centers in the USA (USTC) and the Netherlands (NLTC).

Methods

In this retrospective cohort study, 1331 adult patients (470 from five NLTC and 861 from three USTC) with truncal penetrating injuries admitted between July 2011 and December 2014 were included. In-hospital mortality was the primary outcome. Outcome comparisons were adjusted for differences in population characteristics in multivariable analyses.

Results

In USTC, gunshot wound injuries (36.1 vs. 17.4%, p?<?0.001) and assaults were more frequent (91.2 vs. 77.7%, p?<?0.001). ISS was higher in USTC, but the Revised Trauma Score (RTS) was comparable. In-hospital mortality was similar (5.0 vs. 3.6% in NLTC, p?=?0.25). The adjusted odds ratio for mortality in USTC compared to NLTC was 0.95 (95% confidence interval 0.35–2.54). Hospital stay length of stay was shorter in USTC (difference 0.17 days, 95% CI ?0.29 to ?0.05, p?=?0.005), ICU admission rate was comparable (OR 0.96, 95% CI 0.71–1.31, p?=?0.80), and ICU length of stay was longer in USTC (difference of 0.39 days, 95% CI 0.18–0.60, p?<?0.0001). More USTC patients were discharged to home (86.9 vs. 80.6%, p?<?0.001). Readmission rates were similar (5.6 vs. 3.8%, p?=?0.17).

Conclusion

Despite the higher incidence of penetrating trauma, particularly firearm-related injuries, and higher hospital volumes in the USTC compared to the NLTC, the in-hospital mortality was similar. In this study, outcome of care was not significantly influenced by differences in incidence of firearm-related injuries.