Analysis of a prospectively randomized comparison of doxorubicin versus 5-fluorouracil, doxorubicin, and BCNU in advanced gastric cancer: implications for future studies

A multi-institutional cooperative study of patients with locally advanced, recurrent, or metastatic gastric adenocarcinoma who had not previously received chemotherapy was conducted, prospectively randomizing patients to receive either doxorubicin or the three-drug combination, 5-fluorouracil (5-FU), doxorubicin (Adriamycin; Adria Laboratories, Columbus, Ohio), and BCNU (FAB). The 187 evaluable patients were initially stratified according to the presence of measurable or evaluable disease and performance status. There was a significantly higher response rate observed for FAB (40%) compared with doxorubicin (13%) among the 145 measurable-disease patients. Duration of response and survival were significantly longer for FAB in the measurable-disease group, but for the total patient population an early advantage for FAB in time to disease progression and survival was lost with continued follow-up. Median survival was 33 weeks for patients receiving FAB and 19 weeks for those receiving doxorubicin. Significant pretreatment factors adversely affecting survival included poor performance status, weight loss of greater than 10%, and more than two sites of metastases. Toxicity was not severe in either treatment arm, and only thrombocytopenia occurred significantly more often with FAB. It is contended that in the treatment of advanced gastric cancer, chemotherapy only exerts a relatively short-term and modest beneficial effect, most apparent in patients with intermediate tumor bulk. 5-FU remains the most active single agent, and combination chemotherapy has not yet proven its overall worth. Further studies are indicated comparing the most active combinations with 5-FU using optimal doses and schedules, and consideration must be given to the incorporation of no-treatment controls.     

Meeting patients' information needs beyond the year 2000

Advances in information technology, and changing patient expectation in regard to provision of information and participation in clinical decisions are already influencing the cancer consultation. In future, the oncologist's role will evolve further, and the cancer consultation beyond the year 2000 will be an opportunity for information relating to the particular patient's circumstances to be presented according to the patient's wishes. Patients' desired input into clinical decisions will be respected, and consultation audiotapes will be a widely used aid for patients after the consultation.Presented as an invited lecture at the 8th International Symposium: Supportive Care in Cancer, Toronto, Canada, 19–22 June 1996     

Osteoarthritis and the inflammatory arthritides

This article aims to provide surgeons with a practical, clinical overview of different forms of ‘arthritis’ – a term encompassing most of the joint pathology causing joint symptoms or dysfunction. Conventionally, arthritis can be non-inflammatory (osteoarthritis) or inflammatory (crystal and autoimmune arthropathies). Septic arthritis is an important differential diagnosis when patients present with tender, swollen joints, but is not covered here. Common symptoms and signs in patients with different types of arthritis are reviewed, as well as aetiology and pathogenesis. Non-surgical treatment is described, with particular reference to the inflammatory arthropathies since the new, effective biologic treatments are particularly important where surgery is planned or patients present with suspected sepsis. Diagnosis of inflammatory arthritis (particularly in children) may be delayed and in an era of effective treatment it is important that all clinicians involved in musculoskeletal medicine and surgery are aware of potential differential diagnoses for joint pain and deformity. Good communication between rheumatologists and surgeons in managing different forms of arthritis is especially important.     

Starting insulin treatment as an outpatient. Report of 100 consecutive patients followed up for at least one year

Most textbooks advise that newly diagnosed insulin-dependent diabetics be admitted to the hospital. Nevertheless, if they are not acutely ill, we start insulin treatment on an outpatient basis. We report herein the logistics, efficacy, and safety of our system. Over two years, 115 newly diagnosed insulin-dependent diabetics were seen in our hospital. Fifteen (66% of them ketoacidotic) were admitted. The other 100 were treated as outpatients by a nurse specialist with a starting dosage of 6 to 10 units of intermediate-acting insulin twice daily. Hemoglobin A1 concentration at diagnosis was 15.2% +/- 2.7% (mean +/- SD); at six months, 10.9% +/- 2.9%; and at one year, 10.6% +/- 2.8%. Only three outpatient starters were hospitalized in the first year, one for hypoglycemia and two with respiratory tract infections. Our findings suggest that outpatient stabilization is both safe and cost-effective.     

Does Knowledge of Islet Cell Antibody Status Help in Managing Diabetes Presenting in Middle and Old Age?

It has been suggested that screening all patients with diabetes diagnosed in later life for islet cell antibodies (ICA) would help predict insulin dependence. We have surveyed the case notes of 55 patients (22 male; ages 37-88 years) who were found to be ICA positive over a 9-year screening period to assess what contribution knowledge of ICA status made to their management. Forty-two patients had been put on insulin (half within 6 months of diagnosis and the rest after up to 6 years). Of the 13 patients not on insulin, six were on diet alone and seven on oral hypoglycaemic agents after a median follow-up of 3 years. In 37 of the 42 patients, insulin treatment was started for clinical rather than immunological reasons (diabetic ketoacidosis, ketonuria, weight loss and/or severe symptoms). Five patients were started on insulin because of ICA status when there was no compelling reason on clinical grounds. Knowledge that seven non-insulin-treated patients were ICA positive made doctors reluctant to discharge them from clinic. The data suggest that routine ICA estimation in this age group is unnecessary, as the decision to treat with insulin is best made on clinical grounds, and ICA estimation can lead to unwarranted insulin treatment, or anxiety in patients and doctors who are aware of a positive result.     

Heparin-Free Dialysis with an On-Line Hemodiafiltration System

Abstract: In heparin-free hemodialysis, the extracorporeal circuit is frequently flushed with normal saline. We report about an on-line hemodiafiltration (HDF) machine for performing heparin-free dialysis. The circuit is periodically flushed with fluid produced by filtration of the dialysis fluid. Because the fluid is derived from the volumetric dialysate circuit, it causes an equivalent ultrafiltration from the patient, and there is no need to allow for it in the fluid balance calculation. The use of the on-line HDF system in heparin-free dialysis is simple and cheaper than the saline-flush method. Automation of this system is possible and would result in even easier operation.     

Asking questions can help: development of a question prompt list for cancer patients seeing a surgeon.

A question prompt list (QPL) is a structured list of questions designed to encourage patients to acquire information during a medical consultation. It has been shown to be an effective, inexpensive means of helping cancer patients ask questions in certain content areas when consulting an oncologist. The objective of this study was to develop a QPL for cancer patients seeing a surgeon initially, targeting issues identified by patients as important. Focus groups and structured interviews were convened with 22 cancer patients. One focus group was conducted with allied health professionals. Focus groups were audiotaped, transcribed and content analysed to ensure all issues were identified. The results led to the identification of 59 questions covering five themes. We have grouped the questions under the following themes: preliminary negotiation and discussion of diagnosis and its implications; further investigations--why and how; am I seeing the right doctor--who else should I see?; treatment information and options; and support. Participants believed that the QPL would be useful not only during diagnosis and discussions regarding the surgical care but also subsequently. Patients felt that provision and endorsement of a QPL would assist them to achieve their information needs and participation preferences.     

Self-help and benzodiazepine withdrawal.

Despite an increased understanding of the potential dangers of benzodiazepines among doctors and patients, and a decline in anxiolytic prescribing, motivating and supporting current benzodiazepine users through withdrawal can be difficult and time consuming for medical services. Self-help organisations offer another approach. This is a study of one such organisation, TRANX (UK), which examined the characteristics of its members and their outcome. The results suggest that this organisation did provide effective counselling and support for its members, and implies that self-help is a realistic alternative or adjunct to orthodox health care for those wishing to withdraw from benzodiazepines.