Outcome and quality of life in medicine: a conceptual framework to put quality of life research into practice

It is rather counterproductive to get caught up in never ending discussions on what quality of life (QOL) is and whether it can be assessed. This article is based on the idea that it is much more important to improve the conceptual frameworks that allow the use of the QOL concept in clinical practice. Survival of the QOL concept within the medical community will depend on its contributions to a better understanding of patients and to improving patient care. It is important to accept that QOL should not be viewed in isolation but in synopsis, with other psychologic concepts and clinical data. We propose a profile format that presents QOL data in a way that is easily accessible for clinicians, allowing action to be taken immediately. QOL profiles are never a substitute but a starting point for a patient-doctor interaction. A profile driven interaction has the potential to be structured, efficient, and leading to action.     

The palliative value of tumor necrosis factor alpha-based isolated limb perfusion in patients with metastatic sarcoma and melanoma

BACKGROUND: Both patients with soft tissue sarcoma (STS) and patients with melanoma have limited treatment possibilities once the tumor has metastasized systemically. In patients with extremity STS or bulky melanoma in-transit metastases, the local tumor burden may be so problematic that, even in patients with systemically metastasized disease, an amputation may be inevitable. Isolated limb perfusion (ILP) has proven to be an excellent, local, limb-saving treatment option in patients with locally advanced extremity tumors. In this study, the authors investigated the palliative value of the ILP procedure to avoid amputation in patients who had Stage IV STS and melanoma. METHODS: From 1991 to 2003, of 339 tumor necrosis factor alpha (TNF)-based ILPs, 51 procedures were performed for either Stage IV STS (n = 37 patients) or Stage IV melanoma (n = 14 patients). All patients underwent an ILP with TNF and melphalan of the upper limb (n = 4 patients) or the lower limb (n = 47 patients) with 26-140 mg melphalan and 2-4 mg TNF. RESULTS: The overall response in patients with Stage IV STS was 84%, and their median survival was 12 months after ILP. Limb salvage was achieved in 36 of 37 patients, with 1 patient undergoing amputation due to treatment toxicity. In the patients with Stage IV melanoma, the complete response rate was 43%. All patients with melanoma preserved their limb during a median survival of 7 months. CONCLUSIONS: TNF-based ILP is an excellent procedure that provided tumor control and limb salvage for the short survival of patients with metastasized, very bulky, limb-threatening tumors of the extremity.     

Outcome and prognostic factor analysis of 217 consecutive isolated limb perfusions with tumor necrosis factor-alpha and melphalan for limb-threatening soft tissue sarcoma

BACKGROUND: Extensive and mutilating surgery is often required for locally advanced soft tissue sarcoma (STS) of the limb. As it has become apparent that amputation for STS does not improve survival rates, the interest in limb-preserving approaches has increased. Isolated limb perfusion (ILP) with tumor necrosis factor-alpha (TNF) and melphalan is successful in providing local tumor control and enables limb-preserving surgery in a majority of cases. A mature, large, single-institution experience with 217 consecutive ILPs for STS of the extremity is reported. METHODS: At a prospectively maintained database at a tertiary referral center, 217 ILPs were performed from July 1991 to July 2003 in 197 patients with locally advanced STS of the extremity. ILPs were performed at mild hyperthermic conditions with 1-4 mg of TNF and 10-13 mg/L limb-volume melphalan (M) for leg and arm perfusions, respectively. RESULTS: The overall response rate was 75%. Limb salvage was achieved in 87% of the perfused limbs. Median survival post-ILP was 57 months and prognostic factors for survival were Trojani grade of the tumor and ILP for single versus multiple STS. The procedure could be performed safely, with a perioperative mortality of 0.5% in all patients with no age limit (median age, 54 yrs; range, 12-91). Systemic and locoregional toxicity were modest and easily manageable. CONCLUSION: TNF+M-based ILP can provide limb salvage in a significant percentage of patients with locally advanced STS and has therefore gained a permanent place in the multimodality treatment of STS.     

Zum Problem der sogenannten Simultanagnosie

Zusammenfassung Bei einem Patienten mit einem vorzugsweise lobär verlaufenden hirnatrophischen Prozeß wurden die Störungen der Gesamtauffassung bildlich dargestellter Situationen (Simultanagnosie), die er neben Wortfindungsschwierigkeiten, Paraphasien, Dysgraphie, Dyskalkulie und Merkschwäche bot, einer Analyse unterzogen. Die gestörte Intellektualität der Wahrnehmung zeigte sich als ein Darniederliegen ihrer sinngerichteten Aktivität. Der Patient war nicht in der Lage, Strukturen in eine Wahrnehmungsgegebenheit zu bringen, war unfähig, eine Gestalt aufzubauen. Durch Störungen des Übersehens hatte die Überschaubarkeit des Wahrnehmungsfeldes gelitten. Bei schneller Absättigung des Sinnfindungsbedürfnisses kam es zum sinngemäßen Illusionieren innerhalb kurzschlüssig hergestellter Sinneinheiten. Die durch das Zurücktreten der Gestalt gegenüber der Physiognomie des Gegenstandes gekennzeichneten Zeichnungen des Patienten wurden den raumagnastischen Gestaltungsstörungen zugeordnet. Die Bedeutung der Störungen für das Leben des Patienten erhellen sein Verzicht auf Wahrnehmung und seine Unsicherheit gegenüber einer eindringlicher gewordenen, nicht mehr dahingestellten Welt.     

Polybrominated biphenyls, polychlorinated biphenyls, body weight, and incidence of adult-onset diabetes mellitus

BACKGROUND: Prior studies have reported an increased risk of diabetes related to polychlorinated biphenyl (PCB) exposure. No study has yet investigated whether polybrominated biphenyls (PBBs), which are similar in chemical structure, increase the incidence of diabetes. METHODS: The Michigan PBB cohort was established in 1976 and surveyed again in 1991-1993 and in 2001. PBB and PCB serum levels were measured from blood collected at enrollment. To determine the incidence of adult-onset diabetes, we analyzed cohort members without diabetes at enrollment, ages 20 years and older, with known PBB and PCB levels, who participated in at least 1 follow-up survey (n = 1384). Using Poisson regression, we determined the incidence density ratio (IDR) of diabetes for different serum levels of PBB and PCB, controlling for age, body mass index, smoking, and alcohol consumption at enrollment. RESULTS: Analyzing 25 years of follow-up data, we did not find that higher PBB serum levels were a risk factor for the incidence of diabetes mellitus. However, in women, but not in men, higher PCB serum levels were associated with increased incidence of diabetes (IDR = 2.33; 95% confidence interval = 1.25-4.34 in the highest PCB group compared with the lowest). In both men and women, overweight and obesity increased the diabetes incidence. CONCLUSIONS: We found no association between PBB serum levels and diabetes incidence. In women, there was a positive linear association of diabetes incidence with PCB serum levels at enrollment. This finding is in agreement with 2 prior studies indicating a higher relative risk of diabetes in PCB-exposed women.     

Clinical and prognostic value of [(18)F]FDG-PET for surveillance of oral squamous cell carcinoma after surgical salvage therapy

[(18)F]FDG-PET was found to be useful for recurrence detection in patients with oral squamous cell carcinoma (OSCC), as a negative PET scan predicted a favorable outcome and survival. Here, we evaluate PET performance in the management of OSCC patients with recurrent/second primary disease after potentially curative second-line therapy. Forty one OSCC patients underwent salvage surgery and 31/41 had received radiation therapy. Thirty five/41 developed recurrent and 6/41 second primary OSCC. Patients had PET evaluation 8.4months (median) after surgery and were followed for at least 6months until disease recurrence or death. For surviving patients, the median follow-up was 33.6months after PET. In OSCC patients who had undergone potentially curative second-line therapy, PET had an overall sensitivity of 85% (92% for recurrence or second primaries, 88% for lymph node failure and 73% for distant metastases). Overall survival was 71% in the PET negative group and 35% in the PET positive group (p<0.01, log-rank test). Moderate glucose metabolism (standardized uptake value4) suggested promising outcome, while SUV>4 indicated a fatal disease course. The data suggest that [(18)F]FDG-PET can facilitate re-staging and clinical management in "high-risk" patients with OSCC.     

Continuity of care by Pflegeüberleitung? Results of participant observation

Continuity of care between health care institutions is of increasing importance. In a two-year research project on this topic extensive participant observation was carried out for data gathering in three hospitals in Düsseldorf (Germany). In each institution four patients were observed until their discharge and all interactions between them and health care professionals were documented using a semi-structured data-gathering instrument. Furthermore, the researchers questioned the involved professionals after each situation. Altogether a total of 980 situations were documented during 100 shifts, thus professional activities aiming at continuity of care can be regarded as extensively covered. The results show that care professionals (nurses, physicians, social workers etc.) in the three participating hospitals only incompletely assess individual needs or even fail to do so at all. In addition, there is no regular interprofessional collaboration and the professionals' horizon is essentially limited to their own institution. Patients and their relatives are not systematically involved and their views rarely considered. Two cases are used as examples to illustrate these aspects. A third example shows that also successful processes were observed. In most cases, however, the implicit logic of the hospital system dominates over individual needs and therefore a successful continuity of care processes cannot be assumed. Finally, the necessity for a fundamental change of this counterproductive systems logic is briefly discussed.     

Infective larvae of the human hookworms Necator americanus and Ancylostoma duodenale differ in their orientation behaviour when crawling on surfaces

The infective third stage larvae of hookworms infect their hosts by active skin invasion, and they find and recognize their hosts by the behavioural phases of activation, directed crawling, and penetration. Here we analyse the orientation of the infective larvae of the human hookworms Necator americanus and Ancylostoma duodenale when crawling on surfaces. Their behaviour differed from that of the larvae of the dog hookworm Ancylostoma caninum, but the two species also differed from each other. N. americanus crawled towards light, but A. duodenale did not. Both species migrated towards the warm ends of thermal gradients, and this response was more sensitive than in other skin-invading helminths (threshold 0.09°C/cm). However, A. duodenale turned back and accumulated at higher temperatures than N. americanus [turn-back 45.7 (44.5–49.9) vs 41.5 (38.5–43.9)°C; accumulation 43.6 (41.6–46.0) vs 39.5 (37.9–43.0)°C]. In contrast to other skin-invading helminths, both species showed no chemo-orientation towards skin compounds when crawling on surfaces. This behaviour may reflect adaptations for reaching the skin surface from hairs or adhering material, but the differences in the orientation of the two species could not be attributed to differing transmission strategies.     

Evaluation of a new DNA test compared with the lactose hydrogen breath test for the diagnosis of lactase non-persistence

BACKGROUND AND AIMS: Recent publications have found that the CC genotype of the DNA variant -13910 T/C upstream of the LCT gene is associated with lactase non-persistence. We therefore compared the value of DNA testing for this variant (DNA test) with the lactose hydrogen breath test (H2 test), which is the clinical standard for the diagnosis of lactase non-persistence. PATIENTS AND METHODS: One hundred and twenty-three consecutive patients with suspected lactose malabsorption were tested for the presence of the -13910 T/C variant by polymerase chain reaction-restriction fragment length polymorphism analysis. These patients also underwent the H2 test after ingestion of 50 g lactose. RESULTS: Thirty-seven subjects had a CC genotype of the -13910 T>C polymorphism suggesting lactase non-persistence; 36 (97%) had also a positive H2 test. Eighty-six subjects had either a TC or a TT genotype suggestive of lactase persistence. Seventy-four (86%) of these tested negative on the H2 test, while 12 patients had a positive H2 test. In eight of these 12 patients duodenal biopsies showed no evidence of small bowel disease. One patient carrying a CC genotype had a negative H2 test. In this patient the rise in serum glucose after oral lactose was normal, furthermore H2 non-excretion was also excluded. CONCLUSIONS: An excellent correlation is observed between a CC genotype and a positive H2 test, whereas the correlation between a TC or TT genotype and a negative H2 test result is less strong. Analysis of the -13910 T/C variant can be considered a good test for predicting the presence of lactase non-persistence in a patient population with suspected lactose malabsorption.