Management of gastric lymphoma with chemotherapy alone

Purpose. The optimal therapy for gastric lymphoma except MALToma has not yet been established. This study was undertaken to investigate whether gastric lymphoma can be managed effectively and safely with chemotherapy alone.

Patients and methods. A total of 58 patients (median age 56 years) with newly diagnosed gastric lymphoma between 1989 - 2001 at Seoul National University Hospital and who were initially managed with chemotherapy alone were evaluated. MALToma was excluded from the pathologic review.

Results. All patients received initially anthracycline-containing chemotherapy. ECOG performance scale 0 - 1 was 88% and B symptoms were present in 41.4%. Diffuse large B cell type was the most common (74.1%). Stage IE, II₁E accounted for 51.7% and II₂E, IIIE, IV for 48.3%. The international prognostic index (IPI) of risk was low in 39.7%, low-intermediate in 22.4%, high-intermediate in 15.5% and high in 22.4%. The complete response rate after first-line chemotherapy was 71.4% and the partial response rate was 12.2%. (overall response rate: 83.6%). Among patients who did not reach the complete response, a further complete response was achieved by second-line chemotherapy including etoposide-based regimen. Ultimately, the maximum complete response rate by chemotherapy was 83.7% (92% in stage IE, II₁E, 75% in stage II₂E, IIIE, IV). Median overall survival was 47.4 months (84.7 months in stage IE, II₁E, 32.5 months in stage II₂E, IIIE, IV) and the 5-year survival rate was 46%. Bleeding as a complication occurred in 3 of 58 patients (5.6%) and these cases were controlled by embolization or conservative management. No perforation episode occurred and surgical intervention due to complication was not necessary. Organ preservation was possible in 57 of 58 patients (98%). The one gastrectomy was performed due to a partial clinical response to chemotherapy but the specimen showed pathologic CR. Multivariate analysis revealed that only IPI had a significant influence on survival.

Conclusions. Gastric lymphoma except MALToma can be managed effectively and safely with chemotherapy alone.     

Termination of life support after severe child abuse: the role of a guardian ad litem

Discontinuation of life-sustaining interventions often raises ethical concerns. In cases of severe child abuse with poor prognosis for recovery, accused parents may have a conflict of interest regarding medical decision-making for their child, because the outcome of such decisions may impact legal charges filed against them. The recently issued American Academy of Pediatrics guidelines for addressing such cases recommended the appointment of a guardian ad litem for medical decision-making. We present the case of an 8-month-old infant who was abused severely by her father, resulting in a persistent vegetative state. We describe our experience with appointing a guardian ad litem and the ethical issues involved.     

Positive selection of anti-thy-1 autoreactive B-1 cells and natural serum autoantibody production independent from bone marrow B cell development

A natural serum autoantibody specific for the Thy-1 glycoprotein (anti-Thy-1 autoantibody [ATA]) is produced by B-1 cells that are positively selected by self-antigen. Here, using ATA micro kappa transgenic mice we show that cells with this B cell receptor are negatively selected during bone marrow (BM) development. In a Thy-1 null environment, BM ATA B cells progress to a normal follicular stage in spleen. However, in a self-antigen-positive environment, development is arrested at an immature stage in the spleen, concomitant with induction of CD5. Such cells are tolerant and short-lived, different from B-1. Nonetheless, ATA-positive selection was evident by self-antigen-dependent high serum ATA production, comprising approximately 90% of serum immunoglobulin M in ATA micro kappa mice. Splenectomy did not eliminate ATA production and transfer of tolerant splenic B cells did not induce it. These findings demonstrate that B-1 positive selection, resulting in the production of natural serum ATA, arises independently from the major pathway of BM B cell development and selection.     

Are critical pathways effective for reducing postoperative length of stay?

BACKGROUND: Many hospitals use critical pathways to attempt to reduce postoperative length of stay (PLOS) for diverse conditions and procedures. OBJECTIVE: To evaluate whether critical pathways were associated with reductions in postoperative PLOS after accounting for prepathway trends in PLOS. RESEARCH DESIGN: Retrospective cohort study, from 1988 to 1998. SETTING: Academic medical center department of surgery. SUBJECTS: A total of 10,960 admissions eligible for 1 of 26 critical pathways implemented from 1990 to 1996, from 2 years before to 2 years after each pathway implementation date. Coding definitions were developed and validated to identify admissions eligible for each pathway, and data were abstracted from the hospital's discharge database. MEASURE: A pathway was considered effective if, after its implementation, there was a statistically significant decrease in the prepathway trend for PLOS. RESULTS: Median number of annual eligible admissions per pathway was 59 (range, 18-706). Median PLOS for the prepathway periods was 8 days (interquartile range, 5-10 days). For 16 (62%) pathways, PLOS was already declining in the prepathway period. After adjusting for demographics, comorbidity, admission characteristics, and prepathway time trends in PLOS, 7 (27%) pathways were associated with a significant postimplementation decrease in the rate of change in PLOS (range among the 7 pathways, 5-45% decrease) and none with a significant increase from the prepathway trend for PLOS. CONCLUSION: Critical pathways may decrease postoperative stay for some, but not all, surgeries. Trends toward decreasing length of stay over time may reduce the impact of critical pathways on this outcome.     

Health Insurance Disparities in Traditional and Contingent/Alternative Employment

Relative to whites, Hispanics and blacks are less likely to have employer health insurance coverage. We examine whether ethnicity or race affects employment in traditional jobs or in contingent and alternative work arrangements, and whether ethnicity or race affects insurance offer, eligibility, and/or enrollment, conditional on employment sector. Health insurance disparities relative to whites are more pronounced for Hispanics, primarily due to disparities in employment by firms that offer coverage. Eliminating racial/ethnic disparities in offers, eligibility, and takeup would increase insurance coverage rates of Hispanics in traditional jobs and of both Hispanics and blacks in contingent and alternative jobs. JEL classification: I10, J32, J70     

Methodological approaches for a systematic review of end-of-life care

As background for a National Institutes of Health State of the Science Conference on End-of-Life-Care, we performed a systematic review of end-of-life care and outcomes. The systematic review was intended to evaluate the evidence in the field from the perspective of concerns important to patients, caregivers, and the health care system. This article relates the challenges in performing a systematic review of end-of-life care and outcomes, and describes the methods that we used to define the scope, search the literature, develop exclusion and inclusion criteria, incorporate various types of articles, and synthesize the results. Major challenges to conducting a review included the need to define "end of life," clarify a conceptual framework of outcomes including definitions of terms and the relationships among terms, and determine specific goals for the review. The review identified 24,423 total citations, of which 911 comprised the final set used for the evidence report. This very large, diverse body of literature reflects the tremendous growth of the field of end-of-life care over the last decade.     

The effects of social demand on breast self-examination self-report

The measurement of breast self-examination (BSE) adherence typically relies on verbal self-report. These studies systematically manipulated social demand within a face-to-face interview and examined the effects on self-reported BSE frequency. In Study 1, subjects (n=37) received either a high-demand or a low-demand preface prior to being asked about BSE practice over the past year. Study 2 (n=89) was a replication, with the addition of a no-preface (control) condition. Results from Study 1 indicated that although the conditions were comparable on demographic and breast cancer/BSE knowledge variables, the high-demand condition reported a significantly higher number of BSEs than the low-demand condition. An attenuation of this pattern was found in Study 2, with the control condition reporting a frequency between the low demand's and the high demand's reported frequencies. The implications for BSE intervention and prevalence research are discussed.