The management of symptoms in advanced cancer: experience in a hospital-based continuing care unit.

The treatment received by 158 patients with advanced cancer admitted over one year to the Continuing Care Unit at the Royal Marsden Hospital has been reviewed. The unit is an integral part of the hospital and this is reflected in the fact that 46 patients (29%) received radiotherapy, hormone therapy, chemotherapy or surgery in addition to symptomatic treatment for palliation of troublesome symptoms. One hundred and thirty-one patients received oral morphine in doses ranging from 2.5 mg 4-hourly to 700 mg 4-hourly. Patients with renal or hepatic impairment required lower doses of morphine and there was a highly significant inverse relationship between morphine dose and age. Eighty-five patients (54%) received parenteral diamorphine at some time due to their inability to take oral morphine. One hundred and twenty-three patients (78%) received a co-analgesic drug and anti-emetics were required by 78 patients (49% overall; 56% of those receiving morphine). Transcutaneous electrical nerve stimulation, acupuncture and relaxation were employed in selected patients, and graduated compression sleeves were used to treat lymphoedema. These data highlight the wide range of therapeutic options available to control the symptoms of advanced cancer and also indicate that tumoricidal treatments used in conjunction with symptomatic treatments may have a significant part to play.     

Immunogenicity study of low-dose administration of hepatitis B virus vaccine in newborn infants: A cost reduction trial

Different doses of hepatitis B virus vaccine—prepared by Korea Green Cross Corporation, were given to healthy infants born to HBsAg-negative mothers at birth, 1 and 6 months of age. A dose of 2 μg was administered intradermally in Group A and, in the three other groups, the vaccine was given intramuscularly (i.m.). An adequate follow-up observation was possible for 9 months after birth in 22, 25, 23 and 21 infants in Groups A, B, C and D, respecvely.
Group C (5 μg, i.m.) produced seroconversion most rapidly, showing the highest rate (96%) at 9 months of age. The lowest seroconversion rate (5%) was found at the age of 1 month in Group A subjects, but the rate increased to 91% after a booster dose was given at 6 months of age.
While it can be concluded that a 5 μg i.m. dose of vaccine at 0, 1 and 6 months of age is optimum for the immunization of infants in efficacy and economy, a 2 μg intradermal dose can also be considered as an immunogenic and economical regimen, though the immune response is slower and a special technique is required for immunization.     

Developing a Documentation System That Works

A documentation system that facilitates accurate and complete recording is needed by every obstetric/neonatal nursing service. Developing an individualized system is a major undertaking. However, specific steps can be taken to ease the process. These steps are described, beginning with the assessment phase and concluding with evaluation.     

EFNS Guidelines on diagnosis and treatment of brain metastases: report of an EFNS Task Force

The objectives have been to establish evidence-based guidelines and identify controversies regarding the management of patients with brain metastases. The collection of scientific data was obtained by consulting the Cochrane Library, bibliographic databases, overview papers and previous guidelines from scientific societies and organizations. A tissue diagnosis is necessary when the primary tumor is unknown or the aspect on computed tomography/magnetic resonance imaging is atypical. Dexamethasone is the corticosteroid of choice for cerebral edema. Anticonvulsants should not be prescribed prophylactically. Surgery should be considered in patients with up to three brain metastases, being effective in prolonging survival when the systemic disease is absent/controlled and the performance status is high. Stereotactic radiosurgery should be considered in patients with metastases of 3–3.5 cm of maximum diameter. Whole-brain radiotherapy (WBRT) after surgery or radiosurgery is debated: in case of absent/controlled systemic cancer and Karnofsky Performance score of 70 or more, one can either withhold initial WBRT or deliver early WBRT with conventional fractionation to avoid late neurotoxicity. WBRT alone is the treatment of choice for patients with single or multiple brain metastases not amenable to surgery or radiosurgery. Chemotherapy may be the initial treatment for patients with brain metastases from chemosensitive tumors.     

44Sacral extracorporeal magnetic stimulation is an effective treatment for pelvic floor dyssynergia; Comparative study with biofeedback therapy

Background: Recent development of extracorporeal magnetic stimulation (ECMS) which uses current‐changing magnetic fields allows the induction of electrical stimulation in the desired deep tissue. Recent study showed the sacral nerve stimulation reduces corticoanal excitability that may play a functional role in anal continence mechanisms. Preliminary study shows that ECMS of sacral nerve can modify pelvic floor function and expel rectal balloon in patients with pelvic floor dyssynergia (PFD). Aims: To evaluate the effect of ECMS compared with biofeedback therapy (BF) in patients with PFD. Methods and Materials: Thirty‐eight patients who fulfilled Rome II criteria for PFD by colon transit time and anorectal function tests, were randomly treated with 8 sessions of ECMS (2/weeks; n = 19) at prone position or BF (2/weeks; n = 19) at sitting position. Stimulation parameters were set at 50–80% of maximum intensity, 10 and 50 Hz frequency, 3 s burst length with 3 and 6 s off using arm‐typed stimulator (BioCom‐1000, Mcube Co., Korea). Symptom scores for constipation with/without anorectal function test were repeatedly measured after each treatment. Response was defined as 50% or more decreased symptom score after treatment (partial response: 30–50%, poor: <30%). Results: Fifteen patients (age 49.1 ± 13.4 years, mean ± SD; 4 men) completed 8 session of BF and 14 patients (54.5 ± 17.6 years, 3 men) completed 8 session of ECMS. Four patients of BF group discontinued treatment due to unsatisfactory therapeutic effect (n = 1) and withdrew consent (n = 3) and 5 patients of ECMS group discontinued treatment because of same reasons (n = 1, 4). Total symptom scores were significantly decreased after treatment of 8 session in both treatment groups (13.4 ± 6.6 vs. 4.3 ± 4.0 for BF, p = 0.009; 14.9 ± 5.6 vs. 3.4 ± 4.0 for ECMS, p < 0.001). Bowel movements per week were also significantly increased after treatment in both groups (median 2 vs. 7 for BF, p = 0.035; median 2 vs. 7 for ECMS, p = 0.008). Thirteen out of 15 patients showed response in BF group and 12 out of 14 showed good response in ECMS group. No adverse effects in both groups. Conclusions: ECMS is as effective as BF for the treatment of PFD. Long‐term effect of ECMS for the patients with pelvic floor dyssynergia need to be evaluated in the near future.     

Inhibition by sumatriptan of central trigeminal neurones only after blood-brain barrier disruption.

1. The 5-hydroxytryptamine (5-HT1)-like agonist, sumatriptan, is highly efficient in the relief of migraine headache and its accompanying symptoms. 2. Experimental evidence has indicated that its site of action may be on the cranial vessels or on the trigeminal innervation of the cranium, or both, since sumatriptan does not pass the blood-brain barrier easily under normal circumstances. It is, however, not clear whether the blood-brain barrier is normal or abnormal during a migraine attack. 3. In this study, single unit activity and trigeminal somatosensory evoked potentials in central trigeminal neurones were monitored during electrical stimulation of the superior sagittal sinus. 4. Intravenous administration of sumatriptan (100 micrograms kg-1) did not alter trigeminal evoked activity unless the permeability of the blood-brain barrier had been increased by infusion of an hyperosmolar mannitol solution. After blood-brain barrier disruption, sumatriptan decreased the peak-to-peak amplitude of evoked potentials by 40 +/- 6% and the probability of firing of single units by 30 +/- 9%. Mannitol infusions alone in control animals caused no changes in evoked potentials or single unit activity. 5. The data suggest that in normal circumstances sumatriptan does not have sufficient access to trigeminal neurons to alter their function.     

A Group-Based Training Programme for General Practitioners: A Norwegian Experience

Westin S, stensen A I, Lvslett K, Prytz J, Telje J, TelstadW and Lie A. A group-based training programme for general practitioners:a Norwegian experience. Family Practice 1988; 5: 244–252. There are approximately 3000 general practitioners in Norway,serving a population of slightly above four million people.A three year postgraduate education scheme for general practitionershas been in effect since 1973, to be replaced by a five yearvocational training programme from January 1985, making generalpractice a fully recognized specialty from that date. The educationalrequirements consist of one year of hospital training, fouryears of training in general practice, and a total of 400 hoursof course education, mainly in clinical subjects. The core elementof the training is attendance at a group-based structured educationalprogramme of two years' duration. This article describes theconcepts and content of this decentralized group-based education,as well as some of the conflicting considerations which eventuallyled to this new Norwegian model of general practice training.The first evaluation studies indicate that the educational programmehas met a long standing need among general practitioners.