Oral cyclophosphamide in recurrent ovarian cancer.

AIMS: Cyclophosphamide was widely used as a single agent prior to the advent of platinum-based regimens for epithelial ovarian cancer, and, in combination with platinum, prior to the adoption of platinum and paclitaxel as standard first-line therapy. As cyclophosphamide currently has no defined role in ovarian cancer we aimed to assess its activity in women with recurrent disease. METHODS: A retrospective review was conducted of patients from three centers in Melbourne, Australia who had received oral cyclophosphamide treatment for recurrent ovarian cancer. The primary end-point was response rate to oral cyclophosphamide (150 mg p.o. day 1-14) based on Gynecologic Cancer InterGroup (GCIG) CA125 and/or Response Evaluation Criteria in Solid Tumors (RECIST) criteria. Secondary end-points included overall and progression-free survival and toxicity. RESULTS: In all, 26 patients were identified and 23 patients were evaluable for response. The median number of prior chemotherapy regimens was three (range 1-6). The response rate to oral cyclophosphamide was 44% with 10 of the 23 patients achieving a partial response (PR) based on GCIG (CA125) criteria. The median number of cycles received was three (range 1-16). Cyclophosphamide showed activity both in patients with platinum-sensitive (seven of 13 PR) and resistant or refractory disease (three of 10 PR). There was no grade 3 or 4 toxicity but two patients ceased cyclophosphamide due to less severe non-hematological toxicity. CONCLUSION: Single agent oral cyclophosphamide is active and well tolerated in recurrent ovarian cancer. Further investigation of oral cyclophosphamide in patients with platinum-sensitive and platinum-resistant disease is warranted.

Tonsillar cancer: the Peter MacCallum experience with unilateral and bilateral irradiation.

BACKGROUND: The primary purpose of this study was to review the efficacy of unilateral treatment of lateralized tonsil primaries, in particular whether laterality of the primary is a more powerful determinant of contralateral neck failure than advanced ipsilateral nodal classification. METHODS: A retrospective study of all patients with tonsillar cancer treated with curative intent between January 1990 and December 2002 was performed. RESULTS: There were 167 patients, 76% men, median age 58 years, 86% current or ex-smokers. The majority of patients (58%) had stage IV disease. Five-year local, nodal, locoregional, and distant failure rates were 14%, 4%, 18%, and 8%, respectively. Of the 58 patients treated unilaterally, 33% had N2a, N2b, or N3 nodal disease. There were no contralateral nodal failures in the unilaterally treated group. CONCLUSION: These results support the potential use of unilateral radiation therapy (RT) for lateralized tonsil primaries even with advanced ipsilateral nodal disease.

The utility of 18 F-FDG PET/CT for suspected recurrent breast cancer: impact and prognostic stratification.

BACKGROUND: The incremental value of 18FDG PET/CT in patients with breast cancer (BC) compared to conventional imaging (CI) in clinical practice is unclear. The aim of this study was to evaluate the management impact and prognostic value of 18 F-FDG PET/CT in this setting. METHODS: Sixty-three patients who were referred to our institution for suspicion of BC relapse were retrospectively enrolled. All patients had been evaluated with CI and underwent PET/CT. At a median follow-up of 61 months, serial clinical, imaging and pathologic results were obtained to validate diagnostic findings. Overall Survival (OS) was estimated using Kaplan Meier methods and analyzed using the Cox proportional hazards regression models. RESULTS: Forty-two patients had a confirmed relapse with 37 (88%) positive on CI and 40 (95%) positive on PET/CT. When compared with CI, PET/CT had a higher negative predictive value (86% versus 54%) and positive predictive value (95% versus 70%). The management impact of PET/CT was high (change of treatment modality or intent) in 30 patients (48%) and medium (change in radiation treatment volume or dose fractionation) in 6 patients (9%). Thirty-nine patients (62%) died during follow-up. The PET/CT result was a highly significant predictor of OS (Hazard Ratio [95% Confidence Interval] =4.7 [2.0-10.9] for PET positive versus PET negative for a systemic recurrence; p = 0.0003). In a Cox multivariate analysis including other prognosis factors, PET/CT findings predicted survival (p = 0.005). In contrast, restaging by CI was not significant predictor of survival. CONCLUSION: Our study support the value of 18 F-FDG PET/CT in providing incremental information that influence patient management and refine prognostic stratification in the setting of suspected recurrent breast cancer.

Being satisfied at work does affect burnout among psychiatrists: a national follow-up study from New Zealand.

BACKGROUND: Burnout and job satisfaction in psychiatrists has been an area of considerable interest. Longitudinal studies on the subject are lacking, rendering it difficult to establish whether burnout changes with time or whether low job satisfaction may predict high burnout with time in psychiatrists. AIMS: This longitudinal study of burnout and job satisfaction in a cohort of New Zealand psychiatrists was conducted to examine if initial scores on the Job Diagnostic Survey (JDS) predicted scores on the Maslach Burnout Inventory (MBI) three years later and vice versa. METHODS: Three questionnaires (a socio-demographic questionnaire, the JDS and the MBI) were sent to all registered psychiatrists in 2008, which included all those who had participated in a study three years earlier. Scores on these three questionnaires were compared for those who had participated in both studies. RESULTS: The overall number of psychiatrists reporting a high level of emotional exhaustion (EE) did not change across the two phases. The number of psychiatrists reporting high levels of depersonalization (DP) increased from 31 (13%) to 45 (20.2%); the mean DP score for the cohort significantly increased by 17.5% (p < .01). Those reporting reduced personal accomplishment (PA) increased from 90 (37.7%) to 98 (43.9%); the mean PA score for the cohort significantly reduced by 14.5% (p < .001). Low scores on skill variety, task Identity, and feedback of the JDS were significantly correlated with high EE scores three years later, whereas low scores on skill variety were significantly correlated with high scores on DP, and low scores on task significance and feedback were correlated with low scores on PA three years later. CONCLUSIONS: Paying attention to aspects of job satisfaction may assist us in developing specific interventions for psychiatrists who may score high on different dimensions of burnout.

Difficulties with defining lymphoedema after axillary dissection for breast cancer.

AIM: Axillary lymph node dissection(AND) is a common treatment for breast cancer. An important side effect of the surgery is lymphoedema (LO). The primary aims of this study were to assess the local prevalence of LO in patients who had undergone AND and how the subjective symptoms described by patients compare with objective measurements. Secondary aims were to investigate the relationship between risk factors and the prevalence of LO and to establish an easy and convenient way to detect LO patients in surgical clinics. METHOD: Eligible women after AND for breast cancer underwent three circumference measurements on the operated and non operated (control) arm. LO was defined as one or more measurements with an increase ≥7.5% than control after dominant arm correction. Questionnaires were used to assess severity of symptoms related to lymphoedema. 73 patients also had serial measurements in arms and change in arm volume in operated arm was calculated using Casley-Smith method and LO was defined as ≥20% increase in volume. RESULTS: 193 women with AND were analysed. Mean age was 61 years and mean time since surgery was 56 months. The overall prevalence of LO was 23.3%. LO prevalence by arm volume was 8.2%. Using volume as the standard, an arm circumference increase of ≥7.5% and ≥10% showed a sensitivity and specificity of 83% and 81%, and 66% and 89% respectively. Significant risk factors for LO were age, radiotherapy and infection to the operated arm CONCLUSION: Circumference measures are a simple office method of screening for LO. A patient history and ≥10% increase in any circumference is optimal for determining LO after AND.

A dietitian-led clinic for patients receiving (chemo)radiotherapy for head and neck cancer.

PURPOSE: Malnutrition is prevalent in head and neck cancer patients and is associated with poorer outcomes and increased health care costs. This study aimed to evaluate the acceptability, organisational efficiency and clinical outcomes of a dietitian-led head and neck cancer clinic. METHODS: Two consecutive, independent, patient cohorts were studied with a pre-post-test design of 98 patients prior to the introduction of a dietitian-led clinic (DLC) and the subsequent 100 patients who attended the newly formulated DLC. The two groups were compared for frequency of dietitian intervention, weight loss, enteral feeding, hospital admissions and post-treatment medical follow-up requirements. RESULTS: Nutritional management in a DLC was associated with reduced nutrition-related admissions from 12% to 4.5% (p = 0.0029), unplanned nasogastric tube insertions from 75% to 39% (p = 0.02), improved transition to oral diet post-radiotherapy from 68.3% to 76.7% (p = 0.10) and reduced radiation oncologist review at 2 weeks post-radiotherapy from 32% to 15% patients (p = 0.009) compared to the cohort prior to the DLC. CONCLUSIONS: A dietitian-led head and neck cancer clinic is associated with improved efficiency and nutritional management of head and neck cancer patients and offers a feasible model of care.

The utility of PET/CT in staging and assessment of treatment response of nasopharyngeal cancer.

INTRODUCTION: The aim of this study was to evaluate the impact of positron emission tomography/computerised tomography (PET/CT) as an adjunct to conventional imaging (CI) in the management of nasopharyngeal cancer (NPC) both for initial staging and assessment of post-treatment response. METHODS: All NPC cases referred to the Peter MacCallum Centre for Metabolic Imaging between January 2002 and December 2007 were identified. In patients undergoing initial staging, any differences between the pre-PET/CT management plan based on CI and that following performance of the PET/CT scan were noted. Clinical impact was scored using the Centre's published criteria: 'high' if PET/CT changed the primary treatment modality or intent, 'medium' if treatment modality was unchanged but the radiotherapy technique or dose was altered, and 'low' if there was no change in treatment modality or intent. Patients undergoing PET/CT following definitive treatment were scored according to whether or not they achieved a complete metabolic response. RESULTS: Forty-eight patients underwent a staging PET/CT. The clinical impact was high in 8%, medium in 25% and low in 66% of patients. Twenty-one patients were scanned for post-treatment response. PET/CT was less frequently equivocal than MRI (3 vs 8/21). A complete metabolic response on PET/CT was associated with a 93% negative predictive value for subsequent recurrence. CONCLUSION: PET/CT is a valuable staging tool for the detection of occult metastatic disease and defining the extent of neck nodal disease. Post-treatment, a complete metabolic response on PET/CT has a very high negative predictive value with fewer equivocal results than MRI.

Risk and response adapted therapy for early stage Hodgkin lymphoma: a prospective multicenter study of the Australasian Leukaemia and Lymphoma Group/Trans-Tasman Radiation Oncology Group.

In this prospective, multicenter, non-randomized study for patients with stage I-II Hodgkin lymphoma, group 1 (without risk-factors [RF]) had three cycles of ABVD chemotherapy (adriamycin, bleomycin, vinblastine, and dacarbazine) and group 2 (any of bulk, extranodal site, >3 regions, raised erythrocyte sedimentation rate [ESR]) and group 3 (B-symptoms) received four cycles. Involved field radiotherapy (IFRT) 30 Gy was given after adequate chemotherapy response. Five-year overall survival and freedom from progression (FFP) were 96% (95% confidence interval [CI] 91-98%) and 90% (84-94%), respectively. Five-year FFP was 97% (90-99%), 89% (75-95%), and 73% (52-86%) for groups 1, 2, and 3, respectively. In patients with RF, chemotherapy responses of complete response unconfirmed (CRu), partial response (PR), and stable disease (SD) were associated with FFP of 90%, 86%, and 62% (p=0.17), and CR/no CR on functional imaging with FFP of 90%/67%, respectively (p=0.05). The 97% FFP in group 1 compares favorably with previously reported results from cooperative trial groups. Intensification of therapy warrants study in patients with RF and a poor chemotherapy response.

Stresses experienced by psychiatrists and their role in burnout: a national follow-up study.

BACKGROUND: Many studies have looked at sources of stress in psychiatrists, yet the role played by different factors in the causation of burnout in psychiatrists remains unclear. We had two aims, first, to develop a predictive model for the onset of burnout. Second, we aimed to study the differences in the perception of what caused stress between psychiatrists who rated themselves high on Emotional Exhaustion compared to those who rated themselves as low on Emotional Exhaustion. METHODS: A previously described questionnaire that identified stressors relevant to consultant psychiatrists was mailed out to 426 psychiatrists, with 240 replies. Scores on the Emotional Exhaustion dimension of the Maslach Burnout Inventory were available for 131 respondents. RESULTS: Based on an earlier literature review, the Sources of Stress Questionnaire (SOS-Q) used in the study had 45 factors, categorized into predisposing, precipitating, perpetuating and protective factors for burnout in psychiatrists. Of these, factor analysis identified 11 non-correlated factors which were used in the final analysis of this study. Four factors emerged as associated with burnout in psychiatrists in New Zealand: too much work; working long hours; an aggressive administrative environment; and lacking support from management. Two factors negatively correlated with Emotional Exhaustion were a high level of job satisfaction and/or enjoyment, and low pay compared to other countries. CONCLUSIONS: Most factors associated with burnout are preventable and can be managed jointly between psychiatrists and administrators. Service providers need to address burnout seriously.

Long-term mortality after primary percutaneous coronary intervention for high-risk myocardial infarction.

BACKGROUND: Primary percutaneous coronary intervention (PPCI) has evolved, including the introduction of stents and platelet glycoprotein IIb/IIIa receptor inhibitors (GPI). The effects of these changes and other variables on long-term survival for a single-centre service were studied. METHODS: A prospective database of clinical and angiographic variables were kept for patients treated with PPCI in Waikato Hospital from 1996 to 2006 (n=527). This was analysed with long-term mortality data. Survival was recorded using Kaplan-Meier curves. Multivariate analysis of factors at presentation, including ethnicity was performed. RESULTS: 5, 8 & 10-year survival rates were 76.5% (n=274), 72.7% (n=125) & 71.0% (n=19) respectively. Increased stent (42.8% vs. 84.1%, p<0.001) and GPI (39.6% vs. 73.3%, p<0.001) use was seen between early and late stages of the study. Stent use was associated with greater 5-year survival (80.5% vs. 70.8%, p=0.02), but GPI use was not. Multivariate analysis showed stent use independently predicted reduced mortality. Age, Maori ethnicity, renal failure and cardiogenic shock predicted higher mortality. CONCLUSIONS: Survival after PPCI remains high long-term. Stent and GPI use significantly increased. Stent, but not GPI, use was associated with improved survival. Maori ethnicity was under-represented in the study and is associated with worse long-term outcomes after myocardial infarction (MI).

Palliative care provision by rural general practitioners in New Zealand.

OBJECTIVES: The aim of this study was to ascertain the workload for rural general practitioners providing palliative care and to identify barriers to care for patients living in rural areas of New Zealand. DESIGN AND METHODS: This was a cross-sectional survey of rural general practitioners using a postal questionnaire. RESULTS: One hundred eighty-six questionnaires were returned. Of respondents, 98% provided palliative care. The estimated mean number of patients cared for in the previous 12 months was 7.3. Specialist medical advice from a hospice or palliative care consultant was accessed by 77% of respondents. District and community nursing was available to over 90% of respondents but this was not universally available 24 hours a day in all areas. Forty-seven percent of rural palliative care patients died at home. CONCLUSIONS: Commitment of general practitioners to palliative care appeared high although the workload was a relatively small part of their activity. There seems to be a need for wider availability of specialist advice, 24-hour nursing cover, and some support services. A commitment to supporting domiciliary services is needed if large increases in institutional care are to be avoided in the future.

Views and experiences of family/whanau carers of psychiatric service users on diagnosis and classification.

BACKGROUND: Family (whanau) and other carers can play a central part in the natural history of psychiatric service users. Diagnoses or the classification of mental disorders play a significant role in communications between clinicians, psychiatric service users, and family. Despite that centrality, the views and experiences of family on the utility of the present classification systems have been little studied. AIMS: This study aimed to document the understanding and opinions of families/whanau on the utility of diagnostic labels as they observed them being applied to their family members. METHOD: This is a qualitative study. The families of two cultural groups (New Zealand Maori and non-Maori) of psychiatric service users were interviewed using a structured approach. RESULTS: A number of themes on the utility of the diagnostic systems emerged. The single most powerful message being that how the diagnostic labels were communicated, and how they were utilized in the patient management planning, were of paramount importance. There were some cross-cultural differences. From Maori, there was a particular plea for a greater incorporation of culturally syntonic concepts. CONCLUSION: Family/whanau had positive views of the contributions current diagnostic practices make to patient care. The study elicited the view that more contextual issues, and not just phenomenology, should be taken into account in the development of diagnostic systems.

General practitioners' views on the major psychiatric classification systems.

AIM: To understand the views of general practitioners on the utility of diagnostic schema as used by specialist psychiatrists and principles that would increase the value of diagnostic schema to general practitioners. METHOD: A postal survey of 1000 vocationally registered general practitioners in New Zealand RESULTS: Diagnostic schema such as the DSM-IV and ICD-10 are seldom used by general practitioners due primarily to their complexity and a lack of familiarity with them. Providing decision support on pharmaceutical treatment, appropriate secondary care referrals and improving communication across the primary/secondary care divide are principles that should guide the development of future diagnostic schema. Integration of schema into existing computerised practice management systems is considered a key success factor. CONCLUSION: Specialist devised schema fit uncomfortably into general practice. There is need for management orientated diagnostic schema that meet the requirements of general practitioners.

Use of mobile phone cameras for after-hours triage in primary care.

Mobile phone images might be useful in after-hours triage of primary care. We conducted a study to identify population access to mobile phone cameras and to assess the clinical usefulness of mobile phone cameras. The survey was conducted among 480 patients attending two rural New Zealand practices. There were significantly more Maori owners compared to non-Maori (P = 0.002). Age was a significant factor influencing the ownership of mobile phones. We also conducted a clinical quiz among health professionals to assess how the provision of images on a mobile phone and on CD-ROM (to simulate the image that would be seen if email was used to transmit the images) influenced diagnostic confidence. Ten photographable clinical conditions were used to quiz 30 health professionals who were randomized into three groups of 10 each on diagnostic confidence. Images were found to significantly increase diagnostic confidence in all cases except one. It appears that mobile phone cameras are generally acceptable to patients and likely to be of practical use to rural practitioners in a range of clinical scenarios.

New Zealand psychiatrists views on global features of ICD-10 and DSM-IV.

OBJECTIVE: The present accepted classificatory systems (ICD-10 and DSM-IV) represent the culmination of 100 years of post-Kraepelinian evolution. The present paper reports on a study to ascertain the views of New Zealand psychiatrists on their requirements of a classificatory system, and their opinions on those currently in use. METHOD: An anonymous postal survey of 542 psychiatrists and trainees was undertaken in New Zealand. RESULTS: A total of 235 questionnaires were returned, completed. New Zealand psychiatrists primarily use DSM-IV and do so because that is what they were taught on. They make relatively limited use of the multiaxiality. The purposes of classificatory systems that they value most highly are reliable interclinician communication, and to inform patient management planning. The two purposes they valued least were usefulness for a national statistical base, or to indicate prognosis. CONCLUSIONS: New Zealand psychiatrists' views are consistent with some of the stated objectives of ICD-10 and DSM-IV, but there is significant diversity in the former and over-ambition in the latter, with much to be resolved.

CAOS contribution to understanding cultural/ethnic differences in the prevalence of bipolar affective disorder in New Zealand.

OBJECTIVE: To examine whether data on the clinical profiles of psychiatric service users can inform the claim that Maori in the New Zealand community have an increased rate of bipolar disorder. METHOD: The standardized recordings of a variety of clinical phenomena previously collected in a New Zealand study of psychiatric service users was extracted for those persons who were diagnosed with a bipolar mental disorder. The individual clinical phenomena were then compared by ethnicity. RESULTS: The most dramatic result was the increased recording of high levels of overactivity or disruptive aggressive behaviour in Maori compared with European in psychiatric service users, despite which, the rates of the disorder did not significantly differ by ethnicity. CONCLUSION: In the community survey lay raters were deciding on the presence or absence of phenomena including hyperactivity without the contextual knowledge that clinicians use. It is possible that the Composite International Diagnostic Interview decision tree was being fed an excessive amount of that criterion.

Population-based funding formulae cultural coefficients: seeking a more equitable distribution of health dollars in New Zealand.

Evidence and argument for the allocation of funds to forensic psychiatric services to take account of the ethnic disparities in the use of the Justice System is presented. This would reflect the reality of the distribution of Service demand.