Risk of progression and survival in multiple myeloma relapsing after therapy with IMiDs and bortezomib: a multicenter international myeloma working group study.

Promising new drugs are being evaluated for treatment of multiple myeloma (MM), but their impact should be measured against the expected outcome in patients failing current therapies. However, the natural history of relapsed disease in the current era remains unclear. We studied 286 patients with relapsed MM, who were refractory to bortezomib and were relapsed following, refractory to or ineligible to receive, an IMiD (immunomodulatory drug), had measurable disease, and ECOG PS of 0, 1 or 2. The date patients satisfied the entry criteria was defined as time zero (T(0)). The median age at diagnosis was 58 years, and time from diagnosis to T(0) was 3.3 years. Following T(0), 213 (74%) patients had a treatment recorded with one or more regimens (median=1; range 0-8). The first regimen contained bortezomib in 55 (26%) patients and an IMiD in 70 (33%). A minor response or better was seen to at least one therapy after T(0) in 94 patients (44%) including ≥ partial response in 69 (32%). The median overall survival and event-free survival from T(0) were 9 and 5 months, respectively. This study confirms the poor outcome, once patients become refractory to current treatments. The results provide context for interpreting ongoing trials of new drugs.

The Saskatchewan dissemination story.

The Saskatchewan Heart Health Program (SHHP) Dissemination Phase "Building Health Promotion Capacity" is a five-year program funded by Health Canada, Saskatchewan Health and the Heart and Stroke Foundation of Saskatchewan. This phase began in July 1998 and builds on two previous SHHP phases: the provincial heart health survey (Saskatchewan Health, 1990), and the community demonstration projects (SHHP, 1998a, b, c, d). The evolution of the SHHP has occurred in a dynamic provincial context. Saskatchewan is a Canadian prairie province of one million people with most living in the southern and central parts of the province. The population is ageing and urbanizing, and the economy is shifting away from agricultural production toward a diversified service sector. In 1993, health reform created 30 Districts in southern and central Saskatchewan; the formation of three northern Districts followed five years later. All but two Districts are rural-based. Population served ranges from 2,261 to 237,274; total area ranges from 4,019 to 133,900 square kilometers.

Referrals to the Marie Curie nursing service in North Yorkshire.

District and Marie Curie nurses participated in a small-scale study to describe referrals to a Marie Curie service in one English health district over a 3-month period. The number of new patients referred was small; they were geographically clustered and had widely differing life expectancies. Anecdotal reports of difficulties with the 'Nurselink' referral system were not confirmed, and in situations where the system was in operation, Marie Curie nurses were more likely to speak directly to the referring nurse. The most frequently cited reason for referral was general nursing needs; however, Marie Curie nurses felt that they were most often involved to provide family support. These findings suggest that there may not be a shared understanding of the Marie Curie nurse's role, and that equity in community palliative nursing care merits examination. Defining and publicizing the role of the Marie Curie nurse, providing guidance for referrals and prioritizing communication between professionals are proposed not only to enhance the service locally but to ensure that the service is available to all. This article illustrates the value of research to identify ways to improve service delivery.

A story/dialogue method for health promotion knowledge development and evaluation.

Arguments have been made in favour of a constructivist or postpositivist approach to health promotion knowledge development and program evaluation, but little has been articulated about what such an approach would look like. This article describes a 'story/dialogue method' that was created with and for practitioners in response to their concerns that much of their practice did not lend itself to a positivist, or conventional, methodology. Derived from constructivist, feminist and critical pedagogical theory, and with roots in qualitative methods, the method structures group dialogue around case stories addressing particular generative practice themes. While intended for practitioner training, organizational development and evaluation, the method to date has been used primarily for training purposes. This article describes the method, provides an example of its application, and discusses its strengths, weaknesses and relevance to health promotion.

Preserving the patient referral process in the managed care environment.

Referrals are a central component of the American health care system, defining the relationship among generalists, patients, and specialists. The dynamics of the referral process as they existed in a fee-for-service medical environment will evolve under managed care, but retain the basic "Try-out" approach of the generalist and "Rule-out" approach of the specialist. A managed care, contract-based health care system alters some of the assumptions on which the referral relationship has been structured. A four-step approach to assuring quality interactions among patient, generalist, and specialist within the managed care environment is described, including: (1) engage; (2) anticipate; (3) feedback; and (4) reassess. When the referral process is structured as suggested, it can be evaluated for quality and efficacy. Armed with mutual respect and understanding, the forces that polarized specialist and generalist care in the 1980s can be redirected to enhancing patient care in the 1990s.

Enhancing physician adoption of practice guidelines. Dissemination of influenza vaccination guideline using a small-group consensus process.

BACKGROUND: A dissemination intervention to facilitate adoption of a preventive practice guideline (influenza vaccination for older adults) in group practices was developed and evaluated. The intervention, small-group consensus process, started with a physician expert presenting the guideline and followed with the group participating in a structured discussion of ways to implement the guideline that culminated in a public commitment (ie, "buy in") to adopt the guideline. METHODS: Thirteen group practices and their primary care physicians (mean size, 5) were assigned randomly to intervention or control arms. In each group practice, physicians in the intervention arm met for 1 hour. Control physicians participated in an unrelated discussion (non-steroidal drug use). Guideline adoption was determined by changes in physicians' vaccination rates that were obtained through prechart and postchart reviews of 51 physicians. Prequestionnaires and postquestionnaires measured influenza knowledge and prevention attitudes. RESULTS: Using analysis of covariance, the small-group consensus process was found to increase physician vaccination rates by 34% compared with the control arm (F (1,48) = 19.49). All intervention arm physicians increased vaccination rates from before to after compared with 54% of control arm physicians. Attitudes and knowledge did not change and were unrelated to increased vaccination rates. CONCLUSIONS: A case is made for the small-group consensus process as an effective utilization-focused dissemination method. Interventions based on group dynamics and sensitive to local practice contexts can be useful in facilitating adoption of guidelines by physicians in group practices.

Promoting social health in northern Saskatchewan.

In response to concern about social health problems in Northern Saskatchewan, a Working Group on Social Health was established in 1989 in the Research and Development Committee of Northern Medical Services. The Group formulated a concept of mental health in social terms; found and interpreted indicators of the extent of social health problems; identified major determinants of social health problems, barriers to effective coping and problems in providing adequate support and services; and identified strategies and program models that could be more effective in promoting social health in this region. Indicators of problems and underlying determinants are discussed, along with strategies for change. These strategies are based on a community development model, and incorporate innovation and reaffirmation of values and ways that have traditionally given people strength.

Factors in perceived hospital discharge planning effectiveness.

Hospital discharge planning is the process of assessing the needs of hospitalized patients for post-acute care and developing a coordinated plan to provide the care needed. It is an important component of both the financial viability of the hospital and of the overall quality of care provided to the patient across health care settings, and has historically been an important part of social work practice. This research, based on a random sample survey of U.S. non-federal acute medical/surgical hospitals (N = 378 hospitals), suggests those variables that may be most important in shaping the effectiveness of the hospital discharge planning program. A multivariate analysis framework is used to identify those variables that have the strongest independent effect on effectiveness, and to assess the relative strength of each. Power (including discharge planner influence and physician and hospital administrator support) and role clarity emerge as the most important predictors of perceived effectiveness. The model of discharge planning used and characteristics of the hospital (such as size or urban-rural location) are not significant independent predictors. The single most important factor is cooperation and support from the physician staff of the hospital. This research suggests that organizational factors, rather than the use of a particular "system" of discharge planning, may be most important in discharge planning effectiveness.

Duplication of well-baby services.

Parents, community health nurses (CHNs) and physicians in Saskatoon were surveyed to determine if specific components of well-baby services provided by CHNs and physicians were duplicated. A response was obtained from 348 (81%) of the parents, 34 (89%) of the CHNs and 129 (87%) of the physicians. Results of the study indicate that there is extensive duplication of measurements taken by CHNs and physicians at the two, four, six, and twelve-month well-baby visits, especially that of height and weight. Content of well-baby care was also examined. The percentage of both physicians and CHNs who "usually or always" perform specific tasks at each well-baby visit was very high, particularly screening tests and inquiries about nutrition. Assessments and inquiries regarding development were performed less frequently, as were inquiries about safety issues.

Radon exposure, cigarette smoking, and other mining experience in the beaverlodge uranium miners cohort.

A nested case-control study within the Beaverlodge Uranium Miners Cohort was undertaken to assess any possible contribution of confounding by smoking and other mining experience to the risk estimate derived from the original cohort study. Next of kin have been interviewed for 46 lung cancer cases and 95 controls enrolled in the Beaverlodge Uranium Miners Cohort Study who died between 1950 and 1980. Confounding by cigarette smoking and other mining experience appears unlikely to have contributed to the relative risk coefficient for exposure to Rn decay products derived in the parent study. Data for smoking and exposure to Rn decay products are consistent with a multiplicative model, although considerable caution must be applied to this interpretation.

An investigation of factors affecting the accuracy of in vivo measurements of skin pigments by reflectance spectrophotometry.

Factors affecting the accuracy of the in vivo measurement of cutaneous pigments and blood oxygenation by reflectance spectrophotometry have been examined. It was found that stray light, the amounts of haemoglobin and melanin, and the level of blood oxygenation all contributed to the measured reflectance and had to be taken into account when calculating quantitative indices of skin pigments. Measurements on isolated sheets of epidermis demonstrated that over 50% of normally incident radiation is transmitted in a forward direction within 17 degrees of the incident direction and approximately 20% is backscattered between 90 degrees and 180 degrees out of the sample, approximately 6.0% of it by specular reflection at the surface. The effective optical pathlength in suspensions of whole red cells was found to be 7% greater than in simple solutions containing the same concentration of haemoglobin.

Bromocriptine and amantadine in cocaine detoxification.

The effects of bromocriptine and amantadine in treating cocaine withdrawal were compared. Withdrawal symptoms are thought to be due to central dopamine depletion. Both bromocriptine and amantadine are dopamine agonists previously reported to diminish withdrawal symptoms. Thirty subjects were withdrawn for 30 days with amantadine, bromocriptine, or placebo. Bromocriptine and amantadine were more effective than placebo for 15 days. Amantadine's effectiveness then declined so that it was no more effective than placebo by experiment's end. Bromocriptine was significantly more effective than both throughout the latter phase of the study. Amantadine's decline in effectiveness is hypothesized to be due to stimulation of dopamine release.

A portable scanning reflectance spectrophotometer using visible wavelengths for the rapid measurement of skin pigments.

A portable rapid scan reflectance spectrometer (400-700 nm in 2.8 s) has been developed for the measurement of cutaneous pigments. The instrument incorporates a tungsten halogen lamp light source, light transmission by fibre optics and wavelength selection by a circular variable wavelength interference filter. A microcomputer controls the instrument and processes the data. The performance of the instrument was evaluated by undertaking in vitro measurements of the reflectance spectra of blood. An index of the haemoglobin content of the sample based on the gradients of the log inverse reflectance spectrum between isobestic points at 527.5, 544 and 573 nm was devised and shown to be independent of the oxygenation of the haemoglobin. The haemoglobin index was combined with measurements at 558.5 nm, a wavelength at which absorbance is sensitive to the oxygenation of haemoglobin, to give a measure of oxygen saturation. The parameter was validated by determining the oxygen dissociation curve of red cells in plasma in vitro at pH 7.33, 37 degrees C and under a partial pressure of 40 mmHg of CO2.

Therapeutic ratio of photodynamic therapy in the treatment of superficial tumours of skin and subcutaneous tissues in man.

Six patients with a total of 34 assessible subcutaneous or cutaneous lesions were treated with photodynamic therapy using 1.0, 1.5 or 2.0 mg kg-1 of photofrin II and 25-100 J cm-2 of red light (630 nm). The incidence of complete tumour response and skin necrosis were used to try to assess the therapeutic ratio of photodynamic therapy. The tumour response rate was 47%. The rate of tumour control and necrosis increased in parallel with dose of photosensitizer and light used, implying a low therapeutic ratio. However, the use of necrosis with eschar formation as an end-point for severe normal tissue damage is questioned as the skin healed completely in all cases and with minimal discomfort to the patients.

A portable reflectometer for the rapid quantification of cutaneous haemoglobin and melanin.

A portable reflectance instrument for the rapid quantification of cutaneous haemoglobin and melanin is presented. Light emitting diodes (LEDS) are used to illuminate the skin and a silicon photodiode to detect the light diffusely reflected from the surface. Reflectance measurements are made at only three wavelengths and the problems of pigment quantification consequent upon this are discussed. In addition to quantification of haemoglobin and melanin, qualitative information on the redox state of the blood may also be obtained. Measurements made on a port wine stain, which had been treated with 576 nm CW laser radiation at times between 1 and 6 months previously, provided information on the vascular response to this thermal injury. Despite the treated area visually appearing normal at 6 months post-treatment the measured levels of deoxygenated and total haemoglobin were still markedly higher than those in the adjacent uninvolved skin. The cutaneous pigment indices are insensitive to skin movement and almost all body sites are suitable for measurement.