Health resource utilisation associated with skeletal-related events in patients with bone metastases secondary to solid tumours: regional comparisons in an observational study.

Skeletal-related events (SREs) including spinal cord compression, pathologic fracture, and radiation or surgery to bone, occur frequently due to bone metastases in advanced cancer. This analysis of a multicentre, observational study was designed to describe cross-regional differences in health resource utilisation (HRU) of SREs in Western Europe and the US. Patients with bone metastases due to breast, lung or prostate cancer, or multiple myeloma who had experienced a SRE within the past 97 days were enrolled. Investigators recorded HRU associated with SREs, including hospitalisation and length of stay (LOS), outpatient visits, procedures and bisphosphonate use. This subanalysis includes 668 patients with solid tumours (US, n = 190 with 354 SREs; EU, n = 478 with 893 SREs). The rate of SREs associated with hospitalisation(s) was higher in the EU vs. the US (30% vs. 15%, P < 0.001) and LOS was longer in the EU [mean (SD) days/SRE: 19.87 (17.31) vs. 10.61 (9.39)]. However, the US was associated with higher rate of SREs with outpatient visits than the EU (88% vs. 74%, P < 0.0001) and more procedures [mean (SD)/SRE: 11.26 (7.94) vs. 6.91 (6.48)]. Bisphosphonates were less often used in the EU (65% vs. 76% of US, P = 0.0033). In patients experiencing SREs due to bone metastases, HRU patterns reflect regional diversity with a substantial burden in both regions.

Do Not Resuscitate orders and ethical decisions in a neonatal intensive care unit in a Muslim community.

AIMS: To evaluate the need for Do Not Resuscitate (DNR) orders in a tertiary referral centre for neonatal intensive care, the criteria used in making these decisions, and the applicability of the Muslim ethical stance among parents in an Islamic community. METHODS: A prospective evaluation of all DNR decisions in the neonatal intensive care unit at the Royal Hospital in Oman, over a one year period between November 1999 and October 2000. This included decision criteria, and parental responses and expectations. RESULTS: Of 659 admissions to the neonatal intensive care unit during this period, DNR orders were written in 39 (6%) instances. Most related to congenital malformations (24/39, 62%). In those in whom ventilation was commenced (19/39, 49%) withdrawal was not culturally acceptable and expressly permitted in only 11%. For those in whom ventilation was not commenced (20/39, 51%), 70% agreed not to put their child on the ventilator if they did require it. Presence of extended family support (grandparents) and clergy was extremely useful. CONCLUSIONS: Asking parents alone to be explicitly involved or take full responsibility for decisions involving life and death is not culturally or socially acceptable in this community. Presence of extended family, and indirectly sounding out and taking into account their wishes, is more appropriate after assessing the resources and support services available.

Acute pancreatitis associated with interferon alpha therapy for chronic myelogenous leukemia.

Acute pancreatitis related to interferon alpha therapy is very rare. We report two patients with chronic myelogenous leukemia (CML) who developed acute pancreatitis following treatment with interferon alpha. A review of the literature on the association of pancreatitis and interferon alpha is provided. Possible pathophysiologic mechanisms are also discussed.

Ceftazidime and ciprofloxacin as empiric therapy in febrile neutropenic patients undergoing hematopoietic stem cell transplantation.

This pilot study was done to assess the efficacy and toxicity of intravenous ceftazidime and ciprofloxacin in patients developing febrile neutropenia while undergoing high-dose myeloablative therapy and hematopoietic stem cell transplantation (HSCT). All patients undergoing high-dose chemoradiotherapy and HSCT for leukemias, lymphomas, multiple myeloma, and solid tumors received open-label ceftazidime 2 g intravenously every 8 hours and ciprofloxacin 400 mg intravenously every 12 hours if they developed fever while they were neutropenic. Success with or without modification of this regimen was defined as survival through the neutropenic period; failure was defined as death secondary to infection. Among 45 patients treated with this regimen, the success rate was 98%. Sixty-two percent (28 of 45) of the patients achieved defervescence within 48 to 72 hours and remained afebrile without regimen modification. In 16 patients (36%) the regimen was modified because of persistent fever. The combination of ceftazidime and ciprofloxacin as initial empiric antibacterial therapy in febrile neutropenic patients undergoing myeloablative therapy and HSCT appears to be highly effective and is associated with minimal toxicity.

The role of granulocyte colony-stimulating factor in hematopoietic stem cell transplantation.

Recombinant granulocyte colony-stimulating factor (G-CSF) has been shown to decrease the duration of severe neutropenia, the incidence of febrile neutropenic episodes, the overall duration of intravenous antibiotic therapy, and the length of hospitalization in patients receiving myelosuppressive chemotherapy. G-CSF has also been shown to accelerate myeloid recovery after autologous and allogeneic bone marrow transplantation, and to mobilize stem cells in peripheral blood for hematopoietic rescue. However, the optimal dose, schedule, and method of administration of G-CSF in these settings remain to be standardized. This review focuses on the role of G-CSF in bone marrow and peripheral blood stem cell transplantation, and in hematopoietic stem cell mobilization.

The clinical applications of granulocyte colony-stimulating factor in hematopoietic stem cell transplantation: a review.

The administration of recombinant human granulocyte colony-stimulating factor (G-CSF) following chemotherapy, has been shown, in controlled randomized trials, to decrease the incidence of febrile neutropenic episodes, the duration of severe neutropenia and intravenous antimicrobial therapy, and the length of hospitalization. This review focuses on the evolving role of G-CSF in bone marrow and peripheral blood stem cell transplantation, and in hematopoietic stem cell mobilization.

Early drop in protein C and antithrombin III is a predictor for the development of venoocclusive disease in patients undergoing hematopoietic stem cell transplantation.

Venoocclusive disease (VOD) of the liver remains one of the major obstacles for patients undergoing high-dose chemotherapy and hematopoietic stem cell transplantation (HSCT). Many factors have been associated with the development of VOD, including a hypercoagulable state secondary to a drop in protein C and antithrombin III (AT III). We conducted a prospective nonrandomized trial to try to determine whether the development of clinical VOD was associated with a drop in protein C, protein S, and AT III. A total of 42 patients undergoing high-dose chemotherapy and HSCT were enrolled in this study. Eleven patients underwent allogeneic bone marrow transplantation (BMT) following high-dose cyclophosphamide and fractionated total body irradiation (TBI). Thirty-one patients received autologous stem cell rescue following different preparative regimens. Measurements of protein C, protein S, and AT III levels were obtained prior to conditioning therapy and weekly thereafter for 2-3 weeks. A significant difference was noted in the mean levels of protein C on day 7 between those who developed VOD and those who did not (57.5 versus 72.1, p = 0.009). Similarly, there was a significant difference in the mean levels of AT III on days 7 and 14 between the two groups (day 7, 95.5 versus 80.6, p = 0.002; day 14, 99.6 versus 85.2, p = 0.01). The drop in protein S levels on days 7 and 14 was not statistically significant between the two groups. In conclusion, the degree of drop in protein C and AT III levels on day 7 was predictive for the development and severity of VOD.