Use of the Stages of Change transtheoretical model in end-of-life planning conversations.

Reports in the end-of-life literature reveal that patients and health care professionals, including social workers, nurses, and physicians, avoid discussions about preparation for such care. End-of-life care discussion barriers include, but are not limited to, professionals feeling unprepared to have the discussions and patients' lack of readiness to discuss planning for this care. Another barrier is the lack of a structured framework to initiate these discussions, especially with clients with advanced illnesses who may not acknowledge that they are at high risk for needing end-of-life care in the future. In a controlled trial of an Advanced Illness Coordinated Care Program, social workers initiated end-of-life planning discussions using the Stages of Change model (SOC). This article describes how the social workers introduced end-of-life planning discussions using the SOC conceptual structure to illustrate the application of a conceptual framework for professionals working with advanced illness populations.

Doxorubicin cardiotoxicity in African Americans.

PURPOSE: The African-American race was examined as a risk factor for cardiotoxicity from doxorubicin-based therapy for cancer. PATIENTS AND METHODS: Retrospective survey of the Howard University Hospital cancer registry during 1997-2001 identified 100 evaluable patients out of 120 African Americans who underwent doxorubicin-based combination chemotherapy (65% women, 35% men, median age 46 years, range 32-84 years). The fraction of patients who developed post-treatment cardiotoxicity, defined as congestive heart failure or a left-ventricular ejection fraction less than 45%, was compared with that from a retrospective study of 399 patients of unknown age and racial distribution. Cases were stratified by cumulative dose of doxorubicin. Statistical significance of the difference in incidence of cardiotoxicity was tested by chi-square analysis. RESULTS: Patients received multiple doses of doxorubicin (range 264 to 580 mg/m2 with median of 374) with the final echocardiographic assessment at a median of 1.3 years. Howard oncologists frequently used a 48-hour infusion rather than the conventional rapid bolus to reduce the cardiotoxicity of doxorubicin. The fraction with cardiotoxicity in our study versus Lefrak's review at four ranges of doxorubicin was 25% versus 18% at 551-600 mg/m2, 10% versus 4% at 501-550 mg/m2, 4% versus 1% at 451-500 mg/m2, and 0% versus <1% at <450 mg/m2. Seventy-two percent of the patients having depressed ejection fraction and/or heart failure were women. African Americans had a higher rate of cardiotoxicity after doxorubicin (7/100 cases) than that of Lefrak's (10/399) study population and were statistically significant at p<0.027 with an odds ratio of 2.93. CONCLUSION: We have shown for the first time that African Americans at our institution appear to suffer cardiotoxicity from doxorubicin three times more frequently than the previously noted study population. To better clarify this observation, a larger study in a multiracial setting is needed.

Hypopigmentation in an African patient treated with imatinib mesylate: a case report.

Imatinib mesylate (STI 571, Gleevec) is a potent bcr-abl tyrosine kinase inhibitor. It also inhibits c-kit tyrosine kinase. Imatinib mesylate is active in the treatment of cronic myeloid leukemia (CML) and gastrointestinal stromal tumors (GIST). It is considered by some authorities to be the standard of care in newly diagnosed CML as well as patients in chronic phase who do not have a related match. C-kit and its ligand stem-cell factor regulate melanocyte development and survival. Hypopigmentation in patients receiving imatinib mesylate for CML has been reported recently. In this article, we report a black Nigerian male with GIST, who developed hypopigmentation of distal parts of digits, as well as generalized lightening of skin on the body three months after receiving imatinib mesylate. We believe that this is the first case of hypopigmentation reported in a black patient with GIST.

Advanced gastrointestinal stromal tumors successfully treated with imatinib mesylate: a report of two cases.

Activation of kit-receptor tyrosine kinase occurs in all cases of gastrointestinal stromal tumors, regardless of the mutation status of kit. Imatinib mesylate (STI 571,Gleevec) is a selective inhibitor of certain protein tyrosine kinases. It has been shown in preclinical models and clinical studies to have activity against such tumors. The aim of the present study was to report the efficacy of imatinib mesylate in the treatment of advanced gastrointestinal stromal tumors. Two adults with histologically confirmed, unresectable, and metastatic gastrointestinal stromal tumors that expressed CD117 (a marker of kit-receptor tyrosine kinase) were identified at our institution during 2000-2002. As the diseases were advanced and not amenable to surgery, chemotherapy, or radiation therapy, imatinib mesylate was used, because this targeted inhibitor has been shown to be active against advanced gastrointestinal stromal tumors and has a mild toxicity profile. Imatinib mesylate induced a sustained response in both patients with advanced unresectable or metastatic gastrointestinal stromal tumors. Inhibition of the KIT signal-transduction pathway is a promising treatment for advanced gastrointestinal stromal tumors, which resist conventional chemotherapy.