Systemic therapy for bone metastases.

BACKGROUND: Accelerated bone loss in patients with cancer is a frequent problem that may result from invasion of the cancer to bone, paraneoplastic tumor proteins, and/or hormonal therapies utilized for cancer treatment. Patients with osteolytic bone disease from multiple myeloma and bone metastases from solid tumors may develop a vicious cycle of bone destruction involving both osteolytic and osteoblastic effects. Consequently, a variety of skeletal-related events (SREs) may occur, including pathological fractures, hypercalcemia, spinal cord compression, and the need for surgical intervention and radiation therapy. METHODS: This article reviews the results of trials that investigated the safety and efficacy of pharmacologic agents, including bisphosphonates and denosumab, for treatment of bone metastases. This analysis is derived from an assessment of the medical literature. RESULTS: Beneficial systemic therapies for bone metastases have been developed to decrease SREs. Possible antitumor effects of the bisphosphonates are explored. In addition, the utility of markers of bone turnover in relation to response to therapy and survival, the safety and toxicity of bone-targeted therapies, treatment guidelines, and economic considerations are also discussed. CONCLUSIONS: Effective systemic therapies for metastatic bone disease are available. Ongoing and future research projects in this field are also presented.

Evaluation of student performance in combined baccalaureate-MD degree programs.

BACKGROUND: Among the innovations in medical education during the 1960s and early 1970s was the emergence of combined baccalaureate-MD degree programs. Viewed as educational experiments, an evaluation of performance outcomes for these programs is needed. SUMMARY: Performance outcomes of students in combined-degree programs, reported in the literature 1966-1996, are reviewed. Attrition rates are lower for combined-degree students than for traditional premedical students, and there are usually no differences in attrition between combined-degree and traditional students in the medical phase of their education. All measures of performance indicate that students in combined-degree programs achieve a level of competency comparable to traditional medical students. CONCLUSIONS: The support systems of the Baccalaureate-MD degree programs facilitate retention in a medical career. The educational experiment of the combined-degree programs has demonstrated that future physicians can be successfully selected from high school.

First-year residents' performances compared with their medical school class ranks as determined by three ranking systems.

Difficulties encountered with deans' letters have prompted residency directors to rely on performance indicators, including class rank, that indicate the comparative positions of applicants. However, the validity of class rank as a predictor of performance in residency is not well established. The present investigation studied the relationship of class ranks to residents' performances, the systems of class ranking that correlated with residents' performances, and procedures that strengthened the relationship between ranking information and residents' performances. Three systems of class ranking are described. With each system, the authors used the same study group of 124 graduates (classes of 1986 and 1987) from a midwestern medical school with a baccalaureate-M.D. degree program; by 1991, each graduate had completed his or her first year of residency. All three systems were reliable for assignment of class rank. All three systems showed modest correlations with residents' performances. Multiple regression analysis revealed that a weighted combination of clinical performance measures bore the strongest relationship to performances in residency. Thus, the authors conclude that the formal computational ranking of students is not essential for the generation of reliable and valid deans' letters that can predict residents' performances. An in-depth evaluation that includes comparative information based on statistically generated formulas, as well as information based on personal qualities, may be a superior alternative.

Xanthopsia and van Gogh's yellow palette.

A survey of van Gogh's work from 1886 to 1890 indicated that paintings with a yellow dominance were numerous, episodic, and multi-regional. His underlying illness, by his own admission, affected his life and work; furthermore, episodes of malnutrition, substance abuse, environmental exposure, and drug experimentation (all evident from correspondence) exacerbated his condition. Accordingly, we reviewed plausible agents that might have modified the artist's colour perception. Xanthopsia due to overdosage of digitalis or santonin is well documented elsewhere, but evidence of useage of either drug by van Gogh cannot be substantiated. It is unlikely that ageing of the human lens was an influence because of the artist's youth. Sunstroke is too restrictive to fit the multiplicity of regions and motifs. Hallucinations induced by absinthe, the popular liqueur of the period, may explain particular canvases but not the majority of 'high yellow' paintings. Van Gogh's proclivity for exaggerated colours and his embrance of yellow in particular are clear from his letters and, in contradistinction to chemical or physical insults modifying perception, artistic preference is the best working hypothesis to explain the yellow dominance in his palette.

Influence of mitotane on the hypoprothrombinemic effect of warfarin.

Mitotane (o,p'-DDD) is closely related to the organochlorine insecticides and shares their effects on drug metabolism. We have reported the first documented interaction of mitotane and warfarin in a human being. Because the potential for significant toxicity is great when mitotane and warfarin are used concomitantly, caution is recommended when titrating warfarin therapy in patients receiving mitotane. Other drugs susceptible to the influence of enzyme inducers should also be given with caution to patients receiving mitotane.