Gordon Flowerdew

Multimodality therapy for malignant mesothelioma based on a study of natural history

Abstract Forty patients with malignant mesothelioma were studied to assess the efficacy of current treatment concepts and to examine clinical features at diagnosis which correlate with prognosis. Sixty-three per cent had been exposed to asbestos. Women, patients who presented with limited disease and those who had had symptoms for more than six months before diagnosis survived significantly longer (p Thirty of the 40 patients underwent open thoracotomy or laparotomy for diagnosis. The median survival of the 10 patients in whom a subtotal resection was attempted was 15 months, contrasted to 8.5 months for the 24 patients who underwent only an open biopsy. Five patients received aggressive radiotherapy, four immediately following subtotal surgical resection and one after biopsy alone. These patients survived a median of 9.21 months, with one patient disease-free at 52 months after diagnosis. Twenty-nine patients received chemotherapy. A partial response occurred in nine of 22 (40 per cent) previously untreated patients given AdriamycinTM-containing regimens. Patients who received chemotherapy survived a median of 15 months. In contrast, five patients (four who presented with limited disease) who accepted only supportive care survived a median of only 4.2 months after diagnosis. The treatment of mesothelioma is often based on protocols designed for sarcomas. Unlike patients with sarcoma, who generally die of metastatic disease, 78 per cent of our patients who could be evaluated died of complications of their local primary disease. We conclude that mesothelioma is sufficiently different from sarcoma to justify its treatment as a separate disease entity. Otherwise healthy patients with disease limited to a single hemithorax should be offered maximal tumor resection, followed by postoperative radiation therapy to areas of residual disease, followed by chemotherapy with a regimen containing Adriamycin.

A Simplified Protocol for Pessary Management

Objective To evaluate a simplified protocol for pessary management. Methods Women with symptomatic pelvic organ prolapse who opted for pessaries were enrolled in a prospective simplified protocol for pessary management. After the initial pessary fitting, they were seen at 2 weeks for reexamination and thereafter at 3- to 6-month intervals. Results One hundred ten women (mean age 65 years) were enrolled, and 81 (74%) of them were fitted successfully with a pessary. Life-table analysis showed that 66% of those who used a pessary for more than 1 month were still users after 12 months and 53% were still users after 36 months. The severity of pelvic prolapse did not predict the likelihood of pessary failure except in cases of complete vaginal eversion. Patients complaining of stress incontinence were less likely to have a successful pessary fitting and more likely to opt for surgery. Current hormone use and substantial perineal support do not predict greater likelihood of pessary fitting success. No serious complications from using the pessary were observed n the study sample. Conclusion Stringent guidelines calling for frequent Pelvic examinations during pessary use can be relaxed safely. Pessaries can be offered as a safe long-term option for the mangement of pelvic prolapse.

Management of patients with suspected deep vein thrombosis in the Emergency Department: Combining use of a clinical diagnosis model with D-dimer testing

The management of patients presenting to hospital Emergency Departments with suspected deep vein thrombosis is problematic since urgent diagnostic imaging is at times unavailable. We evaluated the accuracy of a rapidly available D-dimer test and the potential of combining D-dimer testing with an explicit clinical model to improve the management of patients with suspected deep vein thrombosis. Two hundred and fourteen patients with suspected deep vein thrombosis presenting to the Emergency Departments of two tertiary care institutions were enrolled in this prospective cohort study. Patients were evaluated by an Emergency Physician who determined the pre-test probability for deep vein thrombosis to be either low, moderate, or high using an explicit clinical model. Patients were managed according to their pre-test probability category by specific algorithms that in all cases included venous ultrasound imaging within 24 h and a 90-day follow-up for the development of thromboembolic complications. Patients also underwent fingerstick SimpliRED(R) whole blood agglutination D-dimer testing; however, D-dimer results did not influence subsequent patient management. D-dimer had a sensitivity of 82.5% and a specificity of 84.9% for the diagnosis of deep vein thrombosis. The observed negative predictive value of D-dimer was 96.9% (95% CI, 93.0% to 99.1%) overall, and 100% (95% CI, 96.3% to 100%) in low probability patients, 94.1% (95% CI, 83.8% to 98.8%) in moderate probability patients, and 86.7% (95% CI, 59.4% to 98.3%) in high probability patients. SimpliRED(R) D-dimer has a high negative predictive value and may be useful in excluding the diagnosis in patients at low pre-test probability for deep vein thrombosis.

Undocumented patient information: an impediment to quality of care

PURPOSE Poor documentation in medical records might reduce the quality of care and undermine analyses based on retrospective chart reviews. We assessed the documentation of cardiac risk factors and cardiac history in the records of patients hospitalized with myocardial infarction or heart failure. METHODS We performed a retrospective cohort study involving direct chart audit of all consecutive hospitalizations for myocardial infarction (n = 2,109) or heart failure (n = 3,392) in Nova Scotia, Canada, from October 15, 1997, to October 14, 1998. The main outcome measures were the documentation rates for prespecified clinical items, including cardiac risk factors and history of myocardial infarction or heart failure, which were recognized as indicators of the quality of care for the conditions under study. RESULTS Information was not documented in a high proportion of cases, ranging from 9% (smoking) to 58% (previous history of heart failure) in charts from patients hospitalized for myocardial infarction, and from 19% (smoking) to 69% (hyperlipidemia) in charts from heart failure hospitalizations. Lack of documentation was more common in women and the elderly. CONCLUSION Documentation of important clinical information is poor even in the hospital charts of patients with severe conditions. This quality-of-care issue has implications for health services and outcomes research, including the development of report cards.

Immediate postmastectomy reconstruction is associated with improved breast cancer-specific survival: evidence and new challenges from the Surveillance, Epidemiology, and End Results database.

Although immediate breast reconstruction is increasingly offered as part of postmastectomy psychosocial rehabilitation, concerns remain that it may delay adjuvant therapy or impair detection of local recurrence. No single population‐based study has examined the relationship between immediate breast reconstruction and breast cancer‐specific survival.

Health care restructuring and family physician care for those who died of cancer

BackgroundDuring the 1990s, health care restructuring in Nova Scotia resulted in downsized hospitals, reduced inpatient length of stay, capped physician incomes and restricted practice locations. Concurrently, the provincial homecare program was redeveloped and out-of-hospital cancer deaths increased from 20% (1992) to 30% (1998). These factors all pointed to a transfer of end-of-life inpatient hospital care to more community-based care. The purpose of this study was to describe the trends in the provision of Family Physician (FP) visits to advanced cancer patients in Nova Scotia (NS) during the years of health care restructuring.MethodsDesign Secondary multivariate analysis of linked population-based datafiles including the Queen Elizabeth II Health Sciences Centre Oncology Patient Information System (NS Cancer Registry, Vital Statistics), the NS Hospital Admissions/Separations file and the Medical Services Insurance Physician Services database. Setting Nova Scotia, an eastern Canadian province (population: 950,000). Subjects: All patients who died of lung, colorectal, breast or prostate cancer between April 1992 and March 1998 (N = 7,212). Outcome Measures Inpatient and ambulatory FP visits, ambulatory visits by location (office, home, long-term care facility, emergency department), time of day (regular hours, after hours), total length of inpatient hospital stay and number of hospital admissions during the last six months of life.ResultsIn total, 139,641 visits were provided by family physicians: 15% of visits in the office, 10% in the home, 5% in the emergency department (ED), 5% in a long-term-care centre and 64% to hospital inpatients. There was no change in the rate of FP visits received for office, home and long-term care despite the fact that there were 13% fewer hospital admissions, and length of hospital stay declined by 21%. Age-sex adjusted estimates using negative binomial regression indicate a decline in hospital inpatient FP visits over time compared to 1992–93 levels (for 1997–98, adjusted RR = 0.88, 95%CI = 0.81–0.95) and an increase in FP ED visits (for 1997–98, adjusted RR = 1.18, 95%CI = 1.05–1.34).ConclusionDespite hospital downsizing and fewer deaths occurring in hospitals, FP ambulatory visits (except for ED visits) did not rise correspondingly. Although such restructuring resulted in more people dying out of hospital, it does not appear FPs responded by providing more medical care to them in the community.

Medication Persistence Rates and Factors Associated with Persistence in Patients Following Stroke: A Cohort Study

BackgroundMedication nonadherence can be as high as 50% and results in suboptimal patient outcomes. Stroke patients in particular can benefit from pharmacotherapy for thrombosis, hypertension, and dyslipidemia but are at high risk for medication nonpersistence.MethodsPatients who were admitted to the Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia, with stroke between January 1, 2001 and December 31, 2002 were analyzed. Data collected were pre-stroke function, stroke subtype, stroke severity, patient outcomes, and medication use at discharge, and six and 12 months post discharge. Medication persistence at six and 12 months and the factors associated with nonpersistence at six months were examined using multivariable stepwise logistic regression.ResultsAt discharge, 420 patients (mean age 68.2 years, 55.7% male) were prescribed an average of 6.4 medications and mean prescription drug cost was

Baseline characteristics of patients enrolled in the Canadian Fabry Disease Initiative

167 monthly. Antihypertensive (91%) and antithrombotic (96%) drug use at discharge were frequent, antilipidemic (73%) and antihyperglycemic (25%) drug use were less common. Self-reported persistence at six and 12 months after stroke was high (> 90%) for all categories.In the multivariable model of medication nonpersistence at six months, people aged 65 to 79 years were less likely to be nonpersistent with antihypertensive medications than people aged 80 years or more (Odds ratio (OR) 0.11, 95% Confidence Interval (CI) 0.03–0.39). Monthly drug costs of <

Protective Associations of School Connectedness with Risk of Depression in Nova Scotia Adolescents

90 or

Urinary Tract Injury at Benign Gynecologic Surgery and the Role of Cystoscopy: A Systematic Review and Meta-analysis.

90–199.99 were associated with greater nonpersistence, compared to monthly drug costs ≥