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Epoprostenol beneficial in primary pulmonary hypertension
THE LANCET
SCIENCE AND MEDICINE
US guidelines published for the management of non-small-cell lung cancer And, since patients’ treatment preferences are influenced by how information is presented (eg, survival versus mortality data), better appreciation of such issues by clinicians should improve patients’ ability to make informed decisions on care.
ew guidelines for managing unresectable non-small-cell lung cancer (NSCLC) have been drawn up by the American Society of Clinical Oncology (ASCO; J Clin Oncol 1997; 15: 2996–3018). The guidelines contain recommendations for diagnosis, prognosis, treatment, follow-up, and lifestyle changes.
Symptom palliation remains a central concern in the management of patients with unresectable NSCLC, but chemotherapy is recommended for patients whose disease has not severely limited their ability to carry out normal tasks. The guidelines should be applied according to each patient’s circumstances, says ASCO.
Epoprostenol beneficial in primary pulmonary hypertension
Half a brain can be better than a whole brain
E
poprostenol, a prostacyclin analogue, lowers pulmonary artery pressure and prolongs survival in patients with primary pulmonary hypertension (PPH; J Am Coll Cardiol 1997; 30: 343-49). In 18 patients with PPH and congestive heart failure (New York Heart Association functional class III or IV) who received epoprostenol by continuous intravenous infusion the mean right ventricular pressure gradient (␦P) fell significantly, from 84·1 mm Hg (SD 24·1) to 62·7 mm Hg (18·2), during long-term followup (330–700 days). The ratio of ␦P to CO flow (measured across the left ventricular outflow tract during systole) also fell significantly, suggesting a reduction in pulmonary vascular resistance. Haemodynamic measurements made within 48 hours of the start of treatment did not predict the long-term outcome: 5 of 7 patients without a short-term fall in ␦P showed a persistent long-term decline in ␦P. Patients with PPH treated with prostacyclin, the authors note, have a significant survival advantage over historical controls. The 1, 2, and 3-year survival rates for patients receiving epoprostenol were 80%, 76%, and 49%, respectively, while survival rates of 88% (at 10 months), 56% (20 months), and 47% (30 months) were predicted for prostacyclin-treated patients in another study. The authors conclude that “treatment with epoprostenol prolongs life in patients with PPH and can safely be used in patients with right heart failure who [like those in the study] cannot tolerate calciumchannel blockers or in whom calcium-channel blockers have failed”.
emispherectomy can relieve seizures and reduce the “burden of medication and general dysfunction” in children with severe or progressive unilateral cortical disease, says paediatric neurologist Eileen Vining, lead author of a study of 58 children who underwent surgery at the Johns Hopkins Medical Institutions (Baltimore, MD, USA). “When half of the brain is bad, it’s better to take it out”, asserts Vining. This allows “the remaining hemisphere to function more normally and often regain function that was lost in the face of constant seizures”. Of the patients, aged 2 months to 20 years, who had hemispherectomy for Rasmussen’s syndrome, cortical dysplasias, or other congenital vascular problems between 1968–1996, 54 survived surgery. 29 are seizure-free, 13 have non-handicapping seizures, but 12 have seizures that interfere to some extent with function. Seizure control alone is not an adequate measure of surgery success, say the researchers. So they constructed a “burden of illness scale”—the first of its kind and as yet unvalidated— based on differences in a child’s
H
Dorothy Bonn
mental and motor disability, disability from seizures, and “the family’s response and overprotection” before and after surgery. Hemispherectomy was very successful in decreasing the burden of illness in 44 children, moderately successful in 7, and minimally successful in 3. “Success was related to the etiology, and early surgery was preferable”, conclude the authors (Pediatrics 1997; 100: 163–171). But, admits Vining, “some people feel what we do is too radical”. Rodney Radtke (Duke University Epilepsy Center, Durham, NC, USA) says the Hopkins’ team “has raised consciousness of the availability of the procedure, and their study offers some support for their argument that it should be applied earlier in the course of disease”. But, the use of “more objective measures” to assess outcome rather than the authors’ own scale “would have strengthened the article”. Standard tests would be “more confirmable” and “provide a potentially fascinating measure of the brain’s adaptation to the removal of one hemisphere”. Marilynn Larkin
Marital strife stresses elderly immune systems Even couples who have been happily married for decades can experience adverse health effects from the stress of “abrasive marital interactions”, report Janice Kiecolt-Glaser and colleagues (Ohio State University, Columbus, USA). The researchers studied 31 couples, married for an average of 42 years, during discussions aimed at resolving issues causing marital problems (Psychosom Med 1997; 59: 339–49). Among wives, but not husbands, escalation of negative behaviours-— criticising, interrupting, disapproving—was associated with changes in stress-related hormones. And couples with troubled marriages had weaker immune responses than those who expressed satisfaction with their marriage. “You might expect that arguments would have less impact on older couples because they’ve gone through these disagreements many times before . . . But that’s not the case”, says Kiecolt-Glaser. Marilynn Larkin Still crazy after all those years Bubbles Photo Library
N
Dorothy Bonn
Vol 350 • August 9, 1997
417
SCIENCE AND MEDICINE
US guidelines published for the management of non-small-cell lung cancer And, since patients’ treatment preferences are influenced by how information is presented (eg, survival versus mortality data), better appreciation of such issues by clinicians should improve patients’ ability to make informed decisions on care.
ew guidelines for managing unresectable non-small-cell lung cancer (NSCLC) have been drawn up by the American Society of Clinical Oncology (ASCO; J Clin Oncol 1997; 15: 2996–3018). The guidelines contain recommendations for diagnosis, prognosis, treatment, follow-up, and lifestyle changes.
Symptom palliation remains a central concern in the management of patients with unresectable NSCLC, but chemotherapy is recommended for patients whose disease has not severely limited their ability to carry out normal tasks. The guidelines should be applied according to each patient’s circumstances, says ASCO.
Epoprostenol beneficial in primary pulmonary hypertension
Half a brain can be better than a whole brain
E
poprostenol, a prostacyclin analogue, lowers pulmonary artery pressure and prolongs survival in patients with primary pulmonary hypertension (PPH; J Am Coll Cardiol 1997; 30: 343-49). In 18 patients with PPH and congestive heart failure (New York Heart Association functional class III or IV) who received epoprostenol by continuous intravenous infusion the mean right ventricular pressure gradient (␦P) fell significantly, from 84·1 mm Hg (SD 24·1) to 62·7 mm Hg (18·2), during long-term followup (330–700 days). The ratio of ␦P to CO flow (measured across the left ventricular outflow tract during systole) also fell significantly, suggesting a reduction in pulmonary vascular resistance. Haemodynamic measurements made within 48 hours of the start of treatment did not predict the long-term outcome: 5 of 7 patients without a short-term fall in ␦P showed a persistent long-term decline in ␦P. Patients with PPH treated with prostacyclin, the authors note, have a significant survival advantage over historical controls. The 1, 2, and 3-year survival rates for patients receiving epoprostenol were 80%, 76%, and 49%, respectively, while survival rates of 88% (at 10 months), 56% (20 months), and 47% (30 months) were predicted for prostacyclin-treated patients in another study. The authors conclude that “treatment with epoprostenol prolongs life in patients with PPH and can safely be used in patients with right heart failure who [like those in the study] cannot tolerate calciumchannel blockers or in whom calcium-channel blockers have failed”.
emispherectomy can relieve seizures and reduce the “burden of medication and general dysfunction” in children with severe or progressive unilateral cortical disease, says paediatric neurologist Eileen Vining, lead author of a study of 58 children who underwent surgery at the Johns Hopkins Medical Institutions (Baltimore, MD, USA). “When half of the brain is bad, it’s better to take it out”, asserts Vining. This allows “the remaining hemisphere to function more normally and often regain function that was lost in the face of constant seizures”. Of the patients, aged 2 months to 20 years, who had hemispherectomy for Rasmussen’s syndrome, cortical dysplasias, or other congenital vascular problems between 1968–1996, 54 survived surgery. 29 are seizure-free, 13 have non-handicapping seizures, but 12 have seizures that interfere to some extent with function. Seizure control alone is not an adequate measure of surgery success, say the researchers. So they constructed a “burden of illness scale”—the first of its kind and as yet unvalidated— based on differences in a child’s
H
Dorothy Bonn
mental and motor disability, disability from seizures, and “the family’s response and overprotection” before and after surgery. Hemispherectomy was very successful in decreasing the burden of illness in 44 children, moderately successful in 7, and minimally successful in 3. “Success was related to the etiology, and early surgery was preferable”, conclude the authors (Pediatrics 1997; 100: 163–171). But, admits Vining, “some people feel what we do is too radical”. Rodney Radtke (Duke University Epilepsy Center, Durham, NC, USA) says the Hopkins’ team “has raised consciousness of the availability of the procedure, and their study offers some support for their argument that it should be applied earlier in the course of disease”. But, the use of “more objective measures” to assess outcome rather than the authors’ own scale “would have strengthened the article”. Standard tests would be “more confirmable” and “provide a potentially fascinating measure of the brain’s adaptation to the removal of one hemisphere”. Marilynn Larkin
Marital strife stresses elderly immune systems Even couples who have been happily married for decades can experience adverse health effects from the stress of “abrasive marital interactions”, report Janice Kiecolt-Glaser and colleagues (Ohio State University, Columbus, USA). The researchers studied 31 couples, married for an average of 42 years, during discussions aimed at resolving issues causing marital problems (Psychosom Med 1997; 59: 339–49). Among wives, but not husbands, escalation of negative behaviours-— criticising, interrupting, disapproving—was associated with changes in stress-related hormones. And couples with troubled marriages had weaker immune responses than those who expressed satisfaction with their marriage. “You might expect that arguments would have less impact on older couples because they’ve gone through these disagreements many times before . . . But that’s not the case”, says Kiecolt-Glaser. Marilynn Larkin Still crazy after all those years Bubbles Photo Library
N
Dorothy Bonn
Vol 350 • August 9, 1997
417