General practitioner's reported use of clinical guidelines for hypertension and ambulatory blood pressure.

ABPM is an invaluable clinical tool, as it has been shown to improve blood pressure control in primary care. Many clinical guidelines for hypertension advocate ambulatory blood pressure monitoring. This study aims to quantify the use of clinical guidelines for hypertension and to explore the role of ABPM in Primary Care. A questionnaire survey was sent to GPs working in the West of Ireland. 88% (n=139) of GPs use clinical guidelines that recommend the use of ABPM. 82% (n=130) of GPs find use of clinic blood pressure monitoring insufficient for the diagnosis and monitoring of hypertension. Despite good access to ABPM, GPs report lack of remuneration, 72% (n=116), cost 68% (n=108), and lack of time, 51% (n=83) as the main limiting factors to use of ABPM. GPs recognise the clinical value of ABPM, but this study identifies definite barriers to the use of ABPM in Primary Care.

Attitudes of general practitioners to prehospital thrombolysis.

The aim of the study was to investigate attitudes of rural Irish General Practitioners (GPs) to prehospital thrombolysis. Postal questionnaires were sent to all General Medical Service (GMS) GPs in the former Western and North Western Health Board regions of Ireland, whose practices were 20km or greater from the nearest acute hospital with a coronary care unit. The response rate was 61% (117/191). 95% were convinced of the benefits of thrombolytic treatment in acute myocardial infarction. 92%/ believed that there were additional benefits of thrombolysing in the community at the earliest opportunity. 89% were not willing to use prehospital thrombolysis without further training. The study demonstrated that the majority of rural Irish GPs are convinced of the benefits of prehospital thrombolysis and are willing to administer it. The need for further training on prehospital thrombolysis is a key issue that must be addressed before rural Irish GPs are willing to provide more widespread prehospital thrombolysis.

Tumour localisation with a metal coil before the administration of neo-adjuvant chemotherapy.

Complete clinical response (CR) with tumour disappearance is not uncommon after neo-adjuvant chemotherapy (NAC) for locally advanced breast cancer, avoiding 25% mastectomies by facilitating breast-conserving procedures. We reviewed our series to understand the feasibility and utility of marking the cancer site before administering NAC. In total, 23 women (median age 47 years) with T2-4, N0-1, M0 tumours were considered unsuitable for breast conserving surgery between January 2002 and November 2003, thus received NAC following a coil placement at the core of tumour. All patients had the coil successfully inserted and no migration or infection was recorded. Eight patients (35%) had a radiological CR (rCR) including 3 (13%) with pathological CR (pCR). In total, 87% patients were managed conservatively. The insertion of a metal coil is a simple mean to provide a landmark for localisation and excision when the breast lump becomes impalpable and radiologically undetectable after the administration of NAC.

Phase I and pharmacokinetic study of DACA (XR5000): a novel inhibitor of topoisomerase I and II. CRC Phase I/II Committee.

DACA, also known as XR5000, is an acridine derivative active against both topoisomerase I and II. In this phase I study, DACA was given as a 3-h intravenous infusion on 3 successive days, repeated every 3 weeks. A total of 41 patients were treated at 11 dose levels between 9 mg m(-2) d(-1) and the maximum tolerated dose of 800 mg m(-2) day(-1). The commonest, and dose-limiting, toxicity was pain in the infusion arm. One patient given DACA through a central venous catheter experienced chest pain with transient electrocardiogram changes, but no evidence of myocardial infarction. At the highest dose levels, several patients also experienced flushing, pain and paraesthesia around the mouth, eyes and nose and a feeling of agitation. Other side-effects, such as nausea and vomiting, myelosuppression, stomatitis and alopecia, were uncommon. There was one minor response but no objective responses. DACA pharmacokinetics were linear and did not differ between days 1 and 3. The pattern of toxicity seen with DACA is unusual and appears related to the mode of delivery. It is possible that higher doses of DACA could be administered using a different schedule of administration.

Pathological T3 and/or margin positive prostate adenocarcinoma with undetectable postoperative PSA - to irradiate or not?: analysis of freedom from PSA failure.

We retrospectively analyzed 48 patients with pathological T3 (PT3) and/or margin positive disease who had undetectable or unknown postoperative serum prostate specific antigen (PSA) following radical prostatectomy. Twenty-nine patients received postoperative adjuvant radiotherapy (RT) while 19 did not. Follow-up ranged from 0.5 to 6.9 years with a median of 3.4 years for the irradiated group and 2.9 years for the surgery alone group. PSA outcome was available on all patients. Freedom from failure was defined as the maintenance of a serum PSA level of < 0.2 ng/ml and the absence of clinical local recurrence and distant metastasis. Actuarial overall survival was 92% for the entire group and showed no difference between the irradiated and non-irradiated groups. However, the 5-year actuarial disease free survival including freedom from PSA failure was statistically better in those treated with adjuvant RT than that in the surgery alone group (88% vs 46%, p=0.0035). The morbidity of adjuvant RT was acceptable with only 2 patients developing Grade 3 genitourinary complication.

A short fractionation radiotherapy treatment for poor prognosis patients with high grade glioma.

Thirty-two patients prospectively identified as having poor prognosis high grade glioma, with a MRC prognostic score >25, were treated with a short palliative course of radiotherapy. A total dose of 36 Gy in 12 fractions was given to the tumour, including oedema and a 2 cm margin, using parallel pair fields prescribed to the midplane with MV photons. Twenty-eight patients completed treatment as planned, while four failed to complete treatment because of clinical deterioration or death. The median survival for the whole group was 16 weeks, with seven patients surviving for more than 6 months. Approximately two-thirds of the surviving patients remained at home after the completion of treatment. A matched case-control comparison with data from patients in previous MRC studies who had received a 6-week course of treatment shows that, for this group of patients, survival is similar (hazard ratio 1.0; 95% confidence interval (CI) 0.57-1.74). The 95% CI for the difference in median survival time excludes a reduction of more than 7 weeks with the 36 Gy course. This shortened radiotherapy regimen may therefore be satisfactory for most poor prognosis patients. However, patients with performance status 3 gained little benefit from treatment, and it is suggested that this group should have a trial period of assessment at home prior to a decision on treatment.

Can radiotherapy salvage isolated local recurrence following radical prostatectomy?

The optimal management of isolated local recurrence of prostate cancer following radical prostatectomy remains unknown. Salvage radiotherapy to the prostatic bed is one of management options. This article reviews the efficacy of salvage radiotherapy. The available data suggest that salvage radiotherapy offers excellent clinical local control. However, the probability of long-term disease free survival with salvage radiotherapy alone appears small as a significant proportion of patients develop distant metastases and rising prostate specific antigen (PSA) following radiotherapy. A strategy of combining systemic therapy with local salvage treatment needs to be explored for this poor prognostic group.