The nausea and vomiting experienced by one in four cancer patients in anticipation of chemotherapy is probably a learned response to treatment. To determine whether behavioral approaches for altering learned responses might be useful treatments for these symptoms, we compared the effects of "systematic desensitization" (a behavioral treatment in which relaxation is learned as a response to situations in which patients have had anticipatory nausea and vomiting) with those of counseling and of no treatment. Sixty ambulatory cancer patients with anticipatory nausea and vomiting before their third and fourth chemotherapy treatments were randomized equally to the three groups. Significantly more patients receiving desensitization reported no anticipatory nausea before their fifth and sixth chemotherapy treatments than patients given counseling (P less than 0.05) or no treatment (P less than 0.01). Desensitized patients also reported significantly less severe anticipatory nausea (P less than 0.01) and vomiting (P less than 0.05) and a shorter duration of anticipatory nausea (P less than 0.01). We conclude that systematic desensitization appears to have an antiemetic effect in cancer patients who receive chemotherapy, and may be useful in the management of these problems.

We have demonstrated that the prognostic value of elevated H-FABP is additive to troponin in low- and intermediate-risk patients with suspected ACS. Other studies suggest that our observations reflect the value of H-FABP as a marker of myocardial ischemia, even in the absence of frank necrosis.

Heart-type fatty acid-binding protein predicts long-term mortality after ACS and identifies high-risk patients in a manner that is additive to the GRACE clinical risk factors, troponin, and hs-CRP, possibly as a result of identifying the occurrence of myocardial ischemia with or without necrosis.

Discharge from a neonatal intensive care unit (NICU) requires assessment, coordination, and possible intervention by a multidisciplinary team. The infant's health condition and the family's social situation must be considered before discharge to design a discharge plan for the child's long-term well-being. This article presents the neonatal discharge assessment tool (N-DAT) as a method to identify risks at the time of discharge. The tool offers specific recommendations for use with infants who are medically or socially high risk. The implications for the NICU team and for coordination with community providers are discussed.

Abstract.A cholecystectomy was performed on a 10-year-old spayed female mixed-breed dog with chronic weight loss, persistently increased liver enzyme activities, and cholecystomegaly identified by ultrasonographic examination. A subsequent diagnosis of a biliary carcinoid was made based on a neuroendocrine-type histologic pattern, cytoplasmic argyrophilia by Grimelius staining, immunopositivity for chromogranin A, and the ultrastructural finding of cytoplasmic secretory granules in neoplastic cells. Extrahepatic biliary carcinoid tumors are rare tumors of humans and have not been documented in domestic animals.Key words: Dogs; gallbladder; biliary; carcinoid. In humans and animals, carcinoid tumors are uncommon neoplasms that arise from dispersed cells of the neuoroendocrine system in the gastrointestinal tract, biliary system, pancreas, and lung. These cells belong to one of two functional groups: 1) the amine precursor uptake and decarboxylation cells that produce serotonin and adrenocorticotrophic hormone, or 2) those cells capable of synthesizing low molecular weight polypeptide or protein hormones such as chromogranin, cholecystokinin and secretin. Definitive diagnosis of carcinoid tumors is based on histologic features, immunostaining for secretory products such as chromogranin, and ultrastructural identification of neuroendocrine secretory granules. 2 In dogs, hepatic, gastrointestinal, and pulmonary carcinoids have been reported. [5][6][7] Intestinal carcinoids have also been documented in a horse and a cow. 2 In horses, three cases of maxillary sinus carcinoid tumors have been reported as well. 8 In humans, carcinoid tumors are frequently found in the gastrointestinal system (74%) and the bronchopulmonary system (25%). Within the gastrointestinal tract, the most common sites include the small bowel (29%), appendix (19%), and rectum (13%). 3 In this case, a 10-year-old spayed female mixed-breed dog initially presented for weight loss and persistent vomition. No abnormalities were noted on physical examination. Serum biochemistry abnormalities included increased liver enzyme activities, including aspartate aminotransferase (625 U/ L; reference range 10-60 U/L), alanine aminotransferase (2,225 U/L; reference range 8-57 U/L), lactate dehydrogenase (531 U/L; reference range (0-250 U/L), and alkaline phosphatase (4,460 U/L; reference range 10-140 U/L) as well as hyperbilirubinemia (Total bilirubin 5.6 mg/dL; reference range 0-0.6 mg/dL) consistent with hepatocellular damage and cholestasis. During the next 8 weeks, progres-

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Objectives Use of cumulative mortality adjusted for case mix in patients with acute myocardial infarction for early detection of variation in clinical practice. Design Observational study. Setting 20 hospitals across the former Yorkshire region. Participants All 2153 consecutive patients with confirmed acute myocardial infarction identified during three months. Main outcome measures Variable life-adjusted displays showing cumulative differences between observed and expected mortality of patients; expected mortality calculated from risk model based on admission characteristics of age, heart rate, and systolic blood pressure. Results The performance of two individual hospitals over three months was examined as an example. One, the smallest district hospital in the region, had a series of 30 consecutive patients but had five more deaths than predicted. The variable life-adjusted display showed minimal variation from that predicted for the first 15 patients followed by a run of unexpectedly high mortality. The second example was the main tertiary referral centre for the region, which admitted 188 consecutive patients. The display showed a period of apparently poor performance followed by substantial improvement, where the plot rose steadily from a cumulative net lives saved of − 4 to 7. These variations in patient outcome are unlikely to have been revealed during conventional audit practice. Conclusions Variable life-adjusted display has been integrated into surgical care as a graphical display of risk-adjusted survival for individual surgeons or centres. In combination with a simple risk model, it may have a role in monitoring performance and outcome in patients with acute myocardial infarction.

Objective-To develop a simple risk model as a basis for evaluating care of patients admitted with acute myocardial infarction. Methods-From coronary care registers, biochemistry records and hospital management systems, 2153 consecutive patients with confirmed acute myocardial infarction were identified. With 30 day all cause mortality as the end point, a multivariable logistic regression model of risk was constructed and validated in independent patient cohorts. The areas under receiver operating characteristic curves were calculated as an assessment of sensitivity and specificity. The model was reapplied to a number of commonly studied subgroups for further assessment of robustness. Results-A three variable model was developed based on age, heart rate, and systolic blood pressure on admission. This produced an individual probability of death by 30 days (P 30 ) where P 30 = 1/(1 + exp(−L 30 )) and L 30 = −5.624 + (0.085 × age) + (0.014 × heart rate) − (0.022 × systolic blood pressure). The areas under the receiver operating characteristic curves for the reference and test cohorts were 0.79 (95% CI 0.76 to 0.82) and 0.76 (95% CI 0.72 to 0.79), respectively. To aid application of the model to routine clinical audit, a normogram relating observed mortality and sample size to the likelihood of a significant deviation from the expected 30 day mortality rate was constructed.Conclusions-This risk model is simple, reproducible, and permits quality of care of acute myocardial infarction patients to be reliably evaluated both within and between centres. (Heart 2001;86:150-154)