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Available under license: Copyright the publishersT h e ne w e ngl a nd jou r na l o f m e dic i ne n engl j med 359;24 www.nejm
The concept of psychosocial effects in cancer cachexia has the potential to sensitize health care professionals to cachexia-related problems and inform their clinical management of the condition.
There are marginal positive effects of CCDSS on specific PRO. Factors that facilitate the use and effect are identified. Easy to use systems with difficult to ignore evidence-based advice need to be developed and tested.
Background Natural ghrelin, a peptide growth hormone secretagogue, has a therapeutic potential in cachexia. We designed a dose-finding trial of subcutaneous natural ghrelin to improve nutritional intake (NI) in advanced cancer patients. Methods Advanced cancer patients with cachexia management (symptom management, physiotherapy, nutritional, and psychosocial support) started with ghrelin at 32 μg/kg body weight, followed by 50% dose increases. Patients self-injected ghrelin twice daily for 4 days followed by a wash-out period. After reaching the primary endpoint, maximal NI (minimal dose for maximal NI), a maintenance period followed during which patients injected 10 doses of ghrelin per week. Safety parameters, NI, and cachexia outcomes (symptoms, narratives, muscle mass, and strength) were measured over 6 weeks. Results Ten patients with metastatic solid tumours were included, and six (100% male, mean age 61.8 ± 8.5 SD) received ghrelin. Minimal dose for maximal NI was reached in four patients. Three patients reached the end-of study visit. Ghrelin was well tolerated with variable results on appetite and eating-related symptoms but a positive effect in the narratives. Mean Functional Assessment of Appetite & Cachexia Therapy score was 6.8 points lower at final measurement compared with baseline, t(5) = 5.98, P < .01. Muscle mass was stable in two patients and increased in one patient, and muscle strength was stable in three patients. Subjective tolerability was high. Patients showed a fluctuating trajectory, and median survival was 88 days (51-412 days). Conclusions Ghrelin was safe in advanced patients with cancer cachexia without dose-limiting toxicity and well tolerated. The intervention was very complex, and the number of patients included was small. There was a positive effect on nutritional intake and patient narratives.
Acute HIV-infection mostly presents with unspecifc symptoms. Thus the acute retroviral syndrome is often not readily recognized. Here we present an interim analysis of a prospective study from 62 patients with documented acute HIV infection acquired between January 2002-August 2004 in the greater Zurich area. 61.5% of patients were infected by homosexual contacts, mostly with HIV-1 subtype B, 34% acquired infection by heterosexual contacts, often with non-B-virus subtypes. Transmission occurred in all sexually active age groups (18-72 years). Clinical symptoms presented as follows: fever (77%), pharyngitis (56%), fatigue (52%), gastrointestinal symptoms (45%), rash (39%). On first physician contact, an ARS was only suspected in 27% of the cases. Patients primarily called on their family doctors (37.5%), went to see larger walk in clinics or emergency rooms (37.5%), and 16% were hospitalised. In 16% of patients other sexually transmitted diseases were diagnosed contemporaneously. Drug resistant virus (single class resistance) was transmitted in only one patient.
The final item bank contains questions that are understood and accepted by the patients. This item bank now needs to be developed into a measurement tool that groups items into domains and can be used in future research studies.
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