Received: from post-ofc05.srv.cis.pitt.edu (root@post-ofc05.srv.cis.pitt.edu [136.142.185.10]) by pop.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cispop-7.2.2.1) ID ; Mon, 29 Mar 1999 23:49:27 -0500 (EST) Received: from localhost (root@localhost) by post-ofc05.srv.cis.pitt.edu (8.8.8/8.8.8/cispo-7.2.2.2) ID ; Mon, 29 Mar 1999 23:48:51 -0500 (EST) Received: via switchmail; Mon, 29 Mar 1999 23:48:50 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Mon, 29 Mar 1999 23:47:59 -0500 (EST) Received: from localhost (majordom@localhost) by list.srv.cis.pitt.edu (8.8.8/8.8.8/cisls-7.2.2.1) ID ; Mon, 29 Mar 1999 23:47:35 -0500 (EST) Received: from mb3.mailbank.com (mb3.mailbank.com [209.133.104.8]) by list.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cisls-7.2.2.1) ID for ; Mon, 29 Mar 1999 23:47:28 -0500 (EST) Received: from localhost (user-2iveshf.dialup.mindspring.com [165.247.114.47]) by mb3.mailbank.com (8.9.1a/8.9.1) with SMTP id UAA18799 for ; Mon, 29 Mar 1999 20:47:23 -0800 Date: Mon, 29 Mar 1999 20:47:23 -0800 Message-Id: <199903300447.UAA18799@mb3.mailbank.com> X-Authentication-Warning: mb3.mailbank.com: Host user-2iveshf.dialup.mindspring.com [165.247.114.47] claimed to be localhost From: Wayne Roberts To: Subject: Re: W-EMED medical certification X-Mailer: HandMail 2.0 Mime-Version: 1.0 Content-Type: text/plain; Charset="iso-8859-1" Content-Transfer-Encoding: 8bit X-MIME-Autoconverted: from quoted-printable to 8bit by list.srv.cis.pitt.edu id XAA23934 Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk Reply-To: wilderness-emergency-medicine@list.pitt.edu X-PMFLAGS: 34078848 0 1 P69250.CNM Piedmont Search & Rescue in VA (part of the Appalachian Search & Rescue Conference in VA, MD, WV, and PA) requires CPR and Basic First Aid, or equivalent, in order to become an Active Member (in addition to 32 hours of SAR training including Call Out Qualified). Wayne Roberts, EMT-CT Richmond, VA PSAR >I am curious what other rescue groups require for medical certification >in their teams, and at what rank (rescue, support, etc) they require >certification? > >Thanks; > >Steve Kelleher >EMS Director >Alpine Rescue Team >Evergreen, CO. >slpknot@ibm.net Do not reproduce without author's express permission. To unsubscribe, send the text "unsubscribe wilderness-emergency-medicine" as the body of a message (no subject) To: Majordomo@list.pitt.edu Submissions To: wilderness-emergency-medicine@list.pitt.edu -- End -- Received: from post-ofc05.srv.cis.pitt.edu (root@post-ofc05.srv.cis.pitt.edu [136.142.185.10]) by pop.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cispop-7.2.2.1) ID ; Mon, 29 Mar 1999 21:42:57 -0500 (EST) Received: from localhost (root@localhost) by post-ofc05.srv.cis.pitt.edu (8.8.8/8.8.8/cispo-7.2.2.2) ID ; Mon, 29 Mar 1999 21:42:14 -0500 (EST) Received: via switchmail; Mon, 29 Mar 1999 21:42:14 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Mon, 29 Mar 1999 21:40:28 -0500 (EST) Received: from localhost (majordom@localhost) by list.srv.cis.pitt.edu (8.8.8/8.8.8/cisls-7.2.2.1) ID ; Mon, 29 Mar 1999 21:39:16 -0500 (EST) Received: from out2.ibm.net (out2.ibm.net [165.87.194.229]) by list.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cisls-7.2.2.1) ID for ; Mon, 29 Mar 1999 21:39:11 -0500 (EST) Received: from ibm.net (root@slip-32-101-226-91.co.us.ibm.net [32.101.226.91]) by out2.ibm.net (8.8.5/8.6.9) with ESMTP id CAA13432 for ; Tue, 30 Mar 1999 02:39:08 GMT Message-ID: <37003920.19EC3586@ibm.net> Date: Mon, 29 Mar 1999 19:38:24 -0700 From: Steve Kelleher X-Mailer: Mozilla 4.07 [en] (X11; I; Linux 2.0.36 i586) MIME-Version: 1.0 To: WEMSI Subject: W-EMED medical certification Content-Type: text/plain; charset=us-ascii Content-Transfer-Encoding: 7bit Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk Reply-To: wilderness-emergency-medicine@list.pitt.edu X-PMFLAGS: 34078848 0 1 P6D440.CNM I am curious what other rescue groups require for medical certification in their teams, and at what rank (rescue, support, etc) they require certification? Thanks; Steve Kelleher EMS Director Alpine Rescue Team Evergreen, CO. slpknot@ibm.net Do not reproduce without author's express permission. To unsubscribe, send the text "unsubscribe wilderness-emergency-medicine" as the body of a message (no subject) To: Majordomo@list.pitt.edu Submissions To: wilderness-emergency-medicine@list.pitt.edu -- End -- Received: from post-ofc05.srv.cis.pitt.edu (root@post-ofc05.srv.cis.pitt.edu [136.142.185.10]) by pop.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cispop-7.2.2.1) ID ; Wed, 24 Mar 1999 16:31:51 -0500 (EST) Received: from localhost (root@localhost) by post-ofc05.srv.cis.pitt.edu (8.8.8/8.8.8/cispo-7.2.2.2) ID ; Wed, 24 Mar 1999 16:30:59 -0500 (EST) Received: via switchmail; Wed, 24 Mar 1999 16:30:56 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Wed, 24 Mar 1999 16:29:35 -0500 (EST) Received: from localhost (majordom@localhost) by list.srv.cis.pitt.edu (8.8.8/8.8.8/cisls-7.2.2.1) ID ; Wed, 24 Mar 1999 16:27:06 -0500 (EST) Received: from m4.boston.juno.com (m4.boston.juno.com [205.231.101.198]) by list.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cisls-7.2.2.1) ID for ; Wed, 24 Mar 1999 16:27:00 -0500 (EST) Received: (from pcrs242@juno.com) by m4.boston.juno.com (queuemail) id D6HN4Y8E; Wed, 24 Mar 1999 16:25:25 EST To: wilderness-emergency-medicine@list.pitt.edu Date: Wed, 24 Mar 1999 16:18:07 -0500 Subject: W-EMED ASRC Message-ID: <19990324.161808.12598.0.pcrs242@juno.com> X-Mailer: Juno 1.49 X-Juno-Line-Breaks: 0,2,4,6-9 From: Deborah M Gessner Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk Reply-To: wilderness-emergency-medicine@list.pitt.edu X-PMFLAGS: 33554560 0 1 P73F00.CNM Suzen Thank You for the invite yes I would like to go, but depends on how much and where and where do we meet,etc. I tried to send several messages to you personal email but it keeps coming back as error in you address and it didn't know why. I received yours fine, let me know something is there a registration? Deborah Long Way Home SAR 1 Dublin,Va. ___________________________________________________________________ You don't need to buy Internet access to use free Internet e-mail. Get completely free e-mail from Juno at http://www.juno.com/getjuno.html or call Juno at (800) 654-JUNO [654-5866] Do not reproduce without author's express permission. To unsubscribe, send the text "unsubscribe wilderness-emergency-medicine" as the body of a message (no subject) To: Majordomo@list.pitt.edu Submissions To: wilderness-emergency-medicine@list.pitt.edu -- End -- Received: from post-ofc03.srv.cis.pitt.edu (root@post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by pop.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cispop-7.2.2.1) ID ; Tue, 23 Mar 1999 15:32:31 -0500 (EST) Received: from localhost (root@localhost) by post-ofc03.srv.cis.pitt.edu (8.8.8/8.8.8/cispo-7.2.2.2) ID ; Tue, 23 Mar 1999 14:22:39 -0500 (EST) Received: via switchmail; Tue, 23 Mar 1999 14:22:36 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Tue, 23 Mar 1999 14:21:34 -0500 (EST) Received: from localhost (majordom@localhost) by list.srv.cis.pitt.edu (8.8.8/8.8.8/cisls-7.2.2.1) ID ; Tue, 23 Mar 1999 14:21:19 -0500 (EST) Received: from mail1.uct.ac.za (exim@mail1.uct.ac.za [137.158.128.73]) by list.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cisls-7.2.2.1) ID for ; Tue, 23 Mar 1999 14:21:02 -0500 (EST) Received: from mort by mail1.uct.ac.za with local (Exim 2.01 #3) for wilderness-emergency-medicine@list.pitt.edu id 10PWjP-0004U6-00; Tue, 23 Mar 1999 21:20:55 +0200 Received: by mail1.uct.ac.za (Mort 2.23alpha) id 539 from ALEWIS@ITS; Tue Mar 23 21:20:55 1999 From: "Andrew Lewis" To: wilderness-emergency-medicine@list.pitt.edu Date: Tue, 23 Mar 1999 21:20:39 SAST-2 Subject: Re: W-EMED Lasik X-mailer: Pegasus Mail v3.40 Message-Id: Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk Reply-To: wilderness-emergency-medicine@list.pitt.edu X-PMFLAGS: 33554560 0 1 P58A70.CNM Hi Jay I presume by LASIK that you mean the corneal slice plus low intensity laser and then the corneal flap being replaced. This is very different (and safer) than RK, which is a bit barbaric. In RK the cornea is sliced and therefor colapses slightly changing the refractive index. In LASIK a permanent lens is 'built' into the eye. I believe RK can cause the cornea to collapse in low pressure resulting in blndness. I have just had LASIK surgery done to both eyes less than a month ago. I had both eyes done at once and basically walked out of the operating theatre and could see perfectly 48hrs later. Since then I have happily gone diving, rock climbing, surfing etc... Side effects (for me) include reduced tolerance to glare and wind (I ride a motorbike) as well as a (slightly) reduced ability to focus on fine visual detail. I may also still need glasses for night driving. It's also taken me about 3 weeks to improve my 'focusing time'. On the whole I am more than happy with the results. I feel much more happy about responding to incidents where I am expecting bad weather. Nothing like having to clean your glasses with a muddy rag while grovelling up some exposed ridge in a storm :-) Also with glasses there's always that last minute panic at night deciding where to hide the specs so my buddies won't walk on them. As for contacts on overnight trips the less said the better. While I haven't been on a helicopter mission since my op I have got hold of a pair of wide 'cycling' sunglasses to protect my eyes from the wind blast. If you want more info on the op please email me directly. regards Andrew Lewis > From: Jaymullen@aol.com > Date sent: Tue, 23 Mar 1999 11:18:33 EST > To: wilderness-emergency-medicine@list.pitt.edu > Subject: W-EMED Lasik > Send reply to: wilderness-emergency-medicine@list.pitt.edu > Anyone have any information regarding Lasik in the wildernessj/ mountaineering > setting? > > I'm considering the surgery, but am a bit worried givent he experience of Beck > Weathers with RK on Everest. > -- ______________________________________ System Software Information Technology Services University of Cape Town ph (+27 21) 650-3032 fax (+27 21) 650-3726 ______________________________________ Do not reproduce without author's express permission. To unsubscribe, send the text "unsubscribe wilderness-emergency-medicine" as the body of a message (no subject) To: Majordomo@list.pitt.edu Submissions To: wilderness-emergency-medicine@list.pitt.edu -- End -- Received: from post-ofc02.srv.cis.pitt.edu (root@post-ofc02.srv.cis.pitt.edu [136.142.185.24]) by pop.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cispop-7.2.2.1) ID ; Wed, 24 Mar 1999 00:38:57 -0500 (EST) Received: from localhost (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.8.8/8.8.8/cispo-7.2.2.2) ID ; Wed, 24 Mar 1999 00:38:18 -0500 (EST) Received: via switchmail; Wed, 24 Mar 1999 00:38:17 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Wed, 24 Mar 1999 00:34:16 -0500 (EST) Received: from localhost (majordom@localhost) by list.srv.cis.pitt.edu (8.8.8/8.8.8/cisls-7.2.2.1) ID ; Wed, 24 Mar 1999 00:33:30 -0500 (EST) Received: from mx0-smtp.goodnet.com (envy.goodnet.com [207.98.129.151]) by list.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cisls-7.2.2.1) ID for ; Wed, 24 Mar 1999 00:33:23 -0500 (EST) Received: from PC_.goodnet.com (d10-17.phoenix.goodnet.com [209.141.106.82]) by mx0-smtp.goodnet.com (8.9.3/8.9.3) with SMTP id WAA29795 for ; Tue, 23 Mar 1999 22:33:20 -0700 (MST) Message-ID: In-Reply-To: References: Conversation with last message X-MSMail-Priority: Normal X-Priority: 3 To: "WEMS News" MIME-Version: 1.0 From: "Tim Kovacs" Subject: W-EMED Andrew Lewis, re LASIK and High Altitude Date: Tue, 23 Mar 99 21:03:10 PST Content-Type: text/plain; charset="ISO-8859-1"; X-MAPIextension=".TXT" Content-Transfer-Encoding: 7bit Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk Reply-To: wilderness-emergency-medicine@list.pitt.edu X-PMFLAGS: 34078848 0 1 P21860.CNM Andy, please give me your email address for a personal inquiry. Thanks, Tim Kovacs, President Mountain Rescue Association tkovacs@goodnet.com www.mra.org "You can't teach people to rescue in the mountains until they have learnt to climb... ...It is a number of small points which have little significance individually that, considered together, spell danger to the experienced rescuer." Hamish MacInnes Do not reproduce without author's express permission. To unsubscribe, send the text "unsubscribe wilderness-emergency-medicine" as the body of a message (no subject) To: Majordomo@list.pitt.edu Submissions To: wilderness-emergency-medicine@list.pitt.edu -- End -- Received: from post-ofc02.srv.cis.pitt.edu (root@post-ofc02.srv.cis.pitt.edu [136.142.185.24]) by pop.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cispop-7.2.2.1) ID ; Tue, 23 Mar 1999 14:17:17 -0500 (EST) Received: from localhost (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.8.8/8.8.8/cispo-7.2.2.2) ID ; Tue, 23 Mar 1999 14:16:34 -0500 (EST) Received: via switchmail; Tue, 23 Mar 1999 14:16:34 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Tue, 23 Mar 1999 14:14:53 -0500 (EST) Received: from localhost (majordom@localhost) by list.srv.cis.pitt.edu (8.8.8/8.8.8/cisls-7.2.2.1) ID ; Tue, 23 Mar 1999 14:14:11 -0500 (EST) Received: from selectrec.net (mail.selectrec.net [209.184.56.3]) by list.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cisls-7.2.2.1) ID for ; Tue, 23 Mar 1999 14:14:05 -0500 (EST) Received: from default (209.184.56.22) by selectrec.net with SMTP (Eudora Internet Mail Server 2.1); Tue, 23 Mar 1999 13:15:05 -0500 From: "selectrec" To: Subject: Re: W-EMED Lasik Date: Tue, 23 Mar 1999 13:13:41 -0600 Message-ID: <01be7561$433cfb20$1638b8d1@default> MIME-Version: 1.0 Content-Type: text/plain; charset="iso-8859-1" Content-Transfer-Encoding: 7bit X-Priority: 3 X-MSMail-Priority: Normal X-Mailer: Microsoft Outlook Express 4.71.1712.3 X-MimeOLE: Produced By Microsoft MimeOLE V4.71.1712.3 Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk Reply-To: wilderness-emergency-medicine@list.pitt.edu X-PMFLAGS: 34078848 0 1 P34F40.CNM Hi Jay.. I had both eyes done in '82 - still at 20/20 Granted, I haven't done Everest - I go the other direction. I have done several caving exepditions - with no problems. I had it done the ol' fashioned way - with a ruby scalpel. The laser wasn't even an option. I work with the Austin Fire Dept - in heat and smoke and do a lot with the National Cave Rescue Commission - again, quite satisfied John Green South Central Regional Coordinator - NCRC USAR Tx TF1 Technical Rescue Instructor Do not reproduce without author's express permission. To unsubscribe, send the text "unsubscribe wilderness-emergency-medicine" as the body of a message (no subject) To: Majordomo@list.pitt.edu Submissions To: wilderness-emergency-medicine@list.pitt.edu -- End -- Received: from post-ofc05.srv.cis.pitt.edu (root@post-ofc05.srv.cis.pitt.edu [136.142.185.10]) by pop.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cispop-7.2.2.1) ID ; Tue, 23 Mar 1999 11:21:45 -0500 (EST) Received: from localhost (root@localhost) by post-ofc05.srv.cis.pitt.edu (8.8.8/8.8.8/cispo-7.2.2.2) ID ; Tue, 23 Mar 1999 11:21:05 -0500 (EST) Received: via switchmail; Tue, 23 Mar 1999 11:21:04 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Tue, 23 Mar 1999 11:20:53 -0500 (EST) Received: from localhost (majordom@localhost) by list.srv.cis.pitt.edu (8.8.8/8.8.8/cisls-7.2.2.1) ID ; Tue, 23 Mar 1999 11:19:21 -0500 (EST) Received: from imo23.mx.aol.com (imo23.mx.aol.com [198.81.17.67]) by list.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cisls-7.2.2.1) ID for ; Tue, 23 Mar 1999 11:19:17 -0500 (EST) From: Jaymullen@aol.com Received: from Jaymullen@aol.com by imo23.mx.aol.com (IMOv19.3) id hKVCa13434 for ; Tue, 23 Mar 1999 11:18:33 -0500 (EST) Message-ID: Date: Tue, 23 Mar 1999 11:18:33 EST To: wilderness-emergency-medicine@list.pitt.edu Mime-Version: 1.0 Subject: W-EMED Lasik Content-type: text/plain; charset=US-ASCII Content-transfer-encoding: 7bit X-Mailer: AOL 4.0 for Windows 95 sub 216 Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk Reply-To: wilderness-emergency-medicine@list.pitt.edu X-PMFLAGS: 34078848 0 1 P2C030.CNM Anyone have any information regarding Lasik in the wildernessj/ mountaineering setting? I'm considering the surgery, but am a bit worried givent he experience of Beck Weathers with RK on Everest. Jay Mullen Do not reproduce without author's express permission. To unsubscribe, send the text "unsubscribe wilderness-emergency-medicine" as the body of a message (no subject) To: Majordomo@list.pitt.edu Submissions To: wilderness-emergency-medicine@list.pitt.edu -- End -- X-cs: From: Self To: "Howard M. Paul" Subject: Re: [NH] Fwd: W-EMED [PSA/PIO] Unusual Emergency Request Cc: wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu MIME-Version: 1.0 Content-type: text/plain; charset=ISO-8859-1 Content-transfer-encoding: 8BIT Date: Mon, 22 Mar 1999 23:28:12 -0500 Howard and responders -- as much as I appreciate the personal agony of situations such as brain cancer, it is quite off topic for this list. On behalf of hundreds of subscribers, please stay to topics relevant to wilderness emergency medicine. I would like to remind all that the policy has always been that those who repeatedly post on off-topic issues will be removed from list. Thank you, and my best wishes for Nena's father. -- End -- Received: from post-ofc06.srv.cis.pitt.edu (root@post-ofc06.srv.cis.pitt.edu [136.142.185.43]) by pop.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cispop-7.2.2.1) ID ; Mon, 22 Mar 1999 23:33:14 -0500 (EST) Received: from localhost (root@localhost) by post-ofc06.srv.cis.pitt.edu (8.8.8/8.8.8/cispo-7.2.2.2) ID ; Mon, 22 Mar 1999 23:32:36 -0500 (EST) Received: via switchmail; Mon, 22 Mar 1999 23:32:36 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Mon, 22 Mar 1999 23:30:37 -0500 (EST) Received: from localhost (majordom@localhost) by list.srv.cis.pitt.edu (8.8.8/8.8.8/cisls-7.2.2.1) ID ; Mon, 22 Mar 1999 23:28:41 -0500 (EST) Received: from post-ofc05.srv.cis.pitt.edu (root@post-ofc05.srv.cis.pitt.edu [136.142.185.10]) by list.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cisls-7.2.2.1) ID for ; Mon, 22 Mar 1999 23:28:28 -0500 (EST) Received: from 136.142.57.10.pitt.edu (ehdup-u-38.rmt.net.pitt.edu [136.142.23.148]) by post-ofc05.srv.cis.pitt.edu with SMTP (8.8.8/8.8.8/cispo-7.2.2.2) ID ; Mon, 22 Mar 1999 23:28:19 -0500 (EST) Message-Id: <199903230428.XAA27197@post-ofc05.srv.cis.pitt.edu> From: "Keith Conover, M.D., FACEP" To: "Howard M. Paul" Date: Mon, 22 Mar 1999 23:28:19 -0500 MIME-Version: 1.0 Content-type: text/plain; charset=US-ASCII Content-transfer-encoding: 7BIT Subject: Re: [NH] Fwd: W-EMED [PSA/PIO] Unusual Emergency Request CC: wilderness-emergency-medicine@list.pitt.edu References: <1fdaeab3.36f6f50c@aol.com> In-reply-to: <3.0.5.32.19990322224036.0086b4a0@mail.highland.net> X-mailer: Pegasus Mail for Win32 (v3.01d) Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk Reply-To: wilderness-emergency-medicine@list.pitt.edu X-PMFLAGS: 34078848 0 1 P2B220.CNM Howard and responders -- as much as I appreciate the personal agony of situations such as brain cancer, it is quite off topic for this list. On behalf of hundreds of subscribers, please stay to topics relevant to wilderness emergency medicine. I would like to remind all that the policy has always been that those who repeatedly post on off-topic issues will be removed from list. Thank you, and my best wishes for Nena's father. --Keith Conover, M.D., FACEP http://www.pitt.edu/~kconover Do not reproduce without author's express permission. To unsubscribe, send the text "unsubscribe wilderness-emergency-medicine" as the body of a message (no subject) To: Majordomo@list.pitt.edu Submissions To: wilderness-emergency-medicine@list.pitt.edu -- End -- X-cs: From: Self To: Shirley Carroll ,"Howard M. Paul" Subject: Re: [NH] Fwd: W-EMED [PSA/PIO] Unusual Emergency Request Cc: wilderness-emergency-medicine@list.pitt.edu Reply-to: kconover+@pitt.edu MIME-Version: 1.0 Content-type: text/plain; charset=ISO-8859-1 Content-transfer-encoding: 8BIT Date: Mon, 22 Mar 1999 23:26:13 -0500 Shirley and Howard -- as much as I appreciate the personal agony of situations such as brain cancer, it is quite off topic for this list. On behalf of hundreds of subscribers, please stay to topics relevant to wilderness emergency medicine. I will also take this opportunity to remind all the those who repeatedly post on off-topic issues will be removed from list by the listowners. Thank you, and my best wishes for Nena's father. -- End -- Received: from post-ofc06.srv.cis.pitt.edu (root@post-ofc06.srv.cis.pitt.edu [136.142.185.43]) by pop.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cispop-7.2.2.1) ID ; Mon, 22 Mar 1999 22:43:05 -0500 (EST) Received: from localhost (root@localhost) by post-ofc06.srv.cis.pitt.edu (8.8.8/8.8.8/cispo-7.2.2.2) ID ; Mon, 22 Mar 1999 22:42:28 -0500 (EST) Received: via switchmail; Mon, 22 Mar 1999 22:42:27 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Mon, 22 Mar 1999 22:41:50 -0500 (EST) Received: from localhost (majordom@localhost) by list.srv.cis.pitt.edu (8.8.8/8.8.8/cisls-7.2.2.1) ID ; Mon, 22 Mar 1999 22:40:02 -0500 (EST) Received: from smtp02.infoave.net (smtp02.infoave.net [165.166.0.27]) by list.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cisls-7.2.2.1) ID for ; Mon, 22 Mar 1999 22:39:57 -0500 (EST) Received: from oemcomputer ("port 1817"@[204.116.59.91]) by SMTP00.InfoAve.Net (PMDF V5.1-12 #23426) with SMTP id <01J95BB2VTK68Y52CP@SMTP00.InfoAve.Net> for wilderness-emergency-medicine@list.pitt.edu; Mon, 22 Mar 1999 22:39:35 EST Date: Mon, 22 Mar 1999 22:40:36 -0500 From: Shirley Carroll Subject: Re: [NH] Fwd: W-EMED [PSA/PIO] Unusual Emergency Request In-reply-to: <1fdaeab3.36f6f50c@aol.com> X-Sender: thehavens@mail.highland.net To: wilderness-emergency-medicine@list.pitt.edu Message-id: <3.0.5.32.19990322224036.0086b4a0@mail.highland.net> MIME-version: 1.0 X-Mailer: QUALCOMM Windows Eudora Light Version 3.0.5 (32) Content-type: text/plain; charset="us-ascii" Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk Reply-To: wilderness-emergency-medicine@list.pitt.edu X-PMFLAGS: 35127424 0 1 P49B50.CNM At 08:57 PM 3/22/99 -0500, you wrote: >Date: Mon, 22 Mar 1999 11:30:37 -0700 >To: wilderness-emergency-medicine@list.pitt.edu >From: Nena Wiley (by way of "Howard M. Paul" > ) >Subject: W-EMED [PSA/PIO] Unusual Emergency Request > >Folks - My Father just had brain surgery to remove a malignant primary, Level >4 tumor called Glioblastoma Multiforme. We are seeking alternative & >experimental treatment & case histories. >If anyone can help me - please write me personally at: coyotearz@aol.com > >Nena Wiley, Maj CAP >PA ACV/SWR Nena, Our prayers are with you and your family. This type of brain cancer is very aggressive. A neighbor we became friends with had a glioblastoma. Unfortunately we met him after surgery and radiation. There was little we could do, although he did improve for a short time. He did not change his diet though, and you cannot eat dead cooked food and expect to gain life from them. What goes in is the fuel the body has to heal with. Change of diet is imperative. Master Formula and organic juicing would be ideal. Anyone who is in a health crisis should only juice and eat raw foods that have LIFE. I would use essential oil of frankincense, diffused, rubbed on the brain stem, on the feet. I would IMMEDIATELY begin taking therapeutic doses of beta glucan and transfer factor. http://www.nautilusnutritionals.com - Products - Immune Modulators. I have been taking beta glucan since 3 weeks after breast cancer surgery (2/97). ALl tumor tests remain normal. It is an immune enhancing supplement made from the cell walls of baker's yeast and has over 30+ years of scientific study and research by such as Harvard and many more. It has been used effectively along with chemotherapy and radiation, even reducing the amounts needed. I did not do any drugs or radiation, but changed diet, use oils, take beta glucan, and for the last year have included Master Formula as part of my daily food. Insulin dependent diabetes of 31+ years has improved also. I have written testimonies, and you can also call 1-888-411-1143 to hear live recorded testimonies. Forms to order with are available on FOD at 1-888-411-1142. Diet is crucial. Truly, what we eat today determines our health tomorrow. This cannot be stressed enough! These are the things I would do to improve my health, especially facing cancer. Time is of the essence. Sherman quit taking radiation and lived 6 more weeks, suffering terribly. It didn't have to be that way. Our prayers are with you. May God bless and watch over you. Shirley ****** Kraig and Shirley Carroll ... in the hills of Kentucky ICQ #26952217 thehavens@highland.net http://www.thehavens.com/ 606-376-3363 Do not reproduce without author's express permission. To unsubscribe, send the text "unsubscribe wilderness-emergency-medicine" as the body of a message (no subject) To: Majordomo@list.pitt.edu Submissions To: wilderness-emergency-medicine@list.pitt.edu -- End -- Received: from post-ofc01.srv.cis.pitt.edu (root@post-ofc01.srv.cis.pitt.edu [136.142.185.25]) by pop.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cispop-7.2.2.1) ID ; Mon, 22 Mar 1999 21:40:37 -0500 (EST) Received: from localhost (root@localhost) by post-ofc01.srv.cis.pitt.edu (8.8.8/8.8.8/cispo-7.2.2.2) ID ; Mon, 22 Mar 1999 21:39:49 -0500 (EST) Received: via switchmail; Mon, 22 Mar 1999 21:39:49 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Mon, 22 Mar 1999 21:37:43 -0500 (EST) Received: from localhost (majordom@localhost) by list.srv.cis.pitt.edu (8.8.8/8.8.8/cisls-7.2.2.1) ID ; Mon, 22 Mar 1999 21:35:59 -0500 (EST) Received: from raven.prod.itd.earthlink.net (raven.prod.itd.earthlink.net [209.178.63.9]) by list.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cisls-7.2.2.1) ID for ; Mon, 22 Mar 1999 21:35:55 -0500 (EST) Received: from default (1Cust230.tnt1.pleasantville.nj.da.uu.net [63.10.1.230]) by raven.prod.itd.earthlink.net (8.8.7/8.8.5) with SMTP id SAA28242 for ; Mon, 22 Mar 1999 18:27:07 -0800 (PST) From: "David Israel" To: Subject: RE: W-EMED [PSA/PIO] Unusual Emergency Request Date: Mon, 22 Mar 1999 21:23:01 -0500 Message-ID: <000101be74d4$135cf320$e6010a3f@default> MIME-Version: 1.0 Content-Type: text/plain; charset="iso-8859-1" Content-Transfer-Encoding: 8bit X-Priority: 3 (Normal) X-MSMail-Priority: Normal X-Mailer: Microsoft Outlook 8.5, Build 4.71.2173.0 Importance: Normal In-Reply-To: <4.1.19990322112925.009ba6f0@pop.ecentral.com> X-MimeOLE: Produced By Microsoft MimeOLE V4.72.3110.3 Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk Reply-To: wilderness-emergency-medicine@list.pitt.edu X-PMFLAGS: 34078848 0 1 P64080.CNM Gene therapy is showing some promise. Here is an article for your review. David Israel Hematology/oncology Clinics of North America Volume 12 • Number 3 • June 1998 Copyright © 1998 W. B. Saunders Company ---------------------------------------------------------------------------- ---- ---------------------------------------------------------------------------- ---- 617 GENE THERAPY ---------------------------------------------------------------------------- ---- GENE THERAPY FOR MALIGNANT GLIOMAS Jane B. Alavi MD Stephen L. Eck MD, PhD ---------------------------------------------------------------------------- ---- This work was supported in part by grant RO1 CA 67799 from the National Institutes of Health. ---------------------------------------------------------------------------- ---- Division of Hematology and Oncology, Department of Medicine, The University of Pennsylvania Medical Center, Philadelphia, Pennsylvania ---------------------------------------------------------------------------- ---- Address reprint requests to Stephen L. Eck, MD, PhD Division of Hematology and Oncology Department of Medicine Room 409 Stellar-Chance Laboratories 422 Curie Blvd. Philadelphia, PA 19104-6100 Relative to their prevalence, malignant gliomas have received a disproportionate amount of attention as targets for gene therapy. [9] Several factors have contributed to the interest in gene therapy techniques for malignant gliomas (principally anaplastic astrocytomas and glioblastoma multiforme). Malignant gliomas are good candidates for gene therapy because their growth is relatively well localized. Although they infiltrate the surrounding brain, thereby making complete surgical excision impossible, they rarely metastasize outside the brain. This tremendously simplifies the targeting of gene vectors to the tumor. Systemic delivery of genetic vectors to widespread metastases is currently not achievable with high efficiency and low toxicity (see article by Drs. Wivel and Wilson on p 483 of this issue). The local delivery to the bulk of the tumor, however, can be achieved through either stereotactic injection of vectors into the brain tumor or infiltration of the tumor with genetic vector at the time of gross total resection. This approach bypasses the blood-brain barrier that limits the entry of many otherwise potentially useful chemotherapy agents. In addition, direct injection of genetic vectors limits systemic exposure to the therapeutic agent and, therefore, minimizes systemic toxicity. Malignant gliomas have extremely high mortality rates that have not been affected significantly by newer surgical, radiation, or drug therapies; thus, experimental, high-risk therapies are more reasonable options for patients with malignant glioma. Currently, ---------------------------------------------------------------------------- ---- 618 several of the glioma gene therapy clinical trials treat patients as part of their initial therapy. Brain tumors comprise a broad spectrum of biologic and clinical features making it unlikely for a single therapeutic approach to be applicable to all patients. Several molecular approaches to these tumors are being developed, including enzyme-prodrug therapy, targeting tumor suppressor and angiogenesis functions, immunotherapy, and the use of oncolytic viruses. This article discusses the preclinical work to develop these approaches and the early clinical trials. ENZYME-PRODRUG GENE THERAPY Malignant gliomas (especially glioblastoma multiforme) show minimal responsiveness to currently available chemotherapy. This stems, in part, from the difficulty in delivering high levels of chemotherapeutic agents across the blood-brain barrier without significant systemic toxicity. This can be potentially overcome by producing high levels of chemotherapy within the tumor itself. [41] Introduction of prodrug activating genes has been studied extensively in brain tumor experimental models and in a few ongoing human clinical trials. [9] [11] [12] [32] In this strategy, the tumor cells are modified genetically to express an enzyme capable of activating an otherwise inactive prodrug. Although the prodrug is administered systematically, only in the genetically modified tumor cells does it encounter the enzyme capable of converting it into a toxic form. [12] The intended result is high-dose, local, sustained delivery of a cytotoxic agent that is largely confined to the tumor. A variety of prodrug-activating enzymes and prodrugs (Table 1) have been tested for this so-called suicide gene therapy. The concept of intratumor delivery of chemotherapy is not new. [12] The recently approved implantation of BCNU-containing wafers (Gliadel, Rhone-Poulenc Rorer, Collegeville, PA) has proven effective (albeit minimally) in treating gliomas [43] and provides a basis for comparison. The enzyme-prodrug combinations that employ foreign (nonhuman) enzymes (e.g., HSVtk and CD, see Table 1) have the advantage of only activating the drug in the tumor. Those enzyme-prodrug combinations that employ enzymes naturally present in other TABLE 1 -- ENZYME-PRODRUG COMBINATIONS Enzyme Prodrug Herpes simplex virus thymidine kinase (HSVtk) Ganciclovir, acyclovir, famciclovir Cytosine deaminase (CD) 5-fluorocytidine (5-FC) Deoxycytidine kinase Cytosine arabinoside, fludarabine, difluorodeoxycytidine Xanthine-guanine phosphoribosyl transferase 6-thioxanthine, 6-thioguanine Nitroreductase 5-(aziridinyl-1-yl)-2,4-dinitrobenzamide Cytochrome P-450 Cyclophosphamide, methyl propylchloroethyl nitrosourea ---------------------------------------------------------------------------- ---- 619 human tissues (e.g., cytochrome P450 in the liver, see Table 1) may have higher systemic toxicity because the prodrug is not activated solely in the brain tumor. As with other forms of chemotherapy, gene-delivered enzyme-prodrug therapy can likely be combined with other conventional therapies such as radiation therapy. [22] For instance, cytosine deaminase (CD) gene therapy converts 5-fluorocytidine (5-FC) to 5-fluorouracil (5-FU), [41] a known radiation sensitizer. [25] Importantly, the therapeutic benefit of enzyme-prodrug gene therapy extends to tumor cells in the tumor mass that have not taken up the therapeutic gene. This so-called bystander effect allows a potentially inefficient gene transfer process (transduction of a small percentage of the tumor cells) to have a large therapeutic effect. [15] The bystander effect stems from several processes whose contribution to the overall effect varies with the enzyme-prodrug combination, tumor type, and experimental model being studied. Figure 1 illustrates the major components of the bystander effect. First, the activated drug is exported to adjacent cells through gap junction connections between adjacent cells. Gap junctions appear to be important in the HSVtk-ganciclovir system, in which the active metabolites are not very stable outside of the tumor cell. [13] Simple diffusion between cells is readily achieved in the cytosine deaminase-fluorocytidine Figure 1. The bystander effect. A tumor cell tranduced with the thymidine kinase gene produces the thymidine kinase enzyme (TK). Systemic administration of ganciclovir results in production of ganciclovir metabolites within the tumor cell. The active drug metabolites diffuse to neighboring cells through gap junctions or are released into the extracellular environment. Tumor cell debris can also be taken up by antigen presenting cells (APC), which in turn stimulate lymphocytes to mount an immune response to the tumor cells. ---------------------------------------------------------------------------- ---- 620 system because the activated drug (5-FU) readily diffuses through tumor cells and is stable in the extracellular environment. [41] Similarly, tumor cell death (as a result of the activated drug) may release more active drug that is taken up by neighboring tumor cells. Finally, in some animal models, it has been observed that tumor cell death results in release of tumor antigens that are taken up by antigen presenting cells (APC), which in turn activate lymphocytes to mount an immune response against the tumor cells. [2] [4] Oldfield [32] was the first to apply enzyme-prodrug gene therapy to patients with malignant gliomas. He employed the HSVtk strategy proposed Figure 2. Injection of retroviral producer cells into brain tumor. Mouse cells (large oval-shaped cells) modified to secrete retrovirus (small ovals) are injected into the tumor. They are taken up by nearby tumor cells (irregular shape) in which the therapeutic gene becomes integrated into the genome of dividing tumor cells. The therapeutic protein is expressed from the integrated gene. ---------------------------------------------------------------------------- ---- 621 by Moolten [27] by implanting modified murine cells (producer cells) that secrete a retroviral vector carrying the HSVtk gene. [32] Injection of the producer cells was used in this clinical trial to increase the effective dose of retroviral vector (see article by Drs. Wivel and Wilson on p 483 of the issue). As shown in Figure 2 , the producer cells are implanted into the tumor where they produce retroviral particles that transduce nearby cells to make thymidine kinase enzyme. Fifteen patients with progressive malignant brain tumors (gliomas, metastatic breast cancer, and melanomas) were treated in the initial clinical trial. [32] The therapy was well tolerated, although seizures (controlled by anticonvulsants) and focal hemorrhages were observed in some patients. Two patients with glioblastoma multiforme had durable responses lasting more than 4 years. [32] In some patients, tumor specimens were removed 7 days after implantation of retroviral producer cells. Analysis of these tumor specimens revealed that gene transfer was limited to a small region surrounding the site of injection. This suggests that neither the injected producer cells nor the secreted retrovirus travels very far within the tumor bed. Nonetheless, this study was the first to demonstrate a clinical benefit in patients, albeit a few highly selected patients with small tumors. This, and similar clinical studies, [21] are now in advanced-phase clinical trials to determine its effectiveness in a larger patient population. This study [32] highlights some of the limitations of retroviral gene therapy. Producer cells needed to be injected because the virus could not be made concentrated sufficiently. The handling of producer cells, which must remain viable, is cumbersome and difficult to apply in general clinical practice. Because the virus only transduces dividing tumor cells, tumor cells that are mitotically arrested (a significant proportion) do not express the therapeutic gene. The authors [11] and others [44] have sought to overcome these problems using a replication defective adenovirus vector. Recombinant adenovirus can be prepared in stable suspensions that are up to a millionfold more concentrated than the retrovirus preparations. Furthermore, the adenovirus transduces tumor cells independent of their mitotic activity; thus, direct injection of the viral particles can be used to transduce a portion of the tumor cells (Fig. 3) . It remains to be determined whether tumor penetration by adenovirus can achieve a greater tissue distribution than that achieved by retroviral particles. Both viruses are very large compared with conventional drugs and may have limited diffusion within the tumor. A potential drawback to the use of adenovirus is the pre-existing immunity to this virus that all patients have. A brisk immune response to the virus could result in severe cerebral edema. [29] Studies [37] in rodents and primates indicated that this approach was feasible despite the immune response to the virus. The authors' trial design at the University of Pennsylvania provided for the treatment of patients with a recombinant adenovirus expressing HSVtk. Four dose levels ranging from 108 to 1011 plaque-forming units were tested with three patients at each dose. Stereotactic injection of virus was carried out at five sites in the malignant glioma, followed by resection of the tumor 1 week later. The residual tumor that ---------------------------------------------------------------------------- ---- 622 Figure 3. Injection of recombinant adenovirus into brain tumor. Recombinant adenovirus is injected directly into the tumor. The adenovirus is taken up by all cells that come in contact with the virus independent of whether the cells are dividing actively. The therapeutic gene does not become integrated into the target cell genome and the adenovirus begins to produce the therapeutic protein within a few hours after injection. could not be removed was re-treated at the time of resection with additional adenovirus at the same dose. Twelve patients have been treated in this manner to date. Overall, the patients tolerated the procedure well with toxicities and complications not different from those found in patients undergoing these procedures without gene therapy. Although virus-induced inflammation may have contributed to increased intracranial pressure in a few patients, this was controlled by standard measures. This study is ongoing in an effort to define the dose-limiting toxicity and potential benefit. To overcome the physical limitations imposed by the local injection ---------------------------------------------------------------------------- ---- 623 of virus into the tumor, Neuwelt and colleagues [28] have examined the feasibility of intra-arterial injection of recombinant virus. They have shown that osmotic blood-brain barrier disruption can facilitate intra-arterial administration of virus into experimental brain tumors. This may offer a means to transduce the tumor cells that have infiltrated the normal brain. Such cells are surgically inaccessible and may not be reached by virus injected into the surgical resection site. If successful, this method would provide widespread delivery to locally infiltrating brain tumors that are not surgically accessible. An alternative approach is to infuse the genetic vector slowly into the tumor through a stereotactically placed catheter. Zhu et al [45] treated rats with experimental gliomas by continuous intracerebral infusion of a HSVtk-liposome complex. They observed a complete response in 36% of the animals following administration of ganciclovir. A variation of this approach has been tested in two patients using infusion of HSVtk vector through an Ommaya (PS Medical, Goleta, CA) reservoir connected to the tumor cavity. [20] Direct interstitial infusion has been clinically tested for its ability to distribute a large protein into malignant brain tumors. [23] This technology also could be applied to the delivery of genetic vectors. Other enzyme-prodrug combinations have shown promise in rodent brain tumor experimental models, including the cytosine deaminase/5-fluorocytosine [16] and cytochrome P450/cyclophosphamide [8] [24] combinations. TARGETING TUMOR SUPPRESSOR AND ANGIOGENESIS FUNCTIONS Tumor suppressor gene therapy is being developed for several cancers including gliomas. The overexpression of wild-type p53 can suppress tumor growth even in cells that express endogenous wild-type p53. Hsiao and colleagues [18] have examined the use of this approach in human glioblastoma cell lines. They found that gene-liposome complexes could penetrate up to 20 tumor cell layers when applied to a model of the postoperative surgical cavity. Liposome-mediated p53 gene transfer in mice bearing xenografted human gliomas suppressed tumor growth and improved overall survival. [18] Similarly, Black and colleagues [3] showed that stereotactic injection of adenovirus expressing p53 into rats with brain tumors decreased tumor volume and induced changes consistent with p53-induced apoptosis. Besides p53 itself, downstream effectors of p53 function can be introduced into glial tumor cells and induce growth arrest. [7] Multicenter clinical trials using adenovirus expressing p53 are under development to test these principles in patients with relapsed malignant gliomas. Overexpression of p53 in tumor cells has been reported to induce a bystander effect through up-regulation of thrombospondin-1, which inhibits tumor angiogenesis. Tumor angiogenesis also can be targeted directly by gene transfer-mediated expression of anti-angiogenic agents. [30] Glioblastoma multiforme ---------------------------------------------------------------------------- ---- 624 has many characteristics of an angiogenesis-dependent tumor. As low-grade glial tumors progress to high-grade glioblastomas, there is a significant increase in tumor growth rate and tumor vascularization. Despite the greater density of blood vessels, glioblastoma multiforme tumors typically outgrow their blood supply and spontaneously develop necrotic centers as the peripheral (better vascularized) cells in the tumor continue to grow. Vascular endothelial growth factor (VEGF) is produced at high levels by glioblastoma cells, at intermediate levels by low-grade glial tumors, and at low levels by normal brain. [31] The production of VEGF is a direct response to tissue hypoxia within the glial tumors. [19] [36] The dependence of malignant gliomas on angiogenesis can be exploited to achieve a therapeutic benefit. For instance, when glioma tumor cells were stably transfected with an antisense DNA construct that diminished VEGF production, the cells inexplicably grew more rapidly in vitro. However, when implanted in vivo, the tumor growth rate was decreased significantly compared with the untransduced control cells. Furthermore, the resulting tumors were more necrotic as a result of a lower blood vessel density. [34] Antisense agents delivered by gene transfer also have been studied for their ability to inhibit other angiogenic factors such as basic fibroblast growth factor. [33] Fine and colleagues [39] have shown that viral-mediated gene transfer of the anti-angiogenic peptide platelet factor 4 can inhibit endothelial proliferation and reduce the vascularity of glial tumors in vivo. These studies demonstrate that gene delivery can be used to inhibit tumor vascularization using a variety of approaches. The use of platelet factor 4 is particularly attractive because this small soluble peptide is excreted into the extracellular space where it can diffuse readily. Therefore, the effects of platelet factor 4 gene transfer may be seen in tumor cells remote from those transduced by the therapeutic gene. IMMUNOTHERAPY OF MALIGNANT GLIOMAS Therapies designed to elicit an immune response to tumors have been sought for over a century with very little success. A better understanding of the immune effector pathways and characterization of cytokines involved in the immune response have led to the development of gene-transfer-based immunotherapies of human gliomas. [10] One approach has been to overcome the endogenous immunosuppressive effects of the tumors themselves. Transforming growth factor (TGF)-beta is produced by many tumors, including human gliomas, and suppresses cell-mediated immunity. Sobol and colleagues [14] demonstrated that blocking TGF-beta secretion could enhance the immune response to an experimental glioma cell vaccine. In this work, rats received intracranial implantation of a fatal dose of glioma cells. Five days later they were immunized with irradiated glioma cells expressing either an antisense TGF-beta construct, or recombinant interleukin (IL)-2, or they received an unmodified cell vaccine. All of those receiving the antisense, TGF-beta-modified ---------------------------------------------------------------------------- ---- 625 cells as a vaccine survived. In contrast, only 30% of the animals receiving the IL-2-secreting vaccine or 20% of the animals receiving unmodified tumor cell vaccine survived. Although these findings are encouraging, the 20% survival rate of control animals indicates that this tumor model is inherently immunogenic and likely overestimates the effect that this maneuver would have in less immunogenic human gliomas. Sampson et al [35] examined the effects of a large panel of immunostimulatory molecules including IL-2, IL-3, IL-4, IL-6, TNF-alpha, INF-gamma, GM-CSF, and B7-1. Implantation of the gene-modified astrocytoma cells (which also produce TGF-beta) showed a dramatic survival benefit for animals receiving IL-2-, IL-4-, or TNF-alpha-modified tumor cells. Chiocca [8] and Tseng et al [42] have seen similar results in related cytokine therapies for experimental gliomas. Direct injection of viral vectors producing cytokines would be easier to implement in the clinical setting. This approach would eliminate the need to produce a gene-modified cell vaccine for each patient as is currently done in some centers. [38] Furthermore, Glick et al [17] have shown that intracerebral vaccination with vector-delivered cytokine (IL-2) is superior to subcutaneous vaccination. There is, however, a significant risk of delivering too much cytokine into the brain. Tjuvajev et al [40] injected retroviral producer cells secreting IL-2 or INF-gamma along with gliomas cells into the brains of rats. Although this induced an immune response to the tumor cells, it also caused very severe central nervous system toxicity as a result of blood-brain barrier disruption and vasogenic edema. Thus, the simplicity and efficacy of this approach are tempered by the need to control cytokine gene expression within the brain carefully so as to confine the effects to the tumor. REPLICATING VIRUSES FOR THE TREATMENT OF GLIOMAS As noted in the discussion of enzyme-prodrug gene therapy, the spread of virus within the tumor may be quite limited when replication-defective viruses are used. This may be potentially overcome by employing a replication conditional virus (i.e., a virus that selectively replicates only in the tumor and not in the normal brain parenchyma). In theory, this should provide better tumor penetration as the virus gradually spreads through the tumor. Several research groups are pursuing such approaches using conditionally replicating adenoviruses and herpes simplex viruses (HSV). For example, disruption of the gamma34.5 gene in HSV arrests the viral growth in the central nervous system of rodents but still permits it to grow in the tumor cells. [6] When gamma34.5 mutant HSV virus is injected into xenogeneic experimental gliomas, long-term survival can be achieved. [1] In this model, tumor cell death is primarily due to the lytic action of the virus as it selectively replicates within and then destroys the tumor cells. Martuza and colleagues [26] have combined this strategy with the previously described thymidine kinase/ganciclovir approach. In this system, tumor cells are killed both by the lytic action ---------------------------------------------------------------------------- ---- 626 of the virus and by the HSVtk-mediated activation of ganciclovir. This may have a safety advantage by allowing the lytic virus to be destroyed before it can invade normal tissues. Adenoviral vectors can be engineered similarly to replicate selectively in p53-deficient cells, [5] but this approach is limited to those patients with glioblastomas that have p53 mutations (Fig. 4) . Clinical trials based on these principles will likely begin in the United States in the near future; however, there is significant concern over the use of replicating-virus therapy in the brain. In this case, the immune response to the virus could be more toxic than the virus itself, which is especially true in patients with pre-existing immunity to the virus such as frequently occurs with adenovirus and herpes Figure 4. Oncolytic action of replication competent virus. A virus engineered to replicate selectively in tumor cells (see text) is injected into the tumor. Infection of a few cells leads to their death and release of progeny virus that infect nearby cells. The cycle of virus replication and cell lysis continues until the edge of the tumor is reached or until an immune response to viral proteins eradicates the virus. ---------------------------------------------------------------------------- ---- 627 viruses. Such a response could induce local inflammation and an increase in intracranial pressure. The authors have seen evidence of this effect when using the replication defective adenovirus at high doses in their current glioma clinical trial. [11] Many of the animal models used to demonstrate the effectiveness of this approach were immunodeficient mice. These studies underestimate immune-mediated toxicity. In patients with an intact immune response and prior exposure to these viruses, the immune response could limit the spread of the virus within the tumor and thereby diminish the efficacy as well. These issues are being addressed in ongoing, preclinical safety testing. CONCLUSION Gene therapy for brain tumors encompasses a broad range of therapeutic approaches. There are two major obstacles in treated gliomas. The delivery of the genetic vector must reach a larger portion of the tumor than has been achieved in the initial clinical trials. In addition, the immune response to current vectors poses a significant risk of inflammation-induced elevation of intracranial pressure. Newer generation viral and synthetic vectors will likely lessen this problem. Finally, additional molecular targets will certainly be identified and brought forth in new clinical trials. References 1. Andreansky SS, He B, Gillespie GY, et al: The application of genetically engineered herpes simplex viruses to the treatment of experimental brain tumors. Proc Natl Acad Sci USA 93:11313-11318, 1996 2. Asai A: Gene therapy for brain tumors: Induction of apoptosis and immunogenic modulation in glioma cells. No Shinkei Geka 23:7-15, 1995 3. Badie B, Drazan KE, Kramar MH, et al: Adenovirus-mediated p53 gene delivery inhibits 9L glioma growth in rats. Neurol Res 17:209-216, 1995 4. Banchereau J, Steinman RM: Dendritic cells and the control of immunity. Nature 392:245-252, 1998 5. Bischoff JR, Kirn DH, Williams A, et al: An adenovirus mutant that replicates selectively in p53-deficient human tumor cells. Science 274:373-376, 1996 6. Chambers R, Gillespie GY, Soroceanu L, et al: Comparison of genetically engineered herpes simplex viruses for the treatment of brain tumors in a scid mouse model of human malignant glioma. Proc Natl Acad Sci USA 92:1411-1415, 1995 7. Chen J, Willingham T, Shuford M, et al: Effects of ectopic overexpression of p21 (WAF1/CIP1) on aneuploidy and the malignant phenotype of human brain tumor cells. Oncogene 13:1395-1403, 1996 8. Chiocca EA: Brain tumor gene therapy in mice with a novel "suicide" gene: The cyclophosphamide-activating CYP2B1 gene. Clin Neurosurg 42:370-382, 1995 9. Culver KW: Gene therapy for malignant neoplasms of the CNS. Bone Marrow Transplant 18(suppl):S6-S9, 1996 10. Dietrich PY, Walker PR, Saas P, et al: Immunobiology of gliomas: New perspectives for therapy. Ann NY Acad Sci 824:124-140, 1997 11. Eck SL, Alavi JB, Alavi A, et al: Clinical protocol: Treatment of advanced CNS malignancies ---------------------------------------------------------------------------- ---- 628 with the recombinant adenovirus H5.010RSVTK: A phase I trial. Hum Gene Ther 7:1465-1482, 1996 12. Eck SL, Wilson JM: Gene-Based Therapy. In Hardman JG, Limbird LE (eds): Goodman & Gilman's: The Pharmacological Basis of Therapeutics. New York, McGraw-Hill, 1995, pp 77-102 13. Elshami AA, Saavedra A, Zhang H, et al: Gap junctions play a role in the `bystander effect' of the herpes simplex virus thymidine kinase/ganciclovir system in vitro. Gene Ther 3:85-92, 1996 14. Fakhrai H, Dorigo O, Shawler DL, et al: Eradication of established intracranial rat gliomas by transforming growth factor beta antisense gene therapy. Proc Natl Acad Sci USA 93:2909-2914, 1996 15. Freeman S, Abboud CN, Whartenby KA, et al: The "bystander effect": Tumor regression when a fraction of the tumor mass is genetically modified. Cancer Res 53:5274-5283, 1993 16. Ge K, Xu L, Zheng Z, et al: Transduction of cytosine deaminase gene makes rat glioma cells highly sensitive to 5-fluorocytosine. Int J Cancer 7:675-679, 1997 17. Glick RP, Lichtor T, Mogharbel A, et al: Intracerebral versus subcutaneous immunization with allogeneic fibroblasts genetically engineered to secrete interleukin-2 in the treatment of central nervous system glioma and melanoma. Neurosurgery 41:898-906, 1997 18. Hsiao M, Tse V, Carmel J, et al: Intracavitary liposome-mediated p53 gene transfer into glioblastoma with endogenous wild-type p53 in vivo results in tumor suppression and long-term survival. Biochem Biophysi Res Commun 233:359-364, 1997 19. Ikeda E, Achen MG, Breier G, et al: Hypoxia-induced transcriptional activation and increased mRNA stability of vascular endothelial growth factor in C6 glioma cells. J Biol Chem 270:19761-19766, 1995 20. Izquierdo M, Cortes ML, Martin V, et al: Gene therapy in brain tumours: Implications of the size of glioblastoma on its curability. Acta Neurol Scand Suppl 68:111-117, 1997 21. Izquierdo M, Martin V, de Felipe P, et al: Human malignant brain tumor response to herpes simplex thymidine kinase (HSVtk)/ganciclovir gene therapy. Gene Ther 3:491-495, 1996 22. Kim SH, Kim JH, Kolozsvary A, et al: Preferential radiosensitization of 9L glioma cells transduced with HSV-tk gene by acyclovir. J Neurooncol 33:189-194, 1997 23. Laske DW, Youle RJ, Oldfield EH: Tumor regression with regional distribution of the targeted toxin TF-CRM107 in patients with malignant brain tumors. Nat Med 3:1362-1368, 1997 24. Manome Y, Wen PY, Chen L, et al: Gene therapy for malignant gliomas using replication incompetent retroviral and adenoviral vectors encoding the cytochrome P450 2B1 gene together with cyclophosphamide. Gene Ther 3:513-520, 1996 25. Minsky BD: The role of adjuvant therapy in the treatment of colorectal cancer. Hematol Oncol Clin North Am 11:679-697, 1997 26. Miyatake S, Martuza RL, Rabkin SD: Defective herpes simplex virus vectors expressing thymidine kinase for the treatment of malignant glioma. Cancer Gene Ther 4:222-228, 1997 27. Moolten F: Tumor chemosensitivity conferred by inserted herpes thymidine kinase genes: paradigm for a prospective cancer control strategy. Cancer Res 46:5276-5281, 1986 28. Nilaver G, Muldoon LL, Kroll RA, et al: Delivery of herpesvirus and adenovirus to nude rat intracerebral tumors after osmotic blood-brain barrier disruption. Proc Natl Acad Sci USA 92:9829-9833, 1995 29. Peltekian E, Parrish E, Bouchard C, et al: Adenovirus-mediated gene transfer to the brain: Methodological assessment. J Neurosci Methods 71:77-84, 1997 30. Plate KH: Gene therapy of malignant glioma via inhibition of tumor angiogenesis. Cancer Metastasis Rev 15:237-240, 1996 31. Plate KH, Risau W: Angiogenesis in malignant gliomas. Glia 15:339-347, 1995 32. Ram Z, Culver KW, Oshiro EM, et al: Therapy of malignant brain tumors by intratumoral implantation of retroviral vector-producing cells. Nat Med 3:1354-1361, 1997 ---------------------------------------------------------------------------- ---- 629 33. Redekop GJ, Naus CC: Transfection with bFGF sense and antisense cDNA resulting in modification of malignant glioma growth. J Neurosurg 82:83-90, 1995 34. Saleh M, Stacker SA, Wilks AF: Inhibition of growth of C6 glioma cells in vivo by expression of antisense vascular endothelial growth factor sequence. Cancer Res 56:393-401, 1996 35. Sampson JH, Ashley DA, Archer GE, et al: Characterization of a spontaneous murine astrocytoma and abrogation of its tumorigenicity by cytokine secretion. Neurosurgery 41:1365-1373, 1997 36. Shweiki D, Itin A, Soffer D, et al: Vascular endothelial growth factor induced by hypoxia may mediate hypoxia-induced angiogenesis. Nature 359:845-848, 1992 37. Smith JG, Raper SE, Wheeldon E, et al: Intracranial administration of adenovirus expressing HSVTK in combination with ganciclovir produces a self-limited, dose-dependent inflammatory response. Hum Gene Ther 8:943-954, 1997 38. Sobol RE, Fakhrai H, Shawler D, et al: Interleukin-2 gene therapy in a patient with glioblastoma. Gene Ther 2:164-167, 1995 39. Tanaka T, Manome Y, Wen P, et al: Viral vector-mediated transduction of a modified platelet factor 4 cDNA inhibits angiogenesis and tumor growth. Nat Med 3:437-442, 1997 40. Tjuvajev J, Gansbacher B, Desai R, et al: RG-2 glioma growth attenuation and severe brain edema caused by local production of interleukin-2 and interferon-gamma. Cancer Res 55:1902-1910, 1995 41. Trinh QT, Austin EA, Murray DM, et al: Enzyme/prodrug gene therapy: Comparison of cytosine deaminase/5-fluorocytosine versus thymidine kinase/ganciclovir enzyme/prodrug systems in a human colorectal carcinoma cell line. Cancer Res 55:4808-4812, 1995 42. Tseng SH, Hwang LH, Lin SM: Induction of antitumor immunity by intracerebrally implanted rat C6 glioma cells genetically engineered to secrete cytokines. J Immunother 20:334-342, 1997 43. Valtonen S, Timonen U, Toivanen P, et al: Interstitial chemotherapy with carmustine-loaded polymers for high-grade gliomas: A randomized double-blind study. Neurosurgery 41:44-48, 1997 44. Vincent AJ, Esandi MC, Avezaat CJ, et al: Preclinical testing of recombinant adenoviral herpes simplex virus-thymidine kinase gene therapy for central nervous system malignancies. Neurosurgery 41:442-451, 1997 45. Zhu J, Zhang L, Hanisch UK, et al: A continuous intracerebral gene delivery system for in vivo liposome-mediated gene therapy. Gene Ther 3:472-476, 1996 ---------------------------------------------------------------------------- ---- MD Consult L.L.C. http://www.mdconsult.com Frameset URL: /das/journal/view/N/10322723?ja=116071&PAGE=1.html&ANCHOR=top&source=CL,MI > -----Original Message----- > From: owner-wilderness-emergency-medicine@list.pitt.edu > [mailto:owner-wilderness-emergency-medicine@list.pitt.edu]On Behalf Of > Nena Wiley (by way of "Howard M. Paul" ) > Sent: Monday, March 22, 1999 1:31 PM > To: wilderness-emergency-medicine@list.pitt.edu > Subject: W-EMED [PSA/PIO] Unusual Emergency Request > > > Folks - My Father just had brain surgery to remove a malignant > primary, Level > 4 tumor called Glioblastoma Multiforme. We are seeking alternative & > experimental treatment & case histories. > If anyone can help me - please write me personally at: coyotearz@aol.com > > Nena Wiley, Maj CAP > PA ACV/SWR > > Do not reproduce without author's express permission. > To unsubscribe, send the text "unsubscribe wilderness-emergency-medicine" > as the body of a message (no subject) To: Majordomo@list.pitt.edu > Submissions To: wilderness-emergency-medicine@list.pitt.edu > Do not reproduce without author's express permission. To unsubscribe, send the text "unsubscribe wilderness-emergency-medicine" as the body of a message (no subject) To: Majordomo@list.pitt.edu Submissions To: wilderness-emergency-medicine@list.pitt.edu -- End -- Received: from post-ofc05.srv.cis.pitt.edu (root@post-ofc05.srv.cis.pitt.edu [136.142.185.10]) by pop.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cispop-7.2.2.1) ID ; Mon, 22 Mar 1999 21:29:41 -0500 (EST) Received: from localhost (root@localhost) by post-ofc05.srv.cis.pitt.edu (8.8.8/8.8.8/cispo-7.2.2.2) ID ; Mon, 22 Mar 1999 21:28:31 -0500 (EST) Received: via switchmail; Mon, 22 Mar 1999 21:28:30 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Mon, 22 Mar 1999 21:26:32 -0500 (EST) Received: from localhost (majordom@localhost) by list.srv.cis.pitt.edu (8.8.8/8.8.8/cisls-7.2.2.1) ID ; Mon, 22 Mar 1999 21:24:21 -0500 (EST) Received: from raven.prod.itd.earthlink.net (raven.prod.itd.earthlink.net [209.178.63.9]) by list.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cisls-7.2.2.1) ID for ; Mon, 22 Mar 1999 21:24:17 -0500 (EST) Received: from default (1Cust230.tnt1.pleasantville.nj.da.uu.net [63.10.1.230]) by raven.prod.itd.earthlink.net (8.8.7/8.8.5) with SMTP id SAA25515 for ; Mon, 22 Mar 1999 18:23:37 -0800 (PST) From: "David Israel" To: Subject: RE: W-EMED [PSA/PIO] Unusual Emergency Request, be careful Date: Mon, 22 Mar 1999 21:19:31 -0500 Message-ID: <000001be74d3$95e09f00$e6010a3f@default> MIME-Version: 1.0 Content-Type: text/plain; charset="iso-8859-1" Content-Transfer-Encoding: 8bit X-Priority: 3 (Normal) X-MSMail-Priority: Normal X-Mailer: Microsoft Outlook 8.5, Build 4.71.2173.0 Importance: Normal In-Reply-To: <4.1.19990322112925.009ba6f0@pop.ecentral.com> X-MimeOLE: Produced By Microsoft MimeOLE V4.72.3110.3 Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk Reply-To: wilderness-emergency-medicine@list.pitt.edu X-PMFLAGS: 34078848 0 1 P7BD10.CNM Dear Maj, Please be careful when choosing alternative therapy for your Dad. I recently came across this article in "Neurology" that might be of help. My thoughts are with you. David Israel, MD LSTC-EMS Education Atlantic City Medical Center Neurology Volume 52 • Number 3 • February 1999 Copyright © 1999 American Academy of Neurology ---------------------------------------------------------------------------- ---- ---------------------------------------------------------------------------- ---- 617 Articles ---------------------------------------------------------------------------- ---- Alternative therapy use in neurologic diseases Use in brain tumor patients Marja J. Verhoef 1 PhD Neil Hagen 2 3 MD, FRCPC Guy Pelletier 3 PhD Peter Forsyth 2 3 MD, FRCPC 1 Department of Community Health Sciences (Dr. Verhoef) 2 Departments of Clinical Neurosciences and Medicine (Drs. Hagen and Forsyth), The University of Calgary 3 Tom Baker Cancer Center (Drs. Hagen, Pelletier, and Forsyth), Calgary, Alberta, Canada. T ---------------------------------------------------------------------------- ---- Parts of this manuscript were presented at the annual meeting of the American Neurological Association; San Diego, CA; September 28 to October 1, 1997. Received June 22, 1998. Accepted in final form October 17, 1998. ---------------------------------------------------------------------------- ---- Address correspondence and reprint requests to Dr. Marja J. Verhoef, Department of Community Health Sciences, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1 Canada; mverhoef@ucalgary.ca Copyright © 1999 by the American Academy of Neurology Article abstract-- Background: The extent of alternative therapy use in brain tumor patients is unknown, but it may be frequent and seems important to those who use it. Objective: To characterize alternative therapy use in brain tumor patients. Methods: Prospective questionnaire-based survey of 167 brain tumor patients who attended a cancer center in Southern Alberta. Physicians completed forms describing clinical information such as disease status. Results: The response rate was 91% (167/184). Twenty-four percent of patients used alternative therapies and often more than one therapy at the same time. Motivation to use these therapies was influenced by the desire for patient-focused treatment and a perceived need to take charge. Alternative therapy users were younger ( p = 0.04) and more likely to be on sick or disability leave ( p = 0.02), to come in for repeat visits ( p = 0.05), and to have received conventional treatments ( p = 0.01). Users tended to have lower quality of life with respect to physical well-being, functional well-being, and a specific brain tumor subscale. Clinical variables, such as disease status, tumor type, and Karnofsky Performance Score, were not related to alternative therapy use. Major changes in number and types of alternative therapy use occurred during the study period. No major side effects or tumor responses were seen with alternative therapies. Conclusions: Alternative therapy use in brain tumor patients is common and may reflect unmet patient needs with respect to their cancer care within the current model of health care delivery. We became interested in the use of alternative therapies when we encountered several brain tumor patients whose hands had an orange hue. When questioned, they told us they were taking beta carotene and that many other brain tumor patients were also using alternative therapies. We were curious as to how commonly these were used, which ones were used, what motivated patients to consider using them, and what their costs and perceived benefits and side effects were. The use of alternative therapies is increasingly popular despite limited proof of their benefit. These therapies are easy to recognize but harder to define. On a practical level, they can be defined as practices that do not conform with the standards of the medical community and are not widely taught at North American medical schools. [1] The use of alternative therapies in cancer patients varies between 9% and 45%. [2] [3] [4] [5] [6] [7] Alternative therapy use varies with geography, historical and political setting, and acceptance of such therapies by the medical community. [8] No prior studies have assessed alternative therapy use in patients with brain tumors. A large study commissioned by the American Cancer Society found that the use of alternative therapies was lowest in patients with cancer of the bladder (2%) and highest in patients with cancer of the brain and CNS (21%). [4] However, no information was provided regarding the therapies used or reasons for use in the latter. In the field of oncology, this issue is recognized, but there are few reports of the use of these therapies in neurologic diseases. Alternative therapies are used in 9 to 56% of neurologic patients with a variety of disorders such as AD, [9] [10] multiple sclerosis, [11] epilepsy, [12] migraine, [13] and postconcussion and whiplash syndromes. [14] Although many patients use these therapies, there are few in-depth studies addressing this issue in neurologic patients. It is not clear what benefit patients derive from the use of alternative therapies. Only a handful of systematic studies addressing the benefit of alternative therapies have been published in peer-reviewed journals. [15] [16] [17] [18] [19] Furthermore, the quality of life of patients taking these therapies is usually reported to ---------------------------------------------------------------------------- ---- This project was funded by a grant from the Alberta Cancer Board. ---------------------------------------------------------------------------- ---- 618 be the same or lower than conventionally treated patients. [20] Although alternative therapies are frequently perceived as "natural" and "nontoxic," there are reports of serious toxicities associated with their use. [21] [22] Finally, the costs of these therapies can be burdensome. [1] [6] The aim of this study was to characterize the use of alternative therapies in brain tumor patients. We also compared the quality of life of patients using these therapies with those who did not and attempted to identify factors that would predict which patients would use alternative therapies. Finally, we examined whether alternative therapy use changed over the disease trajectory of patients living with brain tumors. Methods. The study design was a prospective questionnaire-based survey of primary brain tumor patients. All patients with a histologic or radiographic diagnosis of a primary brain tumor who attended the Tom Baker Cancer Center (TBCC) in Southern Alberta (Canada) between October 1995 and September 1996 were eligible and were asked to participate in the study. TBCC is the sole ambulatory tertiary cancer treatment center in Southern Alberta (referral population 1.3 million) and all brain tumor patients requiring treatment with radiation or chemotherapy are referred there. Patients were asked to complete a self-report questionnaire assessing sociodemographics, treatment information, alternative therapy use, reasons for use, cost and perceived benefits, and side effects of treatment. Clinical information assessing disease status (e.g., improved, stable, recurrent) and treatment status (e.g., first postoperative visit, first postradiotherapy visit, routine follow-up visit) was collected at the time of the visit by the attending physician on a specifically designed form. The questionnaire explained: "Alternative therapies are any treatments other than surgery, radiation, or chemotherapy for your tumor. Common types of alternative therapies are metabolic therapies, diet, vitamin supplements, mental image therapy, spiritual or faith healing, and immune therapies." A list of types of practitioners who might provide these therapies was included, as well as an extensive list of examples of various alternative therapies. Up to two follow-up questionnaires were administered about 6 months after the first visit during the patients' routine scheduled visit. Owing to variation in scheduled appointments, the length of time between these measurements varied somewhat. We developed a questionnaire specifically for brain tumor patients because of a lack of information in this field; one of us (M.J.V.) had developed questionnaires on alternative therapy use in other diseases. [23] [24] The brain tumor patient questionnaire was reviewed extensively by clinic personnel and piloted on about 20 patient volunteers. Most of the data were quantitative (continuous as well as categorical), but a series of open-ended questions were also included. We measured quality of life using the Functional Assessment of Cancer Therapy (FACT-BR) scale. [25] This scale consists of a core questionnaire (FACT-G) assessing general quality of life in cancer patients to which a specific subscale has been added to measure quality of life in patients with brain tumors. The FACT-G consists of subscales assessing physical well-being, social/family well-being, relationship with doctor, emotional well-being, and functional well-being. The validity and reliability of the FACT-BR and the FACT-G have been demonstrated. [25] [26] Data analysis was primarily descriptive, consisting of frequencies, summary measures, t-test, and chi-square analysis. Logistic regression analysis was performed to assess which factors had the strongest independent effect on alternative therapy use. Open coding [27] was used to analyze the responses to the open-ended questions. The study was approved by the Conjoint Health Research Ethics Board of The University of Calgary, and signed, informed consent was obtained from all patients. Results. Of 195 consecutive patients who were approached for the study, four could not be included due to language difficulties and seven were deemed too ill. An additional 17 patients refused to participate in the study. Therefore, 167 patients (91% response rate) form the basis of this report. Follow-up was completed for 99/167 (59%) patients; 34 had died and the remaining 34 did not come in for follow-up visits during the study, refused to fill out the questionnaire a second time, or were too ill to complete the follow-up questionnaire. Patient characteristics. Fifty-six percent of the respondents were men and the mean age was 44 years (range, 20 to 83). The most common tumor types were low-grade glioma (28%), malignant glioma (26%), meningioma (16%), glioblastoma multiforme (14%), medulloblastoma (3%), and other diagnoses (12%). The high frequency of low-grade gliomas in the clinic reflects their superior survival and the young age of our patients. The median Karnofsky Performance Score was 85 (range, 40 to 100). Eighty-five percent of these patients had clinically stable disease, 14% had recurrent disease either at the time of the clinic visit or at some time in the past, and for 1%, disease status was unknown. Interestingly, 94% of patients thought their disease status was stable. Thirty-four (21%) patients were enrolled when they attended the clinic for their first visit. The other 79% were enrolled during follow-up visits and 78% of these visits were routine; nonroutine visits occurred because of clinical or radiographic deterioration or for other reasons (e.g., issues of symptom control or increasing seizures). Seventy-four percent of all patients had received, or were receiving, chemotherapy, radiotherapy, or both. Thirty percent of patients were employed, 30% were on sick or disability leave, and the remainder were homemakers, students, unemployed, or retired. Sixty-two percent had received more than a high school education. Awareness of alternative therapies. Forty-nine percent of respondents had become aware of an average of 2.6 alternative therapies after their tumor was first diagnosed. The most common types of therapies of which patients were aware were herbal therapies (69%), mind-body therapies (40%), and animal- and vegetable-derived therapies, particularly shark cartilage (36%). Patients believed 95% of all therapies they had heard of might be effective. The most common way patients heard about these therapies was from family or friends. Alternative therapy use. Forty patients (24%) had used or were using these therapies to treat their cancer. Together, these patients used 103 different alternative therapies representing six different categories of therapies (table 1) . Twenty-two of the 28 patients who used more ---------------------------------------------------------------------------- ---- 619 TABLE 1 -- Alternative therapies used by brain tumor patients Therapy type Commonly used in therapy Patients using this therapy, % * Herbal Essiac, Echinacea, Pau D'arco 65 Mind-body Imagery/visualization, faith healing, meditation 33 Animal/vegetable-derived Shark cartilage, mushrooms 25 Vitamin Beta carotene, vitamins 20 Dietary Macrobiotic 15 Other Acupuncture, reflexology, homeopathy, chiropractic 20 * Some patients used more than one therapy of the same type. ---------------------------------------------------------------------------- ---- than one alternative therapy used therapies from more than one category (e.g., herbal therapy along with mind-body therapy). No consistent patterns of combinations of alternative therapies emerged. Most commonly, motivation seemed to be influenced by wishes for patient-focused treatment and the need to "take charge" of their care (table 2) . TABLE 2 -- Reasons for alternative therapy use by brain tumor patients (n = 40) Reason No. (%) of patients * 1. My physicians left me little, if any, hope; i.e., "Could not offer available medical options other than `see you in six months' ... " 12 (30) 2. My physicians think differently about causes and treatment of disease than I do; i.e., "[I believe] that conventional medicine has no cures--prolongs life only." 9 (23) 3. Conventional treatment did not provide a cure, does not work; i.e., "I think I made a mistake doing radiation because I feel it didn't do anything for me." 9 (23) 4. To do something, take charge of my health; i.e., "I simply think I have a role in remaining healthy." 9 (23) 5. To augment conventional treatment; i.e., "I believe that the use of all forms (within cost and `personal' perception of possibilities) of treatment should be used." 8 (20) 6. Side effects of conventional therapies; i.e., "The alternative medicine appears to help my memory, my disposition and my tiredness." 6 (15) 7. I will take anything that might help; i.e., "Do anything that might help and might boost my immune system." 4 (10) 8. Other (including wishes of family, natural treatments, curiosity, lack of personal care from physicians, other); i.e., "Keeps the wife and children happy. They are doing the best they can for me"; "I have personally been involved with holistic health for a long period of time"; and "All natural--no side effects." 18 (45) * Multiple responses were common. ---------------------------------------------------------------------------- ---- Sixty-six percent of these therapies were perceived to be helpful in general and 35% were credited with making the tumor shrink or stop growing. The latter effects were mainly perceived for dietary and animal- and vegetable-derived therapies. No patient had an objective response to these therapies that could not otherwise be attributed to radio- or chemotherapy. When asked about benefits, 73% of all therapies had positive effects; most commonly, patients mentioned improved physical or mental well-being and increased energy. Of all reported therapies, 10% were found to have side effects, the most common of which was bad breath. No major objective toxicities attributable to these therapies were found for any patients using alternative therapies. Cost of alternative therapies. A minority of alternative therapy users (15/40; 37%) responded to the question about the average cost of each alternative therapy per month. This may reflect difficulty in assessing the monthly amount or an unwillingness to answer this question. The median cost of alternative therapies per month among responders was $55 (range, $7 to $420). When asked who paid for alternative therapies, more patients responded: 65% (26/40) indicated they paid 100% of the costs themselves, 10% (4) indicated that their families covered 100% of the costs, 15% (6) indicated that they shared the cost with their family, and 10% (4) did not provide this information. Perceptions of physician attitudes toward alternative therapy use. Forty-five percent (18) of alternative therapy users indicated that their doctor was aware they were using these therapies, 33% (13) were not sure whether their doctor knew, and 23% (9) indicated that their doctor was unaware of their use. Of the 18 patients who told their doctor they were using alternative therapies, 28% (5) described a positive (supportive, encouraging) reaction, 33% (6) a negative (discouraging, condescending) reaction, and the remaining 39% (7) a neutral ("don't mind," "try anything," "can't hurt") reaction from their treating physicians. Relationship between alternative therapy use and quality of life. Total scores on the FACT-BR quality of life scale were not significantly different between users and nonusers. However, subscale scores on physical well-being, functional well-being, and the brain subscale were significantly lower in patients who were using alternative therapies, indicating a lower quality of life (table 3) . Factors related to alternative therapy use. Table 4 presents the relationships between self-reported sociodemographic and clinical characteristics and the use of alternative therapies. Users were more likely to have received prior radiotherapy or chemotherapy, to have come in for a follow-up visit, to be on sick or disability leave, to be younger, or to have a higher income than nonusers. None of the clinical characteristics recorded by the physicians (such as whether the tumor was stable or recurrent, type of tumor, or Karnofsky Performance Score) was significantly related to alternative therapy use. However, there was a trend for patients with glioblastoma multiforme and malignant glioma to be more likely to use alternative therapies than patients with other diagnoses. Logistic regression analysis showed that employment status and having received or receiving radio- and chemotherapy significantly and independently affected the use of alternative ---------------------------------------------------------------------------- ---- 620 TABLE 3 -- FACT-BR subscales and total scores for users and nonusers of alternative therapies Subscale Users, mean ± SE Nonusers, mean ± SE p Value Physical 19.5 ± 6.3 * 21.8 ± 5.8 0.035 Social 21.6 ± 4.9 21.4 ± 6.0 0.879 Relationship with doctor 6.2 ± 1.8 6.9 ± 2.0 0.082 Emotional 15.1 ± 4.2 15.1 ± 4.0 0.987 Functional 15.7 ± 6.8 18.9 ± 7.9 0.025 FACT-G 78.7 ± 17.1 83.6 ± 17.0 0.126 Brain subscale 50.6 ± 14.5 55.7 ± 13.4 0.050 FACT-BR 129.8 ± 30.1 138.4 ± 28.4 0.112 FACT = Functional Assessment of Cancer Therapy; G, core questionnaire; BR, core questionnaire with subscale specific to brain tumor patients. * Note: a lower value corresponds to a lower quality of life. ---------------------------------------------------------------------------- ---- therapies. Income was not included in the modeling process, as the response rate for this question was low (59%), which would result in deletion of 70 respondents from the analysis. Changes in alternative therapy use over time. At the time the second questionnaire was completed, 26% of patients (26/97) were using alternative therapies, compared with 24% of users (40/167) identified when the questionnaire was first completed. Although the rate of use remained the same, several changes in use took place over the disease course of brain tumor patients. Table 5 shows TABLE 4 -- Relationship among sociodemographic variables, treatment received, visit number, and alternative therapy use Characteristic Users Nonusers p Value Sex, % male 60 56 0.65 Age, mean 42 47 0.04 Education, % High school 31 41 0.26 > High school 69 59 Employment status, % Employed 22 33 0.02 Sick/disability leave 48 24 Other (homemaker, retired, etc.) 30 43 Income, % $40,000 47 69 >$40,000 53 31 0.03 Visit, % First 10 25 0.05 Follow-up 90 75 Treatment received, % Chemotherapy 31 12 <0.01 Radiotherapy 72 40 <0.001 Radio- and chemotherapy 52 11 <0.0001 TABLE 5 -- Change in alternative therapy use between the first and second time the questionnaire was completed (n = 97) * Alternative therapy use at first completion of the questionnaire Alternative therapy use at second completion of the questionnaire User (n = 29) Nonuser (n = 73) User (n = 26) 15 11 Nonuser (n = 71) 9 62 * This table only applies to patients who completed the questionnaire twice. ---------------------------------------------------------------------------- ---- how many patients started (n = 9), stopped (n = 11), continued using (n = 15), or stayed away from alternative therapy use (n = 62). Of the 15 patients who were still using alternative therapies at the time of the second questionnaire, only three used the same number and the same type of therapies. The other 12 patients changed the number or the type of therapies used, or both. Further exploratory analysis was done to determine whether any factors were related to whether patients would continue, discontinue, or begin using alternative therapies. Men were significantly more likely to be continuing users than women (12/15 versus 3/15; p = 0.03). Patients who had received both chemotherapy and radiation were significantly more likely to be continuing users (7/17) than stoppers (2/11) or new users (0/9; p = 0.05). Although not significant, the disease status of new users was more likely to have recently progressed (3/9) than was that of persistent users (1/15), stoppers (0/11), and nonusers (2/62). Whether patients continued, stopped, or started using alternative therapies was not significantly related to quality of life at the time that the second questionnaire was completed, nor was it related to the quality of life when the initial questionnaire was completed. Discussion. This study shows that alternative therapies are used by 24% of brain tumor patients, which represents half of the patients who were aware of these treatments. The frequency of use is similar to that found in the study commissioned by the American Cancer Society. [4] Our study also determined the types of therapies used and their perceived benefits, side effects, and costs. Why do brain tumor patients use these therapies? The most common reason was that conventional therapies are not very effective. Alternative therapies were often used as a "last resort" after the treatments with radio- and chemotherapy were completed and conventional treatments offered no further hope. A second important reason was patients wanting to be more proactive in their care and to "take charge." Finally, the patients wanted to be sure "everything possible was being done." Given the dismal prognosis for many brain tumor patients, it is somewhat surprising that alternative therapies are not more commonly used. As expected from studies including patients with systemic cancer, patients were likely to be users if they had previously used multiple conventional ---------------------------------------------------------------------------- ---- 621 treatments, were on sick or disability leave, were younger, or had higher incomes. Although these are rather nonspecific factors, they may be useful in identifying patients who are more likely to consider alternative treatments and may require counseling regarding risks, benefits, and costs. Were these therapies useful to patients? Two thirds of patients who used them thought so, at least in a general way, either by improving energy levels or physical and mental well-being. One third of users had high expectations and anticipated that alternative therapies would shrink or cure their tumor. However, we did not encounter any patient who experienced an objective clinical or radiographic response that could not be attributed to concurrent therapy with radiation, chemotherapy, or corticosteroids. We concluded that alternative therapies seemed to provide comfort to patients who believed that every possible treatment was being used and that they had an opportunity to take an active role in their care. Users of alternative therapies had the same or lower quality of life than nonusers, which confirms the results of previous research. [20] This could partly be due to their disease being somewhat more severe or advanced. Was any harm done by taking these treatments? Despite a number of serious side effects reported with alternative therapies, [21] [22] patients did not report any significant adverse effects in our study. No patient reported what would be considered a serious (grade 3 or 4 National Cancer Institute of Canada common toxicity criteria [28] ) toxicity. These may have been unreported, however, as one patient had moderate (grade 3 toxicity) gastrointestinal side effects following enema treatments but did not report them in the study. All the reported side effects were minor (such as bad breath or mild gastrointestinal upset). Although average costs were about $50 per month, they could be as high as $420 per month. We were unable to determine if this was a source of financial hardship for our patients. In summary, we did not find significant harm done by the alternative therapies our patients used, although some had the potential to cause serious side effects and could be expensive. In light of the above results, we would like to point out that it was not the purpose of this study to assess scientific evidence of the efficacy of these therapies. Our study has several strengths and limitations that should be considered. A major strength is the external validity of the study, as virtually everyone in Southern Alberta who required brain tumor treatment was referred to our center and the majority (85%) participated. As a second strength, its longitudinal nature provided information about changes in use over time. There were several limitations. First, we did not survey patients in our population who were not referred for treatment with radiotherapy or chemotherapy. Therefore, patients with completely resected tumors, those treated with hormonal therapy (such as pituitary adenomas), or patients who were too ill to be referred were not sampled. This represents a small proportion of patients. A second limitation is under-reporting. Data of a highly sensitive nature such as income or the costs of these therapies were often not reported. We know of two patients who under-reported the costs of their therapies; the family of one raised money to send him to a clinic in another country and a second patient spent $20,000 on aggressive "cleansing" procedures in another country. We could not determine why this information was not recorded. We may also have under-reported the number of alternative therapies patients were using, as we only included space for four therapies on the questionnaire. Finally, because the use of alternative treatments is exquisitely sensitive to factors such as culture and sociodemographics, types, costs, side effects, or other details will vary considerably from population to population. Therefore, the experience of brain tumor patients in Southern Alberta may not be generalizable to all brain tumor patients. Alternative therapies are used by a significant number of our patients and we suggest that neurologists should discuss them with their patients. Many physicians are uncomfortable dealing with topics such as this in which there are strongly held (and often contradictory) beliefs and little objective data. However, patients need advice and support on these topics, which the physician is uniquely qualified to provide. It is now our practice to raise this issue routinely with our patients and provide advice if it is obvious that the proposed treatments will be highly toxic or expensive. This also highlights the need to study alternative treatments objectively in properly conducted clinical trials in neurologic patients. Potential interaction effects between alternative and conventional therapies also need to be assessed. Because use of alternative therapies may be largely motivated by patients' wishes to be more involved in their treatment, we now directly invite patients to participate in decisions regarding their conventional treatments offered by our cancer facility. Cancer patients vary widely in how much they want to become involved in their own care, and physicians need to facilitate that involvement according to each patient's preferences. [29] References 1. Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Alternative medicine in the United States. Prevalence, costs and patterns of use. N Engl J Med 1993;328:246-252. 2. Cassileth BR, Lusk EJ, Strouse TB, Bodenheimer BJ. Contemporary unorthodox treatments in cancer medicine. A study of patients, treatments and practitioners. Ann Intern Med 1984;101:105-112. 3. Sollner W, Zingg-Schir M, Rumpold G, Fritsch P. Attitude toward alternative therapy, compliance with standard treatment, and need for emotional support in patients with melanoma. Arch Dermatol 1997;133:316-321. 4. Lerner IJ, Kennedy BJ. The prevalence of questionable methods of cancer treatment in the United States. CA Cancer J Clin 1992;42:181-191. ---------------------------------------------------------------------------- ---- 622 5. Risberg T, Kaasa S, Wist E, Melsom H. Why are cancer patients using non-proven complementary therapies? A cross-sectional multicentre study in Norway. Eur J Cancer 1997;33:575-580. 6. Begbie SD, Kerestes ZL, Bell DR. Patterns of alternative medicine use by cancer patients. MJA 1996;165:545-548. 7. Munstedt K, Kirsch K, Milch W, Sachsse S, Vahrson H. Alternative cancer therapy--survey of patients with gynecological malignancy. Arch Gynecol Obstet 1996;258:81-88. 8. Murray RH, Rubel AJ. Physicians and healers--unwilling partners in health care. N Engl J Med 1992;326:61-64. 9. Hogan DB, Ebly EM. Complementary medicine use in a dementia clinic population. Alzheimer Dis Assoc Disord 1996;10:63-67. 10. Coleman LM, Fowler LL, Williams ME. Use of unproven therapies by people with Alzheimer's disease. J Am Geriatr Soc 1995;43:747-750. 11. Fawcett J, Sidney JS, Riley-Lawless K, Hanson MJ. An exploratory study of the relationship between alternative therapies, functional status, and symptom severity among people with multiple sclerosis. J Holist Nurs 1996;14:115-129. 12. Danesi MA, Adetunji JB. Use of alternative medicine by patients with epilepsy: a survey of 265 epileptic patients in a developing country. Epilepsia 1994;35:344-351. 13. MacGregor EA, Vohrah C, Wilkinson M. Analgesic use: a study of treatments used by patients for migraine prior to attending the City of London Migraine Clinic. Headache 1990;30:571-574. 14. Evans RW, Evans RI, Sharp MJ. The physician survey on the post-concussion and whiplash syndromes. Headache 1994;34:268-274. 15. Bagenal F, Easton D, Harris E, Chilvers CE, McElwain TJ. Survival of patients with breast cancer attending Bristol Cancer Help Centre. Lancet 1990;336:606-610. 16. Moertel CG, Fleming TR, Rubin J, et al. A clinical trial of amygdalin (Laetrile) in the treatment of human cancer. N Engl J Med 1982;306:201-206. 17. Spiegel D, Bloom JR, Kraemer HC, Gottheil E. Effect of psychosocial treatment on survival of patients with metastatic breast cancer. Lancet 1989;2:888-891. 18. Chlebowski RT, Bulcavage L, Grosvenor M, et al. Hydrazine sulfate influence on nutritional status and survival in non-small-cell lung cancer. J Clin Oncol 1990;8:9-15. 19. Loprinzi CL, Kuross SA, O'Fallon JR, et al. Randomized placebo-controlled evaluation of hydrazine sulfate in patients with advanced colorectal cancer. J Clin Oncol 1994;12:1121-1125. 20. Cassileth BR, Lusk EJ, Duport G, et al. Survival and quality of life among patients receiving unproven as compared with conventional cancer therapy. N Engl J Med 1991;324:1180-1185. 21. Capobianco DJ, Brazis PW, Fox TP. Proximal muscle weakness induced by herbs. N Engl J Med 1993;329:1430. Letter. 22. Larrey D, Vial T, Pauwels A, et al. Hepatitis after germander ( Teucrium chamaedrys) administration: another instance of herbal medicine hepatoxicity. Ann Intern Med 1992;117:129-132. 23. Verhoef MJ, Sutherland LR, Brkich L. Use of alternative medicine by patients attending a gastroenterology clinic. Can Med Assoc J 1990;142:121-125. 24. Sutherland LR, Verhoef MJ. Alternative medicine consultation by patients attending a multidisciplinary HIV clinic. AIDS Patient Care 1995;9:106-111. 25. Cella DF, Tulsky DS, Gray G, et al. The Functional Assessment of Cancer Therapy scale: development and validation of the general measure. J Clin Oncol 1993;11:570-579. 26. Weitzner MA, Meyers CA, Gelke CK, Byrne KS, Cella DF, Levin VA. The Functional Assessment of Cancer Therapy (FACT) scale. Cancer 1995;75:1151-1161. 27. Creswell JW. Research design. Qualitative and quantitative approaches. Thousand Oaks, CA: Sage Publications, 1994. 28. Forsyth P, Cairncross G, Stewart D, Goodyear H, Wainman N, Eisenhauer E. Phase II trial of docetaxel in patients with recurrent malignant glioma: a study of the National Cancer Institute of Canada Clinical Trials Group. Invest New Drugs 1996;14:203-206. 29. Hagen NA, Whylie B. Putting clinical practice guidelines into the hands of cancer patients. Can Med Assoc J 1998;158:347-348. ---------------------------------------------------------------------------- ---- MD Consult L.L.C. http://www.mdconsult.com Frameset URL: /das/journal/view/N/10583204?ja=137515&PAGE=1.html&ANCHOR=top > -----Original Message----- > From: owner-wilderness-emergency-medicine@list.pitt.edu > [mailto:owner-wilderness-emergency-medicine@list.pitt.edu]On Behalf Of > Nena Wiley (by way of "Howard M. Paul" ) > Sent: Monday, March 22, 1999 1:31 PM > To: wilderness-emergency-medicine@list.pitt.edu > Subject: W-EMED [PSA/PIO] Unusual Emergency Request > > > Folks - My Father just had brain surgery to remove a malignant > primary, Level > 4 tumor called Glioblastoma Multiforme. We are seeking alternative & > experimental treatment & case histories. > If anyone can help me - please write me personally at: coyotearz@aol.com > > Nena Wiley, Maj CAP > PA ACV/SWR > > Do not reproduce without author's express permission. > To unsubscribe, send the text "unsubscribe wilderness-emergency-medicine" > as the body of a message (no subject) To: Majordomo@list.pitt.edu > Submissions To: wilderness-emergency-medicine@list.pitt.edu > Do not reproduce without author's express permission. To unsubscribe, send the text "unsubscribe wilderness-emergency-medicine" as the body of a message (no subject) To: Majordomo@list.pitt.edu Submissions To: wilderness-emergency-medicine@list.pitt.edu -- End -- Received: from post-ofc01.srv.cis.pitt.edu (root@post-ofc01.srv.cis.pitt.edu [136.142.185.25]) by pop.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cispop-7.2.2.1) ID ; Mon, 22 Mar 1999 18:25:33 -0500 (EST) Received: from localhost (root@localhost) by post-ofc01.srv.cis.pitt.edu (8.8.8/8.8.8/cispo-7.2.2.2) ID ; Mon, 22 Mar 1999 18:24:56 -0500 (EST) Received: via switchmail; Mon, 22 Mar 1999 18:24:56 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Mon, 22 Mar 1999 18:23:07 -0500 (EST) Received: from localhost (majordom@localhost) by list.srv.cis.pitt.edu (8.8.8/8.8.8/cisls-7.2.2.1) ID ; Mon, 22 Mar 1999 18:22:38 -0500 (EST) Received: from preytor.ecentral.com (root@preytor.ecentral.com [206.64.70.3]) by list.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cisls-7.2.2.1) ID for ; Mon, 22 Mar 1999 18:22:34 -0500 (EST) Received: from default (ppp2-145.ecentral.com [208.213.102.145]) by preytor.ecentral.com (8.9.1a/8.9.1) with SMTP id QAA15524 for ; Mon, 22 Mar 1999 16:22:31 -0700 Message-Id: <4.1.19990322112925.009ba6f0@pop.ecentral.com> X-Sender: hmpaul@pop.ecentral.com X-Mailer: QUALCOMM Windows Eudora Pro Version 4.1 Date: Mon, 22 Mar 1999 11:30:37 -0700 To: wilderness-emergency-medicine@list.pitt.edu From: Nena Wiley (by way of "Howard M. Paul" ) Subject: W-EMED [PSA/PIO] Unusual Emergency Request Mime-Version: 1.0 Content-Type: text/plain; charset="us-ascii" Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk Reply-To: wilderness-emergency-medicine@list.pitt.edu X-PMFLAGS: 34078848 0 1 P26810.CNM Folks - My Father just had brain surgery to remove a malignant primary, Level 4 tumor called Glioblastoma Multiforme. We are seeking alternative & experimental treatment & case histories. If anyone can help me - please write me personally at: coyotearz@aol.com Nena Wiley, Maj CAP PA ACV/SWR Do not reproduce without author's express permission. To unsubscribe, send the text "unsubscribe wilderness-emergency-medicine" as the body of a message (no subject) To: Majordomo@list.pitt.edu Submissions To: wilderness-emergency-medicine@list.pitt.edu -- End -- Received: from post-ofc01.srv.cis.pitt.edu (root@post-ofc01.srv.cis.pitt.edu [136.142.185.25]) by pop.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cispop-7.2.2.1) ID ; Mon, 22 Mar 1999 01:40:09 -0500 (EST) Received: from localhost (root@localhost) by post-ofc01.srv.cis.pitt.edu (8.8.8/8.8.8/cispo-7.2.2.2) ID ; Mon, 22 Mar 1999 01:39:33 -0500 (EST) Received: via switchmail; Mon, 22 Mar 1999 01:39:33 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Mon, 22 Mar 1999 01:39:22 -0500 (EST) Received: from localhost (majordom@localhost) by list.srv.cis.pitt.edu (8.8.8/8.8.8/cisls-7.2.2.1) ID ; Mon, 22 Mar 1999 01:37:50 -0500 (EST) Received: from m4.boston.juno.com (m4.boston.juno.com [205.231.101.198]) by list.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cisls-7.2.2.1) ID for ; Mon, 22 Mar 1999 01:37:47 -0500 (EST) Received: (from pcrs242@juno.com) by m4.boston.juno.com (queuemail) id D6AXHH43; Mon, 22 Mar 1999 01:37:23 EST To: wilderness-emergency-medicine@list.pitt.edu Date: Mon, 22 Mar 1999 01:30:12 -0500 Subject: W-EMED Re: Significantly Ambitious Scope of SAR Objectives.... Message-ID: <19990322.013014.4878.0.pcrs242@juno.com> References: <19990319.023815.13358.0.pcrs242@juno.com> <36F4B984.F253F4E7@erols.com> X-Mailer: Juno 1.49 X-Juno-Line-Breaks: 0-1,6-8 From: Deborah M Gessner Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk Reply-To: wilderness-emergency-medicine@list.pitt.edu X-PMFLAGS: 33554560 0 1 P18E20.CNM Thanks Gene, You hit on everything I wanted to know and you have answered my questions. I will relay this to the people who ask me to do this. Near us is Southwestern Va. Mt. rescue in Blacksburg and we are suppose to get together this week and talk I will let him know what you said and it all makes sense to me now. Thank you again, I will send more later on our group Deborah ___________________________________________________________________ You don't need to buy Internet access to use free Internet e-mail. Get completely free e-mail from Juno at http://www.juno.com/getjuno.html or call Juno at (800) 654-JUNO [654-5866] Do not reproduce without author's express permission. To unsubscribe, send the text "unsubscribe wilderness-emergency-medicine" as the body of a message (no subject) To: Majordomo@list.pitt.edu Submissions To: wilderness-emergency-medicine@list.pitt.edu -- End -- Received: from post-ofc03.srv.cis.pitt.edu (root@post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by pop.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cispop-7.2.2.1) ID ; Fri, 19 Mar 1999 02:49:36 -0500 (EST) Received: from localhost (root@localhost) by post-ofc03.srv.cis.pitt.edu (8.8.8/8.8.8/cispo-7.2.2.2) ID ; Fri, 19 Mar 1999 02:48:59 -0500 (EST) Received: via switchmail; Fri, 19 Mar 1999 02:48:58 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Fri, 19 Mar 1999 02:47:05 -0500 (EST) Received: from localhost (majordom@localhost) by list.srv.cis.pitt.edu (8.8.8/8.8.8/cisls-7.2.2.1) ID ; Fri, 19 Mar 1999 02:45:15 -0500 (EST) Received: from m4.boston.juno.com (m4.boston.juno.com [205.231.101.198]) by list.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cisls-7.2.2.1) ID for ; Fri, 19 Mar 1999 02:45:12 -0500 (EST) Received: (from pcrs242@juno.com) by m4.boston.juno.com (queuemail) id D53B7EBZ; Fri, 19 Mar 1999 02:45:08 EST To: wilderness-emergency-medicine@list.pitt.edu Date: Fri, 19 Mar 1999 02:38:15 -0500 Message-ID: <19990319.023815.13358.0.pcrs242@juno.com> X-Mailer: Juno 1.49 X-Juno-Line-Breaks: 0-1,3,9-13 From: Deborah M Gessner Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk Reply-To: wilderness-emergency-medicine@list.pitt.edu X-PMFLAGS: 33554560 0 1 P1C470.CNM Hi Gang I need some help here,(all input welcome) Long Way Home Search and Rescue that I started may be taking a new turn. I have been ask about making it a regional group and as a task force. To be called Long Way Home Regional Task Force, to include all special rescues like: SAR, Dive, Tactical, Rope, Cave, Confined space, Extracation including all types of it, Urban SAR, Collapsed building, and anything else that comes up. Regional would be all surrounding fire depts. and rescue squads in our Valley. Should we do this or stay a small sar group? And if we did do it how would we go about doing it? I NEED BIG HELP WITH THIS ONE Can respond here or at : longwayhome-regional-task-force@juno.com Thank You Deborah Gessner at Dublin,Va. ___________________________________________________________________ You don't need to buy Internet access to use free Internet e-mail. Get completely free e-mail from Juno at http://www.juno.com/getjuno.html or call Juno at (800) 654-JUNO [654-5866] Do not reproduce without author's express permission. To unsubscribe, send the text "unsubscribe wilderness-emergency-medicine" as the body of a message (no subject) To: Majordomo@list.pitt.edu Submissions To: wilderness-emergency-medicine@list.pitt.edu -- End -- Received: from post-ofc02.srv.cis.pitt.edu (root@post-ofc02.srv.cis.pitt.edu [136.142.185.24]) by pop.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cispop-7.2.2.1) ID ; Thu, 18 Mar 1999 23:11:46 -0500 (EST) Received: from localhost (root@localhost) by post-ofc02.srv.cis.pitt.edu (8.8.8/8.8.8/cispo-7.2.2.2) ID ; Thu, 18 Mar 1999 23:11:09 -0500 (EST) Received: via switchmail; Thu, 18 Mar 1999 23:11:07 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Thu, 18 Mar 1999 23:09:51 -0500 (EST) Received: from localhost (majordom@localhost) by list.srv.cis.pitt.edu (8.8.8/8.8.8/cisls-7.2.2.1) ID ; Thu, 18 Mar 1999 23:08:56 -0500 (EST) Received: from post-ofc05.srv.cis.pitt.edu (root@post-ofc05.srv.cis.pitt.edu [136.142.185.10]) by list.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cisls-7.2.2.1) ID for ; Thu, 18 Mar 1999 23:08:34 -0500 (EST) Received: from 136.142.57.10.pitt.edu (ehdup-t-91.rmt.net.pitt.edu [136.142.23.101]) by post-ofc05.srv.cis.pitt.edu with SMTP (8.8.8/8.8.8/cispo-7.2.2.2) ID ; Thu, 18 Mar 1999 23:08:26 -0500 (EST) Message-Id: <199903190408.XAA18068@post-ofc05.srv.cis.pitt.edu> From: "Keith Conover, M.D., FACEP" To: Mkeowl@aol.com Date: Thu, 18 Mar 1999 23:08:02 -0500 MIME-Version: 1.0 Content-type: text/plain; charset=US-ASCII Content-transfer-encoding: 7BIT Subject: Re: W-EMED Betadine allergy CC: wilderness-emergency-medicine@list.pitt.edu In-reply-to: X-mailer: Pegasus Mail for Win32 (v3.01d) Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk Reply-To: wilderness-emergency-medicine@list.pitt.edu X-PMFLAGS: 34078848 0 1 P3FEB0.CNM On 17 Mar 99, at 11:49, Mkeowl@aol.com wrote: > Anyway, for my SAR dog and I, I keep and have used diluted Calendula > Tincture or Goldenseal Tincture to clean and flush the wounds. For > punctures or deep wounds I ONLY use Ledum Tincture, diluted, then > Goldenseal. > > I have used these successfully many times. (My conventional vet who is > open- minded, said that he is amazed that some of the wounds -- severe > punctures, lacerations, >10" torn tissue wounds, healed so well without > ANY antibiotics or conventional drugs.) The recommended treatment for contaminated wounds is high- pressure irrigation with plain sterile (or at least clean) water or saline -- even betadine has tissue-toxic properties (though much less so than peroxide, alcohol, merthiolite, or tincture of iodine). So I'm not surprised that you've had good results with homeopathic tinctures -- which are to a very high approximation, distilled water -- as this essentially is the irrigant of choice! The chance of a standard homeopathic dilution actually containing even a molecule of Calendula or Goldenseal is tiny. Certainly homepathic succussed dilutions are much better for irrigating wounds than alcohol, peroxide or the like. And this sort of "superiority" is what led to Hahnemann's success compared to the quacks of his time who were giving toxic drugs. But luckily, we now have better scientific methods to evaluate drugs, including trials that use randomization and blinding and matched control groups to prevent bias. Much better than Hahnemann's provings. Take care. --Keith Conover, M.D., FACEP http://www.pitt.edu/~kconover Do not reproduce without author's express permission. To unsubscribe, send the text "unsubscribe wilderness-emergency-medicine" as the body of a message (no subject) To: Majordomo@list.pitt.edu Submissions To: wilderness-emergency-medicine@list.pitt.edu -- End -- Received: from post-ofc06.srv.cis.pitt.edu (root@post-ofc06.srv.cis.pitt.edu [136.142.185.43]) by pop.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cispop-7.2.2.1) ID ; Thu, 18 Mar 1999 12:39:09 -0500 (EST) Received: from localhost (root@localhost) by post-ofc06.srv.cis.pitt.edu (8.8.8/8.8.8/cispo-7.2.2.2) ID ; Thu, 18 Mar 1999 12:38:28 -0500 (EST) Received: via switchmail; Thu, 18 Mar 1999 12:38:27 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Thu, 18 Mar 1999 12:37:13 -0500 (EST) Received: from localhost (majordom@localhost) by list.srv.cis.pitt.edu (8.8.8/8.8.8/cisls-7.2.2.1) ID ; Thu, 18 Mar 1999 12:36:49 -0500 (EST) Received: from mail.rwth-aachen.de (mail.RWTH-Aachen.DE [137.226.144.9]) by list.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cisls-7.2.2.1) ID for ; Thu, 18 Mar 1999 12:36:39 -0500 (EST) From: ca.t@iname.com Received: from iname.com (s4m061.dialup.RWTH-Aachen.DE) by mail.rwth-aachen.de (PMDF V5.1-12 #30440) with ESMTP id <01J8ZHC8NJFI0002A9@mail.rwth-aachen.de> for wilderness-emergency-medicine@list.pitt.edu; Thu, 18 Mar 1999 18:27:25 +0100 Date: Thu, 18 Mar 1999 18:29:24 +0100 Subject: Re: W-EMED EMT-B-course To: wilderness-emergency-medicine@list.pitt.edu Message-id: <36F137F4.73967EA@iname.com> MIME-version: 1.0 X-Mailer: Mozilla 4.05 [de]C-QXW0310a (Win95; I) Content-type: text/plain; charset=us-ascii Content-transfer-encoding: 7bit References: <36F0C121.BC919B32@iname.com> <19990318.094303.13422.0.pcrs242@juno.com> Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk Reply-To: wilderness-emergency-medicine@list.pitt.edu X-PMFLAGS: 34078848 0 1 P1FC10.CNM Thanks, I am looking forward to your answer. Christian Deborah M Gessner schrieb: > Christian > We are having several courses in our area, EMT-B and higher I will see if > anything is set for the date you need . I am in Dublin, Va. and normally > classes of some sort are being held within a one hour radius of here all > the time. > I will check and get back to you. > Deborah Gessner EMT, SAR-Coordinator > Dublin Va. Do not reproduce without author's express permission. To unsubscribe, send the text "unsubscribe wilderness-emergency-medicine" as the body of a message (no subject) To: Majordomo@list.pitt.edu Submissions To: wilderness-emergency-medicine@list.pitt.edu -- End -- Received: from post-ofc05.srv.cis.pitt.edu (root@post-ofc05.srv.cis.pitt.edu [136.142.185.10]) by pop.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cispop-7.2.2.1) ID ; Thu, 18 Mar 1999 11:10:33 -0500 (EST) Received: from localhost (root@localhost) by post-ofc05.srv.cis.pitt.edu (8.8.8/8.8.8/cispo-7.2.2.2) ID ; Thu, 18 Mar 1999 11:09:46 -0500 (EST) Received: via switchmail; Thu, 18 Mar 1999 11:09:45 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Thu, 18 Mar 1999 11:06:19 -0500 (EST) Received: from localhost (majordom@localhost) by list.srv.cis.pitt.edu (8.8.8/8.8.8/cisls-7.2.2.1) ID ; Thu, 18 Mar 1999 11:05:50 -0500 (EST) Received: from post-ofc05.srv.cis.pitt.edu (root@post-ofc05.srv.cis.pitt.edu [136.142.185.10]) by list.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cisls-7.2.2.1) ID for ; Thu, 18 Mar 1999 11:05:44 -0500 (EST) Received: from emed.upmc.edu (pphled03.dwing.upmc.edu [128.147.175.164]) by post-ofc05.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cispo-7.2.2.2) ID for ; Thu, 18 Mar 1999 11:05:34 -0500 (EST) Received: from EMERG_MED/SpoolDir by emed.upmc.edu (Mercury 1.21); 18 Mar 99 11:21:28 -0500 Received: from SpoolDir by EMERG_MED (Mercury 1.30); 18 Mar 99 11:21:13 -0500 Received: from JTG.isd.upmc.edu by emed.upmc.edu (Mercury 1.30); 18 Mar 99 11:21:09 -0500 From: "Jack T. Grandey" To: Subject: RE: W-EMED EMT-B-course Date: Thu, 18 Mar 1999 11:05:10 -0500 Message-ID: <000001be7159$1a4f8680$7215e59d@JTG.isd.upmc.edu> MIME-Version: 1.0 Content-Type: text/plain; charset="iso-8859-1" Content-Transfer-Encoding: 8bit X-Priority: 3 (Normal) X-MSMail-Priority: Normal X-Mailer: Microsoft Outlook 8.5, Build 4.71.2173.0 Importance: Normal X-MimeOLE: Produced By Microsoft MimeOLE V4.72.2106.4 In-Reply-To: <36F0C121.BC919B32@iname.com> Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk Reply-To: wilderness-emergency-medicine@list.pitt.edu X-PMFLAGS: 34078848 0 1 P1C9B0.CNM There are a number of classes that may meet your needs through the Center for Emergency Medicine. Information on their programs can be found at: http://www.pitt.edu/~cemwp/ Information on WEMT courses is at: http://www.wemsi.org JTG Jack T. Grandey, NREMT-P Director UPMC MedCall                                                  Operations Director UPMC Health System                                     Wilderness EMS Institute http://www.upmc.edu/                                         http://www.wemsi.org/ -----Original Message----- From: owner-wilderness-emergency-medicine@list.pitt.edu [mailto:owner-wilderness-emergency-medicine@list.pitt.edu]On Behalf Of ca.t@iname.com Sent: Thursday, March 18, 1999 04:02 To: wilderness-emergency-medicine@list.pitt.edu Subject: W-EMED EMT-B-course Maybe someone of the list could help me with my problem. I am a German EMT (posted here once before and met a lot of people) looking for a possibility to attend EMT-classes. I´ve had one course already settled, the flight is booked, but I´ve been informed yesterday that the school is going to be closed. I am now looking for a full-time EMT-course ANYWHERE from 7/12 to 8/19/99. EMT-B, higher levels and WEMT would do. If you could help me, please let me know. Christian Neitzel ca.t@iname.com Do not reproduce without author's express permission. To unsubscribe, send the text "unsubscribe wilderness-emergency-medicine" as the body of a message (no subject) To: Majordomo@list.pitt.edu Submissions To: wilderness-emergency-medicine@list.pitt.edu Do not reproduce without author's express permission. To unsubscribe, send the text "unsubscribe wilderness-emergency-medicine" as the body of a message (no subject) To: Majordomo@list.pitt.edu Submissions To: wilderness-emergency-medicine@list.pitt.edu -- End -- Received: from post-ofc03.srv.cis.pitt.edu (root@post-ofc03.srv.cis.pitt.edu [136.142.185.39]) by pop.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cispop-7.2.2.1) ID ; Thu, 18 Mar 1999 09:53:06 -0500 (EST) Received: from localhost (root@localhost) by post-ofc03.srv.cis.pitt.edu (8.8.8/8.8.8/cispo-7.2.2.2) ID ; Thu, 18 Mar 1999 09:52:22 -0500 (EST) Received: via switchmail; Thu, 18 Mar 1999 09:52:20 -0500 (EST) Received: from list.srv.cis.pitt.edu via qmail ID ; Thu, 18 Mar 1999 09:51:11 -0500 (EST) Received: from localhost (majordom@localhost) by list.srv.cis.pitt.edu (8.8.8/8.8.8/cisls-7.2.2.1) ID ; Thu, 18 Mar 1999 09:50:28 -0500 (EST) Received: from m4.boston.juno.com (m4.boston.juno.com [205.231.101.198]) by list.srv.cis.pitt.edu with ESMTP (8.8.8/8.8.8/cisls-7.2.2.1) ID for ; Thu, 18 Mar 1999 09:50:20 -0500 (EST) Received: (from pcrs242@juno.com) by m4.boston.juno.com (queuemail) id D5ZH4HMX; Thu, 18 Mar 1999 09:49:55 EST To: wilderness-emergency-medicine@list.pitt.edu Cc: wilderness-emergency-medicine@list.pitt.edu Date: Thu, 18 Mar 1999 09:43:01 -0500 Subject: Re: W-EMED EMT-B-course Message-ID: <19990318.094303.13422.0.pcrs242@juno.com> References: <36F0C121.BC919B32@iname.com> X-Mailer: Juno 1.49 X-Juno-Line-Breaks: 0,4-28 From: Deborah M Gessner Sender: owner-wilderness-emergency-medicine@list.pitt.edu Precedence: bulk Reply-To: wilderness-emergency-medicine@list.pitt.edu X-PMFLAGS: 33554560 0 1 P79710.CNM Christian We are having several courses in our area, EMT-B and higher I will see if anything is set for the date you need . I am in Dublin, Va. and normally classes of some sort are being held within a one hour radius of here all the time. I will check and get back to you. Deborah Gessner EMT, SAR-Coordinator Dublin Va. On Thu, 18 Mar 1999 10:02:25 +0100 ca.t@iname.com writes: >Maybe someone of the list could help me with my problem. I am a German >EMT (posted here once before and met a lot of people) looking for a >possibility to attend EMT-classes. I´ve had one course already >settled, >the flight is booked, but I´ve been informed yesterday that the school >is going to be closed. >I am now looking for a full-time EMT-course ANYWHERE from 7/12 to >8/19/99. EMT-B, higher levels and WEMT would do. If you could help me, >please let me know. > >Christian Neitzel >ca.t@iname.com >Do not reproduce without author's express permission. >To unsubscribe, send the text "unsubscribe >wilderness-emergency-medicine" >as the body of a message (no subject) To: Majordomo@list.pitt.edu >Submissions To: wilderness-emergency-medicine@list.pitt.edu > ___________________________________________________________________ You don't need to buy Internet access to use free Internet e-mail. Get completely free e-mail from Juno at http://www.juno.com/getjuno.html or call Juno at (800) 654-JUNO [654-5866] Do not reproduce without author's express permission. To unsubscribe, send the text "unsubscribe wilderness-emergency-medicine" as the body of a message (no subject) To: Majordomo@list.pitt.edu Submissions To: wilderness-emergency-medicine@list.pitt.edu -- End -- Received: from post-ofc04.srv.cis.pitt.edu (root@post-ofc04.srv.cis.pitt.edu [136.142.185.11]) by pop.srv.c