p53 and MIB-1 Immunohistochemistry as Predictors of the Clinical Behavior of Nonfunctioning Pituitary Adenomas

ABSTRACT:Background:P53 expression and increased MIB-1 proliferation index have been shown to correlate with invasive behavior in pituitary adenomas. The purpose of this study was to determine whether these indices could be used to predict a higher likelihood of recurrence in clinically nonfunctional pituitary adenomas and thus guide adjuvant therapy.Methods:Fifty-one clinically nonfunctional pituitary adenomas were selected from the database at the Vancouver Hospital and Health Sciences Center between the years 1990-1998. Included were 32 nonrecurrent and 19 recurrent adenomas.Results:The mean initial labelling index for p53 in nonrecurrent tumours was 0.38% (0-1.58%), while it was 0.46% (0-3.65%) for recurrent adenomas. The mean initial MIB-1 index for nonrecurrent tumours was 1.63% (0.08-9.36%), while for recurrent tumours it was 1.92% (0-7.76%). The percentage of p53 positive adenomas was 66% for nonrecurrent tumours and 68% for recurrent tumours. None of the differences in the labelling indices between the recurrent and nonrecurrent groups was statistically significant. As 12 patients (38%) in the nonrecurrent group had undergone radiotherapy as initial adjuvant therapy after surgery and none of the recurrent group had done so, patients who did not receive radiotherapy in the nonrecurrent group were analyzed separately. Again, none of the differences in the labelling indices between the recurrent and nonrecurrent groups was statistically significant when the effect of radiotherapy was removed from the analysis.Conclusions:The results demonstrate no statistical difference in the p53 or MIB-1 labelling indices between recurrent and nonrecurrent nonfunctional pituitary adenomas. Concern should be raised in attaching too much clinical significance to these labelling indices, especially with respect to p53 as a predictor of the clinical behavior of nonfunctional pituitary adenomas.

The Ethical Management of the Noncompliant Patient

It is a rare patient who always does everything healthcare providers advise. Sometimes no harm comes from this; sometimes good does. But occasionally, great harm comes from not listening, as when it results in patients returning time and again for costly and invasive treatments of, say, infections, valve replacements, pressure ulcers, and so forth. No class of patients arouses more anger and resentment in healthcare providers, who often put out a call to invoke some version of the three strikes rule and refuse care. And if the patients are also unemployed substance abusers who live in a local park, impolite or dangerous to staff, disruptive to other patients, and have intimidating visitors, the call to say “No” is louder. Can care ever be refused? If so, when? These are the questions we take up in this article. The answers we provide were developed as part of a Paraplegics and Quadriplegics with Pressure Ulcers Project carried out at Vancouver Hospital and Health Sciences Centre. Following an established usage, we refer to patients who exhibit a cluster of the above characteristics, the dominant one of which is a reluctance to heed medical advice, as “noncompliant patients.” This term is offensive to some, but the politically correct lexicon does not provide any alternative which is as short and clear or substantially different. We use the term as a convenient way of referring to a familiar class of patients and without any imputation of blame.

Outpatient Intravenous Antibiotic Therapy: The Vancouver Hospital experience

From June 1, 1995 to December 31, 1997, 334 patients at the Vancouver Hospital and Health Sciences Centre (VHHSC) were referred to and screened for, outpatient intravenous antibiotic therapy. One hundred and ninety were accepted, 107 of whom were cared for under the VHHSC program and 83 of whom were discharged to continue intravenous therapy in their own health region. Thirty-four of 144 patients not accepted for outpatient intravenous therapy, were screened by the Infectious Disease Service and Pharmacy, and were discharged on oral antibiotics. Peripherally inserted central catheters were employed in 61 of 107 (57%) patients, peripheral short catheters in 20 (19%), Hickman lines in 14 (13%), and Port-a-caths in 12 (12%). Ninety-two of 107 patients treated in the VHHSC program completed their course uneventfully with resolution of the infection. The average duration of hospital therapy was 10.9 days versus 23.6 days of outpatient therapy. In 15 patients, home treatment was discontinued because of clinical deterioration: adverse drug reaction (n=2), phlebitis (n=2), unsuitable home environment (n=1), noncompliance (n=1), line-related sepsis (n=1) and death due to unrelated causes (n=1). There were 15 adverse drug reactions overall in the total of 2534 patient-days of therapy over 18 months. Cost analysis showed a cost of 12 cents on the dollar compared with inhospital therapy.