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Many breast cancers rely on supplies of estrogen to grow and depakote. The journey of a thousand miles begins with a single step. or two. or forty?! We realize that a lot of work is involved in preparing for the program and want to make the process as simple as possible. To this end, we have compiled the following Pre-Program Checklist to aid in your preparations. Not all of it will apply to all of you. If you have any questions, please call or email Daniel Greenberg at the Living Routes' office. And remember, every item you check off brings you one step closer to the journey. Parkinson's Disease: Page 9 Psychiatric Complications1: Depression occurs in 40% of PD patients & must be distinguished from the onset of dementia as well as the depressed appearance stooped posture, psychomotor retardation, energy loss & hypophonia ; that are generalized symptoms of PD. Antiparkinson treatment improves depressive symptoms in most, & should be tried before instituting specific treatment for depression. Selective serotonin uptake inhibitors SSRIs ; & tricyclic antidepressants TCAs ; both work in depressed PD patients. SSRIs are preferred because they don't share the anticholinergic effects of the tricyclics. Agitation, Anxiety & Panic Attacks: Agitated behavior may be a primary response during "off periods" between levodopa doses, may be caused by delirium or dementia, or a side effect of antiparkinson drugs. Those clearly related to "off" periods are primary. The drug related respond to the slow sequential withdrawal of antiparkinson drugs described in the section on dementia & delirium. The benzodiazepines, alazopram Xanax ; , lorazepam Ativan ; or diazepam Valium ; are the most effective anxiolytics. Buspirone Buspar ; may work but it blocks dopamine & may worsen PD symptoms. SSRIs & those TCAs with minimal anticholinergic effects eg nortriptyline or desipramine ; may be helpful, when anxiety & depression coexist. Neither the anxiolytics nor the antidepressants may be tolerated by the cognitively impaired Constipation is common among PD patients owing to a slowing of colonic transit time coupled with failure of timely relaxation of the puborectalis muscle & the anal sphincter during defecation mediated by degeneration of myenteric neurons infiltrated by Lewy bodies. Vigorous exercise, fluids & high-fiber diet are mainstay treatment, followed by the judicious use of stool softeners eg. docusate Colacce ; , followed if necessary by an osmotic laxative such as milk-of-magnesia, lactulose or polyethylene glycol. Stimulant laxatives should be avoided because of the danger of further damage to myenteric neurons. Enemas can be used for "rescue" therapy, & apomorphine injections during "off" periods, as a last resort. The bowel motility agents cisapride & domperidone help, but neither agent is available in the US. Reglan is not used because unlike domperidone, it penetrates the blood-brain barrier & makes PD symptoms worse. Sialorrhea Drooling ; may occur before other signs of PD appear. It is a socially distressing problem for many patients with early PD & it constitutes significant aspiration risk for many with more advanced illness. Defects in the oral, pharyngeal & esophageal phases of swallowing occur in PD & are causally related to sialorrhea. Baseline rates of saliva production are lower among treated PD patients than among matched controls. Patients frequently complain of inappropriate increases in saliva production & sialorrhea associated with emotional excitement, intellectual concentration or physical exertion. Anticholinergic drugs are sometimes tried but rarely work. The 7 most effective recent therapeutic innovation has been botox injections into the salivary glands . Urinary Problems: Nocturia, urgency & frequency followed by delayed voiding occur because of detrussor hyperreflexia & incomplete pelvic floor relaxation. UTI & prostatism should be excluded. Nocturia may respond to evening fluid restriction or a locally acting anticholinergic agent such as oxybutynin 5-10mg h.s. ; , propantheline 7.5-15mg h.s. ; , or tolterodpantheline Detrol ; 11-2mg h.s. Hyoscyamine Levsin ; 0.15-0.30mg before bed may work if these fail. Anticholinergics work by decreasing detrussor contractility, & may therefore cause urinary retention in those with detrussor weakness as occurs with advanced PD ; or outlet obstruction. They may also exacerbate symptoms of dementia. -blockers decrease detrussor contractility & outlet obstruction but they may exacerbate postural hypotension. If advanced bladder atony occurs, scheduled self-catheterization may be the only viable treatment option. Erectile Dysfunction may be the first autonomic manifestation of PD. It is also commonly caused by depression or drug side effects & in unusual cases by endocrine dysfunction. So the initial evaluation should include a medication review looking especially for -blockers, -blockers, guanethidine, thiazides, anxiolytics, antidepressants, H2 antagonists & digoxin. Laboratory tests including TSH, free-T4, prolactin, testosterone, luteinizing hormone should be obtained, & depression treated if present. When specific treatment is required, sildenafil Viagra ; 50-100mg and imuran. Via medicine cup, with ounce of patient's preferred drink additive. Discontinued from Dr. orders: Colade 2 patients Milk of Magnesia 1 patient LiquaFiber - changed to BID 1 patient. Musto P, Cascavilla N, Spriano M, * Zambello R, Guglielmelli T, Catalano L, * Balleari E, Falcone A, Sanpaolo G, Bodenizza C, La Sala A, Mantuano S, Scalzulli P, Nobile M, Dell'Olio M, Melillo L, Greco M, Beltrami G, Carella Jr, Carella * Hematology and Stem Cell Transplantation, IRCCS "Casa Sollievo della Sofferenza", S. Giovanni Rotondo; Hematology * and DIMI, S. Martino Hospital, Genova; Clinical and Experimental Medicine, University of Padova; Hematology, S. Luigi Gonzaga Hospital, Orbassano; Chair of Hematology, Federico II University, Napoli * , Italy * Bortezomib VELCADE, formerly PS-341, Millennium ; is a novel first-class agent that inhibits the proteasome, a multicatalytic cellular enzyme whose activity entails several molecular mechanisms, including, in particular, the NF-B pathway. Recent phase I-II clinical trials have demonstrated the efficay and cytoxan.

COX, which converts arachidonic acid to endoperoxidecontaining intermediates to produce prostaglandins and thromboxanes, exists in multiple isoforms.9 COX-1 and COX-2 share 60% amino acid sequence homology. Both enzymes are membrane bound; however, COX-2 is twice as abundant at the nuclear envelope than within the endoplasmic reticulum, whereas the concentration of COX-1 is equal at both locations.6 Differences in COX isoforms. COX-1 functions predominantly in the endoplasmic reticulum and COX-2 mostly in the nucleus.10, 11 Therefore, it appears that COX-1 and COX-2 are two distinct prostanoid biosynthetic systems with separate biological functions for their products. COX-1 produces prostaglandins constitutively for secretion as extracellular mediators, and COX-2 produces prostaglandins predominantly within the nuclear fat. Convenient simplifications depict COX-1 as a homeostatic continuous regulator that is expressed constitutively and COX-2 as being an inducible enzyme, the expression of which is upregulated by various neurotransmitters, growth factors, proinflammatory cytokines, lipopolysaccharides, calcium, and small peptide hormones.12, 13 However, COX-1 expression can be induced under certain conditions, such as neural insult, 1316 and various tissues, such as kidney and nerve tissue, express COX-2 constitutively.12, 13 The clinical significance of the various isoforms remains incompletely appreciated; for example, studies reveal that mice deficient in COX-2 yield normal inflammatory responses with exogenous arachidonic acid but exhibit an increased incidence of suppurative peritonitis.17 and purinethol. Most experts agree on the explanation for these unexpectedly high Hispanic casualty rates. The majority of Hispanic recruits are either first- or second-generation Americans with relatively low rates of educational achievement. Their test scores simply don't justify placing them in relatively select - and safer - occupations behind the front lines. "Because they're torn between two cultures, Hispanic language skills are more Spanish than English and they're relatively educationally disadvantaged, " Enders says. "They go into the Marines because infantry is the big stress there." Gifford found that blacks, who make up about 20 percent of all active-duty personnel, represented 16.7 percent of all casualties during the war phase and 12.2 percent of deaths after the occupation phase began. Gifford and others agree that a black death rate lower than their proportional representation in the military is relatively easy to explain. African Americans have historically regarded the military as an economic steppingstone and picked relatively safe "support" occupations - medical units, computers, air traffic control - that translate well in the civilian economy. "All the studies show that the military was the first to integrate and is regarded by African Americans as the most fair institution in the country, " says Woodruff, the West Point researcher. "So African Americans are very savvy about using the military for advancement." Whites represent about 65 percent of all active duty personnel, and were underrepresented in deaths during the initial war phase of the conflict, with 60.9 percent of deaths. This probably reflects the fact that whites serve in greater numbers in the relatively protected officer corps, and also heavily populate the more selective "support" functions far from the scene of battle. But this apparent privilege of race dramatically reversed itself during the occupation, and now death rates for whites make up 70.6 percent of the total. This suggests that the randomness of the violence since President Bush declared "Mission Accomplished" - the ambushes of military convoys, mortar attacks on rear command positions, urban conflicts with civilian militias - provides little safety for soldiers in elite specialties or rear positions. But Gifford suggests that the dramatic break in casualty rates for whites between the war and occupation phases may be explained by other factors that should be carefully studied. National Guard and reserve units now represent about a third of the 140, 000 U.S. military personnel in Iraq. The Pentagon's heavy reliance on National Guard and reserve units has clearly affected another vital Iraq War demographic: the rising age of those killed in action. According to Enders, the mean age of soldiers killed in Vietnam was 22.6 years old. But the mean age for soldiers killed in Iraq is 26.3, with significant numbers of soldiers killed. Of the vein into surrounding tissues, . Drugs that can cause extravasation injuries are known as vesiNausea and or vomiting Zofran ondansetron ; , Kytril granisetron ; , Anzemet dolasetron ; , cant chemotherapy agents. Patients Reglan metoclopramide ; , receiving vesicant chemotherapy Decadron dexamethasone ; through a peripheral hand, arm Diarrhea Imodium-AD loperamide ; , Lomotil Constipation Colace docusate sodium ; , milk of or leg ; vein should inspect the chemagnesia motherapy injection site for several Dry skin, hair loss Emollients, vitamin E, zinc supplements days after each treatment. Heart injury Zinecard dexrazoxane ; To prevent potential extravaBladder injury Mesnex mesna ; sation injuries, vesicant chemoNerve injury Ethyol amifostine ; therapy should be given with Extravasation injury to DMSO topically 70% solution ; soft tissue caution to patients with poor Kidney injury Sodium thiosulfate injection quality veins, or patients who are to receive a drug or drugs as a protracted Unfortunately, there are no medications or infusion over several days. For such patients, approaches available that will prevent loss of it may be preferable to place a central venous hair from chemotherapy. However, hair will Other supportive care catheter or vascular access device, e.g. Port-Agrow back in the weeks after therapy is stopped, Cath, prior to therapy. This not only lessens A medical oncologist should offer the most efand may actually begin to grow back during the chance for potential extravasation injury, fective medications or other approaches to continued chemotherapy treatments. maximize the level of supportive care for the but also provides access to a patient's veins to Certain intravenous chemotherapy drugs AIPC patient receiving chemotherapy, in order draw blood and or to give blood products, incan cause significant tissue damage called "exto minimize side effects such as those shown in travenous fluids or any kind of drug. If chemotravasation injury" if they accidentally leak out the following table. therapy extravasation does occur, 70% DMSO applied topically prevents tissue injury and should be administered at least 4-6 times a day National Conference.continued from page 1 until the site of extravasation is fully healed. If co-founder and Medical Director of PCRI and spectacular. I attended with my brother and his stinging occurs with DMSO application, the the founder of Healing Touch Oncology, Dr. wife, my husband and my father-in-law, a repatient should wipe off the remaining DMSO Strum is an internationally recognized meditired surgeon, and we all agreed that we learned and apply aloe vera gel to the skin. cal oncologist who has specialized exclusively a great deal. All of the doctors were excellent It is very important that a patient promptly in the treatment of prostate cancer for the last speakers, technical, but not too technical. They report any unusual symptoms or side effects 15 years. His humanistic approach to prostate were interesting, spoke to the point and were during chemotherapy treatment to his physicancer treatment is well known by patients and passionate about their work. All the guys at PCRI his peers. Mark Scholz, MD, the other co-founder really pulled it off and I know how difficult it cian to be sure that it is not, or does not become of PCRI, was also one of the speakers. was." a major problem. All of the speakers came from prominent The Conference was underwritten by the Summary medical institutions including Johns Hopkins, attendees and by the generous contributions It is important to properly identify AIPC Harvard Medical School, Josephine Ford Canfrom the event's sponsors. Among the sponsors and not confuse it with an androgen recer Center, Stanley Scott Cancer Center and the were Daniel Freeman Hospitals, Freeman Hosceptor mutation ARM ; or with inadequate Universities of Virginia, California, Michigan, pitals Foundation, Amgen, Bristol-Myers suppression of testosterone by an LHRH and Washington. Squibb, Immunex, Rhone-Poulenc Rorer, TAP agonist Lupron or Zoladex ; . Once AIPC Pharmaceuticals, cancerfacts , Life Extenis properly identified, it is equally imporSome attendees followed up after the contant to understand essential principles in sion, Schering, SmithKline Beecham, Ortho ference was over. Mike Korek not only made a the pharmacology of the agents employed Biotech, Inc., Econugenics, and the American donation to PCRI, he also wrote on P2P, "I atin treating and supporting patients with Cancer Society. A complete list is on page 20 ; tended the conference last week and was very AIPC. As there is a need for artistry in doimpressed with the depth, breadth, and dedicaBecause of the Conference's success, the ing a radical prostatectomy, seed implantion of all involved, especially Dr. Strum. I was PCRI Board of Directors approved holding tation, external beam RT or cryosurgery, glad that I could help by making a donation, another conference in the year 2000. Once there is also artistry needed in the mediand I encourage others to do the same." again, it will be held at the Long Beach CA ; cal oncologic care of the PC patient, espeConvention Center on October 14 and 15. Dr. Strum moderated the conference. The cially those with AIPC and requip.

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