CHOP versus MACOP-B in aggressive lymphoma--a Nordic Lymphoma Group randomised trial

BACKGROUND

The long-term survival of patients with advanced stage aggressive lymphoma has not improved significantly during the last twenty years. In a randomised trial, the efficacy of MACOP-B, a six-drug weekly chemotherapy regimen, was compared to CHOP, the current standard regimen, in terms of overall and failure-free survival, toxicity and health related quality of life.

PATIENTS AND METHODS

Four hundred five patients with aggressive lymphoma, stage II-IV, age 18-67, were randomised to receive either 12 weeks of MACOP-B or 8 courses of CHOP over 24 weeks. Special emphasis was put in the definition of Ann Arbor stage in extranodal disease. A subset of 95 patients also entered a quality of life study, based on the EORTC QLQ-C30.

RESULTS

Thirty-one patients were ineligible. Among the remaining 374 patients, the median age was 52 years. According to the age-adjusted International Prognostic Index, 37% were 'high-intermediate' or 'high-risk' patients. No difference could be demonstrated, either in overall survival (60% at five years in the MACOP-B group and 59% in the CHOP group) or in failure-free survival (47% at five years with MACOP-B and 44% with CHOP). In terms of quality of life, physical function and global quality of life were more impaired in patients receiving MACOP-B, who also exhibited more non-haematological toxicity.

CONCLUSION

No superiority of MACOP-B compared to CHOP could be demonstrated. CHOP remains the treatment of choice in low-risk patients. At present, intensified or experimental treatment should be reserved for high-risk disease.

Docetaxel compared with sequential methotrexate and 5-fluorouracil in patients with advanced breast cancer after anthracycline failure: a randomised phase III study with crossover on progression by the Scandinavian Breast Group

The aim of this study was to compare the efficacy and tolerability of docetaxel to methotrexate and 5-fluorouracil in advanced breast cancer after anthracycline failure. A randomised multicentre trial was conducted in 283 patients with advanced breast cancer who had failed previous anthracycline treatment. Docetaxel at a dose of 100 mg/m2 every 3 weeks (n = 143) was compared with sequential methotrexate and 5-fluorouracil (MF; n = 139) given at day 1 and 8 every 3 weeks at dosages of 200 mg/ m2 and 600 mg/m2, respectively. After progression, crossover to the alternative treatment group was recommended. There was a significantly higher overall response rate in the docetaxel 42% (CR 8% + PR 34%) than in the MF arm 21% (CR 3% + PR 18%) (P < 0.001). The median time to progression (TTP) was 6.3 months in the docetaxel arm and 3.0 months in the MF arm (P < 0.001). Docetaxel also had a significantly higher response rate of 27% following crossover compared with MF (12%). Significantly more side-effects (leucopenia, infections, neuropathy, oedema, asthenia, skin, nail changes, alopecia) were seen in the docetaxel than in the MF group. However, grade 3 and 4 side-effects were infrequent with both drugs, with the exception of fatigue, alopecia and infections. Median overall survival (OS) including crossover phase was 10.4 months in the docetaxel and 11.1 months in the MF arm (P = 0.79). Based on the response rate and the primary endpoint of TTP, docetaxel is superior to sequential methotrexate and 5-fluorouracil in advanced breast cancer after anthracycline failure.

Teens teach skin cancer prevention

Cumulative sun exposure has been linked to about 95 percent of all skin cancers. Farmers and their families, by nature of their occupations, are exposed to an abundance of sun over a long period of time and, therefore, are at an increased risk for skin cancer. Because education is known to be a primary means of health, Future Farmers of America (FFA) peer facilitators (teen educators) provided third graders in rural communities sun protection education with the hope that the message would reach the entire family. The FFA facilitators (n = 217) from 39 FFA organizations throughout Wisconsin were trained with skin cancer and sun protection information. The FFA facilitators then gave presentations on sun protection to third graders (n = 2,007) in their school districts. Control schools included 57 facilitators and 669 third graders. Evaluation involved pre-, post-, and six-month follow-up surveys testing knowledge gained by the third graders. Students who correctly responded to a question on the post-survey after incorrectly answering it on the pre-survey were said to have had a knowledge gain for that question. By using chi-square tests, the intervention group demonstrated a statistically significant (P < 0.001) higher proportion of students experiencing knowledge gain than did the control group from pre- to post-surveys for nine of the 10 questions. Summary statistics were used to describe the study population. In addition to skin cancer knowledge questions, the survey of facilitators included sun protection behavior and attitude questions. This intervention was able to use peer educators as instructors to demonstrate knowledge gain in the youths of the target population. The pilot project materials costs were +0.55 per third grade student and +3.50 per facilitator. Using a school-based organization such as FFA provided a cost-effective means of reaching the rural population.

Seroconversion after influenza vaccination in patients with lung cancer

There are no data in the literature about the efficacy of influenza vaccination in lung cancer patients. Paired sera were available from 59 patients who received Fluvirin (Evans Medical). Of 41 patients susceptible to one or more influenza strains, 78% responded fully to vaccination. This response rate is comparable to that obtained from healthy volunteers.

The value of specialist oncological radiology review of cross-sectional imaging

AIM

To determine whether specialist oncological radiology review of outside cross-sectional imaging affects patient management.

MATERIALS AND METHODS

Five hundred and twenty-six patients attending a regional oncology centre had review of outside cross-sectional imaging over a 1-year period. The number of examinations per patient, time interval between examination and review request, and examination technical adequacy were recorded in each case. More detailed evaluation of 124 patients included comparison of outside and review reports for major differences in interpretation by a medical oncologist who also evaluated the effect of the review on patient management. Examinations resulting in major report discrepancies were subjected to independent radiological adjudication.

RESULTS

Eighty-one percent of examinations were reviewed within 3 months of being performed and 94% were considered technically adequate. The hard copy images provided were incomplete in 33% of cases and a calibration rule was absent in 9%. There was a major difference in interpretation in 34% of examinations, the most common cause being differences in interpretation of lymphadenopathy (52%), particularly in the mediastinum (19%). Other problems identified were the failure to record disease dimensions and absence of specific information on key organs in the outside reports. Specialist radiology review changed radiological staging in 19% of patients, affected management in 7% of patients and resulted in a change in treatment in 4%. There was no correlation between management change and any particular tumour type. In 27% of cases, treatment decisions had been made before the review was requested.

CONCLUSION

Specialist oncological radiology review of outside cross-sectional imaging changed radiological staging in 19% of cases but had little impact on patient management. Oncological cross-sectional imaging techniques in the North West of England are of high quality, probably helped by recent RCR guidelines.

Metal working fluid-associated hypersensitivity pneumonitis: an outbreak investigation and case-control study

Occupational exposure to bacterial or fungal antigens has been associated with hypersensivity pneumonitis (HP), an immunologically-mediated pulmonary disease. Between August 1995 and April 1996, 34 employees working in machining and assembly areas of an engine manufacturing plant were clinically diagnosed with HP. Of these, 20 employees met an epidemiologic case definition. In a case-control study, no exposure variables, including duration and intensity of metal working fluid (MWF) exposure, were statistically associated with an increased risk of disease. Neither cases nor controls demonstrated precipitin reactivity against unused samples of the seven MWF and two biocides used in the plant. HP cases had a significantly higher prevalence of positive precipitin reactions to used oil soluble and synthetic MWFs. Reactivity to used but not unused MWF suggests a biocontaminant, probably bacteria or fungi, is the causative antigen in the development of HP in this setting.

Antisense ablation of type I metabotropic glutamate receptor mGluR1 inhibits spinal nociceptive transmission

Electrophysiological and behavioral studies point to a role of group I metabotropic glutamate receptors (mGluR1 and mGluR5) in mediating spinal nociceptive responses in rats. However, antagonists with a high degree of specificity for each of these sites are not yet available. We, therefore, examined the effects of antisense deletion of spinal mGluR1 expression in assays of behavioral analgesia and of electrophysiological responses of dorsal horn neurons. Rats treated with an mGluR1 antisense oligonucleotide reagent, delivered continuously to the intrathecal space of the lumbar spinal cord, developed marked analgesia as measured by an increase in the latency to tail-flick (55 degreesC) over a period of 4-7 d. This correlated with a selective reduction in mGluR1, but not mGluR5, immunoreactivity in the superficial dorsal horn compared with untreated control rats, in parallel with a significant reduction in the proportion of neurons activated by the mGluR group I agonist 3, 5-dihydroxyphenylglycine (DHPG), whereas the proportion of cells excited by the mGluR5 agonist, trans-azetidine-2,4-dicarboxylic acid (t-ADA) remained unaffected. In contrast, rats treated with mGluR1 sense or mismatch probes showed none of these changes compared with untreated, control rats. Furthermore, multireceptive dorsal horn neurons in mGluR1 antisense-treated rats were strongly excited by innocuous stimuli to their peripheral receptive fields, but showed severe reductions in their sustained excitatory responses to the selective C-fiber activator mustard oil and in responses to DHPG.

Never on a Saturday (or a Sunday): the case against using weekend urine specimens to assess arsenic exposure

The Wisconsin Department of Health and Family Services Bureau of Public Health recently investigated two cases of suspected arsenic poisoning. These cases involved four adults whose urinary arsenic levels ranged from 340 to 1485 ug/L (normal 0-30 ug/L). These findings were initially interpreted as evidence of an ongoing exposure to a toxic form of arsenic, however follow-up investigations determined that all of the urine specimens had been collected on a weekend and that each of these individuals had consumed fish within 48-hours of urine collection. Most of the fish was consumed at "Friday night fish fries" which are a popular tradition at many local restaurants. Urine samples collected after these individuals eliminated fish from their diets contained normal arsenic levels. This report suggests the need for laboratories to differentiate non-toxic forms of arsenic that are present in fish and seafood products from other species of this element. Until more specific analytical methods become available, patients should be instructed to omit fish and seafood from their diets for several days prior to collecting urine for arsenic analysis. In addition, elevated urinary arsenic levels should be interpreted cautiously and exposure to toxic forms should be confirmed before a diagnosis of arsenic poisoning is entertained.

Determining anatomic injury with computed tomography in selected torso gunshot wounds

BACKGROUND

Changes in the management of torso gunshot wounds (TGSWs) have evolved in recent years as a result of differences between military and civilian injuries and increasing interest in avoiding nontherapeutic invasive procedures. The objective of this study was to establish the utility and accuracy of computed tomography (CT) in the evaluation of selected patients with TGSWs.

METHODS

Retrospective review for a 6-year period of patients who sustained TGSWs and underwent CT solely for the purpose of trajectory determination. Patients had complete physical examinations and plain radiographic evaluations by a dedicated group of in-house trauma surgeons. When trajectory was indeterminate after evaluation, CT was performed. In some cases, CT was used when trajectory was determined to be intracavitary but organ injury was believed to be unlikely or amenable to nonoperative management.

RESULTS

Fifty TGSW patients underwent 52 computed tomographic scans. Abdominal/pelvic CT was performed in 37 patients, and thoracic CT was performed in 15 patients. All patients were stable and none sustained complications attributable to CT or delay in therapy. Twenty of 37 abdominal/pelvic computed tomographic scans excluded transabdominal or pelvic trajectory. Seventeen of 37 scans proved transabdominal or pelvic trajectory; nine laparotomies were performed, and eight patients were observed. Nine of 15 thoracic computed tomographic scans excluded transmediastinal trajectory. Six of 15 scans suggested vascular proximity and prompted further workup, which was positive in two cases.

CONCLUSION

CT of selected TGSW patients is safe and may reduce the incidence of invasive diagnostic procedures. A prospective evaluation of CT for TGSW patients is warranted.

Histone H3 phosphorylation and expression of cyclins A and B1 measured in individual cells during their progression through G2 and mitosis

Phosphorylation of histone H3 (H3) on Ser-10 correlates with chromatin condensation at mitosis. A new monoclonal antibody (anti-H3-P) was developed that recognizes phosphorylated H3 (H3-P). This antibody was used in multiparameter flow cytometric analysis to relate H3 phosphorylation in individual human leukemic cells to the cells' position in the cycle as well as their expression of cyclins A and B1. Mitotic cells, from prophase to telophase, reacted with anti-H3-P; the binding of the antibody to chromatin of interphase cells was several times weaker. Cell growth in the presence of staurosporine, an inhibitor of the kinase(s) that phosphorylate H3, abolished the cells' reactivity with the antibody. The reactivity also was abolished by incubation of permeabilized mitotic cells with alkaline phosphatase. These data indicate that, within permeabilized cells, the antibody is indeed specific for H3-P and does not detect the unphosphorylated epitope. All cells reacting with anti-H3-P, with the exception of prophase and early prometaphase, were cyclin A negative; the expression of cyclin B1 in these cells was threefold higher than in G2 cells. The analysis of phosphorylation of H3 in individual cells when combined with multiparameter analysis of their cycle position and expression of other proteins offers new possibilities to study molecular mechanisms associated with the G2 to M transition and chromatin condensation. It also offers an assay to screen in vivo inhibitors of kinase(s) or phosphatase(s) involved in H3 phosphorylation or dephosphorylation, and it provides a valuable marker to identify mitotic cells by cytometry.

Risk of cancer among offspring of childhood-cancer survivors. Association of the Nordic Cancer Registries and the Nordic Society of Paediatric Haematology and Oncology

BACKGROUND

Increasing numbers of children with cancer survive and reach reproductive age. However, the risk of cancer (other than retinoblastoma) in the offspring of survivors of childhood and adolescent cancer is uncertain.

METHODS

Using data from national cancer and birth registries, we assessed the risk of cancer among 5847 offspring of 14,652 survivors of cancer in childhood or adolescence diagnosed since the 1940s and 1950s in Denmark, Finland, Iceland, Norway, and Sweden. The offspring were followed up for a diagnosis of cancer for 86,780 person-years, and standardized incidence ratios were calculated.

RESULTS

Among the 5847 offspring, 44 malignant neoplasms were diagnosed (standardized incidence ratio, 2.6; 95 percent confidence interval, 1.9 to 3.5). There were 17 retinoblastomas, yielding a standardized incidence ratio of 37. There were 27 neoplasms other than retinoblastoma (standardized incidence ratio, 1.6; 95 percent confidence interval, 1.1 to 2.4). The second most common primary site of cancer among the offspring was the brain and nervous system, in which eight tumors were observed (standardized incidence ratio, 2.0; 95 percent confidence interval, 0.9 to 3.9.) There were between zero and four apparently sporadic cases of cancer in other primary sites among the offspring. Excluding 4 likely cases of hereditary cancer and 2 subsequent cancers among the offspring with hereditary retinoblastoma, there were 22 sporadic cancers, for a standardized incidence ratio of 1.3 (95 percent confidence interval, 0.8 to 2.0).

CONCLUSIONS

There is no evidence of a significantly increased risk of nonhereditary cancer among the offspring of survivors of cancer in childhood.

Dose intensity in small cell lung cancer

Evidence from preclinical models and from clinical trials describing the importance of dose intensity in securing a better treatment outcome is reviewed. Recent randomized trials have shown statistically significant survival benefits with higher-dose, accelerated chemotherapy regimens with and without granulocyte colony-stimulating factor and granulocyte-macrophage colony-stimulating factor. The novel use of peripheral blood progenitor cells contained in whole blood autotransfusions, which allow a marked increase in dose intensity of an ifosfamide/carboplatin/etoposide regimen, could provide a much easier method of delivering dose-intensive chemotherapy than previously available.

Restenting malignant oesophageal strictures

BACKGROUND

Self-expanding metal stents are used to palliate malignant strictures of the oesophagus. This study was designed to identify the characteristics of patients requiring restenting of malignant oesophageal strictures.

METHODS

Fifty-three stents were inserted in 42 patients. Thirty-two patients did not require further stenting (once-stented group). Ten patients received second stents for recurrent oesophageal obstruction (restented group), with one patient requiring restenting a second time. Comparisons were drawn between the once-stented and restented groups with regard to survival, patient, tumour and procedural characteristics.

RESULTS

There were no significant differences with regard to tumour grade, tumour type, involvement of the cardia, procedural difficulties or the need for postprocedural oesophageal dilatation between the two groups. Survival from initial stenting was significantly greater in the restented group (median 24 (range 4-43) weeks) than in the once-stented group (median 9.5 (range 1-84) weeks) (P < 0.05). The mean length of stents used in the once-stented group was significantly greater than that of the initial stents used in the restented group (12 versus 10 cm, P = 0.032).

CONCLUSION

Inserting a covered stent through a previously inserted uncovered stent is an uncomplicated and well tolerated technique which maintains palliation from obstructing oesophageal carcinoma. The need for restenting cannot be predicted on the basis of tumour characteristics alone.

Three into one will go! Collaborative practice in practice

This paper is concerned with three speech and language therapy services from neighbouring NHS trusts and the single education authority they all share. The authors have always been committed to working collaboratively with local services but found the competitive health care environment of the late 1980s and early 1990s often-made this difficult. It describes how the three services came together to identify common service issues for children of school-age with speech and language difficulties and how these were addressed.

Measuring quality of life: impact of chemotherapy for advanced colorectal cancer. Experience from two recent large phase III trials

When assessing the value of a particular treatment, it is important to consider the impact it may have on the quality of life of those being treated. This is particularly so for cancer patients, whose life expectancy may be short. Patients with advanced colorectal cancer who participated in two international comparative studies of raltitrexed ('Tomudex') vs standard 5-fluorouracil (5-FU) plus leucovorin (LV) completed previously validated quality-of-life questionnaires (EORTC questionnaire, EuroQol and Rotterdam Symptom Check List) at various times during the studies. Early statistically significant advantages of raltitrexed vs 5-FU plus LV on quality of life were observed at week 2 in five of eight of the EuroQol and three of four of the Rotterdam Symptom Check List dimensions. Such advantages were not observed using the EORTC questionnaire, which was not completed until week 12. The necessary dose delays and different dose schedules made it difficult in these studies to compare the impact on quality of life of the two treatments. It may be that performance status, effect on disease-related symptoms and the incidence of toxicity are the most important indications of a patient's quality of life.

Health advisories for consumers of Great Lakes sport fish: is the message being received?

Nationwide, 45 states issue health advisories for sport fish consumers. Chemical contaminants in some Great Lakes (GL) sport fish include compounds suspected of causing adverse reproductive and developmental effects. Although advisories to reduce consumption of contaminated fish, especially by women, have been issued by GL states (i.e., Illinois, Indiana, Michigan, Minnesota, New York, Ohio, Pennsylvania, and Wisconsin) since the mid-1970s, little is known about advisory awareness and GL sport fish consumption in the general population. To estimate the prevalence of GL sport fish consumption and health advisory awareness, we conducted a population-based telephone survey of 8,306 adult residents of the eight GL states. We gathered information concerning respondents' demographic characteristics, fish consumption during the preceding year, and sport fish consumption advisory awareness. The survey response rate was 69%. GL sport fish were eaten during the preceding year by 8.4% -95% confidence interval (CI), 7.6-9.2- of adults in the GL states, approximately 4.7 million persons. Women accounted for 43.9% (CI,39. 4-48.4) of consumers. Although 49.9% of GL sport fish consumers were aware of a health advisory, awareness varied significantly by sex: 58.2% (CI, 51.7-64.7) of males and 39.1% (CI, 32.6-45.6) of females were aware. Using logistic regression, we found awareness associated with male sex -odds ratio (OR) = 2.3; CI, 1.5-3.5), white race (OR = 4.2; CI, 1.9-9.1), college degree (OR = 3.1; CI, 1.3-7.6), and consuming >=24 GL sport fish meals/year (OR = 2.4; CI, 1.4-4.3). Only half of GL sport fish consumers reported awareness of a health advisory concerning eating GL sport fish. Awareness was especially low among women, suggesting the need of targeted risk communication programs for female consumers.

Histopathologic and ultrastructural alterations of white liver disease in sheep experimentally depleted of cobalt

Many cobalt-deficient sheep develop liver lesions known as ovine "white liver" disease, but the etiology of these changes is controversial. It has been suggested that cofactors are required for development of liver damage in cobalt-deficient sheep. In this study, one group of lambs (n = 5) was fed a diet low in cobalt (4.5 micrograms/kg) while a group of control lambs (n = 4) received the same diet after it had been supplemented with cobalt (1000 micrograms/kg). All cobalt-depleted lambs had reduced growth rate, anorexia, lacrimation, and alopecia, and they eventually became emaciated (mean body weight at end of study: 83% of initial body weight). Plasma concentrations of bilirubin and serum activity of glutamate-oxaloacetate transferase were elevated in these animals, while plasma concentrations of vitamin B12 were reduced (less than 220 pmol/L from day 42). Fatty degeneration of the liver associated with reduced concentrations of vitamin B12 (14.5 pmol/g) was seen in these animals at necropsy at 196 days. Microscopic liver lesions included accumulation of lipid droplets and lipofuscin particles in hepatocytes, dissociation and necrosis of hepatocytes, and sparse infiltration by neutrophils, macrophages, and lymphocytes. Ultrastructural hepatocytic alterations included swelling, condensation and proliferation of mitochondria, hypertrophy of smooth endoplasmic reticulum, vesiculation and loss of arrays of rough endoplasmic reticulum, and accumulation of lipid droplets and lipofuscin granules in cytoplasm of hepatocytes. No liver lesions were seen in control lambs. The results of this study indicate that cofactors are not a prerequisite to development of hepatic damage in cobalt-deficient sheep. Reduced activities of the vitamin B12-dependent enzymes, methylmalonyl CoA mutase and methionine synthase, and lipid peroxidation are of likely pathogenetic importance in the development of the lesions.

In vitro anti-HIV activity of biflavonoids isolated from Rhus succedanea and Garcinia multiflora

Eleven biflavonoids, including amentoflavone (1), agathisflavone (2), robustaflavone (3), hinokiflavone (4), volkensiflavone (5), morelloflavone (7), rhusflavanone (9), succedaneaflavanone (10), GB-1a (11), GB-1a 7"-O-beta-glucoside (13), and GB-2a (14) isolated from Rhus succedanea and Garcinia multiflora, as well as their methyl ethers, volkensiflavone hexamethyl ether (6), morelloflavone heptamethyl ether (8), and GB-1a hexamethyl ether (12), were evaluated for their anti-HIV-1 RT activity. The results indicated that compounds 3 and 4 demonstrated similar activity against HIV-1 reverse transcriptase (RT), with IC50 values of 65 microM. Compounds 1, 2, 7, 11, and 14 were moderately active against HIV-1 RT, with IC50 values of 119 microM, 100 microM, 116 microM, 236 microM, and 170 microM, respectively. Morelloflavone (7) also demonstrated significant antiviral activity against HIV-1 (strain LAV-1) in phytohemagglutinin-stimulated primary human peripheral blood mononuclear cells at an EC50 value of 6.9 microM and a selectivity index value of approximately 10. The other biflavonoids were either weakly active, inactive, or not selective against HIV-1 in human lymphocytes.

Single-agent paclitaxel in advanced non-small cell lung cancer: single-center phase II study using a 3-hour administration schedule

The efficacy and safety of paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) administered as a 3-hour infusion was investigated in a phase II study involving 21 patients with stage III/IV non-small cell lung cancer. The study included two quality of life assessments (the Hospital Anxiety and Depression Scale and the Rotterdam Symptom Checklist) to test their suitability for use in a future randomized phase III trial of paclitaxel and best supportive care versus best supportive care alone. Four (19%) of the 21 patients (95% confidence interval, 8% to 38%) achieved a partial response. The median time to disease progression for all patients entered was 19 weeks. Paclitaxel was well tolerated, with dose reduction required in only one patient because of arthralgia/myalgia. No dose reductions, delays, or discontinuations were required for hematologic toxicity. Completion and compliance with quality of life questionnaires was high, and these research tools proved to be acceptable for future use in phase III studies with paclitaxel.

Femoral complications and bed rest duration after coronary arteriography

This randomized study using a pneumatic compression device found no significant difference in the femoral complication rate between 4 and 6 hours of bed rest after Judkin's coronary arteriography. The positive implications for the organization of an efficient service in busy tertiary centers include reduced patient discomfort, earlier ambulation and discharge, efficient staff deployment, and enhanced throughput.

Gemcitabine: symptomatic benefit in advanced non-small cell lung cancer

Recent studies have indicated that chemotherapy not only provides some survival benefit, but also reduces tumor-related symptoms and improves the performance status of patients receiving chemotherapy. Data from single-agent gemcitabine studies demonstrate improvements in a range of tumor symptoms, including cough, hemoptysis, pain, dyspnea, and anorexia, as well as increases in performance status. Indeed, more patients benefit from gemcitabine chemotherapy than suggested by the objective response rate. Surveys also have shown that patients are much more likely to accept chemotherapy for what is perceived by health care professionals as potentially small benefits. Gemcitabine has a role in the palliative treatment of patients with advanced non-small cell lung cancer.

Heat-related illness and death, Wisconsin, 1995

This article examines heat-related illnesses and deaths that occurred in Wisconsin during the summer of 1995, which was among the warmest seasons on record. Death certificates that listed heat exposure as a contributing or underlying cause of 154 deaths and ambulance run reports for 454 heat-related emergency calls were analyzed. The time and place of these events and patient information were used to evaluate risk factors such as age, medical condition, physical activity, and environmental temperature. Three-fourths of the deaths and nearly half of the heat-related illnesses occurred during or shortly after two days of intense heat. Major risk factors for these heat-related illnesses and deaths included age, underlying chronic illness, physical exertion, and lack of air-conditioning. To reduce the number of illnesses and deaths that occur during future heat waves, all residents should be advised to install air-conditioning systems in their homes or apartments and encouraged to use them when indoor temperatures are uncomfortably warm. Summer weather forecasts should include heat index information. During periods of extreme heat, public health advisories should be issued encouraging residents to seek shelter in air-conditioned areas and to avoid strenuous outdoor activities and prolonged sun exposure. Region-specific criteria and procedures for issuing public health advisories should be developed jointly by the National Weather Service and the US Centers for Disease Control and Prevention.

Gemcitabine in the treatment of elderly patients with advanced non-small cell lung cancer

Gemcitabine is active against non-small cell lung cancer (NSCLC), with single-agent response rates of 20% or more in previously untreated patients. Its mild toxicity profile suggests that it should be well tolerated by older patients. To assess the impact of age on the efficacy and tolerance of gemcitabine, the results of four phase II trials of single-agent gemcitabine for the treatment of NSCLC were analyzed retrospectively. Starting doses for gemcitabine ranged from 800 to 1,250 mg/m2/wk, and in all studies gemcitabine was administered weekly for 3 weeks followed by a 1-week rest period. Response rates, toxicity, and dose delivery were compared for two age groups, less than 65 years (255 patients) or > or = 65 years (105 patients). The pretreatment characteristics for both patient groups were well balanced. Overall response rates were 16% and 24% for the younger and older patients, respectively (P = .072). Median survival and 1-year survival rates were 8.1 months and 27% and 9.1 months and 36%, respectively, for patients aged less than 65 years and > or = 65 years. Hematologic and nonhematologic toxicities were similar for both age groups. The number of cycles associated with dose reductions or dose omissions and the mean number of treatment cycles administered were also similar. In summary, gemcitabine is active and well tolerated in elderly patients with NSCLC, and is a promising new alternative for the treatment of this patient population.

Surveillance for silicosis, 1993--Illinois, Michigan, New Jersey, North Carolina, Ohio, Texas, and Wisconsin

PROBLEM/CONDITION

Silicosis is an occupational respiratory disease caused by the inhalation of respirable dust containing crystalline silica. Public health surveillance programs to identify workers at risk for silicosis and target workplace-specific and other prevention efforts are currently being field-tested in seven U.S. states.

REPORTING PERIOD COVERED

Confirmed cases ascertained by state health departments during the period January 1, 1993, through December 31, 1993; the cases and associated workplaces were followed through December 1994.

DESCRIPTION OF SYSTEMS

As part of the Sentinel Event Notification System for Occupational Risks (SENSOR) program initiated by CDC's National Institute for Occupational Safety and Health (NIOSH), development of state-based surveillance and intervention programs for silicosis was initiated in 1987 in Michigan, New Jersey, Ohio, and Wisconsin and in 1992 in Illinois, North Carolina, and Texas.

RESULTS

From January 1, 1993, through December 2, 1994, the SENSOR silicosis programs in Illinois, Michigan, New Jersey, North Carolina, Ohio, Texas, and Wisconsin confirmed 256 cases of silicosis that were initially ascertained in 1993. Overall, 185 (72%) were initially identified through review of hospital discharge data or through hospital reports of silicosis diagnoses; 188 (73%) were associated with silica exposure in manufacturing industries (e.g., foundries; stone, clay, glass, and concrete manufacturers; and industrial and commercial machinery manufacture). Overall, 42 (16%) cases were associated with silica exposure from sandblasting operations. Among the 193 confirmed cases for which information was available about duration of employment in jobs with potential exposure to silica, 37 (19%) were employed < or = 10 years in such jobs and 156 (81%) were employed > or = 11 years. A total of 192 primary workplaces associated with potentially hazardous silica exposures were identified for the 256 confirmed silicosis cases. Of these, nine (5%) workplaces were inspected by state health department (SHD) industrial hygienists, 19 (10%) were referred to the Occupational Safety and Health Administration (OSHA) for follow-up, and seven (4%) were routinely monitored by the Mine Safety and Health Administration. Of the 157 (82%) remaining workplaces, follow-up activities determined that 82 were no longer in operation, eight were no longer using silica, 18 were assigned a lower priority for follow-up, six were associated with building trades and could not be inspected because of the transient nature of work in the construction industry, and 43 workplaces were not inspected for other reasons. Fourteen (7%) of the 192 workplaces were inspected. At 10 of the 14 workplaces, airborne levels of crystalline silica were measured; in nine, silica levels exceeded the NIOSH-recommended exposure level of 0.05 mg/m, and in six, airborne silica levels also exceeded federal permissible exposure limits.

ACTIONS TAKEN

Employee-specific and other preventive interventions have been initiated in response to reported cases. In addition, special silicosis prevention projects have been initiated in Michigan, New Jersey, North Carolina, Ohio, Texas, and Wisconsin. To facilitate the implementation of silicosis surveillance by other states, efforts are ongoing to identify and standardize core data needed by surveillance programs to describe cases and the workplaces where exposure occurred. These core variables will be incorporated into a user-friendly software system that states can use for data collection and reporting.

The significance of ulcer disease on late mortality after partial gastric resection

OBJECTIVE

To study the causes of long-term mortality after peptic ulcer surgery with special attention to the impact of underlying ulcer disease.

DESIGN

Retrospective cohort investigation.

PATIENTS

A cohort of 1305 patients who had surgery for gastric and duodenal ulcer disease 29 to 59 years ago. At the end of follow-up 80% of gastric ulcer patients, and 64% of duodenal ulcer patients were dead.

RESULTS

Overall mortality was significantly higher among gastric ulcer patients: standardized mortality ratio (SMR) 1.17 (95% confidence interval (CI) 1.05-1.29); duodenal ulcer patients had an overall mortality comparable to the reference population: SMR 1.06 (CI 0.97-1.15). Excess mortality among gastric ulcer patients was found to be due to neoplasms in gastrointestinal organs (SMR 1.54 (CI 1.11-2.11) which developed more than 20 years postoperatively, and to respiratory diseases and suicide unrelated to time since surgery. An increased mortality due to malignant tumours, respiratory diseases and suicide was also found among duodenal ulcer patients but this increased mortality was offset due to a significantly decreased mortality in diseases of the heart and vascular system (SMR 0.86 (CI 0.75-0.97)), evident mainly after 20 years postoperatively. Excess mortality due to gastrointestinal cancers outnumbered excess mortality from carcinomas in the respiratory organs, and was due to cancers in the stomach, colon and pancreas.

CONCLUSION

An increased mortality due to gastrointestinal carcinoma, especially gastric and pancreatic carcinoma, is apparent regardless of underlying ulcer disease. As preventive measures against these tumours have yielded little benefit in prospective trials, and as smoking-related diseases and tumours together with suicide constitute 75% of the excess mortality, measures to combat smoking and suicide might be more worthwhile to reduce mortality in this cohort.

Childhood asthma surveillance using computerized billing records: a pilot study

OBJECTIVE

This paper describes a pilot project to develop and implement a low-cost system for ongoing surveillance of childhood asthma in Milwaukee County, Wisconsin.

METHODS

The authors organized a planning workshop to solicit information and ideas for an asthma surveillance system, bringing together national experts with Milwaukee professionals and community representatives involved in the prevention and treatment of asthma. Based on recommendations from the workshop, a pilot surveillance project was implemented in Milwaukee County using records of emergency room visits and hospital admissions for asthma abstracted from the computerized billing records of the Children's Hospital of Wisconsin (CHW), retrospectively for 1993 and prospectively for 1994. Retrospective data were also sought from the other hospital emergency departments in Milwaukee County to evaluate the representativeness of the CHW data. Surveillance data were used to evaluate utilization of care by patient subgroups and to describe temporal patterns in emergency room visits.

RESULTS

Of the emergency department visits for asthma in Milwaukee County in 1993, CHW accounted for 94% among infants less than 1 year of age, 89% among children ages 1 through 5 years, and only 59% among children between the ages of 6 and 18 years. In 1994, the 7% of asthmatic children with repeat hospital admissions accounted for 38% of all hospital admissions for asthma and the 20% with repeat emergency department visits accounted for 50% of all emergency visits. Emergency visits for asthma showed clear seasonality, with a peak in the fall and a smaller peak in the spring.

CONCLUSIONS

Computerized medical billing data provide an opportunity for asthma surveillance at a relatively low cost. The data obtained are useful for tracking trends in exacerbations of asthma and the use of medical services for asthma care and should prove valuable in targeting interventions.

Improving quality of life in patients with non-small cell lung cancer: research experience with gemcitabine

Alongside objective response rate, quality of life of patients is important in the treatment of cancer, particularly in the palliative setting. Quality of life is difficult to define precisely and is correspondingly difficult to assess. However, a number of methods have been devised and self-report questionnaires are now widely used. Patients with metastatic non-small cell lung cancer (NSCLC) have a poor prognosis with few patients surviving longer than 8 or 9 months. Curative treatment is often not possible and few patients receive active treatment. Although some patients will accept toxic treatments in return for increased survival, it is generally hoped that any treatment, curative or palliative, will not adversely affect patients' quality of life. In three studies in which gemcitabine was used as a single agent in metastatic NSCLC, objective response rates of 20% were obtained. Gemcitabine was well tolerated. Symptoms improved in the studies where disease-related symptoms were assessed. The degree of improvement compared well with historical data on the relief offered by standard radiotherapy and combination chemotherapy. These findings have led to the initiation of a randomised trial to compare the relief offered by gemcitabine plus best supportive care with best supportive care, using quality of life assessments as a primary endpoint.

A non-thrombocytopenic bleeding disorder due to an IgG4-kappa anti-GPIIb/IIIa autoantibody

Autoantibodies in chronic immune thrombocytopenic purpura occasionally interfere with platelet function. We describe a patient with a normal platelet count who had clinically significant mucosal bleeding, a prolonged bleeding time and abnormal platelet aggregation. The patient had high titres of an IgG4 kappa autoantibody, directed to a cation-dependent epitope on platelet glycoprotein IIb/IIIa, which blocked the binding of fibrinogen and fibronectin to this complex. Corticosteroid treatment resulted in clinical improvement and a marked drop in autoantibody concentration. The lack of thrombocytopenia in this patient, despite high autoantibody levels, is best explained by the poor recognition of IgG4 antibodies by phagocytic cells.

A phase I study of a 24 hour infusion of gemcitabine in previously untreated patients with inoperable non-small-cell lung cancer

A phase I study to determine the maximum tolerated dose and toxicity of gemcitabine when given as a 24 h infusion to patients with inoperable non-small-cell lung cancer (NSCLC). A total of 24 patients with unresectable stage IIIa-IV NSCLC were entered into the study. Gemcitabine was administered as a 24 h infusion on days 0, 7 and 14. Courses of therapy were repeated every 28 days. There were 16 males and 8 females with a median age of 51 years (range 40-73 years). The WHO performance score was 1 (21 patients) or 2 (3 patients). The TNM stage was IIIa (6), IIIb (10) and IV (8). Three patients were entered at each dose level with six at the maximum tolerated dose (MTD). Dose levels were 10, 20, 40, 80, 120, 180 and 210 mg m-2. The MTD was 180 mg m-2 and dose-limiting toxicity was neutropenia and lethargy. Partial response was observed in five (21%) patients (95% CI 7-42%) lasting 10, 14, 18, 47 and 51 + weeks. The maximum tolerated dose of gemcitabine given as a 24 h infusion was 180 mg m-2.

Blood transfusion as a risk factor for non-Hodgkin lymphoma

In a case-control study of 280 out of 426 consecutive patients with a recent diagnosis of non-Hodgkin lymphoma (NHL) and 1827 control subjects, 53 (19%) and 230 (13%) respectively had received blood transfusions 1 year or more before the interview. Using an age- and sex-stratified analysis the odds ratio (OR) for transfusion was 1.74 (95% CI 1.24-2.44). ORs were also determined for transfusions received in the intervals 1-5, 6-15, 16-25 and > or = 26 years before diagnosis. In the interval 6-15 years, the OR for transfusion was 2.83 (95% CI 1.60-4.99) whereas ORs for transfusions received in other intervals were lower and not significantly elevated. Histological diagnoses (Kiel classification) and results of staging procedures were known for 185 patients. For low-grade NHL of nodal B-cell chronic lymphocytic leukaemia (B-CLL) or immunocytoma type, the OR for transfusions was 4.15 (95% CI 1.92-9.01). For low-grade nodal lymphomas of follicle centre cell type and high-grade nodal lymphomas, no relation to transfusions could be demonstrated. For high-grade extranodal lymphoma as sole manifestation, OR for transfusions was 3.27 (95% CI 1.30-8.24). It is concluded that blood transfusion may be a risk factor for NHLs especially those of B-CLL or immunocytoma type and for high-grade extranodal lymphoma.

Aggressive vs nonaggressive therapy for metastatic NSCLC

Clinicians tend to underestimate potential modest benefits of chemotherapy. They are often reluctant to refer patients for chemotherapy, perhaps because they expect the side effects to outweigh any perceived benefits. However, patients are much more ready to accept chemotherapy, even when the likely benefits are small. Quality of life, change in performance status, and relief of tumor-related symptoms are important additional parameters of treatment assessment. Taking account of these other factors will help clinicians balance quality and quantity of life in patients with metastatic non-small cell lung cancer.

Gemcitabine: once-weekly schedule active and better tolerated than twice-weekly schedule

This paper reviews the toxicity profile of gemcitabine, a novel anticancer drug. Gemcitabine has been administered using two different treatment schedules: once weekly or twice weekly for 3 weeks followed by a week of rest (one cycle). It was well tolerated and alopecia was not a problem. Toxicity was greater in the twice-weekly schedule. Comparing the once-weekly with the twice-weekly schedule, WHO grade 3 or 4 thrombocytopenia was reported in 4.7 and 25.6% of patients, respectively. Other hematological toxicity was minimal. Transient WHO grade 3 or 4 elevations of ALT and AST occurred in 9.2 and 7.2% of patients, respectively, in the once-weekly schedule. For the twice-weekly schedule the corresponding percentages were 12.2 and 13.8%. Symptomatic toxicity was greater in patients who received twice-weekly gemcitabine. Nausea and vomiting was mild and generally well controlled without 5HT3 antagonists. However, there was a greater incidence of nausea and vomiting on the twice-weekly schedule. Flu-like symptoms were documented in 19.8% of patients receiving once-weekly and 63.3% of patients receiving twice-weekly gemcitabine. Peripheral edema, not related to cardiac, hepatic or renal failure, was seen more often in patients on twice-weekly treatment. As the efficacy of gemcitabine in non-small cell lung cancer was equivalent when using both regimens, the better tolerated and more easily administered once-weekly schedule is recommended.

Reproducibility of a self-administered questionnaire for assessment of melanoma risk

BACKGROUND

The reproducibility of a self-administered questionnaire on different epidemiological variables was examined in a random sample of a cohort of healthy women from the South Swedish Health Care Region. An identical questionnaire has previously been used for assessment of melanoma risk, in a population-based, matched, case-control study from the same region.

METHODS

Repeat questionnaires were completed on two occasions, 1-3 years apart, by 670 randomly selected subjects. In addition, exposure data from a case-control study were used to estimate the effect of misclassification.

RESULTS

Overall, there was a fair to good consistency between the answers on the two occasions for the various epidemiological variables. Exposure variables identified as risk factors for melanoma development were reasonably reproducible. The estimated proportion of agreement, A, ranged from 0.74 to 0.92, the average correct classification rate (assuming common sensitivity and specificity), pi, was > or = 0.85 and the kappa coefficient, kappa, ranged between 0.52 and 0.83. However, the question on number of raised naevi on the arm was an exception since it had a lower test-retest reliability (A = 0.62, pi = 0.77, kappa = 0.40). When using data from the case-control study, the effect of the estimated random misclassification was found to only slightly bias odds ratios toward one.

CONCLUSION

Our questionnaire, used for assessment for melanoma risk, provided information with fair to good test-retest reliability, and corrected odds ratios were found to be only slightly higher than observed odds ratios.

Total pancreatectomy for cancer of the pancreas: is it appropriate?

During the late 1960s total pancreatectomy was advocated on theoretic grounds as an operation superior to subtotal (Whipple) resection in patients with pancreatic cancer. There are, however, no prospective randomized studies and only few institutional comparisons between the two operations. The aim of the present paper was to report the clinical outcome of total and subtotal pancreatectomy, respectively, in a consecutive series of patients with exocrine pancreatic cancer. The short- and long-term results of 89 consecutive patients who underwent total pancreatectomy (1959-1984) for pancreatic cancer were retrospectively compared with a similar group of 36 patients who had a subtotal pancreatectomy (1985-1992) for the same diagnosis. The clinical characteristics were on the whole similar in the two groups. Postoperative mortality and morbidity, the amount of intraoperative bleeding, operation time, reoperation rate, postoperative days in the intensive care unit, and duration of hospital stay were statistically significantly increased after total pancreatectomy. The 5-year survival rate was lower after total pancreatectomy when hospital deaths were included in the analysis. At multivariate analysis total pancreatectomy adversely influenced long-term survival compared to subtotal resection, as did positive lymph nodes and poor histologic differentiation. Better early and long-term results were found after subtotal than after total pancreatectomy in patients with exocrine pancreatic cancer. Although the two operations were done during different time periods, we believe the results suggest that total pancreatectomy cannot be recommended as a routine treatment for this patient group.

Rising incidence of pancreatic carcinoma in middle-aged and older women-time trends 1961-90 in the city of Malmö, Sweden

The city of Malmö (population 230 000), situated in the south of Sweden, is in an area which has the highest incidence of pancreatic cancer in the country. The present study was designed to assess time trends of the incidence of pancreatic cancer 1961-90. The 1314 incident cases, 651 men and 663 women, were retrieved from the Regional Tumour Register and the National Cause-of-Death Register. In 75% of cases diagnosis was based on autopsy. Twenty per cent of the these cases were first found at autopsy, being undiagnosed. The average age-standardised incidence was 20.4 per 10(5) person-years for men and 13.7 for women. The incidence was higher for men than for women in all age groups above 44 years. No change in incidence over time was observed for men. In older and middle-aged women there was however a statistically significant increase. The average relative change in women above age 64 was 1.7% per year after age adjustment and in women aged 55-64 years 2.6% per year. We have found no results indicating that this increasing incidence could be caused by detection bias as a result of changing autopsy rates during the study period and hence conclude that the observed increase is explained by a growing number of women being exposed to factors with a potential tumour-promoting or -initiating effect.

Metaphase cytogenetics and DNA flow cytometry with analysis of S-phase fraction in prostate cancer: influence on prognosis

OBJECTIVES

To compare the prognostic significance of chromosome aberrations, DNA ploidy, and S-phase fraction (SPF) in prostate adenocarcinomas and to compare the sensitivity of metaphase cytogenetics with flow cytometry (FCM) in detecting abnormal tumor clones.

METHODS

Prostate adenocarcinomas from 57 men were previously successfully analyzed with metaphase cytogenetics. Archival material from these tumors were further analyzed with FCM for DNA content and SPF.

RESULTS

The patients were followed for 4.5 to 7.7 years. DNA ploidy was analyzed in 51, and SPF in 45 of the 57 tumors. Clonal chromosomal aberrations, DNA aneuploidy, and high SPF were all significantly associated with poor survival. Of these three variables, SPF was the best predictor of survival, but compared with tumor stage and grade in multivariate analysis, SPF was not an independent prognostic factor. Patients with locally advanced tumors or metastatic disease with SPF less than 8% had a median survival of 5.9 years, compared with only 1.3 years for those with SPF more than 8%. Twenty-eight abnormal clones were detected with FCM and 20 with cytogenetic analysis, but only for two of these clones could the results from the two different methods be regarded as concordant.

CONCLUSIONS

SPF was superior to karyotype and ploidy in predicting death in prostate cancer, but it remains to be shown whether SPF analysis adds prognostic information to tumor stage and grade. The cytogenetic analyses correlated poorly with results of FCM, indicating low sensitivity of both methods.

Topoisomerase II inhibitors affect entry into mitosis and chromosome condensation in BHK cells

DNA topoisomerase II (topo II) is required at mitosis in yeast for high chromosome condensation and for chromosome segregation. Recent studies on intact mammalian cells using topo II inhibitors that do not stabilize cleavable complexes also suggest a requirement for topo II for complete chromosome condensation and perhaps also for entry into mitosis. We have investigated the effects of merbarone, ICRF-187, and aclarubicin, three topo II inhibitors that do not stabilize the cleavable complex, on entry into mitosis and on chromosome condensation in BHK and in tsBN2 cells. We have compared their effects with those of etoposide, a topo II inhibitor that stabilizes the cleavable complex. All inhibitors induced a concentration-dependent G2 delay or arrest that could be overcome with fostriecin or okadaic acid or by inactivation of RCC1 in tsBN2 cells. Mitotic chromosomes from cells treated with etoposide were extensively fragmented, whereas mitotic chromosomes from cells treated with merbarone, ICRF-187, or aclarubicin were intact but elongated and tangled. These results provide strong evidence that topo II activity is required in chromosome condensation for final coiling of the chromatids. Our results also indicate that protein phosphatases and RCC1 play a role in G2 delay induced by all inhibitors, whether they do or do not stabilize the cleavable complex.

Methodological aspects of flow cytometry DNA analysis in endometrial carcinoma, with special reference to sampling and reproducibility

Two adjacent paraffin-embedded sections manifested concordance in ploidy status in 96% of cases (45/47), and the standard deviation (SD) for SPF was 2.7%. Analysis of 'micro-heterogeneity', within a distance of < or = 700 microm, yielded results for concordant ploidy status in 94% of cases, and the SD for SPF was 1.9% (n = 17). Frozen and paraffin-embedded material yielded concordant results for ploidy status in 87% (39/45) of cases, and SPF values were significantly lower (mean difference 1.5%) in the frozen samples. Diagnostic and repeat curettage material yielded concordant results for DNA ploidy status in 85% (40/47) of cases, and no significant difference in mean SPF (12% vs. 11%) was found. Discordant DNA ploidy results were attributable to small differences in the DNA histograms influencing the interpretation of near-diploid, near-tetraploid and small non-diploid cell populations, and the influence of debris on SPF estimation. On the basis of our findings and the practical advantage we recommend paraffin-embedded material from diagnostic curettage for FCM DNA analysis; the results are available sooner and the handling and transportation of tumor samples is more convenient.