Randomized phase II trial of gemcitabine plus weekly versus three-weekly paclitaxel in previously untreated advanced non-small-cell lung cancer

INTRODUCTION

Gemcitabine and paclitaxel (Taxol) each provides an efficacious non-platinum option for the treatment of advanced non-small-cell lung cancer (NSCLC), but the optimal dosage and schedule of the two agents used in combination are not well defined.

METHODS

Previously untreated patients with advanced NSCLC were randomized to receive gemcitabine-paclitaxel on a traditional three-weekly schedule (Arm A) or a novel weekly schedule (Arm B) as follows-Arm A (three-weekly): gemcitabine 1000 mg/m2 infused>30 min on days 1 and 8 and paclitaxel 200 mg/m2 infused>3 h on day 1 of a 21-day cycle or Arm B (weekly): gemcitabine 1000 mg/m2 infused>30 min and paclitaxel 100 mg/m2 infused>1 h, both administered on days 1 and 8 of a 21-day cycle.

RESULTS

One hundred patients received at least one dose of treatment. The weekly schedule, Arm B, was more efficacious and less hematologically toxic than Arm A. Confirmed complete and partial response rates were 28.2% and 26.8%, respectively. Median survival was 10.3 months on Arm B and 7.9 months on Arm A (log-rank P=0.10); 1- and 2-year survival rates also favor Arm B: 42.0% versus 34.0% and 18.0% versus 6.0%. Progression-free survival was 5.8 versus 4.8 months, again favoring Arm B (log-rank P=0.06). There was a two-fold lower frequency of grade 3/4 hematologic events with Arm B as follows: neutropenia (16% versus 30%), thrombocytopenia (4% versus 8%), and anemia (2% versus 6%). One patient (2%) in each treatment group developed febrile neutropenia.

CONCLUSION

In this trial, both schedules were efficacious and tolerable, although the weekly schedule resulted in improved survival and lower hematologic toxicity compared with a three-weekly schedule. The weekly schedule of gemcitabine-paclitaxel indicates an improved therapeutic index.

Evaluating end of life care: The Quality Oncology Practice Initiative (QOPI) experience

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Background: Little is known about the quality of end-of-life (EOL) care provided to cancer patients, with data largely available only from administrative databases. QOPI is a practice-based system of quality self-assessment now available to any ASCO physician wishing to participate. QOPI methodology allows comparison of EOL care among practices and provides a basis for self-improvement. Methods: In Summer 2005, during the pilot phase of QOPI, several EOL questions were included in the survey instrument. Practices were requested to review the records of at least 15 patients who had died. Practice members performed standardized chart abstractions and data were entered directly on to a secure web-based application. A total of 455 charts were abstracted from 22 practices. Results: See table. Conclusion : QOPI provides an effective mechanism for collecting practice-specific EOL data. Aggregate data from the 22 QOPI pilot practices demonstrate a high level of performance compared with results reported from population-based studies. Significant variation among practices is present, representing an opportunity to improve the EOL care of cancer patients.

[Table: see text]

No significant financial relationships to disclose.

Hospital and physician volume or specialization and outcomes in cancer treatment: importance in quality of cancer care

PURPOSE

To conduct a comprehensive review of the health services literature to search for evidence that hospital or physician volume or specialty affects the outcome of cancer care.

METHODS

We reviewed the 1988 to 1999 MEDLINE literature that considered the hypothesis that higher volume or specialization equals better outcome in processes or outcomes of cancer treatments.

RESULTS

An extensive, consistent literature that supported a volume-outcome relationship was found for cancers treated with technologically complex surgical procedures, eg, most intra-abdominal and lung cancers. These studies predominantly measured in-hospital or 30-day mortality and used the hospital as the unit of analysis. For cancer primarily treated with low-risk surgery, there were fewer studies. An association with hospital and surgeon volume in colon cancer varied with the volume threshold. For breast cancer, British studies found that physician specialty and volume were associated with improved long-term outcomes, and the single American report showed an association between hospital volume of initial surgery and better 5-year survival. Studies of nonsurgical cancers, principally lymphomas and testicular cancer, were few but consistently showed better long-term outcomes associated with larger hospital volume or specialty focus. Studies in recurrent or metastatic cancer were absent. Across studies, the absolute benefit from care at high-volume centers exceeds the benefit from break-through treatments.

CONCLUSION

Although these reports are all retrospective, rely on registries with dated data, rarely have predefined hypotheses, and may have publication and self-interest biases, most support a positive volume-outcome relationship in initial cancer treatment. Given the public fear of cancer, its well-defined first identification, and the tumor-node-metastasis taxonomy, actual cancer care should and can be prospectively measured, assessed, and benchmarked. The literature suggests that, for all forms of cancer, efforts to concentrate its initial care would be appropriate.

Pamidronate in prevention of bone complications in metastatic breast cancer: a cost-effectiveness analysis

PURPOSE

Pamidronate is effective in reducing bony complications in patients with metastatic breast cancer who have known osteolytic lesions. However, pamidronate does not increase survival and is associated with additional financial costs and inconvenience. We conducted a post-hoc evaluation of the cost-effectiveness of pamidronate using the results of two randomized trials that evaluated pamidronate 90 mg administered intravenously every month versus placebo.

PATIENTS AND METHODS

The trials differed only in the initial systemic therapy administered (hormonal or chemotherapy). Total skeletal related events (SREs), including surgery for pathologic fracture, radiation for fracture or pain control, conservatively treated pathologic fracture, spinal cord compression, or hypercalcemia, were taken directly from the trials. Using a societal perspective, direct health care costs were assigned to each SRE. Each group's monthly survival was equal and was projected to decline using observed median survivals. The cost of pamidronate reflected the average wholesale price of the drug plus infusion. The value or disutility of an adverse event per month was evaluated using a zero value (events avoided) or an assigned one (range, 0.2 to 0.8).

RESULTS

The cost of pamidronate therapy exceeded the cost savings from prevented adverse events. The difference between the treated and placebo groups was larger with hormonal systemic therapy than with chemotherapy (additional $7,685 compared with $3,968 per woman). The projected net cost per SRE avoided was $3,940 with chemotherapy and $9,390 with hormonal therapy. The cost-effectiveness ratios were $108,200 with chemotherapy and $305, 300 with hormonal therapy per quality-adjusted year.

CONCLUSION

Although pamidronate is effective in preventing a feared, common adverse outcome in metastatic breast cancer, its use is associated with high incremental costs per adverse event avoided. The analysis is most sensitive to the costs of pamidronate and pathologic fractures that were asymptomatic or treated conservatively.

A rural cancer outreach program lowers patient care costs and benefits both the rural hospitals and sponsoring academic medical center

The Rural Cancer Outreach Program (RCOP) between two rural hospitals and the Medical College of Virginia's Massey Cancer Center (MCC) was developed to bring state-of-the-art cancer care to medically underserved rural patients. The financial impact of the RCOP on both the rural hospitals and the MCC was analyzed. Pre- and post-RCOP financial data were collected on 1,745 cancer patients treated at the participating centers, two rural community hospitals and the MCC. The main outcome measures were costs (estimated reimbursement from all sources), revenues, contribution margins and profit (or loss) of the program. The RCOP may have enhanced access to cancer care for rural patients at less cost to society. The net annual cost per patient fell from $10,233 to $3,862 associated with more use of outpatient services, more efficient use of resources, and the shift to a less expensive locus of care. The cost for each rural patient admitted to the Medical College of Virginia fell by more than 40 percent compared with only an 8 percent decrease for all other cancer patients. The rural hospitals experienced rapid growth of their programs to more than 200 new patients yearly, and the RCOP generated significant profits for them. MCC benefited from increased referrals from RCOP service areas by 330 percent for cancer patients and by 9 percent for non-cancer patients during the same time period. While it did not generate a major profit for the MCC, the RCOP generated enough revenue to cover costs of the program. The RCOP had a positive financial impact on the rural and academic medical center hospitals, provided state-of-the-art care near home for rural patients and was associated with lower overall cancer treatment costs.

Predictors of Medicare costs in elderly beneficiaries with breast, colorectal, lung, or prostate cancer

BACKGROUND

Determining the apportionment of costs of cancer care and identifying factors that predict costs are important for planning ethical resource allocation for cancer care, especially in markets where managed care has grown.

DESIGN

This study linked tumor registry data with Medicare administrative claims to determine the costs of care for breast, colorectal, lung and prostate cancers during the initial year subsequent to diagnosis, and to develop models to identify factors predicting costs.

SUBJECTS

Patients with a diagnosis of breast (n = 1,952), colorectal (n = 2,563), lung (n = 3,331) or prostate cancer (n = 3,179) diagnosed from 1985 through 1988.

RESULTS

The average costs during the initial treatment period were $12,141 (s.d. = $10,434) for breast cancer, $24,910 (s.d. = $14,870) for colorectal cancer, $21,351 (s.d. = $14,813) for lung cancer, and $14,361 (s.d. = $11,216) for prostate cancer. Using least squares regression analysis, factors significantly associated with cost included comorbidity, hospital length of stay, type of therapy, and ZIP level income for all four cancer sites. Access to health care resources was variably associated with costs of care. Total R2 ranged from 38% (prostate) to 49% (breast). The prediction error for the regression models ranged from < 1% to 4%, by cancer site.

CONCLUSIONS

Linking administrative claims with state tumor registry data can accurately predict costs of cancer care during the first year subsequent to diagnosis for cancer patients. Regression models using both data sources may be useful to health plans and providers and in determining appropriate prospective reimbursement for cancer, particularly with increasing HMO penetration and decreased ability to capture complete and accurate utilization and cost data on this population.

Cancer treatment in rural areas

The inability to deliver cancer prevention and treatment to the rural population poses a significant barrier in the national effort to reduce cancer mortality. Since 25 percent of the U.S. population lives in rural areas and few rural areas are readily accessible to cancer centers or Community Clinical Oncology Programs (CCOPs), the prospects for accomplishing the National Cancer Institute (NCI) Goals for the Year 2000 are limited unless substantive changes occur in rural cancer care delivery. This article reviews the problem of cancer risk and care in rural areas and describes one effort to deliver state-of-the-art cancer treatment to rural patients in Virginia. It describes the needs and barriers to access in rural Virginia, the structural elements of the Rural Cancer Outreach Program, and the health policy issues that result when subspecialty care is exported to disadvantaged areas.

Recommended colorectal cancer surveillance guidelines by the American Society of Clinical Oncology

OBJECTIVE

To determine the most effective, evidence-based, postoperative surveillance strategy for the detection of recurrent colon and rectal cancer. Tests are to be recommended only if they have an impact on the outcomes listed below.

POTENTIAL INTERVENTION

All tests described in the literature for postoperative monitoring were considered. In addition, the data were critically evaluated to determine the optimal frequency of monitoring.

OUTCOMES

Outcomes of interest included overall and disease-free survival, quality of life, toxicity reduction, and cost-effectiveness. The American Society of Clinical Oncology (ASCO) Colorectal Cancer Surveillance Expert Panel was guided by the principle of cost minimization, ie, when two strategies were believed to be equally effective, the least expensive test was recommended.

EVIDENCE

A complete MEDLINE search was performed of the past 20 years of the medical literature. Keywords included colorectal cancer, follow-up, and carcinoembryonic antigen, as well as the names of the specific tests. The search was broadened by articles from the tumor marker ASCO panel literature search, as well as from bibliographies of selected articles.

VALUES

Levels of evidence and guideline grades were rated by a standard process. More weight was given to studies that tested a hypothesis directly relating testing to one of the primary outcomes in a randomized design. BENEFITS/HARMS/COSTS: The possible consequences of false-positive and false-negative tests were considered in evaluating a preference for one of two tests that provide similar information. Cost alone was not a determining factor.

RECOMMENDATIONS

The expert panel's recommended postoperative monitoring schema is discussed in this article.

VALIDATION

Five outside reviewers, the ASCO Health Services Research Committee, and the ASCO Board of Directors examined this document.

SPONSOR

American Society of Clinical Oncology.

A sociodemographic and economic comparison of breast reconstruction, mastectomy, and conservative surgery

BACKGROUND

There are a variety of surgical choices for women with early-stage breast cancer, including breast-conserving surgery, mastectomy, or mastectomy plus reconstructive surgery. This report examines some of the factors that affect these choices and the costs of the various treatment options.

METHODS

Data from the Virginia Cancer Registry were linked to insurance claims from the Trigon Blue Cross and Blue Shield Company for women with local and regional staged breast cancer from 1989 to 1991 in Virginia. Multivariate analyses and cost studies were performed.

RESULTS

There were 592 women who underwent breast-conserving surgery (BCS, 26%), mastectomy (58%), or mastectomy plus reconstruction (16%). Increasing age reduced the use of reconstruction. The choice of reconstruction was not affected by tumor size, nodal status, or race. Sixty percent of women had immediate breast reconstruction at the time of mastectomy; the majority had the implant procedure. The cost of BCS ($21,582) was higher than that of mastectomy ($16,122, P < .01). The costs for BCS and mastectomy were significantly lower than for mastectomy plus reconstruction ($31,047, P < .05). The 2-year cost for immediate reconstruction was $8200 less than for delayed procedures and was similar to the cost of BCS.

CONCLUSIONS

Age was the driving force in reconstruction decisions. Clinical factors such as tumor size and nodal status were more important for the choice between BCS and mastectomy. There are significant cost differences between the various procedures. For a similar cosmetic outcome, BCS is less expensive than breast reconstruction. When reconstruction is required, a simultaneous procedure is less expensive.

Demodex gatoi: new species of hair follicle mite (Acari: Demodecidae) from the domestic cat (Carnivora: Felidae)

Demodex gatoi sp. nov. is described in all its life stages from the domestic cat. The host was diagnosed with presumptive feline acquired immunodeficiency syndrome and harbored enormous numbers of both D. gatoi and D. cati Hirst, 1919. Unlike D. cati, which inhabits the hair follicles, D. gatoi resides on the epidermal surface. More than half of the D. gatoi population sampled was made up of ova indicating rapid population growth.

A comparison of patterns of care of nonsmall cell lung carcinoma patients in a younger and Medigap commercially insured cohort

BACKGROUND

The objective of this study was to examine and compare lifetime treatment patterns and hospitalization of incident nonsmall cell lung carcinoma (NSCLC) between pre-Medicare eligible (age < 65 years) and supplemental Medigap (age > or = 65 years) enrollees in a commercially insured cohort using insurance claims.

METHODS

Claims from Virginia Blue Cross and Blue Shield beneficiaries with NSCLC submitted between 1989-1991 were merged with records from the Virginia Cancer Registry (VCR). Data from the VCR identified incident cases, disease stage, and type of tumor. Initial treatment categories were stratified using Physicians' Current Procedural Terminology codes.

RESULTS

There were 1706 incident NSCLC patients; 349 were age < or = 64 years ("younger") and 1212 were age > or = 65 years ("elderly"). Having commercial insurance was not associated with any survival advantage compared with national averages at 2 years. In comparison with elderly patients, younger patients more often were treated with surgery for local disease (80.2% vs. 54.8%) and surgery alone or in combination with radiation for regional disease (51.9% vs. 32.0%). Radiation was used more often in elderly patients compared with younger patients with local disease (30.5% vs. 14.0%) but less often in patients with distant disease (76.2% vs. 54.9%). Compared with elderly patients, younger patients presenting with distant disease received more chemotherapy (18.8% vs. 5.1%; P <0.001); late palliative use of chemotherapy or radiation occurred in only 4-8% of younger patients. Compared with elderly patients, younger patients with regional or distant disease spent more days in the hospital (compared with national averages at 2 years: regional disease, 30.0 vs. 23.9 days; distant disease, 33.0 vs. 21.4 days; P <0.0001).

CONCLUSIONS

The results of this study show that more comprehensive health insurance is not associated with better outcomes in patients with NSCLC. Age specific trends for greater use of surgery, radiation, and total hospitalization in younger patients is consistent with other reports. Commercial health care claims supplemented by clinical staging from cancer registries can address long term practice patterns in patients with cancer.

Performance measurement in cancer care: uses and challenges

Unnecessary, inappropriate, and futile care are given in all areas of health care including cancer care. Not only does such care increase costs and waste precious resources, but patients may have adverse outcomes when the wrong care is given. One of the ways to address this issue is to measure performance with the use of administrative data sets. Through performance measurement, the best providers can be chosen, providers can be rewarded on the basis of the quality of their performance, opportunities for improvement can be identified, and variation in practice can be minimized. Purchasers should take leadership role in creating data sets that will enhance, clinical performance. Specifically, purchasers should require the following from payers: 1) staging information; 2) requirements and/or incentives for proper International Classification of Diseases coding, including other important (comorbid) conditions; 3) incentives or requirements for proper data collection if the payer is using a reimbursement strategy that places the risk on the provider; and 4) a willingness to collect and report information to providers of care, with a view toward increasing quality and decreasing the costs of cancer care. Demanding better clinical performance can lead to better outcomes. Once good data is presented to patients and providers, better clinical behavior and improved cancer care systems will quickly follow.

Costs of care associated with non-small-cell lung cancer in a commercially insured cohort

PURPOSE

To examine the cost of incident cases of non-small-cell lung cancer (NSCLC) in a commercially insured cohort.

METHODS

Claims from Virginia Blue Cross and Blue Shield (BCBS) beneficiaries with lung cancer from 1989 to 1991 were merged with records from the Virginia Cancer Registry (VCR). Data from the VCR identified incident cases, stage, and type of cancer at diagnosis. Costs for all medical care included insurance payment, copayments, and deductibles for 2 years after diagnosis or until death.

RESULTS

Three hundred forty-nine incident NSCLC patients were evaluated. The mean 2-year cost for each patient after diagnosis or until death was $47,941 (95% confidence interval, $43,758 to $52,124). Total average costs and hospital days were significantly lower for local disease ($37,514, 21.2 days), but were similar for regional ($52,797, 30.0 days) and distant ($49,382, 33.0 days) disease. Hospital days accounted for 48% and hospital-based claims for 70% of costs. Initial treatments, which included radiation, unadjusted for stage, had the lowest survival rates and the highest costs, and were associated with the most hospital days. Initial stage, race, gender, and age were not predictors of total 2-year costs. The independent predictors of total 2-year costs were type of treatment: any radiation therapy, any surgery, or any chemotherapy (all, P < .001). Inpatient hospital days was only a modest predictor of costs after adjusting for type of treatment. Patients who survived less than 1 year spent 30.5 days in hospital and had an average cost of $47,280.

CONCLUSION

The direct health care costs of younger NSCLC patients care are substantial. These results should serve as a benchmark for future comparisons as the United States market shifts to managed care.

Neutropenia and neoplasia: an overview of the pharmacoeconomics of sargramostim in cancer therapy

Sargramostim is a myeloid growth factor that is widely used as adjunctive support in patients with neutropenia. Sargramostim enhances neutrophil recovery and myeloid engraftment, reduces infectious complications, and shortens the duration of hospitalization in selected patients. The high cost of sargramostim and other myeloid growth factors and their ability to reduce infections and days of hospitalization have generated interest in their pharmacoeconomic impact. Cost minimization studies in patients receiving chemotherapy for acute myelogenous leukemia and in recipients of autologous bone marrow transplantation (BMT) show estimated cost savings with sargramostim of 1996 US$12,513 and 1994 US$14,500, respectively. These data are consistent with cost savings of 1989 US$16,000 using molgramostim in autologous BMT recipients. Although no pharmacoeconomic data have been published in patients with other conditions, clinical outcomes research demonstrates a clear benefit for sargramostim administration in recipients of peripheral blood progenitor cell and allogeneic BMT and in patients who experience graft delay or failure. Because of reductions in the duration of hospitalization and infectious complications, economic outcomes of these conditions would probably also support sargramostim use. More data regarding the use of sargramostim for chemotherapy-induced neutropenia are required to properly assess the pharmacoeconomic impact in these patients.

Demodex sinocricetuli: new species of hair follicle mite (Acari:Demodecidae) from the Chinese form of the striped hamster, Cricetulus barabensis (Rodentia:Muridae)

Demodex sinocricetuli sp. nov. is described in all its life stages from the Chinese form of the striped hamster, Cricetulus barabensis. A large sample size of > 11,500 mites (96% adults and only 4% ova and immatures) was surveyed. The cause of the apparent reproductive stasis is not known. Limited data sets from other demodecid species reveal populations that are 42-82% adult.

Measuring standards of care for early breast cancer in an insured population

PURPOSE

To demonstrate the use of a combined data base to evaluate the care for local/regional invasive breast cancer in a large insured population of women aged less than 64 years.

PATIENTS AND METHODS

We linked the procedural and hospital claims from Blue Cross Blue Shield (BCBS) of Virginia with clinical stage data from the Virginia Cancer Registry (VCR) from 1989 to 1991. A total of 918 women were assessed with a median age of 50 years; 68% had tumors less than 2 cm, 30% had positive axillary nodes, and 68% were assessed as having local summary stage. A quality-of-care "report card" was used based on standards of care from international Consensus Conferences.

RESULTS

Eight percent had a mastectomy as the initial biopsy procedure. Sixty-nine percent of women ultimately underwent mastectomy. Of those women who underwent lumpectomy, 86% had subsequent radiation. Within 3 months of diagnosis, 43% had a bone scan and 20% a computed tomography (CT) scan. Of women with positive axillary lymph nodes, 83% aged less than 51 years and 52% aged 51 to 64 years received chemotherapy. Fifty-six percent of all women had claims from a medical oncologist. Of women having a total mastectomy, 27% had claims from a plastic surgeon. Sixty-six percent to 76% of women had a mammogram, 24% a bone scan, and 14% a CT scan in the 0-18 and 18-36 month intervals following primary treatment.

CONCLUSION

This study confirms the feasibility of linking sources of data that provide complementary information needed to develop measurements regarding standards of quality and efficiency of oncologic care. This report should serve as an initial benchmark while we await reports from other populations to define the best practice.

How long does it take to get a "do not resuscitate" order?

Less than 50% of physicians know the resuscitation wishes of their patients and only a small fraction of patients have completed "do not resuscitate" (DNR) orders before death. One of the common reasons given by physicians is that the process of "getting a DNR" takes too long, and some authorities have suggested that additional reimbursement is needed. The purpose of this study is to assess how long the DNR education and consent process actually takes in practice. Our study group was a convenience sample of consecutive patients seen by experienced oncologists in a community and academic practice setting. Physicians were asked to record the time spent in DNR discussions with patients, the outcomes, and their comments. DNR orders were obtained on 16 of 22 patients with a single interview lasting a mean time of 16 minutes. Additional DNR orders were obtained on two more patients after a second interview of 6 patients, mean time 17.5 minutes. After a third interview of 4 patients, mean time 23 minutes, only 2 of 22 patients would not allow DNR orders. Of these two, one died intubated in the intensive care unit and the other underwent continued unsuccessful induction therapy for acute leukemia before dying.

CONCLUSION

DNR orders can be obtained on nearly all patients within the time frame of an inpatient or outpatient visit. Time is not the main obstacle to DNR discussions, and additional reimbursement for additional time is not necessary. A small subset of patients continue to refuse DNR orders. Physician and patient reluctance to broach the subject may be a bigger impediment than time.

Ability of Medicare claims data and cancer registries to identify cancer cases and treatment

The objective of this study is to compare the ability of Medicare and cancer registry data to identify incident cancer cases and initial surgical therapy both singly and in combination. Data from the Virginia Cancer Registry (VCR) were linked to Medicare claims files (Medical Provider Analysis and Review File (MEDPAR)) for Virginia residents aged 65 years and over with breast, colorectal, lung, or prostate cancer diagnosed between 1986 and 1989. MEDPAR found 73-83% of cancer cases identified by VCR. Factors significantly associated with MEDPAR missing a case that was reported to VCR included younger age, male gender, living in an urban area, higher social class, in situ disease, and lack of cancer treatment. A total of 70-82% of cancer cases identified through Medicare claims were reported to the VCR. Older age, female gender, nonwhite race, comorbid conditions, no surgical procedures, multiple cancer admissions, and the position of the cancer diagnostic code on the MEDPAR record were factors significantly related to being missed by the VCR. The rate of capturing initial surgical therapies was similar to that of identifying cases. Combining information from VCR and MEDPAR resulted in increasing sensitivity for identifying incident cases to 92-97%. Using combined data from independent sources may improve reporting, increase the accuracy of cancer incidence estimates, and provide an opportunity to identify reasons for missing data.

Tumor marker utility grading system: a framework to evaluate clinical utility of tumor markers

Introduction of tumor markers into routine clinical practice has been poorly controlled, with few criteria or guidelines as to how such markers should be used. We propose a Tumor Marker Utility Grading System (TMUGS) to evaluate the clinical utility of tumor markers and to establish an investigational agenda for evaluation of new tumor markers. A Tumor Marker Utility Grading Worksheet has been designed. The initial portion of this worksheet is used to clarify the precise characteristics of the marker in question. These characteristics include the marker designation, the molecule and/or substance and the relevant alteration from normalcy, the assay format and reagents, the specimen type, and the neoplastic disease for which the marker is being evaluated. To determine the clinical utility of each marker, one of several potential uses must be designated, including risk assessment, screening, differential diagnosis, prognosis, and monitoring clinical course. For each of these uses, associations between marker assay results and expected biologic process and end points must be determined. However, knowledge of tumor marker data should contribute to a decision in practice that results in a more favorable clinical outcome for the patient, including increased overall survival, increased disease-free survival, improvement in quality of life, or reduction in cost of care. Semiquantitative utility scales have been developed for each end point. The only markers recommended for use in routine clinical practice are those that are assigned utility scores of "++" or " " on a 6-point scale (ranging from 0 to ) in the categories relative to more favorable clinical outcomes. Each utility score assignment should be supported by documentation of the level of evidence used to evaluate the marker. TMUGS will establish a standardized analytic technique to evaluate clinical utility of known and future tumor markers. It should result in improved patient outcomes and more cost-efficient investigation and application of tumor markers.

Economic considerations in the care of lung cancer patients

Lung cancer has been characterized as an expensive, futile, and self-induced illness. One of the most common questions pertaining to treatment is, "Is it worth it?" In the era of health care reform, attention has been directed toward common, high-cost illnesses that may benefit from closer examination of the clinical decisions that drive costs. This review explores the economic considerations of lung cancer treatment from the perspective of the patient, society, and those at risk for the costs of care. The concept of value is proposed as a frame-work to guide how lung cancer treatments should and should not be routinely used. Cost-effectiveness studies are highlighted that do not paint as dim a view of lung cancer therapy as may have been thought. However, it is clear that the 10 billion dollars spent yearly on lung cancer might be better used by limiting expenditures to the aspects of care that produce the best outcomes. This review includes comparisons of the cost-effectiveness of lung cancer care and treatments for other common cancers. It concludes with some strategies to use resources allocated to lung cancer more effectively.

Factors that determine the treatment for local and regional prostate cancer

This article assesses the significance of comorbid and nonclinical factors in type of treatment received by elderly male patients with local-regional stage prostate cancer. Multivariate analysis of data from the Virginia Cancer Registry was linked to Medicare claim files, the Area Resource File, and 1990 Census Data. The type of initial treatment received was studied in 3117 men with local-regional staged prostate cancer diagnosed from 1985 to 1989. The frequency of surgical and radiation therapy for prostate cancer rose between 1985 and 1989 (12.5% to 18.5% for surgery, P < 0.001; 25% to 32% for radiation, P < 0.001). Age was the most important predictor of therapeutic choice; no therapy was given to 26% of men 65 to 69 years old versus 63% of men 85 years or older P < 0.001). Race, residence (rural versus urban), and comorbidity were also strong factors in predicting initial therapy. Using logistic regression, three treatment alternatives were evaluated. Age (odds ratio [OR] .51; 99% confidence interval [CI] = .43, .60), comorbidity (OR .72; 99% CI .63, .82), income (OR 1.14; 99% CI 1.01, 1.28), residence (OR .65; 99% CI .48, .87), diagnosis year (OR 1.15; 99% CI 1.07, 1.23) all were associated independently with treatment versus no treatment. For surgery versus radiation, age (OR .40; 99% CI .27, .57), race (OR 2.92; 99% CI 1.65, 5.15) and education (OR 1.75; 99% CI 1.31, 2.34) were significant factors. For hormonal/orchiectomy versus surgery/radiation, age (OR 5.19; 99% CI 3.84, 7.01), comorbidity (OR 1.28; 99% CI 1.03, 1.58), distance to radiation oncologist (OR .89; 99% CI .80, .99), and diagnosis year (OR .89; 99% CI .79, 1.00) were significant. The number of men receiving surgical and radiation treatments for prostate cancer increased between 1985 and 1989. During that period, age consistently played a significant role in all therapeutic decisions. Other factors, such as comorbidity, race, socioeconomic status, and distance, also were important considerations, depending on the treatment alternative.

Variation in staging and treatment of local and regional breast cancer in the elderly

BACKGROUND

Few studies of practice variation in the management of early breast cancer for elderly women have examined the process of care in depth. This study evaluated the effects of age and other factors on surgical staging techniques and treatment.

METHODS

Virginia cancer registry data were linked with Medicare claims and 1990 census data. The sample included all newly diagnosed patients with pathologic confirmed local and regional breast cancer in 1985-1989 (n = 3,361). Analyses included descriptive univariate statistics and multiple logistic regression analysis for staging and treatment alternatives. Process of care variables included tumor size determination, axillary lymph node dissection, use of adjuvant therapy, and radiation if breast conserving surgery (BCS) was performed.

RESULTS

About 75 percent of women had tumor size and axillary node dissection. Increasing comorbidity was associated with a lower likelihood of axillary node dissection. Nine percent of local compared to 44 percent of regional disease patients received adjuvant therapy. Hormonal therapy increased from 13 percent of women in 1985-1988 to 24 percent in 1989. Hormonal therapy did not vary with patient age. One-third of the patients with positive lymph nodes compared to 8 percent of node negative women received hormonal therapy. Blacks were more likely to present with advanced disease. A logistic regression model evaluated the multiple effects of patients and clinical characteristics: older women were more likely to present with larger tumors, were less likely to have axillary node dissections, and were less likely to receive chemotherapy or radiation.

CONCLUSIONS

Younger age was most consistently associated with staging and the use of chemotherapy in this cohort of elderly breast cancer patients. Based on the reported initial treatment plan, hormonal therapy was infrequently used and information from axillary lymph node assessment was used to stratify treatment. Although the low use of adjuvant hormonal therapy in elderly women may compromise survival, neither comorbid nor socioeconomic factors as measured in this study explained this practice pattern.

The effect of age and comorbidity in the treatment of elderly women with nonmetastatic breast cancer

BACKGROUND

Increasing age has most often been associated with less aggressive approaches to treatment of nonmetastatic breast cancer in elderly women even after controlling for stage of disease at diagnosis.

OBJECTIVE

To examine the influence of patient age on the initial treatment for breast cancer received by elderly women while controlling for the effect of patient comorbidity.

METHODS

Cancer registry records for a cohort of 2252 women aged 66 years or older who were diagnosed as having nonmetastatic, invasive breast cancer between 1984 and 1989 and identified through the Virginia Cancer Registry were linked to Medicare Provider and Reimbursement data files. Multivariate models were used to assess the effects of age and comorbidity (as measured by the International Classification of Diseases, Ninth Edition, codes recorded on Medicare claims) on initial treatment approach while adjusting for stage of disease, race, residential location, marital status, and year of diagnosis.

RESULTS

In baseline multivariable models, age was negatively associated with any surgical treatment, non-breast-conserving procedures, and radiotherapy following breast-conserving surgery. The odds of women aged 85 years and older receiving surgery were less than one third those of women aged 66 to 74 years (odds ratio, 0.31; 95% confidence interval, 0.16 to 0.60), while odds ratios across the same two age groups for nonbreast-conserving surgery and adjuvant radiotherapy were 0.55 (95% confidence interval, 33 to 92) and 0.03 (confidence interval, 0.01 to 0.13), respectively. With additional adjustment for aggregate comorbidity, odds ratio estimates in these same age-group comparisons were virtually unchanged at 0.31, 0.56, and 0.04.

CONCLUSION

Aggregate comorbidity measured by inpatient International Classification of Diseases, Ninth Edition, codes on Medicare inpatient hospital claims does not explain age-related patterns in the initial treatment of elderly patients with breast cancer.

Trade-offs between survival and breast preservation for three initial treatments of ductal carcinoma-in-situ of the breast

PURPOSE

To assess the trade-offs between survival and breast preservation of currently accepted approaches for ductal carcinoma-in-situ (DCIS) of the breast.

PATIENTS AND METHODS

Decision analysis was performed using the Markov model of hypothetical cohorts of 55-year-old white women with nonpalpable mammographic abnormalities found to be DCIS. Strategies were breast-conserving surgery (BCS), BCS with 50-Gy radiation (RT) or initial mastectomy. Recurrence rates were derived from the published literature. Main outcomes were overall, breast cancer-free, and event-free survival plus years of both breasts preserved.

RESULTS

Using the conditions defined in this model, the actuarial survival rates at 10 and 20 years were 91.7% and 74.1% for the initial mastectomy strategy, 91.0% and 72.1% for BCS plus RT, and 89.6% and 68.2% for BCS alone. At 20 years, the initial mastectomy strategy also had a greater breast cancer-free survival rate of 74.5%, compared with 63.3% for BCS plus RT, or 46.8% for BCS alone. However, BCS alone had the highest survival rate with both breasts preserved (64.2%) compared with BCS plus RT (56.0%) or initial mastectomy (0%). Of the breast-conserving strategies at 20 years, the breast event-free survival rate (no invasive cancer or DCIS) was greater for BCS plus RT (47.2%) compared with BCS alone (28.4%). Using just survival as the primary end point, mastectomy is the optimal strategy by a small margin. However, if quality-adjusted survival is at issue, mastectomy is the choice only if the yearly reduction in quality of life due to mastectomy is less than 1%.

CONCLUSION

BCS with or without radiation compared with mastectomy as initial management of DCIS of the breast trades a slight decrease in survival rates for the value of breast preservation. This model should aid clinicians in matching treatments to their patients' preferences.

Differences in initial treatment patterns and outcomes of lung cancer in the elderly

BACKGROUND

Non-small cell lung cancer (NSCLC) accounts for substantial deaths and costs in the elderly greater than 65 years old. The current practice of NSCLC treatment in a Medicare population was examined to ascertain important areas of practice variation, and differences in clinical outcome and costs.

METHODS

Data from incident cases of NSCLC from the Virginia Cancer Registry (VCR), 1985-89, were matched with claims from Medicare Part A and B, census tract data and the Area Resource File. Multivariate models were created to include clinical data, demographics, and access information.

RESULTS

For patients with locoregional disease, increasing age was associated with lower likelihood of therapy (odds ratio (OR) 0.35; confidence intervals (CI) 0.29, 0.43), thoracotomy (OR 0.27; CI 0.21, 0.34), and more use of radiation therapy compared to surgery (OR 1.69; CI 1.39, 2.03). Low education levels were associated with less likelihood of treatment (OR 0.78; CI 0.66, 0.94), or radiation instead of surgery (OR 1.22; CI 1.05, 1.47). Patients in urban areas were less likely to receive therapy (OR 0.67; CI 0.49, 0.92). For distant disease, increasing age was also associated with lower likelihood of treatment (OR 0.48; CI 0.41, 0.56), as was increasing co-morbidity (OR 0.84; CI 0.75, 0.93). Distance to radiation oncologists made no difference in radiotherapy utilization. Two year survival according to therapy was surgery 66%, radiation 15%, no therapy 17%.

CONCLUSIONS

Patterns of care, and survival according to therapy, vary widely for elderly NSCLC patients. Age, low education, higher co-morbidity and urban residence all decrease the likelihood of surgical therapy for locoregional NSCLC. Despite the availability of coverage through the Medicare program, use of therapies and survival is not uniform for all beneficiaries. Possible discrimination by age, co-morbid illnesses not recorded in the Medicare files, or patient and provider choice could all be involved; administrative billing files cannot resolve these important differences.

Cost-effective use of autologous bone marrow transplantation: few answers, many questions, and suggestions for future assessments

High dose chemotherapy with the support of autologous bone marrow transplantation (ABMT) or peripheral blood progenitor cells (PBPC) has been increasingly used in a variety of haematological and epithelial cancers over the last decade. The rationale of this approach is to overcome the chemotherapy resistance of tumour cells by increasing the dose of cytotoxic drugs. However, the clinical benefit of dose-intensification has been difficult to prove. Almost all studies of ABMT have been done without randomised comparisons with the standard form of therapy for a specific condition. From an economic perspective, the cost of ABMT has been steadily decreasing with improvements in supportive care primarily. Still, current ABMT cost estimates range from $US70 000 to $US150 000 for each uncomplicated procedure. Despite the lack of compelling evidence in support of dose-intensification, ABMT has become a default standard of care after relapse for many patients with lymphoma or leukaemia. We used a decision analysis model to estimate the cost effectiveness of the timing of ABMT in relapsed Hodgkin's disease. The model illustrates the difficulty of using available clinical trial data when follow-up of promising early reports is not available. The model showed that in most situations the optimal strategy is ABMT in second relapse despite growing consensus that immediate ABMT is the treatment of choice. ABMT for women with high-risk or early metastatic breast cancer is one of the most controversial areas in clinical oncology. In the US, several ongoing major randomised trials are addressing the role of ABMT in breast cancer. Using a Markov process we found that ABMT is the preferred strategy under almost all assumptions. The size of the benefit and cost effectiveness of ABMT varied markedly depending on the assumptions made. The model does not supplant the need for randomised trials that concurrently measure efficacy, quality of life, and resource utilisation. However, such analyses point out the critical areas where costs could be cut substantially without effecting efficacy. Drawing conclusions about the cost effectiveness of ABMT for all conditions is hampered by the lack of randomised comparisons of efficacy. Concurrent economic appraisals of selected phase III comparative trials should be considered since the supportive care costs associated with ABMT appear to be stabilising. However, the most important point is that randomised trials are the only mechanism for estimating the therapeutic effect of high dose chemotherapy.

Demodex cricetuli: new species of hair follicle mite (Acari: Demodecidae) from the Armenian hamster, Cricetulus migratorius (Rodentia: Cricetidae)

Demodex cricetuli sp. nov. is described, in all life stages, from the Armenian hamster, Cricetulus migratorius. This demodecid inhabits the hair follicles of all body regions of the host. Heavy infestations are associated with dermatitis and alopecia. Demodex cricetuli is most similar to D. aurati, from the Golden hamster, but adults differ in podosomal length, shape of the opisthosomal terminus, genital opening and opisthosomal organ of the male, and overall length-to-width ratios.

Should the elderly receive chemotherapy for node-negative breast cancer? A cost-effectiveness analysis examining total and active life-expectancy outcomes

PURPOSE

This study determines the survival benefit and cost-effectiveness of adjuvant chemotherapy in elderly women with breast cancer. In addition, the analysis measures the impact of substituting active life expectancy for survival in the clinical decision.

PATIENTS AND METHODS

Two cohorts of women with estrogen receptor (ER)-negative, stage I breast cancer from age 60 to 80 years were monitored using a Markov process. One group received standard chemotherapy following primary therapy, and the other had no postoperative treatment. Data were derived from recently published clinical trials and a major meta-analysis. Outcome included the average survival, active life-expectancy, and incremental cost/quality-adjusted life-year (cost/QALY).

RESULTS

Adjuvant chemotherapy prolongs survival in older women, but to a lesser extent compared with younger women. The average gain in quality-adjusted months was 1.8 months in a 75-year-old cohort at a cost/QALY of $4,400. These small benefits were not substantially altered when univariate changes were made in toxicity, recurrence risk, or effectiveness of chemotherapy. When active life expectancy replaced survival as an end point, the benefit for 75-year-old women decreased to 2 weeks at a cost of more than $96,000/QALY.

CONCLUSION

There is a small survival benefit for adjuvant chemotherapy in elderly patients. The cost of this benefit is high, but within the range of commonly reimbursed procedures until a point between 75 and 80 years old. The use of active life expectancy as the primary outcome reduces the benefit and adds to the cost. If physicians and policymakers agree that active life expectancy is a relevant outcome, withholding chemotherapy for patients > or = 70 years old is a reasonable approach.

Principles of cost effectiveness analysis for the assessment of current and new therapies

Economic issues have a prominent place in the debate about reforming the U.S. health care system. If more rational allocations of health care resources are to occur, the principles of decision analysis and clinical economics will need to be understood and used to assess current and new technologies. This requires an explicit assessment of the costs and benefits of a health care intervention, defining the current standard intervention, and clarifying the perspective of the assessment (societal, patient, payer, or provider). Detailed cost accounting of resources is optimal in contrast to costs or charges. These principles were included in 1992 proposed Canadian guidelines for using economic evaluations for adoption of new technologies. Such guidelines provide further impetus for the economic assessment of phase III clinical trials. When applied to peripheral blood progenitor cells, future studies should assess the incremental benefits of the strategy using the progenitor cells, not just the cost savings compared to traditional autologous bone marrow transplantation.

Assessing the cost effectiveness of adjuvant therapies in early breast cancer using a decision analysis model

BACKGROUND

We have developed a decision analysis model that uses the results of available randomized controlled trials to model the natural history of early breast cancer and assess the potential clinical and financial effects of using adjuvant therapies.

PATIENTS AND METHODS

The original model was used to assess the impact of chemotherapy in hypothetical groups of 45-year-old and 60-year-old node-negative, estrogen receptor-negative women. Using the 1992 Early Breast Cancer Trialists' Collaborative Group report, we have expanded and revised the model to assess: 1) the role of tamoxifen alone, chemotherapy alone, or combined therapy in pre-menopausal women, and 2) chemotherapy in elderly women with node-negative, estrogen receptor-negative cancer.

RESULTS

For pre-menopausal women, we found that chemotherapy increases quality adjusted life expectancy and survival by a substantial amount at a cost less than most accepted medical interventions. Combined therapy is beneficial and cost-effective in estrogen receptor-positive cancer. For the elderly, chemotherapy prolongs survival but to a lesser extent compared to younger women. The cost of this benefit is high but within the range of commonly reimbursed procedures for women under age 75 without other co-existing conditions.

CONCLUSIONS

For most patients some form of adjuvant therapy is beneficial and cost-effective. The model builds upon the data derived from collaborative efforts assessing the effectiveness of adjuvant therapies. The model highlights the need for an equal commitment to assessing the economic and quality of life impacts of breast cancer treatments.

Efficacy and cost-effectiveness of autologous bone marrow transplantation in metastatic breast cancer. Estimates using decision analysis while awaiting clinical trial results

OBJECTIVE

To assess the efficacy and cost-effectiveness of standard chemotherapy and high-dose chemotherapy with autologous bone marrow transplantation (ABMT) in metastatic breast cancer.

DESIGN

Decision analysis model using a Markov process.

SETTING

Response and recurrence rates from the published literature for standard therapy and from case series of ABMT. Costs were based on local charges and on adjusted Medicare data.

PATIENTS

Hypothetical cohorts of women with metastatic breast cancer who had no bone marrow involvement and no comorbid illness.

INTERVENTION

The standard chemotherapy cohort received cyclophosphamide, doxorubicin, and fluorouracil. The ABMT cohort was treated with intense induction chemotherapy, then additional high-dose chemotherapy following a remission, with ABMT support.

MAIN OUTCOME MEASURES

Anticipated survival, incremental cost per year of life, and incremental cost per quality-adjusted year of life gained using a 5-year time horizon. Rigorous sensitivity analyses were done, including assessing a benefit "tail" of normal life expectancy for those free of disease after 5 years.

RESULTS

ABMT was the preferred approach under almost all assumptions, but the size of the benefit varied greatly. ABMT had a survival benefit of 6.0 months at 5 years at an incremental cost of $115,800 per year of life saved. If patients who were free of disease after 5 years had normal survival, the benefit was 18.1 months at an incremental cost of $28,600 per year. The benefit of ABMT was primarily dependent on whether the recurrence risk was constant or decreases after a finite period of time.

CONCLUSION

Using reasonable assumptions, ABMT provided a substantial benefit but at a cost that may be untenable. Decision analysis highlights the limitations in the currently available data and the assumptions made for the emotional question of using ABMT in metastatic breast cancer. The model supports the need for randomized clinical trials.

The optimal timing of autologous bone marrow transplantation in Hodgkin's disease patients after a chemotherapy relapse

PURPOSE

The optimal sequence of salvage chemotherapy (SC) and autologous bone marrow transplantation (ABMT) for Hodgkin's disease (HD) patients who relapse after primary chemotherapy is unknown. We created a decision analysis model to determine the optimal treatment strategy and the most cost-effective approach.

METHODS

The decision tree simulated a 25-year-old HD patient who relapsed less than 12 months after mechlorethamine, vincristine, procarbazine, and prednisone (MOPP) chemotherapy. Four strategies used ABMT in some sequence with SC; the final strategy considered SC alone. Clinical data were derived from 17 published reports chosen by explicit criteria. Costs of care were estimated from the published literature and institutional experience.

RESULTS

The optimal strategy was ABMT in second relapse, which was superior to the SC-only option by 1.9 years at an incremental cost of $26,200 per each year of life saved. When the probabilities of complete remission and disease-free survival were reduced for SC, similar to the clinical expectation of SC after a seven- or eight-drug regimen like MOPP/doxorubicin, bleomycin, and vinblastine with or without dacarbazine (MOPP/ABV[D]), ABMT in first relapse was the preferred strategy and provided 6 additional months. However, when the data from favorable (or unfavorable) SC and ABMT reports were compared head-to-head in this model, SC followed by ABMT in second relapse was always optimal.

CONCLUSIONS

All relapsed HD patients should plan to use ABMT in some sequence with SC, if necessary. In most situations the optimal strategy is ABMT in second relapse. This analysis will assist clinicians in planning treatment for relapsed HD patients. It could be refined if historical series were updated to report the incidence and outcomes of SC relapse from seven- or eight-drug regimens.

Neutropenia-wise and pound-foolish: safe and effective chemotherapy in massively obese patients

The massively obese patients had an increased risk of cancer and complications from therapy. Chemotherapy in massively obese patients may be complicated by difficulty in calculating body surface area. No guidelines exist for calculating doses by either actual or ideal weight, and the calculated doses may vary by as much as 25%. The pharmacokinetics of antineoplastic drugs in obese patients are poorly understood and are not sufficient to create standards for rational dosing. We propose that patients being treated with curative intent receive full-dose intensity, using body surface area calculated on actual body weight or on ideal body weight with dose escalations if tolerated. Patients who are treated for short-term palliation may be more safely given doses based on ideal body weight.

Fine-needle aspiration cytology of an unusual primary lung tumor, chondrosarcoma: case report

A case of primary chondrosarcoma of the lung diagnosed by fine-needle aspiration biopsy (FNAB) cytology in a 78-yr-old male is presented. A mass detected on chest x-ray and defined by CT scan was subjected to a preoperative percutaneous fine-needle aspiration under fluoroscopic guidance. The distinctive cytologic features of pleomorphic cells nestled in lacunae surrounded by a chondromyxoid background resulted in a diagnosis of chondrosarcoma. The left upper lobectomy specimen confirmed the FNAB diagnosis and identified the tumor as arising from the left upper lobe bronchus.

Tumor necrosis factor-alpha exhibits greater proinflammatory activity than lymphotoxin in vitro

Tumor necrosis factor-alpha/cachectin (TNF-alpha) and lymphotoxin (LT, TNF-beta) are primarily products of monocytes and lymphocytes, respectively. The proteins are 51% homologous in their primary structure, cause necrosis of Meth A sarcoma in vivo, are toxic to selected tumor cells in vitro, and bind to the same receptor on cells in vitro. However, some recent studies have indicated both qualitative and quantitative differences between recombinant human (rh) LT and rhTNF with respect to inducing human umbilical vein endothelial cell (HEC) adhesiveness for neutrophils and release of hematopoietic growth factor and interleukin-1 (IL-1) from HEC. The rhLT used in these studies was expressed in bacteria and was consequently not glycosylated, whereas natural LT is glycosylated. Therefore, we have compared various preparations of glycosylated and nonglycosylated rhLT with two preparations of rhTNF with respect to their proinflammatory characteristics. We now report that the same LT cDNA, when expressed in mammalian cell line and appropriately glycosylated, is also markedly less potent than rhTNF on a molar basis in inducing endothelial adhesiveness for neutrophils and in directly activating neutrophil adherence to albumin-coated plastic. All recombinant proteins, however, were equipotent on a molar basis in producing cytotoxicity in L929 cells. We conclude that differences in the primary structure of rhTNF and rhLT, rather than alterations induced by prokaryote protein processing, account for the disparate proinflammatory activity in vitro.

Antilipopolysaccharide factor from horseshoe crab, Tachypleus tridentatus, inhibits lipopolysaccharide activation of cultured human endothelial cells

Antilipopolysaccharide (anti-LPS) factor is a basic protein that is purified from the hemocyte lysate of the Japanese and American horseshoe crabs (Tachypleus tridentatus and Limulus polyphemus). Anti-LPS factor has previously been reported to inhibit LPS-mediated activation of limulus factor C, lyse endotoxin-sensitized erythrocytes, and inhibit the growth of some gram-negative bacteria. In this study, we examine the ability of anti-LPS factor purified from T. tridentatus to inhibit the activation of cultured human endothelial cells by LPS. Anti-LPS factor inhibited the stimulation of endothelial adhesiveness for neutrophils by LPS in a dose-dependent manner. Maximum inhibition was achieved when anti-LPS factor was mixed with LPS prior to addition to the endothelial cell monolayers. Anti-LPS factor inhibited endothelial cell activation by LPS derived from Salmonella minnesota Re and Rc mutants as well as from the wild type (smooth), suggesting that it recognizes the lipid A moiety of LPS.

Parathyroid hyperplasia and carcinoma within one gland

A 47-year-old Scottish woman vacationing in the United States presented with a serum calcium level greater than 20 mg/dl and a parathyroid hormone level 16 times greater than normal after a one-week history of severe vomiting and unrelenting abdominal pain. Surgical exploration of the thymus revealed the very rare association of a large (7 by 4 by 0.8 cm) parathyroid carcinoma adjacent to apparently normal parathyroid tissue, separated by a thin fibrous band. Two other hyperplastic and one normal parathyroid glands were also identified. Postoperatively, the patient became hypocalcemic and, for the past nine months, has received maintenance 1-alpha-hydroxycholecalciferol therapy (1 microgram per day) with normal calcium and barely detectable parathyroid hormone levels.

Prazosin and hydralazine in congestive heart failure. Regional hemodynamic effects in relation to dose

Central hemodynamic variables and regional blood flow and vascular resistances were ascertained in patients with severe congestive heart failure before and after the oral administration of prazosin hydrochloride or hydralazine. Prazosin was administered in doses of 2, 5, and 10 mg and hydralazine, 75 and 100 mg. Although both agents significantly increased cardiac output and decreased vascular resistances, their effects on regional blood flow and vascular resistances were considerably different. Prazosin increased hepatic blood flow and reduced hepatic vascular resistance at lower doses; these changes decreased as prazosin was increased. Hydralazine did not significantly alter mean hepatic blood flow or vascular resistance. Prazosin did not affect renal blood flow or renal vascular resistance. In contrast, hydralazine significantly increased renal blood flow and reduced vascular resistance; the changes were dose related. Both drugs augmented limb blood flow and diminished limb vascular resistance; the magnitude of change was dose dependent.

Hydralazine and isosorbide dinitrate: comparative central and regional hemodynamic effects when administered alone or in combination

Central and regional hemodynamic studies were performed before and after the oral administration of 75 mg of hydralazine and/or 20 mg of isosorbide dinitrate in 15 patients with low-output congestive heart failure. Hydralazine increased mean cardiac output 17-25%, mean renal blood flow 19%, and limb blood flow 17% (all p < 0.05). Mean hepatic blood flow did not change significantly with hydralazine. Except for a small increase in cardiac output (6%, p < 0.05) at 30 minutes, isosorbide dinitrate did not significantly alter central, renal, hepatic or limb blood flow. Combining isosorbide dinitrate and hydralazine effected similar increases in cardiac output (17-24%, p < 0.05), renal (17%, p < 0.05) and limb (20%, p < 0.05) blood flow as those elicited by hydralazine alone. The combination did not significantly alter mean hepatic blood flow. Hydralazine, alone or combined with isosorbide dinitrate, increases renal and limb blood flow in congestive heart failure in proportion to the augmented cardiac output; isosorbide dinitrate alone does not alter blood flow to these regions. Neither drug (or combination) changes hepatic blood flow in this clinical setting.