Global survival trends for brain tumors, by histology: analysis of individual records for 556,237 adults diagnosed in 59 countries during 2000-2014 (CONCORD-3)

BACKGROUND

Survival is a key metric of the effectiveness of a health system in managing cancer. We set out to provide a comprehensive examination of worldwide variation and trends in survival from brain tumors in adults, by histology.

METHODS

We analyzed individual data for adults (15-99 years) diagnosed with a brain tumor (ICD-O-3 topography code C71) during 2000-2014, regardless of tumor behavior. Data underwent a 3-phase quality control as part of CONCORD-3. We estimated net survival for 11 histology groups, using the unbiased nonparametric Pohar Perme estimator.

RESULTS

The study included 556,237 adults. In 2010-2014, the global range in age-standardized 5-year net survival for the most common sub-types was broad: in the range 20%-38% for diffuse and anaplastic astrocytoma, from 4% to 17% for glioblastoma, and between 32% and 69% for oligodendroglioma. For patients with glioblastoma, the largest gains in survival occurred between 2000-2004 and 2005-2009. These improvements were more noticeable among adults diagnosed aged 40-70 years than among younger adults.

CONCLUSIONS

To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors by histology in adults. We have highlighted remarkable gains in 5-year survival from glioblastoma since 2005, providing large-scale empirical evidence on the uptake of chemoradiation at population level. Worldwide, survival improvements have been extensive, but some countries still lag behind. Our findings may help clinicians involved in national and international tumor pathway boards to promote initiatives aimed at more extensive implementation of clinical guidelines.

Improved detection and management of advanced HIV disease through a community adult TB-contact tracing intervention with same-day provision of the WHO-recommended package of care including ART initiation in a rural district of Mozambique

INTRODUCTION

AIDS-mortality remains unacceptably high in sub-Saharan Africa, largely driven by advanced HIV disease (AHD). We nested a study in an existing tuberculosis (TB) contact-tracing intervention (Xpatial-TB). The aim was to assess the burden of AHD among high-risk people living with HIV (PLHIV) identified and to evaluate the provision of the WHO-recommended package of care to this population.

METHODS

All PLHIV ≥14 years old identified between June and December 2018 in Manhiça District by Xpatial-TB were offered to participate in the study if ART naïve or had suboptimal ART adherence. Consenting individuals were screened for AHD. Patients with AHD (CD4 < 200 cells/μL or WHO stage 3 or 4) were offered a package of interventions in a single visit, including testing for cryptococcal antigen (CrAg) and TB-lipoarabinomannan (TB-LAM), prophylaxis and treatment for opportunistic infections, adherence support or accelerated ART initiation. We collected information on follow-up visits carried out under routine programmatic conditions for six months.

RESULTS

A total of 2881 adults were identified in the Xpatial TB-contact intervention. Overall, 23% (673/2881) were HIV positive, including 351 TB index (64.2%) and 322 TB contacts (13.8%). Overall, 159/673 PLHIV (24%) were ART naïve or had suboptimal ART adherence, of whom 155 (97%, 124 TB index and 31 TB-contacts) consented to the study and were screened for AHD. Seventy percent of TB index-patients (87/124) and 16% of TB contacts (5/31) had CD4 < 200 cells/µL. Four (13%) of the TB contacts had TB, giving an overall AHD prevalence among TB contacts of 29% (9/31). Serum-CrAg was positive in 4.6% (4/87) of TB-index patients and in zero TB contacts. All ART naïve TB contacts without TB initiated ART within 48 hours of HIV diagnosis. Among TB cases, ART timing was tailored to the presence of TB and cryptococcosis. Six-month mortality was 21% among TB-index cases and zero in TB contacts.

CONCLUSIONS

A TB contact-tracing outreach intervention identified undiagnosed HIV and AHD in TB patients and their contacts, undiagnosed cryptococcosis among TB patients, and resulted in an adequate provision of the WHO-recommended package of care in this rural Mozambican population. Same-day and accelerated ART initiation was feasible and safe in this population including among those with AHD.

Outcomes of Reflex Cryptococcal Antigen (CrAg) Screening in Human Immunodeficiency Virus (HIV)-Positive Patients With CD4 Counts of 100-200 Cells/µL in Botswana

Increasing the CD4-count threshold for cryptococcal antigen (CrAg) screening from ≤100 to ≤200 cells/µL resulted in a 3-fold increase in numbers screened. CrAg-prevalence was 3.5% at CD4 101-200 and 6.2% ≤100 cells/µL. Six-month mortality was 21.4% (9/42) in CrAg-positive CD4 ≤100 cells/µL and 3.2% (1/31) in CrAg-positive CD4 101-200 cells/µL.

Observational study of pre-operative intravenous iron given to anaemic patients before elective cardiac surgery

Cardiac surgical patients with anaemia experience increased morbidity and mortality. Iron deficiency is the most common cause of pre-operative anaemia in this group. We designed and implemented the Cardiff Pathway, a pre-assessment and treatment pathway to identify cardiac surgical patients with anaemia and iron deficiency. Patients identified with anaemia and/or iron deficiency (Hb < 130 g.l^-1 and ferritin < 100 μg.l^-1 ) were offered intravenous iron infusion 20 mg.kg^-1 pre-operatively. Treatment success was defined as Hb ≥ 130g.l^-1 on the day of surgery. We analysed data from 447 patients: 300 (67%) were not anaemic; 75 (17%) were anaemic and treated with intravenous iron; and 72 (16%) were anaemic and not treated. Haemoglobin concentration increased in successfully treated anaemic patients by a mean (95%CI) of 17 (13-21) g.l^-1 and they received a median (IQR [range]) of 0 (0-2 [0-15]) units of blood peri-operatively. Transfusion was avoided in 54% of the successfully treated anaemic patients, which was significantly more than the unsuccessfully treated anaemic (22%, p = 0.005) and untreated anaemic (28%, p = 0.018) patients and similar to non-anaemic patients who received a median (IQR [range] of 0 (0-1 [0-16])) units of blood and, 63% avoided transfusion). Mean (95%CI) Hb fell between pre-assessment and surgery in the untreated anaemic (-2 (0 to -4) g.l^-1 ) and non-anaemic groups (-2 (-1 to -3) g.l^-1 ). Twenty-one (7%) of the non-anaemic group became newly anaemic waiting for surgery. The Cardiff Pathway reliably identified patients with anaemia and iron deficiency. Anaemic patients who had their Hb restored to normal after treatment required less blood peri-operatively and over half of them required no transfusion at all.

An in vitro investigation of the survival and/or growth of Campylobacter jejuni in broiler digestate from different feed types

Campylobacter spp. is the leading cause of bacterial gastroenteritis worldwide and poultry are the primary reservoir. The aim of this study was to investigate the survival and/or growth of Campylobacter jejuni NCTC 11168 in broiler digestate prepared from commercial starter, grower and finisher feed formulations. Bolton broth and digestates were prepared, inoculated with C. jejuni NCTC 11168 (approximately 3 log₁₀ CFU per ml) and incubated under microaerobic conditions at 42°C for 24 h. Samples were taken at t = 0 (immediately after inoculation) and every 3 h thereafter, serially diluted and plated onto mCCDA. Campylobacter jejuni grew as expected in Bolton broth (control) reaching the early stationary phase after approximately 15 h. In contrast, although bacterial concentrations were maintained for at least 9 h, none of the feed digestates supported the growth of C. jejuni, which were not detected after 15 h. It is suggested that the nutrients available in the feed digestates are not enough to support C. jejuni growth and that additional factors may be at play in the avian gastrointestinal tract.

Abstract P5-04-11: Non-canonical, clinical ESR1 mutations promote resistance to antiestrogen therapies

ESR1 hotspot mutations have been identified in 30-40% of patients with ER+ MBC and promote resistance to aromatase inhibitors (AIs). Identification of these mutations has been aided by the use of plasma DNA for their detection, however many such tests only survey for hotspot mutations. In this study, we examined the prevalence, biologic and clinical significance of mutations in ESR1 that lie outside previously described hotspots (E380Q, Y537, D538G). Using next generation sequencing of tumor DNA from over 4000 patients with breast cancer, we have identified numerous somatic alterations in ESR1. Among the somatic alterations were mutations detected in the transcription activation function-1 (AF-1), DNA binding domain, dimerization interface and C-terminus of ER.

We characterized the functional significance of these non-canonical mutations alongside hotspot mutations, starting with assays of ER driven transcription and deduced several classes of mutations: (1) mutations that weakly promote ligand-independent activity, (2) mutations that led to ligand-independent activity comparable to estradiol stimulation, and (3) mutations that resulted in impaired transcriptional activity. Class 2 mutations remain localized at amino acids 536-538, while the class 1 mutations are observed in various domains of ESR1, including the DNA binding domain and dimerization interface. Several Class 3 mutations were found in proximal to Helix 12, highlighting the critical role of this region.

Clinically, non-canonical mutations were not exclusively observed among patients treated with AI, as there were several mutations from SERM/SERD treated patients. We thus examined the effects of different mutants on their sensitivity to ER antagonists, such as fulvestrant or tamoxifen. The data revealed key differences between the different classes of mutants; with majority of the class 2 mutants exhibiting reduced sensitivity to the antagonists compared to wild type. This also correlated with the relative binding affinities (RBA) of the mutants to fulvestrant and 4-hydroxytamoxifen, in which the RBA of class 2 mutants (Y537S and D538G) were significantly lower than wild type, perhaps accounting for their reduced sensitivities. Nevertheless, it appeared that all mutants could be effectively inhibited either by higher concentrations or more potent ER antagonists, implying a continued ability to distort ER into the antagonist conformation. Interestingly, several Class 1 mutants showed weak agonism in response to specific antagonists raising the possibility of their role in SERM/SERD resistance. Taken together, the data demonstrated that not all ESR1 mutations affect receptor function or respond to antiestrogen therapies similarly. These data also imply the importance of more broad sequencing coverage of ESR1 in the clinic to effectively capture the spectrum of biologically relevant alleles.

Citation Format: Toy W, Carlson KE, Martin TA, Razavi P, Berger M, Baselga J, Greene G, Katzenellenbogen J, Chandarlapaty S. Non-canonical, clinical ESR1 mutations promote resistance to antiestrogen therapies [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-04-11.

Path Analysis of Campus Walkability/Bikeability and College Students' Physical Activity Attitudes, Behaviors, and Body Mass Index

PURPOSE

The purpose of this study was to assess the relationship between the walkability/bikeability of college campuses and students' body mass index (BMI) with student physical activity (PA) attitudes and behaviors as potential mediators.

DESIGN

Cross-sectional.

SETTING

Thirteen university campuses.

PARTICIPANTS

A total of 1384 student participants.

MEASURES

Walkability/bikeability environmental score (ES): 12-item audit assessed an average of 44 path segments per campus. Students were measured for height and weight and completed online surveys. Physical activity stage of change/behavior intentions were assessed using the transtheoretical model. The Cognitive Behavioral Physical Activity Questionnaire assessed outcome expectations, self-regulation, and personal barriers. International Physical Activity Questionnaire assessed walking-, moderate-, and vigorous-intensity PA.

ANALYSIS

Descriptive statistics, zero-order correlations, and path analysis with maximum likelihood estimation.

RESULTS

The overall model fit was good with χ² of 171.388 ( df = 18), P < .001, comparative fit index value of .95, and a root mean square of approximation of .079. After controlling for gender, there was a direct negative association between walkability/bikeability ES and BMI (β = -.085) and positive association between personal barriers and BMI (β = .134). Walkability/bikeability ES was positively associated with walking-intensity PA (β = .010). Self-regulation was positively associated with moderate-intensity PA (β = .213), which, in turn, was negatively associated with BMI (β = -.057).

CONCLUSIONS

The ease of walking and biking on a campus was related to college students' walking behavior and their BMI. Students' PA behavioral intentions were associated with moderate PA and lower BMI. These results provide evidence to focus on policies and structural supports for walkable/bikeable environments to supplement and enhance interventions encouraging individual behavior change for PA and weight management.

Understanding doctors' attitudes towards self-disclosure of mental ill health

BACKGROUND

Understanding of doctors' attitudes towards disclosing their own mental illness has improved but assumptions are still made.

AIMS

To investigate doctors' attitudes to disclosing mental illness and the obstacles and enablers to seeking support.

METHODS

An anonymous, UK-wide online survey of doctors with and without a history of mental illness. The main outcome measure was likelihood of workplace disclosure of mental illness.

RESULTS

In total, 1954 doctors responded and 60% had experienced mental illness. There was a discrepancy between how doctors think they might behave and how they actually behaved when experiencing mental illness. Younger doctors were least likely to disclose, as were trainees. There were multiple obstacles which varied across age and training grade.

CONCLUSIONS

For all doctors, regardless of role, this study found that what they think they would do is different to what they actually do when they become unwell. Trainees, staff and associate speciality doctors and locums appeared most vulnerable, being reluctant to disclose mental ill health. Doctors continued to have concerns about disclosure and a lack of care pathways was evident. Concerns about being labelled, confidentiality and not understanding the support structures available were identified as key obstacles to disclosure. Addressing obstacles and enablers is imperative to shape future interventions.

Geospatial distribution and clustering of Chlamydia trachomatis in communities undergoing mass azithromycin treatment

PURPOSE

We detected spatial clustering of households with Chlamydia trachomatis infection (CI) and active trachoma (AT) in villages undergoing mass treatment with azithromycin (MDA) over time.

METHODS

We obtained global positioning system (GPS) coordinates for all households in four villages in Kongwa District, Tanzania. Every 6 months for a period of 42 months, our team examined all children under 10 for AT, and tested for CI with ocular swabbing and Amplicor. Villages underwent four rounds of annual MDA. We classified households as having ≥1 child with CI (or AT) or having 0 children with CI (or AT). We calculated the difference in the K function between households with and without CI or AT to detect clustering at each time point.

RESULTS

Between 918 and 991 households were included over the 42 months of this analysis. At baseline, 306 households (32.59%) had ≥1 child with CI, which declined to 73 households (7.50%) at 42 months. We observed borderline clustering of households with CI at 12 months after one round of MDA and statistically significant clustering with growing cluster sizes between 18 and 24 months after two rounds of MDA. Clusters diminished in size at 30 months after 3 rounds of MDA. Active trachoma did not cluster at any time point.

CONCLUSIONS

This study demonstrates that CI clusters after multiple rounds of MDA. Clusters of infection may increase in size if the annual antibiotic pressure is removed. The absence of growth after the three rounds suggests the start of control of transmission.

Comparison of diet quality, physical activity and biochemical values of older adults either reporting or not reporting use of lipid-lowering medication

OBJECTIVES

The aim of this study was to compare standard lipid profile, reported dietary intake, and physical activity in older adults who reported taking or not taking a lipid-lowering medication, namely statins.

DESIGN

Cross-sectional study utilizing baseline data collected from a subsample of a larger randomized clinical trial, The Study of Exercise and Nutrition in Older Rhode Islanders (SENIOR) Project.

PARTICIPANTS AND SETTING

A total of 115 participants, 33 males and 82 females, over the age of 60, community-dwelling, primarily retired, and from East Providence, Rhode Island and surrounding communities in Rhode Island and Massachusetts.

MEASUREMENTS

Height and weight were measured and used to calculate body mass index. Waist circumference was measured. Medical history and medication use surveys were completed. Dietary assessment was done via three 24 hour recalls using NDS-R. The Yale Physical Activity Survey was used to determine energy expenditure during exercise and a physical activity summary score. Fasting blood samples were obtained to determine lipid profile.

RESULTS

37 participants (32.2%) reported taking lipid-lowering medication, statins exclusively, and 78 (67.8%) reported not taking any lipid-lowering medication. Participants who reported taking statins had better lipid profiles than those participants who reported not taking statins but had significantly lower intakes of vitamin B12, vitamin K, calcium, and potassium. There were no differences between groups on reported physical activity. However, the mean intakes for both groups did not meet the Dietary Reference Intakes for multiple nutrients.

CONCLUSION

Older adults need additional education on the importance of lifestyle changes in reducing CHD risk, whether taking lipid-lowering medications or not.

Excitability in a quantum dot semiconductor laser with optical injection

We experimentally analyze the dynamics of a quantum dot semiconductor laser operating under optical injection. We observe the appearance of single- and double-pulse excitability at one boundary of the locking region. Theoretical considerations show that these pulses are related to a saddle-node bifurcation on a limit cycle as in the Adler equation. The double pulses are related to a period-doubling bifurcation and occur on the same homoclinic curve as the single pulses.

A comparison between three electronic media and in-person learning for continuing education in physical rehabilitation

We produced continuing education material in physical rehabilitation using a variety of electronic media. We compared four methods of delivering the learning modules: in person with a computer projector, desktop videoconferencing, Web pages and CD-ROM. Health-care workers at eight community hospitals and two nursing homes were asked to participate in the project. A total of 394 questionnaires were received for all modalities: 73 for in-person sessions, 50 for desktop conferencing, 227 for Web pages and 44 for CD-ROM. This represents a 100% response rate from the in-person, desktop conferencing and CD-ROM groups; the response rate for the Web group is unknown, since the questionnaires were completed online. Almost all participants found the modules to be helpful in their work. The CD-ROM group gave significantly higher ratings than the Web page group, although all four learning modalities received high ratings. A combination of all four modalities would be required to provide the best possible learning opportunity.

Continuing education in physical rehabilitation using Internet-based modules

A rehabilitation outreach team created evidence-based and peer-reviewed educational modules using standard desktop presentation software. Eighteen modules on various topics in physical rehabilitation were published in several formats, including Web pages, directly from the presentation file, for the benefit of health-care providers in eastern and north-eastern Ontario. An online evaluation form could be completed by anyone visiting the Website; the people responsible for community rehabilitation services were asked to encourage their staff to complete the forms. A total of 174 forms were received. The module 'Principles of transfers for health-care workers' accounted for 18% of the evaluations and the module 'Assisted range-of-motion exercises for arms and legs to maintain joint flexibility' accounted for 14%. Thirty-nine per cent of respondents were registered nurses, 13% were physiotherapists and 26% were people with disabilities. Thirty per cent of the participants had limited or no experience with online learning. In the evaluation, high ratings were given for satisfaction and usefulness. From an educator's perspective, multimedia content could be created and distributed without a substantial investment in equipment, software, training and publication time; this represents a 'write once, publish everywhere' approach.

Distribution analysis of the two chicken estrogen receptor-alpha isoforms and their transcripts in the hypothalamus and anterior pituitary gland

Estrogen plays a key role in the control of reproductive behavior and in the regulation of the neuroendocrine system. To elucidate the mechanisms by which it controls these functions it is important to understand how estrogenic effects are mediated. We have investigated the distribution of the two isoforms of the chicken estrogen receptor alpha (cER-alpha) protein; the previously characterized cER-alpha 66 and a new N-terminal truncated isoform, cER-alpha 61. Immunolocalization demonstrated the presence of cER-alpha 66 protein in hypothalamic areas, principally the nucleus septalis lateralis, bed nucleus striae terminalis medialis, nucleus preopticus medialis, and nucleus infundibuli hypothalami, and in the anterior pituitary gland. When the distribution of ER-alpha immunoreactive cells was compared using the antibodies H 222 (directed against the hormone-binding domain) and ER 221 (directed against the 21-amino acid N-terminus), no apparent differences could be detected. Because this immunocytochemical approach was not able to distinguish whether full-length cER-alpha 66 is the only isoform observed in the ER-positive regions or whether both cER-alpha receptor isoforms are present, SI nuclease assays were performed to compare the relative abundance in these regions of the two distinct classes of cER-alpha mRNA variants (A1-D and A2), which encode the cER-alpha 66 and cER-alpha 61 protein isoforms, respectively. In cockerels and hens, both variants of cER-alpha mRNA are expressed in the anterior pituitary gland and basal hypothalamus with a dominance of the mRNA that encodes cER-alpha 66, whereas the mRNA that encodes cER-alpha 61 was not detectable in the anterior hypothalamus. Therefore, because both receptor isoforms differ in their ability to modulate estrogen target gene expression in a promoter and cell type-specific manner, these differences may mediate the pleiotropic actions of estrogen in reproductive behavior and neuroendocrine functions.

Low-bandwidth, Internet-based videoconferencing for physical rehabilitation consultations

Low-bandwidth, Internet-based videoconferencing was used to provide physical rehabilitation consultation services for eight community hospitals. Videoconferencing and file transmission used a PC and modem. A separate telephone line was used for voice. Over 21 months, 47 physical rehabilitation consultations were completed for communication disorders, foot care, gait problems, orthotics, prosthetics, arm weakness and wheelchair prescription. Consultations were approximately 40 min long. Clinician questionnaires were completed by 47 individuals. While more than 80% of the questionnaire responses supported the telemedicine approach, remote clinicians rated their satisfaction higher than did the specialists. Client questionnaires were completed by 24 individuals (a response rate of 51%). All clients were comfortable with and had confidence in the teleconsultations.

A novel mitogen-activated protein kinase is responsive to Raf and mediates growth factor specificity

The proto-oncogene Raf is a major regulator of growth and differentiation. Previous studies from a number of laboratories indicate that Raf activates a signaling pathway that is independent of the classic MEK1,2-ERK1,2 cascade. However, no other signaling cascade downstream of Raf has been identified. We describe a new member of the mitogen-activated protein kinase family, p97, an ERK5-related kinase that is activated and Raf associated when cells are stimulated by Raf. Furthermore, p97 is selectively responsive to different growth factors, providing a mechanism for specificity in cellular signaling. Thus, p97 is activated by the neurogenic factor fibroblast growth factor (FGF) but not the mitogenic factor epidermal growth factor (EGF) in neuronal cells. Conversely, the related kinase ERK5 is activated by EGF but not FGF. p97 phosphorylates transcription factors such as Elk-1 and Ets-2 but not MEF2C at transactivating sites, whereas ERK5 phosphorylates MEF2C but not Elk-1 or Ets-2. Finally, p97 is expressed in a number of cell types including primary neural and NIH 3T3 cells. Taken together, these results identify a new signaling pathway that is distinct from the classic Raf-MEK1,2-ERK1,2 kinase cascade and can be selectively stimulated by growth factors that produce discrete biological outcomes.

Oestrogen receptor function at classical and alternative response elements

The oestrogen receptor (ER), bound to classical response elements (EREs) in the promoter of target genes, activates transcription by recruiting coactivator proteins. We will describe structural studies that show that oestrogens allow the formation of a hydrophobic cleft on the surface of the ER that serves as a docking site for coactivators. Anti-oestrogens displace part of the receptor, which then occludes the site, blocking coactivator access. In addition to activating at classical EREs, the ER activates transcription at alternative elements such as AP-1 sites. These bind the Jun/Fos proteins but not ER. Interestingly both oestrogen and tamoxifen activate transcription at AP-1 sites. We propose a mechanism whereby oestrogen and anti-oestrogen allow ER to activate transcription from alternative response elements. ER binds to the coactivators, CBP and GRIP1, that have been recruited by Jun/Fos and through this contact 'triggers' these coactivators into full activity. In this circumstance the ER is part of the coactivator complex for Jun/Fos.

Technical evaluation of a low-bandwidth, Internet-based system for teleconsultations

A low-bandwidth telemedicine system was evaluated in eight community hospitals connected to a central hospital via the Internet. PCs were used with videoconferencing software and modem connections to the telephone network. The average data connection rates, still-image transfer times and live-video transmission rates were determined. The time to send 640 x 480, 320 x 240 and 160 x 120 pixel, 24-bit still images ranged from 29 s to 411 s. The average file transfer times for a 10 s MPEG video-clip was 8.6 min. The average live video frame rate was 1 frame/s (at the best image quality), with an average latency of 3 s. The results suggest that Internet-based videoconferencing is acceptable for certain telemedicine applications.

A biopsychosocial approach to finding common ground in the clinical encounter

PURPOSE

Little is known about how clinicians find common ground in conflicts with their patients or how educators can teach physicians-in-training to do so. The authors set out to create a conceptual model for the process of finding common ground.

METHOD

Students in a third-year family practice clerkship wrote up cases they had encountered in which conflicts arose in the patient-doctor relationship. The authors analyzed these cases, first independently and then collectively. After several iterations, they arrived at a model grounded in the case material.

RESULTS

The authors suggest that a modification of the biopsychosocial model first proposed by Engel and later updated by McWhinney is an appropriate and practical schema for classifying sources of conflict. This hierarchical system consists of five levels: (1) individual patient, (2) relationship between patient and physician, (3) patient's family, (4) ethnic belief systems of patient and family, and (5) political economy.

CONCLUSION

This hierarchical, multilevel biopsychosocial approach allows the clinician to identify the level in the system at which a conflict has arisen. This clarifies the strategies for resolution, making it easier for patient and doctor to find common ground. This may also be a useful heuristic model for teaching such skills to physicians-in-training.

A man with inflamed ears

A 23-year-old man presented with fever, dyspnea, nonproductive cough, left eye redness, reduced vision, and bilateral ear pain and tenderness. The symptoms had begun two days earlier, eight days after he was discharged from the hospital with a presumptive diagnosis of Still's disease. He was first seen a month before the current admission for complaints of fever (as high as 39.4 degrees C), nonproductive cough, and asymmetric arthritis. The workup at that time included arthrocentesis of the right knee. Analysis of the joint fluid showed 7,500 white blood cells/mm3 and no crystals. A gram stain and culture of the fluid were negative. HIV and hepatitis tests, bone marrow biopsy and culture, transesophageal echocardiography, abdominal computed tomography, radionuclide bone scanning, and rheumatologic tests failed to identify the problem. The development of an evanescent macular pink rash on day 15 suggested the possibility of Still's disease. Treatment with prednisone (40 mg po qd) was initiated, and the patient was discharged on day 19.

Rural health professionals' satisfaction with a rehabilitation mobile outreach program

OBJECTIVE

To assess the extent to which rural physicians and allied health professionals are satisfied with consultation services provided by an interdisciplinary rehabilitation outreach team.

DESIGN

Descriptive survey.

SETTING

A rehabilitation outreach team that travels to 14 rural communities in eastern and northern Ontario, Canada.

SUBJECTS

Thirty-six rural physicians (response rate, 53.7%) and 62 allied health professionals (response rate, 92.5%) involved in the care of patients referred to the program.

MAIN OUTCOME MEASURE

Consumer satisfaction questionnaire.

RESULTS

Most respondents (94.7%) indicated that they were satisfied with the interdisciplinary consultation, with comparable rates of satisfaction reported by physicians and allied health professionals. The highest satisfaction ratings were given to items addressing the clarity of recommendations provided by team members and the quality of the team's interaction with patients. The lowest ratings were associated with the waiting time between visits. Of all the individual disciplines on the team, physiatry was rated as most important for rural consultations. However, in open-ended comments, respondents indicated that the interdisciplinary aspect of the service was its most valued characteristic, whereas infrequent visits were the greatest drawback.

CONCLUSION

The interdisciplinary outreach approach to rehabilitation consultation receives high satisfaction ratings from rural health professionals who refer patients to the outreach team, which supports this model as a way to enhance rehabilitation services in rural communities.

Suppression of angiogenesis, tumorigenicity, and metastasis by human prostate cancer cells engineered to produce interferon-beta

We determined whether the IFN-beta gene can be used to suppress angiogenesis, tumor growth, and metastasis of human prostate cancer cells growing in the prostate of nude mice. Highly metastatic PC-3M human prostate cancer cells were engineered to constitutively produce murine IFN-beta subsequent to infection with a retroviral vector containing murine IFN-beta cDNA. Parental (PC-3M-P), control vector-transduced (PC-3M-Neo), and IFN-beta-transduced (PC-3M-IFN-beta) cells were injected into the prostate (orthotopic) or subcutis (ectopic) of nude mice. PC-3M-P and PC-3M-Neo cells produced rapidly growing tumors and regional lymph node metastases, whereas PC-3M-IFN-beta cells did not. PC-3M-IFN-beta cells also suppressed the tumorigenicity of bystander nontransduced prostate cancer cells. PC-3M-IFN-beta cells produced small tumors (3-5 mm in diameter) in nude mice treated with anti-asialo GM1 antibodies and in severe combined immunodeficient/Beige mice. Immunohistochemical staining revealed that PC-3M-IFN-beta tumors were homogeneously infiltrated by macrophages, whereas control tumors contained fewer macrophages at their periphery. Most tumor cells in the control tumors were stained positive by an antibody to proliferative cell nuclear antigen; very few were positively stained by terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick-end labeling. In sharp contrast, PC-3M-IFN-beta tumors contained fewer proliferative cell nuclear antigen-positive cells and many terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick-end labeling-positive cells. Staining with antibody against CD31 showed that control tumors contained more blood vessels than PC-3M-IFN-beta tumors. PC-3M-IFN-beta cells were more sensitive to lysis mediated by natural killer cells in vitro or to cytostasis mediated by macrophages than control transduced cells. Conditioned medium from PC-3M-IFN-beta cells augmented splenic cell-mediated cytolysis to control tumor cells, which could be neutralized by antibody against IFN-beta. Collectively, the data suggest that the suppression of tumorigenicity and metastasis of PC-3M-IFN-beta cells is due to inhibition of angiogenesis and activation of host effector cells.