The Outcome of Patients With 2 Different Protocols of Do-Not-Resuscitate Orders: An Observational Cohort Study

Lack of clarity about the exact clinical implications of do-not-resuscitate (DNR) has caused confusion that has been addressed repeatedly in the literature. To provide improved understanding about the portability of DNR and the medical care provided to DNR patients, the state of Ohio passed a Do-Not-Resuscitate Law in 1998, which clearly pointed out 2 different protocols of do-not-resuscitate: DNR comfort care (DNRCC) and DNR comfort care arrest (DNRCC-Arrest). The objective of this study was to examine the outcome of patients with the 2 different protocols of DNR orders.This is a retrospective observational study conducted in a medical intensive care unit (MICU) in a hospital located in Northeast Ohio. The medical records of the initial admissions to the MICU during data collection period were concurrently and retrospectively reviewed. The association between 2 variables was examined using Chi-squared test or Student's t-test. The outcome of DNRCC, DNRCC-Arrest, and No-DNR patients were compared using multivariate logistic regression analysis.The total of 188 DNRCC-Arrest, 88 DNRCC, and 2051 No-DNR patients were included in this study. Compared with the No-DNR patients, the DNRCC (odds ratio = 20.77, P < 0.01) and DNRCC-Arrest (odds ratio = 3.69, P < 0.01) patients were more likely to die in the MICU. Furthermore, the odds of dying during MICU stay for DNRCC patients were 7.85 times significantly higher than that for DNRCC-Arrest patients (odds ratio = 7.85, P < 0.01).Given Do-Not-Resuscitate Law in Ohio, we examined the outcome of the 2 different protocols of DNR orders, and to compare with the conventional DNR orders. Similar to conventional DNR, DNDCC and DNRCC-Arrest were both associated with the increased risk of death. Patients with DNRCC were more likely to be associated with increased risk of death than those with DNRCC-Arrest.

Making a Difference in Migrant Summer School: Testing a Healthy Weight Intervention

OBJECTIVE

Evaluate the effectiveness of a healthy weight intervention designed for children of migrant farmworkers embedded in a 7-week summer Midwest Migrant Education Program (MEP) for changes in: weight; Body Mass Index (BMI); BMI-percentiles (BMI-p); muscle strength and muscle flexibility; nutrition knowledge; attitudes; and behaviors.

DESIGN AND SAMPLE

This is a two-group pre-post quasi-experimental study. Latino children of migrant farmworkers attending summer MEP in grades one through eight were enrolled (n = 171: comparison n = 33, intervention n = 138).

MEASURES

Weight, BMI, BMI-p, muscle strength and flexibility, knowledge, and healthy behaviors.

INTERVENTION

Classroom content included: food variety; increasing fruits and vegetables; healthy breakfasts; more family meals; increasing family time; decreasing TV and electronic game time; increasing physical activity; limiting sugar-sweetened drinks; portion sizes; and food labels.

RESULTS

Statistically significant were increase in comparison group mean weight, decrease in intervention group BMI-p, and improvements in muscle flexibility and healthy behavior attitudes. The intervention students showed trends toward healthy BMI. The number of MEP days attended was significantly correlated in four outcomes.

CONCLUSION

Study findings have the potential to decrease incidence of unhealthy weight in Latino migrant children, reduce rates of premature adult diseases in these children, and a potential to decrease future health care costs.

An analysis of cross sectional survey data of stunting among Palestinian children less than five years of age

The object of this study is to report on determinants of stunting, defined as low height for age, among children in the occupied Palestinian territories. Using 2006-2007 cross sectional survey data collected by the Palestine Central Bureau of Statistics and using multivariate mixed model techniques for logistic regression, the relationships of stunting to characteristics of 9,051 Palestinian children less than 5 years of age living in the Palestinian territories were estimated. These characteristics included demographic and social characteristics of the child, geographic region, type of location (urban, rural, refugee camp) and food insecurity for each governorate. Listed in order of the greater contribution to the explained variation in stunting, children with lower birth weight (P < 0.0001), age greater than 12 months (P < 0.0001), higher levels of food insecurity (P < 0.0001), lower socio-economic status (P < 0.0001), mother illiterate (P = 0.004), urban areas (P = 0.008), and absence of supplementation to breast feeding during the first 4 months of the child's life (P = 0.04) have significantly more stunting. Children living in refugee camps have lower rates of stunting than urban areas; however the difference does not reach statistical significance. The relationship between the child's gender and stunting is not statistically significant. Lack of food security is directly linked to stunting. The continuing incidence of food insecurity means that the deleterious effects of under-nutrition will continue to affect the children of Palestine. Removing the avoidable causes of food insecurity in the occupied Palestinian territories will alleviate under-nutrition and its deleterious effects.

Rehospitalization in a national population of home health care patients with heart failure

OBJECTIVE

Patients with heart failure (HF) have high rates of rehospitalization. Home health care (HHC) patients with HF are not well studied in this regard. The objectives of this study were to determine patient, HHC agency, and geographic (i.e., area variation) factors related to 30-day rehospitalization in a national population of HHC patients with HF, and to describe the extent to which rehospitalizations were potentially avoidable.

DATA SOURCES

Chronic Condition Warehouse data from the Centers for Medicare & Medicaid Services.

STUDY DESIGN

Retrospective cohort design.

DATA EXTRACTION

The 2005 national population of HHC patients was matched with hospital and HHC claims, the Provider of Service file, and the Area Resource File.

PRINCIPAL FINDINGS

The 30-day rehospitalization rate was 26 percent with 42 percent of patients having cardiac-related diagnoses for the rehospitalization. Factors with the strongest association with rehospitalization were consistent between the multilevel model and Cox proportional hazard models: number of prior hospital stays, higher HHC visit intensity category, and dyspnea severity at HHC admission. Substantial numbers of rehospitalizations were judged to be potentially avoidable.

CONCLUSIONS

The persistently high rates of rehospitalization have been difficult to address. There are health care-specific actions and policy implications that are worth examining to improve rehospitalization rates.

Rehospitalization in a national population of home health care patients with heart failure

OBJECTIVE

Patients with heart failure (HF) have high rates of rehospitalization. Home health care (HHC) patients with HF are not well studied in this regard. The objectives of this study were to determine patient, HHC agency, and geographic (i.e., area variation) factors related to 30-day rehospitalization in a national population of HHC patients with HF, and to describe the extent to which rehospitalizations were potentially avoidable.

DATA SOURCES

Chronic Condition Warehouse data from the Centers for Medicare & Medicaid Services.

STUDY DESIGN

Retrospective cohort design.

DATA EXTRACTION

The 2005 national population of HHC patients was matched with hospital and HHC claims, the Provider of Service file, and the Area Resource File.

PRINCIPAL FINDINGS

The 30-day rehospitalization rate was 26 percent with 42 percent of patients having cardiac-related diagnoses for the rehospitalization. Factors with the strongest association with rehospitalization were consistent between the multilevel model and Cox proportional hazard models: number of prior hospital stays, higher HHC visit intensity category, and dyspnea severity at HHC admission. Substantial numbers of rehospitalizations were judged to be potentially avoidable.

CONCLUSIONS

The persistently high rates of rehospitalization have been difficult to address. There are health care-specific actions and policy implications that are worth examining to improve rehospitalization rates.

Examining the positive effects of exercise in intubated adults in ICU: a prospective repeated measures clinical study

BACKGROUND

Determining the optimal timing and progression of mobility exercise has the potential to affect functional recovery of critically ill adults. This study compared standard care with care delivered using a mobility protocol. We examined the effects of exercise on vital signs and inflammatory biomarkers and the effects of the nurse-initiated mobility protocol on outcomes.

METHODS

Prospective, repeated measures study with a control (standard care) and intervention (protocol) period.

RESULTS

75 heterogeneous subjects admitted to a Medical or Surgical intensive care unit (ICU) were enrolled. In <5% of exercise periods, there was a concerning alteration in respiratory rate or peripheral oxygen saturation; no other adverse events occurred. Findings suggested the use of a protocol with one 20 minute episode of exercise daily for 2 or more days reduced ICU length of stay. Duration of exercise was linked to increased IL-10, suggesting brief episodes of low intensity exercise positively altered inflammatory dysregulation in this sample.

CONCLUSION

A growing body of evidence demonstrates that early, progressive exercise has significant benefits to intubated adults. These results should encourage clinicians to add mobility protocols to the care of ICU adults and lead to future studies to determine optimal "dosing" of exercise in ICU patients.

An exploratory study of relational, persuasive, and nonverbal communication in requests for tissue donation

This study explores the effects of tissue requesters' relational, persuasive, and nonverbal communication on families' final donation decisions. One thousand sixteen (N = 1,016) requests for tissue donation were audiotaped and analyzed using the Siminoff Communication Content and Affect Program, a computer application specifically designed to code and assist with the quantitative analysis of communication data. This study supports the important role of communication strategies in health-related decision making. Families were more likely to consent to tissue donation when confirmational messages (e.g., messages that expressed validation or acceptance) or persuasive tactics such as credibility, altruism, or esteem were used during donation discussions. Consent was also more likely when family members exhibited nonverbal immediacy or disclosed private information about themselves or the patient. The results of a hierarchical log-linear regression revealed that the use of relational communication during requests directly predicted family consent. The results provide information about surrogate decision making in end-of-life situations and may be used to guide future practice in obtaining family consent to tissue donation.

Measuring quality of life of long-term breast cancer survivors: the Long Term Quality of Life-Breast Cancer (LTQOL-BC) Scale

The authors developed a quality-of-life measure specific to long-term breast cancer survivors. Participants were women diagnosed with early-stage disease ≥ 7 years postdiagnosis. The final scale is the result of an iterative interview process with the 28-item scale administered to 285 participants. Factor analysis demonstrated with seven domains: physical, sexual and cognitive function, body image, coping, social support, and anxiety. Cronbach's alpha is .88. Convergent and divergent validity are also reported. The Long Term Quality of Life-Breast Cancer Scale has domains specific to breast cancer and will be useful to psychosocial and clinical researchers.

Effectiveness trial of an intensive communication structure for families of long-stay ICU patients

BACKGROUND

Formal family meetings have been recommended as a useful approach to assist in goal setting, facilitate decision making, and reduce use of ineffective resources in the ICU. We examined patient outcomes before and after implementation of an intensive communication system (ICS) to test the effect of regular, structured formal family meetings on patient outcomes among long-stay ICU patients.

METHODS

One hundred thirty-five patients receiving usual care and communication were enrolled as the control group, followed by enrollment of intervention patients (n = 346), from five ICUs. The ICS included a family meeting within 5 days of ICU admission and weekly thereafter. Each meeting discussed medical update, values and preferences, and goals of care; treatment plan; and milestones for judging effectiveness of treatment.

RESULTS

Using multivariate analysis, there were no significant differences between control and intervention patients in length of stay (LOS), the primary end point. Similarly, there were no significant differences in indicators of aggressiveness of care or treatment limitation decisions (ICU mortality, LOS, duration of ventilation, treatment limitation orders, or use of tracheostomy or percutaneous gastrostomy). Exploratory analysis suggested that in the medical ICUs, the intervention was associated with a lower prevalence of tracheostomy among patients who died or had do-not-attempt-resuscitation orders in place.

CONCLUSIONS

The negative findings of the main analysis, in combination with preliminary evidence of differences among types of unit, suggest that further examination of the influence of patient, family, and unit characteristics on the effects of a system of regular family meetings may be warranted. Despite the lack of influence on patient outcomes, structured family meetings may be an effective approach to meeting information and support needs.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT01057238 ; URL: www.clinicaltrials.gov.

Composite outcomes of chronically critically ill patients 4 months after hospital discharge

BACKGROUND

Data on likely postdischarge outcomes are important for decision making about chronically critically ill patients. It seems reasonable to categorize outcomes into "better" or overall desirable states and "worse" or generally undesirable states. Survival, being at home, and being cognitively intact are commonly identified as important to quality of life and thus may be combined to describe composite outcome states.

OBJECTIVE

To categorize postdischarge outcome states of chronically critically ill patients and identify predictors of better and worse states.

METHODS

Reanalysis of data from a trial of a disease management program for chronically critically ill patients. Two composite outcomes were created: (1) the "better" outcome: no cognitive impairment at 2 months after discharge and alive and at home at 4 months (ie, met all 3 criteria), and (2) the "worse" outcome: cognitive impairment 2 months after discharge, or death after discharge, or not living at home 4 months after discharge (ie, met at least 1 of these criteria).

RESULTS

Of 218 patients not requiring ventilatory support at discharge, 111 (50.9%) had a better outcome. Of 159 patients who were cognitively intact at discharge, 111 (69.8%) had a better outcome. Of the 39 patients who required ventilatory support at discharge, only 1 (3%) achieved the better outcome. Of 98 patients who were cognitively impaired at discharge, only 29 (30%) had the better outcome.

CONCLUSION

Need for mechanical ventilatory support and persistent cognitive impairment at discharge were associated with worse outcomes 4 months after discharge.

Thirty-year follow-up of chemo/hormonal therapy in node-positive breast cancer

Results of a thirty-year follow-up of a clinical trial of chemo-hormonal therapy are reported. Eligible patients had recently diagnosed operable breast cancer, positive lymph nodes, no previous history of cancer, age less than 76 years, and no evidence of metastatic disease. A total of 311 patients were stratified by estrogen receptor (ER) status and number of axillary nodes involved with tumor. After stratification, patients were randomly assigned to one of three treatment regimens: cyclophosphamide, methotrexate and 5-fluorouracil (CMF) for 1 year; CMF chemotherapy combined with anti-estrogen therapy (tamoxifen) for 1 year; or CMF plus tamoxifen with BCG during the second year. The endpoint of the trial was a first recurrence. Factors measured at diagnosis and used in the analyses were age, body mass index, ER status, menopausal status, number of positive nodes, tumor diameter, Charlson comorbidity index, socioeconomic status, and race. Causes of death and incidence of other cancer primaries were obtained from death certificates and medical records. Patients treated with tamoxifen had a marginally longer disease-free survival (hazard ratio (HR)=0.83, 95% CI identical with [0.66, 1.04]) and statistically significant longer overall survival (HR=0.77, 95% CI identical with [0.63, 0.96]) that decreased with time. Incidence of other primary cancers and causes of death were similar for the two treatment groups. The addition of 1 year of tamoxifen to CMF therapy provides an early disease-free and overall survival advantage; however long-term effects are negligible. Similarly, the survival advantage of patients diagnosed with ER+ tumors persists for the first two decades after diagnosis.

Cancer communication patterns and the influence of patient characteristics: disparities in information-giving and affective behaviors

OBJECTIVE

To examine whether patient characteristics are associated with communication patterns between oncologists and breast cancer patients.

METHODS

The study was conducted at 14 practices with 58 oncologists with 405 newly diagnosed patients with no prior history of breast cancer. The initial consultation between oncologist and patient was audiotaped and a detailed communication analysis performed. Interviews were conducted with patients and physicians immediately before and after consultations.

RESULTS

Disparities were found across all patient demographics. Younger patients asked more questions as did those who were white had more than a high school education and when they reported an income that was high or medium income, compared to low (p<0.01). Patient proactive behavior, such as volunteering information to the physician unasked, was similarly related with all demographic predictors as was physician tendency to ask patients questions. Despite the inherently emotional nature of this encounter, there was surprisingly little overt discussion about how the patient felt about her diagnosis and how she was coping. Both patients and physicians spent time trying to establish an interpersonal relationship with each other, although patients spent more time. Patients differed in the number of relationship building utterances by age, education and income and physicians spent more time engaged in relationship building with white than non-white patients (p<0.01) and more educated and affluent patients (p<0.05).

CONCLUSION

This study indicates that patient demographic factors, such as race, income level, education and age seem to influence the amount of time physicians spend in almost all communication categories with patients. One recurring difference across most communication categories was race. Racial differences occurred in almost every one of the communication categories examined. White patients had many more utterances in almost every communication category than their non-white counterparts. These differences may mean a less adequate decision-making process for patients who are members of racial or ethnic minorities, patients who are less affluent, older, and have less education.

PRACTICE IMPLICATIONS

This study found that providers communicate differently with patients by age, race, education and income. These differences in communication may lead to disparities in patient outcomes. Communication skills training should explicitly train clinicians to recognize these tendencies. Patients with different demographics characteristics may also required education that is tailored to them.

A decision aid to assist in adjuvant therapy choices for breast cancer

BACKGROUND

Decision aids are tools that help patients make specific and deliberative choices among options. This study was a group randomized controlled trial of a novel decision aid to help patients with breast cancer make adjuvant therapy (AT) decisions.

METHODS

Fourteen oncology practices (n=58 physicians) were randomized to receive the decision aid or a control pamphlet. Complete data were obtained from 405 patient-oncologist pairs. Eligible patients had stage I-III disease and had completed their primary treatment. The decision aid is a simple to use computer program, titled Adjuvant!, that provides estimates of outcome with and without AT. Graphical representations of outcome are shared with patients. Consultations were audiotaped, patients interviewed, and physicians completed a self-administered survey.

RESULTS

In a multivariable model, the 54 patients (13.3%) who took no AT were more likely to have received the decision aid (p=0.02). A differential effect of the Adjuvant! Decision Guide was noted between node negative and positive patients. It was stated by 86.2% of patients that the decision aid was influential when making their treatment decision. Over 95% of patients reported that the Adjuvant Decision Guide was easy to understand and 75% of physicians believed that it helped them understand their patient's treatment preferences and 81.4% reported the information as useful for themselves.

CONCLUSIONS

This study showed that a decision aid made a difference in the choice of whether or not to take AT. The decision aid allowed patients and physicians to consider the benefits of AT in an easy to understand format. Treatment decisions were more individualized for patients in the intervention than in the control group. The use of the decision aid was acceptable to both patients and physicians.

Determinants of anemia in pre-school children in the occupied Palestinian territory

This paper presents the main findings of an analysis linking the dependent variable - anemia in pre-school children - to its determinants, to identify priority groups for action. The study was a cross sectional survey of randomly selected pre-school children 6-59 months (n = 3331) in the occupied Palestinian territory during the current uprising. Anemia (Hb <11 g/dl) in children was determined by a blood sample. Other indicators were examined; 24 variables related to the family, housing, maternal and child characteristics, in addition to changes in income and food intake that occurred during the uprising. Multivariate analysis revealed that anemia was independently related to reduction in income, iron intake, infrequent gastrointestinal infections, stunting and current breast feeding status. In addition, region was an independent risk factor for anemia - in the West Bank there were fewer anemic children in the age group 6-35 months compared to children from the same age group living in the Gaza Strip.

Effects of a CHANGE intervention to increase exercise maintenance following cardiac events

BACKGROUND

Despite participation in a cardiac rehabilitation program, there is a downward trajectory of exercise participation during the year following a cardiac event.

PURPOSE

The purpose of this study was to test the effectiveness of CHANGE (Change Habits by Applying New Goals and Experiences), a lifestyle modification program designed to increase exercise maintenance in the year following a cardiac rehabilitation program. The CHANGE intervention consists of 5 small-group cognitive-behavioral change counseling sessions in which participants are taught self-efficacy enhancement, problem-solving skills, and relapse prevention strategies to address exercise maintenance problems.

METHOD

Participants (N = 250) were randomly assigned to the CHANGE intervention (supplemental to usual care) or a usual-care-only group. Exercise was measured using portable wristwatch heart rate monitors worn during exercise for 1 year. Cox proportional hazards regression was used to determine differences in exercise over the study year between the study groups.

RESULTS

Participants in the usual-care group were 76% more likely than those in the CHANGE group to stop exercising during the year following a cardiac rehabilitation program (hazard ratio = 1.76, 95% confidence interval = 1.08-2.86, p = .02) when adjusting for the significant covariates race, gender, comorbidity, muscle and joint pain, and baseline motivation. Most participants, however, had less than recommended levels of exercise amount and intensity.

CONCLUSIONS

Counseling interventions that use contemporary behavior change strategies, such as the CHANGE intervention, can reduce the number of individuals who do not exercise following cardiac events.

Evaluation of multiple failure time analyses of observational data in patients treated for HIV

The development of protease inhibitors and nonnucleoside reverse transcriptase inhibitors has substantially increased the number of combinations available for multi-drug therapies in human immunodeficiency virus (HIV) infection. Unfortunately, all antiretroviral therapies lose efficacy over time or induce side effects, thus making secondary and tertiary alternatives necessary. With the multiplicity of multi-drug combination therapies, the challenge is to determine which multi-drug combination to use as initial therapy and which to use as subsequent therapy to maximize survival. No standard methodologic approach has been developed to answer this question within the context of observational clinical HIV data. We demonstrate the use of semi-parametric models employing repeated, multiple failure time analysis to compare the relative efficacy of treatments containing zidovudine, stavudine, or other multi-drug combinations for patients in the CHORUS (Collaborations in HIV Outcomes Research - US) database.

Imprints on the consciousness: The impact on Palestinian civilians of the Israeli Army invasion of West Bank towns

BACKGROUND

The dehumanizing aspects of conflict and war are increasingly recognized as serious health and human rights concerns. This paper examines the impact on civilians of the 29 March 2002 Israeli Army invasion and subsequent curfews lasting up to 45 consecutive days, of five West Bank towns.

METHODS

Using focus groups, a 10-item scale was devised to measure the effects of the invasion's impact on the social and health-related quality of life. The scale is an aggregate of three constructs measuring housing, financial, and health-related issues. A survey composed of demographic questions and the 10-item social/health scale was administered to a stratified random sample of inhabitants of the five towns.

RESULTS

the invasion caused extensive destruction, food and cash shortages, internal displacement of civilians, psychological distress, and serious interruptions of basic services, including crucial health services. Overall, Jenin experienced the most deleterious effects. Using the subscales, Jenin experienced the highest overall housing damage, Bethlehem the most financial difficulties, and Ramallah the most health-related hardships.

CONCLUSIONS

civilians inevitably suffer during conflict and war from destruction of the community infrastructure and from personal stress due to disruption of services and the non-fulfilment of basic human needs. In contradistinction to standard damage assessments that focus on collective physical damage, this scale provides richer information on the needs of civilians in conflict-torn areas, and can assist aid workers in the efficient deployment of resources.

The effect of publicly reporting hospital performance on market share and risk-adjusted mortality at high-mortality hospitals

BACKGROUND

It is unclear whether publicly reporting hospitals' risk-adjusted mortality affects market share and mortality at outlier hospitals.

OBJECTIVES

To examine hospitals' market share and risk-adjusted mortality from 1991 to 1997 at hospitals participating in Cleveland Health Quality Choice (CHQC).

RESEARCH DESIGN

Time series.

SUBJECTS

Changes in market share were examined for all patients hospitalized with acute myocardial infarction, heart failure, gastrointestinal hemorrhage, obstructive pulmonary disease, pneumonia, or stroke at all 30 nonfederal hospitals in Northeast Ohio. Patients insured by Medicare were used to examine changes in mortality.

MEASURES

Trends in market share (proportion of patients with the target conditions discharged from a given hospital) and risk-adjusted 30-day mortality.

RESULTS

CHQC identified several hospitals with consistently higher than expected mortality. The five hospitals with the highest mortality tended to lose market share (mean change -0.6%, 95% CI -1.9-0.6), but this was not significant. The only outlier hospital with a large decline in market share had declining volume for 2 years before being declared an outlier. Risk-adjusted mortality declined only slightly at hospitals classified by us as "below average" (-0.8%; 95% CI, 2.9-1.8%) or "worst" (-0.4%; 95% CI -2.3-1.7). However, risk-adjusted mortality at one hospital changed from consistently above expected to consistently below expected shortly after first being declared an outlier.

CONCLUSION

Despite CHQC's strengths, identifying hospitals with higher than expected mortality did not adversely affect their market share or, with one exception, lead to improved outcomes. This failure may have resulted from consumer disinterest or difficulty interpreting CHQC reports, unwillingness of businesses to create incentives targeted to hospitals' performance, and hospitals' inability to develop effective quality improvement programs.

Socioeconomic factors and breast cancer in black and white Americans

The incidence of breast cancer in the US is known to be higher among white than black women and among women of higher socioeconomic status (SES), but once a woman, either black or white, has the disease, she is more likely to have a recurrence and to die of breast cancer if she is of lower socioeconomic status. Explanations for these observed differences are varied and inconsistent making it clear that these reported differentials are not sufficiently understood. In understanding breast cancer in a multicultural setting, delay in diagnosis, follow-up, and treatment are frequently the focus of attention. However these factors do not sufficiently explain the observed differences between blacks and whites. A review of recent literature reveals an increasing focus on the role of SES in breast cancer etiology, and progression; however, the confounding of SES with race/ethnicity (black vs. white) contributes to the insufficient understanding of the effect of these two factors. This report will focus on the interplay between race/ethnicity and SES and their relative effects upon analyses of survival from breast cancer. Findings are based on prospective clinical trial data. SES factors have been associated with most of the known or suspected risk factors for breast cancer incidence and progression. In addition to race/ethnicity, SES is also associated with diet, lifestyle factors, physical characteristics, and tumor characteristics. Without controlling for other risk factors, the ratios of risk for blacks with respect to whites for disease-free survival and overall survival were 1.30 (95% CI: 1.04-1.61) and 1.42 (95% CI: 1.15-1.76), respectively. However, after controlling for patient risk factors, such as the number of positive lymph nodes, tumor diameter, estrogen receptor status and socioeconomic factors, these differences decrease and are not statistically significant. Socioeconomic status is associated both with race/ethnicity and estrogen receptor status. A loglinear analysis demonstrates that the apparent association of race/ethnicity with estrogen receptor status is mediated by socioeconomic status. An implication of this finding is that environmental and lifestyle components rather than genetic factors associated with race may explain the observed differentials between black and white breast cancer patients. Knowledge of environmental factors associated with SES have the potential for providing important clues about the prevention and control of breast cancer.

Mortality trends during a program that publicly reported hospital performance

BACKGROUND

It is unclear whether publicly reporting hospitals' risk-adjusted mortality leads to improvements in outcomes.

OBJECTIVES

To examine mortality trends during a period (1991-1997) when the Cleveland Health Quality Choice program was operational.

RESEARCH DESIGN

Time series.

SUBJECTS

Medicare patients hospitalized with acute myocardial infarction (AMI; n = 10,439), congestive heart failure (CHF; n = 23,505), gastrointestinal hemorrhage (GIH; n = 11,088), chronic obstructive pulmonary disease (COPD; n = 8495), pneumonia (n = 23,719), or stroke (n = 14,293).

MEASURES

Risk-adjusted in-hospital mortality, early postdischarge mortality (between discharge and 30 days after admission), and 30-day mortality.

RESULTS

Risk-adjusted in-hospital mortality declined significantly for all conditions except stroke and GIH, with absolute declines ranging from -2.1% for COPD to -4.8% for pneumonia. However, the mortality rate in the early postdischarge period rose significantly for all conditions except COPD, with increases ranging from 1.4% for GIH to 3.8% for stroke. As a consequence, the 30-day mortality declined significantly only for CHF (absolute decline 1.4%, 95% CI, -2.5 to -0.1%) and COPD (absolute decline 1.6%, 95% CI, -2.8-0.0%). For stroke, risk-adjusted 30-day mortality actually increased by 4.3% (95% CI, 1.8-7.1%).

CONCLUSION

During Cleveland's experiment with hospital report cards, deaths shifted from in hospital to the period immediately after discharge with little or no net reduction in 30-day mortality for most conditions. Hospital profiling remains an unproven strategy for improving outcomes of care for medical conditions. Using in-hospital mortality rates to monitor trends in outcomes for hospitalized patients may lead to spurious conclusions.

Photodynamic therapy of human breast cancer xenografts lacking caspase-3

The human breast cancer cell line MCF-7 is deficient in procaspase-3 and in caspase-3-dependent steps in apoptosis due to deletion of the CASP-3 gene. We previously found that the cells transfected with empty vector (MCF-7v cells) were considerably less sensitive to photodynamic treatment in vitro with the phthalocyanine photosensitizer Pc 4 than were the cells stably transfected with human procaspase-3 cDNA (MCF-7c3 cells); however, overall cell killing, as determined by a clonogenic assay, was not affected by the presence of procaspase-3. The present study was undertaken to determine whether photodynamic therapy (PDT) in vivo was dependent on the ability of the cells to carry out the late steps in apoptosis that are catalyzed by this caspase. Xenografts of MCF-7 cells and the isogenic-derived MCF-7v and MCF-7c3 cells were generated in female athymic nude mice implanted with an estrogen pellet. MCF-7c3 xenografts, but not those of the other two lines, continued to express procaspase-3, as revealed by Western blots of proteins from the cells and the xenografts. When the xenografts reached 50-120 mm(3), some were treated with PDT (1mg/kg Pc 4 i.v. followed 48 h later by 150 J/cm(2) light at 672 nm and 150 mW/cm(2)), while others served as controls (no treatment, light alone, or Pc 4 alone). All Pc 4-PDT-treated tumors and none of the controls exhibited either complete or strong partial responses, and complete responses were durable for the entire observation period of 16 days. The responses were not dependent upon the presence of procaspase-3 in the xenografts. The results indicate that the rapid response of Pc 4-PDT-treated tumors in vivo is not due to their ability to carry out the major caspase-3-mediated late steps in apoptosis.

Hospital readmission among long-term ventilator patients

STUDY OBJECTIVES

Patients experiencing prolonged periods of in-hospital mechanical ventilation have been described as long-term ventilator (LTV) patients. The purpose of this study was to document the incidence of hospital readmission and to identify risk factors for readmission for LTV patients up to 6 months after hospital discharge.

DESIGN

This study was part of a larger prospective longitudinal descriptive study of posthospital outcomes for LTV patients.

SETTING AND PARTICIPANTS

One hundred ninety-nine ICU patients admitted to a university medical center, Veterans Administration hospital, or small community hospital who required > 96 h of continuous in-hospital mechanical ventilation were enrolled.

MEASUREMENTS AND RESULTS

Descriptive statistics, logistic regression, and survival analytic techniques were used. The 6-month hospital readmission rate was 38%. Readmission occurred most often within days 1 to 60 days (mean, 39.2 days) posthospital discharge. Predictive variables for readmission were the following: length of the index hospital stay; length of the index mechanical ventilation; and the need for oxygen at hospital discharge. Using survival analysis, the age category of 66 to 71 years was statistically significant for the relative risk of readmission within the first 30 days of the index hospital discharge.

CONCLUSIONS

LTV patients should be considered at risk for hospital readmission. Further study examining the impact of closer follow-up in the first 60 days posthospital discharge is necessary in order to determine whether there is a more effective way of reducing the risk of readmission for LTV patients.

Phase II and pharmacokinetic/pharmacodynamic trial of sequential topoisomerase I and II inhibition with topotecan and etoposide in advanced non-small-cell lung cancer

PURPOSE

In vitro and in vivo preclinical models have demonstrated synergistic activity when topoisomerase I and II inhibitors are administered sequentially. Topoisomerase I inhibitors increase topoisomerase II levels and increase cell kill induced by topoisomerase II poisons. We evaluated this hypothesis in a cohort of patients with advanced non-small-cell lung cancer (NSCLC).

METHODS

A group of 19 patients with advanced NSCLC (70% adenocarcinoma) received topotecan at a dose of 0.85 mg/m2 per day as a continuous 72-h infusion from days 1 to 3. Etoposide was administered orally at a dose of 100 mg twice daily for 3 days on days 7-9 (schedule and dose derived from prior phase I trials). Total and lactone topotecan concentrations were measured at the end of the 72-h infusion. Blood samples were obtained immediately after each 72-h topotecan infusion in order to measure the mutational frequency at the hypoxanthine phosphoribosyl transferase (HPRT) locus in peripheral lymphocytes.

RESULTS

A total of 55 cycles were administered. Toxicity was mainly hematologic with grade 4 neutropenia occurring in 7% of courses. Only one partial response and two stable diseases were observed. The 1-year survival rate was 33%. There was a statistically significant difference between steady-state lactone concentrations between cycle 1 and cycle 2 with decreasing concentrations with cycle 2 (P = 0.02). This was explained by a statistically significant increase in the clearance of topotecan lactone during cycle 2 (P = 0.03). Total but not lactone concentrations correlated with nadir WBC, ANC and platelet levels. Steady-state plasma lactone levels correlated with the mutational frequency at the HPRT locus (P = 0.06). In the one patient with a partial response a sixfold increase in HPRT mutational frequency was observed, which was not seen in patients with progressive disease.

CONCLUSION

The combination of topotecan and etoposide in this schedule of administration has minimal activity in adenocarcinoma of the lung. This lack of activity may be due to the delay in administration of etoposide after the topotecan as studies have shown that the compensatory increase in topoisomerase II levels after treatment with topoisomerase I inhibitors is shortlived (<24 h). The HPRT mutational frequency results suggest that the lack of clinical response may be associated with failure to achieve sufficient cytotoxic dose as indicated by a lack of increase in mutational frequency in those patients with progressive disease. HPRT mutational frequency may correlate with plasma steady-state topotecan lactone levels. Future studies should be directed toward earlier administration of topoisomerase II inhibitors after topoisomerase I inhibition.

The metabolic syndrome in the West Bank population: an urban-rural comparison

OBJECTIVE

To compare the prevalence of components of the metabolic syndrome, including hypertension, abnormal glucose metabolism, dyslipidemia, central obesity, and overall obesity, between a rural and an urban Palestinian West Bank community.

RESEARCH DESIGN AND METHODS

A total of 500 rural and 492 urban men and women aged 30-65 years participated in a community-based cross-sectional survey Diabetes and impaired glucose tolerance were diagnosed using the oral glucose tolerance test. BMI, waist-to-hip ratio, and blood pressure were measured, and blood samples were taken from each subject. Sociodemographic characteristics were investigated using a questionnaire.

RESULTS

Hypertriglyceridemia, low HDL cholesterol, overall obesity, and smoking were significantly more prevalent in the urban population, whereas central obesity was more prevalent in the rural population. Prevalence of hypertension was not significantly different between the rural and urban populations (25.4 and 21.5%, respectively; P = 0.15). The age-adjusted prevalences of diabetes were high: 11.3% (8.5-14.1 95% CI) and 13.9% (10.8-17.0) in the rural and urban populations, respectively, but not significantly different. In each community, the age-adjusted prevalence of the metabolic syndrome as defined by the World Health Organization was 17%.

CONCLUSIONS

Although no significant differences were found in the prevalences of hypertension and diabetes between the two populations, other components of the metabolic syndrome, namely elevated triglycerides, low HDL cholesterol, and overall obesity, were more prevalent in the urban population. Given the rapid urbanization of the Palestinian population, the implications for a rise in noncommunicable diseases should be a major public health concern.

Managed care for the Medicaid disabled: effect on utilization and costs

The objective of this study was to describe the effect on health care utilization and costs of a program of managed care for the Medicaid disabled. The study was designed as a pre/post enrollment cohort comparison and was carried out in three Ohio counties. The subjects were disabled Medicaid-insured patients who voluntarily enrolled in a managed care program for at least 6 months between July 1, 1995 and December 31, 1997, and who had (1) at least one Medicaid claim in the 24-months pre-enrollment period and (2) overall satisfactory postenrollment encounter-level data. Ohio Medicaid provided claims and reimbursements (costs) for the pre-enrollment period and encounter-level data for the postenrollment period. Postenrollment costs were estimated by applying category-specific average pre-enrollment costs to postenrollment utilization data. We measured the following per patient-month: (1) trends in category-specific utilization and costs for up to 24 months before and after enrollment, (2) differences in overall and category-specific costs 1 year before and after enrollment, and (3) changes in the distribution of services 1 year before and after enrollment. Utilization categories included inpatient care, outpatient hospital (including emergency department) care, physician services, prescription medications, durable medical equipment and supplies, and home health care. We found that satisfactory encounter data were available in two of three counties. Of 1,179 enrollees, 592 met all inclusion criteria. Before enrollment, utilization and costs were increasing significantly in four of six categories and were unchanging in two. Postenrollment, decreasing utilization was observed for three categories, one remained unchanged, and two were increasing, but from a lower "baseline." Except for physician services and home health care, there were lower utilization and estimated costs in all categories in the year after enrollment. Estimated inpatient and total costs declined by $155/patient-month (44.9%) and $210/patient-month (37.1%), respectively. Findings were similar across sites. Inpatient care, outpatient hospital care, and prescription medications accounted for 97% of the reductions in estimated costs in the postenrollment period. Among patients voluntarily enrolled for at least 6 months, managed care for the Medicaid disabled was associated with striking decreases in health care utilization and estimated costs. The effect of managed care on these patients' satisfaction, access to specialized services, quality of care, and health outcomes are understood incompletely.

A phase II and pharmacokinetic study of weekly 72-h topotecan infusion in patients with platinum-resistant and paclitaxel-resistant ovarian carcinoma

BACKGROUND

As suggested by preclinical trials, prolonged administration of topotecan, a reversible inhibitor of topoisomerase-I, may have a therapeutic advantage. Following a phase I trial of weekly 72-h topotecan infusion, we performed a phase II trial utilizing this schedule in ovarian carcinoma.

METHODS

Eligibility included platinum-/paclitaxel-resistant ovarian carcinoma, measurable disease, and adequate hematologic, renal, and hepatic function. A dose of 2.0 mg/m(2) of topotecan was administered as a 72-h infusion weekly via an ambulatory pump. Plasma topotecan concentrations were determined prior to and at the completion of each weekly course.

RESULTS

Twenty-four patients were entered and 23 patients were evaluable for toxicity and response. Two hundred eighteen weekly courses of therapy were administered (median 7 weeks, range 4-46 weeks). Toxicity was mild with grade 3 leukopenia, neutropenia, and anemia occurring in 13, 13, and 17% of patients, respectively. Two of 23 patients (9.1%) (CI 1-28%) had partial responses of 2 and 3 months' duration and 6 had stable disease. Steady state plasma topotecan lactone concentrations were a median of 1.2 ng/ml (range 0.4-8.00 ng/ml) following the first week of infusion. Steady state topotecan lactone concentrations after the first week of infusion were highest in 2 patients with partial responses. Mean steady state plasma topotecan lactone concentrations after the first week of infusion were 4.6, 2.0, and 1.3 ng/ml for partial response, stable disease, and progressive disease, respectively. An analysis of variance of steady state plasma topotecan concentrations after the first week of infusion over all administered cycles demonstrated a significant difference in steady state plasma topotecan lactone concentrations between patients with partial response and stable disease and between partial response and no response (significant at the 0.05 level after adjustment for multiple comparisons). Controlling for cycle number, steady state topotecan lactone concentrations are significantly greater for patients with responding or stable disease than those with progressive disease (P = 0.0003) and have a lower bound of > or = 1.9 ng/ml (95% confidence level).

CONCLUSION

Steady state topotecan lactone concentrations are associated with responding or stable disease in platinum- and paclitaxel-resistant ovarian cancer. Steady state topotecan concentrations could potentially be utilized to modify tumor exposure and response.

O6-methylguanine-DNA methyltransferase (MGMT) transfectants of a 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU)-sensitive colon cancer cell line selectively repopulate heterogenous MGMT+/MGMT- xenografts after BCNU and O6-benzylguanine plus BCNU

To evaluate the role of O6-alkylguanine-DNA alkyltransferase (AGT) in colon tumor chloroethylnitrosourea (CENU) resistance, AGT-deficient VACO 8 cells were transfected with a vector containing or lacking the human O6-methylguanine-DNA methyltransferase (MGMT) cDNA. VACO 8MGMT (V8MGMT) sublines possessed high levels of AGT activity in cell culture and were > 10-fold resistant to the CENU 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU). V8MGMT cells, VACO 8neo cells, and mixtures of both were grown as xenografts in nude mice. MGMT expression in VACO 8 xenografts reflected the percentage of V8MGMT cells present in the tumor inoculum. Xenografts originally containing 0-10% V8MGMT cells were sensitive to BCNU, although partial resistance was observed as the percentage of V8MGMT cells increased. Tumors containing 30-100% V8MGMT cells were completely resistant to BCNU with no regressions and no growth delays. Pretreatment with O6-benzylguanine (BG) depleted tumor AGT activity for at least 6 h and sensitized xenografts containing 1 and 100% V8MGMT cells to BCNU. After BCNU or BG + BCNU, xenografts growing from inoculums containing as low as 0.1% V8MGMT cells had high AGT activities similar to that found in V8MGMT xenografts, with the majority of the cells expressing MGMT. These results provide evidence that MGMT expression influences both intrinsic and acquired colon tumor CENU resistance, that selective expansion of AGT+ colon tumor cells commonly occurs after CENU exposure, and that BG is effective in sensitizing colon tumors to CENUs, even when only a small fraction of the cells in a heterogeneous tumor express MGMT.

Relationship between the size and margin status of ductal carcinoma in situ of the breast and residual disease

BACKGROUND

For women with ductal carcinoma in situ (DCIS) of the breast who have been treated with breastconserving surgery, the usefulness of size and surgical margin status (i.e., presence or absence of disease at the point of excision) as prognostic factors for predicting residual disease has not been well established. This study was conducted to determine more clearly the relationship between size and margin status of mammary DCIS to residual disease.

METHODS

The pathology records of 232 consecutive patients with mammary DCIS who had been initially treated with lumpectomy at the University Hospitals of Cleveland were retrospectively reviewed. The size of the DCIS and the surgical margins of lumpectomy were analyzed. Residual disease was defined as the persistence of DCIS in the re-excision and/or mastectomy specimens.

RESULTS

Residual disease was found in 15 of 101 patients with DCIS of less than 1.0 cm in longest dimension, in 27 of 96 patients with DCIS of 1.0-2.4 cm in size, and in 24 of 35 patients with DCIS of greater than or equal to 2.5 cm in size (P<.001). Residual disease was found in 30 of 77 patients with DCIS and positive margins, in 11 of 59 patients with DCIS and close margins (< or =1mm), and in 10 of 73 patients with DCIS and negative margins (>1 mm) (P =.001). In multivariate analysis, the occurrence of residual disease was associated with large tumor size (i.e., > or =2.5 cm) (odds ratio [OR] = 7.7; 95% confidence interval [CI] = 3.13-20.00; two-sided P = .0001) and with positive margin status (OR = 2.2; 95% CI = 1.02-4.55; two-sided P = .04).

CONCLUSIONS

The size and margin status of DCIS each were found to be independent predictors of residual disease.

The results of intraoperative consultations in 181 ductal carcinomas in situ of the breast

BACKGROUND

The utility of frozen section (FS) examination in the intraoperative management of breast lesions is well established. The accuracy of FS in the diagnosis of borderline noninvasive or preinvasive breast lesions is uncertain.

METHODS

The authors retrospectively reviewed the results of intraoperative consultations/frozen section examinations of 181 ductal carcinomas in situ (DCIS) of the breast. Various clinical and pathologic factors were analyzed and correlated with FS diagnosis.

RESULTS

FS examination was performed on 153 cases (85%) and only macroscopic examination on 28 cases (15%). FS diagnoses were as follows: DCIS in 76 cases (50%), atypical ductal hyperplasia/suspicious for DCIS in 8 cases (5%), benign in 55 cases (36%), deferred in 13 cases (8%), and invasive carcinoma in 1 case. FS accuracy, false-negative rate, and false-positive rate were 55%, 36%, and 0.6%, respectively. Sampling error was the main reason for the low detection rate, and technical inadequacy was a major factor contributing to interpretive problems. In multivariate regression analysis, FS accuracy was significantly associated with the clinical presentation of a palpable mass (odds ratio [OR] = 4.16, 95% confidence interval [CI]: 2.04-8.45), the macroscopic finding of a mass (OR = 3.03, 95% CI: 1.45-6.67), and necrosis (OR = 3.13, 95% CI: 1.4-6.67).

CONCLUSIONS

The authors concluded that the accuracy of FS diagnosis of DCIS was low, mainly due to sampling error. In general, FS examination should not be performed when no lesion/mass is identified by macroscopic examination.

Topotecan increases topoisomerase IIalpha levels and sensitivity to treatment with etoposide in schedule-dependent process

To elucidate the effect of topoisomerase (Topo) I inhibitors in the modulation of Topo II levels and sensitivity to Topo II-directed drugs, athymic mice bearing SW480 human colon cancer xenografts were treated with simultaneous, subsequent, or distant doses of topotecan and etoposide. This in vivo study demonstrates that simultaneous administration of topotecan and etoposide results in an antagonistic response. In contrast, inhibition of Topo I by topotecan results in a compensatory increase in Topo II alpha levels associated with increasing sensitivity of tumors to subsequent treatment with the Topo II inhibitor etoposide. Furthermore, we show that Topo II alpha levels decline 5 days after the last dose of topotecan, resulting in restoration of the original response of the xenografts to etoposide. Thus, this study emphasizes the critical role of schedule dependency to optimize the effectiveness of combination chemotherapy with Topo I and Topo II inhibitors.

Adjuvant chemotherapy plus tamoxifen compared with tamoxifen alone for postmenopausal breast cancer: meta-analysis of quality-adjusted survival

BACKGROUND

Adjuvant tamoxifen for early breast cancer provides an improvement in relapse-free (RFS) and overall survival (OS), especially for older women. We carried out a meta-analysis to find out whether the benefit of adding chemotherapy to tamoxifen outweighs its costs in terms of toxic effects for postmenopausal patients.

METHODS

The meta-analysis of quality-adjusted survival was based on data from 3920 patients aged 50 years or older with node-positive breast cancer randomly assigned in nine trials that compared combination chemotherapy plus tamoxifen with tamoxifen alone. The nine trials were included in the worldwide overview conducted by the early breast cancer trialists' collaborative group (EBCTCG). The quality-adjusted time without symptoms or toxicity (Q-TWiST) method was used to provide treatment comparisons incorporating differences in quality of life associated with subjective toxic effects of treatment and symptoms of disease relapse.

FINDINGS

Within 7 years of follow-up the modest benefit of increased RFS and OS for patients who received chemotherapy just balanced the costs in terms of acute toxic side-effects. Chemotherapy-treated patients gained an average of 5.4 months of RFS and 2 months of OS (neither statistically significant), but had to receive cytotoxic treatment for between 2 and 24 months to achieve these gains. No values of preference weights for time spent undergoing chemotherapy and time after relapse gave significantly more Q-TWiST with chemotherapy plus tamoxifen than with tamoxifen alone.

INTERPRETATION

Within 7 years of follow-up, adjuvant chemoendocrine therapy did not provide more quality-adjusted survival time than tamoxifen alone for women aged 50 years or older with node-positive breast cancer. Better selection and administration of chemotherapy regimen, different scheduling of chemotherapy and tamoxifen, and appropriate use of patient and tumour characteristics may increase the therapeutic advantage of the combination.

Association of education and income with estrogen receptor status in primary breast cancer

The relation of education and income to the estrogen receptor status of primary breast tumors was studied using two patient groups. The first consisted of 887 women from northeastern Ohio who were diagnosed between late 1974 and 1985 and entered into either of two prospective breast cancer clinical trials. All estrogen receptor values were determined by one laboratory. Through loglinear regression, patterns of association were studied among patient characteristics such as age, race/ethnicity, menopausal status, census tract indices of poverty and education, tumor diameter, stage of disease, obesity, and height and weight at the time of diagnosis. In this group of patients, estrogen receptor status was directly related to age, poverty, educational level, and tumor size. Younger women (odds ratio (OR) = 1.57, 95% confidence interval (CI) 1.14-2.17), women from census tracts with greater poverty (OR = 1.77, 95% CI 1.28-2.44) or less education (OR = 1.98, 95% CI 1.43-2.73), and women with larger tumors (OR = 0.67, 95% CI 0.48-0.92) were more likely to have estrogen receptor-negative tumors at the time of diagnosis of primary breast cancer. The second group consisted of 604 patients from northeastern Ohio whose tumors were diagnosed between 1986 and mid-1992 at University Hospitals of Cleveland. All estrogen receptor values were determined by one laboratory. Results from this second group of patients confirmed those from the first. This association of estrogen receptor-negative tumors with low economic and educational levels provides a potential explanation for the poor prognosis of these women.

Modulation of O6-alkylguanine alkyltransferase-directed DNA repair in metastatic colon cancers

PURPOSE

Carmustine (BCNU) resistance has been correlated with tumor expression of the DNA repair enzyme O6-alkylguanine-DNA alkyltransferase (AT). It has been shown that streptozotocin will deplete AT activity of human colon cancer cells in vitro and potentiate BCNU cytotoxicity. This clinical trial was conducted to determine whether streptozotocin can be used as a modulator of AT in metastatic colorectal cancers and thereby overcome clinical resistance to BCNU.

PATIENTS AND METHODS

Fifteen patients with fluorouracil-resistant metastatic colon or rectal cancers were treated sequentially with 2 g/m2 of streptozotocin followed 5 1/2 hours later by BCNU. Sequential biopsies of metastases before and after streptozotocin were conducted to determine whether streptozotocin depletes tumor AT. Peripheral-blood mononuclear cells (PBMCs) were evaluated as a surrogate tissue for prediction of baseline AT levels and streptozotocin posttreatment modulation of the AT in metastases.

RESULTS

Streptozotocin treatment led to a 78% (range, 69% to 89%) decrease in the AT levels in colon cancer metastases; however, myelosuppression and hepatic toxicity limited the BCNU dose to 130 mg/m2. A similar decrease in AT levels of PBMCs was found; however, the absolute levels of AT in PBMCs at baseline and following streptozotocin were not predictive of the levels expressed in metastases from the same patient. Despite the decrease in tumor levels of AT, no clinical responses were observed.

CONCLUSION

Streptozotocin decreases but does not fully deplete AT activity in metastatic colorectal cancers and the residual AT level in metastases is sufficient to maintain clinical resistance to BCNU. We have also demonstrated that sequential computed tomography (CT)-directed biopsies of colorectal cancer metastases can be used to evaluate strategies to investigate modulators of AT-directed repair. AT levels of PBMCs do not predict for the AT level or degree of modulation achieved in the metastatic tumor.

Age does not predict breast cancer outcome

OBJECTIVE

To determine whether age is a prognostic factor of breast cancer and should be used to make treatment recommendations, because younger patients are considered to have a poorer prognosis compared with that of older patients and, thus, often receive more aggressive therapy.

DESIGN

A large group of patients with operable breast cancer, all of whom were followed up prospectively as part of two multicenter trials.

SETTING

Case Western Reserve University, Cleveland, Ohio, was the primary hospital and study center, with 12 participating regional institutions.

PATIENTS

All 1353 patients underwent uniform local-regional therapy that consisted of a modified radical mastectomy. Patients who were node negative were followed up, and patients who were node positive received systemic chemoendocrine therapy.

MAIN OUTCOME MEASURES

Patients were followed up at regular intervals for either recurrence or death.

RESULTS

Patients ranged in age from 22 to 75 years with a median age of 56 years. Younger patients had more estrogen receptor-negative tumors (P < .0001) and a greater number of positive lymph nodes (P < .0001). Of the 241 black patients in the study, a greater percentage were younger compared with white patients (P < .0001). Age was considered in a Cox's multivariate model, together with nodes, tumor diameter, estrogen receptor content, and race. Age was not a significant predictor of either disease-free (P = .33) or overall (P = .30) survival. Using mixture models with covariates, the estimated average hazards (where lambda indicates the force of mortality) of breast cancer deaths per year were similar (P, not significant) for patients 45 years old or younger (lambda = 0.061), older than 45 years but 65 years old or younger (lambda = 0.052), and older than 65 years (lambda = 0.061).

CONCLUSIONS

In conclusion, younger patients as a group have more aggressive and advanced breast cancer at presentation compared with older patients. Considered in a multivariate model, together with other variables, age does not provide independent prognostic information and should not be used alone for management decisions.

Synergistic efficacy of O6-benzylguanine and 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU) in a human colon cancer xenograft completely resistant to BCNU alone

The DNA repair protein O6-alkylguanine-DNA alkyltransferase (alkyltransferase) repairs cytotoxic DNA damage formed by 1,3-bis(2-chloroethyl)-1-nitrosourea (BCNU). High levels of this repair protein cause tumor drug resistance to nitrosoureas. To investigate the ability of a direct alkyltransferase inhibitor, O6-benzylguanine, to reverse the nitrosourea resistance of human colon cancer cells, we studied the VACO 6 cell line which has high alkyltransferase and is completely resistant to BCNU at maximal tolerated doses in the xenograft model. O6-Benzylguanine at 0.5 microgram/mL for 1 hr inactivated VACO 6 alkyltransferase by > 98% and reduced the IC50 of BCNU by 3- to 4-fold. Further analysis indicated that these two agents act in a highly synergistic fashion. In xenograft bearing athymic mice, dose-dependent depletion of hepatic and tumor alkyltransferase was noted. To maintain alkyltransferase depletion in the xenograft for at least 24 hr, two doses of 60 mg/kg O6-benzylguanine were given 1 hr prior and 7 hr after BCNU. Under these conditions, VACO 6 xenografts became responsive to BCNU with significant reductions (P < 0.001) in the tumor growth rate. The combination increased toxicity to the host, reducing the maximum tolerated dose of BCNU by approximately 50%. This study provides definitive evidence that high alkyltransferase activity is responsible for BCNU resistance in human colon cancer xenografts and that with careful drug scheduling, O6-benzylguanine can sensitize a tumor which is completely unresponsive to BCNU alone. Further studies which optimize the therapeutic index of BCNU and O6-benzylguanine in vivo will define the schedule to be used in broader preclinical studies.

Using toxicity grades in the design and analysis of cancer phase I clinical trials

Ethical considerations in a cancer phase I trial require a design allowing determination of the maximum tolerated dose with a minimum number of patients treated at low ineffectual or high overly toxic doses. It would also be advantageous to complete the phase I trial in as short a period of time and with as few patients as possible to allow further resources for later studies in which patients are treated at the optimal dose. Several dose escalation schemes are compared. These are the Fibonacci, two two-stage schemes, and a proposed scheme which uses knowledge of all toxicity grades. Estimates of the maximum tolerated dose are obtained and compared using the dose escalation schemes alone, a logit model, and a proposed mean response model. Confidence intervals using the delta method are obtained from the logit and mean response models. The proposed scheme and the two-stage schemes have the advantage of requiring fewer patients, particularly at low doses. Confidence intervals obtained from the mean response model have better coverage than those from the logit model. Data from a cancer phase I trial of dipyridamole and acivicin is presented to illustrate the methods.

Primary tumor size. Relevance to breast cancer survival

In view of current emphasis on identifying prognostic factors for patients with early breast cancer, we studied the importance of tumor size to survival among 1392 patients with primary operable breast cancer who were followed up prospectively. All patients had modified radical mastectomies. Nine hundred seventeen patients had negative nodes and did not receive postoperative adjuvant therapy. Four hundred seventy-five patients had node involvement and received combination chemoendocrine therapy. In a Cox's proportional hazards model, tumor size was a significant predictor of disease-free and overall survival when the number of positive nodes, estrogen receptor status, menopausal status, and race were considered. Among the node-negative group, tumor size explained considerable variation in disease-free and overall survival, varying from a 10-year disease-free and overall survival of 80% and 99% for patients with estrogen receptor-positive tumors measuring 1 cm or less to a 10-year disease-free and overall survival of 51% and 59% for patients with tumors larger than 5 cm.

Socioeconomic factors and race in breast cancer recurrence and survival

The relation of breast cancer recurrence and overall survival to age, level of estrogen receptors, number of positive lymph nodes, obesity, race, socioeconomic status, and tumor size at the time of diagnosis was considered for 1,392 breast cancer patients (253 black, 1,132 white, and 7 of other races) entered into two multi-institutional prospective clinical trials. Baseline for the first trial was 1974-1979, and that for the second was 1980-1985; follow-up for this report ended in August 1990. Univariately, all factors except age and obesity were significantly related to disease-free survival, and all except age were significantly related to overall survival. A multivariate analysis using Cox's proportional hazards model indicated that a greater number of positive lymph nodes, a larger tumor diameter, lower socioeconomic status, and negative estrogen receptors were significantly related to shorter disease-free survival. After adjustment for socioeconomic status, race ceased to be a significant indicator of either disease-free survival or overall survival. Patients of either race who are of a lower socioeconomic status are more likely to have a recurrence and to die of breast cancer.

Local-regional breast cancer recurrence following mastectomy

Local-regional recurrence patterns were investigated in 1392 patients with breast cancer. Primary treatment for all patients included a mastectomy. Nine hundred seventeen patients had negative nodes and did not receive systemic therapy. Four hundred seventy-five patients had node metastases and were randomized to receive different combinations of chemoendocrine therapy. Follow-up ranged between 5 and 16 years. Two hundred thirty (25.8%) node-negative patients have had recurrences, with the initial recurrence being local-regional in 9.2%. Two hundred forty-two (50.9%) node-positive patients have had recurrences, with the initial recurrence being local-regional in 17.1%. Larger tumors and more extensive node involvement were associated with more first local-regional recurrences. The relative percent of first local-regional recurrence among patients in whom cancer recurred was similar for node-negative and node-positive patients (35.4% and 33.5%, respectively). In 63.6% of patients in whom cancer recurred, first local-regional recurrence were distant. Larger tumors, more extensive node involvement, and a shorter disease-free interval after mastectomy were associated with more rapid appearance of distant recurrence among these patients.

A critical analysis of the largest reported mass fecal occult blood screening program in the United States

Fecal occult blood testing for the detection of colon cancer remains controversial. We performed a mass screening program from January 24, 1988, to February 19, 1988, with intensive media promotion, including 121 minutes of televised air time. A total of 5,000 primary practitioners were notified by mail. Hemoccult-II tests were distributed to 156,000 individuals; 55,051 (35%) were returned. Ninety-five percent of the respondents were informed of the program by television. A total of 3,375 persons (6%) tested positive for fecal occult blood; of these, 2,469 (73%) informed the center that they saw their physician to initiate a work-up. Information from physicians regarding work-ups was returned on only 1,356 (55%) patients. Diagnostic tests numbered 2,227 (1.6 tests per patient). However, 5% had no testing, 16% had a repeat Hemoccult only, and 35% had neither a barium enema nor colonoscopy performed. Thirty-six colorectal cancers and 212 polyps were identified. The predictive value (i.e., number of cancers per number of patients who tested positive) increased directly by decade. Thirty-three of 36 patients (92%) with cancer underwent either a barium enema or colonoscopy versus only 185 of 438 (42%) patients with a "negative" work-up. Cancers found were carcinoma in situ in 10 patients (29%), Dukes A in 12 (35%), Dukes B in 4 (12%), and Dukes C in 8 (24%); distant metastases were not found in any participant. Thirty-six percent of the tumors were located in either the right or transverse colon. We conclude that: (1) Screening identified early cancers. All were potentially curable and 64% were limited to the bowel wall. (2) Massive Hemoccult distribution was possible over a short interval, but patient and physician compliance was disturbingly low. (3) Total colonic evaluation is mandatory, since at least 36% of tumors were beyond the reach of the flexible sigmoidoscope. (4) Many work-ups were unnecessary (repeat Hemoccults) or inadequate, indicating a need for physician education.

Short-term tamoxifen plus chemotherapy: superior results in node-positive breast cancer

Three hundred eleven patients with node-positive breast cancer were randomized to one of three adjuvant treatments: cyclophosphamide (Cytoxan), methotrexate, and 5-fluorouracil; all of the above with tamoxifen citrate; or all of the above with tamoxifen and bacillus Calmette-Guerin vaccination. Local therapy for all patients was a modified radical mastectomy. Estrogen receptors were measured on all primary tumors. Patients were stratified by the number of positive nodes (one to three nodes and more than three nodes) and estrogen-receptor value (less than 3 femtomole/mg and greater than or equal to 3 femtomole/mg). Follow-up is available, with a mean of 9.1 and maximum of 14.2 years. In this study the efficacy of short-term tamoxifen is apparent over that of chemoimmunotherapy alone and continues to be significant with prolonged follow-up. The addition of tamoxifen to chemoimmunotherapy significantly prolonged disease-free survival among patients with estrogen receptor-positive tumors who were postmenopausal, who had larger tumors (greater than 3 cm), or who had more extensive axillary node involvement (more than three nodes). Tamoxifen improved overall survival for patients with estrogen receptor-positive tumors larger than 3 cm. The addition of bacillus Calmette-Guerin Cytoxan, methotrexate, 5-fluorouracil, and tamoxifen did not significantly alter disease-free or overall survival.

Modulation of tissue responsiveness to angiotensin-II in hyperprolactinemic subjects

The present studies were designed to test the hypothesis that hyperprolactinemia modulates target tissue responsiveness to angiotensin-II (AII). Adrenal and pressor responses to AII infusions were determined in six patients with PRL-secreting pituitary microadenomas and in five normal controls during defined electrolyte balance. Hyperprolactinemic and normal subjects had similar mean blood pressures while on a regular Na intake (82.5 +/- 0.5 vs. 81.2 +/- 0.3 mm Hg). However, after 4 days of Na loading (200 meq/day), the mean blood pressure in hyperprolactinemic subjects was higher than that in normal (86.6 +/- 1 vs. 83.4 +/- 0.8 mm Hg; P less than 0.05). In addition, enhancement of the mean blood pressure response to three doses of AII was noted in hyperprolactinemic subjects (P less than 0.05) compared to that in normal subjects. After 4 days of Na restriction (10 meq/day), the mean blood pressure in hyperprolactinemic subjects was similar to that in normal subjects (79.7 +/- 0.6 vs. 78.9 +/- 1 mm Hg). However, despite adequate Na restriction, the pressor response to AII continued to be enhanced (P less than 0.05) in hyperprolactinemic subjects. There were no differences in plasma or urinary electrolytes or in PRA between hyperprolactinemic and normal subjects. Hyperprolactinemic subjects had higher basal (P less than 0.01), AII-stimulated (P less than 0.05), and ACTH-stimulated (P less than 0.02) aldosterone levels during Na loading, but not during Na restriction. The differences disappeared after the correction of the hyperprolactinemia. The data demonstrate significant alterations in adrenal and pressor responsiveness in hyperprolactinemic subjects and suggest a modulating role for PRL on vascular reactivity and steroid biosynthesis. The precise mechanism has not been determined, but may be secondary to PRL-induced up-regulation of adrenal and vascular AII receptors.

Application of the theory of finite mixtures for the estimation of 'cure' rates of treated cancer patients

I assume the survival function of treated cancer patients to be a mixture of two subpopulations, with c equal to the proportion who will die of other causes, and 1--c the proportion who will die of their disease. Using census data, I estimate the parameters of the survival distribution of those patients dying of other causes, and then use follow-up data to determine the maximum likelihood estimates of the proportion constant c and the parameters of the survival function of those dying of their disease. I illustrate the methodology using data from a prospective clinical trial in breast cancer.

A comparison of postoperative pain relief techniques in orchidopexy

Fifty consecutive patients admitted to the Western General Hospital for orchidopexy, were randomly allocated to receive either a caudal bupivacaine block or peroperative wound instillation with bupivacaine, to provide postoperative analgesia. Bupivacaine wound instillation reduced the total operating time, gave more efficient postoperative pain relief in hospital and proved both inexpensive and simple in its application.

Breast cancer survival and perioperative blood transfusion

The effect of perioperative blood transfusion on disease-free and overall survival was studied in 812 patients with stages I and II breast cancer, followed up prospectively in a multicenter study. All patients initially underwent a modified radical mastectomy. Patients with axillary node-negative, stage I cancer were followed up without additional therapy. Patients with axillary node-positive, stage II cancer were randomized to receive adjuvant chemoendocrine therapy. Transfusion was done in 35.8% of the patients with stage I and in 37.3% of the patients with stage II cancer. For the patients with stage II cancer, perioperative blood transfusion did not affect disease-free or overall survival. For the patients with stage I cancer, perioperative blood transfusion resulted in a worse disease-free and overall survival (p = 0.05 and 0.02, respectively), which was particularly evident for those patients who received more than 1 unit. This study suggests that stage of disease, adjuvant therapy, number of transfusions, and duration of follow-up must be considered in further analyses.

Endocrine versus endocrine plus five-drug chemotherapy in postmenopausal women with stage II estrogen receptor-positive breast cancer

Postmenopausal women who underwent modified radical mastectomy for Stage II, estrogen receptor (ER)-positive breast cancer were randomized to receive endocrine treatment (tamoxifen [T], 40 mg daily for 3 years) alone versus endocrine treatment plus five-drug chemotherapy (Cytoxan [cyclophosphamide, C], methotrexate [M], 5-fluorouracil [F], vincristine [V], and prednisone [P], CMFVP, for 1 year). Chemotherapy consisted of oral P (1 month), oral C (12 months), and intravenous MFV weekly for the first 3 months, biweekly for 3 months, and triweekly for 6 months. Patients were entered into the study from October 1979, to October 1985, and the median follow-up is 55 months. Results show that with 94 postmenopausal women, disease-free survival (DFS) is significantly greater (P = 0.04, log-rank test; P = 0.03, multivariate analysis) in patients receiving CMFVPT as compared to those receiving T alone. These results suggest that intensive chemotherapy combined with T is more effective in delaying recurrence than T alone in postmenopausal patients.