Embedding an Education Intervention about Shared Decision Making into an RCT: Ensuring competency and fidelity

Objective

To describe the outcomes of training nephrology clinicians and clinical research participants, to use the Best Case/Worst Case Communication intervention, for discussions about dialysis initiation for patients with life-limiting illness, during a randomized clinical trial to ensure competency, fidelity to the intervention, and adherence to study protocols and the intervention throughout the trial.

Methods

We enrolled 68 nephrologists at ten study sites and randomized them to receive training or wait-list control. We collected copies of completed graphic aids (component of the intervention), used with study-enrolled patients, to measure fidelity and adherence.

Results

We trained 34 of 36 nephrologists to competence and 27 completed the entire program. We received 60 graphic aids for study-enrolled patients for a 73% return rate in the intervention arm. The intervention fidelity score for the graphic aid reflected completion of all elements throughout the study.

Conclusion

We successfully taught the Best Case/Worst Case Communication intervention to clinicians as research participants within a randomized clinical trial.

Innovation

Decisions about dialysis are an opportunity to discuss prognosis and uncertainty in relation to consideration of prolonged life supporting therapy. Our study reveals a strategy to evaluate adherence to a communication intervention in real time during a clinical study.

Orthopaedic Sports Medicine Randomized Controlled Trials Infrequently Report on the Social Determinants of Health Factors of Their Patient Cohorts

PURPOSE

To describe the prevalence of randomized controlled trials (RCTs) in orthopaedic sports medicine-related journals reporting on the social determinants of health (SDOH) of their patient cohorts, including factors receiving less attention, such as education level, employment status, insurance status, and socioeconomic status.

METHODS

The PubMed/MEDLINE database was used to search for RCTs between 2020 and 2022 from 3 high-impact orthopaedic sports medicine-related journals: American Journal of Sports Medicine, Arthroscopy, and Journal of Shoulder and Elbow Surgery. The following information was extracted from each article: age, sex/gender, body mass index, year published, corresponding author country, and self-reported SDOH factors (race, ethnicity, education level, employment status, insurance status, and socioeconomic status).

RESULTS

A total of 189 articles were analyzed. Articles originated from 34 different countries, with the United States (n = 66) producing the greatest number of articles. Overall, age (n = 186; 98.4%) and sex/gender (n = 184; 97.4%) were the factors most commonly reported, followed by body mass index (n = 112; 59.3%), race (n = 17; 9.0%), ethnicity (n = 10; 5.3%), employment status (n = 9; 4.8%), insurance status (n = 7; 3.7%), and education level (n = 5; 2.6%). Socioeconomic status was not reported in any of the articles analyzed. Articles from the United States report on SDOH factors more frequently than international articles, most notably race (24.2% vs 0.8%, respectively) and ethnicity (15.2% and 0%, respectively).

CONCLUSIONS

RCTs from 3 high-impact orthopaedic sports medicine journals infrequently report on SDOH.

CLINICAL RELEVANCE

Better understanding patient SDOH factors in RCTs is important to help orthopaedic surgeons and other practitioners best apply study results to their patients, as well as help researchers and our field ensure that research is being done transparently with relevance to as many patients as possible.

"The Equipoise Ruler:" A National Survey on Surgeon Judgment about the Value of Surgery

OBJECTIVE

The objective of this study was to understand professional norms regarding the value of surgery.

SUMMARY BACKGROUND DATA

Agreed-upon professional norms may improve surgical decision making by contextualizing the nature of surgical treatment for patients. However, the extent to which these norms exist among surgeons practicing in the US is not known.

METHODS

We administered a survey with 30 exemplar cases asking surgeons to use their best judgement to place each case on a scale ranging from "Definitely would do this surgery" to "Definitely would not do this surgery." We then asked surgeons to repeat their assessments after providing responses from the first survey. We interviewed respondents to characterize their rationale.

RESULTS

We received 580 responses, a response rate of 28.5%. For 19 of 30 cases there was consensus (≥60% agreement) about the value of surgery (range 63% - 99%). There was little within-case variation when the mode was for surgery and more variation when the mode was against surgery or equipoise. Exposure to peer response increased the number of cases with consensus. Women were more likely to endorse a non-operative approach when treatment had high mortality. Specialists were less likely to operate for salvage procedures. Surgeons noted their clinical practice was to withhold judgment and let patients decide despite their assessment.

CONCLUSIONS

Professional judgment about the value of surgery exists along a continuum. While there is less variation in judgment for cases that are highly beneficial, consensus can be improved by exposure to the assessments of peers.

Correction to Effect of vitamin K on bone mineral density and fractures in adults: an updated systematic review and meta-analysis of randomised controlled trials

Following the work of Avenell et al. that has raised concerns about the integrity of the Yamaguchi Osteoporosis Prevention Study (YOPS) conducted by Ishida and Kawai we issue here an adjustment to all meta-analysis estimates that contained this work within our systematic review.

Effect of vitamin K on bone mineral density and fractures in adults: an updated systematic review and meta-analysis of randomised controlled trials

Vitamin K may affect bone mineral density and fracture incidence. Since publication of a previous systematic review the integrity of some of the previous evidence has been questioned and further trials have been published. Therefore an update to the systematic review was required.

INTRODUCTION

This systematic review was designed to assess the effectiveness of oral vitamin K supplementation for increasing bone mineral density and reducing fractures in adults.

METHODS

MEDLINE, EMBASE, CENTRAL, CINAHL, clinicaltrials.gov, and WHO-ICTRP were searched for eligible trials. Randomised controlled trials assessing oral vitamin K supplementation that assessed bone mineral density or fractures in adult populations were included. A total of 36 studies were identified. Two independent reviewers extracted data using a piloted extraction form.

RESULTS

For post-menopausal or osteoporotic patients, meta-analysis showed that the odds of any clinical fracture were lower for vitamin K compared to controls (OR, 0.72, 95%CI 0.55 to 0.95). Restricting the analysis to low risk of bias trials reduced the OR to 0.76 (95%CI, 0.58 to 1.01). There was no difference in vertebral fractures between the groups (OR 0.96, 95%CI 0.83 to 1.11). In the bone mineral density meta-analysis, percentage change from baseline at the lumbar spine was higher at 1 year (MD 0.93, 95%, CI - 0.02 to 1.89) and 2 years (MD 1.63%, 95%CI 0.10 to 3.16) for vitamin K compared to controls; however, removing trials at high risk of bias tended to result in smaller differences that were not statistically significant. At 6 months, it was higher in the hip (MD 0.42%, 95%CI 0.01 to 0.83) and femur (MD 0.29%, 95%CI 0.17 to 0.42). There was no significant difference at other anatomical sites.

CONCLUSIONS

For post-menopausal or osteoporotic patients, there is no evidence that vitamin K affects bone mineral density or vertebral fractures; it may reduce clinical fractures; however, the evidence is insufficient to confirm this. There are too few trials to draw conclusions for other patient groups.

Dense WDM transmission at 2 μm enabled by an arrayed waveguide grating

We show, for the first time, dense WDM (8×20  Gbit/s) transmission at 2 μm enabled by advanced modulation formats (4-ASK Fast-OFDM) and the development of key components, including a new arrayed waveguide grating (AWGr) at 2 μm. The AWGr shows -12.8±1.78  dB of excess loss with an 18-dB extinction ratio and a thermal tunability of 0.108 nm/°C.

MicroStructure Element Method (MSEM): viscous flow model for the virtual draw of microstructured optical fibers

We propose a new method to accurately model the structural evolution of a microstructured fiber (MOF) during its drawing process, given its initial preform structure and draw conditions. The method, applicable to a broad range of MOFs with high air-filling fraction and thin glass membranes, is an extension of the Discrete Element Method; it determines forces on the nodes in the microstructure to progressively update their position along the neck-down region, until the fiber reaches a final frozen state. The model is validated through simulation of 6 Hollow Core Photonic Band Gap Fibers (HC-PBGFs) and is shown to predict accurately the final fiber dimensions and cross-sectional distortions. The model is vastly more capable than other state of the art models and allows fast exploration of wide drawing parameter spaces, eliminating the need for expensive and time-consuming empirical parameter scans.

X-ray tomography for structural analysis of microstructured and multimaterial optical fibers and preforms

Specialty optical fibers, in particular microstructured and multi-material optical fibers, have complex geometry in terms of structure and/or material composition. Their fabrication, although rapidly developing, is still at a very early stage of development compared with conventional optical fibers. Structural characterization of these fibers during every step of their multi-stage fabrication process is paramount to optimize the fiber-drawing process. The complexity of these fibers restricts the use of conventional refractometry and microscopy techniques to determine their structural and material composition. Here we present, to the best of our knowledge, the first nondestructive structural and material investigation of specialty optical fibers using X-ray computed tomography (CT) methods, not achievable using other techniques. Recent advances in X-ray CT techniques allow the examination of optical fibers and their preforms with sub-micron resolution while preserving the specimen for onward processing and use. In this work, we study some of the most challenging specialty optical fibers and their preforms. We analyze a hollow core photonic band gap fiber and its preforms, and bond quality at the joint between two fusion-spliced hollow core fibers. Additionally, we studied a multi-element optical fiber and a metal incorporated dual suspended-core optical fiber. The application of X-ray CT can be extended to almost all optical fiber types, preforms and devices.

Hypocycloid-shaped hollow-core photonic crystal fiber Part I: arc curvature effect on confinement loss

We report on numerical and experimental studies showing the influence of arc curvature on the confinement loss in hypocycloid-core Kagome hollow-core photonic crystal fiber. The results prove that with such a design the optical performances are strongly driven by the contour negative curvature of the core-cladding interface. They show that the increase in arc curvature results in a strong decrease in both the confinement loss and the optical power overlap between the core mode and the silica core-surround, including a modal content approaching true single-mode guidance. Fibers with enhanced negative curvature were then fabricated with a record loss-level of 17 dB/km at 1064 nm.

Hypocycloid-shaped hollow-core photonic crystal fiber Part II: cladding effect on confinement and bend loss

We report on numerical and experimental studies on the influence of cladding ring-number on the confinement and bend loss in hypocycloid-shaped Kagome hollow core photonic crystal fiber. The results show that beyond the second ring, the ring number has a minor effect on confinement loss whereas the bend loss is strongly reduced with the ring-number increase. Finally, the results show that the increase in the cladding ring-number improves the modal content of the fiber.

Abstract P5-10-13: Pre-surgical plasma microRNA pattern defines a biologically distinct triple negative breast cancer (TNBC) occuring in black (B) compared to white (W) women

Background: Black women with triple negative breast cancer have 46% lower survival rates; this may be due to differences in tumor biology. We analyzed presurgical plasma microRNA of white (W) and black (B) women with TNBC enrolled in the breast ovarian tissue bank to detect if differences in the pre-surgical plasma microRNA could be detected in B patients relative to W patients relative to healthy controls.

Aims: MicroRNA in pre-surgical plasma of TNBC W or B was compared to plasma from controls race and age matched controls to assess if differences in plasma and tumor microRNA may explain the survival disparity observed in B. We addressed 2 questions 1) are the patterns in the pre-surgical miRNA profiles different between W and B patients, differences that could explain outcomes discrepancy? 2) What are the miRs changes in patients W or B relative to healthy controls?

Methods: Between 2004 and 2011 plasma miRNAs was measured before, after surgery, during and after chemotherapy in 73 surgical breast cancer patients and 11 age and race matched controls. We also analized miRs in the tumor and benign adjacent breast in 5 specimes. Samples were analyzed using qRT-PCR in the ABI's TaqMan OpenArray Panel for 750 miRs. Samples were spiked with ath-miR-159a and hsa-miR-320 most strongly correlated in its expression to ath-miR-159a through the Pearson correlation coefficient. 2-sample t-test was used for comparisons between means and ANOVA followed by post-hoc test to compare the mean response between subject factors of interest. All tests were 2-tailed; statistical significance was set at p < 0.05.

Results: 44 W and 23 B, mean age at surgery 48 years (range 35–78) and 11 controls – mean age 44 years (range 35–67). Black TNBC patients did not express over 70 % of pre-surgical plasma miRs present in the W pre-surgical plasma. B over-expressed high levels of miR-1244, -190 and -638, which were not detected in any of the W patients (p < 0.005). W patients and controls expressed miRs10a, -190, -502-3p, -548, and -9* not detected in B TNBC patients. White patients over-expressed over 80% of plasma miRs present in controls, while black patients over-expressed only 30% of miRs present in controls (P < 0.005).

Conclusions: Patterns of pre-surgical miR expression are different in B versus W patients with TNBC. In B the presence of TNBC leads to silence in circulating plasma miRs in comparison to W and controls. In W the presence of the tumor increases the miR “chatter”. Black patients have a different “communication” style between host-TNBC when analyzed by the response of plasma microRNA. This difference may call for different treatment protocols for patients. Specific treatment interventions, such as administration of chemotherapy before surgery, in an attempt to increase the microRNA levels in plasma may improve the outcomes of black patients with TNBC.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P5-10-13.

Effect of taping on the shoulders of Australian football players

BACKGROUND

Taping of the shoulder is common in many sports, particularly Australian football, a contact sport that often involves marking (catching) the ball overhead and has a high incidence of shoulder instability.

HYPOTHESIS

Taping of the shoulder reduces glenohumeral joint laxity and improves proprioception without impairing function.

STUDY DESIGN

Crossover study design.

METHODS

33 male players aged 18-31 years were recruited from a local Australian football club. The dominant shoulder of each player was tested with and without taping in a randomised fashion by an examiner blinded to the presence or absence of taping. The tests were (1) inferior glenohumeral joint laxity (the Orthopaedic Research Institute laxometer), (2) shoulder joint position sense accuracy using an optical tracking system, and (3) handballing accuracy.

RESULTS

The methods for testing laxity and joint position sense had good intraobserver reliability and sensitivity. All subjects tolerated the taping and testing. Glenohumeral joint laxity (p=0.75), joint position sense (p=0.56) and handballing accuracy (p=0.6) were not changed by taping.

CONCLUSIONS

Taping of the shoulder joint in uninjured and non-symptomatic Australian football players in a pattern that attempted not to restrict their range of overhead movement did not significantly affect the accuracy of joint position sense, inferior laxity or handball accuracy.

CLINICAL RELEVANCE

These data suggest that taping of the shoulder is unlikely to decrease the incidence of injury-specifically dislocation-of the shoulder in Australian football players.

Prognostic indicators for the development of AIDS in HIV antibody positive haemophiliac patients: results of a three-year longitudinal study

In February 1986, 40 out of 75 adult patients with haemophilia A attending St. James's University Hospital were human immunodeficiency virus (HIV) antibody positive. Over a three-year period these patients were prospectively studied with regard to possible prognostic indicators for the development of the acquired immune deficiency syndrome (AIDS). Using the Centres for Disease Control (CDC) classification of HIV infection, 17 patients (42.5%) developed group 4 disease during this time, giving an actuarial three-year progression rate of 44%, and 5 patients (12.5%) died. The following parameters measured at recruitment were found independently to predict progression to AIDS: a serum beta 2-m level of greater than 3.5 mg/l, (chi 2 = 15.95, P less than 0.001), a serum IgA level of greater than 4.5 milligram(s) (chi 2 = 6.08, P less than 0.02) and p24 antigenaemia (chi 2 = 5.7, P less than 0.05). The actuarial three-year progression rate in those patients abnormal by two or more of these parameters was 100% (n = 7), compared to only 7% in patients who were normal by all three values (n = 15). CD4+ lymphocyte counts and CD4+:CD8+ ratios were significantly lower in HIV positive compared with HIV negative patients (P less than 0.01), but did not predict the development of AIDS.

Heparin-induced thrombocytopenia complicating hemodialysis

Hemodialysis complicated by heparin-induced thrombocytopenia (HIT) is a rare event requiring anticoagulation with direct-thrombin inhibitors. Contaminant calcific uremic arteriolopathy (calciphylaxis) further complicates this situation due to the possibility that warfarin anticoagulation may exacerbate skin necrosis. The authors report a patient with renal failure and calciphylaxis who developed HIT after starting hemodialysis. She was successfully treated with Argatroban.

Reliability of a new shoulder laxometer to assess inferior glenohumeral joint translation

OBJECTIVE

This study tested the reliability of the ORI laxometer, a newly developed non-invasive device for testing inferior translation of the humeral head in humans.

DESIGN

The instrument was designed to measure displacement between the top of the acromion and the head of the humerus when loaded in a similar fashion to the sulcus sign.

PARTICIPANTS AND INTERVENTIONS

Sixteen healthy subjects (32 shoulders) were measured for inferior glenohumeral joint laxity. One observer used the laxometer in 16 subjects on three separate occasions for the intra-observer trial. Three observers measured the inferior shoulder laxity of six subjects on one occasion in the inter-observer trial. Asymptomatic and unstable shoulders were also compared in 12 subjects with shoulder instability.

MAIN OUTCOME MEASUREMENTS

Translation in the glenohumeral joint

RESULTS

The range of inferior translation of glenohumeral joint in these subjects was between 0.01 mm and 6.5 mm with a mean of 1.5 mm. The intraclass correlation coefficient (ICC) for inter-observer reliability was 0.74. For intra-observer reliability the ICC was 0.76. These results are considered to be good to excellent. There was no advantage gained by using data from all five cycles of testing compared with three cycles. In patients with shoulder instability, laxometer measurements were significantly greater in their unstable shoulders than in their normal shoulders.

CONCLUSIONS

The laxometer is easy to use, painless and gives objective measures for inferior glenohumeral laxity, with good intra- and inter-observer reliabilities. The ORI laxometer may be useful for assessing and monitoring global glenohumeral joint laxity which usually involves inferior laxity.

Anticoagulation vs. vena caval filters in cancer patients with venous thromboembolism: Improved survival with anticoagulation

8553

Background: Cancer patients (pts) have an increased incidence of venous thromboembolism (VTE). Inferior vena caval (IVC) filters are used extensively in the US; over 40,000 are inserted annually. The impact on survival of cancer pts receiving IVC filters has not been studied. Methods: A retrospective study examined 154 consecutive cancer pts with VTE in order to compare the effects of IVC filter placement with anticoagulation (AC) therapy on overall survival (OS), as measured from the time of VTE. Pts were classified into three treatment groups: AC (n=58), IVC filter (73), or combination IVC filter+AC (23). OS was analyzed using survival analysis methods (e.g., Kaplan-Meier Product-Limit Method, logrank test). Multivariate Cox regression was used to account for the possible confounders: ECOG performance status (PS) and type of thrombus. Results: Treatment groups did not differ with respect to age, gender, or albumin levels. Groups did differ for PS (P<0.033 chi-square test, better PS was associated with AC only) and for type of thrombus (P<0.007 chi-square, DVT was associated with AC, PE with IVC, and DVT/PE with AC+IVC). Median OS was significantly greater in pts treated with AC (11 mos) compared to IVC filters (3 mos) or IVC+AC (3.5 mos) (p<0.0046). IVC pts were 1.73 times more at risk of death than AC only (hazard ratio; 95%CI 1.18–2.52). Multivariate analysis revealed that PS and type of thrombus were not confounders and had no effect on OS. Conclusion: AC should be considered primary therapy for cancer pts with VTE. IVC filters should be considered a therapeutic option only when AC is strictly contraindicated. Prospective randomized trials are needed to address this issue.

No significant financial relationships to disclose.

Challenge of culture, conscience, and contract to general practitioners' care of their own health: qualitative study

OBJECTIVE

To explore general practitioners' perceptions of the effects of their profession and training on their attitudes to illness in themselves and colleagues.

DESIGN

Qualitative study using focus groups and in depth interviews.

SETTING

Primary care in Northern Ireland.

PARTICIPANTS

27 general practitioners, including six recently appointed principals and six who also practised occupational medicine part time.

MAIN OUTCOME MEASURES

Participants' views about their own and colleagues' health.

RESULTS

Participants were concerned about the current level of illness within the profession. They described their need to portray a healthy image to both patients and colleagues. This hindered acknowledgement of personal illness and engaging in health screening. Embarrassment in adopting the role of a patient and concerns about confidentiality also influenced their reactions to personal illness. Doctors' attitudes can impede their access to appropriate health care for themselves, their families, and their colleagues. A sense of conscience towards patients and colleagues and the working arrangements of the practice were cited as reasons for working through illness and expecting colleagues to do likewise.

CONCLUSIONS

General practitioners perceive that their professional position and training adversely influence their attitudes to illness in themselves and their colleagues. Organisational changes within general practice, including revalidation, must take account of barriers experienced by general practitioners in accessing health care. Medical education and culture should strive to promote appropriate self care among doctors.

Motherhood in the teens and twenties: some surprises

We report a study of the association of health and social support variables with motherhood in teenagers and older mothers. Both teenage and older mothers reported poorer physical and mental health and fewer and less frequent social contacts than their nulliparous peers. Contrary to expectation, however, older mothers reported less extensive and less adequate social support networks than did teenagers.

Efficacy of a touchscreen computer based family cancer history questionnaire and subsequent cancer risk assessment

OBJECTIVE

A computer based touchscreen family cancer history questionnaire was developed and implemented to facilitate the provision of cancer risk assessments for the ambulatory and outpatient populations of a free standing cancer hospital.

METHODS

A questionnaire consisting of a series of branched point decision making screens was developed which enables the participant to enter demographic data, personal cancer history, and cancer histories for first and second degree relatives. A freestanding touchscreen computer kiosk system was used to place the questionnaire in public areas of the cancer hospital and clinic. Genetic professionals analysed the data received, using published criteria, and provided a basic cancer risk assessment and surveillance recommendations within 10 business days. A survey was completed by a small random group of users (n = 59) three to six months after receipt of their risk assessment.

RESULTS

After 11 months, 1440 people had entered information and received a written communication. Only 2% of completed questionnaires contained insufficient information to provide a basic risk assessment. Of the small group of participants surveyed, almost all (95%) felt "very comfortable" using the system, 93% remembered receiving the risk assessment letter when queried three to six months later, 42% felt their perceptions about cancer risk had changed, and 20% had made changes in their or their family's cancer surveillance practices.

CONCLUSION

The touchscreen computer family history questionnaire allows easy collection of family history information, provision of risk assessments to a broad population, and promotes increased awareness of familial risk and appropriate surveillance.

Unexplained fainting, near drowning and unusual seizures in childhood: screening for long QT syndrome in New Zealand families

AIMS

To construct detailed pedigrees of five New Zealand families with autosomal dominant long QT syndrome (LQTS) and screen selected individuals based on initial symptomatic and ECG data.

METHODS

Clinical data were collected using a questionnaire and relevant medical record review. Participants were then classified according to ECG diagnostic criteria based on the presence or absence of symptoms and the rate-corrected QT interval (QTc) into three groups: affected, uncertain or unaffected. Blood samples were also collected from each participant and DNA extracted for genetic testing.

RESULTS

Seventy-eight family members were screened. The majority of the 35 symptomatic family members, who were affected on these criteria, had presented with symptoms in childhood. Of the remaining 43 asymptomatic family members, the majority were in the uncertain diagnostic group based on these ECG criteria.

CONCLUSIONS

Autosomal dominant long QT syndrome (Romano Ward syndrome) is being increasingly recognised and must be considered in the investigation of children who present with unexplained fainting, near drowning, unusual seizures and sudden death. Screening long QT syndrome families based on ECG criteria remains difficult leaving a number of family members with an uncertain diagnosis. It is hoped that genetic testing will become useful for diagnosis of presymptomatic carriers of long QT syndrome in New Zealand in the future.

Experiences with vaccination and epidemiological investigations on an anthrax outbreak in Australia in 1997

Between January and February 1997, there was a severe outbreak of anthrax on 83 properties in north-central Victoria, Australia. Vaccination was used as a major tool to control the outbreak by establishing a vaccination buffer zone 30 km by 20 km. In all, 78, 649 cattle in 457 herds were vaccinated in a three week program. In the face of the outbreak, there was a delay before vaccination was able to stop deaths. In the 10 days following vaccination 144 cases of confirmed anthrax occurred and 38 cases occurred more than 10 days after vaccination. When all cattle on at-risk properties were revaccinated in October and early November 1997, there were only two confirmed cases of anthrax in vaccinated seven and nine month old calves in the following anthrax season. Investigations into the epidemiology of the outbreak were unable to establish a single major association for the spread of the disease by flies, biting insects, carrion scavengers, wind, manufactured feed, milk factory tanker routes, veterinary visits, animal treatments, movements of personnel between farms or burning of carcases. The weather conditions in the outbreak area were part of a long dry spell with periods of high daily and night temperatures, continuing high humidity over the period and higher than normal soil temperatures. It is possible that extensive earth works in the district involving irrigated pasture renovation and water channel and drainage renovation could have disturbed old anthrax graves. It is postulated that these works released spores that were dispersed in the preceding wet winter across poorly drained areas that formed the axis for the outbreak. The earth moving renovations establishing irrigation in the area were conducted in the late 1890s, and before the occurrence of anthrax outbreaks were recorded. The axis of the outbreak was the major stock route for cattle and sheep moving from southern Victoria to northern Victoria and southern New South Wales, and undoubtedly there would have been extensive anthrax outbreaks before vaccine became available in the 1890s. In respect of other outbreaks, the events in Victoria most resembled outbreaks of anthrax recorded in the United States of America in the 1950s, 1960s and 1970s.

Teenage mothers and their peers: a research challenge

Recent reports have highlighted the adverse health experience of teenage mothers. The question of how these mothers' perceptions of their own health status and social networks differ from those of their nulliparous peers is explored in this pilot study, which highlights some practical problems associated with research in this important field.

Concomitant infusion cisplatin and hyperfractionated radiotherapy for locally advanced nasopharyngeal and paranasal sinus tumors

PURPOSE

This is a prospective study to improve the therapeutic ratio in the treatment of patients with locally advanced nasopharyngeal and paranasal sinus tumors by using split-course concomitant infusion cisplatin chemotherapy and hyperfractionated radiotherapy.

METHODS AND MATERIALS

From 1983 to 1993, 21 patients with locally advanced nasopharyngeal and paranasal sinus tumors (T3 and T4, or recurrent tumors involving the facial bones and/or the base of the skull) were treated with a regimen of split-course hyperfractioned radiotherapy (1.2 Gy/fraction/bid) and concomitant infusion cisplatin (5-10 mg/m2/24 h). The therapy was given in three separate 2-week sessions with 1 to 2 week breaks between sessions. Seventeen of 21 patients were treated with curative intent with cumulative radiation doses ranging from 64.8 to 70.8 Gy. Four patients were treated with palliative intent to a total dose of less than 60 Gy or to a limited field due to previous irradiation.

RESULTS

Sixteen of 17 patients (94%) treated curatively achieved a complete response. Of the 16 patients who achieved complete response, 7 patients (50%) were alive at the time of analysis (36 to 126 months). One patient was alive at 4 years with no evidence of disease, and died in 10 years at the age of 80 of unknown cause. Two patients died of local recurrence at 21 and 45 months and one patient died of a cerebrovascular accident at 12 months with disease status unknown. Five patients died of distant metastases. The one patient who had a partial response died in 25 months with local disease and metastases to the bone and lung. Four patients that were previously irradiated received a reduced total dose or treated to a limited irradiation field. All had near complete responses, but died within a year of treatment, with the exception of one patient who died at 23 months. Acute reactions included intense erythema of the mucosa in all patients. Five of 21 (23%) developed punctate mucositis and 3 of 21 (14%) developed confluent mucositis. Hematologically, one patient developed neutropenia (1800 WBC/mm3) and one developed thrombocytopenia (38,000/mm3). A rising creatinine was observed in three patients (2.0, 1.7, 1.7) all of whom were treated with the higher 10 mg/m2/day dose of infusional cisplatin. In all three of these cases, the creatinine slowly returned to normal over a 6-month period. Hormonal evaluations were performed in three patients and all were within normal ranges. There was no evidence of neck fibrosis or trismus. One patient with gross recurrent disease of the orbit developed blindness of the involved eye due to corneal opacification. The orbital area had been reirradiated in this patient.

CONCLUSIONS

Concomitant infusion cisplatinum with hyperfractionated radiation improved tumor control, but did not increase normal tissue injury. Acute reactions were minimized by splitting the treatment with a 1- to 2-week break after each 2 weeks of radiation treatment. Late complications were not increased by using a hyperfractionated radiation regimen. The local failure rate was only 18% (3 of 17 patients), but the distant failure rate was 35% (6 patients). Further investigation is needed to prove if adjuvant chemotherapy after concomitant chemoradiation improves survival by decreasing the distant failure in such advanced cases.