Systemic lupus erythematosus in three ethnic groups. IX. Differences in damage accrual

OBJECTIVE

To determine the factors predictive of damage in a multiethnic (Hispanic, African American, and Caucasian) LUMINA (lupus in minority populations, nature versus nurture) cohort of patients with systemic lupus erythematosus (SLE) with disease duration of < or =5 years at enrollment (T0).

METHODS

Variables (socioeconomic/demographic, clinical, immunologic, immunogenetic, behavioral, and psychological) were measured at T0 and annually thereafter. Disease damage was measured with the Systemic Lupus International Collaborating Clinics Damage Index (SDI), and disease activity was measured with the Systemic Lupus Activity Measure. The relationship between the different variables and the SDI at the last visit (TL) was examined (mean followup from diagnosis to TL 61 months; adjusted for disease duration). Poisson regression was used to identify the independent association between the different variables and SDI scores at TL.

RESULTS

Seventy-two Hispanics, 104 African Americans, and 82 Caucasians were included. One-half of patients had not accrued any damage. Caucasians had the lowest SDI scores at T0, and Hispanics had the highest scores at TL. Renal damage occurred more frequently among Hispanics and African Americans, while integument damage was more frequent among African Americans. Neuropsychiatric (20%), renal (16%), and ocular (15%) damage occurred most frequently among all patients. Independent predictors of SDI at TL were age, corticosteroid use (maximum dose at T0), number of American College of Rheumatology (ACR) criteria met, disease activity, and abnormal illness-related behaviors. Other variables were less consistently associated with damage accrual (poverty in African Americans, lack of HLA-DRB1*0301 in Hispanics, presence of HLA-DQB1*0201 and acute onset of SLE in Caucasians).

CONCLUSION

Damage in SLE occurs from the outset in some, but not all, patients; Hispanics accrue damage more rapidly. Disease factors (corticosteroid use, number of ACR criteria met, disease activity, and acute-onset type) are important, but age and abnormal illness-related behaviors also contribute to overall damage in SLE.

An instrument to measure healing in pressure ulcers: development and validation of the pressure ulcer scale for healing (PUSH)

BACKGROUND

Currently, there is no instrument that provides an accurate and simple method of monitoring pressure ulcer healing in clinical practice. This article reports the two studies that were conducted to assess the validity of the Pressure Ulcer Scale for Healing (PUSH) as a tool to monitor healing of stage II-IV pressure ulcers.

METHODS

Subjects in both studies (N = 103 and N = 269) were elderly (mean Study 1, 75 years, mean Study 2, 80 years), and the majority were women (Study 1, 51%, Study 2, 70%). Study data were extracted from patients' permanent records.

RESULTS

Principal components analysis confirmed that the PUSH tool accounted for 58% to 74% of the wound healing variance over a 10-week period in Study 1 and 40% to 57% of the wound healing variance over a 12-week period in Study 2. In addition, multiple regression analysis, used to measure the sensitivity of the model to total healing, showed PUSH accounted for 39% of the variance in 6 weeks and 31% of the variance over 12 weeks (p <.001; Studies 1 and 2, respectively).

CONCLUSIONS

Data from these two studies confirmed that the PUSH tool, with the components of length times width, exudate amount, and tissue type, is a valid and sensitive measure of pressure ulcer healing. It is a practical approach that provides clinically valid data regarding pressure ulcer healing. Further testing is needed to confirm these findings.

Social problem-solving telephone partnerships with family caregivers of persons with stroke

As individuals with significant functional deficits are discharged earlier from the hospital, health care professionals are challenged to develop cost-effective intervention programmes that will assist family members to manage caregiving problems in the home. The literature suggests that social problem-solving can positively influence the physical and psychological well-being of individuals. This paper describes a social problem-solving training procedure provided primarily by telephone to assist family caregivers to manage caregiving issues in the home.

Overview analysis of adjuvant therapies for melanoma--a special reference to results from vaccinia melanoma oncolysate adjuvant therapy trials

A phase III, randomized, double-blind, multi-institutional vaccinia melanoma oncolysate (VMO) trial was performed for patients with stage III (AJCC) melanoma. When compared with the control vaccinia virus (V) therapy, VMO therapy did not show clinical efficacy in the final analysis of data from this trial. However, the data did allude to significant therapeutic efficacy with VMO therapy if it had been compared with an observation arm. Therefore, a comparative overview statistical analysis was performed to identify the therapeutic efficacy of VMO. This review compares VMO results with data from the treatment and observation arms of other prominent randomized anti-melanoma biologic trials (i.e., ECOG EST 1684; SWOG, IFN-gamma (J. Natl. Cancer Inst. 87 (1995) 1710); WHO IFN-alfa-2a (ASCO 14 (1995) 410); Mayo IFN-alfa-2a (J. Clin. Oncol. 13 (1995) 2776); French IFN-alfa-2a (ASCO 15 (1996) 437). The analysis was carried out comparing the disease-free interval (DFI) and overall survival (OS). The analysis shows that the VMO results are fairly comparable to the results of the treatment arms from the ECOG and Mayo trials at the 5-year mark; percent DFI 0.37, 0.37, and 0.4, percent OS 0.48, 0.46, 0.47, respectively. In some cases, VMO DFI is superior to the observation arms from other studies; ECOG, Mayo, and WHO; 0.37 versus 0.26, 0.3, 0.27 (4 years), respectively. These comparative results suggest that the vaccinia arm is not a true observation arm in the VMO trial, and the VMO could have shown an enhanced efficacy had the trial included a no-treatment observation control arm.

Analysis of the posterior fossa in children with the Chiari 0 malformation

OBJECTIVE

We previously reported the resolution of syringohydromyelia without cerebellar tonsillar ectopia in five patients after posterior fossa decompression of the so-called Chiari 0 malformation. A sixth patient is described. In this study, the anatomy of the posterior fossa is analyzed using radiological imaging, enabling features of the posterior fossa in this uncommon subgroup of children to be characterized.

METHODS

Multiple measurements were made on magnetic resonance imaging studies in six children with Chiari 0 malformation to determine the position of the brainstem relative to the foramen magnum. Fifty children with normal magnetic resonance imaging studies of the brain were used as controls.

RESULTS

All children with a Chiari 0 malformation were found to have the following positive results: obices that were located more than 2 standard deviations below normal, an increase in the anteroposterior midsagittal distance of the spinomedullary junction at the level of the foramen magnum, an increase in the angle between the floor of the fourth ventricle and clivus, and an increase in the anteroposterior midsagittal distance of the foramen magnum.

CONCLUSION

The findings of this study suggest that the contents of the posterior fossa are indeed compromised and/or distorted in patients with syringohydromyelia but no tonsillar ectopia. In this group, the brainstem was caudally displaced more than 3 standard deviations below normal.

Is there immune dysregulation in symptomatic Gulf War veterans?

Many Gulf War veterans complain of a variety of symptoms including skin rashes and joint pain which may have a common immunological basis. Other Gulf War veterans have post-traumatic stress disorder (PTSD), an anxiety disorder associated with chronic stress. Whether or not chronic stress may affect the capacity to resist disease has not been fully delineated, but recent work suggests that a dysregulated balance of cytokines produced by T helper cells of the immune system may play a role in stress-related illnesses. It is known that a balanced immune response (cell-mediated and humoral immunity) is an important defense mechanism. Although the mechanism(s) by which a change in immune system balance occurs is not clear, it may be secondary to stress-induced changes in hormones such as cortisol and catecholamines, both of which have been implicated in altering levels of cellular or humoral immunity. For these reasons, we are investigating the function of both the cellular and humoral arms of the immune system as well as the cytokine patterns associated with these different functions in symptomatic Gulf War veterans and control groups consisting of asymptomatic Gulf War veterans and symptomatic non-Gulf War veterans.

Systemic lupus erythematosus in three ethnic groups: III. A comparison of characteristics early in the natural history of the LUMINA cohort. LUpus in MInority populations: NAture vs. Nurture

AIM

To determine and contrast the socioeconomic-demographic and clinical features of patients with recent onset (< or =5 y) systemic lupus erythematosus (SLE) from three ethnic groups, Hispanic, African-American and Caucasian (H, AA, C).

SUBJECTS AND METHODS

SLE cases (American College of Rheumatology criteria) (incident (n = 56), prevalent (n = 173)), were enrolled in a longitudinal study at The University of Alabama at Birmingham, The University of Texas-Houston Health Science Center and The University of Texas Medical Branch at Galveston. Socioeconomic-demographic, clinical, immunological, behavioral and psychological data were obtained using validated instruments and standard laboratory techniques, and compared.

RESULTS

70 H, 88 AA and 71 C SLE patients constitute this cohort. H and AA patients were younger and of lower socioeconomic-demographic status. They also had evidence of more frequent organ system involvement (renal, cardiovascular), more auto-antibodies, more active disease (after adjusting for discrepant socioeconomic-demographic features), lower levels of social support and more abnormal illness-related behaviors (more in H than in AA). H also were more likely to have an abrupt disease onset; C were more likely to be on antimalarials but less likely to be on corticosteroids. H, AA, and C used health care resources comparably. They had similar levels of pain and physical and mental functioning after adjusting for age, disease duration, income, education, social support, illness-related behaviors, and Systemic Lupus Activity Measure or SLAM scores.

CONCLUSIONS

H and AA patients have more active SLE, at an earlier age of onset, and a less favorable socioeconomic-demographic structure (worse among the H than AA) which predispose them to a less favorable natural history.

A longitudinal study of resting energy expenditure relative to body composition during puberty in African American and white children

BACKGROUND

Body composition and resting energy expenditure (REE) have not been examined longitudinally during puberty.

OBJECTIVE

The purpose of this longitudinal study was to examine the influence of pubertal maturation on REE relative to body composition in African American and white children.

DESIGN

The study included 92 white and 64 African American children (mean age at baseline: 8.3 and 7.9 y, respectively) from Birmingham, AL. The children had 2-5 annual measurements of fat mass (FM), lean mass (LM), and REE. The Tanner stages of the children ranged from 1 to 5. Mixed-model repeated-measures analyses were used to test the change in REE relative to body composition with increasing Tanner stage among ethnic and sex groups.

RESULTS

LM increased from Tanner stage 1 to subsequent stages. FM relative to LM decreased from Tanner stage 1 to stages 3, 4, and 5 but not from stage 1 to stage 2. The African American children had relatively higher limb LM and lower trunk LM than did the white children. REE declined with Tanner stage after adjustment for ethnicity, sex, FM, and LM. This decline was significant from Tanner stage 1 to stages 3, 4, and 5 but not to Tanner stage 2. After adjustment for age, Tanner stage, FM, and LM or LM distribution, REE was significantly higher in white than in African American children (by approximately 250 kJ/d).

CONCLUSION

In a large sample of children at various Tanner stages, we found an ethnic difference in REE after adjustment for age, Tanner stage, FM, and LM that was not explained by the difference in LM distribution.

Relationship of urinary myelin basic protein-like material with cranial magnetic resonance imaging in advanced multiple sclerosis

BACKGROUND

A significant correlation exists between disability and the volume of black holes (BHL VOL), defined as hypointense lesions on T1-weighted cranial magnetic resonance imaging. A consistent correlation has also been reported between urinary myelin basic protein-like material (MBPLM) and the transition toward secondary progression (SP) from relapsing-remitting (RR) multiple sclerosis (MS).

OBJECTIVE

To improve the management of MS through a noninvasive and cost-effective test for monitoring disease activity or disease status.

DESIGN AND METHODS

From 662 patients with MS (86 with RR MS, 259 with SP MS without continued attacks, and 317 with SP MS with continued attacks), 24-hour urine samples were obtained at enrollment in the phase 3 Linomide (roquinimex) drug study. The urine specimens were analyzed for MBPLM and correlated with clinical features and findings on cranial magnetic resonance imaging.

RESULTS

Significant but weak correlations existed between urinary MBPLM and BHL VOL in all patients with MS (r = 0.114, P =.003; n = 662), patients with SP MS without attacks (r = 0.185, P =.003; n = 259), and all patients with SP MS (r = 0.122, P =.003; n = 576). No significant correlations were detected in the RR MS group or any of the disease groups or subgroups whose Expanded Disability Status Scale score was 5.0 or lower. In subgroup analysis, the most significant correlation was detected between urinary MBPLM after adjustment for creatinine and BHL VOL in patients with SP MS with an Expanded Disability Status Scale score of 5.5 or higher but without continued relapses (r = 0.417, P<.001; n = 138).

CONCLUSIONS

In patients with advanced SP MS, urinary MBPLM may possibly serve as an indicator of failed remission and axonal damage. Urinary MBPLM correlates with disease status in MS, especially the transition of RR MS to SP MS with advancing disability.

Sociodemographic, physical, and psychosocial characteristics of depressed and non-depressed family caregivers of stroke survivors

A variety of sociodemographic, physical, and psychosocial variables are linked to depressive behaviour in family caregivers. This study was conducted to determine the best predictors of caregiver depression at onset of the caregiver role among persons providing care to a stroke survivor. The relative contributions of stroke survivor and caregiver sociodemographic characteristics, as well as caregiver general health, physical functioning, social support, life satisfaction, preparedness, and reaction in the prediction of depression status, were examined. A correlational study of 52 primary family caregivers of individuals who had a cerebrovascular accident was conducted. General health and physical functioning scales from the SF-36, and measures of caregiver social support, life satisfaction, preparedness, and reaction were used. Caregiver depression was best predicted by lower life satisfaction, lower physical functioning, and a lack of tangible social support.

The position of the conus medullaris in children with a Chiari I malformation

The purpose of this study is to determine whether there is a relationship between the conus level and patients with a Chiari I malformation. This retrospective MRI study evaluated conus levels and degrees of tonsillar ectopia in 26 children ages 5-16 years with a Chiari I malformation. Our results show that there seems to be no relationship between the conus level and the amount of tonsillar ectopia that a child with a Chiari I malformation might have. In fact, there seemed to be an inverse relationship between these two entities. Interestingly, we have also found that of all coni located at the L2-L3 disc space or below, these patients had a syrinx associated with their Chiari I malformation and that all malformations without a syrinx had a 'normally' positioned conus medullaris.

Radiographic assessment of disease progression in rheumatoid arthritis patients treated with methotrexate or minocycline

Radiographic studies of methotrexate (MTX) treated and minocycline treated patients with rheumatoid arthritis (RA) are reviewed. A formal metaanalysis of publications of RA treated with MTX was undertaken at the time when MTX was used for patients with established RA. Thus the conclusions of that metaanalysis may not be applicable to patients treated with MTX earlier in the course of their disease. On the other hand, there are no sufficient data to conduct a formal metaanalysis of patients with RA treated with minocycline.

Do hormonal indices of maturation explain energy expenditure differences in African American and Caucasian prepubertal children?

OBJECTIVE

To examine the relationships between hormonal indices of maturation and total, resting and physical activity-related energy expenditure (TEE, REE and AEE) in African American and Caucasian prepubertal children.

DESIGN

Cross-sectional study.

SUBJECTS

Sixty-four African American and 48 Caucasian prepubertal children.

MEASUREMENTS

TEE (by doubly labeled water), REE (by indirect calorimetry), fat mass and fat-free mass (by dual-energy X-ray absorptiometry), fasting serum dehydroepiandrosterone-sulfate (DHEAS), androstenedione, and estrone-sulfate (by radioimmunoassay).

RESULTS

Serum concentrations of hormones correlated significantly with REE and TEE (r values range from 0.33 to 0.76, P<0.001). Only androstenedione correlated significantly with AEE (r = 0.23, P<0.05). However, these correlations were no longer significant after adjusting energy expenditure components for fat-free mass. In multiple regression models, ethnicity was not a significant determinant of any energy expenditure component after adjusting for body composition and hormone concentrations.

CONCLUSION

Hormonal indices of maturation do not influence energy expenditure in this group of African American and Caucasian prepubertal children.

Urinary myelin basic protein-like material in patients with multiple sclerosis during interferon beta-1b treatment

OBJECTIVES

To determine levels of urinary myelin basic protein-like material (MBPLM) in patients with multiple sclerosis (MS) openly treated with interferon beta-1b and to correlate these with clinical changes.

BACKGROUND

Levels of urinary MBPLM correlate with the presence of the progressive phase of MS and with the disease burden detected on T2-weighted, cranial magnetic resonance imaging. Measurement of urinary MBPLM level may be a feasible test for monitoring or predicting response to therapeutic measures.

DESIGN AND METHODS

In a prospective study at one site, 166 patients with MS (131 with relapsing-remitting [RR] and 35 with secondary progressive [SP] disease) were treated for a minimum of 1 year and up to 3 years with interferon beta-1b and underwent assessment for neurologic disability (Expanded Disability Status Scale and Scripps Neurological Rating Scale) and change in disease subtype. Urine samples were obtained at 1219 of 1378 clinic visits, and urinary MBPLM level was determined and related to creatinine level to adjust for renal function.

RESULTS

Statistical analysis using the general linear models procedure confirmed previous findings that the level of urinary MBPLM related to urinary creatinine level (MBPLM/creatinine) was higher (P<.001) in patients with SP than RR MS. Of the 131 patients with RR MS, SP disease developed in 13 during the observation period. Compared with those in the RR group, the RR to SP group had a higher level (P<.001) of urinary MBPLM and did not differ from the SP group.

CONCLUSIONS

The level of urinary MBPLM is higher in SP MS than RR MS but not in RR MS that converts to SP MS. Level of urinary MBPLM may permit the examination of treatment tested to prevent RR disease from becoming progressive.

Pressure ulcers, hospital complications, and disease severity: impact on hospital costs and length of stay

OBJECTIVE

To determine whether or not the development of a Stage II or greater pressure ulcer in-hospital is associated with increased hospital costs and length of stay after adjusting for admission severity of illness, comorbidities, nosocomial infections, and other hospital complications.

DESIGN

Prospective, inception cohort study.

SETTING

Tertiary care, urban, university teaching hospital.

PARTICIPANTS

286 patients identified within 3 days of admission to a tertiary care, urban teaching hospital were enrolled in a prospective, inception cohort study. Patients were age 55 or greater; expected to be confined to bed or chair or with a hip fracture; and expected to remain in hospital at least 5 days.

MEASUREMENTS

Baseline data were collected within 3 days of admission. Weekly skin assessments were performed by study nurses to document the development of pressure ulcers. Medical record reviews, patient exams, and physician and nurse interviews were used to obtain baseline demographic, medical, functional, nutritional, and global measures of disease severity. The incidence of nosocomial infections and the number of other hospital complications were monitored by medical record reviews. Hospital costs were estimated using category-specific cost-to-charge ratios. Diagnostic-related group (DRG) adjusted length of stay was calculated by subtracting the mean length of stay for assigned DRGs from actual stays.

RESULTS

Incident pressure ulcers were associated with significantly higher mean unadjusted hospital costs ($37,288 vs $13,924, P = 0.0001) and length of stay (30.4 vs 12.8 days, P = 0.0001). In addition to pressure ulcers, other independent predictors of hospital costs and length of stay after multivariable analyses included: admission to an intensive care unit or surgical service, younger age, nosocomial infection, the physician assessment of disease severity, and the number of other hospital complications. Compared with those who did not develop pressure ulcers, patients who developed pressure ulcers also were more likely to develop nosocomial infections (45.9% [17/37] vs 20.1% [50/249], P = 0.001) and other hospital complications (86.5% [32/37] vs 43.0% [107/249], P < 0.001). After adjusting for only the admission predictors of costs and length of stay by multivariable analyses, hospital costs, and length of stay for those who developed pressure ulcers remained significantly greater than for those who did not develop pressure ulcers ($14,260 vs $12,382, P = 0.03, and 16.9 vs 12.9 days, P = 0.02, respectively). The differences in costs and length of stay for those with and without incident pressure ulcers were even greater when adjusted for admission predictors and also the occurrence of nosocomial infections and other complications ($29,048 vs $13,819, P = 0.002, and 20.9 vs 12.7 days, P = 0.0001, respectively).

CONCLUSION

Incident pressure ulcers are associated with substantial and significant increases in hospital costs and length of stay. Nosocomial infections and other hospital complications are additional significant independent predictors of health care utilization among patients at risk for pressure ulcers.

The effect of a self-monitoring tool on self-efficacy, health beliefs, and adherence in patients receiving hemodialysis

OBJECTIVE

Assess the effectiveness of a self-monitoring tool on perceptions of self-efficacy, health beliefs, and adherence in patients receiving hemodialysis.

DESIGN

A monthly intervention using a pretest, posttest design over a 6-month period. Both the treatment and control groups were randomly selected and received surveys to assess health beliefs, perceptions of self-efficacy for performing specific healthful behaviors, and renal diet knowledge at baseline, before intervention, and 6 months later. The treatment group also received monthly feedback of monthly phosphorus levels and interdialytic weight gains.

SETTING

A university hospital-based 43-chair ambulatory dialysis center.

SUBJECTS

Forty patients with end-stage renal disease (25 men and 15 women, age 26 to 78 years), on chronic hemodialysis for at least 2 months and with a history of noncompliance with phosphorus and/or fluid restrictions for 1 or more months.

MAIN OUTCOME MEASURES

Self-efficacy, health beliefs, knowledge, biochemical, and demographic variables were analyzed. Analysis of variance tests of repeated measures were used to examine relationships between adherence with phosphorus and fluid restrictions to health beliefs and perceptions of self-efficacy after training in self-monitoring.

RESULTS

Overall, there were no significant improvements in adherence with phosphorus and fluid restrictions between the two groups, although a comparison within the groups revealed the treatment group had a statistically significant decrease in mean phosphorus levels of 7.14 to 6.22 mg/dL (P = .005) from baseline to month 3. However, because this value was not maintained, it was not statistically significant. No significant differences existed between the two groups for health beliefs and perceptions of self-efficacy. Knowledge scores in the treatment group, however, improved significantly as compared to the control group (P = .008) and was a significant increase from baseline (P = . 002). In the control group, all scores fell slightly but this difference was not significant.

CONCLUSIONS

The benefits of patient self-monitoring and behavioral contracting upon adherence in patients on hemodialysis are inconclusive, as serum phosphorus and interdialytic weight gains did not differ between the two groups. The interventional tools also appeared to have little effect on perceptions of self-efficacy and health beliefs. Trends of improvement, however, did exist for phosphorus within the treatment group and subjects in this group had a statistically significant increase in knowledge scores over time. Additional research using repeated measures design is needed to explore the effects of increased frequency and duration of an intervention on the attainment of patient clinical outcome measures.

Ten-year disease free survival after transperineal sonography-guided iodine-125 brachytherapy with or without 45-gray external beam irradiation in the treatment of patients with clinically localized, low to high Gleason grade prostate carcinoma

BACKGROUND

The authors report observed 10-year brachytherapy results in the treatment of 152 consecutive patients with clinically organ-confined prostate carcinoma.

METHODS

One hundred and fifty-two consecutive patients with T1-T3, low to high Gleason grade, prostate carcinoma were treated between January 1987 and June 1988 at Northwest Hospital in Seattle, Washington. Their median age was 70 years (range, 53-92 years). Of these 152 patients, 98 (64%) received an iodine-125 implant alone (Group 1), and the remaining 54 patients (36%), who were judged to have a higher risk of extraprostatic extension, also were treated with 45 gray (Gy) of external beam irradiation to the pelvis (Group 2). No patient underwent lymph node sampling, and none received androgen ablation therapy. Multivariate regression and the Mann-Whitney rank sum test were used for statistical analysis. Preoperative patient data with associated success or failure outcomes at 10 years after treatment were used for training and validating a back-propagation neural network prediction program.

RESULTS

The average preoperative prostate specific antigen (PSA) value, clinical stage, and Gleason grade were 11.0 ng/mL, T2, and 5, respectively. The median posttreatment follow-up was 119 months (range, 3-134 months). Overall survival 10 years after treatment was 65%. At last follow-up only 3 of the 152 patients (2%) had died of prostate carcinoma. Ninety-seven patients (64%) remained clinically and biochemically free of disease at 10 years of follow-up and had an average PSA value of 0.18 ng/mL (range, 0.01-0.5 ng/mL). In these patients a period of 42 months was required to reach the average PSA (0.5 ng/mL). The median to last PSA follow-up was 95 months (range, 3-134 months). Postoperative needle biopsies were negative in 56% of patients, positive in 15% of patients, and not available in 29% of patients. Only 6% of patients developed bone metastasis. At 10 years there was no statistically significant difference in treatment outcome between patients who received iodine-125 alone, and those who received iodine-125 with 45-Gy external beam irradiation (P = 0.08). Nevertheless, in these two groups preoperative PSA, stage, and Gleason grade were significantly different (P < 0.01). In the artificial neural network analysis, pretreatment serum PSA was the most accurate predictor of disease-free survival.

CONCLUSIONS

Percutaneous prostate brachytherapy is a valid and efficient option for treating patients with clinically organ-confined, low to high Gleason grade, prostate carcinoma. Observed 10-year follow-up documents serum PSA levels superior to those reported in several published external beam irradiation series, and comparable to those published in a number of published radical prostatectomy series.

Systemic lupus erythematosus in three ethnic groups: II. Features predictive of disease activity early in its course. LUMINA Study Group. Lupus in minority populations, nature versus nurture

OBJECTIVE

To determine the factors associated with disease activity in patients with recent-onset (< or =5 years) systemic lupus erythematosus (SLE) who were of Hispanic, African-American, or Caucasian ethnicity.

METHODS

Incident and prevalent cases of SLE, as defined by the American College of Rheumatology criteria for SLE, among the 3 ethnic groups were identified in Alabama (The University of Alabama at Birmingham) and Texas (The University of Texas-Houston Health Science Center and The University of Texas Medical Branch at Galveston). Variables from the sociodemographic, clinical, immunologic, immunogenetic, behavioral, and psychological domains were obtained using validated instruments. Disease activity was ascertained with the Systemic Lupus Activity Measure (SLAM). Stepwise domain regressions with SLAM score as the dependent variable were performed. Final ethnic-specific and overall regression models were obtained by entering variables that were retained in the domain regressions.

RESULTS

SLAM scores at study entry were higher in the African Americans (mean +/- SD 12.6 +/- 6.9) and Hispanics (11.0 +/- 6.2) than in the Caucasians (8.5 +/- 3.7) (P < or = 0.001). The final overall regression model (R2 = 28%) for higher SLAM score included the following variables: African-American ethnicity, lack of private health insurance, abrupt disease onset, presence of anti-Ro antibodies, absence of HLA-DRB1*0301, higher levels of helplessness, and abnormal illness-related behaviors.

CONCLUSION

Socioeconomic, immunologic, immunogenetic, behavioral, and psychological variables were all predictive of disease activity early in the course of SLE, irrespective of ethnic group. However, there remain ethnic group differences in disease activity that were not explained by these factors.

Surgical adjuvant active specific immunotherapy for patients with stage III melanoma: the final analysis of data from a phase III, randomized, double-blind, multicenter vaccinia melanoma oncolysate trial

BACKGROUND

A phase III, randomized, double-blind, multicenter trial of active specific immunotherapy (ASI) using vaccinia melanoma oncolysate (VMO) was performed in patients with stage III (American Joint Commission on Cancer) melanoma to determine the efficacy of VMO to increase the disease-free interval (DFI) or overall survival (OS) in these patients. Two interim analyses of data from this trial were performed in May 1994 and June 1995. Although the results from these analyses showed no statistically significant improvement in DFI or OS in all patients using VMO, two subsets-men aged 44-57 years with one to five positive nodes and all patients with clinical stage I and pathologic stage II disease-showed an overall survival advantage with VMO therapy. A final analysis of data from this trial was performed in May 1996 and is reported here. The design of future melanoma vaccine trials is discussed based on information learned from this first randomized, multicenter trial of ASI therapy.

STUDY DESIGN

A polyvalent VMO was prepared using melanoma cells derived from four melanoma cell lines and vaccinia vaccine virus (V). Patients were accrued from 11 United States institutions and were randomized by the Statistical Center at the University of Alabama, Birmingham. Two hundred fifty patients were randomized to treatment with either VMO (1 U containing 2 mg of total protein derived from 5 x 10(6) melanoma cells and 10(5.6) 50% tissue culture infectious dose of vaccinia virus) or control V (1 U containing 10(5.4) 50% tissue culture infectious dose of vaccinia virus) once a week for 13 weeks and then once every 2 weeks for a total of 12 months, or until recurrence. Patient data were collected by the Statistical Center and analyzed as of May 1996 for DFI and OS using Wilcoxon test and log-rank analysis.

RESULTS

Two hundred seventeen patients were found to be eligible according to the inclusion criteria. Data from these patients were analyzed for DFI and OS after a median followup of 46.3 months (50.2 months for VMO and 41.3 months for V). This final analysis showed no statistically significant increase in either DFI (p = 0.61) or OS (p = 0.79) of patients treated with VMO (n = 104) compared with V (n = 113). At 2-, 3-, and 5-year intervals, 47.8%, 43.8%, and 41.7% of patients treated with VMO were disease-free, respectively, compared with 51.2%, 44.8%, and 40.4% of patients treated with V. At the same intervals, 70.0%, 60.0%, and 48.6% of patients treated with VMO survived, compared with 65.4%, 55.6%, and 48.2% of patients treated with V. In a retrospective subset analysis, male patients aged 44-57 years (n = 20) with one to five positive nodes showed 18.9%, 26.82%, and 21.3% improvement in survival at 2-, 3-, and 5-year intervals, respectively, after treatment with VMO when compared with V (n = 18) (p = 0.046).

CONCLUSIONS

This study was a randomized, multicenter, placebo-controlled evaluation of an active specific immunotherapeutic agent to increase the DFI or OS of patients with stage III melanoma in a surgical adjuvant setting. In this trial, ASI with VMO when compared with V showed no difference in either DFI or OS. In a retrospective subset analysis, however, a subset of men with one to five positive nodes, between the ages of 44 and 57 years, showed a survival advantage with VMO. This result suggests that one must include a detailed subset analysis in the design of future trials of ASI for patients with American Joint Commission on Cancer stage III melanoma. An appropriate control arm also must be included in ASI trials.

Death in shunted hydrocephalic children in the 1990s

Using a combined search of the Children's Hospital (Birmingham, Ala., USA) medical records and the Jefferson County Health Department death records, we reviewed all shunt-related deaths that occurred between January 1990 and July 1996. Of these, we excluded patients who died of nonhydrocephalus-related reasons, such as bronchopulmonary dysplasia, as well as patients who had other serious neurological illnesses such as brain tumor and hydranencephaly. Twenty-eight patients died of shunt-related causes in the 6.5-year period. A survival analysis showed that 96% survived 32 months after first shunting. Of 28 patients, 23 were beyond help prior to medical evaluation. However, at least 10 of these patients had symptoms suggestive of shunt failure at least 24 h and as long as 2 weeks prior to their demise. We conclude that hydrocephalic children still die of shunt failure despite the modern technology of the 1990s. Some of these causes may be avoidable through early detection of symptoms. Guidelines to patients, families, and primary caregivers should be emphasized.

Meta-analysis of chemotherapy versus combined modality treatment trials in Hodgkin's disease. International Database on Hodgkin's Disease Overview Study Group

DESIGN

To perform a meta-analysis of all randomized trials that compared chemotherapy (CT) alone versus combined modality treatment (CT + radiotherapy [RT]) for which individual patient data could be made available.

PATIENTS AND METHODS

Data on 1,740 patients treated on 14 different trials that included 16 relevant comparisons have been analysed. Eight comparisons were designed to evaluate the benefit of additional RT after the same CT (CT1 v CT1 + RT; additional RT design). Eight comparisons were designed to evaluate whether RT in a combined modality setting can be substituted by CT using either more cycles of the same CT or regimens that contain additional drugs (CT1 + CT2 v CT1 + RT or CT1 v CT2 + RT; parallel RT/CT design).

RESULTS

Additional RT showed an 11% overall improvement in tumor control rate after 10 years (P = .0001; 95% confidence interval [CI], 4% to 18%). No difference could be detected with respect to overall survival (P = .57; 95% CI, -10% to 4%). In contrast, when combined modality treatment was compared with CT alone in the parallel-design trials, no difference could be detected in tumor control rates (P = .43; 95% CI, -6% to 9%), but overall survival was significantly better after 10 years in the group that did not receive RT (P = .045; 8% difference; 95% CI, 1% to 15%). There were significantly fewer fatal events among patients in continuous complete remission (relative risk [RR], 1.73; 95% CI, 1.17 to 2.53; P = .005) if no RT was given.

CONCLUSION

Combined modality treatment in patients with advanced-stage Hodgkin's disease overall has a significantly inferior long-term survival outcome than CT alone if CT is given over an appropriate number of cycles. The role of RT in this setting is limited to specific indications.

A hypertension control program tailored to unskilled and minority workers

PURPOSE

A comprehensive worksite health promotion program designed to reduce risk factors for cardiovascular disease among 4000 city of Birmingham employees was used to develop and implement a tailored antihypertensive educational intervention. The mean age of the underlying population was 36 years, 89% were blue-collar or unskilled workers, 50% were African Americans and 20% were female.

METHODS

First, we identified barriers to hypertension control: low literacy, difficulty understanding the need for treatment of asymptomatic disease, and wide variability of health beliefs and priorities. We then tailored an educational program, which offered employees health education sessions on a variety of different topics, including heart disease, cancer, sleep disorders and back injury. All program materials focused on lifestyle changes and the need to seek medical care. This program was offered to all hypertensive workers; 130 chose to enroll, and 81 completed the program. These 81 participants were matched by age, sex, race and baseline BP with nonparticipating hypertensive workers (controls). Changes in SBP and DBP from before to after the educational program were used to evaluate the program.

RESULTS

Overall, intervention participants had a decrease of 4.5 mm Hg in mean SBP (different from zero, [p = 0.03]). African American participants showed a significant decrease (7.4 mm Hg, [p = 0.004]), as did unskilled intervention participants (SBP changes = 7.7 mm Hg, [p = 0.004]). Although not statistically significant, controls showed decreases in BP in the same direction.

CONCLUSION

An educational intervention tailored to the specific health perceptions and working conditions of a low literacy population is feasible, and may have a significant effect on hypertension control.

Using principal component analysis to describe wound status

Principal component (PC) analysis was used to assess the status of pressure ulcers over time in 37 subjects. Content validity was established by literature review and expert opinion. The primary variables in the wound healing model are ulcer surface area, exudate amount, and surface appearance. A linear function based on PC analysis of these values was established at each time point with an appropriate weighting of 2:3:3. This function explained 55% to 65% of the variation in the data. Other variables were considered in the model as well. However, because of the correlation of these variables with the original three, the modeling was not improved. A decreasing function from week 0 to week 8 established a good linear fit to the data and reasonable discrimination between time points, given the limitations of the sample size. There is good discrimination among the time points, at least for the earlier times compared with the later times. The procedure, although promising, requires validation with a larger data set.

Pressure ulcer scale for healing: derivation and validation of the PUSH tool. The PUSH Task Force

Measuring progress toward healing is fundamental to the management of pressure ulcers. A method to assess progress of an individual ulcer over time is lacking. Given the limitations of currently available instruments and the need for a precise and practical method of monitoring healing in clinical practice, the National Pressure Ulcer Advisory Panel initiated the development of a new tool for measuring pressure ulcer healing. The key elements in developing an instrument include simplicity of use in clinical settings, validity for measuring whether ulcers are improving or worsening, and sensitivity to changes in the ulcer between observations. A new tool incorporating surface area, exudate amount, and surface appearance is proposed. Content validity, correlation validity, prospective validity, and sensitivity to change can be met by the proposed Pressure Ulcer Scale for Healing instrument.

Increased survival of patients treated with a vaccinia melanoma oncolysate vaccine: second interim analysis of data from a phase III, multi-institutional trial

OBJECTIVE

The efficacy of vaccinia melanoma oncolysate (VMO) vaccine to increase overall survival and disease-free survival of patients with surgically resected International Union Against Cancer (UICC) stage II melanoma was studied in a phase III, randomized, multi-institutional trial.

SUMMARY BACKGROUND DATA

Phase I and II trials with VMO showed minimal toxicity and clinical efficacy in patients with melanoma. In a recently completed phase III VMO trial, the first interim analysis performed in April 1994 showed an increasing trend in the survival of patients treated with VMO. The second interim analysis was performed in April 1995.

METHODS

Patients with surgically resected stage II (UICC) melanoma were treated with VMO (N = 104) or placebo vaccinia vaccine virus (V) (N = 113) once a week for 13 weeks and then once every 2 weeks for a total of 12 months. Patients' clinical data were collected as of May 1995 and analyzed for survival.

RESULTS

In this second interim analysis, the mean follow-up time is 42.28 months. No survival difference was observed between VMO and V treatments. However, in a retrospective subset analysis, a subset of males between the ages of 44 and 57 years and having one to five positive nodes (at 2-, 3-, and 5-year intervals, 13.6%, 15.9%, and 20.3% difference insurvival in favor of VMO [N = 20] when compared to V [N = 18] [p = 0.037]) and another subset of patients with clinical stage I (at 3- and 5-year intervals, 30% and 7% difference in survival in favor of VMO [N = 20] when compared to V [N = 23], [p = 0.05]) showed significant survival advantage with VMO.

CONCLUSIONS

Although VMO vaccine therapy in surgical adjuvant setting did not produce a significant survival benefit to all patients with melanoma, patients from the above two subsets had significant survival benefit.

Local recurrence in malignant melanoma: long-term results of the multiinstitutional randomized surgical trial

BACKGROUND

In the past, radical margins of excision were prescribed for cutaneous melanoma based on preconceived notions rather than on hard clinical evidence.

METHODS

In a prospective study of 742 patients with intermediate-thickness melanoma (1-4 mm), 470 patients with trunk or proximal extremity lesions were randomized into a 2- or 4-cm margin. Patients with distal extremity or head and neck lesions (n = 272) received uniformly a 2-cm margin.

RESULTS

The overall rate of local recurrence was 3.8%. This rate in the randomized portion (n = 470) was 2.1% for the 2-cm margin and 2.6% for the 4-cm margin (p = 0.72). A progressive increase in local recurrence rates was observed with thickness: 2.3% for lesions 1.0-2.0 mm, 4.2% for those 2.01-3.0 mm, and 11.7% for those 3.01-4.0 mm thick (p = 0.001). Local recurrence occurred in 1.5% of those without ulceration and in 10.6% of those with ulceration of the primary lesion (p = 0.001). The local recurrence rate was not significantly affected by the margin of resection even among the thicker or ulcerated lesions. It also was not affected significantly by the method of closure of the primary site or management of the regional nodes, or the age or gender of the patients.

CONCLUSIONS

A 2-cm margin is as effective as a 4-cm margin in local control and survival of intermediate-thickness melanomas. The local recurrence rate is significantly affected by the thickness of the primary lesion and the presence or not of ulceration.

Efficacy of an elective regional lymph node dissection of 1 to 4 mm thick melanomas for patients 60 years of age and younger

OBJECTIVE

A prospective multi-institutional randomized surgical trial involving 740 stage I and II melanoma patients was conducted by the Intergroup Melanoma Surgical Program to determine whether elective (immediate) lymph node dissection (ELND) for intermediate-thickness melanoma (1-4 mm) improves survival rates compared with clinical observation of the lymph nodes. A second objective was to define subgroups of melanoma patients who would have a higher survival with ELND.

METHODS

The eligible patients were stratified according to tumor thickness, anatomic site, and ulceration, and then were prerandomized to either ELND or nodal observation. Femoral, axillary, or modified neck dissections were performed using standardized surgical guidelines.

RESULTS

The median follow-up was 7.4 years. A multifactorial (Cox regression) analysis showed that the following factors independently influenced survival: tumor ulceration, trunk site, tumor thickness, and patient age. Surgical treatment results were first compared based on randomized intent. Overall 5-year survival was not significantly different for patients who received ELND or nodal observation. However, the 552 patients 60 years of age or younger (75% of total group) with ELND has a significantly better 5-year survival. Among these patients, 5-year survival was better with ELND versus nodal observation for the 335 patients with tumors 1 to 2 mm thick, the 403 patients without tumor ulceration, and the 284 patients with tumors 1 to 2 mm thick and no ulceration. In contrast, patients older than 60 years of age who had ELND actually had a lower survival trend than those who had nodal observation. When survival rates were compared based on treatment actually received (i.e., including crossover patients), the patients with significantly improved 5-year survival rates after ELND included those with tumors 1 to 2 mm thick, those without tumor ulceration, and those 60 years of age or younger with tumors 1 to 2 mm thick or without ulceration.

CONCLUSION

This is the first randomized study to prove the value of surgical treatment for clinically occult regional metastases. Patients 60 years or age or younger with intermediate-thickness melanomas, especially with nonulcerative melanoma and those with tumors 1 to 2 mm thick, may benefit from ELND. However, because some patients still are developing distant disease, these results should be considered an interim analysis.

Weight and length increases in children after gastrostomy placement

OBJECTIVE

To document catch-up growth in children in the first 18 months after gastrostomy surgery and characterize how weight and length growth differ according to medical and nutritional risks.

DESIGN

Repeated measures study to evaluate weight and linear growth in gastrostomy-fed children.

SUBJECTS/SETTING

Seventy-five subject met the selection criteria; gastrostomy placement anytime from birth to age 6.5 years, diagnosis of failure to thrive before gastrostomy. surgery, absence of nonmedical barriers to adequate nutrition. Children were seen in specialty outpatient clinics.

OUTCOME MEASURES

Three measurements of weight and length: at the time of surgery and 12 and 18 months after surgery.

STATISTICAL ANALYSES

Paired t tests of z scores were used to determine catch-up growth. Analysis of variance used variables (age of placement, ambulatory status, prematurity, mode of feeding) to determine statistically significant predictors of growth.

RESULTS

After gastrostomy surgery, catch-up growth was observed in height and weight for children regardless of prematurity or age at the time of gastrostomy placement. Ambulatory children did not achieve catch-up growth, but nonambulatory children did. At 18 months after surgery, catch-up growth occurred in children whose sole source of nutrition was through occurred in children whose sole source of nutrition was through the gastrostomy, as well as in those who were able to receive nutrition by mouth. Children with a diagnosis of cerebral palsy experienced better growth than children with other diagnoses. CONCLUSION/APPLICATION: Failure to thrive in children up to age 6.6 years can be corrected when adequate nutrition is provided. Benefits of gastrostomy surgery observed in catch-up growth reinforce the importance of medical nutrition therapy.

Screening adolescent athletes for exercise-induced asthma

OBJECTIVE

To pilot test an exercise-induced asthma (EIA) screening program using a submaximal step-test and pulmonary function test (PFT) to identify athletes with EIA and to determine if a physical examination or self-reported history could be used to predict the existence of EIA.

DESIGN

Screening and diagnostic testing using a convenience sample.

SETTING

Birmingham, Alabama, during athletic preparticipation examination (PPE).

SUBJECTS

Fifty-two African-American, male football players aged 14-18 years being evaluated for participation in scholastic athletics. No athlete refused participation. Four were excluded because of need for further evaluation unrelated to any pulmonary condition.

INTERVENTION

Each athlete completed a medical history, allergy history, physical examination, preexercise pulmonary function test (PFT), submaximal step-test, and a series of postexercise PFTs.

MAIN OUTCOME MEASURES

Major outcome measurements were changes in forced expiration volume in 1s (FEV1) or peak expiratory flow rate (PEFR) after completing an exercise challenge.

RESULTS

Seventeen of 48 athletes had a > or = 15% decrease in PEFR after exercise. Nine of 48 athletes had a > or = 15% decrease in FEV1 after exercise. The only self-reported item that differentiated subjects with normal and abnormal PFTs was a personal history of asthma (p < 0.05).

CONCLUSION

Many athletes can be identified as having abnormal PFTs by use of a submaximal step-test as an exercise challenge. Self-reporting questionnaires and PPEs do not appear to be sensitive enough to identify athletes with this condition. If validated by future studies, this protocol could be used for the diagnosis of EIA.

Favorable clinical responses in subsets of patients from a randomized, multi-institutional melanoma vaccine trial

BACKGROUND

A phase III, randomized, double-blind, multi-institutional trial was performed evaluating active specific immunotherapy using vaccinia melanoma oncolysate (VMO) in the surgical adjuvant setting in patients with stage II melanoma (UICC staging). The first interim analysis showed no significant difference in disease-free and overall survival. The data were further analyzed to identify subsets of patients with improved outcome when treated with VMO.

METHODS

Patients received either VMO or placebo of live vaccinia vaccine virus (V), once a week for 13 weeks and then once every 2 weeks for an additional 39 weeks or until recurrence. Having stratified patients according to sex, age, number of positive nodes, tumor thickness, and clinical stage, data were analyzed for disease-free survival and overall survival.

RESULTS

Male patients showed a 17% difference in overall survival at 4 years when treated with VMO (p = 0.19). A subset of male patients < 57 years of age with one to five positive nodes showed a 30% difference at 4 years with VMO (p = 0.06). Patients with clinical stage I but pathological stage II disease (both male and female), who had undergone prophylactic node dissection, showed a 23% difference in survival at 3 years with VMO (p = 0.11).

CONCLUSIONS

This subset analysis shows encouraging survival benefit in certain subsets of patients and an increasing trend in overall survival. Further follow-up of this phase III trial from a second interim analysis will be forthcoming.

Systemic lupus erythematosus: predictors of its occurrence among a cohort of patients with early undifferentiated connective tissue disease: multivariate analyses and identification of risk factors

OBJECTIVE

To determine predictors of the occurrence of systemic lupus erythematosus (SLE) in patients with early (< or = 1 yr) undifferentiated connective tissue disease (CTD).

METHODS

Analysis of a cohort of 213 patients with early undifferentiated CTD at entry, followed for 5 yrs at 11 tertiary centers. Baseline demographic, clinical, and laboratory data were compared using univariate and Cox multivariate regression analyses to identify possible predictive features for the subsequent occurrence of SLE.

RESULTS

143 of 213 patients had ascertainable clinical status at 5 yrs. By univariate analyses those who evolved to SLE (13%) were more likely to be younger, African-American, and to have alopecia, serositis, discoid lupus, positive Coombs' test, positive anti-dsDNA and anti-Sm antibodies, positive ANA (homogeneous pattern), and/or a false positive test for syphilis. Discoid lupus (relative risk = 15.8), serositis (4.1), ANA-homogeneous (4.8), and anti-Sm positivity (28.2) were retained as predictors of the occurrence of SLE in the Cox regression model.

CONCLUSION

Some clinical and laboratory features in patients with early undifferentiated CTD can predict the subsequent occurrence of SLE.

Long-term follow-up of a randomized post-induction therapy trial in acute myelogenous leukemia (a Southeastern Cancer Study Group trial)

A phase III clinical trial was designed to determine if more intensive induction and consolidation therapy for acute myeloblastic leukemia increases the remission rate and prolongs survival. A minor objective was to determine if the use of non-cross resistant drugs was more effective than the same drugs used for induction. Patients with untreated leukemia between the ages of 15 and 50 were given daunorubicin 45 mg/m2 for the first 3 days of a 10-day continuous infusion of cytosine arabinoside, initially at a dose of 2000 mg/m2 but reduced to 100 mg/m2 because of toxicity. Those under 36 achieving a complete remission and with an histocompatible donor were assigned to a transplant arm. The rest were randomized to receive one of three consolidation arms: A, cytosine arabinoside, 200 mg/m2 daily for 7 days and daunorubicin 45 mg/m2 daily for 3 days for three courses; B, one course as in Arm A followed by amsacrine, 120 mg/m2 daily for 5 days followed by a 5-day continuous infusion of azacytidine, 150 mg/m2/day; C, thioguanine and cytosine arabinoside, 100 mg/m2 every 12 h and daunorubicin 10 mg/m2 daily for 5 days for three courses followed by four maintenance courses of cytosine arabinoside, 100 mg/m2 daily for 5 days and daunorubicin, 45 mg/m2 for 2 days every 13 weeks. From 1981 to 1986, 398 eligible patients were enrolled and 219 achieved a complete remission. The initial induction dose of cytosine arabinoside was reduced after five of 29 patients exhibited fatal gastrointestinal toxicity. Only 11 patients were assigned to the transplant arm. There were no significant differences in the consolidation arms. The 5 year disease-free survivals were 38, 31 and 27% in arms A, B, and C respectively. Intensive consolidation therapy with the same or different drugs used in induction was as effective as lower dose consolidation followed by maintenance therapy.

Randomized trial of tolerance and efficacy of a small-peptide enteral feeding formula versus a whole-protein formula

Enteral feeding with formulas containing proteins as small peptides may be better tolerated and more efficacious than whole-protein diets, particularly in critically ill patients. We stratified patients beginning enteral feeding according to treatment with antibiotics or not and serum albumin level (< or = 25 or > 25 g/L) and randomly assigned them to treatment with a small-peptide enteral diet or a whole-protein diet. All causes of diarrhea were ascertained (defined as > 200 g stool or > or = three liquid stools on 2 consecutive days). The study was considered complete when diarrhea occurred, or when substantial feeding had been administered without diarrhea for > or = 5 days. Most of the 41 subjects who completed the trial were critically ill. Eight subjects experienced diarrhea (20%), which was caused by tube feeding in six patients (four consuming the small-peptide diet and two consuming the whole-protein diet) and by other factors in two (one on each regimen). Diarrhea was not associated with serum albumin, treatment with antibiotics, or critical illness. There were no differences between treatment groups regarding changes in serum prealbumin or fibronectin. During 5 days of feeding, a small-peptide diet and a whole-protein diet produce similar rates of diarrhea and similar changes in serum proteins.

Pressure ulcer risk factors among hospitalized patients with activity limitation

OBJECTIVE

To identify specific demographic, medical, functional status, and nutritional characteristics that predict the development of stage 2 or greater pressure ulcers among patients whose activity is limited to bed or chair.

DESIGN

Prospective inception cohort study.

SETTING

Tertiary care, urban, university teaching hospital.

PATIENTS

A total of 286 patients fulfilling the following criteria: admitted to the hospital within the previous 3 days, age 55 years or more, expected to be confined to bed or chair for at least 5 days or had a hip fracture, and without a stage 2 or greater pressure ulcer.

MAIN OUTCOME MEASURE

Time to in-hospital development of a stage 2 or greater pressure ulcer.

RESULTS

Total cumulative incidence of pressure ulcers was 12.9% (n = 37) after a median time of 9 days from admission to final skin examination. Age of 75 years or more, dry skin, nonblanchable erythema (a stage 1 pressure ulcer), previous pressure ulcer history, immobility, fecal incontinence, depleted triceps skinfold, lymphopenia (lymphocyte count < 1.50 x 10(9)/L), and decreased body weight (< 58 kg) were significantly associated with pressure ulcer development by univariate Kaplan-Meier survival analyses (P < .05 by log-rank test). Risk ratios (and 95% confidence intervals) for predictors (P < or = .05) of pressure ulcer development after multivariable Cox regression analysis included the following: nonblanchable erythema, 7.52 (1.00 to 59.12); lymphopenia, 4.86 (1.70 to 13.89); immobility, 2.36 (1.14 to 4.85); dry skin, 2.31 (1.02 to 5.21); and decreased body weight, 2.18 (1.05 to 4.52). The 3-week cumulative incidence of pressure ulcers with none, one, two, or three or more of these characteristics was 0%, 11.4%, 39.6%, and 67.9%, respectively (P < .001 by log-rank test).

CONCLUSIONS

These results suggest that nonblanchable erythema, lymphopenia, immobility, dry skin, and decreased body weight are independent and significant risk factors for pressure ulcers in hospitalized patients whose activity is limited to bed or chair.

Categorization of heart rate-eye movement patterns in human fetuses using the statistical technique of discriminant analysis

The purpose of this study was to determine if discriminant analysis could be used to categorize fetal heart rate (FHR) - fetal eye movement (FEM) patterns. Statistical characteristics from 27 normal human fetuses at term for behavioral states, transitions, and insertions were established by combining the digitized FHR-FEM data for subjectively identical epochs. The mean FHR, the variance about the mean, and the presence or absence of FEM were calculated for each 3-min block in a sliding moving window with a 1-min step size. For each fetus, discriminant analysis was then used to assign 3-min blocks to either a behavioral state, a transition, or an insertion by comparing the statistical properties of a 3-min block with that of the data base. We found no difference between discriminant analysis and visual assignment in the average time spent in behavioral states 1F, 2F, and 4F, or in the mean duration of the transition/insertion periods. There was a highly significant linear relationship between computer-generated and visually-determined durations for behavioral states 1F (r = 0.972, p < 0.0001) and 2F (r = 0.989, p < 0.0001) and for the transition/insertion periods (r = 0.863, p < 0.0001). We conclude that discriminant analysis is a reliable computer-based method for behavioral state identification.

A phase III randomized, double-blind multiinstitutional trial of vaccinia melanoma oncolysate-active specific immunotherapy for patients with stage II melanoma

BACKGROUND

In a Phase II trial, surgical adjuvant active specific immunotherapy using a live vaccinia virus-augmented allogeneic polyvalent melanoma cell lysate, vaccinia melanoma oncolysate (VMO), produced a significant disease free interval (DFI) in patients with International Union Against Cancer Stage II melanoma with positive lymph nodes. Therefore, a Phase III randomized prospective, double-blind, multiinstitutional, surgical adjuvant VMO trial was performed to determine the efficacy of VMO to increase the DFI and the overall survival in this group of patients with Stage II disease.

METHODS

Two hundred and fifty patients with Stage II melanoma were divided into two postsurgical groups. One group received VMO (total protein equals 2 mg/ml) and the other received the placebo of live vaccinia vaccine virus (V) (10(5.4) TCID50/ml), an adjuvant component of the VMO. Patients initially received these biologics once a week for 13 weeks and then once every 2 weeks for an additional 39 weeks or until recurrence. All surviving patients have been followed for at least 30 months.

RESULTS

Statistical analysis of survival data (n = 217) for this first interim analysis shows that there is no statistically significant (P = 0.99) increase in DFI of patients treated with VMO (n = 104) when compared with V (n = 113). The median DFI is 38.0 months for patients treated with VMO and 37.0 months for patients treated with V. At 2- and 4-year intervals, 70 and 38%, respectively, of patients treated with VMO vs. 66 and 36%, respectively, of patients treated with V were free of melanoma. The median overall survival is not available because the patients treated with VMO have not yet reached the 50% mark and the median overall survival is 45.0 months for patients treated with V. At 2- and 4-year intervals, 70 and 38%, respectively, of VMO-treated patients survived when compared with 66 and 36%, respectively, of patients treated with V. Although the overall survival of patients treated with VMO is not statistically significant (P = 0.88) at this point, there is an increasing trend in the overall survival of patients treated with VMO; a 10% increase at the 4-year time point. Moreover, in the subset analysis, VMO-treated male patients (n = 63) showed a 17% improvement in survival at 4-year time point when compared with male patients treated with V (n = 67) (P = 0.19) at the same time point and male patients (n = 20) between the ages of 44 and 57 having 1-5 positive lymph nodes showed a 37% difference in overall survival at the 4-year time point when compared with those patients treated with V (n = 18) (P = 0.13) at the same time point.

CONCLUSION

In this first interim analysis, active specific immunotherapy with VMO vs. V showed no difference in the disease free interval or overall survival. Subset analyses likewise showed no significant differences in outcome but the data suggest a potential difference in immunoreactivity between male and female patients with melanoma that awaits further follow up and may merit further investigation.

A phase III trial of high-dose cytosine arabinoside with or without etoposide in relapsed and refractory acute myelogenous leukemia. A Southeastern Cancer Study Group trial

A phase III clinical trial was developed to test whether the addition of etoposide to a high-dose cytosine arabinoside regimen would improve the remission rate, duration of remission, and survival in relapsed and refractory patients with acute myelogenous leukemia. One hundred and thirty-one patients stratified by age, performance status, percentage of marrow blasts, platelet count, bilirubin and presence or absence of clinical infection, refractory or relapsed (+/- 9 months) were randomized to receive high-dose cytosine arabinoside, 3 g/m2 every 12 h for 6 days with or without three doses of etoposide, 100 mg/m2 days 7-9. Of 67 patients randomized to cytosine arabinoside alone, 31% obtained a complete remission with a median remission duration of 11.9 months. Of 66 patients randomized to the combination regimen, 38% obtained a complete remission with a median duration of 25 months. None of these differences were statistically significant. Significantly (p = 0.036) longer survival was seen in patients on the combination regimen under the age of 50. There was no difference in overall survival. Six and 8%, respectively, of patients were free of disease at 5 years. The addition of etoposide to a high-dose cytosine arabinoside regimen had at best a marginal effect at the expense of some increase in toxicity.

Late intensification therapy in adult acute lymphoid leukemia: long-term follow-up of the Southeastern Cancer Study Group experience

One hundred and ninety-two evaluable patients were treated on a multicenter protocol for adult acute lymphoid leukemia to determine in a prospective randomized fashion if late intensification chemotherapy beginning after about six months of treatment would improve remission duration and survival. The complete remission rate was 60%. The median remission duration from beginning of maintenance was 18.7 versus 25.9 months (P = 0.36) for standard maintenance therapy and late intensification, respectively, and the median survival from randomization was 25.8 versus 28.5 months (P = 0.94) respectively. There was a suggestion that the late intensification strategy was helpful with respect to remission duration, and this trend was sustained in long-term follow-up. However, relapse proved to be common during the earlier phases of treatment; thus, insufficient numbers of patients were available at the randomization point to conclusively address the possible value of late intensification. Intensive therapy earlier in the course of treatment should be evaluated, including transplantation in selected patients.

Issues in meta-analysis: an overview

A summary is provided for the relevant issues that investigators must address when wishing to synthesize data via a meta-analysis. The analogy is made to conducting a clinical trial and its components. Both design and statistical issues are discussed with the goal of assuring that the proper elements are included in the meta-analysis. Further, global concerns are presented so that the researcher is aware of the clinical controversies faced when conducting a meta-analysis. Finally a comparison is made of the advantages and disadvantages of a large-scale clinical trial versus a meta-analysis.

Survival impact of autoantibodies in systemic lupus erythematosus

OBJECTIVE

To determine the frequency, the clinical and laboratory associations, and the impact on survival of anti-dsDNA, anti-Sm, anti-nRNP, anti-Ro, and anti-La in patients with systemic lupus erythematosus (SLE).

METHODS

The clinical and laboratory features of 94 patients with SLE tested for anti-dsDNA, anti-nRNP, anti-Sm, anti-Ro and anti-La were studied. Survival analyses were performed by the Kaplan Meier method.

RESULTS

Anti-Ro, anti-nRNP and anti-Sm were found with lower frequency in our patients compared to other reports. There was a higher frequency of anti-Sm (19.5 vs 10%, p = 0.0093) and anti-nRNP positivity (29.2 vs 7.5%, p = 0.006) among African American patients compared to Caucasian patients. No clinical or laboratory associations were found with any of the autoantibodies. Patients had a mean followup up 11.8 years. There were no protective or negative effects of the different autoantibodies on the probability of survival of the patients studied.

CONCLUSION

Our study failed to demonstrate the impact of the autoantibodies studied in the survival of our patients.

Anticardiolipin antibodies in systemic lupus erythematosus: clinical correlates, HLA associations, and impact on survival

OBJECTIVE

To determine the frequency and clinical and HLA associations of anticardiolipin (aCL) antibodies in patients with systemic lupus erythematosus (SLE), as well as their impact on survival.

METHODS

We studied 139 patients with SLE seen at a university based practice. We tested for clinical, laboratory, and HLA associations with levels of aCL antibody isotypes either in sera available in the bank (distant past) or in 2 samples. Demographic, clinical, laboratory, and HLA data were subjected to univariate survival analysis; variables of importance were entered into Cox multivariate regression analyses.

RESULTS

aCL antibodies (any isotype) were present in 57 (41.0%) of the 139 patients tested in the distant past sample, and in 23 (32.3%) as a persistent event in the 71 patient subgroup tested twice. IgG aCL were significantly associated with deep venous thrombosis (DVT) (p = 0.04). No other clinical or HLA association was found with aCL positivity. In the survival analyses, older age at diagnosis, presence of major infections, endstage renal disease, and IgM aCL antibody positivity in the distant past emerged as important independent factors adversely affecting survival. In the subgroup tested twice for aCL antibodies (n = 71), persistent IgM aCL antibody positivity (n = 10) emerged as an important independent factor. Among the subgroup of patients that had HLA data available (n = 88), HLA-DQw7 and thromboembolic events also adversely affected survival.

CONCLUSION

We confirmed the association of IgG aCL antibody positivity with DVT, and the impact on survival of endstage renal disease, major infections, and older age at diagnosis. IgM aCL antibody positivity present either as an isolated event in the distant past or as a persistent finding, thromboembolic events, and HLA-DQw7 emerged as important prognostic factors.

Age-related variability in the use of cardiovascular imaging procedures

OBJECTIVE

To determine if older patients undergo fewer cardiovascular imaging procedures (CIPs) than younger patients when admitted to a tertiary care academic medical center for an acute myocardial infarction (MI), after adjusting for disease severity and comorbidities.

DESIGN

Non-current prospective cohort study.

SETTING

Urban tertiary care academic medical center.

PATIENTS

Medical records of 294 patients admitted and diagnosed with an acute MI between January 1990 and April 1991 were reviewed.

MEASUREMENTS

The total number of different CIPs performed during hospitalization was determined. Cardiac catheterizations, echocardiograms, radionuclide ventriculograms, and thallium scans counted as CIPs. Disease severity was assessed by the Acute Physiology Score (APS) of APACHE II, admission Killip's Classification, and peak creatine phosphokinase (CPK) levels. Comorbidities were assessed using a modified Comorbidity Damage Index of Charlson.

RESULTS

The mean (+/- SD) number of different CIPs performed during hospitalization was significantly less for those > or = 75 years old (1.3 +/- 1.0) than for those < 75 years old (1.7 +/- 1.0) (P = 0.01), and CIP number negatively correlated with age (Spearman r = -0.178; P = 0.01). Mean CIP number decreased from 2.0 +/- 1.1 for those < 45 years old to 0.9 +/- 0.6 for those > or = 85 years old (P = 0.02). Other factors positively associated (P < 0.10) with CIP number were: CPK values in the highest quartile of the study population (> 355 U/L); admission to a cardiology, medical, or family practice service; no CIP performed at an outside hospital prior to transfer; admission Killip's Classification of less than IV, and a Q-wave MI. After adjusting for these variables in a multiple regression model, age > or = 75 remained an independent predictor of decreased CIP use (P = 0.003). The modified comorbidity index score and the APS score, a general measure of severity of illness, were not significantly associated with CIP use. When procedures were examined individually, no significant age-related differences were noted in the use of thallium scans, radionuclide ventriculograms, or echocardiograms. Older patients did, however, remain less likely to undergo cardiac catheterizations (P < 0.001).

CONCLUSION

Older patients, regardless of underlying disease severity or comorbidities, undergo fewer invasive cardiovascular evaluations than younger patients when admitted to a tertiary care academic medical center for an acute MI.

Efficacy of 2-cm surgical margins for intermediate-thickness melanomas (1 to 4 mm). Results of a multi-institutional randomized surgical trial

BACKGROUND

A prospective, multi-institutional, randomized surgical trial involving 486 localized melanoma patients was conducted to determine whether excision margins for intermediate-thickness melanomas (1.0 to 4.0 mm) could be safely reduced from the standard 4-cm radius.

METHODS

Patients with 1- to 4-mm-thick melanomas on the trunk or proximal extremities were randomly assigned to receive either a 2- or 4-cm surgical margin.

RESULTS

The median follow-up time was 6 years. The local recurrence rate was 0.8% for 2-cm margins and 1.7% for 4-cm margins (p value not significant [NS]). The rates of in-transit metastases were 2.1% and 2.5%, respectively (p = NS). Of the six patients with local recurrences, five have died. Recurrence rates did not correlate with surgical margins, even among stratified thickness groups. The overall 5-year survival rate was 79.5% for the 2-cm margin patients and 83.7% for the 4-cm margin patients (p = NS). The need for skin grafting was reduced from 46% with 4-cm surgical margins to 11% with 2-cm surgical margins (p < 0.001). The hospital stay was shortened from 7.0 days for patients receiving 4-cm surgical margins to 5.2 days for those receiving 2-cm margins (p = 0.0001). This reduction was largely due to reduced need for skin grafting, since the hospital stay for those who had a skin graft was 2.5 days longer than that for those who had a primary wound closure (p < 0.01).

CONCLUSION

Margins of excision can be safely reduced to 2 cm for patients with intermediate-thickness melanomas. The narrower margins significantly reduced the need for skin grafting and shortened the hospital stay.

Subacute sinusitis: are antimicrobials necessary?

BACKGROUND

The need for antimicrobials in the treatment of subacute sinusitis was evaluated in 96 afebrile children who were prescribed antimicrobial (amoxicillin, amoxicillin clavulanate potassium, or trimethoprim-sulfamethoxazole) or no antimicrobial medication in addition to a decongestant and saline nasal spray for 3 weeks.

METHODS

Response was determined by complete clearing of the initial radiologic abnormalities or in the case of mucosal thickening, by a significant decrease in thickness to < 6 mm within the maxillary sinuses associated with improvement of the clinical signs and symptoms of sinusitis. If there was evidence of partial clearing by radiograph, the same therapy was continued for another 3 weeks. Nonresponders demonstrated no change or worsening of clinical and radiologic findings.

RESULTS

Sixty-seven of the 96 subjects (70%) responded: 58 (87%) in 3 weeks and 9 (13%) in 6 weeks. Fifty-five of the responders were in the antimicrobial treatment group, and 12 were prescribed no antimicrobial medication. Twenty-nine of the 96 subjects (30%) did not respond to treatment; 22 received an antimicrobial and seven received no antimicrobial medication.

CONCLUSIONS

The number of responders and nonresponders was similar in the antimicrobial- and nonantimicrobial-treated groups (p = NS), and no single antimicrobial medication demonstrated greater treatment effectiveness.

Correlation of myelin basic protein-like material in cerebrospinal fluid of multiple sclerosis patients with their response to glucocorticoid treatment

Predictors and laboratory correlates of the response of patients with multiple sclerosis to glucocorticoids are not well defined. Our study was undertaken to determine if the levels of myelin basic protein (MBP)-like material in cerebrospinal fluid (CSF) might indicate which patients with multiple sclerosis would show a short-term (5 day) or intermediate-term (40 day) improvement of at least a full-grade Kurtzke disability score after initiating treatment with glucocorticoids. A total of 62 patients received 71 courses of treatment consisting of 5 days of intravenous methylprednisolone (500 mg per day) usually followed by a 4-week tapering dose of oral prednisone. CSF was obtained before initiation of treatment and analyzed for MBP-like material by radioimmunoassay. Results were analyzed by chi 2 tests of association and by logistic regression. Individuals having a CSF MBP-like material level of > or = 0.1 ng/ml overall showed a greater likelihood of continued improvement at day 40 (p = 0.014) or further improvement between days 5 and 40 (p = 0.003). Those in the first 15 days of worsening and with an elevated CSF MBP-like level were more likely to respond by day 5. Relapsing-remitting and relapsing-progressive forms of the disease were more likely to respond at both time points than were patients with primary or secondary chronic progressive patterns. The Kurtzke disability score at entry and the major anatomical site of the central nervous system symptomatically affected were not predictive of outcome at either time.(ABSTRACT TRUNCATED AT 250 WORDS)

Hospital-associated malnutrition: a reevaluation 12 years later

A prospective evaluation of general medical patients at the University of Alabama at Birmingham was performed in 1976 and repeated in 1988 to determine change in malnutrition prevalence. Plasma folate, plasma ascorbate, weight for height, triceps skinfold, arm muscle circumference, lymphocyte count, albumin, and hematocrit measurements were combined to form a likelihood of malnutrition (LOM) score. The nutritional status of 228 consecutive patients was assessed by the LOM score at admission and at the 14th day of hospitalization and compared with 1976 findings. The same testing methods were used and the same patient diagnoses and demographic characteristics were found in 1988 and 1976. Of the patients staying more than 14 days, the length of stay was the same in 1988 and 1976 (30 days and 31 days, respectively). However, a smaller percentage of patients stayed 2 weeks or longer in 1988 (21% vs 33% in 1976). In 1988, high LOM scores at admission predicted longer lengths of stay and showed a trend toward increased mortality. The 1976 findings also showed that high LOM scores were associated with longer lengths of stay and increased mortality. LOM scores paired from admission to follow-up improved with stay in 1988 and worsened in 1976. The number of patients with high LOM scores at follow-up was lower in 1988 than in 1976 (46% and 62%, respectively). These findings indicate that identification of malnutrition indicators has improved since 1976. However, dietitians should continue to improve the nutrition assessment and intervention process.

Radiographic evidence of disease progression in methotrexate treated and nonmethotrexate disease modifying antirheumatic drug treated rheumatoid arthritis patients: a meta-analysis

Methotrexate (MTX) has proven to be efficacious in the treatment of rheumatoid (RA), but it remains to be proven whether it can slow disease progression, as determined radiographically, in comparison with other disease modifying antirheumatic drugs (DMARD). We performed a meta-analysis of the available data to answer this question. A literature search, including abstracts, was conducted and inclusion criteria developed (description of patients, accountability of patients, inclusion of a control group of patients, specified radiographic endpoint, and appropriate reading of the radiographs). Publications were scored on a scale of 0 to 5 with a score > or = 3 required for inclusion in the study. For abstracts selected, additional data were obtained directly from the investigators. Data for 353 MTX treated and 205 non-MTX-DMARD treated patients with RA were gathered. Not all publications used the same scoring system, so some assumptions were required to analyze the combined data. Only the erosion score was included since not all publications included a reading of the joint space. All scores were transformed into Sharp scores (Arthritis Rheum 1985;28:1449), including the important contributions of 3 Larsen scored publications. Finally a monthly rate of disease progression was computed. Several comparisons were made. Overall, the rates of disease progression were similar for MTX and non-MTX-DMARD treated patients with RA. The non-MTX-DMARD treated patients with RA were separated into a group treated with gold salts (oral or parenteral) and a group treated with azathioprine with each group compared to the MTX treated patients. MTX had slower rates of disease progression than azathioprine, (rates 0.004 vs 0.012) but not slower rates than gold salts (0.008 vs 0.008). Despite its efficacy, the possible role of MTX in slowing disease progression more than other DMARD, as determined radiographically, appears to be evident only when compared to azathioprine.