Summary of the proceedings of the International Forum 2021: “A more visible radiologist can never be replaced by AI”

The ESR International Forum at the ECR 2021 discussed effects of artificial intelligence on the future of radiology and the need for increased visibility of radiologists. The participating societies were invited to submit written reports detailing the current situation in their country or region. The European Society of Radiology (ESR) established the ESR International Forum in order to discuss hot topics in the profession of radiology with non-European radiological partner societies. At the ESR International Forum 2021, different strategies, initiatives and ideas were presented with regard to radiology community’s response to the changes caused by the emerging AI technology.

The nipple-areolar complex: comprehensive imaging review

The nipple-areolar complex can be affected by a variety of benign and malignant entities that can present with non-specific symptoms. Benign pathologies commonly affecting the nipple-areolar complex include nipple calcifications, nipple adenoma, abscess of Montgomery tubercles, ductal ectasia, periductal mastitis, and papilloma. Malignant pathologies that affect the nipple-areolar complex include Paget's disease of the breast, ductal carcinoma in-situ, and invasive ductal carcinoma. Clinical history and examination, imaging, and tissue sampling when appropriate are co-dependent factors that guide the assessment of nipple-areolar pathologies. This article provides a review of the normal anatomy, common anatomical variants, benign and malignant pathologies, and imaging techniques to guide the diagnostic assessment of the nipple-areolar complex.

Assessing 30-day quantity-frequency of U.S. adolescent cigarette smoking as a predictor of adult smoking 14 years later

BACKGROUND

To improve measures of monthly tobacco cigarette smoking among non-daily smokers, predictive of future non-daily monthly and daily smoking.

METHODS

Data from United States National Longitudinal Study of Adolescent to Adult Health, tracking adolescents, ages 12-21, over 14 years were analyzed. At baseline, 6501 adolescents were assessed; 5114 individuals provided data at waves 1 and 4. Baseline past 30-day non-daily smokers were classified using quantity-frequency measures: cigarettes smoked/day by number of days smoked in the past 30 days.

RESULTS

Three categories of past 30-day non-daily smokers emerged using cigarettes/month (low:1-5, moderate: 6-60, high: 61+) and predicted past 30-day smoking at follow-up (low: 44.5%, moderate: 60.0%, high: 77.0%, versus 74.2% daily smokers; rτ=-0.2319, p<0.001). Two categories of non-smokers plus low, moderate and high categories of non-daily smokers made up a five-category non-daily smoking index (NDSI). High NDSI (61+ cigs/mo.) and daily smokers were equally likely to be smoking 14 years later (High NDSI OR=0.97, 95% CI=0.53-1.80 [daily as reference]). Low (1-5 cigs/mo.) and moderate (6-60 cigs/mo.) NDSI were distinctly different from high NDSI, but similar to one another (OR=0.21, 95% CI=0.15-0.29 and OR=0.22, 95% CI=0.14-0.34, respectively) when estimating future monthly smoking. Among those smoking at both waves, wave 1 non-daily smokers, overall, were less likely than wave 1 daily smokers to be smoking daily 14 years later.

CONCLUSIONS

Non-daily smokers smoking over three packs/month were as likely as daily smokers to be smoking 14-years later. Lower levels of non-daily smoking (at ages 12-21) predicted lower likelihood of future monthly smoking. In terms of surveillance and cessation interventions, high NDSI smokers might be treated similar to daily smokers.

Risky behaviors, e-cigarette use and susceptibility of use among college students

BACKGROUND

Since 2007, there has been a rise in the use of electronic cigarettes (e-cigarettes). The present study uses cross-sectional data (2013) to examine prevalence, correlates and susceptibility to e-cigarettes among young adults.

METHODS

Data were collected using an Internet survey from a convenience sample of 1437, 18-23 year olds attending four colleges/universities in Upstate New York. Results were summarized using descriptive statistics; logistic regression models were analyzed to identify correlates of e-cigarette use and susceptibility to using e-cigarettes.

RESULTS

Nearly all respondents (95.5%) reported awareness of e-cigarettes; 29.9% were ever users and 14.9% were current users. Younger students, males, non-Hispanic Whites, respondents reporting average/below average school ability, ever smokers and experimenters of tobacco cigarettes, and those with lower perceptions of harm regarding e-cigarettes demonstrated higher odds of ever use or current use. Risky behaviors (i.e., tobacco, marijuana or alcohol use) were associated with using e-cigarettes. Among never e-cigarette users, individuals involved in risky behaviors or, with lower harm perceptions for e-cigarettes, were more susceptible to future e-cigarette use.

CONCLUSIONS

More e-cigarette users report use of another nicotine product besides e-cigarettes as the first nicotine product used; this should be considered when examining whether e-cigarette use is related to cigarette susceptibility. Involvement in risky behaviors is related to e-cigarette use and susceptibility to e-cigarette use. Among college students, e-cigarette use is more likely to occur in those who have also used other tobacco products, marijuana, and/or alcohol.

The effects of extended pre-quit varenicline treatment on smoking behavior and short-term abstinence: a randomized clinical trial

Preclinical research and learning theory suggest that a longer duration of varenicline treatment prior to the target quit date (TQD) would reduce smoking rates before cessation and improve abstinence outcomes. A double-blind randomized controlled trial tested this hypothesis in 60 smokers randomized to either an Extended run-in group (4 weeks of pre-TQD varenicline) or a Standard run-in group (3 weeks of placebo, 1 week of pre-TQD varenicline); all the participants received 11 weeks of post-TQD varenicline and brief counseling. During the pre-quit run-in, the reduction in smoking rates was greater in the Extended run-in group than in the Standard run-in group (42% vs. 24%, P < 0.01), and this effect was greater in women than in men (57% vs. 26%, P = 0.001). The rate of continuous abstinence during the final 4 weeks of treatment was higher among women in the Extended group compared to women in the Standard run-in group (67% vs. 35%). Although these data suggest that extension of varenicline treatment reduces smoking during the pre-quit period and may further enhance cessation rates, confirmatory evidence is needed from phase III clinical trials.

Associations between adult and childhood secondhand smoke exposures and fecundity and fetal loss among women who visited a cancer hospital

BACKGROUND

A large percentage of the population continues to be exposed to secondhand smoke (SHS). Although studies have consistently linked active smoking to various pregnancy outcomes, results from the few studies examining SHS exposure and pregnancy difficulties have been inconsistent.

METHODS

Approximately 4800 women who presented to Roswell Park Cancer Institute between 1982 and 1998 and reported being pregnant at least once were queried about their childhood and adult exposures to SHS using a standardised questionnaire. Women were asked to report on selected prenatal pregnancy outcomes (fetal loss and difficulty becoming pregnant).

RESULTS

Approximately 11.3% of women reported difficulty becoming pregnant, while 32% reported a fetal loss or 12.4% reported multiple fetal losses. 40% reported any prenatal pregnancy difficulty (fetal loss and/or difficulty becoming pregnant). SHS exposures from their parents were associated with difficulty becoming pregnant (OR = 1.27, 95% CI 1.03 to 1.56) and lasting >1 year (OR = 1.34, 95% CI 1.12 to 1.60). Exposure to SHS in both at home during childhood and at the time of survey completion was also associated with fetal loss (OR = 1.39, 95% CI 1.17 to 1.66) and multiple fetal losses (OR = 1.62, 95% CI 1.25 to 2.11). Increasing current daily hours of SHS exposure as an adult was related to the occurrence of both multiple fetal loss and reduced fecundity (p(trend) < 0.05).

CONCLUSIONS

Reports of exposures to SHS during childhood and as an adult were associated with increased odds for prenatal pregnancy difficulties. These findings underscore the public health perspective that all people, especially women in their reproductive years, should be fully protected from tobacco smoke.

Risk-based care in survivors of childhood cancer: A report from the Childhood Cancer Survivor Study (CCSS)

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Background: Childhood cancer survivors are at significant risk of morbidity as a result of their therapy. Thus, they require regular medical follow-up focused on their specific long-term risks. We examined the frequency and type of care received by a cohort of adult survivors of childhood cancer and examined the predictors of the receipt of appropriate risk-based care. Methods: Eligible subjects were members of the CCSS, a multi-institutional study of patients who have survived at least 5 years after being diagnosed with childhood cancer between 1970 and 1986. Participants completed a baseline survey and a subsequent survey on health care contact within the preceding 2 years. Contact was classified hierarchically as general care, cancer-related care, basic risk-based care and optimal risk-based care. Optimal risk-based care was assessed only in patients whose therapy is associated with a substantial risk of cardiac disease (=300 mg/m2 of an anthracycline, or any anthracycline plus chest radiation) or breast cancer (females who received chest radiation who are =27 years). Univariate and multivariable analyses were performed to assess associations between demographic/treatment variables and health care outcomes using logistic regression models. Results: The health care questionnaire was completed by 8,448 survivors. Median age (range) at diagnosis was 6.8 (0–21.0) years and at assessment was 31.4 (17.5–54.1) years. 87% reported general medical contact, 31% cancer- related care and 12% basic risk-based cancer care. Amongst patients at increased risk of cardiac disease (N=1,798) or breast cancer (N=852), only 28% reported receiving an echocardiogram and 49% a mammogram, respectively. Patients without health insurance (odds ratio [OR]=2.22, 95% confidence interval [CI]=1.56–3.13, p<0.0001 by Wald statistic), males (OR=1.19, 95% CI=1.03–1.37, p=0.02), younger patients (OR=1.03, 95% CI=1.02–1.04, p<0.0001) and those who perceived their health as good/excellent (OR=1.37, 95% CI=1.13–1.65, p=0.001) were at increased risk of not having received basic risk-based care. Conclusions: Despite a significant risk of late effects after cancer therapy, the majority of adult survivors of childhood cancer do not receive appropriate risk-based health care.

No significant financial relationships to disclose.

Linked claims and medical records for case management of breast cancer diagnosis

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Background: Real time linkage of medical records and administrative claims may assist physicians in managing cancer care. Failure to obtain requisite follow-up (f/u) of abnormal mammograms may delay cancer diagnosis and impact outcome with studies showing that up to 20% of women do not get recommened f/u. We tested the accuracy of claims data linked to medical records in identifying women who did not receive f/u for an abnormal mammogram (BI-RADS 0,3,4,5). Methods: Electronic medical records in a staff model practice affiliated with a single payer were scanned to identify the BI-RADS code for all mammograms performed by practice radiologists. For each woman covered by the payer with a BI-RADS 0,3,4 or 5 mammogram, claims were searched for f/u breast procedures (imaging, biopsy, surgery). For women with more than 1 abnormal mammogram in the study period, only f/u of the first abnormal mammogram was studied. Cases were censured if their insurance coverage with the payer terminated before the required period of follow-up. Medical records of cases defined by claims as not having recommended f/u were reviewed to determine the accuracy of claims analysis. Results: 17,329 women covered by the payer had at least one mammogram in the practice from 1/1/2001 to 12/31/2003. The BI-RADS was 0, 3, 4 or 5 in 1,319 (7.5%). Among 1,206 eligible for f/u, 189 (16%) did not receive the BI-RADS recommended f/u (see table ). Medical record review showed that the claims search accurately identified the follow-up care in 95% of these cases. Conclusions: Administrative claims accurately identify care for diagnostic management of abnormal mammograms. Real-time linkage of claims to mammogram BI-RADS data is being tested as a regional case management system to assist physicians in assuring approrpriate follow-up for abnormal mammograms.

[Table: see text]

No significant financial relationships to disclose.

Childhood leukaemia in Belarus, Russia, and Ukraine following the Chernobyl power station accident: results from an international collaborative population-based case–control study

BACKGROUND

There is little evidence regarding the risk of leukaemia in children following exposure to radionuclides from the Chernobyl Nuclear Power Plant explosion on April 26, 1986.

METHODS

This population-based case-control study investigated whether acute leukaemia is increased among children who were in utero or <6 years of age at the time of the Chernobyl accident. Confirmed cases of leukaemia diagnosed from April 26, 1986 through December 31, 2000 in contaminated regions of Belarus, Russia, and Ukraine were included. Two controls were matched to each case on sex, birth year, and residence. Accumulated absorbed radiation dose to the bone marrow was estimated for each subject.

RESULTS

Median estimated radiation doses of participants were <10 mGy. A significant increase in leukaemia risk with increasing radiation dose to the bone marrow was found. This association was most evident in Ukraine, apparent (but not statistically significant) in Belarus, and not found in Russia.

CONCLUSION

Taken at face value, these findings suggest that prolonged exposure to very low radiation doses may increase leukaemia risk as much as or even more than acute exposure. However the large and statistically significant dose-response might be accounted for, at least in part, by an overestimate of risk in Ukraine. Therefore, we conclude this study provides no convincing evidence of an increased risk of childhood leukaemia as a result of exposure to Chernobyl radiation, since it is unclear whether the results are due to a true radiation-related excess, a sampling-derived bias in Ukraine, or some combination thereof. However, the lack of significant dose-responses in Belarus and Russia also cannot convincingly rule out the possibility of an increase in leukaemia risk at low dose levels.

Smallpox: clinical highlights and considerations for vaccination

Smallpox virus has gained considerable attention as a potential bioterrorism agent. Recommendations for smallpox (vaccinia) vaccination presume a low risk for use of smallpox as a terrorist biological agent and vaccination is currently recommended for selected groups of individuals such as health care workers, public health authorities, and emergency/rescue workers, among others. Information about adverse reactions to the smallpox vaccine is based upon studies completed during the 1950s and 1960s. The prevalence of various diseases has changed over the last four decades and new disease entities have been described during this period. The smallpox vaccination may be contra-indicated in many of these conditions. This has made pre-screening of potential vaccines necessary. It is believed that at present, the risks of vaccine-associated complications far outweigh the potential benefits of vaccination in the general population.

Alcohol, tobacco and breast cancer--collaborative reanalysis of individual data from 53 epidemiological studies, including 58,515 women with breast cancer and 95,067 women without the disease

Alcohol and tobacco consumption are closely correlated and published results on their association with breast cancer have not always allowed adequately for confounding between these exposures. Over 80% of the relevant information worldwide on alcohol and tobacco consumption and breast cancer were collated, checked and analysed centrally. Analyses included 58,515 women with invasive breast cancer and 95,067 controls from 53 studies. Relative risks of breast cancer were estimated, after stratifying by study, age, parity and, where appropriate, women's age when their first child was born and consumption of alcohol and tobacco. The average consumption of alcohol reported by controls from developed countries was 6.0 g per day, i.e. about half a unit/drink of alcohol per day, and was greater in ever-smokers than never-smokers, (8.4 g per day and 5.0 g per day, respectively). Compared with women who reported drinking no alcohol, the relative risk of breast cancer was 1.32 (1.19-1.45, P<0.00001) for an intake of 35-44 g per day alcohol, and 1.46 (1.33-1.61, P<0.00001) for >/=45 g per day alcohol. The relative risk of breast cancer increased by 7.1% (95% CI 5.5-8.7%; P<0.00001) for each additional 10 g per day intake of alcohol, i.e. for each extra unit or drink of alcohol consumed on a daily basis. This increase was the same in ever-smokers and never-smokers (7.1% per 10 g per day, P<0.00001, in each group). By contrast, the relationship between smoking and breast cancer was substantially confounded by the effect of alcohol. When analyses were restricted to 22 255 women with breast cancer and 40 832 controls who reported drinking no alcohol, smoking was not associated with breast cancer (compared to never-smokers, relative risk for ever-smokers=1.03, 95% CI 0.98-1.07, and for current smokers=0.99, 0.92-1.05). The results for alcohol and for tobacco did not vary substantially across studies, study designs, or according to 15 personal characteristics of the women; nor were the findings materially confounded by any of these factors. If the observed relationship for alcohol is causal, these results suggest that about 4% of the breast cancers in developed countries are attributable to alcohol. In developing countries, where alcohol consumption among controls averaged only 0.4 g per day, alcohol would have a negligible effect on the incidence of breast cancer. In conclusion, smoking has little or no independent effect on the risk of developing breast cancer; the effect of alcohol on breast cancer needs to be interpreted in the context of its beneficial effects, in moderation, on cardiovascular disease and its harmful effects on cirrhosis and cancers of the mouth, larynx, oesophagus and liver.

Manipulation of colonic bacteria and volatile fatty acid production by dietary high amylose maize (amylomaize) starch granules

AIMS

To study the effects of amylomaize starch and modified (carboxymethylated and acetylated) amylomaize starches on the composition of colonic bacteria and the production of volatile fatty acids, in mice.

METHODS AND RESULTS

Balb/c mice were fed with experimental diets containing various amount of amylomaize and modified amylomaize starches. Colonic bacterial populations and short-chain fatty acids were monitored. Results showed that the increases in indigenous bifidobacteria were detected in mice fed all starches tested; however, the highest numbers were observed in the group fed with 40% unmodified amylomaize starch. The starch type influenced the populations of indigenous Lactobacillus, Bacteroides and coliforms. High Lactobacillus numbers were achieved in the colon of mice fed with high concentration of amylomaize starch. Acetylated amylomaize starch significantly reduced the population of coliforms. In addition, orally dosed amylomaize utilizing bifidobacteria reached their highest levels when fed together with amylomaize or carboxymethylated amylomaize starch and in both cases butyrate levels were markedly increased.

CONCLUSIONS

These results indicate that different amylomaize starches could generate desirable variation in gut microflora and that particular starches may be used to selectively modify gut function.

SIGNIFICANCE AND IMPACT OF STUDY

Amylomaize starch appeared to enhance the desirable composition of colonic bacteria in mice, and suggested it possessed the potential prebiotic properties. Therefore, resistant starch and its chemical derivatives may exert beneficial impacts to the human colon.

Evaluation of a youth tobacco education program: student, teacher, and presenter perspectives

Few published studies have explored the impact of smoking prevention programs among elementary-school children. This study describes a qualitative, cross-sectional evaluation of the Tar Wars tobacco prevention program among 5th-grade students (n = 888), along with impressions from classroom teachers and program presenters. Results from this evaluation reveal that all constituencies involved with the Tar Wars program--5th-grade students, classroom teachers, and program presenters--indicated high satisfaction with this youth tobacco education program. Students enjoyed the program and indicated understanding of key themes, classroom teachers stated that the program was worthwhile in presenting unique information, and presenters were enthusiastic about the ease of presentation and opportunities for future presentations.

Parental occupational exposures and risk of neuroblastoma: a case-control study (United States)

BACKGROUND

A case-control study was conducted with 183 histologically confirmed neuroblastoma cases aged 0-14 years diagnosed among residents of New York State, excluding New York City, between 1976 and 1987. Three hundred seventy-two controls were selected from the New York State live birth certificate registry and were matched to cases on year of birth.

METHODS

Parental occupational exposures at the time of each child's birth were obtained from maternal telephone interviews, successfully completed for 85% of cases and 87% of controls.

RESULTS

Odds ratios were significantly elevated for maternal occupation in the service (OR = 2.0, 95% CI = 1.0 4.1) and retail (OR = 2.0, 95% CI = 1.1-3.7) industries and paternal occupation in materials handling (OR = 3.8, 95% CI = 1.1-14.6). Odds ratios were also significantly elevated for maternal report of occupational exposure to acetone (OR = 3.1, 95% CI = 1.7-5.6), insecticides (OR = 2.3, 95% CI = 1.4-3.7), lead (OR = 4.7, 95% CI = 1.3-18.2) and petroleum (OR = 3.0, 95% CI = 1.5-6.1) and paternal exposure to creosote (OR = 2.1, 95% CI = 1.1-4.3), dioxin (OR = 6.9, 95% CI = 1.3-68.4), lead (OR = 2.4, 95% CI = 1.2-4.8), and petroleum (OR = 1.8, 95% CI = 1.1-2.8).

CONCLUSIONS

Due to the uncertainty of the biologic plausibility of these associations and the possibility of alternative explanations, these results should be interpreted cautiously.

Clinical predictors of dysphagia and aspiration risk: outcome measures in acute stroke patients

OBJECTIVE

To use an established dysphagia clinical screening system to evaluate outcomes in acute stroke patients.

DESIGN

Case-control study.

SETTING

Tertiary care center.

PARTICIPANTS

Acute stroke patients (n = 56) consecutively referred to a speech pathology service.

MAIN OUTCOME MEASURES

Outcomes (ie, pneumonia, dietary status at discharge) in patients who were referred for a videofluoroscopic swallow study (VSS) based on results of a previously validated clinical screening system were compared with outcomes in patients who were not referred for VSS based on the clinical evaluation.

RESULTS

Thirty-eight of 56 patients (68%) presented with 2 or more clinical predictors of moderate to severe dysphagia and were further evaluated with VSS, whereas 18 patients (32%) had fewer than 2 clinical features and were not evaluated radiographically. Based on patient outcomes and VSS results, identification of at least 2 clinical predictors significantly distinguished patients with moderate to severe dysphagia from patients with mild dysphagia or normal swallowing. None of the patients in either group developed pneumonia while following recommendations of the clinical or dynamic swallowing evaluation, and 93% of the patients returned to a regular diet.

CONCLUSIONS

These data demonstrate that clinical use of this screening system can objectively identify acute stroke patients who warrant further diagnostic studies and can safely determine which patients need no further deglutitive evaluation.

Hypothyroidism and diabetes mellitus in an American Indian population

BACKGROUND

The clinical relationship between diabetes and hypothyroidism is becoming more widely recognized. Although American Indians are disproportionately afflicted with diabetes, the occurrence of hypothyroidism within this group has not been previously reported.

METHODS

We present data from a retrospective chart review of health clinic data from a rural isolated northeastern tribe. A total of 156 cases of diabetes and 25 cases of hypothyroidism were identified among 892 eligible individuals living in the service area.

RESULTS

Both conditions exhibited strong sex differences. The prevalences of diabetes (21%) and hypothyroidism (5%) among women were higher than those observed among men (13% and 0.2%, respectively). The overall prevalence of hypothyroidism among women with diabetes (8.8%) varied by age ranging from 5% among women younger than 60 years to 21% among women aged 60 years and older.

CONCLUSIONS

Our findings support the need for further investigation of the association between diabetes and hypothyroidism in American Indian populations with high prevalence rates of diabetes. This association may be of particular interest to family physicians and other clinicians caring for American Indian populations.

Predictors of anticipated breastfeeding in an urban, low-income setting

BACKGROUND

Although the proportion of women who breastfeed is known to vary by demographic group, breastfeeding practices have not been sufficiently studied among urban, lower income African American populations seen in family medicine centers.

METHODS

A cross-sectional design was used to examine demographic, clinical, and attitudinal factors that affect anticipated infant feeding practices reported by postpartum women from a low-income, urban family practice setting. Data was analyzed using chi-square, odds ratios (OR), and multiple logistic regression techniques.

RESULTS

Among 66 respondents, only 3 subjects (4.5%) indicated that they planned to breastfeed exclusively, while an additional 11 subjects (16.7%) reported plans to use a combination of bottle-feeding and breastfeeding. Based on univariate analyses, women with less than 12 years of education were less likely to report anticipated breastfeeding. Otherwise, breastfeeding plans were not associated with subject demographic features or with reproductive characteristics. Respondents planning to bottle-feed noted that breastfeeding was too complicated. Logistic regression demonstrated an inverse relationship between level of maternal education and anticipated breastfeeding (OR=0.13, 95% confidence interval [CI], 0.05-0.35), and a direct association for encouragement from the baby's father or the woman's mother to breastfeed and anticipated breastfeeding (OR=12.4; 95% CI, 4.92-31.4).

CONCLUSIONS

This study reports unique data regarding anticipated infant feeding practices among patients from an urban, low-income community served by a family medicine center. Findings from this study will be used to develop a family-centered educational intervention involving the mothers, grandmothers, and partners of pregnant patients to promote the benefits of breastfeeding in this community.

An investigation of hypomagnesemia among ambulatory urban African Americans

BACKGROUND

Magnesium represents the fourth most abundant cation in the body and plays an integral role in intracellular metabolism. Although magnesium deficiency states have been associated with a variety of medical conditions, the prevalence of hypomagnesemia has not been well studied, particularly in ambulatory settings.

METHODS

We performed a period prevalence study using 120 patients seen for routine medical care at an urban family medicine center. Chart reviews were completed for these subjects. We used univariate and multivariate analyses to correlate magnesium levels with demographic and clinical factors.

RESULTS

There was a 20% overall prevalence of hypomagnesemia among this predominantly female, African American population. The prevalence of hypomagnesemia was greatest among patients with a history of alcoholism (odds ratio [OR] = 6.00; 95% confidence interval [CI], 1.41-26.1) and among those having 1 or more of the following medical conditions: diabetes, hyperlipidemia, hypertension, renal disease, and asthma (OR = 4.69; 95% CI, 1.37-17.65).

CONCLUSIONS

The prevalence of hypomagnesemia among patients from this urban minority community exceeds that reported in previous studies of the general population. This may be reflective of greater comorbidity, diminished nutritional status, or poorer overall health among patients from this community. The association between hyperlipidemia and magnesium deficiency warrants further investigation.

A clozapine overdose with markedly elevated serum levels

Clozapine (Clozaril) is an atypical antipsychotic agent used to treat schizophrenia refractory to other pharmacological agents. This report describes an accidental clozapine overdose. The half-life of clozapine in this patient was determined from two blood levels, one obtained on admission and the second 10.5 hours later. The calculated half-life of 8.11 hours is consistent with published levels for single doses and suggests an apparent stability in clozapine elimination half-life in the face of overdose. The maximum clozapine blood level attained was probably among the highest nonfatal levels reported. The patient recovered fully following hospital admission for monitoring and supportive care. This case report illustrates the usefulness of following the time course of the changes in blood level at selected time intervals, as well as the importance of entertaining a diagnosis of drug overdose in patients presenting with acute mental status changes.

The health status of American Indians and Alaska Natives: 2. Lessons for cancer educators

Malignant disease is largely unrecognized as a leading cause of death among American Indians and Alaska Natives (AI/ANs). Published studies of cancer incidence, cancer mortality, and cancer survival are highlighted to present an overview on the epidemiology of cancer among Native peoples. Cancer incidence and mortality have demonstrated steady increases among AI/ANs during a relatively limited time frame, as well as unique patterns of site-specific cancers. Cancer-survival data reveal that Native peoples have the poorest survival of any racial group for all cancer sites combined and for eight of the ten leading sites. Opportunities to educate health care providers, through continuing medical education programs and focused conferences for postdoctoral and current medical trainees, can be used to enhance cultural sensitivity and to examine ethnic differences in cancer patterns. Enhancement of recognition of the unique cancer patterns among AI/AN populations may lead to improved identification of at-risk individuals and more effective cancer screening programs within Native communities.

Improving diabetes preventive care in a family practice residency program: a case study in continuous quality improvement

BACKGROUND AND OBJECTIVES

The paradigm of continuous quality improvement (CQI) holds promise for application in clinical settings. This paper highlights results of a CQI project developed and implemented in a residency-based, ambulatory family medicine center for management of non-insulin-dependent diabetes mellitus.

METHODS

We developed a CQI program that used several indicators of diabetes management as measures of quality care. These included dietary counseling, exercise counseling, foot care counseling, ophthalmology referral, and measurement of hemoglobin AIC and renal function.

RESULTS

Overall, compliance with recommendations for diabetes management increased from a baseline proportion of 40% to a level of 70% at the end of 1 year. During the second year, overall compliance was maintained at this level despite the inclusion of additional performance indicators.

CONCLUSIONS

The CQI process can improve physician performance in managing patients with diabetes.

Persistent dysphagia and dysphonia following cervical spine surgery

Persistent dysphagia and dysphonia following anterior cervical spine surgery have been underdiagnosed. Understanding the physiologic mechanism resulting in post-surgical dysphagia and dysphonia is essential to providing appropriate treatment. Two cases of protracted dysphagia and dysphonia following left anterior cervical corpectomy were reviewed. Videofluoroscopic evaluation, videostroboscopic assessment and laryngeal nerve-conduction testing were used to determine swallowing, vocal fold and cranial nerve integrity; to assess the ability to achieve oral nutrition; and to direct therapy and surgical procedures to improve swallowing and voice. With a multidisciplinary approach, the physiologic problems of post-surgical dysphagia and dysphonia can be addressed and therapeutic and/or surgical treatments initiated promptly.

Health status of American Indians/Alaska Natives: general patterns of mortality

BACKGROUND AND OBJECTIVES

Investigations of American Indian and Alaska Native (AI/AN) populations suggest patterns of mortality that differ from the general population. Mortality data reveal excess overall mortality among AI/ANs, as well as excesses for specific causes of death, including accidents, diabetes, liver disease, pneumonia/influenza, suicide, homicide, and tuberculosis. A relative deficit of deaths has been noted for heart disease, cancer, and HIV infections. It is important that physicians demonstrate cultural competence so they may provide quality medical care for the populations they serve. Activities such as provider education, risk assessment, and emphasis on preventive services are offered to facilitate integration into teaching curricula. Knowledge of distinctive mortality patterns among AI/ANs will help clinicians recognize the unique needs of these patients.

Native American Cancer Conference III. Cognitive correlates and impressions of attendees

BACKGROUND

The results of preconference and postconference surveys, as well as conference evaluation forms, distributed to attendees at the "Native American Cancer Conference III: Risk Factors, Outreach and Intervention Strategies," Seattle, Washington, June 16-19, 1995, are presented.

METHODS

Conference attendees were requested to complete a multi-item survey designed to assess knowledge and perceptions relating to cancer among native peoples at the beginning and end of the conference. The evaluation instrument solicited qualitative impressions of the conference.

RESULTS

Survey respondents were predominantly female (70%), and approximately half were native persons representing 48 different American Indian and Alaska Native communities. Knowledge levels were generally high at baseline for most items relating to cancer, with evidence of significant improvement for several items on the postconference survey. The majority of respondents believed that cancer was of equal importance compared with other health problems and that cancer services for American Indians and Alaska Natives are generally less extensive compared with the majority population; there was no evidence of opinion change noted in the postconference survey. Results from the qualitative evaluation expressed the unique and affirmative experiences among participants in terms of the social, cultural, and informational sharing that occurred.

CONCLUSIONS

It is hoped that the positive experiences of conference attendees will serve to stimulate the organization of similar programs and the design of research projects that both assess and expand cancer control services among Native peoples.

Tribal-based cancer control activities. Services and perceptions

BACKGROUND

Cancer is becoming a significant health problem for American Indians and Alaska Natives. Despite the precipitous increase in cancer rates in these populations, limited data are available regarding the extent of cancer control services available in these communities.

METHODS

A cross-sectional survey of tribal health directors of all federally recognized tribes was undertaken to discover the breadth of cancer control activities offered and directors' perceptions of and priorities ascribed to cancer.

RESULTS

Little more than half (53%) of respondents perceived cancer rates to be increasing. Cancer was found to rank fifth among seven health conditions when directors were asked to rank their tribe's commitment to confronting each. Lower relative levels of awareness of cancer patterns coupled with competing health problems relegated cancer control activities to low-priority issues.

CONCLUSIONS

Findings from this study underscore the need to elevate the issue of cancer in Indian Country and to educate investigators to become more sensitive and responsive to other tribal health issues.

Breast cancer and hormonal contraceptives: further results. Collaborative Group on Hormonal Factors in Breast Cancer

The Collaborative Group on Hormonal Factors in Breast Cancer has brought together and reanalysed the worldwide epidemiological evidence on breast cancer risk and use of hormonal contraceptives. Original data from 54 studies, representing about 90% of the information available on the topic, were collected, checked and analysed centrally. The 54 studies were performed in 26 countries and include a total of 53,297 women with breast cancer and 100,239 women without breast cancer. The studies were varied in their design, setting and timing. Most information came from case-control studies with controls chosen from the general population; most women resided in Europe or North America and most cancers were diagnosed during the 1980s. Overall 41% of the women with breast cancer and 40% of the women without breast cancer had used oral contraceptives at some time; the median age at first use was 26 years, the median duration of use was 3 years, the median year of first use was 1968, the median time since first use was 16 years, and the median time since last use was 9 years. The main findings, summarised elsewhere, are that there is a small increase in the risk of having breast cancer diagnosed in current users of combined oral contraceptives and in women who had stopped use in the past 10 years but that there is no evidence of an increase in the risk more than 10 years after stopping use. In addition, the cancers diagnosed in women who had used oral contraceptives tended to be less advanced clinically than the cancers diagnosed in women who had not used them. Despite the large number of possibilities investigated, few factors appeared to modify the main findings either in recent or in past users. For recent users who began use before age 20 the relative risks are higher than for recent users who began at older ages. For women whose use of oral contraceptives ceased more than 10 years before there was some suggestion of a reduction in breast cancer risk in certain subgroups, with a deficit of tumors that had spread beyond the breast, especially among women who had used preparations containing the highest doses of oestrogen and progestogen. These findings are unexpected and need to be confirmed. Although these data represent most of the epidemiological evidence on the topic to date, there is still insufficient information to comment reliably about the effects of specific types of oestrogen or of progestogen. What evidence there is suggests, however, no major differences in the effects for specific types of oestrogen or of progestogen and that the pattern of risk associated with use of hormonal contraceptives containing progestogens alone may be similar to that observed for preparations containing both oestrogens and progestogens. On the basis of these results, there is little difference between women who have and have not used combined oral contraceptives in terms of the estimated cumulative number of breast cancers diagnosed during the period from starting use up to 20 years after stopping. The cancers diagnosed in women who have used oral contraceptives are, however, less advanced clinically than the cancers diagnosed in never users. Further research is needed to establish whether the associations described here are due to earlier diagnosis of breast cancer in women who have used oral contraceptives, to the biological effects of the hormonal contraceptives or to a combination of both. Little information is as yet available about the effects on breast cancer risk of oral contraceptive use that ceased more than 20 years before and as such data accumulate it will be necessary to re-examine the worldwide evidence.

Colorectal cancer in patients aged 30 years or younger

Colorectal cancer (CRC) is believed to carry a grim prognosis in young patients. A retrospective study of patients diagnosed with colorectal cancer at age 30 years or less between 1971 and 1994 was conducted. Statistical analyses were performed using non-parametric one way ANOVA tests and logistic regression models. Sixty-eight of the patients evaluated at our institution were suitable for this study. Risk factors were identified in 28% of patients. The median age at diagnosis was 27 years (range 14-30 years). Fifty-six patients (82%) were Stage III or IV at the time of diagnosis. Twenty-two of the 34 patients who underwent potentially curative surgery had recurring disease at a median of 12 months (range 1-43 months). At a median follow-up of 21.5 months, 54 patients had died from disease. At the time of death, abdominal carcinomatosis and distant disease were the most common patterns of failure. Stage of the primary tumour (P=0.0006) and recurrence (P=0.0001) were the only variables noted to be associated with survival. The stage of the primary tumour and whether the tumour recurred were each associated with survival in patients with colorectal cancer at age 30 years or less.

Gravid health status, medication use, and risk of neuroblastoma

The epidemiology of neuroblastoma suggests that prenatal exposures may be important etiologic factors in this disease. The authors describe the role of maternal health status and prenatal medication usage and risk of neuroblastoma. This retrospective study was based on completed interviews with 183 histologically confirmed neuroblastoma cases aged 0-14 years diagnosed among residents of New York State (excluding New York City) between 1976 and 1987. Controls were matched to cases on year of birth and race and were drawn from the New York State live birth certificate registry. Interviews were satisfactorily completed with 85% of the cases and 87% of controls. Significantly elevated odds ratios were noted for vaginal infections during pregnancy (odds ratio (OR) = 2.2, 95% confidence interval (CI) 1.2-4.0), medical treatments for vaginal infection during pregnancy (OR = 2.4, 95% CI 1.2-4.9), and any reported use of sex hormones during pregnancy (OR = 3.0, 95% CI 1.3-6.9). Point estimates for any hormone use suggested elevated risk among male offspring (OR = 4.4, 95% CI 1.5-13.3). Among the individual exposures comprising any hormone use, only hormone use related to infertility was observed to be significant (OR = 10.4, 95% CI 1.2-89.9). A protective effect was noted for self-reported vitamin use (OR = 0.28, 95% CI 0.03-0.69). Although it is not possible to presume a specific role for prenatal hormone exposure as initiator or promoter, these findings lend support to an association between prenatal hormone exposure and risk of neuroblastoma.

Tribal-based cancer control activities among Alaska Natives: services and perceptions

Cancer has become a significant health problem in American Indian and Alaskan Native (AI/AN) communities. Despite the precipitous rise in cancer rates, limited data are available concerning cancer control services operative in these communities. To address this issue, a cross-sectional survey of all federally recognized tribes was undertaken to ascertain the breadth of cancer control activities offered and Tribal Health Directors perceptions of and priorities ascribed to cancer. This article presents responses given by AN Health Directors juxtaposed to those proffered by AI Health Directors. Nearly three-quarters (71%) of respondents perceived cancer rates to be increasing. Cancer was found to rank third, fifth among AI Health Directors, among seven health conditions when Directors were asked to rank their Tribe's commitment to confronting each one. Awareness of cancer as a public health concern coupled with competing health problems relegates cancer control activities to a lower priority. Findings underscore the need to elevate the issue of cancer in Indian Country as well as to educate investigators to become more sensitive and responsive to other Tribal health issues.

Correlates of cochlear implantation, 1986-1992

There is a paucity of information regarding the use of cochlear implants within large populations. This article describes correlates of cochlear implantation procedures using a statewide hospital discharge database. Among the 146 implant procedures, 55% involved female patients, whereas the largest groups of patients were represented by younger and older persons (27% between ages 2 and 9 years and 24% 60 years and older). A bimodal distribution was apparent for average annual age-specific rates of cochlear implantation, with the highest rates among persons aged 2 to 9 years (5.4 implants per 1 million) and persons aged 60 to 69 years (3.7 implants per 1 million). Total hospital charges, excluding professional fees, exceeded $12,000 per implant and were found to vary significantly when examined by length of stay and by calendar year of procedure. The data presented are unique with regard to the total number of cochlear implant procedures included and the large, diverse population used. This study expands knowledge concerning the epidemiology and utilization of cochlear implantation.

Correlates of Cochlear Implantation, 1986–1992

There is a paucity of information regarding the use of cochlear implants within large populations. This article describes correlates of cochlear implantation procedures using a statewide hospital discharge database. Among the 146 implant procedures, 55% involved female patients, whereas the largest groups of patients were represented by younger and older persons (27% between ages 2 and 9 years and 24% 60 years and older). A bimodal distribution was apparent for average annual age-specific rates of cochlear implantation, with the highest rates among persons aged 2 to 9 years (5.4 implants per 1 million) and persons aged 60 to 69 years (3.7 implants per 1 million). Total hospital charges, excluding professional fees, exceeded $12,000 per implant and were found to vary significantly when examined by length of stay and by calendar year of procedure. The data presented are unique with regard to the total number of cochlear implant procedures included and the large, diverse population used. This study expands knowledge concerning the epidemiology and utilization of cochlear implantation.

Urban-based Native American cancer-control activities: services and perceptions

BACKGROUND

Cancer has become a significant health concern in American Indian communities. Over the past several decades Native peoples have experienced significant increases in life expectancy and, with these gains, significant increases in cancer incidence and mortality. Limited data are available concerning cancer-control activities accessible to American Indian communities. Even less is known about control programs in place for American Indians resident in urban areas, where more that half of all Native peoples reside.

METHODS

To ascertain the extent of available services and perceptions of health directors, a survey of all Indian-Health-Service-recognized urban clinics was undertaken.

RESULTS

Results indicate that the cancer needs of American Indians resident in urban areas are not being adequately addressed. Only one-third of urban health directors reported perceived increases in cancer incidence and mortality rates. The directors ranked cancer fifth among seven health problems in terms of their clinics' commitment to addressing them. Findings from this study are juxtaposed with whose obtained in a separate survey of reservation-based health directors.

CONCLUSIONS

Results indicate a need to develop more responsive cancer-control programs in Indian country and to sensitize researchers to other health needs of these communities.

A bibliometric analysis of cancer among American Indians & Alaska Natives, 1966-1993

A bibliometric analysis was employed to objectively assess scientific studies published between 1966 and 1993 which have described cancer among American Indians and Alaska Natives. Searches of the MEDLINE (1966-1993) and CANCERLIT data bases (1983-1994) were used to identify relevant publications. In addition to examining publication sources and quantitative temporal trends, further bibliometric analyses were completed by considering a subset of papers published between 1982 and 1992. A total of 128 studies of cancer among American Indians and Alaska Natives were published between 1966 and 1993; 62 of these articles (48%) appeared between 1988 and 1993. Nine journals accounted for 53% of the total publications. The subset of 68 papers published between 1982 and 1992 were cited a total of 388 times in 136 different journals; the median number of citations was 2. Results demonstrate a limited number of published papers on cancer among American Indians and Alaska Natives. It is hoped that this paper will increase the awareness of cancer as an important health problem among American Indian and Alaska Natives and thereby serve to stimulate additional cancer-related research activities involving these groups.

Racial variation in spontaneous fetal deaths at 20 weeks or older in upstate New York, 1980-86

The distribution of spontaneous fetal deaths (at age 20 weeks or more) by maternal race has received considerably less study than other adverse pregnancy outcomes. The purpose of this study was twofold--(a) to describe spontaneous fetal deaths among white, black, and American Indian women and (b) to determine if there was any variation by International Classification of Diseases, Ninth Revision (ICD-9) cause of death, gestational age at death, or maternal age at loss among these groups of mothers. Using the fetal death certificate registry maintained by the New York State Department of Health, 8,592 spontaneous fetal deaths at age 20 weeks or more were identified among upstate (exclusive of New York City) mothers between 1980 and 1986. By race it was 7,300 for white women, 1,257 for black women, and 27 for American Indian women. Spontaneous fetal death rates varied by maternal race as listed on vital records--black, 13.5 per 1,000 total births, white, 8.3, and American Indian, 8.1. The three leading causes of death (ICD-9,779, 762, and 761) did not vary by maternal race. Gestational age at death, imputed from last menstrual period, did vary by maternal race. Fetal deaths to white and black mothers were observed to occur most often between 24 weeks of pregnancy (39 percent) and 32 weeks (43 percent), while American Indian fetal deaths generally occurred later (more than 33 weeks) in pregnancy (41 percent). Most spontaneous fetal deaths occurred to mothers ages 20-29 regardless of race. Black teenage mothers, however, experienced the largest proportion of losses(23 percent) compared with white (10 percent) and American Indian (I I percent) teenage mothers.

Desmoid tumors in patients with familial adenomatous polyposis

BACKGROUND

Sporadic desmoid tumors occur mainly in the abdominal wall and in extraabdominal sites. Desmoid tumors in patients with familial adenomatous polyposis (FAP) usually occur in the abdominal wall and in the bowel mesentery. Surgical resection of desmoids in patients with FAP has been controversial.

METHODS

A retrospective review of patients with FAP and desmoid tumors treated from 1950 to 1991 was performed. Patients were evaluated for gender, age, site of desmoid tumors, treatment, recurrence, and survival.

RESULTS

Twenty-one of 24 patients underwent 60 surgical procedures related to the desmoid tumors. Seven of nine patients who underwent potentially curative surgery had recurrences; three were reresected. Major morbidity after palliative or curative surgery was 47%. Five patients were alive with no evidence of disease at a median of 198 months, 10 patients were alive with disease at a median of 102 months, and 5 patients died with disease at a median of 31 months after diagnosis.

CONCLUSIONS

Desmoid tumors are common in patients with FAP. Unresectability and recurrence are more common than cure. Palliative and curative resections have a high morbidity. Surgery should be reserved for those patients with symptomatic mesenteric desmoids.

Historical and contemporary correlates of syphilis and cancer

BACKGROUND

This study examined the relationship between antecedent syphilis infection and cancer incidence in an attempt to identify specific cancer patterns.

METHODS

The study cohort consisted of 16,420 people diagnosed with syphilis between 1972 and 1987 and who were residents of New York State, exclusive of New York City, at time of diagnosis. Incident cancers among cohort members were identified through linkage with files maintained by the New York State Cancer Registry.

RESULTS

A total of 350 cancer cases were diagnosed among cohort members. For males and females combined, incidence was significantly elevated for cancers of the oral cavity standardized incidence ratio (SIR = 169, 95% confidence interval [CI]: 109-249), and specifically for cancer of the tongue (SIR = 251, 95% CI: 108-494). Significantly elevated incidence was observed among males for Kaposi's sarcoma (SIR = 2000, 95% CI: 1290-2950).

CONCLUSION

While no conclusions may be reached concerning causality, the data do argue for increased cancer surveillance among people with syphilis. Moreover, findings are discussed in light of historical considerations.

Provision of cancer control services to Native Americans by state health departments

To examine the extent of cancer prevention and control programs for American Indian and Alaska Native (AI/AN) tribal groups directly supported by state public health agencies, a cross-sectional survey was completed by chronic disease directors in 50 states. Descriptive statistics were used to summarize responses. Sixteen states (32%) reported having sponsored/directly supported cancer prevention and cancer control services specifically targeted to AI/AN populations. Few state public health agencies had developed culturally-relevant cancer education materials for AI/ANs. Although the respondents directed chronic disease or cancer prevention/control programs in their states, many were unfamiliar with cancer patterns or general health problems among AI/ANs. Survey results indicate that cancer prevention and control services are available to AI/AN populations through most state public health agencies. It is hoped that dissemination of survey results will increase awareness of cancer as a health problem among AI/ANs and lead to an expansion of the services available to this "invisible minority" to levels accessible by the majority population.

Oestrogen replacement therapy and breast cancer risk: a case-control study

The relationship between oestrogen replacement therapy and breast cancer risk was examined based on data obtained from a population-based case-control study of breast cancer on Long Island, New York, USA. Cases were defined as female residents of two Long Island counties, aged 20-79, who were diagnosed with breast cancer between 1 January 1984 and 31 December 1986. Age- and county-matched controls were selected from driver's licence files. Among all postmenopausal women, there was no significant association between ever-use of hormones to treat menopausal symptoms and breast cancer risk. There was also no significant positive association in any subgroup defined by type of menopause (natural, hysterectomy with at least one ovary intact, bilateral oophorectomy) or age at menopause. Additionally, there was no increasing trend in risk with duration of use either overall or in any subgroup, nor was there an effect at any interval since last use. A significant elevation in risk was observed in women with 10-19 years since first exposure, which was concentrated in women with a natural menopause or hysterectomy with at least one ovary remaining, and women aged > 45 at menopause. Results of logistic regression analysis revealed no important confounding by any of several established breast cancer risk factors. However, a significant interaction was observed between body mass index (BMI) and oestrogen use, with an effect of oestrogen use being seen only in the thinnest tercile. Although biologically plausible explanations for this finding exist, the effect of chance cannot be ruled out.

Mortality patterns among persons with antecedent syphilis infection

BACKGROUND AND OBJECTIVES

Few studies have examined the patterns of death among persons with a history of syphilis infection.

GOALS OF THIS STUDY

This analysis examines the cause-specific mortality patterns among a cohort of persons diagnosed with syphilis.

STUDY DESIGN

Individuals diagnosed with serologically confirmed syphilis in New York State (excluding New York City) between 1972 and 1987 were matched to the New York State mortality files to identify the deaths among members of the cohort.

RESULTS

The overall observed mortality between 1973 and 1987 was generally comparable to the expected number among both men (SMR = 0.94; 95% CI = 0.87-1.02) and women (SMR = 0.88; 0.78-0.99). An excess of deaths due to all causes was observed among men between the ages of 25 and 54 (SMR = 1.74; 1.53-1.97), with the largest excess observed in the 25- to 34-year-old age group (SMR = 2.32; 1.87-2.85). Among men, excesses were noted for deaths due to AIDS-related causes. Among both genders, excess deaths were observed for possible alcohol-related causes.

CONCLUSION

The unique mortality patterns of this cohort suggest the need for increased identification of and interventions directed toward high-risk behavior of individuals diagnosed with syphilis.