Early Care and Education Professionals' Breastfeeding Knowledge and Practices Before and After an E-Learning Program

Objective

To assess early care and education professionals' breastfeeding knowledge and practices before and after an e-learning program.

Participants

Early care and education professionals from New Hampshire (U.S.A.) licensed child care programs were invited to complete a pre-assessment followed by a 90-minute e-learning breastfeeding program. Three months post-training, participants were invited to complete the post-assessment.

Analysis

McNemar tests were used to assess changes from pre-post-assessment for dichotomous variables. McNemar-Bowker tests were used to determine differences from pre-post for variables with more than two categories. When the McNemar-Bowker test was significant, a multiple comparison correction (Bonferroni) was used.

Results

114 participants completed the e-learning program and pre-post assessment. Results showed significant improvement from pre-post in 10 of 15 breastfeeding knowledge questions related to health of baby, mother and child care centers, economics, and environmental impact. There were significant changes from pre-post in 24 of 50 breastfeeding practice questions in handling breast milk, promoting breastfeeding, and supporting mothers.

Conclusions and Implications

This study indicates improvement in early care and education professionals' breastfeeding knowledge and practices; however, opportunities exist to design targeted initiatives to further strengthen practices that support breastfeeding families in the child care environment.

Glycaemic control and risk of incident urinary incontinence in women with Type 1 diabetes: results from the Diabetes Control and Complications Trial and Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) study

AIMS

To study the impact of glycaemic control on urinary incontinence in women who participated in the Diabetes Control and Complications Trial (DCCT; 1983-1993) and its observational follow-up study, the Epidemiology of Diabetes Interventions and Complications (EDIC; 1994-present).

METHODS

Study participants were women who completed, at both years 10 (2003) and 17 (2010) of the EDIC follow-up, the urological assessment questionnaire (UroEDIC). Urinary incontinence was defined as self-reported involuntary leakage of urine that occurred at least weekly. Incident urinary incontinence was defined as weekly urinary incontinence present at EDIC year 17 but not at EDIC year 10. Multivariable regression models were used to examine the association of incident urinary incontinence with comorbid prevalent conditions and glycaemic control (mean HbA_1c over the first 10 years of EDIC).

RESULTS

A total of 64 (15.3%) women with Type 1 diabetes (mean age 43.6 ± 6.3 years at EDIC year 10) reported incident urinary incontinence at EDIC year 17. When adjusted for clinical covariates (including age, DCCT cohort assignment, DCCT treatment arm, BMI, insulin dosage, parity, hysterectomy, autonomic neuropathy and urinary tract infection in the last year), the mean EDIC HbA_1c was associated with increased odds of incident urinary incontinence (odds ratio 1.03, 95% CI 1.01-1.06 per mmol/mol increase; odds ratio 1.41, 95% CI 1.07-1.89 per % HbA_1c increase).

CONCLUSIONS

Incident urinary incontinence was associated with higher HbA_1c levels in women with Type 1 diabetes, independent of other recognized risk factors. These results suggest the potential for women to modify their risk of urinary incontinence with improved glycaemic control. (Clinical Trials Registry no: NCT00360815 and NCT00360893).

Sustained Release of Cisplatin in Dogs from an Injectable Implant Delivery System

Cisplatin was incorporated into an in-situ forming biodegradable implant delivery system (ATRIGELO) consisting of a biodegradable polymer dissolved in a pharmaceutically acceptable solvent. The polymer solution with the suspended cisplatin was injected subcutaneously into the flank or shoulder of six healthy beagle dogs where the water-insoluble polymer precipitated upon contact with body fluids and formed a solid implant for the controlled release of the drug. Each dog received four injections, spaced thirty days apart, of a formulation containing either poly(DL-lactide-co-caprolactone) (PLC) or pely(DL-lactide-co-glycolide) (PLGA) dissolved in dimethyl sulfoxide (DM8O) and loaded with 8% by weight cisplatin. Dosage levels of 70, 105, and 157.5 mg/m2 were used to determine dosage escalation effects. Injections of the same formulations without the drug served as controls. Samples of blood were taken at appropriate times over the four months of treatment and analyzed for platinum concentration by atomic absorption spectroscopy. Local tissue and systemic toxicities were also determined. Both formulations exhibited sustained release of cisplatin with peak serum concentrations of platinum being attained in about two days followed by gradually decreasing platinum levels to day thirty. Consistent drug release profiles were observed for each of the four thirty-day treatment periods. The dosage escalation results exhibited an approximate 50% increase in peak platinum levels and area-under-the-curve (AUC) values for each 50% increase in drug dose. Local tissue toxicity to the cisplatin-containing implants was variable and appeared to be unrelated to dose level or direction number. Tissue reaction to the implants without drug was minimal indicating a role of cisplatin in the tissue reactions. Systemic toxicity, as judged by clinical parameters and clinicopathologic evaluation, was not noted at any dose level or injection time.

Ovarian reserve in women with Type 1 diabetes in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Study

Markers of ovarian reserve such as anti-Müllerian hormone (AMH) are used in the management of fertility and prediction of menopause. Although women with type 1 diabetes have a high prevalence of reproductive disorders, no studies have examined whether markers of ovarian reserve are associated with randomization to intensive insulin therapy and subsequent markers of glycemic control. Using data from the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Study, we found that the strongest predictor of AMH was chronologic age, and that diabetes-specific variables such as randomization to intensive therapy, insulin dose, and glycemic control were not associated with AMH concentrations.

Rescoring the NIH chronic prostatitis symptom index: nothing new

The NIH-Chronic Prostatitis Symptom Index (NIH-CPSI) is a commonly used 13-item questionnaire for the assessment of symptom severity in men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). For each item, score ranges are 0–1 (6 items), 0–3 (2 items), 0–5 (3 items), 0–6 (1 item), and 0–10 (1 item). This scoring system is straightforward, but items with wider score ranges are de facto weighted more, which could adversely affect the performance characteristics of the questionnaire. We rescored the NIH-CPSI so that equal weights were assigned to each item, and compared the performance of the standard and rescored questionnaires using the original validation dataset. Both the original and revised versions of the scoring algorithm discriminated similarly among groups of men with chronic prostatitis (n=151), benign prostatic hyperplasia (n=149), and controls (n=134). Internal consistency of the questionnaire was slightly better with the revised scoring, but values with the standard scoring were sufficiently high (Cronbach’s alpha ≥0.80). We conclude that although the rescored NIH-CPSI provides better face validity than the standard scoring algorithm, it requires additional calculation efforts and yields only marginal improvements in performance.

Altered monocyte CD44 expression in peripheral arterial disease is corrected by fish oil supplementation

BACKGROUND AND AIMS

CD44 and its splice variants can be expressed on all leukocytes, conferring adhesive properties and enhancing cellular recruitment to the endothelium during inflammation. CD44 expression is increased in inflammatory conditions such as rheumatoid arthritis and CD44 variant 3 (CD44v3) expression may be associated with inflammation. We have examined CD44 and CD44v3 expression on peripheral blood monocytes from patients with peripheral arterial disease (PAD) and healthy controls. We have also examined the effect of fish oil supplementation on these markers.

METHODS AND RESULTS

CD44 and CD44v3 were assessed at baseline and following dietary supplementation with fish oil for 12 weeks in both PAD and control groups. Monocytes from PAD patients had higher CD44 expression than those from controls (median intensity fluorescence (MIF): 480+/-278 vs 336+/-251 (mean+/-SD); p<0.001). Following 12 weeks' dietary supplementation with fish oil, CD44 expression was reduced in PAD patients (MIF: 480+/-278 vs 427+/-262; p=0.05) but not in controls (336+/-251 vs 355+/-280; ns). Monocyte CD44v3 expression was lower in cultured monocytes from PAD patients compared to those from controls (0.15+/-0.15 vs 0.22+/-0.14 OD units; p<0.02). This was increased in the PAD group following fish oil supplementation (0.15+/-0.14 to 0.27+/-0.23 OD units; p<0.001).

CONCLUSION

Monocyte CD44 and CD44v3 expression are altered in arterial disease but are returned towards levels seen in control subjects by dietary fish oil supplementation.

X-linked inhibitor of apoptosis deficiency in the TRAMP mouse prostate cancer model

Deregulation of apoptotic pathways plays a central role in cancer pathogenesis. X-linked inhibitor of apoptosis protein (XIAP), is an antiapoptotic molecule, whose elevated expression has been observed in tumor specimens from patients with prostate carcinoma. Studies in human cancer cell culture models and xenograft tumor models have demonstrated that loss of XIAP sensitizes cancer cells to apoptotic stimuli and abrogates tumor growth. In view of these findings, XIAP represents an attractive antiapoptotic therapeutic target for prostate cancer. To examine the role of XIAP in an immunocompetent mouse cancer model, we have generated transgenic adenocarcinoma of the mouse prostate (TRAMP) mice that lack XIAP. We did not observe a protective effect of Xiap deficiency in TRAMP mice as measured by tumor onset and overall survival. In fact, there was an unexpected trend toward more aggressive disease in the Xiap-deficient mice. These findings suggest that alternative mechanisms of apoptosis resistance are playing a significant oncogenic role in the setting of Xiap deficiency. Our study has implications for XIAP-targeting therapies currently in development. Greater understanding of these mechanisms will aid in combating resistance to XIAP-targeting treatment, in addition to optimizing selection of patients who are most likely to respond to such treatment.

Neoadjuvant docetaxel and capecitabine in patients (Pts) with high-risk prostate cancer (PCa): Final results of a phase II trial

5147

Background: Docetaxel is the most active cytotoxic agent in PCa. Pre-clinically docetaxel increases the expression of thymidine phosphorylase (TP), an enzyme responsible for activation of capecitabine to 5-fluorouracil. We assessed the activity and safety of neoadjuvant docetaxel and capecitabine (DC) in pts with high risk PCa. Methods: Non-metastatic PCa pts with clinical stage >T2, or PSA = 15 ng/ml or biopsy Gleason sum (GS) = 8 received 3–6 cycles of docetaxel (36 mg/m2 IV on days 1, 8, and 15) and capecitabine (1,250 mg/m2/day PO on days 5–18) q 28 days, followed by local therapy. The primary endpoint of this 2-stage phase II trial was rate of = 50% decline in PSA. Secondary endpoints included safety and correlative measures of treatment effect (qualitative changes in histology, tissue TP and survivin expression, and CK18Asp396 [apoptosis marker] in serum). Results: Fifteen pts were enrolled with median age of 58 years, median GS =8 and PSA of 23.2 ng/mL. Five pts met 1, 7 met 2, and 3 met 3 entry criteria. 14 pts completed 3 or more cycles of DC, with a median follow up of 17.5 months (9–34). Six of the 15 patients (40%) experienced a = 50% decline in PSA, which was below the 7 required for expansion of the study. Median testosterone did not change post therapy. Eleven pts underwent radical prostatectomy (RP), with no increase in surgical complications. Six pts had positive margins, and 2 had lymph node involvement. Of the 8 patients who underwent RP alone, 5 developed a biochemical recurrence in a median time of 11 months. Grade 3 or 4 toxicities were diarrhea(3), mucositis(2), hand foot syndrome(1) and neutropenia(2). Post versus pre therapy tissue had only mild chemotherapy-effects (4/7 samples), including focal clear cell changes, apoptosis/pyknosis, and necrosis. While there was no discernable pattern of increased TP expression, 4/7 specimens showed decreased survivin expression, suggesting a possible mechanism for chemotherapy-induced apoptosis. There was no correlation of PSA response and survivin expression and no increase in serum CK18Asp396. Conclusions: Docetaxel and capecitabine in the neoadjuvant setting is well tolerated, but results in modest pathologic and PSA responses. Supported by Sanofi- Aventis.

No significant financial relationships to disclose.

Providing practitioner-specific outcomes is associated with higher patient satisfaction with information about prostate cancer treatment

6106

Background: After being diagnosed with prostate cancer, patients must assimilate abundant cancer related information. Satisfaction with Information (SWI) is a patient’s cognitive evaluation of information sources used to understand and select therapy. We sought to describe sources of information used by prostate cancer patients and to identify factors associated with SWI. Methods: 1,072 men with newly diagnosed prostate cancer have enrolled in the prospective, multi-center PRostate cancer Outcomes and Satisfaction with Treatment Quality Assessment (PROST-QA) study. Reports of source(s) of information were documented prior to treatment (radical prostatectomy, external radiation, brachytherapy or combination). The validated SWI domain of the Service Satisfaction Scale-Cancer (SSS-Ca) was completed by patients 2 months following treatment. Relationships between socio-economic factors, demographics, cancer severity, and types of information sources and satisfaction (SWI) were evaluated with multivariate regression. Results: Sources of information endorsed by patients varied by race ( Table ), education, and study site. The most helpful sources of information were description of treatment by a physician (32.8%), books and internet (18.3% each), family/friends (16.6%) and pamphlets/brochures (11.4%). In bivariate analysis internet use was negatively associated with SWI (p=0.025). In multivariable models patient age (p=0.005) and information provided by the physician regarding their own outcomes (p=0.01) were independently associated with SWI. Conclusions: Although a variety of informational sources were endorsed by patients, only printed results for physician’s own patients was associated with SWI. Because SWI is a function of both experiences and expectations, providing patients with a treating physician’s results may improve satisfaction by enhancing concordance of expectations and outcomes.

[Table: see text]

[Table: see text]

Preliminary study of immunomagnetic quantification of circulating tumor cells in patients with advanced disease

OBJECTIVES

To enumerate the amount of circulating tumor cells (CTCs) in patients with advanced prostate cancer and to investigate the relationship between these numbers, prostate-specific antigen (PSA) and prostate-specific membrane antigen (PSM) expression, and clinical parameters.

METHODS

Whole blood was collected in proprietary CellSave tubes. Mononuclear cell fractions were isolated using epithelial cell antibody-coated magnetic nanoparticles. On one half of each immunomagnetically enriched cell fraction, automated fluorescent microscopy was used to identify the epithelial tumor cells. From the remainder of each sample, RNA extraction, cDNA synthesis, and polymerase chain reaction amplification of PSA and PSM were performed.

RESULTS

Eighty-four patients with advanced prostate cancer submitted 130 samples for analysis. Intact CTCs were identified in 62% of samples; 83.3% of CTC-positive and 0% of CTC-negative samples were reverse transcriptase-polymerase chain reaction positive for PSA and PSM (P = 0.001). A significant positive correlation was found between the CTC number and PSA (r = 0.49), alkaline phosphatase (r = 0.47), and lactate dehydrogenase (r = 0.55) levels, and a significant negative correlation with hemoglobin (r = -0.35). The initial Gleason grade, prior therapy, current therapy, and type of metastasis (bone, soft tissue) did not correlate significantly with the CTC number.

CONCLUSIONS

The presence of intact CTCs and the expression of PSA and PSM demonstrated robust agreement. The tumor cell numbers reflected current disease status and correlated significantly with the clinical disease indicators of PSA, hemoglobin, and liver function tests. These findings warrant further investigation of the diagnostic and prognostic value of enumerating intact CTCs.

The drug delivery and biomaterial attributes of the ATRIGEL®technology in the treatment of periodontal disease

Two new products, ATRIDOX Periodontal Treatment and ATRISORB Guided Tissue Regeneration (GTR) Barrier have been evaluated as therapies for periodontal disease. Both products are based on the unique ATRIGEL technology. The system consists of a solution of a resorbable polymer in a biocompatible carrier. On in vivo administration, the polymer undergoes a phase change from a liquid to an in situ formed implant. Being in liquid form, it initially provides the advantage of in vivo placement by simple means, such as syringes to form implants at the site of use. The system is biocompatible and has the capability of serving as a biomaterial and a drug delivery system. The bioabsorption rates of various polymers and the release rates for a wide variety of drugs ranging from simple organics to proteins and peptides are tailored to the desired indication. Release periods ranging from one week to four months have been achieved with one month being the most often desired. For these reasons the ATRIGEL system is being applied to a number of medical applications ranging from site and systemic oncology to post-operative pain control and bone regeneration using growth factors. However, its most visible application to date has been in the development of a pipeline of products for the treatment of periodontal disease, which is the focus of this paper.

An EP2 receptor-selective prostaglandin E2 agonist induces bone healing

The morbidity and mortality associated with impaired/delayed fracture healing remain high. Our objective was to identify a small nonpeptidyl molecule with the ability to promote fracture healing and prevent malunions. Prostaglandin E2 (PGE2) causes significant increases in bone mass and bone strength when administered systemically or locally to the skeleton. However, due to side effects, PGE2 is an unacceptable therapeutic option for fracture healing. PGE2 mediates its tissue-specific pharmacological activity via four different G protein-coupled receptor subtypes, EP1, -2, -3, and -4. The anabolic action of PGE2 in bone has been linked to an elevated level of cAMP, thereby implicating the EP2 and/or EP4 receptor subtypes in bone formation. We identified an EP2 selective agonist, CP-533,536, which has the ability to heal canine long bone segmental and fracture model defects without the objectionable side effects of PGE2, suggesting that the EP2 receptor subtype is a major contributor to PGE2's local bone anabolic activity. The potent bone anabolic activity of CP-533,536 offers a therapeutic alternative for the treatment of fractures and bone defects in patients.

Effects of GnRH agonist (leuprolide) on reproduction and behaviour in female wapiti (Cervus elaphus nelsoni)

Fertility control offers a potential alternative to traditional methods for regulating the growth of overabundant wild ungulate populations. However, current technology is limited due to practical treatment application, undesirable side-effects and economic considerations. A promising non-steroidal, non-immunological approach to contraception involves the use of a potent GnRH agonist. Two experiments were conducted to evaluate the effectiveness of a GnRH agonist (leuprolide) for controlling fertility in captive female wapiti and to assess physiological and behavioural side-effects of the treatment. In Expt 1, the optimum dose of agonist treatment was determined by measuring serum LH response of eight female wapiti to four formulations of leuprolide (0, 45, 90 and 180 mg) administered as a subcutaneous (s.c.) bioimplant. In Expt 2, the effects of leuprolide on wapiti pregnancy rates, duration of suppression of serum LH and progesterone secretion, and short-term behavioural and physiological side-effects were evaluated. All concentrations of leuprolide in Expt 1 were equally effective in reducing serum LH to non-detectable values throughout the 130 day trial. In Expt 2, leuprolide administered before the breeding season was 100% effective at preventing pregnancy in treated females. Serum LH and progesterone were reduced to baseline values by day 92 and remained at this concentration for 195-251 days after treatment, and returned to pretreatment concentrations in the following breeding season. Reproductive behaviour rates were similar for treated and untreated wapiti for all behaviour categories for both the breeding and post-breeding seasons. Haematology and blood chemistry parameters of treated and un-treated females were similar, and seasonal intake and body weight dynamics appeared normal. In conclusion, leuprolide is a safe, effective contraceptive agent and can potentially suppress fertility in female wapiti for one breeding season.

Loss of CDX2 expression and microsatellite instability are prominent features of large cell minimally differentiated carcinomas of the colon

Most large bowel cancers are moderately to well-differentiated adenocarcinomas comprised chiefly or entirely of glands lined by tall columnar cells. We have identified a subset of poorly differentiated colon carcinomas with a distinctive histopathological appearance that we term large cell minimally differentiated carcinomas (LCMDCs). These tumors likely include a group of poorly differentiated carcinomas previously described by others as medullary adenocarcinomas. To better understand the pathogenesis of these uncommon neoplasms, we compared molecular features of 15 LCMDCs to those present in 25 differentiated adenocarcinomas (DACs) of the colon. Tumors were examined for alterations commonly seen in typical colorectal carcinomas, including increased p53 and beta-catenin immunoreactivity, K-ras gene mutations, microsatellite instability, and loss of heterozygosity of markers on chromosomes 5q, 17p, and 18q. In addition, tumors were evaluated by immunohistochemistry for CDX2, a homeobox protein whose expression in normal adult tissues is restricted to intestinal and colonic epithelium. Markedly reduced or absent CDX2 expression was noted in 13 of 15 (87%) LCMDCs, whereas only 1 of the 25 (4%) DACs showed reduced CDX2 expression (P < 0.001). Nine of 15 (60%) LCMDCs had the high-frequency microsatellite instability phenotype, but only 2 of 25 (8%) DACs had the high-frequency microsatellite instability phenotype (P = 0.002). Our findings provide support for the hypothesis that the molecular pathogenesis of LCMDCs is distinct from that of most DACs. CDX2 alterations and DNA mismatch repair defects have particularly prominent roles in the development of LCMDCs.

The antimutator phenotype of E. coli mud is only apparent and results from delayed appearance of mutants

Antimutator strains are strains that have a lower mutation rate than the wild-type strain. We have reexamined the properties of one reported antimutator strain of Escherichia coli, termed mud [Mol. Gen. Genet. 153 (1977) 87]. This strain contains a temperature-sensitive mutation in the purB gene, leading to adenine-dependent growth at higher temperature. When grown at permissive or semi-permissive temperature in the absence of adenine it displays large reductions in the number of both spontaneous and mutagen-induced mutants (e.g. several hundred-fold for valine-resistant mutants). However, our studies show that strains containing the purB allele generate mutations at the same level as the wild-type strain, and that the apparent antimutator effect is the consequence of the delayed appearance of mutants on the selective plates. This delay likely results from the combined stress exerted by the adenine deficiency and the presence of the selective agent (i.e. valine).

Assessment of early continence recovery after radical prostatectomy: patient reported symptoms and impairment

PURPOSE

Patients considering radical prostatectomy often inquire as to when they can expect to regain urinary continence. However, there is a paucity of patient self-reported data regarding the recovery of continence during the initial 3 months after surgery. Our objectives were to assess urinary continence changes early in the postoperative period and determine which of 2 commonly used definitions of continence more closely relate to patient reported urinary impairment.

MATERIALS AND METHODS

A prospective study of 90 men with clinically localized prostate cancer who selected radical prostatectomy as primary therapy was conducted. Repeated measures of urinary continence as defined by 1) total urinary control, 2) the use of 1 or 0 pads daily, and 3) small or no problem with urinary function were obtained with a brief survey preoperatively and postoperatively.

RESULTS

At 56 days after removal of urethral catheters, the actuarial rates of urinary continence recovery based on definitions 1 to 3 were 43%, 84% and 82%, respectively. The use of definition 2 for continence resulted in a 1.9 times higher actuarial rate for continence recovery when compared to definition 1 at 56 days (p <0.001). However, strong agreement was observed between definitions 2 and 3 (kappa = 0.69).

CONCLUSIONS

Urinary control is recovered in a significant proportion of men who undergo radical prostatectomy during the initial 3 months. Continence rates will vary significantly based on the use of alternative definitions. The clinical practice of asking patients how many pads daily they use may be valid, as it corresponds well to the impairment they have.

Psychosocial characteristics of individuals with non-stage IV melanoma

PURPOSE

Melanoma is the fastest growing solid tumor among men and women and accounts for 79% of skin cancer-related deaths. Research has identified that distress is frequently associated with a diagnosis of cancer and may slow treatment-seeking and recovery, increasing morbidity and even mortality through faster disease course. Given that the 5-year survival rates for individuals with melanoma are determined primarily by the depth and extent of spread, distress that interferes with seeking treatment has the potential to be life-threatening.

PATIENTS AND METHODS

The current study was designed to identify levels of distress present in individuals seeking treatment at a large, Midwestern, multidisciplinary melanoma clinic. It also focused on determining the quality of life, level of anxiety, and coping strategies used by individuals with melanoma before treatment. Given that the course of treatment and outcome for patients with stage IV disease is vastly different from that of patients with stages I to III disease, they were excluded from the study.

RESULTS

Results indicated that most individuals who are presenting to a melanoma clinic do not report a clinically significant level of distress. However, there is some variability in this, with 29% of patients reporting moderate to high levels of distress. Moreover, analyses suggest that distressed individuals are more likely to use maladaptive coping strategies, such as escape-avoidance coping, and to have poorer quality of life.

CONCLUSION

Although most individuals do not present with significant levels of distress, a significant minority are distressed and rely more heavily on coping strategies that do not benefit them. Such individuals would likely benefit most from psychological intervention.

Improving postoperative MR imaging of pituitary macroadenomas: comparison of full and reduced dose of gadopentetate dimeglumine

The aim of this study was to evaluate the efficacy of contrast-medium (CM)-ehanced MR imaging of operated pituitary macroadenomas with reduced dose of gadopentetate dimeglumine. In a prospective study 18 patients were examined with coronal T1-weighted MR imaging prior to and following intravenous CM injections. Two sets of contrast-enhanced coronal images were obtained in each patient; the first set after 50% of the recommended dose of 0.1 mmol/kg body weight (b.w.) had been administered, and the second set immediately after additional CM had been given to make up a total dose of 0.1 mmol/kg b.w. The images were evaluated by three neuroradiologists. The SIPAP classification system was used to evaluate tumour extension, whereas tumour margin conspicuity was scored using an arbitrary scale of 1-5 (1 = indistinct, 5 = well defined). Signal intensity measurements obtained from the most enhancing part of the adenomas demonstrated increased enhancement with increased CM dose. Tumour delineation scores were significantly better on the reduced- and full-dose images than on pre-CM injection images, but, with one exception, tumour extension was identified as the same on all imaging sequences. Postoperative MR imaging of large macroadenoma residues can routinely be performed without intravenous CM. When CM is indicated a reduced dose of gadopentetate dimeglumine should provide sufficient diagnostic information.

Analysis of a managed psychiatric disability program

The cost of mental illness to employers has been well documented; however, efforts to effectively reduce the costs of psychiatric disability are adversely affected by the fragmentation of health care services. This report is a case study of a program in which a managed behavioral health care organization managed the psychiatric disability of a telecommunications company. Compared with a non-random cohort of claimants not managed under the pilot, the duration of disability was reduced by 23% (17.1 days). Patient and provider satisfaction with the program was high. This study illustrates the potential for effectively reducing the cost of psychiatric disability and the challenges in coordinating health care.

Development and validation of the expanded prostate cancer index composite (EPIC) for comprehensive assessment of health-related quality of life in men with prostate cancer

OBJECTIVES

Health-related quality of life (HRQOL) is an increasingly important endpoint in prostate cancer care. However, pivotal issues that are not fully assessed in existing HRQOL instruments include irritative urinary symptoms, hormonal symptoms, and multi-item scores quantifying bother between urinary, sexual, bowel, and hormonal domains. We sought to develop a novel instrument to facilitate more comprehensive assessment of prostate cancer-related HRQOL.

METHODS

Instrument development was based on advice from an expert panel and prostate cancer patients, which led to expanding the 20-item University of California-Los Angeles Prostate Cancer Index (UCLA-PCI) to the 50-item Expanded Prostate Index Composite (EPIC). Summary and subscale scores were derived by content and factor analyses. Reliability and validity were assessed by test-retest correlation, Cronbach's alpha coefficient, interscale correlation, and EPIC correlation with other validated instruments.

RESULTS

Test-retest reliability and internal consistency were high for EPIC urinary, bowel, sexual, and hormonal domain summary scores (each r >/=0.80 and Cronbach's alpha >/=0.82) and for most domain-specific subscales. Correlations between function and bother subscales within domains were high (r >0.60). Correlations between different primary domains were consistently lower, indicating that these domains assess distinct HRQOL components. EPIC domains had weak to modest correlations with the Medical Outcomes Study 12-item Short-Form Health Survey (SF-12), indicating rationale for their concurrent use. Moderate agreement was observed between EPIC domains relevant to the Functional Assessment of Cancer Therapy Prostate module (FACT-P) and the American Urological Association Symptom Index (AUA-SI), providing criterion validity without excessive overlap.

CONCLUSIONS

EPIC is a robust prostate cancer HRQOL instrument that complements prior instruments by measuring a broad spectrum of urinary, bowel, sexual, and hormonal symptoms, thereby providing a unique tool for comprehensive assessment of HRQOL issues important in contemporary prostate cancer management.

Gender-specific effects of modifiable health risk factors on coronary heart disease and related expenditures. HERO Research Committee. Health Enhancement Research Organization

There is a general lack of health-related research focusing on gender-specific differences within a working population. This research attempts to address that void. Our study relied on the Health Enhancement Research Organization (HERO) database, which consists of claims, enrollment information, and health risk data for 39,999 employees of six large employers. The research objective was to determine the gender-specific association between coronary heart disease (CHD) and (1) the prevalence of modifiable health risks and (2) medical expenditures. To accomplish this, the International Classification of Diseases, 9th Revision-Clinical Modification and Current Procedural Terminology codes were used to identify 2452 employees with CHD within the HERO database. These individuals made up the study group, which included 66% male and 34% female participants. Health risk data were obtained from voluntary participation in a health risk appraisal and biometric evaluation provided by the employers. Health risks evaluated were tobacco use, hypertension, obesity, elevated cholesterol, high blood glucose, sedentary lifestyle, stress, depression, and excessive use of alcohol. Descriptive and multivariate statistical techniques were used to analyze the HERO database. We found that obesity was the most consistent predictor of CHD. It was number one (of 10 health risks) in the male and female group, number two in the male-only group, and number one in the female-only group. High stress was the second most consistent predictor. There was no such consistency relative to medical expenditures. This lack of consistency across the male and female groups relative to the association between health risks and medical expenditures was demonstrated for nearly all other health risks evaluated. This study suggests that within a group of employees with CHD, there are important similarities and differences between men and women with respect to the prevalence of risk factors and the association between health risks and medical expenditures.

Overall survival after prostate-specific-antigen-detected recurrence following conformal radiation therapy

PURPOSE

To study the significance, in terms of overall and cause-specific survival, of biochemical failure after conformal external-beam radiation therapy (RT) for prostate cancer.

METHODS AND MATERIALS

Of the 1844 patients in the Radiation Oncology prostate cancer database, 718 were deemed eligible. Patients excluded were those with N1 or M1 disease, those treated after radical prostatectomy, those who received hormone therapy before radiation therapy, and those who died, failed clinically, or had no PSA response in the first 6 months after RT. Patients included were required to have a minimum of 2 post-RT PSAs separated by at least 1 week. Biochemical relapse was defined as 3 consecutive PSA rises. This resulted in 154 patients with biochemical failure. Survival was calculated from the third PSA elevation. The rate of rise of PSA was calculated by fitting a regression line to the four rising PSAs on a ln PSA vs. time plot.

RESULTS

There were 41 deaths among the 154 patients with failure in 23 of the 41 due to prostate cancer. The overall survival after failure was 58% at 5 years, while the cause-specific failure was 73% at 5 years. Among the 154 failures, several factors were evaluated for an association with overall survival: age at failure, pre-RT PSA, PSA at second rise, PSA nadir, time from RT to failure, time to nadir, Gleason score, T-stage, and rate of rise, both from the nadir and from the beginning of the rise. None of these factors were significantly associated with an increased risk of death. As expected, the group of patients with biochemical failure have significantly worse prognostic factors than those without biochemical failure: median pre-RT PSA 15.9 vs. 9.0 (p < 0.001), and Gleason score of 7 or greater for 48% of subjects vs. 40% (p = 0.1). Relative PSA rise and slope of ln PSA vs. time were associated with cause-specific mortality (p < 0.001 and p = 0.007, respectively).

CONCLUSION

Overall survival after conformal radiotherapy for prostate cancer remains high 5 years after biochemical failure. This high survival rate occurs even though the group of patients with biochemical failure has worse than average adverse preradiation prognostic factors. Thus, although biochemical failure can identify patients who have recurrent disease after RT, the ultimate relationship between this endpoint and death remains to be better defined.

Preliminary in vivo studies on the osteogenic potential of bone morphogenetic proteins delivered from an absorbable puttylike polymer matrix

This article describes preliminary in vivo studies evaluating the osteogeneic potential of bone morphogenetic proteins (BMPs) delivered from an absorbable puttylike polymer matrix. In the first study, bovine-derived bone morphogenetic proteins were incorporated in an polymer matrix consisting of 50:50 poly(DL-lactide-co-glycolide) dissolved in N-methyl-2-pyrrolidone. The matrix was implanted in an 8 mm critical-size calvarial defect created in the skull of adult Sprague-Dawley rats (n = 5 per treatment group). After 28 days, the implant sites were removed and examined for new bone formation, polymer degradation, and tissue reaction. Gamma-irradiated polymer matrices appeared to give more bone formation than nonirradiated samples (histological analysis; 2. 76 + 1.34 mm(2) of bone versus 1.30 + 0.90 mm(2) of bone, respectively and x-ray analysis; 27.2 + 15.9 mm(2) of bone versus 20. 7 + 16.7 mm(2) of bone, respectively) and less residual polymer (0.0 + 0.0 versus 0.2 + 0.4, respectively). The polymer implants with bone morphogenetic protein also gave less inflammatory response than the polymer controls (gamma irradiated polymer/BMP = 1.8 + 0.4 and nonirradiated polymer/BMP = 1.2 + 0.4 versus polymer only = 3.0 + 1. 2, respectively). However, despite trends in both the x-ray and histological data there was no statistical difference in the amount of new bone formed among the four treatment groups (P > 0.05). This was most likely due to the large variance in the data scatter and the small number of animals per group. In the second animal study, bovine-derived BMPs and the polymeric carrier were gamma irradiated separately, at doses of 1.5 or 2.5 Mrad, and their ability to form bone in a rat skull onlay model was evaluated using Sprague-Dawley rats (n = 5 per treatment group). Histomorphometry of skull caps harvested 28 days after implantation showed no significant differences as compared to non-irradiated samples, in implant area, new bone area, and percent new bone (P > 0.05). These results suggest gamma irradiation may be useful in sterilization of the bovine-derived BMPs and the polymeric carrier for potential bone repair and/or regeneration applications.