External validation of serum hCG cutoff levels for prediction of resistance to single-agent chemotherapy in patients with persistent trophoblastic disease

Van Trommel et al have previously shown that serum human chorionic gonadotropin (hCG) cutoff levels can provide early prediction of resistance to first-line methotrexate (MTX) in patients with persistent trophoblastic disease (PTD). In this study, we validate this approach of prediction of resistance to single-agent chemotherapy in an independent and larger cohort of PTD patients using a different hCG assay. Receiver operating characteristics (ROC) curves were constructed to determine hCG cutoff levels and sensitivity between patients cured on single-agent chemotherapy (control group) and patients requiring change to combination chemotherapy (study group). Receiver operating characteristics analysis identified an hCG cutoff value of 737 IU l⁻¹ that enabled us to predict the subsequent development of single-agent chemotherapy resistance in 52% of patients before their fourth MTX course at 97.5% specificity. This would have enabled an earlier switch to combination chemotherapy reducing the MTX exposure by an average of 2.5 courses. The present findings confirm that serum hCG cutoff levels predict resistance to single-agent therapy earlier than traditional methods. Change to combination chemotherapy should be considered for patients whose serum hCG levels exceed these hCG cutoff values. For patients not exceeding the hCG cutoff levels, static or rising hCG levels should still be included in the criteria for change of chemotherapy.

Extended weekly dose-dense paclitaxel/carboplatin is feasible and active in heavily pre-treated platinum-resistant recurrent ovarian cancer

There is increasing evidence of the efficacy of dose-dense therapy in the management of platinum-resistant/refractory ovarian cancer. We report our experience of extended weekly carboplatin and paclitaxel in this population group. Twenty patients with platinum-resistant/refractory ovarian cancer received carboplatin AUC 3 and paclitaxel 70 mg m⁻² on day 1, 8, 15 q 4 weekly for six planned cycles. Toxicity was assessed using Common Toxicity Criteria. Response was evaluated using radiological and CA125 criteria. Median age was 61 years (range 40–74 years). Median number of prior therapies is three (range 1–8). Response rate was 60% by radiological criteria (RECIST) and 76% by CA125 assessment. Grade 3 toxicities consisted of neutropenia (29% of patients) and anaemia (5%). One patient experienced grade 4 neutropenia. No grade 3/4 thombocytopaenia was reported. Fatigue, nausea and peripheral neuropathy were the most frequent non-hematological side effects. Median progression-free survival was 7.9 months and overall survival was 13.3 months. The dynamics of response to dose-dense therapy were as rapid as with front-line therapy within the same patient. This dose-dense regimen can be extended to at least 18 weekly cycles over 6 months and is well tolerated with high response rates in heavily pre-treated, platinum-resistant ovarian cancer. It forms a highly active and tolerable cytotoxic scaffold to which molecular-targeted therapies can be added in platinum-resistant ovarian cancer.

Immunoblotting using multiple antigens is essential to demonstrate the true risk of Helicobacter pylori infection for gastric cancer

BACKGROUND

Enzyme-linked immunosorbent assays (ELISAs) for detection of Helicobacter pylori infection, using IgG antibodies, may significantly underestimate the association with gastric cancer.

AIM

To compare associations between H. pylori and cardia (CGC) and noncardia gastric cancer (NCGC) using ELISA and immunoblotting and determine the effect of atrophic gastritis on detection.

METHODS

Nested case-control study within the Melbourne Collaborative Cohort Study. Helicobacter pylori antibodies were detected in subjects with CGC (n = 18), NCGC (n = 34) and controls (n = 69 and 134 respectively) using ELISA (pylori DTect) and immunoblot (Helicoblot 2.1). Pepsinogen I levels were measured using ELISA.

RESULTS

Using ELISA, H. pylori-positivity in the CGC group was 33% vs. 35% in controls [odds ratio (OR = 0.9, 95% CI: 0.3-2.7)], while that in the NCGC group was 79% vs. 63% in controls [OR = 2.3 (95% CI: 0.9-5.8)]. Based on immunoblotting, H. pylori-positivity in the CGC group was 44% vs. 39% in their controls [OR = 1.2 (95% CI: 0.4-3.4)], while that in the NCGC group was 94% vs. 63% in controls [OR = 10.6 (95% CI: 2.4-47.4)]. Pepsinogen I levels in the NCGC cases and controls showed the lowest median level (4 ng/mL) to be in subjects negative by ELISA but positive by immunoblotting.

CONCLUSION

Immunoblotting improves the accuracy of H. pylori studies involving gastric cancer.

Prebiotics enhance survival and prolong the retention period of specific probiotic inocula in an in vivo murine model

AIM

To identify novel prebiotics that could be used to maintain persistence of three representative probiotic strains in vivo.

METHODS AND RESULTS

Test mice were treated with prebiotics soybean oligosaccharide (SOS), fructooligosaccharide (FOS) or inulin, followed by probiotics Lactobacillus acidophilus LAFTI L10 (L10), Bifidobacterium lactis LAFTI B94 (B94) or Lactobacillus casei L26 LAFTI (L26). Faecal samples were then collected and analysed using selective medium and PCR analysis to determine the presence of the probiotic strains. In contrast to the control groups, in mice fed prebiotics, the survival and retention time of the test probiotics was increased extensively. SOS and FOS prolonged the retention period of L10 from 24 to 30 h. Of the three prebiotics, FOS gave the best result with B94, prolonging the retention period from 3 to > or =10 days. Of the three prebiotics, inulin gave the best result for L26, prolonging the retention period from 2 to > or =6 days.

CONCLUSIONS

The prebiotics SOS, FOS and inulin significantly enhance survival and prolong the retention period of L10, B94 and L26 in vivo.

SIGNIFICANCE AND IMPACT OF THE STUDY

Our results demonstrate the potential use of FOS, inulin and SOS as prebiotics in conjunction with the probiotic strains L10, B94 and L26 for new synbiotic products.

Survival and retention of the probiotic Lactobacillus casei LAFTI�L26 in the gastrointestinal tract of the mouse

AIMS

This study aimed to develop methods for the detection of the probiotic Lactobacillus casei LAFTI L26 (L26) from mouse faeces, and to determine the survival and retention time of L26 in the mouse gastrointestinal tract.

METHODS AND RESULTS

A selective medium, de Man Rogosa Sharpe (MRS) + bromocresol green + vancomycin (MGV), was designed for the isolation and enumeration of L26 from faecal samples of mice. PCR primers were designed to confirm the identity of L26-like colonies on MGV. These primers did not produce PCR products from related organisms that grew on MGV. Following the administration of L26 to BALB/c mice, faecal samples were collected and analysed using the designed methods. Survival studies showed viable L26 cells to be present in the faeces of mice for >48 h.

CONCLUSIONS

Our results suggest that L26 is able to survive and be retained within the digestive tract of mice for at least 48 h following oral administration.

SIGNIFICANCE AND IMPACT OF THE STUDY

MGV allows effective recovery of L26 from the background microbiota, including lactobacilli of mice. PCR was used to confirm that L26-like colonies were correctly identified as L26. Given the long retention time of L26 in the gastrointestinal tract of mice, it would appear that this probiotic strain may survive in the human gastrointestinal tract.

Clinical features, diagnosis, treatment and molecular studies in paediatric Cushing's syndrome due to primary nodular adrenocortical hyperplasia

BACKGROUND

Primary nodular adrenocortical hyperplasia (PNAH) is a well recognized, but infrequently studied cause of paediatric Cushing's syndrome (CS).

OBJECTIVE

To assess presentation, diagnosis, radiological imaging, treatment and molecular analysis of patients with childhood-onset CS due to PNAH.

PATIENTS

Four males and two females (median age 12.9 years, range 10.9-16.9 years) were studied.

RESULTS

All had growth failure (mean height SDS -1.2; range -2.5-0.0), weight gain [mean body mass index (BMI) SDS 3.5; range 2.5-4.6] and clinical virilization, while five had hypertension [mean systolic blood pressure (SBP) 130 mmHg, diastolic blood pressure (DBP) 83 mmHg]. One patient had generalized lentigines, one had a tibial chondromyxomatous cyst and two had facial freckling. One patient had a family history of primary nodular adrenocortical disease. The diagnosis of CS was based on elevation of sleeping midnight serum cortisol and urinary free cortisol excretion, and impaired suppression of cortisol on both low- and high-dose dexamethasone suppression tests (DST). All patients had undetectable plasma ACTH with absent responses of both plasma ACTH and serum cortisol to an intravenous (i.v.) corticotrophin-releasing hormone (CRH) test. Computed tomography or magnetic resonance imaging showed normal or small adrenals, with nodules in two patients. All patients underwent bilateral adrenalectomy, performed by open (n = 2) or laparoscopic surgery (n = 4) at a mean of 0.4 years (range 0.2-0.8 years) from diagnosis. Hypercortisolaemia was treated preoperatively by metyrapone alone 0.50-0.75 g/day (n = 4), metyrapone 0.75-1.50 g/day + o'p'DDD/mitotane 1-2 g/day (n = 1), or ketoconazole (n = 1). Adrenal histology showed nodular cortical hyperplasia with shrinkage of intervening cortical tissue and pigmentation, present in four patients. Molecular analysis of the type 1-alpha regulatory subunit of protein kinase A (PRKAR1A) gene revealed a novel germline mutation in one patient. Postadrenalectomy, three patients, had catch-up growth with height velocities increasing from 3.0, 3.9 and 2.5-8.9, 8.3 and 9.0 cm/years, respectively. All six are well at a follow-up (mean 4.0 years; range 0.5-10.8 years).

CONCLUSIONS

PNAH was associated with cushingoid features, virilization and hypertension with a lack of cortisol suppression on high DST, undetectable plasma ACTH and absent cortisol and ACTH responses to CRH. Adrenals were normal or small on imaging. PRKAR1A gene analysis may be helpful in the assessment of these patients.

Differential trafficking of transforming growth factor-beta receptors and ligand in polarized epithelial cells

Epithelial cells in vivo form tight cell-cell associations that spatially separate distinct apical and basolateral domains. These domains provide discrete cellular processes essential for proper tissue and organ development. Using confocal imaging and selective plasma membrane domain activation, the type I and type II transforming growth factor-beta (TGFbeta) receptors were found to be localized specifically at the basolateral surfaces of polarized Madin-Darby canine kidney (MDCK) cells. Receptors concentrated predominantly at the lateral sites of cell-cell contact, adjacent to the gap junctional complex. Cytoplasmic domain truncations for each receptor resulted in the loss of specific lateral domain targeting and dispersion to both the apical and basal domains. Whereas receptors concentrate basolaterally in regions of direct cell-cell contact in nonpolarized MDCK cell monolayers, receptor staining was absent from areas of noncell contact. In contrast to the defined basolateral polarity observed for the TGFbeta receptor complex, TGFbeta ligand secretion was found to be from the apical surfaces. Confocal imaging of MDCK cells with an antibody to TGFbeta1 confirmed a predominant apical localization, with a stark absence at the basal membrane. These findings indicate that cell adhesion regulates the localization of TGFbeta receptors in polarized epithelial cultures and that the response to TGFbeta is dependent upon the spatial distribution and secretion of TGFbeta receptors and ligand, respectively.

Randomized controlled trial evaluating rapid pre-screen of cervical cytology specimens

A randomized controlled trial of 75,355 cervical cytology specimens was performed comparing rapid pre-screen with no pre-screen. While the percentage of cases receiving a final report of definite high-grade abnormality was higher in the no pre-screen arm (no pre-screen = 0.70%, pre-screen = 0.65%), the percentage of cases receiving a final report of possible or definite high-grade abnormality was essentially identical in the two arms of the trial (no pre-screen = 1.22%, pre-screen = 1.21%). In the randomized trial, one extra cytology report of definite high-grade abnormality was made for every 12,568 slides pre-screened. This level of benefit was reduced by about half when rapid pre-screen was adopted as a routine laboratory practice.

Squamous cell carcinoma antigen: a role in the early identification of nodal metastases in men with squamous cell carcinoma of the penis

OBJECTIVE

To evaluate whether serum squamous cell carcinoma antigen (SCCAg) measurements may be of use in identifying nodal metastases in patients with SCC of the penis after treating the primary tumour.

PATIENTS AND METHODS

The levels of SCCAg were analysed in 11 men with penile SCC between 1994 and 2001.

RESULTS

An elevated SCCAg level had a sensitivity of 57% (95% confidence interval, CI, 18-90%) and a specificity of 100% (CI 40-100%) for nodal metastases. Levels of SCCAg increased exponentially in patients who developed nodal metastases after treatment of the primary tumour, and were elevated before clinical or radiological evidence of nodal disease.

CONCLUSION

Either the absolute level or the rate of rise of SCCAg may be a useful tool with which to follow patients after excision of the primary tumour. It may be more sensitive than computed tomography and magnetic resonance imaging in detecting recurrence, but further evaluation is needed.

Influences on the risk of recurrent high grade cervical abnormality

The objective of this study is to determine the risk of recurrent abnormality after a first episode of high-grade epithelial abnormality and its evolution over time in a population setting. Two cohorts were established from a statewide registry. The cervical intraepithelial neoplasia (CIN) cohort comprised 6849 women with a biopsy of CIN 2, 2/3 or 3 (squamous or glandular) during 1990-92. A cohort of 6857 women with negative cytology during 1990-92 was used for comparison. The CIN cohort had a significantly greater rate of subsequent high-grade epithelial abnormality than the negative cohort. The risk increased with age. For women over 50 years at the incident biopsy, the rate ratio for subsequent high-grade epithelial abnormality was 24.45 (95% CI, 7.2, 84.3). The rate of subsequent high-grade epithelial abnormality was greater if the incident biopsy was CIN 3 (rate 13.50 per 1000 person years [95% CI, 12.5, 14.6]) rather than CIN 2 or 2/3 (rate 7.83 per 1000 person years [95% CI, 7.1, 8.7]). The rate ratio for subsequent invasive cancer was 9.46 (95% CI, 2.5, 35.3) when the CIN cohort was compared with the negative cohort. We conclude the risk of recurrent high-grade epithelial abnormality is related to the age and degree of abnormality on the incident biopsy. Screening policies should acknowledge the risk does not diminish with time.

Influences on the risk of recurrent high grade cervical abnormality

The objective of this study is to determine the risk of recurrent abnormality after a first episode of high-grade epithelial abnormality and its evolution over time in a population setting. Two cohorts were established from a statewide registry. The cervical intraepithelial neoplasia (CIN) cohort comprised 6849 women with a biopsy of CIN 2, 2/3 or 3 (squamous or glandular) during 1990–92. A cohort of 6857 women with negative cytology during 1990–92 was used for comparison.

The CIN cohort had a significantly greater rate of subsequent high-grade epithelial abnormality than the negative cohort. The risk increased with age. For women over 50 years at the incident biopsy, the rate ratio for subsequent high-grade epithelial abnormality was 24.45 (95% CI, 7.2, 84.3). The rate of subsequent high-grade epithelial abnormality was greater if the incident biopsy was CIN 3 (rate 13.50 per 1000 person years [95% CI, 12.5, 14.6]) rather than CIN 2 or 2/3 (rate 7.83 per 1000 person years [95% CI, 7.1, 8.7]). The rate ratio for subsequent invasive cancer was 9.46 (95% CI, 2.5, 35.3) when the CIN cohort was compared with the negative cohort. We conclude the risk of recurrent high-grade epithelial abnormality is related to the age and degree of abnormality on the incident biopsy. Screening policies should acknowledge the risk does not diminish with time.

Gastric cancer in sub-Saharan Africa

Gastric cancer has a variable but generally low prevalence in black populations of sub-Saharan Africa, despite a high prevalence of Helicobacter pylori (the 'African enigma'). Evidence from Soweto indicates that the host response to H. pylori may be protective against a virulent organism and that, in most people, H. pylori does not lead to more serious sequelae. This suggests that there may be host protective/inhibitory factors present, which prevent the progression of H. pylori-induced chronic active gastritis to cancer.

Helicobacter pylori--an African perspective

Helicobacter pylori is ubiquitous in Africa, with acquisition in childhood the rule. Despite the prevalence of a virulent strain (in Soweto, most H. pylori organisms are cagA- and vacAS(1)-positive) H. pylori-associated pathology (duodenal ulcer, gastric ulcer and gastric cancer) has a variable, often low distribution in sub-Saharan Africa that does not parallel H. pylori prevalence in the population, suggesting a different natural history from that seen in developed countries. Progression to atrophic gastritis in Africans does not appear to differ from that reported in other regions, but as yet unidentified factors may play a role in inhibiting progression to gastric cancer. Studies have suggested that the specific IgG subclass response to H. pylori is predominately IgG1 (suggestive of a Th2 response), and the Th2 response may provide a protective effect against development of gastric cancer. Host immune mechanisms may be the key to different responses to H. pylori in the developed and developing worlds.

Abnormal cervical cytology in bone marrow transplant recipients

Particular human papillomavirus (HPV) subtypes are implicated in the genesis of abnormal cervical cytology and cervical cancer. While most immunocompetent hosts clear HPV infection with no sequelae, some develop premalignant cytological changes of whom a minority subsequently progress to overt carcinoma. Immunocompromised patients, such as renal allograft recipients and HIV-infected individuals, have a higher rate of cytological abnormalities. This is thought to be due to prolonged persistence of virus due to impaired clearance by the immune system. We undertook a retrospective review of the cervical cytology of all women who underwent BMT at two transplant centres and who had cervical smears performed between 1990 and 1998. The rate of cytological abnormalities was significantly higher than in the general population before BMT (age-adjusted odds ratio (OR) 2.2, P = 0.02) and after BMT (OR 7.0, P < 0.0001). After BMT, allogeneic recipients had a higher rate of abnormalities than did autologous patients (OR 2.6, P = 0.02) although only allogeneic recipients had a higher rate of abnormalities post-BMT compared to pre-BMT (allogeneic OR 6.8, P = 0.004). These observations suggest that pre-transplant disease and treatment factors increase the risk of cytologic abnormalities and that transplant-related factors such as conditioning therapy and immunosuppression further increase this risk. These data suggest that more frequent screening may be required in these at-risk groups, especially allogeneic recipients. Prospective studies are required to further evaluate cytological abnormalities and HPV shedding in these populations.

Effects of physical interventions on house dust mite allergen levels in carpet, bed, and upholstery dust in low-income, urban homes

House dust mite allergen exposure is a postulated risk factor for allergic sensitization, asthma development, and asthma morbidity; however, practical and effective methods to mitigate these allergens from low-income, urban home environments remain elusive. The purpose of this study was to assess the feasibility and effectiveness of physical interventions to mitigate house dust mite allergens in this setting. Homes with high levels of house dust mite allergen (Der f 1 + Der p 1 > or = 10 microg/g dust by enzyme-linked immunosorbent assay) in the bed, bedroom carpet, and/or upholstered furniture were enrolled in the study. Carpets and upholstered furniture were subjected to a single treatment of either dry steam cleaning plus vacuuming (carpet only) or intensive vacuuming alone. Bed interventions consisted of complete encasement of the mattress, box spring, and pillows plus either weekly professional or in-home laundering of nonencased bedding. Dust samples were collected at baseline and again at 3 days (carpet and upholstery only) and 2, 4, and 8 weeks posttreatment. We compared pretreatment mean allergen concentrations and loads to posttreatment values and performed between-group analyses after adjusting for differences in the pretreatment means. Both dry steam cleaning plus vacuuming and vacuuming alone resulted in a significant reduction in carpet house dust mite allergen concentration and load (p < 0.05). Levels approached pretreatment values by 4 weeks posttreatment in the intensive vacuuming group, whereas steam cleaning plus vacuuming effected a decrease that persisted for up to 8 weeks. Significant decreases in bed house dust mite allergen concentration and load were obtained in response to encasement and either professional or in-home laundering (p < 0.001). Between-group analysis revealed significantly less postintervention house dust mite allergen load in professionally laundered compared to home-laundered beds (p < 0.05). Intensive vacuuming and dry steam cleaning both caused a significant reduction in allergen concentration and load in upholstered furniture samples (p < 0.005). Based on these data, we conclude that physical interventions offer practical, effective means of reducing house dust mite allergen levels in low-income, urban home environments.

Predictors of early rescreening in the National Cervical Screening Program, Australia

OBJECTIVE

To identify variables that predict early rescreening after a negative Pap smear report.

METHODS

Cohort study using the records of a statewide Cervical Cytology Registry in Victoria, Australia. The cohort comprised 31,082 women who had a negative Pap smear report during the first half of 1996 and who were rescreened within the subsequent 36 months. Early rescreening was defined as a further Pap smear within 21 months.

RESULTS

The strongest predictor of early rescreening was a recommendation at the time of issuing the negative Pap smear report by the laboratory for retesting before two years (adjusted odds ratio = 3.81, 95% confidence interval (CI) 3.58-4.05). Mention of reactive or inflammatory change as part of the negative Pap smear report was also a powerful predictor (adjusted odds ratio = 1.67, 95% CI 1.50-1.85). Significant predictors associated with the women were young age, high socio-economic status and residence in the capital city. Significant predictors associated with the practitioner were if either the index or subsequent smear was collected by an obstetrician/ gynaecologist or a hospital-based clinic, or if the practitioner collecting the index smear was a female. The population-attributable risk per cent associated with the laboratory recommendation was 27%.

CONCLUSIONS

This data suggests that a multifaceted strategy targeting pathology laboratories, practitioners and women may be needed to reduce early rescreening.

IMPLICATIONS

Early rescreening is wasteful of health resources. New screening programs should be designed to avoid this problem.

The use of parent report to assess the quality of care in primary care visits among children with asthma

OBJECTIVE

To determine the accuracy of parent report and the accuracy of the medical record in documenting physician performance of elements of pediatric asthma care in the primary care setting.

METHODS

A convenience sample of 79 English-speaking parents of 4--12-year old children with asthma presenting to medical center--affiliated inner-city primary care pediatric clinics in the Bronx, Dallas, and Chicago was enrolled, and the office visit was audiotaped. Parents were interviewed 1--16 days after the visit by telephone.

OUTCOME MEASURES

Accuracy of parent report was the primary outcome. The "reference standard" was an independent evaluation of the audiotaped record of the primary care visit. The National Asthma Education and Prevention Program was used as a guide to select data elements to assess quality of pediatric asthma care during primary care visits.

RESULTS

Sufficient documentation was significantly (P <.001) less likely to be present in the medical record than in the follow-up interview for each element of care. When these elements were combined into a cumulative score, 71% of parent interviews but only 37% of medical records scored > or = 5 (out of a possible 6), with 29% of medical records scoring < 3. Parents were able to accurately report (concordance of parent data with audiotape reference standard) whether or not the visit had included performance of 5 of the 6 elements of care.

CONCLUSIONS

Our study suggests that parent telephone interview within 2 weeks after the visit is more accurate than the medical record for documentation of the quality of asthma care in pediatric primary care visits. The medical record was not sufficient to assess the quality of primary care related to asthma, primarily because of missing data. Therefore, our data suggest that assessing quality of care using the medical record will not only bias the findings in the direction of more deficient care but will also make improvement in care more difficult. Further validation of our strategy for using parent report to assess the quality of care in primary care visits will require its application in a variety of other primary care settings.

The sensitivity, specificity, and positive predictive value of screening mammography and symptomatic status

OBJECTIVE

To examine whether the accuracy of screening mammography varies according to symptomatic status reported at the time of screening.

SETTING

Victoria, Australia, where free biennial screening is provided to women aged 40 and older.

METHODS

We examined the sensitivity, specificity, and the positive predictive value of screening mammography by symptom status in 106,826 women from Victoria, who attended for first round mammography in 1994 and who did not have a personal history of breast cancer. Symptomatic status was divided into the following categories: asymptomatic; significant symptoms, if the woman reported a breast lump and/or blood stained or watery nipple discharge; and other symptoms, if reported. Unconditional logistic regression modelling was used to adjust for age, use of hormone replacement therapy (HRT), and family history.

RESULTS

Sensitivity was lower for women with other symptoms (60.0%) than asymptomatic women (75.6%), or women with significant symptoms (80.8%). Specificity was lower for women with significant symptoms (73.7%) than asymptomatic women (94.9%), or women with other symptoms (95.4%). Among women who had invasive cancer detected during screening interval, women with other symptoms were more likely to get a false negative result (odds ratio 1.79, 95% confidence interval 1.03 to 3.04) than asymptomatic women, after adjusting for age, use of HRT, and family history.

CONCLUSION

The lower sensitivity in women with other symptoms requires further investigation. Possible explanations include increased breast density and poor image quality. The high sensitivity in women with significant symptoms is probably due to more cautious radiological practice, which has also resulted in low specificity in this group.

Utility of commonly used commercial human chorionic gonadotropin immunoassays in the diagnosis and management of trophoblastic diseases

BACKGROUND

Patients with trophoblastic diseases produce ordinary and irregular forms of human chorionic gonadotropin (hCG; e.g., nicked hCG, hCG missing the beta-subunit C-terminal segment, hyperglycosylated hCG, and free beta subunit) that are recognized to differing extents by automated immunometric hCG (or hCG beta) assays. This has led to low or false-negative results and misdiagnosis of persistent disease. False-positive hCG immunoreactivity has also been detected, leading to needless therapy for trophoblastic diseases. Here we compare seven commonly used hCG assays.

METHODS

Standards for five irregular forms hCG produced in trophoblastic diseases, serum samples from 59 patients with confirmed trophoblastic diseases, and serum samples from 12 women with previous false-positive hCG results (primarily in the Abbott AxSYM assay) were blindly tested by commercial laboratories in the Beckman Access hCG beta, the Abbott AxSYM hCG beta, the Chiron ACS:180 hCG beta, the Baxter Stratus hCG test, the DPC Immulite hCG test, the Serono MAIAclone hCG beta tests, and in the hCG beta RIA.

RESULTS

Only the RIA and the DPC appropriately detected the five irregular hCG standards. Only the Beckman, DPC, and Abbott assays gave results similar to the RIA in the patients with confirmed trophoblastic diseases (values within 25% of RIA in 49, 49, and 54 of 59 patients, respectively). For samples that were previously found to produce false-positive hCG results, no false-positive results were detected with the DPC and Chiron tests (5 samples, median <2 IU/L), but up to one-third of samples were false positive (>10 IU/L) in the Beckman (1 of 5), Serono (2 of 9), and Baxter assays (1 of 5), and the hCG beta RIA (3 of 9; median for all assays, <5 IU/L). These samples, which produced false-positive results earlier in the Abbott AxSYM assay, continued to produce high values upon reassessment (median, 81 IU/L).

CONCLUSIONS

Of six frequently used hCG immunometric assays, only the DPC detected the five irregular forms of beta hCG, agreed with the RIA, and avoided false-positive results in the samples tested. This assay, and similarly designed assays not tested here, seem appropriate for hCG testing in the diagnosis and management of trophoblastic diseases.

Undetectable ultrasensitive PSA after radical prostatectomy for prostate cancer predicts relapse-free survival

Radical retropubic prostatectomy is considered by many centres to be the treatment of choice for men aged less than 70 years with localized prostate cancer. A rise in serum prostate-specific antigen after radical prostatectomy occurs in 10-40% of cases. This study evaluates the usefulness of novel ultrasensitive PSA assays in the early detection of biochemical relapse. 200 patients of mean age 61. 2 years underwent radical retropubic prostatectomy. Levels < or = 0.01 ng ml-1 were considered undetectable. Mean pre-operative prostate-specific antigen was 13.3 ng ml-1. Biochemical relapse was defined as 3 consecutive rises. The 2-year biochemical disease-free survival for the 134 patients with evaluable prostate-specific antigen nadir data was 61.1% (95% CI: 51.6-70.6%). Only 2 patients with an undetectable prostate-specific antigen after radical retropubic prostatectomy biochemically relapsed (3%), compared to 47 relapses out of 61 patients (75%) who did not reach this level. Cox multivariate analysis confirms prostate-specific antigen nadir < or = 0.01 ng ml-1 to be a superb independent variable predicting a favourable biochemical disease-free survival (P < 0.0001). Early diagnosis of biochemical relapse is feasible with sensitive prostate-specific antigen assays. These assays more accurately measure the prostate-specific antigen nadir, which is an excellent predictor of biochemical disease-free survival. Thus, sensitive prostate-specific antigen assays offer accurate prognostic information and expedite decision-making regarding the use of salvage prostate-bed radiotherapy or hormone therapy.

Do obese inner-city children with asthma have more symptoms than nonobese children with asthma?

OBJECTIVE

To test whether obesity is associated with decreased peak expiratory flow rates (PEFR), increased asthma symptoms, and increased health service use.

DESIGN/METHODS

Secondary analysis of data from a cross-sectional convenience sample.

SETTING

Emergency departments (EDs) and primary care clinics in 8 inner-city areas in 7 cities.

PARTICIPANTS

One thousand three hundred twenty-two children aged 4 to 9 years with asthma.

MEASURES

Obesity was defined as a body mass index (BMI, weight/height(2)) >95th percentile. Nonobese children were those with a BMI between the 5th and 95th percentile. Underweight children with a BMI <5th percentile were eliminated from the study. Demographic and anthropometric data were obtained during a baseline interview with the primary caretaker and the child. Symptoms, health service use data and measurements of PEFR were obtained by parental report during the baseline interview and at 3-month intervals by telephone interview over the following 9-month period.

RESULTS

Obese (n = 249) and nonobese (n = 1073) children did not differ in terms of age, gender, family income, passive smoke exposure, caretaker's mental health, and skin test reactivity to indoor allergens. Obese children were more often Latino (28% vs 17%) and, in the 3 months before the baseline interview, were more likely to have used oral steroids (30% vs 24%). There were no differences between groups in terms of baseline PEFR scores. During the 9 months after baseline assessment, the obese group had a higher mean number of days of wheeze per 2-week period (4.0 vs 3.4), and a greater proportion of obese individuals had unscheduled ED visits (39% vs 31%). There were no differences between the groups in terms of frequency of hospitalization, or in nocturnal awakening.

CONCLUSIONS

In our sample of inner-city children with asthma, obese children used more medicine, wheezed more, and a greater proportion had unscheduled ED visits than the nonobese children.

Cognitive-behavioral predictors of asthma morbidity in inner-city children

Asthma is a growing health problem among children in the United States, particularly in urban, inner-city areas. This article examines the relationship between cognitive-behavioral aspects of asthma management (caretaker asthma knowledge, expectations, and problem-solving) and asthma morbidity in a sample of 1,376 inner-city children with physician-diagnosed asthma. In the analyses, baseline symptom severity served as a covariate, and the average of the 3-, 6-, and 9-month follow-up data served as the outcome measure. Children of caregivers with ineffective problem-solving strategies had significantly more days of wheezing over a 14-day period. Ineffective problem-solving capabilities were also associated with poorer functional status; however, positive caregiver expectations were associated with better functional status. Of the cognitive-behavioral factors studied in a high-risk urban population, caregiver problem-solving skills and expectations emerged as meriting further investigation and possible intervention.

Hormone replacement therapy and accuracy of mammographic screening

BACKGROUND

Hormone replacement therapy (HRT) is commonly used and may affect the accuracy of mammographic screening.

METHODS

We examined the sensitivity, specificity, and small-cancer detection rate according to HRT use in 103,770 women in Victoria, Australia, who attended first-round screening in 1994 and who did not have a personal history of breast cancer or a breast lump or a bloodstained or watery nipple discharge at the time of screening. BreastScreen Victoria provides mammography to women aged 40 years and older every 2 years. Unconditional logistic modelling was used to adjust for age, family history, and symptom status.

FINDINGS

The sensitivity of screening mammography for a 2-year screening interval was lower in HRT users (64.8% [95% CI 58-72]) than non-users (77.3% [74-81]). In the target group (50-69 years), the sensitivity was 64.3% (57-72) in HRT users and 79.8% (76-84) in non-users. Among women who were diagnosed with cancer during the 2-year screening interval, HRT users were more likely to have a false negative result than non-users (odds ratio 1.60 [1.04-2.21]) after adjusting for potential confounding factors. Specificity was 0.6% lower in HRT users compared with non-users. Among women who did not have cancer diagnosed in the interval, HRT users were more likely to have a false positive result (adjusted odds ratio 1.12 [1.05-1.19]).

INTERPRETATION

We show that HRT use reduces the sensitivity of mammographic screening. In countries where HRT use is widespread, the reduction in sensitivity with HRT use may undermine the capacity of population-based mammographic-screening programmes to realise their potential mortality benefit.

To smile again. Reanimation for unilateral facial palsy

‘A smile adds a lot to your face value.’ Anon

The above quotation is a reflection of the value placed by society on the humble smile. But for the person suffering from a facial paralysis, this simple act of expression is impossible.

Inverse relation between prostate-specific antigen and insulin-like growth factor-binding protein 3 in bone metastases and serum of patients with prostate cancer

The usual osteoblastic phenotype of metastatic prostate cancer is unexplained. Here we show that tissue and serum concentrations of prostate-specific antigen (PSA)-vary inversely with a substrate protein that binds a growth factor known to activate osteoblasts. These findings suggest that PSA may contribute to the osteoblastic phenotype, and could thus represent a new drug target devoid of antiandrogenic toxicity.

The relationship between psychosocial factors and asthma morbidity in inner-city children with asthma

OBJECTIVE

Children living in the inner city are affected disproportionately by asthma morbidity and mortality. Previous research has shown that behavioral and psychosocial factors affect asthma morbidity in children. The National Cooperative Inner-City Asthma Study investigated the factors that contribute to asthma morbidity among inner-city children. This article examines the relationship between psychosocial factors and asthma morbidity in this population.

METHODS

A total of 1528 English- and Spanish-speaking children 4 to 9 years of age with asthma and their primary caretakers were recruited from 8 research centers in 7 metropolitan inner-city areas in the United States. Psychosocial variables were assessed at baseline and included measures of child and caretaker mental health, caretaker's problems with alcohol, life stress, social support, and parenting style. Morbidity measures were evaluated at baseline and at 3-, 6-, and 9-month follow-up intervals. These included number of hospitalizations and unscheduled visits for asthma in the past 3 months and number of days of wheeze and functional status in the previous 2-week period.

RESULTS

Of the psychosocial variables assessed, mental health had the strongest relationship to children's asthma morbidity. Children whose caretakers had clinically significant levels of mental health problems were hospitalized for asthma at almost twice the rate as children whose caretakers did not have significant mental health problems. Children with clinically significant behavior problems had significantly more days of wheeze and poorer functional status in the follow-up period.

CONCLUSION

Psychosocial factors, particularly the mental health of children and caretakers, are significant factors in predicting asthma morbidity. They may need to be included in intervention programs aimed at decreasing asthma morbidity in inner-city children with asthma in order for these programs to be successful.

Monitoring interval cancers in an Australian mammographic screening programme

OBJECTIVE

To report the interval cancer rate for BreastScreen Victoria.

DESIGN

Electronic linkage of Breast Screen Victoria records with those of the Victorian Cancer Registry. Interval cancers were expressed as a proportion of the underlying incidence (proportional incidence), and the sensitivity as the number of screen detected invasive breast cancers divided by the total number of invasive breast cancers diagnosed in the screening interval.

SETTING

Victoria, Australia where biennial screening is provided to women aged 40 and older.

SUBJECTS

Victorian women aged 40-79 who attended first round screening in 1994 (103,023 women) and 1995 (107,057 women).

RESULTS

The sensitivity of screening mammography for the two year interval increased with age (p for trend < 0.001) and was 49.4% in women aged 40-49, 68.6% in 50-59 year old women, 80.7% in 60-69 year old women, and 85.2% in women aged 70-79. The proportional incidence in the first year after screening was 59% in 40-49 year old women and 27% in women aged 50-69. In the second year the proportional incidence was 93% in 40-49 year old women and 54% in women aged 50-69.

CONCLUSIONS

Interval cancers comprise such a large proportion of the expected number of cancers in 40-49 year old women that the benefit of screening is likely to be low. For women aged 50-69, the proportional incidence found in this study was similar to those found in the UK programmes.

A randomized clinical trial to reduce asthma morbidity among inner-city children: results of the National Cooperative Inner-City Asthma Study

OBJECTIVE

To evaluate a family-focused asthma intervention designed for inner-city children 5 to 11 years old with moderate to severe asthma.

STUDY DESIGN

Randomized, multisite, controlled trial to minimize symptom days (wheeze, loss of sleep, reduction in play activity) measured by a 2-week recall assessed at 2-month intervals over a 2-year follow-up period. The intervention was tailored to each family's individual asthma risk profile assessed at baseline.

RESULTS

Averaged over the first 12 months, participants in the intervention group (n = 515) reported 3.51 symptom days in the 2 weeks before each follow-up interview compared with 4.06 symptom days for the control group (n = 518), a difference of 0.55 (95% CI, 0.18 to 0.92, P =.004). The reduction among children with severe asthma was approximately 3 times greater (1.54 d/2 wk). More children in the control group (18.9%) were hospitalized during the intervention compared with children in the intervention group (14. 8%), a decrease of 4.19% (CI, -8.75 to 0.36, P =.071). These improvements were maintained in the intervention group during the second year of follow-up, during which they did not have access to the asthma counselor.

CONCLUSIONS

We demonstrated that an individually tailored, multifaceted intervention carried out by Masters-level social workers trained in asthma management can reduce asthma symptoms among children in the inner city.

Outcome after a Pap smear report of low-grade abnormality: a longitudinal comparative study

The rate of subsequent diagnosis of high-grade cervical abnormality was studied among women whose first Pap smear in 1994 was reported as being negative or from the category of low-grade abnormality (excluding CIN 1). Regardless of the degree of low-grade abnormality reported on the entry smear, the rate of subsequent high-grade disease was 3.3 cases per 100 years of follow-up. The rate of subsequent high-grade disease among women with negative Pap smear reports was 0.23 to 0.45 cases per 100 years of follow-up. Within each cohort, a small number of cases of invasive cervical cancer were diagnosed in the 2 years after the entry smear. These data indicate that Pap smear reports which are coded to the registry squamous cell code of 'mild atypia' (with or without evidence of human papillomavirus effect) have a significantly higher risk of emerging high-grade cervical disease than negative Pap smear reports (including those with minor reactive and/or inflammatory change). It is suggested that the former have a uniform recommendation of repeating the smear in 1 year and the latter in 2 years.