The stability of preferences for life-sustaining care among persons with AIDS in the Boston Health Study

BACKGROUND

Clinicians recognize the importance of eliciting patient preferences for life-sustaining care, yet little is known about the stability of those preferences for patients with serious disease.

OBJECTIVES

To examine the stability of preferences for life-sustaining care among persons with AIDS and to assess factors associated with changes in preferences.

DESIGN

Two patient surveys and medical record reviews, administered four months apart in 1990-1991.

SETTING

Three health care settings in Boston.

PATIENTS

252 of 505 eligible persons with AIDS who participated in both baseline and follow-up surveys.

MAIN OUTCOME MEASURES

A single question assessing desire for cardiac resuscitation and a scale of preferences for life-extending treatment conditional on hypothetical health states.

RESULTS

Approximately one-fourth of the respondents changed their minds about life-sustaining care during a four-month period. Of patients who initially desired cardiac resuscitation, 23% decided to forego it four months later, and of those who initially said they would decline care, 34% later said they would accept it. Of those who initially desired any of the life-extending treatments, 25% decided to forego them four months later, and of those who initially said they would decline life-extending care, 24% later said they would accept some treatment. Patients reporting changes in physical function, pain, or suicide ideation were more likely to modify their desires to be resuscitated (all p< or =0.05). Patients lacking an advance directive, not completing high school, or becoming more severely ill were more likely to change their preferences on the Life Extension scale (p< or =0.05). Patients who discussed their preferences with at least one physician were just as likely as others to change desires for cardiac resuscitation. Age, gender, race, emotional health, clinical severity, social support, and site of care were not significant correlates of change for either measure.

CONCLUSIONS

Health care providers should periodically reassess preferences for life-sustaining care, particularly for patients with progressive disease, given the instability in patient preferences. However, predictors of instability may vary with how preferences are measured. In particular, changes in health status may be related to instability of preferences for certain types of treatments.

Differences in the professional satisfaction of general internists in academically affiliated practices in the greater-Boston area. Ambulatory Medicine Quality Improvement Project Investigators

Managed care has created more professional constraints for general internists. We surveyed 198 general internists at 12 academically affiliated practices in the greater-Boston area to examine professional satisfaction. Overall, these physicians were moderately satisfied (mean of 59.1 on a 100-point scale). Before adjustment, women had lower overall satisfaction than men, as well as poorer satisfaction with the domains of career concerns and patient access. Gender had no independent effect on satisfaction after adjustment for age, income, percentage of time providing direct patient care, work status, and site. Younger physicians also had lower overall satisfaction, and these differences remained after adjustment. Improvements in professional satisfaction may be required to ensure the continued recruitment of young physicians, particularly women, into general internal medicine.

Hospital use and health status of women during the 5 years following the birth of a premature, low-birthweight infant

OBJECTIVE

This study examined the health status and hospital use of women after the birth of a premature, low-birthweight infant.

METHODS

The subjects were women with infants who participated in a multisite, randomized trial of an early intervention program. The outcomes examined were (1) a maternal health rating of poor or fair (i.e., poorer health) 5 years following delivery and (2) hospital use for a non-pregnancy-related condition.

RESULTS

By the fifth year after delivery, 29.7% of the women had been hospitalized for a non-pregnancy-related condition. Women who reported poorer health status (adjusted relative risk [RR] = 2.39; 95% confidence interval [CI] = 1.86, 3.07) or who had asthma (RR = 2.24; CI = 1.31, 3.80) were at greatest risk. After 5 years, 16.9% of the women said they were in poorer health. The number of intervening years in poorer health (1 year, RR = 3.17; CI = 2.04, 4.94; > 1 year, RR = 8.42; CI = 2.20, 12.88), more than 1 year of poverty (RR = 3.28; CI = 1.90, 5.66), obesity (RR = 3.30; CI = 1.44, 7.55), and more than 1 year of employment (RR = 0.55; CI = 0.36, 0.86) were all significantly associated with poorer health.

CONCLUSIONS

The continued, substantial morbidity and hospital use of women with a premature, low-birthweight infant has not previously been reported. This observation needs to be verified.

A possible chemical explanation for the events associated with the death of Gloria Ramirez at Riverside General Hospital

The events associated with the death of Gloria Ramirez at Riverside General Hospital on 19 February 1994 have been portrayed as a major medical mystery. A potential chemical explanation for this incident has been developed. The hypothetical scenario depends upon the oxidation of a common solvent, dimethyl sulfoxide, through dimethyl sulfone to dimethyl sulfate. The latter compound is a volatile and highly toxic agent that can be quite hazardous to humans in small amounts. It is also environmentally nonpersistent. Much of the mystery surrounding the circumstances at the hospital may be explainable if this postulated metabolic pathway took place at the time of the emergency room incident. Although dimethyl sulfate was not detected in any analyses pertinent to this event, there are plausible scientific explanations to account for that fact. The sulfate anion, a hydrolysis product of dimethyl sulfate, was measured at an appreciably elevated concentration in Ramirez' blood. The descriptions of the symptoms of the hospital-staff victims appear quite consistent with dimethyl sulfate exposures. This paper attempts to make some sense of the reported data and eyewitness accounts, and perhaps provide new insight for any future research that could further explain this reported occurrence of toxic exposure.

The Boston AIDS Survival Score (BASS): a multidimensional AIDS severity instrument

OBJECTIVES

This study developed a new acquired immunodeficiency syndrome (AIDS) severity system by including diagnostic, physiological, functional, and sociodemographic factors predictive of survival.

METHODS

Three-hundred five persons with AIDS in Boston were interviewed; their medical records were reviewed and vital status ascertained.

RESULTS

Overall median (+/- SD) survival for the cohort from the first interview until death was 560 +/- 14.4 days. The best model for predicting survival, the Boston AIDS Survival Score, included the Justice score (stage 2 relative hazard [RH] = 1.25, 95% confidence interval [CI] = 0.80, 1.96; stage 3 RH = 1.76, 95% CI = 1.15, 2.70), a newly developed opportunistic disease score (Boston Opportunistic Disease Survival Score; stage 2 RH = 1.35, 95% CI = 0.90, 2.02; stage 3 RH = 2.10, 95% CI = 1.38, 3.18), and measures of activities of daily living (any intermediate limitations, RH = 1.84, 95% CI = 1.05, 3.21; any basic limitations, RH = 2.60, 95% CI = 1.44, 4.69). This model had substantially greater predictive power (R2 = .17, C statistic = .68) than the Justice score alone (R2 = .09, C statistic = .61).

CONCLUSIONS

Incorporating data on clinically important events and functional status into a physiologically based system can improve the prediction of survival with AIDS.

Chemical and elemental comparison of two formulations of oleoresin capsicum

In-custody deaths following the application of pepper spray weaponry by law enforcement personnel have increased in California over the last few years. Oleoresin capsicum (OC), an oily extract of hot peppers, is the active ingredient in the spray, but little detailed information on product mixtures is available. Since OC extracts contain a multitude of natural compounds at irregular concentrations, there could be considerable, variation in overall chemical composition among the different formulations of both 'natural' and 'synthetic' OC preparations. This was confirmed by organic and inorganic analyses performed on OC sprays produced by two manufacturers licensed for distribution within the state of California. The results indicated that the differences could lead to considerable inconsistency in weapon effectiveness, and suggested that more comprehensive studies are warranted.

The influence of health-related quality of life and social characteristics on hospital use by patients with AIDS in the Boston Health Study

OBJECTIVES

The authors examine whether health-related quality of life (HRQL) and social factors were independent predictors of future hospital use for persons with acquired immunodeficiency syndrome (AIDS).

METHODS

A panel of 305 patients with AIDS treated at three provider settings in the Boston, Massachusetts area were enrolled during 1990 and 1991. Data were collected at baseline study enrollment and again 4 months later. Patient interviews, hospital bills, and medical charts were used to measure hospital use (admissions and days during the 4 months after enrollment), sociodemographic characteristics (age, gender, race, education, insurance, homelessness, alcohol use, and AIDS risk factors), disease burden (patient severity and a three-level opportunistic diseases and complications score), HRQL (patient-reported symptoms, activities of daily living, neuropsychological status, and global health assessment), system of care, and use of prophylactic drugs. Logistic regression was used to estimate the odds of admission. Total days of hospital care by patients with at least one admission were analyzed using multiple linear regression. Clinical models of hospital use were developed first from the variables measuring disease burden and system of care. Models estimating the associations between hospital use and all other predictor variables measured at baseline then were estimated using stepwise techniques, controlling for variables in the core model.

RESULTS

Patients were more likely than their reference groups to be hospitalized if they had serious opportunistic diseases (adjusted odds ratio [OR] = 2.7), had poorer neuropsychological status (OR = 1.9), were non-white (OR = 2.0), or were homeless (OR = 3.3) (all P < or = 0.05). Activities of daily living were associated moderately (OR = 1.3; P = 0.07). Only system of care and neuropsychological status predicted total hospital days.

CONCLUSIONS

The results indicate that future hospital use by persons with AIDS may be influenced by social and other health-related factors in addition to the more clinically related characteristics that are recorded in a medical chart. It therefore may be appropriate to assess these factors when considering options for intervention or when comparing patterns of use among patient groups or settings.

Prenatal hospitalization and compliance with guidelines for prenatal care

OBJECTIVES

This study examined the relationship between compliance with the US Public Health Service guidelines for prenatal care and the rate of prenatal hospitalization.

METHODS

For all women admitted to a Boston referral center during January and February 1993 with a pregnancy of at least 18 weeks gestation (n = 1400), a proportional hazards model was used to examine factors associated with prenatal hospitalization.

RESULTS

Prenatal hospitalization occurred during 248 (17.7%) pregnancies. The median length of stay for all prenatal admissions was 4 days; the medial total charge was $5667. Prior medical and obstetrical problems were strongly associated with prenatal hospitalization. After adjustment for age, race, and medical and obstetrical complications, women who received less than 70% of the prenatal care recommended were significantly more likely to be hospitalized (relative risk [RR] = 2.14, 95% confidence interval [CI] 1.50, 3.06).

CONCLUSIONS

Prenatal hospitalization is a common, costly complication of pregnancy. Because of its association with compliance with the Public Health Service guidelines for the content of prenatal care, prenatal hospitalization may be a sentinel indicator of inadequate prenatal care amenable to intervention.

The relationship between physicians' qualifications and experience and the adequacy of prenatal care and low birthweight

OBJECTIVES

The purpose of this study was to examine the relationship between physicians' qualifications and experience and rates of completion of the recommended number of prenatal visits and delivery of a low-birthweight infant.

METHODS

All deliveries performed by a permanently licensed physician in Massachusetts in 1990 (n = 80,537) were examined. Qualification was measured by board certification. Experience was measured by both volume of deliveries and duration of practice.

RESULTS

Women cared for by a non-board-certified physician were less likely to receive the recommended number of prenatal visits (odds ratio [OR] = 0.67, 95% confidence interval [CI] = 0.54, 0.85) and were more likely to have a low-birthweight infant (OR = 1.20, 95% CI = 1.00, 1.42). Physicians with a smaller volume of deliveries or a shorter duration of practice were more likely to deliver a low-birthweight infant.

CONCLUSIONS

The data show an association of board certification with rates of the recommended number of prenatal visits and low birthweight. In addition, volume and duration of practice were significantly associated with low birthweight. Further research should examine whether these associations are related to differences in patient referral or to physicians' judgement and efficiency in provision of prenatal care.

Acutely injured patients with trauma in Massachusetts: differences in care and mortality, by insurance status

OBJECTIVES

This study was designed to determine whether resource use and mortality differed by insurance status for patients with acute trauma.

METHODS

All adults emergently hospitalized in Massachusetts during 1990 with acute trauma (n = 15,008) were examined.

RESULTS

After adjustment for confounders, uninsured patients were as likely to receive care in an intensive care unit as were patients with private insurance (odds ratio [OR] = 0.97, 95% confidence interval [CI] = 0.85, 1.11) but were less likely to undergo an operative procedure (OR = 0.68, 95% CI = 0.63, 0.74) or physical therapy (OR = 0.61, 95% CI = 0.57,0.67) and were more likely to die in a hospital (OR = 2.15, 95% CI = 1.44, 3.19). Compared with patients with private insurance, those with Medicaid were less likely to receive an operative procedure (0.85, 0.75-0.97), were equally likely to receive care in an intensive care unit (OR = 1.05, 95% CI = 0.86, 1.30) or physical therapy (OR = 0.90, 95% CI = 0.79, 1.02), and were no more likely to die (OR = 1.28, 95% CI = 0.69,2.39).

CONCLUSIONS

These results suggest that the uninsured receive less trauma-related care and have a higher mortality rate. The excess mortality in uninsured patients may be avoided if their resource use is increased to that of insured patients.

The impact of socioeconomic status on the intensity of ambulatory treatment and health outcomes after hospital discharge for adults with asthma

OBJECTIVES

To examine whether differences in intensities of care by socioeconomic status and race result in worse health among adults with asthma post-hospital discharge.

DESIGN

Patients were enrolled during hospitalization and recontacted three months after discharge.

PATIENTS

Those aged 18-55 years, with a primary diagnosis of asthma (n = 97).

MAIN OUTCOME MEASURES

Regular source of care, "intensive" therapy (use of an anti-inflammatory agent, pulmonary function testing, or an asthma specialist), and patient-reported (Intermediate Activities of Daily Living Scale [IADL] score, dyspnea) and performance-based (peak flow rate) measures of health status post-discharge.

RESULTS

28% of patients with a yearly income less than $16,000 had no regular source of care, compared with 11% of those with an income from $16,000 to $29,999 and no patient with an income of at least $30,000 (p = 0.003). Similarly, intensive therapy was received by 40%, 67%, and 81% of these groups (p = 0.005). Education had similar associations. Patients with no regular source of care or who did not receive intensive therapy had significantly worse health. Patients of lower socioeconomic status had health outcomes that were up to 25% lower than those of patients of higher socioeconomic status (p < 0.05 for differences in LADL score, dyspnea, and peak flow by educational levels and for differences in dyspnea by income levels), after adjustment for age, gender, race, insurance status, and baseline health. After further adjustment for source of care and intensity of therapy, differences in health outcomes by socioeconomic status uniformly decreased in magnitude and only the differences in LADL scores and dyspnea by educational levels remained statistically significant. Although nonwhite patients were less likely to have a regular source of care or to receive intensive therapy, there was no difference in health outcomes by race.

CONCLUSIONS

Patients of lower socioeconomic status who have asthma have worse health outcomes post-hospital discharge, which appear to be due in part to less continuous and less intensive treatment.

The effect of health coverage for uninsured pregnant women on maternal health and the use of cesarean section

OBJECTIVES

Although there has been substantial policy interest in interventions to improve the neonatal outcomes of disadvantaged women, little attention has been paid to the health status of pregnant women themselves. We therefore examined whether the provision of health coverage to uninsured low-income pregnant women affects maternal health status or the use of cesarean section.

DESIGN

Natural experiment in Massachusetts.

PATIENTS

All in-hospital, single-gestation births in 1984 (N = 57,257) and 1987 (N = 64,346).

INTERVENTION

Healthy Start is a statewide health coverage program for uninsured pregnant women. In 1985, it covered women with incomes below 185% of the federal poverty level.

MAIN OUTCOME MEASURES

Rates of adverse maternal outcome (severe pregnancy-related hypertension, placental abruption, and a length of stay at least 1 day longer than infants' stay) and cesarean section for uninsured women, and for two concurrent control groups, women with Medicaid and women with private insurance. We calculated the difference in rates between the uninsured and each concurrent control. We then examined the change in these interpayer differences in rates between 1984 and 1987 to measure the effect of Healthy Start.

MAIN RESULTS

In 1984, uninsured women had higher rates of adverse maternal health outcome than privately insured women (5.5% vs 5.1%, respectively; interpayer difference, 0.4%) and received fewer cesarean sections (17.2% vs 23.0%; interpayer difference, -5.8%). Between 1984 and 1987 there was no statistically significant change in the interpayer difference in adverse outcome relative to women with private insurance. However, the interpayer difference in cesarean sections between the uninsured and the privately insured was reduced by 2.3% (95% confidence interval [CI], +0.4% to +4.2%), although the uninsured continued to undergo fewer cesarean sections (22.4% vs 25.9%). Similar results were observed when the uninsured women were compared with women with Medicaid.

CONCLUSIONS

The provision of health insurance alone to low-income pregnant women may not be associated with an improvement in maternal health. Expanded coverage was associated, however, with an increase in the rate of cesarean section.

Discussion of preferences for life-sustaining care by persons with AIDS. Predictors of failure in patient-physician communication

OBJECTIVES

To assess the determinants of communication about resuscitation between persons with acquired immunodeficiency syndrome (AIDS) and their physician.

DESIGN AND SETTING

Structured patient interview at a staff-model health maintenance organization (HMO), an internal medicine group practice at a private teaching hospital, and an AIDS clinic at a public hospital.

PATIENTS

289 persons with AIDS.

MAIN RESULTS

Only 38% of patients had discussed their preferences for resuscitation with their physician. Using logistic regression, we found that patients were less likely to have discussed resuscitation with their physician if they were nonwhite (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.24 to 0.99), had never been hospitalized (OR, 0.52; 95% CI, 0.27 to 0.99), or were cared for in the HMO (OR, 0.44 relative to the private teaching hospital; 95% CI, 0.23 to 0.82). Patients were more likely to have discussed their preferences if they were not currently taking zidovudine (OR, 1.76; 95% CI, 1.02 to 3.03) and if they had decided to defer life-sustaining therapy (OR, 2.30; 95% CI, 1.35 to 3.91). Among nonwhites, those with a nonwhite physician were more likely to have discussed resuscitation (OR, 4.38; 95% CI, 1.13 to 16.93). Of patients who had not discussed their preferences for life-sustaining care, 72% wanted to do so. Patient desire for discussion of this issue did not vary by race, severity of illness, hospitalization status, use of zidovudine, or site of care.

CONCLUSIONS

A majority of persons with AIDS in this study had not discussed their preferences for life-sustaining care with their physician, despite the desire to do so. Interventions to improve patient-physician communication about resuscitation for nonwhites and other groups at risk of inadequate discussion might lead to clinical decisions that are more consistent with patient preferences.

The effect of providing health coverage to poor uninsured pregnant women in Massachusetts

OBJECTIVES

There has been substantial policy interest in whether the provision of health coverage to poor uninsured pregnant women affects access to prenatal care and birth outcomes. We therefore examined whether the statewide provision of health coverage to uninsured low-income pregnant women affects access to prenatal care and infant birth outcomes.

DESIGN

Natural experiment.

PATIENTS

All in-hospital, single-gestation live births in 1984 (N = 57,257) and 1987 (N = 64,346).

INTERVENTION

In 1985, Massachusetts instituted Healthy Start, a program providing health coverage to uninsured pregnant women with incomes below 185% of the federal poverty level.

MAIN OUTCOME MEASURES

Rates of satisfactory prenatal care, care initiated before the third trimester, and adverse infant outcome for uninsured women and for two concurrent control groups, women with Medicaid, and women with private insurance. We calculated the difference in rates between the uninsured and each concurrent control. To assess the effect of the program, we examined the change in these interpayer differences in rates between 1984 and 1987.

MAIN RESULTS

Between 1984 and 1987, the rate of satisfactory prenatal care declined from 96.4% to 93.8% for all women in Massachusetts (P < .001). There was no statewide change in the overall incidence of adverse birth outcome (6.6% in both years). In 1984, uninsured women were less likely than privately insured women to receive satisfactory prenatal care (90.5% and 98.1%, respectively; interpayer difference, -7.6%) and to initiate care before the third trimester (94.2% and 99.1%; interpayer difference, -4.9%), and were more likely to suffer an adverse birth outcome (7.1% and 5.8%; interpayer difference, 1.3%). Between 1984 and 1987, there were no statistically significant changes in the interpayer differences in rates for any of the outcome measures relative to either control group.

CONCLUSIONS

Our findings suggest that access to prenatal care may have declined for all women in Massachusetts between 1984 and 1987. In the setting of this statewide decline in access, the expansion of health coverage to uninsured low-income pregnant women was not associated with an improvement in access to prenatal care or birth outcomes.

Risk factors for stroke in patients with nonrheumatic atrial fibrillation: a case-control study

PURPOSE

Randomized controlled trials have demonstrated that anticoagulant therapy is very effective at preventing stroke among patients with nonrheumatic atrial fibrillation. However, these trials have reported too few strokes for powerful risk factor analysis. Observational studies may provide additional information. The purpose of this study was to identify risk factors in a larger number of patients with stroke and nonrheumatic atrial fibrillation, using case-control methodology.

PATIENTS AND METHODS

We identified all patients discharged from one hospital over an 8-year period who met our case definition of nonrheumatic atrial fibrillation and ischemic stroke (n = 134), and compared them with contemporaneous control subjects who were discharged with nonrheumatic atrial fibrillation without stroke (n = 131).

RESULTS

Cases and controls were similar in terms of duration of atrial fibrillation; proportion with paroxysmal atrial fibrillation; percentage with a past medical history of angina, myocardial infarction, congestive heart failure, diabetes, or smoking; and mean left atrial size. In contrast, cases were significantly older than controls (78.5 versus 74.8 years, p = 0.002) and more likely to have a history of hypertension (55% versus 38%, p = 0.0093). The relative odds for stroke was 1.91 for patients with hypertension, 1.73 for patients older than 75 years, and 3.26 for patients with both factors.

CONCLUSIONS

Our analysis suggests that age and hypertension should be considered when deciding upon long-term anticoagulant therapy to prevent stroke in patients with nonrheumatic atrial fibrillation.

Sensitivity of treponemal tests for detecting prior treated syphilis during human immunodeficiency virus infection

To evaluate the sensitivity of treponemal tests as a marker of prior syphilis in individuals with human immunodeficiency virus (HIV) infection, the syphilis serology of 109 homosexual men with a documented history of treated syphilis was compared with records of prior results and confirmed on stored serum samples. None of the HIV-seronegative individuals lost reactivity to a treponemal test, whereas 7% of the seropositive asymptomatic individuals and 38% of those with symptomatic HIV infection had loss of reactivity. Symptomatic HIV infection was associated with loss of reactivity, as a T4 lymphocyte count less than 200 X 10(6)/1, a T4-to-T8 ratio less than 0.6, a single prior episode of syphilis, and a low VDRL titer at the time of the last documented episode of syphilis. Although no conclusions can be drawn about the sensitivity of treponemal tests in patients with active syphilis and HIV infection, these data suggest that treponemal tests may not identify those previously infected with Treponema pallidum.

Cisplatin and fluorouracil as neoadjuvant therapy in head and neck cancer. A preliminary report

A randomized, prospective trial utilizing cisplatin and fluorouracil as neoadjuvant chemotherapy in the treatment of advanced squamous cell carcinomas of the upper aerodigestive tract was initiated in January 1983. Sixty patients were stratified by site (oral cavity, 19; larynx, 14; hypopharynx, 14; oropharynx, 11; nasopharynx, one; and paranasal sinuses, one) and by stage (III, 19; IV, 41), and then randomized to receive either standard treatment (defined as preoperative irradiation followed by radical excision or irradiation alone) or adjuvant chemotherapy followed by standard treatment. An additional three patients were entered into the study, but withdrew. Chemotherapy consisted of three cycles for those patients in whom an objective tumor response was observed; nonresponders received standard treatment. Response to chemotherapy was complete in five and partial (greater than 50%) in 18 patients, for an overall response rate of 85%. The follow-up for surviving patients was a minimum of 24 months and a maximum of 44 months. Survival was compared for patients in both treatment groups according to the method of Lee and Desu. Despite excellent tumor response, actuarial survival was 70% in the standard treatment group as opposed to 56% in the experimental group. It was therefore evident that the high response rates reported in previous pilot studies do not necessarily result in improved survival in these cancers.

The effects of delay in standard treatment due to induction chemotherapy in two randomized prospective studies

It is often suggested that tumors will respond to induction chemotherapy and result in improved survival for patients with squamous cell carcinoma of the head and neck. Two regimens of induction chemotherapy were studied in separate randomized, prospective trials over the last 6 years. Eighty-three patients with advanced disease were entered into the first study (43/chemotherapy; 40/control), and 60 into the second (27/chemotherapy; 33/control). Patient randomization was stratified by stage (III/IV) and site (oral cavity, oropharynx, nasopharynx, hypopharynx, larynx, paranasal sinuses). The first study utilized bleomycin, Cytoxan, methotrexate and 5-fluorouracil in two cycles (one cycle if no tumor response), followed by standard treatment which consisted of combined irradiation and surgery or, in some instances, primary irradiation alone. The second study utilized cisplatin and 5-fluorouracil in three cycles prior to standard treatment. An objective tumor response to chemotherapy was observed in 68% in the first study and 85% in the second. The patient survival in both studies (at 24 months in the first; at 19 in the second) was better in the control than that in the experimental groups (43% to 31%; 69% to 46%). In the second study, the average length of delay of standard treatment was longer than in the first study (95 days vs. 66 days; P less than .02). Results combining the P-values of both studies indicate that the relative risk of having persistent disease was 2.9 times greater for patients who received chemotherapy. While toxicity to chemotherapy was not a factor in survival, the number of patients who withdrew from the studies and those who did not comply with treatment were greater in the chemotherapy groups. Except for new drug regimens of exceptional promise, it is recommended that future studies be designed so that chemotherapy is given concurrent with, or following the completion of standard treatment.

Dosimetric comparison of the Fletcher family of gynecologic colpostats 1950-1980

The Fletcher gynecologic applicator was developed for irradiation of carcinoma of the uterine cervix in the early 1950's. Since that time, numerous modifications and changes have been made in the colpostat construction and in the location of the shields that provide a reduced dose to the bladder trigone anteriorly and to the rectal wall posteriorly. The original applicators include the preload radium double colpostat and the preload radium single colpostat. In the 1960's, afterloading colpostats were manufactured as the Fletcher-Suit and the Fletcher-Green devices. With the introduction of the Delclos mini-colpostat, a new generation of applicators followed in the 1970's. The Fletcher-Suit-Delclos colpostat recently manufactured by two companies can be used as a mini-colpostat. By adding a shield-containing cap, these applicators function as the original Fletcher colpostat. With the development of new applicators over the past 30 years, numerous changes in the position of the shields and, therefore, the dose transmitted to the surrounding tissues have been made. This paper describes dosimetric evaluation of all of these applicators and the various changes that have occurred through the generations of Fletcher colpostats in an attempt to provide information for radiation therapists and gynecologists who are using these instruments in their clinical practice.

Nafazatrom: in-vitro assessment of radiation and drug activity against animal and human cell lines

The B-16 melanoma animal cell line and HEC-1A human endometrial cell line treated with Nafazatrom (NFZ) (5 mu/ml) and varying doses of ionizing radiation show a dose response curve of increased colony inhibition with increasing radiation dose. The B-16 line consistently demonstrated enhanced colony inhibition when NFZ was added prior to radiation. This colony inhibition by NFZ was not seen in the HEC-1A cell line. No adverse effect, i.e., increased tumor colony growth, was evident when NFZ and radiation were combined. This study suggests that ionizing radiation can be combined with NFZ without adverse effect on the cell killing effects of either modality.

Experimental evaluation of a posterior drainage system

We have evaluated an experimental artificial shunt to drain intraocular fluid into the retrobulbar space. The device consists of a hollow needle for insertion into the eye, a slit valve to regulate the drainage pressure, and a dome-shaped outflow system. The device was inserted through the sclera, choroid, and retina into the eyes of cynomolgus monkeys. The system was tolerated without producing retinal detachment. A localized foreign body reaction occurred in the retina, choroid, and sclera adjacent to the device. The intraocular pressure was lowered until fibrous encapsulation of the outflow system occurred.

Fletcher-Suit-Delclos gynecologic applicator: evaluation of a new instrument

A new instrument has been added to the Fletcher-Suit-Delclos group of gynecologic applicators. The colpostats can be used as mini-ovoids, but by adding a shielded cap, the instrument has the configuration of the original preload Fletcher colpostat. Dosimetric studies show that this applicator produced transmission ratios (the fraction of radiation transmitted through the tungsten shield) and isodose curves similar to the bladder trigone and anterior rectal wall of 10-25%. With the shield-containing cap removed, the mini-ovoid provides little reduction in dose to those areas and should be used with caution.