Duration of adjuvant tamoxifen therapy

The benefit of using adjuvant tamoxifen to treat breast cancer has been firmly established for patients with estrogen receptor (ER)-positive tumors, regardless of age, lymph node status, or menopausal status. Uncertainty remains, however, regarding the optimal duration of tamoxifen therapy. We reviewed the findings of randomized clinical trials that directly compared alternative treatment durations. Trials comparing short-term adjuvant treatment with tamoxifen (i.e., 1-3 years) with treatments having durations of about 5 years consistently have demonstrated additional benefits stemming from the longer therapy. Trials testing 5 years of treatment with longer durations have, in the aggregate, suggested no additional benefit for the patient. Nevertheless, the number of recurrences reported to date in these trials is not large, and the results of the individual trials are heterogeneous. Furthermore, as a result of tamoxifen's "carryover" effect, duration trials require considerable follow-up before definitive results can be established. Until more definitive data become available, adjuvant treatment with tamoxifen should be limited to 5 years outside the clinical trials setting. Continued accrual of ER-positive patients to ongoing tamoxifen duration trials, including the Adjuvant Tamoxifen Treatment Offer More (aTTom) and Adjuvant Tamoxifen Longer Against Shorter (ATLAS) trials, is appropriate. Alternatively, patients who remain disease free after 5 years of tamoxifen therapy should be encouraged to participate in trials testing crossover to other hormonal interventions, including selective ER modulators or aromatase inhibitors.

Implantable cardioverter-defibrillators in arrhythmias: a rapid and systematic review of effectiveness

OBJECTIVE

To review the effectiveness of implantable cardioverter-defibrillators (ICDs) in the management of risk factors for sudden cardiac death.

DESIGN

Systematic review of randomised controlled trials identified from searching eight electronic databases, bibliographies of relevant studies, and consulting experts.

MAIN OUTCOME MEASURES

Absolute and relative reduction in mortality.

RESULTS

Seven trials met the inclusion criteria. These showed changes in absolute risk of total mortality ranging from +1.7% to -22.8% (relative risk reductions -7% to +54%). Estimated benefits from ICD treatment compared with conventional drug treatment at three years were 0.23 to 0.80 additional years of life.

CONCLUSIONS

Evidence suggests that ICDs reduce total mortality in particular subgroups of patients at high risk of ventricular arrhythmias. The optimal strategy for identifying the patients who could benefit most is not clearly established. Ongoing trials into the treatment of cardiac failure with ICDs may provide further evidence about subgroups in whom ICDs are most cost effective.

A survey to identify the clinical coding and classification systems currently in use across Europe

INTRODUCTION

This is a survey to identify what clinical coding systems are currently in use across the European Union, and the states seeking membership to it. We sought to identify what systems are currently used and to what extent they were subject to local adaptation.

BACKGROUND

Clinical coding should facilitate identifying key medical events in a computerised medical record, and aggregating information across groups of records. The emerging new driver is as the enabler of the life-long computerised medical record. A prerequisite for this level of functionality is the transfer of information between different computer systems. This transfer can be facilitated either by working on the interoperability problems between disparate systems or by harmonising the underlying data. This paper examines the extent to which the latter has occurred across Europe.

METHOD

Literature and Internet search. Requests for information via electronic mail to pan-European mailing lists of health informatics professionals.

RESULTS

Coding systems are now a de facto part of health information systems across Europe. There are relatively few coding systems in existence across Europe. ICD9 and ICD 10, ICPC and Read were the most established. However the local adaptation of these classification systems either on a by country or by computer software manufacturer basis; significantly reduces the ability for the meaning coded with patients computer records to be easily transferred from one medical record system to another.

CONCLUSIONS

There is no longer any debate as to whether a coding or classification system should be used. Convergence of different classifications systems should be encouraged. Countries and computer manufacturers within the EU should be encouraged to stop making local modifications to coding and classification systems, as this practice risks significantly slowing progress towards easy transfer of records between computer systems.

Sensory organ development in the inner ear: molecular and cellular mechanisms

The molecular mechanisms underlying the specification of sensory organs in the inner ear and the development of hair and supporting cells within these organs are described. The different organs are all derived from a common pro-sensory region, and may be specified by their proximity to the boundaries between compartments - broad domains within the otocyst defined by the asymmetric expression patterns of transcription factors. Activation of Notch may specify the pro-sensory region, and lateral inhibition mediated by Notch signalling influences whether cells of common lineage in a sensory patch differentiate as either hair cells or supporting cells. The transcription factors Math1 and Brn3.1 are required for hair cell differentiation, and supporting cells express negative regulators of neurogenesis, Hes1 and Hes5. Retinoic acid and thyroid hormone influence early aspects and timing of hair cell differentiation, respectively. Development of the hair cell's mechanosensory hair bundle involves interactions between the cytoskeleton, cell-surface adhesion molecules, receptors and associated extracellular matrix.

Studies of the microstructure of polymer-modified bitumen emulsions using confocal laser scanning microscopy

Polymer-modified bitumen emulsions present a safer and more environmentally friendly binder for enhancing the properties of roads. Cationic bitumen emulsion binders containing polymer latex were investigated using confocal laser scanning microscopy. The latex was incorporated into the bitumen emulsion by using four different addition methods and all emulsions were processed with a conventional colloid mill. The emulsion binder films were studied after evaporation of the emulsion aqueous phase. We show how the microstructure and distribution of the polymer varies within the bitumen binder depending on latex addition method, and that the microstructure of the binder remains intact when exposed to elevated temperature. It was found that a distinctly fine dispersion of polymer results when the polymer is blended into the bitumen before the emulsifying process (a monophase emulsion). In contrast, bi-phase emulsion binders produced by either post-adding the latex to the bitumen emulsion, or by adding the latex into the emulsifier solution phase before processing, or by comilling the latex with the bitumen, water and emulsifier all resulted in a network formation of bitumen particles surrounded by a continuous polymer film. The use of emulsified binders appears to result in a more evenly distributed polymer network compared to the use of hot polymer-modified binders, and they therefore have greater potential for consistent binder cohesion strength, stone retention and therefore improved pavement performance.

Modifications of microvascular filtration capacity in human limbs by training and electrical stimulation

This study investigated whether an increase in microvascular surface area as a result of endurance training, which increases human skeletal muscle capillarity, would translate to greater capacity for fluid filtration compared with strength training, which does not affect capillary supply. Values for filtration capacity, Kf, derived from the slope of calf volume change, Jv, measured by venous occlusion plethysmography, against cuff pressure during a protocol of small cumulative pressure steps, were significantly higher in endurance athletes (5.78 +/- 0.88 mL min(-1) 100 mL(-1) mmHg(-1) x 10(-3), P < 0.05) than controls (3.38 +/- 0.32 mL min(-1) 100 mL(-1) mmHg(-1) x 10(-3) whereas strength-trained athletes had values similar to control (4.08 +/- 0.56 mL min(-1) 100 mL(-1) mmHg(-1) x 10(-3), ns), suggesting that surface area is important. However, when sedentary subjects underwent either a 4-week unilateral dynamic plantarflexion training programme (70% peak power, 20 min day(-1), 5 days week(-1) or a calf muscle electrical stimulation programme (8 Hz, 3 x 20 min day(-1), 5 days week(-1), neither of which caused limb blood flow to alter after training nor would be expected to increase capillarity, only the stimulation group showed a significant increase in Kf (6.68 +/- 0.62 mL min(-1) 100 mL(-1) mmHg(-1) x 10(-3) post-training vs. 3.38 +/- 0.38 pre-training, P < 0.05). This may be because stimulation enhances perfusion preferentially to glycolytic fibres, or maintains high levels of vascular endothelial growth factor (VEGF) or changes lymph clearance.

Contamination of beef chucks with Escherichia coli during carcass breaking

Samples were obtained by swabbing the whole of the chuck portion on each of the first 500 sides that entered a beef carcass breaking process and the whole of the outer surface of each of the chuck primal cuts that were prepared from those portions. Swabs obtained from groups of 10 sides or cuts that entered or emerged from the process consecutively were combined, and the coliforms and Escherichia coli recovered from each group were enumerated. Coliforms and E. coli were recovered only sporadically from groups of sides at log total numbers of 4.0 and 3.5 log CFU/500 sides, respectively. Coliforms were recovered from three and E. coli from none of the first six groups of cuts. Coliforms and E. coli were recovered from all subsequent groups of cuts, initially at log numbers mostly <3 log CFU/10 cuts, but ultimately at log numbers mostly >3 log CFU/10 cuts. The log total numbers of coliforms and E. coli recovered from cuts were >6.0 and 5.5 log CFU/500 cuts, respectively. After the breaking of about 600 sides, samples were obtained by swabbing a table onto which the part of the side that included the chuck portion was deposited after it was cut from the hanging side, and the belt that was used for conveying chucks. The numbers of coliforms and E. coli recovered from the table and conveyor belt were comparable with the numbers recovered from sides and cuts, respectively. Those findings show that most of the coliforms and E. coli recovered from the cuts were not present on carcass sides but that they originated largely from the cut conveying equipment.

An HIV-1 transgenic rat that develops HIV-related pathology and immunologic dysfunction

We report, to our knowledge, the first HIV type 1 (HIV-1) transgenic (Tg) rat. Expression of the transgene, consisting of an HIV-1 provirus with a functional deletion of gag and pol, is regulated by the viral long terminal repeat. Spliced and unspliced viral transcripts were expressed in lymph nodes, thymus, liver, kidney, and spleen, suggesting that Tat and Rev are functional. Viral proteins were identified in spleen tissue sections by immunohistochemistry and gp120 was present in splenic macrophages, T and B cells, and in serum. Clinical signs included wasting, mild to severe skin lesions, opaque cataracts, neurological signs, and respiratory difficulty. Histopathology included a selective loss of splenocytes within the periarterial lymphoid sheath, increased apoptosis of endothelial cells and splenocytes, follicular hyperplasia of the spleen, lymphocyte depletion of mesenteric lymph nodes, interstitial pneumonia, psoriatic skin lesions, and neurological, cardiac, and renal pathologies. Immunologically, delayed-type hypersensitivity response to keyhole limpet hemocyanin was diminished. By contrast, Ab titers and proliferative response to recall antigen (keyhole limpet hemocyanin) were normal. The HIV-1 Tg rat thus has many similarities to humans infected with HIV-1 in expression of viral genes, immune-response alterations, and pathologies resulting from infection. The HIV-1 Tg rat may provide a valuable model for some of the pathogenic manifestations of chronic HIV-1 diseases and could be useful in testing therapeutic regimens targeted to stages of viral replication subsequent to proviral integration.

Clinical and cost-effectiveness of donepezil, rivastigmine and galantamine for Alzheimer's disease: a rapid and systematic review

BACKGROUND

Alzheimer's disease is the most common cause of dementia and is characterised by an insidious onset and slow deterioration. The estimated prevalence of Alzheimer's disease for a standard health authority (500,000 people) is about 3330. Current service involves a wide range of agencies, and drug therapy for some patients.

OBJECTIVES

To provide a rapid and systematic review of the clinical effectiveness and cost-effectiveness of donepezil, rivastigmine and galantamine in the symptomatic treatment of people suffering from Alzheimer's disease.

METHODS

A systematic review of the literature was undertaken. METHODS - DATA SOURCES: Searches were made of electronic databases, including MEDLINE, EMBASE, The Cochrane Library, Database of Abstracts of Reviews of Effectiveness, NHS Economic Evaluation Database, National Research Register, Science Citation Index, BIOSIS, EconLit, MRC Trials database, Early Warning System, Current Controlled Trials, TOXLINE, Index of Scientific and Technical Proceedings, and Getting Easier Access to Reviews. All sources were searched over the period covered by the databases up to March/July 2000. Bibliographies of related papers were assessed for relevant studies and experts were contacted for advice and peer review, and to identify additional published and unpublished references. Manufacturer submissions to the National Institute for Clinical Excellence (NICE) were reviewed.

METHODS - STUDY SELECTION

Studies were included if they fulfilled the following criteria: (1) INTERVENTION: donepezil, rivastigmine or galantamine used to treat Alzheimer's disease. (2) PARTICIPANTS: people diagnosed with Alzheimer's disease who meet the criteria for treatment with donepezil, rivastigmine and galantamine. (3) OUTCOMES: measures assessing changes in cognition, function, behaviour and mood, quality of life (including studies assessing carer well-being and carer-input), and time to institutionalisation. (4) DESIGN: systematic reviews of randomised controlled trials (RCTs) and RCTs comparing donepezil, rivastigmine or galantamine with placebo or each other or non-drug comparators were included in the review of effectiveness. Economic studies of donepezil, rivastigmine or galantamine used to treat Alzheimer's disease that included a comparator (or placebo) and both the costs and consequence (outcomes) of treatment were included in the review of cost-effectiveness. Studies in non-English language, and abstracts and conference poster presentations of systematic reviews, RCTs and economic evaluations were excluded. Two reviewers identified studies by independently screening study titles and abstracts, and then by examining the full text of selected studies to decide inclusion. METHODS - DATA EXTRACTION AND QUALITY ASSESSMENT: Data extraction and quality assessment were undertaken by one reviewer and checked by a second reviewer, with any disagreements resolved through discussion. The quality of RCTs was assessed using the Jadad scale and the quality of systematic reviews was assessed using criteria developed by the NHS Centre for Reviews and Dissemination. The quality of economic evaluation studies was assessed by their internal validity (i.e. the methods used) using a standard checklist, and external validity (i.e. the generalisability of the economic study to the population of interest) using a series of relevant questions. METHODS - DATA SYNTHESIS: The clinical effectiveness and cost-effectiveness of donepezil, rivastigmine and galantamine were synthesised through a narrative review with full tabulation of results of all included studies. In the economic evaluation, the reviewers assessed whether adjustments could be made to existing models to reflect the current situation in England and Wales. RESULTS - CLINICAL EFFECTIVENESS: (1) Donepezil--three systematic reviews and five RCTs (plus four studies from industry (unpublished data, submitted as commercial in confidence)) were found. Results suggest that donepezil is beneficial when assessed using global and cognitive outcome measures. (2) Rivastigmine--three systematic reviews and five RCTs (plus two studies from industry (unpublished data, submitted as commercial in confidence)) were found. Results suggest that rivastigmine is beneficial in terms of global outcome measures. (3) Galantamine--one systematic review and three RCTs (plus three studies from industry (unpublished data, submitted as commercial in confidence)) were found. Results suggest that galantamine is beneficial in terms of global, cognitive and functional scales. RESULTS - SUMMARY OF BENEFITS: It is difficult to quantify benefits from the evidence available in the literature. Statistically significant improvements in tests such as ADAS-cog (Alzheimer's Disease Assessment Scale cognitive subscale) may not be reflected in changes in daily life. (ABSTRACT TRUNCATED)

Five versus more than five years of tamoxifen for lymph node-negative breast cancer: updated findings from the National Surgical Adjuvant Breast and Bowel Project B-14 randomized trial

BACKGROUND

Previously reported information from B-14, a National Surgical Adjuvant Breast and Bowel Project (NSABP) randomized, placebo-controlled clinical trial, demonstrated that patients with estrogen receptor (ER)-positive breast cancer and negative axillary lymph nodes experienced a prolonged benefit from 5 years of tamoxifen therapy. When these women were rerandomized to receive either placebo or more prolonged tamoxifen therapy, they obtained no additional advantage from tamoxifen through 4 years of follow-up. Because the optimal duration of tamoxifen administration continues to be controversial and because there have been 3 more years of follow-up and a substantial increase in the number of events since our last report, an update of the B-14 study is appropriate.

METHODS

Patients (n = 1172) who had completed 5 years of tamoxifen therapy and who were disease free were rerandomized to receive placebo (n = 579) or tamoxifen (n = 593). Survival, disease-free survival (DFS), and relapse-free survival (RFS) were estimated by the Kaplan-Meier method; the differences between the treatment groups were assessed by the log-rank test. Relative risks of failure (with 95% confidence intervals) were determined by the Cox proportional hazards model. P values were two-sided.

RESULTS

Through 7 years after reassignment of tamoxifen-treated patients to either placebo or continued tamoxifen therapy, a slight advantage was observed in patients who discontinued tamoxifen relative to those who continued to receive it: DFS = 82% versus 78% (P =.03), RFS = 94% versus 92% (P =.13), and survival = 94% versus 91% (P =.07), respectively. The lack of benefit from additional tamoxifen therapy was independent of age or other characteristics.

CONCLUSION

Through 7 years of follow-up after rerandomization, there continues to be no additional benefit from tamoxifen administered beyond 5 years in women with ER-positive breast cancer and negative axillary lymph nodes.

Systematic review of immunomodulatory drugs for the treatment of people with multiple sclerosis: Is there good quality evidence on effectiveness and cost?

OBJECTIVE

To review the clinical effectiveness and costs of a range of disease modifying drugs in multiple sclerosis. Drugs included are azathioprine, cladribine, cyclophosphamide, intravenous immunoglobulin, methotrexate, and mitoxantrone.

METHODS

Electronic databases and bibliographies of related papers were searched for randomised controlled trials (RCTs) and systematic reviews, and experts and pharmaceutical companies were contacted for further information. Inclusion and quality criteria were assessed, data extraction undertaken by one reviewer and checked by a second reviewer, with discrepancies being resolved through discussion. Costs were obtained and cost-effectiveness papers sought.

RESULTS

Seventeen studies met the inclusion criteria for the review. Evidence for the clinical effectiveness of the drugs showed some reductions in relapse rates and/or progression to disability for people with MS, although benefits may be lessened by wide ranging side effects. Annual drug costs/patient are estimated to range from 60 pounds to 10200 pounds. No cost effectiveness studies were found.

CONCLUSION

Evidence for the effectiveness of these drugs in multiple sclerosis is problematic because there are few good quality trials for each drug. Trials often have methodological limitations and use different treatment regimes, patient groups, and outcome measures. Well conducted trials using outcome measures with clinical significance for groups of patients with different types of multiple sclerosis and long term follow up are needed if the evidence base of treatment for the disease is to be improved.

Immunomodulatory drugs for multiple sclerosis: a systematic review of clinical and cost effectiveness

Uncertainties about the clinical and cost effectiveness of immunomodulatory drugs for multiple sclerosis (MS), as well as concerns about funding treatment, continue to influence their use. The National Institute for Clinical Excellence (NICE) in England and Wales has been appraising the evidence on the clinical and cost effectiveness of IFN-beta and glatiramer to provide guidance to the NHS. It has proved a difficult task. This paper is an update of our systematic review which assesses the evidence on the clinical and cost effectiveness of a range of immunomodulatory drugs for MS, including azathioprine, IFN-beta, cladribine, cyclophosphamide, glatiramer, intravenous immunoglobulin (IVIg), methotrexate and mitoxantrone. Searches of electronic databases (such as Medline, Embase and the Cochrane Library) and bibliographies of related papers, as well as consultation with experts, for systematic reviews of randomised controlled trials (RCTs) and direct reports of RCTs revealed 26 studies of clinical effectiveness and eight economic evaluations that met the criteria for inclusion. The quality of the evidence was often poor, affected by methodological limitations. Evidence on the clinical effectiveness of immunomodulatory drugs showed some clinical effect, with reductions in relapse rates and/or progression to disability for people with MS. However, benefits from these drugs may be lessened by side effects. Assessment of cost effectiveness was limited to IFN-beta and glatiramer, showing that any benefit from these drugs was achieved at very high cost. The inadequacies in the evidence of clinical and cost effectiveness on some immunomodulatory drugs for the treatment of people with MS necessitate further rigorous RCTs and comparative economic evaluations of different alternatives.

Implantable cardioverter defibrillators: arrhythmias. A rapid and systematic review

PROPOSED SERVICE: The service proposed is the use of implantable cardioverter defibrillators (ICDs) in the management of risk factors leading to sudden cardiac death (SCD). ICDs are similar in size to a pacemaker and are intended to prevent death due to life-threatening ventricular tachyarrhythmias.

EPIDEMIOLOGY AND BACKGROUND

SCD occurs in approximately 100,000 people annually in the UK and is usually due to ventricular tachyarrhythmia. Increasing numbers of people are surviving a first episode of ventricular tachyarrhythmia and are at high risk of further episodes. Standard treatments for those at high risk have been anti-arrhythmic drugs, catheter ablation or surgery and, increasingly, vasodilating beta-blockers.

METHODS

Electronic databases were searched for the period 1980-99. In addition, bibliographies of related papers were assessed for relevant studies, and experts were contacted to identify additional published and unpublished references. Studies were included if they were systematic reviews, meta-analyses or randomised controlled trials (RCTs) comparing ICDs with conventional therapy in people at high risk of SCD.

NUMBER AND QUALITY OF STUDIES AND DIRECTION OF EVIDENCE

Seven RCTs on effectiveness the majority of which were of good quality, eight cost-effectiveness analyses most of which were older studies and based on non-UK data, and two good-quality literature reviews one of which was a critical appraisal of the literature of effectiveness and cost-effectiveness of ICD therapy, and the other a review of the cost-effectiveness of ICD therapy. These showed changes in absolute risk of total mortality ranging from an increase of 1.7% to a reduction of 22.8% (relative risk reductions of -7% to +54%).

SUMMARY OF BENEFITS

Estimated benefits from RCT data are 0.23-0.8 additional years of life with ICD therapy compared with anti-arrhythmic drug therapy.

COSTS

Unit cost of ICDs (based on 1999/2000 prices), ranges from pound 12,500 to pound 22,000. Total discounted costs for 3 years range from pound 20,000 to pound 29,000. COST-EFFECTIVENESS: Cost-effectiveness estimates in the literature identified range from $11,000 to $146,000 per life-year saved. Using UK cost data from three hospitals and trial survival data from one RCT, the estimate of cost-effectiveness from this review ranges between pound 20,250 and pound 87,000 per life-year saved. COST-UTILITY: Cost per quality-adjusted life-year is estimated by the authors of this review at pound 21,300 to pound 108,800 (using survival data from one trial and quality-of-life indices derived from clinical opinion). These figures remain speculative until quality-of-life data from ongoing trials are available to inform future UK cost-effectiveness/utility analyses.

IMPLICATIONS

If implemented for indications supported by evidence from RCTs, ICDs may cost the NHS in excess of pound 24 million per annum.

FUTURE RESEARCH

Future research should include the use of British Pacing and Electrophysiological Group registries to assess the use of different types of ICD and current service provision.

Effects of hot water pasteurizing treatments on the microbiological condition of manufacturing beef used for hamburger patty manufacture

Ten 12-kg lots of manufacturing beef from a single packing plant were obtained from a hamburger patty manufacturing plant. Each lot was divided into two, 6-kg portions, one of which was not treated while the other was treated with water of 85 degrees C. A portion from one lot was treated for 15 s. A portion from each of three lots was treated for 30 s, three portions were treated for 45 s, and three were treated for 60 s. Twenty-five pieces of meat from each portion were swabbed over areas of 100 cm2. Subsequently, each portion was first coarsely ground then finely ground, with twenty-five 100-g samples being taken from each portion at each stage of grinding. Each swab and sample of ground meat was separately processed for the enumeration of total aerobic counts, coliforms and Escherichia coli at levels of detection of 1 cfu/cm2, 1 cfu/100 cm2 and 1 cfu/100 cm2, respectively, for swab samples; and at a level of detection of 1 cfu/g for all three types of bacteria in samples of ground beef. A 250-kg batch of manufacturing beef was treated with water of 85 degrees C for 60 s. The product was processed through commercial equipment for manufacturing frozen hamburger patties. The flavour of patties prepared from the pasteurized product was compared with the flavour of patties prepared during normal commercial operation of the equipment. The weight of the manufacturing beef was not affected by the treatments. Similar total numbers of coliforms or E. coli were recovered per 2500 cm2 from the 25 swab samples or per 25 g from the 25 ground beef samples from each untreated portion. As the ratio of the surface area in cm2 to the weight in g would likely be < or = 1, the similar numbers indicated that swab sampling was inefficient for recovering coliforms and E. coli from the meat. However, coliforms and E. coli were recovered more frequently from swab than from ground beef samples from treated portions. Thus, some swabs from all three portions of beef treated for 30 s yielded coliforms and E. coli, but samples from portions treated for 45 or 60 s yielded few coliforms and no E. coli. The numbers recovered from the treated and untreated portions indicated that treatments for 45 or 60 s reduced both coliform and E. coli numbers by two orders of magnitude. The flavours of cooked patties prepared from the meat pasteurized with water of 85 degrees C for 60 s were not distinguished from the normal commercial product. The data indicate that pasteurizing manufacturing beef with water of 85 degrees C for 45 s could be a practicable treatment for enhancing the microbiological safety of frozen hamburger patties.

Physical activity and exercise for women with mobility impairments

Decisions regarding exercise or physical activity for women with mobility impairments are more complex than those made by other women and by people without mobility limitations. The epidemiologic caveat that being active improves health and well-being generally is applicable, but on the individual level there will be exceptions. For many mobility-limiting conditions, there has been a paucity of research that includes women and even less that focuses specifically on women. Although there is beginning to be evidence that this is changing, there are many unaddressed needs and opportunities for future study.

HER2 and choice of adjuvant chemotherapy for invasive breast cancer: National Surgical Adjuvant Breast and Bowel Project Protocol B-15

BACKGROUND

Recent retrospective analyses have suggested that breast cancer patients whose tumors overexpress HER2 derive preferential benefit from treatment with anthracyclines such as doxorubicin. This has led some clinicians to propose that HER2 should be used as a predictive marker in choosing between anthracycline-based regimens and combination chemotherapy with cyclophosphamide, methotrexate, and 5-fluorouracil (CMF). We evaluated this recommendation in a retrospective study of National Surgical Adjuvant Breast and Bowel Project Protocol B-15, in which patients received a combination of doxorubicin and cyclophosphamide (AC), CMF, or AC followed by CMF. We hypothesized that AC would be superior to CMF only in the HER2-positive patients.

METHODS

Immunohistochemical detection of HER2 was performed on tumor sections from 2034 of 2295 eligible patients. We used statistical analysis to evaluate the interaction between the efficacy of the assigned treatments and HER2 overexpression. All statistical tests were two-sided.

RESULTS

Tumor sections from 599 patients (29%) stained positive for HER2. AC was superior to CMF in HER2-positive patients only, although differences in outcomes did not reach statistical significance. In the HER2-positive cohort, relative risks of failure (i.e., after AC treatment as compared with CMF treatment) were 0.84 for disease-free survival (DFS) (95% confidence interval [CI] = 0.65--1.07; P =.15), 0.82 for survival (95% CI = 0.63--1.06; P =.14), and 0.80 for recurrence-free survival (RFS) (95% CI = 0.62--1.04; P =.10). Tests for interaction between treatment and HER2 status were suggestive but not statistically significant (P =.19 for DFS, P =.11 for survival, and P =.08 for RFS).

CONCLUSIONS

These results, together with overview results indicating minor overall superiority for anthracycline-based regimens relative to CMF, indicate a preference for the AC regimen in patients with HER2-positive tumors. Both AC and CMF regimens may be considered for patients with HER2-negative tumors.

Phase 1, randomized, double-blind trial of 7-allyl-8-oxoguanosine (loxoribine) in advanced cancer

Guanine ribonucleosides substituted at the 8 position of the guanine ring are a unique class of immunomodulators, the lead compound of which is 7-allyl-8-oxoguanosine (loxoribine). We conducted a double-blind randomized phase I study to evaluate the safety, pharmacokinetics, and immunologic effects of single ascending doses of loxoribine in patients with advanced cancer. Twenty-four patients were treated in three dose tiers of 8 patients each, utilizing a unique statistical design, so that within each group, patients were randomized in blocks of 4 to receive loxoribine initially and then placebo 4 weeks later--a sequence that was reversed in the remaining 4 patients. In 23 courses of loxoribine and 20 courses of placebo, toxicity was mild and infrequent at all dose tiers (1 mg/kg, 5 mg/kg and 10 mg/kg. Both antibody-dependent cellular cytotoxicity and lymphokine-activated killer cytotoxicity were transiently depressed following loxoribine administration at all doses. Loxoribine is safe at doses up to 10 mg/kg in patients with advanced cancer, and produces modest immunologic effects. Further testing, particularly in conjunction with other immunologic agents, is warranted.

Microbiological conditions of sheep carcasses from conventional or inverted dressing processes

At a small abattoir, 25 sheep carcasses were dressed conventionally, with the carcass suspended by the rear legs, and 25 carcasses were dressed while inverted, with the carcasses suspended by the forelegs. Two swab samples were obtained from randomly selected sites on each carcass, and total aerobic, coliform, and Escherichia coli counts were enumerated for each sample. Each type of count was arranged in two sets of 25 counts for each type of dressing process, and a log mean number and/or log total number recovered was calculated for each set of counts. The log mean number of total aerobic counts for one set of counts from carcasses dressed while inverted was less than the corresponding log mean numbers for both sets from the conventionally dressed carcasses and the other set from the carcasses dressed while inverted, and differed from them by about 0.7 log units. The coliforms recovered from carcasses were largely E. coli. The log total numbers of coliform or E. coli counts recovered from carcasses dressed while inverted were about 1.5 log units less than the corresponding log total numbers recovered from conventionally dressed carcasses. Those data indicate that the substitution of inverted for conventional dressing might serve to reduce the numbers of E. coli on sheep carcasses by reducing the microbiological contamination of the hindquarters but that the general microbiological condition of the carcasses would be little improved unless some means of preventing or removing contamination of the forequarters was also used.

Plant enzymes but not Agrobacterium VirD2 mediate T-DNA ligation in vitro

Agrobacterium tumefaciens, a gram-negative soil bacterium, transfers DNA to many plant species. In the plant cell, the transferred DNA (T-DNA) is integrated into the genome. An in vitro ligation-integration assay has been designed to investigate the mechanism of T-DNA ligation and the factors involved in this process. The VirD2 protein, which is produced in Agrobacterium and is covalently attached to T-DNA, did not, under our assay conditions, ligate T-DNA to a model target sequence in vitro. We tested whether plant extracts could ligate T-DNA to target oligonucleotides in our test system. The in vitro ligation-integration reaction did indeed take place in the presence of plant extracts. This reaction was inhibited by dTTP, indicating involvement of a plant DNA ligase. We found that prokaryotic DNA ligases could substitute for plant extracts in this reaction. Ligation of the VirD2-bound oligonucleotide to the target sequence mediated by T4 DNA ligase was less efficient than ligation of a free oligonucleotide to the target. T-DNA ligation mediated by a plant enzyme(s) or T4 DNA ligase requires ATP.

Preventing heel breakdown

The prevalence of heel pressure ulcers is a major health care problem. Heel ulcers develop as a result of pressure, shear, or friction concentrated on a small area over a bony prominence that lacks subcutaneous tissue. Significant risk factors for development of heel breakdown include immobility, age, mental status, nutrition, chronic illness, and orthopaedic surgical procedures, especially hip pinning and hip replacement surgeries. It is important for nurses to identify patients at risk for heel pressure ulcers and to initiate appropriate preventive interventions. This article discusses the etiology of heel pressure ulcers, risk factors, heel assessment, and choice of heel protection devices.

Development of intermediate-grade (mantle cell) and low-grade (small lymphocytic and marginal zone) human non-Hodgkin's lymphomas xenotransplanted in severe combined immunodeficiency mouse models

We have used severe combined immunodeficiency (SCID) (c.b.-17, ICR/SCID) mice to develop xenotransplantation (XT) models for human intermediate-and-low-grade non-Hodgkin's lymphomas (NHL). In the past, SCID mice have provided a variety of useful XT models for human hematopoietic neoplasms that primarily involve the acute leukemias and some nonhematopoietic tumors, but only rare reports exist on use of the SCID mouse model in the study of primary tumor cells from NHL. Intermediate-grade and low-grade NHL are the most common lymphomas seen in adults. There is no effective therapy for those types of NHL, and they have not been established in an animal model to date. The lack of an animal model has hampered studies that can evaluate the disease process in vivo as well as the definition of therapeutic parameters involved in treatment. We report in this study that primary patient samples of NHL ( intermediate grade and low grade) have been successfully established in SCID mice after XT. NHL include intermediate-grade (mantle cell lymphoma) and low-grade (eg, small lymphocytic lymphoma/chronic lymphocytic lymphoma and marginal zone lymphoma) forms. Studies have been directed toward creating appropriate conditions for the optimal grafting of these NHL in SCID mice so that the disease process in humans could be accurately simulated. These studies indicate that development of XT-human lymphoma cells in SCID mice appear to be linked to their biologic and/or clinical behavior, transplanted lymphoma cell number, and age, as well as to the natural killer cell status of the SCID mouse recipients. Evidence has also shown that NHL cells can exhibit homing or trafficking patterns in SCID recipients that resemble those observed in patients with gastrointestinal lymphomatous involvement (particularly that of mantle cell lymphoma). Our studies also indicate that artefactual influences, such as the outgrowth of Epstein-Barr virus-associated lymphoblastoid lesions, are rare occurrences in the human NHL/SCID models that we have established.

Efficacy of a new cream formulation of mupirocin: comparison with oral and topical agents in experimental skin infections

A new cream formulation of mupirocin developed to improve patient compliance was compared with systemic and topical antibiotics commonly used to treat primary and secondary skin infections. A mouse surgical wound model infected with Staphylococcus aureus or Streptococcus pyogenes was used. Topical treatment was applied at 4 and 10 h postinfection or oral treatment at a clinically relevant dose was administered 4, 8, and 12 h postinfection; treatments were continued three times daily for a further 3 days. Mupirocin cream was significantly more effective than (P < 0.01; two of eight studies) or not significantly different from (six of eight studies) mupirocin ointment in reducing bacterial numbers. Mupirocin cream was similar in efficacy to oral flucloxacillin but significantly more effective (P < 0.001) than oral erythromycin. It was also similar in efficacy to cephalexin against S. pyogenes but superior against S. aureus (P < 0.01). Mupirocin cream had a similar efficacy to fusidic acid cream against S. aureus but was significantly superior against S. pyogenes (P < 0.01). A hamster impetigo model infected with S. aureus was also used. Topical or oral treatment was administered at 24 and 30 h postinfection (also 36 h postinfection for oral therapy) and then three times daily for a further 2 days. On day 5, mupirocin cream was significantly more effective than mupirocin ointment in one study (P < 0.01) and of similar efficacy in the other two studies. Mupirocin cream was not significantly different from fusidic acid cream or neomycin-bacitracin cream, but it was significantly superior (P < 0.01) to oral erythromycin and cephalexin. Mupirocin cream was as effective as, or superior to, oral and other topical agents commonly used for skin infections.

The contribution of specific pneumococcal serogroups to different disease manifestations: implications for conjugate vaccine formulation and use, part II

To assess whether certain serogroups of Streptococcus pneumoniae are preferentially associated with specific disease manifestations, we analyzed all recent pneumococcal disease studies and assessed the relative frequency of isolation of each serogroup by clinical site (as a proxy for different disease states). In all age groups, serogroups 1 and 14 were more often isolated from blood, and serogroups 6, 10, and 23 were more often isolated from cerebrospinal fluid (CSF); in young children, serogroups 3, 19, and 23 were more often isolated from middle ear fluid (MEF). Serogroups represented in conjugate vaccines were isolated slightly less frequently from CSF than from blood or MEF. Nonetheless, serogroups in the 9-valent conjugate vaccine formulation still comprised approximately 75% of pneumococcal isolates from the CSF of young children in Europe and in the United States and Canada. These analyses indicate that pneumococcal conjugate vaccines could potentially prevent a substantial proportion of episodes of bacteremic disease, pneumonia, meningitis, and otitis media, especially in young children.

Benchmarks of fairness for health care reform: a policy tool for developing countries

Teams of collaborators from Colombia, Mexico, Pakistan, and Thailand have adapted a policy tool originally developed for evaluating health insurance reforms in the United States into "benchmarks of fairness" for assessing health system reform in developing countries. We describe briefly the history of the benchmark approach, the tool itself, and the uses to which it may be put. Fairness is a wide term that includes exposure to risk factors, access to all forms of care, and to financing. It also includes efficiency of management and resource allocation, accountability, and patient and provider autonomy. The benchmarks standardize the criteria for fairness. Reforms are then evaluated by scoring according to the degree to which they improve the situation, i.e. on a scale of -5 to 5, with zero representing the status quo. The object is to promote discussion about fairness across the disciplinary divisions that keep policy analysts and the public from understanding how trade-offs between different effects of reforms can affect the overall fairness of the reform. The benchmarks can be used at both national and provincial or district levels, and we describe plans for such uses in the collaborating sites. A striking feature of the adaptation process is that there was wide agreement on this ethical framework among the collaborating sites despite their large historical, political and cultural differences.

Which pneumococcal serogroups cause the most invasive disease: implications for conjugate vaccine formulation and use, part I

We analyzed >70 recent data sets to compare the serogroups causing invasive pneumococcal disease (IPD) with those represented in conjugate vaccine formulations. Five to 8 and 10-11 serogroups comprise at least 75% of pneumococcal isolates from young children and older children/adults, respectively, in each geographic region. Serogroups in the 7-valent formulation (4, 6, 9, 14, 18, 19, and 23) cause 70%-88% of IPD in young children in the United States and Canada, Oceania, Africa, and Europe, and <65% in Latin America and Asia. Serogroups in the 9-valent formulation (7-valent+1, 5) cause 80%-90% of IPD in each region except Asia (66%). Serogroup 1 accounts for >6% of IPD in each region, including Europe, except the United States and Canada and Oceania. In contrast, several serogroups not found in 7-, 9-, and 11-valent conjugate formulations are significant causes of disease in older children/adults. Nevertheless, each conjugate formulation could prevent a substantial IPD burden in each region and age group.

Radiotherapy review on national surgical adjuvant breast and bowel project (NSABP) phase III breast cancer clinical trials: is there a need for submission of portal/simulation films?

In all National Surgical Adjuvant Breast and Bowel Project (NSABP) breast cancer trials in which patients are treated with lumpectomy and postoperative breast irradiation, the quality assurance requirements dictate submission of a completed radiotherapy data form with the stated administered doses, the volumes treated, treatment prescription and daily treatment record sheets, dosimetry and calculation sheets, isodose distributions on the breast contour, photos of the patient in the treatment position, and portal or simulation films. A review of radiotherapy data on 1,982 patients who had lumpectomies accrued to seven recent NSABP breast cancer studies revealed only 2 patients who were judged to have inadequate fields. In both cases, a very small portion of the breast tissue was not included in the irradiated volume as demonstrated by the submitted films. On this basis, it was argued that submission of portal or simulation films for patients receiving postlumpectomy breast irradiation is not necessary. However, there was concern as to the incidence of patients with a possible excess amount of lung tissue included in the irradiated volume. To address this concern, the amount of irradiated lung was determined for the first 208 patients who had lumpectomies, with submitted data entered into the recent NSABP pathologic node-positive protocol B-28. Current NSABP radiation therapy guidelines suggest limiting the thickness of the irradiated lung in the portal beams to < or =3 cm. Only two patients (<1%) were found to have >3 cm of irradiated lung tissue in the treatment volume. Portal film submission is a considerable inconvenience to the individual institutions and is costly in terms of shipping, handling, and storage. These results indicate that submission of portal films is not a necessary part of quality assurance in NSABP breast cancer protocols. The NSABP has therefore eliminated the requirement for routine submission of portal films in protocols for which radiotherapy is not part of the test question.

Weighing the risks and benefits of tamoxifen treatment for preventing breast cancer

BACKGROUND

In response to findings from the Breast Cancer Prevention Trial that tamoxifen treatment produced a 49% reduction in the risk of invasive breast cancer in a population of women at elevated risk, the National Cancer Institute sponsored a workshop on July 7 and 8, 1998, to develop information to assist in counseling and in weighing the risks and benefits of tamoxifen. Our study was undertaken to develop tools to identify women for whom the benefits outweigh the risks.

METHODS

Information was reviewed on the incidence of invasive breast cancer and of in situ lesions, as well as on several other health outcomes, in the absence of tamoxifen treatment. Data on the effects of tamoxifen on these outcomes were also reviewed, and methods were developed to compare the risks and benefits of tamoxifen.

RESULTS

The risks and benefits of tamoxifen depend on age and race, as well as on a woman's specific risk factors for breast cancer. In particular, the absolute risks from tamoxifen of endometrial cancer, stroke, pulmonary embolism, and deep vein thrombosis increase with age, and these absolute risks differ between white and black women, as does the protective effect of tamoxifen on fractures. Tables and aids are developed to describe the risks and benefits of tamoxifen and to identify classes of women for whom the benefits outweigh the risks.

CONCLUSIONS

Tamoxifen is most beneficial for younger women with an elevated risk of breast cancer. The quantitative analyses presented can assist health care providers and women in weighing the risks and benefits of tamoxifen for reducing breast cancer risk.

Doppler velocimetry in the fetus with a single umbilical artery

OBJECTIVE

To study Doppler velocimetry in fetuses with a single umbilical artery (SUA) as compared to normal.

STUDY DESIGN

Private and clinic patients were referred to a perinatal center: 45 with SUA and 124 randomly selected fetuses with a three-vessel cord were studied from 18 to 41 weeks' gestation. Color Doppler flow and energy were utilized to evaluate the umbilical arteries at the fetal abdominal wall as well as the course around the bladder. In addition to Doppler velocimetry, an anatomic survey, estimated fetal weight (EFW) and amniotic fluid index (AFI) were assessed at each examination.

RESULTS

Doppler velocimetry in SUA demonstrated indices in the normal range but lower than in normal cords from 26 weeks until near term. Anatomic anomalies were found in 8.9% of SUA as compared to 4.8% for three-vessel cords. Intrauterine growth restriction (IUGR) was seen in four cases of SUA and none in the control group. EFW and AFI for both groups were virtually identical.

CONCLUSION

SUA cords theoretically carry a normal blood volume, and the decreased resistance to flow and larger arterial diameter allow this to occur. Anomalies and IUGR are elevated in infants with SUA. Overall, EFW and AFI were the same in both groups of patients.

Ligand-dependent conformational equilibria of serum albumin revealed by tryptophan fluorescence quenching

Ligand-dependent structural changes in serum albumin are suggested to underlie its role in physiological solute transport and receptor-mediated cellular selection. Evidence of ligand-induced (oleic acid) structural changes in serum albumin are shown in both time-resolved and steady-state fluorescence quenching and anisotropy measurements of tryptophan 214 (Trp214). These studies were augmented with column chromatography separations. It was found that both the steady-state and time-resolved Stern-Volmer collisional quenching studies of Trp214 with acrylamide pointed to the existence of an oleate-dependent structural transformation. The bimolecular quenching rate constant of defatted human serum albumin, 1.96 x 10(9) M-1 s-1, decreased to 0.94 x 10(9) M-1 s-1 after incubation with oleic acid (9:1). Furthermore, Stern-Volmer quenching studies following fractionation of the structural forms by hydrophobic interaction chromatography were in accordance with this interpretation. Time-resolved fluorescence anisotropy measurements of the Trp214 residue yielded information of motion within the protein together with the whole protein molecule. Characteristic changes in these motions were observed after the binding of oleate to albumin. The addition of oleate was accompanied by an increase in the rotational diffusion time of the albumin molecule from approximately 22 to 33.6 ns. Within the body of the protein, however, the rotational diffusion time for Trp214 exhibited a slight decrease from 191 to 182 ps and was accompanied by a decrease in the extent of the angular motion of Trp214, indicating a transition after oleate binding to a more spatially restricted but less viscous environment.