Updated mortality among diverse operating segments of a petroleum company

OBJECTIVES

To update mortality for 34 560 employees from diverse operating segments of a Canadian petroleum company; and to investigate potential relations with occupational factors.

METHODS

Employees from 1964-83 were linked to the Canadian mortality data base to provide 11 years additional follow up. There were 6760 deaths and 750 683 person-years of follow up compared with 3909 and 428 190, respectively, in the earlier study. Analyses used standardised mortality ratios (SMRs) to compare worker cause specific mortality with the Canadian general population. Duration of employment and latency analyses were performed for causes previously found to be increased in this and other petroleum cohorts, as well as any findings of interest.

RESULTS

For the period 1964-94, employees experienced significantly low overall mortality (SMR=0.86 men, SMR=0.80 women). Kidney cancer, which has been increased in some studies of petroleum workers, was not increased. Acute non-lymphocytic leukaemia in exposed operating segments was consistent with the expected or only slightly, non-significantly increased. The most notable finding was increased deaths from mesothelioma among refinery and petrochemical workers (SMR 8.68; 95% confidence interval (95% CI) 5.51 to 13.03), most of whom were long term employees in jobs with presumed exposure to asbestos (mechanical and pipefitters). Deaths from multiple myeloma among marketing and distribution workers, which were previously increased, remained increased (SMR 2.08; 95% CI 0.95 to 3.95) in the update period 1984-94; however, there was no clear pattern by duration of employment or latency. Aortic aneurysms, which also were previously significantly increased among marketing and distribution workers approached the expected in the update period (SMR 1.18; 95% CI 0. 65-1.98). Analyses by duration of employment showed suggestive trends for aortic aneurysms, but earlier studies of this cohort have not found a relation between aortic aneurysms and exposure to hydrocarbons.

CONCLUSION

The additional 2851 deaths and 322 493 person-years of follow up strengthened the assessment of mortality patterns relative to occupational factors. With the exception of mesothelioma, no clear work related increases in disease were identified.

Outcome evaluation of a multi-component violence-prevention program for middle schools: the Students for Peace project

This study evaluated the effect of Students for Peace, a multi-component violence-prevention intervention, on reducing aggressive behaviors among students of eight middle schools randomly assigned into intervention or control conditions. The intervention, based on Social Cognitive Theory, included the formation of a School Health Promotion Council, training of peer mediators and peer helpers, training of teachers in conflict resolution, a violence-prevention curriculum, and newsletters for parents. All students were evaluated in the spring of 1994, 1995 and 1996 (approximately 9000 students per evaluation). Sixth graders in 1994 were followed through seventh grade in 1995 or eighth grade in 1996 or both (n = 2246). Cohort and cross-sectional evaluations indicated little to no intervention effect in reducing aggressive behaviors, fights at school, injuries due to fighting, missing classes because of feeling unsafe at school or being threatened to be hurt. For all variables, the strongest predictors of violence in eighth grade were violence in sixth grade and low academic performance. Although ideal and frequently recommended, the holistic approach to prevention in schools in which teachers, administrators and staff model peaceful conflict resolution is difficult to implement, and, in this case, proved ineffective. The Students for Peace experience suggests that interventions begin prior to middle school, explore social environmental intervention strategies, and involve parents and community members.

Small-Cell Lung Cancer at the Millennium: Radiotherapy Innovations Improve Survival While New Chemotherapy Treatments Remain Unproven

Because of the systemic nature of small-cell lung cancer, one could predict that treatment advances would mainly come from innovations of chemotherapy. Although combination chemotherapy is better than monotherapy, a clearly superior multidrug regimen has not emerged. Investigations of more intensive chemotherapy with increased drug diversity and delivery have not prospered, and advantages of regimens including new agents have not yet been demonstrated in controlled trials. As we enter the new millennium, twenty-five years have passed since the publication of studies describing the combined used of cyclophosphamide, doxorubicin, and vincristine for small-cell lung cancer. It has been almost 20 years since the publication of the combination of etoposide and cisplatin became the widely accepted standard for the treatment of small-cell lung cancer. Today, both treatment regimens continue to be widely used as standard therapy. Ironically, proven advances in this systemic disease have been associated with innovations of local therapy. Data from limited-stage small-cell lung cancer clinical trials published during the 1990s demonstrated that a number of radiotherapy interventions had significant survival benefits. These radiotherapy interventions include addition of thoracic irradiation to chemotherapy, early delivery of thoracic irradiation concurrently with chemotherapy, more intense thoracic irradiation, and prophylactic cranial irradiation. As we await improved systemic therapy in the next millennium, the prognosis for extensive-stage disease remains guarded, and adherence to optimal radiotherapy detail remains crucial for routine management of limited-stage patients.

Small cell carcinoma of the bladder: long term outcome with integrated chemoradiation

BACKGROUND

Small cell carcinoma of the bladder (SCCB) is an uncommon tumor with approximately 8% 5-year survival reported in the literature for patients with disease confined to the pelvis. It exhibits biologic behavior similar to that of small cell carcinoma of the lung (SCLC). The authors sought to determine whether etoposide and cisplatin chemotherapy integrated with local irradiation is associated with improved survival in SCCB, as has been shown in SCLC.

METHODS

The authors performed a retrospective analysis of stage, treatment, disease free survival (DFS), and overall survival (OS) among 14 British Columbia Cancer Agency (BCCA) patients treated between 1985 and 1996 for SCCB.

RESULTS

When multiagent chemotherapy was combined with local irradiation, the authors observed a 70% 2-year and 44% 5-year actuarial OS among 10 patients without contraindications to systemic chemotherapy. Actuarial DFS was 70% at 2 and 5 years. The mean survival was 47 months (95% confidence interval, 18.5-76.1 months) and the median survival was 41 months. Nine of these patients had disease confined to the pelvis, and one had metastases to retroperitoneal lymph nodes. Five patients were alive and disease free an average of 82 months following diagnosis. Two patients had died of other causes without evidence of disease at 34 and 48 months following diagnosis. The incidence of second primary transitional cell bladder neoplasms following successful treatment was 60% at 2 years (3 of 5 long term survivors).

CONCLUSIONS

Integrated chemoradiation for patients with limited stage SCCB generates a realistic expectation of long term survival. Prospective trials to confirm these findings are warranted.

Parental influences on students' aggressive behaviors and weapon carrying

This article describes the association between four family constructs (family structure, relationship with parents, parental monitoring, and perception of parental attitudes toward fighting) and aggressive behaviors and weapon carrying among middle school students. Results are based on a cross-sectional survey of 8,865 6th, 7th, and 8th graders from eight urban schools in Texas (88.5% response rate). The sample was ethnically diverse. An inverse relationship was observed between aggression scores, fighting, injuries due to fighting, and weapon carrying and the family variables: parental monitoring, a positive relationship with parents, and the lack of parental support for fighting. Students who lived with both parents were less likely to report aggression than students in other living arrangements. These four family constructs accounted for almost one-third of the total variance in the aggression score. The perception of parents' attitudes toward fighting was the strongest predictor of aggression. Results provide support for including a strong parental component in the development of violence prevention programs for young people.

A longitudinal study of negative affect and self-perceived competence in young adolescents

In a 4-wave, 2-year longitudinal design, the authors obtained measures of negative affect (NA) and self-perceived competence from 220 boys and 216 girls who were 7th graders at the beginning of this study. NA was operationalized as the common dimension underlying self-reports of depressive symptoms, anxiety symptoms, and negative emotions. Self-perceived competence consisted of 2 higher order constructs: a well-behaved/good-student factor and an attractive/athletic/popular factor. Structural equation modeling revealed very high stability estimates for all constructs. Nevertheless, self-perceived competence in the attractive/athletic/popular domain predicted changes in NA. Conversely, NA predicted changes in self-perceived competence in the well-behaved/good-student domain. The primacy of NA versus self-cognitions depends, in part, on the type of self-cognitions being examined.

The cost of research: an analysis of Auckland Healthcare's research activity

AIM

Research informs clinical practice. It may also increase the cost of health service delivery, especially in an academic medical centre, where there is a greater concentration of research activity. Data on the cost of research in New Zealand Hospital and Health Services, particularly those providing teaching and other academic opportunities, are scarce. This article describes a method for collecting and analysing data related to research activities at Auckland Healthcare, New Zealand's largest Hospital and Health Service and, in association with the Auckland School of Medicine, the largest clinical research facility.

METHOD

During the 1996/1997 financial year, 190 research projects received Auckland Healthcare management approval. The nature, purposes, and budget for each project were recorded on a dedicated database. The financial data excluded the University-funded components of research.

RESULTS

Data presented for the 1996/1997 financial year reveal the volume, nature and cost of research for Auckland Healthcare. The budgeted external revenue was $1.6M, with 52% coming from commercial sponsors. Interestingly, 8% of the research projects during this period were budgeted to generate savings to the cost of standard clinical care. This was achieved primarily through the sponsorship of pharmaceuticals in commercial clinical trials. When these revenues and savings are deducted, the net budgeted cost of research at Auckland Healthcare in the 1996/1997 financial year was $86 572, or only 0.02% of total cost.

CONCLUSION

The Ministry of Health and the Health Funding Authority are voicing concern over the diversion of clinical care funding for research in Hospital and Health Services. While these concerns might be philosophically challenged on the grounds that sound research informs best clinical practice, it is also clear from these results that the net cost of research at Auckland Healthcare is indeed very small.

A longitudinal study of negative affect and self-perceived competence in young adolescents

In a 4-wave, 2-year longitudinal design, the authors obtained measures of negative affect (NA) and self-perceived competence from 220 boys and 216 girls who were 7th graders at the beginning of this study. NA was operationalized as the common dimension underlying self-reports of depressive symptoms, anxiety symptoms, and negative emotions. Self-perceived competence consisted of 2 higher order constructs: a well-behaved/good-student factor and an attractive/athletic/popular factor. Structural equation modeling revealed very high stability estimates for all constructs. Nevertheless, self-perceived competence in the attractive/athletic/popular domain predicted changes in NA. Conversely, NA predicted changes in self-perceived competence in the well-behaved/good-student domain. The primacy of NA versus self-cognitions depends, in part, on the type of self-cognitions being examined.

Gemcitabine plus cisplatin, an active regimen in advanced urothelial cancer: a phase II trial of the National Cancer Institute of Canada Clinical Trials Group

PURPOSE

To evaluate the efficacy and toxicity of gemcitabine (2', 2'-difluorodeoxycytidine) plus cisplatin in previously untreated patients with advanced transitional-cell carcinoma.

PATIENTS AND METHODS

Thirty-one patients with measurable advanced transitional-cell carcinoma who had received no prior chemotherapy for metastatic disease were scheduled to receive gemcitabine 1,000 mg/m(2) intravenously over 30 minutes on days 1, 8, and 15 and cisplatin 70 mg/m(2) over 1 hour on day 2 of a 28-day cycle. Prior adjuvant or neoadjuvant therapy for locally advanced disease was allowed if this was completed more than 1 year before study entry.

RESULTS

There were six complete responses and 10 partial responses in 28 assessable patients, for an overall response rate of 16 of 28 (57%). The response rate on an intent-to-treat basis was 16 of 31 patients (52%). The median survival is 13.2 months, with 18 patients still alive at this time. Toxicity was primarily hematologic, with 12 of 31 patients (39%) having > or = grade 3 granulocytopenia and 17 of 31 (55%) having > or = grade 3 thrombocytopenia. Two patients had febrile neutropenia. All patients required a dose modification of gemcitabine at some point in their therapy; the primary reason was thrombocytopenia and/or neutropenia.

CONCLUSION

Gemcitabine plus cisplatin is an active regimen for the treatment of urothelial cancer.

Randomized study of CODE versus alternating CAV/EP for extensive-stage small-cell lung cancer: an Intergroup Study of the National Cancer Institute of Canada Clinical Trials Group and the Southwest Oncology Group

PURPOSE

To determine whether an intensive weekly chemotherapy regimen plus thoracic irradiation is superior to standard chemotherapy in the treatment of extensive-stage small-cell lung cancer (ESCLC).

PATIENTS AND METHODS

Patients with ESCLC were considered eligible for the study if they were younger than 68 years, had a performance status of 0 to 2, and were free of brain metastases. Patients were randomized to receive cisplatin, vincristine, doxorubicin, and etoposide (CODE) or alternating cyclophosphamide, doxorubicin, vincristine/etoposide and cisplatin (CAV/EP). Consolidative thoracic irradiation and prophylactic cranial irradiation were given to patients responding to CODE and according to investigator discretion on the CAV/EP arm.

RESULTS

The fidelity of drug delivery on both drug regimens was equal, and more than 70% of all patients received the intended protocol chemotherapy. Although rates of neutropenic fever were similar, nine (8.2%) of 110 patients on the CODE arm died during chemotherapy, whereas one (0.9%) of 109 patients died on the CAV/EP arm. Response rates after chemotherapy were higher (P =.006) with CODE (87%) than with CAV/EP (70%). However, progression-free survival (median of 0.66 years on both arms) and overall survival (median, 0.98 years for CODE and 0. 91 years for CAV/EP) were not statistically different.

CONCLUSION

The CODE regimen increased two-fold the received dose-intensity of four of the most active drugs in small-cell lung cancer compared with the standard CAV/EP regimen while maintaining an approximately equal total dose. Despite supportive care (but not routine prophylactic use of granulocyte colony-stimulating factor), there was excessive toxic mortality with the CODE regimen. The response rate with CODE was higher than that of CAV/EP, but progression-free and overall survival were not significantly improved. In view of increased toxicity and similar efficacy, the CODE chemotherapy regimen is not recommended for treatment of ESCLC.

Improving survival in metastatic carcinoma of unknown origin

Metastatic carcinoma from an unknown primary site accounts for 3% to 5% of all newly diagnosed malignant lesions. Although 85% of patients who receive this diagnosis are dead within a year, 5% to 10% may be long-term survivors. Close cooperation between an experienced pathologist and the referring physician is essential in the management of these patients. One important task for the physician is to recognize those subgroups of patients who may have a better prognosis and thus may be treated in a different fashion. A second challenge is not to overinvestigate or overtreat patients who fall into the poor prognosis category. Empirical chemotherapy should not be given simply for the sake of doing something. Rather, proper emphasis should be placed on regional therapy, symptomatic treatment, and the best palliative care. Patients may be confused and frustrated when confronted with the news that the source of their tumor is not apparent. They should be reassured that this lack does not preclude development of a rational treatment plan and that those cancers for which highly effective systemic therapy exists have been excluded. A caring, informed physician may help empower the patient to make educated and informed choices.

The origin of chaos in the outer solar system

Classical analytic theories of the solar system indicate that it is stable, but numerical integrations suggest that it is chaotic. This disagreement is resolved by a new analytic theory. The theory shows that the chaos among the jovian planets results from the overlap of the components of a mean motion resonance among Jupiter, Saturn, and Uranus, and provides rough estimates of the Lyapunov time (10(7) years) and the dynamical lifetime of Uranus (10(18) years). The jovian planets must have entered the resonance after all the gas and most of the planetesimals in the protoplanetary disk were removed.

Maintenance intravenous iron therapy in hepmodialysis patients receiving recombinant human erythropoientin

Iron Supplementation is crucial in raising hematocrit as well as dosage saving for recombinant human erythropoietin therapy (rHuEPO) in maintenance hemodialysis patients. Intravenous iron has proved to be both safe and efficacious in this patient's population. However, the exact iron requirement has not been worked our. In this study we found that 1000 mg of element iron (given as iron saccharate) per moth was effective in maintaining hematocrit and hemoglobin at 33% and 110 gm/L respectively, and reducing the erythropoietin (EPO) dosage by about 20% in maintenance hemodialysis patients who were iron-replete. The serum ferritin increased from 219+/-144 to 320+/-234 microg/L (P< 0.05). There were no major side effects and patients tolerated the monthly iron therapy well. Our study suggests that intravenous iron saccharate (100 mg/month) is effective and safe in patients on maintenance hemodialysis receiving RHUEPO.

The influence of age on the delivery, tolerance, and efficacy of thoracic irradiation in the combined modality treatment of limited stage small cell lung cancer

PURPOSE

To assess the impact of age on the delivery, tolerance, and efficacy of thoracic irradiation (TI) for limited small cell lung cancer (L-SCLC).

METHODS AND MATERIALS

This is a retrospective review of data from 608 patients 80 years or less with L-SCLC, who participated in two previously reported randomized trials (BR3 and BR.6) of the National Cancer Institute of Canada. All patients received the same chemotherapy, consisting of cyclophosphamide, doxorubicin, vincristine (CAV), and etoposide cisplatin (EP) delivered either in sequential or alternating sequence. In BR.3, TI was given after chemotherapy with randomization to 25 Gy in 10 fractions or 37.5 Gy in 15 fractions. In BR.6, TI (40 Gy in 15 fractions) was given concurrently with EP with randomization to either the early (with cycle 2, week 4) or late (with cycle 6, week 16) arm.

RESULTS

A total of 665 patients entered these two trials. Of these, 608 patients were eligible for analysis, 300 in BR.3 and 308 in BR.6. Five hundred and twenty patients were under age 70 and 88 patients were 70 years or older. Baseline characteristics between the two groups were comparable. In BR3, 179 patients (60%) participated in radiotherapy randomization (61% young, 52% elderly), and 176 patients actually received TI. In BR.6, randomization occurred at study entry for all patients, and 282 (91.6%) patients received TI (92% young, 88% elderly). More patients of both age groups randomized to receive late TI did not receive TI (13% and 14%) than those randomized to the early TI arm (3%) of BR.6. We could identify no tendency to reduce field sizes to minimize toxicity in either age group at higher doses of TI. Once TI was started, there was no difference between the two age groups with regards to the proportion of patients who completed TI, although elderly patients were less likely to complete high dose TI. Of those who completed TI, there was no difference in the time to complete TI, mean dose delivered or in the incidence of acute and late TI-related toxicities. No statistical difference in response rate, local relapse rate, or overall survival was seen between young and older age groups.

CONCLUSION

In summary, in the dose range examined, age does not appear to impact on the delivery, tolerance or efficacy of TI in the combined modality management of L-SCLC. Potentially curative combined modality treatment should not be withheld on the basis of age.

Resolution of recurrent hepatitis B in two liver transplant recipients treated with famciclovir

Recurrent hepatitis B infection after orthotopic liver transplantation remains problematic despite prophylaxis with hepatitis B immune globulin (anti-HBs IgG). Recently, famciclovir (an oral nucleoside analog) has been shown to have potent antiviral activity against hepatitis B in vitro as well as in patients with chronic hepatitis B. We present two patients who developed recurrent hepatitis B after orthotopic liver transplantation and were treated with famciclovir, 500 mg t.i.d. Both patients subsequently responded with marked improvement in biochemical liver tests and histology, with subsequent loss of hepatitis B surface antigen. Famciclovir is a useful agent in the treatment of hepatitis B in the liver transplant recipient.

Abbreviated treatment for elderly, infirm, or noncompliant patients with limited-stage small-cell lung cancer

PURPOSE

To evaluate the efficacy of an abbreviated treatment plan consisting of two cycles of chemotherapy plus thoracic irradiation in a population of limited-stage small-cell lung cancer (LSCLC) patients who were elderly, infirm, or noncompliant with standard-duration therapy.

PATIENTS AND METHODS

Fifty-five LSCLC patients (median age, 73) were treated with one cycle of cyclophosphamide, doxorubicin, and vincristine (CAV) followed 3 weeks later by one cycle of etoposide and cisplatin (EP). Both regimens were administered at conventional full dose. Thoracic irradiation (20 to 30 Gy) was delivered concurrently with EP.

RESULTS

Complete response occurred in 28 patients (51%) and partial response in 21 (38%). The median survival time was 54 weeks; the 2-year survival rate was 28% and the actual 5-year survival rate was 18%. Three patients died of toxicity.

CONCLUSION

Elderly, infirm, or noncompliant LSCLC patients who are unable to receive standard-duration chemotherapy may have useful palliation and potential for long-term survival with abbreviated chemotherapy (two cycles) and thoracic irradiation.

Treatment strategies for small bowel bacterial overgrowth in short bowel syndrome

BACKGROUND

Small bowel bacterial overgrowth is a common complication of short bowel syndrome, and although it is often controlled with antimicrobial therapy, alternative strategies may occasionally be needed.

METHODS

Six patients with bacterial overgrowth are described, who did not respond to antimicrobial therapy and required additional medical or surgical measures to control the overgrowth.

RESULTS

Recalcitrant bacterial overgrowth was successfully treated with periodic small bowel irrigation with a balanced hypertonic electrolyte solution, colonic flushes, encouraging frequent stooling, intestinal lengthening procedure, or probiotic therapy with Lactobacillus plantarum 299V and Lactobacillus GG.

CONCLUSIONS

Small bowel bacterial overgrowth should be aggressively evaluated in patients with short bowel syndrome who are not progressing in a normal manner. Inadequate or incomplete response to antibiotic therapy is common, and several additional treatment possibilities are available.

New combination of the old drugs for elderly patients with small-cell lung cancer: a phase II study of the PAVE regimen

PURPOSE

A regimen of cisplatin, doxorubicin, vincristine, and etoposide (PAVE) was designed for patients with small-cell lung cancer (SCLC) who were older than 65 years, with the following objectives compared with standard chemotherapy regimens: maintain efficacy, diminish toxicity, enhance compliance, and improve chemotherapy administration convenience at an acceptable cost.

PATIENTS AND METHODS

The PAVE regimen consisted of cisplatin 30 mg/m2 intravenously (i.v.) day 1; doxorubicin 40 mg/m2 i.v. day 1; vincristine 1.0 mg/m2 i.v. day 1; and etoposide 100 mg/m2 i.v. day 1 and orally days 3 and 5. Cycles were repeated every 3 weeks for four cycles. Patients with limited-stage disease and selected patients with extensive-stage disease received thoracic irradiation delivered concurrently with etoposide-cisplatin (EP) at the time of the second chemotherapy cycle.

RESULTS

Sixty-six eligible patients were treated, which included 25 patients with limited-stage disease and 41 patients with extensive-stage disease. Median survival was 70 weeks and 5-year survival was 25% for limited-stage disease. Median survival was 46 weeks for extensive-stage disease. Only one treatment-related death occurred and severe toxicity was infrequent. The median delivered dose-intensity was according to protocol and the mean delivered total dose was 80% of intended.

CONCLUSION

The treatment outcome achieved with PAVE in a phase II study of elderly patients compared favorably with published results of standard regimens in patient populations with better prognostic factors. Because the PAVE regimen can be delivered with good compliance, has acceptable toxicity, and is associated with logistic advantages compared with standard regimens, this protocol is suitable for further investigative trials in elderly patients with SCLC.