Changing demographics in the United States. Implications for health professionals

Allogeneic hematopoietic stem cell transplantation in the elderly

The development of reduced intensity or non-myeloablative conditioning (NST) in preparation for allogeneic stem cell transplantation (SCT) revolutionized the field and led to reconsideration of the dogma of upper age limit that was set up by the transplant centers as an eligibility parameter. Analysis of the literature data showed that NST regimens are associated with decreased transplant related mortality, and graft-versus-host disease, in comparison with standard myeloablative conditioning, in patients above the age of 50-55 years, or in younger patients with significant comorbidities. However we have to mention, that our considerations are based on the retrospective analysis of the literature data, and that well controlled prospective randomized studies are needed in order to definitely assess the role of NST. Comorbidity indices might be proved as the most important parameters for the choice of the most proper regimen for each patient in need and should be included in future trials.

Ablative allogeneic hematopoietic cell transplantation in adults 60 years of age and older

PURPOSE

To evaluate outcomes of ablative allogeneic hematopoietic cell transplantation (HCT) in older patients with hematologic malignancies.

PATIENTS AND METHODS

We treated 52 patients from 1979 to 2002 with a median age of 62.8 years (range, 60.1 to 67.8 years) using ablative preparative regimens followed by allogeneic HCT from sibling donors. Diagnoses included myelodysplastic syndrome (MDS; n = 35), chronic myeloid leukemia (CML; n = 8), acute myeloid leukemia (AML; n = 6), and other (n = 3). Conditioning regimens included cyclophosphamide (CY) and busulfan (BU) (67%), total-body irradiation and CY (21%), BU-fludarabine (10%), and CY (2%).

RESULTS

Eighteen (35%) of 52 patients are alive at a median of 4.6 years (range, 0.8 to 9.1 years) after transplantation. Median overall survival (OS) and progression-free survival were 300 and 218 days, respectively. Three-year OS and relapse rates are estimated to be 34% and 24%, respectively. Nonrelapse mortality (NRM) rates at 100 days and 3 years are estimated to be 27% and 43%, respectively. Grade 3 to 4 acute graft-versus-host disease (GVHD) occurred in 20% of patients, and chronic extensive GVHD was described in 53% of patients. Fourteen (40%) of 35 patients with MDS are alive at a median of 2.8 years (range, 0.8 to 8.2 years). Four of six patients with CML in chronic or accelerated phase are alive at a median of 6.9 years (range, 4.1 to 9.1 years) after transplantation. None of the patients with AML, CML in blast crisis, or other diagnoses have survived. Patients who underwent transplantation after 1993 had improved survival.

CONCLUSION

These data suggest that allogeneic HCT is feasible in selected patients > or = 60 years of age, although novel methods to reduce NRM while maintaining efficacy are needed.

Effect of age on the development of ARDS in trauma patients

STUDY OBJECTIVES

The purpose of this study was to determine the independent effect of age on the risk of developing ARDS in patients with trauma.

DESIGN

Prospective cohort study.

SETTING

Level I trauma center.

MEASUREMENTS AND RESULTS

A total of 4,020 consecutive trauma patients who were > 12 years of age were identified through the Harborview Medical Center Trauma Registry over a 3-year period. During this time, 484 of the trauma patients (12%) developed ARDS, as identified by the Harborview Medical Center ARDS Registry. Patients who developed ARDS were, on average, older (mean [+/- SD] age, 44.0 +/- 18.8 vs 40.2 +/- 20.0 years, respectively; p < 0.0001) and had higher injury severity scores (23.7 +/- 11.3 vs 18.0 +/- 10.3, respectively; p < 0.0001) than trauma patients who did not develop ARDS. The maximum unadjusted odds ratio for developing ARDS was 2.93 (95% confidence interval, 1.91 to 4.50) for the group 60 to 69 years of age compared to the group 13 to 19 years of age. Patients aged > or = 80 years had an equal risk of developing ARDS compared to those age 13 to 19 years.

CONCLUSIONS

Age demonstrated a complex relationship with risk for ARDS development. Older patients showed increasingly higher risks for ARDS development up to 60 to 69 years of age, when the risk for ARDS declined. We concluded that older patients are at significantly greater risk of developing ARDS when compared to younger patients, while the oldest patients may be at less risk.

Perceived risks of certain types of cancer and heart disease among Asian American smokers and non-smokers

This study assessed knowledge levels of health risks of tobacco use among the Asian American (AA) community in the Delaware Valley region of Pennsylvania and New Jersey, including metropolitan Philadelphia. A cross-sectional self-report survey was conducted to collect the information, and a stratified-cluster proportional sampling technique was used to obtain a representative sample size of the target population of Chinese, Korean, Vietnamese, and Cambodians. 1374 AA were recruited from 26 randomly selected community organization clusters; of the total recruited, 1174 completed the survey, which consisted of 410 Chinese, 436 Korean, 196 Vietnamese, 100 Cambodian and 32 other-group. Other-group was excluded for this study. Ten questions were asked to determine the knowledge level of the sample population. Results indicated that the vast majority of respondents (82.2%) recognized the association between smoking and increased risk of developing various types of cancers and heart disease. Between 81.3% and 93.3% of respondents recognized the increased risk for lung, mouth, throat.and esophageal cancer and heart disease. For these variables, there were statistically significant differences between the ethnic groups: Koreans were the most knowledgeable, followed by Chinese, Vietnamese, and Cambodians. For bladder, pancreatic, cervical, and kidney cancers, the percentage of respondents indicating an association between these cancers and smoking ranged from 49.2 to 56.8. There were no statistically significant differences among the four ethnic groups for these variables. Generally, however, results showed that the awareness level was higher among women and the more educated respondents, non-smokers and former smokers, and Chinese and Korean groups.

Factors related to cancer screening in Hispanics: a comparison of the perceptions of Hispanic community members, health care providers, and representatives of organizations that serve Hispanics

Hispanics have lower rates of screening for cervical, breast, and colon cancer than non-Hispanics. Activities to increase cancer screening in this population may not be informed by Hispanics, which may have implications for success rates of interventions. In this study, the perceptions about cancer screening behaviors in Hispanics are compared among three groups: a random sample of respondents (75% Hispanic) to a population-based survey, health care providers (primarily non-Hispanic), and representatives of organizations that serve Hispanics (36% Hispanic). While there was agreement that socioeconomic factors were important for cancer screening, differing views were expressed regarding the importance of cultural factors for cancer screening among Hispanics. Interventions developed by those who serve the Hispanic population may be based on inaccurate perceptions about the beliefs and practices of the population served. For effective interventions, it will be necessary to understand the factors important to Hispanics for cancer screening.

Graftskin heals an ulcer on an amputation stump

BACKGROUND

A 51-year-old man presented with a chronic ulcer of 28 years' duration on the amputation stump of his right foot. The prosthesis was aggravating the ulcer, despite multiple therapies.

OBJECTIVE

To heal the ulcer and avoid a below-the-knee amputation. Graftskin, a bilayered living skin construct, was applied.

METHODS

Graftskin was sutured in place following gentle debridement. Pentoxifylline was given to improve circulation. The dressing was changed 5 days after Graftskin application, then weekly for 7 weeks.

RESULTS

Crusting was evident at 3 weeks, with an underlying white coating at 4 weeks. By 7 weeks, full reepithelialization was present under the crust and no ulceration remained. Over succeeding weeks the ulcer bed became flush with the surrounding skin. The patient's pain ceased, and some sensation and warmth returned to the stump.

CONCLUSION

Graftskin treatment successfully healed a chronic ulcer, possibly preventing a more extensive amputation.

Cultural health care or child abuse? The Southeast Asian practice of cao gio

Although the immigration of Southeast Asians more than doubled over the past 20 years, much misunderstanding still persists regarding traditional, culture-bound health practices used by Vietnamese, Cambodian and Laotian families. The research presented in this paper explains one such traditional practice, that of cao gio. Cao gio, a dermabrasion therapy, is used extensively by many Southeast Asian women to treat a variety of illnesses. Health care providers do not appreciate this practice, however, to the extent that it is claimed to be a form of child abuse in some of the literature reviewed. A better understanding of the practice by those involved in the primary care of Southeast Asian families is not only necessary, but essential to avoid the mislabeling and misinterpretation of cultural, traditional health practices as child abuse. Lack of awareness of Southeast Asian cultural practices is quite significant, even though the United States experienced three major waves of Southeast Asian immigration during the past 20 years (Takeuchi, & Young, 1994). Over the past decade, the number of Southeast Asian immigrants and refugees to the United States has increased 108% or by more than 1 million individuals (Fong, & Mokuau, 1994; Frank-Stromborg, 1991; Ja, & Aoki, 1993; Tran, 1991; U.S. Census Bureau, 1998). Yet, despite this, Southeast Asian individuals are poorly understood, and the literature reveals little about what health, illness and treatment constitute for these different cultures (Boston, 1992; Buchwald, Panwala, & Hooton, 1992). The ethnic groups that comprise Southeast Asians, formerly known as the Indochinese, include individuals from Vietnam, Cambodia and Laos (Catanzaro, & Moser, 1982; Chung, & Kagawa-Singer, 1993). The majority of these individuals are refugees who fled their countries due to political persecution (Toole, & Waldman, 1993). This paper describes the findings of a phenomenological research study completed among 19 Southeast Asian women regarding beliefs about health and health practices. The women discussed the practice of cao gio (phonetically pronounced as gow yaw) and its importance, effectiveness and significance to their cultures. The discussion relates the study findings to the debate and issues surrounding child abuse, the consequences of misreporting, as well as the consequences of cultural ignorance in the provision of health care to those of different cultural practices and beliefs, particularly those of Southeast Asian ethnicity.

[The relationship between place of birth and certain health characteristics in Ontario]

The relationship between place of birth and some health characteristics of the population of Ontario was investigated using data from the 1990 Ontario Health Survey. Adult respondents were categorized according to their region, sub-region, and country of birth. Multiple logistic and linear regression analyses indicated that immigrants were less frequently obese than were Canadian-born respondents (odds ratio [OR] = 0.75, confidence interval [CI] 0.63, 0.90), and Asians particularly so (OR = 0.56, CI 0.34, 0.91). Asians also more often had a low body mass index (OR = 3.40, CI 2.11, 5.50). Immigrants less frequently reported a health problem (OR = 0.74, CI 0.62, 0.88) than did respondents born in Canada, but they perceived their health less positively. Place of birth influences some health characteristics of the Ontario population. The differences observed need to be investigated further to develop health services adapted to the needs of the multi-cultural population of Ontario.

Increasing incidence of myelodysplastic syndromes: real or fictitious?

Over the past 10-20 years, there has been a growing interest in the myelodysplastic syndromes (MDS). Due to difficulties of diagnosis, classification and case recording, the epidemiological features of MDS are still poorly defined. Recently, a number of cancer registries have published data on the regional occurrence of MDS, suggesting that MDS are much more common than previously thought. The crude incidence of MDS in these studies was 3.5-12.6 per 100,000 population per year. In people over the age of 70 years, incidence rates varied between 15 and 50 per 100,000 per year. Contrary to the assumption of most hematologists, cancer surveys usually failed to demonstrate a rising incidence of MDS. In those studies showing a significant increase in MDS, the rising number of cases was probably due to increased physician awareness and extended use of invasive diagnostic procedures in elderly people. Differences in incidence figures between regional studies may be attributed to several causes, including regional variations in disease incidence, small and ill-defined reference populations, bias due to patient referral patterns, varying intensity of diagnostic procedures and different observation periods. Because of the paucity of clinical symptoms and insignificance of morphological bone marrow changes particularly in early stage MDS, the currently available incidence figures are likely to underestimate the true incidence of MDS. Large-scale epidemiological studies are required for obtaining truly representative statistics on the incidence and prevalence of the MDS. In industrialized countries, a dramatic increase in these disorders can be expected over the next few decades due to the 'greying' of the population.

Epidemiological and etiological aspects of myelodysplastic syndromes

Myelodysplastic syndromes (MDS) are increasingly recognized as a cause of bone marrow failure, and are at least as frequent as acute myeloid leukemias. While the overall incidence is about 2-4/100,000/year, incidence figures rise steeply with age. Incidence rates of 20-30/100,000/year in persons over 70 demonstrate that MDS are among the most common hematological neoplasias in this age group. However, due to difficulties of diagnosis and classification, patient registration in population-based registers is far from complete. As a prerequisite for truly representative statistics, future revisions of disease classification systems must incorporate MDS as a separate group of disorders. The difficulties in conducting epidemiological studies also impede the identification of risk factors for the development of MDS. Current knowledge of occupational risk factors is also reviewed here. More rapid progress in our understanding of MDS may come from recent advances in methodology that have begun to shed some light on the cytogenetic and molecular aspects of leukemogenesis in general, and MDS in particular. Non-random chromosomal changes can be found in about 50% of cases at diagnosis, but they are probably late events in the evolution of MDS, reflecting the progressive genomic instability of the premalignant clone. Proto-oncogene mutations have also been suggested to be relevant to the pathogenesis of MDS, but longitudinal studies of point mutations of the N-ras proto-oncogene revealed that such events, although often associated with rapid deterioration and transformation to AML, also appear to be late events during the course of disease. Therefore, it remains a major challenge to identify those lesions that initiate the multistep development of preleukemia. As the incidence of MDS correlates strongly with age, it is reasonable to presume that age-dependent changes of the hematopoietic system may play a role in the initiation of MDS. Aging is probably associated with a compromised marrow reserve through reduction in the size of the stem cell pool. Through increased proliferative activity, the remaining stem cells may be particularly vulnerable to mutagenic insults. Immunological attack on stem cells, mitochondrial DNA mutations, and the regulatory influence of the hematopoietic microenvironment must also be considered as possibly contributing to the early stages of MDS.

Caring for the indigent patient: resources to improve care

Numerous resources can be used to meet the needs of indigent persons with cancer. Most pharmaceutical companies have professional information hotlines and programs to help patients obtain medications when they are unable to pay for them. Most communities provide numerous informational and support services. In order to provide optimal patient care, oncology nurses must be able to make referrals to appropriate community agencies. Programs are also available that provide financial assistance and lodging.

Breast cancer screening among older Hispanic women: knowledge, attitudes, and practices

A survey was conducted with 409 Hispanic and 138 Anglo women in Tucson, Arizona, to assess their knowledge of breast cancer and cancer screening tests, their attitudes toward breast cancer and cancer screening, and their use of screening tests. There were few differences between these two groups in use of breast cancer screening tests, with both group falling well below the recommended levels of screening frequency. Clinical breast exam was most often used, followed by breast self-exam, with mammography a distant third. Levels of knowledge about the risks for breast cancer and the ways to detect it were also low. Comparison with national data show Arizona women to have lower rates of breast cancer screening than the national average; this may be due to the absence of the Medicaid program in Arizona. The rates for Tucson Hispanics, although lower than that for Anglos, are comparable with the findings of other studies. More needs to be done to alert all older women about breast cancer screening, but more specific attention needs to be paid to the population of older Hispanic women. We suggest some culturally relevant strategies to address this problem.

Age-related incidence and other epidemiological aspects of myelodysplastic syndromes

Although most haematologists perceive a rising prevalence and incidence of myelodysplastic syndromes (MDS), reliable epidemiological data on these disorders are largely lacking. The bone marrow register of the University of Düsseldorf allowed us to assess among other epidemiological features the incidence of MDS, which was compared to that of acute myeloid leukaemia (AML). Among a total of 18,416 different patients registered between 1975 and 1990, 584 cases of MDS (3.2%) and 506 cases of AML (2.8%) were identified. Over the study period, the percentage of newly diagnosed MDS rose from 1.3% to 4.5%, while there was no upward trend for AML. Among all patients undergoing bone marrow biopsy, the proportion of those over 60 years of age increased from 41.9% in 1975 to 54.1% in 1990. We found a strong correlation between the proportion of elderly patients and the relative frequency of MDS diagnoses. Thirty-one patients (5.3%) were classified as a secondary MDS because of previous treatment with cytotoxic chemotherapy and/or irradiation for a variety of malignancies. Twelve patients were identified in whom occupational exposure to organic solvents could not be ruled out. For calculating age-specific incidence rates, the analysis was confined to the town district of Düsseldorf (575,000 inhabitants), because exact demographical data were available for this population. In the last quinquennium of the study period (1986-90), myelodysplastic syndromes were more frequent than AML in the age group 50-70 years (4.9 v 1.8/100,000/year). In patients over 70, the incidence of MDS was more than 3 times that of AML (22.8 v 6.7/100,000). In this group, men had a higher incidence of MDS (33.9/100,000) than women (18/100,000). Crude annual incidence (all age groups) was also higher for MDS (4.1/100,000) than for AML (2.1/100,000) in recent years. We conclude that MDS are relatively common haematological neoplasias. The rising incidence in recent years is probably not due to changes in aetiological factors, but may reflect increased awareness on the part of physicians and extended use of diagnostic procedures in elderly patients.