Hospital and geographic variability in two colorectal cancer surgery outcomes: complications and mortality after complications

BACKGROUND

The purpose of this study was to describe hospital and geographic variation in 30-day risk of surgical complications and death among colorectal cancer (CRC) patients and the extent to which patient-, hospital-, and census-tract-level characteristics increased risk of these outcomes.

METHODS

We included patients at least 66 years old with first primary stage I-III CRC from the 2000-2005 National Cancer Institute's Surveillance, Epidemiology, and End Results data linked with 1999-2005 Medicare claims. A multilevel, cross-classified logistic model was used to account for nesting of patients within hospitals and within residential census tracts. Outcomes were risk of complications and death after a complication within 30 days of surgery.

RESULTS

Data were analyzed for 35,946 patients undergoing surgery at 1,222 hospitals and residing in 12,187 census tracts; 27.2 % of patients developed complications, and of these 13.4 % died. Risk-adjusted variability in complications across hospitals and census tracts was similar. Variability in mortality was larger than variability in complications, across hospitals and across census tracts. Specific characteristics increased risk of complications (e.g., census-tract-poverty rate, emergency surgery, and being African-American). No hospital characteristics increased complication risk. Specific characteristics increased risk of death (e.g. census-tract-poverty rate, being diagnosed with colon (versus rectal) cancer, and emergency surgery), while hospitals with at least 500 beds showed reduced death risk.

CONCLUSIONS

Large, unexplained variations exist in mortality after surgical complications in CRC across hospitals and geographic areas. The potential exists for quality improvement efforts targeted at the hospital and/or census-tract levels to prevent complications and augment hospitals' ability to reduce mortality risk.

Broadening the examination of sociocultural constructs relevant to African-American colorectal cancer screening

The importance of sociocultural constructs as influences on cancer attitudes and screening has been established in the literature. This paper reports on the efforts to explore alternatives to sociocultural constructs previously associated with African-American cancer screening, but with low acceptance among community members or incomplete measurement (empowerment and collectivism) and develop a measure for a recently identified construct of interest (privacy). We report preliminary psychometric data on these sociocultural scales and their associations with cancer attitudes. African-Americans (N = 1021), 50-75 years of age participated in this study. Participants were identified via a listed sample and completed a telephone survey administered via call center. Sociocultural attitudes were assessed using items identified through computerized database searches, reviewed by advisory panels, edited and tested using cognitive response strategies. Cancer screening pros and cons, cancer worry, perceived cancer risk, colorectal cancer (CRC) screening subjective norms, and perceived self-efficacy for colorectal cancer screening (CRCS) were also assessed. Confirmatory factor analyses and multivariate analyses were conducted to provide support for the validity of the constructs and to understand the associations among the selected sociocultural constructs (empowerment, collectivism, and privacy) and cancer beliefs and attitudes (CRC perceived benefits and barriers, perceived risks, subjective norms, and perceived behavioral control/self-efficacy). Consistent with the literature, the factor analytic model (RMSEA for the model was .062; 90% CI: .060-.065) provided support for the empowerment, collectivism, and privacy constructs. The modified collectivism and privacy scales had acceptable reliability. The privacy scale demonstrated the strongest associations with measures of cancer beliefs and attitudes. The implication of the findings and need for further scale development activities is discussed.

DPP IV inhibitors: successes, failures and future prospects

The dipeptidyl peptidase IV (DPP IV) enzyme is a novel target for the treatment of type 2 diabetes. Several DPP IV inhibitors are in the clinical development, since they are safe and tolerable with no increased risk of adverse events compared to placebo and have a low risk of hypoglycemia. They are flourishing as monotherapy and also in combination with commonly prescribed antidiabetic agents and are appropriate for once-daily oral dosing. However, further studies are needed to validate both long-term β-cell preservation and the role of these agents in the management of diabetes. The present review gives an inside out of the DPP IV inhibitors for its success, failure and future prospects in the treatment of diabetes and associated complication.

Abstract P6-13-03: Local Treatment Strategies in Young and Elderly Stage IV Breast Cancer Patients in the USA and The Netherlands

Introduction

Approximately 5-10% of breast cancer patients present with stage IV at diagnosis. The appropriate treatment is still under debate. This study focused on differences in treatment regimens between the United States (USA) and the Netherlands (NL) within age groups.

Methods

As we included data from NL and the USA, we were able to construct an instrumental variable as a substitute for randomization and get around selection bias. We compared Dutch and USA treatment strategies; restrictive versus more often extensive local therapy. Data from the NL Cancer Registry and the US Survaillance, Epidemiology and End Results Program were used to construct a database for analyses. All primary stage IV breast cancer patients diagnosed in 1995-2003 were included. Follow up cutoff date was 12- 31-2005 (USA) and 12-31-2008 (NL). Analyses were stratified by age (<65, 65-75 and ≥75 years). Chi Square Tests were performed for therapy rates, overall survival was calculated by Cox Proportional Hazard Analyses.

Results

A total number of 11030 patients were included (5354 NL, 5676 USA). Within each age category, surgery was applied more often in the USA (<65: NL37%-USA52%, P<0.001. 65-75: NL28%-USA42%, P<0.001. ≥75: NL21%-USA39%, P<0.001).

Similar results were observed for use of radiotherapy after surgery (<65: NL30%-USA47%, P<0.001. 65-75: NL26%-USA44%, P<0.001. ≥75: NL 17%-USA36%, P<0.001). Rate of radiotherapy without surgery did not differ between the two countries. With increasing age, use of surgery and use of radiotherapy after surgical treatment decreased (NL, USA each P<0.001). Use of radiotherapy without surgical intervention however increased with age in both countries (NL p=0.002, USA p=0.001). Although unadjusted analysis showed enhanced overall survival for patients <65 years of age in the USA compared to NL (HR 0.92 (0.86-0.98), p=0.006), these results were not confirmed in multivariable analyses. Patients ≥75 years of age in the USA compared to NL, however, had worse overall survival, confirmed in multivariable analyses (HR 1.17 (1.08-1.27), P<0.001).

Conclusion

Surgery and radiotherapy after surgical treatment for stage IV breast cancer patients was applied more often in the USA compared to NL in all age categories. Use of local therapy decreased with increasing age. In multivariable analyses, patients ≥75 years of age had a worse overall survival in the USA. This finding suggests that a more extensive local treatment strategy does not improve overall survival in this group of elderly patients. The opposite was true for young patients, although these results were not confirmed in multivariable analyses.

Hepatoprotective activity of Luffa acutangula against CCl4 and rifampicin induced liver toxicity in rats: a biochemical and histopathological evaluation

Hepatoprotective activity of hydroalcoholic extract of Luffa acutangula (HAELA) against carbon tetrachloride (CCl4) and rifampicin-induced hepatotoxicity in rats was evaluated and probable mechanism(s) of action has been suggested. Administration of standard drug- silymarin and HAELA showed significant hepatoprotection against CCl4 and rifampicin induced hepatotoxicity in rats. Hepatoprotective activity of HAELA was due to the decreased levels of serum marker enzymes viz., (AST, ALT, ALP and LDH) and increased total protein including the improvement in histoarchitecture of liver cells of the treated groups as compared to the control group. HAELA also showed significant decrease in malondialdehyde (MDA) formation, increased activity of non-enzymatic intracellular antioxidant, glutathione and enzymatic antioxidants, catalase and superoxide dismutase. Results of this study demonstrated that endogenous antioxidants and inhibition of lipid peroxidation of membrane contribute to hepatoprotective activity of HAELA.

Stem bark extraction of Ficus bengalensis Linn for anti-inflammatory and analgesic activity in animal models

In the present study, anti-inflammatory and analgesic effect of aqueous extract of Ficus bengalensis (AEFB) and methanolic extract of F. bengalensis (MEFB) was evaluated in animal models. Preliminary results indicated that MEFB treatment possesses significant anti-inflammatory potential as compared to AEFB. The anti-inflammatory activity of MEFB exhibited in both acute (carrageenan induced hind paw edema and acetic acid induced vascular permeability) and subchronic (cotton pellet-induced granuloma) models of inflammation was found to be significant. In addition, the extract also showed significant analgesic activity in acetic acid induced writhing. Pretreatment with MEFB during inflammatory condition (both acute and sub-chronic) prevented increase in malondialdehyde (MDA) formation and myeloperoxidase activity in edematous as well as granulomatous tissue. Further, serum marker enzymes (AST, ALT and ALP) increased in inflammatory conditions were also inhibited with MEFB treatment. Hence, the anti-inflammatory activity observed in the present study with MEFB could be attributed largely to its antioxidant and lysosomal membrane stabilizing effects.

Purification and partial characterization of thermostable serine alkaline protease from a newly isolated Bacillus species HSRB08 from hotspring

The purpose of the research was to study the purification and partial characterization of thermostable serine alkaline protease from a newly isolated Bacillus species HSRB08, which was isolated from hotspring. The enzyme was purified in a 2-step procedure involving ammonium sulfate precipitation and Sephadex G-200 chromatography. The enzyme was shown to have molecular weight of 66 kD by sodium dodecyl sulphate polyacrylamide gel electrophoresis (SDS-PAGE) and Gelatin Zymogram and was purified 15.3-fold with a yield of 7.5%. It was most active at 45 degrees C, pH 9.0, with casein as substrate. It was strongly activated by metal ions such as Ca2+, Mg2+, and Mn2+. Enzyme activity was inhibited strongly by phenylmethyl sulphonyl fluoride (PMSF) but was not inhibited by ethylene diamine tetra acetic acid (EDTA), while a slight inhibition was observed with beta-mercaptoethanol (beta-ME). The compatibility of the enzyme was studied with commercial and local detergents in the presence of 10 mM CaCl2. The addition of 10 mM CaCl2 individually and in combination, was found to be very effective in improving the enzyme stability. This enzyme improved the cleansing power of various detergents. It removed blood stains completely when used with detergents in the presence of 10 mM CaCl2.

Simultaneous spectrophotometric estimation of Hydrochlorothiazide, Atenolol and Losartan potassium in tablet dosage form

Two simple, accurate and reproducible spectrophotometric methods have been developed for the simultaneous estimation of Hydrochlorothiazide (Hctz), Atenolol (Atn) and Losartan potassium (Los) in combined tablet dosage forms. The first method involves determination using the simultaneous equation method, the sampling wavelengths selected are, 272.5 nm, 224 nm and 250 nm over the concentration ranges of 0.5-30 microg/ml, 1-50 microg/ ml and 1-60 microg/ml for Hctz, Atn and Los respectively. The second method is the First order derivative method, the sampling wavelengths selected for estimation of Hctz, Atn and Los are 280.5 nm, 233 nm and 244 nm with linearity in the concentration ranges of 0.5-30 microg/ ml, 1-50 microg/ml and 1-60 microg/ml respectively. The results of the analysis were validated statistically and recovery studies were carried out as per ICH guidelines.

Cardioprotective effect of Azadirachta indica A. Juss. on isoprenaline induced myocardial infarction in rats

The present study was designed to evaluate the cardioprotective potential of aqueous leaf extract of Azadirachta indica A. Juss. (AI) on the basis of haemodynamic, biochemical and histopathological parameters in isoprenaline induced myocardial infarction in rats and to compare with vitamin E, a known cardioprotective antioxidant. A significant (p<0.01) decrease in mean arterial blood pressure (MAP), systolic arterial blood pressure (SAP), diastolic arterial blood pressure (DAP) and increase in heart rate (HR) were observed in isoprenaline control group. Isoprenaline showed significant decrease in the level of cardiac marker enzymes [Lactate dehydrogenase (LDH) and Serum Glutamate Oxalotransaminase (SGOT)] in the heart homogenate with a corresponding increase in their level in serum. In vitamin E control group significant (p<0.05) increase in LDH in heart homogenate and decrease of SGOT and LDH in serum was observed. In isoprenaline control group, significant (p<0.01) increase in total cholesterol and triglycerides levels while decrease in high-density lipoproteins (HDL) was observed. On histopathological examination, myocardial damage in isoprenaline control group further confirmed cardiotoxic effect of isoprenaline. Our data showed that AI (250, 500 and 1000 mg/kg, p.o.) and vitamin E (100 mg/kg, p.o.) significantly restores most of the haemodynamic, biochemical and histopathalogical parameters. Finally we concluded that AI leaf extract exerts equipotent cardioprotective activity in the experimental model of isoprenalin induced myocardial necrosis in rats as compared to vitamin E, a known cardioprotective antioxidant.

Perceived and observed neighborhood indicators of obesity among urban adults

OBJECTIVE

The global obesity epidemic has been partially attributed to modern environments that encourage inactivity and overeating, yet few studies have examined specific features of the physical neighborhood environment that influence obesity. Using two different measurement methods, this study sought to identify and compare perceived and observed neighborhood indicators of obesity and a high-risk profile of being obese and inactive.

DESIGN

Cross-sectional telephone surveys (perceived) and street-scale environmental audits (observed) were conducted concurrently in two diverse US cities to assess recreational facility access, land use, transportation infrastructure and aesthetics.

SUBJECTS

A total of 1032 randomly selected urban residents (20% obese, 32% black, 65% female).

ANALYSIS

Bivariate and multivariate logistic regression analyses were conducted to estimate the association (adjusted prevalence odds ratio (aOR)) between the primary outcome (obese vs normal weight) and perceived and observed environmental indicators, controlling for demographic variables.

RESULTS

Being obese was significantly associated with perceived indicators of no nearby nonresidential destinations (aOR=2.2), absence of sidewalks (aOR=2.2), unpleasant community (aOR=3.1) and lack of interesting sites (aOR=4.8) and observed indicators of poor sidewalk quality (aOR=2.1), physical disorder (aOR=4.0) and presence of garbage (aOR=3.7). Perceived and observed indicators of land use and aesthetics were the most robust neighborhood correlates of obesity in multivariate analyses.

CONCLUSIONS

The findings contribute substantially to the growing evidence base of community-level correlates of obesity and suggest salient environmental and policy intervention strategies that may reduce population-level obesity prevalence. Continued use of both measurement methods is recommended to clarify inconsistent associations across perceived and observed indicators within the same domain.

Primary amebic meningoencephalitis

This case is reported with the intention of highlighting the presentation of primary amebic meningoencephalitis as acute meningitis, a rare differential diagnosis with presence of free living amoebas in the CSF.

Polycyclic aromatic hydrocarbon metabolites in the bile of a territorial benthic fish, oyster toadfish (Opsanus tau) from the Elizabeth River, Virginia

Reverse-phase high-performance liquid chromatographic analyses of bile of a territorial benthic fish, oyster toadfish (Opsanus tau), indicated that fish from reference stations in the York and Elizabeth Rivers, Virginia, contained lower concentrations of polycyclic aromatic hydrocarbon (PAH) metabolites than fish from polluted stations. PAH metabolite levels in the bile of fish from mildly polluted stations were 7 to 10 times greater than those from reference stations. PAH metabolite levels in fish from a moderately polluted station and a highly polluted station were, respectively, 20 and 50 times greater than those from reference stations. Differential patterns of five major PAH metabolites in fish from the same station suggested individual variability in metabolic pathways possibly further convoluted by the differential inductions or suppressions of hepatic mixed-function oxygenase isozyme systems under various natural or anthropogenic habitat parameters. PAH metabolite levels in the bile of oyster toadfish correlated well with the gradient of PAH contamination in the Elizabeth River sediments. High levels of biliary PAH metabolites were not detected in muskrats (Ondatra zibethicus) collected along the polluted sections of the Elizabeth River, probably due to their primarily herbivorous nature. Assuming that the hepatobiliary system and the gastrointestinal tract are the major routes of biotransformation and excretion of PAHs in the muskrats, the contaminated diet appears to be a more important routes of exposure of muskrats (and possibly oyster toadfish) to PAHs than the transdermal transfer. Occurrence permitting, we propose oyster toadfish as a useful biological sentinel for early detection of estuarine PAH pollution.

Identification of biological/biochemical marker(s) for preterm delivery

Fetal and neonatal mortality and morbidity rates are strongly associated with gestational age for delivery: the risk for poor outcome increases as gestational age decreases. Attempts to predict preterm delivery (PTD, spontaneous delivery before 37 weeks' gestation) have been largely unsuccessful, and rates of PTD have not improved in recent decades. More recently, the reported associations between infections in pregnancy and PTD suggest preventive initiatives that could be taken. The overall objective of the current study is to assess whether specific markers of infection (primarily interleukin (IL) 1beta, tumour necrosis factor (TNF) alpha, IL-6, and IL-10) obtained from maternal blood during pregnancy, alone or in combination with other risk factors for PTD, permit identification of women at risk for spontaneous PTD. To achieve this objective, data are obtained from two Danish prospective cohort studies involving serial collection of maternal blood samples, newborn cord blood samples, and relevant confounders and other risk factors for PTD. The first study consists of a completed Danish regional cohort of 3000 pregnant women enrolled in a study of microbiological causes of PTD, upon which a nested case-control study of PTD in 84 cases and 400 controls has been performed. The second study is a nested case-control study of 675 PTD cases (equally divided into three gestational age categories of 24-29 weeks' gestation, 30-33 weeks' gestation, and 34-36 weeks' gestation) and 675 controls drawn from the ongoing Danish National Birth Cohort study of 100 000 pregnant women enrolled during 1997-2001. The second study will provide the opportunity to refine and retest hypotheses from the first study, as well as to explore new hypotheses. Our preliminary work suggests that a single predictive marker effectively accounting for a large proportion of PTD is unlikely to be found. Rather, a search for multiple markers indicative of the multifactorial aetiology of PTD is likely to be more successful. Knowledge gained from the proposed studies will be implemented in a third, clinical intervention study against PTD. The first phase of the clinical intervention study will be to establish a risk-assessment model based on the "best" combination of biological/biochemical measures and other factors associated with PTD in order to identify pregnant women at very high risk of PTD. The second phase will be to apply an intervention model of tailored obstetric care to the very high-risk pregnant women for PTD identified in phase one. The intervention will be carried out against each specific risk factor associated with PTD identified for the individual. The aim is to reduce the risk for PTD attributed to the combination of risk factors included in the clinical intervention study.

Breast-feeding education and support: association with the decision to breast-feed

CONTEXT

Rates of breast-feeding in the United States are well below the Healthy People 2000 objective of 75% and do not meet recent American Academy of Pediatrics guidelines.

OBJECTIVE

To identify factors associated with the initiation and duration of breast-feeding in managed care enrollees who had had a normal vaginal delivery.

DESIGN

Telephone survey of 5213 new mothers (4 to 6 months postpartum) enrolled in commercial managed care plans (response rate 72%).

MAIN OUTCOME MEASURES

Starting breast-feeding (ever vs never) and duration of breast-feeding (< or = 6 weeks vs > 6 weeks).

ANALYSIS

Logistic regression models controlling for sociodemographic variables. Given the prevalence of the outcome, odds ratios were converted to relative risks (RRs).

RESULTS

Seventy-five percent of respondents reported ever breast-feeding, and of those women, 75% reported breast-feeding for more than 6 weeks. In adjusted multivariate analyses, breast-feeding was affected by education, employment, and marital status. Women who were more likely to breast-feed were those who attended childbirth classes (RR, 1.16; 95% CI, 1.11 to 1.20), those who received prenatal breast-feeding advice (RR, 1.24; CI, 1.19 to 1.27), and those who received postpartum breast-feeding assistance (RR, 1.31; CI, 1.15 to 1.34). Breast-feeding for more than 6 weeks postpartum was associated with education, employment status, and the adequacy of postpartum information.

CONCLUSIONS

These findings suggest that health plans and employees may promote breast-feeding by providing breast-feeding education and support.

Recurrent Bell's palsy in pregnancy

A case of recurrent Bell's palsy occurring in two successive pregnancies in a 37-year-old woman is presented. The causes of facial nerve paralysis of the lower motor neurone type are discussed. The rate of recurrence of Bell's palsy during pregnancy is unknown. Treatment with corticosteroids of Bell's palsy during pregnancy poses the threat of possible side effects on the fetus.

Identification of cholesterol as a mouse skin lipid that reacts with nitrogen dioxide to yield a nitrosating agent, and of cholesteryl nitrite as the nitrosating agent produced in a chemical system from cholesterol

The skin lipids of mice exposed to nitrogen dioxide (NO2) and mouse skin lipids exposed in vitro to NO2 contain nitrosating agents (NSAs), that react with amines to produce nitrosamines. This situation represents a potential hazard of exposure to NO2. A principal NSA precursor in mouse skin lipids was purified by thin-layer and high-performance liquid chromatography. Each fraction was assayed by bubbling in NO2 and determining NSA. The precursor was identified as cholesterol on the basis of its chromatographic behavior and spectral properties. In a chemical system, cholesterol reacted with NO2 to give 13% yields of an NSA, which was identified from its spectral properties as the previously known compound, cholesteryl-3-beta-nitrite. These findings and the chromatographic behavior of a major NSA in the skin lipids of NO2-exposed mice suggested that this NSA was cholesteryl nitrite.

Beta- to omega-hydroxylation of the esophageal carcinogen methyl-n-amylnitrosamine by the rat esophagus and related tissues

When the esophageal carcinogen methyl-n-amylnitrosamine (MNAN; concentration, 3 mg/liter) was incubated in vitro with rat esophagi for 3 hr, five principal neutral metabolites (Metabolites 2 to 6; total yield, 3.0% of the MNAN per 100 mg tissue) were separated by gas chromatography, with detection by a thermal energy analyzer. Rat liver produced similar metabolites (total yield, 2.1% of the MNAN per 100 mg tissue). Metabolites 4 to 6 and a minor product, Metabolite 7, were tentatively identified as 2-, 3-, 4-, and 5-hydroxy-MNAN (HO-MNAN), respectively, from a comparison of their gas chromatography retention times with those of the synthesized compounds. Rat esophagus produced similar amounts of 3- and 4-HO-MNAN and lesser amounts of 2-HO-MNAN, whereas rat liver produced mainly 4-HO-MNAN. Rat nasal tissue metabolized 8.0% of the MNAN per 100 mg tissue, with a metabolite pattern like that of the esophagus. Rat lungs produced mostly 5-HO-MNAN. A comparison of yields from tissues of rats, hamsters, guinea pigs, and mice supported the view that the total production of neutral MNAN metabolites indicated the sensitivity of MNAN carcinogenesis, with some exceptions. MNAN injected i.p. was less carcinogenic for the esophagus and nasal cavity in Sprague-Dawley than in MRC-Wistar rats, perhaps because the livers of Sprague-Dawley rats metabolized more of the MNAN. The urine of MNAN-treated MRC-Wistar rats contained MNAN and metabolites provisionally identified as 2-, 3-, and (as the major product) 4-HO-MNAN. The identity of the urinary 4-HO-MNAN was confirmed by gas chromatography-mass spectrometry. We speculate that tissues like the esophagus, which (unlike the liver) produce significant proportions of 2- and 3-HO-MNAN, also produce significant amounts of the most likely proximal carcinogen, 1-HO-MNAN.