Abstract P3-10-01: A pilot feasibility study of the WISDOM study, a preference-tolerant randomized controlled trial evaluating a risk-based breast cancer screening strategy

Background: For almost 30 years, annual mammograms for women over 40 have been a cornerstone of the US strategy to reduce breast cancer mortality. Introduction of the 2009 USPSTF screening guidelines, though based on a thorough review of the scientific literature, has triggered scientific debate and a stalemate. The solution is not to prolong the controversy with repetitious reviews of past studies, but rather to test and implement a personalized model that leverages advances in breast cancer biology, risk assessment, and imaging to provide screening recommendations based upon well-characterized measures of risk. Our WISDOM (Women Informed to Screen Depending On Measures of risk) study, a preference-tolerant randomized controlled trial funded through PCORI, will evaluate whether such a risk-based screening strategy, compared to annual screening, is as safe, is less morbid, enables prevention and is preferred by women. This upcoming pilot study will test the feasibility and technical implementation of the WISDOM trial, focusing on recruitment, enrollment, and randomization processes, a coverage with evidence development approach to enable rapid adoption, and patient experience and satisfaction. Findings will directly inform implementation of the full trial, slated to begin in fall 2015 throughout the Athena Breast Health Network, a research and care collaboration across the five UC Medical Centers and Sanford Health.

Trial Design: 225 participants will be recruited from Athena patients receiving care at UCSF. Participants must be female; between age 40 and 75; have had a normal mammogram at UCSF in the past 6 months; and in the Athena research cohort. Exclusion criteria are a breast cancer or DCIS diagnosis; inability to provide consent; or inability to speak English. After education about the trial, patients will be asked if they are willing to be randomized to either the risk-based or annual screening schedule; if not, they can self-assign to their preferred schedule. The randomized and self-assigned cohorts will receive the same interventions. The risk-based screening strategy will incorporate risk assessment based on the latest Breast Cancer Surveillance Consortium model along with established and recently validated genetic risk factors, co-morbidities, and breast density, and will be used to tailor individual recommendations for starting and stopping age, frequency, and screening modality. A saliva assay will be administered to participants in the risk-based arm to screen for genetic breast cancer risk factors (BRCA1 & BRCA2 + 9 additional genes + 81 single nucleotide polymorphisms).

Statistical Methods: Descriptive statistics for the proportion of women who are willing to be randomized, choose the risk-based arm in the self-assigned cohort, and are willing to accept their assigned or chosen screening schedule, as well as the distribution of participant anxiety scores, will be analyzed. This will inform statistical design for the full trial, including the number of women who should be approached to enroll 65,000 randomized participants and the sample size needed to measure anxiety and decision regret in the randomized cohort. Results from the pilot will be available September 30, 2015.

Citation Format: Narasimmaraj PR, Stover Fiscalini A, Kaplan CP, van't Veer LJ, Hallada AM, Thompson CK, Theiner S, Borowsky A, Naeim A, Anton-Culver H, LaCroix A, Athena Breast Health Network Investigators, Esserman LJ. A pilot feasibility study of the WISDOM study, a preference-tolerant randomized controlled trial evaluating a risk-based breast cancer screening strategy. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-10-01.

Abstract P6-02-08: Breast cancer screening in the precision medicine era

We are entering the era of precision medicine in which cancer screening, prevention and treatment will be tailored to each individual. The progress made in this field is due, in part, to advances in our understanding of cancer risk and tumor biology. The challenge before us is to harness this knowledge and apply it in the clinical setting. Breast cancer screening provides an excellent opportunity to test the value of precision medicine in the real world. In this report we describe the process of designing a model of personalized breast cancer screening.

Methods

Risk factors were selected that have the greatest impact, have been validated and can be measured across a population. A risk model was selected that is highly calibrated, has been validated in a large screening cohort and is easy to apply in a large population of women. An expert committee was convened that set risk thresholds for stratifying women into groups that will be recommended to undergo biennial, annual or every six month screening. Risk thresholds and screening schedules are in accordance with the United States Preventive Services Task Force breast cancer screening recommendations.

Results

Risk factors: Age, race/ethnicity, personal history of breast biopsies and benign breast disease, family history, breast density and breast cancer-associated genetic mutations and single nucleotide polymorphisms (SNPs) were chosen as the risk factors that will be used to determine breast cancer risk. Risk model: The Breast Cancer Surveillance Consortium risk model will be used to calculate a woman's 5-year risk and will be modified by a polygenic risk score based on 81 SNPs. Risk thresholds: Women will be recommended to undergo biennial screening mammography when they reach the age of 50 or have the risk of an average 50 year-old woman (1.3% 5-year risk). Women will be advised to undergo annual screening if they are at increased risk of developing an interval cancer (women in their forties with extremely dense breasts and women at increased risk of developing estrogen receptor negative breast cancer based on their SNPs). Women will be recommended to undergo annual mammography and annual MRI if they are found to be gene mutation positive, have the risk of a BRCA1 mutation carrier (6% 5-year risk) or have a history of mantle radiation.

Discussion

Selecting the appropriate risk factors and risk model and determining risk thresholds are key components of designing a personalized breast cancer screening model. Personalized screening may be the way forward, but this can only be determined within the setting of a randomized controlled trial. We will conduct such a trial to determine if personalized screening is as safe as, less morbid than, more preferred by women than and enables prevention when compared to annual screening. The WISDOM (Women Informed to Screen Depending on Measures of risk) study will compare risk-based screening to annual screening within the Athena Breast Health Network with support from the Patient-Centered Outcomes Research Institute. Our intent is that this trial will provide us with the data that we need to determine the safest and most effective way to screen women for breast cancer in the era of precision medicine.

Citation Format: Thompson CK, Fiscalini AS, Donnellan P, Kaplan CP, Madlensky L, Eklund M, Ziv E, van't Veer LJ, Tice JA, Esserman LJ. Breast cancer screening in the precision medicine era. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-02-08.

Abstract P1-10-22: Evaluating the incidence of supportive care referrals generated using patient reported data from the Athena health questionnaire system

Background

Patients at risk for or diagnosed with breast cancer have many symptoms and need for supportive care services. As part of the Athena Breast Health Network (a University of California-wide collaboration), the UCSF Breast Care Center (BCC) has incorporated an electronic health questionnaire system (HQS) prior to new patient and follow-up clinic visits, allowing patients to provide information on their personal health and family history, physical and psychological symptoms, and lifestyle. Based on these patient-reported outcomes (PRO), automated referrals for services including genetic counseling, psycho-oncology, social work, fertility preservation, and smoking cessation are generated. Algorithms defining thresholds to trigger these referrals were developed by clinicians and supportive care providers to proactively meet patients' needs.

Objectives

To evaluate the incidence and outcomes of supportive care referrals based on existing algorithms, and identify reasons for non-utilization of the services offered. The ultimate goal for this evaluation is to modify the existing algorithms to better meet patients' needs.

Methods

Patients initiating care at the UCSF BCC are invited by email to complete an HQS that provides information relevant to their clinical care. Patients sign an electronic consent, agreeing to have their PRO stored and accessed for research purposes. Family history, health behaviors, desired services, and responses to National Cancer Institute Patient Reported Outcomes Measurement Information System (PROMIS) items are processed through algorithms, generating referrals based on defined thresholds. A clinician summary report is generated and scanned into the electronic medical record (EMR), identifying services for which the patient has met thresholds. Referrals are sent to the clinician as pended orders through the EMR. Once signed by the care provider (physician or nurse practitioner), the order is routed through the EMR to the appropriate service and the patient is offered a visit or phone consultation when appropriate.

Results

Between 1/1/14 and 12/31/14, 1297 patients initiating care at the UCSF BCC completed an HQS prior to their clinic visit. 1108 patients (85.4%) agreed to have their data used for research. 623 patients (56.2%) were referred to at least one supportive care service. The table below summarizes the percentage of patients who met the defined referral thresholds:

Referrals Made, 2014Referral TypeNumber of ReferralsPercent of Patients Referred (n=1108)Genetic Counseling Services44340.0%Psychological Services25723.2%Social Work13712.4%Smoking Cessation343.1%Fertility Preservation292.6%

Ongoing analyses are underway to determine the percentage of patients who received services, explore barriers to accessing these services, and evaluate patients' preferences regarding provision of services in alternate formats, including webinars, online content, and group sessions.

Conclusions

Effective use of PRO identifies a high percentage of patients in need of supportive care services. Through analysis of utilization of services based on our existing thresholds, we hope to optimize our algorithms to better serve our patients' needs throughout the continuum of cancer care.

Citation Format: Wong EC, Kaplan CP, Shumay DM, Leykin Y, Etzel KA, Stover Fiscalini A, van't Veer LJ, Esserman LJ, Melisko ME. Evaluating the incidence of supportive care referrals generated using patient reported data from the Athena health questionnaire system. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-10-22.

Bupropion in breast milk: an exposure assessment for potential treatment to prevent post-partum tobacco use

OBJECTIVES

To assess potential infant exposure to bupropion and its active metabolites in breast milk such as would occur during treatment to prevent post-partum relapse to tobacco use, and to compare the concentrations of bupropion in urine and saliva with plasma and breast milk.

DESIGN AND SETTING

Cohort study, outpatient clinical research centre.

SUBJECTS

Ten healthy post-partum volunteers who agreed to take bupropion for seven days, pump and discard their breast milk, and have samples of breast milk, plasma, saliva, and urine analysed.

INTERVENTION

Bupropion 150 mg a day for three days and then 300 mg a day for four days.

MAIN OUTCOME MEASURES

Concentrations of bupropion and its active metabolites (hydroxybupropion, erythrohydrobupropion, threohydrobupropion) in breast milk, plasma, saliva, and urine. Determination of average infant exposure.

RESULTS

The calculated average dosage of bupropion in breast milk was 6.75 microg/kg/day. Therefore, the average infant exposure is 0.14% of the standard adult dose of bupropion, corrected for the difference in body weight. Considering the sum of bupropion and its active metabolites, the average infant exposure is expected to be 2% of the standard maternal dose on a molar basis. The concentration of bupropion and its active metabolites in breast milk was not associated with age, body mass index, use of oral contraceptive pills, age of infant, or the frequency of breast feeding at the time the study was initiated. The coefficient of determination (r2) between the concentration of bupropion in breast milk and in urine was 0.77 (p < 0.01).

CONCLUSIONS

Bupropion and its active metabolites are present in the breast milk of lactating women. The concentrations of bupropion in breast milk and urine were highly correlated. These results indicate that the daily dose of bupropion and metabolites that would be delivered to an infant of a woman taking a therapeutic dose of bupropion is small. These results suggest that the effectiveness of bupropion to prevent post-partum relapse to tobacco use should be evaluated without excluding women who plan to breast feed.

Does willingness to pay vary by race/ethnicity? An analysis using mammography among low-income women

As part of a population-based intervention to improve periodic mammogram screening, we examined WTP for mammography in five ethnic groups. Through random digit dialing, we contacted households in low-income census tracts of Alameda County, California (San Francisco Bay area). Women who met the ethnicity, age and cancer-free eligibility criteria were invited to participate. For the baseline assessment, women were surveyed over the phone in their preferred language. Of the 1465 surveyed women, 499 identified themselves as African-American, 199 were Chinese, 167 were Filipino, 300 were Latina, and 300 were non-Hispanic white. Bivariate and multivariate analysis showed that WTP varied significantly by ethnicity (P<0.05). We also found that when Filipino and Chinese women had a female relative with breast cancer, they were willing to pay less money for a mammogram. African-American, Latino, and non-Hispanic white women, however, were willing to pay more money for a mammogram if a female relative had had breast cancer. This ethnic difference, when there is a familial link to breast cancer, needs further study as it has implication for genetic testing. Nevertheless, WTP studies that do not account for ethnic differences may be overstating net benefits to society.

Young Latinas and abortion: the role of cultural factors, reproductive behavior, and alternative roles to motherhood

Latina women have often been portrayed as holding strong traditional family values leading to a greater propensity for rejection of contraception and abortion. Increasingly, the literature has consistently shown that Latina women use contraception effectively when available; however, much less is known about the prevalence of abortion and the factors related to its use in this population. In this article we examine Latinas' use of abortion and identify factors affecting its use among 1,207 ever-pregnant Latina women age 14-24 recruited at two federally-funded family planning clinics in the Los Angeles metropolitan area. Only a small proportion of the young women in our sample (7.5%) had ever had an induced abortion. In multivariate analysis the variables significantly associated with past abortion included less traditional attitudes about women's roles, higher gravidity, shorter periods of sexual activity, and a higher number of lifetime sexual partners. We conclude that use of abortion among Latinas is driven by role orientation and reproductive variables.

The community integration questionnaire with new scoring guidelines: concurrent validity and need for appropriate norms

OBJECTIVE

To investigate the influence of demographic variables and concurrent validity when new scoring guidelines are used with the Community Integration Questionnaire (CIQ).

METHOD

Thirty-three adult outpatients with biopsy confirmed malignant brain tumours were evaluated prior to chemotherapy. In contrast to TBI subjects, the brain tumour sample was older (x age= 46.3 years), better educated (x = 13.7 years); and gender was more evenly represented (16 male, 17 female).

RESULTS

Demographic variables mediated CIQ scores. Gender effects were still seen, with women significantly higher on Home Integration (r = 0.40, p < 0.05). Older subjects had lower CIQ scores: CIQ total (r = -0.54, p < 0.005); Home Integration (r = -0.42, p < 0.01); Social Integration (r = -0.44, p < -0.005); and Productivity (r = -0.45, p < 0.005). More education was related to higher CIQ total (r = 0.31, p < 0.05); Social Integration (r = 0.30, p < 0.05); and Productivity (r = 0.35, p < 0.05). Significant relationships were seen between CIQ scores and both the Social Activity and Inactivity subscales of the Chronic Illness Problem Inventory (r = -0.43, p < 0.005 and r = -0.68, p < 0.005, respectively).

CONCLUSIONS

CIQ norms for age, education, sex, and marital status are strongly recommended. Moderate concurrent validity remained with new scoring guidelines.

The effect of data collection mode on smoking attitudes and behavior in young African American and Latina women. Face-to-face interview versus self-administered questionnaires

Evaluating smoking prevention and cessation programs requires valid data collection. This study examined two survey modes--face-to-face (FTF) interview and self-administered questionnaire (SAQ)--comparing response rates, sample characteristics, data quality, and response effects. From two family planning clinics, 601 female Latina and African American clients ages 12 to 21 were recruited and randomized to either group. Results reveal that neither mode is superior to the other. The SAQ may therefore be preferable for this population, despite its higher rate of incompletes, because it yields results similar to the FTF yet is more cost effective and less disruptive to clinic routines.

Smoking acquisition among adolescents and young Latinas: the role of socioenvironmental and personal factors

This paper examined the effects of socioenvironmental and personal factors on two stages of the smoking continuum--onset of smoking and regular smoking--among a sample of 1411 Latina clients, ages 14-24, at two federally funded family planning clinics. The socioenvironmental factors included cultural indicators, smoking behavior of family and peers, and norms. The personal factors were risk-taking behaviors and intention to smoke in the future. Results showed that the indicators associated with experimentation were different than those linked with regular smoking. Socioenvironmental factors associated with the transition from never having smoked to trying cigarettes included acculturation, as measured by language and familialism, and peer smoking behavior. Among the personal factors, risk-taking behavior (past use of drugs, alcohol, and general risk attitude) and smoking intentions were correlates of experimentation. The transition from experimenter to regular smoker was associated with peer smoking behavior (P< .05) in the socioenvironmental domain and drug use and intention to smoke in the future among the personal factors (both P values <.001). Age, years of education, marital status, norms, and parental smoking did not independently predict either of the smoking outcomes. Intention to smoke was the strongest predictor of experimentation (OR = 8.3, Cl 5.87-11.60) and regular smoking (OR= 19.9, CI 12.31-29.21) and could help identify those most likely to benefit from smoking prevention and cessation interventions.

Identification and characterisation of PEX6 orthologues from plants

The sunflower (Helianthus annuus) orthologue of PEX6, an AAA ATPase essential for the biogenesis of peroxisomes in yeasts and mammals, was isolated. HaPex6p is immunologically related to Pichia pastoris Pex6p. Like other genes involved in peroxisome biogenesis and function HaPEX6 mRNA and protein levels peak in early post-germinative growth and mRNA levels also increase in senescent tissue. HaPEX6 identifies probable orthologues in Arabidopsis and rice.

Maximizing qualitative responses about smoking in structured interviews

This article addresses the important methodological issue of whether face-to-face or self-administered interviews elicit better qualitative data on reasons for smoking and quitting among 173 current and former smokers. The data are from a study of smoking behaviors among 601 African American and Latina women age 14 to 21 years recruited from family planning clinics in Los Angeles from 1995 to 1996. Results suggest that responses to closed questions about smoking behavior are similar in both methods but that self-administered surveys elicit more responses to open-ended questions than face-to-face interviews. The authors encourage the use of self-administered surveys in smoking research because they are cheaper to administer, yield similar data on closed-question items, and elicit richer and more provocative responses to open-ended questions.

Improving follow-up after an abnormal pap smear: results from a quasi-experimental intervention study

The success of cervical cancer control programs depends on regular screening with the Pap smear test and prompt and appropriate treatment of early neoplastic lesions. Recognizing the potentially grave consequences of lack of follow-up for abnormal Pap smears, numerous intervention studies have tested the impact of a variety of strategies to increase return for follow-up. The majority of these studies were evaluated under controlled experimental conditions. Despite the encouraging findings of these trials, the next step in the research continuum requires that the effectiveness of these interventions be demonstrated in real world settings before full implementation is initiated. We report the results of an evaluation study assessing the combined effectiveness of three intervention modalities found effective in prior randomized studies: a tracking follow-up protocol, transportation incentives, and financial incentives. This study used a before-after, nonequivalent control group design to assess the impact of a multifaceted intervention that included a computerized tracking protocol with transportation and financial incentives. The study was implemented at two major hospitals, two comprehensive health centers (CHC), and nine public health centers (PHC) under the jurisdiction of the Los Angeles County Department of Health Services. One hospital, one CHC, and the four PHC located in the catchment area of the CHC were selected as experimental sites. The control sites - one hospital, one CHC, and five PHC - provided usual care. All women with an abnormal Pap smear at the intervention and control sites were included in the study. The study consisted of a 1-year period of baseline data collection (September 1989-August 1990), followed by a 2(1/2)-year intervention period (September 1990-February 1993). During the intervention period, the intervention protocol was implemented at the experimental sites, and the control sites provided usual care. Overall, we found that the rates of receipt of follow-up care were consistent with those found in similar studies. In contrast to results obtained in these prior randomized trials, we did not find strong and consistent evidence for intervention effects. Significant findings emerged only at the CHC and hospital levels and only for selected years. Results underscore the importance of testing interventions in real world conditions before large-scale implementation is initiated. In addition, this study highlights the challenge of detecting intervention effects in large-scale studies because of the greater measurement difficulties in field studies as compared with controlled experiments.

Community Integration Questionnaire for patients with brain tumor: a comparative study

OBJECTIVES

This study compares mean scores obtained on the Community Integration Questionnaire among patients with brain tumor and published data for traumatic brain injury and nonpatient groups.

DESIGN

Subjects included 33 adult outpatients with biopsy-confirmed high-grade malignant brain tumors. Both sexes were represented. Subjects were older and better educated than historic samples. The Community Integration Questionnaire was positively skewed.

RESULTS

Subjects had higher scores on the Social Integration Scale than on Productivity. Higher education was associated with Productivity and the Community Integration Questionnaire total score. However, greater age was associated with lower scores. Significant gender effects were obtained.

CONCLUSIONS

Women with brain tumors had significantly higher Home Integration Scores than males with tumors. However, Home Integration was lower for persons with brain tumors than for either the corresponding gender in the traumatic brain injury model systems group for males and females, respectively. Similarly, compared with community-dwelling persons with traumatic brain injury, males, but not females, with cerebral tumors had significantly lower Social Integration scores. When compared with nondisabled adults, persons with brain tumors reported significantly lower Productivity and Community Integration Questionnaire total scores.

Relationships: importance for patients with cerebral tumours

OBJECTIVE

To investigate the influence of relationships on psychosocial status in patients with Stage III and IV brain tumours.

PATIENTS AND METHODS

Thirty-three outpatients at a university medical centre were referred to the study by their treating physician prior to the initiation of aggressive chemotherapy. All subjects underwent a comprehensive psychosocial assessment.

RESULTS

Depressive and anxious complaints were common, but not related to gender. Single/divorced status suggested greater vulnerability to anxiety as 88% of singles and only 48% of patients with partners reported clinical levels of anxiety. Single patients' anxiety was related to inactivity (r = 0.78, p < 0.05) and fears of financial difficulties (r = 0.72, p < 0.05). State and trait anxiety related differently to married patients' complaints. Married patients more frequently reported clinical levels of depressive symptoms (44% partnered vs 28% singles). Depression among married patients was predicted by problems with sex, finances, marital difficulties, and inactivity [R2 = 0.803; F = 20.420, df(4,20), p < 0.0001)]. Problems with relationships were disassociated from problems with sex. Married patients' problematic relationships were predicted by overprotection, inactivity, concerns of bodily deterioration, depression, and anxiety [R2 = 0.775, F = 13.060, df(5, 19) < 0.0001].

CONCLUSIONS

Married neuro-oncology patients may experience depressive symptoms arising from the marriage, but appear to be buffered from anxiety when compared with single/divorced patients. The prevalence of anxiety among single patients suggests modifications of interventions by relationship status.

Cognitive outcome after emergent treatment of acute herpes simplex encephalitis with acyclovir

Longitudinally designed case studies, reporting cognitive and psychosocial outcome of herpes simplex virus encephalitis (HSVE), were conducted prior to current antiviral medication usage and primarily in persons with either left hemispheric or bilateral temporal lobe involvement. The current study demonstrated relatively better outcome (cognitive recovery and functional independence for activities of daily life) in an individual treated with IV Acyclovir within hours of initial symptoms and whose CT scans showed right hemispheric involvement. In contrast with earlier case reports, no semantic specific categories of memory impairment were noted on serial assessment. The time from first symptoms to antiviral medical treatment appears to be the best predictor of outcome from HSVE. Historical case studies with relatively poorer outcome and differing deficits suggest survivors of HSVE are a heterogenous group. Variability in anatomic lesions and time to treatment contribute to outcome.

Anoxic-hypotensive brain injury: neuropsychological performance at 1 month as an indicator of recovery

DESIGN

This case control study included assessments at 3 and 8 weeks post brain injury. Controls were the non-brain injured subjects whose normative data has been published for neuropsychological measures. Data and medical information were obtained with informed consent.

OBJECTIVE

This study explored cognitive sequella of anoxic-hypotensive brain injury following cardiac arrest in a 49 year old man with high premorbid function.

RESULTS

Improvement was noted at 3 weeks post-injury. By 8 weeks neuropsychological test scores including verbal and visual memory were in the normal range, although they were likely to be lower than premorbid levels.

CONCLUSIONS

Relatively good cognitive function within the first month post-anoxia likely indicates improved recovery and benefit from continued rehabilitation. Despite initial presentation, steep recovery curves can be found among survivors of anoxia with eventual return to independent function including driving/child care and return to gainful employment. Rehabilitation teams are encouraged to remember that good cognitive function is not predicted by initial Glasgow Coma Scores, but may be predicted by return of recall memory during the first month post-anoxic event. Serial cognitive screens can identify individuals with the potential for better recovery.

SCL 90-R interpretation and brain tumour: a correction factor?

OBJECTIVE

Determine whether spurious SCL 90-R profiles resulting from endorsement of neurologic treatment items can be corrected and still retain ecological validity.

DESIGN

The proportion of subjects' item endorsement was compared with the adult non-patient norm group. Items with discriminative power (chi 2 > 25, p < 0.001 and endorsement by at least 25% of subjects) underwent principal-components analysis with somatic treatment and psychiatric factors identified. Items in the somatic treatment factor were extracted as the corrective factor. The resultant corrected T scores were plotted against original SCL 90-R profiles.

SETTING

University medical centre.

PATIENTS

Thirty community dwelling adults with biopsy confirmed malignant brain tumours referred by their treating physician for evaluation prior to aggressive treatment.

INTERVENTIONS

The SCL 90-R was part of a neuropsychological test battery.

MAIN OUTCOME MEASURE

The SCL 90-R was selected prior to data collection because it is the second most frequently used psychosocial instrument in medical settings, yet has demonstrated attenuated validity with neurologic patients.

RESULTS

Extraction of 10 somatic treatment items resulted in lower profiles on Somatization, OBSESSIVE: Compulsive, Depression, and Anxiety dimensions and the global indicators. However, clinical caseness for individuals remained greater than indicated by clinical interview.

CONCLUSION

Correction for SCL 90-R neurologic treatment items resulted in reduced sensitivity and poorer ecological validity.

Does the SCL 90-R obsessive-compulsive dimension identify cognitive impairments?

OBJECTIVE

To investigate the relevance of the Symptom Checklist 90-R Obsessive-Compulsive subscale to cognition in individuals with brain tumor.

DESIGN

A prospective study of patients assessed with a neuropsychological test battery.

SETTING

A university medical center.

PATIENTS

Nineteen adults with biopsy-confirmed diagnoses of malignant brain tumors were assessed prior to aggressive chemotherapy.

MAIN OUTCOME MEASURES

Included in the assessment were the Mattis Dementia Rating Scale, California Verbal Learning Test, Trail Making Test B, Symptom Checklist 90-R, Mood Assessment Scale, Beck Anxiety Inventory, and Chronic Illness Problem Inventory.

RESULTS

The SCL 90-R Obsessive-Compulsive subscale was not related to objective measures of attention, verbal memory, or age. It was related significantly to symptoms of depression (r = .81, P < .005), anxiety (r = .66, P < .005), and subjective complaints of memory problems (r = .75, P < .005). Multivariate analyses indicated that reported symptoms of depression contributed 66% of the variance in predicting SCL 90-R Obsessive-Compulsive Scores, whereas symptoms of anxiety contributed an additional 6% (P < .0001).

CONCLUSIONS

Our data suggest that the SCL 90-R is best viewed as an indicator of unidimensional emotional distress and somatic effects of structural brain injury.

Interpretive risks: the use of the Hopkins Symptom Checklist 90-Revised (SCL 90-R) with brain tumour patients

Patients with brain tumours often report distress. Interpretive problems ensue when measures normed on healthy persons are utilized to quantify distress. This study investigated potentially spurious elevations on the Hopkins Symptom Checklist 90 Revised (SCL 90-R). Responses of 17 patients were obtained prior to aggressive chemotherapy. Traditional interpretation indicated that 47% of the patients endorsed clinical levels of somatization, 53% obsessive-compulsive and 59% psychotic disorders. Elevations were attributable to common consequences of brain tumours, medication and the emotional reaction to prognosis. Conventional interpretation would lead to inappropriate classifications. The majority of SCL 90-R item endorsements were significantly different than those of the norm group. Appropriate interpretation of scores is discussed.

Reducing loss-to-follow-up among women with abnormal Pap smears. Results from a randomized trial testing an intensive follow-up protocol and economic incentives

OBJECTIVES

This study evaluates the efficacy of two interventions designed to reduce loss-to-follow-up among women with abnormal Pap smears.

METHODS

The two interventions were evaluated in two large public hospitals using a randomized 2 x 2 factorial design. One intervention involved an intensive follow-up protocol that relied on multiple attempts (mail and telephone) to contact the patient. The second intervention provided patients with economic vouchers to offset out-of-pocket expenses associated with the follow-up visits. Loss-to-follow-up was addressed by medical chart reviews and telephone interviews.

RESULTS

The study population (n = 1453) was primarily Hispanic, married or otherwise living with a significant other, relatively young in age, and with no source of payment for health care. Overall, 30% of the total sample was loss-to-follow-up (i.e., no return visits). Among patients assigned to the control condition, loss-to-follow-up was 36.1% compared with 27.8% for the intensive follow-up condition, 28.8% for the voucher condition, and 29.0% for the intensive follow-up plus voucher condition. Both intervention conditions significantly improved follow-up rates. The odds ratio for intensive follow-up was 1.56 compared with 1.50 for the voucher intervention. The combined intervention condition (intensive follow-up x voucher program) did not have a significant effect after taking into account the main effects of the two interventions. Correlates of loss-to-follow-up included age (younger women had lower return rates), race/ethnicity (African American women had lower return rates), live-in relationship (women who were not married or living as married had lower return rates), and severity of the abnormal Pap smear (less severe abnormalities were associated with lower return rates).

CONCLUSIONS

Both interventions were associated with moderate reductions in loss-to-follow-up in this underserved population. The implications of these findings are discussed relative to implementing cervical cancer control programs within state and local health departments.

Isolation of a cDNA encoding an Arabidopsis galactokinase by functional expression in yeast

A cDNA clone encoding Arabidopsis thaliana galactokinase was fortuitously isolated during the course of a screen for plant homologues of a Saccharomyces cerevisiae peroxisome assembly gene, PAS9. Clones were sought which restored the ability of pas9 cells to grow on oleate as a sole carbon source, as oleate metabolism requires peroxisomal beta-oxidation and therefore functional peroxisomes. Subsequent experiments showed that high level expression of the galactokinase cDNA did not complement the peroxisomal assembly defect, but instead permitted the cells to grow on agar plates in the absence of an external carbon source. Agar plates were shown to contain a small amount of galactose released from the agar as a result of autoclaving. The galactokinase clone was shown to be functional, as it could complement a S. cerevisiae galactokinase mutant. Galactokinase is a single copy gene in Arabidopsis, which has been designated AGK1, and is expressed in all the major organs of the plant.

Pseudotumour cerebri: risk for cognitive impairment?

Does increased intracranial pressure in patients with pseudotumour cerebri (PTC) result in cognitive impairments? The results of previous investigations have not clarified this question. It may be that there is a subgroup within those diagnosed with PTC that does experience cognitive decline with increased intracranial pressure. However, elevated intracranial pressure, headache, and emotional distress also can contribute to reduced cognitive performance and increased self-monitoring. As a result of the lack of clarity regarding the impact of PTC on cognition clinicians are left with no empirically derived practice guidelines. A case study demonstrates subjective complaints of concentration and memory deficits in a depressed patient with PTC whose neuropsychological stores (except Seashore Rhythm Test) were in the normal range.

Anxiety and depression in elderly patients receiving treatment for cerebral tumours

Little is known regarding affect and the quality of life of elderly persons with malignant brain tumours. More elderly patients are currently being diagnosed with primary malignant CNS tumours and current, aggressive treatment has extended median life expectancy. This case study indicated significant levels of clinical depression and anxiety may be experienced. Additionally, trait anxiety was found to increase with tumour progression. The patient's concern regarding loss of conjugal closeness and social inactivity was identified for the first time in persons with malignant brain tumours. Being progressively less active physically, and more isolated emotionally, this patient used her relatively good general intellectual abilities to worry about her situation. At the present time integration into the community and distress over her ability to be assertive decreased. Practical barriers to the delivery of psychological services were encountered and are likely to have been under appreciated.

Protein targeting and translocation; a comparative survey

The last few years has seen enormous progress in understanding of protein targeting and translocation across biological membranes. Many of the key molecules involved have been identified, isolated, and the corresponding genes cloned, opening up the way for detailed analysis of the structure and function of these molecular machines. It has become clear that the protein translocation machinery of the endoplasmic reticulum is very closely related to that of bacteria, and probably represents an ancient solution to the problem of how to get a protein across a membrane. One of the thylakoid translocation systems looks as if it will also be very similar, and probably represents a pathway inherited from the ancestral endosymbiont. It is interesting that, so far, there is a perfect correlation between thylakoid proteins which are present in photosynthetic prokaryotes and those which use the sec pathway in chloroplasts; conversely, OE16 and 23 which use the delta pH pathway are not found in cyanobacteria. To date, no Sec-related proteins have been found in mitochondria, although these organelles also arose as a result of endosymbiotic events. However, virtually nothing is known about the insertion of mitochondrially encoded proteins into the inner membrane. Is the inner membrane machinery which translocates cytoplasmically synthesized proteins capable of operating in reverse to export proteins from the matrix, or is there a separate system? Alternatively, do membrane proteins encoded by mitochondrial DNA insert independently of accessory proteins? Unlike nuclear-encoded proteins, proteins encoded by mtDNA are not faced with a choice of membrane and, in principle, could simply partition into the inner membrane. The ancestors of mitochondria almost certainly had a Sec system; has this been lost along with many of the proteins once encoded in the endosymbiont genome, or is there still such a system waiting to be discovered? The answer to this question may also shed light on the controversy concerning the sorting of the inter-membrane space proteins cytochrome c1 and cytochrome b2, as the conservative-sorting hypothesis would predict re-export of matrix intermediates via an ancestral (possibly Sec-type) pathway. Whereas the ER and bacterial systems clearly share homologous proteins, the protein import machineries of mitochondria and chloroplasts appear to be analogous rather than homologous. In both cases, import occurs through contact sites and there are separate translocation complexes in each membrane, however, with the exception of some of the chaperone molecules, the individual protein components do not appear to be related. Their similarities may be a case of convergent rather than divergent evolution, and may reflect what appear to be common requirements for translocation, namely unfolding, a receptor, a pore complex and refolding. There are also important differences. Translocation across the mitochondrial inner membrane is absolutely dependent upon delta psi, but no GTP requirement has been identified. In chloroplasts the reverse is the case. The roles of delta psi and GTP, respectively, remain uncertain, but it is tempting to speculate that they may play a role in regulating the import process, perhaps by controlling the assembly of a functional translocation complex. In the case of peroxisomes, much still remains to be learned. Many genes involved in peroxisome biogenesis have been identified but, in most cases, the biochemical function remains to be elucidated. In this respect, understanding of peroxisome biogenesis is at a similar stage to that of the ER 10 years ago. The coming together of genetic and biochemical approaches, as with the other organelles, should provide many of the answers.

Determinants of adherence among health department patients referred for a mammogram

This paper examines adherence to a referral for a screening mammogram among an ethnically diverse sample of 576 female county health department patients age 50 and over. Data were obtained by interview approximately one year after the referral for a screening mammogram. Overall, approximately 80% of the sample were adherent to the referral. Medical record validation of self-reports of mammography receipt verified receipt of a mammogram for 82% of those reporting one. In logistic regression analysis, determinants of adherence included: transportation barriers, fear of immigration authorities, perceived control over getting breast cancer, self-rated health status, age, and perceived quality of provider-patient communication. The most prevalent concerns about mammography were concern over finding cancer, treatment for breast cancer, and removal of a breast. Reporting of these concerns was not significantly related to adherence. Also reported are barriers to health care experienced by this population over the past 12 months. The high adherence rate found in this study emphasizes the importance of provider referral in the delivery of screening mammography, and invalidates assumptions that women of lower education and lower income are less likely to adhere to provider recommendations.

Localization and targeting of isocitrate lyases in Saccharomyces cerevisiae

Native isocitrate lyase from castor bean and a C-terminally truncated variant were expressed in Saccharomyces cerevisiae under the control of a galactose-inducible promoter. Both forms of isocitrate lyase were targeted to the yeast peroxisomes. They co-fractionated with catalase on sucrose-density-gradient centrifugation of a post-nuclear supernatant prepared from cells grown on oleic acid plus galactose, but were found in the cytosolic fractions when the cells were grown under conditions that repress peroxisome formation. The endogenous S. cerevisiae isocitrate lyase was found solely in the cytoplasmic fractions, even under growth conditions that induce peroxisome proliferation. This result shows that the presence of isocitrate lyase in peroxisomes is not essential for a functional glyoxylate cycle. Although the heterologous enzyme was transported to peroxisomes it was not enzymically active. Immunocytochemical studies provide independent evidence that the plant enzyme is imported into the matrix of yeast peroxisomes.

The effects of interview mode on smoking attitudes and behavior: self-report among female Latino adolescents

Although a substantial literature compares data on health-related behaviors collected by face-to-face and telephone interview formats, little attention has been paid to the comparability of responses regarding cigarette-smoking-related behavior, particularly among Latino youth. This study compares telephone and face-to-face interview methods for assessing smoking behaviors, attitudes, and beliefs among Latina adolescents. Data indicated no significant differences in demographic characteristics or smoking-related behaviors between the face-to-face and telephone groups. However, respondents interviewed face-to-face were significantly more likely to express dislike of smokers and state that quitting smoking was easy.

Initial and repeat mammography screening in a low income multi-ethnic population in Los Angeles

Low income, older, minority women are at high risk for underutilization of screening mammography. One strategy for increasing utilization is to conduct interventions targeting local and state health departments where a majority of these women seek health care. A prerequisite for conducting effective screening programs is to obtain current and accurate information on baseline screening rates to understand the nature and scope of the problem and to plan appropriate intervention strategies. The sample consisted of 3240 women who were 50+ years of age from 2 hospitals and 2 comprehensive health centers operated by the Los Angeles County Department of Health Services. Reviews of medical records indicated that only 21% of the sample had received a mammogram in the 12 months prior to the clinic visit on which they were sampled and 23% of the sample received a mammogram in the following 9 months. Approximately 5% of the total sample received a repeat mammogram in the 21-month period over which they were tracked. Prospective independent predictors of screening were age, number of visits to primary care clinics, number of visits to specialty care clinics, and history of breast abnormalities. The results underscore the importance of implementing programs to increase mammography implementing programs to increase mammography screening within public facilities serving low income multiethnic women. An important finding is that a large number of older women are seen in specialty clinics, which represents an untapped resource for increasing screening in this population. Innovative interventions targeting such specialty clinics could substantially contribute to increasing screening rates. A comprehensive approach targeting system, physician, and patient barriers is recommended.

The relationship between cognition and functional independence in adults with traumatic brain injury

This study investigates the relationship between cognitive impairment, as measured by Orientation Group Monitoring System (OGMS) scores, and disability as measured by Functional Independence Measure (FIM) scores in a sample of 122 persons with traumatic brain injury admitted to an inpatient rehabilitation unit. The relationships between Aggregate OGMS and FIM Total, FIM Motor, and FIM Cognitive scores were significant (rho = .49, p < .001; .40, p < .001; and .64 p < .001 respectively). Lower cognition was related to greater disability; with this relationship stronger for FIM Cognitive versus FIM Motor scores. Consistent with prior research, time to rehabilitation was significantly related to FIM Total (rho = -.42 p < .001) at admission to rehabilitation, with shorter time to rehabilitation related to greater functional independence. Stepwise regression indicated that the Aggregate OGMS score contributed 24%, and time to rehabilitation 5% unique variance to FIM Total score. These results support previous findings of distinct cognitive and motor subscales of the FIM, and suggest the importance of cognitive impairment to both.

The choline transporter is the major site of control of choline oxidation in isolated rat liver mitochondria

The degree of control exerted by the mitochondrial choline transporter over the oxidation pathway was measured in isolated rat liver mitochondria. Choline transporter activity was titrated with hemicholinium-3, a known competitive inhibitor of the transporter. It was shown that the rate of betaine efflux from mitochondria was an accurate measure of choline oxidation. The relative rate of choline oxidation was measured as a function of the relative degree of inhibition of the transporter. The resulting data gave a flux control coefficient over choline oxidation of 0.9 for the choline transporter. It is concluded that the choline transporter is the major site for control of choline oxidation in isolated rat liver mitochondria.

Effect of blood alcohol level on recovery from severe closed head injury

A retrospective archival study of 129 moderate to severe closed head-injury patients from a university-based rehabilitation hospital was conducted to investigate the effect of blood alcohol level (BAL) at time of trauma on the length of post-traumatic amnesia (PTA), length of hospitalization and cognitive status on clearing PTA. While no statistical significance was obtained for the effect of BAL on length of PTA, a mean difference of 15.4 days between 'no alcohol' and 'intoxicated' patient groups was observed. A low, but significant correlation, r = 0.249, p less than 0.05, indicated that as blood alcohol level increased, time to rehabilitation admission increased. The sex of the patient had a significant effect on length of PTA, BAL and time of recovery variable F (6,81) = 2.468, p less than 0.05. Females experienced longer length of PTA, but had lower BALs than males. Measures of cognitive status on clearing PTA did not show a statistically significant effect of BAL. Results are discussed in terms of mediating variables in the relationship between BAL and the length of acute hospitalization, prolonged PTA in patients with a positive BAL, and potential physiological bases for the interaction among sex, BAL and PTA duration.

Improving adherence to screening follow-up among women with abnormal Pap smears: results from a large clinic-based trial of three intervention strategies

In a large randomized trial involving over 2,000 women with abnormal cervical cytology (pap smear), three clinic-based interventions were tested as strategies to increase return rates for screening follow-up: 1) a personalized follow-up letter and pamphlet; 2) a slide-tape program on pap smears; and 3) transportation incentives (bus passes/parking permits). The three interventions were evaluated using a 2 x 2 x 2 factorial design. Results of this study confirm a high rate of loss to screening follow-up (i.e., no return visits) among women with abnormal pap smears (29% overall), with substantial variability among the 12 participating clinics (13% to 42/%). For the sample as a whole, both transportation incentives and the combined intervention condition of personalized follow-up and slide-tape program had a significant positive impact on screening follow-up. However, transportation incentives emerged as the dominant intervention condition among patient subgroups that can be characterized as more disadvantaged socioeconomically and at higher risk of developing cervical cancer, including patients receiving care from the county health department (odds ratio (OR) = 1.51; P less than .05); patients without health insurance (OR = 1.77; P less than .01); and patients with more severe pap smear results (OR = 1.71; P less than .05). In contrast, among patient subgroups that can be characterized as relatively more advantaged and at lower risk of developing cervical cancer, only the combined intervention condition of personalized follow-up and slide-tape program was associated with a higher patient return rate. Subgroups reflecting this pattern included patients seen in noncounty clinics (OR = 4.54; P less than .05) and patients with less severe pap smear results (OR = 5.16; P less than .01). The implications of these findings are discussed in terms of designing clinic-based interventions to improve screening follow-up.

Differential reading recovery in patients with severe to moderate closed head injury

A differential recovery was seen when alternate forms of a nationally standardized test of Reading Vocabulary, Literal Reading Comprehension and Inferential Reading Comprehension was administered serially to 10 consecutive closed head injury admissions to a university rehabilitation hospital. Inferential Reading Comprehension was the most impaired and had the fastest recovery rate. Subtle cognitive deficits in Inferential Reading Comprehension were detected when Reading Vocabulary was at or better than a twelfth grade level. Maximal recovery of all three reading functions occurred within 4 months after trauma, with most occurring in the first 3 months. The reading recovery pattern parallels the recovery of intelligence scores in the literature.

Screening for cervical cancer in emergency centers and sexually transmitted disease clinics

Low-income women are at increased risk of developing cervical cancer compared with middle- and upper-income women. How can poor women be reached for screening and early diagnosis of cervical cancer and its precursor stages? One answer to this question is based on the observation that a high percentage of the unscreened population has received some form of medical care within the previous 5 years. Emergency centers and sexually transmitted disease (STD) clinics often provide such care to patients who lack a regular source of health care. Thus, they represent potential resources for cervical cancer screening. However, in a survey of 19 hospitals whose patient populations include a high proportion of low-income patients, only five reported a protocol for cervical cancer screening in their emergency centers. Similarly, all 11 STD clinics included in this survey reported that fewer than 5% of their female patients had a Papanicolaou smear taken even though virtually all of them received a pelvic examination. Based on these findings, it appears that health care administrators and policymakers could intensify their cancer prevention programs by mobilizing these resources for cancer control.