Durvalumab Treatment Patterns for Patients with Unresectable Stage III Non-Small Cell Lung Cancer in the Veterans Health Administration (VHA): A Nationwide, Real-World Study

BACKGROUND

Durvalumab is approved for the treatment of adults with unresectable stage III non-small cell lung cancer (NSCLC) post-chemoradiotherapy (CRT). This real-world study describes patient characteristics and durvalumab treatment patterns (number of doses and therapy duration; treatment initiation delays, interruptions, discontinuations, and associated reasons) among VHA-treated patients.

METHODS

This was a retrospective cohort study of adults with unresectable stage III NSCLC receiving durvalumab at the VHA between 1 January 2017 and 30 June 2020. Patient characteristics and treatment patterns were presented descriptively.

RESULTS

A total of 935 patients were included (median age: 69 years; 95% males; 21% Blacks; 46% current smokers; 16% ECOG performance scores ≥ 2; 50% squamous histology). Durvalumab initiation was delayed in 39% of patients (n = 367). Among the 200 patients with recorded reasons, delays were mainly due to physician preference (20%) and CRT toxicity (11%). Overall, patients received a median (interquartile range) of 16 (7-24) doses of durvalumab over 9.0 (2.9-11.8) months. Treatment interruptions were experienced by 19% of patients (n = 180), with toxicity (7.8%) and social reasons (2.6%) being the most cited reasons. Early discontinuation occurred in 59% of patients (n = 551), largely due to disease progression (24.2%) and toxicity (18.2%).

CONCLUSIONS

These real-world analyses corroborate PACIFIC study results in terms of the main reasons for treatment discontinuation in a VHA population with worse prognostic factors, including older age, predominantly male sex, and poorer performance score. One of the main reasons for durvalumab initiation delays, treatment interruptions, or discontinuations was due to toxicities. Patients could benefit from improved strategies to prevent, identify, and manage CRT and durvalumab toxicities timely and effectively.

Impact of equal access by race and ethnicity on patients in the Veterans Health Administration (VHA) treated for diffuse large B-cell lymphoma (DLBCL)

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Background: Racial and ethnic disparities in access to care and outcomes are well-established and are critical issues across several malignancies, including DLBCL. Previous studies from national registry datasets have shown racial disparities in DLBCL disease characteristics, treatment and outcomes. The VHA is an equal access system providing a unique environment to investigate cancer disparities across the disease continuum. Methods: This is a retrospective chart review of 4033 randomly selected patients with an ICD code for lymphoma treated within the VHA between 01/01/2011 and 12/31/2017. Data abstractors collected baseline patient and disease characteristics and treatment responses for those with an initial diagnosis of DLBCL in that time frame. Survival time was determined via electronic health record query on 11/30/2021. Chi-square tests were used to analyze relationship between race and variables of interest. Cox proportional hazards model was used to estimate hazard ratios (HR) for race and controlling factors. Results: 2141 DLBCL patients met our inclusion criteria. 97% were male. Majority were Non-Hispanic Whites (NHW 75%) followed by Non-Hispanic Blacks (NHB 12.5%), Hispanics (H 5.7%) and others (O 6.8%). NHB were diagnosed at younger median age (63 years) when compared to the NHW, H and O (68 years). There was no statistically significant difference in stage at diagnosis, IPI score, cell of origin (COO) and hit status amongst racial subgroups. Outcomes analysis (Table) revealed similar treatment and response rates, median OS, 1- and 2- year survival across all racial subgroups. However, after adjusting for age, IPI, COO, and exposure to agent orange, and including up to 10-years of survival data, H had 36% lower risk of death (HR=0.64, 95% CI 0.44-0.93) than NHW, while NHB and O had similar outcomes to NHW. Conclusions: This large retrospective study is a continuation of our group’s work (Williams et al, 2020) that doubles the cohort size and confirms that when standard of care therapy is given with equal access to care, short-term treatment and survival outcomes are same for all races. Further studies are needed to analyze risk factors associated with differences in long term outcomes.[Table: see text]

Treatment interruptions and discontinuations among patients with stage III unresectable non–small cell lung cancer treated with durvalumab at the Veterans Health Administration

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Background: The PD-1/PD-L1 pathway is a mechanism of immune evasion and disruption of this pathway with immune checkpoint inhibitors (ICIs) has shown clinical benefit in multiple malignancies. Based on results from the PACIFIC trial, durvalumab is approved as consolidation therapy in patients (pts) with stage III unresectable non-small cell lung cancer (UR-NSCLC) without progression following concurrent chemoradiotherapy (cCRT). Durvalumab has been used extensively in Veterans Health Administration (VHA) facilities, providing an opportunity to evaluate durvalumab treatment interruptions (TI), treatment discontinuations (TD), and the reasons for these on a national scale. Methods: Patients with stage III UR-NSCLC receiving durvalumab consolidation immunotherapy at the VHA between January 1, 2017 and June 30, 2020 with a minimum follow up for 12 months were included using ICD-10, HCPCS, and J codes and followed from their durvalumab start date through the earliest of last VHA visit, loss to follow up, death, or end of study (excluded if durvalumab therapy was ongoing at the end of the study, because the full treatment course could not be determined). TI were defined as durvalumab infusions separated by >28 days. Reasons for TI and TD are presented descriptively. Durations are reported using medians and interquartile ranges (IQR). Results: 935 pts were included (median age = 69 years; 95% males; 96% current or former smokers; 70% with COPD; histologies [squamous (50%), non-squamous (43%), other/missing (7%)]; and 77% with carboplatin-paclitaxel as their platinum-based CRT). Durvalumab TI were experienced by 19% of pts (median [IQR] number of TI = 1 [1-1], median [IQR] TI duration = 53 days [39-90]). The main reasons for TI were toxicity (8%) and social reasons (3%) (Table). The median duration of treatment (DoT) with durvalumab (TI included) was 9.0 months (IQR 2.9-11.8). Durvalumab TD occurred in 59% of pts. Top reasons for discontinuation across all 935 pts included disease progression (24%) and toxicity (18%) (Table). Conclusions: In this real world analysis of national VHA data, durvalumab DoT was similar to PACIFIC despite having a patient population with worse prognostic factors (e.g. more males, squamous, COPD) with 8% of VHA pts experiencing TI and 18% TD due to toxicity. Patients could benefit from additional efforts to prevent, identify, and manage toxicities in the UR-NSCLC population [Table: see text]

Durvalumab treatment initiation delays in patients with unresectable stage III non–small cell lung cancer treated at Veterans Health Administration facilities

8556

Background: Durvalumab is an FDA-approved immunotherapy for the treatment of adults with UnResectable stage III non-small cell lung cancer (UR-NSCLC) without disease progression following concurrent chemoradiotherapy (CRT). There are limited real-world data regarding Durvalumab treatment initiation delays (TIDs) and reasons for them in the UR-NSCLC population. Methods: Patients with stage III UR-NSCLC receiving consolidation Durvalumab at the Veterans Health Administration (VHA) between January 1, 2017 and June 30, 2020 were selected from the VHA database using ICD-10, HCPCS, and J codes. All had the opportunity to be treated for 12 months and were followed from Durvalumab initiation through the earliest of their last VHA visit, loss to follow up, death, or the study’s end (and excluded if Durvalumab therapy was ongoing at the study’s end). Trained data abstractors determined the occurrence and reasons for TIDs (> 6 weeks from end of CRT to initiation of Durvalumab as in the PACIFIC trial) by chart review. Results: 935 patients were eligible for analysis (median age = 69 years; 95% males; 16% with ECOG performance status >1). TIDs occurred in 39% of the patients (Table). Durvalumab was initiated 61 days (median) from the end of CRT in TID patients vs. 31 days for those without TIDs. There were no significant (α<0.05) differences in age, race, smoking status, histology, or ECOG performance status and no comorbidity differences (except in patients with a history of cerebrovascular accident, for whom TIDs were more likely) between the TID/No-TID patients. Patients without timely post-CRT scans were more likely to have a TID. Of the 367 patients who experienced TIDs, 200 had documented reasons for the delay, consisting of other (not categorized) (28.5%), physician preference (20%), toxicity (11%), patient preference (10.5%), decline in performance status (10%), system issues (9.5%), social reasons (9%), and progression (0.5%). Conclusions: This is one of the largest retrospective cohort studies reporting real-world data in patients with UR-NSCLC receiving Durvalumab. TIDs were associated with increased time to post-CRT scans. This potential issue can be improved with care coordination and involvement of cancer navigators. Additional studies are needed to assess the impact of TIDs on survival outcomes.[Table: see text]

Clinicopathologic differences and mortality among Latinos and non-Latino whites with gastric cancer at a majority-minority cancer center in South Texas

BACKGROUND

Latino patients have a higher incidence of gastric cancer compared to non-Latino white patients nationwide, with greater disparities in South Texas. However, the impact of Latino ethnicity on mortality in gastric cancer is controversial. We evaluated clinicopathological characteristics and survival outcomes in Latino vs. non-Latino white patients at our National Cancer Institute (NCI)-designated cancer center and its affiliated hospital.

METHODS

We conducted a retrospective chart review of Latino and non-Latino white patients diagnosed with gastric cancer who were seen at Mays Cancer Center at the University of Texas Health in San Antonio, Texas, from 2000-2018. Median overall survival (mOS) was estimated from Kaplan-Meier curves and groups were compared with the log-rank test.

RESULTS

A total of 193 patients met inclusion criteria and 65% (n=126) were Latino. Median age for all patients was 61 years. Female patients represented almost 50% of Latinos vs. 36% of non-Latino whites. There were no differences in Eastern Cooperative Oncology Group (ECOG) performance status, primary tumor location, stage, Helicobacter pylori status, HER2 status, or histologic subtype at diagnosis. Median overall survival was 14 months (95% CI: 13-36) for Latinos vs. 33 months (95% CI: 14 to n/a) for non-Latino whites (P=0.36).

CONCLUSIONS

Compared to non-Latino white patients, Latino patients with gastric cancer at a majority-minority cancer center in South Texas did not have significant differences in baseline clinicopathologic features or survival outcomes. Further prospective studies are needed to evaluate epidemiologic, pathogenetic, and molecular differences in gastric cancer in order to identify variables associated with treatment efficacy and survival.

Double disparities in patients with gastric cancer: Clinicopathology and survival of older adults in a Hispanic-rich population

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Background: Gastric cancer incidence increases with advancing age with a median age at diagnosis of 68. However, older adults (age ≥65) are underrepresented in clinical trials. Additionally, Hispanic populations have a higher incidence of gastric cancer compared with non-Hispanic patients and there is evidence that this population has worse outcomes. Given this double disparity in older Hispanic adults, we evaluated the differences in disease characteristics at diagnosis and survival outcomes in older adults compared to younger adults with gastric cancer at our South Texas cancer center serving a predominantly Hispanic population. Methods: We performed a retrospective analysis of patients with a diagnosis of gastric cancer from 2000 – 2018, who had follow-up at Mays Cancer Center, San Antonio, TX. Older patients were defined as ≥65 years and younger patients were defined as <65 years. Median overall survival (mOS) was estimated from Kaplan-Meier curves and groups were compared using the log-rank test. Results: A total of 190 patients met criteria for analysis. Patients were predominantly younger (age <65), with 128 (67.4%) young and 62 (32.6%) older. Most patients were Hispanic (66.4% of younger and 64.5% of older) and male (51.6% of younger and 66.1% of older). The majority of patients had an ECOG performance status of 0-2, including 61.7% and 64.5% (p = 0.55) of younger and older patients, respectively. At baseline, there was no significant difference in location of primary tumor, grade, stage at diagnosis, or histologic classification between younger and older patients (Table). There was also no significant difference between the two groups in H. pylori status, location of metastases, or HER2 status. Of the 109 patients with follow-up for survival, the mOS was 17 months (95% CI: 15-55) for younger patients versus 14 months (95% CI: 13-NR) for older patients (p = 0.19). Conclusions: In this retrospective analysis of predominantly Hispanic patients with gastric cancer, we found that there were no statistically significant differences in clinicopathologic features at diagnosis or in survival between younger versus older adults. Our study was approximately 2/3 Hispanic, a population for which there is a paucity of data, especially in older adults. Given the limited published research available to guide the management of older patients with gastric cancer, including Hispanics, further prospective real-world studies are needed to evaluate toxicity and quality of life in order to improve the care of older adults with gastric cancer. [Table: see text]

Testicular cancer in Hispanics: Are we approaching ethnic parity?

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Background: Hispanics (HI) are the fastest growing ethnic group in the US, representing 52% of US population growth from 2010-2018. In the past decade, they have also experienced a rise in incidence of testicular cancer. Studies have shown that HI have a higher incidence of Non-Seminomatous Germ Cell Tumors (NSGCT), present at an earlier age, have advanced stage at diagnosis, and worse outcomes (including increased mortality) when compared to Non-Hispanics (NH). However, there is a paucity of data and a growing need to better characterize this patient population. To our knowledge, this is the largest cohort of testicular cancer patients from a single academic institution that serves primarily HI. Methods: We retrospectively reviewed 243 patients with Testicular Cancer, both Seminoma and NSGCT; all diagnosed between 2010-2018. Key variables included age, race/ethnicity, comorbidities, insurance status, diagnosis, stage, treatment received/response and vitality status in 2018. Continuously distributed outcomes were summarized with mean/standard deviation; categorical outcomes with frequencies/percentages. Significance of associations between categorical outcomes was assessed with Chi Square test of association. Results: We identified 243 patients with testicular cancer, 168 (69%) HI and 75 (31%) NH. See Table. Median duration of follow up was 18.7 months (SD 27.3). When comparing HI vs NH: 65% vs 64% achieved complete response after primary treatment (p value 0.982); 16% vs 23% had a disease relapse (p value 0.184); and 82 vs 90% were alive at end of 2018 (p value 0.257). Conclusions: Our study supports available data that HI present at an earlier age. However, we found no significant difference in insurance status, histology, stage at diagnosis and outcomes in HI compared to NH. HI predominance in our population could explain the lack of difference observed but further studies are needed. Research Sponsor: None.[Table: see text]

Systemic sclerosis associated pulmonary hypertension: improved survival in the current era

OBJECTIVES

To measure survival, haemodynamic function and functional class in patients with systemic sclerosis associated pulmonary arterial hypertension (SSc-PAH) in two treatment eras.

METHODS

Six year longitudinal study of 92 consecutive patients with SSc-PAH diagnosed by cardiac catheterisation. Data were collected both prospectively and retrospectively. Patients were given basic treatment (diuretics, digoxin, oxygen and warfarin). Where clinically indicated, a prostanoid was used as advanced treatment (historical control group). From 2002, the range of treatments available expanded to include bosentan, which was generally the preferred treatment (current treatment era group). Survival was measured from the date of diagnosis of pulmonary hypertension by cardiac catheterisation. Six minute walking distance and haemodynamic function were measured at the time of diagnosis and at least one month after treatment was started.

RESULTS

The historical control group comprised 47 patients, all of whom received basic treatment; 27 of these were also treated with prostanoids. The current treatment era group comprised 45 patients, all of whom received bosentan as preferred treatment. Kaplan-Meier survival in the historical control group was 68% at one year and 47% at two years. Survival in the current treatment era group was 81% and 71% (p = 0.016) at one and two years, respectively. Pulmonary vascular resistance increased in the historical control group (by 147 dyn.s.cm(-5)), whereas in the current treatment era group, it remained stable over an average of nine months (decrease of 16 dyn x s x cm(-5), p < 0.006).

CONCLUSION

Survival of selected patients with SSc-PAH has improved in the current treatment era. In contrast to patients treated historically with basic drugs and prostanoids, patients treated in the current treatment era had improved survival associated with a lack of deterioration in cardiac haemodynamic function.

The spectrum of IgG GQ1(b) syndrome: an unusual cluster

Four patients with IgG GQ1(b)antibodies were admitted to the Gold Coast Hospital, a public hospital providing medical service to a population of approximately 400,000, over a 4-month period. This represents an unusual cluster of this syndrome, for which there is no apparent reason. Further, the four cases demonstrate the broad spectrum of the disorder from the benign ophthalmoplegia, ataxia and areflexia, Miller Fisher Syndrome, to the severe form with encephalitis (Bickerstaff's brainstem encephalitis).

Developing a regional healthcare information network

The Internet and associated technology is transforming the dissemination of healthcare information. As this occurs, means must be developed to manage and coordinate it effectively. One approach is through community healthcare information networks (CHINs), which benefit both information providers and consumers. This paper reports on a regional CHIN operational in Scotland.

Co-operative health information networks in Europe: experiences from Greece and Scotland

BACKGROUND

Internet technology is transforming the general approach to communication and dissemination of information in the field of healthcare. However, it is also creating problems in terms of finding information, and knowing what credibility to place on the information found. The chaotic nature of the World Wide Web (WWW) and the simplistic approach adopted by search engines can make the task of finding relevant information difficult, and the user can waste considerable amounts of time on the process. Even when information is found, there is no general quality assurance process that can guarantee the credibility of the resulting information.

OBJECTIVE

The aim of this research was to develop an approach for establishing co-operative health information networks (CHINs) with different focuses, which can be used in different parts of Europe. The resulting CHINs would provide organised healthcare information and support comprehensive and integrated sets of healthcare telematic services for a broad range of users. Such developments would reduce the difficulties of finding information and knowing what credibility to ascribe to it.

METHODS

A common approach has been developed based on drawing together contributions from the major healthcare service providers in the region. Standard structures are recommended so that information is presented in a uniform way. Appropriate mechanisms ensure adequate security and a level of quality assurance for the end user.

RESULTS

Since 1996, CHINs have been developed in six European countries as part of a European Union (EU) project. This paper presents the overall approach adopted, and the achievements in two different regions of Europe (Greece and Scotland). Although the circumstances in these two regions are very different, in both cases the resulting CHIN has proved successful.

CONCLUSIONS

CHINs offer a solution to the difficulty of finding relevant health information on the Internet and guaranteeing its credibility. They can be used in different ways in different regions, and have major benefits for both information providers and end users.

Developing a health care information system for Scotland

The rapid development and uptake of Internet technology has created opportunities for large-scale information networks to replace paper-based information sources. In order to obtain the maximum benefits for patients and medical practitioners it is important that health care providers work together to produce an integrated information service. However, the task of bringing together a large number of different information providers to create a huge structured pool of information covering a wide range of topics with appropriate quality assurance is non-trivial. This paper describes an approach being used to create healthcare information systems in a set of co-operative healthcare information networks in Europe, and specifically in Scotland.

A secure Web-based interface to maternity records with decision support

The recent developments in Web technology now make it easy to create user-friendly interfaces to databases and link them to the Internet or to local Intranets. With the acceptance of this new approach one can take advantage of the opportunity to use this development to incorporate additional knowledge into the interface. Not only can this provide a more supportive interface, but it can also create the opportunity for sharing and comparing such knowledge in the future. This paper describes how this has been used to develop an interface to a database of maternity case records which incorporates a knowledge base of rules relating to care plan protocols and uses this to provide decision support to the carer. The issue of security is a serious problem and some aspects of the measures taken are discussed.

American College of Sports Medicine roundtable. The physiological and health effects of oral creatine supplementation

Creatine (Cr) supplementation has become a common practice among professional, elite, collegiate, amateur, and recreational athletes with the expectation of enhancing exercise performance. Research indicates that Cr supplementation can increase muscle phosphocreatine (PCr) content, but not in all individuals. A high dose of 20 g x d(-1) that is common to many research studies is not necessary, as 3 g x d(-1) will achieve the same increase in PCr given time. Coincident ingestion of carbohydrate with Cr may increase muscle uptake; however, the procedure requires a large amount of carbohydrate. Exercise performance involving short periods of extremely powerful activity can be enhanced, especially during repeated bouts of activity. This is in keeping with the theoretical importance of an elevated PCr content in skeletal muscle. Cr supplementation does not increase maximal isometric strength, the rate of maximal force production, nor aerobic exercise performance. Most of the evidence has been obtained from healthy young adult male subjects with mixed athletic ability and training status. Less research information is available related to the alterations due to age and gender. Cr supplementation leads to weight gain within the first few days, likely due to water retention related to Cr uptake in the muscle. Cr supplementation is associated with an enhanced accrual of strength in strength-training programs, a response not independent from the initial weight gain, but may be related to a greater volume and intensity of training that can be achieved. There is no definitive evidence that Cr supplementation causes gastrointestinal, renal, and/or muscle cramping complications. The potential acute effects of high-dose Cr supplementation on body fluid balance has not been fully investigated, and ingestion of Cr before or during exercise is not recommended. There is evidence that medical use of Cr supplementation is warranted in certain patients (e.g.. neuromuscular disease); future research may establish its potential usefulness in other medical applications. Although Cr supplementation exhibits small but significant physiological and performance changes, the increases in performance are realized during very specific exercise conditions. This suggests that the apparent high expectations for performance enhancement, evident by the extensive use of Cr supplementation, are inordinate.

Facts and fallacies of purported ergogenic amino acid supplements

Although current research suggests that individuals involved in either high-intensity resistance or endurance exercise may have an increased need for dietary protein, the available research is either equivocal or negative relative to the ergogenic effects of supplementation with individual amino acids. Although some research suggests that the induction of hyperaminoacidemia via intravenous infusion of a balanced amino acid mixture may induce an increased muscle protein synthesis after exercise, no data support the finding that oral supplementation with amino acids, in contrast to dietary protein, as the source of amino acids is more effective. Some well-controlled studies suggest that aspartate salt supplementation may enhance endurance performance, but other studies do not, meriting additional research. Current data, including results for several well-controlled studies, indicated that supplementation with arginine, ornithine, or lysine, either separately or in combination, does not enhance the effect of exercise stimulation on either hGH or various measures of muscular strength or power in experienced weightlifters. Plasma levels of BCAA and tryptophan may play important roles in the cause of central fatigue during exercise, but the effects of BCAA or tryptophan supplementation do not seem to be effective ergogenics for endurance exercise performance, particularly when compared with carbohydrate supplementation, a more natural choice. Although glutamine supplementation may increase plasma glutamine levels, its effect on enhancement of the immune system and prevention of adverse effects of the overtraining syndrome are equivocal. Glycine, a precursor for creatine, does not seem to possess the ergogenic potential of creatine supplementation. Research with metabolic by-products of amino acid metabolism is in its infancy, and current research findings are equivocal relative to ergogenic applications. In general, physically active individuals are advised to obtain necessary amino acids through consumption of natural, high-quality protein foods.

Creatine supplementation and exercise performance: an update

Creatine, a natural nutrient found in animal foods, is alleged to be an effective nutritional ergogenic aid to enhance sport or exercise performance. Research suggests that oral creatine monohydrate supplementation may increase total muscle creatine [TCr], including both free creatine [FCr] and phosphocreatine [PCr]. Some, but not all, studies suggest that creatine supplementation may enhance performance in high-intensity, short-term exercise tasks that are dependent primarily on PCr (i.e., < 30 seconds), particularly laboratory tests involving repeated exercise bouts with limited recovery time between repetitions; additional corroborative research is needed regarding its ergogenic potential in actual field exercise performance tasks dependent on PCr. Creatine supplementation has not consistently been shown to enhance performance in exercise tasks dependent on anaerobic glycolysis, but additional laboratory and field research is merited. Additionally, creatine supplementation has not been shown to enhance performance in exercise tasks dependent on aerobic glycolysis, but additional research is warranted, particularly on the effect of chronic supplementation as an aid to training for improvement in competitive performance. Short-term creatine supplementation appears to increase body mass in males, although the initial increase is most likely water. Chronic creatine supplementation, in conjunction with physical training involving resistance exercise, may increase lean body mass. However, confirmatory research data are needed. Creatine supplementation up to 8 weeks has not been associated with major health risks, but the safety of more prolonged creatine supplementation has not been established. Creatine is currently legal and its use by athletes is not construed as doping.

Changes in public psychiatric hospitalization in Oregon over the past two decades

OBJECTIVE

In 1988 a governor's commission in Oregon recommended dramatic changes in the state's approach to public psychiatric hospitalization. To evaluate the effect of the recommendations, this study examined characteristics of hospitalization for patients with schizophrenia and bipolar disorder in public psychiatric facilities between 1981 and 1984 and between 1991 and 1994.

METHODS

Patients with schizophrenia and bipolar disorder (N=621) were identified as part of a larger study that examined civil commitment in one of Oregon's state hospitals in 1986. Data on the patients' hospitalizations were obtained from a statewide computerized mental health information system.

RESULTS

The legal status of hospitalized patients differed between the two time periods, with voluntary hospitalizations overrepresented in 1981-1984 and civil commitments overrepresented in 1991-1994. The locus of hospitalization varied greatly between the two time periods. All hospitalizations in 1981-1984 took place in one of Oregon's three state hospitals. In 1991-1994, subjects were hospitalized in 13 different institutions, including state and community hospitals and specially designed nonhospital inpatient facilities.

CONCLUSIONS

Patterns of inpatient hospitalization for public psychiatric patients changed dramatically from 1981-1984 to 1991-1994. The extensive use of community and nonhospital facilities raises questions about monitoring of quality of care in these diverse and decentralized facilities.

Treatment refusal procedures and service utilization: a comparison of involuntarily hospitalized populations

This article examines treatment refusal in a large group of hospitalized civilly committed patients. Comparison is made between those subjects whose refusal was reviewed by Oregon's administrative procedures for treatment refusal (override group) and those committed patients who more readily accepted treatment and were not evaluated by this procedure. The objective was to examine the override process and to explore potential differences between these groups in their utilization of hospital and community mental health services before and after the index hospitalization. We reviewed hospital charts on all subjects who went through the administrative override procedure and collected state hospital and community mental health services information from the statewide computerized information system on all subjects in the study. Several key differences were found between the groups. The override sample had significantly more women, and these patients spent significantly more time in the index hospitalization and had had more past hospitalizations. There were no differences between the groups in their utilization of community services before or after the index hospitalization and no difference in hospitalization rates after the index hospitalization. The conclusion is that the Oregon override procedure is functioning consistently, without undue delay in decision making. More investigation is necessary to determine whether override subjects represent a distinct subpopulation within the larger group of chronically mentally ill patients.

The effect of oral creatine monohydrate supplementation on running velocity

Creatine supplementation has been shown to augment muscle PCr content and increase the rate of ATP resynthesis. Thus, we hypothesized that creatine supplementation might enhance sprinting performance. Eighteen subjects completed both of two testing sessions (control and postsupplement) 1 week apart, wherein they sprinted three 60-m distance trials that were recorded with videotape. Following the control session, for 7 days, subjects in the treatment group ingested a creatine-glucose mixture, while the placebo group consumed a glucose powder, followed by the postsupplementation session. Velocities of the subjects through three testing zones within the 60-m sprint were calculated from the videotape. Resultant velocities were analyzed using a MANOVA with a 2 x 2 x 3 x 3 (Group x Session x Trial x Zone) design. Results indicated that there were no statistically significant main or interaction effects on velocity between groups for session, trial, or zone. These data do not support the hypothesis that supplementary creatine ingestion will enhance velocity during the early or latter segments of a 60-m sprint.

Effect of Eleutherococcus senticosus on submaximal and maximal exercise performance

We investigated the effect of Eleutherococcus senticosus Maxim L (ESML) on performance during submaximal and maximal aerobic exercise. Twenty highly trained distance runners randomly assigned in matched pairs to either an experimental (ESML) or placebo (PL) group, participated in an 8-wk double-blind study during which they completed five trails of a 10-min treadmill run at their 10 km (10K) race pace and a maximal treadmill test (T(max)). Following a baseline trail, ESML and PL consumed, respectively, 3.4 ml of ESML extract or placebo daily for 6 wk. Subjects were tested every 2 wk during supplementation and 2 wk following withdrawal. Heart rate (HR), oxygen consumption (VO2), expired minute volume (VE), ventilatory equivalent for oxygen (VE/VO2), respiratory exchange ratio (RER), and rating of perceived exertion (RPE) were measured during the 10K and T(max) tests. Resting, post-10K and post-T(max) blood samples were analyzed for serum lactate. No significant differences were observed between ESML and PL for: HR, VO2, VE, VE/VO2, RER, or RPE; T(max) time to exhaustion; or serum lactate. The data do not support an ergogenic effect of ESML supplementation on selected metabolic, performance, or psychologic parameters associated with submaximal and maximal aerobic exercise tasks.

Trusses in the management of hernia today

In the UK an estimated 40,000 trusses are issued annually. The rate of 700 per million is higher than that presently found in other countries and may be because of reduced access to surgery. Despite the high use of trusses little has been published on their effectiveness, complication rates and value. This review summarizes current knowledge, and concludes that further studies on the benefits and effectiveness of trusses need to be performed to enable patients to receive appropriate advice and guidance.

Quality of life measurement in patients with oesophageal cancer

Quality of life (QOL) measurement may aid decision making in the treatment of patients with oesophageal cancer but must be clinically valid to be useful. This study considered if the European Organisation for Research and Treatment of Cancer QOL questionnaire, the QLQ-C30, showed differing results in two clinically distinct groups of patients with oesophageal cancer and also investigated the correlation between dysphagia grade and various scales of QOL. Patients treated by oesophagectomy reported significantly better physical, emotional, cognitive, and global health scores than those in the palliative treatment group. Patients who received palliative treatment had significantly worse pain, fatigue, appetite loss, constipation, and dysphagia. The correlations between dysphagia grade and each of the QOL scales and items in both groups of patients were poor. This questionnaire differentiates clearly between the two clinically distinct groups of patients, but to be an entirely appropriate indicator of QOL in patients with oesophageal cancer, an additional specific oesophageal module including a dysphagia scale is required.

Observer variation in assessment of quality of life in patients with oesophageal cancer

Quality of life (QOL) assessment may improve the evaluation of treatment for oesophageal cancer but patient compliance using self completion questionnaires is often poor. The use of a proxy to estimate QOL might improve data collection from patients who are either unable or unwilling to complete the questionnaire. This study examined whether a doctor or patients' carers could accurately assess QOL using the QLQ-C30 questionnaire developed by the European Organisation for Research and Treatment of Cancer Study Group on Quality of Life. One doctor, 52 patients and 39 carers completed the instrument independently. Proxy and patient ratings were analysed for agreement using weighted kappa scores. Agreement was poor or moderate in most QOL scales and items (kappa < or = 60). This study demonstrates that a carer or doctor is not sufficiently accurate to postulate the patient's responses to the questionnaire. Quality of life data, therefore, should come from the patients themselves.

Antioxidants, carnitine, and choline as putative ergogenic aids

Three nutritional products that have very different mechanisms of action are antioxidant vitamins, carnitine, and choline. Antioxidant vitamins do not appear to have a direct effect on physical performance in well-fed people but have been touted for their ability to detoxify potentially damaging free radicals produced during exercise. Carnitine purportedly enhances lipid oxidation, increases VO2max, and decreases plasma lactate accumulation during exercise. However, studies of carnitine do not generally support its use for ergogenic purposes. Choline supplements have been advocated as a means of preventing the decline in acetylcholine production purported to occur during exercise; this decline may reduce the transmission of contraction-generating impulses across the skeletal muscle, an effect that could impair one's ability to perform muscular work. However, there are no definitive studies in humans that justify choline supplementation. Much of the scientific data regarding the aforementioned nutrients are equivocal and contradictory. Their potential efficacy for improving physical performance remains largely theoretical.

Nutritional ergogenics in athletics

Nutritional ergogenic aids may be theorized to improve performance in athletics in a variety of ways, primarily by enhancing energy efficiency, energy control or energy production. Athletes have utilized almost every nutrient possible, ranging from amino acids to zinc, as well as numerous purported nutritional substances, such as ginseng, in attempts to enhance physical performance. This review focuses primarily on nutritional ergogenic aids thought to enhance performance by favourably affecting energy metabolism. Although most purported nutritional ergogenic aids have not been shown to enhance physical performance in well-trained, well-nourished athletes, some reliable scientific data support an ergogenic efficacy of several substances, including caffeine, creatine and sodium bicarbonate, but additional research is needed to evaluate their potential for enhancing performance in specific athletics events.

How useful are clinical reports concerning the consequences of therapist-patient sex?

The harmfulness and prevalence of sex between therapist and patient are difficult to research. One reason for this is the difficult of establishing a rate of harm; general population trends cannot be established within reasonable limits. A second problem involves determining the cause of observed harm. Therapists who treat patients who have had sex with a therapist may incorrectly conclude that symptoms resulted from that inappropriate relationship, while another therapist might attribute them to childhood sexual abuse or other causes. Patients with borderline or histrionic personality disorder may be at greatest risk of therapist-patient sex. Outrage at these violations of professional ethics must be separated from assessment of symptoms. Important questions are: (1) did lasting harm result? and (2) if harm resulted, how much did the sex contribute to it? Outrage should not alter the standards of validity adopted by authors of clinical reports.

Death and thromboembolic disease after total hip replacement. A series of 1162 cases with no routine chemical prophylaxis

We studied 1162 consecutive total hip replacements (THR) to establish the incidence of fatal pulmonary embolism (PE), clinical non-fatal PE and deep-vein thrombosis (DVT) in the six months after surgery. Chemical thromboprophylaxis had not been routinely used. We used a validated questionnaire supplemented by post-mortem records and a review of the clinical notes. Follow-up was 100%. The death rate from PE was 0.34% (95% CI 0.09 to 0.88), with one fatal PE after discharge 40 days after operation. The clinical PE rate confirmed by imaging was 1.20% (CI 0.65 to 2.02), with 0.7% of patients readmitted. The venographically-confirmed clinical DVT rate was 1.89% (CI 1.11 to 2.76), with 1.13% readmitted. The total thromboembolic morbidity was 3.4% (95% CI 2.5% to 4.7%); prophylaxis to reduce this would be justifiable if the complications of such prophylaxis did not produce an alternative morbidity. The fatal PE rate after THR without routine chemical prophylaxis was low; a very large randomised clinical trial would be required to demonstrate directly whether any prophylactic measure could reduce this. There is a large discrepancy between the high DVT rate reported in clinical trials using universal screening venography and the symptomatic DVT rate shown in this study. We found insufficient evidence to recommend continuing thromboprophylaxis after discharge from hospital.

The use of nutritional ergogenic aids in sports: is it an ethical issue?

As nutritional technology advanced, scientists have been able to synthesize and manufacture all known nutrients, and many of their metabolic by-products, essential to human physiology. Many of these substances are theorized to possess ergogenic potential when taken in quantities or forms normally not found in typical foods or diets. Research, although limited in most cases, supports the ergogenicity of some nutrients (e.g., creatine) when consumed in substantial amounts, suggesting such nutrients may function as drugs or nutraceuticals. The International Olympic Committee (IOC) doping legislation stipulates that any physiologic substance taken in abnormal quantity with the intention of artificially and unfairly increasing performance should be construed as doping, violating the ethics of sport performance. Given this stipulation, the IOC and other athletic-governing organizations should consider the legality and ethics underlying the use of ergogenic nutraceuticals in sport.

Making heterogeneous medical databases interoperable

The increasing use of computer systems for storing patient information in different hospitals, in different departments within the same hospital, in clinics and even in doctors' surgeries, is creating a problem in terms of the fragmentation of the patient record. The lack of any coordination or standardization in the way in which data are represented and stored in these different systems makes the task of finding and retrieving data that much more difficult. This paper considers two aspects of this problem and describes an architecture which can be used to overcome them.

Oregon's civil commitment law: 140 years of change

Legislatures, professional groups, and mental health consumers across the United States are currently engaged in a debate about the need for change in civil commitment procedures. The authors summarize modifications of legislation and judicial opinion in the history of Oregon's civil commitment procedures from 1853 to the present to show that changes in civil commitment reflect broader shifts in the social and political aspects of the mental health system. Many current issues in civil commitment, such as the question of a patient's competency to make treatment decisions, are not new, and they are likely to continue to be controversial as mental health systems attempt to balance concerns about the liberty interests of mentally ill persons with concerns about providing appropriate treatment for mental illness.

Prevalence of total hip replacement: how much demand has been met?

OBJECTIVE

To determine the prevalence of completed elective total hip replacements in a defined elderly population.

DESIGN

Cross sectional postal questionnaire survey with additional data and validation from general practice and hospital records.

SETTING

Six general practices in the English counties of Avon, Somerset, and Oxfordshire.

SUBJECTS

A total of 7806 patients aged 65 years and over (94.7% response).

RESULTS

The overall prevalence (95% confidence intervals) of elective total hip replacement was 5.3 (4.8,5.8)% Age and sex specific prevalences were 2.7 (2.0,3.5)% in men and 4.1 (3.3,4.9)% in women aged 65-74 years, and 5.2 (4.0,6.5)% in men and 8.8 (7.6,10.0)% in women aged 75 years and over. Of the 415 patients who had received elective total hip replacement, 28.2% had required bilateral surgery, 20% had received at least one operation privately, and 13% had required revision surgery.

CONCLUSION

Our results show an increased level of satisfied demand for total hip replacement in elderly people compared with earlier estimates. The increasing prevalence of hip replacement is an indicator of increasing potential demand for revision procedures. Population based surveys are required to establish the level of unmet demand for primary procedures. Differences in past surgical activity may be important in interpreting the wide variation in current surgical rates.

Effect of postharvest heat treatments on fruit quality, surface structure, and fungal disease in Valencia oranges

The effect of prestorage heat treatments on the quality of Valencia oranges and on postharvest disease was investigated during a 6-week storage trial. Fruit receiving a hot water immersion regime (45�C core temperature for 42 min) designed to disinfest against Queensland fruit fly lost significantly less moisture and remained firmer during storage than unheated control fruit. Disinfestation treatment also significantly reduced fruit acidity and number of viable spores of Colletotrichum gloeosporioides, Penicillium digitatum, and P. italicum. The gradual heating process involved with disinfestation was more successful in maintaining fruit quality than surface sterilisation by hot water immersion (12 min at 53�C), or conditioning in air (24 h at 30�C and 90% relative humidity). Heat-treated fruit showed enhanced colour development. Light and electron microscopy studies showed that heating had little effect on the structure of surface waxes; however, collapsed oil glands were observed after cool storage. Prestorage heat treatments could be a favourable alternative to chemicals for control of pests.

Evidence of unmet need in the care of severely physically disabled adults

OBJECTIVE

To identify unmet needs in the care of severely disabled people aged 16-64.

DESIGN

Detailed personal interview and physical assessment of physically disabled adults; personal or telephone interview with carers.

SETTING

Somerset Health District.

SUBJECTS

181 severely disabled adults and their carers.

MAIN OUTCOME MEASURES

Independence in activities of daily living; identity of requirements for assessing communication disorders; appropriate provision of services and allowances.

RESULTS

53 (29.3%) of the 181 disabled subjects had unmet needs for aids to allow independence in activities of daily living-namely, 43% of subjects (41/95) with progressive disorders and 14% of subjects (12/86) with non-progressive disorders. The prevalence of unmet need was higher among subjects whose sole regular professional contact was with health services personnel (48 (40.3%) of 119 subjects). Only 18 (31.6%) of the 57 subjects with communication disorders had ever been assessed by a speech therapist.

CONCLUSIONS

This study shows that the needs of severely physically disabled adults in the community--especially those with progressive disorders--are being monitored inadequately by health professionals.

Ergogenic and ergolytic substances

Genetic endowment and proper training are the major factors contributing to athletic success in endurance and ultraendurance events. Proper nutrition, primarily adequate carbohydrate and fluid, prior to and during the event is also critical. Endurance athletes often utilize other nutritional substances or practices, often referred to as ergogenics, in attempts to obtain a competitive edge by enhancing energy utilization and delaying the onset of fatigue. Numerous nutritional ergogenics have been used in attempts to enhance endurance performance, but with several exceptions most have been shown to be ineffective, including bee pollen, L-carnitine, CoQ10, inosine, amino acids, alkaline salts, and vitamin E at sea level. Research findings are equivocal relative to the ergogenicity of caffeine, phosphate salts, and vitamin E at altitude. Loss of excess body fat, a nutritional practice, may be an effective ergogenic. Conversely, some agents such as alcohol may impair performance, an ergolytic effect. Additional research is necessary to support the efficacy of several nutritional ergogenics to enhance prolonged endurance performance, such as caffeine, phosphates, specific amino acids, and various commercial products. Such research should involve exercise tasks comparable in intensity and duration to that experienced in the marathon and similar endurance events.

The involvement of schizophrenic insanity acquittees in the mental health and criminal justice systems

This article described the mental health and criminal justice involvement of a large group of schizophrenic insanity acquittees and the program designed to manage and treat these individuals. Most insanity acquittees in our system are chronically mentally ill individuals who fit well into the psychosocial rehabilitation models that have developed over the past 15 years. In addition, the use of conditional release and monitored care in the community appears to be the most realistic approach to this group of individuals who show a high degree of involvement with the mental health and criminal justice service systems. This research has continued implications for the development of outpatient civil commitment and for the attempt to give people as much liberty as they are capable of handling while being realistic about their capacities to survive in the community.

Exploitation and inference. Mapping the damage from therapist-patient sexual involvement

A growing body of evidence documents a clinical pattern of harmful effects of therapist-patient sexual involvement. In addition, surveys suggest that 1 to 12% of all therapists may have engaged in this behavior at least once in their careers. In order to develop a more comprehensive research agenda, several of these studies are reviewed in terms of inferences that may or may not be drawn. Case studies and surveys may provide for inference of clinical harm and syndrome, but they are limited in terms of generalizations about incidence in the overall population. A population approach coupled with case sampling may provide a useful tool by which to approximate a minimum level of incidence and of effects.