Breast cancer risk in elderly women with systemic autoimmune rheumatic diseases: a population-based case-control study

Systemic autoimmune rheumatic diseases (SARDs) are chronic inflammatory and immuno-modulatory conditions that have been suggested to affect cancer risk. Using the Surveillance, Epidemiology and End Results–Medicare-linked database, women aged 67–99 years and diagnosed with incident breast cancer in 1993–2002 (n=84 778) were compared with an equal number of age-matched cancer-free female controls. Diagnoses of SARDs, including rheumatoid arthritis (RA, n=5238), systemic lupus erythematosus (SLE, n=340), Sjogren's syndrome (n=374), systemic sclerosis (n=128), and dermatomyositis (n=31), were determined from claim files for individuals from age 65 years to 1 year before selection. Associations of SARD diagnoses with breast cancer, overall and by oestrogen receptor (ER) expression, were assessed using odds ratio (OR) estimates from multivariable logistic regression models. The women diagnosed with RA were less likely to develop breast cancer (OR=0.87, 95% confidence interval (CI)=0.82–0.93). The risk reduction did not differ by tumour ER-status (OR=0.83, 95% CI=0.78–0.89 for ER-positive vs OR=0.91, 95% CI=0.81–1.04 for ER-negative, P for heterogeneity=0.14). The breast cancer risk was not associated with any of the other SARDs, except for a risk reduction of ER-negative cases (OR=0.49, 95% CI=0.26–0.93) among women with SLE. These findings suggest that systemic inflammation may affect breast epithelial neoplasia.

Clinical significance of pleural lavage cytology in non-small cell lung cancer: A meta-analysis

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Background: The clinical significance of pleural lavage cytology (PLC) in non-small-cell lung cancer (NSCLC) remains controversial. This study was performed to estimate the associations of positive PLC with the main clinicopathological characteristics, and its prognostic value. Methods: PLC studies were identified on Medline, supplemented by manual search of bibliographies and proceedings. Authors were contacted for updated information. The quality of the studies was evaluated, and the data were extracted. Pooled odds ratios (ORs) and pooled hazard ratios (HRs) with confidence intervals [95% CIs] were calculated to evaluate the association of positive PLC with clinico-pathological characteristics and survival respectively. Results: Nineteen articles assessing PLC in NSCLC were selected for this study after exclusion of repeated publications or reports with little clinical detail. Positive PLC was diagnosed in 10.2% (516) of a total of 5073 patients. Positive PLC was strongly associated with lymphatic permeation (OR 4.96 [3.29, 7.54]), pleural invasion (OR 4.38 [2.16, 8.89], and vascular involvement (OR 2.94 [1.99, 4.35]). It was also found to be associated with advanced T stage, N stage, and TNM stage. Positive PLC was more frequent in adenocarcinoma than in squamous cell carcinoma (OR 2.32, [1.51, 3.52]). It was relatively more common in moderately- and poorly-differentiated tumors than in well-differentiated tumors (OR 1.89 [0.86, 4.16]). No association was found between positive PLC and fine needle aspiration cytology (OR 1.04 [0.58, 1.81]). Positive PLC was associated with high overall recurrence (OR 2.51 [1.79, 3.53]), as well as high local recurrence (OR 3.85 [1.57, 9.44]) and distant recurrence (2.58 [1.76, 3.76]). In analysis of survival, the overall HR for mortality was 2.43 [1.87, 3.16], suggesting significantly poorer survival for patients with positive PLC. Conclusions: Positive PLC in NSCLC is strongly associated with several existing poor prognosticators including pleural invasion, lymphatic spread, and vascular involvement. It may indicate locally advanced disease with high risk of recurrence and poor survival. We recommend that the PLC test be included in future clinical trials of adjuvant therapy for patients with NSCLC.

No significant financial relationships to disclose.

Full publication of results initially presented in abstracts

BACKGROUND

Abstracts of presentations at scientific meetings are usually available only in conference proceedings. If subsequent full publication of abstract results is based on the magnitude or direction of study results, publication bias may result. Publication bias, in turn, creates problems for those conducting systematic reviews or relying on the published literature for evidence.

OBJECTIVES

To determine the rate at which abstract results are subsequently published in full, and the time between meeting presentation and full publication. To assess the association between study characteristics and full publication.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, The Cochrane Library, Science Citation Index, reference lists, and author files. Date of most recent search: June 2003.

SELECTION CRITERIA

We included all reports that examined the subsequent full publication rate of biomedical results initially presented as abstracts or in summary form. Follow-up of abstracts had to be at least two years.

DATA COLLECTION AND ANALYSIS

Two reviewers extracted data. We calculated the weighted mean full publication rate and time to full publication. Dichotomous variables were analyzed using relative risk and random effects models. We assessed time to publication using Kaplan-Meier survival analyses.

MAIN RESULTS

Combining data from 79 reports (29,729 abstracts) resulted in a weighted mean full publication rate of 44.5% (95% confidence interval (CI) 43.9 to 45.1). Survival analyses resulted in an estimated publication rate at 9 years of 52.6% for all studies, 63.1% for randomized or controlled clinical trials, and 49.3% for other types of study designs.'Positive' results defined as any 'significant' result showed an association with full publication (RR = 1.30; CI 1.14 to 1.47), as did 'positive' results defined as a result favoring the experimental treatment (RR =1.17; CI 1.02 to 1.35), and 'positive' results emanating from randomized or controlled clinical trials (RR = 1.18, CI 1.07 to 1.30). Other factors associated with full publication include oral presentation (RR = 1.28; CI 1.09 to 1.49); acceptance for meeting presentation (RR = 1.78; CI 1.50 to 2.12); randomized trial study design (RR = 1.24; CI 1.14 to 1.36); and basic research (RR = 0.79; CI 0.70 to 0.89). Higher quality of abstracts describing randomized or controlled clinical trials was also associated with full publication (RR = 1.30, CI 1.00 to 1.71).

AUTHORS' CONCLUSIONS

Only 63% of results from abstracts describing randomized or controlled clinical trials are published in full. 'Positive' results were more frequently published than not 'positive' results.

Relation of body mass and sex steroid hormone levels to hot flushes in a sample of mid-life women

OBJECTIVE

Previous studies indicate that obesity is associated with a higher risk of experiencing hot flushes in mid-life women. The reasons for this association are unknown, although altered hormone levels have been associated with both hot flushes and obesity. Thus, this current study tested the hypothesis that obesity is associated with hot flushes in mid-life women through a mechanism involving levels of total and free androgen, free estrogen, progesterone, and sex hormone binding globulin (SHBG).

METHODS

Women aged 45-54 years were recruited from Baltimore and its surrounding counties. Each participant (n=628) was weighed, measured, completed a questionnaire, and provided a blood sample that was used to measure estradiol, estrone, testosterone, androstenedione, dehydroepiandrosterone sulfate, progesterone, and SHBG.

RESULTS

Obese mid-life women (body mass index (BMI)>or=30.0 kg/m2) had significantly higher testosterone, and lower estradiol, estrone, progesterone, and SHBG levels than normal-weight mid-life women (BMI<or=24.9 kg/m2) after adjustment for age, race, smoking, and number of days since last menstrual period. The association between obesity and hot flushes was no longer significant after adjustment for estrogens and progesterone, and/or SHBG.

CONCLUSION

These data suggest that obesity may be associated with hot flushes through a mechanism involving multiple hormones and SHBG.

Factors associated with determinants of sexual functioning in midlife women

OBJECTIVES

The present study was conducted to assess the associations between a woman's passionate love for her partner and sexual satisfaction and demographic factors, health and life-style characteristics, menopausal status, and menopausal symptoms.

METHODS

A cross-sectional study was conducted among women (40-60 years) residing in Maryland (n = 846). chi(2)-tests were performed to evaluate the associations between each of the outcome variables (sexual satisfaction and passionate love for the partner) and predictor/independent variables. Logistic regression analysis was performed to determine whether significant associations from chi(2) analyses remained significant after adjustment for confounders.

RESULTS

Older age (adjusted odds ratio (OR) 1.04; 95% confidence interval (CI) 1.01, 1.07), higher education (OR 1.47; 95% CI 1.09, 1.99), and alcohol intake (OR 1.42; 95% CI 1.03, 1.95) were associated with low passion for the partner. Older age was also a significant predictor of low sexual satisfaction (OR 1.04; 95% CI 1.01, 1.07). Women experiencing vaginal dryness had higher odds of low passion for partner (OR 1.67; 95% CI 1.21, 1.31) and low sexual satisfaction (OR 1.58; 95% CI 1.14, 2.20) than women not experiencing vaginal dryness.

CONCLUSIONS

Older age, higher education, alcohol intake, and vaginal dryness are significantly associated with lower levels of passionate love for the partner, while older age and vaginal dryness are significantly associated with lower levels of sexual satisfaction in midlife women.

Ovarian volume and antral follicle counts as indicators of menopausal status

OBJECTIVE

Recent studies suggest that ovarian volume and antral follicle numbers may be sensitive, specific, and early indicators of menopausal status. The accuracy of these markers, however, has not been compared directly to more traditional markers [age and follicle-stimulating hormone (FSH) levels]. Thus, the purpose of this study was to test whether ovarian volume and antral follicle counts are more sensitive and specific markers of menopausal status than age or FSH levels.

DESIGN

Premenopausal (n = 34) and postmenopausal (n = 25) women between 40 and 54 years old received a transvaginal ultrasound for determination of ovarian volume and antral follicle numbers, provided blood for measurement of FSH levels, and completed a questionnaire. FSH levels, age, ovarian volume, and antral follicle numbers were compared using t tests. Receiver operating characteristic curves were generated to evaluate the sensitivity and specificity of each marker.

RESULTS

Postmenopausal women had significantly higher FSH levels (p < or = 0.0001), smaller ovarian volumes (p < or = 0.002), and fewer antral follicles (p < or = 0.002) than premenopausal women. Ovarian volume and antral follicle numbers had similar sensitivity (27.3-100%) and specificity (3.4-92.9%) in indicating postmenopausal status as FSH levels and age.

CONCLUSION

These data suggest that ovarian volume and antral follicle numbers may be useful indicators of menopausal status.

Instabilotyping: comprehensive identification of frameshift mutations caused by coding region microsatellite instability

Coding region frameshift mutation caused by microsatellite instability (MSI) is one mechanism contributing to tumorigenesis in cancers with MSI in high frequency. Mutation of TGFBR2 is one example of this process. To identify additional examples, a large-scale genomic screen of coding region microsatellites was conducted. 1115 coding homopolymeric loci with six or more nucleotides were identified in an online genetic database. Mutational screening was performed at 152 of these loci in 46 colorectal tumors with MSI in high frequency. Nine loci were mutated in > or =20% of tumors, 10 loci in 10-20%, 24 loci in 5-10%, 43 loci in <5%, and 66 loci were not mutated in any tumors. The most frequently mutated novel loci were the activin type II receptor gene (58.1%), SEC63 (48.8%), AIM 2 (47.6%), a gene encoding a subunit of the NADH-ubiquinone oxidoreductase complex (27.9%), a homologue of mouse cordon-bleu (23.8%), and EBP1/PA2G4 (20.9%). This genome-wide approach identifies coding region MSI in genes or pathways not implicated previously in colorectal tumorigenesis, which may merit functional study or other additional analysis.

Psychosocial factors and intervention-associated changes in those factors as correlates of change in fruit and vegetable consumption in the Maryland WIC 5 A Day Promotion Program

This study sought to examine: (a) the relative effects of baseline demographic and psychosocial factors and an intensive nutritional intervention on changes in fruit and vegetable consumption in low-income, ethnically diverse women served by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program in Maryland; (b) whether this intervention, designed to modify psychosocial factors associated with fruit and vegetable consumption, was successful in changing these factors; and (c) whether changes in these factors were associated with increased consumption. The same women from 15 WIC program sites were surveyed at baseline and postintervention 8 months later. Women randomized to the intervention group showed significantly greater mean change in self-efficacy, attitudes, social support, and knowledge of national consumption recommendations than control group women. Changes in all psychosocial factors were significantly associated with nutrition session attendance and increased consumption. In a hierarchical model, changes in these factors accounted for most of the intervention effect on increased consumption.

Media coverage of women's health issues: is there a bias in the reporting of an association between hormone replacement therapy and breast cancer?

Media coverage of scientific research plays a major role in shaping public opinion and influencing medical practice. When an association is controversial, such as with hormone replacement therapy (HRT) and breast cancer, it is important that a balanced picture of the scientific literature be reported. The objective of this study was to assess whether scientific publications that do and do not support an HRT/breast cancer association were cited in the media in proportions similar to those with which they appear in the scientific literature. Scientific publications reporting on the HRT/breast cancer association published from January 1, 1995, to June 30, 2000, were identified through a systematic Medline search. Media reports from newspapers, magazines, television, and radio that reported on HRT and breast cancer were retrieved from an online database. Investigators independently recorded characteristics of the scientific publications and media reports. A total of 32 scientific publications were identified: 20 (62.5%) concluded there was an increased risk of breast cancer associated with HRT (positive publications), and 12 (37.5%) concluded there was no evidence for an association (null publications). Nearly half (47%) of the scientific publications were not cited by the media. There were 203 media citations of scientific publications: 82% were of positive publications and 18% were of null publications, representing a significant excess of citations of positive publications (p < 0.01). Media coverage of this controversial issue is based on a limited sample of the scientific publications. Moreover, the excess of media citations for positive scientific publications suggests a bias against null scientific publications.

Non-high-density lipoprotein cholesterol level as a predictor of cardiovascular disease mortality

BACKGROUND

Non-high-density lipoprotein cholesterol (non-HDL-C) contains all known and potential atherogenic lipid particles. Therefore, non-HDL-C level may be as good a potential predictor of risk for cardiovascular disease (CVD) as low-density lipoprotein cholesterol (LDL-C).

OBJECTIVES

To determine whether non-HDL-C level could be useful in predicting CVD mortality and to compare the predictive value of non-HDL-C and LDL-C levels.

METHODS

Data are from the Lipid Research Clinics Program Follow-up Study, a mortality study with baseline data gathered from 1972 through 1976, and mortality ascertained through 1995. A total of 2406 men and 2056 women aged 40 to 64 years at entry were observed for an average of 19 years, with CVD death as the main outcome measure.

RESULTS

A total of 234 CVD deaths in men and 113 CVD deaths in women occurred during follow-up. Levels of HDL-C and non-HDL-C at baseline were significant and strong predictors of CVD death in both sexes. In contrast, LDL-C level was a somewhat weaker predictor of CVD death in both. Differences of 0.78 mmol/L (30 mg/dL) in non-HDL-C and LDL-C levels corresponded to increases in CVD risk of 19% and 15%, respectively, in men. In women, differences of 0.78 mmol/L (30 mg/dL) in non-HDL-C and LDL-C levels corresponded to increases in CVD risk of 11% and 8%, respectively.

CONCLUSIONS

Non-HDL-C level is a somewhat better predictor of CVD mortality than LDL-C level. Screening for non-HDL-C level may be useful for CVD risk assessment.

The role of human papillomavirus deoxyribonucleic acid assay and repeated cervical cytologic examination in the detection of cervical intraepithelial neoplasia among human immunodeficiency virus-infected women. Cervical Disease Study Group of the American Foundation for AIDS Research Community Based Clinical Trials Network

OBJECTIVES

We sought to measure the characteristics of a quantitative human papillomavirus deoxyribonucleic acid assay and repeated cervical cytologic examination in screening for cervical intraepithelial neoplasia among human immunodeficiency virus-infected women.

STUDY DESIGN

Human immunodeficiency virus-infected women with screening CD4+ lymphocyte counts of < or = 500 cells/mm3 (n = 103) were examined by quantitative human papillomavirus deoxyribonucleic acid assay and serial cervical cytologic examination and by colposcopy with biopsy and endocervical curettage during the course of 1 year.

RESULTS

Quantitative measures of total human papillomavirus deoxyribonucleic acid and high-risk human papillomavirus deoxyribonucleic acid were strongly associated with any cervical intraepithelial neoplasia (P = .005) and high-grade cervical intraepithelial neoplasia (P = .0006), but they improved the sensitivity and negative predictive value of baseline screening only slightly when combined with cervical cytologic examination. Incident cervical intraepithelial neoplasia occurred frequently (20%) during 1 year of follow-up and was more common among human papillomavirus-infected women. Repeated cytologic examination identified 60% of women with new cervical intraepithelial neoplasia.

CONCLUSION

Human immunodeficiency virus-infected women with at least mild immunosuppression have a high incidence of cervical intraepithelial neoplasia, which warrants close follow-up. Those with high baseline human papillomavirus deoxyribonucleic acid levels may be at the highest risk for incident cervical intraepithelial neoplasia.

The effect of the Maryland WIC 5-A-Day promotion program on participants' stages of change for fruit and vegetable consumption

The Maryland Women, Infants and Children (WIC) 5-A-Day Promotion Program examined the effect of a multifaceted nutrition intervention on changing the fruit and vegetable consumption of low-income women in the WIC program in Maryland. The sample consisted of 3,122 participants (1,443 intervention and 1,679 control) with a mean age of 27.2. Fifty-six percent were Black/African American. This article focuses on the effect of the intervention on the stages of change of the participants. Intervention participants showed significantly greater positive movement through the stages than control participants. Stages of change were measured for two specific target behaviors: eating five servings of fruits and vegetables a day and eating more servings of fruit and vegetables a day. Results demonstrated significant differences in the stage status of intervention and control women and in movement through the stages. The effectiveness of the intervention across groups depended on which staging measure was used.

Surveillance for uterine abnormalities in tamoxifen-treated breast carcinoma survivors: a community based study

BACKGROUND

Tamoxifen-treated breast carcinoma survivors are at elevated risk of endometrial carcinoma. Whether to recommend annual surveillance for uterine abnormalities in this population is currently under debate.

METHODS

This study was a cross-sectional, community-based investigation of tamoxifen use and the frequency of surveillance for endometrial carcinomas in 541 women with breast carcinoma. Study participants whose breast carcinoma was diagnosed in 1994 were interviewed in 1998. Data were collected from a telephone interview and from a cancer registry record. Tests for uterine abnormalities, based on participant reports of endometrial biopsy and transvaginal ultrasound, were categorized according to frequency. Testing for uterine abnormalities was defined as irregular if women reported tests once every 3 years, on average, and as regular, if they reported annual tests.

RESULTS

Forty-nine percent of respondents were current tamoxifen users, 12% were former tamoxifen users, and 39% reported never taking tamoxifen. Of respondents with a uterus (n = 385), 19% reported irregular and 30% regular testing for uterine abnormalities after their breast carcinoma diagnosis. Respondents more frequently reported transvaginal ultrasound (37%) than endometrial biopsy (29%). Women 65 years of age and older were significantly less likely to report regular surveillance for uterine abnormalities (16%) than those younger than 65 years (35%). Current tamoxifen users more frequently reported regular surveillance (43%) than either former (35%) or never tamoxifen users (15%). Multivariable analyses showed tamoxifen users were more likely to have regular (odds ratio [OR], 9.8; 95% confidence interval [CI], 4.4-21.8) or to have irregular testing for uterine abnormalities (OR, 3.9; 95% CI, 1.9-8.1) compared with women who never used tamoxifen, after adjustment for age, number of recent gynecologic visits, and gynecologic symptoms.

CONCLUSIONS

The results of the current study indicate that half of the breast carcinoma survivors in this population were tested for uterine abnormalities. Although at increased risk, 38% of tamoxifen users never had a test. Clear guidelines need to be established for the type and frequency of testing for uterine abnormalities among tamoxifen-treated breast carcinoma patients.

Breast Imaging Reporting and Data System: inter- and intraobserver variability in feature analysis and final assessment

OBJECTIVE

We sought to evaluate the use of the Breast Imaging Reporting and Data System (BI-RADS) standardized mammography lexicon among and within observers and to distinguish variability in feature analysis from variability in lesion management.

MATERIALS AND METHODS

Five experienced mammographers, not specifically trained in BI-RADS, used the lexicon to describe and assess 103 screening mammograms, including 30 (29%) showing cancer, and a subset of 86 mammograms with diagnostic evaluation, including 23 (27%) showing cancer. A subset of 13 screening mammograms (two with malignant findings, 11 with diagnostic evaluation) were rereviewed by each observer 2 months later. Kappa statistics were calculated as measures of agreement beyond chance.

RESULTS

After diagnostic evaluation, the interobserver kappa values for describing features were as follows: breast density, 0.43; lesion type, 0.75; mass borders, 0.40; special cases, 0.56; mass density, 0.40; mass shape, 0.28; microcalcification morphology, 0.36; and microcalcification distribution, 0.47. Lesion management was highly variable, with a kappa value for final assessment of 0.37. When we grouped assessments recommending immediate additional evaluation and biopsy (BI-RADS categories 0, 4, and 5 combined) versus follow-up (categories 1, 2, and 3 combined), five observers agreed on management for only 47 (55%) of 86 lesions. Intraobserver agreement on management (additional evaluation or biopsy versus follow-up) was seen in 47 (85%) of 55 interpretations, with a kappa value of 0.35-1.0 (mean, 0.60) for final assessment.

CONCLUSION

Inter- and intraobserver variability in mammographic interpretation is substantial for both feature analysis and management. Continued development of methods to improve standardization in mammographic interpretation is needed.

Uses of process evaluation in the Maryland WIC 5-a-day promotion program

Using a crossover design, the authors conducted a 6-month intervention program aimed at increasing fruit and vegetable consumption among women served by the Women, Infants, and Children program in Baltimore City and six Maryland counties. The theoretical framework for the interventions was the Transtheoretical Model of Change. At 2 months postintervention, mean daily consumption had increased significantly more in intervention participants than in control participants. Extensive process evaluation data were collected to assess the quantity and quality of program services delivered. These included participant nutrition session evaluation forms and attendance logs, focus groups of attenders and nonattenders of sessions, information about peer educators, and postintervention surveys. Many lessons were learned about program delivery, factors affecting attendance, and the obstacles to dietary change. Strategies to increase participants' consumption of fruits and vegetables were modified based on these lessons and the process evaluations.

Ovarian volume and menopausal status

OBJECTIVE

The purposes of this study were to (1) examine whether ovarian volume differs by age and menopausal status in healthy women; (2) evaluate whether ovarian volume could be a sensitive and specific predictor of menopausal status; and (3) assess whether ovarian volume is affected by cigarette smoke, oral contraceptives (OCs), and hormone replacement therapy (HRT).

DESIGN

Each participant (527 women) completed an extensive in-home interview that assessed age, menopausal status, smoking history, OC use, and HRT use. Each participant also received a transvaginal ultrasound that measured ovarian volume. Geometric means for ovarian volume were compared between premenopausal and postmenopausal women using t tests. Tests for trends were conducted using linear regression analyses.

RESULTS

Ovarian volume declined with age (p < or = 0.0001) and also differed by menopausal status; postmenopausal women had smaller ovarian volumes than premenopausal women of the same age (p < or = 0.0001). Ovarian volume was not associated with smoking history or HRT use. However, it was significantly smaller in current users of OCs compared with past users of or those who never used OCs (p < or = 0.0001). Ovarian volume was a sensitive and specific predictor of postmenopausal status.

CONCLUSIONS

The data suggest that age, menopausal status, and OC use may be determinants of ovarian volume. They also suggest that ovarian volume may be useful for predicting menopausal status in women.

Weight, weight change, mortality in a random sample of older community-dwelling women

OBJECTIVE

To evaluate the relationship between measured weight, weight change, and 6-year mortality risk in a random sample of 648 community-dwelling women aged 65 and older from Baltimore, Maryland.

MEASUREMENTS

Data were collected using a standardized questionnaire and administered in person by trained interviewers. Questionnaires were completed annually from 1984 to 1986, and body weight was measured at each interview. Weight was defined as body mass index (BMI) of low (< 23 kg/m2), average (> or = 23 kg/m2 to < or = 28 kg/m2), and high (> 28 kg/m2). Four mutually exclusive categories of weight change of at least 4.5% in BMI over the three annual interviews were developed to describe all possible weight change patterns: weight gain, weight loss, no change, and weight cycling.

RESULTS

During the follow-up period, 106 women (16%) died. Women with low baseline BMI, regardless of weight change, and those who lost weight, regardless of baseline BMI had increased mortality risk. Women with average baseline BMI and weight loss had a very high mortality risk (hazard ratio (HR) 3.84, 95% Confidence interval (CI) 2.14-6.89). Women who weight cycled had increased mortality risk at low and high baseline weights, and a nonsignificant increased risk at average baseline weight (P = .069). Analyses were adjusted for age, education, smoking, alcohol usage, and pre-existing illness and included an interaction between weight change and baseline BMI.

CONCLUSIONS

These results suggest that white, older, community-dwelling women are at an increased risk of mortality if they are underweight, lose weight, or weight cycle.

Evaluation of acupuncture for pain control after oral surgery: a placebo-controlled trial

BACKGROUND

Acupuncture is increasingly being used by the general population and investigated by conventional medicine; however, studies of its effects on pain still lack adequate control procedures.

OBJECTIVES

To evaluate the (1) efficacy of Chinese acupuncture in treating postoperative oral surgery pain, (2) validity of a placebo-controlled procedure, and (3) effects of psychological factors on outcomes.

DESIGN

Randomized, double-blind, placebo-controlled trial.

SETTING

Dental School Outpatient Clinic, University of Maryland at Baltimore.

PARTICIPANTS

Thirty-nine healthy subjects, aged 18 to 40 years, assigned to treatment (n=19) and control (n=20) groups.

MAIN OUTCOME MEASURES

Patients' self-reports of time until moderate pain, time until medication use, total pain relief, pain half gone, and total pain medication consumption.

RESULTS

Mean pain-free postoperative time was significantly longer in the acupuncture group (172.9 minutes) than in the placebo group (93.8 minutes) (P=.01), as was time until moderate pain (P=.008). Mean number of minutes before requesting pain rescue medication was significantly longer in the treatment group (242.1 minutes) than in the placebo group (166.2 minutes) (P=.01), as was time until medication use (P=.01). Average pain medication consumption was significantly less in the treatment group (1.1 tablets) than in the placebo group (1.65 tablets) (P=.05). There were no significant between-groups differences on total-pain-relief scores or pain-half-gone scores (P>.05). Nearly half or more of all patients were uncertain of or incorrect about their group assignment. Outcomes were not associated with psychological factors in multivariate models.

CONCLUSIONS

Acupuncture is superior to the placebo in preventing postoperative dental pain; noninsertion placebo procedure is valid as a control.

Factors associated with attendance in a voluntary nutrition education program

PURPOSE

This paper examines factors associated with attendance in a National Cancer Institute-funded randomized trial of nutrition education to increase fruit and vegetable consumption among women served by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

SETTING

The study took place at 16 WIC sites in Maryland.

SUBJECTS

The participants were 1528 women who were enrolled in WIC or who had children enrolled in WIC, were > or = 18 years of age, and planned to continue enrollment at that WIC site for at least 6 months (68% of eligible women approached agreed to participate).

INTERVENTION

Women received personal invitations, letters, and telephone reminders from peer educators encouraging their attendance at three bimonthly nutrition sessions.

MEASURES

Demographic data were collected in a baseline survey. Attendance data and telephone and address changes were also collected. The postintervention survey included a question regarding reasons for nonattendance. Focus groups were also held to ascertain reasons for attendance or nonattendance. Chi-square tests of trend and multiple logistic regression, adjusted for within-site correlation, were used in statistical analyses.

RESULTS

Fifty-four percent of enrollees attended at least one session. Multiple logistic regression analysis showed increased odds of attending with higher age, breast-feeding, and/or knowledge of the recommendation to eat five or more servings of fruits and vegetables daily. There were decreased odds of attending for pregnant women who already had children. There were nonsignificant trends toward decreased attendance among unmarried women compared with married women and among blacks compared with nonblacks. Reasons given for nonattendance included withdrawal from WIC, moving, conflicting activities, negative feelings about nutrition education, and lack of transportation or child care.

CONCLUSIONS

The results suggest that numerous barriers hinder participation in nutrition programs aimed at low-income women. These barriers should be considered by health care professionals when planning intervention programs. Overcoming these barriers presents a major challenge.

A randomized trial of acupuncture as an adjunctive therapy in osteoarthritis of the knee

OBJECTIVE

The purpose of this study was to investigate the efficacy of acupuncture as an adjunctive therapy to standard care for the relief of pain and dysfunction in elderly patients with osteoarthritis (OA) of the knee.

METHODS

Seventy-three patients with symptomatic OA of the knee were randomly assigned to treatment (acupuncture) or standard care (control). Analysis was performed on last score carried forward to account for patients who dropped out before completion. Patients self-scored Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Lequesne indices at baseline and at 4, 8 and 12 weeks. Patients in the control group were offered acupuncture treatment after 12 weeks. The data for these patients are pooled with those from the original acupuncture group for within-group analysis.

RESULTS

Patients randomized to acupuncture improved on both WOMAC and Lequesne indices compared to those who received standard treatment alone. Significant differences on total WOMAC Scale were seen at 4 and 8 weeks. There appears to be a slight decline in effect at 4 weeks after cessation of treatment (12 weeks after first treatment). No adverse effects of acupuncture were reported.

CONCLUSION

These data suggest that acupuncture is an effective and safe adjunctive therapy to conventional care for patients with OA of the knee.

Effects of menopause on seizures in women with epilepsy

PURPOSE

Although important associations between epilepsy and women's hormonal phases are described, the relation of menopause to epilepsy has received little attention.

METHODS

By using a structured interview, we studied menopausal women with epilepsy seen at the University of Maryland Epilepsy Center over a 1-year period from 1994 to 1995. We analyzed the characteristics and temporal relation of the seizures to menopause and compared the frequency and severity of the seizures with those in a similar group of premenopausal women.

RESULTS

We identified 61 menopausal women (46 who were postmenopausal and 15 perimenopausal) and compared them with 46 premenopausal women. No statistically significant differences were noted in either the frequency or the severity of seizures comparing all menopausal or only postmenopausal with premenopausal women. However, 12 (20%) of the 61 menopausal women noted that their seizures first began during or after menopause, with eight having no proven cause for their seizures. Many individual women described changes in their seizures with menopause. Among the 61 menopausal women, 49 had established epilepsy before the onset of menopause, and 20 (41%) reported worsening of their seizures with menopause, 13 (27%) noted improvement, and 16 (33%) described no changes. These observations were similar for peri- and postmenopausal women. Of the 15 menopausal women taking hormone replacement therapy, the six taking progestin were significantly less likely to report worsening of their seizures.

CONCLUSIONS

These findings support the view that hormonal influences are important in women with seizures. Although, in aggregate, menopausal (combined perimenopausal and postmenopausal) and postmenopausal women's seizures were similar in frequency and severity to those of other women, menopause was associated with changes in seizures for some women. Moreover, menopause may be a previously unrecognized factor for some new-onset seizures. The relations between menopause and epilepsy deserve to be more fully investigated.

Factors associated with fruit and vegetable consumption among women participating in WIC

OBJECTIVE

The purpose of this analysis was to assess to what extent sociodemographic and psychosocial characteristics predict consumption of fruits and vegetables in women served by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

DESIGN

Baseline survey data were analyzed for women enrolled in the Maryland WIC 5 A Day Promotion Program, a study sponsored by the National Cancer Institute. Sociodemographic variables included age, race, education, marital status, working status, pregnancy status, and smoking status. Psychosocial variables included self-efficacy, knowledge, attitudes, social support, and perceived barriers to consuming 5 or more servings daily of fruits and vegetables.

SUBJECTS/SETTING

Analyses are based on 3,122 women enrolled at 15 WIC sites in Baltimore and 6 counties in Maryland.

STATISTICAL ANALYSES PERFORMED

Because psychosocial characteristics were measured on different scales and varied in dispersion, we standardized scores for these variables. Multiple regression analyses were then performed to assess contributions of the sociodemographic variables and the standardized psychosocial variable scores to the variance in consumption of fruits and vegetables.

RESULTS

Sociodemographic variables were not powerful predictors of fruit and vegetable consumption. In contrast, an increase of 1 standard deviation in self-efficacy resulted in a mean increase of 0.76 servings, and an increase of 1 standard deviation in perceived barriers resulted in a decrease of 0.50 servings. About 21% of the variance in consumption was explained by all of the variables examined.

APPLICATIONS

Dietitians and intervention programs should focus on increasing clients' self-efficacy, positive attitudes, and knowledge relating to fruits and vegetables while trying to reduce perceived barriers to consumption of fruits and vegetables.

Final results of the Maryland WIC 5-A-Day Promotion Program

OBJECTIVES

This National Cancer Institute-funded study sought to increase fruit and vegetable consumption among women served by the WIC program in Maryland.

METHODS

Over a 2-year period, a multifaceted intervention program using a randomized crossover design sought to increase fruit and vegetable consumption at 16 WIC program sites in Baltimore City and 6 Maryland counties. Participants were surveyed at baseline, 2 months postintervention, and 1 year later.

RESULTS

Two months postintervention, mean daily consumption had increased by 0.56 +/- 0.11 servings in intervention participants and 0.13 +/- 0.07 servings in control participants (P = .002). Intervention participants also showed greater changes in stages of change, knowledge, attitudes, and self-efficacy. Changes in consumption were closely related to number of nutrition sessions attended, baseline stage of change, race, and education. One year later, mean consumption had increased by an additional 0.27 servings in both intervention and control participants.

CONCLUSIONS

Dietary changes to prevent cancer can be achieved and sustained in this hard-to-reach, low-income population. However, many obstacles must be overcome to achieve such changes.

Associations among caregiving difficulties, burden, and rewards in caregivers to older post-rehabilitation patients

The associations between self-reported rewards and difficulties of caregiving and burden were examined in a sample of 200 informal caregivers to older post-rehabilitation patients. Sixteen percent (16%) of caregivers reported that caregiving was physically difficult only, 15% reported emotional difficulties only, 11% reported social difficulties only, 17% reported multiple difficulties, and 40% had no difficulties. Each type of difficulty (e.g., social, emotional, and physical) was significantly associated with burden in univariate and multiple linear regression analyses, controlling for confounding characteristics. Caregivers reporting multiple types of difficulty experienced higher levels of burden than caregivers who reported only one type of difficulty. Caregivers who received more rewards from caregiving reported fewer difficulties. Caregiving rewards had no independent effect on burden but modified the associations between social and emotional difficulties and burden. In summary, caregiving rewards and difficulties were not mutually exclusive, and their relationship in turn affected burden.

Isolated single umbilical artery anomaly and the risk for congenital malformations: a meta-analysis

BACKGROUND/PURPOSE

Single umbilical artery (SUA) is an associated finding in many chromosomal abnormalities and congenital malformations. However, SUAcan also be seen as an isolated finding. The extent of diagnostic investigation and follow-up needed in infants with SUA as an isolated finding has long been debated. In this study the authors examined this issue by an analysis of the published papers concerning SUA anomaly.

METHODS

A meta-analysis of 37 studies related to SUA published over a 40-year period was performed. Eleven of 37 studies were considered group 1 because the diagnosis of SUA was made using specimens obtained from early abortuses, fetal deaths, or autopsies. The remaining 26 studies were considered group 2 because the diagnosis of SUA was made from examining placental and umbilical cord specimens obtained from live-born infants or by examination of the umbilicus soon after birth.

RESULTS

The mean (and 95% CI) SUA incidence was 2.13% (1.92%, 2.34%) in group 1, and 0.55% (0.44%, 0.66%) in group 2. The mean incidence of congenital malformation associated with SUA was 66.3% (67.7%, 70.8%) in group 1, and 27% (21.6%, 32.3%) in group 2; these differences were significant (P< .05). In 7 of 26 group 2 studies, additional urologic investigations were performed in 204 infants who had an isolated SUA anomaly. Thirty-three of these 204 infants (16.2%, 95% CI, 7.7%, 25.6%) had some form of renal anomaly, but in 18 of 33 (54.5%) the anomalies were minor or self limiting. A cost-versus-benefit analysis showed that 14 isolated SUA cases need to be investigated to detect one major renal malformation; however, the value of detecting them early remained unclear because most of the anomalies would be apparent with good pediatric follow-up.

CONCLUSIONS

When SUA is an isolated anomaly in an otherwise healthy infant, there is a slight increase in the risk for renal malformations. This association is of similar magnitude to the coexistence of another anomaly with the presence of one anomaly. Most renal anomalies in isolated SUA cases are minor and self limiting, and even major anomalies are no different from those that are diagnosed during routine pediatric follow-up in otherwise healthy infants. Therefore, unless additional risk factors for malformations exist, the current data do not justify extensive urologic radiographic investigations in asymptomatic newborns having an isolated SUA anomaly.

Prospective study on the relation between living arrangement and change in functional health status of elderly women

Limited prospective data exist on how living arrangements are associated with change in functional health. This study evaluated whether elderly women living alone were less likely to experience functional decline when compared with women who lived with others. A total of 619 community-dwelling, white women from Baltimore, Maryland, aged 65-99 years at baseline were questioned annually from 1984 to 1986. Functional health was measured as the sum of limitations in seven physical and seven instrumental activities of daily living (Instrumental ADL). A total of 148 women experienced functional decline over the 2 years, primarily as a deterioration in Instrumental ADL. The association between living arrangement and change in Instrumental ADL depended on the level of physical impairment. Among women without severe impairment, Instrumental ADL deterioration was significantly less for those living alone compared with those living with spouses (odds ratio (OR) = 0.60, 95% confidence interval (CI) 0.45-0.92) or nonspouse others (OR = 0.62, 95% CI 0.45-0.96). For women with severe impairment, however, those living alone had a greater decline in Instrumental ADL, especially when compared with those living with nonspouse others (OR = 5.13, 95% CI 1.23-21.28). These results suggest that, unless severely physically impaired, women living independently have less deterioration in functional health when compared with peers in alternate living arrangements.

Single agent versus combination chemotherapy in patients with advanced nonsmall cell lung carcinoma: a meta-analysis of response, toxicity, and survival

BACKGROUND

This meta-analysis was conducted to compare the effects of single agent versus combination chemotherapy on response rate, toxicity, and survival of patients with advanced nonsmall cell lung carcinoma (NSCLC).

METHODS

The authors reviewed randomized clinical trials published in the medical literature and the reference lists of relevant articles. Objective response rate, survival at 6 and 12 months, and the incidence of treatment-related death were compared among all patients receiving single agent chemotherapy and those receiving combination chemotherapy. A subgroup analysis for all outcomes was conducted for 10 trials published between 1989 and 1996 that used a platinum analogue or vinorelbine as the single agent arm.

RESULTS

The authors identified 38 potentially eligible trials, 25 of which (with a total of 5156 patients) were included in the meta-analysis. Overall, combination chemotherapy produced a nearly 2-fold increase in response rate compared with single agent chemotherapy (response rate [RR], 1.93; 95% confidence interval [CI], 1.54-2.42). However, combination chemotherapy also increased toxicity significantly, including a 3.6-fold increase in the risk of treatment-related death (RR, 3.5; 95% CI, 1.8-6.7). Survival at 6 months (RR, 1.10; 95% CI, 1.02-1.19) and 12 months (RR, 1.22; 95% CI, 1.03-1.45) was modestly superior with combination chemotherapy when all trials are included. However, when a platinum analogue or vinorelbine are used as single agents, this difference was no longer statistically significant at 6 months (RR, 1.03; 95% CI, 0.92-1.15) or at 12 months (RR, 1.10; 95% CI, 0.94-1.43).

CONCLUSIONS

Combination chemotherapy increased objective response and toxicity rates compared with single-agent chemotherapy. Survival was prolonged only modestly with combination chemotherapy but not significantly so when more active single agents were used.

Vitamin E prophylaxis to reduce retinopathy of prematurity: a reappraisal of published trials

OBJECTIVE

We conducted a meta-analysis of the published randomized clinical trials of vitamin E prophylaxis designed to reduce retinopathy of prematurity (ROP) to determine whether increased serum concentrations of vitamin E reduced the incidence of severe, threshold (Stage 3+) ROP in the very low birth weight (VLBW) infant subset.

STUDY DESIGN

Among the six trials considered eligible for analyses, the incidence for all stages of ROP and for Stage 3+ ROP was computed for all randomly assigned infants (intention-to-treat analysis) and for those infants completing the trials. Odds ratios (ORs) and pooled estimates for event rate reductions (and the respective 95% confidence intervals [CIs]) were calculated for these outcome end points.

RESULTS

There were 704 VLBW infants in the vitamin E prophylaxis groups and 714 in control groups; 536 (76.1%) infants in the vitamin E and 551 (77.2%) in the control groups completed the trials. In all trials the mean serum vitamin E concentrations were within or above the physiologic range in the vitamin-treated groups and at or below the physiologic ranges in the control groups. The overall incidence of any stage ROP was similar between the groups: 39.8% in the vitamin E group and 43.5% in the control group. The overall incidence for Stage 3+ ROP was lower in the vitamin E-treated groups than in the control group (2.4% in vitamin E vs 5.3% in control). The pooled OR for developing Stage 3+ ROP with vitamin E prophylaxis was 0.44 (95% CI, 0.21, 0.81, p < 0.02). The reciprocal of the pooled estimate of mean risk reduction (2.8%, 95% CI: 0.55%, 5.1%) for Stage 3+ ROP revealed that on average, vitamin E prophylaxis given to 35 VLBW infants would prevent one case of threshold, Stage 3+ ROP.

CONCLUSIONS

Considering that there was a 52% reduction in the incidence of Stage 3+ ROP, we suggest that the role of vitamin E in reducing severe ROP be re-evaluated. We could not assess the adverse effect rates from vitamin E therapy in the trials analyzed; therefore, we recommend a well-controlled and focused trial in which the issues of benefit, adverse effects, and cost can be assessed with vitamin E prophylaxis in extremely low birth weight (< 1000 gm) infants.

Hormone replacement and menopausal symptoms following hysterectomy

Hormone replacement therapy (HRT) is recommended for most women who experience surgical menopause following hysterectomy/oophorectomy for noncancerous conditions; it is also commonly prescribed for postmenopausal women. Beginning in 1992, 1,299 women undergoing hysterectomy in 28 hospitals throughout Maryland were interviewed prior to hysterectomy and were subsequently followed over a 2-year period. Interviews included questions about HRT use and symptoms associated with menopause. The majority of the women (66 percent) were white, 55 percent had a high school education or better, 49 percent were obese (body mass index > or =27.3), and 11 percent were postmenopausal. Over 40 percent of premenopausal women underwent bilateral oophorectomy. At 3 months posthysterectomy, 89 percent of these women were on HRT; this figure dropped to 85 percent at 24 months. Among postmenopausal women, 50 percent were on HRT both at 3 months and at 24 months posthysterectomy. Among premenopausal women who had unilateral oophorectomy, 21 percent were on HRT at 3 months, increasing to 35 percent at 24 months. Among premenopausal women who had no ovaries removed, 5 percent were on HRT at 3 months, increasing to 13 percent at 24 months. There were few within-group differences between HRT users and nonusers, except that among postmenopausal women, HRT users were younger and more likely to be white and had higher income and educational levels. Women who were postmenopausal or who underwent bilateral oophorectomy were less likely to have hot flashes if they were on HRT, but women with 0-1 ovary removed who were on HRT were more likely to have hot flashes than those not on HRT. Black women were significantly more likely to experience hot flashes than were white women, independent of HRT status and weight. Obese women were on HRT at approximately the same rates as nonobese women but were significantly more likely to have hot flashes, even when analyses controlled for HRT and race.

Participation in the Ischemic Optic Neuropathy Decompression Trial: sex, race, and age

BACKGROUND

The Ischemic Optic Neuropathy Decompression Trial (IONDT) is a randomized, single masked, multicenter trial designed to assess the safety and efficacy of optic nerve decompression surgery compared with careful follow-up in patients 50 years or older with non-arteritic anterior ischemic neuropathy (NAION).

OBJECTIVES

To examine and evaluate the sex, race, and age distributions of the screened, and subsequently enrolled, IONDT population, especially the proportions of female, minority, and elderly patients, and demographic characteristics of clinical center investigators, the geographical location of IONDT Clinical Centers, and the referral patterns of local physicians.

SETTING

Twenty-five U.S. clinical centers.

PARTICIPANTS

There were 1,681 referrals to the Clinical Centers; an Eligibility Screening Form providing demographic information was completed for 1,152.

FINDINGS

Forty-three percent (495/1,152) of screened cases were women. Seven percent (85/1,152) were minorities: 33 African-Americans, 34 Hispanics, 17 Asians, and 1 Native-American. The average age was 66 +/- 10 years with a range of 22-92 years of age. Of the 1,152 referred patients, 305 were eligible for randomization; 258 (85%) of these agreed to participate in the trial. The demographic makeup of the randomized IONDT patients was similar to that of the screened population.

CONCLUSIONS

Women and the elderly are well represented in the IONDT. Because the number of participating minorities was low, we cannot reliably assess their level of participation. Both a low incidence of NAION in minorities and a low referral rate of minorities to clinical trials are plausible explanations for our findings.

The effect on risk estimates of excluding cases from a case-control study of ischemic stroke

There is limited information about the effect on stroke risk estimates of excluding cases who are unable to respond to interviews. A case-control study of ischemic stroke between 1988 and 1990 in Shreveport, La., USA, provided a basis for studying this question. Of 197 consecutively admitted cases of ischemic stroke, 77 were excluded due to dementia, aphasia or impaired consciousness. Information about risk factors and stroke characteristics was obtained from hospital records. Excluded cases had more left hemispheric (52 versus 19%) and fewer vertebrobasilar (12 versus 29%) and lacunar (5 versus 13%) infarcts than included cases. Excluded cases were also older (p < 0.01), and they had larger infarcts (p < 0.01), multiple strokes (p < 0.01) and congestive heart failure (p < 0.01) more often than included cases. Cases were matched to hospital controls by age, sex, race, and date of admission. Odds ratios (ORs) were higher for excluded cases for 5 of 6 exposures with a significantly higher OR for congestive heart failure (p < 0.01). The ORs changed by as much as 63% when excluded cases were added. These results emphasize the importance of acquiring information about excluded cases and considering selection bias when interpreting stroke studies that exclude cases who are unable to respond to interviews.

The association of nocturnal asthma with asthma severity

The objective of this study is to assess nocturnal asthma as a marker for poor control of asthma. Cross-sectional study of asthmatic patients was conducted in six general practices in East Anglia, England. Subjects were 240 asthma patients, between the ages of 20 and 54 years, from the above general practices. A continuous asthma severity score (range 6-26), consisting of the summation of ordinal responses to questions regarding asthma symptoms during the last 6 months, was used for analysis. The crude association between nocturnal asthma and severity score was statistically highly significant. Regression analysis suggests that, after controlling for possible confounding variables, there remains a strong association between nocturnal asthma (NA) and severity, which is modified by self-report of current consultation for "nervous/emotional trouble" (current NT). In the absence of current NT, NA raises the severity score by 5.3 (95% CI 4.5, 6.2), whereas in the presence of current NT, NA raises the severity score by 8.2 (95% CI 4.8, 11.6). NA appears promising as a marker for poorly controlled asthma. Confirmation of the association found in this study by objective measures of severity would strengthen the utility of NA as a marker.

Cost-Effectiveness of Laparoscopic-Assisted Vaginal Hysterectomy

This study enrolled nearly 1300 women having hysterectomy for benign indications at 28 hospitals during 1992 and 1993. Of these procedures, 816 were performed abdominally, 311 vaginally, and 154 were laparoscopic-assisted vaginal hysterectomies (LAVH). On average, LAVH was more expensive ($4294) than abdominal ($2753) and vaginal ($2312) hysterectomies, primarily due to higher operating room and surgical supply costs. Women who had LAVH were younger, had higher incomes, were more educated, more likely to be treated at nonteaching and smaller hospitals, and had lower comorbidity scores than those in the other two groups. After adjusting for these differences, LAVH was not significantly different from vaginal hysterectomy in terms of operative and postoperative complications, readmissions, postoperative days of pain, days in bed, days of feeling tired, days before resuming full activities, and days before going back to work full time. Compared with abdominal hysterectomy the vaginal groups combined had significantly fewer days of pain, days of feeling tired, and days back to work full time. By 6 months after surgery the three groups were quite similar in terms of patient satisfaction and other outcome measures.

Uterine leiomyomas. Racial differences in severity, symptoms and age at diagnosis

OBJECTIVE

To investigate racial differences in the presence of leiomyomas, condition severity, associated symptoms and age at diagnosis between black and white hysterectomy patients.

STUDY DESIGN

This study included 409 black women and 836 white women aged 18 or older who underwent hysterectomy for noncancerous conditions at 28 hospitals in Maryland. Patients were interviewed shortly before surgery, and hospital records were abstracted after discharge.

RESULTS

Overall, 89% of the black women and 59% of the white women were found to have leiomyomas. Among those with a confirmed presurgical diagnosis of leiomyomas, the average age at diagnosis was 37.5 years for black women and 41.6 for white women, and the average age at hysterectomy was 41.7 for black women and 44.6 for white women. The average uterine weight for black women with leiomyomas was 420.8 g and for white women was 319.1 g. Black women were more likely to have seven or more leiomyomas (57%) in comparison to white women (36%). Black women with leiomyomas were more likely to be anemic (56%) than white women (38%) and more likely to report having very severe or severe pelvic pain (59%) than white women (41%).

CONCLUSION

Black women having hysterectomy had larger and more numerous leiomyomas, and the leiomyomas were more symptomatic than in white women despite a younger age at diagnosis and hysterectomy.

Relationship between blood lead and dietary iron intake in preschool children. A cross-sectional study

The relationship between dietary iron intake and blood lead levels in urban preschool children was investigated in a cross-sectional study of 299 children from 9 months to 5 years old. Mothers of children attending the University of Maryland Pediatric Ambulatory Clinic volunteered for the children and themselves to join the study. The data collected included nutritional status, socioeconomic status, medical history, and potential sources of lead exposure. Blood samples from all participants were evaluated for levels of blood lead, serum iron (ferritin), free erythrocyte protoporphyrin, calcium, and hematocrit. The average blood lead level (standard deviation) in the studied population was 11.4 (7.3) micrograms/dL. With multiple linear and logistic regression analyses to adjust for covariates, a negative association (P = 0.03) between blood lead and dietary iron intake was found. This finding is consistent with similar results from experimental studies. It is concluded that there is evidence that higher dietary iron intake is associated with lower blood lead among urban preschool children in the studied population.

Cost differences among women's primary care physicians

A secondary analysis of data from the 1987 National Medical Expenditure Survey revealed that women with distinct demographic and socio-economic characteristics identify different physician specialty groups as their usual source of care. The use of certain physician groups for primary care resulted in higher rates of use and expenditures, particularly for younger women. Identifying an internist, rather than a family/general practitioner or an obstetrician/gynecologist, as a usual source of care placed one at higher odds of making more visits and incurring higher total outpatient costs.

Relationship between blood lead and nutritional factors in preschool children: a cross-sectional study

OBJECTIVE

The purpose of this study was to assess the relationships between selected nutritional factors and blood lead levels of preschool children.

METHODOLOGY

Data on 296 children, aged 9 to 72 months, who were cared for at the University of Maryland at Baltimore Pediatric Ambulatory Center were examined in this cross-sectional study. Nutritional status, socioeconomic aspects, medical history, and potential sources of lead exposure were assessed. Blood samples were evaluated for levels of blood lead, serum iron (ferritin), free erythrocyte photoporphyrin, calcium, and hematocrit.

RESULTS

The average blood lead level was 11.4 micrograms/dL. Multicollinearity of nutritional factors was addressed using regression techniques. After adjusting for confounders, significant positive associations with blood lead were found for total caloric intake (P = .01) and dietary fat (P = .05).

CONCLUSIONS

The findings of this study suggest that even when behavioral and environmental exposures to lead were statistically controlled, total caloric intake and dietary fat each had an independent and significant association with the level of blood lead.

Combined continuous hormone replacement therapy: a critical review

OBJECTIVE

To evaluate the putative benefits of combined continuous hormone replacement therapy for postmenopausal women.

DATA SOURCES

A Medline search was performed for relevant English-language studies published during 1981-1995.

METHOD OF STUDY SELECTION

Forty-two studies were identified, all using a continuous daily regimen of an estrogen and a progestin given to postmenopausal women with intact uteri.

DATA EXTRACTION AND SYNTHESIS

Each study was reviewed for the design, number of subjects enrolled, duration of protocol, and type and dosage of medications used. Data were extracted from texts, tables, figures, or personal communications regarding the effects of treatment on patient compliance (ie, drop-out rates), the occurrence of vasomotor symptoms, uterine bleeding patterns, endometrial histology, and lipid and bone density measurements. These data were then arranged in tabular form for the purpose of comparing and identifying trends. The lipid data from six randomized, double-blind studies that compared sequential and combined continuous regimens of conjugated equine estrogen and medroxyprogesterone acetate were further analyzed by meta-analysis. Findings revealed compliance rates of approximately 80% (range 35-100). Vasomotor symptoms improved almost universally. Irregular uterine bleeding was noted to be a common problem in the first 6 months of treatment; thereafter, most studies reported rates of amenorrhea of 75% or greater. In patients undergoing endometrial biopsy, rates of atrophic endometrium were noted to be 90-100%, and rates of endometrial hyperplasia were less than 1%. Adenocarcinoma of the endometrium was documented in two patients with a history of atypical endometrial hyperplasia and bleeding after established amenorrhea. The effects of treatment on lipid levels varied from study to study, but a meta-analysis revealed the combined continuous and sequential regimens to produce a treatment-associated decline in total and low-density lipoprotein cholesterol and an increase in high-density lipoprotein cholesterol. Studies examining bone density documented either no change or an increase with treatment.

CONCLUSION

Combined continuous hormone replacement is well accepted by patients in clinical trials, effective in relieving vasomotor symptoms, and produces amenorrhea (though often after an initial period of irregular bleeding), an atrophic endometrium, and favorable changes in circulating lipids as well as maintaining bone density. Data on the impact of this regimen on long-term patient compliance, cardiovascular disease risk, and urogenital atrophy are lacking.

Efficacy of Chinese acupuncture on postoperative oral surgery pain

One of the challenges of acupuncture research is designing appropriate control groups. To address this problem, after surgical third molar extractions 19 patients were randomly assigned to an acupuncture group (n = 11) or a placebo acupuncture group (n = 8). The length of time for reaching moderate pain and pain intensity after oral surgery were recorded by standard patient self-report. The results indicated that subjects treated with acupuncture reported longer pain-free duration times (mean, 181 versus 71 minutes; p < or = 0.046) and experienced less pain intensity than those who received placebo acupuncture. This study provides a model for an acupuncture control that could examine the placebo effect in clinical acupuncture research.

Full publication of results initially presented in abstracts. A meta-analysis

OBJECTIVES

To estimate the rate of full publication of the results of randomized clinical trials initially presented as abstracts at national ophthalmology meetings in 1988 and 1989; and to combine data from this study with data from similar studies to determine the rate at which abstracts are subsequently published in full and the association between selected study characteristics and full publication.

DATA SOURCES

Ophthalmology abstracts were identified by review of 1988 and 1989 meeting abstracts for the Association for Research in Vision and Ophthalmology and the American Academy of Ophthalmology. Similar studies were identified either from reports contained in our files or through a MEDLINE search, which combined the textword "abstract" with "or" statements to the Medical Subject Headings ABSTRACTING & INDEXING, CLINICAL TRIALS, PEER REVIEW, PERIODICALS, MEDICAL SOCIETIES, PUBLISHING, MEDLINE, INFORMATION SERVICES, and REGISTRIES.

STUDY SELECTION

Ophthalmology abstracts were selected from the meeting proceedings if they reported results from a randomized controlled trial. For the summary study, similar studies were eligible for inclusion if they described followup and subsequent full publication for a cohort of abstracts describing the results of any type of research study. All studies had to have followed up abstracts for at least 24 months to be included.

DATA EXTRACTION

Authors of ophthalmology abstracts were contacted by letter to ascertain whether there was subsequent full publication. Other information, including characteristics of the study design possibly related to publication, was taken from the abstract. For the summary study, rates of full publication were taken directly from reported results, as were associations between study factors (ie, "significant" results and sample size) and full publication.

DATA SYNTHESIS

Sixty-six percent (61/93) of ophthalmology abstracts were published in full. Combined results from 11 studies showed that 51% (1198/2391) of all abstracts were subsequently published in full. Full publication was weakly associated with "significant" results and sample size above the median.

CONCLUSIONS

Approximately one half of all studies initially presented in abstract form are subsequently published as full-length reports. Most are published in full within 2 years of appearance as abstracts. Full publication may be associated with "significant" results and sample size.

Pulmonary hemorrhage and exogenous surfactant therapy: a metaanalysis

A metaanalysis of surfactant clinical trials was carried out to assess whether or not an association exists between exogenous surfactant therapy and pulmonary hemorrhage. Trials that reported the pulmonary hemorrhage occurrence (group 1) and those that did not (group 2) were analyzed. Thirty-three treatment strategies were tested in 29 publications from 1980 through 1992. Eleven of these were group 1 trials, which reported a 3% overall incidence of pulmonary hemorrhage. The rates were significantly higher in both the treated and the control groups of natural surfactant trials than in synthetic surfactant trails (5.87% and 5.36% in the natural surfactant trials vs 2.51% and 1.04% in the synthetic surfactant trials, respectively). The pooled estimate of relative risk for pulmonary hemorrhage with any surfactant therapy was 1.47 (95% confidence interval 1.05, 2.07; p < 0.05). Logistic regression modeling revealed that the nature of surfactant, treatment strategy, and lower mean birth weight had a significant influence on the relative risk of pulmonary hemorrhage; a similar trend was seen with higher mortality rates. Variation in the rates of patent ductus arteriosus did not have an independent effect on the estimated pulmonary hemorrhage risk. Most group 2 trials were published before 1990, and the median total sample size was 73, compared with 402 for the group 1 trials (p < 0.05), most of which were published in the 1990s. In 10 (50%) of 20 group 2 trials, pulmonary hemorrhage data were collected methodically, in comparison with all group 1 trials, most of which collected data prospectively. We conclude that pulmonary hemorrhage is a rare complication of respiratory distress syndrome. An awareness of the possible association of pulmonary hemorrhage with surfactant use in later trials and the differences in definitions and reporting practices probably explain variations in the reported incidence among the trials. The risk of pulmonary hemorrhage increases slightly, on an average of 47%, with any surfactant therapy. This increased risk is small compared with the documented benefits of surfactant therapy in respiratory distress syndrome.

The socioeconomic correlates of hysterectomies in the United States

The purpose of this study was to examine the relationship between incidence of prior hysterectomy and education, income, and race. Data concerning previous hysterectomy and socioeconomic information were collected from 12,465 women 18 years or older as part of the Behavioral Risk Factor Surveillance System conducted in 16 states in 1988. The results indicate that women with less education and lower incomes were more likely to have had a hysterectomy. Race was not related to hysterectomy rate.

The second Chicago televised smoking cessation program: a 24-month follow-up

OBJECTIVES

As smoking decreases in the population, the remaining smoking population will change, and cessation initiatives will have to incorporate strategies designed for these smokers.

METHODS

To study patterns of response to a cessation intervention composed of 20 televised segments and the American Lung Association Freedom from Smoking in 20 Days manual, this study compared cessation rates over 24 months in a cohort of smokers who registered for a cessation program with those in a cohort selected from the smoking population at large.

RESULTS

At post intervention, multiple point prevalence of cessation among participants, adjusted for baseline smoking, was 14% among registrants and 6% in the population; at 24 months the adjusted rates were 6% and 2%, respectively. Heavy smokers benefited more than light smokers, and there was a consistent dose-response relationship between extent of exposure to the intervention and cessation.

CONCLUSION

The effects of the intervention were strongest for those who read the manual and watched the programs daily. Manual use was important, and those who did not read it did not appear to benefit. Compared to the population and given full participation, heavy smokers benefited more than lighter smokers.

A treatment program for adolescents with phenylketonuria

A treatment program for adolescents with phenylketonuria (PKU), incorporating education, goal-setting, self-monitoring, contracts, and rewards, was evaluated by measuring knowledge of PKU, blood phenylalanine concentrations, and health locus of control (LOC) before and after participation in the program. Of the 16 subjects, seven subjects successfully completed the program by achieving behavioral goals. These subjects increased their knowledge of PKU and decreased their blood phenylalanine concentrations, but the nine nonsuccessful subjects did not. There was no significant change in LOC scores for either group. There was a significant relationship between baseline blood phenylalanine levels and success with the program. Therefore, this pilot study demonstrates that adolescents who have already achieved some measure of metabolic control can be expected to be most successful with this program and realize the greatest benefits from it in the form of increased knowledge of PKU and even better metabolic control.