Design of the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial

The objectives of the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial are to determine in screenees ages 55-74 at entry whether screening with flexible sigmoidoscopy (60-cm sigmoidoscope) can reduce mortality from colorectal cancer, whether screening with chest X-ray can reduce mortality from lung cancer, whether screening men with digital rectal examination (DRE) plus serum prostate-specific antigen (PSA) can reduce mortality from prostate cancer, and whether screening women with CA125 and transvaginal ultrasound (TVU) can reduce mortality from ovarian cancer. Secondary objectives are to assess screening variables other than mortality for each of the interventions including sensitivity, specificity, and positive predictive value; to assess incidence, stage, and survival of cancer cases; and to investigate biologic and/or prognostic characterizations of tumor tissue and biochemical products as intermediate endpoints. The design is a multicenter, two-armed, randomized trial with 37,000 females and 37,000 males in each of the two arms. In the intervention arm, the PSA and CA125 tests are performed at entry, then annually for 5 years. The DRE, TVU, and chest X-ray exams are performed at entry and then annually for 3 years. Sigmoidoscopy is performed at entry and then at the 5-year point. Participants in the control arm follow their usual medical care practices. Participants will be followed for at least 13 years from randomization to ascertain all cancers of the prostate, lung, colorectum, and ovary, as well as deaths from all causes. A pilot phase was undertaken to assess the randomization, screening, and data collection procedures of the trial and to estimate design parameters such as compliance and contamination levels. This paper describes eligibility, consent, and other design features of the trial, randomization and screening procedures, and an outline of the follow-up procedures. Sample-size calculations are reported, and a data analysis plan is presented.

Outcomes of a field trial to improve children's dietary patterns and physical activity. The Child and Adolescent Trial for Cardiovascular Health. CATCH collaborative group

OBJECTIVE

To assess the outcomes of health behavior interventions, focusing on the elementary school environment, classroom curricula, and home programs, for the primary prevention of cardiovascular disease.

DESIGN

A randomized, controlled field trial at four sites with 56 intervention and 40 control elementary schools. Outcomes were assessed using prerandomization measures (fall 1991) and follow-up measures (spring 1994).

PARTICIPANTS

A total of 5106 initially third-grade students from ethnically diverse backgrounds in public schools located in California, Louisiana, Minnesota, and Texas.

INTERVENTION

Twenty-eight schools participated in a third-grade through fifth-grade intervention including school food service modifications, enhanced physical education (PE), and classroom health curricula. Twenty-eight additional schools received these components plus family education.

MAIN OUTCOME MEASURES

At the school level, two primary end points were changes in the fat content of food service lunch offerings and the amount of moderate-to-vigorous physical activity in the PE programs. At the level of the individual student, serum cholesterol change was the primary end point and was used for power calculations for the study. Individual level secondary end points included psychological factors, recall measures of eating and physical activity patterns, and other physiologic measures.

RESULTS

In intervention school lunches, the percentage of energy intake from fat fell significantly more (from 38.7% to 31.9%) than in control lunches (from 38.9% to 36.2%)(P<.001). The intensity of physical activity in PE classes during the Child and Adolescent Trial for Cardiovascular Health (CATCH) intervention increased significantly in the intervention schools compared with the control schools (P<.02). Self-reported daily energy intake from fat among students in the intervention schools was significantly reduced (from 32.7% to 30.3%) compared with that among students in the control schools (from 32.6% to 32.2%)(P<.001). Intervention students reported significantly more daily vigorous activity than controls (58.6 minutes vs 46.5 minutes; P<.003). Blood pressure, body size, and cholesterol measures did not differ significantly between treatment groups. No evidence of deleterious effects of this intervention on growth or development was observed.

CONCLUSION

The CATCH intervention was able to modify the fat content of school lunches, increase moderate-to-vigorous physical activity in PE, and improve eating and physical activity behaviors in children during 3 school years.

The risk of Parkinson's disease with exposure to pesticides, farming, well water, and rural living

We assessed exposure to pesticides, farming, well water use, and rural living as risk factors for Parkinson's disease (PD) in a population-based case-control study consisting of men and women > or = 50 years of age who had primary medical care at Henry Ford Health System in metropolitan Detroit. Enrolled PD patients (n = 144) and control subjects (n = 464) were frequency-matched for age, race, and sex. When adjusted for these variables and smoking status, there was a significant association of occupational exposure to herbicides (odds ratio [OR], 4.10; 95% CI, 1.37, 12.24) and insecticides (OR, 3.55; 95% CI, 1.75, 7.18) with PD, but no relation was found with fungicide exposure. Farming as an occupation was significantly associated with PD (OR, 2.79; 95% CI, 1.03, 7.55), but there was no increased risk of the disease with rural or farm residence or well water use. The association of occupational exposure to herbicides or insecticides with PD remained after adjustment for farming. The association of farming with PD was maintained after adjustment for occupational herbicide exposure and was of borderline significance after adjustment for occupational insecticide exposure. These results suggest that PD is associated with occupational exposure to herbicides and insecticides and to farming and that the risk of farming cannot be accounted for by pesticide exposure alone.

The transepicondylar axis approximates the optimal flexion axis of the knee

The traditional understanding of knee kinematics holds that no single fixed axis of rotation exists in the knee. In contrast, a recent hypothesis suggests that knee kinematics are better described simply as two simultaneous rotations occurring about fixed axes. Knee flexion and extension occurs about an optimal flexion axis fixed in the femur, whereas tibial internal and external rotations occur about a longitudinal rotation axis fixed in the tibia. No other translations or rotations exist. This hypothesis has been tested. Tibiofemoral kinematics were measured for 15 cadaveric knees undergoing a realistic loadbearing activity (simulated squatting). An optimization technique was used to identify the locations of the optimal flexion and longitudinal rotation axes such that simultaneous rotations about them could best represent the measured kinematics. The optimal flexion axis was compared with the transepicondylar axis defined by bony landmarks. The longitudinal rotation axis was found to pass through the medial joint compartment. The optimal flexion axis passed through the centers of the posterior femoral condyles. No significant difference was found between the optimal flexion and transepicondylar axes. To an average accuracy of better than 3.4 mm in translation, and 2.9 degrees in orientation, knee kinematics were represented successfully by simple rotations about the optimal flexion and longitudinal rotation axes. The optimal flexion axis is fixed in the femur and can be considered the true flexion axis of the knee. The transepicondylar axis axis, which is identified easily by palpation, closely approximates the optimal flexion axis.

Occupational exposures to metals as risk factors for Parkinson's disease

In a population-based case-control study, we investigated the potential role of occupational exposure to iron, copper, manganese, mercury, zinc, and lead as risk factors for Parkinson's disease (PD). Concurrently recruited, nondemented patients (n = 144) with idiopathic PD and controls (n = 464) consisting of men and women > or =50 years of age, frequency-matched for age (within 5 years), race, and sex were enrolled. All had primary medical care at Henry Ford Health System in urban/suburban metropolitan Detroit. Subjects were given an extensive risk-factor questionnaire detailing actual worksite conditions of all jobs held for more than 6 months from age 18 onward. An industrial hygienist, blinded to the case-control status of subjects, rated occupational exposure to each of the metals of interest. When adjusted for sex, race, age, and smoking status, we found in those with more than 20 years' exposure a significantly increased association with PD for copper (OR = 2.49, 95% CI = 1.06, 5.89) and manganese (OR = 10.61, 95% CI = 1.06, 105.83). For more than 20 years' exposure to combinations of lead-copper (OR = 5.24, 95% CI = 1.59, 17.21), lead-iron (OR = 2.83, 95% CI = 1.07, 7.50), and iron-copper (OR = 3.69, 95% CI = 1.40, 9.71), there was a greater association with PD than with any of these metals alone. These findings suggest that chronic exposure to these metals is associated with PD, and that they may act alone or together over time to help produce the disease.

Hormone replacement therapy in postmenopausal women: urinary N-telopeptide of type I collagen monitors therapeutic effect and predicts response of bone mineral density

PURPOSE

To assess the ability of the urinary N-telopeptide of type I collagen (NTx) to monitor and predict therapeutic effects of hormone replacement therapy (HRT) in postmenopausal women.

PATIENTS AND METHODS

To assess the relationship between baseline or change in NTx (predictive variable), and change in lumbar and hip bone mineral density (BMD; outcome variable), we conducted a 2-year randomized controlled study at academic university and private practice medical centers in 236 healthy women 1 to 3 years postmenopausal; 227 women completed the study. Women received estrogen plus progesterone plus calcium (treated group) or calcium alone (control group).

RESULTS

In the treated group NTx significantly (P < 0.0001) decreased, and spine and hip BMD significantly (P < 0.00001 and P < 0.005, respectively) increased; in the control group NTx did not change but BMD decreased significantly (P < 0.01). Subjects in the highest quartiles for baseline NTx (67 to 188 units) or decreasing NTx (-66% to -87%) through 6 months demonstrated the greatest gain in BMD in response to HRT (P < 0.05 and P < 0.005). For every increase of 30 units in baseline NTx the odds of gain in BMD in response to HRT increased by a factor of 5.0 (95% confidence interval [CI] 1.9 to 13.3); for every 30% decrease in NTx through 6 months, the odds of gaining BMD in response to HRT increased by a factor of 2.6 (95% CI 1.6 to 4.4). In the control group an increase of 30 units in mean NTx across the study indicated a higher odds of losing BMD by a factor of 3.2 (95% CI 1.6 to 6.5). A high baseline NTx (> 67 units) indicated a 17.3 times higher risk of BMD loss if not treated with HRT.

CONCLUSION

These data support the clinical utility of NTx to monitor the antiresorptive effect of HRT in recently postmenopausal women, and to predict changes in BMD in response to HRT.

Cytotoxicity of mineral trioxide aggregate using human periodontal ligament fibroblasts

The purpose of the present study was to compare the cytotoxicity of mineral trioxide aggregate (MTA) to other commonly used retrofilling materials, Super-EBA and amalgam. This was accomplished using a cell viability assay for mitochondrial dehydrogenase activity in human periodontal ligament fibroblasts after 24-hr exposure to extracts of varying concentrations of the test materials, in both freshly mixed and 24-hr set states. Methyl methacrylate 2% (vol/vol) served as the positive control, and complete culture medium served as the negative control. Differences in mean cell viability values were assessed by ANOVA (p < 0.05). In the freshly mixed state, the sequence of toxicity was amalgam > Super-EBA > MTA. In the 24-hr set state the sequence of toxicity at a low extract concentration was Super-EBA > MTA, amalgam, and Super-EBA > amalgam > MTA at a higher extract concentration. This study supports the use of MTA in the root-end environment.

The geochemistry of iodine - a review

Iodine has long been recognised as an important element environmentally. Despite this there are many gaps in our knowledge of its geochemistry and even where information is available much of this is based on old data which, in the light of recent data, are suspect.Iodine forms few independent minerals and is unlikely to enter most rock-forming minerals. In igneous rocks its concentration is fairly uniform and averages 0.24 mg/kg. Sedimentary rocks tend to have higher concentrations with average iodine contents of:-recent sediments 5-200 mg/kg, carbonates 2.7 mg/kg, shales 2.3 mg/kg and sandstones 0.8 mg/kg. Organic-rich sediments are particularly enriched in iodine.Soils, generally, are much richer in iodine than the parent rocks with the actual level being decided mainly by soil type and locality. Little soil iodine is water-soluble and much iodine is thought to be associated with organic matter, clays and aluminium and iron oxides. Most iodine in soils is derived from the atmosphere where, in turn, it has been derived from the oceans. Seawater has a mean iodine content of 58 μg/L, while non-saline surface waters have lower and very variable levels. Subsurface brines and mineral waters are generally strongly enriched in iodine.Marine plants are frequently enriched in iodine while terrestrial plants have generally low contents. Iodine is essential for all mammals.Consideration of the geochemical cycle of iodine reveals that its transfer from the oceans to the atmosphere is probably the most important process in its geochemistry.

Smoking and Parkinson's disease: a dose-response relationship

OBJECTIVE

To determine whether an inverse dose-response relationship exists between cigarette smoking and PD among ever-smokers and ex-smokers.

METHODS

Smoking and alcohol consumption were analyzed in 144 PD patients and 464 control subjects, who were frequency matched for sex, race, and age (+/-5 years), in a population-based case-control study of men and women > or =50 years old in the Henry Ford Health System.

RESULTS

With never-smokers as the reference category, there was an inverse association between current light smokers (>0 to 30 pack-years) and PD patients (odds ratio [OR], 0.59; 95% CI, 0.23 to 1.53), and a stronger inverse association of PD with current heavy smokers (>30 pack-years; OR, 0.08; 95% CI, 0.01 to 0.62). When former >30-pack-year smokers were stratified by the interval since quitting, there was an inverse association between those who stopped >20 years ago and PD (OR, 0.86; 95% CI, 0.42 to 1.75), and a greater inverse relationship with those who stopped 1 to 20 years ago (OR, 0.37; 95% CI, 0.19 to 0.72). Alcohol consumption had no independent, significant association with PD, but heavy drinking (>10 drink-years) had a greater effect than light-moderate drinking in reducing but not eliminating the inverse association between smoking and PD.

CONCLUSIONS

The inverse dose-response relationship between PD and smoking and its cessation is unlikely to be due to bias or confounding, as discussed, providing indirect evidence that smoking is biologically protective.

Etiologic and early marker studies in the prostate, lung, colorectal and ovarian (PLCO) cancer screening trial

The Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial, which is randomizing 74,000 screening arm participants (37,000 men, 37,000 women; ages 55-74) and an equal number of nonscreened controls, is a unique setting for the investigation of the etiology of cancer and other diseases and for the evaluation of potential molecular markers of early disease. At entry, baseline information is collected by questionnaire on dietary intake, tobacco and alcohol use, reproductive history (for women), family history of cancer, use of selected drugs, and other selected risk factors. Blood samples collected at the baseline screening exam are aliquoted to serum, plasma, red blood cell, and buffy coat fractions. At the next two annual screening visits, serum samples are collected. At the third annual reexamination, cryopreserved whole blood is obtained, in addition to serum, plasma, red blood cell, and buffy coat fractions. At the fourth and fifth years, serum, plasma, and buffy coat are collected. All blood samples are shipped to a central repository for long-term storage at -70 degrees C. Dietary questionnaires and buccal cells for DNA analysis are obtained from nonscreened controls. Cancer cases are identified through annual follow-up questionnaires, and all deaths are identified through vital status tracing mechanisms. Procedures are being developed to obtain archival pathologic material for selected cases of cancer and related diseases. Initial investigations are focusing on the etiology of colorectal cancer and on the operative characteristics of tests for the early detection of colorectal and prostate cancer.

Parkinson's disease and its comorbid disorders: an analysis of Michigan mortality data, 1970 to 1990

Using data from death certificates, we compared underlying causes of death for two populations of Michigan decedents: (1) persons 40 years of age and older for whom Parkinson's disease (PD) was listed as a contributing cause of death and who died in the years 1970 through 1989, and (2) all persons in Michigan over 40 years of age who died in 1970, 1980, or 1990. PD decedents were approximately 1.5 times more likely to die from cerebrovascular disease and three to four times more likely to die from pneumonia/influenza, but they had just 29% of the expected number of deaths due to cancer. These associations were maintained irrespective of gender or race. PD decedents had diabetes mellitus and heart diseases as frequently as decedents in the general population, but liver diseases were less frequent among PD decedents. These trends held throughout the 21-year study period. When we stratified cancers by whether they are known to be (1) highly related, (2) moderately related, or (3) weakly related or unrelated to smoking, there were still 2.5 times fewer cancers unrelated or weakly related to smoking among PD decedents than among decedents in the general population. We believe that the greater frequency of cerebrovascular disease in PD decedents may be due to a detection bias, since PD patients are more likely to be seen by neurologists, who are more apt to diagnose and document diseases of the nervous system. Pneumonia/influenza is more common among PD patients because of their relative immobility near the end of life.(ABSTRACT TRUNCATED AT 250 WORDS)

Calcaneal ultrasonic measurements discriminate hip fracture independently of bone mass

We studied 336 elderly white women, of whom 22 had previously suffered a hip fracture and 22 had previously suffered a vertebral fracture. All subjects were 60 years old or older with a mean age of 73:7 years. Measurements of ultrasonic transmission velocity (UTV), broad-band ultrasonic attenuation (BUA) and stiffness (STF) were made at the os calcis using a Lunar Achilles ultrasound device. Measurements of lumbar spine bone mineral density (L2-4 BMD) and femoral neck BMD were made using dual-energy X-ray absorptiometry. The fracture groups were significantly older and had more years since menopause than the control groups. Logistic regression showed that measurements of UTV, STF and BUA discriminated between fracture and non-fracture subjects for both the hip (p < 0.001) and spine (p < 0.05). Femoral neck BMD discriminated both hip and vertebral fractures from controls (p < 0.001 and p < 0.01, respectively). Spinal BMD discriminated between subjects with vertebral fractures and those without (p < 0.01), but not hip fractures (p = 0.64). For hip fracture, areas under receiver-operating characteristic (ROC) curves were 0.85 for UTV, 0.83 for STF, 0.79 for BUA, 0.78 for femoral neck BMD and 0.53 for spinal BMD. For vertebral fracture, areas under the ROC curve were 0.68 for UTV, 0.70 for STF, 0.66 for BUA, 0.66 for femoral neck BMD and 0.67 for spinal BMD.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult nutrient intake as a risk factor for Parkinson's disease

BACKGROUND

This population-based case-control study evaluated nutrient intake as a risk factor for Parkinson's disease (PD) among people aged > or =50 years in metropolitan Detroit.

METHODS

Cases (n = 126) were diagnosed between 1991 and 1995 and neurologist-confirmed. Controls (n = 432) were frequency-matched for sex, age (+/-5 years) and race. Using a standardized food frequency questionnaire, subjects reported the foods they ate within the past year.

RESULTS

Estimating the association between PD and risk of being in the highest versus the lowest intake quartile, there were elevated odds ratios for total fat (OR 1.94, 95% confidence interval [CI] : 1.05-3.58), cholesterol (OR 2.11, 95% CI: 1.14-3.90), lutein (OR 2.52, 95% CI: 1.32-4.84) and iron (OR 1.88, 95% CI: 1.05-3.38).

CONCLUSIONS

These results suggest an association of PD with high intake of total fat, saturated fats, cholesterol, lutein and iron.

The effects of the Child and Adolescent Trial for Cardiovascular Health upon psychosocial determinants of diet and physical activity behavior

BACKGROUND

The Child and Adolescent Trial for Cardiovascular Health is a multisite study of a school-based intervention to reduce or prevent the development of risk factors for cardiovascular disease. The purpose of this paper is to present the evaluation results of the 3-year intervention, focusing upon the psychosocial variables conceptualized as determinants of dietary and physical activity behaviors.

METHODS

A total of 96 schools across four study sites (California, Louisiana, Minnesota, and Texas) were randomized to two treatment conditions: intervention and control. Pre- and postmeasurements on the health behavior questionnaire were collected from over 6,000 students. The data analyses utilized a nested design approach in which schools served as the primary unit of analysis. Repeated-measures multivariate analyses were applied to investigate effect sizes for each determinant and to explore theoretical relationships among the determinants over time.

RESULTS

The findings indicated sustained significant effects in improved knowledge, intentions, self-efficacy, usual behavior, and perceived social reinforcement for healthy food choices (P < 0.0001 for these five variables) after 3 years. Intermittent effects were observed for perceived support and self-efficacy for physical activity. No gender by determinant interaction effects were observed, and girls reported significantly greater perceived reinforcement for healthy eating than did boys.

CONCLUSION

The CATCH program was effective in changing the psychosocial variables likely to influence a reduction in behavior for cardiovascular disease. The study is significant in that it demonstrates the viability and effectiveness of a sustained multifaceted intervention in a preadolescent population. The results point to a need for greater understanding of adolescent developmental issues and the role of community environment (particularly social support) in creating effective curricula.

The effect of adult participation in a school-based family intervention to improve Children's diet and physical activity: the Child and Adolescent Trial for Cardiovascular Health

BACKGROUND. There are strong theoretical reasons for including a family component with a school-based intervention aimed at eating, activity, and smoking behaviors, but the empirical findings to date are limited and show mixed results. The overall CATCH family intervention added only knowledge and attitudinal effects, but no additional behavioral outcomes. This study provides a dose analysis of the family component of the CATCH study by assessing the effect of the level of adult participation.

METHOD

This secondary analysis included students who attended a CATCH family intervention school during all 3 years of the study. The extent of the adult-child interaction, the key aspect of the CATCH family intervention, was measured by the number of activity packets that an adult household member completed with the child. Multiple regression analysis was used to assess the association of adult participation with the child's knowledge, attitudes, and behaviors related to diet and physical activity.

RESULTS

Statistically significant results suggested that dose effects were found for knowledge and attitudes related to diet and physical activity. These effects were more pronounced for minority and male students.

CONCLUSIONS

These results suggest that dose response of a family intervention has been shown in the acquisition of positive knowledge and attitudes toward health habit changes. The methodology of dose response can be applied to other health promotion projects.

Parkinson's disease mortality and the industrial use of heavy metals in Michigan

Parkinson's disease (PD) mortality rates in Michigan counties for 1986-1988 were calculated with respect to potential heavy metal exposure (iron, zinc, copper, mercury, magnesium, and manganese) from industry based on recent census data. Individuals were counted as a PD death if the diagnosis was listed as an "underlying" or "related" cause of death on the death certificate. Counties with an industry in the paper, chemical, iron, or copper related-industrial categories (ICs) had statistically significantly (p < 0.05) higher PD death rates than counties without these industries. Significant correlations of chemical (rs = 0.22; p = 0.05), paper (rs = 0.22; p = 0.05) and iron (rs = 0.29; p = 0.008) industry densities with PD death rates were also present. Counties were divided into high (> 15/100,000 individuals 45 years old and over) and low (< = 15/100,000) PD death rate counties by cluster analysis. Geographically, counties with high PD mortality were located mainly in the southern half of the lower peninsula and eastern half of the upper peninsula; low PD death rate counties formed two distinct clusters in the western edge of the upper peninsula and the north-central portion of the lower peninsula. Other possible risk factors that may explain the varied distribution of PD death rates in Michigan were examined. Those significantly correlated with PD mortality included population density (rs = 0.31; p = 0.005), farming density (rs = 0.25; p = 0.02), and well water use (rs = -0.24; p = 0.03). These ecologic findings suggest a geographic association between PD mortality and the industrial use of heavy metals.

Is shorter always better? Relative importance of questionnaire length and cognitive ease on response rates and data quality for two dietary questionnaires

In this study, the authors sought to determine the effects of length and clarity on response rates and data quality for two food frequency questionnaires (FFQs): the newly developed 36-page Diet History Questionnaire (DHQ), designed to be cognitively easier for respondents, and a 16-page FFQ developed earlier for the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial. The PLCO Trial is a 23-year randomized controlled clinical trial begun in 1992. The sample for this substudy, which was conducted from January to April of 1998, consisted of 900 control and 450 screened PLCO participants aged 55-74 years. Controls received either the DHQ or the PLCO FFQ by mail. Screenees, who had previously completed the PLCO FFQ at baseline, were administered the DHQ. Among controls, the response rate for both FFQs was 82%. Average amounts of time needed by controls to complete the DHQ and the PLCO FFQ were 68 minutes and 39 minutes, respectively. Percentages of missing or uninterpretable responses were similar between instruments for questions on frequency of intake but were approximately 3 and 9 percentage points lower (p < or = 0.001) in the DHQ for questions on portion size and use of vitamin/mineral supplements, respectively. Among screenees, response rates for the DHQ and the PLCO FFQ were 84% and 89%, respectively, and analyses of questions on portion size and supplement use showed few differences. These data indicated that the shorter FFQ was not better from the perspective of response rate and data quality, and that clarity and ease of administration may compensate for questionnaire length.

Race and differences in breast cancer survival in a managed care population

BACKGROUND

African-American women with breast cancer have poorer survival than European-American women. After adjustment for socioeconomic variables, survival differences diminish but do not disappear, possibly because of residual differences in health care access, biology, or behavior. This study compared breast cancer survival in African-American and European-American women with similar health care access.

METHODS

We measured survival in women with breast cancer who are served by a large medical group and a metropolitan Detroit health maintenance organization where screening, diagnosis, treatment, and follow-up are based on standard practices and mammography is a covered benefit. We abstracted data on African-American and European-American women who had been diagnosed with breast cancer from January 1986 through April 1996 (n = 886) and followed these women for survival through April 1997 (137 deaths).

RESULTS

African-American women were diagnosed at a later stage than were European-American women. Median follow-up was 50 months. Five-year survival was 77% for African-American and 84% for European-American women. The crude hazard ratio for African-American women relative to European-American women was 1.6 (95% confidence interval [CI] = 1.1-2.2). Adjusting only for stage, the hazard ratio was 1.3 (95% CI = 0.9-1.9). Adjusting only for sociodemographic factors (age, marital status, and income), the hazard ratio was 1.2 (95% CI = 0.8-1.9). After adjusting for age, marital status, income, and stage, the hazard ratio was 1.0 (95% CI = 0.7-1.5).

CONCLUSION

Among women with similar medical care access since before their diagnoses, we found ethnic differences in stage of breast cancer at diagnosis. Adjustment for this difference and for income, age, and marital status resulted in a negligible effect of race on survival.

Occupational metal exposures and the risk of Parkinson's disease

Occupational exposure to specific metals (manganese, copper, lead, iron, mercury, zinc, aluminum and others) appears to be a risk factor for Parkinson's disease (PD) in some, but not all, case-control studies. These epidemiological studies are reviewed. Several methodological issues that may account for the lack of unanimity of findings are discussed, and suggestions for improved case-control methodology are offered. The study of the neurological disease outcome of workers who have had long-term, well-defined occupational exposure to one or more metals is also urged, with collaborative work including industrial hygienists, occupational toxicologists, neurologists, epidemiologists and biostatisticians. Such efforts, employing state-of-the-art case and control ascertainment and enrollment from suitable population bases, neurological diagnostic rigor and exposure assessment, will help to further define the potentially important roles played by metals in PD and other neurodegenerative disorders.

Structure of the muscles of the upper eyelid

The human and monkey orbicularis muscle has fibers that are more uniform in size and structure than those of rectus muscles. They have distinct myofibrils, a moderate number of mitochondria, and a well-developed transverse T-tube system. The levator muscle also has relatively uniform fibers, but the myofibrils are less distinct than those of the orbicularis. Especially noteworthy is the unusual arrangement whereby Muller muscle arises directly from the undersurface of the levator muscle, causing an intimate intermingling of smooth and striated fibers. Muller muscle then inserts on the tarsus, whereas the levator muscle extends by an aponeurosis into the septa of the orbicularis muscle. In surgical specimens from patients with ptosis, the levator fibers show varying degrees of abnormality, whereas Muller fibers are normal.

High-level penicillin resistance among isolates of enterococci. Implications for treatment of enterococcal infections

STUDY OBJECTIVE

To determine the extent and clinical significance of high-level penicillin-resistant Enterococcus faecium at our institution.

DESIGN

Surveillance of clinical enterococcal isolates, in-vitro susceptibility and timed survival studies, and determination of antibiotic efficacy in an experimental model of enterococcal endocarditis.

MEASUREMENTS AND MAIN RESULTS

For a 6-month period, 14% of enterococcal isolates (30 of 212) were identified as E. faecium. One third of the isolates were highly resistant to penicillin G (minimum inhibitory concentration [MIC], greater than or equal to 200 micrograms/mL) but did not produce beta-lactamase. The findings from in-vitro survival studies showed that this high-level resistance resulted in the loss of bactericidal activity normally observed when an aminoglycoside antibiotic agent is combined with penicillin. An experimental rat model of endocarditis provided in-vivo data that confirmed our in-vitro observations. After the rats received therapy for 72 hours, penicillin G either alone or in combination with gentamicin did not significantly decrease the numbers of enterococci in vegetations on heart valves compared with untreated controls (P = 0.62 and P = 0.58, respectively).

CONCLUSIONS

Enterococcus faecium accounts for a notable proportion of clinical enterococcal isolates. Many strains from patients at our institution, as well as from patients at other institutions throughout the country, are highly resistant to penicillin. Because high-level penicillin resistance has important therapeutic implications, periodic surveillance and MIC testing of significant enterococcal isolates, especially E. faecium, are suggested.

The accumulation of whole body skeletal mass in third- and fourth-grade children: effects of age, gender, ethnicity, and body composition

The purpose of this longitudinal study is to describe bone mass and body composition, and the annual changes in these measurements, among third grade students recruited from a suburban school district. Whole body bone mineral content (WBBMC), bone mineral density (WBBMD), fat, and lean mass were measured by dual-energy X-ray absorptiometry. Bone mass in the lumbar spine (LBMC) region of the whole body scan was also utilized. 773 students (38% white, 57% black, 5% other) had baseline visits; 561 had a second measurement a year later. At baseline, black children have significantly higher WBBMC, WBBMD, height, and lean mass than whites. Black males, but not black females, have a greater LBMC. There are no significant gender differences in body size, WBBMC, or WBBMD, although girls have a greater LBMC and fat mass, and boys have a higher lean mass. Most of these differences persist in visit 2. The annual change in bone and lean mass is greater in blacks. Stepwise linear regression analyses of bone mass on body size, gender, and ethnicity and their interactions indicate that log-transformed weight explains most of the variance in both WBBMC and WBBMD (multiple r2 = 0.90 and 0.64, respectively). There are significant black/white differences in intercepts and slopes. Other variables explain only another 1%-2% of the variance. The strongest Pearson correlations are between changes in bone mass and changes in lean mass and log-transformed weight (r ranging from 0.62 to 0.84, p = 0.0001). We conclude that there is a significant black/white, but not male/female difference in whole body bone mass and bone density before puberty. Ethnic and gender differences in bone and body composition suggest that the lean component may contribute to a greater peak bone mass in blacks vs. whites, and perhaps in males vs. females.

Design of process evaluation within the Child and Adolescent Trial for Cardiovascular Health (CATCH)

Process evaluation complements outcome evaluation by providing data to describe how a program was implemented, how well the activities delivered fit the original design, to whom services were delivered, the extent to which the target population was reached, and factors external to the program that may compete with the program effects. The process evaluation system used in the Child and Adolescent Trial for Cardiovascular Health (CATCH) is presented in this paper. The conceptual model underlying the CATCH process evaluation system is described, and process measures and data collection protocols are reviewed. Functions of process evaluation data in the trial include: (1) describing the implementation of the program, (2) quality control and monitoring, and (3) explaining program effects. The importance of incorporating process evaluation into final outcome analyses and assessments of program impact is emphasized.

Outcomes of a high school program to increase fruit and vegetable consumption: Gimme 5--a fresh nutrition concept for students

This paper describes an intervention to increase high school students' fruit and vegetable consumption. Twelve schools were randomized to intervention or control conditions. The cohort (2,213 students; 56% females, 84% Caucasian) were followed from 9th to 12th grades. Interventions comprised a media campaign, classroom workshops, school meal modification, and parental support. Usual daily servings of fruit/vegetables increased 14% in the intervention compared to the control group (p > 0.001) the first three years. At follow-up, consumption within the control group also increased, resulting in no significant difference between groups. Intervention group knowledge scores and awareness indicators were significantly higher than those of the control group (p < 0.0001). Gimme 5 provided a first model to show that dietary habits of high school students can be influenced by positive media messages relative to that age group, increased exposure to a variety of tasty products, and minimal classroom activity.