High-Temporal/High-Spatial Resolution Breast Magnetic Resonance Imaging Improves Diagnostic Accuracy Compared With Standard Breast Magnetic Resonance Imaging in Patients With High Background Parenchymal Enhancement

PURPOSE

To compare breast magnetic resonance imaging (MRI) diagnostic performance using a standard high-spatial resolution protocol versus a simultaneous high-temporal/high-spatial resolution (HTHS) protocol in women with high levels of background parenchymal enhancement (BPE).

MATERIALS AND METHODS

We conducted a retrospective study of contrast-enhanced breast MRIs performed at our institution before and after the introduction of the HTHS protocol. We compared diagnostic performance of the HTHS and standard protocol by comparing cancer detection rate (CDR) and positive predictive value of biopsy (PPV3) among women with high BPE (ie, marked or moderate).

RESULTS

Among women with high BPE, the HTHS protocol demonstrated increased CDR (23.6 per 1,000 patients v 7.9 per 1,000 patients; P = 0. 013) and increased PPV3 (16.0% v 6.3%; P = .021) compared with the standard protocol. This corresponded to a 9.8% (95% CI, 1.29 to 18.3) decrease in the proportion of unnecessary biopsies among high-BPE patients and an additional cancer yield of 15.7 per 1,000 patients (95% CI, 1.3 to 18.3).

CONCLUSION

Among women with high BPE, HTHS MRI improved diagnostic performance, leading to an additional cancer yield of 15.7 cancers per 1,000 women and concomitantly decreasing unnecessary biopsies by 9.8%. A multisite prospective trial is warranted to confirm these findings and to pave the way for more widespread clinical implementation.

Identifying Food Parenting Practices From Comprehensive Home Environment Survey

OBJECTIVE

Conducting exploratory factor analysis (EFA) with the existing home environment assessment-the Comprehensive Home Environment Survey (CHES), to identify scales related to food parenting practices.

METHODS

Parents of 3- to 5-year-old children (n = 172) completed the CHES surveys. After selected items from CHES were categorized into food parenting practice constructs, EFA was used to identify potential subconstructs. Internal consistency and Spearman correlation analysis were also conducted.

RESULTS

The EFAs identified 4 factors within the structure, 4 within coercive control, and 2 within autonomy support.

CONCLUSIONS AND IMPLICATIONS

The results provided preliminary evidence and support that the CHES can be used to measure food parenting practices. The study was limited to a small sample of non-Hispanic White and highly educated participants, less identified items within autonomy support, and lower internal consistency for several identified factors. Confirmatory factor analysis in a larger and more diverse sample is needed for future research.

Adjusting the TMIST study design to accommodate slower than expected accrual: ECOG-ACRIN EA1151

TPS10614

Background: The ECOG-ACRIN Tomosynthesis Mammographic Imaging Screening Trial (TMIST), which opened in 2017, is a randomized trial designed to assess whether Tomosynthesis Mammography (TM) should replace Digital Mammography (DM) for breast cancer screening. It is hypothesized that women assigned to TM for 3-5 screening rounds will have fewer advanced breast cancers than the women assigned to DM. Advanced cancers are those that have distant metastases or positive nodes, are invasive tumors greater than or equal to 2.0 cm in size, or are invasive tumors greater than 1.0 cm in size that are triple negative or HER 2+. The initially planned enrollment of 164,946 women was due to be completed by the end of 2020, with follow-up concluded by 2025. There were substantial challenges in meeting this timeline, including the organizational and funding structure of the NCI National Clinical Trials Network which is dependent upon sites using their existing staffing resources (not always readily available at the time of study activation). This led to longer than anticipated start of enrollment for most interested sites and lower than anticipated annual enrollment per participating site based ultimately on the staffing support that could be allocated to manage TMIST. In addition, research staffing shortages and periodic research operations closures due to COVID-19 have also impacted enrolling TMIST sites, though unevenly, since the start of the pandemic. Enrollment plateaued at approximately 2,100 subjects per month by the end of 2020. With that accrual rate expected, the trial design was modified to reduce the sample size so that the study could be completed by 2027. Methods: With the approval of the NCI CIRB, we changed how the primary endpoint measure for TMIST is assessed from the number of advanced cancers that occur by 4.5 years after randomization to the time from randomization to occurrence of advanced cancers. All advanced cancers occurring within 7 years of randomization are now included and all participants followed for at least three years. In addition, the power of the study of the study was modified from 0.9 to 0.85, while the originally assumed effect size at 4.5 years was retained These changes allowed a reduction of sample size to 128,905, with subject recruitment projected to end in 2024. As of February 14, 2022, there are 125 sites open, 114 in the U.S. and 11 in other countries, with an additional 31 sites planning to open. As of February 14, 2022, a total of 63,845 women have been enrolled in the trial worldwide at 115 sites, with 20% of US participants self-identifying as belonging to minority racial and ethnic groups and 70% consenting to optional blood and/or buccal cell collection. Clinical trial information: NCT03233191.

Parenting Styles, Food Parenting Practices and Dietary Intakes of Preschoolers

Previous evidence suggests that children’s eating behaviors were largely influenced by the parent and home eating structure. This study examined the relationship between parenting styles (including authoritative, authoritarian, indulgent, and uninvolved), food parenting practices (within Structure, Coercive Control, and Autonomy Support constructs) and dietary intakes of preschoolers. Children aged 3–5 years and their parents were recruited from preschools/daycare centers and parents completed the surveys (n = 166). Dietary intakes were collected using the Harvard Service Food Frequency Questionnaire (HSFFQ), parenting style was assessed using the Parenting Dimensions Inventory-Short Version (PDI-S), and food parenting practices were measured using Comprehensive Home Environment Survey (CHES). The results showed that food parenting practices had a higher number of specific significant findings on children’s nutrient and food group intakes than parenting styles. Correlation analyses showed positive parenting practices within Structure were significantly related to healthier children’s intakes (e.g., vegetables, iron, and folate) and less unhealthy dietary intakes (e.g., sweets and total fats). Regression models show that children with authoritative parents consumed more fruits compared to children with authoritarian parents and indulgent parents. The results addressed the importance of parental influences for preschoolers’ healthy dietary intakes, which suggested that future interventions and educational programs could enhance parenting practices to impact child diet.

Predictors of surgery preference and quality of life in DCIS after breast MRI: A trial of the ECOG-ACRIN Cancer Research Group (E4112)

6564

Background: Management of ductal carcinoma in situ (DCIS) remains variable, requiring an understanding of patient preferences and concerns to enhance the treatment decision-making process. Pre-operative MRI and surgeon recommendation can further inform surgery choice. Quality of life (QoL) is also an important consideration in treatment decision-making. The aims of this study were to assess patients’ treatment preferences before and after MRI and surgeon consultation, concordance between treatment preference and surgery received, and trends in health-related QoL (HRQL) among a prospective cohort of women newly diagnosed with DCIS. Methods: A prospective nonrandomized clinical trial by the ECOG-ACRIN Cancer Research Group (E4112) enrolled women diagnosed with unilateral DCIS from 75 institutions between March 2015 and April 2016. Participants underwent either wide local excision (WLE) or mastectomy. Surveys queried patient-reported outcomes (PRO) including treatment preference and concerns, and HRQL before and after surgery. Logistic regression models were used to associate surgery preference and actual surgery received with demographic, clinical and PRO data. Change from baseline in HRQL was assessed using linear regression. Results: At study entry, age (OR 0.39, per 5-year increment, 95%CI, 0.21-0.75; p = 0.005) and treatment goals related to the importance of keeping one’s breast (OR 0.51, 95%CI 0.34-0.76; p = 0.001) and removal of the breast for peace of mind (OR 1.46, 95%CI 1.09-1.95; p = 0.01) drove surgery preference for mastectomy vs. WLE. After receipt of MRI and surgeon consultation, surgery preference was primarily mediated by MRI upstaging (OR 11.18, 95%CI 3.19-39.16; p < 0.001). Only 4% of women received a type of surgery that did not match their final treatment preference. The strongest predictors of actual surgery received were MRI upstaging (OR 15.80, 95%CI 4.85-51.46) and surgeon recommendation of mastectomy (OR 4.60, 95%CI 1.52-13.94). Receipt of a single surgery was associated with significantly improved mental health from baseline to one year after definitive surgery (p = 0.02 for mastectomy; p = 0.003 for single WLE). Self-reported Black race was an independent predictor of worsened mental (p = 0.001) and physical (p = 0.04) health at one year after definitive surgery, despite no significant racial differences in baseline HRQL. Conclusions: Our findings highlight the importance of communication between providers and patients regarding treatment preferences and goals, the clinical significance of MRI findings, and the benefits/risks of available treatment options. Future research to identify modifiable factors associated with declining mental and physical health is needed to inform targeted interventions to mitigate racial disparities and enhance HRQL in patients with DCIS.

Engaging the radiology community in the National Clinical Trials Network: The ECOG-ACRIN TMIST experience

TPS10609

Background: ECOG-ACRIN launched the Tomosynthesis Mammographic Imaging Screening Trial (TMIST) through the National Cancer Institute’s National Clinical Trials Network (NCTN)— a network of academic medical centers, community hospitals, and private clinical practices that are committed to participating in NCI-funded clinical trials. The NCI NCTN was developed to support rapid trial start-up of NCI-funded cancer control/prevention, cancer treatment, and non-therapeutic clinical trials that occur within the institution through centralized institutional administration and shared clinical resource allocation (personnel, lab services). TMIST is a randomized clinical trial assessing two breast cancer screening imaging modalities, tomosynthesis and digital mammography, in the population of women presenting for screening mammography and therefore requires active involvement of radiology. Methods: TMIST seeks to enroll 164,946 women, ages 45 to 74 years who present for screening mammography. Because the population under evaluation are women already scheduled for screening mammography, the mammography clinic is critical to successful recruitment as well as adherence to imaging randomization assignments over a 5-year period and therefore must be actively engaged in this trial with a breast imaging radiologist championing the trial within this service. To get active engagement of breast imaging radiologists, we needed to first make them aware of TMIST. Breast imaging radiologists that were already actively involved in the NCTN received notification of the trial through the NCTN email lists. So our goal was to come up with a strategy to reach out to breast imaging radiologists that were not active members in the NCTN. This was achieved through in-person informational sessions to introduce the trial at national and international breast imaging meetings, introduction of the trial and the workings of the NCTN network to the radiology community through articles placed in American College of Radiology (ACR) newsletters, ads promoting TMIST on ACR social media platforms, and direct email by the TMIST study chair to key radiology stakeholders. As of February 15, 2021, there are 115 sites open: 106 in the U.S. and 9 internationally with an additional 54 sites planning to open. A total of 39,366 women are enrolled in the trial with two-thirds also consenting to optional blood and/or buccal cell collection. Minority populations’ participation in the trial is over 20%. A significant drop in enrollment occurred in Spring 2020 coinciding with the suspension of mammography services globally due to COVID-19 beginning mid-March 2020. Enrollment and follow-up screening visits for TMIST restarted in May 2020 and gradually ramped back up to pre-COVID totals in September 2020. Our highest monthly accrual so far occurred in November 2020 with 2,148 subjects enrolled. Clinical trial information: NCT03233191 .

Breast mass segmentation in ultrasound with selective kernel U-Net convolutional neural network

In this work, we propose a deep learning method for breast mass segmentation in ultrasound (US). Variations in breast mass size and image characteristics make the automatic segmentation difficult. To address this issue, we developed a selective kernel (SK) U-Net convolutional neural network. The aim of the SKs was to adjust network's receptive fields via an attention mechanism, and fuse feature maps extracted with dilated and conventional convolutions. The proposed method was developed and evaluated using US images collected from 882 breast masses. Moreover, we used three datasets of US images collected at different medical centers for testing (893 US images). On our test set of 150 US images, the SK-U-Net achieved mean Dice score of 0.826, and outperformed regular U-Net, Dice score of 0.778. When evaluated on three separate datasets, the proposed method yielded mean Dice scores ranging from 0.646 to 0.780. Additional fine-tuning of our better-performing model with data collected at different centers improved mean Dice scores by ~6%. SK-U-Net utilized both dilated and regular convolutions to process US images. We found strong correlation, Spearman's rank coefficient of 0.7, between the utilization of dilated convolutions and breast mass size in the case of network's expansion path. Our study shows the usefulness of deep learning methods for breast mass segmentation. SK-U-Net implementation and pre-trained weights can be found at github.com/mbyr/bus_seg.

ECOG-ACRIN tomosynthesis mammographic imaging screening trial (EA1151)

TPS1597

Background: This randomized trial is intended to determine whether tomosynthesis (TM) should replace the current standard for breast cancer (BC) screening, digital mammography (DM). It is hypothesized that the population of women assigned TM screening for 3-5 rounds will have fewer advanced cancers than the population assigned to DM screening. Methods: 164,946 women, ages 45 to 74 years who present for screening mammography and consent to participate will be enrolled across 150 sites in the US, Canada and abroad. Women will be randomized to TM or DM. The frequency and number of screening examinations over a five year period will vary based on menopausal status and whether they have specific risk factors, including - hormone use, family history of BC, deleterious genes, prior benign breast biopsy with diagnosis of LCIS or atypia any kind, or dense breasts. Blood and buccal cells will be collected from as many enrolled women as are willing to provide the samples. All breast biopsies during the trial will undergo gene expression analysis for the PAM50 and other progression pathways (PAM50-plus). All subjects enrolled will be followed long term for at least eight years. The primary endpoint is the proportion of participants who have an advanced breast cancer diagnosed at any time within 4.5 years of randomization in to the trial. Secondary endpoints include measures of diagnostic and predictive performance; rates of recall, biopsy, and interval cancers, prevalence of breast cancer subtypes, and tumor subtype based on PAM50-plus analysis. As of January 17th 2020, there are 104 sites open and 21,452 women enrolled in the trial. The DSMC last reviewed the trial in June 2019 and suggested that the trial continue as planned. Clinical trial information: NCT03233191.

Association of Magnetic Resonance Imaging and a 12-Gene Expression Assay With Breast Ductal Carcinoma In Situ Treatment

Importance

Advanced diagnostics, such as magnetic resonance imaging (MRI) and gene expression profiles, are potentially useful to guide targeted treatment in patients with ductal carcinoma in situ (DCIS).

Objectives

To examine the proportion of patients who converted to mastectomy after MRI and the reasons for those conversions and to measure patient adherence to radiotherapy guided by the 12-gene DCIS score.

Design, Setting, and Participants

Analysis of a prospective, cohort, nonrandomized clinical trial that enrolled women with DCIS on core biopsy who were candidates for wide local excision (WLE) from 75 institutions from March 25, 2015, to April 27, 2016, through the Eastern Cooperative Oncology Group-American College of Radiology Imaging Network trial E4112.

Interventions

Participants underwent breast MRI before surgery, and subsequent management incorporated MRI findings for choice of surgery. The DCIS score was used to guide radiotherapy recommendations among women with DCIS who had WLE as the final procedure and had tumor-free excision margins of 2 mm or greater.

Main Outcomes and Measures

The primary end point was to estimate the conversion rate to mastectomy and the reason for conversion.

Results

Of 339 evaluable women (mean [SD] age, 59.1 [10.1] years; 262 [77.3%] of European descent) eligible for WLE before MRI, 65 (19.2%; 95% CI, 15.3%-23.7%) converted to mastectomy. Of these 65 patients, conversion was based on MRI findings in 25 (38.5%), patient preference in 25 (38.5%), positive margins after attempted WLE in 10 (15.4%), positive genetic test results in 3 (4.6%), and contraindication to radiotherapy in 2 (3.1%). Among the 285 who had WLE performed after MRI as the first surgical procedure, 274 (96.1%) achieved successful breast conservation. Of 171 women eligible for radiotherapy guided by DCIS score (clear margins, absence of invasive disease, and score obtained), the score was low (<39) in 82 (48.0%; 95% CI, 40.6%-55.4%) and intermediate-high (≥39) in 89 (52.0%; 95% CI, 44.6%-59.4%). Of these 171 patients, 159 (93.0%) were adherent with recommendations.

Conclusions and Relevance

Among women with DCIS who were WLE candidates based on conventional imaging, multiple factors were associated with conversion to mastectomy. This study may provide useful preliminary information required for designing a planned randomized clinical trial to determine the effect of MRI and DCIS score on surgical management, radiotherapy, overall resource use, and clinical outcomes, with the ultimate goal of achieving greater therapeutic precision.

Trial Registration

ClinicalTrials.gov identifier: NCT02352883.

Prospective study of magnetic resonance imaging (MRI) and multiparameter gene expression assay in ductal carcinoma in situ (DCIS): A trial of the ECOG-ACRIN Cancer Research Group (E4112)

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Background: Prior retrospective studies have evaluated breast MRI in DCIS, and prospective-retrospective biomarker studies have shown that the DCIS Score is prognostic for recurrence after BCS alone. E4112 is a prospective cohort study designed to assess the combined impact of breast MRI and DCIS Score on surgical and RT management. Methods: Women diagnosed with screen-detected DCIS on core biopsy, if BCS eligible, underwent breast MRI. Those remaining so following MRI and related biopsies, with no invasive disease, underwent BCS. If final surgical margins were ≥2 mm, the DCIS lesion was submitted for DCIS Score assay. Women with low DCIS Score (≤39, LS) were advised that RT could be avoided; RT was recommended to those with high/intermediate (H/I) scores. The primary objective was to estimate the fraction converting to mastectomy (Mx) following MRI. Secondary objectives included estimation of re-operation rates after first BCS, and DCIS Score distribution.A sample size of 333 evaluable women would allow estimation of Mx rate of 12% with 95% confidence interval 9-16%. Results: 334 enrolled women had completed surgery; the first surgical procedure was Mx in 54 (16.2%) and BCS in 280 (83.8%), of whom 62 (22.1%) required at least one re-excision, and 11 (3.9%) converted to Mx. DCIS Scores were obtained on 171 patients who completed BCS, of whom 82 were LS and 89 were H/I. Demographics were similar between the two groups, other features will be reported. Only 7/82 (8.5%) of the LS group received RT, whereas 82/89 (92.1%) of the H/I group received RT. Of the 98 BCS patients who did not qualify for DCIS Score-based therapy, 23 had invasive disease, 34 had final surgical margins < 2 mm, and 13 had both. There was insufficient tissue for DCIS Score in 11, and 17 did not complete follow-up. Conclusions: In this study, among DCIS patients who were BCS-eligible following MRI, total mastectomy rate was 19.5%; re-excision rate was 22.1% for women who had BCS. Approximately half had low DCIS Scores, and RT recommendations based on the DCIS Score were acceptable to most women. Clinical trial information: E4112.

Survival outcomes of screening with breast MRI in high-risk women

1508

Background: Mammography is the only imaging modality proven to reduce mortality from breast cancer. Over the past decade, magnetic resonance imaging (MRI) screening of women with increased risk of breast cancer ( > 20% cumulative life time risk) has been recommended. However, there is little evidence that supplemental screening with MRI improves survival. The purpose of this study was to compare survival outcomes of combined screening with MRI and mammography to screening mammography alone in women at increased risk for breast cancer. Methods: A total of 3,002 women at increased risk underwent at least two screening rounds between 2001 and 2005, with at least 5 years of follow-up. 1,534 women had combined screening (MRI and mammography), and 1,468 had screening mammography alone. Cancer detection yield and survival were determined in the two groups. Results: 60 women were diagnosed with breast cancer, 38 patients in the combined screening group and 22 in the mammography-only group. Cancer yield was 24.8 per 1000 (95% CI, 17.6-33.8) combined screening and 15.0 per 1000 (95% CI, 9.4-22.6) mammography-only. No interval cancers occurred in women undergoing combined screening, while 9 interval cancers were found in women undergoing only mammography screening. During a median follow-up of 10.8 years (range, 0.7-15.2), a total of 11 recurrences and 5 deaths (4 breast cancer cause and 1 unknown cause) were found. Of the 11 recurrences, 6 were in the combined screening group and 5 were in the mammography-only group. All deaths were in the mammography-only group. The Kaplan-Meier estimate for disease-free survival showed no statistically significant difference between the two groups ( P = .325). However, patients in the combined screening group had a significantly better overall survival compared with patients in the mammography-only group ( P = .002). Conclusions: Combined screening with MRI and mammography in women with increased risk of breast cancer resulted in not only a higher cancer detection yield but also better overall survival.

Deep Sequencing of T-cell Receptor DNA as a Biomarker of Clonally Expanded TILs in Breast Cancer after Immunotherapy

In early-stage breast cancer, the degree of tumor-infiltrating lymphocytes (TIL) predicts response to chemotherapy and overall survival. Combination immunotherapy with immune checkpoint antibody plus tumor cryoablation can induce lymphocytic infiltrates and improve survival in mice. We used T-cell receptor (TCR) DNA sequencing to evaluate both the effect of cryoimmunotherapy in humans and the feasibility of TCR sequencing in early-stage breast cancer. In a pilot clinical trial, 18 women with early-stage breast cancer were treated preoperatively with cryoablation, single-dose anti-CTLA-4 (ipilimumab), or cryoablation + ipilimumab. TCRs within serially collected peripheral blood and tumor tissue were sequenced. In baseline tumor tissues, T-cell density as measured by TCR sequencing correlated with TIL scores obtained by hematoxylin and eosin (H&E) staining. However, tumors with little or no lymphocytes by H&E contained up to 3.6 × 10⁶ TCR DNA sequences, highlighting the sensitivity of the ImmunoSEQ platform. In this dataset, ipilimumab increased intratumoral T-cell density over time, whereas cryoablation ± ipilimumab diversified and remodeled the intratumoral T-cell clonal repertoire. Compared with monotherapy, cryoablation plus ipilimumab was associated with numerically greater numbers of peripheral blood and intratumoral T-cell clones expanding robustly following therapy. In conclusion, TCR sequencing correlates with H&E lymphocyte scoring and provides additional information on clonal diversity. These findings support further study of the use of TCR sequencing as a biomarker for T-cell responses to therapy and for the study of cryoimmunotherapy in early-stage breast cancer. Cancer Immunol Res; 4(10); 835-44. ©2016 AACR.

A Pilot Study of Preoperative Single-Dose Ipilimumab and/or Cryoablation in Women with Early-Stage Breast Cancer with Comprehensive Immune Profiling

PURPOSE

To assess the safety and tolerability of preoperative cryoablation-mediated tumor antigen presentation and/or ipilimumab-mediated immune modulation in women with operable breast cancer.

EXPERIMENTAL DESIGN

In this pilot study, 19 women with breast cancer for whom mastectomy was planned were treated with preoperative tumor cryoablation (n = 7), single-dose ipilimumab at 10 mg/kg (n = 6), or both (n = 6). The primary outcome for this pilot study was safety/tolerability as defined as freedom from delays in pre-planned, curative-intent mastectomy. Exploratory studies of immune activation were performed on peripheral blood and tumor.

RESULTS

Preoperative cryoablation and/or ipilimumab were safe and tolerable, with no delays in pre-planned surgery. Grade III toxicity was seen in 1 of 19 (unrelated rash after ipilimumab). Combination therapy was associated with sustained peripheral elevations in: Th1-type cytokines, activated (ICOS⁺) and proliferating (Ki67⁺) CD4⁺ and CD8⁺ T cells, and posttreatment proliferative T-effector cells relative to T-regulatory cells within tumor.

CONCLUSIONS

Preoperative cryoablation and single-dose ipilimumab are safe alone or in combination with no surgical delays incurred. Potentially favorable intratumoral and systemic immunologic effects were observed with the combination, suggesting the possibility for induced and synergistic antitumor immunity with this strategy. Clin Cancer Res; 22(23); 5729-37. ©2016 AACR.

First International Consensus Conference on lesions of uncertain malignant potential in the breast (B3 lesions)

The purpose of this study is to obtain a consensus for the therapy of B3 lesions. The first International Consensus Conference on lesions of uncertain malignant potential in the breast (B3 lesions) including atypical ductal hyperplasia (ADH), flat epithelial atypia (FEA), classical lobular neoplasia (LN), papillary lesions (PL), benign phyllodes tumors (PT), and radial scars (RS) took place in January 2016 in Zurich, Switzerland organized by the International Breast Ultrasound School and the Swiss Minimally Invasive Breast Biopsy group-a subgroup of the Swiss Society of Senology. Consensus recommendations for the management and follow-up surveillance of these B3 lesions were developed and areas of research priorities were identified. The consensus recommendation for FEA, LN, PL, and RS diagnosed on core needle biopsy or vacuum-assisted biopsy (VAB) is to therapeutically excise the lesion seen on imaging by VAB and no longer by open surgery, with follow-up surveillance imaging for 5 years. The consensus recommendation for ADH and PT is, with some exceptions, therapeutic first-line open surgical excision. Minimally invasive management of selected B3 lesions with therapeutic VAB is acceptable as an alternative to first-line surgical excision.

Assessing the Environment for Support of Youth Physical Activity in Rural Communities

OBJECTIVE

Assess environmental support of physical activity (PA) in rural areas and determine whether there is a correlation between the measured environment for PA and participant perceptions of the environment for PA.

DESIGN

The PA environment was assessed using the Active Neighborhood Checklist (ANC) and the Physical Activity Resource Assessment (PARA). Youth behavior and perceptions related to PA and the local environment were assessed using 5 questions from previously validated tools.

SETTING

Four rural low-income communities in South Dakota and Kansas.

PARTICIPANTS

Sixth- through eighth-grade youth.

VARIABLES MEASURED

Physical Activity Resource Assessment, ANC, behavior, and perception.

ANALYSIS

The authors used ANOVA to determine whether there were differences in ANC, PARA, and Perception of the Environment scores among communities. Pearson correlations were used to assess associations between ANC and student perception of the environment and PARA and student perception of the environment.

RESULTS

There were no differences in total ANC or total PARA among communities. Perception was weakly correlated with total ANC (multivariate coefficient, 0.016; P = .026; n = 308) but not total PARA.

CONCLUSIONS AND IMPLICATIONS

Perception of PA in rural communities may not match objective measures. Future research should work toward refining and improving existing environmental audit tools and developing new, comprehensive, location-specific tools.

Abstract P2-15-01: Integrated immunologic assessment of tumor infiltrating lymphocytes (TILs) and peripheral blood to assess synergy of cryoablation (cryo) plus ipilimumab (ipi) in early stage breast cancer (ESBC) patients (pts)

Background: In pts with ESBC, cryo combined with cytotoxic T-lymphocyte antigen 4 blockade was well tolerated and did not delay standard-of-care mastectomy. As observed in mice, cryo+ipi may liberate tumor-associated antigens, synergistically activate tumor-reactive T-cells, and confer long-term anti-tumor immunity. Because singular biomarkers of response to immunotherapy have not been well defined, we conducted an integrated immunologic assessment to explore potential predictors of immune activation and response.

Methods: Serial blood and pre-/post-treatment tumor tissue were collected from 18 pts treated with cryo (6 pts), single-dose ipi at 10mg/kg (6 pts), or cryo + ipi (6 pts). A Meso Scale Discovery platform was used to measure plasma cytokine interferon gamma (IFNγ). Multiparameter flow cytometry was used to evaluate peripheral and intratumoral T-cell and myeloid cell quantity, T-cell phenotype (effector versus regulatory), proliferation state (Ki67), and activation state (inducible costimulator [ICOS] expression). Finally, a DNA deep sequencing platform was used to conduct T-cell repertoire analysis of peripheral T-cells and TILs.

Results: Sustained &gt;2-fold elevations (1 month post-treatment) in plasma IFNγ were observed in the majority (4/6) of pts receiving cryo/ipi (median 6-fold increase), but in the minority of pts receiving cryo (0/6, median 0-fold) or ipi (2/6, median 0-fold). Similarly, sustained &gt;2 fold elevations in ICOS expression in peripheral CD3+CD4+ T-cells, a known pharmacodynamic marker of ipi, were observed in the majority (5/6) of pts receiving cryo/ipi (median 4-fold increase), but in the minority of pts receiving cryo (0/6, median 0-fold) or ipi (2/6 ipi; median 1-fold). No trends were observed in peripheral myeloid derived suppressor cells. Analysis of TILs by flow cytometry identified increased numbers of proliferating CD8+ T-cells (CD8+Ki67+) in ipi and cryo/ipi groups relative to cryo alone; furthermore, the ratio of proliferating (CD8+Ki67+) to regulatory (CD4+CD25+FoxP3+) cells was enhanced in the cryo/ipi group. Finally, analysis of T-cell repertoire in TILs demonstrated that cryo/ipi generated an influx of novel T-cell clones, with select clones surging dramatically in predominance and circulating within the periphery.

Conclusions: Utilizing an integrated assessment, we identified evidence of immunologic synergy with combination cryo/ipi versus either therapy alone. Of the tested parameters, peripheral CD4+ ICOS expression, plasma IFNγ, Ki67-gated TIL effector/regulatory ratios, and clonal repertoire analysis were identified as promising biomarkers of immune activation. These findings will inform a prospective assessment of potential immunologic biomarkers of immune response and clinical benefit in a phase 2 study of cryo-immunotherapy in ESBC.

Citation Format: David Page, Jianda Yuan, Adi Diab, Zhiwan Dong, Arielle Ginsberg, Phillip Wong, Ryan Emerson, David Redmond, Brian Blum, Zhenyu Mu, Chunjun Zhao, Christopher Comstock, Elizabeth Morris, Elizabeth Comen, Alan Kotin, Janice Sung, Edi Brogi, Monica Morrow, Stephen Solomon, Virgilio Sacchini, Majid Maybody, Deirdre Neville, Harlan Robins, Sujata Patil, Jedd Wolchok, Clifford Hudis, Larry Norton, James Allison, Padmanee Sharma, Heather McArthur. Integrated immunologic assessment of tumor infiltrating lymphocytes (TILs) and peripheral blood to assess synergy of cryoablation (cryo) plus ipilimumab (ipi) in early stage breast cancer (ESBC) patients (pts) [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-15-01.

Ultrasonographic features and clinical implications of benign palpable breast lesions in young women

PURPOSE

The purpose of this study was to describe the breast ultrasonography (US) features and to investigate whether performing a core biopsy is warranted in young women having palpable solid breast masses.

METHODS

A total of 76 solid palpable masses in 68 consecutive women (≤25 years old) underwent tissue diagnosis by percutaneous core biopsy. Two radiologists, who were blinded to the clinical history and histopathology, independently evaluated the US features according to Breast Imaging-Reporting and Data System (BI-RADS) lexicon. The frequency of benign and malignant descriptor terms that were used to characterize the lesions were compared to the final pathology.

RESULTS

All 76 palpable solid masses yielded benign pathology. On the US, the shape of the mass was described by radiologists 1 and 2 as oval or round (63.2% and 71.1%), margin as circumscribed (68.4% and 77.6%) and orientation as parallel (85.5% and 90.8%); the frequency of using all three benign descriptors was 61.8% and 68.5%, respectively. Suspicious descriptors were used less frequently by radiologists 1 and 2 including irregular shape (9.2% and 13.1%), non-circumscribed margin (31.6% and 22.4%) and non-parallel orientation (14.5% and 9.2%); the frequency of using all three suspicious descriptors was 9.2% and 11.8%, respectively.

CONCLUSION

Despite the variable US features, breast malignancy seems extremely low in 25 years or younger women for palpable breast lesions. Using the BI-RADS lexicon, US accurately predicted benignity in about two thirds of our patients, supporting US surveillance as a safe alternative to invasive tissue sampling in this setting.

Tumor and systemic immune responses to preoperative (pre-op) cryoablation (cryo) plus immune therapy with ipilimumab (ipi) in early-stage breast cancer (ESBC)

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Background: In mice, tumor cryo plus immunologic checkpoint blockade generates tumor antigen release, proliferation of tumor-specific T-cells, and enhanced survival. We previously demonstrated in a pilot study that pre-op cryo+ipi is well tolerated in women with ESBC and did not delay standard of care surgical resection. Here, we analyze pilot study tissue and blood to explore immune response. Methods: 18 ESBC patients (pts) were treated with preop cryo (n=6), single-dose ipi 10mg/kg (n=6), or cryo+ipi (n=6). As a potential surrogate for tumor immunogenicity, baseline T-cell tumor infiltrating lymphocyte (TIL) density was evaluated by T-cell receptor quantitative DNA sequencing. We explored the systemic immune response to cryo and/or ipi using previously described laboratory measures including inducible costimulator (ICOS, a marker of activated CD4+ T-cells) and plasma interferon gamma (IFNγ, a cytokine associated with T-cell activity). Results: Of the 18 study pts, 13 pts had hormone receptor-positive (HR+) disease, 2 pts had HER2+ disease (both treated with ipi alone) and 3 pts had triple-negative (TN) disease (1 ipi alone and 2 cryo/ipi). Baseline TIL density was highly variable overall (range 2-30%), but higher in HER2+ and TN pts (median 15%) compared with HR+ pts (median 5%). Sustained >2-fold elevations in ICOS and IFNγ were observed in the majority of cryo+ipi pts 30 days following treatment (ICOS: 5/6 pts; IFNγ: 4/6 pts), but in the minority of ipi pts (ICOS: 2/6 pts; IFNγ: 2/6 pts) or cryo pts (ICOS: 0/6 pts; IFNγ: 0/6 pts). Sustained ICOS and IFNγ elevations were observed regardless of baseline TIL density. Conclusions: Cryo+ipi was more likely to induce systemic immune activation compared to cryo or ipi alone. These potentially beneficial immune effects were observed in both HR+ and HR- subtypes, as well as in tumors with low or high baseline TIL density. These data support further studies of cryo+ipi in ESBC across HR+ and HR- subtypes, as well as in tumors that do not appear immunogenic at baseline.

Percutaneous image-guided ablation of breast tumors: an overview

Percutaneous non-surgical image-guided ablation is emerging as an adjunct or alternative to surgery in the management of benign and malignant breast tumors. This review covers the current state of the literature regarding percutaneous image-guided ablation modalities, clinical factors regarding patient selection, and future directions for research.

BI-RADS 3 for magnetic resonance imaging

A BI-RADS (Breast Imaging Reporting and Data System) 3, or probably benign, assessment is given in approximately 7% to 12% of breast magnetic resonance (MR) images. However, the imaging features of probably benign lesions on MR imaging have not been well defined. As with mammography and ultrasonography, a BI-RADS 3 assessment should be used only when there is a less than 2% likelihood of malignancy. The use of BI-RADS 3 for classically benign findings should be avoided. Certain masses, foci, and areas of nonmass enhancement may be categorized as probably benign on baseline MR imaging.

A pilot study of preoperative (Pre-op), single-dose ipilimumab (Ipi) and/or cryoablation (Cryo) in women (pts) with early-stage/resectable breast cancer (ESBC)

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Background: Intratumoral cryo combined with immune modulation generates a potent systemic anti-tumor immune response that might improve recurrence free survival in ESBC. In this study, we evaluate the safety of pre-op cryo and/or ipi (10mg/kg) in pts with ESBC. Radiographic correlates and intratumoral/serologic immune responses are also explored. Methods: Eligible pts are ≥18y of age with operable ≥1.5 cm invasive ESBC, no history of autoimmune disease and planned mastectomy. Pts are sequentially assigned to receive pre-op: cryo alone (Group-A), ipi alone (B), or ipi with cryo (C). Cryo is administered 7-10d prior to surgery. Ipi is administered 8-15d prior to surgery (1-5d prior to cryo). If at least 5/6 pts in each group proceed with surgery without delay, the regimen will be considered safe/tolerable. Toxicity evaluation continues for 12 wks after ipi administration for Groups B and C. Results: As of May 1, 2013, 7/7 pts were enrolled to Group-A (expanded after a possible technical failure in 1 pt) and 6/6 pts were enrolled to Group-B. The median age was 45y (range 39-69y). All 13 pts in Groups A and B underwent mastectomy without delay. Group C is now accruing with 1/6 patients enrolled and awaiting surgery. 6/7 pts in Group-A and none in Group-B had ischemic tumor necrosis/infarction in the mastectomy tissue. Overall, pre-op cryo or ipi alone have been well tolerated with no study related grade 3/4 adverse events (AE) reported (Table). Conclusions: To date, pre-op cryo or ipi is safe and tolerable in pts with ESBC. A Phase II study of pre-op ipi and cryo in ESBC is planned. Clinical trial information: NCT01502592. [Table: see text]

A pilot study of preoperative, single-dose ipilimumab (Ipi) and/or cryoablation (Cryo) in women (pts) with early stage/resectable breast cancer (ESBC)

TPS3120

Background: Intratumoral cryo combined with immune modulation generates a potent systemic anti-tumor immune response that might improve recurrence-free survival in ESBC. Cryo-mediated tumor destruction results in necrosis and immunogenic cell death which exposes dendritic cells (DC) to sufficient quantities of tumor antigens and inflammatory cytokines to induce their maturation and activation and elicit tumor specific T cell responses. To further amplify this immune response we use ipi, a human monoclonal antibody that blocks cytotoxic T lymphocyte antigen-4 (CTLA4). In preclinical murine models, the combination of cryo with CTLA4 blockade successfully mediates rejection of metastatic prostate cancer lesions and prevents growth of secondary tumors. We therefore hypothesize that this strategy could confer long-term immunity for pts with ESBC. In this study, we evaluate the safety of pre-op cryo and/or immune modulation with single dose ipi (at 10 mg/kg) in pts with ESBC. Methods: Pts are sequentially assigned to receive pre-op: cryo alone (Group A), ipi alone (B), or ipi with cryo (C). Cryo is administered 7-10 d prior to surgery. Ipi is administered 8-15 d prior to surgery (1-5 d prior to cryo). If at least 5/6 pts in each group proceed with surgery without delay, the regimen will be considered safe/tolerable.Primary aim: To evaluate the safety of pre-op cryo and/or ipi (10mg/kg) in pts with ESBC.Seconday aims: To characterize pre- and post-intervention radiographic and immunological (peripheral blood and tumor tissue) correlates. Eligibility: Pts ≥18y of age with operable ≥1.5 cm invasive ESBC, no history of autoimmune disease and planned mastectomy. Study status: As of January 25, 2013 7/7 pts were enrolled to Group A (expanded after 1 pt had suspected incomplete cryo) and 5/6 pts were enrolled to Group B. Enrollment to Group C will open when the pts in Group B meet the safety endpoint 30 d (+/-10 d) after surgery. Toxicity evaluation continues for 12 wks after ipi administration for Groups B and C. Clinical trial information: NCT01502592.

OT2-05-06: ACOSOG Z11101/ACRIN 6694: Effect of Preoperative Breast MRI on Surgical Outcomes, Costs and Quality of Life of Women with Breast Cancer

Background

Surgical planning and local-regional treatment of breast cancer relies on accurate assessment of disease extent including the primary tumor size and the presence/absence of multiple tumor foci. As a staging modality for breast cancer, MRI has shown high sensitivity for detection of additional foci of diseases within the index breast. However, the impact of preoperative breast MRI on reducing re-excision rates and improving local control is less clear. Data from the COMICE trial in the UK suggested that routine use of pre-operative breast MRI did not alter rates of re-excision; however issues have been raised about the lack of quality standards for the MR imaging that may have resulted in the negative results of this trial. Retrospective data suggest that local recurrence is not impacted by use of breast MRI. In concert with data showing no improvement in clinical outcomes of breast cancer patients, concerns have been raised that routine use of preoperative breast MRI is associated with increased rates of mastectomy and delays to surgery. Therefore, the application of MRI for preoperative surgical staging remains controversial. In order to address this ongoing controversy, a joint effort has been launched by ACOSOG and ACRIN for a prospective clinical trial focused on evaluating the impact of preoperative breast MRI on clinically relevant patient outcomes. An important part of this collaboration is implementation of standards of how MRI findings should be clinically managed and used to direct localization methods and surgical planning, thereby creating guidelines for subsequent patient intervention.

Trial design/eligibility criteria: A prospective multicenter trial will include women eligible for BCT by standard criteria and randomized between current standard of care, clinical examination and mammography (+/− ultrasound) and the same plus preoperative breast MRI. The study will focus on women at the highest risk of local recurrence: ER/PR/HER-2 negative (triple negative) and HER-2 amplified breast cancers.

Specific aims: To compare the rates of local recurrence following breast conserving therapy in a cohort randomized to preoperative staging with mammography or mammography plus breast MRI. Additionally, a comparison of rates of re-operation, time to local recurrence, survival outcomes, contralateral breast cancer rates, rates of multicentric disease and other secondary aims will be performed. Costs and quality of life measures will also be investigated.

Statistical methods: A stratified logrank test and Cox partial likelihood score test will be used to assess whether the distribution of LR times differs with respect to diagnostic work-up approach having adjusted for tumor stage. Cox modeling with the Cox partial likelihood score test will be used to examine the strength of association between these time to event distributions and such additional potential prognostic factors as menopausal status, chemotherapy, radiation therapy, ER, PR, number of positive lymph nodes, HER-2/neu expression, Nottingham grade, and Ki-67 expression.

Target Accrual: 556 patients

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr OT2-05-06.

Near infrared transillumination imaging of breast cancer with vasoactive inhalation contrast

Inhalation of vasoactive gases such as carbon dioxide and oxygen can provide strong changes in tissue hemodynamics. In this report, we present a preliminary clinical study aimed at assessing the feasibility of inhalation-based contrast with near infrared continuous wave transillumination for breast imaging. We describe a method for fitting the transient absorbance that provides the wavelength dependence of the optical pathlength as parametrized by tissue oxygenation and scatter power as well as the differential changes in oxy- and deoxy-hemoglobin. We also present a principal component analysis data reduction technique to assess the dynamic response from the tissue that uses coercion to provide single temporal eigenvalues associated with both oxy- and deoxy-hemoglobin changes.

Effect of a low-lying placenta on delivery outcome

OBJECTIVES

To evaluate delivery outcome in pregnancies with a low-lying placenta (within 2 cm of, but not covering, the internal os) that had been identified within 4 weeks of delivery. We examined the likelihood of a vaginal delivery and investigated the clinical significance of the placental edge to internal os measurement.

METHODS

A retrospective chart review was performed for singleton pregnancies delivering in the third trimester with a low-lying placenta identified within 4 weeks of delivery. Outcome variables included type of delivery, maternal and neonatal hemoglobin levels, and umbilical artery pH levels.

RESULTS

Eighty-six patients met the study criteria of a low-lying placenta identified within 4 weeks of delivery. Forty-five of these patients were allowed to labor and, of these, 29 (64.4%) delivered vaginally. The vaginal delivery rate was 76.5% in patients with a placenta to cervical os distance of 1-2 cm, significantly greater than the rate of 27.3% in patients in whom the placenta was within 1 cm of the cervix (P = 0.0085). A maternal hemoglobin level below 8.0 g/dL was the most common morbidity associated with low-lying placenta. Analysis of morbidity observed did not clearly favor either elective Cesarean delivery or attempted vaginal delivery.

CONCLUSIONS

In this retrospective study, most laboring patients with a low-lying placenta were able to have a vaginal delivery with limited morbidity. The likelihood of a vaginal delivery was greater with increased placenta to cervical os distance. Further studies are needed to determine the clinical significance of the placenta to cervical os distance and the interval from scan to delivery.

Breast imaging: a surgeon's prospective

Mammography, ultrasound, magnetic resonance imaging, positron emission tomography, gamma camera and intraoperative gamma detection, and computed tomography are employed in the diagnosis and treatment of breast cancer. This paper summarizes the role of each modality from the perspective of the physician responsible for management of the patient's care. An understanding of an imaging modality's current role can provide insights into the design of new applications and diagnostic agents. Moreover, knowledge of the mechanism by which each modality provides clinical information can guide the design of new imaging methods that complement and add certainty to the patient's management. The reader should note the lack of molecular information provided by the current imaging methods. The perspective concludes with a request for an imaging technique that can measure the biologic aggressiveness of a woman's cancer. The surgeon notes that basing the formation of an image on a molecular process would be compatible with current medical practice, which utilizes molecular concepts to base medical decisions. In addition, molecular imaging will enable rapid translation between basic science and medical practice.

Fetal schistocytic hemolytic anemia and umbilical vein varix

A rare case of schistocytic hemolytic anemia presenting in a fetus secondary to a varix of the intra-abdominal umbilical vein is reported. A patient was referred to our hospital at 32 weeks of gestation because of an abnormal hypoechoic finding in the fetal liver. Prenatal ultrasound showed turbulent flow through a 12-mm diameter dilatation of the fetal intra-abdominal umbilical vein consistent with a varix. Cardiomegaly also was noted. At birth, the 1098-g, growth-retarded, male neonate was in severe congestive heart failure secondary to anemia as the initial hemoglobin was 5 g/dL. Additional evaluation found the anemia to be secondary to schistocytic hemolysis. After the neonate received a transfusion of packed erythrocytes and supportive care, the anemia quickly resolved, and he was discharged to home doing well after a 6-week stay in the neonatal intensive care unit. Prompt recognition of the varix prenatally and thorough evaluation of the newborn postnatally led to appropriate diagnosis and treatment.

Eye examinations for VA patients with diabetes: standardizing performance measures

OBJECTIVE

To demonstrate the potential of the Health Plan Employer Data and Information Set (HEDIS) for the calculation of a performance measure for eye exams in the diabetic population using Veterans Health Administration (VA) administrative data.

DESIGN

We calculated a 1-year HEDIS-defined patient denominator and three alternative denominators that considered coding factors in identifying a VA patient as diabetic. We calculated the HEDIS-defined numerator, along with alternative specifications that captured other types of eye exams. Finally, we supplemented national data with VA pharmacy and Medicare claims data to identify all VA diabetic patients at 14 selected VA facilities and to establish a more accurate picture of non-VA health care utilization.

RESULTS

The national average annual HEDIS-defined eye exam rate in the VA was 26% in fiscal 1997 compared with 39% for managed care organizations. Medicare utilization raised this by 15 percentage points at 14 northeastern VA hospitals. Over 2 years, at least two-thirds of diabetic VA patients had some type of eye exam through VA or Medicare.

CONCLUSION

A HEDIS measure of eye exams for VA patients with diabetes can be calculated using VA administrative data only. However, the question remains to what extent the denominator and numerator accurately and completely identify all diabetic patients using VA services and all appropriate eye exams. We recommend caution in interpreting the results of performance measurement across different health care sectors based on what we currently know are data system limitations.

Private sector coverage of people with dual diagnoses

In general, people with dual diagnoses account for a significant proportion of both the mental health and substance abuse populations. Most published information on dual diagnosis comes from research on selected treatment programs that are largely funded from public sources. This analysis uses private health insurance claims and eligibility files for 1989 to 1991 for three large firms to identify individuals with both substance abuse and mental health claims and to examine their characteristics, charges, and utilization. More than half of people with dual diagnoses incurred significant charges over three years in both mental health and substance abuse. These individuals with high mental health charges were more likely to be male than were patients with mental health claims alone; they were less likely to be male than were patients with claims for substance abuse and no mental health services. They were also significantly younger than were patients with substance abuse or mental health utilization only for two of the firms. The average charges for people with dual diagnoses were higher than those for patients with substance abuse or mental health claims only.

Do individuals with substance abuse diagnoses incur higher charges than individuals with other chronic conditions?

Concerns about high costs have led to limits on the services covered by most insurance plans for substance abuse treatment. But, the commonly used comparison group for cost analyses, all enrollees in a health-care plan, may not be appropriate because addiction is a chronic condition. Therefore, to determine whether substance abusers incur higher charges than patients with other serious chronic conditions, we used health insurance information for employees and dependents over 3 years (1989 to 1991) for two firms with a total of almost 40,000 employees to do alternate comparisons. We compared average annual charges for patients with the following diagnoses: substance abuse, substance abuse with mental illness, arthritis, asthma, and diabetes. Patients who undergo treatment for abusing alcohol, drugs, or both often (but not always) incur higher charges than people with other chronic conditions. Clear differences in average charges emerge between patients with and without mental health claims.

Using health insurance claims data to analyze substance abuse charges and utilization

It is crucial to evaluate whether health insurance data sets will provide robust answers to significant research questions in advance of undertaking large research studies using these data. In this article, we present the research challenges of using insurance claims data sets to study substance abuse. Using illustrations from the itemized claims from three large employers, we focus on using administrative data to analyze costs to employers, utilization of services to treat abuse of specific drugs, and the effects of managed care strategies. We conclude that insurance claims data sets are useful for reporting employers' payments for treatment of identified substance abusers and for tracking changes over time but are not useful for studies of the use of treatment for specific drugs.

Reimplantation of a contaminated and devitalized bone fragment after autoclaving in an open fracture

This case report describes a technique for dealing with open fractures with segmental bone loss and a critical need for restoration of anatomical alignment. In the majority of cases, autogenous bone graft can and should be used successfully. Regardless of the treatment option chosen though, meticulous debridement and sound judgment in regards to wound care and bony stabilization remain the foundation to a successful outcome. Autoclaving a devitalized bone fragment with subsequent reimplantation as described in this case report, although not the procedure of choice, does offer the orthopaedist another option in dealing with the difficult segmental fracture.

A clinical and radiographic study of the "safe area" using the direct lateral approach for total hip arthroplasty

The purpose of this clinical and radiographic study is to determine whether the surgeon can remain within the 5 cm "safe zone" while using the direct lateral approach during total hip arthroplasty (THA) without endangering the superior gluteal nerve. The direct lateral approach was used in a prospective, consecutive series of 36 primary THAs in 31 patients performed by one surgeon. At the time of closure of the abductor muscle layer, a small metallic clip was placed at the superior extent of the incision into the gluteus medius. After surgery, the patients were mobilized on crutches with protected weight bearing for either a 6-week (hybrid THA) or 12-week (uncemented THA) period. Before surgery, and at 3, 6, and 12 months after surgery, abductor strength and the Trendelenburg sign were measured by the same physical therapist. The vertical distance from the superior pole of the greater trochanter to the base of the clip was measured on all radiographs of the pelvis and corrected for magnification. Before surgery, only 25 of the 36 hips demonstrated abduction strength of 4/5 or greater. Three months after surgery, 34 hips had a grade of 4/5 or greater for abductor strength. The Trendelenburg sign was positive in 24 of 34 hips before surgery, in 5 hips at 3 months, in 1 hip at 6 months, but negative in all hips by 12 months. The clip was located 3.2 +/- 1.3 cm (mean +/- SD) vertically from the superior pole of the greater trochanter. In 34 of 36 hips (95%), the 5 cm safe zone was respected.(ABSTRACT TRUNCATED AT 250 WORDS)

Pudendal nerve palsy after femoral intramedullary nailing

Pudendal nerve palsy after femoral intramedullary (IM) nailing was retrospectively reviewed in 65 nailings performed on 63 patients. Ten pudendal nerve palsies (15%) were noted in eight male patients and two female patients. Three male patients had autonomic involvement affecting erections. All palsies were transient (3-173 days), and occurred in patients done in the supine position as opposed to the lateral position. A possible etiology is the smaller perineal post used in the supine position that may penetrate the pelvis deeper, compressing the pudendal nerve. Other factors may be operating time and amount of traction. As prevention, the perineal post must always be adequately padded, and the operating time and amount of traction should be minimized to decrease the incidence of pudendal nerve palsy. Because pudendal nerve palsy appears to be a common complication in femoral IM nailing, the patient must be informed of this possibility.

Coronary heart disease in Massachusetts: the years of change (1980-1984)

During this decade, diagnosis and treatment of coronary heart disease (CHD) have become far more aggressive and invasive than in prior decades. This study documents rates of hospitalization, use of various treatment options, a case fatality in the state of Massachusetts during 4 of the first 5 years of this decade (1980, 1982, 1983, and 1984). The data base was that of the Massachusetts Health Data Consortium (MHDC), covering all hospital discharges in the state, a total of 3.8 million discharge records for this period. Of these, about 190,000 (5%) fell into two active symptomatic categories of CHD: chronic active coronary disease (CACD) and acute myocardial infarction (AMI). Total hospitalization rate for these CHD categories increased by 17%; this was due both to an increased rate of hospital transfers (or readmissions) and to a larger cohort of patients under care. The case fatality rate for hospitalized CHD decreased approximately 16%, from 9.7% (1980) to 8.1% (1984). In CACD the frequency of coronary angiography (CA) rose; the use of percutaneous transluminal coronary angioplasty (PTCA) increased much faster than the rate of coronary artery bypass grafting (CABG), with a resultant increase in PTCA as a fraction of total interventions. Similar findings were recorded for AMI, but with much more marked changes, the total intervention rate increasing almost twenty-fold from 1980 to 1984. The statewide mortality rate for hospitalized CHD patients remained essentially unchanged at 71 to 74 hospital deaths per 100,000 population.

Report on variation in rates of utilization of surgical services in the Commonwealth of Massachusetts

This article presents an analysis of over 140,000 selected surgical procedures performed in Massachusetts in 1980, giving the per capita rates of 14 common procedures and of four less frequently performed procedures. The analysis defines 172 geographic areas for the commonly performed procedures and 45 for the less frequently performed procedures. Per capita surgical rates among the defined areas are significantly different from both a statistical and a clinical point of view. Twofold and threefold variations occur frequently across geographic areas. In certain areas, some surgical services appear to be provided at rates substantially different from the statewide rate. We discuss the importance of these data for physicians as well as the implications for the distribution and quality of clinical care and for containment of medical care costs.