Patient characteristics associated with definitive diagnosis of metastatic pancreatic cancer in those initially diagnosed with cancer of unknown primary

Cancer of unknown primary (CUP) and pancreatic cancer (PC) are malignancies associated with poor prognosis. CUP is the fourth most common cause of cancer mortality in the US, and median survival time is 3-4 months. PC is the third most common cause of cancer mortality in the US, and median survival time for patients with stage 3 or 4 PC is 2-3 months. The present study aimed to understand the patient characteristics of those initially misdiagnosed with CUP who ultimately received a diagnosis of PC. The present study used 2010-2015 Surveillance, Epidemiology, and End Results-Medicare data, a US population-based cancer registry linked to Medicare health insurance claims. Odds ratios (ORs) and 95% confidence intervals were calculated using two binary logistic regression models to compare the characteristics of patients who received definitive diagnosis between the CUP-PC group (those with an initial diagnosis of CUP who eventually received a stage 3 or 4 PC diagnosis) and the PC group (those diagnosed with stage 3 or 4 PC only). Approximately 26% of patients who received a definitive diagnosis of metastatic PC started with an initial diagnosis of CUP (n=17,565). The odds of definitive PC diagnosis in patients with CUP were lower for those with a comorbidity score of 0 [OR, 0.85 (95% CI: 0.79, 0.91)] and epithelial/unspecified histology [OR, 0.76 (95% CI: 0.71, 0.82)]. The odds of definitive PC diagnosis in patients with CUP were higher for patients of other race [OR, 1.27 (95% CI: 1.13, 1.43)] compared with white patients. Definitive diagnosis of PC in patients with CUP was lower in patients who were older with fewer or no comorbidities and unspecified histology. The complexity of CUP diagnosis and patient performance status may influence delays in diagnosis to a known primary site.

Detection of Antibody-Dependent Cell-Mediated Cytotoxicity-Supporting Antibodies by NK-92-CD16A Cell Externalization of CD107a: Recognition of Antibody Afucosylation and Assay Optimization

Antibody-dependent cell-mediated cytotoxicity (ADCC) by natural killer (NK) lymphocytes eliminates cells infected with viruses. Anti-viral ADCC requires three components: (1) antibody; (2) effector lymphocytes with the Fc-IgG receptor CD16A; and (3) viral proteins in infected cell membranes. Fc-afucosylated antibodies bind with greater affinity to CD16A than fucosylated antibodies; individuals' variation in afucosylation contributes to differences in ADCC. Current assays for afucosylated antibodies involve expensive methods. We report an improved bioassay for antibodies that supports ADCC, which encompasses afucosylation. This assay utilizes the externalization of CD107a by NK-92-CD16A cells after antibody recognition. We used anti-CD20 monoclonal antibodies, GA101 WT or glycoengineered (GE), 10% or ~50% afucosylated, and CD20-positive Raji target cells. CD107a increased detection 7-fold compared to flow cytometry to detect Raji-bound antibodies. WT and GE antibody effective concentrations (EC50s) for CD107a externalization differed by 20-fold, with afucosylated GA101-GE more detectable. The EC50s for CD107a externalization vs. 51Cr cell death were similar for NK-92-CD16A and blood NK cells. Notably, the % CD107a-positive cells were negatively correlated with dead Raji cells and were nearly undetectable at high NK:Raji ratios required for cytotoxicity. This bioassay is very sensitive and adaptable to assess anti-viral antibodies but unsuitable as a surrogate assay to monitor cell death after ADCC.

Systematic review of the CUP trials characteristics and perspectives for next-generation studies

BACKGROUND

Research on therapeutic strategies for patients with unknown primary cancer (CUP) has been underwhelming. This paper summarized and evaluated the CUP therapeutic research over the previous five years. Based on this evaluation, recommendations for clinical trial designs are made to improve the impact of CUP research on patients.

METHODS

Published and ongoing research were evaluated. PubMed was searched from January 1, 2015, to November 1, 2021. The start date of 2015 was chosen to identify research published after ESMO issued new diagnostic and therapeutic guidelines. The US National Library of Medicine indexed ongoing clinical trials.

FINDINGS

Of the 244 CUP studies indexed in PubMed, 11.9% were prospective studies, and 4.9% were clinical trials. The review protocol deemed 65 publications eligible for full-text review. Eleven studies evaluating therapeutic regimens were retained. The two prospective studies and non-randomized trials showed promising outcomes for site-specific treatments. Randomized clinical trials were less promising; however, the trials had recruitment challenges resulting in biased accrual and the inability to keep pace with advancing diagnostics and therapeutics. Most of the 35 ongoing studies were phase II single-arm trials assessing immune checkpoint inhibitors (ICI) or site-specific therapies among CUP patients with suspected favorable prognoses.

CONCLUSION

Our evaluation suggests two prospective clinical trial designs that addressed recent study design and recruitment challenges. A visionary approach uses a multi-arm, multistage randomized trial to address rapid advancements in diagnosis and therapy. A pragmatic approach utilizes a single-arm trial with historical controls to overcome comparison group and recruitment challenges.

CD95/Fas-ligation and resting NK or IL-2 activated NK (LAK) attack limit NK-92 efficacy

Adoptively transferred NK-92 cells and genetically modified variants must undergo irradiation to prevent proliferation, since NK-92 cells are themselves tumors. This malignant quality also makes NK-92 cells susceptible to attack by patients’ NK cells. Here, we investigated the effect of gamma-irradiation and/or Fas-ligation on NK-92 killing against K562 tumor cells, as well as the effect of irradiation on the susceptibility of NK-92 cells to attack by primary NK cells. To evaluate killing, we used a 51Cr-release assay with multiple effector to target (E:T) K562 tumor cell ratios at 4- and 8-hour time points, 10 Gy irradiation and IgM antibody ligation of Fas. (K562 cells lack detectable Fas). NK-92 cells, maintained in 1000 U/ml of recombinant IL-2, retained high cytotoxic activity immediately after irradiation, but lost >50% activity one day after 10 Gy irradiation. NK-92 cells were highly resistant to death initiated by CD95-ligation, whether irradiated or not. However, the surviving NK-92 cells suffered loss of cytotoxicity following Fas-ligation. This loss of cytotoxicity was more pronounced when Fas-ligation and irradiation were combined. Irradiation also made NK-92 cells more sensitive to attack by resting NK cells and IL-2 activated NK (LAK) cells. These findings demonstrate that Fas-ligation and irradiation are detrimental to NK-92 functionality and support the recommendation that genetic removal of CD95/Fas may increase cytotoxicity by NK-92 cells and potentially, other cell lines used for adoptive immunotherapies.

This research was supported in part by a UNR Foundation Award, an NIH P30 GM110767 for the Cytometry Center, a Nevada Undergraduate Research Award, and by the Nevada INBRE program (NIH GM103440) for research scholarship and supplies that helped support the project.

Evaluation of the DNA topoisomerase inhibitor irinotecan (CPT-11) as an alternative to irradiation for pretreatment of NK-92s prior to adoptive cell immunotherapy

Irradiation damages both proteins and DNA, which reduces the cytotoxicity of NK-92 cells as well as preventing their growth and engraftment when used for adoptive immunotherapies of cancer. We evaluated the DNA topoisomerase inhibitor irinotecan (CPT-11) as an alternative method to 10 Gy irradiation that might better preserve the perforin-granzyme cytotoxicity mediated by NK-92 cells towards tumor cells. Irinotecan is enzymatically converted into an active metabolite SN-38 which promotes its potential to become a delayed inhibitor in comparison to camptothecin which is a structurally similar topoisomerase inhibitor that is immediately active. We pretreated NK-92 cells for 4 hours with different concentrations of CPT-11, and measured NK-92 cell death and the effects on cell-mediated cytotoxicity towards Raji tumor cells (measured by 51Cr release one day after pretreatment). Previous experiments with 10 Gy irradiation were used for comparative purposes. Irinotecan had a dose response on cell death which progressed for 5 days. We found that one day after pretreatment with as little as 80 – 100 uM CPT-11, viable cell recoveries were similar to 10 Gy irradiated with over 50% compared to the counts of control cells. Activity of the viable cells after CPT-11 pretreatment, compared by lytic units, was over 30% conserved whereas irradiated cell activity was 2.9%, compared to controls. This data demonstrate that the negative effects of anti-proliferative treatment are less pronounced with irinotecan, than for irradiation. We conclude that optimization of dosage and exposure times to irinotecan may offer a means to prolong the life and function of NK-92 cells that are used for adoptive immunotherapies.

Supported by the Nevada INBRE NIH GM103440, for student summer research scholarship and the UNR Foundation C.E. Hudig Fund.

Optimizing NK-92 serial killers: gamma irradiation, CD95/Fas-ligation, and NK or LAK attack limit cytotoxic efficacy

BACKGROUND

The NK cell line NK-92 and its genetically modified variants are receiving attention as immunotherapies to treat a range of malignancies. However, since NK-92 cells are themselves tumors, they require irradiation prior to transfer and are potentially susceptible to attack by patients' immune systems. Here, we investigated NK-92 cell-mediated serial killing for the effects of gamma-irradiation and ligation of the death receptor Fas (CD95), and NK-92 cell susceptibility to attack by activated primary blood NK cells.

METHODS

To evaluate serial killing, we used 51Cr-release assays with low NK-92 effector cell to target Raji, Daudi or K562 tumor cell (E:T) ratios to determine killing frequencies at 2-, 4-, 6-, and 8-h.

RESULTS

NK-92 cells were able to kill up to 14 Raji cells per NK-92 cell in 8 h. NK-92 cells retained high cytotoxic activity immediately after irradiation with 10 Gy but the cells surviving irradiation lost > 50% activity 1 day after irradiation. Despite high expression of CD95, NK-92 cells maintained their viability following overnight Fas/CD95-ligation but lost some cytotoxic activity. However, 1 day after irradiation, NK-92 cells were more susceptible to Fas ligation, resulting in decreased cytotoxic activity of the cells surviving irradiation. Irradiated NK-92 cells were also susceptible to killing by both unstimulated and IL-2 activated primary NK cells (LAK). In contrast, non-irradiated NK-92 cells were more resistant to attack by NK and LAK cells.

CONCLUSIONS

Irradiation is deleterious to both the survival and cytotoxicity mediated by NK-92 cells and renders the NK-92 cells susceptible to Fas-initiated death and death initiated by primary blood NK cells. Therefore, replacement of irradiation as an antiproliferative pretreatment and genetic deletion of Fas and/or NK activation ligands from adoptively transferred cell lines are indicated as new approaches to increase therapeutic efficacy.

The outcome of patients with serous papillary peritoneal cancer, fallopian tube cancer, and epithelial ovarian cancer by treatment eras: 27 years data from the SEER registry

AIM

To determine the differential effect of the treatment periods on the survival of patients with stage IV serous papillary peritoneal carcinoma (SPPC), fallopian tube cancers, and epithelial ovarian cancers (EOC).

METHODS

This was an exploratory, population-based observational study of all patients with stage IV SPPC, fallopian tube cancers, and EOC collected from the SEER Research Data 1973-2017. The study period was divided into three time-periods: platinum combinations before the taxane era (1990-1995), platinum plus taxane chemotherapy era (1996-2013), and bevacizumab era (2014-2017).

RESULTS

A total of 9828 patients were eligible for analyses: SPPC (3898 patients; 39.7%), fallopian tube cancers (1290 patients; 13.1%) and EOC (4640 patients, 47.2%). In the 1990-1995 era, the 3-year cause-specific survival was 40% for SPPC, 53% for fallopian tube cancers, and 40% for POC. In the following era 1993-2013, the 3-year cause-specific survival increased to 55% for SPPC, 74% for fallopian tube cancers, and 45% for POC. The last era 2014-2017 showed a 3-year cause-specific survival of 64%, 67%, and 45% for patients with SPPC, fallopian tube cancers, and POC, respectively. The differences in cause-specific survival were statistically significant for patients with SPPC (p=0.004). Multivariable analysis showed that the treatment eras and age at diagnosis were associated with cause-specific survival.

CONCLUSION

The results of this study are hypothesis-generating and cannot be considered conclusive given the inherent limitations of registry analysis. Subgroup analyses of the phase III randomized controlled trials, by tumor subset (EOC, fallopian tube cancer, and SPPC) would shed more light on the differential effects of novel therapies.

NK-92 serial killers - characterization of potential limitations to cytotoxic capacity

The NK cell line NK-92 and transgenic variants are receiving attention as adoptive transfer immunotherapies to treat a range of malignancies. However, since NK-92s are themselves tumors, they require irradiation prior to transfer and are potentially susceptible to attack by patients’ immune systems. In the present study, we investigated NK-92 serial killing against various tumor cells as well as the effects of gamma-irradiation and ligation of the death receptor Fas (CD95) on NK-92 cells and the susceptibility of NK-92s to attack by primary NK cells. To evaluate serial killing, we used a 51Cr-release assay with very low effector to target (E:T) Raji, Daudi or K562 tumor cell ratios at 2, 4, 6, and 8 hour time points. NK-92s that were maintained in high concentrations of recombinant IL-2 were able to kill as many as 14 Raji cells per NK-92 cell in 8 hours at an E:T of 1:32. NK-92 cells retained high cytotoxic activity immediately after irradiation with 10 Gy but lost >50% activity 24 hours after just 7 Gy irradiation. Despite strong expression of CD95, NK-92s maintained viability after 24 hours of Fas-ligation with an anti-CD95 IgM as compared to cells treated with an isotype control antibody. While NK-92s survived 16 hours of exposure to unstimulated primary NK cells, they were killed when exposed to IL-2 activated primary LAK cells. In conclusion, we recommend that adoptive transfer of irradiated NK-92 cells into patients be made as quickly as possible post-irradiation of the NK-92s. Genetic modification of NK-92 cell lines to secrete IL-2 as an autocrine growth factor may need reconsideration because in vivo activation of endogenous LAK cells by IL-2 could reduce the number of NK-92 cells within tumors and thus decrease therapeutic efficacy.

Narrative review on serous primary peritoneal carcinoma of unknown primary site: four questions to be answered

Serous peritoneal papillary carcinoma (SPPC) represents a particular cancer of unknown primary (CUP) entity that arises in the peritoneal surface lining the abdomen and pelvis without a discriminative primary tumor site. In this review, we discuss the validity of SPPC as a distinct entity. Clinically, patients with SPPC are older, have higher parity and later menarche, are more often obese and probably have poorer survival compared to those with primary ovarian cancer. Pathologically, SPPC is more anaplastic and multifocal, unlike primary ovarian cancer which is commonly unifocal. Biologically, it presents a higher expression of proliferative signals and similar cell cycle and DNA repair protein expression. These differences hint towards SPPC and primary ovarian cancer being as a spectrum of disease. Patients with SPPC are traditionally managed similarly to stage III–IV ovarian cancer. The recommended approach integrates aggressive cytoreductive surgery, hyperthermic intraperitoneal chemotherapy, and systemic chemotherapy to remove the macroscopic tumor, eradicate the microscopic residual disease, and control the microscopic metastasis. However, the available evidence lacks proper randomized or prospective studies on SPPC and is limited to retrospective series. The diligent identification of SPPC is warranted to design specific clinical trials that eventually evaluate the impact of the new therapeutics on this distinct entity.

Natural Killer (NK) Cell Expression of CD2 as a Predictor of Serial Antibody-Dependent Cell-Mediated Cytotoxicity (ADCC)

NK cell ADCC supports monoclonal antibody anti-tumor therapies. We investigated serial ADCC and whether it could be predicted by NK phenotypes, including expression of CD16A, CD2 and perforin. CD16A, the NK receptor for antibodies, has AA158 valine or phenylalanine variants with different affinities for IgG. CD2, a costimulatory protein, associates with CD16A and can augment CD16A-signaling. Pore-forming perforin is essential for rapid NK-mediated killing. NK cells were monitored for their ADCC serial killing frequency (KF). KF is the average number of target cells killed per cell by a cytotoxic cell population. KF comparisons were made at 1:4 CD16pos NK effector:target ratios. ADCC was toward Daudi cells labeled with ⁵¹Cr and obinutuzumab anti-CD20 antibody. CD16A genotypes were determined by DNA sequencing. CD2, CD16A, and perforin expression was monitored by flow cytometry. Serial killing KFs varied two-fold among 24 donors and were independent of CD16A genotypes and perforin levels. However, high percentages of CD2pos of the CD16Apos NK cells and high levels of CD16A were associated with high KFs. ROC analysis indicated that the %CD2pos of CD16Apos NK cells can predict KFs. In conclusion, the extent of serial ADCC varies significantly among donors and appears predictable by the CD2posCD16Apos NK phenotype.

Inclusion of family members without ME/CFS in research studies promotes discovery of biomarkers specific for ME/CFS

BACKGROUND

The search for a biomarker specific for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) has been long, arduous and, to date, unsuccessful. Researchers need to consider their expenditures on each new candidate biomarker. In a previous study of antibody-dependent cell-mediated cytotoxicity (ADCC) by natural killer lymphocytes, we found lower ADCC for ME/CFS patients vs. unrelated donors but ruled against low ADCC as a biomarker because of similar ADCC for patients vs. their family members without ME/CFS.

OBJECTIVE

We applied inclusion of family members without ME/CFS, from families with multiple CFS patients, as a second non-ME/CFS control group in order to re-examine inflammation in ME/CFS.

METHOD

Total and CD16A-positive 'non-classical' anti-inflammatory monocytes were monitored.

RESULTS

Non-classical monocytes were elevated for patients vs. unrelated healthy donors but these differences were insignificant between patients vs. unaffected family members.

CONCLUSIONS

Inclusion of family members ruled against biomarker considerations for the monocytes characterized. These pilot findings for the non-classical monocytes are novel in the field of ME/CFS. We recommend that occupational therapists advocate and explain to family members without ME/CFS the need for the family members' participation as a second set of controls in pilot studies to rapidly eliminate false biomarkers, optimize patient participation, and save researchers' labor.

Two-color flow cytometric detection of serial cell-mediated cytotoxicity by natural killer (NK) lymphocytes

Serial killers are much more productive than one-hit wonders, especially when it comes to killing cancer. Natural killer lymphocytes are significant cells in many anti-cancer immunotherapies, such as monoclonal antibody based- and adoptive cell transfer therapies. However, current data show that less than 30% of peripheral blood NK cells are capable of sequentially killing more than one cell, i.e., serial killing. These serial killers are not only capable of killing up to 6 target cancer cells each, but are also reported to deliver lytic hits at a faster rate and with more killing power than their counterpart NK cells. Current methods to identify serial killer NK cells, such as time-lapse cinematography, are laborious, expensive, and require highly skilled expertise and equipment. In order to enrich and grow serial NK cells, an inexpensive, simple assay is needed to detect and isolate them from blood for subsequent in vitro growth. Here we developed a flow cytometric method to identify serial killers via 2-color detection of the cell surface marker CD107a, expressed on the NK cell surface following killing. The NK-92 cell line was incubated with target Raji B leukemia cells for 2-hours, then labeled with one color, AF647, anti-CD107a mAb. Cells were then re-incubated for an additional 4-hours and subsequently labeled with a second color, PE, anti-CD107a mAb. Serial killers labeled double positive for both colors at 6 hours. We found that NK-92s are capable of killing at least 14 target Raji cells each and about 18% of the NK-92s can be identified as serial killers via two-color CD107a mAb labeling.

Evidence for serial antibody-dependent cell-mediated cytotoxicity (ADCC) by primary unstimulated human natural killer (NK) lymphocytes

Serial killers are more desirable than single-hit attackers when it comes to treating cancer. Antibody-dependent cell-mediated cytotoxicity (ADCC) mediated by NK lymphocytes is a significant component of many monoclonal antibody anti-cancer immunotherapies. However, there is a significant problem associated with ADCC: the NK cells lose their CD16A Fc-receptors and can no longer recognize target cells coated with antibodies, due to the action of NK cell metalloproteases. In this report, we searched for evidence for serial ADCC before the effector cells lose their receptors. Human ADCC measured by 51Cr-release at multiple NK effector to tumor cell ratios (E:Ts) was largely finished after 4 hours when the targets were Daudi B leukemia cells coated with non-fucosylated obinutuzumab anti-CD20. We reasoned that serial killing is evident when the number of dead targets exceeds the number of initial CD16A NK effectors. We assessed the dead Daudi per NK effector (D/E) at an E:T of 1:4 to detect serial killers given an excess of targets. For 28 healthy human subjects, the total ratio of dead targets per CD16Apos NK effector cell ranged from 0.6 to 2.2, with a median of 1.5 and average of 1.5 +/− 0.4. Four donors (14%) had D/Es >2. The D/E values were similar for CD16A AA158 F/F donors compared to F/V & V/V donors, even though the V-positive donors had greater initial NK cellular levels of CD16A. We conclude that this gross measurement (D/E) can detect serial ADCC even without the information provided by time-lapse cinematography to indicate the actual fraction of effectors that are serial killers. This simple measurement may be useful to screen for promotion of serial killing by reagents that reduce proteolytic loss of NK cell CD16A.

Antibody-Dependent Cell-mediated Cytotoxicity (ADCC) in Familial Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS)

Background

Chronic fatigue syndrome (CFS) is an illness of unknown origin that may have familial risks. Low natural killer (NK) lymphocyte activity was proposed as a risk for familial CFS in 1998. Since then, there have been many studies of NK lymphocytes in CFS in general populations but few in familial CFS. Antibody-dependent cell-mediated cytotoxicity (ADCC) by NK lymphocytes helps control viral infections. ADCC is affected by variant CD16A receptors for antibody that are genetically encoded by FCGR3A.

Methods

This report characterizes ADCC effector NK cell numbers, ADCC activities, and FCGR3A variants of five families each with 2-5 CFS patients, their family members without CFS and unrelated controls. The patients met the Fukuda diagnostic criteria. We determined: CD16Apositive blood NK cell counts; EC50s for NK cell recognition of antibody; ADCC lytic capacity; FCGR3A alleles encoding CD16A variants, ROC tests for biomarkers, and synergistic risks.

Results

CFS patients and their family members had fewer CD16Apositive NK cells, required more antibody, and had ADCC that was lower than the unrelated controls. CFS family members were predominantly genetically CD16A F/F s for the variant with low affinity for antibodies. ROC tests indicated unsuitability of ADCC as a biomarker for CFS because of the low ADCC of family members without CFS. Familial synergistic risk vs. controls was evident for the combination of CD16Apositive NK cell counts with ADCC capacity.

Conclusions

low ADCC may be a risk factor for familial CFS. Furthermore, characterization of familial CFS represents an opportunity to identify pathogenic mechanisms of CFS.

Breastmilk Pumping for the Mental Health of the NICU Mother

Objective

While much is known about breastfeeding and postpartum depression, little is known about breast milk pumping's impact on postpartum depression among mothers with infants in the neonatal intensive care unit (NICU).

Methods

Thirty-two mothers of infants admitted to a Level III NICU between February and July 2017 were screened for postpartum depression using the Edinburgh Postnatal Depression Scale (EPDS). They were also surveyed for current breastmilk pumping activities and demographic factors. Multivariable logistic regression was used to assess the associations between postpartum depression and breast milk pumping, adjusting for confounding variables.

Results

After controlling for confounding variables, mothers who did not pump breast milk (relative to mothers who did) were 11 times more likely to have lower EPDS depression scores indicative of probable postpartum depression (OR = 11.7, p-value .05).

Conclusions

Our results suggest a significant reduction in probable postpartum depression among NICU mothers who express breastmilk.

Monocytes of Chronic Fatigue Syndrome Patients, their Family Members without CFS, and Unrelated Healthy Donors: Searching for Differences

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is characterized by fatigue that does not improve with rest and worsens with exertion. ME/CFS may involve inflammation in the brain and/or be associated with viral infections. Increased numbers of pro-inflammatory monocytes in blood are a hallmark of infection. Biomarkers for, and information about, the CFS disease process are greatly needed. Here we queried circulating monocytes. In a pilot study, CFS patients and family members without CFS from three families were compared in order to reduce genetic and environmental variables. The patients conformed to the Fukuda 1994 standards. Unrelated healthy control subjects matched to the patients were included in the study. Blood monocytes were stained and analyzed by flow cytometry: counted with TruCountR beads, or stained after isolation and overnight culture of isolated peripheral blood monocytes. M1 pro-inflammatory monocytes are CD16A negative, while anti-inflammatory monocytes are CD16A positive; CD2 is a marker for dendritic monocytes, and changes in forward scatter could indicate in vitro activation. Notably, there were statistically significant differences between the lower percentages of M1 monocytes of the CFS patients compared to the controls; however, these differences were not significant between the patients and their family members without CFS. Also, the CD16A MFIs of the patients' monocytes were lower compared to controls but not to family members. One conclusion is that it is important to include family members without CFS as a control group in the search for biomarkers to diagnose CFS.

Scope-of-practice laws and expanded health services: the case of underserved women and advanced cervical cancer diagnoses

BACKGROUND

Underserved women (rural, minority or poor) are disproportionally diagnosed with late-stage cervical cancer, indicative of inadequate access to, and use of, preventative healthcare. The Institute of Medicine (IOM) has proposed that nurse practitioners (NP) can address provider shortages among underserved populations, but to reduce shortages, scope-of-practice laws that restrict the delivery of care, must be revised. We examined the IOM recommendation of NP expanded scope-of-practice laws on reducing the disparity of underserved women diagnosed with late-stage cervical cancer.

METHODS

We examined the cohort of 10 673 women diagnosed with cervical cancer between 2010 and 2014 and reported to the Surveillance, Epidemiology and End Results cancer registry. We linked state-level laws regarding NP scope-of-practice to patients with cancer by their state of residence, diagnosis date and law enactment date. Hierarchical regression was used to explore NP full scope-of-practice law's impact on late-stage cancer diagnoses considering the moderating effect of women living in medically underserved areas. We adjusted for known confounders available in this population-based data set.

RESULTS

Medically underserved women living in states with laws that restrict NP full scope-of-practice are twofold more likely to be diagnosed with late-stage cancer; adjusted OR and 95% CI (OR 2.08, 95% CI 1.4 to 3.1). These disparities were not observed among underserved women living in areas with NP full scope-of-practice laws (OR 0.95, 95% CI 0.7 to 1.3).

CONCLUSIONS

NP full scope-of-practice laws could provide a pragmatic and cost-effective solution to healthcare provider shortages associated with late stage of cervical cancer diagnoses among underserved women.

Case Report of the Incidence of Maternal Depression at a Community Level III, 39-Bed NICU

Postpartum depression (PPD) is a vastly undetected, underdiagnosed, and untreated mental health concern for all mothers with infants. Having an infant in the neonatal intensive care unit (NICU) has an even higher impact on mothers’ mental health, predisposing them to a higher rate of PPD. The aim of this project was to identify the incidence of PPD in a Level III NICU to determine appropriate intervention strategies. All mothers with NICU infants 14 to 20 days were invited to complete the 10-question Edinburgh Postnatal Depression Screening (EPDS). The EPDS was scored, and a NICU social worker discussed the results and offered resources for those with scores of ≥10. The incidence of positive screens at our institution was 71.9% for an EPDS score with a cutoff ≥10, and 50% for an EPDS score with a cutoff ≥13. Simple strategies, including routine screening, PPD groups, and NICU support groups, were implemented. All NICUs should know the incidence of mothers’ PPD. Acting on this information flows downstream to improving the health of the infant and family.

Low NK Cell ADCC as a Risk Factor in Chronic Fatigue Syndrome (CFS): Familial Risk for CFS or Differences between Human Populations?

ADCC (antibody-dependent cell-mediated cytotoxicity) requires the cytotoxic subset of NK cells that can also recognize antibody. In vivo function may depend on the number of these ADCC NK cells. We report on ADCC activity and the number of IgG FcR-positive NK cells/ul blood as risk factors for chronic fatigue syndrome (CFS). ADCC capacity was measured as CX1:1 (PMID 29113954), the % Daudi B tumor cells killed at a 1:1 ratio of CD16A FcR-pos CD56pos NK effector cells to Daudi targets with obinutuzumab anti-CD20. CFS patients met the 1994 Fukuda diagnostic guidelines. We examined 5 families with 2 or more patients per family, comparing patients with their non-CFS family members and with unrelated healthy controls. ADCC activity and effector cell counts were similar between CFS patients and their family members. Surprisingly, the CX1:1 of both the CFS patients and their non-CFS family members was low, 77% of the controls (P=0.03). The ADCC effector cell counts/ul blood were also lower for both (two-tailed P=0.09, insignificant). The potential for synergistic interaction of low CX1:1 and low effector cell counts was 24-fold greater for CFS family members than for unrelated healthy controls (P<0.05). The ADCC similarity between patients and family members indicates that lower ADCC is unlikely to influence who is affected with CFS within families. The combined lower ADCC and lower effector cell counts of CFS family members could indicate a familial risk for CFS. However, caution is warranted by evidence that the CFS families are from a Utah population that is genetically skewed, while the controls have diversity representative of the USA. The ADCC differences could be between 2 human populations or between people more or less likely to suffer from CFS.

An improved method to quantify human NK cell-mediated antibody-dependent cell-mediated cytotoxicity (ADCC) per IgG FcR-positive NK cell without purification of NK cells

Natural killer (NK) lymphocyte ADCC supports anti-viral protection and monoclonal antibody (mAb) anti-tumor therapies. To predict in vivo ADCC therapeutic responses of different individuals, measurement of both ADCC cellular lytic capacity and their NK cellular receptor recognition of antibodies on 'target' cells are needed, using clinically available amounts of blood. Twenty ml of blood provides sufficient peripheral blood mononuclear cells (PBMCs) for the new assay for lytic capacity described here and for an antibody EC₅₀ assay for Fc-receptor recognition. For the lytic capacity assay, we employed flow cytometry to quantify the CD16A IgG Fc-receptor positive NK effector cells from PBMCs to avoid loss of NKs during isolation. Targets were ⁵¹Cr-labeled Daudi B cells pretreated with excess obinutuzumab type 2 anti-CD20 mAb and washed; remaining free mAb was insufficient to convert B cells in the PBMCs into 'targets'. We calculated: the percentage Daudis killed at a 1:1 ratio of CD16A-positive NK cells to Daudis (CX1:1); lytic slopes; and ADCC₅₀ lytic units. Among 27 donors, we detected wide ranges in CX1:1 (16-73% targets killed) and in lytic slopes. Slope variations prevented application of lytic units. We recommend CX1:1 to compare individuals' ADCC capacity. CX1:1 was similar for purified NK cells vs. PBMCs and independent of CD16A V & F genotypes and antibody EC₅₀s. With high mAb bound onto targets and the high affinity of obinutuzumab Fc for CD16A, CX1:1 measurements discern ADCC lytic capacity rather than antibody recognition. This assay allows ADCC to be quantified without NK cell isolation and avoids distortion associated with lytic units.

Latina Women and Cervical Cancer Screening: Decisional Balance and Self-Efficacy

BACKGROUND

Latina women in the United States have greater cervical cancer mortality rates than non-Latina women because of their low rates of Papanicolau (Pap) smear screening.

OBJECTIVES

The purpose of this article is to assess differences in perceived benefits, perceived barriers, and self-efficacy among Latina women to obtain Pap smears using the framework of the Transtheoretical Model.

METHODS

A descriptive design with a snowball sample was used. The researchers assessed demographics, three perceived benefits, 12 barriers, and seven self-efficacy measures for 121 Latina women in northern Nevada.

FINDINGS

Participants in precontemplation and relapse perceived greater barriers than those in action and maintenance for three items.

Outpatient Surgical Management of Patients with Complex Wounds Through a Multispecialty Wound Care Clinic

Category:

Diabetes

Introduction/Purpose:

Management of patients with lower extremity wounds is complex and generally attributed to diabetes, neuropathy, and/or peripheral vascular disease (PVD). Often, these patients have poor control of their disease and limited resources. Hospitalizations related to lower extremity wounds are expensive with relatively high length of stay. Much of this time is spent organizing outpatient interventions. The purpose of this study is to evaluate the efficacy of outpatient surgical management of patients with lower extremity wounds that could lead to hospitalization. We hypothesize that through a multispecialty wound clinic, utilizing wound care specialists, orthotist/prosthetist, infectious disease specialist, and orthopaedic surgeons, at-risk patients could be identified for non-healing wounds through successful outpatient surgical management with preoperative insurance approval of postoperative wound care, offloading devices and antibiotic treatment.

Methods:

Patients seen through our outpatient multispecialty wound clinic were evaluated and those who underwent an outpatient surgical procedure over a 12-month period were identified. Additional inclusion criteria included failure of non-surgical management and 90-day minimum follow-up. Exclusion criteria included any patient who was septic, medically unstable, or unable to comply with the postoperative plan. Preoperative parameters regarding disease severity (HbA1c), infection severity (WBC, ESR, CRP), and wound healing potential (albumin, total protein) were identified. In addition, preoperative determination of wound severity was measured using Wagner’s Score. Outcomes included hospitalizations related to their wound within 90 days, requirements for additional surgical procedures, and time to resolve their wound postoperatively.

Results:

Nineteen patients met the inclusion criteria. Average age was 58.6 years and eleven were male. Ten had diabetes, thirteen had neuropathy, and five had PVD. Average preoperative HbA1c was 7.9, and average WBC, CRP, ESR, albumin, and total protein was 8.1, 1.1, 29.6, 3.7, and 7.0, respectively. All patients had preoperative conservative intervention. Eight patients were preapproved for outpatient IV antibiotics and four for wound vac therapy. Table 1 outlines the procedures performed. Patients presented an average of 7.3 weeks following their outpatient procedure until resolution of their wound. One patient was re-admitted to the hospital within 90 days for a problem related to their initial wound.

Conclusion:

Our study demonstrates that outpatient surgical management of medically stable patients with lower extremity diabetic, neuropathic, and/or PVD wounds resulted in wound resolution and eliminating hospitalization. This is accomplished with the preoperative organization through a multispecialty wound care clinic for patient’s postoperative needs, eliminating the time spent in the hospital during admissions waiting for OR availability, insurance approval and organization of outpatient wound care and antibiotics. This traditional process results in high medical costs without active intervention. Outpatient management can save valuable hospital resources as well as a substantial cost savings by eliminating days spent in the hospital.

Correlation of NK Cell Phenotypic Properties with Individual Differences in Human Antibody-Dependent Cell-Mediated Cytotoxicity (ADCC)

Antibody-dependent cell-mediated cytotoxicity (ADCC) supports anti-viral protection and monoclonal antibody anti-tumor therapies. We used two assays to compare ADCC of healthy donors: CX@1:1 (the percentage cells killed at a 1:1 ratio of CD16Apositive NK cells to ‘target’ cells that were pre-labeled with saturating antibody); and EC50 (the effective concentration of antibody that supports 50% of maximal ADCC). CX@1:1 measures lytic capacity while the EC50 measures cellular recognition; there was no correlation between the 2 assays though we observed 4.5-fold differences among donors in each assay. We correlated ADCC with 5 cytometric parameters (the median fluorescent intensities [MFIs] of the CD16A IgG Fc-receptor; the %NK cells positive & MFIs of the adhesion molecule CD2; the MFIs of perforin; and the %CD16Apositive of CD56positive NK cells) and with CD16A V&F genotypes that affect FcR affinity. For CX@1:1, the best donor killed 73% of targets while the worst killed 16% and perforin levels correlated weakly (P=0.11). Unexpectedly and inexplicably, the %CD16Apositive cells among NK cells correlated (P<0.05). CD16A and CD2 were dissociated from CX@1:1 as might be expected for the high antibody concentrations. For EC50s, there were no statistical correlations except for the expected difference between V/V &V/F vs. F/F genotypes, though the P=0.11. We conclude that substantial individual differences in ADCC per CD16Apositive NK cell are determined by parameters other than cell surface receptors and perforin. The unanticipated correlation of %CD16Apositive NK cells with CX@1:1 has potential as a surrogate marker for ADCC function.

Reanalysis of the anthrax epidemic in Rhodesia, 1978-1984

In the mid-1980s, the largest epidemic of anthrax of the last 200 years was documented in a little known series of studies by Davies in The Central African Journal of Medicine. This epidemic involved thousands of cattle and 10,738 human cases with 200 fatalities in Rhodesia during the Counterinsurgency. Grossly unusual epidemiological features were noted that, to this day, have not been definitively explained. This study performed a historical reanalysis of the data to reveal an estimated geographic involvement of 245,750 km², with 171,990 cattle and 17,199 human cases. Here we present the first documented geotemporal visualization of the human anthrax epidemic.

A comparison of marginal odds ratio estimators

Uses of the propensity score to obtain estimates of causal effect have been investigated thoroughly under assumptions of linearity and additivity of exposure effect. When the outcome variable is binary relationships such as collapsibility, valid for the linear model, do not always hold. This article examines uses of the propensity score when both exposure and outcome are binary variables and the parameter of interest is the marginal odds ratio. We review stratification and matching by the propensity score when calculating the Mantel-Haenszel estimator and show that it is consistent for neither the marginal nor conditional odds ratio. We also investigate a marginal odds ratio estimator based on doubly robust estimators and summarize its performance relative to other recently proposed estimators under various conditions, including low exposure prevalence and model misspecification. Finally, we apply all estimators to a case study estimating the effect of Medicare plan type on the quality of care received by African-American breast cancer patients.

Initiation of a Limb Preservation Service at a Tertiary Care Community Hospital Utilizing a Clinical Care Coordinator

Category:

Diabetes

Introduction/Purpose:

Lower extremity wounds and infections associated with diabetes result in significant use of health care resources and expenditures. Patients admitted to the hospital potentially require involvement of hospitalists and specialists from infectious diseases, orthopaedics, vascular and plastic surgery. Hospital services from the laboratory, radiology, and surgical departments may also be utilized, with case management for the complicated discharge planning of outpatient intravenous antibiotics and wound care. We hypothesized that utilization of a dedicated clinical care coordinator (CCC) would decrease patient length of stay and use of hospital resources for patients admitted to a tertiary care with a diabetes related lower extremity wound and/or infection.

Methods:

We initiated a Limb Preservation Service (LPS) utilizing a nurse practitioner with advanced training in wound care to act as the CCC. The CCC evaluates patients with diabetic lower extremity wounds and/or infections and coordinates specialty and/or surgical consults, vascular studies and advanced imaging. The CCC also supervises and directs all wound care personnel. The CCC remains the patient liaison throughout the hospitalization, being the point of contact for all specialties and discharge planning. Orthopaedic and vascular surgeons are consulted based on patient need, with the goal of expediting surgical management. Patients were identified over a six-month period before and after initiation of the LPS. We included patients with diagnosis and procedure codes customarily seen in the LPS service. We excluded patients with missing procedure information and diagnosis codes unrelated to diabetes and diabetic foot and ankle wounds. Comparative evaluation regarding hospitalization cost, length of stay, and hospital resource utilization were evaluated.

Results:

Sixty-six patients were identified for comparison after exclusion criteria. Overall length of stay (LOS) was shorter during the LPS period relative to the pre-LPS period (8.6 vs. 9.2 days). The LPS period was associated with a decreased LOS for patients with private insurance, self-pay, and workers compensation payment sources (6.3 vs 8.3 days). Greater numbers of orthopaedic and/or vascular consults were requested for patients during the LPS period (82 vs. 75%) and were associated with shorter LOS (8.1 vs. 10.4 days). Consults received in the pre-LPS period resulted in longer hospital stays. Patients discharged to home had shorter LOS after the LPS service was implemented relative to before the LPS was implemented (7.1 vs 7.7 days).

Conclusion:

Initiation of a limb preservation service with utilization of a CCC having advanced training and experience in wound care demonstrated an improvement in patient care efficiency and hospital costs associated with the management of patients admitted to the hospital with diabetes-related lower extremity wounds and/or infections. The LPS, under the supervision of the CCC, demonstrated decreased hospital resource utilization, expedited referrals and surgical treatment, and facilitated disposition from the hospital.

How Does Managed Care Improve the Quality of Breast Cancer Care Among Medicare-Insured Minority Women?

PURPOSE

The aim of this study is to investigate if evidence-based clinical guidelines are implemented equitability among ethnic minority breast cancer patients using Medicare Advantage and investigate if presumed advantages of managed care over fee-for-service are greater for minorities than for Whites.

METHODS

Data from the Surveillance, Epidemiology, and End Results and Medicare were used to examine 70,755 women over age 65 diagnosed with early stage breast cancer between 2005 and 2009. Implementation of two clinical guidelines was assessed: receipt of radiation therapy after breast conserving surgery and estrogen receptor status documentation. Multilevel logistic regression and inverse propensity weighting controlled for confounding.

RESULTS

African Americans are still less likely than Whites to receive radiation therapy after breast-conserving surgery, whether they use Medicare fee-for-service (OR 95 % CI) = 0.90 (0.83, 0.98) or managed care (OR 95 % CI) = 0.87 (0.76, 1.00). Differences between receipt of radiation therapy by insurance plan type was nonexistent. Relative to FFS, the use of managed care improved the odds of having estrogen receptor status documented by 44 % in African Americans, (OR 95 % CI) = 1.44 (1.15, 1.83) and by 42 % in Latina patients (OR 95 % CI) = 1.42 (1.17, 1.78).

CONCLUSIONS

Compared to Medicare fee-for-service, ethnic and racial disparities among Medicare Advantage users were reduced. We observed fewer disparities, but not an elimination of disparities, among Medicare Advantage enrollees receiving breast cancer care with an organizational and patient component of care. This suggests managed care may still need to focus on minority patient empowerment and involvement in care.

Zika Virus: Medical Countermeasure Development Challenges

INTRODUCTION

Reports of high rates of primary microcephaly and Guillain-Barré syndrome associated with Zika virus infection in French Polynesia and Brazil have raised concerns that the virus circulating in these regions is a rapidly developing neuropathic, teratogenic, emerging infectious public health threat. There are no licensed medical countermeasures (vaccines, therapies or preventive drugs) available for Zika virus infection and disease. The Pan American Health Organization (PAHO) predicts that Zika virus will continue to spread and eventually reach all countries and territories in the Americas with endemic Aedes mosquitoes. This paper reviews the status of the Zika virus outbreak, including medical countermeasure options, with a focus on how the epidemiology, insect vectors, neuropathology, virology and immunology inform options and strategies available for medical countermeasure development and deployment.

METHODS

Multiple information sources were employed to support the review. These included publically available literature, patents, official communications, English and Lusophone lay press. Online surveys were distributed to physicians in the US, Mexico and Argentina and responses analyzed. Computational epitope analysis as well as infectious disease outbreak modeling and forecasting were implemented. Field observations in Brazil were compiled and interviews conducted with public health officials.

Lifestyle and Risk of Hypertension: Follow-Up of a Young Pre-Hypertensive Cohort

OBJECTIVES

To determine whether healthy lifestyle decreases the risk of developing hypertension in pre-hypertensive patients.

STUDY DESIGN

A longitudinal study.

SETTING & PARTICIPANTS

Randomly selected pre-hypertensive young adults 20-45 years old without any vascular disease such as stroke or diabetes.

PREDICTORS

Four lifestyle factors (a body mass index [BMI] of 18.5-24.9 kg/m2, regular physical activity, no alcohol use and 6-8 h of sleep per day), individually and in combination.

OUTCOMES

Hypertension was defined as a systolic blood pressure (SBP) ≥ 140 mmHg, or a diastolic BP (DBP) ≥ 90 mmHg or self-reported hypertension.

MEASUREMENTS

Multivariate adjusted Cox proportional hazards.

RESULTS

During a median follow-up of 4.7 years, 1009 patients were enrolled in our study, and 182 patients developed hypertension. Compared with a BMI of 18.5-24.9 kg/m2, a BMI of 25-30 kg/m2 and a BMI of >30 kg/m2 were associated with an increased risk of hypertension occurrence (hazard ratio [HR], 1.83; 95% confidence interval [CI], 1.19-2.84 and HR, 2.62; 95% CI, 1.01-6.80, respectively). Compared with sleep duration of >8 h/day, 6-8 h/day of sleep was associated with a lower risk of hypertension occurrence (HR, 0.40; 95% CI, 0.18-0.86). There were no statistically significant associations between physical activity or alcohol use and hypertension occurrence (P>0.05).

LIMITATION

All lifestyle factors were measured only once.

CONCLUSION

Healthy BMI (18.5-24.9 kg/m(2)) and sleep duration (6-8 h/day) were associated with a lower risk of the occurrence of hypertension in pre-hypertension patients.

Breastfeeding laws and breastfeeding practices by race and ethnicity

OBJECTIVES

We sought to examine breastfeeding practices by race and ethnicity in areas with and without eight specific breastfeeding laws.

METHODS

The 2003 through 2010 National Health and Nutrition Examination Survey provides national breastfeeding practice information. We assessed eight breastfeeding laws before and after legislation was enacted and linked to population-based estimates of breastfeeding initiation and duration for children between birth and age one.

FINDINGS

Relative to Whites, Mexican-American infants were 30% more likely to breastfeed for at least 6 months in areas with laws protecting break-time from work to pump, and 20% more likely to breastfeed for at least 6 months in areas with pumping law enforcement provisions. Unexpectedly, five laws with the intention of supporting breastfeeding duration were significantly less helpful for African-American women relative to White women. African-American women were nearly half as likely to breastfeed for at least 6 months, relative to Whites in areas with provisions to provide break-time from work (adjusted odds ratio [AOR], 0.6; 95% confidence interval [CI], 0.5-0.8), private areas to pump at work (AOR, 0.6; 95% CI, 0.4-0.8), exemption from jury duty (AOR, 0.6; 95% CI, 0.4-0.9), awareness education campaigns (AOR, 0.5; 95% CI, 0.3-0.8), and pumping law enforcement provisions (AOR, 0.6; 95% CI, 0.5-0.8).

CONCLUSIONS

Breastfeeding laws influence African Americans and Mexican Americans differently than Whites. Examination of specific laws in conjunction with the interaction of known specific barriers for African-American mothers could help to achieve the Healthy People 2020 goals for breastfeeding.

Practices that reduce the Latina survival disparity after breast cancer

OBJECTIVES

Latina breast cancer patients are 20 percent more likely to die within 5 years after diagnosis compared with white women, even though they have a lower incidence of breast cancer, lower general mortality rates, and some better health behaviors. Existing data only examine disparities in the utilization of breast cancer care; this research expands the study question to which utilization factors drive the shorter survival in Latina women compared with white women.

METHODS

This longitudinal linked Surveillance Epidemiology and End Results (SEER)-Medicare cohort study examined early stage breast cancer patients diagnosed between 1992 and 2000 and followed for 5-11 years after diagnosis (N=44,999). Modifiable utilization factors included consistent visits to primary care providers and to specialists after diagnosis, consistent post-diagnosis mammograms, and receipt of initial care consistent with current standards of care.

RESULTS

Of the four utilization factors potentially driving this disparity, a lack of consistent post-diagnosis mammograms was the strongest driver of the Latina breast cancer survival disparity. Consistent mammograms attenuated the hazard of death from 23% [hazard ratio, HR, (95% confidence interval, 95%CI)=1.23 (1.1,1.4)] to a nonsignificant 12% [HR (95%CI)=1.12 (0.7,1.3)] and reduced the excess hazard of death in Latina women by 55%. Effect modification identified that visits to primary care providers have a greater protective impact on the survival of Latina compared to white women [HR (95%CI)=0.9 (0.9,0.9)].

CONCLUSIONS

We provide evidence that undetected new or recurrent breast cancers due to less consistent post-diagnosis mammograms contribute substantially to the long-observed Latina survival disadvantage. Interventions involving primary care providers may be especially beneficial to this population.

Xenotropic murine leukemia virus-related virus-associated chronic fatigue syndrome reveals a distinct inflammatory signature

BACKGROUND

The recent identification of xenotropic murine leukemia virus-related virus (XMRV) in the blood of patients with chronic fatigue syndrome (CFS) establishes that a retrovirus may play a role in the pathology in this disease. Knowledge of the immune response might lead to a better understanding of the role XMRV plays in this syndrome. Our objective was to investigate the cytokine and chemokine response in XMRV-associated CFS.

MATERIALS AND METHODS

Using Luminex multi-analyte profiling technology, we measured cytokine and chemokine values in the plasma of XMRV-infected CFS patients and compared these data to those of healthy controls. Analysis was performed using the Gene Expression Pattern Analysis Suite and the Random Forest tree classification algorithm.

RESULTS

This study identifies a signature of 10 cytokines and chemokines which correctly identifies XMRV/CFS patients with 93% specificity and 96% sensitivity.

CONCLUSION

These data show, for the first time, an immunological pattern associated with XMRV/CFS.

Quality-of-life and surgical treatments for rectal cancer--a longitudinal analysis using the California Cancer Registry

BACKGROUND

Heterogeneous results for research investigating health-related quality of life (HRQL) in patients undergoing sphincter-ablating procedures for rectal cancer are likely due to single institution experiences and measurement of HRQL. To address this heterogeneity, we evaluated HRQL in patients with rectal cancer by type of surgery, location of tumor, and receipt of adjuvant therapy using an HRQL instrument that has not been used to address rectal cancer patients in a population-based sample over time.

METHODS

The Functional Assessment of Cancer Therapy-Colorectal instrument was administered at 9 and 19 months after diagnosis to a consecutive sample of 160 patients in Northern California identified by the California Cancer Registry. A broad multidimensional interpretation of HRQL was used to examine the impact of tumor location and treatment status, stage of disease, age, and gender.

RESULTS

In general, men had lower social well-being scores, and younger patients had lower physical and emotional well-being scores and colorectal concerns scores. We found no differences in HRQL by either tumor location or type of surgery, at either 9 or 19 months after diagnosis. Lower physical well-being and greater adverse colorectal concerns were reported at 9 months among patients who received adjuvant therapy; however, only adverse colorectal concerns persisted over time.

CONCLUSIONS

This study provides additional evidence that sphincter-ablating procedures do not necessarily reduce quality of life in patients with rectal cancer. Distinctive features of this study include a broad multidimensional interpretation of HRQL, the 19 months of longitudinal follow-up, and a prospective population-based study design.

Examination of health behaviours in a dynamic population

BACKGROUND

An increasing USA population, especially as a result of foreign immigration, has been the recent focus of healthcare research and policy debate. However, little is known about domestic immigration and its impact on the measures of health conditions and behaviours used to develop and evaluate public health policies and programmes. The objective of this research is to compare health conditions and behaviours between domestic immigrants and established residents in Nevada, the fastest-growing state in the USA.

METHODS

The Nevada 2004-2006 Behavioural Risk Factor Surveillance Survey and added state residency questions were used to examine the associations between length of residence and 24 explanatory variables on health behaviours and conditions. Weighted multiple logistic regressions were used for data analyses.

RESULTS

Among the 8663 respondents weighted to the total Nevada population, long-term residents (5 to <10 years), compared with newcomers or short-term residents, were more likely to report fair or poor health (OR=1.98, 95% CI 1.15 to 3.40) and obesity (OR=2.18, 95% CI 1.10 to 4.32), and to live with firearms in the home (OR=6.34, 95% CI 1.75 to 22.9). They were less likely to report having diabetes (OR=0.49, 95% CI 0.25 to 0.96), having had an HIV test (OR=0.60 95% CI 0.41 to 0.89), having prostate cancer (OR=0.20 95% CI 0.04 to 0.93) or having had a mammogram (OR=0.41, 95% CI 0.25 to 0.70).

CONCLUSIONS

Long-term residents, compared with newcomers, provide a unique comparison group that share the same physical and policy environment but in different time periods. Knowledge of differences such as these can improve the specificity in identifying target groups for particular interventions.

Factors associated with time to availability for cases reported to population-based cancer registries⋆

OBJECTIVE

Population-based cancer registries provide an excellent source of data for cancer surveillance and research. However, delays in reporting and processing can affect the accuracy of incidence rates and the availability of cases for research. This study was designed to describe factors related to delays in availability of cancer cases for epidemiologic analysis.

METHODS

We identified all cancer cases diagnosed in 2000 and reported to the California Cancer Registry by August 2004. We analyzed factors associated with time to availability, defined as the time from diagnosis until the time the case was available for research.

RESULTS

A total of 137,270 cancer cases were reported during the study period. The median time to availability for all cases was 382 days. Forty-five percent of cases were available within the first 12 months and 96% were available within 24 months after diagnosis. Cases reported by hospitals had the shortest time to availability (373 days) followed by doctors' offices and laboratories. Melanoma and prostate cancers had longer times to be available than other types of cancer. Time to availability varied by geographic region, but differences by age, gender, race and stage at diagnosis were minimal or non-significant.

CONCLUSION

Strategies are needed to improve timeliness without sacrificing quality and completeness.