Comparison of Exit -Site Infections in Disconnect versus Nondisconnect Systems for Peritoneal Dialysis

Objective

To determine if disconnect systems reduce the incidence of exit-site infections when compared to nondisconnect systems.

Design

We prospectively monitored exit-site infections and peritonitis rates in 96 disconnect patients (Yset, automated peritoneal dialysis (APD)) and 60 nondisconnect patients (spike, ultraviolet connection device (UVXD)).

Setting

A freestanding chronic peritoneal dialysis unit staffed by physicians from both a medical school and a private setting.

Patients

All patients who began peritoneal dialysis at our unit were monitored, regardless of cause of endstage renal disease (ESRD) or age.

Intervention

Patients were dialyzed using the system (Y-set, spike, etc.) most appropriate for their life-style and their ability to administer self-care.

Main Outcome

We attempted to follow disconnect and nondisconnect patients for a similar median time on dialysis and compared differences in exit-site infections.

Results

Peritonitis rates (episodes/pt year) were reduced for disconnect (0.60) versus nondisconnect (0.99) systems (p=0.0006). Despite the marked reduction in peritonitis rates, there was no difference in exit-site infection rates (0.35 vs 0.38), the time to the first exit -site infection, or the time to the first catheter removal for disconnect versus nondisconnect groups. When individual systems were compared, differences in exit-site infection rates (episodes/pt years) were noted (0.62, spike; 0.26,UVXD; 0.32,Y-set; 0.41,APD).

Conclusion

We found no overall difference in exit site infection rates for disconnect versus nondisconnect systems, despite a reduction in peritonitis rates for disconnect systems.

Safely Identifying Emergency Department Patients With Acute Chest Pain for Early Discharge

BACKGROUND

The HEART Pathway (history, ECG, age, risk factors, and initial troponin) is an accelerated diagnostic protocol designed to identify low-risk emergency department patients with chest pain for early discharge without stress testing or angiography. The objective of this study was to determine whether implementation of the HEART Pathway is safe (30-day death and myocardial infarction rate <1% in low-risk patients) and effective (reduces 30-day hospitalizations) in emergency department patients with possible acute coronary syndrome.

METHODS

A prospective pre-post study was conducted at 3 US sites among 8474 adult emergency department patients with possible acute coronary syndrome. Patients included were ≥21 years old, investigated for possible acute coronary syndrome, and had no evidence of ST-segment-elevation myocardial infarction on ECG. Accrual occurred for 12 months before and after HEART Pathway implementation from November 2013 to January 2016. The HEART Pathway accelerated diagnostic protocol was integrated into the electronic health record at each site as an interactive clinical decision support tool. After accelerated diagnostic protocol integration, ED providers prospectively used the HEART Pathway to identify patients with possible acute coronary syndrome as low risk (appropriate for early discharge without stress testing or angiography) or non-low risk (appropriate for further in-hospital evaluation). The primary safety and effectiveness outcomes, death, and myocardial infarction (MI) and hospitalization rates at 30 days were determined from health records, insurance claims, and death index data.

RESULTS

Preimplementation and postimplementation cohorts included 3713 and 4761 patients, respectively. The HEART Pathway identified 30.7% as low risk; 0.4% of these patients experienced death or MI within 30 days. Hospitalization at 30 days was reduced by 6% in the postimplementation versus preimplementation cohort (55.6% versus 61.6%; adjusted odds ratio, 0.79; 95% CI, 0.71-0.87). During the index visit, more MIs were detected in the postimplementation cohort (6.6% versus 5.7%; adjusted odds ratio, 1.36; 95% CI, 1.12-1.65). Rates of death or MI during follow-up were similar (1.1% versus 1.3%; adjusted odds ratio, 0.88; 95% CI, 0.58-1.33).

CONCLUSIONS

HEART Pathway implementation was associated with decreased hospitalizations, increased identification of index visit MIs, and a very low death and MI rate among low-risk patients. These findings support use of the HEART Pathway to identify low-risk patients who can be safely discharged without stress testing or angiography.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov . Unique identifier: NCT02056964.

Long-term Weight Loss Maintenance in the Continuation of a Randomized Diabetes Prevention Translational Study: The Healthy Living Partnerships to Prevent Diabetes (HELP PD) Continuation Trial

OBJECTIVE

HELP PD was a clinical trial of 301 adults with prediabetes. Participants were randomized to enhanced usual care (EUC) or to a lifestyle weight loss (LWL) intervention led by community health workers that consisted of a 6-month intensive phase (phase 1) and 18 months of maintenance (phase 2). At 24 months, participants were asked to enroll in phase 3 to assess whether continued group maintenance (GM) sessions would maintain improvements realized in phases 1 and 2 compared with self-directed maintenance (SM) or EUC.

RESEARCH DESIGN AND METHODS

In phase 3, LWL participants were randomly assigned to GM or SM. EUC participants remained in the EUC arm and, along with participants in SM, received monthly newsletters. All participants received semiannual dietitian sessions. Anthropometrics and biomarkers were assessed every 6 months. Mixed-effects models were used to assess changes in outcomes over time.

RESULTS

Eighty-two of the 151 intervention participants (54%) agreed to participate in phase 3; 41 were randomized to GM and 41 to SM. Of the 150 EUC participants, 107 (71%) continued. Ninety percent of clinic visits were completed. Over 48 months of additional follow-up, outcomes remained relatively stable in the EUC participants; the GM group was able to maintain body weight, BMI, and waist circumference; and these measures all increased significantly (P < 0.001) in the SM group.

CONCLUSIONS

Participants in the GM arm maintained weight loss achieved in phases 1 and 2, while those in the SM arm regained weight. Because group session attendance by the participants in the GM arm was low, it is unclear what intervention components led to successful weight maintenance.

Cognitive functioning following brain irradiation as part of cancer treatment: Characterizing better cognitive performance

OBJECTIVE

Although brain radiation therapy (RT) impacts cognitive function, little is known about the subset of survivors with minimal cognitive deficits. This study compares the characteristics of patients receiving brain irradiation as part of cancer treatment with minimal cognitive deficits to those with poorer cognitive functioning.

METHODS

Adults at least 6 months postbrain RT (N = 198) completed cognitive measures of attention, memory, and executive functions. Cognitive functioning was categorized into better- and poorer-performing groups, with better-performing survivors scoring no worse than 1.5 standard deviations below the published normative mean on all cognitive measures. Logistic regression was used to identify variables associated with better-performing group membership.

RESULTS

Approximately 25% of the sample met the criteria for the better-performing group. In unadjusted analyses, RT type (whole brain irradiation and partial brain irradiation), sedating medications, and fatigue were independently associated with cognition. Sociodemographic and other clinical characteristics were not significant. In adjusted analyses, only fatigue remained significantly associated with group membership (OR = 1.05, 95% CI = 1.01-1.09, P = .009).

CONCLUSIONS

There is a subgroup of survivors with minimal long-term cognitive deficits despite undergoing a full course of brain RT as part of cancer treatment. Lower fatigue had the strongest association with better cognitive performance. Interventions targeting cancer-related fatigue may help buffer the neurotoxic effects of brain RT.

Quality of life of irradiated brain tumor survivors treated with donepezil or placebo: Results of the WFU CCOP research base protocol 91105

Background

The health-related quality of life (HRQL) and fatigue of brain cancer survivors treated with donepezil or placebo for cognitive symptoms after radiation therapy were examined.

Methods

One hundred ninety-eight patients who completed >30 Gy fractionated whole or partial brain irradiation at least 6 months prior to enrollment were randomized to either placebo or donepezil (5 mg for 6 weeks followed by 10 mg for 18 weeks) in a phase 3 trial. A neurocognitive battery, the Functional Assessment of Cancer Therapy-Brain (FACT-Br) and the Functional Assessment of Chronic Illness Therapy (FACIT)-fatigue, was administered at baseline, 12 weeks, and 24 weeks.

Results

At 12 weeks, donepezil resulted in improvements in only emotional functioning (P = .04), with no significant effects at week 24. Associations by level of baseline cognitive symptoms (above or below the median score of the baseline FACT-Br "additional concerns/brain" subscale), indicated that participants with more baseline symptoms who received donepezil versus placebo, showed improvements in social (P = .02) and emotional well-being (P = .038), other concerns/brain (P = .003) and the FACT-Br total score (P = .004) at 12 weeks, but not 24 weeks. However, participants with fewer baseline symptoms randomized to donepezil versus placebo reported lower functional well-being at both 12 (P = .015) and 24 weeks (P = .009), and greater fatigue (P = .02) at 24 weeks.

Conclusions

The positive impact of donepezil on HRQL was greater in survivors reporting more baseline cognitive symptoms. Donepezil had significantly worse effects on fatigue and functional well-being among participants with fewer baseline symptoms. Future interventions with donepezil should target participants with more baseline cognitive complaints to achieve greater therapeutic impact and lessen potential side effects of treatment.

The 24-month metabolic benefits of the healthy living partnerships to prevent diabetes: A community-based translational study

AIMS

Large-scale clinical trials and translational studies have demonstrated that weight loss achieved through diet and physical activity reduced the development of diabetes in overweight individuals with prediabetes. These interventions also reduced the occurrence of metabolic syndrome and risk factors linked to other chronic conditions including obesity-driven cancers and cardiovascular disease. The Healthy Living Partnerships to Prevent Diabetes (HELP PD) was a clinical trial in which participants were randomized to receive a community-based lifestyle intervention translated from the Diabetes Prevention Program (DPP) or an enhanced usual care condition. The objective of this study is to compare the 12 and 24 month prevalence of metabolic syndrome in the two treatment arms of HELP PD.

MATERIALS AND METHODS

The intervention involved a group-based, behavioral weight-loss program led by community health workers monitored by personnel from a local diabetes education program. The enhanced usual care condition included dietary counseling and written materials.

RESULTS

HELP PD included 301 overweight or obese participants (BMI 25-39.9kg/m²) with elevated fasting glucose levels (95-125mg/dl). At 12 and 24 months of follow-up there were significant improvements in individual components of the metabolic syndrome: fasting blood glucose, waist circumference, HDL, triglycerides and blood pressure and the occurrence of the metabolic syndrome in the intervention group compared to the usual care group.

CONCLUSIONS

This study demonstrates that a community diabetes prevention program in participants with prediabetes results in metabolic benefits and a reduction in the occurrence of the metabolic syndrome in the intervention group compared to the enhanced usual care group.

Self-reported adherence and biomarker levels of CoQ10 and alpha-tocopherol

PURPOSE

Women with breast cancer were randomized to receive coenzyme Q10 (CoQ10) plus Vitamin E or placebo in a clinical trial. The objective of this evaluation is to examine the association between participant self-reported adherence to the study supplements and changes in plasma biomarker levels.

PATIENTS AND METHODS

Correlation coefficients quantified the association between changes in alpha-tocopherol and CoQ10 levels and the association between self-reported adherence and changes in biomarkers. Participants were categorized by self-reported adherence; Kruskal- Wallis tests compared changes in alpha-tocopherol and CoQ10 levels between self-reported adherence groups.

RESULTS

Women (N=155) provided baseline and post-treatment biomarkers; 147 completed at least one diary. While changes in alpha-tocopherol and CoQ10 levels were moderately correlated, correlations ranged from 0.40 to 0.48, association between self-reported adherence and plasma alpha-tocopherol or CoQ10 levels was weak; correlations ranged from 0.10 to 0.29 at weeks 8, 16, and 24. Some participants with high self-reported adherence actually had decreases in their biomarker levels.

CONCLUSION

These findings support that self-reported adherence is likely to be overestimated. Biological and other measures of adherence that can better identify true adherence to study pills provided in clinical trials are greatly needed as they may assist in improving the interpretation of findings of future clinical trials.

A Randomized Double-Blind Placebo-Controlled Trial of Fruit and Vegetable Concentrates on Intermediate Biomarkers in Head and Neck Cancer

Background. Head and neck cancer (HNC) patients are at an increased risk for developing second primary tumors (SPTs). Diets rich in fruits and vegetables (FVs) may lower HNC risk. FV concentrates may offer a potential alternative to increasing FV intake. Methods. We conducted a randomized, double-blind, placebo-controlled trial to evaluate whether Juice PLUS+ (JP; a commercial product with multiple FV concentrates) has an effect on p27 and Ki-67, biomarkers associated with the risk of SPTs. During 2004-2008, we randomized 134 HNC patients to 12 weeks of JP (n = 72) or placebo (n = 62). Oral cavity mucosal biopsies and whole blood were obtained at baseline and after 12 weeks. All participants were given the opportunity to receive JP for 5 years following the end of the intervention period, and they were followed yearly for the development of SPTs. Results. After 12 weeks, patients on JP had significantly higher serum α-carotene (P = .009), β-carotene (P < .0001), and lutein (P = .003) but did not differ significantly in p27 (P = .23) or Ki-67 (P = .95). JP use following the initial 12-week trial was not significantly associated with SPT prevention. Conclusions. Despite increased serum micronutrient levels, our results do not suggest a clinical benefit of JP in HNC patients. Future studies should focus on longer intervention periods and/or modified supplement formulations with demonstrated chemopreventive properties.

Effect of ArginMax on sexual functioning and quality of life among female cancer survivors: results of the WFU CCOP Research Base Protocol 97106

BACKGROUND

Problems with sexual functioning are common following therapy for breast and gynecologic cancers, although there are few effective treatments.

OBJECTIVE

To assess the impact of ArginMax, a nutritional supplement comprised of extracts of L-arginine, ginseng, gingko, and damiana, as well as multivitamins and minerals, on sexual functioning and quality of life in female cancer survivors.

METHODS

This was a 12-week, randomized, placebo-controlled trial of eligible patients who were 6 months or more from active treatment and reporting problems with sexual interest, satisfaction, and functioning after therapy. The participants took 3 capsules of Arginmax or placebo twice daily. Outcome measures were the Female Sexual Function Inventory (FSFI) and the Functional Assessment of Cancer Therapy - General (FACT-G). Assessments were done at baseline, 4, 8, and 12 weeks.

RESULTS

186 patients with a median age of 50 years were accrued between May 10, 2007 and March 24, 2010. 76% of the patients were non-Hispanic white. Most had breast or a gynecologic cancer (78% and 12%, respectively). At 12 weeks, there were no differences between the ArginMax group (n = 96) and placebo (n = 92) group in sexual desire, arousal, lubrication, orgasm,satisfaction or pain. However, FACT-G total scores were significantly better for participants who took ArginMax compared with those who took placebo (least squares [LS] means, 87.5 vs 82.9, respectively; P = .009). The Fact-G subscales that were most affected were Physical (25.37 vs. 23.51, P = .001) and Functional Well-Being (22.46 vs. 20.72, P = .007). Toxicities were similar for both groups.

LIMITATIONS

Study results are limited by a lack of data on the participants' psychological and physical symptoms and sexual partner variables.

CONCLUSIONS

ArginMax had no significant impact on sexual functioning, but patient quality of life was significantly better at 12 weeks in participants who received ArginMax.

Standardized Rehabilitation and Hospital Length of Stay Among Patients With Acute Respiratory Failure: A Randomized Clinical Trial

IMPORTANCE

Physical rehabilitation in the intensive care unit (ICU) may improve the outcomes of patients with acute respiratory failure.

OBJECTIVE

To compare standardized rehabilitation therapy (SRT) to usual ICU care in acute respiratory failure.

DESIGN, SETTING, AND PARTICIPANTS

Single-center, randomized clinical trial at Wake Forest Baptist Medical Center, North Carolina. Adult patients (mean age, 58 years; women, 55%) admitted to the ICU with acute respiratory failure requiring mechanical ventilation were randomized to SRT (n=150) or usual care (n=150) from October 2009 through May 2014 with 6-month follow-up.

INTERVENTIONS

Patients in the SRT group received daily therapy until hospital discharge, consisting of passive range of motion, physical therapy, and progressive resistance exercise. The usual care group received weekday physical therapy when ordered by the clinical team. For the SRT group, the median (interquartile range [IQR]) days of delivery of therapy were 8.0 (5.0-14.0) for passive range of motion, 5.0 (3.0-8.0) for physical therapy, and 3.0 (1.0-5.0) for progressive resistance exercise. The median days of delivery of physical therapy for the usual care group was 1.0 (IQR, 0.0-8.0).

MAIN OUTCOMES AND MEASURES

Both groups underwent assessor-blinded testing at ICU and hospital discharge and at 2, 4, and 6 months. The primary outcome was hospital length of stay (LOS). Secondary outcomes were ventilator days, ICU days, Short Physical Performance Battery (SPPB) score, 36-item Short-Form Health Surveys (SF-36) for physical and mental health and physical function scale score, Functional Performance Inventory (FPI) score, Mini-Mental State Examination (MMSE) score, and handgrip and handheld dynamometer strength.

RESULTS

Among 300 randomized patients, the median hospital LOS was 10 days (IQR, 6 to 17) for the SRT group and 10 days (IQR, 7 to 16) for the usual care group (median difference, 0 [95% CI, -1.5 to 3], P = .41). There was no difference in duration of ventilation or ICU care. There was no effect at 6 months for handgrip (difference, 2.0 kg [95% CI, -1.3 to 5.4], P = .23) and handheld dynamometer strength (difference, 0.4 lb [95% CI, -2.9 to 3.7], P = .82), SF-36 physical health score (difference, 3.4 [95% CI, -0.02 to 7.0], P = .05), SF-36 mental health score (difference, 2.4 [95% CI, -1.2 to 6.0], P = .19), or MMSE score (difference, 0.6 [95% CI, -0.2 to 1.4], P = .17). There were higher scores at 6 months in the SRT group for the SPPB score (difference, 1.1 [95% CI, 0.04 to 2.1, P = .04), SF-36 physical function scale score (difference, 12.2 [95% CI, 3.8 to 20.7], P = .001), and the FPI score (difference, 0.2 [95% CI, 0.04 to 0.4], P = .02).

CONCLUSIONS AND RELEVANCE

Among patients hospitalized with acute respiratory failure, SRT compared with usual care did not decrease hospital LOS.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00976833.

Trajectories of Posttraumatic Growth and Associated Characteristics in Women with Breast Cancer

BACKGROUND

Cancer survivors may experience posttraumatic growth (PTG), positive psychological changes resulting from highly stressful events; however, the longitudinal course of PTG is poorly understood.

PURPOSE

The purpose of the present study was to determine trajectories of PTG in breast cancer survivors and associated characteristics.

METHODS

Women (N = 653) participating in a longitudinal observational study completed questionnaires within 8 months of breast cancer diagnosis and 6, 12, and 18 months later. Group-based modeling identified PTG trajectories. Chi-square tests and ANOVA detected group differences in demographic, medical, and psychosocial variables.

RESULTS

Six trajectory groups emerged. Three were stable at different levels of PTG, two increased modestly, and one increased substantially over time. Trajectory groups differed by age, race, receipt of chemotherapy, illness intrusiveness, depressive symptoms, active-adaptive coping, and social support.

CONCLUSIONS

This first examination of PTG trajectories in US cancer survivors elucidates heterogeneity in longitudinal patterns of PTG. Future research should determine whether other samples exhibit similar trajectories and whether various PTG trajectories predict mental and physical health outcomes.

Trajectories of depressive symptoms following breast cancer diagnosis

BACKGROUND

This longitudinal study sought to identify groups of breast cancer survivors exhibiting distinct trajectories of depressive symptoms up to 24 months following diagnosis, and to describe characteristics associated with these trajectories.

METHODS

A total of 653 women completed baseline questionnaires within 8 months of breast cancer diagnosis on patient characteristics, symptoms, and psychosocial variables. Depressive symptoms were assessed at baseline and 6, 12, and 18 months after baseline. Chart reviews provided cancer and treatment-related data. Finite mixture modeling identified trajectories of depressive symptoms measured with the Beck Depression Inventory (BDI).

RESULTS

Six distinct trajectories were identified. Just over half of the sample had consistently very low (3.8%) or low (47.3%) BDI scores well below the traditional BDI cutoff point of 10 thought to be indicative of clinically significant depression; 29.2% had consistently borderline scores; 11.3% had initially high scores that declined over time, but remained above the cutoff point; 7.2% showed increased BDI over time; and a small but unique group (1.1%) reported chronically high scores above 25. Women in groups with lower depressive symptom levels were older, had less rigorous chemotherapy, fewer physical symptoms (fatigue and pain), and lower levels of illness intrusiveness.

CONCLUSIONS

Approximately 20% of women had levels of depressive symptoms indicative of clinical depression that were maintained 2 years postdiagnosis. Factors related to trajectory membership such as illness intrusiveness, social support, fatigue, pain, and vasomotor symptoms suggest targets for possible intervention.

IMPACT

Results demonstrate the heterogeneity of depressive symptoms following breast cancer and the need for continued screening posttreatment.

Tumor-induced loss of mural Connexin 43 gap junction activity promotes endothelial proliferation

Background

Proper functional association between mural cells and endothelial cells (EC) causes EC of blood vessels to become quiescent. Mural cells on tumor vessels exhibit decreased attachment to EC, which allows vessels to be unstable and proliferative. The mechanisms by which tumors prevent proper association between mural cells and EC are not well understood. Since gap junctions (GJ) play an important role in cell-cell contact and communication, we investigated whether loss of GJ plays a role in tumor-induced mural cell dissociation.

Methods

Mural cell regulation of endothelial proliferation was assessed by direct co-culture assays of fluorescently labeled cells quantified by flow cytometry or plate reader. Gap junction function was assessed by parachute assay. Connexin 43 (Cx43) protein in mural cells exposed to conditioned media from cancer cells was assessed by Western and confocal microscopy; mRNA levels were assessed by quantitative real-time PCR. Expression vectors or siRNA were utilized to overexpress or knock down Cx43. Tumor growth and angiogenesis was assessed in mouse hosts deficient for Cx43.

Results

Using parachute dye transfer assay, we demonstrate that media conditioned by MDA-MB-231 breast cancer cells diminishes GJ communication between mural cells (vascular smooth muscle cells, vSMC) and EC. Both protein and mRNA of the GJ component Connexin 43 (Cx43) are downregulated in mural cells by tumor-conditioned media; media from non-tumorigenic MCF10A cells had no effect. Loss of GJ communication by Cx43 siRNA knockdown, treatment with blocking peptide, or exposure to tumor-conditioned media diminishes the ability of mural cells to inhibit EC proliferation in co-culture assays, while overexpression of Cx43 in vSMC restores GJ and endothelial inhibition. Breast tumor cells implanted into mice heterozygous for Cx43 show no changes in tumor growth, but exhibit significantly increased tumor vascularization determined by CD31 staining, along with decreased mural cell support detected by NG2 staining.

Conclusions

Our data indicate that i) functional Cx43 is required for mural cell-induced endothelial quiescence, and ii) downregulation of Cx43 GJ by tumors frees endothelium to respond to angiogenic cues. These data define a novel and important role for maintained Cx43 function in regulation of vessel quiescence, and suggest its loss may contribute to pathological tumor angiogenesis.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-015-1420-9) contains supplementary material, which is available to authorized users.

Disparities in barriers to follow-up care between African American and White breast cancer survivors

PURPOSE

Despite recommendations for breast cancer survivorship care, African American women are less likely to receive appropriate follow-up care, which is concerning due to their higher mortality rates. This study describes differences in barriers to follow-up care between African American and White breast cancer survivors.

METHODS

We conducted a mailed survey of women treated for non-metastatic breast cancer in 2009-2011, 6-24 months post-treatment (N = 203). Survivors were asked about 14 potential barriers to follow-up care. We used logistic regression to explore associations between barriers and race, adjusting for covariates.

RESULTS

Our participants included 31 African American and 160 White survivors. At least one barrier to follow-up care was reported by 62 %. Compared to White survivors, African Americans were more likely to identify barriers related to out-of-pocket costs (28 vs. 51.6 %, p = 0.01), other health care costs (21.3 vs. 45.2 %, p = 0.01), anxiety/worry (29.4 vs. 51.6 %, p = 0.02), and transportation (4.4 vs. 16.1 %, p = 0.03). After adjustment for covariates, African Americans were three times as likely to report at least one barrier to care (odds ratio (OR) = 3.3, 95 % confidence interval (CI) = 1.1-10.1).

CONCLUSIONS

Barriers to care are common among breast cancer survivors, especially African American women. Financial barriers to care may prevent minority and underserved survivors from accessing follow-up care. Enhancing insurance coverage or addressing out-of-pocket costs may help address financial barriers to follow-up care among breast cancer survivors. Psychosocial care aimed at reducing fear of recurrence may also be important to improve access among African American breast cancer survivors.

Abstract C35: Racial disparities in barriers to follow-up care among breast cancer survivors

Purpose: After completing primary treatment for breast cancer, regular follow-up care is recommended to monitor for recurrence and second primary cancers, and to manage late and long-term effects of cancer and its treatment, comorbidities, and psychosocial issue. Lack of follow-up care may be particularly concerning for African American women, who have higher breast cancer mortality despite lower incidence rates compared to White women. Reasons why survivors may not receive follow-up care are poorly understood; therefore we describe breast cancer survivors' perceived barriers to follow-up care, including differences between African American and White women, and examine factors associated with perceived barriers to care.

Methods: We conducted a mailed cross-sectional survey of women identified from an institutional cancer registry and treated for non-metastatic breast cancer 6 to 24 months post-treatment. Survivors were asked whether each of 14 potential barriers presented a big problem, somewhat of a problem or no problem in receiving follow-up care. The list of barriers was adapted from an earlier survey of follow-up care among cancer survivors. We created two dichotomous measures: any barrier to care (any barrier rated as “somewhat of a problem” or “a big problem,” vs. all 14 barriers reported as “no problem”) and cost-related barriers to care (any of three cost-related barriers rated as “somewhat of a problem” or “big problem versus all three barriers reported as “no problem). We used logistic regression analysis to explore associations between barriers (any barrier and cost-related barriers) and race, adjusting for age at diagnosis, current residence, marital status, education, employment, health insurance coverage, and time since diagnosis.

Results: Thirty-one African American and 160 White survivors made up our analytic sample. The mean age at diagnosis was 58.5 (SD=11.4), all had surgery, 37% received chemotherapy, 51% received radiation therapy, and 53% received hormone therapy. Sixty-two percent of survivors reported at least one barrier to follow-up care. African American survivors were more likely to identify the following barriers to care compared to White survivors: out of pocket medical costs (52% vs. 28%), cannot afford other associated costs (45% vs. 21%), feeling anxious or worried (52% vs. 29%), and lack of transportation to doctor (16% vs. 4%). Compared to African American survivors, White survivors were more likely to report distance to travel to see doctor as a barrier (3% vs. 19%). Overall, African American survivors were more likely to report at least one barrier (81% vs. 58%) and at least one cost-related barrier (59% vs. 33%). In models adjusting for sociodemographic and clinical characteristics, African Americans were more likely to report any barrier (OR=3.3, 95% CI=1.1-10.1). For cost-related barriers, race was not significant after adjusting for other factors (OR=2.5, 95% CI=0.9-6.6); however, having public health insurance coverage (OR=4.8, 95% CI=1.1-20.4) and no insurance (OR=31.0, 95% CI=2.7-360.5) remained significant predictors compared to having both public and private health insurance.

Conclusions: A majority of breast cancer survivors report barriers to follow-up care, most commonly anxiety or worry or financial concerns. African American breast cancer survivors were more likely to report any barrier to care, even after adjustment for sociodemographic and clinical factors. Different interventions are likely needed to help survivors overcome barriers to care. Enhancing insurance coverage or addressing out of pocket costs may reduce financial barriers, but psychosocial care aimed at reducing fear of cancer recurrence may reduce barriers associated with anxiety or fear.

Citation Format: Nynikka Palmer, Kathryn Weaver, Sally Hauser, Jennifer Talton, L. Douglas Case, Julia Lawrence, Kimberly Dezern, Ann Geiger. Racial disparities in barriers to follow-up care among breast cancer survivors. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr C35. doi:10.1158/1538-7755.DISP13-C35

Oral paricalcitol (19-nor-1,25-dihydroxyvitamin D2) in women receiving chemotherapy for metastatic breast cancer: a feasibility trial

The vitamin D hormone, [1,25(OH) 2D, calcitriol], inhibits proliferation and angiogenesis in breast cancer but its therapeutic use is limited by hypercalcemia. Synthetic analogs of 1,25(OH) 2D that are less calcemic, such as paricalcitol (19-nor-1,25-Dihydroxyvitamin D 2), are used to treat hyperparathyroidism associated with chronic kidney disease. We sought to determine the safety and feasibility of taking oral paricalcitol with taxane-based chemotherapy in women with metastatic breast cancer (MBC). Oral paricalcitol was considered safe if it did not result in excessive toxicity, defined as grade 3 or higher serum calcium levels. It was considered feasible if the majority of women could take eight weeks of continuous therapy in the first three months. Serum calcium was monitored weekly and the paricalcitol dose was adjusted based on its calcemic effect. Intact parathyroid hormone (iPTH) was monitored as a marker of paricalcitol activity. Twenty-four women with MBC were enrolled. Twenty women (83%) received eight weeks of continuous therapy. Paricalcitol was well-tolerated with no instances of hypercalcemia grade 2 or greater. Fourteen women (54%) were able to escalate the dose. The dose range of paricalcitol in the first 3 mo was 2-7 ug/day. Serum iPTH levels at baseline were significantly higher in women with serum 25-Hydroxyvitamin D (25-OHD) levels less than 30 ng/ml (96.4 ± 40.9 pg/ml) vs. 46.2 ± 20.3 pg/ml (p = 0 0.001) (iPTH reference 12-72 pg/ml). We conclude that paricalcitol is safe and feasible in women with MBC who are receiving chemotherapy.

Predictors of posttraumatic growth in women with breast cancer

OBJECTIVE

Posttraumatic growth (PTG) is defined as 'positive psychological change experienced as a result of a struggle with highly challenging life circumstances'. The current study examined change in PTG over 2 years following breast cancer diagnosis and variables associated with PTG over time.

METHODS

Women recently diagnosed with breast cancer completed surveys within 8 months of diagnosis and 6, 12, and 18 months later. Linear mixed effects models were used to assess the longitudinal effects of demographic, medical, and psychosocial variables on PTG as measured by the Posttraumatic Growth Inventory (PTGI).

RESULTS

A total of 653 women were accrued (mean age = 54.9, SD = 12.6). Total PTGI score increased over time mostly within the first few months following diagnosis. In the longitudinal model, greater PTGI scores were associated with education level, longer time since diagnosis, greater baseline level of illness intrusiveness, and increases in social support, spirituality, use of active-adaptive coping strategies, and mental health. Findings for the PTGI domains were similar to those for the total score except for the Spiritual Change domain.

CONCLUSION

PTG develops relatively soon after a breast cancer diagnosis and is associated with baseline illness intrusiveness and increases in social support, spirituality, use of active-adaptive coping strategies, and mental health.

Impact of rural residence on forgoing healthcare after cancer because of cost

BACKGROUND

Routine follow-up care is recommended to promote the well-being of cancer survivors, but financial difficulties may interfere. Rural-urban disparities in forgoing healthcare due to cost have been observed in the general population; however, it is unknown whether this disparity persists among survivors. The purpose of this study was to examine rural-urban disparities in forgoing healthcare after cancer due to cost.

METHODS

We analyzed data from 7,804 cancer survivors in the 2006 to 2010 National Health Interview Survey. Logistic regression models, adjusting for sociodemographic and clinical characteristics, were used to assess rural-urban disparities in forgoing medical care, prescription medications, and dental care due to cost, stratified by age (younger: 18-64, older: 65+).

RESULTS

Compared with urban survivors, younger rural survivors were more likely to forgo medical care (P < 0.001) and prescription medications (P < 0.001) due to cost; older rural survivors were more likely to forgo medical (P < 0.001) and dental care (P = 0.05). Rural-urban disparities did not persist among younger survivors in adjusted analyses; however, older rural survivors remained more likely to forgo medical [OR = 1.66, 95% confidence interval (CI) = 1.11-2.48] and dental care (OR = 1.54, 95%CI = 1.08-2.20).

CONCLUSIONS

Adjustment for health insurance and other sociodemographic characteristics attenuates rural-urban disparities in forgoing healthcare among younger survivors, but not older survivors. Financial factors relating to healthcare use among rural survivors should be a topic of continued investigation.

IMPACT

Addressing out-of-pocket costs may be an important step in reducing rural-urban disparities in healthcare, especially for older survivors. It will be important to monitor how healthcare reform efforts impact disparities observed in this vulnerable population.

Incorporating prosocial behavior to promote physical activity in older adults: rationale and design of the Program for Active Aging and Community Engagement (PACE)

Despite the benefits of regular physical activity among older adults, physical activity rates are low in this population. The Program for Active Aging and Community Engagement (PACE) is an ongoing randomized controlled trial designed to compare the effects of two interventions on physical activity at 12 months among older adults. A total of 300 men and women aged 55 years or older will be randomized into either a healthy aging (HA) control intervention (n = 150), which is largely based upon educational sessions, or a prosocial behavior physical activity (PBPA) intervention (n = 150), which incorporates structured physical activity sessions, cognitive-behavioral counseling, and opportunities to earn food for donation to a regional food bank based on weekly physical activity and volunteering. The PBPA intervention is delivered at a local YMCA, and a regional grocery store chain donates the food to the food bank. Data will be collected at baseline, 3, 6, and 12 months. The primary outcome is physical activity as assessed by the Community Healthy Activities Model Program for Seniors (CHAMPS) Questionnaire at 12 months. Secondary outcomes include physical function and health-related quality of life. If successful, the PACE study will demonstrate that prosocial behavior and volunteerism may be efficaciously incorporated into interventions and will provide evidence for a novel motivating factor for physical activity.

Conservative Sample Size Determination for Repeated Measures Analysis of Covariance

In the design of a randomized clinical trial with one pre and multiple post randomized assessments of the outcome variable, one needs to account for the repeated measures in determining the appropriate sample size. Unfortunately, one seldom has a good estimate of the variance of the outcome measure, let alone the correlations among the measurements over time. We show how sample sizes can be calculated by making conservative assumptions regarding the correlations for a variety of covariance structures. The most conservative choice for the correlation depends on the covariance structure and the number of repeated measures. In the absence of good estimates of the correlations, the sample size is often based on a two-sample t-test, making the 'ultra' conservative and unrealistic assumption that there are zero correlations between the baseline and follow-up measures while at the same time assuming there are perfect correlations between the follow-up measures. Compared to the case of taking a single measurement, substantial savings in sample size can be realized by accounting for the repeated measures, even with very conservative assumptions regarding the parameters of the assumed correlation matrix. Assuming compound symmetry, the sample size from the two-sample t-test calculation can be reduced at least 44%, 56%, and 61% for repeated measures analysis of covariance by taking 2, 3, and 4 follow-up measures, respectively. The results offer a rational basis for determining a fairly conservative, yet efficient, sample size for clinical trials with repeated measures and a baseline value.

Racial/Ethnic disparities in health care receipt among male cancer survivors

OBJECTIVES

We examined racial/ethnic disparities in health care receipt among a nationally representative sample of male cancer survivors.

METHODS

We identified men aged 18 years and older from the 2006-2010 National Health Interview Survey who reported a history of cancer. We assessed health care receipt in 4 self-reported measures: primary care visit, specialist visit, flu vaccination, and pneumococcal vaccination. We used hierarchical logistic regression modeling, stratified by age (< 65 years vs ≥ 65 years).

RESULTS

In adjusted models, older African American and Hispanic survivors were approximately twice as likely as were non-Hispanic Whites to not see a specialist (odds ratio [OR] = 1.78; 95% confidence interval [CI] = 1.19, 2.68 and OR = 2.09; 95% CI = 1.18, 3.70, respectively), not receive the flu vaccine (OR = 2.21; 95% CI = 1.45, 3.37 and OR = 2.20; 95% CI = 1.21, 4.01, respectively), and not receive the pneumococcal vaccine (OR = 2.24; 95% CI = 1.54, 3.24 and OR = 3.10; 95% CI = 1.75, 5.51, respectively).

CONCLUSIONS

Racial/ethnic disparities in health care receipt are evident among older, but not younger, cancer survivors, despite access to Medicare. These survivors may be less likely to see specialists, including oncologists, and receive basic preventive care.

Rural-urban differences in health behaviors and implications for health status among US cancer survivors

PURPOSE

Rural US adults have increased risk of poor outcomes after cancer, including increased cancer mortality. Rural-urban differences in health behaviors have been identified in the general population and may contribute to cancer health disparities, but have not yet been examined among US survivors. We examined rural-urban differences in health behaviors among cancer survivors and associations with self-reported health and health-related unemployment.

METHODS

We identified rural (n = 1,642) and urban (n = 6,162) survivors from the cross-sectional National Health Interview Survey (2006-2010) and calculated the prevalence of smoking, physical activity, overweight/obesity, and alcohol consumption. Multivariable models were used to examine the associations of fair/poor health and health-related unemployment with health behaviors and rural-urban residence.

RESULTS

The prevalence of fair/poor health (rural 36.7 %, urban 26.6 %), health-related unemployment (rural 18.5 %, urban 10.6 %), smoking (rural 25.3 %, urban 15.8 %), and physical inactivity (rural 50.7 %, urban 38.7 %) was significantly higher in rural survivors (all p < .05); alcohol consumption was lower (rural 46.3 %, urban 58.6 %), and there were no significant differences in overweight/obesity (rural 65.4 %, urban 62.6 %). All health behaviors were significantly associated with fair/poor health and health-related unemployment in both univariate and multivariable models. After adjustment for behaviors, rural survivors remained more likely than urban survivors to report fair/poor health (OR = 1.21, 95 % CI 1.03-1.43) and health-related unemployment (OR = 1.49, 95 % CI 1.18-1.88).

CONCLUSIONS

Rural survivors may need tailored, accessible health promotion interventions to address health-compromising behaviors and improve outcomes after cancer.

Trajectories of illness intrusiveness domains following a diagnosis of breast cancer

OBJECTIVE

To identify trajectories of illness intrusiveness over the first 2 years after a breast cancer diagnosis and describe associated patient and treatment characteristics. Illness intrusiveness, or how much an illness disrupts life domains, has been shown to be highly related to quality of life.

METHODS

Women recruited within 8 months of a breast cancer diagnosis (n = 653) completed questionnaires at baseline and 6, 12, and 18 months postbaseline. Group-based trajectory modeling was used to identify trajectories in three established domains of illness intrusiveness: instrumental, intimacy, and relationships and personal development. Bivariate analyses identified contextual, disease/treatment, psychological, and social characteristics of women in trajectory groups.

RESULTS

Forty-one percent of women fell into a trajectory of consistently low illness intrusiveness (Low) across all three domains. Other women varied such that some reported illness intrusiveness that decreased over time on at least one domain (9-34%), and others reported consistently high intrusiveness on at least one domain (11-17%). A fourth trajectory of increased illness intrusiveness emerged in the relationship and personal development domain (9%). Characteristics of women in the Low group were being older; being less likely to have children at home; and having stage I cancer, fewer symptoms, and better psychosocial status.

CONCLUSIONS

Women experienced different patterns of illness intrusiveness in the first 2 years after a diagnosis of breast cancer with a high percentage reporting Low intrusiveness. However, women differentially followed the other trajectory patterns by domain, suggesting that the effect of breast cancer on some women's lives may be specific to certain areas.

Fatty acid metabolites in rapidly proliferating breast cancer

PURPOSE

Breast cancers that over-express a lipoxygenase or cyclooxygenase are associated with poor survival possibly because they overproduce metabolites that alter the cancer's malignant behaviors. However, these metabolites and behaviors have not been identified. We here identify which metabolites among those that stimulate breast cancer cell proliferation in vitro are associated with rapidly proliferating breast cancer.

EXPERIMENTAL DESIGN

We used selective ion monitoring-mass spectrometry to quantify in the cancer and normal breast tissue of 27 patients metabolites that stimulate (15-, 12-, 5-hydroxy-, and 5-oxo-eicosatetraenoate, 13-hydroxy-octadecaenoate [HODE]) or inhibit (prostaglandin [PG]E2 and D2) breast cancer cell proliferation. We then related their levels to each cancer's proliferation rate as defined by its Mib1 score.

RESULTS

13-HODE was the only metabolite strongly, significantly, and positively associated with Mib1 scores. It was similarly associated with aggressive grade and a key component of grade, mitosis, and also trended to be associated with lymph node metastasis. PGE2 and PGD2 trended to be negatively associated with these markers. No other metabolite in cancer and no metabolite in normal tissue had this profile of associations.

CONCLUSIONS

Our data fit a model wherein the overproduction of 13-HODE by 15-lipoxygenase-1 shortens breast cancer survival by stimulating its cells to proliferate and possibly metastasize; no other oxygenase-metabolite pathway, including cyclooxygenase-PGE2/D2 pathways, uses this specific mechanism to shorten survival.

Age-related longitudinal changes in depressive symptoms following breast cancer diagnosis and treatment

Younger women being treated for breast cancer consistently show greater depression shortly after diagnosis than older women. In this longitudinal study, we examine whether these age differences persist over the first 26 months following diagnosis and identify factors related to change in depressive symptoms. A total of 653 women within 8 months of a first time breast cancer diagnosis completed questionnaires at baseline and three additional timepoints (6, 12, and 18 months after baseline) on contextual/patient characteristics, symptoms, and psychosocial variables. Chart reviews provided cancer and treatment-related data. The primary outcome was depressive symptomatology assessed by the Beck Depression Inventory. Among women younger than age 65, depressive symptoms were highest soon after diagnosis and significantly decreased over time. Depressive symptoms remained stable and low for women aged 65 and older. Age was no longer significantly related to depressive symptoms in multivariable analyses controlling for a wide range of covariates. The primary factors related to levels of and declines in depressive symptomatology were the ability to pay for basics; completing chemotherapy with doxorubicin; and decreases in pain, vasomotor symptoms, illness intrusiveness, and passive coping. Increased sense of meaning/peace and social support were related to decreased depression. Interventions to reduce symptoms and illness intrusiveness, improve a sense of meaning and peace, and increase social support, may help reduce depression and such interventions may be especially relevant for younger women.

Rural-urban disparities in health status among US cancer survivors

BACKGROUND

Although rural residents are more likely to be diagnosed with more advanced cancers and to die of cancer, little is known about rural-urban disparities in self-reported health among survivors.

METHODS

The authors identified adults who had a self-reported history of cancer from the National Health Interview Survey (2006-2010). Rural-urban residence was defined using US Census definitions. Logistic regression with weighting to account for complex sampling was used to assess rural-urban differences in health status after accounting for differences in demographic characteristics.

RESULTS

Of the 7804 identified cancer survivors, 20.8% were rural residents. This translated to a population of 2.8 million rural cancer survivors in the United States. Rural survivors were more likely than urban survivors to be non-Hispanic white (P < .001), to have less education (P < .001), and to lack health insurance (P < .001). Rural survivors reported worse health in all domains. After adjustment for sex, race/ethnicity, age, marital status, education, insurance, time since diagnosis, and number of cancers, rural survivors were more likely to report fair/poor health (odds ratio, 1.39; 95% confidence interval, 1.20-1.62), psychological distress (odds ratio, 1.23; 95% confidence interval, 1.00-1.50), ≥2 noncancer comorbidities (odds ratio, 1.15; 95% confidence interval, 1.01-1.32), and health-related unemployment (odds ratio, 1.66; 95% confidence interval, 1.35-2.03).

CONCLUSIONS

The current results provide the first estimates of the proportion and number of US adult cancer survivors who reside in rural areas. Rural cancer survivors are at greater risk for a variety of poor health outcomes, even many years after their cancer diagnosis, and should be a target for interventions to improve their health and well being.

Reduction in observation unit length of stay with coronary computed tomography angiography depends on time of emergency department presentation

OBJECTIVES

Prior studies demonstrating shorter length of stay (LOS) from coronary computed tomography angiography (CCTA) relative to stress testing in emergency department (ED) patients have not considered time of patient presentation. The objectives of this study were to determine whether low-risk chest pain patients receiving stress testing or CCTA have differences in ED plus observation unit (OU) LOS and if there are disparities in testing modality use, based on the time of patient presentation to the ED.

METHODS

The authors examined a cohort of low-risk chest pain patients evaluated in an ED-based OU using prospective and retrospective OU registry data. During the study period, stress testing and CCTA were both available from 08:00 to 17:00 hours. CCTA was not available on weekends, and therefore only subjects presenting on weekdays were included. Cox regression analysis was used to model the effect of testing modality (stress testing vs. CCTA) on OU LOS. Separate models were fit based on time of patient presentation to the ED using 4-hour blocks beginning at midnight. The primary independent variable was testing modality: stress testing or CCTA. Age, sex, and race were included as covariates. Logistic regression was used to model testing modality choice by time period adjusted for age, sex, and race.

RESULTS

Over the study period, 841 subjects presented Monday through Friday. Median LOS was 18.0 hours (interquartile range [IQR] = 11.7 to 22.9 hours). Objective cardiac testing was completed in 788 of 841 (94%) patients, with 496 (63%) receiving stress testing and 292 (37%) receiving CCTA. After age, race, and sex were adjusted for, patients presenting between 08:00 and 11:59 hours not only had a shorter LOS associated with CCTA (p < 0.0001), but also had a greater likelihood of being tested by CCTA (p = 0.001). None of the other time periods had significant differences in LOS or testing modality choice for CCTA relative to stress testing.

CONCLUSIONS

In an OU setting with weekday and standard business hours CCTA availability, CCTA testing was associated with shorter LOS among low-risk chest pain patients only in patients presenting to the ED between 08:00 and 11:59 hours. That time period was also associated with a greater likelihood of being tested by CCTA, suggesting that ED providers may have intuited the inability of CCTA to shorten LOS during other times.

Nightmares and dysfunctional beliefs about sleep mediate the effect of insomnia symptoms on suicidal ideation

STUDY OBJECTIVES

Many studies have reported a positive association between sleep problems and suicidal ideation. Some prospective studies in the elderly have shown that insomnia is a risk factor for suicide death after controlling for other depressive symptoms. However, hypotheses to explain how this risk is mediated have not previously been assessed. We tested the hypothesis that insomnia symptoms are related to suicidal ideation through mediation by dysfunctional beliefs and attitudes about sleep and/or nightmares.

METHODS

We measured symptoms of depression, hopelessness, insomnia severity, dysfunctional beliefs and attitudes about sleep, nightmares, and suicidal ideation intensity on a convenience sample of 50 patients with depressive disorders, including 23 outpatients, 16 inpatients, and 11 suicidal ED patients. Mediation analysis was used to assess the indirect effects of insomnia symptoms on suicidal ideation through dysfunctional beliefs about sleep and through nightmares.

RESULTS

Our findings again confirmed a positive association between insomnia symptoms and the intensity of suicidal ideas in depressed patients (b = 0.64, 95% CI = [0.14, 1.15]). However, we extended and clarified our earlier findings by now showing that dysfunctional beliefs and attitudes about sleep as well as nightmares may mediate the association between insomnia symptoms and suicidal ideation. The indirect effects of insomnia symptoms through dysfunctional beliefs about sleep and through nightmares were 0.38 (-0.03, 0.97) and 0.35 (0.05, 0.75), respectively.

CONCLUSIONS

Nightmares as well as dysfunctional beliefs and attitudes about sleep each are positively and independently related to the intensity of suicidal ideation, and the effect of insomnia symptoms appears to be mediated through these two variables.

The YMCA Healthy, Fit, and Strong Program: a community-based, family-centered, low-cost obesity prevention/treatment pilot study

BACKGROUND

Many resources are available for adults, but there are few community-based programs for overweight and obese children. Community engagement may be instrumental in overcoming barriers physicians experience in managing childhood obesity. Our objective was to design and test the feasibility of a community-based (YMCA), family-centered, low-cost intervention for overweight and obese children.

METHODS

Children 6-11 years over the 85th BMI percentile for age and sex were recruited to YMCA sites in four North Carolina communities. The children had physical activity sessions three times weekly for 3 months (one activity session weekly was family night). The parents received a once-weekly nutrition education class conducted by a registered dietitian using the NC Eat Smart Move More curriculum (10 sessions). Changes in BMI were measured at 3, 6, and 12 months and diet and activity behaviors at 3 and 12 months after baseline.

RESULTS

Significant reductions were observed in BMI percentile for age and BMI z-scores at 3, 6, and 12 months. Improvements occurred in dietary and physical activity behaviors, including drinking fewer sugar-sweetened beverages, spending more time in physically active behaviors, and spending less time in sedentary behaviors. The program was low-cost, and qualitative comments suggest the parents and children benefited from the experience.

CONCLUSIONS

This low-cost YMCA-based intervention was associated with BMI reductions and positive nutritional and activity behavior changes, providing an additional strategy for addressing childhood obesity in community settings.

Electrocardiographic and clinical predictors separating atherosclerotic sudden cardiac death from incident coronary heart disease

OBJECTIVE

To identify specific ECG and clinical predictors that separate atherosclerotic sudden cardiac death (SCD) from incident coronary heart disease (CHD) (non-fatal events and non-sudden death) in the combined cohorts of the Atherosclerosis Risk in Communities study and the Cardiovascular Health Study.

METHODS

This analysis included 18,497 participants (58% females, 24% black individuals, mean age 58 years) who were initially free of clinical CHD. A competing risk analysis was conducted to examine the prognostic significance of baseline clinical characteristics and an extensive electronic database of ECG measurements for prediction of 229 cases of SCD as a first event versus 2297 incident CHD cases (2122 non-fatal events and 175 non-sudden death) that occurred during a median follow-up time of 13 years in the Cardiovascular Health Study and 14 years in the Atherosclerosis Risk in Communities study.

RESULTS

After adjusting for common CHD risk factors, a number of clinical characteristics and ECG measurements were independently predictive of SCD and CHD. However, the risk of SCD versus incident CHD was significantly different for race/ethnicity, hypertension, body mass index (BMI), heart rate, QTc, abnormally inverted T wave in any ECG lead group and level of ST elevation in V2. Black race/ethnicity (compared to non-black) was predictive of high SCD risk but less risk of incident CHD (p value for differences in the risk (HR) for SCD versus CHD <0.0001). Hypertension, increased heart rate, prolongation of QTc and abnormally inverted T wave were stronger predictors of high SCD risk compared to CHD (p value=0.0460, 0.0398, 0.0158 and 0.0265, respectively). BMI was not predictive of incident CHD but was predictive of high SCD risk in a quadratic fashion (p value=0.0220). On the other hand, elevated ST height as measured at the J point and that measured at 60 ms after the J point in V2 were not predictive of SCD but were predictive of high incident CHD risk (p value=0.0251 and 0.0155, respectively).

CONCLUSIONS

SCD and CHD have many risk factors in common. Hypertension, race/ethnicity, BMI, heart rate, QTc, abnormally inverted T wave in any ECG lead group and level of ST elevation in V2 have the potential to separate between the risks of SCD and CHD. These results need to be validated in another cohort.

Effects of liquid type, delivery method, and bolus volume on penetration-aspiration scores in healthy older adults during flexible endoscopic evaluation of swallowing

OBJECTIVES

The type of liquid (eg, water or milk) that should be used during flexible endoscopic evaluation of swallowing (FEES) has received little investigation. Aspiration may vary as a function of the thin liquid type used during FEES.

METHODS

We measured the effects of liquid type (water, skim milk, 2% milk, and whole milk; all dyed with green food coloring), delivery method (cup and straw), and bolus volume (5, 10, 15, and 20 mL) on Penetration-Aspiration Scale (PAS) scores in 14 healthy older adults (mean, 75 years; range, 69 to 85 years). Each participant generated 32 swallows.

RESULTS

The PAS scores differed significantly by liquid type (p = 0.003) and by bolus volume (p = 0.017), but not by delivery method (p = 0.442). The PAS scores were significantly greater for 2% milk and whole milk than for skim milk and water (p < 0.05), and for 20 mL versus smaller volumes. Penetration and aspiration were observed on 113 (25%) and 15 (3%) of 448 swallows, respectively.

CONCLUSIONS

These findings suggest that both milk and water should be used during FEES for an accurate assessment of aspiration status.

A phase I dose escalation study of hypofractionated IMRT field-in-field boost for newly diagnosed glioblastoma multiforme

OBJECTIVES

To describe the results of a Phase I dose escalation trial for newly diagnosed glioblastoma multiforme (GBM) using a hypofractionated concurrent intensity-modulated radiotherapy (IMRT) boost.

METHODS

Twenty-one patients were enrolled between April 1999 and August 2003. Radiotherapy consisted of daily fractions of 1.8 Gy with a concurrent boost of 0.7 Gy (total 2.5 Gy daily) to a total dose of 70, 75, or 80 Gy. Concurrent chemotherapy was not permitted. Seven patients were enrolled at each dose and dose limiting toxicities were defined as irreversible Grade 3 or any Grade 4-5 acute neurotoxicity attributable to radiotherapy.

RESULTS

All patients experienced Grade 1 or 2 acute toxicities. Acutely, 8 patients experienced Grade 3 and 1 patient experienced Grade 3 and 4 toxicities. Of these, only two reversible cases of otitis media were attributable to radiotherapy. No dose-limiting toxicities were encountered. Only 2 patients experienced Grade 3 delayed toxicity and there was no delayed Grade 4 toxicity. Eleven patients requiring repeat resection or biopsy were found to have viable tumor and radiation changes with no cases of radionecrosis alone. Median overall and progression-free survival for this cohort were 13.6 and 6.5 months, respectively. One- and 2-year survival rates were 57% and 19%. At recurrence, 15 patients received chemotherapy, 9 underwent resection, and 5 received radiotherapy.

CONCLUSIONS

Using a hypofractionated concurrent IMRT boost, we were able to safely treat patients to 80 Gy without any dose-limiting toxicity. Given that local failure still remains the predominant pattern for GBM patients, a trial of dose escalation with IMRT and temozolomide is warranted.

Soy use and vasomotor symptoms: Soy Estrogen Alternative follow-up study

PURPOSE

To evaluate vasomotor symptoms and soy and hormone therapy use in women who had previously participated in the Soy Estrogen Alternative (SEA) study, a trial conducted to compare the effects of soy protein supplements containing differing levels of isoflavones on menopausal symptoms, chronic disease risk factors, and health-related quality of life in perimenopausal and postmenopausal women.

PARTICIPANTS AND METHODS

Two years after the SEA study ended participants were recontacted to complete questionnaires to quantify their health status, medications, menopausal symptoms, and their use of hormone therapy and soy-based foods and supplements. Participants were also asked to record vasomotor symptoms for seven days.

RESULTS

Surveys were collected from 182 of the 241 participants who had been enrolled in the SEA study (76% response rate). Women were 55 ± 2.8 years of age, well educated (80% more than high school), and 93% reported good to excellent health. All but six reported experiencing at least one menopausal symptom, and 56% reported one or more hot flashes on one or more days. Eighty-one women (45%) continued to use soy for menopausal symptom relief, and 58 (32%) were using hormone therapy. Women taking hormone therapy were experiencing fewer and less severe hot flashes than those who were not taking hormone therapy (P < 0.001); hot flash frequency and severity did not differ significantly between those who did and did not use soy, after controlling for hormone therapy use.

CONCLUSION

Most participants reported they were still experiencing menopausal symptoms. Additionally, half of the most symptomatic women (not taking hormone therapy) were still consuming soy products for vasomotor symptoms.

Effect of a multifaceted, church-based wellness program on metabolic syndrome in 41 overweight or obese congregants

INTRODUCTION

A rise in obesity, poor-quality diets, and low physical activity has led to a dramatic increase in the number of Americans with metabolic syndrome and diabetes. Our objective was to determine the effect of a short-term, multifaceted wellness program carried out in a church setting on weight, metabolic syndrome, and self-reported wellness.

METHODS

Forty-one overweight or obese adults in a church congregation provided fasting blood samples and answered a wellness questionnaire before and after completing an 8-week diet and exercise program. We also measured weight, body fat, body mass index, and waist and hip circumference.

RESULTS

The intervention decreased weight, body fat, and central adiposity; improved indexes of metabolic syndrome; and increased self-reported wellness.

CONCLUSION

A multifaceted wellness intervention that emphasizes diet and exercise can rapidly influence weight, insulin resistance, metabolic syndrome, and self-reported wellness.

Association of type 1 diabetes with month of birth among U.S. youth: The SEARCH for Diabetes in Youth Study

OBJECTIVE

Seasonal environment at birth may influence diabetes incidence in later life. We sought evidence for this effect in a large sample of diabetic youth residing in the U.S.

RESEARCH DESIGN AND METHODS

We compared the distribution of birth months within the SEARCH for Diabetes in Youth Study (SEARCH study) with the monthly distributions in U.S. births tabulated by race for years 1982-2005. SEARCH study participants (9,737 youth with type 1 diabetes and 1,749 with type 2 diabetes) were identified by six collaborating U.S. centers.

RESULTS

Among type 1 diabetic youth, the percentage of observed to expected births differed across the months (P = 0.0092; decreased in October-February and increased in March-July). Their smoothed birth-month estimates demonstrated a deficit in November-February births and an excess in April-July births (smoothed May versus January relative risk [RR] = 1.06 [95% CI 1.02-1.11]). Stratifications by sex or by three racial groups showed similar patterns relating type 1 diabetes to month of birth. Stratification by geographic regions showed a peak-to-nadir RR of 1.10 [1.04-1.16] in study regions from the northern latitudes (Colorado, western Washington State, and southern Ohio) but no birth-month effect (P > 0.9) in study regions from more southern locations. Among type 2 diabetic youth, associations with birth month were inconclusive.

CONCLUSIONS

Spring births were associated with increased likelihood of type 1 diabetes but possibly not in all U.S. regions. Causal mechanisms may involve factors dependent on geographic latitude such as solar irradiance, but it is unknown whether they influence prenatal or early postnatal development.

Candidate gene polymorphisms for ischemic stroke

BACKGROUND AND PURPOSE

Ischemic stroke (IS) is a multifactorial disorder with strong evidence from twin, family, and animal model studies suggesting a genetic influence on risk and prognosis. Several candidate genes for IS have been proposed, but few have been replicated. We investigated the contribution of 67 candidate genes (369 single nucleotide polymorphisms [SNPs]) on the risk of IS in a North American population of European descent.

METHODS

Two independent studies were performed. In the first, 342 SNPs from 52 candidate genes were genotyped in 307 IS cases and 324 control subjects. The SNPs significantly associated with IS were tested for replication in another cohort of 583 IS cases and 270 control subjects. In the second study, 212 SNPs from 62 candidate genes were analyzed in 710 IS cases with subtyping available and 3751 control subjects.

RESULTS

None of the candidate genes (SNPs) were significantly associated with IS risk independent of known stroke risk factors after correction for multiple hypotheses testing.

CONCLUSIONS

These results are consistent with previous meta-analyses that demonstrate an absence of genetic association of variants in plausible candidate genes with IS risk. Our study suggests that the effect of the investigated SNPs may be weak or restricted to specific populations or IS subtypes.

Prestroke physical activity and early functional status after stroke

BACKGROUND

The importance of physical activity as a modifiable risk factor for stroke in particular and cardiovascular disease in general is well documented. The effect of exercise on stroke severity and stroke outcomes is less clear. This study aimed to assess that effect.

METHODS

Data collected for patients enrolled in the Ischemic Stroke Genetics Study were reviewed for prestroke self-reported levels of activity and four measures of stroke outcome assessed at enrollment and approximately 3 months after enrollment. Logistic regression was used to assess the association between physical activity and stroke outcomes, unadjusted and adjusted for patient characteristics.

RESULTS

A total of 673 patients were enrolled; 50.5% reported aerobic physical activity less than once a week, 28.5% reported aerobic physical activity one to three times weekly, and 21% reported aerobic physical activity four times a week or more. Patients with moderate and high levels of physical activity were more likely to have higher Barthel Index (BI) scores at enrollment. A similar association was detected for exercise and good outcomes for the Oxford Handicap Scale (OHS). After 3 months of follow-up, moderate activity was still associated with a high BI score. No significant association was detected for activity and the OHS or Glasgow Outcome Scale at follow-up after adjustment for patient characteristics.

CONCLUSIONS

Higher levels of self-reported prestroke physical activity may be associated with functional advantages after stroke. Our findings should be seen as exploratory, requiring confirmation, ideally in a longitudinal study of exercise in an older population.

Effect of dietary fatty acids on inflammatory gene expression in healthy humans

Over the past 100 years, changes in the food supply in Western nations have resulted in alterations in dietary fatty acid consumption, leading to a dramatic increase in the ratio of omega-6 (omega6) to omega3 polyunsaturated fatty acids (PUFA) in circulation and in tissues. Increased omega6/omega3 ratios are hypothesized to increase inflammatory mediator production, leading to higher incidence of inflammatory diseases, and may impact inflammatory gene expression. To determine the effect of reducing the omega6/omega3 ratio on expression of inflammatory pathway genes in mononuclear cells, healthy humans were placed on a controlled diet for 1 week, then given fish oil and borage oil for an additional 4 weeks. Serum and neutrophil fatty acid composition and ex vivo leukotriene B(4) production from stimulated neutrophils were measured at the start and end of the supplementation period and after a 2-week washout. RNA was isolated from mononuclear cells and expression of PI3K, Akt, NFkappaB, and inflammatory cytokines was measured by real-time PCR. A marked increase was seen in serum and neutrophil levels of long-chain omega3 PUFA concomitant with a reduction in the omega6/omega3 PUFA ratio (40%). The ex vivo capacity of stimulated neutrophils to produce leukotriene B(4) was decreased by 31%. Expression of PI3Kalpha and PI3Kgamma and the quantity of PI3Kalpha protein in mononuclear cells was reduced after supplementation, as was the expression of several proinflammatory cytokines. These data reveal that PUFA may exert their clinical effects via their capacity to regulate the expression of signal transduction genes and genes for proinflammatory cytokines.

Ethnic distribution of ECG predictors of atrial fibrillation and its impact on understanding the ethnic distribution of ischemic stroke in the Atherosclerosis Risk in Communities (ARIC) study

BACKGROUND AND PURPOSE

The paradox of the reported low prevalence of atrial fibrillation (AF) in blacks compared with whites despite higher stroke rates in the former could be related to limitations in the current methods used to diagnose AF in population-based studies. Hence, this study aimed to use the ethnic distribution of ECG predictors of AF as measures of AF propensity in different ethnic groups.

METHODS

The distribution of baseline measures of P-wave terminal force, P-wave duration, P-wave area, and PR duration (referred to as AF predictors) were compared by ethnicity in 15 429 participants (27% black) from the Atherosclerosis Risk in Communities (ARIC) study by unpaired t test, chi(2), and logistic-regression analysis, as appropriate. Cox proportional-hazards analysis was used to separately examine the association of AF predictors with incident AF and ischemic stroke.

RESULTS

Whereas AF was significantly less common in blacks compared with whites (0.24% vs 0.95%, P<0.0001), similar to what has been reported in previous studies, blacks had significantly higher and more abnormal values of AF predictors (P<0.0001 for all comparisons). Black ethnicity was significantly associated with abnormal AF predictors compared with whites; odds ratios for different AF predictors ranged from 2.1 to 3.1. AF predictors were significantly and independently associated with AF and ischemic stroke with no significant interaction between ethnicity and AF predictors, findings that further justify using AF predictors as an earlier indicator of future risk of AF and stroke.

CONCLUSIONS

There is a disconnect between the ethnic distribution of AF predictors and the ethnic distribution of AF, probably because the former, unlike the latter, do not suffer from low sensitivity. These results raise the possibility that blacks might actually have a higher prevalence of AF that might have been missed by previous studies owing to limited methodology, a difference that could partially explain the greater stroke risk in blacks.

BMI influences prognosis following surgery and adjuvant chemotherapy for lymph node positive breast cancer

Increased body mass index (BMI) at diagnosis has been shown to be associated with an increased risk of disease recurrence and death. However, the association has not been consistent in the literature and may depend on several factors such as menopausal status, extent of disease, and receptor status. We performed a secondary analysis on what we believe is the largest prospective trial of adjuvant chemotherapy to assess the effect of BMI on prognosis in women with lymph node positive breast cancer. The study included 636 women with a median follow-up of over 13 years. Cox's proportional hazards regression model was used to assess the effect of BMI on outcomes. Kaplan-Meier methods were used to estimate survival curves and log rank tests were used to assess differences in survival for BMI groups. We found that increased BMI was generally predictive of faster time to recurrence and decreased survival, but that the relationship was stronger for younger women, those with progesterone receptor negative disease and those with a greater number of lymph nodes that were positive.

Interobserver agreement in the trial of org 10172 in acute stroke treatment classification of stroke based on retrospective medical record review

BACKGROUND

The reliability of the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification system of stroke in siblings of stroke-affected probands has not been tested. Similarly, the reliability of using clinical medical records to classify ischemic stroke has not been assessed. The purpose of this study was to establish the interrater reliability of sibling stroke subtyping by applying the TOAST criteria to retrospectively obtained medical records.

METHODS

Thirty medical records were randomly sampled from among the records of all siblings previously classified as stroke affected by the Siblings with Ischemic Stroke Study (SWISS) Stroke Verification Committee. Blinded medical records for these individuals were sent to 6 physician reviewers who independently classified TOAST stroke subtype on the basis of record review.

RESULTS

Using the kappa statistic to assess interrater reliability, the overall reliability (SE) for assigning a TOAST subtype of stroke was 0.54 (0.03). Pair-wise comparisons between the original SWISS Stroke Verification Committee diagnoses and the diagnoses made by other reviewers exhibited moderate reliability (kappa range 0.41-0.56). The kappa statistics for common stroke subtypes were large vessel, 0.80 (0.06); cardioembolic, 0.80 (0.06); small vessel, 0.53 (0.06); and unknown cause, 0.40 (0.06).

CONCLUSION

We conclude that TOAST subtyping had moderate interrater reliability. Large-artery and cardioembolic subtype diagnoses seemed most reliable.

Results of a diet/exercise feasibility trial to prevent adverse body composition change in breast cancer patients on adjuvant chemotherapy

PURPOSE

Patients with breast cancer on adjuvant chemotherapy can experience weight gain and concurrent losses in muscle mass. Exercise interventions can prevent these changes, but time and travel pose barriers to participation. The Survivor Training for Enhancing Total Health (STRENGTH) trial assessed the feasibility and impact of 2 home-based interventions.

PATIENTS AND METHODS

Ninety premenopausal patients with breast cancer on adjuvant chemotherapy were randomized to a calcium-rich diet (CA) intervention (attention control) or to 2 experimental arms: a CA + exercise (EX) arm or a CA + EX and high fruit and vegetable, low-fat diet (FVLF) arm. Exercise arms included aerobic and strength-training exercises. Body composition, weight status, waist circumference, dietary intake, physical activity, quality of life, anxiety, depression, serum lipids, sex hormone binding globulin, insulin, proinsulin, C-reactive protein, interleukin-1B, and tumor-necrosis factor receptor-II were measured at baseline and at 6-month follow-up.

RESULTS

Accrual targets were achieved and modest attrition was observed (8.8%). Self-reports suggest increased calcium intakes in all arms, and higher fruit and vegetable and lower fat intake in the CA + EX + FVLF arm; no differences in physical activity were observed. While measures of adiposity were generally lower in the CA + EX + FVLF arm, the only significant difference was in percentage of body fat (arms and legs); change in scores (mean +/- standard deviation) were +0.7% +/- 2.3% (CA); +1.2% +/- 2.7% (CA + EX); and +0.1% +/- 2% (CA + EX + FVLF; P = .047). Lean body mass was largely preserved, even in the control arm (net gain of 452 g +/- 2395 g). No differences were observed in other endpoints.

CONCLUSION

Diet and exercise interventions can prevent weight gain and adverse body composition changes, but more research is needed to determine optimally effective interventions that can be implemented during active treatment and that promote adherence.

Polymorphisms in drug metabolism genes, smoking, and p53 mutations in breast cancer

Polymorphisms in phase I and phase II enzymes may enhance the occurrence of mutations at critical tumor suppressor genes, such as p53, and increase breast cancer risk by either increasing the activation or detoxification of carcinogens and/or endogenous estrogens. We analyzed polymorphisms in CYP1B1, GSTM1, GSTT1, and GSTP1 and p53 mutations in 323 breast tumor samples. Approximately 11% of patients exhibited mutations in p53. Women with mutations had a significantly younger age of diagnosis (P = 0.01) and a greater incidence of tumors classified as stage II or higher (P = 0.002). More women with mutations had a history of smoking (55%) compared to women without mutations (39%). Although none of the genotypes alone were associated with p53 mutations, positive smoking history was associated with p53 mutations in women with the GSTM1 null allele [OR = 3.54; 95% CI = 0.97-12.90 P = 0.06] compared to women with the wild-type genotype and smoking history [OR = 0.62, 95% CI = 0.19-2.07], although this association did not reach statistical significance. To test for gene-gene interactions, our exploratory analysis in the Caucasian cases suggested that individuals with the combined GSTP1 105 VV, CYP1B1 432 LV/VV, and GSTM1 positive genotype were more likely to harbor mutations in p53 [OR = 4.94; 95% CI = 1.11-22.06]. Our results suggest that gene-smoking and gene-gene interactions may impact the prevalence of p53 mutations in breast tumors. Elucidating the etiology of breast cancer as a consequence of common genetic polymorphisms and the genotoxic effects of smoking will enable us to improve the design of prevention strategies, such as lifestyle modifications, in genetically susceptible subpopulations.

Impact of restricting enrollment in stroke genetics research to adults able to provide informed consent

BACKGROUND AND PURPOSE

The extent of potential consent bias in observational studies elucidating genetic and environmental contributions to ischemic stroke is largely unknown. The purpose of this study was to assess differences in stroke cohort characteristics between those who provided informed consent and those whose enrollment was authorized by surrogate decision makers.

METHODS

The Ischemic Stroke Genetics Study (ISGS) is a prospective, 5-center, case-control study of first-ever ischemic stroke. Demographic, clinical, and stroke characteristics were compared between cases enrolled by self versus by surrogate. Data from one site that limits enrollment only to those able to self-consent were also analyzed to compare those who enrolled with those not able to consent.

RESULTS

Overall, 10% (54 of 517) were enrolled using surrogate authorization. Self-consented and surrogate-authorized cases did not differ significantly in age, sex, or conventional risk factors. Surrogate-authorized cases had significantly more severe stroke deficits, larger infarcts, and infarcts localizing to left supratentorial regions. Similarly, at the site restricting enrollment, stroke severity and characteristics differed between self-consented individuals and those otherwise eligible but unable to provide consent.

CONCLUSIONS

Failure to permit surrogate authorization in genetic studies of ischemic stroke may skew enrollment toward less severe strokes caused by smaller infarcts. This potential consent bias may undermine the ability to identify genetic determinants of risk and severity and suggests that surrogate enrollment in these studies can be ethically justifiable.

A Phase III, Double-Blind, Placebo-Controlled Prospective Randomized Clinical Trial of d-Threo-Methylphenidate HCl in Brain Tumor Patients Receiving Radiation Therapy

PURPOSE

The quality of life (QOL) and neurocognitive function of patients with brain tumors are negatively affected by the symptoms of their disease and brain radiation therapy (RT). We assessed the effect of prophylactic d-threo-methylphenidate HCl (d-MPH), a central nervous system (CNS) stimulant on QOL and cognitive function in patients undergoing RT.

METHODS AND MATERIALS

Sixty-eight patients with primary or metastatic brain tumors were randomly assigned to receive d-MPH or placebo. The starting dose of d-MPH was 5 mg twice daily (b.i.d.) and was escalated by 5 mg b.i.d. to a maximum of 15 mg b.i.d. The placebo was administered as one pill b.i.d. escalating three pills b.i.d. The primary outcome was fatigue. Patients were assessed at baseline, the end of radiation therapy, and 4, 8, and 12 weeks after brain RT using the Functional Assessment of Cancer Therapy with brain and fatigue (FACIT-F) subscales, as well as the Center for Epidemiologic Studies Scale and Mini-Mental Status Exam.

RESULTS

The Mean Fatigue Subscale Score at baseline was 34.7 for the d-MPH arm and 33.3 for the placebo arm (p = 0.61). At 8 weeks after the completion of brain RT, there was no difference in fatigue between patient groups. The adjusted least squares estimate of the Mean Fatigue Subscale Score was 33.7 for the d-MPH and 35.6 for the placebo arm (p = 0.64). Secondary outcomes were not different between the two treatment arms.

CONCLUSIONS

Prophylactic use of d-MPH in brain tumor patients undergoing RT did not result in an improvement in QOL.

Sex differences in stroke evaluations in the Ischemic Stroke Genetics Study

BACKGROUND

Epidemiologic studies suggest sex differences in evaluation of patients presenting with ischemic stroke. Sex differences in stroke evaluation could lead to sex differences in the validity of diagnosing ischemic stroke subtypes. This study assessed sex differences in the Ischemic Stroke Genetics Study (ISGS).

METHODS

The ISGS is a prospective case-control genetic association study of patients with first-ever ischemic stroke at 5 US tertiary stroke centers. The diagnostic tests performed as part of medical care were recorded for each enrolled patient.

RESULTS

A total of 505 patients were enrolled; 45% (229 of 505) were women and 55% (276 of 505) were men. Mean age at time of stroke was greater for women (66.6 v 61.9 years; P = .001). Frequency of brain computed tomography was 92% (254 of 276) for men and 90% (206 of 229) for women (P = .42). Magnetic resonance imaging was completed in 84% (232 of 276) of men and 83% (191 of 229) of women (P = .91). Frequency of electrocardiography was 91% (252 of 276) for men and 90% (206 of 229) for women (P = .60). Echocardiography was done in 74% (203 of 276) of men and 79% (180 of 229) of women (P = .19). Cervical arterial imaging occurred in 91% (208 of 229) of women and 86% (237 of 276) of men (P = .09). Intracranial vascular imaging was performed in 75% (207 of 276) of men and 79% (181 of 229) of women (P = .28).

CONCLUSIONS

Our findings suggest no significant sex differences in the extent to which major diagnostic tests were performed in patients in ISGS. Dedicated tertiary stroke centers may reduce the sex bias in stroke evaluation that has been identified by previous studies.

Sex differences in stroke severity, symptoms, and deficits after first-ever ischemic stroke

OBJECTIVE

The purpose of the study was to assess whether there were sex differences in stroke severity, infarct characteristics, symptoms, or the symptoms-deficit relationship at the time of acute stroke presentation.

METHODS

In a prospective study of 505 patients with first-ever ischemic stroke (the Ischemic Stroke Genetics Study), stroke subtype was centrally adjudicated and infarcts were characterized by imaging. Deficits were assessed by National Institutes of Health Stroke Scale (NIHSS) and stroke symptoms were assessed using a structured interview. Kappa statistics were generated to assess agreement between the NIHSS and the structured interview, and a Chi square test was used to assess agreement between the NIHSS and the structured interview by sex.

RESULTS

In all, 276 patients (55%) were men and 229 (45%) were women. Ages ranged from 19 to 94 years (median, 65 years). The mean (+/-SD) NIHSS score of 3.8 (+/-4.5) for men and 4.3 (+/-5.2) for women was similar (P = .15). No sex difference was observed for the symptoms of numbness, visual deficits, or language. Weakness occurred in a greater proportion of women (69%) than men (59%) (P = .03). Stroke subtype did not differ significantly between sexes (P = .79). Infarct size and location were similar for each sex. The association between symptoms and neurologic deficits did not differ by sex.

CONCLUSIONS

We found no sex difference in stroke severity, stroke subtype, or infarct size and location in patients with incident ischemic stroke. A greater proportion of women presented with weakness; however, similar proportions of men and women presented with other traditional stroke symptoms.

The epidemiology of arm and hand swelling in premenopausal breast cancer survivors

BACKGROUND

Breast cancer survivors suffer from lymphedema of the arm and/or hand. Accurate estimates of the incidence and prevalence of lymphedema are lacking, as are the effects of this condition on overall quality of life.

METHODS

Six hundred twenty-two breast cancer survivors (age, <or=45 years at diagnosis) were followed with semiannual questionnaires for 36 months after surgery to determine the incidence of lymphedema, prevalence of persistent swelling, factors associated with each, and quality of life.

RESULTS

Of those contacted and eligible for the study, 93% agreed to participate. Fifty-four percent reported arm or hand swelling by 36 months after surgery, with 32% reporting persistent swelling. Swelling was reported to occur in the upper arm (43%), the hand only (34%), and both arm and hand (22%). Factors associated with an increased risk of developing swelling included having a greater number of lymph nodes removed [hazards ratio (HR), 1.02; P < 0.01], receiving chemotherapy (HR, 1.76; P = 0.02), being obese (HR, 1.51 versus normal weight; P = 0.01), and being married (HR, 1.36; P = 0.05). Factors associated with persistent swelling were having more lymph nodes removed (odds ratio, 1.03; P = 0.01) and being obese (odds ratio, 2.24 versus normal weight; P < 0.01). Women reporting swelling had significantly lower quality of life as measured by the functional assessment of cancer therapy-breast total score and the SF-12 physical and mental health subscales (P < 0.01 for each).

CONCLUSIONS

Lymphedema occurs among a substantial proportion of young breast cancer survivors. Weight management may be a potential intervention for those at greatest risk of lymphedema to maintain optimal health-related quality of life among survivors.