Müllerian-Type Clear Cell Carcinoma of Donor Origin in a Male Patient with a Kidney Transplant: Ascertained by Molecular Testing

Clear cell carcinomas of Müllerian origin have a strong female predominance and only extremely rarely will arise within the kidney, presumably due to ectopic Müllerian embryogenesis. Herein, we report a unique case of metastatic Müllerian type clear cell carcinoma in a 37-year-old patient who had previously received a transplanted kidney from his father at age 11 (due to severe bilateral vesicoureteral reflux) and remained on chronic immunosuppression. The tumor was highly aggressive and demonstrated somatic mutations in NF2 and SETD2. Imaging of the transplanted kidney did not reveal any clear evidence of malignancy. However, targeted multigene sequencing and short tandem repeat testing revealed that the cancer was of donor origin, presumably from ectopic Müllerian tissue transplanted to the patient along with the kidney graft. The tumor was resistant to first-line therapy with a triple combination of carboplatin plus paclitaxel plus bevacizumab, as well as to second-line immunotherapy with nivolumab plus ipilimumab after tapering down the patient's immunosuppression. Despite the tumor being genetically distinct from the host, the use of immune checkpoint therapy with nivolumab plus ipilimumab did not yield a response. This unique case showcases the value of molecular testing in determining the tumor origin in patients with solid organ transplants who present with cancers of unknown primary. This can prompt the potential investigation of other recipients from the same donor.

Evaluation of Technology-Enabled Monitoring of Patient-Reported Outcomes to Detect and Treat Toxic Effects Linked to Immune Checkpoint Inhibitors

IMPORTANCE

Immune checkpoint inhibitors can produce distinct toxic effects that require prompt recognition and timely management.

OBJECTIVE

To develop a technology-enabled, dynamically adaptive protocol that can provide the accurate information needed to inform specific remedies for immune toxic effects in patients treated with immune checkpoint inhibitors.

DESIGN, SETTING, AND PARTICIPANTS

An open-label cohort study was conducted at a single tertiary referral center from September 6, 2019, to September 3, 2020. The median follow-up duration was 63 (interquartile range, 35.5-122) days. Fifty patients with genitourinary cancers treated with immune checkpoint inhibitors were enrolled.

INTERVENTIONS

A fit-for-purpose electronic platform was developed to enable active patient and care team participation. A smartphone application downloaded onto patients' personal mobile devices prompted them to report their symptoms at least 3 times per week. The set of symptoms and associated queries were paired with alert thresholds for symptoms requiring clinical action.

MAIN OUTCOMES AND MEASURES

The primary end point of this interim analysis was feasibility, as measured by patient and care team adherence, and lack of increase in care team staffing. Operating characteristics were estimated for each symptom alert and used to dynamically adapt the alert thresholds to ensure sensitivity while reducing unnecessary alerts.

RESULTS

Of the 50 patients enrolled, 47 had at least 1 follow-up visit and were included in the analysis. Median age was 65 years (range, 37-86), 39 patients (83%) were men, and 39 patients (83%) had metastatic cancer, with the most common being urothelial cell carcinoma and renal cell carcinoma (22 [47%] patients each). After initial onboarding, no further care team training or additional care team staffing was required. Patients had a median study adherence rate of 74% (interquartile range, 60%-86%) and 73% of automated alerts were reviewed within 3 days by the clinic team. Symptoms with the highest positive predictive value for adverse events requiring acute intervention included dizziness (21%), nausea/vomiting (26%), and shortness of breath (14%). The symptoms most likely to result in unnecessary alerts were arthralgia and myalgia, fatigue, and cough.

CONCLUSIONS AND RELEVANCE

The findings of this cohort study suggest an acceptable and fiscally sound method can be developed to create a dynamic learning system to detect and manage immune-related toxic effects.

Safe and effective use of nivolumab plus ipilimumab in a patient with metastatic clear-cell renal cell carcinoma with sarcomatoid dedifferentiation and end stage renal disease on hemodialysis

Targeting the programmed cell death protein-1 (PD-1) and cytotoxic T-lymphocyte associated protein-4 (CTLA-4) pathways using the combination immune checkpoint inhibitors (ICI) nivolumab and ipilimumab is an approved frontline therapy for patients with metastatic clear-cell renal cell carcinoma (mccRCC). Certain populations pose clinical challenges due to exclusion from large clinical trials that established the safety and efficacy of these treatments, including patients with end stage renal disease (ESRD). While there are reports successfully administering single-agent ICI in patients with ESRD, we present herein a case of safe and effective use of combination nivolumab plus ipilimumab in a 53-year-old man with mccRCC with sarcomatoid dedifferentiation and ESRD on hemodialysis.

Efficiency comparison between 99m Tc-tetrofosmin and 99m Tc-sestamibi myocardial perfusion studies

The purpose of this investigation was to compare the efficiency of two different imaging protocols using two different clinically available 99mTc labelled myocardial perfusion tracers. One thousand one hundred and thirty-four imaging studies were performed prospectively, using either 99mTc-tetrofosmin or 99mTc-sestamibi, alternating the use of each tracer for a total period of 8 months. 99mTc-tetrofosmin rest studies were performed with injections of 259MBq-370MBq and imaging 30 min later. Exercise studies were performed with injections of 777MBq-1.11GBq and imaging 20 min later. 99mTc-sestamibi studies used doses similar to those in the 99mTc-tetrofosmin studies. Imaging followed a standard procedure, at 60 min after rest injection, and 30 min after exercise. For patients undergoing pharmacological stress testing99mTc-sestamibi was imaged 45 min after injection and 99mTc-tetrofosmin was imaged 30 min after injection. Variables analysed were (1) injection-to-imaging time for the procedure, and (2) the number of repeated scans because of extra cardiac activity. The completion time for the rest study was significantly shorter for 99mTc-tetrofosmin compared to 99mTc-sestamibi (47.7+/-21.7 min vs 74.3+/-25.8 min P<0.0001). Likewise, the total study time was shorter for 99mTc-tetrofosmin compared to 99mTc-sestamibi (90+/-32.7 min vs 124+/-37 min, P<0.0001). More importantly, the number of repeated scans was higher with 99mTc-sestamibi compared to 99mTc-tetrofosmin, 21.4% vs 10%, P=0.001 for rest studies and 16.4% vs 7.9% P=0.001 [corrected] for rest and stress. It was concluded that, using a same day rest/stress protocol, 99mTc-tetrofosmin provided higher patient throughput with fewer repeat scans. These factors may be considered for efficiency improvement in nuclear cardiology laboratories using 99mTc perfusion tracers.

Assessing the clinical and economic burden of coronary artery disease: 1986-1998

BACKGROUND

The acute phase of coronary artery disease (CAD) is dramatic and receives much attention because of its high mortality and associated treatment cost. However, the acute phase typically resolves within 30 days whereas CAD is a chronic disease, which most patients will live with for more than a decade. We compared the clinical and economic burden of CAD during the acute phase (first 30 days) with that in the postacute phase (31st day through 10 years).

METHODS

We included acute coronary syndrome (ACS) patients with significant CAD receiving an initial cardiac catheterization at Duke University Medical Center between 1986 and 1997 with follow-up continuing through 1998. Inpatient medical costs were estimated from ACS clinical trial and economic study data. Costs were adjusted to 1997 values and discounted at 3% per annum.

RESULTS

Our study included 9,876 ACS patients (5,557 with an acute myocardial infarction [MI] and 4,319 with unstable angina [UA]). Acute MI patients had higher 30-day mortality than UA patients (5.6% vs. 2.3%, P <0.001). In addition, acute MI and UA patients had significant 10-year unadjusted and adjusted survival differences (both P <0.001). For patients who survived to 30 days, there was no difference in 10-year survival between acute MI and UA patients before adjustment (P = 0.472). After adjustment, however, unstable angina patients who survived to 30 days had greater survival than myocardial infarction patients (P = 0.011). Mean 10-year discounted ACS inpatient medical costs were $45,253 ($23,510 acute phase and $21,819 postacute phase, P = 0.002). Ten year costs for unstable angina patients were $46,423 ($21,824 acute phase and $24,599 postacute phase, P = 0.003); ten year costs for myocardial infarction patients were $44,663 ($24,823 acute phase and $19,840 postacute phase, P <0.001).

CONCLUSIONS

We found that the clinical and economic burden of CAD continues long after a patient's acute event has resolved and that postacute CAD cardiac event rates and inpatient medical costs may be higher than previously estimated. With much of all medical costs occurring in the postacute phase, the potential for effective secondary prevention therapies is substantial.

Cardiac rehabilitation and survival in patients with left ventricular systolic dysfunction

BACKGROUND

Exercise training, the major component of cardiac rehabilitation (CR), has been shown in previous trials to improve many pathophysiologic changes found in patients with left ventricular systolic dysfunction. It remains unproven whether exercise training improves survival.

METHODS

By using the Duke Databank for Cardiovascular Disease, we identified patients with an ejection fraction < or = 40% and no recent myocardial infarction, congenital heart disease, or primary valvular disease who survived > or = 30 days after a cardiac catheterization (n = 1902). Participation in CR (n = 70) was identified through computer billing records. We developed a multivariable Cox proportional hazards regression model to estimate survival by using variables known to be independent predictors of survival in patients with systolic dysfunction.

RESULTS

Patients participating in CR were less likely to be female or black and more likely to have a history consistent with ischemic cardiomyopathy. Participation in CR was associated with significantly improved survival after adjustment for baseline characteristics (hazard ratio, 0.39; 95% confidence interval, 0.15 to 0.62, P < .0001). Survival increased when patients participated in > 6 CR sessions (hazard ratio, 0.10; 95% confidence interval, 0.03 to 0.39; P < .0001).

CONCLUSIONS

Participation in CR was associated with improved survival for patients with cardiomyopathy. There appears to be a dose response with improved survival benefit for patients with left ventricular systolic dysfunction participating in cardiac rehabilitation.

Incremental prognostic value of RNA ejection fraction measurements during pharmacologic stress testing: a comparison with clinical and perfusion variables

This investigation examined the prognostic power of first-pass radionuclide angiocardiography (RNA) ejection fraction compared with clinical information and myocardial perfusion imaging in patients undergoing pharmacologic stress testing. The value of RNA and myocardial perfusion imaging in predicting death or nonfatal myocardial infarction (MI) is well established. However, limited information exists on the usefulness of combined myocardial perfusion imaging and RNA to predict prognosis, especially in patients undergoing pharmacologic stress testing.

METHODS

We identified 240 patients who underwent pharmacologic stress testing with myocardial perfusion imaging and combined RNA. The patients were followed for a mean of 1.4 y. Cox proportional hazards models were used to assess the value in predicting death and MI. Multivariable models were generated to assess the independent incremental predictive value of clinical and nuclear imaging variables. Kaplan-Meier survival and event-free survival estimates were examined in patients with low (< or = 45%) versus high (>45%) ejection fractions.

RESULTS

Clinical information, myocardial perfusion imaging, and RNA ejection fraction were significant predictors of the death/MI composite outcome (chi(2) = 7.4, 14.0, and 21.8, respectively). The addition of myocardial perfusion imaging to the clinical information provided incremental prognostic information (chi(2) = 15.2). The addition of RNA ejection fraction provided further predictive information (chi(2) = 22.5). However, when RNA ejection fraction was first added to the clinical information, myocardial perfusion imaging had no incremental prognostic value.

CONCLUSION

For hard cardiac events, RNA ejection fraction provides prognostic information besides that provided by clinical and myocardial perfusion imaging. In patients who cannot exercise and are undergoing noninvasive evaluation with pharmacologic stress testing and myocardial perfusion imaging, ejection fraction should be measured simultaneously for risk assessment optimization.

Delays in thrombolytic therapy for acute myocardial infarction: association with mode of transportation to the hospital, age, sex, and race

BACKGROUND: Although increased myocardial salvage and reduced mortality are associated with timely thrombolytic therapy for acute myocardial infarction, some patients still experience delays in treatment. OBJECTIVES: To examine treatment times in patients with acute myocardial infarction treated with thrombolytic therapy and to determine whether delays in treatment are associated with mode of transportation to the hospital, age, sex, or race. METHODS: Medical records of 176 patients with acute myocardial infarction treated with thrombolytic therapy at a community hospital were reviewed and analyzed retrospectively. RESULTS: Median times for the interval between arrival at the hospital and acquisition of a diagnostic electrocardiogram (door-to-electrocardiography time) and the interval between arrival and start of thrombolytic therapy (door-to-drug time) were 6 minutes and 34 minutes, respectively. However, 76.1% of the patients met the recommendation of the American College of Cardiology/American Heart Association of door-to-electrocardiography time of 10 minutes, and 47.2% met the recommendation of door-to-drug time of 30 minutes or less. Door-to-drug times did not differ significantly according to race or mode of transportation to the hospital. Door-to-electrocardiography and electrocardiography-to-drug times were significantly longer for older patients than for younger patients (P = .005 and P &lt; .001, respectively), and electrocardiography-to-drug times were significantly longer for females than for males (P = .01). CONCLUSIONS: With increased emphasis on recognition and rapid treatment of patients with acute myocardial infarction at highest risk for delays in treatment, that is, women and the elderly, benefits of thrombolytic therapy might be maximized.

Delays in thrombolytic therapy for acute myocardial infarction: association with mode of transportation to the hospital, age, sex, and race

BACKGROUND

Although increased myocardial salvage and reduced mortality are associated with timely thrombolytic therapy for acute myocardial infarction, some patients still experience delays in treatment.

OBJECTIVES

To examine treatment times in patients with acute myocardial infarction treated with thrombolytic therapy and to determine whether delays in treatment are associated with mode of transportation to the hospital, age, sex, or race.

METHODS

Medical records of 176 patients with acute myocardial infarction treated with thrombolytic therapy at a community hospital were reviewed and analyzed retrospectively.

RESULTS

Median times for the interval between arrival at the hospital and acquisition of a diagnostic electrocardiogram (door-to-electrocardiography time) and the interval between arrival and start of thrombolytic therapy (door-to-drug time) were 6 minutes and 34 minutes, respectively. However, 76.1% of the patients met the recommendation of the American College of Cardiology/American Heart Association of door-to-electrocardiography time of 10 minutes, and 47.2% met the recommendation of door-to-drug time of 30 minutes or less. Door-to-drug times did not differ significantly according to race or mode of transportation to the hospital. Door-to-electrocardiography and electrocardiography-to-drug times were significantly longer for older patients than for younger patients (P = .005 and P < .001, respectively), and electrocardiography-to-drug times were significantly longer for females than for males (P = .01).

CONCLUSIONS

With increased emphasis on recognition and rapid treatment of patients with acute myocardial infarction at highest risk for delays in treatment, that is, women and the elderly, benefits of thrombolytic therapy might be maximized.

Poststress measurements of left ventricular function with gated perfusion SPECT: comparison with resting measurements by using a same-day perfusion-function protocol

PURPOSE

To investigate the relationship between the development of ischemia during stress testing and the changes in left ventricular ejection fraction (LVEF) measurements obtained after stress and at rest with a same-day perfusion-function imaging protocol.

MATERIALS AND METHODS

One hundred twenty-six patients underwent a same-day rest-stress (61%) or stress-rest (39%) protocol and gated single photon emission computed tomography (SPECT). Perfusion analysis was performed with a 12-segment model. Defects were scored (0 = no defect, 1 = mild defect, 2 = moderate defect, and 3 = severe defect); differences between the summed stress and resting scores of greater than three indicated substantial ischemia.

RESULTS

Resting and poststress LVEFs correlated significantly (r = 0.97, P <.001); however, patients with and patients without ischemia had significant differences in poststress versus resting LVEFs (-4.0 vs 1.0, respectively; P <.01). In patients with ischemia versus patients without ischemia, subgroup analysis stress-rest (-2.5 vs 1.0, P =.047) and rest-stress (-4.0 vs 1.0, P =.006) protocols yielded similar results.

CONCLUSION

In patients with clinically important stress-induced perfusion abnormalities, the LVEF after stress was significantly lower than the LVEF at rest with same-day rest-stress and stress-rest imaging protocols. In the clinical setting, poststress LVEFs may be lower than true resting measurements, particularly in patients with moderate to severe stress-induced ischemia.

The added value of simultaneous myocardial perfusion and left ventricular function

The focus of this review is the advantages of simultaneously assessing myocardial perfusion and left ventricular function. Nuclear cardiology imaging techniques as well as the development of technetium-labeled perfusion tracers now permit combined myocardial-perfusion and left-ventricular function studies at a single testing interval. Radionuclide angiography as well as electrocardiographic-gated images of the perfused myocardium are the two well-established techniques for that purpose with a single injection of a technetium-labeled perfusion tracer. Recent data have demonstrated the impact and clinical role of these studies, when combined, in the diagnosis as well as prognosis and risk stratification of patients with suspected or known coronary artery disease. The addition of functional information to perfusion data has shown to improve the detection of multivessel disease. Most recent data have also demonstrated the ability of these combined measurements to improve the prediction of hard events. It appears that the role of each of these tests may differ, depending on the patient population, particularly in relation to gender and type of stress test performed. Finally, a third area of potential application of these combined techniques would be in the assessment of myocardial viability using pharmacologic stress tests in combination with wall-motion analysis by gated images of the perfused myocardium.

Value of exercise treadmill testing in women

OBJECTIVES

We sought to determine the ability of a treadmill score to provide accurate diagnostic and prognostic risk estimates in women.

BACKGROUND

Treadmill testing has been reported to have a lower accuracy for diagnosis of chest pain in women. The diagnostic and prognostic value of the Duke Treadmill Score (DTS) in women is unknown.

METHODS

We determined the diagnostic and prognostic value of the DTS in 976 women and 2,249 men who underwent both treadmill testing and cardiac catheterization in a single institution from 1984 to 1994.

RESULTS

Women and men differed significantly in DTS (1.6 vs. -0.3, p < 0.0001), disease prevalence (32% vs. 72% significant coronary artery disease [CAD], p < 0.001), and 2-year mortality (1.9% vs. 4.9%, p < 0.0001). The DTS provided information beyond clinical predictors of both coronary disease and survival in women and men. Although overall women had better survival, the DTS performed equally well in stratifying both genders into prognostic categories. The DTS actually performed better in women than in men for excluding disease, with fewer low risk women having any significant coronary disease (> or = 1 vessel with > or =75% stenosis) (20% vs. 47%, p < 0.001), or severe disease (3-vessel disease or > or =75% left main stenosis) (3.5% vs. 11.4%, p < 0.001).

CONCLUSIONS

By combining several aspects of treadmill testing, the DTS effectively stratifies women into diagnostic and prognostic risk categories.

Use of a prognostic treadmill score in identifying diagnostic coronary disease subgroups

BACKGROUND

Exercise testing is useful in the assessment of symptomatic patients for diagnosis of significant or extensive coronary disease and to predict their future risk of cardiac events. The Duke treadmill score (DTS) is a composite index that was designed to provide survival estimates based on results from the exercise test, including ST-segment depression, chest pain, and exercise duration. However, its usefulness for providing diagnostic estimates has yet to be determined.

METHODS AND RESULTS

A logistic regression model was used to predict significant (>/=75% stenosis) and severe (3-vessel or left main) coronary artery disease, and a Cox regression analysis was used to predict cardiac survival. After adjustment for baseline clinical risk, the DTS was effectively diagnostic for significant (P<0.0001) and severe (P<0.0001) coronary artery disease. For low-risk patients (score >/=+5), 60% had no coronary stenosis >/=75% and 16% had single-vessel >/=75% stenosis. By comparison, 74% of high-risk patients (score <-11) had 3-vessel or left main coronary disease. Five-year mortality was 3%, 10%, and 35% for low-, moderate-, and high-risk DTS groups (P<0.0001).

CONCLUSIONS

The composite DTS provides accurate diagnostic and prognostic information for the evaluation of symptomatic patients evaluated for clinically suspected ischemic heart disease.

Specificity of electrocardiographic myocardial infarction screening criteria in patients with nonischemic cardiomyopathies

BACKGROUND

The 32-point, 54-criteria Selvester QRS scoring system has been successfully used to estimate the size of nonacute myocardial infarction (MI). Three criteria of the system have been shown to be sensitive for the identification of nonacute MI and specific in normal control subjects. The validity of the system has not been tested in patients with cardiomyopathy of nonischemic origin. The purpose of this study was to examine the electrocardiographs (ECGs) of patients with abnormal left ventricular function but no presence of coronary disease to determine the diagnostic specificity of the MI screening criteria subset of the Selvester QRS scoring system.

METHODS AND RESULTS

Six hundred ninety patients were considered. Exclusion criteria included age <10 years, cardiac transplantation, thrombolytic therapy, any angiographic evidence of coronary disease, left ventricular ejection fraction (LVEF) >60%, or history of myocardial revascularization. ECG exclusion criteria included left ventricular hypertrophy, right ventricular hypertrophy, left bundle branch block, right bundle branch block, ventricular pacing, left anterior fascicular block, left posterior fascicular block, ventricular preexcitation, and low voltage, because these confounding factors could mimic an infarct on the ECG. The 261 remaining patients were then examined for the presence of the MI screening criteria subset: (1) inferior location: Q > or =30 msec in aVF, (2) anterior location: either any Q or R< or =0.1 mV and < or =10 msec in V2, and (3) posterior location: R> or =40 msec in V1. Thirty-two of the 261 patients falsely met at least 1 of the 3 MI screening criteria, resulting in an overall specificity of 88% (vs 95% in normal control subjects, P=.0006). A specificity of 98% (n = 256) was achieved for the inferior MI screening criterion alone, whereas the anterior and posterior MI screening criteria alone achieved significantly lower specificities: 94% (n = 245) and 95% (n = 249), respectively. When the patient population was divided into LVEF <30% and LVEF > or =30%, no significant association was found between MI screening criteria and LVEF with specificities of 87% and 88%, respectively, for the 2 groups (P= .34).

CONCLUSIONS

The MI screening criteria subset is relatively specific in patients with nonischemic cardiomyopathy, falsely identifying only 12% with nonacute MI. However, this specificity is lower than the 95% achieved in normal subjects. Regional accumulation of scarring caused by cardiomyopathy could result in false-positive indication of MI in the present population. Another possibility could be that some patients could have hypertrophy of the myocardium insufficient to produce positive ECG criteria for left ventricular hypertrophy or right ventricular hypertrophy but sufficient to mimic infarction.

Clinical determinants of mortality in patients with angiographically diagnosed ischemic or nonischemic cardiomyopathy

OBJECTIVES

We sought to characterize the clinical determinants of mortality in patients with angiographically diagnosed ischemic or nonischemic cardiomyopathy.

BACKGROUND

Patients with ischemic cardiomyopathy may have a worse prognosis than patients with nonischemic cardiomyopathy. Few studies have assessed the effect of ischemic versus nonischemic etiology on outcomes.

METHODS

We analyzed prospectively collected data on 3,787 patients with a left ventricular ejection fraction < or = 40% who underwent coronary angiography. Patients were considered to have ischemic cardiomyopathy (n = 3,112) if they had a history of myocardial infarction, percutaneous transluminal coronary angioplasty, coronary artery bypass graft surgery or at least one major epicardial coronary artery with > or = 75% stenosis; all others were considered to have nonischemic cardiomyopathy (n = 675).

RESULTS

The median age, ejection fraction and proportion of patients with New York Heart Association functional class III or IV symptoms for the nonischemic and ischemic groups were 55 years versus 63 years, 27% versus 32% and 57% versus 25%, respectively. After adjustment for baseline clinical risk factors and presenting characteristics, ischemic etiology remained an important independent predictor of 5-year mortality (p < 0.0001). The extent of coronary artery disease was a better predictor of survival than ischemic or nonischemic etiology (log likelihood chi-square 700 vs. 675, respectively).

CONCLUSIONS

Ischemic etiology is a significant independent predictor of mortality in patients with cardiomyopathy. However, the extent of coronary artery disease contributes more prognostic information than the clinical diagnosis of ischemic or nonischemic cardiomyopathy. Further research is needed to refine the clinical definition of ischemic cardiomyopathy so that physicians can appropriately prescribe treatment and accurately predict outcome.

Racial variation in the use of coronary-revascularization procedures. Are the differences real? Do they matter?

BACKGROUND

Studies have reported that blacks undergo fewer coronary-revascularization procedures than whites, but it is not clear whether the clinical characteristics of the patients account for these differences or whether they indicate underuse of the procedures in blacks or overuse in whites.

METHODS

In a study at Duke University of 12,402 patients (10.3 percent of whom were black) with coronary disease, we calculated unadjusted and adjusted rates of angioplasty and bypass surgery in blacks and whites after cardiac catheterization. We also examined patterns of treatment after stratifying the patients according to the severity of disease, angina status, and estimated survival benefit due to revascularization. Finally, we compared five-year survival rates in blacks and whites.

RESULTS

After adjustment for the severity of disease and other characteristics, blacks were 13 percent less likely than whites to undergo angioplasty and 32 percent less likely to undergo bypass surgery. The adjusted black:white odds ratios for receiving these procedures were 0.87 (95 percent confidence interval, 0.73 to 1.03) and 0.68 (95 percent confidence interval, 0.56 to 0.82), respectively. The racial differences in rates of bypass surgery persisted among those with severe anginal symptoms (31 percent of blacks underwent surgery, vs. 45 percent of whites, P<0.001) and among those predicted to have the greatest survival benefit from revascularization (42 percent vs. 61 percent, P<0.001). Finally, unadjusted and adjusted rates of survival for five years were significantly lower in blacks than in whites.

CONCLUSIONS

Blacks with coronary disease were significantly less likely than whites to undergo coronary revascularization, particularly bypass surgery - a difference that could not be explained by the clinical features of their disease. The differences in treatment were most pronounced among those predicted to benefit the most from revascularization. Since these differences also correlated with a lower survival rate in blacks, we conclude that coronary revascularization appears to be underused in blacks.

Absence of sex bias in the referral of patients for cardiac catheterization

BACKGROUND

It has been suggested that women with clinical evidence of coronary artery disease are less often referred for cardiac catheterization than are men. To determine whether there is sex-related bias in referral for cardiac catheterization, we prospectively studied a cohort of 410 symptomatic outpatients (280 men and 130 women) who were being evaluated with exercise testing for possible-coronary artery disease.

METHODS

Before the patients underwent exercise testing, 15 cardiologists from an academic medical center were asked to predict the probability that the patients they saw in the cardiology clinic would have angiographic evidence of any obstructive coronary disease (stenosis of 75 percent or more); the probability of severe coronary disease (three-vessel or left main coronary artery disease); the probability of left main coronary artery disease; and the probability of survival one, three, and five years after the evaluation. Similar predictions were generated by previously validated statistical models with use of data collected before exercise testing from the history, physical examination, and 12-lead electrocardiography with the patient at rest.

RESULTS

Overall, women were referred for cardiac catheterization significantly less often than men (18 percent vs. 27 percent, P = 0.03). As compared with men, women had a significantly lower pretest probability of coronary disease (as estimated by their physicians) and a lower rate of positive exercise-test results. After accounting for differences in these two factors, sex was not an independent predictor of referral for catheterization. Comparing physicians' estimates of outcome with those generated by the statistical models revealed no evidence that the physicians were underestimating the risk of coronary disease in women. Furthermore, physicians' predictions did not underestimate the probability of any obstructive coronary disease in men and women who subsequently underwent catheterization.

CONCLUSIONS

Academic cardiologists made appropriately lower pretest predictions of categories of disease in women with possible coronary artery disease than in men, and these assessments, along with women's lower rate of positive exercise tests, rather than bias based on sex, accounted for the lower rate of catheterization among women.

Nouns in early lexicons: evidence, explanations and implications

Many theories of grammatical and lexical acquisition assume that children learn predominantly nouns, and specifically names of objects, when they first begin to acquire words in the second year. We show that the noun bias in early vocabularies is far from universal, and that it rests only in part on the acquisition of object names. An analysis of vocabulary composition from 45 children at 1;8 indicates that more nouns are acquired than all other word classes, but that of the nouns acquired only about half are the names of basic level object classes (BLOCs). An examination of the use of nouns in mother-child discourse shows that non-object words referencing locations, actions and events, for example, are used in distinctive pragmatic and grammatical contexts which might enable a child to grasp the word's use and eventually its meaning. It is concluded that a theory of lexical acquisition in discourse context is required to explain word learning at all levels and for all word types. Implications for semantic bootstrapping theories are considered.

The mortality of Ontario undertakers and a review of formaldehyde-related mortality studies

In a study of the mortality of Ontario undertakers, a cohort of 1,477 men first licensed during 1928 through 1957 was followed up until the end of 1977. Numbers of observed and expected deaths were determined for the period 1950 through 1977, using mortality rates of Ontario men as the standard. In all, 319 persons had died, compared with 322 expected. Ontario undertakers were not at increased risk of death from cancers at sites of contact with formaldehyde. Cirrhosis of the liver (standardized mortality ratio, 238) and chronic rheumatic heart disease (standardized mortality ratio, 199) were the only causes of death found to be significantly in excess. The data are discussed in the context of current epidemiologic information on the mortality experience of persons exposed to formaldehyde.