An evaluation of the outcome metric 'days alive and at home' in older patients after hip fracture surgery

'Days alive and at home' is a validated measure that estimates the time spent at home, defined as the place of residence before admission to hospital. We evaluated this metric in older adults after hip fracture surgery and assessed two follow-up durations, 30 and 90 days. Patients aged ≥ 70 years who underwent hip fracture surgery were identified retrospectively via hospital admission and government mortality records. Patients who successfully returned home and were still alive within 90 days of surgery were distinguished from those who were not. Regression models were used to examine which variables were associated with failure to return home and number of days at home among those who did return, within 90 days of surgery. We analysed the records of 825 patients. Median (IQR [range]) number of days at home within 90 days (n = 788) was 54 (0-76 [0-88]) days and within 30 days (n = 797) it was 2 (0-21 [0-28]) days. Out of these, 274 (35%) patients did not return home within 90 days and 374 (47%) within 30 days after surgery. Known peri-operative risk-factors such as older age, pre-operative anaemia and postoperative acute renal impairment were associated with failure to return home. This study supports days alive and at home as a useful patient-centred outcome measure in older adults after hip fracture surgery. We recommend that this metric should be used in clinical trials and measured at 90, rather than 30, postoperative days. As nearly half of this patient population did not return home within 30 days, the shorter time-period catches fewer meaningful events.

Serological Immunoglobulin G antibody titers to Helicobacter pylori in Japanese Brazilian and Non-Japanese Brazilian gastric cancer patients and controls in São Paulo

Helicobacter pylori (H. pylori) infection is considered a cause of gastric cancer (GC), though evidence for this association is scarce in high-risk areas. Possible case control and/or ethnic differences were investigated as to the presence of H. pylori and its immunogloblin G antibody titer in the multi-ethnic city of São Paulo, where the incidence of GC is relatively high. We performed a cross-sectional comparison of antibody titers to H. pylori in Japanese Brazilian, and non-Japanese Brazilian GC patients and their controls. Japanese Brazilian patients were matched by age, sex and ethnicity with two controls, while non-Japanese Brazilian patients were matched as above with one control. Among Japanese Brazilians, 59 of 93 (63.4%) patients with GC and 127 of 186 (68.3%) controls were positive for H. pylori-specific antibody (odds ratio (OR) = 0.80, 95% confidence interval (CI) = 0.47 - 1.36), while among non-Japanese Brazilians, 171 of 228 patients with GC (75.7%) and 178 of 226 controls (78.8%) were positive (OR = 0.84, 95% CI = 0.54 - 1.30). The median serum antibody titer was lower in cases than in controls in both ethnic groups. A high titer (H. pylori titer > or = 50) was associated with less likelihood of GC for both ethnic groups (for Japanese Brazilians, OR = 0.39, 95% CI = 0.16 - 0.92; for non-Japanese Brazilians, OR = 0.56, 95% CI = 0.31 - 1.02). The high titer can be regarded as a sign of the necessity of eradication, and low titer is regarded as a sign of the necessity of close screening for GC in both ethnic groups, because extended atrophy may cause spontaneous disappearance of H. pylori from the stomach.

Ethnic differences in serum pepsinogen levels among Japanese and non-Japanese Brazilian gastric cancer patients and controls

A low level of serum pepsinogen I (Pg I) is a risk factor for gastric cancer (GC); low levels of Pg I and the pepsinogen ratio (Pg I:Pg II) are correlated with chronic atrophic gastritis. We report serum Pg levels and compare the degree of association with GC among Japanese and non-Japanese Brazilians. Sera were cross-sectionally ascertained from 93 Japanese Brazilian patients category matched by age and sex with 110 controls, and 228 non-Japanese Brazilian patients individually matched by age and sex with one control. Among non-Japanese Brazilians, GC was associated with a Pg I level <30 ng/ml (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.7-3.8) and a Pg I:Pg II ratio < 3.0 (OR, 3.4; 95% CI, 2.2-5.3). However, among Japanese Brazilians, the association was present with a level of Pg I < 30 ng/ml (OR, 3.5; 95% CI, 1.9-6.3), and was weak with a Pg I:Pg II ratio < 3.0 (OR, 1.3; 95% CI, 0.73-2.4). Serum Pg I may be preferred to the Pg I:Pg II ratio to study the association between Pg and GC among Japanese Brazilians.

Alcohol consumption and all-cause and cancer mortality among middle-aged Japanese men: seven-year follow-up of the JPHC study Cohort I. Japan Public Health Center

To examine the association between alcohol consumption and mortality in Japan, where mortality and lifestyle differ substantially from Western countries, a population-based prospective study was conducted in four public health center areas as part of the Japan Public Health Center-based prospective study on cancer and cardiovascular disease (JPHC). After excluding subjects with self-reported serious diseases at baseline, 19,231 men aged 40-59 years who reported their alcohol intake were followed from 1990 through 1996, and 548 deaths were documented. The association between all-cause mortality and alcohol consumption was J-shaped. The lowest risk was observed for men who consumed 1-149 g/week (relative risk (RR) = 0.64, 95% confidence interval (CI) 0.46, 0.88), while the highest risk was seen for men who consumed > or =450 g/week (RR = 1.32, 95% CI 1.00, 1.74), after adjustment for possible confounders. The association did not change after excluding deaths that occurred in the first 2 years of follow-up. However, the association was modified by smoking, and beneficial effects of moderate drinking were largely limited to nonsmokers. The risk of cancer death showed a similar trend, but increased more in heavy drinkers. The background characteristics of moderate drinkers were healthier than either nondrinkers or heavy drinkers. The authors conclude that moderate alcohol consumption was associated with the lowest risks of all-cause and cancer mortality, especially among nonsmokers.

Assessment of DNA content in formalin-fixed, paraffin-embedded tissue of lung cancer by laser scanning cytometer

A new cytometric device, a laser scanning cytometer was developed to overcome the limitations of flow cytometry (FCM) and image analyses. The purpose of this study was to develop a method that allows laser scanning cytometry (LSC) to be used for measuring the cellular DNA content of paraffin-embedded tissues. Paraffin-embedded lung cancer tissue from 30 patients was analyzed by both FCM (p-FCM) and LSC (p-LSC). In addition, touch preparations from fresh frozen tissues were prepared to provide material for LSC (f-LSC). The limits of agreement for the DNA indices (DI) measured by p-LSC and p-FCM were -0.07 to 0.07, indicating that for a given case, these methods would be expected to differ by no more than 0.07. The limits of agreement for comparisons between the other materials and methods were wider and depended upon the size of the measurements. Agreement between f-LSC and p-FCM was good for small DI values, but poor for large values. Agreement between f-LSC and p-LSC was poor for small and large DI values, but good for moderately sized values. Discordancies in DNA ploidy status between different materials and methods may have been caused by either the heterogeneity within tumors, sampling errors or differences in the interpretation of histograms. This method allows a comparison of the results of DNA analysis with histologic findings from hematoxylineosin-stained sections and the prognosis of the patients.

Helicobacter pylori infection and atrophic gastritis in middle-aged Japanese residents of São Paulo and Lima

BACKGROUND

Helicobacter pylori infection and atrophic gastritis (AG) are markedly more prevalent in Japan than in other industrialized countries, however, the reasons for such a high prevalence are not fully understood. To add to information on H. pylori infection and its association with AG, the authors studied Japanese living in less developed countries.

METHODS

Cross-sectional surveys were conducted of randomly selected Japanese residents aged 40-59 years in São Paulo, Brazil and Lima, Peru. Serum IgG antibody to H. pylori and pepsinogen I (PGI) and II (PGII) were measured as markers of AG.

RESULTS

The prevalence of H. pylori infection was similar in both populations, 77% (95% CI: 70-83) in São Paulo and 75% (95% CI: 65-82) in Lima, and was within the range of five populations in Japan from our previous study. However, the prevalence of AG, defined by PGI < 70 ng/ml and PGI/PGII < 3.0 was more prevalent among Japanese in São Paulo (39% [95% CI: 32-47]), than Japanese in Lima (18% [95% CI: 12-27]). This difference was not explained by sex, age, generation or H. pylori infection.

CONCLUSIONS

Helicobacter pylori infection among Japanese in less developed countries was similar to Japanese in Japan, although prevalence of AG varied. Factors other than H. pylori infection are important in the development of AG among Japanese.

Prognostic value of nuclear morphometry in patients with TNM stage T1 ovarian clear cell adenocarcinoma

In 40 patients with TNM stage T1 ovarian clear cell adenocarcinoma, we used nuclear morphometry to study the relations among morphometric variables, clinical prognostic factors and outcome. The presence of one or more giant nuclear cells was positively associated with death (OR = 10.6, P = 0.02) and tended to be associated with disease recurrence (OR = 5.1, P = 0.07). Nuclear irregularity (expressed in terms of the nuclear roundness factor) was positively associated with both death (OR = 8.6, P = 0.02) and disease recurrence (OR = 8.2, P = 0.02). A combination of giant nuclear cell presence or nuclear irregularity proved to be a useful prognostic indicator, with a sensitivity and specificity of 83% and 71% in the prediction of death, and 75% and 71% in the prediction of disease recurrence. Patients' age and substage were of no prognostic value. We conclude that the nuclear morphometric characteristics, especially the presence of giant nuclear cells and nuclear irregularity, may be useful in predicting outcome in patients with early stage ovarian clear cell adenocarcinoma.

Four food-frequency categories of fruit intake as a predictor of plasma ascorbic acid level in middle-aged Japanese men

PURPOSE

Plasma levels of ascorbic acid are assumed to be determined not only by dietary amount of ingested vitamin C, but also by other dietary and nondietary factors. To assess the predictability of plasma ascorbic acid level in Japanese men, we examined its association with dietary sources of vitamin C and other lifestyle factors.

METHODS

In a cross-sectional study of 621 healthy men aged 40-49 years who were sampled randomly from five areas in Japan, the weekly intake frequency of foods rich in vitamin C (< 1, 1-2, 3-4, > or = 5 days/week), alcohol consumption per week, use of vitamin C supplements, and smoking were assessed by use of a food-frequency questionnaire (FFQ) (all subjects) and a 3-day weighed dietary record (DR) from 203 volunteers.

RESULTS

In univariate analyses of FFQ data, the intake frequency of fruit (R2 = 0.12), pickled vegetables (R2 = 0.03), potatoes (R2 = 0.01), and alcohol consumption (R2 = 0.02) were significant determinants of plasma ascorbic acid in addition to supplement use and study area. In a multivariate analysis, four FFQ categories of fruit intake accounted for 19% of the variation in plasma ascorbic acid among nonsupplement users after adjustment for study area and alcohol intake. The association between plasma ascorbic acid level and quartile of dietary vitamin C intake (mg/day) measured by DR was weaker (R2 = 0.04) than the association between plasma ascorbic acid level and dietary intake of fresh fruit (g/day) (R2 = 0.09).

CONCLUSION

The predictability of plasma ascorbic acid by a four-category FFQ assessment of fruit intake was superior to calculated vitamin C or fruit intake assessed by detailed DR.

Interpopulation and intrapopulation variability of nutrient intake in five regions of Japan

OBJECTIVES

To determine the extent to which interpopulation (between-population) variance, relative to intrapopulation (within-population) variance, contribute to the total variability in nutrient intakes.

DESIGN

Cross-sectional study.

SETTING

Five Public Health Center districts in Japan.

SUBJECTS

Two hundred and seven men and 183 spouses.

INTERVENTIONS

A three-day weighed food record.

MAIN OUTCOME MEASURES

The total variance in the consumption of 17 nutrient variables was partitioned by analysis of variance into its inter- and intrapopulation components separately for men and women.

RESULTS

The percentage contribution of the interpopulation to total variance differed according to the nutrient; it was notable (8-17%) for total energy, carbohydrates, phosphorus, and sodium in both men and women, but was negligible (less than 4%) for micronutrients such as retinol, carotene, thiamin, riboflavin, niacin and ascorbic acid. The ratio of intra- to interpopulation variance was estimated for 31 nutrients (17 in men and 14 in women). The point estimates of the ratio were larger than unity in all nutrients, and the lower limit of the 95% confidence intervals exceeded unity for all but 5 nutrients. Of the two sources of intrapopulation variation, intraindividual variance was larger than interindividual variance in most of the nutrient.

CONCLUSIONS

The relative magnitude of interpopulation variation in dietary data can be used to quantify the range of exposure in ecological studies and to examine the heterogeneity of populations pooled for individual-based analysis.

Meta-analysis of Pap test accuracy

A literature search identified 62 studies published by August 1992 comparing Papanicolaou (Pap) test results with histology. Critical appraisal revealed that 82% of these had potential for verification bias and that only 37% stated that cytology and histology were independently assessed. Estimates of sensitivity and specificity ranged from 11 to 99% and 14 to 97%, respectively, and were highly negatively correlated (r = -0.63). Meta-analysis was used to combine data from 59 studies to estimate the accuracy of the Pap test using a summary receiver operating characteristic curve and to examine the effect of study quality. The summary receiver operating characteristic curve suggests that the Pap test may be unable to achieve concurrently high sensitivity and specificity. For example, specificity in the 90-95% range corresponds to sensitivity in the 20-35% range. Pap test accuracy was not associated with reported study characteristics or dimensions of quality. Future primary studies should pay more attention to methodologic standards for the conduct and reporting of diagnostic test evaluations.