3-Year Follow-Up of the Partial Breast Irradiation Trial for DCIS Using the MammoSite® Brachytherapy Balloon Catheter

Purpose: To report the 3-year median follow-up of a prospective Phase II partial breast irradiation (PBI) trial utilizing the MammoSite® interstitial balloon as the sole radiation therapy treatment after lumpectomy for ductal carcinoma in situ (DCIS).Materials and Methods: One hundred and thirty-three patients were enrolled from May 2003 through January 2006 to reach the 100-patient partial breast irradiation (PBI) target goal of 34 Gy in 10 fractions, 1 cm peripheral to the MammoSite® balloon surface, b.i.d. with Iridium192 HDR brachytherapy. The eligibility criteria were age 45, unicentric pure DCIS, mammographic size ≤3cm, negative margin of ≥1 mm, gross pathology size ≤5 cm, clinically node negative, post-lumpectomy mammogram absent of residual microcalcificaion. A USC/VNPI score was then calculated based on age, tumor size, margin width, and nuclear grade [ref: Silverstein MJ, Am J Surg 2003;186(4):337-343]. Placement of the balloon was performed at the time of lumpectomy or post-lumpectomy with a required minimum distance of the balloon surface to skin (skin bridge) of 5 mm. Data was collected at enrollment, at implant, 3 and 6-months, then yearly for local control, cosmesis (Harvard Scale), toxicity, adverse events, disease-free survival, cause-specific survival, and contralateral breast failure. Local recurrence is defined as either invasive or non-invasive within the target volume. Ipsilateral elsewhere recurrence (IER) is defined as invasive or non-invasive outside of the target volume.Results: Of the 133 patients enrolled, thirty-three were not treated for the following reasons: less than 5 mm skin bridge (n=13), poor cavity conformance (n=10), positive margin (n=3), microinvasion (n=3), MD decision (n=2), patient request (1), and other (1). The nuclear grade distribution of the tumors were: NG1(17%), NG2(44%), and NG3(39%). The mean age was 60.8 years. The mean tumor size was 10.6 mm; mean closest surgical margin was 6.8 mm (R=0.1-40mm); post-lumpectomy placement in 72%; mean skin bridge distance was 13 mm with 89% ≥7mm. No patients have been lost to follow-up, and at a median 3-year follow-up, the cosmetic results have been rated as excellent/good in 94 and fair in 6 patients. There have been only four recurrences, all non-invasive with the following histological patterns listed in the table below. One was an IER.Recurrence DetailsCase No.Months Since PlacementInvasiveUSC/VNPI ScoreOriginal Tumor GradeComedo Necrosis18No93Yes211No83No317No62Yes432No52Yes No serious adverse events were reported with an infection rate of 9% (7 breast infections; 2 cellulitis).Conclusion: This is the longest reported prospective Phase II study using a PBI technique for pure DCIS patients, and continues to demonstrate the efficacy of the MammoSite® balloon for treating pure DCIS breast tumors, with no new recurrences since our last report at SABCS 2007. All the recurrences were noninvasive, and had at least one or more risk factors of a high USC/VNPI score, high nuclear tumor grade, or had a comedo necrosis pattern. There have been no recurrences in nuclear grade 1 or 2 patients in the absence of a comedo necrosis pattern. The cosmesis also continues to be excellent or good long-term in 96% patients.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 952.

Does engagement with life enhance survival of elderly people in Sweden? The role of social and leisure activities

OBJECTIVES

This research examined whether engagement with life, defined as involvement in social, leisure, and productive activities, produced a survival advantage among oldest old persons in Sweden. Survival was investigated with respect to activities that involved (a) social integration, (b) physical mobility, and (c) neither social nor physical aspects. The authors also investigated the degree to which any observed survival benefits were related to prior health differences that select older adults into active roles.

METHODS

Baseline data derived from the Swedish Panel Study of Living Conditions of the Oldest Old, a nationally representative sample of persons aged 77 years and older living in Sweden in 1992. The authors used factor analysis to apply a simplifying measurement structure to frequency of participation in 10 leisure activities. They used Cox proportional hazard regression to estimate the relative effects of activity factors and other independent variables on the logged hazard rate of mortality up to 1996.

RESULTS

Analyses revealed 4 domains of activities that lie along 2 basic dimensions: solitary-social and sedentary-active. Among men, only participation in activities that were both solitary and active was significantly associated with reduced mortality risk when health variables were controlled. Among women, none of the activity domains was significant when health variables were controlled. For the entire sample, greater participation in solitary-active activities significantly reduced risk of mortality when all other activity domains and health factors were controlled.

DISCUSSION

Although most of the observed associations between activity involvement and survival are a byproduct of the confound between poor initial health and low activity levels, solitary activities have a positive influence on the survival of very old individuals, especially men, suggesting that nonsocial aspects of activities may promote health and longevity in late old age.

Changing attitudes toward aging policy in the United States during the 1980s and 1990s: a cohort analysis

OBJECTIVES

This research assessed how the attitudes of Americans toward government programs that serve older people changed between the mid-1980s and late 1990s and how much of the shift was dueto intracohort change and how much was due to cohort replacement.

METHODS

Data come from three nationally representative cross-sectional samples, surveyed by telephone in 1986 (N = 1.209), 1990 (N = 1,500), and 1997 (N = 1,559).

RESULTS

Attitudes of Americans have become less supportive of expanding entitlement programs for older people and more supportive of cutting their costs and benefits. Between 1986 and 1997, most cohorts, particularly older adults, grew more in favor of maintaining Social Security benefit levels but less in favor of expanding them. Young adults tended to be driving the societal shift in attitudes toward decreasing benefits. Intercohort change was more important than cohort replacement in this process. Analyses of change in 2 attitude domains between 1990 and 1997 revealed that the general population felt less strongly that older people are entitled to benefits and expressed greater opposition to the associated costs. However, young adults moderated their concerns about costs as they got older, although the young adults in the cohort replacing them had become more critical of the principle of entitlement.

DISCUSSION

These findings enhance the understanding of the roles that historical conditions and aging play in shaping the attitudes of adult cohorts toward public programs for older citizens. Discrepant findings based on the intercohort change in younger age groups are reconciled by differentiating maturation effects from period effects on impressionable youth.

A health and demographic profile of noninstitutionalized older Americans residing in environments with home modifications

OBJECTIVES

In this analysis the authors investigate the demographic characteristics, the health conditions/events, and the disabilities of community-dwelling Americans 70 years of age and older that are associated with residing in environments with specific home modifications.

METHODS

Data from a large population-based study of the elderly are used to estimate logistic regression equations that reveal profiles of older individuals who are likely to have distinct home modifications.

RESULTS

Having diseases such as diabetes and stroke, having experienced a hip fracture, a fall or a joint replacement, and having greater limitations with activities of daily living raise the likelihood of having home modifications. Low income, Hispanic, and African American elderly appear underrepresented among those with modifications.

DISCUSSION

The authors conclude that specialized housing alternatives will be an increasingly important issue in the future as individuals aim to achieve and maintain the delicate balance between their functional ability and their living environment.

A sociocultural stress and coping model for mental health outcomes among African American caregivers in Southern California

A sociocultural stress and coping model to explain emotional distress among caregivers of family members who have dementia across ethnic and cultural groups is presented and explored in a sample of 41 African American and 128 non-African American caregivers. In this sample, African American caregivers reported lower levels of burden but equal levels of depression and anxiety. In the structural equation model, previous reports that African Americans' lower appraisal of caregiving as burdensome resulted in lower levels of emotional distress were confirmed. However, in this model, this pathway was counterbalanced by a tendency of African American caregivers to use emotion-focused coping and, therefore, increase emotional distress. African American caregivers were also younger and in poorer health, factors which tend to increase both burden and emotional distress outcomes. As suggested by the sociocultural stress and coping model, the influences of ethnic group variables on stress and coping processes are complex and multidirectional.

Clinical implications of penicillin and ceftriaxone resistance among children with pneumococcal bacteremia

OBJECTIVES

To determine whether reduced penicillin or ceftriaxone susceptibility affects clinical presentation and outcome in children with pneumococcal bacteremia.

DESIGN

Retrospective review of patients with Streptococcus pneumoniae bacteremia.

RESULTS

We reviewed 922 cases of pneumococcal bacteremia. Of 744 isolates with known penicillin (PCN) susceptibilities 56 were PCN-nonsusceptible. The majority displayed intermediate resistance; 14 of 730 isolates with known ceftriaxone (CTX) susceptibilities were CTX-nonsusceptible. Neither the PCN- nor the CTX-nonsusceptible cohort displayed a difference from its susceptible counterpart in temperature, respiratory rate or white blood cell count on initial patient evaluation, although trend suggested they were more often admitted at the initial visit. At follow-up only children treated initially with antibiotic were evaluated. Children with PCN-nonsusceptible isolates were no more likely to be febrile than those with PCN-susceptible isolates (28% vs. 25%, P = 0.61) and were no more likely to have a positive repeat blood culture (0% vs. 1%, P = 0.59) or a new focal infection (10% vs. 6%, P = 0.79). Data concerning CTX-nonsusceptible organisms were limited by the low number of such isolates. Although patients with CTX-nonsusceptible pneumococci were more likely to be febrile at follow-up than those with CTX-susceptible organisms (67% vs. 24%, P = 0.04), we were unable to demonstrate a significant difference for other endpoints.

CONCLUSIONS

Reduced antibiotic susceptibility does not alter the clinical presentation of pneumococcal bacteremia. With current practice intermediate resistance to PCN is of little clinical significance in nonmeningitic systemic pneumococcal infections.

Removal of a Norplant implant located near a major nerve using interventional radiology-digital subtraction fluoroscopy

Norplant implants can be removed easily, if inserted properly. When they are inserted deeply and can not be palpated, or if they are located close to the neurovascular structures of the upper arm, radiological guidance may be needed to locate and remove the implants without causing injury to the surrounding vital structures. Digital subtraction fluoroscopic guidance is helpful in removing deeply located contraceptive implants and those that are close to the neurovascular structures, where blind removal may result in injury to those structures. We describe a case in which an implant that was located close to a major nerve near the axilla was removed under digital subtraction fluoroscopic guidance.

CONTEMPORARY TRANSFORMATIONS OF LOCAL LINGUISTIC COMMUNITIES

▪ Abstract  An emergent focus of linguistic anthropological research is discernible in the investigation of the causes and consequences of contact of local language communities with forces of the wider polities in which they have become incorporated. This focus can be sketched by surveying a number of its component conceptual approaches, such as anthropological linguistics, ethnography of communication, variationist sociolinguistics, and the sociology and politics of languages. Its consideration of language as a total cultural fact is outlined by reference to studies that differentially emphasize language structure, entextualization/contextualization of language, and language ideology.

Older parents' expectations of moving closer to their children

Research shows that older parents engage in return migration in older to live closer to children from whom they receive care. However, less is known about how characteristics of adult children influence this process. Data for this analysis are from 5,382 older parents participating in the 1993/4 AHEAD national survey of adults aged 70 years old and older. Findings demonstrate that elderly parents who expect to move closer to adult children tend to be older, female, and have at least one child who is better-off financially than they are. Living alone magnifies the effect of poor self-rated health on expecting to move closer to a child. Random effects modeling of children's characteristics reveals that parents are more likely to expect to move closer to a daughter than to a son. Greater parental functional impairment was found to further depress the selection of sons. Overall, the findings suggest that older parents expect to move closer to adult children out of need and tend to select a target child with greater potential to provide support.

Comparison of U.S. Occupational Safety and Health Administration standards and German Berufsgenossenschaften Guidelines for Preventive Occupational Health Examinations

Thirty-three U.S. Occupational Safety and Health Administration (OSHA) standards contain mandated medical service provisions. The German Berufsgenossenschaften Guidelines for Preventive Occupational Health Examinations currently comprise 38 guidelines, which contain mandated medical service provisions. Based on a previously published method for scoring several medical program elements, the Berufsgenossenchaften guidelines were compared with the OSHA standards. Specific program elements were combined to generate and compare quality control scores, screening scores and surveillance scores. The asbestos standard/guidelines were compared in more detail (e.g., physical examination, laboratory tests, examination schedule, eligibility). The German medical requirements consistently ranked higher than their U.S. counterparts for overall scores and the scoring indices for quality control, screening, and surveillance. However, this comparison also reveals that few surveillance features have been incorporated into the medical requirements of either country, suggesting that neither country is making full use of workplace medical services for primary prevention.

Health and social precursors of later life retirement-community migration

This study uses the developmental migration paradigm developed by Litwak and Longino (1987) as a framework to investigate the health and social determinants of late-life elderly mobility to retirement communities. Data from four waves of the Longitudinal Study of Aging are used to predict the likelihood of moving from the general community to two types of retirement communities--those with group meals and those without group meals. Multinomial logistic regression reveals that the likelihood of migrating to both types of retirement communities increases as disability advances to moderate levels, but declines as disability becomes severe. Migration to retirement communities is also more likely among elderly persons who live alone and among those whose children do not live nearby. The results suggest that retirement community migration in middle and late old age is motivated not only by social and amenity considerations, but also by the need for assisted living arising from physical frailty. Implications for developmental migration theory and long-term care policy are discussed.

Remembering the past, acting for the future

Michael Silverstein, Director of Policy for the Occupational Safety and Health Administration, made these remarks at a Workers' Memorial Day observance held in April by the Philadelphia Area Project on Occupational Safety and Health (PHILAPOSH).

Stability and change in temporal distance between the elderly and their children

Drawing on a developmental model of late-life migration, this paper investigates how older people's health and social characteristics influence stability and change in their temporal distance from their children. Data from the Longitudinal Study of Aging are used to examine both discrete transitions and continuous change in distance over a four-year period. Decline in older parents' physical health increased the propensity of parents and children to become temporally closer to each other. Among those parent-child pairs who had become closer, the conjunction of declining health and widowhood increased both the degree of non-coresident proximity and the likelihood of transition to coresidence. The findings portray a geographically resilient family that adjusts to the changing needs of its older members.

Laparoscopic enterolysis and placement of an intestinal sling before radiation therapy for the treatment of prostate cancer

We present an interesting application of laparoscopy in a man who was otherwise not a candidate for radiotherapy because of an adherent loop of small bowel in the proposed treatment field. Laparoscopic enterolysis was performed and the involved segment was displaced out of the pelvis; a synthetic mesh was placed to serve as a sling to prevent caudal migration back into the pelvis. The patient had a rapid recovery and subsequently completed a full course of radiotherapy. The experienced laparoscopist may find this a good alternative to open surgery in patients with a fixed loop of small bowel who require radiation therapy for pelvic malignancies.

Analysis of medical screening and surveillance in 21 Occupational Safety and Health Administration standards: support for a generic medical surveillance standard

Twenty-one Occupational Safety and Health Act (OSHA) standards were identified which contain medical service provisions intended to help in the identification and control of harmful health effects of workplace exposures. The utility and effectiveness of these provisions have not previously been evaluated. All 21 standards were reviewed and assigned numerical scores for each of 24 potential medical program elements. Several of these elements were combined to calculate Quality Control, Screening Utility, and Surveillance Utility scores for each standard. Total scores varied greatly, suggesting a lack of consistency and uniformity which was even more obvious when the actual regulatory language was examined. The mean Quality score was only 26% of potential points. Seventeen of 21 standards received less than half the total possible Quality score. When arrayed on a two by two matrix only two standards scored above 50% for both Screening and Surveillance Utility. It was concluded that the medical service provisions in OSHA standards are lacking in consistency and coherence. Two major shortcomings are the lack of quality control elements and the absence of surveillance features which would permit medical program results to be utilized for prevention activities including the identification and control of workplace hazards. A generic occupational medical surveillance standard could address these current weaknesses. Elements of such a generic standard are proposed.

Does intergenerational social support influence the psychological well-being of older parents? The contingencies of declining health and widowhood

This study investigates whether social support from adult children improves the psychological well-being of elderly parents. Support is studied as a direct influence on emotional distress and as a moderator of the distressing consequences of health problems and widowhood. Research questions are addressed using data from elderly parents participating in 1985 and 1988 surveys of the U.S.C., Longitudinal Study of Three Generation Families. Results from multiple regression analyses indicate that instrumental and expressive forms of social support are weakly related to 3-year change in positive and negative aspects of psychological well-being. However, both types of support moderate declines in well-being associated with poor health and widowhood. We conclude that the psychological benefits of intergenerational social support are contingent on the vulnerability of the older parent, when expectations for assistance are at their greatest. This finding has considerable implications for family theory and policy.

Neuropsychological deficit and aggressive behavior: a prospective study

1. Failures in higher cortical executive functions and dyscontrol of aggressive impulses were hypothesized to co-occur in aggressive men. 2. The performance of a sample of violent forensic patients on selected neuropsychological measures (Judgment of Line Orientation, Stroop Color Word Test, Emotion Perception Test, Test Of Nonverbal Intelligence, Wisconsin Card Sorting Test, and Symbol Digit Modalities Test) were used to predict their overt aggressive behavior during a one-year period using the Overt Aggression Scale. 3. Whole-set correlation analyses revealed that scores on the Judgment of Line Orientation, Stroop Color Word Test, and Emotion Perception Test accounted for 57% of the variance of aggression scores. 4. Frequency of aggression, but not severity of aggression, can be predicted using these three scores.