Participant experiences in HIV cure-directed trial with an extended analytical treatment interruption in Philadelphia, United States

BACKGROUND

A feature of HIV cure trials is the need to interrupt treatment to test the efficacy of experimental interventions-a process known as analytical treatment interruptions (ATIs).

OBJECTIVES

We report the experiences of participants after they completed an extended ATI.

METHODS

From April to November 2022, we conducted post-ATI in-depth interviews with BEAT2 clinical trial (NCT03588715) participants who stopped ART while receiving an immunotherapy regimen. We used conventional content analysis to code the data.

RESULTS

We conducted interviews with 11 Black/African American and three White/Caucasian participants (11 males, two females, and one transgender woman). The mean ATI was 38 weeks. Participants noted several significant experiences surrounding the interventions' side effects, ATI, and returning to medication. Some participants had positive experiences with their ATI. Other participants were nervous during the ATI. Rising viral loads led some to feel a sense of failure. Although trial experiences were heterogeneous, participants unanimously had positive interactions with the clinical trial staff which facilitated their retention in the trial. Participants shared their experiences with the trial, including changes in expectations, experiences with experimental interventions and procedures, compensation as a measure of respect, effort, transportation, and effects of COVID-19 during the trial. Based on these results, we provide considerations for the conduct of future HIV cure-directed clinical trials involving ATIs.

CONCLUSIONS

Managing expectations, focusing on participants' contributions, and providing support to reduce feelings of having failed the research team and/or the HIV community following viral rebound should be part of HIV cure trial design. Discussing the mental health impact of rebound during consent, distinct from risk, is needed. Continued efforts to understand how people with HIV experience ATIs will improve future designs of HIV cure clinical trials.

A partner protection package for HIV cure-related trials involving analytical treatment interruptions

Analytical treatment interruptions (ATIs) have become a key methodological approach to evaluate the effects of experimental HIV cure-related research interventions. During ATIs, sex partners of trial participants might be at risk of acquiring HIV. This risk raises both ethical and feasibility concerns about ATI trials. We propose a partner protection package (P3) approach to address these concerns. A P3 approach would provide guidance to investigators, sponsors, and those who are designing and implementing context-specific partner protections in HIV cure-related trials involving ATIs. The approach would also help assure institutional review boards, trial participants, and communities that ATI trials with a P3 would provide appropriate partner protections. We offer a prototype P3 framework that delineates three basic considerations for protecting participants' sex partners during ATI trials: (1) ensuring the scientific and social value of the ATI and the trial, (2) reducing the likelihood of unintended HIV transmission, and (3) ensuring prompt management of any acquired HIV infection. We outline possible ways of implementing these basic considerations.

Community engagement group model in basic and biomedical research: lessons learned from the BEAT-HIV Delaney Collaboratory towards an HIV-1 cure

INTRODUCTION

Achieving effective community engagement has been an objective of U.S. National Institutes of Health-funded HIV research efforts, including participation of persons with HIV. Community Advisory Boards (CABs) have remained the predominant model for community engagement since their creation in 1989. As HIV cure-directed research efforts have grown into larger academic-industry partnerships directing resources toward both basic and clinical research under the Martin Delaney Collaboratories (MDC), community input models have also evolved. The BEAT-HIV MDC Collaboratory, based at The Wistar Institute in Philadelphia, United States, implemented a three-part model for community engagement that has shown success in providing greater impact for community engagement across basic, biomedical, and social sciences research efforts.

DISCUSSION

In this paper, we review the case study of the formation of the BEAT-HIV Community Engagement Group (CEG) model, starting with the historical partnership between The Wistar Institute as a basic research center and Philadelphia FIGHT as a not-for-profit community-based organization (CBO), and culminating with the growth of community engagement under the BEAT-HIV MDC. Second, we present the impact of a cooperative structure including a Community Advisory Board (CAB), CBO, and researchers through the BEAT-HIV CEG model, and highlight collaborative projects that demonstrate the potential strengths, challenges, and opportunities of this model. We also describe challenges and future opportunities for the use of the CEG model.

CONCLUSIONS

Our CEG model integrating a CBO, CAB and scientists could help move us towards the goal of effective, equitable and ethical engagement in HIV cure-directed research. In sharing our lessons learned, challenges and growing pains, we contribute to the science of community engagement into biomedical research efforts with an emphasis on HIV cure-directed research. Our documented experience with implementing the CEG supports greater discussion and independent implementation efforts for this model to engage communities into working teams in a way we find a meaningful, ethical, and sustainable model in support of basic, clinical/biomedical, social sciences and ethics research.

"We are looking at the future right now": community acceptability of a home-based viral load test device in the context of HIV cure-related research with analytical treatment interruptions in the United States

BACKGROUND

People with HIV (PWH) and community members have advocated for the development of a home-based viral load test device that could make analytical treatment interruptions (ATIs) less burdensome.

OBJECTIVE

We assessed community acceptability of a novel home-based viral load test device.

METHODS

In 2021, we conducted 15 interviews and 3 virtual focus groups with PWH involved in HIV cure research. We used conventional thematic analysis to analyze the data.

RESULTS

PWH viewed the home-based viral load test device as a critical adjunct in ongoing HIV cure trials with ATIs. The ability to test for viral load at home on demand would alleviate anxiety around being off ART. Participants drew parallels with glucometers used for diabetes. A preference was expressed for the home-based test to clearly indicate whether one was detectable or undetectable for HIV to mitigate risk of HIV transmission to partners. Perceived advantages of the device included convenience, sense of control, and no puncturing of veins. Perceived concerns were possible physical marks, user errors and navigating the logistics of mailing samples to a laboratory and receiving test results. Participants expressed mixed effects on stigma, such as helping normalize HIV, but increased potential for inadvertent disclosure of HIV status or ATI participation. Increasing pluri-potency of the device beyond viral load testing (e.g., CD4+ count test) would increase its utility. Participants suggested pairing the device with telemedicine and mobile health technologies.

CONCLUSIONS

If proven effective, the home-based viral load test device will become a critical adjunct in HIV cure research and HIV care.

Outcomes of Abbreviated MRI (Ab-MRI) for Women of any Breast Cancer Risk and Breast Density in a Community Academic Setting

BACKGROUND

Abbreviated magnetic resonance imaging (Ab-MRI) has been evaluated for elevated breast cancer risk or dense breasts but has not been evaluated across all risk profiles.

METHODS

Patients selected underwent Ab-MRI from February 2020 to September 2021. Women were older than aged 30 years, up to date with screening mammography, and paid $299 cash.

RESULTS

A total of 93 patients were identified with a mean age of 52 years; 92.5% were Caucasian, 0% black, and 97.9% were from high socioeconomic status. Mean Gail score was 14.2, and 83.3% had a lifetime risk of breast cancer <20%. Reasons for Ab-MRI: dense breasts (36.6%); family history (24.7%); palpable mass (12.9%). Providers ordering: OBGYN (49.5%); breast surgeon (39.1%); primary care (6.6%). Thirteen biopsies (14%) detected one breast cancer. 31.1% had a change in follow-up screening: 58.6% 6-month MRI, 20.7% 6-month mammogram, and 10.3% 6-month ultrasound. Negative predictive value was 100% (95% confidence interval [CI]: 95-100%, p < 0.0001). Sensitivity was 100% (95% CI: 2.5-100%, p < 0.0001), and specificity was 87% (95% CI: 78.3-93.1%, p < 0.0001) compared with 77.6% and 98.8% for mammography. Only one cancer was detected: cost of $27,807 plus cost of 13 MRI or ultrasound (US)-guided biopsies and additional follow-up imaging. Historically 20% of abnormalities detected on full MRI are malignant; however, 7.7% of ab-MRI abnormalities were malignant CONCLUSIONS: One third of women were recommended a change in follow-up, which predominantly included a 6-month MRI. Ab-MRI may introduce average risk women to unnecessary follow-up and increased biopsies with a lower cancer detection rate. Ab-MRI should be evaluated closely before implementation.

Preliminary Acceptability of a Home-Based Peripheral Blood Collection Device for Viral Load Testing in the Context of Analytical Treatment Interruptions in HIV Cure Trials: Results from a Nationwide Survey in the United States

Frequent viral load testing is necessary during analytical treatment interruptions (ATIs) in HIV cure-directed clinical trials, though such may be burdensome and inconvenient to trial participants. We implemented a national, cross-sectional survey in the United States to examine the acceptability of a novel home-based peripheral blood collection device for HIV viral load testing. Between June and August 2021, we distributed an online survey to people with HIV (PWH) and community members, biomedical HIV cure researchers and HIV care providers. We performed descriptive analyses to summarize the results. We received 73 survey responses, with 51 from community members, 12 from biomedical HIV cure researchers and 10 from HIV care providers. Of those, 51 (70%) were cisgender men and 50 (68%) reported living with HIV. Most (>80% overall) indicated that the device would be helpful during ATI trials and they would feel comfortable using it themselves or recommending it to their patients/participants. Of the 50 PWH, 42 (84%) indicated they would use the device if they were participating in an ATI trial and 27 (54%) also expressed a willingness to use the device outside of HIV cure studies. Increasing sensitivity of viral load tests and pluri-potency of the device (CD4 count, chemistries) would augment acceptability. Survey findings provide evidence that viral load home testing would be an important adjunct to ongoing HIV cure-directed trials involving ATIs. Survey findings may help inform successful implementation and uptake of the device in the context of personalized HIV care.

COVID-19 Pandemic: Changes in Care for a Community Academic Breast Center and Patient Perception of Those Changes

Background

Philadelphia and its suburbs were an epicenter for the initial COVID-19 outbreak. Accordingly, alterations were made in breast cancer care at a community hospital.

Methods

The authors developed a prospective database of all the patients with invasive or in situ breast cancer between March 1 and June 15 at their breast center. Any change in a breast cancer plan due to the pandemic was documented, and the patients were grouped into two cohorts according to whether a change was made (CTX) or no change was made (NC) in their care. The patients were asked a series of questions about their care, including those in the Generalized Anxiety Disorder two-item questionnaire (GAD-2), via telephone.

Results

The study enrolled 73 patients: 41 NC patients (56%) and 32 CTX patients (44%). The two cohorts did not differ in terms of age, race, or stage. Changes included delay in therapy (15.1%) and use of neoadjuvant endocrine therapy (NET, 28.8%). The median time to surgery was 24 days (interequartile range [IQR], 16–45 days) for the NC patients and 82 day s (IQR, 52–98 days) for the CTX patients (p ≤ 0.001). The median duration of NET was 78 days. The GAD-2 showed anxiety positivity to be 29.6% for the CTX patients and 32.4% for the NC patients (p = 1.00). More than half (55.6%) of the CTX patients believed COVID-19 affected their treatment outlook compared with 25.7% of the NC patients (p = 0.021).

Conclusions

A prospective database captured changes in breast cancer care at a community academic breast center during the initial phase of the COVID-19 pandemic. 44% of patients experienced a change in breast cancer care due to COVID-19. The same level of anxiety and depression was seen in both change in therapy (CTX) and no change (NC). 55.6% of CTX cohort believed COVID-19 affected their treatment outlook.

Metabolic Syndrome: does this influence breast cancer outcomes in the triple-negative population?

INTRODUCTION

Metabolic syndrome (MS) is defined by having at least 3 of 4 components: obesity, dyslipidemia, hypertension (HTN), and diabetes. Prior studies analyzed the individual components of MS for all breast cancers which are predominantly hormone positive. Our study is the first to evaluate MS in triple-negative breast cancer (TNBC).

METHODS

A retrospective review of TNBC from 2007 to 2013 identified 177 patients with complete information for statistical analysis. Cox proportional hazards models were used to test the association between MS, disease-free survival (DFS), and overall survival (OS).

RESULTS

48 (27%) patients had MS. After controlling for age, race, pathologic stage, surgery type, and additional comorbidities outside of MS, MS was significantly associated with poorer DFS (adjusted HR: 2.24, p = 0.030), but not associated with OS (adjusted HR: 1.92, p = 0.103). HTN was significantly associated with poorer DFS (adjusted HR: 3.63, p = 0.006) and OS (adjusted HR: 3.45, p = 0.035) in the univariable and multivariable analyses. Diabetes was not associated with worse OS or DFS. The 5-year age-adjusted OS rates for 60-year-old patients with and without diabetes were 85.8% and 87.3%, respectively. The age-adjusted 5-year OS rate for 60-year old patients was higher in patients with a body mass index (BMI) > 30 (90.2%) versus BMIs of 25-29.9 (88.2%) or < 25 (83.5%).

CONCLUSION

In the TNBC population, MS was significantly associated with poorer DFS, but not associated with OS. HTN was the only component of MS that was significantly associated with both DFS and OS. Obesity has a potential small protective benefit in the TNBC population.

Abstract P4-12-06: Long-term follow-up of patients with invasive breast cancer treated with catheter-based accelerated partial breast irradiation following lumpectomy

Introduction: A large number of breast cancer patients who are eligible for breast-conserving therapy (radiation following complete resection via lumpectomy) elect to undergo mastectomy to avoid radiation - with treatment length being the most significant deterrent. The development of accelerated partial breast irradiation (APBI) tailored treatment to target tissue at greatest risk of recurrence, balancing treatment-associated benefits with radiation exposure risk while shortening therapy duration from 6 weeks to 5 days. This study analyzed rates of ipsilateral breast tumor recurrence (IBTR) in patients with invasive breast cancer treated with resection followed by APBI delivered via catheter-based brachytherapy.

Methods: Retrospective data was collected on 406 patients with primary invasive breast cancer diagnosed from January 2007 to February 2014, treated with lumpectomy and adjuvant APBI catheter-based brachytherapy. Follow-up data was available for 390 patients (97.5%). Mean and median follow-up were 80.9 and 83.5 months respectively. 193 patients (49.4%) had at least 7 years of follow-up.

Results: 21 patients (5.4%) were found to have an IBTR. Of these patients, 14 (66.7%) experienced an IBTR in the same quadrant as their index cancer. 7 patients (33.3%) experienced an IBTR in a different quadrant. Only one patient (4.8%) experienced an IBTR within the first two years after conclusion of their primary treatment. Of the entire cohort, 7 patients (1.8%) were found to have a metastatic recurrence (one which occurred within the first two years after primary treatment) and 7 patients (1.8%) experienced new primary cancers diagnosed in their contralateral breasts.

Conclusion: The results of this investigation demonstrate catheter-based brachytherapy APBI delivered after breast-conserving surgery carries a relatively low risk for IBTR in patients with invasive breast cancer. We support its' use as an effective and valid alternative for selected early breast cancer patients desiring a significantly shorter, more convenient course of treatment in the adjuvant setting without increased risk of recurrence.

Citation Format: Cynthia Chen, Chi Chi Do-Nguyen, Lisa Poole, Lina Sizer, William B Carter, Thomas G. Frazier. Long-term follow-up of patients with invasive breast cancer treated with catheter-based accelerated partial breast irradiation following lumpectomy [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P4-12-06.

Abstract P3-13-10: A comparison of the micro-impulse radar SAVI SCOUT to the radioactive I125 seed in localization of non-palpable breast cancer for breast conserving therapy

Breast conservation and primary radiation (BCT) is a widely used treatment for early stage breast cancer patients. Studies report a 20-40 percent re-excision rate to obtain clear margins. Current localization practices include needle, radioactive seed and intraoperative U/S. Seed localization has been found to decrease tissue volume excision and improve patient satisfaction. However, radioactive seed programs are difficult to implement due to cumbersome regulations by the Nuclear Regulatory Commission (NRC). SAVI SCOUT® is a new technology cleared by the FDA for tumor localization. This device utilizes non-radioactive, micro-impulse radar (radar) to provide surgical guidance. The aim of this study was to evaluate the SCOUT® and determine its equivalence to seed localization by comparing re-excision rates and specimen volume.

70 patients with clinical stage 0, I, or II breast cancer who were treated with BCT were included in this IRB approved review. 35 patients were compared using the SCOUT radar localization technique with 35 patients using the radioactive iodine 125 seed localization technique. All patients received a wide segmental resection. The tissue was oriented and assessed clinically (visualization and palpation) and radiographically (Kubtec's XPERT 40 Digital Specimen Radiography System) in the operating room. Additional margins were excised if deemed to be suspicious by the surgeon (unless the anterior margin was skin or the posterior margin was the pectoral muscle fascia). Final margin status for both groups was compared. A positive margin was any margin with tumor on ink. The total volume of the excised specimen plus additional margins was recorded by the pathologist.

In all 70 patients, the targeted lesions, seed and/or reflectors were successfully removed. There were 420 margins assessed (6 for each specimen), using the additional margins excised as the final margin for evaluation of tumor on ink. Of the 210 final margins in the specimens excised using the seed, 5 margins (2.38%) in 4 patients were positive. 5 margins (2.38%) were also positive in 4 patients using the SCOUT. Nine patients in total returned to the operating room for re-excision. [One re-excision was performed as physician preference for close (&lt;2mm) margins for DCIS.] 5/9 patients requiring re-excision were found to have residual disease. A total of 119 additional margins were excised from 51 patients at the initial operation. 68 margins from 26 patients (SCOUT) and 51 margins from 25 patients (seed). Of the 119, 5 margins were found to be positive. 3 margins 4.41% (3/68) in the SCOUT group and 2 margins 3.92% (2/51) in the seed group. The average volume resected from the SCOUT averaged 81.28 cm3 while the volume of the seed averaged 100.39 cm3 (p-value 0.209).

The use of SCOUT for non-palpable tumor localization was equivalent to seed localization when comparing margin re-excision rate and tissue volumes. We conclude that SCOUT is an excellent alternative in breast cancer localization and can be easily implemented in most hospitals for breast conservation therapy.

Citation Format: Nolano SE, Thalhiemer LO, Yu E, Grujic E, Carter WB, Frazier TG. A comparison of the micro-impulse radar SAVI SCOUT to the radioactive I125 seed in localization of non-palpable breast cancer for breast conserving therapy [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-13-10.

Chemotherapy-induced moderate tolife-threatening anemia in early-stage breast cancer

Purpose. We evaluated the incidence and severity of anemia experienced by women treated with doxorubicin and cyclophosphamide (AC) therapy for early-stage breast cancer are described. We also explored the possibility of identifying clinical characteristics that will allow early identification of women more likely to develop anemia and may require anemia treatment.

Methods. This study used a historic case series from 13 oncology practices that participated in the Oncology Practice Pattern Study. The analysis focused on 411 patients who received AC chemotherapy from 1993 through 1999. Seventeen percent of the study population was excluded from the analysis due to missing data. Anemia was defined as a hemoglobin (Hb) value of < 12 g/dL. Hb ≤10 g/dL was considered the threshold value for treatment.

Results. Among patients receiving AC, 18.0% was anemic prior to chemotherapy. Overall, 14.9 -16.9% of women with early-stage breast cancer who started AC chemotherapy with a normal Hb (≥12 g/dL) developed anemia. Nearly 11% developed severe to life-threatening anemia (Hb < 8 g/dL). Data on blood transfusions and erythropoietic therapy were unavailable. Multivariate logistic regression analysis showed that patients who started with a normal prechemotherapy Hb and dropped to ≤10 g/dL at some point during chemotherapy were more likely to be ≥65 years of age, have a low body surface area (< 1.78), and have four or more positive nodes.

Conclusion. The incidence of anemia increased substantially from baseline to post-chemotherapy. The data suggested the importance of monitoring and managing Hb levels of patients at increased risk for developing chemotherapy-induced anemia.

Determinants of Interpersonal Disclosure: Some Competitive Tests

The amount and content of the information exchanged in an interpersonal interaction was examined. Both the medium of exchange and the content of the messages had significant effects on the subjects' responses but personality measures did not. These results are discussed in terms of recent theoretical developments in the area of interpersonal exchange.

Additive manufacturing of polymer-derived ceramics

The extremely high melting point of many ceramics adds challenges to additive manufacturing as compared with metals and polymers. Because ceramics cannot be cast or machined easily, three-dimensional (3D) printing enables a big leap in geometrical flexibility. We report preceramic monomers that are cured with ultraviolet light in a stereolithography 3D printer or through a patterned mask, forming 3D polymer structures that can have complex shape and cellular architecture. These polymer structures can be pyrolyzed to a ceramic with uniform shrinkage and virtually no porosity. Silicon oxycarbide microlattice and honeycomb cellular materials fabricated with this approach exhibit higher strength than ceramic foams of similar density. Additive manufacturing of such materials is of interest for propulsion components, thermal protection systems, porous burners, microelectromechanical systems, and electronic device packaging.

Ultralight metallic microlattices

Ultralight (<10 milligrams per cubic centimeter) cellular materials are desirable for thermal insulation; battery electrodes; catalyst supports; and acoustic, vibration, or shock energy damping. We present ultralight materials based on periodic hollow-tube microlattices. These materials are fabricated by starting with a template formed by self-propagating photopolymer waveguide prototyping, coating the template by electroless nickel plating, and subsequently etching away the template. The resulting metallic microlattices exhibit densities ρ ≥ 0.9 milligram per cubic centimeter, complete recovery after compression exceeding 50% strain, and energy absorption similar to elastomers. Young's modulus E scales with density as E ~ ρ(2), in contrast to the E ~ ρ(3) scaling observed for ultralight aerogels and carbon nanotube foams with stochastic architecture. We attribute these properties to structural hierarchy at the nanometer, micrometer, and millimeter scales.

Catastrophic vs gradual collapse of thin-walled nanocrystalline Ni hollow cylinders as building blocks of microlattice structures

Lightweight yet stiff and strong lattice structures are attractive for various engineering applications, such as cores of sandwich shells and components designed for impact mitigation. Recent breakthroughs in manufacturing enable efficient fabrication of hierarchically architected microlattices, with dimensional control spanning seven orders of magnitude in length scale. These materials have the potential to exploit desirable nanoscale-size effects in a macroscopic structure, as long as their mechanical behavior at each appropriate scale - nano, micro, and macro levels - is properly understood. In this letter, we report the nanomechanical response of individual microlattice members. We show that hollow nanocrystalline Ni cylinders differing only in wall thicknesses, 500 and 150 nm, exhibit strikingly different collapse modes: the 500 nm sample collapses in a brittle manner, via a single strain burst, while the 150 nm sample shows a gradual collapse, via a series of small and discrete strain bursts. Further, compressive strength in 150 nm sample is 99.2% lower than predicted by shell buckling theory, likely due to localized buckling and fracture events observed during in situ compression experiments. We attribute this difference to the size-induced transition in deformation behavior, unique to nanoscale, and discuss it in the framework of "size effects" in crystalline strength.

A mammaglobin-A targeting agent for noninvasive detection of breast cancer metastasis in lymph nodes

Pathologic axillary lymph node (ALN) status is an important prognostic factor for staging breast cancer. Currently, status is determined by histopathology following surgical excision of sentinel lymph node(s), which is an invasive, time consuming, and costly procedure with potential morbidity to the patient. Here, we describe an imaging platform for noninvasive assessment of ALN status, eliminating the need for surgical examination of patients to rule out nodal involvement. A targeted imaging probe (MamAb-680) was developed by conjugation of a mammaglobin-A-specific monoclonal antibody to a near-infrared fluorescent dye. Using DNA and tissue microarray, mammaglobin-A was validated as a cell-surface target that is expressed in ALN-positive patient samples but is not expressed in normal lymph nodes. In vivo selectivity was determined by i.v. injection of MamAb-680 into mice with mammaglobin-A-positive and -negative mammary fat pad (MFP) tumors; and by peritumoral MFP injection of the targeted imaging probe in mice with spontaneous ALN metastases. Fluorescence imaging showed that probe was only retained in positive tumors and metastases. As few as 1,000 cells that endogenously express mammaglobin-A were detected in ALN, indicating high sensitivity of this method. Translation of this approach offers considerable potential as a noninvasive clinical strategy to stage breast cancer.

Health-related quality of life, depressive symptoms, anemia, and malnutrition at hemodialysis initiation

BACKGROUND AND METHODS

We administered the Kidney Disease Quality of Life (KDQOL) short form and a three-item depression screening measure derived from the Diagnostic Interview Schedule to 422 new patients with end-stage renal disease (ESRD; incident cohort) who began maintenance hemodialysis (HD) therapy at 151 outpatient dialysis facilities across the United States.

RESULTS

At HD therapy initiation, 56% of patients had hemoglobin levels less than 10 g/dL (100 g/L), and 52% had albumin levels of 3.5 g/dL (35 g/L) or less. The 36-Item Short Form Health Survey (SF-36) scores (part of the KDQOL) for this incident cohort were significantly lower than those of a prevalent HD cohort and a severe chronic disease cohort (P < 0.01 to 0.001), and physical health scores were among the lowest ever reported. SF-36 summary scores were 2 SDs below those of an age- and sex-adjusted US general population in physical health and half an SD below those in mental health. Patients who screened positive for depression (45% of sample) scored even lower on all eight SF-36 scale scores and 9 of 12 of the KDQOL kidney disease-targeted scales (P < 0.05 to 0.01), but did not differ from nondepressed patients on demographic, clinical, or laboratory study variables.

CONCLUSION

The extent to which the profound impairment documented in this study can be improved by more timely high-quality predialysis care requires further investigation. Nevertheless, the high prevalence of anemia, hypoalbuminemia, and depressive symptoms at dialysis therapy initiation suggests the need for more aggressive and broader spectrum pre-ESRD care.

Impact of age and colony-stimulating factor use on hospital length of stay for febrile neutropenia in CHOP-treated non-Hodgkin's lymphoma

BACKGROUND

In intermediate-grade non-Hodgkin's lymphoma (NHL) patients, full-dose CHOP improves survival but increases myelosuppression, causing febrile neutropenia hospitalization (FNH) in 28% of patients 65 years of age or greater. Several risk factors for FNH are known, but their relationship to length of stay (LOS), an indicator of the total burden of FNH, is unclear.

METHODS

We conducted a study to identify factors associated with the incidence, recurrence, and duration of hospitalizations for FN and to describe the frequency of administration of colony-stimulating factor (CSF) as primary and secondary prophylaxis and its association with repeated hospitalization episodes.

RESULTS

Compared with patients who did not experience hospitalizations for FN, those who did were significantly older, had more comorbid conditions, were planned for standard dose intensity, and received CSF less often during the first 5 days of cycle 1 (early CSF). Overall, 73% of these hospitalizations occurred within the first 2 cycles of chemotherapy, with 56% occurring within the first cycle. Patients age > or = 65 years accounted for 66% of cycle 1 FNH. Patients receiving early CSF were less likely to experience repeated hospitalizations (0% vs 12%; P<.05). Multiple regression analysis of those hospitalized found a 3.9-day longer LOS for patients age > or = 65 years and a 5.13-day longer LOS for those not receiving early CSF.

CONCLUSIONS

Older NHL patients have a higher risk of hospitalization for FN and longer LOS. The majority of hospitalization days occur in the first 2 cycles of chemotherapy. Early CSF use is associated with decreased risk of repeated hospitalizations and shorter total LOS. Secondary CSF use is also associated with reduced risk of repeated FNH.

Parathyroid-produced angiopoietin-2 modulates angiogenic response

BACKGROUND

Upon explant, parathyroid tissue (PTH) upregulates vascular endothelial growth factor (VEGF), a potent endothelial cell mitogen, yet PTH induces a more robust angiogenic response than VEGF alone. This implies that other angiogenic factors are also produced. We tested PTH for production and function of angiopoietin-2 (Ang-2), a protein known to modulate VEGF response.

METHODS

With use of reverse transcriptase-polymerase chain reaction and SELDI (Surface Enhanced Laser Desorption/Ionization) (Ciphergen, Freemont, Calif) technology, we tested explanted PTH for Ang-2 production and determined the time sequence of Ang-2 upregulation. With use of an in vitro rat microvessel angiogenesis assay, we determined the angiogenic response to PTH-produced Ang-2.

RESULTS

Ang-2 messenger RNA was induced within 1 hour of parathyroid explant, with a maximum level detectable at 24 hours. Ang-2 protein production was maximal at 24 hours, with elimination by 48 hours. Ang-2 supplemented gels appeared to prompt earlier angiogenic induction, whereas sequestration of Ang-2 with soluble Tie2 receptor appeared to delay angiogenic induction. Soluble Tie2 treatment did not significantly decrease cumulative microvessel length, and no significant increase in neovessel length was seen with Ang-2 supplemented gels.

CONCLUSIONS

PTH upregulates Ang-2 upon explantation, with peak protein production by 24 hours. Ang-2 appears to functionally enhance initiation of PTH-induced angiogenesis, although the ultimate neovessel length appears to be dependent on other PTH-produced factors.

Patterns of chemotherapy administration in patients with intermediate-grade non-Hodgkin's lymphoma

Records from 653 patients treated between 1991 and 1998 in the Oncology Practice Patterns Study (OPPS) were analyzed to determine contemporary chemotherapy delivery patterns in patients with intermediate-grade non-Hodgkin's lymphoma (NHL). Of the 653 patient records reviewed, 90 (14%) omitted an anthracycline or mitoxantrone (Novantrone) from primary therapy. Among patients receiving CHOP (cyclophosphamide [Cytoxan, Neosar], doxorubicin HCl, vincristine [Oncovin], prednisone) or CNOP (cyclophosphamide, mitoxantrone, vincristine, prednisone), 134 (27%) of 492 received an average relative dose intensity of less than 80% of the literature-referenced dose, due either to an inadequate planned or delivered dose. Of 181 advanced-stage patients with responsive disease, 28 (15%) failed to receive at least six treatment cycles. Overall, 283 (43%) of 653 patients potentially received suboptimal chemotherapy due either to choice of regimen or chemotherapy delivered. Patient age > or = 65 years and cardiac comorbidity appeared to have the greatest influence on a physician's decision regarding chemotherapy administration. Among the 492 patients who received CHOP or CNOP, 235 (48%) experienced a delay or reduction in chemotherapy dose (usually neutropenia-related), 100 (20%) developed mucositis, and 116 (24%) were hospitalized for febrile neutropenia. Growth factor was administered to 261 patients (53%), and its primary prophylactic use was associated with a significant reduction in the incidence of hospitalizations for febrile neutropenia in all patient subgroups receiving appropriate chemotherapeutic dose intensity (P = .02). This assessment of chemotherapy delivery to patients with intermediate-grade NHL showed significant variation from current standards. Further analysis of factors influencing chemotherapy delivery might improve therapeutic outcomes.

Delivering adjuvant chemotherapy to women with early-stage breast carcinoma: current patterns of care

BACKGROUND

Variations in practice patterns are markers for the quality of patient care in general medicine, but little is known about variation in care delivered to cancer patients. This study's purpose was to describe chemotherapy use, variations in chemotherapy delivery, and the incidence of complications in community practice settings.

METHODS

Data describing adjuvant chemotherapy for patients with early-stage breast carcinoma (ESBC) were collected from an ongoing Oncology Practice Pattern Study at 13 large managed care, academic, and community practices (1111 patients). Data collection included information about diagnoses and adjuvant chemotherapy treatments, laboratory results, supportive care, complications, and treatment modifications.

RESULTS

The median patient age was 50 years, and most patients had zero to three positive lymph nodes. Chemotherapy regimens consisting of cyclophosphamide, methotrexate, and 5-fluororacil (CMF) and of doxorubicin and cyclophosphamide (AC) accounted for 76% of the adjuvant therapies used. Overall, 30% of patients had delivered average relative dose intensities </= 85% of the referenced targets. Delivered summation dose intensities (SDIs) frequently were well below targeted SDIs. Neutropenia-related dose modifications occurred for 27.6% of patients and recurred with a 60.7% rate. AC was the regimen delivered with a dose intensity closest to the referenced target. However, patients who were treated with AC regimens and with regimens consisting of cyclophosphamide, doxorubicin, and 5-fluorouracil had significantly higher rates of chemotherapy-related complications compared with patients who were treated with CMF regimens in the most recent treatment years.

CONCLUSIONS

Adjuvant chemotherapy for patients with ESBC frequently is not administered as referenced in off-protocol community settings. Variation in the delivered SDI raises concerns about potential treatment outcomes and warrants strategies to identify patients who are at risk for complications early in therapy.

HER2 signaling--induced microvessel dismantling

BACKGROUND

The human epidermal growth factor receptor 2 protein (HER2) signaling in breast cancer imparts a metastatic advantage to the cell, likely by regulating gene expression. The HER2 signaling up-regulates angiopoietin-2 (Ang-2), which disrupts endothelial cell (EC) adherens junctions. We postulated that HER2 signaling may facilitate angioinvasion by disrupting microvessel integrity.

METHODS

Rat microvessels, embedded in collagen, were grown into capillary networks and cocultured with MCF-7 or HER2 overexpressing MCF-7 (HER) to test for microvessel breakdown. We quantitated this effect by determining the cumulative length of intact microvessels. Other experiments used Herceptin- or heregulin beta 1-pretreated MCF-7 cells to modulate HER2 signaling, or soluble Tie-2/Fc receptor fusion protein (sTie2) to sequester tumor-cell released Ang-2.

RESULTS

The MCF-7 cells induced a time-dependent loss of microvessel integrity. At 12 hours, HER cells induced a 90% reduction in cumulative length (P <.05). Pretreatment with Herceptin reduced whereas heregulin beta 1 augmented microvessel dismantling (P <.01). Sequestration of Ang-2 significantly, though not dramatically, reduced the MCF-7 cell induction of microvessel dismantling (P <.01).

CONCLUSIONS

We show that HER2 signaling in breast cancer cells leads to induction of microvessel dismantling, which may open a portal for angioinvasion. It appears that Ang-2 affects this mechanism, although other factors also function in microvessel dismantling.

The impact of age on delivered dose intensity and hospitalizations for febrile neutropenia in patients with intermediate-grade non-Hodgkin's lymphoma receiving initial CHOP chemotherapy: a risk factor analysis

The purpose of this historical case series study was to evaluate the association of age on delivered dose intensity of initial CHOP (cyclophosphamide/doxorubicin/ vincristine/prednisone) chemotherapy and the occurrence of hospitalizations for febrile neutropenia for patients with intermediate-grade non-Hodgkin's lymphoma (NHL). Findings are reported for 12 managed community and academic practices. Medical records of 930 NHL patients not enrolled on clinical trial protocols were reviewed. We reported on 577 of the study patients (62%) who received initial CHOP chemotherapy. Median age of the patients was 65.1 years. Older patients (age > or = 65 years) had more hospitalizations for febrile neutropenia (28% vs. 16%; P < 0.05) than younger patients (age, 18-64 years). In patients with advanced-stage NHL (stage III/IV), older patients received fewer cycles of CHOP (< 6 cycles, 35% vs. 22%; P < 0.05) than younger patients. Older patients were planned for lower average relative dose intensity (ARDI < or = 80%; P < 0.05) and had more heart disease and comorbid conditions (P < 0.05) than younger patients. Multiple logistic regression models showed that older patients were more likely to receive a lower dose intensity (ARDI < or = 80%; odds ratio = 2.46, 95% confidence interval [CI]: 1.62-3.72) during their first 3 cycles of therapy and to experience more hospitalizations for febrile neutropenia (odds ratio = 2.17, 95% CI: 1.43-3.30). We found the dose intensity of delivered CHOP chemotherapy for elderly patients to be less than standard CHOP therapy and the risk of hospitalizations for febrile neutropenia to be greater than in younger patients. Prospective clinical trials examining supportive care measures, such as colony-stimulating factor, for elderly NHL patients are recommended.

HER2/neu over-expression induces endothelial cell retraction

Over-expression of the HER2/neu (HER2) proto-oncogene in breast carcinoma imparts an enhanced metastatic potential. Metastasis requires escape of the tumor cell from the vasculature into subjacent tissue, a transmigration event across an endothelial cell (EC) monolayer. EC retraction has been reported to precede transmigration in several tumor metastatic models. Using intact human iliac vein EC monolayers, we tested the abilities of MCF-7 breast cancer cells and HER cells, a transfected MCF-7 line over-expressing HER2, to induce EC retraction. We further analyzed whether HER2 signaling influenced cancer cell-induced EC retraction. MCF-7 or HER cells were co-cultured onto mature EC monolayers. More HER than MCF-7 cells induced EC retraction (76 +/- 19% vs. 17 +/- 12%, p < 0.001) with resultant exposure of subendothelial matrix (6.80 +/- 2.86% vs. 0.85 +/- 0.39%, p < 0.001). Blockade of HER2 signaling using Herceptin nearly eliminated EC retraction (p < 0.01), while stimulation of HER2 using heregulin-beta1-augmented EC retraction (p < 0.05). Further, there was no difference between cell lines in either the number of cells adhered or the strength of adherence to EC under shear stress. These data suggest that HER2 signaling enhances metastasis in breast cancer cells by inducing EC retraction, a process that appears to precede endothelial transmigration.

HER2/neu over-expression induces endothelial cell retraction

Over-expression of the HER2/neu (HER2) proto-oncogene in breast carcinoma imparts an enhanced metastatic potential. Metastasis requires escape of the tumor cell from the vasculature into subjacent tissue, a transmigration event across an endothelial cell (EC) monolayer. EC retraction has been reported to precede transmigration in several tumor metastatic models. Using intact human iliac vein EC monolayers, we tested the abilities of MCF-7 breast cancer cells and HER cells, a transfected MCF-7 line over-expressing HER2, to induce EC retraction. We further analyzed whether HER2 signaling influenced cancer cell-induced EC retraction. MCF-7 or HER cells were co-cultured onto mature EC monolayers. More HER than MCF-7 cells induced EC retraction (76 +/- 19% vs. 17 +/- 12%, p < 0.001) with resultant exposure of subendothelial matrix (6.80 +/- 2.86% vs. 0.85 +/- 0.39%, p < 0.001). Blockade of HER2 signaling using Herceptin nearly eliminated EC retraction (p < 0.01), while stimulation of HER2 using heregulin-beta1-augmented EC retraction (p < 0.05). Further, there was no difference between cell lines in either the number of cells adhered or the strength of adherence to EC under shear stress. These data suggest that HER2 signaling enhances metastasis in breast cancer cells by inducing EC retraction, a process that appears to precede endothelial transmigration.

HER2/neu over-expression induces endothelial cell retraction

Over-expression of the HER2/neu (HER2) proto-oncogene in breast carcinoma imparts an enhanced metastatic potential. Metastasis requires escape of the tumor cell from the vasculature into subjacent tissue, a transmigration event across an endothelial cell (EC) monolayer. EC retraction has been reported to precede transmigration in several tumor metastatic models. Using intact human iliac vein EC monolayers, we tested the abilities of MCF-7 breast cancer cells and HER cells, a transfected MCF-7 line over-expressing HER2, to induce EC retraction. We further analyzed whether HER2 signaling influenced cancer cell-induced EC retraction. MCF-7 or HER cells were co-cultured onto mature EC monolayers. More HER than MCF-7 cells induced EC retraction (76 +/- 19% vs. 17 +/- 12%, p < 0.001) with resultant exposure of subendothelial matrix (6.80 +/- 2.86% vs. 0.85 +/- 0.39%, p < 0.001). Blockade of HER2 signaling using Herceptin nearly eliminated EC retraction (p < 0.01), while stimulation of HER2 using heregulin-beta1-augmented EC retraction (p < 0.05). Further, there was no difference between cell lines in either the number of cells adhered or the strength of adherence to EC under shear stress. These data suggest that HER2 signaling enhances metastasis in breast cancer cells by inducing EC retraction, a process that appears to precede endothelial transmigration.

Multiple ectopic parathyroid glands

Parathyroid surgery to correct primary hyperparathyroidism is successful in 80 to 97 per cent of initial explorations. Failures are often linked to inability to locate ectopic parathyroid glands. Although ectopic parathyroid glands are relatively common (15%) multiple ectopic glands are rarely reported. We describe a case of multiple ectopic parathyroid glands and the intraoperative approach to their localization and review the anatomy and embryology of ectopic parathyroid glands. A 39-year-old woman presented with fatigue, lethargy, and depression. On biochemical evaluation she was noted to be hypercalcemic and hyperparathyroid. Preoperative parathyroid localization failed to identify abnormal parathyroid glands. At exploration three of four parathyroid glands, including an adenoma, were located in ectopic positions by a meticulous and systematic dissection. A careful exploration coupled with a thorough knowledge of parathyroid anatomy and embryology will produce successful surgical correction of primary hyperparathyroidism in greater than 95 per cent of patients even in the few patients with multiple ectopic parathyroid glands.

Parathyroid-induced angiogenesis is VEGF-dependent

BACKGROUND

Autotransplantation of parathyroid tissue after parathyroidectomy is successful at salvaging parathyroid function. The relatively high success of parathyroid transplantation is thought to be due, in part, to the ability of parathyroid tissue to induce angiogenesis and thus recruit a new vasculature. Vascular endothelial growth factor (VEGF) is a potent angiogenic factor produced by a number of tumors and hypoxic tissues. Using a 3-dimensional intact microvessel angiogenesis system, we evaluated the role of VEGF in the stimulation of angiogenesis by human parathyroid cells.

METHODS

Freshly isolated rat microvessels embedded in a 3-dimensional collagen I matrix were treated with healthy 1-mm(3) fragments of human parathyroid tissue or isolated parathyroid cells. Other gels were supplemented with VEGF(165) or FLT-1 soluble receptor fusion protein to bind VEGF. After 11 days in culture, the gels were stained with Gs-1 lectin, a marker for rat endothelium, and linear growth of the microvessels was determined by using image analysis. Parathyroid production of VEGF was determined with reverse transcriptase-polymerase chain reaction.

RESULTS

A significant increase in microvessel growth was seen in parathyroid coculture (8.4 +/- 1.0 mm) versus VEGF(165) supplemented gels (6.2 +/- 0.3 mm, P <.01). VEGF(165) significantly augmented parathyroid-stimulated angiogenesis (13.7 +/- 2.4 mm, P <.05 vs parathyroid alone). Using quantitative reverse transcriptase-polymerase chain reaction, we identified VEGF messenger RNA (mRNA) induction within 1 hour of parathyroid explant, with a 12-fold increase by 24 hours. Treatment of parathyroid cocultures with 0.2 microg/mL FLT-1 soluble receptor protein completely eliminated the parathyroid induction of angiogenesis.

CONCLUSIONS

Parathyroid tissue expresses low levels of VEGF mRNA, which is significantly upregulated on explantation. Furthermore, the increased VEGF expression is essential to drive parathyroid-induced angiogenesis in our model. However, our data suggests that other parathyroid-produced factors are involved in mediating parathyroid-induced angiogenesis.

Development of subscales from the symptoms/problems and effects of kidney disease scales of the kidney disease quality of life instrument

BACKGROUND

The Kidney Disease Quality of Life Instrument (KDQOL) was developed to provide clinicians with a comprehensive assessment of the important domains of health-related quality of life (HRQOL) for patients with end-stage renal disease who are undergoing hemodialysis.

OBJECTIVE

The purpose of this study was to develop subscales from the 55 items comprising the Symptoms/Problems and Effects of Kidney Disease scales of the KDQOL and to measure the internal consistency reliability of these subscales.

METHODS

The 55 items from the Symptoms/Problems and Effects of Kidney Disease scales were arranged into substantively meaningful clusters using an affinity mapping procedure. The resulting subscales were assessed for internal consistency reliability using data from a sample of 165 individuals with kidney disease who had completed the KDQOL.

RESULTS

Eleven multi-item subscales were identified: pain, psychological dependency, cognitive functioning, social functioning, dialysis-related symptoms, cardiopulmonary symptoms, sleep, energy, cramps, diet, and appetite. Four items (clotting or other problems with access site, high blood pressure, numbness in hands or feet, and blurred vision) were not included in any of these subscales. Internal consistency reliability estimates for the 11 subscales ranged from 0.66 to 0.92. These subscales correlated with the scales from the 36-Item Short-Form Health Survey as hypothesized (ie, corresponding pain, energy, and social functioning scales had the highest correlations). In addition, several subscales were significantly associated, as hypothesized, with other variables such as the number of disability days.

CONCLUSIONS

The results of this study further support the reliability and validity of the KDQOL. The 11 subscales identified yield more detailed information on the HRQOL of patients with kidney disease and provide a basis for specific improvements in the quality of care delivered to these patients.

HER2 regulatory control of angiopoietin-2 in breast cancer

BACKGROUND

HER2 overexpression is a marker of aggressive breast cancer. Tumors that overexpress HER2 induce endothelial cell retraction and endothelial destabilization. Because angiopoietin-2 (Ang-2) also destabilizes microvessels, we postulated that HER2 signaling upregulates Ang-2 as a mechanism of angioinvasion.

METHODS

We tested human breast cancers and breast cancer cell lines for coexpression of HER2 and Ang-2 with Northern blot, reverse transcriptase-polymerase chain reaction, and enzyme-linked immunosorbent assay. Further, we manipulated HER2 signaling with 100 ng/mL MAbHu HER2 (Herceptin; Genentech, San Francisco, Calif) and Heregulin beta1 (100 ng/mL; R&D Systems, Inc, Minneapolis, Minn) to test for HER2 regulation of Ang-2 production.

RESULTS

Three of 4 breast cancer cell lines expressed HER2 protein and Ang-2 mRNA. HER cells, a stably transfected cell line that overexpresses HER2 6-fold, showed a 430% increase in Ang-2 mRNA compared to parental MCF-7 cells. Heregulin beta1 stimulation of HER2 signaling in MCF-7 cells increased Ang-2 by 20% (P <.05). HER2 signaling blockade with 100 ng/mL Herceptin reduced Ang-2 mRNA 90% (P <.001). Five of 11 cancers expressed both HER2 and Ang-2; 2 cancers expressed only Ang-2.

CONCLUSIONS

We conclude that human breast cancers express Ang-2. HER2 signaling appears to regulate Ang-2 expression, although other signaling pathways may also regulate Ang-2. Ang-2 may be a therapeutic target in these cancers and may define which patients would benefit from Herceptin therapy.

Preoperative detection of sporadic parathyroid adenomas using technetium-99m-sestamibi: what role in clinical practice?

Preoperative localization of pathologic parathyroid glands remains controversial. Because experienced parathyroid surgeons can identify and cure parathyroid pathology in sporadic primary hyperparathyroidism in better than 95 per cent of first-time explorations, few consider preoperative localization studies cost effective in this population. However, the primary reason for failure at the initial exploration is the inability of the surgeon to identify an adenoma in a normal anatomical location. Recent reports have indicated that operative time can be reduced and initial success improved with preoperative localization of adenomas using the highly sensitive technetium-99m (Tc)-sestamibi scan. We evaluated 16 consecutive patients with sporadic primary hyperparathyroidism using a double-phase Tc-sestamibi scan with delayed images, hypothesizing that 90 per cent of adenomas would be accurately detected, and furthermore that a negative scan would predict multigland disease. Of the 16 scans, 13 showed a focal delayed washout of the tracer, constituting a positive scan. Eleven of 13 were true positive (85%), with two false positive scans (15%), both of which also had nodular thyroid disease. The three negative scans were indeed hyperplastic multigland disease, determined at exploration. The mean operative time for a bilateral exploration for the true positive cases was 109 minutes, compared to 148 minutes for a small cohort group without imaging (not significant). In conclusion, 85 per cent of adenomas can be successfully localized with the Tc-sestamibi delayed-image technique, and may decrease operative time. Additionally, a negative scan is a likely predictor of multigland disease, which allows for improved preoperative patient education and preparation for cryopreservation. These data suggest that preoperative Tc-sestamibi scanning may improve the success rate for the occasional parathyroid surgeon, and that an extended prospective trial is warranted.

Stimulation of angiogenesis by canine parathyroid tissue

BACKGROUND

Autotransplanted parathyroid tissue is capable of inducing neovascularization in vivo, restoring calcium homeostasis with regulatory control. The mechanisms of parathyroid-induced neovascularization remain to be determined. Using an unique three-dimensional in vitro model, we tested the ability of parathyroid tissue to stimulate angiogenesis.

METHODS

Healthy 1 mm3 fragments of normal canine parathyroid tissue were cocultured with freshly isolated microvessels that were embedded in a collagen I gel. After 7 days the gels were stained with Gs-1 lectin, a specific marker for rat endothelium. With image analysis the microvessel density (as the percentage of area) was determined.

RESULTS

A significant increase in mean microvessel density (20.90% +/- 1.28 versus 16.51% +/- 1.66%) was seen with parathyroid coculture compared with control (n = 17, p < 0.05). There was no difference in microvessel density between controls and microvessels exposed to increasing concentrations of parathyroid hormone or calcium. The density of seeded microvessels influenced the effect of parathyroid stimulation of angiogenesis. The effect was apparent only at low seeding densities.

CONCLUSIONS

We conclude that parathyroid tissue intrinsically stimulates angiogenesis in vitro by a secreted product, independent of calcium or parathyroid hormone.

Using the theory of reasoned action (TRA) to understand the decision to use condoms in an STD clinic population

The theory of reasoned action (TRA) provides useful information when designing health education interventions. In this study, 703 heterosexual STD clinic clients responded to a TRA-based survey. With steady partners, social norms and attitudes toward condom use were significant predictors of intention for both men and women. The interaction of attitude and norm increased prediction for men (R = .64, p < 0.001) and women (R = .70, p < 0.001). With casual partners, attitude was a predictor for men and social norm was a predictor for women. Prior use of condoms increased prediction for men (R = .38, p < 0.001) and women (R = .47, p < 0.001). Findings suggest that, in addition to traditional TRA model variables, the relationship between sexual partners and the individual's prior experience with condom use should be incorporated into attempts to understand this complex, dyadic behavior. Examining specific outcome and normative beliefs also provides important information for intervention design.

A review of health-related quality-of-life measures used in end-stage renal disease

Health-related quality of life (HRQOL) is a critical issue in the treatment of end-stage renal disease (ESRD) patients. The variety of symptoms, comorbidities, and treatments of ESRD over the course of its chronic disease trajectory necessitate comprehensive assessment of the impact of interventions on HRQOL. A literature review of ESRD HRQOL studies was performed to provide an overview of the instruments used and to provide recommendations for HRQOL assessment in future studies. Instruments were classified based on the health domains they assess and whether they are generic or disease targeted. The instruments were judged in terms of their comprehensiveness, reliability, and validity.

Characteristics of health promotion programs in Federal worksites: findings from the Federal Employee Worksite Project

PURPOSE

To describe how well-established health promotion programs at selected federal worksites were designed, organized, and implemented and to identify factors related to employee participation.

DESIGN

This descriptive study related characteristics of the health promotion program, worksites, and workforce to employee participation and perceptions of program impacts.

SETTING

The study was conducted at 10 established federal worksite health promotion programs in various regions of the country.

SUBJECTS

A total of 3403 of 5757 federal employees (59%) sampled completed employee surveys.

MEASURES

Study data were collected from on-site observations, interviews, focus groups, and employee surveys.

RESULTS

Overall, program participation rates were high, and employees reported positive impacts on their health and attitudes toward the agency. Participation in health screening, perceived program convenience, and perceived support by management and others were important determinants of participation and of perceived work-related outcomes.

CONCLUSIONS

Although site selection and response rate limit generalizability, the sites evaluated represent a broad cross-section of different types and sizes of agencies. The findings should be relevant in many other settings. Study programs compare favorably with private sector programs. Employees viewed the programs very positively. The most cogent challenge in justifying these, and perhaps other, worksite programs is that most participants already or simultaneously engage in health promotion activities elsewhere "on their own."

Comparing the performance of health status measures for healthy older adults

OBJECTIVES

The specific goals of the study were to compare three health status measures among older adults for their correlations with similar scales and to examine whether extreme (positive) health states might lead to measurement problems. We also report on practical administration and response problems among older adults.

DESIGN

Eligible and randomly selected health plan enrollees aged 65 and older were sent a baseline survey about their health. A random sample of persons who returned this survey was recruited to participate in the comparative study. Additional questionnaires were completed by mail and telephone interviews. Measures were repeated at a 1-year follow-up mailing.

SETTING

This study was conducted at Group Health Co-operative (GHC) of Puget Sound, a large prepaid health maintenance organization.

PARTICIPANTS

Subjects were 200 of the 283 older adults selected (68.2% response). Mean age was 72.5 years.

MEASUREMENTS

The primary measures were the Sickness Impact Profile (SIP), the Quality of Well-being Scale (QWB), and three scales of the Medical Outcomes Study Short-Form 36 (SF-36). Also included were a stress scale, the Positive Affect Scale, and the Chronic Disease Score (CDS) computed from the automated pharmacy data.

RESULTS

SIP scores showed a very strong skew toward low (good health) scores with a mean of 3.4% (+/- SD 4.4). The QWB scores ranged from .50 to .90 (mean .73 +/- .09). For the MOS SF-36 scales, scores of 100 (good health) were common for both of the physical health scales but not for general health. Analyses showed the SIP, QWB, and MOS SF-36 scales were moderately to strongly correlated with similar measurement scales and with the independent measure of chronic disease and psychosocial health. Scales repeated at 1 year were highly correlated: intraclass correlation coefficients between baseline and 1 year ranged from an r = .51 to .73.

CONCLUSIONS

Our results suggest that the SIP is not a useful tool for rating healthy, community-dwelling older adults. Two MOS SF-36 measures used in this study showed some tendency for "ceiling" measurement effects. The QWB demonstrated an acceptable distribution of scale scores; however, it is the most complex of the three measures to administer. Among the broad range of older adults, no one tool appears to apply to every situation.

Barriers to screening: the theory of reasoned action applied to mammography use in a military beneficiary population

BACKGROUND

Mammography practices of women eligible for military health care are not known.

METHODS

A questionnaire was mailed to a stratified sample of 500 military beneficiary women. The hypothesis was that this group would not differ from the general population in regular mammography use (31%) and that the theory of reasoned action (TRA) is significantly associated with intent to obtain a mammogram.

RESULTS

Only 12.8% of these women had regular mammography according to current recommendations. High participation is associated with breast cancer risk factors, income, education, perceived risk of breast cancer, and a doctor's recommendation. The expanded model of the TRA regression is significantly associated with intent.

CONCLUSIONS

Regular use of mammography among military beneficiaries is lower than rates in the non-military population. Providers need to stress regular use and address scheduling problems and patient beliefs about mammography. The TRA is a useful model for screening behavior.

Development of the kidney disease quality of life (KDQOL) instrument

This paper describes the Kidney Disease Quality of Life (KDQOL) Instrument (dialysis version), a self-report measure that includes a 36-item health survey as the generic core, supplemented with multi-item scales targeted at particular concerns of individuals with kidney disease and on dialysis (symptom/problems, effects of kidney disease on daily life, burden of kidney disease, cognitive function, work status, sexual function, quality of social interaction, sleep). Also included were multi-item measures of social support, dialysis staff encouragement and patient satisfaction, and a single-item overall rating of health. The KDQOL was administered to 165 individuals with kidney disease (52% female; 48% male; 47% White; 27% African-American; 11% Hispanic; 8% Asian; 4% Native American; and 3% other ethnicities), sampled from nine different outpatient dialysis centres located in Southern California, the Northwest, and the Midwest. The average age of the sample was 53 years (range from 22 to 87), and 10% were 75 years or older. Internal consistency reliability estimates for the 19 multi-item scales exceeded 0.75 for every measure except one. The mean scores for individuals in this sample on the 36-item health scales were lower than the general population by one-quarter (emotional well-being) to a full standard deviation (physical function, role limitations due to physical health, general health), but similar to scores for dialysis patients in other studies. Correlations of the KDQOL scales with number of hospital days in the last 6 months were statistically significant (p < 0.05) for 14 of the 19 scales and number of medications currently being taken for nine of the scales. Results of this study provide support for the reliability and validity of the KDQOL.

Role of selective arteriography in the diagnosis of a ruptured middle colic artery aneurysm

A case of a ruptured middle colic artery is reported. The diagnosis was initially overlooked and eventually made by selective arteriography. Aneurysms of visceral arteries are rare and rupture of them even more infrequent. Awareness of this potentially fatal and treatable entity should enable early detection by selective visceral arteriography. The roles of embolization and surgery in the management of visceral aneurysms are discussed.

Screening for depression in well older adults: evaluation of a short form of the CES-D (Center for Epidemiologic Studies Depression Scale)

We derived and tested a short form of the Center for Epidemiologic Studies Depression Scale (CES-D) for reliability and validity among a sample of well older adults in a large Health Maintenance Organization. The 10-item screening questionnaire, the CESD-10, showed good predictive accuracy when compared to the full-length 20-item version of the CES-D (kappa = .97, P < .001). Cutoff scores for depressive symptoms were > or = 16 for the full-length questionnaire and > or = 10 for the 10-item version. We discuss other potential cutoff values. The CESD-10 showed an expected positive correlation with poorer health status scores (r = .37) and a strong negative correlation with positive affect (r = -.63). Retest correlations for the CESD-10 were comparable to those in other studies (r = .71). We administered the CESD-10 again after 12 months, and scores were stable with strong correlation of r = .59.

Cause and current management of reoperative hyperparathyroidism

We reviewed 137 cases of hyperparathyroidism followed for 6-72 months to determine the reasons for failure and to outline the successful management of reoperative hyperparathyroidism. Of 127 patients treated initially at Thomas Jefferson University Hospital, three required reoperation (2.4%) and 10 were referred with recurrent or persistent hyperparathyroidism. Reasons for failure were a missed gland in eight cases (62%), an ectopic gland in two cases (15%), supernumerary glands in two cases (15%), and malignant degeneration of an autotransplant in one case (8%). One patient had shortterm hypoparathyroidism requiring vitamin D supplementation (5.6%), but there were no injuries to the recurrent laryngeal nerves. We conclude that adequate knowledge of the location of normal and ectopic glands with meticulous search will reduce most reoperations, and, with identification of all four glands and routine cervical thymectomy in multigland disease, the rate should be less than 5 per cent. Patients requiring reoperation should undergo noninvasive localization studies and, if equivocal, selective venous sampling for parathyroid hormone. The major complication rate should be less than 10 per cent.

Community-based surveillance of acute ischemic heart disease: are one-time mailed questionnaires to physicians useful?

A 12-month data collection from medical records in Seattle/King County for acute ischemic heart disease among patients with diabetes mellitus was augmented with mailed questionnaires to personal physicians. The responsible Human Subjects Committee restricted the study to a one-time questionnaire mailing. Only 380 of 1,235 patients required physician contact when information was missing from primary data sources. Questionnaires were highly personalized, and most were limited to one page. Seventy-seven per cent of 330 physicians returned at least one questionnaire, and 62% of all questionnaires were returned with usable data. We conclude that useful data may be collected from physicians by way of mailed questionnaires if researchers use a brief and personal format.

Psychology and decision making: modelling health behavior with multiattribute utility theory

The success of much of dental practice is linked to patient behavior. Understanding the issues that influence patients' decisions when they choose to not follow preventive or therapeutic dental recommendations is instrumental to improving adherence, and ultimately, to improving dental health outcomes. Multiattribute Utility Theory (MAU) provides a methodology for systematically exploring these issues. It is based on a well-established body of knowledge in the psychological literature, and currently represents a state-of-the-art model for predicting behavior and delineating potentially modifiable behavioral determinants. Two examples are presented to illustrate how MAU can be used in clinical settings. In the first example, MAU is used to identify key reasons why nearly 70 percent high-risk patients did not obtain flu shots, a behavioral problem comparable to many confronted in dentistry. MAU correctly predicted the vaccination behavior of 82 percent of patients, and an intervention based on MAU findings nearly doubled vaccination rates. The second example used MAU to identify physician behaviors that influenced patients' satisfaction with an ambulatory care visit. MAU findings from this study identified specific behaviors in a provider's style that if modified may improve patient satisfaction. These MAU applications also emphasize the importance of soliciting the patient's perspective in clinical interactions since some of the most important determinants of patient behavior are not represented in traditional clinical decision models.