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Background: Few studies have described preventive strategies for central line–associated bloodstream infections (CLABSIs) in pediatric hematopoietic stem cell transplantation (HSCT) recipients. Methods: We performed a pilot intervention study in our pediatric HSCT population in 2006-2008 and compared CLABSI rates before and after implementation of preventive strategies (ie, training staff and caregivers in procedures for dressing changes and drawing blood) in the inpatient, outpatient, and non–health care (ie, home) settings. We also studied the pathogens associated with hospital-onset versus community-onset CLABSIs. Results: During the study period, 90 children (median age, 10 years) underwent HSCT. Fifty-nine children (66%) developed a CLABSI; 18 in the hospital, 27 in the community, and 14 in both settings. After implementation of central line (CL) maintenance care strategies, the overall CLABSI rate declined from 10.03 to 3.00 CLABSIs per 1,000 CL-days (rate ratio, 0.3; 95% confidence interval, 0.2-0.5, P < .0001) and rates declined for both hospital- and community-onset CLABSIs. Gram negative pathogens caused more community-onset (45/65, 69%) than hospital-onset (22/46, 48%) CLABSIs (odds ratio, 2.5; 95% confidence interval, 1.1-5.4; P = .02). Conclusions: Standardization of care practices for CL maintenance was associated with a reduction of CLABSIs in our pediatric HSCT population. A multicenter study is needed to confirm these observations. [ABSTRACT FROM AUTHOR]

BACKGROUND: Very few published studies have dealt with the management of locally advanced cervix carcinoma among human immunodeficiency virus (HIV)-positive patients. The objective of this study was to compare the clinical characteristics, radiation and chemotherapy treatments, and outcomes in a cohort of HIV-positive and HIV-negative women with cervical cancer. METHODS: The authors reviewed the charts of 59 HIV-positive patients and 324 HIV-negative patients who had stage IB1 to IIIB cervical carcinoma and who received radiation therapy. Demographic and clinical characteristics were compared at the time of diagnosis; and radiation doses, chemotherapy cycles, and responses were compared at the time of brachytherapy and at 6-week follow-up. Logistic regression models of response to treatment were developed. RESULTS: Forty-nine HIV-positive patients (88.1%) but only 213 HIV-negative patients (65.7%) presented with stage IIIB disease ( P = .009). Forty-seven HIV-positive patients (79.7%) and 291 HIV-negative patients (89.8%) completed the equivalent dose of 68 Grays (Gy) external- beam radiation and high-dose-rate brachytherapy. ( P = .03). Of the 333 patients who commenced concurrent chemotherapy, 26 HIV-positive patients (53.1%) and 212 HIV-negative patients (74.6%) completed ≥4 weekly cycles of platinum-based treatment. Follow-up was censured at 6 weeks. In models that included age, disease stage, HIV status, and treatment, a poor response at 6 weeks was associated only with stage IIIB disease (odds ratio, 2.39; 95% confidence interval, 1.45-3.96) and receiving an equivalent radiation dose in 2-Gy fractions of <68 Gy (OR, 3.14; 95% CI, 1.24-7.94). CONCLUSIONS: HIV-positive patients fared worse than HIV-negative patients because of later presentation and a decreased likelihood of completing treatment. The current findings emphasize the importance of completing irradiation therapy. Further studies will address the association of these variables with survival. Cancer 2011. © 2011 American Cancer Society. [ABSTRACT FROM AUTHOR]

In oncology, quality of care is a major issue for patients and providers. Significant variations in care, including nonreceipt of adjuvant systemic therapy, nonadherence to therapy, and/or early discontinuation of therapy, occur frequently and may impact survival. Reasons for these variations are not well understood, but may play a role in the prominent disparity in breast cancer survival between blacks and whites. Since May 2006, the Breast Cancer Quality of Care Study (BQUAL) has recruited 1158 women with nonmetastatic breast cancer from several centers across the country, with completed data on 1057 participants to date. Detailed information on demographic, behavioral, biomedical, and emotional factors related to chemotherapy use was collected on each participant at baseline and at two follow-up interviews during the first 6 months. In addition, for women with ER+ tumors, further questionnaires were completed every 6 months regarding hormonal therapy use. Each participant was also asked to provide a DNA sample, and to allow medical record review. We surveyed physicians providing care to the study participants regarding attitudes toward adjuvant treatment. The mean age of participants was 58 years (SD 11.6), and 15% ( n = 160) were black. The majority had an annual household income <$90,000 ( n = 683), had college education or higher ( n = 802), 55.9% were married, and 57.9% were not currently employed. Seventy-six percent had hormone-receptor-positive tumors, 49.9% initiated chemotherapy and 82.7% started hormonal therapy. Blacks were more likely to have lower annual household income (p < 0001), less education (p = 0.0005), ER negative tumor status (p = 0.02), and poorly differentiated cancer (p = 0.0002). The main endpoints of the study are noninitiation of chemotherapy or hormonal therapy, nonadherence to therapy and early discontinuation of therapy. Treatment and outcomes will be compared on the 15% of participants who are black versus other participants. The BQUAL Study will be a rich ongoing source of information regarding reasons for differences in receipt of both adjuvant chemotherapy and hormonal therapy. This information may be useful in planning interventions to improve quality of care. [ABSTRACT FROM AUTHOR]

Differential exposure to combustion by-products and allergens may partially explain the marked disparity in asthma prevalence (3-18%) among New York City neighborhoods. Subclinical changes in airway inflammation can be measured by fractional exhaled nitric oxide (FeNO). FeNO could be used to test independent effects of these environmental exposures on airway inflammation. Seven- and eight-year-old children from neighborhoods with lower (range 3-9%, n=119) and higher (range 11-18%, n=121) asthma prevalence participated in an asthma case-control study. During home visits, FeNO was measured, and samples of bed dust (allergens) and air (black carbon; BC) were collected. Neighborhood built-environment characteristics were assessed for the 500 m surrounding participants' homes. Airborne BC concentrations in homes correlated with neighborhood asthma prevalence (P<0.001) and neighborhood densities of truck routes (P<0.001) and buildings burning residual oil (P<0.001). FeNO concentrations were higher among asthmatics with than in those without frequent wheeze (≥4 times/year) (P=0.002). FeNO concentrations correlated with domestic BC among children without seroatopy (P=0.012) and with dust mite allergen among children with seroatopy (P=0.020). The association between airborne BC in homes and both neighborhood asthma prevalence and FeNO suggest that further public health interventions on truck emissions standards and residual oil use are warranted. [ABSTRACT FROM AUTHOR]

Summary CD34-selected haploidentical and unrelated donor allogeneic stem cell transplantation (Allo SCT) in paediatric recipients is associated with sustained engraftment and low risk of acute graft- versus-host disease (a GVHD), but limited by delayed immune reconstitution and increased risk of viral and fungal infection. The optimal dose of donor T cells to prevent graft failure and minimize risk of early opportunistic infection and post-transplant lymphoproliferative disorder ( PTLD), while avoiding severe a GVHD, remains unknown. We prospectively studied CD34-selected 8-10/10 human leucocyte antigen ( HLA)-matched unrelated donor ( MUD) peripheral blood stem cell transplantation ( PBSCT) in a cohort of 19 paediatric Allo SCT recipients with malignant ( n = 13) or non-malignant ( n = 6) diseases. T cells were added back to achieve total dose 1·0-2·5 × 105 CD3+/kg. GVHD pharmacoprophylaxis consisted only of tacrolimus. All patients engrafted neutrophils. Probabilities of grade II- IV a GVHD, limited chronic GVHD (c GVHD), and extensive c GVHD were 15·8%, 23·3%, and 0%, respectively. One patient developed PTLD. One-year infection-related mortality was 5·6%. T cell immune reconstitution was delayed. One-year overall survival was 82·3%. Five patients with malignant disease ultimately died from progressive disease. CD34-selected MUD PBSCT using a defined dose of T cell add-back resulted in high rates of engraftment and low risk of grade II- IV a GVHD, early transplantation-related mortality, and extensive c GVHD. [ABSTRACT FROM AUTHOR]

Summary Immune reconstitution appears to be delayed following myeloablative conditioning (MAC) and umbilical cord blood transplantation (UCBT) in paediatric recipients. Although reduced toxicity conditioning (RTC) versus MAC prior to allogeneic stem cell transplantation is associated with decreased transplant-related mortality, the effects of RTC versus MAC prior to UCBT on immune reconstitution and risk of graft-versus-host disease (GVHD) are unknown. In 88 consecutive paediatric recipients of UCBT, we assessed immune cell recovery and immunoglobulin reconstitution at days +100, 180 and 365 and analysed risk factors associated with acute and chronic GVHD. Immune cell subset recovery, immunoglobulin reconstitution, and the incidence of opportunistic infections did not differ significantly between MAC versus RTC groups. In a Cox model, MAC versus RTC recipients had significantly higher risk of grade II-IV acute GVHD [Hazard Ratio (HR) 6·1, P = 0·002] as did recipients of 4/6 vs. 5-6/6 HLA-matched UCBT (HR 3·1, P = 0·03), who also had significantly increased risk of chronic GVHD (HR 18·5, P = 0·04). In multivariate analyses, MAC versus RTC was furthermore associated with significantly increased transplant-related (Odds Ratio 26·8, P = 0·008) and overall mortality (HR = 4·1, P = 0·0001). The use of adoptive cellular immunotherapy to accelerate immune reconstitution and prevent and treat opportunistic infections and malignant relapse following UCBT warrants further investigation. [ABSTRACT FROM AUTHOR]

The article presents a study on racial and insurance differences in liver transplantation among hepatocellular carcinoma (HCC) patients and their impact to patient survival. The compared clinical and demographic characteristics of HCC patients were subjected to multivariable logistic regression and Cox hazard models to determine transplant predictors and mortality. Results revealed that receipt of transplant varies by race and insurance, but transplantation is still the determinant of mortality.

Background: Although many patients take antioxidant dietary supplements during breast cancer treatment, the benefits of such supplementation are unproven. The authors of this report analyzed the prevalence of and factors associated with antioxidant supplement use during breast cancer (BC) treatment among women who participated in the Long Island Breast Cancer Study Project.Methods: From 2002 through 2004, women with BC who had participated a case-control study from 1996 to 1997 were invited to participate in a follow-up interview. Antioxidant supplement use was defined as any self-reported intake of supplemental vitamin C, vitamin E, beta-carotene, or selenium in individual supplements or multivitamins.Results: Follow-up interview participants were younger, more predominantly white, and of higher socioeconomic status than women who did not respond. Among 764 participants who completed the follow-up interview, 663 (86.8%) reported receiving adjuvant treatment for their BC. Of those 663 women, 401 (60.5%) reported using antioxidants during adjuvant treatment: One hundred twenty of 310 women (38.7%) used antioxidants during chemotherapy, 196 of 464 women (42.2%) used them during radiation, and 286 of 462 women (61.9%) used them during tamoxifen therapy. Of 401 antioxidant users, 278 women (69.3%) used high doses (doses higher than those contained in a Centrum multivitamin). The factors that were associated with high antioxidant supplement use during treatment were higher fruit and vegetable intake at diagnosis (relative risk [RR], 1.71; 95% confidence interval [CI], 1.13-2.59), tamoxifen use (RR, 3.66; 95% CI, 2.32-5.78), ever using herbal products (RR, 3.49; 95% CI, 2.26-5.38), and ever engaging in mind-body practices (RR, 1.72; 95% CI, 1.13-2.64).Conclusions: Given the common use of antioxidant supplements during BC treatment, often at high doses and in conjunction with other complementary therapies, future research should address the effects of antioxidant supplementation on BC outcomes. [ABSTRACT FROM AUTHOR]

Neutropenia associated with race/ethnicity has essentially been unexplained and, although thought to be benign, may affect therapy for cancer or other illnesses. A recent study linked a single nucleotide polymorphism (SNP) (rs2814778) in the Duffy antigen/receptor chemokine gene ( DARC) with white blood cell count. We therefore analysed the association of the rs2814778 CC, TC and TT genotypes with absolute neutrophil count (ANC) among asymptomatic women from the Caribbean, Europe and the United States. Among 261 study participants, 33/47 women from Barbados/Trinidad-Tobago, 34/49 from Haiti, 26/37 from Jamaica, and 29/38 US-born black women, but only 4/50 from the Dominican Republic and 0/40 US- or European-born whites ( P = 0·0001) had the CC genotype. In a linear regression model that included percentage African ancestry, national origin, cytokines, socio-economic factors and the ELA2 rs57834246 SNP, only the DARC rs2814778 genotype and C-reactive protein were associated with ANC ( P < 0·0001). Women with the CC genotype had lower ANC than other women. Further research is needed on the associations of rs2814778 genotype with neutropenia and treatment delay in the setting of cancer. A better understanding of these associations may help to improve cancer outcomes among individuals of African ancestry. [ABSTRACT FROM AUTHOR]

The article presents a comparative study of low white blood cell counts (WBC) and absolute neutrophil counts (ANC) from six ethnic groups in the U.S. and the Caribbean Area. The methodology of the study made use of 261 healthy women blood samples and is analyzed based on the growth factor levels and cytokine levels. The study concludes that there is a strong association of neutropenia in a certain ethnic group.

Summary: Objective: The purpose of this study was to explore changes in quality of life (QOL), anxiety, stress, and immune markers after a stay at a raw vegan institute. Design: Prospective observational study. Setting: English-speaking attendees at Hippocrates Health Institute (Florida, US), a raw vegan institute, were recruited on arrival and typically stayed 1–3 weeks. Main outcome measures: Participants completed questionnaires assessing overall QOL (SF-36), dietary QOL (QOL related to dietary change), perceived stress (Perceived Stress Scale), anxiety, and depression (Hospital Anxiety and Depression Scale) upon arrival and 12 weeks later. C-reactive protein (CRP), lymphocytes, T cells, CD4 cells, CD8 cells, B cells, and NK cells were measured at baseline and 12 weeks in participants living in North America. Results: Of 107 attendees eligible for the questionnaire study and 82 for the blood marker substudy, 51 and 38 participants, respectively, provided complete follow-up data. Overall QOL improved 11.5% (p =0.001), driven mostly by the mental component. Anxiety decreased 18.6% (p =0.009) and perceived stress decreased 16.4% (p <0.001). Participants’ ratings of the food''s taste were unchanged, but their ratings of how well they were taking care of themselves improved. CRP, lymphocytes, T cells, and B cells did not change significantly, but CD4, CD8, and NK cells decreased slightly. Conclusions: A stay at a raw vegan institute was associated with improved mental and emotional QOL. Studies are needed to determine the feasibility of conducting a clinical trial of the raw vegan diet among healthy people, and subsequently among patients with specific diseases. [Copyright &y& Elsevier]

Background Adjuvant radiotherapy following breast conservation surgery (BCS) is considered to be an indicator of quality of care for the majority of women with breast cancer, but many women do not receive adjuvant radiotherapy. We investigated the association of surgeon-related factors with receipt of adjuvant radio- therapy after BCS. Methods We used the linked Surveillance, Epidemiology and End Results (SEER)-Medicare database to identify women aged 65 years or older with stage I/II breast cancer who were diagnosed between 1991 and 2002 and underwent BCS. We collected demographic and clinical data from SEER and treatment information from Medicare claims data. The American Medical Association Masterfile was used to obtain information on surgeons' characteristics, including sex, medical school location (United States or elsewhere), and type of degree (MD or Doctorate in Osteopathic Medicine [DO]). The associations of patient (age, race, rural vs urban residence, comorbidities, marital status), tumor (hormone receptor status, grade, stage), and surgeon-related factors with receipt of adjuvant radiotherapy were analyzed using Generalized Estimating Equations to control for clustering. All statistical tests were two-sided. Results Of 29 760 women in our sample, 22 207 (75%) received radiotherapy. Patients who received adjuvant radiotherapy were younger, had fewer comorbidities, and were more likely to be white, married, from an urban area, and diagnosed in a later year compared with those who did not. They were also more likely to have a surgeon who was female (79% vs 73%), had an MD degree (75% vs 68%), or was US trained (75% vs 70%). The multivariable analysis confirmed the association of radiotherapy with having a surgeon who was female (odds ratio [OR] = 1.13; 95% confidence interval [CI] = 1.06 to 1.27), had an MD degree (OR = 1.55; 95% CI = 1.24 to 1.91), was US trained (OR = 1.12; 95% CI = 1.01 to 1.25), or had more than 15 patients (OR = 1.18; 95% CI = 1.10 to 1.28). Conclusions Surgeon characteristics were associated with patients' receipt of adjuvant radiotherapy after BCS after controlling for patient and tumor characteristics, although the individual effect sizes were small for surgeon sex, location of training, and type of medical degree. More research is warranted to confirm the associations to determine whether they reflect surgeon behavior, patient response, or physician-patient interactions. [ABSTRACT FROM AUTHOR]

Summary: The purpose of this study was to evaluate adherence and identify predictors of adherence to a raw vegan diet (i.e., uncooked plant foods) following a stay at a raw vegan institute. In this cohort study of guests at a raw vegan institute, subjects completed written questionnaires upon arrival and 12 weeks later. Of 107 eligible guests, 84 participated. Mean age was 54 years, 23 were male, and 73 white. Fifty-one completed the 12-week follow-up. Eight (16%) reported their diet to be ⩾80% raw vegan at baseline and 14 (28%) at follow-up. Based on a raw vegan dietary adherence score (range 0–42) created for this study, mean adherence (SD) increased from 15.1 (5.4) to 17.0 (5.8) over 12 weeks (). Baseline predictors of adherence included: education (), severity of disease , and self-efficacy to adhere . Future interventions that evaluate this diet should address self-efficacy, an important, potentially remediable predictor of adherence. [Copyright &y& Elsevier]

Background: Among inner-city children with asthma, cockroach allergen exposure has been associated with allergic sensitization. Objective: We hypothesized that cockroach allergen levels in homes would be associated with sensitization to cockroach allergens in children. Methods: From a low-income preschool program, 341 four-year-old children selected on the basis of the willingness of their caregivers to participate in the study were enrolled. Dust from their beds and kitchens were analyzed for cockroach (Bla g 2), mouse (mouse urinary proteins), and cat allergens (Fel d 1). Serum samples were analyzed for allergen-specific IgE antibodies by immunoassay. Results: Bla g 2 levels >1 U/g in children''s bed and kitchen dust samples were independently associated with cockroach-specific IgE (odds ratio [OR], 2.7; 95% CI, 1.1-6.4; and OR, 3.4; 95% CI, 1.2-9.4, respectively), adjusting for sex, ethnicity, asthma, pet ownership, mother''s allergic sensitization, environmental tobacco smoke, and having lived in other homes. Bla g 2 was associated (OR, 3.6; 95% CI, 1.0-13.1) with cockroach-specific IgE among children with asthma. Among children without asthma, the ORs were similar (OR, 3.0; 95% CI, 0.9-10.3), but the association was not statistically significant. Conclusion: Concentrations of the major cockroach allergen, Bla g 2, in settled dust were associated with cockroach-specific IgE independent of other factors in a cohort of 4-year-old inner-city children. [Copyright &y& Elsevier]

Introduction: Aromatase inhibitors (AIs) have become the standard of care for the adjuvant treatment of postmenopausal, hormone-sensitive breast cancer. However, patients receiving AIs may experience joint symptoms, which may lead to early discontinuation of this effective therapy. We hypothesize that acupuncture is a safe and effective treatment for AI-induced arthralgias.Methods: Postmenopausal women with early-stage breast cancer who had self-reported musculoskeletal pain related to adjuvant AI therapy were randomized in a crossover study to receive acupuncture twice weekly for 6 weeks followed by observation or vice-versa. The intervention included full body and auricular acupuncture, and a joint-specific point prescription. Outcome measures included the Brief Pain Inventory-Short Form (BPI-SF), Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index, the Functional Assessment of Cancer Therapy-General (FACT-G) quality of life measure, and serum levels of inflammatory markers, IL-1 beta and TNF-alpha.Results: Twenty-one women were enrolled and two discontinued early. From baseline to the end of treatment, patients reported improvement in the mean BPI-SF worst pain scores (5.3 to 3.3, p = 0.01), pain severity (3.7 to 2.5, p = 0.02), and pain-related functional interference (3.1 to 1.7, p = 0.02), as well as the WOMAC function subscale and FACT-G physical well-being (p = 0.02 and 0.04, respectively). No adverse events were reported.Discussion/conclusions: In this pilot study, acupuncture reduced AI-related joint symptoms and improved functional ability and was well-tolerated.Implications For Cancer Survivors: Musculoskeletal side effects are common among breast cancer survivors on adjuvant AI therapy, therefore, effective treatments are needed for symptom relief and to improve adherence to these life-saving medications. [ABSTRACT FROM AUTHOR]

This article discusses findings of a study, which examined within-stage racial differences in tumor size and number of positive lymph nodes in women with breast cancer. Based on the annual report of cancer statistics released by the American Cancer Society, there is a disparity of diagnosis between white and black women. Some information considered in TNM staging for breast cancer include tumor size, the number of positive axillary lymph nodes and distant metastasis.

Background Recently, increasing numbers of women receiving adjuvant chemotherapy for breast cancer have also received granulocyte colony-stimulating factors (G-CSFs) or granulocyte-macrophage colony-stimulating factors (GM-CSFs). Although these growth factors support chemotherapy, their long-term safety has not been evaluated. We studied the association between G-CSF use and incidence of leukemia in a population- based sample of breast cancer patients. Methods Among women aged 65 years or older in the Surveillance, Epidemiology, and End Results-Medicare database who were diagnosed with stages I-Ill breast cancer from January 1, 1991, to December 31, 1999, we identified those who received G-CSF or GM-CSF concurrently with chemotherapy. We used Cox proportional hazards models to estimate hazard ratios for the association of treatment with G-CSF or GM-CSF and subsequent (through December 31, 2003) diagnosis of acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS). All statistical tests were two-sided. Results Of 5510 women treated with chemotherapy, 906 (16%) received G-CSF or GM-CSF therapy, and 64 (1.16%) were subsequently diagnosed with either MDS or AML before a cancer recurrence. Use of G-CSF and GM-CSF was associated with more recent diagnosis, younger age, urban residence, fewer comorbidities, receipt of radiation therapy, positive lymph nodes, and cyclophosphamide treatment. Of the 906 patients who were treated with G-CSF, 16 (1.77%) developed AML or MDS; of the 4604 patients not treated with G-CSF, 48(1.04%) developed AML or MDS. The hazard rate ratio for AML or MDS among those treated with G-CSF or GM-CSF compared with those who were not was 2.14 (95% confidence interval [CI] = 1.12 to 4.08). AML or MDS developed within 48 months of breast cancer diagnosis in 1.8% of patients who received G-CSF or GM-CSF but only in 0.7% of patients who did not (hazard ratio = 2.59, 95% CI = 1.30 to 5.15). Conclusions The use of G-CSF was associated with a doubling in the risk of subsequent AML or MDS among the population that we studied, although the absolute risk remained low. Even if this association is confirmed, the benefits of G-CSF may still outweigh the risks. Meanwhile, however, G-CSF use should not be assumed to be risk free. [ABSTRACT FROM AUTHOR]

Objectives: To describe the different approaches that investigators in several countries have used to obtain, register, assess, and research exceptional case histories after the use of complementary and alternative medicine (CAM). Methods: Searches have been carried out currently in the databases PubMed and MEDLINE® using the keywords: . We have only found a few papers limited to best-case series and cancer. Furthermore, we have used the "snowball method" by contacting researchers in different countries starting with with the National Cancer Institute in the United States in order to get information about ongoing approaches to obtain, register, assess, and research exceptional case histories after the use of CAM. Results: There appears to be a gap between "evidence-based" knowledge drawn from randomized controlled trials, systematic reviews, and meta-analyses and experience-based knowledge of treatment outcomes reported by patients and CAM providers. Several research groups in different countries have initiated studies on patients experiencing exceptional treatment outcomes after the use of CAM. Four different approaches to collecting and assessing such case histories have been identified. Three of the approaches collect histories from the treatment providers, whereas the fourth recruits case histories mainly from patients themselves. The medical assessments are generally similar, and seek to document whether the course of disease is different than would have been expected in a conventional treatment situation. Conclusions: Given differences in the current procedures, the establishment of an international formal collaboration for the recruitment, assessment, and study of exceptional patients is likely to take time. Comparative studies may, however, generate new knowledge about exceptional disease courses across disease categories, cultural contexts, and national boundaries. Our recommendations are that therapeutic approaches that show promising results should warrant prospective study and randomized clinical trials. In addition we recommend that there be (1) agreement on the definition of an exceptional patient, (2) agreement on the interpretation of treatment results, (3) agreement on content requirements of medical records, (4) more consideration of worst cases, (5) more international exchange of experience with registration procedures, and (6) more international exchange of experience with medical assessment procedures. [ABSTRACT FROM AUTHOR]

Background: For BRCA1 or BRCA2 mutation carriers, decision analysis indicates that prophylactic surgery or chemoprevention leads to better survival than surveillance alone. Objective: To evaluate the cost-effectiveness of the preventive strategies that are available to unaffected women carrying a single BRCA1 or BRCA2 mutation with high cancer penetrance. Design: Markov modeling with Monte Carlo simulations and probabilistic sensitivity analyses. Data Sources: Breast and ovarian cancer incidence and mortality rates, preference ratings, and costs derived from the literature; the Surveillance, Epidemiology, and End Results (SEER) Program; and the Health Care Financing Administration (now the Centers for Medicare & Medicaid Services). Target Population: Unaffected carriers of a single BRCA1 or BRCA2 mutation 35 to 50 years of age. Time Horizon: Lifetime. Perspective: Health policy, societal. Interventions: Tamoxifen, oral contraceptives, bilateral salpingooophorectomy, mastectomy, both surgeries, or surveillance. Outcome Measures: Cost-effectiveness. Results of Base-Case Analysis: For mutation carriers 35 years of age, both surgeries (prophylactic bilateral mastectomy and oophorectomy) had an incremental cost-effectiveness ratio over oophorectomy alone of $2352 per life-year for BRCA1 and $100 per life-year for BRCA2. With quality adjustment, oophorectomy dominated all other strategies for BRCA1 and had an incremental costeffectiveness ratio of $2281 per life-year for BRCA2. Results of Sensitivity Analysis: Older age at intervention increased the cost-effectiveness of prophylactic mastectomy for BRCA1 mutation carriers to $73 755 per life-year. Varying the penetrance, mortality rates, costs, discount rates, and preferences had minimal effects on outcomes. Limitations: Results are dependent on the accuracy of model assumptions. Conclusion: On the basis of this model, the most cost-effective strategies for BRCA mutation carriers, with and without quality adjustment, were oophorectomy alone and oophorectomy and mastectomy, respectively. [ABSTRACT FROM AUTHOR]

Summary: A growing body of research in neuroscience points to the impact of variations in maternal nurturing on child development and provides a rationale for interventions that target stress adaptation conditioning through natural family nurturing. This pilot study was collected within the course of private practice to assess the progress of children with severe behavioral disorders who were treated effectively with a multiple family therapy prototype, Prolonged Parent–Child Embrace (PPCE) Therapy. Subjects were a consecutive series of 102 patient children aged 4–18 years and their families. Children and their family members were guided for 16h over two consecutive days through intense PPCE Therapy. Families were instructed to continue PPCE Therapy at home for at least 1 year. Scores were compared statistically using t-tests and analysis of variance. For 96 children scores declined on two written measures by approximately 50% between baseline and follow-up (P<0.001). Results showed that PPCE Therapy resulted in significant and prolonged improvements in symptomatic behavior in a majority of children. [Copyright &y& Elsevier]

Background. Although patterns of utilization of complementary and alternative medicine (CAM) in the community have begun to be described, few studies have addressed the relationships between dispositional psychological factors and the use of CAM. The aim of this study was to examine the associations between CAM use and personality, coping strategies, and perceived social support in a representative sample of adults in the United States.Methods. Data were drawn from the Midlife Development in the United States Survey (MIDUS), a representative sample of 3,032 adults aged 25–74 in the US population. We analyzed use of acupuncture, biofeedback, chiropractic, energy healing, exercise/movement therapy, herbal medicine, high-dose megavitamins, homeopathy, hypnosis, imagery techniques, massage, prayer/spiritual practice, relaxation/mediation, and special diet within the last year. Multiple logistic regression analyses were used to evaluate the association of personality, dispositional coping strategies (primary and secondary control), and perceived social support and strain with CAM use, controlling for sociodemographic factors, medical care access, and physical and mental disorders.Results. Openness was positively associated with the use of all types of CAM except manipulative body-based methods. Extroversion was inversely correlated with the use of mind–body therapies. Primary control was inversely and secondary control directly correlated with the use of CAM. Perceived friend support was positively associated with the use of mind–body therapies, manipulative body-based methods, and alternative medical systems. Perceived partner strain was positively associated with the use of biologically based therapies, and family strain increased the odds of manipulative body-based methods.Conclusions. This study is the first to document a significant association between specific domains of personality, coping strategies, and social support, and the use of CAM among adults in the general population. Understanding the relationships between psychological factors and CAM use may help researchers and health care providers to address patients'' needs more effectively and to achieve better adherence to treatment recommendations. [Copyright &y& Elsevier]

Background. Platinum-based chemotherapy is the standard of care for women with advanced ovarian cancer based on the results of randomized trials. We previously showed that only about half of women over the age of 65 years with this disease received platinum-based chemotherapy, and that the likelihood of receiving it decreases with age.Methods. We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database to identify women diagnosed from 1/1/92 to 12/31/96 with stage III or IV ovarian cancer who survived ≥120 days beyond diagnosis, and were ≥65 years of age. Cox proportional hazards models and propensity scores were used to control for known predictors of receiving treatment and to estimate the relative effectiveness of different platinum-based regimens.Results. Of the 1759 patients in the sample who met our eligibility criteria, 53% received platinum-based therapy. For this sample, the Cox proportional hazard ratio was 0.72 (95% CI, 0.62–0.91) for mortality associated with the use of any platinum-based therapy, and 0.59 (95% CI, 0.45–0.76) for combination platinum/paclitaxel therapy. Similar results were obtained using propensity score modeling.Conclusions. In this population-based study, we found that only about half of women with advanced ovarian cancer over age 65 were treated with platinum-based chemotherapy; however, survival improved by 38% in treated women, similar to the benefits described in randomized controlled trials among younger patients, and were greatest when platinum was combined with paclitaxel. An effort to increase the utilization of platinum combination therapy among older patients with advanced ovarian cancer is justified. [Copyright &y& Elsevier]

Examines the variations in the use of adjuvant 5-fluorouracil (5-FU) treatment for elderly patients with node-positive colon cancer in the United States. Increase in the number of patients treated with 5-FU; Ages of elderly patients treated with 5-FU; Ratio of Hispanic black patients treated with 5-FU; Administration of 5-FU in patients with three or less positive lymph nodes.

PURPOSE. The recent Breast Cancer Prevention Trial has shown that tamoxifen may prevent invasive breast cancer. We used a Markov model to estimate the long-term effects of chemoprevention with tamoxifen on survival, quality-adjusted survival, and health care costs. METHODS. We used a hypothetical cohort of women with breast-cancer risk similar to that of participants in the Breast Cancer Prevention Trial. and a computer-based decision analysis (Markov model and 500 Monte Carlo simulations) to model the outcomes of interest. Survival calculations were from Surveillance, Epidemiology, and End-Results (SEER) data; preference ratings from a time trade-off questionnaire administered to a group of average-risk women; and cost estimates from the Group Health Cooperative of Puget Sound and the Health Care Financing Administration. We obtained utility measures for quality-adjustment by administering a time trade-off questionnaire to a group of community-based women. RESULTS. Use of tamoxifen prolonged the average survival of cohort members by 69 days (95% probability interval [PI] 27 to 117) for those who started use at age 35 years; 40 days (95% PI 16 to 67) for those who started use at age 50 years; and 27 days (95% PI 14 to 40) for those who started use at age 60 years. Tamoxifen extended quality-adjusted survival by 38 days (95% PI 0.1 to 82) at age 35, 25 days (95% PI 0 to 50) at age 50, and 22 days (95% PI 5 to 39) days at age 60. Chemoprevention with tamoxifen cost $46,619 (95% PI $27,928 to $98,796) per life year life saved for women who started at age 35; for women over age 50, it cost more than $50,000 per life year saved. DISCUSSION. Tamoxifen use may improve long-term survival and quality-adjusted survival among women who are at increased risk of breast cancer, but this benefit diminishes with age. Tamoxifen is cost-effective in comparison with other cancer treatment strategies for younger women only. [ABSTRACT FROM AUTHOR]

PURPOSE Recent randomized controlled trials have shown that tamoxifen and raloxifene may prevent invasive breast cancer. This decision analysis study compares the outcomes of chemoprevention with tamoxifen, raloxifene, or oral contraceptives with the outcomes of prophylactic surgery among women with high-risk BRCA1/2 mutations. PATIENTS AND METHODS We used a simulated cohort of 30-year-old women who tested positive for BRCA1/2 mutations and constructed a Markov model with Monte Carlo simulations, incorporating cumulative breast and ovarian cancer incidence rates from the literature and survival figures from SEER data. We assumed that prophylactic surgery reduces ovarian cancer risk by 45% and breast cancer risk by 90%, that tamoxifen reduces invasive breast cancer risk by 49%, and that raloxifene has similar efficacy and safety in premenopausal and postmenopausal women. We used data obtained from high-risk women by a time trade-off questionnaire to calculate quality-adjusted life-years. We based our cost estimates for hospital and ambulatory care on Health Care Financing Administration payments, the SEER-HCFA database, and the Pharmacy Fundamental Reference. RESULTS In our model, a 30-year-old BRCA1/2+ woman could prolong survival by 0.9 years (95% probability interval, 0.4-1.2 years) by having bilateral oophorectomy, 3.4 years (2.7-3.7 years) by having bilateral mastectomy, and 4.3 years (3.6-4.6 years) by having both procedures instead of surveillance alone. Chemoprevention with tamoxifen and raloxifene increased survival by 1.6 years (1.0-2.1 years) and 2.2 years (1.3-2.8 years), respectively. Chemoprevention yielded more quality-adjusted life-years than did prophylactic surgery, even when treatment was delayed to age 40 or 50 years. All these procedures were cost-effective or cost-saving compared with surveillance alone. DISCUSSION Our model suggests that although surgery may yield more substantial survival and cost benefits, quality of life issues may make chemoprevention a more attractive option for young women at high genetic risk (Cancer J Sci Am 2000;6:13-20) [ABSTRACT FROM AUTHOR]

Compares the preferences assigned to cancer states and prevention measures by women who had breast cancer, were at high risk for breast cancer, or had neither condition. Administration of a trade-off questionnaire to compare their preference for either breast or ovarian cancer; Lack of preference for prophylactic mastectomy.