Phase I trial of an oral immunomodulator and interferon inducer in cancer patients.

Imiquimod [1-(2-methylpropyl)-1H-imidazo[4,5c]quinolin-4-amine] is a compound of low molecular weight that, when administered p.o., induces interferon-alpha in several animal species and inhibits tumor growth in mice. To determine maximum tolerated dose, toxicity, and biological response in humans, a phase I clinical trial was conducted with 14 eligible cancer patients who received 100-500 mg imiquimod p.o. either once or twice weekly. Imiquimod induced interferon-alpha in serum in 10 of 19 doses of 200-300 mg. Interferon serum levels peaked 8-24 h after treatment and reached a maximum of 23,000 IU/ml in one patient. Significant mean increases (P < 0.01) in serum beta 2-microglobulin (1.5-fold), serum neopterin (3.5-fold), and 2-5A synthetase activity in peripheral blood mononuclear cells (7.9-fold) indicated that 200-300 mg imiquimod had biological and immunological activity in all evaluable patients. Increases in serum interferon, beta 2-microglobulin, and neopterin correlated significantly with dose (P < 0.001). No patient developed measurable antibody to interferon-alpha. Dose-limiting side effects included fatigue, malaise, fever, headache, and lymphocytopenia; no hepatic or renal toxicity or other hematological changes exceeded the normal range. Patients tolerated weekly doses of up to 500 mg, with the longest treatment lasting 4 weeks at 200 mg weekly. Twice-weekly doses up to to 300 mg were tolerated, with the longest twice-weekly treatments being 200 mg for 9 weeks and 100 mg for 25 weeks. No clinical responses were observed. Imiquimod, as an oral inducer of interferon, may have therapeutic usefulness in human cancers, viral infections, and other diseases. However, before initiation of phase II trials, additional work will be required to establish a tolerated dose and schedule for continued administration.

Is economic hardship on the families of the seriously ill associated with patient and surrogate care preferences? SUPPORT Investigators.

BACKGROUND: Serious illness often causes economic hardship for patients' families. However, it is not known whether this hardship is associated with a preference for the goal of care to focus on maximizing comfort instead of maximizing life expectancy or whether economic hardship might give rise to disagreement between patients and surrogates over the goal of care. METHODS: We performed a cross-sectional study of 3158 seriously ill patients (median age, 63 years; 44% women) at 5 tertiary medical centers with 1 of 9 diagnoses associated with a high risk of mortality. Two months after their index hospitalization, patients and surrogates were surveyed about patients' preferences for the primary goal of care: either care focused on extending life or care focused on maximizing comfort. Patients and surrogates were also surveyed about the financial impact of the illness on the patient's family. RESULTS: A report of economic hardship on the family as a result of the illness was associated with a preference for comfort care over life-extending care (odds ratio, 1.26; 95% confidence interval, 1.07-1.48) in an age-stratified bivariate analysis. Similarly, in a multivariable analysis controlling for patient demographics, illness severity, functional dependency, depression, anxiety, and pain, economic hardship on the family remained associated with a preference for comfort care over life-extending care (odds ratio, 1.31; 95% confidence interval, 1.10-1.57). Economic hardship on the family did not affect either the frequency or direction of patient-surrogate disagreements about the goal of care. CONCLUSIONS: In patients with serious illness, economic hardship on the family is associated with preferences for comfort care over life-extending care. However, economic hardship on the family does not appear to be a factor in patient-surrogate disagreements about the goal of care.

Outcomes, preferences for resuscitation, and physician-patient communication among patients with metastatic colorectal cancer. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.

PURPOSE: To describe characteristics, outcomes, and decision making in patients with colorectal cancer metastatic to the liver, and to examine the relationship of doctor-patient communication with patient understanding of prognosis and physician understanding of patients' treatment preferences. PATIENTS AND METHODS: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) was a prospective cohort study conducted at five teaching hospitals in the United States between 1989 and 1994. Participants in this study were hospitalized patients 18 years of age or older with known liver metastases who had been diagnosed with colorectal cancer at least 1 month earlier. Data were collected by patient interview and chart review at study entry; patients were interviewed again at 2 and 6 months. Data collected by physician interview included estimates of survival and impressions of patients' preferences for cardiopulmonary resuscitation (CPR). Patients and physicians were also asked about discussions about prognosis and resuscitation preferences. RESULTS: We studied 520 patients with metastatic colorectal cancer (median age 64, 56% male, 80% white, 2-month survival 78%, 6-month survival 56%). Quality of life (62% "good" to "excellent") and functional status (median number of disabilities = 0) were high at study entry and remained so among interviewed survivors at 2 and 6 months. Of 339 patients with available information, 212 (63%) of 339 wanted CPR in the event of a cardiopulmonary arrest. Factors independently associated with preference for resuscitation included younger age, better quality of life, absence of lung metastases, and greater patient estimate of 2-month prognosis. Of the patients who preferred not to receive CPR, less than half had a do-not-resuscitate note or order written. Patients' self-assessed prognoses were less accurate than those of their physicians. Physicians incorrectly identified patient CPR preferences in 30% of cases. Neither patient prognostication nor physician understanding of preferences were significantly better when discussions were reported between doctors and patients. CONCLUSIONS: A majority of patients with colorectal cancer have preferences regarding end of life care. The substantial misunderstanding between patients and their physicians about prognosis and treatment preferences appears not to be improved by direct communication. Future research focused on enhancing the effectiveness of communication between patients and physicians about end of life issues is needed.

Generalizability of clinical studies conducted at tertiary care medical centers: a population-based analysis.

The Marshfield Epidemiologic Study Area (MESA), a geographically defined population registry at one of the participating sites in SUPPORT (a multicenter study of the care of seriously ill hospitalized patients) permitted assessment of generalizability in that study. On the basis of age- and sex-specific rates of enrollment of SUPPORT patients in MESA, we estimate that about 400,000 patients per year would fulfill SUPPORT eligibility criteria in the United States. However, an estimated 925,000 patients, particularly the elderly and those with impairments in their activities of daily living (ADLs), have SUPPORT-like illnesses annually, but do not receive the aggressive care required for study enrollment. The absence of patients not interested in aggressive care in tertiary care-based studies is compounded by the overrepresentation of patients referred from distant areas to the tertiary care center. Such patients tended to be older and to have different diseases than patients in MESA. Care should be taken in generalizing results from clinical and epidemiologic studies conducted at tertiary care centers.

Influence of patient preferences and local health system characteristics on the place of death. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Risks and Outcomes of Treatment.

OBJECTIVE: To examine the degree to which variation in place of death is explained by differences in the characteristics of patients, including preferences for dying at home, and by differences in the characteristics of local health systems. DESIGN: We drew on a clinically rich database to carry out a prospective study using data from the observational phase of the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT component). We used administrative databases for the Medicare program to carry out a national cross-sectional analysis of Medicare enrollees place of death (Medicare component). SETTING: Five teaching hospitals (SUPPORT); All U.S. Hospital Referral Regions (Medicare). STUDY POPULATIONS: Patients dying after the enrollment hospitalization in the observational phase of SUPPORT for whom place of death and preferences were known. Medicare beneficiaries who died in 1992 or 1993. MAIN OUTCOME MEASURES: Place of death (hospital vs non-hospital). RESULTS: In SUPPORT, most patients expressed a preference for dying at home, yet most died in the hospital. The percent of SUPPORT patients dying in-hospital varied by greater than 2-fold across the five SUPPORT sites (29 to 66%). For Medicare beneficiaries, the percent dying in-hospital varied from 23 to 54% across U.S. Hospital Referral Regions (HRRs). In SUPPORT, variations in place of death across site were not explained by sociodemographic or clinical characteristics or patient preferences. Patient level (SUPPORT) and national cross-sectional (Medicare) multivariate models gave consistent results. The risk of in-hospital death was increased for residents of regions with greater hospital bed availability and use; the risk of in-hospital death was decreased in regions with greater nursing home and hospice availability and use. Measures of hospital bed availability and use were the most powerful predictors of place of death across HRRs. CONCLUSIONS: Whether people die in the hospital or not is powerfully influenced by characteristics of the local health system but not by patient preferences or other patient characteristics. These findings may explain the failure of the SUPPORT intervention to alter care patterns for seriously ill and dying patients. Reforming the care of dying patients may require modification of local resource availability and provider routines.

Seriously ill hospitalized adults: do we spend less on older patients? Support Investigators. Study to Understand Prognoses and Preference for Outcomes and Risks of Treatments.

OBJECTIVE: To determine the effect of age on hospital resource use for seriously ill adults, and to explore whether age-related differences in resource use are explained by patients' severity of illness and preferences for life-extending care. STUDY DESIGN: Prospective cohort study. SETTING: Five geographically diverse academic acute care medical centers participating in the SUPPORT Project. PATIENTS: A total of 4301 hospitalized adults with at least one of nine serious illnesses associated with an average 6-month mortality of 50%. MEASUREMENTS: Resource utilization was measured using a modified version of the Therapeutic Intervention Scoring System (TISS); the performance of three invasive procedures (major surgery, dialysis, and right heart catheter placement); and estimated hospital costs. RESULTS: The median patient age was 65; 43% were female, and 48% died within 6 months. After adjustment for severity of illness, prior functional status, and study site, when compared with patients younger than 50, patients 80 years or older were less likely to undergo major surgery (adjusted odds ratio .46), dialysis (.19), and right heart catheter placement (.59) and had median TISS scores and estimated hospital costs that were 3.4 points and $ 71.61 lower, respectively. These differences persisted after further adjustment for patients' preferences for life-extending care. CONCLUSIONS: Compared with similar younger patients, seriously ill older patients receive fewer invasive procedures and hospital care that is less resource-intensive and less costly. This preferential allocation of hospital services to younger patients is not based on differences in patients' severity of illness or general preferences for life-extending care.

Norepinephrine levels in traumatized spinal cord of catecholamine-depleted cats.

This study was designed to elucidate the origin of norepinephrine (NE) measured in spinal cord following trauma. In normal cats the NE concentration at the lesion site increased 63% over control 1 h following experimentally produced blunt trauma (400 g-cm). Spinal cords of adrenalectomized cats were also traumatized, but there was no increase in NE levels 1 h post-trauma. Spinal cord NE levels in these animals were not significantly different from normal or adrenalectomized non-injured controls. In the absence of one of the major peripheral sources of catecholamine, the adrenal medulla, our decreased NE levels prompt us to disagree with the hypothesis that NE measured in injured spinal cord is liberated from intrinsic neuronal systems. It is likely that the mechanism of NE accumulation is directly related to increased circulating levels of NE. The authors speculate on a possible reason for the conflicting results obtained by different laboratories in this area of research.

Intraventricular cavernous hemangioma: report of three cases and review of the literature.

The clinical and radiographic presentations of 3 patients with intraventricular cavernous hemangioma are described. The accumulated total of 19 cases from the literature are compared to determine whether there is a common clinical and radiographic presentation for this benign intraventricular lesion. The differential diagnosis of intraventricular cavernous hemangioma includes intraventricular meningioma, choroid plexus papilloma, arteriovenous malformation, low grade astrocytoma, and ependymoma.

The treatment of older adult patients with acute myeloid leukemia by triple infusion chemotherapy.

Adult patients (> or = 56 years old) with acute myeloid leukemia (AML) received induction therapy consisting of daunorubicin (60 mg/m2), etoposide (80 mg/m2), and cytarabine (200 mg/m2) daily for 5 days by continuous i.v. infusion (120 hours). The initial protocol was modified so that patients who were not hypoplastic after the first cycle of chemotherapy received a second cycle of treatment, utilizing 30 mg/m2 of daunorubicin/24 hours for 5 days plus etoposide and cytarabine as used in the first cycle. Two courses of consolidation with etoposide and cytarabine at the same dose and schedule were given. Patients were then maintained on cytarabine monthly. Twelve of 29 previously untreated patients (41%) achieved complete remission (CR). Excluding patients with secondary AML, 48% of all patients (11/23) achieved CR, including 56% > or = 70 years old. The median duration of CR was 41 weeks and median survival of CR patients was 54 weeks. Six of 13 patients (46%) with relapsed AML achieved CR. Toxicity in these older adult patients has been mild. Two patients (8%) had severe mucositis and one had severe (bloody) diarrhea. Most patients developed a mild transient asymptomatic rash. Triple infusion chemotherapy (TIC) may be as effective as other chemotherapy regimens for AML in older adults and has acceptable toxicity.

Peer discussions of cancer among Hispanic migrant farm workers.

Hispanic migrant agricultural workers' exposure to pesticides and other agrichemicals places them at increased risk for a variety of acute and chronic conditions, including cancer. As a socioeconomically disadvantaged group, migrant workers also face many barriers to effective cancer control. In 1992, a series of focus groups was held with 55 Hispanic migrant agricultural workers (22 women, 33 men) in central Wisconsin to gather information on their knowledge and attitudes regarding cancer etiology and treatment, their practices regarding cancer screening and early detection, and their concerns regarding occupational exposure to pesticides. Beliefs that pesticides are toxic and can cause health problems were common among participants. In addition, however, participants reported that they are reluctant to demand occupational protections to which they are entitled because they are afraid of losing their jobs. Study results also suggest that barriers to effective primary and secondary prevention of cancer in this Hispanic migrant agricultural worker population include knowledge and information barriers, cultural barriers, and socioeconomic barriers. A lack of knowledge and information regarding the causes of cancer, its prevention, and its early detection and treatment was evident among participants, which in turn was reflected in strong fatalistic attitudes toward the disease. Cultural barriers included attitudes of embarrassment and shame associated with physical examinations and women's strong discomfort with male clinicians. Socioeconomic barriers to secondary prevention included the cost of obtaining health services, time constraints associated with the need to work and long working days, and a lack of transportation. Efforts to improve cancer screening as well as other preventive health services in the Hispanic migrant agricultural worker population must acknowledge these barriers and address as many of them as possible to be successful.

Identification of a gene frequently mutated in prostate tumors.

Although prostate cancer is the second leading cause of cancer death for men in the United States, the genetics of tumor development are poorly understood. Several expressed sequence tagged genes (ESTs) that are expressed predominantly in the prostate have recently been identified, although their role in the development and maintenance of the prostate is unknown. Here, we demonstrate that the gene identified as UNIGENE cluster Hs. 104215, which codes for a message found predominantly in the prostate, may be important in tumor development. We name this gene PCan1 for Prostate Cancer gene 1. Northern blot experiments were performed using RNA isolated from tumor-derived cell lines and human prostate to determine the expression pattern of the gene. DNA sequencing was used to identify mutations that occurred in tumor tissue. By Northern blot analysis, this gene product was not detectable in LNCaP, DU 145, or PC-3 prostate cancer cell lines, although it was readily observed in RNA isolated from total prostate and from dissected central and peripheral regions of prostate. Sequence analysis of genomic DNA from LNCaP, DU 145, or PC-3 cells demonstrated a G/A polymorphism at position 193. Analysis of matched tumor-derived DNA and blood-derived DNA samples from 11 of 13 patients who had undergone a radical prostatectomy and who were homozygous for A in blood-derived DNA demonstrated mutation of position 193 in matched tumor samples resulting in G/A polymorphism. Sixteen additional patient samples were G/A polymorphic in both blood-derived DNA and tumor-derived DNA and two samples were GG in both blood-derived and tumor-derived DNA. Our results suggest that this gene may be a hot spot for mutation in prostate cancer, especially because our radiation hybrid mapping located this gene within a region identified in linkage mapping studies of affected families with prostate cancer. Loss of heterozygosity in prostate tumors has also been reported at the location of PCan1. Further studies to determine the functional role of this candidate tumor suppressor gene are warranted.

Expression and initial promoter characterization of PCAN1 in retinal tissue and prostate cell lines.

Prostate cancer is the most frequently diagnosed neoplasia in men and one of the leading causes of cancer-related deaths in men over 60. In an effort to understand the molecular events leading to prostate cancer, we have identified PCAN1 (prostate cancer gene 1) (also known as GDEP), a gene that is highly expressed in prostate epithelial tissue and frequently mutated in prostate tumors. Here we demonstrate its expression in neural retina, and retinoblastoma cell culture but not retinal pigment epithelial cell culture. We further characterize PCAN1 expression in the prostate cell lines RWPE1, RWPE2, and LnCAP FGC. We demonstrate an increase in expression when the cells are grown in the presence of Matrigel, an artificial extracellular basement membrane. Expression was time dependent, with expression observed on d 6 and little or no expression on d 12. Testosterone was not found to increase PCAN1 expression in this culture system. In addition, normal prostate epithelial cells co-cultured with normal prostate stromal cells did not exhibit PCAN1 expression at any time. To definitively locate the transcription initiation sites, we performed restriction-ligase-mediated 5' RACE, to selectively amplify only mRNA with a 5' cap. An initial characterization of the sequence upstream of the initiation sites determined six possible binding sites for the prostate specific regulatory protein NKX3.1 and four potential binding sites for the PPAR/RXR heterodimer that is involved in the control of cell differentiation and apoptosis.

Teens teach skin cancer prevention.

Cumulative sun exposure has been linked to about 95 percent of all skin cancers. Farmers and their families, by nature of their occupations, are exposed to an abundance of sun over a long period of time and, therefore, are at an increased risk for skin cancer. Because education is known to be a primary means of health, Future Farmers of America (FFA) peer facilitators (teen educators) provided third graders in rural communities sun protection education with the hope that the message would reach the entire family. The FFA facilitators (n = 217) from 39 FFA organizations throughout Wisconsin were trained with skin cancer and sun protection information. The FFA facilitators then gave presentations on sun protection to third graders (n = 2,007) in their school districts. Control schools included 57 facilitators and 669 third graders. Evaluation involved pre-, post-, and six-month follow-up surveys testing knowledge gained by the third graders. Students who correctly responded to a question on the post-survey after incorrectly answering it on the pre-survey were said to have had a knowledge gain for that question. By using chi-square tests, the intervention group demonstrated a statistically significant (P < 0.001) higher proportion of students experiencing knowledge gain than did the control group from pre- to post-surveys for nine of the 10 questions. Summary statistics were used to describe the study population. In addition to skin cancer knowledge questions, the survey of facilitators included sun protection behavior and attitude questions. This intervention was able to use peer educators as instructors to demonstrate knowledge gain in the youths of the target population. The pilot project materials costs were +0.55 per third grade student and +3.50 per facilitator. Using a school-based organization such as FFA provided a cost-effective means of reaching the rural population.

Wisconsin farmer cancer mortality, 1981 to 1990: selected malignancies.

Cancer mortality risks for Wisconsin white male farmers were examined during the years 1981 to 1990. Four malignancies were studied: Non-Hodgkin's lymphoma, melanoma, colon cancer, and rectal cancer. Occupation coded deaths were segmented into farmer and nonfarmer groups and population counts for the groups were estimated from 1980 and 1990 Bureau of the Census data. Standardized mortality ratios (SMRs) were constructed from the ratio of observed farmer deaths and the expected number of farmer deaths. Expected deaths were generated from the underlying statewide nonfarmer rate for the malignancy multiplied into the farmer population at risk. Farmers had significantly lower mortality risks for melanoma (SMR: 0.659; 95% CI: 0.993-0.326) and colon cancer (SMR: 0.763; 95% CI: 0.928-0.599). Farmers also exhibited a nonsignificant decrement for non-Hodgkin's lymphoma (SMR: 0.930; 95% CI: 1.214-0.645). For rectal cancer, farmers experienced a slightly higher but essentially the same risk as nonfarmers (SMR: 1.013; 95% CI: 1.418-0.608)--the SMR was not significant. This study corroborates a number of cancer incidence and mortality investigations demonstrating that farmers generally experience the same or lower mortality risks for these malignancies.

Experience with simultaneous ventriculo-peritoneal shunt placement and myelomeningocele repair.

A program evaluating simultaneous shunt placement and neural tube repair is described and compared with a concomitant series of patients whose surgeons preferred delayed shunting. Twenty-two patients had simultaneous closure of neural tube defects and placement of ventriculoperitoneal shunts; one was shunted 1 day prior to closure of a leaking myelomeningocele. Eleven other patients had closure of myelomeningoceles followed by shunting 6 to 14 days later. Four patients have not required shunting. Three patients needed complex flap rotations and silastic dural closures, but the complexity of the myelomeningocele closure was not a criterion for excluding simultaneous shunting. The only criteria were preference of the attending surgeon, and ventricular size. All but one in the simultaneous shunting (SS) group had moderate to marked hydrocephalus at birth; one initially selected not to have a shunt, but within 24 hours had marked increase in ventricular size by ultrasonography performed when the child was anesthetized for the myelomeningocele closure. In the SS group, surgical innovations included (1) use of the semilateral position for exposure of both operative sites for shunting and the myelomeningocele closure, (2) posteriorly-placed subcutaneous peritoneal catheter, and (3) a combined surgical approach using two surgeons and separate instrumentation. There was no operative mortality in either group; there were no infections within 30 days in either group. There was one infection at 5 months in the SS group, and one at 2 months in the delayed shunting (DS) group; the long-term infection rate was 5%, comparable to any published series.(ABSTRACT TRUNCATED AT 250 WORDS)

Hematopoietic growth factors. A promising future for use in bone marrow dysfunction.

The clinical future of hematopoietic growth factors appears promising. They will probably achieve broad clinical application in a wide variety of hematologic disorders. Their use in infectious diseases associated with granulocytopenia and in cancer-treatment regimens as adjuvant agents against myelosuppression and perhaps as stimulants of the natural anti-cancer effects of host cells also seems appropriate.

Evidence of a healthy volunteer effect in the prostate, lung, colorectal, and ovarian cancer screening trial.

Volunteers for prevention or screening trials are generally healthier and have lower mortality than the general population. The Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO) is an ongoing, multicenter, randomized trial that randomized 155,000 men and women aged 55-74 years to a screening or control arm between 1993 and 2001. The authors compared demographics, mortality rates, and cancer incidence and survival rates of PLCO subjects during the early phase of the trial with those of the US population. Incidence and mortality from PLCO cancers (prostate, lung, colorectal, and ovarian) were excluded because they are the subject of the ongoing trial. Standardized mortality ratios for all-cause mortality were 46 for men, 38 for women, and 43 overall (100 = standard). Cause-specific standardized mortality ratios were 56 for cancer, 37 for cardiovascular disease, and 34 for both respiratory and digestive diseases. Standardized mortality ratios for all-cause mortality increased with time on study from 31 at year 1 to 48 at year 7. Adjusting the PLCO population to a standardized demographic distribution would increase the standardized mortality ratio only modestly to 54 for women and 55 for men. Standardized incidence ratios for all cancer were 84 in women and 73 in men, with a large range of standardized incidence ratios observed for specific cancers.

The Upper Midwest Health Study: a case-control study of primary intracranial gliomas in farm and rural residents.

Since several studies indicated that farmers and agricultural workers had an excess risk of brain cancer, the National Institute for Occupational Safety and Health initiated the Upper Midwest Health Study to examine risk of intracranial glioma in the non-metropolitan population. This population-based, case-control study evaluated associations between gliomas and rural and farm exposures among adults (ages 18 to 80) in four upper midwestern states (Iowa, Michigan, Minnesota, Wisconsin). At diagnosis/selection, participants lived in non-metropolitan counties where the largest population center had fewer than 250,000 residents. Cases were diagnosed 1 January 1995 through 31 January 1997. Over 90% of 873 eligible ascertained cases and over 70% of 1670 eligible controls consented to participate. Participants and nonparticipants, evaluated for "critical questions" on main and refusant questionnaires, differed significantly in farming and occupational experience, ethnicity, education, and lifestyle. The 1,175 controls were more likely than the 798 cases to have reported ever drinking alcohol (77% vs. 73%, adjusted odds ratio (OR) 0. 73, 95% confidence interval (CI) 0.59-0.92) and having had panoramic dental x-rays (34% vs. 29%, OR 0. 75, CI 0.61-0.92). Controls spent a greater percentage of their lives in non-metropolitan counties (78% vs. 75%, OR 0.81, CI 0.67-1.09). Among ever-farmers, controls were more likely to have had exposure to farm insecticides (57% vs. 50%, OR 0.75, CI 0.59-0.95) and farm animals (96% vs. 91%, OR 0.48, CI 0.25-0.90). Moving to a farm as an adolescent (ages 11 to 20) vs. as an adult was associated with a greater risk of glioma. In our study sample, farm or rural residence and summary farm exposures were associated with decreased glioma risk. However, nonparticipation by never-farming eligible controls could have affected results. Comparisons of farm chemical exposures may clarify associations between farming and glioma that others have reported.

Lessons learned: geographic information systems and farmworkers in the Lake States.

Agencies serving the estimated 42,000 to 137,000 migrant and seasonal farmworkers in the Lake States (Wisconsin, Michigan, and Minnesota) face distinct challenges, including inadequate access to farmworker data to address their needs. This project developed and evaluated a geographical information system (GIS) database for compiling and displaying existing farmworker data in the Lake States. A three-step study was conducted in the Lake States: (1) a preliminary resource and needs assessment was conducted among agencies serving farmworkers, (2) a GIS product was created using data available from state agencies, and (3) the GIS product was evaluated by an advisory board of qualified occupational health and safety representatives for appropriateness, applications, and ease of use. Agencies participated by sharing their available farmworker data. The GIS product consisted of a CD-ROM with data displayed in a graphic format and downloadable spreadsheet files consolidated by county demographic, crop, housing, and migrant health clinic information. Evaluators of the GIS product found it to be an accessible, unique clearinghouse for farmworker-related data. The GIS product can become a valuable tool for agencies serving farmworkers and those researching farmworker-related issues. Agencies and health professionals require useful and comprehensive databases to track and serve farmworkers, and a multi-agency partnership using GIS technology could provide this capability. Further research is required with improved definitions and resources to apply the GIS product.

Health education delivery by Wisconsin veterinarians.

Established methods of health promotion for the general population are not as effective with rural populations, in part because conventional health education delivery systems may not penetrate isolated rural areas. In particular, the self-reliant behaviors of farmers make them less likely to seek traditional forms of health care, including health promotional activity. Yet farmers place a great deal of trust in their veterinarian and highly rate veterinarian integrity. Wisconsin veterinarians expressed an interest in the health of their human clients as well as the health of the animals in their care. An education demonstration project was developed to determine farmers' acceptance of veterinarians delivering human health information to their workplace (farms). Thirteen veterinarians who provide services in one north central Wisconsin county delivered skin cancer and sun protection information to farmers as part of their routine herd health checks. Participating farmers reported this to be an acceptable way to receive information about human health issues. This novel method of education delivery may be an effective means to disseminate human health information to difficult-to-reach rural populations.