Lung cancer in young patients: analysis of a Surveillance, Epidemiology, and End Results database.

PURPOSE: A large community-based cancer registry was analyzed to determine if the clinicopathologic characteristics and/or survival rates of lung cancer patients under 50 years of age at diagnosis differ from those of patients 50 years of age or greater at diagnosis. PATIENTS AND METHODS: Data regarding demographics, stage, histology, initial therapy, and survival were obtained on all patients with primary bronchogenic carcinoma registered in the metropolitan Detroit Surveillance, Epidemiology and End Results (SEER) registry from 1973 to 1992. RESULTS: Of 31,266 patients, 9.0% were under 50 years of age at diagnosis. Females (40.1% v 31.2%; P < .001) and blacks (28.7% v 21.9%, P < .001) were overrepresented in the younger group compared with the older group. Younger patients had a significantly higher incidence of adenocarcinoma and were less likely to present with local-stage disease (18.6% v 25.2%; P < .001). Younger patients were significantly more likely to undergo surgery and/or combined-modality therapy. Relative survival at 5 years was significantly better in the younger group (16.1% v 13.4%; P < .001), mainly because of better survival in patients with local-stage disease (48.7% v 35.4%; P < .001). In a multivariate analysis, advanced-stage, nonsurgical initial therapy, age 50 years or greater at diagnosis, and male gender were independent negative prognostic factors. CONCLUSION: The overrepresentation of females and blacks in the group of younger patients with lung cancer suggests an increased susceptibility to lung carcinogens in these populations. Overall, this study suggests that lung cancer is not a more aggressive disease in younger patients and that all patients with lung cancer should be managed along the same therapeutic guidelines.

Increasing incidence of cancer of the prostate. The experience of black and white men in the Detroit metropolitan area.

BACKGROUND: Prostate cancer mortality and incidence rates have been gradually increasing for decades in the United States, with an accelerated increase in incidence noted in the past several years. This study explores in detail the occurrence of prostate cancer in southeast Michigan from 1973 through 1991. METHODS: Data from the National Cancer Institute Surveillance, Epidemiology, and End Results program are analyzed with emphasis on time trends by race, age, stage, and treatment. RESULTS: Population-based rates for prostate cancer increased by 70% between 1988 and 1991. Increases are most pronounced for early stage disease and among whites compared with blacks. Corresponding increases in treatment with radical prostatectomy are also observed. CONCLUSION: Increased incidence of prostate cancer is likely a result of widespread use of prostate-specific antigen.

Electroconvulsive therapy and memory dysfunction: is there evidence for prolonged defects?

The authors reviewed 39 papers which concern the long-term effects of electroconvulsive therapy (ECT) on human memory. Although the authors caution that methodological considerations preclude a decisive assessment, the majority of the studies suggest that ECT does not normally produce prolonged memory defects. Some recent studies do document subtle but persistent defects several months after ECT, especially in personal autobiographical material. These defects appear to be more annoying than seriously incapacitating. Variables considered important in an ideal design of studies on ECT and memory are discussed.

Increasing incidence of adenocarcinomas and carcinoid tumors of the small intestine in adults.

Malignant neoplasms of the small intestine are relatively rare and have received little study. We report on trends in the age-adjusted, sex-, and race-specific incidence rates of adenocarcinomas and carcinoid tumors of the small intestine in the United States from 1973 through 1991. Data were derived from the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute. There were statistically significant increases in the incidence rates of both adenocarcinomas and carcinoid tumors during the time frame of the study. Rates increased most dramatically in black males, with 2- and 4-fold increases in adenocarcinomas and carcinoid tumors, respectively. The only rates that remained relatively unchanged were those of adenocarcinoma among white females. It remains to be determined if changing environmental factors are important causes of these observed trends. If environmental factors are involved in the etiology of small intestine cancers, analytic studies conducted while the disease is increasing in incidence may provide useful insights.

Serum cholesterol and colorectal polyps.

Colorectal cancer and hypocholesterolemia have recently been associated, and colorectal polyps have a known relationship with colorectal cancer. In order to establish further evidence regarding the nature of the serum cholesterol-colorectal cancer relationship, this study investigated the hypothesis that men with colorectal polyps would have lower serum cholesterol levels than men without polyps. Of the 1380 men screened by sigmoidoscopy for colorectal polyps, 246 had at least one polyp. The men with polyps were older than those without, and also had higher cholesterol levels, but after controlling for age, there were no serum cholesterol differences. These data suggest that low serum cholesterol is not etiologically linked to cancer. Analyses of potentially confounding variables showed smoking to be strongly related to the presence of polyps.

Bacterial/viral filtration: let the breather beware!

Most clinicians believe that any device that is marketed as a "bacterial/viral filter" must necessarily be capable of capturing any individual bacteria or viruses that might be suspended within inhaled or exhaled gases. We were surprised to discover that this is, by no means, a justifiable assumption. This article describes testing methods that manufacturers employ to generate the often-misleading efficiency specifications that are claimed for some of these devices. We discuss articles that have documented the presence of airborne pathogens in the effluent of a ventilator circuit, and characterize the attributes that a competent filter must exhibit if it is to succeed in protecting patients and caregivers from incidental exposure to bacteria, viruses, aerosolized drugs, and endotoxins. This article continues with a discussion of the numbers of particles that are commonly produced with commercially available pneumatic nebulizers, the comparative performance characteristics of filters and heat/moisture exchanging filters (HMEFs), and the success or failure of various brands of HMEFs to comply with the guidelines recently developed by the Centers for Disease Control and Prevention for the management of patients who are harboring active tuberculosis. The presentation concludes with a description of the standards that apply to any filter that classifies as a high-efficiency particulate aerosol (HEPA) device, and demonstrates that the performance of filters/HMEFs in common clinical use can range from approximately 1/50th to > 30-fold the efficiency of a HEPA-grade device. Those who frequent the bedside of patients receiving ventilation might unwittingly be placing themselves at considerable risk of exposure to infectious microaerosols, but methods are available to dramatically decrease those risks.

Effect of age and race on the survival of men with prostate cancer in the Metropolitan Detroit tricounty area, 1973 to 1987.

OBJECTIVES: Reports have demonstrated that African Americans diagnosed with prostate cancer have a poor survival compared with whites. We examined the impact of age, race, and stage of disease on survival for men diagnosed with prostate cancer. METHODS: A retrospective analysis was made of men diagnosed with prostate cancer utilizing the Surveillance, Epidemiology, and End Results Program (SEER) database. A total of 12,907 men (9339 white, 3568 black) diagnosed from January 1, 1973 through December 31, 1987 were included in the study. For each stage of disease, survival experience was examined using Kaplan-Meier and life table methods, followed by analysis using Cox's proportional hazard model. RESULTS: African-American men have a poorer survival than whites for all stages of prostate cancer when the cancer is diagnosed at younger ages. These differences in survival were not demonstrated for men diagnosed with prostate cancer after age 70. CONCLUSIONS: Age and race should be taken into account when assessing the survival of patients with prostate cancer.

Environmental medicine content in medical school curricula.

BACKGROUND: The Institute of Medicine has recommended basic clinical competence in environmental medicine (EM) for all physicians. However, the amount and content of instruction in EM currently offered in U.S. medical schools is unknown. METHOD: This cross-sectional study was based on responses to a questionnaire regarding the EM curriculum content of U.S. medical schools, mailed in June 1994 with the Association of American Medical Colleges curriculum survey. RESULTS: Of the 126 schools, 119 (94%) responded. Of these, 29 (24%) reported no required EM content in the curriculum. Schools with EM content averaged seven hours of instruction. Eighty-one schools (68%) had faculty with environmental and occupational medicine expertise, primarily within the departments of medicine, preventive medicine, and family medicine. CONCLUSION: There is a need for increased instruction in EM in medical school curricula for students to acquire the knowledge and skills to prevent, diagnose, and treat health problems with an environmental exposure component. For those schools without EM content in the curriculum, the necessary expertise to develop EM curriculum may be available in current faculty.

Incongruence between self-reported symptoms and objective evidence of respiratory disease among construction workers.

In clinical settings, self-reported symptoms and objective evidence of disease may be poorly correlated. In the present study, symptoms and objective evidence of pulmonary disease were compared in a community sample of construction workers with occupational exposure to asbestos. Symptoms of dyspnea and cough were assessed by a standardized questionnaire. The clinical examination included a chest X-ray, pulmonary function testing (PFT), and a physical examination. Both symptoms and objective clinical findings were strongly related to years in these trades. However, less than 1% of workers reported symptoms in the absence of any clinical evidence of disease. A similar low percentage of workers denied any symptoms yet produced clear evidence of pulmonary disease on clinical examination. Results were interpreted in terms of the variety of factors which have been associated with patients' readiness, and conversely, reluctance to report symptoms. The comparatively low frequency of incongruence between symptoms and objective clinical findings in this study suggests over emphasis of malingering by other authors. Health care might be improved if more attention is given by clinicians and researchers to patients who fail to report symptoms in the presence of disease.

Termination of health benefits for Pittston mine workers: impact on the health and security of miners and their families.

Mine workers represented by the United Mine Workers of America (UMWA) have had comprehensive medical care coverage since 1950. On February 1, 1988, UMWA employees of the Pittston Coal Group had their health care benefits abruptly terminated. Renewal of these benefits became a major reason for the subsequent UMWA strike against Pittston. In December, 1989, physician interviewers were organized to document the human experience of this termination of health care benefits. This report summarizes these interviews, and concludes that the UMWA experience in the Pittston coal fields is one example of the barriers to health care experienced by an increasing proportion of the United States population.

Consistency of occupational exposure history from pattern and model makers.

This study investigates the consistency of occupational histories reported by the same men in 1985 and again in 1988. Detroit-area pattern and model makers participating in a colorectal cancer screening program that was offered at 3-year intervals completed a career length occupational exposure questionnaire at each screening. Analysis of the data from the 243 men who participated in both screening programs provided the opportunity to examine the consistency with which these workers reported the extent of their exposure to 13 substances commonly found in their work environment. Workers were asked to provide a work history, and for each different pattern or model maker job they had held, to estimate the percentage of time they were exposed to the 13 substances. The data indicated that over the 3-year study period, pattern and model makers were highly consistent in reporting whether or not they were exposed to the 13 substances. In addition, their first estimates of the percentage of time they were exposed to each substance were within 10% of their second estimates more than 70% of the time. This concordance was somewhat diminished after excluding those who reported no exposure. These findings suggest that skilled tradesman can provide occupational exposure information that is likely to be useful for physicians in considering an occupational cause for a presenting health concern.

Managing up in times of financial crisis.

The use of managing up in an institution's time of financial crisis is described. The goals of crisis management include survival, maintaining quality and service, learning issues and impacts, supporting the team, and preparing for the aftermath as the crisis subsides. Survival calls for a commitment by leaders to remain focused, and to maintain and support the management team. Pharmacy directors must be able to adapt to chaos and to the limited information disseminated by senior leadership. Identifying the underlying cause of the crisis, which may not be directly related to the measures taken to resolve it, is also critical to survival. Among the keys to maintaining quality and service are keeping the staff focused on patient care and maintaining credibility by sharing all information that is available. Pharmacy directors need to maintain the confidence of their staff members and to encourage them to do the best they can with the resources available. Taking the initiative to acquire appropriate data, to translate that data into relevant information, and to seek benchmarks for comparison is also important. Once the crisis has passed, attention must be given to updating and maintaining databases, supporting the staff, and improving morale. Scenario planning can help identify measures that might be taken if another crisis should develop. Using principles of managing up can prepare pharmacy directors for optimal response to an institutional financial crisis.

Use of medical services during a 2-month period in the Seattle-King County (Washington) jail.

Total health care utilization in the Seattle-King County jail over a 2-month period in spring 1979 was studied. The annualized visit rate for men was 48 per prisoner per year, 2.6 times the rate for men studied in a long-term prison and almost 20 times the rate for men studied in the general population. The annualized rate for female prisoners was three times that of male prisoners. For all prisoners, the most common problems seen were skin conditions (9.7 percent), musculoskeletal (8.3 percent), and psychiatric (8.2 percent). An examination of practitioners' patterns in providing care demonstrated the primary role of registered nurses, who saw 70 percent of the patients. During the study period, 125 transfers were made to a hospital; 48.8 percent were for medical problems, 41.6 percent for trauma, and 9.6 percent for psychosocial problems.

Lymphocytopenia and occupational exposures among pattern and model makers.

OBJECTIVES: The study was performed to examine the relationship between a high prevalence of lymphocytopenia observed during a cancer screening program for pattern and model makers, who produce industrial prototypes and patterns, and 15 occupational exposures. METHODS: The cases (N = 83) were workers with lymphocyte counts of less than 1000, while the referents (N = 529) had counts of 1500 or higher. Exposures at the current workplace, and at up to 19 previous pattern and model shops, were assessed with the use of a questionnaire. RESULTS: Elevated risks were associated with exposure to epoxy resins [odds ratio (OR) 1.94, 95% confidence interval (95% CI) 1.02-3.70) and plastic dusts (OR 2.60, 95% CI 1.19-5.68) after adjustment for age and smoking status. No clear associations were found with duration of exposure or percentage of time potentially exposed. Although the results were based upon small numbers, epoxy resins and wood dust displayed the most consistent relationships in an analysis of changes in lymphocyte count and exposure status over time. CONCLUSION: While firm conclusions cannot be drawn, the strongest associations observed in this study were for exposure to epoxy resins.

Prostate cancer trends in southeast Michigan 1973-1992.

Prostate cancer incidence has been increasing in the United States (US) for many decades. This increased has been accelerating since 1989. It is speculated that this trend of increased incidence is due primarily to the use of the prostate specific antigen (PSA) screening test. This study describes prostate cancer trends in southeast Michigan since 1973.

Some potential pitfalls associated with the use of computers and microprocessors.

Although digital computers and microprocessors are marvelously sophisticated devices, users are well advised to be aware of certain possible drawbacks associated with their use in the clinical environment. One relates to flawed software, the use of which can generate spurious data upon which subsequent treatment decisions might be based. Another drawback may arise when the computational power of a computer is tapped to generate data that, though mathematically correct, are interpreted in the context of physiologic assumptions that may themselves be faulty. Finally, one must resist the temptation to use computers solely "because they are there." Certain tasks are better left undone, and one must exercise restraint and not plunge into a task simply because a computer is very well suited for that task.

Administration of ribavirin to neonatal and pediatric patients during mechanical ventilation.

We have modified the circuits of pressure-preset and volume-preset ventilators to permit the administration of ribavirin to mechanically ventilated infants suffering from respiratory syncytial virus. The modifications isolate the ventilator itself and permit continuous aerosolization for as long as seven days without ventilator malfunction from the effects of crystallized medication. Excessive spilling of ribavirin into the environment is also avoided. Each institution must devise its own experimental protocols and gain permission from its own committee on human experimentation and from the parent/guardian of the patient before administering such treatment.

An outbreak of acinetobacter infection associated with the use of a ventilator spirometer.

Although respiratory therapy equipment is a well-known source of nosocomial infection, ventilator spirometers have not been previously implicated. We report 17 Acinetobacter calcoaceticus variety anitratus infections traced to contaminated spirometers. Isolates from infected patients were recovered from urine, sputum, wounds, and blood. A review of attack rates for Acinetobacter was prompted by a dramatic increase in blood culture isolates. Prospective surveillance of intensive care environment, personnel, and patients established that Bennett MA-1 spirometers constituted the major reservoir of infecting organisms. Despite daily sterilization, 30% of spirometers in use were found to be contaminated. The hands of 12% of intensive care nurses and 10% of respiratory therapists cultured were found to be colonized. In addition to the infected patients, 28 other patients on spirometer-equipped ventilators were judged to be colonized by Acinetobacter following examination of sputa and/or mouthwashings. Following discontinuation of spirometer use and following increased emphasis on proper handwashing, the incidence of Acinetobacter infections dropped dramatically. Antibiosis in the intensive care environment and a deterioration in aseptic awareness serve to make Acinetobacter an environmental opportunist of increasing importance.

Health care seeking behaviors of family practitioners.

Questionnaires were sent to 358 family physicians in the state of Michigan, asking which medical specialists provided most of the primary medical care for themselves and their families, and which type of specialists they would attend for ten specific medical problems. A total of 221 (62%) of the questionnaires were adequately completed and returned. They indicated that a majority of the primary care provided respondents and their family members was by a physician other than a family practitioner. Care seeking behaviors were not significantly different between practitioners who were family practice residency trained and those who were not, except in the care given to the respondent's spouse, when a family practitioner was used more often. The responses also revealed that the majority of office visits for three of the specific medical problem categories were made to family practitioners, while in four other categories the majority of visits were to specialists. Approximately half of the visits in the remaining three categories were made to family practitioners. There is an apparent discrepancy between the tenet that family physicians can competently care for a vast majority of medical problems and their actual care seeking behaviors.

The home visit in resident education: program description and evaluation.

A home visit rotation was developed to provide family practice residents with a more comprehensive understanding of the effect of patient life-style on health status. The rotation emphasizes geriatric, community, and rehabilitative medicine. In addition, the curriculum addresses issues related to patient compliance, assessment of activities of daily living, patient psychosocial needs, community services, and exposure to medical equipment of potential use to homebound individuals. Over a three-year period, 209 home visits were made. Program evaluation data suggest that at the end of the three-month rotation, residents were less concerned with personal safety and more likely to agree that home visits were an important part of residency training. A comparison of pre- and post-test knowledge scores indicated significant increases in geriatric medicine, patient compliance issues, patient functional status, and community services. A follow-up telephone interview with patients found that some patients experienced anxiety when the home visit was scheduled, but the majority were positive about the experience.