Neoadjuvant chemoradiotherapy with concurrent cisplatin/5-fluorouracil is associated with increased pathologic complete response and improved survival compared to carboplatin/paclitaxel in patients with locally advanced esophageal cancer.

Trimodal therapy consisting of neoadjuvant chemoradiation followed by esophagectomy has become the standard of care in North America for locally advanced esophageal cancer. While cisplatin/5-fluorouracil has been a common concurrent chemotherapy regimen since the 1980s, its utilization has declined in recent years as the Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study (CROSS) trial regimen of carboplatin/paclitaxel has become widely adopted. The efficacy of the CROSS regimen compared to alternate chemotherapy choices, however, has rarely been evaluated when each is used as a component of a trimodal treatment approach. The aim of this study is to report our institutional experience with these two concurrent chemotherapy regimens at a specialized esophageal cancer center.We performed an Institutional Review Board-approved retrospective review of a prospectively maintained institutional foregut registry from a single National Cancer Institute-designated cancer center. Esophageal cancer patients who completed trimodal therapy with a chemotherapy regimen of either carboplatin/paclitaxel or cisplatin/5-fluorouracil were identified and divided into groups based on their chemotherapy regimens. Multivariable logistic regression was used to analyze pathologic complete response rates, while the Kaplan-Meier and Cox proportional hazards models were utilized to evaluate recurrence-free and overall survival. Analytical models were adjusted for age, clinical stage, radiation dose, histologic subtype (adenocarcinoma vs. squamous cell carcinoma), and time interval from completion of neoadjuvant therapy to surgery.One hundred and forty-two patients treated between January of 2000 and July of 2015 were identified as meeting inclusion criteria. Of this group, 87 had received the CROSS regimen of carboplatin/paclitaxel, while 55 had completed cisplatin/5-fluorouracil. Multivariable analysis demonstrated that the cisplatin/5-fluorouracil.group had an increased odds of pathologic complete response (odds ratio = 2.68, 95% confidence interval, P = 0.032), as well as significantly improved recurrence-free survival (hazard ratio = 0.39, 95% confidence interval 0.21-0.73, P = 0.003) and overall survival (hazard ratio = 0.46, 95% confidence interval 0.24-0.87, P = 0.016), compared to the carboplatin/paclitaxel group.Concurrent chemotherapy with cisplatin/5-fluorouracil in locally advanced esophageal cancer is associated with higher rates of pathologic complete response and improved recurrence-free and overall survival compared to the CROSS regimen of carboplatin/paclitaxel. This suggests that, for select patients, alternate neoadjuvant chemotherapy approaches, such as cisplatin/5-fluorouracil, merit reconsideration as potential primary treatment choices in the management of this highly morbid disease.

Effect of frequency of feed delivery on the behavior and productivity of lactating dairy cows.

The objective of this study was to determine the effect of feed delivery frequency on the behavioral patterns and productivity of lactating dairy cows. Twelve freestall-housed, lactating Holstein dairy cows, including 6 primiparous (PP) and 6 multiparous (MP), milked 3 ×/d (at 1400, 2200, and 0600 h), were exposed to each of 3 treatments (over 21-d periods) in a replicated Latin square design. Treatments included feed delivery frequency of (1) 1 ×/d (at 1400 h), (2) 2 ×/d (at 1400 and 2200 h), and (3) 3 ×/d (at 1400, 2200, and 0600 h). Milk production as well as feeding, lying, and rumination behaviors were electronically monitored for each animal for the last 7d of each treatment period. Milk samples were collected for the last 3d of each period for milk component analysis. Dry matter intake (DMI) varied with feed delivery frequency, with greatest DMI observed in cows fed 3 ×/d (27.8 kg/d) compared with those fed 2 ×/d (27.0 kg/d) or 1 ×/d (27.4 kg/d). Treatment had no effect on milk yield (41.3 kg/d) or efficiency of production (1.54 kg of milk/kg of DMI). Cows that did not receive delivery of feed following the 2200 h milking (treatment 1) and 0600 h milking (treatments 1 and 2) had lower DMI during the first hour after milking than those that received feed at all milkings (treatment 3). Total feeding time and meal frequency, size, and duration did not vary by treatment, but PP cows consumed smaller meals at a slower rate, resulting in lower DMI compared with MP cows. Primiparous cows consumed 50.1% and 26.1% less dry matter than MP cows during the first meal following the first and second milkings, respectively. Lying time did not vary by treatment, but PP cows spent more time lying (10.3 vs. 8.3h/d) than MP cows. Under 3 ×/d milking schedules, greater feed delivery frequency resulted in greater DMI as a function of increased DMI following the return from milking and the delivery of feed.

Effect of milking frequency on the behavior and productivity of lactating dairy cows.

The objective of this study was to determine the effect of milking frequency on the behavioral patterns and productivity of lactating dairy cows. Twelve freestall-housed, lactating Holstein dairy cows (7 primiparous and 5 multiparous) were exposed to each of 2 treatments (over 21-d periods) in a replicated crossover design. Treatments were milking frequency of 2× /d (at 0600 and 1800 h) or 3× /d (at 0600, 1400, and 2200 h). Milk production, feeding, lying, and rumination behavior were monitored for each animal for the last 7d of each treatment period. Milk samples were collected for the last 3d of each period for milk component analysis. The results indicated that cows milked 3× /d produced 2.9 kg/d more milk than those milked 2× /d. Primiparous cows consumed 3.9 kg/d less dry matter (DM) than did multiparous cows. The extra time (14.6 min/d) required for milking 3× /d altered the distribution of cow behavioral activity throughout the day. Although this did not affect total daily lying or rumination time, we observed a tendency for cows milked 2× /d to spend less time (224.6 vs. 237.5 min/d) feeding and, thus, those cows tended to consume their feed at a faster rate (0.13 vs. 0.12 kg of DM/min) than cows milked 3× /d. For multiparous cows, the increase in feeding activity was facilitated through having longer (40.1 vs. 36.8 min/meal) and numerically larger meals (4.8 vs. 4.6 kg of DM/meal) when milked 3× /d. Alternatively, primiparous cows consumed smaller (2.9 vs. 3.2 kg of DM/meal) and more frequent meals (9.1 vs. 7.7 meals/d) throughout the day when milked 3× /d, resulting in a tendency for greater DM intake (24.7 vs. 23.6 kg/d) compared with primiparous cows milked 2× /d. These results indicate that under 3× /d milking schedules, primiparous cows will positively adjust their feeding behavior to achieve similar production increases as multiparous cows. In summary, milking 3× /d can be used to improve production; however, greater milking frequency elicits varying effects on the behavior of primiparous and multiparous cows, suggesting that grouping and management of cows based on parity may be beneficial.

Evaluating large and complex demonstrations: the CHAMPUS reform initiative experience. Civilian Health and Medical Program of the Uniformed Services.

OBJECTIVE: To examine the evaluation process for the CHAMPUS Reform Initiative (CRI) both to highlight issues that evaluators must consider when undertaking such projects and to provide policymakers with tools to better assess demonstration project evaluations. DATA SOURCES: The CRI evaluation. STUDY DESIGN: Case study. DATA COLLECTION: Review of CRI evaluation reports. PRINCIPAL FINDINGS: Although policymakers increasingly rely on the evaluations of demonstration projects to determine whether to extend the scope and funding of many public programs, the results of these evaluations are often difficult to assess. Despite its analytical sophistication, the CRI evaluation was no exception. The somewhat artificial time constraints imposed by policymakers made projection of the CRI's performance beyond the demonstration period particularly difficult. CONCLUSIONS: Much uncertainty generally remains even after well-planned and well-executed evaluations of demonstration projects.

Metropolitan governance, residential segregation, and mortality among African Americans.

OBJECTIVES: This study tested the hypothesis that the degree to which local government is metropolitanized is associated with mortality rates for African Americans and with residential segregation, which has itself previously been shown to be positively associated with mortality among African Americans. METHODS: One hundred fourteen US standard metropolitan statistical areas were examined. The primary dependent variable was the age-adjusted, race- and sex-specific all-cause mortality rate, averaged for 1990 and 1991. The 2 primary independent variables were residential segregation, as measured by the index of dissimilarity, and metropolitanization of government, as measured by the central city's elasticity score. RESULTS: Mortality rates for male and female African Americans were lower in metropolitan statistical areas with more metropolitanized local governments and lower levels of residential segregation. Mortality for male and female Whites was not associated in either direction with residential segregation. White male mortality showed no association with level of metropolitanization, but lower White female mortality rates were associated with less metropolitanization. CONCLUSIONS: This study suggests the need for further research into whether policy changes in areas not traditionally thought of as "health policy" areas can improve the health of urban minorities.

PIP: The relationship between metropolitanization and mortality among African Americans in the United States is analyzed using data from 114 standard metropolitan statistical areas for 1991-1992 taken from the NCHS Mortality Detail Files and the census. The results confirm the finding that segregation is positively associated with mortality among adult African Americans. The results also indicate that less metropolitanization is associated with more segregation.