Is hypovitaminosis D associated with abdominal aortic aneurysm, and is there a dose-response relationship?

OBJECTIVE: This study aims to investigate the association between plasma 25-hydroxyvitamin D (25(OH)D) concentrations with the presence of abdominal aortic aneurysm (AAA) and aortic diameter. DESIGN: An observational study of 4233 community-dwelling men aged 70-88 years, who participated in a randomised controlled trial of screening for AAA. METHODS: Infrarenal aortic diameter measured by ultrasound and 25(OH)D by immunoassay. RESULTS: A total of 311 men (7.4%) with AAA (defined as aortic diameter ≥ 30 mm) comprised the study. Multivariable models were adjusted for age, smoking, cardiovascular disease, hypertension, diabetes, dyslipidaemia, body mass index and serum creatinine concentration. Amongst men with the lowest 25(OH)D quartile of values compared with the highest quartile, the adjusted odds ratio of having an AAA increased in a graded fashion from 1.23 (95% confidence interval (CI) 0.87-1.73) for AAA ≥ 30 mm to 5.42 (95% CI 1.85-15.88) for AAA ≥ 40 mm. Similarly, there was a dose-response relationship between 25(OH)D concentrations and the size of the AAA: every 10-nmol l(-1) decrease in 25(OH)D levels was associated with 0.49 mm (95% CI 0.11-0.87) increase in mean aortic diameter. CONCLUSIONS: Low vitamin D status is associated with the presence of larger AAA in older men, and there is a graded inverse relationship between 25(OH)D concentrations and AAA diameter. Further research is needed to clarify the mechanisms underlying these associations.

Aspirin decreases the risk of depression in older men with high plasma homocysteine.

High total plasma homocysteine (tHcy) is associated with increased risk of cardiovascular events and depression. Consumption of B-vitamins (B6, B9 and B12) reduces tHcy by about 15%, but has equivocal effects on these health outcomes, suggesting that this relationship is either not causal or is confounded by other factors. The results of recent randomized trials suggest that antiplatelet therapy may confound these associations. This cross-sectional study assessed 3687 men aged 69-87 years for history of clinically significant depression (Geriatric Depression Scale 15 items 7) or a recorded diagnosis of depression in the Western Australian Data Linkage System, and collected information on the use of aspirin, B-vitamins and antidepressant medication, along with age, education, living arrangements, smoking history and medical comorbidity as assessed by the Charlson index. Participants donated a blood sample for the measurement of tHcy, and concentrations15 µmol l(-1) were considered high. Five hundred and thirteen (13.9%) men showed evidence of depression, and of those 31.4% had high tHcy, 41.5% were using aspirin, 6.8% were consuming B-vitamins. Multivariate logistic regression showed that high tHcy was associated with increased odds of depression (odds ratio (OR)=1.60, 95% confidence interval (CI)=1.20-2.14), as was the use of B-vitamins (OR=1.95, 95% CI=1.21-3.13). There was a significant interaction between high tHcy and aspirin use (OR=0.57, 95% CI=0.36-0.91), but not between high tHcy and B-vitamin use (OR=0.80, 95% CI=0.26-2.46). The analyses were adjusted for smoking status, Charlson index and use of antidepressants. The results of this study indicate that older men with high tHcy who use aspirin have lower risk of depression, and suggest that antiplatelet therapy may be an effective preventive or management strategy for these cases. Randomized trials are required to confirm the antidepressant effect of aspirin in people with high tHcy.

Associations of total osteocalcin with all-cause and cardiovascular mortality in older men. The Health In Men Study.

SUMMARY: In older men, both lower and higher total osteocalcin levels predict increased all-cause mortality, with comparable associations for cardiovascular and non-cardiovascular deaths. Differences in osteocalcin levels might influence glucose metabolism and thereby cardiovascular risk, or reflect changes in bone turnover thus representing a marker for poorer health outcomes. INTRODUCTION: Reduced levels of total osteocalcin (TOC) are associated with adiposity, insulin resistance and type 2 diabetes, implying this bone-derived peptide might modulate cardiovascular risk. However, there are few longitudinal data relating TOC levels to survival. We examined associations of TOC level with all-cause and cardiovascular mortality in older men. METHODS: We conducted a prospective cohort study of community-dwelling men aged 70-89 years. Aliquots of plasma collected at baseline (2001-2004) were assayed for TOC. Incidence and causes of death to 31 December 2008 were ascertained using data linkage. Cox regression analyses were performed with adjustment for conventional cardiovascular risk factors. RESULTS: From 3,542 men followed for median 5.2 years there were 572 deaths (16.1%). Mortality was lowest in men with TOC levels in the second quintile (12.6%). In multivariate analyses, men with TOC in the lowest and highest quintiles of values had increased all-cause mortality (Q1 vs Q2: hazard ratio [HR], 1.36; 95% confidence interval 1.02-1.80 and Q5 vs Q2: HR, 1.53, 95% CI 1.18-1.98). Men with low TOC levels had similar HR for cardiovascular and non-cardiovascular deaths (Q1 vs Q2: HR, 1.35 and 1.30 respectively). Higher TOC levels predicted cardiovascular disease (CVD)-related mortality (Q5 vs Q2, HR, 1.69, 95% CI 1.09-2.64). CONCLUSIONS: TOC predicts all-cause and CVD-related mortality in community-dwelling older men. However, the relationship is U shaped with men at both ends of the distribution at increased risk. Further investigation is required to clarify whether the underlying mechanisms involve altered bone turnover or relate specifically to the biological activity of osteocalcin.

Population-based study of prognostic factors in stage II colonic cancer.

BACKGROUND: Adjuvant chemotherapy in stage II colorectal cancer may be considered for patients whose tumours have poor prognostic features. The aim of this study was to evaluate the prognostic significance of commonly reported clinical and pathological features of stage II colonic cancer. METHODS: A population-based observational study of all patients with stage II colonic cancer diagnosed in the state of Western Australia from 1993 to 2003 was performed. A total of 1306 patients treated by surgery alone were identified, with a median follow-up of 59 (range 0-145) months. RESULTS: Multivariable analysis revealed that the only independent prognostic factors for disease-specific survival were stage T4 (hazard ratio (HR) 1.75 (95 per cent confidence interval (c.i.) 1.32 to 2.32); P < 0.001) and vascular invasion (HR 1.63 (95 per cent c.i. 1.15 to 2.30); P < 0.001). In younger patients (aged 75 years or less), who are more likely to be considered for chemotherapy, these two features showed independent prognostic significance but with higher HR values (1.96 for stage T4 and 2.73 for vascular invasion). Stage T4 and/or the presence of vascular invasion identified a 'poor' prognostic group, comprising 26.6 per cent of younger patients and with a 5-year survival rate of 71.2 per cent. The remaining 'good' prognostic group had a survival rate of 84.3 per cent at 5 years' follow-up. CONCLUSION: This study highlights the importance of accurate pathological assessment of tumour stage and vascular invasion for the prognostic stratification of patients with stage II colonic cancer. The results provide clarification of guidelines for the management of stage II disease in relation to recommendations for chemotherapy.

Adverse effects to quality of life arising from treatment can recover with intermittent androgen suppression in men with prostate cancer.

Health-related quality of life (HQOL) research is a means of broadening the assessment of treatment effects. This longitudinal study investigated the dynamic change to quality of life (QOL) and testosterone dependant physiology in men commencing an intermittent maximal androgen blockade program (IMAB). Two hundred and fifty men were accrued to the multi-centre study of IMAB (Flutamide 250 mg TDS, Leuprolide 22.5 mg depot) ceasing treatment after 9 months if PSA <4 ng/ml, and restarting when PSA >20 ng/ml. QOL was assessed every 3 months for 30 months using the EORTC QLQ-C30 and EORTC QLQ-PR25 module. Data completion for the whole study was 90%. At baseline, our cohort was less symptomatic and had better function than the EORTC reference cohort, which may be related to a shift in clinical practice with time. Testosterone suppression (AS) lead to a significant reduction in global HQOL and deterioration in most function and symptom scales. During the off period, there was a trend of progressive improvement in HQOL that paralleled testosterone recovery but was slower than the rate of deterioration during the treatment phase. Maximum recovery of HQOL occurred most frequently by months 9-12. Testosterone recovery was slower and less complete in older men, and lead to concomitant poorer HOQL recovery. Whilst the magnitude of mean change to scale scores was small, there was a consistent and simultaneous deterioration during maximal androgen blockade (MAB) and improvement during androgen recovery. Older men are more likely to show an impaired testosterone recovery, and this was paralleled by a slower HQOL recovery. Newer methods of analysis to describe results in a way that has meaning to the individual patient are warranted.

Validation of a water consumption questionnaire for a study of the adverse health outcomes associated with disinfection by-products.

The aim of this study was to assess the validity and reliability of a questionnaire to estimate water exposure through drinking, showering, bathing or swimming. Forty-seven pregnant women were recruited from antenatal or exercise classes and were randomly allocated into three groups. The first group completed the water exposure questionnaire one-week apart. The second group completed a three-day diary and then the questionnaire. The third group completed the questionnaire first followed by the diary. Agreement was assessed by the Intraclass correlation coefficient (ICC) and the Kappa statistic. The questionnaire demonstrated good reliability (ICC 0.93 for water consumption and 0.91 for time spent showering). With regard to validity, average daily water consumption was estimated to be 8.1 glasses/day (2 litres) from the diary compared with 12.2 (3 litres) from the questionnaire. The ICCs comparing the diary and questionnaire responses were 0.31 for water consumption and 0.72 for showering. The water exposure questionnaire overestimated levels of exposure when compared with diary-reporting of consumption. While a water exposure questionnaire may be a less intrusive research instrument than a diary, further development is required to improve the validity of this instrument.

Barriers to success for an evidence-based guideline for chronic obstructive pulmonary disease.

OBJECTIVES: To evaluate 1) barriers to clinical guideline use and 2) the relationship between guideline use and inpatient outcomes in chronic obstructive pulmonary disease (COPD). METHODS: 1) Four focus groups of specific health professions (n = 30), from three metropolitan hospitals, and interview of 99 medical officers (MOs), linked to 349 admissions, both guided by behavioural modelling theory; 2) association between guideline use and patient outcomes (length of hospital stay > or = 14 days, and readmission within 28 or 90 days) was evaluated in a cohort of 405 COPD patients. RESULTS: 1) In focus groups, nurses and allied health professionals emphasized facilitation issues including paperwork duplication and time limitations as barriers, but considered improved patient care outcomes as the major guideline use determinant. There were similar findings in junior MOs (nonconsultants) by both focus group and interview, with the addition of a need for a sense of ownership. Senior MOs (consultants) greatly emphasized sense of ownership. Barriers to guideline use varied between types of units. Behavioural modelling explained 49% of the variation in intention to use the guideline for MOs. For nonconsultants, habit and intention were significantly associated with extent of guideline use. 2) Patient outcomes: guideline use was not associated with length of stay or readmission. CONCLUSIONS: 1) Guideline implementation should address issues relevant to different health professions, units and seniority of profession. 2) Guideline use was not associated with reductions in readmission or length of stay.

Trends in coronary artery revascularisation procedures in Western Australia, 1980-2001.

OBJECTIVES: To describe trends in the use of coronary artery revascularisation procedures (CARPs) and to determine whether or when CARP rates will stabilise. SETTING: State of Western Australia. PATIENTS: All patients treated by coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) between 1980 and 2001. DESIGN: Descriptive study. MAIN OUTCOME MEASURES: Age standardised rates of first and total CARPs, CABGs, and PCIs. RESULTS: Overall rates for both total and first CARPs among men and women rose steeply from 1980 to 1993, when they abruptly stabilised or actually started to decline. Rates in age groups under 65 years tended to rise earlier in the period and remained relatively flat, while rates for people over the age of 75 years started to rise later and were still increasing at the end of the study. CONCLUSIONS: Despite continuing increases in capacity to perform both CABG and PCI in Western Australia and evidence of continuing increases in the use of CARPs in the elderly population, rates appear to have stabilised for the first time since they were introduced.

Trends in two year risk of repeat revascularisation or death from cardiovascular disease after coronary artery bypass grafting or percutaneous coronary intervention in Western Australia, 1980-2001.

AIMS: To investigate whether, over the 21 year period 1980-2001, there had been a reduction in the risk of repeat revascularisation or death from cardiovascular disease in the cohort of all patients who were treated by coronary revascularisation in Western Australia. SETTING: State of Western Australia. PATIENTS: All patients treated by coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) between 1980 and 2001. DESIGN: Cohort study. MAIN OUTCOME MEASURES: Risk of repeat coronary artery revascularisation procedures (CARP) and risk of death from cardiovascular disease after first CARP. RESULTS: After a CABG procedure, the two year risk of repeat revascularisation remained low (less than 2%) across the period 1980-2001. For PCI, however, this risk declined significantly from 33.6% in 1985-9 to 12.4% in 2000-1. The risk of death from cardiovascular disease after a CARP declined by about 50% between 1985 and 2001. CONCLUSIONS: Outcomes such as the risk of repeat revascularisation and the risk of death from cardiovascular disease have improved significantly for patients who underwent CARPs across the period 1980-2001. This has occurred despite an increasing trend in first CARP rates among older people and those with a recent history of myocardial infarction.

Prevalence of gastroenteritis among 4-year-old children in South Australia.

The aim of this study was to determine the prevalence of gastroenteritis among children aged 4 years in South Australia. A cross-sectional survey of 9543 South Australian children aged 4 years was undertaken. Parents completed a questionnaire on behalf of their child who had attended a pre-school health check in 1998. The questionnaire covered gastrointestinal and respiratory symptoms experienced by the child in the previous 2 weeks and other risk factors for gastroenteritis. The 2-week prevalence of gastroenteritis among 4-year-old children was 14.2%. The major risk factors for gastroenteritis were presence of persons who had gastroenteritis inside the home, contact with persons who had gastroenteritis outside the home, antibiotic use and sore throat. Medical attention was sought for 20% of children who had gastroenteritis. Gastroenteritis is a significant cause of morbidity among young children and presents a considerable burden on the community. A substantial proportion of these occurrences of highly credible gastrointestinal symptoms may be manifestations of respiratory infections.

Changing incidence of primary total hip arthroplasty and total knee arthroplasty for primary osteoarthritis.

This study reports on the incidence of primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) for primary osteoarthritis in Australia. Age-specific and gender-specific numbers for Australia, 1994 through 1998, and South Australia, 1988 through 1998, were obtained. Incidences were calculated per 100,000 population. In Australia, primary THA increased from 50.9/10(5) (1994) to 60.9/10(5) (1998). TKA increased from 56.4/10(5) to 76.8/10(5). Stratified by age and gender, changes in incidence for South Australia with respect to time were tested using regression analysis. South Australia showed a significant increase in the overall incidence of THA (P=.012) and TKA (P<.001), although this was not uniform across all age groups. No significant gender differences were found. The incidence of THA is increasing, and the incidence of TKA is increasing at a greater rate.

Characteristics of responding-, nonresponding- and refusing-parents in an adolescent lifestyle choice study.

The acquisition of a random sample is one of the many methodological problems that arise when conducting research with adolescent populations. Frequently, due to ethical considerations associated with collecting data from adolescents, active parental consent procedures are required. The current study examined characteristics of parents who consented, refused consent, or did not respond to an active consent request for their children to participate in a large-scale study of adolescent lifestyle behaviors. Results indicated nonresponding-parents were more likely to be employed than consenting-parents. Further, differences were found for a number of attitudinal variables and about the importance of adolescent research. There were significant differences between refusing-parents, and consenting- and nonresponding-parents who were similar in their attitudes toward adolescent research. The findings suggest that nonresponding-parents are characteristically more similar to consenting-parents than to refusing-parents, which supports the use of passive consent procedures as a reasonable alternative to requiring active parental consent in adolescent research.

Ki-ras mutation type and the survival benefit from adjuvant chemotherapy in Dukes' C colorectal cancer.

Ki-ras mutations are associated with an increased risk of relapse and death in colorectal cancer (CRC) patients, with some mutations being more aggressive than others. The present study examined the predictive value of different Ki-ras mutation types in a retrospective series of 430 Dukes' C stage CRC patients, of whom 208 (48%) had received adjuvant chemotherapy with 5-fluorouracil/levamisole or 5-fluorouracil/leucovorin. A total of 140 mutations were detected, the majority (58%, 81/140) being glycine to aspartate mutations in codons 12 and 13. Glycine to valine mutations in codon 12 (14%, 20/140) and other less frequent, non-specified mutation types (28%, 39/140) accounted for the remaining mutations. Kaplan-Meier survival analysis revealed that both Ki-ras wild-type and mutant patient groups derived significant survival benefit from chemotherapy. However, when patients were stratified according to the type of mutation, those with non-aspartate mutations appeared to gain more benefit from this treatment than those with aspartate mutations. Multivariate analysis that included other possible predictive factors in Dukes' C CRC (tumour site, patient sex, TP53 mutation) demonstrated that non-aspartate mutations in particular were associated with a significant survival benefit from chemotherapy (HR=0.11, 95% CI: 0.04-0.30, p<0.001). These results suggest that the type of Ki-ras mutation could be a clinically useful molecular marker for the identification of CRC subgroups that are likely to benefit from 5-fluorouracil-based adjuvant chemotherapy.

P53 alteration and microsatellite instability have predictive value for survival benefit from chemotherapy in stage III colorectal carcinoma.

PURPOSE: We recently presented evidence for tumor site and gender-specificity in the survival benefit from adjuvant chemotherapy in Stage III colorectal cancer (CRC). In the current study, we examined whether p53 alteration or the microsatellite instability (MSI) phenotype provide additional predictive information in CRC patients. EXPERIMENTAL DESIGN: A retrospective series of 891 Stage III CRC patients with negative surgical margins was investigated. Thirty percent (270 of 891) received postoperative adjuvant chemotherapy with curative intent and comprising of 5-fluorouracil/levamisole. Adjuvant treatment and nontreatment patient groups were well matched for tumor site, grade, p53 alterations, and MSI. Surgical tumor specimens were investigated for p53 overexpression using immunohistochemistry and for p53 mutation and MSI using single-strand conformation polymorphism analysis. The predictive value of these markers was evaluated by comparing the survival of adjuvant-treated and nonadjuvant treated patients. RESULTS: A strong inverse correlation was observed between p53 alteration and MSI (P < 0.0001). In univariate analysis, the factors of sex, site, p53 alteration, and MSI were each strong predictors of a survival benefit from chemotherapy. Multivariate analysis revealed that chemotherapy provided maximal survival benefit for female patients (P = 0.005) and for patients whose tumors contained normal p53 (P = 0.041). Males whose tumors contained a p53 alteration and were negative for MSI appeared not to benefit from chemotherapy. CONCLUSIONS: Our findings suggest that p53 alteration and MSI could be clinically useful molecular predictive markers for the identification of CRC patients who might benefit from 5-fluorouracil-based chemotherapy.

Mortality from aortic aneurysms in Australia, 1968 to 1997.

OBJECTIVES: Describe trends in mortality for aortic aneurysms in Australia for the period 1968 to 1997. DESIGN: Descriptive study of time trends in mortality. MAIN OUTCOME MEASURE: Age-sex-standardised mortality rates with statistical analysis of trends using negative-binomial regression. RESULTS: While overall mortality rates for aortic aneurysms remained relatively constant for the period 1968 to 1992 in Australia, there has been a small but significant reduction in the rate from then until the end of the series in 1997. When different types of aneurysms are considered, there have been increases in the rates associated with abdominal aortic aneurysms and thoracic aortic aneurysms, while those for dissecting aortic aneurysms have declined. Most significantly, mortality rates for unspecified aortic aneurysms have declined. CONCLUSION: Aortic aneurysm mortality has declined in Australia in recent years. The reasons for this are unclear. While there have been increases associated with abdominal aortic aneurysm mortality, this is likely to be a result of more precise coding of death rather than any real increase in mortality.

Use of fake tanning lotions in the South Australian population.

OBJECTIVE: To explore the relationship between the use of fake tanning lotions and repeated sunburn among South Australian adults, with a view to informing the Anti-Cancer Foundation of South Australia's (ACFSA) policy on fake tanning products. STUDY DESIGN: Population survey. PARTICIPANTS: 2005 South Australians aged 18 years or older, selected randomly from the electronic White Pages. MAIN OUTCOME MEASURES: Self-reported use of fake tanning lotions in the past 12 months; frequency of sunburn over summer; and various sun-protective behaviours. RESULTS: 2,005 of the 2,536 eligible participants (79%) were surveyed by telephone. Fake tan use was most prevalent among women (15.9%), people aged 18-24 years (15.4%), and people with household incomes above $40 000 per year (11.9%). Fake tan users were more likely than non-users to use sunscreens (81.3% v 56.5%; P < 0.001), but less likely to take other precautions such as wearing hats (40.9% v 51.0%; P = 0.04) and protective clothing (22.3% v 34.1%; P = 0.005). They were also more likely to report having been burnt more than once over summer (26.2% v 16.5%; P = 0.025). Multivariate analysis indicates a statistically significant association between fake tan use and repeated sunburn (odds ratio, 2.07; 95% confidence interval, 1.17-3.69), which was independent of age, sex, skin type and sun-protection practices. CONCLUSION: Users of fake tanning products may be at greater risk of repeated sunburn. The ACFSA sees no justification at this stage for altering its present policy position of not actively promoting the use of fake tanning lotions as a means of reducing sunburn.

Prevalence of non-specific health symptoms in South Australia.

Non-specific health symptoms are commonly reported in communities exposed to environmental hazards. However these symptoms commonly occur in the general community as a result of lifestyle factors, illness such as cold and allergy, medical treatment, in addition to environmental and occupational exposures. This paper describes the prevalence of non-specific health symptoms in South Australia. A cross-sectional survey of 3016 persons aged 15 years and over across the State was undertaken. Stuffy nose was the most commonly reported symptoms, with a 2-week prevalence of 46%. Headaches, unusual tiredness, cough, sore throat and itchy eyes were each experienced by at least one in five persons in the previous 2-week period. Symptom reporting was greater among females compared with males and higher in younger age groups. These rates provide a useful reference for rates normally found in a community exposed to a broad range of personal, environmental and occupational factors that may lead to these symptoms.

Restrictions on smoking at home and urinary cotinine levels among children with asthma.

OBJECTIVES: The purpose of this study was to determine the extent to which various levels of restrictions on smoking in the home may be associated with children's exposure to environmental tobacco smoke (ETS). METHODS: The methodology consisted of a cross-sectional survey involving 249 children with asthma aged 1 to 11 attending hospital outpatient clinics, with at least one parent who smoked, linked to the child's urinary cotinine to creatinine ratios (CCR). RESULTS: After adjustment for child's age, mother's smoking status, and total parental daily cigarette consumption, a total ban was associated with significantly lower urinary CCR levels (7.6 nmol/mmol) than bans with exceptions or limited smoking in the home. Where exceptions to bans were made (14.9 nmol/mmol), children's urinary CCR levels were no different from homes in which smoking was allowed in rooms the child rarely frequented (14.1 nmol/mmol). These two intermediate levels of restriction were in turn associated with significantly lower CCR levels than unrestricted smoking in the home (26.0 nmol/mmol). CONCLUSIONS: Making exceptions to bans on smoking at home measurably undermines the protective effect of a ban. However, making some exceptions to a ban and limiting smoking to rooms where the child rarely goes may result in reduced exposure to ETS, compared with unrestricted smoking.

Treatment of steroid-resistant acute graft-versus-host disease with rabbit antithymocyte globulin.

Acute graft-versus-host disease (A-GVHD) is a life-threatening complication of allogeneic stem cell transplantation (SCT), and primary therapy consists of high-dose corticosteroids. Patients who fail to respond adequately to corticosteroids require salvage treatment, with anti-T cell antibodies being the most commonly utilized group of agents. We report our institution's experience treating steroid-resistant GVHD in 36 adult patients (median age 39 years, range 24-55) with a rabbit antithymocyte globulin product (thymoglobulin). Eleven patients had undergone sibling SCT (10 histocompatible, 1 one-antigen mismatched) and 25 patients had received unrelated donor bone marrow (17 matched, 8 one-antigen mismatched); 32 patients (89%) had grade III or IV A-GVHD. Thymoglobulin was administered in two different regimens; group 1 patients (n = 13) received 2.5 mg/kg/day x 4-6 consecutive days with maintenance of all other immunosuppressives. Group 2 patients (n = 21) were given the same dose of thymoglobulin on days 1, 3, 5, and 7 with discontinuation of cyclosporine for 14 days, during which the corticosteroid dose was held at 2-3 mg/kg/day. Two patients had severe adverse reactions to thymoglobulin (hypoxemia and hypotension) and could not complete treatment, however, in the other patients, aside from transient leukopenia (25%) and and hepatic dysfunction (25%), the antibody preparation was well tolerated. Of the 34 evaluable patients, 13 patients had a complete response (38%) and 7 patients (21%) had a partial response, for an overall response rate of 59%. Response rate was higher in group 1 patients (77%) compared to group 2 patients (48%), (p = 0.15); skin GVHD was more responsive (96% of patients) than gut GVHD (46% of patients) or hepatic GHVD (36% of patients). Opportunistic infections were a significant complication, with 11 patients developing systemic fungal infections and 9 patients serious viral infections; there were seven episodes of bacteremia following thymoglobulin treatment and one fatal protozoal infection. There were 9 patients (25%) who developed post-SCT lymphoproliferative disorder (PTLD) and 4 patients who had a relapse of underlying primary malignancy; none of these patients survived. Of the 36 patients entered on the study, only 2 patients (6%) survive, at 15+ and 34+ months post-unrelated donor SCT. Although thymoglobulin is associated with an impressive response rate when administered for advanced steroid-resistant GVHD, long-term survival is uncommon, even in responders, primarily due to the high risk of developing either an opportunistic infection or a PTLD.

Telephone therapy for patients with breast cancer.

PURPOSE/OBJECTIVES: To test the value of telephone-administered cognitive-behavioral therapy in a study of patients with breast cancer. DESIGN: Women were assigned randomly to a therapy group or an assessment-only control group. SETTING: A tertiary cancer treatment center serving rural areas of North Dakota and Minnesota. SAMPLE: Women were recruited within three to four months of stage I (n = 27) or stage II (n = 26) breast cancer diagnosis. Age ranged from 30-82 (mean = 51.5 years). Most participants (n = 35) underwent a modified radical mastectomy; 17 underwent a lumpectomy. METHODS: Therapy involved 10 30-minute (or less) telephone sessions. Data that were collected from mailed questionnaires included psychological distress (Profile of Mood States), perceived stress, coping (Coping Response Indices-Revised), quality of life (Medical Outcome Scale), and satisfaction with therapy. Measures were completed at baseline and at 4- and 10-month follow-up intervals. MAIN RESEARCH VARIABLES: Telephone therapy, stress, coping, and quality of life. FINDINGS: With time, women in the therapy and control groups reported reduced stress and improved quality of life. However, significant reductions in some kinds of distress (anxiety, anger, depression, and confusion) were not observed. Most therapy participants liked the telephone treatment sessions but showed only modest improvement (less anxiety and confusion) compared with women in the control group. CONCLUSIONS: Most patients reported being comfortable with the telephone therapy and said that they felt better as a result of it. However, the outcome data showed that telephone therapy--as carried out in this study--produced only modest benefits. Researchers need to consider who is best for delivering such therapy. IMPLICATIONS FOR NURSING PRACTICE: Providing telephone therapy to patients with breast cancer has potential benefits, and nurses may be the appropriate professionals to administer the therapy.