Is prostate cancer stage migration continuing for black men in the PSA era?

BACKGROUND: In the United States, disease-specific mortality from prostate cancer (PC) is highest among black men. While the introduction of widespread PSA testing has been associated with a downward stage migration, whether this trend continues in the late PSA era and for black men is unknown. The objective of our study was to evaluate current PC stage migration patterns in the United States by race. METHODS: The Surveillance, Epidemiology and End Results (SEER) registry was queried to obtain all cases of PC reported between 2000 and 2013. Year of diagnosis was categorized into 2000-2003, 2004-2007, 2008-2010 and 2011-2013. Predictors of distant stage PC at diagnosis were determined using logistic regression adjusted for year of diagnosis, age at diagnosis, SEER region and race. RESULTS: A total of 791 184 PC cases were identified. The cohort comprised 78.9% (n=594 920) white and 14.1% (n=106 133) black men. The stage at diagnosis was 83.3% localized, 12.0% regional and 4.7% distant. Age-adjusted incidence demonstrated a steady decline for black men in all time groups while white men had a stable incidence of distant disease between 2000 and 2013. In univariate analysis, black men in the 2004-2007 (OR 0.86 (0.81-0.93)) and 2008-2010 cohorts (OR 0.85 (0.79-0.91)) were less likely to be diagnosed with metastatic PC as compared with the 2000-2003 baseline cohort. In multivariate analysis, the 2004-2007 black cohort was less likely to be diagnosed with distant PC (OR 0.90 (0.84-0.97)). This trend was not observed in white men who in multivariate analysis had an increased risk of distant PC in the 2004-2007 (OR 1.08 (1.04-1.11)), 2008-2010 (OR 1.22 (1.18-1.27)) and 2011-2013 (OR 1.65 (1.59-1.71)) groups. CONCLUSIONS: PC downward stage migration continues in black men but not in white men. Discontinuation of PSA-based screening for PC could disproportionately affect black men.

Lessons Learned From a Community-Based Participatory Research Mental Health Promotion Program for American Indian Youth.

Background American Indian (AI) youth have the highest rates of suicide among racial/ethnic minority groups in the United States. Community-based strategies are essential to address this issue, and community-based participatory research (CBPR) offers a model to engage AI communities in mental health promotion programming. Objectives This article describes successes and challenges of a CBPR, mixed-method project, The Lumbee Rite of Passage (LROP), an academic-community partnership to develop and implement a suicide prevention program for Lumbee AI youth in North Carolina. Method LROP was conducted in two phases to (1) understand knowledge and perceptions of existing mental health resources and (2) develop, implement, and evaluate a cultural enrichment program as a means of suicide prevention. Discussion/Results LROP implemented an effective community-academic partnership by (1) identifying and understanding community contexts, (2) maintaining equitable partnerships, and (3) implementing a culturally tailored research design targeting multilevel changes to support mental health. Strategies formed from the partnership alleviated challenges in each of these key CBPR concept areas. Conclusions LROP highlights how a CBPR approach contributes to positive outcomes and identifies opportunities for future collaboration in a tribal community. Using culturally appropriate CBPR strategies is critical to achieving sustainable, effective programs to improve mental health of AI youth.

Force of removal for untunnelled, tunnelled and double-tunnelled peripheral nerve catheters.

We compared the force of extraction for peripheral nerve catheters under three different situations in a porcine model using untunnelled, tunnelled and double-tunnelled catheters. Following insertion of the catheter into the porcine model, the catheters were either left untunnelled or a single or double tunnel was created for the catheter. The force required to displace the catheter by one centimetre was then measured in each of the three groups. The mean (SD) force required for displacement of the catheter was 0.23 (0.06) N for the untunnelled catheters, 1.16 (0.51) N for the single-tunnelled catheters, and 4.00 (1.70) N for the double-tunnelled catheters (p < 0.0001). Tunnelling a peripheral nerve catheter leads to a significant increase in the force required for dislodgement. This is increased further by introducing a second tunnel.

Admixture and population stratification in African Caribbean populations.

Throughout biomedical research, there is growing interest in the use of ancestry informative markers (AIMs) to deconstruct racial categories into useful variables. Studies on recently admixed populations have shown significant population substructure due to differences in individual ancestry; however, few studies have examined Caribbean populations. Here we used a panel of 28 AIMs to examine the genetic ancestry of 298 individuals of African descent from the Caribbean islands of Jamaica, St. Thomas and Barbados. Differences in global admixture were observed, with Barbados having the highest level of West African ancestry (89.6%+/- 2.0) and the lowest levels of European (10.2%+/- 2.2) and Native American ancestry (0.2%+/- 2.0), while Jamaica possessed the highest levels of European (12.4%+/- 3.5) and Native American ancestry (3.2%+/- 3.1). St. Thomas, USVI had ancestry levels quite similar to African Americans in continental U.S. (86.8%+/- 2.2 West African, 10.6%+/- 2.3 European, and 2.6%+/- 2.1 Native American). Significant substructure was observed in the islands of Jamaica and St. Thomas but not Barbados (K=1), indicating that differences in population substructure exist across these three Caribbean islands. These differences likely stem from diverse colonial and historical experiences, and subsequent evolutionary processes. Most importantly, these differences may have significant ramifications for case-control studies of complex disease in Caribbean populations.

Germline BCL-2 sequence variants and inherited predisposition to prostate cancer.

Apoptosis is an essential physiological process that regulates cellular proliferation. Here, we explored the effect of DNA sequence variation within the BCL-2 gene on prostate cancer susceptibility in three clinical populations, consisting of 428 African Americans, 214 Jamaicans and 218 European Americans. We observed a 70% reduced risk for prostate cancer among the European Americans who had possessed two copies of a promoter variant -938C/A. Additionally, common BCL-2 haplotypes appeared to influence prostate cancer risk; however, studies in larger data sets are needed to confirm our findings. Our data suggest that inherited BCL-2 variants may be associated with a decrease in prostate cancer susceptibility.

Survival of patients with SLE admitted to an intensive care unit-a retrospective study.

We examined the demography, reasons for admission and cause of death in systemic lupus erythematosus (SLE) patients admitted to a medical intensive care unit (ICU) over a 7-year period. Fourteen patients were admitted during this period-all were female, 13 were of mixed ethnic ancestry and one a black South African. Of the 14 patients, 12 were admitted as a result of lupus activity, 2 had sepsis as the major cause of admission, although 5 other patients developed infection during their admission. Five patients had a generalised flare of their disease or progressive renal failure. Seven patients were admitted with a variety of lupus-related pathologies. In general the precise cause of death was difficult to determine. Of the 14 patients, 9 had impaired renal function on admission including 1 with sepsis and 1 of the survivors. Three patients (21%) survived, one with respiratory failure due to shrinking lung, a second with an acute flare of SLE and a third with pulmonary emboli. This study demonstrates that lupus in our community may produce life-threatening flares. Although cause of death was not always definitely identified, admission to the ICU was primarily due to active SLE and not sepsis or iatrogenic disease.

Evaluation of left ventricular enlargement in the lateral position of the chest using the Hoffman and Rigler sign.

OBJECTIVE: To evaluate left ventricular enlargement in the lateral projection of the chest using the Hoffman and Rigler sign. BACKGROUND: The Hoffman and Rigler sign for determining left ventricular enlargement was suggested as early as 1965 before the routine use of echocardiography. METHODS: We studied 136 patients who had had cardiac ultrasound and chest X-rays with lateral projections. We assessed left ventricular size on the lateral projection using the Hoffman and Rigler method (measurement A) and compared this measurement to the value obtained by cardiac ultrasound. The effect of right ventricular size on this measurement was also evaluated. RESULTS The average value of measurement A in all patients with echocardiographic evidence of left vetricular enlargement (LVED above 59 mm) was 19 mm (SD +/- 4.03) (95% CI 17.96 to 20.04). Of the 48 patients with a normal size left ventricle on echocardiography, 25.58% had measurement A 18 mm and above, and 13.95% had a value 19 mm and above. Of the 19 patients with right ventricular enlargement (normal left ventricle) on echocardiography, 36.84% had measurement A18 mm and above, whereas 21.05% had this value 19 mm and above. Measurement A in patients with left ventricular enlargement compared with those with right ventricular enlargement showed a significant difference (p < 0.05). CONCLUSIONS: When the crossing of the inferior vena cava and the left ventricle can be adequately visualised, the Hoffman and Rigler sign of evaluating left ventricular enlargement in the lateral projection of the chest is a valuable alternative where cardiac ultrasound is not readily available.

Prevalence of iron deficiency in 12-mo-old infants from 11 European areas and influence of dietary factors on iron status (Euro-Growth study).

A prospective longitudinal cohort study was performed to assess the prevalence of iron deficiency in European infants at 12 mo of age, and to study the influence of socio-economic status, dietary factors, growth and morbidity on iron status. The cohort consisted of 488 normal term infants from primary healthcare centres in 11 European areas. Assessed were socio-economic variables, dietary intake, anthropometry and morbidity at regular intervals from birth to 12 mo, and haemoglobin, serum ferritin, mean corpuscular volume, transferrin saturation and serum transferrin receptor concentrations at age 12 mo. The prevalence of anaemia was 9.4%, of iron deficiency 7.2%, and of iron deficiency anaemia 2.3%. More than 40% of anaemia was associated with normal iron status and associated with an increased frequency of recent infections. Iron deficiency anaemia was significantly more frequent with low (5.1%) than high socio-economic status (0%). Dietary factors accounted for most of this variation in multiple regression analysis. Early introduction of cows' milk was the strongest negative determinant of iron status. Feeding of iron-fortified formula was the main factor positively influencing iron status. Other dietary factors, including breastfeeding, did not play a significant role as determinants of iron status at age 12 mo. Conclusion. Iron deficiency anaemia is present in 2.3% of 12-mo-old European infants. The prevalence of iron deficiency anaemia varies strongly with socio-economic status. Avoidance of cows' milk feeding during the first year of life is the key measure in the prevention of iron deficiency.

Are urban safety-net hospitals losing low-risk Medicaid maternity patients?

OBJECTIVE: To examine data on Medicaid and self-pay/charity maternity cases to address four questions: (1) Did safety-net hospitals' share of Medicaid patients decline while their shares of self-pay/charity-care patients increased from 1991 to 1994? (2) Did Medicaid patients' propensity to use safety-net hospitals decline during 1991-94? (3) Did self-pay/charity patients' propensity to use safety-net hospitals increase during 1991-94? (4) Did the change in Medicaid patients' use of safety-net hospitals differ for low- and high-risk patients? STUDY DESIGN: We use hospital discharge data to estimate logistic regression models of hospital choice for low-risk and high-risk Medicaid and self-pay/charity maternity patients for 25 metropolitan statistical areas (MSAs) in five states for the years 1991 and 1994. We define low-risk patients as discharges without comorbidities and high-risk patients as discharges with comorbidities that may substantially increase hospital costs, length of stay, or morbidity. The five states are California, Florida, Massachusetts, New Jersey, and New York. The MSAs in the analysis are those with at least one safety-net hospital and a population of 500,000 or more. This study also uses data from the 1990 Census and AHA Annual Survey of Hospitals. The regression analysis estimates the change between 1991 and 1994 in the relative odds of a Medicaid or self-pay/charity patient using a safety-net hospital. We explore whether this change in the relative odds is related to the risk status of the patient. PRINCIPAL FINDINGS: The findings suggest that competition for Medicaid patients increased from 1991 to 1994. Over time, safety-net hospitals lost low-risk maternity Medicaid patients while services to high-risk maternity Medicaid patients and self-pay/charity maternity patients remained concentrated in safety-net hospitals. IMPLICATIONS FOR POLICY: Safety-net hospitals use Medicaid patient revenues and public subsidies that are based on Medicaid patient volumes to subsidize care for uninsured and underinsured patients. If safety-net hospitals continue to lose their low-risk Medicaid patients, their ability to finance care for the medically indigent will be impaired. Increased hospital competition may improve access to hospital care for low-risk Medicaid patients, but policymakers should be cognizant of the potential reduction in access to hospital care for uninsured and underinsured patients. Public policymakers should ensure that safety-net hospitals have sufficient financial resources to care for these patients by subsidizing their care directly.

Assessing the effect of fatty acids on prostate carcinogenesis in humans: does self-reported dietary intake rank prostatic exposure correctly?

BACKGROUND: Dietary fatty acids may influence prostate carcinogenesis. Although the standard for assessing dietary effects in humans is the semiquantitative food-frequency questionnaire, the extent to which self-reported intake correctly ranks prostatic exposure is unknown. OBJECTIVE: The objective was to examine the correlation between reported intakes of different fatty acids and their concentrations in prostate tissue. DESIGN: This was a cross-sectional study of 52 men undergoing surgical resection of the prostate gland. Usual dietary intake of saturated, total unsaturated, oleic, and linoleic fatty acids over the previous year was estimated with use of a 122-item version of the Health Habits and History Questionnaire. Concentrations in prostate tissue were measured directly by use of gas chromatography in healthy tissue collected at the time of surgery and were expressed as a percentage of total fatty acids. Correlations with 4 measures of dietary intake [g/d, g/d adjusted for total daily energy intake, % of total fat (as g/d), and % of total energy] were evaluated by Spearman's rank-order correlation coefficients. RESULTS: Linoleic acid concentrations in prostate tissue were significantly correlated with dietary intake expressed as g/d adjusted for total energy [r = 0.29 (95% CI: 0.03, 0.49), P = 0.04], % of total fat [r = 0.36 (0.14, 0.550), P = 0.008], and % of total energy [r = 0.28 (0.04, 0.49), P = 0.042], but not as g/d. Although mean concentrations of saturated, total unsaturated, and oleic fatty acids in prostate tissue resembled mean intakes for the group, prostatic concentrations did not correlate with individual intakes. CONCLUSION: Self-reported intake of fatty acids is a satisfactory marker of prostatic exposure at the group level, but, with the exception of linoleic acid, does not correctly rank individuals with respect to intensity of exposure.

Height and risk of fatal prostate cancer: findings from the National Health Interview Survey (1986 to 1994).

PURPOSE: Height is determined by genetic and nutritional factors mediated through the endocrine system early in life and, thus, may be related to subsequent risk of fatal prostate cancer. This hypothesis was examined in a large representative U.S. national sample. METHODS: Data from the National Health Interview Survey (NHIS) were analyzed to determine whether height was prospectively related to the risk of fatal prostate cancer in 110,042 men age > or = 50 years old interviewed between 1986 and 1994. Height was self-reported and vital status and causes of death ascertained using the National Death Index. Endpoints were deaths that listed prostate cancer as the underlying cause and deaths with any mention of prostate cancer. Relative risks (RR) and their 95% confidence intervals (CI) were calculated using Cox proportional hazards models adjusted for age, race, weight, and education. RESULTS: Six hundred and thirty-three deaths listing of prostate cancer as the underlying cause and 910 deaths with any mention of prostate cancer were identified. Height was associated neither with risk of death with prostate cancer listed as the underlying cause nor with risk of death with any mention of prostate cancer (multivariate p for trend = 0.1318 and 0.0698, respectively). Risks were marginally greater among the tallest men compared to the shortest (< or = 171.4 vs. > or = 182.9 cm), but not significantly (RR = 1.21, 95% CI = 0.92 to 1.57, and RR = 1.24, 95% CI = 0.98 to 1.58 for 'underlying cause' and 'any mention', respectively). CONCLUSIONS: Height alone was not related to risk of fatal prostate cancer in this population.

Prostatic levels of fatty acids and the histopathology of localized prostate cancer.

PURPOSE: The consumption of various fatty acids has been associated with advanced stage and fatal prostate cancer. While numerous mechanisms have been postulated, to our knowledge there physiological data linking exposure and prognosis in humans are lacking. We examined prostatic levels of individual fatty acids in relation to the prevalence of histopathological characteristics associated with invasiveness and the risk of progression in 49 men undergoing radical prostatectomy for localized prostate cancer. MATERIALS AND METHODS: Fatty acids were measured using capillary gas chromatography in fresh nonmalignant prostate tissue collected at surgery. Markers of invasiveness and increased risk of progression (Gleason sum 7 or greater, perineural invasion, anatomical or surgical margin involvement, extracapsular extension, seminal vesical involvement and stage T3 tumor) were evaluated separately. Each marker was dichotomized into a yes (case) and no (control) level with patients grouped accordingly. Mean concentrations were compared using the Wilcoxon rank sum test. RESULTS: The percent of total prostatic polyunsaturated fat and polyunsaturated-to-saturated fat ratios were significantly lower in the presence of perineural invasion, seminal vesical involvement and stage T3 tumor (p = 0.02 to 0.049). alpha-Linolenic acid was significantly lower when tumor extended to an anatomical or surgical margin (p = 0.008). The omega-3 and omega-3-to-omega-6 fatty acid ratios were 1.5 to 3.3-fold lower in cases than in controls, reaching borderline significance in nearly all comparisons (p = 0.052 to 0.097). Saturated and monounsaturated fatty acids were not associated with the traits examined. CONCLUSIONS: These data suggest that polyunsaturated fatty acids and perhaps essential fatty acids in particular help to regulate prostate carcinogenesis in humans.

Wolf-Hirschorn syndrome resulting from partial monosomy 4p/trisomy 9p.

An infant girl was referred for a genetic consultation because of facial appearance suggestive of Wolf-Hirschorn syndrome (WHS), growth retardation and generalized hypotonia. She had an unbalanced karyotype 46,XX,der(4)t(4;9)(p15.2;p22)mat resulting in the deletion of the critical region for WHS and duplication of the critical region for the 9p duplication syndrome. The mother and the grandmother of proposita were the carriers of an apparently balanced translocation 46,XX,t(4;9)(p15.2;p22). The infant's phenotype was characteristic of WHS syndrome rather than that of duplication 9p phenotype. This is probably the first description of WHS phenotype resulting from a familial 4;9 translocation.

Patterns of milk and food intake in infants from birth to age 36 months: the Euro-growth study.

BACKGROUND: Little detailed information is available on feeding practices of infants in Europe. The Euro-Growth Study is a longitudinal, observational, multicenter study of milk feeding, the introduction of complementary solid foods, and vitamin and mineral supplementation. Current practice is compared with international feeding recommendations. METHOD: Healthy term infants (n = 2,245) were recruited at birth or during the first month of life. Dietary records were completed at the ages 1, 2, 3, 4, 5, 6, 9, 12, 18, 24, 30, and 36 months by semiquantitative dietary recall. RESULTS: At the age of I month, 52% of the infants were exclusively breast fed and 26% were exclusively formula fed. At the age of 9 months, 18% of infants were fed only cow's milk. At the ages of 3, 4, and 5 months, 50%, 67%, and 95% of infants were fed solid foods, respectively. CONCLUSIONS: Feeding practices vary considerably throughout Europe. High rates of breast-feeding initiation are found in Umea, Sweden, and in Athens, Greece; and low rates in Dublin, Ireland, in Toulouse, France, and in Glasgow, United Kingdom. The use of cow's milk as the main milk drink before the age of 12 months is still common in certain European centers.

Prostatic levels of tocopherols, carotenoids, and retinol in relation to plasma levels and self-reported usual dietary intake.

This study evaluated how prostatic levels of antioxidants relate to plasma levels and self-reported usual dietary intake. Definition of these relations may aid in interpreting studies of antioxidant exposure and prostate cancer risk. Between July 1996 and April 1997, plasma and prostatic tissue levels of tocopherols, carotenoids, and retinol were measured in 47 men undergoing radical prostatectomy or transurethral prostatectomy at Loyola University Medical Center, Maywood, Illinois, and an affiliate hospital. Dietary intake was measured by using a 122-item version of the Block Health Habits and History Questionnaire, and correlations were assessed with Pearson's coefficients. Prostatic levels of tocopherols and carotenoids (but not retinol) were significantly correlated with plasma levels (r= 0.31-0.56, p < 0.05-0.0001); the strongest correlations were associated with lycopene, beta-carotene, and gamma-tocopherol (0.56, 0.54, and 0.52, respectively; p < 0.0001). Relative concentrations of tocopherols and carotenoids in prostate tissue were proportionate to those in plasma. No correlation between prostatic levels and reported dietary intake was observed (r = -0.09 to 0.16, p < not significant). Adjustment for energy intake, body mass index, and serum lipids did not impact these relations. These results suggest that plasma levels of tocopherols and carotenoids better reflect prostatic exposure than self-reported usual dietary intake.

Lying for patients: physician deception of third-party payers.

BACKGROUND: Some physicians may resort to deception to secure third-party payer approval for patient procedures. Related physician attitudes, including willingness to use deception, are not well understood. OBJECTIVE: To determine physician willingness to deceive a third-party payer and physician attitudes toward deception of third-party payers. METHODS: A cross-sectional mailed survey was used to evaluate physician willingness to use deception in 6 vignettes of varying clinical severity: coronary bypass surgery, arterial revascularization, intravenous pain medication and nutrition, screening mammography, emergent psychiatric referral, and cosmetic rhinoplasty. We evaluated 169 board-certified internists randomly selected from 4 high- and 4 low-managed care penetration metropolitan markets nationwide for willingness to use deception in each vignette. RESULTS: Physicians were willing to use deception in the coronary bypass surgery (57.7%), arterial revascularization (56.2%), intravenous pain medication and nutrition (47.5%), screening mammography (34.8%), and emergent psychiatric referral (32.1%) vignettes. There was little willingness to use deception for cosmetic rhinoplasty (2.5%). Rates were highest for physicians practicing in predominantly managed care markets, for clinically severe vignettes, and for physicians spending less time in clinical practice. Physician ratings of the justifiability of deception varied by perspective and vignette. CONCLUSIONS: Many physicians sanction the use of deception to secure third-party payers' approval of medically indicated care. Such deception may reflect a tension between the traditional ethic of patient advocacy and the new ethic of cost control that restricts patient and physician choice in the use of limited resources.

Costs of developing childhood immunization registries: case studies from four All Kids Count projects.

We conducted case studies using structured interviews at four sites to understand the financial resources needed to implement childhood immunization registries. The total cost of planning and implementing a central registry ranged from $2.4 million to almost $7 million over the first five years. In addition, substantial investment by individual or group providers often was required. Registries are large information systems that require considerable investment of developmental resources, regardless of the number of children eventually entered into the system. Given the substantial investment that a registry represents, the realistic anticipation of such resource needs is important to successful planning and implementation.