Real-world febrile neutropenia rates with same-day versus next-day pegfilgrastim after myelosuppressive chemotherapy.

Aim: To compare the incidence of febrile neutropenia (FN) after same-day versus next-day pegfilgrastim. Materials & methods: This single-institution, real-world, retrospective electronic health record-based study included patients who received chemotherapy and prophylactic same-day or next-day pegfilgrastim/pegfilgrastim-cbqv. Results: In cycle 1, 117 patients received same-day pegfilgrastim and 180 patients received next-day pegfilgrastim. FN episodes in cycle 1 occurred in 6.0 versus 6.7% of patients with same-day versus next-day pegfilgrastim, respectively (p = 0.814). Across all cycles, 8.5 and 9.4% of patients experienced ≥1 FN episode after same-day versus next-day pegfilgrastim, respectively (p = 0.793). In the breast cancer patient subgroup, FN occurred 3.2% of same-day pegfilgrastim cycles versus 1.8% of next-day pegfilgrastim cycles (p = 0.938). Conclusion: No significant differences were detected between same-day and next-day pegfilgrastim administration.

A common side effect of chemotherapy is the unintended killing of important immune cells that can fight infections. Because of this effect, patients with cancer who are treated with chemotherapy can experience a serious, sometimes deadly condition called febrile neutropenia (FN). Pegfilgrastim is a medication that is usually given on the day after chemotherapy to help immune cells grow and prevent FN. Many patients prefer to have pegfilgrastim administered on the same day as chemotherapy to avoid a second clinic visit, but it has not been proven whether this approach is as effective and safe as giving pegfilgrastim a day later. This study from the Utah Cancer Specialists in patients with various tumor types (e.g., breast cancer, lung cancer) showed that similar, low proportions of patients had FN when they were given pegfilgrastim on the same day as or the day after chemotherapy.

Granisetron Extended-Release Subcutaneous Injection versus Palonosetron Infusion for CINV Prevention: Cost Comparison of Unscheduled Hydration.

Background: Granisetron extended-release subcutaneous (SC) injection is a novel formulation of granisetron for the prevention of acute and delayed chemotherapy-induced nausea and vomiting (CINV). Palonosetron is administered intravenously and is indicated for CINV prevention in acute and delayed phases after the use of moderately emetogenic chemotherapy (MEC) and in the acute phase after highly emetogenic chemotherapy (HEC). No data are available regarding the impact of SC granisetron on the cost of unscheduled hydration compared with other antiemetic drugs, specifically the older-generation palonosetron. Objective: To compare the costs of unscheduled hydration associated with breakthrough CINV after SC granisetron versus palonosetron administration in patients receiving MEC or HEC. Methods: This retrospective analysis was based on electronic medical records data from a single multicenter, community-based practice involving patients receiving MEC or HEC with a 3-drug antiemetic regimen, including a neurokinin-1 receptor antagonist, dexamethasone, and either SC granisetron or palonosetron. A cost-of-care analysis for SC granisetron and palonosetron was based on the maximum per-unit Medicare reimbursement amounts for the use of unscheduled hydration, administration of rescue antiemetic drugs, laboratory tests, and patient office evaluations. Results: A total of 182 patient records were evaluated, 91 for patients receiving SC granisetron and 91 receiving palonosetron. The mean per-patient cost of care related to unscheduled hydration in patients receiving HEC or MEC was significantly lower with SC granisetron ($296) than palonosetron ($837; P <.0001), including subset analysis of patients requiring additional care (SC granisetron [$691], N = 39; palonosetron [$1058], N = 72; P = .0260). The mean hydration costs per patient receiving HEC or MEC were lower with SC granisetron ($62) than with palonosetron ($253; P <.0001). The hydration costs per patient receiving only HEC were lower with SC granisetron ($66) than palonosetron ($280; P <.0001). The per-patient costs were lower when SC granisetron was administered than when palonosetron was administered as part of the antiemetic regimen, except for the cost of rescue antiemetic drug in patients receiving MEC. Fewer median unscheduled hydration therapies per patient were used with SC granisetron versus palonosetron (HEC, 3 vs 5; MEC, 2 vs 3). Conclusion: The use of SC granisetron reduced the total per-patient costs of care associated with unscheduled hydration compared with palonosetron in patients receiving HEC or MEC for breakthrough CINV events.

Granisetron Extended-Release Subcutaneous Injection versus Palonosetron Infusion for CINV Prevention: Cost Comparison of Unscheduled Hydration.

Background: Granisetron extended-release subcutaneous (SC) injection is a novel formulation of granisetron for the prevention of acute and delayed chemotherapy-induced nausea and vomiting (CINV). Palonosetron is administered intravenously and is indicated for CINV prevention in acute and delayed phases after the use of moderately emetogenic chemotherapy (MEC) and in the acute phase after highly emetogenic chemotherapy (HEC). No data are available regarding the impact of SC granisetron on the cost of unscheduled hydration compared with other antiemetic drugs, specifically the older-generation palonosetron. Objective: To compare the costs of unscheduled hydration associated with breakthrough CINV after SC granisetron versus palonosetron administration in patients receiving MEC or HEC. Methods: This retrospective analysis was based on electronic medical records data from a single multicenter, community-based practice involving patients receiving MEC or HEC with a 3-drug antiemetic regimen, including a neurokinin-1 receptor antagonist, dexamethasone, and either SC granisetron or palonosetron. A cost-of-care analysis for SC granisetron and palonosetron was based on the maximum per-unit Medicare reimbursement amounts for the use of unscheduled hydration, administration of rescue antiemetic drugs, laboratory tests, and patient office evaluations. Results: A total of 182 patient records were evaluated, 91 for patients receiving SC granisetron and 91 receiving palonosetron. The mean per-patient cost of care related to unscheduled hydration in patients receiving HEC or MEC was significantly lower with SC granisetron ($296) than palonosetron ($837; P <.0001), including subset analysis of patients requiring additional care (SC granisetron [$691], N = 39; palonosetron [$1058], N = 72; P = .0260). The mean hydration costs per patient receiving HEC or MEC were lower with SC granisetron ($62) than with palonosetron ($253; P <.0001). The hydration costs per patient receiving only HEC were lower with SC granisetron ($66) than palonosetron ($280; P <.0001). The per-patient costs were lower when SC granisetron was administered than when palonosetron was administered as part of the antiemetic regimen, except for the cost of rescue antiemetic drug in patients receiving MEC. Fewer median unscheduled hydration therapies per patient were used with SC granisetron versus palonosetron (HEC, 3 vs 5; MEC, 2 vs 3). Conclusion: The use of SC granisetron reduced the total per-patient costs of care associated with unscheduled hydration compared with palonosetron in patients receiving HEC or MEC for breakthrough CINV events.

Crossover safety study of aprepitant: 2-min injection vs 30-min infusion in cancer patients receiving emetogenic chemotherapy.

Introduction: HTX-019 (CINVANTI®) is a novel injectable emulsion formulation of the neurokinin 1 receptor antagonist (RA) aprepitant, approved for preventing acute and delayed chemotherapy-induced nausea and vomiting (CINV). HTX-019 has demonstrated a tolerable safety profile when administered via 30-min intravenous (IV) infusion and 2-min IV injection in healthy volunteers. This prospective study evaluated the safety of HTX-019 administered via 30-min IV infusion and 2-min injection (IV push) in patients with cancer. Materials and methods: This prospective single-center, randomized, safety, 2-sequence, 2-period, crossover study evaluated HTX-019 130 mg within a guideline-recommended 3-drug regimen for CINV prophylaxis in patients receiving highly (HEC) or moderately emetogenic chemotherapy (MEC). Treatment-emergent adverse events (TEAEs) were assessed at 0-30 (primary endpoint), 30-60, and >60 mins (chemotherapy administration period) following the initiation of the HTX-019 administration, focusing on infusion-site adverse events and hypersensitivity reactions (dyspnea, anaphylaxis). Results: Among 135 patients (35 MEC, 100 HEC), the most common diagnoses were ovarian (32), lung (17), endometrial (17), and colorectal (15) cancer. Patients were randomized 1:1 to a 2-min injection and a 30-min infusion of HTX-019 (sequence AB or BA), followed by a 5-hydroxytryptamine type 3 RA IV (palonosetron 0.25 mg for 30 s or ondansetron 8-16 mg for 5-10 mins), dexamethasone IV (8-12 mg for 15 mins), and the chemotherapy regimen. Both administration methods were generally well tolerated. No TEAEs occurred within 30 mins after start of HTX-019 administration. All TEAEs occurred during chemotherapy administration; 2 patients experienced 2 TEAEs following injection, and 5 experienced 8 TEAEs following infusion. Three adverse events following infusion (2 dyspnea, 1 throat closing) were considered serious. No TEAEs were considered related to HTX-019. Conclusion: Short injection of HTX-019 has a tolerable safety profile in patients with cancer, and represents an alternative method of HTX-019 administration for CINV prevention.

Hydration requirements in patients receiving highly emetogenic chemotherapy.

AIM: Chemotherapy-induced nausea and vomiting diminishes quality of life and increases healthcare resource use. This retrospective medical records analysis evaluated hydration requirements with emetogenic chemotherapy. PATIENTS & METHODS: Cancer patients received moderately emetogenic chemotherapy (MEC) or highly emetogenic chemotherapy (HEC), and antiemetics palonosetron or granisetron extended-release subcutaneous (GERSC), neurokinin 1 receptor antagonist and dexamethasone. Unscheduled hydration event rates were determined. RESULTS: For 186 patients (92 palonosetron, 94 GERSC) overall, mean hydration rate was significantly higher with palonosetron (0.6 vs 0.2; p = 0.0005). Proportion of patients with ≥1 hydration event was significantly higher with palonosetron overall (54 vs 33%; p = 0.0033) and in cycles 2-4 and the HEC subgroup. CONCLUSION: GERSC within a three-drug antiemetic regimen may reduce unscheduled hydration requirements with MEC or HEC.

APF530 versus ondansetron, each in a guideline-recommended three-drug regimen, for the prevention of chemotherapy-induced nausea and vomiting due to anthracycline plus cyclophosphamide-based highly emetogenic chemotherapy regimens: a post hoc subgroup analysis of the Phase III randomized MAGIC trial.

BACKGROUND: APF530, a novel extended-release granisetron injection, was superior to ondansetron in a guideline-recommended three-drug regimen in preventing delayed-phase chemotherapy-induced nausea and vomiting (CINV) among patients receiving highly emetogenic chemotherapy (HEC) in the double-blind Phase III Modified Absorption of Granisetron In the prevention of CINV (MAGIC) trial. PATIENTS AND METHODS: This MAGIC post hoc analysis evaluated CINV prevention efficacy and safety of APF530 versus ondansetron, each with fosaprepitant and dexamethasone, in patient subgroup receiving an anthracycline plus cyclophosphamide (AC) regimen. Patients were randomized 1:1 to APF530 500 mg subcutaneously (granisetron 10 mg) or ondansetron 0.15 mg/kg intravenously (IV) (≤16 mg); stratification was by planned cisplatin ≥50 mg/m2 (yes/no). Patients were to receive fosaprepitant 150 mg IV and dexamethasone 12 mg IV on day 1, then dexamethasone 8 mg orally once daily on day 2 and twice daily on days 3 and 4. Patients were mostly younger females (APF530 arm, mean age 54.1 years, female, 99.3%; ondansetron arm, 53.8 years, female 98.3%). The primary end point was delayed-phase (>24-120 hours) complete response (CR). RESULTS: APF530 versus ondansetron regimens achieved numerically better CINV control in delayed and overall (0-120 hours) phases for CR, complete control, total response, rescue medication use, and proportion with no nausea. APF530 trends are consistent with the overall population, although not statistically superior given the underpowered AC subgroup analysis. The APF530 regimen in this population was generally well tolerated, with safety comparable to that of the overall population. CONCLUSION: APF530 plus fosaprepitant and dexamethasone effectively prevented CINV among patients receiving AC-based HEC, a large subgroup in whom CINV control has traditionally been challenging.

APF530 (granisetron injection extended-release) in a three-drug regimen for delayed CINV in highly emetogenic chemotherapy.

AIM: APF530, extended-release granisetron, provides sustained release for ≥5 days for acute- and delayed-phase chemotherapy-induced nausea and vomiting (CINV). We compared efficacy and safety of APF530 versus ondansetron for delayed CINV after highly emetogenic chemotherapy (HEC), following a guideline-recommended three-drug regimen. METHODS: HEC patients received APF530 500 mg subcutaneously or ondansetron 0.15 mg/kg intravenously, with dexamethasone and fosaprepitant. Primary end point was delayed-phase complete response (no emesis or rescue medication). RESULTS: A higher percentage of APF530 versus ondansetron patients had delayed-phase complete response (p = 0.014). APF530 was generally well tolerated; treatment-emergent adverse event incidence was similar across arms, mostly mild-to-moderate injection-site reactions. CONCLUSION: APF530 versus the standard three-drug regimen provided superior control of delayed-phase CINV following HEC. ClinicalTrials.gov : NCT02106494.

The Affordable Health Care Act annual wellness visits: the effectiveness of a nurse-run clinic in promoting adherence to mammogram and colonoscopy recommendations.

OBJECTIVE: The aim of this study was to determine the effectiveness of the nurse-run annual wellness visit (AWV) in improving adherence to cancer screening recommendations for colonoscopies and/or mammograms. BACKGROUND: The Affordable Health Care Act provides Medicare beneficiaries access to AWVs. Nurse-run AWVs offer individualized education, reinforce health screening recommendations, and may enhance the patients' intent to complete the screenings. METHODS: A nonexperimental comparative study was conducted using data collected from chart audits comparing patients who only attended the AWV, patients who attended the AWV linked with a physician visit, and patients who have not attended an AWV. RESULTS: Patients who attended the AWV showed greater adherence to mammogram completion regardless of the link to the physician follow-up visit. Differences in adherence to colonoscopy recommendations were not significant, likely because of the low number of colonoscopies reported. CONCLUSIONS: Nurse-run AWV clinics are associated with adherence to mammograms and show promise of increasing colonoscopy compliance.

Cemented all-polyethylene acetabular implants vs other forms of acetabular fixation: a systematic review and meta-analysis of randomized controlled trials.

The cost of primary total hip replacement products approaches 65% of the total reimbursement. Durability of total hip replacement resides with the acetabular component. This systematic review and meta-analysis determined if the outcomes of durability, function, and adverse events associated with cemented all-polyethylene acetabular components was similar to other acetabular designs, holding other variables constant. Randomized controlled trials only were evaluated. Two independent reviewers collected the data from 6 randomized controlled trials. Appropriate statistical analysis was performed. There was no statistical difference in regard to the outcomes at various time points (≤3, 4-8, and ≥10 years) in the 907 implants evaluated. There does, however, appear to be a trend toward abject failure with cemented all-polyethylene acetabular component implants consistent with findings of increased radiolucencies more than 10 years out. The issue of increased radiolucencies over time and failure with these types of implants bears closer scrutiny.

Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis.

BACKGROUND: Since the patient's skin is a major source of pathogens that cause surgical-site infection, optimization of preoperative skin antisepsis may decrease postoperative infections. We hypothesized that preoperative skin cleansing with chlorhexidine-alcohol is more protective against infection than is povidone-iodine. METHODS: We randomly assigned adults undergoing clean-contaminated surgery in six hospitals to preoperative skin preparation with either chlorhexidine-alcohol scrub or povidone-iodine scrub and paint. The primary outcome was any surgical-site infection within 30 days after surgery. Secondary outcomes included individual types of surgical-site infections. RESULTS: A total of 849 subjects (409 in the chlorhexidine-alcohol group and 440 in the povidone-iodine group) qualified for the intention-to-treat analysis. The overall rate of surgical-site infection was significantly lower in the chlorhexidine-alcohol group than in the povidone-iodine group (9.5% vs. 16.1%; P=0.004; relative risk, 0.59; 95% confidence interval, 0.41 to 0.85). Chlorhexidine-alcohol was significantly more protective than povidone-iodine against both superficial incisional infections (4.2% vs. 8.6%, P=0.008) and deep incisional infections (1% vs. 3%, P=0.05) but not against organ-space infections (4.4% vs. 4.5%). Similar results were observed in the per-protocol analysis of the 813 patients who remained in the study during the 30-day follow-up period. Adverse events were similar in the two study groups. CONCLUSIONS: Preoperative cleansing of the patient's skin with chlorhexidine-alcohol is superior to cleansing with povidone-iodine for preventing surgical-site infection after clean-contaminated surgery. (ClinicalTrials.gov number, NCT00290290.)

Statistical analysis of data from studies on experimental autoimmune encephalomyelitis.

Research in multiple sclerosis often employs animal models of the disease, especially experimental autoimmune encephalomyelitis (EAE) in rodents. The statistical analysis procedures chosen for these studies are often suboptimal, either because of violations of the assumptions of the procedure or because the analysis selected is inappropriate for the research question. In this paper, we discuss the types of research questions frequently asked in EAE studies and suggest appropriate and useful research designs and statistical methods that will optimize the information contained within the data. We also discuss other troublesome issues such as missing data, atypical disease profiles, and power analysis.

Healthcare providers' treatment of college smokers.

About 28% of college students smoke tobacco, and many will continue smoking into adulthood. Although little is known about how to help college students quit smoking, 1 promising strategy is healthcare providers' advice. To estimate their life-time receipt of brief advice and to identify characteristics that predict who may receive that advice, 348 college students completed a survey about their smoking and related practices. Seventy-seven percent of the smokers (73% of the students) were asked about smoking. Of those smokers, 57% were advised to quit, 22% were given advice about quitting, 5% were helped with setting a quit date, and 4% were offered follow-up. Occasional smokers were less likely than daily smokers to be advised to quit. Although 36.2% of the smokers did not report their smoking accurately, smokers who were accurate were more likely to be advised to quit and to be given advice about quitting.

Differences in smoking and quitting experiences by levels of smoking among African Americans.

BACKGROUND: Despite smoking fewer cigarettes per day than their White counterparts, African Americans have higher tobacco-related morbidity and mortality. Since most tobacco control efforts have focused on heavy smokers, little is known about smoking and quitting experiences of African-American occasional and light smokers. METHODS: We conducted a survey of 484 African-American smokers, which included: 104 occasional (smoked in < or = 25 of last 30 days), 176 light [smoked 1-10 cigarettes per day (cpd)], 69 moderate (11-19 cpd), and 135 heavy (> or = 20 cpd) attending an inner-city clinic. The survey assessed their sociodemographic characteristics, smoking characteristics, and cessation experiences. RESULTS: Compared with moderate and heavy smokers, occasional and light smokers were, on average, younger, more likely to be female, and more likely to initiate regular smoking at an older age. Forty percent of occasional smokers used other tobacco products compared to 23.3%, 24.6%, and 27.4% for light, moderate, and heavy smokers, respectively. Motivation and confidence to quit were higher among occasional and light smokers. Interest in participating in a formal cessation program was equally high in all 4 groups (mean ranged from 7.6-8.0 on a scale of 1-10). The use of pharmacotherapy for smoking cessation was similar, and generally low, among all 4 groups. CONCLUSIONS: High levels of motivation for smoking cessation exist among African-American occasional and light smokers. The interest of these lighter smokers in smoking cessation represents a window of opportunity to design programs for a group that has been excluded from most cessation interventions.

Cigarette smoking among marijuana users in the United States.

The vast majority of drug users smoke cigarettes. Most use marijuana and no other illicit drug. We analyzed adult responses to the 1997 NHSDA (n = 16,661) to explore relationships between marijuana use and cigarette smoking. Multivariate analyses controlled for other illicit drug use and other potential covariates. Nearly three-quarters of current marijuana users (74%) smoked cigarettes. Compared to nonusers, the adjusted odds of being a smoker were 5.43 for current marijuana users, 3.58 for past year marijuana users, and 2.02 for former marijuana users. Odds for cigarette smoking among current poly-drug users, compared to nonusers, were 2.3 to 1. Level of cigarette smoking was directly associated with frequency of marijuana use. Nationwide, an estimated 7 million adults smoke both substances and are at increased risk for respiratory illnesses and mortality. Cigarette smoking is a major co-morbidity of marijuana use and smoking cessation should be addressed among marijuana users in addition to their other illicit drug involvement.

Smoking cessation, smoking reduction, and delayed quitting among smokers given nicotine patches and a self-help pamphlet.

Over-the-counter nicotine replacement raises questions regarding its "real world" efficacy. This was an open-label, prospective study of 223 smokers who received 42 free nicotine patches and a self-help booklet via shopping mall distribution. The overall quit rate 6 months following distribution of the nicotine patches was 22% (50/223), almost the same quit rate found 6 weeks following patch distribution (21%, 47/223). Twelve percent (27/223) were abstinent at both 6 weeks and 6 months. Among the 83 participants who did not quit, cigarettes smoked per day dropped from 28 to 18. A substantial subgroup of quitters (14%) who, although still smoking at 6 weeks, were smoke free at 6 months, and it appears they had purposefully delayed a serious quit attempt. These results support the usefulness of nicotine patches in helping smokers quit, even with only minimal intervention such as a self-help manual.

Brief training to promote the use of less intrusive prompts by nursing assistants in a dementia care unit.

We evaluated the efficacy of a brief staff-training procedure to increase the use of graduated prompting by 2 certified nursing assistants (CNAs) while they helped to dress 3 persons with dementia in a seven-bed dementia care unit. The multiple baseline design across participants showed that CNAs dressed residents with minimal resident involvement during baseline observations. Following brief in-service training, CNAs provided graduated prompts and praise appropriately, suggesting that CNAs can promote active involvement in personal care routines by older adults with dementia.

Rehabilitation for patients with chronic obstructive pulmonary disease: meta-analysis of randomized controlled trials.

OBJECTIVE: To develop a meta-analysis to determine the effectiveness of rehabilitation in patients with chronic obstructive pulmonary disease (COPD). DATA SOURCES: medline, cinhal, and Cochrane Library searches for trials of rehabilitation for COPD patients. Abstracts presented at national meetings and the reference lists of pertinent articles were reviewed. STUDY SELECTION: Studies were included if: trials were randomized; patients were symptomatic with forced expiratory volume in one second (FEV1) <70% or FEV1 divided by forced vital capacity (FEV1/FVC) <70% predicted; rehabilitation group received at least 4 weeks of rehabilitation; control group received no rehabilitation; and outcome measures included exercise capacity or shortness of breath. We identified 69 trials, of which 20 trials were included in the final analysis. DATA EXTRACTION: Effect of rehabilitation was calculated as the standardized effect size (ES) using random effects estimation techniques. RESULTS: The rehabilitation groups of 20 trials (979 patients) did significantly better than control groups on walking test (ES = 0.71; 95% confidence interval [95% CI], 0.43 to 0.99). The rehabilitation groups of 12 trials (723 patients) that used the Chronic Respiratory Disease Questionnaire had less shortness of breath than did the control groups (ES = 0.62; 95% CI, 0.35 to 0.89). Trials that used respiratory muscle training only showed no significant difference between rehabilitation and control groups, whereas trials that used at least lower-extremity training showed that rehabilitation groups did significantly better than control groups on walking test and shortness of breath. Trials that included severe COPD patients showed that rehabilitation groups did significantly better than control groups only when the rehabilitation programs were 6 months or longer. Trials that included mild/moderate COPD patients showed that rehabilitation groups did significantly better than control groups with both short- and long-term rehabilitation programs. CONCLUSION: COPD patients who receive rehabilitation have a better exercise capacity and they experience less shortness of breath than patients who do not receive rehabilitation. COPD patients may benefit from rehabilitation programs that include at least lower-extremity training. Patients with mild/moderate COPD benefit from short- and long-term rehabilitation, whereas patients with severe COPD may benefit from rehabilitation programs of at least 6 months.

Epidural analgesia and severe perineal laceration in a community-based obstetric practice.

BACKGROUND: This study assessed whether epidural analgesia was an independent risk factor for severe perineal laceration. METHODS: A retrospective cohort study analyzed 2,759 patients at St. Francis Regional Medical Center who had vertex, spontaneous or induced, singleton, live, vaginal deliveries of neonates of at least 36 weeks' gestation. Patients with diabetes or severe cardiac disease were excluded. Outcomes measured were third- or fourth-degree perineal lacerations. RESULTS: Overall rate of severe perineal laceration was 6.38% (n = 176). Epidural analgesia was given to 634 (22.98%) women. Among women who had epidural analgesia, 10.25% (65 of 634) had severe perineal lacerations compared with 5.22% (111 of 2,125) of the women who did not have epidural analgesia. After controlling for major variables in a logistic regression analysis, epidural analgesia remained a significant predictor of severe perineal injury (odds ratio [OR] = 1.528, 95% confidence interval [CI] = 1.092-2.137). When instrument use was included in the model, epidural analgesia was no longer a statistically significant, independent predictor of severe perineal injury. (OR = 1.287, 95% CI = 0.907-1.826). Instrument use was found to be a strong predictor of severe laceration (OR = 3.245, 95% CI = 2.162-4.869). A logistic regression model examining predictors of instrument use found that epidural analgesia does significantly predict instrument use (OR = 3.01, 95% CI = 2.225-4.075). CONCLUSION: Epidural analgesia is associated with an increase in severe perineal trauma as a result of an associated threefold increased risk of instrument use. Instrument use in vaginal delivery more than triples the risk of severe perineal laceration.

A population-based study of cigarette smoking among illicit drug users in the United States.

AIMS: People who use illicit drugs are thought to have high rates of cigarette smoking; however, few population-based studies have been reported. We describe smoking patterns among illicit drug users, assess whether cigarette smoking is more prevalent among illicit drug users than it is among non-users and explore how smoking relates to level and type of drug use. DESIGN, SETTING, PARTICIPANTS: We used adult responses to the 1997 National Household Survey on Drug Abuse (n = 16 661). Multivariate analyses used SUDAAN to adjust standard errors for the sampling design and controlled for age, race, sex, education, depression, treatment history and alcohol. MEASUREMENTS: Smoking rates, cessation rates and smoking levels. FINDINGS: Seventy-one per cent of recent illicit drug users smoked cigarettes at least once in the past month. Their adjusted odds of being a smoker were much greater than for the general population (OR = 3.07, P < 0.0001). Their quit rate, although substantial, was half that of non-users (23% versus 56%, P=0.0001). Odds of being a smoker were higher for poly- versus monodrug users (OR = 2.35, P=0.0020) and rose with increased drug use (OR = 1.36, P=0.0374). Illicit drug users who perceived smoking to be risky were four times less likely to smoke (OR = 0.23, P=0.0008). CONCLUSIONS: Although most recent illicit drug users smoke, some are able to quit. Better understanding of concurrent cigarette and illicit drug use may provide impetus for policy change and shed light on underlying mechanisms of addiction. Clinicians, policy makers and user advocates should address tobacco use in drug treatment and in harm reduction interventions.

Impact of geographic barriers on the utilization of mammograms by older rural women.

OBJECTIVES: To examine whether geographic proximity to mammography facilities influences mammogram utilization. DESIGN: Retrospective cohort analysis. SETTING: Rural state. PARTICIPANTS: Female Kansas Medicare beneficiaries aged 65 to 79 (N=117,901). MEASUREMENTS: Using Medicare claims data, we measured county-level mammography rates for beneficiaries in Kansas. We calculated mammography rate differences for beneficiaries according to age, race, distance from permanent and mobile mammography sites, and county characteristics including county mammography service availability. RESULTS: Of 105 counties, 37% had only permanent mammography facilities, 22% had both permanent and mobile sites, 29% had only mobile facilities, and 11% had neither, representing 44%, 44%, 9%, and 3% of the 117,901 beneficiaries, respectively. Of the beneficiaries, 91% lived less than 20 miles from a permanent facility; of the remaining 9%, 67% lived less than 20 miles from a mobile site. In 30 counties with only mobile sites, 90% of the 10,439 beneficiaries residing in the counties had access to the sites fewer than 2 days per month. County-level mammography rates ranged from 37% to 72%. Mammography utilization was 57% in counties with permanent facilities only, 55% in counties with both permanent and mobile sites, 53% in counties with only mobile sites, and 53% in counties with neither (P=0.12). After adjusting for age, race, and county education level, the odds of receiving a mammogram was slightly lower for persons residing longer distances from a permanent facility (odds ratio=0.97 for each 5-mile increase in distance, 95% confidence interval=0.95-0.99). CONCLUSION: The majority of Kansans live near a mammography facility. Although there is a large variation in county-level mammography rates across Kansas, this disparity is not well explained by proximity to mammography facilities.