Recent Publications by CFE Educators

OBJECTIVE

To reveal areas of research/knowledge related to social inequities and cervical cancer.

METHODS

A Medline search was performed looking for US based research on cervical cancer and social inequities since 1990. The papers found were organized into cells defined by a "cancer disparities grid."

RESULTS

The majority of research published about cervical cancer and social inequities in the US, lies within the social domains of: race/ethnicity and socioeconomic position. Conflicting information exists as to whether race/ethnicity is a good predictor of screening and survival. Some research implied that differentials based on race/ethnicity are likely secondary to differentials in socioeconomic position. Some research about age, insurance status, and immigrant status and cervical cancer was found. Scarce information was found relating to sexuality, language, disability and geography and cervical cancer.

DISCUSSION

The "cancer disparities grid" facilitated a systematic and visual review of existing literature on social inequities and cervical cancer. The grid helped to elucidate uncontested existing social inequities, conflicting social inequities, and areas where social inequity data does not exist. The cancer disparities grid can be used as a research tool to help identify areas for future research, clinical programs, and political action related to cervical cancer and social inequities.

Cardiovascular disease is the leading cause of mortality for women in the United States. Coronary heart disease, which includes coronary atherosclerotic disease, myocardial infarction, acute coronary syndromes, and angina, is the largest subset of this mortality, with >240,000 women dying annually from the disease. Atherosclerotic coronary artery disease (CAD) is the focus of this consensus statement. Research continues to report underrecognition and underdiagnosis of CAD as contributory to high mortality rates in women. Timely and accurate diagnosis can significantly reduce CAD mortality for women; indeed, once the diagnosis is made, it does appear that current treatments are equally effective at reducing risk in both women and men. As such, noninvasive diagnostic and prognostic testing offers the potential to identify women at increased CAD risk as the basis for instituting preventive and therapeutic interventions. Nevertheless, the recent evidence-based practice program report from the Agency for Healthcare Research and Quality noted the paucity of women enrolled in diagnostic research studies. Consequently, much of the evidence supporting contemporary recommendations for noninvasive diagnostic studies in women is extrapolated from studies conducted predominantly in cohorts of middle-aged men. The majority of diagnostic and prognostic evidence in cardiac imaging in women and men has been derived from observational registries and referral populations that are affected by selection and other biases. Thus, a better understanding of the potential impact of sex differences on noninvasive cardiac testing in women may greatly improve clinical decision making. This consensus statement provides a synopsis of available evidence on the role of the exercise ECG and cardiac imaging modalities, both those in common use as well as developing technologies that may add clinical value to the diagnosis and risk assessment of the symptomatic and asymptomatic woman with suspected CAD.

Three siblings and their mother are reported who all had cytogenetically proven velocardiofacial syndrome (VCFS). One boy had normal dental and craniofacial findings, except for an increased cranial base angle. His sister had only one central incisor in the maxilla. One central incisor had also been missing in the primary dentition. She had no labial frenulum present. Cephalometry showed a small maxillary unit length indicating mild maxillary hypoplasia, an increased anterior face height, steep mandibular plane angle, retruded chin, and a large cranial base angle. Dental measurements showed retroclined lower incisors and increased interincisal angle. A second sister had a cleft of the secondary palate. All permanent teeth were present with the exception of a missing central incisor in the lower jaw: the single lower central incisor was situated in the midline. Her cephalometry showed similar findings as in her sister. All three siblings required palate surgery for speech. Mother was not available for detailed dental and other oral investigations. A single maxillary central incisor has previously been reported in VCFS, but to our knowledge a single central incisor in the mandible has not been reported previously in this entity.

PURPOSE OF REVIEW

Pheochromocytoma is a rare, but clinically important tumor of chromaffin cells. Advances in our understanding of the genetic alterations causing hereditary forms and the increasing sensitivity of biochemical assays allow for early identification of high risk individuals and families. Surgical intervention remains the treatment of choice for patients with pheochromocytoma. This article reviews recent developments in the diagnosis, treatment, and pathophysiology of pheochromocytoma, with the objective of developing new guidelines in the identification and management of the disease. It emphasizes current diagnostic and surgical approaches and discusses the potential for future developments in the field.

SUMMARY

Advances in the molecular basis of pheochromocytoma have introduced new diagnostic modalities. Refinements in imaging techniques have improved the rate of detection of metastatic disease. Innovations in surgical techniques and trials of adrenal sparing surgery may find a niche in the surgical armamentarium.

BACKGROUND

Idiopathic pulmonary fibrosis (IPF) is a devastating disease, yet validated, reliable criteria for evaluating patient response to therapies in clinical trials are lacking.

METHODS

To optimize selection of end point criteria for the study of interferon (IFN)-gamma1b in patients with IPF, we retrospectively analyzed the components of the primary efficacy end point used in a large, controlled study of 330 patients for reliability, validity, and sensitivity to treatment effect. The primary end point components were death, disease progression defined as a > or = 5 mm Hg increase in resting alveolar-arterial oxygen pressure gradient (P[A-a]O2), and disease progression defined as a > or = 10% decrease in percentage of predicted FVC.

RESULTS

We found that the P(A-a)O2 criterion was not reliable and was not associated with mortality. In contrast, the FVC criterion was reliable and was associated with a 2.4-fold increase in the risk of death. Of the three measures, only mortality was sensitive to a treatment effect of IFN-gamma1b. Additionally, the tendency for mortality benefit was observed in nearly all patient subgroups defined by baseline physiology. The effect of IFN-gamma1b on mortality was strongest in patients with baseline percentage of predicted FVC > or = 55% (p = 0.004) or percentage of predicted diffusing capacity of the lung for carbon monoxide > or = 30% (p = 0.008).

CONCLUSION

We conclude that mortality is the most inclusive end point for future trials of IFN- gamma1b in patients with IPF, and that a > 10% decrement in the percentage of predicted FVC represents a valid measure of disease progression.

To determine whether in the natural history of metastatic non-small cell lung cancer (NSCLC) a time interval exists when metastases are limited in number and/or destination organs. Thirty-eight stage IIIB (pleural effusion)/IV NSCLC patients were treated on a phase II trial of oxaliplatin and paclitaxel. Patients' charts were reviewed and all sites of disease at initial presentation and at subsequent follow-ups were recorded, including the number of organs involved and the number of individual metastatic sites. At presentation, 74% of patients had metastases confined to one or two organs (including the lung primary). Fifty percent had or =3 metastatic sites in addition to the lung primary. At last follow-up, 17 patients developed new lesions, 14 in a new organ and 3 in a previously involved organ. Nineteen (50%) had stable (n=12) or progressive (n=7) disease in initially involved sites without developing any new metastatic tumors. Among the 17 patients who presented with or =4 metastatic sites and no pleural effusion, 11 (65%) had stable or progressive disease in initially involved sites without developing new metastases. These results suggest that a subset of patients who present with metastatic NSCLC may not have widely disseminated disease and that some form of local treatment combined with systemic therapy might be beneficial in these patients. Our data support the feasibility of a clinical trial that incorporates local therapies to sterilize metastases in patients with NSCLC.

OBJECTIVE

Macrosomia is associated with adverse maternal outcomes. The objective of this study was to characterize the epidemiology of macrosomia and related maternal complications.

METHOD

Live births (146,526) were identified between 1995 and 1999 in the Kaiser Permanente Medical Care Program's Northern California Region (KPMCP NCR) database. Bivariate and multivariate analyses were performed for risk factors and complications associated with macrosomia (birth weight >4500 g).

RESULT

Male infant sex, multiparity, maternal age 30-40, white race, diabetes, and gestational age >41 weeks were associated with macrosomia (p0.001). In bivariate and multivariate analyses, macrosomia was associated with higher rates of cesarean birth, chorioamnionitis, shoulder dystocia, fourth-degree perineal lacerations, postpartum hemorrhage, and prolonged hospital stay (p0.01).

CONCLUSION

Macrosomia was associated with adverse maternal outcomes in this cohort. More research is needed to determine how to prevent complications related to excessive birth weight.