The longitudinal relationship between community programmes and policies to prevent childhood obesity and BMI in children: the Healthy Communities Study.

BACKGROUND: Although a national epidemic of childhood obesity is apparent, how community-based programmes and policies (CPPs) affect this outcome is not well understood. OBJECTIVES: This study examined the longitudinal relationship between the intensity of CPPs in 130 communities over 10 years and body mass index (BMI) of resident children. We also examined whether these relationships differ by key family or community characteristics. METHODS: Five thousand one hundred thirty-eight children in grades K-8 were recruited through 436 schools located within 130 diverse US communities. Measures of height, weight, nutrition, physical activity and behavioural and demographic family characteristics were obtained during in-home visits. A subsample of families consented to medical record review; these weight and height measures were used to calculate BMI over time for 3227 children. A total of 9681 CPPs were reported during structured interviews of 1421 community key informants, and used to calculate a time series of CPP intensity scores within each community over the previous decade. Linear mixed effect models were used to assess longitudinal relationships between childhood BMI and CPP intensity. RESULTS: An average BMI difference of 1.4 kg/m2 (p-value < 0.01) was observed between communities with the highest and lowest observed CPP intensity scores, after adjusting for community and child level covariates. BMI/CPP relationships differed significantly by child grade, race/ethnicity, family income and parental education; as well as community-level race/ethnicity. CONCLUSIONS: These results indicate that, over time, more intense CPP interventions are related to lower childhood BMI, and that there are disparities in this association by sociodemographic characteristics of families and communities.

Prostate-specific antigen to predict outcome of external beam radiation for prostate cancer: Walter Reed Army Medical Center experience, 1988-1995.

OBJECTIVES: To assess the ability of pretreatment and post-treatment prostate-specific antigen (PSA) measurements, clinical tumor stage, tumor grade, Gleason sum, race, age, and radiation dose to predict the recurrence of prostate cancer following external beam radiation therapy (XRT) since the introduction of PSA as a tumor marker at one tertiary care center. METHODS: The recurrence of prostate cancer among 371 evaluable patients of 389 patients treated with XRT at Walter Reed Army Medical Center was analyzed using Kaplan-Meier survival methodology and Cox multivariable regression models. Serologic (PSA) recurrence was determined using three consecutive rises in PSA after a nadir value. Clinical recurrence was defined as local recurrence (palpable or positive biopsy) and/or distant (radiographically evident) recurrence. Mean and median follow-up is 40.2 and 39.4 months, respectively (range 3.0 to 89.5), and minimum follow-up is 18 months for patients who were alive at the time of analysis. No patient received adjuvant hormonal therapy. Potential prognostic factors evaluated are pretreatment PSA, PSA nadir, age, race, clinical tumor stage, tumor grade, Gleason sum, and radiation dose. RESULTS: Of the 371 evaluable patients, 125 had disease recurrence. The Kaplan-Meier 5-year disease-free survival (DFS) rates for significant pretreatment variables in univariate analyses are as follows: pretreatment PSA less than 4 (79%), 4.1 to 10 (67%), 10.1 to 20 (57%), 20.1 to 50 (27%), and more than 50 (0%); for clinical tumor Stage T1a-T1c (84%), T2a-T2c (51 %), and T3-T4 (29%); for tumor grade well (58%), moderate (58%), and poor (30%). Four-year DFS rates for Gleason sum are 2 to 4 (82%), 5 (72%), 6 (56%), and 7 to 10 (48%). In multivariable Cox regression analysis with backward elimination of nonsignificant variables, age, race, tumor grade, and radiation dose were eliminated, leaving pretreatment PSA, clinical tumor stage, and Gleason sum as significant prognostic factors. Analysis of a Cox model that included nadir PSA as a time-dependent variable showed it to be the strongest prognostic factor variable in the analysis. CONCLUSIONS: XRT remains a suitable treatment modality for patients with pretreatment PSA less than 20.0, clinical tumor Stages T1-T2, and Gleason sum 2 to 6 prostate cancer. Patients achieving a nadir value less than 0.5 have more durable treatment outcomes.

Esophageal passage of iodine-131 capsules.

UNLABELLED: The purpose of this study was to determine the orogastric transit time of standard 131I capsules and the incidence of transit delay. METHODS: We studied 58 consecutive subjects receiving outpatient diagnostic and therapeutic 131I dosages. A standard ion chamber survey meter, placed over the left upper quadrant of the abdomen, monitored orogastric transit. Each subject had ample water to subjectively swallow their capsule. Orogastric transit times, volume of water ingested, capsule size, and demographic and historical data were recorded for each subject. RESULTS: Seventeen subjects (29%) had delayed transit, with an orogastric transit time > 90 sec (median 140 sec, range 100-930 sec). Forty-one subjects had normal transit (median 14 sec, range 4-51 sec). We identified delayed transit in 7 of 37 women (19%) and 10 of 21 men (48%) (p = 0.035). Age, capsule size and initial water volume ingested did not differ significantly between subject groups. CONCLUSION: Men were more likely than women to have prolonged orogastric transit of standard 131I capsules. Other than sex, we found no identifiable clinical feature or medical history to predict delayed orogastric transit. A standard survey meter can identify adherent capsules to minimize esophageal radiation exposure.

Prospective use of free prostate-specific antigen to avoid repeat prostate biopsies in men with elevated total prostate-specific antigen.

OBJECTIVES: We prospectively evaluated whether free PSA improves the specificity of PSA and can be useful as a clinical guide to avoid repeat prostate biopsies in patients with persistent PSA elevations, normal digital rectal examinations, and previous negative prostate biopsies. METHODS: Sixty-seven men with persistent PSA elevations (median 9.5, range 4.1-24.8 ng/mL), normal digital rectal examinations and two or more prior sextant biopsies (mean 2.8) had serum collected for measurement of total and free PSA. All patients were rebiopsied to determine the receiver operating characteristics of total PSA versus percent free PSA for prostate cancer detection. RESULTS: The study biopsy identified 11 prostate cancer cases. The median percent free PSA was significantly higher at 18.0% among men without prostate cancer compared to 6.7% in men with prostate cancer (P < 0.00005). When sensitivity was plotted against 1-specificity, the area under the receiver operating characteristic curve for percent free PSA was 0.93, compared to 0.69 for free PSA density, 0.66 for PSA density, and 0.51 for PSA. In patients with elevated total PSA levels, normal digital rectal examinations and two prior negative sets of sextant prostate biopsies, a cutoff of 10% free PSA would maintain sensitivity at 91% with a corresponding specificity of 86%. CONCLUSIONS: Selective measurement of percent free PSA can significantly improve the specificity of prostate cancer screening with PSA. A low percent free PSA (< 10%) appears to be a powerful predictor of prostate cancer even after two negative prostate biopsies.

Prospective use of free PSA to avoid repeat prostate biopsies in men with elevated total PSA.

BACKGROUND: Prostate-specific antigen (PSA) is a most valuable tool for the early detection of prostate cancer; however, it has a high false-positive rate as presently used in prostate cancer screening programs. Patients with persistent PSA elevations, normal digital rectal examinations, and multiple negative biopsies present a clinical dilemma. We prospectively evaluated whether free PSA improves the specificity of PSA and can be useful as a clinical guide to avoid repeat prostate biopsies in a group of such patients. METHODS: Sixty-seven men with persistent PSA elevations (mean 9.6 ng/mL; range 4.1-24.8 ng/mL), normal digital rectal examinations, and two or more prior sextant biopsies (mean 2.8), had serum collected for measurement of total and free PSA. All patients were rebiopsied to determine the receiver-operating characteristics (ROC) of total PSA vs. percent free PSA for prostate cancer detection. RESULTS: This study by biopsy identified 11 new prostate cancer cases. The median percent free PSA was significantly higher at 18.1% among men without prostate cancer, compared to 6.4% in men with prostate cancer (P < 0.00005). When sensitivity was plotted against I-specificity, the area under the receiver-operating curve (ROC) for percent free PSA was 0.95, compared to 0.75 for free PSA density, 0.59 for PSA density, and 0.54 for PSA. In patients with elevated total PSA levels, normal digital rectal examinations, and two prior sets of negative sextant prostate biopsies, a cutoff of 10% free PSA would maintain sensitivity at 91% with a corresponding specificity of 86%. CONCLUSIONS: Selective measurement of percent free PSA in cases of uncertain diagnosis can significantly improve the specificity of prostate cancer detection compared to total PSA alone. A low percent free PSA (< 10%) appears to be a significant predictor of prostate cancer even after two or more negative prostate biopsies.

Intraoperative cholangiography. A review of indications and analysis of age-sex groups.

A retrospective review was performed of patients who had biliary tract stone formation as the primary diagnosis for hospitalization and indication for surgery. Five hundred and eighty-nine consecutive charts were reviewed of patients admitted between 1975 and 1979. Intraoperative cholangiography was performed in 166 patients of whom 22 had common duct exploration. Choledochotomy in this series was performed in 63 cases without utilizing pre-exploratory cholangiography. A normal intraoperative cholangiogram was found to be 100% accurate; however, an abnormal cholangiogram was associated with a 16% false positive rate of exploration of the common duct. The incidence of unsuspected common duct stones detected only by intraoperative cholangiography was 2.3%. Age-sex analysis confirms a 10-year mean age difference between men and women within the population of this study (p less than 0.001). This age-sex difference is maintained in patients without common duct pathology as well as in patients with sterile bile. However, the mean age difference between male and female patients with either demonstrable common duct obstruction by stones or infected bile as determined by routine intraoperative culture is not statistically significant. A review of the role of intraoperative cholangiography, and the experience at Northeastern Hospital is discussed.

Prevalence and implications of multi-drug abuse in a population of methadone-maintained women.

Within our study population of 100 women for whom 3,980 urine toxicology reports were accomplished, 98 percent were multi-drug users. This proportion is far greater than would have been calculated from the percent of urines that were positive for the drugs of abuse and is a more realistic estimate of the extent of the problem than is often reported. Despite this high percentage of multi-drug use, due to the uniqueness of our patient population (pregnant women), it is not possible to deny them pharmacologic therapy for their addiction. Therefore, the use of urine toxicology reports in our clinical setting has broader implications than adherence to the methadone regulations. These reports serve as excellent devices to assess newborn abstinence symptomatology, in addition to helping us monitor the physical and psychological status of our patients. The implications are that self-medication may be used to achieve a particular effect concomitant with methadone therapy. The effects are generally to enhance the action of methadone and to decrease undesirable side effects.