Pneumococcal immunizations at flu clinics: the impact of community-wide outreach.

This study examined the effectiveness of a community-wide outreach campaign to promote the use of pneumococcal vaccine at public flu immunization clinics, and assessed whether this intervention was more effective than simply making pneumococcal vaccination available at such clinics. In 1997, a community-wide outreach campaign promoting pneumococcal and influenza immunizations was launched in a 17 zip code area of Dutchess County, NY. The campaign was aimed at 7,961 Medicare beneficiaries urging them to obtain pneumococcal immunization from local flu clinics. Medicare reimbursement data were used to assess the countywide pneumococcal vaccination rate, and to analyze differences between rates for beneficiaries in the target area and elsewhere in the county. Between 1996 and 1997 there was a 94% increase in pneumococcal vaccination billed to Medicare beneficiaries in Dutchess County. The 1997 annual rate of pneumococcal immunization in the target area reached 16.3% versus 12.2% elsewhere in the county (p < 0.001), with an increase over the previous year of 8.7% and 5.6%, respectively. Nearly all of the increase is accounted for by pneumococcal vaccination delivered at flu clinics. It is possible to significantly increase the use of pneumococcal immunization by linking its delivery to community-based flu clinics and by developing local outreach strategies. The outreach campaign has a significant additive effect over simply making PPV available at flu shot clinics. Additional community-wide outreach can further improve pneumococcal immunization utilization rates.

Improving access to mammograms through community-based influenza clinics. A quasi-experimental study.

BACKGROUND: It is a national priority to increase breast-cancer screening among women aged > or = 50. Annual influenza clinics may represent an efficient setting in which to promote breast-cancer screening among older women. To our knowledge, this possibility has not previously been explored. OBJECTIVE: To examine whether offering women attending community-based influenza clinics the opportunity to receive a scheduling telephone call from a mammography facility will result in an increase in the number of mammograms performed over a 6-month period. METHODS: We used a quasi-experimental design with 6-month follow-up. A contemporaneous population-based survey provided a further control group for comparison. The sample group consisted of a total of 284 women attending nine community-based influenza clinics in a semirural county in Connecticut. All women were aged > or = 50 and reported no mammogram in the preceding 12 months. All women received informational literature on mammography. Experimental subjects were each asked if a radiology facility chosen by the subject could call her at home to schedule a mammogram. Mammograms performed were determined by hospital record for participants who received a scheduling call from a radiology facility, and by self-report for all other participants. RESULTS: Mammography use following access through influenza clinics was approximately twice that of women attending influenza clinics where access to mammography was not offered. Using three different assumptions regarding participants whose mammography status was unknown, the relative risks ranged between 1.6 and 2.1. For each assumption the results were statistically significant (chi(2)=8.51-12.2; p<0.001). CONCLUSIONS: Linking access to mammography at community-based influenza clinics can significantly increase the use of mammograms among women aged > or = 50. Further studies should seek to confirm these findings and determine the degree to which they can be replicated in a variety of communities. Enhancing preventive health practice through the bundling of services suggests a new strategy to exploit available interventions to improve health.

Loss of heterozygosity and genomic instability in synchronous endometrioid tumors of the ovary and endometrium.

BACKGROUND: The unknown etiology of endometrioid carcinomas of the ovary and the relatively high frequency of a concomitant carcinoma of the endometrium in these patients warrants study of such tumors. The aim of this study was to identify the genetic alterations involved in endometrioid ovarian cancer development, and to determine whether primary tumors of the endometrium and synchronous primary endometrioid tumors of the ovary could be distinguished based on differing patterns of genetic alterations. The distinction of metastatic carcinoma of the ovary from other synchronous primary tumors is often difficult but has important therapeutic and prognostic implications. METHODS: This study examined the genetic alterations at 28 polymorphic DNA markers in the DNA of tumors of 17 patients with endometrioid carcinoma of the ovary, including 5 nonmetastatic ovarian tumors, 5 ovarian tumors metastatic to the uterus, and 7 endometrioid ovarian tumors with a synchronous primary endometrial tumor. RESULTS: Chromosomes 17 and 22 were found to be the most common sites of loss of heterozygosity (LOH) in the 17 patients studied. Loss of heterozygosity on chromosome 17 was associated with advanced stage ovarian tumors. In 96% of LOH events in the metastatic tumors, LOH was observed in the primary tumor and in the metastatic site. Conversely, in four of seven synchronous tumors in which LOH was observed, LOH was confined to the ovarian tumor. Genomic instability was identified in two of seven patients with synchronously occurring tumors that did not demonstrate LOH. A positive family history was noted for these two patients. CONCLUSIONS: A lack of shared genetic alterations and in synchronously occurring endometrial and endometrioid ovarian tumors indicates independent developmental pathways for these tumors. Loss of heterozygosity on chromosome 17 in endometrioid ovarian carcinoma may indicate transition to a more aggressive tumor.

The efficacy of a sonographic morphology index in identifying ovarian cancer: a multi-institutional investigation.

Transvaginal sonography (TVS) has been shown to be the most effective means to screen for ovarian cancer. TVS is associated with a high sensitivity and specificity. However, the positive predictive value associated with TVS in the diagnosis of malignancy is low. A morphologic scoring index for use with TVS has been used at the University of Kentucky since 1991. The current study was performed to more fully evaluate the efficacy and interobserver variation in ultrasonographic morphology index scores attributed to ovarian tumors. Ultrasound records of 213 patients from five participating centers were reviewed by three independent observers. Morphology index scores were assigned to each tumor in a blinded fashion. The morphology index scores were then compared with the final histopathologic findings. One hundred sixty-nine patients had benign tumors and 44 patients had ovarian malignancies. The mean morphology index scores were significantly higher in malignant ovarian tumors (MI 7.3 +/- 1.9) than in benign ovarian tumors (MI 3.3 +/- 1.8). Statistical evaluation of the morphology index scores revealed a sensitivity of 89% and a positive predictive value of 46%. Interobserver variation was lowest in assessing ovarian volume and higher in the evaluation of wall structure and septal structure. A multilogistic regression model was used to evaluate the predictive power of each component of the morphology index. The use of a morphology index is an effective and cost-efficient method of increasing the positive predictive value of TVS screening for ovarian cancer. Use of this index in large numbers of patients will generate data which should help refine appropriate structural scoring categories and reduce interobserver variation.

Ovarian cancer screening in asymptomatic postmenopausal women.

From 1987 to 1992, 3220 asymptomatic postmenopausal women underwent screening with transvaginal sonography (TVS) as part of the University of Kentucky Ovarian Cancer Screening Project. Ovarian volume was calculated using the prolate ellipsoid formula (length x height x width x 0.523). An abnormal sonogram was defined by (1) an ovarian volume > 10cm3 or (2) a papillary projection into a cystic ovarian tumor. All women with an abnormal TVS had a repeat sonogram in 4-6 weeks. If the repeat sonogram was abnormal, a morphology index score was assigned to each tumor, and a serum CA-125 was obtained. The patient then had a pelvic examination and an exploratory laparotomy. Forty-four patients (1.4%) with a persisting abnormality on TVS underwent exploratory laparotomy. Twenty-one patients had serous cystadenomas and 3 had primary ovarian cancers. Two patients with primary ovarian cancer had Stage IA disease and one had Stage IIIB disease. All patients with ovarian cancer had normal pelvic examinations and normal serum CA-125 levels, and are presently alive and well 32, 31, and 8 months after conventional therapy. Over 5000 screening years have been accumulated at this institution, and there have been no ovarian cancer deaths in the screened population. TVS screening has produced a decrease in stage at detection and case-specific mortality from ovarian cancer. A multi-institutional trial to test the efficacy of TVS as a screening method for ovarian cancer is indicated.

A morphology index based on sonographic findings in ovarian cancer.

A morphology index based on morphologic characteristics of ovarian tumors was developed. Specific categories included tumor volume, wall structure, and septal structure. A point scale (0-4) was developed within each category with the total points per evaluation varying from 0-12. Sonograms on 121 patients undergoing exploratory laparotomy for ovarian masses were evaluated using this index. Eighty ovarian tumors had a morphology index score < 5, and all were benign (negative predictive value, 1.000). In postmenopausal patients, a morphology index score > or = 5 had a positive predictive value for malignancy of 0.45. All ovarian malignancies had significant abnormalities in wall structure and all had a total volume in excess of 10 cm3. The findings of the present investigation indicate that the morphology index is a cost effective adjuvant method which significantly increases the specificity and positive predictive value of transvaginal sonography. The routine application of a morphology index to screening sonography should decrease the amount of diagnostic surgery performed in order to detect each case of ovarian cancer.

Suicide risk in patients with human immunodeficiency virus infection and acquired immunodeficiency syndrome.

To describe the current understanding of suicide risk among persons with human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS), we reviewed published reports on suicidal ideation, attempted suicide, and suicide in the HIV/AIDS population. We also drew on our own clinical experience. Suicidal ideation, attempted suicide, and suicide occur at a higher rate across the spectrum of patients with HIV infection than in the general population. Individuals with HIV and AIDS are subject to disease-specific stressors and to a greater number of general suicide risk factors. The assessment of suicide risk in these patients involves a careful exploration of these vulnerabilities.

Laparoscopic para-aortic lymph node sampling: development of a technique.

Clinical staging is woefully inadequate in predicting lymph node metastasis and dictating prudent radiation ports in women undergoing therapy for cervical malignancies. Surgical staging with evaluation of the precaval lymph nodes (via a transperitoneal or extraperitoneal approach) has associated rates of complication that are felt by many clinicians to be excessive. A laparoscopic approach could avoid many of these complications while still obtaining valuable information regarding spread of disease. After experimentation with different forms of laparoscopic approaches in the swine model, we have found an easy and efficient way to visualize and sample the infrarenal precaval lymph nodes. The laparoscope is placed suprapubically, and accessory operating trocars are placed suprapubically and periumbilically. Laparoscopically placed sutures are placed on the incised posterior peritoneum. The sutures exit through the periumbilical trocars. When drawn taut, the sutures pull the peritoneum in a cephalad and ventral fashion so as to act as a tent, retracting the intraperitoneal contents and exposing the precaval area. Using this technique in the swine, we were able to remove 88% of all right-side common iliac and paraaortic nodes laparoscopically without injuring surrounding structures. Evaluation of this technique in humans should be considered.

Economic and policy implications of early intervention in HIV disease.

Early medical intervention in human immunodeficiency virus disease has far-reaching implications for the health care system of the United States. Several factors are enabling the medical community to begin intervention prior to a patient's diagnosis of acquired immunodeficiency syndrome. These factors include an understanding of the biologic markers of disease progression; advances in antiviral therapeutics; and an improved ability to control the most common presenting opportunistic infection, Pneumocystis carinii pneumonia. Providing adequate ambulatory care for large numbers of asymptomatic human immunodeficiency virus-infected individuals and coordinating inner-city health care facilities will become critical. Important questions regarding service provision need to be adequately addressed. The cost of yearly treatment, estimated to be $5 billion per year, will require a major financial commitment at all levels of government and the private sector. Effective early intervention in human immunodeficiency virus disease may alter the course of one of the most devastating epidemics in modern history. Planning for its implementation should begin immediately.

KIE: The promise of early intervention in the course of human immunodeficiency virus (HIV) disease to slow or prevent its progression to AIDS has far-reaching implications for health care in the United States. Medical advances could bring tens of thousands of asymptomatic seropositive individuals into the health care system. The demand for HIV testing, counseling, laboratory monitoring, medications, and overall primary health care will be great, particularly among previously underserved groups such as intravenous drug users and the urban poor. Treatment of HIV positive patients could cost as much as $5 billion per year, and would require a major financial commitment from all levels of government as well as from the private sector. The authors call for rational planning for early intervention in HIV disease to avoid the crisis-driven policy making that has characterized the AIDS epidemic until now.