Tobacco use among multi-ethnic Latino populations.

OBJECTIVES: To examine tobacco use among New York City resident Latin Americans from different countries of origin and with different levels of acculturation reflected by language use. DESIGN: Effective health promotion programs, particularly those aimed at smoking cessation and prevention, require careful investigation into possible cultural and societal factors influencing predictors and barriers to preventive health behavior. National data characterizing cigarette smoking behavior among broadly defined racial/ethnic groups (e.g., black, Hispanic) have rarely examined the extent or importance of cultural variation and acculturation within and among ethnic groups. This report addresses these issues. METHODS: In this study, we examine self-reported cigarette smoking behavior from a 1992 telephone survey of a quota sample of Puerto Rican, Dominican, Colombian, and Ecuadorian Hispanics living in New York City. We compare results from these data with results from a random sample of New York City Hispanics from the Tobacco Use Supplement to the 1992-93 Current Population Survey. RESULTS: Both data sets demonstrated that Puerto Ricans were significantly more likely to be current smokers and ever smokers than the other three Latino groups. Among Hispanic women in the quota sample, those who chose to complete the interview in English were much more likely to report ever smoking than those women who chose to complete the interview in Spanish. CONCLUSIONS: The relationship between smoking behavior and acculturation (as measured by language usage) appears to be complex and sensitive to methodological issues of sampling and interview language.

Radiation therapy for rhabdomyosarcoma: local failure risk for Clinical Group III patients on Intergroup Rhabdomyosarcoma Study II.

PURPOSE: A subset of 362 pediatric patients with rhabdomyosarcoma was selected from a total of 532 eligible IRS-II patients in Clinical Group III to assess the local and regional failure rates following radiotherapy and to determine patient, tumor, and treatment factors contributing to the risk for local and regional failure. METHODS AND MATERIALS: The study population was selected from all eligible IRS-II Clinical Group III patients. Excluded patients were those with "special pelvic" primary sites whose protocol management restricted radiotherapy (n = 123), and those who were removed from the study before radiotherapy was to begin, or because it was omitted (n = 47). A binary recursive partitioning model was used to identify subgroups of the remaining 362 patients at risk of local or regional failure. RESULTS: The local (only) failure rate was 17% (95% confidence interval, 13-21%), and the local (all) failure rate was 20% (95% confidence interval, 16-24%). The 5-year actuarial risk of local (all) failure was 22% (95% confidence interval, 18-27%). The risk of regional (nodal) failure was between 2% and 23%. Increasing tumor size predicted an increased local failure risk. Primary tumors located above the clavicle had a reduced risk of local failure. The binary recursive partitioning model identified a subset of patients at high risk of local failure. Those patients had primary tumors in the chest, pelvic region, extremity, or trunk, or tumors > 10 cm in diameter. Their local failure rate was 35% (compared to 15% for the remaining patients). The subset of patients at high risk for regional (nodal) failure had node involvement at diagnosis and a primary tumor originating at a site other than orbit, parameningeal, or trunk. Compliance with radiation treatment guidelines approached but did not achieve statistical significance as a predictive factor for local failure. By univariate analysis, factors not influencing local failure risk were age, race, gender, adenopathy, and histology. CONCLUSION: Radiation therapy and chemotherapy administered to Clinical Group III patients entered into the IRS-II protocol produced sustained local control in most cases. Knowledge of the factors which predict an increased risk of local or regional failure will facilitate the design of new treatment strategies.

The argument for conservative, delayed surgery in the management of prostatic rhabdomyosarcoma.

Exenteration is no longer required for most patients who have rhabdomyosarcoma (RMS) of the prostate. This site comprised only about 5% of newly diagnosed cases in the IRS-III (1984-1991). The mean age at the time of diagnosis was 5.3 yrs (range, 0 to 19 years). Most tumors were relatively large, had embryonal histology, and were clinically localized but unresectable without major loss of organ function. The 44 patients with group III tumors (gross residual disease) were treated according to the IRS-III protocol. Forty-three of them underwent biopsy only, and one patient had subtotal resection as the initial procedure. The average number of surgical procedures per patient was two (range, one to five). Six of the 44 patients had no additional surgery. The second-look procedures performed in the other 38 patients included exenteration (14), prostatectomy (7), cystoscopic/perineal needle biopsy (8), laparotomy with biopsy (6), and subtotal excision with bladder salvage (3). Additional surgery was required for four patients, for evaluation of a residual mass, postoperative fistula, ureteral stricture, or small bowel obstruction. Six patients with relapse or residual disease underwent additional chemotherapy and late exenteration (3), prostatectomy (1), or biopsy (2). Four of the six have been cured, one is in treatment for a second malignancy, and the other has residual disease after exenteration. Thirty-six of the 44 patients with group III tumors have been cured (minimum follow-up period, 6 years; range, 6 to 11 years), compared with 23 of the 47 in IRS-II (1978-1984) (P = .001). Two of the six deaths in this group were caused by infection. The bladder salvage rate for those cured of their disease also was better (64% v 57% for IRS-II). The two patients with group IIA tumors were cured by gross primary excision, local radiotherapy, and vincristine and actinomycin therapy. By contrast, all patients with metastatic disease (group IV) died of the tumor. Conservative, delayed surgery, performed after intensive chemotherapy with or without radiotherapy, yields a better cure rate while maintaining a high rate of bladder salvage in children with group III prostatic RMS.

Vomiting and recovery after outpatient tonsillectomy and adenoidectomy in children. Comparison of four anesthetic techniques using nitrous oxide with halothane or propofol.

BACKGROUND: The authors' purpose in this study was to compare prospectively four different anesthetic induction and maintenance techniques using nitrous oxide with halothane and/or propofol for vomiting and recovery after outpatient tonsillectomy and adenoidectomy procedures in children. METHODS: Eighty unpremedicated children, aged 3-10 yr, were assigned randomly to four groups: group H/H, 0.5-2% halothane induction/halothane maintenance; group P/P, 3-5 mg.kg-1 propofol induction and 0.1-0.3 mg.kg-1.min-1 propofol maintenance; group H/P, 0.1-0.3 mg.kg-1.min-1 halothane induction/propofol maintenance; and group P/H, 3-5 mg.kg-1 propofol induction and 0.5-2% halothane maintenance. Nitrous oxide (67%) and oxygen (33%) were administered in all the groups. Other treatments and procedures were standardized intra- and postoperatively. Results of postoperative vomiting and recovery were analyzed in the first 6 h and beyond 6 h. RESULTS: Logistic regression showed that vomiting occurred 3.5 times as often when halothane was used for maintenance of anesthesia (groups H/H and P/H) compared with the use of propofol (groups P/P and H/P; Odds Ratio 3.5; 95% confidence interval 1.3 and 9.4, respectively; P = 0.012). A significant association between vomiting ( < 6 h: yes/no) and discharge times ( > 6 h: yes/no) (Odd's Ratio = 3.6; 95% confidence interval: 1.02, 12.4, respectively) (P = 0.046) was shown. However, no significant differences among the groups in the incidence of vomiting beyond 6 h, recurrent vomiting, or hospital discharge times were shown. CONCLUSIONS: After tonsillectomy and adenoidectomy procedures, despite reduced postoperative vomiting with use of propofol rather than halothane, along with nitrous oxide for anesthetic maintenance, the authors found no differences in "true" endpoints such as unplanned admissions or discharge times. Among the groups, the main factor that delayed hospital discharge beyond 6 h was vomiting within the first 6 h.

Assessment of a technology that permits individualized scan delays on helical hepatic CT: a technique to improve efficiency in use of contrast material.

OBJECTIVE: We performed this study to assess the usefulness of a computer automated scan technology (CAST) for individualizing scan delay during helical CT to improve the efficiency of hepatic enhancement. SUBJECTS AND METHODS: We prospectively evaluated 183 patients who were randomized into five groups. Control patients received 100 or 150 ml of contrast material (320 mg I/ml) with a 60-sec delay between contrast injection at 3 ml/sec and scanning. CAST patients received 100, 125, or 150 ml. In our latter groups we used an hepatic enhancement threshold of 50 H over baseline to determine the optimum delay between contrast injection and scanning. For the intergroup comparisons, we measured the liver on baseline and enhanced helical CT scans at the upper, mid, and lower levels of the liver. RESULTS: The mean enhancement in patients who received 150 ml of contrast material was 70.7 +/- 19.4 H for the control group and 81.0 +/- 17.5 H for the CAST group (p < .05). Hepatic enhancement above 50 H was achieved in 84% of the control subjects compared with 100% of CAST subjects; more than 60 H hepatic enhancement was achieved in 73% of control subjects and in 89% of CAST subjects. The use of CAST software with 125-ml contrast doses provided enhancement equivalent to that of control subjects who received 150 ml of contrast material (mean enhancement in CAST subjects, 70.3 +/- 15.4 H). Enhancement above 50 H was reached in 98% of CAST and 84% of control patients. With 100 ml of contrast material, 24% of patients failed to initiate CAST, resulting in enhancement similar to control patients (CAST, 54.2 +/- 11.4 H; controls, 56.9 +/- 15.2 H). CONCLUSION: Using a contrast dose of 150 ml, CAST provided significantly increased hepatic enhancement than that achieved in control subjects with less variability. For equivalent hepatic enhancement, contrast doses could be decreased by 25 ml using CAST technology because it provides individualized scan delays.

Epidemiology of idiopathic dilated cardiomyopathy in the elderly: pooled results from two case-control studies.

Although idiopathic dilated cardiomyopathy is often viewed as an affliction of young of middle-aged adults, morbidity and mortality rates from idiopathic dilated cardiomyopathy rise sharply with age and are the highest in the elderly. To learn more about the determinants of this increasingly important cause of heart failure in the elderly, the authors conducted a pooled analysis of data from two case-control studies of idiopathic dilated cardiomyopathy carried out in Baltimore, Maryland (1984-1986), and in Washington, DC (1990-1992). Identical diagnostic criteria and interviewing procedures had been used in both studies. All of the cases of idiopathic dilated cardiomyopathy had evidence of ventricular dilation and hypokinesis, with a left ventricular ejection fraction of < 40%. Cases with a history of coronary artery disease were excluded along with those with known secondary forms of cardiomyopathy, Up to two neighborhood controls of the same sex and appropriate age (+/- 5 years) were selected for each case using a random digit dialing technique. The subjects or a suitable surrogate was interviewed by telephone to obtain medical history information. The present analysis was limited to 94 cases and 152 matched controls who were at least 60 years of age. Conditional logistic regression methods were used in the analysis. Significant associations were observed with lower educational attainment and a history of hypertension (P < 0.05). The association with hypertension (relative odds = 2.2, 95% confidence interval 1.1-4.6) persisted after adjustment for race, education, and diabetes and was not accounted for by coronary angiography utilization patterns. The association with diabetes was of borderline significance (p < 0.10). The pattern of risk factors identified in this analysis may allow for the early identification of elderly persons who are at increased risk of idiopathic dilated cardiomyopathy.

Barriers to breast and cervical cancer screening in underserved women of the District of Columbia.

PURPOSE/OBJECTIVES: To identify barriers to breast and cervical cancer screening services from the perspective of medically underserved women of the District of Columbia (DC) that may influence intentions to perform breast and cervical cancer screening behaviors; to determine any relationship between attitudes and influence of significant others on intended behaviors; and to identify a relationship between the site where services are provided and the underserved women's intentions to engage in screening behaviors. DESIGN: Cross-sectional, correlational. SETTING: Breast and cervical cancer screening clinics in DC. SAMPLE: 339 medically underserved, adult women. METHODS: Face-to-face investigator-conducted interviews. MAIN RESEARCH VARIABLES: Demographic and contextual variables as well as attitudes and influence of significant others. Intention to have a mammogram or Pap test or perform breast self-examination (BSE) monthly. FINDINGS: Intention to have a mammogram was positively related to influence of significant others and negatively related to uncaring healthcare professionals. Intention to have a Pap test had a positive relationship with one's attitude toward the test and with the influence of significant others. Intention to perform BSE was positively related to attitude toward and previous performance of BSE and influence of significant others. No significant relationships were observed between intention to perform screening behaviors and demographic variables. CONCLUSIONS: Factors that influence women's attitudes toward screening and intention to perform these behaviors include previous screening behaviors, influence of significant others, and relationships with healthcare professionals. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses are well-positioned to develop and test intervention strategies designed to increase access to and compliance with recommended screening guidelines among the medically underserved. Findings from this study potentially could guide development and evaluation of such strategies that are sensitive to this special population.

Helical CT of the liver: clinical application of an automated computer technique, SmartPrep, for obtaining images with optimal contrast enhancement.

OBJECTIVES: The purpose of this study was to evaluate an automated computer technique (SmartPrep) for achieving a consistently high level of contrast enhancement in the liver with helical CT. The technique compensates for variability between patients by indicating graphically the time at which scanning should be initiated to reach a desired level of hepatic enhancement. MATERIALS AND METHODS: One hundred nine consecutive patients undergoing helical CT of the abdomen were randomly evaluated, using either a standard 70-sec delay from the start of the injection of contrast material to scanning or a newly developed, commercially available automated technique, SmartPrep. A series of multiple low-dose scans was performed until an arbitrary threshold of hepatic enhancement (50 H) over baseline was achieved. Three regions of interest (ROIs) were imaged on a baseline scan and on contrast-enhanced scans at the upper, mid, and lower liver. Average hepatic enhancement and the standard deviation over baseline was calculated for each group at all anatomic levels. For the SmartPrep group, the range of time between scan initiation and onset of scanning was calculated. RESULTS: The mean hepatic enhancement for the control group (n = 56) was 59.8 +/- 20.1 H, which differed significantly (p = .0002) from that for the SmartPrep group (n = 53), which was 71.6 +/- 15.2 H. Comparison of the variability between the two groups' enhancement levels was also significant (p = .02). The range of delay times for the SmartPrep group was 48-86 sec. In two additional cases, abnormal graphically displayed enhancement curves were the first indication of an improper injection. CONCLUSION: Use of SmartPrep yields a greater and more consistent level of hepatic enhancement from patient to patient than does use of a conventional fixed delay time. The ability to scan more efficiently to achieve greater hepatic enhancement using SmartPrep has significant implications for potential contrast cost savings.

Conspicuity of hepatic metastases on helical CT: effect of different time delays between contrast administration and scanning.

OBJECTIVE: The purpose of this study was to compare two time delays between injection of contrast material and helical CT scanning to determine relative conspicuity of hepatic metastases. SUBJECTS AND METHODS: Twenty-five patients with hepatic metastases were examined with helical CT. The first imaging phase was initiated at 50 sec and the second 75 sec after the start of contrast material injection (3 ml/sec, 150 ml). Differences in lesion and liver attenuation were measured quantitatively. Four radiologists used a 5-point scale to assess lesion conspicuity subjectively. RESULTS: Mean differences in enhancement between liver and lesion were 41 H during the first phase and 59 H for the second phase (p = .0001). Radiologists' conspicuity score averaged 2.4 for lesions in the first phase versus 3.3 for lesions in the second phase (p = .0001). In 56 (88%) of 64 lesions, objective measurements showed greater enhancement of lesions during the later phase. Radiologists found 60 (94%) of 64 lesions to be more conspicuous on these later images. CONCLUSION: Our results show that conspicuity of hepatic metastases on helical CT scans is better with a 75-sec scan delay between contrast administration and scanning than with a 50-sec scan delay. The longer delay time should be used when scanning is used to detect metastases.

A phase II trial of paclitaxel (Taxol) as first line treatment in advanced breast cancer.

Paclitaxel (Taxol) is a natural product with a broad spectrum of activity against various solid tumors. This report includes nineteen patients with advanced breast cancer who have not previously received chemotherapy for metastatic disease. Fifteen patients had received adjuvant chemotherapy, eight of which were doxorubicin based. Patients were treated with 135 mg/m2 over 24 hours by continuous infusion given every 21 days. There were 2 complete and 4 partial responses for an objective response rate of 32% (95% C.I.: 14%, 57%) and eight patients or 42% with stable disease. Three of eight patients (38%) who had received adjuvant doxorubicin did respond to paclitaxel. Responses occurred in lung, liver, and soft tissue. The primary toxicity was hematologic with 13 hospitalizations for febrile neutropenia in 180 cycles (7%). Paclitaxel has moderate activity in a small number of patients with metastatic breast cancer at the dose of 135 mg/m2 over 24 hours in this study.

Black-white differences in mortality in idiopathic dilated cardiomyopathy: the Washington, DC, dilated cardiomyopathy study.

Racial, socioeconomic, and clinical factors were examined as predictors of survival in idiopathic dilated cardiomyopathy using cases from five Washington, DC-area hospitals. One hundred three (80.5%) of the patients were black and 25 (19.5%) were white. The black patients were less likely to have private health insurance, less educated on average, and more likely to have a household income of $15,000 or less (P < or = .05). No racial differences were found in cardiac medication usage, with the exception of beta blockers and antiarrhythmics. The cumulative survival among black patients at 12 and 24 months was 71.5% and 63.6%, respectively, as compared with 92.0% and 86.3% among whites. The 12-month survival of black patients with ventricular arrhythmias or an ejection fraction of less than 25% was particularly poor. Age, ventricular arrhythmias, ejection fraction, and cigarette usage were significant predictors of survival in univariate analysis using the proportional hazards model. The univariate association with black race was of borderline significance (P < or = .07). In multivariate analysis, age and race were statistically significant independent predictors of survival. A strong association with black race was observed with an estimated relative risk of mortality of 5.41 (P < or = .02) after adjustment for age, ejection fraction, ventricular arrhythmias, and educational attainment. Poorer survival among blacks may be caused by a greater severity of disease at the time of diagnosis or by racial differences in cardiac care, comorbid conditions, or biologic factors affecting survival.

The epidemiology of idiopathic dilated cardiomyopathy in women: the Washington DC Dilated Cardiomyopathy Study.

We examined possible risk factors for idiopathic dilated cardiomyopathy in women by comparing newly diagnosed cases (N = 61) ascertained from five Washington DC area hospitals with neighborhood controls (N = 122) identified using a random digit dialing technique. We matched the cases and controls on 5-year age intervals and telephone exchange and analyzed the data using conditional logistic regression methods. We found that idiopathic dilated cardiomyopathy was associated with history of asthma, diabetes mellitus, hypertension, and black race. The association with hypertension was particularly strong among women who were less than 50 years of age [crude relative odds (RO) = 21.0, 95% confidence interval (CI) = 4.6-96.9]. We found a strong inverse association with history of oral contraceptive use (crude RO = 0.3, 95% CI = 0.1-0.7; adjusted RO = 0.1, 95% CI = 0.1-0.5, controlling for other identified risk factors). Only 13.2% (7 of 53) of the cases had a reported history of contraceptive use, as compared with 35.5% (43 of 121) of the controls. The possible protective effect from oral contraceptive use was not explained by race, educational attainment, asthma, diabetes mellitus, or hypertension, and was more pronounced among women who were less than 50 years of age.

Predictors of coronary angiography in patients with idiopathic dilated cardiomyopathy: the Washington, DC Dilated Cardiomyopathy Study.

Although a number of clinical and demographic factors have been associated with the performance of angiography in cardiac patients, clinical studies of idiopathic dilated cardiomyopathy (DCM) have often excluded patients who have not undergone coronary angiography to rule out coronary artery disease (CAD). To examine the impact of this diagnostic criterion on population-based studies of idiopathic DCM, we examined characteristics of probable cases of DCM who did or did not have a recorded history of angiography. The cases (n = 129) were ascertained from five medical centers in the Washington, DC metropolitan area over the period 1 July 1990 through 29 February 1992. All of these cases had evidence of ventricular dilation and hypokinesis, with a left ventricular ejection fraction of less than 40%. Cases with a history of known CAD, congenital heart disease, valvular heart disease, or secondary cardiomyopathy were excluded. Sixty-two (48%) of the cases had a recorded history of angiography. Age, educational level, diabetes, alcohol use, insurance status, and type of hospital were significantly associated with angiography in bivariate analysis (p < 0.05). Diabetes and hypertension were inversely associated with history of angiography among black cases, and positively associated with angiography among whites. In logistic regression analysis, age was the strongest independent predictor of angiography (p < 0.025). The associations with educational attainment and alcohol use were of borderline significance (p < 0.10). Thus, in epidemiologic studies of idiopathic DCM, particularly in biracial populations, the exclusion of cases who have not undergone angiography may bias risk estimates and result in the underestimation of incidence and prevalence.

Etoposide in combination with cyclophosphamide and total body irradiation or busulfan as conditioning for marrow transplantation in adults and children.

PURPOSE: In an attempt to intensify conditioning therapy for bone marrow transplantation of hematologic malignancies, a retrospective three center evaluation of escalating doses of etoposide added to cyclophosphamide and either total body irradiation or busulfan was undertaken. METHODS AND MATERIALS: Seventy-six patients who received etoposide (25-65 mg/kg) added to cyclophosphamide (60-120 mg/kg) and either total body irradiation (12.0-13.2 Gy) or busulfan (12-16 mg/kg) were evaluable for toxicity. Fifty-one of the evaluable patients received allogeneic transplants, while twenty-six received autologous transplants. A comparative analysis of toxicities according to conditioning regimen, donor source and etoposide dose was made. RESULTS: Similar toxicities were observed among the treatment groups with the exception of more frequent skin (p = 0.003) and life threatening hepatic toxicities (p = 0.01) in the busulfan treated patients. Life threatening or fatal toxicities were not influenced by donor source, either when analyzed by treatment group or etoposide dose. Etoposide at a dose of 60-65 mg/kg in combination with TBI and cyclophosphamide was associated with a significantly increased incidence of life threatening or fatal toxicities compared with a combination using a dose of 25-50 mg/kg (15 of 24 vs. 5 of 20; p = 0.013). The maximally tolerated dose of etoposide in combination with busulfan and cyclophosphamide cannot be definitively established in this analysis in part due to the heterogeneity of the patient population and treatment schemes. CONCLUSION: Although toxicities with bone marrow transplant preparative regimens containing etoposide in combination with cyclophosphamide and total body irradiation or busulfan were frequently severe, treatment related mortality risk was believed to be acceptably low.

Diabetes mellitus and risk of idiopathic dilated cardiomyopathy. The Washington, DC Dilated Cardiomyopathy Study.

An epidemiologic study was carried out to examine the possible role of diabetes mellitus and other factors in the development of idiopathic dilated cardiomyopathy. Possible associations with diabetes and other factors were examined by comparing newly diagnosed case patients (n = 129) ascertained from five Washington, DC area hospitals with neighborhood control subjects (n = 258) identified using a random-digit dialing technique. The case patients and control subjects were matched by sex and 5-year age intervals and were compared in the analysis using conditional logistic regression methods. A statistically significant association was observed between idiopathic dilated cardiomyopathy and history of diabetes (relative odds = 2.2; 95% confidence interval: 1.5 to 3.3). The association with diabetes was not explained by race, income, cigarette usage, or hypertension. A total of 28.7% (37/129) of the case patients had a reported history of diabetes, as compared with 13.6% (35/258) of the control subjects (P < 0.05). A possible interactive effect was also observed between diabetes and history of hypertension (P > 0.05). These findings support the view that diabetics, particularly those with a history of hypertension, may be at increased risk of idiopathic dilated cardiomyopathy.

Black-white differences in idiopathic dilated cardiomyopathy: the Washington DC dilated Cardiomyopathy Study.

We conducted an epidemiologic study to examine the extent to which differences in purported risk factors account for black-white differences in risk of idiopathic dilated cardiomyopathy. We examined associations with race and other factors by comparing newly diagnosed cases (N = 122), ascertained from five Washington DC area hospitals, with neighborhood controls (N = 234) identified using a random digit dialing technique. We matched the cases and controls on sex and 5-year age intervals and analyzed the data using conditional logistic regression methods. We found that blacks were at increased risk for idiopathic dilated cardiomyopathy (relative odds = 2.6, 95% confidence interval = 1.6-4.3). The increased risk for blacks could not be explained by income, educational attainment, alcohol consumption, cigarette smoking, or history of hypertension, obesity, diabetes, or asthma. We also observed a possible interactive effect between black race and hypertension.