Lack of association between sputum atypia and chronic obstructive pulmonary disease mortality.

HYPOTHESIS: Chronic obstructive pulmonary disease (COPD) and lung cancer are thought to share common elements in pathogenesis. The authors hypothesized that sputum atypia would reflect the processes leading to progressive airflow obstruction and might be a novel biomarker of more rapidly progressive COPD. METHODS: The authors analyzed the association between COPD death and sputum cytologic atypia in an ongoing cohort of 2013 smokers with varying degrees of airflow obstruction during the period between January 1, 1993, and July 1, 2001. RESULTS: There were 326 deaths attributed to COPD over 4495 person-years, giving a COPD death rate of 7.25 deaths per 100 person-years, which is highly elevated compared with fewer than 0.2 COPD deaths per 100 person-years for the United States population aged between 65 and 74 years. Sputum atypia was not associated with either the degree of airflow obstruction or death from COPD. COPD death was associated with age and degree of airflow obstruction, as expected. CONCLUSION: Sputum cytologic atypia is not predictive of death from COPD. As sputum cytologic grades of moderate or worse atypia are associated with a significant increase in the risk for lung cancer and do not denote a group with increased competing death rates from COPD, patients with sputum atypia are a good high risk group in whom chemoprevention and early detection studies can be conducted.

Multi-target interphase fluorescence in situ hybridization assay increases sensitivity of sputum cytology as a predictor of lung cancer.

Survival rates for lung cancer are low because patients have disseminated disease at diagnosis; therefore tests for early diagnosis are highly desirable. This pilot study investigated occurrence of chromosomal aneusomy in sputum from a 33 case-control cohort matched on age, gender, and date of sample collection. Subjects had chronic obstructive pulmonary disease and > or = 30 pack-years of tobacco use, and aneusomy was tested using a multi-target DNA FISH assay (LAVysion, Abbott/Vysis). In specimens collected within 12 months of lung cancer diagnosis, abnormality was more frequent among the 18 cases (41%) than the 17 controls (6%; P = 0.04). Aneusomy had no significant association with cytologic atypia, which might indicate that molecular and morphological changes could be independent markers of tumorigenesis. Combining both tests, abnormality was found in 83% of the cases and 20% of the controls (P = 0.0004) suggesting that FISH may improve the sensitivity of cytologic atypia as a predictor of lung cancer.

Assessing the role of influential mentors in the research development of primary care fellows.

PURPOSE: To assess the association between mentorship and both subsequent research productivity and career development among primary care research fellows. METHOD: In 1998, using a self-administered questionnaire, the authors surveyed 215 fellows who graduated from 25 National Research Service Award (NRSA) primary care research programs between 1988-1997 to assess quantitative aspects and qualitative domains of their mentorship experience during fellowship training. RESULTS: A total of 139 fellows (65%) responded to mentorship questions a median of four years after their fellowship. Thirty-seven fellows (26.6%) did not have an influential mentor, 42 (30.2%) reported influential but not sustained mentorship, and 60 (43.2%) had influential and sustained mentorship. Individuals with influential mentorship spent more time conducting research (p =.007), published more papers (p =.003), were more likely to be the principal investigator on a grant (p =.008), and more often provided research mentorship to others (72.5% versus 66.7% of those with unsustained mentorship, and 36.4% of those with no influential mentor, p =.008). After controlling for other predictors, influential and sustained mentorship remained an important determinant of career development in research. On qualitative analysis, fellows identified three important domains of mentorship: the relationship between mentor and fellow (such as guidance and support), professional attributes of the mentor (such as reputation), and personal attributes of the mentor (such as availability and caring). CONCLUSIONS: Influential and sustained mentorship enhances the research activity of primary care fellows. Research training programs should develop and support their mentors to ensure that they assume this critical role.

Podiatric problems are associated with worse health status in persons with severe mental illness.

The objective of this study was to determine the prevalence of self-reported podiatric impairments and their effect on health status in persons with severe mental illness. A sample of psychiatric outpatients (N=309) underwent interviews assessing medical conditions and health status with the Medical Outcomes Study Short Form-36 (SF-36). Podiatric health was assessed using nine items from the National Health Interview Survey (NHIS). Eighty percent of patients reported at least one podiatric problem. The most common problems were foot pain (48%), nail disorders (35%) and corns/calluses (28%). Prevalence rates were 4-11 times higher than those reported by the general population in the 1990 NHIS. The total number of podiatric problems was inversely related to eight self-reported health status domains and both summary SF-36 scores (all P<==.0001). After controlling for sociodemographic factors, psychiatric illness and medical conditions, the total number of podiatric limitations remained significantly associated with lower patient ratings in four of the eight SF-36 domains and both summary scores. We concluded that persons with severe and persistent mental illness have markedly elevated rates of podiatric problems when compared to the general population group. These problems are associated with worsened self-perceived health status. Addressing podiatric health may be a successful way to improve the overall health of this population.

Sputum cytological atypia as a predictor of incident lung cancer in a cohort of heavy smokers with airflow obstruction.

Individuals with cytological atypia in sputum may be at increased risk for lung cancer. We conducted a longitudinal analysis of the association between lung cancer incidence and cytological atypia in sputum samples collected prospectively from an ongoing cohort of adults at high risk for lung cancer. Cohort members had a smoking history of > or = 30 pack-years and chronic obstructive pulmonary disease documented by pulmonary airflow testing. Sputum samples collected at baseline and periodically thereafter were examined by standard cytological methods. From the cohort of 2,006 people, there were 83 incident lung cancers over 4,469 person-years of observation. At baseline, the association between personal and behavioral characteristics, and sputum cytological atypia was assessed by multiple logistic regression. The association between sputum cytological atypia and incident lung cancer was then assessed by hazard ratios using proportional hazards regression analysis, adjusting for potential confounding factors. Cytological atypia graded as moderate or worse was associated with continuing cigarette smoking (adjusted odds ratio, 2.5; 95% confidence interval, 1.5-4.1), and with lower levels of intake of fruits and vegetables (P for trend = 0.04). Atypia was not associated with several other factors, including the degree of airflow obstruction, the use of vitamin supplements, nonsteroidal anti-inflammatory drugs, or metered-dose steroid inhalers. Incident lung cancer was increased among those with moderate or worse cytological atypia (adjusted hazards ratio, 2.8; 95% confidence interval, 1.4-5.5). This association was not confounded by other risk factors. We conclude that in this high-risk cohort, cytological atypia is associated with continuing smoking and low intake of fruits and vegetables, but that independent of these and other factors, the risk of incident lung cancer is increased among those with moderate or worse grades of cytological atypia in their sputum.

Indicators of early research productivity among primary care fellows.

OBJECTIVE: Little is known about the impact of fellowship training in primary care on subsequent research productivity. Our goal was to identify characteristics of research fellows and their training associated with subsequent publications and research funding. DESIGN: Mail survey in 1998. SETTING AND PARTICIPANTS: 1988-1997 graduates of 25 National Research Service Award primary care research fellowships in the United States. OUTCOME MEASURES: 1) Publishing 1 or more papers per year since the beginning of fellowship, or 2) serving as principal investigator (PI) on a federal or non-federal grant. RESULTS: One hundred forty-six of two hundred fifteen program graduates (68%) completed the survey. The median age was 38 years, and 51% were male. Thirty-two percent had published 1 or more papers per year, and 44% were PIs. Male gender (odds ratio [OR], 3.6; 95% confidence interval [95% CI], 1.4 to 9.2), self-reported allocation of 40% or more of fellowship time to research (OR, 4.4; 95% CI, 1.8 to 11.2), and having an influential mentor during fellowship (OR, 5.0; 95% CI, 1.5 to 17.2) were independently associated with publishing 1 or more papers per year. Fellows with funding as a PI were also more likely to have an influential mentor (OR, 3.0; 95% CI, 1.3 to 7.2). CONCLUSION: Primary care fellows who had influential mentors were more productive in research early after fellowship. Awareness of the indicators of early research success can inform the policies of agencies that fund research training and the curricula of training programs themselves.

The training and career paths of fellows in the National Research Service Award (NRSA) Program for Research in Primary Medical Care.

PURPOSE: To describe the training and career paths of fellows in the National Research Service Award (NRSA) Program for Research in Primary Medical Care. METHOD: All fellows who graduated from 25 NRSA programs nationally between July 1988 and June 1997 (n = 215) were mailed a questionnaire. Personal characteristics, fellowship experiences, and current professional positions were compared between faculty researchers, faculty clinician-educators, and individuals who were not in full-time academic positions. RESULTS: A total of 146 NRSA graduates (68%) completed the survey. A mean of four years had elapsed since their fellowships. Of the respondents, 36% were faculty researchers, 32% were faculty clinician-educators, and 32% were not on full-time faculties. Faculty researchers did not differ from the other groups in demographics or acquisition of advanced degrees, but they were more often general internists than general pediatricians, family physicians, or from other disciplines (p =.002). Fellowship graduates spent a mean of 29% of their training in course work and 38% conducting research. Faculty researchers spent a greater proportion of their fellowship conducting research (46% versus 34% for clinician-educators and 31% for those not on full-time faculties, respectively, p <.0001). They were also more productive in terms of subsequent publications and grant acquisitions. CONCLUSIONS: Only a minority of those completing NRSA programs held positions as faculty researchers. The preponderance of general internists among researchers may indicate problems in the capacity of general pediatrics and family medicine to support primary care research. The amounts of direct research time during these fellowships may need to be increased to enhance the likelihood of subsequent research success.