Major lower-extremity amputation: contemporary experience in a single Veterans Affairs institution

Our objective is to describe our current experience with major lower-extremity amputation secondary to vascular disease. We conducted a retrospective review of sequential amputations over a 3-year period at one Veterans Affairs institution. One hundred thirteen amputations were performed in 99 men (age 70 +/- 11 years). Seventy-five per cent were diabetic and 23 per cent were on dialysis. Fifty-six per cent were primary amputations. The final AKA/BKA (above-knee to below-knee amputation) ratio was 3:2 and was not related to prior bypass, ethnicity, or dialysis status (P > 0.5). Forty-three per cent of amputations were BKAs in diabetics versus 26 per cent in nondiabetics (P = 0.08). The in-hospital and 30-day mortality rates were 2.6 and 8 per cent and were not related to amputation level (P = 0.76). Forty per cent experienced postoperative complications that were most frequently wound related (22%). Wound complications were more frequent with BKA than AKA (P = 0.04). At an average follow-up of 10 +/- 8 months only 65 per cent were alive. Although 51 per cent were discharged to rehabilitation units only 26 per cent regularly wore a prosthesis with 23 per cent ambulating. BKA patients were more likely to ambulate than AKA (34% vs 9%; P = 0.001), and dialysis patients were less likely to ambulate than nondialysis patients (5% vs 25%; P < 0.02). During follow-up 17 per cent of patients discharged with an intact contralateral limb required amputation of that limb and 7 per cent had bypass surgery on that limb. Complication rates were higher in African Americans and Hispanics than in whites (59%, 45%, and 23%, respectively; P < 0.001), although mortality and ambulation rates were similar. Despite an acceptable perioperative mortality complication rates remain high especially in nonwhites. One-year mortality is high. Low rehabilitation rates especially in dialysis patients mandate further efforts in this regard. Vigilant follow-up of the contralateral limb is essential.     

Comparison of two methods used to assess first-ray mobility

Mobility of the first-ray is associated with several common lower extremity disorders. However, the reliability and validity of clinical measurement remains unclear. In this study we examined first-ray mobility by using one hand to stabilize the lesser metatarsals while the clinician's other hand applied a displacement force to the head of the first metatarsal. The amount of mobility was graded as stiff, normal or hypermobile. We then used a well-validated mechanical device to perform similar tests and assessed validity, intrarater reliability and interrater reliability. Three clinicians having varied levels of experience graded first-ray mobility on 15 subjects. A separate investigator measured dorsal mobility with a mechanical device. Both methods of testing were repeated to assess measurement reliability. Reliability was estimated by kappa (K) statistics. Spearman correlation assessed the relationship between mobility graded manually and dorsal mobility measured by device. Manual examination intrarater K values ranged from 0.50 to 0.85, and interrater agreement from 0.09 to 0.16. Manual grading was not related (r = -0.21) to the absolute measure of total dorsal mobility made by device. This brings into question the validity and reliability of manual estimates of first-ray mobility.     

Financial incentives to promote smoking cessation: evidence from 11 quit and win contests.

In an effort footline to motivate smokers across New York State to stop smoking, tobacco control programs across the state held 'Quit and Win' incentive-based stop-smoking contests. These contests encouraged smokers to make a quit attempt by offering a chance to win cash prize (usually 1,000 dollars) for successfully stopping smoking for at least 1 month. Between 2001 and 2004, 11 different Quit and Win Contests involving 5,504 adult smokers were sponsored in different communities across New York State. Follow-up surveys were conducted 4 to 6 months after each contest ended to evaluate participants' success in quitting smoking. Expenditures for promoting contests varied from a high of 91,441 dollars to a low of 4,345 dollars, with a median of 25,928 dollars. An average of 0.55 percent of smokers was recruited to join contests across the 11 communities. Among smokers who enrolled in a contest, 9 out of 10 reported making a quit attempt, and between 53 percent and 72 percent reported quitting for the full month of the contest. At 4 to 6 months follow-up, self-reported quit rates (7-day point prevalence) among contestants ranged from 22 percent to 49 percent, with an average of 31 percent. Based on a statewide population survey, 8 of the 11 programs showed quit rates that were significantly higher (P < .001 by Wilcoxon rank-sum test) than the estimated quit rate of 21 percent seen among smokers making a quit attempt in the past year. This study shows that for a relatively modest investment of resources, thousands of smokers can be recruited to make a serious quit attempt, with many remaining smoke-free months later.     

Determinants of physician unwillingness to offer medical abortion using mifepristone.

PURPOSE: We sought to identify factors associated with contemplating versus not contemplating offering medical abortion with mifepristone among physicians not opposed to it. METHODS: We analyzed data from a Kaiser Family Foundation survey of a nationally representative sample of 790 American obstetrician/gynecologists and primary care physicians. Our study sample consisted of 419 physicians who were not personally opposed to medical abortion and could be classified as not actively considering (precontemplation) or actively considering (contemplation) offering mifepristone. We conducted multivariate logistic regression to predict being unlikely to offer mifepristone (i.e., in the precontemplation stage of change). PRINCIPAL FINDINGS: In 2001, 1 year after U.S. Food and Drug Administration (FDA) approval, 5% of physicians surveyed were offering mifepristone. Among the 750 physicians not offering mifepristone, 57% were not opposed. Of those not opposed, 74% reported that they were unlikely to offer mifepristone in the next year (precontemplation) as compared to 23% who might offer it (contemplation). Independent predictors of being in the precontemplation stage were being a primary care versus OB/GYN physician (odds ratio [OR] 3.29, p = .02), being in private versus hospital-based practice (OR 2.40, p = .03), and lacking concerns about FDA regulations (OR 2.06, p = .01) or violence and protests (OR 1.93, p = .03) as barriers to offering mifepristone. CONCLUSIONS: For precontemplation-stage physicians, the most efficient strategy for increasing the availability of medical abortion may be to design programs that emphasize clinical benefits and feasibility to stimulate interest in the procedure. For contemplation-stage physicians, the optimum approach may be one that helps to overcome barriers associated with FDA regulations and concerns about violence and protests.     

Use of computer kiosks for breast cancer education in five community settings.

Finding ways to bring effective computer-based behavioral interventions to those with limited access to technology is a continuing challenge for health educators. Computer kiosks placed in community settings may help reach such populations. The Reflections of You kiosk generates individually tailored magazines on breast cancer and mammography and was adapted from an evidence-based intervention that increased mammography use in African American women. This usage study tracked patterns of use and characteristics of kiosk users in beauty salons, churches, neighborhood health centers, Laundromats, and social service agencies in St. Louis. Kiosks were used 4,527 times in 470 kiosk days at 40 different host sites. Highly significant differences among community settings were found in rates and patterns of kiosk use as well as user characteristics, breast cancer knowledge, and use of mammography. Findings inform strategic decision making about technology dissemination and community outreach to women needing information about breast cancer and mammography.     

Concordance of Patient-Physician Obesity Diagnosis and Treatment Beliefs in Rural Practice Settings

CONTEXT: Although clinical guidelines recommend routine screening and treatment for obesity in primary care, lack of agreement between physicians and patients about the need for obesity treatment in the primary care setting may be an unexplored factor contributing to the obesity epidemic. PURPOSE AND METHODS: To better understand this dynamic, we surveyed 439 obese patients (body mass index >or=30) at the time of clinic visits in 2003 at diverse primary care settings in rural Kansas and conducted same-day interviews with their physicians (N = 28). We used Spearman's correlation to describe and compare patient and physician responses. FINDINGS: Most patients were women (66%). Their mean age was 55.8 years, and mean body mass index was 37.7. Half (51%) reported discussing their weight on that visit date. Overall, 51% of patients wanted to discuss weight more often with their physician and 54% wanted to discuss weight sooner. Patients and physicians gave similar assessments of the patient's preference for discussing weight loss, how often weight was discussed at visits, and the patient's motivation for weight loss. Spearman's correlations on these variables were .33, .54, and .25, respectively (all P < .001). CONCLUSIONS: These patients and their physicians demonstrated a weak to moderate agreement on several variables crucial to initiating and continuing obesity care. Understanding patient and provider beliefs and preferences regarding obesity diagnosis and treatment is essential in designing obesity interventions for primary care.     

Association of the progesterone receptor gene with breast cancer risk: a single-nucleotide polymorphism tagging approach.

Association studies on susceptibility to breast cancer using single nucleotide polymorphisms (SNP) in the progesterone receptor (PGR) gene have been previously published, but the results have been inconclusive. We used a comprehensive SNP-tagging approach to search for low-penetrance susceptibility alleles in a study of up to 4,647 cases and 4,564 controls, in a two-stage study design. We identified seven tagging SNPs using genotype data from the National Institute of Environmental Health Sciences (NIEHS) Environmental Genome Project and typed these, and an additional three SNPs, in 2,345 breast cancer cases and 2,284 controls (set 1). Three SNPs showed no evidence for association and were not studied further, whereas seven SNPs (rs11571171, rs7116336, rs660149, rs10895068, rs500760, rs566351, and rs1042838) exhibited significant associations at P < 0.1 using either a heterogeneity or trend test and progressed to be genotyped in set 2. After both stages, only one SNP was significantly associated with an increased risk of breast cancer - the PGR-12 (rs1042638) V660L valine to leucine polymorphism [VL heterozygotes (odds ratio, 1.13; 95% confidence interval, 1.03-1.24) and the LL homozygotes (odds ratio, 1.30; 95% confidence interval, 0.98-1.73), P(het) = 0.008, P(trend) = 0.002]. Similar estimates were obtained in a combined analysis of our data with those from three other published studies. We conclude that the 660L allele may be associated with a moderately increased risk of breast cancer, but that other common SNPs in the PGR gene are unlikely to be associated with a substantial risk of breast cancer.     

The AIB1 polyglutamine repeat does not modify breast cancer risk in BRCA1 and BRCA2 mutation carriers.

This is by far the largest study of its kind to date, and further suggests that AIB1 does not play a substantial role in modifying the phenotype of BRCA1 and BRCA2 carriers. The AIB1 gene encodes the AIB1/SRC-3 steroid hormone receptor coactivator, and amplification of the gene and/or protein occurs in breast and ovarian tumors. A CAG/CAA repeat length polymorphism encodes a stretch of 17 to 29 glutamines in the HR-interacting carboxyl-terminal region of the protein which is somatically unstable in tumor tissues and cell lines. There is conflicting evidence regarding the role of this polymorphism as a modifier of breast cancer risk in BRCA1 and BRCA2 carriers. To further evaluate the evidence for an association between AIB1 glutamine repeat length and breast cancer risk in BRCA1 and BRCA2 mutation carriers, we have genotyped this polymorphism in 1,090 BRCA1 and 661 BRCA2 mutation carriers from Australia, Europe, and North America. There was no evidence for an increased risk associated with AIB1 glutamine repeat length. Given the large sample size, with more than adequate power to detect previously reported effects, we conclude that the AIB1 glutamine repeat does not substantially modify risk of breast cancer in BRCA1 and BRCA2 mutation carriers.     

Thallium-201SPECT assessment in the detection of recurrences of treated gliomas and ependymomas

Introduction The aim of this study was to establish the value of thalium-²⁰¹ single-photon emission computed tomography (²⁰¹Tl-SPECT) in the detection of recurrences in the follow-up of patients with treated primary neuroepithelial tumours. Material and methods Sixty-three²⁰¹Tl-SPECT were performed in 36 patients with glioma (12 males, mean age of 46±13 years). All patients underwent surgery and adjuvant radiotherapy (and some of them received chemotherapy). All patients were submitted to morphological neuroimaging techniques as well (and²⁰¹ Tl-SPECT). Mean follow-up was 18.3±14.6 months. Gold standard was based on clinical follow-up, therapeutical decisions (at least 4 months after²⁰¹Tl-SPECT) and imaging features. Results Sensitivity and specificity of²⁰¹Tl-SPECT to detect glioma recurrences were 90% and 100% respectively and 93% accuracy. Sensitivity and specificity for high grade tumours, were 100% respectively. Due to 4 false negatives, sensitivity and specificity for low grade gliomas were 78% and 100%. In the positive²⁰¹Tl-SPECT group of patients overall survival was 13.64% at the end of the study. The negative²⁰¹Tl-SPECT group had 84.62% overall survival at the end of the study (p=0.0003). Conclusions ²⁰¹Tl-SPECT is a valuable and noninvasive diagnostic procedure to detect recurrence or progression disease for treated gliomas and ependymomas.²⁰¹Tl-SPECT has a good correlation with short term prognosis with excellent diagnostic accuracy.