Combined chemotherapy with carmustine, doxorubicin, etoposide, vincristine, and cyclophosphamide plus mitoxantrone, cytarabine and methotrexate with citrovorum factor for the treatment of aggressive non-Hodgkin lymphoma: a long-term follow-up study

BACKGROUND: The standard treatment for patients with aggressive non-Hodgkin lymphoma (NHL) is cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP). Since 1989, the authors have used a new chemotherapy regimen with combined carmustine, doxorubicin, etoposide, vincristine, and cyclophosphamide plus mitoxantrone, cytarabine and methotrexate with citrovorum factor called BAVEC-MiMA. The objective of the current study was to explore, after a long follow-up period, the impact of this third-generation regimen for the treatment of aggressive NHL. METHODS: One hundred and one consecutive patients (median age, 41 years) with either B-cell (n=94 patients) or non-B-cell (n=7 patients), aggressive lymphoma were diagnosed and treated between 1989 and 1999 with the BAVEC-MiMA regimen. RESULTS: The complete response rate was 74%, and the overall response rate was 89%. Eleven patients with refractory disease died rapidly after a median period of 5 months. The major toxicity was Grade 4 neutropenia (according to World Health Organization criteria), which was observed in 15 patients (15%). There were four toxicity-related deaths. The overall survival rate was 63% at 9 years. In multivariate analysis, factors that were associated with advantage in overall survival were response to induction therapy, bulky disease, and high score on the International Prognostic Index (IPI). The disease-free survival rate was 77% at 9 years. In multivariate analysis, the IPI was the most important variable for the definition of disease-free survival. CONCLUSIONS: The BAVEC-MiMA regimen was feasible on an outpatient basis, it was tolerated well, and it showed a low toxicity-related mortality. The long follow-up in patients with NHL, which is a rapidly fatal disease, led the authors to observe that, with this regimen, a cure was obtained in > 50% of patients who had low-risk or low-to-intermediate-risk, aggressive NHL.     

Risk factors for the development of second primary tumors among men after laryngeal and hypopharyngeal carcinoma

BACKGROUND: Second primary tumors (SPT) constitute a major threat to the survival of patients with laryngeal carcinoma. However, to the authors' knowledge little is known regarding the risk factors for developing SPTs or about the strategy to be followed to avoid them. METHODS: Eight hundred seventy-six male patients with laryngeal/hypopharyngeal carcinoma enrolled in a population-based, case-control study in 5 centers from South Europe during 1979-1982 were followed up to ascertain the occurrence of SPTs. Standardized incidence ratios were calculated to estimate the risk of SPT occurring in the cohort. Cox proportional hazard models were fitted to estimate the hazard ratio for development of SPTs in relation to use of tobacco smoking, alcohol consumption, and dietary habits before the first primary tumor. RESULTS: One hundred forty-five patients developed an SPT with an annual average rate of 2.1%. An excess risk of developing an SPT of the tongue, mouth, esophagus, and lung was observed. No elevated risks of SPTs were observed in other organs. Alcohol consumption strongly increased the risk of developing an SPT of the upper aerodigestive tract (UADT). Heavy cumulative cigarette smoking increased the risk of developing a lung SPT. A protective effect of high intake of citrus fruit was noticed for SPT in the lung, whereas high butter intake was associated with an increased risk for SPT of the UADT. CONCLUSIONS: Continuous medical surveillance was essential in the UADT and lung to reduce the risk from an SPT after initial laryngeal/hypopahryngeal carcinoma. Alcohol consumption before the first primary tumor was a risk factor for SPT of the UADT. The study suggested a protective role of citrus fruits in the development of a lung SPT.     

Phase II study of hepatic intraarterial epirubicin and cisplatin, with systemic 5-fluorouracil in patients with unresectable biliary tract tumors

BACKGROUND: Patients with unresectable biliary tract carcinomas have a very poor prognosis. To improve the efficacy and tolerance of the ECF regimen (epirubicin at a dose of 50 mg/m2, cisplatin at a dose of 60 mg/m2, and 5-fluorouracil [5-FU] at a dose of 200 mg/m2 per day by continuous infusion), the authors designed a novel approach that combined locoregional and systemic chemotherapy with the same agents at the same dosages. METHODS: Thirty consecutive patients with advanced or metastatic biliary tumors were treated with epirubicin at a dose of 50 mg/m2 and cisplatin at a dose of 60 mg/m2 administered as a bolus in the hepatic artery on Day 1, combined with systemic continuous infusion of 5-FU at a dose of 200 mg/m2 per day, from Day 1 to Day 14, every 3 weeks. RESULTS: Tumor sites were the intrahepatic bile ducts in 25 patients and the gallbladder in 5 patients. The overall response rate was 40% (12 of 30 patients), including 1 complete response and 11 partial responses. Stable disease was observed in 12 of 30 patients (40%) and progressive disease in 6 of 30 patients (20%). The median progression-free and overall survival periods were 7.1 and 13.2 months, respectively, and the 1-year and 2-year survival rates were 54% and 20%, respectively. Performance status improved in 9 of 30 patients (30%) and a weight gain of > 7% was observed in 4 of 30 patients (13%). The treatment was well tolerated with minimal hematologic toxicity. The major clinical problem was the deep venous thrombosis related to the central venous catheter, which occurred in 5 patients (17%). CONCLUSIONS: This novel combined locoregional and systemic chemotherapeutic regimen was found to be active and safe for patients with advanced biliary tract carcinoma.     

Limited english proficiency, primary language at home, and disparities in children's health care: how language barriers are measured matters

BACKGROUND: Approximately 3.5 million U.S. schoolchildren are limited in English proficiency (LEP). Disparities in children's health and health care are associated with both LEP and speaking a language other than English at home, but prior research has not examined which of these two measures of language barriers is most useful in examining health care disparities. OBJECTIVES: Our objectives were to compare primary language spoken at home vs. parental LEP and their associations with health status, access to care, and use of health services in children. METHODS: We surveyed parents at urban community sites in Boston, asking 74 questions on children's health status, access to health care, and use of health services. RESULTS: Some 98% of the 1,100 participating children and families were of non-white race/ethnicity, 72% of parents were LEP, and 13 different primary languages were spoken at home. "Dose-response" relationships were observed between parental English proficiency and several child and parental sociodemographic features, including children's insurance coverage, parental educational attainment, citizenship and employment, and family income. Similar "dose-response" relationships were noted between the primary language spoken at home and many but not all of the same sociodemographic features. In multivariate analyses, LEP parents were associated with triple the odds of a child having fair/poor health status, double the odds of the child spending at least one day in bed for illness in the past year, and significantly greater odds of children not being brought in for needed medical care for six of nine access barriers to care. None of these findings were observed in analyses of the primary language spoken at home. Individual parental LEP categories were associated with different risks of adverse health status and outcomes. CONCLUSIONS: Parental LEP is superior to the primary language spoken at home as a measure of the impact of language barriers on children's health and health care. Individual parental LEP categories are associated with different risks of adverse outcomes in children's health and health care. Consistent data collection on parental English proficiency and referral of LEP parents to English classes by pediatric providers have the potential to contribute toward reduction and elimination of health care disparities for children of LEP parents.     

Assessment of lunch served in the Workers' Food Program, Brazil

OBJECTIVE: In the light of the Workers' Food Program (WFP) growth and its recent review of nutritional parameters regulations, the study aimed at evaluating food intake in WFP through dietary assessment of lunch served in the program and workers' nutritional status. METHODS: A cross-sectional study was carried out in a representative sample of workers in Brasilia, Federal District, Brazil. A total of 1,044 subjects who had lunch at 52 food and nutrition units were evaluated. Social-economic and demographic data were collected as well as anthropometric measures for calculating the Body Mass Index. Food intake was assessed by dish weight and direct observation of dish composition. RESULTS: Of all subjects, 43% had excess weight, 33.7% were overweight and 9.3% were obese. Males were most affected. Median lunch energy intake was 515 kcal in women and 736 kcal in men. Median dietary fiber intake was 6.0 g among women and 8.3 g among men, and median cholesterol intake was over 90 mg among subjects with excess weight. CONCLUSIONS: The results indicate that the study population who is often seen as healthy is at nutritional risk. Workers in WFP should be targeted for health promotion strategies using especially nutritionists' skills as educators.     

Prevalence of trachoma in preschool and schoolchildren in the city of São Paulo

OBJECTIVE: To assess the prevalence of trachoma among preschool and school children of public schools to give new focus to control programs. METHODS: An epidemiological survey was carried out in S?o Paulo City in 1999. Children between four and 14 years old were selected by a cluster sampling where school shift was the sampling unit. External eye examination was conducted to detect trachoma. RESULTS: A total of 27,091 children were examined and 597 cases of trachoma were found (2.2%; 95% CI: 1.86-2.55). The prevalence ranged from 0.4% to 4.2% in 10 city areas. The trachoma detection rate in the household contacts examined was 8.7%. Follicular trachoma was found in 99% of the cases and intense trachoma in 1.0%. It was observed that 21.8% of the cases were asymptomatic. CONCLUSIONS: Though the trachoma prevalence was low, the occurrence of severe cases points out to the likelihood of cicatricial trachoma cases in the future if they are not adequately treated and controlled. The great difference in the prevalences in different city areas indicates the need for strengthening epidemiological surveillance activities.     

The daily life of nurses in the Brazilian expeditionary force in the theater of operations during World War II, in Italy (1942-1945)

This historic-sociological study aims to analyze the daily challenges faced by army nurses in the Theater of Operations during the Second World War in Italy. The primary sources of investigation consist of three photographs taken during that period as well as testimonies by nine nurses, while literature on the subject is used as a secondary source. The discussion is supported by Pierre Bourdieu's concepts. The results show that these nurses faced the challenges of daily life at war and managed to adapt themselves to the adversities of the camping sites and wards. We infer that their daily life in this scenario not only made them overcome barriers, but also provided them with an opportunity to get to know new cultures and technologies.     

Cost effectiveness of statins in coronary heart disease

INTRODUCTION: Statin therapy reduces the rate of coronary heart disease, but high costs in combination with a large population eligible for treatment ask for priority setting. Although trials agree on the size of the benefit, economic analyses of statins report contradictory results. This article reviewed cost effectiveness analyses of statins and sought to synthesise cost effectiveness ratios for categories of risk of coronary heart disease and age. METHODS: The review searched for studies comparing statins with no treatment for the prevention of either cardiovascular or coronary heart disease in men and presenting cost per years of life saved as outcome. Estimates were extracted, standardised for calendar year and currency, and stratified by categories of risk, age, and funding source RESULTS: 24 studies were included (from 50 retrieved), yielding 216 cost effectiveness ratios. Estimated ratios increase with decreasing risk. After stratification by risk, heterogeneity of ratios is large varying from savings to $59 000 per life year saved in the highest risk category and from 6500 dollars to 490,000 dollars in the lowest category. The pooled estimates show values of 21571 dollars per life year saved for a 10 year coronary heart disease risk of 20% and 16862 dollars per life year saved for 10 year risk of 30%. CONCLUSION: Statin therapy is cost effective for high levels of risk, but inconsistencies exist at lower levels. Although the cost effectiveness of statins depends mainly on absolute risk, important heterogeneity remains after adjusting for absolute risk. Economic analyses need to increase their transparency to reduce their vulnerability to bias and increase their reproducibility.     

Traffic air pollution and hospital admission for asthma: a case–control approach in a Turin (Italy) population

OBJECTIVES: This study investigated the relationship between traffic air pollution and asthma, using a case-control design applied to routinely collected data. METHODS: Subjects resident in Turin during the period 1997-1999 and admitted for asthma were defined as cases; patients admitted for causes other than respiratory diseases or heart diseases were defined as controls. Nitrogen dioxide and total suspended particulate were considered as indicators of traffic air pollution. Statistical analysis were performed, separately for young (0-14 years), adult (15-64 years) and elderly (>64 years) patients, with a logistic regression model; results are expressed as percentage of risk modification for a 10 g/m(3) increase in exposure to pollutants. RESULTS: The risk of emergency admissions for asthma rose significantly with increased exposure to nitrogen dioxide [2.4%, 95% Confidence Interval: 0.5%; 4.3%], and total suspended particulate [2.3%, 95% Confidence Interval: 1.1%-3.6%]. The significant association was evident, in particular, among young and elderly patients for both pollutants. CONCLUSION: Using a case-control design both easy to use and manage, the study confirms the significant association between hospital emergency admissions for asthma and exposure to nitrogen dioxide and total suspended particulate pollutants.