Cost-effectiveness comparison of five interventions to increase mammography screening

BACKGROUND: Mammography is the primary method used for breast cancer screening. However, compliance with recommended screening practices is still below acceptable levels. This study examined the cost-effectiveness of five combinations of physician recommendation and telephone or in-person individualized counseling strategies for increasing compliance with mammography. METHODS: There were 808 participants who were randomly assigned to one of six groups. A logistic regression model with compliance as the dependent variable and group as the independent variable was used to test for significant differences and a ratio of cost to improvement in mammogram compliance evaluated the cost-effectiveness. RESULTS: Three of the interventions (in-person, telephone plus letter, and in-person plus letter) had significantly better compliance rates compared with the control, physician letter, or telephone alone. However, when considering costs, only one emerged as the superior strategy. The cost-effectiveness ratios for the five interventions show that telephone-plus-letter is the most cost-effective strategy, achieving a 35.6% mammography compliance at a marginal cost of $0.78 per 1% increase in women screened. CONCLUSIONS: A tailored phone prompt and physician reminder is an effective and economical intervention to increase mammography. Future research should confirm this finding and address its applicability to practice.     

Transitional Cell Carcinoma Involving the Prostate with a Proposed Staging Classification for Stromal Invasion

Purpose

We investigated the effect on survival of transitional cell carcinoma of the prostatic urethra, ducts and stroma, and determined the difference between prostatic stromal involvement occurring via direct extension through the bladder wall versus stromal invasion arising intraurethrally.

Materials and Methods

Between August 1971 and December 1989, 489 men underwent radical cystoprostatectomy for transitional cell carcinoma, including 143 (29.2 percent) identified with prostate involvement by transitional cell carcinoma in the cystectomy specimen. Patients were separated into 2 groups: 1–19 in whom the primary bladder tumor extended full thickness through the bladder wall to invade the prostate (classified as P4a) and 2–124 in whom prostate involvement arose from within the prostatic urethra.

Results

Five-year recurrence-free and overall survival rates were 25 and 21 percent, respectively, in group 1 versus 64 and 55 percent, respectively, in group 2. In the 124 patients in group 2 survival rates were similar for those with prostatic urethral tumors or carcinoma in situ and ductal tumors (no stromal invasion). Five-year overall survival rates without and with stromal invasion were 71 and 36 percent, respectively (p less than 0.0001). Transitional cell carcinoma of the prostatic urethra or ducts does not alter survival predicted by primary bladder stage alone. Prostatic stromal invasion arising intraurethrally significantly decreases survival, which varies based on primary bladder stage (64.6 percent in stage P1, 30.8 percent in stages P2/P3a and 13.6 percent in stage P3b, p = 0.0001). P1 bladder tumors with prostatic stromal invasion arising intraurethrally had a significantly higher survival rate than P4a tumors (64.6 versus 21 percent, p = 0.0001). P3b bladder tumors with stromal invasion had a survival rate similar to that of P4a tumors (p = 0.78).

Conclusions

Prostatic urethral or ductal transitional cell carcinoma does not alter survival determined by primary bladder stage alone and it should not be classified as P4a. Prostatic stromal involvement arising intraurethrally significantly decreases survival predicted by primary bladder stage alone. P1 bladder tumors with prostatic stromal invasion arising intraurethrally have a significantly higher survival rate than P4a tumors and they should be separately classified as P1str. Muscle invasive (P2/P3a) bladder tumors with stromal invasion have a higher survival rate than P4a tumors (no statistical significance) and they should be designated separately (that is P2str). P3b bladder tumors with prostatic stromal invasion arising intraurethrally are indistinguishable from P4a tumors.     

Responses of long descending propriospinal neurons to natural and electrical types of stimuli in cat

Long descending propriospinal (LDP) neurons (antidromically identified) having cell bodies of origin in the cervical enlargement and projecting axons at least as far as the L2 segment were studied. Extracellular recording of responses to natural and electrical stimuli was done in high-spinal cats.

(1) A receptive field for natural stimuli was found for 123 LDP neurons. An additional 108 LDP cells were not activated by the natural stimuli used, but some of these fired spike potentials in response to electrical stimulation of peripheral nerves of the forelimb. There was no distinction between neurons activated and those not activated by natural stimuli on the basis of location or conduction velocity.

(2) The most effective natural stimuli were mechanical manipulation of the skin (both low and high threshold), movement of joints of the paw, and pressure to the deep tissues, especially to the extensor side of the arm. These modalities of stimuli were most often excitatory, but could be inhibitory as well.

(3) On the basis of modality, 4 subgroups of LDP cells were identified: those which were responsive only to mechanical-cutaneous, joint-movement, or deep-pressure stimuli, and those which responded to several of these modalities of stimuli, the multimodal group. These subgroups could not be distinguished on the basis of conduction velocity.

(4) The receptive fields varied in size from small (one digit) to large (all of a forelimb). For single LDP cells they included ones with single and/or multimodal input from one or both forelimbs and various combinations of excitation and/or inhibition. However, those in the dorsal horn had only ipsilateral receptive fields, mainly of the mechanical-cutaneous type. Cells with bilateral receptive fields were mainly located medially in the ventral gray in laminae VII and VIII.

(5) A comparison of the location of the subtypes of LDP cells revealed that neurons activated by mechanical-cutaneous stimuli were in laminae I and IV–VIII; whereas deep-pressure and multimodal activated neurons were almost exclusively in laminae VII and VIII.

(6) LDP cells receiving input from deep-pressure receptors in the extensor muscles of the arm, joint-movement, or deep-pressure receptors of the paw probably relay position or weight-bearing information about the forelimbs to the lumbosacral spinal cord. This arrangement suggests that LDP neurons function in interlimb coordination and would be active during locomotion. They probably participate also in other reflexes elicited by cutaneous and deep stimuli.

Immunocytochemical identification of oestrogen receptors in the ovine pars tuberalis: localization within gonadotrophs

The pars tuberalis (PT) of the pituitary gland shows dense binding of melatonin and consequently this region may be involved in modulating seasonal reproduction. Oestrogen is well established as a critical gonadal steroid in controlling seasonally via its ability to alter luteinizing hormone (LH) release. Using immunocytochemistry techniques with antibodies specific for the oestrogen receptor (ER) and the ovine βLH (oβLH) subunit, we have identified large populations of ER-immunoreactive (-IR) and LH-IR cells in the anteroventral region of the ovine PT. In contrast, few ER- or LH-IR cells were identified in the anterodorsal or posterior regions of the PT. Double-labelling experiments revealed that all ER-IR cells in the PT are also immunoreactive for LH. These results show that cells immunoreactive for the ER are concentrated in the anteroventral aspect of the PT and that these receptors are located in the nuclei of the PT gonadotrophs. These results suggest that the anteroventral PT, a region which also expresses high melatonin binding, may be a site of integrated oestrogen and melatonin action on LH secretion from the PT.     

Complications of surgery for gastroesophageal reflux

In the course of approximately 350 operations for gastroesophageal reflux and 1,500 evaluations of patients previously operated on or being assessed for therapy, a number of complications and undesirable side effects of antireflux surgery have been encountered. This report describes unfavorable outcomes including postoperative dysphagia, gas-bloat syndrome, postoperative gastric dilatation, unplanned vagotomy, failure to relieve symptoms, persistence or recurrence of reflux or hiatal hernia, perforation of the esophagus or stomach, postoperative bleeding, unplanned splenectomy, and persistence of stricture, which have followed the antireflux repairs introduced by Belsey, Nissen, or Hill, the gastroplasty procedures described by Thal, and by Collis, intrathoracic fundoplication, and esophageal resection with gastrointestinal interposition.

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Résumé Dans les suites de quelques 350 opérations pour reflux gastro-oesophagien et au cours de 1,500 examens de malades opérés ou mis au point en vue d'un traitement, nous avons observé un certain nombre de complications et de séquelles de la chirurgie anti-reflux. Le présent travail les décrit: vagotomie accidentelle, perforation de l'oesophage ou de l'estomac, splénectomie inutile, dilatation gastrique aigüe et hémorragie postopératoire, dysphagie postopératoire, syndrome de distension gastrique, persistance des symptomes préopératoires, persistance ou récidive du reflux ou de la hernie hiatale, persistance de la sténose. Ces complications ont été observées après diverses interventions: plastics anti-reflux de types Belsey, Nissen ou Hill, gastroplasties de types Thal ou Collis, fundoplicature intrathoracique, résection oesophagienne avec interposition jéjunale.

     

Minority recruitment in hereditary breast cancer research.

Although recruitment of ethnic and racial minorities in medical research has been evaluated in several studies, much less is known about the methods used to recruit these populations to participate in cancer genetics research. This report reviews the resources that have been used to identify and recruit ethnic and racial minorities to participate in hereditary breast cancer research. Overall, hospital-based resources were used most often to identify potential subjects, and active recruitment methods were used most frequently to enroll eligible subjects. This review suggests that there appears to be a finite number of resources and strategies to identify and recruit potential subjects to participate in cancer genetics research; however, options for improving awareness about cancer genetics research among ethnic and racial minorities have not been extensively evaluated. To study ethnic and racial minority participation in cancer genetics research, stronger evaluation components will need to be integrated into research methods. Both observational and experimental studies are needed to determine resources that are most effective for identifying potential subjects who are ethnic and racial minorities and to evaluate the effects of different recruitment strategies on enrollment decisions among these populations.     

Tube gastrostomy after radical cystectomy and urinary diversion: surgical technique and experience in 709 patients

We describe our surgical technique of tube gastrostomy and report our experience with 709 patients who underwent cystectomy and urinary diversion with gastrostomy tube placement from January 1988 to December 1997. This modified Stamm technique provides an effective means of gastric decompression without the discomfort associated with nasogastric decompression, is associated with a low complication rate (0.05%), and may be considered as the procedure of choice when gastric drainage is required after radical cystectomy and lower urinary tract reconstruction.