Systemic therapy in patients with node-negative breast cancer. A commentary based on two National Surgical Adjuvant Breast and Bowel Project (NSABP) clinical trials

OBJECTIVE: To determine whether in the previous National Surgical Adjuvant Breast and Bowel Project (NSABP) studies of node-negative breast cancer there were either cohorts of patients with a prognosis favorable enough to preclude using systemic therapy or subsets of patients who failed to benefit from the treatments. DESIGN: Randomized clinical trials with stratification after surgery. SETTING: NSABP trials at institutions in the United States and Canada. PATIENTS: Data were collected on 731 eligible patients (Protocol B-13) with estrogen-receptor-negative tumors who randomly received either no therapy after surgery or sequential methotrexate and fluorouracil (M----F) followed by leucovorin. Data were also collected on 2834 patients (Protocol B-14) with estrogen-receptor-positive tumors who randomly received either placebo or tamoxifen treatment. The percentage of patients surviving disease-free was determined through 4 years of follow-up using life-table estimates. INTERVENTIONS: Protocol B-13 patients received 12 courses of M----F given intravenously on days 1 and 8 every 4 weeks. Leucovorin therapy was begun 24 hours after M----F administration. Protocol B-14 patients received 5-year treatment with either tamoxifen (10 mg twice daily by mouth) or placebo. RESULTS: When the outcome of untreated patients in either trial was related to the stratification variables, women were found to have a disease-free survival of less than 80% through 4 years of follow-up. This percentage is apt to decrease because the probability of treatment failure increases with time. In both trials, all subsets of women benefited from M----F or tamoxifen therapy. CONCLUSIONS: The disease-free survival of all cohorts of node-negative patients with estrogen-receptor-negative or estrogen-receptor-positive tumors was poor enough to justify systemic treatment. The benefits of the therapies used are insufficient to eliminate the need for assessing putatively better regimens.     

The effect of educational preparation on physician performance with a sexually transmitted disease-simulated patient.

BACKGROUND--Simulated patients are used with increased frequency for medical students and residents, but have not been used very often with practicing physicians. We hypothesized that educational materials could improve primary care physicians sexual practices history taking and counseling as assessed by a simulated patient in the physician's office. METHODS--Simulated patient (SP) visits were made to 232 (75% of eligible) primary care physicians. The patient simulated was a sexually active young woman with vaginitis and sexually transmitted disease/human immunodeficiency virus risk behaviors. In advance of the visit, physicians were provided educational materials (monograph, pamphlet, and audiotape) developed for the study, including a risk assessment questionnaire that could be used with patients. RESULTS--Most physicians randomly allocated to the intervention participated. Twenty-one percent of physicians refused to schedule an SP visit. Physicians who received an SP rated the experience highly. Physicians who prepared for the visit with the educational materials performed significantly better than those who did not. About two thirds of physicians reviewed the materials, many for the second time, after the SP visit. Physicians who used the study risk assessment questionnaire performed better. Many physicians (24.9% to 39.8%) did not meet each of the four goals for the visit, as assessed subjectively by the SP. Physician performance was better for measures of general patient interaction than for measures of sexual practices history taking and counseling techniques. CONCLUSION--The SP visit was acceptable to most physicians practicing in a community and was evaluated by them as an appealing and an effective educational experience. The SP, however, has limited feasibility because of cost. The SP led to review of materials by nearly all physicians either before or after the visit. Physicians who prepared before the visit performed better on every dimension, eliciting more information, displaying better patient interaction skills, and meeting more of the educational goals. Even with educational preparation, however, many physicians were not perceived as being effective counselors.     

Improving HIV Screening and Receipt of Results by Nurse-Initiated Streamlined Counseling and Rapid Testing

Background  HIV testing is cost-effective in unselected general medical populations, yet testing rates among those at risk remain low, even among those with regular primary care. HIV rapid testing is effective in many healthcare settings, but scant research has been done within primary care settings or within the US Department of Veteran’s Affairs Healthcare System. Objectives  We evaluated three methods proven effective in other diseases/settings: nurse standing orders for testing, streamlined counseling, and HIV rapid testing. Design  Randomized, controlled trial with three intervention models: model A (traditional counseling/testing); model B (nurse-initiated screening, traditional counseling/testing); model C (nurse-initiated screening, streamlined counseling/rapid testing). Participants  Two hundred fifty-one patients with primary/urgent care appointments in two VA clinics in the same city (one large urban hospital, one freestanding outpatient clinic in a high HIV prevalence area). Measurements  Rates of HIV testing and receipt of results; sexual risk reduction; HIV knowledge improvement. Results  Testing rates were 40.2% (model A), 84.5% (model B), and 89.3% (model C; p = <.01). Test result receipt rates were 14.6% (model A), 31.0% (model B), 79.8% (model C; all p = <.01). Sexual risk reduction and knowledge improvement did not differ significantly between counseling methods. Conclusions  Streamlined counseling with rapid testing significantly increased testing and receipt rates over current practice without changes in risk behavior or posttest knowledge. Increased testing and receipt of results could lead to earlier disease identification, increased treatment, and reduced morbidity/mortality. Policymakers should consider streamlined counseling/rapid testing when implementing routine HIV testing into primary/urgent care.     

Lessons Learned about Implementing Research Evidence into Clinical Practice

The mission of the Veterans Health Administration's (VHA) quality enhancement research initiative (QUERI) is to enhance the quality of VHA health care by implementing clinical research findings into routine care. This paper presents lessons that QUERI investigators have learned through their initial attempts to pursue the QUERI mission. The lessons in this paper represent those that were common across multiple QUERI projects and were mutually agreed on as having substantial impact on the success of implementation. While the lessons are consistent with commonly recognized ingredients of successful implementation efforts, the examples highlight the fact that, even with a thorough knowledge of the literature and thoughtful planning, unexpected circumstances arise during implementation efforts that require flexibility and adaptability. The findings stress the importance of utilizing formative evaluation techniques to identify barriers to successful implementation and strategies to address these barriers.     

Anemia of the Belgrade rat: evidence for defective membrane transport of iron

The mechanisms underlying the impaired utilization of transferrin-bound iron by erythroid cells in the anemia of the Belgrade laboratory rat were investigated using reticulocytes from homozygous anemic animals and transferrin labeled with 59Fe and 125I. The results were compared with those obtained using reticulocytes from phenylhydrazine-treated rats and iron-deficient rats. Each step in the iron uptake mechanism was investigated, ie, transferrin-receptor interaction, transferrin endocytosis, iron release from transferrin, and transferrin exocytosis. Although there were quantitative differences, no fundamental difference was found in any of the abovementioned aspects of cellular function when the reticulocytes from Belgrade rats were compared with those from iron-deficient animals. The basic defect in the Belgrade reticulocytes must therefore reside in subsequent steps in iron uptake, after it is released from transferrin within endocytotic vesicles, ie, in the mechanism by which it is transferred across the lining membrane of the vesicles into the cell cytosol. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) of reticulocyte ghosts extracts demonstrated a prominent protein band of mol wt 69,000 that was absent or present only in low concentration extracts from the other two types of reticulocytes. This may be a result of the genetic defect.     

Specificity of psychological treatments for bulimia nervosa and binge eating disorder? A meta-analysis of direct comparisons

Treatment guidelines state that cognitive–behavioral therapy (CBT) and interpersonal therapy are the best-supported psychotherapies for bulimia nervosa (BN) and that CBT is the preferred psychological treatment for binge eating disorder (BED). However, no meta-analysis which both examined direct comparisons between psychological treatments for BN and BED and considered the role of moderating variables, such as the degree to which psychotherapy was bona fide, has previously been conducted Thus, such an analysis was undertaken. We included 77 comparisons reported in 53 studies. The results indicated that: (a) bona fide therapies outperformed non-bona fide treatments, (b) bona fide CBT outperformed bona fide non-CBT interventions by a statistically significant margin (only approaching statistical significance for BN and BED when examined individually), but many of these trials had confounds which limited their internal validity, (c) full CBT treatments offered no benefit over their components, and (d) the distribution of effect size differences between bona fide CBT treatments was homogeneously distributed around zero. These findings provide little support for treatment specificity in psychotherapy for BN and BED.     

Description of fecal shedding of Cryptosporidium parvum oocysts in experimentally challenged dairy calves

The objective was to describe the probability of Cryptosporidium parvum fecal oocyst shedding at different magnitudes of exposure, the pattern of fecal shedding over time, and factors affecting fecal shedding in dairy calves. Within the first 24 h of life, 36 calves were experimentally challenged with C. parvum oocysts at one of four possible magnitudes of oral exposure (1?×?10³, 1?×?10⁴, 1?×?10⁵, and 1?×?10⁶ oocysts), and 7 control calves were sham dosed. Fecal shedding occurred in 33 (91.7 %) experimentally challenged calves and in none of the control calves. There was a difference in the log-total number of oocysts counted per gram of feces dry weight among the four exposure groups; calves with the lowest magnitude of exposure (1?×?10³ oocysts) shed less than the other three groups. At higher magnitudes of exposure, there was more variability in the range of fecal oocyst shedding. There was an inverse relationship between the log-total amount of oocysts counted per gram of feces dry weight and the number of days to the onset of fecal shedding per calf, i.e., the more time that elapsed to the onset of fecal shedding, the fewer oocysts that were shed. The pattern of fecal shedding over time for all calves shedding oocysts was curvilinear; the number of oocysts increased with time, reached a peak, and declined. Therefore, the dynamics of oocyst shedding can be influenced in part by limiting exposure among calves and delaying the onset of fecal oocyst shedding.     

A Theoretical Model of Transition to Practice for Athletic Trainers

ContextThe transition to practice of newly credentialed athletic trainers (ATs) has become an area of focus in the athletic training literature. However, no theoretical model has been developed to describe the phenomenon and drive investigation.ObjectiveTo better understand the lived experience of the transition to practice and develop a theoretical model of transition to practice for ATs.DesignQualitative study.SettingTelephone interviews.Patients or Other ParticipantsFourteen professional master''s athletic training students (7 men, 7 women, age = 25.6 ± 3.7 years, from 9 higher education institutions) in the first year of clinical practice as newly credentialed ATs.Data Collection and AnalysisParticipants completed semistructured phone interviews at 3 timepoints over 12 to 15 months. The first interview was conducted just before graduation, the second 4 to 6 months later, and the third at 10 to 12 months. The interviews were transcribed and analyzed using a grounded theory approach.ResultsWe developed a theoretical model to explain the causal conditions that triggered transition, how the causal conditions were experienced, the coping strategies used to persist through the first year of practice, and the consequences of those strategies.ConclusionsThe model provides a framework for new athletic training clinicians, educators, and employers to better understand the transition process in order to help new clinicians respond by accepting or adapting to their environment or their behaviors.     

Frustrations Among Graduates of Athletic Training Education Programs

Context

Although previous researchers have begun to identify sources of athletic training student stress, the specific reasons for student frustrations are not yet fully understood. It is important for athletic training administrators to understand sources of student frustration to provide a supportive learning environment.

Objective

To determine the factors that lead to feelings of frustration while completing a professional athletic training education program (ATEP).

Design

Qualitative study.

Setting

National Athletic Trainers'' Association (NATA) accredited postprofessional education program.

Patients or Other Participants

Fourteen successful graduates (12 women, 2 men) of accredited professional undergraduate ATEPs enrolled in an NATA-accredited postprofessional education program.

Data Collection and Analysis

We conducted semistructured interviews and analyzed data with a grounded theory approach using open, axial, and selective coding procedures. We negotiated over the coding scheme and performed peer debriefings and member checks to ensure trustworthiness of the results.

Results

Four themes emerged from the data: (1) Athletic training student frustrations appear to stem from the amount of stress involved in completing an ATEP, leading to anxiety and feelings of being overwhelmed. (2) The interactions students have with classmates, faculty, and preceptors can also be a source of frustration for athletic training students. (3) Monotonous clinical experiences often left students feeling disengaged. (4) Students questioned entering the athletic training profession because of the fear of work-life balance problems and low compensation.

Conclusions

In order to reduce frustration, athletic training education programs should validate students'' decisions to pursue athletic training and validate their contributions to the ATEP; provide clinical education experiences with graded autonomy; encourage positive personal interactions between students, faculty, and preceptors; and successfully model the benefits of a career in athletic training.Key Words: stress, retention, matriculation

Key Points

• • Graduates of athletic training education programs experience numerous pressures and stresses over their academic career.
• • Negative interactions with fellow students and instructors in addition to monotonous clinical experiences can increase frustration levels among athletic training students.
• • Athletic training education programs are encouraged to foster a dynamic, positive, and nurturing learning environment in order to reduce athletic training students'' frustrations.

Exploring potential threats to athletic training student success is becoming more valuable to athletic training educators. Retaining and graduating strong students is a key factor to preserve the status and quality of athletic training education programs (ATEPs).¹ Recruits today have a much larger range of health care-related programs from which to choose,² making an ATEP''s reputation increasingly important. Fostering a supportive learning environment for students may improve retention rates and supply the workforce with sufficient clinicians as the profession expects to see a 37% increase in the number of positions available by the year 2018.³Previous researchers⁴ have found that students who switch from athletic training to different academic programs often do so because of poor integration into the academic and clinical portions of their ATEP. Integration is achieved when students find congruency with the ATEP community, which in turn enhances commitments to their program and educational goals⁵ by engaging them in a positive atmosphere. Stress and student frustration occur when students are not engaged appropriately with graded autonomy during clinical education.⁶ This finding is unfortunate as many students spend much of their clinical education experiences unengaged.⁷ Athletic training students (ATSs) have also listed a lack of respect during their clinical experiences as a point of frustration.⁶ The time commitment of clinical education and the wide range of responsibilities ATSs undertake have been shown to result in burnout, especially during the senior year.⁸ Other work⁹ has identified academic and financial concerns as the greatest sources of stress for ATSs, especially during midterms and the end of the semester due to examinations. Finally, stress levels have been found to be higher for females, seniors, and older students.¹⁰ Sources of ATS stress, frustration, and burnout can not only hinder integration but also lead students toward feelings of apathy for their studies,⁹ thoughts of departing their ATEP,⁴ or contemplations of leaving the profession.⁸Although sources of ATS stress and burnout have begun to be acknowledged, the factors that may increase student frustrations while completing their undergraduate degree are yet to be fully understood. It is important for athletic training faculty, staff, and preceptors to more fully understand the sources of ATSs'' frustrations to provide a supportive learning environment. Therefore, the purpose of this research was to describe which factors caused frustration for recent graduates enrolled in a National Athletic Trainers'' Association (NATA) accredited postprofessional degree program. We felt exploring factors that frustrate successful graduates seeking advanced training in athletic training would lead to an understanding of how to provide an educational environment capable of fostering student success.     

Effectiveness of methyl-GAG (methylglyoxal-bis[guanylhydrazone]) in patients with advanced malignant lymphoma

We treated 51 patients with advanced malignant lymphoma refractory to conventional therapy with methyl-glyoxal-bis(guanylhydrazone) (methyl- GAG) at doses ranging from 400 to 800 mg/sq m. Therapy was started on a weekly schedule and was switched to every other week in responding patients at the onset of toxicity. Partial responses were observed in 6 of 13 evaluable patients with Hodgkin's disease (46%), 5 of 10 patients with diffuse poorly differentiated lymphocytic lymphoma (50%), 2 of 4 patients with nodular poorly differentiated lymphocytic lymphoma (50%), and 3 of 13 patients with diffuse histiocytic lymphoma (23%). Two of six patients with mycosis fungoides showed objective improvement in cutaneous disease. Toxicity was generally mild and included muscular weakness, myalgia, mucositis, and diarrhea; two patients developed bronchospasm following drug infusions. We conclude that methyl-GAG has major antitumor activity when administered on this schedule to patients with advanced malignant lymphoma. The low degree of toxicity, unique mechanism of action, and minimal myelosuppressive effects suggest that methyl-GAG will prove useful in future trials of combination chemotherapy regimens for the treatment of lymphoma.