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BACKGROUND: Anterior compartment prolapse is the most common pelvic organ prolapse (POP) with a range of surgical treatment options available. // OBJECTIVES: To compare the clinical and cost effectiveness of surgical treatments for the repair of anterior POP. // METHODS: We conducted a systematic review of randomised controlled trials (RCTs) comparing surgical treatments for women with POP. Network meta-analysis (NMA) was possible for anterior POP, same site recurrence outcome. A Markov model was used to compare the cost-utility of surgical treatments for the primary repair of anterior POP from a UK National Health Service perspective. // MAIN RESULTS: We identified 27 eligible trials for the NMA involving eight surgical treatments tested on 3,194 women. Synthetic mesh was the most effective in preventing recurrence at the same site. There was no evidence to suggest a difference between synthetic non-absorbable mesh, synthetic partially absorbable mesh, and biological mesh. The cost-utility analysis which incorporated effectiveness, complications, and cost data found non-mesh repair to have the highest probability of being cost-effective. The conclusions were robust to model inputs including effectiveness, costs, and utility values. // CONCLUSIONS: Anterior colporrhaphy augmented with mesh appeared to be cost-ineffective in women requiring primary repair of anterior POP. There is a need for further research on long-term effectiveness and the safety of mesh products to establish their relative cost-effectiveness with a greater certainty. // FUNDING: The guideline referred to in this article was produced by the National Guideline Alliance (NGA) at the Royal College of Obstetricians and Gynaecologists (RCOG) for the National Institute for Health and Care Excellence (NICE). The views expressed in this article are those of the authors and not necessarily those of RCOG, NGA or NICE.

With the large number of estuaries within many jurisdictions, it is not always feasible to develop estuary‐specific management plans. Typologies that identify ecologically similar estuaries may assist in delineating groups of estuaries across which common conservation strategies may be developed, where key threatening processes are also similar. Estuarine typologies have been implemented in many countries, but most are based on hydrology and/or geomorphology rather than ecology. This study assessed the extent to which an Australian estuarine ternary classification scheme, which assigns estuaries to geomorphic classes according to wave, tidal and riverine influences, also captures differences in the mosaic of habitat types present. An analysis of 352 Australian estuaries and coastal waterways, for which geomorphological classifications and areas of key habitats were available, revealed strong differences in habitat mosaics among geomorphic classes. These differences among classes in habitat mosaics were independent of the extent of anthropogenic modification. The areal extent of mangrove and saltmarsh habitats displayed particularly large differences among estuarine geomorphic classes, being greatest in tide‐dominated estuaries and deltas, and being smallest in wave‐dominated estuaries, deltas, and strandplains. Overall, results suggest that geomorphic classification schemes may be useful in identifying groups of ecologically similar estuaries, for which common conservation strategies might be developed, depending on stressors. This approach will be particularly useful in developing management strategies for estuaries where detailed habitat maps are not available.

BACKGROUND Tobacco assessment and cessation support are not routinely included in cancer care. An automated tobacco assessment and cessation program was developed to increase the delivery of tobacco cessation support for cancer patients. METHODS A structured tobacco assessment was incorporated into the electronic health record at Roswell Park Cancer Institute to identify tobacco use in cancer patients at diagnosis and during follow-up. All patients who reported tobacco use within the past 30 days were automatically referred to a dedicated cessation program that provided cessation counseling. Data were analyzed for referral accuracy and interest in cessation support. RESULTS Between October 2010 and December 2012, 11,868 patients were screened for tobacco use, and 2765 were identified as tobacco users and were referred to the cessation service. In referred patients, 1381 of those patients received only a mailed invitation to contact the cessation service, and 1384 received a mailing as well as telephone contact attempts from the cessation service. In the 1126 (81.4%) patients contacted by telephone, 51 (4.5%) reported no tobacco use within the past 30 days, 35 (3.1%) were medically unable to participate, and 30 (2.7%) declined participation. Of the 1381 patients who received only a mailed invitation, 16 (1.2%) contacted the cessation program for assistance. Three questions at initial consult and follow-up generated over 98% of referrals. Tobacco assessment frequency every 4 weeks delayed referral in

Due to the high incidence of breast cancer among US females, risk-reduction strategies are essential. Before considering approaches to breast cancer risk reduction, it is important for clinicians to complete individualized qualitative and quantitative assessments of risk for their patients in order to inform physicians' clinical decision making and management and to engage patients collaboratively in a thorough discussion of risks and benefits. This review will summarize information on potential pharmacologic, nutritional, surgical, and behavioral approaches to reducing breast cancer risk. While there is no clear evidence that specific dietary components can effectively reduce breast cancer risk, weight gain and obesity in adulthood are risk factors for the development of postmenopausal breast cancer. Alcohol consumption, even at moderate levels, increases breast cancer risk, although some of the detrimental effects may be reduced by sufficient folate intake. Women at increased risk of breast cancer can opt to reduce their breast cancer risk through the use of tamoxifen or raloxifene; other chemopreventive agents remain under investigation. Surgical approaches to risk reductions are restricted to those patients with a substantially increased risk of developing breast cancer. Patients should be encouraged to maintain a healthy lifestyle for their overall well-being and to remain up to date with recommendations for screening and surveillance.

Background Studies of childhood and adolescent cancer survivorship have tended to focus on limited survival intervals (e.g., 5 and 10 years). Our report evaluates gender-specific overall mortality, as well as mortality by age group, and by cause, among 15+ year survivors of cancer diagnosed during childhood or adolescence. Procedure This was a retrospective cohort study of 565 15+ year childhood cancer survivors from Roswell Park Cancer Institute's Long-Term Follow-Up Project. Sex- and age-specific person-years at risk were accumulated and applied to age-specific mortality rates for New York State, excluding New York City. Standardized mortality ratios (SMRs), and 95% confidence intervals, were calculated and compared to mortality risks of the general population. Results Second malignancy was the leading cause of death among male and female survivors (15/38 deaths, 39%). Excess overall mortality was noted among both males (SMR = 284) and females (SMR = 371). Significant mortality excesses were seen in both genders for deaths due to primary malignant neoplasms and secondary malignancies, as well as cardiac deaths among males. Excess mortality was noted across most age strata. In the scenario of no cancer relapse, overall mortality in both genders did not differ significantly from the general population. Conclusions Long-term survivors of childhood and adolescent cancers continue to demonstrate significant excess mortality. However, overall mortality among 15+ year survivors without a relapse appears to be comparable to the general population. The leading cause of death among 15+ year survivors is second malignancy in this study, which represents a novel and important finding in terms of long-term follow-up. Pediatr Blood Cancer 2007;48:333–338. © 2006 Wiley-Liss, Inc.

BACKGROUND. Failure to obtain the requisite follow-up of patients with abnormal mammograms may delay cancer diagnosis and impact outcome. Up to 20% of women do not receive timely recommended follow-up. The current study tested the accuracy of the linkage of payer claims and clinical data to identify the appropriate treatment for patients with abnormal mammograms. METHODS. Electronic medical records in a staff model practice that was affiliated with a single health payer were scanned to identify the Breast Imaging Reporting and Data System (BI-RADS®) code for all mammograms. For each woman with a BI-RADS code 0, 3, 4, or 5 mammogram, the payer claims were searched for follow-up breast procedures (imaging, biopsy, and surgery) occurring within 2 months for BI-RADS code 0, 4, and 5 mammograms and within 8 months for BI-RADS code 3 mammograms. For women with >1 abnormal mammogram during the study period, only follow-up for the first abnormal mammogram was examined. The medical records of cases defined by claims as not having recommended follow-up care were reviewed to determine the accuracy of claims analyses. RESULTS. A total of 17,329 women underwent 23,721 mammograms between January 1, 2001 and December 31, 2003. BI-RADS codes 0, 3, 4, or 5 occurred in 1490 mammograms (6.3%). Among 1206 women with a first abnormal mammogram who were eligible for claims follow-up, 16% did not receive recommended follow-up care. Medical record review demonstrated that the claims search accurately identified follow-up care in 97% of these cases. CONCLUSIONS. Administrative claims supplemented with BI-RADS data were found to accurately identify the follow-up care of patients with abnormal mammograms. Case management using this method may assist physicians in ensuring that all patients receive appropriate care. Cancer 2007. © 2007 American Cancer Society.

As the third most common occurring malignancy and 3rd leading cause of cancer-related mortality, colorectal cancer (CRC) represents as a significant public health concern. CRC affects ~1 in 20 people over their lifetimes and 50,000+ deaths from CRC were expected in 2013. Substantial disparities exist for CRC with elevated incidence rates and mortality among African Americans (AA) compared to Whites (W). Further evidence of a disparity is the 5 year relative survival rate from colon cancer (20022008) which is 56% among AAs compared to 64% among whites. While many reasons have been suggested for these differences, the precise cause remains unknown and is likely multifactorial. As the third most common occurring malignancy and 3rd leading cause of cancer-related mortality, colorectal cancer (CRC) represents an important public health concern. Substantial disparities exist for CRC with elevated incidence and relative survival rate among African Americans (AA) compared to White (W). Purpose: To determine the feasibility of recruiting African Americans (AA) and White (W) subjects into a training intervention study to improve physiologic and quality of life measures. Methods: Former CRC patients were contacted and if available, were consented and screened for eligibility. Eligible patients completed exercise and spirometry tests prior to 12 weeks of progressive exercise training. Results: After fifteen months of recruitment, 119 AA, 125 W patients have been contacted. Of those contacted, 10 AA (8.4%), 5 W (4.0%) patients were available and consented to begin the study. 2 AA (1.7%) and 2 W (1.6%) have completed the entire study with 2 W in progress of completion. Conclusion: Subject recruitment for a twelve week intervention study of colorectal cancer survivors has not been very successful with race not being an issue of consent or study completion.

– A 2-year study of the threatened Australian grayling, Prototroctes mareana, was undertaken to investigate its reproductive strategy in relation to river flow. Monitoring of reproductive maturity in the Barwon River in south-eastern Australia indicated that no spawning occurred in the 2 years. In both years, ovarian involution was observed in a large proportion of the sampled population; flows during this period were less than the historical average. When coupled with the historical evidence, these observations suggest that spawning coincides with increased river discharge. River regulation may inhibit spawning.

The accuracy of a lead screening questionnaire in predicting elevated blood lead levels was examined in a pediatric practice in a rural part of New York state. A retrospective chart review was used to collect data on children ages 9 to 24 months who presented for well-child visits. Children with both questionnaire and lead level results available in the chart were included in the study (n = 171). The mean blood lead level among all children was 1.6 microg/dl (median = 2.0 microg/dl, range 0 to 24 microg/dl). Four children (2.3%) had elevated lead levels (greater than 10 microg/dl), with levels for two of these children being greater than 20 microg/dl. Although our lead screening questionnaire was expanded from the standard 1991 CDC questionnaire by the inclusion of six additional items, it was not especially useful in predicting elevated blood lead levels above 10 microg/dl. However, the questionnaire exhibited some utility in predicting marked elevations in blood lead levels (over 20 microg/dl). Although results in other geographic areas might differ, the lead questionnaire may have value by enhancing parents' awareness of potential lead hazards in their children's environment and may prove to be more useful in areas of high risk to lead exposure.

Purpose To determine nurse practitioners' (NPs') knowledge, practice, and attitudes about tobacco cessation counseling and lung cancer early detection. Data Source A descriptive, cross-sectional survey design was used to examine NPs' approaches to primary and secondary prevention of tobacco use among patients in western New York. Conclusions Among the 175 respondents, NPs appropriately counseled tobacco users on tobacco cessation. However, there was limited understanding of first-line pharmacological agents used for tobacco cessation and of how to manage treatment for a patient at high risk for lung cancer. Implications for Practice These findings suggest the need to implement professional educational programs aimed at conveying not only the importance of tobacco cessation counseling but also information on the most effective first-line pharmacological agents and appropriate management options for patients at increased risk of developing lung cancer.

To gain a better understanding into the mechanisms of damage incurred by neurons in periods following heavy alcohol exposure during development, we used an in vitro system to monitor the effects of alcohol and hypoxia on cell survival and DNA integrity. Samples representing the first few hours of exposure to alcohol and hypoxia were compared to those resulting from hypoxia alone. Measurements were taken from cell counts using Trypan blue exclusion and TUNEL assays as well as digital scans of the ethidium bromide fluorescence of genomic DNA isolated from the treated tissue. We found that DNA degradation from hypoxia was accelerated by several hours in the presence of 100 mM ethanol. This result depended on age, with adult animals (>8 months) having a similar response to 4-day postnatal animals, while the effect on 10-day postnatal animals and those of intermediate age (45 days postnatal) was increasingly delayed. Different methods of inducing the processive degradation of DNA produced laddering typical of apoptosis, a biphasic degradative process, or patterns usually associated with necrosis.

The purpose of this study was to investigate the spontaneous activity of mature rat cerebellar neurons that had been exposed to ethanol (EtOH) during postnatal days 4 to 10, which corresponds to the third trimester in humans. Newborn Sprague-Dawley rats were implanted with gastric feeding tubes and were artificially reared from postnatal days 4 to 10 with two different diets. The experimental group received 4.5 g/kg/day of EtOH delivered in a milk solution. Controls received similar feeding with an isocaloric supplement replacing the EtOH. Electrophysiological evaluations were performed after an EtOH-free rearing period. Although lobules IX and X of the cerebellar vermis appeared morphologically smaller in the animals neonatally exposed to EtOH, compared with controls, extracellular recordings from both Purkinje cells and Golgi interneurons in adult rats showed no differences in spontaneous activity or firing pattern between the control and EtOH-exposed animals. Similarly, excitations and inhibitions of Purkinje neuron activity evoked by parallel pathway stimulation appeared unaffected by the developmental EtOH exposure. However, we did observe a significant decrease in the proportion of Purkinje neurons generating complex spike bursts in the group exposed to EtOH neonatally. These data suggest that, although fewer Purkinje neurons may survive the brain growth spurt if exposed to EtOH during this critical period of development, those that do survive appear to function normally. The observed abnormality in complex spike production may result from EtOH effects on developing neurons in the inferior olive that give rise to the climbing fibers that cause this bursting pattern in Purkinje neurons.

BACKGROUND. The results of preconference and postconference surveys, as well as conference evaluation forms, distributed to attendees at the Native American Cancer Conference III : Risk Factors, Outreach and Intervention Strategies, Seattle, Washington, June 16-19, 1995, are presented. METHODS. Conference attendees were requested to complete a multi-item survey designed to assess knowledge and perceptions relating to cancer among native peoples at the beginning and end of the conference. The evaluation instrument solicited qualitative impressions of the conference. RESULTS. Survey respondents were predominantly female (70%), and approximately half were Native persons representing 48 different American Indian and Alaska Native communities. Knowledge levels were generally high at baseline for most items relating to cancer, with evidence of significant improvement for several items on the postconference survey. The majority of respondents believed that cancer was of equal importance compared with other health problems and that cancer services for American Indians and Alaska Natives are generally less extensive compared with the majority population ; there was no evidence of opinion change noted in the postconference survey. Results from the qualitative evaluation expressed the unique and affirmative experiences among participants in terms of the social, cultural, and informational sharing that occurred. CONCLUSIONS. It is hoped that the positive experiences of conference attendees will serve to stimulate the organization of similar programs and the design of research projects that both assess and expand cancer control services among Native peoples.

Background. Sporadic desmoid tumors occur mainly in the abdominal wall and in extraabdominal sites. Desmoid tumors in patients with familial adenomatous polyposis (FAP) usually occur in the abdominal wall and in the bowel mesentery. Surgical resection of desmoids in patients with FAP has been controversial. Methods. A retrospective review of patients with FAP and desmoid tumors treated from 1950 to 1991 was performed. Patients were evaluated for gender, age, site of desmoid tumors, treatment, recurrence, and survival. Results. Twenty-one of 24 patients underwent 60 surgical procedures related to the desmoid tumors. Seven of nine patients who underwent potentially curative surgery had recurrences; three were reresected. Major morbidity after palliative or curative surgery was 47%. Five patients were alive with no evidence of disease at a median of 198 months, 10 patients were alive with disease at a median of 102 months, and 5 patients died with disease at a median of 31 months after diagnosis. Conclusions. Desmoid tumors are common in patients with FAP. Unresectability and recurrence are more common than cure. Palliative and curative resections have a high morbidity. Surgery should be reserved for those patients with symptomatic mesenteric desmoids.

The relationship between population density and rates of mortality from unintentional and intentional injuries is examined using mortality data from New York State (exclusive of New York City), 1978-1982. Records for 26,118 individuals with an underlying cause of death due to injury were assigned to population density quintiles based on residence of decedent at time of death. Mortality rates for each population density quintile were examined separately by sex and for 11 causes of injury death. Overall, injury mortality is highest in the most rural and most urban populations. For both sexes, there is an inverse relationship between mortality from motor vehicle incidents and population density, and a positive relationship between homicide and population density. Male mortality from unintentional poisoning deaths shows a positive relationship with population density. Male mortality from fires shows a U-shaped relatinship with population density, with the highest mortality in the most rural and most urban populations. The relationships observed here between injury mortality and population density are most likely due to concomitant variation with aspects of the physical and cultural environments, such as socioeconomic status, ethnicity, and individual risk behaviors.

Purpose: To evaluate in a phantom study the dose to adult female breast tissue using current clinical body CT protocols on 64‐slice systems. Method and Materials: An anthropomorphic phantom with breast modules (Rando‐ Alderson) was scanned on a variety of 64‐slice CTscanners(GE LightSpeed VCT; Toshiba Aquilion; Siemens Sensation64; Philips Brilliance — in progress). Standard clinical protocols which either directly expose the breast or have scatter/edge‐of‐field dose were evaluated: (1) lung screening (smoker); (2) chest‐abdomen‐pelvis (CAP ‐oncology follow‐up); (3) cardiac calcium scoring (60bpm); and (4) virtual colonoscopy (supine & prone). Protocols were similar, but not identical, between systems. Scan coverage was matched; no breast shields. Absorbed dose to the breast tissue was measured by loading 10 TLDs into each breast module. LiF TLDs were calibrated individually for 9mm Al HVL (120 kVp), with an NIST traceable ion chamber, and a correction applied for the CT HVL. Imagenoise was also measured. Results: Standard clinical protocols for an adult female, including adaptive mA methods for the CAP exam, were utilized on each scanner. Averages of the TLDdose to the breast ranged from: (1) 0.56–1.36 cGy lung exam; (2) 1.27–2.98 cGy CAP; (3) 1.01–2.98 cGy calcium scoring; (4) 0.67–1.35 cGy virtual colonoscopy. Conclusion: The expected broad range of breast tissue dose for various CT exams was seen, but also indicate a possible reduction in dose compared to earlier reports from 4‐slice (Mahoney et al, RSNA 2005) and 16‐slice systems (Hurwitz et al, 2006 — extrapolated estimate). Variation between manufacturers was observed, but note that the protocols tested were those currently in clinical use. Further optimization of protocols for the given system design is/may be possible, especially given the significant interest from the entire radiological community to improve awareness of dose issues and to minimize exposures.

This study compares cancer incidence among the Seneca Nation of Indians (SNI) between 1955 and 1984 with cancer incidence patterns exhibited by the general population of New York State (NYS), exclusive of New York City. The cohort for this study consisted of all members of the SNI enrolled on January 1, 1955 and residing in NYS (N = 3262). Cancer incidence among the SNI is compared with cancer incidence patterns in NYS using age and sex standardized incidence ratios (SIR). Decreased cancer incidence was observed for all sites combined with SNI males exhibiting 64% of expected incidence and females exhibiting 53% of expected incidence. Although incidence deficits were observed for several sites, cancer incidence was not significantly elevated for any cancer site. Results from this investigation will contribute to the understanding of patterns of malignant disease among native peoples and aid in directing cancer control programs and services available to native groups.

The mechanisms by which alpha 1-antitrypsin and antithrombin III inhibit trypsin were investigated by chemical stability studies and amino acid sequence analyses of the enzyme-inhibitor complexes. One-to-one covalently linked complexes were formed between each of the inhibitors and trypsin. The complexes were stable over the course of the experiments at pH 8 or lower, and benzamidine, hydroxylamine, thiols, guanidine, or dodecyl sulfate had no apparent effect on the stability of the complexes. The complexes dissociated slowly at pH 9 or greater. Neither of the inhibitors was active after dissociation from its complex with trypsin. Sequence analysis indicated that no new amino terminus was generated when alpha 1-antitrypsin formed its complex with trypsin, but that two new amino termini were formed in approximately one-to-one ratio when the complex dissociated. This may indicate that alpha 1-antitrypsin contains two inhibitory sites for trypsin in close spatial proximity on the molecule.