Daniel H. Freeman

A clinical trial of antioxidant vitamins to prevent colorectal adenoma

BACKGROUNDnPeople who consume a diet high in vegetables and fruits have a lower risk of cancer of the large bowel. Antioxidant vitamins, which are present in vegetables and fruits, have been associated with a diminished risk of cancers at various anatomical sites. We conducted a randomized, controlled clinical trial to test the efficacy of beta carotene and vitamins C and E in preventing colorectal adenoma, a precursor of invasive cancer.nnnMETHODSnWe randomly assigned 864 patients, using a two-by-two factorial design, to four treatment groups, which received placebo; beta carotene (25 mg daily); vitamin C (1 g daily) and vitamin E (400 mg daily); or the beta carotene plus vitamins C and E. In order to identify new adenomas, we performed complete colonoscopic examinations in the patients one year and four years after they entered the study. The primary end points for analyses were new adenomas identified after the first of these two follow-up examinations.nnnRESULTSnPatients adhered well to the prescribed regimen, and 751 completed the four-year clinical trial. There was no evidence that either beta carotene or vitamins C and E reduced the incidence of adenomas; the relative risk for beta carotene was 1.01 (95 percent confidence interval, 0.85 to 1.20); for vitamins C and E, it was 1.08 (95 percent confidence interval, 0.91 to 1.29). Neither treatment appeared to be effective in any subgroup of patients or in the prevention of any subtype of polyp defined by size or location.nnnCONCLUSIONSnThe lack of efficacy of these vitamins argues against the use of supplemental beta carotene and vitamins C and E to prevent colorectal cancer. Although our data do not prove definitively that these antioxidants have no anticancer effect, other dietary factors may make more important contributions to the reduction in the risk of cancer associated with a diet high in vegetables and fruits.

Lack of Social Participation or Religious Strength and Comfort as Risk Factors for Death After Cardiac Surgery in the Elderly

The purpose of this study was to examine the relationship of social support and religion to mortality after elective open heart surgery in older patients.Of the 232 patients included in the study, 21 died within 6 months of surgery. Three biomedical variables were significant predictors of mortality and selected as adjustment variables for a multivariate analysis: history of previous cardiac surgery; greater impairment in presurgery basic activities of daily living; and older age. Among the social support and religion variables, two were consistent predictors of mortality in the multivariate analyses: lack of participation in social or community groups and absence of strength and comfort from religion. These results suggest that in older persons lack of participation in groups and absence of strength and comfort in religion are independently related to risk for death during the 6-month period after cardiac surgery.

A clinical trial of beta carotene to prevent basal-cell and squamous-cell cancers of the skin

BACKGROUNDnBeta carotene has been associated with a decreased risk of human cancer in many studies employing dietary questionnaires or blood measurements, and it has had protective effects in some animal models of carcinogenesis.nnnMETHODSnWe tested the possible cancer-preventing effects of beta carotene by randomly assigning 1805 patients who had had a recent nonmelanoma skin cancer to receive either 50 mg of beta carotene or placebo per day and by conducting annual skin examinations to determine the occurrence of new nonmelanoma skin cancer.nnnRESULTSnAdherence to the prescribed treatment was good, and after one year the actively treated groups median plasma beta carotene level (3021 nmol per liter) was much higher than that of the control group (354 nmol per liter). After five years of follow-up, however, there was no difference between the groups in the rate of occurrence of the first new nonmelanoma skin cancer (relative rate, 1.05; 95 percent confidence interval, 0.91 to 1.22). In subgroup analyses, active treatment showed no efficacy either in the patients whose initial plasma beta carotene level was in the lowest quartile or in those who currently smoked. There was also no significant difference between treated and control groups in the mean number of new nonmelanoma skin cancers per patient-year.nnnCONCLUSIONSnIn persons with a previous nonmelanoma skin cancer, treatment with beta carotene does not reduce the occurrence of new skin cancers over a five-year period of treatment and observation.

Social and economic factors in the choice of lung cancer treatment. A population-based study in two rural states.

We reviewed 1808 hospital charts representing virtually all patients given a diagnosis of non-small-cell lung cancer in New Hampshire and Vermont between 1973 and 1976 and found that the treatment of patients varied according to their marital status, medical insurance coverage, and proximity to a cancer-treatment center. Patients were more likely to be treated with surgery if they were married (odds ratio, 1.67; 95 percent confidence interval, 1.08 to 2.57) or had private medical insurance (1.52; 1.03 to 2.26). Among patients who did not have surgery, those with private insurance were more likely to receive another form of anticancer therapy--either radiation or chemotherapy (1.57; 1.18 to 2.09). Residing farther from a cancer-treatment center was associated with a greater chance of having surgery. Patients 75 years of age and older were less likely to have surgery (0.16; 0.08 to 0.35) or any other tumor-directed therapy (0.32; 0.19 to 0.54). The relation between the type of treatment and a patients characteristics was not based on apparent differences in tumor stage or functional status, although both these factors were also strongly predictive of the type of treatment. Despite the fact that privately insured and married patients were more aggressively treated, they did not survive longer after diagnosis. We conclude that for non-small-cell lung cancer, socio-economic as well as medical factors determine treatment.

Factors affecting the utilization of specialty and general medical mental health services.

This study compares the extent to which need, predisposing, and enabling factors affect the use of mental health services in the specialty and general medical health sectors during a 6-month period. Data are drawn from the first wave of interviews of the Epidemiological Catchment Area (ECA) project at the Yale University site. The results indicate that 1) in the general population, factors affecting use of the two sectors differ; 2) among those using any mental health services, factors affecting use of the two sectors differ; 3) indicators of need have the strongest relationships with utilization; and 4) the effects of predisposing and enabling factors are contingent upon the presence of need.

Help Seeking for Mental Health Care Among Poor Puerto Ricans: Problem Recognition, Service Use, and Type of Provider

OBJECTIVESnThis study examines the effects of health, predisposing, and enabling factors on recognition of a mental health problem, use of formal mental health care, and contact with a specialized mental health provider.nnnMETHODSnInterviews were conducted with a probability sample of 3,435 adults. The variables examined include measures of mental health; social and demographic factors; and enabling factors relevant to the help-seeking process.nnnRESULTSnSubjective and objective measures of mental health were associated with the recognition of a mental health problem. The objective assessment of definite need for services was relevant for the use of formal services. However, the subjects perception of poor mental health was strongly related to receiving care from a mental health specialist. Although interaction with social networks is associated with use of formal services, low economic strain is related to receiving care from the specialty sector.nnnCONCLUSIONSnThe results support the importance of using multiple measures of mental health problems. The finding that individuals perceived economic strain increases the likelihood of receiving specialized care suggests that studies of economic barriers to the use of mental health services might benefit from the adoption of measures that assess perceived economic circumstances.

Frequency and Correlates of Adjustment Disorder Related to Cardiac Surgery in Older Patients

The diagnosis of adjustment disorder is a dilemma in older medically ill patients. The authors conducted a prospective study of older cardiac surgery patients. Semistructured interview techniques were used to distinguish emotional impairment from physical impairment to diagnose an adjustment disorder. Among 71 patients interviewed at three points in time, 50.7% had an adjustment disorder. At 6 months after surgery, 30.6% were still showing evidence of emotional functional impairment. Continued impairment was related to initial severity of depressive and anxiety symptoms. Implications and suggestions for future research are discussed.

Social Support and Depression After Cardiac Surgery in Elderly Patients

Two methods of measuring social support components were compared for their ability to predict depression 6 months after cardiac surgery in older patients (N = 155). Multiple regression models were used to compare summary support measures with subtype measures. A personality inventory was also included to rule out the possibility that significant findings about relationships of depression and social support were due primarily to personality dimensions. In the summary model, only the number of network members seen regularly was associated with less depression. In the subtype model, the number of relatives seen regularly and perceived adequacy of support from friends were associated with less depression, whereas receipt of tangible support was associated with more. When examined together with personality dimensions, both the summary components and subtypes of components of social support were better predictors of depressive symptomatology than the personality dimensions. The results helped confirm the importance of social support factors to the occurrence of depression in elderly patients and suggested that measures of social support subtypes were more informative than summary measures of social support.