Journal of the Association for Academic Minority Physicians : the official publication of the Association for Academic Minority Physicians最新文献

Esophageal cancer is known for its marked variation by geographic region, race, ethnicity, and gender. In the United States, incidence rates for African Americans are more than twice the rates for whites, and rates for whites exceed those for Hispanics, Asian Americans, and Native Americans. In addition, decreases in incidence of squamous cell carcinoma of the esophagus and increases in esophageal adenocarcinoma have been observed over the past several decades. This paper will explore the role of race/ethnicity in the epidemiology of esophageal cancer and the extent to which alcohol, tobacco, diet, and social class may contribute to racial/ethnic differences in incidence and mortality.

Interest in and use of complementary and alternative medicine have increased in recent years, with as much as 40% of the general population having used some form of complementary and alternative medicine in the past year. Although recent national surveys have not adequately assessed the use of complementary and alternative medicine in minority populations, its use in many minority populations is at least equal to and possibly greater than that in the general population. One condition for which minority populations are likely to use complementary and alternative medicine therapies is diabetes, which is particularly prevalent in Mexican-American and Native-American communities. Many minority cultures have a long history of using herbal preparations to treat diabetes, and recent research suggests that some herbal therapies may have a role in the treatment of this complex disease. However, many questions remain regarding the proper use of herbal therapies for diabetes, particularly in regard to dosage and contaminants. Therefore, physicians who work with minority populations should ask patients about their use of these therapies and must become knowledgeable about their safety and efficacy.

America has always described itself as a melting pot of people and cultures. Perhaps it has become more of a "boiling pot" as assaults against affirmative action and charges of racism run rampant. Underrepresented minorities in the United States remain well below the national average with regard to education, employment, and health status. While today these minorities make up nearly 25% of the US population, historically they continue to be underrepresented in the medical and research professions. Some progress has been made during the last several decades, but it has stalled. And there is reason to believe that we are facing potentially rapid reversals of what has been painfully achieved. There is a significant pipeline problem in the production of minority doctorate recipients in America today. A review of a cohort of 17-year-old white and black students using a national longitudinal survey of the high school class of 1980 determined that 28% of white students graduated from college, compared with only 11% of black students--a 60% difference. Less than 1% of this original cohort of black students went on to earn science degrees. Doctoral programs now increasingly compete for the same small group of academically qualified minority students. The only long-term solution is to improve the educational opportunities starting from the early stages of the educational pipeline, beginning in elementary school. High school is too late. This process is complicated and will be costly. Pipeline initiatives will demand creativity, flexibility, and a commitment from all of us. We must increase the motivation and preparation of minority students regarding careers in science, engineering, and health care. We in academic health centers must play a key role in strengthening science education and in changing our behavior. We need to address the reasons why more than half of black students who enter college fail to graduate, why there is so little interest in science, and why minority students are not better prepared in science while they are in secondary school. And we need to address these issues now.

To determine changes in the morbidity and mortality of ventilated, very low-birth-weight infants before and after the introduction of surfactant therapy in 1990, we retrospectively studied the infants in a tertiary neonatal intensive care unit. All ventilated patients admitted from January 1, 1984, to December 31, 1997, with birth weight of 1500 g or less, excluding 76 transferred to other hospitals, were included in the analysis (N = 1336). The primary outcomes studied included mortality, length of stay, and survival without bronchopulmonary dysplasia. Although post-surfactant mortality and pulmonary air leak for infants with birth weight greater than 750 g decreased more than 50% (P < or = .026), the proportion of infants surviving without bronchopulmonary dysplasia also decreased (P < or = .034). For surviving infants with birth weight of 751 to 1000 g, mean post-surfactant length of stay increased 16 days (P = .008). Postnatal age at death also increased in the post-surfactant period for infants with birth weight of 750 g or less (P = .002). For infants with birth weight of 1000 g or less, post-surfactant increases were seen in the mean duration of assisted ventilation (+22% to 32%, P < or = .005) and the incidence of bronchopulmonary dysplasia at 36 weeks' postmenstrual age (+62% to 162%, P < .001). For all infants, the incidence of bacteremia, duration of supplemental oxygen therapy, and likelihood of discharge on home oxygen were increased in the post-surfactant period (P < or = .011). The implicit benefits of mortality reduction in the post-surfactant era may be offset by increasing respiratory morbidity in some survivors and by an unwelcome prolongation of death for some nonsurvivors. We speculate that the ultimate costs of these undesirable outcomes may greatly surpass the ostensible cost benefits of neonatal surfactant therapy.

Esophageal cancer in advanced stages grows to occlude the esophageal lumen; presenting symptoms include dysphagia and weight loss. Esophageal cancer rarely grows to occupy a narrow column of the esophagus or manifests neurologic symptoms. We report the case of a 58-year-old man with a history of tobacco and alcohol abuse and chronic obstructive airway disease who presented with headaches, left-sided weakness, unsteady gait, and weight loss. Physical examination showed left-sided weakness. Computed tomographic scan of the brain and chest revealed, respectively, a right frontoparietal mass and a tumor mass in the distal esophagus. The patient's weakness and headaches improved after treatment with dexamethasone and craniotomy with partial enucleation of the brain lesion. An esophagogastroduodenoscopy revealed a large, elongated mass in the esophagus. Pathologic analyses of biopsies of the esophageal mass showed mixed adenosquamous carcinoma. The brain mass histology showed poorly differentiated carcinoma. Several weeks after craniotomy, the patient developed respiratory failure and died. While it appears that the esophageal cancer metastasized to the brain, there is the possibility of other undetected primary tumor with metastasis to the brain. Nonetheless, the endoscopic appearance and clinical presentation of this case are unusual and noteworthy.

Colorectal cancer is the second leading cause of cancer death in the United States. In 1997, more than 131,000 new cases and more than 54,000 deaths were estimated. Racial and ethnic disparities in incidence, mortality and survival rates, and trends exist for this disease. Differences in colorectal cancer screening, early detection, and treatment in minority communities are related to therapeutic outcomes. Age-adjusted incidence rates for men with colorectal cancer are highest for Alaskan native men, followed by Japanese, then African-American men. For women, the incidence is highest for Alaskan native women, followed by African-American, then Japanese women. Mortality rates in men are highest for African Americans, followed by Alaskan natives and then Hawaiians. In women, mortality rates are highest for Alaskan natives, then African Americans and whites. Colorectal cancer screening rates vary by race, income, and education. It is interesting that, when compared with whites, African-American men demonstrate the higher reported rate of screening for this disease. In addition, site specificity is different for African Americans compared with whites. Findings also reveal that stage at diagnosis is an influential factor with regard to mortality and survival. This may be related in part to socioeconomic factors, differences in anatomic site, and treatment differences in African Americans. Risk factor data for this disease are scarce for minority populations. Documented differences in colorectal cancer incidence, mortality, and survival rates exist between minorities and whites. Additional research is needed on risk factors specific to African Americans and other minorities, differences in treatment, and the role of socioeconomic status.

Many diseases that account for the majority of morbidity and mortality in African Americans are also associated with racial disparity. Such diseases include cardiovascular disease, diabetes, hypertension, cancer, acquired immunodeficiency syndrome, and violent injuries. Epidemiologic associations find the excess burden for these diseases to be rooted in biological, psychosocial, and socioeconomic factors. Community-based efforts often function in isolation, attempting to have impact on diseases that affect local residents; unfortunately, such programs cannot be comprehensive in their approach. Foreseeable gaps allow morbidity and mortality to continue to exist. The Baltimore Alliance for the Prevention and Control of Hypertension and Diabetes (the Alliance), based at the University of Maryland School of Medicine, provides an infrastructure where successful community-based programs that target hypertension and diabetes join together in collaborative effort. The Alliance creates an association that supports community-based efforts, helping improve the efficiency and efficacy of such programs. Such associations can help close gaps, enabling programs to have a more comprehensive impact on communities.

Cardiovascular disease is the major cause of morbidity and mortality in patients with diabetes. Diabetic individuals have a 200% to 400% greater risk for vascular disease than nondiabetics, with a disproportionately greater burden of disease complications in non-white minorities. Although the atherosclerotic plaques in the two groups are similar, diabetics have more severe and more diffuse disease than nondiabetics. Recent advances in the treatment of coronary disease have improved survival for diabetics and nondiabetics, but diabetics still have double the case fatality rate as nondiabetics, and diabetic women have particularly poor outcomes. Diabetic individuals also have an increased frequency of silent ischemia, systolic and diastolic left ventricular dysfunction, and cardiac autonomic neuropathy. The high frequency of modifiable risk factors provides great opportunities for prevention, the cornerstones of therapy being glycemic control, aggressive risk factor modification, and ongoing patient surveillance and monitoring to facilitate early disease detection and prompt intervention. In patients with coronary disease who require revascularization, both mechanical coronary interventions and bypass surgery are effective therapies. Patients with multivessel coronary disease have better results following bypass surgery with arterial grafts than following coronary interventions. However, diabetic patients are at increased risk for poor long-term outcome following either revascularization modality, with high rates of restenosis following mechanical interventions and the development of atherosclerosis in conduits following bypass surgery.

The incidence of esophageal adenocarcinoma has increased significantly during the past 25 years in the United States and Europe. This increase has occurred predominantly among white men. To determine the effect of ethnicity and selected clinical features on the type of esophageal cancer in an urban, minority population, we retrospectively reviewed esophageal cancer at our institution. All patients with esophageal cancer from 1980 to 1995 were identified using the tumor registry data base and patient medical records at UMDNJ-University Hospital. Inclusion criteria were self-reported ethnicity and a confirmed pathologic diagnosis of either esophageal adenocarcinoma (ADENO) or squamous cell carcinoma (SCCA). Data abstracted from the record included age and year of diagnosis, weeks of survival, and risk factors, such as Barrett's esophagus and tobacco and alcohol abuse. Of 150 cases of esophageal cancer, 139 (93%) were SCCA and 11 (7%) were ADENO; the male:female ratio was 11:4. African and Latino Americans comprised 87% and white Americans 13% of the group. The incidence of ADENO increased during the study period: 1980-1984, 1 case; 1985-1989, 3 cases; and 1990-1995, 7 cases (P = .022); whereas the incidence of SCCA remained constant during the same intervals: 51, 52, and 36 cases, respectively (P > .05). By ethnicity, ADENO occurred more frequently among whites (7/19, 37%) than among African and Latino Americans (4/131, 3%); SCCA was more common among African and Latino Americans (127/131, 97%) than among whites (12/19, 63%) (P < .001). Other risk factors did not influence the type of esophageal cancer. The study concluded that the incidence of ADENO increased, primarily among white men, from 1980 to 1995 at UMDNJ-University Hospital. In contrast, the incidence of SCCA remained constant and was the primary type of esophageal cancer in African and Latino Americans. This study supports previous reports that ethnicity influences the histology of esophageal cancer.

Immunoproliferative small intestinal disease (IPSID) is a subtype of lymphoma of mucosa-associated lymphoid tissue. Notable for a high production of alpha-heavy chains, it is designated alpha-heavy-chain disease. IPSID is a debilitating disease that has a predilection for impoverished populations of developing countries. It has been documented primarily in subjects of Middle Eastern countries and thus was previously referred to as Mediterranean lymphoma. We report the case of a 42-year-old man from Senegal who presented with chronic diarrhea, dehydration, and weight loss. The endoscopic, pathologic, and serologic findings before, during, and after treatment with fludarabine phosphate are presented. We review the literature concerning current concepts on the etiology, pathogenesis, and management of IPSID.