Who is likely to develop persistent low back pain? A longitudinal analysis of prognostic occupational factors

OBJECTIVE: Occupational low back pain (LBP) is considered to be the most expensive form of work disability, with the socioeconomic costs of persistent LBP exceeding the costs of acute and subacute LBP by far. This makes the early identification of patients at risk of developing persistent LBP essential, especially in working populations. The aim of the study was to evaluate both risk factors (for the development of persistent LBP) and protective factors (preventing the development of persistent LBP) in the same cohort. PARTICIPANTS: An inception cohort of 315 patients with acute to subacute or with recurrent LBP was recruited from 14 health practitioners (twelve general practitioners and two physiotherapists) across New Zealand. METHODS: Patients with persistent LBP at six-month follow-up were compared to patients with non-persistent LBP looking at occupational, psychological, biomedical and demographic/lifestyle predictors at baseline using multiple logistic regression analyses. All significant variables from the different domains were combined into a one predictor model. RESULTS: A final two-predictor model with an overall predictive value of 78% included social support at work (OR 0.67; 95%CI 0.45 to 0.99) and somatization (OR 1.08; 95%CI 1.01 to 1.15). CONCLUSIONS: Social support at work should be considered as a resource preventing the development of persistent LBP whereas somatization should be considered as a risk factor for the development of persistent LBP. Further studies are needed to determine if addressing these factors in workplace interventions for patients suffering from acute, subacute or recurrent LBP prevents subsequent development of persistent LBP.

Surgical hip dislocation for treatment of femoroacetabular impingement: factors predicting 5-year survivorship.

BACKGROUND Patients with femoroacetabular impingement (FAI) often develop pain, impaired function, and progression of osteoarthritis (OA); this is commonly treated using surgical hip dislocation, femoral neck and acetabular rim osteoplasty, and labral reattachment. However, results with these approaches, in particular risk factors for OA progression and conversion to THA, have varied. QUESTIONS/PURPOSES We asked if patients undergoing surgical hip dislocation with labral reattachment to treat FAI experienced (1) improved hip pain and function; and (2) prevention of OA progression; we then determined (3) the survival of the hip at 5-year followup with the end points defined as the need for conversion to THA, progression of OA by at least one Tönnis grade, and/or a Merle d'Aubigné-Postel score less than 15; and calculated (4) factors predicting these end points. METHODS Between July 2001 and March 2003, we performed 146 of these procedures in 121 patients. After excluding 35 patients (37 hips) who had prior open surgery and 11 patients (12 hips) who had a diagnosis of Perthes disease, this study evaluated the 75 patients (97 hips, 66% of the procedures we performed during that time) who had a mean followup of 6 years (range, 5-7 years). We used the anterior impingement test to assess pain, the Merle d'Aubigné-Postel score to assess function, and the Tönnis grade to assess OA. Survival and predictive factors were calculated using the method of Kaplan and Meier and Cox regression, respectively. RESULTS The proportion of patients with anterior impingement decreased from 95% to 17% (p < 0.001); the Merle d'Aubigné-Postel score improved from a mean of 15 to 17 (p < 0.001). Seven hips (7%) showed progression of OA and another seven hips (7%) converted to THA Survival free from any end point (THA, progression of OA, or a Merle d'Aubigné-Postel < 15) of well-functioning joints at 5 years was 91%; and excessive acetabular rim trimming, preoperative OA, increased age at operation, and weight were predictive factors for the end points. CONCLUSIONS At 5-year followup, 91% of patients with FAI treated with surgical hip dislocation, osteoplasty, and labral reattachment showed no THA, progression of OA, or an insufficient clinical result, but excessive acetabular trimming, OA, increased age, and weight were associated with early failure. To prevent early deterioration of the joint, excessive rim trimming or trimming of borderline dysplastic hips has to be avoided.

Factors Associated with the Cessation of Intimate Partner Violence in Women Attending Primary Care in Spain

This study aimed to identify factors associated with the likelihood of IPV cessation among women attending Spanish primary healthcare. Of the 2465 women who reported lifetime IPV, 36.1 % stated that violence had ceased. Those women not currently abused had higher levels of education and social support, were workers or students, and had no dependent children. When IPV duration was less than 5 years, the likelihood of cessation was two times higher than when IPV continued beyond 5 years. For women who have experienced physical IPV, the probability of ending the violent relationship was 10 times higher than for those suffering from psychological IPV. The implications of the findings regarding clinical significance and future research are discussed.

Physical and psychological factors maintain long-term predictive capacity post-whiplash injury

Higher initial levels of pain and disability, older age, cold hyperalgesia, impaired sympathetic vasoconstriction and moderate post-traumatic stress symptoms have been shown to be associated with poor outcome 6 months following whiplash injury. This study prospectively investigated the predictive capacity of these variables at a long-term follow-up. Sixty-five of an initial cohort of 76 acutely injured whiplash participants were followed to 2-3 years post-accident. Motor function (ROM; kinaesthetic sense; activity of the superficial neck flexors (EMG) during cranio-cervical flexion), quantitative sensory testing (pressure, thermal pain thresholds and brachial plexus provocation test), sympathetic vasoconstrictor responses and psychological distress (GHQ-28, TSK and IES) were measured. The outcome measure was Neck Disability Index (NDI) scores. Participants with ongoing moderate/severe symptoms at 2-3 years continued to manifest decreased ROM, increased EMG during cranio-cervical flexion, sensory hypersensitivity and elevated levels of psychological distress when compared to recovered participants and those with milder symptoms. The latter two groups showed only persistent deficits in cervical muscle recruitment patterns. Higher initial NDI scores (OR 1.00-1.1), older age (OR 1.00-1.13), cold hyperalgesia (OR 1.1-1.13) and post-traumatic stress symptoms (OR 1.03-1.2) remained significant predictors of poor outcome at long-term follow-up (r(2) = 0.56). The robustness of these physical and psychological factors suggests that their assessment in the acute stage following whiplash injury will be important. (c) 2006 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.

Factors associated with hospitalization after suicide spectrum behaviors: results from a multicentre study in Spain

Objectives: to identify factors associated with admission after suicide spectrum behaviors. Methods: Patient's characteristics, the nature of their suicidal behavior, admission rates between centres, and factors associated with admission have been examined in suicide spectrum presentations to emergency departments in three Spanish cities. Results: Intent of the suicidal behavior had the greatest impact on hospitalization. Older age, living alone, self-harm method not involving drug overdose, previous history of suicide spectrum behaviors and psychiatric diagnosis of schizophrenia, mood or personality disorder were independently associated with being admitted. There was a three-fold between-centre difference in the rate of hospitalization. Conclusions: widespread differences in the rate of hospitalization were primarily accounted for by characteristics of the individual patients and their suicidal behavior.

Karst hazard analysis towards the development of predictive karst models for southern Ontario

An investigation into karst hazard in southern Ontario has been undertaken with the intention of leading to the development of predictive karst models for this region. The reason these are not currently feasible is a lack of sufficient karst data, though this is not entirely due to the lack of karst features. Geophysical data was collected at Lake on the Mountain, Ontario as part of this karst investigation. This data was collected in order to validate the long-standing hypothesis that Lake on the Mountain was formed from a sinkhole collapse. Sub-bottom acoustic profiling data was collected in order to image the lake bottom sediments and bedrock. Vertical bedrock features interpreted as solutionally enlarged fractures were taken as evidence for karst processes on the lake bottom. Additionally, the bedrock topography shows a narrower and more elongated basin than was previously identified, and this also lies parallel to a mapped fault system in the area. This suggests that Lake on the Mountain was formed over a fault zone which also supports the sinkhole hypothesis as it would provide groundwater pathways for karst dissolution to occur. Previous sediment cores suggest that Lake on the Mountain would have formed at some point during the Wisconsinan glaciation with glacial meltwater and glacial loading as potential contributing factors to sinkhole development. A probabilistic karst model for the state of Kentucky, USA, has been generated using the Weights of Evidence method. This model is presented as an example of the predictive capabilities of these kind of data-driven modelling techniques and to show how such models could be applied to karst in Ontario. The model was able to classify 70% of the validation dataset correctly while minimizing false positive identifications. This is moderately successful and could stand to be improved. Finally, suggestions to improving the current karst model of southern Ontario are suggested with the goal of increasing investigation into karst in Ontario and streamlining the reporting system for sinkholes, caves, and other karst features so as to improve the current Ontario karst database.

Modelling the influence of biotic factors on species distribution patterns

Biotic interactions can have large effects on species distributions yet their role in shaping species ranges is seldom explored due to historical difficulties in incorporating biotic factors into models without a priori knowledge on interspecific interactions. Improved SDMs, which account for biotic factors and do not require a priori knowledge on species interactions, are needed to fully understand species distributions. Here, we model the influence of abiotic and biotic factors on species distribution patterns and explore the robustness of distributions under future climate change. We fit hierarchical spatial models using Integrated Nested Laplace Approximation (INLA) for lagomorph species throughout Europe and test the predictive ability of models containing only abiotic factors against models containing abiotic and biotic factors. We account for residual spatial autocorrelation using a conditional autoregressive (CAR) model. Model outputs are used to estimate areas in which abiotic and biotic factors determine species’ ranges. INLA models containing both abiotic and biotic factors had substantially better predictive ability than models containing abiotic factors only, for all but one of the four species. In models containing abiotic and biotic factors, both appeared equally important as determinants of lagomorph ranges, but the influences were spatially heterogeneous. Parts of widespread lagomorph ranges highly influenced by biotic factors will be less robust to future changes in climate, whereas parts of more localised species ranges highly influenced by the environment may be less robust to future climate. SDMs that do not explicitly include biotic factors are potentially misleading and omit a very important source of variation. For the field of species distribution modelling to advance, biotic factors must be taken into account in order to improve the reliability of predicting species distribution patterns both presently and under future climate change.

Should I stay or should I go – Factors associated with hospitalization risk among older persons in Sweden

An increasingly older population will most likely lead to greater demands on the health care system, as older age is associated with an increased risk of having acute and chronic conditions. The number of diseases or disabilities is not the only marker of the amount of health care utilized, as persons may seek hospitalization without a disease and/or illness that requires hospital healthcare. Hospitalization may pose a severe risk to older persons, as exposure to the hospital environment may lead to increased risks of iatrogenic disorders, confusion, falls and nosocomial infections, i.e., disorders that may involve unnecessary suffering and lead to serious consequences. Aims: The overall aim of this thesis was to describe and explore individual trajectories of cognitive development in relation to hospitalization and risk factors for hospitalization among older persons living in different accommodations in Sweden and to explore older persons' reasons for being transferred to a hospital. Methods: The study designs were longitudinal, prospective and descriptive, and both quantitative and qualitative methods were used. Specifically, latent growth curve modelling was used to assess the association of cognitive development with hospitalization. The Cox proportional hazards regression model was used to analyse factors associated with hospitalization risk overtime. In addition, an explorative descriptive design was used to explore how home health care patients experienced and perceived their decision to seek hospital care. Results: The most common reasons for hospitalization were cardiovascular diseases, which caused more than one-quarter of first hospitalizations among the persons living in ordinary housing and nursing home residents (NHRs). The persons who had been hospitalized had a lower mean level of cognitive performance in general cognition, verbal, spatial/fluid, memory and processing speed abilities compared to those who had not been hospitalized. Significantly steeper declines in general cognition, spatial/fluid and processing speed abilities were observed among the persons who had been hospitalized. Cox proportional hazards regression analysis showed that the number of diseases, number of drugs used, having experienced a fall and being assessed as malnourished according to the Mini Nutritional Assessment scale were related to an increased hospitalization risk among the NHRs. Among the older persons living in ordinary housing, the risk factors for hospitalization were related to marital status, i.e., unmarried persons and widows/widowers had a decreased hospitalization risk. In addition, among social factors, receipt of support from relatives was related to an increased hospitalization risk, while receipt of support from friends was related to a decreased risk. The number of illnesses was not associated with the hospitalization risk for older persons in any age group or for those of either sex, when controlling for other variables. The older persons who received home health care described different reasons for their decisions to seek hospital care. The underlying theme of the home health care patients’ perceptions of their transfer to a hospital involved trust in hospitals. This trust was shared by the home health care patients, their relatives and the home health care staff, according to the patients. Conclusions: This thesis revealed that middle-aged and older persons who had been hospitalized exhibited a steeper decline in cognition. Specifically, spatial/fluid, processing speed, and general cognitive abilities were affected. The steeper decline in cognition among those who had been hospitalized remained even after controlling for comorbidities. The most common causes of hospitalization among the older persons living in ordinary housing and in nursing homes were cardiovascular diseases, tumours and falls. Not only health-related factors, such as the number of diseases, number of drugs used, and being assessed as malnourished, but also social factors and marital status were related to the hospitalization risk among the older persons living in ordinary housing and in nursing homes. Some risk factors associated with hospitalization differed not only between the men and women but also among the different age groups. The information provided in this thesis could be applied in care settings by professionals who interact with older persons before they decide to seek hospital care. To meet the needs of an older population, health care systems need to offer the proper health care at the most appropriate level, and they need to increase integration and coordination among health care delivered by different care services.

Performance of protective factors assessment in risk prediction for adults: systematic review and meta-analysis

Protective factors are neglected in risk assessment in adult psychiatric and criminal justice populations. This review investigated the predictive efficacy of selected tools that assess protective factors. Five databases were searched using comprehensive terms for records up to June 2014, resulting in 17 studies (n = 2,198). Results were combined in a multilevel meta-analysis using the R (R Core Team, R: A Language and Environment for Statistical Computing, Vienna, Austria: R Foundation for Statistical Computing, 2015) metafor package (Viechtbauer, Journal of Statistical Software, 2010, 36, 1). Prediction of outcomes was poor relative to a reference category of violent offending, with the exception of prediction of discharge from secure units. There were no significant differences between the predictive efficacy of risk scales, protective scales, and summary judgments. Protective factor assessment may be clinically useful, but more development is required. Claims that use of these tools is therapeutically beneficial require testing.

Analysis of extracellular vesicles from patients with advanced pancreatic cancer identifies miRNAs with predictive value for treatment with gemcitabine + nab-paclitaxel

Pancreatic cancer (PC) is the seventh leading cause of cancer death. Despite recent therapy advancements, 5-year survival is 11%. Resistance to therapy is common, and no predictive factors, except for BRCA1/2 and PALB2 mutations, can drive treatment selection. Based on the easy isolation of extracellular vesicles (EVs) from blood and the role of EV-borne miRNAs in chemoresistance, we analyzed EVs and their miRNA content in order to identify predictive factors. First, we analyzed samples from 28 PC patients and 7 healthy subjects, in order to establish methods for isolation and analysis of EVs and their miRNA content. We observed a significantly different expression of 28 miRNAs, including oncogenic or tumor suppressor miRNAs, showing the ability of our approach to detect candidate biomarkers. Then, we analyzed samples of 21 advanced PC patients, collected before first-line treatment with gemcitabine + nab-paclitaxel, and compared findings in responders and non-responders. EVs have been analyzed with Nanoparticle tracking analysis, flow cytometry and RNA-Seq; then, laboratory results have been matched with clinical data. Nanoparticle tracking analysis did not show any significant difference. Flow cytometry showed a lower expression of SSE4 and CD81 in responders. Finally, miRNA analysis showed 25 upregulated and 19 downregulated miRNAs in responders. In particular, in responders we observed upregulation of miR-141-3p, miR-141-5p, miR-200a-3p, miR-200b-3p, miR-200c-3p, miR-375-3p, miR-429, miR-545-5p. These miRNAs have targets with a previously reported role in PC. In conclusion, we show the feasibility of the proposed approach to identify EV-derived biomarkers with predictive value for therapy with gemcitabine + nab-paclitaxel in PC. Our findings highlight the possibility to exploit liquid biopsy for personalized treatment in PC, in order to maximize chances of response and patients’ outcome. These findings are worthy of further investigation: in the same setting, with different chemotherapy schedules, and in different disease settings such as preoperative therapy.

Impact on human health of particulate matter emitted from burnings in the Brazilian Amazon region

OBJECTIVE: To analyze the impact on human health of exposure to particulate matter emitted from burnings in the Brazilian Amazon region. METHODS: This was an ecological study using an environmental exposure indicator presented as the percentage of annual hours (AH%) of PM2.5 above 80 μg/m3. The outcome variables were the rates of hospitalization due to respiratory disease among children, the elderly and the intermediate age group, and due to childbirth. Data were obtained from the National Space Research Institute and the Ministry of Health for all of the microregions of the Brazilian Amazon region, for the years 2004 and 2005. Multiple regression models for the outcome variables in relation to the predictive variable AH% of PM2.5 above 80 μg/m3 were analyzed. The Human Development Index (HDI) and mean number of complete blood counts per 100 inhabitants in the Brazilian Amazon region were the control variables in the regression analyses. RESULTS: The association of the exposure indicator (AH%) was higher for the elderly than for other age groups (β = 0.10). For each 1% increase in the exposure indicator there was an increase of 8% in child hospitalization, 10% in hospitalization of the elderly, and 5% for the intermediate age group, even after controlling for HDI and mean number of complete blood counts. No association was found between the AH% and hospitalization due to childbirth. CONCLUSIONS: The indicator of atmospheric pollution showed an association with occurrences of respiratory diseases in the Brazilian Amazon region, especially in the more vulnerable age groups. This indicator may be used to assess the effects of forest burning on human health.

Cross-National Analysis of the Associations among Mental Disorders and Suicidal Behavior: Findings from the WHO World Mental Health Surveys

Background: Suicide is a leading cause of death worldwide. Mental disorders are among the strongest predictors of suicide; however, little is known about which disorders are uniquely predictive of suicidal behavior, the extent to which disorders predict suicide attempts beyond their association with suicidal thoughts, and whether these associations are similar across developed and developing countries. This study was designed to test each of these questions with a focus on nonfatal suicide attempts. Methods and Findings: Data on the lifetime presence and age-of-onset of Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) mental disorders and nonfatal suicidal behaviors were collected via structured face-to-face interviews with 108,664 respondents from 21 countries participating in the WHO World Mental Health Surveys. The results show that each lifetime disorder examined significantly predicts the subsequent first onset of suicide attempt (odds ratios [ORs] = 2.9-8.9). After controlling for comorbidity, these associations decreased substantially (ORs = 1.5-5.6) but remained significant in most cases. Overall, mental disorders were equally predictive in developed and developing countries, with a key difference being that the strongest predictors of suicide attempts in developed countries were mood disorders, whereas in developing countries impulse-control, substance use, and post-traumatic stress disorders were most predictive. Disaggregation of the associations between mental disorders and nonfatal suicide attempts showed that these associations are largely due to disorders predicting the onset of suicidal thoughts rather than predicting progression from thoughts to attempts. In the few instances where mental disorders predicted the transition from suicidal thoughts to attempts, the significant disorders are characterized by anxiety and poor impulse-control. The limitations of this study include the use of retrospective self-reports of lifetime occurrence and age-of-onset of mental disorders and suicidal behaviors, as well as the narrow focus on mental disorders as predictors of nonfatal suicidal behaviors, each of which must be addressed in future studies. Conclusions: This study found that a wide range of mental disorders increased the odds of experiencing suicide ideation. However, after controlling for psychiatric comorbidity, only disorders characterized by anxiety and poor impulse-control predict which people with suicide ideation act on such thoughts. These findings provide a more fine-grained understanding of the associations between mental disorders and subsequent suicidal behavior than previously available and indicate that mental disorders predict suicidal behaviors similarly in both developed and developing countries. Future research is needed to delineate the mechanisms through which people come to think about suicide and subsequently progress from ideation to attempts.

Adverse drug events in an intensive care unit of a university hospital

Purpose Adverse drug events (ADEs) are harmful and occur with alarming frequency in critically ill patients. Complex pharmacotherapy with multiple medications increases the probability of a drug interaction (DI) and ADEs in patients in intensive care units (ICUs). The objective of the study is to determine the frequency of ADEs among patients in the ICU of a university hospital and the drugs implicated. Also, factors associated with ADEs are investigated. Methods This cross-sectional study investigated 299 medical records of patients hospitalized for 5 or more days in an ICU. ADEs were identified through intensive monitoring adopted in hospital pharmacovigilance and also ADE triggers. Adverse drug reactions (ADR) causality was classified using the Naranjo algorithm. Data were analyzed through descriptive analysis, and through univariate and multiple logistic regression. Results The most frequent ADEs were ADRs type A, of possible causality and moderate severity. The most frequent ADR was drug-induced acute kidney injury. Patients with ADEs related to DIs corresponded to 7% of the sample. The multiple logistic regression showed that length of hospitalization (OR = 1.06) and administration of cardiovascular drugs (OR = 2.2) were associated with the occurrence of ADEs. Conclusion Adverse drug reactions of clinical significance were the most frequent ADEs in the ICU studied, which reduces patient safety. The number of ADEs related to drug interactions was small, suggesting that clinical manifestations of drug interactions that harm patients are not frequent in ICUs.

Clinical indicators of ineffective airway clearance in children with congenital heart disease

To analyse the sensitivity and specificity of clinical indicators of ineffective airway clearance in children with congenital heart disease and to identify the indicators that have high predictive power. The precise establishment of nursing diagnoses has been found to be one of the factors contributing to higher quality of care and cost reduction in healthcare institutions. The use of indicators to diagnose ineffective airway clearance could improve care of children with congenital heart disease. Longitudinal study. Participants consisted of 45 children, <= 1 year of age, with congenital heart disease, who had not had definitive or palliative surgical correction. Six assessments were made at 2-day intervals. Each clinical indicator was defined based on previously established operational criteria. Sensitivity, specificity and positive and negative predictive values of each indicator were calculated based on a model for the longitudinal data. A nursing diagnosis of ineffective airway clearance was made in 31% of patients on the first assessment, rising to 71% on the last assessment, for a 40% increase. Sensitivity was highest for Changes in Respiratory Rates/Rhythms (0.99), followed by Adventitious Breath Sounds (0.97), Sputum Production (0.85) and Restlessness (0.53). Specificity was higher for Sputum Production (0.92), followed by Restlessness (0.73), Adventitious Breath Sounds (0.70) and Changes in Respiratory Rates/Rhythms (0.17). The best positive predictive values occurred for Sputum Production (0.93) and Adventitious Breath Sounds (0.80). Adventitious Breath Sounds followed by Sputum Production were the indicators that had the best overall sensitivity and specificity as well as the highest positive predictive values. The use of simple indicators in nursing diagnoses can improve identification of ineffective airway clearance in children with congenital heart disease, thus leading to early treatment of the problem and better care for these children.

Predictors of local recurrence after treatment of ductal carcinoma in situ - A meta-analysis

lBACKGROUND. Management of patients with ductal carcinoma in situ (DCIS) is a dilemma, as mastectomy provides nearly a 100% cure rate but at the expense of physical and psychologic morbidity. It would be helpful if we could predict which patients with DCIS are at sufficiently high risk of local recurrence after conservative surgery (CS) alone to warrant postoperative radiotherapy (RT) and which patients are at sufficient risk of local recurrence after CS + RT to warrant mastectomy. The authors reviewed the published studies and identified the factors that may be predictive of local recurrence after management by mastectomy, CS alone, or CS + RT. METHODS. The authors examined patient, tumor, and treatment factors as potential predictors for local recurrence and estimated the risks of recurrence based on a review of published studies. They examined the effects of patient factors (age at diagnosis and family history), tumor factors (sub-type of DCIS, grade, tumor size, necrosis, and margins), and treatment (mastectomy, CS alone, and CS + RT). The 95% confidence intervals (CI) of the recurrence rates for each of the studies were calculated for subtype, grade, and necrosis, using the exact binomial; the summary recurrence rate and 95% CI for each treatment category were calculated by quantitative meta-analysis using the fixed and random effects models applied to proportions. RESULTS, Meta-analysis yielded a summary recurrence rate of 22.5% (95% CI = 16.9-28.2) for studies employing CS alone, 8.9% (95% CI = 6.8-11.0) for CS + RT, and 1.4% (95% CI = 0.7-2.1) for studies involving mastectomy alone. These summary figures indicate a clear and statistically significant separation, and therefore outcome, between the recurrence rates of each treatment category, despite the likelihood that the patients who underwent CS alone were likely to have had smaller, possibly low grade lesions with clear margins. The patients with risk factors of presence of necrosis, high grade cytologic features, or comedo subtype were found to derive the greatest improvement in local control with the addition of RT to CS. Local recurrence among patients treated by CS alone is approximately 20%, and one-half of the recurrences are invasive cancers. For most patients, RT reduces the risk of recurrence after CS alone by at least 50%. The differences in local recurrence between CS alone and CS + RT are most apparent for those patients with high grade tumors or DCIS with necrosis, or of the comedo subtype, or DCIS with close or positive surgical margins. CONCLUSIONS, The authors recommend that radiation be added to CS if patients with DCIS who also have the risk factors for local recurrence choose breast conservation over mastectomy. The patients who may be suitable for CS alone outside of a clinical trial may be those who have low grade lesions with little or no necrosis, and with clear surgical margins. Use of the summary statistics when discussing outcomes with patients may help the patient make treatment decisions. Cancer 1999;85:616-28. (C) 1999 American Cancer Society.