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Provider ; level. As Pedan et al. suggested, statistical methods should be used to identify specific physicians or pharmacies that represent patients with particularly poor adherence. With the identification of the providers, customized interventions might be used to improve medication adherence. In addition, it is important to identify pharmacies or physicians that serve patients with higher adherence, finding out why they are doing well and replicating the success in other providers. Although it would be difficult to apply the hierarchical model in the iden tification process due to the complex nature of the method, some simple algorithms based on claims data from health plans could be developed to identify these higherperforming provid ers. The potential measures could be similar to the Healthcare Effectiveness Data and Information Set measures that are devel oped by the National Committee for Quality Assurance. In sum, although the study by Pedan et al. was not conclusive and some of its findings are hard to interpret, it was generally consistent with previous research. This study confirmed that patient medication adherence behavior is a complex subject. Variation in medication adherence among physicians and phar macies suggests a compelling need to know more--and do more--about system factors that have the potential to improve patient compliance. Jingdong Chao, PhD Senior Manager Abbott Laboratories 200 Abbott Park Rd. Abbott Park, IL 60041 jingdong.chao abbott This commentary represents the personal opinions of the author.

TABLE 1. RISK FACTORS FOR SCHIZOPHRENIA AND THEIR EFFECT SIZES. The interaction of proflavine with core particles, chromatosomes devoid of the external histones Hl and H5, polynucleosomes with the full complement of histones, and mononucleosomal DNA was examined by UV-visible absorption methods and sedimentation velocity techniques. These studies suggest that for ligand phosphate ratios below 0.004 very little, if any, proflavine associates with the core particle and that binding commences only when the core particle begins to unfold as inferred from sedimentation data. In contrast, the chromatosome and polynucleosome preparations do exhibit some degree of association with proflavine prior to unfolding of the core particle substructure. For a given ligand phosphate ratio less than 0.02, the chromatosome appears to bind more proflavine than the polynucleosomes. These data support a model in which only a small fraction of the total number of intercalation sites potential ; are actually physically accessible in the native structure of chromatin J. Theo. Biol., 98 1982 ; 29-43 ; . The implications of this model are that any recognition step in transcription and replication that involves intercalation can only take place initially in the linker region of DNA or that the core particle substructure must first unfold, and also that intercalating ligands such as proflavine and ethidium bromide cannot be used to study the dynamics of DNA in the native core particle as would be the case in fluorescence depolarization studies. This research was partially supported by grants from the American Cancer Society and NSF.

Received June 11, 2002; revision accepted July 24, 2002. From the Winship Cancer Institute D.Z. ; and Department of Medicine X.L. ; , Emory University, Atlanta, Ga, and the Michael E. DeBakey Department of Surgery B.S.C., P.H.L., A.B.L., Q.Y., C.C. ; , Baylor College of Medicine, Houston, Tex. Correspondence to Changyi Johnny ; Chen, MD, PhD, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 6550 Fannin, SM 1661, Houston, TX 77030. E-mail jchen bcm.tmc 2002 American Heart Association, Inc. Arterioscler Thromb Vasc Biol. is available at : atvbaha DOI: 10.1161 01 V.0000034707.40046.02.
About 2-fold after a 4-h progesterone treatment in Evsa-T cells data not shown ; . assess further the involvement of HMG domain proteins in mediating cisplatin cytotoxicity, we investigated the effects of elevated HMG1 levels on the sensitivity of cells to the drug. As initially anticipated from the repair shielding hypothesis, we found that elevated HMG1 expression levels were indeed paralleled by increased sensitivity toward cisplatin. In MCF-7 cells, estrogen or progesterone treatment increased cisplatin sensitivity about 2-fold, according to the cisplatin concentrations where only 50% of the cells are viable Fig. 2A ; . A combination of estrogen and progesterone sensitized the cells to cisplatin by a factor of 4 Fig. 2 A this additive effect suggests that they independently up-regulate HMG1. In Evsa-T cells, progesterone treatment induced 1.5-fold sensitization toward cisplatin, whereas estrogen treatment had no effect because of the absence of ER Fig. 2B ; . In addition, the cisplatin sensitivity of HeLa cells, an ER-negative cervical cancer cell line, did not change after estrogen treatment Fig. 2C ; . The timing of hormone treatment plays an important role in the degree of sensitization of cells to cisplatin. Cotreatment of estrogen and cisplatin caused 2-fold sensitization in MCF-7 cells; pretreatment with estrogen for 24 h did not cause any sensitization data not shown ; . In Evsa-T cells, the effect of sensitization by progesterone was not observed with cotreatment data not shown ; but was 2-fold with a 2-h pretreatment of progesterone Fig. 2B ; . Carboplatin is an analogue of cisplatin that can form similar bifunctional DNA adducts, because the products of aquation are the same for the two compounds 37 ; . Estrogen had no effect on the carboplatin sensitivity of cells treated simultaneously with the two reagents, but a 24-h pretreatment of carboplatin followed by a 4-h estrogen treatment increased the sensitivity by 2-fold Fig. 3 and cefprozil. The trial opened for patient accrual on January 16, 1990, and closed on November 14, 1997. When the protocol was planned, we estimated that it would take 3 years to accrue 80 eligible patients to this trial on the basis of previous adjuvant trials. In fact, it took 8 years, reflecting the difficulty of recruiting patients to a randomized trial with markedly different treatments and the impact on public opinion of the published results of uncontrolled clinical trials with high-dose chemotherapy. Seventy-eight patients were registered and found to be eligible 48 after primary surgery and 30 after primary chemotherapy ; , and all were considered to be subjects who could be evaluated. Thirty-nine patients were randomly assigned to receive FAC alone, and 39 were randomly assigned to receive FAC high-dose chemotherapy. Compliance With Treatment In the group randomly assigned to receive FAC alone, 36 patients received treatment as scheduled four of these patients developed recurrent metastatic disease during FAC chemotherapy ; . However, three patients, after signing the informed consent, elected to receive high-dose chemotherapy at other institutions. One patient received high-dose CEP; another received high-dose cyclophosphamide, carmustine, and thiotepa; and the third received a high-dose chemotherapy regimen unknown to us. Among the 39 patients randomly assigned to the FAC highdose chemotherapy arm, 31 received treatment as scheduled, including four who relapsed during the FAC induction therapy similar to the four who developed metastases during FAC chemotherapy in the FAC-alone group ; . Four patients received only one cycle of high-dose chemotherapy three for reasons of toxicity during the first cycle and one who refused to have a second cycle ; . Two patients received high-dose chemotherapy with regimens different from those dictated by the protocol one received one cycle of CEP followed by a second cycle of cyclophosphamide, carmustine, thiotepa, and interleukin 2; the other received high-dose cyclophosphamide, paclitaxel, and carboplatin ; . Therefore, 33 85% ; of 39 patients in this arm received high-dose chemotherapy or relapsed during assigned treatment. Six additional patients received only FAC: one because of insurance denial, three because they refused high-dose chemotherapy after completing the eight cycles of FAC, one because she developed a hepatitis B viral infection after being randomly assigned to treatment, and the sixth who was considered ineligible because of age and general health by the time high-dose chemotherapy was to start. Doses of FAC were administered with no change to 23 patients in the FAC group and to 22 patients in the FAC high-dose chemotherapy group. In eight additional patients, the doses were increased; in 25 others equally distributed between the two arms.

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