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Burns RB, Potter JE, Ricciotti HA, Reynolds EE. Screening Pelvic Examinations in Adult Women: Grand Rounds Discussion From the Beth Israel Deaconess Medical Center. Ann Intern Med 2015; 163:537-47. [PMID: 26436618 DOI: 10.7326/m15-1220] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Pelvic examinations have historically been a part of regular preventive care. However, because women can now be screened for cervical cancer at intervals up to every 5 years, the question of whether women need to be seen annually for routine pelvic examinations has arisen. In July 2014, the American College of Physicians (ACP) issued a guideline presenting the available evidence on screening for pathologic conditions using pelvic examination in adult, asymptomatic women at average risk. The American College of Obstetricians and Gynecologists (ACOG) Committee on Gynecologic Practice had previously issued a committee opinion in August 2012 on the need for annual examinations and provided guidelines on important elements of this procedure, including when to examine asymptomatic women. ACOG reaffirmed its initial position after publication of the ACP guideline. The guidelines differ-the ACP guideline recommends against and the ACOG committee opinion recommends in favor of routine annual pelvic examination. This paper summarizes a discussion between an internist and a gynecologist on how they would balance these recommendations in general and what they would suggest for an individual patient.
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Mittleman MA, Taylor WC, Smetana G, Burns RB. Treatment of Blood Cholesterol to Reduce Risk for Atherosclerotic Cardiovascular Disease: Grand Rounds Discussion From the Beth Israel Deaconess Medical Center. Ann Intern Med 2015; 163:280-90. [PMID: 26280414 DOI: 10.7326/m15-1125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
In November 2013, the American College of Cardiology and the American Heart Association released a clinical practice guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular disease (ASCVD) risk in adults. The recommendation identifies 4 patient groups with strong evidence that the benefits of reduction in ASCVD events from statin therapy exceed adverse events. For these patients, initiating statin therapy of an appropriate intensity to reduce ASCVD risk and minimize adverse effects is recommended. A new risk estimator based on a pooled cohort equation is presented for estimating 10-year ASCVD risk. There is also a recommendation to engage in a clinician-patient discussion before initiating a statin, especially for primary prevention of ASCVD. This paper summarizes a discussion between a cardiologist and an internist about how each clinician would balance these factors and what treatment they would suggest for an individual patient.
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McCarthy EP, Pencina MJ, Kelly-Hayes M, Evans JC, Oberacker EJ, D'Agostino RB, Burns RB, Murabito JM. Advance care planning and health care preferences of community-dwelling elders: the Framingham Heart Study. J Gerontol A Biol Sci Med Sci 2008; 63:951-9. [PMID: 18840800 DOI: 10.1093/gerona/63.9.951] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The study objective was to describe self-reported advance care planning, health care preferences, use of advance directives, and health perceptions in a very elderly community-dwelling sample. METHODS We interviewed surviving participants of the original cohort of the Framingham Heart Study who were cognitively intact and attended a routine research examination between February 2004 and October 2005. Participants were queried about discussions about end-of-life care, preferences for care, documentation of advance directives, and health perceptions. RESULTS Among 220 community-dwelling respondents, 67% were women with a mean age of 88 years (range 84-100 years). Overall, 69% discussed their wishes for medical care at the end of life with someone, but only 17% discussed their wishes with a physician or health care provider. Two thirds had a health care proxy, 55% had a living will, and 41% had both. Most (80%) respondents preferred comfort care over life-extending care, and 71% preferred to die at home; however, substantially fewer respondents said they would rather die than receive specific life-prolonging interventions (chronic ventilator [63%] or feeding tube [64%]). Many were willing to endure distressing health states, with fewer than half indicating that they would rather die than live out their life in a great deal of pain (46%) or be confused and/or forgetful (45%) all of the time. CONCLUSIONS Although the vast majority of very elderly community-dwellers in this sample appear to prefer comfort measures at the end of life, many said they were willing to endure specific life-prolonging interventions and distressing health states to avoid death. Our results highlight the need for physicians to better understand patients' preferences and goals of care to help them make informed decisions at the end of life.
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Sabatino SA, McCarthy EP, Phillips RS, Burns RB. Breast cancer risk assessment and management in primary care: Provider attitudes, practices, and barriers. ACTA ACUST UNITED AC 2007; 31:375-83. [DOI: 10.1016/j.cdp.2007.08.003] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2007] [Indexed: 10/22/2022]
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Burns RB. A 59-year-old woman with gastroesophageal reflux disease and barrett esophagus, 4 years later. JAMA 2006; 296:2140. [PMID: 17077379 DOI: 10.1001/jama.296.17.2140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Sabatino SA, Burns RB, Davis RB, Phillips RS, McCarthy EP. Breast cancer risk and provider recommendation for mammography among recently unscreened women in the United States. J Gen Intern Med 2006; 21:285-91. [PMID: 16686802 PMCID: PMC1484729 DOI: 10.1111/j.1525-1497.2006.00348.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVE Many women with increased breast cancer risk have not been screened recently. Provider recommendation for mammography is an important reason many women undergo screening. We examined the association between breast cancer risk and reported provider recommendation for mammography in recently unscreened women. DESIGN Cross-sectional study using 2000 National Health Interview Survey. PARTICIPANTS In all, 1673 women ages 40 to 75 years without cancer who saw a health care provider in the prior year and had no mammogram within 2 years. MEASUREMENTS AND ANALYSIS We assessed breast cancer risk by Gail score and risk factors. We used multivariable logistic regression models in SUDAAN adjusted for age, race and illness burden, to examine the association between risk and reported recommendation for mammography within 1 year for all women and women ages 50 to 75 years. RESULTS Of 1673 recently unscreened women, 29% reported a recommendation. Twelve percent of women had increased Gail risk and of these recently unscreened, high-risk women, 25% reported a recommendation. After adjustment, high-risk women were not more likely to report a recommendation than average-risk women. Results were similar for women 50 to 75 years old. No individual breast cancer factors other than age were associated with reporting a recommendation. CONCLUSIONS Approximately 70% of recently unscreened women seen by a health care provider in the prior year reported no recommendation for mammography, regardless of breast cancer risk. This did not include women who received a recommendation and were screened. Increasing reported recommendation rates may represent an opportunity to increase screening participation among recently unscreened women, particularly for women with increased breast cancer risk.
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Goel MS, Burns RB, Phillips RS, Davis RB, Ngo-Metzger Q, McCarthy EP. Trends in breast conserving surgery among Asian Americans and Pacific Islanders, 1992-2000. J Gen Intern Med 2005; 20:604-11. [PMID: 16050854 PMCID: PMC1490151 DOI: 10.1111/j.1525-1497.2005.0090.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/06/2004] [Indexed: 11/28/2022]
Abstract
BACKGROUND Breast-conserving surgery (BCS) has been the recommended treatment for early-stage breast cancer since 1990 yet many women still do not receive this procedure. OBJECTIVE To examine the relationship between birthplace and use of BCS in Asian-American and Pacific-Islander (AAPI) women, and to determine whether disparities between white and AAPI women persist over time. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS Women with newly diagnosed stage I or II breast cancer from 1992 to 2000 in the Surveillance, Epidemiology, and End Results program. OUTCOME Receipt of breast -conserving surgery for initial treatment of stage I or II breast cancer. MAIN RESULTS Overall, AAPI women had lower rates of BCS than white women (47% vs 59%; P<.01). Foreign-born AAPI women had lower rates of BCS than U.S.-born AAPI and white women (43% vs 56% vs 59%; P<.01). After adjustment for age, marital status, tumor registry, year of diagnosis, stage at diagnosis, tumor size, histology, grade, and hormone receptor status, foreign-born AAPI women (adjusted OR [aOR], 0.49; 95% CI, 0.32 to 0.76) and U.S.-born AAPI women (aOR, 0.77; 95% CI, 0.62 to 0.95) had lower odds of receiving BCS than white women. Use of BCS increased over time for each racial/ethnic group; however, foreign-born AAPI women had persistently lower rates of BCS than non-Hispanic white women. CONCLUSIONS AAPI women, especially those who are foreign born, are less likely to receive BCS than non-Hispanic white women. Of particular concern, differences in BCS use among foreign-born and U.S.-born AAPI women and non-Hispanic white women have persisted over time. These differences may reflect inequities in the treatment of early-stage breast cancer for AAPI women, particularly those born abroad.
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Burns RB. Update: A 54-year-old man with obstructive sleep apnea. JAMA 2004; 291:3004. [PMID: 15213213 DOI: 10.1001/jama.291.24.3004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Sabatino SA, Burns RB, Davis RB, Phillips RS, Chen YH, McCarthy EP. Breast carcinoma screening and risk perception among women at increased risk for breast carcinoma. Cancer 2004; 100:2338-46. [PMID: 15160336 DOI: 10.1002/cncr.20274] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The Gail model is validated to estimate breast carcinoma risk. The authors assessed the association of Gail risk scores with screening and cancer risk perception. METHODS Using the 2000 National Health Interview Survey, the authors studied women ages 41-70 without a cancer history. Gail scores > or = 1.66% defined increased risk. The authors used logistic regression to assess associations between breast carcinoma risk and previous and recent (< or = 1 year) mammography and clinical breast examination (CBE). RESULTS Of 6410 women, 15.7% had increased risk. High-risk women more frequently reported previous mammograms (94% vs. 85%; P < 0.0001), previous CBE (93% vs. 88%; P < 0.0001), recent mammograms (70% vs. 54%; P < 0.0001), recent CBE (71% vs. 61%; P < 0.0001), and high cancer risk perception (20% vs. 9%; P < 0.0001). However, 30% of high-risk women had not received a recent mammogram. After adjustment for sociodemographic factors, access to care factors, and cancer risk perception, high-risk women remained more likely to have received recent mammography (adjusted odds ratio [OR], 1.45, 95% confidence interval [95% CI], 1.19-1.77), recent CBE (OR, 1.32; 95% CI, 1.08-1.61]), and previous mammography than average-risk women. The authors observed an interaction between risk and age, with women ages 41-49 years more frequently reporting previous mammography (OR, 4.79; 95% CI, 1.55-4.81) than average-risk, same-age women. For women age > or = 50 years, the odds of previous mammography were similar regardless of risk. CONCLUSIONS In a nationally representative sample, 15.7% of women had increased breast carcinoma risk using the Gail model. High-risk women perceived higher cancer risk and more often received screening. However, nearly one in three high-risk women did not receive recent screening and most of these women did not perceive increased risk.
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Burns RB, Hartman EE. A 58-year-old man with a diagnosis of chronic Lyme disease, 1 year later. JAMA 2003; 290:3247. [PMID: 14693878 DOI: 10.1001/jama.290.24.3247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Cintron A, Hamel MB, Davis RB, Burns RB, Phillips RS, McCarthy EP. Hospitalization of Hospice Patients with Cancer. J Palliat Med 2003; 6:757-68. [PMID: 14622455 DOI: 10.1089/109662103322515266] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To identify factors associated with hospitalization of elderly hospice patients with cancer and to describe their hospital experiences. DESIGN Retrospective analysis of the last year of life. SETTING Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. PARTICIPANTS Medicare beneficiaries dying of lung or colorectal cancer between 1988 and 1998 who enrolled in hospice. MEASUREMENTS Hospitalization after hospice entry. For hospitalized patients, we describe admission diagnoses, aggressiveness of care, and in-hospital death. RESULTS Of the 23608 patients, 1423 (6.0%) were hospitalized after hospice enrollment. Hospitalization declined over time by 7.0% per year of hospice enrollment. Factors associated with higher hospitalization rates were younger age, male gender, black race/ethnicity, local cancer stage at diagnosis, and hospice enrollment within 4 months of cancer diagnosis. The most common reasons for hospital admission were lung cancer, metastatic disease, bone fracture, pneumonia, and volume depletion. Of the 1423 patients hospitalized, 34.6% received aggressive care and 35.8% died in the hospital. CONCLUSION The rates of hospitalization for elderly hospice patients with lung or colorectal cancer appear to be declining. However, patients who are hospitalized undergo aggressive care and often die in the hospital rather than at home. This aggressive care may be consistent with changes in patients' care preferences, but could also reflect the current culture of acute care hospitals, which focuses on curative treatment and is ill-equipped to provide palliative care.
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Ngo-Metzger Q, McCarthy EP, Burns RB, Davis RB, Li FP, Phillips RS. Older Asian Americans and Pacific Islanders dying of cancer use hospice less frequently than older white patients. Am J Med 2003; 115:47-53. [PMID: 12867234 DOI: 10.1016/s0002-9343(03)00258-4] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE Cancer is the leading cause of death among Asian Americans, yet little is known about their use of hospice care. We examined hospice use by Asian patients compared with white patients, and assessed whether utilization differs among those born in the United States or abroad. METHODS We studied Asian and white Medicare beneficiaries registered in the Surveillance, Epidemiology, and End Results (SEER) Program who died of primary lung, colorectal, prostate, breast, gastric, or liver cancer between 1988 and 1998. We used logistic regression to determine the effects of race/ethnicity and birthplace on hospice use, adjusting for demographic characteristics, managed care insurance, year of diagnosis, tumor stage at diagnosis, and tumor registry. RESULTS Of the 184,081 patients, 5% (n = 8614) were Asian Americans, of whom 45% (n = 3847) were foreign born. Compared with whites, Asian Americans were more likely to be male, married, and enrolled in managed care. Compared with U.S.-born Asian Americans, foreign-born Asian Americans were more likely to reside in low-income areas. After adjustment, patients who were Asian American (odds ratio [OR] = 0.67; 95% confidence interval [CI]: 0.62 to 0.73) and born abroad (OR = 0.90; 95% CI: 0.86 to 0.94) were less likely to use hospice care than were white patients. These results were consistent across the six cancer diagnoses that were examined. CONCLUSION Older Asian Americans dying of cancer, especially those who are born abroad, are less likely than white patients to use hospice care at the end of life. Additional research is needed to understand the reasons for these differences and to eliminate potential barriers to hospice care.
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McCarthy EP, Burns RB, Ngo-Metzger Q, Davis RB, Phillips RS. Hospice use among Medicare managed care and fee-for-service patients dying with cancer. JAMA 2003; 289:2238-45. [PMID: 12734135 DOI: 10.1001/jama.289.17.2238] [Citation(s) in RCA: 108] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT For most patients aged 65 years or older with cancer, hospice services are uniformly covered by Medicare. Hospice care is believed to improve care for patients at the end of life. However, few patients use hospice and others enroll too late to maximize the benefits of hospice services. OBJECTIVES Because type of insurance may affect use, we examined whether patients with Medicare managed care insurance enrolled in hospice earlier and had longer hospice stays than patients with Medicare fee-for-service (FFS) insurance. DESIGN AND SETTING Retrospective analysis of the last year of life using the Linked Medicare-Tumor Registry Database in 1 of 9 Surveillance, Epidemiology, and End Results program coverage areas. PATIENTS A total of 260 090 Medicare beneficiaries aged 66 years or older diagnosed with first primary lung (n = 62 117), colorectal (n = 57 260), prostate (n = 59 826), female breast (n = 37 609), bladder (n = 19 598), pancreatic (n = 11 378), gastric (n = 9599), or liver (n = 2703) cancer between January 1, 1973, and December 31, 1996, and who died between January 1, 1988, and December 31, 1998. MAIN OUTCOME MEASURES Time from diagnosis to hospice entry and hospice length of stay for patients enrolled in FFS vs managed care plans after adjusting for patient demographics, tumor registry, year of hospice entry, and type and cancer stage. RESULTS Of the 260 090 patients, most were men (59%), white (85%), and enrolled in FFS (89.7%). Only 54 937 patients (21.1%) received hospice care before death. Hospice use varied by type of primary cancer ranging from 31.8% of patients with pancreatic cancer to 15.6% with bladder cancer. Managed care patients were more likely to use hospice than FFS patients (32.4% vs 19.8%, P<.001). Among hospice patients, median (interquartile range) length of stay was longer for managed care vs FFS patients (32 days [11-82] vs 25 days [9-66], P<.001). After adjustment, managed care patients had higher rates of hospice enrollment (adjusted hazard ratio [HR], 1.38; 95% CI, 1.35-1.42) and had a longer length of stay (adjusted HR, 0.91; 95% CI, 0.88-0.94) vs FFS patients. Managed care patients were less likely to enroll in hospice within 7 days of their death (18.6% vs 22.6%, P<.001) and somewhat more likely to enroll in hospice more than 180 days before death (7.8% vs 6.1%, P<.001); the results for each of the 8 cancer diagnoses were similar. Hospice enrollment and length of stay among managed care vs FFS patients differed significantly by region. CONCLUSION Medicare beneficiaries enrolled in managed care had consistently higher rates of hospice use and significantly longer hospice stays than those enrolled in FFS. Although these differences may reflect patient and family preferences, our findings raise the possibility that some managed care plans are more successful at facilitating or encouraging hospice use for patients dying with cancer.
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Burns RB, Hartman EE. A 44-year-old woman with borderline personality disorder, 1 year later. JAMA 2003; 289:1026. [PMID: 12597756 DOI: 10.1001/jama.289.8.1026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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McCarthy EP, Burns RB, Davis RB, Phillips RS. Barriers to hospice care among older patients dying with lung and colorectal cancer. J Clin Oncol 2003; 21:728-35. [PMID: 12586813 DOI: 10.1200/jco.2003.06.142] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To identify factors associated with hospice enrollment and length of stay in hospice among patients dying with lung or colorectal cancer. METHODS We used the Linked Medicare-Tumor Registry Database to conduct a retrospective analysis of the last year of life among Medicare beneficiaries diagnosed with lung or colorectal cancer at age > or = 66 years between January 1, 1973, and December 31, 1996, in the Surveillance, Epidemiology, and End Results Program who died between January 1, 1988, and December 31, 1998. Our outcomes of interest were time from cancer diagnosis to hospice enrollment and length of stay in hospice care. We used Cox proportional hazards regression to adjust for demographic and clinical information. RESULTS We studied elderly patients dying with lung cancer (n = 62,117) or colorectal cancer (n = 57,260). Overall, 27% of patients (n = 16,750) with lung cancer and 20% of patients (n = 11,332) with colorectal cancer received hospice care before death. Median length of stay for hospice patients with lung and colorectal cancer was 25 and 28 days, respectively. Overall, 20% of patients entered hospice within 1 week of death, whereas 6% entered more than 6 months before death. Factors associated with later hospice enrollment include being male; being of nonwhite, nonblack race; having fee-for-service insurance; and residing in a rural community. Many of these factors also were associated with shorter stays in hospice. CONCLUSION Although use of hospice care has increased dramatically over time, specific patient groups, including men, patients residing in rural communities, and patients with fee-for-service insurance continue to experience delays in hospice enrollment.
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Burns RB, Hartman EE. A 47-year-old woman with tension-type headaches, 1 year later. JAMA 2002; 288:1011. [PMID: 12190372 DOI: 10.1001/jama.288.8.1011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Burns RB, Hartman EE. A 28-year-old woman with panic disorder, 1 year later. JAMA 2002; 288:494. [PMID: 12132981 DOI: 10.1001/jama.288.4.494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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McCarthy EP, Burns RB, Freund KM, Ash AS, Shwartz M, Marwill SL, Moskowitz MA. Mammography use, breast cancer stage at diagnosis, and survival among older women. J Am Geriatr Soc 2000; 48:1226-33. [PMID: 11037009 DOI: 10.1111/j.1532-5415.2000.tb02595.x] [Citation(s) in RCA: 141] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Women age 65 years and older account for most newly diagnosed breast cancers and deaths from breast cancer. Yet, older women are least likely to undergo mammography, perhaps because mammography's value is less well demonstrated in older women. OBJECTIVE To investigate the relationship between prior mammography use, cancer stage at diagnosis, and breast cancer mortality among older women with breast cancer. DESIGN Retrospective cohort study using the Linked Medicare-Tumor Registry Database. SETTING Population-based data from three geographic areas included in the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program. PARTICIPANTS Women aged 67 and older diagnosed with a first primary breast cancer, from 1987 to 1993, residing in Connecticut, metropolitan Atlanta, Georgia, or Seattle-Puget Sound, Washington. MEASUREMENTS Medicare claims were reviewed and women were classified according to their mammography use during the 2 years before diagnosis: nonusers (no prior mammograms), regular users (at least two mammograms at least 10 months apart), or peri-diagnosis users (only mammogram(s) within 3 months before diagnosis). Mammography utilization was linked with SEER data to determine stage at diagnosis and cause of death. Our main outcome variables were (1) stage at diagnosis, classified as early (in situ/Stage I) or late (Stage II or greater), and (2) breast cancer mortality, measured from diagnosis until death from breast cancer or end of the follow-up period (December 31, 1994). RESULTS Older women who were nonusers of mammography were diagnosed with breast cancer at Stage II or greater more often than regular users (adjusted odds ratio (OR), 3.12; 95% confidence interval (CI), 2.74-3.58). This association was present within each age group studied. Nonusers of mammography were at significantly greater risk of dying from their breast cancer than regular users for all women (adjusted hazard ratio (HR), 3.38; 95% CI, 2.65-4.32) and for women within each age group. Even assuming a lead time of 1.25 years, nonusers of mammography continued to be at increased risk of dying from breast cancer. Our findings remained significant for all women and for the two youngest age groups (67-74 years, 75-85 years), although the benefit was no longer statistically significant for the oldest women (85 years and older). CONCLUSIONS Older women who undergo regular mammography are diagnosed with an earlier stage of disease and are less likely to die from their disease. These data support the use of regular mammography in older women and suggest that mammography can reduce breast cancer mortality in older women, even for women age 85 and older.
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Burns RB, Embree L. Validation of high-performance liquid chromatographic assay methods for the analysis of carboplatin in plasma ultrafiltrate. JOURNAL OF CHROMATOGRAPHY. B, BIOMEDICAL SCIENCES AND APPLICATIONS 2000; 744:367-76. [PMID: 10993526 DOI: 10.1016/s0378-4347(00)00262-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Validation of two HPLC assays for the quantitation of carboplatin in human plasma ultrafiltrate is described. Both assay methods employed a YMC ODS-AQ 3.9 x 150 mm (3 microm) column for the chromatographic separation. The first method utilized direct UV detection, the second method utilized UV detection following post-column derivatization with sodium bisulfite. Structural analogues of carboplatin were synthesized and used as internal standards for the assays. With direct UV detection, sample clean-up using solid-phase extraction on amino cartridges was required prior to injection, with extraction recoveries ranging from 80 to 90%. This extraction procedure was not necessary with the post-column reaction method, which employed a more selective analytical wavelength. Unfortunately, instability of the post-column reagent was a problem and led to greater variability in predicted concentration values. For standard curves, a weighted (1/y2) regression approach was used for plots of peak area or peak height ratio (carboplatin/internal standard) vs. carboplatin concentration. The limit of detection of both assays was 0.025 microg/ml and both were validated for carboplatin concentrations from 0.05 to 40 microg/ml. Accuracy and precision data were generated using three batches of validation samples, each batch consisting of a standard curve and five sets of quality control samples. Stability of carboplatin in blood, plasma, plasma ultrafiltrate, and reconstituted extracts was evaluated. The assay methods were employed for the pharmacokinetic analysis of blood samples drawn from a pediatric patient that received a 400 mg/m2 dose of carboplatin.
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Krupat E, Irish JT, Kasten LE, Freund KM, Burns RB, Moskowitz MA, McKinlay JB. Patient assertiveness and physician decision-making among older breast cancer patients. Soc Sci Med 1999; 49:449-57. [PMID: 10414805 DOI: 10.1016/s0277-9536(99)00106-9] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The objective of this study was to determine whether assertive patient behavior influences physician decision-making in the treatment of older breast cancer patients. One hundred and twenty-eight physicians saw videotapes depicting women seeking care for breast cancer and then recommended evaluation and treatment plans. Identical scripts were used, but the age, race, socioeconomic status, mobility, general health, and assertive behavior of the patients were experimentally varied along with the physician's specialty and length of practice. No direct effects of assertive patient behavior were seen. However, black, comorbid, and lower SES women were more likely to have full staging of their tumors ordered when they made an assertive request. Treatment recommendations also showed an interaction of assertiveness with patient's age and social class as well as physicians' specialty. The results indicate that a moderately assertive patient request may change provider behavior, although the effects of assertiveness vary most by what type of patient demonstrates this behavior. In particular, assertiveness led to more careful diagnostic testing for patients who came from groups that are "disadvantaged."
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Burns RB, Crislip D, Daviou P, Temkin A, Vesmarovich S, Anshutz J, Furbish C, Jones ML. Using telerehabilitation to support assistive technology. Assist Technol 1999; 10:126-33. [PMID: 10339280 DOI: 10.1080/10400435.1998.10131970] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Telerehabilitation--the use of telecommunications technology to provide rehabilitation and long-term support to people with disabilities--offers exciting possibilities for the delivery and support of assistive technology services. This article describes the experiences of a specialty hospital serving persons with disabilities in exploring telerehabilitation to support assistive technology use in the home. Four case studies are presented to illustrate how telerehabilitation may be used in relation to seating evaluation, evaluation of home accessibility, setup of computer access systems, and training in use of augmentative communication devices.
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Burns RB, Moskowitz MA, Ash A, Kane RL, Finch M, McCarthy EP. Do hip replacements improve outcomes for hip fracture patients? Med Care 1999; 37:285-94. [PMID: 10098572 DOI: 10.1097/00005650-199903000-00008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hip fracture is a common problem among older Americans. Two types of procedures are available for repairing hip fractures: hip replacement and open or closed reduction with or without internal fixation. The assumption has been that hip replacement produces better functional outcomes. Although that is the common wisdom, outcome studies evaluating hip replacement for treatment of hip fracture are few and have not clearly documented its superiority. OBJECTIVES To compare outcomes of hip fracture patients who receive hip replacement versus another stabilizing procedure (open or closed reduction with or without internal fixation). DESIGN Prospective cohort study. PARTICIPANTS We studied 332 patients (age, > 65) who were hospitalized for a femoral neck fracture and discharged alive. MEASUREMENTS We examined 2 treatment groups, hip replacement versus another procedure, on 6 outcomes [Activities of Daily Living (ADLs), walking, living situation (institutionalized or not), perceived health (excellent/good vs. fair/poor), rehospitalization, and mortality] at 3 postdischarge times (6 weeks, 6 months and 1 year). RESULTS Mean age was 80, 80% were female, 96% White, 28% married, and 71% had a hip replacement. The treatment groups were similar at baseline (3 months before admission as reported at discharge) on ADLs, walking, living situation, and perceived health (all P > 0.24). After adjusting for demographics, clinical characteristics, fracture characteristics, and prior ADLs, walking ability, living situation, and perceived health, patients with a hip replacement did not do better at 6 weeks, 6 months, or 1 year post-discharge on any of the 6 outcome measures (all 18 P > 0.10). A global test of all 6 outcomes finds hip replacement patients doing less well at one year (P = 0.02). CONCLUSIONS Despite the commonly held belief that hip replacement is a superior treatment for hip fracture, we found no suggestion of better outcomes for hip replacement on any of 6 key outcomes.
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Lanford RE, Chavez D, Brasky KM, Burns RB, Rico-Hesse R. Isolation of a hepadnavirus from the woolly monkey, a New World primate. Proc Natl Acad Sci U S A 1998; 95:5757-61. [PMID: 9576957 PMCID: PMC20452 DOI: 10.1073/pnas.95.10.5757] [Citation(s) in RCA: 155] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Hepatitis B virus (HBV) infections are a major worldwide health problem with chronic infections leading to cirrhosis and liver cancer. Viruses related to human HBV have been isolated from birds and rodents, but despite efforts to find hepadnaviruses that infect species intermediate in evolution between rodents and humans, none have been described. We recently isolated a hepadnavirus from a woolly monkey (Lagothrix lagotricha) that was suffering from fulminant hepatitis. Phylogenetic analysis of the nucleotide sequences of the core and surface genes indicated that the virus was distinct from the human HBV family, and because it is basal (ancestral) to the human monophyletic group, it probably represents a progenitor of the human viruses. This virus was designated woolly monkey hepatitis B virus (WMHBV). Analysis of woolly monkey colonies at five zoos indicated that WMHBV infections occurred in most of the animals at the Louisville zoo but not at four other zoos in the United States. The host range of WMHBV was examined by inoculation of one chimpanzee and two black-handed spider monkeys (Ateles geoffroyi), the closest nonendangered relative of the woolly monkey. The data suggest that spider monkeys are susceptible to infection with WMHBV and that minimal replication was observed in a chimpanzee. Thus, we have isolated a hepadnavirus with a host intermediate between humans and rodents and establishes a new animal model for evaluation of antiviral therapies for treating HBV chronic infections.
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