Use of tanning devices and risk of basal cell and squamous cell skin cancers

Use of artificial tanning devices that emit UV radiation, such as tanning lamps and tanning beds, has become increasingly popular in the United States. Although an excess risk of nonmelanoma skin cancers might be predicted from this exposure, little epidemiologic data exist. We conducted a population-based, case-control study that included 603 basal cell carcinoma (BCC) case patients, 293 squamous cell carcinoma (SCC) case patients, and 540 control subjects. Study participants were interviewed in person to obtain information on tanning device use, sun exposure history, sun sensitivity, and other risk factors for skin cancer. Overall, any use of tanning devices was associated with odds ratios of 2.5 (95% confidence interval [CI] = 1.7 to 3.8) for SCC and 1.5 (95% CI = 1.1 to 2.1) for BCC. Adjustment for history of sunburns, sunbathing, and sun exposure did not affect our results. Our findings suggest that the use of tanning devices may contribute to the incidence of nonmelanoma skin cancers. They highlight the need to further evaluate the potential risks of BCC and SCC that are associated with tanning lamp exposure and the appropriate public health response.

An epidemic of inhalation anthrax, the first in the twentieth century: I. Clinical features. 1960

Acute respiratory tract infections are the most common illnesses in all individuals, regardless of age or gender. Epidemiologic surveys and community-based studies conducted since the beginning of the 20th century have determined the rates of illness and the pathogens involved in such infections. These studies have shown that rhinoviruses cause the great majority of these respiratory illnesses, and their findings have examined the means of transmission of respiratory illness. More recently, advances in diagnostic techniques have enabled more complete identification of the viruses involved in respiratory infections, which has aided in the ability to direct specific therapeutic agents at the causative pathogens.

Relation between parental restrictions on movies and adolescent use of tobacco and alcohol

CONTEXT

Viewing smoking and drinking in movies may prompt adolescents to initiate these behaviors. Movies with R ratings contain more smoking than do movies in all other rating categories.

OBJECTIVE

To evaluate the extent to which parents restrict the exposure of adolescents to R-rated movies and to determine whether such restrictions are associated with decreased tobacco and alcohol use in adolescents.

DESIGN

Cross-sectional, self-administered survey.

PARTICIPANTS

Students in grades 5 through 8 enrolled in New Hampshire and Vermont schools. SAMPLING STRATEGY: Fifteen schools in Vermont and New Hampshire were randomly selected from all middle schools with > or = 150 students.

OUTCOME MEASURES

Students who had tried smoking cigarettes or tried drinking alcohol without parental knowledge.

RESULTS

Of 4544 students surveyed, 18% had tried cigarettes and 23% had tried alcohol. Although 90% were younger than 14 years of age, only 16% were completely restricted from viewing R-rated movies. The prevalence of having tried smoking was 35% for those with no restrictions on viewing R-rated movies, 12% for those with partial restrictions, and 2% for those with complete restrictions. The prevalence of having tried alcohol was 46% for those with no restrictions on viewing R-rated movies, 16% for those with partial restrictions, and 4% for those with complete restrictions. Even after controlling for other factors, including grade, parental disapproval of smoking, maternal supervision, maternal responsiveness, peer and family smoking, and child personality characteristics, children who were completely restricted from viewing R-rated movies were significantly less likely to smoke (relative risk, 0.29; 95% CI, 0.19 to 0.45) or drink (relative risk, 0.30; CI, 0.21 to 0.42) compared with those who had no restrictions on viewing R-rated movies.

CONCLUSION

Limiting the exposure of adolescents to R-rated movies may prevent early use of alcohol and tobacco.

Effect of seeing tobacco use in films on trying smoking among adolescents: cross sectional study

OBJECTIVE

To test the hypothesis that greater exposure to smoking in films is associated with trying smoking among adolescents.

DESIGN

Cross sectional survey of 4919 schoolchildren aged 9-15 years, and assessment of occurrence of smoking in 601 films.

SETTING

Randomly selected middle schools in Vermont and New Hampshire, USA.

MAIN OUTCOME MEASURE

Number of schoolchildren who had ever tried smoking a cigarette.

RESULTS

The films contained a median of 5 (interquartile range 1-12) occurrences of smoking. The typical adolescent had seen 17 of 50 films listed. Exposure to smoking in films varied widely: median 91 (49-152) occurrences. The prevalence of ever trying smoking increased with higher categories of exposure: 4.9% among students who saw 0-50 occurrences of smoking, 13.7% for 51-100 occurrences, 22.1% for 101-150, and 31.3% for >150. The association remained significant after adjustment for age; sex; school performance; school; parents' education; smoking by friend, sibling, or parent; and receptivity to tobacco promotions. The adjusted odds ratios of ever trying smoking for students in the higher categories of exposure, compared with students exposed to 0-50 occurrences of smoking in films, were 1.7 (95% confidence interval 1.2 to 2.4), 2.4 (1.7 to 3.4), and 2.7 (2.0 to 3.8). These odds ratios were not substantially affected by adjustment for parenting style or for personality traits of the adolescent.

CONCLUSION

In this sample of adolescents there was a strong, direct, and independent association between seeing tobacco use in films and trying cigarettes, a finding that supports the hypothesis that smoking in films has a role in the initiation of smoking in adolescents.

Roadway safety in rural and small urbanized areas

Police Accident Reports (PAR) reveal that in a 5-year period between 1993 and 1997, there were 892 crashes at 87 two lane, undivided roadway sites in Strafford County, NH, a county consisting of suburban and rural communities. The purpose of this paper is to describe: (1) logistic regression model building efforts to identify statistically significant factors that predict the probabilities of crashes and injury crashes; and (2) to use these models to perform a risk assessment of the study region. The models are functions of factors that describe a site by its land use activity, roadside design, use of traffic control devices and traffic exposure. Comparative risk assessment results show village sites to be less hazardous than residential and shopping sites. Residential and shopping sites, which are distinctly different from village sites, reside in single-purpose, land-use zones consisting mostly of single-family dwelling units and roadside shopping units with ample off-street parking. Village sites reside in multi-purpose, land-use zones permitting a combination of activities found in residential, shopping and commercial areas. They are pedestrian friendly, that is, have sidewalks and crosswalks, permit onstreet parking, have speed limits and other amenities that promote walking. Adjusted odds ratios and other comparative risk measures are used to explain why one site is more hazardous than another one. For example, the probability of a crash is two times more likely at a site without a sidewalk than at a site with one. The implications on roadway design to improve safety are discussed.

Fatal pediatric lead poisoning--New Hamphshire, 2000

Fatal pediatric lead poisoning is rare in the United States because of multiple public health measures that have reduced blood lead levels (BLLs) in the population. However, the risk for elevated BLLs among children remains high in some neighborhoods and populations, including children living in older housing with deteriorated leaded paint. This report describes the investigation of the first reported death of a child from lead poisoning since 1990 (1). The investigation implicated leaded paint and dust in a home environment as the most likely source of the poisoning. Lead poisoning can be prevented by correcting lead hazards, especially in older housing, and by screening children at risk according to established guidelines (2).

Utilization of essential medications by vulnerable older people after a drug benefit cap: importance of mental disorders, chronic pain, and practice setting

OBJECTIVE

To identify specific characteristics of patients, physicians, and treatment settings associated with decreased receipt of essential medications in a chronically ill, older population following a Medicaid three-prescription monthly reimbursement limit (cap).

DESIGN

Quasi-experiment with bivariate and multivariate regression.

SETTING

Patients in the New Hampshire Medicaid program and their regular prescribing physicians.

PARTICIPANTS

Three hundred and forty-three chronically ill Medicaid enrollees with regular use of essential medications for heart disease, asthma/chronic obstructive pulmonary disease, diabetes mellitus, seizure, or coagulation disorders who received an average of three or more prescriptions per month during the baseline year.

MEASUREMENTS

Postcap patient-level change in standard monthly dose of essential medications compared with the baseline period, presence of 11 comorbidities (defined by regular use of specific indicator drugs), practice setting, and location of regular prescribing physician.

RESULTS

The mean percentage change in standard doses of essential medications following the cap was -34.4%. Larger changes were significantly associated with several baseline measures: greater numbers of precap medications, greater numbers of comorbidities, longer hospitalizations, and greater use of ambulatory services. The three comorbidities associated with the largest relative reduction in essential drug use were psychoses/bipolar disorders, anxiety/sleep problems, and chronic pain. Patients of physicians in group practices, clinics, or hospitals tended to have smaller dose reductions than those whose physicians were in solo or small-group practice.

CONCLUSIONS

Patients most at risk of reduced access to essential medications because of a reimbursement cap include those with multiple chronic illnesses requiring drug therapy, especially illnesses with a mental health component. Physicians in clinics or large group practices may have maintained patient medication regimens more effectively.

Incidence of bilateral proximal femoral fractures in a tertiary care center

Over a 7-year period, a total of 545 osteoporotic fractures involving the proximal femur were treated at our institution. Twenty-nine patients sustained fractures of both hips, representing an overall incidence of bilateral hip fractures of approximately 5.5%. Of the 29 patients with bilateral hip fractures, adequate records and radiographs were avaialable for 28. There was a significant similarity between fracture patterns in the majority of bilateral hip fracture patients: 18 (64%) patients demonstrated similar fracture patterns on both sides. In these 18 patients, the average interval between fractures was approximately 1.7 years; in the remaining 10 patients, in whom the fractures were of dissimilar nature, the average interval between fractures was approximately 3.5 years. These findings suggest that at least 1 in 20 patients who sustain a fracture about the hip can expect to suffer a fracture involving the contralateral side. Moreover, the difference in the average interval for fractures of similar nature compared to fractures of dissimilar nature suggests the effects of physiologic age and the accordant changes in bone architecture play a larger role in predicting subsequent fracture pattern.

Atypical piscine mycobacteriosis in Japanese medaka (Oryzias latipes)

Japanese medaka, (Oryzias latipes), small, freshwater, tropical cyprinodonts, are principally used for toxicologic and carcinogenicity assays, but are finding more applications in developmental genetic and biological research. An increase in mortality began in brood stock of adult medaka that had been shipped and housed separately by sex. Initially, mortality averaged one fish daily and began in females two weeks after they were received. Cohabitation began eight weeks after arrival. After four to six weeks of cohabitation in different spawning aquaria, mortality was observed in males. Clinical signs of disease included loss of scale luster and color, with subsequent blanching of dorsal flank musculature, small raised nodules on various external surfaces, emaciation, fraying of fin tips, and equilibrium disturbances. Histologic examination of affected adults revealed multi-organ granulomatous inflammation with intracellular acid-fast bacilli. Specimens from 46 juvenile medaka that were spawned from affected adults, were submitted for culture and histologic evaluation. Of 18 fish, two had lesions similar to those of adults. The organism isolated from the remaining fish was identified as Mycobacterium fortuitum. Due to atypical rapid progression of disease, spread of M. fortuitum to progeny, and poor prognosis, the entire colony was euthanized.

The relationship between trauma, PTSD, and medical utilization in three high risk medical populations

OBJECTIVE

Increased use of medical and psychiatric services has been reported as a correlate of exposure to trauma. Recent studies suggest that: 1) physical and sexual abuse traumas are particularly associated with increased utilization and 2) posttraumatic stress disorder (PTSD), a common sequela of abuse, mediates the relationship between trauma exposure andelevated utilization. The goal of this study was to explore the relationships between trauma, abuse, PTSD, and medical utilization in three medical help seeking groups reported to be at high risk for trauma exposure.

METHOD

One hundred and seven patients receiving care at a university-affiliated medical center were surveyed for trauma history and PTSD using the Trauma History Questionnaire (THQ) and the PTSD Checklist (PCL). The sample included: forty-eight gynecologic outpatients, thirty-five inpatients with seizure disorders, and twenty-four psychiatric inpatients with non-PTSD admitting diagnoses. Medical utilization data were obtained from a computerized medical center data base.

RESULTS

Ninety-six patients reported a trauma history. Of these patients, sixty-six reported abuse and forty-five qualified for PTSD diagnoses. Total number of traumas and reported sexual and physical abuse correlated significantly with elevated medical utilization and PTSD prevalence. PTSD diagnosis was not significantly correlated with utilization, but the five highest utilizers received PTSD diagnoses.

CONCLUSIONS

Study results supported hypotheses regarding the relation of trauma exposure to medical utilization, but were less clear about the mediating role of PTSD. These findings suggest that routine screening of high-risk patient groups might promote timely identification of trauma history and PTSD, and subsequently impact health care utilization.

Skin cancer risk in relation to toenail arsenic concentrations in a US population-based case-control study

Arsenic is a known carcinogen specifically linked to skin cancer occurrence in regions with highly contaminated drinking water or in individuals who took arsenic-containing medicines. Presently, it is unknown whether such effects occur at environmental levels found in the United States. To address this question, the authors used data collected on 587 basal cell and 284 squamous cell skin cancer cases and 524 controls interviewed as part of a case-control study conducted in New Hampshire between 1993 and 1996. Arsenic was determined in toenail clippings using instrumental neutron activation analysis. The odds ratios for squamous cell carcinoma (SCC) and basal cell carcinoma (BCC) were close to unity in all but the highest category. Among individuals with toenail arsenic concentrations above the 97th percentile, the adjusted odds ratios were 2.07 (95% confidence interval (CI): 0.92, 4.66) for SCC and 1.44 (95% CI: 0.74, 2.81) for BCC, compared with those with concentrations at or below the median. While the risks of SCC and BCC did not appear elevated at the toenail arsenic concentrations detected in most study subjects, the authors cannot exclude the possibility of a dose-related increase at the highest levels of exposure experienced in the New Hampshire population.

Favourite movie stars, their tobacco use in contemporary movies, and its association with adolescent smoking

OBJECTIVE

To assess the relation between adolescents' favourite movie stars, the portrayal of tobacco use by those stars in contemporary motion pictures, and adolescent smoking.

DESIGN AND SETTING

632 students (sixth to 12th grade, ages 10-19 years) from five rural New England public schools completed a voluntary, self administered survey in October 1996. The survey assessed tobacco use, other variables associated with adolescent smoking, and favourite movie star. In addition, tobacco use by 43 selected movie stars was measured in films between 1994 and 1996.

OUTCOME MEASURES

Students were categorised into an ordinal five point index (tobacco status) based on their smoking behaviour and their smoking susceptibility: non-susceptible never smokers, susceptible never smokers, non-current experimenters, current experimenters, and smokers. We determined the adjusted cumulative odds of having advanced smoking status based on the amount of on-screen tobacco use by their favourite film star.

RESULTS

Of the 43 stars, 65% used tobacco at least once, and 42% portrayed smoking as an essential character trait in one or more films. Stars who smoked more than twice in a film were considered smokers. For adolescents whose favourite stars smoked in only one film, the odds of being higher on the smoking index was 0.78 (95% confidence interval (CI) 0.53 to 1.15). For adolescents whose favourite stars smoked in two films, the odds of being higher on the smoking index was 1.5 (95% CI 1.01 to 2.32). For adolescents whose favourite stars smoked in three or more films (Leonardo DiCaprio, Sharon Stone, John Travolta), the odds of being higher on the smoking index was 3.1 (95% CI 1.34 to 7.12). Among never smokers (n = 281), those who chose stars who were smokers in three or more films were much more likely to have favourable attitudes toward smoking (adjusted odds ratio 16.2, 95% CI 2.3 to 112).

CONCLUSIONS

Adolescents who choose movie stars who use tobacco on-screen are significantly more likely to have an advanced smoking status and more favourable attitudes toward smoking than adolescents who choose non-smoking stars. This finding supports the proposition that the portrayal of tobacco use in contemporary motion pictures, particularly by stars who are admired by adolescents, contributes to adolescent smoking.

Survival of patients transferred to tertiary intensive care from rural community hospitals

BACKGROUND

Accessibility to tertiary intensive care resources differs among hospitals within a rural region. Determining whether accessibility is associated with outcome is important for understanding the role of regionalization when providing critical care to a rural population.

METHODS

In a prospective design, we identified and recorded the mortality ratio, percentage of unanticipated deaths, length of stay in the intensive care unit (ICU), and survival time of 147 patients transferred directly from other hospitals and 178 transferred from the wards within a rural tertiary-care hospital.

RESULTS

The two groups did not differ significantly in the characteristics measured. Differences in access to tertiary critical care in this rural region did not affect survival or length of stay after admission to this tertiary ICU. The odds ratio (1.14; 95% confidence interval 0.72-1.83) for mortality associated with transfer from a rural community hospital was not statistically significant.

CONCLUSIONS

Patients at community hospitals in this area who develop need for tertiary critical care are just as likely to survive as patients who develop ICU needs on the wards of this rural tertiary-care hospital, despite different accessibility to tertiary intensive-care services.

Population based study of coffee, alcohol and tobacco use and risk of ovarian cancer

Coffee, alcohol and tobacco use have been examined in many epidemiologic studies of ovarian cancer but findings have generally been inconclusive. To explain prior inconsistent findings, we sought to determine whether associations with these exposures might vary by histologic subtype of ovarian cancer or menopausal status at diagnosis. We conducted a population-based case-control study in eastern Massachusetts and New Hampshire involving 549 women with newly-diagnosed epithelial ovarian cancer and 516 control women selected either by random digit dialing or through lists of residents. Coffee and alcohol consumption was assessed through a semi-quantitative food-frequency questionnaire, and information on tobacco smoking was collected through personal interview. Consumption of coffee and caffeine was associated with increased risk for ovarian cancer but only among premenopausal women. There was no increase in risk for ovarian cancer overall associated with tobacco or alcohol use in either pre- or post-menopausal women. Association of borderline significance for tobacco and invasive serous cancers and alcohol and mucinous cancers were observed but reduced after adjustment for coffee consumption. We conclude that coffee and caffeine consumption may increase risk for ovarian cancer among premenopausal women and are findings that have some epidemiologic and biologic support.

Therapeutic ionizing radiation and the incidence of basal cell carcinoma and squamous cell carcinoma. The New Hampshire Skin Cancer Study Group

OBJECTIVE

To estimate the relative risk of developing basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) after receiving therapeutic ionizing radiation.

DESIGN

Population-based case-control study.

SETTING

New Hampshire.

PATIENTS

A total of 592 cases of BCC and 289 cases of SCC identified through a statewide surveillance system and 536 age- and sex-matched controls selected from population lists.

MAIN OUTCOME MEASURES

Histologically confirmed BCC and invasive SCC diagnosed between July 1, 1993, through June 30, 1995, among New Hampshire residents.

RESULTS

Information regarding radiotherapy and other factors was obtained through personal interviews. An attempt was made to review the radiation treatment records of subjects who reported a history of radiotherapy. Overall, an increased risk of both BCC and SCC was found in relation to therapeutic ionizing radiation. Elevated risks were confined to the site of radiation exposure (BCC odds ratio, 3. 30; 95% confidence interval, 1.60-6.81; SCC odds ratio, 2.94; 95% confidence interval, 1.30-6.67) and were most pronounced for those irradiated for acne exposure. For SCC, an association with radiotherapy was observed only among those whose skin was likely to sunburn with sun exposure.

CONCLUSIONS

These results largely agree with those of previous studies on the risk of BCC in relation to ionizing radiation exposure. In addition, they suggest that the risk of SCC may be increased by radiotherapy, especially in individuals prone to sunburn with sun exposure. Arch Dermatol. 2000;136:1007-1011

Perineal group A streptococcal disease in a pediatric practice

OBJECTIVE

This study was designed to document the frequency and define the clinical, epidemiologic, and microbiologic characteristics of perineal disease caused by group A beta-hemolytic streptococci (GAS) in a pediatric practice in which increased numbers of cases had been observed.

METHODS

Clinical, epidemiologic, and microbiologic data were collected on all culture-confirmed cases of perineal GAS disease during the calendar year 1997. GAS isolates from clinical cases and a comparison group of children with GAS pharyngitis were analyzed by T typing, emm gene analysis, and pulsed-field gel electrophoresis (PFGE).

RESULTS

Twenty-three cases of GAS perineal disease were diagnosed during 4530 office visits in 1997. Thirteen cases had perianal disease, 8 had vulvovaginal infection, and 2 were infected at both sites. No cases of penile disease were identified. Infections peaked in late winter and early spring and affected children with an average age of 5 years with a range of perineal, gastrointestinal, and genitourinary symptoms. Analysis of T and emm types showed the majority (82%) of perineal isolates to be T 28 emm 28, showing 2 closely related PFGE patterns. In contrast, the pharyngeal isolates were distributed among 6 different T and emm types.

CONCLUSION

Perineal infection caused by GAS may be a relatively common diagnosis in a pediatric or family practice setting. There may be specific GAS types that have a tropism for perineal tissues but the mechanism of infection is yet to be established.

Mental health service use by elderly patients with bipolar disorder and unipolar major depression

Symptoms, functioning, and mental health service use were compared in older out-patients with bipolar disorder and unipolar depression. Bipolar outpatients (n = 37, mean age = 69.7) had higher total symptom severity and positive symptom scores, more impaired community-living skills, and earlier age at onset of illness than patients with unipolar depression (n = 85, mean age = 70.9). Bipolar elderly patients used almost four times the total amount of mental health services and were four times more likely to have had a psychiatric hospitalization over the previous 6 months. These findings underscore the need for effective services for elderly patients with bipolar disorder, who account for a minority of patients with affective disorders, but use a disproportionate amount of costly services.

Weight change and risk of postmenopausal breast cancer (United States)

OBJECTIVE

Although many studies have shown that higher weight increases the risk of postmenopausal breast cancer, some aspects of this association are unclear. In order to examine the risk associated with different patterns of weight change, we analyzed data from a large case-control study of postmenopausal breast cancer.

METHODS

Participants included women aged 50 79 years (n = 5031) who are newly diagnosed with invasive breast cancer in Massachusetts, New Hampshire, and Wisconsin. Similarly-aged population controls (n = 5255) were selected at random from driver's license files and Medicare beneficiary lists. Height, weight, and information on other breast cancer risk factors were ascertained by structured telephone interviews from 1992 to 1995, and logistic regression was used to estimate multivariable-adjusted odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Women in the top quintile groups for height at age 20, recent weight, and recent body mass index had significantly increased risks of breast cancer. Among women who reached their highest adult weight at younger ages (<45 years), increasing weight loss since that age was associated with a reduced risk of postmenopausal breast cancer (OR 0.90, CI 0.84 0.98, per 5 kg). However, weight loss among women whose highest weight occurred after age 45 was not associated with risk (OR 1.00, CI 0.95 1.05, per 5 kg). Weight gain since the lowest adult weight increased risk by 8% for each 5 kg of gain (OR 1.08, CI 1.06-1. 11). Temporary weight cycling (weight loss followed by weight gain) was not associated with increased risk.

CONCLUSIONS

Weight gain clearly increased risk of postmenopausal breast cancer. These data lend further support to efforts aimed at helping women avoid weight gain as they age.

Suspected brucellosis case prompts investigation of possible bioterrorism-related activity--New Hampshire and Massachusetts, 1999

Brucella species, particularly B. melitensis and B. suis, are potential agents of biological terrorism (1,2). This report describes the public health and law enforcement assessment of a suspected case of brucellosis in a woman, in which the atypical clinical presentation and suspicious circumstances surrounding the case raised the possibility of biological terrorism. Although the investigation did not identify evidence of biological terrorism, the safe resolution of the case illustrates the value of integrated clinical, public health, and law enforcement biological terrorism preparedness and response.

Helping women quit smoking: results of a community intervention program

OBJECTIVES

This intervention was implemented to reduce the prevalence of cigarette smoking among women.

METHODS

We used community organization approaches to create coalitions and task forces to develop and implement a multicomponent intervention in 2 counties in Vermont and New Hampshire, with a special focus on providing support to help women quit smoking. Evaluation was by pre-intervention and post-intervention random-digit-dialed telephone surveys in the intervention counties and the 2 matched comparison counties.

RESULTS

In the intervention counties, compared with the comparison counties, the odds of a woman being a smoker after 4 years of program activities were 0.88 (95% confidence interval = 0.78, 1.00) (P = .02, 1-tailed); women smokers' perceptions of community norms about women smoking were significantly more negative (P = .002, 1-tailed); and the quit rate in the past 5 years was significantly greater (25.4% vs 21.4%; P = .02, 1-tailed). Quit rates were significantly higher in the intervention counties among younger women (aged 18 to 44 years); among women with household annual incomes of $25,000 or less; and among heavier smokers (those who smoked 25 or more cigarettes daily).

CONCLUSIONS

In these rural counties, community participation in planning and implementing interventions was accompanied by favorable changes in women's smoking behavior.

An outbreak of Yersinia enterocolitica O:8 infections associated with pasteurized milk

In October 1995, an outbreak of Yersinia enterocolitica O:8 infections occurred in the Upper Valley of Vermont and New Hampshire. Ten patients were identified, median age 9 years (range, 6 months-44 years). Three patients were hospitalized; 1 underwent an appendectomy. Consumption of bottled pasteurized milk from a local dairy was associated with illness (matched odds ratio undefined; lower 95% confidence interval, 1.9). No deficiencies in pasteurization procedures or equipment were detected. Y. enterocolitica O:8 was isolated from 1 raw-milk sample and from a fecal sample from 1 dairy pig. The route of contamination was not determined; this outbreak likely resulted from postpasteurization contamination of milk. Dairy pigs were the most likely source of contamination. Milk bottles were likely contaminated by rinsing with untreated well water prior to filling or by other environmental routes. Educating dairy owners about Y. enterocolitica and postpasteurization contamination is necessary to prevent further outbreaks.

Effect of cigarette promotions on smoking uptake among adolescents

BACKGROUND

The purpose of this study was to evaluate the association between receptivity to cigarette promotions and smoking uptake in a cohort of adolescents.

METHODS AND MEASURES

This was a prospective cohort study of 480 4th- to 11th-grade students conducted in three rural Vermont K-12 schools. Cigarette use was determined by self-report at baseline, 12 months (survey 2), and 21 months (survey 3). Proportional odds models were used to evaluate smoking uptake as a function of baseline measures of cigarette use, receptivity to cigarette promotions, and confounding factors, including grade, parental education, peer smoking, and family smoking. Adolescents were receptive to cigarette promotions if they owned or were willing to use a personal item bearing a cigarette brand logo [cigarette promotional item (CPI)]. Smoking status was measured using a 6-point ordinal index that combined experience and attitudes: 0 = never smoker/not susceptible to smoking, 1 = never smoker/susceptible to smoking, 2 = puffer (1 cigarette or less in lifetime), 3 = non-current experimenter (2-99 cigarettes in lifetime/none in past 30 days), 4 = current experimenter, and 5 = smoker (> or =100 cigarettes in lifetime).

RESULTS

The 480 students were equally distributed across grade at baseline. Environmental exposure to smoking was high, and 30% were receptive to cigarette promotions at baseline. Higher levels on the smoking index at baseline were associated with higher grade in school, peer smoking, and receptivity to cigarette promotions. One hundred eighty-five students (38.5%) had moved to a higher category on the smoking index by survey 3, of whom 30 had become smokers. Receptivity to cigarette promotions at baseline was significantly associated with higher smoking uptake, with 48.7% of receptive students moving up one or more categories on the smoking index [adjusted proportional odds 1.9 (95% CI 1.3, 2.9)]. Acquisition of receptivity to cigarette promotions was also associated with increased smoking uptake, with those becoming receptive in surveys 2 or 3 having significantly higher odds of progression [3.6 (1.8, 7.0) and 2.9 (1.5, 5.5), respectively] compared with those who did not change. Conversely, those who were receptive at one point but became non-receptive in surveys 2 or 3 had lower odds of progression [0.4 (0.2, 0.9) and 0.5 (0.3, 1.1), respectively].

CONCLUSIONS

This study supports a close linkage between tobacco promotional activities and uptake of smoking among adolescents beyond baseline descriptions of receptivity to cigarette promotions. Over time, the likelihood of smoking uptake is increased when an adolescent acquires a CPI or becomes willing to use one and is decreased when an adolescent who owns a CPI loses it or becomes unwilling to use it. This provides strong evidence that elimination of cigarette promotional campaigns could reduce adolescent smoking.

Population-based management of all pregnant women delivers healthy babies

The incidence of preterm delivery in New Hampshire has declined dramatically thanks to the concentrated efforts of the state's largest health plan. Find out how the plan identifies women who may be at risk for early delivery, keeps tabs on them throughout pregnancy, and keeps newborns safe and out of the hospital after delivery.

Children's symptoms in the wake of Challenger: a field study of distant-traumatic effects and an outline of related conditions

OBJECTIVE

The Challenger space shuttle explosion in January 1986 offered an opportunity to determine what, if any, symptoms of posttraumatic stress disorder (PTSD) and bereavement normal latency-age children and adolescents would develop after a distant, horrifying event.

METHOD

With a structured interview, the authors assessed the symptoms of 153 randomly selected children from Concord, N.H., and Porterville, Calif. Responses were statistically compared between East Coast children, who saw the event on television and who generally cared more about the teacher aboard Challenger, and West Coast children, who heard about it first; between latency-age children and adolescents; and between children seen 5-7 weeks later and those same children seen 14 months later.

RESULTS

More than 60% of the subjects feared at least one stimulus related to Challenger within the first 5-7 weeks of the explosion. The East Coast and latency-age groups appeared significantly more symptomatic than did the West Coast and adolescent groups. Over the 14-month study period, most symptoms dramatically faded. However, adolescents' diminished expectations for the future in general increased, and latency-age children's changed approach to space careers held relatively steady. Three East Coast latency-age children met the DSM-III-R symptom requirements for PTSD in 1986; no children met these in 1987.

CONCLUSIONS

Children's symptomatic patterns after Challenger relate to the patterns for PTSD listed in diagnostic manuals and to three symptoms not in the DSM-IV list. To the authors, distant traumas appear to be one of a newly defined spectrum of trauma-related conditions that include relatively evanescent symptoms and a few longer-lasting ones. These symptoms may affect large numbers of normal children.

Increase in incidence rates of basal cell and squamous cell skin cancer in New Hampshire, USA. New Hampshire Skin Cancer Study Group

We conducted a study to estimate the current incidence rates of basal-cell carcinoma (BCC) and squamous-cell carcinoma (SCC) of the skin in the population of New Hampshire (NH), USA, and to quantify recent changes in the incidence rates of these malignancies. BCCs and SCCs diagnosed among NH residents were identified through physician practices and central pathology laboratories in NH and bordering regions from June 1979 through May 1980 and from July 1993 through June 1994. For each diagnosis period, we estimated the age-adjusted incidence rates for both BCC and SCC among both men and women and for separate anatomic sites. Between 1979-1980 and 1993-1994, incidence rates of SCC increased by 235% in men and by 350% in women. Incidence rates of BCC increased by more than 80% in both men and women. While the absolute increase was greatest for tumors of the head and neck, the relative change was most pronounced for tumors on the trunk in men and on the lower limb in women. Thus, there has been a marked rise in the incidence rates of BCC and SCC skin cancers in NH in recent years. The anatomic pattern of increase in BCC and SCC incidence is consistent with an effect of greater sunlight exposure. Studies of BCC and SCC occurrence are needed to identify possible behavioral and environmental factors and to assess possible changes in diagnostic practices that might account for the rise in incidence of these common malignancies.

Legal system involvement and costs for persons in treatment for severe mental illness and substance use disorders

OBJECTIVE

Persons with co-occurring severe mental illness and substance use disorders were followed for three years to better understand how they are involved with the legal system and to identify factors associated with different kinds of involvement.

METHODS

Data came from a three-year study of 203 persons enrolled in specialized treatment for dual disorders. Cost and utilization data were collected from multiple data sources, including police, sheriffs and deputies, officers of the court, public defenders, prosecutors, private attorneys, local and county jails, state prisons, and paid legal guardians.

RESULTS

Over three years 169 participants (83 percent) had contact with the legal system, and 90 (44 percent) were arrested at least once. Participants were four times more likely to have encounters with the legal system that did not result in arrest than they were to be arrested. Costs associated with nonarrest encounters were significantly less than costs associated with arrests. Mean costs per person associated with an arrest were $2,295, and mean costs associated with a nonarrest encounter were $385. Combined three-year costs averaged $2,680 per person. Arrests and incarcerations declined over time. Continued substance use and unstable housing were associated with a greater likelihood of arrest. Poor treatment engagement was associated with multiple arrests. Men were more likely to be arrested, and women were more likely to be the victims of crime.

CONCLUSIONS

Effective treatment of substance use among persons with mental illness appears to reduce arrests and incarcerations but not the frequency of nonarrest encounters. Stable housing may also reduce the likelihood and number of arrests.

HIV risk factors among people with severe mental illness in urban and rural areas

No studies have reported HIV risk behavior in rural populations with severe mental illness. A total of 84 rural patients with severe mental illness in New Hampshire and 158 urban patients in Baltimore were interviewed about their HIV risk behavior in the past six months using the Risk Assessment Battery, a 38-item structured clinical interview. Rates of sexual and drug risk behavior among rural patients were significantly lower than among urban patients. Regression analyses showed that urban setting, younger age, never having been married, and a bisexual or gay orientation significantly predicted higher HIV risk scores. The differences in risk behaviors may reflect urban-rural differences in drug availability and sexual practices.

Conduct disorder, antisocial personality disorder and substance use disorders in schizophrenia and major affective disorders

OBJECTIVE

To examine the relationships between childhood conduct disorder (CD), antisocial personality disorder (ASPD) and substance use disorders (substance abuse or substance dependence) in psychiatric patients with severe mental illness.

METHOD

Substance use-related problems on screening instruments, lifetime and recent prevalence of substance use disorders, and family history of substance use disorder were evaluated in four groups of 293 patients with mainly schizophrenia-spectrum and major affective disorders: No ASPD/CD, CD Only, Adult ASPD Only, Full ASPD.

RESULTS

Full ASPD was strongly related to all measures of substance use problems and disorders, as well as fathers' history of substance use disorder. The odds ratios for Full ASPD and substance use disorders ranged between 3.96 (lifetime cannabis use disorder) to 11.35 (recent cocaine use disorder). To a lesser extent, patients with CD Only or Adult ASPD Only were also at increased risk for having substance use disorders compared to the No ASPD/CD patients.

CONCLUSIONS

Childhood CD and adult ASPD represent significant risk factors for substance use disorders in patients with schizophrenia-spectrum and major affective disorders. Considering other research indicating that CD and ASPD have a higher prevalence in patients with severe mental illness, the present findings suggest that CD and ASPD could reflect a common factor that independently increases patients' vulnerability to both psychiatric and substance use disorders.

Data collection key to effective perfusion benchmarking

Quality improvement for cardiac surgery focuses on perfusion services. National and regional projects are taking a closer look at morbidity and mortality associated with extracorporeal perfusion. Find out how researchers in New England are gathering and using data to give a detailed picture of risks the life-saving technology may introduce.

Relationship of asthma severity and psychological problems in children

OBJECTIVE

To determine whether physiological severity of asthma is associated with increased psychological symptoms in children.

METHOD

Participants were 337 children, aged 7 to 19 years (mean 11.9, SE 0.13), and a parent of each child. Children's asthma severity was rated by experienced pediatric asthma specialists using current guidelines from the National Heart, Lung, and Blood Institute. Children filled out the Children's Manifest Anxiety Scale and the Weinberger Adjustment Inventory. Parents reported on their child's medical history, completed the Child Behavior Checklist (CBCL) about their child, and completed the Pennebaker Inventory of Linguid Languidness as a measure of their own physical symptoms.

RESULTS

Child-rated anxiety symptoms were unrelated to asthma severity or to markers of asthma functional morbidity. Parental ratings of internalizing symptoms in their children were related to severity. Parent physical symptoms explained 10.2% of the variance in CBCL Internalizing symptoms, and asthma severity added an additional 6.7% to the variance.

CONCLUSIONS

Asthma severity may be a more salient stressor to parents, who in turn report higher levels of child internalizing symptoms for children with severe asthma, than to children themselves. Contrary to prior hypotheses, children with severe asthma did not rate themselves as having higher levels of anxiety than those with mild or moderate asthma or than standardized norms.

Design of an epidemiologic study of drinking water arsenic exposure and skin and bladder cancer risk in a U.S. population

Ingestion of arsenic-contaminated drinking water is associated with an increased risk of several cancers, including skin and bladder malignancies; but it is not yet clear whether such adverse effects are present at levels to which the U.S. population is exposed. In New Hampshire, detectable levels of arsenic have been reported in drinking water supplies throughout the state. Therefore, we have begun a population-based epidemiologic case-control study in which residents of New Hampshire diagnosed with primary squamous cell (n = 900) and basal cell (n = 1200) skin cancers are being selected from a special statewide skin cancer incidence survey; patients diagnosed with primary bladder cancers (n = 450) are being identified through the New Hampshire State Cancer Registry. Exposure histories of these patients will be compared to a control group of individuals randomly selected from population lists (n = 1200). Along with a detailed personal interview, arsenic and other trace elements are being measured in toenail clipping samples using instrumental neutron activation analysis. Household water samples are being tested on selected participants using a hydride generation technique with high-resolution inductively coupled plasma mass spectrometry. In the first 793 households tested arsenic concentrations ranged from undetectable (0.01 microgram/l) to 180 microgram/l. Over 10% of the private wells contained levels above 10 microgram/l and 2.5% were above 50 microgram/l. Based on our projected sample size, we expect at least 80% power to detect a 2-fold risk of basal cell or squamous cell skin cancer or bladder cancer among individuals with the highest 5% toenail concentrations of arsenic.

Lung cancer mortality in a cohort of older pulp and paper workers

The occurrence of deaths due to lung cancer was studied among 883 white male workers from a pulp and paper company in northern New Hampshire. All subjects had participated in a longitudinal study of respiratory morbidity, and data from interviews were used to construct lifetime cigarette smoking and occupational histories. Most of the subjects had entered follow-up in the 1960s and, at that time, their mean age was 51 years and they had worked for the pulp and paper company a mean of 25 years. By the end of follow-up in 1992, the 512 deceased subjects included 35 whose underlying cause of death had been lung cancer. With an internal comparison using the Cox proportional-hazards model, the hazard ratio for sulfite pulp mill work was 2.5 (95% CI 1.3-4.9), while controlling for the effects of age, cigarette smoking, and work in other parts of the pulping operation. In addition, the hazard ratio for the combination of >35 pack-years of smoking and >10 years sulfite mill work was greater than the product of the hazard ratios for each factor alone. While these findings are consistent with past asbestos exposure in the sulfite pulp mill environment, the absence of mesothelioma cases is inconsistent with this type of exposure.

Teenage driving fatalities

BACKGROUND/PURPOSE

A recent legislative effort in New Hampshire to institute a graduated licensing system for teenagers (TA) led to an analysis of state data on fatal crashes involving TA drivers. This provides an overview of these events and suggests possible prevention strategies.

METHODS

Data on fatal crashes involving TA drivers was obtained for the years 1991 through 1996 from the Fatal Accident Unit, Division of State Police, New Hampshire Department of Safety.

RESULTS

From 1991 through 1996, there were 100 events resulting in 109 total deaths, of which 76 were TA. Five involved motorcycles. Four drivers struck pedestrians, and two struck children on bicycles. In one case, an object fell from a truck, crushing a car. The remaining 88 were single- or multiple-car crashes, and these were analyzed further. Two thirds of the drivers were boys. The driver breakdown by age was 15 years, 3; 16 years, 21; 17 years, 26; 18 years, 20; 19 years, 18. The TA driver was killed in 47% of the events. Nineteen percent resulted in the death of the driver of another car. In 62 events, there were passengers in the TA's car, and in 55% of these, a passenger was killed. Twenty percent of the crashes involved drugs or alcohol, and almost two thirds of these occurred between 10:00 PM and 6:00 AM. Seat belts were not used by at least 72% of those injured fatally. In 59%, known traffic violations, usually speeding, contributed. More detailed data were available for 1995 through 1996, during which there were 30 crashes resulting in 33 deaths. Speed limit did not correlate with number of crashes. One-car crashes outnumbered multiple-car, 57% to 43%. Ninety percent occurred on single-lane roads. Most significantly, 63% of the drivers had been licensed less than 1 year and 47% less than 6 months. In this latter group, drugs and alcohol played no role, and none occurred between 11:00 PM and 6:00 AM.

CONCLUSIONS

Two at-risk groups exist. The first is inexperienced sober TA drivers on single-lane roads during conventional hours. As experience increases, the second group appears: TA who have been drinking and are out late at night. Prevention strategies must take into account these two groups.

Variation in the management of pediatric splenic injuries in New Hampshire

PURPOSE

The aim of this study was to determine if variation in the management of pediatric splenic injuries occurs among hospitals in New Hampshire.

METHODS

Data accrued for each patient less than 18 years of age discharged from an acute care hospital in New Hampshire with a splenic injury diagnosis code or splenic procedure code were analyzed for the years 1991 through 1994. The splenectomy, splenorrhaphy, and nonoperative management rates of each hospital were analyzed and adjusted for case mix using direct standardization. Management rates were determined for patients with isolated splenic injuries, which were then adjusted for case mix.

RESULTS

Variation in the management of pediatric splenic injuries was found to occur among hospitals in New Hampshire. Management variation persisted despite adjustment for case mix. Variation was also noted in the management of patients with isolated splenic injuries and persisted after case mix adjustment.

CONCLUSION

Even after adjustment for case mix, if all children with splenic injuries in New Hampshire were treated in the same fashion as at the state's children's hospital, over 73% of splenectomies and 70% of splenorrhaphies performed for trauma may have been avoided.

Exposure to breast milk in infancy and adult breast cancer risk

BACKGROUND

There is considerable interest in the possibility of an infectious etiology for human breast cancer. Although studies have shown that certain strains of mice transmit mammary tumor virus via breast milk, few epidemiologic studies have addressed this topic in humans.

METHODS

We evaluated the relationship between having been breast-fed as an infant and breast cancer risk among 8299 women who participated in a population-based, case-control study of breast cancer in women aged 50 years or more. Case women were identified through cancer registries in three states (Massachusetts, New Hampshire, and Wisconsin); control women were identified through statewide driver's license lists (age <65 years) or Medicare lists (ages 65-79 years). Information on epidemiologic risk factors was obtained through telephone interview. We used multiple logistic regression to assess having been breast-fed and maternal history of breast cancer in relation to breast cancer occurrence both in premenopausal women (205 case women; 220 control women) and in postmenopausal women (3803 case women; 4071 control women).

RESULTS

We found no evidence that having been breast-fed increased breast cancer risk in either premenopausal women (odds ratio [OR] = 0.65; 95% confidence interval [CI] = 0.41-1.04) or postmenopausal women (OR = 0.95; 95% CI = 0.85-1.07). In addition, breast cancer risk was not increased by having been breast-fed by a mother who later developed breast cancer.

CONCLUSION

Our results do not support the hypothesis that a transmissible agent in breast milk increases breast cancer risk. Because premenopausal women were not well represented in our study population, our findings with regard to this group may not be generalizable and should be viewed with caution.

Reexploration for hemorrhage following coronary artery bypass grafting: incidence and risk factors. Northern New England Cardiovascular Disease Study Group

OBJECTIVE

To assess mortality and risk factors associated with reexploration for hemorrhage in patients undergoing coronary artery bypass grafting (CABG).

DESIGN

Regional cohort study. Patient characteristics, treatment variables, and outcome measures were collected prospectively.

SETTING

All 5 centers performing cardiac surgery in Maine, New Hampshire, and Vermont.

PATIENTS

A consecutive cohort of 8586 patients undergoing isolated CABG between 1992 and 1995.

MAIN OUTCOME MEASURES

Postoperative hemorrhage leading to reexploration, in-hospital mortality, and length of stay.

RESULTS

A total of 305 patients (3.6%) underwent reexploration for bleeding. In these patients, in-hospital mortality was nearly 3 times higher (9.5% vs 3.3% for patients not requiring reoperation, P<.001) and average length of stay from surgery to discharge was significantly longer (14.5 days vs 8.6 days, P<.001). High rates of reexploration for hemorrhage were observed in patients with prolonged (> 150 minutes) cardiopulmonary bypass (39 [11.1%] of 351) and in those requiring an intra-aortic balloon pump intraoperatively (12 [8%] of 139). In multivariate analysis, older age, smaller body surface area, prolonged cardiopulmonary bypass, and number of distal anastomoses were associated with increased bleeding risks. The use of thrombolytic therapy within 48 hours of surgery was weakly but not significantly associated with the need for reexploration. Factors not significantly associated with reexploration included patient sex, preoperative ejection fraction, surgical priority, history of liver disease, myocardial infarction, prior CABG, renal failure, and diabetes mellitus.

CONCLUSIONS

Hemorrhage requiring reexploration after CABG is associated with markedly increased mortality and length of stay. Patients predicted to have increased risks of bleeding may benefit from prophylactic use of aprotinin, aminocaproic acid, or other agents shown to reduce hemorrhage.

Over-the-counter analgesics and risk of ovarian cancer

BACKGROUND

Evidence that aspirin and other non-steroidal anti-inflammatory drugs reduce risk for colorectal cancer has prompted interest in their ability to prevent other cancers. We aimed to find out what effect over-the-counter analgesics have on risk of ovarian cancer.

METHODS

In a case-control study we compared use of over-the-counter analgesics by 563 women from eastern Massachusetts and New Hampshire, USA, who had epithelial ovarian cancer with 523 women from the general population. We calculated exposure odds ratios to estimate the effect of over-the-counter analgesics on ovarian cancer risk. Use of over-the-counter analgesics was assessed through interviews and defined as use at least once a week continuously for at least 6 months.

FINDINGS

The odds ratio for risk of ovarian cancer for aspirin use was 0.75 (95% CI 0.52-1.10), that for ibuprofen was 1.03 (0.64-1.64), and that for paracetamol was 0.52 (0.31-0.86), after adjusting for age, study centre, education, religion, parity, oral contraceptive use, and menstrual, arthritic, or headache pain. Relative to no use, the lower risk of ovarian cancer associated with paracetamol was more apparent for use on a daily basis, 0.39 (0.21-0.74), for more than 10 years of use, 0.40 (0.19-0.88), or for more than 20 tablet years defined as (tablets per day x years of use), 0.45 (0.20-0.99).

INTERPRETATION

In our data, there was a statistically significant inverse association between paracetamol use and ovarian cancer risk. There was a modest but non-significant inverse association with aspirin use and ovarian cancer and no association with ibuprofen use. Experimental studies in rodents demonstrating uterine and ovarian atrophy at high doses of paracetamol and decreased ovarian-cyst formation at lower doses suggest a biological basis for our observations.

Surgical aspects of an outbreak of Yersinia enterocolitis

Eleven patients with Yersinia enterocolitica infections were identified in the Upper Valley of New Hampshire and Vermont during October and November of 1995. Three children presented with an appendicitis-like picture. Two underwent appendectomy, one of whom was the outbreak's index case. Both appendectomy patients presented with lower abdominal pain, fever, vomiting, and a right lower quadrant mass associated with leukocytosis. Both had terminal ileitis, and in both, cultures of peritoneal fluid and a mesenteric lymph node grew Y. enterocolitica. Even during an outbreak there is no consistently reliable nonoperative way to separate a sporadic case of appendicitis from one whose appendicitis-like symptoms are due to Yersinia. In addition, a small percentage of Yersinia patients will present with true appendicitis as a complication of their disease.

Endoparasites of plethodontid salamanders from Paradise Brook, New Hampshire

Totals of 52 dusky salamanders Desmognathus fuscus, 51 two-lined salamanders Eurycea bislineata, 54 red-backed salamanders Plethodon cinereus, and 3 spring salamanders Gyrinophilus porphyriticus (Plethodontidae) collected in June and August 1995 from Paradise Brook, a tributary to Hubbard Brook, New Hampshire, were examined for parasites. Parasites found were Brachycoelium storeriae, Brachycoelium sp., Bothriocephalus rarus, Falcaustra sp., Omeia sp., Batracholandros magnavulvaris, and Cepedietta michiganensis. Eighty-six percent of the red-backed salamanders, a terrestrial species, harbored 1 or more parasites. Among the aquatic and semiaquatic species, 27% of the dusky and 45% of the two-lined salamanders were infected with 1 or more parasites.

Epidermal tumors of rainbow smelt with associated virus

Epithelial tumors of the skin occurred in landlocked populations of rainbow smelt (Osmerus mordax) in several lakes in New Hampshire (USA) during the spawning runs. Histologically, these were noninvasive epithelial cell lesions. Herpesvirus-like particles could be seen in the nucleus and cytoplasm. The lesions occurred in both males and females. Prevalence which varied annually, was as high as 30%.

How well do ambulatory care groups predict expenditures on mental health and substance abuse patients?

This paper evaluates the ability of Ambulatory Care Groups (ACGs) to prospectively predict mental health and substance abuse expenditures and total health care expenditures of persons enrolled in the New Hampshire Medicaid Program during fiscal years 1993 and 1994. A series of multi-part models is estimated separately for adults and children and a synthetic R-squared and the mean absolute predictive error are calculated. The results show that with the exception of predicting total expenditures for children, ACGs do not perform as well as simple models containing various demographic and prior mental health/substance abuse utilization measures.

Evolution of services for the chronically mentally ill in a managed care setting: a case study

Managed care plans have expanded to serve individuals with severe and chronic mental illness over the past 25 years. During that time, the evolution of several key clinical phases has been witnessed: the creation of a diverse spectrum of services; the development of treatment algorithms; and the implementation of treatment outcomes measures as a way to gauge program success and develop future strategies. At the same time, a number of additional factors have had a significant impact upon the development of clinical programs targeted toward the chronically mentally ill: dollars allocated to mental health services; the influence of different models of delivery; and the incentives inherent in various methods of payment.

Variation in female breast cancer risk by occupation

Data from a population-based case control study were used to estimate occupation-specific relative risks for female breast cancer, adjusted for established breast cancer risk factors. Breast cancer cases under age 75 were identified from tumor registries in four states. Controls were randomly selected from driver's license and Medicare beneficiary lists. Information on usual occupation and risk factors was obtained by telephone interview. Odds ratios from logistic regression adjusted for age, state, body mass index, benign breast disease, family history of breast cancer, menopausal status, age at menarche, parity, age of first birth, lactation history, education, and alcohol consumption were calculated for each of 26 occupational groups. Complete occupational information was obtained for 6,835 cases and 9,453 controls. Of 26 occupational groups, only "administrative support occupations" had a statistically significantly increased risk of breast cancer (OR = 1.15, 95% CI 1.06-1.24). In these data, no specific occupational group had an unusual risk of breast cancer. Increased risks reported elsewhere for nurses and teachers were not corroborated.

Helping women quit smoking: baseline observations for a community health education project

INTRODUCTION

Our objectives were (1) to examine the relationship between women's intention of stopping smoking in the next month and a broad range of mediating variables and (2) to assess the implications of these relationships for intervention components of a comprehensive community-wide health education program to help women quit smoking.

METHODS

In preparation for the community-wide program to help women quit smoking, baseline data were collected through a random digit dialing telephone survey of 6,324 adult women, 18-64 years of age.

RESULTS

At baseline, smoking prevalence, defined as smoking an average of one or more cigarettes per day, was 25.8% and showed clear relationships with age and income, but most strikingly with education, indicating the need for programs for women of childbearing age with low incomes and fewer years of schooling. Among female smokers, knowledge of the health effects of smoking; motivations toward quitting; confidence in controlling weight, or handling stress, anger or boredom; number of strategies named to cope when upset of angry; number of community smoking cessation resources named; perceptions of support for quitting; and perceptions of norms concerning women smoking varied significantly with level of intention to quit smoking in the next month.

CONCLUSIONS

These relationships provided support for the broad range of health behavior change strategies proposed for this community-based program to help women quit smoking.

Recent oral contraceptive use and risk of breast cancer (United States)

We examined the association between recent oral contraceptive (OC) use and the risk of breast cancer in data from a large population-based case-control study in the United States. Cases (n = 6,751) were women less than 75 years old who had breast cancer identified from statewide tumor registries in Wisconsin, Massachusetts, Maine, and New Hampshire. Controls (n = 9,311) were selected randomly from lists of licensed drivers (if aged under 65 years) and from lists of Medicare beneficiaries (if aged 65 through 74 years). Information on OC use, reproductive experiences, and family and medical history was obtained by telephone interview. After adjustment for parity, age at first delivery, and other risk factors, women who had ever used OCs were at similar risk of breast cancer as never-users (relative risk [RR] = 1.1, 95 percent confidence interval [CI] = 1.0-1.2). Total duration of use also was not related to risk. There was a suggestion that more recent use was associated with an increased risk of breast cancer; use less than two years ago was associated with an RR of 1.3 (CI = 0.9-1.9). However, only among women aged 35 to 45 years at diagnosis was the increase in risk among recent users statistically significantly elevated (RR = 2.0, CI = 1.1-3.9). Use prior to the first pregnancy or among nulliparous women was not associated with increased risk. Among recent users of OCs, the risk associated with use was greatest among non-obese women, e.g., among women with body mass index (kg/m2) less than 20.4, RR = 1.7, CI = 1.1-2.8. While these results suggest that, in general, breast cancer risk is not increased substantially among women who have used OCs, they also are consistent with a slight increased risk among subgroups of recent users.

Cigarette smoking and breast cancer

A priori hypotheses suggest that cigarette smoking could either increase or decrease breast cancer incidence. To clarify these competing hypotheses, we used data from a very large population-based breast cancer case-control study to investigate the impact of smoking on breast cancer risk. Breast cancer patients less than 75 years old were identified from statewide tumor registries in Wisconsin, Massachusetts, Maine, and New Hampshire; controls were randomly selected from driver's license lists (age less than 65) or lists of Medicare beneficiaries (age 65-74). Information on reproductive history, medical history, and personal habits including cigarette smoking was obtained by telephone interview. A total of 6,888 cases and 9,529 controls were interviewed. There was virtually no relationship between current smoking and breast cancer risk (multivariate odds ratio, 1.00; 95% confidence interval, 0.92-1.09), and former smokers had a barely increased risk (odds ratio, 1.10; 95% confidence interval, 1.01-1.19). Similar results were observed among both premenopausal and postmenopausal women. There was no suggestion that heavy or long-term smoking increased or decreased risk, nor were there indications that women who began smoking at an early age were at increased risk, as has been hypothesized. The results of this large population-based study indicate that smoking does not influence the risk of breast cancer, even among heavy smokers who began smoking at an early age.

Moose-motor vehicle collisions. An increasing hazard in northern New England

OBJECTIVE

To analyze the epidemiology and epizootiology of moose-motor vehicle collisions (MMVC) and outcomes in severely injured patients to identify variables that might be modified to reduce the impact of this mutually deleterious interspecies interaction.

DESIGN

Wildlife and Traffic Safety databases permitted retrospective, population-based assessment of MMVC epidemiology. A case series compiled from hospital trauma registries characterized morbidity and mortality from MMVC.

SETTING

New Hampshire and Maine area.

PATIENTS

All victims of MMVC (1980 through 1991) were included in population-based analyses. Twenty-three patients hospitalized at three rural trauma centers (January 1990 through June 1994) were included in the case series.

MAIN OUTCOME MEASURES

Location, time of day and seasonal occurrence of MMVC were determined. Injury patterns and Injury Severity Scores were analyzed in 23 representative patients. Maine's 1991 traffic and medical data were linked, and factors predictive of injury from MMVC were identified using multivariate logistics.

RESULTS

Most MMVC occur from April through October after dark. Of 23 subjects, 70% sustained head and/or face injuries and 26%, cervical spine injuries. Mortality was 9%. Mean Injury Severity Score was 15.7 (SD=9.0). Safety belt use, rear seat location, and light truck occupancy were associated with reduced injury (p<.05).

CONCLUSIONS

Moose-motor vehicle collisions are increasing in rural regions. Prevention programs should emphasize defensive driving and seat belt use, especially during high-risk periods. Injury patterns in MMVC suggest a need for automobile design modifications that better protect the passenger compartment form direct impact.

Rural adolescent drinking behavior: three year follow-up in the New Hampshire substance abuse prevention study

A three-year follow-up study of alcohol prevention among 4,406 children showed that neither a comprehensive school curriculum nor a community intervention was successful in preventing adolescent drinking. Predictor variables for drinking are examined and the importance of tolerance and encouragement of drinking by adult role models are noted.