Can fruit and vegetable aggregation systems better balance improved producer livelihoods with more equitable distribution?

The need for food systems to generate sustainable and equitable benefits for all is a global imperative. However, whilst ample evidence exists linking smallholder farmer coordination and aggregation (i.e. the collective transport and marketing of produce on behalf of multiple farmers) to improved market participation and farmer incomes, the extent to which interventions that aim to improve farmer market engagement may co-develop equitable consumer benefits remains uncertain. This challenge is pertinent to the horticultural systems of South Asia, where the increasing purchasing power of urban consumers, lengthening urban catchments, underdeveloped rural infrastructures and inadequate local demands combine to undermine the delivery of fresh fruits and vegetables to smaller, often rural or semi-rural markets serving nutritionally insecure populations. To this end, we investigate the potential for aggregation to be developed to increase fruit and vegetable delivery to these neglected smaller markets, whilst simultaneously improving farmer returns. Using an innovative system dynamics modelling approach based on an aggregation scheme in Bihar, India, we identify potential trade-offs between outcomes relating to farmers and consumers in smaller local markets. We find that changes to aggregation alone (i.e. scaling-up participation; subsidising small market transportation; mandating quotas for smaller markets) are unable to achieve significant improvements in smaller market delivery without risking reduced farmer participation in aggregation. Contrastingly, combining aggregation with the introduction of market-based cold storage and measures that boost demand improves fruit and vegetable availability significantly in smaller markets, whilst avoiding farmer-facing trade-offs. Critically, our study emphasises the benefits that may be attained from combining multiple nutrition-sensitive market interventions, and stresses the need for policies that narrow the fruit and vegetable cold storage deficits that exist away from more lucrative markets in developing countries. The future pathways and policy options discovered work towards making win-win futures for farmers and disadvantaged consumers a reality.

Receipt of Next-generation Genomic Sequencing among Patients with Metastatic Colorectal Cancer (mCRC) in a Real-World Cohort

Purpose of the Study: Disparities in genomic precision medicine approaches, through molecular profiling or next- generation sequencing (NGS), by race/ethnicity, insurance, and poverty have been identified in lung cancer, but not mCRC. Our goal was to examine disparities in receipt of NGS in patients with mCRC. Methods: We used all-payer electronic health record (EHR)-derived de-identified data from the Flatiron Health database generated from routine clinical care across the United States. Our study population included 26,524 patients with mCRC during the years 2013–2020. In addition to date of NGS testing, the FH-EHR data include demographics (age, sex, and race/ethnicity), payer type, and Eastern Cooperative Oncology Group (ECOG) performance status. We conducted descriptive analyses and multivariable logistic regression analysis to identify correlates of receipt of NGS within 6 months of metastatic diagnosis. Results: Among the 26,524 people with mCRC, 45% (n = 11,946) were women, 48% (n = 12,732) had a Commercial Health Plan, and the majority were seen in a community practice (92%) vs academic hospitals. Over 70% of the patients were White, 12% Black or African-American (AA), and 14% Other. Thirty-three percent (n = 8,821) of patients had documentation in the EHR of having received NGS. After simultaneously adjusting for other factors in the model, older age (ORper year increase: 0.97, 95% CI: 0.96–0.98) and Black/AA race (OR: 0.74, 95% CI: 0.68–0.81), compared to White, was associated with lower odds of receiving NGS testing. Conversely, female sex, better ECOG performance status, later calendar year, being seen in an academic practice, and having a Commercial Health Plan were associated with greater odds of receiving NGS. Conclusions: Our findings indicate that NGS is not received uniformly by all patients with mCRC. Future analyses will incorporate receipt of individual molecular biomarker tests, as recommended by professional societies, as well as their results (e.g., KRAS, NRAS, BRAF, MMR/MSI), treatment information, and survival.

Abstract P6-02-01: Perceived life expectancy, multimorbidity, and breast cancer screening in older women

Objective: Screening mammography (SM) benefits are maximal in women who have a several years' life expectancy. Perceived life expectancy (PLE), however, can be compromised by older age, and/or poor health. Prior studies have shown low rates of SM in younger and/or healthier women, while women who are older and/or those presenting with multimorbidity (MM) continue to undergo screening. The resulting under/overuse of SM causes an imbalance in the use of finite resources that should be rectified as we prepare for population aging. In this study, we investigate the use of SM in women 50 years of age or older in the context of age, PLE, MM, and other social determinants of health.

Methods: This is a cross-sectional study using the nationally-representative 2012 U.S. Health and Retirement Study (n= 8934 women). In addition to demographics, we examined a broad range of variables on social determinants of health; as well as conditions constituting MM, including self-reported chronic conditions (e.g., heart disease), functional limitations (e.g., strength, and mobility limitations), and geriatric syndromes (e.g., low cognitive performance). We defined MM0-MM3 as gradients of MM, based on the occurrence/co-occurrence of chronic conditions, functional limitations, and/or geriatric syndromes. PLE was calculated based on respondent's age-specific assessment of the chance they would live another 10-15 years. The outcome variable was self-reported mammography in the past 2 years. We conducted logistic regression analysis to evaluate the independent and interactive association between each of PLE and MM relative to SM, adjusting for potential confounders.

Results: The median age was 65.7 years; 10.5% were Non-Hispanic Black (NHB), 7.8% were Hispanic, and 3.2% were Other Race. The percent of women with SM was 71.5% in the total population. The median assessment of PLE was a 50% chance of living another 10-15 years. 71.9% of women presented with chronic conditions, 36.8% with functional limitations, and 58.2 with geriatric syndromes. Adjusting for confounders, receipt of mammogram was positively associated with greater certainty of PLE (AOR for an increase of 10% –1.03 (1.01, 1.05)). Compared to those with no conditions (MM0), the co-occurrence of chronic conditions, functional limitations, and/or geriatric syndromes was also positively associated with SM (AOR MM1– 1.48 (1.19, 1.84); AOR MM2– 1.35 (1.09, 1.69); and AOR MM3– 1.29 (1.02, 1.62)). In addition, PLE further strengthened the association between MM and SM. Although age was negatively associated with SM, this interacted with PLE such that the likelihood of having a mammogram was unrelated to age among women 100% certain they would live another 10-15 years.

Conclusion: Both multimorbidity (MM) and perceived life expectancy (PLE) are independently and interactively associated with increased screening mammography (SM), suggesting overuse. Indeed, even among women 75 years of age or older, when SM may be least beneficial, receipt of SM in the past two years was 59.6% in the presence of highest MM gradient, and 68.1% when they were at least 75% certain they will live 10-15 years. A more detailed examination of the basis for PLE is warranted to understand the context in which screening recommendation is made.

Citation Format: Koroukian SM, Warner DF, Schiltz NK, Cooper GS, Owusu C, Stange KC, Berger NA. Perceived life expectancy, multimorbidity, and breast cancer screening in older women [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-02-01.

Elevated C-reactive protein and self-reported disease activity in systemic lupus erythematosus

C-reactive protein (CRP), a biomarker of inflammation, has been associated with increased disease activity in rheumatoid arthritis. However, the association in systemic lupus erythematosus (SLE) remains unclear. We examined the association of CRP with self-reported disease activity in the Carolina Lupus Study and described differences by sociodemographic characteristics. The study included baseline and three-year follow-up data on 107 African-American and 69 Caucasian SLE patients enrolled at a median 13 months since diagnosis. Models estimated prevalence differences in the association of baseline CRP with self-reported flares, adjusting for age, sex, race and education. Active disease or flare was reported by 59% at baseline and 58% at follow-up. Higher CRP (>10 µg/ml vs. <3 µg/ml) was associated with a 17% (95% confidence interval (CI): -20, 53%) higher prevalence of flare at baseline and a 26% (95% CI: -9, 62%) higher prevalence of flare at follow-up. These CRP-flare associations were notably stronger in patients with lower education at baseline and in African-Americans at follow-up. These findings suggest that CRP may be a useful marker in studies of SLE health disparities.

Endoscopist-directed propofol administration versus anesthesiologist assistance for colorectal cancer screening: a cost-effectiveness analysis

BACKGROUND

Propofol for colonoscopy is largely administered by anesthesiologists or anesthesiology nurses in the United States (US) and Europe. Endoscopist-directed administration of propofol (EDP) by nonanesthesiologists has recently been proposed, with potential savings of anesthetist reimbursement costs. We aimed to assess potential EDP-related benefit in a screening setting.

METHODS

In a Markov model the total number of screening and follow-up colonoscopies in a cohort of 100 000 US subjects were estimated. Anesthetist-assisted colonoscopy was compared with an EDP strategy. Model outputs were projected onto the 50 - 80-year-old US population, assuming 27 % as the current uptake for colonoscopy screening. Anesthetist costs were estimated using the mean reimbursement for the corresponding Medicare code (≥ 65-year-olds) and from commercial insurance information (50 - 64-year-olds). The proportion of colonoscopies with anesthesiologist assistance was estimated from the Medicare database. Mean nurse salary was used to estimate the cost of a 2-week EDP training. The absolute number of US endoscopists was estimated by inflating by 33 % the number of board-certified gastroenterologists. No EDP mortality was assumed in the reference scenario, and 0.0008 % mortality in the sensitivity analysis. US census data were adopted. Analogous inputs were used for France to assess EDP-related benefit in a European country.

RESULTS

EDP training for 17 166 nurses (one for each US endoscopist) showed a cost of $ 47 million. Cost estimates for anesthesiologist assistance for colonoscopy were $ 95 (Medicare) and $ 450 (non-Medicare commercial insurance), with 34.8 % of colonoscopies requiring anesthesiologist assistance. US implementation of an EDP policy showed a 10-year saving of $ 3.2 billion (Monte Carlo analysis 5 - 95 % percentiles $ 2.7 - $ 11.9 billion). In the sensitivity analysis, assuming 50 % of colonoscopies were anesthetist-assisted showed an EDP benefit of $ 4.6 billion. Assuming a 0.0008 % mortality rate, the incremental cost - effectiveness of anesthetist-assisted colonoscopy versus an EDP policy was $ 1.5 million per life-year gained, supporting EDP as the optimal choice. A 31-fold increase of EDP-related mortality or a 17-fold cost reduction for anesthetist-assisted colonoscopy was required for EDP to become not cost-effective in this scenario. Implementation of an EDP policy in France, within a guaiac-fecal occult blood test (g-FOBT) screening program, was estimated to save € 0.8 billion in 10 years.

CONCLUSIONS

The absolute economic benefit of EDP implementation in a screening setting is probably substantial with 10-year savings of $3.2 billion in the US and €0.8 billion in France. The impact of an eventual EDP-related mortality on EDP cost - effectiveness seems marginal. The huge economic and medical resources entailed by anesthetist-assisted colonoscopy could be more efficiently invested in other clinical fields.

Total serum IgE levels in systemic lupus erythematosus and associations with childhood onset allergies

Elevated serum IgE has been described in systemic lupus erythematosus (SLE), but associations with disease risk and characteristics remain unresolved. We assessed total serum IgE levels and atopy (IgE > 100 IU/ml) in recently diagnosed SLE patients (n = 228) compared with population controls (n = 293) and in relation to disease activity, autoantibodies, clinical features, total immunoglobulins, C-reactive protein, and allergy history. Multivariate models estimated determinants of IgE and atopy in patients and controls, and associations of SLE with allergy and atopy. Total IgE levels were higher in patients than controls (median = 42 vs. 29 IU/ml); 32% of patients and 25% of controls were atopic (p = 0.06). IgE levels were significantly higher in non-Whites and patients reporting childhood onset (<18 years) asthma and hives, and in controls reporting childhood asthma, hay fever, eczema, and adult onset hives. After accounting for racial differences, atopy was not associated with SLE, nephritis, or other clinical and laboratory parameters. In sum, our findings provide limited evidence of a direct association between total serum IgE and SLE overall or with other disease characteristics after adjusting for demographic characteristics and allergy history. Future studies may want to explore potentially shared risk factors for development of allergy, atopy, and SLE.

Childhood agricultural and adult occupational exposures to organic dusts in a population-based case-control study of systemic lupus erythematosus

Organic dust exposure can influence the development and symptoms of immune-related diseases such as atopy and asthma, but has rarely been examined in relation to systemic autoimmunity. The present analyses explore the association of lifetime farm and occupational organic dust exposures with systemic lupus erythematosus (SLE) in recently diagnosed patients (n = 265) compared with controls (n = 355) frequency matched by age, sex and state. Questionnaire data included childhood farm residence, childhood and adult experience with specific crops, and adult work in textiles, hog or poultry processing and paper or furniture manufacture. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were estimated by logistic regression models including age, sex, state, race, education and silica exposure. Overall childhood or adult farm contact and childhood farm residence were not associated with SLE. Farm contact with livestock was inversely associated with SLE (OR = 0.55, 95% CI 0.35, 0.88). This effect was most pronounced among those with childhood farm residence and both childhood and adult livestock exposure (OR = 0.19; 95% CI 0.06, 0.63), but was difficult to separate from adult exposure to grains or corn. Other adult occupational exposures were not associated with SLE risk overall, regardless of childhood farm residence or livestock exposure, although an inverse association was seen among non-smokers (OR = 0.59; 95% CI 0.33, 1.1), particularly for textile work (OR = 0.34; 95% CI 0.19, 0.64). These exploratory findings support the development of studies to specifically investigate the effects of organic dust exposure on SLE risk, with particular attention to exposure assessment and characterization of demographics, smoking and other occupational exposures.

Occupational exposures and risk of systemic lupus erythematosus: a review of the evidence and exposure assessment methods in population- and clinic-based studies

Epidemiologic and experimental research suggests a potential role of occupational exposures in the development of systemic lupus erythematosus (SLE). A plausible association has been identified in studies of occupational silica exposure and SLE, complemented by experimental studies in lupus-prone mice exploring potential mechanisms related to apoptosis and immune dysregulation. Experimental studies of the solvent trichloroethylene in lupus-prone mice provide evidence of effects on immune function, including increased production of autoantibodies and activation of CD4+ T cells. However, few studies of occupational solvent exposure and SLE have been conducted, and those that are available show little evidence of an association. There is some suggestion from the available studies of the potential influence of pesticides on SLE, but as with solvents, the specific type of pesticides that may be implicated is not known. Our understanding of the role of occupational exposures in SLE could be advanced by the development of larger, multisite or parallel studies that utilize similar questionnaire and exposure evaluation methods. Multiple studies using comparable exposure measures are needed to provide sufficient sample size for examining gene-environment interactions. We provide a general overview of data requirements and methods available for the assessment and evaluation of occupational exposures in clinical and population-based studies of SLE.

Lack of recording of systemic lupus erythematosus in the death certificates of lupus patients

OBJECTIVE

To determine to what extent the diagnosis of systemic lupus erythematosus (SLE) in deceased lupus patients is under-reported in death certificates, and the patient characteristics associated with such an occurrence.

METHODS

The death certificates of 76 of the 81 deceased SLE patients from two US lupus cohorts (LUMINA for Lupus in Minorities: Nature vs Nurture and CLU for Carolina Lupus Study), including 570 and 265 patients, respectively, were obtained from the Offices of Vital Statistics of the states where the patients died (Alabama, Georgia, North Carolina, South Carolina, Tennessee and Texas). Both cohorts included patients with SLE as per the American College of Rheumatology criteria, aged > or =16 yr, and disease duration at enrolment of < or =5 yr. The median duration of follow-up in each cohort at the time of these analyses ranged from 38.1 to 53.0 months. Standard univariable analyses were performed comparing patients with SLE recorded anywhere in the death certificate and those without it. A multivariable logistic regression model was performed to identify the variables independently associated with not recording SLE in death certificates.

RESULTS

In 30 (40%) death certificates, SLE was not recorded anywhere in the death certificate. In univariable analyses, older age was associated with lack of recording of SLE in death certificates [mean age (standard deviation) 50.9 (15.6) years and 39.1 (18.6) yr among those for whom SLE was omitted and included on the death certificates, respectively, P = 0.005]. Patients without health insurance, those dying of a cardiovascular event and those of Caucasian ethnicity were also more likely to be in the non-recorded group. In the multivariable analysis, variables independently associated with not recording SLE as cause of death were older age [odds ratio = (95% confidence interval) 1.043 (1.005-1.083 per yr increase); P = 0.023] and lack of health insurance [4.649 (1.152-18.768); P = 0.031].

CONCLUSIONS

A high proportion of SLE diagnoses are not recorded in death certificates. Older patients and those without health insurance are more prone to have SLE not recorded. These findings do have implications for the assessment of the impact of this disease in epidemiological studies conducted using vital statistics records.

Single-nucleotide polymorphisms in the C-reactive protein (CRP) gene promoter that affect transcription factor binding, alter transcriptional activity, and associate with differences in baseline serum CRP level

To investigate whether functional polymorphisms exist in the C-reactive protein (CRP) gene, i.e., ones that contribute directly to differences in baseline CRP among individuals, we sequenced a 1,156-nucleotide-long stretch of the CRP gene promoter in 287 ostensibly healthy people. We identified two single-nucleotide polymorphisms (SNPs), a bi-allelic one at nucleotide -409 (G-->A), and a tri-allelic one at -390 (C-->T-->A), both resident within the hexameric core of transcription factor binding E-box elements. Electrophoretic mobility shift assays confirmed that the SNP within the sequence (-412)CACGTG(-407) (E-box 1) modulates transcription factor binding, and that the one within (-394)CACTTG(-389) (E-box 2) supports transcription factor binding only when the -390 T allele is present. The commonest of four E-box 1/E-box 2 haplotypes (-409G/-390T) identified in the population supported highest promoter activity in luciferase reporter assays, and the rarest one (-409A/-390T) supported the least. Importantly, serum CRP in people with these haplotypes reproduced this rank order, i.e., people with the -409G/-390T haplotype had the highest baseline serum CRP (mean +/- SEM 10.9 +/- 2.25 microg/ml) and people with the -409A/-390T haplotype had the lowest (5.01 +/- 1.56 microg/ml). Furthermore, haplotype-associated differences in baseline CRP were not due to differences in age, sex, or race, and were still apparent in people with no history of smoking. At least two other SNPs in the CRP promoter lie within E-box elements (-198 C-->T, E-box 4, and -861 T-->C, E-box 3), indicating that not only is the quality of E-box sites in CRP a major determinant of baseline CRP level, but also that the number of E-boxes may be important. These data confirm that the CRP promoter does encode functional polymorphisms, which should be considered when baseline CRP is being used as an indicator of clinical outcome. Ultimately, development of genetic tests to screen for CRP expression variants could allow categorization of healthy people into groups at high versus low future risk of inflammatory disease.

CTLA-4 gene polymorphisms and systemic lupus erythematosus in a population-based study of whites and African-Americans in the southeastern United States

Cytotoxic lymphocyte antigen-4 (CTLA-4) plays an important role in regulating T cell activation, and may help to limit T cell response under conditions of inflammation. Genetic variability in CTLA-4 has been implicated in the development of several autoimmune diseases. Some studies have described associations between CTLA-4 polymorphisms and systemic lupus erythematosus (SLE), but findings have been inconsistent. We examined polymorphisms in the CTLA-4 gene promoter region (-1722T/C, -1661 A/G, -318C/T) and exon I (+49G/A) with respect to SLE in a population-based case-control study in the southeastern US. Genotypes from 230 recently diagnosed cases and 276 controls were examined separately for African-Americans and whites. We observed no overall associations between SLE and the four CTLA-4 polymorphisms examined. Subgroup analyses revealed effect modification by age for the presence of the -1661G allele, yielding a significant positive association with SLE in younger (<35 years) African-Americans (OR = 3.3). CTLA-4 genotypes also interacted with HLA-DR2 and GM allotype to contribute to risk of SLE. These findings suggest allelic variation in this region of CTLA4 is not a major independent risk factor for SLE, but may contribute to risk of disease in younger African-Americans or in the presence of certain immunogenetic markers.

Pesticide use and menstrual cycle characteristics among premenopausal women in the Agricultural Health Study

Menstrual cycle characteristics may have implications for women's fecundability and risk of hormonally related diseases. Certain pesticides disrupt the estrous cycle in animals. The authors investigated the cross-sectional association between pesticide use and menstrual function among 3,103 women living on farms in Iowa and North Carolina. Women were aged 21-40 years, premenopausal, not pregnant or breastfeeding, and not taking oral contraceptives. At study enrollment (1993-1997), women completed two self-administered questionnaires on pesticide use and reproductive health. Exposures of interest were lifetime use of any pesticide and hormonally active pesticides. Menstrual cycle characteristics of interest included cycle length, missed periods, and intermenstrual bleeding. The authors used generalized estimating equations to assess the association between pesticide use and menstrual cycle characteristics, controlling for age, body mass index, and current smoking status. Women who used pesticides experienced longer menstrual cycles and increased odds of missed periods (odds ratio = 1.5, 95% confidence interval: 1.2, 1.9) compared with women who never used pesticides. Women who used probable hormonally active pesticides had a 60-100% increased odds of experiencing long cycles, missed periods, and intermenstrual bleeding compared with women who had never used pesticides. Associations remained after control for occupational physical activity.

Atomic force microscopy reveals defects within mica supported lipid bilayers induced by the amyloidogenic human amylin peptide

To date, over 20 peptides or proteins have been identified that can form amyloid fibrils in the body and are thought to cause disease. The mechanism by which amyloid peptides cause the cytotoxicity observed and disease is not understood. However, one of the major hypotheses is that amyloid peptides cause membrane perturbation. Hence, we have studied the interaction between lipid bilayers and the 37 amino acid residue polypeptide amylin, which is the primary constituent of the pancreatic amyloid associated with type 2 diabetes. Using a dye release assay we confirmed that the amyloidogenic human amylin peptide causes membrane disruption; however, time-lapse atomic force microscopy revealed that this did not occur by the formation of defined pores. On the contrary, the peptide induced the formation of small defects spreading over the lipid surface. We also found that rat amylin, which has 84% identity with human amylin but cannot form amyloid fibrils, could also induce similar lesions to supported lipid bilayers. The effect, however, for rat amylin but not human amylin, was inhibited under high ionic conditions. These data provide an alternative theory to pore formation, and how amyloid peptides may cause membrane disruption and possibly cytotoxicity.

Systemic lupus erythematosus and genetic variation in the interleukin 1 gene cluster: a population based study in the southeastern United States

BACKGROUND

Interleukin (IL)1alpha and IL1beta, and their endogenous receptor antagonist (IL1Ra), have been related to the pathology of systemic lupus erythematosus (SLE), but the role of IL1 polymorphisms in the aetiology of SLE is unknown.

OBJECTIVE

To examine polymorphisms at IL1alpha -889(C-->T), IL1alpha +4845(C-->T), IL1beta -511(C-->T), IL1beta +3953(G-->T), and IL1Ra (86 bp VNTR) in a population based study of SLE in North Carolina and South Carolina.

METHODS

Genotypes from 230 cases who met ACR classification criteria, and from 275 controls matched for age, sex, and state, were analysed separately for African Americans and whites. Odds ratios (ORs) were estimated by logistic regression models for each locus alone and also after adjusting for polymorphisms at adjacent loci.

RESULTS

An increased risk of SLE for the IL1alpha -889C/C genotype compared with carriage of the -889T allele was found in both African Americans (OR = 3.1, p = 0.001) and whites (OR = 2.9, p = 0.005). In African Americans, carriage of the IL1beta -511T allele was associated with a higher risk of SLE than carriage of the -511C/C genotype (OR = 2.4, p = 0.017), independent of variation at IL1alpha -889.

CONCLUSIONS

The observed associations support the hypothesis that genetic variation in IL1 is involved in the aetiology of SLE and merit further investigation.

Differences by race, sex and age in the clinical and immunologic features of recently diagnosed systemic lupus erythematosus patients in the southeastern United States

We examined the prevalence of clinical and immunologic features of systemic lupus erythematosus (SLE) by race, sex and age in a population-based study of 265 SLE patients. Patients fulfilled the American College of Rheumatology classification criteria. The median time between diagnosis and study enrollment was 13 months. The clinical and hematologic data were limited to occurrences up to 6 months after the diagnosis date, as documented in medical records. We used sera collected at study enrollment from 244 (92%) patients for serologic testing of autoantibodies. The associations between clinical and immunological features of SLE and age, sex and race were examined using logistic regression. The effect of each of these variables was examined adjusting for the other two demographic factors. Mean age at diagnosis was 6 years younger among African-Americans and other minorities compared with white patients (P < 0.01). Discoid lupus, proteinuria, anti-Sm and anti-RNP autoantibodies were more commonly seen in African-American patients, with odds ratios higher than 3.0. Photosensitivity and mucosal ulcers were noted less often in African-American patients. Proteinuria, leukopenia, lymphopenia and thrombocytopenia were approximately three times more common in men compared with women. The prevalence of oral or nasal ulcers and anti-DNA autoantibodies declined with age. The extent to which the differences we observed reflect genetic or environmental influences on the disease process should be investigated.

Familial aggregation of Barrett's oesophagus, oesophageal adenocarcinoma, and oesophagogastric junctional adenocarcinoma in Caucasian adults

BACKGROUND

Although familial clusters of Barrett's oesophagus and oesophageal adenocarcinoma have been reported, a familial predisposition to these diseases has not been systematically investigated.

AIMS

To determine whether Barrett's oesophagus and oesophageal (or oesophagogastric junctional) adenocarcinoma aggregate in families.

PATIENTS AND METHODS

A structured questionnaire eliciting details on reflux symptoms, exposure history, and family history was given to Caucasian case (n=58) subjects with Barrett's oesophagus, oesophageal adenocarcinoma, or oesophagogastric junctional adenocarcinoma, and to Caucasian control (n=106) subjects with symptomatic gastro-oesophageal reflux disease without Barrett's oesophagus. Reported diagnoses of family members were confirmed by review of medical records.

RESULTS

The presence of a positive family history (that is, first or second degree relative with Barrett's oesophagus, oesophageal adenocarcinoma, or oesophagogastric junctional adenocarcinoma) was significantly higher among case subjects compared with controls (24% v 5%; p<0.005). Case subjects were more likely to be older (p<0.001) and male (74% v 43% male; p<0.0005) compared with control subjects. In a multivariate logistic regression analysis, family history was independently associated with the presence of Barrett's oesophagus, oesophageal adenocarcinoma, or oesophagogastric junctional adenocarcinoma (odds ratio 12.23, 95% confidence interval 3.34-44.76) after adjusting for age, sex, and the presence of obesity 10 or more years prior to study enrollment.

CONCLUSIONS

Individuals with Barrett's oesophagus, oesophageal adenocarcinoma, or oesophagogastric junctional adenocarcinoma are more likely to have a positive family history of Barrett's oesophagus, oesophageal adenocarcinoma, or oesophagogastric junctional adenocarcinoma than individuals without Barrett's oesophagus, oesophageal adenocarcinoma, or oesophagogastric junctional adenocarcinoma. A positive family history should be considered when making decisions about screening endoscopy in patients with symptoms of gastro-oesophageal reflux.

Association between baseline levels of C-reactive protein (CRP) and a dinucleotide repeat polymorphism in the intron of the CRP gene

Elevation of baseline C-reactive protein (CRP) is associated with increased risk of cardiac disease. This increase might reflect low-grade inflammation, but differences in CRP serum levels might also have a genetic component. To test this possibility, we investigated whether a polymorphic GT-repeat in the intron of the CRP gene contributes to variation in baseline CRP. We found that the polymorphism was associated with differences in baseline CRP in both normal individuals and in patients with the inflammatory disease systemic lupus erythematosus, viz. donors carrying two GT(16) alleles, two GT(21)alleles, or GT(16/21) heterozygotes had two-fold lower serum CRP than those with other genotypes. The frequency of GT(16) and GT(21) was two-fold higher in Caucasians than in African-Americans, but there was no difference in allele distribution between patients and controls. It is not yet known how this genetic polymorphism mediates its effect on CRP expression, and it probably is not a systemic lupus erythematosus susceptibility factor. Rather, the CRP intron polymorphism likely modifies the disease phenotype. On the other hand, the fact that baseline CRP does have a genetic component suggests that in coronary disease, stratification of risk assessment based on CRP levels might be enhanced by consideration of this polymorphism.

Smoking and use of hair treatments in relation to risk of developing systemic lupus erythematosus

OBJECTIVE

To examine the association between smoking and hair treatments (dyes, permanents) and risk of developing systemic lupus erythematosus (SLE).

METHODS

Patients (n = 265) diagnosed between January 1, 1995, and July 31, 1999, were recruited through 4 university based and 30 community based rheumatology practices in eastern North Carolina and South Carolina. Controls (n = 355) were identified through driver's license records and were frequency matched to patients by age, sex, and state. Data collection included a 60 min in-person interview. Analyses were limited to experiences that occurred before age at diagnosis (patients) or reference age (controls). Because the prevalence of use of hair treatments among men was very low, the analyses of those exposures were limited to women.

RESULTS

There was no association with smoking history and risk of developing SLE when analyzed as status (current, former, or never-smoker) or measures of dose (duration or pack-years). Use of permanent hair dyes in women was associated with a small increased risk of developing SLE (OR 1.5, 95% CI 1.0, 2.2). This association increased with longer duration of use (compared with nonusers, OR 1.7, 95% CI 1.0, 2.7 for 6 or more years). There was little evidence of an association between SLE and use of temporary dyes or of permanents and straighteners.

CONCLUSION

These results suggest at most a weak association between SLE risk and permanent hair dyes or smoking. Genetic variability in the metabolism of these products may be important to assess in future studies.

Immunoglobulin GM and KM allotypes in systemic lupus erythematosus

Genetic variation in immunoglobulin gamma (GM) and kappa (KM) chains was associated with systemic lupus erythematosus (SLE) in some studies. However, the data are conflicting, and only one study examined associations in African-Americans. We examined GM and KM allotypes, by race, in a population-based case-control study of SLE. Sera from patients (n = 222) and controls (n = 273) were typed for GM and KM allotypes by a hemagglutination inhibition method. GM phenotypes were not significantly associated with SLE in African-Americans or Caucasians. However, the frequency of KM phenotypes in Caucasian patients was significantly different from that in controls (p = 0.032). KM3,3 was associated with an increased risk, whereas KM1,3 was associated with a lower relative risk of SLE. In African-Americans, however, the pattern of associations with KM phenotypes differed from that in Caucasians, and the overall difference between patients and controls was not statistically significant.

The delivery of preventive services for patient symptoms

BACKGROUND

Although data are available on rates of delivery of preventive services by primary care physicians, the proportion of services delivered because of related symptoms or signs, rather than for primary or secondary prevention of disease is not known.

METHODS

Research nurses directly observed 4454 consecutive visits to 138 practicing family physicians. Direct observation was used to identify delivery of 36 different services recommended by the U.S. Preventive Services Task Force and to assess whether delivery of these services was associated with related signs or symptoms.

RESULTS

One or more preventive services were delivered in 33% of visits, with rates ranging from 0.2% (HIV prevention) to 19.9% (tobacco counseling). In contrast to pure prevention, services were frequently performed for assessment or care of symptoms or signs, with the ratio ranging from 0% (eye examination; car seat, poison control, and HIV prevention counseling) to 66.7% (hearing test). Physicians varied considerably in the frequency at which their delivery of recommended preventive services was associated with patient symptoms, from 0% to 100% for screening services and from 0% to 100% for counseling services.

CONCLUSIONS

Because of the illness focus of most primary care visits, preventive service delivery is often associated with related signs or symptoms. Care of illnesses appears to present an important impetus and perhaps teachable moments for providing preventive care. Clinician variability in preventive service delivery for patient symptoms shows an opportunity to improve the primary and secondary prevention focus of practice to meet public health prevention goals.

Evaluation of a rapid urine amylase test using post-ERCP hyperamylasemia as a model

OBJECTIVE

The initial diagnosis of acute pancreatitis is often based on clinical criteria together with elevations of serum amylase and lipase. A reliable bedside urine test could facilitate the early diagnosis of pancreatitis. We evaluated a rapid urine amylase test (Rapignost) by using post-ERCP hyperamylasemia as a human model of acute development of hyperamylasemia suggestive of pancreatitis.

METHODS

Seventy-five patients undergoing ERCP were prospectively evaluated. Patients with renal insufficiency, hyperlipidemia, or hyperglycemia were excluded. Before ERCP, patients had serum amylase and lipase measured, and urine amylase tested with the Rapignost test strip. At 4 and 16-24 h post-ERCP, a serum and urine (test strip) amylase were measured again; the adequacy of urine collection was verified by measuring a 2-h creatinine clearance. Patients were clinically assessed for the development of clinical pancreatitis. The concordance of the strip result with post-ERCP hyperamylasemia was assessed.

RESULTS

The sensitivity of the test strip for the detection of hyperamylasemia was greatest at 16-24 h post-ERCP (78%). Specificity was uniformally high (100% specificity at 16-24 h post-procedure). The test strip was positive in all cases of clinical pancreatitis. Of three cases of clinically evident ERCP-induced pancreatitis, only one was urine test strip positive by 4 h post-procedure.

CONCLUSIONS

Using post-ERCP hyperamylasemia as a model, the Rapignost rapid urine amylase test strip was only marginally sensitive but highly specific for hyperamylasemia. The urine test strip was positive in all cases of clinical pancreatitis and may be a useful bedside test for the diagnosis of acute pancreatitis.

Age at natural menopause and the risk of epithelial ovarian cancer

OBJECTIVE

To investigate the relationship between age at natural menopause and risk of developing epithelial ovarian cancer.

METHODS

Using data from six population-based, case-control studies conducted in the United States, age at natural menopause among 1411 women with epithelial ovarian cancer and 6380 control subjects were analyzed using survival analysis methods, including Kaplan-Meier and proportional hazards models. Subjects ranged from 20 to 81 years of age.

RESULTS

The median age at natural menopause was 50 years among cases compared with 51 years among controls, a difference of borderline statistical significance (P =.06). The hazard ratio for the relationship between case-control status and age at natural menopause was 1.09 (95% confidence interval 0.99, 1.20). Controlling for potential confounders including parity, oral contraceptive use, tubal ligation, smoking, and body mass index did not appreciably change this association. There was little evidence of an association between early age at natural menopause and early onset ovarian cancer (diagnosis age under 48 years).

CONCLUSION

We observed a weak association between ovarian cancer risk and age at natural menopause and, among women with early onset disease, there was little evidence to suggest that early menopause is related to ovarian cancer. Thus, there seems little need for increased surveillance or screening for ovarian cancer among women with early natural menopause.

Determination of county-level prostate carcinoma incidence and detection rates with Medicare claims data

BACKGROUND

To the authors' knowledge, national-level population-based data regarding prostate carcinoma incidence and detection currently are not available. The availability of such data could identify those regions with a disproportionately high cancer incidence as well as the population-level association between prostate carcinoma detection and incidence.

METHODS

Inpatient, hospital outpatient, and physician/supplier Medicare claims from 1997 were used to identify incident cases of prostate carcinoma in men age > or = 65 years and to calculate state and county-level incidence rates. The 1991 and 1997 claims data were used to determine small area rates of prostate-specific antigen (PSA) testing and prostate biopsy and to determine their correlation with incidence.

RESULTS

The calculated incidence rates for 1997 were 890 per 100,000 and 1196 per 100,000, respectively, in white males and African-American males and varied substantially between counties (i.e., 25--75th percentile, 676--1124 per 100,000). Rates of PSA and prostate biopsy increased markedly from 1991 to 1997 in both white men (1580 per 100,000 to 24,286 per 100,000) and African-American men (1277 per 100,000 to 15,190 per 100,000), and considerable variation in detection between counties was observed. Counties that had higher rates of prostate biopsy also had higher age-adjusted incidence rates, and county-level PSA testing was found to be associated with incidence in African-American patients, but not in white patients.

CONCLUSIONS

Medicare claims may provide an alternative source of population-based data, particularly for areas in which registry data are not readily available or are of limited scope. In addition, claims provide otherwise unavailable national data concerning cancer detection.

Effects of alcohol-related disease on hip fracture and mortality: a retrospective cohort study of hospitalized Medicare beneficiaries

OBJECTIVES

This study investigated the effect of alcohol-related disease on hip fracture and mortality.

METHODS

A retrospective cohort design was used. The study cohort consisted of hospitalized Medicare beneficiaries with alcohol-related disease (n = 150,119) and randomly matched controls without alcohol-related disease (n = 726,218) identified through the 1988-1989 inpatient claims file. Incidence rates of hip fracture and mortality were examined.

RESULTS

During the study period, 20,620 patients developed hip fracture, with 6973 cases among patients with alcohol-related disease and 13,647 cases among patients without alcohol-related disease. After adjustment for potential confounders, patients with alcohol-related disease had a 2.6-fold increased risk of hip fracture relative to patients without alcohol-related disease (95% confidence interval = 2.5, 2.6). Patients with alcohol-related disease had a higher risk of mortality at 1 year after hip fracture.

CONCLUSIONS

Alcohol-related disease increases the risk of hip fracture significantly and reduces long-term survival. The present results suggest that patients hospitalized for alcohol-related disease should be targeted for hip fracture prevention programs.

Measures of menopausal status in relation to demographic, reproductive, and behavioral characteristics in a population-based study of women aged 35-49 years

The purpose of this cross-sectional analysis of women aged 35-49 years from the Third National Health and Nutrition Examination Survey, conducted between 1988 and 1994, was to assess associations with menopausal status based either on menstrual cycle patterns or on elevated (>20 IU/liter) follicle-stimulating hormone. Menstrual cycle-based menopausal status was defined for women who had not had surgical menopause by months since the last period (<2, 2-12, and >12 months for pre-, peri-, and postmenopause, respectively). Logistic regression was adjusted for age, smoking, and unilateral oophorectomy. Higher body mass index (> or =30 kg/m(2) compared with < 25.0 kg/m(2)) was associated with a lower likelihood of elevated follicle-stimulating hormone (odds ratio (OR)=0.6, 95% confidence interval (CI): 0.4, 0.9) but this association was not seen with the menstrual measure of menopause. Exercise (three or more times per week) was associated with a lower likelihood of being postmenopausal on the basis of menstrual (OR = 0.3, 95% CI: 0.2, 0.7) and hormonal (OR = 0.6, 95% CI: 0.4, 1.0) measures. Alcohol use also tended to be associated with postmenopausal status by either measure, but not significantly so. There was little evidence of associations with ethnicity, education, age at menarche, number of livebirths, and oral contraceptive use. Menstrual-based definitions of menopause can be misclassified for women with menstrual irregularity. This might explain why obese women were classified menstrually as menopausal while remaining hormonally premenopausal.

Impact of a guideline-based disease management team on outcomes of hospitalized patients with congestive heart failure

BACKGROUND

Congestive heart failure is the most common reason for hospitalization in the United States, and guidelines to improve the quality of care for patients with congestive heart failure have been developed. However, adherence is typically low. We hypothesized that a guideline-based care management team would result in greater quality and efficiency of care than guidelines alone.

METHODS

A faculty cardiologist and nurse care manager at an academic medical center reviewed each patient's data and made guideline-based recommendations. Hospital length of stay, total costs, and use of recommended guidelines were compared between 173 patients before team implementation but with available guidelines, 283 care-managed patients, and 126 concurrent non-care-managed patients.

RESULTS

Care-managed patients achieved higher rates of use of angiotensin-converting enzyme inhibitor than baseline or non-care-managed patients (95%, 60%, and 75%, respectively; P<.001), as well as increased adherence to guidelines for daily weight monitoring and assessment of left ventricular function. Hospital length of stay was lower (median, 3, 4, and 5 days, respectively; P<.001) as were costs of hospitalization (median, $2934, $3209, and $4830, respectively; P<.01). These differences persisted after adjustment for severity of illness.

CONCLUSIONS

When compared with dissemination of guidelines alone, an active care management approach was associated with significant improvements in quality and efficiency of care for hospitalized patients with congestive heart failure.

Effectiveness of endoscopy in patients admitted to the intensive care unit with upper GI hemorrhage

BACKGROUND

Esophagogastroduodenoscopy (EGD) is generally indicated for the management of patients admitted to intensive care units (ICUs) with upper gastrointestinal (GI) hemorrhage but its impact in community practice has not been measured. Thus, the effectiveness of 3 EGD factors, viz., accurate initial diagnosis, performance within 24 hours of admission (early EGD), and appropriate intervention, was examined.

METHODS

Records of 214 patients admitted to the ICU of 10 metropolitan hospitals with upper GI hemorrhage were reviewed. Unadjusted and severity-adjusted associations of the 3 EGD factors with length of hospital stay, length of ICU stay, readmission to ICU, recurrent bleeding, surgery, and death were evaluated.

RESULTS

Inaccurate diagnosis occurred in 10% of patients at initial EGD and was associated with significant increases in risk of recurrent bleeding (70% vs. 11%, p < 0.001), rate of surgery (20% vs. 4%, p < 0.05), length of hospital stay (median 7.5 vs. 5 days, p < 0.005), length of ICU stay (median 4 vs. 2 days, p < 0.005), and rate of readmission to ICU (20% vs. 0.6%, p < 0.001). These associations persisted after adjusting for severity of illness. Early EGD performed in 82% of patients was associated with significant severity-adjusted reductions in hospital (-33%: 95% CI [-45%, -18%]) and ICU (-20%: 95% CI [-24%, -3%]) stay. Appropriate intervention at initial EGD, performed in 84% of patients, was associated with reductions in severity-adjusted length of ICU stay (-18%: 95% CI [-32%, 0%]) and rate of recurrent bleeding (odds ratio = 0.37, 95% CI [0.13, 1.06]).

CONCLUSIONS

Early, accurate EGD with appropriate therapeutic intervention is effective as practiced in the community and is associated with improved outcomes for patients with upper GI hemorrhage admitted to the ICU. Inaccurate diagnosis at initial EGD is uncommon but has a significant adverse association with all outcome measures.

Exposure to 1,1-dichloro-2,2-bis(p-chlorophenyl)ethylene (DDT) in relation to bone mineral density and rate of bone loss in menopausal women

The organochlorine pesticide 2,2-bis(p-chlorophenyl)-1,1,1,-trichloroethane (DDT) and its metabolite 1,1-dichloro-2,2-bis(p-chlorophenyl)ethylene (DDE) are examples of an environmental contaminant that may have hormonal properties. Bone metabolism is both estrogen- and androgen-dependent. Exposures to various environmental endocrine disrupters can affect bone metabolism in animals, but there are no published data concerning the effect of DDE exposure on bone metabolism in humans. We hypothesized that high levels of DDE would be associated with lower bone density in peri- and postmenopausal women than in premenopausal women. Study subjects were drawn from the cohort of women who had participated in the Mount Sinai Medical Center Longitudinal Normative Bone Density Study (1984-1987). We used serum samples obtained at study entry to measure DDE levels in 103 (50 black, 53 white) women (mean age = 54.5 y [standard deviation = 5 y]). Measurements of bone mineral density at the lumbar spine and radius were made at 6-mo intervals during a 2-y period. DDE concentrations were significantly (p < .001) higher in blacks (13.9 ng/ml) than in whites (8.4 ng/ml), but there was no correlation between DDE concentration and bone density at the spine (mean levels = 1.065 g/cm2 and 1.043 g/cm2 in the lowest and highest quartiles, respectively, of DDE [trend p value = .85]) or at the radius (mean levels = 0.658 g/cm and 0.664 g/cm in the lowest and highest quartiles, respectively, of DDE [trend p value = .34]). Longitudinal analyses revealed no correlation between DDE and the rate of bone loss at either bone site. Similar results were seen in race-stratified analyses, as well as in analyses in which we controlled for lactation history and other potential confounders. We found little evidence that chronic low-level DDT exposure is associated with bone density in peri- and postmenopausal women.

Menstrual patterns and risk of adult-onset diabetes mellitus

We examined the association between menstrual patterns and risk of developing adult-onset diabetes in a prospective study of 668 white, college-educated women who completed menstrual diaries throughout their reproductive years. We calculated summary measures of cycle length and variability and bleeding duration for ages < or = 22, 23-27, 28-32, and 33-37 years. The analysis included 35,418 person-years of follow-up and 49 self-reported cases of diabetes (median age at diagnosis, 63 years). There was no association between diabetes risk and age at menarche, mean cycle length, cycle variability, or frequency of long cycles (> 42 days). Longer bleeding periods in the mid- and late reproductive years were somewhat associated with an increased risk of diabetes (adjusted rate ratio 1.4, 95% confidence interval 1.0-1.8 per day increase in bleeding duration for menses during ages 28-32). These results do not support the association of long or irregular menstrual cycles with post-menopausal diabetes incidence, but do suggest a possible association of longer bleeding duration with subsequent onset of diabetes.

Effectiveness of ERCP in cholangitis: a community-based study

BACKGROUND

Although experts have demonstrated the efficacy of endoscopic retrograde cholangiopancreatography (ERCP) in cholangitis, the effectiveness of ERCP in unselected patients has not been measured. The aim was to investigate the clinical impact of ERCP performed at any time and of early ERCP (within 24 hours of admission) in patients with a primary discharge diagnosis of cholangitis.

METHODS

A retrospective record review of patients admitted to eight area hospitals with an International Classification of Diseases (ICD)-9 diagnosis consistent with cholangitis was performed. Extracted data included clinical characteristics, ERCP findings, and patient outcome. The associations of ERCP overall and early ERCP with length of stay were examined. Confounding factors including severity of illness, etiology of cholangitis, and hospital type were adjusted for in a multivariate analysis.

RESULTS

A total of 116 patients were studied. ERCP was performed in 71 patients with endoscopic therapy administered in 57 (80%). ERCP overall was not associated with any change in length of hospital stay. However, compared with other invasive biliary procedures, ERCP was associated with a shorter hospital stay (median 5 vs. 9.5 days, p = 0.01) and a 36% (95% CI [5%, 57%]) reduction in severity-adjusted length of stay. Patients who had early ERCP had a significantly shorter hospital stay than those who had delayed ERCP (median 4 vs. 7 days, p < 0.005) and early ERCP was associated with a 34% (95% CI [11%, 48%]) reduction in severity-adjusted length of stay.

CONCLUSION

Early ERCP may be an effective strategy for shortening the length of stay in patients hospitalized with cholangitis.

Role of Doppler US in acute peptic ulcer hemorrhage: can it predict failure of endoscopic therapy?

BACKGROUND

Recurrent bleeding after successful primary endoscopic hemostasis of acutely bleeding ulcers is a significant problem. This study evaluates endoscopic Doppler ultrasound (US) in assessing risk of recurrent bleeding in patients presenting with acute peptic ulcer hemorrhage.

METHODS

In this prospective, double-blind, nonrandomized trial, patients were enrolled from a single academic institution. Only patients with endoscopically confirmed gastric, duodenal, pyloric, or anastomotic ulcers were enrolled. The therapeutic endoscopist was blinded to the Doppler US signal from the ulcer and based treatment decisions on standard guidelines. A 16 MHz pulsed-wave, linear scanning, US probe was used through the accessory channel of an endoscope to assess for the presence of a Doppler signal.

RESULTS

Fifty-two of 139 screened patients entered the trial (55 Doppler sessions). Endoscopic therapy was performed in 42% (30-day recurrent bleeding rate of 17%). Ulcers that remained persistently Doppler positive immediately after endoscopic therapy had a significantly higher rate of recurrent bleeding than ulcers where the Doppler signal was abolished: 100% versus 11% (p = 0.003). There were no bleeding-related deaths.

CONCLUSIONS

A persistently positive Doppler US signal appears to be a marker of inadequate endoscopic therapy in patients with acutely bleeding peptic ulcers.

Risk of ovarian cancer in relation to use of phenolphthalein-containing laxatives

We examined ovarian cancer risk in relation to use of phenolphthalein-containing laxatives in 410 epithelial ovarian cancer cases and 713 controls. Compared to women who never used a laxative, ever use of a phenolphthalein-containing laxative was not associated with an increased risk of ovarian cancer (odds ratio, OR, 1.1, 95% confidence interval, CI, 0.9-1.4). Risk was slightly, but not significantly, higher with more frequent use (OR 1.2 for 75 or more days of use). When women who used non-phenolphthalein containing laxatives was used as the reference group, the associations were slightly, but not significantly larger (OR 1.4 for any use of phenolphthalein-containing laxatives and OR 1.5 for 75 or more days of use)

Design and implementation of an inpatient disease management program

OBJECTIVE

To describe the development and implementation of an inpatient disease management program.

STUDY DESIGN

Prospective observational study.

PATIENTS AND METHODS

On the basis of opportunities for improving quality or efficiency of inpatient and emergency department care, 4 diagnoses, including congestive heart failure (CHF), gastrointestinal hemorrhage, community-acquired pneumonia and sickle-cell crisis were selected for implementation of a disease management program. For each diagnosis, a task force assembled a disease management team led by a "physician champion" and nurse care manager and identified opportunities for improvement through medical literature review and interviews with caregivers. A limited number of disease-specific guidelines and corresponding interventions were selected with consensus of the team and disseminated to caregivers. Physician and nurse team leaders were actively involved in patient care to facilitate adherence to guidelines.

RESULTS

For quarter 2 to 4 of 1997, there were improvements in angiotensin-converting enzyme inhibitor use, daily weight compliance, assessment of left ventricular function, hospital costs, and length of stay for care-managed patients with CHF. Differences in utilization-related outcomes persisted even after adjustment for severity of illness. For the other 3 diagnoses, the observational period was shorter (quarter 4 only), and hence preliminary data showed similar hospital costs and length of stay for care-managed and noncare-managed patients.

CONCLUSIONS

An interdisciplinary approach to inpatient disease management resulted in substantial improvements in both quality and efficiency of care for patients with CHF. Additional data are needed to determine the program's impact on outcomes of other targeted diagnoses.

Patterns of endoscopic follow-up after surgery for nonmetastatic colorectal cancer

BACKGROUND

Endoscopic examinations of the colon are often recommended for surveillance following colorectal cancer resection. The actual use and outcome of this testing are not known.

METHODS

Five thousand seven hundred sixteen patients 65 years of age or older with local or regional stage colorectal cancer diagnosed in 1991 were identified through the Surveillance Epidemiology and End Results registry. All inpatient and outpatient Medicare claims from 6 months after diagnosis through the end of 1994 were examined to determine use of endoscopic procedures.

RESULTS

One or more colonoscopies were performed in 51%, with an average of 2.9 procedures performed among those tested; sigmoidoscopy was performed in 17%. The rate of colonoscopy was highest during the initial 18 months. Polypectomy was performed in 21% of all patients, and subsequent primary colorectal tumors were diagnosed in 1.3%. Factors associated with colonoscopy and sigmoidoscopy use included younger age, survival through follow-up, and geographic region; sigmoidoscopy was also more common in relation to rectal cancers.

CONCLUSIONS

There is variability in the use of endoscopic procedures following potentially curative resection for colorectal cancer, with patient-related factors and local practice patterns accounting for the variation. Further studies are needed to elicit the reasons for lack of follow-up and adherence to practice guidelines.

Endosonographic assessment of multimodality therapy predicts survival of esophageal carcinoma patients

BACKGROUND

Standard endosonographic (EUS) staging criteria are unreliable for staging esophageal carcinoma after neoadjuvant therapy; however, measurement of tumor size reduction can identify patients who have achieved a pathologic response. In the current study the authors prospectively compared survival between patients classified as responders and those classified as nonresponders by EUS.

METHODS

The maximal transverse cross-sectional area of the tumor was measured before and after neoadjuvant therapy in patients who were candidates for multimodality treatment. Response was defined as a > or = 50% reduction in tumor area.

RESULTS

A total of 59 patients at 2 centers were followed for a median of 19 months. EUS assessed response in 34 patients (58%). Overall, responders had a median survival of 17.6 months compared with 14.5 months for nonresponders (P < 0.005). Survival was significantly longer in responders compared with nonresponders in the patient subgroup who underwent surgical resection (19.7 months vs. 14.6 months; P < 0. 005), the patient subgroup with adenocarcinoma (21.4 months vs. 10.8 months; P < 0.005), and the patient subgroup initially classified as having T3N1 disease (17.6 months vs. 14.1 months; P < 0.05). Survival was not found to differ significantly between responders and nonresponders in the subgroup of patients with squamous cell carcinoma. EUS response was the only clinical variable that was associated with survival time in a multivariate analysis (relative hazard = 0.27; P < 0.005).

CONCLUSIONS

Patients with esophageal carcinoma who respond to neoadjuvant treatment as identified by EUS measurement of reduction in tumor size have a significantly better prognosis than nonresponders.

Use of intensive care-specific interventions in major teaching and other hospitals: a regional comparison

OBJECTIVE

To compare the use of 40 specific medical interventions in intensive care units (ICUs) of major teaching and other hospitals

DESIGN

Retrospective cohort study.

SETTING

Thirty-eight ICUs in 28 hospitals in a large metropolitan region.

PATIENTS

A total of 12,929 consecutive eligible admissions to medical, surgical, neurologic, or mixed medical/surgical ICUs between January 1, and June 30, 1994.

MEASUREMENTS

The use of 40 diagnostic and therapeutic interventions during the first 24 hrs of ICU admission were obtained from patient medical records and a weighted intervention score was determined for each patient. Admission severity of illness was measured by using the Acute Physiology and Chronic Health Evaluation III methodology.

MAIN RESULTS

Patients at the five teaching hospitals had a greater severity of illness (mean predicted risk of in-hospital death, 15.1%+/-21.9% vs. 11.2%+/-19.0%; p < .01) than patients at the 23 other hospitals. Patients at major teaching hospitals also had higher mean intervention scores (3.5+/-4.9 vs. 2.3+/-3.7; p < .01). Differences in intervention scores persisted after controlling for severity of illness, admission diagnosis, and admission source. However, scores varied among the major teaching hospitals. When examined individually, only three of the five major teaching hospitals had higher (p < .05) interventions scores, compared with other hospitals, whereas one had a lower (p < .05) intervention score.

CONCLUSIONS

Patients in ICUs at major teaching hospitals were, in aggregate, more likely to receive diagnostic and therapeutic interventions than patients at other hospitals. Variation among major teaching hospitals suggests that factors other than teaching status also affect the use of these interventions.

Agreement of Medicare claims and tumor registry data for assessment of cancer-related treatment

BACKGROUND

Although health claims data are increasingly used in evaluating variations in patterns of cancer care and outcomes, little is known about the comparability of these data with tumor registry information.

OBJECTIVES

To evaluate the agreement between Medicare claims and tumor registry data in measuring patterns of diagnostic and therapeutic procedures for older cancer patients.

RESEARCH DESIGN

Analysis of a database linking Surveillance, Epidemiology and End Results (SEER) registry data and Medicare claims in patients aged > or =65 years with cancer.

SUBJECTS

361,255 Medicare patients with invasive breast, colorectal, endometrial, lung, pancreatic, and prostate cancer diagnosed between 1984 and 1993.

MEASURES

Concordance of SEER files with corresponding Medicare claims.

RESULTS

Medicare claims generally identified patients who underwent resection and radical surgery according to SEER (ie, concordance > or =85%-90%) but less likely biopsy or local excision (ie, concordance < or =50%). In some instances, claims also categorized patients as having more invasive surgery than was listed in SEER and also provided incremental information about the use of surgical treatment after 4 months. SEER files and, to a lesser degree, Medicare claims identified radiation therapy not included in the other data source, and Medicare files also captured a significant number of patients with codes for chemotherapy.

CONCLUSIONS

Medicare files may be appropriate for studies of patterns of use of surgical treatment, but not for diagnostic procedures. The potential benefit of Medicare claims in identifying delayed surgical intervention and chemotherapy deserves further study.

The accuracy of diagnosis and procedural codes for patients with upper GI hemorrhage

BACKGROUND

Little is known about the accuracy of diagnostic and procedural codes for common gastrointestinal (GI) conditions and endoscopic procedures.

METHODS

Eight hundred eighty-two patients with upper GI hemorrhage admitted in 1994 to 1 of 13 regional hospitals were studied. Based on endoscopy reports, the source of hemorrhage, performance of upper endoscopy and use of endoscopic therapy were determined, and we assessed the sensitivity and positive predictive value of discharge codes for measuring the source of hemorrhage and use of upper endoscopy.

RESULTS

The sensitivity and positive predictive value of principal diagnosis coding for source of hemorrhage were typically 85% to 95%. The sensitivity and predictive value of coding for upper endoscopy were 97.7% and 99.9%, respectively, and were 72.3% and 99.4%, respectively, for endoscopic therapy. Accuracy did not differ between the 4 major teaching and 9 other hospitals.

CONCLUSIONS

Hospital-based diagnostic and procedural codes are a reasonably accurate source of data for clinical and outcomes analyses of upper GI hemorrhage. In particular, it is possible to discern from these data the source of hemorrhage and the overall use of upper endoscopy.

Age at menopause and childbearing patterns in relation to mortality

Several studies have reported increased mortality risk with early natural menopause. More recently, mortality risk was reported to be reduced among women who gave birth at age > or =40 years. The association between reproductive history and mortality was explored among 826 women in a prospective study involving 18,959 person-years of follow-up (from age 50 to 1990-1991) and 108 deaths. After adjustment for age and other covariates, the risk ratio among parous women was 1.53 (95% confidence interval: 0.58, 4.07) for natural menopause at age < or =45 years compared with > or =51 years. In contrast to a previous report, however, the highest estimated mortality risk was seen among women who gave birth in their forties (adjusted risk ratio = 2.14, 95% confidence interval: 1.05, 4.38) compared with having a last birth at ages 30-34 years.

The association between hospital type and mortality and length of stay: a study of 16.9 million hospitalized Medicare beneficiaries

OBJECTIVES

To examine the association between hospital type and mortality and length of stay using hospitalized Medicare beneficiaries for a 10-year period.

METHODS

The retrospective cohort study included 16.9 million hospitalized Medicare beneficiaries > or = 65 years of age admitted for 10 common medical conditions and 10 common surgical procedures from 1984 to 1993. A total of 5,127 acute-care hospitals in the United States were grouped into 6 mutually exclusive hospital types based on teaching status and financial structure (for-profit [FP], not-for-profit [NFP], osteopathic [OSTEO], public [PUB], teaching not-for-profit [TNFP], and teaching public [TPUB]) as reported in the 1988 American Hospital Association database. Logistic and linear regression methods were used to examine risk-adjusted 30-day and 6-month mortality and length of stay.

RESULTS

During the 10-year study period, 10.6 million patients were admitted with 1 of the 10 selected medical conditions, and 6.3 million patients were hospitalized for 1 of the 10 selected surgical procedures. Patients at TNFP hospitals had significantly lower risk-adjusted 30-day mortality rates than patients at other hospital types when all diagnoses or procedures were combined (combined diagnoses: RR(TNFP) = 1.00 [reference], RR(TPUB) = 1.40, RR(OSTEO) = 1.14, RR(PUB) = 1.07, RR(FP) = 1.03, RR(NFP) = 1.02; combined procedures: RR(TNFP) = 1.00 [reference], RR(OSTEO) = 1.36, RR(TPUB) = 1.30, RR(PUB) = 1.16, RR(FP) = 1.13, RR(NFP) = 1.08). The results were mostly consistent when diagnoses and procedures were examined separately. After adjustment for patient characteristics, patients at other hospital types had 10% to 20% shorter lengths of stay (LOS) than patients at TNFP hospitals for most diagnoses and procedures studied.

CONCLUSION

As measured by the risk-adjusted 30-day mortality, TNFP hospitals had an overall better performance than other hospital types. However, patients at TNFP hospitals had relatively longer LOS than patients at other hospital types, perhaps reflecting the medical education and research activities found at teaching institutions. Future research should examine the empirical evidence to help elucidate the adequate LOS for a given condition or procedure while maintaining the quality of care.

FSH levels in relation to hysterectomy and to unilateral oophorectomy

OBJECTIVE

To examine the association between hysterectomy, unilateral oophorectomy, and ovarian status, measured by FSH concentrations, in women aged 35-49 years.

METHODS

From the National Health and Examination Survey III, 1716 women aged 35-49 years were studied. Information on menopausal status, surgical history (hysterectomy, single or bilateral oophorectomy), smoking, and other characteristics was collected in a structured interview, height and weight were measured, and one blood sample was collected. We used logistic regression to analyze FSH concentration in relation to hysterectomy and oophorectomy, controlling for age, ethnicity, body mass index, smoking, education, nulligravidity, and exercise.

RESULTS

Hysterectomy with unilateral oophorectomy was associated with an increased prevalence of elevated FSH (above 20 IU/L) (adjusted odds ratio [OR] 2.4, 95% confidence interval [CI] 1.3, 4.6) compared with women who had not had hysterectomies or oophorectomies. Among women with two ovaries, hysterectomy was associated with increased prevalence of elevated FSH (adjusted OR 1.5, 95% CI 1.0, 2.5). As a comparison of the effect size, the observed association between hysterectomy and elevated FSH was smaller than the association between FSH and current smoking (OR 2.0), a factor associated with a 1-2 year decrease in mean age at natural menopause.

CONCLUSION

Although the differences in FSH levels were small, there was evidence of elevated FSH in women who have had hysterectomies, even if at least one ovary remained.

Colorectal carcinoma screening attitudes and practices among primary care physicians in counties at extremes of either high or low cancer case-fatality

BACKGROUND

To the authors' knowledge, physician attitudes and reported practices regarding colorectal carcinoma screening have not been studied in areas of highest risk for cancer death.

METHODS

Medicare claims were used to calculate colorectal carcinoma 2-year case-fatality rates for counties with >100 incident cases of colorectal carcinoma between 1991-1993. All 2682 practicing primary care physicians in 20 counties with the lowest case-fatality rates (mean of 29.9%) and 19 counties with the highest case-fatality rates (mean of 47.8%) were surveyed regarding their screening procedures and attitudes.

RESULTS

Among the 972 respondents (36.1%), the reported use of fecal occult blood testing (FOBT) and flexible sigmoidoscopy was similar in the low and high case-fatality counties. However, physicians who practiced in the high case-fatality counties were less likely to be trained in and to perform sigmoidoscopy themselves (37.0% vs. 45.6%; P<0.01). Moreover, practitioners in the high case-fatality counties were more likely than the other physicians to consider or plan enhanced FOBT and sigmoidoscopic screening in the near future. FOBT and sigmoidoscopy screening rates at the county level were associated negatively with cancer incidence rates, case-fatality rates, and metastatic disease rates, suggesting a potentially protective effect.

CONCLUSIONS

Geographically targeted interventions are a potentially cost-effective strategy for focusing additional screening services on the highest risk populations. The primary care clinicians in these high risk areas are logical partners for these interventions by virtue of their high degree of readiness to change their current screening practices.

Active and passive smoking and the occurrence of natural menopause

We examined smoking in relation to natural menopause in 543 women who prospectively recorded menstrual data from their 20s. Mean age at natural menopause was 0.8 years younger (95% CL = -1.5, -0.0) in 98 women who smoked at menopause compared with 362 never-smokers (RR 1.3, 95% CI = 1.0-1.7). We did not observe a decrease in age at natural menopause in former smokers, a dose-response among current smokers, or a lower age at menopause with passive smoke exposure at home. These results suggest that the effect of smoking on ovarian senescence is limited to active smoking during the menopausal transition.

Occupational exposure to crystalline silica and autoimmune disease

Occupational exposure to silica dust has been examined as a possible risk factor with respect to several systemic autoimmune diseases, including scleroderma, rheumatoid arthritis, systemic lupus erythematosus, and some of the small vessel vasculitidies with renal involvement (e.g., Wegener granulomatosis). Crystalline silica, or quartz, is an abundant mineral found in sand, rock, and soil. High-level exposure to respirable silica dust can cause chronic inflammation and fibrosis in the lung and other organs. Studies of specific occupational groups with high-level silica exposure (e.g., miners) have shown increased rates of autoimmune diseases compared to the expected rates in the general population. However, some clinic- and population-based studies have not demonstrated an association between silica exposure and risk of autoimmune diseases. This lack of effect may be due to the limited statistical power of these studies to examine this association or because the lower- or moderate-level exposures that may be more common in the general population were not considered. Experimental studies demonstrate that silica can act as an adjuvant to nonspecifically enhance the immune response. This is one mechanism by which silica might be involved in the development of autoimmune diseases. Given that several different autoimmune diseases may be associated with silica dust exposure, silica dust may act to promote or accelerate disease development, requiring some other factor to break immune tolerance or initiate autoimmunity. The specific manifestation of this effect may depend on underlying differences in genetic susceptibility or other environmental exposures.

The role of genetic factors in autoimmune disease: implications for environmental research

Studies in both humans and in animal models of specific disorders suggest that polymorphisms of multiple genes are involved in conferring either a predisposition to or protection from autoimmune diseases. Genes encoding polymorphic proteins that regulate immune responses or the rates and extent of metabolism of certain chemical structures have been the focus of much of the research regarding genetic susceptibility. We examine the type and strength of evidence concerning genetic factors and disease etiology, drawing examples from a number of autoimmune diseases. Twin studies of rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), type I diabetes, and multiple sclerosis (MS) indicate that disease concordance in monozygotic twins is 4 or more times higher than in dizygotic twins. Strong familial associations (odds ratio ranging from 5-10) are seen in studies of MS, type I diabetes, Graves disease, discoid lupus, and SLE. Familial association studies have also reported an increased risk of several systemic autoimmune diseases among relatives of patients with a systemic autoimmune disease. This association may reflect a common etiologic pathway with shared genetic or environmental influences among these diseases. Recent genomewide searches in RA, SLE, and MS provide evidence for multiple susceptibility genes involving major histocompatibility complex (MHC) and non-MHC loci; there is also evidence that many autoimmune diseases share a common set of susceptibility genes. The multifactorial nature of the genetic risk factors and the low penetrance of disease underscore the potential influence of environmental factors and gene-environment interactions on the etiology of autoimmune diseases.

Use of open access in GI endoscopy at an academic medical center

BACKGROUND

Open access endoscopy systems (those in which endoscopy is performed without prior gastroenterology consultation) are becoming more common in the current cost-conscious environment. The aim of this study was to compare appropriateness and yield of endoscopy for patients referred for open access endoscopy with those for patients who had prior contact with a gastroenterologist. We also evaluated patients' preference for undergoing open access endoscopy as opposed to having prior consultation with a gastroenterologist and compared preparedness for endoscopic procedures between the two groups.

METHODS

The cases of all outpatients referred for upper endoscopy and colonoscopy were assessed prospectively over a 5-month period. American Society for Gastrointestinal Endoscopy (ASGE) guidelines for indications for gastrointestinal endoscopy were used to determine appropriateness of referrals. Significant pathologic findings were rated independently by two investigators using defined criteria. Patients' opinions regarding preparedness for endoscopy and referral preference were measured by means of questionnaires administered before endoscopy.

RESULTS

Eighty-six percent of endoscopies after consultation with gastroenterologists were performed for accepted indications compared with 65% of open access procedures (p < 0.01). Significant pathologic findings were present in 40% of the former group compared with 28% of those undergoing open access endoscopy (p < 0.01). Significant pathologic findings were found in 37% of endoscopies performed for indications listed in the ASGE guidelines compared with 20% for unlisted indications (p < 0.01). Forty percent of patients referred for open access endoscopy would have preferred prior consultation with a gastroenterologist.

CONCLUSION

Patients initially seen by a gastroenterologist are more likely to undergo endoscopy for accepted indications, and the yield of endoscopy is higher than among patients referred through an open access system. The system of open access endoscopy as currently practiced may have to be reassessed.