Health Care Utilization and Costs Associated with Childhood Abuse

Background Physical and sexual childhood abuse is associated with poor health across the lifespan. However, the association between these types of abuse and actual health care use and costs over the long run has not been documented. Objective To examine long-term health care utilization and costs associated with physical, sexual, or both physical and sexual childhood abuse. Design Retrospective cohort. Participants Three thousand three hundred thirty-three women (mean age, 47 years) randomly selected from the membership files of a large integrated health care delivery system. Measurements Automated annual health care utilization and costs were assembled over an average of 7.4 years for women with physical only, sexual only, or both physical and sexual childhood abuse (as reported in a telephone survey), and for women without these abuse histories (reference group). Results Significantly higher annual health care use and costs were observed for women with a child abuse history compared to women without comparable abuse histories. The most pronounced use and costs were observed for women with a history of both physical and sexual child abuse. Women with both abuse types had higher annual mental health (relative risk [RR] = 2.07; 95% confidence interval [95%CI] = 1.67–2.57); emergency department (RR = 1.86; 95%CI = 1.47–2.35); hospital outpatient (RR = 1.35 = 95%CI = 1.10–1.65); pharmacy (incident rate ratio [IRR] = 1.57; 95%CI = 1.33–1.86); primary care (IRR = 1.41; 95%CI = 1.28–1.56); and specialty care use (IRR = 1.32; 95%CI = 1.13–1.54). Total adjusted annual health care costs were 36% higher for women with both abuse types, 22% higher for women with physical abuse only, and 16% higher for women with sexual abuse only. Conclusions Child abuse is associated with long-term elevated health care use and costs, particularly for women who suffer both physical and sexual abuse.     

HLA class 1 associations in Henoch Schonlein purpura: increased and decreased frequencies

Henoch Schonlein purpura (HSP) is the most common vasculitis of childhood. Susceptibility to HSP and associated clinical heterogeneity in HSP may be conferred by a number of genetic loci, including the major histocompatibility complex. We aimed to investigate the implications of the human leukocyte antigen (HLA) class 1 alleles in susceptibility to HSP and determine the possible associations with renal, gastrointestinal (GI), and joint manifestations of the disease. 110 children with HSP (66 boys, 44 girls) and 250 unrelated healthy controls were enrolled in the study. The mean age was 8.65 ± 3.59 years. HSP was diagnosed on the basis of clinical and laboratory data according to the American College of Rheumatology classification. The diagnosis was supported with skin and/or kidney in most of the patients. Clinical and laboratory findings revealed: skin involvement in 110 (100%), joint manifestations in 82 (74.5%), GI symptoms in 58 (52.7%), and hematuria and/or proteinuria in 36 (32.7%) patients. HLA class 1 alleles were identified by DNA amplification, hybridized with specific primer sequences. Comparison of frequencies between patients and controls were made by using the Fisher’s exact test. Odds ratio (OR) was used as the measure of association. HLA A2, A11, and B35 antigens showed an increased risk for predisposition to HSP (OR = 1.714, 95%CI = 1.088–2.700, p = 0.020; OR = 2.185, 95%CI = 1.289–3.703, p = 0.003; and OR = 2.292, 95%CI = 1.451–3.619, p = 0.000, respectively), while HLA A1, B49, and B50 antigens revealed decreased risk for predisposition to HSP (OR = 4.739, 95%CI = 1.828–12.345, p = 0.001; OR = 3.268, 95%CI = 0.955–11.236, p = 0.047; and OR = 7.462, 95%CI = 0.975–55.555, p = 0.024, respectively). Considering the renal involvement and severity of proteinuria, there was no association with HLA class 1 alleles. Our results suggest that the increased frequency of HLA A2, A11, and B35 alleles in unselected pediatric HSP patient population and miscarrying of HLA A1, B49, and B50 could be considered as a risk factor for susceptibility to HSP.     

Cytotoxic T lymphocyte antigen-4 promoter ?658CT gene polymorphism is associated with ulcerative colitis in Chinese patients

Background and aim  Cytotoxic T lymphocyte antigen-4 (CTLA-4) plays a role in the downregulation of T cell activation. The present study aimed to examine an association between the CTLA-4 gene polymorphisms and ulcerative colitis (UC) in the Han Chinese in central China. Materials and methods  One hundred seventeen patients with UC and 246 healthy controls were genotyped for CTLA-4 gene −658CT in the promoter and CT61 at the 3′ untranslated region using a method of polymerase chain reaction-based restriction fragment length polymorphism and single-strand conformation polymorphism, respectively. The distributions of the genotypes and the allele frequencies of the CTLA-4 gene in UC patients and healthy controls were compared by chi-square test. Results  The frequency of the T/T+C/T genotype at the CTLA-4 gene −658CT in the promoter was significantly higher in UC patients than in healthy controls (26.5% vs 15.4%, χ ² = 6.287, P = 0.015, OR = 1.973, 95%CI = 1.153–3.375). The frequency of the T allele at the CTLA-4 −658CT was also significantly higher in UC patients than in the controls (13.2% vs 8.1%, χ ² = 4.707, P = 0.033, OR = 1.726, 95%CI = 1.049–2.838). The frequency of the T/T genotype at the −658 locus was highly associated with extensive colitis in UC patients (P = 0.037, OR = 3.955, 95%CI = 1.068–14.647). The frequency of the T allele at the −658 locus was highly associated with extensive colitis in UC patients (P = 0.0067, OR = 3.05, 95%CI = 1.320–7.048). Conclusion  The T allele of CTLA-4 −658 polymorphism in the promoter of CTLA-4 gene was highly associated with UC in the Han Chinese in central China.     

The predictors of foot ulceration in patients with rheumatoid arthritis: a preliminary investigation

We explored the predictors of foot ulceration in patients with rheumatoid arthritis (RA). The cases were 15 patients with RA reporting foot ulceration in response to a postal survey of patients sampled from a diagnostic register in secondary care (n = 1,130). The controls were 66 patients with RA randomly sampled from the survey respondents (n = 883) after matching for age, sex and disease duration. Patients with co-existent diabetes were excluded. Clinical examination included the assessment of known risk factors for foot ulceration in diabetes including: neuropathy (insensitivity to 10 g monofilament), peripheral vascular disease (ankle brachial pressure index [ABPI]), foot deformity (Platto indices) and raised plantar pressure (PressureStat™ readings). A 44 swollen-joint count, the presence of pre-ulcerative lesions and current steroid therapy were identified through univariate analysis as additional potential predictors in patients with RA. Forward step-wise logistic regression analysis showed that the following variables were significant predictors of ulceration: steroid therapy (OR = 9.70, 95%CI = 2.09–45.11, p = 0.004), abnormal ABPI (OR = 13.45, 95%CI = 1.19–151.43, p = 0.035), the presence of pre-ulcerative lesions (OR = 7.40, 95%CI = 1.51–36.30, p = 0.014) and swollen-joint count (OR = 1.25, 95%CI = 1.02–1.53, p = 0.034). Abnormal sensation, foot deformity and raised plantar pressures were not significant predictors of ulceration. The wide confidence intervals for ABPI were due to sparse data with very few abnormal values, and the results of exact logistic regression (more accurate where data is sparse and case matching employed) found that ABPI was no longer a significant predictor (p = 0.054). The significance of the other predictors did not differ substantially. In this preliminary study, abnormal sensation, foot deformity and raised plantar pressures were not significantly associated with foot ulceration but active disease and current steroid therapy were. The contribution of peripheral vascular disease to risk is unclear and further investigation is needed in a larger cohort.     

Caregiver Time and Cost of Home Care for Alzheimer’s Disease: A Clinic-based Observational Study in Beijing,China

This cross-sectional study was conducted to estimate the caregiver time and calculate the cost of informal care for AD, and to explore the potential predictors of caregiver time. Seventy-one community-dwelling AD patient-caregiver dyads completed the assessment and questionnaire. AD patients were assessed with Mini-mental status examination (MMSE), activities of daily living (ADL), and Neuropsychiatric Inventory (NPI). Caregiver time was recorded using the Resource Utilization in Dementia (RUD). According to the MMSE score, subjects were classified as mild (n = 18), moderate (n = 43), and severe (n = 10) groups. The PADL care time was significantly different among three groups, with highest in severe group (172.5 ± 208.0 h/month), and least in mild group (24.9 ± 70.5 h/month) (F = 5.215, df = 2, P = 0.008). The supervision time was higher in severe group compared to mild group (F = 3.330, df = 2, P = 0.042), while there were no differences between mild and moderate groups, and between moderate and severe groups. There was no difference in IADL caregiver time among three groups. The estimated annual cost of PADL care ranged from 903 USD (mild) to 6,259 USD (severe), IADL care from 4042USD to 7645USD, and supervision from 871 USD to 6,172 USD. Stepwise logistic regression analysis showed that MMSE score was significant predictor of PADL care time. For every one unit increase in MMSE, the odds of PADL care time decrease by a factor of 0.791 (χ2 = 13.628, P = 0.000). Spouse caregivers significantly predict greater IADL care time (OR = 4.469, 95%CI = 1.248–15.999, P = 0.021), and male caregiver was a protector for IADL care time (OR = 0.157, 95%CI = 0.040–0.609, P = 0.007). The ADL score was a significant predictor of supervision time. For every one unit increase in ADL, the odds of supervision time increase by a factor of 1.132 (95%CI = 1.055–1.215, P = 0.001). Higher educational level of the patient predicted decrease in supervision time (OR = 0.888, 95%CI = 0.794–0.994, P = 0.038). Caregiver time and cost of home care for AD was substantial in China. Care time of PADL increased with the progression of cognitive decline. The IADL care time was strongly influenced by the biographical characteristics of caregivers. Supervision was mostly predicted by the functional status of the patient.     

The effect of smoking after surgery for Crohn’s disease: a meta-analysis of observational studies

Objective  The aim of the study was to quantify the risk of disease recurrence associated with cigarette smoking for individuals with Crohn’s disease after disease-modifying surgery. Design  Meta-analysis of observational studies. Data sources  Medline, Embase, Ovid and the Cochrane database. Materials and methods  A literature search was performed to identify studies published between 1966 and 2007 comparing outcomes of smokers, ex-smokers and non-smokers with Crohn’s disease. Random-effect meta-analytical techniques were employed to assess the risk of medical or surgical recurrence. Results  Sixteen studies encompassing 2,962 patients including 1,425 non-smokers (48.1%), 1,393 smokers (47.0%) and 137 ex-smokers (4.6%) were included. Smokers had significantly higher clinical post-operative recurrence than non-smokers (odds ratio [OR] = 2.15; 95%CI = 1.42, 3.27; p < 0.001). Smokers were also more likely to experience surgical recurrence by 5 (OR = 1.06; 95%CI = 0.32; 3.53, p = 0.04) and 10 years of follow-up (OR = 2.56; 95%CI = 1.79, 3.67; p < 0.001) compared to non-smokers, although the crude re-operation rate was not statistically significant. When matched for operation and disease site, smokers had significantly higher re-operation rates to non-smokers (OR = 2.3; 95%CI = 1.29, 4.08; p = 0.005). There was no significant difference between ex-smokers and non-smokers in re-operation rate at 10 years (OR = 0.30; 95%CI = 0.09, 1.07; p = 0.10) or in post-operative acute relapses (OR = 1.54; 95%CI = 0.78, 3.02; p = 0.21). Conclusions  Patients with Crohn’s disease who smoke have a 2.5-fold increased risk of surgical recurrence and a twofold risk of clinical recurrence compared to non-smokers. Patients with Crohn’s disease should be encouraged to stop smoking since the risk of disease relapse is minimised upon its cessation. George E. Reese and Theodore Nanidis with equal contribution.     

Differences in the Quality of the Patient–Physician Relationship Among Terminally Ill African-American and White Patients: Impact on Advance Care Planning and Treatment Preferences

BACKGROUND Little is known about the quality of the patient–physician relationship for terminally ill African Americans. OBJECTIVE To compare the quality of the patient–physician relationship between African-American and white patients and examine the extent to which relationship quality contributes to differences in advance care planning (ACP) and preferences for intensive life-sustaining treatment (LST). DESIGN Cross sectional survey of 803 terminally ill African-American and white patients. MEASUREMENTS Patient-reported quality of the patient–physician relationship (degree of trust, perceived respect, and joint decision making; skill in breaking bad news and listening; help in navigating the medical system), ACP, preferences for LST (cardiopulmonary resuscitation, major surgery, mechanical ventilation, and dialysis). RESULTS The quality of the patient–physician relationship was worse for African Americans than for white patients by all measures except trust. African Americans were less likely to have an ACP (adjusted relative risk [aRR] = 0.66, 95%CI = 0.52–0.84), and were more likely to have a preference for cardiopulmonary resuscitation and dialysis (aRR = 1.28, 95%CI = 1.03–1.58; aRR = 1.25, 95%CI = 1.07–1.47, respectively). Additional adjustment for the quality of the patient–physician relationship had no impact on the differences in ACP and treatment preferences. CONCLUSIONS Lower reported patient–physician relationship quality for African-American patients does not explain the observed differences between African Americans and whites in ACP and preferences for LST.     

A systematic review and meta-analysis of rituximab-based immunochemotherapy for subtypes of diffuse large B cell lymphoma

Addition of rituximab to chemotherapy (R-chemo) has been shown to improve overall survival (OS) in patients with diffuse large B cell lymphoma (DLBCL). Germinal center B cell-like (GCB) subtype of DLBCL has a significantly better clinical outcome than those with non-germinal center B cell-like (non-GCB) subtype. Further research is needed to confirm this difference between those two subtypes treated with R-chemo. We searched for randomized controlled trials that compared R-chemo with identical chemotherapy alone in patients with newly diagnosed or relapsed DLBCL. A random versus fixed effects model was selected according to heterogeneity. Six eligible trials involving 748 adult patients were included in this meta-analysis. Fixed-effects analysis showed OS to be superior for the GCB patients treated with R-chemo (relative risk (RR) = 1.16, 95% confidence interval (CI) = 1.03–1.31, P = 0.02). Superiority was also observed for the GCB subtype under R-chemo with respect to disease control (RR = 1.16, 95% CI = 0.99–1.36) and overall response (RR = 1.19, 95% CI = 0.99–1.99). Both subtypes showed an increased OS (RR = 1.30, 95% CI = 1.11–1.51; RR = 1.89, 95% CI = 1.52–2.35, respectively) and disease control rate (RR = 1.27, 95% CI = 1.05–1.54, P = 0.01; RR = 2.21, 95% CI = 1.68–2.90, respectively) following R-chemo. Therefore, treated with R-chemo, GCB patients still has a significantly better clinical outcome than those with non-GCB subtype.     

Barriers to Obtaining Waivers to Prescribe Buprenorphine for Opioid Addiction Treatment Among HIV Physicians

Background Illicit drug use is common among HIV-infected individuals. Buprenorphine enables physicians to simultaneously treat HIV and opioid dependence, offering opportunities to improve health outcomes. Despite this, few physicians prescribe buprenorphine. Objective To examine barriers to obtaining waivers to prescribe buprenorphine. Design Cross-sectional survey study. Participants 375 physicians attending HIV educational conferences in six cities in 2006. Approach Anonymous questionnaires were distributed and analyzed to test whether confidence addressing drug problems and perceived barriers to prescribing buprenorphine were associated with having a buprenorphine waiver, using chi-square, t tests, and logistic regression. Results 25.1% of HIV physicians had waivers to prescribe buprenorphine. In bivariate analyses, physicians with waivers versus those without waivers were less likely to be male (51.1 vs 63.7%, p < .05), more likely to be in New York (51.1 vs 29.5%, p < .01), less likely to be infectious disease specialists (25.5 vs 41.6%, p < .05), and more likely to be general internists (43.6 vs 33.5%, p < .05). Adjusting for physician characteristics, confidence addressing drug problems (adjusted odds ratio [AOR] = 2.05, 95% confidence interval [95% CI] = 1.08–3.88) and concern about lack of access to addiction experts (AOR = 0.56, 95% CI = 0.32–0.97) were significantly associated with having a buprenorphine waiver. Conclusions Among HIV physicians attending educational conferences, confidence addressing drug problems was positively associated with having a buprenorphine waiver, and concern about lack of access to addiction experts was negatively associated with it. HIV physicians are uniquely positioned to provide opioid addiction treatment in the HIV primary care setting. Understanding and remediating barriers HIV physicians face may lead to new opportunities to improve outcomes for opioid-dependent HIV-infected patients.     

Determinants of NCI Cancer Center Attendance in Medicare Patients with Lung, Breast, Colorectal, or Prostate Cancer

BACKGROUND  Geographic access to NCI-Cancer Centers varies by region, race/ethnicity, and place of residence, but utilization of these specialized centers has not been examined at the national level in the U.S. This study identified determinants of NCI-Cancer Center attendance in Medicare cancer patients. METHODS  SEER-Medicare (Surveillance Epidemiology and End Results) data were used to identify individuals with an incident cancer of the breast, lung, colon/rectum, or prostate from 1998–2002. NCI-Cancer Center attendance was determined based on utilization claims from 1998–2003. Demographic, clinical, and geographic factors were examined in multilevel models. We performed sensitivity analyses for the NCI-Cancer Center attendance definition. RESULTS  Overall, 7.3% of this SEER-Medicare cohort (N = 211,048) attended an NCI-Cancer Center. Travel-time to the nearest NCI-Cancer Center was inversely related to attendance, showing 11% decreased likelihood of attendance for every 10 minutes of additional travel-time (OR = 0.89, 95%CI 0.88–0.90). Receiving predominantly generalist care prior to diagnosis was associated with a lower likelihood of attendance (OR = 0.79, 95%CI 0.77–0.82). The other factors associated with greater NCI-Cancer attendance were later stage at diagnosis, fewer comorbidities, and urban residence in conjunction with African-American race. CONCLUSIONS  Attendance at NCI-Cancer Centers is low among Medicare beneficiaries, but is strongly influenced by proximity and general provider care prior to diagnosis. Other patient factors are predictive of NCI-Cancer Center attendance and may be important in better understanding cancer care utilization.     

Risk factors for infection and treatment outcome of extended-spectrum β-lactamase-producing <Emphasis Type="Italic">Escherichia coli</Emphasis> and <Emphasis Type="Italic">Klebsiella pneumoniae</Emphasis> bacteremia in patients with hematologic malignancy

This study was performed to evaluate the impact of extended-spectrum β-lactamase (ESBL)-producing bacteremia on outcome in patients with hematologic malignancy. We collected and analyzed data on 156 hematologic malignancy patients with Escherichia coli or Klebsiella pneumoniae bacteremia from the database of nationwide surveillance studies for bacteremia. Thirty-seven of the 156 patients (23.7%) harbored ESBL-producing bacteremia. No significant differences in underlying diseases were found in either group. The multivariate analysis showed that significant factors associated with ESBL-producing bacteremia were ICU care (OR = 7.03, 95% CI = 1.79–27.6) and nosocomial acquisition (OR = 5.66, 95% CI = 1.60–20.23). There was an association between prior receipt of cephalosporins and ESBL-producing bacteremia, although this association was not statistically significant (OR = 2.27, 95% CI = 0.99–5.23). The overall 30-day mortality rate of the study population was 20.4% (29/142), and the 30-day mortality rate for the ESBL group was significantly higher than that for the non-ESBL group (44.8% vs. 14.2%, P < 0.001). Multivariate analysis showed that ESBL-producing bacteremia was the most important risk factor associated with 30-day mortality (OR, 5.64; 95% CI, 1.91–16.67), along with ICU care (OR = 4.35, 95% CI = 1.16–16.26) and higher Pitt bacteremia score (per 1-point increment) (OR = 1.50, 95% CI = 1.18–1.92). In conclusion, ESBL-producing bacteremia was the most important risk factor associated with 30-day mortality in patients with hematologic malignancy, along with ICU care and higher Pitt bacteremia score. Our data suggest that determining the optimal empiric antimicrobial therapy in patients with hematologic malignancy is now becoming a challenge for clinicians in the era of multidrug-resistant Gram-negative bacilli.     

The association between TNF-α promoter polymorphisms and ankylosing spondylitis: a meta-analysis

The relationship of TNF-α promoter polymorphisms and ankylosing spondylitis (AS) has been reported with conflicting results. We perform this meta-analysis to collect all the relevant studies up to date to further clarify the association of TNF-α promoter polymorphisms with AS. A review was conducted of studies reporting on the association between TNF-α promoter polymorphisms and AS susceptibility in Medline, Pubmed, Embase, and Web of Science. The numbers of individuals with various genotypes and alleles in both the case and control groups were extracted from relevant studies. Odds ratios (ORs) with 95% confidence interval (CI) were used to estimate the association. Fourteen eligible studies, contributing data on 3,880 subjects (1,766 patients; 2,114 controls), were included in this meta-analysis. The ORs of various comparisons indicated that there was no association between TNF-α 238, 308 polymorphisms, and AS susceptibility in the overall population. For HLA-B27+ population, although the frequency of 308 A allele decreased in AS patients (OR = 0.721; 95%CI = 0.522–0.995), the result was no longer statistically significant after excluding the Hardy–Weinberg equilibrium violation studies (OR = 1.150; 95%CI = 0.568–2.310). No relationship was found between TNF-α promoter 238 polymorphisms and AS in HLA-b27+ population. No association was found between TNF-α promoter 238/308 polymorphisms and ankylosing spondylitis susceptibility in both the overall and HLA-B27+ population.     

Boswellia serrata extract for the treatment of collagenous colitis. A double-blind, randomized, placebo-controlled, multicenter trial

Background and aims The objective of this study was to investigate the effect of Boswellia serrata extract (BSE) on symptoms, quality of life, and histology in patients with collagenous colitis. Materials and methods Patients with chronic diarrhea and histologically proven collagenous colitis were randomized to receive either oral BSE 400 mg three times daily for 6 weeks or placebo. Complete colonoscopy and histology were performed before and after treatment. Clinical symptoms and quality of life were assessed by standardized questionnaires and SF-36. The primary endpoint was the percentage of patients with clinical remission after 6 weeks (stool frequency ≤3 soft /solid stools per day on average during the last week). Patients of the placebo group with persistent diarrhea received open-label BSE therapy for a further 6 weeks. Results Thirty-one patients were randomized; 26 patients were available for per-protocol-analysis. After 6 weeks, the proportion of patients in clinical remission was higher in the BSE group than in the placebo group (per protocol 63.6%; 95%CI, 30.8–89.1 vs 26.7%, 95%CI, 7.7–55.1; p = 0.04; intention-to-treat 43.8% vs 26.7%, p = 0.25). Compared to placebo, BSE treatment had no effect on histology and quality of life. Five patients discontinued BSE treatment prematurely. Discontinuation was due to adverse events (n = 1), unwillingness to continue (n = 3), or loss to follow-up for unknown reasons (n = 1). Seven patients received open-label BSE therapy, five of whom achieved complete remission. Conclusions Our study suggests that BSE might be clinically effective in patients with collagenous colitis. Larger trials are clearly necessary to establish the clinical efficacy of BSE.     

Lipoprotein receptor associated protein (LRPAP1) insertion/deletion polymorphism: association with gallbladder cancer susceptibility

Background Low-density lipoprotein receptor-related protein associated protein (LRPAP1) insertion/deletion polymorphism influences cholesterol homeostasis and may confer risk for gallstone disease and gallbladder carcinoma (GBC) incidence usually parallels with the prevalence of cholelithiosis. Aim We aimed to examine the role of LRPAP1 polymorphism in susceptibility to GBC. Methods Present case control study included 129 proven GBC patients, 183 gallstone patients, and 208 healthy controls. Genotyping was done by polymerase chain reaction–restriction fragment length polymorphism method. Results The D allele of LRPAP1 was significantly higher in GBC patients as compared to gallstone patients (p = 0.013; OR = 1.6, 95% CI = 1.1–2.4). However, II genotype and I allele was associated with reduced risk of GBC as compared to gallstone patients (p = 0.002; OR = 0.1, 95% CI = 0.1–0.6; p = 0.013; OR = 0.6, 95% CI = 0.4–0.8) The increased risk due to D allele was limited to female GBC patients (p = 0.021; OR = 1.8, 95% CI = 1.1–3.0). However, reduced risk due to II genotype and I allele was observed which was also confined to female GBC patients (p = 0.005; OR = 0.1, 95% CI = 0.1–0.6; p = 0.021; OR = 0.5, 95% CI = 0.3–0.8). On comparing GBC patients having gallstone with gallstone patients, high risk was observed in the GBC patients having gallstone due to the presence of D allele (p = 0.032; OR = 1.7, 95% CI = 1.0–2.8). However, low risk was observed because of I allele in GBC patients with gallstone in comparison to gallstone patients (p = 0.032, OR = 0.6, 95% CI = 0.4–0.9). Conclusion It appears that ‘D’ allele may modulate the susceptibility of GBC, and the risk is independent to genetic risk of gallstone.     

The association between selected risk factors for pancreatic cancer and the expression of p53 and K-ras codon 12 mutations

Background Pancreatic cancer is a major contributor to cancer mortality. Studies suggest that a few risk factors, including cigarette smoking, body mass index, having a relative with pancreatic cancer, and diabetes may be related to pancreatic cancer risk. Aim of the Study We conducted a case–control study in southeastern Michigan to examine the relation between the abovementioned risk factors and mutations of the K-ras oncogene and p53 tumor suppressor gene. Methods Two hundred forty-five patients with newly diagnosed pancreatic cancer and 420 general population controls were enrolled in the study. For this analysis, all case subjects were restricted to the pancreatic cancer patients that had tissue blocks available for study (n = 51). In-person interviews were conducted to ascertain information on demographic and lifestyle factors. Adjusted logistic regression analyses were conducted to compare various subject characteristics of pancreatic cancer patients with K-ras and p53 mutations and their subtypes to the characteristics of the general population controls. Results Smoking (adjusted odds ratio [aOR] = 2.0; 95% confidence interval [95%CI] = 0.9–4.3) and diabetes diagnosed 5 or more years before interview (aOR = 3.4; 95%CI = 1.3–8.8) were associated with pancreatic cancer patients positive for K-ras codon 12 mutations, but not with pancreatic cancer patients negative for K-ras codon 12 mutations. On the other hand, none of the examined risk factors were meaningfully related to patients with p53 mutations. Conclusions This study suggests that some recognized risk factors for pancreatic cancer may also be associated with K-ras codon 12 mutations. However, further large-scale studies are warranted.     

Physician Reminders to Promote Surveillance Colonoscopy for Colorectal Adenomas

Background  Most colorectal cancers develop from adenomatous polyps. National guidelines recommend surveillance colonoscopy within 5 years after such polyps are removed. Objective  To determine whether surveillance colonoscopy can be increased among overdue patients by reminders to their primary physicians. Design  Randomized, controlled trial of patient-specific reminders mailed to 141 physicians in 2 Massachusetts primary care networks during April, 2006. Patients  Seven hundred seventeen patients who had colorectal adenomas removed during 1995 through 2000 and no follow-up colonoscopy identified via automated review of electronic records through March, 2006. Measurements and Main Results  The use of colonoscopy and detection of new adenomas or cancer were assessed at 6 months by a blinded medical record review in all patients. Among 358 patients whose physicians received reminders, 33 (9.2%) patients underwent colonoscopy within 6 months, compared with 16 (4.5%) of 359 patients whose physicians did not receive reminders (P = 0.009). In prespecified subgroups, this effect did not differ statistically between 2 primary care networks, elderly and nonelderly patients, or women and men (all P > 0.60 by Breslow–Day test). New adenomas or cancer were detected in 14 (3.9%) intervention patients and 6 (1.7%) control patients (P = 0.06), representing 42.4% and 37.5% of patients who underwent colonoscopy in each group, respectively. Despite using advanced electronic health records to identify eligible patients, 22.5% of enrolled patients had a prior follow-up colonoscopy ascertained only by visual record review, and physicians reported 27.9% of intervention patients were no longer active in their practice. Conclusions  Among patients with prior colorectal adenomas, physician reminders increased the use of surveillance colonoscopy, but better systems are needed to identify eligible patients (ClinicalTrials.gov ID number NCT00397969). The study was presented at the Annual Meeting of the Society of General Internal Medicine in Toronto, Ontario on April 26, 2007.     

Awareness of Hepatitis C Diagnosis is Associated with Less Alcohol Use Among Persons Co-Infected with HIV

BACKGROUND AND OBJECTIVE It is unknown whether testing HIV-infected individuals for hepatitis C virus (HCV) and informing them of their HCV status impacts subsequent alcohol use. We hypothesized that HIV-infected individuals with current or past alcohol problems who reported being told they had HCV were more likely to 1) abstain from alcohol and 2) not drink unhealthy amounts compared to individuals who had not been told. DESIGN, PARTICIPANTS, AND MEASUREMENTS Data from a prospective, observational cohort study (HIV-Longitudinal Interrelationships of Viruses and Ethanol) were used to assess the association between awareness of having HCV at baseline and subsequent abstinence and not drinking unhealthy amounts as reported at 6-month follow-up intervals. General estimating equations logistic regression was used to account for the correlation from using repeated observations from the same subject over time. We adjusted for age, sex, race, homelessness, injection drug use, depressive symptoms, and having abnormal liver tests. RESULTS Participants who reported being told they had HCV were more likely to report abstaining from alcohol (AOR = 1.60; 95% CI: 1.13 to 2.27) and not drinking unhealthy amounts (AOR = 1.46; 95% CI: 1.01 to 2.11). CONCLUSIONS Among patients infected with HIV who had a history of alcohol problems, reporting being told one had HCV was associated with greater abstinence from alcohol and less unhealthy amounts of drinking.     

Mortality in Peripheral Arterial Disease: A Comparison of Patients Managed by Vascular Specialists and General Practitioners

BACKGROUND Peripheral arterial disease (PAD) is undertreated by general practitioners (GPs). However, the impact of the suboptimal clinical management is unknown. OBJECTIVE To assess the mortality rate of PAD patients in relation to the type of physician who provides their care (GP or vascular specialist). DESIGN Prospective study. SETTING Primary care practice and academic vascular laboratory. PARTICIPANTS GP patients (n = 60) were those of the Peripheral Arteriopathy and Cardiovascular Events study (PACE). Patients managed by specialists (n = 82) were consecutive subjects with established PAD who were referred to our vascular laboratory during the enrolment period of the PACE study. MEASUREMENTS All-cause and cardiovascular mortality. RESULTS After 32 months of follow-up, specialist management was associated with a lower rate of all-cause mortality (RR = 0.04; 95% CI 0.01–0.34; p = .003) and cardiovascular mortality (RR = 0.07; 95% CI 0.01–0.65; p = .020), after adjustment for patients’ characteristics. Specialists were more likely to use antiplatelet agents (93% vs 73%, p < .001), statins (62% vs 25%, p < .001) and beta blockers (28% vs 3%, p < .001). Survival differences between specialists and GPs disappeared once the use of pharmacotherapies was added to the proportional hazard model. The fully adjusted model showed that the use of statins was significantly associated with a reduced risk of all-cause mortality (RR = 0.02; 95% CI 0.01–0.73, p = .034) and cardiovascular mortality (RR = 0.02; 95% CI 0.01–0.71, p = .033). CONCLUSIONS Specialist management of patients with symptomatic PAD resulted in better survival than generalist management. This effect appears to be mainly caused by the more frequent use of effective medicines by specialists.     

Modified Epworth Sleepiness Scale in Chinese children with obstructive sleep apnea: a retrospective study

Background and objective  The purpose of this study is to assess whether Chinese children with high apnea–hypopnea index (AHI) are sleepier by a modified Epworth Sleepiness Scale (ESS). Materials and methods  Records were retrospectively reviewed. We included children who were between 3 and 12 years old, admitted for overnight polysomnogram because of suspected obstructive sleep apnea syndrome (OSAS). A modified ESS was used to assess excessive daytime sleepiness (EDS) of the children. Results  One hundred ninety-two Chinese children were included. Children with high AHI, defined as AHI > 5.0, were sleepier than children with AHI less than or equal to 5. After adjustment by age, gender, and obesity, children with high AHI remained significantly sleepier. Modified ESS was significantly correlated with AHI (rho = 0.124, 95% CI = 0.004–0.281). Modified ESS score of >8 was the best cutoff point with the sensitivity and specificity of 0.29 and 0.91, respectively. The odds ratio of children with modified ESS > 10 having high AHI was 4.231 (95%CI = 1.248 to 14.338) and children with modified ESS > 8 had the highest odds ratio, 4.295(95%CI = 1.66 to 11.1), of having high AHI. Conclusion   Chinese children with high AHI appear to be sleepier than children with low AHI. Children with suspected OSAS and high modified ESS, i.e., ESS > 8, had significantly higher odds ratio of having high AHI. Increased sleepiness is a specific but not a sensitive symptom in snoring children with high AHI. Screening for EDS in snoring children may help us identify those with high AHI and prioritize the management of those children. All authors worked and the study was carried out in Kwong Wah Hospital in Hong Kong. There was no conflict of interest and no specific source of funding for the study.