RESUMO
OBJECTIVES: (1) To characterize the influence of type 2 diabetes mellitus (DM) on cortical auditory-evoked potentials (CAEPs) separate from the effects of normal aging, and (2) to determine whether the disease-related effects are modified by insulin dependence. DESIGN: A cross-sectional study was conducted in a large cohort of Veterans to investigate the relationships among type 2 DM, age, and CAEPs in randomly selected participants with (N = 108) and without (N = 114) the disease and who had no more than a moderate hearing loss. Participants with DM were classified as insulin-dependent (IDDM, N = 47) or noninsulin-dependent (NIDDM, N = 61). Other DM measures included concurrent serum glucose, HbA1c, and duration of disease. CAEPs were evoked using a passive homogeneous paradigm (single repeating stimulus) by suprathreshold tones presented to the right ear, left ear, or both ears. Outcome measures were adjusted for the pure-tone threshold average for frequencies of 0.5, 1, and 2 kHz and analyzed for differences in age effects between participant groups using multiple regression. RESULTS: There is little variation across test ear conditions (left, right, binaural) on any CAEP peak in any of the groups. Among no-DM controls, P2 latency increases about 9 msec per decade of life. DM is associated with an additional delay in the P2 latency of 7 and 9 msec for the IDDM and NIDDM groups, respectively. Moreover, the slope of the function relating P2 latency with age is similar across participant groups and thus the DM effect appears constant across age. Effects on N1 latency are considerably weaker, with age effects of less than 4 msec per decade across all groups, and DM effects of only 2 (IDDM) or 3 msec (NIDDM). In the NIDDM group, the slope relating N1 latency to age is steeper relative to that observed for the no-DM group, providing some evidence of accelerated "aging" for this CAEP peak. DM does not substantially reduce N1-P2 amplitude and age relationships with N1-P2 amplitude are effectively absent. There is no association between pure-tone average at 0.5, 1, and 2 kHz and any aspect of CAEPs in this cohort. CONCLUSIONS: In a large cohort of Veterans, we found that type 2 DM is associated with prolonged N1 and P2 latencies regardless of whether insulin is required to manage the disease and independent of peripheral hearing thresholds. The DM-related effects on CAEP latencies are threefold greater for P2 compared with N1, and there is little support that at the cortical level, IDDM participants had poorer responses compared with NIDDM participants, although their responses were more variable. Overall, these results indicate that DM is associated with slowed preattentive neural conduction. Moreover, the observed 7 to 9 msec P2 latency delay due to DM is substantial compared with normal age changes in P2, which are 9 msec per decade of life in this cohort. Results also suggest that whereas N1 latency changes with age are more pronounced among individuals with DM versus without DM, there was no evidence for more rapid aging of P2 among patients with DM. Thus, the damage responsible for the major DM-related differences may occur early in the DM disease process. These cross-sectional results should be verified using a longitudinal study design.
Assuntos
Envelhecimento/fisiologia , Diabetes Mellitus Tipo 2/fisiopatologia , Potenciais Evocados Auditivos/fisiologia , Idoso , Glicemia/metabolismo , Estudos de Casos e Controles , Estudos de Coortes , Estudos Transversais , Diabetes Mellitus Tipo 2/tratamento farmacológico , Diabetes Mellitus Tipo 2/metabolismo , Eletroencefalografia , Feminino , Hemoglobinas Glicadas/metabolismo , Humanos , Hipoglicemiantes/uso terapêutico , Insulina/uso terapêutico , Masculino , Pessoa de Meia-Idade , Índice de Gravidade de Doença , Fatores de Tempo , VeteranosRESUMO
OBJECTIVE: Type 2 diabetes is epidemic among veterans, approaching three times the prevalence of the general population. Diabetes leads to devastating complications of vascular and neurologic malfunction and appears to impair auditory function. Hearing loss prevention is a major health-related initiative in the Veterans Health Administration. Thus, this research sought to identify, and quantify with effect sizes, differences in hearing, speech recognition, and hearing-related quality of life (QOL) measures associated with diabetes and to determine whether well-controlled diabetes diminishes the differences. DESIGN: The authors examined selected cross-sectional data from the baseline (initial) visit of a longitudinal study of Veterans with and without type 2 diabetes designed to assess the possible differences in age-related trajectories of peripheral and central auditory function between the two groups. In addition, the diabetes group was divided into subgroups on the basis of medical diagnosis of diabetes and current glycated hemoglobin (HbA1c) as a metric of disease severity and control. Outcome measures were pure-tone thresholds, word recognition using sentences presented in noise or time-compressed, and an inventory assessing the self-perceived impact of hearing loss on QOL. Data were analyzed from 130 Veterans ages 24 to 73 (mean 48) years with well-controlled (controlled) diabetes, poorly controlled (uncontrolled) diabetes, prediabetes, and no diabetes. Regression was used to identify any group differences in age, noise exposure history, and other sociodemographic factors, and multiple regression was used to model each outcome variable, adjusting for potential confounders. Results were evaluated in relation to diabetes duration, use of insulin (yes, no), and presence of selected diabetes complications (neuropathy and retinopathy). RESULTS: Compared with nondiabetics, Veterans with uncontrolled diabetes had significant differences in hearing at speech frequencies, including poorer hearing by 3 to 3.5 dB for thresholds at 250 Hz and in a clinical pure-tone average, respectively. Compared with nondiabetic controls, individuals with uncontrolled diabetes also significantly more frequently reported that their hearing adversely impacted QOL on one of the three subscales (ability to adapt). Despite this, although they also had slightly poorer mean scores on both word recognition tasks performed, these differences did not reach statistical significance and all subjects performed well on these tasks. Compared with Veterans with controlled diabetes, those with uncontrolled disease tended to have had diabetes longer, be insulin-dependent, and have a greater prevalence of diabetic retinopathy. Results are generally comparable with the literature with regard to the magnitude of threshold differences and the prevalence of hearing impairment but extend prior work by providing threshold difference and hearing loss prevalence effect sizes by category of diabetes control and by including additional functional measures. CONCLUSIONS: In a cohort of Veterans with type 2 diabetes and relatively good hearing, significant effects of disease severity were found for hearing thresholds at a subset of frequencies and for one of the three QOL subscales. Significant differences were concentrated among those with poorly controlled diabetes based on current HbA1c. Results provide evidence that the observed hearing dysfunction in type 2 diabetes might be prevented or delayed through tight metabolic control. Findings need to be corroborated using longitudinal assessments.
Assuntos
Diabetes Mellitus Tipo 2/metabolismo , Hemoglobinas Glicadas/metabolismo , Perda Auditiva/fisiopatologia , Qualidade de Vida , Percepção da Fala , Veteranos , Adulto , Idoso , Audiometria de Tons Puros , Estudos de Coortes , Comorbidade , Estudos Transversais , Diabetes Mellitus Tipo 2/epidemiologia , Neuropatias Diabéticas/epidemiologia , Retinopatia Diabética/epidemiologia , Feminino , Perda Auditiva/epidemiologia , Testes Auditivos , Humanos , Masculino , Pessoa de Meia-Idade , Índice de Gravidade de Doença , Estados Unidos/epidemiologia , Adulto JovemRESUMO
Recipients of liver transplantation (LT) for hepatocellular carcinoma (HCC) have an 8% to 20% risk of HCC recurrence. Single-center studies suggest that a period of waiting after HCC therapy may facilitate the selection of patients at low risk for post-LT HCC recurrence and mortality. We evaluated whether a longer waiting time after Model for End-Stage Liver Disease (MELD) prioritization for HCC predicts longer post-LT survival. From the United Network for Organ Sharing registry, we selected 2 groups registered for LT between March 2005 and March 2009: (1) HCC patients receiving MELD prioritization and (2) non-HCC patients. Patients were stratified by their MELD status at LT (a marker of time on the wait list after HCC MELD prioritization) and were followed from LT until death or censoring through October 2012. By comparing post-LT survival to intention-to-treat (ITT) survival from registration, we assessed predictors of post-LT survival and estimated the benefit of LT. The median MELD scores at LT were 22 (HCC) and 24 (non-HCC). A higher MELD score at LT was independently associated with lower post-LT mortality in the HCC group [hazard ratio (HR) = 0.84, 95% confidence interval (CI) = 0.73-0.98] and higher post-LT mortality in the non-HCC group (HR = 1.20, 95% CI = 1.15-1.25). Compared with the HCC group, the non-HCC group had lower post-LT mortality [relative risk (RR) = 0.85, log-rank P < 0.01] but higher ITT mortality (RR = 1.25, log-rank P < 0.01) because of a 33 percentage point lower probability of undergoing LT. In conclusion, a longer waiting time before LT for HCC predicted longer post-LT survival in a national transplant registry. Delaying LT for HCC may reduce disparities in ITT survival and access to LT among different indications and thereby improve system utility and organ allocation equity for the overall pool of LT candidates.
Assuntos
Carcinoma Hepatocelular/cirurgia , Neoplasias Hepáticas/cirurgia , Transplante de Fígado , Tempo para o Tratamento , Doadores de Tecidos/provisão & distribuição , Listas de Espera , Carcinoma Hepatocelular/mortalidade , Carcinoma Hepatocelular/patologia , Feminino , Acessibilidade aos Serviços de Saúde , Disparidades em Assistência à Saúde , Humanos , Estimativa de Kaplan-Meier , Neoplasias Hepáticas/mortalidade , Neoplasias Hepáticas/patologia , Transplante de Fígado/efeitos adversos , Transplante de Fígado/mortalidade , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Modelos de Riscos Proporcionais , Sistema de Registros , Fatores de Risco , Fatores de Tempo , Obtenção de Tecidos e Órgãos , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
PURPOSE: This cross-sectional study had two goals: (1) Identify and quantify the effects of aging on the auditory brainstem response (ABR); (2) Describe how click rate and hearing impairment modify effects of aging. RESEARCH DESIGN AND ANALYSIS: ABR measures were obtained from 131 predominately male Veteran participants aged 26 to 71 yr. Metrics analyzed include amplitude and latency for waves I, III, and V, and the I-V interpeak latency interval (IPI) at three repetition rates (11, 51, and 71 clicks/sec) using both polarities. In order to avoid confounding from missing data due to hearing impairment, participants had hearing thresholds <40 dB HL at 2 kHz and 70 dB HL at 4 kHz in at least one ear. Additionally, the median 2, 3, and 4 kHz pure tone threshold average (PTA2,3,4) for the sample, â¼17 dB HL, was used to delineate subgroups of better and worse hearing ears, and only the better hearing sample was modeled statistically. We modeled ABR responses using age, repetition rate, and PTA2,3,4 as covariates. Random effects were used to model correlation between the two ears of a subject and across repetition rates. Inferences regarding effects of aging on ABR measures at each rate were derived from the fitted model. Results were compared to data from subjects with poorer hearing. RESULTS: Aging substantially diminished amplitudes of all of the principal ABR peaks, largely independent of any threshold differences within the group. For waves I and III, age-related amplitude decrements were greatest at a low (11/sec) click rate. At the 11/sec rate, the model-based mean wave III amplitude was significantly smaller in older compared with younger subjects even after adjusting for wave I amplitude. Aging also increased ABR peak latencies, with significant shifts limited to early waves. The I-V IPI did not change with age. For both younger and older subjects, increasing click presentation rate significantly decreased amplitudes of early peaks and prolonged latencies of later peaks, resulting in increased IPIs. Advanced age did not enhance effects of rate. Instead, the rate effect on wave I and III amplitudes was attenuated for the older subjects due to reduced peak amplitudes at lower click rates. Compared with model predictions from the sample of better hearing subjects, mean ABR amplitudes were diminished in the group with poorer hearing, and wave V latencies were prolonged. CONCLUSIONS: In a sample of veterans, aging substantially reduced amplitudes of all principal ABR peaks, with significant latency shifts limited to waves I and III. Aging did not influence the I-V IPI even at high click rates, suggesting that the observed absolute latency changes associated with aging can be attributed to changes in auditory nerve input. In contrast, ABR amplitude changes with age are not adequately explained by changes in wave I. Results suggest that aging reduces the numbers and/or synchrony of contributing auditory nerve units. Results also support the concept that aging reduces the numbers, though perhaps not the synchrony, of central ABR generators.
Assuntos
Envelhecimento/fisiologia , Limiar Auditivo/fisiologia , Potenciais Evocados Auditivos do Tronco Encefálico/fisiologia , Perda Auditiva/fisiopatologia , Presbiacusia/fisiopatologia , Adulto , Distribuição por Idade , Idoso , Audiometria de Tons Puros , Nervo Coclear/fisiologia , Estudos Transversais , Feminino , Perda Auditiva/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Presbiacusia/epidemiologia , Tempo de Reação/fisiologia , Análise de Regressão , Distribuição por Sexo , Veteranos/estatística & dados numéricosRESUMO
INTRODUCTION: A nonbehavioral method for monitoring ototoxicity in patients treated with cisplatin is needed because patients enduring chemotherapy may not be well or cooperative enough to undergo repeated hearing tests. Distortion-product otoacoustic emissions (DPOAEs) provide a nonbehavioral measure of auditory function that is sensitive to cisplatin exposure. However, interpreting DPOAE findings in the context of ototoxicity monitoring requires that their accuracy be determined in relation to a clinically accepted gold standard test. OBJECTIVES: Among patients receiving cisplatin for the treatment of cancer, we sought to (1) identify the combination of DPOAE metrics and ototoxicity risk factors that best classified ears with and without ototoxic-induced hearing changes; and (2) evaluate the test performance achieved by the composite measure as well as by DPOAEs alone. DESIGN: Odds of experiencing hearing changes at a given patient visit were determined using data collected prospectively from 24 Veterans receiving cisplatin. Pure-tone thresholds were examined within an octave of each subject's high-frequency hearing limit. DPOAE were collected as a set of four response growth (input/output) functions near the highest f2 frequency that yielded a robust response at L2 = L1 = 65 dB SPL. Logistic regression modeled the risk of hearing change using several DPOAE metrics, drug treatment factors, and other patient factors as independent variables. An optimal discriminant function was derived by reducing the model so that only statistically significant variables were included. Receiver operating characteristic curve analyses were used to evaluate test performance. RESULTS: At higher cisplatin doses, ears with better hearing at baseline were more likely to exhibit ototoxic hearing changes than those with poorer hearing. Measures of pre-exposure hearing, cumulative drug dose, and DPOAEs generated a highly accurate discriminant function with a cross-validated area under the receiver operating characteristic curve of 0.9. DPOAEs alone also provided an indication of ototoxic hearing change when measured at the highest DPOAE test frequency that yielded a robust response. CONCLUSIONS: DPOAEs alone and especially in combination with pre-exposure hearing and cisplatin dose provide an indication of whether or not hearing has changed as a result of cisplatin administration. These promising results need to be validated in a separate sample.
Assuntos
Antineoplásicos/toxicidade , Cisplatino/toxicidade , Perda Auditiva Neurossensorial/induzido quimicamente , Emissões Otoacústicas Espontâneas/efeitos dos fármacos , Adulto , Idoso , Antineoplásicos/uso terapêutico , Audiometria de Tons Puros , Limiar Auditivo/efeitos dos fármacos , Cisplatino/uso terapêutico , Feminino , Perda Auditiva Neurossensorial/diagnóstico , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Padrões de ReferênciaRESUMO
PURPOSE: Anti-tumor necrosis factor-alpha (anti-TNF) therapies are associated with severe mycobacterial infections in rheumatoid arthritis patients. We developed and validated electronic record search algorithms for these serious infections. METHODS: The study used electronic clinical, microbiologic, and pharmacy records from Kaiser Permanente Northern California (KPNC) and the Portland Veterans Affairs Medical Center (PVAMC). We identified suspect tuberculosis and nontuberculous mycobacteria (NTM) cases using inpatient and outpatient diagnostic codes, culture results, and anti-tuberculous medication dispensing. We manually reviewed records to validate our case-finding algorithms. RESULTS: We identified 64 tuberculosis and 367 NTM potential cases, respectively. For tuberculosis, diagnostic code positive predictive value (PPV) was 54% at KPNC and 9% at PVAMC. Adding medication dispensings improved these to 87% and 46%, respectively. Positive tuberculosis cultures had a PPV of 100% with sensitivities of 79% (KPNC) and 55% (PVAMC). For NTM, the PPV of diagnostic codes was 91% (KPNC) and 76% (PVAMC). At KPNC, ≥ 1 positive NTM culture was sensitive (100%) and specific (PPV, 74%) if non-pathogenic species were excluded; at PVAMC, ≥1 positive NTM culture identified 76% of cases with PPV of 41%. Application of the American Thoracic Society NTM microbiology criteria yielded the highest PPV (100% KPNC, 78% PVAMC). CONCLUSIONS: The sensitivity and predictive value of electronic microbiologic data for tuberculosis and NTM infections is generally high, but varies with different facilities or models of care. Unlike NTM, tuberculosis diagnostic codes have poor PPV, and in the absence of laboratory data, should be combined with anti-tuberculous therapy dispensings for pharmacoepidemiologic research.
Assuntos
Artrite Reumatoide/microbiologia , Codificação Clínica/normas , Infecções por Mycobacterium/microbiologia , Infecções Oportunistas/microbiologia , Tuberculose/microbiologia , Fator de Necrose Tumoral alfa/antagonistas & inibidores , Algoritmos , Artrite Reumatoide/complicações , Artrite Reumatoide/tratamento farmacológico , Artrite Reumatoide/epidemiologia , California , Estudos de Coortes , Registros Eletrônicos de Saúde/normas , Humanos , Infecções por Mycobacterium/complicações , Infecções por Mycobacterium/tratamento farmacológico , Infecções por Mycobacterium/epidemiologia , Infecções Oportunistas/complicações , Infecções Oportunistas/tratamento farmacológico , Infecções Oportunistas/epidemiologia , Oregon , Reprodutibilidade dos Testes , Tuberculose/complicações , Tuberculose/tratamento farmacológico , Tuberculose/epidemiologiaRESUMO
The manner in which humans smoke cigarettes is an important determinant of smoking risks. Of the few investigators that have predicted cancer risks from smoking on a chemical-specific basis, most used mainstream cigarette smoke (MCS) carcinogen emissions obtained via machine smoking protocols that only approximate human smoking conditions. Here we use data of Djordjevic et al. [Djordjevic, M.V., Stellman, S.D., Zang, E., 2000. Doses of nicotine and lung carcinogens delivered to cigarette smokers. J. Natl. Cancer Inst. 92, 106-111] for MCS emissions of three carcinogens measured under human smoking conditions to compute probability distributions of incremental lifetime cancer risk (ILCR) values using Monte Carlo simulations. The three carcinogens considered are benzo[a]pyrene, N'-nitrosonornicotine (NNN), and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK). Computed NNK ILCR values were compared with lifetime risks of lung cancer (ILCR(CMD)(obsSigma-lung)) derived from American Cancer Society Cancer Prevention Studies (CPS) I and II. Within the Monte Carlo simulation results, NNK was responsible for the greatest ILCR values for all cancer endpoints: median ILCR values for NNK were approximately 18-fold and 120-fold higher than medians for NNN and benzo[a]pyrene, respectively. For "regular" cigarettes, the NNK median ILCR for lung cancer was lower than ILCR(CMD)(obsSigma-lung) from CPS-I and II by >90-fold for men and >4-fold for women. Given what is known about chemical carcinogens in MCS, this study shows that there is a higher incidence of lung cancer from exposure to MCS than can be predicted with current risk assessment methods using available toxicity and emission data.
Assuntos
Benzo(a)pireno/toxicidade , Carcinógenos/toxicidade , Neoplasias Pulmonares/etiologia , Nitrosaminas/toxicidade , Fumar/efeitos adversos , Relação Dose-Resposta a Droga , Feminino , Humanos , Exposição por Inalação/efeitos adversos , Neoplasias Pulmonares/epidemiologia , Masculino , Método de Monte Carlo , Medição de Risco , Fumaça/análise , Fumar/epidemiologia , Estados Unidos/epidemiologiaRESUMO
OBJECTIVES: We evaluated the effect of standardized clinical breast examination (CBE) training on residents' ability to detect a 3-mm breast mass in a silicone breast model. METHODS: In this nonrandomized controlled trial, 75 first year residents (R1s) at 8 family medicine, internal medicine, and obstetrics and gynecology training programs received the intervention and second year residents (R2s) did not. Trained residency faculty taught R1s vertical strip, three-pressure method (VS3PM) CBE using a standardized curriculum, including a 1- to 2-hour online self-study with video and 2.5-hour practicum using silicone models and a trained patient surrogate. RESULTS: Solitary mass detection: 84% by R1s, 46% by R2s (RR = 1.82, 95%CI = 1.36, 2.43, P < 0.0001). Of those finding a mass, 62% of R1s and 10% of R2s used at least 5 of 8 standardized descriptors (RR = 6.19, 95%CI = 2.06, 18.59, P = 0.001). R1s false positive findings were not statistically different from R2s (P = 0.54). Both the use of VS3PM and total time spent on CBE were independently highly predictive of finding the mass in either group. CONCLUSIONS: Most untrained primary care residents are not proficient in CBE. Standardized VS3PM CBE training improves the ability to detect and describe a small mass in a silicone breast model. Better CBE training for residents may improve the early detection of breast cancer.
Assuntos
Doenças Mamárias/diagnóstico , Competência Clínica , Currículo , Internato e Residência , Exame Físico/métodos , Estudos de Casos e Controles , Diagnóstico Precoce , Reações Falso-Negativas , Reações Falso-Positivas , Humanos , ManequinsRESUMO
Trichloroethylene (TCE), a common groundwater contaminant, was found at high levels at an Oregon work site in 1998. According to a recent report released by the National Research Council, "the evidence on carcinogenic risk and other health hazards from exposure to trichloroethylene has strengthened since 2001." A convenience sample of 13 former workers from the Oregon work site was recruited for a series of focus groups. Information obtained on plant processes, safety procedures, attitudes regarding medical record access, and opinions about proxy accuracy was subjected to qualitative content analysis. Workers recalled few safety policies and no training or support for control of safety. Most thought co-workers and family members would be the best source of proxy exposure information and favored granting access to medical records. Job-role mobility confirmed the importance of using a job or task exposure matrix. Information obtained will be used in development of an exposure assessment interview tool.
Assuntos
Grupos Focais , Exposição Ocupacional/análise , Tricloroetileno/efeitos adversos , Poluentes Químicos da Água/efeitos adversos , Atitude Frente a Saúde , Projetos de Pesquisa Epidemiológica , Feminino , Humanos , Masculino , Prontuários Médicos/estatística & dados numéricos , Exposição Ocupacional/prevenção & controle , Oregon , Política Organizacional , Gestão da Segurança/organização & administraçãoRESUMO
Toxicant deliveries (by machine smoking) are compiled and associated cancer risks are calculated for 13 carcinogens from 26 brands of conventional cigarettes categorized as "regular" (R), "light" (Lt), or "ultralight" (ULt), and for a reference cigarette. Eight "potentially reduced exposure product" (PREP) cigarettes are also considered. Because agency-to-agency differences exist in the cancer slope factor (CSF) values adopted for some carcinogens, two CSF sets were used in the calculations: set I [U.S. Environmental Protection Agency (EPA)-accepted values plus California EPA-accepted values as needed to fill data gaps] and set II (vice versa). The potential effects of human smoking patterns on cigarette deliveries are considered. Acetaldehyde, 1,3-butadiene, and acrylonitrile are associated with the largest calculated cancer risks for all 26 brands of conventional cigarettes. The calculated risks are proportional to the smoking dose z (pack-years). Using CSF set I and z = 1 pack-year (7,300 cigarettes), the calculated brand-average incremental lifetime cancer risk ILCR(1)(acetaldehyde) values are R, 6 x 10(-5); Lt, 5 x 10(-5); and ULt, 3 x 10(-5) (cf. typical U.S. EPA risk benchmark of 10(-6)). These values are similar, especially given the tendency of smokers to "compensate" when smoking Lt and ULt cigarettes. ILCR(1)(subSigma-lung) is the brand-average per pack-year subtotal risk for the measured human lung carcinogens. Using CSF set I, the ILCR(1)(subSigma-lung) values for R, Lt, and ULt cigarettes account for Assuntos
Carcinógenos/análise
, Carcinógenos/farmacocinética
, Neoplasias Pulmonares/etiologia
, Pulmão/química
, Medição de Risco
, Fumar/efeitos adversos
, Acetaldeído/análise
, Acrilonitrila/análise
, Biomarcadores/análise
, Butadienos/análise
, Humanos
, Alcatrões/análise
RESUMO
OBJECTIVE: This study assessed the cost effectiveness of different types of television and radio advertisements and the time of day in which advertisements were placed in generating calls to the Oregon tobacco quitline. DESIGN: Cost effectiveness was measured by cost per call, calculated as the cost of advertising divided by the number of quitline calls generated by that advertising. Advertising was bought in one-week or two-week blocks and included 27 daytime television buys, 22 evening television buys and 31 radio buys. RESULTS: Cost effectiveness varied widely by medium, time of day and advertisement used. Daytime television was seven times more cost effective than evening television and also more cost effective than radio. The most effective advertisements at generating quitline calls were real life testimonials by people who lost family members to tobacco and advertisements that deal practically with how to quit. CONCLUSIONS: Placement of television advertisements during the day versus the evening can increase an advertisement's effectiveness in generating calls to a quitline. Some advertising messages were more effective than others in generating calls to a quitline. Quitline providers can apply findings from previous research when planning media campaigns. In addition, call volume should be monitored in order to assess the cost effectiveness of different strategies to promote use of the quitline.
Assuntos
Publicidade/métodos , Linhas Diretas/estatística & dados numéricos , Abandono do Hábito de Fumar/métodos , Publicidade/economia , Análise Custo-Benefício , Humanos , Oregon , Rádio/economia , Prevenção do Hábito de Fumar , Televisão/economiaRESUMO
BACKGROUND: The Accreditation Council for Graduate Medical Education's (ACGME) new requirements raise multiple challenges for academic medical centers. We sought to evaluate career satisfaction, emotional states, positive and negative experiences, work hours and sleep among residents and faculty simultaneously in one academic medical center after implementation of the ACGME duty hour requirements. METHODS: Residents and faculty (1330) in the academic health center were asked to participate in a confidential survey; 72% of the residents and 66% of the faculty completed the survey. RESULTS: Compared to residents, faculty had higher levels of satisfaction with career choice, competence, importance and usefulness; lower levels of anxiousness and depression. The most positive experiences for both groups corresponded to strong interpersonal relationships and educational value; most negative experiences to poor interpersonal relationships and issues perceived outside of the physician's control. Approximately 13% of the residents and 14% of the faculty were out of compliance with duty hour requirements. Nearly 5% of faculty reported working more than 100 hours per week. For faculty who worked 24 hour shifts, nearly 60% were out of compliance with the duty-hour requirements. CONCLUSION: Reasons for increased satisfaction with career choice, positive emotional states and experiences for faculty compared to residents are unexplained. Earlier studies from this institution identified similar positive findings among advanced residents compared to more junior residents. Faculty are more frequently at risk for duty-hour violations. If patient safety is of prime importance, faculty, in particular, should be compliant with the duty hour requirements. Perhaps the ACGME should contain faculty work hours as part of its regulatory function.
Assuntos
Centros Médicos Acadêmicos , Atitude do Pessoal de Saúde , Docentes de Medicina , Internato e Residência , Satisfação no Emprego , Admissão e Escalonamento de Pessoal/normas , Carga de Trabalho/psicologia , Centros Médicos Acadêmicos/normas , Acreditação , Escolha da Profissão , Estudos de Coortes , Emoções , Docentes de Medicina/normas , Fidelidade a Diretrizes , Pesquisas sobre Atenção à Saúde , Humanos , Internato e Residência/normas , Relações Interpessoais , Oregon , Admissão e Escalonamento de Pessoal/estatística & dados numéricos , Medição de Risco , Segurança , Sono , Fatores de Tempo , Tolerância ao Trabalho Programado , Recursos Humanos , Carga de Trabalho/normas , Carga de Trabalho/estatística & dados numéricosRESUMO
We evaluated whether susceptibility, the stages of smoking acquisition, and socio-environmental factors can identify adolescents who will become smokers. Our data came from a randomized controlled trial of an intervention to prevent adolescent smoking. Subjects were adolescents (n=1955) ages 14-17 being seen for routine medical care. The dependent variable was 30-day smoking status at 2-year follow-up (89.6% response rate). Independent variables included susceptibility, the stages of acquisition, and socio-environmental factors. Susceptible adolescents were two to three times more likely to be smokers than non-susceptible adolescents. Compared to acquisition precontemplators, acquisition contemplators were three to five times more likely, and acquisition preparers were five to eight times more likely, to be smokers. When combined into a single measure, susceptible precontemplators were two times, contemplators were six times, and preparers were nine times more likely to be smokers than non-susceptible precontemplators. Our findings suggest that acquisition stage and susceptibility can independently predict smoking onset. They may be used together to target teens for smoking prevention efforts in the clinical setting.
Assuntos
Fumar/psicologia , Adolescente , Feminino , Promoção da Saúde , Humanos , Masculino , Motivação , Psicologia do Adolescente , Curva ROC , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Prevenção do Hábito de FumarRESUMO
Hearing loss and tinnitus are the two most prevalent service-connected disabilities among U.S. veterans. The number of veterans receiving compensation and services from the Department of Veterans Affairs (VA) for these conditions continues to increase annually. However, the majority of veterans in the United States do not use VA medical centers or clinics for healthcare and do not receive VA compensation payments. Therefore, the prevalence of hearing loss and tinnitus among U.S. veterans is unknown. This study used National Health and Nutrition Examination Survey data to estimate the prevalence of these auditory conditions among male veterans. Between 1999 and 2006, pure tone audiometric data collected from 845 male veterans were compared with pure tone thresholds collected from 2,086 male nonveterans. We used questionnaire data collected between 1999 and 2004 to calculate and compare the prevalence of tinnitus for 2,174 veterans and 4,995 nonveterans. In general, pure tone thresholds did not differ significantly between veterans and nonveterans for most frequencies tested (500-8,000 Hz). The overall prevalence of tinnitus was greater for veterans than that for nonveterans (p < 0.001), with statistically significant differences in the 50 to 59 and 60 to 69 age groups.
Assuntos
Limiar Auditivo , Perda Auditiva Provocada por Ruído/epidemiologia , Zumbido/epidemiologia , Veteranos , Adulto , Idoso , Idoso de 80 Anos ou mais , Audiometria de Tons Puros , Humanos , Masculino , Pessoa de Meia-Idade , Inquéritos Nutricionais , Prevalência , Estados Unidos/epidemiologia , Adulto JovemRESUMO
OBJECTIVES/HYPOTHESIS: Determine effects on auditory brainstem response (ABR) of diabetes mellitus (DM) severity. STUDY DESIGN: A cross-sectional study investigating DM severity and ABR in military Veteran subjects with (166) and without (138) DM and with no more than moderate hearing loss. METHODS: Subjects were classified by three age tertiles (<50, 50-56, and 57+). DM severity was classified as insulin-dependent (IDDM), non-insulin-dependent (NIDDM), or no DM. Other DM measures included serum glucose, HbA1c, and several DM-related complications. ABR measures included wave I, III, and V latencies; I-III, III-V, and I-V latency intervals; and wave V amplitude; for each ear at three repetition rates (11, 51, and 71 clicks/second), and both polarities. Outcomes were stratified by age tertile and adjusted for pure tone threshold at 3 kHz. Repeated measures multivariate analysis of covariance modeled the ABR response at each repetition rate for DM severity (main effect) and hearing at 3 kHz (covariate). Modeled contrasts between ABR variables in subjects with and without DM were examined. RESULTS: Significant differences existed between no DM and IDDM groups in the younger tertile only. Adjusting for threshold at 3 kHz had minimal effect. Self-reported noise exposure was not related to ABR differences, but HbA1c and poor circulation were. CONCLUSIONS: IDDM is associated with an increased wave V latency, wave I-V interval, and reduced wave V amplitude among Veterans under 50 years. Results were related to several DM complications.
Assuntos
Diabetes Mellitus/fisiopatologia , Potenciais Evocados Auditivos do Tronco Encefálico , Adulto , Idoso , Estudos Transversais , Complicações do Diabetes/fisiopatologia , Diabetes Mellitus Tipo 1/fisiopatologia , Diabetes Mellitus Tipo 2/fisiopatologia , Perda Auditiva/complicações , Humanos , Pessoa de Meia-IdadeRESUMO
BACKGROUND: The use of adjuvant chemoradiation for pancreatic adenocarcinoma (PAC) is accepted in North America, but there is a paucity of data to support this practice. The relation between adjuvant therapy and survival was assessed in a population-based cohort of patients with PAC. METHODS: A review was conducted of all cases of resected PAC from 1996 to 2003 using data from the state cancer registry augmented with data from primary medical record review. Use of adjuvant therapy was ascertained from registry data. Survival was assessed using the Kaplan-Meier method, and a Cox proportional hazards model was developed for multivariate analysis. RESULTS: A total of 298 patients from 27 hospitals met criteria for inclusion. There were 228 patients (76.5%) who were resected with curative intent, with a median overall survival of 12 months. The 6-month, 1-year, and 5-year survival rates were 80.2%, 58.4%, and 6.7%, respectively. Of the 228 patients resected, 122 (53.5%) received adjuvant treatment and had a median survival of 13.0 months versus 11.0 months for those with no adjuvant treatment (P = .16). After adjustment for surrogates of performance status, significant predictors of overall survival included no weight loss, T1/T2 pathologic stage, a microscopically complete resection (R0), and receipt of adjuvant therapy. CONCLUSIONS: An R0 resection and adjuvant therapy were found to be independently associated with an increase in overall survival in patients with resected PAC. These data underscore the importance of adjuvant therapy in resected PAC and the need for ongoing clinical trials to refine the efficacy and timing of adjuvant therapy in this disease.
Assuntos
Adenocarcinoma/mortalidade , Adenocarcinoma/terapia , Neoplasias Pancreáticas/mortalidade , Neoplasias Pancreáticas/terapia , Adenocarcinoma/patologia , Adenocarcinoma/cirurgia , Idoso , Antineoplásicos/uso terapêutico , Quimioterapia Adjuvante , Terapia Combinada , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias Pancreáticas/patologia , Neoplasias Pancreáticas/cirurgia , Radioterapia Adjuvante , Taxa de SobrevidaRESUMO
BACKGROUND: Recent years have brought important developments in preoperative imaging and use of laparoscopic staging of patients with pancreatic adenocarcinoma (PAC). There are few data about the optimal combination of preoperative studies to accurately identify resectable patients. STUDY DESIGN: We conducted a statewide review of all patients with surgically managed PAC from 1996 to 2003 using data from the Oregon State Cancer Registry, augmented with clinical information from primary medical record review. We documented the use of all staging modalities, including CT, endoscopic ultrasonography, and laparoscopy. Primary outcomes included resection with curative intent. The association between staging modalities, clinical features, and resection was measured using a multivariate logistic regression model. RESULTS: There were 298 patients from 24 hospitals who met the eligibility criteria. Patients were staged using a combination of CT (98%), laparoscopy (29%), and endoscopic ultrasonography (32%). The overall proportion of patients who went to surgical exploration and were resected was 87%. Of patients undergoing diagnostic laparoscopy, metastatic disease that precluded resection was discovered in 24 (27.6%). For patients who underwent diagnostic laparoscopy and were not resected, vascular invasion was the most common determinant of unresectability (56.6%). In multivariate analysis, preoperative weight loss and surgeon decision to use laparoscopy predicted unresectability at laparotomy. CONCLUSIONS: This population-based study demonstrates that surgeons appear to use laparoscopy in a subset of patients at high risk for metastatic disease. The combination of current staging techniques is associated with a high proportion of resectability for patients taken to surgical exploration. With current imaging modalities, selective application of laparoscopy with a dual-phase CT scan as the cornerstone of staging is a sound clinical approach to evaluate pancreatic cancer patients for potential resectability.
Assuntos
Adenocarcinoma/patologia , Adenocarcinoma/cirurgia , Laparoscopia , Neoplasias Pancreáticas/patologia , Neoplasias Pancreáticas/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Humanos , Masculino , Auditoria Médica , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Oregon , Seleção de Pacientes , Cuidados Pré-Operatórios , Sistema de Registros , Estudos RetrospectivosRESUMO
OBJECTIVES/HYPOTHESIS: Determine the effects on hearing of diabetes mellitus (DM) severity. STUDY DESIGN: We conducted a cross-sectional study among Veterans to investigate the relationship of diabetes severity and hearing in randomly selected subjects with (165) and without (137) DM and who had no more than a moderate hearing loss. METHODS: Subjects were classified by three age tertiles (<50, 50-56, and 57+ years). Diabetes severity was classified as insulin-dependent (IDDM), noninsulin-dependent (NIDDM), or no DM. Other DM measures included concurrent serum glucose, serum HbA(1c), duration of disease, and several measures of DM-related complications. Pure-tone thresholds were measured in both ears of each subject at frequencies from 250 Hz through 14,000 Hz. Outcome measures were adjusted for age and frequency and analyzed for differences between subject groups using analysis of variance. Contrasts of the mean NIDDM and IDDM thresholds at each frequency to the DM group, and controlled for the effects of frequency, age, and interactions were modeled. RESULTS: There was greater hearing loss in younger tertile DM subjects compared to those without DM. Significant hearing differences were at all frequencies for NIDDM subjects, but for IDDM subjects, differences were at 1,000 Hz and below, and 10,000 Hz and above. Over age 50 years, there were significant associations between hearing at low frequencies and IDDM only. Self-report of prior noise exposure did not explain observed differences. CONCLUSIONS: Diabetes is associated with an increased risk of hearing loss, and this difference is manifest particularly in adults <50 years old.
Assuntos
Diabetes Mellitus Tipo 1/complicações , Diabetes Mellitus Tipo 2/complicações , Perda Auditiva/epidemiologia , Adulto , Fatores Etários , Idoso , Audiometria de Tons Puros , Estudos Transversais , Complicações do Diabetes/epidemiologia , Feminino , Hemoglobinas Glicadas , Humanos , Masculino , Pessoa de Meia-Idade , Índice de Gravidade de Doença , Estados Unidos , VeteranosRESUMO
PURPOSE: To ascertain the frequency of uveitis in Veterans Affairs (VA) patients in the Pacific Northwest and to compare disease rates with those in previously published epidemiologic studies. DESIGN: Cross-sectional, population based-study. METHODS: The medical records of 152,267 patients seen at six VA Medical Centers in Oregon and Washington during fiscal year 2004 were searched for uveitis-related International Classification of Diseases 9th edition codes. Cases were reviewed and classified anatomically, by associated systemic disease, and as incident or prevalent. Only definite cases were used for disease rate calculations. RESULTS: This study found a crude incidence of 25.6 cases/100,000 person-years and a crude prevalence of 69 cases/100,000 persons. The most common anatomic location for uveitis was anterior. Approximately half of cases were idiopathic, with human leukocyte antigen-B27-related diseases being the most common identified cause. There was no statistical evidence of increased or decreased incidence with age, although uveitis seemed to be more prevalent in the younger age groups. CONCLUSIONS: Our data are consistent with those of most published population-based studies on the epidemiologic features of uveitis, but we detected significantly lower incidence and prevalence than those reported in a recently published study from Kaiser Permanente. The significance of and possible explanations for the differences between our data and that published by the Kaiser group are discussed.
Assuntos
Hospitais de Veteranos/estatística & dados numéricos , United States Department of Veterans Affairs/estatística & dados numéricos , Uveíte/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Oregon/epidemiologia , Prevalência , Estados Unidos , Uveíte/classificação , Washington/epidemiologiaRESUMO
OBJECTIVE: To conduct a systematic review to evaluate the evidence for the effect of breastfeeding on the risk of developing childhood leukemia. REVIEW METHODS: We sought studies providing data regarding the association of breastfeeding and occurrence of childhood leukemia. Studies were identified by using Medline, HHS Blueprint for Action on Breastfeeding, US Department of Health and Human Services Office on Women's Health, Cochrane Database of Systematic Reviews, National Centre for Reviews and Dissemination, reference lists, and national experts. Methodologic quality was evaluated for each study by using criteria from the US Preventive Services Task Force and the National Health Service Centre for Reviews and Dissemination. RESULTS: We reviewed 111 citations to identify 32 potentially eligible full-text articles. Of the 10 studies reviewed, only 4 were sufficient to provide at least fair-quality evidence regarding the association between maternal breastfeeding and childhood leukemia. Studies conflicted regarding the protective effect of breastfeeding on childhood leukemia. In the 2 largest and highest quality studies, breastfeeding was associated with a significant risk reduction in one study with longer breastfeeding duration, reflecting greater protection, and a nonsignificant but suggestive difference in the other. Taken together, half of the studies associated breastfeeding with a lower risk of acute lymphocytic leukemia. CONCLUSIONS: There are few high-quality studies that examine the potential for a protective effect of breastfeeding for childhood leukemia. Furthermore, the few studies that exist disagree regarding the association. It is estimated that the United States spends 1.4 billion dollars annually on the treatment of childhood leukemia. Patients, clinicians, and policy makers do not have the data that they need to make decisions regarding this important potential preventive measure.