Impact of Colonoscopy Bowel Preparation Quality on Follow-up Interval Recommendations for Average-risk Patients With Normal Screening Colonoscopies: Data From the New Hampshire Colonoscopy Registry.

BACKGROUND AND AIMS: National guidelines for colonoscopy screening and surveillance assume adequate bowel preparation. We used New Hampshire Colonoscopy Registry (NHCR) data to investigate the influence of bowel preparation quality on endoscopist recommendations for follow-up intervals in average-risk patients following normal screening colonoscopies. METHODS: The analysis included 9170 normal screening colonoscopies performed on average risk individuals aged 50 and above between February 2005 and September 2013. The NHCR Procedure Form instructs endoscopists to score based on the worst prepped segment after clearing all colon segments, using the following categories: excellent (essentially 100% visualization), good (very unlikely to impair visualization), fair (possibly impairing visualization), and poor (definitely impairing visualization). We categorized examinations into 3 preparation groups: optimal (excellent/good) (n=8453), fair (n=598), and poor (n=119). Recommendations other than 10 years for examinations with optimal preparation, and >1 year for examinations with poor preparation, were considered nonadherent. RESULTS: Of all examinations, 6.2% overall received nonadherent recommendations, including 5% of examinations with optimal preparation and 89.9% of examinations with poor preparation. Of normal examinations with fair preparation, 20.7% of recommendations were for an interval <10 years. Among those examinations with fair preparation, shorter-interval recommendations were associated with female sex, former/nonsmokers, and endoscopists with adenoma detection rate ≥20%. CONCLUSIONS: In 8453 colonoscopies with optimal preparations, most recommendations (95%) were guideline-adherent. No guideline recommendation currently exists for fair preparation, but in this investigation into community practice, the majority of the fair preparation group received 10-year follow-up recommendations. A strikingly high proportion of examinations with poor preparation received a follow-up recommendation greater than the 1-year guideline recommendation. Provider education is needed to ensure that patients with poor bowel preparation are followed appropriately to reduce the risk of missing important lesions.

Risk of Metachronous High-Risk Adenomas and Large Serrated Polyps in Individuals With Serrated Polyps on Index Colonoscopy: Data From the New Hampshire Colonoscopy Registry.

BACKGROUND & AIMS: Surveillance guidelines for serrated polyps (SPs) are based on limited data on longitudinal outcomes of patients. We used the New Hampshire Colonoscopy Registry to evaluate risk of clinically important metachronous lesions associated with SPs detected during index colonoscopies. METHODS: We collected data from a population-based colonoscopy registry that has been collecting and analyzing data on colonoscopies across the state of New Hampshire since 2004, including rates of adenoma and SP detection. Patients completed a questionnaire to determine demographic characteristics, health history, and risk factors for colorectal cancer, and were followed from index colonoscopy through all subsequent surveillance colonoscopies. Our analyses included 5433 participants (median age, 61 years; 49.7% male) with 2 colonoscopies (median time to surveillance, 4.9 years). We used multivariable logistic regression models to assess effects of index SPs (n = 1016), high-risk adenomas (HRA, n = 817), low-risk adenomas (n = 1418), and no adenomas (n = 3198) on subsequent HRA or large SPs (>1 cm) on surveillance colonoscopy (metachronous lesions). Synchronous SPs, within each index risk group, were assessed for size and by histology. SPs comprise hyperplastic polyps, sessile serrated adenomas/polyps (SSA/Ps), and traditional serrated adenomas. In this study, SSA/Ps and traditional serrated adenomas are referred to collectively as STSAs. RESULTS: HRA and synchronous large SP (odds ratio [OR], 5.61; 95% confidence interval [CI], 1.72-18.28), HRA with synchronous STSA (OR, 16.04; 95% CI, 6.95-37.00), and HRA alone (OR, 3.86; 95% CI, 2.77-5.39) at index colonoscopy significantly increased the risk of metachronous HRA compared to the reference group (no index adenomas or SPs). Large index SPs alone (OR, 14.34; 95% CI, 5.03-40.86) or index STSA alone (OR, 9.70; 95% CI, 3.63-25.92) significantly increased the risk of a large metachronous SP. CONCLUSIONS: In an analysis of data from a population-based colonoscopy registry, we found index large SP or index STSA with no index HRA increased risk of metachronous large SPs but not metachronous HRA. HRA and synchronous SPs at index colonoscopy significantly increased risk of metachronous HRA. Individuals with HRA and synchronous large SP or any STSA could therefore benefit from close surveillance.

Personal history of proliferative breast disease with atypia and risk of multifocal breast cancer.

BACKGROUND: A history of proliferative breast disease with atypia (PBDA) may be indicative of an increased risk not just of breast cancer but also of a more aggressive form of breast cancer. METHODS: Multifocal breast cancer (MFBC), defined as 2 or more tumors in the same breast upon a diagnosis of cancer, is associated with a poorer prognosis than unifocal (single-tumor) breast cancer. PBDA, including atypical ductal hyperplasia and atypical lobular hyperplasia, is a known risk factor for breast cancer. Using New Hampshire Mammography Network data collected for 3567 women diagnosed with incident breast cancer from 2004 to 2014, this study assessed the risk of MFBC associated with a previous diagnosis of PBDA. RESULTS: Women with a history of PBDA were found to be twice as likely to be subsequently diagnosed with MFBC as women with no history of benign breast disease (BBD; odds ratio [OR], 2.23; 95% confidence interval [CI], 1.08-4.61). Ductal carcinoma in situ on initial biopsy was associated with a 2-fold increased risk of MFBC in comparison with invasive cancer (OR, 2.13; 95% CI, 1.58-2.88). BBD and proliferative BBD without atypia were not associated with MFBC. CONCLUSIONS: Women with a history of previous PBDA may be at increased risk for MFBC. Women with a history of PBDA may benefit from additional presurgical clinical workup. Cancer 2018;124:1350-7. © 2017 American Cancer Society.

Providing data for serrated polyp detection rate benchmarks: an analysis of the New Hampshire Colonoscopy Registry.

BACKGROUND AND AIMS: Similar to achieving adenoma detection rate (ADR) benchmarks to prevent colorectal cancer (CRC), achieving adequate serrated polyp detection rates (SDRs) may be essential to the prevention of CRC associated with the serrated pathway. Previous studies have been based on data from high-volume endoscopists at single academic centers. Based on a hypothesis that ADR is correlated with SDR, we stratified a large, diverse group of endoscopists (n = 77 practicing at 28 centers) into high performers and low performers, based on ADR, to provide data for corresponding target SDR benchmarks. METHODS: By using colonoscopies in adults aged ≥50 years (4/09-12/14), we stratified endoscopists by high and low ADRs (<15%, 15%-<25%, 25%-<35%, ≥35%) to determine corresponding SDRs by using 2 SDR measures, for screening and surveillance colonoscopies separately: (1) Clinically significant SDR (CSSDR), meaning colonoscopies with any sessile serrated adenoma/polyp (SSA/P), traditional serrated adenoma (TSA), or hyperplastic polyp (HP) >1 cm anywhere in the colon or HP >5 mm in the proximal colon only divided by the total number of screening and surveillance colonoscopies, respectively. (2) Proximal SDR (PSDR) meaning colonoscopies with any serrated polyp (SSA/P, HP, TSA) of any size proximal to the sigmoid colon divided by the total number of screening and surveillance colonoscopies, respectively. RESULTS: A total of 45,996 (29,960 screening) colonoscopies by 77 endoscopists (28 facilities) were included. Moderately strong positive correlation coefficients were observed for screening ADR/CSSDR (P = .69) and ADR/PSDR (P = .79) and a strong positive correlation (P = .82) for CSSDR/PSDR (P < .0001 for all) was observed. For ADR ≥25%, endoscopists' median (interquartile range) screening CSSDR was 6.8% (4.3%-8.6%) and PSDR was 10.8% (8.6%-16.1%). CONCLUSIONS: Derived from ADR, the primary colonoscopy quality indicator, our results suggest potential SDR benchmarks (CSSDR = 7% and PSDR = 11%) that may guide adequate serrated polyp detection. Because CSSDR and PSDR are strongly correlated, endoscopists could use the simpler PSDR calculation to assess quality.

Adenoma Detection Rates for Screening Colonoscopies in Smokers and Obese Adults: Data From the New Hampshire Colonoscopy Registry.

GOAL: To examine screening adenoma detection rates (ADR) and serrated detection rates (SDR) among smokers and obese adults in the New Hampshire Colonoscopy Registry. BACKGROUND: ADR, a quality measure for screening colonoscopies, is associated with protection from interval colorectal cancer. Currently, only sex-specific ADR benchmarks are reported. However, obesity and smoking ≥20 pack-years are strong predictors for colorectal neoplasia, as highlighted by the 2009 American College of Gastroenterology CRC Screening Guidelines. Data comparing ADR in smokers and obese adults to those without these risks are limited. STUDY: We calculated ADR, SDR, and 95% confidence intervals for screening colonoscopies in participants ≥50 years. Sex-specific and sex-age-specific rates were compared by smoking exposure (never vs. <20 vs. ≥20 pack-years) and body mass index (<30 vs. ≥30). RESULTS: A total of 21,539 screening colonoscopies were performed by 77 endoscopists at 20 facilities (April 2009 to September 2013). The difference in ADR between nonsmokers and smokers with ≥20 pack-years was 8.8% (P<0.0001) and between obesity groups 5.0% (P<0.0001). Significant sex-specific and sex-age-specific increases in ADR and SDR were found among smokers and obese participants. CONCLUSIONS: ADR and SDR for smokers and obese adults were significantly higher than their counterparts without those risks. Endoscopists should consider the prevalence of these risks within their screening population when comparing their rates to established benchmarks. Calculating sex-specific or sex-age-specific ADR and SDR based on smoking and obesity may provide optimal protection for populations with a particularly high prevalence of smokers and obese adults.

Breast MRI in the Diagnostic and Preoperative Workup Among Medicare Beneficiaries With Breast Cancer.

PURPOSE: We compared the frequency and sequence of breast imaging and biopsy use for the diagnostic and preoperative workup of breast cancer according to breast magnetic resonance imaging (MRI) use among older women. MATERIALS AND METHODS: Using SEER-Medicare data from 2004 to 2010, we identified women with and without breast MRI as part of their diagnostic and preoperative breast cancer workup and measured the number and sequence of breast imaging and biopsy events per woman. RESULTS: A total of 10,766 (20%) women had an MRI in the diagnostic/preoperative period, 32,178 (60%) had mammogram and ultrasound, and 10,669 (20%) had mammography alone. MRI use increased across study years, tripling from 2005 to 2009 (9%-29%). Women with MRI had higher rates of breast imaging and biopsy compared with those with mammogram and ultrasound or those with mammography alone (5.8 vs. 4.1 vs. 2.8, respectively). There were 4254 unique sequences of breast events; the dominant patterns for women with MRI were an MRI occurring at the end of the care pathway. Among women receiving an MRI postdiagnosis, 26% had a subsequent biopsy compared with 51% receiving a subsequent biopsy in the subgroup without MRI. CONCLUSIONS: Older women who receive breast MRI undergo additional breast imaging and biopsy events. There is much variability in the diagnostic/preoperative work-up in older women, demonstrating the opportunity to increase standardization to optimize care for all women.

Serrated and adenomatous polyp detection increases with longer withdrawal time: results from the New Hampshire Colonoscopy Registry.

OBJECTIVES: Detection and removal of adenomas and clinically significant serrated polyps (CSSPs) is critical to the effectiveness of colonoscopy in preventing colorectal cancer. Although longer withdrawal time has been found to increase polyp detection, this association and the use of withdrawal time as a quality indicator remains controversial. Few studies have reported on withdrawal time and serrated polyp detection. Using data from the New Hampshire Colonoscopy Registry, we examined how an endoscopist's withdrawal time in normal colonoscopies affects adenoma and serrated polyp detection. METHODS: We analyzed 7,996 colonoscopies performed in 7,972 patients between 2009 and 2011 by 42 endoscopists at 14 hospitals, ambulatory surgery centers, and community practices. CSSPs were defined as sessile serrated polyps and hyperplastic polyps proximal to the sigmoid. Adenoma and CSSP detection rates were calculated based on median endoscopist withdrawal time in normal exams. Regression models were used to estimate the association of increased normal withdrawal time and polyp, adenoma, and CSSP detection. RESULTS: Polyp and adenoma detection rates were highest among endoscopists with 9 min median normal withdrawal time, and detection of CSSPs reached its highest levels at 8-9 min. Incident rate ratios for adenoma and CSSP detection increased with each minute of normal withdrawal time above 6 min, with maximum benefit at 9 min for adenomas (1.50, 95% confidence interval (CI) (1.21, 1.85)) and CSSPs (1.77, 95% CI (1.15, 2.72)). When modeling was used to set the minimum withdrawal time at 9 min, we predicted that adenomas and CSSPs would be detected in 302 (3.8%) and 191 (2.4%) more patients. The increase in detection was most striking for the CSSPs, with nearly a 30% relative increase. CONCLUSIONS: A withdrawal time of 9 min resulted in a statistically significant increase in adenoma and serrated polyp detection. Colonoscopy quality may improve with a median normal withdrawal time benchmark of 9 min.

Impact of fair bowel preparation quality on adenoma and serrated polyp detection: data from the New Hampshire colonoscopy registry by using a standardized preparation-quality rating.

BACKGROUND: The effect of colon preparation quality on adenoma detection rates (ADRs) is unclear, partly because of lack of uniform colon preparation ratings in prior studies. The New Hampshire Colonoscopy Registry collects detailed data from colonoscopies statewide, by using a uniform preparation quality scale after the endoscopist has cleaned the mucosa. OBJECTIVE: To compare the overall and proximal ADR and serrated polyp detection rates (SDR) in colonoscopies with differing levels of colon preparation quality. DESIGN: Cross-sectional. SETTING: New Hampshire statewide registry. PATIENTS: Patients undergoing colonoscopy. INTERVENTIONS: We examined colon preparation quality for 13,022 colonoscopies, graded by using specific descriptions provided to endoscopists. ADR and SDR are the number of colonoscopies with at least 1 adenoma or serrated polyp (excluding those in the rectum and/or sigmoid colon) detected divided by the total number of colonoscopies, for the preparation categories: optimal (excellent and/or good), fair, and poor. MAIN OUTCOME MEASUREMENTS: Overall/proximal ADR/SDR. RESULTS: The overall detection rates in examinations with fair colon preparation quality (SDR 8.9%; 95% confidence interval [CI], 7.4-10.7, ADR 27.1%; 95% CI, 24.6-30.0) were similar to rates observed in colonoscopies with optimal preparation quality (SDR 8.8%; 95% CI, 8.3-9.4, ADR 26.3%; 95% CI, 25.6-27.2). This finding also was observed for rates in the proximal colon. A logistic regression model (including withdrawal time) found that proximal ADR was statistically lower in the poor preparation category (odds ratio 0.45; 95% CI, 0.24-0.84; P < .01) than in adequately prepared colons. LIMITATIONS: Homogeneous population. CONCLUSION: In our sample, there was no significant difference in overall or proximal ADR or SDR between colonoscopies with fair versus optimal colon preparation quality. Poor colon preparation quality may reduce the proximal ADR.

Differences in detection rates of adenomas and serrated polyps in screening versus surveillance colonoscopies, based on the new hampshire colonoscopy registry.

BACKGROUND & AIMS: The adenoma detection rate (ADR) is an important quality indicator originally developed for screening colonoscopies. However, it is unclear whether the ADR should be calculated using data from screening and surveillance examinations. The recommended benchmark ADR for screening examinations is 20% (15% for women and 25% for men ≥50 y). There are few data available to compare ADRs from surveillance vs screening colonoscopies. We used a population-based registry to compare ADRs from screening vs surveillance colonoscopies. The serrated polyp detection rate (SDR), a potential new quality indicator, also was examined. METHODS: By using data from the statewide New Hampshire Colonoscopy Registry, we excluded incomplete and diagnostic colonoscopies, and those performed in patients with inflammatory bowel disease, familial syndromes, or poor bowel preparation. We calculated the ADR and SDR (number of colonoscopies with at least 1 adenoma or serrated polyp detected, respectively, divided by the number of colonoscopies) from 9100 colonoscopies. The ADR and SDR were compared by colonoscopy indication (screening, surveillance), age at colonoscopy (50-64 y, ≥65 y), and sex. RESULTS: The ADR was significantly higher in surveillance colonoscopies (37%) than screening colonoscopies (25%; P < .001). This difference was observed for both sexes and age groups. There was a smaller difference in the SDR of screening (8%) vs surveillance colonoscopies (10%; P < .001). CONCLUSIONS: In a population-based study, we found that addition of data from surveillance colonoscopies increased the ADR but had a smaller effect on the SDR. These findings indicate that when calculating ADR as a quality measure, endoscopists should use screening, rather than surveillance colonoscopy, data.

Clinical utility of the wireless pH capsule.

GOAL: The aim of this prospective study was to determine whether this test changes patient diagnosis, provides new information, or alters patient care. BACKGROUND: The wireless pH capsule is widely used to evaluate symptoms of acid reflux, although the clinical utility of this test is unknown. STUDY: Before pH capsule placement, referring providers completed a questionnaire requesting indications for the test, symptoms, prior testing, and medication use. A follow-up survey determined whether providers believed that results of the wireless pH test provided new information, changed patient diagnosis or altered patient management. RESULTS: During a 14-month period, 598 wireless pH capsule studies were conducted; 490 patients were eligible for inclusion, and 309 questionnaires were returned (63%). Mean patient age=48 (±15 y). The most common symptom leading to pH capsule placement was acid reflux (heartburn/regurgitation; 62%), followed by chest pain (11%). Wireless pH capsule results provided new information in 88% of patients, changed the diagnosis in 22%, and altered management in 63%. CONCLUSIONS: This study shows the clinical utility of the wireless pH capsule, with test results frequently providing new information, altering patient management or changing patient diagnoses. Future studies should define specific test characteristics most likely to influence patient care.

The clinical utility of esophageal manometry.

BACKGROUND AND AIMS: Esophageal manometry (EM) is performed to evaluate symptoms of chest pain and dysphagia, although its clinical utility is not known. The aim of this study was to evaluate the clinical utility of EM by determining whether EM provides new information, changes diagnoses, or alters patient management. METHODS: Before performing EM, referring providers noted indications for the test, symptoms, previous tests performed, and medication use. After EM was completed, a follow-up questionnaire ascertained whether EM provided new information or changed the patient's diagnosis or management plan. Patients provided demographic information. RESULTS: During a 12-month period, 569 EMs were performed and 444 were available for inclusion; 286 fully completed questionnaires were returned (64%) and are the basis for this analysis. The mean age (+/-SD) at the time of manometry was 52 (+/-15) years; 58% were women; 98% were white. EM was requested to assist placement of a pH measuring device (34%), and to evaluate symptoms of dysphagia (29%), chest pain (12%), or acid reflux (11%). Overall, 64% of EM were abnormal; 81% in gastroesophageal reflux disease patients, 74% in dysphagia, and 59% in chest pain. New information was obtained in 87% of patients, whereas a change in diagnosis occurred in 30% of patients, and management changed in 44% of patients. CONCLUSIONS: EM is a clinically useful test because it frequently provides new information and often changes patient diagnosis and management. The clinical utility of EM is greatest in patients with dysphagia.

Discovery of breast cancers within 1 year of a normal screening mammogram: how are they found?

PURPOSE: We sought to determine how breast cancers that occur within 1 year after a normal mammogram are discovered. METHODS: Using population-based mammography registry data from 2000-2002, we identified 143 women with interval breast cancers and 481 women with screen-detected breast cancers. We surveyed women's primary care clinicians to assess how the interval breast cancers were found and factors associated with their discovery. RESULTS: Women with interval cancers were twice as likely to have a personal history of breast cancer (30.1%) as women with screen-detected cancers (13.6%). Among women with interval cancers, one half of the invasive tumors (49.5%) were discovered when women initiated a health care visit because of a breast concern, and 16.8% were discovered when a clinician found an area of concern while conducting a routine clinical breast examination. Having a lump and both a personal and a family history of breast cancer was the most common reason why women initiated a health care visit (44%) (P <.01). CONCLUSIONS: Women with interval cancers are most likely to initiate a visit to a primary care clinician when they have 2 or more breast concerns. These concerns are most likely to include having a lump and a personal and/or family history of breast cancer. Women at highest risk for breast cancer may need closer surveillance by their primary care clinicians and may benefit from a strong educational message to come for a visit as soon as they find a lump.

Hormone therapies in women aged 40 and older: prevalence and correlates of use.

CONTEXT: The objective of this paper is to report the prevalence and correlates of both prescription and non-prescription hormone use. DESIGN/SETTING/SAMPLE: Cross-sectional baseline study from a prospective cohort of 30,448 women receiving mammography in New Hampshire. MAIN OUTCOME MEASURES: Odds of prescription hormone and non-prescription hormone use. RESULTS: 29,851 women were included; 62% reported some use of prescription hormone therapy, with current long-term prescription hormone therapy users representing the largest group (25%). Among ever-users, estrogen only was the most commonly used preparation (71% versus 30% for estrogen and progestin combined). Both single agent estrogen and estrogen and progestin combined regimens were taken primarily for treatment of menopausal symptoms or disease prevention. Correlates for prescription hormone use included a family history of breast cancer (associated with decreased use-OR 0.88; 95% CI: 0.84, 0.93), and family history of heart disease (associated with increased use-OR 1.11; 95% CI: 1.06, 1.17). Ten percent of women reported ever use of phytoestrogens (over-the-counter hormones). Family history of breast cancer was a correlate of over-the-counter hormone use (OR 1.10; 95% CI: 1.01, 1.19). CONCLUSION: Management of menopausal symptoms and disease prevention were the main reasons for using prescription hormones, and health histories were important correlates of both prescription and over-the-counter hormone exposures. As evidence changes regarding risks and benefits of hormone exposure, primary care physicians should help women reassess their use of hormonal agents.

Dendritic Cell Infiltration in Colon Cancer.

We quantitatively evaluated dendritic cell (DC) infiltration in primary colorectal cancers from 44 patients and metastatic colorectal tumors from 13 patients using immunohistochemistry for the DC marker CD83, HLA-DR, and the DC activation molecules CD40 and CD86. Nearly all CD83+ cells were also HLA-DR+, CD40+, and CD86+, indicating that the DCs that infiltrate colon cancer in vivo express the activation and costimulatory molecules associated with a mature DC phenotype. The density of DCs in colorectal cancer primaries was three times lower than that seen in normal colonic mucosa (0.29 versus 0.84 CD83+ cells/ high-power field (hpf), p < 0.001). Dendritic cells were rarely observed in metastatic tumors: DC density in metastases was sixfold lower than in colorectal primary tumors (0.05 versus 0.29 CD83+ cells/hpf, p < 0.001). Because cytokines have been shown, in vitro, to exert potent effects on DCs, we also evaluated the relationship between intratumor DC density and the expression of cytokines by tumor-infiltrating lymphocytes (TILs) and tumor cells. Expression of interleukin-10 and transforming growth factor beta by either TIL or tumor cells was not associated with decreased DC density or decreased expression of CD40 or CD86 on DCs. Tumor expression of vascular endothelial growth factor was associated with a more than twofold increase in DC density (p = 0.01). Patients who had a high proportion of TILs expressing tumor necrosis factor (TNF) had a greater intratumor mature DC density than patients with a low proportion of TNF + TIL (0.54 versus 0.21 CD83+ cells/hpf, p < 0.01).

Parental efficacy and child behavior in a community sample of children with and without attention-deficit hyperactivity disorder (ADHD).

Most studies of attention-deficit hyperactivity disorder (ADHD) youth have obtained data from the perspective of either children or parents, but not both simultaneously. The purpose of this study was to examine child and parent perspectives on parenting in a large community-based sample of children with and without ADHD. We identified children in grades 4-6 and their parents through surveys administered to a random sample of public schools. We used multivariable logistic regression to determine independent associations between child and parent characteristics and the presence of ADHD while controlling for covariates and clustering by school. Sufficient data were achieved for 2,509 child/parent dyads. Ten percent of youths (n = 240) had been diagnosed with ADHD. Compared with those without ADHD, those with ADHD were more commonly male (67.9 vs. 48.0 %, p < .001) and age 12 or over (16.3 vs. 10.3 %). After adjusting for covariates and clustering, compared to children without ADHD, children with ADHD were significantly more likely to report lower self-regulation (OR = 0.68, 95 % CI = 0.53, 0.88) and higher levels of rebelliousness (OR = 2.00, 95 % CI = 1.52, 2.69). Compared with parents whose children did not have ADHD, parents of children with ADHD rated their overall parental efficacy substantially lower (OR = 0.23, 95 % CI = 0.15, 0.33). However, child assessment of parenting style was similar by ADHD. Despite the internal challenges community-based youth with ADHD face, many parents of ADHD youth exhibit valuable parental skills from the perspective of their children. Feedback of this information to parents may improve parental self-efficacy, which is known to be positively associated with improved ADHD outcomes.

Influence of movie smoking exposure and team sports participation on established smoking.

OBJECTIVE: To examine the joint effects of movie smoking exposure and team sports participation on established smoking. DESIGN: Longitudinal study. SETTING: School- and telephone-based surveys in New Hampshire and Vermont between September 1999 through November 1999 and February 2006 through February 2007. PARTICIPANTS: A total of 2048 youths aged 16 to 21 years at follow-up. Main Exposures Baseline movie smoking exposure categorized in quartiles assessed when respondents were aged 9 to 14 years and team sports participation assessed when respondents were aged 16 to 21 years. Main Outcome Measure Established smoking (having smoked > or =100 cigarettes in one's lifetime) at follow-up. RESULTS: At follow-up, 353 respondents (17.2%) were established smokers. Exposure to the highest quartile of movie smoking compared with the lowest increased the likelihood of established smoking (odds ratio = 1.63; 95% confidence interval, 1.03-2.57), and team sports nonparticipants compared with participants were twice as likely to be established smokers (odds ratio = 2.01; 95% confidence interval, 1.47-2.74). The joint effects of movie smoking exposure and team sports participation revealed that at each quartile of movie smoking exposure, the odds of established smoking were greater for team sports nonparticipants than for participants. We saw a dose-response relationship of movie smoking exposure for established smoking only among team sports participants. CONCLUSIONS: Team sports participation clearly plays a protective role against established smoking, even in the face of exposure to movie smoking. However, movie smoking exposure increases the risk of established smoking among both team sports participants and nonparticipants. Parents, teachers, coaches, and clinicians should be aware that encouraging team sports participation in tandem with minimizing early exposure to movie smoking may offer the greatest likelihood of preventing youth smoking.

Safety and tolerability of transoral Bravo capsule placement after transnasal manometry using a validated conversion factor.

OBJECTIVES: To prospectively calculate and validate a conversion factor in healthy volunteers that allows accurate nonsedated, transoral (TO) Bravo capsule placement after transnasal (TN) manometry, and to evaluate the ease and safety of nonendoscopic Bravo placement compared with endoscopic placement. METHODS: Part 1. Twenty-five healthy volunteers underwent sequential TN and TO esophageal manometry to measure the distance to the lower esophageal sphincter (LES). A TN to TO conversion factor was calculated from these measurements. Part 2. Twenty volunteers underwent TN manometry followed by unsedated TO Bravo capsule placement using the conversion factor calculated in part 1. TN endoscopy then measured the location of the Bravo capsule in relationship to the squamocolumnar junction (SCJ). Part 3. During an 18-month period, 370 consecutive patients referred for a Bravo procedure underwent nonendoscopic, unsedated TO placement (308 patients) or standard endoscopically assisted placement (62 patients). RESULTS: Part 1. All 25 volunteers completed TN and TO manometry; a conversion factor of 4 cm was calculated. Part 2. Using the calculated conversion factor of 4 cm, a Bravo capsule was deployed TO 5 cm above the proximal border of the LES. The mean +/- standard deviation (SD) TN endoscopic distance to the capsule was 6.0 cm (+/-0.3 cm) above the SCJ. Part 3. A total of 333 patients completed the entire study (90%). Analysis of 48-h pH measurements did not reveal any significant differences between the two groups. CONCLUSIONS: A reliable and valid conversion factor of 4 cm following TN manometry permits accurate TO placement of the Bravo capsule without endoscopy. TO, unsedated Bravo placement is safe, well tolerated, and may minimize costs and potential risks associated with endoscopy.

Breast density in relation to risk of ductal carcinoma in situ of the breast in women undergoing screening mammography.

OBJECTIVE: To examine the association between breast density and risk of breast ductal carcinoma in situ (DCIS). METHODS: We assessed breast density in relation to DCIS risk using combined data from statewide mammography registries in NH and VT. The prospective analyses were based on 572 DCIS cases arising in 154,936 women (58,496 premenopausal and 96,440 postmenopausal). Women in the study were followed on average 4.1 years. Breast density was scored by community radiologists using BIRADS categories (fatty, scattered density, heterogeneous density, extreme density). RESULTS: In premenopausal women, based on 157 cases, the RR for DCIS risk were 0.29 (95% CI: 0.0.04, 2.24) for fatty breasts, 2.06 (95% CI: 1.39, 3.05) for heterogeneous density, and 2.40 (95% CI: 1.47, 3.91) for extreme density, relative to scattered density. In postmenopausal women, based on 369 cases, the RR for DCIS risk were 0.58 (95% CI: 0.37, 0.93) for fatty breasts, 1.41 (95% CI: 1.12, 1.78) for heterogeneous density, and 1.49 (95% CI: 0.93, 2.37) for extreme density, relative to scattered density. The possible interaction between breast density and menopausal status in relation to DCIS risk was not statistically significant. CONCLUSIONS: We observed an association between breast density and DCIS risk. Although the association seemed stronger in premenopausal women, there was no evidence of an interaction involving breast density and menopausal status.

Screening mammography: costs and use of screening-related services.

PURPOSE: To determine the costs and screening-related services in women undergoing screening mammography. MATERIALS AND METHODS: Study procedures were approved by the institutional committee for the protection of human subjects, and participants gave prior written consent. Data from a statewide mammography registry were used to identify imaging examinations, clinical consultations, interventional procedures, and pathology reports associated with screening mammography. The analysis included 99 064 women in the New Hampshire Mammography Network who underwent screening mammography between November 1, 1996, and March 31, 2000. Use of screening-related services in each case was tracked over an 18-month period, and procedure-specific national Medicare reimbursement rates from 2002 were applied for estimation of costs. Descriptive statistics (means, medians, standard deviations, 95% confidence intervals, frequencies, and percentages of resources and of costs) were calculated. RESULTS: The majority of subjects (85 809, or 87%) underwent screening mammography only. Of the 13 255 (13%) who underwent diagnostic imaging, additional mammographic views were obtained in most at the time of screening, within days or weeks of screening, or at short-interval follow-up. The total cost was $12 287 739. Approximately 80% ($9 777 670) of the total cost was related to imaging, and 68% ($8 410 313), specifically to screening mammography. Twenty percent ($2 510 069) of the total cost was associated with consultation and interventional procedures in only 2942 (3%) of the women, primarily those who underwent biopsy. Procedures resulted in benign findings in 2247 (76%) of the 2942. Mean total direct medical costs per capita were low ($99) in women who underwent screening mammography only, moderate ($286) in women who also underwent diagnostic imaging, and substantially greater in women who underwent biopsy ($993). CONCLUSION: While the largest component cost of screening mammography is that incurred in obtaining screening views alone, the highest costs per capita are associated with interventional procedures.

Utilization of screening mammography in New Hampshire: a population-based assessment.

BACKGROUND: The objective of screening mammography is to identify breast carcinoma early, which requires routine screening. Although self-report data indicate that screening utilization is high, the results of this population-based assessment indicated that utilization is lower than reported previously. METHODS: The authors compared New Hampshire population data from the 2000 Census with clinical encounter data for the corresponding time obtained from the New Hampshire Mammography Network, a mammography registry that captures approximately 90% of the mammograms performed in participating New Hampshire facilities. RESULTS: The results showed that approximately 36% of New Hampshire women either never had a mammogram or had not had a mammogram in > 27 months (irregular screenees), and older women (80 yrs and older) were less likely to be screened (79% unscreened/underscreened) compared with younger women (ages 40-69 yrs; 28-32% unscreened/underscreened). Of the screened women, 44% were adhering to an interval of 14 months, and 21% were adhering within 15 months and 26 months. The remaining 35% of the women had 1 or 2 mammograms and did not return within 27 months. CONCLUSIONS: Routine mammography screening may be occurring less often than believed when survey data alone are used. An important, compelling concern is the reason women had one or two mammograms only and then did not return for additional screening. This area deserves additional research.