Associations of actigraph sleep characteristics with blood pressure among older adults.

OBJECTIVES: Many studies have examined links between sleep and blood pressure, with mixed findings, mostly using self-reported sleep data and cross-sectional designs. We examined whether actigraph-estimated sleep characteristics are associated with concurrent blood pressure or 5-year blood pressure change in a national cohort of older adults (National Social Life, Health and Aging Project), and whether these associations differ by hypertension medication use. METHODS: Subjects were 669 older adults (62-90years), 471 with 5-year follow-up data. Sleep characteristics were duration (linear plus quadratic terms); sleep percentage; and categorical onset, midpoint, and waking times. Multivariable linear models adjusted for age, race, gender, obesity, smoking, daytime napping, and hypertension medication use. Interactions between sleep characteristics and hypertension medication were tested among the 401 subjects with consistent hypertension medication status over time. RESULTS: We found U-shaped cross-sectional and longitudinal relationships between duration and blood pressure, with shorter and longer sleep times associated with higher blood pressure. Later onset times were cross-sectionally associated with higher systolic blood pressure, while earlier onset times were longitudinally associated with systolic blood pressure increase. Midpoint, wake time, and sleep percentage were not significantly associated with blood pressure. Significant interaction terms suggested hypertension medications attenuated associations of sleep onset and wake time with diastolic blood pressure. CONCLUSIONS: These results with actigraph-estimated parameters confirm some, but not all, associations reported from research based on self-reported sleep data. Our findings are consistent with recommended intermediate sleep durations for cardiovascular health and suggest hypertension medication may attenuate some associations between sleep timing and blood pressure.

Stress, Isolation, and Sleep Quality among Breast Cancer Survivors throughout the COVID-19 Pandemic: A Longitudinal Study in a Multi-Ethnic Cohort.

Purpose: This study examined how stress, isolation, and sleep quality were impacted throughout the COVID-19 pandemic among breast cancer survivors (BCS). Methods: BCS enrolled in the Chicago Multiethnic Epidemiologic Breast Cancer Cohort were surveyed in 2020, 2021, and 2022. An 11-item isolation/stress score was repeatedly measured in each survey and its changes were examined through mixed-effects models. Sleep quality was assessed in 2022 by the Insomnia Severity Index (ISI). Results: In total, 1899 BCS responded (response rate: 62.8%), of whom 69% were White and 24% Black (median time since diagnosis: 5.1 years, IQR: 2.3-9.2). The isolation/stress score decreased significantly from 2020 to 2022 for White BCS, but only started declining for Black BCS in 2022. Consequently, although there were no significant racial difference in 2020, Black BCS had significantly higher isolation/stress scores in 2021 and 2022 (P < .01), while it became nonsignificant after adjusting for socioeconomic factors. BCS who were single, on Medicaid, without a high school degree, or with annual household income <$35,000 had significantly higher isolation/stress scores. Regarding sleep quality, 48% of BCS reported clinically-significant insomnia (ISI ≥ 8), and insomnia was strongly associated with higher isolation/stress scores (P-trend < .001). Conclusions: Our findings suggested that the isolation/stress level improved among BCS as the pandemic subsided, but this positive trend was not observed equally across racial/ethnic groups potentially due to lack of resources. Implications for Cancer Survivors: Additional resources, such as access to counseling services and sleep assistance programs, might support the post-pandemic recovery of undersevered BCS.

Machine learning with multimodal data for COVID-19.

In response to the unprecedented global healthcare crisis of the COVID-19 pandemic, the scientific community has joined forces to tackle the challenges and prepare for future pandemics. Multiple modalities of data have been investigated to understand the nature of COVID-19. In this paper, MIDRC investigators present an overview of the state-of-the-art development of multimodal machine learning for COVID-19 and model assessment considerations for future studies. We begin with a discussion of the lessons learned from radiogenomic studies for cancer diagnosis. We then summarize the multi-modality COVID-19 data investigated in the literature including symptoms and other clinical data, laboratory tests, imaging, pathology, physiology, and other omics data. Publicly available multimodal COVID-19 data provided by MIDRC and other sources are summarized. After an overview of machine learning developments using multimodal data for COVID-19, we present our perspectives on the future development of multimodal machine learning models for COVID-19.

U.S. trends in elective and emergent major abdominal surgical procedures from 2002 to 2014 in older adults.

BACKGROUND: The U.S. population is aging and projected to undergo an increasing number of general surgical procedures. However, recent trends in the frequency of major abdominal procedures in older adults are currently unknown as improvements in non-operative interventions may obviate the need for major surgery. Thus, we evaluated the trends of major abdominal surgical procedures in older adults in the United States. METHODS: We performed a retrospective cohort study using the National Inpatient Sample from 2002 to 2014 with trend analysis using National Cancer Institute's Joinpoint Trend Analysis Software. We identified the average annual percent change (AAPC) in the yearly frequency of major abdominal surgical procedures in older adults (≥50 years of age). RESULTS: Our cohort included a total of 3,951,947 survey-weighted discharges that included a major abdominal surgery in adults ≥50 years of age between 2002 and 2014. Of these discharges, 2,529,507 (64.0%) were for elective abdominal surgeries, 2,062,835 (52.0%) were for female patients, and mean (SD) age was 61.4 (15.9) years. The frequency of major abdominal procedures (elective and emergent) decreased for adults aged 65-74 (AAPC: -1.43, -1.75, -1.11, p < 0.0001), 75-84 (AAPC: -2.75, -3.33, -2.16, p < 0.001), and ≥85 (AAPC: -4.07, -4.67, -3.47, p < 0.0001). The AAPC for elective procedures decreased for older adults aged 75-84 (AAPC = -1.65; -2.44, -0.85: p = 0.0001) and >85 (AAPC = -3.53; -4.57, -2.48: p < 0.0001). All age groups showed decreases in emergent procedures in 50-64 (AAPC = -1.76, -2.00, -1.52, p < 0.0001), 65-74 (AAPC = -3.59, -4.03, -3.14, p < 0.0001), 75-84 (AAPC = -3.90, -4.34, -3.46, p < 0.0001), ≥85 (AAPC = -4.58, -4.98, -4.17, p < 0.0001) age groups. CONCLUSIONS AND RELEVANCE: In this cohort of older adults, the frequency of emergent and elective major abdominal procedures in adults ≥65 years of age decreased with significant variation among individual procedure types. Future studies are needed to identify the generalizability of our findings to other surgical procedures.

Tobacco and marijuana use and their association with serum prostate-specific antigen levels among African American men in Chicago.

African American (AA) men experience more than twice the prostate cancer mortality as White men yet are under-represented in academic research involving prostate-specific antigen (PSA), a biomarker of prostate cancer aggressiveness. We examined the impact of self-reported tobacco (cigarette pack-years and current tobacco use including e-cigarettes) and current regular marijuana use on serum PSA level based on clinical laboratory testing among 928 AA men interviewed 2013-2018 in Chicago. We defined outcome of elevated PSA ≥ 4.0 ng/mL for logistic regression models and continuous PSA increases for general linear models. All models were adjusted for age, sociodemographic characteristics, healthcare utilization, body mass index, and self-reported health. Among 431 AA men age ≥ 55 years, we observed ∼ 5 times the odds of elevated PSA among those with > 1 pack-years of cigarette smoking vs. never-smokers (odds ratio [OR] = 5.09; 95% confidence interval [CI] = 1.57-16.6) and a quarter the odds of elevated PSA among current marijuana users vs. non-users (OR = 0.27; 95% CI = 0.08-0.96). PSA increased on average 1.20 ng/mL among other current tobacco users vs. non-users. Among older AA men, cigarette smoking history and current tobacco use were positively associated with an increase in PSA levels and current marijuana use were inversely associated with PSA levels. Future work with studies of diverse patient populations with cancer outcomes are needed to assess whether these behavioral characteristics contribute to racial/ ethnic disparities in prostate cancer outcomes. Our study provides novel evidence regarding potential differences in PSA levels among older AA men according to behavioral characteristics.

Measuring Physical Activity with Hip Accelerometry among U.S. Older Adults: How Many Days Are Enough?

INTRODUCTION: Accelerometers are increasingly used in research. Four to 7 days of monitoring is preferred to estimate average activity but may be burdensome for older adults. We aimed to investigate: 1) 7-day accelerometry protocol adherence, 2) demographic predictors of adherence, 3) day of the week effect, and 4) average activity calculated from 7 versus fewer days among older adults. METHODS: We used the 2003-2006 older adult hip accelerometry data from the National Health and Nutrition Examination Survey (NHANES) sample. We determined proportions with 1-7 valid (10-20 hours) wear days and identified wear day correlates using ordinal logistic regression. We determined the day of week effect on 5 accelerometry measures (counts per minute, CPM; % sedentary behavior; % light-lifestyle activity; % moderate-vigorous activity, MVPA; total activity counts) using multivariate linear regression and compared averages estimated over 2 or 3 versus 7 days using correlations, linear regression, and Bland-Altman plots. RESULTS: Among 2,208 participants aged 65+, 85% of participants had ≥2 and 44% had 7 valid wear days. Increasing age (p = 0.01) and non-white race (p < 0.001) were associated with fewer days. Daily CPM, % MVPA, and total daily activity counts were similar Monday through Saturday, but significantly lower on Sundays (p < 0.001). Daily % sedentary behavior and % light-lifestyle activity were significantly different on Saturdays (p = 0.04-0.045) and Sundays (p < 0.001) compared to weekdays. Among participants with 7 valid days, 2 or 3 day averages were highly correlated with 7 day averages for all 5 accelerometry measures (2 versus 7 days: r = 0.90-0.93, 3 versus 7 days: r = 0.94-0.96). CONCLUSIONS: Protocols of 2-3 days, adjusting for Sundays (average CPM, % moderate-vigorous activity, and average total daily activity counts) or weekends (% sedentary behavior and % light-lifestyle activity), give reliable estimates of older adult activity.

Pre-pregnancy and Early Prenatal Care are Associated with Lower Risk of Ectopic Pregnancy Complications in the Medicaid Population: 2004-08.

BACKGROUND: Ectopic pregnancy causes significant maternal morbidity and mortality. Complications are more common among women with Medicaid or no insurance compared to those with private insurance. It is unknown whether preventive care prior to pregnancy and prenatal care, which are covered by Medicaid, would decrease complications if they were more fully utilised. METHODS: Medicaid claims were used to identify a clinical cohort of women who experienced an ectopic pregnancy during 2004-08 among all female Medicaid enrolees from a large 14-state population, ages 15-44. Diagnosis and procedure codes were used to identify ectopic pregnancies and associated complications. The primary outcomes were complications associated with ectopic pregnancy: blood transfusion, sterilisation, or hospitalisation with length of stay greater than 2 days. Independent variables were documentation of preventive care within 1 year prior to the ectopic pregnancy and prenatal care within 4 months prior. RESULTS: Controlling for race, age, and state of residence, women's risks of any ectopic pregnancy complication were independently higher among those who did not receive any Medicaid-covered preventive care within 1 year before the ectopic pregnancy compared to those who did (RR 1.12, 95% confidence interval (CI) 1.09, 1.16), and among those who did not receive any Medicaid-covered prenatal care within 4 months prior, compared to those who did (RR 1.89, 95% CI 1.83, 1.96). CONCLUSIONS: Pre-pregnancy and prenatal care are independently associated with decreased risk of ectopic pregnancy complications among Medicaid beneficiaries.

Sex-Specific and Time-Varying Associations Between Cigarette Smoking and Telomere Length Among Older Adults.

Inconsistent associations between smoking and telomere length (TL) have been reported in epidemiologic studies, perhaps because of the time-varying nature of smoking behaviors. We estimated the associations of TL, which was measured by quantitative polymerase chain reaction using saliva DNA, with concurrent and past smoking status reported biennially for up to 16 years before TL measurement in 5,624 participants in the Health and Retirement Study (1992-2008). Smoking was associated with reduced TL when we used prospective data on smoking statuses among men and women, but the association was strongly attenuated among men in cross-sectional analyses. This attenuation was largely due to a higher rate of smoking cessation during the study period among men with shorter TL than among men with longer TL. Short TL was also associated with poorer overall health in men, which suggests that male smokers with short TL were more likely to quit smoking because of poor health. Analyses of years since cessation, smoking duration, and pack-years of smoking all support the hypothesis that increased cigarette use shortens TL. Our results provide a potential explanation for the inconsistent associations between smoking and TL reported in previous cross-sectional studies. Time-varying associations should be considered in future studies of smoking behavior, TL, aging, and disease risk.

Sleep Duration and White Matter Quality in Middle-Aged Adults.

STUDY OBJECTIVES: Sleep duration has been associated with risk of dementia and stroke, but few studies have investigated the relationship between sleep duration and brain MRI measures, particularly in middle age. METHODS: In a prospective cohort of 613 black and white adults (mean age = 45.4 years) enrolled in the Coronary Artery Risk Development in Young Adults (CARDIA) study, participants reported typical sleep duration, dichotomized into moderate sleep duration (> 6 to ≤ 8 h) and short sleep duration (≤ 6 h) at baseline (2005-2006). Five years later, we obtained brain MRI markers of white matter including fractional anisotropy, mean diffusivity, and white matter hyperintensities. RESULTS: Compared to moderate sleepers, short sleepers had an elevated ratio of white matter hyperintensities to normal tissue in the parietal region (OR = 2.31, 95% CI: 1.47, 3.61) adjusted for age, race/sex, education, hypertension, stroke/TIA, depression, smoking status, and physical activity. White matter diffusivity was also higher, approximately a 0.2 standard deviation difference, in frontal, parietal, and temporal white matter regions, among those reporting shorter sleep duration in (P < 0.05 for all). CONCLUSIONS: Short sleep duration was associated with worse markers of white matter integrity in midlife. These mid-life differences in white matter may underlie the link between poor sleep and risk of dementia and stroke.

Differences between husbands and wives in colonoscopy use: Results from a national sample of married couples.

Marriage is linked to improved colorectal cancer-related health, likely in part through preventive health behaviors, but it is unclear what role spouses play in colorectal cancer screening. We therefore determine whether self-reported colonoscopy rates are correlated within married couples and the characteristics of spouses associated with colonoscopy use in each partner. We use US nationally-representative 2010 data which includes 804 male-female married couples drawn from a total sample of 3137 community-dwelling adults aged 55-90years old. Using a logistic regression model in the full sample (N=3137), we first find married men have higher adjusted colonoscopy rates than unmarried men (61% versus 52%, p=0.023), but women's rates do not differ by marital status. In the couples' sample (N=804 couples), we use a bivariate probit regression model to estimate multiple regression equations for the two spouses simultaneously as a function of individual and spousal covariates, as well as the adjusted correlation within couples. We find that individuals are nearly twice as likely to receive a colonoscopy if their spouse recently has had one (OR=1.94, 95% CI: 1.39, 2.67, p<0.001). Additionally, we find that husbands have higher adjusted colonoscopy rates whose wives are: 1) happier with the marital relationship (65% vs 51%, p=0.020); 2) more highly educated (72% vs 51%, p=0.020), and 3) viewed as more supportive (65% vs 52%, p=0.020). Recognizing the role of marital status, relationship quality, and spousal characteristics on colonoscopy uptake, particularly in men, could help physicians increase guideline adherence.

Sleep disturbance and longitudinal risk of inflammation: Moderating influences of social integration and social isolation in the Coronary Artery Risk Development in Young Adults (CARDIA) study.

Both sleep disturbance and social isolation increase the risk for morbidity and mortality. Systemic inflammation is suspected as a potential mechanism of these associations. However, the complex relationships between sleep disturbance, social isolation, and inflammation have not been examined in a population-based longitudinal study. This study examined the longitudinal association between sleep disturbance and systemic inflammation, and the moderating effects of social isolation on this association. The CARDIA study is a population-based longitudinal study conducted in four US cities. Sleep disturbance - i.e., insomnia complaints and short sleep duration - was assessed in 2962 African-American and White adults at baseline (2000-2001, ages 33-45years). Circulating C-reactive protein (CRP) was measured at baseline and follow-up (2005-2006). Interleukin-6 (IL-6) and subjective and objective social isolation (i.e., feelings of social isolation and social network size) were measured at follow-up. Sleep disturbance was a significant predictor of inflammation five years later after full adjustment for covariates (adjusted betas: 0.048, P=0.012 for CRP; 0.047, P=0.017 for IL-6). Further adjustment for baseline CRP revealed that sleep disturbance also impacted the longitudinal change in CRP levels over five years (adjusted beta: 0.044, P=0.013). Subjective social isolation was a significant moderator of this association between sleep disturbance and CRP (adjusted beta 0.131, P=0.002). Sleep disturbance was associated with heightened systemic inflammation in a general population over a five-year follow-up, and this association was significantly stronger in those who reported feelings of social isolation. Clinical interventions targeting sleep disturbances may be a potential avenue for reducing inflammation, particularly in individuals who feel socially isolated.

Reconsidering the age thresholds for type II diabetes screening in the U.S.

BACKGROUND: Type II diabetes and its complications can sometimes be prevented, if identified and treated early. One fifth of diabetics in the U.S. remain undiagnosed. Commonly used screening guidelines are inconsistent. PURPOSE: To examine the optimal age cut-point for opportunistic universal screening, compared to targeted screening, which is recommended by U.S. Preventive Services Task Force (USPSTF) and American Diabetes Association (ADA) guidelines. METHODS: Cross-sectional analysis of a nationally representative sample from the National Health and Nutrition Examination Survey, 2007-2010. Number of people needed to screen (NNS) to obtain one positive test result was calculated for different guidelines. Sampling weights were applied to construct national estimates. The 2010 Medicare fee schedule was used for cost estimation. Analysis was conducted in January 2014. RESULTS: NNS, under universal screening, drops sharply at age 35 years, from 80 (30-34-year-olds) to 31 (35-39-year-olds). Opportunistic universal screening of eligible people aged ≥35 years would yield an NNS of 15, translating to $66 per positive test. Among people aged 35-44 years (who are not recommended for universal screening by ADA), most (71%) were overweight or obese and all had at least one other ADA risk factor. Only 34% of individuals aged ≥35 years met USPSTF criteria. Strictly enforcing USPSTF guidelines would have resulted in a majority (61%) of potential positive test cases being missed (5,508,164 cases nationwide). CONCLUSIONS: Opportunistic universal screening among individuals aged ≥35 years could greatly reduce the national prevalence of undiagnosed pre-diabetes or diabetes at relatively low cost.

Objective sleep, a novel risk factor for alterations in kidney function: the CARDIA study.

OBJECTIVE: To determine the association between objectively measured sleep and 10-year changes in estimated glomerular filtration rate (eGFR). METHODS: From 2003 to 2005, an ancillary sleep study was conducted at the Chicago site of the Coronary Artery Risk Development in Young Adults (CARDIA) study. Community-based black and white adults (aged 32-51 years) wore a wrist actigraph for up to six nights to record sleep duration and fragmentation. Sleep quality was measured with the Pittsburgh Sleep Quality Index (PSQI). Participants without history of cardiovascular or chronic kidney diseases, proteinuria, or hypertension at the 2000-2001 CARDIA examination were followed over 10 years (n = 463). eGFR was estimated from serum creatinine (eGFRCr) at the 2000-2001, 2005-2006, and 2010-2011 CARDIA examinations, whereas cystatin-C-estimated eGFR (eGFRCys) was measured at the 2000-2001 and 2005-2006 examinations. Generalized estimating equation regression and linear models estimated the associations of each sleep parameter with changes in eGFRCr and eGFRCys, controlling for cardiovascular and renal risk. RESULTS: Sleep parameters were not related to 5-year change in eGFRCys. However, each 1 h decrease in sleep duration was significantly associated with a 1.5 mL/min/1.73 m2 higher eGFRCr [95% confidence interval (CI), 0.2-2.7], and each one-point increase in PSQI was significantly associated with a 0.5 mL/min/1.73 m2 higher eGFRCr (95% CI, 0.04-0.9) over 10 years. CONCLUSION: In this community-based sample, shorter sleep and poorer sleep quality were related to higher kidney filtration rates over 10 years.

Screening tests during prenatal care: does practice follow the evidence?

To examine whether the frequency of four screening tests during prenatal care conforms to evidence of effectiveness. We estimated rates of urine culture, anemia screening, oral glucose tolerance test (OGTT), and urinalysis during prenatal care. To do this, we used national probability samples of office visits to physicians (National Ambulatory Medical Care Survey) and to hospital outpatient departments (National Hospital Ambulatory Medical Care Survey) from 2001 to 2006. We compare observed rates to recommendations from the U.S. Preventive Services Task Force (USPSTF). On average, women received a urine culture in less than half of pregnancies. Women received just over one anemia screening on average per pregnancy. From 2001-2003, women received an average of 5.6 urinalyses per pregnancy; the average dropped to 4.3 urinalyses per pregnancy in 2004-2006. On average, women received just under one OGTT per pregnancy. Minorities and older women tend to get more anemia screenings, urine cultures, and OGTTs than white women and younger women. Compared to USPSTF recommendations, too few women are receiving a urine culture during prenatal care. In contrast, women receive far too many urinalyses, but the rate appears to be falling. Anemia screening conforms closely to recommendations. The USPSTF does not recommend for or against universal diabetes screening using OGTT. Women appear to receive OGTT routinely.

Association between neighborhood context and smoking prevalence among Asian Americans.

OBJECTIVES: To study neighborhood-level determinants of smoking among Asian Americans, we examined 3 neighborhood factors (ethnic enclave, socioeconomics, and perceived social cohesion) and smoking prevalence in a population-based sample. METHODS: We linked data from the 2003 California Health Interview Survey to tract-level data from the 2000 Census. We used multivariate logistic regression models to estimate the associations between smoking and neighborhood-level factors, independent of individual factors. RESULTS: Twenty-two percent of 1693 Asian men and 6% of 2174 Asian women reported current smoking. Women living in an Asian enclave were less likely to smoke (adjusted odds ratio [AOR] = 0.27; 95% confidence interval [CI] = 0.08, 0.88). Among men, higher levels of perceived neighborhood social cohesion were associated with lower odds of smoking (AOR = 0.74; 95% CI = 0.61, 0.91). CONCLUSIONS: The association between contextual factors and smoking differed for men and women. For women, living in an Asian enclave may represent cultural behavioral norms. For men, neighborhood trust and cohesiveness may buffer stress. Smoking prevention and cessation interventions among Asian Americans may be more effective if they address contextual factors.

Short sleep duration and incident coronary artery calcification.

CONTEXT: Coronary artery calcification is a subclinical predictor of coronary heart disease. Recent studies have found that sleep duration is correlated with established risk factors for calcification including glucose regulation, blood pressure, sex, age, education, and body mass index. OBJECTIVE: To determine whether objective and subjective measures of sleep duration and quality are associated with incidence of calcification over 5 years and whether calcification risk factors mediate the association. DESIGN, SETTING, AND PARTICIPANTS: Observational cohort of home monitoring in a healthy middle-aged population of 495 participants from the Coronary Artery Risk Development in Young Adults (CARDIA) cohort Chicago site (black and white men and women aged 35-47 years at year 15 of the study in 2000-2001 with follow-up data at year 20 in 2005-2006). Potential confounders (age, sex, race, education, apnea risk, smoking status) and mediators (lipids, blood pressure, body mass index, diabetes, inflammatory markers, alcohol consumption, depression, hostility, self-reported medical conditions) were measured at both baseline and follow-up. Sleep metrics (wrist actigraphy measured duration and fragmentation, daytime sleepiness, overall quality, self-reported duration) were examined for association with incident calcification. Participants had no detectable calcification at baseline. MAIN OUTCOME MEASURE: Coronary artery calcification was measured by computed tomography in 2000-2001 and 2005-2006 and incidence of new calcification over that time was the primary outcome. RESULTS: Five-year calcification incidence was 12.3% (n = 61). Longer measured sleep duration was significantly associated with reduced calcification incidence (adjusted odds ratio, 0.67 per hour [95% confidence interval, 0.49-0.91 per hour]; P = .01). No potential mediators appreciably altered the magnitude or significance of sleep (adjusted odds ratio estimates ranged from 0.64 to 0.68 per sleep hour; maximum P = .02). Alternative sleep metrics were not significantly associated with calcification. CONCLUSION: Longer measured sleep is associated with lower calcification incidence independent of examined potential mediators and confounders.

Cancer death rates for older Asian-Americans: classification by race versus ethnicity.

OBJECTIVE: For most US health statistics, Asian-Americans are grouped into a single race category. We use a unique data file to determine site-specific cancer death rates for persons aged 65 and older in six Asian-American ethnic subgroups (Chinese, Indian, Japanese, Korean, Filipino, and Vietnamese) and determine for which cancer sites the aggregate Asian-American race category is a misleading summary of subgroup cancer risk. METHODS: We previously determined all-cause death rates for Asian-American subgroups using Social Security files, in collaboration with a colleague at the Social Security Administration. By linking these records to death certificates, we determine cause-specific death rates for 21 cancer sites. We test whether there is significant heterogeneity among subgroups, using Poisson regression. RESULTS: For about half of cancer sites, all Asian subgroups have lower rates than Whites. For three sites most subgroups have higher rates than Whites (stomach, liver, and cervix), but there is significant heterogeneity. For other cancer sites, there is an inconsistent pattern, with some subgroups having rates lower than Whites and some having rates similar to Whites. Asian Indians are most often the Asian subgroup with a divergent rate. CONCLUSION: The aggregate Asian-American rate masks significant subgroup heterogeneity for many, but not all, cancer sites.

NSAIDs and colorectal cancer risk: do administrative data support a chemopreventive effect?

BACKGROUND: Randomized trials show non-steroidal anti-inflammatory drugs (NSAIDs) reduce precancerous polyps. Observational studies of the NSAID aspirin (ASA) suggest that it reduces invasive colorectal cancer (CRC) incidence, but because ASA use may also be a marker for healthy behaviors, these studies may be subject to selection bias. We sought to estimate the effectiveness of NSAIDs in CRC prevention in the population of elderly Medicare beneficiaries, minimizing this selection bias. METHODS: With National Ambulatory Medical Care Survey data, we find that patients with a diagnosis of osteoarthritis (OA) are 4.4 times more likely to concurrently have NSAID use documented than patients without such a diagnosis. We use this figure to estimate the expected NSAID-mediated reduction in CRC risk associated with a diagnosis of OA. Using Survival Epidemiology and End-Results (SEER)-Medicare data, we compare cases of elderly Medicare beneficiaries diagnosed with CRC in 1995 to persons without CRC to determine if their odds of antecedent OA differ. RESULTS: We estimate the expected NSAID-mediated reduction in CRC associated with an OA diagnosis to be between 6 and 16% (i.e., RR, 0.84-0.94). In the SEER-Medicare data, we find that individuals with a diagnosis of OA in Medicare claims in the previous 3 years had 15% lower odds of being diagnosed with CRC than individuals whose claims did not reflect antecedent OA (OR 0.85, 95%CI 0.80-0.91). CONCLUSIONS: This case-control study finds that elderly Medicare beneficiaries with histories of OA have 15% lower odds of developing CRC. These results are consistent with a preventive role for NSAIDs in CRC among the elderly.

Predictors of patient selection in bariatric surgery.

OBJECTIVE: To identify sociodemographic and clinical predictors of patient selection in bariatric surgery. SUMMARY BACKGROUND DATA: Population-based studies suggest that bariatric surgery patients are disproportionately privately insured, middle-aged white women. It is uncertain whether such disparities are due to surgeon decisions to operate, differences among morbidly obese individuals in access to surgery, or patients' personal preferences regarding surgical treatment. METHODS: We conducted a national survey of 1343 U.S. bariatric surgeons. The questionnaire contained clinical vignettes generated using a balanced fractional factorial design. For each of 3 hypothetical patients unique in age, race, gender, body mass index (BMI), comorbidities, social support, functional status, and insurance, respondents were asked if they would operate. Logistic regression was used to determine the odds of selection for each characteristic while controlling for the other 7 characteristics. Subset analyses were also performed using combinations of BMI and comorbidities. RESULTS: A total of 62.5% of eligible surgeons responded (n = 820). Patient race did not influence surgeon decisions to operate. Hypothetical patient age, BMI, and social support were most influential. In the subgroup of patients who did not meet current NIH BMI and comorbidity criteria for bariatric surgery, male sex (odds ratio [OR], 0.33; 95% confidence interval [CI], 0.14-0.76) was associated with decreased odds of selection. Overall, younger age (OR, 0.09; 95% CI, 0.07-0.11), older age (OR, 0.70; 95% CI, 0.56-0.90), limited functional status (OR, 0.66; 95% CI, 0.52-0.82), poor social support (OR, 0.37; 95% CI, 0.30-0.47), self-pay (OR, 0.72; 95% CI, 0.57-0.91), and public insurance (OR, 0.54; 95% CI, 0.43-0.67) were associated with decreased odds of selection. BMI and comorbidity criteria influenced the magnitude of these effects. CONCLUSIONS: Patient race did not play a role in surgeon decisions to operate. Further research should examine the roles of unequal access to bariatric surgery and differing socio-cultural perceptions of morbid obesity on racial disparities. The influence of patient age, gender, insurance status, social support, and functional status on decisions to operate was mitigated by BMI and comorbidities. Policy-makers currently debating BMI and comorbidity criteria for bariatric surgery should also consider guidelines pertaining to these sociodemographic issues that influence patient selection in bariatric surgery.

Impact of incidental bilateral salpingo-oophorectomy in a family member on breast cancer risk assessment: clinical considerations.

BACKGROUND: Hysterectomy (TAH/TVH) with bilateral salpingo-oophorectomy (BSO) remains prevalent in the general population; however, current risk tools do not account for the potential impact of BSO on breast cancer risk calculations in family members. METHODS: CancerGene software was used to estimate the effect of BSO in a family member on proband risk across a range of simulated family cancer histories. RESULTS: Impact of BSO on proband risk appears most salient when it occurs in a first-degree relative. Race appears to modify the attainment of clinically significant risk thresholds, suggesting possible systematic risk underestimations among black women. CONCLUSIONS: When clinicians calculate risk in families where a close relative had BSO, they may choose to supplement standard risk calculations with numerical ranges of risk that account for the risk-reducing effect of BSO. More consideration is needed of whether failing to account for BSO in risk models perpetuates race-based health disparities.