Bladder management and the functional outcome of elderly ischemic stroke patients.

The purpose of this study was to investigate how bladder management, rather than urinary incontinence, may affect the functional outcome of ischemic stroke patients. We studied 919 consecutive patients admitted for ischemic stroke rehabilitation. Level of bladder management was determined by Functional Independence Measurement (FIM TM) sub-scale scores relevant to bladder control. FIM scores less than 5 points was determined as low-bladder management score (Low-BMS) while FIM scores greater than 5 was determined as high-bladder management score (High-BMS). Data were analyzed by t-test, Pearson correlation, and chi-square test as well as by multiple linear regression analysis. There were 594 low-bladder score patients (Low-BMS) and 325 high-bladder score patients (High-BMS), at admission. Compared with High-BMS, Low-BMS patients were slightly older (p = 0.002), had longer rehabilitation stays (p < 0.001) and lower mini-mental state examination (MMSE) scores (p < 0.001). Total FIM at admission and discharge were lower in Low-BMS, yet their total FIM gain upon discharge was higher, compared with High-BMS (19.5 ± 16.46 vs. 17.59 ± 12.55, p = 0.07). Multiple linear regression analyses showed that total FIM at discharge was inversely associated with Low-BMS at admission (beta = -0.407; p<0.001) and age (beta = -0.127; p < 0.001). A high MMSE score (beta = 0.334; p < 0.001) emerged as predicting higher total FIM scores upon discharge. Low-BMS was independently predictive for total FIM gain at discharge (beta = 0.166; p < 0.001). The findings suggest that Low-BMS should be held as adversely affecting the rehabilitation outcomes of elderly stroke patients. However, Low-BMS patients do obtain significant gains and should not be deprived of rehabilitation.

Discharge hemoglobin and functional outcome of elderly hip fractured patients undergoing rehabilitation.

AIM: Low hemoglobin level is considered a marker of poor functional outcome. The objective of this study was to explore possible relationship of discharge hemoglobin levels and functional outcome of elderly hip fracture patients, undergoing in-hospital rehabilitation. METHODS: A retrospective chart review study, comprising consecutive elderly patients suffering traumatic hip fractures. Main outcome measurement was the functional outcome of patients, as assessed by motor and total Functional Independence Measurement (FIM) scores upon admission and discharge. RESULTS: Mean discharge hemoglobin levels were significantly associated with prefracture function and Mini Mental State Examination (MMSE) score (P=0.002 and P=0.01, respectively). The authors observed a significant positive correlation between serum hemoglobin and total FIM at discharge (Pearson's coefficient =0.13; P=0.005) as well as with motor FIM at discharge (Pearson's coefficient =0.13; P=0.005). Regression analyses showed that high MMSE scores (beta=0.55; P<0.001), female gender (beta=0.07; P=0.01), younger age (beta=-0.10, P=0.001) and a better pre-fracture function (beta=-0.27 P<0.001) are associated with higher total FIM scores upon discharge. Neither discharge hemoglobin levels nor the number of transfused blood packs were significantly associated with better total FIM, motor FIM, FIM gain or FIM= or >80.scores. CONCLUSION: Higher hemoglobin at discharge was not associated with a better postfracture function, as reflected by FIM scores. The authors suggest that clinically reasonable low hemoglobin levels are not associated with adverse functional outcome of elderly hip fracture patients, thus, actively correcting hemoglobin levels, per se, may not result in better functional outcomes in this population.

Rehabilitation outcome of hip fracture patients: the importance of a positive albumin gain.

Low serum albumin level is associated with poor functional outcome and predicting a greater functional decline in the elderly. The aim of this study is to determine the interrelation between change of serum albumin level during rehabilitation period and functional outcome in hip fracture patients. We studied 433 consecutive elderly hip fracture patients admitted for rehabilitation. Functional outcome was assessed by the Functional Independence Measure (FIM) at admission and discharge of patients with no albumin gain (<0 g/dl) or with positive albumin gain (>or=0 g/dl). Data were analyzed by t-test, Pearson correlation, chi(2)-test and linear regression. Of patients 66.7% showed no albumin gain. These patients had a higher prevalence of previous stroke (p=0.04), lower Mini Mental State Examination (MMSE) scores (p=0.05) and were less likely to have hyperlipidemia (p=0.008) compared with patients with albumin gains. Admission and discharge FIM parameters and total and motor FIM gain/day were statistically significantly lower among patients with no albumin gain. In a linear regression analysis total FIM at discharge was inversely associated with pre-fracture function (beta=-0.148; p<0.001), Albumin gain (beta=0.047; p=0.005), high MMSE score (beta=0.143; p<0.001), and higher admission total FIM score (beta=0.69; p<0.001) emerged as significant predictors of higher total FIM scores upon discharge. The results suggest that patients with albumin gain have better admission and discharge FIM scores. Albumin gain emerged as a significant predictor for higher discharge FIM scores. We conclude that greater attention and efforts should be made regarding the dietary intervention and protein supplementation, in order to improve the rehabilitation outcome.

Infertility, ovulation induction treatments and the incidence of breast cancer--a historical prospective cohort of Israeli women.

CONTEXT: Ovulation induction drugs may be associated with increased breast cancer risk. Results so far have been inconclusive. OBJECTIVE: To evaluate the association between infertility, exposure to ovulation induction drugs and the incidence of breast cancer. DESIGN: Historical prospective cohort and nested case-control study. SETTING: Institutional practice PATIENTS: About 5,788 women attending five infertility centers in Israel between 1964 and 1984. INTENTION: Abstracting of medical records and telephone interviews. MAIN OUTCOME MEASURE: Breast cancer incidence was determined through linkage with the National Cancer Registry database. Standardized incidence ratios (SIRs) and 95% confidence intervals were computed by comparing the observed to the expected cancer rates in the general population. In addition, a nested case-control study within the cohort was performed with interviews of breast cancer cases and two matched controls. RESULTS: The study cohort included 120,895 women years of follow-up. Compared to 115.2 expected breast cancer cases, 131 cases were observed (SIR = 1.1; 95% CI 0.9-1.4). Risk for breast cancer was significantly higher for women treated with clomiphene citrate (SIR = 1.4; 95% CI 1.0-1.8). Similar results were noted when comparisons were carried out between treated and untreated women, and when multivariate models were applied. In the nested case-control study, higher cycle index (OR = 2.2; 95% CI 1.0-4.8) and treatment with clomiphene citrate (OR=2.7; 95% CI 1.3-5.7) were associated with higher risk for breast cancer. CONCLUSION: Infertility and usage of infertility drugs in general are not associated with increased risk for breast cancer. However, for infertile women treated with clomiphene citrate, breast cancer risk is elevated.

A harmonized measure of activities of daily living was a reliable and valid instrument for comparing disability in older people across countries.

BACKGROUND AND OBJECTIVES: Our aim was to construct a harmonized measure of activities of daily living (ADL) across six countries, and to evaluate the reliability and validity of this measure. METHODS: A population of 9,297 persons, aged 65-89 years, was drawn from the Comparison of Longitudinal European Studies on Aging (CLESA) study, which includes data from five European countries and Israel. Because the number, type, and response format of the ADL items differed across the six studies, a four-item scale was constructed to harmonize the data, using items common to most countries. A procedure was devised to substitute or construct items that were not available in two of the countries. RESULTS: Cronbach's alpha for the four-item ADL measure varied from 0.81 in Spain to 0.92 in Finland, and was similar to the alpha of scales including five or six items. Kappa scores between substituted or constructed items and the actual items varied from 0.50 to 0.78. In all countries, the percentage of persons with ADL disability differed significantly across age and was associated with chronic diseases, poor self-rated health, global disability, and home help utilization. CONCLUSION: The harmonized four-item ADL measure seems a reliable and valid instrument for comparing ADL disability in older people across countries.

Disability and social ties: comparative findings of the CLESA study.

The associations between prevalence, incidence and recovery from activities of daily living (ADL) disability and social ties among community-dwelling persons over 65 in Finland, The Netherlands and Spain are examined. Data were harmonized in the CLESA study. The baseline sample was composed of 3,648 subjects between 65 and 85 years old, living in Finland, The Netherlands and Spain. Disability in four activities of daily living was determined at baseline and at follow-up. Social participation, number of family ties and presence of friends were added to obtain a social ties index. Logistic regressions were fitted to the prevalence, incidence and recovery data to estimate the associations between disability and social ties, adjusting for education, co-morbidity and self-rated health. The modifying effects of country, age and sex were tested in all models. For every country, the social ties index, having friends and social participation were negatively associated with ADL disability prevalence. ADL incidence was negatively related to the number of family ties, with a stronger relationship in Spain than in The Netherlands or Finland. ADL recovery was associated with the social ties index. No age or gender differences in these associations were found. Social ties appear to generate a beneficial effect on the maintenance and restoration of ADL function. While social ties play an important role in maintaining and restoring function in all three countries, family ties appear to generate a stronger effect on protection from disability incidence than does social participation, and the strength of this effect varies by culture.

Disability-free life expectancy: a cross-national comparison of six longitudinal studies on aging. The CLESA project.

Disability-free life expectancy (DFLE) was compared in six countries taking part in the Cross-national Determinants of Quality of Life and Health Services for the Elderly (CLESA) project. Data from six existing longitudinal studies were used: TamELSA (Tampere, Finland), CALAS (Israel), ILSA (Italy), LASA (The Netherlands), Aging in Leganés (Leganés, Spain) and SATSA (Sweden). A harmonised four-item disability measure (bathing, dressing, transferring, toileting) was used to calculate DFLE; the harmonised measure was dichotomised into 'independent in all four activities' vs. 'dependent in at least one'. Calculations of DFLE were made using the multistate life table approach and the IMaCh program (INED/EuroREVES, http://eurorevesinedfr/imach/) for subjects aged 65-89 years. Prevalence ratios of disability varied significantly across countries, with Italy and Leganés having the highest percentages among men and among women, respectively, while The Netherlands presented the lowest for both sexes. At 75 years of age the estimated total life expectancy among men ranged from 7.8 years in Tampere and Sweden to 9.0 years in Israel; among women it ranged from 9.5 years in Israel to 11.6 years in Italy. For both sexes Italy showed the lowest total life expectancy without disability (72% among men, 61% among women) and Sweden the highest (89% among men and 71% among women). The results yielded a north/south gradient, with residents in Tampere, The Netherlands and Sweden expected to spend a higher percentage of their lives without disability than those in Italy, Israel and Leganés.

Social factors and mortality in the old-old in Israel: the CALAS study.

OBJECTIVES: Using a theoretical framework that divided social factors measures into structure, function, and social engagement, this study determined those aspects of social networks most significantly associated with 8-year, all-cause mortality among the old-old in Israel. METHODS: Jews (n = 1,340) aged 75-94 living in Israel on January 1, 1989, were randomly selected from the National Population Register; stratified by age, sex, and place of birth; and interviewed in person. Mortality was determined according to the National Death Registry (December 1997). RESULTS: After controlling for sociodemographics and measures of health, cognitive status, depressive symptoms, and physical function, the measures of social engagement that explicitly involved others were associated with a lower risk of mortality. No measure of the function of the social network was associated with risk of mortality. Living in the community without a spouse and with a child and living in an institution were significantly associated with a higher risk of mortality. DISCUSSION: The finding that participating in activities with people outside of the immediate family is associated with a lower risk of death has practical implications for helping the aging population and their families in their decision-making process. Lack of support for the hypothesis that those with more social support would show reduced risk of mortality may indicate that the positive effect of perceiving support and the negative effect of needing support may cancel each other out and result in no perceived effect. In this population, the association between socioeconomic status (SES) and the risk of mortality seems to be expressed through the living arrangements, with the sick and frail, both in institutions (higher SES) and in the community with a child or other (lower SES), having a higher risk of mortality. These findings are consistent with the use of children as a substitute for institutionalization, and imply that at least some cohabitation was the caretaking solution for the noninstitutionalized old-old who were of low SES, frail, and close to death.

Assistance with personal care activities among the old-old in Israel: a national epidemiological study.

OBJECTIVES: The objectives of this study were to (1) estimate rates of difficulty, need for assistance, and receipt of assistance with activities of daily living (ADLs) among the old-old in Israel; (2) describe the living arrangements of the dependent old-old; and (3) gain insight into the caregiving provided to the disabled members of this population. DESIGN: A random stratified sample of 1,820 subjects age 75 to 94 selected from the National Population Register (NPR), a complete listing of the Israeli population maintained by the Ministry of the Interior. The study sample consisted of Jews living in Israel on January 1, 1989, stratified by age (four 5-year age groups: 75-79, 80-84, 85-89, 90-94), sex, and place of birth (Europe-America, Middle East/North Africa, Israel). SETTING: National sample of old-old Jewish Israelis. PARTICIPANTS: One thousand eight hundred twenty Israelis age 75 to 94 who were living in the community or in institutions at the time of the baseline interview. MEASUREMENTS: Participants' disability status was classified in terms of difficulty with, needing help with, and receiving help with any of five ADLs (washing/bathing, dressing, transferring, toileting, and eating). Only those receiving assistance from a person (as opposed to a device) were considered to be receiving help. The independent variables used included sociodemographic, health, and social network characteristics of the participants. RESULTS: Twenty-one percent of those age 75 to 94 were found to be receiving personal assistance with at least one ADL. The most dependent were those age 90 to 94, women, those born in the Middle East or North Africa, and those living in an institution. Among those dependent in one or more ADLs, the overall community:institutionalized ratio was 2.4:1. Those who were dependent in three to five ADLs were about twice as likely to live in an institution as were those who were dependent in one or two ADLs. The Middle Eastern/North African born were more likely to be dependent, and at any given level of disability were more likely to be living in the community with a child and receiving the majority of their caretaking from the informal sector, primarily their family. CONCLUSION: We conclude that the families of disabled older people, particularly the Middle Eastern/North African born, provide a great deal of care for their older relatives despite the availability of a full range of services, providing no evidence of withdrawal of family care when state home and institutional care are available. This finding may imply underutilization of services, which should be investigated further to determine if it is caused by barriers to utilization or by the free choice of the disabled old-old and their families.

Incidence of leukemia and other cancers in Down syndrome subjects in Israel.

Epidemiologic data have confirmed the high susceptibility of persons with Down syndrome (DS) to leukemia. The question of proneness to other kinds of cancer is still open. In this study we reassessed the incidence rates of leukemia and other malignancies in Israeli DS subjects, based on the total population. The target population consisted of all DS subjects in Israel in the period of 1948--1995. Due to incompleteness of data, the target population was not fully achieved, thus the study population was divided into 2 subgroups: subjects born in Israel between 1979 and 1995 (registry group) and currently or past-institutionalized subjects born before 1979 (institution group). The cohort was linked with the Cancer Registry, and cancer cases that had been diagnosed through December 1995 were subsequently identified. Observed incidence rates were compared with expected rates in the general population. Standardized incidence ratios (SIR) and 95% confidence intervals (CI) were computed for each disease category. Analyses were performed separately for each subgroup of the study population. In the registry group, 7 cancer cases were observed, compared with 1.5 expected (SIR = 4.67, 95% CI 1.9--9.6), all leukemia cases. For the institution group a total of 17 cancer cases were observed, compared with 12.8 expected. These included 4 cases of leukemia (SIR = 6.90, 95% CI 1.90--17.70). An excess of gastric cancer in male subjects (SIR = 11.9, 95% CI 1.3--42.9) was also observed. Significant excess of leukemia in DS population in Israel is in accordance with previously published data. An excess of gastric cancer in DS male subjects born before 1979, which has not been reported before, should be further explored.

Physician visits, emergency room utilization, and overnight hospitalization in the old-old in Israel: the cross-sectional and longitudinal aging study (CALAS).

OBJECTIVES: The objective of this paper is to assess the risk factors for physician contact in the month before the interview (PM) and emergency room utilization (ERU) and overnight hospitalization (OH) in the year before the interview, through the use of the behavioral model as a conceptual framework. DESIGN: A random stratified sample of subjects age 75 to 94 was selected from the National Population Register (a complete listing of the Israeli population maintained by the Ministry of the Interior). The study sample consisted of Jews living in Israel on January 1, 1989, stratified by age (four 5-year age groups: 75-79, 80-84, 85-89, and 90-94), sex, and place of birth (Europe/America, Asia/Africa, and Israel). SETTING: Community-dwelling old-old Jewish Israelis. PARTICIPANTS: 1,487 people living in the community at the time of the baseline interview. MEASUREMENTS: The dependent variables were PM in the month before the interview and ERU and OH in the previous year. The independent variables were: predisposing variables (age, sex, place of birth, and education); enabling variables (income and the social network variables of marital status, living arrangements, and number of in-person contacts per week with any child); and need variables (number of self-reported chronic medical conditions, subjective health, depressive symptoms, number of difficulties with activities of daily living and instrumental activities of daily living, measures of physical robustness, and engaging in regular physical sportive activities). RESULTS: The predisposing and enabling factors were only minimally associated with utilization rates in the old old in Israel, with the exception of lower rates of ERU by those who were living alone. Age was not significantly associated with healthcare utilization in the old-old population studied. Healthcare utilization was found to be associated primarily with health and functional status. CONCLUSION: In a system of free and equal access to healthcare services, the demand for health services by a population with high levels of chronic disease and disability is driven primarily by health needs, rather than by extraneous factors such as income and education. The study indicates that equity in the provision of health services is attainable. Policy makers should provide for actual need, remove artificial barriers, and prepare accurate estimates of future needs.

Characteristics of clients attending confidential versus anonymous testing clinics for human immunodeficiency virus.

OBJECTIVES: To compare risk behavior between subjects attending anonymous and confidential clinics for human immunodeficiency virus testing, and to assess whether anonymous testing results in a higher accrual of persons at risk for HIV. METHODS: An anonymous questionnaire that addressed sociodemographic and risk behavior aspects was administered to 140 subjects attending an anonymous clinic and 124 attending a confidential clinic in the Tel Aviv area. A logistic regression analysis was used to compare the effects of various behavioral factors on the probability of attending each clinic. RESULTS: Chronological age, age at first sexual intercourse, and the percent of married subjects were similar in both clinics. However, there was a significant difference in the sex ratio and in educational attainment (85.0% versus 55.6% were males, P < 0.001; and 58% vs. 34% had over 12 years of education, P < 0.001, in the anonymous and confidential clinics respectively). There was a striking difference between the two clinics with regard to sexual experience characteristics: of the subjects reaching the anonymous clinic 21.4% were homosexual and 10.0% bisexual versus a total of 2.6% in the confidential clinic. A logistic regression analysis, comparing the effects of various behavioral factors on the probability of attending each clinic, showed that gender (male), high education, homosexuality, number of partners and sexual encounter with sex workers were the strongest predictors for selecting anonymous HIV examination. CONCLUSIONS: Individuals at high risk for HIV, such as homosexuals and bisexuals, prefer to attend an anonymous clinic.

Selected risk factors for transitional cell bladder cancer.

Cancer of the bladder has long been associated with environmental risk factors, such as occupational hazards and smoking. The aim of the current study was to evaluate the contribution of known risk factors on a community basis in the 1990s, in view of the recent worldwide efforts to control environmental hazards. The study population included 140 male patients and 280 matched controls. Information on demographic data, occupational exposure, smoking habits and disease history was obtained by personal interviews. Our study confirmed the role of industrial occupation (OR=2.21; 95% Cl=1. 21-4.02) and exposure to 3 or more metals (OR=3.65; 95% Cl=1.21-11. 08) as risk factors. Prostate enlargement was also found significant, but probably not causal (OR=2.23; 95% Cl=1.29-3.87). Surprisingly, smoking showed only an inconsistent association with higher rates among those who started to smoke before 18 years of age (OR=2.64; 95% Cl=1.4-4.99) and those who smoked more than 30 cigarettes per day (OR=1.82; 95% Cl=0.95-3.49). The above data suggest that current efforts to reduce the load of bladder cancer in the population, via environmental measures, have not as yet yielded significant effects.

Cancer following cardiac catheterization in childhood.

BACKGROUND: Low-dose ionizing radiation is one of the definitive risk factors for cancer development. Nevertheless, only a few follow-up studies of children subjected to cardiac catheterization have been performed, yielding inconsistent results. METHODS: Our study group included 674 children who underwent cardiac catheterization due to congenital anomalies, between the years 1950-1970 in three major medical centres in Israel. A registered nurse conducted a review of the children's medical files in each hospital. Demographic data and vital status were ascertained from the Israeli National Registry, using a unique identity number. Subsequently, the study cohort was linked with the Israeli National Cancer Registry, in order to identify cancer cases that had been diagnosed through December 1996, the last follow-up date of the study. RESULTS: Over 75% of the study participants were native-born; 56.2% were males. Approximately 78% of the cohort subjects were alive at the end of follow-up; 28.6% of the participants underwent more than one procedure. All of the diagnosed cases occurred in males. Expected number of malignancies for all sites was 4.75, while the observed number was 11.0 (standardized incidence ratio [SIR] = 2. 3; 95% CI : 1.2-4.1). Of the 11 cancer cases, 4 lymphomas were observed (0.63 were expected, SIR = 6.3; 95% CI : 1.7-16.2). One of these was Hodgkin's Disease. There were also three cases of melanoma as opposed to 0.62 expected (SIR = 4.9; 95% CI : 1.0-14.2). CONCLUSIONS: This finding is compatible with current knowledge about the carcinogenic effect of low-dose irradiation but differs in the occurrence of an excess of lymphoma in the absence of an excess of leukaemia, which has not been reported before. The dissonance between males and females is yet to be resolved. IMPLICATIONS: Radiation doses that are used currently during cardiac catheterization are lower than in the past. Yet, the procedure is more common and frequently involves longer duration due to therapeutic interventions. The possible long-term results of such an exposure should be kept in mind.

A longitudinal study of characteristics and predictors of perceived instrumental and emotional support among the old-old in Israel.

The structure and function of social networks and the perceived instrumental and emotional support associated with these networks were studied longitudinally among a random sample of 687 Jewish Israelis aged seventy-five to ninety-four, stratified by five-year age groups, place of birth (Europe-America, Asia-Africa, or Israel), and gender, interviewed in 1989-92 and 1993-94. Perceived instrumental support at follow-up was predicted by baseline measures of proximity of at least one child and by four or more weekly contacts with intimate friends or family, whereas perceived emotional support was more broadly based and was predicted by more frequent contacts with children, neighborliness, and having more intimate friends. Changes occurring during the follow-up interval, such as entering long-term care or losing a confidant, were associated with a decrease in perceived emotional support but not with a loss of instrumental support. Emotional support was less replaceable over time than was instrumental support.

Gender differences in positive and negative self-assessments of health status in a national epidemiological study of Israeli aged.

The literature in subjective health appraisals frequently notes that elderly women, more so than men, generally experience a lower quality of life in all major indicators (physical health status, functional ability, perceived income adequacy, social contacts, psychological distress, and cognitive ability). The current epidemiological study, of 1,352 reporting Israeli subjects between the ages of 75-94, was undertaken in order to obtain reliable estimates of "poor" and "excellent/good" self assessments of health in a national sample of aged; to identify the most significant correlates of "poor" and "excellent/good" assessments; and to ascertain whether the models of "poor" and "good/excellent" subjective health are different for elderly men and women. While it was found that women indeed rate their health as being poorer than men, of greater theoretical interest was the finding that the pattern of variables predicting to "poor" and "good/excellent" health are different for men and women. The findings point to the fact that the simple health self-evaluation question is not a unitary construct, but rather a complex attitudinal measure which yields different structural and conceptual results when controlling for the subjective health outcome ("poor" or "good/excellent") and when analyzing gender-dichotomized models.

Morbidity, comorbidity, and their association with disability among community-dwelling oldest-old in Israel.

BACKGROUND: The impact of chronic conditions on the development of disability has not yet been comprehensively studied among the elderly population living in Israel. This study evaluates the prevalence of disability and morbidity among the community-dwelling oldest-old population and examines the association between medical conditions, comorbidity, and disability in basic and instrumental activities of daily living (ADLs, IADLs). METHOD: The data are based on a national random stratified sample of 1,820 Israeli Jewish individuals 75-94 years old, of whom 1,487 lived in the community. RESULTS: Nineteen percent of the population was disabled in ADLs and 36% in IADLs. Disability rose with age and was higher for women and among individuals of Middle Eastern and North African origin. Stepwise logistic regression indicates that the variables associated with disability in ADLs and IADLs were older age, Middle Eastern or North African origin, living with others, and the following conditions: stroke, hip fracture, diabetes, osteoporosis, anemia, and heart attack. In addition, lower education and suffering from urinary or kidney diseases, respiratory disease, and/or Parkinson's disease were related to disability in ADLs; being a woman and suffering from heart diseases other than heart attack were related to disability in IADLs. Comorbidity was related to increased disability only for individuals with three or more conditions. CONCLUSIONS: The identification of medical conditions and sociodemographic variables related to limitations in functioning may serve as a basis for health promotion and disease prevention in elders by attempting to reduce the incidence and disabling consequences of known disabling conditions.

Cancer incidence in a cohort of infertile women.

Among 2,496 infertile Israeli women treated between 1964 and 1974, 143 cancer cases were observed as compared with 116.1 expected (standardized incidence ratio (SIR) = 1.2, 95% confidence interval (CI) 1.0-1.5) through 1991. Site-specific analysis revealed 12 ovarian cancers versus 7.2 expected (SIR = 1.6, 95% CI 0.8-2.9), 21 endometrial cancers versus 4.3 expected (SIR = 4.85, 95% CI 3.0-7.4), and 59 breast cancers versus 46.6 expected (SIR = 1.3, 95% CI 0.96-1.6). Sensitivity analysis revealed that confounding was unlikely to explain the raised risk of endometrial cancer, but nulliparity might explain the increased risk of ovarian cancer. The excess of endometrial cancer was prominent among patients with normal estrogen production but progesterone deficiency (SIR = 9.4, 95% CI 5.0-16.0). The risk for ovarian cancer was similar among the total groups of treated and untreated patients (SIR = 1.7 vs. 1.6). The standardized incidence ratio for endometrial cancer was higher among the treated group than the untreated group, although not significantly. Treatment with ovulation-inducing drugs does not appear to increase the risk for ovarian cancer, but its role cannot be completely excluded.

Second primary cancers in a cohort of Israeli women with primary gynecologic malignancies.

Second cancer in a women with a primary gynecological malignancy could reflect a common etiology or sequealae of a potentially carcinogenic treatment. The aim of the present study was to determine the incidence rate of second primary cancer in a cohort of women with primary gynecological cancer and patient characteristics, namely age, diagnosis, type of treatment, and duration of follow-up. The study cohort comprised 925 Israeli Jewish women with histologically confirmed gynecologic malignancies. The file was linked by computer matching to the Israel Cancer Registry for identification of second primary cancers. Standardized incidence rates (SIRs) for site-specific as well as for all cancer were computed. A significant excess for subsequent leukemia among ovarian (SIR 10; 95% CI 1.1-36.1) and uterine corporal cancer patients (SIR 10.0; 95% CI 2.7-25.6) was found. The significant increase in leukemia was treatment-related and limited to patients treated with radiotherapy. Age older than 60 years constituted a significantly unfavorable factor. The estimated probability of developing a subsequent cancer at 175 months is 6.1%. Physicians should be aware of the possibility of a second primary malignancy when prescribing treatment and during follow-up.