Welfare dental intervention improves employment and quality of life.

Chronic, untreated oral disease adversely affects one's systemic health, quality of life, and economic productivity. This study evaluated the effect of rehabilitative dental treatment on the oral-health-related quality of life and employment of welfare recipients. Three hundred and seventy-seven participants in a novel welfare dental program received oral examinations, questionnaires, and rehabilitative dental treatment. Seventy-nine percent of participants exhibited improvement in their oral-health-related quality-of-life scores following dental treatment. Improved OHIP-14 change scores were associated with being Caucasian or African-American, initial poor general health, severity of treatment urgency, worse baseline oral-health-related quality-of-life scores, subsequent patient satisfaction with the Dental Program, and resolution of their chief complaint (all p < 0.04). Those who completed their dental treatment were twice as likely to achieve a favorable/neutral employment outcome (OR = 2.01, 95%CI = 1.12, 3.62). Thus, oral health improved the quality of life and employment outcome for this welfare population.

Causes and consequences of comorbidity: a review.

A literature search was carried out to identify and summarize the existing information on causes and consequences of comorbidity of chronic somatic diseases. A selection of 82 articles met our inclusion criteria. Very little work has been done on the causes of comorbidity. On the other hand, much work has been done on consequences of comorbidity, although comorbidity is seldom the main subject of study. We found comorbidity in general to be associated with mortality, quality of life, and health care. The consequences of specific disease combinations, however, depended on many factors. We recommend more etiological studies on shared risk factors, especially for those comorbidities that occur at a higher rate than expected. New insights in this field can lead to better prevention strategies. Health care workers need to take comorbid diseases into account in monitoring and treating patients. Future studies on consequences of comorbidity should investigate specific disease combinations.

Patterns of comorbidity and the use of health services in the Dutch population.

BACKGROUND: The study objective was to examine the relation between combinations of chronic conditions in the same person and the volume and variety of health care utilization. METHODS: Analysis of continuous Netherlands Health Interview Survey data (1990-1997). The study population consisted of adults (16 years and older) reporting at least one chronic condition from the following six disease clusters: musculoskeletal diseases, lung diseases, neurological disorders, heart diseases, diabetes, and cancer (n = 13,806). Health care utilization is categorized in terms of contacts in the preceding year with a general practitioner (GP), medical specialist, physiotherapist, home help and/or home nursing, and hospital admission. Utilization was adjusted for age, gender and year of interview. Statistical methods used are contingency table analysis and (logistic) multiple regression. RESULTS: Almost one-fifth of the study population reported more than one chronic condition. Musculoskeletal disease, in addition to being the most common single condition, was found to be the condition most likely to occur with one of the remaining five disease clusters. Seven per cent reported not having used any services at all. Two-thirds of the study population used at least two different services in the previous year. In contrast, 26% of the study population reported comprehensive utilization patterns (GP and/or home care and/or physiotherapist and/or medical specialist and/or hospitalization: minimum of three types). Persons with more than one chronic condition reported having used more services, in terms of volume and variety, than those with only one condition. CONCLUSIONS: There is a strong association between comorbidity and the volume and variety of health care services that are used. Since many people have comorbid conditions, their use of health services is more complex than would be suggested by a one-disease approach. New disease management systems need to be developed to reflect the multiplicity of health care needs of the growing number patients with more than one chronic condition.

Limiting comorbid conditions and breast cancer stage at diagnosis.

BACKGROUND: Contrasting hypotheses exist regarding the relationship between comorbidity and breast cancer stage at diagnosis. One suggestion is that disabling comorbid conditions would result in a later stage diagnosis of breast cancer because such conditions would limit mobility and thus access to medical care. This article examines this hypothesis by building a comorbidity summary measure of functionally limiting comorbid conditions and by testing the effectiveness of this measure in predicting the stage at which breast cancer is diagnosed. METHODS: Cases with newly diagnosed breast cancer were identified through the population-based Metropolitan Detroit Cancer Surveillance System, a participant of the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute. Of 1191 eligible cases, 1011 (85%) were interviewed 2-4 months following diagnosis. The analyses for this study were limited to 731 cases for which there were complete data on all variables. Five individual comorbid conditions that predicted functional limitation were combined into a comorbidity summary measure: arthritis, eye conditions, gastrointestinal conditions, kidney conditions, and respiratory conditions. Breast cancer stage was categorized in relation to whether women had local or advanced (regional or remote) disease. RESULTS: Women with two or more of these five functionally limiting conditions were about half as likely as those with none of these conditions to receive an advanced stage diagnosis of breast cancer (odds ratio [OR] = 0.49, 95% confidence interval [CI] 0.28-0.86, p = .01). CONCLUSIONS: These findings do not support the suggestion that the presence of disabling comorbid conditions results in later stage breast cancer. The five conditions summarized by this measure, although functionally limiting, may also require greater medical monitoring due to associated symptoms and/or treatment requirements and thus lead to increased opportunities for cancer screening.

Evaluating pterygium severity: a survey of corneal specialists.

PURPOSE: Accurate and reliable evaluation techniques are essential for clinical and epidemiologic studies. This survey of corneal specialists was designed to lay a foundation for the further development of methods for evaluating and staging pterygium. METHODS: In a self-administered, mailed questionnaire, 213 corneal specialists rated the importance of nine symptoms, nine signs, and nine clinical tests for the severity of primary pterygium. Severity was defined as the present need for surgical intervention. RESULTS: The most important factors for determining primary pterygium severity were the extent of encroachment onto the cornea, decreased visual acuity, restricted ocular motility, and increased rate of growth. Many patient symptoms were rated as moderately to highly important. The questionnaire was shown to have good response reliability by test-retest comparisons. Cronbach's alpha was 0.89, which indicates very good internal consistency reliability. CONCLUSION: The survey identifies the priorities of experts in determining the severity of pterygium. More precise and clearly defined evaluation methods will enhance future clinical and epidemiologic studies of pterygium. The ranked list of pterygium signs, symptoms, and tests can serve as a guide for developing pterygium evaluation methods in the future. There is a need for a method that accurately and precisely quantifies the distance of pterygium encroachment onto the cornea and the pterygium progression rate. Furthermore, there is a need for an assessment of patient symptoms.

Reasons given by older people for limitation or avoidance of leisure time physical activity.

OBJECTIVES: This study investigates reasons given by older people for limitation or avoidance of physical exercise. DESIGN: Community-based longitudinal study of free-living persons age 55 years or older in Sonoma, California. METHODS: Baseline standardized interviews were conducted (n = 2046) as part of a longitudinal study of aging and physical performance. Seventeen reasons for limitation or avoidance of physical activities were evaluated, with responses grouped as: no limitations, medical, non-medical, and combined medical and non-medical reasons. Patterns of physical activity and medical conditions and direct measures of physical function were evaluated in relation to reasons for activity limitation by multinomial logistic regression. RESULTS: Women reported more limitations/avoidance of physical activity than men (81.0% vs 73.5%). Medical reasons increased with age. Reduced walking speed and depressive symptomatology were associated with a combination of medical and non-medical reasons in both sexes. Living arrangements were associated with non-medical reasons for women but were not for men. Non-medical reasons were associated with a 20 to 30% reduction in the number of subjects who reported physical activity at recommended levels. DISCUSSION: Non-medical factors are important determinants of activity limitation and should serve as targets for patient care providers and future interventions to improve participation in physical activity by older people.

The relationship between diet and breast cancer in men (United States).

OBJECTIVES: The purpose of this paper was to investigate the relationship between food and beverage consumption and the development of breast cancer in men. METHODS: Possible relationships of dietary factors to risk of breast cancer in men were assessed in a case-control study conducted between 1983 and 1986. Cases (N = 220) were ascertained from ten population-based cancer registries. Controls (N = 291) were selected by random-digit dialing (< age 65) and from Health Care Financing Administration Medicare beneficiary lists (> or = age 65). RESULTS: No trends in risk were observed with increasing intakes of specific foods, except for an increase in risk with citrus fruits. No increase in risk with increasing amounts of specific fats, vitamins, or minerals or with amounts of protein, fiber, carbohydrate, starches, nitrites, or alcohol consumed was observed, except for an increase in risk with dietary vitamin C consumption. A decreasing trend in risk with dietary niacin and with coffee and an increasing trend in risk with tea consumption were observed. No associations were found with use of any dietary supplements, including vitamin C. CONCLUSIONS: The observed associations are not consistent with findings from studies of breast cancer in women and probably do not represent causal relationships. Dietary factors are unlikely to be strong determinants of breast cancer in men.

Cause of death in men diagnosed with prostate carcinoma.

BACKGROUND: Prostate carcinoma is one of the leading causes of death in men. Although the mortality rate is high, it still may underestimate the number of deaths associated with the disease. This study was conducted to compare causes of death among men previously diagnosed with prostate carcinoma and to examine the extent to which differences in cause of death (death from prostate carcinoma vs. death from other causes) varied by age, race, clinical factors, and comorbid conditions. METHODS: A review was conducted of the medical records of decedent members of the Kaiser Permanente Medical Care program who previously were diagnosed with prostate carcinoma between January 1980 and December 1984 (n=584). The review focused on demographic factors, symptoms, diagnostic tests, stage of disease, and treatment. Data on comorbidity were obtained from a computerized discharge summary. Logistic regression analysis was used to estimate odds ratios. RESULTS: Approximately 54% of the decedent prostate carcinoma patients died of their prostate carcinoma. Decedents who were black, age < or = 65 years, diagnosed with more advanced disease stage, recipients of hormonal therapy, and whose death occurred > 6 months after diagnosis were more likely than others to die of prostate carcinoma. In contrast, the likelihood of dying of some other cause was associated with concurrent cardiovascular disease, after adjustment for the effects of race, age, and disease stage. There also were significant two-way age-race and age-time-to-death interactions. CONCLUSIONS: The prognostic significance of cardiovascular disease in prostate carcinoma patients should be investigated in subsequent survival studies. A number of questions need to be addressed delineating the complex relations between coexisting diseases and their treatment.

Alcohol consumption and breast cancer stage at diagnosis.

The stage at which breast cancer is diagnosed is an important determinant of prognosis. In contrast to the many investigations of the relationship between alcohol consumption and the risk of developing breast cancer, few have examined how alcohol consumption may affect the stage of this cancer at diagnosis. This article examines the relationship between alcohol intake and breast cancer stage and assesses consumption in relation to the volume of drinks consumed per week and the patterns of consumption 1 year prior to the breast cancer diagnosis. A total of 1191 women, aged 40 to 84 years, with newly diagnosed breast cancer were identified through the population-based Metropolitan Detroit Cancer Surveillance System, a participant of the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute. Of these, 1011 (85%) were interviewed 2 to 4 months following diagnosis. The analyses for this article were limited to 920 cases with local and regional stage disease. The bivariate analysis showed that frequent drinkers were more likely than abstainers or infrequent drinkers to present with regional disease. Logistic regression showed that frequent drinkers were 1.45 times more likely than infrequent drinkers to be diagnosed with later stage breast cancer (95% CI: 1.01-2.10; p = 05). The association between alcohol consumption and disease stage may be due to the relationship between heavy consumption and other unhealthy behaviors. In addition, women who drink more frequently may have less awareness of and access to cancer screening services. Heavy exposure to alcohol may also contribute to accelerated tumor growth once breast cancer is present.

Association between self-reported leisure-time physical activity and measures of cardiorespiratory fitness in an elderly population.

Leisure-time physical activity enhances health and functioning in older populations. However, few data are available on the correlation between self-reported leisure-time physical activity and cardiorespiratory fitness in the elderly. Treadmill exercise testing results were obtained for 1,006 members (median age 67 years) of a community-based sample. Subjects completed a standardized evaluation of medical/social history and measures of physical function. Leisure-time physical activity in the 12 months and 7 days before interview and over subjects' lifetimes was summarized as total and activity-specific METs/week and [METs * (hours/week)]. Multiple linear regression was used to investigate the cross-sectional, sex-specific associations between peak oxygen consumption (VO2) and exercise duration. After adjustment for age, body mass index, smoking history, medical morbidity, direct measures of physical functioning, forced expiratory volumes, and maximum respiratory muscle pressure, leisure-time physical activity accounted for < or = 5% of the variance of VO2 and exercise duration. Results were unchanged when analyses were restricted to subjects who achieved high levels of exercise. These data indicate that measures of aerobic capacity cannot be used to "validate" self-reported leisure-time physical activity in older subjects, and they further suggest that beneficial effects of physical activity in the elderly are the result of metabolic effects that are not reflected well by maximal aerobic capacity during exercise testing.

A census-based design for the recruitment of a community sample of older adults: efficacy and costs.

PURPOSE: This is a report of the scientific and cost implications of a census-based design to identify residents aged 55 and over for a community study of the effects of aging on physical function. METHODS: A census of residents in a study community was conducted by the use of a mailed questionnaire. For households that did not complete and return the mailed census questionnaire, contact was attempted first by telephone and then by home visit. A comparison was made of the unit costs and characteristics of subjects identified by the different methods. RESULTS: A total of 3509 age-eligible subjects were identified (78.3% by mailer, 19.5% by telephone, and 2.0% by home visit). Costs per enrolled age-eligible subject were lower for mailing and telephone ($7.76 and $4.72 respectively) than for home visit ($36.25). Subjects identified by home visit were significantly younger than subjects identified either by mail or telephone. After adjustment for age, subjects identified by telephone had less education and income and poorer health and functional status than subjects identified by mail. With the exception of age, there were no significant differences between subjects identified by mailer and home visit. CONCLUSIONS: A mailed questionnaire with telephone recontact is a practical strategy for community-based recruitment. Recontact of subjects by telephone can be expected to identify subjects who are not well-represented in a sample based only on a mailer. In contrast, the home visit is expensive and identifies subjects who do not differ meaningfully from those identified by mailer.

Unemployment and the likelihood of detecting early-stage breast cancer.

OBJECTIVES: The objective of this study was to test the hypothesis that unexpectedly high unemployment in a community is associated with reduced odds that registered breast tumors are local. METHODS: The hypothesis was tested with data from San Francisco for the 132 months beginning with January 1983. RESULTS: Registered breast tumors were less likely to be local during periods of unexpectedly high unemployment (8% less likely among non-Hispanic White women and 24% less likely among African-American women). CONCLUSIONS: Job loss may restrict access to health services. Fear of job loss may also distract women from breast self-examination and the identification of suspicious breast signs.

Reliability of physical performance and self-reported functional measures in an older population.

BACKGROUND: Functional assessments and direct measures of physical performance are standard components of community-based studies of older populations. Estimates of the reliability of these measures are necessary for the assessment of functional change. METHODS: The reproducibility of 13 measures of self-reported function and 11 direct measures of physical performance was assessed. A sample of subjects (N=199; > or =55 yrs) was selected from a larger population-based cohort. Subjects were tested in their homes twice, 48 hours apart, by the same interviewer to replicate study conditions. Age-adjusted kappa statistics were used to assess the reliability of measures of physical function; product moment correlation (Pearson r) and intraclass correlation coefficients (ICC) were used to assess direct measures of performance. A repeated measures model was used to assess learning or practice effects of performance, adjusted for age, sex, general health, and cognitive function. RESULTS: Age-adjusted kappa statistics were > or = .60 for most self-reported items. ICC ranged from .63 to .92. Significant improvements (practice effects) were found for the chair stand, walking speed, and the 360 degree turn. Measures of grip strength, reaching down, and hand dexterity were found to be reliable, with no significant test effect. CONCLUSION: Three commonly used measures (chair stand, walking speed, and 360 degree turn) may be less reliable than previously reported. Sample sizes that may be needed to detect change in these areas of performance may be larger than previously estimated given this level of imprecision. Future studies of reproducibility should assess both the level of agreement and the presence of possible practice effects.

Upper-body strength and breast cancer: a comparison of the effects of age and disease.

BACKGROUND: In most studies of functional limitations in women with breast cancer, it is difficult to determine what difficulties are associated with breast cancer and what problems are likely to be found in women of the same age without the disease. In the present study, we report the age-specific prevalence of upper-body limitations in women with breast cancer over the course of one year, compared to that experienced by women of the same age without the disease. METHODS: Interviews were conducted with women with breast cancer ages 40-84 at 3 months (n = 934) and 12 months after diagnosis (n = 843). Controls were interviewed twice over the same period (n = 991 and 887, respectively). The main outcome was upper-body limitation, defined as the number of tasks requiring upper-body strength (0-4) reported by the respondent to be very difficult to complete or not done on doctor's orders. RESULTS: Cases ages 40-54, 55-64, and 65-74 were approximately twice as likely as age-matched controls to report upper-body limitations, adjusting for race, education, financial status, and comorbidity. There was no case/control difference among those ages 75-84. At one year, the breast cancer patients ages 40-54 and 55-64 showed the greatest improvement. CONCLUSIONS: Many women who survive breast cancer report significant limitations in upper-body strength in the first few months, followed, especially among younger women, by a period of recuperation. Rehabilitation and home-care programs should be designed to meet the special and more persistent needs of older women. New strategies for assessing upper-body strength are also suggested.

Comorbidity and breast cancer survival: a comparison between black and white women.

The presence of concurrent health conditions (comorbidity) at the time of breast cancer diagnosis has an adverse effect on survival. It is unclear, however, whether the strength of the association between comorbidity and survival varies in different populations of breast cancer patients. It is necessary, therefore, to establish (1) whether a comorbidity index derived from a general population of patients (mostly white) would predict survival in a black population, and (2) whether comorbidity would have the same degree of relationship to mortality in black as in white populations. We studied 1196 breast cancer patients who were members of the Kaiser Permanente Medical Care Program and were diagnosed with local (n = 708), regional (n = 446), or remote (n = 49) stage breast cancer from 1973 to 1986. Mortality follow-up was completed to December 1994. Ten-year survival was studied in relation to the Charlson comorbidity index for black women and for white women, and for both groups of women combined. Compared to women with a Charlson comorbidity score of 0 (no comorbidity), patients with scores of 1, 2, and 3+ had risk ratios for ten-year mortality of 1.23 (P = 0.10), 2.58 (P < 0.001), and 3.44 (P < 0.001), respectively. This pattern of risk associated with comorbidity was similar to that found in the original Charlson study. The pattern of risk ratios for different levels of comorbidity was very similar for black and white patients. The results confirm previous studies indicating that comorbidity (in particular, the Charlson Comorbidity Index) predicts the survival of women with breast cancer, independently of other factors, such as stage of breast cancer at diagnosis. The Charlson index has prognostic significance for both black and white populations. Research is needed to determine whether the Charlson index can be improved by including health conditions that are particularly prevalent or severe in specific subgroups of women.

Comorbidity and survival in HIV-infected men in the San Francisco Men's Health Survey.

The course of disease associated with infection with the human immunodeficiency virus varies widely. Some patients deteriorate rapidly, while others live for years, even after an illness that defines the acquired immunodeficiency syndrome (AIDS). In this study, comorbidity, or the presence of concurrent health problems, was investigated prospectively as a possible co-factor for different rates of decline in 395 homosexual/bisexual men in the San Francisco Men's Health Study (SFMHS) who were infected with the human immunodeficiency virus (HIV). Comorbidity data obtained from baseline interviews included both chronic and infectious diseases as well as depression. Smoking, alcohol, and drug use were also examined. The most prevalent comorbid conditions were sexually transmitted diseases (90%) and hepatitis B infection (76%). Most chronic and acute concurrent health conditions were not significant discrete predictors of survival to AIDS or death after controlling for immune status and markers of disease progression. Significantly, other risk factors (e.g., depression and smoking) were found to be associated with more rapid progression. Men with symptoms of depression had a higher risk of progression of AIDS diagnosis; the relative hazard (RH) was 1.4 (95% confidence interval [CI], 1.00-2.08); smoking was associated with higher risk of death (RH, 1.6; 95% CI, 1.20-2.17). Older age was marginally associated with poorer survival to death. No associations were found between survival and alcohol and drug use.

Imbalance in an older population: an epidemiological analysis.

Difficulties with balance are associated with limitations in activities of daily living. There is little information, however, about the epidemiology of imbalance. Imbalance, defined as the inability to maintain a full-tandem stand for 10 seconds, was assessed as part of an interview with 2,018 residents of Marin County, California, age 55 and older. The likelihood of imbalance was greater in women, those aged 85 and older, and those with less than 12 years of education. It was also associated with specific chronic conditions, including a history of hypertension, stroke, or cataracts. Even after adjusting for these conditions, imbalance was associated with reduced lower-body strength as well as poor short-term memory, hip pain, vision problems, abstention from alcohol, and current cigarette smoking. With those aged 85 and older representing the fastest growing age group in developed nations, imbalance may become a major health problem.

The likelihood of returning to work after breast cancer.

OBJECTIVE: This is an examination of factors associated with returning to work after the diagnosis of breast cancer. METHODS: Three months after being diagnosed with breast cancer, 296 employed women from the Detroit metropolitan area (52 black and 244 white women) were interviewed. These women were part of a larger cohort of 1,011 breast cancer patients ages 40 to 84 interviewed for the study "Health and Functioning in Women with Breast Cancer". RESULTS: Although most employed women returned to work within three months of the diagnosis of breast cancer, black women were twice as likely as white women to be on medical leave three months after diagnosis (OR = 1.94; 95% CI 1.04 to 3.62). Being on leave was found to be associated with the need for assistance with transportation, limitations in upper-body strength, and employment in jobs requiring physical activity. After adjusting for these factors, the racial difference was reduced and no longer statistically significant (OR = 1.34; 95% CI 0.67, 2.70). CONCLUSION: Breast cancer rehabilitation programs should not only address the patient's physical capacity but also the daily demands she is likely to face once she leaves the hospital and returns to work.

Limitations in upper-body strength associated with breast cancer: a comparison of black and white women.

We examined differences in reported upper-body limitations between black and white breast cancer cases and controls aged 40 to 84 years at 3 and 12 months after diagnosis in the Detroit metropolitan area (n = 954 cases and 1000 controls at 3 months; n = 879 cases and 909 controls at 12 months). At 3 months black cases were more likely than white cases to report limitations in upper-body strength (30.4 versus 19.8%). No difference was found between black and white controls (8.0 versus 9.4%). At 12 months, the proportion of white patients with upper-body limitation returned to the same level as white controls. Black patients with limitations, however, did not return to the same level as black controls. Stage of disease was strongly associated with upper-body limitations, especially for black women. Race and stage differences in upper-body limitation could not be explained by differences in breast cancer treatment, financial adequacy, education, marital status, or comorbidity. Recommendations are made for more comprehensive studies of rehabilitation.