Neighborhood disparities in stroke and myocardial infarction mortality: a GIS and spatial scan statistics approach.

BACKGROUND: Stroke and myocardial infarction (MI) are serious public health burdens in the US. These burdens vary by geographic location with the highest mortality risks reported in the southeastern US. While these disparities have been investigated at state and county levels, little is known regarding disparities in risk at lower levels of geography, such as neighborhoods. Therefore, the objective of this study was to investigate spatial patterns of stroke and MI mortality risks in the East Tennessee Appalachian Region so as to identify neighborhoods with the highest risks. METHODS: Stroke and MI mortality data for the period 1999-2007, obtained free of charge upon request from the Tennessee Department of Health, were aggregated to the census tract (neighborhood) level. Mortality risks were age-standardized by the direct method. To adjust for spatial autocorrelation, population heterogeneity, and variance instability, standardized risks were smoothed using Spatial Empirical Bayesian technique. Spatial clusters of high risks were identified using spatial scan statistics, with a discrete Poisson model adjusted for age and using a 5% scanning window. Significance testing was performed using 999 Monte Carlo permutations. Logistic models were used to investigate neighborhood level socioeconomic and demographic predictors of the identified spatial clusters. RESULTS: There were 3,824 stroke deaths and 5,018 MI deaths. Neighborhoods with significantly high mortality risks were identified. Annual stroke mortality risks ranged from 0 to 182 per 100,000 population (median: 55.6), while annual MI mortality risks ranged from 0 to 243 per 100,000 population (median: 65.5). Stroke and MI mortality risks exceeded the state risks of 67.5 and 85.5 in 28% and 32% of the neighborhoods, respectively. Six and ten significant (p < 0.001) spatial clusters of high risk of stroke and MI mortality were identified, respectively. Neighborhoods belonging to high risk clusters of stroke and MI mortality tended to have high proportions of the population with low education attainment. CONCLUSIONS: These methods for identifying disparities in mortality risks across neighborhoods are useful for identifying high risk communities and for guiding population health programs aimed at addressing health disparities and improving population health.

Mortality patterns among Paducah Gaseous Diffusion Plant workers.

OBJECTIVE: To determine whether Paducah Gaseous Diffusion Plant workers had mortality patterns that differed from the general US population and to investigate whether mortality patterns were associated with job title or workplace exposures. METHODS: A retrospective occupational cohort mortality study was conducted on 6759 workers. Standardized mortality ratio analyses compared the cohort with the referent US population. Internal comparisons producing standardized rate ratios were conducted by job title, metal exposure, and cumulative internal and external radiation exposures. RESULTS: Overall mortality and cancer rates were lower than the referent population, reflecting a strong healthy worker effect. Individual not significant standardized mortality ratios and standardized rate ratios were noted for cancers of the lymphatic and hematopoietic tissue. CONCLUSIONS: Although relatively low exposures to radiation and metals did not produce statistically significant health effects, no significant elevations for lymphatic and hematopoietic cancers were consistent with previous studies of nuclear workers.

Brain cancer survival in Kentucky: 1996-2000.

This is a report of brain cancer survival patterns in certain Area Development Districts (ADDs) in Kentucky, the state, and the nation. Brain cancer is of national and regional concern as it is a disease of high case fatality rates and relatively short survival. Comparisons for survival were made between the U.S.A. and the state. Kentucky has higher brain cancer mortality rates than the U.S.A., but significantly better cause-specific survival (p < 0.05). In order to examine within state variations for brain cancer survival, data organized for the fifteen ADDs from the state's central cancer registry were used. The analytic focus of this analysis were three regions expressly: the Purchase ADD (location of the Paducah Gaseous Diffusion Plant), the Green River ADD (the location of elevated brain cancer mortality rates), and the Kentucky River ADD (comprising counties that each have significantly more than the state average of persons living below the national poverty level). We found no evidence of lower survival for brain cancer among the poorer region of the state. The western districts were found to have lower cause-specific survival than the state (p < 0.05) and the U.S.A. Such a regional variation alerts population-based researchers to consider varying survival trends within the state's population.

Stroke mortality in Tennessee: an eco-epidemiologic perspective.

Prevention of stroke mortality in Tennessee is a statewide public health priority. These analyses describe how the distribution of Caucasian stroke mortality is greater among the state's Appalachian Counties. For African-American residents, the elevated stroke mortality risk is not distinctive for geographic regions, although Upper East Tennessee rates are elevated. If the Caucasian criteria for assigning "high" rates were used with African-American stroke mortality data, the entire state would be designated as having elevated levels for stroke mortality. Race-gender specific analyses at the county-level (ecological attributes) illustrate the greater risks for "high" county-level stroke mortality rates are present for urban and poor communities in our state. African-American males are a clear exception, where the poorer, rural communities show a protective effect for "high" county-level stroke mortality rates. We support implementing stroke prevention programming and public health interventions based on the mortality data distributions; compatible statewide initiatives are underway We recommend strategic over-sampling of the state's priority populations for stroke risk to facilitate the monitoring of prevention and intervention program impacts over time.

Unstaged lung cancer in Kentucky.

Comparisons were made for unstaged lung cancer cases both to "staged" lung cancer cases and to unstaged cases from all other sites, in Kentucky for 1996-2000. Principal findings were that the likelihood of the lung cancer cases to be unstaged was greater when the cancer incidence report came from sources other than a hospital. This may implicate data system forces [for availability of necessary data for completing stage at diagnosis] rather than differences between cases per se. The risk of being unstaged by smoking status was reversed between lung cancer (lower risk) than for all other cancer sites (higher risk), an unexpected pattern. No difference for survival was found for unstaged versus staged lung cancer cases, as well as no differences for race and gender. The finding of no differences suggests that other forces (eg, age, source of payment) may contribute more greatly to one's likelihood of being unstaged with a diagnosis of lung cancer than for "all other cancer sites." These patterns pose provocative implications for how smoking status may influence clinical perspectives and those of persons faced with a diagnosis of cancer.

Scale and shape issues in focused cluster power for count data.

BACKGROUND: Interest in the development of statistical methods for disease cluster detection has experienced rapid growth in recent years. Evaluations of statistical power provide important information for the selection of an appropriate statistical method in environmentally-related disease cluster investigations. Published power evaluations have not yet addressed the use of models for focused cluster detection and have not fully investigated the issues of disease cluster scale and shape. As meteorological and other factors can impact the dispersion of environmental toxicants, it follows that environmental exposures and associated diseases can be dispersed in a variety of spatial patterns. This study simulates disease clusters in a variety of shapes and scales around a centrally located single pollution source. We evaluate the power of a range of focused cluster tests and generalized linear models to detect these various cluster shapes and scales for count data. RESULTS: In general, the power of hypothesis tests and models to detect focused clusters improved when the test or model included parameters specific to the shape of cluster being examined (i.e. inclusion of a function for direction improved power of models to detect clustering with an angular effect). However, power to detect clusters where the risk peaked and then declined was limited. CONCLUSION: Findings from this investigation show sizeable changes in power according to the scale and shape of the cluster and the test or model applied. These findings demonstrate the importance of selecting a test or model with functions appropriate to detect the spatial pattern of the disease cluster.

Pediatric cancer in Kentucky: good news.

Pediatric cancer is one of the more poignant aspects associated with the occurrence of this prominent chronic disease. Nationally, pediatric cancers occur with vastly lesser frequency than does adult disease, about 1:40 ratio. Nationally the rate is 14.6 per 100,000 population, age, 0-14 years. In Kentucky, all pediatric cancer rates are consistently lower, a statewide rate of 11.3 per 100,000. A rigorous examination was made for any evidence of unusual risk for pediatric cancer within the state; none was found. The population center of Jefferson County was examined with a bit greater detail, owing simply to the larger number. Again, no basis for public health or follow-back was identified. Among the most frequent pediatric cancers, leukemia, central nervous system, and brain were studied for implications of residential proximity to environmental hazards; no evidence of increased risk was identified. In all of the state, only Hardin County evinced any excess pediatric cancer risk, i.e., was significantly greater than the national rates. Yet this highly mobile population [owing to a large military population] may simply represent rates that are more compatible with those of the nation. For the Kentucky comprehensive disease control efforts, then, no emphasis need be placed with pediatric cancer beyond the intense personal tragedy that it poses.

Which life?

"Saving a life" is a credible definition of heroism in the United States. However, the pervasive societal impression of immediate gratification has led to a widespread recognition of "life saving" only in circumstances of immediate danger. The lengthening national life expectancy is not accorded respect as an accomplishment in and of itself. Families of dying, elderly persons still mistake the "loss" by failing to appreciate the many times this life has been saved and esteeming the accomplishment that death at a later age poses. Public health and preventive medicine both suffer general disregard for this shortsighted perspective, from the public and those who determine federal funding priorities. This narrative expounds on this frustration and describes its implication for the future of public health as it is currently practiced in this nation.

Mentorship and competencies for applied chronic disease epidemiology.

To understand the potential and establish a framework for mentoring as a method to develop professional competencies of state-level applied chronic disease epidemiologists, model mentorship programs were reviewed, specific competencies were identified, and competencies were then matched to essential public health services. Although few existing mentorship programs in public health were identified, common themes in other professional mentorship programs support the potential of mentoring as an effective means to develop capacity for applied chronic disease epidemiology. Proposed competencies for chronic disease epidemiologists in a mentorship program include planning, analysis, communication, basic public health, informatics and computer knowledge, and cultural diversity. Mentoring may constitute a viable strategy to build chronic disease epidemiology capacity, especially in public health agencies where resource and personnel system constraints limit opportunities to recruit and hire new staff.

Things to know and do about cancer clusters.

Perceived cancer clusters present difficulties and opportunities for clinicians and public health officials alike. Public health officials receive reports of perceived cancer clusters, evaluate the validity of these reports, and/or launch investigations to identify potential causes. Clinicians interact directly with the affected patients, families, or community representatives who question the occurrence of cancer and the underlying causes. Clinicians may identify cancer clusters when they question the unusual occurrence of a rare form of cancer within their practice or community. In addition, clinicians may be asked to discuss cancer clusters and inform local debates. In this paper, we describe the public health practice experience with cancer clusters and identify cancer prevention and control opportunities for clinicians and public health officials. Scientific investigations of cancer clusters rarely uncover new knowledge about the causes of cancer. However, a set of common characteristics, unique to etiologic cluster investigations have uncovered new information about the causes of cancer or demonstrated a preventable link to a known carcinogen. These characteristics may provide useful clues for sorting out the small number of clusters worthy of further scientific investigation. Public awareness of cancer clusters may promote an opportunity to inform and motivate people about the preventable causes of cancer and effective cancer screening methods.

Clinical trial enrollment of rural patients with cancer.

PURPOSE: The goal of this study was to examine the effect of a rural community clinical oncology program-based cancer-care intervention program that was launched to increase the number of rural patients with cancer enrolled in clinical trials. DESCRIPTION OF STUDY: Five rural counties in eastern North Carolina served as intervention communities, and five rural counties in South Carolina served as the comparison region. The intervention counties used a rapid tumor-reporting system, a nurse facilitator who identified and prompted oncologists to enter patients into clinical trials, a quarterly newsletter to primary-care physicians about cancer treatment and clinical trials, and a health educator who focused on community-wide education regarding cancer prevention, treatment, and clinical trial information. Outcomes included changes in knowledge and attitudes about clinical trials among the primary-care providers who were surveyed and enrollment in clinical treatment trials for breast and colorectal cancer, as analyzed by comparing practice pattern data from before and after the intervention. RESULTS: The results indicate that the intervention was not effective. The proportion of primary-care physicians who were aware of clinical trials for their patients with cancer rose slightly in comparison counties (26% to 34%) but remained constant (41% to 43%) in intervention counties. Perceived patient and actual physician barriers toward clinical trial participation were reported by the physicians. A minority of potentially eligible patients with breast or colon cancer in both North Carolina and South Carolina were enrolled in clinical trials. CLINICAL IMPLICATIONS: These data suggest that different types of interventions may be needed to improve accrual to cancer treatment trials in rural communities. In addition, the role that primary-care providers play in encouraging patients with cancer to participate in clinical treatment trials needs further exploration.