Predicting 10-year alcohol use trajectories among men age 50 years and older.

OBJECTIVE: To describe common 10-year drinking trajectories followed by men age 50 years or older and identify risk factors for those trajectories. DESIGN: Longitudinal data were used to derive a semiparametric group-based model. PARTICIPANTS: Men from the Health and Retirement Study age 50-65 years in 1998 who completed three or more of the six interviews conducted from 1998 to 2008, including our 1998 baseline interview. MEASUREMENTS: Biannual data on number of drinks per drinking day were used to derive drinking trajectories. Risk factors included baseline age, race, ethnicity, education, marital status, retirement, smoking, binge drinking, vigorous exercise, body mass index, depression, pain, self-reported health, and chronic disease. RESULTS: The best-fitting model included consistent infrequent drinkers and nondrinkers (40.6% of cohort), increasing drinkers (5.5%), decreasing drinkers (7.6%), consistent at-risk drinkers (15.6%), and consistent moderate drinkers (30.7%). Adjusted logistic regression models comparing men with similar 1998 drinking levels who subsequently followed different trajectories identified significant risks associated with age, education, smoking, binge drinking, depression, pain, and self-reported health. To illustrate, odds ratios (ORs) and 95% confidence intervals (95% CIs) suggest that baseline infrequent drinkers were less likely to follow an increasing drinkers trajectory if they were older (OR: 0.57, 95% CI: 0.38-0.82) and smoked cigarettes (OR: 0.47, 95% CI: 0.30-0.74). Baseline drinkers were less likely to follow a decreasing trajectory if they reported more than 12 years of education (OR: 0.58, 95% CI: 0.42-0.82) and thought that their health was excellent or very good (OR: 0.54, 95% CI: 0.39-0.76). CONCLUSION: Only 30.7% of older men in this cohort were moderate drinkers throughout the follow-up. Many older men may benefit from brief counseling on the risks and benefits of drinking.

Characteristics of US counties with no mammography capacity.

Access to screening mammography may be limited by the availability of facilities and machines, and nationwide mammography capacity has been declining. We assessed nationwide capacity at state and county levels from 2003 to 2009, the most recent year for which complete data were available. Using mammography facility certification and inspection data from the Food and Drug Administration, we geocoded all mammography facilities in the United States and determined the total number of fully accredited mammography machines in each US County. We categorized mammography capacity as counties with zero capacity (i.e., 0 machines) or counties with capacity (i.e.,≥1 machines), and then compared those two categories by sociodemographic, health care, and geographic characteristics. We found that mammography capacity was not distributed equally across counties within states and that more than 27 % of counties had zero capacity. Although the number of mammography facilities and machines decreased slightly from 2003 to 2009, the percentage of counties with zero capacity changed little. In adjusted analyses, having zero mammography capacity was most strongly associated with low population density (OR = 11.0; 95 % CI 7.7-15.9), low primary care physician density (OR = 8.9; 95 % CI 6.8-11.7), and a low percentage of insured residents (OR = 3.3; 95 % CI 2.5-4.3) when compared with counties having at least one mammography machine. Mammography capacity has been and remains a concern for a portion of the US population--a population that is mostly but not entirely rural.

Identifying social drinkers likely to consume alcohol during pregnancy: findings from a prospective cohort study.

To prevent fetal alcohol syndrome, some social drinkers who may become pregnant need more than a brief caution, but they can be difficult to detect in clinical settings. National Longitudinal Survey of Youth data from 754 women who completed up to four alcohol history interviews during their college-age years (18-21), and semiparametric group-based models were used to identify groups more likely to drink during a future pregnancy. Two drinking trajectories were observed. About 87% of the women were occasional or nondrinkers during their college-age years; 13% were frequent drinkers. Among first-births to women 22 yr. and older, the adjusted odds ratio for alcohol use during that pregnancy for frequent drinkers versus occasional and nondrinkers was 2.29 (95% confidence interval: 1.25-4.17). This finding suggests women who report frequent drinking during their college-age years may require additional assistance to reduce their risk of drinking during subsequent pregnancies.

Changes in the prevalence of alcohol use during pregnancy among recent and at-risk drinkers in the NLSY cohort.

PURPOSE: To support efforts to prevent fetal alcohol syndrome (FAS), population-based data are needed on the prevalence of alcohol use at any time during gestation, particularly among women who were recent and at-risk drinkers. METHODS: We used National Longitudinal Survey of Labor Market Experiences in Youth (NLSY) files to estimate the prevalence of any drinking during pregnancy and to evaluate alcohol history risk factors among 6676 births reported by women with prepregnancy drinking data. Prevalence estimates were obtained for 2-year intervals for all 1982-1995 births and for subsets with prepregnancy recent and at-risk drinking. RESULTS: Among all births, drinking during pregnancy declined from 38.3% in 1982-1983 to 23.0% in 1994-1995 (p < 0.0001). Drinking during pregnancy also declined over time among recent and at-risk drinkers (p < 0.0001), but the 1994-1995 prevalences were still high (39.3% and 29.0%, respectively). Adjusted logistic models confirmed both the decrease in risk for the later birth years and the persistent heightened risk for births among recent and at-risk drinkers. CONCLUSIONS: In addition to ongoing universal prevention strategies that have helped reduce the prevalence of drinking during pregnancy, selective and indicated prevention approaches are needed to encourage abstinence during pregnancy among recent and at-risk drinkers.

On-schedule mammography rescreening in the National Breast and Cervical Cancer Early Detection Program.

OBJECTIVE: The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides free cancer screening to many low-income, underinsured women annually but does not routinely collect all data necessary for precise estimation of mammography rescreening rates among enrollees. MATERIALS AND METHODS: To determine the percentages rescreened and to identify factors that encourage on-schedule rescreening, telephone interview and medical record data were collected from 1685 enrollees in Maryland, New York, Ohio, and Texas at least 30 months after their 1997 index mammogram. RESULTS: Overall, 72.4% [95% confidence interval (95% CI) = 70.1-74.7] were rescreened within 18 months and 81.5% (95% CI = 79.6-83.5) within 30 months. At 30 months, the adjusted odds ratios (ORs) for rescreening were higher among Hispanics (OR = 1.95, 95% CI = 1.15-3.28), women with a history of breast cancer before the index mammogram (OR = 3.36, 95% CI = 1.07-10.53), and those who had used hormone replacement therapy before their index mammogram (OR =1.94, 95% CI = 1.30-2.91). The 30-month adjusted ORs were lower for women who reported poor health status (OR = 0.60, 95% CI = 0.42-0.85), did not have a usual source of care (OR = 0.61, 95% CI = 0.40-0.94), did not know if they could have another free mammogram (OR = 0.28, 95% CI = 0.14-0.51), described their index screen as their first mammogram ever (OR for no prior mammograms versus three or more = 0.40, 95% CI = 0.27-0.60), did not recall receiving a rescreening reminder (OR = 0.35, 95% CI = 0.25-0.48), or did not think they had been encouraged to rescreen by their provider (OR = 0.61, 95% CI = 0.44-0.86). DISCUSSION: Rescreening behavior in this sample of NBCCEDP enrollees was comparable with that observed in other populations. To facilitate routine rescreening among low-income women, ongoing efforts are needed to ensure that they receive annual reminders and encouragements from their medical providers and that they know how to obtain the services they need.

Increasing and decreasing alcohol use trajectories among older women in the U.S. across a 10-year interval.

Older women who routinely drink alcohol may experience health benefits, but they are also at risk for adverse effects. Despite the importance of their drinking patterns, few studies have analyzed longitudinal data on changes in drinking among community-based samples of women ages 50 and older. Reported here are findings from a semi-parametric group-based model that used data from 4,439 randomly sampled U.S. women who enrolled in the Health and Retirement Study (HRS) and completed ≥ 3 biannual alcohol assessments during 1998-2008. The best-fitting model based on the drinks per day data had four trajectories labeled as "Increasing Drinkers" (5.3% of sample), "Decreasing Drinkers" (5.9%), "Stable Drinkers" (24.2%), and "Non/Infrequent Drinkers" (64.6%). Using group assignments generated by the trajectory model, one adjusted logistic regression analysis contrasted the groups with low alcohol intake in 1998 (Increasing Drinkers and Non/Infrequent Drinkers). In this model, baseline education, physical activity, cigarette smoking, and binge drinking were significant factors. Another analysis compared the groups with higher intake in 1998 (Decreasing Drinkers versus Stable Drinkers). In this comparison, baseline depression, cigarette smoking, binge drinking, and retirement status were significant. Findings underscore the need to periodically counsel all older women on the risks and benefits of alcohol use.

The effect of caregiving on women in families with Duchenne/Becker muscular dystrophy.

Duchenne/Becker muscular dystrophy (DBMD) is a disorder of progressive muscle weakness that causes an increasing need for assistance with activities of daily living. Our objective was to assess the psychosocial health and contributing factors among female caregivers in families with DBMD. We conducted a survey of adult women among families with DBMD in the United States (US) from June 2006 through January 2007, collecting data related to the care recipient, perception of caregiving demands, personal factors, and socio-ecologic factors. Life satisfaction, stress, and distress were assessed as outcomes. Existing validated instruments were used when available. We received responses from 1238 women who were caring for someone with DBMD, 24.2% of whom were caring for two or more people with DBMD. Caregivers were more likely to be married/cohabitating than women in the general US population, and a high level of resiliency was reported by 89.3% of caregivers. However, the rate of serious psychological distress was significantly higher among caregivers than among the general population. Likewise, 46.4% reported a high level of stress, and only 61.7% reported that they were satisfied with their life. A high level of caregiving demands based on the Zarit Burden Interview (ZBI) was reported by 50.4% of caregivers. The post-ambulatory phase of DBMD was associated with decreased social support and increased ZBI scores. In multivariate logistic regression modelling, life satisfaction was dependent on high social support, high resiliency, high income, and form of DBMD. Distress and high stress were predicted by low resiliency, low social support, and low income. Employment outside of the home was also a predictor of high stress. Interventions focused on resiliency and social support are likely to improve the quality of life of DBMD caregivers, and perhaps caregivers of children with other disabilities or special health care needs as well.

Alcohol use trajectories in two cohorts of U.S. women aged 50 to 65 at baseline.

OBJECTIVES: To examine drinking trajectories followed by two cohorts of older women over 8 to 10 years of follow-up. DESIGN: Longitudinal analyses of two nationally representative cohorts using semiparametric group-based models weighted and adjusted for baseline age. SETTING: Study data were obtained from detailed interviews conducted in the home or by telephone. PARTICIPANTS: One cohort included 5,231 women in the Health and Retirement Study (HRS) aged 50 to 65 in 1996; the other included 1,658 women in the National Longitudinal Survey (NLS) aged 50 to 65 in 1995. MEASUREMENTS: Both cohorts reported any recent drinking and average number of drinks per drinking day using similar but not identical questions. HRS women completed six interviews (one every other year) from 1996 to 2006. NLS women completed five interviews from 1995 to 2003. RESULTS: All trajectory models yielded similar results. For HRS women, four trajectory groups were observed in the model based on drinks per day: increasing drinkers (4.9% of cohort), infrequent and nondrinkers (61.8%), consistent drinkers (25.9%), and decreasing drinkers (7.4%). Corresponding NLS values from the drinks per day model were 8.8%, 61.4%, 21.2%, and 8.6%, respectively. In 2006, the average number of drinks per day for HRS women in the increasing drinker and consistent drinker trajectories was 1.31 and 1.59, respectively. In 2003, these values for NLS women were 0.99 and 1.38, respectively. CONCLUSION: Most women do not markedly change their drinking behavior after age 50, but some increase their alcohol use substantially, whereas others continue to exceed current recommendations. These findings underscore the importance of periodically asking older women about their drinking to assess, advise, and assist those who may be at risk for developing alcohol-related problems.

Adherence to american academy of pediatrics recommendations for cardiac care among female carriers of duchenne and becker muscular dystrophy.

OBJECTIVE: The goal was to assess women's knowledge and heart health behaviors consistent with the American Academy of Pediatrics recommendations for cardiac care among female carriers of Duchenne/Becker muscular dystrophy. METHODS: Using an advocacy group mailing list and working with 50 Muscular Dystrophy Association clinics, we surveyed women who had given birth to a son with Duchenne/Becker muscular dystrophy, thought that they were definitely or probably (>/=50% likelihood) a Duchenne/Becker muscular dystrophy carrier, or both. Self-report data classified respondents as carriers, noncarriers, or women with unknown status. RESULTS: The respondents included 833 Duchenne/Becker muscular dystrophy carriers, 376 noncarriers, and 192 women with unknown status. Carriers were more likely than noncarriers and women in the unknown-status group to have ever undergone electrocardiography or other heart testing and to have seen a cardiologist in the past year, but they were not more likely to report a recent blood pressure or cholesterol level check. Only 64.4% of the carriers had ever had a heart test; 18.3% had seen a cardiologist in the past year. Only 62.9% of the carriers were aware of their cardiomyopathy risks before participating in the survey; 69.3% had informed their health care provider of their carrier status. Among carriers who had informed their provider, 70.2% had ever had a heart test and 21.4% had seen a cardiologist in the past year. In adjusted logistic regression models, factors that significantly increased the likelihood among carriers of ever having had a heart test and seeing a cardiologist in the previous year included older age (>/=50 years), feeling informed about their cardiomyopathy risks before the survey, and having told their provider about their carrier status. CONCLUSION: More health education efforts are needed for both patients and their providers, to improve adherence to the American Academy of Pediatrics cardiac care guidelines for female Duchenne/Becker muscular dystrophy carriers.

Efforts to locate low-income women for a study on mammography rescreening: implications for public health practice.

Public health practice often requires locating individuals in the community. This article presents information on the methods and amount of time and effort required to locate over 2300 low-income and minority women in Maryland, New York, Ohio, and Texas for a mammography rescreening study. In 1999, we identified 2528 low-income women who had a mammogram in 1997 funded by the National Breast and Cervical Cancer Early Detection Program. Starting 30 months after that mammogram, we made numerous attempts to locate each woman while recording the number of calls, letters, and tracing attempts used and the date she was found. More than 93% of the women were located. On average, it took 73.8 days (range 1-492 days) and 7.2 calls and letters (range 1-48) to reach each woman. Locating women in racial and ethnic minority groups required more time and effort. About 10% of all located women were found only after our subject tracing protocol was implemented. The percentage of located women increased markedly with more months of effort and additional calls and letters. Because women who were more difficult to locate were less likely to have been rescreened, the mammography rescreening percentages at the end of the study were slightly lower than they would have been had we terminated location efforts after 1-3 months. Locating low-income women in the community is difficult, particularly when obtaining a high response rate from all groups is important. Terminating data collection prematurely may decrease minority group representation and introduce bias.

Impact of women's experiences during mammography on adherence to rescreening (United States).

OBJECTIVE: To examine the relationship between womens' experiences during mammography and their likelihood of being rescreened after receiving a negative or benign mammogram. METHODS: Telephone interview and medical record data were collected from a random sample of enrollees from four states in a national screening program targeting uninsured and underinsured women at least 30 months after they had undergone an index mammogram in 1997. We calculated 30-month rescreening rates by prior mammography characteristics including pain and embarrassment, worry, convenience of appointment time, treatment by staff, and financial considerations. RESULTS: Of the 2,000 women in the sampling frame, 1,895 (93.6%) were located, 1,685 (88.6%) were interviewed and 1,680 provided data required for our analysis. Overall, 81.5% of the women had undergone rescreening. More than 90% of the women reported being 'satisfied' or 'very satisfied' with treatment by facility staff, facility location and wait time during the appointment. Statistically significant decreased rescreening rates were seen for women who reported feeling embarrassed and for women reporting dissatisfaction with ability to schedule a convenient appointment time. CONCLUSION: These results suggest that providing additional reassurance and privacy may increase rescreening rates.

Recall of age of weaning and other breastfeeding variables.

BACKGROUND: Many studies of the impact of breastfeeding on child or maternal health have relied on data reported retrospectively. The goal of this study was to assess recall accuracy among breastfeeding mothers of retrospectively collected data on age of weaning, reasons for cessation, breast pain, lactation mastitis, and pumping. METHODS: Women in Michigan and Nebraska, U.S.A. were interviewed by telephone every 3 weeks during the first 3 months after the birth of their child, and mailed a questionnaire at 6 months. A subset was interviewed again by telephone approximately 1-3.5 years after the birth. The results for the three recall periods, collected 1994-1998, were compared using correlation, linear and Cox regression analysis, and sensitivity and specificity estimates. RESULTS: The 184 participants were aged 18-42, mostly white (95%) and 63% had an older child. The age of weaning tended to be overestimated in interviews 1-3.5 years after birth compared to those within 3 weeks of the event, by approximately one month for 1-3.5 year recall and two weeks for 6-month recall (p < 0.001 in both cases). Recall accuracy of reasons for weaning varied greatly by reason, with mastitis and return to work having the most recall validity. The sensitivity of 1-3.5 year recall of mastitis was 80%, but was only 54% for nipple cracks or sores. CONCLUSION: Breastfeeding duration among short-term breastfeeders tended to be somewhat overestimated when measured at 1-3.5 years post-partum. Reporting of other breastfeeding characteristics had variable reliability. Studies employing retrospective breastfeeding data should consider the possibility of such errors.

Activities of epidemiologists in state and territorial cancer control programs, 1999.

The Council of State and Territorial Epidemiologists surveyed the chronic disease program directors in 1999. Forty-eight (89%) of the health agencies responded. Nearly 90 percent reported having an epidemiologist who devoted some time to cancer control activities. More than 90 percent reported the availability and use of the mortality, incidence, and risk factor data. Almost 70 percent of the respondents produced annual cancer reports, but less than half reported publishing in a state bulletin or scientific journal. These findings suggest that despite widespread access to epidemiologic expertise and cancer-related data, considerable variability persists in the use and dissemination of crucial cancer statistics.

Risk factors for failure to detect a cancer during clinical breast examinations (United States).

BACKGROUND: Although clinical breast examinations (CBEs) provide important opportunities to detect breast cancer, little is known about factors that affect cancer detection during CBEs performed in community settings. To evaluate several potential factors, we analyzed data from 1,056,153 cancer screening records reported to the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). METHODS: Using case-series methods, we compared 2159 cancers missed during CBEs with 3161 cancers detected during CBEs. Cancers missed during CBE were found by mammography and confirmed by biopsy or fine needle aspiration. RESULTS: After controling for cancer stage, tumor size, and breast symptoms at time of CBE, we found that patient age and CBE history were significantly associated with the likelihood of cancer detection. Compared to women 50-59, women 40-49 were more likely to have their cancer detected during CBE (odds ratio (OR) = 1.84, 95% confidence interval (95% CI) 1.47-2.29), while women 70 and older were less likely to have it detected (OR = 0.74, 95% CI: 0.55-1.00). Among women receiving their first NBCCEDP-funded CBE, 67.5% had their cancer detected by CBE. Among women receiving their second or third CBE, the values were 59.3 and 48.8%, respectively. In an adjusted logistic model, a significant inverse relationship was observed between number of prior CBEs and percent of cancers detected in the index CBE (OR = 0.79, 95% CI: 0.72-0.88). CONCLUSIONS: Among women diagnosed with breast cancer, older women and those who have had multiple CBEs were more likely to have their cancer missed during CBE.

Lactation mastitis: occurrence and medical management among 946 breastfeeding women in the United States.

In 1994-1998, the authors followed 946 breastfeeding women from Michigan and Nebraska for the first 3 months postpartum or until they stopped breastfeeding to describe mastitis incidence, mastitis treatment, and any associations between mastitis occurrence and hypothesized host characteristics and behaviors. Participants were interviewed by telephone at 3, 6, 9, and 12 weeks postpartum or until they ceased breastfeeding. A total of 9.5% reported provider-diagnosed lactation mastitis at least once during the 12-week period, with 64% diagnosed via telephone. After adjustment in a logistic regression model, history of mastitis with a previous child (odds ratio (OR) = 4.0, 95% confidence interval (CI): 2.64, 6.11), cracks and nipple sores in the same week as mastitis (OR = 3.4, 95% CI: 2.04, 5.51), using an antifungal nipple cream (presumably for nipple thrush) in the same 3-week interval as mastitis (OR = 3.4, 95% CI: 1.37, 8.54), and (for women with no prior mastitis history) using a manual breast pump (OR = 3.3, 95% CI: 1.92, 5.62) strongly predicted mastitis. Feeding fewer than 10 times per day was protective regardless of whether or not feeding frequency in the same week or the week before mastitis was included in the model (for the same week: 7-9 times: OR = 0.6, 95% CI: 0.41, 1.01; < or =6 times: OR = 0.4, 95% CI: 0.19, 0.82). Duration of feeding was not associated with mastitis risk.

Clinical breast examination: practical recommendations for optimizing performance and reporting.

Clinical breast examination (CBE) seeks to detect breast abnormalities or evaluate patient reports of symptoms to find palpable breast cancers at an earlier stage of progression. Treatment options for earlier-stage cancers are generally more numerous, include less toxic alternatives, and are usually more effective than treatments for later-stage cancers. For average-risk women aged 40 and younger, earlier detection of palpable tumors identified by CBE can lead to earlier therapy. After age 40, when mammography is recommended, CBE is regarded as an adjunct to mammography. Recent debate, however, has questioned the contributions of CBE to the detection of breast cancer in asymptomatic women and particularly to improved survival and reduced mortality rates. Clinicians remain widely divided about the level of evidence supporting CBE and their confidence in the examination. Yet, CBE is practiced extensively in the United States and continues to be recommended by many leading health organizations. It is in this context that this report provides a brief review of evidence for CBE's role in the earlier detection of breast cancer, highlights current practice issues, and presents recommendations that, when implemented, could contribute to greater standardization of the practice and reporting of CBE. These recommendations may also lead to improved evidence of the nature and extent of CBE's contribution to the earlier detection of breast cancer.