The call for change in breast cancer screening guidelines.
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Adult↗
Biomedical subjects
S Shapiro
Publications and source records attributed to S Shapiro.
The effects of early education intervention on maternal employment, public assistance, and health insurance: the infant health and development program.
OBJECTIVES: The purpose of this study was to test whether early education intervention influences maternal employment, education, fertility, and receipt of public assistance and health insurance. METHODS: The Infant Health and Development Program is a randomized trial of the efficacy of early education on the outcomes of 985 low-birthweight, premature children. Families in eight sites received either pediatric follow-up and referral (follow-up only group) or pediatric services plus early intervention services (intervention group) for the first 3 years of the child's life. RESULTS: Mothers in the intervention group were employed more months and returned to the work force earlier than those in the follow-up only group. Fertility and education were not associated with treatment. Mothers who had some college education received more months of public assistance in the intervention group compared with the follow-up only group. Mothers who were employed received more public assistance and public health insurance in the intervention group compared with the follow-up only group, when maternal employment was controlled. CONCLUSIONS: Findings are discussed in terms of the recent emphasis on two-generational programs directed to providing health, welfare, and child care services to young children and their families.
Adult↗
Health-related information postdischarge: telephone versus face-to-face interviewing.
This study had two primary aims: (1) to determine the usefulness of a telephone-administered health status questionnaire as an epidemiological survey instrument in groups at high risk for morbidity and disability; and (2) to evaluate the value of a telephone interview for making judgments about individual patient management. A structured telephone interview was compared with a face-to-face interview in 366 individuals with a stroke or an orthopedic condition up to 5 years after discharge from a rehabilitation hospital. Standardized assessments including the Barthel Index, the Zung Scale, the Reintegration to Normal Living (RNL) Index, and the Pfeiffer Short Portable Mental Status Questionnaire (SPMSQ), along with questions on health, medication use, and health events were administered using both modes. Comparability between the modes was also assessed according to the type of respondent, self, or proxy. On the Barthel Index, the Zung Scale, the RNL Index, and the SPMSQ the percentage of patients indicated as having no disability was similar between the modes. Proxies' responses were, in general, as consistent between the modes as patients' responses. The reliability coefficients indicated moderate to substantial agreement between the modes on the majority of indices and health-related questions. Discord between modes, when present, was greatest for individuals with moderate and severe disability, with less frequent reporting of disability on the telephone. This study supports the use of telephone interviews in determining the prevalence of disability in the community and supports the use of the telephone interview in the case finding process.
Adult↗
Predictive factors for post-poliomyelitis syndrome.
Post-poliomyelitis syndrome (PPS) is generally defined as a clinical syndrome of new weakness, fatigue, and pain in individuals who have previously recovered from acute paralytic poliomyelitis. The purpose of this study was to identify, through a case-control study design, factors that predict subsequent PPS in patients with prior paralytic poliomyelitis. Among patients attending a university-affiliated hospital post-polio clinic, "cases" were patients with new weakness and fatigue, and "controls" were patients without these complaints. A chart review of 353 patients identified 127 cases and 39 controls. Logistic regression modeling was used to calculate adjusted and unadjusted odds ratios. In univariate analyses, significant risk factors for PPS were a greater age at time of presentation to clinic (p = 0.01), a longer time since acute polio (p = 0.01), and more weakness at acute polio (p = 0.02). Other significant associated, but not necessarily causal factors were a recent weight gain (p = 0.005), muscle pain (p = 0.01) particularly that associated with exercise (p = 0.005), and joint pain (p = 0.04). Multivariate analyses revealed that a model containing age at presentation to clinic, severity of weakness at acute polio, muscle pain with exercise, recent weight gain, and joint pain best distinguished cases from controls. Age at acute polio, degree of recovery after polio, weakness at best point after polio, physical activity, and sex were not contributing factors. These findings suggest that the degree of initial motor unit involvement as measured by weakness at acute polio, and possibly the aging process and overuse are important in predicting PPS.
Adult↗
Detection of HIV proviral DNA on toothbrushes: a preliminary study.
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Adult↗
Number of pregnancies and risk of cardiovascular disease.
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Adult↗
Acute thrombocytopenic purpura in relation to the use of drugs.
The relation of acute thrombocytopenic purpura (TP) to the use of drugs was investigated in a case-control study conducted in eastern Massachusetts, Rhode Island, and the Philadelphia region; 62 cases over the age of 16 years with acute onset and with a rapid recovery were compared with 2,625 hospital controls. After control for confounding by multiple logistic regression, use of the following drugs in the week before the onset of symptoms was significantly associated: trimethoprim/sulfamethoxazole (relative risk [RR] estimate, 124), quinidine/quinine (101), dipyridamole (14), sulfonylureas (4.8), and salicylates (2.6). The overall annual incidence of acute TP was estimated to be 18 cases per million population. The excess risks for the associated drugs were estimated to be 38 cases per million users of trimethoprim/sulfamethoxazole per week, 26 per million for quinidine/quinine, 3.9 per million for dipyridamole, 1.2 per million for sulfonylureas, and 0.4 per million for salicylates. Associations with sulfonamides, quinidine/quinine, sulfonylureas, and salicylates have been previously reported, but the present study has provided the first quantitative measures of the risk. The association with dipyridamole was unexpected. In general, despite large RRs, the incidence rates attributable to the drugs at issue (excess risks) were low, suggesting that TP is not an important consideration in the use of the various drugs.
Acute Disease↗
Report of the International Workshop on Screening for Breast Cancer.
BACKGROUND: Over the past 30 years, eight major randomized controlled trials of breast cancer screening--with mammography and/or clinical breast examination--have been conducted. Results from several trials have been updated during the past year, and initial results of three other trials have been reported. PURPOSE: The National Cancer Institute held an International Workshop on Screening for Breast Cancer in February 1993 to conduct a thorough and objective critical review of the world's most recent clinical trial data on breast cancer screening, consider the new evidence, assess the current state of knowledge, and identify issues needing further research. METHODS: Investigators representing the eight randomized controlled trials of breast cancer screening in women aged 40-74 presented published and unpublished data. Evidence relating to the effectiveness of breast cancer screening in different age groups, especially women aged 40-49, was presented. RESULTS: For women aged 40-49, randomized controlled trials consistently demonstrated no benefit from screening in the first 5-7 years after study entry. A meta-analysis of six trials found a relative risk of 1.08 (95% confidence interval = 0.85-1.39) after 7 years' follow-up. After 10-12 years of follow-up, none of four trials have found a statistically significant benefit in mortality; a combined analysis of Swedish studies showed a statistically insignificant 13% decrease in mortality at 12 years. Only one trial (Health Insurance Plan) has data beyond 12 years of follow-up, and results show a 25% decrease in mortality at 10-18 years. Statistical significance of this result is disputed, however. In women aged 50-69, all studies show mortality reductions; three of four studies show reductions of about 30% at 10-12 years after study entry. Results from two of these trials were statistically significant. Too few women over age 70 have been included in studies for adequate analysis. CONCLUSIONS: For women aged 40-49, randomized controlled trials of breast cancer screening show no benefit 5-7 years after entry. At 10-12 years, benefit is uncertain and, if present, marginal; thereafter, it is unknown. For women aged 50-69, screening reduces breast cancer mortality by about a third. Currently available data for women age 70 or older are inadequate to judge the effectiveness of screening. IMPLICATIONS: Randomized trials have provided stronger scientific evidence regarding the effectiveness of screening for breast cancer than for any other cancer. However, much still needs to be learned. Periodic gatherings of scientists in the field should speed the process.
Adult↗
Periconceptional folic acid exposure and risk of occurrent neural tube defects.
OBJECTIVES: A recent controlled trial has established that use of a 4-mg folic acid supplement before and during early pregnancy reduces the risk of recurrent neural tube defects (NTDs) by 72%. The present study was designed to determine whether folic acid also reduces the risk of first (occurrent) NTDs. DESIGN: Case-control study. SETTING: Tertiary and birth hospitals in metropolitan areas of Boston, Mass, Philadelphia, Pa, and Toronto, Ontario. PARTICIPANTS: Mothers of 436 occurrent cases with NTDs and mothers of 2615 controls with other major malformations. MAIN OUTCOME MEASURES: The prevalence of use of multivitamins containing folic acid was compared between mothers of cases and controls. RESULTS: The mothers of 17% of cases and 3% of controls reported knowledge of the folic acid-NTD hypothesis and were excluded from further analysis. For daily use of a multivitamins containing folic acid in the periconceptional period (28 days before through 28 days after the last menstrual period), the relative risk (RR) (and 95% confidence interval) was 0.4 (0.2 to 0.6). The most commonly used dose of folic acid was 0.4 mg, and the RR estimate was 0.3 (95% confidence interval, 0.1 to 0.6). For dietary folate, there was a dose-related decline in risk according to the quintile of intake (P for trend = .02). CONCLUSION: These findings suggest that daily periconceptional intake of 0.4 mg of folic acid (the dose most commonly contained in over-the-counter multivitamin preparations) reduces the risk of occurrent NTDs by approximately 60%. A relatively high dietary intake of folate may also reduce the risk.
Case-Control Studies↗
A case-control study of baldness in relation to myocardial infarction in men.
OBJECTIVE: To examine the relationship between male pattern baldness and the risk of myocardial infarction in men under the age of 55 years. DESIGN AND PARTICIPANTS: A hospital-based, case-control study was conducted in eastern Massachusetts and Rhode Island. Cases were men admitted to a hospital for a first nonfatal myocardial infarction (n = 665); controls were men admitted to the same hospitals with noncardiac diagnoses (n = 772). Extent of baldness was assessed using the 12-point modified Hamilton Baldness Scale; other information was obtained by personal interview. Among the controls, the prevalence of any baldness was 34%, while the prevalence of baldness involving the vertex scalp was 23%. RESULTS: After allowing for age, the relative risk estimate for frontal baldness compared with no hair loss was 0.9 (95% confidence interval, 0.6 to 1.3), for baldness involving the vertex scalp it was 1.4 (95% confidence interval, 1.2 to 1.9). Risk of myocardial infarction increased as the degree of vertex baldness increased (P < .01); for severe vertex baldness the relative risk was 3.4 (95% confidence interval, 1.7 to 7.0). The relationship between vertex baldness and myocardial infarction was consistent within strata defined by age and other risk factors for coronary artery disease. CONCLUSION: These data support the hypothesis that male pattern baldness involving the vertex scalp is associated with coronary artery disease in men under the age of 55 years.
Adult↗
A case-control study of myocardial infarction in relation to use of estrogen supplements.
Observational epidemiologic studies suggest that the incidence of cardiovascular disease is reduced by about 50% in users of unopposed estrogens, but the reduction may have been overestimated because of a greater tendency for women at lower risk to use estrogens. To minimize bias due to such behavior, the authors conducted a case-control study of first myocardial infarction among Massachusetts women aged 45-69 years during 1986-1990, in which each of 858 cases was age-matched with a control from the same geographic area, and important correlates of estrogen use and myocardial infarction were controlled by conditional logistic regression. The estimated relative risk was 0.9 for ever use of unopposed estrogen (95% confidence interval 0.7-1.2); the estimate decreased with increasing duration of use to 0.6 for 5 or more years of use (p for trend = 0.08). The association with long-term use was stronger for recent use (p for trend < 0.05) than for past use (p for trend = 0.86). There were insufficient data to evaluate estrogens taken together with progestins. The results suggest that unopposed estrogen use may reduce the risk of first myocardial infarction, that the reduction is related to the duration and recency of use, and that it may be smaller than previously believed. Despite efforts to control confounding, observational studies cannot rule out the possibility that a tendency for women at lower risk for myocardial infarction to use estrogens has contributed to the reduced risk in estrogen users, and randomized trials are needed.
Aged↗
Risk of agranulocytosis and aplastic anemia in relation to history of infectious mononucleosis: a report from the international agranulocytosis and aplastic anemia study.
The general objective of this study was to evaluate the risks of agranulocytosis and aplastic anemia in relation to drug use. Other potential risk factors, including history of infectious mononucleosis, were also evaluated. In an international population-based case-control study, cases of agranulocytosis and aplastic anemia and controls, who were patients with selected diagnoses, were identified from the same hospitals. Information on drug use was obtained in a structured interview. Limited information on environmental exposures and on selected items of medical history, including infectious mononucleosis, was also recorded. The possible effects of these factors on the risk of the two blood dyscrasias were evaluated. Relative risks were estimated by stratified analysis and by multiple logistic regression. Among 319 cases of agranulocytosis, 12 patients (4%) gave a history of infectious mononucleosis at least 1 year previously; among 2180 controls the corresponding number was 11 (0.5%) (multivariate relative risk estimate, 6.2; 95% confidence interval, 2.3-17). A nonsignificant elevation in the relative risk was observed for aplastic anemia. The data suggest that infectious mononucleosis may confer a long-term increase in the risk of agranulocytosis. However, the association was an unexpected one, identified in the course of multiple comparisons, and it must be independently confirmed.
Adolescent↗
Nonsteroidal anti-inflammatory drug use in relation to major upper gastrointestinal bleeding.
In a study in the United States, Sweden, and Hungary, 335 cases of gastric bleeding without predisposing factors were compared with 670 control subjects, and 239 cases of duodenal bleeding were compared with 489 control subjects. For aspirin taken at least every other day during the week before the onset of bleeding (regular use), the relative risk of gastric bleeding was 4.4 (95% confidence interval [CI], 2.9 to 6.7); for occasional use, it was 3.3 (95% CI, 2.1 to 5.0). For ibuprofen, the corresponding estimates were 1.0 (95% CI, 0.4 to 2.6) and 1.1 (95% CI, 0.5 to 2.4). For naproxen, the estimate for regular use was 4.0 (95% CI, 1.5 to 11). The estimates for any use of piroxicam (crude estimate), indomethacin, and diclofenac during the week before onset were 18 (95% CI, 4.1 to 83), 1.6 (95% CI, 0.4 to 5.9), and 0.9 (95% CI, 0.2 to 4.2), respectively. The corresponding relative risks of duodenal bleeding were 7.1 (95% CI, 4.2 to 12) and 2.2 (95% CI, 1.3 to 3.7) for the regular and occasional use of aspirin, 2.4 (95% CI, 0.5 to 11) and 0.8 (95% CI, 0.3 to 2.0) for ibuprofen, 12 (95% CI, 2.8 to 54) and 9.9 (95% CI, 2.3 to 44) for naproxen, 17 (95% CI, 3.6 to 79) for any use of piroxicam (crude estimate), and 1.7 (95% CI, 0.2 to 14) for any use of indomethacin. There was a significant trend in the risk of gastric bleeding with increasing dose of regular aspirin use (p = 0.002). The relative risk estimates for the regular use of 325 mg or less were significantly elevated for both gastric and duodenal bleeding at 3.1 and 6.4, respectively.
Aged↗
A role for complement as the major opsonin in the sequestration of erythrocytes from elderly and young donors.
Erythrocytes from elderly donors (> 70 years), but not young donors (18-35 years), are shown to undergo sequestration in an in vitro erythrophagocytosis assay. Comparable levels of sequestration are observed for high density erythrocytes from young individuals and both low density and high density erythrocytes from elderly individuals. These cells, which are susceptible to phagocytosis with no additional treatment are collectively termed 'in situ aged' erythrocytes. We present evidence for the involvement of complement in the sequestration of 'in situ aged' erythrocytes and correlate levels of complement bound to 'in situ aged' erythrocytes from young and elderly donors with levels of phagocytosis. We also demonstrate that the in vitro sequestration of erythrocytes from elderly donors can be inhibited by beta-galactosyl sugars and arginine-glycine-aspartic acid (RGD) but not by mannose nor by Protein-G, a specific inhibitor of Fc-gamma mediated phagocytosis. These experiments show that IgG is not the major opsonin in the sequestration of red cells from elderly donors. In support of the role of complement rather than IgG as the major opsonin in red cell sequestration, we further demonstrate that C'3 bearing immune complexes block in vitro sequestration of erythrocytes from elderly donors. This competition is not dependent upon the isotype of the immunoglobulin (IgM or IgG) in the complex but rather on the presence of active complement.
Adolescent↗
Exposure to complement-bearing immune complexes enhances the in vitro sequestration of erythrocytes from young but not elderly donors.
Complement and immunoglobulin have each been claimed to be the major opsonins responsible for sequestration of the effete erythrocyte. Binding of immune complexes to the erythrocyte via CR1 (CD35) provides a model for studying the effects of increments in membrane-bound complement and immunoglobulin on the sequestration of the erythrocyte ('innocent bystander' sequestration). It is possible that C3b-bearing immune complexes (IC-C3b) bound to erythrocyte CR1 contribute to the levels of immunoglobulin and complement fragments detectable on the human erythrocyte. We have, therefore, compared the capacity of erythrocytes from young and elderly donors to bind IC-C3b and the effect of this binding on in vitro sequestration. Erythrocytes from young donors exposed to IC-C3b bind these complexes, as attested by an increment in membrane-bound C3, and undergo 'innocent bystander' sequestration. However, when density-separated erythrocytes are so exposed, it is only the low density (young) erythrocytes from young donors which are susceptible to 'innocent bystander' sequestration. High density (old) erythrocytes from young donors and all erythrocytes from elderly donors show initially high in vitro sequestration and are resistant to the 'innocent bystander' effect. (Those erythrocytes which show initially high in vitro sequestration are referred to collectively as 'in situ aged' erythrocytes.) There is a great similarity between the mechanisms of sequestration of 'in situ aged' and 'innocent bystander' erythrocytes in that they are both inhibited by the integrin binding peptide arginine-glycine-aspartic acid (RGD) and the beta-galactosyl sugar N-acetyl-galactosamine, and unaffected by the Fc-gamma binding protein, Protein-G. Complement is the major opsonin in 'innocent bystander' sequestration since this sequestration occurs whether the isotype of the antibody in the immune complex is IgM or IgG, and Protein-G, which inhibits IgG-dependent erythrophagocytosis, has no effect on 'innocent bystander' sequestration. The present studies demonstrate that in vitro sequestration of 'in situ aged' erythrocytes is similar to complement-dependent 'innocent bystander' sequestration, thus supporting the contention that complement recognition is cardinal in sequestration of 'in situ aged' erythrocytes.
Adolescent↗
Cauda equina syndrome secondary to lumbar disc herniation.
Between 1986 and 1991, 14 patients (nine men and five women), ranging in age from 22 to 67 years (mean, 43 yr), presented with acute cauda equina syndrome from a herniated lumbar disc. All presented with bilateral sciatica and leg weakness; 13 (93%) had urine or stool incontinence, or both. At presentation, all were emergently studied with myelogram/computed tomographic or magnetic resonance imaging. Nine (64%) had large or massive herniations, including two with tethered cords. Five had smaller herniations superimposed on preexisting stenosis. Three had previous surgery; two-thirds had a herniation at a different level. The levels of the herniations were L4-L5 in nine patients, L5-S1 in three patients, and L3-L4 in two patients. The time to surgery ranged from less than 24 hours to more than 30 days; 11 patients underwent surgery within 5 days of onset. Follow-up ranged from 6 months to 5 years (mean, 3.3 yr). Postoperatively, six patients (44%) were normal, four (28%) had chronic pain and numbness, and four (28%) had persistent incontinence and weakness. All the patients were ambulatory. There were no operative deaths, and only one patient had a wound infection. Of the 10 patients who had no incontinence after surgery, 7 underwent surgery within 48 hours of onset. Of the four patients with persistent incontinence, all underwent surgery after 48 hours. Previous reports and our experience demonstrate the following most common characteristics for this presentation: 1) male sex; 2) L4-L5 herniations; and 3) onset in the 4th decade.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Workplace smoking policies in New Jersey businesses.
A New Jersey law enacted in 1985 requires smoking policies for work sites with 50 or more employees. In 1988, we surveyed a sample of New Jersey businesses to determine their smoking policies. Eighty-three percent of respondents with 50 or more employees reported implementing restrictive smoking policies. Of respondents with 2 to 49 employees, 35% had implemented policies. Our findings identify some of the factors other than a legal mandate that lead employers to restrict smoking in the workplace.
Commerce↗
Oral inflammatory disease and the toothbrush.
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Adolescent↗