Hormonal risk factors and testicular cancer

The cause of testicular cancer is not known and recent hypotheses have suggested an altered hormonal milieu may increase the risk of testis cancer. This study examined modulation of testicular cancer risk by hormonal factors, specifically: environmental xenoestrogens (e.g. organochlorines), prenatal maternal estrogens, testosterone indices (age at puberty, severe adolescent acne, self-reported balding), sedentary lifestyle and dietary consumption of fats and phytoestrogens.^ A hospital based friend matched case-control study was conducted at the University of Texas M. D. Anderson Cancer Center in Houston, Texas, between January 1990 and October 1996. Cases had a first primary testis tumor diagnosed between age 18 to 50 years and resided in Texas, Louisiana, Oklahoma or Arkansas.^ Cases and friend controls completed a mail questionnaire and case/control mothers were contacted by phone regarding pregnancy related variables. The study population comprised 187 cases, 148 controls, 147 case mothers and 86 control mothers. Odds ratios were virtually identical whether the match was retained or dissolved, thus the analyses were conducted using unconditional logistic regression.^ Cryptorchidism was a strong risk factor for testis cancer with an age-adjusted odds ratio (OR) of 7.7 (95% confidence interval (CI): 2.3-26.3). In a final model (adjusted for age, education, and cryptorchidism), history of severe adolescent acne and self-reported balding were both significantly protective, as hypothesized. For acne (yes vs. no) the OR was 0.5 (CI: 0.3-1.0) and for balding (yes vs. no) the OR was 0.6 (CI: 0.3-1.0). Marijuana smoking was a risk factor among heavy, regular users (17 times/week, OR = 2.4; CI: 0.9-6.4) and higher saturated fat intake increased testis cancer risk (saturated fat intake $>$ 15.2 grams/day vs. $<$ 11.8 grams/day, OR = 3.3; CI: 1.5-7.1). Early puberty, xenoestrogen exposure, elevated maternal estrogen levels, sedentary lifestyle and dietary phytoestrogen intake were not associated with risk of testicular cancer.^ In conclusion, testicular cancer may be associated with endogenous androgen metabolism although environmental estrogen exposure can not be ruled out. Further research is needed to understand the underlying hormonal mechanisms and possible dietary influences. ^

Attitudes, stress and use of force in selected areas of Texas law enforcement

This research aimed to explore the extent to which police use of force was related to attitudes towards violence, agency type, and racism. Previous studies have found a culture of honor in the psychology of violence in the Southern United States. Were similar attitudes measurable among Texas professional line officers? Are there predictors of use of force?^ A self reported anonymous survey was administered to Texas patrol officers in the cities of Austin and Houston, and the Counties of Harris and Travis. A total of seventy-four questionnaires were used in the statistical analyses. Scales were developed measuring use of force, attitudes towards violence, and feelings on racism. Their relationship was examined.^ A regression model shows a strong and significant relationship between the officers' attitudes towards violence and the self-reported use of force. Further, agency type, municipal versus sheriff, also predicts use of force. Attitudes regarding race or racism, as measured by this study, were not predictive of use of force. ^

The transformation of a health care system: An ecology perspective

Beginning in the early 1980s, the health care system experienced momentous realignments. Fundamental changes in structures of traditional health care organizations, shifts in authority and relationships of professionals and institutions, and the increasing influence of managed care contributed to a relatively stable industry entering into a state of turbulence. The dynamics of these changes are recurring themes in the health services literature. The purpose of this dissertation was to examine the content of this literature over a defined time period and within the perspective of a theory of organizational change. ^ Using a theoretical framework based upon the organizational theory known as Organizational Ecology, secondary data from the period between 1983 and 1994 was reviewed. Analysis of the literature identified through a defined search methodology was focused upon determining the manner in which the literature characterized changes that were described. Using a model constructed from fundamentals of Organizational Ecology with which to structure an assessment of content, literature was summarized for the manner and extent of change in specific organizational forms and for the changes in emphasis by the environmental dynamics directing changes in the population of organizations. Although it was not the intent of the analysis to substantiate causal relationships between environmental resources selected as the determinants of organizational change and the observed changes in organizational forms, the structured review of content of the literature established a strong basis for inferring such a relationship. ^ The results of the integrative review of the literature and the power of the appraisal achieved through the theoretical framework constructed for the analysis indicate that there is considerable value in such an approach. An historical perspective on changes which have transformed the health care system developed within a defined organizational theory provide a unique insight into these changes and indicate the need for further development of such an analytical model. ^

Predictors of participation in genetic testing for hereditary breast and ovarian cancer

Up to 10% of all breast and ovarian cancers are attributable to mutations in cancer susceptibility genes. Clinical genetic testing for deleterious gene mutations that predispose to hereditary breast and ovarian cancer (HBOC) syndrome is available. Mutation carriers may benefit from following high-risk guidelines for cancer prevention and early detection; however, few studies have reported the uptake of clinical genetic testing for HBOC. This study identified predictors of HBOC genetic testing uptake among a case series of 268 women who underwent genetic counseling at The University of Texas M. D. Anderson Cancer Center from October, 1996, through July, 2000. Women completed a baseline questionnaire that measured psychosocial and demographic variables. Additional medical characteristics were obtained from the medical charts. Logistic regression modeling identified predictors of participation in HBOC genetic testing. Psychological variables were hypothesized to be the strongest predictors of testing uptake—in particular, one's readiness (intention) to have testing. Testing uptake among all women in this study was 37% (n = 99). Contrary to the hypotheses, one's actual risk of carrying a BRCA1 or BRCA2 gene mutation was the strongest predictor of testing participation (OR = 15.37, CI = 5.15, 45.86). Other predictors included religious background, greater readiness to have testing, knowledge about HBOC and genetic testing, not having female children, and adherence to breast self-exam. Among the subgroup of women who were at ≥10% risk of carrying a mutation, 51% (n = 90) had genetic testing. Consistent with the hypotheses, predictors of testing participation in the high-risk subgroup included greater readiness to have testing, knowledge, and greater self-efficacy regarding one's ability to cope with test results. Women with CES-D scores ≥16, indicating the presence of depressive symptoms, were less likely to have genetic testing. Results indicate that among women with a wide range of risk for HBOC, actual risk of carrying an HBOC-predisposing mutation may be the strongest predictor of their decision to have genetic testing. Psychological variables (e.g., distress and self-efficacy) may influence testing participation only among women at highest risk of carrying a mutation, for whom genetic testing is most likely to be informative. ^

Determinants of quality of advanced cancer care in Latin America. A look at five countries: Argentina, Brazil, Cuba, Mexico and Peru

The World Health Organization reports that nearly half a million people died of cancer in Latin America in 2001. As a growing public health problem, cancer is now either the first or second leading cause of death among adults in most Latin American nations. Despite these trends, information on the quality of care people with advanced cancer in Latin America receive has been limited. This study assessed the quality of advanced cancer care in diverse Latin American countries and institutions by surveying cancer care providers from: Argentina; Brazil; Cuba; Mexico; and Peru. This study also identified the most salient factors that influence the quality of this care at the national and institutional levels and compared these factors across countries. This study was based on the secondary analyses of data collected by the University of Texas M. D. Anderson's WHO/PAHO Collaborating Center in Supportive Cancer Care from March 2000 to November 2002. The sample for this survey was a convenience sample of physicians and nurses who treat cancer patients in these regions. Strategies for the dissemination of this survey included: mass mailings; distribution at professional meetings/conferences; collaboration with regional institutions, professional organizations and PAHO; and the posting of online surveys. The strongest predictor of providers' assessments of the quality of advanced cancer care was their ratings of access to care. This major finding reflects a shared equitable notion of quality care among providers from diverse countries and medical institutions that is highly interrelated with providing accessible care to those with advanced cancer. Higher ratings of the affordability of care, an increased reported availability of end-of-life services and opioid analgesics, practicing in either a private hospital or specialized cancer center, and practicing in Cuba were also associated with higher provider ratings of the quality of advanced cancer care. The findings of this study contribute towards the much needed body of knowledge that may guide the formulation of policies and interventions aimed at improving the care for people with advanced cancer in Latin America. ^

Chronic volatile substance abuse among the adult Kickapoo traditional tribe of Texas: Disease and disability profiles, neuropsychosocial consequences, and social implications for treatment

The purpose of this study, based on secondary data from attendees at a substance abuse clinic for the Kickapoo Healing Grounds in Eagle Pass, Texas, is two fold: (1) to elucidate neuro-behavioral performance of volatile substance abusers in the Kickapoo tribe and (2) to determine factors associated with their treatment completion and rehabilitation as measured by their employment at follow-up. Volatile substance abuse (VSA) is associated with a host of neurological manifestations, and secondary prevention or clinical treatment and rehabilitation remains the mainstay of control efforts. Very little is known about VSA in general, and especially among Native American populations. It is anticipated that the results will help determine and assist other tribes and non-tribal substance abuse centers with treatment planning for volatile substance abusers among Native American populations. ^

Logistic regression models for ordinal response: A study of self-efficacy in colorectal cancer screening

The ordinal logistic regression models are used to analyze the dependant variable with multiple outcomes that can be ranked, but have been underutilized. In this study, we describe four logistic regression models for analyzing the ordinal response variable. ^ In this methodological study, the four regression models are proposed. The first model uses the multinomial logistic model. The second is adjacent-category logit model. The third is the proportional odds model and the fourth model is the continuation-ratio model. We illustrate and compare the fit of these models using data from the survey designed by the University of Texas, School of Public Health research project PCCaSO (Promoting Colon Cancer Screening in people 50 and Over), to study the patient’s confidence in the completion colorectal cancer screening (CRCS). ^ The purpose of this study is two fold: first, to provide a synthesized review of models for analyzing data with ordinal response, and second, to evaluate their usefulness in epidemiological research, with particular emphasis on model formulation, interpretation of model coefficients, and their implications. Four ordinal logistic models that are used in this study include (1) Multinomial logistic model, (2) Adjacent-category logistic model [9], (3) Continuation-ratio logistic model [10], (4) Proportional logistic model [11]. We recommend that the analyst performs (1) goodness-of-fit tests, (2) sensitivity analysis by fitting and comparing different models.^

Restoring mortality as a measure of community health

In the last several decades traditional community health indicators have become ambiguous and lost some of their relevance. During this same period national and international health agencies adopted new expanded definitions of Health that include underlying social determinants. These two influences are responsible for a proliferation of new health indicators and many are constructed from a combination of older mortality measures and available information on morbidity. Problems inherent in attempting to combine these sources of information have produced a situation where some indicators are difficult to calculate at the national level and may not function at all for small communities. What is needed is a relevant measure of the burden of ill health appropriate for smaller populations that is accessible to local health planners. ^ Death records are still the best available population health information. In Europe the burden of health problems is often portrayed using 'premature' death. Health agencies in the United States have moved to adopt Years of Potential Life Lost. Both these regions are also developing systems of 'avoidable' or 'preventable' death as health indicators. This research proposes a method combining these methodologies to produce a relevant indicator portraying the burden of ill health in communities. ^

A case-control study of tea/coffee consumption and lung cancer risk

Background. Despite the increasing attention to the effects of dietary factors on lung cancer risk, epidemiological research on the role of black/green tea and coffee intake and lung cancer risk is scarce. The purpose of this study was to explore the following three hypotheses: (1) the preventive (protective) effect from lung cancer is higher in green tea than in black tea and coffee consumption. (2) brewed tea (either black or green) daily drinkers have lower odds of lung cancer than non-drinkers of brewed tea (3) regular black and green tea have more preventive effect against lung cancer than decaffeinated teas due to the synergistic effect of caffeine and other tea components. ^ Methods. Data on 1,088 lung cancer cases and 1,127 controls from an ongoing epidemiological study of lung cancer by the Department of Epidemiology of the University of Texas M.D. Anderson Cancer were analyzed. Multiple logistic regressions were performed for testing associations between frequency of specific types of tea/coffee consumption and the risk of lung cancer. ^ Results. We observed that more than a cup a week of green tea and decaffeinated black tea were significantly associated with reduced odds of lung cancer by 64% for green tea (adjusted OR = 0.44; 95% CI = 0.31–0.64), 36% for decaffeinated black tea (OR = 0.64; 95% CI = 0.45–0.90), when compared with non-drinkers and those who drank less than a cup a week. On the other hand, increasing intake of regular coffee (more than 3 cups a day) was associated with a 30% higher odds ratio of lung cancer (OR = 1.30; 95% CI = 1.01–1.09). No association was found between regular black tea, decaffeinated coffee consumption and the odds ratio of lung cancer. However, when drinkers of other tea/coffee beverages were excluded from each model in order to explore the independent effect of each type of tea/coffee, green tea and decaffeinated black tea-lung cancer associations remained but no association was observed for drinkers of regular coffee. ^ Conclusion. We report the chemopreventive effects of more than a cup a week of green tea and decaffeinated black tea on lung cancer. ^

Analysis of Mycobacterium tuberculosis in the state of Texas for rifampin resistance using molecular beacons

Mycobacterium tuberculosis, a bacillus known to cause disease in humans since ancient times, is the etiological agent of tuberculosis (TB). The infection is primarily pulmonary, although other organs may also be affected. The prevalence of pulmonary TB disease in the US is highest along the US-Mexico border, and of the four US states bordering Mexico, Texas had the second highest percentage of cases of TB disease among Mexico-born individuals in 1999 (CDC, 2001). Between the years of 1993 and 1998, the prevalence of drug-resistant (DR) TB was 9.1% among Mexican-born individuals and 4.4% among US-born individuals (CDC, 2001). In the same time period, the prevalence of multi-drug resistant (MDR) TB was 1.4% among Mexican-born individuals and 0.6% among US-born individuals (CDC, 2001). There is a renewed urgency in the quest for faster and more effective screening, diagnosis, and treatment methods for TB due to the resurgence of tuberculosis in the US during the mid-1980s and early 1990s (CDC, 2007a), and the emergence of drug-resistant, multidrug-resistant, and extremely drug-resistant tuberculosis worldwide. Failure to identify DR and MDR-TB quickly leads to poorer treatment outcomes (CDC, 2007b). The recent rise in TB/HIV comorbidity further complicates TB control efforts. The gold standard for identification of DR-TB requires mycobacterial growth in culture, a technique taking up to three weeks, during which time DR/MDR-TB individuals harboring resistant organisms may be receiving inappropriate treatment. The goal of this study was to determine the sensitivity and specificity of real-time quantitative polymerase chain reaction (qPCR) using molecular beacons in the Texas population. qPCR using molecular beacons is a novel approach to detect mycobacterial mutations conferring drug resistance. This technique is time-efficient and has been shown to have high sensitivity and specificity in several populations worldwide. Rifampin (RIF) susceptibility was chosen as the test parameter because strains of M. tuberculosis which are resistant to RIF are likely to also be MDR. Due to its status as a point of entry for many immigrants into the US, control efforts against TB and drug-resistant TB in Texas is a vital component of prevention efforts in the US as a whole. We show that qPCR using molecular beacons has high sensitivity and specificity when compared with culture (94% and 87%, respectively) and DNA sequencing (90% and 96%, respectively). We also used receiver operator curve analysis to calculate cutoff values for the objective determination of results obtained by qPCR using molecular beacons. ^

Hormonal exposure and risk of pancreatic cancer in the United States

Background. In the United States, the incidence of pancreatic cancer has increased; more than 37,000 new cases of pancreatic cancer were diagnosed in the year 2007. Overall, the five-year survival rate is about 5% and pancreatic cancer ranks the fourth leading cause of cancer-related mortality among men and women. Despite the observed progress in cancer diagnosis and treatment, pancreatic cancer remains an unresolved significant public health problem in the United States. Familial pancreatic cancer has been confirmed to be responsible for approximately 10% of pancreatic cancer cases. However, 90% are still without known inherited predisposition. Until now, the role of oral contraceptive pills (OCPs) and hormonal replacement therapy (HRT) among women with pancreatic cancer remain unclear. We examined the association of exogenous hormonal uses in US women with risk of pancreatic cancer. ^ Methods. This was an active hospital-based case-control study which is conducted at the department of gastrointestinal medical oncology in The University of Texas M.D. Anderson Cancer Center. Between January 2005 and December 2007, a total of 287 women with pathologically confirmed pancreatic cancer (cases) and 287 healthy women (controls) were included in this investigation. Both cases and controls were frequency matched by age and race. Information about the use of hormonal contraceptives and hormonal replacement therapy (HRT) preparations as well as information about several risk factors of pancreatic cancer were collected by personal interview. Univariate and multivariate analyses were performed in this study to analyze the data. ^ Results. We found a statistical significant protective effect for use of exogenous hormone preparations on pancreatic cancer development (adjusted odds ratio [AOR], 0.4; 95% confidence interval [CI], 0.2–0.8). In addition, a 40% reduction in pancreatic cancer risk was observed among women who ever used any of the contraceptive methods including oral contraceptive pills (AOR, 6; 95% CI, 0.4–0.9). ^ Conclusions. Consistent with previous studies, the use of exogenous hormone preparations including oral contraceptive pills may confers a protective effect for pancreatic cancer development. More studies are warranted to explore for the underlying mechanism of such protection.^

A qualitative assessment of the impact of Texas policy changes on nutrition in child care centers in Travis County, Texas

Background. Over half of children in the United States under age five spend 32 hours a week in child care, facilities, where they consume approximately 33-50% of their food intake. ^ Objectives. The aim of this research was to identify the effects of state nutrition policies on provision of food in child care centers. ^ Subjects. Eleven directors or their designee from ten randomly selected licensed child care centers in Travis County, Texas were interviewed. Centers included both nonprofit and for-profit centers, with enrollments ranging from 19 to 82. ^ Methods. Centers were selected using a web-based list of licensed child care providers in the Austin area. One-on-one interviews were conducted in person with center directors using a standard set of questions developed from previous pilot work. Interview items included demographic data, questions about state policies regarding provision of foods in centers, effects of policies on child care center budgets and foods offered, and changes in the provision of food. All interviews were audiotaped and transcribed, and themes were identified using standard qualitative techniques. ^ Results. Four of the centers provided both meals and snacks, four provided snacks only, and two did not provide any food. Directors of centers that provided food were more likely to report adherence to the Minimum Standards than directors of centers that did not. In general, center directors reported that the regulations were loosely enforced. In contrast, center directors were more concerned about a local city-county regulation that required food permits and new standards for kitchens. Most of these local regulations were cost prohibitive and, as a result, centers had changed the types of foods provided, which included providing less fresh produce and more prepackaged items. Although implementation of local regulations had reduced provision of fruits and vegetables to children, no adjustments were reported for allocation of resources, tuition costs or care of the children. ^ Conclusions. Qualitative data from a small sample of child care directors indicate that the implementation and accountability of food- and nutrition-related guidelines for centers is sporadic, uncoordinated, and can have unforeseen effects on the provision of food. A quantitative survey and dietary assessment methods should be conducted to verify these findings in a larger and more representative sample.^

Examination of the influence of behavioral, normative and control beliefs on the adherence to a prescribed renal diet among elderly populations with chronic to end-stage renal disease

The 1999-2004 prevalence of chronic kidney disease in adults 20 year or older (15.5 million) is an estimated 7.69%. The risk of developing CKD is exacerbated by diabetes, hypertension and/or a family history of kidney disease. African Americans, Hispanics, Pacific Islanders, Native Americans, and the elderly are more susceptible to higher incidence of CKD. The challenges of aging coupled with co-morbidities such as kidney disease raises the potential for malnutrition among elderly (for the purpose of this study 55 years or older) populations. Lack of adherence to prescribed nutrition guidelines specific to renal failure jeopardizes body homeostasis and increases the likelihood of future morbidity and resultant mortality. The relationship and synergy that exists between diet and disease is evident. Clinical experience with renal patients has indicated the importance of adherence to diet therapy specific to kidney disease. Extension investigation of diet adherence among endstage renal disease patients revealed a sizeable dearth in the current literature. This thesis study was undertaken to help reduce that void. The study design is qualitative and descriptive. Support, cooperation, and collaboration were provided by the University of Texas Nephrology Department, University of Texas Physicians, and DaVita Dialysis Centers. Approximately 105 male and female chronic to end-stage kidney disease patients were approached to participate in elicitation interviews in dialysis treatment facilities regarding their present diet beliefs and practices. Eighty-five were recruited and agreed to participate. Inclusion criteria required individuals to be between 35-90 years of age; capable of completing a 5-10 minute interview; and English speaking. Each kidney patient was asked seven (7) non-leading questions developed from the constructs of the Theory of Planned Behavior. The study presents a descriptive comparison of behavioral, normative, and control beliefs that influence adherence to renal diets by age, race, and gender. The study successfully concluded that behavioral, normative, and control beliefs of chronic to end-stage renal patients promoted execution and adherence to prescribed nutrition. This study provides valuable information for dietitians, technicians, nurses, and physicians to assess patient compliance toward prescribed nutrition and the means to support or improve that performance. ^

School screening for tuberculosis in high risk areas of Texas

Screening for latent tuberculosis infection (LTBI) is an integral component of an effective tuberculosis control strategy, but one that is often relegated to the lowest priority. In a state with higher than national average rates of tuberculosis, due consideration should be given to LTBI screening. Recent large scale contact investigations in the middle school of Del Rio, Texas, raised questions about the status of school screening for LTBI. An evidence based approach was used to evaluate school screening in high risk areas of Texas. A review of the literature revealed that the current recommendations for LTBI screening in children is based on administration of a risk factor questionnaire that should be based on the four main risk factors for LTBI in children that have been identified. Six representative areas in Texas were identified for evaluation of the occurrence of contact investigations in schools for the period of 2006 to 2009 and any use of school screening programs. Of the five reporting areas that responded, only one utilized a school screening program; this reporting area had the lowest percentage of contact investigations occurring in schools. Contact investigations were most common in middle schools and least common in elementary schools. In metropolitan areas, colleges represented up to 42.9% of contact investigations. The number of contact investigations has increased from 2006 to 2008. This report represents a small sample, and further research into the frequency, distribution and risk for contact investigations in schools and the efficacy of screening programs should be done. ^

Statistical and methodological challenges for disaster preparedness and medical needs assessment in Rio Grande Valley of Texas

In recent years, disaster preparedness through assessment of medical and special needs persons (MSNP) has taken a center place in public eye in effect of frequent natural disasters such as hurricanes, storm surge or tsunami due to climate change and increased human activity on our planet. Statistical methods complex survey design and analysis have equally gained significance as a consequence. However, there exist many challenges still, to infer such assessments over the target population for policy level advocacy and implementation. ^ Objective. This study discusses the use of some of the statistical methods for disaster preparedness and medical needs assessment to facilitate local and state governments for its policy level decision making and logistic support to avoid any loss of life and property in future calamities. ^ Methods. In order to obtain precise and unbiased estimates for Medical Special Needs Persons (MSNP) and disaster preparedness for evacuation in Rio Grande Valley (RGV) of Texas, a stratified and cluster-randomized multi-stage sampling design was implemented. US School of Public Health, Brownsville surveyed 3088 households in three counties namely Cameron, Hidalgo, and Willacy. Multiple statistical methods were implemented and estimates were obtained taking into count probability of selection and clustering effects. Statistical methods for data analysis discussed were Multivariate Linear Regression (MLR), Survey Linear Regression (Svy-Reg), Generalized Estimation Equation (GEE) and Multilevel Mixed Models (MLM) all with and without sampling weights. ^ Results. Estimated population for RGV was 1,146,796. There were 51.5% female, 90% Hispanic, 73% married, 56% unemployed and 37% with their personal transport. 40% people attained education up to elementary school, another 42% reaching high school and only 18% went to college. Median household income is less than $15,000/year. MSNP estimated to be 44,196 (3.98%) [95% CI: 39,029; 51,123]. All statistical models are in concordance with MSNP estimates ranging from 44,000 to 48,000. MSNP estimates for statistical methods are: MLR (47,707; 95% CI: 42,462; 52,999), MLR with weights (45,882; 95% CI: 39,792; 51,972), Bootstrap Regression (47,730; 95% CI: 41,629; 53,785), GEE (47,649; 95% CI: 41,629; 53,670), GEE with weights (45,076; 95% CI: 39,029; 51,123), Svy-Reg (44,196; 95% CI: 40,004; 48,390) and MLM (46,513; 95% CI: 39,869; 53,157). ^ Conclusion. RGV is a flood zone, most susceptible to hurricanes and other natural disasters. People in the region are mostly Hispanic, under-educated with least income levels in the U.S. In case of any disaster people in large are incapacitated with only 37% have their personal transport to take care of MSNP. Local and state government’s intervention in terms of planning, preparation and support for evacuation is necessary in any such disaster to avoid loss of precious human life. ^ Key words: Complex Surveys, statistical methods, multilevel models, cluster randomized, sampling weights, raking, survey regression, generalized estimation equations (GEE), random effects, Intracluster correlation coefficient (ICC).^