Nutritional factors and the risk of cervical dysplasia

A case comparison study of 159 women was conducted to test the hypotheses that women with cervical dysplasia had a higher prevalence of low dietary intakes of carotenoids, vitamin C, and folacin than women without cervical dysplasia, and that there would be no association between the risk of having cervical dysplasia and dietary intake of retinol. Information regarding the prevalence of known risk factors for cervical dysplasia, early age at first intercourse, multiple sexual partners, early age at first pregnancy, history of having sexually transmitted diseases, cigarette smoking, and sociodemographic data was collected. Dietary intake was estimated using a 97 item quantified food frequency questionnaire designed to obtain information on consumption of all sources of retinol, carotenoids, vitamin C and folacin. Univariate analyses showed that the presence of cervical dysplasia was positively and significantly associated with all the risk factors. In analyses of the association of the dietary variables with cervical dysplasia, information on carotenoid intake was calculated in two ways, as total carotenoid intake and as intake of lycopene and other carotenoids. While there appeared to be an inverse association between the presence of cervical dysplasia and intakes of lycopene and folacin, lower intake of retinol, total carotenoids, other carotenoids (non-lycopene carotenoids) or vitamin C did not increase the risk of having cervical dysplasia. Multivariable analyses showed that, in comparison to women who usually consume 105 RE/day of lycopene, the odds of having cervical dysplasia for women who consume 31-104 RE/day and 30 RE/day or less were 1.31 and 1.66 respectively. The odds of having cervical dysplasia in women who consume 199-396 mcg/day and 198 mcg/day or less of folacin were 2.66 and 2.97 respectively as compared to women who usually consume 397 mcg/day or more. These results suggest the importance of re-evaluating existing dietary data and planning in future studies to evaluate the associations of lycopene and folacin with cervical cancer, as well as to extend these results to other diet/cancer investigations. ^

Genetic epidemiology of childhood brain tumors

A rare familial cancer syndrome involving childhood brain tumors (CBT), breast cancer, sarcomas and an array of other tumors has been described (Li and Fraumeni 1969, 1975, 1982, 1987). A survey of CBT identified through the Connnecticut Tumor Registry in 1984 revealed a high frequency of CBT, leukemia and other childhood cancer in siblings of CBT patients (Farwell and Flannery, 1984). Other syndromes such as neurofibromatosis and nevoid basal cell carcinoma syndrome have also been associated with CBT; however, no systematic family studies have been conducted to determine the extent to which cancer aggregates in family members of CBT patients. This family study was designed to determine the frequency of cancer aggregation overall or at specific sites, to determine the frequency of known or potentially hereditary syndromes in families of CBT patients, and to determine a genetic model to characterize familial cancer syndromes and to identify specific kindreds to which such a model(s) might apply. This study includes 244 confirmed CBT patients referred to the University of Texas M. D. Anderson Cancer Center between the years 1944 and 1983, diagnosed under the age of 15 years and resident in the U.S. or Canada. Family histories were obtained on the proband's first (parents, siblings and offspring) and second degree (proband's aunts, uncles and grandparents) relatives following sequential sampling scheme rules. To determine if cancer aggregates in families, we compared the cancer experience in the population to that expected in the general population using Connecticut Tumor Registry calendar year, age, race and sex-specific rates. The standardized incidence ratio (SIR) for cancer overall was 0.91 (41 observed (O) and 44.94 expected (E); 95% Confidence Interval (CI) = 0.65-1.24). We observed a significant excess of colon cancer among the proband's first degree relatives (O/E = 5/1.64; 95% CI = 1.01-7.65), in particular those under age 45 year. Segregation analysis showed evidence for multifactorial inheritance in the small percentage (N = 5) of the families. ^

Comparison of medical care costs, utilization, and satisfaction of AIDS patients with and without home care

A sample of 157 AIDS patients 17 years of age or over were followed for six months from the date of hospital discharge to derive average total cost of medical care, utilization and satisfaction with care. Those referred for home care follow-up after discharge from the hospital were compared with those who did not receive home care.^ The average total cost of medical care for all patients was $34,984. Home care patient costs averaged \$29,614 while patients with no home care averaged $37,091. Private hospital patients had average costs of \$50,650 compared with $25,494 for public hospital patients. Hospital days for the six months period averaged 23.9 per patient for the no home care group and 18.5 days for home care group. Patient satisfaction with care was higher in the home care group than no home care group, with a mean score of 68.2 compared with 61.1.^ Other health services information indicated that 98% of the private hospital patients had insurance while only 2% of public hospital patients had coverage. The time between the initial date of diagnosis with AIDS and admission to the study was longer for private hospital patients, survival time over the study period was shorter, and the number of hospitalizations prior to entering the study was higher for private hospital patients. These results suggest that patients treated in the private hospital were sicker than public hospital patients, which may explain their higher average total cost. Statistical analyses showed that cost and utilization have no significant relationship with home care or no home care when controlling for indicators of the severity of illness and treatment in public or private hospital.^ In future studies, selecting a matched group of patients from the same hospital and following them for nine months to one year would be helpful in making a more realistic comparison of the cost effectiveness of home care. ^

Multivariate methods for correlated effects sizes

Current statistical methods for estimation of parametric effect sizes from a series of experiments are generally restricted to univariate comparisons of standardized mean differences between two treatments. Multivariate methods are presented for the case in which effect size is a vector of standardized multivariate mean differences and the number of treatment groups is two or more. The proposed methods employ a vector of independent sample means for each response variable that leads to a covariance structure which depends only on correlations among the $p$ responses on each subject. Using weighted least squares theory and the assumption that the observations are from normally distributed populations, multivariate hypotheses analogous to common hypotheses used for testing effect sizes were formulated and tested for treatment effects which are correlated through a common control group, through multiple response variables observed on each subject, or both conditions.^ The asymptotic multivariate distribution for correlated effect sizes is obtained by extending univariate methods for estimating effect sizes which are correlated through common control groups. The joint distribution of vectors of effect sizes (from $p$ responses on each subject) from one treatment and one control group and from several treatment groups sharing a common control group are derived. Methods are given for estimation of linear combinations of effect sizes when certain homogeneity conditions are met, and for estimation of vectors of effect sizes and confidence intervals from $p$ responses on each subject. Computational illustrations are provided using data from studies of effects of electric field exposure on small laboratory animals. ^

The relationship between calcium and fluoride intake, pregnancy and lactation and the risk of height loss in white women

This study was designed to investigate the effect of calcium and fluoride intake, and parity and lactation on the risk of spinal osteoporosis. Height loss was used as a surrogate measure for spinal fractures by taking advantage of documented changes in height found during the 25-year follow-up of the Charleston Heart Study cohort. Women who had lost 2-4" in height or who had no change in height during the follow-up period were defined as case and comparison subjects respectively. Calcium intake when the subjects were "about 25" and in the recent past, average intake of fluoride over 25 years, and parity and history of breastfeeding were ascertained by questionnaire from 54 case and 77 comparison subjects. Low calcium intake in the past decreased the risk of height loss (age-adjusted OR = 0.3, 95%CI: 0.1-0.96) although several potentially important confounding variables could not be adjusted for. There was no association between risk of height loss and present calcium intake (OR = 0.8, 95%CI: 0.3-2.6 for low versus high intake) after adjustment for past calcium intake. High fluoride intake decreased the risk of height loss (adjusted OR = 0.4, 95%CI: 0.1-1.2). The effect of fluoride or calcium intake in the present was modified by the level of the other nutrient. Compared to a low intake of both calcium and fluoride, a high intake of one increased the risk of height loss (crude OR = 3.3 for high fluoride/low calcium, crude OR = 6.0 for high calcium/low fluoride) although a high intake of both was slightly protective (crude OR = 0.7). It is estimated that a "high" nutrient intake in this population was greater than 850mg/day for calcium and 2mg/day for fluoride. After adjustment for age, increasing parity decreased the risk of height loss in women who had never breastfed (OR = 0.2, 95%CI: 0.01-1.7 for 4 or more children). Women who had breastfed were also at lower risk of height loss than nulliparous women (OR = 0.3, 95%CI: 0.1-1.2 for 4 or more children) although at any level of parity, breastfeeding women had a greater risk of height loss than did non-breastfeeding women. ^

The relationship between enterotoxigenic {\it Escherichia coli\/} infection and environmental risk factors in Bilbeis, Egypt, 1981--1983

Diarrheal disease associated with enterotoxigenic Escherichia coli (ETEC) infection is one of the major public health problems in many developing countries, especially in infants and young children. Because tests suitable for field laboratories have been developed only relatively recently, the literature on the environmental risk factors associated with ETEC is not as complete as for many other pathogens or for diarrhea of unspecified etiology.^ Data from a diarrheal disease surveillance project in rural Egypt in which stool samples were tested for a variety of pathogens, and in which an environmental questionnaire was completed for the same study households, provided an opportunity to test for an association between ETEC and various risk factors present in those households. ETEC laboratory-positive specimens were compared with ETEC laboratory-negative specimens for both symptomatic and asymptomatic children less than three years of age at the individual and household level using a case-comparison design.^ Individual children more likely to have LT infection were those who lived in HHs that had cooked food stored for subsequent consumption at the time of the visit, where caretakers used water but not soap to clean an infant after a diarrheal stool, and that had an indoor, private water source. LT was more common in HHs where the caretaker did not clean an infant with soap after a diarrheal stool, and where a sleeping infant was not covered with a net. At both the individual and HH level, LT was significantly associated with good water supply in terms of quantity and storage.^ ST was isolated more frequently at the individual level where a sleeping infant was covered with a net, where large animals were kept in or around the house, where water was always available and was not potable, and where the water container was not covered. At the HH level, the absence of a toilet or latrine and the indiscriminate disposal of animal waste decreased risk. Using animal feces for fertilizer, the presence of large animals, and poor water quality were associated with ST at both the individual and HH level.^ These findings are mostly consistent with those of other studies, and/or are biologically plausible, with the obvious exception of those from this study where poorer water supplies are associated with less infection, at least in the case of LT. More direct observation of how animal ownership and feces disposal relates to different types of water supply and usage might clarify mechanisms through which some ETEC infection could be prevented in similar settings. ^

Patients' compliance with physician's advice in Costa Rica

The penetration of the western-developed pharmaceutical industry in developing nations has had an impact not only on access to medicines but also on the value attached to medicines and the way they are consumed. People in developing countries have more faith in medicines than in doctors. Medicines constitute a large share of government health expenses but little emphasis has been placed on how medicines are being used. This dissertation includes a discussion on the penetration of pharmaceuticals in the Costa Rican society, a thorough literature review on patients' compliance with medical recommendations (including studies conducted in developed and developing countries, factors affecting adherence, issues involved in measuring compliance, treatment compliance models, and strategies to improve patients' recollection and compliance with medical recommendations), results of a compliance survey conducted in Costa Rica, and a presentation of a compliance model for developing societies.^ The Costa Rican survey includes observations on 505 medical encounters involving 13 general practitioners and 1 pediatrician in 1 urban and 2 rural clinics. Home visits yielded information on patients' adherence to medical recommendations on 404 patients and 988 medicines. The level of patients' adherence in Costa Rica is similar to what has been documented in developed societies but the strategies to improve adherence are different. Costa Ricans are prone to follow the behaviors advertised through the media or recommended by persons they consider knowlegeable in health matters and with whom they can have a personal relationship. Programs to improve adherence to medical regimens should include mass media campaigns, a re-organization of the way drugs are being dispensed, and educating health professionals to communicate and establish meaningful relationships with their patients. ^

Type A behavior and blood pressure during adolescence

In The Woodlands, Texas, 346 students in grades 9-12, age 14-18 participated in a screening examination for cardiovascular risk factors. The relationships between blood pressure with Type-A-behavior and its components were evaluated. Type-A-behavior was measured using the Hunter-Wolf Type-A-behavior scale.^ The following results refer to the current 24-item version of the Hunter-Wolf Type-A-behavior scale and subscales derived in the Bogalusa study which thereafter were applied to The Woodlands population.^ No significant differences in blood pressure were observed among children in the highest vs. lowest quintile of the Type-A-behavior score or subscales scores. The correlation coefficients of blood pressure with the Type-A-behavior and its components were small and non-significant in both boys and girls. Multiple regression analyses conducted by sex, showed that after adjustment for age, weight and height, the addition of the total Type-A-behavior score or subscale scores did not increase significantly the amount of the variability explained for any of the blood pressure components.^ These analyses were repeated with results from the original 17-item version of the Hunter-Wolf Type-A-behavior scale and subscales derived in Bogalusa. Similarly, no relationship was observed between the 17-item Type-A-behavior score or subscales scores with blood pressure levels in The Woodlands population.^ Finally, it was important to determine whether subscales derived within The Woodlands population would differ from those described in Bogalusa and would relate differently to blood pressure among students in The Woodlands. The corresponding analyses showed that the subscales derived from the two studies were different, but in fact neither set of subscales was importantly related with blood pressure in The Woodlands population.^ The results of this study are largely consistent with those obtained by Hunter and Wolf in Bogalusa, who among the white population found only the factor "Eagerness-Energy" to be associated with fourth phase diastolic blood pressure among girls. Even this relationship which they observed was weak and inconsistent across sex-race groups and blood pressure components. This study does not support even this positive finding. In conclusion, evidence indicates that blood pressure is not associated with Type-A-behavior or its components as measured by the Hunter-Wolf Type-A-behavior scale among white adolescents. ^

Sickle cell disease: Its signs, symptoms and varied manifestations

Seventy-five sickle cell patients, age 3-36 years from Houston, Texas, participated in the research study to investigate sickle cell manifestations, conducted between November 1989 and August 1990. All the participants were blacks. There were 35 females and 39 males among the participants in this research study. One of the participants did not document the gender.^ The sickle cell history questionnaire was administered to the participants. Data collected from this study were statistically analyzed using frequencies, percentages, crosstabulations and chi-squares.^ Regular source of health care influences the time of diagnosis of sickle cell disease. Early diagnosis of sickle cell disease with proper care and management will reduce the morbidity and mortality rate of the disease.^ Fevers, bacterial infection, pneumoniae, anemiae, pains, ulcers and cardiovascular problems are common causes of hospitalizations. The average length of stay in the hospital on admission were higher among the sickle cell patients than their family members who themselves did not have sickle cell disease. ^

Satisfaction with medical care among Mexican-Americans (Hispanic HANES, 1982--1984)

This research focussed on the extent to which the characteristics of a sample of 8,554 Mexican-Americans affected their satisfaction with medical care by: (1) describing satisfaction with medical care among the population, (2) examining the relationships between satisfaction with health services and personal characteristics of the population, and (3) comparing the results of the research with the results of studies of personal health services in other times, places, and populations.^ The distribution of sex among this population was close to even with men representing 50.4%, however respondents over age 50 years represent 11.3% of the sample. The highest grade attended was found in the Elementary (37.9%), and 70% responded they have a good health. Ninety-three percent of the sample were attended to within thirty minutes they arrived at their clinic/health center. Eighty-two percent of the sample were "Very Satisfied" with the care they received during their last visit.^ Ten hypotheses were tested in this research. Females tend to be more satisfied than males; age was found to correlate with satisfaction with respondents over 40 years reporting more satisfaction levels; there was no correlation between education and satisfaction with the educated expressing more skepticism about medical care; respondents covered by Medicare or Medicaid were more satisfied; perceived health status rating was highly correlated with satisfaction; respondents who spent less than 30 minutes traveling to the clinic/health center were more satisfied while 82% of respondents who had less than 30 minutes waiting time expressed more satisfaction.^ As remarked by Hulka and Aday that responses to client satisfaction questionnaire often provided socially acceptable answers, the results found in this sample was therefore not surprising. The author recommends that instruments for the collection of information on client satisfaction should be studied and modified where applicable to reduce what John Ware termed Acquiescent Response Set (ARS)--a tendency to agree with statement of opinion regardless of content. ^

The effect of specific carotenoids on lung cancer risk

A population-based case-comparison study of histologically confirmed lung cancer among white male and female residents of six Texas coastal counties was conducted from 1979-1982. Dietary information as well as information concerning smoking, alcohol consumption, occupational and residential exposures, and family history of cancer was obtained from 149 living cases and 359 comparison subjects.^ These data support the findings of previous studies that reported a protective association of total carotene intake with lung cancer (OR = 4.07, CI = 3.36-4.78), and no association for total Vitamin A or retinol. Of six specific carotenoids examined, these data reveal a statistically significant protective effect for alpha carotene (OR = 3.58, CI = 2.85-4.31), and an elevated, although non-significant effect for beta carotene (OR = 1.46, CI = 0.61-2.31). No consistent significant effect was found for cryptoxanthin, other xanthins, lutein or lycopene.^ Similar results were found for both males and females, and for both squamous cell and adenocarcinoma subtypes, although loss of power resulting from stratification may have rendered the celltype specific results more imprecise. These results should be considered with caution until confirmed by other studies, however, they suggest the importance of evaluating specific carotenoids in future diet-lung cancer investigations. ^

The epidemiology of uterine cervical cancer among Anglo and Hispanic women in Texas

This study describes the incidence and mortality of uterine cervical cancer among Texas Anglo and Hispanic women, compares these data with respective data from the U.S. SEER Program, and determines factors which explain observed differences between the Texas ethnic groups and between Texas and SEER women. A total of 1,052 invasive and 1,852 in situ cervical cancer cases diagnosed during 1976-1985 among Texas residents were identified from the Texas Cancer Registry for study.^ The effect of ethnicity on the incidence of cervical cancer was found to be strongly modified by age. Texas Hispanic women 35 years and older were found to be at significantly greater risk (two- to four-fold) of invasive cervical cancer than Texas Anglos, and the risk was greatest among women 55-69 years. Compared with SEER females, both Texas ethnic groups exhibited excess risks of invasive cancer, but the magnitude varied with age. In contrast, Texas females were diagnosed less frequently with in situ cervical cancer than SEER females, and Hispanics had the largest differentials.^ As an indicator of differences in screening utilization between Texas and SEER ethnic groups, comparisons of in situ with invasive rates revealed both Texas ethnic groups in all age groups to have lower ratios than respective SEER females. Texas Hispanics had the lowest ratios. A larger percentage of squamous cell tumors were diagnosed among SEER females compared with Texas females, also supporting the finding of less screening. Texas invasive cases did not differ by ethnic group in the distribution of cell types. Hispanics 35-54 years had higher rates than Texas Anglos and SEER Hispanics for all four cell types.^ Declines in the incidence of invasive tumors over time were seen among Texas Anglos 35-54 years and Hispanics 55+ years. The mortality of cervical cancer also declined among Texas Anglo and Hispanic females 55+ years, but the rates still remained highest among these groups.^ In summary, these data indicate increased risks of invasive cervical cancer and less screening among subgroups of Texas females. Prevention efforts should be directed toward these Texas women at high risk of invasive cervical tumors. ^

The social construction of infant mortality: From grassroots to medicalization

Infant mortality as a problematic situation has been recognized for some 130 years in one form or another. It has undergone various changes in its empirical dimensions relative to whom we study within the population, what we study--low birth-weight vs. pre-term births--and how we study it--whether demographically or medically. An analysis of the process by which the condition was raised by claims makers as an intolerable situation among America's urban residents reveals that demographic and medical data were sparse. Nonetheless, a judgement about the meaning and significance of the condition was made, and that interpretation led to the promulgation of systems to both document and address the condition as it has come to be defined.^ This investigation depicts the historical context and natural history of infant mortality as one of a number of social problems that came to be defined through the interplay among groups and individuals making claims and how their claims came to the public policy agenda as worthy of collective resources--who won, who lost and why. The process of social definition focuses attention on the claims makers and the ways they contrast the meaning, origins and remedies for this troubling condition. The historical context becomes the frame of reference for understanding the actions of the claims makers and the meaning and significance they attached to the problem.^ We purport that "context" provides a closer reality than disjoined "value free" accounts. Context provides the evidence for the definition, who participated in the process, why and by what means.^ The role of women in the definitional process reveals the differences in approaches utilized by the women of the settlement house reform movement and African-American women working at the grass-roots. Much of the work done by these two groups provided options to the problem's remedy; however, their differences paved the way to our current (principally medically-oriented) definition and its inherent limitations. ^

Relating one's social support network to one's mid term grade

Much has been written about the relation of social support to health outcomes. Support networks were found to be predictive of health status. Not so clear was the manner in which social support helped the individual to avoid health complications. Whereas some aspects of the support network were protective, others were burdensome. Duties to one's network could serve as a stressor and duties outside one's network might stress the support system itself. Exposure to one's network was associated with certain health risks while disruption in one's social support network was associated with other health risks.^ Many factors contributed to the impact of a social support network upon the individual member: the characteristics of the individual, the individual's role or position within the network, qualities of the network and duties or indebtedness of the individual to the network. This investigation considered the possibility that performance could serve as a stressor in a fashion similar to an exposure to a health hazard.^ Because the literature includes many examples of studies in which the subjects were college students, academic progress is a performance common to most subjects. A profile of the support networks of successful students was contrasted with those of less successful students in this correlational study.^ What was uncovered in this investigation was a very complex web of interrelated constructs. Most aspects of the social support network did not significantly predict academic performance. Only a limited number of characteristics were associated with academic success: the frequency of support, student age, the existence of a 'mentor' within one' s network, and the extent to which one received a predominant source of support. Other factors had a tendency to be negatively correlated with midterm grade, suggesting those factors may impede academic performance.^ Medical status did not predict grades, but was correlated with many aspects of the network. Disruptions in particular parts of one's network were correlated with particular health categories. In fact, disruption in social support was more predictive of academic outcomes than medical complications. Whereas the individual's values were related to the contributing factors, only the individual's satisfaction with certain aspects of the support network were predictive of higher midterm grades in a psychology class. Dissatisfaction was associated with lower grades, suggesting a disruptive effect within the network. Associations among the features of support networks which predicted academic progress were considered. ^

Selection of body fat distribution indices in adults and associations with plasma lipid metabolism variables

Body fat distribution is a cardiovascular health risk factor in adults. Body fat distribution can be measured through various methods including anthropometry. It is not clear which anthropometric index is suitable for epidemiologic studies of fat distribution and cardiovascular disease. The purpose of the present study was to select a measure of body fat distribution from among a series of indices (those traditionally used in the literature and others constructed from the analysis) that is most highly correlated with lipid-related variables and is independent of overall fatness. Subjects were Mexican-American men and women (N = 1004) from a study of gallbladder disease in Starr County, Texas. Multivariate associations were sought between lipid profile measures (lipids, lipoproteins, and apolipoproteins) and two sets of anthropometric variables (4 circumferences and 6 skinfolds). This was done to assess the association between lipid-related measures and the two sets of anthropometric variables and guide the construction of indices.^ Two indices emerged from the analysis that seemed to be highly correlated with lipid profile measures independent of obesity. These indices are: 2*arm circumference-thigh skinfold in pre- and post-menopausal women and arm/thigh circumference ratio in men. Next, using the sum of all skinfolds to represent obesity and the selected body fat distribution indices, the following hypotheses were tested: (1) state of obesity and centrally/upper distributed body fat are equally predictive of lipids, lipoproteins and apolipoproteins, and (2) the correlation among the lipid-related measures is not altered by obesity and body fat distribution.^ With respect to the first hypothesis, the present study found that most lipids, lipoproteins and apolipoproteins were significantly associated with both overall fatness and anatomical location of body fat in both sex and menopausal groups. However, within men and post-menopausal women, certain lipid profile measures (triglyceride and HDLT among post-menopausal women and apos C-II, CIII, and E among men) had substantially higher correlation with body fat distribution as compared with overall fatness.^ With respect to the second hypothesis, both obesity and body fat distribution were found to alter the association among plasma lipid variables in men and women. There was a suggestion from the data that the pattern of correlations among men and post-menopausal women are more comparable. Among men correlations involving apo A-I, HDLT, and HDL$\sb2$ seemed greatly influenced by obesity, and A-II by fat distribution; among post-menopausal women correlations involving apos A-I and A-II were highly affected by the location of body fat.^ Thus, these data point out that not only can obesity and fat distribution affect levels of single measures, they also can markedly influence the pattern of relationship among measures. The fact that such changes are seen for both obesity and fat distribution is significant, since the indices employed were chosen because they were independent of one another. ^