Factors associated with advanced disease stage at diagnosis in a population-based study of patients with newly diagnosed breast cancer

Breast cancer is diagnosed at a younger age and a more advanced stage in African-American women than in White women. The authors investigated the effects of several factors, including race, on stage of breast cancer in women aged 20-54 years living in Atlanta, Georgia, and diagnosed between 1990 and 1992. A total of 251 African-American and 580 White women were interviewed and their medical records reviewed. By use of polytomous logistic regression, factors possibly influencing stage and racial differences in stage were studied. In African-American women, the odds of stage III/IV breast cancer at diagnosis were almost four times the odds in White women (odds ratio = 3.79, 95% confidence interval: 2.45, 5.89) and approximately two and one-half times for stage IIA or stage IIB disease (odds ratio = 2.57, 95% confidence interval: 1.66, 3.99; odds ratio = 1.94, 95% confidence interval: 1.31, 2.86, respectively). These racial differences appeared to be largely explained by insurance status, poverty, history of mammography, method of tumor detection, and obesity. Interventions targeting these factors could potentially lower the stage at diagnosis for African-American breast cancer patients and, in doing so, improve their survival and other outcomes.

High prevalence and presumptive treatment of schistosomiasis and strongyloidiasis among African refugees

BACKGROUND

Schistosomiasis and strongyloidiasis cause substantial morbidity and mortality among hundreds of millions of infected persons worldwide. In the United States, these infections are most commonly found among international travelers, immigrants, and refugees from areas of endemicity. Refugees resettled to the United States since 2000 include >3800 "Lost Boys and Girls" of Sudan and 8000 Somali Bantu. Many Lost Boys and Girls of Sudan reported chronic abdominal pain only since arrival, and some received diagnoses of schistosomiasis or strongyloidiasis. We assessed seroprevalence of these infections among these refugees and hypothesized an association between infection and abdominal pain.

METHODS

We offered a survey assessing chronic abdominal pain and serologic testing for schistosomiasis and strongyloidiasis to all 800 attendees of a Lost Boys and Girls of Sudan reunion in the United States. Serologic testing was performed on preimmigration specimens obtained from 100 United States-bound Somali Bantu refugees.

RESULTS

Of the 462 Sudanese refugees (58%) tested, 44% and 46% were seropositive for schistosomiasis (primarily due to Schistosoma mansoni) and strongyloidiasis, respectively; 24% of those who tested positive for schistosomiasis had S. mansoni antigenemia. Forty-six percent reported chronic abdominal pain, which was not associated with either infection. Among 100 Somali Bantu, 73% and 23% tested seropositive for schistosomiasis (primarily due to Schistosoma haematobium) and strongyloidiasis, respectively.

CONCLUSIONS

The high seroprevalence of schistosomiasis and strongyloidiasis among Sudanese Lost Boys and Girls and Somali Bantu refugees supports presumptive treatment for these refugees. Current refugee resettlement policies inadequately address these diseases; our data support consideration of predeparture presumptive therapy for all refugees from areas of endemicity.

Oral Contraceptives and Survival in Breast Cancer Patients Aged 20 to 54 Years

Recent oral contraceptive (OC) use is associated with modestly higher breast cancer incidence among younger women, but its impact on survival is unclear. This study examined the relationship between OC use before breast cancer diagnosis and survival. A population-based sample of 1,264 women aged 20 to 54 years with a first primary invasive breast cancer during 1990 to 1992 were followed up for 8 to 10 years. OC and covariate data were obtained by interviews conducted shortly after diagnosis and from medial records. All-cause mortality was ascertained through the National Death Index (n = 292 deaths). Age- and income-adjusted hazard ratios (HR) and 95% confidence intervals (95% CI) were estimated by Cox regression methods. All-cause mortality was not associated with ever use of OCs or duration of use. Compared with nonusers, mortality estimates were elevated among women who were using OCs at diagnosis or stopped use in the previous year (HR, 1.57; 95% CI, 0.95-2.61). The HR for use of high-dose estrogen pills within 5 years before diagnosis was double that of nonusers (HR, 2.39; 95% CI, 1.29-4.41) or, if the most recent pill included the progestin levonorgestrel, compared with nonusers (HR, 2.01; 95% CI, 1.03-3.91). Because subgroup estimates were based on small numbers of OC users, these results should be cautiously interpreted. Overall, most aspects of OC use did not seem to influence survival, although there is limited evidence that OC use just before diagnosis, particularly use of some pill types, may negatively impact survival in breast cancer patients aged 20 to 54 years.

General and abdominal obesity and survival among young women with breast cancer

Among postmenopausal women, obesity is linked to increased risk of breast cancer and poorer subsequent survival. For premenopausal women, obesity may reduce incidence, but less is known about its effect on prognosis, particularly for abdominal obesity. This study investigated whether general or abdominal obesity at diagnosis influenced survival in a cohort of young women with breast cancer. A population-based follow-up study was conducted among 1,254 women ages 20 to 54 who were diagnosed with invasive breast cancer between 1990 and 1992 in Atlanta or New Jersey. Women were interviewed within several months of diagnosis and asked about their weight and height at age 20 and in the year before diagnosis. Study personnel did anthropometric measures at the interview. With 8 to 10 years of follow-up, all-cause mortality status was determined using the National Death Index (n = 290 deaths). Increased mortality was observed for women who were obese [body mass index (BMI), > or =30] at the time of interview compared with women of ideal weight [BMI, 18.5-24.9; stage- and income-adjusted hazard ratio (HR), 1.48; 95% confidence interval (95% CI), 1.09-2.01]. A similar result was seen for the highest versus lowest quartile of waist-to-hip ratio (HR, 1.52; 95% CI, 1.05-2.19). Strong associations with mortality were found for women who were obese at age 20 (HR, 2.49; 95% CI, 1.15-5.37) or who were overweight/obese (BMI, > or =25) at both age 20 and the time of interview (HR, 2.22; 95% CI, 1.45-3.40). This study provides evidence that breast cancer survival is reduced among younger women with general or abdominal obesity.

Association between reproductive factors and breast cancer survival in younger women

This analysis investigated whether reproductive factors such as age at menarche, parity, and timing and outcomes of pregnancies were associated with survival among women with breast cancer younger than 55 years. Female residents of Atlanta, Georgia, and central New Jersey who were diagnosed with a primary, incident invasive breast cancer between 1990 and 1992 and enrolled in a population-based study (n = 1,264) were followed for 8-10 years. Detailed exposure and covariate information was collected via in-person interviews administered shortly after diagnosis. Vital status as of January 1, 2000 was ascertained through the National Death Index via the state cancer registries (n = 292 deaths). Cox regression methods were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) adjusted for confounders. Parity of 4 or more births, as compared with nulliparity, was positively associated with all-cause mortality, [HR (95% CI) = 1.71 (1.09-2.67)]. Increased mortality was associated with having given birth within 5 years prior to diagnosis (<or=5 vs. >5 years) [1.78 (1.28-2.47)], and was more pronounced among women with a pre-diagnostic body mass index of <25 kg/m2 [2.54 (1.61-4.00)]. Early age at menarche and early age at first birth also modestly increased mortality; history of miscarriage, induced abortion, and ever breastfeeding were not related to survival. These results may help elucidate breast cancer progression mechanisms and enable a better understanding of how reproductive characteristics influence breast cancer survival.

Risk of severe acute respiratory syndrome-associated coronavirus transmission aboard commercial aircraft

BACKGROUND

Severe acute respiratory syndrome-associated coronavirus (SARS-CoV) was introduced to the United States through air travel. Although the risk of SARS-CoV transmission within aircraft cabins has been addressed by several studies, the magnitude of the risk remains unclear.

METHODS

We attempted to contact all persons with working US telephone numbers aboard seven US-bound flights carrying SARS patients. Consenting participants responded to a questionnaire, and a serum sample was collected at least 38 days after the flight and tested for SARS-CoV-associated antibodies. Participants reporting an illness compatible with SARS, with onset during the 2- to 10-day incubation period, were considered suspect cases; positive serology was required for confirmed cases.

RESULTS

Among 1,766 passengers and crew, 339 (19%) persons were contacted. Of these, 312 (92%) completed questionnaires, and blood was collected from 127 (37%). Serology was negative for all 127 participants, including three of four who met the clinical case criteria for SARS, and the fourth had a mild illness that lasted only 5 days.

CONCLUSIONS

Transmission of SARS-associated CoV was not observed, suggesting that the risk of transmission is not amplified aboard aircraft.

Body Size and Risk of Epithelial Ovarian Cancer (United States)

OBJECTIVE

We conducted a population-based case-control study of epithelial ovarian cancer in relation to measures of body size and adult weight change. In particular, we sought to characterize the independent relation of body weight at particular ages with risk.

METHODS

In-person interviews were sought with 35-54 year-old female residents of metropolitan Atlanta, Seattle or Detroit diagnosed with ovarian cancer during 1994-1998, and with controls sampled from these populations. Information provided by 355 cases and 1,637 controls was analyzed using unconditional logistic regression.

RESULTS

The risk among women in the top tenth, relative to women in the lowest fourth, of the distribution of body weight at age 18 years was 1.5 (95% confidence interval, 1.0-2.2); at age 30, 1.9 (1.2-2.9); and 5 years before the reference date, it was 2.1 (1.4-3.3). While our results did not substantiate risk elevations reported in previous studies among subsets of women (e.g., with particular histologic tumor subtypes or according to past oral contraceptive use), we noted a particularly increased risk among women who reported 10 or more pounds gained during their first year of oral contraceptive use.

CONCLUSIONS

Our findings suggest that risk of epithelial ovarian cancer may be most closely linked with body weight in the relatively recent past (but before the time in which the disease may manifest as weight loss) among women who develop this disease during the years before or shortly after menopause.

Recreational physical activity and survival among young women with breast cancer

BACKGROUND

Most epidemiologic studies report a reduced risk of developing breast cancer associated with higher levels of recreational physical activity, but little is known regarding its effect on prognosis.

METHODS

In this study, the authors investigated whether activity undertaken prior to diagnosis influenced breast cancer survival in a population-based cohort. A follow-up study was conducted among 1264 women ages 20 to 54 years who were diagnosed with invasive breast cancer between 1990 and 1992. Women in the study were interviewed within several months of diagnosis and were asked about their average frequency of moderate and vigorous activity at age 13 years, age 20 years, and during the year before diagnosis. With 8 to 10 years of follow-up, all-cause mortality status was determined by using the National Death Index (n = 290 deaths).

RESULTS

A modest reduction in the hazards ratio (HR) was observed for the highest quartile of activity in the year before diagnosis compared with the lowest quartile (stage-adjusted and income-adjusted HR, 0.78; 95% confidence interval [95% CI], 0.56-1.08). High activity was associated with a reduced HR among women who were overweight or obese at the time of diagnosis (HR, 0.70; 95% CI, 0.49-0.99) but not among ideal weight or underweight women (HR, 1.08; 95% CI, 0.77-1.52). A reduced HR was not evident for activity at age 13 years or 20 years or for average activity across the 3 periods studied.

CONCLUSIONS

The results of this study provided some suggestive evidence for a beneficial effect on survival of recreational physical activity undertaken in the year before diagnosis, particularly among women who are overweight or obese near the time of diagnosis.

Rapid malaria screening and targeted treatment of United States-bound Montagnard refugees from Cambodia in 2002

In 2002, a group of Montagnard refugees living in Cambodia was accepted for resettlement in the United States. Pre-departure malaria screening and targeted treatment was conducted to prevent morbidity, and minimize the potential for local malaria transmission post-arrival. We screened 902 of 906 refugees using rapid diagnostic tests (RDTs), microscopy, and polymerase chain reaction (PCR) analysis. Twelve (1.3%) RDT results were positive and 28 (3.1%) were indeterminate. Microscopy confirmed Plasmodium species in two of the positive RDT and one of the indeterminate results. Among a random 10% sample of negative RDT results (n = 86), none were positive by microscopy. The PCR confirmed the two microscopically (and RDT) positive specimens. The PCR result was negative for all other specimens tested. Eighteen (2.0%) refugees were treated with antimalarials. The RDTs were useful in this setting, facilitating timely, sensitive diagnosis and targeted treatment. Evaluations to determine the most appropriate interventions in other refugee settings should include cost-effectiveness analyses of alternative strategies.

A case-control study of ovarian cancer in relation to infertility and the use of ovulation-inducing drugs

The authors conducted a population-based, case-control study among women aged 35-54 years to assess the influence of infertility and use of ovulation-inducing drugs on ovarian cancer risk. The study was conducted from 1994 to 1998 in three regions (metropolitan Atlanta, Georgia, Detroit, Michigan, and Seattle, Washington) and included 378 cases and 1,637 controls. Data were obtained through in-person interviews, and analysis was conducted using unconditional logistic regression. Among parous women, the authors observed no association of cancer risk with a history of infertility, medical evaluation for infertility, specific types of infertility, or use of ovulation-inducing drugs. Among nulliparous women, risk was increased among women with a history of infertility (odds ratio = 1.6, 95% confidence interval: 1.0, 2.6), particularly when infertility first became manifest relatively late in reproductive life (for first infertility at > or =30 years of age: odds ratio = 2.2, 95% confidence interval: 1.1, 4.5); risk was not associated with medical evaluation for infertility, specific types of infertility, or use of ovulation-inducing drugs. Findings were similar when borderline and invasive epithelial tumors were considered separately. While the results of this study support the hypothesis that a subset of nulliparous women who experience infertility may be at increased risk of ovarian cancer, the reasons for this increase in risk remain unclear.

Racial differences in diagnosis, treatment, and clinical delays in a population-based study of patients with newly diagnosed breast carcinoma

BACKGROUND

Few studies have addressed the issue of whether delays in the interval between medical consultation and the diagnosis and treatment of breast carcinoma are greater for African American women than for white women. The authors examined differences with respect to these delays and analyzed the factors that may have contributed to such differences among women ages 20-54 years who had invasive breast carcinoma diagnosed between 1990 and 1992 and who lived in Atlanta, Georgia.

METHODS

A total of 251 African American women and 580 white women were interviewed and had their medical records reviewed. The authors estimated racial differences in delay times and used polytomous logistic regression to determine the contributions of various factors (socioeconomic and other) to these differences.

RESULTS

Although most women in both groups were treated within 3 months of initial consultation, 22.4% of African American women and 14.3% of white women had clinical delays of > 3 months. Compared with white women, African American women were more likely to experience delays in diagnosis and treatment. Access to care (as represented by method of detection and insurance status) and poverty index partially accounted for these differences in delay time; however, racial differences in terms of delayed treatment and diagnosis remained even after adjustment for contributing factors.

CONCLUSIONS

The findings of the current study suggest that among women ages 20-54 years who have breast carcinoma, potentially clinically significant differences in terms of delayed diagnosis and treatment exist between African American women and white women. Improvements in access to care and in socioeconomic circumstances may address these differences to some degree, but additional research is needed to identify other contributing factors.

Racial differences in the expression of cell cycle-regulatory proteins in breast carcinoma

BACKGROUND

African-American (AA) women are more likely to be diagnosed with an advanced stage of breast carcinoma than are white women. After adjustment for disease stage, many studies indicate that tumors in AA women are more likely than tumors in white women are to exhibit a high level of cell proliferation and features of poor prognosis. The purpose of the current study was to compare tumor characteristics and cell cycle alterations in AA women and white women that might affect the aggressiveness of breast carcinoma.

METHODS

The study included 124 AA and 397 white women, ages 20-54 years. These women were enrolled in a case-control study in Atlanta, Georgia, between 1990 and 1992. Breast tumor specimens obtained from these women were centrally reviewed for histologic characteristics and evaluated for expression of estrogen and progesterone receptors (ER/PR), c-ErbB-2, Ki-67, p53, cyclin E, cyclin D1, p27, p16, pRb, and p21 by immunohistochemistry. Logistic regression models were used to assess the age- and stage-adjusted associations of various tumor characteristics with race.

RESULTS

The odds of a breast carcinoma diagnosis at a younger age and at a later stage were higher for AA women than for white women. After adjustment for disease stage and age at diagnosis, AA women also were found to have increased odds of having a higher-grade tumor, a higher mitotic index, marked tumor necrosis, ductal histology, loss of ER and PR, overexpression of cyclin E, p16, and p53 and low expression of cyclin D1 at diagnosis.

CONCLUSIONS

The observed differences between tumor specimens obtained from AA women and tumor specimens obtained from white women, independent of stage and age at diagnosis, indicated that race may be a determinant, or a surrogate for other determinants, of aggressive breast carcinoma and specific cell cycle defects.

Validation of self-reported screening mammography histories among women with and without breast cancer

As part of a case-control study of the efficacy of screening mammography, the authors validated the mammography histories of 2,495 women aged 40-64 years with incident breast cancer diagnosed in 1994-1998 and a 25% random sample of 615 controls never diagnosed with breast cancer, all reporting a mammogram in the past 5 years. Subjects from five metropolitan areas of the United States were cross-classified by facility records ("gold standard") and self-report according to history of a recent screening mammogram (within 1 year or within 2 years). Sensitivity and specificity of self-reported screening at 1 year were 0.93 and 0.82, respectively, for cases and 0.92 and 0.80 for controls. At 2 years, sensitivity and specificity were 0.97 and 0.78 for both cases and controls. Confidence intervals for the differences in sensitivity and specificity were narrow and included zero. Scant evidence was found of telescoping (recollection of events as more recent than actual). Findings suggest that, in an interview-based case-control study of the efficacy of screening mammography, 1) estimated true prevalences of recent screening mammography adjusted for sensitivity and specificity will be slightly lower than self-reported prevalences, and 2) differential misclassification of exposure status is slight. Therefore, odds ratios will likely be biased toward the null, underestimating screening efficacy.

Diet Quality Index as a predictor of short-term mortality in the American Cancer Society Cancer Prevention Study II Nutrition Cohort

The Diet Quality Index (DQI) was developed to measure overall dietary patterns and to predict chronic disease risk. This study examined associations between DQI and short-term all-cause, all-circulatory-disease, and all-cancer mortality in the American Cancer Society Cancer Prevention Study II Nutrition Cohort, a cohort of US adults aged 50-79 years enrolled in a prospective study. After 4 years of follow-up (1992-1996), there were 869 deaths among 63,109 women and 1,736 deaths among 52,724 men. All study participants reported being disease free at baseline in 1992-1993. In age-adjusted Cox models, a higher DQI, which was indicative of a poorer quality diet, was positively related to all-cause and all-circulatory-disease mortality rates in both women and men and to cancer mortality in men only. However, in fully adjusted Cox models, only circulatory disease mortality was clearly positively related to DQI and only in women (medium-low-quality diet vs. highest-quality diet: rate ratio = 1.86, 95% confidence interval: 1.19, 2.89). Although trend tests indicated significant positive relations between DQI and all-cause mortality, effects were small (rate ratios </= 1.31), and confidence intervals were wide, generally including 1.0. DQI was unrelated to cancer mortality. As currently constructed, the DQI may have limited ability to predict mortality.

Influence of usual source of care on differences by race/ethnicity in receipt of preventive services

OBJECTIVE

We examined the relation between race/ethnicity and receipt of preventive services and the effect of having a usual source of care (USOC) on receipt of preventive services in different racial and ethnic groups.

DESIGN/PARTICIPANTS

We analyzed data from adults, aged 18 to 64 years in the Household Component of the 1996 Medical Expenditure Panel Survey, a nationally representative survey of health care use for the United States.

MEASUREMENTS

The proportion of adults who received age-appropriate preventive services.

RESULTS

Compared to white respondents, Hispanics were less likely to receive breast exams and blood pressure and cholesterol screening than were white respondents, and blacks were more likely to report receiving a Pap smear. Despite being less likely to report having a USOC, black and Hispanic women were as likely or more likely to report receiving breast and cervical cancer screening, after controlling for having a USOC and other factors. Hispanics reported receiving blood pressure screening less often, and blacks reported receiving more cholesterol screening. For each race/ethnicity group, having a USOC was associated with receiving preventive services. However, controlling for USOC and other confounders attenuated, but did not eliminate, differences by race/ethnicity.

CONCLUSION

The differences by race in receipt of preventive services suggest the need for different starting points for devising strategies to address racial differences in disease outcomes. While having a USOC will be important in narrowing the differences by race in receipt of preventive services, attending to other factors that contribute to disparities in health will also be essential.

Agricultural exposure history among African-American farmers in Georgia

Agricultural exposures differ across the United States by region, calendar time period, and agricultural practice, but most of the published literature focuses on white men in the Midwest. A pilot study was conducted to explore the breadth and diversity of farming practices over time among African-American farmers in Georgia whose exposures may differ in important ways. Using a comprehensive life events calendar questionnaire, 17 male African-American farmers aged 36 to 86 yr residing in southeastern Georgia were interviewed regarding their agricultural history in July 1997. Most men (15/17) reported working on multiple farms in their lifetime; 3 men worked on 5 different farms during their lifetime. These farmers reported using more chemicals during their lifetime than farmers in the Midwest. Used motor oil was the most frequently reported insecticide applied to animals; this apparently common practice has not been described in the literature and should be better understood since its use may result in dermal exposure to polyaromatic hydrocarbons. Better characterization of regionally specific farming history and individual farming practices will facilitate studies of the health effects of farming.

Patterns and predictors of the breast cancer detection methods in women under 45 years of age (United States)

OBJECTIVES

Few studies have examined methods by which breast cancers are detected, and only one study has been published on predictors of those methods. This study examined patterns and predictors of breast cancer detection methods during 1990-1992 among women age 20-44.

METHODS

In-person interview and medical record data were obtained during a population-based case-control study of 1619 women newly diagnosed with breast cancer in three areas of the United States (US).

RESULTS

Seventy-one percent of the cancers were identified by self-detection, 9% by routine clinical breast exam (CBE), and 20% by routine mammography. Cancers detected by mammography and CBE, but not those detected by breast self-exam, were much more likely to be early-stage. Detection by mammography increased with age, and a history of mammography use was associated with detection by mammography or CBE. Several commonly studied predictors of screening utilization in the US population were associated with CBE detection, but were less clearly related to or unrelated to mammography detection.

CONCLUSION

Findings suggest that, during the 1990s in the US, most breast cancers among women under age 45, including those age 40-44, were self-detected. Few factors other than age and prior screening are verified predictors of method of breast cancer detection.

Comparison of telephone sampling and area sampling: response rates and within-household coverage

Random digit dialing is used frequently in epidemiologic case-control studies to select population-based controls, even when both cases and controls are interviewed face-to-face. However, concerns persist about the potential biases of random digit dialing, particularly given its generally lower response rates. In an Atlanta, Georgia, case-control study of breast cancer among women aged 20-54 years, all of whom were interviewed face-to-face, two statistically independent control groups were compared: those obtained through random digit dialing (n = 652) and those obtained through area probability sampling (n = 640). The household screening rate was significantly higher for the area sample, by 5.5%. Interview response rates were comparable. The telephone sample estimated a significantly larger percentage (by approximately 7%) of households to have no age-eligible women. Both control groups, appropriately weighted, had characteristics similar to US Census demographic characteristics for Atlanta women, except that respondents in both control groups were more educated and more likely to be married. The authors conclude that households contacted through random digit dialing are somewhat less likely to participate in the household screening process, and if they are cooperative, some households may not disclose that age-eligible women reside therein. Investigators need to develop improved methods for screening and enumerating household members in random digit dialing surveys that target a specific subpopulation, such as women.

Validation of the American Cancer Society Cancer Prevention Study II Nutrition Survey Cohort Food Frequency Questionnaire

We assessed the validity and reproducibility of a self-administered 68-item food frequency questionnaire completed in 1992-1993 by approximately 185,000 adults. Four hundred forty-one participants completed four 24-hour dietary recall interviews over a 1-year period and a repeat administration of the food frequency questionnaire. For 20 nutrients and 10 food groups, measured nutrient intakes, but not food group intakes, were consistently lower by food frequency questionnaire than by recall. Energy-adjusted, attenuation-corrected Pearson validity correlations ranged from 0.12 to 0.80, with a median of 0.58. Reproducibility measures were generally high, with a median of 0.69. The food frequency questionnaire performed similarly to food frequency questionnaires used in other cohort studies, indicating similar ability to examine diet-disease relations.

Use of a life events calendar approach to elicit occupational history from farmers

BACKGROUND

Precise and valid exposure assessment is generally the primary challenge in retrospective occupational epidemiology studies, particularly when the only available method for exposure characterization is a personal interview. Agricultural workers may represent a particular challenge; for example, whereas many farmers have worked from childhood at the same location, raising the same crops and animals, they may have used different equipment, chemicals, and protective gear over time. One method to assist in recall is the "life events calendar," a cognitive tool based on the subject's own life history to help anchor occupational activities in time.

METHODS

Unstructured interviews of farmers, focus groups, and pilot interviews among rural men, primarily African-Americans, were conducted to create a questionnaire for obtaining farm history information within the context of personal life events.

RESULTS

Farmers used both personal events and national events (as well as events relating directly to farming) to recall their activities. These subjects had extensive history of farming (10-75 years) and chemical use (median lifetime chemicals = 13).

CONCLUSION

The life events calendar provided a useful tool to facilitate the recall of a lifetime of agricultural activity. Life events calendars are useful additions to the tools available for retrospective occupational exposure assessment.

Glutathione in human plasma: decline in association with aging, age-related macular degeneration, and diabetes

Blood samples were analyzed for GSH and GSH redox state in 40 age-related macular degeneration (ARMD) patients (> 60 y), 33 non-ARMD diabetic patients (> 60 years), 27 similarly aged non-ARMD and nondiabetic individuals (> 60 years), and 19 younger individuals (< 60 years) without ARMD or diabetes. Results showed a significantly lower plasma GSH in older individuals (ARMD, diabetes, and controls) than in younger individuals (p < .01). Total GSH (GSHt) obtained following treatment with dithiothreitol was significantly lower only in diabetic cases (p < .05) but also approached significance for ARMD cases (p = .089). Estimation of redox potential indicated that the plasma GSH pool is considerably more oxidized in all of the older groups. Analyses of whole blood GSH showed that GSH was significantly lower in diabetic cases compared to the other groups, but did not reveal any difference associated with age or ARMD. In contrast, GSSG in whole blood was significantly higher in the older groups compared to the younger controls. The results suggest that in studies of age-related pathologies, oxidation of GSH may be a more important parameter than a decline in pool size, while in specific pathologies such as diabetes, both oxidation and a decline in pool size may be important.

Energy intake and net weight gain in pregnant women according to body mass index (BMI) status

OBJECTIVE

To investigate whether body mass index (BMI) is related to energy intake during pregnancy, and whether BMI, energy intake and other factors are related to net weight gain.

DESIGN

Longitudinal, duration of pregnancy.

SUBJECTS

156 healthy pregnant women residing in Quedlinburg county, Germany.

METHODS

Weighed 7 d food records and standardized anthropometric measures in the first, second and third trimester. The analysis of variance (ANOVA) statistical technique was used to analyze differences in energy intake, net weight gain and birthweight across BMI groups, and the Cochran-Mantel Haenszel test was used to analyze food group intake by BMI group.

RESULTS

Women at the highest level of BMI were significantly less often in the high energy intake category than women at the medium or low level of BMI (15% vs 36% and 48%). Net weight gain during pregnancy was independently influenced by BMI status and energy intake. Women at the highest level of BMI gained significantly less weight (4.2 kg) from first to third trimester than women at the medium or low levels of BMI (weight gains of 6.2 kg and 5.9 kg, respectively). Women with a low daily energy intake gained 4.6 kg during pregnancy, while women with medium and high energy intakes gained 6.0 kg and 6.1 kg, respectively. Examination of net weight gain simultaneously across BMI and parity groups revealed a much lower net weight gain among multigravid women at the highest BMI level (3.3 kg). Primigravid high BMI women, in contrast, gained 6.9 kg, whereas multigravid and primigravid women at medium and low BMI levels gained average of 4.8 kg and 6.5 kg, respectively. The mean birth weight in the three BMI groups did not differ and was not influenced by age, marital status, education, parity or smoking.

CONCLUSION

Because other studies have shown that weight gain during pregnancy increases the risk of subsequent overweight, multigravid high BMI women may prevent an increased weight retention after pregnancy due to lower weight gain in the current gestation. A lower caloric diet may help to accomplish a lower weight gain during pregnancy in overweight women without increased risk of low birth weight infants. These findings indicate further investigation of the associations between BMI, parity and caloric intake during pregnancy are needed to increase understanding of factors affecting subsequent weight gain.

The NIMH Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study: background and methodology

OBJECTIVE

A collaborative study was conducted to develop methods for surveys of mental disorder and service utilization in unscreened population-based samples of children and adolescents.

METHOD

Probability household samples of youths 9 through 17 years of age were selected at four sites and interviews were conducted with a total of 1,285 pairs of youths and their adult caretakers in their homes. Lay interviewers administered a computer-assisted version of the NIMH Diagnostic Interview Schedule for Children Version 2.3 and structured interviews to assess demographic variables, functional impairment, risk factors, service utilization, and barriers to service utilization.

RESULTS

More than 7,500 households were enumerated at four sites, with enumeration response rates above 99%. Across sites, 84% of eligible youth-caretaker pairs were interviewed for about 2 hours each. Ninety-five percent of both youths and caretakers found the interview to be acceptable enough to recommend to a friend.

CONCLUSIONS

These findings indicate that large-scale epidemiological surveys of mental disorders and mental health service use involving lengthy interviews in the homes of unscreened population-based samples of youths and their adult caretakers are acceptable to the community and can achieve good response rates. The other reports in this Special Section address the reliability and validity of the various survey instruments and other key findings.

Epidemiologic studies of antioxidants and cancer in humans

To assess whether antioxidants may reduce the risk of cancer, we reviewed the epidemiologic literature from 1985 through 1993. We assessed the separate relationships of three antioxidants (carotenoids, vitamin C, and vitamin E) with six sites of cancer (lung, upper aerodigestive tract, uterine cervix, colon, breast, prostate). This review was limited to dietary intake or serum nutrient studies that met a predefined set of methodologic standards. We judged the evidence in support of causal relationships based upon consistency of results across studies, strength of association, and evidence of a dose-response relationship. The data concerning carotenoids and lung cancer risk were most consistent (protection found in 4 of 8 diet studies and 5 of 6 serum studies), with strong associations that tended to follow a dose-response pattern. For lung cancer, there was weaker evidence of protection from vitamin C (2 of 6 diet studies) and vitamin E (3 of 4 serum studies). For upper aerodigestive tract cancers (oral cavity, pharynx, or larynx), there was evidence of a protective effect of carotenoids (3 of 4 diet studies) and vitamin C (4 of 5 diet studies). For cancer of the uterine cervix, we found suggestive evidence of protection from vitamin C (4 of 5 diet studies) and perhaps carotenoids (2 of 5 diet studies). For cancers of the colon, breast, and prostate, the current data do not support a protective effect of antioxidants. More definite conclusions about the benefits of antioxidants in cancer prevention will be derived from on-going intervention trials.