Voice Disorders in the General Population: Prevalence, Risk Factors, and Occupational Impact

OBJECTIVES

Epidemiologic studies of the prevalence and risk factors of voice disorders in the general adult population are rare. The purpose of this investigation was to 1) determine the prevalence of voice disorders, 2) identify variables associated with increased risk of voice disorders, and 3) establish the functional impact of voice disorders on the general population.

STUDY DESIGN

Cross-sectional telephone survey.

METHODS

A random sample (n = 1,326) of adults in Iowa and Utah was interviewed using a questionnaire that addressed three areas related to voice disorders: prevalence, potential risk factors, and occupational consequences/effects.

RESULTS

The lifetime prevalence of a voice disorder was 29.9%, with 6.6% of participants reporting a current voice disorder. Stepwise logistic regression identified specific factors that uniquely contributed to increased odds of reporting a chronic voice disorder including sex (women), age (40-59 years), voice use patterns and demands, esophageal reflux, chemical exposures, and frequent cold/sinus infections. However, tobacco or alcohol use did not independently increase the odds of reporting of a chronic voice disorder. Voice disorders adversely impacted job performance and attendance, with 4.3% of participants indicating that their voice had limited or rendered them unable to do certain tasks in their current job. Furthermore, 7.2% of employed respondents reported that they were absent from work 1 or more days in the past year because of their voice, and 2% reported more than 4 days of voice-related absence.

CONCLUSIONS

The results of this large epidemiologic study provide valuable information regarding the prevalence of voice disorders, factors that contribute to voice disorder vulnerability, and the functional impact of voice problems on the general population.

Prevalence of voice disorders in teachers and the general population

Over 3 million teachers in the United States use their voice as a primary tool of trade and are thought to be at higher risk for occupation-related voice disorders than the general population. However, estimates regarding the prevalence of voice disorders in teachers and the general population vary considerably. To determine the extent that teachers are at greater risk for voice disorders, 2,531 randomly selected participants from Iowa and Utah (1,243 teachers and 1,288 nonteachers) were interviewed by telephone using a voice disorder questionnaire. Prevalence-the number of cases per population at risk at a specific time-was determined. The prevalence of reporting a current voice problem was significantly greater in teachers compared with nonteachers (11.0% vs. 6.2%), chi(2)(1) = 18.2, p <.001, as was the prevalence of voice disorders during their lifetime (57.7% for teachers vs. 28.8% for nonteachers), chi(2)(1) = 215.2, p <.001. Teachers were also significantly more likely than nonteachers to have consulted a physician or speech-language pathologist regarding a voice disorder (14.3% vs. 5.5%), chi(2)(1) = 55.3, p <.001. Women, compared with men, not only had a higher lifetime prevalence of voice disorders (46.3% vs. 36.9%), chi(2)(1) = 20.9, p <.001, but also had a higher prevalence of chronic voice disorders (>4 weeks in duration), compared with acute voice disorders (20.9% vs. 13.3%), chi(2)(1) = 8.7, p =.003. To assess the association between past voice disorders and possible risks, adjusted odds ratios (ORs) were estimated using multiple logistic regression. The results identified that being a teacher, being a woman, being between 40 and 59 years of age, having 16 or more years of education, and having a family history of voice disorders were each positively associated with having experienced a voice disorder in the past. These results support the notion that teaching is a high-risk occupation for voice disorders. Important information is also provided regarding additional factors that might contribute to the development of voice disorders.

Cancer surveillance series: interpreting trends in prostate cancer--part I: Evidence of the effects of screening in recent prostate cancer incidence, mortality, and survival rates

BACKGROUND

The prostate-specific antigen test was approved by the U.S. Food and Drug Administration in 1986 to monitor the disease status in patients with prostate cancer and, in 1994, to aid in prostate cancer detection. However, after 1986, the test was performed on many men who had not been previously diagnosed with prostate cancer, apparently resulting in the diagnosis of a substantial number of early tumors. Our purpose is to provide insight into the effect of screening on prostate cancer rates. Detailed data are presented for whites because the size of the population allows for calculating statistically reliable rates; however, similar overall trends are seen for African-Americans and other races.

METHODS

Prostate cancer incidence data from the National Cancer Institute's Surveillance, Epidemiology, and End Results Program and mortality data from the National Center for Health Statistics were analyzed.

RESULTS/CONCLUSIONS

The following findings are consistent with a screening effect: 1) the recent decrease since 1991 in the incidence of distant stage disease, after not having been perturbed by screening; 2) the decline in the incidence of earlier stage disease beginning the following year (i.e., 1992); 3) the recent increases and decreases in prostate cancer incidence and mortality by age that appear to indicate a calendar period effect; and 4) trends in the incidence of distant stage disease by tumor grade and trends in the survival of patients with distant stage disease by calendar year that provide suggestive evidence of the tendency of screening to detect slower growing tumors.

IMPLICATIONS

The decline in the incidence of distant stage disease holds the promise that testing for prostate-specific antigen may lead to a sustained decline in prostate cancer mortality. However, population data are complex, and it is difficult to confidently attribute relatively small changes in mortality to any one cause.

Voice disorders in teachers and the general population: effects on work performance, attendance, and future career choices

To examine the frequency and adverse effects of voice disorders on job performance and attendance in teachers and the general population, 2,401 participants from Iowa and Utah (n1 = 1,243 teachers and n2 = 1,279 nonteachers) were randomly selected and were interviewed by telephone using a voice disorder questionnaire. Teachers were significantly more likely than nonteachers to have experienced multiple voice symptoms and signs including hoarseness, discomfort, and increased effort while using their voice, tiring or experiencing a change in voice quality after short use, difficulty projecting their voice, trouble speaking or singing softly, and a loss of their singing range (all odds ratios [ORs] p <.05). Furthermore, teachers consistently attributed these voice symptoms to their occupation and were significantly more likely to indicate that their voice limited their ability to perform certain tasks at work, and had reduced activities or interactions as a result. Teachers, as compared with nonteachers, had missed more workdays over the preceding year because of voice problems and were more likely to consider changing occupations because of their voice (all comparisons p <.05). These findings strongly suggest that occupationally related voice dysfunction in teachers can have significant adverse effects on job performance, attendance, and future career choices.

Partitioning linear trends in age-adjusted rates

OBJECTIVE

Surveillance of chronic diseases includes monitoring trends in age-adjusted rates in the general population. Statistics that are calculated to describe and compare trends include the annual percent change and the percent change for a specified time period. However, it is also of interest to determine the contribution specific diseases make to an overall trend in order to better understand the impact of interventions and changes in the prevalence of risk factors. The objective here is to provide a method for partitioning a linear trend in age-adjusted rates into disease-specific components.

METHODS

The method presented is based on linear regression. The decreasing trend in age-adjusted cancer mortality rates for the total United States during the period 1991-96 is analyzed to illustrate the method.

RESULTS

Trends in mortality for cancers of the colon/rectum, breast, lung/bronchus, and prostate are found to be responsible for 75% of the decreasing trend in cancer mortality.

CONCLUSIONS

It is possible to partition an overall trend in age-adjusted rates under the assumption that it and the trends for all mutually exclusive and exhaustive subgroups of interest are linear.

Cancer surveillance series: interpreting trends in prostate cancer--part II: Cause of death misclassification and the recent rise and fall in prostate cancer mortality

BACKGROUND

The rise and fall of prostate cancer mortality correspond closely to the rise and fall of newly diagnosed cases. To understand this phenomenon, we explored the role that screening, treatment, iatrogenic (i.e., treatment-induced) deaths, and attribution bias (incorrect labeling of death from other causes as death from prostate cancer) have played in recent mortality trends.

METHODS

Join point regression is utilized to assess the recent rise and fall in mortality and the relationship of total U.S. trends to those areas served by the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Cancer Registry Program. Incidence-based mortality (IBM) is estimated with the use of prostate cancer data from the SEER Program to partition (from overall prostate cancer mortality trends) the contribution of cases diagnosed since the widespread use of prostate-specific antigen (PSA) testing starting in 1987. IBM is also used to examine the contribution of stage at diagnosis to the recent prostate cancer mortality trends.

RESULTS

IBM for cases diagnosed since 1987 rose above the pre-1987 secular (i.e., background) trend, peaked in the early 1990s, and almost returned to the secular trend by 1994. This rise and fall of IBM track with the pool of prevalent cases diagnosed within the prior 2 years. IBM for cases diagnosed with metastatic disease fell starting in 1991, while IBM for those diagnosed with localized/regional disease was relatively flat.

CONCLUSIONS

The rise and fall in prostate cancer mortality observed since the introduction of PSA testing in the general population are consistent with a hypothesis that a fixed percent of the rising and falling pool of recently diagnosed patients who die of other causes may be mislabeled as dying of prostate cancer. The decline in IBM for distant stage disease and flat IBM trends for localized/regional disease provide some evidence of improved prognosis for screen-detected cases, although alternative interpretations are possible.

Dysphagia in the elderly: preliminary evidence of prevalence, risk factors, and socioemotional effects

OBJECTIVES

Epidemiological studies of dysphagia in the elderly are rare. A non-treatment-seeking, elderly cohort was surveyed to provide preliminary evidence regarding the prevalence, risks, and socioemotional effects of swallowing disorders.

METHODS

Using a prospective, cross-sectional survey design, we interviewed 117 seniors living independently in Utah and Kentucky (39 men and 78 women; mean age, 76.1 years; SD, 8.5 years; range, 65 to 94 years) regarding 4 primary areas related to swallowing disorders: lifetime and current prevalence, symptoms and signs, risk and protective factors, and socioemotional consequences.

RESULTS

The lifetime prevalence of a swallowing disorder was 38%, and 33% of the participants reported a current problem. Most seniors with dysphagia described a sudden onset with chronic problems that had persisted for at least 4 weeks. Stepwise logistic regression identified 3 primary symptoms uniquely associated with a history of swallowing disorders: taking a longer time to eat (odds ratio [OR], 9.5; 95% confidence interval [CI], 2.3 to 40.2); coughing, throat clearing, or choking before, during, or after eating (OR, 3.4; 95% CI, 1.1 to 10.2); and a sensation of food stuck in the throat (OR, 5.2; 95% CI, 1.8 to 10.0). Stroke (p = .02), esophageal reflux (p = .003), chronic obstructive pulmonary disease (p = .05), and chronic pain (p = .03) were medical conditions associated with a history of dysphagia. Furthermore, dysphagia produced numerous adverse socioemotional effects.

CONCLUSIONS

This study provides preliminary evidence to suggest that chronic swallowing disorders are common among the elderly, and highlights the need for larger epidemiological studies of these disorders.

Epidemiology of Voice Disorders in the Elderly: Preliminary Findings

OBJECTIVES

Epidemiologic studies of the prevalence and risk factors of voice disorders in the elderly, nontreatment seeking population are nonexistent. The purpose of this preliminary investigation was to 1) estimate the prevalence of voice disorders, 2) identify variables associated with increased risk of voice disorders, and 3) measure the socioemotional impact of voice disorders on the elderly who live independently.

STUDY DESIGN

Prospective, cross-sectional survey.

METHODS

One hundred seventeen seniors (39 males and 78 females; mean age, 76.1 yr; SD, 8.5 yr; range, 65-94 yr), residing in Utah and Kentucky, were interviewed using a questionnaire that addressed three areas related to voice disorders: prevalence, potential risk factors, and socioemotional consequences/effects.

RESULTS

The lifetime prevalence of a voice disorder was 47%, with 29.1% of participants reporting a current voice disorder. The majority of respondents (60%) reported chronic voice problems persisting for at least 4 weeks. Seniors who had experienced esophageal reflux, severe neck/back injury, and chronic pain were at increased risk. Voice-related effort and discomfort, combined with increased anxiety and frustration and the need to repeat oneself, were specific areas that adversely affected quality of life.

CONCLUSIONS

This preliminary epidemiologic study confirmed that voice disorders are common among the elderly, and further research is needed to identify additional risk factors contributing to voice disorder vulnerability.

Cancer surveillance series: interpreting trends in prostate cancer--part III: Quantifying the link between population prostate-specific antigen testing and recent declines in prostate cancer mortality

BACKGROUND

The objective of this study was to investigate the circumstances under which dissemination of prostate-specific antigen (PSA) testing, beginning in 1988, could plausibly explain the declines in prostate cancer mortality observed from 1992 through 1994.

METHODS

We developed a computer simulation model by use of information on population-based PSA testing patterns, cancer detection rates, average lead time (the time by which diagnosis is advanced by screening), and projected decreased risk of death associated with early diagnosis of prostate cancer through PSA testing. The model provides estimates of the number of deaths prevented by PSA testing for the 7-year period from 1988 through 1994 and projects what prostate cancer mortality for these years would have been in the absence of PSA testing.

RESULTS

Results were generated by assuming a level of screening efficacy similar to that hypothesized for the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial. Under this assumption, the projected mortality in the absence of PSA testing continued the increasing trend observed before 1991 only when it was assumed that the mean lead time was 3 years or less. Projected mortality trends in the absence of PSA screening were not consistent with pre-1991 increasing trends for lead times of 5 years and 7 years.

CONCLUSIONS

When screening is assumed to be at least as efficacious as hypothesized in the PLCO trial, it is unlikely that the entire decline in prostate cancer mortality can be explained by PSA testing based on current beliefs concerning lead time. Only very short lead times would produce a decline in mortality of the magnitude that has been observed.

Financial impact of a comprehensive multisite workplace health promotion program

INTRODUCTION

The purpose of this study is to determine if the Washoe County School District Wellness Program impacted employee health care costs and rates of absenteeism over a 2-year period.

METHODS

Outcome variables included health care costs and absenteeism during 2001-2002. Data were collected on 6246 employees over a 6-year period from 1997-2002. Baseline health claims costs and absenteeism from 1997-2000, age, gender, job classification, and years worked at the school district were treated as covariates. Logistic regression was used to compare 2-year costs and absenteeism rates between nonparticipants and employees who participated for 1 and 2 years.

RESULTS

No significant differences in health care costs were found between those who participated in any of the wellness programs and those who did not participate. There was a significant negative association between participation and absenteeism; program participants averaged three fewer missed workdays than those who did not participate in any wellness programs. The decrease in absenteeism translated into a cost savings of 15.60 US dollars for every dollar spent on the program.

CONCLUSIONS

After controlling for several confounding variables, wellness program participation was associated with large reductions in employee absenteeism.

Detection of human cytomegalovirus in plasma of AIDS patients during acute visceral disease by DNA amplification

By using the polymerase chain reaction (PCR) amplification procedure, 19 (83%) of 23 plasma specimens obtained from individuals with AIDS and human cytomegalovirus (HCMV) visceral disease were found to be positive for plasma viremia as detected by PCR (PV-PCR), whereas 78% of cultures of peripheral blood leukocytes from the same samples were found to be positive. All 11 specimens prospectively obtained from individuals with acute HCMV disease were positive by PV-PCR. Plasma specimens from patients who received ganciclovir therapy rapidly became both culture and PV-PCR negative, and there was an excellent correlation between the two procedures. DNA detected by PV-PCR was unaffected by filtering plasma through a 0.2-microns-pore-size filter, although a conserved cellular gene, HLA-DQ alpha, was undetectable by PCR following filtration. HCMV DNA in plasma could be quantitated by PV-PCR by using endpoint serial dilutions, with detectable virus being present in 10(1) to 10(-2) microliters of plasma. A low titer of infectious virus could be detected in 2 of 11 plasma samples. The detection of HCMV DNA in plasma by PV-PCR promises to be a useful procedure for monitoring patients with AIDS suspected of having impending, acute, or recurrent HCMV visceral disease and suggests an additional route by which virus may disseminate in the immunocompromised host.

Occupational risk factors associated with voice disorders among teachers

PURPOSE

This study was designed to determine the occupational risk factors associated with voice disorders among schoolteachers, a high-risk population for developing voice problems.

METHODS

Telephone interviews were completed by 1243 teachers from Utah and Iowa. Response rates were 98% and 95%, respectively. Bivariate analyses were computed and assessed using chi-square test and Cochran-Mantel-Haenszel test, and logistic regression analyses were performed and resulting odds ratios assessed using 95% confidence intervals.

RESULTS

Teachers of vocal music, drama, other performing arts and chemistry were at significantly greater risk of having a voice disorder (OR=2.2, 95% CI: 1.2-4.0; OR=2.1, 95% CI: 0.9-4.8; OR=1.6, 95% CI: 1.0-2.4; OR=2.0, 95% CI: 1.1-3.4), while teachers of special and vocational education had a significantly lower risk (OR=0.5, 95% CI: 0.3-0.7; OR=0.6, 95% CI: 0.4-0.9). When adjusted for the intensity of vocalization, only teachers of chemistry were significantly at risk (OR=2.0, 95% CI: 1.1-3.5) while teachers of special education continued to have less of a risk (OR=0.5, 95% CI: 0.4-0.8). Chronic voice disorders were more prevalent among teachers of vocal music (OR=4.1, 95% CI: 2.2-7.9) and less prevalent among teachers of vocational education (OR=0.29, 95% CI: 0.09-0.95).

CONCLUSIONS

These findings suggest that teachers of specific courses are at greater risk of developing a voice disorder.

The role of prostate-specific antigen (PSA) testing patterns in the recent prostate cancer incidence decline in the United States

OBJECTIVES

Trends in first-time and later PSA procedure rates are ascertained using longitudinal data from a population-based cohort. These trends are compared to trends in prostate cancer incidence to determine the role of PSA in the recent decline in prostate cancer incidence.

METHODS

Medicare data were linked with tumor registry data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program. A 5 percent random sample (n = 39985) of Medicare beneficiaries from the SEER areas without a previous diagnosis of prostate cancer as of January 1, 1988 was followed through 1994. Trends in first-time PSA use were distinguished from those of second or later for men without diagnosed prostate cancer.

RESULTS

Trends in the rate of first-time PSA procedures track closely with trends in prostate cancer incidence rates, increasing until 1992 and decreasing thereafter. Similar patterns were observed by race and age group. Geographic variability in the dissemination of PSA screening was observed, yet the association between testing and incidence remained. Men in the cohort had a 4.7 percent chance of being diagnosed within three months of an initial PSA test, with the percentage falling for subsequent tests.

CONCLUSIONS

It is informative to distinguish first from later tests when assessing the effect of the diffusion of a test in a population. Taking this approach was useful in illuminating the role of PSA testing in a reversal of a long-term increase in prostate cancer incidence rates.

Children who recover from early stunting and children who are not stunted demonstrate similar levels of cognition

Stunting is associated with adverse cognitive development in childhood and adolescence, fewer years of schooling, decreased productivity, and reduced adult stature. Recovery from early stunting is possible; however, few studies explore whether those who demonstrate linear catch-up growth experience long-term cognitive deficits. Using longitudinal data on 1674 Peruvian children from the Young Lives study, we identified factors associated with catch-up growth and assessed whether children who displayed catch-up growth have significantly lower cognition than children who were not stunted during infancy and childhood. Based on anthropometric data for children 6-18 mo of age and again for the same children when they were 4.5-6 y of age, we categorized participants as not stunted, stunted in infancy but not childhood (catch-up), stunted in childhood, and stunted in infancy and childhood. Children who had grandparents in the home, had less severe stunting in infancy, and had taller mothers were more likely to demonstrate catch-up growth by round 2. Children who experienced catch-up growth had verbal vocabulary and quantitative test scores that did not differ from children who were not stunted (P = 0.6 and P = 0.7, respectively). Those stunted in childhood as well as those stunted in infancy and childhood scored significantly lower on both assessments than children who were not stunted. Based on findings from this study, policy makers and program planners should consider redoubling efforts to prevent stunting and promote catch-up growth over the first few years of life as a way of improving children's physical and intellectual development.

The diversification of Heliconius butterflies: what have we learned in 150 years?

Research into Heliconius butterflies has made a significant contribution to evolutionary biology. Here, we review our understanding of the diversification of these butterflies, covering recent advances and a vast foundation of earlier work. Whereas no single group of organisms can be sufficient for understanding life's diversity, after years of intensive study, research into Heliconius has addressed a wide variety of evolutionary questions. We first discuss evidence for widespread gene flow between Heliconius species and what this reveals about the nature of species. We then address the evolution and diversity of warning patterns, both as the target of selection and with respect to their underlying genetic basis. The identification of major genes involved in mimetic shifts, and homology at these loci between distantly related taxa, has revealed a surprising predictability in the genetic basis of evolution. In the final sections, we consider the evolution of warning patterns, and Heliconius diversity more generally, within a broader context of ecological and sexual selection. We consider how different traits and modes of selection can interact and influence the evolution of reproductive isolation.

Conditional survival among patients with carcinoma of the lung

OBJECTIVE

One- and 5-year probabilities of survival or death change once a patient has already survived > or = 1 year after diagnosis. The current paper reports these probabilities for lung cancer patients according to histologic subtype, stage, and age at diagnosis.

METHODS

Cumulative observed survival rates were calculated and compared among 95,283 patients with histologically confirmed lung cancer (diagnosed from 1983 to 1992 and followed through 1995) by the life-table method using population-based tumor registries participating in the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute. On the basis of the cumulative survival estimates, we derived the probability of death in the next year, conditioned on having already survived to the start of the year (annual hazards), and the probability of survival conditioned on having already survived > or = 1 year (conditional survival). These rates were reported according to histologic subtype, stage, and age groups.

RESULTS

At the time of diagnosis, annual hazard rates differ greatly among histologic subtypes. However, by 5 years after diagnosis, the rates become similar. Bronchioloalveolar carcinoma displays the lowest annual hazards and small-cell carcinoma displays the highest annual hazards. Stage-age subcategories within histologic subtypes continue to show large differences in annual hazard rates. Five-year conditional survival probabilities are also reported, providing survival information that is consistent to that obtained from the annual hazards.

CONCLUSIONS

One- and 5-year prognosis for lung cancer patients is influenced by years already survived and histology, stage, and age at diagnosis. Annual hazards and conditional survival provides useful and more relevant information than conventional survival estimates for patients and their physicians. These statistics can be directly obtained from cumulative survival estimates and should be more widely reported.

Conditional survival among cancer patients in the United States

PURPOSE

To report 5-year relative cancer survival probabilities conditional on having already survived > or = 1 years after the initial diagnosis for 11 cancer sites, diagnosed during 1990-2001 and followed through 2006.

METHODS

Analyses are based on 1,151,496 cancer cases in population-based cancer registries in the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute.

RESULTS

The 5-year relative conditional survival probability tended to improve with each year already survived. Improvement was greatest for more lethal cancers (e.g., lung or pancreas) and for cases with a more advanced stage at diagnosis. The 5-year relative survival probability conditional on already having survived 5 years exceeded 90% for locally staged prostate cancer, melanoma (whites only), breast cancer (females only), corpus uteri cancer, urinary bladder cancer, Hodgkin's lymphoma, rectal cancer, colon cancer, ovary cancer, and pancreatic cancer. Only lung cancer did not reach 90%. For these cancer sites combined, 5-year relative survival probability conditional on already having survived 5 years averaged about 85% for regionally staged disease, 68% for distant staged disease, and 87% for unknown staged disease. The 5-year relative conditional survival probability tended to be significantly lower among patients diagnosed at older ages, among males, among nonwhites, and among those diagnosed during 1990-1995 compared with later years.

CONCLUSION

Conditional survival probability estimation provides further useful prognostic information to cancer patients, tailored to the time already survived since diagnosis.

Impact of early and concurrent stunting on cognition

Undernutrition is associated with poor cognitive development, late entry into school, decreased years of schooling, reduced productivity and smaller adult stature. We use longitudinal data from 1674 Peruvian children participating in the Young Lives study to assess the relative impact of early stunting (stunted at 6-18 months of age) and concurrent stunting (stunted at 4.5-6 years of age) on cognitive ability. Anthropometric data were longitudinally collected for children at 6-18 months of age and 4.5-6 years of age at which time verbal and quantitative ability were also assessed. We estimate that an increase in concurrent height-for-age z-scores (HAZ) by one standard deviation was associated with an increase in a child's score on the Peabody Picture Vocabulary Test (PPVT) by 2.35 points [confidence interval (CI): 1.55-3.15] and a 0.16 point increase on the cognitive development assessment (CDA) (CI: 0.05-0.27). Furthermore, we report that the estimate for concurrent HAZ and PPVT is significantly higher than the estimate for early stunting and PPVT. We found no significant difference between early and concurrent estimates for HAZ and CDA. Children from older mothers, children whose mothers had higher education levels, children living in urban areas, children who attended pre-school, children with fewer siblings and children from wealthier backgrounds scored higher on both assessments. Cognitive skills of children entering school were associated with early stunting but the strongest association was found with concurrent stunting suggesting that interventions preventing linear growth faltering should not only focus on the under 2s but include children up to 5 years of age.

Prostate cancer incidence and mortality rates among white and black men

This paper presents prostate cancer incidence and mortality rates in the United States by factors associated with the disease at diagnosis and explores racial differences in these rates. The analysis is based on population-based cancer data from the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute. Incidence rates increased sharply from 1973 to 1992 (more so among whites), with the increase attributed to screening and preferential finding of low-risk, slow-growing tumors (that is, length bias). Mortality rates increased slightly (more so among blacks). The 1988-1992 white and black prostate cancer mortality rates comprise cases diagnosed as early as 1973. These rates remained fairly constant for each stage category at diagnosis, except for black men diagnosed with localized or unstaged disease, in whom the rates increased. Of the white prostate cancer cases, 33% are diagnosed with localized disease, 16% are diagnosed with regional disease, and 38% are diagnosed with distant disease. The corresponding percentage for black patients are 31, 12, and 45%. Prostate cancer mortality rates for blacks diagnosed with localized, regional, distant, and unstaged disease are 1.9, 1.5, 2.4, and 2.0 times those of whites. The time from diagnosis to death depends on the stage and age at diagnosis, with the time somewhat longer for whites than blacks. This longer time period is due, in part, to better staging and length bias. The effect of therapy on prostate cancer mortality rates is unclear.

Cancer prevalence estimates based on tumour registry data in the Surveillance, Epidemiology, and End Results (SEER) Program

BACKGROUND

The Connecticut Tumor Registry (CTR) has collected cancer data for a sufficiently long period of time to capture essentially all prevalent cases of cancer, and to provide unbiased estimates of cancer prevalence. However, prevalence proportions estimated from Connecticut data may not be representative of the total US, particularly for racial/ethnic subgroups. The purpose of this study is to apply the modelling approach developed by Capocaccia and De Angelis to cancer data from the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute to obtain more representative US site-specific cancer prevalence proportion estimates for white and black patients.

METHODS

Incidence and relative survival were modelled and used to obtain estimated completeness indices of SEER prevalence proportions for all cancer sites combined, stomach, cervix uteri, skin melanomas, non-Hodgkin's lymphomas, lung and bronchus, colon/rectum, female breast, and prostate. For validation purposes, modelled completeness indices were computed for Connecticut and compared with empirical completeness indices (the ratio of Connecticut based prevalence proportion estimates using 1973-1993 data to 1940-1993 data). The SEER-based modelled completeness indices were used to adjust SEER prevalence proportion estimates for white and black patients.

RESULTS

Model validation showed that the adjusted SEER cancer prevalence proportions provided reasonably unbiased prevalence proportion estimates in general, although more complex modelling of the completeness indices is necessary for female cancers of the colon, melanoma, breast, cervix, and all cancers combined. The SEER-based cancer prevalence proportions are incomplete for most cancer sites, more so for women, whites, and at older ages. For all cancers combined, prevalence proportions tended to be higher for whites than blacks. For the site-specific cancers this was true for stomach, prostate, cervix uteri, and lung and bronchus (men only). For colon/rectal cancers the prevalence proportions were higher for blacks through ages 59 (men) and 64 (women), and then for the remaining ages they were higher for whites. Prevalence proportions were lowest for stomach cancer and highest for prostate and female breast cancers. Men experienced higher prevalence proportions than women for skin melanomas, non-Hodgkin's lymphomas, lung and bronchus, and colon/rectal cancers.

CONCLUSION

The modelling approach applied to SEER data generally provided reasonable estimates of cancer prevalence. These estimates are useful because they are more representative of cancer prevalence than previously obtained and reported in the US.

Rural vs urban residence affects risk-appropriate colorectal cancer screening

BACKGROUND & AIMS

Little is known about the effects of geographic factors, such as rural vs urban residence and travel time to colonoscopy providers, on risk-appropriate use of colorectal cancer (CRC) screening in the general population. We evaluated the effects of geographic factors on adherence to CRC screening and differences in screening use among familial risk groups.

METHODS

We analyzed data from the 2010 Utah Behavior Risk Factor Surveillance System, which included state-added questions on familial CRC. By using multiple logistic regression models, we assessed the effects of rural vs urban residence, travel time to the nearest colonoscopy provider, and spatial accessibility of providers on adherence to risk-appropriate screening guidelines. Study participants (n = 4260) were respondents aged 50 to 75 years.

RESULTS

Sixty-six percent of the sample adhered to risk-appropriate CRC screening guidelines, with significant differences between urban and rural residents (68% vs 57%, respectively; P < .001) across all familial risk groups. Rural residents were less likely than urban dwellers to be up-to-date with screening guidelines (multivariate odds ratio, 0.65; 95% confidence interval, 0.53-0.79). In the unadjusted analysis, rural vs urban residence (P < .001), travel time to the nearest colonoscopy provider (P = .003), and spatial accessibility of providers (P = .012) were associated significantly with adherence to screening guidelines. However, rural vs urban residence (P < .001) was the only geographic variable independently associated with screening adherence in the adjusted analyses.

CONCLUSIONS

There are marked disparities in use of risk-appropriate CRC screening between rural and urban residents in Utah. Differences in travel time to the nearest colonoscopy provider and spatial accessibility of providers did not account for the geographic variations observed in screening adherence.

Unintentional prescription opioid-related overdose deaths: description of decedents by next of kin or best contact, Utah, 2008-2009

BACKGROUND

Little is known about the characteristics that may predispose an individual to being at risk for fatal overdose from prescription opioids.

OBJECTIVE

To identify characteristics related to unintentional prescription opioid overdose deaths in Utah.

DESIGN

Interviews were conducted (October 2008-October 2009) with a relative or friend most knowledgeable about the decedent's life.

SUBJECTS

Analyses involved 254 decedents aged 18 or older, where cause of death included overdose on at least one prescription opioid.

KEY RESULTS

Decedents were more likely to be middle-aged, Caucasian, non-Hispanic/Latino, less educated, not married, or reside in rural areas than the general adult population in Utah. In the year prior to death, 87.4 % were prescribed prescription pain medication. Reported potential misuse prescription pain medication in the year prior to their death was high (e.g., taken more often than prescribed [52.9 %], obtained from more than one doctor during the previous year [31.6 %], and used for reasons other than treating pain [29.8 %, almost half of which "to get high"]). Compared with the general population, decedents were more likely to experience financial problems, unemployment, physical disability, mental illness (primarily depression), and to smoke cigarettes, drink alcohol, and use illicit drugs. The primary source of prescription pain medication was from a healthcare provider (91.8 %), but other sources (not mutually exclusive) included: for free from a friend or relative (24 %); from someone without their knowledge (18.2 %); purchase from a friend, relative, or acquaintance (16.4 %); and purchase from a dealer (not a pharmacy) (11.6 %).

CONCLUSIONS

The large majority of decedents were prescribed opioids for management of chronic pain and many exhibited behaviors indicative of prescribed medication misuse. Financial problems, unemployment, physical disability, depression, and substance use (including illegal drugs) were also common.

Cancer mortality risk, fine particulate air pollution, and smoking in a large, representative cohort of US adults

PURPOSE

Air pollution and smoking are associated with various types of mortality, including cancer. The current study utilizes a publicly accessible, nationally representative cohort to explore relationships between fine particulate matter (PM2.5) exposure, smoking, and cancer mortality.

METHODS

National Health Interview Survey and mortality follow-up data were combined to create a study population of 635,539 individuals surveyed from 1987 to 2014. A sub-cohort of 341,665 never-smokers from the full cohort was also created. Individuals were assigned modeled PM2.5 exposure based on average exposure from 1999 to 2015 at residential census tract. Cox Proportional Hazard models were utilized to estimate hazard ratios for cancer-specific mortality controlling for age, sex, race, smoking status, body mass, income, education, marital status, rural versus urban, region, and survey year.

RESULTS

The risk of all cancer mortality was adversely associated with PM2.5 (per 10 µg/m3 increase) in the full cohort (hazard ratio [HR] 1.15, 95% confidence interval [CI] 1.08-1.22) and the never-smokers' cohort (HR 1.19, 95% CI 1.06-1.33). PM2.5-morality associations were observed specifically for lung, stomach, colorectal, liver, breast, cervix, and bladder, as well as Hodgkin lymphoma, non-Hodgkin lymphoma, and leukemia. The PM2.5-morality association with lung cancer in never-smokers was statistically significant adjusting for multiple comparisons. Cigarette smoking was statistically associated with mortality for many cancer types.

CONCLUSIONS

Exposure to PM2.5 air pollution contributes to lung cancer mortality and may be a risk factor for other cancer types. Cigarette smoking has a larger impact on cancer mortality than PM2.5 , but is associated with similar cancer types.

Intensive stuttering modification therapy: a multidimensional assessment of treatment outcomes

Nineteen adults who stutter participated in a 3-week intensive stuttering modification treatment program (the Successful Stuttering Management Program [SSMP]). A series of 14 fluency and affective-based measures were assessed before treatment, immediately after treatment, and 6 months after treatment. Measures included stuttering frequency; the Stuttering Severity Instrument for Children and Adults, Third Edition (SSI-3); a self-rating of stuttering severity; the Perceptions of Stuttering Inventory (PSI); the Locus of Control of Behavior Scale; the Beck Depression Inventory; the Multicomponent Anxiety Inventory IV (MCAI-IV); and the State-Trait Anxiety Inventory. Statistically significant improvements were observed on 4 of the total 14 measures immediately following treatment and on 4 measures at 6 months posttreatment. Statistically significant improvements observed immediately posttreatment included scores on the SSI and the Struggle, Avoidance, and Expectancy subscales of the PSI. Sustained statistically significant improvements at 6 months posttreatment were observed only on client-reported perceptions of stuttering (the Avoidance and Expectancy subscales of the PSI) and 2 specific affective functioning measures (the Psychic and Somatic Anxiety subscales of the MCAI-IV). The SSMP generated some anxiolytic effects but was ineffective in producing durable reductions of core stuttering behaviors, such as stuttering frequency and severity. The discussion focuses on the strengths, weaknesses, and durability of the SSMP treatment approach.

Disparities in diabetes management practice between racial and ethnic groups in the United States

PURPOSE

The purpose of this study was to evaluate the association between race/ethnicity and self-management practices of people with diabetes.

METHODS

Analyses were based on data from the 2001 Behavioral Risk Factor Surveillance System. Contingency tables and multiple logistic regression were used to assess the data.

RESULTS

Frequency distributions of selected diabetes management variables significantly varied across levels of race/ethnicity. These differences persisted after adjusting for current age, age at diagnosis, gender, marital status, income, and education. Analyses revealed that Hispanics, compared with whites, were more likely to take oral agents to control their blood glucose, less likely to monitor their blood glucose daily, and less likely to check their feet for sores or irritation. There was no difference among the racial/ethnic groups use having participated in a diabetes education class.

CONCLUSIONS

Health literacy and cultural factors, including the influence of family, beliefs about diabetes, and access and utilization of health care, may influence Hispanic diabetes management behaviors. Understanding these influences is essential to the development of programs, policies, and other strategies that are culturally appropriate and relevant.