Public health protection vs. informed consent.
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Biomedical Research↗
Biomedical subjects
A P Bender
Publications and source records attributed to A P Bender.
Minnesota population cancer risk.
BACKGROUND: The Minnesota Cancer Surveillance System (MCSS) provides information on the occurrence of newly diagnosed cancers among Minnesota residents. Cancer is a major cause of death and morbidity in older persons. Population cancer risk (PCR) was assessed as a measure of the number of cancers that will occur in the lifetime of 1000 persons. METHODS: Approximately 98.6% of all cancers diagnosed in residents of Minnesota are reported by pathologists to the MCSS. By statistical methodology an estimate was made of the total number of cancers that will occur in the lifetime of 1000 people (PCR). The calculation assumes people born today will have the 1988-1990 Minnesota cancer incidence and life expectancy rates. RESULTS: Incidence rates for all cancers in Minnesota have been increasing. Life expectancy in Minnesota is greater than in most areas of the United States. Approximately 50% of all cancers occurred in Minnesotans older than 70 years. The overall PCR is 459 cancers per 1000 lifetimes. It is estimated that by the year 2020 more than 100,000 living Minnesotans will have had cancer diagnosed during their lifetime. CONCLUSION: During the next 20 years, as the Baby Boomer generation in Minnesota moves into the high-risk years for cancer, the number of newly diagnosed cancers will increase disproportionately more than the increase in size of the older population. In view of the projected number of patients with cancer by the year 2020, cancer care will be different from what it is today. Geriatric cancer care will become a significant medical, public health, economic, bioethical, and social issue.
Adolescent↗
Experiences of a state-sponsored notification and screening program for asbestos workers.
Worker notification can involve a broad range of activities including medical screening, personal and mass communications, cohort identification and tracing, and even litigation. The inclusion or exclusion of various supporting activities in a worker notification program may pose significant medical, public health, financial, logistical, and even legal implications for targeted individuals as well as for the agencies involved. This report describes some experiences in a state-sponsored notification and screening program of approximately 4,500 asbestos workers in Minnesota. In this program, a variety of factors led to the decision to provide medical screening to 1,101 workers and 451 spouses. It is anticipated that another 3,400 workers will be notified but not screened. A follow-up survey of notified workers showed overwhelming support for this program. It is estimated that this program will cost more than $650,000 by its completion. The decision to institute medical screening and other support activities should be made with careful consideration of the diverse implications of these activities to the individuals, communities, and agencies involved.
Asbestos↗
Data on prior pesticide use collected from self- and proxy respondents.
Proxy respondents have often been used in case-control studies of cancer and pesticides. To evaluate the effect of exposure misclassification, we compared data collected during 1981-1983 from participants interviewed for a case-control study of leukemia and non-Hodgkin's lymphoma with data collected during 1990-1991 from proxy respondents for participants who died or became incompetent since the initial interview (328 self-proxy pairs). As questions increased in detail, agreement percentages decreased. Agreement percentages were highest for demographic and general farming information (averages = 88-90%) and lowest for specific pesticide use (averages = 68-74%). Generally, odds ratios calculated from proxy respondent data were less than those from self-respondent data; however, several exceptions occurred. The findings indicate that pesticide data provided by proxy respondents will not necessarily result in the same estimate of risk and/or lead to the same conclusions as data provided by self-respondents.
Adult↗
A standard person-years approach to estimating lifetime cancer risk. The Section of Chronic Disease and Environmental Epidemiology Minnesota Department of Health.
Several methods have been used to estimate the lifetime probability of cancer, such as simple cumulative incidence or competing risk models. These methods are characterized by either simplistic assumptions or detailed computations. The standard person-years method, that parallels cohort analyses, offers a simpler and more accurate method of approximating the lifetime risks of cancer. Since lifetime cancer risk refers to the aggregate risk to a cohort rather than the risk to an individual, it is suggested that a new term, population cancer risk, be used in describing these risks. A reasonable definition for the population cancer risk is the expected number of cancers in the lifetimes of 1,000 people. Estimates of lifetime risks of cancer are interpreted best as a composite measure of the joint forces of cancer morbidity and all-cause mortality at a point in time. The overall population cancer risk (lifetime risk) for residents of Minnesota (United States) is calculated to be 465 cancers/1,000 people; national data provide similar results.
Adolescent↗
C-peptide response to meal challenge in nondiabetic and diabetic adults living in Wadena, Minnesota.
OBJECTIVE: The goal of the study was to provide cross-sectional descriptive data on the response of C-peptide to a vigorous meal stimulus in a population-based sample of nondiabetic adults compared with a population-based sample of adults with NIDDM. Available information is scanty, especially in subjects greater than 50 yr old. RESEARCH DESIGN AND METHODS: The group under study included 377 adults without previously known diabetes randomly chosen from the population of the city of Wadena, Minnesota, almost all of northern European background, and 88 adults with known diabetes. PCP was measured 90 min after ingestion of 480 ml liquid meal Ensure-Plus, which includes 95 g dextrose, 26 g protein, and 25 g fat. C-peptide also was measured in a 260-min urine collection after the meal challenge. Novo antibody M1221 was used for C-peptide assay throughout the study. Participants whose medical record indicated insulin-dependent diabetes with a history of acetone production were excluded from analyses. RESULTS: The distribution of UCP and PCP in this group of subjects appears very broad. Both the highest and lowest values for C-peptide were observed in individuals with diabetic glucose tolerance. The mean and median values in the nondiabetic group are higher than in previously published reports. After statistical adjustment for age, sex, BMI, and concomitant plasma glucose, participants with IGT produced significantly more C-peptide than the group with NGT (3.48 vs. 2.96 nM PCP, P less than 0.05). Participants with diabetic glucose tolerance and who were not taking insulin produced as much or more C-peptide than either the NGT or IGT groups, depending on the statistical model used for adjusting for plasma glucose. Diabetic participants who were taking insulin produced significantly lower amounts of C-peptide than any of the non-insulin-taking groups (approximately 30% of the C-peptide produced by the non-insulin-taking diabetic participants). A decline in PCP production with increasing years since diagnosis (5.7%/yr) was observed exclusively in the insulin-taking NIDDM participants. Effect modification by glucose tolerance classification was observed on the relationship between plasma glucose and PCP: PCP increased with increasing plasma glucose in NGT and IGT groups, but a nonsignificant negative relationship was exhibited in diabetic participants. CONCLUSIONS: The data suggest that two forms of NIDDM may exist, crudely distinguished by the clinical decision to use insulin to control blood glucose levels. The insulin-taking diabetic individuals may experience a greater likelihood of pancreatic failure, whereas non-insulin-taking diabetic individuals probably experience stable pancreatic function over the course of their disease. Longitudinal observation of the Wadena cohort will provide more insight into this possibility.
Adult↗
Effects of asbestos-related pleural disease on pulmonary function.
The relationship between loss of pulmonary function and the presence of asbestos-related pleural disease was evaluated for 913 Minnesota asbestos workers. Asbestos-related pleural disease was categorized as circumscribed plaques or diffuse thickening. Compared with workers with normal pleura, workers with plaques had a decreased mean percentage for predicted forced vital capacity (FVC) and predicted forced expiratory volume in 1 s (FEV1.0). Diffuse thickening was associated with more profound decreases in FVC and FEV1.0. No relationship was seen between FEV % [(100 x FEV1.0)/FVC)] and either type of pleural disease. Dyspnea was associated with diffuse thickening more so than plaques. These results remained after control for pack-years of smoking, extent of parenchymal disease, and the presence of pulmonary disease history. Pleural plaques and diffuse pleural thickening were considered independent risk factors for the loss of lung function.
Asbestosis↗
Use of coded mortality data to assess area cancer rates: impact of residence reporting and coding errors.
In spite of their limitations, mortality data are used in many epidemiologic and public health settings. In this investigation, the authors examined the extent to which community cancer mortality rates were affected by incorrect reporting or coding of residence on death certificates. Observed and expected cancer mortality for two adjacent communities in northern rural Minnesota for the periods 1970-1974 and 1980-1984 were obtained from computerized state mortality data. Using statewide rates to obtain expected values, standardized mortality ratios for total cancers for both periods combined were 138 for men (101 observed deaths) and 148 for women (86 observed deaths). These excesses were statistically significant (p less than 0.05). However, after review of data from the actual death certificates, city maps, and information from city officials, 44 of the 187 total cancer deaths (24%) were found to have had an incorrectly reported or coded residence status. After removal of these cases, the standardized mortality ratio for total cancers for males went from 138 to 107, and for females the standardized mortality ratio went from 148 to 111. No standardized mortality ratios remained statistically significant. These findings may have implications for those who use mortality data for assessing cancer rates in communities in rural areas.
Death Certificates↗
Appropriate public health responses to clusters: the art of being responsibly responsive.
Between 1981 and 1988, the Minnesota Department of Health actively responded to over 400 reports from persons concerned about disease occurrence in their community, school, or workplace. Almost all of these reports involved perceived excesses of cases of cancer. Although there is little potential for identifying unsuspected public health problems or developing new etiologic insights, the Minnesota Department of Health has found that responding to reported clusters is a legitimate and necessary public health activity. To be responsibly responsive to these concerns, the Department has developed four steps to prioritize investigation of reported disease clusters, as well as six criteria for determination of the feasibility of environmental epidemiologic investigations. Approximately 95% of all concerns have been handled within the first two steps of this approach, generally requiring only education, or sometimes examination of readily-available data. Less than 5% of the concerns have required additional data collection and evaluation, and only about 1% have resulted in full-scale epidemiologic studies. Successful conclusions at all levels of this process require that public health officials develop effective communication, maintain objectivity, and provide leadership for controversial and difficult issues.
Clinical Protocols↗
Minnesota highway maintenance worker cohort mortality study: methods and noncancer mortality.
In 1984, the Minnesota Department of Health (MDH) began a cohort mortality study of 4,849 workers to follow up concerns with the health and safety of highway maintenance workers (HMWs). A total of 1,530 deaths had occurred, resulting in a standardized mortality ratio (SMR) of 91 (p less than .01) and an all cancer SMR of 84 (p less than .01). There was a significant elevation in the SMR for chronic renal failure among long-term rural workers (SMR = 676, p less than .05). The SMR was also elevated for transportation injuries. The latter SMR was highest among short-term urban workers (SMR = 280, p less than .01). In addition, the SMR for transportation-related injury deaths tended to increase the later the decade of starting work. The SMRs were 137, 259, 502, and 2,145 for urban workers starting work in the decades 1945-1954, 1955-1964, 1965-1974, and 1975-1984, respectively. This study demonstrates the possible adverse health effects of highway maintenance work and the need to comprehensively evaluate injury mortality among selected occupational cohorts.
Accidents, Traffic↗
Minnesota Highway Maintenance Worker Study: cancer mortality.
Highway maintenance workers (HMWs) have been exposed to a broad range of potentially toxic substances, including diesel fuels and exhaust, asphalts and tars, herbicides, gasoline, polynuclear aromatic hydrocarbons, benzene, and lead. The number of current and former state, county, and municipal HMWs in the United States exceeds 500,000, yet the health risks of this occupation had never been studied. To fill this void and to respond to the public perception that Minnesota HMWs were at high risk of developing leukemia, an occupational cohort mortality study was conducted of Minnesota HMWs employed between 1945 and 1984. Leukemia mortality in HMWs with 30-39 years of work (standardized mortality ratio [SMR] = 425; 95% confidence interval [CI] = 171-876) and urologic cancer mortality in HMWs with 40-49 year latency (SMR = 292; CI = 117-602) were significantly elevated. The extent to which these and other findings were directly related to work exposures is unknown. Further investigations to resolve the significance of the risks associated with the HMW occupation are currently underway.
Cohort Studies↗
Public health implications of the variability in the interpretation of 'B' readings for pleural changes.
During 1985 in Minnesota, an initial reading of 566 radiographs found 30% of them to be positive for pleural changes. However, only 4% were considered positive by at least two out of three readers from National Institute for Occupational Safety and Health panel reading the radiographs under blind conditions. The implications of this variability in radiographic readings for public health decisions was illustrated in Minnesota, where selective overreading of radiographs of female subjects created an illusion of a generalized environmental problem rather than an occupational exposure. One solution to this dilemma is establishment of criteria to minimize false-positive pleural findings. The study also supports the need for more careful consideration of other disease processes in the interpretation of "B" readings.
False Negative Reactions↗
No involvement of bovine leukemia virus in childhood acute lymphoblastic leukemia and non-Hodgkin's lymphoma.
Bovine leukemia virus (BLV) is the causative agent of enzootic bovine lymphosarcoma. Much speculation continues to be directed at the role of BLV in human leukemia. To test this hypothesis rigorously, a case-control study of childhood acute lymphoblastic leukemia and non-Hodgkin's lymphoma was conducted between December 1983 and February 1986. Cases (less than or equal to 16 years at diagnosis) derived from patients diagnosed at the primary institutions and affiliated hospitals were matched (age, sex, and race) with regional population controls. DNA samples from bone marrow or peripheral blood from 157 cases (131 acute lymphoblastic leukemia, 26 non-Hodgkin's lymphoma) and peripheral blood from 136 controls were analyzed by Southern blot technique, under highly stringent conditions, using cloned BLV DNA as a probe. None of the 157 case or 136 control DNA samples hybridized with the probe. The high statistical power and specificity of this study provide the best evidence to date that genomic integration of BLV is not a factor in childhood acute lymphoblastic leukemia/non-Hodgkin's lymphoma.
Adolescent↗
Usefulness of comprehensive feasibility studies in environmental epidemiology investigations: a case study in Minnesota.
Episodes of public water supply contamination with industrial or agricultural chemicals frequently give rise to public concerns about adverse health effects. These concerns may precipitate epidemiologic or clinical investigations requiring large expenditures of state and federal resources regardless of whether such investigations are justified by scientific criteria. An alternative is a comprehensive feasibility study, utilizing all available information to determine whether large-scale studies are warranted or feasible. At a relatively modest cost, a feasibility study allows health officials to identify information needs and deficiencies, outline potential study options and costs, clearly establish the rationale for a proposed study or, conversely, prevent unwarranted expenditures of public resources. Furthermore, a feasibility study may in itself resolve many community and scientific concerns. This article provides a case study of the usefulness of a formal feasibility study in a situation involving an elevated cancer rate and contaminated municipal water supply wells surrounding a federal superfund site.
Costs and Cost Analysis↗
Prevalence of hypertension and associated risk factors among diabetic individuals. The Three-City Study.
A cross-sectional study was conducted from 1979 through 1982 in three rural Minnesota cities to describe the natural history of diabetes mellitus. Detailed abstracts of the medical records of physician-defined diabetic individuals were used to construct medical profiles. As part of the effort, the date of physician-defined hypertension was identified and used to calculate hypertension prevalence. The crude hypertension prevalence was 56.8% for women and 33.99% for men, with an overall crude prevalence of 47.2%. No hypertensive patients were identified among diabetic patients less than 15 yr old, and most hypertensive diabetic patients were greater than 70 yr old. Hypertension prevalence in diabetic individuals demonstrated a highly significant trend with age (P less than .01). Compared with the general population, diabetic individuals had a significantly higher prevalence of hypertension (P less than .01), largely explained by the higher prevalence in women. Variables known to be associated with hypertension risk in the general population were also significantly associated with hypertension among diabetic individuals. Older age, being female, and increased body mass index were strongly associated with hypertension in this study population. Diabetic individuals with hypertension were six times more likely to have renal disease than those without hypertension. The level of blood glucose control, diabetes treatment (i.e., insulin or oral hypoglycemics versus diet), and diabetes duration were not associated with hypertension.
Adolescent↗
Feasibility study of a statewide pathology-based cancer surveillance system in Minnesota. I. Information characteristics.
The Minnesota Department of Health has completed a 2-year feasibility study comparing the completeness and accuracy of information from pathology-based cancer ascertainment with that of the traditional surveillance method based on hospital discharge records. Overall, for incident cancers, the primary site designation of the pathology-based system was correct for 94.5% of the cancers, and the histologic designation was correct for 97.0% of the cancers. For prevalent cancers the accuracy of both site and histology designation was inadequate at 81.0 and 76.8% respectively. Pathology-based ascertainment was more complete than discharge-based surveillance (98.4% vs. 96.6%), which reflected the growing number of cancers diagnosed in hospital outpatient departments and medical clinics. The major limitation of the pathology-based system was the inability to determine from written pathology reports whether the cancer was newly diagnosed. However, when asked, pathologists correctly determined the incidence status for approximately 75% of the cancers. In light of the results of the feasibility study, Minnesota is implementing a pathology-based system as a cost-effective, scientifically valid method to meet the state's current and future needs for cancer surveillance.
Data Collection↗
On disease clustering.
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Data Collection↗
The quality of occupational data recorded from the face sheet of Minnesota hospital medical records.
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Hospital Records↗