BACKGROUND: A case-control study was conducted with 183 histologically confirmed neuroblastoma cases aged 0-14 years diagnosed among residents of New York State, excluding New York City, between 1976 and 1987. Three hundred seventy-two controls were selected from the New York State live birth certificate registry and were matched to cases on year of birth. METHODS: Parental occupational exposures at the time of each child's birth were obtained from maternal telephone interviews, successfully completed for 85% of cases and 87% of controls. RESULTS: Odds ratios were significantly elevated for maternal occupation in the service (OR = 2.0, 95% CI = 1.0 4.1) and retail (OR = 2.0, 95% CI = 1.1-3.7) industries and paternal occupation in materials handling (OR = 3.8, 95% CI = 1.1-14.6). Odds ratios were also significantly elevated for maternal report of occupational exposure to acetone (OR = 3.1, 95% CI = 1.7-5.6), insecticides (OR = 2.3, 95% CI = 1.4-3.7), lead (OR = 4.7, 95% CI = 1.3-18.2) and petroleum (OR = 3.0, 95% CI = 1.5-6.1) and paternal exposure to creosote (OR = 2.1, 95% CI = 1.1-4.3), dioxin (OR = 6.9, 95% CI = 1.3-68.4), lead (OR = 2.4, 95% CI = 1.2-4.8), and petroleum (OR = 1.8, 95% CI = 1.1-2.8). CONCLUSIONS: Due to the uncertainty of the biologic plausibility of these associations and the possibility of alternative explanations, these results should be interpreted cautiously.

Acetone↗

PubMed2000

Clinical predictors of dysphagia and aspiration risk: outcome measures in acute stroke patients.

OBJECTIVE: To use an established dysphagia clinical screening system to evaluate outcomes in acute stroke patients. DESIGN: Case-control study. SETTING: Tertiary care center. PARTICIPANTS: Acute stroke patients (n = 56) consecutively referred to a speech pathology service. MAIN OUTCOME MEASURES: Outcomes (ie, pneumonia, dietary status at discharge) in patients who were referred for a videofluoroscopic swallow study (VSS) based on results of a previously validated clinical screening system were compared with outcomes in patients who were not referred for VSS based on the clinical evaluation. RESULTS: Thirty-eight of 56 patients (68%) presented with 2 or more clinical predictors of moderate to severe dysphagia and were further evaluated with VSS, whereas 18 patients (32%) had fewer than 2 clinical features and were not evaluated radiographically. Based on patient outcomes and VSS results, identification of at least 2 clinical predictors significantly distinguished patients with moderate to severe dysphagia from patients with mild dysphagia or normal swallowing. None of the patients in either group developed pneumonia while following recommendations of the clinical or dynamic swallowing evaluation, and 93% of the patients returned to a regular diet. CONCLUSIONS: These data demonstrate that clinical use of this screening system can objectively identify acute stroke patients who warrant further diagnostic studies and can safely determine which patients need no further deglutitive evaluation.

Case-Control Studies↗

PubMed2000

Predictors of anticipated breastfeeding in an urban, low-income setting.

BACKGROUND: Although the proportion of women who breastfeed is known to vary by demographic group, breastfeeding practices have not been sufficiently studied among urban, lower income African American populations seen in family medicine centers. METHODS: A cross-sectional design was used to examine demographic, clinical, and attitudinal factors that affect anticipated infant feeding practices reported by postpartum women from a low-income, urban family practice setting. Data was analyzed using chi-square, odds ratios (OR), and multiple logistic regression techniques. RESULTS: Among 66 respondents, only 3 subjects (4.5%) indicated that they planned to breastfeed exclusively, while an additional 11 subjects (16.7%) reported plans to use a combination of bottle-feeding and breastfeeding. Based on univariate analyses, women with less than 12 years of education were less likely to report anticipated breastfeeding. Otherwise, breastfeeding plans were not associated with subject demographic features or with reproductive characteristics. Respondents planning to bottle-feed noted that breastfeeding was too complicated. Logistic regression demonstrated an inverse relationship between level of maternal education and anticipated breastfeeding (OR=0.13, 95% confidence interval [CI], 0.05-0.35), and a direct association for encouragement from the baby's father or the woman's mother to breastfeed and anticipated breastfeeding (OR=12.4; 95% CI, 4.92-31.4). CONCLUSIONS: This study reports unique data regarding anticipated infant feeding practices among patients from an urban, low-income community served by a family medicine center. Findings from this study will be used to develop a family-centered educational intervention involving the mothers, grandmothers, and partners of pregnant patients to promote the benefits of breastfeeding in this community.

Adolescent↗

PubMed2000

Hypothyroidism and diabetes mellitus in an American Indian population.

BACKGROUND: The clinical relationship between diabetes and hypothyroidism is becoming more widely recognized. Although American Indians are disproportionately afflicted with diabetes, the occurrence of hypothyroidism within this group has not been previously reported. METHODS: We present data from a retrospective chart review of health clinic data from a rural isolated northeastern tribe. A total of 156 cases of diabetes and 25 cases of hypothyroidism were identified among 892 eligible individuals living in the service area. RESULTS: Both conditions exhibited strong sex differences. The prevalences of diabetes (21%) and hypothyroidism (5%) among women were higher than those observed among men (13% and 0.2%, respectively). The overall prevalence of hypothyroidism among women with diabetes (8.8%) varied by age ranging from 5% among women younger than 60 years to 21% among women aged 60 years and older. CONCLUSIONS: Our findings support the need for further investigation of the association between diabetes and hypothyroidism in American Indian populations with high prevalence rates of diabetes. This association may be of particular interest to family physicians and other clinicians caring for American Indian populations.

Diabetes Complications↗

PubMed1999

The health status of American Indians and Alaska Natives: 2. Lessons for cancer educators.

Malignant disease is largely unrecognized as a leading cause of death among American Indians and Alaska Natives (AI/ANs). Published studies of cancer incidence, cancer mortality, and cancer survival are highlighted to present an overview on the epidemiology of cancer among Native peoples. Cancer incidence and mortality have demonstrated steady increases among AI/ANs during a relatively limited time frame, as well as unique patterns of site-specific cancers. Cancer-survival data reveal that Native peoples have the poorest survival of any racial group for all cancer sites combined and for eight of the ten leading sites. Opportunities to educate health care providers, through continuing medical education programs and focused conferences for postdoctoral and current medical trainees, can be used to enhance cultural sensitivity and to examine ethnic differences in cancer patterns. Enhancement of recognition of the unique cancer patterns among AI/AN populations may lead to improved identification of at-risk individuals and more effective cancer screening programs within Native communities.

Cause of Death↗

PubMed1999

A clozapine overdose with markedly elevated serum levels.

Clozapine (Clozaril) is an atypical antipsychotic agent used to treat schizophrenia refractory to other pharmacological agents. This report describes an accidental clozapine overdose. The half-life of clozapine in this patient was determined from two blood levels, one obtained on admission and the second 10.5 hours later. The calculated half-life of 8.11 hours is consistent with published levels for single doses and suggests an apparent stability in clozapine elimination half-life in the face of overdose. The maximum clozapine blood level attained was probably among the highest nonfatal levels reported. The patient recovered fully following hospital admission for monitoring and supportive care. This case report illustrates the usefulness of following the time course of the changes in blood level at selected time intervals, as well as the importance of entertaining a diagnosis of drug overdose in patients presenting with acute mental status changes.

Adult↗

PubMed1999

An investigation of hypomagnesemia among ambulatory urban African Americans.

BACKGROUND: Magnesium represents the fourth most abundant cation in the body and plays an integral role in intracellular metabolism. Although magnesium deficiency states have been associated with a variety of medical conditions, the prevalence of hypomagnesemia has not been well studied, particularly in ambulatory settings. METHODS: We performed a period prevalence study using 120 patients seen for routine medical care at an urban family medicine center. Chart reviews were completed for these subjects. We used univariate and multivariate analyses to correlate magnesium levels with demographic and clinical factors. RESULTS: There was a 20% overall prevalence of hypomagnesemia among this predominantly female, African American population. The prevalence of hypomagnesemia was greatest among patients with a history of alcoholism (odds ratio [OR] = 6.00; 95% confidence interval [CI], 1.41-26.1) and among those having 1 or more of the following medical conditions: diabetes, hyperlipidemia, hypertension, renal disease, and asthma (OR = 4.69; 95% CI, 1.37-17.65). CONCLUSIONS: The prevalence of hypomagnesemia among patients from this urban minority community exceeds that reported in previous studies of the general population. This may be reflective of greater comorbidity, diminished nutritional status, or poorer overall health among patients from this community. The association between hyperlipidemia and magnesium deficiency warrants further investigation.

Adult↗

PubMed1998

Health status of American Indians/Alaska Natives: general patterns of mortality.

BACKGROUND AND OBJECTIVES: Investigations of American Indian and Alaska Native (AI/AN) populations suggest patterns of mortality that differ from the general population. Mortality data reveal excess overall mortality among AI/ANs, as well as excesses for specific causes of death, including accidents, diabetes, liver disease, pneumonia/influenza, suicide, homicide, and tuberculosis. A relative deficit of deaths has been noted for heart disease, cancer, and HIV infections. It is important that physicians demonstrate cultural competence so they may provide quality medical care for the populations they serve. Activities such as provider education, risk assessment, and emphasis on preventive services are offered to facilitate integration into teaching curricula. Knowledge of distinctive mortality patterns among AI/ANs will help clinicians recognize the unique needs of these patients.

Accidents↗

PubMed1998

Improving diabetes preventive care in a family practice residency program: a case study in continuous quality improvement.

BACKGROUND AND OBJECTIVES: The paradigm of continuous quality improvement (CQI) holds promise for application in clinical settings. This paper highlights results of a CQI project developed and implemented in a residency-based, ambulatory family medicine center for management of non-insulin-dependent diabetes mellitus. METHODS: We developed a CQI program that used several indicators of diabetes management as measures of quality care. These included dietary counseling, exercise counseling, foot care counseling, ophthalmology referral, and measurement of hemoglobin AIC and renal function. RESULTS: Overall, compliance with recommendations for diabetes management increased from a baseline proportion of 40% to a level of 70% at the end of 1 year. During the second year, overall compliance was maintained at this level despite the inclusion of additional performance indicators. CONCLUSIONS: The CQI process can improve physician performance in managing patients with diabetes.

Clinical Competence↗

PubMed1998

Persistent dysphagia and dysphonia following cervical spine surgery.

Persistent dysphagia and dysphonia following anterior cervical spine surgery have been underdiagnosed. Understanding the physiologic mechanism resulting in post-surgical dysphagia and dysphonia is essential to providing appropriate treatment. Two cases of protracted dysphagia and dysphonia following left anterior cervical corpectomy were reviewed. Videofluoroscopic evaluation, videostroboscopic assessment and laryngeal nerve-conduction testing were used to determine swallowing, vocal fold and cranial nerve integrity; to assess the ability to achieve oral nutrition; and to direct therapy and surgical procedures to improve swallowing and voice. With a multidisciplinary approach, the physiologic problems of post-surgical dysphagia and dysphonia can be addressed and therapeutic and/or surgical treatments initiated promptly.

Cervical Vertebrae↗

PubMed1996

Native American Cancer Conference III. Cognitive correlates and impressions of attendees.

BACKGROUND: The results of preconference and postconference surveys, as well as conference evaluation forms, distributed to attendees at the "Native American Cancer Conference III: Risk Factors, Outreach and Intervention Strategies," Seattle, Washington, June 16-19, 1995, are presented. METHODS: Conference attendees were requested to complete a multi-item survey designed to assess knowledge and perceptions relating to cancer among native peoples at the beginning and end of the conference. The evaluation instrument solicited qualitative impressions of the conference. RESULTS: Survey respondents were predominantly female (70%), and approximately half were native persons representing 48 different American Indian and Alaska Native communities. Knowledge levels were generally high at baseline for most items relating to cancer, with evidence of significant improvement for several items on the postconference survey. The majority of respondents believed that cancer was of equal importance compared with other health problems and that cancer services for American Indians and Alaska Natives are generally less extensive compared with the majority population; there was no evidence of opinion change noted in the postconference survey. Results from the qualitative evaluation expressed the unique and affirmative experiences among participants in terms of the social, cultural, and informational sharing that occurred. CONCLUSIONS: It is hoped that the positive experiences of conference attendees will serve to stimulate the organization of similar programs and the design of research projects that both assess and expand cancer control services among Native peoples.

Adult↗

PubMed1996

Tribal-based cancer control activities. Services and perceptions.

BACKGROUND: Cancer is becoming a significant health problem for American Indians and Alaska Natives. Despite the precipitous increase in cancer rates in these populations, limited data are available regarding the extent of cancer control services available in these communities. METHODS: A cross-sectional survey of tribal health directors of all federally recognized tribes was undertaken to discover the breadth of cancer control activities offered and directors' perceptions of and priorities ascribed to cancer. RESULTS: Little more than half (53%) of respondents perceived cancer rates to be increasing. Cancer was found to rank fifth among seven health conditions when directors were asked to rank their tribe's commitment to confronting each. Lower relative levels of awareness of cancer patterns coupled with competing health problems relegated cancer control activities to low-priority issues. CONCLUSIONS: Findings from this study underscore the need to elevate the issue of cancer in Indian Country and to educate investigators to become more sensitive and responsive to other tribal health issues.

Alaska↗

PubMed1996

Gravid health status, medication use, and risk of neuroblastoma.

The epidemiology of neuroblastoma suggests that prenatal exposures may be important etiologic factors in this disease. The authors describe the role of maternal health status and prenatal medication usage and risk of neuroblastoma. This retrospective study was based on completed interviews with 183 histologically confirmed neuroblastoma cases aged 0-14 years diagnosed among residents of New York State (excluding New York City) between 1976 and 1987. Controls were matched to cases on year of birth and race and were drawn from the New York State live birth certificate registry. Interviews were satisfactorily completed with 85% of the cases and 87% of controls. Significantly elevated odds ratios were noted for vaginal infections during pregnancy (odds ratio (OR) = 2.2, 95% confidence interval (CI) 1.2-4.0), medical treatments for vaginal infection during pregnancy (OR = 2.4, 95% CI 1.2-4.9), and any reported use of sex hormones during pregnancy (OR = 3.0, 95% CI 1.3-6.9). Point estimates for any hormone use suggested elevated risk among male offspring (OR = 4.4, 95% CI 1.5-13.3). Among the individual exposures comprising any hormone use, only hormone use related to infertility was observed to be significant (OR = 10.4, 95% CI 1.2-89.9). A protective effect was noted for self-reported vitamin use (OR = 0.28, 95% CI 0.03-0.69). Although it is not possible to presume a specific role for prenatal hormone exposure as initiator or promoter, these findings lend support to an association between prenatal hormone exposure and risk of neuroblastoma.

Adolescent↗

PubMed1996

Correlates of cochlear implantation, 1986-1992.

There is a paucity of information regarding the use of cochlear implants within large populations. This article describes correlates of cochlear implantation procedures using a statewide hospital discharge database. Among the 146 implant procedures, 55% involved female patients, whereas the largest groups of patients were represented by younger and older persons (27% between ages 2 and 9 years and 24% 60 years and older). A bimodal distribution was apparent for average annual age-specific rates of cochlear implantation, with the highest rates among persons aged 2 to 9 years (5.4 implants per 1 million) and persons aged 60 to 69 years (3.7 implants per 1 million). Total hospital charges, excluding professional fees, exceeded $12,000 per implant and were found to vary significantly when examined by length of stay and by calendar year of procedure. The data presented are unique with regard to the total number of cochlear implant procedures included and the large, diverse population used. This study expands knowledge concerning the epidemiology and utilization of cochlear implantation.

Adolescent↗