AIMS: To describe the causes of severe visual impairment and blindness (SVI/BL) in children in schools for the blind in north India, and explore temporal trends in the major causes. METHODS: A total of 703 children were examined in 13 blind schools in Delhi. A modified WHO/PBL eye examination record for children with blindness and low vision which included sections on visual acuity, additional non-ocular disabilities, onset of visual loss, the most affected anatomical part of the eye concerning visual impairment, and the aetiological category of the child's disorder based on the timing of insult leading to visual loss was administered in all children. RESULTS: With best correction, 22 (3.1%) were severely visually impaired (visual acuity in the better eye of <6/60) and 628 (89.3%) children were blind (visual acuity in the better eye of <3/60). Anatomical sites of SVI/BL were whole globe in 27.4% children, cornea 21.7%, retina 15.1%, and lens 10.9%. The underlying cause of visual loss was undetermined in 56.5% children (mainly abnormality since birth 42.3% and cataract 8.3%), childhood disorders were responsible in 28.0% (mainly vitamin A deficiency/measles 20.5%), and hereditary factors were identified in 13.4%. Study of temporal trends of SVI/BL by comparing causes in children in three different age groups-5-8 years, 9-12 years, and 13-16 years-suggests that retinal disorders have become more important while childhood onset disorders (particularly vitamin A deficiency) have declined. CONCLUSIONS: Almost half of the children suffered from potentially preventable and/or treatable conditions, with vitamin A deficiency/measles and cataract the leading causes. Retinal disorders seem to be increasing in importance while childhood disorders have declined over a period of 10 years.

Adolescent↗

PubMed2001

Comorbid illness and the early detection of cancer.

BACKGROUND: Comorbidity may be associated with later detection of cancer. METHODS: Incident cases of colorectal, breast, and prostate cancer and melanoma were determined from the 1994 Florida state tumor registry (N = 32,074). The relationship between comorbidity and late stage at diagnosis was examined using multiple logistic regression. RESULTS: Patients with comorbid conditions had greater odds of late stage diagnosis for each of the four cancers (colorectal, melanoma, breast, and prostate). Higher mortality rates were observed among patients with comorbid illness, not as a result of later stage at diagnosis, but rather due to their underlying disease. CONCLUSIONS: Comorbidity was associated with later stage diagnosis. Further research is needed to determine mechanisms by which comorbidity might influence stage at diagnosis.

Breast Neoplasms↗

PubMed2001

Predictors of advanced stage colorectal cancer diagnosis: results of a population-based study.

While colon cancer is a leading cause of morbidity and mortality among men and women, little is known about demographic variables associated with advanced stage diagnosis at diagnosis. We examined the relationship of age, gender, income, education, marital status, smoking status, urban versus rural residence, and proximal versus distal tumor location on stage at diagnosis. Data from Florida statewide cancer registry for the year 1994 with over 8,933 cases of colorectal cancer was analyzed. Using multivariate analysis, an odds ratio of being diagnosed with advanced stage disease was determined for each demographic variable. We found a significantly increased probability (P < .05) of diagnosis with advanced stage disease for distal lesions in middle-aged persons, smokers, and those with higher education or lower income status. If these findings are verified, they may suggest a group that warrants targeted screening intervention or programs over and above today's current colorectal screening recommendations.

Adenocarcinoma↗

PubMed2000

Effects of health insurance and race on breast carcinoma treatments and outcomes.

BACKGROUND: The authors hypothesized that insurance payer and race would influence the care and outcomes for patients with breast carcinoma. METHODS: The authors examined treatments and adjusted risk of death (through 1997) for all incident cases of breast carcinoma occurring in Florida in 1994 (n = 11,113) by using state tumor registry data. RESULTS: Patients lacking health insurance were less likely to receive breast-conserving surgery (BCS) compared with patients who had private health insurance. Among patients insured by Medicare, those belonging to a health maintenance organization (HMO) were more likely to receive BCS but less likely to receive radiation therapy after BCS. Non-Hispanic African Americans had higher mortality rates even when stage at diagnosis, insurance payer, and treatment modalities used were adjusted in multivariate models (adjusted risk ratio [RR], 1.35; 95% confidence interval [CI], 1.12-1.61; P = 0.001). Patients who had HMO insurance had similar survival rates compared with those with fee-for-service (FFS) insurance. Among non-Medicare patients, mortality rates were higher for patients who had Medicaid insurance (RR, 1.58, 95% CI, 1.18-2.11; P = 0.002) and those who lacked health insurance (RR, 1.31; 95% CI, 1.03-1.68; P = 0.03) compared with patients who had commercial FFS insurance. There were no insurance-related differences in survival rates, however, once stage at diagnosis was controlled. CONCLUSIONS: As a result of later stage at diagnosis, patients with breast carcinoma who were uninsured, or insured by Medicaid, had higher mortality rates. Mortality rates were also higher among non-Hispanic African Americans, a finding that was not fully explained by differences in stage at diagnosis, treatment modalities used, or insurance payer.

Black or African American↗

PubMed2000

Clinical and demographic predictors of late-stage cervical cancer.

BACKGROUND: Despite increasingly widespread use of the Papanicolaou smear, almost half of all women with invasive cervical cancer are diagnosed at a late stage (regional or distant). Little is known about factors associated with late-stage diagnosis of cervical cancer. OBJECTIVE: To examine the relationship of age, race, education level, income level, smoking, marital status, health insurance type, comorbidity, and residence in an urban or rural setting to late stage at diagnosis of cervical cancer. METHODS: Incident cases of invasive cervical cancer occurring in 1994 in Florida were identified from the state tumor registry (N = 852). Cases were linked with state discharge abstracts and the 1990 US census. Multiple logistic regression was used to determine the relationship between predictor variables (age, race or ethnicity, marital status, smoking status, education level, income level, insurance type, comorbidity, and urban vs rural residence) and the odds of late-stage diagnosis. RESULTS: Age, marital status, and insurance type were associated with late-stage diagnosis. Each additional year of age was associated with a 3% increased odds of late-stage diagnosis (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.02-1.05; P<.001). Being unmarried was associated with a 63% increased odds of late-stage diagnosis (OR, 1.63; 95% CI, 1.18-2.25; P=.003). Being uninsured was associated with a 60% increased odds of late-stage diagnosis (OR, 1.60; 95% CI, 1.07-2.38; P=.02). Having commercial health maintenance organization insurance was associated with a 46% decreased odds of late-stage disease (OR, 0.54; 95% CI, 0.30-0.96; P=.04). Race, education level, income level, smoking status, comorbidity, and urban residence were not associated with stage at diagnosis. CONCLUSIONS: Women with cervical cancer who are elderly, unmarried, and uninsured are more likely to be diagnosed at a late stage. These women should be targeted for cervical cancer education and screening programs.

Adult↗

PubMed2000

Demographic predictors of melanoma stage at diagnosis.

OBJECTIVE: To examine sociodemographic characteristics as possible predictors of late-stage melanoma diagnosis. We hypothesized that late-stage diagnosis would be associated with the following: older age, male sex, unmarried status, lower educational attainment and income level, rural residence, and cigarette smoking. METHODS: We used data from the state tumor registry to study all incident cases of melanoma occurring in Florida during 1994 whose stage at diagnosis was available (N = 1884). We used multiple logistic regression to determine the effects of sociodemographic characteristics on the odds of late-stage (regional or distant metastases) diagnosis. RESULTS: There were 243 patients (12.9%) diagnosed as having melanoma that had metastasized to either regional lymph nodes or distant sites. Patients who were unmarried (odds ratio, 1.5; P= .01), male (odds ratio, 2.2; P<.001), or smokers (odds ratio, 2.2; P<.001) or who resided in communities with lower median educational attainment (odds ratio, 1.5; P= .048) had greater odds of having a late-stage diagnosis. CONCLUSIONS: To detect these cancers at an earlier stage and improve outcomes, there should be increased educational efforts directed toward physicians who treat these patients. A recognition that there may be additional risk factors for late-stage diagnosis, beyond the established risk factors, such as family history and excess sun exposure, should be included in the initial assessment. Specific public education efforts should also be targeted to these patients to increase their self-surveillance and surveillance of their partners.

Adolescent↗

PubMed2000

The use and outcomes of outpatient mastectomy in Florida.

BACKGROUND: To identify patient characteristics associated with outpatient mastectomies and their outcomes. METHODS: Patients diagnosed with breast cancer and treated with mastectomies in Florida in 1994 were identified from state discharge abstracts and the state tumor registry. The relationship between clinical/demographic characteristics and the odds of having an outpatient mastectomy was identified using multiple logistic regression. Outcomes were assessed by calculating the risk of being rehospitalized within 30 days of discharge. RESULTS: Twenty percent of mastectomies were performed on an outpatient basis. Outpatient mastectomies were more likely to be performed on women who were older, who lived in higher income communities, or who were uninsured. Health insurance type was not associated with having an outpatient mastectomy. Women undergoing outpatient mastectomy were more likely to be readmitted within 30 days of discharge; however, the excess risk was very small (0.7%). CONCLUSIONS: The risks from outpatient mastectomy are small. Ongoing monitoring of outcomes and assessment of patient satisfaction are needed.

Ambulatory Surgical Procedures↗

PubMed2000

Increasing supplies of dermatologists and family physicians are associated with earlier stage of melanoma detection.

BACKGROUND: Physicians are important in the early detection of melanoma. We investigated whether primary care physician supply and the supply of dermatologists were related to stage at diagnosis for malignant melanoma. METHODS: From the state tumor registry in Florida in 1994, we identified incident cases of malignant melanoma for which stage at diagnosis was available (N = 1884). Data on physician supply was obtained from the 1994 American Medical Association Physician Masterfile. Logistic regression determined the effects of physician supply (at the ZIP code level) on the odds of early-stage diagnosis controlling for patients' age, gender, race/ethnicity, marital status, education level, income level, comorbidity, and type of health insurance. RESULTS: Each additional dermatologist per 10,000 population was associated with a 39% increased odds of early diagnosis (odds ratio = 1.39, 95% confidence interval [CI] 1.09-1.70, P =.010). For each additional family physician per 10,000 population, the odds of early diagnosis increased 21% (odds ratio = 1.21, 95% CI 1.09-1.33, P <.001). Each additional general internist per 10,000 population was associated with a 10% decrease in the odds of early-stage diagnosis (odds ratio = 0.90, 95% CI 0.83-0.98, P =.009). The supplies of general practitioners, obstetrician/gynecologists, and other nonprimary care specialists were not associated with stage at diagnosis. CONCLUSIONS: Increasing supplies of dermatologists and family physicians were associated with earlier detection of melanoma. In contrast, increasing supplies of general internists were associated with reduced odds of early detection. Our findings suggest that the composition of the physician work force may affect important health outcomes and needs further study.

Dermatology↗

PubMed2000

Effects of health insurance and race on colorectal cancer treatments and outcomes.

OBJECTIVES: We hypothesized that health insurance payer and race might influence the care and outcomes of patients with colorectal cancer. METHODS: We examined treatments received for all incident cases of colorectal cancer occurring in Florida in 1994 (n = 9551), using state tumor registry data. We also estimated the adjusted risk of death (through 1997), using proportional hazards regression analysis controlling for other predictors of mortality. RESULTS: Treatments received by patients varied considerably according to their insurance payer. Among non-Medicare patients, those in the following groups had higher adjusted risks of death relative to commercial fee-for-service insurance: commercial HMO (risk ratio [RR] = 1.40; 95% confidence interval [CI] = 1.18, 1.67; P = .0001), Medicaid (RR = 1.44; 95% CI = 1.06, 1.97; P = .02), and uninsured (RR = 1.41; 95% CI = 1.12, 1.77; P = .003). Non-Hispanic African Americans had higher mortality rates (RR = 1.18; 95% CI = 1.01, 1.37; P = .04) than non-Hispanic Whites. CONCLUSIONS: Patients with colorectal cancer who were uninsured or insured by Medicaid or commercial HMOs had higher mortality rates than patients with commercial fee-for-service insurance. Mortality was also higher among non-Hispanic African American patients.

Black or African American↗

PubMed2000

Comparing the toxicity of digoxin and digitoxin in a geriatric population: should an old drug be rediscovered?

BACKGROUND: Little information is available regarding toxicity rates of the two available forms of cardiac glycosides (digoxin, digitoxin) when used in elderly patients. METHODS: We retrospectively analyzed the charts of all patients more than 60 years of age who were chronically managed with a cardiac glycoside and were hospitalized during the period January 1995 through January 1998. Toxicity was defined as any clinical event that required either a reduction in dose of the drug or its discontinuance. RESULTS: Toxicity occurred among 7.6% of hospitalizations in which digitoxin was used, compared with 18.3% of hospitalizations in which digoxin was used. In multivariate analysis, the odds of toxicity adjusted for other clinical characteristics were three times greater for patients taking digoxin than for patients taking digitoxin. CONCLUSION: Hospitalized elderly patients taking digitoxin had a lower rate of toxicity than those taking digoxin.

Aged↗

PubMed2000

The accuracy of community-based automated blood pressure machines.

BACKGROUND: Despite widespread use, the accuracy of community-based automated blood pressure machines has been questioned. We sought to determine if these machines are as accurate and reliable as those obtained by a clinician with a mercury manometer. METHODS: We randomly selected 25 pharmacies and compared blood pressure readings obtained from their automated machines with from a mercury manometer. We used 3 volunteers with arm circumferences at the low, medium, and high ends of the acceptable range of a normal adult cuff size. RESULTS: For the subject with the small arm size, store machines reported systolic pressure readings that were, on average, 10 mm Hg higher than those obtained by the clinician (P <.001) and diastolic pressures 9 mm Hg higher (P <.001). The mean systolic pressure readings for the subject with the medium arm size were not significantly different between the store machine and the mercury manometer, and the readings were only modestly different for diastolic pressure. For the subject with the large arm size, store machines reported diastolic pressure readings that were, on average, 8.3 mm Hg lower than those obtained using the mercury manometer (P <.001), but with no significant difference in the systolic pressure. CONCLUSIONS: We found that automated blood pressure machines from a representative community-based sample of pharmacies did not meet the accepted standards of accuracy and reliability. Accuracy of readings is especially uncertain for patients having arm sizes larger or smaller than average.

Adult↗