Appathurai Balamurugan

Years of potential life lost and productivity costs because of cancer mortality and for specific cancer sites where human papillomavirus may be a risk factor for carcinogenesis-United States, 2003.

Although years of potential life lost (YPLL) and mortality‐related productivity costs comprise a substantial portion of the burden of cancers where human papillomavirus (HPV) may be a risk factor for carcinogenesis (called HPV‐associated cancers in this report), estimates of these costs are limited. The authors estimated the mortality‐related burden (in terms of YPLL and productivity costs) of HPV‐associated cancers (without regard to the percentage of each of these cancers that could be attributed to HPV) and all malignant cancers in the United States in 2003.

Subsequent primary cancers among men and women with in situ and invasive melanoma of the skin

BACKGROUND An estimated 750,000 melanoma survivors in the United States are at increased risk of subsequent primary cancers. OBJECTIVE We sought to assess the risk of developing subsequent primary cancers among people with cutaneous melanoma. METHODS Using 1992 to 2006 data from the National Cancer Institute Surveillance, Epidemiology, and End Results Program, 40,881 people with in situ melanoma and 76,041 people with invasive melanoma were followed up (mean of 5.6 years) for the development of subsequent primary cancers. The observed number of subsequent cancers was compared with those expected based on age-/race-/year-/site-specific rates in the Surveillance, Epidemiology, and End Results population. Standardized incidence ratios (SIRs) (SIR = observed number/expected number) were considered statistically significant if they differed from 1, with an alpha level of 0.05. RESULTS After a first primary in situ melanoma, risk was significantly elevated for subsequent invasive melanoma and chronic lymphocytic leukemia among men (SIRs = 8.43 and 1.44, respectively) and women (SIRs = 12.33 and 1.79, respectively). After a first primary invasive melanoma, risk was significantly elevated for subsequent invasive melanoma, thyroid cancer, non-Hodgkin lymphoma, and chronic lymphocytic leukemia among both men (SIRs = 12.50, 2.67, 1.56, and 1.57, respectively) and women (SIRs = 15.67, 1.77, 1.42, and 1.63, respectively). LIMITATIONS Case ascertainment issues particularly affecting in situ melanoma cases could affect results. The role of detection bias in the diagnoses of some subsequent cancers cannot be completely eliminated. CONCLUSIONS The findings of the study should guide the development of strategies such as posttreatment surveillance, screening, and ultraviolet exposure education among melanoma survivors to improve cancer survivorship.

Potential Role of Human Papillomavirus in the Development of Subsequent Primary In Situ and Invasive Cancers Among Cervical Cancer Survivors

The recent licensure of human papillomavirus (HPV) vaccines will likely decrease the development of primary in situ and invasive cervical cancers and possibly other HPV‐associated cancers such as vaginal, vulvar, and anal cancers. Because the HPV vaccine has the ability to impact the development of >1 HPV‐associated cancer in the same individual, the risk of developing subsequent primary cancers among cervical cancer survivors was examined.

Access to and Use of Eye Care Services in Rural Arkansas

CONTEXT Rural residents are more likely to be uninsured and have low income. PURPOSE To determine if rural residents in Arkansas have decreased access to eye care services and use them less frequently than urban residents. METHODS Data from the 2006 Visual Impairment and Access to Eye Care Module from the Arkansas Behavioral Risk Factor Surveillance System (BRFSS) were used in the analysis. Adults age 40 years and older were included (n = 4,289). Results were weighted to reflect the age, race, and gender distribution of the population of Arkansas. Multiple logistic regression was used to adjust for demographic differences between rural and urban populations. FINDINGS Significantly fewer rural residents (45%) reported having insurance coverage for eye care services compared with residents living in urban areas (55%). Rural residents were less likely (45%) than urban residents (49%) to have had a dilated eye exam within the past year. Among residents aged 40-64, those from rural areas were more likely than their urban counterparts to report cost/lack of insurance as the main reason for not having a recent eye care visit. CONCLUSIONS In 2006, rates of eye care insurance coverage were significantly lower for rural residents while use of eye care services differed slightly between rural and urban residents. Rural residents in Arkansas age 40-64 would benefit from having increased access to eye care insurance and/or low cost eye care services.

The Neighborhood Where You Live Is a Risk Factor for Stroke

Background— The excess stroke mortality in the southeastern states of the United States (stroke-belt states) is well known; however, the factors associated with this pattern have not been fully elucidated. We measured the contribution of several demographic factors by analyzing stroke mortality data (2005–2009) at the census block group (BG) level in the state of Arkansas. Methods and Results— Census BGs were used as proxies for neighborhoods. BGs were stratified using 5 census measures: poverty (percent of population below federal poverty level), population density (population per square mile), education (percent of population aged >25 years who did not graduate from high school), population mobility (percent of population who resided at the same address 1 year ago), and the percent of non-Hispanic blacks (percent of population that is black). Generalized additive models were used to estimate the variation in stroke mortality among BGs and to assess the impact of different demographic variables. From 2005 to 2009, there were 8930 stroke deaths in Arkansas. There was considerable variation in the relative risk even between adjacent BGs within a single county. The geographically weighted regression analyses indicated that 4.5% to 9% of deviance in stroke mortality among BGs could be explained by poverty, education, population density, and population mobility. Race/ethnicity (non-Hispanic blacks) explains <2% of the deviance in stroke mortality among BGs. Conclusions— Our study shows that primordial risk factors such as poverty and education drive disparities in stroke mortality among neighborhoods in Arkansas.

Aldehyde dehydrogenase as an alternative to enumeration of total and viable CD34+ cells in autologous hematopoietic progenitor cell transplantation

We validated the correlation of aldehyde dehydrogenase ALDH(br) cells with total and viable CD34(+) cells in fresh and thawed hematopoietic progenitor cell (HPC) products, and looked for a correlation with time to white blood cell (WBC) and platelet engraftment after autologous transplantation, using simple linear regression analyzes. We found a significant correlation between pre-freeze ALDH(br) cell numbers and pre-freeze total CD34(+) (P < 0.001), viable CD34(+) (P < 0.001) and post-thaw viable CD34(+) (P < 0.001) cell numbers. We suggest that ALDH(br) may be substituted for CD34(+) cell numbers when evaluating HPC. As post-thaw viability testing apparently adds no significant information, we suggest that it may not be necessary. Finally, neither marker correlated with time to engraftment in our patients, supporting previous data suggesting the existence of a threshold dose for timely engraftment around 2.5 × 10(6) cells/kg.

Change in mortality from coronary heart disease and stroke in Arkansas (1979 to 2007).

Coronary heart disease (CHD)- and stroke-related mortality rates have been greater in the Southern states than in the rest of the United States. Although a sustained decrease in mortality from CHD and stroke has occurred in the United States during the past 3 decades, it is not known whether a similar decrease occurred in the Southern states. We examined CHD- and stroke-related deaths from 1979 to 2007 in Arkansas and observed a marked and steady decrease in both death rates. A concurrent increase occurred in the prevalence of obesity, hypertension, and diabetes mellitus, with a decrease in physical inactivity and poverty during this period. However, we noted a significant decrease in the per capita cigarette sales in Arkansas that closely paralleled the decrease in CHD- and stroke-related deaths. In conclusion, although the extensive use of cardioprotective drugs, as well as coronary revascularization, might have contributed to the decrease, we have provided evidence to suggest that the decrease in cigarette smoking was a very important factor in the decrease in CHD- and stroke-related mortality.

Neighborhood and Acute Myocardial Infarction Mortality as Related to the Driving Time to Percutaneous Coronary Intervention–Capable Hospital

Background Driving time to a percutaneous coronary intervention (PCI)–capable hospital is important in timely treatment of acute myocardial infarction (AMI). Our objective was to determine whether driving time from ones residence to a PCI‐capable hospital contributes to AMI deaths. We conducted a cross‐sectional study of age‐ and sex‐adjusted mortality in census block groups to evaluate this question. Methods and Results We studied all (14 027) AMI deaths that occurred during 2008–2012 in Arkansas to assess the relationship between driving time from the population center of a block group (neighborhood) to the nearest PCI‐capable hospital. We estimated standardized mortality ratios in block groups that were adjusted for education (population over 25 years of age who did not graduate from high school), poverty (population living below federal poverty level), population density (population per square mile), mobility (population residing at the same address as 1 year ago), black (population that is black), rurality (rural households), geodesic distance, and driving time. The median geodesic distance and driving time were 12.8 miles (interquartile range 3.6–30.1) and 28.3 minutes (interquartile range 9.6–58.7), respectively. Risks in neighborhoods with long driving times (90th percentile) were 26% greater than risks in neighborhoods with short driving times (10th percentile), even after adjusting for education, poverty, population density, rurality, and black race (P<0.0001). Conclusions AMI mortality increases with increasing driving time to the nearest PCI‐capable hospital. Improving the healthcare system by reducing time to arrive at a PCI‐capable hospital could reduce AMI deaths.

Diabetic retinopathy and its risk factors in a population-based study.

Aim: To assess the prevalence of diabetic retinopathy and its risk factors among people with diabetes using a population-based survey and discuss strategies that can be used to both prevent and manage diabetes-related complications in a primary care setting. Methods: The prevalence of self-reported doctor-diagnosed diabetic retinopathy and its risk factors were estimated using data from the Arkansas Behavioral Risk Factor Survey, 2003–2007. Five years of survey data were combined and weighted to the population to assess the risk factors that predict the prevalence of diabetic retinopathy. The study involved 2477 people who reported that they have been diagnosed with diabetes. Results: Twenty-two percent of survey respondents with diabetes had been diagnosed with diabetic retinopathy. Using a multivariate adjusted model, blacks (odds ratio [OR] = 1.76, 95% confidence interval [CI], 1.26, 2.45), those with some high school education (OR = 2.78, 95% CI, 1.80, 4.28), people with diabetes for more than 10 years (OR = 2.14, 95% CI 1.61, 2.85), people on insulin treatment (OR = 2.35, 95% CI 1.78, 3.08), those who had taken a course to manage their diabetes (OR = 1.54, 95% CI 1.20, 1.99), and those with chronic foot ulcers (OR = 2.24, 95% CI 1.62, 3.09) were more likely to have been diagnosed with diabetic retinopathy. Conclusions: The prevalence of diabetic retinopathy and its risk factors are evident. Novel approaches to increase the screening and treatment of these frequent complications are key to optimize diabetes care.

The Role of Depression in Chronic Disease Management: An Analysis of the U.S. Behavioral Risk Factor Surveillance System

Introduction: Depression is a major comorbidity among people with chronic diseases such as diabetes, hypertension, and asthma. The relationship between depression and chronic disease management is complex and not well understood. The objective of our study was to assess the role of depression in effective chronic disease management. Methods: The study used data from 491,773 respondents participating in the 2013 Behavioral Risk Factor Surveillance System. Chronic conditions were compared for adults with vs. without a self-reported medical history of depression. The odds of reporting no past year physician-led preventive care (physician follow-up, annual eye exam, A1c checks, and foot exam) and no past year patient self-care practices (medication adherence, blood glucose monitoring and watching or reducing salt intake) among those with depression were calculated. A multivariate logistic regression model was used to account for interaction and confounding effects, and adjusted odds ratios were reported. Results: A significantly higher proportion of those with vs. without depression had diabetes (15.1% vs. 9.2%; p=<0.0001), hypertension (41.8% vs. 30.5%; p=<0.0001), asthma (24.3% vs. 11.9%; p=<0.0001), and chronic obstructive pulmonary disease (14.3% vs. 4.7%; p=<0.0001). Using a multivariate adjusted model, we found adults with diabetes had twice the odds of not having their feet checked by a professional in the past year if they had depression, especially if they were under 44 years of age (OR = 2.0, 95% CI, 1.41, 2.85). Conclusion: Adults with depression have a higher prevalence of chronic disease, but are less likely to report physicianled preventive care practices. Screening and effectively managing depression in primary care can improve patient outcomes among those populations and enhanced collaboration with behavioral health care professionals may be needed to improve patients’ quality of life and reduce chronic disease management costs.