Deron Galusha

Statins and Mortality Among Elderly Patients Hospitalized With Heart Failure

Background— Small studies suggest that statins may improve mortality in patients with heart failure (HF). Whether these results are generalizable to a broader group of patients with HF remains unclear. Our objective was to evaluate the association between statin use and survival among a national sample of elderly patients hospitalized with HF. Methods and Results— A nationwide sample of 61 939 eligible Medicare beneficiaries ≥65 years of age who were hospitalized with a primary discharge diagnosis of HF between April 1998 and March 1999 or July 2000 and June 2001 was evaluated. The analysis was restricted to patients with no contraindications to statins (n=54 960). Of these patients, only 16.7% received statins on discharge. Older patients were less likely to receive a statin at discharge. Patients with hyperlipidemia and those cared for by a cardiologist or cared for in a teaching hospital were more likely to receive a statin at discharge. In a Cox proportional hazards model that took into account demographic, clinical characteristics, treatments, physician specialty, and hospital characteristics, discharge statin therapy was associated with significant improvements in 1- and 3-year mortality (hazard ratio, 0.80; 95% CI, 0.76 to 0.84; and hazard ratio, 0.82; 95% CI, 0.79 to 0.85, respectively). Regardless of total cholesterol level or coronary artery disease status, statin therapy was associated with significant differences in mortality. Conclusions— Our data demonstrate that statin therapy is associated with better long-term mortality in older patients with HF. This study suggests a potential role for statins as an adjunct to current HF therapy. Randomized clinical trials are required to determine the role of these agents in improving outcomes in the large and growing group of patients with HF.

National Trends in Patient Safety for Four Common Conditions, 2005–2011

BACKGROUND Changes in adverse-event rates among Medicare patients with common medical conditions and conditions requiring surgery remain largely unknown. METHODS We used Medicare Patient Safety Monitoring System data abstracted from medical records on 21 adverse events in patients hospitalized in the United States between 2005 and 2011 for acute myocardial infarction, congestive heart failure, pneumonia, or conditions requiring surgery. We estimated trends in the rate of occurrence of adverse events for which patients were at risk, the proportion of patients with one or more adverse events, and the number of adverse events per 1000 hospitalizations. RESULTS The study included 61,523 patients hospitalized for acute myocardial infarction (19%), congestive heart failure (25%), pneumonia (30%), and conditions requiring surgery (27%). From 2005 through 2011, among patients with acute myocardial infarction, the rate of occurrence of adverse events declined from 5.0% to 3.7% (difference, 1.3 percentage points; 95% confidence interval [CI], 0.7 to 1.9), the proportion of patients with one or more adverse events declined from 26.0% to 19.4% (difference, 6.6 percentage points; 95% CI, 3.3 to 10.2), and the number of adverse events per 1000 hospitalizations declined from 401.9 to 262.2 (difference, 139.7; 95% CI, 90.6 to 189.0). Among patients with congestive heart failure, the rate of occurrence of adverse events declined from 3.7% to 2.7% (difference, 1.0 percentage points; 95% CI, 0.5 to 1.4), the proportion of patients with one or more adverse events declined from 17.5% to 14.2% (difference, 3.3 percentage points; 95% CI, 1.0 to 5.5), and the number of adverse events per 1000 hospitalizations declined from 235.2 to 166.9 (difference, 68.3; 95% CI, 39.9 to 96.7). Patients with pneumonia and those with conditions requiring surgery had no significant declines in adverse-event rates. CONCLUSIONS From 2005 through 2011, adverse-event rates declined substantially among patients hospitalized for acute myocardial infarction or congestive heart failure but not among those hospitalized for pneumonia or conditions requiring surgery. (Funded by the Agency for Healthcare Research and Quality and others.).

Proximity to Pollution Sources and Risk of Amphibian Limb Malformation

The cause of limb deformities in wild amphibian populations remains unclear, even though the apparent increase in prevalence of this condition may have implications for human health. Few studies have simultaneously assessed the effect of multiple exposures on the risk of limb deformities. In a cross-sectional survey of 5,264 hylid and ranid metamorphs in 42 Vermont wetlands, we assessed independent risk factors for nontraumatic limb malformation. The rate of nontraumatic limb malformation varied by location from 0 to 10.2%. Analysis of a subsample did not demonstrate any evidence of infection with the parasite Ribeiroia. We used geographic information system (GIS) land-use/land-cover data to validate field observations of land use in the proximity of study wetlands. In a multiple logistic regression model that included land use as well as developmental stage, genus, and water-quality measures, proximity to agricultural land use was associated with an increased risk of limb malformation (odds ratio = 2.26; 95% confidence interval, 1.42–3.58; p < 0.001). The overall discriminant power of the statistical model was high (C = 0.79). These findings from one of the largest systematic surveys to date provide support for the role of chemical toxicants in the development of amphibian limb malformation and demonstrate the value of an epidemiologic approach to this problem.

Postmastectomy Radiation and Survival in Older Women With Breast Cancer

PURPOSE Clinical trials indicate that postmastectomy radiation therapy (PMRT) improves survival for women age younger than 70 years with high-risk breast cancer. However, for women age 70 years or older, the benefits of PMRT are unknown. As recent evidence suggests that certain adjuvant treatments appropriate for younger women may only be marginally beneficial for older women, we sought to determine whether PMRT improves survival for older women with breast cancer. METHODS Using the Surveillance, Epidemiology and End Results Medicare data spanning 1992 to 1999, we identified 11,594 women age 70 years or older treated with mastectomy for invasive breast cancer. A proportional hazards model adjusted for clinical-pathologic covariates tested whether PMRT was associated with improved overall survival for low-risk (T1/2 N0), intermediate-risk (T1/2 N1), and high-risk (T3/4 and/or N2/3) patients. RESULTS A total of 502 (7%) of 7,416 low-risk, 242 (11%) of 2,145 intermediate-risk, and 785 (38%) of 2,053 high-risk patients received PMRT. Median follow-up was 6.2 years. For low- and intermediate-risk patients, PMRT was not associated with survival. For high-risk patients, PMRT was associated with a significant improvement in survival (hazard ratio, 0.85; 95% CI, 0.75 to 0.97; P = .02). Five-year adjusted survival was 50% for patients not treated with PMRT or chemotherapy, 56% for patients treated with PMRT only, 57% for patients treated with chemotherapy only, and 59% for patients treated with both PMRT and chemotherapy. CONCLUSION PMRT is associated with improved survival for older women with high-risk breast cancer. Randomized clinical trials are urgently needed to confirm this finding and define optimal treatment strategies for this patient group.

Hydroxymethylglutaryl-CoA Reductase Inhibitors in Older Persons with Acute Myocardial Infarction: Evidence for an Age–Statin Interaction

OBJECTIVES: To characterize the relationship between hydroxymethylglutaryl‐CoA reductase inhibitors (statins) and outcomes in older persons with acute myocardial infarction (AMI).

Do ambient noise exposure levels predict hearing loss in a modern industrial cohort

Background: Much of what is known about the exposure–response relationship between occupational noise exposures and hearing loss comes from cross-sectional studies conducted before the widespread implementation of workplace hearing conservation programmes. Little is known about the current relationship of ambient noise exposure measurements to hearing loss risk. Aim: To examine the relationship between rates of high frequency hearing loss and measured levels of noise exposure in a modern industrial workforce. Methods: Ten-year hearing loss rates were determined for 6217 employees of an aluminium manufacturing company. Industrial hygiene and human resources records allowed for reconstruction of individual noise exposures. Hearing loss rates were compared to ANSI 3.44 predictions based on age and noise exposure. Associations between hearing loss, noise exposure, and covariate risk factors were assessed using multivariate regression. Results: Workers in higher ambient noise jobs tended to experience less high frequency hearing loss than co-workers exposed at lower noise levels. This trend was also seen in stratified analyses of white males and non-hunters. At higher noise exposure levels, the magnitude of hearing loss was less than predicted by ANSI 3.44 formulae. There was no indication that a healthy worker effect could explain these findings. The majority of 10 dB standard threshold shifts (STS) occurred in workers whose calculated ambient noise exposures were less than or equal to 85 dBA. Conclusions: In this modern industrial cohort, hearing conservation efforts appear to be reducing hearing loss rates, especially at higher ambient noise levels. This could be related to differential use of hearing protection. The greatest burden of preventable occupational hearing loss was found in workers whose noise exposure averaged 85 dBA or less. To further reduce rates of occupational hearing loss, hearing conservation programmes may require innovative approaches targeting workers with noise exposures close to 85 dBA.

Patterns of secondary prevention in older patients undergoing coronary artery bypass grafting during hospitalization for acute myocardial infarction

Background—Aggressive risk factor modification decreases cardiovascular events and mortality in patients after coronary artery bypass grafting (CABG). Little is known regarding the use of secondary prevention in older patients undergoing CABG during hospitalization for acute myocardial infarction (AMI). Methods and Results—Medical records were reviewed for a sample of 37,513 patients hospitalized with AMI in the United States between April 1998 and March 1999. Patients ≥65 years of age who underwent CABG after AMI (n=2,267 [8%]) were evaluated for the prescription of 4 therapies at discharge: aspirin, &bgr;-blockers, angiotensin-converting enzyme (ACE) inhibitors, and lipid lowering, in eligible patients without contraindications to therapy and compared with patients who did not undergo CABG (n=26,484 [92%]). Patients undergoing CABG had higher rates of aspirin than patients who did not undergo CABG (88.0% versus 83.2%, P =0.0002). However, CABG patients were less likely to receive &bgr;-blockers (61.5% versus 72.1%, P <0.0001), ACE inhibitors (55.5% versus 72.1%, P <0.0001), or lipid lowering (34.7% versus 55.7%, P <0.0001) prescriptions than patients who did not undergo CABG. After adjustment for disease severity, patients undergoing CABG were no longer more likely to receive discharge aspirin, and the magnitude of other differences in care increased. Conclusions—Evidence-based discharge therapies are underutilized in older patients who underwent CABG during hospitalization for AMI. Although national efforts focusing on improving short-term surgical mortality have been successful, strategies should be developed to increase the utilization of therapies known to improve long-term mortality in patients undergoing CABG.

Trends in the prevalence of hearing loss among young adults entering an industrial workforce 1985 to 2004

Objectives: Studies have suggested that hearing loss due to recreational noise exposure may be on the rise among adolescents and young adults. This study examines whether the hearing status of young US adults entering an industrial workforce has worsened over the past 20 yr. Design: The baseline audiograms of 2526 individuals ages 17 to 25 beginning employment at a multisite US corporation between 1985 and 2004 were analyzed to determine the yearly prevalence of hearing loss. Results: Approximately 16% of the young adults in the sample had high frequency hearing loss (defined as hearing thresholds greater than 15 dB in either ear at 3,4, or 6 kHz). In a linear regression model, this prevalence decreased over the 20-yr period (odds ratio (OR) = 0.96, 95% confidence interval (CI): 0.94, 0.99). Almost 20% of subjects had audiometric “notches” consistent with noise exposure; this rate remained constant over the 20 yr, as did the prevalence (5%) of low frequency hearing loss. Conclusions: These results indicate that despite concern about widespread recreational noise exposures, the prevalence of hearing loss among a group of young US adults has not significantly increased over the past two decades.

Audiogram notches in noise-exposed workers.

Objectives: Diagnostic criteria for noise-induced hearing loss include the audiometric notch, yet no standardized definition exists. This study tested whether objective notch metrics could match the clinical judgments of an expert panel. Design: A panel of occupational physicians, otolaryngologists, and audiologists reviewed audiograms of noise-exposed workers. In a two-sample process, the panel judged whether a notch was present and whether hearing loss had progressed in a notch pattern. Quantitative notch metrics were compared against expert decisions. Results: At least five of six experts agreed about notch identification in 71 and 72% of the cases in the two samples, and agreement about notch progression was 61 and 67%. Notch depth and professional specialty appeared to affect notch judgments. Despite this variability, a notch metric showed excellent agreement with expert notch consensus in each sample (94.7 and 96.6%; kappa = 0.88 and 0.92). Conclusions: Audiogram notch metrics can agree with expert clinical consensus and assist in the surveillance of noise-exposed workers.

Contribution of health status and prevalent chronic disease to individual risk for workplace injury in the manufacturing environment

Objectives An ‘information gap’ has been identified regarding the effects of chronic disease on occupational injury risk. We investigated the association of ischaemic heart disease, hypertension, diabetes, depression and asthma with acute occupational injury in a cohort of manufacturing workers from 1 January 1997 through 31 December 2007. Methods We used administrative data on real-time injury, medical claims, workplace characteristics and demographics to examine this association. We employed a piecewise exponential model within an Andersen–Gill framework with a frailty term at the employee level to account for inclusion of multiple injuries for each employee, random effects at the employee level due to correlation among jobs held by an employee, and experience on the job as a covariate. Results One-third of employees had at least one of the diseases during the study period. After adjusting for potential confounders, presence of these diseases was associated with increased hazard of injury: heart disease (HR 1.23, 95% CI 1.11 to 1.36), diabetes (HR 1.17, 95% CI 1.08 to 1.27), depression (HR 1.25, 95% CI 1.12 to 1.38) and asthma (HR 1.14, 95% CI 1.02 to 1.287). Hypertension was not significantly associated with hazard of injury. Associations of chronic disease with injury risk were less evident for more serious reportable injuries; only depression and a summary health metric derived from claims remained significantly positive in this subset. Conclusions Our results suggest that chronic heart disease, diabetes and depression confer an increased risk for acute occupational injury.