Isabel Diana Fernandez

Length of Stay and Mortality Associated With Febrile Neutropenia Among Children With Cancer

PURPOSE The aim of this study was to evaluate risk factors for longer length of stay (los) and mortality among hospitalized children with cancer who have febrile neutropenia. METHODS This study involved analysis of longitudinal data from the University HealthSystem Consortium database from 1995 to 2002. All patients who were 21 years or younger, with diagnostic codes for both neoplastic disease and febrile neutropenia at discharge, were included. RESULTS A total of 12,446 patients were identified for the study. The los was 5 days or less for 6,799 patients, and greater than 5 days for 5,647 patients. The mortality rate was 3%. On bivariate analysis, race, age, cancer type, and associated complications (bacteremia/sepsis, hypotension, pneumonia, and fungal infections) were significantly associated with longer length of stay and death. On multivariate analysis, age group, race, cancer type (acute myeloid leukemia, multiple cancers v acute lymphoblastic leukemia), and the complication variables were significantly associated with increased risk of longer los and death. Certain types of cancer (Hodgkins disease, osteosarcoma/Ewings sarcoma, rhabdomyosarcoma, compared with acute lymphoblastic leukemia) and year of discharge after 1995 were significantly associated with a reduced risk of longer length of stay and/or mortality. CONCLUSION Race, age group, year of discharge, associated complications, and cancer type were significantly associated with risk of longer los and mortality. These factors may potentially help in identifying high-risk patients who might benefit from targeted antibiotic therapy or prophylactic hematopoietic growth factor support.

Design characteristics of worksite environmental interventions for obesity prevention.

Objective: This paper describes the design characteristics of the National Heart, Lung, and Blood Institute (NHLBI)‐funded studies that are testing innovative environmental interventions for weight control and obesity prevention at worksites.

Prevalence of nutritional wasting in populations: building explanatory models using secondary data

OBJECTIVE To understand how social context affects the nutritional status of populations, as reflected by the prevalence of wasting in children under 5 years of age from Africa, Latin America, and Asia; to present a systematic way of building models for wasting prevalence, using a conceptual framework for the determinants of malnutrition; and to examine the feasibility of using readily available data collected over time to build models of wasting prevalence in populations. METHODS Associations between prevalence of wasting and environmental variables were examined in the three regions. General linear mixed models were fitted using anthropometric survey data for countries within each region. FINDINGS Low birth weight (LBW), measles incidence, and access to a safe water supply explained 64% of wasting variability in Asia. In Latin America, LBW and survey year explained 38%; in Africa, LBW, survey year, and adult literacy explained 7%. CONCLUSION LBW emerged as a predictor of wasting prevalence in all three regions. Actions regarding womens rights may have an effect on the nutritional status of children since LBW seems to reflect several aspects of the conditions of women in society. Databases have to be made compatible with each other to facilitate integrated analysis for nutritional research and policy decision-making. In addition, the validity of the variables representing the conceptual framework should be improved.

Elevated Blood Pressure, Race/Ethnicity, and C-Reactive Protein Levels in Children and Adolescents

OBJECTIVE. Adult hypertension is independently associated with elevated C-reactive protein levels, after controlling for obesity and other cardiovascular risk factors. The objective of this study was to determine, with a nationally representative sample of children, whether the relationship between elevated blood pressure and C-reactive protein levels may be evident before adulthood. METHODS. Cross-sectional data for children 8 to 17 years of age who participated in the National Health and Nutrition Examination Survey between 1999 and 2004 were analyzed. Bivariate analyses compared children with C-reactive protein levels of >3 mg/L versus ≤3 mg/L with respect to blood pressure and other cardiovascular risk factors. Multivariate linear regression was used to evaluate the relationship between elevated blood pressure and C-reactive protein levels. RESULTS. Among 6112 children, 3% had systolic blood pressure of ≥95th percentile and 1.3% had diastolic blood pressure of ≥95th percentile. Children with C-reactive protein levels of >3 mg/L had higher systolic blood pressure, compared with children with C-reactive protein levels of ≤3 mg/L (109 vs 105 mm Hg). Obesity, high-density lipoprotein cholesterol levels of <40 mg/dL, and Hispanic ethnicity were independent predictors of elevated C-reactive protein levels. Diastolic blood pressure did not differ between groups. Linear regression analyses showed that systolic blood pressure of ≥95th percentile was independently associated with C-reactive protein levels in boys but not girls. Subset analyses according to race/ethnicity demonstrated that the independent association of elevated systolic blood pressure with C-reactive protein levels was largely limited to black boys. CONCLUSIONS. These data indicate that there is interplay between race/ethnicity, elevated systolic blood pressure, obesity, and inflammation in children, a finding that has potential implications for disparities in cardiovascular disease later in life.

“Pizza Is Cheaper Than Salad”: Assessing Workers' Views for an Environmental Food Intervention

Objective: “Images of a Healthy Worksite” aims to provide easy access to healthful foods and to reduce sedentarism at the worksite—to prevent weight gain. Formative research for the nutrition intervention component was aimed at gaining a broad understanding of the sociocultural role of food and eating among workers and worker perspectives on socially feasible and culturally acceptable environmental intervention strategies.

Effects of yoga on cancer-related fatigue and global side-effect burden in older cancer survivors

BACKGROUND Sixty percent of cancer survivors are 65years of age or older. Cancer and its treatments lead to cancer-related fatigue and many other side effects, in turn, creating substantial global side-effect burden (total burden from all side effects) which, ultimately, compromises functional independence and quality of life. Various modes of exercise, such as yoga, reduce cancer-related fatigue and global side-effect burden in younger cancer survivors, but no studies have specifically examined the effects of yoga on older cancer survivors. OBJECTIVES The purpose of this study was to assess the effects of a 4-week yoga intervention (Yoga for Cancer Survivors: YOCAS©®) on overall cancer-related fatigue, and due to its multidimensional nature, the subdomains of cancer-related fatigue (general, physical, emotional, and mental) and global side-effect burden in older cancer survivors. MATERIALS AND METHODS We conducted a secondary analysis on data from a multicenter phase III randomized controlled clinical trial with 2 arms (standard care and standard care plus a 4-week YOCAS©® intervention). The sample for this secondary analysis was 97 older cancer survivors (≥60years of age), between 2months and 2years post-treatment, who participated in the original trial. RESULTS Participants in the YOCAS©® intervention arm reported significantly lower cancer-related fatigue, physical fatigue, mental fatigue, and global side-effect burden than participants in the standard care arm following the 4-week intervention period (p<0.05). CONCLUSIONS YOCAS©® is an effective standardized yoga intervention for reducing cancer-related fatigue, physical fatigue, mental fatigue, and global side-effect burden among older cancer survivors.

Effects of lipids and lipid‐lowering therapy on hemostatic factors in patients with myocardial infarction

Summary.  Background: The risk of cardiovascular disease (CVD) is associated with specific hemostatic markers and lipid profiles, and evidence indicates that there are associations between lipid profiles and the levels of certain hemostatic factors. The disturbances in hemostasis and the risk of CVD can be ameliorated by lipid‐lowering therapy. Objective: We investigated the associations of lipid profiles with factor (F)VIIa, von Willebrand factor (VWF), d‐dimer and plasminogen activator inhibitor‐1 (PAI‐1), and examined whether lipid‐lowering statin therapy would affect the levels of these hemostatic markers. Patients and methods: This cross‐sectional study analyzed 1045 postmyocardial infarction patients. Results: In multivariate regression analyses (without adjusting for clinical covariates) HDL‐cholesterol (HDL‐C) and HDL size were independent and significant predictors of FVIIa; HDL size was a predictor of VWF; HDL size, HDL‐C and LDL size were predictors of d‐dimer; and triglyceride and HDL size were predictors of PAI‐1. After adjusting for clinical covariates, HDL‐C, lipoprotein (Lp)(a), apolipoprotein B (apoB) and warfarin were independent and significant predictors of FVIIa; HDL size, age, diabetes mellitus, insulin, race and warfarin were predictors of VWF; HDL‐C, HDL size, LDL size, age, warfarin, hypertension and gender were predictors of d‐dimer; and triglyceride, HDL size, body mass index, insulin and hypertension were predictors of PAI‐1. Patients on statin therapy had significantly lower levels of d‐dimer than those who were not on this therapy. Conclusion: There are significant associations of lipid profiles with hemostatic factors, the directions of which suggest novel pathways by which dyslipidemia may contribute to coronary heart disease.

Survival after HLA-identical allogeneic peripheral blood stem cell and bone marrow transplantation for hematologic malignancies: meta-analysis of randomized controlled trials

Summary:The impact of peripheral blood stem cell transplantation (PBSCT) on survival relative to bone marrow transplantation (BMT) remains poorly defined. Several randomized controlled trials (RCTs) comparing HLA-matched related PBSC- and BMT for patients with hematologic malignancies have been published, yielding differing results. We conducted a meta-analysis of published RCTs to more precisely estimate the effect of PBSCT on survival. Seven trials that assessed survival were identified and included in our analysis. Using a fixed effects model, and combining the results of all seven trials, the summary odds ratio for mortality after PBSCT was 0.81 (95% CI, 0.62–1.05) when compared to BMT. Subgroup analysis revealed no association between the median PBSCT 34+ cell dose and relative risk for morality after PBSCT. However, there was an association between the proportion of patients enrolled with advanced-stage disease and the summary odds ratio for mortality. The pooled estimate was 0.64 for studies where patients with intermediate/advanced disease comprised at least 25% of enrollment, and was 1.07 for the studies enrolling a smaller proportion. This finding substantiates results from previously published studies that have demonstrated a survival advantage with PBSCT limited to patients with advanced disease.

Association of workplace chronic and acute stressors with employee weight status: Data from worksites in turmoil.

Objectives: To examine the independent and joint effects of psychosocial chronic and acute stressors with weight status and to report the intraclass correlation coefficient for body mass index (BMI). Methods: Baseline data on 2782 employees from a group-randomized weight gain prevention intervention were examined to investigate the effect of high job strain and job insecurity on BMI and on the odds of overweight/obesity including potential confounders and mediating variables. Data were analyzed using mixed models. Results: The mediating variables removed the effect of high job strain on weight (&bgr; = 0.68, P = 0.07; odds ratios = 1.34, confidence interval = 1.00 to 1.80) whereas job insecurity was never significant. Intraclass correlation coefficient for BMI is 0.0195, 0.0193, and 0.0346 overall, for men and women, respectively. Conclusion: Worksite wellness should target health enhancing behaviors to minimize the health effects of psychosocial work conditions.

Bacteremia in children with sickle hemoglobinopathies.

Background: Bacteremia is one of the most feared infectious complications of sickle cell disease, and it is associated with a high mortality rate in children. The objective of our study was to investigate the proportion of bacteremia among febrile children with sickle hemoglobinopathies and the clinical factors associated with bacteremia. Methods: Clinical and microbiological data from children with sickle hemoglobinopathies being followed up at the Pediatric Hematology Clinic at the University of Rochester Medical Center in Rochester, New York, were retrospectively analyzed. The data were collected from medical records covering the time period of June 1997 to December 2006, which included the periods before and after the introduction of routine heptavalent pneumococcal conjugate vaccine usage. Proportions of positive blood cultures among febrile children, the types of organisms causing bacteremia, and clinical and sociodemographic factors were analyzed by &khgr;2 and t tests as appropriate. Results: The overall proportion of positive blood cultures was 3.8%; 1% was considered to yield true pathogens. Pneumococcal bacteremia decreased from 0.7% in the pre–pneumococcal conjugate vaccine-7 era to 0.2% in the post–pneumococcal conjugate vaccine-7 era; however, the difference was not statistically significant. Pathogens other than pneumococcus were responsible for most bacteremic episodes. No clinical or social factors were found to have statistically significant associations with positive blood cultures. Conclusions: Approximately 1% of children with sickle hemoglobinopathies with fever have bacteremia despite current penicillin prophylaxis and pneumococcal immunization, although most episodes are due to nonpneumococcal pathogens. Prompt evaluation of such febrile children with sickle hemoglobinopathies remains warranted.