Judith A. Malmgren

Screening for Depression in Well Older Adults: Evaluation of a Short Form of the CES-D

We derived and tested a short form of the Center for Epidemiologic Studies Depression Scale (CES-D) for reliability and validity among a sample of well older adults in a large Health Maintenance Organization. The 10-item screening questionnaire, the CESD-10, showed good predictive accuracy when compared to the full-length 20-item version of the CES-D (kappa = .97, P < .001). Cutoff scores for depressive symptoms were > or = 16 for the full-length questionnaire and > or = 10 for the 10-item version. We discuss other potential cutoff values. The CESD-10 showed an expected positive correlation with poorer health status scores (r = .37) and a strong negative correlation with positive affect (r = -.63). Retest correlations for the CESD-10 were comparable to those in other studies (r = .71). We administered the CESD-10 again after 12 months, and scores were stable with strong correlation of r = .59.

The volume of primary angioplasty procedures and survival after acute myocardial infarction. National Registry of Myocardial Infarction 2 Investigators.

BACKGROUND There is an inverse relation between mortality from cardiovascular causes and the number of elective cardiac procedures (coronary angioplasty, stenting, or coronary bypass surgery) performed by individual practitioners or hospitals. However, it is not known whether patients with acute myocardial infarction fare better at centers where more patients undergo primary angioplasty or thrombolytic therapy than at centers with lower volumes. METHODS We analyzed data from the National Registry of Myocardial Infarction to determine the relation between the number of patients receiving reperfusion therapy (primary angioplasty or thrombolytic therapy) and subsequent in-hospital mortality. A total of 450 hospitals were divided into quartiles according to the volume of primary angioplasty. Multiple logistic-regression models were used to determine whether the volume of primary angioplasty procedures was an independent predictor of in-hospital mortality among patients undergoing this procedure. Similar analyses were performed for patients receiving thrombolytic therapy at 516 hospitals. RESULTS In-hospital mortality was 28 percent lower among patients who underwent primary angioplasty at hospitals with the highest volume than among those who underwent angioplasty at hospitals with the lowest volume (adjusted relative risk, 0.72; 95 percent confidence interval, 0.60 to 0.87; P<0.001). This lower rate, which represented 2.0 fewer deaths per 100 patients treated, was independent of the total volume of patients with myocardial infarction at each hospital, year of admission, and use or nonuse of adjunctive pharmacologic therapies. There was no significant relation between the volume of thrombolytic interventions and in-hospital mortality among patients who received thrombolytic therapy (7.0 percent for patients in the highest-volume hospitals vs. 6.9 percent for those in the lowest-volume hospitals, P=0.36). CONCLUSIONS Among hospitals in the United States that have full interventional capabilities, a higher volume of angioplasty procedures is associated with a lower mortality rate among patients undergoing primary angioplasty, but there is no association between volume and mortality for thrombolytic therapy.

Use of Lipid-Lowering Medications at Discharge in Patients With Acute Myocardial Infarction Data From the National Registry of Myocardial Infarction 3

Background—The present study aimed to assess use of lipid-lowering medication at discharge in a current national sample of patients hospitalized with acute myocardial infarction and to evaluate factors associated with prescribing patterns. Methods and Results—Demographic, procedural, and discharge medication data were collected from 138 001 patients with acute myocardial infarction discharged from 1470 US hospitals participating in the National Registry of Myocardial Infarction 3 from July 1998 to June 1999. Lipid-lowering medications were part of the discharge regimen in 31.7%. Among patients with prior history of CAD, revascularization, or diabetes, less than one half of the patients were discharged on treatment. In multivariate analysis, factors independently related to lipid-lowering use included history of hypercholesterolemia (odds ratio [OR] 4.93; 95% CI 4.79 to 5.07), cardiac catheterization during hospitalization (OR 1.29; 95% CI 1.24 to 1.34), care provided at a teaching hospital, (OR 1.26; 95% CI 1.22 to 1.32), use of &bgr;-blocker (OR 1.43; 95% CI 1.39 to 1.48), and smoking cessation counseling (OR 1.51; 95% CI 1.44 to 1.59). Lipid-lowering medications were given less often to patients who were older (65 to 74 versus <55 years of age; OR 0.82; 95% CI 0.78 to 0.86), those with a history of hypertension (OR 0.92; 95% CI 0.89 to 0.95), and those undergoing coronary artery bypass graft surgery (OR 0.58; 95% CI 0.55 to 0.60). Conclusions—Analysis of current practice patterns for the use of lipid-lowering medications in patients hospitalized with acute myocardial infarction reveals that a significant proportion of high-risk patients did not receive treatment at time of discharge.

High-quality controlled trials on preventing episodes of back problems: systematic literature review in working-age adults.

BACKGROUND CONTEXT Back problems (BPs), with their cost and disability, are a substantial burden for individuals, employers, and society. PURPOSE This systematic review of controlled trials evaluates the effectiveness of interventions to prevent BP episodes in working age adults. DATA SOURCES We searched MEDLINE/EMBASE through May 2007, and COCHRANE/Trials Registry through August 22, 2008 using search terms of back pain, back injuries or sciatica, linked to prevention, control, workplace interventions, or ergonomics and searched article bibliographies. STUDY SELECTION For systematic review inclusion, articles had to describe prospective controlled trials of interventions to prevent BPs in working-age adults, with intervention assignment either to individual participants or preexisting groups. Of 185 articles identified as potentially relevant, 20 trials (11%) met inclusion criteria. DATA EXTRACTION Researchers extracted relevant information from controlled trials and graded methodological quality. Because of heterogeneity of trials, meta-analysis was not performed. RESULTS Only exercise was found effective for preventing self-reported BPs in seven of eight trials (effect size 0.39 to >0.69). Other interventions were not found to reduce either incidence or severity of BP episodes compared with controls. Negative trials included five trials of education, four of lumbar supports, two of shoe inserts, and four of reduced lifting programs. CONCLUSIONS Twenty high-quality controlled trials found strong, consistent evidence to guide prevention of BP episodes in working-age adults. Trials found exercise interventions effective and other interventions not effective, including stress management, shoe inserts, back supports, ergonomic/back education, and reduced lifting programs. The varied successful exercise approaches suggest possible benefits beyond their intended physiologic goals. LEVEL OF EVIDENCE Systematic review Level I evidence.

Impact of Triple Negative Phenotype on Breast Cancer Prognosis

Abstract:  Triple negative (TN) [estrogen receptor (ER), progesterone receptor (PgR)] (ER−/PgR−/Her2/neu−) breast cancer (BC) is an aggressive disease without tumor‐specific treatment options. Our objective is to evaluate the relative contribution of combined Her2/neu (Her2) and hormone receptor (HR) status to BC progression. A prospective primary BC cohort of 1550 patients at our institution, stage I–IV, from 1998 to 2003 were categorized by HR and Her2 status into ER+/PgR+/Her2− (HR+/Her2−) (n = 1134), ER+/PgR+/Her2+ [triple positive (TP)] (n = 138), ER−/PgR−/Her2− (TN) (n = 183), and ER−/PgR−/Her2+ (HR−/Her2+) (n = 95). Clinical variables were chart abstracted and vital and disease status updated annually. Log‐rank tests and Cox regression analyses were used to assess associations with survival. Patient age ranged from 21 to 88 years and average length of follow‐up was 4.24 years. Overall survival at 5 years was 94% (HR+/Her2−), 91% (TP), and 81% (TN and HR−/Her2+) (log rank test = 22.22, p < 0.001). Disease‐specific survival at 5 years was 98% (HR+/Her2−), 93% (TP), 88% (TN), and 86% (HR−/Her2+) (log rank test = 25.85, p < 0.001) and 5‐year relapse‐free survival was 95% (HR+/Her2−), 89% (TP), 84% (TN), and 76% (HR−/Her2+) (log rank test = 20.29, p < 0.001). In a model adjusted for age, race, TNM stage, and treatment using HR+/Her2− patients as the reference group, recurrence risk was 1.98 for TP (95% CI = 1.02 to 3.84), 2.32 for TN (95% CI = 1.32 to 4.08), and 4.25 for HR−/Her2+ patients (95% CI = 2.33, 7.75). A hierarchy of BC phenotypes defined by HR and Her2 status exists with progressively worse disease outcomes by category.

T1N0 Triple Negative Breast Cancer: Risk of Recurrence and Adjuvant Chemotherapy

Abstract:  Adjuvant treatment of T1N0 breast cancer (BC) has evolved in recent years with chemotherapy options dependent on tumor size and cellular characteristics. Our goal is to describe the difference in outcome between T1N0 triple negative (TriNeg) and estrogen/progesterone receptor positive/her2/neu‐negative BC. From our institute’s registry, we identified primary BC patients diagnosed from 1998 to 2005, estrogen/progesterone receptor negative (ER−/PR−)/her‐2/neu negative (her2−) (TriNeg = 110) and ER+/PR+/her2− (HR+/her2− = 919). Clinical diagnosis and treatment variables were chart abstracted. Vital and disease status were updated annually. Pearson chi‐squared tests were used for bivariate analysis. Hazard ratios were calculated using the Cox proportional hazards model. Average patient age was 59 years, range 23–93 years and average length of follow‐up was 4.22 years. T‐stage distribution for HR+/her2− patients was 9% T1a (>0.1, ≤0.5 cm), 34% T1b (>0.5 cm, ≤1 cm), 57% T1c (>1 cm, ≤2 cm) and for TriNeg, 6% T1a, 21% T1b, and 73% T1c. Sixty‐five per cent of T1b and 73% T1c TriNeg patients received chemotherapy versus 7% of T1b and 32% of T1c HR+/her2− patients with TriNeg patients more likely to receive doxorubicin/cyclophosphamide/paclitaxel combined therapy. Recurrence rates were the following, T1b: 8.7%, TriNeg (2/23) versus 0%, HR+/her2− (0/315) and T1c: 8.8%, TriNeg (7/80) versus 2.1%, HR+/her2− (11/523). Five year relapse‐free survival was 98% in the HR+/her2− group and 89% in the TriNeg group (log rank test = 27.77, p < 0.001). The hazard ratio for recurrence in the TriNeg group was 6.57 (95% CI = 2.34, 18.49) adjusted for age, tumor size, and adjuvant chemotherapy. Triple negative T1N0 patients have greater recurrence risk in spite of more aggressive therapy by both number treated and adjuvant chemotherapy type even in a low‐risk category. New treatment modalities specific for triple negative disease are urgently needed.

Impact of Mammography Detection on the Course of Breast Cancer in Women Aged 40–49 Years

PURPOSE To analyze trends in detection method related to breast cancer stage at diagnosis, treatments, and outcomes over time among 40-49-year-old women. MATERIALS AND METHODS i This study was institutional review board approved, with a waiver of informed consent, and HIPAA compliant. A longitudinal prospective cohort study was conducted of women aged 40-49 years who had primary breast cancer, during 1990-2008, and were identified and tracked by a dedicated registry database (n = 1977). Method of detection--patient detected (PtD), physician detected (PhysD), or mammography detected (MamD)--was chart abstracted. Disease-specific survival and relapse-free survival statistics were calculated by using the Kaplan-Meier method for stage I-IV breast cancer. RESULTS A significant increase in the percentage of MamD breast cancer over time (28%-58%) and a concurrent decline in patient and physician detected (Pt/PhysD) breast cancer (73%-42%) (Pearson x(2) = 72.72, P < .001) were observed over time from 1990 to 2008, with an overall increase in lower-stage disease detection and a decrease in higher-stage disease. MamD breast cancer patients were more likely to undergo lumpectomy (67% vs 48% of Pt/PhysD breast cancer patients) and less likely to undergo modified radical mastectomy (25% vs 47% of the Pt/PhysD breast cancer patients) (P < .001). Uncorrected for stage, 13% of MamD breast cancer patients underwent surgery and chemotherapy versus 22% of Pt/PhysD breast cancer patients (P < .001), and 31% of MamD breast cancer patients underwent surgery, radiation therapy, and chemotherapy versus 59% of Pt/PhysD breast cancer patients (x(2) = 305.13, P < .001). Analyzing invasive cancers only, 5-year relapse-free survival for MamD breast cancer patients was 92% versus 88% for Pt/PhysD patients (log-rank test, 12.47; P < .001). CONCLUSION Increased mammography-detected breast cancer over time coincided with lower-stage disease detection resulting in reduced treatment and lower rates of recurrence, adding factors to consider when evaluating the benefits of mammography screening of women aged 40-49 years.

Comparing the performance of health status measures for healthy older adults.

OBJECTIVES: The specific goals of the study were to compare three health status measures among older adults for their correlations with similar scales and to examine whether extreme (positive) health states might lead to measurement problems. We also report on practical administration and response problems among older adults.

Hospital transfer of patients with acute myocardial infarction: the effects of age, race, and insurance type

BACKGROUND Many factors precipitate the transfer of patients hospitalized for acute myocardial infarction, including clinical status and the need for diagnostic testing and therapeutic interventions not available at the admitting hospital. The objectives of this study were to assess the frequency of transfer to another hospital and to determine whether nonmedical factors, such as age, sex, race, and insurance status, are associated with transfer. METHODS We conducted a prospective study of patients with acute myocardial infarction who were enrolled in the National Registry of Myocardial Infarction 2 from June 1994 through March 1998. The Registry involves 1674 hospitals in the United States. All patients survived to the time of hospital discharge or until transfer. Multivariable logistic regression models, with transfer as the outcome variable, were developed for the entire sample, as well as for subgroups determined by the interventional capabilities of the admitting hospital. RESULTS Of 537,283 patients with acute myocardial infarction, 152,310 (28%) were transferred to another hospital after admission. After adjustment for differences in clinical and hospital characteristics, factors that were most associated with a reduced odds of transfer included older age (odds ratio [OR] = 0.43; 95% confidence interval [CI]: 0.42 to 0.44 for those aged >75 vs. <65 years), African-American race (OR = 0.69; 95% CI: 0.67 to 0.71 for African Americans vs. whites), and Medicaid/self-pay insurance status (OR = 0.68; 95% CI: 0.66 to 0.70 for Medicaid/self-pay vs. commercial insurance). These effects were most apparent for patients admitted to hospitals without full invasive diagnostic and therapeutic capabilities, but persisted to some extent among those admitted to hospitals with full invasive services. CONCLUSION Our findings suggest that nonmedical factors, including age, race, and insurance type, affect decisions regarding the transfer of patients hospitalized with acute myocardial infarction. As only a minority of the nations hospitals offers a full range of cardiovascular diagnostic and therapeutic procedures, these findings reinforce ongoing concerns about disparities in access to health care services for some patients.

Treatment and outcomes of left bundle-branch block patients with myocardial infarction who present without chest pain

Abstract OBJECTIVES We sought to determine the importance of chest pain on presentation as a predictor of in-hospital treatment and mortality in myocardial infarction (MI) patients with left bundle-branch block (LBBB). BACKGROUND Left bundle-branch block patients have a high mortality after MI but are unlikely to receive reperfusion therapy despite evidence from clinical trials demonstrating the efficacy of thrombolytic therapy. Nearly half of MI patients with LBBB present without chest pain. METHODS We studied the clinical features, treatment and in-hospital survival of 29,585 patients with LBBB enrolled in the National Registry of MI 2 (June 1994 through March 1998). Multivariate logistic regression was used to assess the independent effect of chest pain on reperfusion decisions and in-hospital mortality. RESULTS Left bundle-branch block patients with chest pain were greater than five-fold more likely to receive reperfusion therapy (13.6% vs. 2.6%) than LBBB patients without chest pain; they were also more likely to receive aspirin, beta-adrenergic blocking agents, heparin and nitrates (all p CONCLUSIONS Left bundle-branch block patients with MI who present without chest pain are less likely to receive optimal therapy and are at increased risk of death. Prompt recognition and treatment of this high-risk subgroup should improve survival.