Laura Rudkin

Neighborhood context and self-rated health in older Mexican Americans

PURPOSE To determine whether neighborhood characteristics are associated with self-rated health in older Mexican Americans. METHODS Epidemiologic data on 3050 older Mexican Americans residing in the southwestern United States during 1993 and 1994 were merged with 1990 US Census data. All subjects were matched to one of 210 census tracts (neighborhoods). Multilevel ordinal logit models were used to examine relationships between self-rated health and individual- and neighborhood-level variables. RESULTS After adjusting for individual characteristics, older Mexican Americans were more likely to rate their health poorer if they lived in neighborhoods that were economically disadvantaged, less populated by other Hispanics, or located within 50 miles of the US-Mexico border. In addition, residence in a border community moderated the relationship between self-rated health and neighborhood economic disadvantage. The effect of neighborhood economic disadvantage on poorer self-rated health was two to three times stronger for subjects living near the border region than subjects living further away from the border. CONCLUSIONS This study demonstrates the importance of considering several dimensions of neighborhood context, especially for Mexican Americans. Residence in a border community and neighborhood economic disadvantage were important predictors of poorer self-rated health status. In addition, older Mexican Americans experience a health benefit from living in neighborhoods populated with other Hispanics.

Grandparents Caring for Grandchildren What Do We Know

Approximately 5% to 6% of grandchildren and 10% of grandparents live in grandparent-grandchild households at any point in time. The proportion of children living with grandparents appears to have remained relatively stable over time. In this article, the authors critically review previous research on the determinants of grandparent care for grandchildren. This research suggests that grandparent care generally is precipitated by need or problems experienced by parents. However, the determinants of custodial care (in which grandparents become sole caretakers) and of coresidence (three-generation households) are quite different. Custodial care generally occurs when parents are no longer able or willing to take care of their children. Coresidence more commonly is associated with the middle generations problems with living independently or with transition among roles.

Disability in older adults. 2: Physical activity as prevention.

In this 2nd article in the series on older adults (persons aged ≥65 years), the role of physical activity in preventing disability associated with aging in the absence of specific illnesses is discussed, and different types of activities and the measures of outcome are described. Evidence for physical activity as a prevention measure is restricted to primary and secondary prevention because the application of physical activity for tertiary prevention of disability is limited. Chronic disease is considered in the context of its influence on disability only when physical activity offers some potential benefit to elderly persons.

Disability in Older Adults 1: Prevalence, Causes, and Consequences

The effects of disability on an aging populations health and welfare are an important issue in gerontological research. The rapid growth of the elderly population and increases in longevity have led to an ongoing debate about whether longer lives can be matched by longer active lives that are free from disability. After a detailed review of current disability literature, the authors discuss the impact of disability in the elderly, defining disability and reviewing three classes of disability-physical, mental, and social. Both subjective and objective disability measures are described, and disability trends and prevalence rates are reviewed and compared cross culturally, by gender, by age, and over time. The path from chronic disease to disability is described and the consequences of living with disability are discussed in terms of family burdens and the increased need for medical care.

Gender Differences in Economic Well-Being Among the Elderly of Java*

With populations aging rapidly in many developing nations, issues of economic dependency among the elderly are of increasing importance. Using data from a 1986 survey of the elderly on Java, Indonesia, I describe gender differences in economic well-being and identify characteristics associated with economic disadvantage. At both the individual and the household level, older women have fewer resources than older men. Even within categories of support (work income and remittances), women have lower levels of well-being. Gender differences in household-level economic well-being are due primarily to differences in household structure and in levels of skills. Gender differences in individual receipts (from all sources) are more complicated, but can be understood more clearly with reference to gender differences in skills levels (literacy, language, job skills), current work status and authority, and domestic authority.

Characteristics of the healthy worker effect : A comparison of male and female occupational cohorts

The healthy worker effect (HWE) poses a serious methodological problem to investigators of occupational cohorts in that it may mask mortality excesses that result from occupational exposures. This problem is further complicated by the fact that the strength of the HWE generally varies according to sociodemographic, employment, and time-related factors. While the HWE has been well documented among numerous cohorts of male workers, little is known about its expression among female occupational workers. Follow-up mortality data on 44,154 employees from the Hanford nuclear facility for the period of 1944-1986 were examined using standardized mortality ratio (SMR) analysis to assess whether modifiers of the HWE were expressed differently in females than in males. Results of this analysis show that while the HWE was modified by race, age at hire, occupational class, and length of follow-up in both male and female cohorts, different patterns of modification emerged across the two subgroups. Learning about how gender differentiates expression of the HWE will help investigators more precisely assess the confounding effect of the HWE in studies of working cohorts. Therefore, this studys findings are relevant for designing and interpreting future occupational cohort studies.

Functional disability in older Mexican Americans

Little is known about the prevalence of functional limitations in the Mexican-American older population. Recent data from a large epidemiologic study of Mexican-American community-dwelling older adults are compared with data from two other large-scale studies of White and African-American older persons. The rates of functional disability in Mexican-American older adults (measured by activities of daily living) were found to be somewhat higher than those of Other Whites and somewhat lower than those of African Americans. Socioeconomic status differences in functional limitations within the Mexican-American sample were not very large. Findings are discussed in terms of the effect of low rates of institutionalization on increasing rates of disability of community-dwelling Mexican-American older persons. Absence of notable socioeconomic status differences within the Mexican-American sample are attributed to restricted range in socioeconomic status and possible effects of earlier higher mortality among person of lower socioeconomic status. Findings have implications for community-based care of the Mexican-American older population.

Changes in Marital Satisfaction in Three Generations of Mexican Americans

Changes in marital satisfaction over 11 years are investigated in a three-generation sample of Mexican Americans from the San Antonio area originally interviewed during 1981-82 and reinterviewed in 1992-93. Among persons married to the same spouses, results showed no significant changes in the negative sentiment component of the Guilford and Bengtson marital satisfaction scale in any of the categories. However, significant declines in the positive interaction component were observed among women in all generations and among younger males. Declines among women over 11 years were consistent with cross-sectional findings at baseline showing successively lower positive interaction from younger to older generations among women. Results are discussed with regard to the U-shaped curve suggested by the literature on marital satisfaction across the life cycle.

The US Cancer Moonshot initiative

Correspondence avoid surgery in rapidly progressive or chemo-insensitive disease. 4 Genotyping of pancreatic tumours via fine needle aspiration could influence the clinical management of pancreatic cancer. Fine-needle aspiration sequencing was used to identify subgroups of patients with specific actionable mutations related to resectable or locally advanced tumours. 5 In patients with radiologically resectable or borderline resectable tumours, preoperative fine-needle aspiration sequencing could distinguish between patients with a genetic pattern associated with micrometastatic tumours, who should undergo neoadjuvant therapy, and those with a truly localised disease that would be amenable to a surgery-first strategy. Michele Reni has served as a consultant for or on the advisory boards of Celgene, Boehringer-Ingelheim, Lilly, Genentech, Baxalta, Novocure, Astra-Zeneca, Pfizer, and Merck-Serono, and has received honoraria from Celgene. Massimo Falconi has received honoraria from Celgene, Ipsen and Novartis. The other authors declare no competing interests. *Stefano Crippa, Michele Reni, Gianpaolo Balzano, Claudio Doglioni, Massimo Falconi crippa1.stefano@hsr.it Division of Pancreatic Surgery, IRCCS San Raffaele Hospital, Milan, Italy (SC, GB, MF); Medical Oncology Department, IRCCS San Raffaele Hospital , Milan, Italy (MR); Department of Pathology, IRCCS San Raffaele Hospital , Milan, Italy (CD); Clinical and Translational Research Program on Pancreatic Cancer, IRCCS San Raffaele Hospital, Milan, Italy (SC, MR, GB, CD, MF) e178 Barreto SG, Windsor JA. Justifying vein resection with pancreatoduodenectomy. Lancet Oncol 2016; 17: e118–24 Giovinazzo F, Turri G, Katz MH, Heaton N, Ahmed I. Meta-analysis of benefit of portal-superior mesenteric vein resection in pancreatic resection for ductal adenocarcinoma. Br J Surg 2016; 103: 179–91. Bapat AA, Hostetter G, Von Hoff DD, Han H. Perineural invasion and associated pain in pancreatic cancer. Nat Rev Cancer 2011; Sohal DP, Walsh RM, Ramanathan RK, Khorana AA. Pancreatic adenocarcinoma: treating a systemic disease with systemic therapy. J Natl Cancer Inst 2014; 106: dju011 Valero V, Saunders TJ, He J, et al. Reliable detection of somatic mutations in fine needle aspirates of pancreatic cancer with next-generation sequencing: implications for surgical management. Ann Surg 2016; Author’s reply Stefano Crippa and colleagues, in responding to our manuscript, 1 agree that increasing the radicality of surgery for pancreatic ductal adenocarcinoma, including synchronous vein resection, is suspect. Indeed, a recent meta-analysis 2 indicates that synchronous vein resection, as reported, increases mortality and decreases survival. Crippa and colleagues put forward two interesting ideas that warrant further discussion. The first is that the surgery-first approach for pancreatic ductal adenocarcinoma might ultimately be retired, given that pancreatic ductal adenocarcinoma is usually systemic at presentation, local treatments have little effect, and neoadjuvant therapy has possible benefits. For now, the absence of high-level evidence for neoadjuvant therapy leaves largely theoretical benefits; namely that neoadjuvant therapy will reveal the biology (ie, those patients that can progress on neoadjuvant therapy will avoid futile surgery), or alter the biology (ie, those patients that are downstaged will become resectable). The preliminary results of the ALLIANCE trial 3 damages the lustre of these purported benefits with no improvement in the number of resections (10 [50%] of 20 patients who completed all preoperative therapy), and no rescue of aggressive tumour biology. This leads to the second idea, in which Crippa and colleagues suggest a biological (rather than radiological) basis for selecting patients for neoadjuvant therapy with a view to reduce the number of synchronous vein resections. Endoscopic ultrasonography- guided genotyping is a possible way to select subgroups of patients with heterogenous pancreatic ductal adenocarcinoma 4 who will benefit from neoadjuvant therapy. In support of this method, Hruban and colleagues 5 suggested that an intact SMAD4/DPC4 gene might be used to select surgery because there is lesser risk of distant metastases for this genotype. 6 In the future, we hope to more accurately select a subgroup of patients in whom a surgery-first approach, and even synchronous vein resection, is justified, but it is much more likely that precision neoadjuvant therapy will ultimately result in less radical surgery and the introduction of non-surgical techniques to support the response to neoadjuvant therapy. We declare no competing interests. Savio G Barreto, *John A Windsor j.windsor@auckland.ac.nz Department of Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India (SGB); Hepatobiliary Pancreatic and Upper GI Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand (JAW) Barreto S, Windsor J. Justifying vein resection with pancreatoduodenectomy. Lancet Oncol 2016; 17: e118–24. Giovinazzo F, Turri G, Katz MH, Heaton N, Ahmed I. Meta-analysis of benefits of portal-superior mesenteric vein resection in pancreatic resection for ductal adenocarcinoma. Br J Surg 2016; Varadhachary G, Fleming J, Crane C, et al. Phase II study of preoperation mFOLFIRINOX and chemoradiation for high-risk resectable and borderline resectable pancreatic adenocarcinoma. Proc Am Soc Clin Oncol 2015; 33 (suppl 3): abstr 362. Killock D. Pancreatic cancer: a problem quartered—new subtypes, new solutions? Nat Rev Clin Oncol 2016; 13: 201. Hruban RH, Adsay NV. Molecular classification of neoplasms of the pancreas. Hum Pathol Iacobuzio-Donahue CA, Fu B, Yachida S, et al. DPC4 gene status of the primary carcinoma correlates with patterns of failure in patients with pancreatic cancer. J Clin Oncol 2009; The US Cancer Moonshot initiative We recently sent the following letter to Vice President of the USA, Joe Biden, to state that we, as Deans and Directors of Public Health schools and programmes around the USA, strongly support the goals of the Cancer Moonshot initiative to www.thelancet.com/oncology Vol 17 May 2016

Emergency department usage by uninsured patients in Galveston County, Texas

The number of uninsured Texas residents who rely on the medical emergency department as their primary health care provider continues to increase. Unfortunately, little information about the characteristics of this group of emergency department users is available. Using an administrative billing database, we conducted a descriptive study to examine the demographic and clinical features of 17,110 consecutive patients without medical insurance who presented to the emergency department of the University of Texas Medical Branch in Galveston over a 12-month period. We also analyzed the risk of multiple emergency department visits or hospitalization according to demographic characteristics. Twenty percent of the study population made two or more emergency department visits during the study period; 19% of the population was admitted to the hospital via the emergency department. The risk of multiple emergency department visits was significantly elevated among African Americans and increased in a stepwise fashion according to age. The risk of being hospitalized was significantly reduced among females, African Americans, and Hispanics. There was an age-related monotonic increase in the risk of hospitalization. Abdominal pain, cellulitis, and spinal disorders were the most common primary diagnoses in patients who made multiple emergency department visits. Hospitalization occurred most frequently in patients with a primary diagnosis of chest pain, nonischemic heart disease, or an affective disorder. Additional studies of emergency department usage by uninsured patients from other regions of Texas are warranted. Such data may prove helpful in developing effective community-based alternatives to the emergency department for this growing segment of our population. Local policymakers who are responsible for the development of safety net programs throughout the state should find this information particularly useful.