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Background The purpose of this study was to compare the rates of all-cause and breast cancer–specific mortality after breast-conserving surgery (BCS) only, BCS plus radiation therapy (RT), mastectomy, and the receipt of adjuvant tamoxifen in a large population-based cohort of older women with early-stage disease. Study Design This cohort study was conducted within six US integrated health-care delivery systems. Automated administrative databases, medical records, and tumor registries were used to identify women aged 65 years or older who received BCS or mastectomy to treat stage I or II breast cancer diagnosed from January 1, 1990, through December 31, 1994. We compared cause-specific 10-year mortality rates across treatment categories by fitting Cox proportional hazards models adjusted for demographics and tumor characteristics. Results We identified 1,837 women having operations for stage I or II breast cancer. Compared with women receiving mastectomy, those receiving BCS without RT were twice as likely to die of breast cancer (adjusted hazards ratio [HR]=2.19, 95% confidence interval [CI], 1.51 to 3.18). Breast cancer mortality rates were similar between women receiving BCS plus RT and women receiving mastectomy (adjusted HR=1.08, 95% CI, 0.79 to 1.48). In the subset of 886 chemotherapy-naive women treated with tamoxifen, those treated with tamoxifen for less than 1 year had a substantially higher breast cancer mortality rate than those exposed 5 years or more (adjusted HR=6.26, 95% CI, 3.10 to 12.64). Conclusions Our findings indicate that older women receiving BCS alone have higher rates of breast cancer death than those receiving BCS + RT or mastectomy and that the survival benefit from tamoxifen increases with increasing duration of treatment.

Background The choice between paper data collection methods and electronic data collection (EDC) methods has become a key question for clinical researchers. There remains a need to examine potential benefits, efficiencies, and innovations associated with an EDC system in a multi-center medical record review study. Methods A computer-based automated menu-driven system with 658 data fields was developed for a cohort study of women aged 65 years or older, diagnosed with invasive histologically confirmed primary breast cancer (N = 1859), at 6 Cancer Research Network sites. Medical record review with direct data entry into the EDC system was implemented. An inter-rater and intra-rater reliability (IRR) system was developed using a modified version of the EDC. Results Automation of EDC accelerated the flow of study information and resulted in an efficient data collection process. Data collection time was reduced by approximately four months compared to the project schedule and funded time available for manuscript preparation increased by 12 months. In addition, an innovative modified version of the EDC permitted an automated evaluation of inter-rater and intra-rater reliability across six data collection sites. Conclusion Automated EDC is a powerful tool for research efficiency and innovation, especially when multiple data collection sites are involved.

The utilization of ultrasound offers a facile tool for the synthesis of Au / AgCl hybrid particles. We have obtained the architectures of Au nanoparticles on AgCl sub-micrometer cubes by simply ultrasonic irradiating their precursors in ethylene glycol (EG). The formation process of Au / AgCl hybrid particles in the reaction solution has been studied based on the optical absorption spectra and the scanning electron microscope (SEM) images of the particles obtained at different ultrasonic irradiation stages. The dynamic changes of Au / AgCl hybrid particles under electron beam irradiation have been investigated in both SEM and in situ liquid cell transmission electron microscope (TEM). Hollow Au / AgCl hybrid particle structures have been obtained under the electron beam irradiation in liquid, with the cuboid contour shape preserved.

Background In 1999, the American Academy of Pediatrics and U.S. Public Health Service recommended suspending the birth dose of hepatitis B vaccine due to concerns about potential mercury exposure. A previous report found that overall national hepatitis B vaccination coverage rates decreased in association with the suspension. It is unknown whether this underimmunization occurred uniformly or was associated with how providers changed their practices for the timing of hepatitis B vaccine doses. We evaluate the impact of the birth dose suspension on underimmunization for the hepatitis B vaccine series among 24-month-olds in five large provider groups and describe provider practices potentially associated with underimmunization following the suspension. Methods Retrospective cohort study of children enrolled in five large provider groups in the United States (A-E). Logistic regression was used to evaluate the association between the birth dose suspension and a child's probability of being underimmunized at 24 months for the hepatitis B vaccine series. Results Prior to July 1999, the percent of children who received a hepatitis B vaccination at birth varied widely (3% to 90%) across the five provider groups. After the national recommendation to suspend the hepatitis B birth dose, the percent of children who received a hepatitis B vaccination at birth decreased in all provider groups, and this trend persisted after the policy was reversed. The most substantial decreases were observed in the two provider groups that shifted the first hepatitis B dose from birth to 5–6 months of age. Accounting for temporal trend, children in these two provider groups were significantly more likely to be underimmunized for the hepatitis B series at 24 months of age if they were in the birth dose suspension cohort compared with baseline (Group D OR 2.7, 95% CI 1.7 – 4.4; Group E OR 3.1, 95% CI 2.3 – 4.2). This represented 6% more children in Group D and 9% more children in Group E who were underimmunized in the suspension cohort compared with baseline. Children in the reversal cohort in these groups remained significantly more likely to be underimmunized compared with baseline. In contrast, in a third provider group where the typical timing of the third dose was unchanged and in two other provider groups whose hepatitis B vaccination schedules were unaffected by the birth dose suspension, hepatitis B vaccination coverage either was maintained or improved. Conclusion When the hepatitis B birth dose was suspended, provider groups that moved the first dose of vaccination to 5–6 months of age or later had decreases in hepatitis B vaccine coverage at 24 months. These findings suggest that as vaccine policy changes occur, providers could attempt to minimize underimmunization by adopting vaccination schedules that minimize delays in the recommended timing of vaccine doses.

Improvements in cancer detection and treatment have resulted in increasing numbers of breast cancer survivors. Information regarding the use of mammography by breast cancer survivors is limited.The use of surveillance mammography was examined over a 5-year period in a retrospective cohort of women ageor=55 years who were diagnosed with incident primary breast cancer (1996-1997) while enrolled in 1 of 4 geographically diverse integrated health systems.Of the 797 women included in the study, 80% (n=636) underwent mammograms during the first year after treatment for breast cancer. The percentage of women having mammograms during each yearly period decreased significantly over time. In multivariable analyses, older women with comorbid illnesses or those with late-stage disease were less likely to undergo mammograms, whereas those who underwent breast-conserving therapy (adjusted odds ratio [OR] of 1.38 [95% confidence interval (95% CI), 1.09-1.75]) were more likely to have mammograms. Women who had outpatient visits with a gynecologist (adjusted OR of 3.49 [95% CI, 2.55-4.79]), or a primary care physician (adjusted OR of 2.21 [95% CI, 1.73-2.82]) during the year were more likely to undergo mammograms in that year.The use of mammography among breast cancer survivors declines over time. Efforts are needed to increase awareness among healthcare providers and breast cancer survivors of the value of follow-up mammography. The current findings highlight the importance of maintaining ongoing contact with primary care physicians and gynecologists.

Background: We examined the impact of race, education, and household income on changes in rates of discontinuation and initiation of hormone therapy before and after release of the Women’s Health Initiative estrogen plus progestin trial results. Methods: We conducted an observational cohort study of 221 378 women aged 40 – 80 years enrolled in fi ve health maintenance organizations to estimate the prevalence and rates of discontinuation and initiation of estrogen plus progestin and estrogen only between September 1, 1999, to June 31, 2002 (baseline), and December 31, 2002 (follow-up). We identifi ed the census block group for each participant by geocoding her 2003 residential address. We categorized women into racial, education, and income groups based on the distribution of these characteristics in her community from year 2000 census data and the distributions of these characteristics within her HMO. Results: There were signifi cant differences in estrogen plus progestin and estrogen only prevalence by race, education level, and household income, and in estrogen plus progestin initiation by race and education level, but not by household income at follow-up. However, there were no differences by community race, education, or household income in change in the prevalence of either hormone therapy use at follow-up or in the rates of hor mone therapy discontinuation or initiation from baseline to follow-up. Conclusions: Given the wide spread media attention to the Women’s Health Initiative estrogen plus progestin trial results, our fi ndings suggest comparable dissemination of this information across diverse socioeconomic groups. [J Natl Cancer Inst Monogr 2005;35:106 – 12]

Determine the impact of fracture, coronary disease, and diabetes on changes in rates of discontinuation and initiation of estrogen therapy with (EPT) and without (ET) progestin, before (September 1, 1999 to June 30, 2002, baseline) versus 5 months after (follow-up) release of the Women's Health Initiative EPT trial results (WHI).Observational cohort; 169,586 women 40 to 80 years old from 5 U.S. HMOs.We used pharmacy data to identify ET and EPT users. A woman was a user any month she filledor =1 estrogen prescription and in subsequent months based upon the number of pills/patches dispensed. We used inpatient and outpatient claims to identify fracture January 1, 1999 to June 30, 2002 and pharmacy data to identify disease-based groups of medications for diabetes and cardiovascular disease.EPT/ET prevalence, initiation, and discontinuation rates.Baseline to follow-up EPT and ET prevalence declined 45% and 22%, respectively, with no difference by comorbidity. Follow-up EPT initiation was half the baseline rate irrespective of comorbidity. Compared to baseline, follow-up EPT discontinuation rates increased among women with diabetes (relative risk [RR], 6.9; 95% confidence interval [CI], 5.6 to 8.4), cardiovascular disease (RR, 5.5; 95% CI, 4.9 to 6.2), fracture (RR, 3.8; 95% CI, 2.4 to 5.7), and no comorbidity (RR, 4.4; 95% CI, 3.9 to 4.9). The RRs for follow-up versus baseline EPT discontinuation were higher among women with diabetes (P.01) and cardiovascular disease (P.01) versus women without these comorbidities. ET discontinuation rates among these same groups were elevated 2- to 2.8-fold.Diabetes and cardiovascular disease were associated with higher EPT discontinuation rates post-WHI compared to women without comorbidity; comorbidity had little impact on changes in prevalence or initiation of ET/EPT after release of the WHI.

OBJECTIVE We sought to examine prescribing patterns (prevalence and rates of initiation and discontinuation) for estrogen plus progestin (hormone therapy [HT] and estrogen alone [ET]) in the United States in the 2 years before the published results of Women's Health Initiative's (WHI) HT trial's early termination and for 5 months after their release. METHODS We conducted an observational cohort study of 169,586 women aged 40-80 years who were enrolled in 5 health maintenance organizations in the United States to estimate the prevalence of HT and ET and discontinuation and initiation rates between September 1, 1999, to June 31, 2002 (baseline), and December 31, 2002 (follow-up). We used automated pharmacy data to identify all oral and transdermal estrogen and progestin dispensed during the study period. RESULTS The prevalence of HT declined 46% from baseline to follow-up (14.6% to 7.9%); ET use declined 28% during the same period (12.6% to 9.1%). The discontinuation of HT increased almost immediately, from 2.5% at baseline to 13.8% in October 2002. We saw an immediate decrease in HT and ET initiation rates, from 0.4% and 0.3% at baseline, respectively, to 0.2% for HT and ET at follow-up. CONCLUSION The diffusion of the WHI HT trial results had an immediate impact on the discontinuation of HT and ET and is likely responsible for the 46% and 28% decline in the initiation of these respective therapies. Further exploration of why women continue to use HT and identification of methods for addressing reasons for continued use are indicated. LEVEL OF EVIDENCE II-2.

To determine whether depression is treated differently in older and younger patients in primary care clinics.Administrative data were used to identify patients with a depression diagnosis code. The sources of data were baseline and 3-month follow-up surveys, the health plan electronic database, and chart audits.Nine primary care clinics owned by a health maintenance organization in the Midwest.The study sample (N=1023) consisted of adult patients, aged 19 to 93, and was divided into six age groups, from young adult, under age 35, to old old, 75 or older.Independent variables were a series of dummy variables: age groups, baseline depression severity, sex, and incident depression. Outcomes were defined as care processes (assessment, resources) and improvement in depression symptoms (Center for Epidemiologic Studies-Depression scale short form). Univariate and multivariate logistic regression analyses were used to analyze patient characteristics, depression symptoms, and care process variables. Significance level was reported based on the chi-square test of probability, Por=.05.The adjusted response rates to the baseline and follow-up surveys were 69% and 82%. Elderly depressed patients were more likely than younger depressed patients to be widowed, have low levels of education, have fair or poor health, and have three or more comorbid health problems. There were no differences, by age, in number of depressive symptoms, antidepressant treatment, or recommendation for a follow-up appointment. Younger patients were more likely than older patients to have a new diagnosis of depression and to report being depressed most of the past year. Providers were only 6% as likely to ask old-old depressed patients about suicide risk, about one-fourth as likely to referral them to a mental health therapist, about one-fifth as likely to ask if they felt depressed, and one-twentieth as likely to ask about a problem with alcohol as they were with young-adult depressed patients. The old-old were about one-third as likely to report improvement in depression symptoms after 3 months as the young-adult patients.This study suggests a possible pattern of underattention to the oldest depressed patients. Failure to ask about suicide risk is especially of concern because of the high suicide rate of depressed geriatric patients. The finding that physicians are less likely to focus on depression with old-old patients may be explained, in part, by the concept of invisibility of the ordinary.

To determine the validity of calculating the chlamydia Health Plan Employer Data and Information Set (HEDIS) measure using administrative data available in a mixed-model managed care organization (MCO).Retrospective cohort study.A review of International Classification of Diseases, Ninth Revision (ICD-9), Current Procedural Termin-ology (CPT), Healthcare Common Procedure Coding System (HCPCS), and National Drug Code codes and electronic laboratory files in 1998 and a medical chart review to validate sexual activity and chlamydia testing codes specified by the National Committee for Quality Assurance (NCQA) in 1999 for the chlamydia HEDIS 2000 measure.Fewer than 25% of female enrollees with laboratory evidence of a chlamydia test had a CPT code for chlamydia testing as specified by the NCQA. Non-pathogen-specific test codes instead of NCQA-specified codes were used in 1998 to code chlamydia tests. By incorporating electronic laboratory data into the automated claims-generating process, all chlamydia tests performed at staff-model clinics were coded. Use of pharmacy dispensing data to identify contraceptive prescriptions increased the proportion of enrollees classified as sexually active by 4% to 5% vs documentation of sexual activity using ICD-9, CPT, and HCPCS codes only.The MCO quality assurance specialists examining chlamydia testing rates under HEDIS may want to evaluate chlamydia testing coding practices in their MCOs to determine whether simple changes in coding practices may present a more accurate picture of actual testing practices. The proportion of female enrollees classified as sexually active using different data available in the staff and network models varied only slightly.

To understand the process, outcomes, and patient satisfaction of usual primary care for patients given a diagnostic code for depression.Health plan data were used to identify patients with a diagnostic code for depression (and no such diagnosis in the preceding 6 months). Patients were surveyed by mail soon after the coded visit and again 3 months later about the care they had received; their charts were also audited.The 274 patients in 9 primary care clinics who responded to both surveys reported on their personal characteristics, depression symptoms and history, the care received in that initial visit, and the follow-up care during the next 3 months. They also reported on their satisfaction with various aspects of that care.These patients were likely to be given antidepressant medications as their main or only treatment. Referral for mental health therapies was not used often, even though referral is readily available in this setting; other types of self-management recommendations and support were even less frequent. Patient outcomes and levels of satisfaction during a 3-month follow-up period were unimpressive.To successfully maintain a key role in the care of this important problem for their patients, primary care physicians may need to incorporate a more comprehensive and systematic approach to management that involves other team members and is more satisfying to patients.

OBJECTIVES: To assess the separate effects of depressive symptoms and antidepressant treatment on healthcare utilization and cost. SETTING: Social Health Maintenance Organization (HMO) at Health Partners in Minnesota. PARTICIPANTS: Geriatric Social HMO enrollees were screened for depressive symptoms using the 30-item Geriatric Depression Scale. A stratified sample was created, composed of geriatric enrollees with depressive symptoms, with antidepressant prescriptions, or with neither (n = 516). DESIGN: Regression analyses were conducted with separate equations for utilization and charge outcome variables, both outpatient and inpatient (log-transformed). The Charlson Comorbidity Index, age, and gender served as covariates. MEASUREMENT: Depressive symptoms were identified through the Diagnostic Interview Schedule. Antidepressant treatment was determined from the HMO pharmacy database. RESULTS: Having depressive symptoms was associated with a 19% increase in the number of outpatient encounters and a 30% increase in total outpatient charges. Antidepressant treatment was associated with a 32% increase in total outpatient charges but was not significantly associated with number of outpatient encounters. Depressive symptoms and antidepressant therapy were not significantly associated with inpatient utilization or charges. CONCLUSION: This study found that patients with depressive symptoms generated more outpatient health care and higher charges but not necessarily more inpatient care. Our findings suggest that programs targeted to geriatric patients whose depression is comorbid with other chronic medical conditions might be cost-effective and particularly appropriate for geriatric care.

We demonstrate a high contrast imaging technique, termed localized surface plasmon assisted contrast microscopy, by combining localized surface plasmon resonances (LSPR) and dark-field microscopy technique. Due to the sensitive response of LSPR to the refractive index of the surrounding media, this technique is capable of converting a small refractive index difference to a change in scattering intensity, resulting in a high-contrast, diffraction limited image of a thin unstained specimen with small, gradual refractive-index variation.

To assess factors associated with participation in pharmaceutical care and the benefits of participation--in terms of amount of information about medications, administration of medications, and awareness of side effects.Quasi-experimental design, with a control group. Medication Survey, administered 6 months after pharmaceutical care intervention to participants, refusers, and controls. Logistic regression analyses.Three staff clinic pharmacies and three contract clinic pharmacies affiliated with a health maintenance organization (HMO).Patients with chronic health conditions (asthma, chronic obstructive pulmonary disease, or heart disease) enrolled at six intervention sites, identified through the HMO's electronic pharmacy database. Control sample with the same chronic health conditions, without access to pharmaceutical care (n = 210 participants, 162 refusers, and 368 controls; overall adjusted response rate = 72%).Pharmaceutical care, in the form of a comprehensive drug therapy management program.Predictors of participation, amount of information about medications, use of reminder methods, and awareness of side effects.The following variables were significantly associated with the probability of participating in pharmaceutical care (P.05): number of medications, employment, income, health status, education, and living situation. Participants were more likely than controls to say they received "a lot of information" from their pharmacist about all aspects of medications (odds ratio [OR], 1.75 to 2.68). Participants were more likely to report leaving their medication container in a visible place and using two or more reminder methods (OR, 1.87 to 1.48). There were no significant differences in the probability of missing doses. Participants were more likely to report experiencing "symptoms or problems" associated with prescription medications (OR, 1.81).Pharmaceutical care appears to increase the information given to patients about medications, promote more effective self-administration of medications by encouraging patients to use systematic reminders, and increase awareness of medication side effects.

The immunization rate for St. Louis, Missouri, children age two and younger is only 49 percent, below the statewide rate of 64 percent and far below the estimated national rate of 75 percent. In response to this crisis, the St. Louis Integrated Immunization Information System (SLIIIS) was designed to establish an on-line immunization information system, identify barriers to immunization among health care providers and the client population, and implement methods for removing these barriers. Available to both public and private health care providers, SLIIIS uses a population-based approach to monitoring and improving immunization levels in the Eastern Missouri Region. SLIIIS was initiated by a partnership of an academic center with community agencies and institutions. Review of initial development efforts and system design may be valuable to others involved in creating regionally integrated information systems.

We propose and demonstrate a compact, alignment-free dark-field microscopy technique, termed as organic light-emitting-diode-based plasmonic dark-field microscopy. Experimental results show that it is capable of forming dark-field images of the specimens utilizing a highly integrated chip-scale plasmonic condenser. This technique has high z resolution and high imaging contrast and is suitable for the dynamics study near the contact regions of living cells and the substrate.

Background: The Women’s Health Initiative (WHI) clinical trials offer a wealth of data on patient outcomes including cancer, coronary heart disease, and hip fracture, which were confirmed via medical record review. Diabetes was self-reported, but was not validated by independent review. The literature shows wide variations on the validity of self-reported diabetes in diverse populations. Aims: To compare the rates of positive and negative predictive values of self-reports of incident and prevalent diabetes during the WHI trials. Methods: At four WHI field centers (Minneapolis MN, Winston- Salem NC, Birmingham AL, Portland OR), all WHI trial participants with a self-report of diabetes at baseline or follow-up were identified. A random sample of participants who did not self-report diabetes was also identified. Women were surveyed regarding details of their diagnosis and treatment of diabetes. Medical records were obtained and reviewed for consenting subjects using a standardized protocol based on documented treatment with anti-diabetic medications, or physician diagnosis of diabetes supported by laboratory measurements of glucose. Results: A total of 1280 eligible subjects were available across the four sites. To date, subject information from the Minneapolis field center has been collected and analyzed. Of the 295 eligible subjects contacted at the Minneapolis site, 227 (77%) consented to participate and provided survey data. Medical records were obtained for 224 (57 prevalent, 81 incident, and 86 no self-reported diabetes). Medical records confirmed 84% (95% CI 74%–94%) of self-reported prevalent diabetes and 85% (95% CI 74%–94%) of self-reported incident diabetes. Among those who never self-reported diabetes there was no medical record evidence for diabetes in 99% (95% CI 92% to 100%). Results from all four sites will be presented. Conclusions: Preliminary data suggest a high positive predictive value of both prevalent (84%) and incident self-report of diabetes (85%) from WHI and a low false negative rate of about 1%. These results indicate that self-reports of diabetes may be sufficiently accurate for use in epidemiologic studies.

We studied silicon, carbon, and SiC x nanostructures fabricated using liquid-phase electron-beam-induced deposition technology in transmission electron microscopy systems. Nanodots obtained from fixed electron beam irradiation followed a universal size versus beam dose trend, with precursor concentrations from pure SiCl4 to 0 % SiCl4 in CH2Cl2, and electron beam intensity ranges of two orders of magnitude, showing good controllability of the deposition. Secondary electrons contributed to the determination of the lateral sizes of the nanostructures, while the primary beam appeared to have an effect in reducing the vertical growth rate. These results can be used to generate donut-shaped nanostructures. Using a scanning electron beam, line structures with both branched and unbranched morphologies were also obtained. The liquid-phase electron-beam-induced deposition technology is shown to be an effective tool for advanced nanostructured material generation.

Background This study evaluated the utility of immunization registries in identifying vaccine refusals among children. Among refusers, we studied their socioeconomic characteristics and health care utilization patterns. Methods Medical records were reviewed to validate refusal status in the immunization registries of two health plans. Racial, education, and income characteristics of children claiming refusal were collected based on the census tract of each child. Health care utilization was identified using both electronic medical record and insurance claims. Within the immunization registries of two HMOs in the study, some providers use refusal and medical contraindication interchangeably, and some providers tend to always use "ever refusal." Therefore, we combined medical contraindication and refusal together and treated them all as "refusal" in this study. Results The immunization registry, compared to chart review, had negative predictive values of 85–92% and 90–97% for 2- and 6-year olds, and positive predictive values of only 52–74% and 59–62% to identify vaccine refusals. Refusers were more likely to reside in well-educated, higher income areas than non-refusers. Refusers had not opted out of health care system and continued, although less frequently for the age 2 and under group, to use services. Conclusion Without enhancements to immunization registries, identifying children with immunization refusal would be time consuming. Since communities where refusers live are well educated, interventions should target these communities to communicate vaccine adverse events and consequences of vaccine preventable diseases.