Thesis (Ph.D.)--Brown University, 2008. / Vita. Advisor: Kate L. Lapane. Includes bibliographical references (leaves 52-57).

<p> Diabetes is one of the most common chronic comorbid condition seen in elderly CRC patients. Outcomes of CRC patients with diabetes specifically stage at diagnosis, emergency condition for CRC surgery, survival, and mortality have been insufficiently explored. The aims of the study were to investigate the association between diabetes and stage at diagnosis of CRC in elderly Medicare beneficiaries; to check the association of diabetes with presenting as an emergency condition for CRC surgery in the elderly and; to explore the effect of diabetes on survival of elderly Medicare beneficiaries with CRC. Using the SEER-Medicare data from 2003-2005, patients newly diagnosed with CRC were selected and divided into diabetic and nondiabetic cohorts. The two cohorts were compared in terms of stage at CRC diagnosis, emergency presentation for CRC surgery, and five year survival. Logistic regressions were used to check the association between diabetes and stage at diagnosis and emergency condition for CRC surgery. Survival analysis was employed compare time to death between diabetic and non-diabetic CRC patients. Covariates used in the study included the three most common comorbid conditions besides diabetes: coronary atherosclerosis, congestive heart failure, and chronic obstructive pulmonary disease, age, sex, race, tumor location, region in the country, patient location, and frequency of physician office visits. For survival analysis additional treatment variables &ndash; chemotherapy, radiation, and surgery were included. For stage at diagnosis of CRC, diabetes showed a significant inverse association (OR 0.92; 95% CI 0.85-1.00). On adding quintile of physician office visits this association was not significant. Odds of being diagnosed at a later stage was significantly associated with the least number of office visits (OR 2.13; 95% CI 1.86-2.44) as was having a proximal tumor (OR 1.40, 95% C 1.30-1.51) Although the odds of a diabetic patient being an emergency patient were lower than a non-diabetic, this was not statistically significant (OR 0.89; 95% CI 0.79-1.01) Mortality risk was significantly greater for diabetic CRC patients than nondiabetics (HR 1.15, 95% CI 1.09-1.20). Presenting emergently increased the risk of mortality (HR 1.61, 95% CI 1.54-1.68). Surgery for CRC reduced the risk of mortality (HR 0.41, 95% CI 0.39-0.43) and although in bivariate analyses patients who received chemotherapy were more likely to die, the hazard model showed a significant benefit associated with chemotherapy or radiation (HR 0.70, 95% CI 0.67-0.74). The worse terminal outcomes seen in diabetic CRC patients indicates the need for early and timely screening to prevent the disease or diagnosis at earlier stages.</p>

Background. Studies of recognition of depression in elderly (aged 65 or more) medical inpatients showed low recognition of depression by attending physicians. However, few studies have compared different measures of recognition of depression. / Objectives. To evaluate the validity of four recognition indicators and a global measure of recognition against a diagnosis of depression and the effect of patient characteristics on recognition of depression. / Methods. In a cohort of 264 medical inpatients 65 years and over (115 with major or minor depression, 78 with no depression), using data from two previous studies, sensitivities, specificities, and diagnostic odds ratios (DOR) of four indicators of recognition (Diagnosis, Symptoms, Treatment and Referral) and a global measure of recognition (any of the four indicators) were calculated. Stratified analysis was conducted to assess recognition by age, gender, history of depression, antidepressant use before admission, severity of depression, comorbidity, duration of hospitalization, disability and hospital of admission. The associations of patient characteristics with recognition were described among patients with major or minor depression using multiple logistic regression. / Results. Less than half of the patients were recognized according to the global measure of recognition. The indicator with the highest sensitivity was Treatment (27.8%, 95% CI: 20.0-37.0), while the indicator with the best specificity was Diagnosis (96.6%, 95% CI:91.9-98.7). The unadjusted DOR of global recognition was 2.6 (95% CI: 1.5, 4.4). Comorbidity, severity of depression, history of depression, duration of hospitalization, antidepressant use before admission and hospital of admission were significantly associated with global recognition. / Conclusion. Recognition of depression in elderly medical inpatients is low. Identifying factors that hinder recognition may guide interventions aimed at improving diagnosis and treatment of depression in elderly medical inpatients.

The safety of the novel class of nonsteroidal anti-inflammatory drugs (NSAIDs), the COX-2 inhibitors, is currently debated, with the focus on their cardiovascular toxicity. Here, the association of NSAIDs with acute renal failure (ARF) was assessed in a nested case-control study using the administrative databases of Quebec. / The risk of ARF for all NSAIDs combined was highest within 30 days of treatment initiation (adjusted rate ratio (RR) 2.05, 95% confidence interval (CI) 1.61 - 2.60) and receded thereafter. After at least 30 days without an NSAID-prescription, the risk had returned to baseline. The associations with ARF were comparable for rofecoxib (RR 2.31, 95%CI 1.73 - 3.08), naproxen (RR 2.42, 95%CI 1.52 - 3.85) and non-selective, non-naproxen NSAIDs (RR 2.30, 95%CI 1.60 - 3.32), but lower for celecoxib (RR 1.54, 95%CI 1.14 - 2.09). They were dose-dependent for celecoxib, naproxen, and rofecoxib. Results were confirmed when using an alternative exposure definition. Interactions between NSAIDs and aspirin, and NSAIDs and nephrotoxic drugs could not be demonstrated conclusively. / There is a significant association for both selective and non-selective NSAIDs with ARE Celecoxib appears to have a more favorable renal safety profile but confirmatory studies are required.

The Biomarkers of Cervical Cancer Risk (BCCR) case-control study was designed to address the role of human leukocyte antigen (HLA) alleles as cofactors in the development of high-grade cervical intraepithelial neoplasia (HG-CIN). Cases were women with histologically-confirmed HG-CIN attending colposcopy clinics and controls were women from outpatient clinics with normal cytological screening smears. Cervical specimens were submitted for both human papilloma virus (HPV) testing and HLA genotyping. Risk ratios were generated using logistic regression modelling. This analysis includes 381 case and 884 control subjects, mainly of French-Canadian descent. The B7-DRB1*1501-DQB1*0602 haplotype was associated with a 41 % reduction in risk of HG-CIN [relative risk = 0.59; 95 % confidence interval = 0.36-0.96], and an 83 % reduction in risk for HPV 16 or HPV 18-positive subjects. Possession of the B7-DRB1*1501-DQB1*0602 haplotype was moderately protective, and may be associated with slowing of disease progression to HG-CIN in women who are carriers of common oncogenic HPV types.

The objectives of this thesis are to describe door-to-reperfusion therapy wait times in ST-elevation myocardial infarction (STEMI) at selected hospitals in Quebec, and to identify factors associated with prolonged wait times. We undertook an observational study of patients with STEMI who received reperfusion therapy, at 17 hospitals in Quebec in 2003. Door-to-reperfusion therapy wait times were available for 1,189 of 1,432 patients for patients who received reperfusion therapy. The median door-to-reperfusion therapy wait times were 32 minutes for patients who received fibrinolytic therapy, and 145 and 109 minutes for patients who underwent primary percutaneous coronary intervention (PCI) with and without inter-hospital transfers, respectively. / We conclude that door-to-reperfusion therapy wait times for STEMI approached recommended times for fibrinolytic therapy, but remained prolonged for primary PCI at these 17 hospitals in 2003. Efforts are needed to reduce door-to-reperfusion therapy wait times and especially wait times to primary PCI, to assure maximum benefits from prompt delivery of reperfusion therapy for patients with STEMI.

Background. The Response Evaluation Criteria in Solid Tumours (RECIST) assess the efficacy of new therapies in clinical trials of solid tumours but not of lymphoma. These criteria, with some modifications, could replace the International Workshop Classification (IWC) for assessing efficacy in lymphoma. A lymphoma-adapted version of RECIST (LAR) would be simpler to apply than the IWC criteria and allow efficacy assessment to be standardized across clinical trials. / Methods. RECIST was modified to apply to the unique features of lymphoma. Using data from three phase II lymphoma trials (n=115), the clinical qualities of this modified scale were studied. Face, content and construct validity, and responsiveness were considered. Content validity was measured qualitatively using a pre-existing tool. Construct validity was measured using conventional agreement statistics. Responsiveness was evaluated using several responsiveness statistics. / Results. Face and content validity demonstrated that the LAR has some advantages over the IWC. Measures of construct validity between the LAR and IWC indicated high agreement. There is a moderate to high responsiveness for both the LAR and IWC. / Conclusion. Since the LAR is simpler to apply and yields near identical tumour response measures as the IWC, as well as similar responsiveness, it should be studied further as a tool to assess treatment response in lymphoma.

<p>The purpose of this prospective quantitative study was to examine primary caregivers' perceptions on the potential dangers of secondhand marijuana smoke on children and their knowledge of the health consequences of marijuana smoke. The sample included 33 primary caregivers in Los Angeles and Orange County, California. The online survey consisted of 25 multiple-choice questions. </p><p> The results revealed that 87.9% of the participants felt secondhand marijuana smoke is potentially dangerous to children. However, despite this high percentage of concerned caregivers, 90% of participants were in the low-knowledge category on the health consequences of marijuana. These findings suggest the need to provide better education to the public on the health risks for direct users of marijuana and cast light on the need to conduct further research on the potential dangers to children from secondhand marijuana smoke. </p>

<p> Full (complete) childhood immunization against tuberculosis, poliomyelitis, diphtheria, tetanus, hepatitis B, yellow fever, measles, and the maternal retention of immunization documentation are the most cost-effective interventions against vaccine-preventable childhood diseases. The full childhood immunization rate in Nigeria has not reached the expected target level of compliance at 90%. Using the social ecological model, this study investigated the influence of maternal satisfaction with postnatal services and paternal support on full childhood immunization status; it also examined the association between maternal factors and the maternal retention of immunization documentation in Owerri, Nigeria. The hypotheses were that maternal satisfaction with postnatal services and paternal support were associated with full childhood immunization status. This study was a quantitative, cross-sectional survey design that included validated modified WHO/EPI-30 cluster immunization survey information from the cluster sample of 560 mothers of children between the ages of 12 and 23 months old. The multivariate logistic regression analysis (at the .05 level) indicated that the odds of full childhood immunization status were lower for participants who indicated no maternal satisfaction with postnatal services compared with those who indicated satisfaction with postnatal services. Public health workers and policymakers should invest more resources in maternal and child health care resources to increase maternal satisfaction with postnatal services. The study outcomes may help to evolve a system that may increase childhood immunization status and reduce vaccine-preventable diseases in Owerri, and serve as a model for other countries.</p>

<p> CHIK is a viral infection transmitted by the <i>Aedes aegypti</i> mosquito which causes an illness with symptoms of severe joint pain, high fever, and rash. The joint pain can continue for months, causing disability and economic strain on families. This study included implementation of a baseline needs assessment, and development, implementation, and evaluation of an experimental community-based educational intervention in rural Tamil Nadu, India. A total of 184 households, across 12 purposively sampled villages (six intervention and six control), participated in the needs assessment between August and December 2010. The experimental community-based educational intervention was implemented between December 2010 and August 2011, in the six intervention villages. A total of 180 households, from the same 12 villages, participated in the post-intervention evaluation. A randomized block design with repetition was used to test whether there was a change in CHIK knowledge scores from baseline to post-intervention in the treatment group. A model including respondent variables, household larval status, household container larval status, recent experience with CHIK, numbers of livestock, socioeconomic position (SEP) variables, and water variables were used to predict CHIK knowledge scores in rural Tamil Nadu. Respondent age, measures of luxury amenities and water source were statistically significant predictors of knowledge in this model. The CHIK knowledge score increased from 9.0 to 9.4 in the intervention group (p=0.6457) and from 8.5 to 9.2 in the control group (p=0.393), showing that the educational intervention did not increase CHIK knowledge in the intervention group. Although this low-cost intervention, utilized in a resource poor area of Tamil Nadu, India did not result in an increase of CHIK knowledge, the process of developing the educational intervention may provide a template for future interventions. Future studies should investigate methods of sustainability in the use of educational messages. </p>