Last data update: Nov 04, 2024. (Total: 48056 publications since 2009)
Records 1-28 (of 28 Records) |
Query Trace: Steenland M[original query] |
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PFAS and cancer, a scoping review of the epidemiologic evidence
Steenland K , Winquist A . Environ Res 2020 194 110690 BACKGROUND: The number of studies addressing per- and polyfluoroalkyl substances (PFAS) and cancer is increasing. Many communities have had water contaminated by PFAS, and cancer is one of the important community concerns related to PFAS exposure. OBJECTIVES: We critically reviewed the evidence relating to PFAS and cancer from an epidemiologic standpoint to highlight directions for future research that would be the most likely to meaningfully increase knowledge. METHODS: We conducted a search in PubMed for studies of cancer and PFAS (through 9/20/2020). We identified epidemiologic studies that provided a quantitative estimate for some measure of the association between PFAS and cancer. Here, we review that literature, including several aspects of epidemiologic study design that impact the usefulness of study results. RESULTS: We identified 16 cohort (or case-cohort) studies, 10 case-control studies (4 nested within cohorts and 6 non-nested), 1 cross sectional study and 1 ecologic study. The cancer sites with the most evidence of an association with PFAS are testicular and kidney cancer. There are also some suggestions in a few studies of an association with prostate cancer, but the data are inconsistent. DISCUSSION: Each study's design has strengths and limitations. Weaknesses in study design and methods can, in some cases, lead to questionable associations, but in other cases can make it more difficult to detect true associations, if they are present. Overall, the evidence for an association between cancer and PFAS remains sparse. A variety of studies with different strengths and weaknesses can be helpful to clarify associations between PFAS and cancer. Long term follow-up of large-sized cohorts with large exposure contrasts are most likely to be informative. |
An educational intervention on the risk perception of pesticides exposure and organophosphate metabolites urinary concentrations in rural school children in Maule Region, Chile
Munoz-Quezada MT , Lucero B , Bradman A , Steenland K , Zuniga L , Calafat AM , Ospina M , Iglesias V , Munoz MP , Buralli RJ , Fredes C , Gutierrez JP . Environ Res 2019 176 108554 BACKGROUND: Organophosphate (OP) pesticides can be hazardous to human health if not applied with appropriate precautions. There is evidence in the Maule region of Chile that rural schoolchildren are exposed to OP pesticides. OBJECTIVE: To evaluate the effectiveness of an educational intervention on OP exposure and understanding of pesticides and their hazards (risk perception) in two school communities in the Maule Region of Chile during 2016. METHOD: We conducted a quasi-experimental study about the effects on OP pesticide exposure of a community outreach and education program (COEP) administered in four 2-h sessions that's included hands-on activities among 48 schoolchildren from two rural schools. The intervention was directed to groups of parents and school-children separately, and aimed to educate them about the risks of exposure to pesticides and their effects on health. We measured 3,5,6-trichloro-2-pyridinol (TCPy), 2-isopropyl-4-methyl-6-hydroxypyrimidine (IMPY), malathion dicarboxylic acid (MDA), p-nitrophenol (PNP), specific urinary metabolites of the OP pesticides chlorpyrifos, diazinon, malathion and parathion, respectively, as well as the non-specific diethylakylphosphates (DEAPs) and dimethylalkylphosphates (DMAPs) in 192 urine samples of schoolchildren collected before and after the intervention. The risk perception of school children and their parents was also assessed through a questionnaire before and after the intervention. Generalized Estimated Equations were used to account for each child's repeated measures during four sessions, two in September 2016 (pre-intervention) and two in November 2016 (post-intervention). RESULTS: The intervention level had significant effect on the risk perception of adults and children, which increased after the intervention. However, the intervention was not associated with reduced of urinary metabolites levels, with no significant differences between the pre and post measures. The detection frequencies were 1.1% (MDA), 71.4% (TCPy), 43.3% (IMPY), 98.96% (PNP), and 100% (DEAPs and DMAPs). Higher DEAPs urine concentrations were associated with eating more fruit at school (p=0.03), a younger age (p=0.03), and being male (p=0.01). DMAPs showed no associations with potential predictor variables (e.g. OPs applied at home, fruit consumption at school, among others). Higher TCPy was associated with attending a school closer to farms (p=0.04) and living in a home closer to farm fields (p=0.01); higher PNP was marginally associated with children younger age (p=0.035). CONCLUSION: Environmental exposure to OP pesticides was unchanged even after behavior changes. It is possible that a longer time period is needed to observe changes in both behavior and urinary metabolites. The levels of DEP and DMP metabolites found here are above the reference population of the US, and our findings indicate exposure to a wide variety of OP pesticides. Given that individual-level interventions were not associated with lower exposures, efforts to reduce exposure must occur upstream and require stricter regulation and control of pesticide use by government agencies. |
Assessment of drinking water sold from private sector kiosks in post-earthquake Port-au-Prince, Haiti
Patrick M , Steenland M , Dismer A , Pierre-Louis J , Murphy JL , Kahler A , Mull B , Etheart MD , Rossignol E , Boncy J , Hill V , Handzel T . Am J Trop Med Hyg 2017 97 84-91 Consumption of drinking water from private vendors has increased considerably in Port-au-Prince, Haiti, in recent decades. A major type of vendor is private kiosks, advertising reverse osmosis-treated water for sale by volume. To describe the scale and geographical distribution of private kiosks in metropolitan Port-au-Prince, an inventory of private kiosks was conducted from July to August 2013. Coordinates of kiosks were recorded with global positioning system units and a brief questionnaire was administered with the operator to document key kiosk characteristics. To assess the quality of water originating from private kiosks, water quality analyses were also conducted on a sample of those inventoried as well as from the major provider company sites. The parameters tested were Escherichia coli, free chlorine residual, pH, turbidity, and total dissolved solids. More than 1,300 kiosks were inventoried, the majority of which were franchises of four large provider companies. Approximately half of kiosks reported opening within 12 months of the date of the inventory. The kiosk treatment chain and sales price was consistent among a majority of the kiosks. Of the 757 kiosks sampled for water quality, 90.9% of samples met World Health Organization (WHO) microbiological guideline at the point of sale for nondetectable E. coli in a 100-mL sample. Of the eight provider company sites tested, all samples met the WHO microbiological guideline. Because of the increasing role of the private sector in drinking water provision in Port-au-Prince and elsewhere in Haiti, this assessment was an important first step for government regulation of this sector. |
Re: Bias in the proportionate mortality ratio analysis of small study populations: A case on analyses of radiation and mesothelioma
Hein MJ , Schubauer-Berigan MK . Int J Radiat Biol 2015 91 (11) 908-10 Studies of mortality in occupational groups frequently use proportionate mortality ratio (PMR) analyses (Steenland et al.Citation1990). In the simplest case, the PMR is the ratio of the proportion of deaths due to a specific cause in the study population to the proportion of deaths due to the same cause in a referent population. Software packages such as the NIOSH Life-Table Analysis System (LTAS.NET) can estimate PMRs that are adjusted for gender, race, age, and calendar year (Schubauer-Berigan et al. Citation2011). Zhou (Citation2014) recently claimed that the PMR reported in the NIOSH LTAS.NET program is biased under certain conditions - namely, when the number of deaths available for analysis is small relative to the number of cause-of-death categories, resulting in categories with zero observed deaths. To remove the bias, Zhou proposed an adjustment that involved excluding deaths from the referent population for categories with zero deaths in the sample when estimating the PMR. The objective of this letter is to point out faulty logic in Zhou's proposed adjustment and assure users of LTAS.NET that the PMR estimates produced by LTAS.NET are not biased. |
Identifying the most sensitive and specific sign and symptom combinations for cholera: results from an analysis of laboratory-based surveillance data from Haiti, 2012-2013
Lucien MA , Schaad N , Steenland MW , Mintz ED , Emmanuel R , Freeman N , Boncy J , Adrien P , Joseph GA , Katz MA . Am J Trop Med Hyg 2015 92 (4) 758-764 Since October 2010, over 700,000 cholera cases have been reported in Haiti. We used data from laboratory-based surveillance for diarrhea in Haiti to evaluate the sensitivity, specificity, and positive (PPV) and negative predictive values (NPV) of the cholera case definitions recommended by the World Health Organization (WHO). From April 2012 to May 2013, we tested 1,878 samples from hospitalized patients with acute watery diarrhea; 1,178 (62.7%) yielded Vibrio cholerae O1. The sensitivity and specificity of the WHO case definition for cholera in an epidemic setting were 91.3% and 43.1%, respectively, and the PPV and NPV were 72.8% and 74.8%, respectively. The WHO case definition for cholera in an area where cholera is not known to be present had lower sensitivity (63.1%) and NPV (55.1%) but higher specificity (74.2%) and PPV (80.0%). When laboratory diagnostic testing is not immediately available, clinicians can evaluate signs and symptoms to more accurately identify cholera patients. |
Predictors of blood trihalomethane concentrations in NHANES 1999-2006
Riederer AM , Dhingra R , Blount BC , Steenland K . Environ Health Perspect 2014 122 (7) 695-702 BACKGROUND: Trihalomethanes (THMs) are water disinfection by-products that have been associated with bladder cancer and adverse birth outcomes. Four (bromoform, chloroform, bromodichloromethane, dibromochloromethane) were measured in blood and tap water of U.S. adults in NHANES 1999-2006. THMs are metabolized to potentially toxic/mutagenic intermediates by cytochrome p450 (CYP) 2D6 and CYP2E1 enzymes. OBJECTIVES: We conducted exploratory analyses of blood THMs including factors affecting CYP2D6 and CYP2E1 activity. METHODS: We used weighted multivariable regression to evaluate associations between blood THMs and water concentrations, survey year, and other factors potentially affecting THM exposure or metabolism (e.g., prescription medications, cruciferous vegetables, diabetes, fasting, pregnancy, swimming). RESULTS: From 1999-2006, geometric mean blood and water THM levels dropped in parallel-32%-76% in blood and 38%-52% in water-likely resulting, in part, from the lowering of the total THM drinking water standard in 2002-2004. The strongest predictors of blood THM levels were survey year and water concentration (N=4,232 total THM; N=4,582 chloroform; N=4,080 bromoform; N=4,374 bromodichloromethane; N=4,464 dibromochloromethane). Statistically significant inverse associations were detected with diabetes and eating cruciferous vegetables in all but the bromoform model. Medications did not consistently predict blood levels. Afternoon/evening blood samples had lower THM concentrations than morning samples. In a sub-sample (n=230), air chloroform better predicted blood chloroform than water chloroform, suggesting showering/bathing was a more important source than drinking. CONCLUSIONS: We identified several factors associated with blood THMs which may be factors affecting their metabolism; potential health implications require further study. |
Hospitalizations and deaths caused by diarrhea in children five years old and younger at four hospitals in Haiti, 2010-2012
Derby KS , Lucien MA , Leshem E , Steenland MW , Juin S , Gerard AJ , Katz MA . Am J Trop Med Hyg 2013 90 (2) 291-3 Worldwide, diarrhea is a major contributor to morbidity and mortality in children; however, there are few data on the burden of diarrheal disease in Haiti. We conducted a retrospective review of hospital discharge registries from 2010 to 2012 in the pediatric wards of four Haitian hospitals and recorded the number of all-cause hospitalizations and deaths as well as diarrheal hospitalizations and deaths by age (≤ 2 and 3-5 years) and epidemiological week. Diarrhea was associated with 3,582 (33.7%) of 10,621 hospitalizations and 62 (11.5%) of 540 in-hospital deaths in children ≤ 5 years old. Of these children, 88.5% and 96.8%, respectively, were among children ≤ 2 years old. The highest proportions of diarrhea-associated hospitalizations occurred from January to April. At four Haitian hospitals over a 3-year period, during which time a major epidemic of cholera occurred, diarrheal disease in children ≤ 5 years was a major contributor to pediatric hospitalizations and mortality. |
Laboratory-confirmed cholera and rotavirus among patients with acute diarrhea in four hospitals in Haiti, 2012-2013
Steenland MW , Joseph GA , Lucien MA , Freeman N , Hast M , Nygren BL , Leshem E , Juin S , Parsons MB , Talkington DF , Mintz ED , Vertefeuille J , Balajee SA , Boncy J , Katz MA . Am J Trop Med Hyg 2013 89 (4) 641-6 An outbreak of cholera began in Haiti in October of 2010. To understand the progression of epidemic cholera in Haiti, in April of 2012, we initiated laboratory-enhanced surveillance for diarrheal disease in four Haitian hospitals in three departments. At each site, we sampled up to 10 hospitalized patients each week with acute watery diarrhea. We tested 1,616 specimens collected from April 2, 2012 to March 28, 2013; 1,030 (63.7%) specimens yielded Vibrio cholerae, 13 (0.8%) specimens yielded Shigella, 6 (0.4%) specimens yielded Salmonella, and 63 (3.9%) specimens tested positive for rotavirus. Additionally, 13.5% of children < 5 years old tested positive for rotavirus. Of 1,030 V. cholerae isolates, 1,020 (99.0%) isolates were serotype Ogawa, 9 (0.9%) isolates were serotype Inaba, and 1 isolate was non-toxigenic V. cholerae O139. During 1 year of surveillance, toxigenic cholera continued to be the main cause of acute diarrhea in hospitalized patients, and rotavirus was an important cause of diarrhea-related hospitalizations in children. |
The state of US health, 1990-2010: burden of diseases, injuries, and risk factors
Murray CJ , Abraham J , Ali MK , Alvarado M , Atkinson C , Baddour LM , Bartels DH , Benjamin EJ , Bhalla K , Birbeck G , Bolliger I , Burstein R , Carnahan E , Chen H , Chou D , Chugh SS , Cohen A , Colson KE , Cooper LT , Couser W , Criqui MH , Dabhadkar KC , Dahodwala N , Danaei G , Dellavalle RP , Des Jarlais DC , Dicker D , Ding EL , Dorsey ER , Duber H , Ebel BE , Engell RE , Ezzati M , Felson DT , Finucane MM , Flaxman S , Flaxman AD , Fleming T , Forouzanfar MH , Freedman G , Freeman MK , Gabriel SE , Gakidou E , Gillum RF , Gonzalez-Medina D , Gosselin R , Grant B , Gutierrez HR , Hagan H , Havmoeller R , Hoffman H , Jacobsen KH , James SL , Jasrasaria R , Jayaraman S , Johns N , Kassebaum N , Khatibzadeh S , Knowlton LM , Lan Q , Leasher JL , Lim S , Lin JK , Lipshultz SE , London S , Lozano R , Lu Y , Macintyre MF , Mallinger L , McDermott MM , Meltzer M , Mensah GA , Michaud C , Miller TR , Mock C , Moffitt TE , Mokdad AA , Mokdad AH , Moran AE , Mozaffarian D , Murphy T , Naghavi M , Narayan KM , Nelson RG , Olives C , Omer SB , Ortblad K , Ostro B , Pelizzari PM , Phillips D , Pope CA , Raju M , Ranganathan D , Razavi H , Ritz B , Rivara FP , Roberts T , Sacco RL , Salomon JA , Sampson U , Sanman E , Sapkota A , Schwebel DC , Shahraz S , Shibuya K , Shivakoti R , Silberberg D , Singh GM , Singh D , Singh JA , Sleet DA , Steenland K , Tavakkoli M , Taylor JA , Thurston GD , Towbin JA , Vavilala MS , Vos T , Wagner GR , Weinstock MA , Weisskopf MG , Wilkinson JD , Wulf S , Zabetian A , Lopez AD . JAMA 2013 310 (6) 591-608 IMPORTANCE: Understanding the major health problems in the United States and how they are changing over time is critical for informing national health policy. OBJECTIVES: To measure the burden of diseases, injuries, and leading risk factors in the United States from 1990 to 2010 and to compare these measurements with those of the 34 countries in the Organisation for Economic Co-operation and Development (OECD) countries. DESIGN: We used the systematic analysis of descriptive epidemiology of 291 diseases and injuries, 1160 sequelae of these diseases and injuries, and 67 risk factors or clusters of risk factors from 1990 to 2010 for 187 countries developed for the Global Burden of Disease 2010 Study to describe the health status of the United States and to compare US health outcomes with those of 34 OECD countries. Years of life lost due to premature mortality (YLLs) were computed by multiplying the number of deaths at each age by a reference life expectancy at that age. Years lived with disability (YLDs) were calculated by multiplying prevalence (based on systematic reviews) by the disability weight (based on population-based surveys) for each sequela; disability in this study refers to any short- or long-term loss of health. Disability-adjusted life-years (DALYs) were estimated as the sum of YLDs and YLLs. Deaths and DALYs related to risk factors were based on systematic reviews and meta-analyses of exposure data and relative risks for risk-outcome pairs. Healthy life expectancy (HALE) was used to summarize overall population health, accounting for both length of life and levels of ill health experienced at different ages. RESULTS: US life expectancy for both sexes combined increased from 75.2 years in 1990 to 78.2 years in 2010; during the same period, HALE increased from 65.8 years to 68.1 years. The diseases and injuries with the largest number of YLLs in 2010 were ischemic heart disease, lung cancer, stroke, chronic obstructive pulmonary disease, and road injury. Age-standardized YLL rates increased for Alzheimer disease, drug use disorders, chronic kidney disease, kidney cancer, and falls. The diseases with the largest number of YLDs in 2010 were low back pain, major depressive disorder, other musculoskeletal disorders, neck pain, and anxiety disorders. As the US population has aged, YLDs have comprised a larger share of DALYs than have YLLs. The leading risk factors related to DALYs were dietary risks, tobacco smoking, high body mass index, high blood pressure, high fasting plasma glucose, physical inactivity, and alcohol use. Among 34 OECD countries between 1990 and 2010, the US rank for the age-standardized death rate changed from 18th to 27th, for the age-standardized YLL rate from 23rd to 28th, for the age-standardized YLD rate from 5th to 6th, for life expectancy at birth from 20th to 27th, and for HALE from 14th to 26th. CONCLUSIONS AND RELEVANCE: From 1990 to 2010, the United States made substantial progress in improving health. Life expectancy at birth and HALE increased, all-cause death rates at all ages decreased, and age-specific rates of years lived with disability remained stable. However, morbidity and chronic disability now account for nearly half of the US health burden, and improvements in population health in the United States have not kept pace with advances in population health in other wealthy nations. |
Reductions in serum lipids with a 4-year decline in serum perfluorooctanoic acid and perfluorooctanesulfonic acid
Fitz-Simon N , Fletcher T , Luster MI , Steenland K , Calafat AM , Kato K , Armstrong B . Epidemiology 2013 24 (4) 569-76 BACKGROUND: Several epidemiological cross-sectional studies have found positive associations between serum concentrations of lipids and perfluorooctanoic acid (PFOA, or C8). A longitudinal study should be less susceptible to biases from uncontrolled confounding or reverse causality. METHODS: We investigated the association between within-individual changes in serum PFOA and perfluorooctanesulfonic acid (PFOS) and changes in serum lipid levels (low-density lipoprotein [LDL] cholesterol, high-density lipoprotein cholesterol, total cholesterol, and triglycerides) over a 4.4-year period. The study population consisted of 560 adults living in parts of Ohio and West Virginia where public drinking water had been contaminated with PFOA. They had participated in a cross-sectional study in 2005-2006, and were followed up in 2010, by which time exposure to PFOA had been substantially reduced. RESULTS: Overall serum concentrations of PFOA and PFOS fell by half from initial geometric means of 74.8 and 18.5 ng/mL, respectively, with little corresponding change in LDL cholesterol (mean increase 1.8%, standard deviation 26.6%). However, there was a tendency for people with greater declines in serum PFOA or PFOS to have greater LDL decrease. For a person whose serum PFOA fell by half, the predicted fall in LDL cholesterol was 3.6% (95% confidence interval = 1.5-5.7%). The association with a decline in PFOS was even stronger, with a 5% decrease in LDL (2.5-7.4%). CONCLUSIONS: Our findings from this longitudinal study support previous evidence from cross-sectional studies of positive associations between PFOA and PFOS in serum and LDL cholesterol. |
Cholera surveillance during the Haiti epidemic - the first 2 years
Barzilay EJ , Schaad N , Magloire R , Mung KS , Boncy J , Dahourou GA , Mintz ED , Steenland MW , Vertefeuille JF , Tappero JW . N Engl J Med 2013 368 (7) 599-609 BACKGROUND: In October 2010, nearly 10 months after a devastating earthquake, Haiti was stricken by epidemic cholera. Within days after detection, the Ministry of Public Health and Population established a National Cholera Surveillance System (NCSS). METHODS: The NCSS used a modified World Health Organization case definition for cholera that included acute watery diarrhea, with or without vomiting, in persons of all ages residing in an area in which at least one case of Vibrio cholerae O1 infection had been confirmed by culture. RESULTS: Within 29 days after the first report, cases of V. cholerae O1 (serotype Ogawa, biotype El Tor) were confirmed in all 10 administrative departments (similar to states or provinces) in Haiti. Through October 20, 2012, the public health ministry reported 604,634 cases of infection, 329,697 hospitalizations, and 7436 deaths from cholera and isolated V. cholerae O1 from 1675 of 2703 stool specimens tested (62.0%). The cumulative attack rate was 5.1% at the end of the first year and 6.1% at the end of the second year. The cumulative case fatality rate consistently trended downward, reaching 1.2% at the close of year 2, with departmental cumulative rates ranging from 0.6% to 4.6% (median, 1.4%). Within 3 months after the start of the epidemic, the rolling 14-day case fatality rate was 1.0% and remained at or below this level with few, brief exceptions. Overall, the cholera epidemic in Haiti accounted for 57% of all cholera cases and 53% of all cholera deaths reported to the World Health Organization in 2010 and 58% of all cholera cases and 37% of all cholera deaths in 2011. CONCLUSIONS: A review of NCSS data shows that during the first 2 years of the cholera epidemic in Haiti, the cumulative attack rate was 6.1%, with cases reported in all 10 departments. Within 3 months after the first case was reported, there was a downward trend in mortality, with a 14-day case fatality rate of 1.0% or less in most areas. |
A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010
Lim Stephen S , Vos Theo , Flaxman Abraham D , Danaei Goodarz , Shibuya Kenji , Adair-Rohani Heather , Amann Markus , Anderson H Ross , Andrews Kathryn G , Aryee Martin , Atkinson Charles , Bacchus Loraine J , Bahalim Adil N , Balakrishnan Kalpana , Balmes John , Barker-Collo Suzanne , Baxter Amanda , Bell Michelle L , Blore Jed D , Blyth Fiona , Bonner Carissa , Borges Guilherme , Bourne Rupert , Boussinesq Michel , Brauer Michael , Brooks Peter , Bruce Nigel G , Brunekreef Bert , Bryan-Hancock Claire , Bucello Chiara , Buchbinder Rachelle , Bull Fiona , Burnett Richard T , Byers Tim E , Calabria Bianca , Carapetis Jonathan , Carnahan Emily , Chafe Zoe , Charlson Fiona , Chen Honglei , Chen Jian Shen , Cheng Andrew Tai-Ann , Child Jennifer Christine , Cohen Aaron , Colson K Ellicott , Cowie Benjamin C , Darby Sarah , Darling Susan , Davis Adrian , Degenhardt Louisa , Dentener Frank , Des Jarlais Don C , Devries Karen , Dherani Mukesh , Ding Eric L , Dorsey E Ray , Driscoll Tim , Edmond Karen , Ali Suad Eltahir , Engell Rebecca E , Erwin Patricia J , Fahimi Saman , Falder Gail , Farzadfar Farshad , Ferrari Alize , Finucane Mariel M , Flaxman Seth , Fowkes Francis Gerry R , Freedman Greg , Freeman Michael K , Gakidou Emmanuela , Ghosh Santu , Giovannucci Edward , Gmel Gerhard , Graham Kathryn , Grainger Rebecca , Grant Bridget , Gunnell David , Gutierrez Hialy R , Hall Wayne , Hoek Hans W , Hogan Anthony , Hosgood H Dean 3rd , Hoy Damian , Hu Howard , Hubbell Bryan J , Hutchings Sally J , Ibeanusi Sydney E , Jacklyn Gemma L , Jasrasaria Rashmi , Jonas Jost B , Kan Haidong , Kanis John A , Kassebaum Nicholas , Kawakami Norito , Khang Young-Ho , Khatibzadeh Shahab , Khoo Jon-Paul , Kok Cindy , Laden Francine , Lalloo Ratilal , Lan Qing , Lathlean Tim , Leasher Janet L , Leigh James , Li Yang , Lin John Kent , Lipshultz Steven E , London Stephanie , Lozano Rafael , Lu Yuan , Mak Joelle , Malekzadeh Reza , Mallinger Leslie , Marcenes Wagner , March Lyn , Marks Robin , Martin Randall , McGale Paul , McGrath John , Mehta Sumi , Mensah George A , Merriman Tony R , Micha Renata , Michaud Catherine , Mishra Vinod , Hanafiah Khayriyyah Mohd , Mokdad Ali A , Morawska Lidia , Mozaffarian Dariush , Murphy Tasha , Naghavi Mohsen , Neal Bruce , Nelson Paul K , Nolla Joan Miquel , Norman Rosana , Olives Casey , Omer Saad B , Orchard Jessica , Osborne Richard , Ostro Bart , Page Andrew , Pandey Kiran D , Parry Charles D H , Passmore Erin , Patra Jayadeep , Pearce Neil , Pelizzari Pamela M , Petzold Max , Phillips Michael R , Pope Dan , Pope C Arden 3rd , Powles John , Rao Mayuree , Razavi Homie , Rehfuess Eva A , Rehm Jurgen T , Ritz Beate , Rivara Frederick P , Roberts Thomas , Robinson Carolyn , Rodriguez-Portales Jose A , Romieu Isabelle , Room Robin , Rosenfeld Lisa C , Roy Ananya , Rushton Lesley , Salomon Joshua A , Sampson Uchechukwu , Sanchez-Riera Lidia , Sanman Ella , Sapkota Amir , Seedat Soraya , Shi Peilin , Shield Kevin , Shivakoti Rupak , Singh Gitanjali M , Sleet David A , Smith Emma , Smith Kirk R , Stapelberg Nicolas J C , Steenland Kyle , Stockl Heidi , Stovner Lars Jacob , Straif Kurt , Straney Lahn , Thurston George D , Tran Jimmy H , Van Dingenen Rita , van Donkelaar Aaron , Veerman J Lennert , Vijayakumar Lakshmi , Weintraub Robert , Weissman Myrna M , White Richard A , Whiteford Harvey , Wiersma Steven T , Wilkinson James D , Williams Hywel C , Williams Warwick , Wilson Nicholas , Woolf Anthony D , Yip Paul , Zielinski Jan M , Lopez Alan D , Murray Christopher J L , Ezzati Majid , Global Burden of Disease Study 2010 . Lancet 2013 380 (9859) 2224-60 BACKGROUND: Quantification of the disease burden caused by different risks informs prevention by providing an account of health loss different to that provided by a disease-by-disease analysis. No complete revision of global disease burden caused by risk factors has been done since a comparative risk assessment in 2000, and no previous analysis has assessed changes in burden attributable to risk factors over time. METHODS: We estimated deaths and disability-adjusted life years (DALYs; sum of years lived with disability [YLD] and years of life lost [YLL]) attributable to the independent effects of 67 risk factors and clusters of risk factors for 21 regions in 1990 and 2010. We estimated exposure distributions for each year, region, sex, and age group, and relative risks per unit of exposure by systematically reviewing and synthesising published and unpublished data. We used these estimates, together with estimates of cause-specific deaths and DALYs from the Global Burden of Disease Study 2010, to calculate the burden attributable to each risk factor exposure compared with the theoretical-minimum-risk exposure. We incorporated uncertainty in disease burden, relative risks, and exposures into our estimates of attributable burden. FINDINGS: In 2010, the three leading risk factors for global disease burden were high blood pressure (7.0% [95% uncertainty interval 6.2-7.7] of global DALYs), tobacco smoking including second-hand smoke (6.3% [5.5-7.0]), and alcohol use (5.5% [5.0-5.9]). In 1990, the leading risks were childhood underweight (7.9% [6.8-9.4]), household air pollution from solid fuels (HAP; 7.0% [5.6-8.3]), and tobacco smoking including second-hand smoke (6.1% [5.4-6.8]). Dietary risk factors and physical inactivity collectively accounted for 10.0% (95% UI 9.2-10.8) of global DALYs in 2010, with the most prominent dietary risks being diets low in fruits and those high in sodium. Several risks that primarily affect childhood communicable diseases, including unimproved water and sanitation and childhood micronutrient deficiencies, fell in rank between 1990 and 2010, with unimproved water and sanitation accounting for 0.9% (0.4-1.6) of global DALYs in 2010. However, in most of sub-Saharan Africa childhood underweight, HAP, and non-exclusive and discontinued breastfeeding were the leading risks in 2010, while HAP was the leading risk in south Asia. The leading risk factor in Eastern Europe, most of Latin America, and southern sub-Saharan Africa in 2010 was alcohol use; in most of Asia, North Africa and Middle East, and central Europe it was high blood pressure. Despite declines, tobacco smoking including second-hand smoke remained the leading risk in high-income north America and western Europe. High body-mass index has increased globally and it is the leading risk in Australasia and southern Latin America, and also ranks high in other high-income regions, North Africa and Middle East, and Oceania. INTERPRETATION: Worldwide, the contribution of different risk factors to disease burden has changed substantially, with a shift away from risks for communicable diseases in children towards those for non-communicable diseases in adults. These changes are related to the ageing population, decreased mortality among children younger than 5 years, changes in cause-of-death composition, and changes in risk factor exposures. New evidence has led to changes in the magnitude of key risks including unimproved water and sanitation, vitamin A and zinc deficiencies, and ambient particulate matter pollution. The extent to which the epidemiological shift has occurred and what the leading risks currently are varies greatly across regions. In much of sub-Saharan Africa, the leading risks are still those associated with poverty and those that affect children. FUNDING: Bill & Melinda Gates Foundation. |
Appropriate follow up to detect potential adverse events after initiation of select contraceptive methods: a systematic review
Steenland MW , Zapata LB , Brahmi D , Marchbanks PA , Curtis KM . Contraception 2012 87 (5) 611-24 BACKGROUND: After a woman initiates certain methods of contraception [e.g., hormonal methods, intrauterine devices (IUDs)], she is generally asked to return at some interval for a follow-up visit; however, is it unclear whether follow up is needed, what an appropriate follow-up schedule is and what should be done at follow-up visits. METHODS: We conducted four separate searches in the PubMed database for all peer-reviewed articles in any language published from database inception through April 2012 that examined the following health outcomes for combined hormonal contraceptives (CHCs), IUDs or medroxyprogesterone acetate (DMPA): (a) incidence of hypertension among women who began using a CHC compared to women not using a CHC; (b) incidence of migraine among women who began using a CHC compared to women not using a CHC; (c) incidence of pelvic inflammatory disease (PID) among women who began using an IUD compared to women who started another form or used no method of contraception or examined incidence of PID at two or more time periods after IUD insertion and (d) whether initial weight gain predicts future weight gain among women who began using DMPA. The quality of each study was assessed using the United States Preventive Services Task Force grading system. RESULTS: A total of 15 studies met our inclusion criteria: 5 examined hypertension and combined oral contraceptive (COC) use, 7 examined PID and IUD use and 3 examined weight gain after DMPA initiation. No studies that examined migraine after CHC initiation met our inclusion criteria. Few women developed hypertension after initiating COCs, and studies examining increases in blood pressure after COC initiation found mixed results (Level I, fair to II-2, fair). Among women who had a copper IUD inserted, there was little difference in incidence of PID, or IUD removal for PID, compared with women who initiated DMPA, a hormone-releasing IUD, or COCs (Level I, good to Level II-2, fair). Studies that examined when women were diagnosed with PID after IUD insertion found mixed results. The study with the largest sample size found a much greater incidence of PID in the first 20 days after insertion, with very low rates of PID up to 8 years postinsertion (Level I, good to Level II-3, poor). Studies that examined weight gain after DMPA initiation found that weight gain >5% of baseline weight at 6 months was associated with greater mean change in weight and greater mean change in body mass index at follow-up times ranging from 12 to 36 months (Level II-2, fair to Level II-3, fair). CONCLUSIONS: Evidence on select adverse events associated with initiation of contraceptive use is limited but does not suggest increased risk of hypertension among COC users or increased risk of PID among IUD users. DMPA users who gain >5% of baseline body weight may be at increased risk of future weight gain. |
Physical examination prior to initiating hormonal contraception: a systematic review
Tepper NK , Curtis KM , Steenland MW , Marchbanks PA . Contraception 2012 87 (5) 650-4 BACKGROUND: Provision of contraception is often linked with physical examination, including clinical breast examination (CBE) and pelvic examination. This review was conducted to evaluate the evidence regarding outcomes among women with and without physical examination prior to initiating hormonal contraceptives. STUDY DESIGN: The PubMed database was searched from database inception through March 2012 for all peer-reviewed articles in any language concerning CBE and pelvic examination prior to initiating hormonal contraceptives. The quality of each study was assessed using the United States Preventive Services Task Force grading system. RESULTS: The search did not identify any evidence regarding outcomes among women screened versus not screened with CBE prior to initiation of hormonal contraceptives. The search identified two case-control studies of fair quality which compared women who did or did not undergo pelvic examination prior to initiating oral contraceptives (OCs) or depot medroxyprogesterone acetate (DMPA). No differences in risk factors for cervical neoplasia, incidence of sexually transmitted infections, incidence of abnormal Pap smears or incidence of abnormal wet mount findings were observed. CONCLUSIONS: Although women with breast cancer should not use hormonal contraceptives, there is little utility in screening prior to initiation, due to the low incidence of breast cancer and uncertain value of CBE among women of reproductive age. Two fair quality studies demonstrated no differences between women who did or did not undergo pelvic examination prior to initiating OCs or DMPA with respect to risk factors or clinical outcomes. In addition, pelvic examination is not likely to detect any conditions for which hormonal contraceptives would be unsafe. |
Effect of missed combined hormonal contraceptives on contraceptive effectiveness: a systematic review
Zapata LB , Steenland MW , Brahmi D , Marchbanks PA , Curtis KM . Contraception 2012 87 (5) 685-700 BACKGROUND: Combined hormonal contraceptives (CHCs) are popular methods of reversible contraception in the United States, but adherence remains an issue as reflected in their lower rates of typical use effectiveness. The objective of this systematic review was to evaluate evidence on the effect of missed CHCs on pregnancy rates as well as surrogate measures of contraceptive effectiveness (e.g., ovulation, follicular development, changes in hormone levels, cervical mucus quality). STUDY DESIGN: We searched the PubMed database for peer-reviewed articles published in any language from database inception through April 2012. We included studies that examined measures of contraceptive effectiveness during cycles with extended hormone-free intervals or nonadherence (e.g., omission of pills, delayed patch replacement) on days not adjacent to the hormone-free interval. We used standard abstract forms and grading systems to summarize and assess the quality of the evidence. RESULTS: The search strategy identified 1387 articles, of which 26 met our study selection criteria. There is wide variability in the amount of follicular development and risk of ovulation among women who extended the pill-free interval to 8-14 days; in general, the risk of ovulation was low, and among women who did ovulate, cycles were usually abnormal (i.e., low progesterone levels, small follicles and/or poor cervical mucus) (Level I, good, indirect to Level II-3, fair, indirect). Studies of women who missed one to four consecutive pills or 1-3 consecutive days of delay before patch replacement at times other than adjacent to the hormone-free interval reported little follicular activity and low risk of ovulation (Level I, fair, indirect to Level II-3, poor, indirect). Studies comparing 30 mcg versus 20 mcg mc ethinyl estradiol pills showed more follicular activity when 20 mcg ethinyl estradiol pills were missed (Level I, good, indirect). CONCLUSION: Most of the studies in this evidence base relied on surrogate measures of pregnancy risk and ranged in quality. For studies providing indirect evidence on the effects of missed CHCs, it is unclear how differences in surrogate measures correspond to pregnancy risk. Fewer studies examined the transdermal patch and vaginal ring than combined oral contraceptives. |
Blood pressure measurement prior to initiating hormonal contraception: a systematic review
Tepper NK , Curtis KM , Steenland MW , Marchbanks PA . Contraception 2012 87 (5) 631-8 BACKGROUND: Women with hypertension who use hormonal methods of contraception may have an increased risk for cardiovascular events. This review was conducted to evaluate the evidence regarding whether blood pressure should be measured prior to initiating hormonal contraceptives. STUDY DESIGN: The PubMed database was searched from database inception through March 2012 for all peer-reviewed articles in any language concerning blood pressure measurement prior to initiation of hormonal contraceptives. Articles were included if they reported on women with and without blood pressure measurement prior to current hormonal contraceptive usage and assessed cardiovascular outcomes. The quality of each study was assessed using the United States Preventive Services Task Force grading system. RESULTS: Six fair-quality articles from three studies met inclusion criteria for this review. Three case-control studies showed that women who did not have blood pressure measurement prior to initiating combined oral contraceptives (COCs) had a higher risk for acute myocardial infarction (AMI) than women who did have blood pressure measurement. Two case-control studies showed that women who did not have blood pressure measurement prior to initiating COCs had a higher risk for ischemic stroke than women who did have blood pressure measurement. One case-control study showed no difference in the risk for hemorrhagic stroke among women who initiated COCs based on whether or not blood pressure was measured. CONCLUSIONS: Fair-quality evidence from five reports showed that women who did not have blood pressure measurement prior to COC initiation had a higher risk for AMI and ischemic stroke than women who did have blood pressure measurement. One fair-quality study showed no increased risk for hemorrhagic stroke based on whether or not blood pressure was measured. Studies that examined hormonal contraceptive methods other than COCs were not identified. |
Hemoglobin measurement prior to initiating copper intrauterine devices: a systematic review
Tepper NK , Steenland MW , Marchbanks PA , Curtis KM . Contraception 2012 87 (5) 639-44 BACKGROUND: Women using copper intrauterine devices (IUDs) frequently experience bleeding abnormalities. This review was conducted to evaluate the evidence regarding whether hemoglobin levels should be measured prior to copper IUD insertion. STUDY DESIGN: The PubMed database was searched from database inception through March 2012 for all peer-reviewed articles in any language concerning hemoglobin changes among women with anemia who have copper IUDs inserted. Articles were included if they reported changes in hemoglobin among anemic women over a specified period of time following copper IUD insertion. Articles were excluded in which there were no women with anemia at baseline or outcomes among women with anemia were not reported separately. For indirect evidence, articles were included which addressed hemoglobin changes among women without anemia who had copper IUDs inserted. The quality of each direct study was assessed using the US Preventive Services Task Force grading system. RESULTS: Four level I to II-2 studies of fair quality met inclusion criteria as direct evidence. Evidence from one randomized trial and one prospective cohort study showed no statistically significant changes in hemoglobin among copper IUD users with anemia, while two prospective cohort studies showed a statistically significant, but clinically small, mean decrease in hemoglobin levels over 12 months of follow-up. We also identified 21 studies examining changes in hemoglobin among healthy women using copper IUDs as indirect evidence; this body of evidence was not graded. These studies generally showed no clinically significant changes in hemoglobin levels with up to 5 years of follow-up. CONCLUSIONS: Limited fair-quality evidence was mixed but generally showed no clinically significant changes in hemoglobin among women with anemia who used copper IUDs for up to 12 months. Indirect evidence among healthy women using copper IUDs did not show clinically significant changes in hemoglobin levels when followed for up to 5 years of use. |
How does the number of oral contraceptive pill packs dispensed or prescribed affect continuation and other measures of consistent and correct use? A systematic review
Steenland MW , Rodriguez MI , Marchbanks PA , Curtis KM . Contraception 2012 87 (5) 605-10 BACKGROUND: The review was conducted to examine studies that assess whether the number of pill packs dispensed, or prescribed, affects method continuation and other measures of use. STUDY DESIGN: PubMed database was searched from inception through March 2012 for all peer-reviewed articles, in any language, that examined the effect of the number of oral contraceptive pill packs dispensed on method continuation, and other measures of use. The quality of each study was assessed using the United States Preventive Services Task Force grading system. RESULTS: Four studies met the inclusion criteria for this review. Studies that compared 1 vs. 12, 1 vs. 12-13, or 3 vs. 7 packs found increased method continuation. However, one study that examined the difference between providing one and then three packs versus providing four packs all at once did not find a difference in continuation. In addition to continuation, evidence from the individual studies included found that a greater number of pill packs was associated with fewer pregnancy tests, fewer pregnancies and less cost per client. A greater number of pill packs was, however, also associated with increased pill wastage. CONCLUSIONS: A small body of evidence suggests that dispensing a greater number of oral contraceptive pill packs may increase continuation of use. |
The effect of follow-up visits or contacts after contraceptive initiation on method continuation and correct use
Steenland MW , Zapata LB , Brahmi D , Marchbanks PA , Curtis KM . Contraception 2012 87 (5) 625-30 BACKGROUND: We conducted a systematic review to assess whether follow-up visits or contacts after a woman begins using contraception improve method continuation and correct use. STUDY DESIGN: We searched the PubMed database for all peer-reviewed articles in any language published from database inception through May 2012 that examined the effect of a structured follow-up schedule of visits or contacts on contraceptive use. We included studies that compared women who initiated a method of contraception with a certain follow-up schedule compared to women with a different follow-up schedule or no follow-up at all. To be included, studies must have compared groups on a measure of contraceptive use (e.g., pregnancy, correct use, consistent use, method discontinuation including expulsion). Though not ideally suited to answer our review question, studies in which women used a variety of contraceptive methods but results were not stratified by method type were included. RESULTS: Four studies met our inclusion criteria (Level I, poor to II-2, poor). Two studies examined the effect of a specific follow-up visit schedule on intrauterine device (IUD) continuation: one examining frequency of visits and one examining the timing of the first follow-up visit. Women with more frequent follow-up visits did not have a statistically significant difference in proportion of removals for medical reasons compared with women who had fewer follow-up visits; among women who had their IUDs removed for medical reasons, those who had more frequent follow-up visits had a longer mean time of use prior to removal. The other study found more removals and shorter continuation among women with a follow-up visit at 1 week compared to women with a follow-up visit at 1 month after IUD insertion (no statistical tests reported). Two studies examined the effect of follow-up phone calls compared to no follow-up phone calls after an initial family planning visit among adolescents initiating a variety of contraceptive methods. Neither of the two studies found any differences in method continuation or correct use between study groups. CONCLUSIONS: It is difficult to determine what effect, if any, follow-up visits or contacts have on contraceptive method continuation or correct use. Few studies were identified, and those that were identified were mostly of poor quality, were not method specific and had either poor patient compliance with follow-up visits or poor phone contact completion rates. |
Retention of intrauterine devices in women who acquire pelvic inflammatory disease: a systematic review
Tepper NK , Steenland MW , Gaffield ME , Marchbanks PA , Curtis KM . Contraception 2012 87 (5) 655-60 BACKGROUND: Women using intrauterine devices (IUDs) are not protected against acquiring pelvic inflammatory disease (PID). If a woman has an IUD in place when she is diagnosed with PID, there is a theoretical concern that presence of an IUD might impact the course of treatment. This review was conducted to evaluate the evidence regarding whether an IUD should be retained or removed if a woman develops PID. STUDY DESIGN: The PubMed database was searched from database inception through April 2012 for all peer-reviewed articles in any language concerning PID in women using IUDs. Articles were included if they examined women with IUDs who developed PID and compared the clinical course of women in whom the IUD was retained versus women in whom the IUD was removed. Articles were excluded if the infection was diagnosed before or at the time of IUD insertion. The quality of each study was assessed using the United States Preventive Services Task Force grading system. RESULTS: Four fair-quality studies met inclusion criteria for this review. One randomized controlled trial showed that women with IUDs removed had longer hospitalizations than those with IUD retention (15% versus 4%, p<.01), although there were no differences in PID recurrences or subsequent pregnancies. Another randomized controlled trial showed no differences in laboratory parameters among women who retained the IUD when compared with women in whom the IUD was removed. One prospective cohort study showed that there were no differences in clinical or laboratory parameters during hospitalization; however, the IUD removal group had a higher proportion hospitalized for more than 2 weeks compared with the IUD retention group (33% versus 19%, p<.05). One randomized controlled trial showed that women who had the IUD removed experienced improved recovery in most clinical signs and symptoms compared with women who retained the IUD. CONCLUSIONS: Three fair-quality studies showed no difference in clinical or laboratory outcomes among women who retained IUDs when compared with women who had IUDs removed, and two of these studies showed that women who had IUDs removed had longer hospitalizations. In contrast, one fair quality study showed improved clinical signs and symptoms among women who had IUDs removed. Overall, women who retained their IUDs had similar or better outcomes than women who had their IUDs removed. |
Laboratory screening prior to initiating contraception: a systematic review
Tepper NK , Steenland MW , Marchbanks PA , Curtis KM . Contraception 2012 87 (5) 645-9 BACKGROUND: Certain contraceptive methods may increase the risk of adverse events for women with certain medical conditions, including some women with diabetes, hyperlipidemia, liver disease, cervical cancer, sexually transmitted infections (STIs) or human immunodeficiency virus (HIV). This review was conducted to evaluate the evidence regarding health outcomes among women with and without laboratory testing to identify certain medical conditions prior to initiating contraceptives. STUDY DESIGN: The PubMed database was searched from database inception through April 2012 for all peer-reviewed articles in any language evaluating health outcomes among women who initiated certain contraceptive methods and who had or had not received glucose, lipid, liver enzyme, cervical cytology, STI or HIV screening. RESULTS: The systematic review did not identify any relevant direct evidence. CONCLUSIONS: While certain methods of hormonal contraception may not be safe for use by some women with diabetes, hyperlipidemia or liver disease, there is little value in screening for these conditions in asymptomatic women prior to initiation of contraceptive methods due to the low prevalence of these conditions among women of reproductive age. Although intrauterine devices (IUDs) and cervical caps should not be initiated in women with cervical cancer, the high rates of cervical screening and low incidence of cervical cancer in the United States make this scenario unlikely. Although some women at risk for, or infected with, STIs or HIV should not undergo IUD insertion, if women have been screened for STIs or HIV according to guidelines, additional screening at the time of IUD insertion is not warranted. Requiring unnecessary laboratory screening prior to initiation of contraceptive methods may impose barriers to contraceptive access, and efforts to remove such barriers are critical in reducing unintended pregnancy. |
Patient understanding of oral contraceptive pill instructions related to missed pills: a systematic review
Zapata LB , Steenland MW , Brahmi D , Marchbanks PA , Curtis KM . Contraception 2012 87 (5) 674-84 BACKGROUND: Instructions on what to do after pills are missed are critical to reducing unintended pregnancies resulting from patient non-adherence to oral contraceptive (OC) regimens. Missed pill instructions have previously been criticized for being too complex, lacking a definition of what is meant by "missed pills," and for being confusing to women who may not know the estrogen content of their formulation. To help inform the development of missed pill guidance to be included in the forthcoming US Selected Practice Recommendations, the objective of this systematic review was to evaluate the evidence on patient understanding of missed pill instructions. STUDY DESIGN: We searched the PubMed database for peer-reviewed articles that examined patient understanding of OC pill instructions that were published in any language from inception of the database through March 2012. We included studies that examined women's knowledge and understanding of missed pill instructions after exposure to some written material (e.g., patient package insert, brochure), as well as studies that compared different types of missed pill instructions on women's comprehension. We used standard abstract forms and grading systems to summarize and assess the quality of the evidence. RESULTS: From 1620 articles, nine studies met our inclusion criteria. Evidence from one randomized controlled trial (RCT) and two descriptive studies found that more women knew what to do after missing 1 pill than after missing 2 or 3 pills (Level I, good, to Level II-3, poor), and two descriptive studies found that more women knew what to do after missing 2 pills than after missing 3 pills (Level II-3, fair). Data from two descriptive studies documented the difficulty women have understanding missed pill instructions contained in patient package inserts (Level II-3, poor), and evidence from two RCTs found that providing written brochures with information on missed pill instructions in addition to contraceptive counseling significantly improved knowledge of how to manage missed pills for up to three months compared to contraceptive counseling alone (Level I, fair). Evidence from one RCT found that graphic-based missed pill instructions were better than text-only instructions (Level I, good), and data from two RCTs found that less information resulted in improved comprehension (Level I, good to fair). Evidence from one descriptive study found that many women missing pills did not intend to follow recommended actions per missed pill instructions despite understanding the guidance (Level II-3, poor). CONCLUSIONS: There is wide variability in the percent of women having correct knowledge on what to do when pills are missed after exposure to written missed pills instructions, with more women knowing what to do after missing 1 pill than after missing 2 or 3 pills. Women have difficulty understanding missed pill instructions contained in patient package inserts. Providing written brochures with information on missed pill instructions in addition to contraceptive counseling may improve knowledge of how to manage missed pills. Graphic-based missed pill instructions and those containing less information may result in improved comprehension. Even with clear instructions, many women missing pills may choose not to follow the recommended actions. |
Pregnancy outcomes with an IUD in situ: a systematic review
Brahmi D , Steenland MW , Renner RM , Gaffield ME , Curtis KM . Contraception 2012 85 (2) 131-9 BACKGROUND: While intrauterine devices (IUDs) provide highly effective contraception, pregnancies among IUD users do rarely occur. The objective of this systematic review is to assess the evidence about risks for adverse pregnancy outcomes among women who conceive with an IUD in situ. METHODS: We searched MEDLINE, POPLINE, EMBASE and LILACS databases from inception through April 2011 for peer-reviewed articles containing evidence related to pregnancy outcomes among women who conceived while using copper (Cu) and levonorgestrel-releasing (LNG) IUDs. RESULTS: Nine articles met our inclusion criteria. Women with retained IUDs were at the greatest risk of adverse pregnancy outcomes, including spontaneous abortion, preterm delivery, septic abortion and chorioamnionitis. Cu-IUD removal decreased risks but not to the baseline risk of pregnancies without an IUD. One case series examined the LNG-IUD; when left in situ, 8 in 10 ended in spontaneous abortions. CONCLUSION: Pregnancies complicated by a remaining IUD in situ were at greater risk of adverse pregnancy outcomes. Early IUD removal appeared to improve outcomes but did not entirely eliminate risks. |
Prostate cancer treatment ascertained from several sources: analysis of disagreement and error
Goodman M , Steenland NK , Almon ML , Liff JS , Dilorio CK , Butler SO , Ekwueme DU , Hall IJ , Smith JL , Master VA , Roberts PL . Ann Oncol 2012 23 (1) 256-63 BACKGROUND: Treatment data for prostate cancer can be obtained from a variety of sources. Each of these sources has its own strengths and weaknesses and is subject to error. MATERIALS AND METHODS: In a population-based cohort of 319 prostate cancer patients, data on treatment were obtained from five sources: two patient interviews at 6 and 12 months after diagnosis, primary caregiver interviews, physician questionnaires, and medical records. Inter-reporting agreement and accuracy of reporting (compared with medical records) were assessed. Multivariate analyses examined patient, caregiver, and physician characteristics as determinants of reporting error. RESULTS: The agreement among different reporting methods was generally good to excellent for prostatectomy and brachytherapy (kappa range 0.70-0.90) and fair to good (kappa range 0.35-0.75) for external beam radiation and hormonal treatment. Compared with medical records, the interview- and questionnaire-based data collection methods were more accurate for prostatectomy and brachytherapy than for external beam radiation and hormonal therapy. Using medical records as the 'gold standard', patient and caregiver interviews at 6 months after the diagnosis had higher sensitivity and specificity than other reporting sources. CONCLUSION: Interviews of prostate cancer patients and caregivers are useful alternatives to medical record abstraction, particularly if carried out during, or soon after, treatment. |
Intrauterine contraceptive insertion postabortion: a systematic review
Steenland MW , Tepper NK , Curtis KM , Kapp N . Contraception 2011 84 (5) 447-64 BACKGROUND: This review was conducted to evaluate the evidence regarding the safety and effectiveness of intrauterine device (IUD) insertion immediately following spontaneous or induced abortion. STUDY DESIGN: We searched MEDLINE databases for all articles (in all languages) published in peer-reviewed journals from January 1966 through March 2010 for evidence comparing immediate postabortion IUD insertion with either no IUD insertion, insertion at a different time, insertion following first-trimester compared with second-trimester abortion or copper IUD insertion compared with hormone-releasing IUD insertion postabortion. We used standard abstraction forms to summarize and assess the quality of the evidence. RESULTS: The search strategy identified a total of 990 articles, of which 19 met our inclusion criteria for this review. Studies comparing immediate postabortion IUD insertion with no IUD insertion found that both groups experienced similar rates of pain and infection and a similar number of bleeding days, but one study reported that women with copper IUD insertion experienced a greater amount of bleeding than women without IUD insertion after abortion. Results from studies comparing immediate postabortion IUD insertion and insertion at a time not associated with pregnancy did not report differences between the two groups in the duration of bleeding, pain, expulsions or pelvic inflammatory disease (PID). One study however reported a greater amount of bleeding and another reported more removals for medical reasons among women with postabortion IUD insertion. Evidence from studies that examined immediate vs. delayed postabortion insertion reported minimal differences in bleeding, pain, expulsion and PID between groups. Studies comparing immediate IUD insertion after first- vs. second-trimester abortion reported no difference in removals for pain and bleeding, and an increased risk of expulsion among those women who had insertions after second-trimester abortion. In addition, women with insertions immediately after abortions occurring later in the first trimester had higher expulsion rates than those with insertions after early first-trimester abortions. Studies examining women using a copper IUD compared with a hormone-releasing IUD reported inconsistent results, with one paper reporting more bleeding days in the copper IUD group and another finding higher rates of removal for bleeding in the progesterone-releasing IUD group. CONCLUSION: Intrauterine device insertion immediately after abortion is not associated with an increased risk of adverse outcomes compared with use of other contraceptive methods or with no IUD insertion after abortion and compared with IUD insertion at times other than immediately after abortion. Intrauterine device expulsion rates, while generally low, were higher with insertions that occurred after later first-trimester abortion compared with after early first-trimester abortion and higher with IUD insertion after second-trimester abortion compared with after first-trimester abortion. |
Update of the NIOSH life table analysis system: a person-years analysis program for the windows computing environment
Schubauer-Berigan MK , Hein MJ , Raudabaugh WM , Ruder AM , Silver SR , Spaeth S , Steenland K , Petersen MR , Waters KM . Am J Ind Med 2011 54 (12) 915-24 BACKGROUND: Person-years analysis is a fundamental tool of occupational epidemiology. A life table analysis system (LTAS), previously developed by the National Institute for Occupational Safety and Health, was limited by its platform and analysis and reporting capabilities. We describe the updating of LTAS for the Windows operating system (LTAS.NET) with improved properties. SOFTWARE DEVELOPMENT PROCESS: A group of epidemiologists, programmers, and statisticians developed software, platform, and computing requirements. Statistical methods include the use of (indirectly) standardized mortality ratios, (directly) standardized rate ratios, confidence intervals, and P values based on the normal approximation and exact Poisson methods, and a trend estimator for linear exposure-response associations. SOFTWARE FEATURES: We show examples using LTAS.NET to stratify and analyze multiple fixed and time-dependent variables. Data import, stratification, and reporting options are highly flexible. Users may export stratified data for Poisson regression modeling. CONCLUSIONS: LTAS.NET incorporates improvements that will facilitate more complex person-years analysis of occupational cohort data. |
The effect of race and rural residence on prostate cancer treatment choice among men in Georgia
Steenland K , Goodman M , Liff J , Diiorio C , Butler S , Roberts P , Smith JL , Ekwueme D , Hall IJ . Urology 2011 77 (3) 581-7 OBJECTIVE: To analyze differences for prostate cancer by race and in rural areas. METHODS: We studied 516 men younger than 75 years old with incident prostate cancer during 2005-08 in 33 counties in Southwest Georgia (SWGA), a rural area of 700,000 (40% African American). Treatment data were abstracted from medical records, and interviews conducted with 314 men. We also compared treatments in SWGA vs. Atlanta in 2005. RESULTS: External radiation plus brachytherapy was the most common treatment in SWGA (31%), followed by external radiation alone (27%), and surgery (18%). Patients in SWGA had higher odds of external radiation vs. surgery than men in Atlanta (OR 2.66, 95% CI 1.85-3.81). African Americans had higher odds of choosing treatment other than surgery, compared with whites (OR 2.04, 95% CI 1.57-2.63), more so in SWGA (OR 3.51, 95% CI 1.92-6.41) than Atlanta (OR 1.76, 95% CI 1.32-2.35) (P = .05). Poor communication with their physician was reported by 13% of men in SWGA, more among African Americans than whites (OR 3.95, 95% CI 1.52-10.30), and more among those who had no treatment vs. some treatment (OR 5.77, 95% CI 1.88-11.46). CONCLUSIONS: In both rural and urban Georgia, white men with prostate cancer had surgery more frequently than African Americans, although data suggest this may be caused more by income differences than race. Rural patients as opposed to urban patients were more likely to receive external radiation and less likely to receive brachytherapy alone or surgery. Poor communication with a physician, particularly prevalent among African Americans, was associated with choosing no treatment in SWGA. |
Rate of decline in serum PFOA concentrations after granular activated carbon filtration at two public water systems in Ohio and West Virginia
Bartell SM , Calafat AM , Lyu C , Kato K , Ryan PB , Steenland K . Environ Health Perspect 2010 118 (2) 222-8 Background: Drinking water in multiple water districts in the Mid-Ohio Valley has been contaminated with perfluorooctanoic acid (PFOA), which was released by a nearby DuPont chemical plant. Two highly contaminated water districts began granular activated carbon filtration in 2007. Objectives: To determine the rate of decline in serum PFOA, and its corresponding half-life, during the first year after filtration. Methods: Up to six blood samples were collected from each of 200 participants from May 2007 until August 2008. The primary source of drinking water varied over time for some participants; our analyses were grouped according to water source at baseline in MayJune 2007. Results: For Lubeck Public Service District customers, the average decrease in serum PFOA concentrations between MayJune 2007 and MayAugust 2008 was 32 ng/mL (26%) for those primarily consuming public water at home (n = 130), and 16 ng/mL (28%) for those primarily consuming bottled water at home (n = 17). For Little Hocking Water Association customers, the average decrease in serum PFOA concentrations between NovemberDecember 2007 and MayJune 2008 was 39 ng/mL (11%) for consumers of public water (n = 39) and 28 ng/mL (20%) for consumers of bottled water (n = 11). The covariate-adjusted average rate of decrease in serum PFOA concentration after water filtration was 26% per year (95% confidence interval, 2528% per year). Conclusions: The observed data are consistent with first-order elimination and a median serum PFOA half-life of 2.3 years. Ongoing follow-up will lead to improved half-life estimation. Editor's Summary: Release of perfluorooctanoic acid (PFOA) from a chemical plant in West Virginia contaminated drinking water in several water districts, but use of granular activated-carbon filtration in two water districts reduced PFOA concentrations to levels below the limit of detection. Bartell et al. (p. 222) measured serum PFOA concentrations in up to six blood samples collected over approximately 12 months from a stratified random sample of 200 eligible participants in the C8 Health Project cohort, including baseline samples collected before initiation of water filtration to remove PFOA. The authors report that the average covariate-adjusted average rate of decrease in serum PFOA concentration after water filtration was 26% per year [95% confidence interval (CI), 2528% per year], consistent with a median serum PFOA half-life of 2.3 years (95% CI, 2.12.4 years). However, the authors also noted substantial variation in estimated half-lives among individuals, which may reflect ongoing exposures among some participants (e.g., through consumption of contaminated home-grown produce) and/or individual differences in PFOA elimination rates. In addition, they suggest that the accuracy of half-life estimates will improve with longer follow-up. |
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