Copyright (c) 2009 University of Massachusetts Medical School All rights reserved. http://escholarship.umassmed.edu/wfc_pp Recent documents in Women's Faculty Committee Publications and Presentations en-us Fri, 09 Oct 2009 08:27:05 PDT 3600 http://escholarship.umassmed.edu/wfc_pp/450 http://escholarship.umassmed.edu/wfc_pp/450 Tue, 04 Mar 2008 09:14:54 PST Patterns of smoking cessation using 6- and 12-month follow-up data are reported for 1,261 primary care patients randomized to 3 physician-delivered smoking interventions: advice only (AO), counseling (CI), and counseling plus availability of nicotine-containing gum (CI + NCG). One-week-point-prevalence cessation rates at 12 months did not differ among the interventions: AO (15.2%), CI (12.9%) and CI + NCG (16.7%). However, maintained cessation rates (abstinent at both 6 and 12 months) increased with intervention intensity: AO (6.0%), CI (7.8%) and CI + NCG (10.0%): Test of trend chi 2 = 5.06, p = .02. CI + NCG was significantly higher than AO (p = .02). The findings support the following conclusions: Brief physician-delivered intervention with availability of nicotine-containing gum can have a beneficial long-term effect on smoking cessation, and cohort data as well as point-prevalence rates are important when assessing the long-term impact of lifestyle interventions. Judith K. Ockene Adolescent Adult Aged Ambulatory Care Chewing Gum Cohort Studies Counseling Female Follow-Up Studies Humans Male Middle Aged Nicotine *Patient Education as Topic *Physician-Patient Relations Primary Health Care Smoking Cessation Treatment Outcome http://escholarship.umassmed.edu/wfc_pp/449 http://escholarship.umassmed.edu/wfc_pp/449 Tue, 04 Mar 2008 09:14:45 PST Attitudes toward smoking intervention, and the intervention practices of 65 residents, 51 attending physicians, and 292 community physicians in central and western Massachusetts were assessed through a mailed questionnaire. Nearly all physicians reported that they obtained information on the smoking status of new patients and told smokers to quit. Proportionately fewer physicians, however, reported that they counseled their patients on how to stop smoking; those who did, did so for relatively brief periods of time. After differences in physician age and smoking status were controlled for, residents were significantly more likely than attending physicians to counsel their patients on how to stop smoking, but were also more likely (than attending and community physicians) to recommend or refer their patients to formal smoking cessation programs. A small percentage of the physicians responding (3%-16%) reported that they were prepared to counsel smokers, but most reported that information on where to refer patients, smoking cessation techniques, and skills training would be of great value. The results of this survey suggest practical differences between residents and attending and community physicians in approaching patients who smoke and in attitudes toward the need for additional skills and financial and organizational assistance. Judith K. Ockene Adult Attitude to Health Counseling Female Humans Internship and Residency Male Massachusetts Middle Aged Patient Acceptance of Health Care Patient Education as Topic *Physician's Practice Patterns Physicians, Family Smoking http://escholarship.umassmed.edu/wfc_pp/448 http://escholarship.umassmed.edu/wfc_pp/448 Tue, 04 Mar 2008 09:14:35 PST OBJECTIVE: To extend the findings of the first Development and Assessment of Nicotine Dependence in Youth study by using diagnostic criteria for tobacco dependence and a biochemical measure of nicotine intake. The first study found that symptoms of dependence commonly appeared soon after the onset of intermittent smoking. DESIGN: A 4-year prospective study. SETTING: Public schools in 6 Massachusetts communities. PARTICIPANTS: A cohort of 1246 sixth-grade students. INTERVENTIONS: Eleven interviews. MAIN OUTCOME MEASURES: Loss of autonomy over tobacco as measured by the Hooked on Nicotine Checklist, and tobacco dependence as defined in International Classification of Diseases, 10th Revision (ICD-10). RESULTS: Among the 217 inhalers, 127 lost autonomy over their tobacco use, 10% having done so within 2 days and 25% having done so within 30 days of first inhaling from a cigarette; half had lost autonomy by the time they were smoking 7 cigarettes per month. Among the 83 inhalers who developed ICD-10-defined dependence, half had done so by the time they were smoking 46 cigarettes per month. At the interview following the onset of ICD-10-defined dependence, the median salivary cotinine concentration of current smokers was 5.35 ng/mL, a level that falls well below the cutoff used to distinguish active from passive smokers. CONCLUSIONS: The most susceptible youths lose autonomy over tobacco within a day or 2 of first inhaling from a cigarette. The appearance of tobacco withdrawal symptoms and failed attempts at cessation can precede daily smoking; ICD-10-defined dependence can precede daily smoking and typically appears before consumption reaches 2 cigarettes per day. Joseph R. DiFranza Adolescent Behavior, Addictive Child Cotinine Female Humans Incidence International Classification of Diseases Interviews as Topic Male Massachusetts *Personal Autonomy Prospective Studies Psychological Tests Risk Assessment Risk Factors Saliva Schools Smoking Smoking Cessation Students Time Factors Tobacco Use Disorder http://escholarship.umassmed.edu/wfc_pp/447 http://escholarship.umassmed.edu/wfc_pp/447 Tue, 04 Mar 2008 09:14:27 PST OBJECTIVE: To identify predictors of dietary change to and maintenance of a low-fat eating pattern (<20% energy from fat, > or = 5 servings fruits/vegetables daily, and > or = 6 servings grains daily) among a cohort of postmenopausal women. Candidate predictors included intrapersonal, interpersonal, intervention program characteristics, and clinical center. DESIGN: Longitudinal study within the Women's Health Initiative Dietary Modification Trial. Dietary change was evaluated after 1 year of participation in the Women's Health Initiative Dietary Modification Trial, and dietary maintenance after 3 years. SUBJECTS: Postmenopausal women aged 50 to 79 years at baseline who were randomized to the intervention arm of the Women's Health Initiative Dietary Modification Trial (n=19,541). STATISTICAL ANALYSIS: Univariate and multivariate linear regression analysis was performed and associations evaluated between candidate predictors and each of the three dietary goals: percent energy from fat, fruit/vegetable servings, and grain servings. RESULTS: Year 1 (change) predictors of percent energy from fat (P<0.005) included being younger (beta=2.12; 70 to 79 years vs 50 to 59 years), more educated (beta=-.69; college vs high school), more optimistic (beta=-.07), attending more sessions (beta=-.69), and submitting more self-monitoring records (beta=-.74). At year 3 (maintenance), the predictors of percent energy from fat (P<0.005) included attending more sessions (beta=-.65) and submitting more self-monitoring scores (beta=-.71). The analytic model predicted 22% of the variance in fat intake at year 1 and 27% at year 3 (P<0.01). CONCLUSIONS: The strongest predictors of dietary change and maintenance were attending intervention sessions and self-monitoring dietary intake. Novel was the finding that optimism predicted dietary change. Lesley F. Tinker Age Factors Aged Analysis of Variance Cereals Diet, Fat-Restricted Dietary Fats Educational Status Energy Intake Female Fruit Health Planning Health Surveys Humans Longitudinal Studies Middle Aged Nutritional Sciences Patient Compliance Postmenopause Vegetables *Women's Health http://escholarship.umassmed.edu/wfc_pp/446 http://escholarship.umassmed.edu/wfc_pp/446 Tue, 04 Mar 2008 09:14:19 PST BACKGROUND: Calcified plaque in the coronary arteries is a marker for atheromatous-plaque burden and is predictive of future risk of cardiovascular events. We examined the relationship between estrogen therapy and coronary-artery calcium in the context of a randomized clinical trial. METHODS: In our ancillary substudy of the Women's Health Initiative trial of conjugated equine estrogens (0.625 mg per day) as compared with placebo in women who had undergone hysterectomy, we performed computed tomography of the heart in 1064 women aged 50 to 59 years at randomization. Imaging was conducted at 28 of 40 centers after a mean of 7.4 years of treatment and 1.3 years after the trial was completed (8.7 years after randomization). Coronary-artery calcium (or Agatston) scores were measured at a central reading center without knowledge of randomization status. RESULTS: The mean coronary-artery calcium score after trial completion was lower among women receiving estrogen (83.1) than among those receiving placebo (123.1) (P=0.02 by rank test). After adjustment for coronary risk factors, the multivariate odds ratios for coronary-artery calcium scores of more than 0, 10 or more, and 100 or more in the group receiving estrogen as compared with placebo were 0.78 (95% confidence interval, 0.58 to 1.04), 0.74 (0.55 to 0.99), and 0.69 (0.48 to 0.98), respectively. The corresponding odds ratios among women with at least 80% adherence to the study estrogen or placebo were 0.64 (P=0.01), 0.55 (P<0.001), and 0.46 (P=0.001). For coronary-artery calcium scores of more than 300 (vs. <10), the multivariate odds ratio was 0.58 (P=0.03) in an intention-to-treat analysis and 0.39 (P=0.004) among women with at least 80% adherence. CONCLUSIONS: Among women 50 to 59 years old at enrollment, the calcified-plaque burden in the coronary arteries after trial completion was lower in women assigned to estrogen than in those assigned to placebo. However, estrogen has complex biologic effects and may influence the risk of cardiovascular events and other outcomes through multiple pathways. (ClinicalTrials.gov number, NCT00000611.) JoAnn E. Manson Calcinosis Coronary Angiography Coronary Disease *Estrogen Replacement Therapy Estrogens, Conjugated (USP) Female Humans Hysterectomy Logistic Models Middle Aged Multivariate Analysis Odds Ratio Postmenopause Risk Factors Tomography, X-Ray Computed http://escholarship.umassmed.edu/wfc_pp/445 http://escholarship.umassmed.edu/wfc_pp/445 Tue, 04 Mar 2008 09:14:10 PST RATIONALE AND OBJECTIVES: The rates of enrollment of volunteers for brain magnetic resonance imaging (MRI) studies vary by demographic and clinical characteristics. We use data from a large MRI study to identify factors associated with differential enrollment and to examine potential biases this may produce in study results. MATERIALS AND METHODS: Results from recruitment of 1,431 women into the MRI substudy of the Women's Health Initiative Memory Study (WHIMS-MRI) are described. A sensitivity analysis was conducted to estimate the degree of bias associated with missing data on estimates of risk factor relationships. RESULTS: Of 2,345 women contacted from an established cohort of women older than 70 years of age, 72% consented to undergo screening for WHIMS-MRI. Scanning was ultimately completed on 61%. Completion rates varied according to a range of sociodemographic, lifestyle, and clinical characteristics that may be related to study outcomes. Plausible levels of selective enrollment in magnetic resonance imaging studies may produce moderate biases (< +/-20%) in characterizations of risk factor relationships. Adverse events, such as claustrophobia, occurred during 1.7% of the attempted scans and, in 0.8% of instances, led to lost data. CONCLUSIONS: Enrollment of older women into brain imaging studies is feasible, although selection biases may limit how well study cohorts reflect more general populations. Sarah A. Jaramillo Aged *Biomedical Research Cognition Disorders Estrogen Replacement Therapy Female Humans Informed Consent Logistic Models *Magnetic Resonance Imaging *Patient Selection Randomized Controlled Trials as Topic *Women's Health http://escholarship.umassmed.edu/wfc_pp/444 http://escholarship.umassmed.edu/wfc_pp/444 Tue, 04 Mar 2008 09:14:02 PST Multiple and diverse preventive strategies in clinical and community settings are necessary to improve health. This paper (1) introduces evidence-based recommendations from the U.S. Preventive Services Task Force sponsored by the Agency for Healthcare Research and Quality and the Community Task Force sponsored by the Centers for Disease Control and Prevention, (2) examines, using a social-ecologic model, the evidence-based strategies for use in clinical and community settings to address preventable health-related problems such as tobacco use and obesity, and (3) advocates for prioritization and integration of clinical and community preventive strategies in the planning of programs and policy development, calling for additional research to develop the strategies and systems needed to integrate them. Judith K. Ockene Centers for Disease Control and Prevention (U.S.) Community Health Planning *Community Health Services Ecology *Evidence-Based Medicine Health Promotion Humans Obesity Preventive Medicine Program Development Tobacco Use Disorder United States United States Public Health Service http://escholarship.umassmed.edu/wfc_pp/443 http://escholarship.umassmed.edu/wfc_pp/443 Tue, 04 Mar 2008 09:13:54 PST BACKGROUND: Women are more likely than men to have nonspecific chest pain (NSCP) symptoms. The long-term outcomes in women discharged with a diagnosis of NSCP are unknown. METHODS: The Women's Health Initiative Observational Study enrolled postmenopausal women aged 50-79 years. After excluding those with prior cardiovascular disease (CVD), 83,622 women were studied. NSCP cases were defined as having an initial primary hospital discharge diagnosis of NSCP (ICD-9 codes 786.50, 786.51, 786.59) without a prior diagnosis of coronary heart disease (CHD). Risks of subsequent CHD events were estimated from Cox proportional hazard ratio (HR) models stratified by clinic and adjusted for baseline age, cardiovascular risk factors, and hormone use. RESULTS: Over an average of 8 years of follow-up, 11% (230 of 2,092) of women with NSCP experienced a cardiovascular event compared with 9.5% (7,724 of 81,530) who did not. Compared with women without a hospitalization for NSCP during follow-up, those with NSCP had a greater than 2-fold higher risk of a subsequent hospitalization for clinically diagnosed angina (HR 2.18, 95% CI 1.66-2.86) and at least a 1.5-fold higher risk of nonfatal myocardial infarction (MI) (HR 1.59, 1.10-2.31), revascularization (HR 1.67, 1.28-2.20), and congestive heart failure (HR 1.75, 1.27-2.41). Women with NSCP who subsequently experienced a CHD event were more likely to be over age 65 or to have cardiovascular risk factors. CONCLUSIONS: Older women discharged with a diagnosis of NSCP may be at increased risk of CHD morbidity. Further research is needed to replicate these findings in other populations. Jennifer G. Robinson Aged Cardiovascular Diseases and control Chest Pain Cohort Studies Confidence Intervals Female Health Status Humans Middle Aged Odds Ratio Postmenopause Risk Assessment Risk Factors Severity of Illness Index Stroke United States *Women's Health http://escholarship.umassmed.edu/wfc_pp/442 http://escholarship.umassmed.edu/wfc_pp/442 Tue, 04 Mar 2008 09:13:45 PST OBJECTIVES: We evaluated the hypothesis that cyclooxygenase (COX) inhibitor use might have counteracted a beneficial effect of postmenopausal hormone therapy, and account for the absence of cardioprotection in the Women's Health Initiative hormone trials. Estrogen increases COX expression, and inhibitors of COX such as nonsteroidal anti-inflammatory agents appear to increase coronary risk, raising the possibility of a clinically important interaction in the trials. DESIGN: The hormone trials were randomized, double-blind, and placebo-controlled. Use of nonsteroidal anti-inflammatory drugs was assessed at baseline and at years 1, 3, and 6. SETTING: The Women's Health Initiative hormone trials were conducted at 40 clinical sites in the United States. PARTICIPANTS: The trials enrolled 27,347 postmenopausal women, aged 50-79 y. INTERVENTIONS: We randomized 16,608 women with intact uterus to conjugated estrogens 0.625 mg with medroxyprogesterone acetate 2.5 mg daily or to placebo, and 10,739 women with prior hysterectomy to conjugated estrogens 0.625 mg daily or placebo. OUTCOME MEASURES: Myocardial infarction, coronary death, and coronary revascularization were ascertained during 5.6 y of follow-up in the estrogen plus progestin trial and 6.8 y of follow-up in the estrogen alone trial. RESULTS: Hazard ratios with 95% confidence intervals were calculated from Cox proportional hazard models stratified by COX inhibitor use. The hazard ratio for myocardial infarction/coronary death with estrogen plus progestin was 1.13 (95% confidence interval 0.68-1.89) among non-users of COX inhibitors, and 1.35 (95% confidence interval 0.86-2.10) among continuous users. The hazard ratio with estrogen alone was 0.92 (95% confidence interval 0.57-1.48) among non-users of COX inhibitors, and 1.08 (95% confidence interval 0.69-1.70) among continuous users. In a second analytic approach, hazard ratios were calculated from Cox models that included hormone trial assignment as well as a time-dependent covariate for medication use, and an interaction term. No significant interaction was identified. CONCLUSIONS: Use of COX inhibitors did not significantly affect the Women's Health Initiative hormone trial results. Judith Hsia Cyclooxygenase Inhibitors Estrogens Estrogens, Conjugated (USP) Female Follow-Up Studies *Hormone Replacement Therapy Humans Postmenopause Myocardial Infarction Myocardial Revascularization United States http://escholarship.umassmed.edu/wfc_pp/441 http://escholarship.umassmed.edu/wfc_pp/441 Tue, 04 Mar 2008 09:13:37 PST OBJECTIVE: The purpose of this study was to study the effect of pregnancy outcomes on risks of continued smoking in subsequent pregnancy. STUDY DESIGN: Cohort study of first and second single births among 98,778 Swedish women who were daily smokers in first pregnancy. RESULTS: In all, 70.2% of women continued to smoke in second pregnancy. Compared with women with a previous normal pregnancy outcome, risk of smoking in second pregnancy was increased among women with a previous small-for-gestational-age birth (adjusted odds ratio [OR], 95% CI 1.28 [95% CI 1.19-1.37]), and reduced among women who had experienced a stillbirth (OR 0.76 [95% CI 0.63-0.93]) or an infant death because of congenital malformations (OR 0.67 [95% CI 0.49-0.92]. A previous preterm birth, Sudden Infant Death Syndrome, and other causes of infant death did not influence risk. CONCLUSION: A previous adverse pregnancy outcome has only a modest influence on smoking habits in the successive pregnancy. Sven Cnattingius Adult Cohort Studies Congenital Abnormalities Female Humans Infant, Newborn *Infant, Small for Gestational Age Medical Records Pregnancy Prevalence Registries Risk Assessment *Smoking *Smoking Cessation *Stillbirth Sudden Infant Death