Use of antidepressant medications in relation to the incidence of breast cancer.

Although associations have been reported between antidepressant use and risk of breast cancer, the findings have been inconsistent. We conducted a population-based case-control study among women enrolled in Group Health Cooperative (GHC), a health maintenance organization in Washington State. Women with a first primary breast cancer diagnosed between 1990 and 2001 were identified (N = 2904) and five controls were selected for each case (N = 14396). Information on antidepressant use was ascertained through the GHC pharmacy database and on breast cancer risk factors and screening mammograms from GHC records. Prior to one year before diagnosis of breast cancer, about 20% of cases and controls had used tricyclic antidepressants (adjusted odds ratio = 1.06, 95% CI 0.94-1.19) and 6% of each group had used selective serotonin reuptake inhibitors (OR = 0.98, 95% CI 0.80-1.18). There also were no differences between cases and controls with regard to the number of prescriptions filled or the timing of use. Taken as a whole, the results from this and other studies to date do not indicate an altered risk of breast cancer associated with the use of antidepressants overall, by class, or for individual antidepressants.

MR nerve imaging in a prospective cohort of patients with suspected carpal tunnel syndrome.

OBJECTIVES: To evaluate the reliability and diagnostic accuracy of high-resolution MRI of the median nerve in a prospectively assembled cohort of subjects with clinically suspected carpal tunnel syndrome (CTS). METHODS: The authors prospectively identified 120 subjects with clinically suspected CTS from five Seattle-area clinics. All subjects completed a hand-pain diagram and underwent a standardized nerve conduction study (NCS). The reference standard for determining CTS status was a classic or probable hand pain diagram and NCS with a difference >0.3 ms between the 8-cm median and ulnar peak latencies. Readers graded multiple imaging parameters of the MRI on four-point scales. The authors also performed quantitative measurements of both the median nerve and carpal tunnel cross-sectional areas. NCS and MRI were interpreted without knowledge of the other study or the hand pain diagram. RESULTS: Intrareader reliability was substantial to near perfect (kappa = 0.76 to 0.88). Interreader agreement was lower but still substantial (kappa = 0.60 to 0.67). Sensitivity of MRI was greatest for the overall impression of the images (96%) followed by increased median nerve signal (91%); however, specificities were low (33 to 38%). The length of abnormal signal on T2-weighted images was significantly correlated with nerve conduction latency, and median nerve area was larger at the distal radioulnar joint (15.8 vs 11.8 mm(2)) in patients with CTS. A logistic regression model combining these two MR variables had a receiver operating characteristic area under the curve of 0.85. CONCLUSIONS: The reliability of MRI is high but the diagnostic accuracy is only moderate compared with a research-definition reference standard.

A case-control study of physical activity and non-insulin dependent diabetes mellitus (NIDDM). the San Luis Valley Diabetes Study.

PURPOSE: The purpose of this study was to examine the association between physical activity and non-insulin dependent diabetes mellitus (NIDDM). METHODS: We conducted a population-based case-control study in Hispanic and non-Hispanic white men and women, ages 20-74. A total of 167 cases with NIDDM and 1100 controls with normal glucose tolerance were included. All subjects completed an oral glucose tolerance test. RESULTS: Persons with recently diagnosed NIDDM reported significantly lower levels of physical activity than control subjects. For total metabolic units, the odds ratio for subjects in the highest tertile compared to those in the lowest tertile was 0.60 (95% confidence interval (CI) = 0.37-0.98) after adjusting for age, sex, ethnicity, and family history of diabetes. The adjusted odds ratio for persons reporting high levels of vigorous activity (at least three times per week for 20 minutes) was also less than 1, but was not statistically significant (odds ratio (OR) = 0.73, 95% CI = 0.47-1.14). Similar adjusted odds ratios were observed for high versus low levels of self-assessed work activity (OR = 0.50, 95% CI = 0.34-0.74) and leisure time physical activity (OR = 0.62, 95% CI = 0.44-0.90). Further adjustments for body mass index attenuated the strength of the association between physical activity and NIDDM. This is consistent with the hypothesis that obesity is one consequence of physical inactivity that puts individuals at increased risk for NIDDM. The association of physical activity and NIDDM was stronger in Hispanic than in non-Hispanic white subjects, although this difference was not statistically significant. CONCLUSIONS: High levels of physical activity are associated with lower odds of NIDDM and this relationship may be stronger in Hispanic subjects.

Outcomes of pain center treatment in Washington State workers' compensation.

BACKGROUND: Injured workers with chronic pain who have failed conventional therapies often receive treatment at pain centers. This study evaluated the effect of pain center treatment on time loss status of Washington State injured workers. The primary hypothesis was that treatment at a pain center would lead to a reduction in the probability of a worker's receiving time loss benefits at a 2-year follow-up. METHODS: A population-based retrospective cohort study was performed on 2,032 Washington State workers' compensation patients who underwent pain center evaluations. Subjects who received pain center treatment were compared to those who were evaluated but not treated with respect to time loss status at 2-year follow-up. RESULTS: Univariate analysis revealed that at 2-year follow-up, 35% of treated subjects were receiving time loss payments vs. 40% of evaluated only subjects (P < 0.05). Subjects who were younger, female, and less chronic were more likely to undergo pain center treatment and were less likely to be on time loss at 2-year follow-up. In multivariate analyses, which statistically controlled baseline differences between the two groups, there was no difference between treated subjects and evaluated only subjects. CONCLUSIONS: There was no evidence that pain center treatment alters 2-year time loss status of already disabled workers.

Years of productivity lost among injured workers in Washington state: modeling disability burden in workers' compensation.

BACKGROUND: Few studies have examined the impact of disability from nonfatal work-related injuries and illnesses. We developed Years of Productivity Lost (YPL) as a measure of the burden of disability. METHODS: YPL was calculated for incident workers' compensation claims with compensable injuries filed in 1986 in Washington State. Final work disability status was determined in June, 1993. We estimated YPL by adding actual accumulated time loss and future lost productivity predicted from permanent partial disability awards and pensions. RESULTS: Back and neck sprains were associated with the highest YPL followed by sprains of the lower and upper extremities. Using actual accumulated time loss, we calculated 14,624 years of productivity lost for compensable injuries in 1986. After including predicted lost productivity, YPL ranged from 28,017 to 33,502 years. CONCLUSIONS: YPL can be used to quantify the burden of disability due to occupational injuries and illnesses and to prioritize efforts to prevent long-term disability.

Outcome of surgery for thoracic outlet syndrome in Washington state workers' compensation.

OBJECTIVE: To determine the predictors of outcome of thoracic outlet syndrome (TOS) surgery in a population-based cohort of injured workers. METHODS: All injured workers in the Washington State Workers' Compensation system who received TOS surgery during 1986 to 1991 were identified by computerized bill payment records and validated by medical record review (n = 158). The main outcome measure was work disability status 1 year after surgery. Additional functional status and quality of life outcomes were determined by telephone survey an average of 4.8 years after operation. A sample of workers with a TOS diagnosis who did not receive surgery during 1987 to 1989 were identified as a comparison group (n = 95). RESULTS: Sixty percent of workers were still work disabled 1 year after surgery. The strongest predictors of remaining disabled were the amount of work disability before surgery (OR = 1.85; 95% CI, 1.51 to 2.28), longer time between injury and TOS diagnosis (OR = 1.34; 95% CI, 1.09 to 1.64), and older age at injury (OR = 1.07; 95% CI, 1.00 to 1.13). There was no relationship between type of surgery, presence of any provocative tests, or experience of surgeon and work disability outcome. In follow-up surveys an average of 4.8 years after surgery, 72.5% of workers still reported they were "limited a lot" in vigorous activities. Compared with a nonsurgical sample of TOS patients, those receiving surgery had 50% greater medical costs and were three to four times more likely to be work disabled. CONCLUSIONS: The outcome of TOS surgery among injured workers is worse than has generally been reported. The nonspecific neurogenic TOS diagnosis, the complexity of workers' compensation cases, and the adverse event profile are likely substantial contributors to the worse outcomes reported here. Well-designed prospective studies and randomized trials are required to elucidate any role of TOS surgery in nonspecific TOS.

Comparison of fatal and severe nonfatal traumatic work-related injuries in Washington state.

OBJECTIVE: To compare fatal and hospitalized nonfatal work-related traumatic injuries by occupation and cause. METHODS: Fatal and hospitalized nonfatal injuries occurring from 1991-1995 were identified from Washington State workers' compensation claims data. Nonfatal injuries were classified as severe if they had at least one of the following criteria: a brain or spinal cord injury, an Injury Severity Score of >/=16, or were hospitalized for more than 7 days. The frequency and rate of fatal and severe nonfatal injuries were then described by industrial risk class and cause. RESULTS: The study identified 335 fatal injuries and 4,405 hospitalized nonfatal injuries, of which 1,105 were classified as severe. Tree topping and pruning, carnival work, roofing, and metal siding and gutters risk classes had several severe nonfatal injuries, but few, if any, fatalities. Causes of fatal and severe nonfatal injuries were notably different for the roofing, restaurant, and orchard workers risk classes. CONCLUSIONS: The inclusion of severe hospitalized injuries in occupational injury surveillance systems will provide a broader view of high-risk occupations and profile of injury causation with which to direct occupational injury prevention efforts.

Risk of job-related injury among construction laborers with a diagnosis of substance abuse.

This study attempts to determine whether a diagnosis of substance abuse among construction laborers is associated with an increased risk of work-related injuries. Records for construction laborers in Washington State who were covered by health insurance through the local union were matched against workers' compensation records in the Washington State Department of Labor and Industries. Using the health insurance records, we identified those who had a diagnosis of substance abuse during the two-year period 1990-1991. Using the workers' compensation records, we were then able to compare injury rates for those with substance abuse diagnoses with the rates for those without such diagnoses. The total cohort consisted of 7,895 laborers. Among the 422 who had a substance abuse diagnosis, the rate of time-loss injuries per 100 full-time equivalent workers was 15.1, compared with 10.9 among the remainder of the cohort. Most of the difference appeared in the 25-34-year age group, in which the rate of injury per 100 full-time equivalent workers was 23.6 for substance abusers, compared with a rate of 12.2 for non-substance abusers, for a statistically significant relative risk of 1.93. The study suggests that younger workers might be an appropriate target for interventions aimed at reducing the level of substance abuse as a way of preventing injuries on the job. Studies by others have indicated some degree of success in this direction through the use of employee assistance programs in which the worker is referred to specific programs or providers for treatment. The state legislature in Washington has recently passed legislation providing incentives for the use of employee assistance programs. More effort is needed, however, to evaluate the effectiveness of such programs.

Occupational hearing loss in Washington state, 1984-1991: I. Statewide and industry-specific incidence.

This study examined non-federal workers' compensation claims accepted for hearing-related conditions in Washington state during 1984-1991. Seventy percent of 6,539 filed claims were accepted (n = 4,547); most accepted claims resulted in disability compensation (n = 3,660; 80%). A transient 50-fold increase in claims from one worksite accounted for one-third of all hearing-related claims in the state for 2 years. The number and incidence of accepted claims from all other worksites increased significantly across the study period. The incidence was 0.3 per 10(3) workers per year, overall, but was at least five-fold higher in industries that accounted for half of accepted claims, and reached 38- to 71-fold higher in some industries. This study indicates: 1) workers' compensation claims under-estimate the true frequency of occupational illness, representing only the "tip of the iceberg;" 2) hearing loss is a growing problem in occupational health; and 3) workers' compensation data are potentially useful to identify specific high-incidence industries for possible interventions.

Occupational hearing loss in Washington state, 1984-1991: II. Morbidity and associated costs.

This study examined 4,547 workers' compensation claims accepted for hearing-related conditions in Washington state between 1984 and 1991; 80% resulted in disability compensation (n = 3,660). Acute hearing-related conditions comprised 11% of accepted conditions (95% confidence interval [CI], 2-15%); most claims were for chronic noise-related hearing loss. Tinnitus was reported in 64% of accepted claims (95% CI, 54-75%). The median binaural-equivalent hearing loss in compensated claims was 12.5% (inter-quartile interval, 5-22%; 90th percentile, 34%), although it declined by 30% during the study period. The number of claims and associated impairment increased with claimant age, but the number of claims dropped dramatically after age 65. Annual total disability settlements almost tripled in 8 years, totaling $22.8 million. This study indicates that occupational hearing-related conditions: 1) are manifested by mild to moderate hearing loss, accompanied by tinnitus in a majority of cases; 2) may be under-recognized in older, formerly noise-exposed individuals; and 3) were associated with substantial increases in compensation and medical costs over time, through 1991.

Outcomes research in Washington state workers' compensation.

The extensive claim and medical bill payment databases of the Washington state workers' compensation system have been used to conduct epidemiologic and outcome studies of work-related conditions. Computerized administrative data must be supplemented with medical record review and structured interview of workers in outcome studies in order to adequately adjust for baseline severity and to address functional and patient satisfaction outcomes, respectively. Three examples of surgical outcome studies are described (carpal tunnel, lumbar fusion, thoracic outlet). Duration of disability prior to surgical intervention is an important predictor of duration of disability following surgery, even when other biologic markers of severity are included in multivariate modeling. Sufficient follow-up time is required to adequately assess longer-term outcomes, such as return-to-work status and the substantial effects of residual impairment even after claim settlement. Finally, well-conducted outcome studies may be linked to the development of surgical treatment guidelines in workers' compensation.

Determinants of total high density lipoprotein cholesterol and high density lipoprotein subfraction levels among Hispanic and non-Hispanic white persons with normal glucose tolerance: the San Luis Valley Diabetes Study.

Determinants of total high-density lipoprotein cholesterol (HDL-C) and HDL subfractions were assessed in Hispanic and non-Hispanic white persons (n = 932), aged 20-74 years, in the San Luis Valley, Colorado. Using multiple regression, BMI was negatively associated with HDL-C, HDL2-C, and HDL3-C in men and HDL-C and HDL3-C in women. Among females, current smokers had lower HDL-C and subfractions. Women on beta-blockers had lower HDL3-C levels. For both sexes, a positive association was observed between age and HDL-C and subfractions and physical activity with HDL-C and HDL3-C. Drinking alcohol (> or = 50 g/week) was associated with higher HDL-C and HDL3-C in both sexes and HDL2-C in women. The positive association of age and negative associations of the subscapular/triceps ratio and fasting insulin had consistent relationships with HDL-C, HDL2-C, and HDL3-C in men and women. Ethnicity was not significantly associated with HDL-C or subfractions after controlling for body fat distribution or fasting insulin.

Are self-reported dates of mammograms accurate?

BACKGROUND: This paper assesses the accuracy of self-reported dates of last mammograms from a postal survey compared to dates of mammograms in medical records. METHODS: The subjects included women 50 years of age and older who were members of a local health maintenance organization, had reported ever having a mammogram, and had completed a postal questionnaire about breast cancer screening. The date of last mammogram from the postal surveys was compared to the date in medical records. RESULTS: Of 78 women who self-reported both the month and year of last mammogram in a postal survey, agreement within 1 month with the medical record data was 62.8% and agreement within 3 months was 75.6%. A total of 32.1% of the subjects underestimated the time since their last mammogram, while only 5.1% overestimated. Based on self-reported dates, 85.9% of the subjects had a mammogram within the last year compared to 76.9% based on medical records. Using medical records as the "gold standard", the sensitivity of self-reported mammogram within the last year versus more than 1 year ago was 98% and the specificity was 56%.