Secondary Prevention Efforts Research Articles

Self-efficacy and Barriers to Healthy Diet in Cardiac Rehabilitation Participants and Nonparticipants

Participation in cardiac rehabilitation (CR) can result in positive outcomes for patients, but this population comprises only up to 20% of the total cardiac population. Thus, it is also necessary to examine the determinants of lifestyle behaviors in cardiac patients who do not attend CR programs. Studies have focused largely on physical health and outcomes of exercise participation, with less attention to dietary habits and the psychological determinants of behavior change. The purpose of this descriptive comparative study was to examine the differences in self-efficacy for and barriers to healthy dietary intake between CR participants and nonparticipants at 6 and 12 weeks after hospital discharge. A prospective longitudinal design was used. The sample consisted of 51 adults who (1) were diagnosed with/recovering from an acute cardiac event, treatment, or intervention; (2) received phase I CR; and (3) were physically able to participate in phase II CR. Participants were primarily male, elderly, married, and white; had more than a high school education; and had incomes more than $30,000. Analysis of covariance was used to determine differences over time in self-efficacy and barriers to healthy dietary intake between groups. Although time 1 findings between groups were not significant, CR participants reported higher self-efficacy for healthy dietary intake than did nonparticipants. At time 2, CR participants also reported greater self-efficacy (F3,40 = 13.69, P ≤ .0001), indicating more confidence they could commit to a healthy diet. A significant difference was found in barriers to healthy dietary intake (t = 2.13, P = .04) at time 1, with CR participants reporting fewer barriers. At time 2, CR participants reported fewer barriers to healthy dietary intake (F3,39 = 18.19, P < .0001), indicating a more positive perception. Findings improve understanding of factors influencing adoption of healthy diet behaviors and are useful for designing interventions to assist individuals in sustaining secondary preventive efforts over time.

Secondary Prevention Efforts at a Residential Facility for Students with Emotional and Behavioral Disorders: Function-Based Check-in, Check-out

Check-in, check-out (CICO) is a secondary-tier intervention with proven utility for reducing problem behaviors and increasing responsiveness to primary-tier expectations of positive behavioral interventions and supports (PBIS). CICO has been investigated at the elementary and middle school levels in traditional school settings with students both with and without disabilities. This study seeks to extend this literature base by (a) investigating the utility of CICO in residential settings for students with emotional and behavior disorders, (b) investigating the role of function in responsiveness to CICO intervention efforts, and (c) using direct observation data and a multiple-baseline design to measure responsiveness across participants. Limitations and future directions also are discussed.

A systematic review and meta-analysis of the prevalence of chlamydia, gonorrhoea and syphilis in incarcerated persons

Communicable diseases are common in people who are incarcerated. We aimed to define the prevalence of chlamydia, gonorrhoea and syphilis in people who are incarcerated and to identify subgroups with the highest risk of infection. We searched for prevalence studies of chlamydia, gonorrhoea or syphilis in incarcerated populations. Pooled estimates were generated, and meta-regression was conducted. Random effects models yielded pooled prevalence estimates of 5.75% (95% confidence interval [CI] 5.01, 6.48) and 12.31% (95% CI 10.61, 14.01) for chlamydia in men and women, 1.4% (95% CI 1.09, 1.70) and 5.73% (4.76, 6.69) for gonorrhoea in men and women, and 2.45% (95% CI 2.08, 2.82) and 6.10% (95% CI 4.75, 7.46) for syphilis in men and women, respectively. Each infection was associated with female gender in meta-regression models. Chlamydia, gonorrhoea and syphilis are highly prevalent in these populations. Primary and secondary prevention efforts could improve individual and population health.

Reducing Residual Risk in Secondary Prevention of Cardiovascular Disease

Prevention of cardiovascular disease (CVD) spans the human lifespan, including primordial, primary, and secondary prevention efforts. Extensive evidence from epidemiological, genetic, and animal studies confirms the central importance of elevated low-density lipoprotein (LDL) cholesterol (LDL-C) in atherosclerotic CVD events.1 The Cholesterol Treatment Trialists Collaboration provides per-person documentation from large-scale randomized clinical trials of the striking reduction in CVD events per 1 mmol (38.8 mg/dL) of LDL-C lowering with statins over a wide range of baseline LDL-C values.2,3 It is worth recalling that the major statin trials were not designed to determine the effectiveness of titration to LDL-C or even to non–high-density lipoprotein cholesterol goals by statins but were fixed-dose comparisons of various statins against placebo and then, more recently, large-dose statin therapy versus moderate-dose statin therapy. What is not so clear is whether we can intervene to reduce so-called residual risk further in secondary prevention patients optimally treated with statin therapy. A promising short list of proposed potential targets other than LDL includes efforts to promote smoking cessation and therapies to improve the prothrombotic and inflammatory state of the metabolic syndrome and to control elevated blood pressure.4 Article see p 1979 The article by Mora et al5 in this issue of Circulation is helpful in shedding light on this unresolved but important clinical problem. The investigators used data from a large-scale clinical trial of secondary prevention patients called Treating to New Targets (TNT). They evaluated risk factors for recurrent CVD events in those treated with intensive statin therapy (atorvastatin 80 mg/d) to address the challenges inherent in further risk reduction for those who had major cardiovascular events despite high-dose (atorvastatin 80 mg/d) statin therapy. The trial design of TNT included enrollment of participants with chronic coronary artery …

Abstract P273: Influence of Fatigue and Depressive Symptoms on Physical Functioning 30-Days after Treatment for Stable Coronary Artery Disease

Fatigue and depressive symptoms are pervasive in patients with coronary heart disease. It is unknown how these symptoms impact physical functioning and secondary prevention efforts in patients with stable coronary artery disease (SCAD) who are treated with either percutaneous coronary intervention (PCI) and optimal medical therapy (OMT) or OMT alone. The purpose of this study was to evaluate the influence of fatigue and depressive symptoms on physical functioning in patients with SCAD 30-days after treatment with PCI/OMT or OMT. In this prospective design, a convenience sample of SCAD patients ( n =180, age M=65.1, SD=8.3) were recruited after treatment with PCI/OMT ( n =90) or OMT ( n =90). Data collection occurred at baseline (post-procedure) and 30-days after discharge. Mailed surveys were used at 30-days with a 52.8% (94/180) response rate (OMT n =46, PCI/OMT n =48). Measurements included the Profile of Mood States (POMS) for fatigue, Patient Health Questionnaire-9 (PHQ-9) for depressive symptoms, and Short Form-36 (SF-36) for physical functioning. Two linear regression models (see table ) were conducted to evaluate physical functioning predictors at 30-days for patients treated with PCI/OMT and OMT. Fatigue was a significant contributor for physical functioning after treatment with PCI/OMT and OMT. For PCI/OMT, fatigue ( b =-.434, p &lt;.001) and age ( b =-.245, p =.03, bivariate: r=-.414, p=.003) were significant predictors for physical functioning at 30-days. For OMT, fatigue ( b =-.630, p =.03) and gender ( b =.499, p &lt;.01) were found to influence physical functioning after treatment, with men demonstrating lower functioning at 30-days (m=37.6, sd=9) compared to women (m=49.6, sd=9.1). Depressive symptoms did not influence physical functioning in treatment groups (PMI/OMT: b =-.239, p =.05; OMT: b =.019, p =.89). Persistent fatigue may deter patients from engaging in physical activity to promote secondary prevention. Further research is needed to investigate the impact of fatigue on physical functioning. Predictors of Physical Functioning 30-Days After Treatment for Stable Coronary Artery Disease PCI/OMT Predictors Standardized Beta t value p value 95% CI (Lower Bound) 95% CI (Upper Bound) Age −.245 −.21 .03 −.495 −.017 Gender .082 .82 .41 −.273 6.505 Ejection Fraction .097 .85 .40 −.078 .191 POMS-Fatigue −.434 −.38 &lt;.01 −1.419 −.441 PHQ-9 Depressive Symptoms −.239 −.20 .05 −1.673 −.002 OMT Predictors Standardized Beta t value p value 95% CI (Lower Bound) 95% CI (Upper Bound) Age .268 1.96 .05 −.008 .606 Gender .499 .42 &lt;.01 6.470 18.401 Ejection Fraction −.195 −1.31 .19 −.427 .090 POMS-Fatigue −.630 −4.37 &lt;.01 −2.319 −.852 PHQ-9 Depressive Symptoms .019 .13 .890 −1.474 1.691 Abbreviations: CI, Confidence Interval. Model Information: PCI/OMT n=48, f=11.23, df=6, r2=.622,p&lt;.01. OMT: n=46, f=6.91, df=6, r2=.516, p&lt;.01

Abstract MP093: Clinical Features, Treatment Practices, and Short-term Outcomes of Patients &lt; 55 Years of Age Hospitalized with an Acute Coronary Syndrome: The Global Registry of Acute Coronary Events

Limited data are available describing the magnitude, clinical features, treatment practices, and short-term outcomes of comparatively young adults hospitalized with acute coronary syndromes (ACS). The objectives of this large multinational observational study, using data from the GRACE Registry, were to describe nearly decade long trends in these endpoints among adults &lt; 55 years old who were hospitalized with an ACS between 1999 and 2007. The overall proportion of young adult patients in our study population was 23% (n=15,052 of 65,119) and this proportion remained relatively constant over the study years. Baseline demographic and clinical characteristics of our study sample did not change significantly, whereas, the length of hospital stay declined by more than 1 day, on average, during the years under study. The overall in-hospital and 30-day multivariable adjusted case-fatality rates (CFRs) declined by approximately one-third (table) between 1999 and 2007 (crude 30-day CFR= 2.4% in 1999 and 1.7% in 2007). The use of evidence-based cardiac therapies demonstrated to improve outcomes of patients with an ACS increased significantly over time. In conclusion, improving trends in short-term outcomes of comparatively young patients hospitalized with an ACS during the nearly decade long period under study likely reflect enhanced primary and secondary prevention and treatment efforts. Odds of Dying in Younger Patients Hospitalized with an Acute Coronary Syndrome Study Period Crude Odds Ratios of In-Hospital Death Multivariable Adjusted Odds Ratios of In-Hospital Death * Crude Odds Ratios of 30-day Death Multivariable Adjusted Odds Ratios of 30-day Death * 1999-2001º 1.0 1.0 1.0 1.0 2002-2004 0.89 (0.82-0.97) 0.83 (0.76-0.91) 0.93 (0.86-1.0) 0.83 (0.76-0.90) 2005-2007 0.74 (0.67-0.81) 0.66 (0.60-0.74) 0.74 (0.68-0.81) 0.62 (0.57-0.69) * Adjusted for age, sex, length of hospital stay, and medical history ºreferent period

Sexual Risk Behavior and Risk Reduction Beliefs Among HIV-Positive Young Men Who have Sex with Men

With young men who have sex with men (YMSM) continuing to be disproportionately affected by the HIV/AIDS epidemic in the U.S., secondary prevention efforts with this population take on increasing significance. We surveyed 200 HIV-positive YMSM (ages 16-24, 66% Black, 18% Latino, 7% White, 7% Multiracial/Other) recruited from 14 HIV primary care sites to examine associations of unprotected anal intercourse (UAI) and partner HIV status with endorsement of serosorting, sexual positioning, and viral load beliefs. Proportions of participants engaging in UAI one or more times during the past three months were consistent across type of UAI (insertive or receptive) and partner status. Belief that an undetectable viral load reduces infectiousness was significantly associated with insertive UAI (p < .05) and receptive UAI (p < .05) with HIV-negative or unknown status partners and receptive UAI with HIV-positive partners (p < .01). Endorsement of belief in serosorting was significantly associated with receptive UAI (p < .01) and insertive UAI (p < .05) with HIV-positive male partners. Implications for sexual behavior and risk reduction beliefs in this population are discussed.

Corliss et al. Respond

The letter by Rice et al. provides further evidence that sexual-minority adolescents are at greater risk for homelessness than adolescents in general. To understand the scope of the problem nationally, we strongly urge surveillance mechanisms, such as the Youth Risk Behavior Surveillance System (YRBSS), to collect standardized data on sexual orientation and homelessness. In addition to Massachusetts, a number of other state and regional YRBSSs collect sexual orientation data. Standardizing sexual orientation questions across surveys and increasing the number of surveys that collect these data will improve our ability to quantify the scope of the problem. Additionally, we suggest using a homeless question like the one in the Massachusetts YRBSS1 because it is based on the McKinney-Vento2 federal definition of homelessness (i.e., lacking a fixed, regular, and adequate nighttime residence) and provides detailed information on type of living situation and unaccompanied status. As Rice et al. note, there is great variation in homelessness by region. There are also regional differences in attitudes toward homosexuality and gender-role norms.3,4 Systematic data collection will allow us to examine how risk for homelessness in sexual-minority teens may vary by region and other sociodemographic characteristics such as race/ethnicity and gender. The 2005 Massachusetts YRBSS estimated that 4.2% of Massachusetts public high school students were homeless, yet only 0.6% of Massachusetts high school students were identified by schools as homeless during the 2004–2005 academic year.5 Health and social service professionals need to do a better job working with schools to identify homeless students and to link them with services to find stable housing, to assist them with their educational needs, and to support their health and well-being. In public health, these efforts are known as secondary (i.e., intervening early to end homelessness) and tertiary (i.e., providing services to those currently homeless such as temporary shelter, food, and other social and medical services) prevention efforts. Equally important are primary prevention efforts that focus on preventing homelessness in the first place. Efforts to identify effective primary, secondary, and tertiary prevention strategies for sexual-minority youth at risk for homelessness are clearly needed. What strategies help families overcome challenges leading to sexual-minority teen homelessness? Are programs in schools and communities for homeless youth effective at reaching sexual minorities and addressing their specific needs? Because homeless sexual-minority teens are likely to be unaccompanied by their parents/guardians, does this influence their access to shelter-based and other services? Answers to these and other questions will help us eliminate the unconscionable sexual orientation disparities in youth homelessness.

Racial and ethnic disparities in police-reported intimate partner violence perpetration: a mixed methods approach.

The objectives of this study were to examine racial and ethnic disparities in perpetrator and incident characteristics and discrepancies between police charges and reported perpetrator behaviors in police-reported intimate partner violence (IPV). This cross-sectional study used standardized police data and victim narratives of IPV incidents reported to the police in Dallas, Texas in 2004. The sample included non-Hispanic White, non-Hispanic Black, and Hispanic male perpetrators who were residents of Dallas (N = 4470). Offense charges were prioritized in descending order: sexual assault, aggravated assault, simple assault, kidnapping, robbery, and intimidation. Textual data from the victim narratives were coded, based on the revised Conflict Tactics Scales (CTS), and categorized in descending order of priority: sexual (severe, minor), physical (severe, minor), and psychological (severe, minor) assault. Perpetrators were more likely to be Black and Hispanic. Perpetrator and incident characteristics varied significantly by race/ethnicity, particularly age, age difference between partners, marital status, injury, and interracial relationships. Qualitative data revealed that greater proportions of Black and Hispanic men perpetrated severe physical, but not sexual violence, compared with White men. The greatest disparity between CTS categories and police charges occurred among those cases identified by the CTS as severe physical IPV; 84% were charged with simple assault. Significant differences by race/ethnicity were found only for simple assault charges, which were coded as severe physical as opposed to minor physical IPV more often among Black (69% and 31%) compared with White (62% and 38%) men. The disparities revealed in this study highlight the need to enhance primary and secondary prevention efforts within Black and Hispanic communities and to increase linkages between police, community, and public health organizations.

Secondary Prevention Efforts at the Middle School Level: An Application of the Behavior Education Program

In this study we examine the impact of the Behavior Education Program (BEP; Hawken, MacLeod, & Rawlings, 2007) with four middle school students who were not responsive to a comprehensive primary prevention program including academic, behavioral and social components. To extend this line of inquiry we (a) conducted a functional behavioral assessment prior to implementing the BEP and (b) employed a changing criterion design to determine if a functional relation could be established between the introduction of the BEP program and changes in student performance. Results suggest this intervention may be effective for students whose challenging behaviors are maintained by attention and escape. However, the variability in scores raises questions and concerns regarding the nature of the behavior change that may have occurred. Additional limitations and future direction are discussed.

Arsenic and human health: epidemiologic progress and public health implications

Elevated concentrations of arsenic in groundwater pose a public health threat to millions of people worldwide, including severely affected populations in South and Southeast Asia. Although arsenic is an established human carcinogen and has been associated with a multitude of health outcomes in epidemiologic studies, a mode of action has yet to be determined for some aspects of arsenic toxicity. Herein, we emphasize the role of recent genetic and molecular epidemiologic investigations of arsenic toxicity. Additionally, we discuss considerations for the public health impacts of arsenic exposure through drinking water with respect to primary and secondary prevention efforts.

Financial incentives in workers’ compensation: an analysis of the experience-rating programme in Ontario, Canada

AbstractObjectives: To investigate the incentive for health and safety and cost management at the firm level associated with the degree of experience rating in a retrospective workers’ compensation programme in Ontario, Canada.Methods: We use panel data on all firms in the principal Ontario experience-rating programme between 1998 and 2007 to estimate regression models of the relationship between the degree of experience rating and various claim rates. We control for firm characteristics and contextual factors that may be associated with the outcomes under investigation.Results: A higher degree of experience rating was found to be associated with a lower lost-time claim rate and a higher no-lost-time claim rate. The relationship with the total claim rate was insignificant. The degree of experience rating was also associated with outcomes that proxied for cost management practices.Conclusions: A higher degree of experience rating appears to be associated primarily with increased secondary prevention effort...

Editorial for International Journal of Behavioral Medicine: Special Issue on Cancer

Contributions of Behavioral Medicine to CancerPrevention and ControlOver the past several decades, behavioral medicine hascontributed in many significant ways to cancer preventionand control (CPC) research [1]. This includes primaryprevention theory development and behavioral interven-tions designed to modify cancer risk behaviors tied toexposure to high-fat diet, sexually transmitted viruses,tobacco, and excessive sunlight. This has led to markeddecreases in the incidence of lung, skin, colorectal, andcervical cancers. Other work in behavioral medicine hascontributed to efforts in secondary prevention by increasingour understanding of processes underlying decisions toundergo cancer screening (mammogram, Pap smears, fecaloccult blood testing (FOBT), skin cancer screening) as wellas the role of behavioral and psychosocial factors inpostscreening follow-up behaviors [1]. This secondaryprevention work is designed to reduce mortality as well aspsychosocial and physical morbidity [1] and has beenwidely responsible for the increased use of establishedscreening procedures for breast, cervical, and skin cancers,and is making some gains in increasing screening forprostate, lung, and colorectal cancer. Behavioral medicineresearch has also extended to examine factors underlyingthe choice to undergo testing for genetic risk factors such asBRCA 1 and 2, which connote surplus risk for breast andovarian cancers. This work has led to increased expertise ingenetic counseling to guide individuals in the decision-making challenges (e.g., prophylactic surgery, increasedscreening frequency) that follow a positive test result.A huge amount of behavioral medicine research in CPChas been done within the field of “psycho-oncology”mostly targeted to tertiary prevention, wherein behavioraland psychosocial models have been applied to helpdiagnosed cancer patients optimize psychosocial andphysiological adaptation to the stressors of diagnosis,treatment and reentry to their premorbid lives—a periodoften referred to as early survivorship. The ultimate goal ofthis work is to enhance quality of life in patients and thoseconnected to them (e.g., family caregivers) as they navigatethe cancer experience. This work has applied multiplepsychological theories (e.g., cognitive behavioral, existen-tial) to better understand how patients rally their intrapsy-chic, interpersonal, and spiritual resources to cope with andadapt to the mental and physical challenges of this 1–2-yearperiod. This has resulted in the completion of over 300randomized trials testing the effects of a wide range ofbehavioral and psychosocial interventions, which haveshown modest but reliable effects on improved quality oflife and mood, and reduced side effects (e.g., sleepdisruption, fatigue, pain). In a small subset of studies, thereis a suggestion that these interventions may help reducephysiologic effects of treatment (compromised immunefunction) [2]. Very recent work suggests that stressprocesses may contribute to cancer disease progression,which may help to explain the provocative but difficult toreplicate observation that some cancer patients whoparticipate in group-based psychosocial interventions showlonger survival times and disease-free intervals [3].Completing the ways in which behavioral medicinecontributes to CPC are quaternary prevention studies thatfocus on the role of behavioral and psychosocial processesin optimal long-term survivorship after curative and initial

Influence of a sedentary lifestyle on self-reported mental health status among community-dwelling older adults with depression: Implications for secondary prevention efforts

The relationship between sedentary behavior and mental health is documented in the primary prevention literature in the context of mental illnesses such as depression. However, these relationships have not been studied to the same extent for secondary prevention efforts, especially among at risk communitydwelling older adults. The Brazos Valley Health Assessment was administered to nearly 4000 adults. Respondents self-reported disease status, lifestyle behaviors such as physical activity and nutrition habits, perceptions of physical and mental health, and socio-demographics. The selection criteria for inclusion in our study sample were being at least 55 years old and having been diagnosed with depression by a healthcare provider. This criterion resulted in a sample of 545. Negative binomial regression was used to examine the association between number of the past 30 days where mental health days were not good and sedentary behaviors such as time spent watching television and time spent using a computer. For each day per week respondents did not engage in at least 10 min of moderate physical activity (such as fast walking) relative to their peers, they were 5% less likely to report positive mental health (IRR=0.95, P=0.036). For each additional hour per day respondents spent watching television relative to their peers, they were 12% more likely to report poorer mental health (IRR=1.12, P=0.033). Secondary prevention efforts should recognize the influence of sedentary behaviors and emphasize similar interventions used for primary prevention of depression.

Ageing in place: Implications of morbidity patterns among older persons – findings from a cross‐sectional study in a developing country (Jamaica)

This paper describes morbidity patterns among older people, relevant health-care resources in a localised population in a developing country (Jamaica) and implications for ageing in place in the community. Local morbidity patterns among older people were determined in Jamaica from a 2007 cross-sectional study involving record searches at major hospitals and clinics. Age-specific morbidity distributions were compiled. Data on health-care staff complement were also collected. Non-communicable diseases predominate in older people in Jamaica; 50% of diagnoses related to cardiovascular disorders and diabetes. Staff-to-population ratios were low compared with other international data. A high prevalence of non-communicable disease coupled with inadequate staffing threatens the likelihood of ageing in place in the Jamaican community. Secondary prevention efforts and social support services which enhance ageing in place are needed.

Substance Use: Impact on Adherence and HIV Medical Treatment

Substance use is highly prevalent among people living with HIV/AIDS, is often comorbid with other mental health problems, related to poor HIV medical outcomes, and, is associated with poor medication and treatment adherence. The current review reports on the recent state of the literature in terms of substance use and its relation to HIV medication and treatment adherence, and offers recommendations for advancing treatment and secondary HIV prevention efforts. Identifying substance users within HIV primary care and developing, evaluating, and refining integrative substance use-mental health-adherence interventions may be clinically important targets for effective disease management and may contribute to secondary HIV prevention efforts.

P2-84 Chronic conditions and major depression in community-dwelling older adults

ObjectivesTo estimate (1) the prevalence of long-term medical conditions and of comorbid major depression, and (2) the associations between major depression and various chronic medical conditions in a general population...

How Can Social Work Affect Health Care Reform?

Although health care reform is a serious challenge for health care social workers, it also creates many opportunities. Most often, social workers define this type of challenge from a reactive perspective. Rather than think of the impact of health care reform on the social work profession, perhaps health care social workers should ask this question: How can the profession of social work actually affect health care reform? Prior to coming to the Catholic University of America in 2002, I was one of the five associate directors at the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University in Baltimore. In this role, I was responsible for community programs and research that attempted to understand the significant disparities that existed in mortality among all of the most prevalent cancer diagnoses in Baltimore city. I, along with the members of my team, was shocked to learn in the year 2000 that the leading cause of death for African American men under the age 30 was homicide, whereas for African American men over the age of 30, it was prostate cancer. Yes, prostate cancer. Based on mortality statistics for 1997 through 1999, African American men died of prostate cancer at a rate three times higher than that for any other population in Baltimore city. When you read these types of statistics (and there are many other examples in other chronic illnesses), health care reform--in terms of access to care and the provision of health care services--is essential. Today, we need to examine health care reform from a number of perspectives. Let me raise three questions that need to be explored: 1. Has the time arrived for social workers in health care to fully embrace the concept of illness prevention and control and actively involve themselves in primary and secondary prevention efforts? By preventing the onset of a disease such as cancer, or through the design of an early detection programs, can social work interventions actually save lives among the most vulnerable populations? The answers to these two questions are yes and yes. 2. Must social workers adopt evidence-based interventions under the realm of tertiary prevention to minimize the effects of a range of chronic illnesses? The answer is yes. 3. Can social workers design interventions and programs that significantly reduce health care spending? Again, the answer is yes, and this requires further examination. Much research exists that has demonstrated a significant association between cancer, psychological distress, and unsatisfactory quality of life, not only at the time of diagnosis, but throughout treatment and recovery (Worden, 1989; Zabora et al., 1997). It is clear that cancer patients are at risk for the development of psychological symptoms and problems, perhaps to an even greater extent than patients with other medical illnesses (Mishel, 1999). Some of the potential risk factors hypothesized to be involved in the development of cancer patients' distress are social isolation, pessimistic attitudes, loss of control, loss of hope, socioeconomic factors, pain, side effects of cancer treatments, and poor problem-solving skills (Zabora, 2009). Undetected and untreated psychological distress may be transformed into somatic complaints such as fatigue, pain, or sleep disorders. Health care providers may assess these somatic complaints and respond with medications, lab tests, scans, or procedures (Allison et al., 1995; Zabora, 1998). Somatic complaints may well continue until the true source of a complaint is identified and treated. Brief psychosocial interventions that address significantly elevated levels of anxiety or depression at the initiation of treatment may be far less costly than a series of non-medically appropriate procedures and scans or an avoidable hospitalization if physical complaints increase in severity. Given that one-third of all cancer patients (and there is evidence to indicate comparable rates among patients with cardiovascular disease and diabetes) experience significant distress that may interfere with the delivery of effective cancer therapies (Zabora, Loscalzo, & Weber, 2003), it is highly unlikely that significant progress in health care reform can be achieved unless the need for the integration of mental health care is simultaneously addressed. …

Thirty-Year (1975 to 2005) Trends in the Incidence Rates, Clinical Features, Treatment Practices, and Short-Term Outcomes of Patients

Sparse data are available describing recent trends in the magnitude, clinical features, treatment practices, and outcomes of comparatively young adults hospitalized with acute myocardial infarction (AMI). The objectives of this population-based study were to describe 3 decade-long trends (1975 to 2005) in these end points in adults <55 years old who were hospitalized with an initial AMI. The study population consisted of 1,703 residents of the Worcester (Massachusetts) metropolitan area 25 to 54 years of age who were hospitalized with initial AMIs at all central Massachusetts medical centers during 15 annual periods from 1975 through 2005. Overall hospital incidence rate (per 100,000 residents) of initial AMI in our study population was 66 (95% confidence interval 63 to 69) and incidence rates of AMI decreased inconsistently over time. Patients hospitalized during the most recent study years were more likely to have important cardiovascular risk factors and co-morbidities present but were less likely to have developed heart failure during their index hospitalization. In-hospital and 30-day death rates decreased by approximately 50% (p = 0.04) during the years under study concomitant with increasing use of effective cardiac therapies. In conclusion, the results of this community-wide investigation provide insights into the magnitude, changing characteristics, and short-term outcomes of comparatively young patients hospitalized with a first AMI. Decreasing odds of developing or dying from an initial AMI during the 30 years under study likely reflect increased primary and secondary prevention and treatment efforts.

Disordered Gambling: Etiology, Trajectory, and Clinical Considerations

Gambling-related research has advanced rapidly during the past 20 years. As a result of expanding interest in pathological gambling (PG), stakeholders (e.g., clinicians, regulators, and policy makers) have a better understanding of excessive gambling, including its etiology (e.g., neurobiological/neurogenetic, psychological, and sociological factors) and trajectory (e.g., initiation, course, and adaptation to gambling exposure). In this article, we examine these advances in PG-related research and then consider some of the clinical implications of these advances. We consider criteria changes for PG recently proposed by the DSM-V Impulse Control Work Group for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). We also review how clinicians can more accurately and efficiently diagnose clients seeking help for gambling-related problems by utilizing brief screens. Finally, we consider the importance of future research that can identify behavioral markers for PG. We suggest that identifying these markers will allow clinicians to make earlier diagnoses, recommend targeted treatments, and advance secondary prevention efforts.