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1.  The Influence of Comorbidities on Overall Survival Among Older Women Diagnosed With Breast Cancer 
Background
Previous studies have shown that summary measures of comorbid conditions are associated with decreased overall survival in breast cancer patients. However, less is known about associations between specific comorbid conditions on the survival of breast cancer patients.
Methods
The Surveillance, Epidemiology, and End Results–Medicare database was used to identify primary breast cancers diagnosed from 1992 to 2000 among women aged 66 years or older. Inpatient, outpatient, and physician visits within the Medicare system were searched to determine the presence of 13 comorbid conditions present at the time of diagnosis. Overall survival was estimated using age-specific Kaplan–Meier curves, and mortality was estimated using Cox proportional hazards models adjusted for age, race and/or ethnicity, tumor stage, cancer prognostic markers, and treatment. All statistical tests were two-sided.
Results
The study population included 64 034 patients with breast cancer diagnosed at a median age of 75 years. None of the selected comorbid conditions were identified in 37 306 (58%) of the 64 034 patients in the study population. Each of the 13 comorbid conditions examined was associated with decreased overall survival and increased mortality (from prior myocardial infarction, adjusted hazard ratio [HR] of death = 1.11, 95% CI = 1.03 to 1.19, P = .006; to liver disease, adjusted HR of death = 2.32, 95% CI = 1.97 to 2.73, P < .001). When patients of age 66–74 years were stratified by stage and individual comorbidity status, patients with each comorbid condition and a stage I tumor had similar or poorer overall survival compared with patients who had no comorbid conditions and stage II tumors.
Conclusions
In a US population of older breast cancer patients, 13 individual comorbid conditions were associated with decreased overall survival and increased mortality.
doi:10.1093/jnci/djr188
PMCID: PMC3139585  PMID: 21719777
2.  Environmental Predictors of Human West Nile Virus Infections, Colorado 
Emerging Infectious Diseases  2007;13(11):1788-1790.
To determine whether environmental surveillance of West Nile virus–positive dead birds, mosquito pools, equines, and sentinel chickens helped predict human cases in metropolitan Denver, Colorado, during 2003, we analyzed human surveillance data and environmental data. Birds successfully predicted the highest proportion of human cases, followed by mosquito pools, and equines.
doi:10.3201/eid1311.070506
PMCID: PMC3375805  PMID: 18217573
West Nile virus; epidemic; predictors; space-time; dispatch
3.  Follow-up of 2003 Human West Nile Virus Infections, Denver, Colorado 
Emerging Infectious Diseases  2006;12(7):1129-1131.
Tri-County Health Department and Boulder County Public Health conducted a follow-up study of all nonfatal West Nile virus (WNV) cases reported during 2003 in 4 metropolitan Denver, Colorado, counties. Self-reported patient information was obtained ≈6 months after onset. A total of 656 (81.2%) eligible WNV patients are included in this study.
doi:10.3201/eid1207.051399
PMCID: PMC3291048  PMID: 16836833
West Nile virus; epidemic; meningitis; encephalitis; fever
4.  Use of Hospital Discharge Data to Evaluate Notifiable Disease Reporting to Colorado's Electronic Disease Reporting System 
Public Health Reports  2011;126(1):100-106.
SYNOPSIS
Objective
Notifiable disease surveillance systems are critical for communicable disease control, and accurate and timely reporting of hospitalized patients who represent the most severe cases is important. A local health department in metropolitan Denver used inpatient hospital discharge (IHD) data to evaluate the sensitivity, timeliness, and data quality of reporting eight notifiable diseases to the Colorado Electronic Disease Reporting System (CEDRS).
Methods
Using IHD data, we detected hospitalized patients admitted from 2003 through 2005 with a discharge diagnosis associated with one of eight notifiable diseases. Initially, we compared all cases identified through IHD diagnoses fields with cases reported to CEDRS. Second, we chose four diseases and conducted medical record review to confirm the IHD diagnoses before comparison with CEDRS cases.
Results
Relying on IHD diagnoses only, shigellosis, salmonellosis, and Neisseria meningitidis invasive disease had high sensitivity (≥90%) and timeliness (≥75%); legionellosis, pertussis, and West Nile virus infection were intermediate; and hepatitis A and Haemophilus influenzae (H. influenzae) invasive disease had low sensitivity (≥90% and timeliness to ≥80% for H. influenza invasive disease, legionellosis, and pertussis; however, hepatitis A retained suboptimal sensitivity (67%) and timeliness (25%).
Conclusions
Hospital discharge data are useful for evaluating notifiable disease surveillance systems. Limitations encountered by using discharge diagnoses alone can be overcome by conducting medical record review. Public health agencies should conduct periodic surveillance system evaluations among hospitalized patients and reinforce notifiable disease reporting among the people responsible for this activity.
PMCID: PMC3001805  PMID: 21337935
5.  Cardiovascular disease competes with breast cancer as the leading cause of death for older females diagnosed with breast cancer: a retrospective cohort study 
Introduction
Many women who survive breast cancer die of causes unrelated to their cancer diagnosis. This study was undertaken to assess factors that are related to breast cancer mortality versus mortality from other causes and to describe the leading causes of death among older women diagnosed with breast cancer.
Methods
Women diagnosed with breast cancer at age 66 or older between 1992 and 2000 were identified in the Surveillance, Epidemiology and End Results-Medicare linked database and followed through the end of 2005.
Results
A total of 63,566 women diagnosed with breast cancer met the inclusion criteria and were followed for a median of approximately nine years. Almost one-half (48.7%) were alive at the end of follow-up. Ages and comorbidities at the time of diagnosis had the largest effects on mortality from other causes, while tumor stage, tumor grade, estrogen receptor status, age and comorbidities at the time of diagnosis all had effects on breast cancer-specific mortality. Fully adjusted relative hazards of the effects of comorbidities on breast cancer-specific mortality were 1.24 (95% confidence interval (95% CI) 1.13 to 1.26) for cardiovascular disease, 1.13 (95% CI 1.13 to 1.26) for previous cancer, 1.13 (95% CI 1.05 to 1.22) for chronic obstructive pulmonary disease and 1.10 (95% CI 1.03 to 1.16) for diabetes. Among the total study population, cardiovascular disease was the primary cause of death in the study population (15.9% (95% CI 15.6 to 16.2)), followed closely by breast cancer (15.1% (95% CI 14.8 to 15.4)).
Conclusions
Comorbid conditions contribute importantly to both total mortality and breast cancer-specific mortality among breast cancer survivors. Attention to reducing the risk of cardiovascular disease should be a priority for the long-term care of women following the diagnosis and treatment of breast cancer.
doi:10.1186/bcr2901
PMCID: PMC3218953  PMID: 21689398
6.  Assessment of Missing Immunizations and Immunization-Related Barriers Among WIC Populations at the Local Level 
Public Health Reports  2007;122(5):602-606.
SYNOPSIS
Objective.
Low childhood immunization rates have been a challenge in Colorado, an issue that was exacerbated by a diphtheria-tetanus-acellular pertussis (DTaP) vaccine shortage that began in 2001. To combat this shortage, the locally based Tri-County Health Department conducted a study to assess immunization-related barriers among children in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), a population at risk for undervaccination.
Methods.
This study assessed characteristics and perceptions of WIC mothers in conjunction with their children's immunization status in four clinics.
Results.
Results indicated poor immunization rates, which improved with assessment and referral. The uninsured were at higher risk for undervaccination. DTaP was the most commonly missing vaccine, and discrepancies existed between the children's perceived and actual immunization status, particularly regarding DTaP. Targeted interventions were initiated as a result of this study.
Conclusion.
Local health departments should target immunization-related interventions by assessing their own WIC populations to identify unique vaccine-related deficiencies, misperceptions, and high-risk subpopulations.
PMCID: PMC1936967  PMID: 17877307
7.  Internet- versus Telephone-based Local Outbreak Investigations 
Emerging Infectious Diseases  2008;14(6):975-977.
We compared 5 locally conducted, Internet-based outbreak investigations with 5 telephone-based investigations. Internet-based surveys required less completion time, and response rates were similar for both investigation methods. Participant satisfaction with Internet-based surveys was high.
doi:10.3201/eid1406.071513
PMCID: PMC2600312  PMID: 18507919
Internet; disease outbreaks; local government; dispatch

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