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1.  Urinary Lead Exposure and Breast Cancer Risk in a Population-Based Case-Control Study 
Lead is a toxic non-essential metal with widespread exposure starting in utero. Lead has been reclassified in 2004 by the International Agency for Research on Cancer Working Group from a “possible” to “probably” human carcinogen. Lead may be a facilitative or permissive carcinogen which means that lead may permit or augment the genotoxic effects of other exposures.
This population-based study in Wisconsin gathered survey data and home-collected urine specimens from 246 women, aged 20–69 years, with incident invasive breast cancer identified from the Wisconsin state registry and 254 age-matched control subjects from population lists from September 2004 to February 2005. We measured urinary lead concentrations by inductively-coupled plasma mass spectrometry, adjusted the values by specific gravity and conducted interviews by telephone to obtain information on known and suspected breast cancer risk factors.
Women in the highest quartile of specific gravity-adjusted lead level (≥1.10 μg/L) had twice the breast cancer risk of those in the lowest quartile (<0.42 μg/L; OR = 1.99, 95% CI = 1.1 to 3.6) after adjustment for established risk factors. Excluding women who were currently taking nonsteroidal aromatase inhibitors (n=52), we did not observe any increased breast cancer risk after adjustment for established risk factors.
Our population-based case-control study suggests that lead exposure, as determined by specific gravity-adjusted urinary lead concentrations, is not associated with a significant increased risk for breast cancer.
PMCID: PMC4317251  PMID: 18768499
breast cancer; lead exposure; urine samples
2.  Dietary Cadmium Intake and Risk of Breast, Endometrial and Ovarian Cancer in Danish Postmenopausal Women: A Prospective Cohort Study 
PLoS ONE  2014;9(6):e100815.
Cadmium is a human lung carcinogen and possesses estrogen-like activity. This combination of carcinogenic and estrogenic activity makes cadmium a contaminant of high concern for hormone-related cancers. Diet and smoking are the main sources of cadmium exposure. The aim of this study was to investigate the association between dietary cadmium intake and risk of breast, endometrial and ovarian cancer in Danish postmenopausal woman.
We estimated dietary cadmium intake in the Diet, Cancer and Health cohort at enrolment 1993-97. The estimates were based on food frequency questionnaires and cadmium contents in all foods. Among 23,815 postmenopausal women we identified 1390 breast, 192 endometrial, and 146 ovarian cancer cases from enrolment through December 31, 2010 using the Danish Cancer Registry. Cox regression was used to analyse the association between dietary cadmium intake and cancer risk.
Mean dietary cadmium intake was 14 µg/day. Cadmium was not associated with breast cancer, incidence rate ratio (IRR) = 0.99, 95% confidence interval (CI): 0.87–1.13 per 10 µg higher dietary cadmium intake/day; endometrial cancer, IRR = 1.08, 95% CI: 0.76–1.53; or ovarian cancer, IRR = 1.15, 95% CI: 0.78–1.70. We found a positive association between cadmium and endometrial cancer for the women with BMI<25 (IRR = 1.50, 95% CI: 0.94–2.39), whereas an inverse association was seen for the women with BMI≥25 (IRR = 0.69, 95% CI: 0.42–1.12); p value for interaction  = 0.02.
Our study does not indicate that our estimated dietary cadmium intake is associated with hormone-related cancers in women.
PMCID: PMC4071014  PMID: 24963789
3.  Nitrate-Nitrogen Levels in Rural Drinking Water: Is There an Association with Age-related Macular Degeneration? 
We examined the association of nitrate-nitrogen exposure from rural private drinking water and incidence of age-related macular degeneration (AMD). Participants of the Beaver Dam Eye Study living in rural areas within the 53916 zone improvement plan code but outside the city limits of Beaver Dam, Wisconsin (Beaver Dam Township) completed a questionnaire and ocular examination including standardized, graded fundus photographs at five examinations. Data from an environmental monitoring study with probabilistic-based agro-chemical sampling, including nitrate-nitrogen, of rural private drinking water were available. Incidence of early AMD was associated with elevated nitrate-nitrogen levels in rural private drinking water supply (10.0% for low, 19.2% for medium, and 26.1% for high nitrate-nitrogen level in the right eye). The odds ratios (ORs) were 1.77 (95% confidence interval [CI]: 1.12–2.78) for medium and 2.88 (95% CI: 1.59–5.23) for high nitrate-nitrogen level. Incidence of late AMD was increased for those with medium or high levels of nitrate-nitrogen compared to low levels (2.3% for low and 5.1% for the medium or high nitrate-nitrogen level, for the right eye). The OR for medium or high nitrate-nitrogen groups was 2.80 (95% CI: 1.07–7.31) compared to the low nitrate-nitrogen group.
PMCID: PMC4068731  PMID: 24007430
Disease; Epidemiology; Personal exposure; Population based studies
4.  Smoking Initiation, Tobacco Product Use, and Secondhand Smoke Exposure Among General Population and Sexual Minority Youth, Missouri, 2011–2012 
Research indicates disparities in risky health behaviors between heterosexual and sexual minority (referred to as LGBQ; also known as lesbian, gay, bisexual, queer, and questioning) youth. Limited data are available for tobacco-use–related behaviors beyond smoking status. We compared data on tobacco age of initiation, product use, and secondhand smoke exposure between general population and LGBQ youth.
Data for general population youth were from the statewide, representative 2011 Missouri Youth Tobacco Survey, and data for LGBQ youth were from the 2012 Out, Proud and Healthy survey (collected at Missouri Pride Festivals). Age-adjusted Cochran-Mantel-Haenszel tests were used to examine differences between general population (N = 1,547) and LGBQ (N = 410) youth, aged 14 to 18 years. Logistic regression models identified variables associated with current smoking.
The 2 groups differed significantly on many tobacco-use–related factors. General population youth initiated smoking at a younger age, and LGBQ youth did not catch up in smoking initiation until age 15 or 16. LGBQ youth (41.0%) soon surpassed general population youth (11.2%) in initiation and proportion of current smokers. LGBQ youth were more likely to use cigars/cigarillos, be poly-tobacco users, and be exposed to secondhand smoke (SHS) in a vehicle (for never smokers). Older age (odds ratio [OR] = 1.39, 95% confidence interval [95% CI] = 1.18–1.62), female sex (OR = 1.64, 95% CI = 1.13–2.37), LGBQ identity (OR = 3.86, 95% CI = 2.50–5.94), other tobacco product use (OR = 8.67, 95% CI = 6.01–12.51), and SHS exposure in a vehicle (OR = 5.97, 95% CI = 3.83–9.31) all significantly increased the odds of being a current smoker.
This study highlights a need for the collection of data on sexual orientation on youth tobacco surveys to address health disparities among LGBQ youth.
PMCID: PMC4082434  PMID: 24995655
5.  Potential advantage of student-run clinics for diversifying a medical school class 
The purpose of this study was to evaluate the influence of a student-run clinic on the diversification of a medical student class. We distributed a two-page, 20-item, paper survey to students of the University of Missouri School of Medicine (MU SOM) class of 2015 in July of 2011. The survey gathered information on general demographics, opinions on the importance of medical education opportunities, and opinions on the importance of medical school characteristics in applying to and attending MU SOM. A total of 104 students responded to the survey. A majority of the students identified the MedZou Community Health Clinic, a student-run, free health clinic affiliated with MU SOM, and simulated-patient encounters as important educational experiences (81% and 94%, respectively). More than half of the self-identified "non-white" students reported MedZou as an important factor in their choice to apply to (60%; 95% confidence interval [CI], 32 to 88) and attend (71%; 95% CI, 44 to 98) MU SOM, over half of the females reported MedZou as important in their choice to apply (59%; 95% CI, 43 to 76) and attend (57%; 95% CI, 40 to 74), and over half of non-Missouri residents reported MedZou as important in their choice to apply (64%; 95% CI, 36 to 93) and attend (71%; 95% CI, 44 to 98). According to the above results, it can be said that students clearly value both MedZou and simulated-patient encounters as important educational experiences. Women, minorities, and non-Missouri residents value MedZou more highly than their peers who are First Year Medical Students who are Missouri residents, suggesting that MedZou may provide a promising opportunity to advance diversity within MU SOM. These results highlight the need for additional research to further explore MedZou's potential to enhance the recruitment of a diverse medical student class.
PMCID: PMC3362695  PMID: 22679531
Medical student; Clinic; Evaluation; Medical education
6.  The Survey of the Health of Wisconsin (SHOW), a novel infrastructure for population health research: rationale and methods 
BMC Public Health  2010;10:785.
Evidence-based public health requires the existence of reliable information systems for priority setting and evaluation of interventions. Existing data systems in the United States are either too crude (e.g., vital statistics), rely on administrative data (e.g., Medicare) or, because of their national scope (e.g., NHANES), lack the discriminatory power to assess specific needs and to evaluate community health activities at the state and local level. This manuscript describes the rationale and methods of the Survey of the Health of Wisconsin (SHOW), a novel infrastructure for population health research.
The program consists of a series of independent annual surveys gathering health-related data on representative samples of state residents and communities. Two-stage cluster sampling is used to select households and recruit approximately 800-1,000 adult participants (21-74 years old) each year. Recruitment and initial interviews are done at the household; additional interviews and physical exams are conducted at permanent or mobile examination centers. Individual survey data include physical, mental, and oral health history, health literacy, demographics, behavioral, lifestyle, occupational, and household characteristics as well as health care access and utilization. The physical exam includes blood pressure, anthropometry, bioimpedance, spirometry, urine collection and blood draws. Serum, plasma, and buffy coats (for DNA extraction) are stored in a biorepository for future studies. Every household is geocoded for linkage with existing contextual data including community level measures of the social and physical environment; local neighborhood characteristics are also recorded using an audit tool. Participants are re-contacted bi-annually by phone for health history updates.
SHOW generates data to assess health disparities across state communities as well as trends on prevalence of health outcomes and determinants. SHOW also serves as a platform for ancillary epidemiologic studies and for studies to evaluate the effect of community-specific interventions. It addresses key gaps in our current data resources and increases capacity for etiologic, applied and translational population health research. It is hoped that this program will serve as a model to better support evidence-based public health, facilitate intervention evaluation research, and ultimately help improve health throughout the state and nation.
PMCID: PMC3022857  PMID: 21182792
7.  Measuring the attitudes of healthcare providers in Dane County toward adolescent immunization with HPV vaccine 
Evaluate regional healthcare practitioners’ views of human papillomavirus (HPV) vaccination recommendations for adolescent patients through a mailed survey.
A 16-question self-administered questionnaire was mailed to 518 physicians, physician assistants, and nurse practitioners in Dane County, WI working in family medicine, pediatrics, or gynecology in September 2006. The survey addressed providers’ willingness to recommend the HPV vaccine, as well as targeted patient populations to recommend the vaccine to in their own practices and justifications provided to patients regarding the benefits of HPV vaccination.
We had a 39% response rate. The majority (95%) of providers were willing to recommend the HPV vaccine to their adolescent patients. Most practitioners (67%) are planning to recommend the vaccine to their female patients only and are most comfortable vaccinating patients >10 years of age. Healthcare providers are looking to their own health professional organizations for vaccination recommendations.
Healthcare providers in family medicine, pediatrics, and gynecology in Dane County, WI have positive attitudes regarding HPV vaccine recommendation in their adolescent patients.
PMCID: PMC2937262  PMID: 19753828
8.  Smoking, Barriers to Quitting, and Smoking-Related Knowledge, Attitudes, and Patient Practices Among Male Physicians in China 
Preventing Chronic Disease  2008;6(1):A06.
Successful interventions to reduce the high rate of smoking among male physicians in China might contribute to reduction in tobacco use in the country overall. Better characterization of smoking, barriers to quitting, and smoking-related knowledge, attitudes, and patient practices in this physician population will help plan such interventions and provide baseline data to evaluate their effectiveness.
A self-administered survey of smoking-related knowledge, attitudes, behaviors, and patient practices was conducted among health care professionals in 2 large teaching hospitals in China.
Of 103 male physicians, those who smoked (n = 51) had a more limited knowledge of smoking-related disease and were less likely to advise patients to quit smoking compared with nonsmoking physicians (n = 52). More than one-fourth (29%) of nonsmoking physicians accepted gift cigarettes, and these physicians were less likely to ask their patients about their smoking status than those who did not accept gift cigarettes. Seventy-five percent of smokers reported that their hospitals did not help them quit, and only 19% reported receiving training in how to help their patients quit.
High rates of smoking, gifting of cigarettes, limited support for physician quitting, and limited training on cessation approaches may compromise the ability of male physicians in China to effectively treat their patients who smoke.
PMCID: PMC2644602  PMID: 19080012
9.  Environmental Exposures and Child Health: What we Might Learn in the 21st Century from the National Children’s Study? 
PMCID: PMC3091343  PMID: 21572836
child health; longitudinal study; environmental exposures; epidemiology
10.  Trends in kidney transplantation rates and disparities. 
OBJECTIVE: To examine the likelihood of transplantation and trends over time among persons with end-stage renal disease (ESRD) in Wisconsin. METHODS: We examined the influence of patient- and community-level characteristics on the rate of kidney transplantation in Wisconsin among 22,387 patients diagnosed with ESRD between January 1, 1982 and October 30, 2005. We grouped patients by the year of ESRD onset in order to model the change in transplantation rates over time. RESULTS: After multivariate adjustment, all other racial groups were significantly less likely to be transplanted compared with whites, and the racial disparity increased over calendar time. Older patients were less likely to be transplanted in all periods. Higher community income and education level and a greater distance from patients' residence to the nearest dialysis center significantly increased the likelihood of transplantation. Males also had a significantly higher rate of transplantation than females. CONCLUSION: These results demonstrate a growing disparity in transplantation rates by demographic characteristics and a consistent disparity in transplantation by socioeconomic characteristics. Future studies should focus on identifying specific barriers to transplantation among different subpopulations in order to target effective interventions.
PMCID: PMC2574300  PMID: 17722672
11.  Identifying Geographic Disparities in the Early Detection of Breast Cancer Using a Geographic Information System 
Preventing Chronic Disease  2005;3(1):A10.
Identifying communities with lower rates of mammography screening is a critical step to providing targeted screening programs; however, population-based data necessary for identifying these geographic areas are limited. This study presents methods to identify geographic disparities in the early detection of breast cancer.
Data for all women residing in Dane County, Wisconsin, at the time of their breast cancer diagnosis from 1981 through 2000 (N = 4769) were obtained from the Wisconsin Cancer Reporting System (Wisconsin's tumor registry) by ZIP code of residence. Hierarchical logistic regression models for disease mapping were used to identify geographic differences in the early detection of breast cancer.
The percentage of breast cancer cases diagnosed in situ (excluding lobular carcinoma in situ) increased from 1.3% in 1981 to 11.9% in 2000. This increase, reflecting increasing mammography use, occurred sooner in Dane County than in Wisconsin as a whole. From 1981 through 1985, the proportion of breast cancer diagnosed in situ in Dane county was universally low (2%–3%). From 1986 through 1990, urban and suburban ZIP codes had significantly higher rates (10%) compared with rural ZIP codes (5%). From 1991 through 1995, mammography screening had increased in rural ZIP codes (7% of breast cancer diagnosed in situ). From 1996 through 2000, mammography use was fairly homogeneous across the entire county (13%–14% of breast cancer diagnosed in situ).
The percentage of breast cancer cases diagnosed in situ increased in the state and in all areas of Dane County from 1981 through 2000. Visual display of the geographic differences in the early detection of breast cancer demonstrates the diffusion of mammography use across the county over the 20-year period.
PMCID: PMC1500964  PMID: 16356363
12.  Potential exposure to PCBs, DDT, and PBDEs from sport-caught fish consumption in relation to breast cancer risk in Wisconsin. 
Environmental Health Perspectives  2004;112(2):156-162.
In Wisconsin, consumption of Great Lakes fish is an important source of exposure to polychlorinated biphenyls (PCBs), dichlorodiphenyltrichloroethane (DDT), polybrominated diphenyl ethers (PBDEs), and other halogenated hydrocarbons, all of which may act as potential risk factors for breast cancer. We examined the association between sport-caught fish consumption and breast cancer incidence as part of an ongoing population-based case-control study. We identified breast cancer cases 20-69 years of age who were diagnosed in 1998-2000 (n = 1,481) from the Wisconsin Cancer Reporting System. Female controls of similar age were randomly selected from population lists (n = 1,301). Information about all sport-caught (Great Lakes and other lakes) fish consumption and breast cancer risk factors was obtained through telephone interviews. After adjustment for known and suspected risk factors, the relative risk of breast cancer for women who had recently consumed sport-caught fish was similar to women who had never eaten sport-caught fish [relative risk (RR) = 1.00; 95% confidence interval (CI), 0.86-1.17]. Frequency of consumption and location of sport-caught fish were not associated with an increased risk of breast cancer. Recent consumption of Great Lakes fish was not associated with postmenopausal breast cancer (RR = 0.78; 95% CI, 0.57-1.07), whereas risk associated with premenopausal breast cancer was elevated (RR = 1.70; 95% CI, 1.16-2.50). In this study we found no overall association between recent consumption of sport-caught fish and breast cancer, although there may be an increased breast cancer risk for subgroups of women who are young and/or premenopausal.
PMCID: PMC1241824  PMID: 14754569

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