Importance Disability persists after hip fracture in older persons. Current rehabilitation may not be sufficient to restore ability to walk in the community. Objective To compare a multicomponent home-based physical therapy intervention (training) with an active control on ability to walk in the community. Design, Setting, and Participants Parallel, 2-group randomized clinical trial conducted at 3 US clinical centers (Arcadia University, University of Connecticut Health Center, and University of Maryland, Baltimore). Randomization began on September 16, 2013, and ended on June 20, 2017; follow-up ended on October 17, 2017. Patients aged 60 years and older were enrolled after nonpathologic, minimal trauma hip fracture, if they were living in the community and walking without human assistance before the fracture, were assessed within 26 weeks of hospitalization, and were not able to walk during daily activities at the time of enrollment. A total of 210 participants were randomized and reassessed 16 and 40 weeks later. Interventions The training intervention (active treatment) (n = 105) included aerobic, strength, balance, and functional training. The active control group (n = 105) received transcutaneous electrical nerve stimulation and active range-of-motion exercises. Both groups received 2 to 3 home visits from a physical therapist weekly for 16 weeks; nutritional counseling; and daily vitamin D (2000 IU), calcium (600 mg), and multivitamins. Main Outcomes and Measures The primary outcome (community ambulation) was defined as walking 300 m or more in 6 minutes at 16 weeks after randomization. The study was designed to test a 1-sided hypothesis of superiority of training compared with active control. Results Among 210 randomized participants (mean age, 80.8 years; 161 women [76.7%]), 197 (93.8%) completed the trial (187 [89.0%] by completing the 6-minute walk test at 16 weeks and 10 [4.8%] by adjudication of the primary outcome). Among these, 22 of 96 training participants (22.9%) and 18 of 101 active control participants (17.8%) (difference, 5.1% [1-sided 97.5% CI, -∞ to 16.3%]; 1-sided P = .19) became community ambulators. Seventeen training participants (16.2%) and 15 control participants (14.3%) had 1 or more reportable adverse events during the intervention period. The most common reportable adverse events reported were falls (training: 6 [5.7%], control: 4 [3.8%]), femur/hip fracture (2 in each group), pneumonia (training: 2, control: 0), urinary tract infection (training: 2, control: 0), dehydration (training: 0, control: 2), and dyspnea (training: 0, control: 2). Conclusions and Relevance Among older adults with a hip fracture, a multicomponent home-based physical therapy intervention compared with an active control that included transcutaneous electrical nerve stimulation and active range-of-motion exercises did not result in a statistically significant improvement in the ability to walk 300 m or more in 6 minutes after 16 weeks. Trial Registration ClinicalTrials.gov Identifier: NCT01783704.

Objective: To estimate the association between age at antiretroviral therapy (ART) initiation and immunologic response over time by stratum of baseline CD4+ cell counts. Design: Retrospective cohort analysis of data pooled from four President's Emergency Plan for AIDS Relief funded countries in Sub-Saharan Africa. Methods: General linear models were used to estimate the mean CD4+ cell count by age group within groups defined by baseline CD4+ cell count. Kaplan–Meier methods were used to estimate time to achieving a CD4+ cell count of at least 500 cells/&mgr;l by age group and stratified by baseline CD4+ cell count. Results: A total of 126 672 previously treatment-naive patients provided 466 482 repeated CD4+ cell count measurements over 4 years of ART. The median baseline CD4+ cell count for all age groups was less than 200 cells/&mgr;l. Patients aged 30–39, 40–49, 50–59, and 60 and older at ART initiation had significantly lower mean CD4+ cell counts in most strata and at most time points than those 20–29 years old. Compared with those 20–29, all older age groups had a significantly longer time to, and lower rate of, achieving a CD4+ cell count of 500 cells. Conclusion: Age is associated with the magnitude of CD4+ cell gain and the amount of time it takes to gain cells at different levels of baseline CD4+ cell count. The delay in achieving a robust immune response could have significant implications for the risk of tuberculosis reactivation as well as comorbidities associated with age in the management of older HIV-infected patients.

Objective: To determine factors associated with increased risk of developing cardiovascular disease in a high-risk patient population. Design: Cross-sectional analysis of a retrospective cohort study. Methods: One-hundred patients at an inner city HIV clinic in 2008 were reviewed. The atherosclerotic vascular disease risk score was calculated using the Pooled Cohort Equation. Chi-square test was performed to identify associations of potential risk factors with elevated atherosclerotic vascular disease risk. Results: Eighty-one participants were included in the final analysis. In total, 95.1% were African American, and 38.3% were women. The median atherosclerotic vascular disease risk score was 8.8% and 8.1% in 2008 and 2012, respectively. The medical co-morbidities associated with increased atherosclerotic vascular disease risk were hepatitis C infection (X-2=3.93; p value=0.048), elevated triglycerides levels (X-2=4.0; p value=0.046), and low albumin (X-2=4.65; p value=0.031). There were a higher number of women with known atherosclerotic vascular disease despite lower median atherosclerotic vascular disease risk score compared to men. Conclusion: An elevated risk of developing cardiovascular disease persists in high-risk demographic groups of the HIV epidemic even in the current HIV era. There is an unexplained gender disparity and some non-traditional risk factors not accounted for in the Pooled Cohort Equation may be contributing to the excess cardiovascular disease risk observed among HIV-infected patients.

INTRODUCTION:After a hip fracture in older persons, significant disability often remains; dependency in functional activities commonly persists beyond 3 months after surgery. Endurance, dynamic balance, quadriceps strength, and function are compromised, and contribute to an inability to walk independently in the community. In the United States, people aged 65 years and older are eligible to receive Medicare funding for physiotherapy for a limited time after a hip fracture. A goal of outpatient physiotherapy is independent and safe household ambulation 2 to 3 months after surgery. Current Medicare-reimbursed post-hip-fracture rehabilitation fails to return many patients to pre-fracture levels of function. Interventions delivered in the home after usual hip fracture physiotherapy has ended could promote higher levels of functional independence in these frail and older adult patients.PRIMARY OBJECTIVE:To evaluate the effect of a specific multi-component physiotherapy intervention (PUSH), compared with a non-specific multi-component control physiotherapy intervention (PULSE), on the ability to ambulate independently in the community 16 weeks after randomisation.DESIGN:Parallel, two-group randomised multicentre trial of 210 older adults with a hip fracture assessed at baseline and 16 weeks after randomisation, and at 40 weeks after randomisation for a subset of approximately 150 participants.PARTICIPANTS AND SETTING:A total of 210 hip fracture patients are being enrolled at three clinical sites and randomised up to 26 weeks after admission. Study inclusion criteria are: closed, non-pathologic, minimal trauma hip fracture with surgical fixation; aged ≥ 60 years at the time of randomisation; community residing at the time of fracture and randomisation; ambulating without human assistance 2 months prior to fracture; and being unable to walk at least 300 m in 6minutes at baseline. Participants are ineligible if the interventions are deemed to be unsafe or unfeasible, or if the participant has low potential to benefit from the interventions.INTERVENTIONS:Participants are randomly assigned to one of two multi-component treatment groups: PUSH or PULSE. PUSH is based on aerobic conditioning, specificity of training, and muscle overload, while PULSE includes transcutaneous electrical nerve stimulation, flexibility activities, and active range of motion exercises. Participants in both groups receive 32 visits in their place of residence from a study physiotherapist (two visits per week on non-consecutive days for 16 weeks). The physiotherapists' adherence to the treatment protocol, and the participants' receipt of the prescribed activities are assessed. Participants also receive counselling from a registered dietician and vitamin D, calcium and multivitamin supplements during the 16-week intervention period.MEASUREMENTS:The primary outcome (community ambulation) is the ability to walk 300 m or more in 6minutes, as assessed by the 6-minute walk test, at 16 weeks after randomisation. Other measures at 16 and 40 weeks include cost-effectiveness, endurance, dynamic balance, walking speed, quadriceps strength, lower extremity function, activities of daily living, balance confidence, quality of life, physical activity, depressive symptoms, increase of ≥ 50 m in distance walked in 6minutes, cognitive status, and nutritional status.ANALYSIS:Analyses for all aims will be performed according to the intention-to-treat paradigm. Except for testing of the primary hypothesis, all statistical tests will be two-sided and not adjusted for multiple comparisons. The test of the primary hypothesis (comparing groups on the proportion who are community ambulators at 16 weeks after randomisation) will be based on a one-sided 0.025-level hypothesis test using a procedure consisting of four interim analyses and one final analysis with critical values chosen by a Hwang-Shih-Decani alpha-spending function. Analyses will be performed to test group differences on other outcome measures and to examine the differential impact of PUSH relative to PULSE in subgroups defined by pre-selected participant characteristics. Generalised estimating equations will be used to explore possible delayed or sustained effects in a subset of participants by comparing the difference between PUSH and PULSE in the proportion of community ambulators at 16 weeks with the difference at 40 weeks.DISCUSSION:This multicentre randomised study will be the first to test whether a home-based multi-component physiotherapy intervention targeting specific precursors of community ambulation (PUSH) is more likely to lead to community ambulation than a home-based non-specific multi-component physiotherapy intervention (PULSE) in older adults after hip fracture. The study will also estimate the potential economic value of the interventions.

ObjectiveTo estimate the dynamic causal effects of depressive symptoms on osteoarthritis (OA) knee pain.MethodsMarginal structural models were used to examine dynamic associations between depressive symptoms and pain over 48 months among older adults (n = 2,287) with radiographic knee OA (Kellgren/Lawrence grade 2 or 3) in the Osteoarthritis Initiative. Depressive symptoms at each annual visit were assessed (threshold ≥16) using the Center for Epidemiologic Studies Depression Scale. OA knee pain was measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale, rescaled to range from 0 to 100.ResultsDepressive symptoms at each visit were generally not associated with greater OA knee pain at subsequent time points. Causal mean differences in WOMAC pain score comparing depressed to nondepressed patients ranged from 1.78 (95% confidence interval [95% CI] −0.73, 4.30) to 2.58 (95% CI 0.23, 4.93) within the first and fourth years, and the depressive symptoms by time interaction were not statistically significant (P = 0.94). However, there was a statistically significant dose‐response relationship between the persistence of depressive symptoms and OA knee pain severity (P = 0.002). Causal mean differences in WOMAC pain score comparing depressed to nondepressed patients were 0.89 (95% CI −0.17, 1.96) for 1 visit with depressive symptoms, 2.35 (95% CI 0.64, 4.06) for 2 visits with depressive symptoms, and 3.57 (95% CI 0.43, 6.71) for 3 visits with depressive symptoms.ConclusionThe causal effect of depressive symptoms on OA knee pain does not change over time, but pain severity significantly increases with the persistence of depressed mood.

Objective:Following traumatic brain injury (TBI), older adults are at an increased risk of hemorrhagic and thromboembolic events, but it is unclear whether the increased risk continues after hospital discharge. We estimated incidence rates of hemorrhagic and ischemic stroke following hospital discharge for TBI among adults 65 years or older and compared them with pre-TBI rates. Participants:A total of 16 936 Medicare beneficiaries 65 years or older with a diagnosis of TBI in any position on an inpatient claim between June 1, 2006, and December 31, 2009, who survived to hospital discharge. Design:Retrospective analysis of a random 5% sample of Medicare claims data. Main Measures:Hemorrhagic stroke was defined as ICD-9 (International Classification of Diseases, Ninth Revision) codes 430.xx-432.xx. Ischemic stroke was defined as ICD-9 codes 433.xx-435.xx, 437.0x, and 437.1x. Results:There was a 6-fold increase in the rate of hemorrhagic stroke following TBI compared with the pre-TBI period (adjusted rate ratio, 6.5; 95% confidence interval, 5.3-7.8), controlling for age and sex. A smaller increase in the rate of ischemic stroke was observed (adjusted rate ratio, 1.3; 95% CI, 1.2-1.4). Conclusion:Future studies should investigate causes of increased stroke risk post-TBI as well as effective treatment options to reduce stroke risk and improve outcomes post-TBI among older adults.

This study examined warfarin usage for elderly Medicare beneficiaries with atrial fibrillation (AF) who suffered traumatic brain injury (TBI), hip fracture, or torso injuries. Using the 5% Chronic Condition Data Warehouse administrative claims data, this study included fee-for-service Medicare beneficiaries who had a single injury hospitalization (TBI, hip fracture, or major torso injury) between 1/1/2007 and 12/31/2009, with complete Medicare Parts A, B (no Medicare Advantage), and D coverage 6 months before injury, and who were aged 66 years or older and diagnosed with AF at least 1 year before injury. About 45% of the AF patients were using warfarin before TBI or torso injury, and 35% before hip fracture. After injury, there was a dramatic and persistent decrease in warfarin use in TBI and torso injury groups (30% for TBI and 37% for torso injury at 12 months after injury). Warfarin usage in hip fracture patients also dropped after injury but returned to pre-injury level within 4 months. TBI and torso injury lead to significant decreases in warfarin usage in elderly AF patients. Further research is needed to understand reasons for the pattern and to develop evidence-based management strategies in the post-acute setting.

ObjectivesTo identify care‐related factors associated with hospital‐acquired pressure ulcers (HAPUs).DesignProspective cohort study.SettingNine hospitals in Baltimore Hip Studies network.ParticipantsSix hundred fifty‐eight individuals aged 65 and older who underwent surgery for hip fracture.MeasurementsSkin examinations at baseline and on alternating days until hospital discharge. Participants were deemed to have a HAPU if they developed one or more new Stage 2 or higher pressure ulcers (PUs) during the hospital stay.ResultsLonger emergency department stays were associated with lower HAPU incidence (>4–6 hours: adjusted incidence rate ratio (aIRR) = 0.68, 95% confidence interval (CI) = 0.48–0.96; >6 hours: aIRR = 0.68, 95% CI = 0.46–0.99, both vs ≤ 4 hours). Participants with 24 hours or longer between admission and surgery had a higher postsurgery HAPU rate than those with less than 24 hours (aIRR = 1.62, 95% CI = 1.24–2.11). Surgery with general anesthesia had a lower postsurgery HAPU rate than surgery with other types of anesthesia (aIRR = 0.66, 95% CI = 0.49–0.88). There was no significant association between HAPU incidence and timing of transport to the hospital, type of transport to the hospital, or surgery duration.ConclusionMost of the factors hypothesized to be associated with higher PU incidence were associated with lower incidence or were not significantly associated, suggesting that HAPU development may not be as sensitive to care‐related factors as commonly believed. Rigorous studies of innovative preventive interventions are needed to inform policy and practice.

Parkinson's disease (PD) is a common, treatable movement disorder that often remains undiagnosed despite clinically manifest symptoms. Screening for parkinsonism could lead to improved detection and earlier treatment, and facilitate research studies of PD prevalence. In order to determine the feasibility of screening, this study evaluated the validity of previously developed screening questionnaires. We systematically searched online databases PubMed and EMBASE for English-language studies published between 1980 and 2009. In each database a "Parkinson(s) disease" or "parkinsonism" term was combined with a screening term ("screening instrument," "screening questionnaire," "screen" or "prevalence survey") and a validity term ("validation," "sensitivity" and "specificity"). Included studies reported the psychometric properties of at least one self-report questionnaire for parkinsonism. Twenty-seven studies met the inclusion criteria. From these studies, 9 screening questionnaires were identified. Sensitivity and specificity estimates varied widely. Sensitivity estimates were as high as 100% when questionnaires were tested among previously diagnosed PD patients and included a high number of parkinsonism specific items, but were as low as 48% when tested among early cases in a community-based sample. Specificity estimates were lower, ranging from 22 to 100%. An older sample, presence of multiple co-morbid conditions and lower literacy led to lower specificity estimates. Higher specificity estimates were seen when the screening questionnaires were administered by a physician. Screening questionnaires can detect symptomatic parkinsonism. However, the performance of these questionnaires varied based on the individual items, study sample, and method of administration. The performance of screening questionnaires in the detection of early or mild parkinsonism was modest.

OBJECTIVES: To evaluate the association between pressure-redistributing support surface (PRSS) use and incident pressure ulcers in older adults with hip fracture.DESIGN: Secondary analysis of data from prospective cohort with assessments performed as soon as possible after hospital admission and on alternating days for 21 days.SETTING: Nine hospitals in the Baltimore Hip Studies network and 105 postacute facilities to which participants were discharged.PARTICIPANTS: Six hundred fifty-eight people aged 65 and older who underwent surgery for hip fracture.MEASUREMENTS: Full-body examination for pressure ulcers; bedbound status; and PRSS use, recorded as none, powered (alternating pressure mattresses, low-air-loss mattresses, and alternating pressure overlays), or nonpowered (high-density foam, static air, or gel-filled mattresses or pressure-redistributing overlays except for alternating pressure overlays).RESULTS: Incident pressure ulcers (IPUs), Stage 2 or higher, were observed at 4.2% (195/4,638) of visits after no PRSS use, 4.5% (28/623) of visits after powered PRSS use, and 3.6% (54/1,496) of visits after nonpowered PRSS use. The rate of IPU per person-day of follow-up did not differ significantly between participants using powered PRSSs and those not using PRSSs. The rate also did not differ significantly between participants using nonpowered PRSSs and those not using PRSSs, except in the subset of bedbound participants (incidence rate ratio = 0.3, 95% confidence interval = 0.1-0.7).CONCLUSION: PRSS use was not associated with a lower IPU rate. Clinical guidelines may need revision for the limited effect of PRSS use, and it may be appropriate to target PRSS use to bedbound patients at risk of pressure ulcers. J Am Geriatr Soc 59:1052-1059, 2011.

PURPOSE To estimate the frequency of use of pressure-redistributing support surfaces (PRSS) among hip fracture patients and to determine whether higher pressure ulcer risk is associated with greater PRSS use. DESIGN AND METHODS Patients (n = 658) aged >or=65 years who had surgery for hip fracture were examined by research nurses at baseline and on alternating days for 21 days. Information on PRSS use and pressure ulcer risk factors was recorded at each assessment visit. Other information was obtained by interview and chart review. RESULTS A PRSS was observed at 36.4% of the 5,940 study visits. The odds of PRSS use were lower in the rehabilitation setting (adjusted odds ratio [OR] 0.4, 95% confidence interval [CI] 0.3-0.6), in the nursing home (adjusted OR 0.2, 95% CI 0.1-0.3), and during readmission to the acute setting (adjusted OR 0.6, 95% CI 0.4-0.9) than in the initial acute setting. There was wide variation in frequency of PRSS use by admission hospital, even after adjusting for pressure ulcer risk factors. The relationships between PRSS use and pressure ulcer risk factors were not strong. IMPLICATIONS In this study of hip fracture patients, adherence to guidelines for PRSS use was low and was based more on facility-related factors than on patient risk. There is an urgent need for health care providers to improve strategies for the prevention of pressure ulcers in high-risk patients.

ABSTRACTFrequent manual repositioning is an established part of pressure ulcer prevention, but there is little evidence for its effectiveness. This study examined the association between repositioning and pressure ulcer incidence among bed‐bound elderly hip fracture patients, using data from a 2004–2007 cohort study in nine Maryland and Pennsylvania hospitals. Eligible patients (n=269) were age ≥65 years, underwent hip fracture surgery, and were bed‐bound at index study visits (during the first 5 days of hospitalization). Information about repositioning on the days of index visits was collected from patient charts; study nurses assessed presence of stage 2+ pressure ulcers 2 days later. The association between frequent manual repositioning and pressure ulcer incidence was estimated, adjusting for pressure ulcer risk factors using generalized estimating equations and weighted estimating equations. Patients were frequently repositioned (at least every 2 hours) on only 53% (187/354) of index visit days. New pressure ulcers developed at 12% of visits following frequent repositioning vs. 10% following less frequent repositioning; the incidence rate of pressure ulcers per person‐day did not differ between the two groups (incidence rate ratio 1.1, 95% confidence interval 0.5–2.4). No association was found between frequent repositioning of bed‐bound patients and lower pressure ulcer incidence, calling into question the allocation of resources for repositioning.

Elmer Abbo Darrell R. Abernethy Surafeal Abraha Bo Abrahamsen Chris Adamopoulos Alyce S. Adams John S. Adams Karen E. Adams Daniel C. Adelman Philip A. Ades Deborah B. Adey Neill Adhikari Robert A. Adler Olivia Affuso Muhammad Afzal Anil K. Agarwal Shikhar Agarwal Rajesh Agarwala Joseph V. Agostini N.K. Agrawal Varun Agrawal Farah Ahmad Ameena T. Ahmed Lorena Airaghi Krittapoom Akrawinthawong Soham Al Snih Muhyi Al-Sarraf Graciela Alarcon Mark Albanese Thomas K. Aldrich Caleb Alexander Patrick Alguire Joseph Ali Joseph Alisky Hisham Aljadhey Ricardo Alkmim Teixeira Yannick Allanore Alessandro Allegra Carmen Allegra Matthew A. Allison Richard L. Allman Ban M. Allos W. Kemper Alston Keri N. Althoff Domenico Alvaro Beatrice R. Amann-Vesti Jacques Amar Devanand Anantham Paul Anaya Jessica S. Ancker Daren Anderson Garnet L. Anderson Lisa Anderson-Shaw Giuseppe Ando Raúl J. Andrade Ashish Aneja Jelili A. Apalara Alejandro Aparicio Peter C. Applebaum Allen I. Arieff Benjamin Armbruster Carmel Armon Katrina Armstrong Paul W. Armstrong Donald M. Arnold Robert Arnold Julia H. Arnsten Paul Aronowitz Vineet Arora Janet B. Arrowsmith Adnan Arseven David Arterburn Subhash C. Arya Keiko Asao Federico M. Asch John Astin Arne Astrup Haris Athar Vasilios G. Athyros Wendy S. Atkin Evan Atlantis Steven J. Atlas Julie Aultman Moises Auron Gregory L. Austin Najib T. Ayas Jonathan G. Ayres J. Carlos Ayus Judith Baars Hilary M. Babcock Peter B. Bach Richard Bach Lucas M.M. Bachmann Maha Badawi Larry M. Baddour Angela M. Bader Robert G. Badgett Hala Badran Rong Bai William B. Baine C. Noel Bairey-Merz David Baker William L. Baker Satish Balan Lodovico Balducci Ethan M. Balk Noel H. Ballentine Kenneth A. Ballew Stanley P. Ballou Heejung Bang Sripal Bangalore Wei Bao Srinivas R. Bapoje Tiziano Barbui Frances K. Barg Jeffrey H. Barker Judith C. Barker Alan Barkun Peter Barland Amber E. Barnato H. Verdain Barnes Peter F. Barnes Allison L. Baroco Jeremiah A. Barondess Michael S. Barr Brendan J. Barrett Eileen Barrett A. Sidney Barritt Jeremy S. Barron Michael J. Barry Gavin Bart Mary B. Barton Phoebe L. Barton Lori D. Bash Holly A. Batal Eric R. Bates Daniel C. Batlle Murray D. Batt Douglas C. Bauer Kenneth A. Bauer John H. Bauman Mona Baumgarten Anthony Bavry J. David Baxter Paul D. Baxter Ahmet Baydur Harold E. Bays Jeffrey Bazarian Mary Catherine Beach John C. Beck Howard B. Beckman Joshua A. Beckman Updesh Singh Bedi Vikram Behera David S. Bell Gardner Bemis Bradley Bender Christian Benedict Alexandre Benjo Joel S. Bennett Neal L. Benowitz Kaaron Benson Lionel Bercovitch Alfred Berg Christine Berg Lee Berkowitz Michelle Berlin Nancy Berlinger Amy Berning Jeffrey S. Berns David Bernstein Gerard T. Berry Roberta Berry Zail S. Berry Thomas Bersot Howard A. Bessen Jennifer A. Best Robert Bettiker Robert F. Betts Surya P. Bhatt Nina Bickell Barbara C. Biedermann Michael F. Bierer Daniel Bikle J.A. Billings Henry J. Binder Giuseppe Biondi-Zoccai Alan L. Bisno Maureen Bisognano Bruce R. Bistrian Johannes Bitzer George L. Blackburn Susan Blalock Jason P. Block Zachary Bloomgarden John Blosnich Chris Blosser Stephan Blossom John W. Blotzer Stanley Blumenthal Henry C. Bodenheimer Jr. Julia Bohlius Mark J. Bolland Alfred J. Bollet Chester M. Boltwood Lawrence R. Boly John S. Bomalaski Stefano Bonassi Kenneth Boockvar Romsai T. Boonyasai Jonathan Boote Michael Bornemann Susan E. Boruchoff Xavier Bosch Patrick M. Bossuyt Hayden B. Bosworth V. Alin Botoman Malaz Boustani Cynthia M. Boyd Keith M. Boyd Edward J. Boyko Gregory L. Braden Sara Bradley Steven M. Bradley Donald W. Brady Teresa J. Brady Bernard M. Branson Somjot S. Brar Patrice Brassard Norbert Brau Barbara I. Braun Daniel J. Brauner Dawn M. Bravata Lewis E. Braverman Miriam Bredella Francisco R. Breijo-Márquez John Breitner Beatrice Brembilla-Perrot Hermann Brenner Philip W. Brickner Ralph Brindis Allen D. Brinker Jeff Brinker Irwin Brodsky John T. Brooks James Brophy Daniel J. Brotman Rebecca Brown Natale Daniele Brunetti David R. Brush R. Nick Bryan Robert J. Bryg Chiara Bucciarelli-Ducci Rachelle Buchbinder Vardaman Buckalew Edwarda M. Buda-Okreglak Daniel S. Budnitz Matthew J. Budoff Raffaele Bugiardini Roswitha Vera Bugnon-Hartmann Zakeya Bukhary John B. Bulger Roger J. Bulger T. Jared Bunch Harry B. Burke Lillian P. Burke Wylie Burke John C. Burnham Francesca Bursi Harold J. Burstein John Buse Roger W. Bush Thanks to Reviewers—2010

Systemic autoimmune rheumatic diseases (SARDs) are chronic inflammatory and immuno-modulatory conditions that have been suggested to affect cancer risk. Using the Surveillance, Epidemiology and End Results-Medicare-linked database, women aged 67-99 years and diagnosed with incident breast cancer in 1993-2002 (n = 84 778) were compared with an equal number of age-matched cancer-free female controls. Diagnoses of SARDs, including rheumatoid arthritis (RA, n = 5238), systemic lupus erythematosus (SLE, n = 340), Sjogren's syndrome (n = 374), systemic sclerosis (n = 128), and dermatomyositis (n = 31), were determined from claim files for individuals from age 65 years to 1 year before selection. Associations of SARD diagnoses with breast cancer, overall and by oestrogen receptor (ER) expression, were assessed using odds ratio (OR) estimates from multivariable logistic regression models. The women diagnosed with RA were less likely to develop breast cancer (OR = 0.87, 95% confidence interval (CI) = 0.82-0.93). The risk reduction did not differ by tumour ER-status (OR = 0.83, 95% CI = 0.78-0.89 for ER-positive vs OR = 0.91, 95% CI = 0.81-1.04 for ER-negative, P for heterogeneity = 0.14). The breast cancer risk was not associated with any of the other SARDs, except for a risk reduction of ER-negative cases (OR = 0.49, 95% CI = 0.26-0.93) among women with SLE. These findings suggest that systemic inflammation may affect breast epithelial neoplasia.