Prevalence and correlates of the insulin resistance syndrome among Native Americans. The Inter-Tribal Heart Project.
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OBJECTIVE: The clustering of factors characterizing the insulin resistance syndrome has not been assessed among Native Americans, a population at high risk for diabetes and cardiovascular disease. We examined the distribution and correlates of the insulin resistance syndrome among individuals in three Chippewa and Menominee communities in Wisconsin and Minnesota. RESEARCH DESIGN AND METHODS: Cross-sectional data from 488 men and 822 women ages > or = 25 years in the Inter-Tribal Heart Project (1992-1994) were included. The clustering of each individual trait (hypertension, diabetes, high triglycerides, and low HDL cholesterol) with the other traits and the association of the number of traits with measures of adiposity and insulin levels were examined. RESULTS: Among the men, 40.4, 32.6, 17.4, and 9.6% had none, one, two, or at least three of the four traits, respectively; among the women, the respective percentages were 53.2, 25.6, 15.3, and 6.0%. The percentage of individuals with each particular trait significantly increased (P < 0.01) among those with none, one, or at least two other syndrome traits. Having more syndrome traits was significantly related (P < 0.001) to higher BMI, conicity index, waist circumference, and waist-to-hip and waist-to-thigh ratios. Among individuals with normal glucose levels, having more syndrome traits was significantly related (P < or = 0.05) to higher fasting insulin levels after adjusting for age and measures of adiposity, although associations were attenuated with adjustment for either BMI or waist circumference. CONCLUSIONS: Traits characterizing the insulin resistance syndrome were found to be clustered to a significant degree among Native Americans in this study. Comprehensive public health efforts are needed to reduce adverse levels of these risk factors in this high-risk population. (+info)
Prognosis of gastric ulcer: twenty-five year followup.
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Four hundred twenty-two patients with gastric ulcer treated during 1950-1960 were followed up to 25 years with a mean followup of 9 years. Nonoperative treatment was used in 59% with a hospital mortality of 35%, one-third of these deaths being directly due to gastric ulcer perforation or hemorrhage. Operative treatment was used in 41% of patients. The most common operation (86%) was gastric resection without vagotomy. Overall operative mortality was 16%; 34% for emergency procedures and 6% for elective procedures. Cachexia seemed to be the most important factor related to operative mortality. Nonoperative treatment resulted in more than twice the hospital mortality compared to operative treatment. Approximately one-half of all patients treated non-operatively had a recurrent gastric ulcer at some time during this study. The recurrence rate following definitive gastric resection was 1.3% compared with 16% during nonoperative therapy. Three-fourths of recurrences occurred later than two years and nearly half of recurrences after more than 5 years of followup. Patients with a prior history of overt bleeding from gastric ulcer disease particularly were at risk for further bleeding. There were coincidental duodenal ulcers in 10% of our patients and a 0.8% incidence of gastric cancer during followup. Long term followup demonstrates the superiority of operative treatment of gastric ulcer and also reveals the continuous propensity of such ulcers to recurrence following nonoperative treatment. Earlier elective operation in patients with overt bleeding, recurrence or persisting symptoms should decrease overall mortality and result in a lower overall long-term risk of ulcer complications. (+info)
Implications of managed care denials for pediatric inpatient care.
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With the growing penetration of managed care into the healthcare market, providers continue to experience increasing cost constraints. In this environment, it is important to track reimbursement denials and understand the managed care organization's rationale for refusal of payment. This is especially critical for providers of pediatric care, as children justifiably have unique healthcare needs and utilization patterns. We developed a system for tracking and documenting denials in our institution and found that health maintenance organizations denied claims primarily for one of three reasons: medically unnecessary care, care provided as a response to social (rather than medical) need, and provider inefficiencies. Health maintenance organization denials are also growing annually at our institutions. This knowledge can not only help providers of pediatric care more effectively negotiate future contracts, but provides an opportunity to differentiate the health needs of the pediatric patient from those of the adult. This information can be used as a basis for education, pediatric outcome studies, and guideline development--all tools that can help providers receive reasonable reimbursement for pediatric services and enable them to meet the complex health needs of children. Recommendations for action are discussed. (+info)
AIDS information needs: conceptual and content analyses of questions asked of AIDS information hotlines.
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Dissemination of accurate information about HIV is an essential element of national AIDS prevention strategies and AIDS telephone hotlines serve a vital function in providing such information. In this study, questions asked of two AIDS information hotlines were collected and examined to determine the AIDS information needs of the general public. Questions asked of local AIDS lines in Houston and Milwaukee (N = 1611) were independently classified into 30 content areas, with two independent raters achieving 94% agreement. The content areas were organized for analysis into 11 broader information domains. Questions about HIV antibody testing were the most frequently asked (27%), followed by questions about sexual transmission of HIV (16%), HIV-related symptoms (16%) and situations that do not confer risk for HIV infection (14%). Content analyses suggested that individuals were motivated to call hotlines by fears of contracting HIV from actual risk behaviors or to dismiss concerns about contracting HIV through casual modes. Many individuals had information needs related to their own personal experiences that could not be addressed through media campaigns or other means of mass public health education. Results suggest that HIV information dissemination to the public through hotlines and other means of direct health education serves both preventive and destigmatizing functions. (+info)
The 10-year incidence of renal insufficiency in people with type 1 diabetes.
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OBJECTIVE: To describe the 10-year decrease in estimated creatinine clearance and the incidence of renal insufficiency and end-stage renal disease in a cohort of people with type 1 diabetes. RESEARCH DESIGN AND METHODS: A population-based cohort of individuals with younger-onset diabetes (diagnosed at < 30 years old and taking insulin) participated in an examination during 1984-1986 (n = 891), a 6-year follow-up examination during 1990-1992 (n = 765), and a 10-year follow-up examination during 1995-1996 (n = 634). Serum creatinine and risk factors were measured during standardized protocols at each examination. Estimated adjusted creatinine clearance was computed by a modification of the Cockroft-Gault formula. A clinically meaningful change was defined as a decrease in the estimated annual creatinine clearance of > or = 3 ml.min-1.1.73 m-2.year-1. Renal insufficiency was defined by the development of a serum creatinine of 2.0 mg/dl or greater after the 1984-1986 examination. RESULTS: The 10-year estimated incidence of an annual decrease in the creatinine clearance of > or = 3 ml.min-1.1.73 m-2 for the cohort was 52.5%, and the cumulative 10-year incidence of renal insufficiency and end-stage renal failure was 14.4%. In univariate analyses, incidence of a decrease in the estimated creatinine clearance of > or = 3 ml.min-1.1.73 m-2.year-1 and the incidence of renal insufficiency were both related to higher glycosylated hemoglobin; higher diastolic blood pressure; the presence of microalbuminuria and gross proteinuria; more severe retinopathy; and a history of loss of tactile sensation or temperature sensitivity at baseline. In logistic regression analysis, after adjusting for the presence of microalbuminuria and gross proteinuria at baseline, higher glycosylated hemoglobin and higher diastolic blood pressure were associated with decreasing estimated creatinine clearance. In logistic regression analyses, after adjusting for the presence of microalbuminuria and gross proteinuria at baseline, the incidence of renal insufficiency was independently associated with age, glycosylated hemoglobin, hypertension, and serum HDL cholesterol. CONCLUSIONS: These data suggest that a public health approach aimed at controlling glycemia, blood pressure, and serum lipids might result in reducing the rate of decline in renal function and development of renal insufficiency in people with type 1 diabetes. (+info)
Mortality and hormone-related exposures in women with diabetes.
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OBJECTIVE: Hormone-related events and exposures are related to mortality and especially to cardiovascular disease in women. We evaluated whether such exposures influenced risk in a well-defined group of women with diabetes. RESEARCH DESIGN AND METHODS: Women with younger- and older-onset diabetes who were identified during a population-based study were queried about number of pregnancies, age at menarche, use of oral contraceptives, use of estrogen replacement therapy, and menopausal status at examinations in 1984-1986. Analyses are limited to women aged > or = 18 years (n = 398 and 542 in those with younger- and older-onset diabetes, respectively). Cohort mortality was monitored carefully, and causes of death were abstracted from death certificates. RESULTS: There were 58 deaths in the first group and 338 deaths in the second group since the 1984-1986 examination. The number of pregnancies was significantly associated with all-cause mortality (hazard ratio, 0.96 [95% CI 0.92-1.00]) in older-onset women only. CONCLUSIONS: These data suggest and are compatible with the notion that the hormone exposures examined are unrelated to cardiovascular mortality in women with diabetes, with the exception of a minimal effect of the number of pregnancies in older-onset women. Whether there is a difference in these exposure-outcome relationships between women with diabetes and those without diabetes is uncertain and requires further investigation. (+info)
The 14-year incidence of lower-extremity amputations in a diabetic population. The Wisconsin Epidemiologic Study of Diabetic Retinopathy.
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OBJECTIVE: To estimate the cumulative 14-year incidence of lower-extremity amputations (LEAs) and evaluate risk factors for LEA. RESEARCH DESIGN AND METHODS: Study subjects consisted of population-based cohorts of younger-onset (diagnosed before age 30 years and taking insulin, n = 906) and older-onset (diagnosed after age 30 years, n = 984) individuals with diabetes. Subjects participated in baseline (1980-1982), 4-year, 10-year, and 14-year examinations or interviews. LEAs were determined by history. RESULTS: The cumulative 14-year incidence of LEA was 7.2% in younger- and 9.9% in older-onset patients. In multivariable analyses based on the discrete linear logistic model, LEA in the younger-onset group was more likely for males (odds ratio [OR] 5.21 [95% CI 2.50-10.88]), older age (OR for 10 years 1.71 [1.30-2.24]), higher glycosylated hemoglobin (OR for 1% 1.39 [1.22-1.59]), higher diastolic blood pressure (OR for 10 mmHg 1.58 [1.20-2.07]), history of ulcers of the feet (3.19 [1.71-5.95]), and more severe retinopathy (OR for one step 1.16 [1.08-1.24]). In younger-onset patients aged > or = 18, pack-years smoked (OR for 10 years 1.20 [1.03-1.41]) was also associated with LEAs, and daily aspirin use was inversely associated (OR 0.11 [0.01-0.83]). In the older-onset group, LEA was more likely for men (2.66 [1.49, 4.76]) and if the subject had higher glycosylated hemoglobin (OR for 1% 1.25 [1.09-1.43]), higher pulse pressure (OR for 10 mmHg 1.19 [1.04-1.37]), history of ulcers (3.56 [1.84-6.89]), and more severe retinopathy (OR for one step 1.07 [1.00-1.13]). CONCLUSIONS: There are several risk factors for LEA with potential for modification and preventive strategies. (+info)
Discontinuation rates of cholesterol-lowering medications: implications for primary care.
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OBJECTIVE: To evaluate long-term continuation rates for cholesterol-lowering therapy (niacin, sequestrants, statins) in a multidisciplinary lipid clinic and to evaluate the effectiveness of 2 different dosing strategies designed to improve long-term continuation of therapy. STUDY DESIGN: An observational study was done at the Milwaukee Department of Veterans Affairs Medical Center Lipid Clinic, where healthcare personnel were trained to improve patient tolerance to cholesterol-lowering medications. Primary outcomes were recorded prospectively. PATIENTS AND METHODS: Patients were 970 consecutive veterans who began therapy with niacin, sequestrants, or statins between March 1988 and December 1995. In 1992, two different dosing strategies were initiated to reduce the discontinuation rates for niacin and sequestrants: (1) the niacin titration schedule was lengthened from 3 to 6 weeks and (2) the initial sequestrant dose was reduced from four to two scoops daily. RESULTS: Discontinuation rates for niacin and sequestrants were both very high. For niacin, 48% and 71% of all patients who began therapy discontinued the drug by 1 and 4 years, respectively. For sequestrants, drug discontinuation rates were 59% and 83% at 1 and 4 years, respectively. On the other hand, statin discontinuation rates at 1 and 4 years were only 10% and 28%, respectively. Neither the longer niacin titration schedule nor the lower sequestrant initiation dose reduced these high discontinuation rates. CONCLUSIONS: Despite initiation of niacin and sequestrant therapy in the setting of a multidisciplinary lipid clinic, drug discontinuation rates were high and were similar to rates observed in primary-care settings. Neither the specialized resources available in a lipid clinic nor protocols designed to improve tolerance to therapy reduced the high drug discontinuation rate. Unless more tolerable niacin and sequestrant formulations become available, reliance on statins as the preferred cholesterol-lowering agents will continue because they have fewer side effects and lower discontinuation rates. (+info)