Association of high dietary saturated fat intake and uncontrolled diabetes with constipation: evidence from the National Health and Nutrition Examination Survey.

BACKGROUND: Constipation is highly prevalent in the United States. The association of dietary fat intake with constipation has not been well studied. We recently reported that mice fed a high-fat diet had higher incidence of constipation than regular diet fed mice. The aim of this study was to assess if increased intake of dietary saturated fat in humans is also associated with higher risk of constipation and reduced stool frequency. METHODS: Analyses were based on data from 6207 adults (≥20 years) from the 2005-2006 and 2007-2008 cycles of the National Health and Nutrition Examination Surveys who had completed the bowel health questionnaire. Constipation was defined as a stool frequency of less than three times per week. Multivariable logistic regression analysis was used to calculate adjusted prevalence odds ratio (OR) estimates. Statistical analyses were performed using R and RStudio softwares. KEY RESULTS: The prevalence of constipation in this sample was 3.1%. After multivariable adjustment high saturated fat remained associated with constipation. The OR for high saturated fat intake associated with constipation was much higher in diabetics above 65 years, especially in non-Hispanic blacks, females, and those with poor glycemic control, compared to the control group. CONCLUSIONS & INFERENCES: To the best of our knowledge, this is the first report to investigate the association of high saturated fat diet, bowel frequency, and diabetes. This study demonstrates that a high dietary saturated fat intake is associated with significant increase in the prevalence of constipation, especially in the uncontrolled diabetic, non-Hispanic black, female patients.

Gender as risk factor for 30 days post-discharge hospital utilisation: a secondary data analysis.

OBJECTIVE: In the 30 days after hospital discharge, hospital utilisation is common and costly. This study evaluated the association between gender and hospital utilisation within 30 days of discharge. DESIGN: Secondary data analysis using Poisson regression stratified by gender. PARTICIPANTS: 737 English-speaking hospitalised adults from general medical service in urban, academic safety-net medical centre who participated in the Project Re-Engineered clinical trial (clinicaltrials.gov identifier: NCT00252057). MAIN OUTCOME MEASURE: The primary end point was hospital utilisation, defined as total emergency department visits and hospital readmissions within 30 days after index discharge. RESULTS: Female subjects had a rate of 29 events for every 100 people and male subjects had a rate of 47 events for every 100 people (incident rate ratio (IRR) 1.62, 95% CI 1.28 to 2.06). Among men, risk factors included hospital utilisation in the 6 months prior to the index hospitalisation (IRR 3.55, 95% CI 2.38 to 5.29), being unmarried (IRR 1.72, 95% CI 1.12 to 2.64), having a positive depression screen (IRR 1.53, 95% CI 1.09 to 2.13) and no primary care physician (PCP) visit within 30 days (IRR 1.64, 95% CI 1.08 to 2.50). Among women, the only risk factor was hospital utilisation in the 6 months prior to the index hospitalisation (IRR 3.08, 95% CI 1.86 to 5.10). CONCLUSIONS: In our data, male subjects had a higher rate of hospital utilisation within 30 days of discharge than female subjects. For men-but not for women-risk factors were being retired, unmarried, having depressive symptoms and having no PCP visit within 30 days. Interventions addressing these factors might lower hospital utilisation rates observed among men.

Alcohol and folate intake and breast cancer risk in the WHI Observational Study.

BACKGROUND: Alcohol increases breast cancer risk. Epidemiological studies suggest folate may modify this relationship. OBJECTIVE: To examine the relationship among breast cancer, alcohol and folate in the Women's Health Initiative-Observational Study (WHI-OS). METHODS: 88,530 postmenopausal women 50-79 years completed baseline questionnaires between October 1993 and December 1998, which addressed alcohol and folate intake and breast cancer risk factors. Cox proportional hazards analysis examined the relationship between self-reported baseline alcohol and folate intake and incident breast cancer. RESULTS: 1,783 breast cancer cases occurred over 5 years. Alcohol was associated with increased risk of breast cancer (RR = 1.005, 95%CI 1.001-1.009). Risk increased with consumption of alcohol (up to 5 g/d, adjusted HR = 1.10, 95%CI 0.96-1.32; >5-15 g/d HR = 1.14, 95%CI 0.99-1.31; and >15 g/d HR = 1.13 95%CI 0.96-1.32). We found no significant interaction between alcohol and folate in our adjusted model. CONCLUSIONS: We found no evidence for folate attenuating alcohol's effect on breast cancer risk in postmenopausal women. Our results may be due to misclassification of folate intake or the relatively short follow-up period.

Use of survey and clinical data for screening and diagnosis.

BACKGROUND: U.S. prevalence of diabetes in 2005 was 20.8 million people (6.2 million undiagnosed) (Diabetes Statistics. 2006). Recognizable preclinical stage is between 7 and 12 years. Efficient screening and early diagnosis can help: 1. avoid or delay development of diabetes. 2. treat early and avoid co-morbidities. DESIGN: Retrospective cross-sectional study of 153 113 adults ages 24 to 83 from the Behavioural Risk Factor Surveillance Systems (BRFSS)-2003 of whom 4379 had diabetes at their current age or during the previous year and 2190 adults ages 40 to 74 from the National Health and Nutrition Examination Survey III, 211 of whom had glucose tolerance test result > or = 200 mg/dL. OBJECTIVES: To develop statistical models for screening and diagnosis. METHODS: Logistic and generalized linear and additive regression models, Akaike information criterion, area under the receiver operating characteristic (ROC) curve, Baye's rule. RESULTS: Area under the 'productivity' curve using BRFSS data is 0.65 indicating an average yield of 17.3 per cent. Survey data is useful also for diagnosis. Area under the ROC curve (AUC) using only survey data is 0.68. AUC for fasting plasma glucose (FPG) alone is 0.91. Stepwise drop one method of selecting co-variates for diagnosis included pre-test probability from BRFSS. When both FPG and pre-test information are included, AUC increases to 0.93. Reduction in residual deviance and 0.02 increase in AUC are statistically significant (p = 0.0012). Clinical significance of prior odds is shown by increase in accuracy and weighted average of sensitivity and specificity. Empirically estimated regression weights for pre-test and test information vary with age and race and are not equal, as required by Baye's theorem. Overfitting index was less than 1 per cent. CONCLUSIONS: Cross-section surveys are useful for increasing screening efficiency and diagnostic accuracy.

Web-based versus face-to-face learning of diabetes management: the results of a comparative trial of educational methods.

BACKGROUND AND OBJECTIVES: Relatively little is known about the effectiveness of Web-based learning (WBL) in medical education and how it compares to conventional methods. This study examined the influence of an interactive, online curriculum in a third-year medical school family medicine clerkship on students' ability to create a management plan for a patient newly diagnosed with type 2 diabetes. We also evaluated how the online curriculum compared to a conventionally taught curriculum. METHODS: The online course included three integrated activities: (1) self-study modules, (2) a patient case study, and (3) a moderated discussion board for posting and discussing patient care plans. The WBL curriculum was compared to small-group case-based sessions with a faculty facilitator. Students completed a test case before and after the clerkship. RESULTS: Among standard-of-care diabetic management interventions not ordered on the pretest, 38% were subsequently correctly ordered by WBL students on the posttest, versus 33% by students in the comparison group. For four out of five subgroups assessed on the case write-ups, the gain from before to after the clerkship favored the WBL group. CONCLUSIONS: Improvement among students learning online exceeded that of students learning face to face. This suggests superiority of the online method, a finding consistent with other recently published, well-controlled studies.

Maternal hypertension as a risk factor for low birth weight infants: comparison of Haitian and African-American women.

BACKGROUND: The rate of low birth weight (LBW) of Black women is more than twice that of White women. This study explores if the rate of LBW differs between Haitian and African-American women with chronic hypertension. METHODS: A retrospective cohort study of all Black women self-identified as African-American (n = 12,258) or Haitian (n = 4320) delivering a singleton infant in Massachusetts between 1996 and 2000. RESULTS: Haitian women were more likely than African-American women to have chronic hypertension (2.7% vs. 2.1%, p = 0.006), but had similar rates of preeclampsia (3.1% vs. 3.3%, p = 0.27). The LBW rate was 10% among African-American women and 8.2% among Haitian women. After adjustment for sociodemographic, medical, and prenatal care characteristics, the greatest risks for delivering a LBW infant for Haitian women were chronic hypertension (OR = 6.8; 95% CI, 4.3, 10.6) and preeclampsia (OR = 3.2; 95% CI, 2.0, 5.1). For African-American women, the greatest risks for LBW infants were a history of delivering a LBW infant (OR = 3.9; 95% CI, 2.8, 5.4) and chronic hypertension (OR = 2.9; 95% CI, 2.1, 4.0). In a combined logistic regression model including interaction terms, chronic hypertension and preeclampsia continued to be associated with the greatest risk of LBW among all women. CONCLUSIONS: Differences in maternal risk factors and rates of LBW (8.2% vs. 10%) exist between Haitian and African-American women delivering infants in Massachusetts. While chronic hypertension and preeclampsia are strong risk factors for LBW for both Haitian and African-American women, unknown factors make these disorders much more potent for Haitian women.

A cost-minimizing diagnostic methodology for discrimination between neoplastic and non-neoplastic brain lesions: utilizing a genetic algorithm.

RATIONAL AND OBJECTIVES: The purpose of this study was to make an improvement in the performance of a logistic regression model in predicting the presence of brain neoplasia with magnetic resonance spectroscopy data by using a new approach for logistic regression coefficient estimation. This new approach, termed cost minimizing (C-min), introduced by one of the authors (Chetty), uses the cost function for prediction outcomes to estimate model coefficients and the prediction decision rule. To do this requires use of a genetic algorithm. MATERIALS AND METHODS: Consecutive patients with suspected brain neoplasms or recurrent neoplasia referred for magnetic resonance spectroscopy were enrolled once a final diagnosis was established by histopathology or clinical course, laboratory data, and serial imaging. For the same magnetic resonance spectroscopy explanatory (input) variables, logistic regression models were constructed with conventional and C-min coefficient estimates, and sensitivity and specificity outcomes were compared at alternative probability threshold levels. RESULTS: The C-min approach dominated the conventional approach in 14 of 18 trials, in that C-min had either fewer of both false negatives and false positives, or it had the same number of one type, and less of the other type of diagnostic error. C-min was always less costly. CONCLUSION: The C-min approach to logistic or other regression model estimation may be a step forward in reducing the cost and, often, the errors of diagnostic (and treatment) processes. However, this new approach must be validated on larger and more varied datasets, and its statistical performance characteristics determined before it can be implemented as a practical clinical tool.

Family physicians are an important source of newborn care: the case of the state of Maine.

Family physicians (FPs) provided 30 percent of inpatient newborn care in Maine in the year 2000. FPs cared for a large proportion of newborns, especially those insured by Medicaid and in smaller, rural hospitals where FPs also delivered babies. Family medicine's commitment to serve vulnerable populations of newborns requires continued federal, state, and institutional support for training and development of future FPs.

Family physicians make a substantial contribution to maternity care: the case of the state of Maine.

Family physicians provided nearly 20 percent of labor and delivery care in Maine in the year 2000. A substantial proportion of this care was provided to women insured by Medicaid and those delivering in smaller, rural hospitals and residency-affiliated hospitals. As family medicine explores its future scope, research identifying regional variations in the maternity care workforce may clarify the need for maternity care training in residency and labor and delivery services in practice.

Hospital readmission and morbidity following early newborn discharge.

To examine causes of newborn hospital readmission and morbidity related to early nursery discharge, we reviewed the charts of 664 newborns readmitted from home under the age of 15 days, between 1993 and 1995. Early discharge (ED) was defined as nursery length of stay of < or = 2 days. Morbidity related to ED: onset of symptoms within 1 day of ED; and in diseases with insidious onset: serum bilirubin level > 20 mg/dL (340 mumol/L), or dehydration following poor breastfeeding since birth. Seventeen percent of all readmitted infants had ED-related morbidity; 9% had major morbidity. Onset of symptoms prior to the age of 3 days occurred in 43% of ductal-dependent cardiac lesions, intestinal obstruction, seizures, and major infections. Morbidity was less pronounced in infants who were followed up within 2 days following ED. Specific findings related to subsequent morbidity were identified in the perinatal history of infants who were readmitted with major infections and with hyperbilirubinemia. Our findings suggest that: (1) close to half of the cases with acute-onset major morbidity can be identified within 3 days of birth, and (2) attention to the perinatal history and timely follow-up will contribute to a reduction in both morbidity and complications.

Stochastic technology, production organization and costs.

Using a model including patients, physicians, insurers and uncertain diagnostic technology, the optimal cesarean rate is derived from preferences, technology and the incidence rate, when the choice of insured patients is constrained only by technology. Uncertain diagnosis produces unnecessary cesareans and unsafe vaginal births. Technical progress can lead to more cesareans and higher costs. Joint production of goods and bads and collective payments require incentive compatible pricing schemes, different from RBRVS. Equilibrium outcomes of HMOs and free-for-service organizations are identical. However, implementable incentive schemes involve additional costs. Efficiency requires insurers, and not providers, to be liable for malpractice claims.

Neonatal hospital lengths of stay, readmissions, and charges.

OBJECTIVE: To evaluate trends in length of hospital stay, hospital charges, and readmission rates of Wisconsin newborns from 1989 through 1994 in light of recent policies requiring earlier discharges after delivery of newborns. METHODOLOGY: Two data sources were used: 1) 1989-1994 Hospital Inpatient Discharge Data from the Wisconsin Office of Health Care Information, and 2) 1994 birth certificate and matched infant mortality data from the Wisconsin Center for Health Statistics. Average lengths of stay and average hospital (delivery and readmission) charges were calculated, and readmission rates were estimated for full-term, premature, and sick newborns. RESULTS: There were 368 955 full-term and 26 668 premature newborns in Wisconsin from 1989 through 1994. The average length of stay decreased by 24% in full-term newborns from 1989 through 1994, while average hospital (delivery and readmission) charges rose over 40% during the same period. Average length of stay for premature infants increased by 24% while their hospital delivery charges increased 214% during the study period. Readmission rates halved, yet charges per readmission doubled for full-term infants. More than twice as many full-term newborns were classified as sick in 1994 (43%) compared with 1989 (19%). CONCLUSIONS: Managed care efforts to control costs of neonatal care through earlier newborn discharge policies may have limited impact. Physicians or hospitals may be compensating for these policies by classifying more newborns as sick, thereby allowing for longer hospital stays to be reimbursed by the insurance carriers. Premature infants, <7% of the total births, account for half of all hospital delivery charges. Efforts to reduce premature births may have a greater impact on neonatal health care costs than efforts to discharge full-term newborns earlier.

Accuracy of single-voxel proton MR spectroscopy in distinguishing neoplastic from nonneoplastic brain lesions.

PURPOSE: To measure the accuracy of single-voxel, image-guided proton MR spectroscopy in distinguishing normal from abnormal brain tissue and neoplastic from nonneoplastic brain disease. METHODS: MR spectroscopy was performed at 0.5 T with the point-resolved spectroscopic pulse sequence and conventional postprocessing techniques. Subjects consisted of a consecutive series of patients with suspected brain neoplasms or recurrent neoplasia and 10 healthy adult volunteers. Fifty-five lesions in 53 patients with subsequently verified final diagnoses were included. Spectra were interpreted qualitatively by visual inspection by nonblinded readers (prospectively) with the benefit of prior clinical data and imaging studies, and by blinded readers (retrospectively). The nonblinded readers interpreted the spectra as diagnostic or not, and, if diagnostic, as neoplastic or nonneoplastic. The blinded readers classified the spectra as diagnostic or not, and, if diagnostic, as normal or abnormal and as neoplastic or nonneoplastic (when abnormal). The sensitivity, specificity, positive and negative predictive values, and accuracy were calculated from blinded and nonblinded MR spectroscopy interpretations. A receiver operator characteristic (ROC) curve analysis was performed on blinded MR spectroscopy interpretations. RESULTS: The diagnostic accuracy averaged across four blinded readers in differentiating patients from control subjects was .96, while the area under the aggregate (pooled interpretations) ROC curve approached unity. Accuracy in the nonblinded and blinded discrimination of neoplastic from nonneoplastic disease was .96 and .83, respectively. The area under the aggregate ROC curve in the blinded discrimination of neoplasm from nonneoplasm was .89. CONCLUSIONS: Image-guided proton spectra obtained at 0.5 T from patients with suspected neoplasia can be distinguished from spectra in healthy control subjects, and neoplastic spectra can be distinguished from nonneoplastic spectra with a high degree of diagnostic accuracy.

Medicare costs in urban areas and the supply of primary care physicians.

BACKGROUND: The supply of primary care physicians may be important determinants of health care costs. We examined the association between primary care physician supply and geographic location with respect to variation in Medicare Supplementary Medical Insurance (Part B) reimbursement. METHODS: We performed an analysis of data from all US metropolitan counties. Physician supply data were derived from the American Medical Association Masterfile. Medicare Part B reimbursements and enrollment data came from the Health Care Financing Administration. Physician supply was calculated for family practice, general internal medicine, and non-primary care specialties. Linear regression was used to test the association of physician supply and Medicare costs and to adjust for potential confounding variables. RESULTS: The average Medicare Part B reimbursement per enrollee was $1283. After adjusting for local price differences and county characteristics, a greater supply of family physicians and general internists was significantly associated with lower Medicare Part B reimbursements. The reduction in reimbursements between counties in the highest quintile of family physician supply and the lowest quintile was $261 per enrollee. In contrast, a greater supply of general practitioners and non-primary care physicians was associated with higher reimbursements per enrollee. CONCLUSIONS: These results add to the evidence than an increased supply of primary care physicians is associated with lower health care costs. If this association is causal, it supports the theory that increasing the number of primary care physicians may lower health care costs.