Skin preparation before hip replacement in emergency setting versus elective scheduled arthroplasty: bacteriological comparative analysis.

INTRODUCTION: Hip arthroplasty needs to be performed in an emergency setting after intracapsular femur neck fracture, whereas pain makes preoperative skin preparation of the limb difficult and it may therefore be incomplete. To date no study has analyzed the patient's skin bacteriological status in these surgical conditions. HYPOTHESIS: The skin's bacterial flora is quantitatively and qualitatively different in the trauma context compared to an elective scheduled arthroplasty for chronic hip disease. MATERIALS AND METHODS: Two groups of patients, undergoing hip arthroplasty and having the same preparation at the time of surgery but different skin preparation procedures the day before and the day of surgery, were prospectively compared: 30 patients operated on in an emergency setting for fracture (group A) had no skin preparation and 32 patients operated on in scheduled surgery (group B). Group A had no skin disinfection before going into surgery, whereas group B followed a predefined protocol the day before surgery. Skin samples were taken on gelose at three different stages of skin preparation at the time of surgery (before and after detersive cleaning, and at the end of the surgery) and on two sites (inguinal and greater trochanter). The bacteriological analysis took place after 48 hours of incubation. RESULTS: Before detersive cleaning, group A had 3.6 times more bacteria than group B in the trochanter region and 2.7 times more in the inguinal area. After detersive cleaning, the contamination rate in the trochanter area was similar in both groups (group A: 10%; group B: 12.5%), but different in the inguinal region (group A: 33%; group B: 3%; P=0.002). At the end of the surgery, no difference was identified. Coagulase-negative Staphylococcus and Bacillus cereus accounted for 44% and 37%, respectively, of the bacteria isolated. In addition, the frequency of pathogenic non-saprotrophic bacteria was higher in group A (38%) compared to group B (6%). At a mean follow-up of 9.7 months (range: 8-11 months), no infection of the surgical site was identified. CONCLUSION: The dermal flora is more abundant and different when the patient is managed in an emergency context. Although effective in the trochanter area, cutaneous detersive cleaning in the operating room is insufficient in the inguinal area and the frequency of pathogenic bacteria warrants identical rigor in preoperative preparation in all situations. LEVEL OF EVIDENCE: III. Prospective case - control study.

Recent population changes in HbA(1c) and fasting insulin concentrations among US adults with preserved glucose homeostasis.

AIMS/HYPOTHESIS: Although diagnosed type 2 diabetes has increased in the past decade, little is known about accompanying changes in fasting plasma glucose (FPG), HbA(1c) and fasting serum insulin (FI) levels in the non-diabetic population. METHODS: Using population estimates from National Health and Nutrition Examination Surveys, we compared distribution of FPG, HbA(1c) and FI in non-diabetic US persons who were >or=20 years old in 1999 to 2006 with that in persons of the same age in 1988 to 1994. RESULTS: Age-, sex- and race-adjusted mean FPG levels between the two study periods did not change, but mean HbA(1c) and FI levels increased (0.10% and 4.8 pmol/l, respectively; p < 0.001 for both). The increased HbA(1c) level was driven largely by an upward shift in the lower end of the HbA(1c) distribution. In contrast, the increased FI level was driven primarily by an upward shift in the middle and higher end of FI distribution, especially among persons aged 20 to 44 years. After adjustments for BMI or waist circumference, the increase in the mean HbA(1c) level was attenuated (0.06%; p < 0.001), whereas the mean FPG level decreased by 0.1 mmol/l (p < 0.001) and the mean FI level no longer demonstrated significant change. CONCLUSIONS/INTERPRETATION: Despite little change in the distribution of FPG levels, HbA(1c) and FI levels increased in the non-diabetic population in the past decade. The increase in FI levels suggests that levels of insulin resistance were greater among US adults, especially young adults, than in the previous decade.

Visual impairment and eye care among older adults - five States, 2005.

Blindness and visual impairment are among the 10 most common causes of disability in the United States and are associated with shorter life expectancy and lower quality of life. Previously, state-specific prevalences of visual impairment and eye disease were estimated from national prevalences. However, in 2005, five states (Iowa, Louisiana, Ohio, Tennessee, and Texas) provided state-specific estimates by using the new CDC Behavioral Risk Factor Surveillance System (BRFSS) vision module. CDC analyzed data from the module to determine the self-reported prevalence of visual impairment, eye disease, eye injury, and lack of eye-care insurance and eye examination among persons aged >or=50 years in each of these five states and among certain sociodemographic populations overall. This report describes the results of that analysis, which indicated variation in disease prevalence and use of eye care among individual states and also among racial/ethnic populations and age groups within the five states combined. The variability among state data suggests that statespecific surveillance of visual impairment and eye care and investigation by states to identify influencing factors might lead to creation of vision programs better suited to individual state needs.

Lipids as indicators of eutrophication in marine coastal sediments.

Total organic carbon (TOC) and sedimentary lipid contents were investigated in the Bunnefjord, the most inner part of the Oslofjord (Norway). The Bunnefjord is an intermittent anoxic basin and has undergone major eutrophication since the early 1800s. A core from this fjord was collected at 100 m depths under anoxic remnant waters. The first 15 cm corresponding to deposits from 1500 to present were considered for analysis. Lipid classes were quantified by TLC-FID and the molecular composition of selected lipid classes was investigated by GC and GC-MS. Lipids were dominated by two main classes, phospholipids and hydrocarbons. The hydrocarbons represented up to 7.4% of total lipids in the sediment layers covering the period when the most extensive cultural eutrophication took place (1900 to 1970). The higher fluxes of organic carbon produced during this period may have controlled hydrocarbon inputs into the sediments, due to the hydrophobic character of these pollutants. The hydrocarbon concentration reversed toward pre-industrial levels in the more recent layers, which suggests an improvement of the water quality, possibly in response to improved treatment of the sewage in the cities around Bunnefjord. The second most abundant pool of lipids consists in phospholipids, mostly contributed by bacteria. Even though the concentration decreased with depth, their relative proportions to total lipids remained high, mainly in the deepest layers (>80% of total lipids). A rapid decrease of the polyunsaturated fatty acid methyl esters (FAME) from the phospholipid fraction in the upper 4 cm suggests a rapid biodegradation of planktonic inputs and meiofauna. Odd branched fatty acids were more probably contributed by bacteria linked to the high sedimentary hydrocarbon content. The down core distribution of 16:1omega7, 18:1omega7, 18:1omega5 esterified to phospholipids suggests a vertical zonation of the microbial community in relation to redox conditions and available organic matter. In addition to bacterial sulphur biomass, the presence of hopanoic acids in the phospholipids fraction suggests the contribution of bacteria growing on methane. According to the sterol composition, dominated by 4alpha(H)-methylsterols, dinoflagellates represent the major contributors to the organic matter produced in the water column, particularly during the period of extensive eutrophication. Long-chain diols (1,13-C(26), 1,15-C(30) and 1,15-C(32)) and long-chain keto-ols (1,15-C(30) and 1,15-C(32)) are reported for the first time at high latitudes. Their relative distributions (diol and keto-ol indexes of Versteegh et al. [Org. Geochem. 27 (1997)]) have allowed depicting a particular event during the eutrophication period, a freshwater intrusion with inputs of land-derived organic matter. This is in accordance with the downcore distribution of freshwater/terrestrial markers as sitosterol, dehydroabietic acid and iso- and anteiso-pimaric acids. The diol and keto-ol indexes have also underlined the general transition trend from marine to more brackish waters in the Bunnefjord. These last observations provide confidence into the use of these compounds in paleoenvironmental reconstruction.

Projection of diabetes burden through 2050: impact of changing demography and disease prevalence in the U.S.

OBJECTIVE: To project the number of people with diagnosed diabetes in the U.S. through 2050, accounting for changing demography and diabetes prevalence rates. RESEARCH DESIGN AND METHODS: We combined age-, sex-, and race-specific diagnosed diabetes prevalence rates-predicted from 1980-1998 trends in prevalence data from the National Health Interview Survey-with Bureau of Census population demographic projections. Sensitivity analyses were performed by varying both prevalence rate and population projections. RESULTS: The number of Americans with diagnosed diabetes is projected to increase 165%, from 11 million in 2000 (prevalence of 4.0%) to 29 million in 2050 (prevalence of 7.2%). The largest percent increase in diagnosed diabetes will be among those aged > or =75 years (+271% in women and +437% in men). The fastest growing ethnic group with diagnosed diabetes is expected to be black males (+363% from 2000-2050), with black females (+217%), white males (+148%), and white females (+107%) following. Of the projected 18 million increase in the number of cases of diabetes in 2050, 37% are due to changes in demographic composition, 27% are due to population growth, and 36% are due to increasing prevalence rates. CONCLUSIONS: If recent trends in diabetes prevalence rates continue linearly over the next 50 years, future changes in the size and demographic characteristics of the U.S. population will lead to dramatic increases in the number of Americans with diagnosed diabetes.

Use of diabetes preventive care and complications risk in two African-American communities.

BACKGROUND: We examined levels of diabetes preventive care services and glycemic and lipid control among African Americans with diabetes in two North Carolina communities. METHODS: Cross-sectional, population-based study of 625 African-American adults with diagnosed diabetes. Participants had a household interview to determine receipt of preventive care services including glycosylated hemoglobin (HbA(1c)), blood pressure, lipid, foot, dilated eye, and dental examinations; diabetes education; and health promotion counseling. A total of 383 gave blood samples to determine HbA(1c) and lipid values. RESULTS: Annual dilated eye, foot, and lipid examinations were reported by 70% to 80% of the population, but only 46% reported HbA(1c) tests. Rates of regular physical activity (31%) and daily self-monitoring of blood glucose (40%) were low. Sixty percent of the population had an HbA(1c) level >8% and one fourth had an HbA(1c) level >10%. Half of the population had a low-density lipoprotein value >130 mg/dL. Lack of insurance was the most consistent correlate of inadequate care (odds ratio [OR]=2.3; 95% confidence interval [CI]=1.3-3.9), having HbA(1c) >9.5% (OR=2.1, 95% CI=1.1-4.2), and LDL levels >130 mg/dL (OR=2.1; 95% CI=1.0-4.5). CONCLUSIONS: Levels of diabetes preventive care services were comparable to U.S. estimates, but glycemic and lipid control and levels of self-management behaviors were poor. These findings indicate a need to understand barriers to achieving and implementing good glycemic and lipid control among African Americans with diabetes.

Population-based estimates of mortality associated with diabetes: use of a death certificate check box in North Dakota.

OBJECTIVES: Overall and cause-specific mortality among persons with diabetes in North Dakota was estimated and compared with estimates from previous population-based studies. METHODS: Data were derived from North Dakota death certificate data, which included unique information on decedents' diabetes status and Behavioral Risk Factor Surveillance System estimates of the diabetic and nondiabetic adult populations of North Dakota. RESULTS: The risk of death among adults with diabetes was 2.6 (2.2, 2.9) times that of adults without diabetes. Relative risks of death among adults with diabetes were at least twice as high for heart disease, cerebrovascular disease, accidents and adverse events, and kidney disease and 70% to 80% higher for pneumonia and influenza, malignant neoplasms, arterial disease, and other causes. Risks remained substantial in the oldest age group. These findings are comparable to results of other population-based studies. CONCLUSIONS: Diabetes status information enhanced the usefulness of death certificate data in examining mortality associated with diabetes and confirms that the effect of diabetes on death is substantial.

Prevalence of diabetes among Native Americans and Alaska Natives, 1990-1997: an increasing burden.

OBJECTIVE: To determine trends in diabetes prevalence among Native Americans and Alaska Natives. RESEARCH DESIGN AND METHODS: From 1990 to 1997, Native Americans and Alaska Natives with diabetes were identified from the Indian Health Service (IHS) national outpatient database, and prevalence was calculated using these cases and estimates of the Native American and Alaskan population served by IHS and tribal health facilities. Prevalence was age-adjusted by the direct method based on the 1980 U.S. population. RESULTS: Between 1990 and 1997, the number of Native Americans and Alaska Natives of all ages with diagnosed diabetes increased from 43,262 to 64,474 individuals. Prevalence of diagnosed diabetes increased by 29%. By 1997, prevalence among Native Americans and Alaska Natives was 5.4%, and the age-adjusted prevalence was 8.0%. During the entire 1990-1997 period, prevalence among women was higher than that among men, but the rate of increase was higher among men than women (37 vs. 25%). In 1997, age-adjusted prevalence of diabetes varied by region and ranged from 3% in the Alaska region to 17% in the Atlantic region. The increase in prevalence between 1990 and 1997 ranged from 16% in the Northern Plains region to 76% in the Alaska region. CONCLUSIONS: Diabetes is common among Native Americans and Alaska Natives, and it increased substantially during the 8-year period examined. Effective interventions for primary, secondary, and tertiary, prevention are needed to address the substantial and rapidly growing burden of diabetes among Native Americans and Alaska Natives.

Type 2 diabetes among North American children and adolescents: an epidemiologic review and a public health perspective.

OBJECTIVES: To review the magnitude, characteristics, and public health importance of type 2 diabetes in North American youth. RESULTS: Among 15- to 19-year-old North American Indians, prevalence of type 2 diabetes per 1000 was 50.9 for Pima Indians, 4.5 for all US American Indians, and 2.3 for Canadian Cree and Ojibway Indians in Manitoba. From 1967-1976 to 1987-1996, prevalence increased 6-fold for Pima Indian adolescents. Among African Americans and whites aged 10 to 19 years in Ohio, type 2 diabetes accounted for 33% of all cases of diabetes. Youth with type 2 diabetes were generally 10 to 19 years old, were obese and had a family history of type 2 diabetes, had acanthosis nigricans, belonged to minority populations, and were more likely to be girls than boys. At follow-up, glucose control was often poor, and diabetic complications could occur early. CONCLUSIONS: Type 2 diabetes is an important problem among American Indian and First Nation youth. Other populations have not been well studied, but cases are now occurring in all population groups, especially in ethnic minorities. Type 2 diabetes among youth is an emerging public health problem, for which there is a great potential to improve primary and secondary prevention.

Impact of diabetes mellitus on mortality associated with pneumonia and influenza among non-Hispanic black and white US adults.

OBJECTIVES: This study assessed the impact of diabetes on mortality associated with pneumonia and influenza among non-Hispanic Black and White US adults. METHODS: Data were derived from the National Mortality Followback Survey (1986) and the National Health Interview Survey (1987-1989). RESULTS: Regardless of race, sex, and socioeconomic status, people with diabetes who died at 25 to 64 years of age were more likely to have pneumonia and influenza recorded on the death certificate than people without diabetes who died at comparable ages (odds ratio [OR] = 4.0, 95% confidence interval [CI] = 2.3, 7.7). For those 65 years and older, the risk remained elevated among Whites with diabetes (OR = 2.2, 95% CI = 1.7, 2.7) but not among Blacks with diabetes (OR = 1.0, 95% CI = 0.6, 1.7). It was estimated that about 17,000 (10.3%) of the 167,000 deaths associated with pneumonia and influenza that occurred in 1986 were attributable to diabetes. CONCLUSIONS: The impact of diabetes on deaths associated with pneumonia and influenza is substantial. Targeted immunizations among people with diabetes may reduce unnecessary deaths associated with pneumonia and influenza.

Identifying persons with diabetes using Medicare claims data.

The objective of this study was to develop and validate a method for identifying Medicare beneficiaries with diabetes by using Medicare claims data. We used self-reports of diabetes status from participants in the Medicare Current Beneficiary Survey to determine disease status, and then we examined these participants' Medicare claims. Using self-reported diabetes status as the "gold standard," we determined the sensitivity, specificity, and reliability of claims data in identifying beneficiaries with diabetes. We found that to construct a method that is adequately sensitive (> or = 70%), highly specific (> or = 97.5%), and reliable (kappa > or = 0.80), researchers must combine information from different types of Medicare claims files, use 2 years of data to identify cases, and require at least 2 diagnoses of diabetes among claims involving ambulatory care. Since these criteria are met by more than one method, the choice of method should be governed by the goals of the research as well as more practical concerns.

Use of services by diabetes patients in managed care organizations. Development of a diabetes surveillance system. CDC Diabetes in Managed Care Work Group.

OBJECTIVE: To develop a diabetes surveillance system that estimates the prevalence of diabetes and characterizes service use in diverse managed care organizations (MCOs). RESEARCH DESIGN AND METHODS: Computerized inpatient, pharmacy, outpatient, and laboratory records were used to develop an algorithm to identify diabetes patients and to develop surveillance indicators common to the three participating MCOs. Using 1993 data, the availability, specifications, and limitations of various surveillance indicators were determined. RESULTS: An extensive set of diabetes surveillance indicators was identified from the four sources of data. Consistent data specifications across MCOs needed to consider variation in the type of data collected, a lack of documentation on level of coverage, differences in coding data, and different models of health care delivery. A total of 16,363 diabetes patients were identified. The age-adjusted prevalence of diabetes ranged from 24 to 29 per 1,000 enrollees. Approximately one-third of patients with diabetes (32-34%) were taking insulin. The majority had one or more visits to a primary care physician during the year (72-94%). Visits to specialists were less frequent. Ophthalmologists and optometrists were the most commonly used specialists: 29-60% of the patients with diabetes at the three MCOs had visited an ophthalmologist or optometrist. About one-fifth had an overnight hospital stay during the year. CONCLUSIONS: This diabetes surveillance system is a useful tool for MCOs to track trends in prevalence of diabetes, use of health services, and delivery of preventive care to individuals with diabetes. This system may also be useful for health care planning and for assessing use changes after new developments in diabetes care or new quality management initiatives.

A project to reduce the burden of diabetes in the African-American Community: Project DIRECT.

Project DIRECT (Diabetes Interventions Reaching and Educating Communities Together) is the first comprehensive community diabetes demonstration project in the United States in an African-American community. This article describes its intervention components and evaluation design. The development and implementation of Project DIRECT has included the community since the project's beginning. Interventions are targeted in three areas: health promotion (improving diet and physical activity levels), outreach (improving diabetes awareness, detection of undiagnosed diabetes, and ensuring that persons with diabetes who are not receiving continuing diabetes care are integrated into the health-care system), and diabetes care (improving self-care, increasing access, and improving the quality of diabetes preventive care received within the health-care system). Evaluation will be internal (conducted by Project DIRECT staff to assess process outcomes in persons directly exposed to each specific intervention) and external (review of outcomes to assess the impact of the multi-intervention program at the level of the entire community). Because diabetes exacts a disproportionate toll among African Americans, the findings from this project should aid in developing strategies to lessen the burden of this disorder, particularly among minority populations.

Surveillance for diabetes mellitus--United States, 1980-1989.

PROBLEM/CONDITION: In the United States, diabetes mellitus is the most important cause of lower-extremity amputation and end-stage renal disease; the major cause of blindness among working-age adults; a major cause of disability, premature mortality, congenital malformations, perinatal mortality, and health-care costs; and an important risk factor for the development of many other acute and chronic conditions (e.g., diabetic ketoacidosis, ischemic heart disease, stroke). Surveillance data describing diabetes and its complications are critical to increasing recognition of the public health burden of diabetes, formulating health-care policy, identifying high-risk groups, developing strategies to reduce the burden of this disease, and evaluating progress in disease prevention and control. REPORTING PERIOD COVERED: In this report, data are summarized from CDC's diabetes surveillance system; trends in diabetes and its complications are evaluated by age, sex, and race for the years 1980-1989. DESCRIPTION OF SYSTEM: CDC has established an ongoing and evolving surveillance system to analyze and compile periodic, representative data on the disease burden of diabetes and its complications in the United States. Data sources currently include vital statistics, the National Health Interview Survey, the National Hospital Discharge Survey, and Medicare claims data for end-stage renal disease. RESULTS AND INTERPRETATION: In 1989, approximately 6.7 million persons in the United States reported that they had diabetes mellitus, and a similar number probably had this disabling chronic disease without being aware of it. The disease burden of diabetes and its complications is large and is likely to increase as the population grows older. Effective primary, secondary, and tertiary prevention strategies are needed, and these efforts need to be intensified among groups at highest risk, including blacks. Important gaps exist in periodic and representative data for describing the disease burden. ACTIONS TAKEN: CDC is assisting diabetes control programs in 26 states and one territory. These programs attempt to reduce the burden of diabetes by preventing blindness, lower-extremity amputations, cardiovascular disease, and adverse outcomes of pregnancy among persons with diabetes. Because of important limitations in measuring the burden of diabetes, CDC is exploring sources of surveillance data for blindness, adverse outcomes of pregnancy, and the public health burden of diabetes among minority groups.

Sentinel health events surveillance in diabetes. Deaths among persons under age 45 with diabetes.

The pilot study for a sentinel health events surveillance system for deaths among persons under age 45 with diabetes was conducted in six states in 1984 and 1985. Two hundred and thirty-three events were identified. Information from death certificates, physicians, and families revealed that 22% died from acute complications of diabetes and 53% from chronic complications. Blood pressure measurement and urinalysis testing had been performed in the last year for almost all of the decedents, but other preventive practices were reported less frequently. Hypertension was present in 57% and of those, was not controlled in 73%. Forty-four percent were cigarette smokers at the time of death. Agreement between physicians and families was generally higher for clinical conditions than for care practices. This surveillance system appears to yield information about the health care of persons with diabetes not readily available from other sources, although modifications may be necessary before implementation.

Diabetes and renal mortality in the United States.

The risk of renal death is examined in the United States population 15 years of age and older with and without diabetes. The renal mortality rate is 174.6 per 100,000 among people with diabetes and 42.5 per 100,000 among people without diabetes. The relative risk of renal mortality is 4.1 for diabetics, age-adjusted relative risk, 2.6. The risk of renal mortality is highest in young people with diabetes. Rates of renal mortality are higher than previously believed among Whites with diabetes and among women with diabetes.

Gestational diabetes. Incidence, maternal characteristics, and perinatal outcome.

Accurate estimates of the incidence of abnormal glucose tolerance during pregnancy are virtually nonexistent. Screening select populations of women with risk factors for the condition and the nonrandom, non-population-based nature of most studies have given rise to wide variances in reported incidence. We analyzed data from the states of Mississippi and Washington and from the National Natality and Fetal Mortality Surveys conducted in 1980 in an attempt to provide more accurate population-based estimates of the incidence of gestational diabetes mellitus (GDM). In the national surveys GDM was noted (screening and diagnostic criteria were unavailable) as a complication in 0.38% of all sampled pregnancies; overt (type I and type II) diabetes was noted in 0.78%. Mean maternal age for the GDM group was 28.4 yr; 85% were white (81% controls) and 15% non-white (19% controls). Prepregnancy weights were higher in the GDM group by an average of 20 lb. However, mean weight gain was less in this group than in controls (23 versus 29 lb). Perinatal mortality was noted in approximately 2.8% (1.3% in controls) of the offspring in GDM-complicated pregnancies and congenital malformations in 6.4% (7.9% in controls). Methodologic problems were encountered and included lack of screening and diagnostic criteria, underreporting, and underrecording.