Systemic inflammation, enteropathogenic E. Coli, and micronutrient insufficiencies in the first trimester as possible predictors of preterm birth in rural Bangladesh: a prospective study.

BACKGROUND: An incomplete understanding of preterm birth is especially concerning for low-middle income countries, where preterm birth has poorer prognoses. While systemic proinflammatory processes are a reportedly normal component of gestation, excessive inflammation has been demonstrated as a risk factor for preterm birth. There is minimal research on the impact of excessive maternal inflammation in the first trimester on the risk of preterm birth in low-middle income countries specifically. METHODS: Pregnant women were enrolled at the rural Bangladesh site of the National Institute of Child Health Global Network Maternal Newborn Health Registry. Serum samples were collected to measure concentrations of the inflammatory markers C-reactive protein (CRP) and Alpha-1-acid glycoprotein (AGP), and stool samples were collected and analyzed for enteropathogens. We examined associations of maternal markers in the first-trimester with preterm birth using logistic regression models. CRP and AGP were primarily modeled with a composite inflammation predictor. RESULTS: Out of 376 singleton births analyzed, 12.5% were preterm. First trimester inflammation was observed in 58.8% of all births, and was significantly associated with increased odds of preterm birth (adjusted odds ratio [aOR] = 2.23; 95% confidence interval [CI]: 1.03, 5.16), independent of anemia. Maternal vitamin B12 insufficiency (aOR = 3.33; 95% CI: 1.29, 8.21) and maternal anemia (aOR = 2.56; 95% CI: 1.26, 5.17) were also associated with higher odds of preterm birth. Atypical enteropathogenic E. coli detection showed a significant association with elevated AGP levels and was significantly associated with preterm birth (odds ratio [OR] = 2.36; 95% CI: 1.21, 4.57), but not associated with CRP. CONCLUSIONS: Inflammation, anemia, and vitamin B12 insufficiency in the first trimester were significantly associated with preterm birth in our cohort from rural Bangladesh. Inflammation and anemia were independent predictors of premature birth in this low-middle income setting where inflammation during gestation was widespread. Further research is needed to identify if infections such as enteropathogenic E. coli are a cause of inflammation in the first trimester, and if intervention for infection would decrease preterm birth.

Bone mineral density and the risk of incident dementia: A meta-analysis.

BACKGROUND: It is not known whether bone mineral density (BMD) measured at baseline or as the rate of decline prior to baseline (prior bone loss) is a stronger predictor of incident dementia or Alzheimer's disease (AD). METHODS: We performed a meta-analysis of three longitudinal studies, the Framingham Heart Study (FHS), the Rotterdam Study (RS), and the Rush Memory and Aging Project (MAP), modeling the time to diagnosis of dementia as a function of BMD measures accounting for covariates. We included individuals with one or two BMD assessments, aged ≥60 years, and free of dementia at baseline with follow-up available. BMD was measured at the hip femoral neck using dual-energy X-ray absorptiometry (DXA), or at the heel calcaneus using quantitative ultrasound to calculate estimated BMD (eBMD). BMD at study baseline ("baseline BMD") and annualized percentage change in BMD prior to baseline ("prior bone loss") were included as continuous measures. The primary outcome was incident dementia diagnosis within 10 years of baseline, and incident AD was a secondary outcome. Baseline covariates included age, sex, body mass index, ApoE4 genotype, and education. RESULTS: The combined sample size across all three studies was 4431 with 606 incident dementia diagnoses, 498 of which were AD. A meta-analysis of baseline BMD across three studies showed higher BMD to have a significant protective association with incident dementia with a hazard ratio of 0.47 (95% CI: 0.23-0.96; p = 0.038) per increase in g/cm2 , or 0.91 (95% CI: 0.84-0.995) per standard deviation increase. We observed a significant association between prior bone loss and incident dementia with a hazard ratio of 1.30 (95% CI: 1.12-1.51; p < 0.001) per percent increase in prior bone loss only in the FHS cohort. CONCLUSIONS: Baseline BMD but not prior bone loss was associated with incident dementia in a meta-analysis across three studies.

Keloids, hypertrophic scars, and uterine fibroid development: a prospective ultrasound study of Black and African American women.

OBJECTIVE: To examine the association between keloids, hypertrophic scars, and uterine fibroid incidence as well as growth. Both keloids and fibroids are fibroproliferative conditions that have been reported to be more prevalent among Blacks than Whites, and they share similar fibrotic tissue structures, including extracellular matrix composition, gene expression, and protein profiles. We hypothesized that women with a history of keloids would have greater uterine fibroid development. DESIGN: A prospective community cohort study (enrollment 2010-2012) with 4 study visits over 5 years to conduct standardized ultrasounds to detect and measure fibroids ≥0.5 cm in diameter, assess the history of keloid and hypertrophic scars, and update covariates. SETTING: Detroit, Michigan area. PATIENTS: A total of 1,610 self-identified Black and/or African American women aged 23-35 years at enrollment without a previous clinical diagnosis of fibroids. EXPOSURE(S): Keloids (raised scars that grow beyond the margins of the original injury) and hypertrophic scars (raised scars that stay within the bounds of the original injury). Because of the difficulties in distinguishing keloids and hypertrophic scars, we separately examined the history of keloids and the history of either keloids or hypertrophic scars (any abnormal scarring) and their associations with fibroid incidence and growth. MAIN OUTCOME MEASURE(S): Fibroid incidence (new fibroid after a fibroid-free ultrasound at enrollment) was assessed using Cox proportional-hazards regression. Fibroid growth was assessed using linear mixed models. The estimates for the change in log volume per 18 months were converted to the estimated percentage difference in volume for scarring vs. no-scarring. Both incidence and growth models were adjusted for time-varying demographic, reproductive, and anthropometric factors. RESULT(S): Of the 1,230 fibroid-free participants, 199 (16%) reported ever having keloids, 578 (47%) reported keloids or hypertrophic scars, and 293 (24%) developed incident fibroids. Neither keloids (adjusted hazard ratio = 1.04; 95% confidence interval: 0.77, 1.40) nor any abnormal scarring (adjusted hazard ratio = 1.10; 95% confidence interval: 0.88, 1.38) were associated with fibroid incidence. Fibroid growth differed little by scarring status. CONCLUSION(S): Despite molecular similarities, self-reported keloid and hypertrophic scars did not show an association with fibroid development. Future research may benefit from the examination of dermatologist-confirmed keloids or hypertrophic scars; however, our data suggest little shared susceptibility for these 2 types of fibrotic conditions.

Urinary incontinence in community-dwelling older Mexican American and European American women.

The aim was to measure prevalence and correlates of urinary incontinence in community-dwelling Mexican American (MA) and European American (EA) women from a cross-sectional analysis of baseline data from a longitudinal cohort. Participants were MA and EA women, aged 65 years and older, in the San Antonio Longitudinal Study of Aging (SALSA), of whom 421 (97.4%) responded to the question "How often do you have difficulty holding your urine until you can get to a toilet." Measurements included sociodemographic, functional, cognitive, psychosocial, and clinical status variables derived from bilingual interviews and performance-based tests. Urinary incontinence prevalence was 36.6% (n=154). MA women reported less incontinence than did EAs (29% versus 45%, p=0.001). In multivariable analyses in MA women, urinary incontinence correlated with the presence of fecal incontinence (OR 4.0, 95% CI 1.1-14.0) and more dependency in activities of daily living (1.4, 1.1-1.8) after controlling for significant sociodemographic factors. In EA women, only age >75 (4.2, 1.4-12.4) was associated with urinary incontinence. MA women were less likely to report incontinence compared to EAs, despite MAs having increased number of children, less education, higher BMI, and more diabetes. Further research is needed to evaluate risk factors for urinary incontinence among MA women.

Holistic assessment of chronic pain among elders.

This pilot study assessed pain using 7 dimensions of pain (physiologic, behavioral, sensory, affective, cognitive, sociocultural, and spiritual) to better understand and identify patterns of elder response to chronic pain within a holistic framework. Previously validated instruments were used to assess 150 cognitively intact subjects, aged 65 years and older, with chronic pain. Thirteen patterns were identified reflecting distinct patterns of pain response. Two patterns comprised 85% of the responses: (1) high spiritual well-being, low physiologic pain, and high perceived independent functioning; and (2) high spiritual well-being, low physiologic pain, and lower perceived independent functioning. The 11 other patterns of pain response also varied in their responses to the pain experience. These responses reflect the unique and holistic experience of chronic pain among older adults. Holistic assessment enhances the understanding of the pain specific to the individual. Self-perceived functional dependence and the spiritual component significantly influence chronic pain experiences.

Caring for older Americans: the future of geriatric medicine.

In response to the needs and demands of an aging population, geriatric medicine has grown rapidly during the past 3 decades. The discipline has defined its core values as well as the knowledge base and clinical skills needed to improve the health, functioning, and well-being of older persons and to provide appropriate palliative care. Geriatric medicine has developed new models of care, advanced the treatment of common geriatric conditions, and advocated for the health and health care of older persons. Nevertheless, at the beginning of the 21st century, the health care of older persons is at a crossroads. Despite the substantial progress that geriatric medicine has made, much more remains to be done to meet the healthcare needs of our aging population. The clinical, educational, and research approaches of the 20th century are unable to keep pace and require major revisions. Maintaining the status quo will mean falling further and further behind. The healthcare delivery and financing systems need fundamental redesign to improve quality and eliminate waste. The American Geriatrics Society (AGS) Task Force on the Future of Geriatric Medicine has identified five goals aimed at optimizing the health of older persons: To ensure that every older person receives high-quality, patient-centered health care; To expand the geriatrics knowledge base; To increase the number of healthcare professionals who employ the principles of geriatric medicine in caring for older persons; To recruit physicians and other healthcare professionals into careers in geriatric medicine; To unite professional and lay groups in the effort to influence public policy to continually improve the health and health care of seniors. Geriatric medicine cannot accomplish these goals alone. Accordingly, the Task Force has articulated a set of recommendations primarily aimed at the government, organizations, agencies, foundations, and other partners whose collaboration will be essential in accomplishing these goals. The vision described in this document and the accompanying recommendations are only the broad outline of an agenda for the future. Geriatric medicine, through its professional organizations and its partners, will need to mobilize resources to identify and implement the specific steps that will make the vision a reality. Doing so will require broad participation, consensus building, creativity, and perseverance. The consequences of inaction will be profound. The combination of a burgeoning number of older persons and an inadequately prepared, poorly organized physician workforce is a recipe for expensive, fragmented health care that does not meet the needs of our older population. By virtue of their unique skills and advocacy for the health of older persons, geriatricians can be key leaders of change to achieve the goals of geriatric medicine and optimize the health of our aging population. Nevertheless, the goals of geriatric medicine will be accomplished only if geriatricians and their partners work in a system that is designed to provide high-quality, efficient care and recognizes the value of geriatrics.

Measuring subclinical disability in older mexican americans.

OBJECTIVE: The purpose of this study was to develop a comprehensive list of adaptive strategies to prevent disability and use this information to devise a preliminary measure of subclinical disability (state of sustained independence in the presence of latent or manifest functional limitations) suitable for older Mexican Americans. METHOD: Semistructured interviews were conducted with 24 community-dwelling Mexican American elders (> or =65 years old) to elicit information about adaptations in performance of daily living tasks (eg, walking, dressing, and shopping) that may indicate presence of subclinical disability. This information was used to construct a quantitative self-report measure of subclinical disability administered to 207 older Mexican Americans. Item and factor analyses were performed to reduce the number of items and establish their underlying structure. Construct and discriminant validity of the reduced instrument was determined. RESULTS: A framework comprised of nine categories of daily living tasks, three functional levels, and five adaptation types was generated from the qualitative data. The initial 133-item measure (named the ADAPT) was reduced to a 44-item scale with three subscales (physical, household, and social). ADAPT scores correlated significantly in the expected direction with standard functional status measures, but the shared variance was modest, indicating that the ADAPT captured substantial, unique variance. Mean ADAPT scores differed significantly and were monotonically lower across subgroups classified as independent, subclinically disabled, and disabled, respectively. CONCLUSIONS: The ADAPT seems to have construct and discriminant validity as a measure of subclinical disability. Additional research is required to determine sensitivity to change and clinically significant cut points for varying risk of frank disability.

Recruitment of older participants in frailty/injury prevention studies.

Despite the lifelong health benefits of physical activity, frailer older adults have typically been excluded from studies promoting more active lifestyles. This study documents the recruitment process and costs from a multisite study to identify effective strategies for recruiting older adults in frailty/injury prevention research. Randomized controlled clinical trials were conducted at 7 sites; an 8th site was a compliance study. Interventions reflected center- and home-based health promotion programs. Site objectives, eligibility criteria, and contact and screening methods were obtained from manuals of operation. Recruitment results (number screened, eligibility rates, randomized to screened ratios) were ascertained from recruitment data. Sites furnished estimated recruitment costs (nonlabor expenses, investigator and staff time, fringe benefits) up to signing the consent form. The sites targeted diverse populations and sample sizes. The majority revised recruitment methods to meet their recruitment goals. Most sites estimated costs of recruitment at over $300 per participant randomized. Recruitment costs were affected by staff time spent alleviating concerns about participants' health, essential interactions with family members, and arranging for transportation. Neither frailty nor intervention intensity was found to be a major predictor of recruitment outcomes. Recruitment expense was associated with selection criteria and frailty status of the target population. Older people can be successfully recruited into beneficial health promotion programs, but it is often challenging. In planning health promotion studies, investigators need to be aware of the numbers of older people they may need to screen and different strategies for increasing recruitment success.