Estimating missing concentrations of p,p'-DDT in the 1999-2004 National Health and Nutrition Examination Survey using multiple imputation.

We investigated the association between diabetes and p,p'-DDT (dichlorodiphenyltrichloroethane) in blood of Mexican Americans who participated in the 1999-2004 National Health and Nutrition Examination Survey (NHANES). In this sample, p,p'-DDT were missing in 50% of subjects and we used multiple imputation (MI) to address the problem. Compared to ignoring the missing data, MI led to a more robust threshold for the p,p'-DDT reference category. Whereas previously p,p'-DDT ≤ 0.0860 ng/g was used as the reference category, using MI, we were able to use p,p'-DDT < 0.0574 ng/g as the reference category to study the association between p,p'-DDT and diabetes via logistic regression. In this analysis, p,p'-DDT ≥ 0.0750 ng/g was associated with an odds ratio of 1.99 (95% CI 1.09-3.61) for diabetes and 4.20 (95% CI 1.93-9.12) for diabetic nephropathy. The reference category for diabetes without nephropathy outcome stayed consistent after MI but our analysis confirmed that p,p'-DDT > 0.0860 ng/g was associated with diabetes without nephropathy with an odds ratio of 1.89 (95% CI 1.09-3.27). Our study showed that MI can be effectively used to deal with missing at random data in persistent organic pollutants measured in the 1999-2004 NHANES.

Dual Healthcare System Use During Episodes of Acute Care Heart Failure Associated With Higher Healthcare Utilization and Mortality Risk.

Background Individuals receiving cross-system care (dual users) have higher rates of healthcare utilization and worse outcomes for heart failure ( HF ) and other conditions. Individuals can be dual users or single-system users at different times, though, and little is known about utilization and mortality within discrete episodes of care. Methods and Results A retrospective cohort of 3439 patients with 5231 discrete episodes of HF exacerbation were identified between 2007 and 2011. Episodes encompassed the period from 2 weeks before an initial HF emergency department ( ED ) visit or hospitalization, included any acute care visits within 30 days after initial visit, and ended 30 days after the last acute care visit in the episode chain. All-cause and HF -specific ED visits and hospitalization within 30 days of index visit were analyzed using generalized estimating equations with robust variance. Hazard for death within episodes of acute illness was analyzed using Cox proportional hazards models. In adjusted analyses, dual use acute HF episodes were associated with higher odds of all-cause ED visits (odds ratio 1.61, 95% confidence interval [ CI ], 1.33, 1.95), HF -specific ED visits, (odds ratio 1.54, 95% CI , 1.12, 2.13), all-cause hospitalization (odds ratio 1.89, 95% CI , 1.50, 2.38), and HF -specific hospitalization (odds ratio 1.62, 95% CI , 1.15-2.30) as compared with Veterans Health Administration-only episodes of acute HF care. Dual use episodes of care were associated with higher hazard for mortality (hazard ratio=1.52, 95% CI 1.07, 2.16) as compared with all-Veterans Health Administration episodes of care. Conclusions Episodes of acute HF care spanning across healthcare systems appear to be associated with higher risk of subsequent ED visits, hospitalization, and mortality.

The interaction between rural/urban status and dual use status among veterans with heart failure.

INTRODUCTION: Dual healthcare system use is associated with higher rates of healthcare utilization, but the influence of rurality on this phenomenon is unclear. This study aimed to determine the extent to which rurality in the USA modifies the likelihood for acute healthcare use among veterans with heart failure (HF). METHODS: Using merged Veterans Affairs (VA), Medicare, and state-level administrative data, a retrospective cohort study of 4985 veterans with HF was performed. Negative binomial regression with interaction term for dual use and geographic location was used to estimate and compare the associations between dual use (as compared to VA-only use) and emergency department (ED) visits, hospitalizations, and 30-day hospital readmissions in rural/highly rural veterans versus urban veterans. RESULTS: The association between dual use compared to VA-only use and ED visits was stronger in rural/highly rural veterans (RR=1.28 (95%CI: 1.21,1.35)) than in urban veterans (rate ratio (RR)=1.17 (95% confidence interval (CI): 1.11,1.22)) (interaction p-value=0.0109), while the association between dual use and all-cause hospitalizations was similar in rural/highly rural veterans (RR=2.00 (95%CI: 1.87, 2.14)) and in urban veterans (RR=1.87 (95%CI: 1.77,1.98)). The association between dual use and all-cause 30-day hospital readmission was also similar in rural/highly rural versus urban veterans. CONCLUSION: Rurality significantly modifies the likelihood of ED visits for HF, although this effect was not observed for hospitalizations or hospital readmissions. While other patient- or system-level factors may more heavily influence hospitalization and readmission in this population, dual use appears to be a marker for higher healthcare utilization and worse outcomes for both urban and rural veterans.

Exposure to DDT and diabetic nephropathy among Mexican Americans in the 1999-2004 National Health and Nutrition Examination Survey.

Concentrations of the pesticide DDT (dichlorodiphenyltrichloroethane) and its metabolite DDE (dichlorodiphenyldichloroethylene), in the blood of Mexican Americans, were evaluated to determine their relationships with diabetes and diabetic nephropathy. The data were derived from the National Health and Nutrition Examination Survey (NHANES) 1999-2004 (unweighted N = 1,411, population estimate = 13,760,609). The sample included teens, 12-19 years old, which accounted for 19.8% of the data. The time of the study overlapped the banning of DDT in Mexico in the year 2000, and those participants born in Mexico were exposed to DDT before they immigrated to the US. We sought to better understand the relationship of DDT with diabetes in a race/ethnicity group prone to develop diabetes and exposed to DDT. In this study, nephropathy was defined as urinary albumin to creatinine ratio >30 mg/g, representing microalbuminuria and macroalbuminuria, and total diabetes was defined as diagnosed and undiagnosed diabetes (glycohemoglobin, A1c ≥ 6.5%). The proportion with the isomer p,p'-DDT >0.086 ng/g (above the maximum limit of detection) was 13.3% for Mexican Americans born in the US, and 36.9% for those born in Mexico. Levels of p,p'-DDT >0.086 ng/g were associated with total diabetes with nephropathy (odds ratio = 4.42, 95% CI 2.23-8.76), and with total diabetes without nephropathy (odds ratio = 2.02, 95% CI 1.19-3.44). The third quartile of p,p'-DDE (2.99-7.67 ng/g) and the fourth quartile of p,p'-DDE (≥7.68 ng/g) were associated with diabetic nephropathy and had odds ratios of 5.32 (95% CI 1.05-26.87) and 14.95 (95% CI 2.96-75.48) compared to less than the median, respectively, whereas p,p'-DDE was not associated with total diabetes without nephropathy. The findings of this study differ from those of a prior investigation of the general adult US population in that there were more associations found with the Mexican Americans sample.

Dual health care system use is associated with higher rates of hospitalization and hospital readmission among veterans with heart failure.

BACKGROUND: Heart failure (HF) frequently causes hospital admission and readmission. Patients receiving care from multiple providers and facilities (dual users) may risk higher health care utilization and worse health outcomes. METHODS: To determine rates of emergency department (ED) visits, hospitalizations, and hospital readmissions relative to dual use among HF patients, we analyzed a retrospective cohort of 13,977 veterans with HF hospitalized at the Veterans Affairs (VA) or non-VA facilities from 2007 to 2011; we analyzed rates of acute health care utilization using zero-inflated negative binomial regression. RESULTS: Compared to VA-only users and dual users, individuals receiving all of their ED and hospital care outside the VA tended to be older, more likely to be non-Hispanic white and married, and less likely to have high levels of service connected disability. Compared to VA-only users, dual users had significantly higher rates of ED visits for HF as a primary diagnosis (adjusted rate ratio 1.15, 95% CI 1.04-1.27), hospitalization for HF (adjusted rate ratio 1.4, 95% CI 1.26-1.56), hospital readmission after HF hospitalization (all cause) (1.46, 95% CI 1.30-1.65), and HF-specific hospital readmission after HF hospitalization (1.46, 95% CI 1.31-1.63). With the exception of hospitalization for any primary diagnosis, non-VA-only users had significantly lower rates of ED visits, hospitalization, and readmission compared to VA-only users. CONCLUSIONS: Dual use is associated with higher rates of health care utilization among patients with HF. Interventions should be devised to encourage continuity of care where possible and to improve the effectiveness and safety of dual use in instances where it is necessary or desired.

Association of dioxins, furans and dioxin-like PCBs in human blood with nephropathy among US teens and young adults.

We assessed the association of three chlorinated dibenzo-p-dioxins, a chlorinated dibenzofuran, and four dioxin-like polychlorinated biphenyls (PCBs) in human blood with nephropathy (microalbuminuria or macroalbuminuria) among teens and young adults (12-30 years old) having normal glycohemoglobin (A1c <5.7%). The data were derived from the 1999-2004 National Health and Nutrition Examination Survey (unweighted n=1504, population estimate=38,806,338). In this paper, nephropathy refers to normal A1c with nephropathy. In an all-adult sample (Everett CJ, Thompson OM. Dioxins, furans and dioxin-like PCBs in human blood: causes or consequences of diabetic nephropathy? Environ Res 2014;132:126-31), the cut-offs for these chemicals being considered elevated, were defined as the 75th percentile. Using these same cut-offs again, the proportion of those with one or more of the eight dioxin-like compounds elevated was 9.9%. The four chemicals associated with nephropathy were 1,2,3,6,7,8-hexachlorodibenzo-p-dioxin, PCB 126, PCB 169, and PCB 156. The proportion with one or more of these four dioxin-like chemicals elevated was 3.9% (unweighted n=46) and the odds ratio (OR) for nephropathy was 7.1 [95% confidence interval (CI) 1.8-28.1]. The association was strong among females (OR 17.4, 95% CI 3.4-88.6), but among males there were no cases of nephropathy when one or more of the four dioxin-like chemicals were elevated, and therefore no association. In a separate analysis, elevated toxic equivalency, defined using the eight dioxin-like chemicals (TEQ8), was associated with nephropathy. TEQ8 ≥50.12 fg/g included 2.6% of the sample (unweighted n=28) and had an OR of 5.8 (95% 1.3-25.9) for nephropathy. As found in the analysis of one or more of four dioxin-like chemicals elevated, TEQ8 ≥50.12 fg/g was associated with nephropathy among females (OR 11.9, 95% CI 1.6-87.2), but not males. Trends for least-squares means also differed by gender, but there were no significant differences in mean TEQ8 between normal subjects and those having nephropathy in either males or females. We also evaluated pre-diabetes (A1c 5.7-6.4%) without nephropathy and found no associations when one or more of four dioxin-like compounds were elevated, or when TEQ8 was ≥50.12 fg/g. In this study, associations of dioxin-like chemicals with nephropathy were found among females at an early age. Prospective studies are needed to determine if dioxin-like compounds cause nephropathy, or if these relationships are cases of reverse causation.

Association of DDT and heptachlor epoxide in human blood with diabetic nephropathy.

Six organochlorine pesticides and pesticide metabolites in human blood were tested to determine their relationships with diabetic nephropathy. The data were derived from the National Health and Nutrition Examination Survey (NHANES) 1999-2004 (unweighted, n=2992, population estimate=133,088,752). The six chemicals were p,p'-DDT (dichlorodiphenyltrichloroethane), p,p'-DDE (dichlorodiphenyltrichloroethylene), beta-hexachlorocyclohexane, oxychlordane, trans-nonachlor and heptachlor epoxide. In this research, total diabetes included diagnosed and undiagnosed diabetes (glycohemoglobin, A1c ≥6.5%), and nephropathy was defined as a urinary albumin to creatinine ratio >30 mg/g, representing microalbuminuria and macroalbuminuria. The pesticide p,p'-DDT and pesticide metabolite heptachlor epoxide were significantly associated with total diabetes with nephropathy, with odds ratios of 2.08 (95% CI 1.06-4.11) and 1.75 (95% CI 1.05-2.93), respectively. Organochlorine pesticides are thought to act through the constitutive androstane receptor/pregnane X receptor disease pathway, but this is not well established. When p,p'-DDT and heptachlor epoxide were both elevated, the odds ratio for diabetic nephropathy was 2.76 (95% CI 1.31-5.81), and when six of six organochlorine pesticides and pesticide metabolites, were elevated, the odds ratio for diabetic nephropathy was 3.00 (95% CI 1.08-8.36). The differences in the odds ratios for these groups appear to be due to differences in the mean heptachlor epoxide concentration of each category. Organochlorine pesticides and pesticide metabolites are known to have estrogenic, antiestrogenic or antiandrogenic activity. The constitutive androstane receptor/pregnane X receptor pathway is thought to interact with the aryl hydrocarbon receptor pathway, and the associations noted may be due to that interaction.

Dioxins, furans and dioxin-like PCBs in human blood: causes or consequences of diabetic nephropathy?

Nephropathy, or kidney disease, is a major, potential complication of diabetes. We assessed the association of 6 chlorinated dibenzo-p-dioxins, 9 chlorinated dibenzofurans and 8 polychlorinated biphenyls (PCBs) in blood with diabetic nephropathy in the 1999-2004 National Health and Nutrition Examination Survey (unweighted N=2588, population estimate=117,658,357). Diabetes was defined as diagnosed or undiagnosed (glycohemoglobin ≥ 6.5%) and nephropathy defined as urinary albumin to creatinine ratio >30 mg/g, representing microalbuminuria or macroalbuminuria. For the 8 chemicals analyzed separately, values above the 75th percentile were considered elevated, whereas for the other 15 compounds values above the maximum limit of detection were considered elevated. Seven of 8 dioxins and dioxin-like compounds, analyzed separately, were found to be associated with diabetic nephropathy. The chemicals associated with diabetic nephropathy were: 1,2,3,6,7,8-Hexachlorodibenzo-p-dioxin; 1,2,3,4,6,7,8,9-Octachlorodibenzo-p-dioxin; 2,3,4,7,8-Pentachlorodibenzofuran; PCB 126; PCB 169; PCB 118; and PCB 156. Three of the 8 dioxins and dioxin-like compounds; 1,2,3,4,6,7,8,9-Octachlorodibenzo-p-dioxin; 2,3,4,7,8-Pentachlorodibenzofuran and PCB 118; expressed as log-transformed continuous variables; were associated with diabetes without nephropathy. When 4 or more of the 23 chemicals were elevated the odds ratios were 7.00 (95% CI=1.80-27.20) for diabetic nephropathy and 2.13 (95% CI=0.95-4.78) for diabetes without nephropathy. Log-transformed toxic equivalency (TEQ) was associated with both diabetic nephropathy, and diabetes without nephropathy, the odds ratios were 2.35 (95% CI=1.57-3.52) for diabetic nephropathy, and 1.44 (95% CI=1.11-1.87) for diabetes without nephropathy. As the kidneys function to remove waste products from the blood, diabetic nephropathy could be either the cause or the consequence (or both) of exposure to dioxins, furans and dioxin-like PCBs.

Chlamydia pneumoniae and progression of subclinical atherosclerosis.

BACKGROUND: Cross-sectional investigation between presence of antibodies and coronary artery calcification (CAC) in past studies has shown no relationship, but progression over time has not been investigated. The objective of this study was to determine the relationship between presence of Chlamydia pneumoniae antibodies and progression of CAC and ankle-brachial index (ABI). DESIGN: The Multiethnic Study of Atherosclerosis (MESA) is a prospective population-based cohort of racially and ethnically diverse male and female participants recruited from six communities in the USA, age 45-84 years, free of clinical cardiovascular disease at baseline. METHODS: The main outcomes were progression of mean CAC and ABI between exams 1 (2000-02) and 3 (2004-05) (median follow-up of 3.13 years) by C. pneumoniae antibody. Multivariate models adjusting for demographics, obesity, smoking, alcohol use, and physical activity were computed. RESULTS: Of 2223 subjects analysed, 76% were positive for C. pneumoniae antibodies. Progression of CAC was significantly higher in the antibody-positive group (93.8 vs. 78.2 agatston units, p = 0.02) and in antibody-positive subjects with CAC ≥10 at baseline (216.5 vs. 178.6, p = 0.02) than antibody-negative group. Smoking and body mass index ≥30 kg/m(2) both had interactions with presence of C. pneumoniae yielding significantly greater CAC progression. Progression of ABI did not significantly differ by C. pneumoniae antibody status in models adjusted for covariates. CONCLUSIONS: C. pneumoniae antibodies are related to progression of CAC, particularly in individuals with CAC present at baseline. This provides evidence that certain groups are at higher risk of atherosclerotic progression and may be useful for risk stratification and treatment.

Impact of healthy lifestyle on mortality in people with normal blood pressure, LDL cholesterol, and C-reactive protein.

BACKGROUND: To investigate the impact of healthy lifestyle on cardiovascular risk and mortality in people without a history of cardiovascular disease and without elevation of lipid, blood pressure, or inflammatory markers. DESIGN: Cohort study. METHODS: Study of a diverse sample of adults in the NHANES III follow-up Mortality Survey, to determine the benefit of adhering to healthy lifestyle habits (five or more fruits and vegetables/day, regular exercise, or being non-obese (body mass index 18.5-29.9 kg/m(2)), no current smoking, moderate alcohol consumption) in adults without common cardiovascular risk factors such as elevated cholesterol (low-density lipoprotein, LDL, cholesterol >130 mg/dl), inflammation (C-reactive protein, CRP, >3.0 mg/l, or hypertension (blood pressure >140/90 mmHg). RESULTS: Of 11,841 participants, 14.9% were adherent to all five healthy habits. After controlling for age, race, and gender, individuals with lower LDL cholesterol (HR 6.33, 95% CI 2.80-14.30), low CRP (HR 3.48, 95% CI 2.23-5.41), or normal blood pressure (HR 2.87, 95% CI 1.58-5.20) and 0-1 healthy habits had significantly higher all-cause (shown) and cardiovascular mortality than people adhering to all five healthy habits. People without common risk factors and lacking only 1-2 of the healthy habits remained at higher risk of all-cause mortality. CONCLUSIONS: People without a history of cardiovascular disease who lack common cardiovascular risk factors remain at significantly greater risk of cardiovascular and all-cause mortality if they do not adhere to a healthy lifestyle. Strategies to encourage adopting healthy lifestyles should be implemented among individuals across all risk levels.

Associations of dioxins, furans and dioxin-like PCBs with diabetes and pre-diabetes: is the toxic equivalency approach useful?

Toxic equivalency factors for dioxins and dioxin-like compounds have been established by the World Health Organization. Toxic equivalency (TEQ) was derived using 6 chlorinated dibenzo-p-dioxins, 9 chlorinated dibenzofurans and 8 polychlorinated biphenyls, in blood, from the 1999-2004 National Health and Nutrition Examination Survey. Relationships of 8 individual chemicals, the number of compounds elevated, and TEQ with pre-diabetes and total diabetes (diagnosed and undiagnosed) were investigated using logistic regressions. For the 8 chemicals analyzed separately, values above the 75th percentile were considered elevated, whereas for the other 15 compounds, values above the maximum limit of detection were considered elevated. Pre-diabetes with glycohemoglobin (A1c) 5.9-6.4% was associated with PCB 126, PCB 118 and having one or more compounds elevated (odds ratio 2.47, 95% CI 1.51-4.06). Pre-diabetes with A1c 5.7-5.8% was not associated with any individual chemical or the number of compounds elevated. Total diabetes was associated with 6 of the 8 individual compounds tested, and was associated with having 4 or more compounds elevated. Toxic equivalency ≥81.58 TEQ fg/g was associated with total diabetes (odds ratio 3.08, 95% CI 1.20-7.90), but was not associated with A1c 5.9-6.4%. Having multiple compounds elevated appeared to be important for total diabetes, whereas for pre-diabetes with A1c 5.9-6.4%, having a single compound elevated appeared most important. Diabetes plus A1c ≥5.9% was associated with 34.16-81.57 TEQ fg/g (odds ratio 2.00, 95% CI 1.06-3.77) and with ≥81.58 TEQ fg/g (odds ratio 2.48, 95% CI 1.21-5.11), indicating that half the population has elevated risk for this combination of conditions.

A national survey of hemochromatosis patients.

BACKGROUND: Hereditary hemochromatosis (HH) is a common genetic disease in the United States, but little is known about the diagnosis from the patient's perspective. The purpose of this study was to characterize the circumstances surrounding the diagnosis of HH and assess treatments and health information needs. METHODS: We surveyed US adults aged 18 years and older who were diagnosed with HH after 1996. Response rate was 46%, with a total sample size of 979. Respondents were asked about the use of genetic and clinical markers in their diagnosis, current treatments, and health information needs. RESULTS: Results were stratified by age, education, and income status. Total of 90.0% of women and 75.5% of men were genetically tested for HH (P < .01). Approximately half (52.5%) were diagnosed by a gastroenterologist, hematologist, or other specialty physician and half were diagnosed by a primary care provider. Most of the respondents thought their HH had improved with the initial treatment and most patients were still receiving treatment for HH. Patient interest in learning more about specific hemochromatosis topics was generally high. CONCLUSIONS: Since the introduction of genetic identification of HH, these tests have been used in the diagnosis of the majority of patients. Primary care physicians may need to be more aware HH and strategies for diagnosis.

Healthy lifestyle habits and mortality in overweight and obese individuals.

BACKGROUND: Though the benefits of healthy lifestyle choices are well-established among the general population, less is known about how developing and adhering to healthy lifestyle habits benefits obese versus normal weight or overweight individuals. The purpose of this study was to determine the association between healthy lifestyle habits (eating 5 or more fruits and vegetables daily, exercising regularly, consuming alcohol in moderation, and not smoking) and mortality in a large, population-based sample stratified by body mass index (BMI). METHODS: We examined the association between healthy lifestyle habits and mortality in a sample of 11,761 men and women from the National Health and Nutrition Examination Survey III; subjects were ages 21 and older and fell at various points along the BMI scale, from normal weight to obese. Subjects were enrolled between October 1988 and October 1994 and were followed for an average of 170 months. RESULTS: After multivariable adjustment for age, sex, race, education, and marital status, the hazard ratios (95% CIs) for all-cause mortality for individuals who adhered to 0, 1, 2, or 3 healthy habits were 3.27 (2.36-4.54), 2.59 (2.06-3.25), 1.74 (1.51-2.02), and 1.29 (1.09-1.53), respectively, relative to individuals who adhered to all 4 healthy habits. When stratified into normal weight, overweight, and obese groups, all groups benefited from the adoption of healthy habits, with the greatest benefit seen within the obese group. CONCLUSIONS: Healthy lifestyle habits are associated with a significant decrease in mortality regardless of baseline body mass index.

The impact of pioglitazone on ADMA and oxidative stress markers in patients with type 2 diabetes.

AIMS: To determine whether pioglitazone 30 mg daily reduces levels of ADMA in adult patients with diabetes, and whether there is improvement in markers of oxidative stress. METHODS: Prospective randomized cross-over placebo-controlled study of 36 adults age 40-75 years with type 2 diabetes recruited from a single academic health center. Intervention was for 12 weeks, followed by a 4-week wash-out period, followed by a second 12-week cross-over treatment period. The main outcome was comparison of the change in ADMA levels in the two treatment periods. Secondary outcomes included change in NOx and F2-isoprostanes. RESULTS: Thirty-six patients were enrolled in the study, 31 completed the protocol; the study enrollment met the sample size required to detect a change of 18% in levels. There were no differences in ADMA, NOx and F2-isoprostanes levels in the two treatment periods. Non-study medication changes or changes in dose were infrequent, and a statin was added during the study period in only one patient. CONCLUSIONS: Despite previous animal data that showed an effect of pioglitazone on ADMA, the current study in human patients did not demonstrate any differences in ADMA, NOx, or F2-isoprostane levels. The results do not favor that pioglitazone has a significant impact on ADMA levels in human patients with diabetes.

Impact of insurance and hospital ownership on hospital length of stay among patients with ambulatory care-sensitive conditions.

PURPOSE Some studies suggest proprietary (for-profit) hospitals are maximizing financial margins from patient care by limiting therapies or decreasing length of stay for uninsured patients. This study examines the role of insurance related to length of stay once the patient is in the hospital and risk for mortality, particularly in a for-profit environment. METHODS We undertook an analysis of hospitalizations in the National Hospital Discharge Survey (NHDS) of the 5-year period of 2003 to 2007 for patients aged 18 to 64 years (unweighted n = 849,866; weighted n = 90 million). The analysis included those who were hospitalized with both ambulatory care-sensitive conditions (ACSCs), hospitalizations considered to be preventable, and non-ACSCs. We analyzed the transformed mean length of stay between individuals who had Medicaid or all other insurance types while hospitalized and those who were hospitalized without insurance. This analysis was stratified by hospital ownership. We also examined the relationship between in-hospital mortality and insurance status. RESULTS After controlling for comorbidities; age, sex, and race/ethnicity; and hospitalizations with either an ACSC or non-ACSC diagnosis, patients without insurance tended to have a significantly shorter length of stay. Across all hospital types, the mean length of stay for ACSCs was significantly shorter for individuals without insurance (2.77 days) than for those with either private insurance (2.89 days, P = .04) or Medicaid (3.19, P <.01). Among hospitalizations for ACSCs, in-hospital mortality rate for individuals with either private insurance or Medicaid was not significantly different from the mortality rate for those without insurance. CONCLUSIONS Patients without insurance have shorter lengths of stay for both ACSCs and non-ACSCs. Future research should examine whether patients without insurance are being discharged prematurely.

Uric acid as a potential cue to screen for iron overload.

BACKGROUND: It is suggested that targeted screening for hemochromatosis and iron overload may be worthwhile. The aim of this study was to examine uric acid as a potential indicator of the presence of iron overload. METHODS: We analyzed adults aged 20 and older in the National Health and Nutrition Examination Survey 1999 to 2002. We computed logistic regressions controlling for age, sex, race/ethnicity, liver or kidney condition, and alcohol use to see the relationship between combinations of uric acid and ferritin with the outcomes of elevated liver enzymes and proteinuria. RESULTS: In unadjusted analyses, 20.7% of individuals with high uric acid had high ferritin levels versus 8.8% of individuals with low uric acid levels (P<.001). Individuals with both elevated uric acid and elevated ferritin levels had significantly higher liver enzymes than individuals with either elevated uric acid or ferritin. With low uric acid and low ferritin as the reference category, individuals with high uric acid and high ferritin were significantly more likely to also have proteinuria (odds ratio, 2.66; 95% CI, 1.82-3.91). CONCLUSIONS: Elevated levels of uric acid is associated with elevated ferritin levels and may serve as a risk stratification variable for presence of iron overload and hemochromatosis.

IRon Overload screeNing tool (IRON): development of a tool to guide screening in primary care.

Iron overload is associated with significant morbidity and mortality yet is easily treated. The objective of this study was to create a tool that could be easily adapted to clinical practice that indicates the likelihood of a patient having undetected iron overload. We used the National Health and Nutrition Examination Survey (NHANES) 1999-2002 for US adults aged 20 years and older to build a model (unweighted n=8,779). We chose potential variables for inclusion that could be gathered by self-report or measured without laboratory data and were suggested by past literature on hemochromatosis and iron overload. We computed logistic regressions to create the scores by initially evaluating the variables' relationship with elevated ferritin and elevated transferrin saturation and then using odds ratios to correspond to scores. The resulting score on the IRon Overload ScreeNing Tool (IRON) was then validated with data on 13,844 adults in the NHANES III, 1988-94. Predictors in the final tool were age, gender, previous diagnoses of liver condition, osteoporosis or thyroid disease. The IRON score yielded an area under the curve (AUC) in the NHANES 1999-02 of 0.720 and an AUC of 0.685 in the NHANES III validation sample. The IRON score is a tool to assist in identification of patients with iron overload that has several qualities that make it attractive for use in clinical practice with an undifferentiated patient population including brevity, easily collected information and predictive ability comparable to other tools that help in directing screening.

Tea and coffee consumption and MRSA nasal carriage.

PURPOSE: Hot tea and coffee have been found to have antimicrobial properties. The purpose of this study was to determine whether the consumption of tea, coffee, or both is associated with less frequent nasal carriage of methicillin-resistant Staphylococcus aureus (MRSA). METHODS: We performed a secondary analysis of data from the 2003-2004 National Health and Nutrition Examination Survey to investigate the relationship between the consumption of coffee, hot tea, cold tea, and soft drinks, and MRSA nasal carriage among the noninstitutionalized population of the United States. RESULTS: An estimated 2.5 million persons (1.4% of the population) were MRSA nasal carriers. In an adjusted logistic regression analysis controlling for age, race, sex, poverty-income ratio, current health status, hospitalization in the past 12 months, and use of antibiotics in the past month, individuals who reported consuming hot tea were one-half as likely to have MRSA nasal carriage relative to individuals who drank no hot tea (odds ratio = 0.47; 95% confidence interval, 0.31-0.71). Similarly, individuals who reported consuming coffee had about a one-half reduction in the risk of MRSA nasal carriage relative to individuals who drank no coffee (odds ratio = 0.47; 95% confidence interval, 0.24-0.93). CONCLUSIONS: Consumption of hot tea or coffee is associated with a lower likelihood of MRSA nasal carriage. Our findings raise the possibility of a promising new method to decrease MRSA nasal carriage that is safe, inexpensive, and easily accessible.

Impact of EHR-based clinical decision support on adherence to guidelines for patients on NSAIDs: a randomized controlled trial.

PURPOSE: Electronic health records (EHRs) with clinical decision support hold promise for improving quality of care, but their impact on management of chronic conditions has been mixed. This study examined the impact of EHR-based clinical decision support on adherence to guidelines for reducing gastrointestinal complications in primary care patients on nonsteroidal anti-inflammatory drugs (NSAIDs). METHODS: This randomized controlled trial was conducted in a national network of primary care offices using an EHR and focused on patients taking traditional NSAIDs who had factors associated with a high risk for gastrointestinal complications (a history of peptic ulcer disease; concomitant use of anticoagulants, anti-platelet medications [including aspirin], or corticosteroids; or an age of 75 years or older). The offices were randomized to receive EHR-based guidelines and alerts for high-risk patients on NSAIDs, or usual care. The primary outcome was the proportion of patients who received guideline-concordant care during the 1-year study period (June 2007-June 2008), defined as having their traditional NSAID discontinued (including a switch to a lower-risk medication), having a gastroprotective medication coprescribed, or both. RESULTS: Participants included 27 offices with 119 clinicians and 5,234 high-risk patients. Intervention patients were more likely than usual care patients to receive guideline-concordant care (25.4% vs 22.4%, adjusted odds ratio = 1.19; 95% confidence interval, 1.01-1.42). For individual high-risk groups, patients on low-dose aspirin were more likely to receive guideline-concordant care with the intervention vs usual care (25.0% vs 20.8%, adjusted odds ratio = 1.30; 95% confidence interval, 1.04-1.62), but there was no significant difference for patients in other high-risk groups. CONCLUSIONS: This study showed only a small impact of EHR-based clinical decision support for high-risk patients on NSAIDs in primary care offices. These results add to the growing literature about the complexity of EHR-based clinical decision support for improving quality of care.