Sex differences of high-risk carotid atherosclerotic plaque with less than 50% stenosis in asymptomatic patients: an in vivo 3T MRI study.

BACKGROUND AND PURPOSE: Men have a greater prevalence of high-risk carotid plaque features associated with stroke compared with women who have ≥50% stenosis, but little is known about these features in less significantly stenotic carotid arteries. This study aims to evaluate sex differences in complicated carotid plaque features in asymptomatic patients with <50% stenosis. MATERIALS AND METHODS: Ninety-six patients (50 men, 46 women) with <50% carotid stenosis on MRA who had been referred for analysis of contralateral >50% carotid stenosis were included. The associations between sex and plaque features as identified by 3T MR carotid plaque imaging were examined by using logistic and linear regression models controlling for demographic characteristics, MRA stenosis, and the presence of contralateral plaque features. RESULTS: The presence of a thin/ruptured fibrous cap (16% versus 2%, adjusted odds ratio = 8.57, P = .047), IPH (24% versus 6%, adjusted odds ratio = 4.53, P = .027), and American Heart Association type VI plaque (26% versus 6%, adjusted odds ratio = 5.04, P = .017) was significantly higher in men than in women. These associations remained significant following adjustment for contralateral plaque features. Men demonstrated a larger percentage volume of LR/NC (median, 1.66% versus -0.21%; P < .01). Calcification was not significantly associated with sex. CONCLUSIONS: There is a sex difference of higher risk carotid plaque features during the early stage of disease seen in patients recruited for MR imaging evaluation of contralateral moderate-to-severe stenosis. Given the potential of using LR/NC without or with IPH to monitor therapy, these results indicate the possible importance of sex-based management in patients with asymptomatic carotid atherosclerosis across all stages of carotid stenosis.

Health-related fitness and academic achievement in middle school students.

AIM: The aim of the present study was to determine the association between health-related fitness (HRF) and academic achievement in middle school youth. METHODS: Subjects were 312 middle school students. HRF was assessed using the FITNESSGRAM test battery. Students were grouped by the number of fitness tests in which they performed within the Healthy Fitness Zone, ranging from <1 test (lowest fitness) to all 5 tests (highest fitness). Academic achievement was assessed using grades (A - F) from four core classes, which were converted to interval data (A=5, F=1) and summed over the academic year and a standardized test (percentile). Maturity offset was calculated to control for the possible effect of maturity status on the association between HRF and academic achievement. Differences in academic achievement among HRF groups were determined using ANOVA. RESULTS: Grades and standardized test percentiles were higher in HRF group 5 (P<0.01) compared to HRF groups <2, 3, and 4. Cardiorespiratory endurance and muscular strength and endurance were the HRF components most strongly associated with academic achievement. CONCLUSION: HRF was related to academic achievement in youth. Students with the highest fitness level performed better on standardized tests and students with the lowest fitness level performed lower in class grades.

The use of in utero MRI to supplement ultrasound in the foetus at high risk of developmental brain or spine abnormality.

OBJECTIVES: It is widely accepted that the diagnosis of foetal central nervous system (CNS) abnormalities can be improved by performing MRI examinations in utero. Most of the published literature has concentrated on pregnancies in which a developmental abnormality has been detected (or suspected) on ultrasound in an otherwise low-risk pregnancy. In this paper, we test the hypothesis that in utero MRI of the foetal brain in high-risk pregnancies will detect abnormalities not shown by ultrasound at a rate that justifies its use in clinical practice. METHODS: 100 females were recruited into the study from foeto-maternal or clinical genetic departments. They all had a foetus/child with a CNS malformation from an earlier pregnancy, which led to an increased risk of recurrence being quoted for the present pregnancy. All in utero MRI examinations were performed on 1.5 T clinical MRI systems at 18 weeks gestational age or later. RESULTS: In 78% of cases, the ultrasound and MRI results agreed and showed no abnormality. In 13%, ultrasound and MRI described identical abnormal findings. In 9%, the ultrasound and MRI examinations had discrepant findings; in all these cases the MRI findings described more serious CNS pathology. The effects on management were judged to be major, by at least one assessor, in 7/9 of those cases. CONCLUSION: As in many other situations involving antenatal detection of CNS abnormalities, in utero MRI should be considered in females with increased risk of foetal CNS malformation based on the results of an earlier pregnancy. Advances in knowledge In utero MRI of the foetus has an important role in antenatal diagnosis of females carrying a foetus with an increased risk of a brain abnormality.

The use of in utero MR imaging to delineate developmental brain abnormalities in multifetal pregnancies.

BACKGROUND AND PURPOSE: iuMR has been shown to increase the detection rate of developmental abnormalities of the CNS, though most reports are limited to singleton pregnancies. The hypothesis tested in this study was that iuMR performed in multifetal pregnancies will show additional information about fetal CNS abnormalities in a similar proportion of cases when compared with singleton pregnancies. MATERIALS AND METHODS: Fifty women with multifetal pregnancies were recruited consecutively carrying at least 1 fetus with a suspected developmental fetal CNS abnormality on sonography. All had iuMR at the same center by using the same MR imaging protocol. When the sonography and MR imaging reports were discrepant, 1 fetomaternal expert assessed the reports independently to predict in what percentage a change in prognosis/counseling would have occurred if iuMR was included in the diagnostic pathway. RESULTS: There was agreement between the sonography and iuMR reports in 66% and disagreement in 34% of cases. The major cause for discrepancy was the presence or absence of the corpus callosum, which accounted for 10/17 of the disagreements. In 12/17 of the discrepant cases, the effect on management was judged to be significant. CONCLUSIONS: We conclude that iuMR has a similar rate of discrepancy to sonography in multifetal pregnancies compared with the published data concerning singleton pregnancies. Our analysis of the effect on management shows that changes in the decision to consider termination of pregnancy would have occurred in 12/17 of the discrepant cases (ie, in 24% of our cases overall).

Fetuses with ventriculomegaly diagnosed in the second trimester of pregnancy by in utero MR imaging: what happens in the third trimester?

BACKGROUND AND PURPOSE: Although MR imaging of the fetal brain has been shown to provide additional diagnostic information, the optimal timing of the study and the value of repeat studies remain unclear. The primary purpose of this study was to look for structural abnormalities of the fetal brain shown at 30-32 weeks' gestational age but not on the 20-24 weeks' study in fetuses originally referred with isolated VM. In particular, we wished to study the hypothesis that third-trimester fetal MR imaging studies would not show extra brain abnormalities compared with the second-trimester studies in this group. MATERIALS AND METHODS: Ninety-nine women were admitted for a fetal MR study between 20-24 weeks' gestational age, and 46 of these women agreed to return for a second MR imaging examination at 30-32 weeks' gestational age. The other women were either lost to follow-up or declined the invitation to return. Two experienced observers measured the width of the trigones, and the results were compared, to test reliability. Changes in the degree of VM are reported along with changes in the diagnosis of structural brain abnormalities. RESULTS: There was excellent reproducibility of trigone measurements between the 2 observers, with a mean absolute difference of <1 mm in the 40 fetuses that were ultimately shown to have isolated VM. Twenty-eight of 40 fetuses studied had mild VM on the first iuMR imaging examination, but in just more than half, the category of VM changed between the studies (5 had become normal-sized, 7 had progressed to moderate, 3 had become severe, and 13 remained mild). In 1 case, hypogenesis of the corpus callosum was recognized at 30-32 weeks but had not been reported on the 20-24 weeks' examination; the other 5 fetuses had brain pathology recognized on both fetal MR studies. CONCLUSIONS: Trigone measurements can be made in a highly repeatable fashion on iuMR imaging. We have not shown any major advantage in repeating iuMR imaging at 30-32 weeks' gestation in terms of improved diagnosis of other structural brain abnormalities. With the converse of that argument, however, our data suggest that there is no advantage in delaying iuMR imaging studies to 30-32 weeks in the hope of improving detection rates.

MR carotid plaque imaging and contrast-enhanced MR angiography identifies lesions associated with recent ipsilateral thromboembolic symptoms: an in vivo study at 3T.

BACKGROUND AND PURPOSE: Recent research has suggested the importance of plaque composition to identify patients at risk for stroke. This study aims to identify specific plaque features on 3T carotid MR imaging and CE-MRA associated with recent carotid thromboembolic symptoms in patients with mild/moderate versus severe stenosis. MATERIALS AND METHODS: Ninety-seven consecutive patients (symptomatic, 13; asymptomatic, 84) with 50%-99% stenosis by sonography or CT angiography underwent carotid plaque imaging combined with MRA at 3T. The symptomatic carotid artery or the most stenotic asymptomatic carotid artery was chosen as the index vessel to be analyzed. Plaque features were compared by symptomatic status in patients with mild/moderate (30%-70%) versus severe (70%-99%) stenosis on MRA. RESULTS: Ninety (92.8%) patients had sufficient image quality for interpretation. In 50 patients with mild/moderate stenosis, there were significant associations between the presence of the following plaque characteristics and symptoms: thin/ruptured fibrous cap (100% versus 36%, P = .006) and lipid-rich necrotic core (100% versus 39%, P = .022), with marginal association with hemorrhage (86% versus 33%, P = .055). In 40 patients with severe stenosis, only the angiographic presence of ulceration (86% versus 36%, P = .039) was associated with symptoms. CONCLUSIONS: Several plaque components identified on 3T MR imaging are correlated with recent ipsilateral carotid thromboembolic symptoms. These preliminary results also suggest that associations between plaque characteristics and symptom history may vary by degree of stenosis. If confirmed in larger studies, carotid MR imaging may distinguish stable from unstable lesions, particularly in individuals with mild/moderate stenosis in whom the role of surgical intervention is currently unclear.

A prospective study of fetuses with isolated ventriculomegaly investigated by antenatal sonography and in utero MR imaging.

BACKGROUND AND PURPOSE: Fetal ventriculomegaly (VM) is important because of its high prevalence and high risk of association with other brain abnormalities. The purpose of this article was to investigate the hypotheses that including in utero MR imaging (iuMR) in the diagnostic pathway for fetuses with isolated VM on antenatal imaging will show other brain abnormalities in a high proportion of cases and that these will have a significant effect on clinical management. MATERIALS AND METHODS: One hundred forty-seven pregnant women were recruited prospectively from 8 fetomaternal centers in Britain. All of the fetuses had VM diagnosed on sonography but no other abnormality. iuMR was performed, and the results of the examinations were compared with those of sonography. Two fetomaternal experts made independent assessments of the effects of any new diagnoses on clinical management. RESULTS: Categoric assessments of ventricular size were the same in approximately 90% of fetuses. Other abnormalities were shown in 17% of fetuses. The most frequent additional brain abnormality shown on iuMR was agenesis of the corpus callosum. Severe VM was associated with an approximately 10-fold increase in the risk of another brain abnormality being present when compared with fetuses with mild VM. The most profound effects on clinical management, however, were found in cases of mild VM. CONCLUSIONS: This work supports our hypotheses by showing a high detection rate of other brain pathology when iuMR was used to supplement antenatal sonography (17%). In a high proportion of cases, the detection of the extra pathology would have led to significant changes in clinical management.

Influence of stroke subtype on quality of care in the Get With The Guidelines-Stroke Program.

OBJECTIVE: Little is known about in-hospital care for hemorrhagic stroke. We examined quality of care in intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) admissions in the national Get With The Guidelines-Stroke (GWTG-Stroke) database, and compared them to ischemic stroke (IS) or TIA admissions. METHODS: Between April 1, 2003, and December 30, 2007, 905 hospitals contributed 479,284 consecutive stroke and TIA admissions. The proportions receiving each quality of care measure were calculated by dividing the total number of patients receiving the intervention by the total number of patients eligible for the intervention, excluding ineligible patients or those with contraindications to treatment. Logistic regression models were used to determine associations between measure compliance and stroke subtype, controlling for patient and hospital characteristics. RESULTS: Stroke subtypes were 61.7% IS, 23.8% TIA, 11.1% ICH, and 3.5% SAH. Performance on care measures was generally lower in ICH and SAH compared to IS/TIA, including guideline-recommended measures for deep venous thrombosis (DVT) prevention (for ICH) and smoking cessation (for SAH) (multivariable-adjusted p < 0.001 for all comparisons). Exceptions were that ICH patients were more likely than IS/TIA to have door-to-CT times <25 minutes (multivariable-adjusted p < 0.001) and to undergo dysphagia screening (multivariable-adjusted p < 0.001). Time spent in the GWTG-Stroke program was associated with improvements in many measures of care for ICH and SAH patients, including DVT prevention and smoking cessation therapy (multivariable-adjusted p < 0.001). CONCLUSIONS: Many hospital-based acute care and prevention measures are underutilized in intracerebral hemorrhage and subarachnoid hemorrhage compared to ischemic stroke /TIA. Duration of Get With The Guidelines-Stroke participation is associated with improving quality of care for hemorrhagic stroke.

The epidemiology of stroke in Pakistan: past, present, and future.

Stroke is a major public health problem in developing countries of South Asia. In this paper, we review the epidemiology of stroke in Pakistan. Most of the available data are based on hospital-centred case series addressing established stroke risk factors, stroke-related mortality and disability, functional status, and case fatality rates. There are limited population-based data regarding the prevalence of established stroke risk factors in the general population, and no epidemiologic studies have been conducted to specifically identify potential stroke risk factors unique to the region. The limited data that are available from Pakistan indicate that stroke epidemiology differs between Pakistan and Western populations - in Pakistan first stroke occurs at a younger age, particularly among women, and there is a higher proportion of haemorrhagic strokes. Besides the established stroke risk factors (e.g. hypertension, smoking, and diabetes) some potentially unique stroke risk factors related to life style and dietary habits such as huqqa smoking, use of dalda and desi ghee, and orally consumed forms of tobacco, may exist in Pakistan, and warrant further investigation. The shortage of trained stroke epidemiologists is a major limiting factor to the conduct of epidemiological stroke studies in Pakistan. Epidemiologic data are essential to guide health policy development aimed at decreasing the mortality and morbidity from stroke in Pakistan. To facilitate this process, medical professionals in Pakistan could participate in the World Health Organization's STEPwise approach to stroke surveillance, which provides a framework for data collection and comparison between and within populations.

Quality of hospital care in African American and white patients with ischemic stroke and TIA.

OBJECTIVE: To examine whether differences exist in the in-hospital diagnostic evaluation and treatment of African American and white patients with ischemic stroke (IS) and TIA. METHODS: The authors used a state-wide hospital-based stroke registry prototype designed to measure and track the quality of acute stroke care. Weighted descriptive statistics for each racial group are reported for the following variables, which were deemed to be potential confounders of the association between race and the quality of stroke care: age, gender, insurance status, emergency medical services arrival, functional status on presentation, modified Rankin score at discharge, stroke subtype, neurologist involved in care, and stroke pathway utilization. The magnitude and significance of the associations between race and each quality indicator of in-hospital acute stroke care were determined by separate multiple logistic regression models, adjusting for all potential confounding variables. RESULTS: Among patients admitted with IS and TIA who were alive at discharge (n = 1,837), 340 (18.5%) were African American and 1497 (81.5%) were white. After multivariate analysis, African Americans were less likely to have a door-to-CT time of less than 25 minutes (odds ratio [OR] 0.13 [CI 0.049 to 0.32]), obtain cardiac monitoring (OR 0.54 [CI 0.29 to 1.03]), undergo dysphagia screening (OR 0.69 [CI 0.50 to 0.95]), and receive smoking cessation counseling (OR 0.27 [CI 0.17 to 0.42]). CONCLUSIONS: Quality of hospital care for African American and white patients with acute ischemic stroke and TIA was similar in many respects. However, African Americans were less likely to receive a CT within 25 minutes of arrival, cardiac monitoring, dysphagia screening, and smoking cessation counseling.

IV tissue plasminogen activator use in acute stroke: experience from a statewide registry.

OBJECTIVE: To assess the use of IV recombinant tissue plasminogen activator (rt-PA) in a statewide hospital-based stroke registry and to identify factors associated with its use among eligible patients. METHODS: A modified stratified sampling scheme was used to obtain a representative sample of 16 hospitals. Prospective case ascertainment and data collection were used to identify all acute stroke admissions over a 6-month period. Subjects eligible for IV rt-PA were defined as those who arrived within 3 hours of onset, who had no evidence of hemorrhage on initial brain image, and who had no physician-documented reasons for non-treatment with IV rt-PA. Multivariate logistic regression was used to identify factors associated with IV rt-PA use. RESULTS: Of 2,566 stroke admissions, 330 (12.9%) met the eligibility criteria for rt-PA treatment, and of these 43 (13%) received IV rt-PA treatment. Among 2,236 admissions excluded from consideration, 21% had evidence of hemorrhage on initial imaging, 35% had unknown stroke onset times, 38% had an onset to arrival time >3 hours, and 6% had physician documented contraindications. Among eligible patients, being male, use of emergency medical services, and rapid presentation were associated with increased IV rt-PA use. CONCLUSIONS: Treatment with IV rt-PA was underutilized in this hospital-based stroke registry. The primary reason for nontreatment was delayed presentation. Reducing prehospital and in-hospital response times would help increase IV rt-PA use, as would greater emergency medical services use. Improving the documentation of onset times would help clarify the underlying causes of delayed presentation.

Blood lipids in young distance runners.

PURPOSE: The purpose of this study was to examine the age-and sex-associated variation in blood lipids among young athletes. METHODS: A mixed-longitudinal design was used to examine the development of blood lipids in competitive young distance runners followed from 1982 to 1985. Serial data included 99 annual measurements for 27 male subjects and 84 annual measurements for 27 female subjects aged 9-18 yr. Total cholesterol (TC), high-density lipoprotein (HDL-C), low-density lipoprotein (LDL-C), and triglycerides (TG) were determined by standard procedures. RESULTS: In general, cross-sectional age group means showed that TC and LDL-C remained stable and HDL-C declined with age, especially in male subjects. TG increased with age. Age-related trends were statistically significant for HDL-C and TG in boys only (P < 0.05). TC and LDL-C were slightly greater in boys at all ages except 11, 15, and 17 yr (P > 0.05). HDL-C was similar between the sexes until 13 yr when values became greater in girls (3.2-13.8 mg.dL(-1)) (P < 0.05 in 17+ yr). No clear pattern of sex differences emerged for TG. Compared with the general population, blood lipids of young distance runners showed the following trends: 1) TC was above reference medians, 2) LDL-C tended to approximate or to be slightly above reference medians, 3) TG fluctuated about the reference medians, and 4) HDL-C was higher in distance runners compared to the reference medians before age 14 yr, but in the older age groups, especially male subjects, HDL-C either approximated or fell slightly below the reference medians. There was considerable variability in blood lipid levels among the runners. In 21 male and 18 female subjects with serial data for 3-5 yr, HDL-C declined 22.4 and 18.3 mg.dL(-1) (P < 0.05), whereas TG increased 18.0 and 14.0 mg.dL(-1)(P < 0.05 in female subjects only) in male and female subjects, respectively. Tracking coefficients over intervals of 3-5 yr were moderate to high (0.48-0.90), except for TG in male subjects (0.08). CONCLUSIONS: The results indicate that the development of blood lipids in young distance runners is similar to youth in the general population. In contrast to observations in adult endurance athletes, young distance runners did not possess a superior blood lipid profile except for HDL-C in the younger age groups.

Blood lipids of young distance runners: distribution and inter-relationships among training volume, peak oxygen consumption, and body fatness.

This study describes the distribution of blood lipid concentrations and examines relationships among training volume (TV, kilometers per week), peak oxygen consumption (VO2peak), body fatness, and blood lipid concentrations in 48 male and 22 female distance runners, aged 10-19 years. Comparisons were made to a current reference sample and clinical cut-off points. Relationships were assessed by partial correlations allowing for age and sexual maturity. Compared to reference median values, mean concentrations of total cholesterol (P=0.07) and low density lipoprotein-cholesterol (P<0.005) were higher, while high density lipoprotein-cholesterol (HDL-C; P=0.24) was comparable in male distance runners. Blood lipid concentrations in female distance runners were comparable to reference median values. Although some subjects had dyslipidemic values, most possessed clinically normal concentrations of blood lipids. The TV was weakly correlated with blood lipid concentrations, but may have been indirectly related with HDL-C through its relationship with VO2peak in males runners (r=0.32). In female runners, correlations between sum of skinfolds (SSF), the trunk-to-extremity ratio (TER) and blood lipid concentrations were low (r=0.16 to -0.27), with one exception (TER and HDL-C, r=-0.60). The most consistent relationships existed among TV, VO2peak, SSF, and HDL-C with partial correlations ranging from low (r=0.10 TV) to moderate (r=0.37 SSF, r=0.41 VO2peak). The correlation between VO2peak and HDL-C remained significant after allowing for age and SSF, while the partial correlation between SSF and HDL-C, allowing for age and VO2peak, was reduced and not significant (r=-0.19, P=0.20). In female runners, the correlation between VO2peak and HDL-C was r=0.32, whereas the partial correlation between SSF and HDLC, allowing for age and VO2peak, was r=0.00. Blood lipid concentrations of young male distance runners were not, on average, different to the general population of the youth of the United States. The young distance runners showed considerable heterogeneity in blood lipid phenotypes, including dyslipidemic values. The results highlight the complex relationships among TV, VO2peak, body fat and HDL-C, and indicate the unique contribution of VO2peak as an important predictor of HDL-C in young distance runners.

Use of patient reminder letters to promote cancer screening services in women: A population-based study in Wisconsin.

BACKGROUND: Patient reminder letters are an effective method of promoting cancer screening services in women; however, information on their actual use in a population setting is lacking. METHODS: Data were obtained from a population-based, random digit dial telephone survey of 896 adult women living in Wisconsin. Respondents were asked if they had received a reminder letter for Pap or mammography screening within the past year. RESULTS: Among women aged >/=18 years, 12.9% (95% confidence interval [95% CI] = 10.1-15. 6) received a Pap test reminder within the past year, while 13.0% (95% CI = 9.3-16.7) of women aged >/=40 years received a mammography reminder. Women without health care coverage were unlikely to receive either type of reminder. Current compliance with screening recommendations was greater among those women who received a reminder letter for Pap tests (94.3 versus 78.1%, P < 0.0001) and for mammography (81.7 versus 59.4%, P < 0.001). In contrast to the infrequent use of cancer screening reminders, 54.2% (95% CI = 50. 1-58.3) and 72.7% (95% CI = 67.6-77.8) of women reported receiving a reminder letter from their dentist or veterinarian, respectively. CONCLUSIONS: Reminder letters for cancer screening services were rarely utilized in this study population. Receipt of a reminder letter was associated with greater compliance with current screening recommendations.

Evaluation of bovine viral diarrhea virus control using a mathematical model of infection dynamics.

A mathematical model for infection with bovine viral diarrhea virus (BVDV) was created comprising a series of coupled differential equations. The model architecture is a development of the traditional model framework using susceptible, infectious and removed animals (the SIR model). The model predicts 1.2% persistent infection (within the range of field estimates) and is fairly insensitive to alterations of structure or parameter values. This model allows us to draw important conclusions regarding the control of BVD, particularly with respect to the importance of persistently infected (PI) animals in maintaining BVD as an endemic entity in the herd. Herds without PI animals are likely to experience episodic reproductive losses at intervals of two to three years, unlike herds with PI animals which will not see such marked episodic manifestations of infection. Instead, these herds will experience an initial peak of disease which will settle to low-level chronic reproductive losses. The model indicates that vaccine coverage for herd immunity (to avoid episodic manifestations of disease) need be only 57% without PI animals, although 97% coverage is required when PI animals are present. Analysis of model behavior suggests a program of detection and removal of PI animals may enhance the effectiveness of a vaccine program provided these animals are in the herd for 10 days or less. The best results would be seen with PI animals in the herd for 5 or fewer days.

Chronic disease mortality among Wisconsin Native American Indians, 1984-1993.

Premature chronic disease mortality continues to be a problem among American Indian populations. To document the chronic disease burden in the Wisconsin American Indian population, age- and sex-specific incidence-density mortality rates for ten chronic diseases (ischemic heart disease, stroke, diabetes, chronic obstructive pulmonary disease, cirrhosis, and cancer of the breast, cervix, lung, colorectum and prostate) were estimated for a 10-year period (1984-1993) and compared with the Wisconsin non-Hispanic white population. Compared with whites, American Indians had markedly higher mortality rates from diabetes and cirrhosis in all age- and sex-specific groups. Ischemic heart disease mortality was significantly greater in both American Indian men and women 45-64 years of age (Rate Ratio [RR] = 1.7 and 2.1, respectively) compared to whites of the same age, but was lower in American Indians 65 years of age or older (RR = 0.9 for both sexes). Overall, these ten chronic diseases were responsible for a significant excess number of deaths in middle-aged American Indian men and women (i.e., 45-64 years of age), whereas the chronic disease mortality experience of older American Indian men and women (i.e., > or = 65 years of age) was similar to that of the older white population. Diabetes and cirrhosis were the most important causes of increased mortality overall; however, ischemic heart disease was responsible for a large number of excess deaths in middle-aged American Indian men and women.

Nonsteroidal anti-inflammatory drug use and protection against colorectal cancer in women.

Several epidemiological studies have identified an association between nonsteroidal anti-inflammatory drug (NSAID) use and colorectal cancer risk in women. We examined this association in a population-based case-control study in Wisconsin women. Between 1991 and 1992, 184 women ages 40-74 years with colorectal cancer were identified through the statewide cancer registry and 293 population-based control women were randomly selected via telephone. Regular NSAID use was defined as at least twice weekly for 12 months or longer. After adjusting the data for age, controls were more likely than cases to report regular NSAID use (38 versus 27%). Following adjustment for age, prior sigmoidoscopy use, family history of large bowel cancer, and body mass index, women who regularly used NSAIDs were approximately one-third less likely to be diagnosed with colorectal cancer compared to women who did not use NSAIDs [odds ratio (OR), 0.65; 95% confidence interval (CI), 0.40-1.03]. A statistically significant effect of duration of use was identified, although the ORs did not show a consistent trend. No significant effect of frequency of NSAID use was observed. When the type of NSAID used was examined (aspirin or nonaspirin), subjects who used nonaspirin compounds had a statistically significantly lower risk of colorectal cancer (OR, 0.43; 95% CI, 0.20-0.89), compared to nonusers, whereas aspirin users had only a small, nonsignificant reduction in cancer risk (OR, 0.79; 95% CI, 0.46-1.36). These data add support to the hypothesis that regular NSAID use is associated with lower colorectal cancer risk in women and suggest that the type of NSAID used may be important.

A new concept for implementation of a required general surgery clerkship.

BACKGROUND: Two years ago our institution abbreviated the junior internal medicine and general surgery clerkships to accommodate a 4-week family practice clerkship and a 4-week elective clerkship. As a consequence, 1-month mandatory internal medicine and general surgery clerkships were placed in the senior year. METHODS: The surgical disorders most commonly encountered by the generalist are discussed. The senior students spend 4 weeks with a community-based surgeon. All lectures are presented by full-time faculty and adhere to the student manual, which is designed to coincide with examination material. Three histories and physicals are reviewed by the course director to determine utilization of critical thinking skills. The development of healthy interpersonal and professional relationships is addressed by a 2-hour module on the essentials of integrity, compassion, humility, and self-knowledge. A faculty development seminar provides an awareness of course objectives and logistics. Student grades are determined by the preceptor's evaluation (50%), an in-house written examination (50%), and submission of adequate history and physicals. RESULTS: Subjective reviews by students (n = 115) reveal that although only 27% of the students care to pursue a surgical practice, 85% feel that their time was effectively spent and 83% feel that the clerkship should be offered to future fourth year medical students. Seventy percent of submitted history and physicals (n = 420) exhibit appropriate critical thinking skills. CONCLUSIONS: We are currently in the midst of our third year of implementation. The students are receiving insight into a surgical approach to common disease processes. History and physical examination skills and healthy interpersonal relationships are reinforced. Although change is often difficult to accomplish and accept, the positive response to the newly formatted senior curriculum has exceeded expectations.