A pharmacoepidemiologic study of community-dwelling, disabled older women: Factors associated with medication use.

BACKGROUND: Although disabled older adults may be among the subpopulation of adults with the highest risk for adverse drug events (ADEs), reliable data on their use of medications are limited. OBJECTIVES: The aims of this study were to describe the extent and patterns of medication use in community-dwelling, disabled older women, and to identify factors associated with medication use in this population. METHODS: Cross-sectional analyses of baseline data on medication use from the Women's Health and Aging Study I (WHAS I) were performed. WHAS I was an observational study of 1002 community-dwelling women aged >or=65 years who self-reported difficulty in at least 2 of 4 domains of physical functioning (ie, upper-extremity functions, mobility, self-care, and higher functioning tasks needed for independent living in the community). After descriptive analyses of their prescription and over-the-counter (OTC) drugs, associations between participants' characteristics and medication utilization were determined, using generalized linear models. RESULTS: Of the 975 participants, 580 (59.5%) used >or=5 medications and 115 (11.8%) used >or=10 medications (prescriptions and OTCs). The mean number of medications used was 3.9 for prescription drugs and 1.9 for OTC drugs. Cardiovascular drugs and analgesics were the most frequently used prescription and OTC drugs, respectively. Participants with complete outcome and covariate data (n = 803) were included in the multivariate analyses. Cancer was associated with a 13% increase in total medication use (95% CI, 1.00-1.27). Multimorbidity (1.08; 95% CI, 1.02-1.15), frailty (1.13; 95% CI, 1.02-1.26), high Mini-Mental State Examination score (1.03; 95% CI, 1.01-1.05), congestive heart failure (CHF) (1.39; 95% CI, 1.23-1.58), angina (1.27; 95% CI, 1.12-1.44), chronic obstructive pulmonary disease (COPD) (1.20; 95% CI, 1.05-1.37), diabetes mellitus (DM) (1.24; 95% CI, 1.07-1.43), difficulty with shopping for personal items such as medicines and toiletries (1.20; 95% CI, 1.06-1.35), and possession of health insurance (1.21; 95% CI, 1.04-1.40) or a prescription plan (1.16; 95% CI, 1.05-1.29) were independently associated with increased use of prescription drugs. A diagnosis of osteoarthritis of the hands (1.29; 95% CI, 1.121.49) and having a spouse (1.19; 95% CI, 1.01-1.40) were associated with increased use of OTC drugs. Participants with DM (0.78; 95% CI, 0.65-0.94), African Americans (0.70; 95% CI, 0.60-0.82), and those who had difficulty shopping (0.85; 95% CI, 0.72-0.99) used fewer OTCs than did participants without these characteristics. CONCLUSIONS: Most of the disabled older women in this study took >=5 medications at baseline, potentially putting them at high risk for ADEs. Those with multimorbidity, frailty, CHF, angina, DM, COPD, cancer, and difficulty with instrumental activities of daily living are target subpopulations for polypharmacy intervention.

Diarrhea and fever as risk factors for anemia among children under age five living in urban slum areas of Indonesia.

OBJECTIVES: To characterize diarrhea and fever as risk factors for anemia among children in developing countries. METHODS: We characterized risk factors for anemia in a sample of 32873 children, aged 6-59 months, from poor families in urban slum areas of Indonesia from 2000 to 2003. RESULTS: The prevalence of anemia was 58.7%. In separate multivariate models, after adjusting for age, sex, stunting, maternal age and education, and weekly per capita household expenditure, current diarrhea (OR 1.20, 95% CI 1.07-1.35, p=0.002), current fever (OR 1.44, 95% CI 1.18-1.75, p<0.0001), and a history of diarrhea in the previous seven days (OR 1.12, 95% CI 1.03-1.23, p=0.024) were associated with an increased risk of anemia. CONCLUSIONS: Diarrhea and fever are important risk factors for anemia among young children living in urban slum communities in Indonesia.

Types of anemia and mortality among older disabled women living in the community: the Women's Health and Aging Study I.

AIMS: To classify the different types of anemia among moderately to severely disabled women living in the community and examine the relationship between types of anemia and mortality. METHODS: We studied anemia in 688 women, >or=65 years, in the Women's Health and Aging Study I, a population based study of moderately to severely disabled older women living in the community in Baltimore, Maryland. Anemia was defined by World Health Organization criteria. Causes of anemia were classified as due to nutritional deficiencies (iron, folate, and B12 deficiencies), anemia of chronic inflammation, anemia with renal disease, and unexplained anemia. RESULTS: 147 of 688 (21.4%) women were anemic (hemoglobin <12 g/dL). Of the 147 anemic women, 22 (15.0%) had anemia due to nutritional causes, 45 (30.6%) had anemia due to chronic inflammation, 29 (19.7%) had anemia and renal disease, and 51 (34.7%) had unexplained anemia. The proportions of those who died over five years among non-anemic women and women with anemia due to nutritional causes, chronic inflammation, renal disease, and unexplained anemia were 26.1%, 18.2%, 38.6%, 64.3%, and 33.3%, respectively (p<0.0001). Compared with non-anemic women, those with anemia and renal disease (HR 1.99, 95% CI 1.18-3.35, p=0.009) and anemia of chronic inflammation (HR 1.69, 95% CI 1.00-2.84, p=0.05) had higher risk of death. CONCLUSIONS: Anemia is common among moderately to severely disabled older women living in the community, and about one-third of the anemia is unexplained. Anemia with renal disease and anemia of chronic inflammation are associated with a higher mortality.

Malnutrition and infectious disease morbidity among children missed by the childhood immunization program in Indonesia.

Although it has been thought that child immunization programs may miss the children who are in greatest need, there are little published quantitative data to support this idea. We sought to characterize malnutrition and morbidity among children who are missed by the childhood immunization program in Indonesia. Vaccination and morbidity histories, anthropometry, and other data were collected for 286,500 children, aged 12-59 months, in rural Indonesia. Seventy-three point nine percent of children received complete immunizations (3 doses of diphtheria-pertussis-tetanus, 3 doses of oral poliovirus, and measles), 16.8% had partial coverage (1-6 of 7 vaccine doses), and 9.3% received no vaccines. Of children with complete, partial, and no immunization coverage, respectively, the prevalence of severe underweight (weight-for-age Z score < -3) was 5.4, 9.9, and 12.6%, severe stunting (height-for-age Z score < -3) was 10.2, 16.2, and 21.5%, and current diarrhea was 3.8, 7.3, and 8.6% (all p < 0.0001), respectively. In families where the child had complete, partial, and no immunizations, the history of infant mortality was 6.4, 11.4, and 16.5%, and under-five child mortality was 7.3, 13.4, and 19.2% (both p < 0.0001). Expanded programmatic coverage is needed to reach children who are missed by childhood immunizations in rural Indonesia, as missed children are at higher risk of morbidity and mortality.

Soluble transferrin receptor as an indicator of iron deficiency in HIV-infected infants.

BACKGROUND: Iron deficiency is common in human immunodeficiency virus (HIV)-infected infants in sub-Saharan Africa. It is not known whether soluble transferrin receptor (sTfR) is a good indicator of iron deficiency in infants with HIV. METHODS: We evaluated sTfR as an indicator of iron deficiency in 134 HIV-infected 9-month-old infants in Kampala, Uganda. Ferritin <12 microg/L and microcytic, hypochromic anaemia were used as indicators of iron deficiency, respectively. The presence of inflammation was indicated by C-reactive protein >5 mg/L or alpha1-acid glycoprotein >1 g/L. RESULTS: Receiver operator characteristic curves showed that the area under the curve was 0.67 when sTfR receptor was compared with low ferritin and 0.71 when sTfR was compared with microcytic, hypochromic anaemia. The appropriate calculated cut-offs of sTfR >3.74 microg/mL (43.98 nmol/L) and >3.53 microg/mL (41.55 nmol/L) show adequate specificities of 60% and sensitivities of 63% and 69% for low ferritin and microcytic, hypochromic anaemia, respectively. C-reactive protein and alpha 1-acid glycoprotein were strongly correlated with serum ferritin (r=0.371 and r=0.458, respectively, both p<0.0001) but were not correlated with sTfR (r=0.009 and r= -0.003, respectively, both p=0.9). In all, 78.6% of infants had alpha l-acid glycoprotein >1 g/L and 54.7% had C-reactive protein >5 g/L. CONCLUSIONS: Soluble TfR appears to be an adequate indicator of iron deficiency in HIV-infected infants.

Change over time in incidence of ganciclovir resistance in patients with cytomegalovirus retinitis.

BACKGROUND: In the mid-1990s, the incidence of cytomegalovirus (CMV) resistance to ganciclovir was estimated to be approximately 25% by 1 year after diagnosis of retinitis in patients with acquired immunodeficiency syndrome. METHODS: Two hundred fifty-seven patients with CMV retinitis were enrolled in a prospective observational study during 1993-2003 and were treated with ganciclovir. Demographic characteristics and data on CMV disease, antiretroviral therapy, and ganciclovir resistance were recorded for all patients. Human immunodeficiency virus (HIV) load and CMV load were measured for patients enrolled in 1996 or later. Kaplan-Meier and Cox proportional hazards regression methods were used to examine incidence of resistance. RESULTS: The 2-year incidence of resistance was 28% among patients enrolled before 1996 and 9% among those enrolled in or after 1996 (P=.001). All cases of resistance occurred among patients with CD4+ T cell counts <50 cells/microL, and positive CMV culture results at baseline were associated with a approximately 4-fold increase in resistance. Among patients whose CMV and HIV loads were measured, a detectable CMV load at baseline and during follow-up was associated with increased risk of resistance, but a detectable HIV load was not. CONCLUSIONS: Rates of resistance have decreased from the high levels seen in the pre-HAART era. Better control of CMV replication may have contributed to this decrease.

Paternal smoking is associated with increased risk of child malnutrition among poor urban families in Indonesia.

OBJECTIVE: Paternal smoking is highly prevalent in Asia, and tobacco may account for a large proportion of household expenditures among poor families. We sought to characterise the relationship between paternal smoking, child malnutrition and food expenditures. DESIGN: Data on smoking, household expenditures and child malnutrition were examined in a stratified multistage cluster sample of households in the Indonesia nutrition surveillance system. Main outcome measures were child wasting (weight-for-height Z-score < - 2), underweight (weight-for-age Z-score < - 2) and stunting (height-for-age Z-score < - 2), and severe wasting, underweight and stunting (defined by respective Z-scores < - 3). SETTING: In total, 175,583 households from urban slum areas in Indonesia. SUBJECTS: Children 0-59 months of age. RESULTS: The prevalence of paternal smoking was 73.8%. After adjusting for child gender and age, maternal age and education, and weekly per capita household expenditures, paternal smoking was associated with child stunting (odds ratio (OR) = 1.11, 95% confidence interval (CI) 1.08-1.14, P < 0.0001), severe wasting (OR = 1.17, 95% CI 1.03-1.33, P = 0.018) and severe stunting (OR = 1.09, 95% CI 1.04-1.15, P < 0.001). In households where the father was a smoker, tobacco accounted for 22% of weekly per capita household expenditures, with less money spent on food compared with households in which the father was a non-smoker. CONCLUSIONS: Among poor families in urban slum areas of Indonesia, paternal smoking diverts household money from food to tobacco and exacerbates child malnutrition.

Low serum carotenoids and development of severe walking disability among older women living in the community: the women's health and aging study I.

OBJECTIVE: to determine whether low serum carotenoid levels, an indicator of low intake of fruits and vegetables, are associated with the progression of disability in older women. DESIGN: longitudinal analysis in a population-based cohort. SETTING: moderately-severely disabled women, >or=65 years, living in the community in Baltimore, Maryland (the Women's Health and Aging Study I). PARTICIPANTS: 554 women without severe walking disability (inability to walk or walking speed <0.4 m/s) at baseline. MAIN OUTCOME MEASURE: incidence of severe walking disability assessed every 6 months over 3 years. RESULTS: 155 women (27.9%) developed severe walking disability during follow-up. Rates of development of severe walking disability per 100 person-years among women in the lowest and in the three upper quartiles of total carotenoids were, respectively, 13.8 versus 10.9 (P=0.0017). Adjusting for confounders, women in the lowest quartile of total carotenoids were more likely to develop severe walking disability (hazards ratio 1.57, 95% confidence interval 1.24-2.00, P=0.0002) compared with women in the three upper quartiles. CONCLUSION: low serum carotenoid levels, an indicator of low intake of fruits and vegetables, are independent predictors of the progression towards severe walking disability among older women living in the community.

Low micronutrient levels as a predictor of incident disability in older women.

BACKGROUND: The role of nutritional status in the disablement process is still unclear. The objective of this study was to assess whether low concentrations of nutrients predict the development and course of disability. METHODS: Longitudinal study including community-dwelling women 65 years or older enrolled in the Women's Health and Aging Study I. In total, 643 women were assessed prospectively at 6-month intervals from 1992 to 1995. RESULTS: Incidence rates of disability in activities of daily living (ADLs) during 3 years of follow-up. Incidence rates in the lowest quartile of each selected nutrient were compared with those in the upper quartiles. The hazard ratios were estimated from Cox models adjusted for potential confounders. Women in the lowest quartile of serum concentrations of vitamin B(6) (hazard ratio [HR], 1.31; 95% confidence interval [CI], 1.03-1.67), vitamin B(12) (HR, 1.40; 95% CI, 1.12-1.74), and selenium (HR, 1.38; 95% CI, 1.12-1.71) had significantly higher risk of disability in ADLs during 3 years of follow-up compared with women in the upper 3 quartiles. CONCLUSIONS: Low serum concentrations of vitamins B(6) and B(12) and selenium predict subsequent disability in ADLs in older women living in the community. Nutritional status is one of the key factors to be considered in the development of strategies aimed at preventing or delaying the disablement process.

Low Serum Selenium Is Associated with Anemia Among Older Women Living in the Community: the Women's Health and Aging Studies I and II.

Anemia is common among older adults, and a substantial proportion of anemia in the older population is of indeterminate cause. Low selenium levels have been associated with anemia in animals, but this relationship has not been well characterized in humans. The objective was to determine whether low serum selenium concentrations are associated with anemia among older women. We conducted a cross-sectional analysis of participants in the Women's Health and Aging Studies, a population-based sample of women living in the community in Baltimore, MD, USA. Of 632 women, aged 70-79 yr, 14.1% of women were anemic (hemoglobin <120 g/L). The prevalence of anemia among women in the lowest to highest quartile of serum selenium was 22.4%, 14.6%, 11.9% and 6.6%, respectively (p < 0.0001). An increase in loge selenium was associated with a reduced risk of anemia (odds ratio per 1 SD increase = 0.63, 95% confidence interval = 0.47-0.84), adjusting for age, education, chronic diseases, iron status, and serum interleukin-6. We conclude that low serum selenium is independently associated with anemia among older women living in the community.

Vitamin and carotenoid status in older women: associations with the frailty syndrome.

OBJECTIVE: We investigated the relationship of micronutrient deficiencies with the frailty syndrome in older women living in the community. METHODS: Frailty status and serum micronutrients were assessed in a cross-sectional study of 754 women, 70-80 years old, from the Women's Health and Aging Studies I and II. RESULTS: Among nonfrail, prefrail, and frail women, respectively, geometric mean serum concentrations were 1.842, 1.593, and 1.376 micromol/L for total carotenoids (p <.001); 2.66, 2.51, and 2.43 micromol/L for retinol (p =.04); 50.9, 47.4, and 43.8 nmol/L for 25-hydroxyvitamin D (p =.019); 43.0, 35.8, and 30.9 nmol/L for vitamin B(6) (p =.002); and 10.2, 9.3, and 8.7 ng/mL for folate (p =.03). Frail women were more likely to have at least two or more micronutrient deficiencies (p =.05). The age-adjusted odds ratios of being frail were significantly higher for those participants whose micronutrient concentrations were in the lowest quartile compared to the top three quartiles for total carotenoids, alpha-tocopherol, 25-hydroxyvitamin D, and vitamin B(6). The association between nutrients and frailty was strongest for beta-carotene, lutein/zeaxanthin, and total carotenoids (odds ratio ranging from 1.82 to 2.45, p =.05), after adjusting for age, sociodemographic status, smoking status, and body mass index. CONCLUSION: Frail women are more likely to have relatively low serum carotenoid and micronutrient concentrations and are more likely to have multiple micronutrient deficiencies. Future longitudinal studies are needed to examine the relationships between micronutrient concentrations and frailty in older women.

Detection of ganciclovir resistance in patients with AIDS and cytomegalovirus retinitis: correlation of genotypic methods with viral phenotype and clinical outcome.

BACKGROUND: The cytomegalovirus (CMV) UL97 gene can be sequenced either from blood specimens directly amplified by polymerase chain reaction (PCR) or from culture isolates, to detect resistance to ganciclovir. METHODS: A prospective epidemiological study was conducted in which paired specimens were routinely obtained for sequencing of the UL97 gene from blood specimens (i.e., plasma and leukocytes) directly amplified by PCR and from CMV culture isolates. The specimens then were compared with each other and in terms of results of susceptibility testing and their association with progression of retinitis. RESULTS: A total of 845 paired specimens were obtained from 165 patients with AIDS and CMV retinitis. There typically was >90% agreement between the UL97 gene sequences from blood specimens directly amplified by PCR and those from culture isolates. The agreement between phenotypic resistance and the detection of UL97 mutations was >92% for PCR-amplified blood specimens and >97% for culture isolates. Plasma and leukocytes performed similarly. Progression of retinitis was correlated with the detection of UL97 mutations in PCR-amplified blood specimens, with adjusted odds ratios of 7.02 (P=.002) for leukocytes, 9.11 (P=.02) for plasma, and 17.6 for culture isolates (P<.0001). CONCLUSIONS: Because blood specimens directly amplified by PCR can be analyzed more rapidly than can cultures (< or =48 h vs. > or =4 weeks), sequencing the CMV UL97 gene from blood specimens directly amplified by PCR may be useful clinically.

Low serum selenium and total carotenoids predict mortality among older women living in the community: the women's health and aging studies.

Selenium and the carotenoids play an important role in antioxidant defenses and in the redox regulation involved in inflammation. We tested the hypothesis that low selenium and carotenoids predict mortality in older women living in the community. Women who were enrolled in the Women's Health and Aging Studies I and II in Baltimore, MD (n = 632; 70-79 y old) had serum selenium and carotenoids measured at baseline and were followed for mortality over 60 mo. Median (minimum, maximum) serum selenium and carotenoids were 1.53 (0.73, 2.51) micromol/L and 1.67 (0.13, 9.10) micromol/L; 14.1% of the women died. The 5 major causes of death were heart disease (32.6%), cancer (18.0%), stroke (9.0%), infection (6.7%), and chronic obstructive pulmonary disease (5.6%). Adjusting for age, education, smoking, BMI, poor appetite, and chronic diseases, higher serum selenium [hazard ratio (HR) 0.71, 95% CI 0.56-0.90/1 SD increase in log(e) selenium; P = 0.005] and higher serum total carotenoids (HR 0.77, 95% CI 0.64-0.84/1 SD increase in log(e) total carotenoids; P = 0.009) were associated with a lower risk of mortality. Women living in the community who have higher serum selenium and carotenoids are at a lower risk of death.

Cytomegalovirus (CMV) blood DNA load, CMV retinitis progression, and occurrence of resistant CMV in patients with CMV retinitis.

BACKGROUND: The amount of cytomegalovirus (CMV) DNA in the blood (CMV load) may be a marker for detection of resistant CMV.METHODS. A total of 165 patients with AIDS and CMV retinitis had CMV load measurements (plasma and leukocyte) and cultures performed every 3 months; these measurements were correlated with CMV resistance to antiviral drugs and CMV retinitis progression (from masked readings of retinal photographs).RESULTS. Detectable plasma and leukocyte CMV loads were associated with CMV retinitis progression (odds ratios [OR], 6.3; P<.0001 and OR, 6.6; P<.0001, respectively), phenotypic resistance (OR, 6.1; P<.0001 and OR, 23.4; P=.0002, respectively), and genotypic resistance (OR, 17.5; P<.0001 and OR, 51.6; P=.0004, respectively). The sensitivity, specificity, and positive and negative predictive values of plasma CMV loads were 0.47, 0.86, 0.36, and 0.91, respectively, for progression and 0.59, 0.81, 0.07, and 0.99, respectively, for resistance; those of leukocyte CMV loads were 0.52, 0.83, 0.35, and 0.91, respectively, for progression and 0.82, 0.78, 0.08, and 0.99, respectively, for resistance. A detectable plasma CMV load at the time of diagnosis of CMV retinitis was associated with mortality (median survival time, 13.6 vs. 29.7 months; P=.007).CONCLUSIONS. CMV load has limited clinical utility, because of its low positive predictive value. Its high negative predictive value for occurrence of resistant CMV suggests that it may have utility as a screening tool to exclude resistance.

Breast milk retinol concentrations are not associated with systemic inflammation among breast-feeding women in Malawi.

The acute phase response and inflammation are associated with lower plasma retinol concentrations, but their effect on breast milk retinol concentrations is unclear. We measured plasma retinol concentrations, acute phase proteins, and breast milk retinol concentrations in 237 breast-feeding women at 2 wk postpartum in Blantyre, Malawi; 16.5% of the women had plasma retinol < 0.70 micromol/L and 14.8% had breast milk retinol < 1.05 micromol/L. Among women with and without inflammation [alpha(1)-acid glycoprotein (AGP) > 1 g/L and/or C-reactive protein (CRP) > 5 mg/L], geometric mean (95% CI) plasma retinol was 0.89 (0.84, 0.94) and 1.05 (1.01, 1.17) mumol/L, respectively (P < 0.0001). Among women with and without inflammation, geometric mean (95% CI) breast milk retinol was 2.12 (1.89, 2.36) and 2.05 (1.75, 2.39) micromol/L, respectively (P = 0.74). In multiple linear regression models adjusting for age, parity, education, BMI, and days postpartum, plasma retinol concentrations were associated with plasma AGP and CRP concentrations (P < 0.0001 and P = 0.01, respectively), whereas breast milk retinol concentrations were unaffected by plasma AGP and CRP concentrations (P = 0.22 and P = 0.86, respectively). These findings suggest that breast milk retinol concentrations are not affected by systemic inflammation.

T cell subsets and mortality in older community-dwelling women.

The relationship between specific T cell subset alterations and mortality has not been well characterized in older adults. The specific aim was to determine whether specific T cell subsets are associated with an increased risk of death. We conducted a case-control study of T cell subsets (CD4+ and CD8+ T cells, and subsets of these cells defined by expression or non-expression of CD28, CD45RA, and CD45RO) nested within two complementary prospective cohorts of women aged 65 and over living in the community, the Women's Health and Aging Studies (WHAS). Cases consisted of 61 women who died during 5 years of follow-up, and controls consisted of 61 women matched by age, frailty, and morbidities who survived during 7 years of follow-up. There were no significant differences between cases and controls in any of the T cell subsets studied. When analyses were stratified by frailty status, these data suggest that CD8+CD28- lymphocyte counts were significantly higher among women who were frail compared with pre-frail and non-frail women.

Status of carotenoids, vitamin A, and vitamin E in the mother-infant dyad and anthropometric status of infants in Malawi.

This prospective study was carried out during February 2000-April 2003 to characterize the relationship between the status of carotenoids, vitamin E, and retinol and anthropometric status in apparently healthy infants and their mothers in Blantyre, Malawi. Anthropometric status of infants and concentrations of carotenoids (alpha-carotene, beta-carotene, beta-cryptoxanthin, lutein, zeaxanthin, and lycopene), retinol, and alpha-tocopherol in plasma were measured in 173 infants at 12 months of age, and concentrations of carotenoids, retinol, and a-tocopherol in plasma were measured in their mothers two weeks postpartum. In multivariate analyses, concentrations of retinol, total carotenoids, non-provitamin A carotenoids, and alpha-tocopherol in infants were associated with under-weight (p = 0.05). Concentrations of a-tocopherol were associated with wasting (p = 0.04). Concentrations in mothers and infants were all correlated (correlation coefficients from 0.230 to 0.502, p < 0.003). The findings suggest that poor status of carotenoids, retinol, and alpha-tocopherol in infants is associated with their poor anthropometric status, and status of carotenoids, retinol, and alpha-tocopherol in mothers and infants has a low-to-moderate association in the mother-infant dyad.

Vitamin A deficiency and inflammatory markers among preschool children in the Republic of the Marshall Islands.

BACKGROUND: The exclusion of individuals with elevated acute phase proteins has been advocated in order to improve prevalence estimates of vitamin A deficiency in surveys, but it is unclear whether this will lead to sampling bias. The purpose of the study was to determine whether the exclusion of individuals with elevated acute phase proteins is associated with sampling bias and to characterize inflammation in children with night blindness. METHODS: In a survey in the Republic of the Marshall Islands involving 281 children, aged 1-5 years, serum retinol, C-reactive protein (CRP), and alpha1-acid glycoprotein (AGP) were measured. RESULTS: Of 281 children, 24 (8.5%) had night blindness and 165 (58.7%) had serum retinol < 0.70 micromol/L. Of 248 children with AGP and CRP measurements, 123 (49.6%) had elevated acute phase proteins (CRP > mg/L and/or AGP > 1000 mg/L). Among children with and without night blindness, the proportion with serum retinol < 0.70 micromol/L was 79.2% and 56.8% (P = 0.03) and with anemia was 58.3% and 35.7% (P = 0.029), respectively. The proportion of children with serum retinol < 0.70 micromol/L was 52.0% after excluding children with elevated acute phase proteins. Among children with and without elevated acute phase proteins, mean age was 2.8 vs 3.2 years (P = 0.016), the proportion of boys was 43.1% vs. 54.3% (P = 0.075), with no hospitalizations in the last year was 11.0% vs 23.6% (P = 0.024), and with anemia was 43.8% vs 31.7% (P = 0.05), respectively. CONCLUSIONS: Exclusion of children with inflammation in this survey of vitamin A deficiency does not improve prevalence estimates for vitamin A deficiency and instead leads to sampling bias for variables such as age, gender, anemia, and hospitalization history.

Carotenoid status among preschool children with vitamin A deficiency in the Republic of the Marshall Islands.

Although carotenoids are known to be important dietary sources of vitamin A, there have been few epidemiological studies that have characterized the serum concentrations of major dietary carotenoids among preschool children with vitamin A deficiency. We conducted a population-based, cross-sectional study of serum pro-vitamin A carotenoids (alpha -carotene, beta-carotene, beta-cryptoxanthin), non-provitamin A carotenoids (lutein/zeaxanthin, and lycopene), and retinol among 278 children, aged 1-5 y, in the Republic of the Marshall Islands. Vitamin A deficiency was defined as serum retinol <0.70 micromol/L. Geometric mean serum concentrations of carotenoids among children with and without vitamin A deficiency were 0.003 vs 0.006 micromol/L for alpha-carotene (P = 0.0017), 0.011 vs 0.023 micromol/L for beta-carotene (P <0.0001), 0.023 vs 0.034 micromol/L for beta-cryptoxanthin (P = 0.0075), 0.007 vs 0.012 micromol/L for lycopene (P = 0.037), 0.044 vs 0.052 micromol/L for lutein/zeaxanthin (P = 0.2), and 0.045 vs 0.074 micromol/L for total provitamin A carotenoids (P <0.0001) respectively. In a multivariate analysis adjusting for sex, age (Odds Ratio [O.R.] 1.44, 95% confidence interval [C.I.] 1.16-1.78), and serum provitamin A carotenoids (O.R. 0.49, 95% C.I. 0.34-0.71) were associated with vitamin A deficiency, but serum non-provitamin A carotenoids were not associated with vitamin A deficiency (O.R. 0.93, 95% C.I. 0.67-1.28). Preschool children with vitamin A deficiency in the Republic of the Marshall Islands have extremely low serum concentrations of provitamin A carotenoids and interventions are needed to improve the dietary intake of provitamin A carotenoids among Marshallese children.

Comparability of two fundus photograph reading centers in grading cytomegalovirus retinitis progression.

PURPOSE: To compare grading of cytomegalovirus retinitis progression by two different fundus photograph reading centers (FPRCs). DESIGN: Patients with AIDS followed in an ophthalmology service were enrolled in a prospective epidemiologic study of the prevalence and incidence of resistant cytomegalovirus in vitro. METHODS: We compared masked replicate gradings by two different FPRCs of monthly fundus photographs for retinitis progression (onset of a separate new lesion or expansion of an existing lesion by > or =one-half disk diameter). RESULTS: For 77 patients, Kaplan-Meier plots of progression over time were similar between FPRCs (median time to progression, 65 vs 69 days). Agreement between FPRCs was 51% (kappa [kappa] =.37, "fair") on exact visit of progression (28 patients) or on absence of progression through follow-up (11 patients) and 62% (kappa =.38) on progression visit +/- 1 month. Eight of 12 patients with progression graded as more than 1 month apart were only 2 months apart. Considering each monthly visit as a choice point, overall agreement on progression was 78% (kappa =.55, "moderate"). Baseline evaluation of retinitis showed 95% agreement on presence/absence and a concordance correlation coefficient of.75 for extent in combined zones 1 and 2. Rates of retinal loss over follow-up were estimated as 2.8%/month vs 2.0%/month (P =.015). CONCLUSIONS: By adopting similar protocols and procedures, different FPRCs can achieve good agreement on presence and extent of cytomegalovirus retinitis. Further efforts to harmonize evaluation through ongoing comparison of gradings would likely improve agreement on retinitis progression.