The severely to profoundly hearing-impaired population in the United States: prevalence estimates and demographics.

This study informs policy makers and third-party payers of the prevalence and characteristics of the severely to profoundly hearing-impaired population in the United States. Nationally representative data were used for estimations in consultation with an expert advisory panel. The prevalence of severe to profound hearing impairment among the US population ranges from 464,000 to 738,000, with 54 percent of this population over age 65 years. Persons with hearing impairment are more likely to be publicly insured, less likely to have private insurance, have lower family incomes, are less educated, and are more likely to be unemployed than the general population. Approximately half a million Americans are severely to profoundly hearing impaired and appear to be more vulnerable, both financially and educationally, as compared to the US population. As a result, access to medical and technological interventions that may assist their hearing loss may be limited.

Serum folate and cardiovascular disease mortality among US men and women.

BACKGROUND: Folate has been linked to cardiovascular disease (CVD) through its role in homocysteine metabolism. OBJECTIVE: To assess the relationship between serum folate and CVD mortality. DESIGN: In this prospective study, serum folate concentrations were measured on a subset of adults during the Second National Health and Nutrition Examination Survey (1976-1980) and vital status ascertained after 12 to 16 years. SETTING AND PATIENTS: A national probability sample consisting of 689 adults who were 30 to 75 years of age and did not have a history of CVD at baseline. MAIN OUTCOME MEASURE: Vital status was determined by searching national databases that contained information about US decedents. RESULTS: The associations between serum folate and CVD and all-cause mortality differed by diabetes status (P =.04 and P =.03, respectively). Participants without diabetes in the lowest compared with the highest serum folate tertile had more than twice the risk of CVD mortality after adjustment for age and sex (relative risk [RR], 2.64; 95% confidence interval [CI], 1.15-6.09). This increased risk for participants in the lowest tertile was attenuated after adjustment for CVD risk factors (RR, 2.28; 95% CI, 0.96-5.40). Serum folate tertiles were not significantly associated with total mortality, although the age- and sex-adjusted risk was increased for participants in the lowest compared with highest tertile (RR, 1.74; 95% CI, 0.96-3.15). Risk estimates for participants with diabetes were unstable because of the small sample size (n = 52). CONCLUSION: These data suggest that low serum folate concentrations are associated with an increased risk of CVD mortality among adults who do not have diabetes. Arch Intern Med. 2000;160:3258-3262.

The societal costs of severe to profound hearing loss in the United States.

OBJECTIVE: Severe to profound hearing impairment affects one-half to three-quarters of a million Americans. To function in a hearing society, hearing-impaired persons require specialized educational, social services, and other resources. The primary purpose of this study is to provide a comprehensive, national, and recent estimate of the economic burden of hearing impairment. METHODS: We constructed a cohort-survival model to estimate the lifetime costs of hearing impairment. Data for the model were derived principally from the analyses of secondary data sources, including the National Health Interview Survey Hearing Loss and Disability Supplements (1990-91 and 1994-95), the Department of Education's National Longitudinal Transition Study (1987), and Gallaudet University's Annual Survey of Deaf and Hard of Hearing Youth (1997-98). These analyses were supplemented by a review of the literature and consultation with a four-member expert panel. Monte Carlo analysis was used for sensitivity testing. RESULTS: Severe to profound hearing loss is expected to cost society $297,000 over the lifetime of an individual. Most of these losses (67%) are due to reduced work productivity, although the use of special education resources among children contributes an additional 21%. Lifetime costs for those with prelingual onset exceed $1 million. CONCLUSIONS: Results indicate that an additional $4.6 billion will be spent over the lifetime of persons who acquired their impairment in 1998. The particularly high costs associated with prelingual onset of severe to profound hearing impairment suggest interventions aimed at children, such as early identification and/or aggressive medical intervention, may have a substantial payback.

Homicide rates among US teenagers and young adults: differences by mechanism, level of urbanization, race, and sex, 1987 through 1995.

CONTEXT: Homicide rates for persons 15 through 24 years old began to decline between 1993 and 1994, but recent trends in homicide rates by mechanism of homicide and urbanization group have not been described. OBJECTIVE: To examine homicide trends from 1987 through 1995 for persons 15 through 24 years old by urbanization level. DESIGN: Homicide rates by urbanization level were analyzed using the Compressed Mortality File, a county-level mortality and population database maintained by the National Center for Health Statistics, Centers for Disease Control and Prevention, and the rural-urban continuum codes developed by the Economic Research Service, US Department of Agriculture. SETTING: United States, 1987 through 1995, according to 5 urbanization strata: core, counties with the primary central city of a metropolitan statistical area (MSA) of 1 million or more; fringe, remaining counties within an MSA of 1 million or more; medium, counties within an MSA of 250000 to 999999; small, counties in an MSA of less than 250000; and nonmetropolitan, counties not in an MSA. SUBJECTS: All persons 15 through 24 years old by race whose cause of death was homicide (International Classification of Diseases, Ninth Revision codes E960-E969). MAIN OUTCOME MEASURES: Firearm and nonfirearm homicide rates and average annual percentage changes by 5 urbanization levels, race, and sex. RESULTS: From 1987 through 1991, the average annual firearm homicide rates among persons 15 through 24 years old among all 5 urbanization strata increased between 10.7% in small counties and 19.8% in fringe counties. From 1991 through 1993, the rates increased between 3.3% in core counties and 11.7% in small counties. From 1993 through 1995, the rates declined between 4.4% in fringe counties and 15.3% in medium counties. By 1995, firearm homicide rates among persons 15 through 24 years old ranged from 6.5 and 7.3 per 100000 in the nonmetropolitan and small counties, respectively, to 9.6 and 13.3 per 100000 in the fringe and medium strata, respectively, to 33.5 per 100000 in the core stratum. During 1987 through 1990, nonfirearm homicide rates either were stable or increased, and from 1990 through 1995, nonfirearm homicide rates declined in all 5 strata, on average 3.7% to 8.0% per year, with rates in 1995 ranging from 2.1 to 4.7 per 100000 across the strata. CONCLUSIONS: After increasing since 1987, firearm and nonfirearm homicide rates began declining between 1993 and 1995 among persons 15 through 24 years old. These declines are taking place across all urbanization strata and among white and black males and females.

Neuropsychological deficits in adolescents with fetal alcohol syndrome: clinical findings.

Understanding the nature of cognitive deficits among adolescent patients with fetal alcohol syndrome (FAS) can direct future research on assessment and intervention. In an exploratory study, nine nonretarded teenagers with FAS were administered tests of IQ and adaptive behavior, and neuropsychological tests presumed sensitive to alcohol effects. Their performance was compared with psychometric norms and to data from a sample of 174 adolescents with minimal or no prenatal alcohol exposure. These nonretarded FAS patients commonly showed behavior problems, decreased social competence, and poor school performance. Neuropsychological testing revealed significant deficits, although no one neuropsychological profile characterized all patients and not all tests revealed problems. Relatively intact performance was observed in procedural memory, some measures of reaction time, and some reading measures. Deficits were seen on attentional and memory tasks tapping visual-spatial skills, short-term auditory attention and memory, declarative learning, and cognitive flexibility and planning. Difficulties in processing speed and accuracy were also seen. Comparison with a subgroup of 52 nonalcohol-exposed or minimally alcohol-exposed adolescents with a similar range of IQ scores demonstrated that deficits among these FAS patients were not fully explained by a general lowering of IQ.

Cohort study of effect of being overweight and change in weight on risk of coronary heart disease in old age.

OBJECTIVE: To evaluate risk of late life coronary heart disease associated with being overweight in late middle or old age and to assess whether weight change modifies this risk. DESIGN: Longitudinal study of subjects in the epidemiological follow up study of the national health and nutrition examination survey I. SETTING: United States. SUBJECTS: 621 men and 960 women free of coronary heart disease in 1982-84 (mean age 77 years). MAIN OUTCOME MEASURE: Incidence of coronary heart disease. RESULTS: Body mass index of 27 or more in late middle age was associated with increased risk of coronary heart disease in late life (relative risk = 1.7 (95% confidence interval 1.3 to 2.1)) while body mass index of 27 or more in old age was not (1.1 (0.8 to 1.5)). This difference in risk was due largely to weight loss between middle and old age. Exclusion of those with weight loss of 10% or more increased risk associated with heavier weight in old age (1.4 (1.0 to 1.9)). Thinner older people who lost weight and heavier people who had gained weight showed increased risk of coronary heart disease compared with thinner people with stable weight. CONCLUSIONS: Heavier weight in late middle age was a risk factor for coronary heart disease in late life. Heavier weight in old age was associated with an increased risk once those with substantial weight loss were excluded. The contribution of weight to risk of coronary heart disease in older people may be underestimated if weight history is neglected.

Plan and operation of the NHANES I Epidemiologic Followup Study, 1992.

OBJECTIVES: The NHANES I Epidemiologic Followup Study (NHEFS) is a longitudinal study that uses as its baseline those adult persons 25-74 years of age who were examined in the first National Health and Nutrition Examination Survey (NHANES I). NHEFS was designed to investigate the association between factors measured at baseline and the development of specific health conditions. The three major objectives of NHEFS are to study morbidity and mortality associated with suspected risk factors, changes over time in participants' characteristics, and the natural history of chronic disease and functional impairments. METHODS: Tracing and data collection in the 1992 Followup were undertaken for the 11,195 subjects who were not known to be deceased in the previous surveys. No additional information was collected in the 1992 NHEFS for the 3,212 subjects who were known to be deceased before the 1992 NHEFS data collection period. RESULTS: By the end of the 1992 NHEFS survey period, 90.0 percent of the 11,195 subjects in the 1992 Followup cohort had been successfully traced. Interviews were conducted for 9,281 subjects. An interview was conducted for 8,151 of the 8,687 surviving subjects; 551 interviews were administered to a proxy respondent because the subject was incapacitated. A proxy interview was conducted for 1,130 of the 1,392 decedents identified in the 1992 NHEFS. In addition, 10,535 facility stay records were collected for 4,162 subjects reporting overnight facility stays. Death certificates were obtained for 1,374 of the 1,392 subjects who were identified as deceased since last contact. Approximately 32 percent of the NHEFS cohort is known to be deceased with a death certificate available for 98 percent of the 4,604 NHEFS decedents.

Overweight, weight loss, and risk of coronary heart disease in older women. The NHANES I Epidemiologic Follow-up Study.

Little is known about the relation of overweight to risk of coronary heart disease in older women. In this paper, the authors used measured weight for 1,259 white women aged 65-74 years from the Epidemiologic Follow-up Study of the First National Health and Nutrition Examination Survey to examine the effect of overweight on coronary heart disease incidence (mean length of follow-up, 14 years). They also used reported lifetime maximum weight to examine the effect of weight loss on this association. Women with a Quetelet index (weight (kg)/height (m)2) of 29 or more showed an increased risk of coronary heart disease (relative risk (RR) = 1.5, 95% confidence interval (CI) 1.1-2.1) after adjustment for age and smoking in comparison with those with a Quetelet index of less than 21, while women with a Quetelet index of 23-24 had a lower risk of coronary heart disease (RR = 0.6, 95% CI 0.4-0.9). However, the pattern of risk associated with measured weight was modified by weight loss. Among heavier women whose weight was relatively stable, those with a Quetelet index of 29 or more had an increased risk of heart disease (RR = 2.7, 95% CI 1.7-4.4). Among those with greater weight loss, the relation between Quetelet index and risk of coronary heart disease was J-shaped. Overweight is an independent risk factor for coronary heart disease in older women, a finding strengthened after previous weight loss is accounted for. Reasons for the unexpected increase in risk of coronary heart disease in thinner women who lost weight are unclear, and further investigation is warranted.

Plan and operation of the NHANES I Epidemiologic Followup Study, 1987.

This report describes the plan and operation for the 1987 data collection wave of the Epidemiologic Followup to the first National Health and Nutrition Examination Survey (NHANES I). Tracing and data collection were conducted on 11,750 persons 25-74 years of age at NHANES I who were not known to be deceased in the 1982-84 and 1986 data collection waves of the NHANES I Epidemiologic Followup Study.

The ptotic (witch's) chin deformity: an excisional approach.

Ptosis of the chin pad is common and can be seen in patients of all ages. It may be associated with too little or (at times) too much anterior chin projection. Often there is an associated deep submental skin crease present. Frequently, the primary concern of the patient is the appearance or exaggeration of chin ptosis in smiling ("dynamic" ptosis). This report describes a flexible approach to the correction of developmental (and some iatrogenic) ptotic chin deformities. The key element in the approach is the direct excision of sagging or excess chin fat, muscle, and skin. No attempt is made to reposition or lift ptosis-prone soft tissues. If a deep submental skin crease is present, it too is excised. If the chin needs added anterior projection, it is accomplished with a stable alloplastic chin implant. The approach is uniquely suited to correct anterior overprojection caused by an excess of soft tissue at the front of the chin and has been successful in correcting the "dynamic" ptosis that appears with smiling.

Firearm and nonfirearm homicide among persons 15 through 19 years of age. Differences by level of urbanization, United States, 1979 through 1989.

OBJECTIVE: To examine trends (1979 through 1989) and current status in firearm and nonfirearm homicide rates by level of urbanization among persons 15 through 19 years of age. DESIGN: The Compressed Mortality File, a county-level mortality and population database maintained by the National Center for Health Statistics, Centers for Disease Control, Hyattsville, Md, and the 1980 Human Resource Profile County Codes are used to analyze age-, sex-, and race-specific firearm and nonfirearm homicide rates by urbanization level. SETTING: United States, 1979 through 1989. SUBJECTS: Black and white males and females 15 through 19 years of age whose underlying cause of death was either firearm homicide (E965.0 through E965.4 or E970) or nonfirearm homicide (E960 through E964, E965.5 through E969, or E971 through E978) in the ICD-9 (International Statistical Classification of Diseases, Injuries, and Causes of Death, Ninth Revision). MAIN OUTCOME MEASURES: Urbanization level-specific firearm and nonfirearm homicide rates. RESULTS: The 1989 firearm homicide rate in metropolitan counties was nearly five times the rate in nonmetropolitan counties (13.7 vs 2.9 deaths per 100,000 population). Firearm homicide rates were highest in core metropolitan counties, 27.7 per 100,000 population; rates were higher for black males than for any other race-sex group in each of five county urbanization strata for 1979 through 1989. Nonfirearm homicide rates are considerably lower, with smaller urban differentials; the rate in metropolitan counties was 1.4 times the rate in nonmetropolitan counties (2.6 vs 1.8 per 100,000 population). From 1979 through 1984, firearm homicide rates declined in each of the county strata. From 1984 through 1987, firearm homicide rates increased, and from 1987 through 1989 they increased rapidly, from 23% to 35% per year in the four metropolitan strata. From 1979 through 1989, nonfirearm homicide rates declined or remained stable. CONCLUSIONS: Large urbanization differentials in firearm homicide and smaller differentials in nonfirearm homicide are identified. Firearm homicide rates are highest and increasing the fastest among black teenage males in the core, fringe, and medium metropolitan strata.

Firearm homicide among black teenage males in metropolitan counties. Comparison of death rates in two periods, 1983 through 1985 and 1987 through 1989.

OBJECTIVE: To identify US counties (1) that had either significantly high or significantly low firearm homicide rates among black males 15 through 19 years of age in 1983 through 1985 and in 1987 through 1989, and/or (2) that experienced a significant increase in the firearm homicide rate between 1983 through 1985 and 1987 through 1989. DESIGN: Using the Compressed Mortality File, a county-level mortality and population database maintained by the National Center for Health Statistics, Centers for Disease Control, Hyattsville, Md, county-level firearm homicide rates are analyzed. SETTING: Eighty counties with a population of at least 10,000 black males 15 through 19 years of age in 1987 through 1989. SUBJECTS: Black males 15 through 19 years of age whose underlying cause of death was classified as firearm homicide (E965.0 through E965.4, or E970) in the ICD-9 (International Statistical Classification of Diseases, Injuries, and Causes of Death, Ninth Revision). MAIN OUTCOME MEASURE: County-specific firearm homicide rate. RESULTS: In 1983 through 1985 and in 1987 through 1989, seven and 13 counties, respectively, were identified that had significantly high firearm homicide rates. Firearm homicide rates were significantly high in both time periods in the following counties: Los Angeles, California; Wayne, Michigan; Kings, New York; St Louis City, Missouri; and Baltimore City, Maryland. Firearm homicide rates increased significantly between 1983 through 1985 and 1987 through 1989 in 34 of the 80 counties. Twenty counties had significantly low rates in both time periods. Several counties with low rates in 1983 through 1985 experienced significant increases and by 1987 through 1989 were among those with high rates. CONCLUSIONS: Surveillance of firearm homicide rates at the county levels in counties with high and with low rates is a necessary first step in the development of successful violence prevention programs. Those counties where rates are high and increasing are the counties that are in greatest need for intervention strategies. Knowledge of the incidence of nonfatal firearm injuries is also needed.

Increased mortality from brain tumors: a combined outcome of diagnostic technology and change of attitude toward the elderly.

United States national data were used to assess factors responsible for the increase of brain tumor mortality. Between 1968 and 1988, death rates increased 50% among those aged 65-74 years, 200% among those aged 75-84 years, and 800% in the oldest old. Rate of increase and maximum death rate have changed over time. Death rate among the population aged 65-74 years peaked in the mid-1980s, while among those aged 85 years and older it is projected to continue increasing throughout the 1990s. The patterns of rate increases were almost identical in the two sexes, as well as among whites and nonwhites. There was a strong correlation over time of death rates with head diagnostic procedures (r = 0.96) and with the pace of computerized axial tomography installation (r = 0.91). The authors conclude that the reported increase in brain tumor mortality is not genuine, but represents a combination of three factors: availability of more sophisticated, noninvasive diagnostic technology; change in the attitude toward care of the elderly; and introduction of support programs such as Medicare that facilitate diagnostic procedures in the elderly.

The low cholesterol-mortality association in a national cohort.

The relationship of low serum cholesterol and mortality was examined in data from the NHANES I Epidemiologic Followup Study (NHEFS) for 10,295 persons aged 35-74, 5833 women with 1281 deaths and 4462 men with 1748 deaths (mean (followup = 14.1 years). Serum cholesterol below 4.1 mmol/l was associated with increased risk of death in comparison with serum cholesterol of 4.1-5.1 mmol/l (relative risk (RR) for women = 1.7, 95% confidence interval (CI) = (1.2, 2.3); for men RR = 1.4, CI = (1.1, 1.7)). However, the low serum cholesterol-mortality relationship was modified by time, age, and among older persons, activity level. The low serum cholesterol-mortality association was strongest in the first 10 years of followup. Moreover, this relationship occurred primarily among older persons (RR for low serum cholesterol for women 35-59 = 1.0 (0.6, 1.8), for women 70-74, RR = 2.1 (1.2, 3.7); RR for low serum cholesterol for men 35-59 = 1.2 (0.8, 2.0), for men 70-74, RR = 1.9 (1.3, 2.7)). Among older persons, however, the low serum cholesterol-mortality association was confined only to those with low activity at baseline. Factors related to underlying health status, rather than a mortality-enhancing effect of low cholesterol, likely accounts for the excess risk of death among persons with low cholesterol. The observed low cholesterol-mortality association therefore should not discourage public health programs directed at lowering serum cholesterol.

Corset platysmaplasty.

This method represents a nontraditional approach to platysma tightening in which the muscle is moved primarily in an anterior direction. A long infolded, multilayered midline seam approximates the two platysma halves into a single sheet of shaped muscle across the entire front of the neck. Vertical submandibular muscle pleats and sling sutures further refine neck contour. No muscle is resected or transected. Subplatysmal lipectomy can be done without the risk of central neck depression or laryngeal skeletonization. A bulging submandibular salivary gland can often be corrected.

A method to redefine stays on the 1985 National Nursing Home Survey.

This report describes a method for standardizing definitions of episodes of nursing home care in the 1985 National Nursing Home Survey. The method shows how the information on nursing home admissions and discharges collected on the Current and Discharged Resident Questionnaires can be used to redefine the endpoints of nursing home stays. The report also explains how errors caused by missing and inconsistent nursing home admission and discharge data were resolved.

Is weight loss a modifier of the cholesterol-heart disease relationship in older persons? Data from the NHANES I Epidemiologic Follow-up Study.

The relationship between cholesterol and 14-year incidence of coronary heart disease was compared for men and women of two age groups, 25 to 64 years and 65 to 74 years. While cholesterol levels of 6.2 mmol/L or higher were associated with a risk of coronary heart disease in the younger group, this was not true for either men or women aged 65 to 74. Further analyses for older persons showed that weight loss modified the cholesterol-heart disease relationship. Those with stable weight showed a positive relationship between cholesterol and coronary heart disease, similar to the younger age group (relative risk [RR] = 1.8 [95% confidence interval: 1.1, 2.9] for men; RR = 1.6 [.7, 3.4] for women). Among those with a weight loss of 10% or more, the relationship of cholesterol to heart disease was inverse (RR = .8 [.5, 1.2] for men; RR = .6 [.3, 1.0] for women). These data suggest that the relationship of cholesterol to coronary disease in healthier older persons may be similar to that in younger persons, and that health status should be considered in analyses of cholesterol risk in old age.