Chronic diseases in male veterans with multiple sclerosis.

INTRODUCTION: Chronic disease risk may be high in people with multiple sclerosis (MS). Our objective was to identify chronic health conditions that may disproportionately affect male veterans with MS. METHODS: We collected primary survey data for male veterans with MS (n = 1,142) in 2003 and 2004 and compared the data with 2003 Behavioral Risk Factor Surveillance System secondary data for comparison groups without MS (veteran population, n = 31,500; general population = 68,357). We compared disease prevalence by group and identified variables associated with chronic diseases in male veterans with MS. RESULTS: Overall, veterans with MS had a high prevalence of hypercholesterolemia (49%), hypertension (47%), diabetes (16%), coronary heart disease (11%), and stroke (7%). Overall and for the subset of people aged 50 years or older, diabetes, hypertension, hypercholesterolemia, coronary heart disease, and stroke were significantly more prevalent among male veterans with MS than among the general population. Diabetes, hypertension, hypercholesterolemia, and stroke were more prevalent overall among male veterans with MS than among the general veteran population; however, except for stroke, differences were not significant for the group aged 50 or older. Explanatory variables (eg, age, education, race) and dynamic associations between conditions (higher odds for each when ≥ 1 of the other conditions were present) for chronic disease in men with MS were similar to findings in the general population literature for select conditions. CONCLUSION: These findings raise awareness of chronic disease in a veteran cohort and help bridge a gap in the literature on chronic disease epidemiology in men with MS. We identified chronic disease priorities that may benefit from focused interventions to reduce disparities.

Prevalence of drug resistant tuberculosis among patients at high-risk for Hiv attending outpatient clinics in Delhi, India.

We sought to determine tuberculosis (TB) prevalence including multidrug resistant (MDR)-TB among a cohort of high risk patients at two directly observed treatment short course (DOTS) clinics in Delhi, India. We also aimed to compare the sensitivity of acid-fast bacilli (AFB) smear tests for patients with HIV using sputum cultures as the gold standard. A cross-section study was conducted among adult patients (> or = 18 years old) with prolonged cough (greater than two weeks), night sweats, fever, and/or weight loss suspected of pulmonary TB between February and March 2006. Sputum samples were obtained and processed for 165 patients; 53 (32.1%) were culture positive for TB. Patients with TB were predominantly male (92.1%), young (median age of 32 years), and the HIV-seroprevalence was high (41.5%). In the multivariable analysis adjusted for age, HIV infection was significantly associated (POR = 2.0, p < 0.05) with the presence of TB disease. Among Mycobacterium tuberculosis isolates recovered from 53 cases, 25 (47.2%) were resistant to > or = 1 first line anti-TB drugs and 7 (13.2%) were MDR-TB. The sensitivity of AFB smears among HIV negative and positive participants was 35.5% and 18.0%, respectively. Our findings demonstrated that the sensitivity of AFB smears to detect TB among HIV positive patients was low. Additionally, we found that even in regions where population drug resistance estimates are low, sentinel surveillance of MDR-TB in high-risk populations is useful to prioritize target groups in need of additional prevention, monitoring and health outreach.

Frequent ear infections in infancy and the risk of asthma in Mexican American children.

OBJECTIVES: This study examined the associations of history of ear infections in infancy with doctor-diagnosed asthma in a large sample of Mexican American children. METHODS: In this population-based cross-sectional study, parents of 2023 children completed a questionnaire that collected data on doctor-diagnosed asthma, doctor-diagnosed ear infections, as well as antibiotics use in infancy, and other potential confounding variables. RESULTS: Children with a history of ear infections in infancy were more likely to have asthma compared with those who had no history of ear infections in infancy; the adjusted odds ratios (ORs) were 2.52 (95% confidence interval [CI]: 1.35-4.69) and 1.27 (95% CI: 0.79-2.04) in children who had >or=3 and 1-2 (versus none) ear infections in infancy, respectively, p for trend = .0074. These associations were independent of antibiotics use, acetaminophen consumption, and history of various infections (other than ear infections) in the first year of life. In stratified analyses, the increased risk of asthma in children with recurrent ear infections in infancy persisted among children whose parents reported no lifetime history of rhinitis but not in children who had a history of rhinitis. CONCLUSIONS: This study demonstrated significant associations of asthma with history of ear infections in infancy, with a significant dose-response effect of repeated ear infections on the odds of asthma. These findings add to the growing body of literature linking early childhood infections with the risk of asthma and highlight the need for more research to identify the mechanisms through which ear infections may be associated with asthma.

Cesarean delivery for the prevention of anal incontinence.

BACKGROUND: Caesarean delivery (CD) is a common form of delivery of a baby, rising in frequency. One reason for its performance is to preserve maternal pelvic floor function, part of which is anal continence. OBJECTIVES: To assess the ability of CD in comparison to vaginal delivery (VD) to preserve anal continence in a systematic review SEARCH STRATEGY: Search terms include: "Caesarean section, Cesarean delivery, vaginal delivery, incontinence and randomised". PubMed, EMBASE and the Cochrane Central Register of Controlled Trials (Central) were searched from their inception through July, 2009. SELECTION CRITERIA: Both randomised and non-randomised studies that allowed comparisons of post partum anal continence (both fecal and flatus) in women who had had babies delivered by either CD or VD were included. DATA COLLECTION AND ANALYSIS: Mode of delivery, and when possible mode of all previous deliveries prior to the index pregnancy were extracted, as well as assessment of continence post partum of both faeces and flatus. In Non-RCTs, available adjusted odds ratios were the primary end point sought. Incontinence of flatus is reported as a separate outcome. Summary odds ratios are not presented as no study was analysed as a randomised controlled trial. Numbers needed to treat (NNT) are presented, that is, the number of CDs needed to be performed to prevent a single case of fecal or flatus incontinence, for each individual study. Quality criteria were developed, selecting studies that allowed maternal age adjustment, studies that allowed a sufficient time after the birth of the baby for continence assessment and studies in which mode of delivery of prior pregnancies was known. Subgroup analyses were done selecting studies meeting all quality criteria and in comparisons of elective versus emergency CD, elective CD versus VD and nulliparous women versus those delivered by VD or CD, in each case again, not calculating a summary risk statistic. MAIN RESULTS: Twentyone reports have been found eligible for inclusion in the review, encompassing 31,698 women having had 6,028 CDs and 25,170 VDs as the index event prior to anal continence assessment . Only one report randomised women (with breech presentation) to CD or VD, but because of extensive crossing over, 52.1%, after randomisation, it was analysed along with the other 20 studies as treated, i.e. as a non-randomised trial. Only one of these reports demonstrated a significant benefit of CD in the preservation of anal continence, a report in which incontinence incidence was extremely high, 39% in CD and 48% in VD, questioning, relative to other reports, the timing and nature of continence assessment. The greater the quality of the report, the closer its Odds ratio approached 1.0. There was no difference in continence preservation in women have emergency versus elective CD. AUTHORS' CONCLUSIONS: Without demonstrable benefit, preservation of anal continence should not be used as a criterion for choosing elective primary CD. The strength of this conclusion would be greatly strengthened if there were studies that randomised women with average risk pregnancies to CD versus VD.

Factors associated with self-reported health: a twin study of older African American women.

This study examined risk factors associated with self-reported health (SRH) in a genetically informative sample of older African American female twins. An interview was conducted with a national sample of 180 African American female twin pairs. Questions included: SRH, demographics, health behaviors, chronic diseases, and functional status. SRH was dichotomized into negative (fair/poor) and positive (good/very good/excellent). Logistic regression for clustered data was used to estimate the odds ratios and 95% confidence intervals. In multivariable analyses, IADL limitations (OR = 1.5, 95% CI = 1.7-2.0) and a chronic disease index (OR = 1.9, 95% CI = 1.4-2.5) were associated with negative SRH. In multivariate within-twin pair analysis, controlling for genetics/shared familial environment, IADLs (OR = 1.8, 95% CI = 1.1-2.7), and increasing numbers of chronic diseases (OR = 2.0, 95% CI = 1.3-3.2) remained significantly associated with negative SRH.

Associations of doctor-diagnosed asthma with immigration status, age at immigration, and length of residence in the United States in a sample of Mexican American School Children in Chicago.

OBJECTIVES: Among Mexican Americans in the United States, children who were born in the US had higher rates of asthma than their Mexico-born peers. The purpose of this study was to examine the associations of doctor-diagnosed asthma with immigration-related variables and to investigate whether these associations could be explained by factors that may change with migration. METHODS: We surveyed parents of 2,023 school children of Mexican descent and examined the associations of asthma with nativity, age at immigration, and length of residence in the US after adjusting for potential confounding variables. RESULTS: In multivariate analyses, US-born children had a 2.42-fold (95% confidence interval [CI]: 1.52-3.83) increased odds of asthma compared with their Mexico-born peers. Mexico-born participants who moved to the US before 2 years of age were almost twice as likely to experience asthma compared with Mexico-born children who moved to the US >or=2 years of age. In addition, Mexico-born participants who lived in the US for 10 years or more were 2.37 times more likely to have asthma than Mexico-born students who lived in the US for less than 10 years. These associations were not explained by a wide variety of factors such as place of residence in infancy; exposure to animals/pets; history of infections, Tylenol use, and antibiotic use in infancy; breastfeeding; exposure to environmental tobacco smoke; daycare attendance and number of siblings; and language use. CONCLUSIONS: Our findings point to the effects of nativity, age at immigration, and duration of residence in the US on the risk of asthma in Mexican American children, suggesting that potentially modifiable factors that change with migration may be linked with the disease. The findings of this study should stimulate further research to explain factors that may be responsible for the observed differentials in the risk of asthma among Mexican Americans.

Twin study of depressive symptoms among older african-american women.

This study examines factors associated with depressive symptoms in a genetically informative sample of African-American female twins aged 65 years and older. A telephone interview was conducted with 180 pairs of twins. Questions included demographics, health behaviors, health status, activities of daily living (ADLs), instrumental ADLs, and depressive symptoms as measured by the Center for Epidemiologic Studies-Depression scale. Regression methods for clustered data were used to examine the associations. In univariate analyses, ADLs (odds ratio or OR = 1.4, 95% confidence interval or CI = 1.1-1.7), fractures (OR = 4.4, 95% CI = 1.3-15.6), and vision problems (OR = 1.9, 95% CI = 1.0-3.8) were significantly associated with depressive symptoms. In multivariable analyses, ADLs (OR = 1.4, 95% CI = 1.2-1.7) and vision problems (OR = 2.0, 95% CI = 1.2-3.5) remained significantly associated with depressive symptoms. A within-pair analysis, controlling for genetic or familial influences, produced similar results. The results suggest that efforts targeted at reducing levels of disability may reduce depressive symptoms in this population.

One-year follow-up of a randomized clinical trial comparing flexion distraction with an exercise program for chronic low-back pain.

OBJECTIVE: Flexion distraction is a commonly used form of chiropractic care with chiropractor utilization rates of 58%. However, no previous randomized clinical trial has assessed the effectiveness of this form of care. The objective of this investigation was to compare the pain and disability during the year after active care based on treatment group allocation (Flexion Distraction versus Exercise Program). STUDY DESIGN: Randomized clinical trial, follow-up. SUBJECTS: Two hundred and thirty-five (235) subjects who were previously randomized to either chiropractic care (flexion distraction) or physical therapy (exercise program) within a clinical trial. OUTCOME MEASURES: Subjects were followed for 1 year via mailed questionnaires to assess levels of pain (Visual Analog Scale) and dysfunction (Roland Morris). RESULTS: Study subjects had a decrease in pain and disability after intervention regardless of which group they attended (p < 0.002), however, during the year after care, subjects who received chiropractic care (flexion distraction therapy) had significantly lower pain scores than subjects who received physical therapy (exercise program) (p = 0.02). CONCLUSIONS: In this first trial on flexion distraction care, flexion distraction was found to be more effective in reducing pain for 1 year when compared to a form of physical therapy.

Amount of health care and self-care following a randomized clinical trial comparing flexion-distraction with exercise program for chronic low back pain.

BACKGROUND: Previous clinical trials have assessed the percentage of participants who utilized further health care after a period of conservative care for low back pain, however no chiropractic clinical trial has determined the total amount of care during this time and any differences based on assigned treatment group. The objective of this clinical trial follow-up was to assess if there was a difference in the total number of office visits for low back pain over one year after a four week clinical trial of either a form of physical therapy (Exercise Program) or a form of chiropractic care (Flexion Distraction) for chronic low back pain. METHODS: In this randomized clinical trial follow up study, 195 participants were followed for one year after a four-week period of either a form of chiropractic care (FD) or a form of physical therapy (EP). Weekly structured telephone interview questions regarded visitation of various health care practitioners and the practice of self-care for low back pain. RESULTS: Participants in the physical therapy group demonstrated on average significantly more visits to any health care provider and to a general practitioner during the year after trial care (p < 0.05). No group differences were noted in the number of visits to a chiropractor or physical therapist. Self-care was initiated by nearly every participant in both groups. CONCLUSION: During a one-year follow-up, participants previously randomized to physical therapy attended significantly more health care visits than those participants who received chiropractic care.

Risk factors for the development of fecal and urinary incontinence in Wisconsin nursing home residents.

PURPOSE: To determine factors associated with the development of urinary and fecal incontinence in nursing homes. DESIGN AND METHODS: Residents of Wisconsin skilled nursing facilities reported in the Wisconsin annual nursing home survey continent to both urine and stool in 1992 were re-assessed 1 year later for the development of urinary and/or fecal incontinence. Independent variables were elements of the HCFA minimum data set found to be significantly associated with incontinence in cross-sectional surveys of Wisconsin nursing home residents. RESULTS: Dementia and advancing age were consistently associated with the development of incontinence, but the strongest associations were impairment of activities of daily living and the use of patient restraints. IMPLICATION: Adjusting for the major reasons to apply patient restraint: dementia, blindness, arthritis and stroke, along with other risk factors for incontinence, the use of patient restraints is the most significant cause for the development of incontinence in nursing homes.

A co-twin control study of physical function in elderly African America women.

OBJECTIVE: This study investigated variables associated with physical functioning limitations among elderly African American women, controlling for genetics and common family environment. METHOD: Activities of daily living limitations (ADL) and instrumental activities of daily living limitations (IADL) are examined in 180 pairs of African American elderly twins using a co-twin control design. The association of chronic disease, other physical problems, lifestyle, and demographic factors with both measures are investigated. RESULTS: Arthritis, hypertension, and more than 1 chronic disease are associated with ADL limitations and arthritis; diabetes, heart attack, and more than 1 chronic disease are associated with IADL limitations in univariate analyses. In multivariate analyses, a different set of additional variables is associated with the two measures. DISCUSSION: Among elderly African American women, physical functioning limitations are influenced by the presence of chronic diseases, other physical problems, lifestyle, and demographics. These associations are not due to genetics or common family environment effects.

Development of a student-mentored research program between a complementary and alternative medicine university and a traditional, research-intensive university.

The global need to develop clinician-scientists capable of using research in clinical practice, translating research knowledge into practice, and carrying out research that affects the quality, efficacy, and efficiency of health care is well documented. The complementary and alternative medicine (CAM) professions embrace the call to develop physician-researchers to carry out translational and applied research for CAM modalities. CAM universities face unique challenges when implementing research training compared with traditional, research-intensive (TRI) universities and medical centers where the majority of medical research is carried out.The authors present the development and outcomes of a mentored research program (MRP) between a CAM and a TRI institution, the National University of Health Sciences and the University of Illinois at Chicago School of Public Health, between 2006 and 2012. CAM predoctoral students engaged in a full-immersion semester at the TRI, including didactic courses and active research with a TRI faculty research mentor. Half of the participating doctor of chiropractic (DC) students continued on to PhD programs, and half established integrative medicine, primary care clinical careers.Establishing rigorous criteria for mentors and mentees, communicating expectations, developing solid relationships between the mentor, mentee, and home school advisor, responding quickly to impediments, and providing adequate support from CAM and TRI investigators were key to the MRP's success. To sustain research opportunities, coordinated degree programs for the DC and master of public health and master of clinical and translational research were established.

Shut-In? Impact of Chronic Conditions on Community Participation Restriction among Older Adults.

Community participation may be especially important for older adults, who are often at risk for unwanted declines in participation. We estimated the prevalence of community participation restriction (PR) due to perceived environmental barriers among older adults (≥50 years) and compared the impact among those with selected chronic conditions. Individuals with low-prevalence conditions reported high community PR (9.1-20.4%), while those with highly prevalent conditions (e.g., arthritis) had relatively low community PR (5.1-10.0%) but represented the greatest absolute numbers of condition-associated burden (>1 million). Across all conditions, more than half of those with community PR reported being restricted "always or often." Community PR most often resulted from modifiable environmental barriers. Promising targets to reduce community PR among adults ≥50 years with chronic conditions, particularly arthritis, include building design, sidewalks/curbs, crowd control, and interventions that improve the built environment.

Health-related quality of life of US adults with arthritis: analysis of data from the behavioral risk factor surveillance system, 2003, 2005, and 2007.

OBJECTIVE: To describe the health-related quality of life (HRQOL) of persons with and without arthritis in the 50 US states and the District of Columbia, and to determine correlates of poor HRQOL in persons with arthritis. METHODS: Data from the Behavioral Risk Factor Surveillance System were used. Descriptive analyses were age standardized and multivariate analyses used logistic regression. RESULTS: Of persons ages ≥18 years with arthritis, 27% reported fair/poor health, compared to 12% without arthritis. The mean numbers of physically unhealthy, mentally unhealthy, and activity-limited days for persons with arthritis exceeded those for persons without arthritis. In regression analyses, black non-Hispanics reported better HRQOL than white non-Hispanics, especially in the ≥14 versus 0 days comparisons. Yet no difference existed in self-reported health status between these two groups. Having a low family income and being unable to work were both strongly associated with poor HRQOL. Being physically active was associated with better HRQOL. Binge drinking was associated with poor HRQOL for some measures, but was associated with better self-reported health. Cost being a barrier to care and having diabetes mellitus were strongly associated with worse HRQOL. CONCLUSION: Adults from the US with arthritis had worse HRQOL than those without. Physical health and mental health were both affected by arthritis; therefore, efforts to alleviate the arthritis burden should address both domains. Given the current and projected high prevalence of arthritis, we face a significant burden of poor HRQOL. Increasing physical activity, reducing comorbidities, and increasing access to health care could improve the HRQOL of persons with arthritis.

Breastfeeding and genetic factors in the etiology of inflammatory bowel disease in children.

Inflammatory bowel disease is a chronic, debilitating disorder of the gastrointestinal tract. The etiology of inflammatory bowel disease has not been elucidated, but is thought to be multifactorial with both environ-mental and genetic influences. A large body of research has been conducted to elucidate the etiology of inflammatory bowel disease. This article reviews this literature, emphasizing the studies of breastfeeding and the studies of genetic factors, particularly NOD2 polymorphisms.

A systematic review of the efficacy of cesarean section in the preservation of anal continence.

PURPOSE: Elective primary cesarean section is performed largely to avoid maternal pelvic trauma that may result in anal incontinence, although its efficacy in this regard has not been thoroughly assessed. We perform a systematic review of published reports that compare anal incontinence risk by mode of delivery. METHODS: PubMed was searched from 1966 through August 2005. Authors were contacted for missing data or analyses. Both randomized and nonrandomized reports were included. Eligible studies included females having vaginal delivery or cesarean section, fecal and/or flatal incontinence was reported as an outcome, and risk was calculable from the reported data. Crude data were extracted from the reports, as well as reported odds ratios and confidence intervals. In the nonrandomized studies, adjusted odds ratios also were extracted and additional data obtained from authors to adjust risks for age and parity if not originally done. Sensitivity analyses were performed using quality indicators: age and parity adjustment, time to continence assessment, and mode of previous delivery. RESULTS: Fifteen studies were found eligible, encompassing 3,010 cesarean sections and 11,440 vaginal deliveries. The summary relative risk for fecal incontinence was 0.91 (95 percent confidence interval, 0.74-1.14). For flatus the relative risk was 0.98 (range, 0.86-1.13). The number needed to treat by cesarean section was 167 to prevent a single case of fecal incontinence. Five studies were judged to be of high quality. In these studies, the summary relative risk was 0.94 (range, 0.72-1.22) and number needed to treat was 198. CONCLUSIONS: The best evidence to assess the efficacy of cesarean section in the prevention of anal incontinence would be in randomized trials of average-risk pregnancies with few crossovers. In the absence of such trials and based on this review, cesarean section does not prevent anal incontinence. This implies that incontinence associated with delivery may be more likely incontinence caused by pregnancy.

A twin study of posttraumatic stress disorder symptoms and chronic widespread pain.

Previous studies of the association between posttraumatic stress disorder (PTSD) and chronic widespread pain (CWP) or fibromyalgia have not examined the role of familial or genetic factors. The goals of this study were to determine if symptoms of PTSD are related to CWP in a genetically informative community-based sample of twin pairs, and if so, to ascertain if the association is due to familial or genetic factors. Data were obtained from the University of Washington Twin Registry, which contains 1042 monozygotic and 828 dizygotic twin pairs. To assess the symptoms of PTSD, we used questions from the Impact of Events Scale (IES). IES scores were partitioned into terciles. CWP was defined as pain located in 3 body regions lasting at least 1 week during the past 3 months. Random-effects regression models, adjusted for demographic features and depression, examined the relationship between IES and CWP. IES scores were strongly associated with CWP (P<0.0001). Compared to those in the lowest IES tercile, twins in the highest tercile were 3.5 times more likely to report CWP. Although IES scores were associated with CWP more strongly among dizygotic than among monozygotic twins, this difference was not significant. Our findings suggest that PTSD symptoms, as measured by IES, are strongly linked to CWP, but this association is not explained by a common familial or genetic vulnerability to both conditions. Future research is needed to understand the temporal association of PTSD and CWP, as well as the physiological underpinnings of this relationship.

A new method for classifying patterns of prenatal care utilization using cluster analysis.

OBJECTIVES: The objectives of this study were: to 1) define patterns of prenatal care utilization using cluster analysis, 2) describe two alternative cluster solutions and compare these groupings to the Adequacy of Prenatal Care Utilization Index (APNCU), 3) compare the cluster solutions and the APNCU with respect to maternal age and prematurity, and 4) discuss advantages and disadvantages of using cluster analysis to study prenatal care. METHODS: The study sample included 3544 women in the 1988 National Maternal and Infant Health Survey for whom complete prenatal care visit data were available. Clustering was carried out in two stages, first employing nearest centroid sorting (the k means method), a nonhierarchical approach, and then using Ward's Minimum Variance Method, a hierarchical clustering technique. RESULTS: Patterns of prenatal care defined by cluster analysis varied by timing of the first visit, total number of visits, and the rate of accumulation of visits, but this variation was different compared to that seen for the APNCU. While the cluster solutions and the APNCU identified a similar normative pattern of care, other patterns identified were quite different. In particular, the six-cluster solution differentiated among women who entered care at similar times, but accumulated visits at differing rates and experienced differing rates of preterm delivery. CONCLUSION: Cluster analysis is a new tool for studying prenatal care. Further studies are needed to refine the method and test whether the alternative perspective it provides will lead to new findings concerning the relationship of prenatal care and birth outcomes.