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.

Health service areas for the United States.

The objectives of this report are to document methods used to identify health service areas for the United States and to describe and evaluate these areas. A health service area is defined as one or more counties that are relatively self-contained with respect to the provision of routine hospital care. Service areas that include more than one county are characterized by travel between the counties for routine hospital care.

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.

The effect of collection technique on tear composition.

Selected proteins were quantitated after collecting samples of the tears by using two sampling techniques. Tears from the same individual were collected via absorption by Schirmer filter paper strip from the unanesthetized, inferior, conjunctival sac and were compared with tears collected by a capillary tube (taking care not to touch the conjunctiva), after stimulation of tearing by irritation of the nasal mucosa with ammonia vapor. Tear samples were quantitated immunochemically for two typical lacrimal proteins, lysozyme and lactoferrin, and three typical serum proteins, albumin, transferrin, and IgG. Tear analysis of all constituents were performed on a single sample of tears collected by each method from the same individual. Normal subjects without ocular pain or discomfort comprised a sample of 12 subjects ranging in age from 19 to 57 years and consisting of 9 men and 3 women. Concentrations of lysozyme and lactoferrin in samples collected by either method were not significantly different. In contrast, the concentration of albumin, IgG and transferrin collected by Schirmer filter paper technique was significantly higher (P less than 0.01) than the concentration in tears collected by the capillary tube technique. A highly significant increase in serum proteins was seen when the Schirmer filter paper strip was used to collect tears compared to tears collected without mechanical stimulation of the conjunctiva.

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.

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.

An overview of body weight of older persons, including the impact on mortality. The National Health and Nutrition Examination Survey I--Epidemiologic Follow-up Study.

The authors studied distributions of body weight for height, change in body weight with age, and the relationship between body mass index and mortality among participants in the Epidemiologic Follow-up Study of the first National Health and Nutrition Examination Survey (NHEFS) (n = 14,407), a cohort study based on an representative sample of the U.S. population. Percentiles of body weight for height according to age and sex are presented. Cross-sectional analyses of body weight suggest that mean body weight increases with age until late middle age, then plateaus and decreases for older aged persons. However, longitudinal analysis of change in weight with age shows that younger persons in the lower quintile at baseline tend to gain more than those in the higher quintile. Older persons in the higher quintile at baseline have the greatest average loss in weight. The relationship of body mass index to mortality is a U-shaped curve, with increased risks in the lowest and highest 15% of the distribution. Increased risk of mortality associated with the highest 15th percentile of the body mass index distribution, as well as the highest 15% of the joint distribution of body mass index and skinfold thickness, is statistically significant for white women. However, the risk diminishes when adjusted for the presence of disease and factors related to disease. More noteworthy is the fact that there is a statistically significant excess risk of mortality for both race and sex groups in the lowest 15% of the body mass index distribution after adjusting for smoking history, and presence of disease. Those in the lowest 15% of the joint body mass index and skinfold thickness distribution, were also at increased risk. Risk of mortality for both men and women who have lost 10% or more of their maximum lifetime weight within the last 10 years is statistically significant, even when controlling for current weight. This study has replicated previously reported relationships, while correcting for several methodological issues.

Utilization of services for preventable disease: a case study of dental care in a southern rural area of the United States.

The use made of dental services, both preventive and symptomatic, was explored in a small rural southern community in North Carolina as part of a case study illustrative of southern rural patterns of utilization of elective health services. The target population of 1689 persons in 545 households was interviewed in a household survey and in each of four follow-up panel visits over a period of one year--1974--75. Though overall utilization of dental services was low and preventive dental services even lower in both blacks and whites, blacks were at a considerable disadvantage. Unlike whites, increasing education did not increase use of services in blacks; also, unlike whites, black mothers' preventive behaviour was not associated with increased dental preventive behaviour in their children. In addition to barriers to care suffered by the poor, blacks in the south still have additional barriers to overcome: Established patterns of practice are slow to change even when legal and financial barriers are lowered.

Trends in total mortality and mortality from heart disease in 26 countries from 1950 to 1978.

Death rates for total mortality and for non-rheumatic heart disease and hypertension ('heart disease') are described for men and women ages 45-64 in six time periods during 1950-78 for 26 countries. Rates for men in high-rate countries are three times those in low-rate countries. This variation is more striking for men than women. There were marked increases for heart disease in men in most countries, but in 13 countries there was a slowing or reversal of that trend in the 1960's or 1970's or acceleration of an already downward trend. In 22 countries long-term declines for heart disease occurred in women. There was a widening of the north/south gradient in Europe and of the male/female ratio of heart disease mortality. Countries with high heart disease death rates in men had high ratios of heart disease to total death. Other countries experienced a rise in proportionate mortality. In women, proportionate mortality for heart disease remained flat or declined in most countries. In spite of these changes in rates, each country seems to have a range for heart disease mortality that is characteristic of its population and environmental setting so that profound changes in rates do not substantially alter their relative ranking. Our intent is to stimulate the search for reasons why heart disease mortality recently declined in some countries but not in others (already begun in the WHO-sponsored MONICA programme). Our forthcoming monograph on international mortality trends for the major causes of death will be a next step in this process.

Is the serum cholesterol-coronary heart disease relationship modified by activity level in older persons?

Although coronary heart disease remains a leading cause of death and disability in old age, the relationship of serum cholesterol level to risk of coronary heart disease in old age is controversial. Data for 2,388 white persons aged 65-74 who participated in the National Health and Nutrition Examination Survey (NHANES) I Epidemiologic Follow-up Study (NHEFS) were examined to determine the relationship of serum cholesterol level to coronary heart disease incidence and whether activity level would modify this relationship. While there was no overall relationship between serum cholesterol level and coronary heart disease risk in either men or women, the relationship between serum cholesterol level and coronary heart disease differed within activity groups. For persons who were more active, serum cholesterol level was associated with a graded increase in risk of coronary heart disease, from 1.3 (95% CI 0.7, 2.3) in those with serum cholesterol level of 4.7-5.1 to 1.7 in those with serum cholesterol level of 6.2 mmol/L or more (95% CI 1.0, 2.7), when compared with those with serum cholesterol level below 4.7. For the least active persons, all levels of cholesterol were associated with a significant inverse relative risk, including cholesterol of 6.2 mmol/L or more (Relative risk = 0.4 (95% CI 0.2, 0.7]. These data suggest that factors such as activity level may modify the serum cholesterol-coronary heart disease association in old age. The serum cholesterol-coronary heart disease association in more active older persons resembles that seen in younger populations, whereas the association in less active persons is that of serum cholesterol level and risk of cancer or death. The modification of the serum cholesterol-coronary heart disease association by activity level may have implications for appropriate clinical management as well as appropriate design of research studies of this association.

Injury fatalities among young children.

Injuries and violence are the primary causes of death among young children in the United States. In particular, in 1982-84 motor vehicle injuries, fires, drowning, and homicide were the leading external causes of death at ages 1-4 years and 5-9 years, accounting for nearly 80 percent of all deaths from external causes. The purpose of this article is to analyze race and sex differentials in injury fatalities among young children. Race and sex differentials in injury mortality were measured in terms of relative risks, that is, race (black to white) and sex (male to female) mortality ratios. Race ratios for external causes ranged from 1.7 to 1.9 for children 1-4 and 5-9, while sex ratios were somewhat lower, 1.4 to 1.8. Although race and sex ratios were relatively small for passenger-related motor vehicle fatalities (0.8 to 1.2) the ratios for pedestrian-related injuries were considerably greater (1.5 to 2.0). Race ratios for deaths caused by fires and homicide were particularly large (3.4 to 4.3). Mortality differences were also measured in terms of excess mortality. For each age-race group more than 65 percent of the overall excess deaths among males were due to external causes of death. Pedestrian-related motor vehicle injuries and drownings accounted for the largest proportion of excess deaths among males. At ages 1-4, 53 percent of the overall excess deaths among blacks were due to external causes. Deaths caused by fires and homicide accounted for more than two-fifths of the excess in this age group. At ages 5-9, 81 percent of excess mortality among black males and 69 percent among black females were accounted for by external causes. Fires, pedestrian-related motor vehicle fatalities, and homicides accounted for nearly 65 percent of excess mortality among black children.There has been a 30 percent decline in death rates from all external causes between 1972-74 and 1982-84. Pedestrian-related motor vehicle death rates declined the most in both age groups.Mortality also declined in each age-race-sex group for passenger-related motor vehicle injuries, for drownings, and for fires except among black males ages 5-9. Homicide, in contrast, increased in both age groups. There has been little change, however,in the incidence of injuries among children. Thus,it appears that declines in fatalities accounted for a major portion of the mortality reduction.

10 years after NHANES I: report of initial followup, 1982-84.

The NHANES I Epidemiologic Followup Study (NHEFS) was jointly initiated by the National Center for Health Statistics and the National Institute on Aging in collaboration with other National Institutes of Health and Public Health Service agencies. The goal of NHEFS is to examine the relationship of baseline clinical, nutritional, and behavioral factors assessed in the first National Health and Nutrition Examination Survey (NHANES I-1971-75) to subsequent morbidity and mortality. Data collection for the initial phase of followup took place between 1982 and 1984 and included tracing of all NHANES I participants, determining their vital status, conducting in-depth interviews with surviving participants or with proxies for those who were deceased or incapacitated, conducting selected physical measurements, obtaining facility records for stays in hospitals or nursing homes that occurred during the period of followup, and obtaining death certificates for decedents. Ninety-three percent of the original cohort was successfully traced. Interviews were conducted for 93 percent of traced, surviving participants and 84 percent of traced, surviving participants and 84 percent of traced, deceased subjects. Physical measurements were obtained for approximately 95 percent of surviving, interviewed subjects. Death certificates are available for more than 95 percent of the decedents, and 18,136 facility records were received for 6,477 subjects.

10 years after NHANES I: mortality experience at initial followup, 1982-84.

The NHANES I Epidemiologic Followup Study (NHEFS) was initiated jointly by the National Center for Health Statistics and the National Institute on Aging in collaboration with other National Institutes of Health and Public Health Service agencies. The goal of NHEFS is to examine the relationship of baseline clinical, nutritional, and behavioral factors assessed in the first National Health and Nutrition Examination Survey (NHANES I-1971-75) to subsequent morbidity and mortality. Tracing for the initial followup began in 1981 and ended in 1984. This article compares the mortality experience of the NHEFS cohort with survival probabilities and cause-of-death distributions derived from U.S. vital statistics data. The analysis was done for 28 age-race-sex specific subgroups. The survival of each group of the NHEFS cohort corresponds quite closely to that expected on the basis of the U.S. life table survival probabilities. Mortality differentials by age, race, and sex are also quite similar between NHEFS and U.S. vital statistics. In addition, the cause-of-death distributions among NHEFS participants are quite similar to those expected based on national vital statistics. Thus, there do not seem to be any serious biases in the mortality data. The NHEFS, therefore, provides a unique resource for assessing the effects of baseline sociodemographic, health, and nutritional factors on future mortality in a large, heterogeneous sample that is representative of the nation's population.

National health and nutrition examination I--epidemiologic follow-up survey.

An epidemiologic follow-up of the first National Health and Nutrition Examination Survey (NHANES I), being conducted from 1982 to 1984, is expected to provide estimates of the risks of certain health conditions for a sample of the U.S. population and to make it possible to relate these conditions to the nutritional, social, demographic, and behavioral characteristics of the sample. As part of the followup study, the baseline data obtained in NHANES I have been reviewed to define hypotheses and to identify pertinent variables that can be used in studying changes over time and the relationships of these variables to outcome measures. Because the followup study provides cohort data on a large sample of the U.S. population, it presents a unique opportunity for epidemiologists.

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.

Corset platysmaplasty.

Contemporary surgery to rejuvenate the aging neck commonly includes some type of platysma modification. Most currently used methods of platysmaplasty involve upper midline plication, muscle resection, or transection. These methods, however, have their shortcomings, often producing necks that display persistent or recurrent paramedian muscle bands, visible submandibular gland bulges, and various contour irregularities. Corset platysmaplasty was developed to avoid these postoperative imperfections. After an adequate subcutaneous and subplatysmal lipectomy has been performed, the two medial edges of the platysma are joined together with a continuous suture that runs down, and up, and down almost the full-height of the neck to create a smooth, flat, multilayered seam, leaving no free muscle edges to return as visible bands. Progressive side-to-side tightening along the midline seam defines the "waistline" of the neck. Additional submandibular suturing is then done to create strong, flat, vertical muscle pleats that correct submandibular gland bulging and refine the jawline and anterolateral neck contours. Corset platysmaplasty is useful for all patients with visible paramedian muscle bands and all patients who would benefit from having a decussated upper neck platysma opened for submuscular defatting, including patients with oblique, palpably firm necks that suggest a vertically short platysma muscle or low-lying hyoid bone. The paper is based on the results with 75 patients having undergone corset platysmaplasty, most having been followed for 1 to 3 years.

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.

The medial gastrocnemius myocutaneous flap.

Our experience with the medial gastrocnemius myocutaneous flap is presented. We have found it to be a reliable flap which can be transferred in one stage to solve difficult coverage problems about the knee and upper leg.

Symmastia: the problem of medial confluence of the breasts.

This paper presents the problem of medial confluence of the breasts producing a web across the midline. Significant references in the literature dealing with uncommon clinical problems are virtually nonexistent. The purpose of this paper is to stimulate discussion of this entity and its surgical management and to propose the term symmastia to facilitate retrieval of information about this entity in the future. Two cases that highlight the central problem but which differ in the specifics of the surgical approach are presented. In the first case, the medial web was corrected by elevating an inferiorly based triangular skin flap that was advanced superiorly in an inverted Y-V manner after the excess medial soft tissue was divided and sutured superiorly to the medial pectoralis fascia to create a brassiere-band sling effect. In the second case, a superiorly based medial flap containing both skin and soft tissue was elevated. The excess skin and soft tissue were then excised. The remaining flap was tailored to fit into a V-shaped defect in the inferior incision to place the scar in a less viable place inferior to the sternum. The relative advantages of the two surgical approaches are discussed and a third approach based on the strengths of the two approaches is suggested. This approach would consist of the vertical division and superior rotation of the excess subcutaneous tissue flaps and the elevation of a superiorly based skin flap inserted into a V-shaped defect in the inferior incision.

The use of health service areas for measuring provider availability.

Measurement of the availability of health care providers in a geographic area is a useful component in assessing access to health care. One of the problems associated with the county provider-to-population ratio as a measure of availability is that patients frequently travel outside their counties of residence for health care, especially those residing in nonmetropolitan counties. Thus, in measuring the number of providers per capita, it is important that the geographic unit of analysis be a health service area. We have defined health care service areas for the coterminous United States, based on 1988 Medicare data on travel patterns between counties for routine hospital care. We used hierarchical cluster analysis to group counties into 802 service areas. More than one half of the service areas include only nonmetropolitan counties. The service areas vary substantially in the availability of health care resources as measured by physicians and hospital beds per 100,000 population. For almost all of the service areas, the majority of hospital stays by area residents occur within the service area. In contrast, for 39 percent of counties, the majority of hospital stays by county residents occur outside the county. Thus, the service areas are a more appropriate geographic unit than the county for measuring the availability of health care.