Impact of the COVID-19 Pandemic on the Provision of Dialysis Service and Mortality in Veterans Receiving Maintenance Hemodialysis in the VA: An Interrupted Time-Series Analysis.

INTRODUCTION: According to the US Renal Data System (USRDS), patients with end-stage kidney disease (ESKD) on maintenance dialysis had higher mortality during early COVID-19 pandemic. Less is known about the effect of the pandemic on the delivery of outpatient maintenance hemodialysis and its impact on death. We examined the effect of pandemic-related disruption on the delivery of dialysis treatment and mortality in patients with ESKD receiving maintenance hemodialysis in the Veterans Health Administration (VHA) facilities, the largest integrated national healthcare system in the USA. METHODS: Using national VHA electronic health records data, we identified 7,302 Veterans with ESKD who received outpatient maintenance hemodialysis in VHA healthcare facilities during the COVID-19 pandemic (February 1, 2020, to December 31, 2021). We estimated the average change in the number of hemodialysis treatments received and deaths per 1,000 patients per month during the pandemic by conducting interrupted time-series analyses. We used seasonal autoregressive moving average (SARMA) models, in which February 2020 was used as the conditional intercept and months thereafter as conditional slope. The models were adjusted for seasonal variations and trends in rates during the pre-pandemic period (January 1, 2007, to January 31, 2020). RESULTS: The number (95% CI) of hemodialysis treatments received per 1,000 patients per month during the pre-pandemic and pandemic periods were 12,670 (12,525-12,796) and 12,865 (12,729-13,002), respectively. Respective all-cause mortality rates (95% CI) were 17.1 (16.7-17.5) and 19.6 (18.5-20.7) per 1,000 patients per month. Findings from SARMA models demonstrate that there was no reduction in the dialysis treatments delivered during the pandemic (rate ratio: 0.999; 95% CI: 0.998-1.001), but there was a 2.3% (95% CI: 1.5-3.1%) increase in mortality. During the pandemic, the non-COVID hospitalization rate was 146 (95% CI: 143-149) per 1,000 patients per month, which was lower than the pre-pandemic rate of 175 (95% CI: 173-176). In contrast, there was evidence of higher use of telephone encounters during the pandemic (3,023; 95% CI: 2,957-3,089), compared with the pre-pandemic rate (1,282; 95% CI: 1,241-1,324). CONCLUSIONS: We found no evidence that there was a disruption in the delivery of outpatient maintenance hemodialysis treatment in VHA facilities during the COVID-19 pandemic and that the modest rise in deaths during the pandemic is unlikely to be due to missed dialysis.

Relationships between Cerebral Vasculopathies and Microinfarcts in a Community-Based Cohort of Older Adults.

Cerebral microinfarcts are associated with cognitive impairment and dementia. Small vessel diseases such as cerebral arteriolosclerosis and cerebral amyloid angiography (CAA) have been found to be associated with microinfarcts. Less is known about the associations of these vasculopathies with the presence, numbers, and location of microinfarcts. These associations were examined in the clinical and autopsy data of 842 participants in the Adult Changes in Thought (ACT) study. Both vasculopathies were categorized by severity (none, mild, moderate, and severe) and region (cortical and subcortical). Odds ratios (OR) and 95% CIs for microinfarcts associated with arteriolosclerosis and CAA adjusted for possible modifying covariates such as age at death, sex, blood pressure, APOE genotype, Braak, and CERAD were estimated. 417 (49.5%) had microinfarcts (cortical, 301; subcortical, 249), 708 (84.1%) had cerebral arteriolosclerosis, 320 (38%) had CAA, and 284 (34%) had both. Ors (95% CI) for any microinfarct were 2.16 (1.46-3.18) and 4.63 (2.90-7.40) for those with moderate (n = 183) and severe (n = 124) arteriolosclerosis, respectively. Respective Ors (95% CI) for the number of microinfarcts were 2.25 (1.54-3.30) and 4.91 (3.18-7.60). Similar associations were observed for cortical and subcortical microinfarcts. Ors (95% Cis) for the number of microinfarcts associated with mild (n = 75), moderate (n = 73), and severe (n = 15) amyloid angiopathy were 0.95 (0.66-1.35), 1.04 (0.71-1.52), and 2.05 (0.94-4.45), respectively. Respective Ors (95% Cis) for cortical microinfarcts were 1.05 (0.71-1.56), 1.50 (0.99-2.27), and 1.69 (0.73-3.91). Respective Ors (95% Cis) for subcortical microinfarcts were 0.84 (0.55-1.28), 0.72 (0.46-1.14), and 0.92 (0.37-2.28). These findings suggest a significant association of cerebral arteriolosclerosis with the presence, number, and location (cortical and subcortical) of microinfarcts, and a weak and non-significant association of CAA with each microinfarct, highlighting the need for future research to better understand the role of small vessel diseases in the pathogenesis of cerebral microinfarcts.

Relationships between Late-Life Blood Pressure and Cerebral Microinfarcts in Octogenarians: An Observational Autopsy Study.

Mid-life high blood pressure (BP) is a risk factor for cerebral microinfarcts. Less is known about the relationship between late-life BP and cerebral microinfarcts, the examination of which is the objective of the current study. This case-control study analyzed data from 551 participants (94.6% aged ≥80 years; 58.6% women) in the Adult Changes in Thought (ACT) study who had autopsy data on microinfarcts and four values of systolic and diastolic blood pressure (SBP and DBP) before death. Using the average of four values, SBP was categorized using 10 mmHg intervals; a trend was defined as a ≥10 mmHg rise or fall from the first to fourth values (average gap of 6.5 years). Multivariable-adjusted regression models were used to examine the associations of BP and microinfarcts, adjusting for age, sex, last BP-to-death time, APOE genotype, and antihypertensive medication use. Microinfarcts were present in 274 (49.7%) participants; there were multiple in 51.8% of the participants, and they were located in cortical areas in 40.5%, subcortical areas in 29.6%, and both areas in 29.9% of the participants. All SBP categories (reference of 100-119 mmHg) and both SBP trends were associated with higher odds of both the presence and number of microinfarcts. The magnitude of these associations was numerically greater for subcortical than cortical microinfarcts. Similar associations were observed with DBP. These hypothesis-generating findings provide new information about the overall relationship between BP and cerebral microinfarcts in octogenarians.

Characteristics and Predictors of Alzheimer's Disease Resilience Phenotype.

Alzheimer's disease (AD) is characterized by cognitive impairment in the presence of cerebral amyloid plaques and neurofibrillary tangles. Less is known about the characteristics and predictors of resilience to cognitive impairment in the presence of neuropathological evidence of AD, the focus of this study. Of 3170 adults age ≥65 years in the National Alzheimer's Coordinating Center (NACC) brain autopsy cohort, 1373 had evidence of CERAD level moderate to frequent neuritic plaque density and Braak stage V-VI neurofibrillary tangles. Resilience was defined by CDR-SOB and CDR-Global scores of 0-2.5 and 0-0.5, respectively, and non-resilience, CDR-SOB and CDR-Global scores >2.5 and >0.5, respectively. Multivariable logistic regression models were used to examine the independent associations of patient characteristics with resilience. There were 62 participants (4.8%) with resilience. Those with resilience were older (mean age, 88.3 vs. 82.4 years), more likely to be women (61.3% vs. 47.3%) and had a lower prevalence of the APOE-e4 carrier (41.9% vs. 56.2%). They also had a higher prevalence of hypertension, heart failure, atrial fibrillation, diuretic use, beta-blocker use, and APOE-e2 carrier status. Greater age at death, diuretic use, and APOE-e2 were the only characteristics independently associated with higher odds of the AD resilience phenotype (adjusted OR, 1.09; 95% CI, 1.05-1.13; p < 0.01; 2.00 (1.04-3.87), p = 0.04, 2.71 (1.31-5.64), p < 0.01, respectively). The phenotype of resilience to cognitive impairment is uncommon in older adults who have neuropathological evidence of AD.

Race- and sex-specific associations of parental education with insulin resistance in middle-aged participants: the CARDIA study.

Low childhood socioeconomic status (SES) has been linked with insulin resistance (HOMA-IR) in adulthood. Our aim was to examine if maternal and paternal education, as indicators of childhood SES, equally contributed to increased HOMA-IR in later life. Of 5,115 adults from the Coronary Artery Disease Risk Development in Young Adults (CARDIA) Study aged 18-30 years in 1985-1986, data on 1,370 females and 1,060 males with baseline and 20 year follow-up data were used to estimate associations of maternal and paternal education with HOMA-IR, adjusting for personal education, BMI, lipids, blood pressure, and lifestyle factors. Parental education was determined as high with ≥ 12 years of schooling and classified as both high, only mother high, only father high, both low education. Distinct combinations of maternal and paternal education were associated with HOMA-IR across race and sex groups. Lowest year 20 HOMA-IR in European American (EA) females occurred when both parents were better educated, but was highest when only the father had better education. HOMA-IR was lowest in African American (AA) participants when the mother was better educated but the father had less education, but was highest when both parents were better educated. Parental education was unrelated to HOMA-IR in EA males. Associations of parental education with HOMA-IR are seen in AA females, AA males, and EA females but not in EA males. The distinct combinations of parental education and their associations with HOMA-IR especially in AA participants need to be addressed in further research on health disparities.

Assessment of Lung Cancer Risk Among Smokers for Whom Annual Screening Is Not Recommended.

Importance: The US Preventive Services Task Force does not recommend annual lung cancer screening with low-dose computed tomography (LDCT) for adults aged 50 to 80 years who are former smokers with 20 or more pack-years of smoking who quit 15 or more years ago or current smokers with less than 20 pack-years of smoking. Objective: To determine the risk of lung cancer in older smokers for whom LDCT screening is not recommended. Design, Settings, and Participants: This cohort study used the Cardiovascular Health Study (CHS) data sets obtained from the National Heart, Lung and Blood Institute, which also sponsored the study. The CHS enrolled 5888 community-dwelling individuals aged 65 years and older in the US from June 1989 to June 1993 and collected extensive baseline data on smoking history. The current analysis was restricted to 4279 individuals free of cancer who had baseline data on pack-year smoking history and duration of smoking cessation. The current analysis was conducted from January 7, 2022, to May 25, 2022. Exposures: Current and prior tobacco use. Main Outcomes and Measures: Incident lung cancer during a median (IQR) of 13.3 (7.9-18.8) years of follow-up (range, 0 to 22.6) through December 31, 2011. A Fine-Gray subdistribution hazard model was used to estimate incidence of lung cancer in the presence of competing risk of death. Cox cause-specific hazard regression models were used to estimate hazard ratios (HRs) and 95% CIs for incident lung cancer. Results: There were 4279 CHS participants (mean [SD] age, 72.8 [5.6] years; 2450 [57.3%] women; 663 [15.5%] African American, 3585 [83.8%] White, and 31 [0.7%] of other race or ethnicity) included in the current analysis. Among the 861 nonheavy smokers (<20 pack-years), the median (IQR) pack-year smoking history was 7.6 (3.3-13.5) pack-years for the 615 former smokers with 15 or more years of smoking cessation, 10.0 (5.3-14.9) pack-years for the 146 former smokers with less than 15 years of smoking cessation, and 11.4 (7.3-14.4) pack-years for the 100 current smokers. Among the 1445 heavy smokers (20 or more pack-years), the median (IQR) pack-year smoking history was 34.8 (26.3-48.0) pack-years for the 516 former smokers with 15 or more years of smoking cessation, 48.0 (35.0-70.0) pack-years for the 497 former smokers with less than 15 years of smoking cessation, and 48.8 (31.6-57.0) pack-years for the 432 current smokers. Incident lung cancer occurred in 10 of 1973 never smokers (0.5%), 5 of 100 current smokers with less than 20 pack-years of smoking (5.0%), and 26 of 516 former smokers with 20 or more pack-years of smoking with 15 or more years of smoking cessation (5.0%). Compared with never smokers, cause-specific HRs for incident lung cancer in the 2 groups for whom LDCT is not recommended were 10.54 (95% CI, 3.60-30.83) for the current nonheavy smokers and 11.19 (95% CI, 5.40-23.21) for the former smokers with 15 or more years of smoking cessation; age, sex, and race-adjusted HRs were 10.06 (95% CI, 3.41-29.70) for the current nonheavy smokers and 10.22 (4.86-21.50) for the former smokers with 15 or more years of smoking cessation compared with never smokers. Conclusions and Relevance: The findings of this cohort study suggest that there is a high risk of lung cancer among smokers for whom LDCT screening is not recommended, suggesting that prediction models are needed to identify high-risk subsets of these smokers for screening.

Serum urate and its relationship with alcoholic beverage intake in men and women: findings from the Coronary Artery Risk Development in Young Adults (CARDIA) cohort.

OBJECTIVE: To investigate if beer, liquor (spirits), wine and total alcohol intakes have different associations with serum urate (SU) concentrations at different ages in a cohort of young men and women. METHODS: Data from 3123 participants at baseline and follow-up at 20 years were used, with balanced proportions of Caucasians and African Americans. The relationships of SU with categories of beer, liquor, wine and total alcohol intake referent to no intake were examined in sex-specific, cross-sectional analyses. RESULTS: Mean age (SD) at the beginning of follow-up was 25.1 (3.6) years. Compared with non-drinkers, significant associations between higher SU concentrations and greater beer intake were observed among men and women, with more pronounced and consistent associations for women. An association between greater liquor intake and higher SU concentrations was only seen for men at the year 20 evaluation. Wine intake was not associated with SU in either sex and total alcohol was associated with higher SU concentrations in both men and women. The magnitude of the associations between alcoholic beverages intake and SU was modest (≤0.03 mg/dl/alcoholic beverage serving). CONCLUSION: An association between higher SU concentrations and greater beer intake was consistent and pronounced among women, but also present in men. Despite the small magnitude of the increases in SU associated with alcohol intake, clinical implications in conditions such as cardiovascular disease and gout in young adults who are moderate and heavy drinkers cannot be ruled out.

Trajectories of life-space mobility after hospitalization.

BACKGROUND: Life space is a measure of where a person goes, the frequency of going there, and the dependency in getting there. It may be a more accurate measure of mobility in older adults because it reflects participation in society as well as physical ability. OBJECTIVE: To assess effects of hospitalization on life space in older adults, and to compare life-space trajectories associated with surgical and nonsurgical hospitalizations. DESIGN: Prospective observational study. SETTING: Central Alabama. PARTICIPANTS: 687 community-dwelling Medicare beneficiaries at least 65 years of age with surgical (n = 44), nonsurgical (n = 167), or no (n = 476) hospitalizations. MEASUREMENTS: Life-Space Assessment (LSA) scores before and after hospitalization (range, 0 to 120; higher scores reflect greater mobility). RESULTS: Mean age of participants was 74.6 years (SD, 6.3). Fifty percent were black, and 46% were male. Before hospitalization, adjusted LSA scores were similar in participants with surgical and nonsurgical admissions. Life-space assessment scores decreased in both groups immediately after hospitalization; however, participants with surgical hospitalizations had a greater decrease in scores (12.1 more points [95% CI, 3.6 to 20.7 points]; P = 0.005) than those with nonsurgical hospitalizations. However, participants with surgical hospitalizations recovered more rapidly over time (gain of 4.7 more points [CI, 2.0 to 7.4 points] per ln [week after discharge]; P < 0.001). Score recovery for participants with nonsurgical hospitalizations did not significantly differ from the null (average recovery, 0.7 points [CI, -0.6 to 1.9 points] per ln [week after discharge]). LIMITATION: Life space immediately before and after hospitalization was self-reported, often after hospital discharge. CONCLUSION: Hospitalization decreases life space in older adults. Surgical hospitalizations are associated with immediate marked life-space declines followed by rapid recovery, in contrast to nonsurgical hospitalizations, which are associated with more modest immediate declines and little evidence of recovery after several years of follow-up. PRIMARY FUNDING SOURCE: National Institute on Aging.

Regional differences in diabetes as a possible contributor to the geographic disparity in stroke mortality: the REasons for Geographic And Racial Differences in Stroke Study.

BACKGROUND AND PURPOSE: Diabetes and hypertension impart approximately the same increased relative risk for stroke, although hypertension has a larger population-attributable risk because of its higher population prevalence. With a growing epidemic of obesity and associated increasing prevalence of diabetes that disproportionately impacts the southeastern Stroke Belt states, any potential contribution of diabetes to the geographic disparity in stroke mortality will only increase. METHODS: Racial and geographic differences in diabetes prevalence and diabetes awareness, treatment, and control were assessed in the REasons for Geographic And Racial Differences in Stroke study, a national population-based cohort of black and white participants older than 45 years of age. At the time of this report, 21 959 had been enrolled. RESULTS: The odds of diabetes were significantly increased in both white and black residents of the stroke buckle (OR, 1.26; [1.10, 1.44]; OR, 1.45 [1.26, 1.66], respectively) and Stroke Belt (OR, 1.22; [1.09, 1.36]; OR, 1.13 [1.02, 1.26]) compared to the rest of the United States. In the buckle, regional differences were not fully mediated and remained significant when controlling for socioeconomic status and risk factors. Addition of hypertension to the models did not reduce the magnitude of the associations. There were no significant differences by region with regard to awareness, treatment, or control for either race. CONCLUSIONS: These analyses support a possible role of regional variation in the prevalence of diabetes as, in part, an explanation for the regional variation in stroke mortality but fail to support the potential for a contribution of regional differences in diabetes management.

Bereavement among African American and White older adults.

PURPOSE: The authors examined epidemiology and sociodemographic predictors of spousal, non-spousal family, and friendship bereavement among African American and White community-dwelling older adults using longitudinal data from 839 participants of the University of Alabama at Birmingham Study of Aging, a prospective cohort study of a random sample of Alabama Medicare beneficiaries. METHOD: Authors calculated cumulative incidences of each type of loss and used logistic regression to identify factors significantly and independently associated with loss. RESULTS: Of participants, 71% reported at least one loss; 50% reported non-spousal family loss, and 37% reported friendship loss. For married participants, the cumulative incidence of spousal loss was 8.1%. Female sex and income < $12,000 were predictors of spousal loss. Female sex and education >/= 12 years were predictors of friendship loss. Higher educated African American women were at greater risk of non-spousal family loss. DISCUSSION: Future research should examine bereavement burden and identify health outcomes of multiple losses.

Causes and demographic, medical, lifestyle and psychosocial predictors of premature mortality: the CARDIA study.

We examined the 16-year mortality experience among participants in the baseline examination (1985-86) of the Coronary Artery Risk Development in Young Adults (CARDIA) Study, a U.S. cohort of 5115 urban adults initially 18-30 years old and balanced by sex and race (black and whites) in the USA. We observed 127 deaths (annual mortality of 0.15%). Compared to white women, the rate ratio (95% confidence interval) of all-cause mortality was 9.3 (4.4, 19.4) among black men, 5.3 (2.5, 11.4) among white men and 2.7 (1.2, 6.1) among black women. The predominant causes of death, which also differed greatly by sex-race, were AIDS (28% of deaths), homicide (16%), unintentional injury (10%), suicide (7%), cancer (7%) and coronary disease (7%). The significant baseline predictors of all-cause mortality in multivariate analysis were male sex, black race, diabetes, self-reported liver and kidney disease, current cigarette smoking and low social support. Two other factors, self-reported thyroid disease and high hostility, were significant predictors in analyses adjusted for age, sex and race. In conclusion, we found striking differences in the rates and underlying cause of death across sex-race groups and several independent predictors of young adult mortality that have major implications for preventive medicine and social policies.

Discharge Hospice Referral and Lower 30-Day All-Cause Readmission in Medicare Beneficiaries Hospitalized for Heart Failure.

BACKGROUND: Heart failure (HF) is the leading cause for hospital readmission. Hospice care may help palliate HF symptoms but its association with 30-day all-cause readmission remains unknown. METHODS AND RESULTS: Of the 8032 Medicare beneficiaries hospitalized for HF in 106 Alabama hospitals (1998-2001), 182 (2%) received discharge hospice referrals. Of the 7850 patients not receiving hospice referrals, 1608 (20%) died within 6 months post discharge (the hospice-eligible group). Propensity scores for hospice referral were estimated for each of the 1790 (182+1608) patients and were used to match 179 hospice-referral patients with 179 hospice-eligible patients who were balanced on 28 baseline characteristics (mean age, 79 years; 58% women; 18% non-white). Overall, 22% (1742/8032) died in 6 months, of whom 8% (134/1742) received hospice referrals. Among the 358 matched patients, 30-day all-cause readmission occurred in 5% and 41% of hospice-referral and hospice-eligible patients, respectively (hazard ratio associated with hospice referral, 0.12; 95% confidence interval, 0.06-0.24). Hazard ratios (95% confidence intervals) for 30-day all-cause readmission associated with hospice referral among the 126 patients who died and 232 patients who survived 30-day post discharge were 0.03 (0.04-0.21) and 0.17 (0.08-0.36), respectively. Although 30-day mortality was higher in the hospice referral group (43% versus 27%), it was similar at 90 days (64% versus 67% among hospice-eligible patients). CONCLUSIONS: A discharge hospice referral was associated with lower 30-day all-cause readmission among hospitalized patients with HF. However, most patients with HF who died within 6 months of hospital discharge did not receive a discharge hospice referral.

Correlates and outcomes of preserved left ventricular systolic function among older adults hospitalized with heart failure.

BACKGROUND: Heart failure (HF) in older adults is often associated with preserved left ventricular systolic function (LVSF). The objective of this retrospective follow-up study was to determine the correlates and outcomes of preserved LVSF among older adults hospitalized with HF. METHODS: We studied older Medicare beneficiaries hospitalized with HF (n = 1091) who had documented LVSF evaluation (n = 438). LVSF was defined as preserved if left ventricular ejection fraction was > or =40%. The Fisher exact test and the Student t test were used to compare baseline characteristics between patients with preserved versus those with impaired LVSF. Multivariate logistic regression analysis was used to determine the correlates of preserved LVSF. Cox proportional hazards analyses were used to determine the associations between LVSF and both 4-year mortality rates and 6-month readmission rates and the associations between angiotensin-converting enzyme (ACE) inhibitor use and 4-year mortality rates, separately, in patients with preserved and impaired LVSF. RESULTS: Of the 438 patients, 200 (46%) had preserved LVSF. Women were more likely to have preserved LVSF (odds ratio [OR] = 2.44, 95% CI 1.57-3.81) than men. Preserved LVSF was associated with lower 4-year mortality rates (adjusted hazards ratio [HR] = 0.67, 95% CI 0.52-0.86) but not with 6-month readmission rates (adjusted HR = 0.66, 95% CI 0.41-1.09). The use of ACE inhibitors was associated with lower 4-year mortality rates in patients with impaired LVSF (adjusted HR = 0.61, 95% CI 0.43-0.86) but not in those with preserved LVSF (HR = 0.96, 95% CI 0.65-1.42). CONCLUSIONS: Among older adults hospitalized with HF, preserved LVSF was common among women and was associated with significantly higher morbidity and mortality rates, which were unaffected by treatment with ACE inhibitors.

Absence of risk factor change in young adults after family heart attack or stroke: the CARDIA Study.

BACKGROUND: Health behavior theories suggest that occurrence of heart attack or stroke in an immediate family member should increase one's perceived susceptibility to these conditions, which might lead to improved risk factor behavior and control. METHODS: Changes in measures of smoking, physical activity, lipids/lipoproteins, body weight, and blood pressure were investigated over two consecutive 5-year follow-up periods among 3950 participants (aged 18 to 30 years) in the Coronary Artery Risk Development in Young Adults (CARDIA) study, who either did or did not have an immediate family member experience a heart attack or stroke. Recruitment and examinations for Years 0, 5, and 10 took place in 1985-1986, 1990-1991, and 1995-1996, respectively. RESULTS: After adjustment for baseline demographics and risk factors, young adults who experienced a change in family history of heart attack or stroke over a 5-year period were no more likely than those who did not to quit smoking, or to experience more positive changes in weight, physical activity, LDL cholesterol, HDL cholesterol, triglycerides, or systolic or diastolic blood pressure. These findings persisted among the few study participants with one or more established risk factors at baseline. CONCLUSIONS: The occurrence of a heart attack or stroke in an immediate family member does not appear to lead to self-initiated, sustained change in modifiable risk factors in young adults. Since family history of heart attack and stroke is associated with known risk factors and is an independent risk factor for incident development of these conditions, interventions should be developed and tested to motivate sustained risk-factor control following occurrence of a severe vascular event in a family member.

Genetics and cardiovascular disease.

Cardiovascular disease (CVD) is a designation for multiple clinical phenotypes that result from the interaction of genetic variants, lifestyle choices, and environmental exposures. This article points to the utility of assessing a person's family history of CVD, which is the sum of genetic factors, environment and common lifestyle influences, which may be shared among family members and provides information useful for estimating risk for CVD. It also presents several approaches utilized in attempts to identify variants in genes that are involved in the etiology of CVD. Specifically, examples of the candidate gene approach to identify genetic risk factors for coronary heart disease from our own research are presented. The utilization of genetic profiling to predict an individual's long-term prognosis, to target preventive strategies, and to select the most efficacious drug for treatment are discussed, as well as, the need to consider newer approaches to understanding complex diseases.

Marital status and health: exploring pre-widowhood.

BACKGROUND: Health and function vary by marital status across the life-course, but little is known about older adults approaching spousal loss (pre-widowed). OBJECTIVE: To explore health and function by marital status focusing on the pre-widowed and to examine factors associated with shorter time to spousal loss. PARTICIPANTS, DESIGN, AND MEASUREMENTS: We used 3 years of data from African American and white community-dwelling older adults in the UAB Study of Aging (N = 1000). Participants were categorized as "continuously married" (married at baseline and 3 years), "widowed" (widowed at baseline), "single" (never married/divorced); and "pre-widowed" (married at baseline and widowed within 3 years). Assessments included sociodemographic characteristics, and measures of depression, anxiety, life-space mobility, and self-reported health. chi(2) and analysis of variance (ANOVA) were used to examine baseline differences. Using Cox regression, we explored factors having independent and significant associations with shorter time to spousal loss among married older adults. RESULTS: There were significant differences by marital status category for sociodemographic factors, health, and function. Pre-widows differed from other categories by sociodemographic characteristics as well as levels of depression, anxiety and self-reported health. Among married older adults, being female and having lower self-reported health at baseline were independent significant hazards for shorter time to widowhood; while rural residence and providing spousal care were independent significant hazards for a longer progression to widowhood. CONCLUSIONS: Health deficits associated with spousal bereavement may be evident earlier in the marital transition than previously thought, warranting attention to the health of elderly persons whose spouses have chronic/life-limiting conditions.

Ten-year change in serum uric acid and its relation to changes in other metabolic risk factors in young black and white adults: the CARDIA study.

Elevated serum uric acid is commonly seen in association with obesity, glucose intolerance, hypertension and dyslipidemia. There is currently no satisfactory explanation for the relation of uric acid and the metabolic syndrome (MetSyn). This study aimed to evaluate the relations of change in serum uric acid with changes in components of the MetSyn in young adults. We studied 1,249 male and 1,362 female black and white subjects aged 17-35 years (baseline) from the Coronary Artery Risk Development in Young Adults (CARDIA) Study, which attended a 10-year follow-up. Metabolic factors assessed at both time periods included BMI, waist circumference, blood pressure, fasting glucose, insulin, and lipids. Confounders examined (baseline and change variables) were serum creatinine, alcohol, smoking, physical activity, and oral contraceptives. Mean uric acid increased the most in black males (+0.5 mg/dl), followed by white males (+0.3 mg/dl) and black females (+0.2 mg/dl) (all P < 0.01), with the least change among white females (+0.1 mg/dl) (ns). Although change in all of the metabolic factors was associated with change in uric acid in the anticipated directions, in multivariable analyses only BMI and triglycerides had a significant independent association with uric acid in all race-sex-groups. Among confounders, only change in serum creatinine showed a strong independent association with uric acid. In conclusion, besides weight gain and renal excretion, increasing uric acid concentrations in young adults are strongly related to corresponding changes in triglycerides. The correlation of uric acid and triglycerides was found within the normal range and could not be explained by obesity.

Risk factors for recurrent gastroesophageal reflux disease after fundoplication in pediatric patients: a case-control study.

BACKGROUND/PURPOSE: Recurrent gastroesophageal reflux disease (rGERD) is a common problem after fundoplication. Previous studies attempting to identify risk factors for rGERD have failed to control for confounding variables. The purpose of this study was to identify significant risk factors for rGERD after controlling for potential confounding variables. METHODS: A retrospective, matched case-control study was conducted at a tertiary children's hospital. Cases (n = 116) met 1 of these criteria: reoperation for rGERD, symptomatic rGERD (confirmed by upper gastrointestinal series, esophagogastroduodenoscopy, or pH monitoring), or postoperative reinstitution of antireflux medication for more than 8 weeks. Controls (n = 209) were matched for surgeon, approach (laparoscopic/open), technique (partial/complete), and approximate operative date. Univariate and multivariable associations were analyzed by conditional logistic regression. RESULTS: Significant risk factors for rGERD were age of less than 6 years (odds ratio [OR], 3.6; 95% confidence interval [CI], 1.7-7.5), preoperative hiatal hernia (OR, 3.2; 95% CI, 1.4-7.3), postoperative retching (OR, 5.1; 95% CI, 2.6-10.0), and postoperative esophageal dilatation (OR, 10.8; 95% CI, 1.8-65.4). Interestingly, significant association was not found between neurologic impairment and rGERD after controlling for potential confounding variables. CONCLUSION: Age of less than 6 years, preoperative hiatal hernia, postoperative retching, and postoperative esophageal dilatation are independently associated with increased risk of rGERD. Neurologic impairment alone does not increase the risk of developing rGERD.

African-American and Hispanic ethnicities, renal involvement and obesity predispose to hypertension in systemic lupus erythematosus: results from LUMINA, a multiethnic cohort (LUMINAXLV).

OBJECTIVE: To examine the predictors of the occurrence of hypertension in a large multiethnic US cohort. PATIENTS AND METHODS: There were 614 patients with systemic lupus erythematoses (SLE; > or = 4 American College of Rheumatology revised criteria) with < or = 5 years of disease duration at entry into the cohort (T0) and of Hispanic (Texan or Puerto Rican), African-American or Caucasian ethnicity. T0 variables were compared between patients who did and did not develop hypertension (blood pressure > or = 140/90 mm Hg on at least two occasions and/or the use of antihypertensive drugs) after T0. Significant and clinically relevant variables were then examined by a stepwise logistic regression model. RESULTS: A total of 379 patients without hypertension at T0 were included (patients who developed hypertension prior to SLE diagnosis (n = 126) or before T0 (n = 109) were excluded). Predictors of hypertension were African-American and Texan-Hispanic ethnicities, renal involvement and a higher body mass index. CONCLUSIONS: Traditional cardiovascular risk factors, disease-related factors and ethnicity play a role in the occurrence of hypertension in patients with SLE. Controlling renal involvement and optimising body weight may prevent the occurrence of hypertension.

Migration patterns following HIV diagnosis among adults residing in the nonurban Deep South.

Health care needs of those infected with the human immunodeficiency virus (HIV) and subsequent transmission dynamics are altered by migration after infection. We interviewed 760 HIV-infected persons attending HIV-specialty clinics living in non-urban Alabama and Mississippi to ascertain the likely geographic origins of their infections, determine their post-HIV diagnosis mobility, and identify predictors of this mobility. Most subjects (81%) were living in these two states when diagnosed and have not moved since learning of their HIV status (70%). Of those who moved their primary residence post-HIV diagnosis (25% of the entire study population), the majority in-migrated to Alabama or Mississippi from elsewhere. Persons who had moved post-HIV diagnosis were more likely to be male, an injection drug user, an urban resident at HIV diagnosis, have an AIDS-defining condition, and have moved prior to HIV diagnosis. We conclude that most HIV transmission in non-urban Alabama and Mississippi is acquired locally. These results underline the need to expand HIV prevention programs in the Deep South.