Calcium intake and the relationship of dietary sodium and potassium to blood pressure.

Using First National Health and Nutrition Examination Survey (NHANES I) data, we studied the relationships of dietary sodium, potassium, and alcohol to blood pressure in relation to levels of dietary calcium intake. At low Ca intakes (less than 400 mg/d for men and less than 800 mg/d for women) the ratio of Na to K (Na:K) was significantly related to blood pressure (p less than 0.01) after controlling for age, body mass index (BMI), race, and gender. At higher Ca intakes neither Na:K nor any other nutrient (with the exception of alcohol) was related to either systolic or diastolic blood pressures. Na:K was more strongly related to blood pressure than either nutrient alone and low Ca intakes were necessary for the Na:K-blood pressure relationship to be evident. Interaction of these three dietary factors in relation to blood pressure was evident in all race and gender groups. Associations of age, BMI, gender, and alcohol with blood pressure were not affected by Ca levels.

Alcohol consumption, nutrient intake and relative body weight among US adults.

Data from the first National Health and Nutrition Examination Survey (HANES I) were analyzed for differences in nutrient intakes based on the amounts of alcohol consumed by US adults, and for relationships between alcohol consumption, calorie intake, and relative body weight. Drinkers had significantly higher intakes of total calories than nondrinkers, but only because of their intakes of alcoholic calories. Among drinkers, the intakes of nonalcoholic calories decreased as alcohol intakes increased, and it was estimated that between 15 and 41% of the alcoholic calories replaced nonalcoholic calories. Despite their higher caloric intakes, drinkers were not more obese than nondrinkers, suggesting that alcoholic calories may be less efficiently utilized than nonalcoholic calories, or may interfere with utilization of nonalcoholic calories. The most salient difference in nutrient intake between drinkers and nondrinkers was the substantially lower carbohydrate intake of drinkers.

Treatment of multiple sclerosis with hyperbaric oxygen. Results of a national registry.

Three hundred twelve patients were entered into a long-term study of effects of hyperbaric oxygen on multiple sclerosis. The protocol called for an initial 20 treatments in either the monoplace or multiplace chamber on a daily basis followed by monthly booster treatments for 2 years. One hundred seventy neurologists and 22 institutions provided data for this study. There was no control group, but the study was based on Schumacher's postulation that a scientifically valid study to test the efficacy of a new therapy was possible by choosing patients who were definitively diagnosed with multiple sclerosis and following them up for 2 years after the imposed treatment. If the overwhelming majority of the subjects failed to get worse over the 2-year observation period, the efficacy of the treatment would be manifest. The expanded Kurtzke Disability Status Scale (EDSS) was used to assess the severity of the disease state. The dropout rate was high with only 76% (237 of 312 patients) finishing the initial 20 treatments. Twenty-two percent (69 of 312) finished 1 year of booster therapy, and 9% (28 of 312) completed 2 years of monthly boosters. The mean deterioration on the Kurtzke EDSS score was 0.93 or almost a full step from the beginning of treatment until the last evaluation. There was no difference in outcome between those who had the shortest and longest periods of time between onset of symptoms and hyperbaric oxygen treatment. Treatment pressure made no difference in outcome. Changes in the Kurtzke EDSS score bore no relationship to the use of booster treatment. Patients who were reasonably well off at the onset of treatment with initial Kurtzke EDSS scores of 1 or 2 (n = 21) deteriorated by an average of 1.7 Kurtzke points. Those patients whose initial Kurtzke EDSS scores were greater than 2 (n = 164) deteriorated on an average of 0.82 points. Of interest was that 19.5% (39 of 200) of the patients reported a temporary improvement in bladder function, but improvement was maintained in only 11 patients (5.5%) at 2-year follow-up. Fifteen patients (7.5%) indicated long-term worsening. There was no significant change in the working status of the patients following hyperbaric oxygen treatment. Although this study treated the patients in accordance with protocols reported to produce a benefit in multiple sclerosis, we were unable to substantiate any useful long-term effect of hyperbaric oxygen therapy.

Effects of drinking patterns on the relationship between alcohol an coronary occlusion.

Previous reports have described an inverse relationship between alcohol consumption and the prevalence of myocardial infarction or the extent of coronary artery occlusion. The study reported here explored the relationship between patterns of alcohol intake and coronary occlusion in 526 patients who have had coronary arteriography. Patients were characterized as regular drinkers, occasional drinkers and non-drinkers. Regular drinkers were further characterized as drinking relatively consistent amounts or variable amounts. The inverse correlation between amounts of alcohol consumed and coronary occlusion found in previous studies was reaffirmed. It was also observed that the pattern of alcohol intake was related to the degree of occlusion. Higher levels of occlusion were found among non-drinkers, occasional drinkers, and regular drinkers with patterns of variable intake, while significantly lower levels of occlusion were observed for regular drinkers who drank relatively consistent amounts (P = 0.014). Furthermore, while occlusion scores were inversely correlated with amounts consumed by regular drinkers with consistent intake (P = 0.019), drinkers with variable drinking patterns had higher occlusion scores regardless of amounts consumed. Analyses of serum lipids according to drinking patterns showed a significant association between the total/HDL cholesterol ratio and drinking patterns. These findings suggest that whatever attenuating effect alcohol consumption might exert on coronary occlusion, it appears to be reversed by a variable or sporadic pattern of alcohol intake.

Risk factors and the anatomic distribution of coronary artery disease.

Differences in the importance of risk factors according to the anatomic location of coronary artery disease (CAD) were assessed in 4722 men and 1069 women who underwent arteriography. Examined characteristics included total and high-density lipoprotein (HDL)-cholesterol, triglycerides, obesity, smoking, alcohol consumption, diabetes, and hypertension. Of these risk factors, the ratio of total to HDL-cholesterol showed the highest correlation with the overall severity of CAD (r = 0.24, men; r = 0.38, women); in contrast, its relation to left main (LM) disease was much lower (r = 0.10, men; r = 0.08 women) than were correlations with stenotic disease in the left anterior descending, circumflex, and right coronary arteries. Other risk factors also showed weaker associations with LM disease than with stenoses in other vessels, and none was related to increased LM disease after controlling for disease in other vessels. For example, as compared with men who had no significant CAD, those with 1-, 2-, and 3-vessel disease had mean increases in total cholesterol of 12, 18, and 19 mg/dl, respectively. In contrast, after adjusting for disease in other vessels, LM disease (present in 293 men) was associated with only a 4 mg/dl increase in mean cholesterol levels (P = 0.20). These results indicate that the relation of risk factors to CAD differs according to the location of the stenotic disease, and that LM disease is poorly predicted by the standard risk factors.

Black/white differences in risk factors for arteriographically documented coronary artery disease in men.

Although the leading cause of death among black men in the United States is coronary artery disease (CAD), risk factors have not been well documented in black populations. Therefore, possible racial differences in the relation of several characteristics to the extent of CAD were assessed in 4,722 white and 169 black men who underwent arteriography. Associations between an occlusion score (ranging from 0 to 300), reflecting the severity of CAD, and levels of total and high-density lipoprotein (HDL) cholesterol, triglycerides, cigarette smoking, alcohol intake, relative weight, systemic hypertension and diabetes mellitus were examined. Most risk factors were significantly related to the extent of CAD in both races, but lipid levels showed stronger associations with CAD among blacks: correlations between CAD and total cholesterol were 0.16 (whites) vs 0.29 (blacks) and associations with HDL cholesterol were -0.22 (whites) vs -0.49 (blacks). In addition, at adverse levels of certain risk factors, blacks had more extensive CAD than did whites: mean occlusion scores were 148 (whites) and 238 (blacks) at HDL cholesterol levels less than 30 mg/dl. As assessed by multiple linear regression, however, only triglyceride levels were differentially related to CAD between whites (beta = 0) and blacks (beta = 0.47), p less than 0.01 for racial contrast. These results document the importance of risk factors in black men and indicate black/white differences in the relation of triglycerides to CAD.

Diabetes mellitus and arteriographically-documented coronary artery disease.

Diabetics are at increased risk for coronary heart disease even after accounting for other risk factors, and the impact of diabetes mellitus may be particularly strong among females and at adverse levels of other risk factors. Therefore, the independent relation of diabetes to arteriographically-documented coronary artery disease (CAD) was examined in 5620 patients (18% female) referred to two Milwaukee hospitals from 1972 to 1986. As assessed by questionnaire, the prevalence of diabetes mellitus among these patients was 8% (n = 466). Diabetics had increased CAD (assessed by the number and severity of stenoses) even after accounting for levels of total and high-density lipoprotein cholesterol, triglycerides, hypertension, obesity, smoking, and alcohol consumption. In addition, regression analyses indicated that as compared with nondiabetics, female diabetics tended to have a greater increase in CAD than did male diabetics (p = 0.06 for sex x diabetes interaction). Although adverse levels of other risk factors did not increase the association between diabetes and CAD, female diabetics who were using oral hypoglycemics or insulin showed almost a two-fold increase in CAD severity (p less than 0.01). Results suggest that the higher relative risk of coronary heart disease among female (vs male) diabetics may be due to a proportionately greater increase in atherosclerosis.

Cholesterol and coronary artery disease: age as an effect modifier.

An elevation of serum cholesterol has been one of the more frequently cited risk factors for coronary heart disease, found in both case-control and cohort studies. As a result, this country has undertaken massive screening of adults older than 20 years of age in an attempt to identify those persons with cholesterol levels greater than 200 mg/dl, and follow up with an active approach for intervention. The suggested cutpoints for borderline (200-240 mg/dl), and definite (> or = 240 mg/dl) hypercholesterolemia have been applied to all age groups despite suggestions of a diminution of risk conferred by cholesterol in the elderly. This study of 2544 white men undergoing coronary angiography shows that for all men, aged 25-84 years, plasma cholesterol levels were associated with an increase in coronary artery occlusion (rs = 0.15, p < 0.01). However, when stratified by age, this association held only for the younger men, the association diminishing to near zero in the oldest age group. The negative interaction between cholesterol levels and age in predicting coronary artery disease proved highly significant (p < 0.001) in multivariable linear regression analysis, suggesting that cholesterol levels are much less predictive of coronary artery disease in the elderly as compared to the young. These results point to the need for a more finely tuned set of criteria for the evaluation of hypercholesterolemia, one that takes into account the age of the screenee.

Risk factors among patients undergoing repeat aorta-coronary bypass procedures.

It is estimated that as many as 7% of patients who have an aorta-coronary bypass operation will require a second bypass procedure within 10 to 12 years. Using information from the Milwaukee Cardiovascular Data Registry, we matched 166 men who underwent two coronary bypass operations at least 6 months apart, between 1968 and 1981, with 428 patients who had a single procedure. Patients were matched according to date of operation and left ventricular wall motility function for analysis of risk factors for repeat operation. Elevated triglyceride levels were found to be the strongest risk factors associated with reoperation. In addition, both younger age and less complete revascularization during the first operation were significant predictive factors of repeat operation. The results suggest that efforts to reduce plasma triglyceride levels and ensure adequate revascularization may significantly reduce the need for repeat coronary bypass.

Pediatric Trauma Score. Predictor of hospital resource use?

The Pediatric Trauma Score has been recommended to triage children with scores of 8 or less to a level 1 pediatric trauma center. The Injury Severity Score correlates well with the Pediatric Trauma Score. During a 36-month period ending December 31, 1985, paramedics saw 983 pediatric trauma patients (aged 17 years and younger) and intervened with advanced life support procedures in 196 (20%). One hundred forty-four patients receiving advanced life support were transported to either a level 1 adult trauma center or a pediatric community hospital. Our data confirm the correlation between Pediatric Trauma Score and Injury Severity Score and support recommendations to transport patients with Pediatric Trauma Scores of 8 or less to trauma facilities. We also conclude that Pediatric Trauma Scores may be useful in predicting hospital resource use.

Primary care providers need a variety of nutrition and wellness patient education materials.

OBJECTIVE: To assess and document the need for nutrition and wellness patient education materials. DESIGN: The results of open-ended interviews and focus groups were used to develop a mail-type survey. The 46-item survey addressed barriers to using nutrition and wellness education materials as well as format, education/reading level, foreign languages, and topics needed. North Carolina Cooperative Extension Service (NCCES) family and consumer education agents distributed surveys to family and general practices throughout North Carolina. SUBJECTS: Of the 721 primary care providers surveyed, 303 (42%) returned usable surveys. Respondents practiced in 89 of the 100 counties of the state served by NCCES family and consumer education agents. STATISTICAL ANALYSIS PERFORMED: Descriptive statistics and independent sample t tests were used to analyze survey results. RESULTS: Limited time with patients and inability to obtain materials because of cost or being unsure of sources were most often identified as barriers to using nutrition and wellness materials. Of the 26 topics surveyed, 6 had mean levels of need greater than or equal to high need (mean score > or = 4): weight control for adults, smoking cessation, changing dietary fat intake, exercise guidelines for healthy adults, general stress management guidelines, and healthful eating for older adults. Twenty-four of the 26 topics had mean levels of need greater than or equal to moderate need (mean score > or = 3). Topics with moderate need included guidelines for overweight children and adolescents, nutrition for chronic disease prevention, and healthful eating for various stages of the life cycle. The combined mean score for topics dealing with weight control and exercise for adults, adolescents, and children was greater than the score for high need (mean score > 4). Eighty-three percent of respondents preferred 1-page, printed handouts. Forty-five percent requested materials in Spanish. APPLICATIONS: Dietitians who work in a variety of settings can use techniques similar to those described here to determine the patient education materials practitioners need for the populations they serve. The information obtained from this study will be used to develop 1-page, printed handouts. A registered dietitian and a food and nutrition specialist with NCCES will develop and pilot-test the handouts. These materials will be made available to primary care providers in North Carolina via local NCCES family and consumer education agents, many of whom are registered dietitians.

Coping with DRGs--a nursing home's experience.

The introduction of prospective payment system (PPS) based on diagnostic related groups (DRGs) has had a significant impact on hospitals. To determine the impact of PPS on nursing homes, the authors studied the activity of a Veterans Administration teaching nursing home (admissions, acute hospital transfers, and discharges) during 1 year preceding implementation of DRGs and for 3 consecutive years following implementation of DRGs. In 1983, pre-DRGs, a total of 36 patients, were admitted to the nursing home. Following implementation of DRGs, a sevenfold increase was noted in the number of patients admitted when comparing 1983 and 1986, with the monthly average of patients admitted increasing from 3 in 1983 to 9.7, 22, and 23.8 in 1984, 1985, and 1986, respectively. Associated with the increase in patients admitted following DRGs was an increase in patients requiring transfer to the acute hospital, within 30 days of admission to the nursing home. In 1986, approximately 27% of patients admitted to the nursing home required transfer to the acute hospital within 30 days of their admission. The number of patients discharged from the nursing home also increased following DRGs. None of the patients admitted to the nursing home in 1983 were discharged within 30 days of admission. Subsequent to introduction of DRGs, an average of two patients per month were discharged within 30 days of nursing home admission.(ABSTRACT TRUNCATED AT 250 WORDS)

An epidemiologic study of tennis elbow. Incidence, recurrence, and effectiveness of prevention strategies.

An epidemiologic study of the incidence and recurrence of tennis elbow among over 500 tennis players (278 men, 254 women; age range, 20 to 50 years) indicated that age and amount of playing time per day were contributing factors to the injury. Both incidence and recurrence rates increased with age. An interactive effect of playing time and age was observed with increased playing time associated with higher incidence at younger ages. Larger grip size was also associated with higher incidence in the older group. These findings were interpreted as being consistent with the hypothesis that tennis elbow is a degenerative disease, the onset of which is hastened by overuse of the arm and elbow. Changes in stroke technique and types of racket were successful in preventing recurrence. Least successful was the forearm brace.

Catecholamine activity and infectious disease episodes.

The profile of 3-hydroxy-4-methoxy mandelic acid (VMA) excretion was studied in relation to reported acute infectious disease episodes. Daily VMA excretion levels and symptom reports were analyzed for a group of 47 volunteers over a four-week period. Results showed a tendency for elevated VMA levels to occur with greater frequency within three days prior to the onset of symptoms. These findings are interpreted as suggesting that elevated levels of catecholamine activity may increase susceptibility to disease by interfering with the immune response, and in the presence of an agent lead to an infectious disease episode.

Socialization and the human physiologic response to crowding.

Cross-sectional data were analyzed for a possible relationship between household densities and physiologic alteration, based on socialization experiences with siblings in an earlier home environment. The measure of household density was persons-per-room and the measure of physiologic alteration was urinary vanillylmandelic acid. The results show an interaction between number-of-sibs and number-of-younger-sibs, with a statistically significant positive correlation between household densities and VMA values for subjects with fewer total sibs and no younger sibs, while a negative correlation was observed for subjects with one or more younger sibs. One possible interpretation of these results is that the physiologic response to crowding in humans is dependent at least in part on the earlier socialization experiences of the individual.

PIP: The relationship between crowding, the individual's socialization, and physiologic alteration was studied in 283 females, mostly white, who completed detailed interview forms and provided a urine specimen for vanillymandelic acid (VMA) analysis. VMA is a urinary catecholamine metabolite and indicator of sympathetic adrenal medullary activity. Significantly fewer than expected of those with incomes below $5000 a year supplied specimens so the sample is biased toward those with higher incomes. Household densities ranged as high as 2.2 persons per room, but most were 1 or less per room with mean density of .61. The overall partial correlation between VMA values and household density, controlling for age, is -.040. This, however, breaks down into 2 distinct groups. Those with 0-1 siblings had a strong positive correlation while those with larger numbers of sibs had a weaker negative correlation (p less than .025). Even greater difference is found when VMA density is based on number of younger sibs. Overall partial correlation for respondents with no younger sibs is strongly positive (p less than .01) while those with more showed weaker correlations. 2 explanations are offered. Those who had not experienced crowding as a youngster would have more difficulty developing coping strategies for crowded conditions, or an individual reacts with stress whenever current living conditions are substantially different from those experienced as a child.

Alcohol consumption and the diet-heart controversy.

The effectiveness of dietary changes as a means of reducing blood lipid levels and ultimately controlling the development of coronary heart disease has been debated for many years. The possible effects of alcohol consumption on blood lipids were usually not considered. Our findings indicate a significant positive correlation between the extent of coronary artery occlusion and total plasma cholesterol levels and a negative association between the coronary occlusion and high density lipoprotein (HDL) cholesterol. Since moderate alcohol consumption increases the HDL cholesterol levels, one can also postulate that it affects coronary artery lesions. The attenuating effect of alcohol on the coronary occlusion was negated by sporadic drinking of large amounts of alcohol. In evaluating the possible effect of alcohol on coronary artery disease, it is also necessary to consider its addictive potential as well as other untoward sequelae of alcohol consumption such as hypertension, damage to the myocardium, and increased prevalence of malignancies.

Alcohol consumption and ischemic heart disease mortality: are time-series correlations meaningful?

Recently, time-series correlations of aggregated data have been used to demonstrate the length of latency periods for environmental factors, such as economic conditions and alcohol consumption, in influencing heart disease mortality. Latency periods were specified by lagging mortality rates relative to the economic indicators or rates of alcohol consumption until the highest correlations were achieved. The tendency has been to interpret these correlations without regard to whether the latency periods described are biologically plausible. The authors have identified four models which represent all the possible outcomes of correlational studies of time-series data. Using United States and Canadian mortality rates in relationship to alcohol consumption, they have demonstrated the application of each of these models. For three of the four models, the time-series (lag) correlations are uniform regardless of the number of years mortality is lagged relative to alcohol consumption, and this uniformity does not permit a latency period to be identified. Only the lag correlations between two nonlinear variables show variations over time, depending on the degree of correspondence between the increasing and decreasing line segments of the two curves. Correlations ranging from high positive to high negative are possible, and several peak correlations (positive and negative) can occur. However, the biologic interpretation of multiple peaks with the same or different signs is problematic. The authors conclude that time-series correlations of aggregated data are not useful for the study of latency periods, and that analysis of time-series correlations for this purpose can be at best ambiguous, and at worst, completely misleading.

The relation between religiosity, selected health behaviors, and blood pressure among adult females.

BACKGROUND: This study examined the association between blood pressure (BP), selected health behaviors, and various dimensions of religiosity among females. METHODS: Data were obtained on 112 females who were at least 35 years of age and of Judeo-Christian faith. Resting BP measures were taken with an automated sphygmomanometer, height and weight were measured to determine body mass index (BMI), and intermediate health variables (e.g., physical activity, smoking, diet, and alcohol consumption) were measured by questionnaire. A multifactorial questionnaire was used to assess various dimensions of religiosity. Multiple regression path analyses were conducted to determine the direct and indirect effects of religiosity on BP with age and BMI controlled statistically. RESULTS: The direct effects of religiosity on SBP and DBP were more substantial than the indirect effects through the intermediate health variables, suggesting that religiosity may be associated with lower levels of BP via a direct pathway, such as improving the ability to cope with stress. In general, DBP was more influenced by religiosity than SBP and the dimensions of "intrinsic religiosity" and "religious coping" were most influential. Results also indicated that "religious experiences" may exert a greater beneficial effect on DBP in older (50-80 years) age groups. CONCLUSIONS: These results support a direct relationship between religiosity and BP, rather than an indirect effect through intermediate health behaviors.