Exposure to N,N-Diethyl-Meta-Toluamide Insect Repellent and Human Health Markers: Population Based Estimates from the National Health and Nutrition Examination Survey.

N,N-diethyl-meta-toluamide (DEET) is one of the most commonly used insect repellants in the United States, yet the existing literature regarding DEET's potential deleterious impact on humans is mixed and is based mostly on case reports. The primary aim of this study was to address this lack of population-based evidence of the effects of DEET exposure on human health in the United States. Our primary outcome measures were biomarkers related to systemic inflammation (high sensitivity C-reactive protein), immune function (lymphocyte), liver function (aspartate aminotransferase, alanine aminotransferase, and γ-glutamyl transferace), and kidney function (estimated glomerular filtration rate). We analyzed data from the population-based National Health and Nutrition Examination Survey, 2015-2016, and identified 1,205 patients (age 20+ years) who had DEET metabolite levels recorded at or above detection limits. A Pearson correlation was used to assess the relationship between DEET metabolite, and each biomarker found there was no significant correlation. Thus, there is no evidence that DEET exposure has any impact on the biomarkers identified.

A Practical Risk Measure for Identification of Adults With Oncogenic Oral Human Papillomavirus: Potential Use in Primary Care.

BACKGROUND AND OBJECTIVES: Oral human papillomavirus (HPV) infection is the main cause of oropharyngeal cancer. However, there is no assessment tool for early detection and prevention of oropharyngeal cancer in practice. The purpose of the study was to develop and validate a risk assessment tool to predict the presence of HPV associated with oropharyngeal cancer. METHODS: Using data from the National Health and Nutrition Examination Survey 2011-2014, 6,978 US adults aged 18 to 59 years who were tested for oral HPV infection were included for this study. We carried out an analysis to test and validate risk predictive models for oral HPV infection. Presence of one of the 20 HPV subtypes associated with oropharyngeal cancer was used for the outcome. RESULTS: Of 6,978 participants aged 18-59, 303 (4.3%; 6.6 million) were found to have oncogenic HPV subtypes. Our final model included sex, income-to-poverty ratio, current smoking, and the lifetime number of oral sex partners. The discriminatory power of the oral HPV risk score to predict the presence of oncogenic HPV was good (C-statistic=0.73). The risk score performed comparably in the validation population (C-statistic=0.72). The comparison between observed and estimated proportions of population with oncogenic oral HPV demonstrated excellent calibration. CONCLUSIONS: We developed and validated the oral HPV risk score that predicts the risk of oral HPV requiring only self-reported data and no laboratory testing. The Oral HPV risk score has the potential to provide clinicians with a no-cost, easy way to screen for patients at greater risk for oncogenic HPV infection.

Shared Care for Adults with Sickle Cell Disease: An Analysis of Care from Eight Health Systems.

Adult sickle cell disease (SCD) patients frequently transition from pediatric hematology to adult primary care. We examined healthcare utilization for adult patients with SCD with shared care between hematologists and primary care providers (PCP). We analyzed the OneFlorida Data Trust, a centralized data repository of electronic medical record (EMR) data from eight different health systems in Florida. The number of included adults with SCD was 1147. We examined frequent hospitalizations and emergency department (ED) visits by whether the patient had shared care or single specialty care alone. Most patients were seen by a PCP only (30.4%), followed by both PCP and hematologist (27.5%), neither PCP nor hematologist (23.3%), and hematologist only (18.7%). For patients with shared care versus single specialist care other than hematologist, the shared care group had a lower likelihood of frequent hospitalizations (OR 0.63; 95% CI 0.43-0.90). Similarly, when compared to care from a hematologist only, the shared care group had a lower likelihood of frequent hospitalizations (OR 0.67; 95% CI 0.47-0.95). There was no significant relationship between shared care and ED use. When patients with SCD have both a PCP and hematologist involved in their care there is a benefit in decreased hospitalizations.

Effect of Sedentary Lifestyle on Cardiovascular Disease Risk Among Healthy Adults With Body Mass Indexes 18.5 to 29.9 kg/m2.

A substantial proportion of adults at healthy body mass index (BMI) are potentially at high risk for cardiovascular disease (CVD). The objective of this study is to determine if sedentary lifestyle characteristics in healthy weight adults increase their likelihood of being at high CVD risk to that of individuals who are overweight. Adults aged 40 to 79 years in the 2011 to 2016 National Health and Nutrition Examination Survey at a healthy BMI (18.5 to 24.9) and overweight BMI (25 to 29.9; unweighted n = 4,572; weighted n = 43,919,354) were analyzed. The American College of Cardiology/American Heart Association atherosclerotic CVD risk score was used to assess CVD risk. For individuals with a BMI 18.5 to 24.9, 29.6% had increased risk of a CVD event. In logistic regressions adjusted for age, race, gender, education, poverty/income ratio, insurance status, and number of visits to a healthcare provider in the past year, individuals with unhealthy sagittal abdominal diameter (odds ratio [OR] 2.44; 95% confidence interval [CI], 0.97 to 6.14), shortness of breath upon exertion (OR 1.35; 95% CI, 0.65 to 2.79), unhealthy waist circumference (OR 0.99; 95% CI, 0.60 to 1.61), and less than recommended levels of physical activity (OR 0.73; 95% CI, 0.43 to 1.23) were not significantly different than overweight adults in being at high risk for CVD events. Individuals with healthy characteristics and a BMI 18.5 to 24.9 were significantly less likely than overweight adults to be at high risk for CVD. In conclusion, the findings suggest that in individuals at a BMI 18.5 to 24.9, characteristics of a sedentary lifestyle increase the likelihood of being at high risk for CVD to that of overweight individuals.

Effectiveness of Clinical Decision Support Based Intervention in the Improvement of Care for Adult Sickle Cell Disease Patients in Primary Care.

INTRODUCTION: Although most patients with rare diseases like sickle cell disease (SCD) are treated in the primary care setting, primary care physicians may find it challenging to keep abreast of medication improvements and complications associated with treatment for rare and complex diseases. The purpose of this study was to evaluate the effectiveness of a clinical decision support (CDS) -based intervention system for transfusional iron overload in adults with SCD to improve management in primary care. METHODS: An electronic medical record based clinical decision support system for potential transfusional iron overload in SCD patients in primary care was evaluated. The intervention was implemented in 3 family medicine clinics with a control group of 3 general internal medicine clinics. Data were collected in the 6 months before the intervention and 6 months after the intervention. There were 47 patients in the family medicine group and 24 in the general internal medicine group. RESULTS: There was no management change in the control group while the intervention group improved primary care management from 0% to 44% (P < .001). CONCLUSION: A CDS tool can improve management of SCD patients in primary care.

Trends in Cardiovascular Disease Risk in the U.S., 1999-2014.

INTRODUCTION: Cardiovascular disease is the leading cause of death in the U.S. and national prevalence of the proportion of individuals at high risk is unknown. The objective of this study was to investigate the prevalence and trends in high cardiovascular disease risk among adults in the U.S. METHODS: In 2017, the authors performed a cross-sectional analysis of data from the National Health and Nutrition Examination Survey, 1999-2014 for adults aged 40-79 years without a diagnosis of cardiovascular disease (unweighted n=18,269, weighted n=96,512,989). The American College of Cardiology/American Heart Association Atherosclerotic Cardiovascular Disease risk score was calculated for all participants with complete data. Change in prevalence of individuals at high risk of cardiovascular disease was assessed, defined as ≥7.5% 10-year risk and ≥20% 10-year risk. RESULTS: The prevalence of high risk level did not significantly change over time for the entire sample using the 7.5% 10-year risk level, but did decline significantly at 20% 10-year risk level. Logistic regression results showed that prevalence among non-Hispanic black males increased significantly from 53.5% in 1999-2002 to 65.2% in 2011-2014 using the 7.5% 10-year risk cut off (p-trend=0.003). CONCLUSIONS: A substantial proportion of the population is at high risk of cardiovascular disease. Prevalence of high-risk individuals is prominent for non-Hispanic black males; the reasons for which are unclear. Public health efforts to increase awareness should be considered for this vulnerable population.

Association between race/ethnicity and disability status and receipt of vaccines among older adults in Florida.

BACKGROUND: Individuals living with a disability or are a member of a certain racial/ethnic group may be at heightened risk for not receiving important vaccinations. OBJECTIVE: This study examined whether race/ethnicity and disability status are associated with the receipt of two vaccines (influenza and pneumococcal) among older adults living in Florida. METHODS: Using the 2011-2015 Florida Behavioral Risk Factor Surveillance System, a cross-sectional survey, we ran bivariate and multivariate analyses to determine the associations for race/ethnicity and disability status with receipt of vaccinations among individuals 65 years and older. Interactions between race/ethnicity and disability status were tested in each model. RESULTS: Among our study sample, 68% received the pneumococcal vaccine in their lifetime and 54% of them received influenza vaccine in the past 12 months. Multivariate logistic regression indicated that Non-Hispanic Blacks and Hispanics were less likely to receive both vaccines compared to Non-Hispanic Whites. Older adults with a disability were more likely to receive influenza and pneumococcal vaccines compared to those without. A significant interaction was observed between race/ethnicity and disability status for predicting pneumococcal vaccination receipt. CONCLUSIONS: Large proportions of older adults in Florida continue to go without needed vaccinations. Although race/ethnicity and disability status were shown to have some association with receipt of vaccines, having a regular source of care, employment and income also were shown to be important predictors.

Prevalence and Risk of Penile Human Papillomavirus Infection: Evidence From The National Health and Nutrition Examination Survey 2013-2014.

BACKGROUND: The epidemiology of penile human papillomavirus (HPV) infection is not well understood. Our objective was to determine the prevalence of penile HPV infection in the United States. METHODS: We analyzed a nationally representative sample of civilian noninstitutionalized US men from the National Health and Nutritional Examination Survey (NHANES) 2013-2014. Penile swab samples were collected from men aged 18-59 years. For detection of HPV types, a Roche Linear Array test was performed. We used NHANES sampling weights to estimate the population prevalence of penile HPV infection. RESULTS: The overall prevalence of any HPV infection was 45.2% (95% confidence interval [CI], 41.3%-49.3%). The prevalence of any high-risk HPV types and low-risk HPV types (mutually exclusive of high-risk HPV) was 30.5% (95% CI, 28.0%-33.0%) and 14.8% (95% CI, 12.7%-17.2%), respectively. Overall HPV prevalence increased with increasing age: the prevalence was lowest among 18- to 24-year-old men (33.8%) and highest among 55- to 59-year-old men (53.4%). HPV types 16 and 18 were detected in 4.3% (95% CI, 3.2%-5.7%) and 1.7% (95% CI, 1.1%-2.6%) of men, respectively. The prevalence of any HPV infection was almost 80% among men who reported having ≥16 lifetime sexual partners and using condoms intermittently. CONCLUSIONS: Our findings indicate that penile HPV is common among men in the United States. Almost one-third of all men are infected with high-risk HPV. Prevalence of penile HPV infection increases with increasing age.

Physical Activity and Abnormal Blood Glucose Among Healthy Weight Adults.

INTRODUCTION: Physical activity has been linked to prevention and treatment of prediabetes and diabetes in overweight and obese adults. This study examines the relationship between low physical activity levels and risk of abnormal blood glucose (prediabetes or undiagnosed diabetes) in healthy weight adults. METHODS: Data from the 2014 Health Survey for England were analyzed in July 2016, focusing on adults with a BMI ≥18.5 and <25 who had never been diagnosed with diabetes (N=1,153). Abnormal blood glucose was defined as hemoglobin A1c ≥5.7. Physical activity was measured through the International Physical Activity Questionnaire. Bivariate analyses and Poisson models were conducted on the effect of physical activity on abnormal blood glucose, controlling for age, sex, waist to hip ratio, sitting time, age X physical activity interaction, sex X physical activity, and race. RESULTS: Abnormal blood glucose was detected in 23.7% of individuals with low activity levels, 14.8% of those with medium activity levels, and 12.2% of those with high activity levels (p<0.003). Similarly, 25.4% of inactive individuals (physically active for <30 minutes per week) were more likely to have abnormal blood glucose levels than active individuals (13.4%, p<0.0001). Higher physical activity was associated with a lower likelihood of abnormal blood glucose in an adjusted Poisson regression. CONCLUSIONS: Among healthy weight adults, low physical activity levels are significantly associated with abnormal blood glucose (prediabetes and undiagnosed diabetes). These findings suggest that healthy weight individuals may benefit from physical exercise.

Hearing Impairment and Undiagnosed Disease: The Potential Role of Clinical Recommendations.

Purpose: The objective of this study was to use cross-sectional, nationally representative data to examine the relationship between self-reported hearing impairment and undetected diabetes, hypertension, hypercholesterolemia, and chronic kidney disease. Method: We analyzed the National Health and Nutrition Examination Survey for the years 2007-2012 for individuals 40 years of age and older without previously diagnosed cardiovascular disease. Analyses were conducted examining hearing impairment and undiagnosed disease. Results: The unweighted sample size was 9,786, representing 123,444,066 Americans. Hearing impairment was reported in 10.2% of the individuals. In unadjusted analyses, there was no significant difference between adults with hearing impairment and adults with typical hearing for undiagnosed diabetes, hypertension, or hypercholesterolemia. A higher proportion of adults with hearing impairment than adults with typical hearing had undiagnosed chronic kidney disease (20.1% vs. 10.7%; p = .0001). In models adjusting for demographics and health care utilization, hearing impairment was associated with a higher likelihood of having undiagnosed chronic kidney disease (odds ratio = 1.53, 95% CI [1.23, 1.91]). Conclusions: Individuals with hearing impairment are more likely to have undiagnosed chronic kidney disease. Hearing impairment may affect disclosure of important signs and symptoms as well as the comprehension of medical conversations for chronic disease management. General practitioners can play a critical role in improving medical communication by responding with sensitivity to the signs of hearing impairment in their patients.

Prevalence of Prediabetes and Abdominal Obesity Among Healthy-Weight Adults: 18-Year Trend.

PURPOSE: Trends in sedentary lifestyle may have influenced adult body composition and metabolic health among individuals at presumably healthy weights. This study examines the nationally representative prevalence of prediabetes and abdominal obesity among healthy-weight adults in 1988 through 2012. METHODS: We analyzed the National Health and Nutrition Examination Survey (NHANES) III (1988-1994) and NHANES for the years 1999 to 2012, focusing on adults aged 20 years and older who have a body mass index (BMI) of 18.5 to 24.99 and do not have diabetes, either diagnosed or undiagnosed. We defined prediabetes using glycated hemoglobin (HbA1c) level ranges from 5.7% to 6.4%, as specified by the American Diabetes Association. Abdominal obesity was measured by waist circumference and waist-to-height ratio. RESULTS: The prevalence of prediabetes among healthy-weight adults, aged 20 years and older and without diagnosed or undiagnosed diabetes, increased from 10.2% in 1988-1994 to 18.5% in 2012. Among individuals aged 45 years and older, the prevalence of prediabetes increased from 22.0% to 33.1%. The percentage of adults aged 20 years and older with an unhealthy waist circumference increased from 5.6% in 1988-1994 to 7.6% in 2012. The percentage of individuals with an unhealthy waist-to-height ratio increased from 27.2% in 1988-1994 to 33.7% in 2012. Adjusted models found that measures of abdominal obesity were not independent predictors of prediabetes among adults with a healthy BMI. CONCLUSIONS: Among individuals within a healthy BMI range, the prevalence of prediabetes and abdominal obesity has substantially increased. Abdominal obesity does not appear to be the primary cause of the increase.

Low Grip Strength and Prediabetes in Normal-Weight Adults.

INTRODUCTION: Detection of prediabetes is an important step in diabetes prevention in primary care. Risk stratification of healthy-weight individuals for detection of prediabetes is necessary to avoid missed opportunities for diabetes prevention. METHODS: Using data from the 2011 to 2012 National Health and Nutrition Examination Survey, we studied the relationship between combined handgrip strength, a proxy for lean muscle mass, and prediabetes among adults aged ≥20 years without diagnosed or undiagnosed diabetes who had a healthy body mass index (18.5-24.9 kg/m(2); unweighted n = 1340, weighted n = 58,360,690). Prediabetes was defined as having a glycohemoglobin level between 5.7% and 6.4%. RESULTS: Of the healthy-weight adults, 20.5% had prediabetes. Combined mean grip strength was lower for individuals with prediabetes than those with normoglycemia in the full sample (63.8 vs 70.9 kg; P = .004). Similar results were seen among both men (87.9 vs 82.1 kg; P = .03) and women (51.8 vs 56.5 kg; P = .001) in subgroup analysis. CONCLUSIONS: Grip strength is associated with prediabetes among healthy-weight US adults. Grip strength may have utility as an indicator for screening healthy-weight individuals for prediabetes.

Prediabetes Diagnosis and Treatment in Primary Care.

BACKGROUND: The increasing prevalence of diabetes is a major health problem. The detection and treatment of prediabetes can delay the onset of diabetes and presents an important diabetes prevention strategy. METHODS: Using data from the 2012 National Ambulatory Medical Care Survey, we studied visits by adults aged ≥45 years without diagnosed diabetes who had an HbA1c test within 90 days of the visit (n = 518 unweighted visits; n = 11,167,004 weighted visits). HbA1c results were categorized into normal, prediabetes, and diabetes, and we examined patient characteristics (age, sex, race, payer type, body mass index) and treatment of prediabetes. RESULTS: Among visiting adults, 54.6% had a normal HbA1c value, 33.6% had prediabetes, and 11.9% had diabetes. Of those patient visits with HbA1c consistent with prediabetes, the number of patients diagnosed with prediabetes was too low for a reliable population estimate. Indication of treatment in the medical record (lifestyle modification counseling and/or metformin) was present in 23.0% of those with diagnosed or undiagnosed prediabetes. The most common treatment was lifestyle modification counseling. CONCLUSIONS: Our findings show that there are missed opportunities for diabetes prevention in primary care. Providers need to change their approach to prediabetes and play a more effective role in preventing diabetes.

Prediabetes Screening and Treatment in Diabetes Prevention: The Impact of Physician Attitudes.

PURPOSE: Detection and treatment of prediabetes is an effective strategy in diabetes prevention. However, most patients with prediabetes are not identified. Our objective was to evaluate the relationship between attitudes toward prediabetes as a clinical construct and screening/treatment behaviors for diabetes prevention among US family physicians. METHODS: An electronic survey of a national sample of academic family physicians (n 1248) was conducted in 2016. Attitude toward prediabetes was calculated using a summated scale assessing agreement with statements regarding prediabetes as a clinical construct. Perceived barriers to diabetes prevention, current strategies for diabetes prevention, and perceptions of peers were also examined. RESULTS: Physicians who have a positive attitude toward prediabetes as a clinical construct are more likely to follow national guidelines for screening (58.4% vs 44.4; P < .0001) and recommend metformin to their patients for prediabetes (36.4% vs 20.9%; P < .0001). Physicians perceived a number of barriers to treatment, including a patient's economic resources (71.9%), sustaining patient motivation (83.2%), a patient's ability to modify his or her lifestyle (75.3%), and time to educate patient (75.3%) as barriers to diabetes prevention. CONCLUSIONS: How physicians view prediabetes varies significantly, and this variation is related to treatment/screening behaviors for diabetes prevention.

Acute Dietary Nitrate Supplementation and Exercise Performance in COPD: A Double-Blind, Placebo-Controlled, Randomised Controlled Pilot Study.

BACKGROUND: Dietary nitrate supplementation can enhance exercise performance in healthy people, but it is not clear if it is beneficial in COPD. We investigated the hypotheses that acute nitrate dosing would improve exercise performance and reduce the oxygen cost of submaximal exercise in people with COPD. METHODS: We performed a double-blind, placebo-controlled, cross-over single dose study. Subjects were randomised to consume either nitrate-rich beetroot juice (containing 12.9 mmoles nitrate) or placebo (nitrate-depleted beetroot juice) 3 hours prior to endurance cycle ergometry, performed at 70% of maximal workload assessed by a prior incremental exercise test. After a minimum washout period of 7 days the protocol was repeated with the crossover beverage. RESULTS: 21 subjects successfully completed the study (age 68 ± 7 years; BMI 25.2 ± 5.5 kg/m2; FEV1 percentage predicted 50.1 ± 21.6%; peak VO2 18.0 ± 5.9 ml/min/kg). Resting diastolic blood pressure fell significantly with nitrate supplementation compared to placebo (-7 ± 8 mmHg nitrate vs. -1 ± 8 mmHg placebo; p = 0.008). Median endurance time did not differ significantly; nitrate 5.65 (3.90-10.40) minutes vs. placebo 6.40 (4.01-9.67) minutes (p = 0.50). However, isotime oxygen consumption (VO2) was lower following nitrate supplementation (16.6 ± 6.0 ml/min/kg nitrate vs. 17.2 ± 6.0 ml/min/kg placebo; p = 0.043), and consequently nitrate supplementation caused a significant lowering of the amplitude of the VO2-percentage isotime curve. CONCLUSIONS: Acute administration of oral nitrate did not enhance endurance exercise performance; however the observation that beetroot juice caused reduced oxygen consumption at isotime suggests that further investigation of this treatment approach is warranted, perhaps targeting a more hypoxic phenotype. TRIAL REGISTRATION: ISRCTN Registry ISRCTN66099139.

Health Considerations in Regulation and Taxation of Electronic Cigarettes.

The use of electronic cigarettes (e-cigarettes) is experiencing unprecedented growth. This can be contrasted to the use of conventional cigarettes which showed a decrease among adults with the current smoker prevalence dropping from 20.9% in 2005 to 17.8% in 2013. There is some data that e-cigarettes are attracting both former smokers and never smokers, and in particular, young people as users. Currently most states do not tax e-cigarettes. Taxation and regulation may have a similar overall goal of decreasing smoking but regulation tends to focus reduced availability of products. In terms of tobacco control, taxation focuses on the demand side of the equation. Taxation is a distinct strategy from regulation and has been shown to decrease new adopters of conventional cigarettes. A variety of potential taxation strategies can be considered by policymakers based on different assumptions about e-cigarettes and their utility, ranging from untaxed to taxation at moderate levels compared to conventional cigarettes to taxation equal to conventional cigarettes. Until more evidence for the benefits of e-cigarettes is presented, it seems prudent to view them as a potentially harmful and addictive product that ought to be regulated and taxed in an equivalent manner to conventional cigarettes.

Grip Strength as a Marker of Hypertension and Diabetes in Healthy Weight Adults.

INTRODUCTION: Muscle strength may play a role in cardiometabolic disease. We examined the relationship between hand grip strength and diabetes and hypertension in a sample of healthy weight adults. METHODS: In 2015, we analyzed the National Health and Nutrition Examination Survey 2011-2012 for adults aged ≥20 years with healthy BMIs (between 18.5 and <25) and no history of cardiovascular disease (unweighted n=1,467; weighted n=61,587,139). Hand grip strength was assessed with a dynamometer. Diabetes was based on hemoglobin A1c level and reported diabetes diagnosis. Hypertension was based on measured blood pressure and reported hypertension diagnosis. RESULTS: Individuals with undiagnosed diabetes compared with individuals without diabetes had lower grip strength (51.9 vs 69.8, p=0.0001), as did individuals with diagnosed diabetes compared with individuals without diabetes (61.7 vs 69.8, p=0.008). Mean grip strength was lower among individuals with undiagnosed hypertension compared with individuals without hypertension (63.5 vs 71.5, p=0.008) as well as among individuals with diagnosed hypertension compared with those without hypertension (60.8 vs 71.5, p<0.0001). In adjusted analyses controlling for age, sex, race, smoking status, and first-degree relative with disease, mean grip strength was lower for undiagnosed diabetes (ß=-10.02, p<0.0001) and diagnosed diabetes (ß=-8.21, p=0.03) compared with individuals without diabetes. In adjusted analyses, grip strength was lower among individuals with undiagnosed hypertension (ß=-6.6, p=0.004) and diagnosed hypertension (ß=-4.27, p=0.04) compared with individuals without hypertension. CONCLUSIONS: Among healthy weight adults, combined grip strength is lower in individuals with diagnosed and undiagnosed diabetes and hypertension.

Attitudes toward Management of Sickle Cell Disease and Its Complications: A National Survey of Academic Family Physicians.

Objective. Sickle cell disease (SCD) is a disease that requires a significant degree of medical intervention, and family physicians are one potential provider of care for patients who do not have access to specialists. The extent to which family physicians are comfortable with the treatment of and concerned about potential complications of SCD among their patients is unclear. Our purpose was to examine family physician's attitudes toward SCD management. Methods. Data was collected as part of the Council of Academic Family Medicine Educational Research Alliance (CERA) survey in the United States and Canada that targeted family physicians who were members of CERA-affiliated organizations. We examined attitudes regarding management of SCD. Results. Overall, 20.4% of respondents felt comfortable with treatment of SCD. There were significant differences in comfort level for treatment of SCD patients depending on whether or not physicians had patients who had SCD, as well as physicians who had more than 10% African American patients. Physicians also felt that clinical decision support (CDS) tools would be useful for treatment (69.4%) and avoiding complications (72.6%) in managing SCD patients. Conclusions. Family physicians are generally uncomfortable with managing SCD patients and recognize the utility of CDS tools in managing patients.

An evaluation of factors associated with completion and benefit from pulmonary rehabilitation in COPD.

BACKGROUND: Pulmonary Rehabilitation (PR) is an important treatment for patients with chronic obstructive pulmonary disease (COPD) but it is not established whether any baseline parameter can predict response or compliance. AIM: To identify whether baseline measures can predict who will complete the programme and who will achieve a clinically significant benefit from a Minimum Clinical Important Difference (MCID) in terms of exercise capacity and health-related quality of life (HRQoL). METHODS: Data were collected prospectively from patients with COPD at their baseline assessment for an outpatient PR programme in one of eight centres across London. 'Completion' was defined as attending at least 75% of the designated PR visits and return for the follow-up evaluation. The MCID for outcome measures was based on published data. RESULTS: 787 outpatients with COPD (68.1±10.5 years old; 49.6% males) were included. Patients who completed PR (n=449, 57.1%) were significantly older with less severe airflow obstruction, lower anxiety and depression scores, less dyspnoea and better HRQoL. Only baseline CAT score (OR=0.925; 95% CI 0.879 to 0.974; p=0.003) was retained in multivariate analysis. Patients with the lowest baseline walking distance were most likely to achieve the MCID for exercise capacity. No baseline variable could independently predict achievement of an MCID in HRQoL. CONCLUSIONS: Patients with better HRQoL are more likely to complete PR while worse baseline exercise performance makes the achievement of a positive MCID in exercise capacity more likely. However, no baseline parameter could predict who would benefit the most in terms of HRQoL.

Prediabetes, elevated iron and all-cause mortality: a cohort study.

OBJECTIVES: Data have indicated low to non-existent increased mortality risk for individuals with prediabetes, but it is unclear if the risk is increased when the patient has elevated iron markers. Our purpose was to examine the mortality risk among adults with prediabetes in the context of coexisting elevated transferrin saturation (TS) or serum ferritin. SETTING: Data collected by the third National Health and Nutrition Examination Survey 1988-1994 (NHANES III) in the USA and by the National Center for Health Statistics for the National Death Index from 1988 to 2006. PARTICIPANTS: Individuals age 40 and older who participated in the NHANES and provided a blood sample. PRIMARY OUTCOME VARIABLE: Mortality was measured as all-cause mortality. RESULTS: Adjusted analyses show that prediabetes has a small increased mortality risk (HR=1.04; 95% CI 1.00 to 1.08). Persons who had prediabetes and elevated serum ferritin had an increased HR for death (HR=1.14; 95% CI 1.04 to 1.24) compared with those who had normal ferritin and normal glucose. Among persons with prediabetes who had elevated TS, they had an increased mortality risk (HR=1.88; 95% CI 1.06 to 3.30) compared with those with normal TS levels and normal glucose. CONCLUSIONS: The mortality risk of prediabetes is low. However, among individuals who have coexisting elevated iron markers, particularly TS, the risk rises substantially.