Association between small for gestational age and paternally inherited 5' insulin haplotypes.

OBJECTIVE: To test the association between small for gestational age and polymorphisms in the insulin gene in newborns and their mothers, as well as the effect of the parental transmission of haplotypes. SUBJECTS: Pairs of healthy African-American full-term newborns (N=207) and mothers were recruited from Memphis TN and Jackson MS with birth weights ranging from 2210 to 4735 g. METHODS: Six single nucleotide polymorphisms (SNPs) located in the insulin (INS) and insulin-like growth factor 2 (IGF2) genes were genotyped in mothers and newborns. Haplotypes composed of three SNPs in the 5' region of the INS-IGF2 locus were computationally inferred. Odds ratios for risk of small for gestational age (SGA) birth were calculated for individual SNPs and inferred haplotypes in the newborns and in the mothers using logistic regression. For 162 mother--newborn pairs the parental transmission of the haplotypes could be inferred, and the risks for SGA birth were calculated for the three common haplotypes in this sample. RESULTS: Three INS SNPs exhibited significant association with risk for SGA birth. The SNP alleles associated with increased risk for SGA were opposite in the maternal and newborn genomes, implying opposing influences on the rate of fetal growth. Consistent with these results, haplotypes composed of complementary nucleotide sequences (CAC at rs3842738, rs689 and rs3842748, respectively, in the newborn versus GTG in the mother) were significantly associated with risk for SGA birth. In analyses of haplotypes according to parental transmission, the same trend in risk for SGA was observed for both maternally and paternally transmitted haplotypes, although a significant difference in risk was observed only for paternally transmitted haplotypes. CONCLUSION: Polymorphisms near the 5' end of the INS-IGF2 locus are significantly associated with risk for SGA birth with a major effect due to the paternally transmitted haplotype, which is preferentially expressed due to imprinting.

Pamidronate infusion in patients with systemic sclerosis results in changes in blood mononuclear cell cytokine profiles.

A single infusion of pamidronate was given to patients with systemic sclerosis (scleroderma, SSc) to assess effects on cytokine production by peripheral blood mononuclear cells (PBMC) and lymphocyte subsets. Eighteen patients with SSc received a single intravenous dose of 60 mg of pamidronate and were followed for 6 months. Assessment of cytokine production [interferon (IFN)-gamma, interleukin (IL)-10, transforming growth factor (TGF)-beta1, tumour necrosis factor (TNF)-alpha and IL-4] by PBMC and lymphocyte subsets by flow cytometry was carried out before and after the pamidronate infusion. Unstimulated PBMC produced increased amounts of IFN-gamma and TNF-alpha and reduced levels of TGF-beta1 for up to 24 weeks after the infusion. gammadelta T cells from patients with SSc were activated in vitro and produced increased IFN-gamma. The effects of pamidronate on modulation of cytokine profiles in patients with SSc may merit future study.

Glycemia and cognitive function in older adults using glucose-lowering drugs.

OBJECTIVES: In experimental studies, both high and low levels of plasma glucose are associated with cognitive impairment. In populations, less is known about the relationship between glycemia and cognitive function, especially in persons using glucose-lowering drugs. DESIGN: A cross-sectional study of 378 high-functioning black and white men and women aged 70 to 79 participating in the Health, Aging, and Body Composition Study (Health ABC) who used glucose-lowering medications. Glycemic measures included fasting plasma glucose (FPG) and glycosylated hemoglobin (HbA1c). Cognitive function was assessed using the Modified Mini-Mental State Examination (3MS) and the Digit Symbol Substitution Test (DSS) at the same examination visit in which the glycemic measures were determined. SETTING: Memphis, Tennessee and Pittsburgh, Pennsylvania. RESULTS: We observed an "inverted-U" relationship (p =.0025 for 3MS, p=.0277 for DSS) between FPG (range 47 - 366 mg/dl) and performance on these two tests. The fasting plasma glucose levels associated with the highest score on the 3MS was 180 mg/dl and 135 mg/dl for the DSS. There was a monotonic inverse relationship between HbA1c and performance on 3MS and DSS without evidence of a threshold effect. CONCLUSION: Our findings suggest that older adults who are treated for diabetes may experience a small degree of cognitive impairment within the recommended fasting glucose levels, yet measures of long-term glycemic control support tight glycemic control. Given the high prevalence of diabetes and the common use of glucose-lowering drugs in older adults, further studies are needed to elucidate these relationships.

Racial differences in the incidence of gliomas: a retrospective study from Memphis, Tennessee.

This study records the incidence of glioblastoma multiforme, astrocytoma and oligodendroglioma in the white and Black patients in the Memphis Statistical Metropolitan Area (MSMA) during a 10.5-year period from 1 January 1984 through 30 June 1994. During this time, only six hospitals performed craniotomy and computer tomography (CT) scanning was routine in each of the hospitals. A total of 824 histologically confirmed first diagnoses were made at these six area hospitals. Based on the zip code listed as the home address, we determined patient's locale and identified 373 patients (232 glioblastoma multiforme, 106 astrocytomas and 35 oligodendroglioma) who resided in the area during the study interval. There were 50 black and 323 white patients. The background population for the area was obtained from the US Census Bureau's statistics for the year 1990. These statistics indicated that 40.5% of the population identified themselves as black and 57.9% as white. Age adjusted incidence rates were 1.550 (p < 0.001) for other astrocytomas, and 0.106 and 0.461 (p = 0.003) in the black and white populations, respectively. There was no significant difference in survival between the two populations. This study confirms a significant disparity in incidence rates for the three most common gliomas between the black and white populations and this disparity is higher than predicted by previous reports.

Improvements in diabetes management and outcomes in a Medicaid managed care system.

OBJECTIVE: To determine the impact of managed care on effectiveness of diabetes management in Tennessee, where a statewide Medicaid program (TennCare) delivers services through capitated managed care organizations (MCOs). RESEARCH DESIGN AND METHODS: This retrospective cohort study documented the health care utilization experiences and clinical outcomes of a convenience sample of Tennessee Medicaid enrollees with chronic diabetes before and after the initiation of TennCare. Exposures to recommended diabetic services and outcomes were compared before and after TennCare for 171 enrollees with diabetes in the state's largest academic MCO who met age, continuous enrollment, insurance, and diagnostic criteria for two years before (1992 and 1993) and two years after TennCare (1995 and 1996). Claims data were used to assess baseline characteristics and chart review data were used to assess health services utilization for 71% of cohort members (n = 121) for whom complete medical records were available. The paired t-test was used to compare exposures and outcomes before and after TennCare. RESULTS: Participants had an average of 6.4 outpatient clinic visits per year before TennCare vs. 8.2 visits per year after TennCare (P = .0009), 0.6 vs. 1.0 diabetic eye examinations (P = .0042), 0.2 vs. 0.5 foot examinations (P = .0358), 0.4 vs. 0.6 cholesterol assessments (P < .0001), and 0.5 vs. 1.0 glycosylated hemoglobin assessments annually (P < .0001). Average glycosylated hemoglobin decreased from 10.3 to 8.2 (P < .0001). Although hospitalizations and hospital days increased overall, there was no increase in emergency visits, preventable emergency visits, or preventable hospitalizations. CONCLUSIONS: Enrollees with diabetes experienced increases in utilization of recommended health services and improved glucose control following the initiation of Medicaid managed care. These improvements may reflect improved chronic disease care in a primary care gatekeeper system.

Monotherapy may be suboptimal for severe bacteremic pneumococcal pneumonia.

BACKGROUND: Although monotherapy for pneumococcal pneumonia is standard, a survival benefit of combination beta-lactam and macrolide therapy has been suggested. HYPOTHESIS: Initial empirical therapy with a combination of effective antibiotic agents would have a better outcome than a single effective antibiotic agent in patients with bacteremic pneumococcal pneumonia. METHODS: A review of adult bacteremic pneumococcal pneumonia within the Methodist Healthcare System, Memphis, Tenn, between January 1, 1996, and July 31, 2000. Empirical therapy was defined as all antibiotic agents received in the first 24 hours after presentation. On the basis of culture results, empirical therapy was classified as single effective therapy (SET), dual effective therapy (DET), or more than DET (MET). Acute Physiology and Chronic Health Evaluation II (APACHE II)-based predicted mortality, and Pneumonia Severity Index scores were calculated. RESULTS: Of the 225 patients identified, 99 were classified as receiving SET, 102 as receiving DET, and 24 as receiving MET. Compared with the other groups, patients who received MET had statistically significantly more severe pneumonia as measured by the Pneumonia Severity Index score (P =.04) and predicted mortality (P =.03). Mortality within the SET group was significantly higher than within the DET group (P =.02, odds ratio, 3.0 [95% confidence intervals, 1.2-7.6]), even when the DET and MET groups (P =.04) were combined. In a logistic regression model including antibiotic therapy and clinical risk factors for mortality, SET remained an independent predictor of mortality with a predicted mortality-adjusted odds ratio for death of 6.4 (95% confidence intervals, 1.9-21.7). All deaths occurred in patients with a Pneumonia Severity Index score higher than 90, and the predicted mortality-adjusted odds ratio for death with SET in this subgroup was 5.5 (95% confidence intervals, 1.7-17.5). CONCLUSIONS: We found that SET is associated with a significantly greater risk of death than DET. Therefore, monotherapy may be suboptimal for patients with severe bacteremic pneumococcal pneumonia who have Pneumonia Severity Index scores higher than 90.

Poison control centers and state-specific poisoning mortality rates.

OBJECTIVE: The purpose of this study was to compare poisoning mortality rates of states served by a poison control center certified by the American Association of Poison Control Centers (AAPCC) to those that are not served by a certified center because health policy has been based on certification status. METHODS: Poisoning mortality rates from 1993 to 1997 were obtained from a public use database of death certificates and were stratified by state and circumstance. Each state was classified as being fully served, partially served, or not served by an AAPCC-certified center. States in one category of service for the entire 5 years were selected for analysis. RESULTS: During this 5-year period, 39 states exhibited a consistent category of poison control center services. The mortality rates per 100,000 population during these 5 years were 5.93, 6.12, 6.01, 6.23, and 6.68 respectively (P <0.05) for all 39 states. The mean 5-year mortality rate for states with certified poison control center services (7.08 +/- 2.59; n = 17) was higher (P <0.05) than those with noncertified service (5.17 +/- 1.46; n = 15) but not significantly different from those with partial certified service (6.25 +/- 1.75; n = 7). CONCLUSION: Increased poisoning mortality rates were associated with AAPCC certification status and year. Poisoning mortality rates may not be an appropriate outcome measure of the impact of poison control centers, AAPCC-certification notwithstanding, at this time. Basing poison control center-related policy on state-specific poisoning mortality rates can not be supported by these findings.

Dementia and disability outcomes in large hypertension trials: lessons learned from the systolic hypertension in the elderly program (SHEP) trial.

In the Systolic Hypertension in the Elderly Program (SHEP) trial (1985-1990), active treatment reduced the incidence of cardiovascular events, but not that of dementia and disability, as compared with placebo. This study aims to evaluate if assessment of cognitive and functional outcomes was biased by differential dropout. Characteristics of subjects who did or did not participate in follow-up cognitive and functional evaluations were compared. The relative risks of incident cognitive impairment and disability were assessed in the two treatment groups, with the use of the reported findings and under the assumption that the proportions of cognitive and functional impairment among dropouts increased. Assignment to the placebo group and the occurrence of cardiovascular events independently predicted missed assessments. From the reported findings, the risk of cognitive and functional impairment was similar between the two treatment groups. However, when 20-30% and 40-80% of the subjects who missed the assessment were assumed to be cognitively and, respectively, functionally impaired, assignment to active treatment reduced the risk of these outcomes. In the SHEP, the cognitive and functional evaluations were biased toward the null effect by differential dropout. This might have obscured the appraisal of a protective effect of treatment on the cognitive and functional decline of older hypertensive adults.

Serum uric acid, diuretic treatment and risk of cardiovascular events in the Systolic Hypertension in the Elderly Program (SHEP).

OBJECTIVE: To assess longitudinally the association of serum uric acid and its change due to diuretic treatment with cardiovascular events in hypertensive patients. DESIGN: Cohort study in a randomized trial. SETTING: Cohort of hypertensive patients. PARTICIPANTS: A total of 4327 men and women, aged > or = 60 years, with isolated systolic hypertension, randomized to placebo or chlorthalidone, with the addition of atenolol or reserpine if needed, were observed for 5 years. MAIN OUTCOME MEASURES: Major cardiovascular events, coronary events, stroke and all-cause mortality. RESULTS: Cardiovascular event rates for quartiles of baseline serum uric acid were: I, 32.7 per 1000 person-years; II, 34.5 per 1000 person-years; III, 38.1 per 1000 person-years; and IV, 41.4 per 1000 person-years (P for trend = 0.02). The adjusted hazard ratio (HR), of cardiovascular events for the highest quartile of serum uric acid versus the lowest quartile was 1.32 (95% CI, 1.03-1.69). The benefit of active treatment was not affected by baseline serum uric acid. After randomization, an increase of serum uric acid < 0.06 mmol/l (median change) in the active treatment group was associated with a HR of 0.58 (0.37-0.92) for coronary events compared with those with a serum uric acid increase > or = 0.06 mmol/l. This difference was not explained by blood pressure effects. Those with a serum uric acid increase > or = 0.06 mmol/l in the active treatment group had a similar risk of coronary events as the placebo group. CONCLUSIONS: Serum uric acid independently predicts cardiovascular events in older persons with isolated systolic hypertension. Monitoring serum uric acid change during diuretic treatment may help to identify patients who will most benefit from treatment.

Hypokalemia associated with diuretic use and cardiovascular events in the Systolic Hypertension in the Elderly Program.

The treatment of hypertension with high-dose thiazide diuretics results in potassium depletion and a limited benefit for preventing coronary events. The clinical relevance of hypokalemia associated with low-dose diuretics has not been assessed. To determine whether hypokalemia that occurs with low-dose diuretics is associated with a reduced benefit on cardiovascular events, we analyzed data of 4126 participants in the Systolic Hypertension in the Elderly Program (SHEP), a 5-year randomized, placebo-controlled clinical trial of chlorthalidone-based treatment of isolated systolic hypertension in older persons. After 1 year of treatment, 7.2% of the participants randomized to active treatment had a serum potassium <3.5 mmol/L compared with 1% of the participants randomized to placebo (P<0.001). During the 4 years after the first annual visit, 451 participants experienced a cardiovascular event, 215 experienced a coronary event, 177 experienced stroke, and 323 died. After adjustment for known risk factors and study drug dose, the participants who received active treatment and who experienced hypokalemia had a similar risk of cardiovascular events, coronary events, and stroke as those randomized to placebo. Within the active treatment group, the risk of these events was 51%, 55%, and 72% lower, respectively, among those who had normal serum potassium levels compared with those who experienced hypokalemia (P<0.05). The participants who had hypokalemia after 1 year of treatment with a low-dose diuretic did not experience the reduction in cardiovascular events achieved among those who did not have hypokalemia.

The role of diastolic blood pressure when treating isolated systolic hypertension.

OBJECTIVE: To assess the role of treated diastolic blood pressure (DBP) level in stroke, coronary heart disease (CHD), and cardiovascular disease (CVD) in patients with isolated systolic hypertension (ISH). DESIGN: An analysis of the 4736 participants in the Systolic Hypertension in the Elderly Program (SHEP) was undertaken. The SHEP was a randomized multicenter double-blind outpatient clinical trial of the impact of treating ISH in men and women aged 60 years and older. MAIN OUTCOME MEASURES: Cox proportional hazards regression analysis, with DBP and systolic blood pressure (SBP) as time-dependent covariables. RESULTS: After adjustment for the baseline risk factors of race (black vs other), sex, use of antihypertensive medication before the study, a composite variable (diabetes, previous heart attack, or stroke), age, and smoking history (ever vs never) and adjustment for the SBP as a time-dependent variable, we found, for the active treatment group only, that a decrease of 5 mm Hg in DBP increased the risk for stroke (relative risk, [RR], 1.14; 95% confidence interval [CI], 1.05-1.22), for CHD (RR, 1.08; 95% CI, 1.00-1.16), and for CVD (RR, 1.11; 95% CI, 1.05-1.16). CONCLUSIONS: Some patients with ISH may be treated to a level that uncovers subclinical disease, and some may be overtreated. Further studies need to determine whether excessively low DBP can be prevented by more careful titration of antihypertensive therapy while maintaining SBP control. It is reassuring that patients receiving treatment for ISH never perform worse than patients receiving placebo in terms of CVD events.

A population comparison of participants and nonparticipants in a health survey.

OBJECTIVES: This study examined the characteristics of Air Force recruits willing to take part in a health survey vs those unwilling to participate. METHODS: US Air Force recruits undergoing basic military training (n = 32,144) were surveyed regarding demographic and health variables. RESULTS: Respondents indicating an unwillingness to participate in a health survey reported less healthy lifestyles than those willing to participate. Prediction equations modeling the characteristics of those engaging in 4 risky behaviors were nearly identical regardless of whether those refusing to participate were included. CONCLUSIONS: Results suggest that, despite some low estimates of health behaviors due to response bias, relationships between most risk factors are generally unaffected by those not responding to health surveys.

Lack of efficacy of oral bovine type II collagen added to existing therapy in rheumatoid arthritis.

OBJECTIVE: To investigate the efficacy of oral type II collagen (CII) in the treatment of rheumatoid arthritis (RA), when added to existing therapy. METHODS: Patients with active RA (n = 190) were randomized into a 6-month, double-blind, placebo-controlled trial. Patients continued to take their current arthritis medications. Patients received either placebo or bovine CII, 0.1 mg/day for 1 month, then 0.5 mg/day for 5 months. RESULTS: There were no significant differences between the baseline characteristics of either group. The primary response parameter was the American College of Rheumatology (ACR) preliminary definition of improvement in RA (ACR 20). There was no statistically significant difference in the ACR 20 after 6 months (20.0% of placebo patients; 16.84% of bovine CII patients). There were significant differences in several clinical variables after treatment, all favoring the placebo group. CONCLUSION: Oral solubilized bovine CII, added to existing therapy, did not improve disease activity in patients with RA.

Injuries and deaths due to firearms in the home.

OBJECTIVE: Determine the relative frequency with which guns in the home are used to injure or kill in self-defense, compared with the number of times these weapons are involved in an unintentional injury, suicide attempt, or criminal assault or homicide. METHODS: We reviewed the police, medical examiner, emergency medical service, emergency department, and hospital records of all fatal and nonfatal shootings in three U.S. cities: Memphis, Tennessee; Seattle, Washington; and Galveston, Texas. RESULTS: During the study interval (12 months in Memphis, 18 months in Seattle, and Galveston) 626 shootings occurred in or around a residence. This total included 54 unintentional shootings, 118 attempted or completed suicides, and 438 assaults/homicides. Thirteen shootings were legally justifiable or an act of self-defense, including three that involved law enforcement officers acting in the line of duty. For every time a gun in the home was used in a self-defense or legally justifiable shooting, there were four unintentional shootings, seven criminal assaults or homicides, and 11 attempted or completed suicides. CONCLUSIONS: Guns kept in homes are more likely to be involved in a fatal or nonfatal accidental shooting, criminal assault, or suicide attempt than to be used to injure or kill in self-defense.

Physicians' experiences with Medicaid managed care: the Tennessee American College of physicians survey on TennCare.

Despite widespread introduction of Medicaid managed care (MMC), physicians have not been surveyed regarding its impact on patient care. This study documented physician experiences with MMC in Tennessee, where a statewide experimental managed care program (TennCare) delivers services through 12 capitated managed care organizations (MCOs). Practicing Tennessee American College of Physician (ACP) members (n = 1,181) were questioned regarding recent experience with the TennCare program, assessment of the program, and suggestions for improvement. The results, derived from 306 physician respondents (response rate 26%), were as expected, based on findings of a prior administrative focus group and independent surveys. Physicians' experiences were similar regardless of practice type. Most physicians rated the TennCare program as either fair (43%) or poor (42%) overall. The majority cited administrative complexity as a major problem that frequently adversely affected patient care. Physician experience suggests that administrative procedures and medication formularies should be streamlined and standardized to improve patient care.

Diuretic-based treatment and cardiovascular events in patients with mild renal dysfunction enrolled in the systolic hypertension in the elderly program.

BACKGROUND: It is expected that the treatment of hypertension in patients with renal disease decreases the risk of cardiovascular events, but the evidence in these patients is lacking. OBJECTIVE: To assess the effect of diuretic-based treatment on cardiovascular events in patients with isolated systolic hypertension and renal dysfunction. METHODS: A total of 4336 persons aged 60 years and older with systolic blood pressures of 160 mm Hg and higher and diastolic blood pressures of less than 90 mm Hg were randomly assigned to receive either placebo or chlorthalidone (12.5-25.0 mg/d), with the addition of atenolol (25-50 mg/d) or reserpine (0.05-0.10 mg/d) if needed, and observed for 5 years. The risk of first-occurring cardiovascular events, including stroke, transient ischemic attack, myocardial infarction, heart failure, coronary artery bypass surgery, angioplasty, aneurysm, endarterectomy, sudden death, or rapid death, was stratified according to baseline serum creatinine levels (35.4-84.0, 84.1-101.6, 101.7-119.3, and 119.4-212.2 micromol/L [0.4-0.9, 1.0-1.1, 1.2-1.3, and 1.4-2.4 mg/dL]). RESULTS: Systolic blood pressure reduction was not affected by baseline serum creatinine levels. Active treatment did not affect the risk of serum creatinine levels becoming elevated during follow-up. The risk of hypokalemia with active treatment decreased significantly with increasing baseline serum creatinine levels. In the 4 baseline serum creatinine groups, the relative risk (95% confidence interval) of cardiovascular events developing with active treatment was 0.73 (0.54-0.97), 0.63 (0.49-0.82), 0.62 (0.44-0.87), and 0.59 (0.38-0.91). The results were similar for the outcomes of stroke or coronary artery events and in analyses stratified by sex or age. CONCLUSION: Diuretic-based treatment of patients with isolated systolic hypertension prevents the development of cardiovascular events in older persons with mild renal dysfunction.

Alcohol and illicit drug abuse and the risk of violent death in the home.

CONTEXT: While acute alcohol and illicit drug use are common in homicide and suicide victims, the role of chronic substance use in violent death is unclear. OBJECTIVE: To measure the magnitude of risk of violent death in the home associated with alcohol use or chronic abuse and use of illicit drugs. DATA SOURCES: Data obtained from a case-control study of risk factors for homicide and suicide in 3 large metropolitan areas of the United States. DESIGN: Matched case-control study including 388 homicide cases, 438 suicide cases, and equal numbers of controls matched for age, sex, race, neighborhood, and county. Data were analyzed by means of conditional logistic regressions in which other potential risk factors for violent death were also considered. OUTCOME AND EXPOSURE MEASURES: Homicide and suicide victims were identified from medical examiner reports in Shelby County, Tennessee; King County, Washington; and Cuyahoga County, Ohio. Structured interviews were conducted with proxy respondents close to the decedents to obtain information about alcohol or illicit drug use, and history of alcohol-related hospitalization or trouble at work because of drinking by the subject. Data about alcohol use by others living in the same house as the subject were also obtained. RESULTS: The risks of homicide and suicide associated with alcohol or illicit drug use were elevated, as were the risks of violent death associated with several indicators of chronic alcohol abuse. In addition, nondrinkers living in a home with alcohol users were at increased risk of homicide (odds ratio, 1.7; 95% confidence interval, 0.98-3.0), and non-drug-using individuals residing in homes with illicit drug users were at greatly increased risk of homicide (odds ratio, 11.3; 95% confidence interval, 4.4-28.8). CONCLUSIONS: Alcohol and illicit drug use appear to be associated with an increased risk of violent death. The risk of homicide was increased for non-substance-abusing individuals living in households in which other members abused alcohol or drugs. The concept of the individual at risk of homicide should be broadened to include not only the abuser but also those who may be at risk because of their exposure to others.

Risk factors for violent death of women in the home.

OBJECTIVES: To determine risk factors for violent death of women in the home, and particularly, to assess the strength and direction of any association between domestic violence or keeping firearms and homicide or suicide in the home. METHODS: Subgroup analysis of a large population-based case-control study database was performed, defining cases as all homicides and suicides occurring in the homes of female victims in 3 metropolitan counties: Shelby County, Tennessee; King County, Washington; and Cuyahoga County, Ohio. Randomly selected control subjects were matched to the victims by neighborhood, sex, race, and age range. Exposures to potential risk factors were ascertained by interviewing a proxy for the victim 3 to 6 weeks after the violent death occurred. These answers were compared with those obtained from controls using matched-pairs methods. RESULTS: All cases (n = 266) were identified in the 3-county area, including 143 homicides and 123 suicides, during a 5-year period. Matching controls (n = 266) were also identified. Firearms were involved in 46% of the homicides and 42% of the suicides. Independent risk factors for suicide in the home included a history of mental illness (odds ratio [OR], 258.8; 95% confidence interval [CI], 18.2-3679.8), living alone (OR, 13.4; 95% CI, 2.0-87.8), and having 1 or more guns in the home (OR, 4.6; 95% CI, 1.2-17.5). Independent risk factors for homicide included living alone (OR, 5.1; 95% CI, 2.0-13.2), illicit drug use by any member of the household (OR, 4.9; 95% CI, 1.3-15.9), prior domestic violence (OR, 4.0; 95% CI, 1.5-10.5), 1 or more guns in the home (OR, 3.4; 95% CI, 1.6-7.1), and previous arrest of any member of the household (OR, 3.0; 95% CI, 1.3-6.6). The increased risk of homicide associated with domestic violence, firearms, or illicit drugs was attributable to the homicides at the hands of a spouse, intimate acquaintance, or close relative. CONCLUSIONS: Among women, mental illness and living alone increase the risk of suicide in the home, and household use of illicit drugs and prior domestic violence increase the risk of homicide. Instead of conferring protection, keeping a gun in the home is associated with increased risk of both suicide and homicide of women. Household use of illicit drugs, domestic violence, and readily available firearms place women at particularly high risk of homicide at the hands of a spouse, an intimate acquaintance, or a close relative. Many factors place women at increased risk of violent death in the home. Community- and clinic-based interventions should target those with identifiable risk factors.