Addition of 25-hydroxyvitamin D levels to the Deyo-Charlson Comorbidity Index improves 90-day mortality prediction in critically ill patients.

BACKGROUND: The Deyo-Charlson Comorbidity Index (DCCI) has low predictive value in the intensive care unit (ICU). Our goal was to determine whether addition of 25-hydroxyvitamin D (25OHD) levels to the DCCI improved 90-day mortality prediction in critically ill patients. METHODS: Plasma 25OHD levels, DCCI, and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were assessed within 24 h of admission in 310 ICU patients. Receiver operating characteristic curves of the prediction scores, without and with the addition of 25OHD levels, for 90-day mortality were constructed and the areas under the curve (AUC) were compared for equality. RESULTS: Mean (standard deviation) plasma 25OHD levels, DCCI, and APACHE II score were 19 (SD 8) ng/mL, 4 (SD 3), and 17 (SD 9), respectively. Overall 90-day mortality was 19 %. AUC for DCCI vs. DCCI + 25OHD was 0.68 (95 % CI 0.58-0.77) vs. 0.75 (95 % CI 0.67-0.83); p < 0.001. AUC for APACHE II vs. APACHE II + 25OHD was 0.81 (95 % CI 0.73-0.88) vs. 0.82 (95 % CI 0.75-0.89); p < 0.001. There was a significant difference between the AUC for DCCI + 25OHD and APACHE II + 25OHD (p = 0.04) but not between the AUC for DCCI + 25OHD and APACHE II (p = 0.12). CONCLUSIONS: In our cohort of ICU patients, the addition of 25OHD levels to the DCCI improved 90-day mortality prediction compared to the DCCI alone. Moreover, the predictive capability of DCCI + 25OHD was comparable to that of APACHE II. Future prospective studies are needed to validate our findings and to determine whether the use of DCCI + 25OHD can influence clinical decision-making.

Genetic determinants of cutaneous melanoma predisposition.

In the last 2 decades, advances in genomic technologies and molecular biology have accelerated the identification of multiple genetic loci that confer risk for cutaneous melanoma. The risk alleles range from rarely occurring, high-risk variants with a strong familial predisposition to low-risk to moderate-risk variants with modest melanoma association. Although the high-risk alleles are limited to the CDKN2A and CDK4 loci, the authors of recent genome-wide association studies have uncovered a set of variants in pigmentation loci that contribute to low risk. A biological validation of these new findings would provide greater understanding of the disease. In this review we describe some of the important risk loci and their association to risk of developing cutaneous melanoma and also address the current clinical challenges in CDKN2A genetic testing.

Rite of passage? Why young adults become uninsured and how new policies can help, 2009 update.

Young adults ages 19 to 29 are one of the largest segments of the U.S. population without health insurance: 13.2 million, or 29 percent, lacked coverage in 2007. They often lose coverage at age 19 or upon high school or college graduation: nearly two of five (38%) high school graduates who do not enroll in college and one-third of college graduates are uninsured for a time during the first year after graduation. Twenty-six states have passed laws to expand coverage of dependents to young adults under parents' insurance policies. Congressional proposals to reform the health system could help uninsured young adults gain coverage and prevent others from losing it. This is the seventh edition of Rite of Passage, first published by The Commonwealth Fund in 2003.

Rite of passage? Why young adults become uninsured and how new policies can help, 2008 update.

Young adults, ages 19 to 29, are one of the largest segments of the U.S. population without health insurance: 13.7 million lacked coverage in 2006. They often lose coverage at age 19 or upon high school or college graduation--most two of five (38%) high school graduates who do not enroll in college and one-third of college graduates are uninsured for a time during the first year after graduation. Several states have passed laws to expand coverage of dependents up to age 24 or 25 under parents' insurance policies. This policy change, in addition to two others--extending eligibility for public insurance programs beyond age 18 and ensuring that colleges require and offer coverage to full- and part-time students to have coverage--could help uninsured young adults gain coverage and prevent others from losing it. This issue brief, the sixth in a series, updates an earlier version of Rite of Passage

Who pays for health care when workers are uninsured?

Employer-sponsored insurance coverage forms the backbone of the U.S. health insurance system, yet there are crucial weaknesses that have contributed to a growing number of uninsured Americans. Ultimately, the lack of employer-based coverage generates public costs in the form of taxpayer bills to fund public insurance or uncompensated care programs for care that would otherwise be paid for through insurance. This report quantifies those costs, using data from the Medical Expenditure Panel Surveys to estimate public program spending and uncompensated care costs for uninsured workers and their dependents. In 2004, uninsured and publicly insured workers and their dependents accounted for $45 billion in public costs. This includes $33 billion associated with public program insurance costs and $12 billion in uncompensated care costs. Public costs associated with uninsured and publicly insured workers and their dependents were 45 percent greater in 2004 than in 1999. All costs are reported in 2004 dollars.

The widening health care gap between high- and low-wage workers.

Rising health care costs affect everyone, but pose a particular problem for low-wage workers and their families. Few of these workers are eligible for public insurance programs or can afford to purchase private insurance, and they are less likely than high-wage workers to work for companies offering health coverage. Using data from the Medical Expenditure Panel Survey, this report finds that, between 1996 and 2003, low-wage workers were more likely than high-wage workers to be uninsured and to spend a proportionally higher share of family income on out-of-pocket health costs. They were less likely to have a usual source of care, less likely to have received preventive services, used fewer health care services overall, and were less likely to use the latest generation of medical technologies (e.g., prescription drugs approved within the prior 20 years). They were also more likely to report worse general and mental health than high-wage workers.

Rite of passage? Why young adults become uninsured and how new policies can help.

Young adults (ages 19 to 29) are one of the largest segments of the U.S.population without health insurance: 13.3 million lacked coverage in 2005. Young adults often lose coverage at age 19 or upon high school or college graduation. Nearly two of five college graduates and one-half of high school graduates who do not enroll in college will be uninsured for a time during the first year after graduation. Several states have passed laws to expand coverage of dependent young adults up to age 24 or 25 under parents' insurance policies. Three policy changes could further help uninsured young adults gain coverage and prevent others from losing it: extending eligibility for public insurance programs beyond age 18; extending dependents' eligibility for their parents' private coverage beyond age 18 or 19; and ensuring that colleges require full- and part-time students to have coverage, and that colleges offer coverage to them.

Socioeconomic status as an independent predictor of physiological biomarkers of cardiovascular disease: evidence from NHANES.

BACKGROUND: C-reactive protein, homocysteine, cholesterol, and fibrinogen are known to vary by socioeconomic status (SES). Using a nationally representative study, we examined whether these factors vary independently of all other known risk factors, such as diet, exercise, and genetic predisposition. METHODS: We analyzed the 1999-2002 National Health Examination and Nutrition Survey using logistic regression models. RESULTS: We found that high-density lipoprotein cholesterol blood levels increase with income and educational attainment after controlling all known risk factors for elevated cholesterol (e.g., diet, exercise, and family history). Blood levels of C-reactive protein are inversely associated with income and education. Homocysteine blood levels are inversely associated with income even after controlling for blood folate level. A non-significant inverse relationship between homocysteine levels and educational attainment was also observed. Blood levels of low-density lipoprotein cholesterol and fibrinogen were not significantly associated with income or education. CONCLUSIONS: Levels of "good" (high density lipoprotein) cholesterol increase with income and education even after controlling for factors known to place people at risk of high cholesterol. Stress differences by social class may play a role.

Rite of passage? Why young adults become uninsured and how new policies can help.

Young adults (ages 19 to 29) are one of the largest and fastest-growing segments of the U.S. population without health insurance: more than 13 million lacked coverage in 2003, an increase of 2.2 million since 2000. Young adults often lose coverage under their parents' policies at age 19, or when they graduate from high school or college. Nearly two of five college graduates and one-half of high school graduates who do not go on to college will be uninsured for a period during the first year after graduation. Three policy changes could extend coverage to uninsured young adults and prevent others from losing it: extending eligibility for dependents under private coverage through age 23; extending eligibility for Medicaid and the State Children's Health Insurance Program to age 23; and ensuring that colleges and universities require full-and part-time students to have insurance, and that they offer coverage to both.