The relation of body mass index and abdominal adiposity with dyslipidemia in 27 general populations of the WHO MONICA Project.

BACKGROUND AND AIMS: The association between adiposity measures and dyslipidemia has seldom been assessed in a multipopulational setting. METHODS AND RESULTS: 27 populations from Europe, Australia, New Zealand and Canada (WHO MONICA project) using health surveys conducted between 1990 and 1997 in adults aged 35-64 years (n = 40,480). Dyslipidemia was defined as the total/HDL cholesterol ratio >6 (men) and >5 (women). Overall prevalence of dyslipidemia was 25% in men and 23% in women. Logistic regression showed that dyslipidemia was strongly associated with body mass index (BMI) in men and with waist circumference (WC) in women, after adjusting for region, age and smoking. Among normal-weight men and women (BMI<25 kg/m(2)), an increase in the odds for being dyslipidemic was observed between lowest and highest WC quartiles (OR = 3.6, p < 0.001). Among obese men (BMI ≥ 30), the corresponding increase was smaller (OR = 1.2, p = 0.036). A similar weakening was observed among women. Classification tree analysis was performed to assign subjects into classes of risk for dyslipidemia. BMI thresholds (25.4 and 29.2 kg/m(2)) in men and WC thresholds (81.7 and 92.6 cm) in women came out at first stages. High WC (>84.8 cm) in normal-weight men, menopause in women and regular smoking further defined subgroups at increased risk. CONCLUSION: standard categories of BMI and WC, or their combinations, do not lead to optimal risk stratification for dyslipidemia in middle-age adults. Sex-specific adaptations are necessary, in particular by taking into account abdominal obesity in normal-weight men, post-menopausal age in women and regular smoking in both sexes.

Factors associated with the technical performance of colonoscopy: An EPAGE Study.

BACKGROUND: Variations in colonoscopy practice exist, which may be related to healthcare quality. AIMS: To determine factors associated with three performance indicators of colonoscopy: complete colonoscopy, adenomatous polyp diagnosis, and duration. PATIENTS: Consecutive patients referred for colonoscopy from 21 centres in 11 countries. METHODS: This prospective observational study used multiple variable regression analyses to identify determinants of the quality indicators. RESULTS: Six thousand and four patients were included in the study. Patients from private, open-access centres (odds ratio: 3.17, 95% confidence interval: 1.87-5.38) were more likely to have a complete colonoscopy than patients from public, gatekeeper centres. Patients from centres where over 50% of the endoscopists were of senior rank were roughly twice as likely to have an adenoma diagnosed, and longer average withdrawal duration (odds ratio: 1.08, 95% confidence interval: 1.07-1.09) was associated with more frequent adenoma diagnoses. Patients who had difficulty during colonoscopy had longer durations to caecum (time ratio: 2.87, 95% confidence interval: 2.72-3.01) and withdrawal durations (time ratio: 1.26, 95% confidence interval: 1.18-1.33) than patients who had no difficulties. CONCLUSIONS: Multiple factors have been identified as being associated with key quality indicators. The non-modifiable factors permit the identification of patients who may be at greater risk of not having quality colonoscopy, while changes to the modifiable factors may help improve the quality of colonoscopy.

The appropriateness of colonoscopy: a multi-center, international, observational study.

OBJECTIVE: To examine the appropriateness and necessity of colonoscopy across Europe. DESIGN: Prospective observational study. SETTING: A total of 21 gastrointestinal centers from 11 countries. PARTICIPANTS: Consecutive patients referred for colonoscopy at each center. INTERVENTION: Appropriateness criteria developed by the European Panel on the Appropriateness of Gastrointestinal Endoscopy, using the RAND appropriateness method, were used to assess the appropriateness of colonoscopy. MAIN OUTCOME MEASURE: Appropriateness of colonoscopy. RESULTS: A total of 5213 of 6004 (86.8%) patients who underwent diagnostic colonoscopy and had an appropriateness rating were included in this study. According to the criteria, 20, 26, 27, or 27% of colonoscopies were judged to be necessary, appropriate, uncertain, or inappropriate, respectively. Older patients and those with a major illness were more likely to have an appropriate or necessary indication for colonoscopy as compared to healthy patients or patients who were 45-54 years old. As compared to screening patients, patients who underwent colonoscopy for iron-deficiency anemia [OR: 30.84, 95% CI: 19.79-48.06] or change in bowel habits [OR: 3.69, 95% CI: 2.74-4.96] were more likely to have an appropriate or necessary indication, whereas patients who underwent colonoscopy for abdominal pain [OR: 0.64, 95% CI: 0.49-0.83] or chronic diarrhea [OR: 0.54, 95% CI: 0.40-0.75] were less likely to have an appropriate or necessary indication. CONCLUSIONS: This study identified significant proportions of inappropriate colonoscopies. Prospective use of the criteria by physicians referring for or performing colonoscopies may improve appropriateness and quality of care, especially in younger patients and in patients with nonspecific symptoms.

Appropriate treatment for Crohn's disease: methodology and summary results of a multidisciplinary international expert panel approach--EPACT.

BACKGROUND/AIMS: For many therapeutic decisions in Crohn's disease (CD), high-grade evidence is lacking. To assist clinical decision-making, explicit panel-based appropriateness criteria were developed by an international, multidisciplinary expert panel. METHODS: 10 gastroenterologists, 3 surgeons and 2 general practitioners from 12 European countries assessed the appropriateness of therapy for CD using the RAND Appropriateness Method. Their assessment was based on the study of a recent literature review of the subject, combined with their own expert clinical judgment. Panelists rated clinical indications and treatment options using a 9-point scale (1 = extremely inappropriate; 9 = extremely appropriate). These scenarios were then discussed in detail at the panel meeting and re-rated. Median ratings and disagreement were used to aggregate ratings into three assessment categories: appropriate (A), uncertain (U) and inappropriate (I). RESULTS: 569 specific indications were rated, dealing with 9 clinical presentations: mild/moderate luminal CD (n = 104), severe CD (n = 126), steroid-dependent CD (n = 25), steroid-refractory CD (n = 37), fistulizing CD (n = 49), fibrostenotic CD (n = 35), maintenance of medical remission of CD (n = 84), maintenance of surgical remission (n = 78), drug safety in pregnancy (n = 24) and use of infliximab (n = 7). Overall, 146 indications (26%) were judged appropriate, 129 (23%) uncertain and 294 (52%) inappropriate. Frank disagreement was low (14% overall) with the greatest disagreement (54% of scenarios) being observed for treatment of steroid-refractory disease. CONCLUSIONS: Detailed explicit appropriateness criteria for the appropriate use of therapy for CD were developed for the first time by a European expert panel. Disease location, severity and previous treatments were the main factors taken into account. User-friendly access to EPACT criteria is available via an Internet site, www.epact.ch, allowing prospective evaluation and improvement of appropriateness of current CD therapy.

Current sedation and monitoring practice for colonoscopy: an International Observational Study (EPAGE).

BACKGROUND AND STUDY AIMS: Sedation and monitoring practice during colonoscopy varies between centers and over time. Knowledge of current practice is needed to ensure quality of care and help focus future research. The objective of this study was to examine sedation and monitoring practice in endoscopy centers internationally. PATIENTS AND METHODS: This observational study included consecutive patients referred for colonoscopy at 21 centers in 11 countries. Endoscopists reported sedation and monitoring practice, using a standard questionnaire for each patient. RESULTS: 6004 patients were included in this study, of whom 53 % received conscious/moderate sedation during colonoscopy, 30 % received deep sedation, and 17 % received no sedation. Sedation agents most commonly used were midazolam (47 %) and opioids (33 %). Pulse oximetry was done during colonoscopy in 77 % of patients, blood pressure monitoring in 34 %, and electrocardiography in 24 %. Pulse oximetry was most commonly used for moderately sedated patients, while blood pressure monitoring and electrocardiography were used predominantly for deeply sedated patients. Sedation and monitoring use ranged from 0 % to 100 % between centers. Oxygen desaturation (

Gastroenterologists overestimate the appropriateness of colonoscopies they perform: an international observational study.

BACKGROUND AND STUDY AIM: Little is known about how gastroenterologists perceive the appropriateness of colonoscopies they perform. The objective of this study was to compare the appropriateness and necessity of colonoscopies as assessed by an expert panel and by the gastroenterologists performing the colonoscopies. METHODS: This observational study included 21 centers in 11 countries. Patients referred for colonoscopy were consecutively included. Appropriateness and necessity of colonoscopies were independently rated on a 9-point scale by the gastroenterologists performing them and by an expert panel using a validated method (RAND). The differences between the ratings from the two groups were examined. RESULTS: 6004 patients were included in the study. Comparisons of ratings were possible for 5381 (89.6 %) patients. The gastroenterologists' mean appropriateness rating was 7.2 +/- 1.7, and the panel's mean appropriateness rating was 5.4 +/- 2.3 ( P < 0.001). The percentages of indications rated inappropriate, uncertain, appropriate, and necessary were 4.1 %, 23.8 %, 14.2 %, and 58.0 % for the gastroenterologists and 27.2 %, 26.7 %, 25.0 %, and 21.1 % for the panel, respectively. Agreement between the two groups' ratings was poor (28.8 %, kappa = 0.11). Differences between the two groups' ratings decreased with increasing patient age, decreasing health status, and decreasing expertise level of the referring physician. However, the gastroenterologists produced consistently higher ratings. CONCLUSIONS: Compared with an expert panel, gastroenterologists tend to overestimate the appropriateness of colonoscopies they perform. Except for well-delineated reasons, participating gastroenterologists weighed patient characteristics differently from the panel when judging appropriateness. Ways to increase the prospective use of appropriateness criteria in order to improve appropriateness and reduce overuse of colonoscopies should be examined further.

Prevalence of hyperuricemia and relation of serum uric acid with cardiovascular risk factors in a developing country.

BACKGROUND: The prevalence of hyperuricemia has rarely been investigated in developing countries. The purpose of the present study was to investigate the prevalence of hyperuricemia and the association between uric acid levels and the various cardiovascular risk factors in a developing country with high average blood pressures (the Seychelles, Indian Ocean, population mainly of African origin). METHODS: This cross-sectional health examination survey was based on a population random sample from the Seychelles. It included 1011 subjects aged 25 to 64 years. Blood pressure (BP), body mass index (BMI), waist circumference, waist-to-hip ratio, total and HDL cholesterol, serum triglycerides and serum uric acid were measured. Data were analyzed using scatterplot smoothing techniques and gender-specific linear regression models. RESULTS: The prevalence of a serum uric acid level >420 micromol/L in men was 35.2% and the prevalence of a serum uric acid level >360 micromol/L was 8.7% in women. Serum uric acid was strongly related to serum triglycerides in men as well as in women (r = 0.73 in men and r = 0.59 in women, p < 0.001). Uric acid levels were also significantly associated but to a lesser degree with age, BMI, blood pressure, alcohol and the use of antihypertensive therapy. In a regression model, triglycerides, age, BMI, antihypertensive therapy and alcohol consumption accounted for about 50% (R2) of the serum uric acid variations in men as well as in women. CONCLUSIONS: This study shows that the prevalence of hyperuricemia can be high in a developing country such as the Seychelles. Besides alcohol consumption and the use of antihypertensive therapy, mainly diuretics, serum uric acid is markedly associated with parameters of the metabolic syndrome, in particular serum triglycerides. Considering the growing incidence of obesity and metabolic syndrome worldwide and the potential link between hyperuricemia and cardiovascular complications, more emphasis should be put on the evolving prevalence of hyperuricemia in developing countries.

Do explicit appropriateness criteria enhance the diagnostic yield of colonoscopy?

BACKGROUND AND STUDY AIMS: Appropriateness of use of colonoscopy is an important issue in health care in the quest to improve quality of care while at the same time containing costs. This prospective study examined whether detailed and explicit appropriateness criteria significantly improve the diagnostic yield of colonoscopy. PATIENTS AND METHODS: Consecutive patients referred for diagnostic colonoscopy at five centers (one university hospital and its outpatient department, two district hospitals, and two gastroenterology practices) were prospectively studied over a 17-month period. The appropriateness of the indications for these colonoscopies was assessed using explicit Swiss criteria developed by the Rand Corporation/University of California at Los Angeles (RAND/UCLA) panel method, and the relationship between appropriateness of use and the presence of clinically relevant endoscopic lesions was analysed. RESULTS: 1188 patients were included in the study. Indications for 1144 (96.3 %) of the colonoscopies could be evaluated using explicit criteria; 64.1 % of the colonoscopies were judged appropriate, 13.3 % uncertain and 22.6 % inappropriate. Significant endoscopic lesions were found in 23.8 % of the colonoscopies. Colonoscopies judged appropriate or uncertain yielded significantly more relevant lesions than did those judged to be inappropriate (25.6 % vs. 17.4 %; P = 0.007). Of 51 colon cancers, all but one were found in colonoscopies judged to be appropriate or uncertain. In a multivariate analysis, the diagnostic yield of colonoscopy was significantly influenced by appropriateness, patient gender and treatment setting. CONCLUSIONS: The use of detailed and explicit appropriateness criteria for colonoscopy significantly enhances the identification of relevant lesions and in particular of colon cancer. The use of such criteria could therefore improve patient selection for colonoscopy and thus contribute to efforts aimed at enhancing the quality and efficiency of care.

Body mass index, abdominal adiposity and blood pressure: consistency of their association across developing and developed countries.

BACKGROUND: Obesity is increasing worldwide because developing countries are adopting Western high-fat foods and sedentary lifestyles. In parallel, in many of them, hypertension is rising more rapidly, particularly with age, than in Western countries. OBJECTIVE: To assess the relationship between adiposity and blood pressure (BP) in a developing country with high average BP (The Seychelles, Indian Ocean, population mainly of African origin) in comparison to a developed country with low average BP (Switzerland, population mainly of Caucasian origin). DESIGN: Cross-sectional health examination surveys based on population random samples. SETTING: The main Seychelles island (Mahé) and two Swiss regions (Vaud-Fribourg and Ticino). SUBJECTS: Three thousand one hundred and sixteen adults (age range 35-64) untreated for hypertension. MEASUREMENTS: Body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR), systolic and diastolic blood pressure (SBP and DBP, mean of two measures). METHODS: Scatterplot smoothing techniques and gender-specific linear regression models. RESULTS: On average, SBP and DBP were found to increase linearly over the whole variation range of BMI, WHR and WC. A modest, but statistically significant linear association was found between each indicator of adiposity and BP levels in separate regression models controlling for age. The regression coefficients were not significantly different between the Seychelles and the two Swiss regions, but were generally higher in women than in men. For the latter, a gain of 1.7 kg/m(2) in BMI, of 4.5 cm in WC or of 3.4% in WHR corresponded to an elevation of 1 mmHg in SBP. For women, corresponding figures were 1.25 kg/m(2), 2.5 cm and 1.8% respectively. Regression coefficients for age reflected a higher effect of this variable on both SBP and DBP in the Seychelles than in Switzerland. CONCLUSION: These findings suggest a stable linear relation of adiposity with BP, independent of age and body fat distribution, across developed and developing countries. The more rapid increase of BP with age observed in the latter countries are likely to reflect higher genetic susceptibility and/or higher cumulative exposure to another risk factor than adiposity.

Depressive symptoms as a predictor of 6-month outcomes and services utilization in elderly medical inpatients.

BACKGROUND: Depressive symptoms have been associated with higher mortality in hospitalized elderly persons, but few data are available associating depressive symptoms with other outcomes. OBJECTIVE: To determine the association between depressive symptoms and the risk of hospital readmission, nursing home admission, and death as well as inpatient services utilization during a 6-month follow-up period in a cohort of elderly medical inpatients. METHODS: We enrolled 401 patients, 75 years and older, admitted to the internal medicine service of an academic hospital in Lausanne, Switzerland. Data on demographic, medical, physical, social, and mental status were collected on admission. Depressive symptoms were defined as a score of 6 or higher on the Geriatric Depression Scale short form. Follow-up data were gathered from the centralized billing system (hospital and nursing home admissions) and from proxies (in cases of death). RESULTS: In bivariate analysis, depressive symptoms were associated with an increased risk of hospital readmission, nursing home placement, and death. After adjustment for demographic, socioeconomic, and functional status and comorbidity, depressive symptoms remained associated with an increased risk of hospital readmission (adjusted hazard ratio, 1.50; 95% confidence interval, 1.03-2.17; P =.03). In addition, depressive symptoms were associated with increased average costs of both acute and rehabilitation services, resulting in higher overall costs of inpatient services. ($175.70 vs $126.00; P<.001). This association remained after adjusting for differences in functional status, comorbidity, and living situation, although it was just short of statistical significance (P =.07). CONCLUSIONS: Elderly medical inpatients with depressive symptoms were more likely than those without to be readmitted and had higher inpatient services utilization during the follow-up period, independent of functional and health status. These results emphasize the need for interventions directed at improving management of depressive symptoms, given the low recognition and treatment rates of this problem in elderly populations.

Helicobacter pylori eradication treatment does not benefit patients with nonulcer dyspepsia.

OBJECTIVES: The aim of this study was to assess the still controversial role of treatment of Helicobacter pylori (H. pylori) infection in patients with nonulcer dyspepsia. METHODS: We conducted a double-blind, randomized, placebo-controlled, multicenter trial comparing the efficacy of 7 days of eradication treatment (lansoprazole 15 mg b.i.d., amoxicillin I g b.i.d., and clarithromycin 500 mg b.i.d.) with a control treatment (lansoprazole 15 mg b.i.d. and placebo) in H. pylori-infected patients with nonulcer dyspepsia. 13C breath tests were performed at baseline and during follow-up. We assessed patient symptoms, health status (based on the SF-12 questionnaire), patient satisfaction, drug consumption, health care consultation behavior, and absenteeism related to dyspepsia over a 1-yr period. RESULTS: A total of 74 patients randomized to eradication treatment and 70 patients randomized to placebo were compared. The rate of eradication of H. pylori infection was 75% in the active treatment group and 4% in the placebo group (p < 0.005). The symptom score improved to a similar extent in the group receiving active treatment (-4.0; 95% CI = -5.0 to -3.0) and placebo (-3.6; 95% CI = -4.5 to -2.7). Treatment response was not related to the severity or duration of initial symptoms or to the severity of gastritis on histology. Quality of life scores were comparable at 12 months. There was no significant difference in dyspepsia-related absenteeism or satisfaction with management of NUD. Patients receiving active treatment were more likely not to have had to use any dyspepsia treatment over the 12 months (60.8% vs 44.3%; p = 0.047). CONCLUSIONS: This study did not demonstrate any substantial benefit of curing H. pylori infection in patients with nonulcer dyspepsia. The study adds further evidence that H. pylori is not the main pathogenetic or therapeutic target in these patients.

Body mass index: comparing mean values and prevalence rates from telephone and examination surveys.

BACKGROUND: Cost effective means of assessing the levels of risk factors in the population have to be defined in order to monitor these factors over time and across populations. This study is aimed at analyzing the difference in population estimates of the mean levels of body mass index (BMI) and the prevalences of overweight, between health examination survey and telephone survey. METHODS: The study compares the results of two health surveys, one by telephone (N=820) and the other by physical examination (N=1318). The two surveys, based on independent random samples of the population, were carried out over the same period (1992-1993) in the same population (canton of Vaud, Switzerland). RESULTS: Overall participation rates were 67% and 53% for the health interview survey (HIS) and the health examination survey (HES) respectively. In the HIS, the reporting rate was over 98% for weight and height values. Self-reported weight was on average lower than measured weight, by 2.2 kg in men and 3.5 kg in women, while self-reported height was on average greater than measured height, by 1.2 cm in men and 1.9 cm in women. As a result, in comparison to HES, HIS led to substantially lower mean levels of BMI, and to a reduction of the prevalence rates of obesity (BMI>30 kg/m(2)) by more than a half. These differences are larger for women than for men. CONCLUSION: The two surveys were based on different sampling procedures. However, this difference in design is unlikely to explain the systematic bias observed between self-reported and measured values for height and weight. This bias entails the overall validity of BMI assessment from telephone surveys.

Depressed mood in a cohort of elderly medical inpatients: prevalence, clinical correlates and recognition rate.

The objectives of this prospective cohort study were to 1) determine the prevalence of depressed mood, 2) identify the characteristics associated with it, and 3) evaluate the recognition rate of depressed mood by clinicians. The study population was a cohort of 401 elderly patients, aged 75 years and older, admitted to the internal medicine service of a tertiary care academic medical center in Western Switzerland over six months. We excluded patients with severe cognitive impairment, terminal disease or those living in a nursing home. Data on demographics, medical, physical, social and mental status were collected upon admission. Presence of depressed mood was defined as a score > or = 6 on the Geriatric Depression Scale (GDS), short form (15-item). An independent reviewer performed a discharge summary abstraction to assess recognition rate. Subjects' mean age was 82.4 years, 60.9% were women. Overall, 90 patients (22.40%) had an abnormal GDS score (> or =6). Compared to those without a depressed mood, these subjects were (all p<0.05) older (83.5 vs 82.0 years), more frequently living alone (66.7 vs 55.0%), dependent in both basic activities of daily living (BADL) and instrumental ADL (48.9 vs 36.0%, and 91.1 vs 84.9%, respectively), and cognitively impaired (47.8 vs 27.7% with MMSE score<24). In addition, they had more comorbidities (Charlson index 1.6 vs 1.2). In multivariate analysis, an independent association remains for subjects living alone (OR 1.8, 95%CI 1.1-3.0), with cognitive impairment (OR 1.9, 95%CI 1.1-3.2), and comorbidities (OR 1.3 per point, 95%CI 1.1-1.5). Detection rate during the index hospitalization was only 16.7% (15/90). In conclusion, depressed mood was frequent but rarely detected in this population. These findings emphasize the need to improve screening efforts, and to develop additional strategies such as using a pre-screening question to enhance clinical recognition.

One-year prevalence of low back pain in two Swiss regions: estimates from the population participating in the 1992-1993 MONICA project.

STUDY DESIGN: A cross-sectional survey was performed. OBJECTIVE: To estimate the extent of low back pain as a public health problem. SUMMARY OF BACKGROUND DATA: Health surveys converge on very high estimates of low back pain in general populations, but few studies have included severity criteria in their definition and conclusions. Because it is unlikely that interventions will influence the prevalence of minimal and infrequent symptoms, greater attention should be paid to characteristics of low back pain that indicate some impact on the life of survey respondents. METHODS: Two regions participated in the MONICA (MONitoring of trends and determinants in CArdiovascular disease) project in Switzerland. Participants randomly selected from the general population completed a standard self-administered questionnaire on cardiovascular risk factors. A special section on low back pain was added in the third (1992-1993) MONICA survey and completed by 3227 participants. RESULTS: A regional difference found in the 12-month prevalence rate disappeared with the inclusion of severity criteria. Low back pain over more than seven cumulated days was reported among men by 20.2% (age range, 25-34 years) to 28.5% (age range, 65-74 years), respectively, among women by 31.1% to 38.5%. Similar rates of reduction in activity (professional, housekeeping, and leisure time) and medical consultation (conventional and nonconventional) motivated by low back pain characterized the two participating regions. The cumulative duration of pain was related to all the indicators showing the impact of low back pain on everyday life. CONCLUSIONS: Determining the cumulative duration of low back pain over the preceding year is a straightforward task, and a cutoff at 1 week seems appropriate for distinguishing between low- and high-impact low back pain.

Is the diagnostic yield of upper GI endoscopy improved by the use of explicit panel-based appropriateness criteria?

BACKGROUND: Increasing the appropriateness of use of upper gastrointestinal (GI) endoscopy is important to improve quality of care while at the same time containing costs. This study explored whether detailed explicit appropriateness criteria significantly improve the diagnostic yield of upper GI endoscopy. METHODS: Consecutive patients referred for upper GI endoscopy at 6 centers (1 university hospital, 2 district hospitals, 3 gastroenterology practices) were prospectively included over a 6-month period. After controlling for disease presentation and patient characteristics, the relationship between the appropriateness of upper GI endoscopy, as assessed by explicit Swiss criteria developed by the RAND/UCLA panel method, and the presence of relevant endoscopic lesions was analyzed. RESULTS: A total of 2088 patients (60% outpatients, 57% men) were included. Analysis was restricted to the 1681 patients referred for diagnostic upper GI endoscopy. Forty-six percent of upper GI endoscopies were judged to be appropriate, 15% uncertain, and 39% inappropriate by the explicit criteria. No cancer was found in upper GI endoscopies judged to be inappropriate. Upper GI endoscopies judged appropriate or uncertain yielded significantly more relevant lesions (60%) than did those judged to be inappropriate (37%; odds ratio 2.6: 95% CI [2.2, 3.2]). In multivariate analyses, the diagnostic yield of upper GI endoscopy was significantly influenced by appropriateness, patient gender and age, treatment setting, and symptoms. CONCLUSIONS: Upper GI endoscopies performed for appropriate indications resulted in detecting significantly more clinically relevant lesions than did those performed for inappropriate indications. In addition, no upper GI endoscopy that resulted in a diagnosis of cancer was judged to be inappropriate. The use of such criteria improves patient selection for upper GI endoscopy and can thus contribute to efforts aimed at enhancing the quality and efficiency of care. (Gastrointest Endosc 2000;52:333-41).

Dyslipidemia and abdominal obesity: an assessment in three general populations.

Several studies show a relationship between abdominal obesity and cardiovascular diseases, partially mediated through an altered metabolism of dyslipidemia. The present study was aimed at testing the robustness of this association across three contrasted populations and at assessing the performances of abdominal obesity as a screening tool for dyslipidemia. Data were drawn from three population health surveys recently conducted in two regions of a developed country (Switzerland, mostly of Caucasian origin, n = 2650) and in a less developed country (Seychelles, Indian Ocean, mostly of black descent, n = 806). Dyslipidemia was defined as a ratio of total cholesterol to high-density lipoprotein cholesterol (TC-HDL) greater than 5. Two anthropometric circumference measurements, waist-to-hip ratio (WHR) and waist circumference (WC), were used to define abdominal obesity either as WHR >/= 0.9 in men and WHR >/= 0.8 in women or as WC >/= 94 cm and WC >/= 80 cm, respectively. A consistent direct association between abdominal obesity and dyslipidemia (odds ratios varying from 1.85 to 4.56) was found in the three populations, independently of gender, age, body mass index, blood pressure, and smoking. This consistency across ethnicities and environments strengthens the hypothesis of a common etiopathological mechanism. The sensitivity for detecting dyslipidemia was generally higher for abdominal obesity, based on either WHR or WC, than for criteria based on the other risk factors under study. In addition, the sensitivity was higher in the study populations with a low prevalence of dyslipidemia (Swiss women and Seychellois of both sexes) than in the others. These findings support that WHR and WC may be useful as simple and inexpensive screening tools to select individuals eligible for more sophisticated and costly serum lipid determinations, especially in developing countries.

Characteristics associated with inappropriate hospital use in elderly patients admitted to a general internal medicine service.

Our objective was to identify patient characteristics associated with inappropriate hospital days in a cohort of elderly medical inpatients. This prospective cohort study included a total of 196 patients aged 75 years and older, who were consecutively admitted over eight months to the internal medicine service of a regional, non-academic public hospital located in a rural area of Western Switzerland. Patients with severe cognitive impairment, terminal disease, or previously living in a nursing home were excluded. Data on demographics, medical, physical, social and mental status were collected at admission. A blinded hospitalization review was performed concurrently using a modified version of the Appropriateness Evaluation Protocol (AEP). Subjects' mean age was 82.4 years; 63.3% were women. Median length of stay was 8 days. Overall, 68 patients (34.7%) had at least one inappropriate day during their stay, including 18 patients (9.2%) whose hospital admission and entire stay were considered inappropriate. Most inappropriate days were due to discharge delays (87.10%), primarily to nursing homes (59.30%). Univariate analysis showed that subjects with inappropriate days were more likely to be living alone (69.1 vs 48.4%, p=0.006), and receiving formal in-home help (48.5 vs 32.8%, p=0.031). In addition, they were more impaired in basic and instrumental activities of daily living (BADLs, and IADLs, p<0.001 and p=0.015, respectively), and more frequently had a depressed mood [29.4 vs 10.9%, p=0.001 with a score > 6 at the Geriatric Depression Scale (GDS), short form]. Using multivariate analysis, independent associations remained for patients living alone (OR 2.6, 95%CI 1.2-5.8, p=0.016), those with a depressed mood (OR 2.8, 95%CI 1.1-7.3, p=0.032), with BADL dependencies (OR 1.5, 95%CI 1.2-1.8, p=0.001), and IADL dependencies (OR 1.3, 95%CI 1.0-1.6, p=0.032). Cardiovascular (OR 0.2, 95%CI 0.1-0.7, p=0.008) and pulmonary admission diagnoses (OR 0.1, 95%CI 0.0-0.7, p=0.022) were inversely associated with inappropriate hospital days. In conclusion, patients living alone, functionally impaired and showing depressive symptoms were at increased risk for inappropriate hospital days. These characteristics might permit better targeting for early discharge planning in these at-risk subjects, and contribute to avoiding premature discharge of other vulnerable elderly patients. Whether these interventions for at-risk patients will also result in prevention of hospitalization hazards, such as deconditioning and related functional decline, will require further study.