Evaluating an Electronic Health Record Intervention for Management of Heart Failure Among Veterans.

Background:We studied the feasibility of using the Veteran Health Administration's electronic health record (EHR), My HealtheVet, as an educational and monitoring tool for veterans with heart failure (HF).Methods:We enrolled 120 HF patients with a mean age (±standard deviation): 64.8 ± 9.6, range: 41-91 years. There were 105 (87.5%) non-Hispanics, 15 (12.5%) Hispanics, 91 (75.8%) whites, and 20 (16.5%) blacks, and 62 (51.7%) were married. Study participants received educational material on managing their HF and were monitored on their weight and HF symptoms weekly. Surveys on My HealtheVet use and secondary outcomes including knowledge of their illness, quality of life (QoL), and self-efficacy were conducted at baseline and 26 weeks after enrollment.Results:Among the participants, 55 (45.8%) had used My HealtheVet. The number of weeks each user responded to the weekly messages by the care coordinator ranged from 1 (4%) to 26 (100%) with a median of 8. Secondary outcome data were available for 54 patients (24 users and 30 nonusers) who participated in both baseline and 26-week surveys. There was a significant improvement in QoL (p < 0.01) among users of My HealtheVet compared with nonusers. There were no significant differences with respect to self-efficacy or HF knowledge. Use of My HealtheVet and ease in using the HealtheVet portal increased from baseline to follow-up.Conclusions:EHR-based interventions have potential for HF monitoring and case management, and may be feasible in improving QoL for patients.

Outcomes of a Mobile Phone Intervention for Heart Failure in a Minority County Hospital Population.

BACKGROUND: Chronic heart failure (HF) causes significant morbidity, mortality, and cost. Managing HF requires considerable self-management skills and self-efficacy. Little information exists about feasibility and potential impact of a mobile monitoring intervention to improve self-efficacy and quality of life (QoL) among minority patients with HF. MATERIALS AND METHODS: We developed a mobile phone-assisted case management program and tested its impact on outcomes in minority patients with HF in a 2:1 randomized controlled trial. We evaluated self-care efficacy, knowledge, behavior, and QoL at baseline and 3 months. RESULTS: We enrolled 61 participants: intervention 42, usual care 19; mean age ± SD: 55 ± 10 years; 64% male; 75% white Hispanic, 25% African American; and 56% high school education or less. Comparison of the two groups with respect to changes from baseline to 3 months showed significant differences for Self-Efficacy for Managing Chronic Disease (2.09 ± 2.32, p-value = 0.005); health distress scale (-1.1 ± 1.5, p-value = 0.017); and QoL (Role Physical, 23.6 ± 44.5, p-value = 0.042, and General Health, 11.1 ± 14.2, p-value = 0.012). CONCLUSIONS: A mobile phone-based disease management program may help improve self-care efficacy and QoL in a minority population and offers a modality to help reduce ethnic disparity.

Mobile Phone Intervention for Heart Failure in a Minority Urban County Hospital Population: Usability and Patient Perspectives.

BACKGROUND: Chronic heart failure (HF) is a complex and costly disease. Daily weight and symptom monitoring is the cornerstone of HF management. Little information exists about feasibility of a mobile monitoring intervention among minority patients with HF. METHODS: We developed and tested usability of a mobile-monitoring system in minority patients with HF in a 2:1 randomized controlled trial. We tracked usage and obtained feedback on usability and the system overall at 1, 2, and 3 months. RESULTS: Forty-two participants aged 53.0 ± 9.4 years (mean ± standard deviation) were randomized to the mobile-monitoring intervention group. They included the following: 67% males, 76% White Hispanics, 21% African Americans, and 52% with high school education or less. Over the 3-month intervention period, 26 (62%) participants used the system over 50% of the time. Overall, on a 1.0-7.0 scale for both, program satisfaction scores were excellent (mean 6.84 ± 0.46), and the usability ratings were all above 6.0. Comparing 1- to 3-month responses, there was a substantial increase in the percentage of participants who felt the system was easy to use after they had gotten used to it (84% vs. 94%) and that navigating the system was not complicated (78% vs. 84%). Almost all participants said that the program made them feel more secure about their health and that they would stay enrolled in a program like this. None of them had used a similar system before. CONCLUSIONS: A mobile phone-based disease management program is feasible in a minority county hospital population and offers a modality to help reduce ethnic disparity.

Exercise limitation in IPF patients: a randomized trial of pulmonary rehabilitation.

BACKGROUND: Patients with idiopathic pulmonary fibrosis (IPF) have severely limited exercise capacity due to dyspnea, hypoxemia, and abnormal lung mechanics. This pilot study was designed to determine whether pulmonary rehabilitation were efficacious in improving the 6-min walk test (6-MWT) distance, exercise oxygen uptake, respiratory muscle strength [maximum inspiratory pressure (MIP)], and dyspnea in patients with IPF. Underlying physiological mechanisms and effects of the intervention were investigated. METHODS: Subjects were randomly assigned to a 3-month pulmonary rehabilitation program (n = 11) or to a control group (n = 10). All subjects initially underwent the 6-MWT and constant load exercise gas exchange studies. RESULTS: Subjects in the rehabilitation group increased treadmill exercise [metabolic equivalent of task-minutes] over the first 14 sessions. Beneficial effects on physical function resulted in those who completed rehabilitation. Subjects who completed the program increased cycle ergometer time and maintained exercise oxygen consumption (exercise VO(2)) at the baseline level over 3 months, while the control group suffered a significant decrease in exercise VO(2). Rehabilitation subjects also increased their MIP. Plasma lactate doubled and brain natriuretic peptide levels increased significantly after exercise, as did the plasma amino acids glutamic acid, arginine, histidine, and methionine. These changes were associated with significant decreases in arterial oxygen saturation and increases in 15-F(2t)-isoprostanes after exercise. CONCLUSIONS: Pulmonary rehabilitation effectively maintained exercise oxygen uptake over 3 months and lengthened constant load exercise time in patients with moderately severe IPF. Exercise endurance on cycle ergometry testing was limited by dyspnea and severe hypoxemia associated with systemic oxidant stress.

Medical students' attitudes toward obese patient avatars of different skin color.

Physicians' biases for skin color and obesity may negatively affect health-care outcomes. Identification of these biases is the first step to address the problem. We randomized 128 U.S medical students into one of four animated videos of avatar physician-patient counseling sessions, varying the weight and skin color of an elderly patient avatar: white-thin, black-thin, white-obese and black-obese. Medical students viewed white obese avatars as unattractive, ugly, noncompliant, lazy, and sloppy. Medical students' comments suggested a paternalistic attitude toward avatar patients. Avatar-mediated experiences can elicit medical students' bias potentially enabling medical educators to implement bias reduction interventions.

Microparticles in stored red blood cells as potential mediators of transfusion complications.

This article reviews evidence for the involvement of cell-derived microparticles (MPs) in transfusion-related adverse events. The controversy concerning possible added risk of older versus fresher stored blood is also reviewed and is consistent with the hypothesis that MPs are involved with adverse events. Although all types of circulating MPs are discussed, the emphasis is on red blood cell-derived MPs (RMPs). The evidence is particularly strong for involvement of RMPs in transfusion-related acute lung injury, but also for postoperative thrombosis. However, this evidence is largely circumstantial. Work in progress to directly test the hypothesis is also briefly reviewed.

Use of HIV primary care by HIV-positive Haitian immigrants in Miami, Florida.

Little is known about the use of HIV primary care among Haitian immigrants in the USA. The present study utilizes data from a survey of HIV-positive Haitians recruited from an HIV primary care clinic in Miami, Florida, to examine barriers and facilitators of regular use of HIV care by this population. Selection of measures was guided by the Andersen Model of Health Services Utilization for Vulnerable Populations. The dependent variable, regular use of HIV primary care, was operationalized as completion of four or more HIV primary care visits during the previous 12 months. Of the 96 participants surveyed, approximately three-fourths did not graduate from high school and reported an annual income of up to $5000. Seventy-nine percent of participants completed four or more visits in the past year. On univariate as well as multivariate analyses, participants without formal education or those with high psychological distress were significantly less likely to have used HIV primary care regularly than those who attended school or who were less distressed, respectively. The findings emphasize the need for health care practitioners to pay close attention to the education level and the mental health status of their Haitian HIV patients. The data also suggest that once these individuals are linked to care and offered assistance with their daily challenges, they are very likely to stay connected to care and to take their antiretroviral medicines.

Sildenafil therapy and exercise tolerance in idiopathic pulmonary fibrosis.

Idiopathic pulmonary fibrosis (IPF) is a form of idiopathic interstitial pneumonia characterized by temporally and spatially heterogeneous fibroblast proliferation and poor prognosis. No therapies have been shown in randomized clinical trials (RCT) to influence survival. Twenty-nine subjects were assigned randomly in a pilot study to a double-blind, placebo-controlled, RCT to test sildenafil in patients with IPF with forced vital capacity 40-90% and diffusing capacity 30-90% of predicted. During the 6-month experimental treatment period, patients underwent 6-min walk tests and estimation of dyspnea using the Borg scale at baseline (0 months), 3 months, and 6 months. Participants had moderate impairment of pulmonary function, and there were no significant differences between placebo (n = 15) and sildenafil (n = 14)-treated groups. Sildenafil did not significantly increase 6-min walk test distance (mean distance +/- SD after 6-month protocol: placebo 355 +/- 82 m, sildenafil 324 +/- 41 m; p = 0.256) nor did it lessen dyspnea after exercise (mean Borg score after 6-month protocol: placebo 3.4 +/- 1.6, sildenafil 4.1 +/- 2.3; p = 0.492). Adverse reactions were few and minor in nature. In this trial, sildenafil did not significantly increase 6-min walk test distance or decrease the Borg dyspnea index in patients with clinically typical IPF. This trial was registered at clinicaltrials.gov as NCT00359736.

Characteristics of Women Enrolled in a Patient Portal Intervention for Menopause.

Background: We developed a 6-month educational intervention addressing menopause and management of menopausal symptoms called "My HealtheVet to Enable And Negotiate for Shared decision-making" or MEANS. MEANS is offered through secure messaging via the My HealtheVet patient portal system. Materials and Methods: Women veterans aged 45-60 years registered at the Miami, West Palm Beach, and Orlando Veterans Affairs Healthcare Systems (VAHS). Intervention group: women in the Miami VAHS enrolled in My HealtheVet who were sent an invitation, agreed to participate, and completed the baseline survey. Comparison group: women from the Miami, West Palm Beach, and Orlando VAHS who responded to the baseline survey. Results: The intervention group enrolled 269 women at Miami VAHS: average age 53.2 years; 42.4% white, 43.1% black, and 24.2% Hispanic; 95.9% already used My Healthe Vet. The Comparison group had 590 women: average age 53.8 years; 70.8% white, 20.7% black, and 10.2% Hispanic; 57.6% already used My Healthe Vet. Conclusions: The differences between the intervention and comparison groups likely represent the regional demographic variations and the disparate recruitment techniques adopted for the two groups. Using within- and between-group comparisons at the end of the 6-month intervention, this novel project will evaluate the feasibility of a patient portal intervention on knowledge and shared decision-making regarding menopause among racially and ethnically diverse women. The study highlights the scalable and enormous potential for patient portals in nonurgent chronic disease management and shared decision-making, important in the existing health care climate, wherein "meaningful use" of electronic health records is mandated. Because of the COVID-19 pandemic, medical care has abruptly changed to telehealth and this approach to patient education is more relevant now than ever before. This quality improvement project's registration number is ClinicalTrials.gov ID: NCT03109145.

Impact of preoperative ureteral stenting on outcome of ureteroscopic treatment for urinary lithiasis.

PURPOSE: Sparse published data exist on the impact of preexistent ureteral stents on the success of ureteroscopic stone surgery. We investigated the impact of a preexistent ureteral stent in relation to a number of parameters and outcomes of ureteroscopic management for urinary lithiasis. MATERIALS AND METHODS: We retrospectively evaluated a cohort of patients undergoing ureteroscopy for renal and ureteral calculi. Data were abstracted on stone side, size, number and site, patient demographics, total stone burden, ureteral access sheath use, preoperative ureteral stent, ureteroscope type and outcome. Statistical analysis was done. RESULTS: The success rate of 1 and 2 ureteroscopic procedures was 86.9% and 97.3%, respectively. Primary analysis included data on 221 initial procedures. The single procedure success rate for stone site was 91.9% for the distal ureter, 89.7% for the proximal ureter, 83.3% for the renal pelvis, 80.5% for the lower pole and 82.4% for the interpolar/upper pole. Success was negatively associated with primary stone size (p = 0.020), total stone number (p = 0.001) and cumulative stone burden (p <0.001). Stone site was not a predictor of success (p = 0.394). A preexistent stent was positively associated with success but it was not statistically significant (adjusted OR 2.22; 95% CI 0.88, 5.63; p = 0.254). Secondary analysis in patients who initially underwent flexible ureteroscopy yielded results consistent with those of primary analysis. CONCLUSIONS: Results show that ureteropyeloscopic lithotripsy and stone extraction may be performed with a high success rate. Success was significantly inversely related to stone size, cumulative stone burden and number of stones. Success was positively related to a preexisting ureteral stent but not significantly so.

A Patient Portal Intervention for Menopause Knowledge and Shared Decision-Making.

Background: Menopause is a time often fraught with changes and symptoms, which may require difficult choices and decision-making. During this period, women would benefit from a better understanding and in-depth discussions with providers regarding menopause, associated conditions, and appropriate therapy. Patient portals offer a potential means to improve knowledge and shared decision-making (SDM) about menopause. Materials and Methods: This protocol article explores the feasibility of using the secure messaging (SM) function of the Veterans Affairs (VA) Patient Portal, "My HealtheVet" to implement an educational intervention and measure its impact on knowledge and SDM in the management of menopause. Results: This is a quality improvement pilot study in which women veterans of menopausal age in the Miami VA are offered an educational intervention via a patient portal, while women veterans in two neighboring VA facilities are not. Intervention participants receive weekly SMs with information on menopause symptoms, and treatment. After 6-months, all participants are surveyed on menopause knowledge, SDM, and satisfaction with the program. Conclusion: This study is among the first to assess the impact of an innovative patient portal intervention to improve knowledge and SDM between patients and providers regarding menopause. If successful, our program will add to the "meaningful use" of patient portals and offer a scalable and timely resource for SDM about menopause.

Comparison of epicardial and pericardial fat thickness assessed by echocardiography in African American and non-Hispanic White men: a pilot study.

OBJECTIVES: Compared to non-Hispanic Whites, African American men have less intra-abdominal visceral adipose tissue (VAT) relative to total fat mass despite having a higher risk of obesity-related diseases. This study explores whether this racial pattern of VAT distribution extends to the intrathoracic VAT. METHODS: We used two-dimensional transthoracic echocardiography to measure pericardial and maximum and minimum epicardial fat thickness anterior to the right ventricle in 50 African American and 106 non-Hispanic White men, aged 40-75 years, consecutively referred for echocardiography for standard clinical indications. Age, coronary risk factors, height, and weight were recorded, and body mass index (BMI) was calculated. The two groups were compared with respect to pericardial and maximum, minimum, and average epicardial fat thicknesses. RESULTS: Among non-Hispanic Whites, pericardial and minimum epicardial fat measured at the mid-rightventricular wall were higher by 37% and 69%, respectively, than among African Americans (5.2+/-3.1 mm vs 3.8+/-3.1 mm, P<.011; 2.2+/-1.6 mm vs 1.3+/-1.2 mm, P<.001). Maximum epicardial fat along the distal right ventricular wall was 19% greater in non-Hispanic Whites, but this difference was not statistically significant (4.3+/-2.6 mm vs 3.6+/-2.0 mm, P=.133). The average epicardial fat measured at two sites was 26% greater in non-Hispanic Whites (2.9+/-2.0 mm vs 2.3+/-1.3 mm, P=.019). CONCLUSIONS: Among men referred for echocardiography, non-Hispanic Whites have more epicardial and pericardial fat than do African Americans. Echocardiography may be a useful research tool for investigating VAT distribution and its relationship to cardiovascular risk.

Prevalence of mitral annulus calcification in African Americans: comparison with non-Hispanic whites and Hispanics.

BACKGROUND: The association of ethnic ancestry with coronary artery calcifications suggests that mitral annulus calcification may also vary with ethnicity. We sought to compare prevalence and clinical correlates of mitral annulus calcification in non-Hispanic Whites, Hispanics, and African Americans. DESIGN: This was a retrospective study of 857 patients age 40-75 years that included 217 (25%) African Americans, 349 (41%) Hispanics, and 291 (34%) non-Hispanic Whites referred for echocardiography. Multiple logistic regression was used to determine the interrelationships between mitral annulus calcification, risk factors, and ethnicity. RESULTS: Mitral annulus calcification was detected in 181 (21.1%) patients including 35 (16.1%) African Americans, 80 (22.9%) Hispanics, and 66 (22.7%) non-Hispanic whites. In univariate analysis, patients with mitral annulus calcification were older and more likely to have hypertension, diabetes, dyslipidemia, smoking history, and two or more risk factors than were those without calcification. In multivariate analysis, age and smoking history were independent predictors of mitral annulus calcification; dyslipidemia and diabetes were borderline significant predictors; and after adjusting for the remaining variables in the model, ethnicity was not an independent significant predictor of mitral annulus calcification. CONCLUSION: In a retrospective study of middle-aged and elderly African Americans, non-Hispanic Whites, and Hispanics referred for echocardiography, mitral annulus calcification is common in all three major ethnic groups but not significantly associated with ethnic ancestry.

Subarachnoid transplant of a human neuronal cell line attenuates chronic allodynia and hyperalgesia after excitotoxic spinal cord injury in the rat.

UNLABELLED: The relief of neuropathic pain after spinal cord injury (SCI) remains daunting, because pharmacologic intervention works incompletely and is accompanied by multiple side effects. Transplantation of human cells that make specific biologic agents that can potentially modulate the sensory responses that are painful would be very useful to treat problems such as pain. To address this need for clinically useful human cells, the human neuronal NT2 cell line was used as a source to isolate a unique human neuronal cell line that synthesizes and secretes/releases the inhibitory neurotransmitters gamma-aminobutyric acid (GABA) and glycine. This new cell line, hNT2.17, expresses an exclusively neuronal phenotype, does not incorporate bromodeoxyuridine during differentiation, and does not express the tumor-related proteins fibroblast growth factor 4 and transforming growth factor-alpha during differentiation after 2 weeks of treatment with retinoic acid and mitotic inhibitors. The transplant of predifferentiated hNT2.17 cells was used in the excitotoxic SCI pain model, after intraspinal injection of the mixed AMPA/metabotropic receptor agonist quisqualic acid (QUIS). When hNT2.17 cells were transplanted into the lumbar subarachnoid space, tactile allodynia and thermal hyperalgesia induced by the injury were quickly and potently reversed. Control cell transplants of nonviable hNT2.17 cells had no effect on the hypersensitivity induced by QUIS. The effects of hNT2.17 cell grafts appeared 1 week after transplants and did not diminish during the 8-week course of the experiment when grafts were placed 2 weeks after SCI. Immunohistochemistry and quantification of the human grafts were used to ensure that many grafted cells were still present and synthesizing GABA at the end of the study. These data suggest that the human neuronal hNT2.17 cells can be used as a "biologic minipump" for antinociception in models of SCI and neuropathic pain. PERSPECTIVE: This study describes the initial characterization and use of a human-derived cell line to treat neuropathic pain that would be suitable for clinical application, once further tested for safety and approved by the Food and Drug Administration. A dose of these human cells could be delivered with a spinal tap and affect the intrathecal spinal environment for sensory system modulation.

Optimizing the transplant dose of a human neuronal cell line graft to treat SCI pain in the rat.

Neuropathic pain is a prevalent and difficult problem in the setting of spinal cord injury (SCI). The use of cellular transplant therapy to treat this pain has been successful with the use of a human neuronal cell line, hNT2.17 [M.J. Eaton, S.Q. Wolfe, M.A. Martinez, M. Hernandez, C. Furst, J. Huang, B.R. Frydel, O. Gomez-Marin, Subarachnoid transplant of a human neuronal cell line attenuates chronic allodynia and hyperalgesia after excitotoxic SCI in the rat, J. Pain 8 (2007) 33-50]. Intrathecal transplant of these cells potently reverses behavioral hypersensitivity after excitotoxic spinal cord injury in the rat model. This study focuses on delineating the optimal dose of these cell grafts in the same model. Two weeks after intraspinal injection of quisqualic acid (QUIS) with subsequent behavioral hypersensitivity, terminally differentiated hNT2.17 cells were transplanted into 300 g Wistar-Furth rats in a logarithmic variation of doses: 10(6), 10(5) and 10(3) cells. Behavioral hypersensitivity testing was performed weekly for 6 weeks following transplant. The dose of 10(6) cells (or approximately 3 million/kg) potently and permanently reversed both cutaneous allodynia (CA) and thermal hyperalgesia (TH). Reduced transplant doses of the hNT2.17 cell line did not permanently reverse behavioral hypersensitivity, suggesting that there is an optimal dose that can be used as a clinical tool to treat SCI-associated neuropathic pain.

Severity of concurrent visual and hearing impairment and mortality: the 1986-1994 National Health Interview Survey.

PURPOSE: Visual impairment and, to a lesser extent, hearing impairment are independent predictors of reduced survival in selected studies of community-residing adults. To date, the association of severity of concurrent impairment and mortality has not been examined. METHOD: The National Health Interview Survey is a continuous, multistage, area probability survey of the U.S. civilian noninstitutionalized population. Mortality linkage with the National Death Index of 116,796 adult participants from 1986 to 1994 with complete impairment data was performed through 1997. RESULTS: Findings indicate that moderate to severe concurrent hearing and visual impairment in women is associated with significantly increased risk of mortality. More modest mortality associations are evident for men and for adults with less severe impairments, irrespective of gender. DISCUSSION: Prevention of severe visual and hearing impairment should be a national public health priority, especially given the aging of the U.S. population.

Vitamin D and Physical Function in Sedentary Older Men.

OBJECTIVES: To determine the effectiveness of vitamin D supplementation in preventing decline in physical function in older men. DESIGN: Randomized, double-blind, placebo-controlled clinical trial. SETTING: Single-center study conducted at a Veterans Affairs Healthcare System. PARTICIPANTS: Sedentary men aged 65 to 90 (mean 72.4 ± 6.8) with baseline 25-hydroxyvitamin D (25(OH)D levels of less than 30 ng/mL and Short Physical Performance Battery (SPPB) test scores of 9 or less (N = 130). INTERVENTION: Daily capsule containing cholecalciferol 4,000 IU daily or placebo for 9 months. MEASUREMENTS: Main outcomes were SPPB score and gait speed. RESULTS: After the intervention, serum 25(OH)D increased from 23.1 ± 5.0 ng/mL to 46.2 ± 12.7 ng/mL in the cholecalciferol group and from 22.5 ± 5.3 ng/mL to 24.0 ± 7.2 ng/mL in the placebo group. At study end, improvements in SPPB score and gait speed were not significantly greater in men receiving cholecalciferol than in those receiving placebo. No differences were found in adverse events or numbers of falls. CONCLUSION: Daily cholecalciferol 4,000 IU for 9 months resulted in significant increases in 25(OH)D concentrations, but achieving these higher levels did not result in improvements in SPPB score or gait speed. These data do not support prescribing vitamin D supplements to older sedentary men to prevent physical function decline.

Concurrent visual and hearing impairment and risk of mortality: the National Health Interview Survey.

OBJECTIVE: To determine the association between reported concurrent visual and hearing impairment and risk of mortality. DESIGN, SETTING, AND PARTICIPANTS: Annual cross-sectional multistage area probability surveys of the US civilian noninstitutionalized population living at addressed dwellings were conducted by the National Center for Health Statistics, Hyattsville, Md. Mortality linkage with the National Death Index of participants from 1986 to 1994 was performed through 1997. Complete reported visual and hearing impairment data and survival status were available for 116 796 adults aged 18 years and older. A total of 3620 participants reported visual impairment only, 12 330 reported hearing impairment only, and 1461 reported concurrent visual and hearing impairment. MAIN OUTCOME MEASURE: Risk of mortality. RESULTS: Mortality linkage identified 8949 deaths with an average follow-up of 7.0 years. After controlling for survey design, age, marital status, educational level, self-rated health, and number of nonocular and nonauditory conditions, white participants and "other-race" participants, but not African American participants, reporting concurrent visual and hearing impairment had significantly increased risk of mortality in comparison with their counterparts reporting no impairment (white participants: hazard ratio [HR] = 1.23, 95% confidence interval [CI], 1.04-1.46 for men and HR = 1.63, 95% CI, 1.37-1.93 for women; African American participants: HR = 1.50, 95% CI, 0.94-2.40 for men and HR = 0.92, 95% CI, 0.51-1.63 for women; participants of other races: HR = 2.47, 95% CI, 1.33-4.57 for men and HR = 2.23, 95% CI, 1.01-4.90 for women). Risk of mortality was generally greater for participants reporting concurrent impairment as compared with that for participants reporting either visual impairment alone or hearing impairment alone. CONCLUSIONS: In the United States, white persons and those of other races, but not African American persons, reporting concurrent visual and hearing impairment have an increased risk of mortality. Reported concurrent impairment is an independent predictor of mortality among white persons and those of other races for both men and women.

Morbidity ranking of U.S. workers employed in 206 occupations: the National Health Interview Survey (NHIS) 1986-1994.

OBJECTIVE: The objective of this study was to rank U.S. occupations by worker morbidity. METHODS: From 1986 through 1994, morbidity information was collected on over 410,000 U.S. workers who participated in the National Health Interview Survey, an annual household survey representative of the U.S. civilian noninstitutionalized population. A multivariate adjusted logistic regression morbidity summary score was created for each worker group based on seven indicators: days of restricted activity, bedrest, and missed work in the previous 2 weeks; doctor visits and hospitalizations in the previous 12 months; reported health conditions; and health status. RESULTS: Worker groups reporting the greatest morbidity included social workers, inspectors, postal clerks, psychologists, and grinding machine operators; worker groups reporting the least morbidity included dentists, pilots, physicians, pharmacists, and dietitians. CONCLUSIONS: These findings aid in the identification of worker groups that require increased attention for morbidity research and prevention.

Risk factors for recurrent lower extremity cellulitis in a U.S. Veterans Medical Center population.

BACKGROUND: Despite the frequency of recurrent acute cellulitis of the lower extremities, factors associated with this infection have not been previously assessed in a case-control study among patients admitted to U.S. hospitals. METHODS: We compared the clinical characteristics of 47 patients with those of 94 age- and sex-matched control subjects admitted to the Miami Veterans Affairs Medical Center. RESULTS: In a multivariate analysis, two physical factors, lower extremity edema and body mass index, one behavioral factor, smoking, and one demographic factor, homelessness, were significantly and independently associated with recurrent cellulitis. The latter two factors have not previously been reported to be independently associated with cellulitis. CONCLUSIONS: Our results suggest that increased emphasis on weight loss, smoking cessation, and improved foot hygiene in the homeless might decrease recurrences of lower extremity cellulitis.