Relation of body fat distribution to metabolic complications of obesity.

The importance of body fat distribution as a predictor of metabolic aberrations was evaluated in 9 nonobese and 25 obese, apparently healthy women. Plasma glucose and insulin levels during oral glucose loading were significantly higher in women with predominantly upper body segment obesity than in women with lower body segment obesity. Of the former group, 10 of 16 subjects had diabetic glucose tolerance results, while none of the latter group was diabetic. Fasting plasma triglyceride levels were also significantly higher in the upper body segment obese women. The site of adiposity in the upper body segment obese women was comprised of large fat cells, while in the lower body segment obese subjects, it was formed of normal size cells. In both types of obesity, abdominal fat cell size correlated significantly with postprandial plasma glucose and insulin levels. Thigh fat cell size gave no indication as to the presence of metabolic complications. Thigh adipocytes were also resistant to epinephrine-stimulated lipolysis, presumably due to an increase in alpha-adrenergic receptors. Thus, in women, the sites of fat predominance offer an important prognostic marker for glucose intolerance, hyperinsulinemia, and hypertriglyceridemia. This association may be related to the disparate morphology and metabolic behavior of fat cells associated with different body fat distributions.

Is adenocarcinoma/large cell carcinoma the most radiocurable type of cancer of the lung?

Radiation therapy is widely considered the primary treatment for inoperable "non-small" cell carcinoma of the lung. In clinical investigations, distinction has been infrequent among the histopathologic subtypes of non-small cell carcinoma. Studies have shown significant differences between squamous cell carcinoma and adenocarcinoma/large cell carcinoma; adenocarcinoma/large cell carcinoma has a greater propensity for extrathoracic dissemination, especially to the brain, and it is less curable by resection when regional lymph node metastases are present. No differences have been documented between adenocarcinoma and large cell carcinoma. A retrospective study was undertaken to determine the results of definitive radiation therapy by histopathologic subtype of non-small cell carcinoma of the lung. Between July 1977 and April 1983, 134 patients with non-small cell carcinoma of the lung underwent definitive radiation therapy with curative intent. All patients had performance status scores of 80 to 100 (Karnofsky), and received minimum total doses within the tumor of 60 Gy in 6 to 7 weeks, five fractions per week. The median period of observation was 63 months. Ninety patients had squamous cell carcinoma; 44 had adenocarcinoma/large cell carcinoma. The two groups of patients were comparable in respect to age and Stage; there were significantly more women with adenocarcinoma/large cell carcinoma (27%) than with squamous cell carcinoma (13%). The median survival for patients with squamous cell carcinoma was 11.5 months; the 2 and 4 year survival rates were 21 and 7%, respectively. The median survival for patients with adenocarcinoma/large cell carcinoma was 18 months; 2 and 4 year survival rates were 38 and 23%, respectively. Comparison of the overall survival experience did not show a significant difference between the two cell types (p = .12 using Gehan's generalized Wilcoxon test). However, comparison of the proportion of patients with adenocarcinoma/large cell carcinoma surviving 18 months (50%) was significantly higher (p = .02) than that with squamous cell carcinoma (30%). A small body of data from the literature also suggests a better long-term prognosis for adenocarcinoma/large cell carcinoma. This observation requires confirmation from large trials with histopathologic review. If it is confirmed, there are important implications for therapeutic strategies in future clinical investigations of inoperable carcinoma of the lung.

The pathophysiologic and roentgenologic effects of chest irradiation in breast carcinoma.

We studied the effects of radiation therapy on lung function in 21 patients who underwent modified radical mastectomy and radiotherapy for breast carcinoma. The patients had pulmonary function studies and chest X rays prior to radiation therapy and at six weeks, and three, six, and twelve months following radiation therapy. All pulmonary function studies showed a small but statistically significant decline within the first three months following radiation therapy. Changes in the moderate and large airways continued to occur after three months. None of the changes in pulmonary function were reversible. Radiographic changes occurred in 12 patients. These changes occurred later than the lung function changes (median time for the changes was twelve months) and were unrelated to changes in lung function.

Mortality after coronary angioplasty and coronary artery bypass surgery (the national Medicare experience).

Mortality rates for Medicare patients who underwent coronary artery bypass surgery were compared with those who had angioplasty or angioplasty and bypass surgery. Two data sets were used for this study: The first contained information on demographic factors, co-morbidities and subsequent mortality on all 96,666 Medicare patients who had bypass surgery or angioplasty in 1985; the second contained additional detailed clinical data collected using the MedisGroups method on a random sample of 2,931 revascularization patients from 6 states. From the national data set 30-day and 1-year mortality rates were 3.8 and 8.2% for 25,423 angioplasty patients and 6.4 and 11.8% for 71,243 bypass surgery patients (p less than 0.001 for both time periods). Mortality rates for the MedisGroups data were 4.4 and 8.5% for the angioplasty patients and 6.5 and 11.9% for the bypass surgery patients. After eliminating patients admitted with a myocardial infarction, mortality rates were 1.9 and 6.0% for 632 angioplasty patients and 5.1 and 10.8% for 1,730 bypass surgery patients. The risk-adjusted relative risk of mortality for bypass surgery versus angioplasty was 1.72 (p = 0.001) for all patients, 2.15 (p less than 0.001) for low-risk patients and 0.90 (p = not significant) for high-risk patients. Results suggest that low-risk patients have better survival with angioplasty because of lower short-term mortality.

Identification of heavy drinkers using a combination of laboratory tests.

OBJECTIVE: This study derived and evaluated a model that used results of commonly performed laboratory tests to identify men who are heavy drinkers. METHOD: The results of 40 commonly available laboratory tests were obtained on a diverse sample of 426 heavy drinkers and 188 light drinkers. A logistic regression equation for identifying heavy drinkers was derived in a training data set of 411 subjects and tested in a validation data set of 203 subjects. RESULTS: Ten laboratory measurements were included in the final regression equation: chloride, sodium, ratio of direct to total bilirubin level, blood urea nitrogen, high density lipoproteins, monocyte count, phosphorus, platelets, aspartate aminotransferase, and mean corpuscular hemoglobin. In the validation data this model correctly identified 98% of the 161 heavy drinkers and 95% of the 42 light drinkers. Other models reported in previous literature were applied to these subjects and did not perform as well. The model performed better for subjects of lower socioeconomic status. CONCLUSIONS: The laboratory tests in our model may help identify heavy drinkers. The performance of models to identify heavy drinkers depends on the demographic characteristics of the subjects.

A weight shape index for assessing risk of disease in 44,820 women.

The medical literature gives ample evidence of the relationship between obesity and specific diseases such as adult-onset diabetes and hypertension. Until recently the sole focus of the relationship has been between morbidity and the degree of overweight which is usually measured as weight relative to height. Recently we have shown that the location of body fat is not only associated with morbidity but that this relationship is independent of the total amount of adipose tissue. Clinical studies have shown that adipocyte size, location and metabolism are related to fat distribution. An excess of large fat cells in the upper body explains the increase risk of diabetes in women. The location of body fat has been used to delineate three body types: gynoid (pear shape), intermediate, and android (apple shape). We used waist girth divided by hip girth for scaling body shape and found that it is associated with morbidity after adjustment for relative weight. The use of relative weight and body shape simultaneously gives a better estimate of risk of morbidity than either alone. This study of 44,820 women presents easy to read graphs, derived from the multiple logistic model, which will permit practicing physicians to estimate visually the combined risks associated with relative weight and body fat location.

Community characteristics associated with elder abuse.

OBJECTIVES: To help define the relationship between elder abuse rates and counties' demographics, healthcare resources, and social service characteristics. DESIGN: County-level data from Iowa were analyzed to test the association between county characteristics and rates of elder abuse between 1984 and 1993 using univariate correlation analysis and stagewise linear regression. SETTING: Ninety-nine counties in Iowa. PARTICIPANTS: Iowa residents aged 65 years and older. MEASUREMENTS: County-level population-adjusted numbers of abused elderly, abused children, children in poverty, high school dropouts, physicians and other healthcare providers, hospital beds, social workers and caseworkers in the Department of Human Services (DHS). RESULTS: Community characteristics that had a positive association with rates of reported or substantiated elder abuse at the P < .001 level were population density, children in poverty, and reported child abuse. Lower substantiated elder abuse rates were associated at P < .05 with higher community rates of high school dropouts, number of chiropractors, and number of nurse practitioners. After adjusting for number of DHS caseworkers and reported child abuse rates (a surrogate for workload) a district effect persists for substantiated elder abuse cases (P = .002). CONCLUSION: County demographics are risk factors for reported and substantiated elder abuse. The strongest risk factor for reported elder abuse was reported child abuse. The difference in districts may reflect differences in resources and/or differing characteristics of caseworkers who substantiate elder abuse. The risk factors may reflect conditions that influence the amount of elder abuse or the detection of existing elder abuse.

BUN as a risk factor for mortality after coronary artery bypass grafting.

BACKGROUND: Although information on blood urea nitrogen (BUN) is universally available for patients who undergo coronary artery bypass grafting, BUN has not often been considered as a risk factor for mortality. This study assessed BUN as a risk factor for CABG patients. METHODS: Four data sets were evaluated that differed with respect to the types of patients and available patient information. In each of these data sets logistic regression analysis was used to examine the relationship between BUN and mortality after adjusting for other risk factors. RESULTS: Blood urea nitrogen level was strongly associated with mortality in each of the data sets. After adjustment for the available risk factors other than creatinine level, patients with BUN levels greater than 30 mg/dL had a relative odds of mortality ranging between 1.86 and 2.49 (p < 0.0001 in three of the data sets). Even after adjustment for creatinine level as well as the other variables, BUN was statistically significant at the p less than 0.01 level for three of the data sets. CONCLUSIONS: The results suggest that BUN provides additional information on cardiac function that supplements the information provided by other risk factors.

Trends during 25 years of coronary artery bypass operation at St. Luke's Medical Center in Milwaukee, Wisconsin.

BACKGROUND: Most studies of changes in coronary artery bypass graft (CABG) operations are from major academic institutions. The present study evaluated changes in CABG operations since 1968 in a community hospital. METHODS: The data were from the St. Luke's Medical Center Cardiovascular Data Registry in Milwaukee, Wisconsin. Mortality rates, risk factors, overall patient risk, and surgical procedures were compared from 1968 to 1994. RESULTS: There was a dramatic decrease in 30-day mortality rates from 1968 to 1972. After 1976, mortality rates increased because of higher risk patients, but the mortality rate, adjusted for patient risk, continued to decline. Both internal mammary arteries and sequential grafts were widely used by 1972, followed by a decline in use until 1980, and then a steep increase in use from 1980 to the present. CONCLUSIONS: This study provided evidence from a community hospital that the skills of the surgical teams improved first dramatically then gradually. The pattern of adapting new surgical techniques suggested that these techniques were critically evaluated for several years after they were introduced.

Correlation of rates of coronary artery bypass surgery, angioplasty, and cardiac catheterization in 305 large communities for persons age 65 and older.

OBJECTIVE: The rate of coronary artery bypass surgery (CABG) has been shown to vary greatly across geographic regions. This study examined whether these rates were associated with the rate of coronary artery angioplasty (PTCA) and with other community characteristics. DATA SOURCES/STUDY SETTING: The health care financing administration provided the number of Medicare hospitalizations in 1988 for conditions and procedures related to coronary artery disease. Information on physicians and hospitals was obtained from the Area Resource File, and the number of persons in each age, sex, and race category was obtained from US. census data. STATISTICAL METHODS: Age-and sex-adjusted hospitalization rates based on the patient's zip code of residence were calculated at the level of the Metropolitan Statistical Area (MSA) for white patients age 65 or older. Rates were obtained for 305 MSAs for CABG, PTCA, cardiac catheterization, angina, and myocardial infarction. PRINCIPAL FINDINGS: The rate of cardiac catheterization had a correlation of .72 with the CABG rate and .64 with the PTCA rate. The correlation of the PTCA and CABG rates with each other was .49. This correlation was not charged by adjusting for the rates of hospitalization for angina or myocardial infection, but it was reduced to only .05 (ns) after adjusting for the rate of cardiac catheterization. The rates of all three procedures had rank correlations of about .15 with the density of thoracic surgeons and about .30 with the density of hospitals with cardiac catheterization and open heart surgery units. CONCLUSIONS: Community CABG and PTCA rates tend to move in the same direction due to community factors that also affect the rates of cardiac catheterization. These community factors do not appear to include the rate of coronary artery disease, but may include resources or attitudes toward aggressive treatment of coronary artery disease.

The relationship between adjusted hospital mortality and the results of peer review.

This study assessed the relationship between the Health Care Financing Administration adjusted mortality rate for a hospital and the errors in care found by the peer review process. The three data sets used were: (1) the 1987-1988 completed reviews from 38 peer review organizations (PROs) of 4,132 hospitals and 2,035,128 patients; (2) all 1987 hospital mortality rates for Medicare patients as adjusted by HCFA for patient mix; and (3) the 1986 American Hospital Association Survey. The PRO data were used to compute the percentage of cases reviewed from each hospital confirmed by a reviewing physician to have a quality problem. The average percentage of confirmed problems was 3.73 percent with state rates ranging from 0.03 percent to 38.5 percent. The average within-state correlation between the problem rate and the adjusted mortality rate for all PROs was .19 (p < .0001), but the correlations were much higher for relatively homogeneous groups of hospitals, .42 for public hospitals and .36 for hospitals in large metropolitan statistical areas (MSAs). These results suggest that the HCFA adjusted hospital mortality rate and the PRO-confirmed problem rate are related methods to compare hospitals on the basis of quality of care. Both methods may compare quality better if used within a group of homogenous hospitals.

Evaluation of the HCFA model for the analysis of mortality following hospitalization.

From 1987 through 1990, the Health Care Financing Administration (HCFA) evaluated variations in the mortality rates experienced by patients admitted to hospitals participating in the Medicare program. This study was conducted to evaluate the adequacy of the model used for that purpose. Detailed clinical data were gathered on 42,773 patients admitted to 84 statistically selected hospitals. The effect of risk adjustment using the HCFA model, which is based on claims data, was compared to a risk-adjustment model based on physiologic and clinical data. Models that include claims data were markedly superior to those containing only demographic characteristics in predicting the probability of patient death, and the addition of clinical data resulted in further improvement. The correlation of ranks of hospitals based on a model that uses only the claims data and on one that uses, in addition, clinical data, was .91. As a screen for the identification of "high (mortality) outlier" hospitals, the claims model had moderate sensitivity (81 percent) and specificity (79 percent), a high negative predictive value (90 percent), and a low positive predictive value (64 percent) when compared to the clinical model. The two mortality models gave similar results when used to determine which structural characteristics of hospitals were related to mortality rates: hospitals with a higher proportion of registered nurses or board-certified physician specialists, or with a greater level of access to high-technology equipment had lower risk-adjusted mortality rates. These data suggest that the current claims-based risk-adjustment procedure may satisfactorily be used to characterize variations in mortality rates associated with hospitalization. The procedure could also be used as a basis for further epidemiological analyses of factors that affect the probability of patient death. However, it does not positively identify outlier hospitals as providers of problematic care.

Unexplained symptoms in primary care: perspectives of doctors and patients.

This study evaluated unexplained symptoms in primary care from the perspective of both patients and physicians. The data were obtained from two 1998 statewide surveys, one targeting Medicaid patients and the other all primary care physicians in the state. There were 439 patients who responded (45% response rate) and 280 primary care physicians who responded (33% response rate). Half of the patients and half of the physicians were in non-metropolitan counties. Half of the patients reported unexplained symptom usually or always, and 75% of whom sought help for these symptoms. Fifty-two percent of these patients believed their physician was very concerned about their unexplained symptoms. Eighty percent of them rated their physician as providing the best possible care compared to only 49% of patients whose physician did not care about their unexplained symptoms (P=.001). Among the physicians, only 14% reported very good or excellent satisfaction with managing unexplained symptoms as compared to 44% who claimed similar satisfaction in managing psychological problems. Physicians who saw themselves as more effective in dealing with somatoform symptoms were more likely to be in solo practice (P<.005), or in the same location for at least five years (P=.04). Residence in a nonmetropolitan county did not affect patient reporting of symptoms, patient perception of physician concern about symptoms, or physician satisfaction in managing these symptoms. These results indicate the prevalence and importance of unexplained symptoms in the Medicaid population and the comfort of physicians in managing these symptoms. There is an unmet need among primary care physicians to learn how to manage patients with unexplained symptoms.

Cisplatin and fluorouracil as neoadjuvant therapy in head and neck cancer. A preliminary report.

A randomized, prospective trial utilizing cisplatin and fluorouracil as neoadjuvant chemotherapy in the treatment of advanced squamous cell carcinomas of the upper aerodigestive tract was initiated in January 1983. Sixty patients were stratified by site (oral cavity, 19; larynx, 14; hypopharynx, 14; oropharynx, 11; nasopharynx, one; and paranasal sinuses, one) and by stage (III, 19; IV, 41), and then randomized to receive either standard treatment (defined as preoperative irradiation followed by radical excision or irradiation alone) or adjuvant chemotherapy followed by standard treatment. An additional three patients were entered into the study, but withdrew. Chemotherapy consisted of three cycles for those patients in whom an objective tumor response was observed; nonresponders received standard treatment. Response to chemotherapy was complete in five and partial (greater than 50%) in 18 patients, for an overall response rate of 85%. The follow-up for surviving patients was a minimum of 24 months and a maximum of 44 months. Survival was compared for patients in both treatment groups according to the method of Lee and Desu. Despite excellent tumor response, actuarial survival was 70% in the standard treatment group as opposed to 56% in the experimental group. It was therefore evident that the high response rates reported in previous pilot studies do not necessarily result in improved survival in these cancers.

Characteristics of long-term survivors after treatment for inoperable carcinoma of the lung.

Between January, 1971 and August, 1978, 410 patients with histologically or cytologically confirmed inoperable or unresectable carcinoma of the lung of all cell types were treated with curative intent. Forty-five patients lived a minimum of 3 years and 32 patients lived 5 or more years. The 3-year survival rate increased from 7.6% (15/197) between January, 1971 and June, 1975 to 14.1% (30/213) for the interval from July, 1975 to August, 1978 (p less than 0.01). Factors associated with long-term survival were performance status (p less than 0.01), early stage (p less than 0.001), high total dose of radiation (p less than 0.02), large cell carcinoma (p less than 0.01), inoperable for medical reasons (p less than 0.001), and thoracotomy to determine unresectability (p less than 0.04). The difference in survival rates between the two time periods was not related to different patient factors. Survival rates were most improved in the second time period for patients with Stage II or Stage III carcinoma of the lung. Eight patients died from cancer between 36 and 54 months of initial treatment. Five patients died of intercurrent disease without evidence of cancer of the lung after 3 years. An increasing proportion of long-term survivors of inoperable carcinoma of the lung can be expected to result from a better understanding of these diseases, more technically sophisticated external irradiation, and the use of combination chemotherapy for small cell carcinoma.

Screening for glaucoma with stereo disc photography.

PURPOSE: To determine the value of taking simultaneous stereo photographs of the optic nerve head as a basis for identification of patients with glaucoma. METHODS: Two hundred fifty-eight patients received complete ophthalmological examinations and were ranked on a scale of 1-5 regarding the likelihood of their having glaucoma. Each eye was also photographed using the NIDEK camera, providing stereo pairs of the optic nerve head. The same patients were reclassified by two independent masked observers on the same scale of 1-5, based solely on examination of the photographs. RESULTS: Examination of stereo photographs alone provided maximum sensitivity of 75% and specificity of 95% in identification of glaucoma patients when photographic readings were compared with all available clinical information. CONCLUSIONS: Stereo photographs of the optic nerve head can be used for glaucoma detection with an accuracy that is significantly greater than simple tonometry and with a sensitivity that is equivalent to screening with computerized perimetry.

The association of smoking with clinical indicators of altered sex steroids--a study of 50,145 women.

This study was designed to test the association of smoking with four clinically apparent conditions that may be related to altered sex steroids: natural and induced menopause, infertility, oligomenorrhea, and hirsutism. Data were obtained from the personal inventories of 50,145 women ages 20-59 years in TOPS, a weight reduction program. The age-adjusted odds ratios of each condition for heavy smokers compared with nonsmokers were 1.59 for natural menopause, 1.49 for induced menopause, 1.35 for infertility, 1.30 for oligomenorrhea among women younger than 40 years, 1.63 for oligomenorrhea among women 40-49 years, and 1.54 for hirsutism (P less than .05 for oligomenorrhea and P less than .001 for all other risks). The odds ratios were not substantially changed after adjustment for obesity, parity, and husband's education level. These results suggest that smoking may affect the ovaries or hormone metabolism, or both, with medical and cosmetic consequences.

Overlap index. An alternative to sensitivity and specificity in comparing the Utility of a laboratory test.

The utility of a laboratory test for differential diagnosis depends on the degree that test results for different disease states overlap. I developed a new overlap index that ranges from zero, for an ideal test with no overlap, to one if the median test result is the same for the two disease states. The index does not depend on defining a normal range or estimating the percentage of observations that lie outside of the normal range. For these reasons it is superior to sensitivity and specificity for comparing laboratory tests, particularly if only limited test data are available.

Outcome and cost analysis of scheduled versus emergency scleral buckling surgery.

Conventional wisdom holds that a retinal detachment of recent onset should be regarded as a surgical emergency. A delay in surgery may result in an extension of detachment for patients with an attached macula and a worse visual outcome for patients with a detached macula. However, the potential disadvantages of performing surgery on an emergency basis must be weighed against the risks of delaying surgery; disadvantages include a greater frequency of operative complications resulting from fatigue factors among the operating personnel, an increased anesthetic risk due to inadequate time to assess and stabilize coexisting medical problems, and higher hospital costs. In this retrospective study covering 4 1/2 years, we compared the risks, benefits, length of hospitalization, and costs of scleral buckling surgery for retinal detachments performed as an emergency procedure or on the day following admission. After a 15% random selection from 884 consecutive operations, 48 emergency procedures were compared with 89 scheduled procedures. Patients selected for emergency surgery had better visual prognoses than scheduled patients. The potential for risk of systemic complications was not a reason for postponing surgery. None of the 18 patients with an attached macula experienced macular involvement while awaiting scheduled surgery. There were no differences between emergency and scheduled patients in ocular or systemic complications, rate of reattachment, rate of decreased visual acuity following surgery, visual outcome adjusted for prognosis, or, since 1985, length of hospital stay. Cost was greater for patients having emergency surgery, because of a difference in pay scales for support personnel.