Susan M. Hailpern

Sodium Intake and Mortality Follow-Up in the Third National Health and Nutrition Examination Survey (NHANES III)

BackgroundSodium restriction is commonly recommended as a measure to lower blood pressure and thus reduce cardiovascular disease (CVD) and all-cause mortality. However, some studies have observed higher mortality associated with lower sodium intake.ObjectiveTo test the hypothesis that lower sodium is associated with subsequent higher cardiovascular disease (CVD) and all cause mortality in the Third National Health and Nutrition Examination Survey (NHANES III).DesignObservational cohort study of mortality subsequent to a baseline survey.ParticipantsRepresentative sample (nu2009=u20098,699) of non-institutionalized US adults age ≥30, without history of CVD events, recruited between 1988–1994.Measurements and main resultsDietary sodium and calorie intakes estimated from a single baseline 24-h dietary recall. Vital status and cause of death were obtained from the National Death Index through the year 2000. Hazard ratio (HR) for CVD mortality of lowest to highest quartile of sodium, adjusted for calories and other CVD risk factors, in a Cox model, was 1.80 (95% CI 1.05, 3.08, pu2009=u20090.03). Non-significant trends of an inverse association of continuous sodium (per 1,000xa0mg) intake with CVD and all-cause mortality were observed with a 99% CI of 0.73, 1.06 (pu2009=u20090.07) and 0.86, 1.04 (pu2009=u20090.11), respectively, while trends for a direct association were not observed.ConclusionObserved associations of lower sodium with higher mortality were modest and mostly not statistically significant. However, these findings also suggest that for the general US adult population, higher sodium is unlikely to be independently associated with higher CVD or all-cause mortality.

Effect of Physician Volume on the Relationship Between Hospital Volume and Mortality During Primary Angioplasty

OBJECTIVESnWe sought to examine the combined effect of hospital and physician volume of primary percutaneous coronary intervention (PCI) on in-hospital mortality.nnnBACKGROUNDnAn inverse relationship between volume and outcome has been observed for both hospitals and physicians after primary PCI for acute myocardial infarction.nnnMETHODSnUsing the New York State PCI registry, we examined yearly hospital volume, physician volume, and risk-adjusted mortality in 7,321 patients undergoing primary PCI for acute myocardial infarction. Risk-adjusted mortality rates for high-volume hospitals (>50 cases/year) and high-volume physicians (>10 cases/year) were compared with their respective low-volume counterparts.nnnRESULTSnPrimary PCI by high-volume hospitals (odds ratio [OR]: 0.58; 95% confidence interval [CI]: 0.38 to 0.88) and high-volume physicians (OR: 0.66; 95% CI: 0.48 to 0.92) was associated with lower odds of mortality. Furthermore, there was a significant interaction between hospital and physician volume on adjusted mortality (p = 0.02). Although unadjusted mortality was lower when primary PCI was performed by high-volume physicians in high-volume hospitals compared with low-volume physicians in low-volume hospitals (3.2% vs. 6.7%, p = 0.03), the risk-adjusted mortality rate was not statistically significant (3.8% vs. 8.4%, p = 0.09). In low-volume hospitals, the average risk-adjusted mortality rate for low-volume physicians was 8.4% versus 4.8% for high-volume physicians (OR: 1.44; 95% CI: 0.68 to 3.03). However, in high-volume hospitals, the risk-adjusted mortality rate for high-volume physicians was 3.8% versus 6.5% for low-volume physicians (OR: 0.58; 95% CI: 0.39 to 0.86).nnnCONCLUSIONSnDuring primary PCI, physician experience significantly modifies the hospital volume-outcome relationship. Therefore, policymakers need to consider physician experience when developing strategies to improve access to primary PCI.

Duration of lactation is associated with lower prevalence of the metabolic syndrome in midlife—SWAN, the study of women’s health across the nation

OBJECTIVEnThe objective of the study was to evaluate whether lactation duration is associated with lower prevalence of metabolic syndrome (MetSyn) in midlife, parous women.nnnSTUDY DESIGNnThis was a cross-sectional cohort analysis of 2516 parous, midlife women using multivariable logistic regression to determine the independent association of lactation and lactation duration on prevalence of MetSyn.nnnRESULTSnOne thousand six hundred twenty women (64.4%) reported a history of breast-feeding, with average lifetime duration of lactation of 1.16 (+/- 1.04) years. MetSyn was present in 536 women (21.3%). Adjusting for age, smoking history, parity, ethnicity, socioeconomic status, study site, physical activity, caloric intake, and high school body mass index, women with prior lactation had significantly lower odds of MetSyn (odds ratio [OR] 0.79, 95% confidence interval [CI] 0.63 to 0.99). Furthermore, increasing duration of lactation was similarly associated with lower odds of MetSyn (OR 0.88, 95% CI 0.77 to 0.99).nnnCONCLUSIONnDuration of lactation is associated with lower prevalence of MetSyn in a dose-response manner in midlife, parous women.

Aspirin resistance associated with HbA1c and obesity in diabetic patients.

INTRODUCTIONnDiabetes is known to be a prothrombotic state. Since serotonin uptake plays a role in both platelet activation and depression, we undertook to examine a hypothesis that aspirin resistance (AR) may be associated with both HbA1c and depressive symptoms and to assess other potential determinants of AR in diabetic patients.nnnMETHODSnA whole-blood desktop platelet function analyzer (PFA-100) with an epinephrine agonist was used to assess AR among patients with type 2 diabetes. AR was defined as PFA closure times <192 s. Depression symptoms were assessed with the Physicians Health Questionnaire. Patients being treated for type 2 diabetes (N=48) who took aspirin within the past 24 h constituted the study sample. Associations with AR were assessed with the use of the Mann-Whitney test and Fishers Exact Test as well as with logistic regression models.nnnRESULTSnAR was observed in 11 patients (23%) and was not significantly associated with age, sex, or race. AR was significantly associated with HbA1c > or = 8% (P=.002) and obesity (BMI> or = 30 kg/m(2); P=.01) and borderline associated with having > or = 1 depressive symptom (P=.07). Results were similar after multivariable adjustment in logistic regression models. No statistically significant associations of AR with age, sex, race, plasma glucose, blood pressure, cholesterol, or smoking were observed.nnnCONCLUSIONnThese data suggest that AR may be of special concern for diabetic patients with poor glucose control and obesity. Whether the PFA-100 or any other practical measure of AR can be used in clinical practice to identify added cardiovascular disease risk and to inform platelet inhibition therapy needs further study.

Association of adolescent obesity and lifetime nulliparity - the Study of Women's Health Across the Nation (SWAN).

OBJECTIVEnTo evaluate whether adolescent obesity is associated with difficulties in becoming pregnant later in life.nnnDESIGNnCross-sectional analysis of baseline data from a longitudinal cohort.nnnSETTINGnMultiethnic, community-based observational study of U.S. women.nnnPATIENT(S)nThree thousand one hundred fifty-four midlife women.nnnMAIN OUTCOME MEASURE(S)nLifetime nulliparity and lifetime nulligravidity.nnnRESULT(S)nFive hundred twenty-seven women (16.7%) women had never delivered a baby. Participants were categorized by self-reported high school body mass index (BMI): underweight (<18.5 kg/m(2)), normal (18.5-24.9 kg/m(2)), overweight (25-29.9 kg/m(2)), and obese (>30 kg/m(2)). The prevalence of lifetime nulliparity increased progressively across the high school BMI categories: 12.7%, 16.7%, 19.2%, and 30.9%, respectively. Multivariable logistic regression analysis confirmed that women who were obese adolescents had significantly higher odds of remaining childless compared with normal weight women (odds ratio [OR] 2.84; 95% confidence interval [CI], 1.59-5.10) after adjusting for adult BMI, history of nongestational amenorrhea, marital status, ethnicity, study site, and measures of socioeconomic status. Furthermore, adolescent obesity was associated with lifetime nulligravidity (OR = 3.93; 95% CI, 2.12-7.26).nnnCONCLUSION(S)nAdolescent obesity is associated with lifetime nulliparity and nulligravidity in midlife U.S. women.

Prevalence of Hemoglobin A1c Greater Than 6.5% and 7.0% among Hospitalized Patients without Known Diagnosis of Diabetes at an Urban Inner City Hospital

CONTEXTnBronx, New York, an urban county with a large low-income, immigrant and minority population, has a prevalence of diabetes that is among the highest in the United States.nnnOBJECTIVEnThe aim of the study was to evaluate the utility of hemoglobin A1c (HbA1c) in identifying patients at risk for diabetes on an in-patient medical service of a hospital serving a high prevalence community.nnnDESIGN AND SETTINGnWe conducted a prospective cohort study at an urban public hospital.nnnPATIENTSnThe study included 971 patients (1132 admissions) admitted to the general medicine service over 4 months.nnnMAIN OUTCOME MEASURESnHbA1c was measured on all patients. Records were checked for prior diagnosis of diabetes and other clinical data. Follow-up data were obtained for those with repeat HbA1c testing or glucose within 1 yr after admission.nnnRESULTSnWe found that 35.2% of the patients (n = 342) had an established diagnosis of diabetes. The remaining 629 patients defined the study cohort of patients without known diabetes. Mean HbA1c was 6.05 +/- 0.87%. A total of 152 patients (24%) had admission HbA1c of at least 6.5% and 62 (9.9%) had HbA1c of at least 7.0%. Fifty-five patients with HbA1c of at least 6.5% had follow-up HbA1c within 1 yr. Of those, 44 (80.0%) met the criteria for diabetes as proposed by The International Expert Committee using repeated HbA1c testing.nnnCONCLUSIONnIn communities with high prevalence of diabetes, a large percentage of patients without a diagnosis of diabetes who are admitted as in-patients have HbA1c of at least 6.5% and 7.0%. Hospital-based HbA1c testing might identify patients for whom further testing is indicated to make the diagnosis of diabetes.

Predictors of Early Hospital Readmission for Asthma Among Inner-City Children

Factors associated with early asthma readmission have not been fully studied. To identify predictors of early readmission, we performed a matched case-control study of children discharged with primary diagnosis of asthma. Cases were readmitted with asthma within 30 days of discharge. Controls were not readmitted. Conditional logistic regression analysis was used. History of asthma hospitalization within the past 12 months was an independent predictor of early readmission (OR 1.89, p = 0.021). Modifiable factors such as medical treatment and management during and upon discharge from the index admission did not predict early asthma readmission.

Survival and toxicity differences between 5-day and weekly cisplatin in patients with locally advanced cervical cancer

Cisplatin (CDDP) administration concomitant with radiotherapy (RT) for the treatment of locally advanced cervical cancer has evolved from an inpatient 5‐day every 21‐day regimen to a weekly outpatient regimen. This study was designed to test for differences in progression‐free survival (PFS) and toxicity between the 2 regimens.

Glucose-Cholesterol Interaction Magnifies Coronary Heart Disease Risk for Hypertensive Patients

Abstract—Elevated cholesterol and glucose are known independent risk factors for coronary heart disease. This study examines whether an adverse synergistic interaction of cholesterol and glucose magnifies coronary heart disease risk among treated hypertensive patients. Subjects were hypertensive patients (n=6672) in a worksite treatment program, with entry fasting glucose <6.99 mmol/L (126 mg/dL) and total cholesterol <6.72 mmol/L (260 mg/dL) observed for mean 5.6±4.5 years follow-up (range 0.5 to 21.7 years). Outcome events were incident hospitalization or death due to coronary heart disease. Cox proportional hazard models were constructed for the whole sample to assess interaction and then stratified by fasting glucose categories with thresholds defined either at impaired fasting glucose (≥6.11 mmol/L [110 mg/dL]) or upper quartile (≥5.72 mmol/L [103 mg/dL]). An interaction product term of total cholesterol and fasting glucose as continuous variables significantly (P =0.009) improved a Cox proportional hazards model, adjusting for total cholesterol, fasting glucose, and other coronary heart disease risk factors. Adjusted hazard ratios for 3 upper total cholesterol categories (with total cholesterol <5.17mmol/L [200 mg/dL] as reference) in the higher fasting glucose stratum were more than double the corresponding hazard ratios in the lower stratum, whether using impaired fasting glucose or upper quartile fasting glucose as the cut point. These results suggest that an adverse synergistic interaction between glucose and cholesterol magnifies coronary heart disease risk associated with total cholesterol among hypertensive patients, raising the possibility that coronary heart disease prevention might be enhanced if cholesterol intervention criteria were modified by glucose status.

Factors Associated With Emergency Department Utilization By Urban Lesbian, Gay, And Bisexual Individuals

There are no published studies to date on emergency department (ED) utilization by the lesbian, gay, and bisexual (LGB) community despite documented lack of access to health care for this community. This study explored the frequency of ED visits and socio-demographic and health-related factors associated with ED utilization among a convenience sample of LGB individuals. A sample of 360 LGB individuals was interviewed to assess socio-demographics, sexual practices, mental health, drug use, chronic disease history, and frequency of emergency department use. Emergency department utilization was categorized as 0, 1, or ≥2 visits. Bivariate statistics were applied to assess the association of various factors with emergency department utilization. Patient characteristics were as follows: age, 29.0; male, 53.1 percent; Hispanic, 57.8 percent; Black, 37.2 percent; and reported less than a college degree, 79.4 percent. Most (77.7 percent) had a primary care doctor and (86.3 percent) were comfortable discussing LGB-related health issues with their provider. Over 12xa0months, 25.3 percent had 1 ED visit and 16.4 percent had ≥2 ED visits. One or more emergency department visits was significantly associated with lower age, lower education, lower income, recent psychological distress, recent mental health counseling or medications, desired mental health treatment, abuse by partner, cigarette use, marijuana use, and asthma (pxa0<xa00.05). Despite reported access to primary care, our LGB sample exhibited a higher proportion of single and ≥2 ED visits than comparable populations. Mental health and cigarette use were associated with emergency department utilization and deserve further exploration for reducing emergency department visitation by and improving emergency department care for LGB individuals.