Postchallenge glucose concentration and coronary heart disease in men of Japanese ancestry. Honolulu Heart Program

Since 1965, the Honolulu Heart Program has followed 8006 men of Japanese ancestry, aged 45-70 yr at study entry, for the development of cardiovascular disease. To investigate the role of glucose concentration 1 h after a 50-g challenge on the risk of fatal coronary heart disease (CHD) and nonfatal myocardial infarction (MI), 6394 nondiabetic men were followed for 12 yr for the first development of CHD. The rate of fatal CHD increased linearly with amount of glucose. Men in the fourth quintile of postchallenge glucose (157-189 mg/dl) had twice the age-adjusted risk of fatal CHD of those in the lowest quintile (P less than .05). Relative risk increased to threefold among those in the top quintile and remained statistically significant after adjustment for other risk factors including body mass, total cholesterol, hypertension, left ventricular hypertrophy, and hematocrit (P less than .001). When glucose was considered as a linear term in the proportional hazards model, a highly significant relation was noted with fatal CHD alone and when combined with nonfatal MI (P less than .001). We conclude that a continuously increasing risk gradient exists between postchallenge glucose and subsequent CHD that is independent of other known risk factors.

Central obesity and coronary heart disease in men

The relation between central body fat distribution, determined by measurement of subscapular skinfold thickness (SSF), and the development of definite coronary heart disease (CHD) was examined after 12 years of follow-up in a cohort of 7692 men who participated in the Honolulu Heart Program. The risk of incident coronary events was directly related to SSF. Compared with men in the lowest tertile of SSF, those in the middle tertile experienced a 70% excess of definite CHD. For those in the highest tertile, the excess more than doubled. For a given level of body mass index (BMI), SSF remains a significant and independent predictor of definite CHD, even after adjustment for age, total cholesterol, glucose, triglycerides, hypertensive status, and cigarette smoking. In contrast, the independent effect of BMI was not significant after adjustment for SSF. Thus centrally obese individuals are at increased risk of CHD, independent of BMI.

Diabetes and the risk of stroke. The Honolulu Heart Program

From 1965 to 1968, the Honolulu Heart Program began following up a cohort of men in a prospective study of cardiovascular disease. For this report, we examined the 12-year risk of stroke in 690 diabetic and 6908 nondiabetic subjects free of coronary heart disease and a history of stroke at study entry. In 12 years of follow-up, 62.3 per 1000 diabetic men and 32.7 per 1000 nondiabetic men experienced a stroke. The relative risk of thromboembolic stroke for those with diabetes compared with those without diabetes was 2.0 (95% confidence limits, 1.4 to 3.0). Although diabetes was usually associated with an atherogenic risk profile, control of hypertension, complicating myocardial infarction, and other risk factors failed to diminish the effect of diabetes on stroke. Among those without diabetes, the relative risk of thromboembolic stroke for those at the 80th percentile of serum glucose level compared with those at the 20th percentile (199 vs 115 mg/dL [11.0 vs 6.4 mmol/L]) was 1.4 (95% confidence limits, 1.1 to 1.8). In the nondiabetic sample, the relative risk of thromboembolic stroke for those with glucosuria compared with those without glucosuria was 2.7 (95% confidence limits, 1.6 to 4.5). There was no association between diabetes, or measures of glucose intolerance, and hemorrhagic stroke. We conclude that diabetes, even in a possibly undiagnosed subset of hyperglycemic individuals, imparts an additional independent risk of stroke unexplained by clinically measured risk factors.

Relationship of magnesium intake and other dietary factors to blood pressure: the Honolulu heart study

Associations between blood pressure and intakes of 61 dietary variables assessed by 24-h recall method were investigated in 615 men of Japanese ancestry living in Hawaii who had no history of cardiovascular disease or treated hypertension. Magnesium, calcium, phosphorus, potassium, fiber, vegetable protein, starch, vitamin C, and vitamin D intakes were significant variables that showed inverse associations with blood pressure in univariate and a multivariate analyses. Magnesium had the strongest association with blood pressure, which supports recent interest in its relation to blood pressure. Nevertheless, it was not possible to separate the effect of magnesium from that of other variables because of the problem of high intercorrelation among many nutrients. While recommendations based upon cross-sectional studies must be viewed cautiously, these results suggest that foods such as vegetables, fruits, whole grains, and low-fat dairy items are major sources of nutrients that may be protective against hypertension.

Plasma lipids and lipoproteins in elderly Japanese-American men

Knowledge about blood lipids in older individuals is limited. In the Lipoprotein Study of the Honolulu Heart Program, plasma cholesterol, triglyceride, and high-density lipoprotein (HDL) were measured during 1980 and 1981 in Japanese-American men over 60 years of age. In addition, low-density lipoprotein cholesterol (LDL-C) was estimated via a regression model. Age-related differences in mean lipid levels between the youngest (60 to 64 years) and the oldest (75 years and older) groups included a decrease in total cholesterol from 214 to 207 mg/dL and plasma triglyceride from 188 to 144 mg/dL. High density lipoprotein cholesterol rose from 47 to 49 mg/dL and LDL was relatively stable (137 and 135 mg/dL, respectively). Age-adjusted total cholesterol tended to significantly increase with increasing body mass index and hematocrit but was not significantly related with systolic blood pressure, physical activity index, cigarettes per day, or alcohol intake. Among those variables HDL-C decreased significantly with increasing body mass index and hematocrit and increased significantly with increasing alcohol intake. Compared with elderly white men in the Lipid Research Clinic Program, total cholesterol values tended to be slightly higher and triglyceride values were substantially higher, whereas HDL and LDL values were appreciably lower. Both cholesterol and triglyceride values were substantially higher than values reported from Japan from men in these age groups.

Risk of stroke in male cigarette smokers

From 1965 to 1968, the Honolulu Heart Program began following 8006 men of Japanese ancestry in a prospective study of cardiovascular disease. Of the subjects who had not had a stroke by the time of study entry, 3435 were cigarette smokers and 4437 were nonsmokers. In 12 years of follow-up, 171 smokers and 117 nonsmokers had a stroke. As compared with nonsmokers, cigarette smokers had two to three times the risk of thromboembolic or hemorrhagic stroke, after control for age, diastolic blood pressure, coronary heart disease, and other risk factors (P less than 0.001). Subjects who continued to smoke in the course of follow-up had the highest risk of stroke. When these subjects were compared with those who never smoked, their risk of hemorrhagic events was increased four- to six-fold (P less than 0.001). Subjects who were smokers at study entry but stopped smoking in the course of follow-up had a slight excess risk of stroke. When these subjects were compared with those who continued to smoke, however, their risk was reduced by more than half after adjustment for risk factors (P less than 0.05), indicating that stopping smoking had significant benefits.

Biological and dietary correlates of plasma lipids and lipoproteins among elderly Japanese men in Hawaii

The relationships of plasma total cholesterol (total-C), high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C), and triglyceride (TG) to a variety of personal attributes were investigated cross-sectionally in a random sample of approximately 1360 elderly Japanese men, aged 60-81 years, in Hawaii. In multivariate analyses, total-C was positively related to hematocrit (p less than 0.01); LDL-C was positively related to hematocrit (p less than 0.0001), and inversely related to alcohol consumption (p less than 0.0001); HDL-C was positively related to alcohol consumption (p less than 0.0001) and physical activity index (p less than 0.05), and inversely related to body mass index (p less than 0.0001) and antihypertensive medication (p less than 0.05); and LogTG was positively related to body mass index (p less than 0.0001), alcohol consumption (p less than 0.0001), antihypertensive medication (p less than 0.0001), and diastolic blood pressure (p less than 0.01), and inversely related to physical activity index (p less than 0.01). Body mass index and alcohol consumption were the most important correlates of plasma lipids and lipoproteins. Several dietary variables were significantly related to each lipid or lipoprotein fraction after controlling for nondietary variables, but their independent contributions were generally quite modest.

Alcohol and hemorrhagic stroke. The Honolulu Heart Program

Since 1965, the Honolulu Heart Program has followed up 8,006 men in a prospective study of cardiovascular disease. Of those subjects free of stroke at the time of study entry, 2,916 were classified as nondrinkers of alcohol and 4,962 as drinkers. In 12 years of follow-up, 197 drinkers and 93 nondrinkers experienced a stroke. No significant relationships were noted between alcohol and thromboembolic stroke. When compared with nondrinkers, however, the risk of hemorrhagic stroke more than doubled for light drinkers and nearly tripled for those considered to be heavy drinkers. These findings are statistically significant and independent of hypertensive status and other risk factors. Results further indicate that alcohol has a greater effect on hemorrhagic strokes that are subarachnoid in origin, conferring a threefold to fourfold increased risk for moderate and heavy drinkers compared with nondrinkers.

Coffee, caffeine, and serum cholesterol in Japanese men in Hawaii

The relationship between coffee consumption and serum cholesterol was investigated in a cohort of 5,858 Japanese males born in 1900-1919 and living in Hawaii in 1965 who are currently followed by the Honolulu Heart Program. Data on coffee consumption, other dietary variables from a 24-hour dietary recall, and other potentially confounding variables collected in 1965 were correlated with serum cholesterol at that examination and at examination six years later. The mean coffee and tea consumption was 3.4 and 1.8 cups/day, respectively. Those consuming no coffee had a mean serum cholesterol of 210 mg/dl, while that of those drinking 9+ cups/day was 220 mg/dl (no such relationship was apparent with tea or cola). The relationship of coffee consumption and serum cholesterol with potentially confounding variables including body mass index, cigarette smoking, diastolic blood pressure, alcohol consumption, physical activity index, serum glucose, serum uric acid, education, age, and fat consumption was examined. When these variables were entered into a multiple regression equation with coffee consumption, a significant relationship between coffee consumption and serum cholesterol (p less than 0.001) persisted, as did that between baseline coffee consumption and serum cholesterol six years later (p less than 0.001). There was no significant relationship between tea or cola, the other major caffeine contributors to the diet, and baseline serum cholesterol. Thus, this analysis indicates a significant positive relationship between coffee consumption and serum cholesterol which is not present with other sources of caffeine.

Psychosocial processes and cancer incidence among Japanese men in Hawaii

As part of the Honolulu Heart Program studies, 4,581 men of Japanese ancestry living in Hawaii completed a psychosocial questionnaire in 1971. By 1980, 280 new cancer cases had been recorded. Among 12 items related to stressful life situations, there were no consistent associations with total or site-specific cancer incidence. Most of the associations which were found were in the direction opposite to that predicted by the stress hypothesis. Among eight items related to social networks, two were significantly associated with total cancer incidence in multivariate analysis, but one of these associations was in the direction opposite to that of the social support hypothesis. Among the different measures of acculturation, there was a general pattern indicating that ties to traditional Japanese culture and diet were associated with an increased risk of cancer. Cancer incidence was associated with low levels of socioeconomic status. In general, there was little evidence to support the idea that either stressful or supportive life situations were associated with cancer incidence.

Sodium-losing nephropathy and nephrocalcinosis after transplantation

Severe, prolonged sodium-wasting (up to 38% FENa) occurred in a man after he received a cadaveric-donor kidney. Posttransplantation supplementation with large amounts of saline and/or salt tablets was mandatory. Fludrocortisone had no clinically apparent effect. Plasma renin activity and plasma aldosterone concentration were markedly increased. As chronic rejection progressed, the syndrome ameliorated. Renal biopsy showed cellular rejection and nephrocalcinosis.

Ten-year incidence of coronary heart disease in the Honolulu Heart Program. Relationship to nutrient intake

Nutrient intake was determined in over 8000 men of Japanese ancestry residing on the island of Oahu. Nutrient determination took place at the initial examination during the years 1965-1968. This report relates nutrient intake to the risk of developing coronary heart disease in the 10 years subsequent to the initial examination. Men who developed coronary heart disease had a lower average intake of calories, carbohydrates, starch, and vegetable protein than men who remained free of coronary heart disease. Men who developed coronary heart disease also had a higher mean intake of percentage of calories from protein, fat, saturated fatty acids, and polyunsaturated fatty acids than men who remained free of coronary heart disease. These men also had a significantly lower mean percentage of calories from carbohydrates and a higher mean ingestion of cholesterol per 1000 calories than men who remained free of coronary heart disease. In multivariate analyses including age, systolic blood pressure, serum cholesterol, cigarettes smoked per day, and physical activity index, carbohydrates, vegetable protein, percentage of calories from saturated fatty acids, and percentage of calories from polyunsaturated fatty acids are no longer significantly related to incidence.

Ten-year incidence of coronary heart disease in the Honolulu Heart Program. Relationship to biologic and lifestyle characteristics

In 10 years of follow-up of 7705 Japanese men living in Hawaii, aged 45-68 years and judged free of coronary heart disease (CHD) at the initial examination during 1965-1968, a total of 511 new CHD cases were identified: fatal CHD, 139; nonfatal myocardial infarction (MI), 216; acute coronary insufficiency, 55; and uncomplicated angina pectoris (AP), 101. The incidence rate of fatal CHD and nonfatal MI for this cohort is less than half the rate for US whites and approximately twice the rate for Japanese men in Japan. The relationships of 14 biologic and lifestyle characteristics measured at baseline examination to the incidence of total CHD and specific manifestations of CHD were examined in bivariate and multivariate analyses. In bivariate analyses, all variables except heart rate were significantly related to the risk of total CHD after adjustment for age. However, when an independent contribution of each variable to CHD risk was evaluated in multiple logistic analyses in which all other variables were taken into account, the numbers of risk factors retaining significant associations varied by clinical subgroup of CHD. Among the characteristics studied, systolic blood pressure was the most powerful and consistent risk factor for all manifestations except AP. Cigarette smoking showed a similar pattern. Serum cholesterol was significantly associated with fatal CHD and nonfatal MI, but its contribution to CHD risk was less potent than systolic blood pressure or cigarette smoking. Glucose intolerance was strongly associated with fatal CHD, but with no other manifestations of CHD. Alcohol consumption demonstrated a strong protective effect upon fatal CHD and nonfatal MI. Uncomplicated AP was distinguished from other CHD manifestations by the lack of association with most of the known major risk factors for CHD, including blood pressure, serum cholesterol, and cigarette smoking.

Risk factors related to ischemic and hemorrhagic cerebrovascular disease at autopsy: the Honolulu Heart Study

This study of cerebrovascular lesions at autopsy among Hawaiian Japanese men identifies similar risks factors for cerebral infarction and hemorrhage that have been identified in a previous incidence study. Demonstrated differences were essentially the same whether subjects with these tissue changes were compared to men showing no central nervous system disease at autopsy or when they were compared with men still alive. Cerebral infarcts accompanied myocardial infarction (CHD) in 58% of autopsy cases and were associated with CHD risk factors (high serum cholesterol, hypertension, severe atherosclerosis of the coronary arteries and aorta). These associations did not persist when CHD cases were removed from the analysis, indicating there were two subsets of men with cerebral infarction. Hypertension was strongly associated with hemorrhagic disease, as were cigarette use and alcohol consumption.

The impact of elevated blood pressure upon 10-year mortality among Japanese men in Hawaii: the Honolulu Heart Program

The impact of blood pressure upon total and cause-specific mortality during 10 years of follow-up was studied for 7610 Japanese men in Hawaii, aged 45-68 at baseline examination. The age adjusted rate of total mortality for men with definite hypertension (WHO criteria) was twice that for normotensive men. The relative risk of mortality was five for all cardiovascular diseases (CVD), four for coronary heart disease (CHD), and six for stroke. Men with borderline hypertension also had significantly high mortality rates intermediate between the definite hypertensives and the normotensives. Both systolic blood pressure (SBP) and diastolic blood pressure (DBP) were the most important independent predictors of total, CVD, CHD and stroke mortality in multivariate analysis, taking account of 11 other known risk factors. However, SBP was more strongly related to total, CVD and CHD mortality than was DBP, whereas the reverse was true for stroke mortality. There was no significant association of either SBP or DBP with cancer and other non-cardiovascular mortality in multivariate analysis. Men who were receiving antihypertensive medication at baseline examination had a higher mortality from CVD, CHD and stroke as compared to untreated men in every category of blood pressure status. This apparently paradoxical finding probably reflects more advanced status of hypertension existing before treatment rather than adverse effects of drugs per se; however, this latter possibility cannot be dismissed.

Human aldehyde dehydrogenase: improved purification procedure and comparison of homogeneous isoenzymes E1 and E2

An improved purification procedure of human aldehyde dehydrogenase (EC 1.2.1.3) isoenzymes E1 and E2 is presented. This procedure employs only three chromatographic steps to produce homogeneous E1 and E2 isoenzymes at 60% overall yield. The isoenzymes have been tested for homogeneity by electrophoresis of native and denatured species, specific activity determinations following rechromatography, as well as mapping of tryptic and CNBr fragments. Total SH group analysis has also been done on each isoenzyme. The results show that both isoenzymes are homogeneous. Similarities between E1 and E2 isoenzymes are noted in the mobility of about 40% of tryptic fragments, total SH content, and the mobility of two CNBr fragments. The results also show considerable structural differences between the isoenzymes in that CNBr maps show fragments from E1 and E2 of different molecular weight and about 60% of tryptic fragments migrate to distinct locations. Only one of SH-containing tryptic fragments migrates to the same location in both isoenzymes. E1 and E2 each consist of subunits which migrate as single bands in both sodium dodecyl sulfate (SDS) and urea electrophoresis. While the mobility of E1 and E2 subunits in SDS gels is similar, it is different in urea, showing that subunits of E1 are distinct from those of E2 and that the isoenzymes do not share subunits. Structural similarity between isoenzymes must, therefore, result from sequence similarity within regions of distinct polypeptide chains composing E1 and E2 molecules. The results presented offer a simplified procedure for preparation of the homogeneous isoenzymes; they also suggest that E1 and E2 are products of distinct genes which probably diverged from a common genetic ancestor through gene duplication and compartmentation of the cell.

Antibiotic use review in ambulatory care using computer-assisted medical record audit

The use of a computer-assisted medical record audit (CAMRA) for reviewing antibiotic use in ambulatory patients was evaluated. A random sample of 40 medical records documenting treatment of streptococcal pharyngitis, otitis media, or acute, uncomplicated urinary tract infections at two family practice clinics was used to evaluate the accuracy and efficiency of computerized prescription screening and CAMRA relative to medical record audit (MRA) alone. Accuracy was the ability to correctly classify antibiotic therapy as appropriate or inappropriate. The initial computerized prescription screening criteria were modified to reduce the proportion of false positives and negatives and a second random sample of 40 medical records was audited. The computerized prescription screening was the most efficient method, requiring less than one hour of professional time to audit 80 medical records. MRA and CAMRA took 17.4 and 3.0 hours, respectively. By definition, MRA was 100% accurate. Computerized prescription screening and CAMRA correctly classified 73% and 78% of the medical records, respectively. The results of this study are similar to a previous study reviewing antihypertensive therapy, but this study showed CAMRA less favorably. This is primarily because of the many diagnoses for which a particular antibiotic can be prescribed and the wide dosage ranges for antibiotics based on body weight. CAMRA could be more useful for evaluating antibiotic therapy if diagnostic information were available before doing the computerized prescription screening and if the computerized prescription screening criteria included patient diagnosis and body weight.

Brain aldehyde dehydrogenase in human alcoholics and controls

Human postmortem brain samples from temporal lobe of 23 alcoholics and 19 controls (13 with cancer and six without cancer) were used for determination of low Km (micromolar) and high Km (millimolar) aldehyde dehydrogenase activity. Despite histories of severe alcoholism leading to death through multiple complications, the mean values for either low or high Km activity did not differ significantly from that of controls similarly studied.

The epidemiology of respiratory distress syndrome in Norway

Information collected through the Medical Birth Registry of Norway on a seven-year cohort of 457,465 live births for the years 1967--73 were used to determine the factors associated with the risk of respiratory distress syndrome (RDS). A total of 1235 cases were identified and 510 of these died, resulting in an incidence rate of 2.7 and a mortality rate of 1.1 per 1000 live births. From a geographic breakdown of counties there was no association of the incidence or mortality of RDS with such environmental factors as latitude, longitude, urbanization, industrialization or level of obstetric care. There was an increase in reported incidence and mortality over time, and a slight peak during fall months. The major factors associated with the risk of RDS in Norway were birth weight, gestational age, male sex, cesarean sections and some other complications of pregnancy or delivery. When rates were adjusted for birth weight and gestational age there was no association with maternal age, parity or marital status. Such adjustments reversed the risk of RDS among multiple births to a rate lower than that for single births.

Current health problems in the South and Central Pacific

Tabulation of monthly reports of infectious diseases from 19 countries and territories in the South and Central Pacific for the years 1973 through 1975 indicated that influenza-like illness, dengue, dysentery, measles, and gonorrhoea were the greatest problems. Reports of the leading causes of hospitalisation from 11 areas indicated that infectious respiratory disease, gastroenteritis and accidents were the most common problems requiring hospitalisation in most Pacific countries. The leading causes of death showed a different pattern with striking differences between traditional and modernised areas. It appeared that the major causes of death were changing from infectious diseases in the traditional areas to chronic diseases such as cardiovascular disease and cancer in the modernised areas.

Amyotrophic lateral sclerosis and parkinsonism-dementia on Guam, 1945-1972. I. Descriptive epidemiology

An overview of the epidemiologic studies of amyotrophic lateral sclerosis (ALS) and parkinsonism-dementia (PD) from 1945 through 1972 is presented. During this period 350 cases of ALS were documented. PD, which is apparently unique to the native Chamorro population, was not recognized during the early years of the study. A total of 213 PD patients have now been seen. The rates of both diseases have declined by approximately 50 per cent since 1965. In the early years incidence per 100,000 for ALS males approached 60; for females it was about 40. For PD males it was about 50; for females it was close to 20. The declines in both diseases have occurred in both sexes and at all age groups and no cohort phenomenon was observed. Marked geographic differences in the distribution of the diseases were observed with southern villages having the highest rates and western villages having the lowest rates; the remainder of the island was intermediate. Recent declines have been most marked in the southern high-rate villages. Chamorros living on the island of Rota have rates similar to those on Guam; those on Saipan have lower rates. A possible excess of ALS among Filipino residents ofGuam was noted; ALS has not been seen among other ethnic groups. Geographic mapping even in high incidence areas did not reveal true clusters or foci. Extensive case-control studies did not reveal any patterns of prior illness, life-style, or exposures distinguishing patients. A tendency for patients to be of somewhat lower socioeconomic level, have less education, eat more homegrown foods and raw meats, and more contact with animals was found. No Mendelian genetic patterns were observed; males were affected more frequently than female for both diseases. Cases did not occur before age 20, reached maximum frequency between ages 55 and 65 and there-after declined. Environmental factors associated with some aspects of the traditional way of life seem to be causally involved, but, since most aspects of the traditional life have changed in the past 50 years, the specific factors remain elusive.

Amyotrophic lateral sclerosis and parkinsonism-dementia on Guam, 1945-1972. II. Familial and genetic studies

The extraordinarily high rate of amyotrophic lateral sclerosis (ALS) and parkinsonism-dementia (PD) in the Chamorro linguistic group on Guam suggested a genetic etiology for these diseases. Results of three studies are described. Two involved comparisons of the rates of disease in relatives and spouses of index patients and controls. In the third we examined offspring of doubly affected parents, 10 spouse pairs with ALS, 3 spouse pairs with PD and 13 spouse pairs in which 1 spouse had ALS and the other PD. Within the limitations of numbers and age of offspring, we found a tendency among siblings and offspring of ALS cases to have a higher risk than control relatives. Numbers were small and in no instance were significant differences encountered. Spouses of patients had at least as high risk of developing ALS or PD as any of the groups of blood relatives. A slightly higher age-specific rate of ALS and PD occurred in the offspring of doubly affected parents. The only group large enough for present analysis are 60 offspring of doubly affected ALS parents over the age of 20. Thus far only 3 have developed ALS. Within our entire patient population of 350 ALS cases and 219 PD cases there were 12 instances in which one parent of the patient was not Chamorro. In addition there is a consistent two- to threefold excess of affected males which could not be accounted for by competitive risks of death from other causes among females. While a familial tendency does exist these findings and observations are not compatible with any simple Mendelian form of inheritance. It is possible that genetic influences affect the occurrence of these diseases but our studies suggest that environmental factors play at least as important a role.

Predicting the duration of Guam amyotrophic lateral sclerosis

During the years of study of amyotrophic lateral sclerosis on Guam we have observed a wide range in clinical signs and rate of progression of the disease. Some patients died within 6 months of onset, while others have lived for 20 years. It was our assumption that some aspects of the early neurologic involvement would be related to length of survival, and hence be of prognostic value. We found that an early age at onset and male sex were associated with longer survival. The detailed analysis of degree of involvement of four major neurologic components of amyotrophic lateral sclerosis (progressive muscular atrophy, lateral sclerosis, bulbar paralysis, and pseudobulbar palsy) showed no meaningful pattern of association with duration of illness that could be useful in predicting the course.