Genome-wide search for genes related to the fat-free body mass in the Québec family study

Fat-free mass (FFM) consists mostly of skeletal muscle and bone tissues, and identification of the genes and molecular mechanisms involved in the control of FFM would have implications for the understanding of sarcopenia and potentially osteoporesis associated with aging, as well as the response to starvation, refeeding, anorexia, and any other conditions in which lean body mass is important. A genome-wide search for genes related to body leanness has been completed in the Quebec Family Study (QFS). Microsatellite markers (N = 292) from the 22 autosomal chromosomes were typed. The mean spacing of the markers was 11.9 centimorgans (cM) (range, <0.1 to 41). FFM was calculated from percent body fat, derived from underwater weighing, and body weight and was adjusted by regression for age and sex effects before analysis. A maximum of 336 sib pairs or 609 pairs of extended relatives were analyzed using single-point Haseman-Elston regression (SIBPAL and RELPAL) and multipoint variance component (SEGPATH) linkage analyses. Significant linkages were observed on chromosomes 15q25-q26 for a CA repeat within the insulin-like growth factor 1 receptor (IGF1R) gene (Lod score = 3.56) and at 18q12 with D18S877 (Lod score = 3.53) and D18S535 (Lod score = 3.58), 2 markers located 10 cM apart. A moderately significant linkage was also observed on chromosome 7p15.3 with the marker D7S1808 (Lod score = 2.72). The most obvious candidate genes within the regions identified by these linkages include the IGF1R on 15q and neuropeptide Y (NPY) and growth hormone-releasing hormone (GHRH) receptor on 7p. On 18q, the melanocortin receptor 4 (MC4R) is not likely the candidate gene for the observed linkage. This study represents the first genome-wide search for genes that may be involved in the regulation of the lean component of body mass in humans.

A tale of two bounties: the impact of competing fees on physician behavior

This study examines how the volume of privately insured services provided in hospital inpatient and outpatient departments changes in response to reductions in Medicare physician payments. We hypothesize that physicians consider relative payment rates when choosing which patients to treat in their practices. When Medicare reduces its payments for surgical procedures, as it did in the late 1980s, physicians are predicted to treat more privately insured patients because they become more lucrative. We use data from 182 hospitals for seventeen major procedures groups, covering a forty-five-month period between 1988 and 1991 that encom passes a twenty-four-month period before the reduction in Medicare fees and twenty-one months after the reduction. Our findings are consistent with the predictions for a number of procedure groups, but not for all of them. One implication of the findings is that societal savings from Medicare fee reductions are overstated if one does not also consider spillover effects in the private insurance market.

Reproducibility of maximal exercise test data in the HERITAGE family study

PURPOSE

The reproducibility of responses to maximal cycle ergometer testing was determined using data from the HERITAGE Family study at four Clinical Centers in the United States and Canada.

METHODS

Reproducibility was determined from maximal exercise test data obtained a) on 2 d in a sample of 390 subjects (198 men and 192 women), b) across 4 d in an Intracenter Quality Control (ICQC) substudy with 55 subjects who were not part of the main study, and c) across 2 wk in a Traveling Crew Quality Control (TCQC) substudy with the same eight subjects who were tested at each of the four centers. Reproducibility was evaluated using technical errors, coefficients of variation (CV) for repeated measures, and intraclass correlation coefficients (ICC) for selected variables obtained on the main cohort, as well as on the ICQC and TCQC substudies.

RESULTS

With the exception of systolic and diastolic blood pressures and respiratory exchange ratio, all the other variables (heart rate, ventilation, VO2, and VCO2) were highly reproducible, with CV below 10% and ICC over 0.86. These results were similar to those previously reported on the same subjects at a submaximal power output associated with 60% VO2max. Results were consistent for the main cohort, the ICQC sample, the TCQC sample, and across all four Clinical Centers.

CONCLUSIONS

Day-to-day variations are small and reproducibility is high for maximal values of heart rate, ventilation, VO2 and VCO2 at each of the four Clinical Centers of the HERITAGE Family Study.

Supplemental health insurance for Medicare beneficiaries

Because Medicare leaves beneficiaries at risk for significant health care costs, most need to obtain some form of supplemental coverage to protect themselves against the financial burden of illnesses. Close to nine out of ten Medicare beneficiaries age 65 or older now have some health coverage that provides additional benefits beyond standard Medicare Part A and Part B. The most common types of supplementation are insurance coverage offered by former employers, policies that individual beneficiaries purchase, benefits offered by Medicare managed care plans and assistance provided through the Medicaid program. This supplementation is expensive--to beneficiaries, employers, states, and to the federal government. The availability and extent of financial protection offered by supplemental coverage provided by former employers and through managed care also appears to be increasingly unstable. Structural reform of the Medicare program needs to include a broad reexamination of the basic benefits package and of the potential benefits and costs of public and private supplementation of the health insurance coverage promised to beneficiaries.

Extrauterine abdominal pregnancy: report of a case

A healthy, 34-year-old, gravida 3, para 1,011, patient presented for cesarean delivery in her 35th week of gestation with a diagnosis of complete placenta previa. During her 26th week of gestation, the patient was admitted to a high-risk obstetric unit with the diagnosis of premature rupture of membranes. Numerous ultrasonographic studies were conducted throughout her 10-week hospital stay, confirming the admitting diagnosis. A routine cesarean section was planned, and preparations were made for a potential increase in blood loss related to the placenta previa. The procedure began under spinal anesthesia and, upon incision of the abdomen, an extrauterine pregnancy was identified. The patient was immediately anesthetized and intubated at the request of the surgeon. During the 3-hour surgical procedure, the patient sustained massive blood loss, transfusions, central line placement, and aggressive pharmacological therapy. The patient was extubated the day after surgery, and was discharged approximately 1 week later. The only major complication was compartment syndrome of the left upper extremity related to the infiltration of vasopressors requiring fasciotomy and closure 2 days later. The incidence, morbidity/mortality, and anesthetic implications of abdominal pregnancy are reviewed.

Total body fat and abdominal visceral fat response to exercise training in the HERITAGE Family Study: evidence for major locus but no multifactorial effects

The familial etiology of the response in total fat mass (FM) and abdominal visceral fat (AVF) to 20 weeks of exercise training was investigated in families participating in the HERITAGE Family Study. AVF (measured by computed tomographic scanning) and FM (measured by underwater weighing techniques) were assessed at baseline (in a sedentary state) and after 20 weeks of exercise training. The response AVF (AVFdelta) and response FM (FMdelta) were computed as the simple delta values (posttraining - baseline) and adjusted for the effects of sex, generation, and a polynomial in age using multiple regression analysis. To index the AVF response independently of the response in FM and the initial level of visceral fat, the AVFdelta was also adjusted for age and baseline AVF (AVFB) and FMdelta. Familial correlation analysis was used to investigate the multifactorial familial effects (polygenic and/or familial environmental), and segregation analysis was used to search for major gene effects. For the age-adjusted AVFdelta, a putative recessive locus accounting for 18% of the variance (q2 = 1%) was detected. Adjusting AVFdelta for AVFB and FMdelta slightly increased the percentage of variance accounted for (to 26%, q2 = 3%) but did not radically alter the pattern of the parameter estimates. For FMdelta, a putative dominant locus accounting for 31% of the variance (q2 = 49%) was noted. In conclusion, the results were consistent across methods in suggesting that there is little evidence of a multifactorial heritability for either AVFdelta or FMdelta. Rather, the familial etiology of the response to exercise training appears to be primarily due to putative major genes (a recessive locus for AVFdelta and a dominant locus for FMdelta). In addition, a pleiotropic/oligogenic system underlying these variables was inferred. That is, the putative loci for FMdelta and/or AVFB also may impact the AVFdelta, with an additional independent major locus effect on AVFdelta after the former influences have been removed.

Alterations in body weight and composition consequent to 20 wk of endurance training: the HERITAGE Family Study

BACKGROUND

Obesity is a major public health problem in the United States. The role of physical activity and formal exercise in controlling body weight has not been clearly determined.

OBJECTIVE

This study determined the magnitude of change in body weight and composition across sex, race, and age in response to 20 wk of endurance training.

DESIGN

Men and women (n = 557) of various ages (16-65 y) and 2 races (black and white) exercised on cycle ergometers 3 d/wk for a total of 60 exercise sessions starting at 55% of maximal oxygen consumption (VO(2)max) for 30 min/session and building to 75% of VO(2)max for 50 min/session, where it was maintained during the last 6 wk. Skinfold-thickness measurements, circumferences, body composition (by hydrostatic weighing), and body fat distribution (by computed tomography scan at L4-L5 and the waist-hip ratio) were determined before and after training.

RESULTS

All skinfold-thickness and circumference measures, waist-hip ratio, body mass index, total body mass, fat mass, percentage body fat, and computed tomography scan measures of total, subcutaneous, and visceral abdominal fat decreased with training, whereas total body density and fat-free mass increased. These changes were significant, but small. There were several differences in training response by sex and race, but not by age.

CONCLUSIONS

A short-term exercise intervention can induce favorable changes in body composition, but the magnitude of these changes is of limited biological significance. Increasing physical activity likely has a major effect on body-composition and fat distribution characteristics only when it is of a greater magnitude and sustained for much longer periods

Body fat, resting and exercise blood pressure and the angiotensinogen M235T polymorphism: the heritage family study

OBJECTIVE

The association of resting and exercise blood pressure (BP) and fat mass with the angiotensinogen (AGT) M235T polymorphism was investigated in 522 sedentary Caucasian subjects from 99 families.

RESEARCH METHODS AND PROCEDURES

Resting BP was measured on two separate days, three times each day, and the mean of six valid measurements was used. Exercise BP was measured during a cycle ergometer test at a constant power output (50 W). Body composition was derived from under-water weighing and the AGT M235T polymorphism was typed with a polymerase chain reaction-based method.

RESULTS

Neither resting nor exercise BP was associated with the AGT genotypes. In mothers, the homozygotes for the T allele showed 8.8 kg and 7.1 kg greater (p=0.017) age-adjusted body fat mass (FM) than the MM homozygotes and heterozygotes, respectively. Sixty-nine percent of all TT homozygotes were found in the highest FM tertile, whereas only 16% of the MM homozygotes fell in the same tertile (p = 0.008). Moreover, a significant interaction was seen between FM and T-allele carrier status in women with regard to resting diastolic BP (p = 0.002). Among women with a FM> or =24 kg, carriers of the T allele showed a 6.3 mmHg higher diastolic blood pressure (DBP) than non-carriers whereas no difference was found in women with a FM less than 24 kg. A similar trend toward an interaction term was evident with resting systolic blood pressure (p = 0.011) and exercise DBP (p = 0.012). Body fat was not associated with the AGT polymorphism in fathers or in offspring.

DISCUSSION

These data suggest that the AGT M235T polymorphism is associated with body fatness in women, and that the relationship between DBP and AGT M235T polymorphism is dependent on FM in middle-aged sedentary normotensive women.

Familial aggregation of VO(2max) response to exercise training: results from the HERITAGE Family Study

The aim of this study was to test the hypothesis that individual differences in the response of maximal O(2) uptake (VO(2max)) to a standardized training program are characterized by familial aggregation. A total of 481 sedentary adult Caucasians from 98 two-generation families was exercise trained for 20 wk and was tested for VO(2max) on a cycle ergometer twice before and twice after the training program. The mean increase in VO(2max) reached approximately 400 ml/min, but there was considerable heterogeneity in responsiveness, with some individuals experiencing little or no gain, whereas others gained >1.0 l/min. An ANOVA revealed that there was 2.5 times more variance between families than within families in the VO(2max) response variance. With the use of a model-fitting procedure, the most parsimonious models yielded a maximal heritability estimate of 47% for the VO(2max) response, which was adjusted for age and sex with a maternal transmission of 28% in one of the models. We conclude that the trainability of VO(2max) is highly familial and includes a significant genetic component.

Segregation analysis of regional fat distribution in families from Andhra Pradesh, India

OBJECTIVE

Segregation analysis was used to examine the major gene evidence for regional fat distribution and whether the effects of covariates such as energy variables (intake and expenditure) or total subcutaneous fat, impact on the major gene inference.

SUBJECTS

The data consist of measurements made on 1691 individuals in 432 pedigrees residing in the Chittor district of Andhra Pradesh, India, during the period from January 1989 to February 1990.

MEASUREMENTS

Fat distribution was computed as the ratio of trunk skinfold sum (subscapular + suprailiac + abdominal) to extremity skinfold sum (biceps + triceps + medial calf). The trunk/extremity skinfold ratio (TER) was also analyzed after adjusting for the amount of energy expended in various activities and energy intake (TER-E), as well as after adjusting for overall level of fatness as measured by the sum of six skinfolds (TER-SF6).

METHODS

Segregation analysis was applied using the unified model (POINTER).

RESULTS

For the TER all of the conditions needed to satisfy a major gene hypothesis were met, and a putative recessive locus in the presence of a multifactorial component was inferred. Adjusting the TER for energy intake (EI) and energy expenditure (EE) did not change these results. However, adjusting for total subcutaneous fat did alter the results. Specifically, after removing the effects due to total fat, there was a major non-Mendelian effect (free tau s) with additional multifactorial influences, and with generation heterogeneity in both components.

CONCLUSIONS

A putative major locus for fat distribution as indexed by the TER was found. However, further analyses suggested the hypothesis that this major gene may be primarily for total fat with secondary effects on fat distribution (that is, major gene pleiotropy). The possibility that there is a second locus that is modified by interactions with gender and age, and that impacts on the preferential accumulation of fat in the trunk vs extremity depots could be inferred.

Should Medicare HMO benefits be standardized?

Legislation enacted in 1990 standardized Medigap benefits but not the benefits of health maintenance organizations (HMOs) that serve Medicare beneficiaries. An examination of marketing materials in two large counties reveals the potential for enormous confusion among beneficiaries because of differences in wording to describe the same benefit, health plans' failure to list Medicare-covered services, and the differences in the benefits themselves. To date, the Health Care Financing Administration (HCFA) has not been able to overcome this confusion through the comparative material distributed on its Web site; indeed, significant errors were found, reflecting to some extent the underlying difficulties in characterizing benefits. Ways of ameliorating the situation are discussed.

Evidence of a major locus for lipoprotein lipase (LPL) activity in addition to a pleiotropic locus for both LPL and fasting insulin: results from the HERITAGE Family Study

A major gene hypothesis for heparin releasable plasma lipoprotein lipase (PH-LPL) activity was assessed using segregation analyses of data on 495 members in 98 normolipidemic sedentary families of Caucasian descent who participated in the HERITAGE Family Study. Segregation analyses were performed on PH-LPL adjusted for age, and on PH-LPL activity adjusted for age and fasting insulin. Prior to adjustment for insulin, neither a major gene effect nor a multifactorial component could be rejected, and support for a major gene was equivocal i.e. neither the Mendelian transmission nor the no transmission (equal tau s) models were rejected. However, after adjusting for the effects of insulin, a major gene effect on PH-LPL activity was unambiguous. The putative locus accounted for 60% of the total phenotypic variance, and the homozygous recessive form affected 10% (q2) of the sample (i.e. gene frequency (q) = 0.31), and led to a low PH-LPL value. The lack of a significant multifactorial effect suggested that the familial etiology of PH-LPL activity adjusted for insulin was likely to be primarily a function of the major locus. In conclusion, the present study is the first to report segregation analyses on PH-LPL activity prior to and after adjusting for insulin, and suggests that there is an indication of a pleiotropic genetic effect on PH-LPL activity and insulin, in addition to a major gene effect on PH-LPL activity alone.

Segregation analysis of body mass index in a large sample selected for obesity: the Swedish Obese Subjects study

OBJECTIVE

To investigate a major gene hypothesis for body mass index (BMI) in a large sample of probands (n = 2580, ages 37-57 years) who were selected for obesity (BMI> or =34 kg/m2 for males and > or =38 kg/m2 for females), along with their spouses and first-degree relatives (n = 11,204 family members). The probands were recruited as part of an intervention trial assessing whether mortality and morbidity were improved after surgical intervention for obesity as part of the Swedish Obese Subjects (SOS) study.

METHODS AND PROCEDURES

The current analyses were based on BMI measures obtained before intervention. Segregation analysis was carried out using the mixed model implementation in PAP (Pedigree Analysis Package), which allowed for ascertainment correction and for genotype-dependent effects of covariates (sex and age) in both the major gene component and the multifactorial (i.e., polygenic and familial environment) component.

RESULTS

Both a major effect and a multifactorial effect were significant. The percentage of the total variance accounted for by the multifactorial effect was 17%-24% (increasing as a function of age), and by the major effect, 8%-34% (decreasing as a function of age). Although tests on the transmission probabilities (taus) were not compatible with Mendelian expectations of 1, 1/2, and 0, the equal taus model was rejected (i.e., the effect is transmitted in families) and the point estimates (0.96, 0.60, and 0.17) compared favorably to Mendelian expectations. The major effect was transmitted in a codominant fashion, consistent with a gene-environment interaction.

DISCUSSION

These results suggest both multifactorial and major effect etiologies for BMI in these families of extremely obese probands. Before 20 years of age, the major effect dominates the BMI expression, but after age 20, multifactorial effects account for the most variance. Although the major effect is transmitted in these families, the pattern does not appear to be consistent with a simple Mendelian trait. The possibility of additional major loci (i.e., epistasis) and gene by environment interactions may explain these findings.

Familial aggregation of resting blood pressure and heart rate in a sedentary population: the HERITAGE Family Study. Health, Risk Factors, Exercise Training, and Genetics

The familial aggregation of resting systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) was assessed in 98 white families, who participated in the HERITAGE Family Study, and were selected to be sedentary, and primarily nonobese and normotensive. In the present study, 522 family members were sedentary at baseline examination, and resting SBP, DBP, and HR measured during this examination were investigated. If physical activity level is a potent environmental factor, then we expected that the relative contribution of environmental factors to the familial aggregation of blood pressure (BP) would be somewhat reduced, because activity was controlled for in this study. Using a familial correlation model, maximal heritabilities were estimated to be 54%, 41%, and 32% for resting SBP, DBP, and HR, respectively, in these families; and they were 51%, 42%, and 34% for resting SBP, DBP, and HR, respectively, when the data were adjusted for body mass index. The estimates are somewhat higher for BP but similar for HR to those reported in previous family studies, suggesting that the distribution of the underlying etiologic factors in these sedentary families may be similar to those in the general population. There was substantial spouse resemblance in this study, which may be explained by a higher concordance for correlated lifestyle factors including diet, similar activity levels, or by assortative mating for relative weight or dietary preferences.

Familial clustering of insulin and abdominal visceral fat: the HERITAGE Family Study

Abdominal visceral fat (AVF) is an obesity-related phenotype thought to be associated with insulin resistance, diabetes mellitus, and atherosclerosis. Significant genetic influences on both AVF and insulin levels have been reported. However, information is lacking as to whether common genetic influences on AVF and insulin levels exist. AVF was assessed by computed tomography scan, and fasting insulin was measured by RIA in 512 members of 98 sedentary Caucasian families participating in the HERITAGE Family Study. Baseline data, collected before exercise training, were used in the present investigation. A bivariate familial correlation model was applied to evaluate whether there are familial influences that are common to insulin and AVF before and after adjustment for total fat mass (FM), and to assess the overall heritability of insulin and AVF. The maximal heritability for AVF, before and after adjustment for total FM, was 42% and 50%, respectively; and for insulin, it was 21%. Interestingly, 29% of the familial influences on insulin were also common to AVF, whereas 14% of the familial influences on AVF were shared by insulin. Furthermore, after AVF was adjusted for total FM, these common familial influences were increased to 48% and 20%. Genes and/or familial nongenetic factors with pleiotropic effects seem to influence both AVF and plasma insulin levels to a certain degree. Genes involved in the regulation of lipid storage and mobilization in the abdominal fat depot are potential candidates for these genetic pleiotropic effects.

Evidence for at least two major loci influencing human fatness

The genetics of human fatness has been the subject of many recent studies, motivated by the increased morbidity and mortality associated with obesity, as well as the increasing prevalence of overweight and obesity. The body-mass index (BMI) and fat mass (FM), measured by underwater weighing, were assessed for 1,630 individuals from approximately 300 families from phase 1 of the Quebec Family Study. The two phenotypes are highly correlated ( approximately .8) in adults, and previous segregation analysis revealed evidence for a recessive major gene for each trait. In our study, we utilized bivariate segregation analysis to determine the source(s) of phenotypic correlation-namely, a pleiotropic major gene, shared familial factors/polygenes, or shared nontransmitted environmental factors. Analysis was performed by use of the Pedigree Analysis Package, with extensions to the bivariate case. Tests of hypotheses provided evidence for two pleiotropic recessive loci, together accounting for 64% and 47% of the variance in BMI and FM, respectively. Under the model, all sources of phenotypic correlation were significant: 73% of the covariance was attributed to the pleiotropic major loci, 8% to residual familial effects, and 19% to nontransmitted environmental factors. The high degree of genetic identity between the two traits is not surprising, since the BMI often is used as a surrogate for FM; however, simultaneous analysis of both phenotypes enabled the detection of a second major locus, which apparently does not affect extreme overweight (as does the primary major locus) but which affects variation in the "normal" range.

Familial resemblance for VO2max in the sedentary state: the HERITAGE family study

This study investigates the familial resemblance of maximal oxygen uptake (VO2max) based on data from 86 nuclear families of Caucasian descent participating in the HERITAGE Family Study. In the current study, VO2max was measured twice on a cycle ergometer in 429 sedentary individuals (170 parents and 259 of their offspring), aged between 16 and 65 yr. The VO2max was adjusted by regression procedures for the effects of 1) age and sex; 2) age, sex, and body mass; and 3) age, sex, body mass, fat mass, and fat-free mass, as determined by underwater weighing. Evidence for significant familial resemblance was observed for each of the three VO2max phenotypes. Spouse, sibling, and parent-offspring correlations were significant, suggesting that both genetic and environmental factors contribute to the familial resemblance for VO2max. Maximal heritability estimates were at least 50%, a value inflated to an undetermined degree by nongenetic factors. The hypothesis of maternal inheritance, with the father's contribution being environmental, was also found to fit the data with estimates of maternal heritability, potentially associated in part with mitochondrial inheritance, reaching about 30%. These results suggest that genetic and nongenetic factors as well as maternal influences contribute to the familial aggregation of VO2max in sedentary individuals.

Familial resemblance for body composition measures: the HERITAGE Family Study

A sex-specific familial correlation model was used to assess the heritable contributions to several measures of body composition in 86 sedentary white families participating in the HERITAGE Family Study. For this study, sedentary families were recruited, tested for a battery of measures, endurance exercise trained for 20 weeks, and remeasured. This sample is unique in that activity level was controlled for in these families at baseline measurement. In this report, three body composition variables measured at baseline were analyzed, two indexing adiposity (total subcutaneous fat based on eight skinfold measurements [SF8] and percent body fat measured by underwater weighing techniques [%BF]) and one assessing fat free mass ([FFM] derived from underwater weighing). The maximal heritabilities for SF8 (34%) and %BF (62%) were consistent with those reported in previous studies. There were no sex nor generation differences in the familial correlations, and the spouse correlation was significant, consistent with the hypothesis that the familial aggregation reflects genetic and familial environmental factors. However, the results for FFM were very different. The most parsimonious pattern of familial resemblance was consistent with mitochondrial inheritance (i.e., mother-offspring and sibling correlations were equal and were larger than those for spouse and father-offspring pairs). Under the mitochondrial hypothesis, 39% of the variance was accounted for by familial/genetic effects. However, under a nonmitochondrial hypothesis, which could not be ruled out, 65% of the FFM phenotypic variance was accounted for by familial/genetic factors. This high heritability level, as compared with results from previous studies, is consistent with the hypothesis that activity may constitute an important environmental determinant of FFM. These alternative hypotheses for FFM warrant further investigation using complex multilocus-multitrait segregation models, which allow for major genetic, polygenic, and environmental sources of variance, as well as interactions among them.

Familial resemblance for abdominal visceral fat: the HERITAGE family study

OBJECTIVES

Abdominal visceral fat (AVF) is considered a risk factor for diabetes, atherogenic lipid profiles and hypertension. However, little is known about the genetic contribution to AVF as compared to total body fat.

DESIGN

AVF was assessed by computerized tomography, and total body fat (fat mass) was assessed by underwater weighing in 86 families participating in the Heritage Family Study. All family members were sedentary at baseline examination. The familial factors underlying the variability in age-adjusted AVF, age-fat mass-adjusted AVF and age-adjusted fat mass, were assessed using a familial correlation model.

RESULTS

The maximal heritability (including genetic and familial environmental effects) for AVF was comparable before (47%) and after (48%) adjusting for fat mass, and was 55% for fat mass itself in these sedentary families. Spouse correlations were significant for fat mass and for AVF prior to, but not after, adjustment for fat mass.

CONCLUSIONS

These results confirm the only previous study which investigated the familial aggregation of AVF (both in pattern and magnitude), suggesting that the factors underlying AVF in these sedentary families may be similar to those in the population at large. Although both genetic and familial environmental factors probably influence each of fat mass and AVF, there appears to be a predominantly genetic etiology for the visceral component which is independent of total body fat. These findings imply that some individuals are more at risk then others because of an inherited tendency to store abdominal fat viscerally rather than subcutaneously.

Cross-trait familial resemblance for body fat and blood lipids: familial correlations in the Quebec Family Study

In an attempt to better understand the genetic basis of the metabolic syndrome, we have undertaken a series of studies on the familial aggregation in the clustering of the coronary heart disease risk factors which characterize this syndrome. In the present study, the hypothesis of shared genetic (pleiotropy) and/or environmental factors between body fat and blood lipids is investigated by examining cross-trait (eg, father's body fat with his son's blood lipid) familial resemblance between 4 indicators of body fat (body mass index [BMI], sum of 6 skin folds [SF6]) and fat distribution (the ratio of the trunk to extremity skin folds adjusted [TER-sf] and unadjusted [TER] for SF6), and 5 blood lipid variables (total cholesterol [CH], triglycerides [TG], cholesterol associated with high-density lipoproteins [HDL], the CH/ HDL ratio and the difference between CH and HDL [CH-HDL]) measured in 1239 individuals from 309 families participating in the Quebec Family Study. A bivariate correlation model was used to obtain maximum likelihood estimates of cross-trait spouse, parent-offspring, and sibling correlations after adjustment of body fat and lipid data for the effects of age, separately in the four sex-by-generation groups. Likelihood ratio tests revealed the presence of significant (P < .05) cross-trait resemblance between body fat (BMI and SF6) and all lipid traits except CH and also between fat distribution (TER and TER-sf) and CH/HDL and CH-HDL. Only sibling cross-trait correlations were significant for all body fat-lipid pairs of measures, with bivariate familiality estimates (i.e., shared genetic and/or environmental factors) ranging from 8% to 40%. Although the hypothesis of genetic pleiotropy cannot be ruled out from the pattern of cross-trait correlations found in the present study, we conclude that environmental factors shared within sibships are probably more important than common genes in determining the covariation between body fat and blood lipids.

Familial resemblance of plasma lipids, lipoproteins and postheparin lipoprotein and hepatic lipases in the HERITAGE Family Study

The familial aggregation of lipids and lipoproteins and plasma postheparin triglyceride lipases was investigated in 86 Caucasian families participating in the HERITAGE Family study, a study investigating the role of genetic factors in the adaptation to exercise training and its relationships with cardiovascular disease risk factors. Accordingly, sedentary subjects were recruited, tested for a battery of measurements, exercise trained for 20 weeks, and were re-measured. The present report includes plasma levels of total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol and triglycerides, and postheparin plasma lipoprotein lipase (LPL) and hepatic lipase (HL) activities measured in 437 sedentary individuals (171 parents and 266 adult offspring) before training. Significant familial resemblance was observed for all the age-adjusted phenotypes. The pattern of familial correlations reveals no spouse correlations but significant parent-offspring and sibling correlations for total cholesterol, HDL-cholesterol and LDL-cholesterol with heritability (h2) estimates of 62%, 83%, and 50%, respectively. For plasma triglyceride concentrations (h2 = 55%) and HL activity (h2 = 40%), significant spouse correlations were found in addition to parent-offspring and sibling correlations, suggesting that common familial environment in addition to genetic factors contribute to the familial resemblance. For plasma LPL activity, there was no spouse correlation, but sex differences were found in the familial correlations with higher heritabilities in female pairs (h2 = 76%) compared to male pairs (h2 = 30%) and opposite-sex pairs (h2 = 44%). These results confirm the findings of previous family studies showing that genetic factors are major determinants of the familial resemblance in plasma lipids and lipoproteins and suggest the presence of sex differences in the heritability of postheparin LPL activity.

Segregation analysis of abdominal visceral fat: the HERITAGE Family Study

A major gene hypothesis for abdominal visceral fat (AVF) level, both before and after adjustment for total body fat mass, was investigated in 86 white families who participated in the HERITAGE Family Study. In this study, sedentary families were tested for a battery of measures (baseline), endurance exercise trained for 20 weeks, and then remeasured again. The baseline measures reported here are unique in that the variance due to a potentially important environmental factor (activity level) was limited. AVF area was assessed at L4 to L5 by the use of computerized tomography scan, and total body fat mass was assessed with underwater weighing. For fat mass, a putative locus accounted for 64% of the variance, but there was no evidence of a multifactorial component (i.e., no polygenic and/or common familial environmental effects). For AVF area, both a major gene effect accounting for 54% of the variance and a multifactorial component accounting for 17% of the variance were significant. However, after AVF area was adjusted for the effects of total level of body fat, the support for a major gene was reduced. In particular, there was a major effect for fat mass-adjusted AVF area, but it was not transmitted from parents to offspring (i.e., the three transmission probabilities were equal). The importance of this study is twofold. First, these results confirm a previous study that suggested that there is a putative major locus for AVF and for total body fat mass. Second, the findings from the HERITAGE Family Study suggest that the factors underlying AVF area in sedentary families may be similar to those in the population at large, which includes both sedentary and active families. Whether the gene(s) responsible for the high levels of AVF area is the same as that which influences total body fat content remains to be further investigated.

The impact of policy standardization on the Medigap market

This study examines the impact of policy standardization on the market for Medicare supplemental, or "Medigap," policies. Prior to 1992, insurance carriers could sell any benefits they chose, so long as minimum benefit requirements were met. In July 1992, federal legislation was implemented that required all new Medigap policies to conform exactly to one of 10 standardized sets of benefits. Using pre- and post-standardized policy information from six states, this study analyzes the impact of this legislation. Overall, standardization has affected the market positively, and as a result, consumers are better able to make informed choices about the benefits they are purchasing.

Motor control differentiates children's from adults' drawings for child and adult judges

In two exploratory studies, motor skill as a possible distinctive feature for differentiating drawings made by second-grade children and by college students was tested by having child and adult judges sort drawings made by children and by adults. Adults drew with their preferred (motorically skilled) or nonpreferred (nonmotorically skilled) hand. Children and adults were equally accurate in discriminating children's from adults' preferred-hand drawings, but child judges confused children's and adults' non-preferred-hand drawings. Child, but not adult, judges confused adults' preferred-hand and adults' non-preferred-hand drawings. Thus, children were sensitive to characteristics of drawings that depended on motor skill when it was an additional feature of difference but not when it was the only distinctive feature. Motor control effects in constructing drawings and evidence of motor control in responding to drawings warrant further study and perhaps greater emphasis in theories of drawing development.

Can markets give us the health system we want?

The purpose of this article is to reconsider the foundations of health economics as applied to the study of competition. It shows that conclusions concerning the purported desirability of competitive markets are based on a number of assumptions--many of which have heretofore been ignored--that typically are not fulfilled in the health care area. Once this is recognized market mechanisms no longer necessarily provide the best way to improve social welfare. The article is divided into two parts: competition and demand. Each of these sections presents and then critiques key assumptions of the conventional economic model, and then provides a number of health applications. It concludes that by not considering the validity of these assumptions in health care applications, researchers and policy analysts will bind themselves to policy options that may be most effective in improving social welfare.

Physician payment policies: impacts and implications

This paper reviews recent changes in physician payment policies, examines evidence on their impacts, and discusses their implications for researchers and policy makers. It first develops a conceptual framework to help explore the economic incentives inherent in different physician payment schemes. It then reviews evidence on the impacts of recent changes in physician payment methods; first, for free-for-service, and then for capitated systems like HMOs. It concludes that much more research needs to be conducted on HMOs to determine the impact of different physician payment incentives on utilization, expenditures, clinical outcomes, and patient satisfaction.

Epidemiology of colonisation of patients and environment with vancomycin-resistant enterococci

BACKGROUND

Vancomycin-resistant enterococci (VRE) have emerged as nosocomial pathogens during the past 5 years, but little is known about the epidemiology of VRE. We investigated colonisation of patients and environmental contamination with VRE in an endemic setting to assess the importance of different sources of colonisation.

METHODS

Between April 12, and May 29, 1995, cultures from body sites (rectum, groin, arm, oropharynx, trachea, and stomach) and from environmental surfaces (bedrails, drawsheet, blood-pressure cuff, urine containers, and enteral feed) were obtained daily from all newly admitted ventilated patients in our medical intensive-care unit (MICU). Rectal cultures were obtained from all non-ventilated patients in the MICU. Strain types of VRE were determined by pulsed-field gel electrophoresis.

FINDINGS

There were 97 admissions of 92 patients, of whom 38 required mechanical ventilation. Colonisation with VRE on admission was more common in ventilated than in non-ventilated patients (nine [24%] vs three [6%], p < 0.05). Of the nine ventilated patients colonised with VRE on admission, one acquired a new strain of VRE in the MICU. Of the 29 ventilated patients who were not colonised with VRE on admission, 12 (41%) acquired VRE in the MICU. The median time to acquisition of VRE was 5 days (interquartile range 3-8). Of the 13 ventilated patients who acquired VRE, 11 (85%) were colonised with VRE by cross-colonisation. VRE were isolated from 157 (12%) of 1294 environmental cultures. The rooms of 13 patients were contaminated with VRE, but only three (23%) of these patients subsequently acquired colonisation with VRE. Pulsed-field gel electrophoresis of 262 isolates showed 20 unique strain types of VRE.

INTERPRETATION

Frequent colonisation with VRE on MICU admission and subsequent cross-colonisation are important factors in the endemic spread of VRE. Persistent VRE colonisation in the gastrointestinal tract and on the skin, the presence of multiple-strain types of VRE, and environmental contamination may all contribute to the spread of VRE.

Familial correlations in the Québec family study: cross-trait familial resemblance for body fat with plasma glucose and insulin

This study represents one component in our investigation of the familial factors underlying the insulin resistance (or metabolic) syndrome involving obesity, hyperinsulinaemia, glucose intolerance, dyslipidaemia, and hypertension. Here we examine the cross-trait familial resemblance between four measures of body size (two assessing total fat [body mass index and sum of six skinfolds] and two assessing fat patterning [ratio of trunk skinfold sum to extremity skinfold sum, adjusted and unadjusted for total subcutaneous fat]) with fasting plasma levels of glucose, insulin, and the ratio of insulin to glucose (IGR) in non-diabetic families participating in phase 1 of the Québec Family Study. A bivariate familial correlation model assessed both intraindividual (e.g. father's body size with father's insulin) and interindividual (e.g. father's body size with son's insulin) cross-trait associations. Intraindividual correlations suggested a greater degree of cross-trait associations for body fat (rather than fat distribution) measures with insulin and the IGR (rather than with glucose) levels. While the intraindividual correlations were significant for most cross-trait comparisons, only the sum of six skinfolds evidenced any familial association (i.e. interindividual resemblance) with insulin and the IGR. Specifically, cross-trait parent-offspring (but not sibling or spouse) correlations were significant, with a bivariate familiality estimate (i.e. polygenic and/or common familial environment) of about 8%. While the lack of sibling correlations does not suggest a simple familial hypothesis, a more complex genetic effect underlying the common covariation between total body fat with insulin and IGR cannot be ruled out.

A comparison of the effect of universal use of gloves and gowns with that of glove use alone on acquisition of vancomycin-resistant enterococci in a medical intensive care unit

OBJECTIVE

To determine the efficacy of the use of gloves and gowns compared with that of the use of gloves alone for the prevention of nosocomial transmission of vancomycin-resistant enterococci.

DESIGN

Epidemiologic study and controlled, nonrandomized clinical trial.

SETTING

University-affiliated, 900-bed, urban teaching hospital in which vancomycin-resistant enterococci are endemic.

PATIENTS

181 consecutive patients admitted to the medical intensive care unit for 48 hours or more.

INTERVENTION

It was determined that all hospital employees would always use gloves and gowns when attending 8 particular beds in the medical intensive care unit and would always use gloves alone when attending 8 others. Compliance with precautions was monitored weekly. Rectal surveillance cultures were taken from patients daily. Cultures of environmental surfaces, such as those of bed rails, bedside tables, and other frequently touched objects in patient rooms and common areas, were taken monthly. Pulsed-field gel electrophoresis was used for molecular epidemiologic typing of vancomycin-resistant enterococci.

MEASUREMENTS

The number of patients becoming colonized by vancomycin-resistant enterococci; the number of days to acquisition of vancomycin-resistant enterococci; and other measurements, including nosocomial infections, length of hospital stay, and mortality rates.

RESULTS

The 93 patients in glove-and-gown rooms and the 88 patients in glove-only rooms had similar demographic and clinical characteristics. Fifteen (16.1%) patients in the glove-and-gown group and 13 (14.8%) in the glove-only group had vancomycin-resistant enterococci on admission to the medical intensive care unit. Twenty-four (25.8%) patients in the glove-and-gown group and 21 (23.9%) in the glove-only group acquired vancomycin-resistant enterococci in the medical intensive care unit. The mean times to colonization among the patients who became colonized were 8.0 days in the glove-and-gown group and 7.1 days in the glove-only group. None of these comparisons were statistically significant. Risk factors for acquisition of vancomycin-resistant enterococci induced length of stay in the medical intensive care unit, use of enteral feeding, and use of sucralfate. Compliance with precautions was 79% in glove-and-gown rooms and 62% in glove-only rooms (P < 0.001). Only 25 of 397 (6.3%) environmental cultures were positive for vancomycin-resistant enterococci. Nineteen types of vancomycin-resistant enterococci were documented by pulsed-field gel electrophoresis during the study period.

CONCLUSIONS

Universal use of gloves and gowns was no better than universal use of gloves only in preventing rectal colonization by vancomycin-resistant enterococci in a medical intensive care unit of a hospital in which vancomycin-resistant enterococci are endemic. Because the use of gowns and gloves together may be associated with better compliance and may help prevent transmission of other infectious agents, this finding may not be applicable to outbreaks caused by single strains or hospitals in which the prevalence of vancomycin-resistant enterococci is low.

A major gene for resting metabolic rate unassociated with body composition: results from the Québec Family Study

A major gene hypothesis for resting metabolic rate (RMR) was investigated using segregation analysis (POINTER) of data on families participating in Phase 2 of the Québec Family Study. Complete analyses were conducted on RMR adjusted for age, and also on RMR adjusted for age and other covariates, primarily fat mass (FM) and fat-free mass (FFM). Prior to adjustment for covariates, support for a major gene hypothesis was equivocal-i.e., there was evidence for either a major gene or a multifactorial component (i.e., polygenic and/or familial environment). The multifactorial model was preferred over the major gene model, although the latter did segregate according to Mendelian expectations. However, after the effects of FM and FFM were accounted for, a major gene effect was unambiguous and compelling. The putative locus accounted for 57% of the variance, affected 7% of the sample, and led to high values of RMR. The lack of a significant multifactorial effect suggested that the familial etiology of RMR adjusted for FM and FFM was likely to be entirely a function of the major locus. Comparing the RMR results from pre- and post-adjustment for FM and FFM suggests a plausible hypothesis. We know from earlier studies in this sample that there is a putative major gene for FM and a major non-Mendelian effect for FFM. The current study leads us to speculate that: (1) the gene(s) affecting body size and body composition also may have an effect on RMR, and further (2) removal of the effect of the major gene(s) for body size and composition allowed for detection of an additional major gene affecting only the RMR. Thus, RMR appears to be an oligogenic trait.

Resistance to interleukin 6 in human non-small cell lung carcinoma cell lines: role of receptor components

The role of interleukin 6 (IL-6) in regulating the growth of three human non-small cell lung carcinoma (NSCLC) cell lines (NSCLC-3, NSCLC-5, and NSCLC-7, derived from a primary lesion, a brain lesion, and lymph node metastases, respectively) was examined. Although IL-6 alone did not alter the growth of these cells, the addition of soluble IL-6 receptor (sIL-6R) led to the inhibition of proliferation of one of the NSCLC cell lines, NSCLC-5. This antiproliferative effect was neutralized by antibodies to IL-6 and the IL-6R binding and signaling component (gp130). The IL-6-related cytokines, leukemia inhibitory factor and oncostatin M, inhibited proliferation of NSCLC-5 cells but were ineffective in NSCLC-3 and NSCLC-7 cells. NSCLC-7 cells (but not NSCLC-3 or NSCLC-5 cells) secreted biologically active IL-6 and expressed IL-6R. However, antibodies to IL-6 or gp130 failed to alter the proliferation of NSCLC-7 cells. All three cell lines expressed gp130 mRNA and protein. The level of expression of gp130 protein varied in the three cell lines (NSCLC-7 > NSCLC-3 > NSCLC-5). The examination of tyrosine phosphorylation of gp130 (as an early event in IL-6 signal transduction) revealed that gp130 could be phosphorylated in all cell lines after stimulation with IL-6 and/or IL-6 + sIL-6R. These results demonstrate that the mechanisms responsible for IL-6 resistance in different NSCLC cell lines vary and involve defects at either one or more levels of the IL-6 signaling cascade. In the NSCLC-5 cell line, IL-6 resistance (which can be reversed in the presence of sIL-6R) is due to the transcriptional inactivation of the IL-6R gene. In contrast, in the other two cell lines (NSCLC-3 and NSCLC-7), defect(s) in the signaling cascade downstream of gp130 phosphorylation, together with a lack of expression of IL-6R in NSCLC-3 cells, result in IL-6 resistance.

Familial clustering of abdominal visceral fat and total fat mass: the Québec Family Study

The evidence for common familial factors underlying total fat mass (estimated from underwater weighing) and abdominal visceral fat (assessed from CT scan) was examined in families participating in phase 2 of the Québec Family Study (QFS) using a bivariate familial correlation model. Previous QFS investigations suggest that both genetic (major and polygenic) and familial environmental factors influence each phenotype, accounting for between 55% to 71% of the phenotypic variance in fat mass, and between 55% to 72% for abdominal visceral fat. The current study suggests that the bivariate familial effect ranges from 29% to 50%. This pattern suggests that there may be common familial determinants for abdominal visceral fat and total fat mass, as well as additional familial factors which are specific to each. The relatively high spouse cross-trait correlations usually suggest that a large percent of the bivariate familial effect may be environmental in origin. However, if mating is not random, then the spouse resemblance may reflect either genetic or environmental causes, depending on the source [i.e., through similar genes or cohabitation (environmental) effects]. Finally, there are significant sex differences in the magnitude of the familial cross-trait correlations involving parents, but not offspring, suggesting complex generation (i.e., age) and sex effects. For example, genes may turn on or off as a function of age and sex, and/or there may be an accumulation over time of effects due to the environment which may vary by sex. Whether the common familial factors are genetic (major and/or polygenic), environmental, or some combination of both, and whether the familial expression depends on sex and/or age warrants further investigation using more complex models.

Major gene for abdominal visceral fat area in the Québec Family Study

OBJECTIVES

The abdominal visceral fat depot is considered to be the most atherogenic, diabetogenic and hypertensiogenic fat depot of the human body. Although the amount of abdominal visceral fat is correlated with total body fat, there remain considerable inter-individual differences in visceral fat at any level of body fat content. No study has been reported to date on the contribution of genetic factors to the variability in abdominal visceral fat level.

DESIGN

Abdominal visceral fat area was assessed by computerized tomography in 382 adult men and women from 100 families of the Québec Family Study. After adjustment for the effects of age and age plus total fat mass (assessed by underwater weighing), a major gene hypothesis for abdominal visceral fat area was investigated using segregation (POINTER) analyses.

RESULTS

Segregation analysis of the age-adjusted variable indicated that variability in visceral fat area was accounted for by a major gene transmitted according to Mendelian expectations. Data support an autosomal recessive locus, associated with high levels of abdominal visceral fat, accounting for 51% of the phenotypic variance and affecting 10% of the sample. An additional 21% of the variance was due to multifactorial (polygenic and/or familial environment) sources. However, after adjusting for total fat mass, support for a major gene for abdominal visceral fat was less strong.

CONCLUSIONS

These results suggest that the familial etiology of abdominal visceral fat level involves a major autosomal recessive locus. Given the critical role of abdominal visceral fat in the metabolic complications of obesity, it will now be important to identify the gene responsible for the high levels of abdominal visceral fat observed in some adults and to investigate whether this gene is the same as that which influences total body fat content.

Genetic pleiotropy for resting metabolic rate with fat-free mass and fat mass: the Québec Family Study

Shared genetic and familial environmental causes for the associations among resting metabolic rate (RMR), fat-free mass (FFM), and fat mass (FM) were investigated in families participating in phase 2 of the Québec Family Study. A multivariate familial correlation model assessing the pattern of significant cross-trait correlations between family members (e.g., RMR in parents with FFM in offspring) was used to infer the etiology of the associations. For each of FM and FFM with RMR, significant sibling, parent-offspring, and intraindividual cross-trait correlations suggests the associations are familial. Furthermore, the lack of significant spouse cross-trait correlations suggests that the familial aggregation is primarily genetic. Bivariate heritability estimates suggest that as much as 45% to 50% of the shared variance between FFM and RMR may be genetic, and as much as 28% to 34% for FM and RMR. This study supports the notion that the gene(s) affecting each of FFM and FM also influence the RMR. Moreover, the lack of any familial associations between FFM and FM suggests that the effects of each body size component on RMR are independent, i.e., more than one genetic source on the RMR-body size association. The possibility that RMR is an oligogenic trait (i.e., more than one underlying genetic etiology) should be further investigated using more complex multivariate segregation methods until specific genes can be tested.

The internal economics of HMOs: a research agenda

As health maintenance organizations (HMOs) emerge as the dominant delivery system, the value of research on the fee-for-service sector will diminish. Health services researchers, purchasers, and HMOs will turn their attention to what makes some HMOs more effective than others. To understand this, researchers should take advantage of natural experiments that occur within an individual HMO. This strategy capitalizes on the diversity within an HMO; a single HMO offers different benefit packages, uses different methods for paying providers, and uses different utilization management programs with different employer groups. The authors reviewed the relatively few studies that take advantage of natural experiments. Findings indicate that patients and physicians respond to economic incentives, but no study has examined the relationship between changes in cost sharing or physician payment and quality of care. To achieve external validity, the authors recommend that funding organizations support consortia that replicate similar natural experiments at different HMOs.

Familial aggregation of abdominal visceral fat level: results from the Quebec family study

The purpose of this study was to investigate the importance of familial aggregation in abdominal visceral fat (AVF) level as assessed by computed tomography (CT). Four measures of abdominal adipose tissue, obtained from an abdominal scan between the fourth and fifth Lumbar vertebrae (L4-L5) taken in 366 adult subjects from 100 French-Canadian nuclear families, were considered in this study. Total abdominal fat, AVF, subcutaneous abdominal fat, obtained by computing the difference between total and AVF tissue areas, and the visceral to total abdominal fat ratio were measured. Spouses, parent-offspring, and sibling correlations were computed by maximum likelihood methods after adjustment of the four phenotypes for age and for age and total fat mass (FM) derived from underwater weighing. Significant familial aggregation was found for all phenotypes, whether adjusted or not for body FM. However, after adjustment of data for body FM, in addition to age, all spouse correlations became nonsignificant, suggesting that the familial aggregation of abdominal fat is primarily genetic. Heritability estimates reached 42% and 56% for subcutaneous fat and AVF, respectively. These results suggest that genetic factors are major determinants of the familial aggregation observed in the amount of abdominal fat, irrespective of total body fat content, and that AVF seems more influenced by genetic factors than abdominal subcutaneous adipose tissue. These findings imply that some individuals are more at risk than others to exhibit the various metabolic complications associated with upper-body obesity because of their inherited tendency to store abdominal fat in the visceral depot rather than in the subcutaneous depot.

In rats, atrial natriuretic peptide secretion is regulated differently in the right and left atria

Recent studies have suggested the secretion of Atrial Natriuretic Peptide (ANP) is regulated by receptor mediated activation of protein kinase C, which causes the autocrine release of prostaglandins. Prostaglandins stimulate ANP secretion via the adenylate cyclase second messenger system. This report examined the response of right and left atrial ANP secreting cells to the three endothelin isopeptides and to cyclooxygenase inhibition. Our results show that right atrial ANP secretion is stimulated by endothelin 1 and 2 but not 3. In addition, right atrial ANP secretion is reduced by inhibition of cyclooxygenase. In contrast, left atrial ANP secretion is stimulated by endothelin 2 and 3 but not 1. Inhibition of cyclooxygenase did not affect left atrial ANP secretion. These results show the regulation of ANP secretion is different between the two atrial chambers. Right atrial cells appear to contain the prostaglandin-mediated response to protein-kinase C activation, whereas left atrial cells regulate ANP secretion differently.

Medigap reform legislation of 1990: have the objectives been met?

The 1990 medigap reform legislation had multiple objectives: To simplify the insurance market in order to facilitate policy comparison, provide consumer choice, provide market stability, promote competition, and avoid adverse selection. Based on case study interviews with a cross-section of individuals and organizations, we report that most of these objectives have been achieved. Consumers of medigap plans are able to make more informed choices, largely because they can adequately compare policies based on standard benefits. Marketing abuses have apparently declined, as evidenced by a decrease in the number of consumer complaints. Finally, no major detrimental impact on the insurance industry was detected. Beneficiaries still face some confusion in this market, however, such as understanding the rating methodologies used to set premiums and how this may affect their choices. Confusion could increase with the growth of managed care options.

Do physicians cost shift?

This study analyzes whether physicians charge their privately insured patients more-a practice known as cost shifting-in response to Medicare payment reductions. As part of congressional legislation in 1989 and 1990, Medicare reduced its payment rates for selected procedures by as much as 30 percent. Here we examine whether reductions in Medicare rates increase how much physicians charge privately insured patients. Our data provide no evidence that physicians respond to Medicare payment reductions by shifting costs to their privately insured patients.

Familial clustering of multiple measures of adiposity and fat distribution in the Québec Family Study: a trivariate analysis of percent body fat, body mass index, and trunk-to-extremity skinfold ratio

OBJECTIVE

To assess whether independent or common (pleiotropic) familial factors (i.e., genetic and/or common environment) underlie the observed associations among measures of body mass, body fat, and its distribution.

DESIGN

A familial correlation model involves both parents and offspring, and gives rise to three types of familial correlations (spouse, parent-offspring, and sibling). A pattern of significant familial correlations suggests that the trait is determined by familial factors (i.e., genetic and/or environmental heritability). Cross-trait familial correlations are also estimated, both within individuals (intraindividual) and between family members (interindividual). Interindividual cross-trait familial correlations (e.g., trait 1 in parents with trait 2 in offspring) lead to the same type of familial inferences regarding bivariate heritabilities.

SUBJECTS AND MEASURES

Measures of total body fat (% body fat-%BF), fat distribution (trunk/extremity skinfold ratio-TER), and body mass index (BMI) were assessed in 1239 individuals from 309 nuclear families participating the Québec Family Study.

RESULTS

All three adiposity measures are cross-correlated within individuals. However, interindividual cross-trait correlations, which alone are capable of suggesting common familial determinants, are significant only for BMI with each of %BF and TER (bivariate heritabilities of 10% and 18%, respectively), and not for %BF and TER.

CONCLUSION

Although all three adiposity measures are correlated within individuals, there appear to be entirely different underlying genes and/or environmental factors influencing the adiposity phenotypes of total body fat and fat distribution. The BMI, however, apparently shares some familial determinants with both total body fat and fat distribution.

Major gene influence on the propensity to store fat in trunk versus extremity depots: evidence from the Québec Family Study

Regional fat distribution is related to higher risks of cardiovascular morbidity and mortality, independent of general obesity. In particular, a centralized pattern of fat deposition, characterized by greater abdominal stores relative to extremity stores, is associated with a higher propensity to metabolic complications. Motivated by these considerations, we have initiated a systematic investigation of several measures of regional fat distribution aimed at the identification of possible major gene effects. Two measures approximate the size of subcutaneous fat stores: the sum of six skinfold thicknesses (SF6 = abdominal + suprailiac + subscapular + calf + triceps + biceps), and the sum of three trunk skinfold thicknesses (TSF3 = abdominal + suprailiac + subscapular). Both of these phenotypes are highly correlated with total fat mass, 0.83 and 0.78 for SF6 and TSF3, respectively. The trunk to extremity ratio [TER = TSF3/ (calf + triceps + biceps)] is perhaps the most important of these phenotypes insofar as it is an index of centralized obesity; it is modestly correlated with fat mass (r = 0.18). Each of these phenotypes was adjusted for total fat mass by regression prior to analysis so that we could examine genetic effects on these measures of regional fat distribution without the confounding influence of the determinants of fat mass itself. Segregation analysis of SF6 and TSF3 controlled for total fat mass suggests the presence of a major effect underlying the observed phenotypic distribution; however, tests on the transmission probabilities did not substantiate the segregation of a Mendelian gene.(ABSTRACT TRUNCATED AT 250 WORDS)

Medigap regulation: lessons for health care reform

Congress enacted legislation in 1990 that dramatically changed the rules for selling supplemental health insurance, or "Medigap" policies, to the elderly. Most notably, policy coverage was standardized. Insurance carriers are allowed to sell only the ten specified packages of benefits, which reduces consumer choice but facilitates comparison shopping. This legislation is important in its own right and also offers lessons for U.S. health care reform. To examine the changes brought about by this legislation and analyze their implications for health care reform, we conducted site visits to nine states and interviewed insurer representatives, executive branch officials, congressional staff, and various interest groups for two years.

Balance billing under Medicare: protecting beneficiaries and preserving physician participation

Medicare's experience with balance billing provides valuable lessons for policy making for national or state health care reform. Medicare developed several policies to encourage physicians to become participating providers who accept Medicare-allowed charges as payment in full. Only nonparticipating physicians are permitted to bill for additional amounts beyond that paid by Medicare, and there are limits on the amount of balance billing per claim. As shown by the analysis of claims presented in this article, Medicare has successfully provided financial protection to beneficiaries. In 1986, more than 60 percent of expenditures for physician services were on assigned claims for which there could be no balance billing; by 1990, 80 percent of expenditures were on assigned claims. Balance billing decreased by about 30 percent during the same period. Although these policies have been successful in reducing total expenditures for balance billing, they may not provide financial protection to the most economically vulnerable beneficiaries. Using survey and claims data, we found that the poor have lower balance billing expenditures for services provided by primary care physicians, but that there is no relationship between poverty status and balance billing expenditures for services of nonprimary care physicians. In addition, most low-income beneficiaries are liable for balance bills. Under health care reform, adoption of Medicare's incentive-based approach with mandatory assignment for the poor would allow for some choice based on price and would provide financial protection for all consumers.

Can regulation improve long-term care insurance? Lessons from the Medigap experience

This article uses recent experiences from the Medigap market to draw conclusions about the advisability of alternative methods of regulating the market for long-term care insurance. The analysis is based in part on interviews of state insurance regulators, insurance companies, and interest-group representatives. The authors conclude that some regulation of the market is appropriate, but that the structure and extent of regulation found in the Medigap market would likely be inappropriate for the long-term care insurance market at this time.

Cross-trait familial resemblance for body fat and blood pressure: familial correlations in the Québec Family Study

Cross-trait resemblance between body fat and blood pressure (BP) was examined among families in the Québec Family Study by using a bivariate familial correlation model assessing both intraindividual (e.g., comparison of father's body fat with his own BP) and interindividual (e.g., comparison of father's body fat with son's BP) cross-trait correlations. Each of six body-fat measures-(i) percent body fat, (ii) body-mass index, (iii) the sum of six skinfolds, (iv) the ratio of the sum of six skinfolds to total fat mass, (v) the ratio of the trunk skinfold sum to the extremity skinfold sum, and (vi) the regression of the trunk-extremity skinfold ratio on the sum of six skinfolds--was analyzed separately with systolic BP and with diastolic BP. Results showed that (1) upper-body fat was the strongest interindividual correlate of BP (especially the correlation of trunk-extremity ratio with diastolic BP), suggesting shared pleiotropic genetic and/or common familial environmental effects; (2) summary body-fat measures either were inconsistent (in the case of both percent body fat and sum of six skinfolds) or gave no evidence of interindividual cross-trait resemblance with BP (in the case of body-mass index); and (3) intraindividual resemblance between the sum of six skinfolds and BP largely vanished once the skinfold sum was adjusted for fat mass, suggesting that the intraindividual association may be mediated largely by the absolute amount of subcutaneous fat rather than by the subcutaneous proportion. Finally, the magnitude of the spouse resemblance for the trunk-extremity ratio with diastolic BP suggests that a significant proportion of the resemblance may be due to environmental influences. In summary, our investigation confirms a heritable link between BP and truncal-abdominal fat as predicted by the metabolic-syndrome hypothesis. That this result is obtained in primarily normotensive, nonobese families, suggests the connection involves normal metabolic paths.