A re-examination of the meaning and importance of supplier-induced demand

Despite twenty years of work on supplier-induced demand (SID) there has been little discussion or investigation of how inducement affects the health of patients. We develop a conceptual framework for SID which includes the clinical effectiveness of the health services utilized as well as the effectiveness of the agency relationship between the physician and the patient. The framework is used to identify several conceptually distinct types of utilization--each with its own policy implications--which have been intermingled in the SID literature. After examining each type of utilization, we conclude that a continued focus by health economists on the phenomenon of inducement (even within an extended conceptual framework) may be too limited for the development of policies regarding health service utilization.

Evidence for an association between dehydroepiandrosterone sulfate and nonfatal, premature myocardial infarction in males

BACKGROUND

Several studies indicate that endogenous hormones play a role in the etiology of coronary artery disease, either as independent risk factors or indirectly, via an effect on lipids, lipoproteins, or other heart disease risk factors.

METHODS AND RESULTS

The relation between endogenous hormone levels and premature (< 56-year-old patients) myocardial infarction was assessed in a retrospective study involving 49 male survivors of premature myocardial infarction and 49 age-matched, volunteer male controls. Serum samples were obtained for each subject the morning after a > or = 12-hour fast and frozen at -70 degrees C for subsequent hormonal analysis. Among the male patients, the average duration between the most recent myocardial infarction and blood sampling was 3.4 years (range, 0.7 to 19.2 years). Individuals reporting the use of any medications with the potential to alter lipid, lipoprotein, or hormone levels were excluded from these analyses. Dehydroepiandrosterone sulfate levels were significantly lower in the patients than in the control subjects. This association remained statistically significant even after accounting for the effects of total cholesterol, triglycerides, the ratio of total to high-density lipoprotein (HDL) cholesterol, HDL, apolipoprotein A-I, apolipoprotein A-II, apolipoprotein B, and body mass index. There were no significant differences in the levels of estradiol, testosterone, or free testosterone or the ratio of estradiol to testosterone between patients and control subjects.

CONCLUSIONS

Our conclusions are limited by the retrospective nature of this study. However, these data indicate that serum dehydroepiandrosterone sulfate levels are inversely related to premature myocardial infarction in males and that this association is independent of the effects of several known risk factors for premature myocardial infarction.

Should insurers pay the same fees under an all-payer system?

Medicare's use of diagnosis-related groups (DRGs) and the resource-based relative value scale (RBRVS) has led to interest in developing a national all-payer system in which insurers use the same payment methods and payment rates. Using data for 81 high-volume DRGs from 457 California hospitals, we conclude that a single set of rates for hospital care would not be appropriate. On average, Medicare patients were 11.7 percent more expensive than commercially insured patients, but less expensive in many DRGs. Further research is needed to determine if Medicare patients require more physician resources compared with non-Medicare patients, particularly for surgical procedures.

Commingling analysis of adiposity in an Indian population

The distributions of five adiposity phenotypes were assessed for the presence of commingling in a sample of 756 adults (> or = 30 years old), residing in the Chittoor district of Andhra Pradesh, India. Three measures of generalized fatness (body mass index, the sum of six skinfolds and the sum of three trunk skinfolds) and two indicators of fat patterning (the ratio of trunk to extremity subcutaneous fat and the ratio of the subscapular skinfold to the sum of the subscapular and the supra-iliac skinfolds) were analysed. Each phenotype was adjusted for the effects of (i) age within sex, and (ii) age, energy intake and energy expenditure within sex. The distribution of each phenotype, under both adjustment schemes, was assessed for evidence of commingling. The commingling analyses were performed separately for males (n = 397) and females (n = 359), and evidence for heterogeneity in the distribution of each phenotype, by sex, was evaluated. There is evidence of commingling in the distribution of each phenotype, under both adjustment schemes. Conclusions regarding the distributions of these phenotypes are, however, influenced by the specific adjustments made to the data. In general, the measures of generalized fatness are more sensitive than measures of fat patterning to the specific adjustments applied to the data. Interestingly, and in contrast with the majority of commingling analyses of adiposity, the smallest components of the commingled distributions often have the lowest mean phenotypic value.

The Cincinnati Myocardial Infarction and Hormone Family Study: family resemblance for dehydroepiandrosterone sulfate in control and myocardial infarction families

Dehydroepiandrosterone sulfate (DHEAS) was examined in random (control) and nonrandom (case) families participating in the Cincinnati Myocardial Infarction and Hormone (CIMIH) family study. The case families were ascertained through white men who survived a myocardial infarction (MI) before the age of 56, whereas control families were recruited through advertisements and through an adolescent boy maturation study. Both familial correlations and genetic effects of DHEAS were investigated. First, maximum likelihood estimates of the sex-specific familial correlations (corrected for nonrandom ascertainment) suggested that there was significant heterogeneity between the two sampling types. This heterogeneity was isolated to the male sibling correlation, which was higher in the case than control families. Post hoc analyses suggested that the sibling group heterogeneity may be in part a function of age, since the control sample offspring were on average much younger than those in case families. No sex differences other than those for the siblings were noted in the familial correlations. Second, heritability was investigated in control families using a simple path model (TAU) that allowed for sex differences. The only significant model parameter was the sex-specific familiarity (combined polygenic and familial environmental effects), which was larger in females (74%) than in males (29%). In general, these analyses suggested that (1) DHEAS may play only a limited role in the increased risk for premature MI, and (2) the degree of heritable (familial) variation may be dependent on sex.

Cincinnati myocardial infarction and hormone family study: family resemblance for testosterone in random and MI families

Familial correlations for total testosterone and free testosterone were examined in both random and nonrandom families participating in the Cincinnati Myocardial Infarction and Hormone Family Study (CIMIH). The non-random families were ascertained through Caucasian males who had survived a myocardial infarction (MI) prior to age 56 years, while random families were recruited largely through an adolescent boy maturation study. Eight sex-specific familial correlations were estimated (father-mother, father-son, father-daughter, mother-son, mother-daughter, son-son, daughter-daughter, and son-daughter) for each of the MI and random samples using maximum likelihood methods with appropriate ascertainment correction. These familial correlations were examined for differences between the random and MI samples, as well as for sex-specific familial patterns. The results suggest that total testosterone levels may have a limited role in determining MI risk, as evidenced by the overall heterogeneity between samples, and lower serum levels in MI than random probands. The pattern of correlations for both androgens suggests that a simple genetic model appears unlikely; however, familiarity cannot be ruled out. Although possible covariate effects such as age and sex may have masked some potentially significant results, especially in males, familiarity in females is suggested (correlations ranging from .3-.9). The relative stability of these hormones in females as compared to that in males may have contributed to its identification, and suggests the familial transmissibility may be associated with adrenal production and/or metabolic clearance of testosterone.

Influence of genotype-dependent effects of covariates on the outcome of segregation analysis of the body mass index

Several recent studies of the body mass index (BMI) have provided support for a recessive major gene influencing heaviness in humans. Segregation analysis of the BMI was carried out recently in a series of randomly sampled French-Canadian families to determine whether we could replicate the major gene finding by using a residual phenotype adjusted for the effects of age and sex. The best model included a recessive major effect for high BMI values with residual familial resemblance; however, Mendelian transmission could not be confirmed, and the no-transmission hypothesis (where all the tau's are constrained to be equal) was not rejected. Considering that the BMI is a complex phenotype affected by many factors and that there are known variations in body composition during growth and aging, we undertook a reanalysis of the data, using a model that allowed the estimation of genotype-specific age and gender effects. New tests on the transmission parameters satisfy the criteria for interfering Mendelian segregation. The results suggest that individuals with the "high" recessive genotype show the greatest degree of heaviness at birth, with a subsequent trend toward lower values throughout life, while individuals with the dominant "normal" genotypes show no appreciable trends with age. In addition, the "high" genotype appears to confer a greater degree of heaviness in females as compared with males. These results, along with other observations from the data, suggest that, while a recessive single gene influence may be discernible, the phenotypic expression of the BMI is likely to be complicated by genotype x environment interactions and, possibly, by the action of other loci. Further, the data also are consistent with the hypothesis that modifying factors may include the adoption of a more prudent life-style by individuals genetically predisposed to heaviness and a secular increase in the incidence, prevalence, and potency of environmentally based triggers leading to a higher penetrance of the "heavy" genotype in the young.

Segregation analysis of fat mass and other body composition measures derived from underwater weighing

Segregation patterns of three body composition measures which were derived from underwater weighing were evaluated in a random sample of 176 French-Canadian families. Two of the variables can be considered as primary partitions of weight (fat mass [FM] and fat-free mass [FFM]), while the remaining variable (percent body fat [%BF]) is a derived index combining the measures of both fat and fat-free weight. This study represents the first report investigating major gene effects for these measures. Segregation analyses revealed that a major locus hypothesis could not be rejected for two of the three phenotypes. The single exception was FFM, for which nearly 60% of the variance was accounted for by a non-Mendelian major effect, which may reflect environmentally based commingling or may be in part a function of gene-environment interactions or correlations. In contrast to the results for FFM, the results for each of FM and %BF were similar and suggested a major locus which accounted for 45% of the variance, with an additional 22%-26% due to a multifactorial component. Given the similarity of the major gene characteristics for these two phenotypes, the possibility that the same gene underlies both measures warrants investigation. A reasonable hypothesis is to consider genes that may influence nutrient partitioning, as the family of candidate genes to receive the major attention.

Bullectomies for bullous sarcoidosis

A 36-year-old woman presented with respiratory insufficiency due to cystic sarcoidosis. She had been previously treated with multiple courses of prednisone without improvement. Enlarging blebs involving both lower lobes impaired the function of the relatively spared upper lobes. Bilateral lower lobectomies were performed in one step via median sternotomy without complications, with prompt subjective and objective improvement of her respiratory status. One-stage bilateral upper-lobe bullectomy for bullous emphysema has been previously reported, but to our knowledge this is the first performance of one-stage bilateral lower-lobe bullectomies for cystic sarcoidosis. The immediate benefits were evident; long-term results will depend on the course of the underlying disease.

Income-related cost sharing in health insurance

The vast majority of health plans in the United States require patients to meet cost-sharing requirements that are unrelated to income. Because this is highly inequitable, the authors propose a new system in which cost sharing is explicitly linked to income levels. This proposal differs from earlier proposals to relate cost sharing to income, which relied on the federal income tax system. In this plan, employers and insurers (both public and private) would collect the information necessary to relate cost sharing amounts to income. The proposal could be applied to nearly any health system reform proposal currently under discussion. The authors examine the experience of a number of U.S. firms that have already incorporated income-related cost sharing, as possible models to apply to health insurance nationwide.

Assessment of adiposity in an Indian population: familial correlations

Familial correlations for five measures of adiposity were assessed using data from 473 nuclear families residing in the Chittoor district of Andhra Pradesh, India. Fat patterning, measured as the ratio of trunk to extremity subcutaneous fat, and the ratio of the subscapular to the sum of the subscapular and suprailiac skinfolds, and three measures of generalized fatness: body mass index, the sum of six skinfolds and the sum of three trunk skinfolds were analyzed. Maximum likelihood estimates of the familial correlations were obtained for each phenotype, after adjusting for the effects of (1) age within sex, and (2) current levels of energy intake and expenditure, and age within sex. Hypotheses regarding sex-specific, and generational differences in these correlations were assessed for each phenotype, under both adjustment schemes. The strength and pattern of the familial correlations for the three measures of generalized fatness were markedly influenced by the specific adjustments applied to the data. In contrast, the familial correlations for the fat patterning phenotypes were quite similar under the two adjustment schemes. Comparison of our results with previously published data indicates that the familial correlations for a subset of these adiposity measures may be heterogeneous across populations.

Is managed competition a field of dreams?

In recent months, managed competition has gained the upper hand in the debate over how to reform the U.S. health system and likely will be a part of President-elect Clinton's proposal. But recent data reveal that managed care plans, an important piece of the managed competition approach, have not significantly altered the rate of increase in costs. These findings cast doubt on the assumption by managed competition advocates that the proper incentives exist to cause the health delivery system to reorganize itself.

Familial resemblance of blood pressure with residual household environmental effects in consanguineous and nonconsanguineous families from Andhra Pradesh, India

Familial aggregation of blood pressure (BP), both systolic (SBP) and diastolic (DBP), was examined in consanguineous and nonconsanguineous families from southern India. Path analysis of BP suggests inbreeding effects, with the genetic variance for SBP being lower in the sample that included inbred families. Specifically, genetic heritability for SBP was 38% in the nonconsanguineous sample but only 23% in the combined sample. Genetic heritability for DBP (30%) did not vary by sample, nor were sample differences in cultural heritability detected for either SBP (over 35%) or DBP (about 18%). These findings are remarkably similar to those in a French-Canadian population of Quebec; both reports found a considerably larger effect of the home environment on BP than previous studies.

Commingling and complex segregation analysis of fasting plasma glucose in the Lipid Research Clinics family study

Commingling and segregation patterns of fasting plasma glucose (GL) were examined in family data from 5 clinics (Cincinnati, Stanford, Iowa, Minnesota, and Oklahoma) of the Lipid Research Clinics (LRC) family study. In addition to the primary question of whether there was a major gene for GL, a secondary purpose was to investigate the possibility of genetic heterogeneity among the 5 clinics. No statistical support was found for heterogeneity among clinics, either in the commingling of distributions or in the segregation patterns. For the combined clinics sample, both a major effect and a multifactorial component were significant. However, the major effect (accounting for 73% of the variance) was not found to be consistent with a major gene, as the hypothesis of Mendelian transmission was rejected. The most parsimonious model involved equal transmission probabilities, which suggests that the major effect is not transmitted from parents to offspring. Possible sources of this major non-Mendelian effect were explored. The multifactorial component accounted for 10% of the variance in GL levels, and no generational differences were noted. Although our study was unable to provide evidence in favor of a major gene effect, it should be noted that a major gene cannot be firmly refuted. For example, a variety of interactions, such as genotype-dependent age effects, could have masked the transmission probabilities.

Commingling analysis of regional fat distribution measures: the Québec family study

Regional fat distribution is related to higher risk of diabetes and cardiovascular morbidity and mortality, independent of excess body mass for height. In particular, the male (android) pattern of fat deposition, which is characterized by greater truncal and abdominal fat stores relative to extremity fat levels, 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 detection of possible single gene effects. In this paper, we assess the evidence for commingling in the distributions of these variables in a large French-Canadian study. Two measures approximating the size of subcutaneous fat stores relative to total body fat were considered: the sum of six skinfolds (SF6 = abdominal + supra-iliac + subscapular + calf + tricep + bicep), and the sum of three trunk skinfolds (TSF3 = abdominal + supra-iliac + subscapular). In addition, two measures assessing the distributional pattern of subcutaneous fat were considered: the ratio of TSF3 to the sum of the three extremity skinfolds (TER), and a relative fat pattern index [RFPI = subscapular/(subscapular + supra-iliac)]. All four measures were assessed both prior to and after adjusting for total fat mass, which was measured using underwater weighing. Significant distributional heterogeneity was observed for some of these measures, either between generations and/or between the sexes. In general, however, fat mass adjustment tended to eliminate the heterogeneity; the exception was for RFPI, for which sex differences were noted both prior to and after the adjustment. The finding of commingling of distributions for almost all phenotypes is consistent with (but not evidence for) major gene effects. However, for some of the measures the effect of a putative major locus genotype may be mediated by covariates such as age and/or sex.

Commingling and segregation analysis of serum uric acid in five North American populations: the Lipid Research Clinics family study

The role of major genes in the expression of serum uric acid (UA) levels was investigated in data collected from five clinics of the Lipid Research Clinics (LRC) family study. Over 2,000 randomly ascertained individuals were analyzed. The UA distributions were homogeneous among the five LRC clinics and between the parental and offspring generations. This result suggested that the data could be pooled across clinics, thereby increasing the statistical power associated with larger sample sizes for testing various null hypotheses. Additionally, a mixture of three normal distributions best characterized the combined-clinics data. Segregation patterns were examined in the untransformed data, as well as in a more conservative (and biologically meaningful) log transformation. Prior to log transformation, both major and multifactorial effects were detected. The major effect was not transmissible, i.e., was not compatible with Mendelian transmission, and accounted for 39% of the variance in UA levels. However, after the log transform was applied to the data and the segregation analysis was repeated, support for the major effect disappeared altogether and only the multifactorial component remained, accounting for 50% of the variation in offspring and 19% in patients.

An alternative framework for evaluating welfare losses in the health care market

A recurring theme in the health economics literature is that 'excess' health insurance reduces society's welfare. This proposition is considered to be a truism by most health economists. Feldman and Morrisey (1990) report that two-thirds of American and Canadian health economists surveyed agree with the statement that, 'the level and type of health insurance held by most U.S. families generate substantial welfare loss due to over-consumption of medical services'. Consequently, most research in the area has attempted to identify the exact dollar value of this welfare loss. In this note, I will try to show that the traditional method of calculating welfare losses from excess health insurance is severely flawed because it is based on assumptions about consumer behavior that are not supported by the available empirical evidence. Furthermore, the methodology masks other, potentially greater societal welfare losses that are likely to exist in the health care sector, and blinds us from seeking the most effective public policy remedies. This note suggests an alternative framework for considering welfare losses based on researchers' evaluations of medical necessity.

Commingling analysis of generalized body mass and composition measures: the Québec Family Study

Human body mass and composition are heterogeneous phenotypes resulting from the combined effects of genes, environmental factors, and their interactions. In order to gain an understanding of the individual genetic determinants leading to obesity, we have initiated a systematic analysis of several measures of fatness and its phenotypes including: the body mass index (wt/ht2), fat mass, fat-free (lean) mass, the ratio of fat mass over fat-free mass, percent body fat, and a fat mass index (fat mass/ht). In this report, we examine the distributions of these age and sex adjusted variables in a large family study from Québec in terms of evidence for commingling and skewness, and evaluate the inter-relationships among the measures. Fat mass, fat-free mass and the fat mass index conceptually represent primary variables in that they are quantitative measures of relevant components of total body weight; the hypothesis of a single distribution was inferred for each of these primary measures, with significant residual skewness except for fat mass. In general, offspring (8-26 years old) distributions were more positively skewed than parent (30-60 years old) distributions. The remaining variables (body mass index, fat mass to fat-free mass ratio, and percent body fat) are indexes combining information on fat and fat-free mass into single measures. Although offspring data were consistent with a single skewed distribution, commingling was found in the parents in each case. The prominent heterogeneity between generations suggests that there may be significant developmental (genetic or environmental) effects in the transition during growing years to adult pattern phenotypes, particularly for the complex indicators of body composition.

Familial aggregation of lipids and lipoproteins in families ascertained through random and nonrandom probands in the Minnesota Lipid Research Clinic Family Study

The familial aggregation of lipids [total cholesterol (CH) and triglyceride (TG)] and lipoproteins [high-density lipoprotein cholesterol (HDL) and low-density lipoprotein cholesterol (LDL)] was investigated in families ascertained through both random and nonrandom probands in the Minnesota Lipid Research Clinic Family Study. Nonrandom proband ascertainment was based on single selection through truncation for hyperlipidemia at an earlier screening. A path model was used to investigate the nature of familial resemblance using appropriate adjustments for ascertainment and to determine whether random and hyperlipidemic samples are heterogeneous with regard to the multifactorial model. The results suggest that parameter estimates are consistent with those from previous studies in which only random families were used and that random and nonrandom samples are homogeneous with regard to the path model for CH and LDL. However, for TG and HDL the random and hyperlipidemic samples are significantly heterogeneous. This heterogeneity would be observed if familial hypertriglyceridemia and/or familial hypoalphalipoproteinemia segregates predominantly in the hyperlipidemic rather than in the random sample, as on might expect.

Familial aggregation of lipids and lipoproteins in families ascertained through random and nonrandom probands in the Stanford Lipid Research Clinics Family Study

We examined the familial aggregation of lipids [total cholesterol (CH) and triglyceride (TG)] and lipoproteins [high-density lipoprotein cholesterol (HDL) and low-density lipoprotein cholesterol (LDL)] in families ascertained through random and nonrandom probands in the Stanford Lipid Research Clinics Family Study. Nonrandom probands were selected because their lipid levels at a prior screening visit exceeded a certain prespecified threshold. The statistical method is based on selection through indirect truncation on a correlated trait (in which the likelihood function is conditioned on the actual event that the proband's value is beyond the threshold). This method allows for estimation of the path model parameters in randomly and nonrandomly ascertained families jointly and separately, thus enabling tests of heterogeneity between the two types of samples. The results suggest that the multifactorial transmission is homogeneous in the random and hyperlipidemic samples for CH. However, the evidence for heterogeneity is moderate for LDL, marked HDL, and mixed for TG. The general pattern of observed results is for somewhat higher genetic heritabilities in the random than nonrandom samples, which is compatible with a higher prevalence in the random sample of certain dyslipoproteinemias associated with nonelevated lipids. Substantial genetic heritability is found for CH, HDL, and LDL, with somewhat lower estimates for TG. Cultural heritability is low but significant for all four traits. Little or no spouse resemblance or nontransmitted shared sibship effects are seen. In contrast to the findings from previous studies, little or no parental cultural transmission is seen.

The effectiveness of consumer choice in the Medicare supplemental health insurance market

This article examines the factors that affect Medicare beneficiaries' choices in the supplemental health insurance market. Data include detailed survey information as well as copies of the health insurance policies owned by a sample of approximately 2,500 Medicare beneficiaries in six states during 1982. Logit analysis is employed to analyze the determinants of four dependent variables: whether a person owns (1) one or more private supplemental insurance policies, (2) two or more policies, (3) at least one policy that we define as "effective," and (4) a policy we define to be "less effective." Those who are better off from a socioeconomic standpoint appear to be making more effective choices in the supplemental health insurance market. However, there does not appear to be a relationship between consumer ignorance or vulnerability and the purchase of multiple supplemental insurance policies. Study results imply an important role for public policy in helping to provide the information necessary to ensure that the most vulnerable beneficiaries make insurance choices that are in their best interest.

The effect of owning private long-term care insurance policies on out-of-pocket costs

This article examines the effect of owning long-term care insurance policies on the amount of out-of-pocket costs incurred by the elderly during their nursing home stays, and the importance of different policy features and restrictions. Data were drawn from the 1985 National Nursing Home Survey, and from copies of long-term care insurance policies collected from 11 leading companies during the spring and summer of 1988. The study results show a great deal of uncertainty concerning amounts the policies are likely to pay toward nursing home stays. This implies that the policies collected did not adequately fulfill one of the primary purposes of insurance: a reduction in risk and uncertainty. To examine whether rapid policy changes in recent years have made a difference, we assessed each of seven policy features and found that the two most important restrictions in long-term care insurance policies are prior hospitalization and level-of-care requirements. Recently, the National Association of Insurance Commissioners (NAIC) recommended that states prohibit the sale of policies containing these restrictions. Our findings confirm the wisdom of this recommendation. We did find, however, that two other policy restrictions--policy maximums and lack of inflation adjustment--are problematic. We recommend that the NAIC expand its model regulations to require that policy maximums be a minimum of four years, and that some form of inflation protection be incorporated into policy benefit structures.

Familial aggregation of lipids and lipoproteins in families ascertained through random and nonrandom probands in the Iowa Lipid Research Clinics family study

The aggregation of lipids [total cholesterol (CH) and triglyceride (TG)] and lipoproteins [high-density lipoprotein cholesterol (HDL) and low-density lipoprotein cholesterol (LDL)] in families ascertained through random and nonrandom probands in the Iowa Lipid Research Clinics family study was examined. Nonrandom probands were selected because their lipid levels (at a prior screening visit) exceeded a certain pre-specified threshold. The statistical method conditions the likelihood function on the actual event that the proband's value is beyond the threshold. This method allows for estimation of the path model parameters in randomly and nonrandomly ascertained families jointly and separately, thus enabling tests of heterogeneity between the two types of samples. Marked heterogeneity between the random and the hyperlipidemic samples is detected in the multifactorial transmission for TG and HDL, and moderate heterogeneity is detected for CH and LDL, with a pattern of higher genetic heritability estimates in the random than nonrandom samples. The observed pattern of heterogeneity is compatible with a higher prevalence in the random sample of certain dyslipoproteinemias that are associated with nonelevated lipids. For the random samples, genetic heritabilities are higher for CH and HDL (about 60%) than for TG and LDL (about 50%). For the nonrandom samples those estimates are about 45, 40, 35 and 30% for HDL, CH, LDL and TG, respectively. Little to no cultural (familial environmental) heritability is evident for CH and LDL, although 10-20% of the phenotypic variance is due to cultural factors for TG and HDL. These results suggest that the etiologies for lipids and lipoproteins may be quite different in random versus hyperlipidemic samples.

Chronic postoperative endophthalmitis associated with Actinomyces species

Actinomyces species, gram-positive, non-spore-forming anaerobic bacilli were isolated from intraocular fluid obtained from four otherwise healthy patients with a delayed onset of postoperative endophthalmitis. One patient had a mixed anaerobic infection with recovery of both Actinomyces israelii and Propionibacterium acnes. In all four patients, early postoperative visual acuity was good but was eventually markedly reduced by intraocular inflammation that was first observed between 21 days and 4 months following uneventful extracapsular cataract extraction and posterior chamber intraocular lens implantation. Inflammation was characterized by anterior segment and vitreous cellular debris in all cases. All eyes responded to therapy that included intraocular, topical, and systemic antibiotics as well as pars plana vitrectomy and partial iridectomy. These cases further illustrate the need for microbiologic investigation, including anaerobic cultures, in all cases of chronic postoperative inflammation following extracapsular cataract extraction, regardless of the time of onset.

Heterogeneity in the familial aggregation of fasting serum uric acid level in five North American populations: the Lipid Research Clinics Family Study

This study represents the first formal examination for heterogeneity in the familial aggregation of fasting serum uric acid (UA) levels. Data from 5 clinics (Cincinnati, Stanford, Iowa, Minnesota, and Oklahoma) participating in the Lipid Research Clinics (LRC) family study, which included a total of 685 nuclear families (N = 2,146), were analyzed. Heterogeneity among the clinics in familial resemblance was detected. However, this heterogeneity could not be attributed to differences in distributional properties (such as means and variances) or to path model parameters representing latent genetic or cultural (environmental) components associated with UA levels. Intergenerational differences in genetic heritabilities were found, with higher offspring (h2 = 43%) than parent (h2z2 = 16%) estimates, but no generational differences were detected for cultural heritability (c2 = 0.09). Equal maternal and paternal cultural transmission was found, and effects due to extra sibling environments and to marital resemblance were both significant. These results show no clear indication as to the source of the heterogeneity observed for familial resemblance of UA levels in randomly selected data. This question should be further investigated, especially in clinical samples such as dyslipoproteinemic families.

Heterogeneity in the familial aggregation of fasting plasma glucose in five North American populations: the Lipid Research Clinics Family Study

Heterogeneity in the familial aggregation of plasma glucose in five samples of the Lipid Research Clinics Family Study (LRC) was investigated using path analysis. This study was deemed appropriate since recent investigations reported a wide range of estimates for genetic and cultural factors. The path model incorporated a measured index of the familial environment in order to separate the effects of genes and environments in the nuclear family design, genetic and environmental heritabilities, spouse resemblance, sibling environmental effects, and parental cultural transmission. The methodology was completely general in allowing sample-specific, as well as pooled-sample, estimation of all or any subset of the model parameters. Genetic heritability estimates were heterogeneous, ranging from zero to 33% across the clinics. Environmental heritability (7%), spouse resemblance, non-transmitted sibling environmental effects, and parental cultural transmission were homogeneous across samples. No support was found for specific maternal effects, nor for intergenerational differences in cultural or genetic heritability. We conclude that the genetic and environmental heritabilities for plasma glucose in the LRC are consistent with the diverse reports by earlier investigators. In addition, we were able to exclude methodological differences as a cause of this heterogeneity. Furthermore, formal hypothesis tests suggest that the aetiology of this heterogeneity is genetic (and not cultural), taking the form of two distinct homogeneous patterns (one for no genetic effect, and one for a moderate genetic effect). Only formal heterogeneity tests of the type described here can detect these effects, and allow pooling of separate studies in order to obtain more precise estimates of the parameters of interest.

A genetic study of immunoglobulin E and atopic disease based on families ascertained through asthmatic children

In order to investigate the modes of inheritance of serum immunoglobulin E (IgE) levels and atopic disease, serum IgE levels and data on allergic disease were obtained from 42 families ascertained through asthmatic children visiting an allergy clinic. Although the mean IgE levels were elevated (mean 637 U/ml), the prevalence of atopic disease in this population was surprisingly low. When the data were analyzed using complex segregation analysis, no major locus could be detected. Moreover, the polygenic heritability was unexpectedly small even though the correlation between serum IgE levels and the liability to atopic disease was around 0.4. Given this unusual set of findings, it is postulated that parasitic infections in this population have (in accordance with well-established results of parasitic disease) caused both elevated levels of serum IgE and a decreased prevalence of allergic disease with the possible masking of the various genetic components of serum IgE levels and atopic disease.

Commingling and segregation analysis of blood pressure in a French-Canadian population

Commingling and segregation of age-sex-adjusted systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial blood pressure (MBP) were examined in 1,560 individuals from 374 French-Canadian nuclear families. After correction for skewness, evidence in favor of two commingled distributions was found for SBP in the combined data (parents and offspring) and in parents, but not in offspring. Segregation analysis (using the computer program POINTER) suggested that a multifactorial contribution to all three phenotypes was greater in offspring than in parents, which could be the result of either polygenic or shared environmental components relevant to sibships, or both. Statistical evidence was found for a major effect on SBP. However, Mendelian transmission of the major effect was rejected, and no transmission of the major effect (equal tau's) was not. This is just the opposite to what would be expected if the major effect was due to a major gene, and it would ordinarily be considered as sufficient evidence to refute a major gene effect on SBP. However, the commingling in parents but not in offspring (who are all below 26 years of age), and the finding of equal transmission probabilities (nearly equal to 1), are compatible with an alternative interpretation. It is possible that there is a real major gene effect on SBP but that the genotype for elevated SBP has not yet expressed itself in the offspring as they have not yet gone through the risk period. Accordingly, this possibility needs to be evaluated further in additional studies involving older offspring.