Determination of Volatile Bases in Seafood Using the Ammonia Ion Selective Electrode: Collaborative Study

Nine collaborating laboratories tested a combination of 23 seafood samples for volatile bases using an ammonia ion selective electrode. Results were reported as mg NH3/100 g fish, but the method reflected levels of both ammonia and trimethylamine, which permeated the ammonia membrane. The 23 samples were broken down into 8 blind duplicate pairs, 2 Youden matched pairs, and 3 single samples covering fresh to spoiled product ranging from 8 to 82 mg NH3/100 g. Seven species were evaluated: Atlantic cod, squid, Atlantic halibut, gray sole, monkfish, dogfish, and Atlantic mackerel. The ammonia electrode assay was performed on an aqueous homogenate consisting of 95 mL distilled water and 5.0 g sample tissue. Alkaline ion strength adjusting solution (2 mL) was added to the homogenate to liberate ammonia that was sensed by the ion specific electrode and measured on a precalibrated portable meter. Repeatability standard deviations (RSDr) ranged from 4.2 to 17%; reproducibility standard deviations (RSDR) ranged from 8.8 to 21%. A standard ammonium chloride solution was provided to all laboratories to spike 3 different samples at 10 mg NH3/100 g. Recoveries of added ammonia as ammonium chloride for fresh, borderline, and spoiled samples were 88.6, 107, and 128%, respectively.

Characterizing pediatric inpatient sleep duration and disruptions

OBJECTIVE

To contextualize inpatient sleep duration and disruptions in a general pediatric hospital ward by comparing in-hospital and at-home sleep durations to recommended guidelines and to objectively measure nighttime room entries.

METHODS

Caregivers of patients four weeks - 18 years of age reported patient sleep duration and disruptions in anonymous surveys. Average at-home and in-hospital sleep durations were compared to National Sleep Foundation recommendations. Objective nighttime traffic was evaluated as the average number of room entries between 11:00pm and 7:00am using GOJO brand hand-hygiene room entry data.

RESULTS

Among 246 patients, patients slept less in the hospital than at home with newborn and infant cohorts experiencing 7- and 4-h sleep deficits respectively (Newborn: 787 ± 318 min at home vs. 354 ± 211 min in hospital, p < 0.001; Infants: 703 ± 203 min at home vs. 412 ± 152 min in hospital, p < 0.01). Newborn children also experienced >2 h sleep deficits at home when compared to NSF recommendations (Newborns: 787 ± 318 min at home vs. 930 min recommended, p < 0.05). Objective nighttime traffic measures revealed that hospitalized children experienced 7.3 room entries/night (7.3 ± 0.25 entries). Nighttime traffic was significantly correlated with caregiver-reported nighttime awakenings (Spearman Rank Correlation Coefficient: 0.83, p < 0.001).

CONCLUSION

Hospitalization is a missed opportunity to improve sleep both in the hospital and at home.

Associations between environmental quality and adult asthma prevalence in medical claims data

As of 2014, approximately 7.4% of U.S. adults had current asthma. The etiology of asthma is complex, involving genetics, behavior, and environmental factors. To explore the association between cumulative environmental quality and asthma prevalence in U.S. adults, we linked the U.S. Environmental Protection Agency's Environmental Quality Index (EQI) to the MarketScan® Commercial Claims and Encounters Database. The EQI is a summary measure of five environmental domains (air, water, land, built, sociodemographic). We defined asthma as having at least 2 claims during the study period, 2003-2013. We used a Bayesian approach with non-informative priors, implementing mixed-effects regression modeling with a Poisson link function. Fixed effects variables were EQI, sex, race, and age. Random effects were counties. We modeled quintiles of the EQI comparing higher quintiles (worse quality) to lowest quintile (best quality) to estimate prevalence ratios (PR) and credible intervals (CIs). We estimated associations using the cumulative EQI and domain-specific EQIs; we assessed U.S. overall (non-stratified) as well as stratified by rural-urban continuum codes (RUCC) to assess rural/urban heterogeneity. Among the 71,577,118 U.S. adults with medical claims who could be geocoded to county of residence, 1,147,564 (1.6%) met the asthma definition. Worse environmental quality was associated with increased asthma prevalence using the non-RUCC-stratified cumulative EQI, comparing the worst to best EQI quintile (PR:1.27; 95% CI: 1.21, 1.34). Patterns varied among different EQI domains, as well as by rural/urban status. Poor environmental quality may increase asthma prevalence, but domain-specific drivers may operate differently depending on rural/urban status.

Understanding Toxoplasmosis in the United States Through "Large Data" Analyses

BACKGROUND

Toxoplasma gondii infection causes substantial morbidity and mortality in the United States, and infects approximately one-third of persons globally. Clinical manifestations vary. Seropositivity is associated with neurologic diseases and malignancies. There are few objective data concerning US incidence and distribution of toxoplasmosis.

METHODS

Truven Health MarketScan Database and International Classification of Diseases, Ninth Revision (ICD-9) codes, including treatment specific to toxoplasmosis, identified patients with this disease. Spatiotemporal distribution and patterns of disease manifestation were analyzed. Comorbidities between patients and matched controls were compared.

RESULTS

Between 2003 and 2012, 9260 patients had ICD-9 codes for toxoplasmosis. This database of patients with ICD-9 codes includes 15% of those in the United States, excluding patients with no or public insurance. Thus, assuming that demographics do not change incidence, the calculated total is 61 700 or 6856 patients per year. Disease was more prevalent in the South. Mean age at diagnosis was 37.5 ± 15.5 years; 2.4% were children aged 0-2 years, likely congenitally infected. Forty-one percent were male, and 73% of women were of reproductive age. Of identified patients, 38% had eye disease and 12% presented with other serious manifestations, including central nervous system and visceral organ damage. Toxoplasmosis was statistically associated with substantial comorbidities, including human immunodeficiency virus, autoimmune diseases, and neurologic diseases.

CONCLUSIONS

Toxoplasmosis causes morbidity and mortality in the United States. Our analysis of private insurance records missed certain at-risk populations and revealed fewer cases of retinal disease than previously estimated, suggesting undercoding, underreporting, undertreating, or differing demographics of those with eye disease. Mandatory reporting of infection to health departments and gestational screening could improve care and facilitate detection of epidemics and, thereby, public health interventions.

The role of statins for primary prevention in non-elderly colorectal cancer patients

BACKGROUND

There is conflicting evidence for the role of statins in the primary prevention of colorectal cancer (CRC). We conducted a case control study (N=357,702) in the non-elderly adult US population (age=18-64 years) with the primary objective to examine the association between CRC and statin use.

PATIENTS AND METHODS

MarketScan® databases were used to identify patients with CRC. A case was defined as having an incident diagnosis of CRC. Up to ten individually matched controls (age, sex, region and date of diagnosis) were selected per case. Statin exposure was assessed by prescription tracking in the 12 months prior to the index date. Conditional logistic regression was used to adjust for multiple potential confounders and calculate adjusted odds ratios (AOR).

RESULTS

The mean age of participants was 54 years; 52% males and 48% females. In a multivariable model, any statin use was associated with 26% reduced odds of CRC (AOR, 0.74, 95% confidence interval (CI), 0.72-0.77, p<0.001). Age-stratified analyses showed a stronger effect of statins on CRC in participants aged 55 years or younger (AOR, 0.67, 95% CI, 0.63-0.71, p<0.001) than in participants aged above 55 years (AOR, 0.79, 95% CI, 0.76-0.82, p<0.001); the age-by-statin interaction was statistically significant (p<0.001). The dose-response analyses performed with simvastatin only showed a trend towards significance between the duration of simvastatin exposure and odds of developing CRC (p=0.06).

CONCLUSIONS

Statins appears to reduce the risk of CRC in non-elderly US population. Chemoprevention with statin might be more effective in non-elderly US population.

The role of metformin for primary prevention in non-elderly diabetic colorectal cancer patients

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Background: There is growing evidence for the beneficial effect of metformin in reducing the incidence of colorectal cancer (CRC) in diabetic patients. However, no such studies are done in the US population. We conducted a case control study (N=8,046) in non-elderly diabetic adult US population (age 18-64 years) to investigate the role of metformin for the primary prevention of CRC. Methods: MarketScan claims database was used to identify diabetic patients with CRC using ICD-9 codes. Only incident cases of CRC in diabetic patients were included in the study. Two matched controls (matched for age, sex, and geographical region) were selected per case. The exposure to metformin was assessed from prescriptions in the 12 months prior to the earliest date of CRC diagnosis. The primary objective was to assess the odds of having CRC in metformin users as compared nonusers. Adjusted odds ratios (AOR) were calculated by adjusting for multiple potential confounders using conditional logistic regression. Results: The mean age of CRC patients was 56 years, 60% were males. Metformin was prescribed to 38.13% patients. A total of 37% (995/2,682) patients developed CRC in metformin exposed group compared to 62.9% (1,687/2,682) patients in non-metformin exposed group. In a multivariate model, any metformin use was associated with a statistically significant 12% reduced risk of developing CRC (AOR 0.88, 95% CI, 0.79-0.98, p<0.026). Prescribed NSAIDs were also associated with decreased incidence of CRC (AOR 0.84, 95% CI, 0.73-0.97, p=0.019). Variables associated with increased incidence of CRC in the multivariate model were IBD (AOR 1.94, 95% CI, 1.13-3.33, p<0.015); use of insulin (AOR 1.45, 95% CI, 1.27-1.65, p<0.001); coronary artery disease (AOR 1.66, 95% CI, 1.43-1.93, p<0.001). There was no significant relationship between CRC incidence and obesity (AOR 1.19, 95% CI, 0.93-1.53, p=0.158); polycystic ovary disease (AOR 0.32, 95% CI, 0.03-2.76, p=0.3); sulfonylureas (AOR 1.09, 95% CI, 0.96-1.24, p=0.15); thiazolidinediones (AOR 0.94, 95% CI, 0.82-1.08, p=0.41); statins (AOR 0.914, 95% CI, 0.82-1.01, p=0.108). Conclusions: The use of metformin appears to reduce the incidence of CRC in non-elderly diabetic adult US population.

Sex disparities in diagnosis of bladder cancer after initial presentation with hematuria: a nationwide claims-based investigation

BACKGROUND

Women have disproportionately higher mortality rates relative to incidence for bladder cancer. Multiple etiologies have been proposed, including delayed diagnosis and treatment. Guidelines recommend ruling out malignancy in men and women presenting with hematuria. This study sought to determine the difference in timing from presentation with hematuria to diagnosis of bladder cancer in women versus men.

METHODS

This is a retrospective population-based study examining the timing from presentation with hematuria to diagnosis of bladder cancer, based on data from the MarketScan databases, which include enrollees of more than 100 health insurance plans of approximately 40 large US employers from 2004 through 2010. All study patients presented with hematuria and were subsequently diagnosed with bladder cancer. The primary outcome measure was number of days between initial presentation with hematuria and diagnosis of bladder cancer by sex.

RESULTS

A total of 5416 men and 2233 women met inclusion criteria. Mean days from initial hematuria claim to bladder cancer claim was significantly longer in women (85.4 versus 73.6 days, P < .001), and the proportion of women with >6 month delay in bladder cancer diagnosis was significantly higher (17.3% versus 14.1%, P < .001). Women were more likely to be diagnosed with urinary tract infection (odds ratio = 2.32, 95% confidence interval = 2.07-2.59) and less likely to undergo abdominal or pelvic imaging (odds ratio = 0.80, 95% confidence interval = 0.71-0.89).

CONCLUSIONS

Both men and women experience significant delays between presentation with hematuria and diagnosis of bladder cancer, with longer delays for women. This may be partly responsible for the sex-based discrepancy in outcomes associated with bladder cancer.

The role of statins for primary prevention in non-elderly colorectal cancer patients

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Background: There is conflicting evidence for the effect of statins in primary prevention of colorectal cancer (CRC). We conducted a case control study (N=357,702) in non-elderly adult US population (age 18-64 years) to investigate the role of statins in primary prevention of CRC. Methods: We used MarketScan claims database to identify patients with CRC using ICD-9 codes. A case was defined as having an incident diagnosis of CRC. Up to ten controls (matched for age, sex, and geographical region) were selected per case. Statins exposure was assessed from prescriptions in the 12 months prior to the earliest date of CRC diagnosis. The primary objective was to assess the incidence of CRC in statin users and nonusers. Conditional logistic regression was used to adjust for multiple potential confounders and calculate adjusted odds ratios (AOR). Results: The mean age of CRC patients was 54 years, 52% were males.Statins were prescribed to 19.1% (68,461/357,702) patients.A total of 8.3% (5,704/68,461) patients developed CRC in statin exposed group compared to 9.3% (26,912/289,241) patients in non-statin exposed group. In a multivariate model, any statin use was associated with 25% reduced risk of CRC (AOR 0.75, 95% CI, 0.73-0.78, p<0.001). An age-stratified analysis showed more benefit in patients aged 55 years or less than those above age 56 years (AOR 0.68 and AOR 0.79 respectively; p<0.001 for interaction between age group and statin exposure). Variables associated with increased incidence of CRC in the multivariate model were obesity (AOR 1.3, 95% CI, 1.2-1.4, p<0.001); DM (AOR 1.2, 95% CI, 1.1-1.2, p<0.001); IBD (AOR 3.1, 95% CI, 2.8-3.5, p<0.001); use of insulin (AOR 1.2, 95% CI, 1.1-1.3, p<0.001) and sulfonylureas (AOR 1.2, 95% CI, 1.1-1.3, p<0.001). Prescribed NSAIDs showed modest reduction in CRC incidence (AOR 0.94, 95% CI, 0.91-0.97, p=0.002). There was no significant relationship between CRC incidence and other oral hypoglycemic drugs. Conclusions: Statins appears to reduce the incidence of CRC in non-elderly adult US population. A randomized controlled trial is needed to validate this finding.

Association of elevated plasminogen activator inhibitor 1 levels with diminished lung function in patients with asthma

BACKGROUND

We previously reported that plasminogen activator inhibitor 1 (PAI-1) was upregulated in human asthmatic airways and promotes airway fibrosis in an allergen-challenged murine model of asthma.

OBJECTIVES

To examine whether elevated plasma levels of PAI-1 are associated with poor lung function in asthmatic patients.

METHODS

Five hundred nineteen adults were eligible for the study, and ultimately 353 adults were enrolled and completed the baseline protocol between January 24, 2004, and July 30, 2005. Of these, 231 adults with asthma from the Chicago Initiative to Raise Asthma Health Equity study were randomly selected and the plasma levels of PAI-1 were measured by enzyme-linked immunosorbent assay. Asthma burden, medication, smoking status, and body mass index (BMI) were obtained by history and spirometry was performed. A multivariate regression analysis was performed to evaluate the association of PAI-1 levels and lung function and the potential determinant variables that were associated with PAI-1.

RESULTS

We found associations between PAI-1 and BMI (β = 0.606, P = .002), smoking (β = 7.526, P = .001), and African American race (β = -9.061, P = .01). Obese patients showed a significant increase in PAI-1, and current smokers demonstrated higher levels of PAI-1 compared with nonsmokers. When we evaluated the associations between lung function parameters and PAI-1, we found that PAI-1 was negatively associated with forced vital capacity (FVC) (β = -0.098, P = .011) but not with forced expiratory volume in 1 second (FEV(1)) or the FEV(1)/FVC ratio. There was a negative association between BMI and FVC, and PAI-1 may mediate some of this association.

CONCLUSIONS

This study suggests a significant association between PAI-1 and lung function in patients with asthma. The effect of obesity on FVC may in part be mediated by PAI-1.

Improving asthma self-efficacy: developing and testing a pilot community-based asthma intervention for African American adults

BACKGROUND

Low-income African American adults in Chicago have disproportionately high asthma morbidity and mortality rates. Interventions that improve asthma self-efficacy for appropriate self-management behaviors might ultimately improve asthma control in this population.

OBJECTIVE

We sought to pilot test an intervention to improve asthma self-efficacy for appropriate self-management behaviors.

METHODS

Participants for this trial were recruited through 2 primary care clinics located in the largest African American community in Chicago. Participants were then randomized into one of 2 groups. The control group received mailed asthma education materials. The intervention group was offered 4 group sessions led by a community social worker and 6 home visits by community health workers. Telephone interviews were conducted at baseline (before intervention), 3 months (after intervention), and 6 months (maintenance).

RESULTS

The 42 participants were predominantly African American and low income and had poorly controlled persistent asthma. The intervention group had significantly higher asthma self-efficacy at 3 months (P < .001) after the completion of the intervention. Asthma action plans were more common in the intervention group at 3 months (P = .06). At 6 months, the intervention group had improved asthma quality of life (P = .002) and improved coping (P = .01) compared with control subjects. Trends in behavioral and clinical outcomes favored the intervention group but were not statistically significant.

CONCLUSIONS

This community-based asthma intervention improved asthma self-efficacy, self-perceived coping skills, and asthma quality of life for low-income African American adults. Larger trials are needed to test the efficacy of this intervention to reduce asthma morbidity in similar high-risk populations.

Cost-Effectiveness of Coronary Artery Bypass Grafts Versus Percutaneous Coronary Intervention for Revascularization of High-Risk Patients

BACKGROUND

A Department of Veterans Affairs Cooperative Study randomized high-risk patients with medically refractory myocardial ischemia, a group largely excluded from previous trials, to urgent revascularization with either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). The present study examined the cost-effectiveness of PCI versus CABG for these high-risk patients.

METHODS AND RESULTS

Of 454 patients at 16 Department of Veterans Affairs medical centers, 445 were available for the economic analysis (218 PCI and 227 CABG patients). Total costs were assessed at 3 and 5 years from the third-party payer's perspective, and effectiveness was measured by survival. After 3 years, average total costs were 63,896 dollars for PCI versus 84,364 dollars for CABG patients, a difference of 20,468 dollars (95% confidence interval [CI] 13,918 dollars to 27,569 dollars). CIs were estimated by bootstrapping. Survival at 3 years was 0.82 for PCI versus 0.79 for CABG patients (P=0.34). Precision of the cost-effectiveness estimates were assessed by bootstrapping. PCI was less costly and more effective at 3 years in 92.6% of the bootstrap replications. After 5 years, average total costs were 81,790 dollars for PCI versus 100,522 dollars for CABG patients, a difference of 18,732 dollars (95% CI 9873 dollars to 27,831 dollars), whereas survival at 5 years was 0.75 for PCI patients versus 0.70 for CABG patients (P=0.21). At 5 years, PCI remained less costly and more effective in 89.4% of the bootstrap replications.

CONCLUSIONS

PCI was less costly and at least as effective for the urgent revascularization of medically refractory, high-risk patients over 5 years.

National Study of Internal Medicine Manpower: XVII. Changes in the characteristics of internal medicine residents and their training programs, 1988-1989

The National Study of Internal Medicine Manpower (NaSimm) has been surveying program directors of internal medicine about their programs and residents for 13 years. The 1988-1989 survey results, when compared with the results for 1987-1988, show an increase in both the number of residency positions offered in internal medicine and the number of residents in internal medicine programs. Although the proportion of graduates from U.S. medical schools who choose internal medicine is not changing (34%), the proportion of U.S. medical school graduates who continue training in internal medicine after their first year is decreasing. The composition of the residents in internal medicine by medical school graduated is also changing. Almost 25% of the first-year residents (R1s) in internal medicine are now graduates of foreign medical schools (FMGs) compared with 14% in 1976. The proportion of first-year female residents in internal medicine has increased to 30%, whereas the proportion of both first-year blacks and Hispanics has remained constant at 5% each. In nearly 25% (109 of 440) of the residency programs, more than 50% of the R1s are FMGs. Hispanics, Asians, and blacks were found to be over-represented in the programs training larger proportions of FMGs. This over-representation is attributable, in part, to the fact that Hispanics and Asians may be FMGs. Training issues of concern to program directors continue to be the provision of ambulatory and primary care experiences and the scheduling of nights on call. The survey results show that many residency program directors have reported a reduction in the number of nights on call and an increase in the amount of time residents spend in ambulatory training.

National Study of Internal Medicine Manpower: XVI. Subspecialty fellowship programs, 1988 update

Much of the debate about medical manpower during the 1980s has focused on the growing number of medical subspecialists. We examined the number of subspecialty fellows since 1976, paying particular attention to data collected in the 1987-1988 academic year. The number of fellows in subspecialty training at a given time has increased by 27% since 1976; however, much of this increase is due to the increased length of the training programs. The number of first-year fellows has increased only 7% since 1976. Growth in the number of fellowships has varied by subspecialty. The number of fellowships in geriatrics, critical care, and general internal medicine has increased dramatically. Additionally, the traditional subspecialties-cardiology, pulmonary disease, gastroenterology, infectious diseases, rheumatology, and allergy-immunology-have all grown to some extent. Program directors in all subspecialties anticipate continued growth in the coming years.

National Study of Internal Medicine Manpower: XV. A decade of change in residency training in internal medicine

We report on trends in the characteristics of residency training programs in internal medicine from 1976 to 1988 and make some comparisons with other specialties. Internal medicine is faring less well in the residency match compared with other specialties than it did 10 years ago. It has also increased the number of residency positions offered more than other major specialties. A sizable proportion of first-year residency positions in internal medicine are not filled through the Match. Foreign medical graduates account for almost 50% of the first-year resident (R1) positions filled outside the Match. Programs most dependent on foreign medical graduates are in hospitals with limited medical school affiliation, smaller size, operated by churches or the Veterans Administration, and located in eastern states and large metropolitan areas. Despite concerns about quality and oversupply, almost 50% of the program directors expected to increase the size of their programs in 1988-1990. Residents are not being scheduled for fewer hours per week than they were 12 years ago but they are being scheduled for fewer nights. No trends were noted toward increased ambulatory care training sites away from the hospital campus.