Characteristics of US adults with the metabolic syndrome and therapeutic implications

BACKGROUND

The third Adult Treatment Panel (ATP III) of the National Cholesterol Education Program defines clinical criteria for diagnosis of the metabolic syndrome, which increases cardiovascular risk and is a target for therapy.

AIM

We analysed the third National Health and Nutrition Examination Survey (NHANES III; 1988-94) to determine how many US adults meet these criteria and are recommended for lipid-modifying drug therapy by ATP III.

METHODS

NHANES III data were used to estimate the number of individuals with the metabolic syndrome and the number recommended for treatment by ATP III, based on 1990 census data.

RESULTS

An estimated 36.3 million (23%) US adults have the metabolic syndrome. Of these, 84% met the criterion for obesity, 76% for blood pressure, 75% for HDL-C, 74% for triglycerides and 41% for glucose. Most (54%) are in the higher risk categories of ATP III, yet only 39% overall are recommended for drug therapy by ATP III cutpoints; of these, most will achieve LDL-C targets with reductions of 35-40%. Of the 15.3 million individuals with the metabolic syndrome and triglycerides > or = 2.26 mmol/l (200 mg/dl), non-HDL-C is above ATP III recommendations in 11.6 million.

CONCLUSIONS

Of the large number of Americans with the metabolic syndrome, ATP III recommends drug therapy for only a minority, because LDL-C typically is not substantially elevated. Instead, high triglycerides and low HDL-C are more common; clinical trial data are needed to determine whether optimal therapy should focus on reductions in LDL-C or on comprehensive improvements to the lipid profile.

Patient satisfaction with oral versus nonoral therapeutic approaches in onychomycosis

The follow-up results of a 9-month observational study of 150 onychomycosis patients treated with a variety of mechanical, topical, and oral therapies by podiatric physicians and dermatologists are presented. Changes from baseline in toenail condition and patient satisfaction were assessed at 4- and 9-month follow-up. At 9 months, patients who had received oral therapy reported significantly fewer onychomycosis-related problems in social situations, including embarrassment or self-consciousness about the appearance of nails, avoidance of contact by others, being perceived as unclean or untidy, and the desire to keep their nails concealed. Patient-reported satisfaction with the treatment program was significantly higher for those receiving oral therapy than for those receiving nonoral therapy.

Postchallenge hyperglycemia and mortality in a national sample of U.S. adults

OBJECTIVE

Although postchallenge hyperglycemia is a well-established feature of type 2 diabetes, its association with risk of mortality is uncertain. Therefore, the aim of this study was to assess the independent association of fasting and 2-h glucose levels with all-cause and cardiovascular disease (CVD) mortality.

RESEARCH DESIGN AND METHODS

We analyzed data from the Second National Health and Nutrition Examination Survey (NHANES II) Mortality Study, a prospective cohort study of U.S. adults examined in the NHANES II, and focused on the 3,092 adults aged 30-74 years who underwent an oral glucose tolerance test at baseline (1976-1980). Deaths were identified from U.S. national mortality files from 1976 to 1992. To account for the complex survey design, we used SUDAAN statistical software for weighted analysis.

RESULTS

Compared with their normoglycemic counterparts (fasting glucose [FG] < 7.0 and 2-h glucose < 7.8 mmol/l), adults with fasting and postchallenge hyperglycemia (FG > or =7.0 and 2-h glucose > or =11.1 mmol/l) had a twofold higher risk of death after 16 years of follow-up (age- and sex-adjusted relative hazard [RH] 2.1, 95% CI 1.4-3.2). However, adults with isolated postchallenge hyperglycemia (FG < 7.0 and 2-h glucose > or =11.1 mmol/l) were also at higher risk of death (1.6, 1.0-2.6). In proportional hazards analysis, FG (fully adjusted RH 1.10 per 1 SD; 95% CI 1.01, 1.22) and 2-h glucose (1.14, 1.00-1.29) showed nearly identical predictive value for mortality. Similar trends were observed for CVD mortality.

CONCLUSIONS

These results suggest that postchallenge hyperglycemia is associated with increased risk of all-cause and CVD mortality independently of other CVD risk factors.

A comparison of two methods for estimating the health care costs of epilepsy

PURPOSE

Previous studies have estimated medical care costs of epilepsy by applying unit costs to estimated utilization or by summing costs for (a) ambulatory care and hospitalizations coded as epilepsy and (b) procedures and drugs specifically associated with the diagnosis or treatment of epilepsy. These methods may underestimate the cost of medical care for epilepsy. Two methods for estimating the medical care costs of epilepsy ("epilepsy-attributable cost method" and "case-control cost method") were compared.

METHODS

The study population was 655 individuals with an epilepsy diagnosis enrolled in a managed care plan in the southwestern United States. The epilepsy-attributable costs were determined by summing costs for inpatient and outpatient encounters coded as epilepsy, procedures for the diagnosis or treatment of epilepsy, and drugs used to treat epilepsy. The case-control method determined costs by calculating the difference in total costs between cases and 1,965 age- and gender-matched controls.

RESULTS

The case-control epilepsy costs were $2,923 per case compared with epilepsy-attributable costs of $1,335 per case. The case-control method found statistically significant differences in costs between cases and controls for inpatient care, prescription drugs, and 8 of 11 categories of outpatient care. The largest contributors to the discrepancy between estimates were inpatient care, emergency department care, laboratory tests, and "other specialist" care.

CONCLUSIONS

Epilepsy-attributable costs accounted for only 46% of the total difference in costs between epilepsy cases and controls. Persons with epilepsy use more medical services than controls, but a substantial portion of this care is not coded to epilepsy.

Impact of evidence-based "clinical judgment" on the number of American adults requiring lipid-lowering therapy based on updated NHANES III data. National Health and Nutrition Examination Survey

BACKGROUND

When the National Cholesterol Education Program Adult Treatment Panel II (ATP II) guidelines were published, National Health and Nutrition Examination Survey III data for 1988 to 1991 were used to estimate the number of Americans requiring lipid-lowering therapy based on ATP II cut points. However, the guidelines recommend using clinical judgment to determine whether to initiate drug therapy in individuals whose low-density lipoprotein cholesterol levels remain above treatment goals with diet therapy but below the initiation level for drug therapy.

METHODS

We analyzed updated (1988-1994) National Health and Nutrition Examination Survey III data, based on a sample of 6796 adults aged 20 years and older, to estimate the numbers of American adults with an elevated low-density lipoprotein cholesterol level and requiring drug therapy using cut points vs clinical judgment as specified in ATP II guidelines.

RESULTS

Assuming a 10% low-density lipoprotein cholesterol reduction with diet, an estimated 10.4 million American adults require drug therapy based on ATP II cut points. If we include individuals for whom the guidelines recommend clinical judgment, the estimate increases to 28.4 million. The largest increase occurs in individuals without known coronary heart disease but with 2 or more risk factors: from 5.5 to 17.5 million. These high-risk individuals have low-density lipoprotein cholesterol concentrations similar to those in patients with coronary heart disease.

CONCLUSIONS

Since the ATP II guidelines were published, clinical judgment has been informed by abundant clinical trial evidence establishing the safety and benefit of lipid-lowering therapy. The large number of individuals at high risk for coronary heart disease emphasizes the need for cost-effective therapy to extend treatment to the greatest number of individuals who may benefit.

A health-related quality of life measure for use in patients with onychomycosis: a validation study

Onychomycosis is a common nail disorder associated with pain, discomfort and varying degrees of physical impairment and loss of dexterity. Psychological and social limitations result from reactions of others to visible impairment. The goal of this research is to validate a questionnaire to measure the impact of toenail onychomycosis on health-related quality of life (HRQoL). One hundred and fifty onychomycosis patients were enrolled in an observational study at eight sites in the US. Attending physicians reported information on clinical status at enrolment. Patients completed a questionnaire covering HRQoL that included general and disease-specific items measuring the impact of onychomycosis on activities and appearance, plus problems and symptoms associated with toenail infection. The subscales of the instrument showed high internal consistency reliability (range = 0.63-0.95). Construct validity reflected the close association of physical functioning scores with onychomycosis impairment. Test-Retest reliability was good to excellent for all scales (ICC = 0.52-0.89). Discriminant validity was evidenced by persons who are younger and female reporting worse disease-specific HRQoL. Responsiveness to clinical change was noted for all disease-specific scale scores for improved patients. This instrument has demonstrated reliability, validity and responsiveness for use in observational and clinical studies of toenail onychomycosis patients. Data indicate that onychomycosis patients report significant pain and discomfort reflecting the need for HRQoL measurement.

Onychomycosis. Baseline results of an observational study

The investigators present an analysis of baseline quality-of-life and patient-management approaches from an observational study of 150 patients being treated by podiatric physicians and dermatologists for onychomycosis. The majority (73%) made the initial office visit specifically because of their onychomycosis. Both men and women indicated that they had substantial physical discomfort as well as concerns related to appearance. Women reported significantly more problems than did men as a result of their onychomycosis. Physicians reported that 54% of patients suffered from toenail discomfort, 36% had pain while walking, 40% reported that their condition limited wearing of shoes, and 67% were embarrassed by the condition. The results of this study suggest that the treatment approach of podiatric physicians is more likely to address the palliative concerns of patients with onychomycosis, while the approach of dermatologists is more likely to attempt a definitive cure.

Manganese pollution in the city environment and its relationship to traffic density

As lead is phased out of gasoline, other additives with anti-knock properties, particularly organic manganese compounds, are being substituted. Unavoidably, such compounds go through the combustion process, are eliminated in exhaust gases, and become part of the city environment. To obtain some indication of the extent of this new pollution street soils from various locations in a heavily trafficked city (Newark, NJ) were analyzed for manganese and lead by atomic absorption. Highly signigicant inverse relationships were found between the concentrations of both contaminants and distances from major traffic arteries. Strong circumstantial evidence is thus provided that: 1) manganese pollution is occurring, along with lead, in the city environment; 2) this new pollution is related to traffic density; and 3) the most likely sources are automobile exhausts. This suspicion is further strengthened by the significant correlations observed between manganese and lead contents in children's blood, suggesting a common source for both. Substantiation of the safety of this practice of adding manganese to gasoline is needed.