The relationship between preventive dental care and overall medical expenditures

OBJECTIVES

To examine the relationship between preventive dental visits (PDVs) and medical expenditures while mitigating bias from unobserved confounding factors.

STUDY DESIGN

Retrospective data analysis of Indiana Medicaid enrollment and claims data (2015-2018) and the Area Health Resources Files.

METHODS

An instrumental variable (IV) approach was used to estimate the relationship between PDVs and medical and pharmacy expenditures among Medicaid enrollees. The instrument was defined as the number of adult enrollees with at least 1 nonpreventive dental claim per total Medicaid enrollees within a Census tract per year.

RESULTS

In naive analyses, enrollees had on average greater medical expenditures if they had a prior-year PDV (β = $397.21; 95% CI, $184.23-$610.18) and a PDV in the same year as expenditures were measured (β = $344.81; 95% CI, $193.06-$496.56). No significant differences in pharmacy expenditures were observed in naive analyses. Using the IV approach, point estimates of overall medical expenditures for the marginal enrollee who had a prior-year PDV (β = $325.17; 95% CI, -$708.03 to $1358.37) or same-year PDV (β = $170.31; 95% CI, -$598.89 to $939.52) were similar to naive results, although not significant. Our IV approach indicated that PDV was not endogenous in some specifications.

CONCLUSIONS

This is the first study to present estimates with causal inference from a quasi-experimental study of the effect of PDVs on overall medical expenditures. We observed that prior- or same-year PDVs were not related to overall medical or pharmacy expenditures.

The Relationship Between Dental Provider Density and Receipt of Dental Care Among Medicaid-enrolled Adults

OBJECTIVE

We sought to measure the association of dental provider density and receipt of dental care among Medicaid-enrolled adults.

METHODS

We used four years of Indiana Medicaid claims and enrollment data (2015 to 2018) and the Area Health Resources File to examine the relationship between any dental visit (ADV) or any preventive dental visit (PDV) and three county-level measures of dental provider density (the total number of Medicaid-participating dentists, a binary indicator of a federally qualified health center (FQHC) with a Medicaid-participating dentist, and the overall county dentist-to-population ratio).

RESULTS

The likelihood of ADV or PDV increased with greater density of Medicaid-participating dentists as well as dentists accepting Medicaid working at an FQHC within the county. The overall dentist-to-population ratio was not associated with dental care use among the adult Medicaid population.

CONCLUSION

Dentist participation in Medicaid program may be a modifiable barrier to Medicaid-enrolled adults' receipt of dental care.

Economic Burden Associated With Untreated Mental Illness in Indiana

Importance

There is a paucity of systematically captured data on the costs incurred by society-individuals, families, and communities-from untreated mental illnesses in the US. However, these data are necessary for decision-making on actions and allocation of societal resources and should be considered by policymakers, clinicians, and employers.

Objective

To estimate the economic burden associated with untreated mental illness at the societal level.

Design, Setting, and Participants

This cross-sectional study used multiple data sources to tabulate the annual cost of untreated mental illness among residents (≥5 years old) in Indiana in 2019: the US National Survey on Drug Use and Health, the National Survey of Children's Health, Indiana government sources, and Indiana Medicaid enrollment and claims data. Data analyses were conducted from January to May 2022.

Main Outcomes and Measures

Direct nonhealth care costs (eg, criminal justice system, homeless shelters), indirect costs (unemployment, workplace productivity losses due to absenteeism and presenteeism, all-cause mortality, suicide, caregiver direct health care, caregiver productivity losses, and missed primary education), and direct health care costs (disease-related health care expenditures).

Results

The study population consisted of 6 179 105 individuals (median [SD] age, 38.0 [0.2] years; 3 132 806 [50.7%] were women) of whom an estimated 429 407 (95% CI, 349 526-528 171) had untreated mental illness in 2019. The economic burden of untreated mental illness in Indiana was estimated to be $4.2 billion annually (range of uncertainty [RoU], $2.1 billion-$7.0 billion). The cost of untreated mental illness included $3.3 billion (RoU, $1.7 billion-$5.4 billion) in indirect costs, $708.5 million (RoU, $335 million-$1.2 billion) in direct health care costs, and $185.4 million (RoU, $29.9 million-$471.5 million) in nonhealth care costs.

Conclusion and Relevance

This cross-sectional study found that untreated mental illness may have significant financial consequences for society. These findings put into perspective the case for action and should be considered by policymakers, clinicians, and employers when allocating societal resources and funding. States can replicate this comprehensive framework as they prioritize key areas for action regarding mental health services and treatments.

Does preventive dental care reduce nonpreventive dental visits and expenditures among Medicaid-enrolled adults?

OBJECTIVE

To determine whether preventive dental visits are associated with fewer subsequent nonpreventive dental visits and lower dental expenditures.

DATA SOURCES

Indiana Medicaid enrollment and claims data (2015-2018) and the Area Health Resource File.

STUDY DESIGN

A repeated measures design with individual and year fixed effects examining the relationship between preventive dental visits (PDVs) and nonpreventive dental visits (NPVs) and dental expenditures.

DATA COLLECTION/EXTRACTION METHODS

Not applicable.

PRINCIPAL FINDINGS

Of 28,152 adults (108,349 observation-years) meeting inclusion criteria, 36.0% had a dental visit, 27.8% a PDV, and 22.1% a NPV. Compared to no PDV in the prior year, at least one was associated with fewer NPVs (β = -0.13; 95% CI -0.12, -0.11), lower NPV expenditures (β = -$29.12.53; 95% CI -28.07, -21.05), and lower total dental expenditures (-$70.12; 95% -74.92, -65.31), as well as fewer PDVs (β = -0.24; 95% CI -0.26, -0.23).

CONCLUSIONS

Our findings suggest that prior year PDVs are associated with fewer subsequent NPVs and lower dental expenditures among Medicaid-enrolled adults. Thus, from a public insurance program standpoint, supporting preventive dental care use may translate into improved population oral health outcomes and lower dental costs among certain low-income adult populations, but barriers to consistent utilization of PDV prohibit definitive findings.

The Impact of Narrow and Tiered Networks on Costs, Access, Quality, and Patient Steering: A Systematic Review

Health insurers use narrow and tiered networks to lower costs by contracting with, or favoring, selected providers. Little is known about the contemporary effects of narrow or tiered networks on key metrics. The purpose of this systematic review was to synthesize the evidence on how narrow and tiered networks impact cost, access, quality, and patient steering. We searched PubMed, MEDLINE, and Cochrane Central Register of Controlled Trials databases for articles published from January 2000 to June 2020. Both narrow and tiered networks are associated with reduced overall health care costs for most cost-related measures. Evidence pertaining to access to care and quality measures were more limited to a narrow set of outcomes or were weak in internal validity, but generally concluded no systematic adverse effects on narrow or tiered networks. Narrow and tiered networks appear to reduce costs without affecting some quality measures. More research on quality outcomes is warranted.

Faculty salaries in health administration: trends and correlates 2015-2021

In this study, we provide updated information on salaries of academic health administration (HA) faculty members based on data collected in 2015, 2018, and 2021 and examine characteristics associated with earnings. We present mean inflation-adjusted salaries by demographic characteristics, education, experience, productivity, and job activities. We find that salaries of assistant, associate, and full professors have kept up with inflation and there have not been significant changes in salary by any characteristics over time. As in previous iterations of similar survey data, there remain differences in salary by both gender and race. Higher salaries were associated with having a 12-month contract, being tenured or tenure-track, having an administrative position, and being in a department whose focus is not primarily teaching. Findings from our study will be of interest to individuals on the HA job market, hiring committees, and doctoral students preparing for a position after graduation.

Primary Care Case Conferences to Mitigate Social Determinants of Health: A Case Study from One FQHC System

Objective

Given the increasing difficulty healthcare providers face in addressing patients' complex social circumstances and underlying health needs, organizations are considering team-based approaches including case conferences. We sought to document various perspectives on the facilitators and challenges of conducting case conferences in primary care settings.

Study Design

Qualitative study using semi-structured telephone interviews.

Methods

We conducted 22 qualitative interviews with members of case conferencing teams, including physicians, nurses, and social workers from a Federally Qualified Health Clinic, as well as local county public health nurses. Interviews were recorded, transcribed, and reviewed using thematic coding to identify key themes/subthemes.

Results

Participants reported perceived benefits to patients, providers, and healthcare organizations including better care, increased inter-professional communication, and shared knowledge. Perceived challenges related to underlying organizational processes and priorities. Perceived facilitators for successful case conferences included generating and maintaining a list of patients to discuss during case conference sessions and team members being prepared to actively participate in addressing tasks and patient needs during each session. Participants offered recommendations for further improving case conferences for patients, providers, and organizations.

Conclusions

Case conferences may be a feasible approach to understanding patient's complex social needs. Participants reported that case conferences may help mitigate the effects of these social issues and that they foster better inter-professional communication and care planning in primary care. The case conference model requires administrative support and organizational resources to be successful. Future research should explore how case conferences fit into a larger population health organizational strategy so that they are resourced commensurately.

Core Competency Gaps Among Governmental Public Health Employees With and Without a Formal Public Health Degree

OBJECTIVES

To examine the role of a formal public health degree as it relates to core competency needs among governmental public health employees.

DESIGN

This cross-sectional study utilizes the 2017 Public Health Workforce Interests and Needs Survey (PH WINS). Bivariate relationships were analyzed by conducting χ tests of respondents' supervisory level and reported skill gaps. Multivariate logistic regressions of reported skill gaps were performed holding gender, age, race/ethnicity, highest degree attained, current employer, role type, tenure in current agency, and public health certificate attainment constant.

SETTING

Nationally representative sample of government public health employees.

PARTICIPANTS

A total of 30 276 governmental public health employees.

MAIN OUTCOME MEASURE

Self-reported competency skills gaps.

RESULTS

Among nonsupervisors, those with a public health degree had significantly lower odds of reporting a competency gap for 8 of the 21 skills assessed. Among supervisors/managers, those who had a formal public health degree had significantly lower odds of reporting a competency gap in 3 of the 22 skills assessed. Having a degree in public health was not significantly related to an executive's likelihood of reporting a skill gap across any of the 22 skills assessed. Regardless of supervisory level, having a public health degree was not associated with a reduced likelihood of reporting skill gaps in effective communication, budgeting and financial management, or change management competency domains.

CONCLUSIONS

Possessing a formal public health degree appears to have greater value for skills required at the nonsupervisor and supervisor/manager levels than for skills needed at the executive level. Future work should focus on longitudinal evaluations of skill gaps reported among the public health workforce as changes in public health curricula may shift over time in response to newly revised accreditation standards. In addition, public health education should increase emphasis on communication, budgeting, systems thinking, and other management skills among their graduates.

Health information exchange use during dental visits

Dental and medical providers require similar patient demographic and clinical information for the management of a mutual patient. Despite an overlap in information needs, medical and dental data are created and stored in multiple records and locations. Electronic health information exchange (HIE) bridge gaps in health data spread across various providers. Enabling exchange via query-based HIE may provide critical information at the point of care during a dental visit. The purpose of this study is to characterize query-based HIE use during dental visits at two Federally Qualified Health Centers (FQHCs) that provided on-site dental services. First, we determine the proportion of dental visits for which providers accessed the HIE. Next, site, patient and visit characteristics associated with query-based HIE use during dental visits are examined. Last, among dental visits with HIE use, the aspects of the HIE that are accessed most frequently are described. HIE use was low (0.17%) during dental visits, however our findings from this study extend the body of research examining HIE use by studying a less explored area of the care continuum.

Using natural language processing to classify social work interventions

OBJECTIVES

Health care organizations are increasingly employing social workers to address patients' social needs. However, social work (SW) activities in health care settings are largely captured as text data within electronic health records (EHRs), making measurement and analysis difficult. This study aims to extract and classify, from EHR notes, interventions intended to address patients' social needs using natural language processing (NLP) and machine learning (ML) algorithms.

STUDY DESIGN

Secondary data analysis of a longitudinal cohort.

METHODS

We extracted 815 SW encounter notes from the EHR system of a federally qualified health center. We reviewed the literature to derive a 10-category classification scheme for SW interventions. We applied NLP and ML algorithms to categorize the documented SW interventions in EHR notes according to the 10-category classification scheme.

RESULTS

Most of the SW notes (n = 598; 73.4%) contained at least 1 SW intervention. The most frequent interventions offered by social workers included care coordination (21.5%), education (21.0%), financial planning (18.5%), referral to community services and organizations (17.1%), and supportive counseling (15.3%). High-performing classification algorithms included the kernelized support vector machine (SVM) (accuracy, 0.97), logistic regression (accuracy, 0.96), linear SVM (accuracy, 0.95), and multinomial naive Bayes classifier (accuracy, 0.92).

CONCLUSIONS

NLP and ML can be utilized for automated identification and classification of SW interventions documented in EHRs. Health care administrators can leverage this automated approach to gain better insight into the most needed social interventions in the patient population served by their organizations. Such information can be applied in managerial decisions related to SW staffing, resource allocation, and patients' social needs.

Does Nonsurgical Periodontal Treatment Improve Systemic Health?

Clinicians frequently stress the importance of maintaining good oral health for multiple reasons, including its link to systemic health. Because periodontal treatment reduces inflammation in oral tissues, some hypothesize it may positively affect systemic outcomes by reducing inflammation in the body. A significant number of systematic reviews (SRs) and meta-analyses (MAs) have evaluated the effect of periodontal treatment on systemic outcomes. However, inconsistent findings and questionable methodological rigor make drawing conclusions difficult. We conducted a systematic review of reviews that studied the effect of nonsurgical periodontal treatment on systemic disease outcomes. We report on outcomes evaluated, categorizing them as biomarkers, and surrogate or clinical endpoints. In addition, we used A MeaSurement Tool to Access systematic Reviews 2 (AMSTAR 2) to evaluate the methodological quality of the reviews. Of the 52 studies included in our review, 21 focused on diabetes, 15 on adverse birth outcomes, 8 on cardiovascular disease, 3 each on obesity and rheumatoid arthritis, and 2 on chronic kidney disease. Across all studies, surrogate endpoints predominated as outcomes, followed by biomarkers and, rarely, actual disease endpoints. Ninety-two percent of studies had "low" or "critically low" AMSTAR 2 confidence ratings. Criteria not met most frequently included advance registration of the protocol, justification for excluding individual studies, risk of bias from individual studies being included in the review, and appropriateness of meta-analytical methods. There is a dearth of robust evidence on whether nonsurgical periodontal treatment improves systemic disease outcomes. Future reviews should adhere more closely to methodological guidelines for conducting and reporting SRs/MAs than has been the case to date. Beyond improved reviews, additional rigorous research on whether periodontal treatment affects systemic health is needed. We highlight the potential of large-scale databases containing matched medical and dental record data to inform and complement future clinical research studying the effect of periodontal treatment on systemic outcomes.

1151 Is Timing Of Light Exposure Different In Women With Chronic Migraine?

Introduction

Light avoidance is a common coping behavior of individuals with migraine headaches. It is not known whether timing of light exposure is different in individuals with chronic migraine (CM) compared to those without migraine and how this may relate to headache frequency and severity. We tested this by examining timing of the brightest and darkest light and headaches in women with chronic migraines and healthy controls.

Methods

Sixteen women with CM (mean age = 33.07) and 18 female healthy controls (HC; mean age = 32.22) completed daily ratings of headache severity (0-10, severity > 2 classified as headache) concurrent with light exposure measured by wrist actigraphy for approximately one month (M=28.00 days, range=21-36). Start time of each day’s 10-hour periods of maximum light (M10) and 5-hour periods of lowest light (L5) were calculated and averaged for each participant. T-tests and Cohen’s d effect sizes were used to compare groups. Pearson correlation coefficients were calculated to examine associations between M10/L5 timing and headache frequency and severity.

Results

M10 was earlier in the CM group compared to the HC group (07:42±00:47 vs. 08:50±00:58, t(32)=3.69, p=0.0008, d=1.08). The CM group exhibited non-significant trend towards earlier L5 compared to the HC group (12:26±00:48 vs. 01:07±01:03, t(32)=1.89, p=0.0723, d=0.62). Among individuals with CM, later M10 timing was associated with more severe average daily headache (r=0.60, p=0.0136) and more frequent headaches (r=0.55, p=0.0257). Later L5 timing was significantly associated with more severe average daily headache (r=0.66, p=0.0052) and showed a non-significant trend toward association with more frequent headaches (r=0.47, p=0.0686).

Conclusion

Timing of the greatest light exposure period was earlier in CM compared to HC. Within the CM group, those who had earlier light and dark periods reported lower headache severity and fewer days with headaches. These findings suggest the possibility of a role for the circadian system in chronic migraine.

Support

This study was supported by grant R21NS081088 from the National Institutes of Health.

NWChem: Past, present, and future

Specialized computational chemistry packages have permanently reshaped the landscape of chemical and materials science by providing tools to support and guide experimental efforts and for the prediction of atomistic and electronic properties. In this regard, electronic structure packages have played a special role by using first-principle-driven methodologies to model complex chemical and materials processes. Over the past few decades, the rapid development of computing technologies and the tremendous increase in computational power have offered a unique chance to study complex transformations using sophisticated and predictive many-body techniques that describe correlated behavior of electrons in molecular and condensed phase systems at different levels of theory. In enabling these simulations, novel parallel algorithms have been able to take advantage of computational resources to address the polynomial scaling of electronic structure methods. In this paper, we briefly review the NWChem computational chemistry suite, including its history, design principles, parallel tools, current capabilities, outreach, and outlook.

Evaluation of a Dental Diagnostic Terminology Subset

The objective of this study was to determine how well a subset of SNODENT, specifically designed for general dentistry, meets the needs of dental practitioners. Participants were asked to locate their written diagnosis for tooth conditions among the SNODENT terminology uploaded into an electronic dental record. Investigators found that 65% of providers’ original written diagnoses were in “agreement” with their selected SNODENT dental diagnostic subset concept(s).

The important role of marine debris networks to prevent and reduce ocean plastic pollution

Societal change is needed to prevent and reduce the growth in the amount of solid waste entering the sea. Marine debris networks cover a broad range of activities in order to protect our oceans. By following a common vision and a collective systematic approach they are capable of creating synergies between all relevant stakeholders that result in reducing the flow of waste into our oceans. Thus, they are key to achieving the Sustainable Development Goals. During the 6th International Marine Debris Conference in San Diego in 2018, different marine debris networks from different parts of the world presented their activities, achievements and challenges. This led to network representatives agreeing to collaborate as members of an International Waste Platform. This platform aims to harmonize objectives, share knowledge, join forces and help new networks to emerge.

Maltreatment clusters among youth in outpatient substance abuse treatment: co-occurring patterns of psychiatric symptoms and sexual risk behaviors

The purpose of the current study was to describe the use of a brief maltreatment assessment instrument to classify adolescents receiving alcohol or other drug (AOD) treatment services based on the extensiveness and severity of prior maltreatment. This goal is significant because maltreatment reduces the effectiveness of AOD treatment and is associated significantly with co-occurring patterns of psychiatric symptoms and sexual risk behaviors. Structured interviews were administered to 300 adolescent treatment clients (202 males, 98 females; M = 16.22 years; SD = 1.13 years) to assess childhood maltreatment experiences, past year psychiatric symptoms, and sexual risk behaviors during the past 180 days. Cluster analysis classified adolescents into unique groups via self-reported sexual abuse, physical punishment, and parental neglect/negative home environment. Significant between-cluster differences in psychiatric symptoms and sexual risk behaviors were documented using MANOVA and chi-square analyses. More severe maltreatment profiles were associated with higher scores for psychiatric symptoms and unprotected intercourse. Significant heterogeneity and distinct types within this treatment sample of adolescents supports the adaptation of selected prevention efforts to promote HIV/STI risk reduction.

Famine Edema and the Mechanism of Its Formation

Famine edema was produced experimentally in 34 normal men who lost a quarter of their body weight while subsisting for 6 months on a European type of semi-starvation diet. The ratio of extracellular water to cellular tissue was roughly doubled. Their clinical state closely resembled that seen in Europe in 1945. There were no signs of renal or cardiac failure. The plasma protein concentration fell only slightly and the A/G ratio remained within normal limits. The venous pressure was roughly 50 per cent below normal. Data from the field lend support to these indications that famine edema is not simply a result of hypoproteinemia or of renal or cardiac failure. It is concluded that there is a dynamic nonequilibrium state of the capillary wall and, accordingly, calculations from equilibrium equations are inadmissible.

The complete genome sequence of Roseobacter denitrificans reveals a mixotrophic rather than photosynthetic metabolism

Purple aerobic anoxygenic phototrophs (AAPs) are the only organisms known to capture light energy to enhance growth only in the presence of oxygen but do not produce oxygen. The highly adaptive AAPs compose more than 10% of the microbial community in some euphotic upper ocean waters and are potentially major contributors to the fixation of the greenhouse gas CO2. We present the complete genomic sequence and feature analysis of the AAP Roseobacter denitrificans, which reveal clues to its physiology. The genome lacks genes that code for known photosynthetic carbon fixation pathways, and most notably missing are genes for the Calvin cycle enzymes ribulose bisphosphate carboxylase (RuBisCO) and phosphoribulokinase. Phylogenetic evidence implies that this absence could be due to a gene loss from a RuBisCO-containing alpha-proteobacterial ancestor. We describe the potential importance of mixotrophic rather than autotrophic CO2 fixation pathways in these organisms and suggest that these pathways function to fix CO2 for the formation of cellular components but do not permit autotrophic growth. While some genes that code for the redox-dependent regulation of photosynthetic machinery are present, many light sensors and transcriptional regulatory motifs found in purple photosynthetic bacteria are absent.

Interlaboratory comparison of red-cell ATP, 2,3-diphosphoglycerate and haemolysis measurements

BACKGROUND AND OBJECTIVES

Red blood cell (RBC) storage systems are licensed based on their ability to prevent haemolysis and maintain RBC 24-h in vivo recovery. Preclinical testing includes measurement of RBC ATP as a surrogate for recovery, 2,3-diphosphoglycerate (DPG) as a surrogate for oxygen affinity, and free haemoglobin, which is indicative of red cell lysis. The reproducibility of RBC ATP, DPG and haemolysis measurements between centres was investigated.

MATERIALS AND METHODS

Five, 4-day-old leucoreduced AS-1 RBC units were pooled, aliquotted and shipped on ice to 14 laboratories in the USA and European Union (EU). Each laboratory was to sample the bag twice on day 7 and measure RBC ATP, DPG, haemoglobin and haemolysis levels in triplicate on each sample. The variability of results was assessed by using coefficients of variation (CV) and analysis of variance.

RESULTS

Measurements were highly reproducible at the individual sites. Between sites, the CV was 16% for ATP, 35% for DPG, 2% for total haemoglobin and 54% for haemolysis. For ATP and total haemoglobin, 94 and 80% of the variance in measurements was contributed by differences between sites, and more than 80% of the variance for DPG and haemolysis measurements came from markedly discordant results from three sites and one site, respectively. In descending order, mathematical errors, unvalidated analytical methods, a lack of shared standards and fluid handling errors contributed to the variability in measurements from different sites.

CONCLUSIONS

While the methods used by laboratories engaged in RBC storage system clinical trials demonstrated good precision, differences in results between laboratories may hinder comparative analysis. Efforts to improve performance should focus on developing robust methods, especially for measuring RBC ATP.

Quasi-transfer as a predictor of transfer from simulator to airplane

Simulators have emerged as important components of flight-training programs. Nevertheless, the development of design principles that can maximize training transfer and cost-benefit trade-offs are not well established. The most significant challenge to research that would bear on simulator design principles is the difficulty and expense of flight transfer experiments. This difficulty and expense can be reduced by the use of an insimulator transfer design, designated here as a quasi-transfer study, in which transfer is to a high-fidelity configuration of a simulator. Of primary concern for such studies is whether the implied assumption of correspondence between quasi-transfer and transfer effects is well founded. In this article, we review evidence that bears on this issue. The evidence is not entirely supportive but does indicate some correspondence between quasi-transfer and transfer.

The effects of wearing protective chemical warfare combat clothing on human performance

U.S. Department of Defense studies to measure performance decrements associated with wearing chemical warfare (CW) protective combat clothing indicate that heat stress seriously degrades human performance. Even when heat stress is not a significant factor, performance of many combat, combat support, and combat service support tasks is degraded. In most field studies, many crews of combat units became operationally ineffective due to voluntary withdrawal of individual crewmembers. Many combined arms, field studies, and laboratory studies indicate that when CW-protective combat clothing is worn performance is seriously degraded for the detection of targets, engagement time, accuracy of fire, and manual dexterity tasks; and that a variety of psychological effects are created. Further, the degree of performance degradation varied with the tasks performed. Training in CW-protective combat clothing permits learning to modify procedures and consequently reduce negative effects, provided heat stress is not a significant factor. A growing body of evidence indicates there is inadequate training in the use of CW-protective combat clothing. A critical need exists for more and better training of skills needed under CW-conditions.

Leukaemia and residence near electricity transmission equipment: a case-control study

A population-based case-control study of leukaemia and residential proximity to electricity supply equipment has been carried out in south-east England. A total of 771 leukaemias was studied, matched for age, sex, year of diagnosis and district of residence to 1,432 controls registered with a solid tumour excluding lymphoma; 231 general population controls aged 18 and over from one part of the study area were also used. The potential for residential exposure to power frequency magnetic fields from power-lines and transformer substations was assessed indirectly from the distance, type and loading of the equipment near each subject's residence. Only 0.6% of subjects lived within 100 m of an overhead power-line, and the risk of leukaemia relative to cancer controls for residence within 100 m was 1.45 (95% confidence interval (CI) 0.54-3.88); within 50 m the relative risk was 2.0 but with a wider confidence interval (95% CI 0.4-9.0). Over 40% of subjects lived within 100 m of a substation, for which the relative risk of leukaemia was 0.99. Residence within 25 m carried a risk of 1.3 (95% CI 0.8-2.0). Weighted exposure indices incorporating measures of the current load carried by the substations did not materially alter these risks estimates. For persons aged less than 18 the relative risk of leukaemia from residence within 50 m of a substation was higher than in adults (PR = 1.5, 95% CI 0.7-3.4).

HIV infection in England and Wales: a changing pattern

Of 32,983 specimens from 307 sources in England and Wales tested in the Virus Reference Laboratory for anti-HIV between 1984 and 1987, 6491 (20%) were positive. Ninety-five per cent of the positive subjects were male and 44% of them were from three London genito-urinary medicine clinics. In 1987 the numbers of newly diagnosed HIV infections decreased in homosexual men and haemophiliacs and increased in injecting drug abusers; 148/1199 (12%) of all the positive findings in 1987 were in females. Between 1984 and 1987 the proportion of anti-HIV positive individuals who were asymptomatic fell by nearly 10% and the proportion with AIDS/ARC rose by nearly 10%. Of the requests leading to positive results 1280 (20%) were recognized as duplicates of previous positive results, while for 34% of the requests no clinical information was provided. These deficiencies in the data compromise HIV surveillance based on diagnostic testing, and supplementary bias-free data are needed.

Instrument flight performance under the influence of certain combinations of antiemetic drugs

Two different combinations of antiemetic drugs were evaluated using a digital flight simulator. Drug treatments consisted of a lactose placebo, a combination of thiethylperazine (10 mg) and cimetidine (300 mg), and a combination which added promethazine (25 mg) to the two-drug combination. The performance effects of these combinations were evaluated on both a dual task (instrument flight task with the Sternberg Memory Scanning task) and a single task condition (Sternberg task only) for 3 h post drug ingestion. Analysis indicated a significant treatment effect on three of the six flight performance variables and that the three-drug combination, containing promethazine, was primarily responsible for the decrease in performance. Implications for operation in a radiation environment are that thiethylperazine and cimetidine will not cause significant performance decrements, but the addition of promethazine to those two drugs will significantly impair performance. The Sternberg task was sensitive to changes in workload.

Atropine sulfate effects on aviator performance and on respiratory-heart period interactions

In this study, 20 human volunteers received a placebo and atropine doses of 0.5, 1.0, 2.0, and 4.0 mg X 75 kg-1 in a Latin Square double blind design, and effects were monitored for 3 h postinjection. The 2.0 mg and the 4.0 mg doses resulted in significant flight simulator performance decrements beginning at 1 h postinjection with only minimal recovery by 3 h postinjection. Electrocardiogram data were used to estimate the amplitude of respiratory sinus arrhythmia (RSA) which was more sensitive than mean heart period or mean heart period variance to the effects of atropine. These parasympathetic effects were relatively rapid in onset and peaked within the first 40-min period for the 2.0 and 4.0 mg doses. The onset of performance effects were delayed 1 h 40 min for the 2.0 mg and 1 h 00 min for the 4.0 mg treatment.

Comparison of the effects of atropine sulfate and ethanol on performance

The flight simulator performance decrements resulting from atropine injections were compared to similar decrements resulting from ethanol toxicosis. There were 20 volunteers that received 0.0, 0.5, 1.0, 2.0, and 4.0 X 75 kg-1 of atropine sulfate under double-blind conditions. The performance decrements at each atropine sulfate treatment level for each subject were determined by computing root mean square (RMS) deviations for five flight performance variables. The data set from a previous study concerned with the effects of ethanol on pilot performance was reanalyzed, and the decrements for the five variables at the 0.082% blood alcohol level (BAL) were computed. Probit analysis was used to estimate the effective dose (ED50) at which 50% of the subjects in the atropine sulfate experiment were expected to display decrements in excess of those observed for the 0.082% BAL. The ED50 was 3.12 mg of atropine sulfate.

Leisure time physical activity and its relationship to coronary risk factors in a population-based sample. The Minnesota Heart Survey

Energy expenditure in leisure time physical activity was measured using the Minnesota Leisure Time Physical Activity Questionnaire in a probability sample of 25- to 74-year-old residents of the seven-county metropolitan area of Minneapolis-St. Paul, Minnesota. Geometric mean estimates of leisure time physical energy expenditure were 193 kcal per day for men and 111 kcal per day for women. Only 34% of men and 17% of women expended 2,000 kcal or more per week in leisure time physical activity. Energy expenditure, especially in heavy intensity activities, declined with age, more so for women than men. Significant associations were observed between leisure time physical activity, particularly heavy intensity activity, and other coronary heart disease risk factors. Greater heavy intensity activity was associated with higher education (r = 0.14 to 0.26), greater Type A behavior (r = 0.14 to 0.15), higher serum high density lipoprotein (HDL) cholesterol levels (r = 0.09 to 0.10), lower serum thiocyanate (r = 0.10 to -0.14), lower body mass index (r = -0.10 to -0.11), lower heart rate (r = -0.07 to -0.10), and lower systolic blood pressure (r = -0.06 to -0.09). Thus, although energy expenditure was generally low in this population, greater leisure time physical activity for the most part was associated with lower coronary risk factors.

Measuring the effects of neurotoxicants on flight simulator performance

The Aviation Research Laboratory has developed a methodology for evaluating toxicant effects on pilot performance. Flight data are collected using a digital flight simulator, the ILLIMAC (ILLInois Micro Aviation Computer), during holding patterns and instrument landing system approaches. The flight data are recorded by a separate microcomputer, which also presents the Sternberg memory searching task. A preliminary study examined pilot performance in the simulator and cholinesterase inhibition by insecticides in agricultural pilots. The correlation between the physiological parameters and the pilot performance data was determined. Experiments are planned to determine the effects of a variety of drugs on pilot performance. Neurotoxicants to be studied include ethanol, three antiemetic drugs, and atropine sulfate.

Dietary measures of physical activity

The relationships between cardiovascular fitness, body fatness, and the number of calories required to maintain stable body weight over a baseline period of three weeks were studied in 21 healthy obese males aged 20-44 years who participated in a controlled feeding experiment at the Division of Epidemiology (formerly the Laboratory of Physiological Hygiene) of the School of Public Health, University of Minnesota, in August 1980-June 1981. statistically significant relationships were found between the number of calories actually consumed per kg of body weight (kcal/kg) and body fatness (r = -0.79, p = 0.001), and number of calories consumer per kg of body weight and physical work capacity (VO2 max) (r = 0.76, p = 0.001). Using body fatness quartiles, the caloric intake per kg of body weight and VO2 max decreased progressively as body fatness increased through its four quartiles. These relationships were also seen when reported caloric intake from a three-day food record was used; however, the magnitude was attenuated. On the other hand, caloric intake unadjusted for body weight, whether actual or reported, was unrelated to both body fatness and VO2 max. To determine whether these relationships hold true for less obese subjects, the authors have also analyzed and compared their results with the data from previously reported feeding experiments done at the University of Minnesota. Correlations between body fat indices and actual caloric intake were similar for both studies. Therefore, the authors conclude that in these relatively young, healthy, and sedentary males with a wide range of body fatness and body weight, the observed relationships between caloric intake adjusted for body weight, body fatness and VO2 max reflect habitual physical activity. These data confirm epidemiologic observations of an inverse relationship between caloric intake per kg of body weight and body fatness, and provide a rationale for using caloric intake adjusted for body weight as a measure of long-term habitual physical activity. Thus, these data bolster the interpretation that an inverse relationship between caloric intake per kg of body weight and mortality reflects a positive health effect of long-term physical activity. This index may be particularly useful in large population studies.

Prevalence of overweight and weight loss behavior in a metropolitan adult population: the Minnesota Heart Survey experience

Data from two major surveys, conducted in the Minneapolis-St. Paul metropolitan area in 1973-74 and 1980-81, were used to estimate the prevalence of overweight. In 1980-81, weight history and the prevalence of dieting behaviors were also obtained. The prevalence of overweight was greater in the 1980-81 survey than in 1973-74. Increases were observed in all ages in women, but only in the 40-59 year age ranges in men. In 1980-81, dieting to control weight was widely reported by both sexes, even among those who had never been overweight. Of those who reported having been overweight, approximately one-third reported they had successfully reduced. More men than women reported having been overweight, but more women reported having dieted to lose weight. Formal weight reduction programs were used much more by women than men. Although most dieting attempts consisted of balanced, reduced calorie regimens, a significant percentage were "fad" types, whose nutritional safety may be questioned. Overall, contrary to findings based on clinical populations, weight reducing efforts often appear to be successful. Nevertheless, overweight remains a significant public health problem in this community.

The effect of "usual care" on cardiovascular risk factors in a clinical trial

The use of referral to "usual care" (UC) for participants in randomized clinical trials satisfies the need for a control group who receive medical attention at the level of community standards. However, it has been suggested that this method, which may include follow-up with multiple examinations to collect trial information, may actually enhance quality of care. To determine the effect of this UC status, 64 UC men from the Multiple Risk Factor Intervention Trial (MRFIT) were matched on serum cholesterol (SC), diastolic blood pressure (DBP), and age with men who had similar characteristics at the initial recruitment screening but were not selected for the trial. Both groups were remeasured an average of 45 months after the initial recruitment. DBP at the second measurement was lower in both groups (11 mm Hg) and did not differ between groups. The percentage taking blood pressure medications was similar. SC was unchanged in either group. Reduction in risk observed in this MRFIT usual care group appears to be related to improved preventive practice in the community, specifically in blood pressure treatment. The additional effect of participation in a clinical trial as a control subject appears minimal for these risk characteristics.

Sudden death and acute myocardial infarction in a metropolitan area, 1970-1980. The Minnesota Heart Survey

To determine the causes of the nationwide decline in deaths due to coronary heart disease, the Minnesota Heart Survey enumerated coronary deaths among persons 30 to 74 years old in Minneapolis-St. Paul. The survey also ascertained rates of hospitalization and case fatality during hospitalization for acute myocardial infarction. For deaths occurring between 1970 and 1978 that were due to coronary heart disease, the rates outside the hospital declined by 43 per cent in men and 40 per cent in women, and the rates in hospital emergency rooms increased by 311 per cent in men and 200 per cent in women. In both these years about two thirds of all such deaths occurred outside hospital wards. Between 1970 and 1980, hospitalization rates for acute infarction in persons 30 to 74 years old declined 8 per cent among men and 26 per cent among women, and case fatality in the hospital in persons 45 to 74 years old declined 29 per cent in men and 27 per cent in women. These changes are probably due to the combined influence of changes in risk factors in the population and improved care of patients with acute myocardial infarction before and during hospitalization.

Improvement in hypertension detection and control from 1973-1974 to 1980-1981. The Minnesota Heart Survey experience

Blood pressures from a 1980-1981 survey of 1,656 adults in Minneapolis-St Paul were compared with BPs from a similar community survey of 3,475 adults conducted in 1973-1974. Mean age-adjusted BPs in 1980-1981 were 3 mm Hg lower for men and 2 mm Hg lower for women than in 1973-1974. Hypertension prevalence, defined as diastolic BP of 95 mm Hg or greater and/or use of antihypertensive medication, was essentially unchanged. In 1973-1974, however, only 40.4% of hypertensive persons had adequately controlled BPs, 13.7% were treated but had conditions that were uncontrolled, 20.4% had known hypertension but were untreated, and 25.5% had previously undetected hypertension. In 1980-1981, the respective percentages were 76.1%, 8.5%, 8.8% and 6.6%. These impressive changes in hypertension detection and control may have contributed to the recent decline in cardiovascular disease mortality in this community.

Plant antitumor agents, 19. Novel triterpenes from Maprounea africana

Four new pentacyclic triterpenes have been isolated from Maprounea africana. These triterpenes are members of the previously unknown urs-12-en-29-oic acid series. The structures of these compounds were deduced from spectral and chemical evidence. The parent compound, maprounic acid, was identified as 3B-hydroxyurs-12-en-29-oic acid. The remaining three triterpenes were identified as maprounic acid 3-p-hydroxybenzoate, 7 beta-hydroxymaprounic acid 3-p-hydroxybenzoate, and 2 alpha-hydroxymaprounic acid 2,3-bis-p-hydroxybenzoate. Of the four triterpenes, only the 7 beta-hydroxy derivative exhibited in vivo P-388 activity.

Performance of chronically implanted induction-powered oscillator epidural pressure transducers

✓ Chronic measurements of epidural pressure made with an induction-powered oscillator transducer revealed several problems with the current design of the device. All transducers failed over a period of months due to the diffusion of extracellular fluid through epoxy seals, which resulted in corrosion of the electrical components. Significant fibrosis occurred around the circumference of the burr hole, which reduced the sensitivity of the transducers. Design modifications are suggested to circumvent these problems.

Indices of obesity and blood pressure in young men followed 32 years

In order to assess the effects of baseline indices of obesity, lean body mass, blood pressure, and weight change on future blood pressure, 112 former college men were examined 20 and 32 years after initial examination at age 20.5 (+/- 2) yr. Baseline body weight, relative body weight, body mass index and body density all showed similar significant correlations with baseline systolic blood pressure (r = 0.35, 0.31, 0.30 - 0.31) but not baseline diastolic blood pressure (r = 0.13, 0.07, 0.10 - 0.11) or follow-up blood pressure. Changes in body weight, relative body weight, body mass index and sum of skinfolds were significantly correlated with change in both systolic and diastolic blood pressure. Baseline systolic blood pressure was the most powerful predictor of 20- and 32-yr follow-up systolic (r = 0.57, 0.42), but baseline diastolic was a much weaker correlate of follow-up diastolic blood pressure (r = 0.24, 0.18).

The relationship of body fat weight, determined densitometrically, to relative weight and triceps skinfold in American youths, 12-17 years of age

The relationship between fat weight, measured densitometrically, and the triceps skinfold and Quetelet's Index has been analyzed by means of linear regression analysis of 235 American youths, 12-17 years of age; 48 males and 41 females were from Minneapolis and 121 males and 25 females from the Greater Philadelphia area. Validation was accomplished by using the results of 10 separate regression analysis, each on 90% of the sample, the remaining 10% serving in each instance as the validation group; this is known as the Jackknife Method. When the Minneapolis and Philadelphia components were pooled, suitable regression models were derived with standard deviations of the errors of prediction of 3.330 kg in males and 2.056 in females. When the sample was subdivided by city the SD's remained essentially the same, but the mean errors were larger. It is concluded that the linear regression models can be used on closely similar populations to estimate fat weight for groups, but estimates for individuals may be expected to have an error of +/- 5-6 kg (i.e., 2 SD's) and are therefore not likely to be suitably accurate for use. The regression weights indicate a greater contribution of the triceps skinfold to fat weight than of Quetelet's Index in males. In females the reverse was found. This may affect sex differences in prevalence rates of obesity, if the diagnosis is based upon a single anthropometric indicator.

Blood lipids in young men followed 32 years

The relationship of baseline characteristics to serum cholesterol at baseline (CHL47) when aged 16-25 (mean 20.5) yr and at 32-yr follow-up (CHL79) was assessed in 162 men. Mean CHL rose over the follow-up period. CHL47 predicted CHL79 (r = 0.61, p less than 0.001) but not CHL79-CHL47. The mean (+/- SD) weight change (DW) was 12.0 kg (+/- 26.0 kg). DW was not significantly related to CHL47, but was independently related to CHL79-CHL47 (4 = 0.30, p less than 0.001). Age, height, DW, any of 7 measures of baseline obesity and CHL47 predicted CHL79 with R2 of 0.40 and CHL79-CHL47 with R2 of 0.37. Thus, weight change but not baseline relative weight was a determinant of serum cholesterol change from youth to middle age. There was strong tracking of serum cholesterol over this period.

Longitudinal study (32 years) of exercise tolerance, breathing response, blood pressure, and blood lipids in young men

Changes in exercise tolerance, blood lipids, and blood pressure from youth to middle age was studied in 106 subjects followed 32 years. In addition, the responses to cold pressor and CO2 stress were studied as correlates of future lipids and blood pressure. Treadmill exercise test, cold pressor test, response to breathing a mixture of 6% CO2, and 21% O2, for 5 minutes, blood pressure, and lipid measurements were performed in 1947 when subjects were 20 +/- 2 years old. Exercise, blood pressure and lipid tests were repeated in 1979. Tracking of blood pressure and pulse response to exercise over the period was demonstrated. Baseline exercise response correlated with future blood pressure, cholesterol, triglycerides, and high density lipoproteins. Change in exercise pulse rate over the period correlated with change in cholesterol. Cold pressor systolic blood pressure response correlated with future systolic blood pressure and triglycerides. Pulse and blood pressure response to CO2 breathing correlated with cholesterol, triglyceride and high density lipoprotein 32 years later. These correlations were independent of baseline values of the variables and body mass index. Individuals who were judged "fit" (exercise pulse rise less than median) at both baseline and follow-up had the best cardiovascular risk profile (blood pressure and lipids). Blood pressure and pulse response to exercise tracked between ages 20 and 50. Exercise, cold pressor, and CO2 responses in youth correlated with blood lipid levels in middle age.

Relationship of physical characteristics and life habits to treadmill exercise capacity

Apparently healthy middle-aged men (n = 175) were recruited from a population sample and completed questionnaires about habitual physical activity, smoking, beverage consumption and sleep habits. Body mass index (BMI), heart rate and blood pressure were measured at rest and during submaximal exercise; frequency of ventricular premature beats (VPB) on an ECG rhythm strip; hand grip strength; and serum cholesterol. These characteristics were correlated with duration of treadmill exercise by the Bruce protocol. Univariate analysis indicated that treadmill performance was significantly and positively correlated with leisure-time physical activity and personal reports of sweating and/or dyspnea occurring regularly during such physical activity. Performance was negatively correlated with age, BMI, resting heart rate, cigarette smoking, and consumption of caffeine-containing beverages, but was insignificantly related to job physical activity, hand grip strength, alcohol consumption, sleep habits, blood pressure, cigar smoking, serum cholesterol, and the frequency of VPB. A 0.75 multiple correlation coefficient was found between treadmill performance and 11 of the above variables and the r is increased to 0.81 by adding heart rate during submaximal exercise. It is concluded that substantial prediction of work capacity and physical fitness of population is achieved by questionnaires and easily obtained, noninvasive physical measures.

Plasma high-density lipoprotein cholesterol: association with measurements of body mass. The Lipid Research Clinics Program Prevalence Study

Relationships between weight, height and ponderal indexes and plasma high-density lipoprotein (HDL) cholesterol and triglyceride were assessed by the Lipid Research Clinics Prevalence Study for 6865 white children and adults (3517 males and 3348 females). Overall, weight, weight/height, weight/height and weight/height were significantly and inversely associated with plasma HDL cholesterol levels and positively associated with plasma triglyceride levels. When the relationships of Quetelet index (weight/height) to HDL cholesterol were assessed by multiple regression analysis, including the explanatory variables of cigarette smoking, alcohol intake and exogenous estrogen hormone use, the Quetelet index was significantly and inversely associated with HDL cholesterol levels in children (by age 12-16 years) and adults of both sexes. After covariance adjustment for smoking, alcohol intake, hormone use and age, mean HDL cholesterol levels for individuals at the Quetelet tenth percentile were 3 mg/dl higher than for those at the fiftieth percentile, and these in turn were 3-4 mg/dl higher than for those at the ninetieth percentile. These differences in HDL cholesterol differences reported to be related to coronary heart disease mortality. Improved approaches to the primary prevention of atherosclerosis may be realized by a better understanding of the inverse relationship of body mass to HDL cholesterol levels.

Strenuous physical activity, treadmill exercise test performance and plasma high-density lipoprotein cholesterol. The Lipid Research Clinics Program Prevalence Study

During the Lipid Research Clinics North American Prevalence Study, plasma lipoprotien determinations and treadmill exercise testing were performed on 2319 white men and 2067 white women ages 20 years or older randomly selected from population surveys by nine clinics in the U.S. and Canada. Before exercise testing, participants were asked if they performed any strenuous physical activity on a regular basis. Data were analyzed to determine the relationship of plasma high-density lipoprotein (HDL) cholesterol to treadmill exercise test performance and a self-report of strenuous activity. Neither treadmill exercise test duration nor heart rate response to submaximal exercise was significantly related to HDL cholesterol levels for either men or women. However, participants who reported some strenuous physical activity generally had higher HDL cholesterol levels than those who reported none, and the more active men ages 30-49 years and active women ages 20-39 had significantly higher values (p < 0.05). When HDL cholesterol was adjusted for age, body mass index, alcohol use, cigarette smoking and interclinic population variation, more active men (47.1 vs 45.2 mg/dl; p = 0.0001) and more active women (59.6 vs 57.7 mg/dl; p = 0.02) had higher HDL cholesterol levels than their sedentary counterparts. Thus, the association between HDL cholesterol and reported physical activity was, at least in part, independent of other factors that influence HDL cholesterol concentration, but was not associated with exercise tolerance as determined by treadmill exercise testing.

Effect of pentobarbital anesthesia on vulnerability to ventricular fibrillation

Ventricular fibrillation threshold (VFT), frequently determined in dogs during pentobarbital sodium anesthesia, usually is replaced by a single repetitive extrasystole threshold (SRET) or a multiple repetitive extrasystole threshold (MRET) determination in conscious animals and in the human being. In the present study SRET, MRET, and VFT were determined initially in 39 pentobarbital sodium-anesthetized dogs. One week later these three thresholds were redetermined during anesthesia in 13 of the 39 dogs (control group). In the remaining 26 dogs (experimental group), thresholds were redetermined while the dogs were conscious. Significant changes in threshold values occurred only in the experimental group for VFT (P < 0.001) and MRET (P < 0.02). The square of the linear correlation coefficient showed conscious state MRET to be a good predictor of conscious state VFT (R2 = 0.90). Conscious state SRET and anesthetized state VFT showed less predictiveness for the conscious VFT (R2 = 0.72 and 0.51, respectively). These data indicate that MRET may be preferable to SRET as an index of VFT. The SRET, MRET, and VFT determined during pentobarbital anesthesia may not accurately reflect the value of these parameters in the conscious animal.