African Americans have a greater risk of cardiovascular disease (CVD) than Caucasians in early chronic kidney disease; however, limited data describe racial and ethnic differences in the risk of ...incident myocardial infarction (MI) among patients with end-stage renal disease (ESRD). We conducted a prospective, observational cohort study among 271 102 incident dialysis patients receiving renal replacement therapy enrolled in the United States Renal Data System (USRDS) for whom Medicare was the primary insurer between 1995 and 2000. The incidence and risk of any MI (non-fatal or fatal) estimated by Cox proportional hazards models was the primary outcome of interest. Of those with prevalent CVD at baseline (118 708), 14 849 had an incident non-fatal MI compared with 9926 events for those without prevalent CVD (152 394). Patients with prevalent CVD had higher crude rates of combined fatal and non-fatal MI (99.3/1000 person-years vs 42.9/1000 person-years) compared with those without prevalent CVD. Among those with prevalent CVD, African Americans (adjusted relative risk (aRR)=0.65, 95% confidence interval (CI):0.62–0.68), Asian Americans (aRR=0.74, 95% CI: 0.66–0.83), and Hispanics (aRR=0.72, 95% CI: 0.68–0.77) were 26–35% less likely to have an incident MI compared to Caucasians. Similarly, among those without prevalent CVD, racial/ethnic minorities were 26–42% less likely to have an incident MI compared to Caucasians. We conclude that in a national setting where comparable access to dialysis and associated medical care, exist, racial/ethnic minorities were found to have a lower risk of non-fatal and fatal MI than Caucasians.
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Summary Background Advances in therapy for hepatitis B virus (HBV) and hepatitis C virus (HCV) have ushered in a new era in chronic hepatitis treatment. To maximise the effectiveness of these ...medicines, individuals must be engaged and retained in care. We analysed operational interventions to enhance chronic viral hepatitis testing, linkage to care, treatment uptake, adherence, and viral suppression or cure. Methods We did a systematic review of operational interventions, and did meta-analyses for sufficiently comparable data. We searched PubMed, Embase, WHO library, International Clinical Trials Registry Platform, PsycINFO, and CINAHL for randomised controlled trials and controlled non-randomised studies that examined operational interventions along the chronic viral hepatitis care continuum, published in English up to Dec 31, 2014. We included non-pharmaceutical intervention studies with primary or secondary outcomes of testing, linkage to care, treatment uptake, treatment adherence, treatment completion, treatment outcome, or viral endpoints. We excluded dissertations and studies of children only. Data were extracted by two independent reviewers, with disagreements resolved by a third reviewer. Studies were assessed for bias. Data from similar interventions were pooled and quality of evidence was assessed using GRADE. This study was registered in PROSPERO (42014015094). Findings We identified 7583 unduplicated studies, and included 56 studies that reported outcomes along the care continuum (41 for HCV and 18 for HBV). All studies except one were from high-income countries. Lay health worker HBV test promotion interventions increased HBV testing rates (relative risk RR 2·68, 95% CI 1·82–3·93). Clinician reminders to prompt HCV testing during clinical visits increased HCV testing rates (3·70, 1·81–7·57). Nurse-led educational interventions improved HCV treatment completion (1·14, 1·05–1·23) and cure (odds ratio OR 1·93, 95% CI 1·44–2·59). Coordinated mental health, substance misuse, and hepatitis treatment services increased HCV treatment uptake (OR 3·03, 1·24–7·37), adherence (RR 1·22, 1·05–1·41), and cure (RR 1·21, 1·07–1·38) compared with usual care. Interpretation Several simple, inexpensive operational interventions can substantially improve engagement and retention along the chronic viral hepatitis care continuum. Further operational research to inform scale-up of hepatitis services is needed in low-income and middle-income countries. Funding World Health Organization and US Fulbright Program.
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This collection of papers highlights the current state of the art of cybersecurity. It is divided into five major sections: humans and information security; security systems design and development; ...security systems management and testing; applications of information security technologies; and outstanding cybersecurity technology development trends.This book will mainly appeal to practitioners in the cybersecurity industry and college faculty and students in the disciplines of cybersecurity, information systems, information technology, and computer science.
A high fructose intake has been shown to be associated with increased serum urate concentration, whereas ascorbate (vitamin C) may lower serum urate by competing with urate for renal reabsorption.
We ...assessed the combined association, as the fructose:vitamin C intake ratio, and the separate associations of dietary fructose and vitamin C intakes on prevalent hyperuricemia.
We conducted cross-sectional analyses of dietary intakes of fructose and vitamin C and serum urate concentrations among Jackson Heart Study participants, a cohort of African Americans in Jackson, Mississippi, aged 21–91 y. In the analytic sample (n = 4576), multivariable logistic regression was used to examine the separate associations of dietary intakes of fructose and vitamin C and the fructose:vitamin C intake ratio with prevalent hyperuricemia (serum urate ≥7 mg/dL), after adjusting for age, sex, smoking, waist circumference, systolic blood pressure, estimated glomerular filtration rate, diuretic medication use, vitamin C supplement use, total energy intake, alcohol consumption, and dietary intake of animal protein. Analyses for individual dietary factors (vitamin C, fructose) were adjusted for the other dietary factor.
In the fully adjusted model, there were 17% greater odds of hyperuricemia associated with a doubling of the fructose:vitamin C intake ratio (OR: 1.17; 95% CI: 1.08, 1.28), 20% greater odds associated with a doubling of fructose intake (OR: 1.20; 95% CI: 1.08, 1.34), and 13% lower odds associated with a doubling of vitamin C intake (OR: 0.87; 95% CI: 0.78, 0.97). Dietary fructose and the fructose:vitamin C intake ratio were more strongly associated with hyperuricemia among men than women (P-interaction ≤ 0.04).
Dietary intakes of fructose and vitamin C are associated with prevalent hyperuricemia in a community-based population of African Americans.
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Racial Differences in Diabetic Nephropathy, Cardiovascular Disease, and Mortality in a National Population of Veterans
Bessie A. Young , MD, MPH 1 2 3 ,
Charles Maynard , PHD 1 4 and
Edward J. Boyko ..., MD, MPH 1 2
1 Epidemiologic Research and Information Center, Department of Veterans Affairs Puget Sound Health Care System, Seattle, Washington
2 Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington
3 Northwest Kidney Centers, Seattle, Washington
4 Department of Health Services, University of Washington, Seattle, Washington
Address correspondence and reprint requests to Bessie A. Young, MD, MPH, VA Puget Sound Health Care System, ERIC (152-E),
1660 S. Columbian Way, Seattle, WA 98108–157. E-mail: youngb{at}u.washington.edu
Abstract
OBJECTIVE —To determine racial differences in the prevalence of diabetic nephropathy, cardiovascular disease (CVD), and risk of mortality
in a national health care system.
RESEARCH DESIGN AND METHODS —A longitudinal cohort study was conducted in 429,918 veterans with diabetes. Racial minority groups were analyzed for baseline
differences in prevalence of early diabetic nephropathy, diabetic end-stage renal disease (ESRD) and CVD, and longitudinal
risk of mortality compared with Caucasians.
RESULTS —The 429,918 patients identified with diabetes were of the following racial groups: Caucasian (56.2%), African American (15.3%),
Asian (0.5%), Native American (0.4%), and unknown race (21.4%). Minority individuals were, on average, younger and less likely
to have CVD but were more likely to have renal disease than Caucasians. After adjustment for age, sex, and economic status,
African Americans (adjusted odds ratio OR = 1.3, 95% CI 1.2–1.4) and Native Americans (1.5, 1.1–2.1) were more likely to
have early diabetic nephropathy than Caucasians. Diabetic ESRD was more likely to be present in African Americans (1.9, 1.9–2.0),
Hispanics (1.4, 1.3–1.4), Asians (1.8, 1.5–2.1), and Native Americans (1.9, 1.5–2.3) than Caucasians. Concurrently, the adjusted
OR of CVD in racial minority groups was 27–49% less than in Caucasians, whereas the 18-month risk of mortality among people
from most racial minority groups was 7–12% lower than in Caucasians.
CONCLUSIONS —We conclude that when access to care is comparable, microvascular complications, macrovascular disease, and subsequent death
occur with different frequencies among various racial groups.
BIRLS, Beneficiary Identification and Record Locator System
COPD, chronic obstructive pulmonary disease
CVD, cardiovascular disease
ESRD, end-stage renal disease
MRFIT, Multiple Risk Factor Intervention Trial
VA, Veterans Affairs
Footnotes
Additional information for this article can be found in an online appendix at http://care.diabetesjournals.org .
A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.
Accepted April 25, 2003.
Received February 19, 2003.
DIABETES CARE
Abstract Background context Although the pathologic processes that affect the spine remain largely unchanged, our techniques to correct them continue to evolve with the development of novel medical ...and surgical interventions. Although the primary purpose of new technologies is to improve patients' quality of life, the economic impact of such therapies must be considered. Purpose To review the available peer-reviewed literature on spine surgery that addresses the cost-effectiveness of various treatments and technologies. Study design A narrative literature review. Methods Articles published between January 1, 2000 and December 31, 2012 were selected from two Pubmed searches using keywords cost-effectiveness AND spine (216 articles) and cost analysis AND spine (358 articles). Relevant articles on cost analyses and cost-effectiveness were selected by the authors and reviewed. Results Cervical and lumbar surgeries (anterior cervical discectomy and fusion, standard open lumbar discectomy, and standard posterior lumbar laminectomy) are reasonably cost effective at 2 years after the procedure (<100,000 US dollars per quality-adjusted life years gained) and become more cost effective with time because of sustained clinical improvements with relatively low additional incurred costs. The usage of transfusion avoidance technology is not cost effective because of the low risk of complications associated with allogenic transfusions. Although intraoperative neuromonitoring and imaging modalities are both cost saving and cost-effective, their cost-effectiveness is largely dependent on the baseline rate of neurologic complications and implant misplacement, respectively. More rigorous studies are needed to evaluate the cost-effectiveness of recombinant bone morphogenetic protein. Conclusions An ideal new technology should be able to achieve maximal improvement in patient health at a cost that society is willing to pay. The cost-effectiveness of technologies and treatments in spine care is dependent on their durability and the rate and severity of the baseline clinical problem that the treatment was designed to address.
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Ankle arthrodesis has become a common surgical procedure for individuals with end-stage ankle arthritis, chronic infection, and bony misalignment. Although arthrodesis is typically managed with ...arthrodesis in situ or realignment, reconstruction may be utilized for patients with more complicated cases that involve metatarsal defects. Our institution utilizes both the pedicled and free fibula flaps for surgical management pertaining to ankle arthrodesis. Our study looks to evaluate the work of a single plastic surgeon and identify patient postoperative outcomes. MethodsA retrospective chart review was conducted at Beaumont Health System, Royal Oak, for patients who underwent ankle arthrodesis with a pedicled fibula flap for nonunion or avascular necrosis of the talus between the years 2014 and 2022. Demographic data, operative details, complications, medical comorbidities, and patient outcomes were retrospectively gathered and analyzed. ResultsA total of six patients were isolated, with three patients undergoing a free fibula approach and three patients undergoing the pedicled fibula approach. All patients were found to have tolerated the procedure well and had no intraoperative complications. In addition, all patients had clinically viable flaps and were satisfied with their surgical result. ConclusionsBoth free and pedicled free fibula flaps may be used effectively in the management of ankle arthrodesis in patients who have failed prior therapy. In our study, free fibula flaps were utilized in a medial approach, while the pedicled fibula flap was utilized in a lateral approach. With the right expertise and patient population, the free and pedicled fibula flaps can be highly successful in the repair of ankle defects.
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