Methods  In 314 subjects, we measured total body, visceral, and subcutaneous fat with magnetic resonance (MR) tomography and fat in the liver and skeletal muscle with proton MR spectroscopy. Insulin sensitivity was estimated from oral glucose tolerance test results. Subjects were divided into 4 groups: normal weight (body mass index [BMI] [calculated as weight in kilograms divided by height in meters squared], <25.0), overweight (BMI, 25.0-29.9), obese–insulin sensitive (IS) (BMI, ≥30.0 and placement in the upper quartile of insulin sensitivity), and obese–insulin resistant (IR) (BMI, ≥30.0 and placement in the lower 3 quartiles of insulin sensitivity).

Results  Total body and visceral fat were higher in the overweight and obese groups compared with the normal-weight group (P < .05); however, no differences were observed between the obese groups. In contrast, ectopic fat in skeletal muscle (P < .001) and particularly the liver (4.3% ± 0.6% vs 9.5% ± 0.8%) and the intima-media thickness of the common carotid artery (0.54 ± 0.02 vs 0.59 ± 0.01 mm) were lower and insulin sensitivity was higher (17.4 ± 0.9 vs 7.3 ± 0.3 arbitrary units) in the obese-IS vs the obese-IR group (P < .05). Unexpectedly, the obese-IS group had almost identical insulin sensitivity and the intima-media thickness was not statistically different compared with the normal-weight group (18.2 ± 0.9 AU and 0.51 ± 0.02 mm, respectively).

Conclusions  A metabolically benign obesity that is not accompanied by insulin resistance and early atherosclerosis exists in humans. Furthermore, ectopic fat in the liver may be more important than visceral fat in the determination of such a beneficial phenotype in obesity.

Methods  The prevalence and correlates of combined body mass index (normal weight, <25.0; overweight, 25.0-29.9; and obese, ≥30.0 [calculated as weight in kilograms divided by height in meters squared]) and cardiometabolic groups (metabolically healthy, 0 or 1 cardiometabolic abnormalities; and metabolically abnormal, ≥2 cardiometabolic abnormalities) were assessed in a cross-sectional sample of 5440 participants of the National Health and Nutrition Examination Surveys 1999-2004. Cardiometabolic abnormalities included elevated blood pressure; elevated levels of triglycerides, fasting plasma glucose, and C-reactive protein; elevated homeostasis model assessment of insulin resistance value; and low high-density lipoprotein cholesterol level.

Results  Among US adults 20 years and older, 23.5% (approximately 16.3 million adults) of normal-weight adults were metabolically abnormal, whereas 51.3% (approximately 35.9 million adults) of overweight adults and 31.7% (approximately 19.5 million adults) of obese adults were metabolically healthy. The independent correlates of clustering of cardiometabolic abnormalities among normal-weight individuals were older age, lower physical activity levels, and larger waist circumference. The independent correlates of 0 or 1 cardiometabolic abnormalities among overweight and obese individuals were younger age, non-Hispanic black race/ethnicity, higher physical activity levels, and smaller waist circumference.

Conclusions  Among US adults, there is a high prevalence of clustering of cardiometabolic abnormalities among normal-weight individuals and a high prevalence of overweight and obese individuals who are metabolically healthy. Further study into the physiologic mechanisms underlying these different phenotypes and their impact on health is needed.

Methods  We tested the association of low 25(OH)D levels with all-cause, cancer, and cardiovascular disease (CVD) mortality in 13 331 nationally representative adults 20 years or older from the Third National Health and Nutrition Examination Survey (NHANES III) linked mortality files. Participant vitamin D levels were collected from 1988 through 1994, and individuals were passively followed for mortality through 2000.

Results  In cross-sectional multivariate analyses, increasing age, female sex, nonwhite race/ethnicity, diabetes, current smoking, and higher body mass index were all independently associated with higher odds of 25(OH)D deficiency (lowest quartile of 25(OH)D level, <17.8 ng/mL [to convert to nanomoles per liter, multiply by 2.496]), while greater physical activity, vitamin D supplementation, and nonwinter season were inversely associated. During a median 8.7 years of follow-up, there were 1806 deaths, including 777 from CVD. In multivariate models (adjusted for baseline demographics, season, and traditional and novel CVD risk factors), compared with the highest quartile, being in the lowest quartile (25[OH]D levels <17.8 ng/mL) was associated with a 26% increased rate of all-cause mortality (mortality rate ratio, 1.26; 95% CI, 1.08-1.46) and a population attributable risk of 3.1%. The adjusted models of CVD and cancer mortality revealed a higher risk, which was not statistically significant.

Conclusion  The lowest quartile of 25(OH)D level (<17.8 ng/mL) is independently associated with all-cause mortality in the general population.

Methods  Annual self-administered questionnaires were sent to 538 members of a nationwide running club and 423 healthy controls from northern California who were 50 years and older beginning in 1984. Data included running and exercise frequency, body mass index, and disability assessed by the Health Assessment Questionnaire Disability Index (HAQ-DI; scored from 0 [no difficulty] to 3 [unable to perform]) through 2005. A total of 284 runners and 156 controls completed the 21-year follow-up. Causes of death through 2003 were ascertained using the National Death Index. Multivariate regression techniques compared groups on disability and mortality.

Results  At baseline, runners were younger, leaner, and less likely to smoke compared with controls. The mean (SD) HAQ-DI score was higher for controls than for runners at all time points and increased with age in both groups, but to a lesser degree in runners (0.17 [0.34]) than in controls (0.36 [0.55]) (P < .001). Multivariate analyses showed that runners had a significantly lower risk of an HAQ-DI score of 0.5 (hazard ratio, 0.62; 95% confidence interval, 0.46-0.84). At 19 years, 15% of runners had died compared with 34% of controls. After adjustment for covariates, runners demonstrated a survival benefit (hazard ratio, 0.61; 95% confidence interval, 0.45-0.82). Disability and survival curves continued to diverge between groups after the 21-year follow-up as participants approached their ninth decade of life.

Conclusion  Vigorous exercise (running) at middle and older ages is associated with reduced disability in later life and a notable survival advantage.

Methods  Patients from the Duke Databank for Cardiovascular Disease undergoing their initial revascularization with DES or BMS from January 1, 2000, through July 31, 2005, were included in the study population. Propensity scores and inverse probability weighted estimators were used to adjust for treatment group imbalances.

Results  The study population included 1501 patients who received DES and 3165 who received BMS. After adjustment, DES reduced target vessel revascularization (TVR) rates at 6, 12, and 24 months compared with BMS (24-month rates: DES, 6.6%; BMS, 16.3%; difference, –9.7%; 95% confidence interval [CI], –11.7% to –7.7%; P < .001). The TVR benefit for DES increased among patients with multivessel CAD (1-vessel CAD: –8.3%; 95% CI, –10.9% to –5.8%; P < .001; 2-vessel CAD: –9.7%; 95% CI, –3.6% to –5.8%; P < .001; 3-vessel CAD: –16.2%; 95% CI, –25.2% to –7.2%; P < .001). However, in the overall cohort there were no statistically significant differences in the composite of death or myocardial infarction.

Conclusions  Patients receiving DES vs BMS in a clinical practice setting have lower TVR rates, albeit with less absolute benefit than those observed in clinical trials. Patients with multivessel vs single-vessel disease experience a greater reduction in TVR.

Methods  We conducted a prospective observational cohort study of 790 healthy first- or second-degree female relatives of patients with documented Graves or Hashimoto disease in the Netherlands. Baseline assessment included measurement of serum thyrotropin (TSH), free thyroxine (FT₄), and thyroid peroxidase (TPO) antibody levels as well as evaluation for the presence and levels of Yersinia enterocolitica antibodies. We also gathered data on family background, smoking habits, use of estrogen medication, pregnancy, and exposure to high levels of iodine. In follow-up, thyroid function was investigated annually for 5 years. As main outcome measures, termed events, we looked for overt hypothyroidism (TSH levels >5.7 mIU/L and FT₄ levels <0.72 ng/dL) or overt hyperthyroidism (TSH levels <0.4 mIU/L and FT₄ levels >1.56 ng/dL).

Results  The cumulative event rate was 7.5% over 5 years. The mean annual event rate was 1.5%. There were 38 hypothyroid and 13 hyperthyroid events. Independent risk factors for events were baseline findings for TSH and TPO antibodies in a level-dependent relationship (for TSH the risk already starts to increase at values >2.0 mIU/L) and family background (with the greatest risk attached to subjects having 2 relatives with Hashimoto disease). A numerical score, the Thyroid Events Amsterdam (THEA) score, was designed to predict events by weighting these 3 risk factors proportionately to their relative risks (maximum score, 21): low (0-7), medium (8-10), high (11-15), and very high (16-21). These THEA scores were associated with observed event rates of 2.7%, 14.6%, 27.1%, and 76.9%, respectively.

Conclusions  An accurate simple predictive score was developed to estimate the 5-year risk of overt hypothyroidism or hyperthyroidism in female relatives of patients with AITD. However, in view of the small number of observed events, independent validation of the THEA score is called for.

Methods  We studied residential region from January 1, 1921, to May 31, 1976, and RA risk in a prospective cohort of women, the Nurses' Health Study. Information on state of residence was collected at baseline in 1976 (when participants were aged 30-55 years) and on state of residence at birth, at age 15 years, and at age 30 years in 1992. Among 83 546 participants reporting residence for all 4 time points, 706 incident RA cases from June 1, 1976, to May 31, 2004, were confirmed by screening questionnaire and record review for American College of Rheumatology criteria. Residential region was classified as West, Midwest, mid-Atlantic, New England, and Southeast. Multivariate Cox proportional hazards regression models were used to assess relationships between region and RA risk, adjusting for age, smoking, body mass index, parity, breastfeeding, postmenopausal status, postmenopausal hormone use, father's occupation, race, and physical activity. Analyses were performed in participants who lived in the same regions, or moved, over time.

Results  Compared with those in the West, women in New England had a 37% to 45% elevated risk of RA in multivariate models at each time point (eg, state of residence in 1976: rate ratio [RR], 1.42; 95% confidence interval [CI], 1.10-1.82). In analyses of women who lived in the same region at birth, age 15 years, and age 30 years, living in the Midwest was associated with greater risk (RR, 1.47; 95% CI, 1.05-2.05), as was living in New England (RR, 1.40; 95% CI, 0.98-2.00). Compared with living in the West at birth, age 15 years, and age 30 years, RA risk was higher in the East.

Conclusions  In this large cohort of US women, significant geographic variation in incident RA existed after controlling for confounders. Potential explanations include regional variation in behavioral factors, climate, environmental exposures, RA diagnosis, and genetic factors.

Methods  A prospective study of a cohort of 3075 white and black women and men, aged 70 to 79 years, recruited from 2 communities from 1997 to 1998. Incident hospitalizations and fractures were validated by medical records by investigators blinded to patient groupings. Analyses of the association between hospitalization, length of stay, number of admissions, and risk of fracture were adjusted for age, race, sex, and other potential confounding factors.

Results  During follow-up with a mean duration of 6.6 years, 2030 (66%) of the 3075 participants were admitted to a hospital and 809 (26%) were admitted 3 or more times; 285 experienced a fracture, including 74 hip fractures. After adjusting for age, race, and sex, those who had any hospitalization had a 2-fold increased risk of fracture (hazard ratio [HR], 2.01; 95% confidence interval [CI], 1.57-2.57), including an increased risk of hip fracture (HR, 2.15; 95% CI, 1.32-3.50). Those who were hospitalized twice during the follow-up period had a 2.42-fold increased risk of hip fracture (95% CI, 1.16-5.05), and 3 or more hospital stays indicated a 3.66-fold increased relative hazard for hip fracture (95% CI, 1.78-7.53).

Conclusions  Hospitalizations, particularly multiple admissions, are very common in elderly individuals and are strongly associated with an increased risk of hip and other types of fracture. Hospitalizations present opportunities to take measures to reduce the risk of fractures.

Methods  We studied 1107 patients for an average of 46 months after a first unprovoked venous thromboembolism and withdrawal of anticoagulant therapy. Excluded were pregnant patients, those requiring long-term antithrombotic treatment, and those who had a previous or secondary thrombosis, natural coagulation inhibitor deficiency, lupus anticoagulant, or cancer. Our study end point was symptomatic recurrent venous thromboembolism.

Results  A total of 168 patients had recurrent venous thromboembolism. Mean (SD) body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared) was significantly higher among patients with recurrence than among those without recurrence: 28.5 (6.0) vs 26.9 (5.0) (P = .01). The relationship between excess body weight and recurrence was linear; the adjusted hazard ratio for each 1-point increase in BMI was 1.044 (95% confidence interval [CI], 1.013-1.076) (P < .001). Four years after discontinuation of anticoagulant therapy, the probability of recurrence was 9.3% (95% CI, 6.0%-12.7%) among patients of normal weight and 16.7% (95% CI, 11.0%-22.3%) and 17.5% (95% CI, 13.0%-22.0%) among overweight and obese patients, respectively. Compared with patients of normal weight, the hazard ratio of recurrence adjusted for age, sex, factor V Leiden, prothrombin G20210A mutation, high factor VIII levels, and type of initial venous thromboembolic event was 1.3 (95% CI, 0.9-1.9) (P = .20) among overweight patients and 1.6 (95% CI, 1.1-2.4) (P = .02) among obese individuals. The population attributable risk corresponding to excess body weight was 26.8% (95% CI, 5.3%-48.2%).

Conclusion  Excess body weight is a risk factor of recurrent venous thromboembolism.

Methods  A Markov model was developed to compare lifelong therapy with ASA alone vs therapy with ASA plus PPI in patients with CHD who are at least 50 years old. Base-case assumptions were (1) starting age, 65 years (range, 50-80 years); (2) UGIB risk category, average risk (range, average to 8-fold increased risk); (3) PPI effectiveness (66% (range, 25%-75%); and (4) annual PPI cost, $250 (range, $250-$1400).

Results  In the base-case analysis, ASA plus PPI resulted in fewer lifetime UGIB events (3.1% vs 9.5%) and UGIB-related deaths (0.4% vs 1.4%). At over-the-counter (OTC) PPI cost, ASA plus PPI was cost-effective, with an incremental cost-effectiveness ratio (ICER) of $40 090 per life-year saved (LYS). Varying PPI effectiveness from 75% to 25% resulted in ICERs of $35 315 to $94 578 per LYS. Varying the starting age of the cohort from 80 to 50 years resulted in ICERs of $16 887 to $79 955 per LYS. At prescription PPI cost, the ICER for average-risk patients was over $100 000 per LYS across all modeled age groups and assumptions of PPI effectiveness, but the ICER for high-risk patients was $10 433 to $51 505 per LYS.

Conclusions  At OTC cost, PPI cotherapy is cost-effective in average-risk patients taking low-dose ASA for secondary prevention. At prescription cost, cotherapy is cost-effective for high-risk patients only.

Methods  We performed an empirical evaluation of the completeness of medical records from 607 randomly selected patients admitted with non–ST-segment elevation acute coronary syndromes (NSTE ACS) to 219 US hospitals in the CRUSADE National Quality Improvement Initiative. Composite medical records scores were summated and compared by hospital academic status and physician specialty. Correlations between medical records scores, use of evidence-based medicine (EBM), and in-hospital mortality were assessed.

Results  Medical records were frequently missing key elements, including cardiac history (23.6%), performance status (64.6%), differential diagnosis (57.8%), and planned use of EBM (44.0%). Evidence-based medicine was more often discussed in medical records from academic medical centers vs nonacademic medical centers (69.7% vs 51.7%) (P < .001) and from cardiologists vs noncardiologists (60.5% vs 48.1%, P = .003). Higher medical records quality scores were associated with greater use of EBM among the medical records quality cohort (P = .006), and a similar trend was observed in CRUSADE overall: adjusted odds ratio, 1.26 (95% confidence interval, 0.92-1.72) for high vs low medical records quality. Higher medical records quality scores were associated with lower in-hospital mortality: adjusted odds ratio, 0.79 (95% confidence interval, 0.65-0.97).

Conclusions  Medical records for patients with NSTE ACS often lack key elements of the history and physical examination. Patients treated at hospitals with better medical records quality have significantly lower mortality and may receive more EBM. The relationship between better medical charting and better medical care could lead to new ways to monitor and improve the quality of medical care.

Methods  A total of 2412 participants (907 with prior diabetes) in the Candesartan in Heart failure: Assessment of Reduction in Mortality and Morbidity (CHARM) program with at least 1 HbA_1c level were followed up for a median of 34 months. The incidence of the primary outcome (CV death or HF hospitalization), CV death, and total mortality was calculated according to eighths of the usual HbA_1c level ranging from 5.8% or less to greater than 8.6%. Adjusted and unadjusted hazard ratios per 1% rise in HbA_1c levels were also calculated.

Results  A total of 99.6% of eligible participants were followed up until they developed an outcome or the study finished. The risk of the primary composite outcome, CV death, hospitalization for worsening HF, and total mortality rose progressively with higher levels of usual HbA_1c (P for trend <.001). After age and sex were adjusted for, hazards of these outcomes per 1% higher HbA_1c level were 1.25 (95% confidence interval [CI ],1.20-1.31), 1.24 (95% CI, 1.17-1.31), 1.25 (95% CI, 1.19-1.31), and 1.22 (95% CI, 1.16-1.29), respectively. This relationship was evident in patients with and without diabetes and with reduced or preserved ejection fraction and persisted after adjustment for diabetes, other risk factors, and allocation to candesartan.

Conclusion  In diabetic and nondiabetic patients with symptomatic chronic HF, the HbA_1c level is an independent progressive risk factor for CV death, hospitalization for HF, and total mortality.

Methods  Among 30 677 adults 18 years or older participating in the adult sample section of the National Health Interview Survey, 23 413 who reported having a usual source of medical care other than the ED and answered the questions related to barriers were included in our analyses. Associations between perceived timely access barriers and reported use of ED in the previous 12 months were examined using logistic regression to control for covariates that also affect ED use.

Results  For those reporting no access barriers, 1 in 5 adult Americans in the noninstitutionalized civilian population visited an ED at least once during the preceding year. For those reporting 1 or more barriers, the proportion having an ED visit was 1 in 3. Four of the 5 following timely access barriers was independently associated with ED use, even after adjusting for other socioeconomic and health-related factors: (1) "couldn't get through on phone" (OR [odds ratio], 1.27; 95% confidence interval [CI], 1.02-1.59); (2) "couldn't get appointment soon enough" (OR, 1.45; 95% CI, 1.21-1.75); (3) "waiting too long in doctor's office" (OR, 1.20; 95% CI, 1.02-1.41); (4) "not open when you could go" (OR, 1.24; 95% CI, 0.99-1.55); and (5) "no transportation" (OR, 1.88; 95% CI, 1.50-2.35).

Conclusions  The benefits of having a usual source of medical care are diminished by barriers that limit effective and timely access to such care. Interventions to improve effective access to medical care such as open access scheduling might have benefits not only for individual patients and practices but also for health policy related to cost-effective health care delivery systems and our need to relieve overcrowded conditions at EDs.

Methods  A prospective follow-up study of 59 000 African American women has been in progress since 1995. Participants reported on food and beverage consumption in 1995 and 2001. Biennial follow-up questionnaires ascertained new diagnoses of type 2 diabetes. The present analyses included 43 960 women who gave complete dietary and weight information and were free from diabetes at baseline. We identified 2713 incident cases of type 2 diabetes mellitus during 338 884 person-years of follow-up. The main outcome measure was the incidence of type 2 diabetes mellitus.

Results  The incidence of type 2 diabetes mellitus was higher with higher intake of both sugar-sweetened soft drinks and fruit drinks. After adjustment for confounding variables including other dietary factors, the incidence rate ratio for 2 or more soft drinks per day was 1.24 (95% confidence interval, 1.06-1.45). For fruit drinks, the comparable incidence rate ratio was 1.31 (95% confidence interval, 1.13-1.52). The association of diabetes with soft drink consumption was almost entirely mediated by body mass index, whereas the association with fruit drink consumption was independent of body mass index.

Conclusions  Regular consumption of sugar-sweetened soft drinks and fruit drinks is associated with an increased risk of type 2 diabetes mellitus in African American women. While there has been increasing public awareness of the adverse health effects of soft drinks, little attention has been given to fruit drinks, which are often marketed as a healthier alternative to soft drinks.

Methods  We administered a semiquantitative food frequency questionnaire to men and women from a population-based prospective cohort (European Prospective Investigation of Cancer–Norfolk) study who were aged 40 to 75 years at baseline (1993-1997) when plasma vitamin C level was determined and habitual intake of fruit and vegetables was assessed. During 12 years of follow-up between February 1993 and the end of December 2005, 735 clinically incident cases of diabetes were identified among 21 831 healthy individuals. We report the odds ratios of diabetes associated with sex-specific quintiles of fruit and vegetable intake and of plasma vitamin C levels.

Results  A strong inverse association was found between plasma vitamin C level and diabetes risk. The odds ratio of diabetes in the top quintile of plasma vitamin C was 0.38 (95% confidence interval, 0.28-0.52) in a model adjusted for demographic, lifestyle, and anthropometric variables. In a similarly adjusted model, the odds ratio of diabetes in the top quintile of fruit and vegetable consumption was 0.78 (95% confidence interval, 0.60-1.00).

Conclusions  Higher plasma vitamin C level and, to a lesser degree, fruit and vegetable intake were associated with a substantially decreased risk of diabetes. Our findings highlight a potentially important public health message on the benefits of a diet rich in fruit and vegetables for the prevention of diabetes.

Methods  A randomized controlled trial was conducted at 40 US clinical centers from 1993 to 2005, including 48 835 postmenopausal women aged 50 to 79 years. Women were randomly assigned to a usual-diet comparison group (n = 29 294 [60.0%]) or an intervention group with a 20% low-fat dietary pattern with increased vegetables, fruits, and grains (n = 19 541 [40.0%]). Self-reported incident diabetes treated with oral agents or insulin was assessed.

Results  Incident treated diabetes was reported by 1303 intervention participants (7.1%) and 2039 comparison participants (7.4%) (hazard ratio, 0.96; 95% confidence interval, 0.90-1.03; P = .25). Weight loss occurred in the intervention group, with a difference between intervention and comparison groups of 1.9 kg after 7.5 years (P < .001). Subgroup analysis suggested that greater decreases in percentage of energy from total fat reduced diabetes risk (P for trend = .04), which was not statistically significant after adjusting for weight loss.

Conclusions  A low-fat dietary pattern among generally healthy postmenopausal women showed no evidence of reducing diabetes risk after 8.1 years. Trends toward reduced incidence were greater with greater decreases in total fat intake and weight loss. Weight loss, rather than macronutrient composition, may be the dominant predictor of reduced risk of diabetes.

Trial Registration  clinicaltrials.gov Identifier: NCT00000611

Methods  We related serum thyrotropin concentrations measured at baseline (March 1977-November 1979) to the risk of Alzheimer disease (AD) in 1864 cognitively intact, clinically euthyroid Framingham original cohort participants (mean age, 71 years; 59% women). Sex-specific Cox proportional hazards models were constructed using tertiles of thyrotropin concentration (tertile 2 as the referent) and adjusting for age, apolipoprotein E 4 allele status, educational level, plasma homocysteine level, current smoking, body mass index, prevalent stroke, and atrial fibrillation.

Results  During a mean follow-up of 12.7 years (range, 1-25 years), 209 participants (142 women) developed AD. Women in the lowest (<1.0 mIU/L) and highest (>2.1 mIU/L) tertiles of serum thyrotropin concentration were at increased risk for AD (multivariate-adjusted hazard ratio, 2.39 [95% confidence interval, 1.47-3.87] [P < .001] and 2.15 [95% confidence interval, 1.31-3.52] [P = .003], respectively) compared with those in the middle tertile. Thyrotropin levels were not related to AD risk in men. Analyses excluding individuals receiving thyroid supplementation did not significantly alter these relationships. In analyses limited to participants with serum thyrotropin levels of 0.1 to 10.0 mIU/L, the U-shaped relationship between thyrotropin level and AD risk was maintained in women but not when analyses were limited to those with thyrotropin levels of 0.5 to 5.0 mIU/L.

Conclusion  Low and high thyrotropin levels were associated with an increased risk of incident AD in women but not in men.

Methods  We determined hearing loss prevalence among US adults and evaluated differences by demographic characteristics and known risk factors for hearing loss (smoking, noise exposure, and cardiovascular risks). A national cross-sectional survey with audiometric testing was performed. Participants were 5742 US adults aged 20 to 69 years who participated in the audiometric component of the National Health and Nutrition Examination Survey 1999-2004. The main outcome measure was 25-dB or higher hearing loss at speech frequencies (0.5, 1, 2, and 4 kHz) and at high frequencies (3, 4, and 6 kHz).

Results  In 2003-2004, 16.1% of US adults (29 million Americans) had speech-frequency hearing loss. In the youngest age group (20-29 years), 8.5% exhibited hearing loss, and the prevalence seems to be growing among this age group. Odds of hearing loss were 5.5-fold higher in men vs women and 70% lower in black subjects vs white subjects. Increases in hearing loss prevalence occurred earlier among participants with smoking, noise exposure, and cardiovascular risks.

Conclusions  Hearing loss is more prevalent among US adults than previously reported. The prevalence of US hearing loss differs across racial/ethnic groups, and our data demonstrate associations with risk factors identified in prior smaller-cohort studies. Our findings also suggest that hearing loss prevention (through modifiable risk factor reduction) and screening should begin in young adulthood.

Methods  A prospective, 16-week, multicenter, randomized, double-blind, placebo-controlled, parallel-group study conducted at 50 sites in the United States and 1 site in Mexico between August 12, 2004, and December 28, 2005. Subjects had type 2 diabetes mellitus that was not adequately controlled (glycated hemoglobin level, 7.5%-9.5%, inclusive) receiving insulin therapy alone or in combination with oral antidiabetes agents. In total 287 subjects (52% men; mean age, 57 years; with a mean baseline glycated hemoglobin level of 8.3%) were randomized: 147 to receive colesevelam hydrochloride, 3.75 g/d, and 140 to receive placebo.

Results  Using the least squares method, the mean (SE) change in glycated hemoglobin level from baseline to week 16 was –0.41% (0.07%) for the colesevelam-treated group and 0.09% (0.07%) for the placebo group (treatment difference, –0.50% [0.09%]; 95% confidence interval, –0.68% to –0.32%; P < .001). Consistent reductions in fasting plasma glucose and fructosamine levels, glycemic-control response rate, and lipid control measures were observed with colesevelam. As expected, the colesevelam-treated group had a 12.8% reduction in low-density lipoprotein cholesterol concentration relative to placebo (P < .001). Of recipients of colesevelam and placebo, respectively, 30 and 26 discontinued the study prematurely; 7 and 9 withdrew because of protocol-specified hyperglycemia, and 10 and 4 withdrew because of adverse events. Both treatments were generally well tolerated.

Conclusions  Colesevelam treatment seems to be safe and effective for improving glycemic control and lipid management in patients with type 2 diabetes mellitus receiving insulin-based therapy, and it may provide a novel treatment for improving dual cardiovascular risk factors.

Trial Registration  clinicaltrials.gov Identifier: NCT00151749

Methods  We performed a retrospective analysis involving 12 395 patients with non–small cell lung cancer in the pre-PET (1994-1998) and PET (1999-2004) periods. Interperiod differences in staging procedures, clinical variables, and patient survival were evaluated.

Results  There was a 5.4% decline in the number of patients with stage III disease and an 8.4% increase in the number of patients with stage IV disease in the PET period, corresponding with an increase in PET use from 6.3% to 20.1% (P < .001). The PET period predicted better survival with a hazard ratio (HR) of 0.95 (95% confidence interval [CI], 0.91-0.99) (P = .02). Use of PET was independently associated with better survival in patients with stage III (HR, 0.77; 95% CI, 0.69-0.85) and stage IV (HR, 0.64; 95% CI, 0.58-0.70) disease, but not those with stage I or II disease.

Conclusion  These data support the notion that stage migration is responsible at least in part for an apparent improvement in survival for patients with stage III and IV non–small cell lung cancer in the PET scan era.

Methods  Between December 1, 1999, and January 31, 2003, 201 overweight and obese women (body mass index [calculated as weight in kilograms divided by height in meters squared], 27 to 40; age range, 21-45 years) with no contraindications to weight loss or physical activity were recruited from a hospital-based weight loss research center. Participants were assigned to 1 of 4 behavioral weight loss intervention groups. They were randomly assigned to groups based on physical activity energy expenditure (1000 vs 2000 kcal/wk) and intensity (moderate vs vigorous). Participants also were told to reduce intake to 1200 to 1500 kcal/d. A combination of in-person conversations and telephone calls were conducted during the 24-month study period.

Results  Weight loss did not differ among the randomized groups at 6 months' (8%-10% of initial body weight) or 24 months' (5% of initial body weight) follow-up. Post-hoc analysis showed that individuals sustaining a loss of 10% or more of initial body weight at 24 months reported performing more physical activity (1835 kcal/wk or 275 min/wk) compared with those sustaining a weight loss of less than 10% of initial body weight (P < .001).

Conclusions  The addition of 275 mins/wk of physical activity, in combination with a reduction in energy intake, is important in allowing overweight women to sustain a weight loss of more than 10%. Interventions to facilitate this level of physical activity are needed.

Trial Registration  clinicaltrials.gov Identifier: NCT00006315.

Methods  We examined all US death certificates from January 1, 1983, to December 31, 2004 (N = 49 586 156), particularly those with fatal medication errors (FMEs) (n = 224 355). We examined trends in 4 types of FMEs that vary according to the relative importance of alcohol/street drugs and the relative likelihood of professional oversight in the consumption of medications.

Results  The overall FME death rate increased by 360.5% (1983-2004). This increase far exceeds the increase in death rates from adverse effects of medications (33.2%) or from alcohol and/or street drugs (40.9%). The increase in FMEs varies markedly by type. Type 1 (domestic FMEs combined with alcohol and/or street drugs) shows the largest increase (3196%). In contrast, type 4 (nondomestic FMEs not involving alcohol and/or street drugs) shows the smallest increase (5%). Types 2 and 3 show intermediate increases. Type 2 (domestic FMEs not involving alcohol and/or street drugs) increased by 564%. Type 3 (nondomestic FMEs combined with alcohol and/or street drugs) increased by 555%. Thus, domestic FMEs combined with alcohol and/or street drugs have become an increasingly important health problem compared with other FMEs.

Conclusions  These findings suggest that a shift in the location of medication consumption from clinical to domestic settings is linked to a steep increase in FMEs. It may now be possible to reduce FMEs by focusing not only on clinical settings but also on domestic settings.

Methods  This longitudinal, 9-year study of 949 participants in the Study of Women's Health Across the Nation investigates the natural history of the menopausal transition. Participants of 5 ethnicities at 7 geographic sites were recruited when they were premenopausal or early perimenopausal and were eligible for this study if they (1) reached menopause during the study; (2) had never taken hormone therapy, and (3) did not have diabetes mellitus or the MetS at baseline. The primary outcome was the presence of MetS using National Cholesterol Education Program Adult Treatment Panel III criteria. Secondary outcomes were the components of the MetS.

Results  By the final menstrual period, 13.7% of the women had new-onset MetS. Longitudinal analyses, centered at the final menstrual period, were adjusted for age at menopause, ethnicity, study site, marital status, education, body mass index, smoking, and aging. Odds of developing the MetS per year in perimenopause were 1.45 (95% confidence interval, 1.35-1.56); after menopause, 1.24 (95% confidence interval, 1.18-1.30). These odds were significantly different (P < .001). An increase in bioavailable testosterone or a decrease in sex hormone–binding globulin levels increased the odds.

Conclusions  As testosterone progressively dominates the hormonal milieu during the menopausal transition, the prevalence of MetS increases, independent of aging and other important covariates. This may be a pathway by which cardiovascular disease increases during menopause.

Methods  To estimate the prevalence of knee and hip osteoarthritis and the appropriateness of joint replacement in a general population of older individuals, the validated Knee and Hip OsteoArthritis Screening Questionnaire (KHOA-SQ) was sent to a random sample of individuals aged 60 to 90 years, stratified by age and sex, living in a single province in Spain. Respondents positive for knee or hip osteoarthritis on the KHOA-SQ were invited to be examined by an orthopedic surgeon. Diagnosis of knee or hip osteoarthritis was based on clinical and radiographic data. For respondents judged as having osteoarthritis, the appropriateness of knee or hip replacement was evaluated using published explicit criteria.

Results  Of 11 002 individuals contacted, 7577 completed the KHOA-SQ. The derived prevalence of hip osteoarthritis was approximately 7.4%. It was slightly higher in women (8.0%) than in men (6.7%) and tended to increase with age. The estimated appropriateness rate for hip replacement was 37.7% in men and 52.7% in women with osteoarthritis. The derived prevalence of knee osteoarthritis was 12.2%; it was significantly higher in women (14.9%) than in men (8.7%) and tended to increase with age. The estimated appropriateness rate for knee replacement was 11.8% in men and 17.9% in women with osteoarthritis.

Conclusions  Knee and hip osteoarthritis are highly prevalent diseases in the older population. The estimation of appropriateness for hip replacement seems to be significantly higher than that for knee replacement.

Methods  We examined visits by patients with SSTIs to physician offices, hospital outpatient departments, and EDs using the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey from 1997 to 2005. We estimated annual visit rates for all SSTIs and a subset classified as abscess/cellulitis. For abscess/cellulitis visits, we examined trends in characteristics of patients and clinical settings and in antibiotic prescribing.

Results  Overall rate of visits for SSTIs increased from 32.1 to 48.1 visits per 1000 population (50%; P = .003 for trend), reaching 14.2 million by 2005. More than 95% of this change was attributable to visits for abscess/cellulitis, which increased from 17.3 to 32.5 visits per 1000 population (88% increase; P < .001 for trend). The largest relative increases occurred in EDs (especially in high safety-net–status EDs and in the South), among black patients, and among patients younger than 18 years. Use of antibiotics recommended for CA-MRSA increased from 7% to 28% of visits (P < .001) during the study period. Independent predictors of treatment with these antibiotics included being younger than 45 years, living in the South, and an ED setting.

Conclusions  The incidence of SSTIs has rapidly increased nationwide in the CA-MRSA era and appears to disproportionately affect certain populations. Although physicians are beginning to modify antibiotic prescribing practices, opportunities for improvement exist, targeting physicians caring for patients who are at high risk.

Methods  We identified relevant studies published between January 1, 1950, and November 19, 2007, by searching MEDLINE, Scopus, PsycINFO, and all 4 Ovid Evidence-Based Medicine Reviews. Eligible English-language publications reported on readmission after HF hospitalization among adult patients. We excluded experimental studies and publications without original data or quantitative outcomes.

Results  From 941 potentially relevant articles, 117 met inclusion criteria: none contained models to compare readmission rates among hospitals, 5 (4.3%) presented models to predict patients' risk of readmission, and 112 (95.7%) examined patient characteristics associated with readmission. Studies varied in case identification, used multiple types of data sources, found few patient characteristics consistently associated with readmission, and examined differing outcomes, often either readmission alone or a combined outcome of readmission or death, measured across varying periods (from 14 days to 4 years). Two articles reported model discriminations of patient readmission risk, both of which were modest (C statistic, 0.60 for both).

Conclusions  Our systematic review identified no model designed to compare hospital rates of readmission, while models designed to predict patients' readmission risk used heterogeneous approaches and found substantial inconsistencies regarding which patient characteristics were predictive. Clinically, patient risk stratification is challenging. From a policy perspective, a validated risk-standardized statistical model to accurately profile hospitals using readmission rates is unavailable in the published English-language literature to date.

Data Sources  We conducted searches of PubMed, EMBASE, and PsychINFO for the date range January 1973 to October 2006. We reviewed the reference lists of identified publications and the bibliographies of experts in physician-patient communication for additional publications.

Study Selection  From our initial group of citations (n = 1146), we included only studies written in English that reported original data on the use of communication or relationship skills and their effect on time use or visit length. Study inclusion was determined by independent review by 2 authors (L.B.M. and D.C.D.). This yielded 9 publications for our analysis.

Data Extraction  The 2 reviewers independently read and classified the 9 publications and cataloged them by type of study, results, and limitations. Differences were resolved by consensus.

Results  Three domains emerged that may enhance communication efficiency: rapport building, up-front agenda setting, and acknowledging social or emotional clues.

Conclusions  Building on these findings, we offer a model blending the quality-enhancing and time management features of selected communication and relationship skills. There is a need for additional research about communication skills that enhance quality and efficiency.

Methods  Physicians were grouped into quartiles based on their performance on the American Board of Internal Medicine examination. Hierarchical generalized linear models examined associations between examination scores and the receipt of processes of care by Medicare patients. The main outcome measures were the associations between diabetes care, using a composite measure of hemoglobin A_1c, and lipid testing and retinal screening, mammography, and lipid testing in patients with cardiovascular disease and the physician's performance on the American Board of Internal Medicine examination, adjusted for the number of Medicare patients with diabetes and cardiovascular disease in a physician's practice panel; frequency of visits; patient comorbidity, age, and ethnicity; and physician training history and type of practice.

Results  Physicians scoring in the top quartile were more likely to perform processes of care for diabetes (composite measure odds ratio [OR], 1.17; 95% confidence interval [CI], 1.07-1.27) and mammography screening (OR, 1.14; 95% CI, 1.08-1.21) than physicians in the lowest physician quartile, even after adjustment for multiple factors. There was no significant difference among the groups in lipid testing of patients with cardiovascular disease (OR, 1.00; 95% CI, 0.91-1.10).

Conclusion  Our findings suggest that physician cognitive skills, as measured by a maintenance of certification examination, are associated with higher rates of processes of care for Medicare patients.

Methods  In a secondary analysis of data from a randomized experiment, we coded 287 audiorecorded interactions between physicians and standardized patients (SPs) using the Observing Patient Involvement (OPTION) system to assess physician SDM behaviors. We performed a series of generalized linear mixed model analyses to examine physician and patient characteristics associated with SDM behavior.

Results  The mean (SD) OPTION score was 11.4 (3.3) of 48 possible points. Older physicians (partial correlation coefficient = –0.29; β = –0.09; P < .01) and physicians who practiced in a health maintenance organization setting (β = –1.60; P < .01) performed fewer SDM behaviors. Longer visit duration was associated with more SDM behaviors (partial correlation coefficient = 0.31; β = 0.08; P < .01). In addition, physicians enacted more SDM behaviors with SPs who made general (β = 2.46; P < .01) and brand-specific (β = 2.21; P < .01) medication requests compared with those who made no request.

Conclusions  In the context of new visits for depressive symptoms, primary care physicians performed few SDM behaviors. However, physician SDM behaviors are influenced by practice setting and patient-initiated requests for medication. Additional research is needed to identify interventions that encourage SDM when indicated.

Methods  A sample of 12 018 community-dwelling Medicare beneficiaries 65 years or older from the 2004 Medicare Current Beneficiary Survey was studied. Multivariate regression was used to describe whether beneficiaries' self-reported satisfaction with their usual-care physician was related to the presence or functions assumed by visit companions.

Results  Overall, 38.6% of beneficiaries reported being typically accompanied to routine medical visits. Accompanied beneficiaries were older, less educated, and in worse health than their unaccompanied counterparts. More than 60% of companions facilitated visit communication by recording physician instructions (44.1%), providing information regarding patients' medical conditions or needs (41.6%), asking questions (41.1%), or explaining physicians' instructions (29.7%). After controlling for sociodemographic and health differences, accompanied beneficiaries were more highly satisfied with their physician's technical skills (odds ratio [OR], 1.15; 95% confidence interval [CI], 1.02-1.30), information giving (OR, 1.19; 95% CI, 1.05-1.35), and interpersonal skills (OR, 1.18; 95% CI, 1.03-1.35) than unaccompanied beneficiaries. Accompanied beneficiaries whose visit companions were more actively engaged in communication rate