Longitudinal Analysis of Hospitalization After Spinal Cord Injury: Variation Based on Race and Ethnicity

Objective

To examine the longitudinal effects of race/ethnicity on hospitalization among adults with spinal cord injury (SCI) in the 10-year period after initial injury.

Design

Retrospective analysis of postinjury hospitalizations among non-Hispanic white, non-Hispanic African American, and Hispanic adults with SCI.

Setting

Community. Data were extracted from the 2011 National Spinal Cord Injury Model Systems database.

Participants

Patients with traumatic SCI (N= 5146; white, 3175; African American, 1396; Hispanic, 575) who received rehabilitation at one of the relevant SCI Model Systems.

Interventions

Not applicable.

Main Outcome Measures

Hospitalization, including rate of hospitalization, number of hospitalizations, and number of days hospitalized during the 12 months before the first-, fifth-, and tenth-year follow-up interviews for the SCI Model Systems.

Results

Significant differences were found in rates of hospitalization at 1 and 5 years postinjury, with participants from Hispanic backgrounds reporting lower rates than either whites or African Americans. At 10 years postinjury, no differences were noted in the rate of hospitalization between racial/ethnic groups; however, compared with whites (P=.011) and Hispanics (P=.051), African Americans with SCI had 13 and 16 more days of hospitalization, respectively. Compared with the first year postinjury, the rate of hospitalization declined over time among whites, African Americans, and Hispanics; however, for African Americans, the number of days hospitalized increased by 12 days (P=.036) at 10 years versus 5 years postinjury.

Conclusions

Racial/ethnic variation appears to exist in postinjury hospitalization for individuals with SCI, with Hispanics showing the lowest rates of hospitalization at 1 and 5 years postinjury and African Americans having a significantly higher number of days hospitalized at 10 years postinjury. Potential explanations for these variations are discussed, and recommendations are made for potential changes to policy and clinical care.     

Relationship of Insulin Sensitivity,Insulin Secretion,and Adiposity With Insulin Clearance in a Multiethnic Population: The Insulin Resistance Atherosclerosis Study

OBJECTIVE

We aimed to examine insulin clearance, a compensatory mechanism to changes in insulin sensitivity, across sex, race/ethnicity populations, and varying states of glucose tolerance.

RESEARCH DESIGN AND METHODS

We measured insulin sensitivity index (S_I), acute insulin response (AIR), and metabolic clearance rate of insulin (MCRI) by the frequently sampled intravenous glucose tolerance test in 1,295 participants in the Insulin Resistance Atherosclerosis Study.

RESULTS

MCRI was positively related to S_I and negatively to AIR and adiposity across sex, race/ethnicity populations, and varying states of glucose tolerance, adiposity, and family history of diabetes. Differences in MCRI by race/ethnicity (lower in African Americans and Hispanics compared with non-Hispanic whites) and glucose tolerance were largely explained by differences in adiposity, S_I, and AIR.

CONCLUSIONS

Insulin sensitivity, insulin secretion, and adiposity are correlates of insulin clearance and appear to explain differences in insulin clearance by race/ethnicity and glucose tolerance status.Reduced insulin clearance has been demonstrated in experimental models of insulin resistance (1) and conditions associated with insulin resistance (2–5). Insulin clearance partially explains the variability of fasting insulin independently of the effect of insulin resistance, insulin secretion, adiposity, and plasma glucose (6). In response to their higher insulin resistance, minority populations have lower insulin clearance than non-Hispanic whites (4,5,7). In these studies, however, results were not adjusted for insulin resistance. Therefore, we aimed to examine insulin clearance across sex, race/ethnicity populations, and varying states of glucose tolerance in the Insulin Resistance Atherosclerosis Study (IRAS) (8).     

Patterns, predictors, and associated benefits of driving a modified vehicle after spinal cord injury: findings from the National Spinal Cord Injury Model Systems

Norweg A, Jette AM, Houlihan B, Ni P, Boninger ML. Patterns, predictors, and associated benefits of driving a modified vehicle after spinal cord injury: findings from the National Spinal Cord Injury Model Systems.

Objectives

To investigate the patterns, predictors, and benefits associated with driving a modified vehicle for people with spinal cord injuries (SCIs).

Design

Cross-sectional retrospective survey design.

Settings

Sixteen Model SCI Systems (MSCISs) throughout the United States.

Participants

People (N=3726) post-SCI from the National MSCIS Database.

Interventions

Not applicable.

Main Outcome Measures

Driving, employment, and community reintegration post-SCI.

Results

The study found that 36.5% of the sample drove a modified vehicle after SCI. Significant predictors of driving a modified vehicle post-SCI included married at injury, younger age at injury, associate's degree or higher before injury, paraplegia, a longer time since the injury, non-Hispanic race, white race, male sex, and using a wheelchair for more than 40 hours a week after the injury (accounting for 37% of the variance). Higher activity of daily living independence (in total motor function) at hospital discharge also increased the odds of driving. Driving increased the odds of being employed at follow-up by almost 2 times compared with not driving postinjury (odds ratio, 1.85). Drivers tended to have higher community reintegration scores, especially for community mobility and total community reintegration. Driving was also associated with small health-related quality-of-life gains, including less depression and pain interference and better life satisfaction, general health status, and transportation availability scores.

Conclusions

The associated benefits of driving and the relatively low percentage of drivers post-SCI in the sample provide evidence for the need to increase rehabilitation and assistive technology services and resources in the United States devoted to facilitating driving after SCI.     

Diagnosis of the metabolic syndrome is associated with disproportionately high levels of high-sensitivity C-reactive protein in non-Hispanic black adolescents: an analysis of NHANES 1999-2008

OBJECTIVE

Whereas it is known that the metabolic syndrome (MetS) has a paradoxically lower prevalence in non–Hispanic black adolescents than in non–Hispanic whites or Hispanics, the relative severity of MetS by race/ethnicity is unknown. Inflammation, indicated by high-sensitivity C-reactive protein (hsCRP), is a key factor linking MetS to cardiovascular disease and type 2 diabetes. Our goal was to determine whether elevations of hsCRP vary by race/ethnicity among adolescents with MetS.

RESEARCH DESIGN AND METHODS

We used the National Health and Nutrition Examination Survey (1999–2008) and evaluated adolescents (age 12–19 years) using a pediatric/adolescent adaptation of the ATP III definition of MetS. We used linear regression to evaluate the interaction between MetS status and ethnicity with respect to hsCRP concentration.

RESULTS

For male and female adolescents, MetS was associated with elevated hsCRP levels compared with adolescents without MetS. However, the elevation in hsCRP between adolescents with and without MetS was greater in non–Hispanic blacks compared with that in non–Hispanic whites (P = 0.04) but not that in Hispanics (P = 0.18). hsCRP concentrations correlated with individual MetS components similarly among all ethnicities. In an evaluation of adolescents diagnosed with MetS, non–Hispanic blacks had higher BMI and more hypertension than other ethnicities but there were no other racial/ethnic differences in the features of MetS.

CONCLUSIONS

Non–Hispanic black adolescents have a greater differential in hsCRP between those with and those without MetS than the differential in non–Hispanic whites but not that in Hispanics. Therefore, even though MetS has a low prevalence in non–Hispanic blacks, MetS is a particularly good indicator of inflammation in non–Hispanic black adolescents.The metabolic syndrome (MetS) is a clustering of cardiovascular risk factors that are related to insulin resistance, specifically, elevated waist circumference, hypertriglyceridemia, low HDL-cholesterol, hypertension, and fasting hyperglycemia (1). MetS is related to inflammation (2) and functions as an independent predictor of long-term risk for cardiovascular disease and type 2 diabetes among both adults (3) and children (4). Whereas the relationships between MetS, inflammation, and long-term risks are well described in the general population, these relationships have not been delineated in non–Hispanic black individuals. Non–Hispanic blacks are less likely than non–Hispanic whites and Hispanics to be classified as having MetS, largely based on a lower prevalence of dyslipidemia (5–7). Nevertheless, non–Hispanic blacks are more likely than non–Hispanic whites to exhibit insulin resistance (8,9) and to develop cardiovascular disease and type 2 diabetes (10,11), which brings into question the accuracy of current criteria for classifying MetS among non–Hispanic blacks (6). Similarly, the relationship of MetS with increased inflammation among non–Hispanic blacks is unclear.High-sensitivity C-reactive protein (hsCRP) is a marker of inflammation that in adults is an independent risk factor for cardiovascular disease and type 2 diabetes (12,13). Among children and adolescents, elevated hsCRP levels are predictive of adult hsCRP levels 20 years later (14) and are independently associated with arterial changes that precede cardiovascular disease, including carotid artery intima-media thickness (15).Our goal was to determine whether elevations in hsCRP values among adolescents with MetS vary by race/ethnicity. We used the National Health and Nutrition Examination Survey (NHANES) 1999–2008 and a pediatric/adolescent adaptation of the Adult Treatment Panel III (ATP III) definition of MetS (1) to explore the relationship between MetS and hsCRP on a race/ethnicity-specific basis.     

Patient Race/Ethnicity and Patient-Physician Race/Ethnicity Concordance in the Management of Cardiovascular Disease Risk Factors for Patients With Diabetes

OBJECTIVE

Patient-physician race/ethnicity concordance can improve care for minority patients. However, its effect on cardiovascular disease (CVD) care and prevention is unknown. We examined associations of patient race/ethnicity and patient-physician race/ethnicity concordance on CVD risk factor levels and appropriate modification of treatment in response to high risk factor values (treatment intensification) in a large cohort of diabetic patients.

RESEARCH DESIGN AND METHODS

The study population included 108,555 adult diabetic patients in Kaiser Permanente Northern California in 2005. Probit models assessed the effect of patient race/ethnicity on risk factor control and treatment intensification after adjusting for patient and physician-level characteristics.

RESULTS

African American patients were less likely than whites to have A1C <8.0% (64 vs. 69%, P < 0.0001), LDL cholesterol <100 mg/dl (40 vs. 47%, P < 0.0001), and systolic blood pressure (SBP) <140 mmHg (70 vs. 78%, P < 0.0001). Hispanic patients were less likely than whites to have A1C <8% (62 vs. 69%, P < 0.0001). African American patients were less likely than whites to have A1C treatment intensification (73 vs. 77%, P < 0.0001; odds ratio [OR] 0.8 [95% CI 0.7–0.9]) but more likely to receive treatment intensification for SBP (78 vs. 71%, P < 0.0001; 1.5 [1.3–1.7]). Hispanic patients were more likely to have LDL cholesterol treatment intensification (47 vs. 45%, P < 0.05; 1.1 [1.0–1.2]). Patient-physician race/ethnicity concordance was not significantly associated with risk factor control or treatment intensification.

CONCLUSIONS

Patient race/ethnicity is associated with risk factor control and treatment intensification, but patient-physician race/ethnicity concordance was not. Further research should investigate other potential drivers of disparities in CVD care.There are well-documented racial disparities in diabetes prevalence and mortality. African Americans and Hispanics have higher diabetes prevalence, death rates, and higher rates of serious complications (1). Even after controlling for access to care and socioeconomic status, diabetes disparities in the U.S. persist (1). There are also widely recognized disparities in cardiovascular risk factors associated with diabetes. African American and Hispanic patients with diabetes are less likely to meet glucose, cholesterol, or blood pressure targets (2).The evidence surrounding whether insured patients of color receive worse care for diabetes and cardiovascular disease (CVD) risk factor control is mixed (3–6). Studies have found significant disparities in the likelihood of receipt of medications (7) and medication intensification (8,9). However, several studies have shown that minority patients received equal or better quality processes of care such as screening and medication intensification (4,10–12).Interpersonal barriers resulting from language or cultural differences between patients and physicians may explain a portion of diabetes management disparities (13,14). Physicians engage in less patient-centered communication with patients of color than with white patients (15). Patient race/ethnicity has been associated with physicians'' assessment of patient intelligence, feelings of affiliation toward the patient, and beliefs about the patients'' likelihood of risk behavior and adherence with medical advice (16,17).Patient-physician race/ethnicity concordance (the patient and health care provider having the same race/ethnicity) may help bridge interpersonal barriers in care for minority patients (18). Race/ethnicity concordance is associated with increased patient trust in the physician (19) and health services utilization and satisfaction (20). However, evidence that race/ethnicity concordance is an important factor in the quality of health care is mixed (21). No studies have examined the association among race/ethnicity concordance, cardiovascular disease processes of care, and levels of intermediate outcomes.The purpose of this study was to examine the association of patient race/ethnicity and patient-physician race/ethnicity concordance on CVD risk factor levels and treatment intensification in a large cohort of diabetic patients in an integrated delivery system.     

Marital status, marital transitions, well-being, and spinal cord injury: an examination of the effects of sex and time

Kalpakjian CZ, Houlihan B, Meade MA, Karana-Zebari D, Heinemann AW, Dijkers MP, Wierbicky J, Charlifue S. Marital status, marital transitions, well-being, and spinal cord injury: an examination of the effects of sex and time.

Objective

To examine the applicability of marital resource (marriage has substantial benefits for well-being over not being married) or marital crisis (marital dissolution leads to poorer well-being) models to the spinal cord injury (SCI) population by studying the effects of sex, marital status, and marital transitions on well-being.

Design

Prospective cohort study from the SCI Model Systems National Database.

Setting

Community.

Participants

Men (n=4864) and women (n=1277) who sustained traumatic SCI and completed a minimum of 1 follow-up interview beginning at 1 year through 15 years postinjury.

Interventions

None.

Main Outcomes Measures

Life satisfaction, depressive symptoms, and self-perceived health status by using linear mixed models for longitudinal data.

Results

In general, well-being improved over time since injury. Hypothesis testing supported the marital crisis model, as marital loss through being or becoming separated or divorced and being or becoming widowed, had the most consistent and negative impact across well-being outcomes, whereas being or becoming married had an advantage for only lower depression symptoms over time. However, marital dissolution or loss did not have a uniformly adverse impact on well-being outcomes, and this effect often was moderated by sex, such that widows had higher depressive symptoms and poorer self-perceived health than widowers, but separated or divorced women had higher life satisfaction and self-perceived health than men. Irrespective of sex, being separated or divorced versus being single was associated with higher depressive symptoms over time.

Conclusions

Results support the marital crisis model and that women and men can experience marital dissolution differently. All marital loss does not result in compromised well-being and all marriage does not enhance well-being, highlighting complex dynamics worthy of further investigation in this population.     

Racial Differences in Employment Outcome After Traumatic Brain Injury at 1, 2, and 5 Years Postinjury

Gary KW, Arango-Lasprilla JC, Ketchum JM, Kreutzer JS, Copolillo A, Novack TA, Jha A. Racial differences in employment outcome after traumatic brain injury at 1, 2, and 5 years postinjury.

Objectives

To examine racial differences in competitive employment outcomes at 1, 2, and 5 years after traumatic brain injury (TBI) and to determine whether changes in not competitive employment rates over time differ between blacks and whites with TBI after adjusting for demographic and injury characteristics.

Design

Retrospective cohort study.

Setting

Sixteen TBI Model System Centers.

Participants

Blacks (n=615) and whites (n=1407) with moderate to severe TBI.

Interventions

Not applicable.

Main Outcome Measure

Employment status dichotomized as competitively employed versus not competitively employed.

Results

After adjusting for demographic and injury characteristics, repeated-measures logistic regression indicated that (1) the odds of not being competitively employed were significantly greater for blacks than whites regardless of the follow-up year (all P<.001); (2) the odds of not being competitively employed declined significantly over time for each race (P≤.004); and (3) changes over time in the odds of not being competitively employed versus being competitively employed were not different between blacks and whites (P=.070). In addition, age, discharge FIM and Disability Rating Scale, length of stay in acute and rehabilitation, preinjury employment, sex, education, marital status, and cause of injury were significant predictors of employment status postinjury.

Conclusions

Short- and long-term employment is not favorable for people with TBI regardless of race; however, blacks fare worse in employment outcomes compared with whites. Rehabilitation professionals should work to improve return to work for all persons with TBI, with special emphasis on addressing specific needs of blacks.     

Psychological contributions to functional independence: a longitudinal investigation of spinal cord injury rehabilitation

Kennedy P, Lude P, Elfström ML, Smithson EF. Psychological contributions to functional independence: a longitudinal investigation of spinal cord injury rehabilitation.

Objectives

To investigate the contribution of prerehabilitation appraisals of spinal cord injury (SCI) and patient's coping strategies to the variance in functional independence postdischarge.

Design

Longitudinal, cohort study. Patients aged 16 and older and sustaining an SCI were recruited from English- and German-speaking specialist spinal injuries centers. Measures of appraisals, coping strategies, mood, and functional independence were administered on commencing active rehabilitation (12-weeks postinjury) and following hospital discharge (1-y postinjury).

Setting

Specialist SCI rehabilitation centers in England, Germany, Switzerland, and Ireland.

Participants

Patients (N=127) completed questionnaires at both time points. Sample age ranged between 17.5 and 64.5 years with a mean age of 39.3 years. Demographic and injury characteristics were similar to those reported in international statistics databases.

Interventions

Not applicable.

Main Outcome Measure

FIM (motor subscale).

Results

Injury characteristics, age, sex, current depression, and the utilization of the coping strategy, social reliance, at 12-weeks postinjury explained 33.5% of the variance in motor FIM at 1-year postinjury. Strong relationships were found between appraisals, coping styles, mood, and functional outcomes.

Conclusions

The coping strategy, social reliance, was found to contribute significantly when explaining the variance in functional outcomes. Suggestions were made to assess appraisals and coping strategies early in rehabilitation in order to provide effective interventions and additional support to those scoring highly on negative coping styles. Further research is recommended to provide support for the relationship between dependent coping strategies and functional outcomes.     

Income and risk of mortality after spinal cord injury

Krause JS, Saunders LL, DeVivo MJ. Income and risk of mortality after spinal cord injury.

Objective

To evaluate the association of household income and formal education with risk of mortality after spinal cord injury (SCI).

Design

Cohort study.

Setting

Twenty hospitals designated as Model SCI Systems of care in the United States.

Participants

Adults (N=8027) with traumatic SCI, seen in one of the Model SCI Systems, who had at least 1 follow-up assessment between 1995 and 2006. All participants were at least 1 year postinjury at the time of assessment. There were 57,957 person-years and 1036 deaths. The follow-up period started with the first assessment between 1995 and 2006 and went until either the date of death or March 2009.

Interventions

Not applicable.

Main Outcome Measures

Mortality status was determined by routine follow-up supplemented by using the Social Security Death Index. A logistic regression model was developed to estimate the chance of dying in any given year.

Results

Educational status and income were significantly predictive of mortality after adjusting for age, sex, race, and severity of injury. Compared with those with household income of $75,000 or greater, the odds of mortality was greater for those who had income between $25,000 and $75,000 (1.61) and still higher for those with less than $25,000 a year (2.41). Life expectancy differed more as a function of household income than the economic subscale of the Craig Handicap Assessment and Reporting Technique.

Conclusion

There was a clear gradation in survival based on familial income (high, middle, low), not just an effect of the lowest income.     

Mechanical ventilation, health, and quality of life following spinal cord injury

Charlifue S, Apple D, Burns SP, Chen D, Cuthbert JP, Donovan WH, Lammertse DP, Meade MA, Pretz CR. Mechanical ventilation, health, and quality of life following spinal cord injury.

Objective

To examine differences in perceived quality of life (QOL) at 1 year postinjury between people with tetraplegia who required mechanical ventilation assistance at discharge from rehabilitation and those who did not.

Design

Prospective cross-sectional examination of people with spinal cord injury (SCI) drawn from the SCI Model Systems National Database.

Setting

Community.

Participants

People with tetraplegia (N=1635) who sustained traumatic SCI between January 1, 1994, and September 30, 2008, who completed a 1-year follow-up interview, including 79 people who required at least some use of a ventilator at discharge from rehabilitation.

Interventions

Not applicable.

Main Outcome Measures

Satisfaction With Life Scale (SWLS); Craig Handicap Assessment and Reporting Technique (CHART)-Short Form Physical Independence, Mobility, Social Integration, and Occupation subscales; Patient Health Questionnaire-9 (PHQ-9), Medical Outcomes Study 36-Item Short-Form Health Survey self-perceived health status.

Results

Significant differences were found between the ventilator-user (VU) group and non–ventilator-user (NVU) group for cause of trauma, proportion with complete injury, neurologic impairment level, and number of rehospitalizations. The NVU group had significantly higher SWLS and CHART Social Integration scores than the VU group after controlling for selected covariates. The NVU group also had more positive perceived health status compared with a year previously and a lower incidence of depression assessed by using the PHQ-9 than the VU group. There were no significant differences between groups for perceived current health status.

Conclusions

People in this study who did not require mechanical ventilation at discharge from rehabilitation post-SCI reported generally better health and improved QOL compared with those who required ventilator assistance at 1 year postinjury. Nonetheless, the literature suggests that perceptions of QOL improve as people live in the community for longer periods.     

Health, secondary conditions, and life expectancy after spinal cord injury

Krause JS, Saunders LL. Health, secondary conditions, and life expectancy after spinal cord injury.

Objective

To evaluate the association of health status, secondary health conditions, hospitalizations, and risk of mortality and life expectancy (LE) after spinal cord injury (SCI).

Design

Prospective cohort study.

Setting

Preliminary data were collected from a specialty hospital in the Southeastern United States, with mortality follow-up and data analysis conducted at a medical university.

Participants

Adults with traumatic SCI (N=1361), all at least 1-year postinjury at the time of assessment, were enrolled in the study. There were 325 deaths. After elimination of those with missing data on key variables, there were 267 deaths and 12,032 person-years.

Interventions

None.

Main Outcome Measures

The mortality status was determined by routine follow-up using the National Death Index through December 31, 2008. A logistic regression model was developed to estimate the probability of dying in any given year using person-years.

Results

A history of chronic pressure ulcers, amputations, a depressive disorder, symptoms of infections, and being hospitalized within the past year were all predictive of mortality. LE estimates were generated using the example of a man with noncervical, nonambulatory SCI. Using 3 age examples (20, 40, 60y), the greatest estimated lost LE was associated with chronic pressure ulcers (50.3%), followed by amputations (35.4%), 1 or more recent hospitalizations (18.5%), and the diagnosis of probable major depression (18%). Symptoms of infections were associated with a 6.7% reduction in LE for a 1 SD increase in infectious symptoms.

Conclusions

Several secondary health conditions represent risk factors for mortality and diminish LE after SCI. The presence of 1 or more of these factors should be taken as an indicator of the need for intervention.     

Race/Ethnicity Disparities in Dysglycemia Among U.S. Women of Childbearing Age Found Mainly in the Nonoverweight/Nonobese

OBJECTIVE

To describe the burden of dysglycemia—abnormal glucose metabolism indicative of diabetes or high risk for diabetes—among U.S. women of childbearing age, focusing on differences by race/ethnicity.

RESEARCH DESIGN AND METHODS

Using U.S. National Health and Nutrition Examination Survey data (1999–2008), we calculated the burden of dysglycemia (i.e., prediabetes or diabetes from measures of fasting glucose, A1C, and self-report) in nonpregnant women of childbearing age (15–49 years) by race/ethnicity status. We estimated prevalence risk ratios (PRRs) for dysglycemia in subpopulations stratified by BMI (measured as kilograms divided by the square of height in meters), using predicted marginal estimates and adjusting for age, waist circumference, C-reactive protein, and socioeconomic factors.

RESULTS

Based on data from 7,162 nonpregnant women, representing >59,000,000 women nationwide, 19% (95% CI 17.2–20.9) had some level of dysglycemia, with higher crude prevalence among non-Hispanic blacks and Mexican Americans vs. non-Hispanic whites (26.3% [95% CI 22.3–30.8] and 23.8% [19.5–28.7] vs. 16.8% [14.4–19.6], respectively). In women with BMI <25 kg/m², dysglycemia prevalence was roughly twice as high in both non-Hispanic blacks and Mexican Americans vs. non-Hispanic whites. This relative increase persisted in adjusted models (PRR_adj 1.86 [1.16–2.98] and 2.23 [1.38–3.60] for non-Hispanic blacks and Mexican Americans, respectively). For women with BMI 25–29.99 kg/m², only non-Hispanic blacks showed increased prevalence vs. non-Hispanic whites (PRR_adj 1.55 [1.03–2.34] and 1.28 [0.73–2.26] for non-Hispanic blacks and Mexican Americans, respectively). In women with BMI >30 kg/m², there was no significant increase in prevalence of dysglycemia by race/ethnicity category.

CONCLUSIONS

Our findings show that dysglycemia affects a significant portion of U.S. women of childbearing age and that disparities by race/ethnicity are most prominent in the nonoverweight/nonobese.While national trends show that diabetes prevalence among all U.S. adults (men and women) has risen in recent years, seemingly concomitantly with rates of overweight and obesity, non-Hispanic blacks and Mexican Americans continue to be disproportionately affected, with rates almost twice those of non-Hispanic whites (1,2). This has also been the trend for impaired fasting glucose (IFG), a marker of future diabetes risk (1,2). Previous research on racial disparities of diabetes prevalence has focused on disparities for common risk factors for the disease: obesity and poverty, among others (3,4). However, findings from these studies show that there appears to be a residual effect of race/ethnicity (3,4), while controlling for the effect of BMI and social factors, with no concrete explanation as to why this might be so.Little attention has been paid specifically to investigating factors associated with disparity in glucose levels among women in their reproductive years. However, this proves an important population to target, not only because of the woman’s health needs and subsequent risk for type 2 diabetes (5), but also because of her role as a caregiver and the potential adverse consequences for her offspring if exposed to gestational hyperglycemia (6–8). We therefore conducted an analysis using U.S. national data to describe the burden of dysglycemia—diabetes, IFG, or high risk for diabetes by A1C criteria—among women of childbearing age, focusing specifically on differences by race/ethnicity. We also explored the extent to which measurements of obesity—measured by BMI and waist circumference—might modify these associations.     

A longitudinal study of depression from 1 to 5 years after spinal cord injury

Hoffman JM, Bombardier CH, Graves DE, Kalpakjian CZ, Krause JS. A longitudinal study of depression from 1 to 5 years after spinal cord injury.

Objective

To describe rates of probable major depression and the development and improvement of depression and to test predictors of depression in a cohort of participants with spinal cord injury (SCI) assessed at 1 and 5 years after injury.

Design

Longitudinal cohort study.

Setting

SCI Model System.

Participants

Participants (N=1035) who completed 1- and 5-year postinjury follow-up interviews from 2000 to 2009.

Interventions

Not applicable.

Main Outcome Measure

Probable major depression, defined as Physician Health Questionnaire-9 score of 10 or higher.

Results

Probable major depression was found in 21% of participants at year 1 and 18% at year 5. Similar numbers of participants had improvement (25%) or worsening (20%) of symptoms over time, with 8.7% depressed at both 1 and 5 years. Increased pain (odds ratio [OR], 1.10), worsening health status (OR, 1.39), and decreasing unsafe use of alcohol (vs no unsafe use of alcohol; OR, 2.95) are risk factors for the development of depression at 5 years. No predictors of improvement in depression were found.

Conclusion

In this sample, probable major depression was found in 18% to 21% of participants 1 to 5 years after injury. To address this high prevalence, clinicians should use these risk factors and ongoing systematic screening to identify those at risk for depression. Worsening health problems and lack of effective depression treatment in participants with SCI may contribute to high rates of chronic or recurrent depression in this population.     

Determinants of Racial/Ethnic Disparities in Incidence of Diabetes in Postmenopausal Women in the U.S.: The Women’s Health Initiative 1993–2009

OBJECTIVE

To examine determinants of racial/ethnic differences in diabetes incidence among postmenopausal women participating in the Women’s Health Initiative.

RESEARCH DESIGN AND METHODS

Data on race/ethnicity, baseline diabetes prevalence, and incident diabetes were obtained from 158,833 women recruited from 1993–1998 and followed through August 2009. The relationship between race/ethnicity, other potential risk factors, and the risk of incident diabetes was estimated using Cox proportional hazards models from which hazard ratios (HRs) and 95% CIs were computed.

RESULTS

Participants were aged 63 years on average at baseline. The racial/ethnic distribution was 84.1% non-Hispanic white, 9.2% non-Hispanic black, 4.1% Hispanic, and 2.6% Asian. After an average of 10.4 years of follow-up, compared with whites and adjusting for potential confounders, the HRs for incident diabetes were 1.55 for blacks (95% CI 1.47–1.63), 1.67 for Hispanics (1.54–1.81), and 1.86 for Asians (1.68–2.06). Whites, blacks, and Hispanics with all factors (i.e., weight, physical activity, dietary quality, and smoking) in the low-risk category had 60, 69, and 63% lower risk for incident diabetes. Although contributions of different risk factors varied slightly by race/ethnicity, most findings were similar across groups, and women who had both a healthy weight and were in the highest tertile of physical activity had less than one-third the risk of diabetes compared with obese and inactive women.

CONCLUSIONS

Despite large racial/ethnic differences in diabetes incidence, most variability could be attributed to lifestyle factors. Our findings show that the majority of diabetes cases are preventable, and risk reduction strategies can be effectively applied to all racial/ethnic groups.More than 25 million Americans have diabetes, and an estimated 300 million worldwide will be diagnosed with diabetes by the year 2025 (1,2). Diabetes is the seventh leading cause of death in the U.S. and is an underlying factor in cardiovascular and cancer mortality (1,3). Non-Hispanic blacks have been reported to be 1.4–2.2 times more likely to receive a diagnosis of diabetes than non-Hispanic whites in the U.S. population (4). U.S. women of Hispanic and Asian ancestry also have a higher prevalence of diabetes than non-Hispanic whites (5). Although racial/ethnic disparities in diabetes risk have been identified, determinants of these differences have not been well studied. Previous studies have considered dietary and lifestyle factors individually, but few studies have considered these factors in aggregate in order to estimate the proportion of diabetes that might be avoided by adopting a pattern of low-risk behaviors (6,7). Moreover, few studies have been large or diverse enough to allow for the assessment of these relationships in individual racial/ethnic groups, particularly among women.The Women''s Health Initiative (WHI) provides a unique opportunity to assess racial/ethnic disparities in both diabetes prevalence and incidence and factors contributing to disparities in diabetes incidence within a large and well-characterized group of postmenopausal women.     

An empirical study of race times in recreational endurance runners

Background

Studies of endurance running have typically involved elite athletes, small sample sizes and measures that require special expertise or equipment.

Methods

We examined factors associated with race performance and explored methods for race time prediction using information routinely available to a recreational runner. An Internet survey was used to collect data from recreational endurance runners (N?=?2303). The cohort was split 2:1 into a training set and validation set to create models to predict race time.

Results

Sex, age, BMI and race training were associated with mean race velocity for all race distances. The difference in velocity between males and females decreased with increasing distance. Tempo runs were more strongly associated with velocity for shorter distances, while typical weekly training mileage and interval training had similar associations with velocity for all race distances. The commonly used Riegel formula for race time prediction was well-calibrated for races up to a half-marathon, but dramatically underestimated marathon time, giving times at least 10 min too fast for half of runners. We built two models to predict marathon time. The mean squared error for Riegel was 381 compared to 228 (model based on one prior race) and 208 (model based on two prior races).

Conclusions

Our findings can be used to inform race training and to provide more accurate race time predictions for better pacing.

     

Prevalence of diabetes in New York City, 2002-2008: comparing foreign-born South Asians and other Asians with U.S.-born whites, blacks, and Hispanics

OBJECTIVE

To describe diabetes prevalence in New York City by race/ethnicity and nativity.

RESEARCH DESIGN AND METHODS

Data were from the New York City 2002–2008 Community Health Surveys. Respondents were categorized on the basis of self-reported race/ethnicity and birth country: foreign-born South Asian (Indian subcontinent), foreign-born other Asian, U.S.-born non-Hispanic black, U.S.-born non-Hispanic white, and U.S.-born Hispanic. Diabetes status was defined by self-reported provider diagnosis. Multivariable models examined diabetes prevalence by race/ethnicity and birth country.

RESULTS

Prevalence among foreign-born South Asians was nearly twice that of foreign-born other Asians (13.6 vs. 7.4%, P = 0.001). In multivariable analyses, normal-BMI foreign-born South Asians had nearly five times the diabetes prevalence of comparable U.S.-born non-Hispanic whites (14.1 vs. 2.9%, P < 0.001) and 2.5 times higher prevalence than foreign-born other Asians (P < 0.001).

CONCLUSIONS

Evaluating Asians as one group masks the higher diabetes burden among South Asians. Researchers and clinicians should be aware of differences in this population.More than 220 million people worldwide have diabetes, and an estimated 6 million are diagnosed annually (1,2). International studies have shown that South Asians (Indian subcontinent) appear to be at greater risk for diabetes than other ethnic groups (3). The few U.S. studies conducted report similar findings, but most were either not population-based, not current, or limited by a small sample size (4–6). Our study uniquely uses a recent population-based sample large enough to allow for subgroup prevalence estimation. Community studies, especially those in urban areas with large immigrant populations such as New York City, can provide insight into racial and ethnic disease patterns.     

Adherence With Multiple National Healthy Lifestyle Recommendations in a Large Pediatric Center Electronic Health Record and Reduced Risk of Obesity

Objective

To evaluate the utility of a routine assessment of lifestyle behaviors incorporated into the electronic health record (EHR) to quantify lifestyle practices and obesity risk at a pediatric primary care center.

Trends in new injuries, prevalent cases, and aging with spinal cord injury

DeVivo MJ, Chen Y. Trends in new injuries, prevalent cases, and aging with spinal cord injury.

Objective

To determine the characteristics of the newly injured and prevalent population with spinal cord injury (SCI) and assess trends over time.

Design

Prospective cohort study.

Setting

SCI Model Systems and Shriners Hospital SCI units.

Participants

The study population included people whose injuries occurred from 1935 to 2008 (N=45,442). The prevalent population was estimated based on those who were still alive in 2008. Losses to follow-up (approximately 10%) were excluded from the prevalent population.

Interventions

Not applicable.

Main Outcome Measures

Demographic and injury characteristics, mortality, self-reported health, rehospitalization, FIM, Craig Handicap Assessment and Reporting Technique, and the Diener Satisfaction with Life Scale.

Results

Mean age at injury increased 9 years since the 1970s. Injuries caused by falls and injuries resulting in high-level tetraplegia and ventilator dependency are increasing, while neurologically complete injuries are decreasing. Discharge to a nursing home is increasing. The mean age of the prevalent population is slightly higher than that of newly injured individuals, and the percentage of incident and prevalent cases older than 60 years is the same (13%). Prevalent cases tend to be less severely injured than incident cases, and less than 5% of prevalent cases reside in nursing homes. Within the prevalent population, life satisfaction and community participation are greater among persons who are at least 30 years postinjury. These findings are a result of very high mortality rates observed after 60 years of age.

Conclusions

Within the prevalent population, the percentage of elderly persons will not increase meaningfully. Those who reach older ages will typically have incomplete and/or lower-level injuries and will have relatively high degrees of independence and overall good health.     

Persistent increase of prevalence of metabolic syndrome among U.S. adults: NHANES III to NHANES 1999-2006

OBJECTIVE

To compare the prevalence in metabolic syndrome (MetSyn) between 1988–1994 and 1999–2006 among U.S. adults of different races or ethnicities.

RESEARCH DESIGN AND METHODS

Analysis of data on 6,423 adult men and nonpregnant women aged ≥20 years from Third National Health and Nutrition Examination Survey (NHANES III) and 6,962 participants from the combined NHANES 1999–2006 were done. The revised National Cholesterol Education Program Adult Treatment Panel III definition was used to calculate MetSyn.

RESULTS

Both the unadjusted prevalence (27.9 ± 1.1% to 34.1 ± 0.8%, P < 0.001) and age-adjusted prevalence (29.2 ± 1.0% to 34.2 ± 0.7%, P < 0.001) increased from NHANES III to NHANES 1999–2006, respectively. Although MetSyn prevalence was highest in Mexican Americans, significant increases in prevalence occurred among non-Hispanic whites and non-Hispanic blacks, especially among younger women.

CONCLUSIONS

The persistent increase of MetSyn among U.S. adults is a serious public health concern because it raises the likelihood of increased prevalence of type 2 diabetes.The metabolic syndrome (MetSyn) is a constellation of metabolic abnormalities and is associated with increased risk of developing diabetes (1), cardiovascular disease (2), and higher mortality from all causes (3). Among the few studies using nationally representative samples on MetSyn (4–9), Ford et al. (9) estimated an increasing trend of MetSyn prevalence by comparing the Third National Health and Nutrition Examination Survey (NHANES III) and NHANES 1999–2000 data. However, because of the smaller sample size of NHANES 1999–2000, the change in MetSyn prevalence for various subpopulations, which is necessary to track age and ethnicity specific trends, was not estimated. Therefore, the objective of this study is to compare the prevalence of MetSyn between NHANES III and NHANES 1999–2006 among U.S. adults of different races or ethnicities.