Mild renal insufficiency and risk of congestive heart failure in men and women > or =70 years of age

Mild renal insufficiency is increasingly recognized as an independent risk factor for cardiovascular disease. However, few data exist regarding its relation to risk of congestive heart failure (CHF), a major public health problem in the elderly. To determine if mild renal insufficiency is associated with risk of incident CHF in the elderly, we analyzed data from 3,618 participants in the prospective, community-based Established Populations for Epidemiologic Studies of the Elderly (EPESE), who had no known CHF and had serum creatinine levels measured from 1987 to 1989. Mean age of the study population was 78.3 +/- 5.4 years; 84% had creatinine values <1.5 mg/dl and 98% had creatinine values < or =2.0 mg/dl. Creatinine clearance (CrCl) was calculated using the Cockcroft-Gault equation. During 3.9 years of follow-up, 488 subjects developed incident CHF as defined by hospital discharge and death certificate data. In a multivariate proportional hazards model, CrCl was inversely associated with CHF risk (p value for trend <0.001). Those in the lowest quartile of CrCl (< or =36.9 ml/min) had a nearly twofold (hazards ratio [HR] 1.99, 95% confidence intervals [CI] 1.43 to 2.79) greater risk of incident CHF compared with those in the highest quartile (>57.4 ml/min). Renal insufficiency, defined as creatinine > or =1.5 mg/dl in men and > or =1.3 mg/dl in women, was also associated with increased CHF risk (multivariate HR 1.43, 95% CI 1.17 to 1.74). Thus, mild renal insufficiency was a strong independent predictor of CHF in this cohort, suggesting that serum creatinine may offer a readily accessible tool to identify elderly patients at risk for CHF.     

Ectopic spleen mimicking an intrinsic fundal lesion of the stomach

Summary This report describes the case of an elderly man with severe pulmonary disease, who had radiographic evidence of a mass involving the fundus of the stomach, which was thought to be a neoplasm that was growing slowly. Abdominal exploratory operation was obviated when a combination of newer technics for study of the upper gastrointestinal tract revealed that the defect was was produced by the impingement of the patient's spleen, which was normal except for its ectopic position. Selective abdominal angiography revealed that the blood supply to the mass was provided by the splenic artery and vein. Scintillation scanning demonstrated that injured red blood cells were sequestered in the mass, a normal function of the spleen. A flexible fiberoptic gastroscope permitted visualization of the mucosa in the fundic and cardioesophageal regions of the stomach and demonstrated that there was no neoplasm of the gastric mucosa in the region of the defect demonstrated in the fundus of the stomach.     

Individual, household and community factors associated with HIV test refusal in rural Malawi

Objective To investigate individual, household and community factors associated with HIV test refusal in a counselling and testing programme offered at population level in rural Malawi. Methods HIV counselling and testing was offered to individuals aged 18–59 at their homes. Individual variables were collected by interviews and physical examinations. Household variables were determined as part of a previous census. Multivariate models allowing for household and community clustering were used to assess associations between HIV test refusal and explanatory variables. Results Of 2303 eligible adults, 2129 were found and 1443 agreed to HIV testing. Test refusal was less likely by those who were never married [adjusted odds ratio (aOR) 0.50 for men (95% CI 0.32; 0.80) and 0.44 (0.21; 0.91) for women] and by farmers [aOR 0.70 (0.52; 0.96) for men and 0.59 (0.40; 0.87) for women]. A 10% increase in cluster refusal rates increased the odds of refusal by 1.48 (1.32; 1.66) in men and 1.68 (1.32; 2.12) in women. Women counsellors increased the odds of refusal by 1.39 (1.00; 1.92) in men. Predictors of HIV test refusal in women were refusal of the husband as head of household [aOR 15.08 (9.39; 24.21)] and living close to the main road [aOR 6.07 (1.76; 20.98)]. Common reasons for refusal were fear of testing positive, previous HIV test, knowledge of HIV serostatus and the need for more time to think. Conclusion Successful VCT strategies need to encourage couples counselling and should involve participation of men and communities.     

Does breastfeeding offer protection against maternal depressive symptomatology?

Mothers who breastfeed typically exhibit lower levels of depressive symptomatology than mothers who do not. However, very few studies have investigated the directionality of this relationship. Of the prospective studies published, all but one focus exclusively on whether maternal depression reduces rates of subsequent breastfeeding. This study again examines this relationship, but also the reverse—that breastfeeding might predict lower levels of later depression. Using multilevel modeling, we investigated the relationship between breastfeeding and self-reported depressive symptomatology in 205 women followed prenatally and at 3, 6, 12, and 24 months after birth. Consistent with previous research, women with prenatal depressive symptomatology weaned their infants 2.3 months earlier, on average, than women without such symptomatology. We also found, however, that women who breastfed more frequently at 3 months postpartum showed greater subsequent declines in depressive symptomatology over time compared to women who breastfed less frequently, resulting in lower absolute levels of depressive symptoms by 24 months postpartum, controlling for important confounds. In sum, these findings are consistent with a bidirectional association between breastfeeding and depression, with prenatal depression predicting less breastfeeding soon after birth and breastfeeding predicting declines in maternal depression up to 2 years after birth. We discuss mechanisms that could potentially explain these associations and avenues for future research.     

Genetics of resistance to infection with Salmonella typhimurium in mice.

Eight strains of inbred mice fell into two sharply defined groups. Four strains (CBA, A/JAX, C3H/He, and DBA/2) were resistant (LD50, greater than 10(5)) to Salmonella typhimurium C5 given subcutaneously. The other four strains (Balb/c, C57BL, B10.D2 [new line], and DBA/1) were susceptible (LD50, less than 10). No intermediate resistance was seen. Examination of the F1, F2, and parental backcross generations bred from matings of CBA and Balb/c mice showed that resistance behaved as a simple Mendelian dominant. Resistance was not linked to H-2 genes, and no useful marker has yet been found. However, as previously demonstrated in the parent strains, resistance in the hybrids was related to the ability to produce a good delayed-type hypersensitivity reaction to an extract of S. typhimurium.     

Anti-Inflammatory Therapy With Canakinumab for the Prevention and Management of Diabetes

Background

Subclinical inflammation mediated in part by interleukin (IL)-1β participates in peripheral insulin resistance and impaired pancreatic insulin secretion.

Accuracy of Medicare claims-based diagnosis of acute myocardial infarction: estimating positive predictive value on the basis of review of hospital records

Background

Many cardiovascular epidemiologic studies rely on diagnosis codes in health care claims databases. Despite important changes in the care and diagnosis of acute myocardial infarction (AMI), the validity of hospital discharge diagnosis codes for AMI in the US Medicare system has not been recently examined. Our objective was to examine the accuracy of International Classification of Diseases—ninth revision—Clinical Modifications (ICD-9-CM) discharge diagnosis codes and diagnosis-related groups (DRG) codes for AMI in a Medicare claims database.

Methods

We sampled hospitalization episodes from Medicare beneficiaries in Pennsylvania during 1999, 2000, or both. We used Medicare data to identify patients with hospitalizations containing indicators of AMI (ICD-9-CM diagnosis codes 410.X0 and 410.X1 or DRG codes 121, 122, and 123). Hospital records for these episodes were reviewed by trained abstractors using World Health Organization criteria for diagnosing AMI. We then calculated the positive predictive value of Medicare claims-based definitions of AMI.

Results

Of 2200 hospitalization episodes with Medicare diagnosis codes suggestive of AMI, 2022 hospital records (91.9%) were obtained. The positive predictive value for a primary Medicare claims-based definition was 94.1% (95% CI, 93.0%-95.2%). Positive predictive values for alternative claims-based definitions ranged slightly, with the definition including DRG codes and length-of-stay restrictions yielding the highest positive predictive value, 95.4% (95% CI, 94.3%-96.4%). Subjects with a history of myocardial infarction had a significantly lower positive predictive value than subjects without a history of myocardial infarction (88.1% vs 94.6%, P <.001).

Conclusions

In this study, we observed high positive predictive values for a Medicare claims-based diagnosis of AMI and a diagnosis based on structured hospital record review.