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The prevalence of chronic obstructive pulmonary disease (COPD) is high in American Indian (AI) populations, as are diabetes and obesity, which are common COPD comorbidities. However, COPD research among AI populations is limited.We conducted a retrospective study to investigate potential health disparities and risk factors among AI and non-Hispanic White (NHW) patients with COPD exacerbations hospitalized at the University of Oklahoma Medical Center between July 2001 and June 2020. Demographics, clinical variables, and outcomes were collected.A total of 76 AI patients and 304 NHW patients were included. AI patients had more comorbidities than did NHW patients (4.3 versus.3.1,AI patients were more likely than NHW patients to need ICU care and ventilator support, have longer ICU stays, and more days on mechanical ventilator support. More studies are needed to identify reasons for these disparities and effective interventions to reduce them.

Huimin Wu,1 Dorothy A Rhoades,2 Sixia Chen,3 Brent Brown1 1Pulmonary, Critical Care and Sleep Medicine, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA; 2General Internal Medicine, College of Medicine, and Stephenson Cancer Center, University of Oklahoma Health Sciences Center, OK, Oklahoma, USA; 3Biostatistics and Epidemiology, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USACorrespondence: Huimin WuPulmonary, Critical Care and Sleep Medicine, College of Medicine, University of Oklahoma Health Sciences Center, 800 Stanton L Young Blvd, Suite 8400, Oklahoma City, OK, 73104, USATel +1 405-271-6173Fax +1 405-271-5892Email huimin-wu@ouhsc.eduPurpose: The prevalence of chronic obstructive pulmonary disease (COPD) and comorbidities (eg diabetes and obesity) among Native American (NA) population are higher than among the general US population. However, studies of COPD in NAs are scarce. Oklahoma has the largest NA population affiliated with federally recognized tribes in the country and is an ideal location for such research. A pilot study was designed to investigate the characteristics of NA patients with COPD exacerbations in a tertiary academic medical center.Patients and Methods: We conducted a retrospective exploratory study of NA adults with COPD exacerbation hospitalizations and/or emergency department visits at the University of Oklahoma Medical Center between July 2001 and June 2020. Medical records were reviewed to confirm COPD exacerbation and outcomes, including death, mechanical ventilation, intensive care unit (ICU) stay, home oxygen, and 30-day readmission. Additional collected data included socio-demographics, body mass index, diabetes, other COPD comorbidities and clinical variables.Results: Of 630 encounters reviewed, 159 met the inclusion criteria, representing 91 patients. Most patients were female (64%), obese or overweight (68%), and had diabetes (42%) or hypertension (71%). Mean age was 60 years old, but women were 5 years younger than men. Among the 76 patients with COPD hospitalizations, 31 patients (41%) had an intensive care unit (ICU) stay and 19 (25%) were intubated in their last hospitalization. Among 9 patients (10%) with 30-day readmissions, 8 were female. Medicare, Indian Health Service, Tribal health service, or Medicaid were the most frequently used payment sources. Sex, diabetes, and obesity were not associated with hospital length of stay, 30-day readmission or supplemental O2 use.Conclusion: Hospitalized NA COPD patients at this tertiary care center had multiple comorbidities. Many required ICU care and intubation. Larger studies of the risk and mitigating factors for COPD health outcomes in NA patients are needed.Keywords: COPD, Native American, comorbidities, hospitalization

Purpose: Lung cancer screening (LCS) with low dose CT scanning reduces mortality but uptake of LCS is poor. Lung cancer mortality in Oklahoma’s Native American population is 45% higher than for the non-Hispanic White population. The Tribally Engaged Approaches to Lung Screening (TEALS) study is a collaboration between the University of Oklahoma Health Sciences Center and the Choctaw Nation of Oklahoma Health Services Authority (CNHSA). The goals of TEALS are to implement a systematic LCS program within Choctaw Nation and to understand LCS decision-making processes, barriers and facilitators. Procedures: Using purposive sampling from 2 of 8 CNHSA clinics in Oklahoma in 2021, we conducted a pilot study using phone interviews with patients who had completed LCS and those who had not. Using a semi-structured interview guide, we asked patients about their experience with the LCS program, factors that influenced their decision, and suggestions for improving the program. Conventional inductive content analysis was used to identify major themes. Multiple coders and peer debriefing enhanced scientific rigor. Results: Completers (4 men and 5 women) and non-completers (3 men and 3 women) were included. Major themes included: (1) Contextual factors influencing the decision-making process; (2) Individual characteristics influencing the decision-making process; and (3) Barriers to screening. Contextual factors included the provider raising the discussion of LCS, which was most frequently cited by completers but not the non-completers. Other contextual factors included the use of handouts and pamphlets during clinic visits. Patient suggestions included brochures/posters in waiting rooms and creating an information video to run on TVs in waiting areas. Individual characteristics included motivation to ‘be there’ for family/children, previous cancer in family/friends, and ease of arranging appointments. Non-completers preferred not to know or were scared to know the results of screening. Barriers included long distance travel to LCS sites, missing work, access to transportation or assistance, confusion about the appointment leading to missed appointments. Interviews highlighted the need to clarify eligibility criteria. Notably, some patients who were classified as ‘non-completers’ had already had a diagnostic CT for respiratory symptoms or as follow-up for prior cancer, indicating a gap in correctly identifying LCS eligibility. Conclusions: Findings from this pilot have guided implementation of the TEALS clinical trial. Large banners are now available in participating clinics. Academic detailing ensures the decision aid pamphlet is available and used in waiting rooms. Providers are reminded of the critical role they play in informing patients about LCS. Appointment reminders and assistance with transportation (e.g., tribal transportation) are in place. Eligibility criteria for the clinical trial have been clarified. Gathering this information from pilot study participants has enabled the team to refine the LCS intervention as it expands to other sites. Citation Format: Kathleen Dwyer, Dorothy A. Rhoades, Mark Doescher, Brook McCann, Michele Gibson, Zsolt Nagykaldi. Exploring facilitators and barriers to low-dose CT screening for lung cancer among Native American patients: The TEALS study [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr A101.

Objectives: American Indian/Alaska Native (AI/AN) adults use smokeless tobacco products (eg, chewing and dip tobacco) more often than other racial/ethnic groups do. Although US adults increasingly use potentially reduced exposure tobacco products (PREPs), such as electronic cigarettes and snus, no studies have examined the use of PREPs among AI/AN smokeless tobacco users. We examined associations between current PREPs use and smokeless tobacco–related measures, including cessation attempts and cotinine levels, in a sample of American Indian adults who currently use smokeless tobacco. Methods: We collected survey and tobacco biomarker data from 299 adult American Indian smokeless tobacco users at Cherokee Nation health care facilities and events in 2016 and 2017. We used multivariable analyses to determine associations between current PREPs use and smokeless tobacco–related characteristics. Results: Current PREPs users were younger, less likely to be married or living with a partner, less likely to report a chronic medical condition, and more likely to report other tobacco use than PREPs nonusers. Among participants with annual household incomes ≤$30 000, current PREPs users were less likely than PREPs nonusers to report a definite desire to quit smokeless tobacco ( P = .02). PREPs use was not associated with planning to quit smokeless tobacco, past 12-month smokeless tobacco quit attempts, amount of smokeless tobacco used per week, cotinine levels, or scores on the Fagerström Test for Nicotine Dependence–Smokeless Tobacco. Conclusions: Our study suggests that American Indian smokeless tobacco users may not be using PREPs as a smokeless tobacco cessation aid. Future studies should take this finding into consideration when evaluating the role of PREPs use in smokeless tobacco cessation and in total tobacco cessation in this population.

The objective of this study was to investigate whether leukocyte telomere length (LTL) predicts the risk for cancer mortality among American Indians participating in the Strong Heart Study (1989–1991). Participants (aged 45–74 years) were followed annually until December 2015 to collect information on morbidity/mortality. LTL was measured by qPCR using genomic DNA isolated from peripheral blood. The association between LTL and risk for cancer mortality was examined using a multivariable Cox proportional hazard model, adjusting for age, gender, education, study site, smoking, alcohol use, physical activity, systolic blood pressure, fasting blood glucose, obesity, and low- and high-density lipoprotein. Of 1945 participants (mean age 56.10 ± 8.17 at baseline, 57% women) followed for an average 20.5 years, 220 died of cancer. Results showed that longer LTL at baseline significantly predicts an increased risk of cancer death among females (HR 1.57, 95% CI 1.08–2.30), but not males (HR 0.74, 95% CI 0.49–1.12) (p for interaction 0.009). Specifically, compared with the women with the longest LTL (fourth quartile), those in the third, second, and first quartiles showed 53%, 41%, and 44% reduced risk for cancer death, respectively. The findings highlight the importance of sex-specific analysis in future telomere research.

American Indians and Alaska Natives (AI/AN) are underserved populations who suffer from several health disparities, 1 of which is cancer. Malignancies, especially cancers of the breast, liver, and lung, are common causes of death in this population. Health care disparities in this population include more limited access to diagnostic radiology because of geographic and/or health system limitations. Early detection of these cancers may be enabled by improving patient and physician access to medical imaging. Awareness by the radiology community of the cancer disparities among this population is needed to support research targeted to this specific ethnic group and to support outreach efforts to provide more imaging opportunities. Providing greater access to imaging facilities will also improve patient compliance with screening recommendations, ultimately improving mortality in these populations.

Background: Epigenetic alterations may contribute to early detection of cancer. We evaluated the association of blood DNA methylation with lymphatic–hematopoietic cancers and, for comparison, with solid cancers. We also evaluated the predictive ability of DNA methylation for lymphatic–hematopoietic cancers. Methods: Blood DNA methylation was measured using the Illumina Infinium methylationEPIC array in 2324 Strong Heart Study participants (41.4% men, mean age 56 years). 788,368 CpG sites were available for differential DNA methylation analysis for lymphatic–hematopoietic, solid and overall cancers using elastic-net and Cox regression models. We conducted replication in an independent population: the Framingham Heart Study. We also analyzed differential variability and conducted bioinformatic analyses to assess for potential biological mechanisms. Results: Over a follow-up of up to 28 years (mean 15), we identified 41 lymphatic–hematopoietic and 394 solid cancer cases. A total of 126 CpGs for lymphatic–hematopoietic cancers, 396 for solid cancers, and 414 for overall cancers were selected as predictors by the elastic-net model. For lymphatic–hematopoietic cancers, the predictive ability (C index) increased from 0.58 to 0.87 when adding these 126 CpGs to the risk factor model in the discovery set. The association was replicated with hazard ratios in the same direction in 28 CpGs in the Framingham Heart Study. When considering the association of variability, rather than mean differences, we found 432 differentially variable regions for lymphatic–hematopoietic cancers. Conclusions: This study suggests that differential methylation and differential variability in blood DNA methylation are associated with lymphatic–hematopoietic cancer risk. DNA methylation data may contribute to early detection of lymphatic–hematopoietic cancers., This work was supported by grants from the National Heart, Lung, and Blood Institute (NHLBI) (Contract Numbers 75N92019D00027, 75N92019D00028, 75N92019D00029 and 75N92019D00030) and previous Grants (R01HL090863, R01HL109315, R01HL109301, R01HL109284, R01HL109282, and R01HL109319 and Cooperative Agreements: U01HL41642, U01HL41652, U01HL41654, U01HL65520 and U01HL65521); by the National Institute of Environmental Health Sciences (Grant Numbers R01ES021367, R01ES025216, P42ES010349, P30ES009089); by the Chilean CONICYT/FONDECYT-POSTDOCTORADO Nº3180486 and by a fellowship from “la Caixa” Foundation (ID 100010434) (fellowship code “LCF/BQ/DR19/11740016”).

Lung cancer and colorectal cancer (CRC) are leading causes of cancer morbidity and mortality among US American Indian and Alaska Native (AI/AN) men and women. For most AI/AN communities, disparities in these cancers occur compared to their non-Hispanic White (NHW) counterparts. This presentation provides a brief overview of the epidemiology of lung and colorectal cancers among AI/AN, and serves as background for talks regarding the impact of revised eligibility criteria for implementing screening programs among AI/AN. In recent years, lung cancer incidence rates among AI/AN persons were 12% higher than rates among NHW in counties with relatively high proportions of AI/AN residents. By region, rates were 17% to 3 times higher in AI/AN than NHW in Pacific Coast, Alaska, and Northern and Southern Plains, in contrast to the Southwest and Eastern US where AI/AN rates were 35% lower. While lung cancer incidence is decreasing overall in both populations, the rate of decrease is slower for AI/AN. Generally, lung cancer occurs at younger ages and at more advanced stages for AI/AN compared with NHW, and AI/AN persons with lung cancer have worse survival. Little is known about the experience of lung cancer screening (LCS) in health care systems that serve AI/AN communities. LCS has not been a mandatory reporting measure for the Indian Health Service. Models of expanded eligibility for LCS suggest that AI/AN will have a higher relative increase in eligible persons compared with NHW, but information on implementation is scarce. Disparities in CRC are also notable among AI/AN. In recent years, incidence rates among AI/AN were 41% higher than among NHW in counties with relatively high proportions of AI/AN residents. CRC incidence rates also vary regionally, but AI/AN in general had higher CRC incidence rates than did NHW. CRC incidence rates have been decreasing overall among both AI/AN and NHW populations, but at a slower pace for AI/AN. Notably, CRC incidence increased among AI/AN in the Southwest. CRC incidence rates have also increased among persons younger than 50 years for both AI/AN and NHW, but more than 1 in 7 CRC cases among AI/AN were diagnosed at ages younger than 50 years, compared with less than 1 in 10 among NHW. AI/AN were more likely to have late-stage diagnoses than were NHW, and AI/AN men had the worst survival than men in other racial groups. Factors encountered in implementing programs to improve lung and CRC screening among AI/AN health care systems will be discussed follow this presentation. Citation Format: Dorothy A. Rhoades. A brief overview of lung and colorectal cancer disparities in American Indian and Alaska Native populations [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr IA-48.

Background Cancer mortality among American Indian (AI) people varies widely, but factors associated with cancer mortality are infrequently assessed. Methods Cancer deaths were identified from death certificate data for 3516 participants of the Strong Heart Study, a population-based cohort study of AI adults ages 45–74 years in Arizona, Oklahoma, and North and South Dakota. Cancer mortality was calculated by age, sex and region. Cox proportional hazards model was used to assess independent associations between baseline factors in 1989 and cancer death by 2010. Results After a median follow-up of 15.3 years, the cancer death rate per 1000 person-years was 6.33 (95 % CI 5.67–7.04). Cancer mortality was highest among men in North/South Dakota (8.18; 95 % CI 6.46–10.23) and lowest among women in Arizona (4.57; 95 % CI 2.87–6.92). Factors independently associated with increased cancer mortality included age, current or former smoking, waist circumference, albuminuria, urinary cadmium, and prior cancer history. Factors associated with decreased cancer mortality included Oklahoma compared to Dakota residence, higher body mass index and total cholesterol. Sex was not associated with cancer mortality. Lung cancer was the leading cause of cancer mortality overall (1.56/1000 person-years), but no lung cancer deaths occurred among Arizona participants. Mortality from unspecified cancer was relatively high (0.48/100 person-years; 95 % CI 0.32−0.71). Conclusions Regional variation in AI cancer mortality persisted despite adjustment for individual risk factors. Mortality from unspecified cancer was high. Better understanding of regional differences in cancer mortality, and better classification of cancer deaths, will help healthcare programs address cancer in AI communities.

Electrocardiographic QRS duration at rest is associated with sudden cardiac death and death from coronary heart disease in the general population. However, its relation to cardiovascular events in American Indians, a population with persistently high cardiovascular disease mortality, is unknown. The relation of QRS duration to incident cardiovascular disease during 17.2 years of follow-up was assessed in 1,851 male and female Strong Heart Study participants aged 45 to 74 years without known cardiovascular disease at baseline. Cox regression with robust standard error estimates was used to determine the association between quintiles of QRS duration and incident cardiovascular disease in gender-stratified analyses, adjusted for age, systolic blood pressure, hypertension, antihypertensive medication use, body mass index, current smoking, diabetes, total cholesterol, high-density lipoprotein cholesterol, and albuminuria. In women only, QRS duration in the highest quintile (≥105 ms) conferred significantly higher risk of cardiovascular disease than QRS duration in the lowest quintile (64 to 84 ms) (hazard ratio 1.6, 95% CI 1.1 to 2.4) likely because of higher risks of coronary heart disease (hazard ratio 1.8, 95% CI 1.1 to 3.1) and myocardial infarction (hazard ratio 2.1, 95% CI 1.0 to 4.7). Furthermore, when added to the Strong Heart Study Coronary Heart Disease Risk Calculator, QRS duration significantly improved prediction of future coronary heart disease events in women (Net Reclassification Index 0.17, 95% CI 0.06 to 0.47). In conclusion, QRS duration is an independent predictor of cardiovascular disease in women in the Strong Heart Study cohort and may have value in estimating risk in populations with similar risk profiles and a high lifetime incidence of cardiovascular disease.

IntroductionDespite American Indian/Alaska Native (AI/AN) people having the highest prevalence of cigarette smoking nationwide, few studies have evaluated e-cigarette use among AI/AN adults who smoke. The primary objective of this observational pilot cohort study was to determine if e-cigarette use is associated with cigarette smoking cessation or reduction among adult AI individuals who smoke.MethodsIn 2016, we collected baseline survey and biomarker data among AI adults who smoke. The survey included questions about cigarette consumption and use of e-cigarettes and biomarkers, such as salivary cotinine markers and exhaled carbon monoxide. After 18 months, we repeated data collection, and asked about changes in cigarette smoking status and cigarettes per day (CPD). Comparisons between groups were performed using the χ2 test, Fisher’s exact test or Wilcoxon rank-sum test.ResultsOf 375 baseline participants, 214 (57.07%) returned for follow-up and were included in analyses. Of these, 20 (9.3%) reported having stopped cigarette smoking and had biochemical verification of cigarette smoking abstinence. Among those who quit smoking, 15% were baseline e-cigarette users; while among those who continued to smoke at follow-up, about 11% were baseline e-cigarette users. This difference was not statistically significant (p=0.48). Among all those who continued to smoke at follow-up, there was no overall decrease in CPD, nor a significant difference in change in CPD between baseline e-cigarette users and non-users (p=0.98).ConclusionsE-cigarette use at baseline was not associated with smoking cessation or a change in CPD in this cohort of AI adults who smoke after an 18-month follow-up period.

Many American Indian communities have a high prevalence of smoking and e-cigarette use, but factors associated with their dual use are rarely studied.In 2016, a total of 375 American Indian adults who smoke completed paper surveys regarding cigarette and e-cigarette use and provided saliva for cotinine levels. In 2018, cross-sectional analyses were performed, comparing dual users (12%), defined as using e-cigarettes on some or every day for the past 30 days, with never users of e-cigarettes (37%).Compared with never users, dual users were younger, more often reported history of depression (56% and 29%, respectively; p0.01) and family history of smoking-related disease (77% and 59%, respectively; p0.05), had lower harm perceptions of e-cigarettes (27% and 47%, respectively; p0.01) or vapor (14% and 35%, respectively; p0.01), and more often perceived e-cigarettes as cessation aids (75% and 16%, respectively; p0.01) and as less harmful than cigarettes (70% and 17%, respectively; p0.01). Dual users were less often uncertain/unknowing about e-cigarette benefits or harms (p0.01) and more often reported likelihood to quit smoking (49% and 24%, respectively; p0.01) and prior attempt to quit smoking, ever (89% and 67%, respectively; p0.01) or in the past year (55% and 32%, respectively; p=0.01). Cigarette consumption and cotinine levels did not differ between groups. Dual users more often tried other nicotine products (p0.02) and more often lived with a vaping partner/spouse (45% and 6%, respectively; p0.01).Dual users perceived e-cigarettes as less harmful than cigarettes and more as cessation aids than cigarette-only users did, but cigarette consumption did not differ between groups. Whether e-cigarettes will reduce smoking-related disparities among American Indian people remains undetermined.

Interest in electronic cigarette (EC) use, or vaping, to help control weight is increasing. Many American Indian (AI) populations have a high prevalence of smoking, obesity, and EC use, but their perceptions of EC use for weight control are unknown. In Oklahoma in 2016, 375 AI adults who smoke completed a survey including perceptions about smoking and EC effects on weight control. Only 24% believed that smoking helps control weight, and 8% believed that vaping helps control weight. Perceptions differed by EC use, with ever users more often than never users perceiving that smoking (30% vs 12%, respectively; p

Significance: American Indians (AI) have a higher prevalence of smoking, higher prevalence of electronic cigarette (EC) use, and higher cancer mortality than most other racial groups, particularly in Oklahoma. However, AI are rarely included in studies of EC use among smokers. As many individuals who smoke also use ECs to reduce harms from cigarettes, understanding correlates of using both products by AI merits greater attention. Methods: In Oklahoma in 2016, 375 AI who smoke and were ages 18 years and older completed a survey collecting demographic information, personal and family history of cancer, perceptions of EC harm and benefits, measures of smoking and dependence, other tobacco use, and EC use by spouse or partner. We defined dual users as using EC within 30 days and every day or some days (n = 44; 12%) and compared dual users to EC never users (n = 137; 37%). Results: Dual users were younger than never users (median 36 vs. 46 years, respectively; p = .01) but did not differ significantly by sex, education, or income. Dual users did not differ significantly from never users in self-reported general health status, personal history of cancer, or other smoking-related medical conditions. Dual users more often reported history of depression (56% vs. 29%; p < .01) and a family history of cancer (lung, head, neck, other) marginally more often than did never users (58% vs. 41%, p = 0.05). While no significant differences were noted for perceived harms of smoking or secondhand smoke, low perceived harm of ECs was more frequent among dual users than never users (64% vs. 24%; p < .01) as well as secondhand vapor (77% vs. 29%; p < .01). Dual users agreed more often that ECs help to quit smoking (75% vs. 16%; p < .01) and are less harmful than smoking (70% vs. 17%; p < .01). Only 9% of dual users did not know or were uncertain about EC harms or benefits, compared to 29% of never users for harms (p < .01) and 38% for benefits (p < .01). Differences between groups were not significant for cigarette consumption, salivary cotinine levels, or smoking dependence scales, but dual users reported a likelihood to quit smoking more often than never users (86% vs. 65%; p = .01), and more often tried to quit in past 12 months (55% vs. 32%; p = .01). Dual users significantly (p ≤ .01) more often ever tried snus (36% vs. 10%), cigars (68% vs. 46%), cigarillos (82% vs. 56%), and hookah (50% vs. 14%) but no differences in ever use of other smokeless tobacco. Among those living with a spouse/partner, dual and never users did not differ in spouse/partner smoking, but dual users much more frequently lived with a spouse/partner who uses ECs (45% vs. 6%; p < .01). Conclusions: EC use is a potential, albeit unproven, harm reduction strategy for people who smoke. The American Cancer Society strongly discourages dual use of EC and cigarettes. This exploratory study of AI found several significant associations with dual EC and cigarette use, but cigarette consumption was similar between groups. It remains to be determined whether ECs will have a role in smoking cessation or reducing cancer health disparities among AI. This abstract is also being presented as Poster A004. Citation Format: Dorothy A. Rhoades, Ashley L. Comiford, Justin D. Dvorak, Kai Ding, Leslie Driskill, Michelle Hopkins, Theodore L. Wagener, Paul Spicer, Mark P. Doescher. Factors associated with dual use of electronic cigarettes among adult American Indians who smoke: A Cherokee Nation cohort study [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr PR01.

Despite the proven effectiveness of colorectal cancer (CRC) screening, American Indians (AIs) have some of the lowest CRC screening rates. Nearly two-thirds of US adults are current with US Preventive Services Task Force guidelines for CRC screening. In contrast, based on Indian Health Service (IHS) Government Performance and Results Act (GPRA) data, AI screening rates range from a low of 28% in the Phoenix Area, to 30% in the Albuquerque Area and a high of only 51% in the Oklahoma Area. The AI CRC Screening Consortium was formed by the National Cancer Institute-Designated Cancer Centers at the Universities of Arizona, New Mexico, and Oklahoma to address the major regional CRC screening disparities. The Consortium’s overall objective is to increase CRC screening delivery and uptake in AIs aged 50 to 75 years at average risk for CRC through the implementation of cost-effective multilevel, multicomponent evidence-based interventions (EBIs) across AI populations (on and off tribal lands) in the tri-state region. As part of the planning phase of the project (Year 1), we completed mixed-methods environmental scans (focus group and interviews, and readiness to change surveys) among tribal members and multisector healthcare providers practicing at Indian Health Service (IHS, I), Tribal (T), and Urban Indian (U) (I/T/U) healthcare facilities across the three states. In all, we conducted seven focus groups, 71 interviews, and three surveys at nine I/T/U healthcare facilities. We organized the focus group and interview data according to The Guide to Community Preventive Services (The Community Guide) recommendations for strategies to increase: community demand, community access, and provider delivery of CRC screening. We will provide quotes and summaries underscoring the EBIs and strategies recommended by the multisector healthcare action teams for implementation at their healthcare facilities. We will also describe the establishment of the Consortium and challenges experienced in conducting research with multiple tribal and federal entities and regulatory authorities. The use of community-academic participatory approaches has facilitated bidirectional and mutually beneficial knowledge integration, collaborative inter-dependent partnerships, equity in data ownership, and capacity enhancement. The scope of this project presents an opportunity to reduce CRC incidence and mortality affecting thousands of AIs. Our collaborative work will create opportunities for future research addressing the spectrum of CRC prevention, detection, and treatment in AI populations across the US. Citation Format: Shiraz I Mishra, Mark P Doescher, Jennifer Hatcher, Kevin English, Dorothy Rhoades, Peter Lance, Shane Pankratz, Jessica Blanchard, Nicholas Edwardson, Michelle Hopkins, Andrew Sussman, Zsolt Nagykaldi, Cheyenne Jim. Evidence-based strategies to enhance colorectal cancer screening in American Indian communities [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C120.

Objective We assessed associations between electronic cigarette (e-cigarette) use and smoking-related measures among American Indians (AIs) who smoke. MethodsWe collected baseline survey and smoking biomarker data in a cohort of 375 adult AI smokers at a Cherokee Nation healthcare facility in Oklahoma. We used multivariate logistic and linear regression analyses to determine associations between e-cigarette use and smoking-related characteristics, including biomarkers. ResultsCurrent e-cigarette users were more likely than never users to report a quit attempt in the past 12 months (current vs never adjusted odds ratio (AOR) = 2.24 [95% CI 1.20-4.16]). Current and past e-cigarette users were more likely than never users to report a likelihood to quit smoking (current vs never AOR = 2.97 [95% CI 1.34-6.56]; past vs never AOR = 1.77 [95% CI 1.08-2.91]). E-cigarette use was not significantly associated with confidence to quit smoking, cigarette packs smoked per day, or cotinine levels. ConclusionsE-cigarette use was associated with previous and future quit attempts, but not with reductions in cigarette smoking or confidence in quitting. This suggests that many dual users might benefit from the addition of evidence-based smoking cessation treatments.

Purpose Patient preferences regarding the role of the primary care provider (PCP) in discussing electronic cigarette (e-cigarette) use are unknown. Methods We administered a cross-sectional survey to 568 adult patients in a family medicine clinic to explore e-cigarette use, sources of information on e-cigarettes, perceived knowledge about e-cigarette health effects, views regarding PCP knowledge of e-cigarettes, interest in discussing e-cigarettes with PCPs and preferred format for e-cigarette information. We performed χ2 testing with a 2-tailed P Results The prevalence of e-cigarette use was 10% for recent (≤30 days) use and 29% for nonrecent (>30 days) use. Prevalence was significantly higher among those who were younger, less educated, or smoked cigarettes, but did not vary by sex or self-reported health status. Roughly one quarter of participants believed they were knowledgeable about the health effects of e-cigarettes, secondhand smoke, and quitting cigarettes. Sources of e-cigarette information included television advertisements (56.6%), friends and family (49.9%), or e-cigarette shops (25.5%), but included physician offices much less frequently (6.0%). Although 30.2% disagreed that their PCP knew a lot about e-cigarettes, 62.0% were comfortable discussing e-cigarettes with their PCP. However, only 25% of all patients wanted their PCP to discuss e-cigarettes with them, but 62.0% of recent e-cigarette users wanted such a discussion. Most preferred a brief discussion or handout to a lengthy discussion. Conclusion PCPs were infrequent sources of information for patients regarding e-cigarette use. PCPs need evidence-based strategies to help them address e-cigarettes in primary care.

The integration of public health practices with federal health care for American Indians and Alaska Natives (AI/ANs) largely derives from three major factors: the sovereign nature of AI/AN tribes, the sociocultural characteristics exhibited by the tribes, and that AI/ANs are distinct populations residing in defined geographic areas. The earliest services consisted of smallpox vaccination to a few AI/AN groups, a purely public health endeavor. Later, emphasis on public health was codified in the Snyder Act of 1921, which provided for, among other things, conservation of the health of AI/AN persons. Attention to the community was greatly expanded with the 1955 transfer of the Indian Health Service from the US Department of the Interior to the Public Health Service and has continued with the assumption of program operations by many tribes themselves. We trace developments in integration of community and public health practices in the provision of federal health care services for AI/AN persons and discuss recent trends.

OBJECTIVES: Describes prevalence of traumatic brain injury (TBI) and associated neuropsychiatric problems among two American Indian (AI) communities. DESIGN: Analysis of cross-sectional epidemiological data. SETTING: A Southwest (SW) and 2 Northern Plains (NP) AI reservations. PARTICIPANTS: AI tribal members (N = 2687; 394 with history of TBI and 2293 noninjured comparisons) aged 15 to 54. OUTCOME MEASURES: Mood or anxiety disorders present more than 1 year after injury. RESULTS: Prevalences were high (>20% in males; >10% in females) in these populations. Associations between TBI and disorders meeting Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition criteria were strong in the SW community (adjusted odds ratio [OR] = 2.4; 95% confidence interval [CI] = 1.5-3.8), less so in the NP community (adjusted OR = 1.4; 95% CI = 0.9-2.2). CONCLUSIONS: TBI is prevalent among AIs and is associated with increased OR of neuropsychiatric difficulties. This association may vary between tribes, though no interaction effect was found. AIs with TBI may require more thorough psychiatric screening to promote healthier outcomes. Language: en

OBJECTIVES: To describe longitudinal changes in the prevalence of major cardiovascular disease (CVD) risk factors in aging American Indians. DESIGN: Population-based ongoing epidemiological study. SETTING: The Strong Heart Study is a study of CVD and its risk factors. Standardized examinations were repeated in 1993 to 1995 and again in 1997 to 1999. PARTICIPANTS: A diverse cohort of 4,549 American Indians aged 45 to 74 at the initial examinations in 1989 to 1991. MEASUREMENTS: Changes in the prevalence of hypertension, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), current smoking, and type 2 diabetes mellitus. RESULTS: The prevalence of hypertension rose rapidly and steadily with aging. A nonsignificant decrease in LDL-C was seen in men, and men and women initially had rapid increases in the prevalence of low HDL-C. The prevalence of smoking decreased, but the prevalence of diabetes mellitus continued to rise for men and women. CONCLUSION: Overall, unfavorable changes in CVD risk factors were seen in the aging participants and will likely be reflected in worsening morbidity and mortality.

To increase our understanding of the psychometric characteristics and factor structure of the SF36 in older American Indian populations.Between 1993 and 1995, SF36 data were collected from 3,488 Phase II participants of the Strong Heart Study (SHS) between the ages of 48 and 81. Comparison data were provided by an age- and gender-matched sample (n = 695) from the National Survey of Functional Health Status (NSFHS) conducted in 1989 and 1990.Generally, the basic psychometric analyses showed that the SF36 performed adequately in these older American Indians. Exploratory factor analyses indicated that a one-factor model best fit the data for both older groups. On the other hand, confirmatory factor analyses showed that a two-factor model with correlated factors provided a superior fit to the data than a one-factor model. An assumption of equivalent factor loadings for the SHS and NSFHS groups was untenable.These analyses demonstrate that use of summary scores assuming a differentiated physical/mental functioning structure is likely improper in at least some populations. The SF36 provides an important opportunity to understand cultural differences in the conceptualization and measurement of health-related quality of life.

The population of older American Indians and Alaska Natives (AI/ANs) is growing rapidly, but few population-based reports of the health of older AI/ANs exist. The objective was to assess the representation of older AI/ANs in population based health data sets. Health- and aging-related population-based data sets were reviewed for inclusion of AI/AN adults. Data sets were identified using online searches of the Inter-University Consortium for Political and Social Research and the National Archive of Computerized Data on Aging, and federal health care and research agencies. Unweighted sample sizes of AI/ANs were collected for each study by age group. Of 190 data sets reviewed, only 25 (13%) contained at least 100 AI/ANs ages 65 years or older, and less than 5% contained 500 or more. Older AI/ANs are underrepresented in national data sets. Concerted efforts to improve data collection regarding the health and health care needs of this population are needed.

Background Few studies have examined surgical risk factors and outcomes in American Indians and Alaska Natives (AI/ANs). My colleagues and I sought to determine if prevalence of preoperative risk factors for morbidity and mortality differed between male AI/AN and Caucasian surgical patients, and to determine if AI/ANs had an increased risk of surgical morbidity or mortality. Study design We obtained data from the Veterans Affairs National Surgical Quality Improvement Program on major, noncardiac, surgical procedures performed between 1991 and 2002 for all AI/AN men (n = 2,155) and a random sample of Caucasian men (n = 2,264), matched by facility. Chi-square and t -test analyses were used to assess differences in preoperative risk factors between the two groups. Logistic regression was used to determine whether AI/AN race was independently associated with 30-day morbidity (defined as 1 or more of 21 postoperative complications) or 30-day all cause mortality after adjustment for major risk factors. Results Prevalence of major preoperative risk factors for morbidity and mortality often differed between the groups. Compared with Caucasians, AI/AN race did not predict morbidity (adjusted odds ratio, 0.92; 95% CI, 0.75–1.13), but AI/ANs were at higher risk for 30-day all cause postoperative mortality (adjusted odds ratio, 1.56; 95% CI, 1.04–2.35). Conclusions Our results add postoperative mortality to health disparities experienced by AI/ANs. Future research should be conducted to identify other factors that contribute to this disparity.

Background— National vital event data suggest that cardiovascular disease (CVD) mortality rates are lower for American Indians and Alaska Natives (AIAN) than for the general US population, but these data are disproportionately flawed for AIAN because of racial misclassification. Methods and Results— Vital event data adjusted for racial misclassification and published by the Indian Health Service were used to compare trends in CVD mortality from 1989 to 1991 to 1996 to 1998 between AIAN, US all-races, and US white populations. Without misclassification accounted for, AIAN initially had the lowest mortality rates from major CVD, but by the end of the study, their rates were the highest. Adjustment for misclassification revealed an early and rapidly growing disparity between CVD mortality rates among AIAN compared with rates in the US all-races and white populations. By 1996 to 1998, the age- and misclassification-adjusted number of CVD deaths per 100 000 among AIAN was 195.9 compared with age-adjusted rates of 166.1 and 159.1 for US all races and whites, respectively. The annual percent change in CVD mortality for AIAN was 0.5 compared with −1.8 in the other groups. Regardless of racial misclassification, the most striking and widening disparities were found for middle-aged AIAN, but CVD mortality among AIAN ≥65 years of age was lower than in the other populations. Conclusions— A previously underrecognized disparity in CVD mortality exists for AIAN, particularly among middle-aged adults. Moreover, these disparities are increasing. Efforts to reduce CVD mortality in AIAN must begin before the onset of middle age.

The objectives of this study were to ascertain the extent of, and health-related characteristics associated with, travel to reservations in a low-income, urban American Indian and Alaska Native (AI/AN) population. We surveyed more than 500 AI/AN adults at a primary care clinic. Measures included time spent visiting a reservation during the past year, and sociodemographic, cultural, and clinical characteristics. More than half (52%) of the patients had not traveled, 34% had traveled up to 30 days, and 14% had spent more than 30 days traveling to reservations. Multivariate ordinal regression revealed that a strong Native American cultural identification, presence of lung disease, absence of thyroid and mental problems, and greater dissatisfaction with care were independently associated with more travel to reservations (por=0.05). This research begins to augment the paucity of information on such travel and its relationship to health status and use of health services among urban AI/ANs.

Purpose The metabolic abnormalities that accompany diabetes mellitus are associated with an increased risk of many cancers. These associations, however, have not been well studied in American Indian populations, which experience a high prevalence of diabetes. The Strong Heart Study is a population-based, prospective cohort study with extensive characterization of diabetes status. Methods Among a total cohort of 4,419 participants who were followed for up to 20 years, 430 cancer deaths were identified. Results After adjusting for sex, age, education, smoking status, drinking status, and body mass index, participants with diabetes at baseline showed an increased risk of gastric (HR 4.09; 95 % CI 1.42–11.79), hepatocellular (HR 2.94; 95 % CI 1.17–7.40), and prostate cancer mortality (HR 3.10; 95 % CI 1.22–7.94). Further adjustment for arsenic exposure showed a significantly increased risk of all-cause cancer mortality with diabetes (HR 1.27; 95 % CI 1.03–1.58). Insulin resistance among participants without diabetes at baseline was associated with hepatocellular cancer mortality (HR 4.70; 95 % CI 1.55–14.26). Conclusions Diabetes mellitus, and/or insulin resistance among those without diabetes, is a risk factor for gastric, hepatocellular, and prostate cancer in these American Indian communities, although relatively small sample size suggests cautious interpretation. Additional research is needed to evaluate the role of diabetes and obesity on cancer incidence in American Indian communities as well as the importance of diabetes prevention and control in reducing the burden of cancer incidence and mortality in the study population.

Purpose This study describes changes in cardiovascular disease (CVD) risk factors in older American Indians over a 4-year period. Methods The Strong Heart Study, a longitudinal population-based study of CVD and CVD risk factors among American Indians aged 45-74 years, measured CVD risk factors among 3638 members of 13 tribes in three geographic areas during examinations in 1989 to 1991 and 1993 to 1995. Results Changes in mean low-density lipoprotein (LDL) cholesterol and the prevalence of elevated LDL cholesterol were inconsistent. Mean high- density lipoprotein (HDL) cholesterol decreased, and the prevalence of low HDL cholesterol increased throughout. Mean systolic blood pressure and hypertension rates increased in nearly all center-sex groups, and hypertension awareness and treatment improved. Smoking rates decreased but remained higher than national rates except among Arizona women. Mean weight and percentage body fat decreased in nearly all center-sex groups but the prevalence of obesity did not change significantly in any group. Diabetes and albuminuria prevalence rates increased throughout the study population. The prevalence of alcohol use decreased, but binge drinking remained common in those who continued to drink. Conclusions Improvements in management and prevention of hypertension, diabetes, renal disease, and obesity, and programs to further reduce smoking and alcohol abuse, are urgently needed.

This paper is a first step in developing a probabilistic hazard model for tephra fall deposits in New Zealand. The database consists of measurements of tephra thickness and eruptive volumefrom 32 past eruptive events at Taupo Volcano. From these are derivedrelations for the mean and maximum tephra thickness as a function ofevent volume and distance from the vent, and for the area enclosed byan isopach as a function of tephra thickness and volume. Thedirectional effects due to wind do not vary appreciably over thevolcanic region of New Zealand. The main feature of wind velocity is aflow to the east that becomes more consistent at higher altitudes. Thelarger the eruption, the more the location of the deposit of maximumthickness (the centre of deposit) tends to be displaced to the east ofvent. A directional attenuation relation about the centre of deposit isderived from the Taupo data. This, in combination with arelation for the position of the centre of deposit relative to thevent, provides a means of estimating the probability of a giventhickness of tephra fall deposit being exceeded at any distance anddirection from the vent in an eruption of given volume.

OBJECTIVE—To estimate incidence rates of diabetes and associated risk factors among participants of the Strong Heart Study. RESEARCH DESIGN AND METHODS—Of the 4,549 Strong Heart Study participants examined at baseline, 3,638 returned for a similar examination after an average of 4 years. The 1985 World Health Organization criteria for diabetes were used to identify new diabetes cases. Rates of diabetes among participants who did not have diabetes at baseline examination were determined. The relationships between the incidence rates of diabetes and a number of risk factors measured at baseline examination were studied. RESULTS—Significant variables associated with the development of diabetes included triglycerides, obesity, fasting plasma glucose, insulin, and degree of American Indian blood among participants with NGT at baseline. For those with IGT at baseline, significant predictors included fasting plasma glucose, 2-h glucose, BMI, degree of American Indian blood, and albuminuria. CONCLUSIONS—The high incidence rates found in this study were alarming. To slow down the rapid increase of this disease in the American Indian population, preventive programs must be designed and implemented. Patients with IGT should be treated with diabetes medication or put on a rigid weight-reduction program to reduce the risk of progression to diabetes.

SummaryUsing data from The National Epidemiologic Survey on Alcohol and Related Conditions, the strength of social networks and the association of self-reported health among American Indians and Alaska Natives (AI/AN) and non-Hispanic Whites (NHW) were compared. Differences in social network–health relationships between AI/ANs and NHWs were also examined. For both groups, those with fewer network members were more likely to report fair or poor health than those with average or more network members, and persons with the fewest types of relationships had worse self-reported health than those with the average or very diverse types of relationships. Furthermore, small social networks were associated with much worse self-reported health in AI/ANs than in NHWs.

To describe longitudinal changes in the prevalence of major cardiovascular disease (CVD) risk factors in aging American Indians.Population-based ongoing epidemiological study.The Strong Heart Study is a study of CVD and its risk factors. Standardized examinations were repeated in 1993 to 1995 and again in 1997 to 1999.A diverse cohort of 4,549 American Indians aged 45 to 74 at the initial examinations in 1989 to 1991.Changes in the prevalence of hypertension, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), current smoking, and type 2 diabetes mellitus.The prevalence of hypertension rose rapidly and steadily with aging. A nonsignificant decrease in LDL-C was seen in men, and men and women initially had rapid increases in the prevalence of low HDL-C. The prevalence of smoking decreased, but the prevalence of diabetes mellitus continued to rise for men and women.Overall, unfavorable changes in CVD risk factors were seen in the aging participants and will likely be reflected in worsening morbidity and mortality.

Despite considerable overall improvement in the clinical prevalence and outcome of cardiovascular disease in the US population during the past 50 years, striking disparities in disease burden plague specific racial/ethnic subgroups. Black patients with cardiovascular disease (CVD) in particular have increased morbidity and mortality as compared with white patients. For example, a black man between 45 and 65 years old is 4 times more likely to have a stroke than his white counterpart. Even when accounting for access to high-quality health care, ethnic minorities bear a higher burden of obesity, type 2 diabetes mellitus, and hypertension as compared with whites. The mechanisms for these disparities remain incompletely understood but likely include a combination of genetic, environmental, and socioeconomic factors. If recent advances in basic science are to be exploited to reduce disparities in cardiovascular health care, then the emerging disciplines in human genetics, biological sciences, and molecular medicine are likely to afford us unprecedented opportunities for deciphering the complex mechanisms involving race/ethnicity, genetic differentiation, allele frequency disparities, and gene–environment interactions. The completion of the draft sequence derived from the Human Genome Project provides the scientific framework for understanding the genetic basis for similarities or differences between population groups. On the basis of the evidence to date, the Human Genome Project suggests that racial classification may not be useful for biomedical research because genetic variation is a continuous phenomenon that does not lend itself to clear boundaries among population groups.1 Indeed, disparities in genomic variation most likely are surrogates of the ethnohistory of the major continental groups. Because race and ethnicity historically have been used as social instruments for subjugation and discrimination, the contextual framework for racial classification in biomedical research will likely remain controversial and highly scrutinized, especially in the United States. Thanks to the Human Genome Project, the …

To assess the prevalence of, and quality of care for, diabetes mellitus among the understudied, yet growing, population of older, urban American Indians and Alaska Natives (AI/ANs).Medical record review.Urban Indian primary care clinic in Seattle, Washington.All (N = 550) AI/AN patientsor = 50 years of age.Provider-documented medical diagnoses and indicators of quality of care of diabetes.Diabetes mellitus was documented in 113 (21%) of the medical records. Persons with diabetes were more likely than those without (Por = .05) to be obese, and to have hypertension, coronary artery disease, and depression. Most patients with diabetes were treated with either insulin (43%) or oral hypoglycemic medication (39%), but 16% received neither. Screening rates within 12 months were high for glycosylated hemoglobin (72%), lipid profile (84%), and foot examination (72%), but were low for urinalysis (23%), ophthalmology referral (23%), and influenza vaccination (46%). Only 46% of patients had ever received pneumococcal vaccination, and even fewer (26%) had received tuberculin skin testing (24%). Although 65% of patients had ever been referred to a dietitian, only 40% had received exercise counseling. The total number of health problems was the factor most often associated with quality of care indicators.The prevalence rate of diabetes among this urban clinic population of older AI/ANs was high. Although performance of quality indicators was suboptimal, it was comparable to, or better than, that found in other older populations for many measures.

OBJECTIVES: To examine hypertension and its management in a population of older urban American Indians and Alaska Natives (AI/ANs). DESIGN: Retrospective cohort study using medical record review. SETTING: Urban health clinic serving predominantly AI/ANs in the Pacific Northwest. PARTICIPANTS: Five hundred twenty-four AI/ANs aged 50 and older seen between 1994 and 1995. MEASUREMENTS: Frequency of diagnosed hypertension, undiagnosed hypertension, comorbid conditions, hypertension treatment, control, and quality of care. RESULTS: The prevalence of diagnosed hypertension was 38%, and the prevalence of possible undiagnosed hypertension was 23%. Patients with diagnosed hypertension were more likely to be obese (age-adjusted odds ratio (OR) = 3.5), have diabetes mellitus (DM) (OR = 2.2), depression (OR = 1.7), heart disease (OR = 3.8), or renal disease (OR = 5.6) than patients without hypertension. Undiagnosed hypertension was inversely associated with number of health problems (OR = 0.8). Eighty-one percent of diagnosed patients were treated pharmacologically, but no factors associated with nontreatment were identified. Diuretic and beta-blocker usage was low. Patients with DM used angiotensin-converting enzyme inhibitors more frequently than patients without DM (OR = 2.4). Blood pressure was well controlled in 37%, with men being less well controlled than women (OR = 0.5). Serum cholesterol, creatinine, and retinal screening were performed more often than urinalyses or electrocardiograms. Lifestyle-modification counseling was uncommon. Number of health problems was the most common factor associated with screening tests for end-organ disease. CONCLUSION: Few studies have examined the care of older urban AI/ANs. Improvements are needed in adherence to recommendations for the detection, management, and monitoring of hypertension and its complications in older urban AI/ANs.

To estimate incidence rates of diabetes and associated risk factors among participants of the Strong Heart Study.Of the 4,549 Strong Heart Study participants examined at baseline, 3,638 returned for a similar examination after an average of 4 years. The 1985 World Health Organization criteria for diabetes were used to identify new diabetes cases. Rates of diabetes among participants who did not have diabetes at baseline examination were determined. The relationships between the incidence rates of diabetes and a number of risk factors measured at baseline examination were studied.Significant variables associated with the development of diabetes included triglycerides, obesity, fasting plasma glucose, insulin, and degree of American Indian blood among participants with NGT at baseline. For those with IGT at baseline, significant predictors included fasting plasma glucose, 2-h glucose, BMI, degree of American Indian blood, and albuminuria.The high incidence rates found in this study were alarming. To slow down the rapid increase of this disease in the American Indian population, preventive programs must be designed and implemented. Patients with IGT should be treated with diabetes medication or put on a rigid weight-reduction program to reduce the risk of progression to diabetes.

Abstract —Diabetes has been shown to increase the risk of coronary heart disease in all populations studied. However, there is a lack of information on the relative importance of diabetes-associated risk factors for cardiovascular disease (CVD), especially the role of lipid levels, because low density lipoprotein (LDL) cholesterol often is not elevated in diabetic individuals. The objective of this analysis was to evaluate CVD risk factors in a large cohort of diabetic individuals and to compare the importance of dyslipidemia (ie, elevated triglycerides and low levels of high density lipoprotein [HDL] cholesterol) and LDL cholesterol in determining CVD risk in diabetic individuals. The Strong Heart Study assesses coronary heart disease and its risk factors in American Indians in Arizona, Oklahoma, and South/North Dakota. The baseline clinical examinations (July 1989 to January 1992) consisted of a personal interview, physical examination, and drawing of blood samples for 4549 study participants (2034 with diabetes), 45 to 74 years of age. Follow-up averaged 4.8 years. Fatal and nonfatal CVD events were confirmed by standardized record review. Participants with diabetes, compared with those with normal glucose tolerance, had lower LDL cholesterol levels but significantly elevated triglyceride levels, lower HDL cholesterol levels, and smaller LDL particle size. Significant independent predictors of CVD in those with diabetes included age, albuminuria, LDL cholesterol, HDL cholesterol (inverse), fibrinogen, and percent body fat (inverse). A 10-mg/dL increase in LDL cholesterol was associated with a 12% increase in CVD risk. Thus, even at concentrations well below the National Cholesterol Education Program target of 130 mg/dL, LDL cholesterol is a strong independent predictor of coronary heart disease in individuals with diabetes, even when components of diabetic dyslipidemia are present. These results support recent recommendations for aggressive control of LDL cholesterol in diabetic individuals, with a target level of

A monoclonal antibody directed against a 65-kDa brain protein demonstrates an epitope found in keratin from human epidermis. By indirect immunofluorescence, the antibody decorates intracytoplasmic filaments in a subclass of astrocytes and Purkinje cells of adult hamster brain. Double-label immunofluorescence study using antibody to glial fibrillary acidic protein and this antibody reveals the 65-kDa protein to be closely associated with glial filaments in astrocytes of fetal mouse brain cultures. Immunoblot analysis of purified human epidermal keratin and hamster brain homogenate confirms the reactivity of this antibody to epidermal keratin polypeptides. All the major epidermal keratins were recognized by this antibody. It did not bind to the remaining major intermediate filament proteins. These findings suggest that monoclonal antibody 34C9 recognizes a cytoskeletal structure connected with intermediate filaments. In addition, the monoclonal antibody demonstrates that epidermal keratins share an epitope not only among themselves but also with a "neural keratin."