Search

Background Epilepsy and progressively worsening severe chronic headaches (WSCH) are the two most common clinical manifestations of neurocysticercosis, a form of cysticercosis. Most community-based studies in sub-Saharan Africa (SSA) use a two-step approach (questionnaire and confirmation) to estimate the prevalence of these neurological disorders and neurocysticercosis. Few validate the questionnaire in the field or account for the imperfect nature of the screening questionnaire and the fact that only those who screen positive have the opportunity to be confirmed. This study aims to obtain community-based validity estimates of a screening questionnaire, and to assess the impact of verification bias and misclassification error on prevalence estimates of epilepsy and WSCH. Methodology/Principal findings Baseline screening questionnaire followed by neurological examination data from a cluster randomized controlled trial collected between February 2011 and January 2012 were used. Bayesian latent-class models were applied to obtain verification bias adjusted validity estimates for the screening questionnaire. These models were also used to compare the adjusted prevalence estimates of epilepsy and WSCH to those directly obtained from the data (i.e. unadjusted prevalence estimates). Different priors were used and their corresponding posterior inference was compared for both WSCH and epilepsy. Screening data were available for 4768 individuals. For epilepsy, posterior estimates for the sensitivity varied with the priors used but remained robust for the specificity, with the highest estimates at 66.1% (95%BCI: 56.4%;75.3%) for sensitivity and 88.9% (88.0%;89.8%) for specificity. For WSCH, the sensitivity and specificity estimates remained robust, with the highest at 59.6% (49.7%;69.1%) and 88.6% (87.6%;89.6%), respectively. The unadjusted prevalence estimates were consistently lower than the adjusted prevalence estimates for both epilepsy and WSCH. Conclusions/Significance This study demonstrates that in some settings, the prevalence of epilepsy and WSCH can be considerably underestimated when using the two-step approach. We provide an analytic solution to obtain more valid prevalence estimates of these neurological disorders, although more community-based validity studies are needed to reduce the uncertainty of the estimates. Valid estimates of these two neurological disorders are essential to obtain accurate burden values for neglected tropical diseases such as neurocysticercosis that manifest as epilepsy or WSCH. Trial registration ClinicalTrials.gov NCT03095339., Author summary Epilepsy and progressively worsening severe chronic headaches are the two most common clinical manifestations of neurocysticercosis, a form of cysticercosis. To understand where the prevalence of these neurological disorders is highest for targeted infection control, valid prevalence estimates are needed. Most neuroepidemiological studies conducted in low-resource settings use a two-step approach to identify cases (screening questionnaire followed by physician examination among screened positives) to obtain prevalence and burden estimates. We found that this most commonly-used two-step approach in community-based studies leads to an underestimation of the prevalence in our study. Our paper provides an analytic solution to reduce errors in estimating the prevalence of neurological disorders in community-based studies when using the two-step approach. Our proposed approach provides more valid estimates of the prevalence of these neurological disorders and could be used to better reflect the consequences that neglected tropical diseases manifesting as epilepsy or headaches have on people’s health and disabilities.

Summary Background The effectiveness of drug-free interventions in controlling human cysticercosis is not well known. We aimed to estimate the effectiveness of a community-based educational intervention in reducing the frequency of human cysticercosis in Burkina Faso. Methods We did a cluster-randomised controlled trial between 2011 and 2014. 60 eligible villages from three provinces (Boulkiemde, Sanguie, and Nayala) were randomly allocated to the intervention or control group. Villages raising pigs, that were not a regional capital or located on a main road, that were more than 20 km from Ouagadougou or 5 km from one another, were eligible. In each village, 60 participants were asked for blood samples at baseline, 18 months later (before randomisation), and 18 months after randomisation. Villages were block randomised (1:1) by pig-raising department immediately after the pre-randomisation visit. The intervention aimed to improve knowledge of Taenia solium transmission and control through screening and structured discussion of a 52-min movie, and to increase community self-efficacy through a Self-esteem, Associative strengths, Resourcefulness, Action planning, Responsibility (SARAR) approach via the Participatory Hygiene and Sanitation Transformation (PHAST) model. The primary outcome was active cysticercosis, defined as the presence of circulating antigens detected by use of B158/B60 ELISA. Effectiveness measured at the village level was estimated by use of three Bayesian hierarchical models. This study is registered with ClinicalTrials.gov, number NCT0309339. Findings Two villages in the same randomisation block were excluded, resulting in a final sample size of 58 villages. Overall, the intervention tended towards a decrease in the cumulative incidence of active cysticercosis from baseline to after randomisation (adjusted cumulative incidence ratio 0·65, 95% Bayesian credible interval [95% CrI] 0·39–1·05) and a decrease in active cysticercosis prevalence from baseline to after randomisation (adjusted prevalence proportion ratio 0·84; 95% CrI 0·59–1·18). The intervention was shown to be effective in Nayala and Sanguie but not in Boulkiemde. Interpretation Community-engaged participatory interventions can be effective at reducing the incidence and prevalence of cysticercosis in some low-resource settings. Funding US National Institutes of Health (National Institute of Neurological Disorders and Stroke, Fogarty International Center, and National Institute of General Medical Sciences).

Summary Purpose: To estimate the lifetime prevalence of neurocysticercosis (NCC)–associated epilepsy and the proportion of NCC among people with epilepsy in three Burkina Faso villages. Methods: Three villages were selected to represent three types of pig-rearing methods: (1) Batondo, where pigs are left to roam; (2) Pabre, where pigs are mostly tethered or penned; and (3) Nyonyogo, where the majority of residents are Muslim and few pigs are raised. In Batondo and Nyonyogo, all concessions (a group of several households) were included. Half of the concessions in Pabre were randomly chosen. All households of selected concessions were included, and one person per household was randomly selected for epilepsy screening and serologic testing for cysticercosis. Self-reported cases of epilepsy were also examined and confirmed cases included in analyses other than the estimate of NCC-associated epilepsy prevalence. Epilepsy was defined as ever having had more than one episode of unprovoked seizures. Individuals with medically confirmed epilepsy had a computerized tomography (CT) scan of the brain before and after contrast medium injection. The diagnosis of NCC was made using a modification of the criteria of Del Brutto et al. Key Findings: Thirty-nine (4%) of 888 randomly selected villagers and 33 (94%) of 35 self-reported seizures cases were confirmed to have epilepsy by medical examination. Among the 68 participants with epilepsy who had a CT scan, 20 patients were diagnosed with definitive or probable NCC for a proportion of 46.9% (95% confidence interval [CI] 30.2–64.1) in Batondo and 45.5% (95% CI 19.0–74.1) in Pabre. No cases of NCC were identified in Nyonyogo. Significance: All the definitive and probable cases of NCC were from the two villages where pig breeding is common. Prevention policies intended to reduce the burden of epilepsy in this country should include measures designed to interrupt the life cycle of Taenia solium.

ACADEMIC EMERGENCY MEDICINE 2011; 18:1208–1216 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: Helicopter emergency medical services (HEMS) transport of trauma patients has been used for decades. Its use, however, is still a subject of debate, including issues such as high costs, increasing numbers of crashes, and conflicting results regarding effectiveness in reducing mortality. The aim of this study was to examine whether mode of transport (HEMS vs. ground EMS) is independently associated with mortality among trauma patients transported directly from the scene of injury to definitive care. Methods: All trauma patients transported directly to a Level I or Level II trauma center by either air or ground EMS over a 4-year period were selected from the Oklahoma State Trauma Registry. Multivariable logistic regression was used to develop propensity scores based on variables measured at the scene of injury. The propensity scores represented the predicted probabilities of a patient being transported by HEMS given a specific set of characteristics and were used as a composite confounding variable in subsequent models of the association of mortality and mode of transport. Along with the propensity scores, Injury Severity Scores (ISS), initial Revised Trauma Score (RTS), and distance from the trauma center were included in a Cox proportional hazards model of the association of mode of transport and 24-hour and 2-week mortality. Results: Overall, the hazard ratio (HR) for 2-week mortality in patients transported by HEMS was 33% lower (HR = 0.67, 95% confidence interval [CI] = 0.54 to 0.84) than in patients transported by ground EMS from the scene of injury, after adjustment for the propensity score and other covariates. In subanalyses, the apparent association of a reduction in the hazard of early mortality among patients transported by HEMS was most evident for patients with an RTS based on injury scene vital signs of 3 to 7 (HR = 0.61, 95% CI = 0.46 to 0.82). The point estimate of the HR was similar (HR = 0.65 95% CI = 0.34 to 1.2) in the 75% of cases who had normal vital signs at the scene of injury, although it was no longer statistically significant because crude mortality was very low (1.7%) in this group. Among those with a RTS of 3 or less at the scene, crude mortality was 58%, and mode of transport was not associated with mortality (HR = 1.02, 95% CI = 0.68 to 1.6). Conclusions: Helicopter EMS transport was associated with a decreased hazard of mortality among certain patients transported from the scene of injury directly to definitive care. Refinements in scene triage and transport guidelines are needed to more effectively select patients that may benefit from HEMS transport from those unlikely to benefit.

The objective of this study was to compare quality of life measures in patients with neurocysticercosis (NCC) to those of a matched control group. The NCC outpatients and their controls were recruited from two neurology referral hospitals in Mexico City, Mexico during 2007–2008. The quality of life of 224 NCC patients was compared with 224 age-sex-hospital-day matched controls using the short form 12 v2 (SF-12 v2) quality of life survey. Medical chart reviews were also conducted for the NCC outpatients to evaluate presenting clinical manifestations. Compared with the controls, NCC patients had a significantly lower score for each of the eight domains of health evaluated and significantly lower Physical and Mental Component Summary scores. Chart reviews indicated that hydrocephalus (48%), severe headaches (47%), and epilepsy (31%) were the most common clinical manifestations in these NCC outpatients.

BACKGROUND:: Whether severely injured patients should be transported directly to tertiary trauma centers, bypassing closer nontertiary facilities, or be transported first to nearby, less-specialized facilities for immediate care and stabilization has been studied with mixed findings. Differences in study locale, case mix, and variation in the structure and level of maturation of the trauma system may explain some of the discrepancy in findings. In addition, risk adjustment strategies used in these studies did not take into account prehospital baseline characteristics as well as time since injury. METHODS:: This was a retrospective cohort study of 1,998 patients treated at a Level I trauma center between January 1, 2006, and December 31, 2007. Propensity-adjusted survival analyses were used to compare short-term mortality outcomes in transferred versus directly transported major trauma patients. RESULTS:: A total of 1,398 patients were transported directly to the Level I trauma center and 600 patients were transferred from lower level facilities. After adjusting for the propensity to be transported directly, age, injury severity score, severe head injury, emergency medical service or emergency department intubation, comorbid conditions, and time to definitive Level I trauma care, the 2-week mortality risk in transferred patients was almost three-fold that of patients transported directly to a Level I trauma center (hazard ratio, 2.7; 95% confidence interval, 1.31-5.6). CONCLUSION:: Transferred patients in a predominantly rural region are at an increased risk of short-term mortality. This suggests that severely injured patients should be transported directly to tertiary trauma centers. For patients requiring immediate stabilization at nontertiary facilities, this should be performed promptly without unnecessary delays. Language: en

Objectives: Recent evidence suggests a measurable reduction in mortality for patients transferred from a nontertiary trauma center (Level III or IV) to a Level I trauma center, but not for those transferred to a Level II trauma center. Whether this can be generalized to a predominantly rural region with fewer tertiary trauma care resources is uncertain. This study sought to evaluate mortality differences for patients initially presenting to nontertiary trauma centers in a predominantly rural region depending on transfer status. Methods: This was a retrospective cohort study of patients initially presenting to 104 nontertiary trauma centers in Oklahoma and meeting the state’s criteria for major trauma. Patients dying within 1 hour of emergency department (ED) arrival at the nontertiary trauma center were excluded. The exposure variable of interest was admission status, which was categorized as either transfer to a tertiary (Level I or II) trauma center within 24 hours or admission to a nontertiary trauma center. Propensity scores were used to minimize the selection bias inherent in the decision to admit or transfer a patient for higher-level care. Multiple logistic regression was used to generate three propensity score models: probability of transfer to either a Level I or II, Level I only, and Level II only. Propensity scores were then included as a covariate in multivariable Cox regression models assessing outcome differences between admitted and transferred patients. The outcome of interest was 30-day mortality, defined as death at either the nontertiary trauma center or the tertiary trauma center within 30 days of arrival at the initial Level III/IV center’s ED. Results: A total of 6,229 patients met study criteria, of whom 2,669 (43%) were transferred to tertiary trauma centers. Of those transferred, 1,422 patients (53%) were transferred to a Level I trauma center. Crude mortality was lower for patients transferred to tertiary trauma centers compared to those remaining at nontertiary trauma facilities (hazard ratio [HR] = 0.59; 95% confidence interval [CI] = 0.48 to 0.72). After adjusting for the propensity to be transferred, Injury Severity Score (ISS), presence of severe head injury, and age, transfer to a tertiary trauma center was associated with a significantly lower 30-day mortality (HR = 0.38; 95% CI = 0.30 to 0.50) compared to admission and treatment at a nontertiary trauma center. The observed survival benefit was similar for patients transferred to a Level I trauma center (HR = 0.36; 95% CI = 0.20 to 0.4) and those transferred to a Level II center (HR = 0.45; 95% CI = 0.33 to 0.61). Conclusions: This study suggests a survival benefit among patients initially presenting to nontertiary trauma centers who are subsequently transferred to tertiary trauma centers compared to those remaining in nontertiary trauma centers, even after adjusting for variables affecting the likelihood of transfer. Although this survival benefit was larger for patients treated at a Level I trauma center, Level II trauma centers in a region with few tertiary trauma resources demonstrated a measurable benefit as well. ACADEMIC EMERGENCY MEDICINE 2010; 17:1223–1232 © 2010 by the Society for Academic Emergency Medicine

This review of human studies of caffeine and reproductive health published between January 2000 and December 2009 serves to update the comprehensive review published by Leviton and Cowan (2002). The adverse reproductive outcomes addressed in this review include: (1) measures of subfecundity; (2) spontaneous abortion; (3) fetal death; (4) preterm birth; (5) congenital malformations; and (6) fetal growth restriction. Methodologic challenges and considerations relevant to investigations of each reproductive endpoint are summarized, followed by a brief critical review of each study. The evidence for an effect of caffeine on reproductive health and fetal development is limited by the inability to rule out plausible alternative explanations for the observed associations, namely confounding by pregnancy symptoms and smoking, and by exposure measurement error. Because of these limitations, the weight of evidence does not support a positive relationship between caffeine consumption and adverse reproductive or perinatal outcomes.

Summary. Background: Coated-platelets, representing a subset of platelets with procoagulant potential, are elevated in patients with non-lacunar ischemic stroke and decreased in patients with spontaneous intracerebral hemorrhage. However, within the non-lacunar patient population there are individuals with lower levels of coated-platelets, which raises the possibility that these individuals would be susceptible to early hemorrhagic transformation (HT) of ischemic stroke. Objective: Because extremes in coated-platelet potential may be associated with either thrombotic or hemorrhagic events, we undertook a pilot study to investigate whether there is an association between coated-platelet production and the presence of early HT in patients with non-lacunar ischemic stroke. Patients and methods: Coated-platelet levels were determined in 115 consecutive eligible patients with a diagnosis of non-lacunar ischemic stroke. Early HT was determined on CT scan examination and confirmed by MRI studies. The distribution of coated-platelet levels was summarized using the median and interquartile range (25th–75th percentiles) and compared statistically between patients with and without early HT using the non-parametric Wilcoxon rank sum test. Results: The median coated-platelet level in all non-lacunar stroke patients was 38.0% (interquartile range 30.5–48.3%). Early HT was detected in 11 patients (9.6%), and these patients had significantly lower coated-platelet levels compared with those without early HT [median 25.1% (interquartile range 20.4–35.5%) vs. 39.2% (31.6–49.5%), P = 0.003]. Conclusions: Lower levels of coated-platelets are associated with the presence of early HT in patients with non-lacunar ischemic stroke.

In 2002, two high school athletes and one college athlete died as a result of head injuries sustained while pole-vaulting. In order to determine the opinions and practices of collegiate coaches on a variety of issues concerning polevaulters, including the use of helmets, an anonymous, web-based survey concerning pole-vaulting was sent to a stratified random sample of 50% of Division I, II, and III NCAA track and field coaches. Information collected from coaches included demographic data, coaching experience, coaching techniques, pole-vaulting equipment, and injury/safety information. One hundred and thirty-one (56%) completed surveys were returned from the estimated 233 schools with active pole-vaulting programs. None of the respondent coaches required vaulters to wear helmets during practice, although 59% (95% CI = 50% to 69%) would do so if helmets were designed specifically for pole-vaulting. Results from this survey of NCAA coaches suggest a general acceptance of the idea of helmet use, especially if helmets were to be designed specifically for pole-vaulting and if the practice of helmet use was initiated at the pre-college level. The lack of evidence demonstrating an improvement in safety was one of the most common reasons given for opposing the idea of helmet use

Cysticercosis and echinococcosis cause illness and productivity losses in human and agricultural animal populations. Recent studies suggest that these diseases have large societal impacts on endemic areas. Estimates of burden provide essential, evidence-based data for conducting cost-benefit and cost-utility analyses that will secure political will, and financial and technical resources. To evaluate the burden, the monetary and non-monetary impacts of these zoonoses on human health, agriculture and society must be considered comprehensively. In this article, we review the framework used to assess the burden of cysticercosis and echinococcosis, and the data needed to estimate the extent of the problem for societies.

Children First (C1), a nurse home visitation programme for first-time mothers, was implemented statewide in Oklahoma in mid-1997. The objective of this study was to compare the risks of low (< 2500 g) and very low birthweight (< 1500 g), preterm (< 37 weeks) and very preterm (< 30 weeks) deliveries and infant mortality between mothers participating and not participating in C1. All 239,466 Oklahoma birth certificates were reviewed. The C1 and birth certificate databases were matched to identify C1 participants. Mother's age at delivery, education level, race, marital status, prior pregnancy loss or pregnancy risk factors, birthweight and gestational age at delivery were measured from the birth certificates. Death certificates were matched to the birth certificates to identify infant deaths. A Bayesian multivariable logistic regression was used to analyse the data. Among single mothers without pregnancy risk factors, the risks of all study outcomes were lower for participants in C1: adjusted odds ratio (aOR) 0.89, [95% Bayesian Credible Interval (BCI) 0.79, 1.00] for preterm delivery; aOR 0.71, [95% BCI 0.50, 0.98] for very preterm delivery; aOR 0.86, [95% BCI 0.75, 0.98] for low birthweight; aOR 0.77, [95% BCI 0.56, 1.02] for very low birthweight and aOR 0.36, [95% BCI 0.17, 0.63] for infant mortality. These risk reductions were not observed among married mothers. In both single and married mothers, the presence of pregnancy risk factors reduced the impact of C1 on lowering the risk of low birthweight and preterm deliveries. The C1 programme targets young, pregnant women of low socio-economic level. We found that among single mothers, the risks of perinatal adverse outcomes are reduced or similar to those found in non-participating mothers. A reduced effect of C1 in the presence of pregnancy risk factors may be because mothers with pregnancy risk factors who did not participate in C1 received better prenatal care, or that C1 interventions do not impact these particular factors. C1 shows promise in reducing infant mortality in single mothers. Lower incidence of preterm and very preterm deliveries is especially interesting and future analyses should focus on isolating programme components specifically associated with influencing these outcomes.

Background:Little is known about the frequency of or risk factors for injuries in middle school or junior high school football players.Purpose:To examine the associations of player characteristics (injury history, conditioning, player position, special equipment) and physical parameters (body mass index, weight, height, grip strength) with risk of injury.Study Design:Prospective cohort study.Methods:We documented risk factors for injury in 646 middle school football players, 10 to 15 years of age, in the Oklahoma City, Oklahoma, school district during the 1998 and 1999 seasons. Player characteristics and physical parameters were measured at the beginning of both seasons. Logistic regression methods were used to determine whether baseline variables were associated with the odds of subsequent injury.Results:More playing experience was the only variable significantly associated with the risk of injury in multivariate analyses. This association was observed regardless of the type of injury and even after indirectly controlling for time at risk of injury by restricting analyses to first-string players. Increasing age was significantly associated with the risk of fractures.Conclusions:Results suggest that physical characteristics play a minor role in risk of injury from football in this age group.

Acute macular neuroretinopathy (AMNR) is a rare condition that produces transient or permanent visual impairment. Typical cases have acute onset multifocal scotomas that correspond rather precisely with reddish, flat, or depressed circumscribed lesions in the macula. These lesions are wedge-shaped and generally point toward the fovea. The pathophysiology of AMNR is unclear, the causes are uncertain, and there is no specific treatment for this condition. This review summarizes the presentation, possible risk factors, and prognosis of the 41 cases of AMNR reported in the published, English-language literature from 1975 through April 2002. Possible areas for future research into the etiology of this rare condition are discussed.

From this detailed review of the literature, several conclusions can be drawn: (a) An association between caffeine consumption and a reproductive hazard is more likely to be seen in lower-quality studies than in studies that come closer to approximating the ideal. This is especially evident for "lower" birthweight and congenital anomalies. (b) The association between caffeine consumption and spontaneous abortion may well reflect the Stein-Susser epiphenomenon (women with prominent nausea tend to reduce caffeine consumption and nausea appears to be a marker of good implantation, perhaps reflecting a favorable balance of hormones produced by a healthy placenta). (c) The claim that caffeine consumption by women delays conception has not been followed by convincing support. (d) Reproductive hazards associated with cigarette smoking tend to be associated with caffeine/coffee consumption. Sometimes this appears to be a consequence of residual confounding associated with inadequate adjustment for cigarette smoking, which is over-represented among those who drink the most coffee/caffeine. Sometimes this reflects the tendency of women to underreport socially undesirable behaviors (e.g. smoking) while accurately reporting socially neutral behaviors (e.g. coffee and caffeine consumption). Thus, it seems reasonable to conclude that no convincing evidence has been presented to show that caffeine consumption increases the risk of any reproductive adversity.

OBJECTIVE—To examine the associations between estrogen use and levels of insulin and glucose as well as the effect of estrogen use on the risk of type 2 diabetes. RESEARCH DESIGN AND METHODS—This report is based on 857 women who were both nondiabetic and postmenopausal at the baseline examination (1989–1992) and who completed a second examination (1993–1995) an average of 4 years later. The participants were divided into three groups: never, past, and current users based on their baseline estrogen use status. ANCOVA was used to compare the insulin and glucose levels among estrogen use groups. Logistic regression was used to evaluate the association between estrogen use and the incidence of type 2 diabetes. RESULTS—Postmenopausal estrogen use was associated with lower fasting glucose (0.2 mmol/l lower) but higher 2-h glucose levels (0.4 mmol/l higher) compared with never users. It was not significantly associated with the risk of type 2 diabetes compared with past and never users, based on American Diabetes Association or World Health Organization definitions of diabetes or on only a 2-h glucose level ≥11.1 mmol/l. However, the risk of type 2 diabetes increased with increasing duration of estrogen use among current users, with an odds ratio of 1.10 per year of use (95% CI: 1.01–1.19). CONCLUSIONS—The data suggest that estrogen use in American Indian postmenopausal women may relate to deterioration of glucose tolerance. Longer duration of estrogen use among current users may relate to an increased risk of type 2 diabetes.

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.

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.

Purpose To examine associations between phthalate metabolite urinary concentrations during early pregnancy and blood glucose levels obtained at the time of screening for gestational diabetes mellitus (GDM). Methods Upon initiation of prenatal care, women with a mean gestational age of 12.8 weeks were recruited for a study of environmental chemical exposures (n = 110) and provided a spot urinary specimen. Blood glucose concentrations (mg/dl) were obtained from the electronic medical record for those patients who did not experience a pregnancy loss and did not transfer care to another facility prior to glucose screening (n = 72). Urinary concentrations of nine phthalate metabolites and creatinine were measured at the US Centers for Disease Control and Prevention. Associations between tertiles of phthalate metabolites concentrations and blood glucose levels were estimated using linear regression. Results Compared to pregnant women in the lowest concentration tertile, women with the highest urinary concentrations (≥3rd tertile) of mono-iso-butyl phthalate (tertile: ≥15.3 μg/l, β = −18.3, 95% CI: −35.4, −1.2) and monobenzyl phthalate (tertile: ≥30.3 μg/l, β = −17.3, 95% CI: −34.1, −0.4) had lower blood glucose levels at the time of GDM screening after adjustment for urinary creatinine and demographic covariates. Conclusion Because maternal glucose levels increase during pregnancy to provide adequate nutrition for fetal growth and development, these findings may have implications for fetal health. However, given the limitations of our study, findings should be interpreted cautiously.

We undertook this study to investigate the relationship between white-matter abnormalities (seen on brain magnetic resonance imaging [MRI]) and muscle tone and muscle stretch reflexes on clinical examination. We identified all patients less than 5 years of age who had undergone cranial MRI studies at Riley Hospital for Children between June 30, 1999, and July 1, 2000, whose scans were read as showing white-matter abnormalities. We measured two ratios and the thickness of the corpus callosum as indicators of the quantity of cerebral white matter. The ratios were R1, the ratio of the thickness of the white matter at the level just above the body of the lateral ventricle compared with the width of the hemisphere, and R2, the ratio of the thickness of the white matter to the width of the hemisphere at the level of the trigone of the lateral ventricle. The thickness of the corpus callosum was measured at the junction of the anterior two thirds and the posterior third. We also evaluated the signal intensity of the cerebral white matter by reviewing the fluid-attenuated inversion-recovery images and grading the signal as normal to severely abnormal depending on the degree and extent of high signal intensity seen (0 = normal to 4+). Thirty-eight children less than 5 years of age who underwent MRI scans between June and August 2000 and who were found to have normal tone prospectively and normal MRI scan on review served as a control group. We identified 215 patients who had white-matter abnormalities; of these, only 142 (66%) had documented tone assessments in their medical record. Our study group was divided into three groups: increased ( n = 35), decreased ( n = 53), and normal tone ( n = 54). All three measurements of white matter in each of the three study groups were significantly below values for control children. The children with white-matter abnormalities and decreased tone had significantly less signal intensity abnormality than the other study groups. Children with white-matter abnormalities and increased tone had a greater frequency of increased reflexes and tended to have more signal abnormalities than the other groups. The group of children with white-matter abnormalities and normal tone had the least amount of cerebral white-matter deficiency of the three study groups. In patients with strikingly decreased quantities of cerebral white matter, those with normal signal-intensity white matter are likely to be hypotonic with normal reflexes and those with increased signal intensity in the white matter are likely to be spastic. ( J Child Neurol 2001;16:668-672).

Objectives:This community-based intervention to reduce urinary incontinence (UI) in elderly women used a small group educational approach. This article reports on change in episodes of incontinence and other urinary symptoms. Methods: Participants were randomly assigned to intervention orwait control condition. This article is restricted to 49 intervention and 59 control participants with acceptable diaries. Results:There was a significant treatment effect for a number of incontinent episodes. In the intervention group, 61% had a 50% or greater reduction in episodes, with more than one third having 100% reduction; 38% of the control group had a reduction of 50% or greater. One year postprogram, 75% of treated women reported subjective improvement. Therewas a reduction in frequency of daily, but not nocturnal, micturition. Discussion:This community-based intervention is an encouraging option for behavioral treatment of UI. Public health models may be particularly appropriate with moderate levels of urinary incontinence.

Many of the risk factors previously identified for disorders such as Alzheimer's disease, periventricular leukomalacia, multiple sclerosis, stroke, cerebral palsy, mental retardation, and acquired learning and attention disorders ultimately may be shown to damage the central and peripheral nervous systems through activation of inflammatory mediators. The challenge to epidemiologists in the future is to expand use of epidemiologic methods to explore how immune-mediated insults produce CNS disorders in human populations. Studies of the association of use of nonsteroidal anti-inflammatory drugs with risk of Alzheimer's disease and those of the association of immune parameters with risk of cerebral palsy are excellent examples of how epidemiology can contribute to our understanding of the causes of neurologic and/or neurodevelopmental disorders. Many of the immune parameters of interest have short half-lives and are difficult to measure outside of the laboratory setting. Questions also remain as to the proper timing of measurements in relation to the initial insult and, in some cases, which tissue is the most appropriate to sample. These measurement issues will need to be resolved before use of immune biomarkers in epidemiologic studies of the etiologies of neurologic disorders can be fully realized. Epidemiologists are most likely to help identify ways to prevent neurologic disorders if they are knowledgeable about the molecular biology of inflammation, modulators of CNS vulnerability, and genetic polymorphisms that influence both inflammation and CNS vulnerability and are prepared to become adept at biomarker epidemiology. This does not necessarily compel them to gain extensive knowledge of neurobiology. Rather, neuroepidemiology in the 21st century will require increased collaboration between epidemiologists, neurologists, and neurobiologists.

Background —Although cardiovascular disease (CVD) used to be rare among American Indians, Indian Health Service data suggest that CVD mortality rates vary greatly among American Indian communities and appear to be increasing. The Strong Heart Study was initiated to investigate CVD and its risk factors in American Indians in 13 communities in Arizona, Oklahoma, and South/North Dakota. Methods and Results —A total of 4549 participants (1846 men and 2703 women 45 to 74 years old) who were seen at the baseline (1989 to 1991) examination were subjected to surveillance (average 4.2 years, 1991 to 1995), and 88% of those remaining alive underwent a second examination (1993 to 1995). The medical records of all participants were exhaustively reviewed to ascertain nonfatal cardiovascular events that occurred since the baseline examination or to definitively determine cause of death. CVD morbidity and mortality rates were higher in men than in women and were similar in the 3 geographic areas. Coronary heart disease (CHD) incidence rates among American Indian men and women were almost 2-fold higher than those in the Atherosclerosis Risk in Communities Study. Significant independent predictors of CVD in women were diabetes, age, obesity (inverse), LDL cholesterol, albuminuria, triglycerides, and hypertension. In men, diabetes, age, LDL cholesterol, albuminuria, and hypertension were independent predictors of CVD. Conclusions —At present, CHD rates in American Indians exceed rates in other US populations and may more often be fatal. Unlike other ethnic groups, American Indians appear to have an increasing incidence of CHD, possibly related to the high prevalence of diabetes. In the general US population, the rising prevalence of obesity and diabetes may reverse the decline in CVD death rates. Therefore, aggressive programs to control diabetes and its risk factors are needed.

OBJECTIVE Many studies have shown that diabetes increases the risk of cardiovascular disease (CVD) in women to a greater extent than in men. One explanation could be that diabetes has more adverse effects on CVD risk factors in women than in men. We compared diabetes-associated differences in CVD risk factors in men and women in the Strong Heart Study, a population-based study of CVD and its risk factors in American Indians. RESEARCH DESIGN AND METHODS A total of 1,846 men and 2,703 women between the ages of 45 and 74 years from 13 American Indian communities in three geographic areas underwent an examination that included a medical history; an electrocardiogram; anthropometric and blood pressure measurements; an oral glucose tolerance test; and measurements of fasting plasma lipoproteins, fibrinogen, insulin, HbA1c, and urinary albumin. RESULTS Statistically significantly greater adverse differences in those with diabetes versus those without diabetes were observed in women than in men for waist-to-hip ratio, HDL cholesterol, apolipoprotein (apo)B, apoA1, fibrinogen, and LDL size. In multiple linear regression models adjusting for age, center, sex, and diabetes, the diabetes by sex interaction terms were statistically significant for waist-to-hip ratio, LDL cholesterol, HDL cholesterol, apoB, apoA1, fibrinogen, and LDL size. CONCLUSIONS Compared with diabetes-associated differences in men, diabetes in women was related to greater adverse differences in levels of several CVD risk factors. Although the magnitude of the individual diabetes-related differences between men and women was not large, the combined effects of these risk factor differences in diabetic women may be substantial. The apparent greater negative impact of diabetes on CVD risk factors in women may explain, in part, the greater risk for CVD in diabetic women.

Abstract Small, dense LDL has been shown to be associated with the insulin resistance syndrome and coronary heart disease (CHD). We examined the distribution of LDL size and phenotype within a population-based sample of American Indians to determine the relationships with prevalent CHD and to examine associations with hyperinsulinemia and other components of the insulin resistance syndrome. Data were available for 4505 men and women between 45 and 74 years of age who are members of 13 American Indian communities in three geographic areas. Diabetes, CHD, and CHD risk factors were assessed by standardized techniques, and LDL size was measured by gradient gel electrophoresis. LDL size was smaller in men than in women and in individuals with diabetes than in those without diabetes. In multivariate analysis, LDL size was significantly related to several components of the insulin resistance syndrome, including triglycerides (inversely) and HDL cholesterol (positively). Although univariate relations were positive, LDL size was not significantly related to fasting insulin concentrations or body mass index in the multivariate model. LDL size also showed no relationship to apolipoprotein E phenotype. When LDL size was compared in individuals with and without CHD, no significant differences were observed, either in nondiabetic or diabetic individuals. We conclude that LDL size is most strongly related to lipoprotein components of the insulin resistance syndrome, especially plasma triglycerides. However, in this population with low LDL, it is not related to cardiovascular disease.

Recent epidemiological studies indicate bisphenol A (BPA), an estrogenic chemical used in production of epoxy, polycarbonate, and plastic may increase risk of insulin resistance and type 2 diabetes. Exposure to BPA during pregnancy may contribute to development of gestational diabetes mellitus (GDM), a precursor to type 2 diabetes in women. This pilot study examined the association between BPA exposure, fasting blood glucose levels (FBG), and GDM diagnosis during pregnancy. Banked urine samples from 22 cases of GDM and 72 controls were analyzed for total (free BPA + conjugates) urinary BPA concentrations (μg/L). FBG levels (mg/dl) were obtained from 1-h 50-g glucose tolerance tests (GTT) that women underwent for routine GDM screening (mean gestational age = 26.6 weeks, SD = 3.8). Those with an initial screening value ≥ 135 mg/dl underwent 3-h 100 g oral GTT. GDM diagnoses were made when the initial screening value was ≥ 200 mg/dl or when values at ≥ 2 time points exceeded 3-h oral GTT thresholds. Among controls, median FBG levels (mg/dL) did not differ across exposure tertiles, defined according to the distribution of total specific-gravity-adjusted urinary BPA concentrations. Logistic regression models controlling for race/ethnicity did not provide evidence of association between BPA exposure and case status across increasing tertiles of BPA exposure (number of GDM cases/controls in tertile1: 13/24; in tertile 2: 6/24; in tertile 3: 3/24). Findings do not support a relationship between total urinary BPA concentrations and altered glucose metabolism during pregnancy. However, due to study limitations, findings need to be interpreted with caution.

As part of the Strong Heart Study assessment of prevalent cardiovascular disease in middle-aged to elderly American Indians, the prevalence of major Minnesota code electrocardiographic (ECG) abnormalities was assessed in 4,531 participants aged 45 to 74 years (59% women) in selected tribal communities in Arizona, South and North Dakota, and Oklahoma. The overall prevalence of major ECG abnormalities was lowest in Arizona participants, (e.g., definite ECG myocardial infarction in 0.3% vs 1.8% in the other centers), although nearly two thirds of them had diabetes. One or more major ECG abnormality occurred in progressively more women (10.4% to 21.2%) and men (13.3% to 32%) (both p0.0001) from 45- to 54- to 55- to 64- and 65- to 74-year age groups, with the latter prevalence rates exceeding those in predominately white age peers in the Cardiovascular Health Study. Diabetes in women, but not in men, and hypertension in both genders showed positive associations with prevalence rates of major ECG abnormalities compatible with coronary artery disease or hypertensive cardiac hypertrophy. Hypercholesterolemia was not associated with ECG abnormalities except for definite myocardial infarction in women. In conclusion, major ECG abnormalities are common in middle-aged to elderly American Indians ,consistent with recent documentation of higher cardiovascular mortality in this population than in similar aged U.S. whites.

Coronary heart disease (CHD) is the leading cause of death among American Indians. However, information on the prevalence of CHD and its association with known risk factors is limited. The purpose of the Strong Heart Study is to quantify CHD and its risk factors among three geographically diverse groups of American Indians. The population consists of 4,549 adults between 45 and 74 years of age in 13 Indian communities in Arizona, Oklahoma, and South and North Dakota. The phase I examination (1989–1991) revealed very high prevalence rates of diabetes that ranged from 33 to 72% in men and women in the three centers. Prevalence rates of definite myocardial infarction (MI) and definite CHD were higher in men than in women in all three centers (P < 0.0001) and in those with diabetes (P = 0.002 and P = 0.0003 in women and men, respectively). Diabetes was associated with a relatively greater increase in prevalence of MI (prevalence rate = 3.8 vs. 1.9) and CHD (prevalence rate = 4.6 vs. 1.8) in women than in men. Logistic regression analysis indicated that the prevalence of CHD among American Indians was significantly related to age, diabetes, hypertension, albuminuria, percentage of body fat, smoking, high concentrations of plasma insulin, and low concentrations of HDL cholesterol. Lower prevalence rates of CHD were found in Arizona despite higher rates of diabetes, obesity, hypertension, and albuminuria; these lower rates may be in part related to lower smoking frequency and lower concentrations of total and LDL cholesterol. These findings from the baseline Strong Heart Study examination emphasize the relative importance of diabetes and its associated variables as risk factors for CHD among American Indian populations.

To investigate the epidemiologic and pathogenetic significance of placental features and neonatal outcome in a high-risk population.One pathologist examined 1252 placentas from clinically selected at-risk singleton pregnancies. Placental pathology features were analyzed relative to gestational age and status of the newborn, including fetal growth restriction (FGR), low 1-minute Apgar score, infection, liver disorder, anomalies, and death in the immediate postnatal period.The most frequent placental pathologic features were ischemic change, meconium staining, and chorioamnionitis. Only 8% of placentas were considered normal. The number of features per placenta increased with gestational age. Among preterm infants, chorioamnionitis occurred most frequently with low 1-minute Apgar score (40%), clinically apparent infection (43%), liver disorder (43%), and anomalies (42%), compared with healthy newborns (15%). Chorioamnionitis at term was most frequent among infants with low 1-minute Apgar score (26%), infection (30%), and liver disorder (23%), compared with healthy newborns (16%). Meconium and ischemic changes were most frequent in placentas from healthy newborns, compared with affected newborns, regardless of gestational age. Multivariable analyses revealed an independent association between chorioamnionitis and low 1-minute Apgar score (P.05), and both chorioamnionitis and villitis were associated with newborn infection (P.05).The frequency of many major pathologic placental features, especially ischemic changes and meconium, in the absence of immediately detectable abnormality is relatively high. Thus, continued follow-up is needed to determine their long-term clinical significance. In addition, associations of ischemic changes and infarction with FGR in term infants suggest that need for comprehensive investigations of the effects of histopathologically apparent low placental blood flow.

Although coronary heart disease (CHD) is currently the leading cause of death among American Indians, information on the prevalence of CHD and its association with known cardiovascular risk factors is limited. The Strong Heart Study was initiated in 1988 to quantify cardiovascular disease and its risk factors among three geographically diverse groups of American Indians. Members of 13 Indian communities in Arizona, Oklahoma, and South and North Dakota between 45 and 74 years of age underwent a physical examination that included medical history; an electrocardiogram; anthropometric and blood pressure measurements; an oral glucose tolerance test; and measurements of fasting plasma lipoproteins, fibrinogen, insulin, hemoglobin A1c, and urinary albumin. Prevalence rates of definite myocardial infarction and definite CHD were higher in men than in women at all three centers (p < 0.0001) and higher in those with diabetes mellitus (p = 0.002 in men and p = 0.0003 in women). Diabetes was associated with relatively higher prevalence rates of myocardial infarction (diabetic:nondiabetic prevalence ratio = 3.8 vs. 1.9) and CHD (prevalence ratio = 4.6 vs. 1.8) in women than in men. Prevalence rates of heart disease were lowest in the communities in Arizona; prevalence rates were similar in Oklahoma and South Dakota/North Dakota and were two- to threefold higher than those in Arizona. By logistic regression, prevalent CHD among American Indians was significantly and independently related to age, diabetes, hypertension, albuminuria, percentage of body fat, smoking, high concentrations of plasma insulin, and low concentrations of high density lipoprotein cholesterol. In contrast to reports from other non-Indian populations, diabetes was the strongest risk factor. The lower prevalence of CHD among Indians in Arizona is distinctive in view of their higher rates of diabetes, obesity, hypertension, and albuminuria, but it may be partly related to their low frequency of smoking and their low concentrations of total and low density lipoprotein cholesterol. These findings from the initial Strong Heart Study examination emphasize the importance of diabetes and its associated variables as risk factors for CHD in Native American populations.

The Strong Heart Study, a study of cardiovascular disease among American Indians, was conducted to determine cardiovascular disease rates and the prevalence of risk factors among members of 13 tribal groups in South Dakota/North Dakota (SD/ND), southeastern Oklahoma, and Arizona. From 1989 to 1992, 4,549 tribal members aged 45-74 years (62% of eligible participants) were surveyed and examined for cardiovascular disease and its risk factors. Mean total cholesterol concentrations were over 20 mg/dl lower among the men and 27 mg/dl lower among the women than national mean levels for the same age groups. Cholesterol levels varied by tribal group; Arizona Indians had mean levels more than 20 mg/dl lower than those of SD/ND Indians. The prevalence of hypercholesterolemia was almost twice as high among SD/ND Indians as among Arizona Indians, but the rates for all three groups were much lower than total US rates (all races). Mean levels of high density lipoprotein cholesterol were lower among Indian men and women than in the US population as a whole. The prevalence of hypertension among Arizona and Oklahoma Indians was higher than that for the entire United States. SD/ND Indians had significantly lower mean blood pressures and prevalence rates of hypertension than Oklahoma and Arizona Indians and the United States as a whole. The prevalence of cigarette smoking was higher for all Indian groups except Arizona women in comparison with US rates. Smoking rates were highest in SD/ND and lowest in Arizona. Indian smokers smoked fewer cigarettes per day than the average US smoker. Arizona Indians had the highest prevalence of diabetes mellitus; over 60% of those participants were diabetic. In Oklahoma and SD/ND, one third of the men and over 40% of the women were diabetic. In addition, 13-20% of the participants had impaired glucose tolerance. Proteinuria was also a common problem; almost half of the Arizona Indians had micro- or macroalbuminuria, and 20% of Oklahoma and SD/ND Indians had significant proteinuria. The prevalence of obesity was high in all three groups, with Arizona Indians having the highest rates and the highest mean body mass indices. The prevalence of current alcohol use was lower among Indians than in the nation as a whole, but binge drinking was common among those who used alcohol. These results indicate that cardiovascular disease risk factors vary significantly among tribal groups. Prevention programs tailored toward decreasing the prevalence of risk factors are recommended for long-term reduction of cardiovascular disease rates in American Indian communities.

OBJECTIVE To estimate prevalence rates of diabetes and impaired glucose tolerance (IGT) in three American Indian populations, using standardized diagnostic criteria, and to assess the association of diabetes with the following selected possible risk factors: age, obesity, family history of diabetes, and amount of Indian ancestry. RESEARCH DESIGN AND METHODS This cross-sectional study involved enrolled members, men and women aged 45-74 years, of 13 American Indian tribes or communities in Arizona, Oklahoma, and South and North Dakota. Eligible participants were invited to the clinic for a personal interview and a physical examination. Diabetes and IGT status were defined by the World Health Organization criteria and were based on fasting plasma glucose and oral glucose tolerance test results. Data on age, family history of diabetes, and amount of Indian ancestry were obtained from the personal interview, and measures of obesity included body mass index, percentage body fat, and waist-to-hip ratio. RESULTS A total of 4,549 eligible participants were examined, and diabetes status was determined for4,304(1,446 in Arizona, 1,449 in Oklahoma, and 1,409 in the Dakotas). In all three centers, diabetes was more prevalent in women than in men. Arizona had the highest age-adjusted rates of diabetes: 65% in men and 72% in women. Diabetes rates in Oklahoma (38% in men and 42% in women) and South and North Dakota (33% in men and 40% in women), although considerably lower than in Arizona, were several times higher than those reported for the U.S. population. Rates of IGT among the three populations (14-17%) were similar to those in the U.S. population. Diabetes rates were positively associated with age, level of obesity, amount of Indian ancestry, and parental diabetes status. CONCLUSIONS Diabetes is found in epidemic proportions in Native American populations. Prevention programs and periodic screening should be implemented among American Indians. Standards of care and intervention have been developed by the Indian Health Service for individuals in whom diabetes is diagnosed. These programs shoula be expanded to include those with IGT to improve glycemie control or to reduce the risk of development of diabetes as well as to reduce the risk of diabetic complications.

Coated-platelets are procoagulant platelets observed upon dual-agonist stimulation with collagen and thrombin. Coated-platelet levels are elevated in patients with nonlacunar (large-vessel) ischemic stroke and decreased in patients with spontaneous intracerebral hemorrhage as compared with controls. The purpose of this study was to investigate a possible relationship between coated-platelet levels and stroke recurrence in patients with nonlacunar ischemic stroke. We assayed coated-platelet levels in 190 consecutive patients with nonlacunar stroke who were followed for up to 12 months; 20 subjects experienced recurrent stroke. Subjects were categorized into tertiles of coated-platelet levels. The distributions of time-to-recurrent stroke were estimated for each tertile using cumulative incidence curves and compared statistically using a log-rank test. The cumulative incidence of recurrent stroke at 12 months differed among the coated-platelet tertiles: 2% for the first tertile (lowest coated-platelet levels), 18% for the second tertile, and 17% for the third tertile (overall log-rank test, P = 0.019). These data suggest that higher levels of coated-platelets, measured shortly after a nonlacunar stroke, are associated with an increased incidence of stroke recurrence. This observation offers an additional tool for identifying patients at highest risk for stroke recurrence following a nonlacunar (large-vessel) infarct.

International audience; PURPOSE: To estimate the association between the prevalence of epilepsy and potential risk factors in three Burkina Faso villages. METHODS: Three villages were selected based on local reports of high numbers of epilepsy cases and pig-rearing practices. One person aged 7 or older was selected at random from all households of selected concessions for epilepsy screening and blood sampling. Epilepsy was confirmed by a physician using the ILAE definition. The cross-sectional associations between epilepsy and selected factors and seroresponse to the antigens of Taenia solium were estimated using a Bayesian hierarchical logistic regression. Prevalence odds ratios (POR) and their 95% Bayesian Credible Intervals (95% BCI) were estimated. RESULTS: Of 888 individuals interviewed, 39 of 70 screened positive were confirmed to have epilepsy for a lifetime prevalence of 4.5% (95% CI: 3.3; 6.0). The prevalence of epilepsy was associated with a positive reaction to cysticercosis Ag-ELISA serology (POR = 3.1, 95% BCI = 1.0; 8.3), past pork consumption (POR = 9.7, 95% BCI = 2.5; 37.9), and being salaried or a trader compared to a farmer or housewife (POR = 2.9, 95% BCI = 1.2; 6.4). DISCUSSION: Several factors were associated with prevalent epilepsy, with Ag-ELISA suggesting the presence of neurocysticercosis. The association between epilepsy and some occupations may reflect differences in local attitudes toward epilepsy and should be further explored.

Background The clinical manifestations of neurocysticercosis (NCC) are poorly understood. This systematic review aims to estimate the frequencies of different manifestations, complications and disabilities associated with NCC. Methods A systematic search of the literature published from January 1, 1990, to June 1, 2008, in 24 different electronic databases and 8 languages was conducted. Meta-analyses were conducted when appropriate. Results A total of 1569 documents were identified, and 21 included in the analysis. Among patients seen in neurology clinics, seizures/epilepsy were the most common manifestations (78.8%, 95%CI: 65.1%–89.7%) followed by headaches (37.9%, 95%CI: 23.3%–53.7%), focal deficits (16.0%, 95%CI: 9.7%–23.6%) and signs of increased intracranial pressure (11.7%, 95%CI: 6.0%–18.9%). All other manifestations occurred in less than 10% of symptomatic NCC patients. Only four studies reported on the mortality rate of NCC. Conclusions NCC is a pleomorphic disease linked to a range of manifestations. Although definitions of manifestations were very rarely provided, and varied from study to study, the proportion of NCC cases with seizures/epilepsy and the proportion of headaches were consistent across studies. These estimates are only applicable to patients who are ill enough to seek care in neurology clinics and likely over estimate the frequency of manifestations among all NCC cases., Author Summary Neurocysticercosis is an infection of the brain with the flatworm Taenia solium which is normally transmitted between humans and pigs. Sometimes, humans can infect other humans and the larva of the parasite can go the brain, causing the disease neurocysticercosis. There has never been a systematic review of what clinical signs are found among people with neurocysticercosis. We conducted a thorough review of the literature to answer this question. We reviewed 1569 and 21 were of a sufficient quality to be included in the final analysis. Among neurocysticercosis patients who are seeking care in neurology clinics, about 79% have seizures/epilepsy, 38% severe headaches, 16% focal deficits and 12% signs of increased intracranial pressure. Several other symptoms were also reported in less than 10% of patients. People with neurocysticercosis who seek care in neurology clinics show a whole range of manifestations. Clinicians should be encouraged to consider neurocysticercosis in their differential diagnosis when a patient presented with one of the symptoms described in this review. This would ultimately improve the estimates of the frequency of symptoms associated with neurocysticercosis.

Objective Neurologic manifestations of copper deficiency in adults are increasingly recognized. We sought to determine if copper supplementation over a period of 12 months would improve functional activities of daily living (ADLs) in patients with copper deficiency. Methods We studied 15 consecutively diagnosed patients with copper deficiency that received 12 months of copper supplementation. Functional ADLs were evaluated by the Barthel Index (BI), administered at the time of diagnosis and repeated after 12 months of copper supplementation. Results BI scores were significantly higher after 12 months of continued supplementation when compared with initial scores [(mean ± SD), 74 ± 11.7 versus 83 ± 13.2, P = 0.007, paired t-test]. A significant inverse linear correlation between the duration of symptoms before treatment and the change in the BI scores was noted (P = 0.005). Conclusions Early initiation and sustained supplementation with copper for at least 12 months may improve functional ADLs in patients with copper deficiency.

Once emergency medical services (EMS) personnel decide to transport a trauma patient directly to definitive care, the next key decision at the scene of injury is whether to transport by air or ground.The aim of this study was to identify factors at the scene of injury that are associated with this decision.All trauma patients transported directly to a level I or level II trauma center by either air or ground EMS over a four-year period were selected from the Oklahoma State Trauma Registry. Initial scene vital signs, Glasgow Coma Scale score (GCS), injury mechanism, anatomic triage criteria, age, time of day, ground EMS service level, and scene location were collected. Scene location ZIP code centroids were geocoded and used to calculate distance to the trauma center. Following bivariate analyses, multivariable logistic regression models were developed within three strata defined by distance (35, 16-35, and16 miles).More than 80% of the patients beyond 35 miles were transported by air, compared with 32% from 16-35 miles and only 4% from16 miles. Regardless of distance, patients transported by helicopter tended to be younger, more often had abnormal vital signs, and more frequently came from areas served by a basic or intermediate ground EMS agency, as compared with patients transported by ground. Within each distance stratum, patients injured in severe motor vehicle crashes, motorcycle crashes, or pedestrian incidents were more likely to be transported by air. A GCS14 was the only patient-related factor consistently associated with increased odds of air transport.Distance is the main factor in deciding whether to use air or ground EMS to transport a trauma patient from the scene of injury to a trauma center. With the exception of GCS14, injury etiology was more strongly and consistently associated with the decision to transport by air than were patient related-factors. Identifying factors influencing the field transport decision will help develop transport guidelines that make efficient use of EMS resources.

Background Whether the plasma triglyceride level is a risk factor for coronary heart disease has been controversial, and evaluation of the triglyceride level as a risk factor is fraught with methodologic difficulties. Methods We studied the association between plasma triglyceride levels and the 12-year incidence of death from coronary heart disease in 10 North American populations participating in the Lipid Research Clinics Follow-up Study, while adjusting for the potential confounding effects of other risk factors for cardiovascular disease, including the level of high-density lipoprotein (HDL) cholesterol. All analyses were sex-specific, and separate analyses were performed in high and low strata of HDL cholesterol, low-density lipoprotein (LDL) cholesterol, fasting plasma glucose, and age. Results The rates of coronary death in both men and women increased with the triglyceride level. In Cox proportional-hazards models adjusted for age, in which the natural log of the triglyceride levels was used to gi...

Recent evidence suggests a measurable reduction in mortality for patients transferred from a nontertiary trauma center (Level III or IV) to a Level I trauma center, but not for those transferred to a Level II trauma center. Whether this can be generalized to a predominantly rural region with fewer tertiary trauma care resources is uncertain. This study sought to evaluate mortality differences for patients initially presenting to nontertiary trauma centers in a predominantly rural region depending on transfer status.This was a retrospective cohort study of patients initially presenting to 104 nontertiary trauma centers in Oklahoma and meeting the state's criteria for major trauma. Patients dying within 1 hour of emergency department (ED) arrival at the nontertiary trauma center were excluded. The exposure variable of interest was admission status, which was categorized as either transfer to a tertiary (Level I or II) trauma center within 24 hours or admission to a nontertiary trauma center. Propensity scores were used to minimize the selection bias inherent in the decision to admit or transfer a patient for higher-level care. Multiple logistic regression was used to generate three propensity score models: probability of transfer to either a Level I or II, Level I only, and Level II only. Propensity scores were then included as a covariate in multivariable Cox regression models assessing outcome differences between admitted and transferred patients. The outcome of interest was 30-day mortality, defined as death at either the nontertiary trauma center or the tertiary trauma center within 30 days of arrival at the initial Level III/IV center's ED.A total of 6,229 patients met study criteria, of whom 2,669 (43%) were transferred to tertiary trauma centers. Of those transferred, 1,422 patients (53%) were transferred to a Level I trauma center. Crude mortality was lower for patients transferred to tertiary trauma centers compared to those remaining at nontertiary trauma facilities (hazard ratio [HR] = 0.59; 95% confidence interval [CI] = 0.48 to 0.72). After adjusting for the propensity to be transferred, Injury Severity Score (ISS), presence of severe head injury, and age, transfer to a tertiary trauma center was associated with a significantly lower 30-day mortality (HR = 0.38; 95% CI = 0.30 to 0.50) compared to admission and treatment at a nontertiary trauma center. The observed survival benefit was similar for patients transferred to a Level I trauma center (HR = 0.36; 95% CI = 0.20 to 0.4) and those transferred to a Level II center (HR = 0.45; 95% CI = 0.33 to 0.61).This study suggests a survival benefit among patients initially presenting to nontertiary trauma centers who are subsequently transferred to tertiary trauma centers compared to those remaining in nontertiary trauma centers, even after adjusting for variables affecting the likelihood of transfer. Although this survival benefit was larger for patients treated at a Level I trauma center, Level II trauma centers in a region with few tertiary trauma resources demonstrated a measurable benefit as well.

Background Little is known about porcine cysticercosis in Burkina Faso. We conducted a pilot study to estimate the prevalence of antigens of Taenia solium cysticercosis and to identify associated factors in pigs of three villages in Burkina Faso, selected to represent different pig management practices: one village where pigs are allowed to roam freely (Batondo), one village where pigs are penned part of the time (Pabré) and one village with limited pig farming (Nyonyogo). Methods/Principal Findings A clustered random sampling design was used. Data on socio-demographic characteristics (source of drinking water, presence of latrines in the household, type and number of breeding animals) and pig management practices were collected using a standardized questionnaire. Blood samples were collected from one pig per household to determine the presence of antigens of the larval stages of T. solium by the B158/B60 Ag-ELISA. The associations between seropositivity and socio-demographic and pig management practices were estimated using logistic regression. Proportions of 32.5% (95% CI 25.4–40.3), 39.6% (31.9–47.8), and 0% of pigs, were found positive for the presence of circulating antigens of T. solium in Batondo, Pabré, and Nyonyogo, respectively. The results of the logistic regression analyses suggested that people acquire knowledge on porcine cysticercosis following the contamination of their animals. The presence of antigens in the pigs' sera was not associated with the absence of latrines in the household, the source of drinking water or the status of infection in humans but was associated with pig rearing practices during the rainy season. Conclusions/Significance The results suggest that education of pig farmers is urgently needed to reduce the prevalence of this infection., Author Summary Taenia solium cysticercosis is a neglected tropical infection transmitted between humans and pigs. This infection is particularly common in areas where sanitation, hygiene and pig management practices are poor, and can sometimes lead to epilepsy in humans. There is very little information about the importance of this infection in Burkina Faso, even though pork meat is widely consumed in many villages. We conducted a pilot study in three villages: two villages where pig rearing and pork consumption are common (Batondo and Pabré) but with different pig management practices, and one village with limited pig farming and pork consumption (Nyonyogo). Blood tests were done on pigs and information on pig raising was collected from farmers. Our study demonstrated that at least one third of pigs are infected with cysticercosis in villages where they are raised, and, particularly when pigs are left to roam some or all of the time. It also demonstrated that farmers may not be aware of this disease until one of their animals is found to be infected. Thus, the study concluded that there is an urgent need for improving education in order to control this tropical disease.

BACKGROUND:: Indications for direct transport may be strongly related to risk of future health outcomes, and these indications may not be adequately controlled by considering only in-hospital variables. This study was designed to identify prehospital factors associated with directness of transport. METHODS:: The study included 2,062 patients treated at a Level I trauma center between January 1, 2006, and December 31, 2007. The outcome of interest was directness of transport to a Level I trauma center. A propensity score analysis was used to identify demographic, clinical, distance, and other injury scene-related variables associated with the probability of direct transport. RESULTS:: A total of 1,459 patients were directly transported to the Level I trauma center and 603 were transferred from lower level facilities. Patients were more likely to be transported directly if they had lower Glasgow Comma Scale scores, had penetrating injuries, were involved in traffic-related injuries, were closer to a Level IV or I trauma center, and if an advanced life support emergency medical service agency transported them from the scene. Patients were more likely to initially stop if they required advanced airway management, met at least one anatomic criterion, were further away from a Level I trauma center, or closer to an intermediate facility. CONCLUSIONS:: Confounding due to unadjusted prehospital factors may be present in studies evaluating the impact of directness of transport on short-term mortality outcomes. Propensity score analysis of treatment indications provides an additional and efficient method to reduce this bias. Language: en

It was reported that high coffee consumption was related to decreased diabetes risk. The aim of this study is to examine the association between coffee consumption and the incidence of type 2 diabetes in persons with normal glucose tolerance in a population with a high incidence and prevalence of diabetes.In a prospective cohort study, information about daily coffee consumption was collected at the baseline examination (1989-1992) in a population-based sample of American Indian men and women 45-74 years of age. Participants with normal glucose tolerance (N = 1141) at the baseline examination were followed for an average of 7.6 years. The incidence of diabetes was compared across the categories of daily coffee consumption. The hazard ratios of diabetes related to coffee consumption were calculated using Cox proportional hazards models, adjusted for potential confounders. Levels of coffee consumption were positively related to levels of current smoking and inversely related to body mass index, waist circumference, female gender, and hypertension. Compared to those who did not drink coffee, participants who drank 12 or more cups of coffee daily had 67% less risk of developing diabetes during the follow-up (hazard ratio: 0.33, 95% confidence interval: 0.13, 0.81).In this population, a high level of coffee consumption was associated with a reduced risk of deterioration of glucose metabolism over an average 7.6 years of follow-up. More work is needed to understand whether there is a plausible biological mechanism for this observation.

The Strong Heart Study is a study of cardiovascular disease and its risk factors among diabetic and nondiabetic Native Americans. The study includes 12 tribes in Arizona, Oklahoma, and North and South Dakota. Phase I, initiated in October 1988, included a mortality survey to determine CVD death rates in individuals 35–74 yr old between 1984 and 1988, and a medical record review to determine rates of myocardial infarction and stroke for individuals ages 45–74 during the same time. In addition, a physical examination was performed on persons 45–74 yr old to measure the prevalence of cardiovascular and peripheral vascular diseases and known and suspected risk factors, in Phase II, CVD mortality and morbidity rates will be determined in the examined cohort by surveillance. CVD risk factors, changes in risk factors over time, and the relationship between risk factors and CVD incidence will be assessed longitudinally. This study provides data on the relative importance of cardiovascular risk factors in nondiabetic and diabetic Native Americans and will provide insight into possible variations in the quantitative or qualitative importance of CVD risk factors among diverse population groups.