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Biomedical subjects

A L Franks

Publications and source records attributed to A L Franks.

At least 19 recordsLinked to original sources
PubMed1999

Screening for hemochromatosis. A public health perspective.

CONTEXT: The discovery of the HFE gene in 1996 has introduced DNA testing as a possible tool for screening and diagnosis of hemochromatosis and increased interest in the disorder. Population screening using transferrin saturation has been advocated by experts to permit early detection and treatment with phlebotomy before the onset of clinical disease. METHODS: Based on a literature review, we consider the relative risks and merits of two screening tests as part of a broader look at the evidence required for the recommendation of universal screening for hemochromatosis. RESULTS: Several questions must be answered before universal screening can be recommended. Uncertainties remain about the penetrance and preventable disease burden, laboratory standardization, and optimal strategies to minimize potential risks of screening for hemochromatosis. CONCLUSIONS: As a common genetic disorder with simple, effective therapy, hemochromatosis offers a model for other genetically influenced chronic diseases that some day may have interventions to improve prognosis. Resolution of questions related to prevention of chronic diseases from hemochromatosis, therefore, will have broad usefulness in the future.

Cost of Illness↗
PubMed1999

Screening for hereditary hemochromatosis: are DNA-based tests the answer?

Universal screening for hereditary hemochromatosis (HH) has been proposed by many experts, with understandable enthusiasm: HH can cause fatal complications, which are preventable with early treatment. The disorder involves excess iron accumulation that can result in tissue iron overload, with secondary cirrhosis, diabetes, heart failure, impotence and arthritis. These complications are preceded by years of iron accumulation, and most are believed to be preventable by removal of excess iron by phlebotomy. Thus, early identification and treatment - the quintessential functions of health screening - seem to make sense for HH. However, the available screening tests are imperfect. While they can identify many persons at increased risk from HH, the proportion that will develop serious clinical manifestations related to iron overload is not known with certainty. DNA-based tests do not provide a simple resolution to these questions.

Genetic Testing↗
PubMed1999

Vaginal estrogen creams: use patterns among a cohort of women.

OBJECTIVE: To assess the prevalence, amount, and duration of use of vaginal estrogen cream among several birth cohorts of women from 1983 through 1992. DESIGN: Analyses are based on automated membership, pharmacy, and hospital discharge databases from Group Health Cooperative (GHC) of Puget Sound, a large health maintenance organization in Seattle, Washington. PARTICIPANTS: A total of 33,822 women, aged 45 years and older as of December 31, 1983, who were enrolled in GHC from 1983 to 1992 or who were enrolled at baseline and died in the following decade. RESULTS: About 24% of the cohort had filled at least one prescription for vaginal estrogen cream during 1983 through 1992, and about 60% of the users had more than one prescription filled. The annual birth cohort-specific prevalence of having filled one or more prescriptions for vaginal estrogen creams ranged between 1.6 and 8.2% across birth cohorts, whereas the average annual prevalence for the cohort was between 5.3 and 6.8%. The total amount, duration of use, and proportion of total estrogen exposure from creams increased with age of the birth cohort. Among the 733 women with intact uteri who were long-term cream users, 60.4% had no progestin prescriptions while averaging 22.1 tubes of estrogen cream. CONCLUSION: The prescription-filling patterns for estrogen in this cohort show an increase in the amount, years of use, and proportion of estrogen exposure from creams with the age of the birth cohort and extensive unopposed cream use among a small proportion of women with intact uteri. The systemic effects of vaginal estrogen cream among older postmenopausal women with urogenital atrophy deserve closer scrutiny.

Administration, Oral↗
PubMed1998

Iron overload, public health, and genetics: evaluating the evidence for hemochromatosis screening.

Population screening for hemochromatosis done by using the transferrin saturation test has been advocated by experts to permit the initiation of therapeutic phlebotomy before the onset of clinical disease. The discovery of a gene associated with hemochromatosis has made DNA testing another option for screening and diagnosis. In this paper, U.S. Preventive Services Task Force criteria are used to evaluate the evidence for the usefulness of population screening done by using iron measures or genetic testing. Published clinical research offers little evidence to suggest that population screening for hemochromatosis done by using genetic testing improves clinical outcomes. Although one recently discovered mutation, C282Y, accounts for 60% to 92% of cases of the disease in series of patients with hemochromatosis, uncertainties remain about the clinical penetrance of various genotypes; the accuracy of genetic testing; and the ethical, legal, and social effects of genetic testing. Before population screening for hemochromatosis done by using transferrin saturation testing can be recommended, laboratory standardization needs to be addressed and questions about risk for clinical disease in asymptomatic persons with mutations or early biochemical expression of disease require resolution. Evidence from case series suggests that hemochromatosis may be associated with liver cancer, other liver disease, diabetes, bradyarrhythmias, and arthritis. In all studies but one, however, estimation of the magnitude and significance of this risk is limited by lack of adequate comparison groups. The need for population data to answer questions about penetrance among asymptomatic persons should not impede efforts to increase the detection and treatment of hemochromatosis in persons found to have elevated iron measures a family history of hemochromatosis, or consistent early signs and symptoms of the disease.

Hemochromatosis↗
PubMed1998

Research priorities in hereditary hemochromatosis.

The Working Group on Research Priorities used a formal nominal group technique to identify and prioritize the specific aims of applied research needed to provide the scientific basis for population screening for iron overload disorders. The most important applied research goal was characterization of the natural history of the relation between genotype and phenotype in hereditary hemochromatosis and other iron overload disorders. Three other important research objectives were development of an optimal approach to screening for iron overload; analyses of the cost-effectiveness of screening; and assessment of the ethical, legal, and social implications of screening. To achieve these specific aims, two research studies were recommended as being of the highest priority: a multicenter, cross-sectional, population-based study of the natural history of iron overload and a multicenter, case-control study of patients with disease manifestations potentially attributable to hereditary hemochromatosis in primary care and subspecialty clinics.

Cost-Benefit Analysis↗
PubMed1998

The prevalence of risk factors among women in the United States by race and age, 1992-1994: opportunities for primary and secondary prevention.

OBJECTIVE: To analyze the prevalence of 11 modifiable behavioral risk factors, including multiple risk factors, among white, black, Asian and Pacific Islander, American Indian, and Hispanic women in the United States. DESIGN: We used Behavioral Risk Factor Surveillance System (BRFSS) data for 1992 to 1994 to examine risk factors (smoking; obesity; diabetes; heavy alcohol consumption; sedentary lifestyle; and inadequate use of seat belts, pap smears, consumption of fruits or vegetables, mammography and colorectal screening, and immunization), among women age 18 to 49, 50 to 64, and 65 and older. We also conducted a multiple regression analysis, comparing the odds of having either 1-2 versus 0 or 3 or more versus 0 risk factors among racial/ethnic groups, controlling for education and family income, to see if racial/ethnic differences can be attributed to socioeconomic differences. RESULTS: US women engage in a variety of behaviors that place them at risk for many causes of morbidity and mortality. Risk profiles vary substantially among racial/ethnic populations: Pacific Islanders have relatively low prevalences of most major risk factors, while blacks and American Indians have relatively high prevalences of many major risk factors. Prevalence differences among racial/ethnic populations are diminished but not eliminated when socioeconomic factors are accounted for. CONCLUSIONS: Appropriately designed programs to help women reduce their behavioral risk factors are needed. Action by health care providers, communities, and policy makers can substantially improve the health of women in the United States.

Adolescent↗
PubMed1993

Racial differences in the use of invasive coronary procedures after acute myocardial infarction in Medicare beneficiaries.

We examined differences in the use of invasive diagnostic and therapeutic coronary procedures between white and black Medicare beneficiaries following acute myocardial infarction. We used Medicare hospitalization data for patients aged 65 years or older who were hospitalized with an acute myocardial infarction in 1988, and we followed them through the calendar year to determine whether they received invasive coronary procedures. We used multivariate logistic regression to control simultaneously for multiple potential confounding factors including age, geographic region, poverty, comorbid conditions, access to hospitals equipped to provide invasive procedures, and short-term survival. We calculated odds ratios for racial differences in use of invasive diagnostic procedures (coronary arteriography, cardiac catheterization) and, separately, of myocardial revascularization procedures (coronary artery bypass grafting, percutaneous transluminal coronary angioplasty). We found that the odds of receiving an invasive diagnostic procedure after acute myocardial infarction were 2.0 times greater for white men than for black men (95% CI: 1.8-2.1); for white women, the odds were 1.5 times greater than for black women (95% CI: 1.4-1.6). Following an invasive diagnostic procedure, the odds of myocardial revascularization were 1.8 times greater among white than among black men (95% CI: 1.6-2.0), and 1.7 times greater among white than among black women (95% CI: 1.6-2.0). We conclude that invasive diagnostic and therapeutic coronary procedures are used more often among white than among black Medicare beneficiaries following acute myocardial infarction. Further investigation of this discrepancy will require detailed clinical and attitudinal information from medical records, patients, and physicians.

Black or African American↗
PubMed1992

Hospitalization for pregnancy complications, United States, 1986 and 1987.

OBJECTIVE: The purpose of our analysis was to provide a national overview of the magnitude of the public health burden associated with inpatient care for pregnancy complications. STUDY DESIGN: We analyzed data from the National Hospital Discharge Survey for 1986 and 1987. We calculated ratios of hospitalizations for pregnancy complications for every 100 hospitalizations involving a birth. Standard errors for these ratios were calculated with RATIOEST, and relative ratios with 95% confidence intervals were calculated for subgroups of interest. RESULTS: We found that for every 100 hospitalizations involving a birth, there were 22.2 nondelivery hospitalizations for pregnancy complications (14.6 antenatal complications, 7.6 pregnancy loss complications). These ratios were higher for black than for white women (relative ratio 1.4, 95% confidence interval 1.2 to 1.6). The effects of marital status, age, and insurance coverage differed between black and white women, and mean length of stay was longer for black than for white women. CONCLUSION: Hospitalization for pregnancy complications is far more common than is widely appreciated and is more frequent among black than white women.

Adolescent↗
PubMed1992

Trends in obstetric operative procedures, 1980 to 1987.

OBJECTIVES: Increasing rates of cesarean deliveries have received widespread attention in recent years, as concern in the United States about unnecessary surgical procedures has increased. However, little information has been published on the national trends of other operative obstetric procedures occurring during deliveries. METHODS: We analyzed data from the National Hospital Discharge Survey to examine trends in the use of forceps, vacuum extraction, and cesarean section from 1980 through 1987. RESULTS: The rate of cesarean sections increased by 48%, while the rate of forceps procedures declined by 43%. Although the risk of cesarean section was significantly increased for older women, the risk of forceps and vacuum extraction procedures did not vary by age. Women with private insurance were significantly more likely to receive a cesarean section (rate ratio [RR] = 1.2), forceps procedure (RR = 1.7), and vacuum extraction procedure (RR = 1.8) than were women without private insurance. CONCLUSIONS: As pressure mounts to decrease the national cesarean section rate from 24% to 15% by the year 2000, attention should also be given to surveillance of other operative delivery procedures.

Adolescent↗
PubMed1990

Contraception and ectopic pregnancy risk.

Studies of the association of ectopic pregnancy with contraception have generated a conflicting array of results because of methodologic differences between studies. We estimated the absolute incidence rates of ectopic pregnancy for various contraceptives by multiplying the pregnancy rate by the proportion of pregnancies with ectopic implantation for each method. Our results indicated a more than 500-fold difference in ectopic pregnancy incidence, from a low of 0.005 ectopic pregnancies per 1000 women years of oral contraception or vasectomy to a high of 2.6 per 1000 women years of no contraception. These estimated incidence rates should be useful for clinicians and patients seeking to better understand the risks and benefits of contraceptives.

Adult↗
PubMed1990

Epidemiology of preeclampsia and eclampsia in the United States, 1979-1986.

Preeclampsia and eclampsia continue to be among the leading causes of maternal death. However, national estimates of the occurrence of these conditions have not been available. To derive national rates of preeclampsia and eclampsia and to characterize the women at highest risk of the development of these conditions, we analyzed data from the National Hospital Discharge Survey for the years 1979 through 1986. We found that 26 per 1000 births during this period were complicated by preeclampsia and 0.56 per 1000 births were complicated by eclampsia. The rate of mild or unspecified preeclampsia remained constant over the study period. In contrast, the rate of severe preeclampsia increased sharply and the rate of eclampsia declined by 36%. Maternal age less than 20 years old was the strongest risk factor for both preeclampsia and eclampsia. These data indicate a need for improved prenatal care among teenagers.

Adolescent↗
PubMed1990

Fatal pulmonary embolism during legal induced abortion in the United States from 1972 to 1985.

To determine the risk factors for abortion-related deaths caused by pulmonary embolism, we investigated all deaths from legal abortions in the United States from 1972 through 1985. Of 213 deaths, 45 (21%) were due to air, blood clot, or amniotic fluid embolism. The risk of embolism death was higher among minority women and older women (34 to 44 years). Our analysis revealed that curettage at less than or equal to 21 weeks and abortions at less than or equal to 12 weeks, regardless of method, were both associated with the least risk of embolism death. In comparing 1972 to 1978 and 1979 to 1985, we found that the embolism mortality rate decreased 79%. During 1979 to 1985, the number of abortions performed by noncurettage methods decreased 58%, possibly as a result of earlier abortion morbidity studies, which showed that these methods carried a greater risk of complications. Although a decrease in mortality rates may be partially attributable to the declining use of these methods, our analysis suggests that changes in methods over time have not been universally applied to all racial groups.

Abortion, Induced↗
PubMed1990

Obstetrical pulmonary embolism mortality, United States, 1970-85.

To investigate pulmonary embolism as a cause of obstetrical death, vital records data from 1970 through 1985 were analyzed. Results showed that the number of obstetrical pulmonary embolism deaths per 100,000 live births declined by 50 percent for both Whites and Blacks. However, Black women maintained more than a 2.5-fold higher risk, and women over age 40 had a ten-fold higher risk of embolism mortality. Thus, although the risk of obstetrical pulmonary embolism death has declined, some subgroups of women remain at higher risk.

Adolescent↗