The geography of stroke mortality in the United States and the concept of a stroke belt.
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Adolescent↗
Biomedical subjects
L H Kuller
Publications and source records attributed to L H Kuller.
Morbidity, mortality, and antihypertensive treatment effects by extent of atherosclerosis in older adults with isolated systolic hypertension.
BACKGROUND AND PURPOSE: The Systolic Hypertension in the Elderly Program (SHEP) demonstrated a significant reduction in stroke and coronary event rates among participants randomly assigned to active blood pressure treatment. Selected participants were evaluated for peripheral atherosclerosis and followed up for cardiovascular events beyond the end of the SHEP trial. Antihypertensive treatment effects were evaluated based on the presence or absence of clinical or subclinical atherosclerosis. METHODS: As an ancillary study to SHEP, 190 participants at the Pittsburgh center were evaluated for peripheral atherosclerosis, defined as either an internal carotid stenosis (by duplex scan) or lower extremity arterial disease (identified by ankle blood pressure). Participants were subsequently followed up for cardiovascular events. RESULTS: Estimates of 4-year mortality rates were 4.8% for participants with no atherosclerosis, 16.7% for those with subclinical atherosclerosis, and 23% among those with clinical evidence of atherosclerosis (P < .001). Fatal plus nonfatal cardiovascular event rates were 10.9%, 29.8%, and 58.3% for the three groups, respectively (P < .001). Differences remained significant after adjustment for age, sex, treatment assignment, smoking, and high-density lipoprotein cholesterol. Individuals assigned to placebo at the beginning of SHEP had higher cardiovascular event rates than individuals assigned to active treatment (P = .011), with the most striking difference 3 or more years after the end of the SHEP trial. When this analysis was stratified by the presence or absence of detectable atherosclerosis, the absolute treatment effect was largest among those with evidence of disease. CONCLUSIONS: Individuals with systolic hypertension and evidence of peripheral atherosclerosis are at high risk for cardiovascular events. Targeting this group for antihypertensive therapy would result in the prevention of a large number of cardiovascular events.
Aged↗
The use of existing databases in morbidity and mortality studies.
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Chronic Disease↗
Herpes zoster in systemic lupus erythematosus.
OBJECTIVE: To define the clinical spectrum and disease sequelae of herpes zoster and to determine the risk factors associated with the development of herpes zoster in patients with systemic lupus erythematosus (SLE). METHODS: Retrospective matched case control study in a consecutive series of patients with SLE first evaluated between 1979 and 1989. Patients were classified as cases if their first episode of zoster occurred after lupus diagnosis. Lupus patients who never had zoster were eligible as controls and were matched 2:1 to cases for age, race, sex, and survival status. Clinical features of the cases from the time of lupus diagnosis to the time of zoster were compared to their respective controls over similar time periods. RESULTS: Forty eight (15%) of 321 patients were classified as cases. Cases were more likely to have received cyclophosphamide (p = 0.03), and azathioprine (p = 0.006). More cases had lupus nephritis (p = 0.02), and a concurrent or previous malignancy (p = 0.01) than their controls. Seven cases had cutaneous dissemination. Seven patients had postherpetic neuralgia > 2 months and in only 2 patients symptoms persisted for > 12 months' duration. Only 3 of 36 patients had immunosuppressive medication discontinued at the time of diagnosis of zoster, and 10 cases received acyclovir for the zoster infection. There were no permanent neurologic deficits or death. CONCLUSION: Immunosuppressive therapy, specifically cyclophosphamide and azathioprine, lupus nephritis, and a concurrent or previous malignancy may be risk factors for the development of herpes zoster infections in patients with SLE. Our study suggests that although herpes zoster occurs frequently in patients with SLE, it has a relatively benign course. Discontinuing needed immunosuppressive therapy in patients with SLE may be unnecessary in the setting of a zoster infection. With the current emphasis on reduction in medical costs, both by limiting inpatient admissions and eliminating unneeded medications, it is necessary to identify which patients require more intensive therapy with antiviral medications and/or hospitalization and which are likely to have a benign, self-limited course without intervention.
Adolescent↗
Body fat distribution and other anthropometric blood pressure correlates in a Nigerian urban elderly population.
Blood pressure (BP) has been reported to be more consistently correlated with body mass index (BMI) than with waist-hip ratio (WHR) in Blacks. We present the correlates of BP in a systematic sample of 152 (65.7 pc response rate) elderly urban Nigerians, with a mean age of 72.7 yrs. +/- 12.1 for males and 73.2 yrs, +/- 11.9 for females. There were 12.3 pc and 22.3 pc obesity rates in the males and females respectively, with an equivalent mean BMI of 22.8 kg/m2 and 23.4 kg/m2 and WHR of 0.97 and 0.94. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) correlated with BMI, r = 0.26; p < 0.01 and r = 0.42; p < 0.001, only in females. WHR did not correlate with BP in either sex, but waist and hip measurements correlated significantly with BP in both sexes. The most important predictor of BP is BMI for females and waist measurement for men. Although smoking and alcohol were not related to BP in either sex, the data suggests that alcohol enhanced, while tobacco inhibited weight gain significantly in males, who on the whole indulged more than the females. Fasting or two hour whole blood glucose were not related to BP. The findings are in support of the adverse effects of weight on BP in the elderly. There is need to study attitudes to adult weight gain as expressed in body shape, and to use the findings in the development of weight control programmes as part of blood pressure control in the elderly.
Aged↗
Limitations of nutritional data.
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Diet Surveys↗
The etiology of breast cancer--from epidemiology to prevention.
Breast cancer is likely caused by the interaction of exposure to environmental carcinogens at an early age, resulting in initiation of neoplastic transformation and growth factors that determine the likelihood of progression to clinical disease. The environmental carcinogens are numerous (each contributing relatively little to overall risk) and probably interact with genetic "host susceptibility". Most women probably have subclinical breast cancer. The growth of the breast cancer is related to sex-hormone levels at the breast and stimulation of local growth factors. Genetic factors (i.e. host susceptibility including polymorphisms related to the enzymes that affect hormone levels, estrogen/progesterone receptors, and protein synthesis) are probably very important. Reproductive and menstrual patterning during the premenopause, especially related to pregnancy, menstrual cycling and lactation are very important determinants of the risks of breast cancer. More attention needs to be placed on the determinants of menstrual cycling and hormone levels in premenopausal women, especially the relationship of obesity, fat distribution and exercise. The degree of obesity, age at onset of obesity, weight gain (peri- to postmenopausal), and possibly body fat distribution are the major determinants of postmenopausal estrogen levels are key risk factors for postmenopausal breast cancer. Dietary fat, fiber, and perhaps other nutrients, also contribute to blood estrogen levels. Other hormones, especially insulin and insulin-like growth factors, and possibly testosterone and androgens, may also contribute to the increased risk of breast cancer. The reduction of breast cancer incidence and mortality will depend, primarily, on modifications of women's lifestyles which would move them from higher to lower estrogen characteristics.
Breast Neoplasms↗
Influence of the perimenopause on cardiovascular risk factors and symptoms of middle-aged healthy women.
OBJECTIVE: To determine the changes in cardiovascular risk factors and psychological and physical symptoms that occur during the perimenopause. DESIGN: Cohort study of 541 healthy middle-aged premenopausal women followed up through the menopause. SETTING: General community. PARTICIPANTS: After a baseline evaluation taken at study entry, 152 women ceased menstruating for 3 months (not due to surgery) and were not using hormone replacement therapy, and were reevaluated in a similar protocol (perimenopausal examination); 105 of the 152 were evaluated a third time when they had ceased menstruating for 12 months and were not using hormone replacement therapy (postmenopausal examination). One hundred nine premenopausal women who were repeatedly tested constituted a comparison group. MAIN OUTCOME MEASURES: Levels of lipids and lipoproteins, triglycerides, fasting glucose and insulin, blood pressure, weight, height, and standardized measures of psychological symptoms. RESULTS: Women who became perimenopausal showed increased levels of cardiovascular risk factors, which were similar in magnitude to those experienced by the comparison group of premenopausal women. Perimenopausal women reported a greater number of symptoms, especially hot flashes, cold sweats, joint pain, aches in the skull and/or neck, and being forgetful; reports of hot flashes at the perimenopausal examination were associated with low concentrations of serum estrogens. Menopausal status was not associated with depressive symptoms. Perimenopausal women who became postmenopausal showed a decline in the level of high-density lipoprotein-2-cholesterol (means, 0.53 to 0.43 mmol/L [20.6 to 16.7 mg/dL]) and a gradual increase in the level of low-density lipoprotein cholesterol (means, 3.14 to 3.33 mmol/L [121.3 to 128.8 mg/dL]), whereas symptom reporting declined. CONCLUSIONS: During mid-life, women experience adverse changes in cardiovascular risk factors and a temporary increase in total number of reported symptoms, with no change in depression. Preventive efforts to reduce the menopause-induced increase in cardiovascular risk factors should begin early in the menopausal transition.
Blood Glucose↗
Re: Temporal patterns in colorectal cancer incidence, survival, and mortality from 1950 through 1990.
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Colorectal Neoplasms↗
Antibodies to glutamic acid decarboxylase and diabetes mellitus in the Multiple Risk Factor Intervention Trial.
Diabetes mellitus is a heterogeneous disease. The better classification of types of diabetes mellitus among adults will improve epidemiologic studies of determinants of risk factors and genetic host susceptibility. Recently, an antibody to a specific enzyme, glutamic acid decarboxylase, has been closely linked to insulin-dependent diabetes mellitus. Sera were collected at baseline between 1972 and 1974 from initially nondiabetic participants in the Multiple Risk Factor Intervention Trial. After approximately 18 years of frozen storage, the serum samples were tested for antibodies to glutamic acid decarboxylase (anti-GAD) in 175 men who developed diabetes and 352 matched controls who did not develop diabetes during the 6-year follow-up. Nine of the 527 samples tested had elevated (19 or more units) titers of anti-GAD. Six of the nine men with elevated anti-GAD subsequently developed diabetes, and three of these six were ultimately placed on insulin therapy. These data suggest that elevated levels of anti-GAD may be a prospective marker for the subsequent development of insulin-dependent diabetes mellitus. The measurement of anti-GAD is relatively easy, can be performed in stored serum specimens, and may be used in epidemiologic studies to enhance the understanding of the determinants of diabetes mellitus.
Adult↗
Black-white differences in serum sex hormones and bone mineral density.
To determine if differences in serum sex hormones contribute to racial differences in bone mass, independent of obesity, the authors compared bone mass and sex steroid hormone levels in 273 white women and 86 black women aged 65 years or older. This study was ancillary to the Study of Osteoporotic Fractures. Black women were recruited at two clinical centers in Baltimore, Maryland, and the Monongahela Valley, near Pittsburgh, Pennsylvania. An age-stratified random sample of white women was chosen from the Pittsburgh clinic. Demographic and historical information and anthropometric measurements were obtained from a clinic questionnaire, interview, and examination. Single photon absorptiometry was obtained at three sites: the distal radius, the proximal radius, and the calcaneus. Serum estrone, androstenedione, and testosterone were measured using extraction, column chromatography, and radioimmunoassay. Serum estrone concentrations were significantly higher and androstenedione levels were significantly lower in black women compared with white women. Racial differences in estrone could be explained largely by differences in the degree of obesity. Bone mass was greater in black women compared with white women within age, body mass index, (kg/m2), and estrone strata. Androgens were not related to bone mass. Within each race, bone mass increased linearly with increasing concentration of serum estrone. There was no interaction between race and serum estrone on bone mass. Each factor contributed independently and significantly to the regression model predicting bone mass. There was no attenuation of the effect of race if estrone was included in the model. In conclusion, race and serum estrone were independent determinants of bone mass.
Aged↗
Lifestyle and sociodemographic factors as determinants of blood lead levels in elderly women.
This report presents descriptive data on blood lead levels in 530 white women aged 65-87 years and examines the association of blood lead level in this population with specific variables, including age, diet, reproductive and lifestyle factors, and place of residence. Women were recruited from an urban (Baltimore, n = 205) and a rural site (the Monongahela Valley, Pennsylvania, n = 325) during the period 1990-1991. Information on lifestyle, medical history, and demographics was obtained by questionnaire and interview. Blood lead concentrations were measured by atomic absorption spectrophotometry. The mean blood lead level of this cohort (5.3 micrograms/dl) was nearly 60% lower than that reported by a national survey in 1976-1980 for white women aged 65-74 years (12.8 micrograms/dl). Urban women had significantly higher blood lead levels than rural women (p < 0.0001). Urban residence, smoking, alcohol consumption, and years since menopause were positively associated with blood lead level, while body mass index, breast feeding, current estrogen replacement therapy, moderate physical activity, and calcium intake were inversely associated. These data suggest that mean blood lead levels have declined dramatically since 1980. Because it is not known at what level of lead exposure adverse health effects occur, other factors that modify lead levels, metabolism, or susceptibility, such as nutrition and consumption of tobacco and alcohol, become important.
Age Factors↗
Predictors of mortality from idiopathic dilated cardiomyopathy in 356,222 men screened for the Multiple Risk Factor Intervention Trial.
Possible predictors of mortality from idiopathic dilated cardiomyopathy were studied in 356,222 men who were screened as part of the Multiple Risk Factor Intervention Trial. The vital status of each member of this cohort was ascertained through 1986. Death certificates were obtained from state health departments and coded by a trained nosologist. Individuals with a history of myocardial infarction were excluded. A total of 206 deaths due to idiopathic dilated cardiomyopathy occurred in the cohort of 356,222 men after an average of 12 years of follow-up. The age-specific rates of mortality from idiopathic dilated cardiomyopathy increased from 0.10 per 10,000 person-years among men aged 35-39 years to 1.16 per 10,000 person-years among men aged 55-57 years. The proportional hazards model was used to obtain adjusted estimates of relative risks. Statistically significant, independent associations were observed with cigarettes smoked per day (p < 0.001), diastolic blood pressure (p < 0.001), and diabetes mellitus (relative risk (RR) = 2.97, p < 0.001). Black race was also associated with an increased risk of death from idiopathic dilated cardiomyopathy (RR = 1.59 and p = 0.045 without adjustment for income; RR = 1.58 and p = 0.058 with adjustment for income). No association was found with serum cholesterol or income. The information about possible risk factors obtained in this study may contribute to future preventive programs for idiopathic dilated cardiomyopathy.
Adult↗
Impact of Medicare reimbursement on influenza vaccination rates in the elderly.
BACKGROUND: Influenza is responsible for significant morbidity, mortality, and medical costs, but immunization rates in the elderly remain low. METHODS: As part of a demonstration project in rural Pennsylvania, 1,989 community-dwelling Medicare beneficiaries, 65-79 years old, completed a health risk appraisal including questions about flu shots. Participants were randomized to two experimental (hospital or physician) or control groups. Experimental groups were offered free flu shots for the 1990-91 flu season. Follow-up interviews to determine vaccination rates were completed about 1 year later. RESULTS: Baseline immunization rates were almost identical for the hospital-based (41.2%), physician-based (41.3%), and control group not offered free immunizations (40.6%). Follow-up rates for the groups offered immunizations rose significantly to 63.6 and 69.1% for hospital and physician groups, respectively, while the control group also increased significantly to 54.1%. Individuals who were more educated, were older, and had greater chronic diseases history (myocardial infarction, hypertension, and pulmonary disease) were more likely to be immunized. Male and married elderly were more likely to be immunized as a result of the demonstration. CONCLUSIONS: Increasing community education and providing immunizations free through Medicare will increase immunization rates among elderly. The elderly are more likely to receive flu shots provided through physicians' offices than through hospital-based clinics.
Age Factors↗
Tracking of blood pressure from adolescence to middle age: the Dormont High School Study.
METHODS: Tracking of blood pressure was studied in a cohort of 86 men and 116 women, initially examined at mean age 17 years and re-examined at mean ages 34 and 47 years in the Dormont High School Follow-up Study. RESULTS: Correlations for systolic blood pressure (men vs women, P < 0.05) were r = 0.42 vs r = 0.39 between mean ages 17 and 34 years; r = 0.38 vs r = 0.54 between mean ages 34 and 47 years; and r = 0.27 vs r = 0.24 between mean ages 17 and 47 years. For diastolic blood pressure, the correlations were lower, but were higher among women than men, and were higher between mean ages 34 and 47 years (r = 0.44 for men and r = 0.54 for women, P < 0.001) than at earlier ages. The correlations for weight were higher than those for blood pressure (men vs women, P < 0.001): r = 0.64 vs r = 0.59 between mean ages 17 and 34 years; r = 0.88 vs r = 0.81 between mean ages 34 and 47 years; and r = 0.58 vs r = 0.49 between mean ages 17 and 47 years. With increase in age and length of follow-up, there was a stronger tendency for those in the extreme tertiles of the blood pressure distribution to maintain their ranks. The significance and magnitude of the blood pressure correlations remained essentially unchanged after adjustment for weight and its changes. However, weight was related to the changes in blood pressure tracking status, but this varied with age. CONCLUSION: These data suggest that the age and gender differences in the degree of blood pressure tracking may be a function of the tracking of weight as well as a reflection of the gender difference in the consistency of the relationship of blood pressure to weight at different ages.
Adolescent↗
Prevention of cardiovascular disease--opportunities for progress.
Steady progress has been made in the prevention of cardiovascular disease. There has been a favorable trend in major risk factor reduction and an average 3% annual decline in cardiovascular disease death rates over the past decade. Yet, CVD death rates still exceed that for many countries and not all segments of the U.S. population have benefited equally. Cardiovascular disease remains the leading cause of death and disability in this country. The role of epidemiologic research and prevention strategies in addressing this issue has been underestimated. Unresolved research questions require further epidemiologic research in order to improve application of known preventive measures and explore other approaches toward the prevention of cardiovascular disease. It is well established that attention to life-style changes and pharmacologic approaches can prevent cardiovascular disease in those at high risk and reduce the likelihood of subsequent cardiac events among patients with known cardiovascular disease. Furthermore, small changes in the distribution of risk factors through community intervention can have tremendous impact on cardiovascular disease morbidity and mortality. Preventive research requires an appropriate framework and plan to satisfy or exceed the needs in keeping with the national goals for Healthy People 2000. The National Heart, Lung, and Blood Institute has addressed this issue by creating a Task Force to develop research priorities for epidemiology and prevention.
Arteriosclerosis↗
Future in lipid and lipoprotein research: from preventing clinical disease to preventing elevated risk factors.
The decline in cardiovascular disease has been a major public health success. The relationship between key risk factors such as blood cholesterol levels, smoking, high blood pressure and clinical disease are universally accepted. The approaches to the prevention of cardiovascular disease are changing to a greater emphasis on the prevention of elevated risk factors by better understanding of the relationship between lifestyle and host susceptibility (genetic attributes) and the risk factor changes with age. The development of new methods to measure vascular disease non-invasively in vivo changes the approaches to evaluation of both risk and definition of endpoints in analytical studies and clinical trials. It is possible now to increase the rate of decline in coronary heart disease.
Arteriosclerosis↗
The quandary of cancer prevention.
The incidence and mortality due to the major cancers such as lung, breast, colon-rectum, prostate, and ovary have changed very little over the past 20-30 years, in spite of the introduction of important new treatments and apparent prolongation of survival of patients with these cancers. The new strategies focus on earlier detection and primary prevention of cancer. Three approaches for prevention are receiving increasing prominence as an approach to reducing the incidence of cancer: (1) control of common source environmental carcinogens, (2) modification of personal health behavior believed to increase or decrease the risk of cancer, and (3) identification of specific genotypes that increase the risk of cancer. All of these approaches offer some hope of reducing cancer incidence and morbidity. All will be costly and, therefore, require careful evaluation. It is likely that the changes in personal health behaviors will have the greatest overall impact on cancer incidence. Identification of specific genotypes will be of importance for high risk families. At present, it is unlikely that control of environmental common sources will substantially reduce cancer incidence without better measures of exposure and risk of disease.
Environmental Health↗