A cross-sectional comparative study of outpatient neurologic practices in Colorado.
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Colorado↗
Biomedical subjects
E J Boyko
Publications and source records attributed to E J Boyko.
Prevalence of diabetes mellitus in Alaskan Eskimos, Indians, and Aleuts.
The prevalence of diabetes mellitus in Alaska Natives has been thought to be low, but no survey of this condition in all natives has been conducted. Medical records from 1979 to 1985 were reviewed to determine the prevalence of diagnosed diabetes mellitus in Alaska Natives. Computerized outpatient and inpatient medical record data and clinician reports were used to identify cases. As of December 1985, 610 living Alaska Natives fulfilled diagnostic criteria for diabetes. Type II diabetes mellitus was found in 564 subjects, type I diabetes was found in 15 subjects, and unspecified type of diabetes was found in 31 subjects. The overall age-adjusted prevalence of diabetes mellitus, 15.7/1000, was lower than the overall United States rate of 24.7/1000. However, age-adjusted prevalence varied considerably by ethnic group; the prevalence was 27.2/1000 among Aleuts, 22.0/1000 among Alaskan Indians, and 8.8/1000 among Alaskan Eskimos. Rates within the Eskimo subgroups varied by a factor of four. Compared with previous reports, the prevalence of diabetes mellitus in Alaskan Eskimos appears to have increased. Diabetes mellitus is no longer a rare condition among Alaska Natives.
Alaska↗
Prevalence of asymptomatic bacteriuria in subjects with NIDDM in San Luis Valley of Colorado.
This study examined whether non-insulin-dependent diabetic (NIDDM) subjects have an increased prevalence of asymptomatic bacteriuria compared with subjects with normal glucose tolerance. Diabetic (n = 206) and normal (n = 418) subjects were identified from a defined geographic area in the San Luis Valley of southern Colorado. Presence of asymptomatic bacteriuria was determined by testing the subjects' urine with a reagent-strip test for nitrite and leukocyte esterase (Chemstrip LN). The ability of the Chemstrip LN to detect bacteriuria was evaluated by comparing its results with those from urine culture on a subsample of subjects. There were 7 control and 12 diabetic subjects with bacteriuria as measured by the Chemstrip LN. The prevalence of urinary tract colonization among diabetic compared with control subjects was increased 3.5-fold (95% confidence interval 1.4-8.6). Adjustment for confounding by age, sex, ethnicity, and county of residence resulted in an adjusted prevalence ratio of 4.4 (95% confidence interval 1.1-17.4). Among diabetic subjects, prevalence of bacteriuria increased with longer disease duration but was not affected by measures of glucose control. We conclude that NIDDM increases the prevalence of bacterial colonization of the urine and, therefore, probably also increases the risk of symptomatic urinary tract infection.
Bacteriuria↗
Effects of cigarette smoking on the clinical course of ulcerative colitis.
We assessed the effect of smoking on the clinical course of ulcerative colitis in 209 subjects by comparing disease severity in smokers and non-smokers as measured by yearly number of hospitalizations for ulcerative colitis treatment and the need for a colectomy. Hospitalization for ulcerative colitis treatment occurred less frequently in persons who smoked after disease onset, but the colectomy rate in persons who smoked after disease onset and non-smokers was similar. Both hospitalization and colectomy for treatment of ulcerative colitis occurred more frequently among smokers who quit before disease onset. Furthermore, hospitalization and colectomy occurred most frequently in the heaviest smokers who quit before disease onset. We found no strong evidence of a therapeutic effect of smoking after ulcerative colitis onset on this illness's clinical course, but smoking before disease onset may affect the clinical severity of this illness.
Adolescent↗
How physicians can help their patients quit smoking. A practical guide.
We describe practical, effective, office-based methods for physicians to use to assist patients to stop smoking that do not require special training or support personnel. Brief counseling achieves smoking cessation in a small percent of well patients but is more effective in patients with smoking-related illnesses or abnormal laboratory test results. Routine prescribing of nicotine gum without participation by the patient in a smoking-cessation program does not increase smoking cessation, and we do not recommend it. The prevention of smoking relapse can probably be enhanced by scheduling follow-up office visits after the patient has quit. Failure to quit on initial attempts should not discourage physicians and patients, since most successful abstainers usually must make several attempts to quit. We outline for physicians two approaches, one brief and one more intensive, to help patients stop smoking.
Humans↗
Risk of ulcerative colitis among former and current cigarette smokers.
We performed a case-control study of the effect of tobacco smoking on the risk of acquiring ulcerative colitis among the 304,000 members of a health maintenance organization. Smoking histories before the date of the onset of ulcerative colitis were compared in 212 cases and an equal number of controls matched for age and sex who were selected from the enrollment file of the health maintenance organization. The relative risk of ulcerative colitis among current cigarette smokers as compared with nonsmokers was 0.6 (95 percent confidence interval, 0.4 to 1.0); however, among former cigarette smokers it was 2.0 (95 percent confidence interval, 1.1 to 3.7). These values remained after adjustment for socioeconomic factors and for coffee and alcohol consumption. The higher risk among former smokers could not be explained by postulating that smokers gave up tobacco near the time of disease onset because of early symptoms of ulcerative colitis. The relative risk of ulcerative colitis among former smokers increased in proportion to the cumulative number of cigarettes smoked before the onset of disease, suggesting a causal relationship between this exposure and disease occurrence. No difference in risk was observed among current smokers according to cumulative amount smoked. We conclude that former and current tobacco use may have opposite effects on the risk of acquiring ulcerative colitis.
Adolescent↗
A multicenter comparative trial of three-day norfloxacin vs ten-day sulfamethoxazole and trimethoprim for the treatment of uncomplicated urinary tract infections.
Two-hundred nine patients with symptoms of acute urinary tract infection and pyuria were randomized to 400 mg of administered norfloxacin twice daily for three days, or 800 mg of sulfamethoxazole and 160 mg of trimethoprim administered twice daily for ten days. Therapeutic outcome was assessed five to nine days and four to six weeks after treatment. The cure rates were 71/74 (96%) with norfloxacin and 81/81 (100%) with sulfamethoxazole and trimethoprim five to nine days after treatment. Only seven patients had a recurrence at the second follow-up visit; four in the norfloxacin group and three in the sulfamethoxazole and trimethoprim group. No isolates were resistant to norfloxacin, but three Escherichia coli were resistant to sulfamethoxazole and trimethoprim. Fifteen patients in each group reported a side effect during treatment. Two patients in the norfloxacin group and four patients in the sulfamethoxazole and trimethoprim group discontinued therapy due to an adverse effect. In this multicenter study, a three-day course of norfloxacin was as effective and safe as a ten-day regimen of sulfamethoxazole and trimethoprim in the treatment of acute uncomplicated urinary tract infections.
Acute Disease↗
Risk factors for acquiring pneumococcal infections.
To identify risk factors for developing pneumococcal infections, we carried out a case-controlled study on a retrospectively constituted cohort of 3074 clinic patients in a presumed high-risk population. Culture-proved pneumococcal infections were identified in 63 men over a period of 5.5 years, yielding an estimated incidence of 6.3 cases per 1000 person-years. By comparing these patients with 130 uninfected control patients, the relative risk of pneumococcal infections related to various exposures was calculated by logistic regression analysis. Statistically significant independent risk factors (and their relative risks) were as follows: dementia (5.82), seizure disorders (4.38), current cigarette smoking (4.00), congestive heart failure (3.83), cerebrovascular disease (3.82), institutionalization (3.13), and chronic obstructive pulmonary disease (2.38). Risk was increased with age and previous hospitalizations, and, to a nonsignificant degree, by hotel residence (3.93), lung cancer (2.24), previous smoking (2.14), corticosteroid use (1.81), and alcoholism (1.35); but not by diabetes mellitus (0.99), nonlung malignancies (0.93), nonwhite race (0.89), or ischemic heart disease (0.58).
Aged↗
Perirectal abscess caused by Legionella pneumophila and mixed anaerobic bacteria.
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Abscess↗
Reference test errors bias the evaluation of diagnostic tests for ischemic heart disease.
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Coronary Angiography↗
Potential problems in the use of necropsy data in epidemiologic research.
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Age Factors↗
Responsiveness of the SF-36 among veterans with diabetes mellitus.
To examine the responsiveness of the Medical Outcomes Study 36-Item Short Form (SF-36) to the development of diabetes complications over time. We studied a cohort of 331 diabetic veterans participating in a prospective study of risk factors for foot complications. Eight SF-36 scales [general health (GH), physical functioning (PF), social functioning (SF), mental health (MH), physical role (RP), emotional role (RE), bodily pain (BP), and vitality (VT)] and 25 diabetes complications characteristics (DCC) from history and symptom questionnaires and physical exam findings were compared over a mean interval of 3.1 years. The subjects were mostly married, white males with a mean age of 63.5 years, with primarily type 2 diabetes (91%) and a mean diabetes duration of 9.7 years at baseline. There was a statistically significant interval decrease in the GH scale of 6.1 points (effect size [ES] 0.24), PF decreased 9.7 (ES 0.38), SF decreased 5.8 (ES 0.19), PR decreased 14.7 (ES 0.38), BP decreased 4. 0 (ES0.14), VT decreased 4.5 (ES 0.16), total DCC increased by 1.8 (ES 0.53), and hemoglobin A(1c) declined 1.3% (ES 0.48). An increase of >1 DCC was associated with an average loss of 7.2 to 11.8 points on six SF-36 scales (GH, PF, SF, RP, BP, VT). The development of any renal complication was related to decrements in five SF-36 scales (GH, PF, SF, RP, VT) while the appearance of any neuropathy complication was associated with a decline in four SF-36 scales (GH, PF, PR, VT). These results imply that six of the SF-36 scales are responsive to the development of diabetes complications over time among elderly veterans, supporting their use in longitudinal research. Renal and neuropathy complications have the greatest effects on the SF-36.
Aged↗
Skin temperature in the neuropathic diabetic foot.
Several authors have reported higher skin temperature in the feet of diabetic subjects with autonomic neuropathy. We reexamined this association in a cross-sectional study of 712 veterans with diabetes mellitus. Potential subjects included all diabetic patients enrolled in a general internal medicine clinic at a veterans affairs healthcare system. Sensory neuropathy was defined as any pedal insensitivity to the 5.07 monofilament. Autonomic neuropathy was determined using standard cardiovascular reflex tests. An infrared surface scanner was used to measure foot skin temperature at multiple sites. Subjects with sensory neuropathy had lower mean plantar foot skin temperature than those without (28.4 degrees C vs. 28.9 degrees C, P=.0101). Autonomic neuropathy as a dichotomous variable was unrelated to foot skin temperature. Foot skin temperature, though, negatively correlated with greater drop in systolic blood pressure with standing, which is an indicator of autonomic neuropathy (r=-.08, P=.0385). Adjustment for potential confounding factors using multiple linear regression analysis resulted in diminution of the associations between foot skin temperature and sensory neuropathy or orthostatic blood pressure drop, but the latter association remained statistically significant in the right foot. Diabetic veterans with sensory or autonomic neuropathy do not have higher foot skin temperature. Our results suggest that skin temperature may be slightly lower with higher orthostatic blood pressure fall. Other causes exist for the frequently observed differences in skin temperature in the feet of diabetic subjects.
Aged↗
A method to describe physician decision thresholds and its application in examining the diagnosis of coronary artery disease based on exercise treadmill testing.
The authors developed a method that utilizes logistic regression analysis to 1) calculate the disease probability with confidence intervals at which any specified proportion of physicians reaches a clinical decision, 2) statistically test whether factors other than disease probability affect this clinical decision, and 3) statistically test whether physician decision making in relation to disease probability varies by other factors. They apply the method to analyze the relationship between disease probability and the proportion of physicians who diagnosed coronary artery disease (CAD) in 127 consecutive subjects who completed the treadmill exercise tolerance test (ETT) at two hospitals. Twenty-five percent of the physicians decided that CAD was possible or definite at a post-ETT disease probability of 0.24 (95% CL= 0.07-0.35); 50% at 0.54 (95% CL = 0.43-0.70); and 75% at 0.82 (95% CL = 0.67-1.0). Multivariate logistic regression analysis revealed three factors significantly and independently related to the diagnosis of CAD: post-ETT disease probability, positive ETT result, and cigarette smoking. The proportion of physicians who reached a diagnosis of CAD did not differ by hospital setting (VA versus university), level of training (attending versus housestaff/fellow), or diagnosing service (cardiology versus other internal medicine). It is concluded that factors other than disease probability may affect physician diagnostic decisions.
Adult↗
Ruling out or ruling in disease with the most sensitive or specific diagnostic test: short cut or wrong turn?
Previous publications have advocated that clinicians choose the most sensitive diagnostic test to rule out disease and the most specific diagnostic test to rule in disease. This paper critically examines the validity of these recommendations. First, the author finds that following these recommendations does not lead to the highest disease probability for a positive test result (thereby best ruling in disease) or the lowest disease probability for a negative test result (thereby best ruling out disease). In general, the ability of a diagnostic test to lead to the highest (rule in) or lowest (rule out) disease probability should be judged based on likelihood ratios. Next, by comparing expected utilities, the author considers whether the most specific test leads to the best clinical outcome when a rule-in strategy is clinically advisable, i.e., when the costs of false-positive results are high, and whether the most sensitive test leads to the best clinical outcome when a rule-out strategy is clinically advisable, i.e., when the costs of false-negative results are high. The author again demonstrates that the greatest clinical utility is not always achieved by using the most specific test in a rule-in decision or the most sensitive test in a rule-out decision. Tradeoffs between sensitivity, specificity, disease probability, and utilities of correct and incorrect disease classifications by the diagnostic test must be simultaneously captured to determine which strategy maximizes clinical utility.
Decision Support Techniques↗
A comparison of diabetic foot ulcer patients managed in VHA and non-VHA settings.
OBJECTIVE: To compare patients with diabetes and new onset foot ulcers treated in Veterans Health Administration (VHA) and non-VHA settings. METHODS: The treatment of patients with new onset diabetic foot ulcers was prospectively monitored in three VHA and three non-VHA hospitals and outpatient settings until ulcer healing, amputation, or death. RESULTS: Of the 302 individuals enrolled in this study, 47% were veterans receiving VHA care. There were no significant differences between veterans and nonveterans in baseline wound classification, diabetes severity, or comorbid conditions. Veterans received significantly fewer sharp debridements, total contact casts, and custom inserts than their nonveteran counterparts, and they had significantly more x-rays, local saline irrigations, IV antibiotics, and prescriptions for bed rest. The percentage of amputations was higher in veterans but did not achieve statistical significance. CONCLUSIONS: Many commonly held stereotypes of veteran men were not found. Veterans and nonveterans with foot ulcers were similar in terms of health and foot history, diabetes severity, and comorbid conditions. There was considerable variation in treatment of diabetic foot ulcers between VHA and non-VHA care. Yet this variation did not result in statistically significant differences in ulcer outcomes.
Aged↗