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Biomedical subjects

J A Pugh

Publications and source records attributed to J A Pugh.

At least 37 records · Page 2Linked to original sources
PubMed1994

Survival among Mexican-Americans, non-Hispanic whites, and African-Americans with end-stage renal disease: the emergence of a minority pattern of increased incidence and prolonged survival.

We undertook this study to determine whether there is a significant difference in survival on treatment for end-stage renal disease between Mexican-Americans, non-Hispanic whites, and African-Americans. A database covering the years 1975 to 1986 was obtained from the Texas Kidney Health Program. Eight-eight percent to 90% of patients starting renal replacement therapy in Texas were included in this database. The patients were followed until death, for 3 years after successful transplantation, or until they were lost to follow-up. Life table analysis as well as age-adjusted analysis using the Cox proportional hazards model were performed comparing ethnic/racial groups, disease etiology, and treatment type. In life-table analyses, African-Americans and Mexican-Americans had a survival advantage in most age, disease, and treatment groups. With age adjustment, this survival advantage remained for all etiologies combined, for diabetes and hypertension cases, and for patients receiving hemodialysis in a center. Multivariate analysis revealed a persistent survival advantage for Mexican-Americans independent of traditional predictor variables, such as age, disease etiology, treatment type, or size of the center in which they received treatment. In this same analysis, African-Americans showed an advantage in the older age groups. Both African-Americans and Mexican-Americans on renal replacement therapy have an increased survival advantage compared with non-Hispanic whites. Given the additional burden of increased incidence of end-stage renal disease in these groups, the cost of renal replacement therapy for these minorities is disproportionately high. Further study should be aimed at elucidation of the mechanisms by which minorities achieve their survival advantage.

Adult↗
PubMed1993

Comparison of the course to end-stage renal disease of type 1 (insulin-dependent) and type 2 (non-insulin-dependent) diabetic nephropathy.

Is the course leading to diabetic end-stage renal disease similar for Type 1 (insulin-dependent) and Type 2 (non-insulin-dependent) diabetes mellitus? We identified all diabetic end-stage renal disease patients starting renal replacement therapy from 1989 to 1991 in two urban counties in Texas. Three ethnic/racial groups were enrolled: Mexican Americans, non-Hispanic Whites, African Americans. Patients were interviewed and their medical records, both inpatient and out-patient, were abstracted for relevant diagnostic and therapeutic information. We attempted to obtain records as far back as the onset of diabetes or hypertension and from all physicians who had cared for the patient. An historical algorithm was used to determine diabetic type. Of the patients enrolled, 91 were Type 1 and 438 were Type 2 diabetic patients. Type 1 diabetic patients had higher mean glucose levels in the first 10 years of diabetes (16.3 vs 11.4 mmol/l) but lower systolic blood pressures (148 vs 157 mmHg). The duration of diabetes prior to end-stage renal disease was longer for Type 1 than Type 2 patients (22 vs 17 years). Type 1 diabetic patients were more likely to have other microvascular complications (retinopathy, neuropathy, gastroparesis), less likely to have coronary disease (myocardial infarction and congestive heart failure), and had similar rates of stroke and vascular surgery procedures (carotid endarterectomy, coronary artery bypass surgery, aortofemoral bypass). Type 1 and Type 2 diabetic patients were just as likely to have a first degree relative with hypertension (60.5 vs 65.5%).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1993

Screening for diabetic retinopathy. The wide-angle retinal camera.

OBJECTIVE: To define the test characteristics of four methods of screening for diabetic retinopathy. RESEARCH DESIGN AND METHODS: Four screening methods (an exam by an ophthalmologist through dilated pupils using direct and indirect ophthalmoscopy, an exam by a physician's assistant through dilated pupils using direct ophthalmoscopy, a single 45 degrees retinal photograph without pharmacological dilation, and a set of three dilated 45 degrees retinal photographs) were compared with a reference standard of stereoscopic 30 degrees retinal photographs of seven standard fields read by a central reading center. Sensitivity, specificity, and positive and negative likelihood ratios were calculated after dichotomizing the retinopathy levels into none and mild nonproliferative versus moderate to severe nonproliferative and proliferative. Two sites were used. All patients with diabetes in a VA hospital outpatient clinic between June 1988 and May 1989 were asked to participate. Patients with diabetes identified from a laboratory list of elevated serum glucose values were recruited from a DOD medical center. RESULTS: The subjects (352) had complete exams excluding the exam by the physician's assistant that was added later. The sensitivities, specificities, and positive and negative likelihood ratios are as follows: ophthalmologist 0.33, 0.99, 72, 0.67; photographs without pharmacological dilation 0.61, 0.85, 4.1, 0.46; dilated photographs 0.81, 0.97, 24, 0.19; and physician's assistant 0.14, 0.99, 12, 0.87. CONCLUSIONS: Fundus photographs taken by the 45 degrees camera through pharmacologically dilated pupils and read by trained readers perform as well as ophthalmologists for detecting diabetic retinopathy. Physician extenders can effectively perform the photography with minimal training but would require more training to perform adequate eye exams. In this older population, many patients did not obtain adequate nonpharmacological dilation for use of the 45 degrees camera.

Diabetic Retinopathy↗
PubMed1992

Cost-effectiveness of alternative methods for diabetic retinopathy screening.

OBJECTIVE: To assess from the perspectives of a government delivery system and patients, the cost-effectiveness of the 45-degrees retinal camera compared to the standard ophthalmologist's exam and an ophthalmic exam by a physician's assistant or nurse practitioner technician, for detecting nonproliferative and proliferative diabetic retinopathy. RESEARCH DESIGN AND METHODS: Comparison of 45-degrees fundus photographs with and without pharmacological pupil dilation taken by technicians and interpreted by experts, direct and indirect ophthalmoscopy by ophthalmologists, and direct ophthalmoscopy by technicians with seven-field stereoscopic fundus photography (reference standard). Costs were estimated from market prices and actual resource use. The study included 352 patients attending outpatient diabetes and general-medicine clinics at VA and DOD facilities. RESULTS: Medical system costs per true positive were: 45-degrees photos with dilation, $295; 45-degrees photos without dilation, $378; ophthalmologist, $390; and technician, $794. Patient costs per true positive were: 45-degrees photos with dilation, $139; 45-degrees photos without dilation, $171; ophthalmologist, $306; and technician, $1009. Cost-effectiveness is sensitive to program size due to high fixed cost of the camera methods but not to prevalence. Cost-effectiveness of the technician exam is strongly affected by its sensitivity. CONCLUSIONS: Primary-care screening with retinal photographs through pharmacologically dilated pupils for diabetic retinopathy is an appropriate and cost-effective alternative to screening by an ophthalmologist in this setting. Ophthalmologists are scarce, primary-care physicians are extremely busy, and large clinics allow fixed equipment costs to be spread across many patients.

Cost-Benefit Analysis↗
PubMed1992

Dietary protein intake is not correlated with clinical proteinuria in NIDDM.

OBJECTIVE: To determine whether dietary protein intake is correlated with clinical proteinuria in subjects with non-insulin-dependent diabetes mellitus (NIDDM). RESEARCH DESIGN AND METHODS: Cross-sectional analysis of data obtained from the San Antonio Heart Study, a population-based survey of diabetes and cardiovascular risk factors. Subjects were enrolled in two phases: phase 1 between 1979 and 1982 and phase 2 between 1984 and 1988. This study was based on 376 NIDDM subjects who had both urinalysis and complete dietary protein intake information available. Dietary protein intake was measured by 24-h dietary recall in phase 1 and by food-frequency questionnaire in phase 2. An early-morning spot urine was obtained from study subjects. Clinical proteinuria was defined as greater than or equal to 1 on Ames Albustix test. RESULTS: In phase 1, the subjects with negative or trace proteinuria had a mean protein intake of 79.9 g/day compared with 72.1 g/day for subjects with greater than or equal to 1 proteinuria. In phase 2, the mean protein intake was 72.2 g/day in the negative/trace group and 65.3 g/day in the greater than or equal to 1 proteinuria group. In multivariate analysis, adjusting for age, sex, ethnicity, systolic blood pressure, and 2-h blood glucose, we were again unable to detect a significant correlation between dietary protein intake and clinical proteinuria. CONCLUSIONS: These data do not support the hypothesis that high-protein intake is a risk factor for clinical proteinuria in NIDDM subjects. Therefore, any recommendation for protein restriction in the diets of NIDDM subjects, before the development of NIDDM-related nephropathy, must be made with caution.

Adult↗
PubMed1992

Is combination sulfonylurea and insulin therapy useful in NIDDM patients? A metaanalysis.

OBJECTIVE: To assess the efficacy of combination therapy with insulin and sulfonylurea in the treatment of NIDDM. RESEARCH DESIGN AND METHODS: Studies published between January 1966 and January 1991 were identified through a computerized Medline search and by hand searching the bibliographies of identified articles. We identified 17 eligible randomized, controlled trials of combination therapy in NIDDM. These trials had a minimum duration of 8 wk and at least one of three outcome measures (fasting glucose, HbA1, or C-peptide) with SD or SE of the mean reported to do metaanalysis. With standardized forms, three independent reviews abstracted measures of study quality and specific descriptive information about population, intervention, and outcome measurements. RESULTS: We calculated effect size and weighted mean changes of the three outcome measures for control and treatment groups. In the treatment group, the fasting plasma glucose decreased from a mean of 11.4 mM (206 mg/dl) at baseline to a mean of 9.16 mM (165 mg/dl) posttreatment, whereas the control group decreased from (11.3 to 10.8 mM) (204 to 194 mg/dl) (effect size 0.39, P less than 0.0001). For HbA1, the treatment group decreased from a baseline of 11.0 to 10.2% compared to 11.0 and 11.2% in the control group (effect size 0.43, P less than 0.0001). For fasting C-peptide, the treatment group increased from 0.49 to 0.58 nM (1.45 to 1.75 ng/ml) compared with 0.47 and 0.43 (1.42 and 1.30) for the control group (effect size 0.26, P less than 0.017). CONCLUSION: Combined insulin-sulfonylurea therapy leads to modest improvement in glycemic control compared with insulin therapy alone. With combined therapy, lower insulin doses may be used to achieve similar control. Obese patients with higher fasting C-peptides may be more likely to respond than others.

Blood Glucose↗
PubMed1990

C595--a monoclonal antibody against the protein core of human urinary epithelial mucin commonly expressed in breast carcinomas.

Urinary mucins which express determinants for the anti-breast carcinoma monoclonal antibody, NCRC-11 (IgM), closely resemble the mammary mucins found in milk fat globules and carcinomas. An IgG3 monoclonal antibody, C595, was prepared against urinary mucins isolated on a NCRC-11 antibody affinity column, and this 'second generation' antibody was shown to have a very similar pattern of reactivity to the original NCRC-11 antibody. By immunohistology, the profile of reactivity of both antibodies with tumour and normal tissue specimens was virtually identical. Both antibodies reacted with epithelial mucins isolated from breast tumours or normal urine using an NCRC-11 antibody affinity column, although the antibodies were unreactive with other antigen preparations. Heterologous immunoradiometric assays ('sandwich' tests) confirmed that NCRC-11 and C595 epitopes were co-expressed on the same molecule. C595 antibodies inhibited the binding of radiolabelled NCRC-11 antibodies to antigen, suggesting that the two epitopes were in close topographical proximity. The protein core of the mammary mucins has recently been shown to consist predominantly of a repeated 20 amino acid sequence (Gendler et al., 1988). Peptides with this complete sequence and small fragments were synthesised, and the C595 antibody was found to recognise an epitope within this repeat. The ability to identify and synthesise monoclonal antibody-defined determinants, as well as those in the adjacent or overlapping sequences within the protein core of epithelial mucins, is viewed as a strategy for facilitating the production of antibodies of new and novel specificity to complement the panels of existing anti-breast cancer reagents.

Antibodies, Monoclonal↗
PubMed1989

The epidemiology of diabetic nephropathy.

Many areas of information in the epidemiology of diabetic nephropathy are lacking, but multiple studies designed specifically to answer these questions are currently being conducted. In the next 5-10 years, our current understanding of the epidemiology of diabetic nephropathy may either be confirmed or discredited. In the meantime, clinicians should use the data available to make decisions about treatment and should focus on the modifiable factors of glucose and blood pressure control in both IDDM and NIDDM, especially in patients with low-level albuminuria or clinical proteinuria.

Albuminuria↗
PubMed1989

Proteinuria in Mexican Americans and non-Hispanic whites with NIDDM.

Mexican Americans have a threefold greater prevalence of non-insulin-dependent diabetes mellitus (NIDDM) than non-Hispanic Whites as found in the San Antonio Heart Study, a population-based study of diabetes and cardiovascular disease. In addition, Mexican-American diabetic subjects have higher levels of glycemia than non-Hispanic White diabetic subjects. We therefore hypothesized that the prevalence of clinical proteinuria would be greater among Mexican-American diabetic subjects (n = 317) than among non-Hispanic White diabetic subjects (n = 67). Clinical proteinuria, defined as greater than or equal to 1+ on the Ames Albustix test, was 2.82 times more prevalent in Mexican-American diabetic subjects compared with non-Hispanic White diabetic subjects adjusting for age and duration (95% confidence interval [CI] = 1.05, 7.55; P = .039). After controlling for other possible confounding variables (i.e., glycemia, systolic blood pressure, smoking, and insulin use), the excess of proteinuria in Mexican-American diabetic subjects was only slightly attenuated, although the statistical significance became borderline (odds ratio [OR] = 2.59, 95% CI = 0.91, 7.32; P = .072). The prevalence of microalbuminuria (greater than 30 mg/L) was also significantly higher in Mexican-American diabetic subjects than in non-Hispanic White diabetic subjects (OR = 3.54, 95% CI = 1.28, 9.81; P = .015). We also compared previously diagnosed Mexican-American diabetic subjects (n = 243) from San Antonio with previously diagnosed non-Hispanic White diabetic subjects in Wisconsin (n = 476).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1989

Effect of daily charge feedback on inpatient charges and physician knowledge and behavior.

Concurrent charge feedback has gained widespread acceptance as a method of minimizing hospitals' losses under the Medicare prospective payment system despite the fact that its effect on patient outcomes, physician behavior, or charges has not been studied in depth. In a controlled trial on two medical wards in an academic medical center, the effect of daily charge feedback on charges was studied. Sixty-eight house staff and 16 teaching attending physicians participated during a 35-week period, taking care of 1057 eligible patients. No significant differences in charges were seen when all patients were included. Since 45% of patients had planned protocol admissions (diagnostic workups or protocol treatment) on which the house staff had little change to impact, a subgroup analysis was performed, excluding these patients. In the remaining patients, a highly significant reduction in mean total charges (17%), length of stay (18%), room charges (18%), and diagnostic testing (20%) was found. In-hospital mortality and preventable readmission within 30 days were similar on the two wards. It was concluded that charge feedback alone is effective in a teaching hospital for decreasing charges.

Attitude of Health Personnel↗
PubMed1988

Hyperinsulinemia, upper body adiposity, and cardiovascular risk factors in non-diabetics.

Previous studies have suggested that hyperinsulinemia and upper body adiposity are each separately associated with elevated BP and triglyceride (TG) levels, and with lower high density lipoprotein (HDL) cholesterol levels. The joint effect of hyperinsulinemia and upper body adiposity on lipids, lipoproteins, and BP, however, has not been previously studied. We hypothesized that the effect of body fat distribution on cardiovascular risk factors might be mediated through hyperinsulinemia. We measured BP, lipids and lipoproteins, HDL subfractions, and insulin and glucose concentrations as part of the San Antonio Heart Study, a population-based study of diabetes and cardiovascular risk factors. Insulinemia and glycemia were assessed as the sum of the fasting, half-hour, one-hour, and two-hour insulin and glucose levels, respectively, measured during a standardized oral glucose tolerance test. Individuals who had diabetes according to National Diabetes Data Group criteria were excluded from the analyses. In univariate analyses, both hyperinsulinemia and waist-to-hip ratio (WHR), a measure of upper body adiposity, were positively associated with TG and negatively associated with total HDL and HDL2 cholesterol levels. However, when the effects of glycemia and insulinemia were controlled for by analysis of variance, WHR was no longer significantly related to TG levels. By contrast, WHR continued to be inversely related to total HDL and HDL2 cholesterol even after adjustment for glycemia and insulinemia. Hyperinsulinemia was only weakly related to HDL cholesterol. These results suggest that insulinemia and glycemia might mediate the effects of upper body adiposity on TG, although not on HDL and HDL2 cholesterol. Hyperinsulinemia was also positively associated with diastolic and systolic BP in men.

Adipose Tissue↗
PubMed1988

Excess incidence of treatment of end-stage renal disease in Mexican Americans.

Mexican Americans are the second largest minority group in the United States (8.73 million people according to the 1980 US census) and are known to have an excess prevalence of obesity and non-insulin-dependent diabetes mellitus, but similar or lower rates of hypertension when compared with non-Hispanic whites. To our knowledge, no data are available on incidence of end-stage renal disease in this population. Using a data base from the Texas Kidney Health Program, a division of the Texas Department of Health, and the 1980 US census for the state of Texas, the authors calculated age-adjusted incidence of treatment of end-stage renal disease in Mexican Americans, non-Hispanic whites, and blacks for the years 1978-1984. Mexican Americans and blacks have an excess of treatment of end-stage renal disease (all etiologies combined) compared with non-Hispanic whites (incidence ratios of 3 and 4, respectively). For diabetes-related end-stage renal disease, Mexican Americans have an incidence ratio of 6, while blacks have an incidence ratio of 4 compared with non-Hispanic whites. For Mexican Americans, this excess is higher than would be expected on the basis of their underlying prevalence of diabetes. The incidence of hypertensive end-stage renal disease in Mexican Americans was 2.5 times higher than in non-Hispanic whites, which is higher than expected given the lack of excess in their underlying prevalence of hypertension. The high prevalence of diabetes in Mexican Americans explains some, but not all, of the excess of treatment of end-stage renal disease in this population.

Adult↗
PubMed1988

Diabetic retinopathy in Mexican Americans and non-Hispanic whites.

Mexican Americans (MAs) have a threefold greater prevalence of non-insulin-dependent diabetes mellitus (NIDDM) than non-Hispanic Whites (NHWs). Because MA diabetic subjects have greater hyperglycemia and an earlier age of onset than NHW diabetic subjects, we postulated that diabetic MAs might also have more severe diabetic retinopathy. Stereoscopic retinal photographs of the seven standard fields of each eye were taken in 257 MAs and 56 NHWs with NIDDM. The photographs were read by the University of Wisconsin Fundus Photographic Reading Center and graded with standardized criteria. The MAs had a nonsignificantly increased risk of retinopathy relative to the NHWs [odds ratio (OR) = 1.71; 95% confidence interval (Cl) = (0.93, 3.17)]. The risk of severe retinopathy (proliferative or preproliferative) relative to background or no retinopathy was significantly greater in MAs than in NHWs [OR = 2.37; 95% Cl = (1.04, 5.39)]. After control by logistic regression for duration of disease, severity of hyperglycemia, age, and systolic blood pressure, MAs still had an increased risk of severe retinopathy relative to NHWs [OR = 3.18; 95% Cl = (1.32, 7.66)]. Severe retinopathy was related to duration of disease, hyperglycemia, and insulin therapy in both ethnic groups. Previously diagnosed MA diabetic subjects also had an increased prevalence of any retinopathy [OR = 2.39; 95% Cl = (1.63, 3.50)] and severe retinopathy [OR = 3.21; 95% Cl = (2.24, 4.59)] relative to previously diagnosed White diabetic subjects (n = 896) from Wisconsin.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1988

A proposal for more informative abstracts of review articles.

This proposal presents guidelines for preparing informative abstracts of review articles. Six guidelines are proposed: 1. The abstract should begin with a precise statement of the primary objective of the review. 2. The data sources for the review should be succinctly summarized. 3. The criteria used to select studies from the data sources and the method by which these criteria were applied should be specified. 4. The guidelines used for abstracting data and assessing data quality should be described. 5. The main results of the review and the methods used to obtain these results should be stated. 6. Conclusions and potential applications of the review's results should be clearly and succinctly stated. Application of these guidelines can lead to efficient identification of relevant, scientifically sound review articles, a greater awareness of the vital elements of a good review article, more precise computerized literature searches, and improved peer-review processes.

Abstracting and Indexing↗
PubMed1986

Hyperinsulinemia in a population at high risk for non-insulin-dependent diabetes mellitus.

The prevalence of non-insulin-dependent diabetes mellitus (NIDDM) is higher in Mexican Americans than in non-Hispanic white Americans, even after adjustment for the former's greater overall and more centralized adiposity. We postulated that this excess risk of NIDDM could be due to resistance to insulin. We performed oral glucose-tolerance tests with measurements of serum insulin concentrations in 225 Mexican Americans and 180 non-Hispanic whites without diabetes as part of the San Antonio Heart Study, a population-based study of risk factors for diabetes. Changes in serum insulin concentrations in response to the glucose challenge were quantified by the area under the serum insulin curve. Overall adiposity was characterized by body-mass index, and regional body-fat distribution by the ratio of subscapular to triceps skinfolds and the ratio of waist to hip circumference. After adjustment for these indicators of adiposity and also for differences in glucose tolerance, Mexican Americans were found to have significantly greater areas under the serum insulin curve than non-Hispanic whites. These data suggest that, like other populations at high risk for NIDDM such as Pima Indians and Micronesians, Mexican Americans have more hyperinsulinemia than can be accounted for by their adiposity.

Adult↗
PubMed1982

Knowledge, attitudes, and behavior related to obesity and dieting in Mexican Americans and Anglos: the San Antonio Heart Study.

An epidemiologic study was carried out on Mexican Americans and Anglos residing in two socioeconomically and culturally distinct target areas in San Antonio: a middle income, ethnically integrated area ("transitional") and an upper income, predominantly Anglo area ("suburbs"). Although suburbanite Mexican Americans were leaner than their lower income counterparts, they were still more overweight than suburbanite Anglos. Even after adjusting for these differences in relative weight, however, Mexican Americans were still more likely than Anglos to express the opinion that Americans are too concerned about losing weight. Expressed as a per cent of the maximum score, Mexican American women in the transitional neighborhood scored 77% on this attitude item compared with 60% for Angle women (p less than 0.0005). Comparable ethnic differences on this attitude item were found in men in the transitional neighborhood and in suburbanites of both sexes. In the transitional neighborhood Mexican American women scored lower than Anglo women on a "sugar avoidance" and a "dieting behavior" scale: 23% for Mexican Americans and 45% for Anglos (p less than 0.0005) on the "sugar avoidance" scale. Comparable ethnic differences on this scale were found for men in the transitional neighborhood and for both sexes on the "dieting behavior" scale. Although no ethnic differences on these behavioral scales were found in the more affluent suburbs, these results nevertheless have public health relevance because the majority of Mexican Americans in the United States are of low socioeconomic status.

Attitude to Health↗
PubMedDate not supplied

Detection and treatment of hypercholesterolemia in a biethnic community, 1979-1985.

Although hypercholesterolemia has been recognized as a risk factor for coronary heart disease (CHD) for decades, only in recent years have clinical trials definitively shown the efficacy of lowering serum cholesterol to prevent the occurrence or worsening of CHD. In 1985, an NIH consensus conference published guidelines for the diagnosis and treatment of hypercholesterolemia. Prior to 1985, physicians and lay people alike were not yet convinced of the necessity to know one's cholesterol level, nor did they know what levels should be treated. In a community-based survey of cardiovascular risk factors, known as the San Antonio Heart Study, in which 1,932 Mexican-Americans (MAs) and 1,133 non-Hispanic whites (NHWs) were examined between 1979 and 1985, the authors found that only 36/501 MAs (7%) and 54/312 NHWs (17%) in the moderate- or high-risk categories were aware that their cholesterols were high. Of the total number aware, including those whose cholesterol levels were in the low-risk range, only 23/97 MAs (24%) and 29/108 NHWs (27%) were receiving dietary or drug treatment. Of those being treated, only 9/23 MAs (39%) and 12/29 NHWs (41%) were effectively controlled. Mexican-Americans were less likely to be aware of their hypercholesterolemia than non-Hispanic whites, but both ethnic groups had low levels of treatment.

Adult↗