W H R Rivers: portrait of a great physician in Pat Barker's Regeneration trilogy.
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Anthropology, Cultural↗
Biomedical subjects
S Shea
Publications and source records attributed to S Shea.
Poverty and health in West Germany.
The relationship between poverty and several health-related characteristics in West Germany was investigated. Data were derived from the National and Regional Health Surveys conducted in West Germany from 1984 to 1992. 25,544 males and 25,719 females with German nationality aged 25-69 years were examined. Poverty was defined as a household income of 50% less than the mean for West Germany. Multiple logistic regression analysis was used to analyze the relationship between poverty and four health variables: individual health behavior, subjective assessment of health status, cardiovascular disease risk factors, and self-reported prevalence of lifetime chronic diseases. 10.2% of males and 12.8% of females were classified as being below the poverty line. For most but not all health parameters, less favourable results were found for the segment of the population with a household income below the poverty line. The most striking poverty-related differences were observed for lack of regular sport activities, subjective health satisfaction, obesity and myocardial infarction/stroke. Significantly lower prevalence rates for study subjects below the poverty line were observed for hypercholesterolemia in females only. Allergic disorders were the only chronic diseases reported significantly less often in males and females below the poverty line. Poverty has strong effects on individual health status and the prevalence of chronic diseases. Due to the rising unemployment rates in Germany in the last years it is very likely that the strong negative consequences of poverty for health are increasing.
Adult↗
Association of apo E polymorphism with plasma lipid levels in a multiethnic elderly population.
Apolipoprotein E polymorphisms are important determinants of blood lipid levels and have been associated with longevity and atherosclerosis. However, information is limited on the effects of apo E variation on the lipids of nonwhite and elderly individuals. We tested the hypothesis that apo E polymorphisms are associated with plasma lipid levels in an elderly, multiethnic population. Cross-sectional data from 1068 noninstitutionalized individuals from northern Manhattan over the age of 64 who were not on a lipid-lowering diet or drug were analyzed. The ethnic distribution was 34% African-Americans, 47% Hispanics, and 19% non-Hispanic Caucasians. In the entire group, the most prevalent apo E allele was epsilon 3 (76%), followed by epsilon 4 (16%) and epsilon 2 (8%); epsilon 4 was more prevalent in African-Americans (21%) than in non-Hispanic Caucasians (12%) or Hispanics (14%). The apo epsilon 2 allele was the most important correlate of plasma lipids, but association varied across ethnoracial groups. After being adjusted for age, sex, obesity, diabetes mellitus, and alcohol intake, LDL cholesterol levels declined with each apo epsilon 2 allele by 8.8 mg/dL in Hispanics and by 25.6 and 18.1 mg/dL in non-Hispanic Caucasians and African-Americans, respectively (P < .001). No significant independent effect was noted for any apo E genotype on HDL cholesterol. Overall, there was a reduction in the total/HDL cholesterol ratio, per apo epsilon 2 allele, of 0.82 in non-Hispanic Caucasians and 0.43 and 0.48 in African-American and Hispanic individuals, respectively (P < .05). In a multivariate model, apo epsilon 4 did not significantly affect plasma lipid levels. Plasma triglyceride levels were inversely correlated with the number of apo epsilon 4 alleles (175, 159, and 143 mg/dL with 0, 1, and 2 alleles, respectively; P =.002), and this effect increased with age. Thus, in an elderly, multiethnic population, apolipoprotein E polymorphisms were important determinants of blood lipids, with differing effects depending on ethnicity. The presence of apo epsilon 2 was associated with lower LDL cholesterol levels and total/HDL cholesterol ratio, although apo epsilon genotype did not influence HDL cholesterol levels. Prospective studies are needed to test whether apo epsilon 2 protects against incident cardiovascular disease in the elderly.
Age Factors↗
Race-ethnicity and determinants of carotid atherosclerosis in a multiethnic population. The Northern Manhattan Stroke Study.
BACKGROUND AND PURPOSE: Risk factors for carotid atherosclerosis have been studied in white populations but infrequently in multiethnic cohorts. The aim of this study was to determine the importance of race-ethnicity and other factors associated with carotid atherosclerosis in a mixed population of Hispanics, blacks, and whites. METHODS: As part of the Northern Manhattan Stroke Study, 526 stroke-free community residents (aged > or = 40 years; 41% men, 59% women; 46% Hispanic, 31% black, 23% white) were recruited through random-digit dialing and had vascular risk factor evaluations. Maximum internal carotid artery plaque thickness (MICPT) was measured with B-mode ultrasound. The frequency distribution of MICPT was examined in the three race-ethnic groups, and multivariate regression was performed to identify factors that were independently associated with MICPT. RESULTS: Mean MICPT in the entire sample was 1.5 +/- 1.4 mm, increased directly with age, and was greater in whites and blacks than Hispanics. Other independent determinants of MICPT included smoking, glucose, LDL cholesterol, and hypertension. After we controlled for these covariates, Hispanic (versus non-Hispanic) race-ethnicity was still an independent determinant of less carotid plaque. There was a significant interaction between race-ethnicity and LDL cholesterol, with a greater effect of increasing LDL cholesterol among Hispanics. CONCLUSIONS: Atherosclerotic risk factors were predictive of MICPT in this mixed-ethnic cohort. Hispanics had significantly less carotid plaque after adjustment for other known risk factors, but they also had a greater impact of increasing LDL cholesterol.
Adult↗
Treatment of children with Williams syndrome with methylphenidate.
Children with Williams syndrome frequently present with symptoms of attention deficit hyperactivity disorder (ADHD), but there is little information that stimulant medication is useful in this population. A series of double-blind, placebo-controlled case studies was used to evaluate the cognitive and behavioral effects of methylphenidate on four children with Williams syndrome. Teachers and mothers completed behavioral rating scales and cognitive tests of attention, learning and memory, and academic productivity and accuracy in mathematics in each medication condition. Two of the children responded favorably in terms of decreased impulsivity, decreased irritability, and lower activity level as well as improved ability to pay attention. Methylphenidate is a useful adjunct in the treatment of some children with Williams syndrome.
Adolescent↗
Compensation to a department of medicine and its faculty members for the teaching of medical students and house staff.
BACKGROUND: Changes in the organization and financing of health care threaten to alter the prevailing system of financing the teaching of medical students and residents. Little information is available from private medical schools and teaching hospitals about the extent of teaching by faculty members or the mechanisms and levels of reimbursement for teaching. METHODS: We surveyed faculty members in the Department of Medicine at Columbia-Presbyterian Medical Center to ascertain the extent of their teaching activities. A standard number of hours was assigned to each activity, and the total number of teaching hours was calculated for each faculty member. Teaching of fellows and in continuing medical education programs was excluded. We also determined how much money the Department of Medicine received in payment for faculty members' teaching activities, and the sources of this compensation. RESULTS: In the 1992-1993 academic year, the 188 full-time faculty members spent a total of 46,086 hours teaching (mean [+/- SD], 245 +/- 178 hours per faculty member); 10,780 hours (23.4 percent) were spent teaching medical students, and 35,306 hours (76.6 percent) teaching house staff. Eighty percent of faculty members taught for 137 or more hours each. In a multivariate analysis including faculty rank, subspecialty division, years since graduation from medical school, sex, and tenure or clinical track, senior faculty members (P = 0.02), members of certain subspecialty divisions (P < 0.001), and women (P = 0.05) contributed more than the average number of teaching hours. An additional 56 non-full-time faculty members contributed a total of 5684 hours. The net reimbursement to the department for teaching totaled $965,808, or about $16 per hour of teaching by full-time faculty members, after the cost of fringe benefits was excluded. CONCLUSIONS: Faculty members of the department of medicine at a major medical center contribute a large number of hours teaching medical students and house staff. This effort is poorly compensated. Cost-containment efforts have the potential to jeopardize fragile social contracts at academic health centers whereby the faculty participates in teaching by contributing unreimbursed or underreimbursed time.
Academic Medical Centers↗
Dietary lipids and antioxidants in Parkinson's disease: a population-based, case-control study.
Oxidative stress plays an important role in the pathogenesis of Parkinson's disease (PD). In a population-based, case-control study we examined whether dietary intake of antioxidants and other oxidative compounds was associated with PD. Dietary intake was assessed by a semiquantitative food-frequency questionnaire in 110 PD case patients and 287 control subjects. A higher caloric intake was observed in patients with PD and did not vary with increasing duration of symptoms. Energy-adjusted fat intake was significantly higher among patients with PD than control subjects (p for trend = 0.007). Intake of protein (p for trend = 0.17) and carbohydrates (p for trend = 0.46) did not differ in patients and control subjects. Analyses of the primary sources of fat indicated that increasing intake of animal fats were strongly related to PD (odds ratio, 5.3; 95% confidence interval, 1.8-15.5; p for trend = 0.001). No significant differences were observed for intake of vitamins with antioxidant activity. An increase in the consumption of animal fats among patients with PD is consistent with the hypothesis that oxidative stress and lipid peroxidation are important in the pathogenesis of this disease. No effect of vitamins with antioxidant activity, either from food or supplements, was observed.
Aged↗
Clinical trial enrollers vs. nonenrollers: the Cardiac Arrhythmia Suppression Trial (CAST) Recruitment and Enrollment Assessment in Clinical Trials (REACT) project.
The Recruitment and Enrollment Assessment in Clinical Trials (REACT) was a National Heart, Lung, and Blood Institute (NHLBI)-sponsored substudy to the Cardiac Arrhythmia Suppression Trial (CAST). Two-hundred-sixty (260) patients who enrolled in CAST and 140 partially or fully eligible patients who did not enroll were compared across several parameters, including demographic variables, disease severity, psychosocial functioning, health beliefs, recruitment experience, and understanding of informed consent procedures used in CAST. Significant predictors of enrollment included several demographic variables (e.g., being male, not having medical insurance), episodes of ventricular tachycardia, and health beliefs (e.g., extra beats are harmful, a higher degree of general health concern). Enrollment was higher for those who read and understood the informed consent and those who were initially recruited after hospital discharge, particularly nondepressed patients. In the multivariate model, the key variables that emerged were the patient's reading of the informed consent form and the patient's lack of medical insurance. These results suggest that (1) the clinical trial staff's interaction with the patient and the time when recruitment is initiated contribute significantly to the decision to enroll; and (2) it may be a greater challenge to motivate patients to enroll in future clinical trials if health care reform improves access to medical insurance coverage. Some of the significant variables are modifiable, suggesting interventions that may increase enrollment rates in future trials.
Aged↗
Reproducibility of the women's module of the Behavioral Risk Factor Surveillance System questionnaire.
The Behavioral Risk Factor Surveillance System (BRFSS) is designed to provide statewide estimates of the prevalence of preventive health practices, including screening. We assessed the reproducibility of responses to the women's health module, which covers breast and cervical cancer screening, hysterectomy, and pregnancy. A random sample of women in Massachusetts (n = 91; response rate for the repeat interview, 70.0%) and a separate random sample of minority women in the state (n = 179; response rate for the repeat interview, 69.4%) were interviewed by telephone twice, 21 to 94 days apart. Differences across administrations in mean prevalence of screening were small. Concordance exceeded 85% for almost all the variables examined, but tended to be lower for nonwhite respondents. After correction for agreement occurring by chance, moderate to excellent values of kappa (range, 0.41 to 0.86) were observed. The women's health module of the BRFSS questionnaire yields highly consistent group mean estimates of prevalence when administered repeatedly to the same individuals. Individual reproducibility is excellent, but may be reduced among minority respondents.
Adolescent↗
The Washington Heights-Inwood Healthy Heart Program: a 6-year report from a disadvantaged urban setting.
OBJECTIVES: This report summarizes 6 years of experience in a large community-based cardiovascular disease prevention program in a predominately minority, urban setting. METHODS: The program seeks to reduce cardiovascular disease risk factors in an area of approximately 240,000 people in New York, NY; this population includes many Latino immigrants of low educational attainment and socioeconomic status. All program materials were in Spanish and English and at a low literacy level. RESULTS: Major elements that achieved high levels of reach and support were a marketing campaign promoting low-fat milk, exercise clubs, and a Spanish-language smoking cessation video. Program elements that did not meet expectations or were abandoned were school-based smoking prevention initiatives, cholesterol screening, and efforts to involve local physicians. At the end of 6 years, the program was transferred to a local community organization. CONCLUSIONS: Conclusions are that it is feasible to implement a complex cardiovascular disease prevention program in a socially disadvantaged urban community; that additional evaluation research is needed; that such programs can be transferred from an academic center to a community organization; and that such programs are unlikely to be sustained effectively without external resources.
Attitude of Health Personnel↗
The validity of hospital administrative data in monitoring variations in breast cancer surgery.
To assess the validity of using hospital administrative data to measure variations in surgery for early-stage breast cancer, ICD-9-CM coded information was compared with corresponding tumor registry data for 1293 breast cancer patients undergoing lumpectomy or mastectomy at a tertiary referral center from January 1989 to October 1993. Relative to "gold standard" tumor registry data, the administrative data proved 83.4% sensitive and 80.4% specific in identifying women with localized disease who would be potential candidates for lumpectomy. The proportion of women with localized disease undergoing lumpectomy in groups defined by race and insurance status was nearly identical, whichever data were used. Administrative data, which is often readily and publicly available, may be useful in studying variations in breast cancer treatment in key demographic groups.
Black or African American↗
Promotion of women physicians in academic medicine.
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Career Mobility↗
Reproducibility of responses to telephone interviews: demographic predictors of discordance in risk factor status.
The reproducibility of responses to the Behavioral Risk Factor Surveillance System questionnaire was examined across the demographic strata used by the Centers for Disease Control and Prevention and state health departments for reporting prevalence estimates (specifically age, sex, income, employment, and marital status), as well as race/ethnicity, which has been previously examined. The authors administered the questionnaire twice, 21-94 days apart, to randomly selected residents of Massachusetts (response rates: first administration, 68% of eligible households; second administration, 68% of persons who completed the first interview). Initial interviews were conducted in March and October 1992. Among 448 respondents to both interviews, group mean distributions of seven demographic characteristics and 19 risk factors were highly consistent across the two interviews. Discordance in individual risk factor status ranged from 1.2% to 21.8% (median, 7.8%) and was symmetric in direction, i.e., as many respondents were considered at increased risk on the basis of the first interview and at low risk on the basis of the second interview as the reverse. Kappas ranged from 0.30 to 0.90 (median, 0.75). Education, household income, and interval between administrations were not associated with prevalence of discordance for any risk factor. Sex, age, race/ethnicity, marital status, and employment status were each predictive of variation in discordance for one or more risk factors, but no consistent effect of any individual demographic characteristic across risk factors was observed. The questionnaire has relatively uniform and generally good reproducibility across all demographic strata used for monitoring the Health Objectives for Year 2000 and other chronic disease surveillance activities.
Adolescent↗
Sequential events contributing to variations in cardiac revascularization rates.
Numerous studies have demonstrated the importance of race, payor, and gender in determining the use of cardiac services, including revascularization procedures (bypass surgery and angioplasty). However, there has been less investigation into where and when in the process of care differences in utilization arise. In this report, the authors examined the sequence of events leading to the use of revascularization procedures, identifying four phases of care (prehospital, intrahospital, interhospital, and posthospital). Following a cohort of 5857 patients admitted to California hospitals with acute myocardial infarction in 1991, the authors found differences in treatment probabilities during nearly every phase for different racial and payor groups. For example, compared with patients who are uninsured, patients with private insurance were more likely to be admitted initially to a hospital offering revascularization (adjusted odds ratio [OR] = 1.40, 95% confidence interval [CI] 1.30 to 1.51). Moreover, once admitted to such a hospital, private patients were more likely to undergo revascularization (adjusted OR = 2.30; 95% CI 1.80 to 2.94). They were also more likely to undergo transfer to receive revascularization (adjusted OR = 1.22; 95% CI 1.03 to 1.45), and to be readmitted for revascularization (adjusted OR = 1.60; 95% CI 1.13 to 2.27). Previously reported discrepancies in service use represent the cumulative effects of multiple phases during which different racial and payor groups experience different processes of care.
California↗
The availability of low-fat milk in an inner-city Latino community: implications for nutrition education.
Substitution of low-fat for whole milk is an important strategy for reducing saturated fat consumption, but intake of whole milk remains high among Latinos. To assess whether this is related to the unavailability of low-fat milk, we surveyed 251 grocery stores (bodegas) and 25 supermarkets in a predominantly low-income, urban Latino community. Low-fat milk was available in 73% of bodegas and 96% of supermarkets, but it constituted only 15% of total milk volume in bodegas and 37% of that volume in supermarkets. Since lack of availability was not a major obstacle to increasing low-fat milk consumption, public health nutrition campaigns should focus on increasing consumer demand.
Animals↗
Social inequalities and health status in western Germany.
STUDY OBJECTIVE: To examine social class gradients for seven self-reported diseases in western Germany. DESIGN: A pooled analysis of three cross-sectional representative health surveys in western Germany and three health surveys in the six intervention regions of the German Cardiovascular Prevention Study. PARTICIPANTS: 44,363 study subjects, of both sexes, with German nationality, aged 25-69 years, were examined in the national and regional health surveys from 1984 to 1991. MEASUREMENT AND MAIN RESULTS: Assessment of disease prevalence was carried out by a standardized self-administered questionnaire. Social class was assessed using a composite index combining educational achievement, occupational status and household income. Cigarette smoking and Pattern A behaviour were based on self-report. Height and weight were measured by physical examination and body mass index was calculated. Statistical analysis were performed using multiple logistical regression. Response rates ranged from 66.0 to 71.4% in the national surveys and from 65.9 to 83.8% in the regional surveys. For both sexes, the prevalence of previous myocardial infarction and the prevalence of stroke, diabetes mellitus and chronic bronchitis was significantly higher in the lower social classes. In males only, the prevalence of intervertebral disc damage and peptic ulcer was significantly higher in the lower social classes. In females only, there was a similar gradient for hyperuricaemia and gout. In both sexes, allergies and hay fever were the only diseases with higher prevalence in the higher social classes. Adjusting these trends for smoking, obesity and Pattern A behaviour resulted in only minor changes in the slopes of the disease-specific social class gradients. CONCLUSION: In western Germany, despite a health system with almost free access for the general population, strong social class inequalities exist for many diseases. These inequalities cannot be explained by social class differences in smoking, obesity or Pattern A behaviour. More research is needed to identify underlying causes for these persistent social inequalities in health status.
Adult↗
Moderate and vigorous leisure-time physical activity and cardiovascular disease risk factors in West Germany, 1984-1991.
The relationship between leisure-time physical activity (LTPA) and cardiovascular disease (CVD) risk factors was analysed based on data of three cross-sectional National Health Surveys, carried out in West Germany between 1984 and 1991. A total of 7663 males and 7722 females, aged 25-69 years, were examined. A self-administered questionnaire was used to assess LTPA which was defined as the mean duration of time (in minutes) spent during the past week on 14 specified sports during the previous 3 months. The mean time for LTPA per week was 102 minutes for males and 70 minutes for females. No significant differences were observed in LTPA mean duration for the three surveys. Younger age and higher social class were strong predictors for greater LTPA. In multiple linear regression models, after adjustment for age and social class, LTPA was significantly associated with lower systolic and diastolic blood pressure (both sexes), total cholesterol (males only), cigarette smoking (males only) and body mass index (females only), and with higher HDL-cholesterol (both sexes). The data suggest that LTPA plays an important role if aiming at reducing CVD risk factors in the general population.
Adult↗
Hypertension control, 1994.
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Adolescent↗