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Obesity and risk of adverse outcomes associated with coronary artery bypass surgery. Northern New England Cardiovascular Disease Study Group.

BACKGROUND: Obesity is frequently cited as a risk factor for adverse outcomes of major surgery. The results of prior studies of the relationship between obesity and risk of adverse outcomes of coronary artery bypass grafting (CABG) have been contradictory because of insufficient power to assess relatively infrequent outcomes or data to adjust for confounding factors. METHODS AND RESULTS: Data on patient age, sex, height, weight, medical history, current clinical status, and treatment factors were assessed prospectively among 11101 consecutive patients undergoing CABG. Body mass index (BMI) was used as the measure of obesity and was categorized as nonobese (1st to 74th percentiles), obese (75th to 94th percentiles), or severely obese (95th to 100th percentiles). Adverse outcomes occurring in-hospital, including mortality, intraoperative/postoperative cerebrovascular accident (CVA), postoperative bleeding, and sternal wound infection, were defined prospectively. Associations between obesity and postoperative outcomes were assessed by use of logistic regression to adjust for potentially confounding variables. Although obesity was not associated with increased mortality (adjusted odds ratio [OR], 1.16; P=.261) or postoperative CVA (adjusted OR, 1.06; P=.765), risks of sternal wound infection were substantially increased in the obese (adjusted OR, 2.10; confidence interval [CI], 1.45 to 3.06; P<.001) and severely obese (adjusted OR, 2.74; CI, 1.49 to 5.02; P=.001). On the other hand, rates of postoperative bleeding were significantly lower in the obese (adjusted OR, 0.66; CI, 0.49 to 0.90; P=.009) and severely obese (adjusted OR, 0.40; CI, 0.20 to 0.81; P=.011). CONCLUSIONS: With the exception of sternal wound infection, the perception among clinicians that obesity predisposes to various postoperative complications with CABG is not supported by these data. Further work is needed to understand the apparent protective effect of obesity on risks of postoperative bleeding.

Aged↗

Gender differences in acute myocardial infarction: the University of Wisconsin experience.

OBJECTIVE: To investigate gender differences in baseline characteristics, presentation, and treatment of patients with acute myocardial infarction (MI) admitted to the University of Wisconsin Hospital Coronary Care Unit (CCU) over a 1-year period. METHODS: A retrospective review was performed on the charts of all patients (n = 293) admitted to the CCU in 1996 with a discharge diagnosis of acute MI. In 83 women and 187 men with analyzable data (n = 270), 42 factors related to baseline characteristics, presentation, treatment, and outcomes were identified and analyzed for gender differences. RESULTS: On average, women were 5 years older than men (p < .01). By univariate comparison, women were less likely than men to be smokers (p < .001); more likely to have underlying hypertension (p < .01), diabetes mellitus (p < 0.05), non-Q-wave infarctions (p < .01), and congestive heart failure (CHF, p < .05); and more likely to have received diuretics (p < .001) and ACE inhibitors (p < .01). While women were less likely than men to undergo coronary angiography (p < .05) and more likely to have echocardiograms (p < 0.05), rates of coronary artery bypass graft surgery, angioplasty, and the use of thrombolytics were similar for men and women. Clinical outcomes were similar in both groups. CHF, hypertension, and use of ACE inhibitors remained the only significant gender differences when data were adjusted for age. CONCLUSION: Comparing men and women with acute MI at UW Hospital revealed some differences in clinical characteristics and management. Except for CHF, hypertension, and use of ACE inhibitors (all of which may be related), these differences disappeared when the data were adjusted for age. This is particularly notable for the disappearance of the difference in the use of coronary angiography between men and women. The comparable use of beta-blockers, aspirin, and nitrates, and the similar clinical outcomes in men and women, suggest less gender difference in MI management at UW Hospital than reported in other studies.

Age Distribution↗

Is volume related to outcome in health care? A systematic review and methodologic critique of the literature.

PURPOSE: To systematically review the methodologic rigor of the research on volume and outcomes and to summarize the magnitude and significance of the association between them. DATA SOURCES: The authors searched MEDLINE from January 1980 to December 2000 for English-language, population-based studies examining the independent relationship between hospital or physician volume and clinical outcomes. Bibliographies were reviewed to identify other articles of interest, and experts were contacted about missing or unpublished studies. STUDY SELECTION: Of 272 studies reviewed, 135 met inclusion criteria and covered 27 procedures and clinical conditions. DATA EXTRACTION: Two investigators independently reviewed each article, using a standard form to abstract information on key study characteristics and results. DATA SYNTHESIS: The methodologic rigor of the primary studies varied. Few studies used clinical data for risk adjustment or examined effects of hospital and physician volume simultaneously. Overall, 71% of all studies of hospital volume and 69% of studies of physician volume reported statistically significant associations between higher volume and better outcomes. The strongest associations were found for AIDS treatment and for surgery on pancreatic cancer, esophageal cancer, abdominal aortic aneurysms, and pediatric cardiac problems (a median of 3.3 to 13 excess deaths per 100 cases were attributed to low volume). Although statistically significant, the volume-outcome relationship for coronary artery bypass surgery, coronary angioplasty, carotid endarterectomy, other cancer surgery, and orthopedic procedures was of much smaller magnitude. Hospital volume-outcome studies that performed risk adjustment by using clinical data were less likely to report significant associations than were studies that adjusted for risk by using administrative data. CONCLUSIONS: High volume is associated with better outcomes across a wide range of procedures and conditions, but the magnitude of the association varies greatly. The clinical and policy significance of these findings is complicated by the methodologic shortcomings of many studies. Differences in case mix and processes of care between high- and low-volume providers may explain part of the observed relationship between volume and outcome.

Delivery of Health Care↗

Unlocking the numerator-denominator bias III: adjustment ratios by ethnicity for 1981-1999 mortality data. The New Zealand Census-Mortality Study.

AIM: Maori and Pacific deaths are under-counted in mortality data relative to census data. This 'numerator-denominator' bias means that routinely calculated mortality rates by ethnicity are incorrect. We used New Zealand Census-Mortality Study data to quantify the bias from 1981 to 1999. METHODS: The 1981, 1986, 1991 and 1996 Censuses were each anonymously and probabilistically linked to three years of subsequent mortality data, allowing a comparison of ethnicity recording. RESULTS: Compared with death registrations, 16% more 0-74 year old decedents during 1981-1984 had self-identified as '1/2 or more Maori' on the 1981 Census, and 32% more during both 1986-1989 and 1991-1994 had self-identified as 'sole Maori' on the 1986 and 1991 Censuses. From September 1995, mortality data have allowed multiple ethnicity to be recorded. During 1996-1999, 7% more decedents identified Maori as one of their ethnic groups on the 1996 Census compared with mortality data. For Pacific decedents, 55%, 76% and 68% more self-identified as 'sole Pacific' on census data compared with data recorded on death registrations for 1981-1984, 1986-1989 and 1991-1994 respectively, but there was no difference for 1996-1999. The bias for Maori (but not for Pacific) was greater among the young and those living in central and southern regions of New Zealand. CONCLUSIONS: The 1995 change to ethnicity recording on mortality data has improved the robustness of ethnicity data collection. These adjustment factors for 1981-1999 allow for more accurate calculations of ethnic-specific mortality rates over the last 20 years.

Adolescent↗

Application of the biotic ligand model to predicting zinc toxicity to rainbow trout, fathead minnow, and Daphnia magna.

The Biotic Ligand Model has been previously developed to explain and predict the effects of water chemistry on the toxicity of copper, silver, and cadmium. In this paper, we describe the development and application of a biotic ligand model for zinc (Zn BLM). The data used in the development of the Zn BLM includes acute zinc LC50 data for several aquatic organisms including rainbow trout, fathead minnow, and Daphnia magna. Important chemical effects were observed that influenced the measured zinc toxicity for these organisms including the effects of hardness and pH. A significant amount of the historical toxicity data for zinc includes concentrations that exceeded zinc solubility. These data exhibited very different responses to chemical adjustment than data that were within solubility limits. Toxicity data that were within solubility limits showed evidence of both zinc complexation, and zinc-proton competition and could be well described by a chemical equilibrium approach such as that used by the Zn BLM.

Animals↗

Measuring data abstraction quality in multiresolution visualizations.

Data abstraction techniques are widely used in multiresolution visualization systems to reduce visual clutter and facilitate analysis from overview to detail. However, analysts are usually unaware of how well the abstracted data represent the original dataset, which can impact the reliability of results gleaned from the abstractions. In this paper, we define two data abstraction quality measures for computing the degree to which the abstraction conveys the original dataset: the Histogram Difference Measure and the Nearest Neighbor Measure. They have been integrated within XmdvTool, a public-domain multiresolution visualization system for multivariate data analysis that supports sampling as well as clustering to simplify data. Several interactive operations are provided, including adjusting the data abstraction level, changing selected regions, and setting the acceptable data abstraction quality level. Conducting these operations, analysts can select an optimal data abstraction level. Also, analysts can compare different abstraction methods using the measures to see how well relative data density and outliers are maintained, and then select an abstraction method that meets the requirement of their analytic tasks.

Journal Article↗

Redistributional consequences of community rating.

OBJECTIVE: To predict the geographical effects of community rating of health insurance premiums on the amount individuals pay for insurance. DATA SOURCES: We estimate premiums and health expenditures for a 5 percent sample of Californians from the 1990 U.S. Census (the Public Use Microdata Sample) and use data from Blue Cross of California to adjust for regional price differences in services. STUDY DESIGN: We use an episodic health simulation model to estimate health expenditures for 975,074 Californians. Because the simulations do not reflect expenditure differences due to price variation in cost of services, we adjust these data for relative price differences by county. This leaves us with a sample of Californians for whom we have estimated health expenditures. We then compute average expenditures within areas of different sizes (all California, two regions, within counties) to estimate community-rated premiums. We then compare these premiums with actual expenditures on a county-by-county basis. PRINCIPAL FINDINGS: With a single California-wide premium, rural residents pay premiums that exceed their use of care, while urban residents pay premiums that are less than their use of care. These transfers are substantial. Dividing California into regional risk pools at the county level still results in poorer communities providing substantial subsidies to their more wealthy counterparts. CONCLUSIONS: Mandated community rating of premiums in a heterogeneous state such as California results in large unintended transfers of wealth from poorer, rural communities to urban, wealthier communities. Allowing premiums to vary with the regional cost of medical care would eliminate some of the transfers without sacrificing the benefits of community rating. Subsidies to low-income families could also effectively mitigate this redistribution. UTILITY: This article points out some potentially regressive consequences of geographic community rating and suggests ways to mitigate them.

California↗

The epidemiology of multiple sclerosis: the Iceland model. Onset-adjusted prevalence rate and other methodological considerations.

The epidemiology of multiple sclerosis (MS) is characterized by the fact that there is an uneven distribution of the disease throughout the world. The two most commonly used indices of its frequency are the incidence and prevalence rates. The incidence rate reflects, to a great extent, the influence of environmental factors in triggering the clinical manifestations of the disease, if it is based upon the actual date of the initiation of symptoms, rather than the date of diagnosis. The prevalence rate is currently based on the date of diagnosis and includes all MS patients who are alive on a particular date, without regard to their ethnic origin, the site and the duration of residence or any other factors that may have influenced the acquisition of the disease. We propose that in order to make the concept of the prevalence rate possibly more meaningful, the term should refer, retrospectively, to all patients whose symptoms eventually led to the diagnosis of MS, even though the diagnosis was not yet established on an earlier prevalence day. In addition, only patients of the same ethnic background who have spent their prepuberal years in the geographical area under study should be included. We are calling this measure the onset-adjusted prevalence rate. Another problem encountered in epidemiological studies of MS relates to the common practice of adjusting prevalence data obtained for age and sex in one area to what is referred to as a "standard" American (or world) population, groups of great ethnic and age diversity. It is also curious that in many studies the bases for comparison of populations are census data obtained many years previously. We suggest that age and sex adjustment should be applied only to similar ethnic groups born and raised under different environmental conditions. We believe that data obtained by calculating an onset-adjusted prevalence rate restricted to a homogeneous group of patients sharing the same environment during the prepuberal years may provide valuable etiological clues.

Age Factors↗

Accuracy of the 1990 census and undercount adjustments.

"In July 1991 the [U.S.] Census Bureau recommended to its parent agency, the Department of Commerce, that the 1990 census be adjusted for undercount. The Secretary of Commerce decided not to adjust, however. Those decisions relied at least partly on the Census Bureau's analyses of the accuracy of the census and of the proposed undercount adjustments based on the Post-Enumeration Survey (PES).... This article describes the total error analysis and loss function analysis of the Census Bureau. In its decision not to adjust the census, the Department of Commerce cited different criteria than aggregate loss functions. Those criteria are identified and discussed."

Americas↗

Action (verb) fluency: test-retest reliability, normative standards, and construct validity.

Action (verb) fluency is a newly developed verbal fluency task that requires the examinee to rapidly generate as many verbs (i.e., "things that people do") as possible within 1 min. Existing literature indicates that action fluency may be more sensitive to frontal-basal ganglia loop pathophysiology than traditional noun fluency tasks (e.g., animal fluency), which is consistent with the hypothesized neural dissociation between noun and verb retrieval. In the current study, a series of analyses were undertaken to examine the psychometric properties of action fluency in a sample of 174 younger healthy participants. The first set of analyses describes the development of demographically adjusted normative data for action fluency. Next, a group of hypothesis-driven correlational analyses reveals significant associations between action fluency and putative tests of executive functions, verbal working memory, verbal fluency, and information processing speed, but not between action fluency and tests of learning or constructional praxis. The final set of analyses demonstrates the test-retest stability of the action fluency test and provides standards for determining statistically reliable changes in performance. In sum, this study enhances the potential clinical applicability of action fluency by providing demographically adjusted normative data and demonstrating evidence for its reliability and construct validity.

Adolescent↗

Growth of abused children. Contrasted with the non-abused in an urban poor community.

While the identification of a growth-retarded or otherwise undernourished child suggests a diagnosis of child abuse or neglect, it is not certain that abused children from poor communities are less well nourished than children living in similar environments. The setting of this study--day care centers in an urban poor city--provided an opportunity to make this comparison with appropriate community-based controls. Measures of height, weight, and weight/height (Body Mass Index (BMI] were compared for 196 children, 2 to 6 years of age, 53 of whom were victims of physical abuse. The data was adjusted for age, sex, and ethnicity using logistic regression analysis to determine occurrence of wasting (weight for height less than 5th percentile) and stunting (height for age less than 5th percentile). Significantly more abused children (16.3%) showed wasting as compared to non-abused (0.7%) with abused children 16.6 times more likely to show wasting than non-abused (95% confidence limits on the Odds Ratio 1.9-145.0). While 11.6 percent of abused children showed stunting compared to 5.6 percent of non-abused, this difference was not significant when the data was adjusted for demographic factors. The BMI (15.02 kg/m2) for abused children was significantly less than that (15.9 kg/m2) for non-abused children (F = 8.11; p = 0.0049). In the present study, significant wasting as seen in acute malnutrition was found among abused children at diagnosis, suggesting that within an urban poor community the growth of children so identified does differ from the growth of children who are not abused.

Child↗

Dietary assessment in the elderly: validation of a semiquantitative food frequency questionnaire.

OBJECTIVE: The study was conducted to assess the relative validity of a 170-item semiquantitative food frequency questionnaire (SFFQ) adapted for use in the elderly. DESIGN AND SUBJECTS: The study was carried out in a sample of 80 men and women aged 55-75 y participating in a community based prospective cohort study in Rotterdam, The Netherlands. The two-step dietary assessment comprised a simple self-administered questionnaire (20 min) followed by a structured interview with trained dietitians (20 min) based on the completed questionnaire. Multiple food records (FR) collected over a one year period served as reference method. 24 h urine urea was used as indirect marker for protein intake. RESULTS: Compared with FR, the SFFQ generally overestimated nutrient intake as reflected by difference in means and the ratio of SFFQ to FR. Energy adjustment reduced the observed overestimation. Pearson's correlation coefficients varied from close to 0.5 to about 0.9 for crude data, and after adjustment for age, sex, total energy intake, and for within-person variability in daily intake for 0.4-0.8. Cross-classification into quintiles resulted in correct classification into the same or adjacent quintile of 75.8% for crude and 76.8% for energy-adjusted data. Validation of protein intake estimated by SFFQ with protein excretion from 24h urine urea indicated overestimation of protein intake by SFFQ. Spearman correlation coefficient between protein intake estimated from urea excretion and SFFQ was 0.67. CONCLUSIONS: Adaptation of a SFFQ for use in the elderly resulted in a valid and time-efficient dietary assessment instrument. Its ability to adequately rank study subjects according to their dietary intake support its application in epidemiological studies in the elderly.

Aged↗

Bias measuring mortality gradients by occupational class in New Zealand.

BACKGROUND: Socioeconomic differences in mortality in New Zealand have traditionally been measured using occupational class from mortality data (based on usual or last occupation) as the numerator, and class from census data (current occupation on census night) as the denominator. Such analyses are prone to numerator-denominator bias. Record linkage of census and mortality data in the New Zealand Census-Mortality Study (NZCMS) allows analyses of 'linked' data that will avoid numerator-denominator bias, but may be prone to other biases. OBJECTIVES: To determine differences in the assignment of occupational class between census and mortality data; to investigate biases in the observed association of class with mortality using linked census-mortality data; and to compare the class-mortality association using unlinked versus linked census-mortality data. METHODS: Census records for males aged 25-64 years on census night 1991 were anonymously and probabilistically linked to 5,844 out of 8,145 eligible deaths occurring in the second and third years following census night. RESULTS: (by objective) Only 47% of linked deaths had an occupation recorded on census data, compared to 84% on mortality data - a census to mortality ratio of 0.56. Relatively fewer deaths were identified as class 4 on census data (census to mortality ratio of 0.45) compared to other classes (ratios 0.55 to 0.64). Linkage bias: A lower likelihood of 25-44 year old deaths (but not 45-64 year olds) from lower socioeconomic classes being successfully linked to a census record meant that analyses using linked census-mortality data underestimated the class-mortality association. Bias due to exclusion of economically inactive: Analyses on linked-census data (using current occupational class) considerably underestimated the estimated association of usual occupational class with mortality. The strength of the association of class with mortality according to linked census-mortality data (and adjusted for the above two biases) and unlinked data were roughly comparable. CONCLUSION: Differences in the recording of occupational class on census and mortality data in New Zealand mean measuring mortality differences by class is thwart with difficulty. If one assumes that biases for any particular method of analysis are similar over time, or one carefully adjusts where possible for bias, using occupational class to monitor trends in socioeconomic mortality gradients may be valid.

Adult↗

Adjusting ante-natal clinic data for improved estimates of HIV prevalence among women in sub-Saharan Africa.

OBJECTIVES: To find a simple and robust method for adjusting ante-natal clinic data on HIV prevalence to represent prevalence in the general female population in the same age range, allowing for fertility differences by HIV status. BACKGROUND: HIV prevalence comparisons for pregnant women and women in the general community show that prevalence in the latter is significantly higher than in the former. An adjustment procedure is needed that is specific for the demographic and epidemiological circumstances of a particular population, making maximum use of data that can easily be collected in ante-natal clinics or are widely available from secondary sources. METHODS: Birth interval length data are used to allow for subfertility among HIV-positive women. To allow for infertility, relative HIV prevalence ratios for fertile and infertile women obtained in community surveys in populations with similar levels of contraception use are applied to demographic survey data that describe the structure of the population not at risk of child-bearing. RESULTS: For populations with low contraception use, the procedure yields estimates of general female HIV prevalence of 35-65% higher than the observed ante-natal prevalence, depending on population structure. Results were verified using general population prevalence data collected in Kisesa (Tanzania) and Masaka (Uganda). For high contraception use populations, adjusted values range from 15% higher to 5% lower, but only limited verification has been possible so far. CONCLUSIONS: The procedure is suitable for estimating general female HIV prevalence in low contraception use populations, but the high contraception variant needs further testing before it can be applied widely.

Adolescent↗

Generalized modeling approaches to risk adjustment of skewed outcomes data.

There are two broad classes of models used to address the econometric problems caused by skewness in data commonly encountered in health care applications: (1) transformation to deal with skewness (e.g., ordinary least square (OLS) on ln(y)); and (2) alternative weighting approaches based on exponential conditional models (ECM) and generalized linear model (GLM) approaches. In this paper, we encompass these two classes of models using the three parameter generalized Gamma (GGM) distribution, which includes several of the standard alternatives as special cases-OLS with a normal error, OLS for the log-normal, the standard Gamma and exponential with a log link, and the Weibull. Using simulation methods, we find the tests of identifying distributions to be robust. The GGM also provides a potentially more robust alternative estimator to the standard alternatives. An example using inpatient expenditures is also analyzed.

Models, Statistical↗

The effect of model structure and data in modeling land conditions in disturbed complex ecosystems.

Off-road vehicles increase soil erosion by reducing vegetation cover and other types of ground cover, and by changing the structure of soil. The investigation of the relationship between disturbance from off-road vehicles and the intensity of the activities that involve use of vehicles is essential for water and soil conservation and facility management. Models have been developed in a previous study to predict disturbance caused by off-road vehicles. However, the effect of data on model quality and model performance, and the appropriate structure of models have not been previously investigated. In order to improve the quality and performance of disturbance models, this study was designed to investigate the effects of model structure and data. The experiment considered and tested: (1) two measures of disturbance based on the Vegetation Cover Factor (C Factor) of the Revised Universal Soil Loss Equation (RUSLE) and Disturbance Intensity; (2) model structure using two modeling approaches; and (3) three subsets of data. The adjusted R-square and residuals from validation data are used to represent model quality and performance, respectively. Analysis of variance (ANOVA) is used to identify factors which have significant effects on model quality and performance. The results of the ANOVA show that subsets of data have significant effects on both model quality and performance for both measures of disturbance. The ANOVA also detected that the C Factor models have higher quality and performance than the Disturbance models. Although modeling approaches are not a significant factor based on the ANOVA tests, models containing interaction terms can increase the adjusted R-squares for nearly all tested conditions and the maximum improvement can reach 31%.

Ecosystem↗

Adjustment to hearing impairment I: description of a heterogeneous clinical population.

To obtain data on adjustment to hearing impairment and its potential predictors, a consortium of five audiology clinics was established. Clinical records generated over 19-27 months were reviewed, and a database (N = 1,008) was compiled that contained standard audiometric test results, demographic and case history information, and responses to the Communication Profile for the Hearing Impaired (CPHI; Demorest & Erdman, 1986, 1987). Clinic populations differed on audiometric measures, gender, race/ethnicity, educational level, employment, marital, and hearing aid status, and on CPHI profiles, but not on age. Internal consistency of CPHI scales was higher than reported by Demorest and Erdman (1987), and standard errors of measurement were smaller for Communication Performance scales. The consortium database is sufficiently heterogeneous to provide normative data applicable to a wide range of local clinical populations and to support investigation of the correlates of adjustment to hearing impairment (see Erdman & Demorest, 1998).

Adolescent↗

Cranial variation in the Marquesas Islands.

The Marquesas Islands have traditionally been divided into a northwestern and a southeastern group, a division which reflects language dialect differences. Additionally, archaeological studies have also suggested that differences in material culture existed between the northwestern and southeastern islands. This study examines Marquesan cranial discrete and metric traits to evaluate the level of intra-archipelago heterogeneity, and to determine if a northwest/southeast division is evident cranially. The data consist of 28 cranial discrete traits and 49 craniofacial measurements of prehistoric Marquesans. Male and female data are pooled for discrete trait and metric data, following a Z-score standardization technique adjustment. The data represent three island samples: Nuku Hiva (northwest), Fatuiva (southeast), and a combined Tahuata/Hiva 'Oa (southeast). Of the 28 discrete traits, 16 are utilized in a mean measure of divergence analysis that provides scores of 0.259 for Fatuiva-Tahuata/Hiva 'Oa, 1.850 for Nuku Hiva-Fatuiva, and 1.491 for Nuku Hiva-Tahuata/Hiva 'Oa. Of the 49 craniofacial measurements, 46 are utilized in RMET/NORM analyses, providing unbiased D(2) values of 0.0433 for Fatuiva-Tahuata/Hiva 'Oa, 0.1328 for Nuku Hiva-Fatuiva, and 0.0813 for Nuku Hiva-Tahuata/Hiva 'Oa. The islands of the southeastern group are closer to each other than either was to the island of the northwestern group. When a sample from 'Ua Huka is included in the craniometric analysis, the unbiased D(2) values of 0.0829, 0.1175, and 0.0431 are calculated for 'Ua Huka and Nuku Hiva, and Fatuiva and Tahuata/Hiva 'Oa pairings, respectively, indicating a close similarity of 'Ua Huka to the southeastern islands. Mean measure of divergence analysis of cranial discrete traits as well as RMET/NORM analyses of craniometric variables reveal that differences exist between the islands of the northwestern and southeastern Marquesas Islands. These results support previous research that documented linguistic and cultural differences between these regions of the archipelago. However, the results indicate that 'Ua Huka, an island traditionally included in the northwestern Marquesas Islands, has an affinity to the southeastern Marquesas Islands, possibly due to its pivotal position as a waypoint in the Marquesas Island interaction sphere.

Anthropology, Physical↗