The Collaborative Initial Glaucoma Treatment Study: interim quality of life findings after initial medical or surgical treatment of glaucoma

OBJECTIVE

To present interim quality of life (QOL) findings in the Collaborative Initial Glaucoma Treatment Study (CIGTS) using all available follow-up through 5 years from treatment initiation.

DESIGN

Randomized controlled clinical trial.

PARTICIPANTS

Six hundred seven newly diagnosed patients with open-angle glaucoma from 14 clinical centers.

INTERVENTION

Patients were randomly assigned to either initial medical therapy or initial trabeculectomy. After treatment initiation and early follow-up, patients received clinical and QOL evaluations at 6-month intervals. QOL assessments were administered by telephone at a centralized interviewing center.

MAIN OUTCOME MEASURES

The CIGTS collected comprehensive QOL information that included both generic and vision-specific QOL measures. This article focuses on initial treatment group differences related to symptom reporting, as measured by a Symptom and Health Problem Checklist, and changes in daily visual functioning, as measured by the Visual Activities Questionnaire (VAQ).

RESULTS

Across both treatment groups, there was an overall decline in the percent of participants reporting symptoms over time. Of 43 possible symptoms, 12 symptoms were reported with greater frequency by the surgically treated group and 7 symptoms more frequently by the medically-treated group. The surgical patients reported more total Symptom Impact Glaucoma (P = 0.005) and, in particular, more bother related to local eye symptoms. Very few treatment group differences were noted in visual functioning, although surgical patients reported more problems with activities related to their visual acuity (P = 0.024). The percentage of patients across treatment groups reporting worry about blindness was 50% at baseline but declined to approximately 25% over time.

CONCLUSIONS

Overall, the QOL impact reported by the two treatment groups as measured by instruments used in this study is remarkably similar, with relatively few significant study group differences observed after up to 5 years of follow-up in the CIGTS. When significant differences in visual function have been detected using the VAQ, they are consistent with the clinical outcomes. To date, the most persistent QOL finding is the increased impact of local eye symptoms reported by the surgical group compared with the medical group. Although no changes are recommended in the treatment of newly diagnosed glaucoma patients at the time of this interim report, further follow-up will allow for more definitive answers to the QOL impact of these two treatment approaches.

Interim clinical outcomes in the Collaborative Initial Glaucoma Treatment Study comparing initial treatment randomized to medications or surgery

PURPOSE

To report interim outcome data, using all available follow-up through 5 years after treatment initiation, in the Collaborative Initial Glaucoma Treatment Study (CIGTS).

DESIGN

Randomized clinical trial.

PARTICIPANTS

Six hundred seven newly diagnosed glaucoma patients.

METHODS

In a randomized clinical trial, 607 patients with newly diagnosed open-angle glaucoma were initially treated with either medication or trabeculectomy (with or without 5-fluorouracil). After treatment onset and early follow-up, patients were evaluated clinically at 6-month intervals. In addition, quality of life telephone interviews were conducted at similar frequency to the clinical visits. Patients in both arms of CIGTS were treated aggressively in an effort to reduce intraocular pressure (IOP) to a level at or below a predetermined target pressure specific for each individual eye. Visual field (VF) scores were analyzed by time-specific comparisons and by repeated measures models.

MAIN OUTCOME MEASURES

VF loss was the primary outcome variable in CIGTS. Secondary outcomes of visual acuity (VA), IOP, and cataract were also studied.

RESULTS

On the basis of completed follow-up through 4 years and partially completed through 5 years, VF loss did not differ significantly by initial treatment. Over the entire period of follow-up, surgical patients had a greater risk of substantial VA loss compared with medical patients. However, by 4 years after treatment, the average VA in the two groups was about equal. Over the course of follow-up, IOP in the medicine group has averaged 17 to 18 mmHg, whereas that in the surgery group averaged 14 to 15 mmHg. The rate of cataract requiring removal was greater in the surgically treated group.

CONCLUSIONS

Both initial medical or initial surgical therapy result in about the same VF outcome after up to 5 years of follow-up. VA loss was greater in the surgery group, but the differences between groups seem to be converging as follow-up continues. When aggressive treatment aimed at substantial reduction in IOP from baseline is used, loss of VF can be seen to be minimal in general. Because 4 to 5 years of follow-up in a chronic disease is not adequate to draw treatment conclusions, these interim CIGTS outcomes do not support altering current treatment approaches to open-angle glaucoma.

Correlation of visual field with quality-of-life measures at diagnosis in the Collaborative Initial Glaucoma Treatment Study (CIGTS)

PURPOSE

To examine the relationship between various clinical measures of visual field and patient-reported measures of symptoms and health status in a large cohort of patients with glaucoma at the time of diagnosis.

PATIENTS AND METHODS

The 607 patients in the Collaborative Initial Glaucoma Treatment Study received standardized examinations of visual field at enrollment. In addition, they completed a telephone-administered, health-related quality-of-life questionnaire, which included the Visual Activities Questionnaire (VAQ) and a symptom and health problem checklist.

RESULTS

The Visual Activities Questionnaire total and subscale scores, particularly the peripheral vision subscale, correlated weakly but significantly with global visual field scores. Symptoms attributed to glaucoma also correlated weakly but significantly to visual field scores. Correlations with other visual field measures, including only central and pericentral test locations in the scores, did not strengthen the association, and simulating binocular visual field scores produced only slightly stronger correlations.

CONCLUSIONS

At diagnosis, most patients were relatively free of glaucoma-related impairments. Various visual field measures derived from clinical visual field test data were only modestly associated with patients' perceptions of health-related quality of life. As the Collaborative Initial Glaucoma Treatment Study population is followed up longitudinally, it will be important to see whether these pertinent associations become stronger.

Quality of life in newly diagnosed glaucoma patients : The Collaborative Initial Glaucoma Treatment Study

OBJECTIVE

The Collaborative Initial Glaucoma Treatment Study (CIGTS) was designed to determine whether patients with newly diagnosed open-angle glaucoma are better treated initially by medicine or immediate filtering surgery. This paper describes the quality-of-life (QOL) measurement approach, instruments included, and the CIGTS participants' QOL findings at the time of diagnosis.

DESIGN

Baseline results from a randomized, controlled clinical trial.

PARTICIPANTS

Six hundred seven patients from 14 clinical centers were enrolled.

INTERVENTION

Patients randomized to initial medication received a stepped medical regimen (n = 307). Those randomized to initial surgery underwent a trabeculectomy (n = 300). The baseline interview was conducted before treatment initiation. All baseline and posttreatment QOL assessments were conducted by telephone from a centralized interviewing center.

MAIN OUTCOME MEASURES

The primary outcome measure described in this paper was QOL. The QOL instrument is multidimensional and incorporates both disease-specific and generic measures, including the Visual Activities Questionnaire, Sickness Impact Profile, and a Symptom and Health Problem CHECKLIST:

RESULTS

The correlations between QOL measures and clinical outcomes were in the expected direction, but relatively weak. At initial diagnosis, difficulty with bright lights and with light and dark adaptation were the most frequently reported symptoms related to visual function, whereas visual distortion was the most bothersome. Approximately half of the patients reported at least some worry or concern about the possibility of blindness. Within the Visual Activities Questionnaire, higher scores on the Peripheral Vision subscale were associated with more field loss (P < 0.01). In regression analyses controlling for sociodemographics and nonocular comorbidities, increased visual field loss was significantly associated with higher dysfunction among five disease-specific QOL measures (P < 0.05).

CONCLUSIONS

Newly diagnosed glaucoma patients reported experiencing some visual function symptoms at the time of diagnosis that would not be intuitively expected based on clinical testing. Some discussion about the association between clinical presentation and worry about blindness may reduce unnecessary concern. These results provide the basis for long-term comparisons of the QOL effects of initial medical and surgical treatment for open-angle glaucoma.

Self-reported walking ability predicts functional mobility performance in frail older adults

OBJECTIVE

To determine how self-reported physical function relates to performance in each of three mobility domains: walking, stance maintenance, and rising from chairs.

DESIGN

Cross-sectional analysis of older adults.

SETTING

University-based laboratory and community-based congregate housing facilities.

PARTICIPANTS

Two hundred twenty-one older adults (mean age, 79.9 years; range, 60-102 years) without clinical evidence of dementia (mean Folstein Mini-Mental State score, 28; range, 24-30).

INTERVENTION AND MAIN OUTCOME MEASURES

We compared the responses of these older adults on a questionnaire battery used by the Established Populations for the Epidemiologic Study of the Elderly (EPESE) project, to performance on mobility tasks of graded difficulty. Responses to the EPESE battery included: (1) whether assistance was required to perform seven Katz activities of daily living (ADL) items, specifically with walking and transferring; (2) three Rosow-Breslau items, including the ability to walk up stairs and walk a half mile; and (3) five Nagi items, including difficulty stooping, reaching, and lifting objects. The performance measures included the ability to perform, and time taken to perform, tasks in three summary score domains: (1) walking ("Walking," seven tasks, including walking with an assistive device, turning, stair climbing, tandem walking); (2) stance maintenance ("Stance," six tasks, including unipedal, bipedal, tandem, and maximum lean); and (3) chair rise ("Chair Rise," six tasks, including rising from a variety of seat heights with and without the use of hands for assistance). A total score combines scores in each Walking, Stance, and Chair Rise domain. We also analyzed how cognitive/ behavioral factors such as depression and self-efficacy related to the residuals from the self-report and performance-based ANOVA models.

RESULTS

Rosow-Breslau items have the strongest relationship with the three performance domains, Walking, Stance, and Chair Rise (eta-squared ranging from 0.21 to 0.44). These three performance domains are as strongly related to one Katz ADL item, walking (eta-squared ranging from 0.15 to 0.33) as all of the Katz ADL items combined (eta-squared ranging from 0.21 to 0.35). Tests of problem solving and psychomotor speed, the Trails A and Trails B tests, are significantly correlated with the residuals from the self-report and performance-based ANOVA models.

CONCLUSIONS

Compared with the rest of the EPESE self-report items, self-report items related to walking (such as Katz walking and Rosow-Breslau items) are better predictors of functional mobility performance on tasks involving walking, stance maintenance, and rising from chairs. Compared with other self-report items, self-reported walking ability may be the best predictor of overall functional mobility.

The impact of the optic neuritis treatment trial on the practices of ophthalmologists and neurologists

OBJECTIVE

To determine whether the Optic Neuritis Treatment Trial (ONTT) results have altered the practice patterns of ophthalmologists and neurologists.

DESIGN

Mail survey.

PARTICIPANTS

A random sample of 987 ophthalmologists and 900 neurologists practicing in the United States were mailed a questionnaire that inquired into decision-making with regard to management of optic neuritis before and after the publication of the ONTT results.

MAIN OUTCOME MEASURES

Responses received from 202 ophthalmologists and 244 neurologists, a response rate of 47%.

RESULTS

Following the ONTT reports, nearly all ophthalmologists and neurologists have reduced their use of oral prednisone alone, substituting a regimen that includes intravenous methylprednisolone. A large proportion of practitioners in both specialties mistakenly believe that intravenous methylprednisolone treatment improves final visual outcome. Only 7% of neurologists and 36% of ophthalmologists (P = 0.0001) are adhering to the ONTT suggestion to use magnetic resonance imaging as a basis for initiating treatment.

CONCLUSIONS

The ONTT has led to a dramatic reduction in the use of oral prednisone without a preceding course of intravenous methylprednisolone in the treatment of acute optic neuritis. Ophthalmologists and neurologists have changed some of their practices without fully understanding the results of the ONTT.

Is patient length of stay related to quality of care?

In this article, we investigate the relationship between hospital length-of-stay (LOS) and quality of care. We use hospital claims records from Medicare beneficiaries in Michigan to estimate condition-specific models for predicting patients' LOSs. With these models and a data set provided by Michigan Peer Review Organization, Inc. (MPRO), each patient's risk-adjusted LOS is then linked to a quality-of-care judgment (good care, poor care) from physician peer reviewers. LOS is a widely used indicator of hospital performance. Most commonly, it is viewed as an indicator of hospital efficiency and as a surrogate measure for costs, with hospitals having long average LOSs considered relatively inefficient in the use of resources and those with low LOSs considered to be efficient. Sometimes, however, LOS is assumed to relate to quality. For example, if hospitals were to respond to the financial incentives of prospective payment by attempting to lower costs by prematurely discharging patients, LOSs significantly lower than expected might be considered indicative of poor quality care. On the other hand, if poor quality of care causes complications, it would tend to extend LOSs. Under this assumption, longer than expected LOSs could be viewed as indicative of poor quality care. This article shows that in every one of the 13 clinical conditions examined, cases that received poor quality care had significantly longer risk-adjusted LOSs than cases whose care was of acceptable quality.

The Collaborative Initial Glaucoma Treatment Study: study design, methods, and baseline characteristics of enrolled patients

OBJECTIVE

The Collaborative Initial Glaucoma Treatment Study (CIGTS) is a randomized, controlled clinical trial designed to determine whether patients with newly diagnosed open-angle glaucoma (primary, pigmentary, or pseudoexfoliative) are better treated by initial treatment with medications or by immediate filtration surgery.

DESIGN

Randomized, controlled clinical trial.

PARTICIPANTS

A total of 607 patients with open-angle glaucoma were enrolled.

INTERVENTION

Patients randomized to initial medications (n=307) received a stepped regimen of medications to lower intraocular pressure. Those randomized to initial surgery (n=300) underwent trabeculectomy to lower intraocular pressure.

MAIN OUTCOME MEASURES

Progression in visual field loss constitutes the study's primary outcome variable. Secondary outcomes include health-related quality of life, visual acuity, and intraocular pressure.

RESULTS

Randomized assignment resulted in a balanced distribution between treatment groups for most demographic and clinical measures assessed at enrollment. More males than females were enrolled (55% were males), and a substantial percentage (38.1 %) of enrollees were blacks. Most enrollees (90.6%) were diagnosed with primary open-angle glaucoma; the remainder had either pseudoexfoliative (4.8%) or pigmentary (4.6%) forms of open-angle glaucoma.

CONCLUSIONS

Follow-up of this well-characterized group of patients should provide well-rounded guidance, based on both traditional ophthalmic measures and patients' perspectives on their health-related quality of life, on how best to initially treat open-angle glaucoma.

Diagnostic and management procedures for compensable back injuries without serious associated injuries. Modeling of the 1991 injury cohort from a major Michigan compensation insurer

STUDY DESIGN

A retrospective cohort of 2425 workers with compensated back conditions was created from the 1991 compensated cohort of the largest compensation insurer in Michigan by linking computerized information on social and demographic factors, diagnostic and management procedures, and cumulative missed worktime.

OBJECTIVE

To describe medical care use from date of injury in 1991 to mid-1993 by type of back condition, to identify factors affecting this use, to determine the effect of alternative model selection strategies on identifying such factors, to investigate the timing of surgery and the use of diagnostic studies in patients with displaced or herniated discs with and without surgery, and to compare the use of medical care in the study group with that recommended by national expert panels.

SUMMARY OF BACKGROUND DATA

Despite the enormous costs involved in medical care for patients with work-related back injuries, almost no information on the use of medical care is available for compensated back injuries by diagnostic and procedure code.

METHODS

Use of medical care was grouped into 18 categories for tabulation. Factors affecting use of medical care were identified by logistic regression, supplemented by Cox analysis for time to first procedure. The Hosmer-Lemeshow chi-square statistic was compared with the Bayes Information Criterion for evaluating model fit. Overall model utility was evaluated by comparing receiver operating characteristic curves generated by the model. For patients with displaced or herniated discs, algorithms were used to identify the diagnostic procedures performed before and after the first surgery and the amount of time that passed before each procedure was performed.

RESULTS

In patients with diagnoses of disc displacement or herniation or vertebrogenic neuritis, approximately 80% underwent radiography to obtain plain views of the spine, 75% underwent diagnostic imaging, 45% underwent electrodiagnostic procedures, and 24% underwent spinal surgery (29.3% had surgical procedures among those with disc conditions). In patients with diagnoses of back sprain or other symptomatic diagnoses, the percentages for the first three procedures are approximately 70%, 12%, and 12%, respectively. Diagnostic category, age, gender, and cumulative missed worktime predicted the receipt of diagnostic and treatment procedures. Women were 30% less likely to undergo computed axial tomography or magnetic resonance imaging and 50% less likely to undergo spinal surgery. Median time to spinal surgery was twice as long in the group that underwent diagnostic imaging and electrodiagnostic testing before surgery (134.5 days). Of the 622 patients with disc displacement/herniation, 510 (approximately 80%) had initial diagnostic imaging studies, and, of the 510, 162 (approximately 30%) had surgery. Thirteen (8%) were reoperated. Of the 162 patients who had surgery, 46 (approximately 30%) had follow-up diagnostic imaging, and, of the 46, nine (approximately 20%) were reoperated. Of the 348 managed conservatively, 96 (approximately 30%) had follow-up diagnostic imaging.

CONCLUSIONS

The data suggest only modest differences in the use of medical care between this study group and noncompensated study populations from previous reports. The authors of this study estimate that 27% of diagnostic imaging studies and 43% of plain radiography of the spine could have been avoided if then available Canadian recommendations or current American, guidelines had been followed. The gender effect remains unexplained and needs to be investigated in additional studies. There was an increase of 6% in the use of surgery in compensated patients compared with the use of surgery in a recent American series involving traditional health insurance, but this may be associated with greater work disability in the compensated group. The results of the current study suggest that the use and reporting of model selection strategies and the use of receiver operati

Concordance between ANSI occupational back injury codes and claim form diagnoses and a lower bound estimate of the fraction associated with disc displacement/herniation

The current BLS Annual Survey of Occupational Illnesses and Injuries and several recent analyses of factors affecting missed worktime in occupational back injuries rely on ANSI-based injury codes derived from injury narratives to classify occupational injuries and estimate incidence and outcome. No population-based studies of the concordance between back injury codes and clinical diagnoses have been reported. Back injury cases were identified in two large work-injured populations totaling almost 80,000 cases in the states of Michigan and Minnesota. In both populations, cases had been coded by the single nature-of-injury and part-of-body-injured codes assigned by an ANSI-based injury-coding system and by as many as four (Michigan) or three (Minnesota) clinical diagnoses according to the International Classification of Diseases-Clinical Modification, 9th Revision. Concordance was measured by the sensitivity and predictive value positive (PVP, aka PV+ or PPA) of the injury coding scheme for related diagnostic groups. We also used an algorithm based on the limited clinical information available to corroborate the diagnosis of displaced/herniated disc for cases that underwent spinal surgery. Cases identified by the algorithm were then used to obtain a lower bound estimate of the fraction with disc injury. The injury coding scheme had PVPs of 82.9-90.1% and overall sensitivities of 69.7-75.9%. Sensitivities for individual diagnostic groups show that their distribution in ANSI-coded injury groups is skewed slightly toward cases with sprain and disc displacement/herniation, but these shifts are modest. The lower bound estimate of the fraction of cases with disc displacement/herniation in a population of cases with back injuries producing at least 1 day of missed worktime is 5.8%. The demographic comparisons indicate that, as the time between injury and cohort ascertainment increases during the first 8 days of missed worktime following injury, the proportion of younger workers in an injury cohort decreases. The relationship between increasing age and increasing missed worktime disability, reported in various outcome studies, is also present during the first few days following injury. The use of ANSI injury codes underestimates the contribution of back injuries to missed worktime because 24-30% of cases are missed by the ANSI coding system. However, the distribution of diagnostic groups in the injury-coded groups approximates that observed with all diagnosed cases and supports the use of such data to study outcome. Our estimate, and one from Quebec, suggest that disc displacement/herniation occurs more frequently in the subset of occupational back injuries compared to the set of back injuries from all sources.

Stepping over obstacles: dividing attention impairs performance of old more than young adults

BACKGROUND

Tripping over an obstacle is a common cause of falls in the elderly. An earlier study of abilities to avoid stepping on suddenly appearing obstacles found that, although healthy old adults had a lower rate-of-success than young adults, the magnitude of that difference was not large. The present study inquired whether dividing attention during such a task would differentially affect young and old healthy adults.

METHODS

Rates-of-success were observed in 16 young and 16 old healthy adults (mean ages 24 and 72 years) in avoiding stepping on a band of light that was suddenly projected across their gait path while they walked at their comfortable gait speed. This virtual obstacle was placed at predicted next-footfall locations to give 350 or 450 msec available response times before footfall. During most of the trials the subjects were asked, in addition to trying not to step on the obstacle, simultaneously to respond vocally as quickly as possible when red lights near the end of the walkway turned on. These attention-dividing reaction time tests were of two types: synchronized, when only red lights lit at intervals synchronized with the appearance of the obstacle, and unsynchronized, when green or yellow lights lit in addition to the red lights, with lighting intervals not synchronized with the appearance of the obstacle.

RESULTS

When synchronized and unsynchronized reaction time tests were conducted concurrently with the obstacle avoidance tasks, mean rates-of-success in avoidance decreased significantly in both young and old adults. With available response times of 350 msec, mean success rates decreased from their no-division values in the young adults by 14.7% for synchronized reaction and by 19.9% for unsynchronized reaction, attention-dividing tests. Corresponding mean decreases for the old adults were 32.0 and 35.7%. This age difference in the effects of dividing attention was significant.

CONCLUSION

Both young and old adults had a significantly increased risk of obstacle contact while negotiating obstacles when their attention was divided, but dividing attention degraded obstacle avoidance abilities of the old significantly more than it did in the young. Diminished abilities to respond to physical hazards present in the environment when attention is directed elsewhere may partially account for high rates of falls among the elderly.

Establishment size and risk of occupational injury

For many years, the annual survey of occupational injuries and illnesses by the Federal Bureau of Labor Statistics (BLS) has consistently reported, without explanation, that injury rates in the smaller establishments (< 50 employees) are substantially lower than those for midsize establishments (100-499 employees). Also during those years, a remarkable increase has been reported in the injury rate in large companies, following the imposition of stiff fines for failure to keep required injury records. The rate patterns are identical for Michigan and the country in general. We investigated possible causes for lower injury rates in small establishments since such rates are inconsistent with reports of higher fatality rates in small establishments in the mining, construction, manufacturing, and transportation industries and higher, or at least comparable, injury rates for small establishments in the mining industry. They are also inconsistent with increased turnover and decreased availability of occupational safety services in small companies. Moreover, injury severity, as measured by missed worktime, is greater for workers in small establishments. We investigated the possibility that interactions of workforce or injury characteristics with establishment size could explain the rate differences. We also reviewed the available literature to see whether differences in labor turnover rates could explain the BLS findings. Graphical and statistical analyses of the 1988 CPS Annual Demographic File, a sample of employed persons in the U.S. workforce, failed to identify any associations between workforce characteristics and enterprise size that would explain the lower rates. Similarly, graphical and statistical analyses of all Michigan workers incurring a compensable injury in 1986 failed to indicate any associations between injury characteristics and establishment size that would explain the lower rates. The potential role of labor turnover on the injury rate was analyzed from data in the literature on turnover rate by establishment size and risk of injury by time on the job. None of these analyses explains the lower injury rates reported for small establishments. This leaves underreporting of injuries from small establishments as a substantial possibility. If small establishments were subject to the same injury incidence rates as midsize establishments, then the 1986 survey for Michigan may have missed as many as 54,000 injuries (and far more nationally). We suggest that BLS undertake methodological studies to validate the completeness of reporting from small establishments.

Radiation dose reduction in CT of the pediatric pelvis

PURPOSE

To determine whether a lower radiation dose technique can be used for computed tomography (CT) of the pediatric pelvis without significant loss of diagnostic image quality.

MATERIALS AND METHODS

Thirty-six pediatric patients underwent CT at 80 mAs (experimental group), and 42 underwent CT at 240 mAs (control group). Anatomic details, image quality, and the degree of confidence in reaching a diagnosis were graded on a scale of 1 (poor) to 4 (excellent).

RESULTS

The difference in perceived image quality between the experimental and control groups was not statistically significant. The mean scores for scans evaluated by the first reader were 3.88 for the experimental group and 3.92 for the control group (P = .2804). The mean scores for the second reader were 3.78 and 3.77 for the experimental and control groups, respectively (P = .8131).

CONCLUSION

A substantial dose reduction can be achieved if pelvic CT is performed at 80 mAs, without a recognizable deterioration of diagnostic image quality.

The association of diabetic status, age, and race to withdrawal from dialysis

Higher rates of withdrawal from dialysis have been shown among young diabetic patients. This study examined the hypothesis that diabetic status has a joint effect with age as the result of an age-related increase in co-morbid conditions among nondiabetic ESRD patients. Using data collected during the 1980s by the Michigan Kidney Registry, the experience of 4,753 white and 2,988 black Michigan dialysis patients (13,863 patient years) is analyzed. During follow-up, 364 white and 80 black patients withdrew from dialysis. By use of a Cox analysis, adjusted rates of withdrawal were shown to be higher among white than black patients (rate ratio (RR) = 3.34; P < 0.001), without significant differences by diabetic status. Rates increased with age (RR = 7.9 for 80+ versus 20 to 35 yr; P < 0.001), without significantly different patterns by race. Adjusted withdrawal rates among diabetics were 2.3 times that of nondiabetics overall (P < 0.001), with a statistically significant joint effect with age, the RR being highest among young patients. Among white patients, nondiabetics using continuous ambulatory peritoneal dialysis had a lower relative withdrawal rate than those using hemodialysis (RR = 0.73; P = 0.07), whereas diabetics using continuous ambulatory peritoneal dialysis showed slightly higher although statistically insignificant rates than their counterparts using hemodialysis (RR = 1.21; P = 0.50). Between 1980 and 1989, withdrawal rates for white patients aged 20 to 34 yr tended to decrease by 20% per year (P = 0.05), whereas they increased by 11% per year for patients aged 50 to 69 yr (P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Applicability of the Greulich and Pyle skeletal age standards to black and white children of today

OBJECTIVE

The Greulich and Pyle skeletal age atlas was derived from white children of upper socioeconomic level during the 1930s. To our knowledge, the Greulich and Pyle standards have not been reassessed for both black and white children; it was the purpose of this study to reassess the applicability of these standards to today's children.

DESIGN

A "blinded" review of hand roentgenograms taken for the evaluation of trauma was performed. Age of the subjects was evenly distributed between 0 and 18 years. The roentgenograms were scored for bone age by five individuals from different disciplines and levels of training. The difference between the median bone age and the child's chronologic age was calculated for each roentgenogram and stratified into four age groups: early childhood (0 to 4 years), middle childhood (4 to 8 years), late childhood (8 to 13 years), and adolescence (13 to 18 years).

SETTING

The roentgenograms were obtained from four hospital emergency rooms in the Lake Erie basin area, the same geographic area from which the Greulich and Pyle standards originated.

PATIENTS

There were 841 children: 452 boys and 389 girls, 461 black and 380 white children.

RESULTS

The bone ages and chronologic ages were similar for white girls of all ages. Black girls were skeletally advanced by 0.4 to 0.7 year (P < .001), except during middle childhood. White boys were skeletally delayed during middle childhood by 0.9 year (P < .001) and during late childhood by 0.4 year (P < .01), but they were advanced during the adolescent years by 0.5 year (P < .01). Black boys showed no difference except for the adolescent group, which was skeletally advanced by 0.4 year (P < .02).

CONCLUSIONS

The Greulich and Pyle atlas is not applicable to all children today, especially black girls. We should be aware of this information when making clinical decisions requiring accurate bone ages.

Current methods of estimating severity for occupational injuries and illnesses: data from the 1986 Michigan Comprehensive Compensable Injury and Illness Database

National and state estimates of the severity of occupational injuries and illnesses (severity = lost work time = missed work days+restricted work days) have come from the annual Survey of Occupational Injuries and Illnesses (Survey) produced by the U.S. Bureau of Labor Statistics. However, we show that the Survey practice of collecting injury information soon after the accident year reduces substantially the accuracy of missed work day estimates, which constitute 85.3% of the Survey lost work time estimate. To develop an independent estimate of missed work days, the research team created the Michigan Comprehensive Compensable Occupational Injury Database (Michigan Database) by linking state files with injury characteristics to files with workers' compensation information for injuries occurring in 1986. The measure of missed work time (days, weeks, or years) is the cumulative duration of compensation from the "date disability commenced," noted on the first payment form, through follow-up to March 1, 1990. Cumulative missed work time has been calculated or estimated for 72,057 injured workers, more than 97% of the 73,609 Michigan workers with compensable occupational injuries in 1986 identified through the close of the study. Our "best" estimate of missed work days, to follow-up, attributable to both fatal and nonfatal compensable occupational injuries and illnesses is 7,518,784, a figure four times that reported for Michigan by the Survey. When insurance industry data on disbursements are also considered, the estimate of missed work days increases to 8,919,079, a figure 4.75 times that reported by the Survey. When insurance data on reserves for future payments are also considered, the estimate of missed work days increases to 16,103,398, a figure 8.58-fold greater than that obtained for Michigan in the Survey. The Michigan data suggest that the national Survey may have failed to identify almost 373 million of 421 million missed work days in the private sector that have resulted, or will result, from 1986 occupational injuries. The present federal/state system for estimating occupational injury severity by measuring lost work days seriously underestimates the magnitude of the problem. The current policy of obtaining incidence and severity data from the same Survey should be reconsidered. We recommend that national estimates of injury severity be obtained from representative states by using state compensation data and that such estimates be used to evaluate current prevention and rehabilitation strategies. The redesigned occupational safety and health Survey (ROSH Survey) should be revised to permit linkage to compensation data.

Comparison of continuous ambulatory peritoneal dialysis and hemodialysis patient survival with evaluation of trends during the 1980s

To evaluate the mortality of continuous ambulatory peritoneal dialysis (CAPD) patients relative to hemodialysis (HD) patients, all Michigan residents 20 to 59 yr of age who initiated therapy for ESRD during the 1980s (N = 4,288) were studied. The study population was stratified by primary renal diagnosis (glomerulonephritis, hypertension, diabetes, other), and analyses were conducted within each group by Cox proportional hazards methods controlling for age, race, sex, and year in which chronic dialysis was initiated. Intent-to-treat (ITT) and treatment history (RxHx) censoring criteria were used. For patients with hypertension or other reported causes of ESRD, there was no significant difference in CAPD and HD patient mortality (relative risk (RR) = 0.99 and 1.05, respectively). In the ITT analysis, both glomerulonephritic (RR = 0.73; P = 0.10) and diabetic patients using CAPD experienced mortality rates lower than their HD counterparts. Among diabetics, this difference ranged from a RR of 0.40 to 0.70, being lowest for younger diabetics and statistically significant (P < or = 0.05) for ages 20 to 52 yr. Evaluation of mortality trends showed a significant (P < 0.01) decrease in diabetic CAPD mortality rates during the decade, whereas diabetic HD mortality rates increased (P = 0.06). Among diabetics, men had higher mortality rates than women (ITT--RxHx; RR = 1.22 to 1.27; P < 0.001) and white patients had higher mortality rates than black patients (ITT--RxHx, RR = 1.34 to 1.44; P < 0.001). Differences in mortality by sex and race were not found among nondiabetics, but mortality did increase significantly with age in all groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Patterns of low incidence of treated end-stage renal disease among the elderly

We present US county-level maps of the 1983 to 1988 incidence of treated end-stage renal disease (ESRD) among white and nonwhite persons 65 years of age and older (N = 66,129). Recent statistical advances permit the investigation of geographical patterns of unusually low disease incidence. Our maps highlight those US counties which have been determined to have rates of ESRD treatment incidence that are low relative to those of all counties, revealing several interesting geographic patterns. For whites, low rates are found in the Northwest, the Midwest, and the South. Nonwhite rates are seen to be low primarily in the South and Alaska. Low treatment incidence could be due to a combination of (1) low true incidence, (2) lack of access to health care services, (3) insufficient diagnosis and referral, and (4) patients' reluctance to accept ESRD therapy, due to cultural or personal concerns. A state-level regression of elderly rates on those aged 40 to 64 years indicates the variation in treatment incidence among the elderly may be due to factors other than variation in true incidence, which the middle-aged rates reflect more closely. Residual analysis corroborates the visual impression of the maps of low ESRD treatment incidence in several southern states, where referral to dialysis may be as much as 40% lower than the national level. Further research on factors contributing to low treatment incidence, including competing risks, regional lags relative to the national trend to dialyze more elderly patients, and lack of access to health care resources, is indicated.

Comparison of two dietary questionnaires validated against multiple dietary records collected during a 1-year period

The validity of two dietary history questionnaires was examined, one the Health Habits and History Questionnaire (HHHQ) developed by Block et al and the other a questionnaire developed by investigators at the University of Michigan (UM). The reference data consisted of the mean of four 4-day dietary records and recalls collected for 1 year before administration of the questionnaires. The sample of 85 persons included black and white men and women aged 25 to 50 years. The HHHQ was entirely self-administered; the UM questionnaire had both self- and interviewer-administered components. The HHHQ group means were similar to food record estimates for energy and most nutrients, whereas the UM questionnaire produced overestimates for energy and all nutrients examined. Correlations ranged from .31 to .60 (median = .48) for the UM questionnaire and from .42 to .68 (median = .57) for the HHHQ. Use of respondent-reported portion sizes with the HHHQ produced higher correlations than use of investigator-determined "standard" portion sizes (median r = .43 vs .57). Food frequency questionnaires can provide useful nutrient data for individuals as well as groups.

Geographic variation in the incidence of treated end-stage renal disease

To facilitate identification of geographic clusters of areas with high or low incidence of treated end-stage renal disease, the 1983 to 1988 incidence by county was studied among whites and nonwhites less than 60 yr of age in the United States. End-stage renal disease incidence counts for 1983 to 1988 were obtained from the United States Renal Data System data base and linked to the 1985 county population obtained from U.S. Census data. Maps were smoothed by the method adopted by the National Cancer Institute that smooths only according to variability of the local rates, ignoring geographic information on clustering of events. In addition to identifying specific counties with exceptionally high or low incidence, geographic patterns were observed with many similarities across whites and nonwhites: notably high rates of disease in areas of the Southwest, the Southeast and in counties with Native American reservations and low rates in the West and Northwest. On the basis of these findings, several hypotheses are presented to explain the observed variation in treated end-stage renal disease incidence rates.

Comparison of three consecutive-day and three random-day records of dietary intake

We conducted this study to determine whether 3 days of dietary records from randomly selected days or from consecutive days more closely estimated the energy and nutrient intake values obtained from 16 days over a 1-year period. Participants consisted of 228 men and women, black and white. No one of three random-day samples or one of five consecutive-day samples better estimated energy and nutrient intake. The group means for intake of energy and seven nutrients were similar for random and consecutive days. However, for energy, protein, fat, carbohydrate, and calcium, the means of the absolute differences between the values for 16 days and those for the random days were significantly smaller than the corresponding means between the values for 16 days and those for consecutive days. Random-day samples may be preferable for describing dietary intake of individuals and small groups when the gain in reliability is worth the cost.

Low oxygen delivery produced by anemia, hypoxia, and low cardiac output

In pentobarbital-anesthetized dogs, oxygen delivery (DO2) was measured by thermodilution cardiac output and cooximeter determined oxygen content, while oxygen consumption (VO2) was measured independently by spirometry. Oxygen delivery was decreased by isovolemic dilutional anemia, breathing hypoxic gas mixtures, or cardiac tamponade to reduce cardiac output. Baseline VO2 (cc/kg/min) for the three groups was 5.9 +/- 0.7 (anemia), 5.4 +/- 0.4 (hypoxia), and 5.6 +/- 0.1 (low C.O.) (NS). A critical level of oxygen delivery (DO2crit) was found at 9-10 cc/kg/min (anemia), 10-11 cc/kg/min (hypoxia), and 9-10 cc/kg/min (low C.O.) (NS.). Below this level, VO2 fell (became supply dependent) and lactic acidosis occurred, regardless of the mechanism of impaired oxygen delivery.

Income and survival in chronic dialysis patients

The relationship between income and survival rates for chronic dialysis patients in Michigan was examined. To evaluate the relative risk (RR) of dying, by income, a Cox survival regression model was used to adjust for age, race (black versus white), gender, dialytic treatment modality, year of first end-stage renal disease (ESRD) therapy, and primary cause of ESRD. The average household income reported from census data for the ZIP Code of residence for each patient was analyzed as a socioeconomic indicator. Treatment modality on day 120 of ESRD was classified as either center hemodialysis (HD) or CAPD. All new patients, aged 20-59 and registered at the Michigan Kidney Registry between 1/1/80 and 12/31/87 were included in the study. Patients were followed from day 180 of ESRD until death, censoring at transplant, or 12/31/87. The adjusted relative risk of dying decreased for black patients by 3.3% per $1,000 increase in income (p less than 0.01), while the trend by income for white patients was negligible (p greater than 0.10). The difference in trends for the two groups was statistically significant (p less than 0.01). This is a surprising result, since white patients have higher death rates, overall, than do black patients, particularly among subgroups with diabetes and hypertension whose RR was 1.77 and 1.82, respectively. Poor socioeconomic status of the area of residence has a strongly negative effect on survival for black patients, but not for white patients. The reasons for the relationship of death rates with income, especially for black patients, need to be examined in greater detail.

A comparison of survival among dialytic therapies of choice: in-center hemodialysis versus continuous ambulatory peritoneal dialysis at home

Analyses were performed on a series of 2,754 dialysis patients between the ages of 20 and 60 years whose end-stage renal disease (ESRD) therapy started in Michigan from 1980 through 1987 with the selection of either center hemodialysis (CH) or continuous ambulatory peritoneal dialysis (CAPD). The dialytic treatment at 6 months after first ESRD therapy was selected as the dialytic "treatment of choice" for each patient. Analyses of subsequent survival showed lower death rates for black patients than for white patients with hypertension (P less than 0.01) and diabetes (P less than 0.01). Death rates increased with patient age more dramatically among glomerulonephritis patients than among the other diagnostic groups (P less than 0.05). Females had significantly lower death rates than did males among diabetic patients (P less than 0.01). While no significant difference was found in average death rates between CH and CAPD (NS), there was a significant difference (P less than 0.05) in the trend in death rates. Death rates among CH patients increased significantly (P less than 0.001) during the study period, whereas death rates among CAPD patients have improved slightly (NS).

Thyroid autoantibodies in black and in white children and adolescents with type 1 diabetes mellitus and their first degree relatives

Genetic susceptibility is an important issue in understanding the mechanism of the autoimmune endocrinopathies and in assessing the risk of these conditions in pediatric patients. To this end, we evaluated autoantibodies to thyroid antigens, thyroglobulin (TgA) and microsomal antigen (TMA), in white and in American black juvenile patients with Type I diabetes mellitus (DM) to determine the predictive value of thyroid autoantibodies for the development of autoimmune thyroid disease. Sera from 159 patients (77 black and 82 white) with Type I DM were evaluated. A greater number of whites (41/82 or 50%) than blacks (12/72 or 16%) had thyroid autoantibodies (p less than 0.01). Fourteen patients (4 black and 10 white) exhibited hypothyroidism, and all had both TgA and TMA. Three patients (all black) had Graves' disease, one of whom had both TgA and TMA. Families of each racial group that had a diabetic child (proband) with thyroid autoantibodies (seropositive) or without thyroid autoantibodies (seronegative) were assessed for TgA and TMA as well as autoimmune thyroid disease. The prevalence of thyroid autoantibodies among siblings of seropositive probands was significantly greater than among the siblings of seronegative probands (p less than 0.01). The white sibling population showed a closer association of thyroid autoantibody prevalence with increasing age (p less than 0.05) than the blacks. Significantly more parents of probands than control parents exhibited thyroid autoantibodies (p less than 0.01). The general pattern of inheritance of either racial group showed that if one or both parents had thyroid autoantibodies, their progeny developed a significantly higher prevalence of thyroid autoantibodies than those of the seronegative parents. While there was no increase in overt thyroid disease among siblings of seropositive probands, a risk of developing autoimmune thyroid disease is probably imparted to these siblings by virtue of the thyroid autoantibodies.

Health care utilization and costs of adult cardiovascular conditions United States, 1980

Cardiovascular conditions have a major economic as well as health impact on adults in the United States. In the National Medical Care Utilization and Expenditure Survey, conducted during 1980, health service data were obtained from a national sample of 17,123 civilian noninstitutionalized individuals. These data have been analyzed to define the impact and demographic patterns of health care utilization and costs attributable to adult cardiovascular conditions. Approximately 28 million persons in the United States, or 17.3 percent of the total civilian noninstitutionalized population 17 years of age and over, had a cardiovascular condition during 1980. Cardiovascular conditions were reported with increasing frequency in successively older age groups and were reported most frequently by black persons. The prevalence and economic impact differed by specific type of cardiovascular condition and whether the condition was complicated by another disease. To examine these differences, persons reporting cardiovascular conditions were categorized into four mutually exclusive groups: persons with hypertension alone, persons with arteriosclerotic cardiovascular and cerebrovascular disease associated with hypertension, persons with arteriosclerotic cardiovascular disease alone, and persons with cardiovascular disease associated with other conditions that might alter medical care utilization and disability. The disability, service utilization, and health care charges were compared among these groups, and data for each group were compared with those for the overall U.S. population. Survey participants were asked to rate their health relative to that of other people their age. The self-rating of persons reporting hypertension alone was lower than the national average. Only 17 percent of the general population rated their health as "fair" or "poor," but 27 percent of persons with hypertension alone used these descriptions. Overall, persons with hypertension alone were much less likely to be employed than the general population (52.2 percent versus 71.6 percent). However, when controlling for age, it was found that persons with hypertension alone were about as likely to be employed as the general population. On the average, persons with hypertension reported only slightly more work-loss days than did the general population (6.5 versus 4.9 days). A modest restriction of activity was reported by those with hypertension alone (20.1 days per year on the average compared with 15.6 for the general population). The mean number of ambulatory visits per year for those with hypertension alone was 7.9, only slightly greater than the 5.7 average for the overall population.(ABSTRACT TRUNCATED AT 400 WORDS)

Comparison of estimated nutrient intakes by food frequency and dietary records in adults

Sixteen days of dietary recall and records collected over 1 year for 228 respondents were compared with an estimate of "usual" diet based on a 116-item food frequency questionnaire (FFQ) for the study year. Respondents were white and black men and women aged 24 to 51. Mean energy values for the total group were 2,111 kcal for the recall/records and 2,766 kcal for the FFQ, a 31% difference. The mean food energy and nutrient values obtained by the FFQ were consistently and significantly higher than the mean recall/record values for all four race-sex groups, although the degree of difference varied by nutrient, food group, and demographic characteristics of the respondents. For the nutrients compared, the smallest difference between methods was for protein--27% for the total group. The greatest difference was for vitamin A--123% for the total sample. Sex-race specific correlation coefficients between methods were relatively high for calcium, vitamin C, and iron.

The effects of sugars intake and frequency of ingestion on dental caries increment in a three-year longitudinal study

A three-year longitudinal study was carried out with a group of children, initially aged 11-15, residing in non-fluoridated rural communities in south-central Michigan. This report analyzes the relation between caries increment and consumption of sugars from all sources to see if accepted relationships have changed with the caries decline in the United States. There were 499 children who provided three or more 24-hour dietary recall interviews, and who received dental examinations at baseline and after three years. Caries increment averaged 2.91 DMFS over the three years, with 81% of new lesions on pit-and-fissure surfaces. Consumption of sugars from all sources averaged 156 g per day for males and 127 g per day for females, an average of 52 kg per person per year. Sugars constituted one-quarter of total caloric intake for both boys and girls, and the average number of eating occasions per day was 4.3. Children who consumed a higher proportion of their total energy intake as sugars had a higher increment of approximal caries, though there was little relation to pit-and-fissure caries. The average number of daily eating occasions was not related to caries increment, nor was the average number of sugary snacks (defined as foods with 15% or more of sugars) consumed between meals, but the average consumption of between-meal sugars was related to the approximal caries increment. When children were categorized by high caries increment compared with no caries increment, a tendency toward more frequent snacks was seen in the high-caries children.(ABSTRACT TRUNCATED AT 250 WORDS)

Counting calories: partitioning energy intake estimates from a food frequency questionnaire

Differences in energy estimates between a food frequency questionnaire and a multi-day dietary record can be partitioned into distinct components due to differences in reported frequency of consumption and in reported serving size, and to differences in nutrient composition between the questionnaire standards and the foods reported on the records. The effect of each component on the relative validity of the questionnaire can be assessed by examining its contribution to the differences between the two methods in estimated group intake and in the relative ranking of individual respondents. This methodology was used for the 1984-1985 University of Michigan Food Frequency Study, in which the estimated energy intake from a quantitative food frequency questionnaire was compared with that from 16 days of food records collected over the course of a year from 228 white and black men and women aged 24-51 years. For all race-sex subgroups, mean energy intake estimated from the questionnaire was significantly greater than mean intake estimated from the record. Within race-sex subgroups, the correlations between estimates from the two methods were low, and agreement in classification by tertiles was poor. The differences in group mean energy intake between the methods were due to the effects of discrepancies in both serving size and frequency of consumption. However, the low correlations and poor agreement in classification for individual respondents were due principally to the effect of discrepancies in frequency. These results suggest that improving the accuracy of frequency estimation is a key element in increasing the relative validity of food frequency questionnaires used for epidemiologic research.

Disability, utilization, and costs associated with musculoskeletal conditions

In this report, data from the 1980 National Medical Care Utilization and Expenditure Survey are used to present health characteristics, types and quantities of services used, and the charges for these services for persons with musculoskeletal diseases. Slightly more than 44 million people, or 19.8 percent of the U.S. civilian noninstitutionalized population, were reported in the survey to have at least one musculoskeletal disorder. These data are generally consistent with those from other health surveys, which show that the prevalence of musculoskeletal disorders increases for successive age categories, that such disorders are more common among women than among men, and that they are less prevalent among black persons than among persons of other races. In terms of both functional limitation and perceived health status, persons with musculoskeletal conditions are, with some notable exceptions, in relatively poor health. Persons having back problems in addition to problems with peripheral joints (such as the knee, hip, or shoulder) were more likely to rate their health as "fair" or "poor" compared with persons having only back problems or compared with persons in the civilian noninstitutionalized population as a whole. Musculoskeletal disorders accounted for a considerable proportion of all disability days reported by the total civilian noninstitutionalized population: 13 percent of restricted-activity days, 8.8 percent of bed-disability days, and 11.2 percent of all work-loss days were directly attributable to musculoskeletal conditions. The disabling effects of musculoskeletal problems pose a significant economic burden; they accounted for a total of $3.9 billion in lost productivity costs during 1980 for employed persons in the work force and for homemakers. For persons with musculoskeletal problems, the mean number of ambulatory visits per year was nearly twice the rate of 5.2 for the general civilian noninstitutionalized population. Of ambulatory visits made to all health care providers by persons with these conditions, 35.6 percent were related in some way to the treatment of their musculoskeletal problems. Musculoskeletal conditions are somewhat different from many other illnesses because their treatment is within the professional domain of several types of health care providers. Approximately 13 percent of persons with any type of musculoskeletal disorder received care from chiropractors during the year and this figure rose to nearly 30 percent for back problems only. However, nearly 33 percent of persons with musculoskeletal problems made no visits for treatment of their condition.(ABSTRACT TRUNCATED AT 400 WORDS)

Incidence, utilization, and costs associated with acute respiratory conditions, United States, 1980

Acute respiratory conditions are common causes of health disturbance in the general population. They are generally self-limiting, although occasionally recurrent, and seldom result in large health care costs for each episode of illness. The National Medical Care Utilization and Expenditure Survey (NMCUES), conducted during 1980, provided an opportunity to assess the effect of acute respiratory conditions on utilization of medical services and on functional capability as well as the cost of related medical care. Acute respiratory conditions were reported by survey respondents and separated into five subgroups: colds, influenza, nasopharyngitis, otitis media, and lower respiratory infections. Allergic conditions and chronic respiratory disorders (tuberculosis, chronic obstructive pulmonary disease, and pneumoconioses) were excluded. The subgroupings of acute respiratory conditions appear to separate the disorders in a manner consistent with the epidemiologic characteristics of each condition. About one-half (50.4 percent) of the U.S. civilian noninstitutionalized population had one or more acute respiratory conditions during 1980. The highest rates for upper respiratory conditions (colds, influenza, nasopharyngitis, and otitis media) were reported for those under 18 years of age, and rates were lower in successively older groups. Lower respiratory infection rates were higher in the youngest and oldest groups. Despite a high incidence in the general population, most symptomatic episodes of colds, influenza, and nasopharyngitis did not result in ambulatory care visits or hospital admissions. Otitis media and lower respiratory infections were more often associated with medical visits. Acute respiratory conditions were associated with lower disability levels than the average for the U.S. civilian noninstitutionalized population during 1980 (5.9 restricted-activity days for acute respiratory conditions, compared with an overall average of 13.8 restricted-activity days). Persons with upper respiratory conditions (colds, influenza, otitis media, and nasopharyngitis) averaged 2.3 to 5.4 restricted-activity days, but persons with lower respiratory infections experienced an average of 8.2 restricted-activity days. Indirect costs attributed to acute respiratory conditions in 1980 were $7.7 billion for employed persons and $698 million for homemakers, for a total of $8.4 billion, about the same as total direct costs ($8.3 billion). These indirect costs were several times larger than the annual indirect costs estimated for either cardiovascular diseases or musculoskeletal diseases, two common chronic or recurrent condition groups. The high indirect costs reflect the high frequency of episodes in the general population during 1980 and the greater likelihood of associated bed-disability and work-loss days than for other conditions.(ABSTRACT TRUNCATED AT 400 WORDS)

Taxonomic identification of human fat patterns

The utility of taxonomic approaches in identification of fat patterning was evaluated using hierarchical cluster analysis on a sample of 64 female and 31 male subjects from 18 to 29 years of age. Four clusters, each composed of subjects with similar distributions of 17 skinfold thicknesses corrected for sex, size and total body fat, showed mean pattern profiles that variously contrasted fatness of the trunk and extremities. Average anthropometric differences between clusters corroborated differences in pattern profile. For comparison, principal-components analysis was carried out on these same data. The results suggest that a taxonomic approach offers advantages in initial interpretation and in design flexibility.

Differential diagnosis of class II malocclusions. Part 1. Facial types associated with class II malocclusions

By means of computer-based statistical methods, several types of Class II malocclusion have been discovered with defining horizontal and vertical characteristics. Of the six horizontal types, four are severe syndromes, one is a loose, ill-defined grouping of cases with mild skeletal features, and one has only the dental features of Class II. Five vertical types associates with Class II were also revealed, although each vertical is not associated with all horizontal types. A simplified simulation of the computerized procedures has been developed for routine use in clinical practice.

New standards of cortical mass in the humerus of neonates: a means of evaluating bone loss in the premature infant

The purpose of this study was to develop standards for quantitating bone loss in premature infants. Cortical measurements of the humerus, including the outside diameter (T), the inner diameter (M), the cortical thickness (C), and the cortical area (CA), were calculated for 132 newborn infants who weighed between 500 and 3,686 g and ranged in gestational age from 22 to 40 weeks. The measurements were correlated with the independent variables of gestational age and birth weight, and are presented graphically. With the method of cortical measurement described in this study, it may be possible to determine the causes of bone loss, and to find ways to correct it.

Capacity of the colon in children

The capacity of the colon was determined in 49 children during filling of the colon under fluoroscopic control. The data were evaluated by regression analysis and a mean from the sample was obtained. The capacity of the colon may be determined in milliliters by the formula: V = 233 + 83.87 X (X being the age of the child in years).

The concept of pattern in craniofacial growth

1. There are semantic and associated problems with the word pattern in biology, particularly in orthodontics and facial growth. 2. Pattern, as we use the term, is invariance of relationships--"a set of constraints operating to preserve the integration of parts under varying conditions and through time." 3. Craniofacial pattern can be described and quantified by the identification of craniofacial constants, measures that are relatively invariant. 4. Growth is change and is best identified by studying those measures of size and shape that vary most sensitively through time over development stages. 5. The many traditional cephalometric measures that represent well neither pattern nor growth (mixed) are of less clinical utility than either pure pattern indices or growth indices. 6. The analytical and conceptual separation of pattern and growth seems useful in analysis of morphology, analysis of growth, prediction of growth, and clinical treatment planning.

Carpal length in children--a useful measurement in the diagnosis of rheumatoid arthritis and some concenital malformation syndromes

The distance between the midpoint of the distal radial epiphyseal growth plate and the proximal end of the third metacarpal offers a useful measure for determining wrist size. Standards of this distance as compared to intermetacarpal width and second metacarpal length are presented. These measures (or ratios) should be useful in evaluating patients with juvenile rheumatoid arthritis and a number of congenital malformation syndromes, particularly when the carpals are still not fully ossified. Shortening of the carpus occurs in multiple epiphyseal dysplasia, the otopalatodigital syndromes, Turner syndrome, arthrogryposis, and in juvenile rheumatoid arthritis. A relatively large carpus is present in achondroplasia.

The effect of age, sex, race, and economic status on dental caries experience of the permanent dentition. Committee to Review the Ten-State Nutrition Survey of 1968-1970

The Ten-State Nutrition Survey data show a consistent, dramatic, and meaningful difference in dental caries experience between black and white children at all ages. This difference transcends socioeconomic grouping, nutritional level, and developmental status. This study also has shown an apparently protective effect of poverty insofar as dental caries is concerned. Children from lower-income families experienced less dental caries than children from higher-income families.