The Relationship between Total Bilirubin Levels and Total Mortality in Older Adults: The United States National Health and Nutrition Examination Survey (NHANES) 1999-2004

Objective

Due to its anti-oxidant and anti-inflammatory properties, bilirubin has been associated with reduced cardiovascular risk. A recent study demonstrated an L-shaped association of pre-treatment total bilirubin levels with total mortality in a statin-treated cohort. We therefore investigated the association of total bilirubin levels with total mortality in a nationally representative sample of older adults from the general population.

Methods

A total of 4,303 participants aged ≥60 years from the United States National Health and Nutrition Examination Survey 1999–2004 with mortality data followed up through December 31, 2006 were included in this analysis, with a mean follow-up period of 4.5 years.

Results

Participants with total bilirubin levels of 0.1–0.4 mg/dl had the highest mortality rate (19.8%). Compared with participants with total bilirubin levels of 0.5–0.7 mg/dl and in a multivariable regression model, a lower total bilirubin level of 0.1–0.4 mg/dl was associated with higher risk of total mortality (hazard ratios, 1.36; 95% confidence interval, 1.07–1.72; P = 0.012), while higher levels (≥0.8 mg/dl) also tended to be associated with higher risk of total mortality, but this did not reach statistical significance (hazard ratios, 1.24; 95% confidence interval, 0.98–1.56; P = 0.072).

Conclusion

In this nationally representative sample of older adults, the association of total bilirubin levels with total mortality was the highest among those with a level between 0.1 and 0.4 mg/dl. Further studies are needed to investigate whether higher total bilirubin levels could be associated with a higher mortality risk, compared to a level of 0.5–0.7 mg/dl.     

National Trends in the Ambulatory Treatment of Hypertension in the United States, 1997-2012

Importance

Hypertension is common and costly. Over the past decade, new antihypertensive therapies have been developed, several have lost patent protection and additional evidence regarding the safety and effectiveness of these agents has accrued.

Objective

To examine trends in the use of antihypertensive therapies in the United States between 1997 and 2012.

Design, Setting and Participants

We used nationally representative audit data from the IMS Health National Disease and Therapeutic Index to examine the ambulatory pharmacologic treatment of hypertension.

Outcome Measures

Our primary unit of analysis was a visit where hypertension was a reported diagnosis and treated with a pharmacotherapy (treatment visit). We restricted analyses to the use of six therapeutic classes of antihypertensive medications among individuals 18 years or older.

Results

Annual hypertension treatment visits increased from 56.9 million treatment visits (95% confidence intervals [CI], 53.9–59.8) in 1997 to 83.3 million visits (CI 79.2–87.3) in 2008, then declined steadily to 70.9 million visits (CI 66.7–75.0) by 2012. Angiotensin receptor blocker utilization increased substantially from 3% of treatment visits in 1997 to 18% by 2012, whereas calcium channel blocker use decreased from 27% to 18% of visits. Rates of diuretic and beta-blocker use remained stable and represented 24%–30% and 14–16% of visits, respectively. Use of direct renin inhibitor accounted for fewer than 2% of annual visits. The proportion of visits treated using fixed-dose combination therapies increased from 28% to 37% of visits.

Conclusions

Several important changes have occurred in the landscape of antihypertensive treatment in the United States during the past decade. Despite their novel mechanism of action, the adoption rate of direct renin inhibitors remains low.     

Confirming a biological pathway in the metabolic syndrome--insight from the NHANES 1999-2002

The objective of this study was to examine the role of obesity in the development of the metabolic syndrome (MS). A total of 3,596 whites aged 19 years and above, who participated in the National Health and Nutrition Examination Survey (NHANES) 1999-2002, were included for analysis. Anthropometric measurements, biochemical profiles, and high-sensitivity C-reactive protein (CRP) were measured. A structural equation model (SEM) was constructed to elucidate a pathway in which obesity initiated the cascade leading to full MS. The results of SEM demonstrated that obesity was positively associated with elevated CRP level (B = 0.05, P < 0.001). This higher inflammatory state directed to insulin resistance (B = 0.32, P < 0.001), which in turn was positively associated with dyslipidemia (B = 0.06, P < 0.001). Obesity could also directly and positively affect blood pressure (B = 0.51, P < 0.001), without the mediation of insulin resistance and/or inflammation. The results of the cross-sectional analysis in the white subjects have shown that obesity has a strong influence on hypertension that obtains little additional influence from inflammation or insulin resistance. The metabolic profile in the NHANES group has been confirmatory with the statement that there is a sequential effect from obesity to inflammation, insulin resistance, and dyslipidemia. This approach has allowed to inferring important biological insights about the nature of the relationships among the components of MS.     

Unmanaged care: the need to regulate new reproductive technologies in the United States

In the aftermath of allegations of the misuse of human eggs in the United States, questions are being raised about whether profitable reproductive services should continue to function in a free market under the aegis of physicians or should be regulated. Other countries in which reproductive technologies are employed to a significant degree have developed regulations governing their use, many as a result of recommendations made by inter-disciplinary commissions that solicited public input. Policy makers in the United States have been reluctant to regulate reproductive technologies, however, because their use is politically controversial, they want to whittle down government, some do not consider infertility an illness, and some believe regulation would interfere with the right to reproduce. Yet the unfettered use of reproductive technologies can create such harms as lack of informed consent, providing procedures not medically indicated for financial gain, practice by unqualified personnel, injury to patients and donors, failure to screen donated gametes, and inadequate medical record keeping. Americans place special value on the welfare of children and those who bring them into the world. Such values can outweigh individual procreative liberty when new reproductive technologies are at issue. Although the optimal course would be to establish a regulatory body to govern reproductive technologies, this is not politically feasible now. The newly established National Bioethics Advisory Commission provides a forum in which issues surrounding reproductive technologies should be addressed at this time in the United States.     

Milk intake and total dairy consumption: associations with early menarche in NHANES 1999-2004

Background

Several components of dairy products have been linked to earlier menarche.

Methods/Findings

This study assessed whether positive associations exist between childhood milk consumption and age at menarche or the likelihood of early menarche (<12 yrs) in a U.S sample. Data derive from the National Health and Nutrition Examination Survey (NHANES) 1999–2004. Two samples were utilized: 2657 women age 20–49 yrs and 1008 girls age 9–12 yrs. In regression analysis, a weak negative relationship was found between frequency of milk consumption at 5–12 yrs and age at menarche (daily milk intake β = −0.32, P<0.10; “sometimes/variable milk intake” β = −0.38, P<0.06, each compared to intake rarely/never). Cox regression yielded no greater risk of early menarche among those who drank milk “sometimes/varied” or daily vs. never/rarely (HR: 1.20, P<0.42, HR: 1.25, P<0.23, respectively). Among the 9–12 yr olds, Cox regression indicated that neither total dairy kcal, calcium and protein, nor daily milk intake in the past 30 days contributed to early menarche. Girls in the middle tertile of milk intake had a marginally lower risk of early menarche than those in the highest tertile (HR: 0.6, P<0.06). Those in the lowest tertiles of dairy fat intake had a greater risk of early menarche than those in the highest (HR: 1.5, P<0.05, HR: 1.6, P<0.07, lowest and middle tertile, respectively), while those with the lowest calcium intake had a lower risk of early menarche (HR: 0.6, P<0.05) than those in the highest tertile. These relationships remained after adjusting for overweight or overweight and height percentile; both increased the risk of earlier menarche. Blacks were more likely than Whites to reach menarche early (HR: 1.7, P<0.03), but not after controlling for overweight.

Conclusions

There is some evidence that greater milk intake is associated with an increased risk of early menarche, or a lower age at menarche.     

The vaginal Bifidobacterium flora in women of reproductive age

The composition of vaginal bifidoflora in 56 clinically healthy women of reproductive age was studied. The study revealed that four species of bifidobacteria, viz. Bifidobacterium bifidum, B. breve, B. adolescentis 2 and B. longum, dominated in the composition of this bifidobacterial population. Nine out of 11 isolated strains were found to be capable of inhibiting indicator microorganisms Staphylococcus aureus and Enterococcus faecalis when tested in vitro; in addition, strains B. adolescentis 2 F1, B. bifidum G1, B. breve P2 and B. longum Z4 inhibited Klebsiella ozaenae, Pseudomonas aeruginosa, Escherichia coli and were also active acid producers. Three of these 4 bifidobacterial strains were capable of adhesion to vaginal epitheliocytes, while B. bifidum G1 was practically incapable of adherence to these cells, similarly to B. bifidum strain 791 of intestinal origin. In addition, the spectra of antibiotic susceptibility varied from strain to strain, but all bifidobacterial strains were susceptible to benzylpenicillin and resistant to lomefloxacin, most of them being also resistant to cyprofloxacin and gentamicin. Thus the data presented in this work are indicative of the possibility and advantages of using bifidobacterial strains belonging to this ecological niche as probiotics for the correction of the microflora of the urogenital tract in females.     

Adiposity is not equal in a multi-race/ethnic adolescent population: NHANES 1999-2004

BMI is the preferred measure of adiposity in adolescents. Recent evidence suggests that in adults the relationship between BMI and adiposity can vary by age and race/ethnicity. We investigated the relationship between BMI and percent body fat (%BF) in a large multi-ethnic, nationally representative sample of US adolescents (National Health and Nutrition Examination Survey, NHANES, 1999-2004). BMI was calculated; %BF was derived from dual-energy X-ray absorptiometry data and compared to BMI among adolescents from three groups: non-Hispanic white (NHW), non-Hispanic black (NHB), and Mexican-American (MA). Fractional polynomials were used to model a new equation to estimate %BF from a given BMI. MA boys weighed significantly less than either NHW or NHB boys, while only NHB girls weighed significantly more than the other girls. Among the boys there were no differences in mean BMI, whereas %BF differed significantly between all three groups. For the girls, both BMI and %BF differed significantly the groups with MA girls having the highest %BF. The significant correlates for modeling %BF from BMI included gender, age, race/ethnicity, weight, [formula in text]: the final model explained 79% of the variance in %BF. NHB adolescents had significantly lower %BF for BMI and MA had higher than NHW. Our results indicate that BMI may not be an equivalent measure of %BF in a multi-ethnic population of US adolescents.     

National estimates and race/ethnic-specific variation of selected birth defects in the United States, 1999-2001

BACKGROUND: In the United States, birth defects affect approximately 3% of all births, are a leading cause of infant mortality, and contribute substantially to childhood morbidity. METHODS: Population-based data from the National Birth Defects Prevention Network were combined to estimate the prevalence of 21 selected defects for 1999-2001, stratified by surveillance system type. National prevalence was estimated for each defect by pooling data from 11 states with active case-finding, and adjusting for the racial/ethnic distribution of US live births. We also assessed racial/ethnic variation of the selected birth defects. RESULTS: National birth defect prevalence estimates ranged from 0.82 per 10,000 live births for truncus arteriosus to 13.65 per 10,000 live births for Down syndrome. Compared with infants of non-Hispanic (NH) white mothers, infants of NH black mothers had a significantly higher birth prevalence of tetralogy of Fallot, lower limb reduction defects, and trisomy 18, and a significantly lower birth prevalence of cleft palate, cleft lip with or without cleft palate, esophageal atresia/tracheoesophageal fistula, gastroschisis, and Down syndrome. Infants of Hispanic mothers, compared with infants of NH white mothers, had a significantly higher birth prevalence of anencephalus, spina bifida, encephalocele, gastroschisis, and Down syndrome, and a significantly lower birth prevalence of tetralogy of Fallot, hypoplastic left heart syndrome, cleft palate without cleft lip, and esophageal atresia/tracheoesophageal fistula. CONCLUSIONS: This study can be used to evaluate individual state surveillance data, and to help plan for public health care and educational needs. It also provides valuable data on racial/ethnic patterns of selected major birth defects.     

Pediatric vancomycin use in 421 hospitals in the United States, 2008

Background

Recommendations to prevent the spread of vancomycin resistance have been in place since 1995 and include guidelines for inpatient pediatric use of vancomycin. The emergence of large databases allows us to describe variation in pediatric vancomycin across hospitals. We analyzed a database with hospitalizations for children under 18 at 421 hospitals in 2008.

Methodology/Principal Findings

The Premier hospital 2008 database, consisting of records for 877,201 pediatric hospitalizations in 421 hospitals, was analyzed. Stratified analyses and logistic mixed effects models were used to calculate the probability of vancomycin use while considering random effects of hospital variation, hospital fixed effects and patient effects, and the hierarchical structure of the data. Most hospitals (221) had fewer than 10 hospitalizations with vancomycin use in the study period, and 47 hospitals reported no vancomycin use in 17,271 pediatric hospitalizations. At the other end of the continuum, 21 hospitals (5.6% of hospitals) each had over 200 hospitalizations with vancomycin use, and together, accounted for more than 50% of the pediatric hospitalizations with vancomycin use. The mixed effects modeling showed hospital variation in the probability of vancomycin use that was statistically significant after controlling for teaching status, urban or rural location, size, region of the country, patient ethnic group, payor status, and APR-mortality and severity codes.

Conclusions/Significance

The number and percentage of pediatric hospitalizations with vancomycin use varied greatly across hospitals and was not explained by hospital or patient characteristics in our logistic models. Public health efforts to reduce vancomycin use should be intensified at hospitals with highest use.     

Sex,status, and reproductive success in the contemporary United States

This paper reexamines the relationship between status and reproductive success (at the ultimate and proximate levels) using data on sex frequency and number of biological children from representative samples of the U.S. population. An ordered probit analysis of data from the 1989–2000 General Social Survey (GSS) shows that high-income men report greater frequency of sex than all others do. An OLS regression of data from the 1994 GSS shows that high-income men have more biological children than do low-income men and high-income women. Furthermore, more educated men have more biological children than do more educated women. Results also show that intelligence decreases the number of offspring and frequency of sex for both men and women.     

葫芦岛地区育龄期女性甲状腺功能指标的调查研究

目的探讨葫芦岛地区育龄期女性甲状腺功能水平与孕前促甲状腺激素(TSH)、抗甲状腺过氧化物酶抗体(TPO-Ab)筛查对优生优育的意义。方法选择葫芦岛市1 540例育龄女性,采用罗氏电化学发光E602检测血清TSH、游离甲状腺素(FT4)、游离三碘甲腺原氨酸(FT3)和TPO-Ab。结果 1 540例育龄妇女中,TSH异常135例,总异常率为8.7%,不同年龄组间TSH的异常率差异有统计学意义(χ2=33.56,P0.05)。TPO-Ab总阳性率为8.2%,TSH正常与异常组间的比较差异有统计学意义(χ2=34.84,P0.05)。进一步分层分析,TSH异常者中,甲亢与甲减组TPO-Ab阳性率的比较组间差异无统计学意义(χ2=0.043,P0.05)。结论葫芦岛地区育龄期女性甲状腺功能异常率较高,应对孕产妇常规进行甲状腺功能检测。     

Propensity of white women in the United States to adopt children

Demographically, adoption is a relatively rare event. In 1982, only 2.3 per cent (or about 650,000) of ever-married white women aged 15 to 44 had adopted one or more children. Adoption is an important and very relevant means of family formation for many women, particularly those for whom biological childbearing is difficult or impossible. Although there is a modest literature on adoption behavior, we have very little information about women who have shown a propensity to adopt children. How should the phenomenon of adoption propensity be conceptualized? How many women are there in the United States with such a propensity? How different is this number from the number of women who eventually adopt children? What are the characteristics of women with a propensity to adopt? The objectives of this paper are (1) to estimate the numbers of U.S. women at three different points in time (1973, 1976, and 1982) who have a propensity to adopt, according to various socioeconomic and demographic characteristics; and (2) to compare via log-linear analysis the major characteristics of these women with women who have not shown such a propensity.