Search

Obesity is thought to be highly prevalent in persons with lower extremity amputations (LEAs) and can impair physical and social functioning.

The degree to which low transplant rates among Asians and Pacific Islanders in the United States are confounded by poverty and reduced access to care is unknown. We examined the relationship between neighborhood poverty and kidney transplant rates among 22 152 patients initiating dialysis during 1995–2003 within 1800 ZIP codes in California, Hawaii and the US‐Pacific Islands. Asians and whites on dialysis were distributed across the spectrum of poverty, while Pacific Islanders were clustered in the poorest areas. Overall, worsening neighborhood poverty was associated with lower relative rates of transplant (adjusted HR [95% CI] for areas with ≥20% vs. <5% residents living in poverty, 0.41 [0.32–0.53], p < 0.001). At every level of poverty, Asians and Pacific Islanders experienced lower transplant rates compared with whites. The degree of disparity increased with worsening neighborhood poverty (adjusted HR [95% CI] for Asians–Pacific Islanders vs. whites, 0.64 [0.51–0.80], p < 0.001 for areas with <5% and 0.30 [0.21–0.44], p < 0.001 for areas with ≥20% residents living in poverty; race–poverty level interaction, p = 0.039). High levels of neighborhood poverty are associated with lower transplant rates among Asians and Pacific Islanders compared with whites. Our findings call for studies to identify cultural and local barriers to transplant among Asians and Pacific Islanders, particularly those residing in resource‐poor neighborhoods.

Background & Aims: Nonalcoholic fatty liver disease has been defined by the presence of hepatic steatosis in the absence of other chronic liver diseases. We sought to determine whether obesity, insulin resistance, and the metabolic syndrome, which are the main risk factors for nonalcoholic fatty liver disease, are associated with similar elevations in serum alanine aminotransferase activity in persons with and those without other causes of chronic liver disease. Methods: Adult participants of the third National Health and Nutrition Examination Survey were divided into those with causes of chronic liver disease (n = 1037), defined as viral hepatitis, excessive alcohol consumption, or increased transferrin-iron saturation, and those without (n = 8004). Results: Among persons with other causes of chronic liver disease, obesity (adjusted odds ratio, 4.9; 95% confidence interval, 2.5-9.4), insulin resistance (adjusted odds ratio, 6.8; 95% confidence interval, 3.0-15.5, comparing the highest and the lowest quartile), and the metabolic syndrome (adjusted odds ratio, 3.3; 95% confidence interval, 1.4-8.0) were all strongly associated with increased alanine aminotransferase activity (>43 IU/L). Among persons without other causes of chronic liver disease, statistically similar associations were identified. Conclusions: Obesity, insulin resistance, and the metabolic syndrome are strong predictors of increased alanine aminotransferase activity in the US population, both in persons with and in persons without other causes of chronic liver disease. We hypothesize that metabolic fatty liver disease related to these conditions is the cause of the increased alanine aminotransferase activity and may be underrecognized in persons with other causes of chronic liver disease.

Background: This study assessed whether EGD reduces mortality from adenocarcinoma of the esophagus or gastric cardia for patients with gastroesophageal reflux. Methods: A case-control study was performed. A total of 245 incident cases of death caused by adenocarcinoma of the esophagus or gastric cardia (1995-1999) in which reflux was present were identified using Veterans Health Administration databases. A total of 980 controls with reflux but no death from adenocarcinoma were frequency matched for age, gender, and race. The occurrences of EGD from 1990 onward were compared for cases and controls. Logistic regression analysis with adjustment for potential confounding factors was performed. Results: All the subjects were men. Cases were significantly less likely to have had an EGD in the time period of interest as compared with controls (adjusted odds ratio 0.66: 95% CI [0.45, 0.96], p = 0.03). This negative association was as strong for any EGD performed within 1 to 8 years before diagnosis as for a more recent EGD. However, there were no controls that included esophagectomy and no controls with a nonfatal diagnosis of adenocarcinoma, raising the question of whether EGD and reduced mortality are causally linked. The risk of dying from adenocarcinoma was significantly lower for men with a diagnosis of GERD as an inpatient relative to men in whom the diagnosis was made as an outpatient (adjusted odds ratio 0.21: 95% CI [0.15, 0.31], p < 0.01). Conclusions: For patients with GERD, performing an EGD is associated with reduced mortality from adenocarcinoma of the esophagus or gastric cardia, but whether this is a causative association remains unclear. (Gastrointest Endosc 2003;57:823-9.)

Disproportionate hyperproinsulinaemia is a manifestation of the β‐cell dysfunction observed in NIDDM. However, it is unclear when this abnormality develops and whether it predicts the development of the disease. To examine whether changes in proinsulin levels predict the development of NIDDM, baseline measurements of proinsulin and immunoreactive insulin levels were made in 87 second‐generation Japanese‐American men, a population at high risk for the subsequent development of NIDDM. Subjects were categorized at baseline using WHO criteria as having normal glucose tolerance (NGT; n= 49) or impaired glucose tolerance (IGT; n= 38). After a 5‐year follow‐up period, subjects were recategorized as having NGT, IGT or NIDDM using the same criteria. During follow‐up, 16 subjects developed NIDDM while 71 were NGT or IGT. At baseline, individuals who subsequently developed NIDDM were more obese as measured by intra‐abdominal fat area on computed tomography (p= 0.046), had higher fasting glucose (p= 0.0042), 2‐h glucose (p= 0.0002), fasting C‐peptide (p= 0.0011 ), fasting proinsulin levels (p = 0.0033), and had disproportionate hyperproinsulinaemia (p= 0.056) when compared to those who remained NGT or IGT after 5 years of follow‐up. These findings suggest that alterations in proinsulin levels may also predict the subsequent development of NIDDM.

The objective of this study was to evaluate the relationship between foot ulceration and short‐term mortality in veterans of the American military services with diabetes mellitus. A total of 725 diabetic subjects participated in a prospective study of risk factors for lower extremity complications between 1990 and 1994. Mean follow‐up was 691.8 days (± SD 339.9, range 28–1436 days). Subjects who died during follow‐up (n= 72) had a similar mean duration of diabetes to those who survived (12.6 years vs 11.2), but their mean age was greater (65.9 years vs 63.2, p= 0.026). The relative risk (RR) of death was 2.39 (95% confidence interval (CI) 1.13 to 4.58) in the subjects who developed foot ulcer (n= 88) compared to those who did not. The risk of death for those with foot ulcer was 12.1 per 100 person‐years of follow‐up compared to 5.1 in those without foot ulcer. Cox regression analysis demonstrated a greater than two‐fold increased risk of death in ulcerated subjects after adjustment for age; diabetes type, duration, and treatment; glycosylated hemoglobin level; history of lower extremity amputation; and cumulative pack years smoked. Higher ankle–arm index was significantly related to lower mortality risk, independent of foot ulcer occurrence. We conclude that foot ulcer and lower extremity vascular disease are related to a higher risk of death in diabetic subjects. The reasons for this excess mortality require further investigation.

We examined neuropathy, ankle pressure index (API), and other factors as predictors of transcutaneous oxygen (TcPO2) in the lower limbs of 657 diabetic subjects. Eligible subjects underwent a clinical assessment that included three standard measures of autonomic neuropathy. TcPO2measurements were performed at 37 °C and 44 °C at four lower limb locations. Associations between potential predictors and TcPO2were tested using univariate and multivariate statistics. Mean TcPO2at any site did not differ by presence of autonomic neuropathy at either temperature, except for a significantly lower value at 44 °C below the knee (56.5 versus 59.2 mmHg, p= 0.021). In multivariate analysis, autonomic neuropathy was significantly and independently related to leg 44 °C TcPO2only (coefficient = −2.6734, p= 0.0182). Much stronger associations were seen between TcPO2and age, ankle blood pressure, and relative body weight on the plantar foot; and between API, glycosylated haemoglobin, ankle blood pressure, and pedal oedema on the dorsal foot and leg. We conclude that factors related to lower limb TcPO2vary depending on measurement site. Autonomic neuropathy is not an important determinant of TcPO2in the feet of diabetic subjects. Although several predictors of TcPO2were identified, most of the variance of this measurement remains unexplained.

The once low prevalence of non‐insulin‐dependent (Type 2) diabetes (NIDDM) in Eskimos and Indians has risen approximately fourfold over the past 30 years, suggesting the presence of a non‐genetic factor affecting NIDDM prevalence. At the same time, traditional physical activities required of a subsistence (self‐sufficiency) lifestyle have diminished. Since physical activity has been shown to prevent NIDDM in other populations, we performed a case–control study of physical activity and glucose intolerance in 666 Yup'ik Eskimos and Athabaskan Indians ≥40 years old in 15 villages in the Yukon Kuskokwim Delta in Alaska. Self‐administered questionnaires were used to determine whether subjects participated in a number of traditional activities and/or their modern counterpart (for example, dog sledding and riding motorized vehicles). Intensity values and a score were defined for the activities. Cases included known or newly discovered impaired glucose tolerance or NIDDM. Newly discovered cases were defined by oral glucose tolerance testing of those individuals were screening blood glucose values ≥6.7 mmol l−1by random capillary blood glucose testing. Cases included 11 newly discovered (1 with a history of IGT) and 26 known cases of NIDDM, and 17 newly discovered and 1 known cases of IGT. The results showed that, compared to a reference group with low‐level physical activity, moderate level physical activity (odds ratio, OR, 0.7, 95 % confidence interval [CI] 0.4–1.3) and high level activity (OR 0.2, CI 0.1–0.6) were associated with a lower prevalence of glucose intolerance, adjusted for age, ethnicity, body mass index, and sex.