Background: A history of atopic respiratory conditions has been linked to an increased risk of stroke. What remains unclear is whether positive allergy skin testing is associated with an increased risk of stroke. The primary goal of this study was to determine whether positive allergy skin testing is associated with an increased risk of fatal stroke. A secondary goal is to determine whether having both positive allergy skin testing and an atopic respiratory condition is associated with a particularly high risk of stroke death. Methods: An analysis was performed of the National Health and Nutrition Examination Survey II Mortality Cohort. Results: Controlling for age, gender, race, alcohol use, smoking status, diabetes, hypertension, and body mass index, patients with positive allergy skin testing had a hazard ratio for stroke mortality of 1.56 (95% CI, 1.01-2.40) versus those without positive allergy testing. Patients with both positive allergy testing and an atopic respiratory condition had a hazard ratio for stroke mortality of 2.31 (95% CI, 1.13-4.73). Conclusions: Individuals with both positive allergy skin testing and an atopic respiratory condition have more than a 2-fold increased risk of fatal stroke. This novel risk factor has substantial implications for a large segment of the population not previously considered at risk. (J Am Board Fam Med 2009; 22: 604-609.)

Objective:The aim of this study was to determine whether frequent onion consumption is associated with increased bone density in perimenopausal and postmenopausal non-Hispanic white women 50 years and older. Methods:An analysis of the National Health and Nutrition Examination Survey 2003-2004 was performed. Perimenopausal and postmenopausal non-Hispanic white female participants (unweighted N = 507; weighted N = 35.7 million) were divided into those who consumed onions less than once a month, twice a month to twice a week, three to six times a week, and once a day or more based on self-reported dietary history. All study participants underwent total body dual-energy x-ray absorptiometry. Results:After controlling for age, body mass index, daily calcium intake, serum vitamin D, serum parathyroid hormone, estrogen use, smoking status, and exercise status, bone density increased as the frequency of onion consumption increased. Individuals who consumed onions once a day or more had an overall bone density that was 5% greater than individuals who consumed onions once a month or less (P < 0.03). Conclusions:Onion consumption seems to have a beneficial effect on bone density in perimenopausal and postmenopausal non-Hispanic white women 50 years and older. Furthermore, older women who consume onions most frequently may decrease their risk of hip fracture by more than 20% versus those who never consume onions.

BACKGROUND: Lifestyle choices are associated with cardiovascular disease and mortality. The purpose of this study was to compare adherence to healthy lifestyle habits in adults between 1988 and 2006.METHODS: Analysis of adherence to 5 healthy lifestyle trends (>= 5 fruits and vegetables/day, regular exercise >12 times/month, maintaining healthy weight [body mass index 18.5-29.9 kg/m(2)], moderate alcohol consumption [up to 1 drink/day for women, 2/day for men] and not smoking) in the National Health and Nutrition Examination Survey 1988-1994 were compared with results from the National Health and Nutrition Examination Survey 2001-2006 among adults aged 40-74 years.RESULTS: Over the last 18 years, the percent of adults aged 40-74 years with a body mass index >= 30 kg/m(2) has increased from 28% to 36% (P <.05); physical activity 12 times a month or more has decreased from 53% to 43% (P <.05); smoking rates have not changed (26.9% to 26.1%); eating 5 or more fruits and vegetables a day has decreased from 42% to 26% (P <.05), and moderate alcohol use has increased from 40% to 51% (P <.05). Adherence to all 5 healthy habits has gone from 15% to 8% (P <.05). Although adherence to a healthy lifestyle was lower among minorities, adherence decreased more among non-Hispanic Whites over the period. Individuals with a history of hypertension/diabetes/cardiovascular disease were no more likely to be adherent to a healthy lifestyle than people without these conditions.CONCLUSIONS: Generally, adherence to a healthy lifestyle pattern has decreased during the last 18 years, with decreases documented in 3 of 5 healthy lifestyle habits. These findings have broad implications for the future risk of cardiovascular disease in adults. (C) 2009 Elsevier Inc. All rights reserved. The American Journal of Medicine (2009) 122, 528-534

PURPOSE Recent evidence in Latino communities indicates substantial self-medication with antibiotics obtained without a prescription (WORx). We implemented and evaluated a culturally sensitive educational intervention to decrease antibiotic self-medication. METHODS We conducted a community-based intervention with preintervention and postintervention measures in the intervention community (Charleston, South Carolina) as well as a postintervention measure in a control community (Greenville, South Carolina) 200 miles away. The 9-month culturally sensitive intervention included multiple media sources (pamphlets, radio, newspapers). We evaluated the use of antibiotics WORx in the United States, as well as the likelihood of importing antibiotics, by surveying Latino adults in the intervention (n = 250) and in the control community (n = 250). RESULTS Most adults in the intervention community (69%) and the control community (60%) reported some exposure to messages about the inappropriate use of antibiotics, and 25.9% in the intervention community and 8.6% in the control community reported seeing our patient education pamphlets. A substantial proportion of Latino adults in both the intervention (31%) and control communities (20%) have obtained antibiotics WORx in the United States. In multivariate analyses, exposure to an educational message was not a significant predictor of having acquired antibiotics WORx in the United States in past 12 months. The primary predictor of respondents' having acquired antibiotics WORx in the United States was whether they had bought antibiotics WORx outside the United States. CONCLUSIONS Novel approaches are needed to decrease the use of antibiotics WORx in Latino communities, as focusing only on education may not be sufficient to change behaviors common in their home countries.

A high-cholesterol diet has been associated with an increased risk of coronary heart disease, but it is unclear whether all high-cholesterol foods increase the risk of heart disease. The purpose of this study is to determine whether shellfish consumption is associated with an increased risk of coronary heart disease. Analysis was performed on the Atherosclerosis Risk in Communities study, a cohort of middle aged and elderly adults in the United States. The association between reported shellfish consumption to the development of coronary heart disease was examined. The cohort was divided into low, medium, and high shellfish consumers. There were 13,355 participants meeting our inclusion criteria, of which 1,382 suffered a coronary heart disease event. Using low shellfish consumers as the reference group, the medium shellfish consumers had an unadjusted hazard ratio of 0.89 (95% confidence interval [CI] 0.79 to 1.00), and the high shellfish consumers had an unadjusted hazard ratio of 0.91 (95% CI 0.80 to 1.03) of suffering a coronary heart disease event. In a model that was adjusted for age, sex, race, smoking status, body mass index, diabetes, hypertension, low-density lipoprotein cholesterol level, high-density lipoprotein cholesterol level, family history of early heart disease, and exercise status using the low shellfish consumers as the reference group, medium shellfish consumers had a hazard ratio of 0.96 (95% CI 0.80 to 1.16), and the high shellfish consumers had a hazard ratio of 0.98 (95% CI 0.82 to 1.18) of experiencing a coronary heart disease event.

Objective: To determine for U.S. ambulatory visits for anxiety how often high blood pressure is unrecognized and the factors associated with being unrecognized. Methods: Analyzed data from the 2005 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey looking at visits for anxiety by patient complaint or provider diagnosis and determined if a hypertension diagnosis was included for visits in which measured blood pressure was in the hypertensive range. This was compared to total visits in the NAMCS and NHAMCS. Logistic regression determined predictors of high blood pressure going unrecognized for visits for anxiety. Results: Of visits for anxiety in 2005 with elevated blood pressure, 32.5% were unrecognized. This compares to 24.6% unrecognized for all visits with hypertension/elevated blood pressure. At visits in which anxiety medications were prescribed (OR 2.44 95%CI 1.01–5.89) and for Hispanic ethnicity (OR 13.9 95%CI 1.46–132.03), high blood pressure was more likely to be unrecognized. High blood pressure was less likely to be unrecognized for those 45 to 64 years old (OR 0.21 95%CI 0.07–0.62), visits not with the primary care provider (OR 0.09 95%CI 0.03–0.33), visits for a chronic problem (OR 0.26 95%CI 0.08–0.86), and visits at which anti-hypertensive medications were prescribed (OR 0.005 95%CI 0.001–0.04). Conclusions: Anxiety is a common reason for visits in U.S. ambulatory settings. Many of these visits have concomitant high blood pressure, a large proportion of which may go unrecognized. Efforts to educate physicians about these issues may help reduce the level of unrecognized high blood pressure in those with anxiety.

Background: Recent data has suggested the use of antibiotics acquired without a prescription by Latinos in the United States. We explored Latino adults' experience in treating common infections particularly in regards to self-medication with antibiotics.Methods: We conducted 3 focus groups (n = 28) in Charleston, South Carolina, with Latino adults (>= 18 years of age) recruited throughout the community: 12 women and 16 men, ranging in age from 18 to 52 years. All of the participants were immigrants, 89% noted Mexico as their country of origin. Focus groups were conducted in Spanish and audiotaped. Transcripts were translated into English and then translated back to Spanish to assure consistency of the language. Themes were identified using an editing style.Results: Participants' previous experiences in countries with limited restrictions on antibiotics influenced acquisition of antibiotics without a prescription in the United States. Participants believed that physician visits for a diagnosis and prescription were unnecessary when the patient was familiar with the symptom and it had previously responded to antibiotic treatment. Access to care was not reported to be a significant barrier to a physician visit when individuals felt they were "sick" or children were the patients. Participants reported using local tiendas (small stores in Latino neighborhoods that sell ethnically consistent and imported products) and importation of medication to meet their need for self-medication with antibiotics. The role of self-medication in the development of antibiotic resistance was essentially unknown among the participants.Conclusions: Successful interventions to improve use of antibiotics need to be culturally sensitive to specific attitudes and behaviors found in the Latino population.

Urban-based randomized clinical trials of integrated supported employment (SE) and mental health services in the United States on average have doubled the employment rates of adults with severe mental illness (SMI) compared to traditional vocational rehabilitation. However, studies have not yet explored if the service integrative functions of SE will be effective in coordinating rural-based services that are limited, loosely linked, and geographically dispersed. In addition, SE's ability to replicate the work outcomes of urban programs in rural economies with scarce and less diverse job opportunities remains unknown. In a rural South Carolina county, we designed and implemented a program blending Assertive Community Treatment (ACT) with an SE model, Individual Placement and Support (IPS). The ACT-IPS program operated with ACT and IPS subteams that tightly integrated vocational with mental health services within each self-contained team. In a 24-month randomized clinical trial, we compared ACT-IPS to a traditional program providing parallel vocational and mental health services on competitive work outcomes for adults with SMI (N = 143; 69% schizophrenia, 77% African American). More ACT-IPS participants held competitive jobs (64 versus 26%; p < .001, effect size [ES] = 0.38) and earned more income (median [Mdn] = 549 US dollars, interquartile range [IQR] = 0-5,145 US dollars, versus Mdn = 0 US dollars, IQR = 0-40 US dollars; p < .001, ES = 0.70) than comparison participants. The competitive work outcomes of this rural ACT-IPS program closely resemble those of urban SE programs. However, achieving economic self-sufficiently and developing careers probably require increasing access to higher education and jobs imparting marketable technical skills.

Insulin resistance is a potentially modifiable midlife risk factor for cognitive decline and dementia.

PURPOSE Nearly one third of diabetes cases in the United States is undiagnosed, with mounting evidence that complications accrue even before clinical diagnosis. We wanted to determine whether persons with undiagnosed diabetes have signs of nephropathy and peripheral neuropathy METHODS We examined the prevalence of positive screening tests for nephropathy and peripheral neuropathy in adults aged ≥40 years with undiagnosed diabetes using secondary analysis of survey and examination data from the population-based United States National Health and Nutrition Examination Survey 1999-2002. We defined a positive screening test for nephropathy as a spot urine albumin-creatinine ratio >30.0 mg/g, representing at least microalbuminuria. We defined ≥1 insensate area on Semmes-Weinstein monofilament testing as a positive finding for neuropathy. Undiagnosed diabetes was defined as a combination of no history of diagnosed diabetes and a measured fasting glucose ≥126 mg/dL. We used SUDAAN for χ2 and regression analyses. RESULTS The prevalence of a positive test when screening for nephropathy among those with undiagnosed diabetes was 26.5% compared with 7.1% in those with no diabetes (χ2, P <.01). After adjusting for age and diagnosed or undiagnosed hypertension, the association of undiagnosed diabetes with nephropathy persisted (odds ratio = 2.35; 95% confidence interval, 1.38–4.01). For peripheral neuropathy, 21.5% with undiagnosed diabetes had positive screening tests compared with 10.1% with no diabetes (χ2, P <.01); however, this effect was not significant after adjustment for age. There was no significant difference in positive screening tests for nephropathy or neuropathy when comparing those with undiagnosed and diagnosed diabetes. CONCLUSIONS A significant proportion of adults with undiagnosed diabetes have signs of nephropathy and peripheral neuropathy. These findings may influence policies about early screening for diabetes.

The Program of Assertive Community Treatment (PACT), a multidisciplinary team approach, delivers integrated community-based treatment, rehabilitation, and support services to help persons with severe and persistent mental illness to avoid psychiatric hospitalization and to live independently in natural community settings. Twenty-five randomized clinical trials of PACT and its close adaptations, conducted over the past 30 years in several countries, demonstrate its effectiveness for this population in reducing use of inpatient psychiatric services and sustaining tenure in normalized housing. Programs based on the PACT model now operate in many countries and most states. Several states have disseminated these programs statewide using a mix of standards, financial incentives, monitoring of program performance, and expert training and consultation. However, despite the strong evidence base for PACT, most states have neither committed the resources nor implemented fidelity assurance methods necessary to widely disseminate PACT and/or its close variants. For the PACT model, we offer our hypotheses about behavioral change processes underlying its approach, describe its major operational structure and process elements, briefly review the research evidence of its effectiveness, and summarize statewide dissemination efforts and factors facilitating effective dissemination. Lastly, as a case study of implementation and dissemination, we report our difficulties in implementing PACT in a rural South Carolina community mental health center (1995–2000), discuss how supervision and consultation by national PACT experts prevented a collapse of our project and turned it into a success, and outline our present plans, supported with a federal grant, to disseminate an integrated PACT and supported employment service in South Carolina's community mental health center system.