Background: Cross-sectional investigation between presence of antibodies and coronary artery calcification (CAC) in past studies has shown no relationship, but progression over time has not been investigated. The objective of this study was to determine the relationship between presence of Chlamydia pneumoniae antibodies and progression of CAC and ankle-brachial index (ABI).Design: The Multiethnic Study of Atherosclerosis (MESA) is a prospective population-based cohort of racially and ethnically diverse male and female participants recruited from six communities in the USA, age 45-84 years, free of clinical cardiovascular disease at baseline.Methods: The main outcomes were progression of mean CAC and ABI between exams 1 (2000-02) and 3 (2004-05) (median follow-up of 3.13 years) by C. pneumoniae antibody. Multivariate models adjusting for demographics, obesity, smoking, alcohol use, and physical activity were computed.Results: Of 2223 subjects analysed, 76% were positive for C. pneumoniae antibodies. Progression of CAC was significantly higher in the antibody-positive group (93.8 vs. 78.2 agatston units, p=0.02) and in antibody-positive subjects with CAC 10 at baseline (216.5 vs. 178.6, p=0.02) than antibody-negative group. Smoking and body mass index 30kg/m(2) both had interactions with presence of C. pneumoniae yielding significantly greater CAC progression. Progression of ABI did not significantly differ by C. pneumoniae antibody status in models adjusted for covariates.Conclusions:C. pneumoniae antibodies are related to progression of CAC, particularly in individuals with CAC present at baseline. This provides evidence that certain groups are at higher risk of atherosclerotic progression and may be useful for risk stratification and treatment.

Abstract Introduction According to the Council on Medical Education in Pediatrics, evidence-based medicine (EBM) skills are necessary for all medical students regardless of specialty career plans. Our EBM subcourse, which is embedded in the 6-week pediatric clerkship, provides an efficient and effective method to train over 160 third-year medical students per year in the use of medical literature. It also encourages these students to develop active learning skills. Methods Our subcourse is built on the premise that the students have some background in EBM. At the beginning of the pediatric clerkship, students test their skills with a scripted scenario (EBM Review). The emphasis is on the students' demonstration of their skills in order to benefit their patients. The conclusion of the subcourse (EBM Finale) is the students' sharing of the clinical scenario of their choice, the clinical question that arose, the literature search, their evaluation of the literature, and how it applies to their patient. The audience for the EBM Finale is their peers and faculty. We provide a comprehensive manual (Instructor's Guide) with an orientation slide for the students, student instruction sheets for the EBM Review and EBM Finale, a sample of a student EBM Finale presentation, and an EBM Finale evaluation form. Results In the fall of 2013, all 167 fourth-year students were sent a 12-question survey to elicit their perspective on this subcourse; 160 students (95%) returned the survey. Of these students, 68% agreed that the subcourse prepared them for their residency/career, 71% had applied what they had learned in other settings, and 90% felt that EBM was valuable. Subcourse aspects rated as most useful were EBM Review, EBM Finale, ward rounds with the EBM preceptor present, and resident EBM conferences. Discussion We have evolved our EBM curriculum over 7 years, adjusting it based on student feedback and our observations. This past year (2013-14), we started having the students provide peer feedback on the EBM presentations. We are still looking for ways to encourage better peer-to-peer feedback. We hope to further explore how and where the students subsequently use their EBM skills. Recently, we have added the requirement for the students to explain one statistical method/test used in their article. We would like to standardize the critical appraisal aspect of our EBM Finale. We are considering having each team of students complete an appraisal worksheet, as appropriate for their chosen article.

Objectives: Aspirin is recommended for cardiovascular disease (CVD) prevention in patients who are at high risk for CVD. The objective of this study was to compare agreement between two American Diabetes Association-endorsed CVD risk calculators in identifying candidates for aspirin therapy.Methods: Adult patients with diabetes mellitus (n = 238) were studied for 1 year in a family medicine clinic. Risk scores were calculated based on the United Kingdom Prospective Diabetes Study Risk Engine and the Atherosclerosis Risk in Communities Coronary Heart Disease Risk Calculator. Analyses included chi(2), kappa scores, and logistic regressions.Results: The Atherosclerosis Risk in Communities Coronary Heart Disease Risk Calculator identified 50.4% of patients as high risk versus 23.5% by the United Kingdom Prospective Diabetes Study Risk Engine. kappa score for agreement identifying high-risk status was 0.3642. Among patients at high risk, African Americans (odds ratio [OR] 0.45, 95% confidence interval [CI] 0.24-0.86) and those with uncontrolled diabetes (OR 0.30, 95% CI 0.16-0.56) had lower odds of disagreement, whereas nonsmokers had higher odds (OR 2.98, 95% CI 1.57-5.69). Among patients at low risk, women (OR 3.83, 95% CI 1.64-8.91), African Americans (OR 5.96, 95% CI 3.07-11.59), and those with high high-density lipoprotein (OR 2.82, 95% CI 1.48-5.37) showed greater odds of disagreement.Conclusions: Improved risk assessment methods are needed to identify patients with diabetes mellitus who benefit from aspirin for the primary prevention of CVD. Prospective trials are needed to provide additional evidence for aspirin use in this population.

Objectives To evaluate in a large, nationally representative cohort the association between high serum transferrin saturation (TS) and hospital length of stay and mortality in older adults. Design Prospective cohort. Setting Longitudinal analyses of the Third National Health and Nutrition Examination Survey linked to Medicare claims from 1991 through 2006. Participants Medicare beneficiaries aged 65 and older at baseline. Measurements Transferrin saturation collected on each participant at baseline was characterized as <20.0%, 20.0% to 54.9%, and 55.0% and greater. Length of stay in the hospital and death in the hospital were primary outcomes. Analyses were adjusted for age, sex, race and ethnicity, education, and severity of illness. Results Individuals hospitalized during the study period (79.4%) with high (odds ratio (OR) = 2.54, 95% confidence interval (CI) = 1.056.12) or low (OR = 1.31, 95% CI = 1.071.62) TS had a significantly greater risk of death than those with moderate TS. Individuals with high TS had longer average length of stay per hospitalization (11.1 days, (standard error, SE 1.7 days), P = .01) than those with moderate TS (8.4 (0.3) days). Individuals with high TS also had more hospital days per year (8.6 (2.0) days, P = .04) than those with moderate TS (6.7 (0.5) days). Conclusion High TS is associated with longer length of stay and death in the hospital (unweighted N = 3,847, weighted N = 28,395,464).

Background: Hereditary hemochromatosis (HH) is a common genetic disease in the United States, but little is known about the diagnosis from the patient's perspective. The purpose of this study was to characterize the circumstances surrounding the diagnosis of HH and assess treatments and health information needs. Methods: We surveyed US adults aged 18 years and older who were diagnosed with HH after 1996. Response rate was 46%, with a total sample size of 979. Respondents were asked about the use of genetic and clinical markers in their diagnosis, current treatments, and health information needs. Results: Results were stratified by age, education, and income status. Total of 90.0% of women and 75.5% of men were genetically tested for HH (P < .01). Approximately half (52.5%) were diagnosed by a gastroenterologist, hematologist, or other specialty physician and half were diagnosed by a primary care provider. Most of the respondents thought their HH had improved with the initial treatment and most patients were still receiving treatment for HH. Patient interest in learning more about specific hemochromatosis topics was generally high. Conclusions: Since the introduction of genetic identification of HH, these tests have been used in the diagnosis of the majority of patients. Primary care physicians may need to be more aware HH and strategies for diagnosis.

PURPOSE:We examined perceptions of 10-year coronary heart disease (CHD) risk or likelihood of having undiagnosed diabetes or impaired fasting glucose (IFG) with actual risk in a community sample of Hispanic adults.METHODS:We conducted a survey of 183 Hispanic adults (> or =18 years) recruited at community events around Charleston, SC. Likelihood of having undiagnosed diabetes/IFG as well as 10-year CHD risk were calculated. Perceived risk was assessed with questions based on the Risk Perception Survey-Diabetes Mellitus.RESULTS:Over half of respondents (54.8%) underestimated their likelihood of undiagnosed diabetes/IFG and 14.8% underestimated their 10-year CHD risk. Older and overweight respondents were more likely to underestimate their likelihood of undiagnosed diabetes/IFG. Respondents with family history of diabetes were the least likely to underestimate their likelihood of current undiagnosed diabetes/IFG. Respondents with diagnosed hypertension, diabetes, high cholesterol or a family history of heart attack were more likely to underestimate their 10-year CHD risk. Men were more likely to underestimate their risk for diabetes/IFG and CHD risk.CONCLUSIONS:Health education to improve accurate risk perception could improve health promotion for this population.

BACKGROUND Physician counseling is effective in promoting healthy behavior. We evaluated whether patient reports of physician acknowledgment of overweight patients' weight status are associated with the patients' perceptions of their own weight and desire to lose weight. METHODS We analyzed the 2005-2008 National Health and Nutrition Examination Survey data on adults aged 20 to 64 years with a body mass index (BMI) of at least 25.0 (calculated as weight in kilograms divided by height in meters squared). Logistic regressions were computed to evaluate the impact of reports of physician acknowledgment of patients' weight status on patients' perceptions of their weight, desire to weigh less, and attempts to lose weight. RESULTS In logistic regressions controlling for relevant confounding variables, participants with a BMI of 25 or greater (odds ratio [OR], 6.11; 95% confidence interval [CI], 4.38-8.53) and those with a BMI of 30 or greater (OR, 7.58; 95% CI, 5.83-9.84) both had an increased likelihood to perceive themselves as overweight if they were told by their physician that they were overweight. Similarly, participants with a BMI of 25 or greater (OR, 2.51; 95% CI, 2.15-2.94) and those with a BMI of 30 or greater (OR, 2.24; 95% CI, 1.74-2.88) had an increased likelihood to have attempted to lose weight in the previous 12 months if they had reported being told they were overweight. However, only 45.2% of individuals with a BMI of 25 or greater and 66.4% of those with a BMI of 30 or greater reported being told by a physician that they were overweight. CONCLUSION Among patients who were overweight or obese, patient reports of being told by a physician that they were overweight were associated with more realistic perceptions of the patients' own weight, desire to lose weight, and recent attempts to lose weight.

PURPOSE Some studies suggest proprietary (for-profit) hospitals are maximizing financial margins from patient care by limiting therapies or decreasing length of stay for uninsured patients. This study examines the role of insurance related to length of stay once the patient is in the hospital and risk for mortality, particularly in a for-profit environment.METHODS We undertook an analysis of hospitalizations in the National Hospital Discharge Survey (NHDS) of the 5-year period of 2003 to 2007 for patients aged 18 to 64 years (unweighted n = 849,866; weighted n = 90 million). The analysis included those who were hospitalized with both ambulatory care sensitive conditions (ACSs), hospitalizations considered to be preventable, and non-ACSCs. We analyzed the transformed mean length of stay between individuals who had Medicaid or all other insurance types while hospitalized and those who were hospitalized without insurance. This analysis was stratified by hospital ownership. We also examined the relationship between in-hospital mortality and insurance status.RESULTS After controlling for comorbidities; age, sex, and race/ethnicity; and hospitalizations with either an ACSC or non-ACSC diagnosis, patients without insurance tended to have a significantly shorter length of stay. Across all hospital types, the mean length of stay for ACSCs was significantly shorter for individuals without insurance (2.77 days) than for those with either private insurance (2.89 days, P = .04) or Medicaid (3.19, P < .01). Among hospitalizations for ACSCs, in-hospital mortality rate for individuals with either private insurance or Medicaid was not significantly different from the mortality rate for those without insurance.CONCLUSIONS Patients without insurance have shorter lengths of stay for both ACSCs and non-ACSCs. Future research should examine whether patients without insurance are being discharged prematurely.

Iron overload is associated with significant morbidity and mortality yet is easily treated. The objective of this study was to create a tool that could be easily adapted to clinical practice that indicates the likelihood of a patient having undetected iron overload. We used the National Health and Nutrition Examination Survey (NHANES) 1999-2002 for US adults aged 20 years and older to build a model (unweighted n=8,779). We chose potential variables for inclusion that could be gathered by self-report or measured without laboratory data and were suggested by past literature on hemochromatosis and iron overload. We computed logistic regressions to create the scores by initially evaluating the variables' relationship with elevated ferritin and elevated transferrin saturation and then using odds ratios to correspond to scores. The resulting score on the IRon Overload ScreeNing Tool (IRON) was then validated with data on 13,844 adults in the NHANES III, 1988-94. Predictors in the final tool were age, gender, previous diagnoses of liver condition, osteoporosis or thyroid disease. The IRON score yielded an area under the curve (AUC) in the NHANES 1999-02 of 0.720 and an AUC of 0.685 in the NHANES III validation sample. The IRON score is a tool to assist in identification of patients with iron overload that has several qualities that make it attractive for use in clinical practice with an undifferentiated patient population including brevity, easily collected information and predictive ability comparable to other tools that help in directing screening.

Background. - Cardiovascular risk is associated with prediabetes states. Ethnic differences in risks related to prediabetes have not been well studied. The purpose of this study was to examine the relationship between prediabetes and the presence of target-organ disease in terms of ethnic differences.Methods. - Cross-sectional analysis of the Multi-Ethnic Study of Atherosclerosis (MESA) involved a prospective cohort of 6814 participants aged 45-84 years in the US, including Black, white and hispanic subjects from an initial examination in 2000 with no known history of heart attack, stroke or diabetes. Main outcomes were comparisons of markers for coronary artery calcification (CAC), carotid stenosis more than 25%, Ankle Brachial Index (ABI) less than 1.0 and presence of protein in urine (>30 mg/g) between participants with normal fasting glucose (NFG) and impaired fasting glucose (IFG), and between ethnic groups with prediabetes/IFG.Results. - There were 2457 white, 1548 black and 1229 Hispanic participants. After adjustments, there were no differences for each outcome between normal and prediabetes black and Hispanic subjects, whereas white participants with prediabetes had significantly higher odds of carotid stenosis (OR: 1.50), low ABI (OR: 1.77) and albuminuria (OR: 1.66) compared with whites with NEG. When comparing those with IFG/prediabetes by ethnicity, blacks and Hispanics had less CAC and carotid stenosis. In addition, Hispanics had lower reduced ABIs (OR: 0.35,95% Cl 0.19-0.65) compared with whites with IFG.Conclusion. - Prediabetes is related to the presence of several indicators of end-organ damage in white subjects, but not in blacks or Hispanics. Further longitudinal investigations into disease risks related to prediabetes in different ethnic groups are also needed. (C) 2011 Elsevier Masson SAS. All rights reserved.

Background: It is suggested that targeted screening for hemochromatosis and iron overload may be worthwhile. The aim of this study was to examine uric acid as a potential indicator of the presence of iron overload. Methods: We analyzed adults aged 20 and older in the National Health and Nutrition Examination Survey 1999 to 2002. We computed logistic regressions controlling for age, sex, race/ethnicity, liver or kidney condition, and alcohol use to see the relationship between combinations of uric acid and ferritin with the outcomes of elevated liver enzymes and proteinuria. Results: In unadjusted analyses, 20.7% of individuals with high uric acid had high ferritin levels versus 8.8% of individuals with low uric acid levels (P < .001). Individuals with both elevated uric acid and elevated ferritin levels had significantly higher liver enzymes than individuals with either elevated uric acid or ferritin. With low uric acid and low ferritin as the reference category, individuals with high uric acid and high ferritin were significantly more likely to also have proteinuria (odds ratio, 2.66; 95% CI, 1.82–3.91). Conclusions: Elevated levels of uric acid is associated with elevated ferritin levels and may serve as a risk stratification variable for presence of iron overload and hemochromatosis.