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1.  The Burden of Influenza in Young Children, 2004–2009 
Pediatrics  2013;131(2):207-216.
OBJECTIVE:
To characterize the health care burden of influenza from 2004 through 2009, years when influenza vaccine recommendations were expanded to all children aged ≥6 months.
METHODS:
Population-based surveillance for laboratory-confirmed influenza was performed among children aged <5 years presenting with fever and/or acute respiratory illness to inpatient and outpatient settings during 5 influenza seasons in 3 US counties. Enrolled children had nasal/throat swabs tested for influenza by reverse transcriptase-polymerase chain reaction and their medical records reviewed. Rates of influenza hospitalizations per 1000 population and proportions of outpatients (emergency department and clinic) with influenza were computed.
RESULTS:
The study population comprised 2970, 2698, and 2920 children from inpatient, emergency department, and clinic settings, respectively. The single-season influenza hospitalization rates were 0.4 to 1.0 per 1000 children aged <5 years and highest for infants <6 months. The proportion of outpatient children with influenza ranged from 10% to 25% annually. Among children hospitalized with influenza, 58% had physician-ordered influenza testing, 35% had discharge diagnoses of influenza, and 2% received antiviral medication. Among outpatients with influenza, 7% were tested for influenza, 7% were diagnosed with influenza, and <1% had antiviral treatment. Throughout the 5 study seasons, <45% of influenza-negative children ≥6 months were fully vaccinated against influenza.
CONCLUSIONS:
Despite expanded vaccination recommendations, many children are insufficiently vaccinated, and substantial influenza burden remains. Antiviral use was low. Future studies need to evaluate trends in use of vaccine and antiviral agents and their impact on disease burden and identify strategies to prevent influenza in young infants.
doi:10.1542/peds.2012-1255
PMCID: PMC3557405  PMID: 23296444
influenza; epidemiology; influenza vaccine; hospitalization; ambulatory care
2.  Sickle Cell Trait, Hemoglobin C Trait and Invasive Pneumococcal Disease 
Epidemiology (Cambridge, Mass.)  2010;21(3):10.1097/EDE.0b013e3181d61af8.
Background
The cause of historically higher rates of invasive pneumococcal disease among blacks than whites has remained unknown. We tested the hypothesis that sickle cell trait or hemoglobin C trait is an independent risk factor for invasive pneumococcal disease.
Methods
Eligible children were born in Tennessee (1996–2003), had a newborn screen, enrolled in TennCare aged <1 year, and resided in a Tennessee county with laboratory-confirmed, pneumococcal surveillance. Race/ethnicity was ascertained from birth certificates. Children were followed through 2005 until loss of enrollment, pneumococcal disease episode, 5th birthday or death. We calculated incidence rates by race/ethnicity and hemoglobin type before and after pneumococcal conjugate vaccine (PCV7) introduction. Poisson regression analyses compared IPD rates among blacks with sickle cell trait or hemoglobin C trait to whites and blacks with normal hemoglobin, controlling for age, gender, time (pre-PCV7, transition year or post-PCV7) and high-risk conditions (i.e. heart disease).
Results
Over 10 years, 415 invasive pneumococcal disease episodes occurred during 451,594 observed child-years. Before PCV7 introduction, disease rates/100,000 child-years were 2941 for blacks with sickle cell disease, 258 for blacks with sickle cell trait or hemoglobin C trait and 188, 172, and 125 for blacks, whites, and Hispanics with normal hemoglobin. Post-PCV7, rates declined for all groups. Blacks with sickle cell trait or hemoglobin C trait had 77% (95% CI 22%–155%) and 42% (95% CI 1%–100%) higher rates than whites and blacks with normal hemoglobin.
Conclusion
Black children with sickle cell trait or hemoglobin C trait have an increased risk of invasive pneumococcal disease.
doi:10.1097/EDE.0b013e3181d61af8
PMCID: PMC3881008  PMID: 20220521
3.  Bivariate mixture modeling of transferrin saturation and serum ferritin concentration in Asians, African Americans, Hispanics, and whites in the Hemochromatosis and Iron Overload Screening (HEIRS) Study 
Bivariate mixture modeling was used to analyze joint population distributions of transferrin saturation (TS) and serum ferritin concentration (SF) measured in the Hemochromatosis and Iron Overload Screening (HEIRS) Study. Four components (C1, C2, C3, and C4) with successively age-adjusted increasing means for TS and SF were identified in data from 26,832 African Americans, 12,620 Asians, 12,264 Hispanics, and 43,254 whites. The largest component, C2, had normal mean TS (21% to 26% for women, 29% to 30% for men) and SF (43–82 μg/L for women, 165–242 μg/L for men), which consisted of component proportions greater than 0.59 for women and greater than 0.68 for men. C3 and C4 had progressively greater mean values for TS and SF with progressively lesser component proportions. C1 had mean TS values less than 16% for women (<20% for men) and SF values less than 28 μg/L for women (<47 μg/L for men). Compared with C2, adjusted odds of iron deficiency were significantly greater in C1 (14.9–47.5 for women, 60.6–3530 for men), adjusted odds of liver disease were significantly greater in C3 and C4 for African-American women and all men, and adjusted odds of any HFE mutation were increased in C3 (1.4–1.8 for women, 1.2–1.9 for men) and in C4 for Hispanic and white women (1.5 and 5.2, respectively) and men (2.8 and 4.7, respectively). Joint mixture modeling identifies a component with lesser SF and TS at risk for iron deficiency and 2 components with greater SF and TS at risk for liver disease or HFE mutations. This approach can identify populations in which hereditary or acquired factors influence metabolism measurement.
doi:10.1016/j.trsl.2007.10.002
PMCID: PMC3785302  PMID: 18201677
4.  Accuracy of Family History of Hemochromatosis or Iron Overload: The Hemochromatosis and Iron Overload Screening Study 
Background & Aims
The aim of this study was to assess the analytic validity of self-reported family history of hemochromatosis or iron overload.
Methods
A total of 141 probands, 549 family members, and 641 controls participated in the primary care Hemochromatosis and Iron Overload Screening Study. Participants received a postscreening clinical examination and completed questionnaires about personal and family histories of hemochromatosis or iron overload, arthritis, diabetes, liver disease, and heart disease. We evaluated sensitivities and specificities of proband-reported family history, and concordance of HFE genotype C282Y/C282Y in probands and siblings who reported having hemochromatosis or iron overload.
Results
The sensitivities of proband-reported family history ranged from 81.4% for hemochromatosis or iron overload to 18.4% for liver disease; specificities for diabetes, liver disease, and heart disease were greater than 94%. Hemochromatosis or iron overload was associated with a positive family history across all racial/ethnic groups in the study (odds ratio, 14.53; 95% confidence intervals, 7.41–28.49; P < .0001) and among Caucasians (odds ratio, 16.98; 95% confidence intervals, 7.53–38.32; P < .0001). There was 100% concordance of HFE genotype C282Y/C282Y in 6 probands and 8 of their siblings who reported having hemochromatosis or iron overload.
Conclusions
Self-reported family history of hemochromatosis or iron overload can be used to identify individuals whose risk of hemochromatosis or iron overload and associated conditions is increased. These individuals could benefit from further evaluation with iron phenotyping and HFE mutation analysis.
doi:10.1016/j.cgh.2008.04.003
PMCID: PMC3779058  PMID: 18585964
5.  New triggers and non-motor findings in a family with rapid-onset dystonia-parkinsonism 
Parkinsonism & related disorders  2012;18(6):737-741.
Background
A woman from Italy presented with dystonic leg symptoms at the age of 59. Rapid-onset dystonia-parkinsonism (RDP) was not suspected until 3 affected children (2 male, 1 female) with presentations consistent with the disorder were recognized.
Methods
The mother and four of her children (3 with and 1 without dystonia) were evaluated with an extensive battery including standardized history questionnaire and rating scales. In addition, all four children had cognitive testing and three of the four children had psychiatric interviews.
Results
In this family, a T613M mutation in the ATP1A3 gene was confirmed, the most common mutation present in patients with RDP. The proband's limb dystonia was atypical of RDP, symptoms of the others affected included dysarthria, asymmetric limb dystonia, and dysphagia more consistent with RDP. The two sons developed dystonia-parkinsonism in adolescence after consuming large amounts of alcohol. All 3 of those with psychiatric interviews reached diagnosable thresholds for mood disorder (bipolar or dysthymia) and some form of anxiety disorder.
Conclusions
The phenotype and age of onset is broader than previously reported in RDP, suggesting that it could be under-reported. Prior to this study, neuropsychologic symptoms associated with RDP were under-appreciated. Those patients who are at risk or suspected of having RDP should be cautioned to avoid excessive alcohol intake. Further study is needed to assess if the cognitive and psychiatric features are part of a broader RDP phenotype and this may have implications for future research into genetic susceptibility for psychiatric disease.
doi:10.1016/j.parkreldis.2012.03.020
PMCID: PMC3753404  PMID: 22534615
Dystonia; RDP; DYT-12; Rapid-onset dystonia-parkinsonism
6.  Potential Impact of Parental Tdap Immunization on Infant Pertussis Hospitalizations 
Vaccine  2012;30(37):5527-5532.
We estimated the potential impact of parental Tdap immunization before delivery, at delivery and at the 2-week newborn visit on U.S. infant pertussis hospitalizations. We used published data for pertussis hospitalization rates among U.S. infants aged 0–4 months, the Tdap vaccine efficacy in adults, and the proportion of infants with pertussis <6 months of age in which either parent was the source (16%–40% from mothers and 16%–20% from fathers). Immunizing parents before pregnancy or ≥2 weeks prior to delivery should reduce pertussis hospitalizations among infants 0–4 months by 2694–9314 if both parents are vaccinated, and by 1347–6909 if only mothers are vaccinated. Greater reductions in pertussis hospitalizations would be achieved if parents are immunized ≥2 weeks prior to delivery than after delivery or the 2-week newborn visit. Although immunizing parents prior to pregnancy or delivery is best, immunizing parents in the postpartum period should provide protection to that newborn and to infants of subsequent pregnancies.
doi:10.1016/j.vaccine.2012.06.047
PMCID: PMC3407342  PMID: 22749592
Bordetella pertussis; parental immunization; Tdap; cocooning
7.  Association of ferroportin Q248H polymorphism with elevated levels of serum ferritin in African-Americans in the Hemochromatosis and Iron Overload Screening (HEIRS) Study 
Blood cells, molecules & diseases  2007;38(3):247-252.
The ferroportin (FPN1) Q248H polymorphism has been associated with increased serum ferritin (SF) levels in sub-Saharan Africans and in African Americans (AA). AA participants of the HEIRS Study who did not have HFE C282Y or H63D who had elevated initial screening SF (≥300 μg/L in men and ≥200 μg/L in women) (defined as cases) were frequency-matched to AA participants with normal SF (defined as controls) to investigate the association of the Q248H with elevated SF. 10.4% of cases and 6.7% of controls were Q248H heterozygotes (P = 0.257). Q248H homozygosity was observed in 0.5% of the cases and none of the controls. The frequency of Q248H was higher among men with elevated SF than among control men (P = 0.047); corresponding differences were not observed among women. This appeared to be unrelated to self-reports of a previous diagnosis of liver disease. Men with elevated SF were three times more likely than women with elevated SF to have Q248H (P = 0.012). There were no significant differences in Q248H frequencies in men and women control participants. We conclude that the frequency of the FPN1 Q248H polymorphism is greater in AA men with elevated SF than in those with normal SF.
doi:10.1016/j.bcmd.2006.12.002
PMCID: PMC3727273  PMID: 17276706
genetics; mutation; transferrin saturation
8.  The Association of Health and Functional Status with Private and Public Religious Practice among Rural, Ethnically Diverse Older Adults with Diabetes 
Purpose
This analysis describes the association of health and functional status with private and public religious practice among ethnically diverse (African American, Native American, white) rural older adults with diabetes.
Methods
Data were collected using a population-based, cross-sectional, stratified, random sample survey of 701 community-dwelling elders with diabetes in two rural North Carolina counties. Outcome measures were private religious practice, church attendance, religious support provided, and religious support received. Correlates included religiosity, health and functional status, and personal characteristics. Statistical significance was assessed using multiple linear regression and logistic regression models.
Findings
These rural elders had high levels of religious belief, and private and public religious practice. Religiosity was associated with private and public religious practice. Health and functional status were not associated with private religious practice, but they were associated with public religious practice, such that those with limited functional status participated less in public religious practice. Ethnicity was associated with private religious practice: African Americans had higher levels of private religious practice than Native Americans or whites, while Native Americans had higher levels than whites.
Conclusions
Variation in private religious practice among rural older adults is related to personal characteristics and religiosity, while public religious practice is related to physical health, functional status and religiosity. Declining health may affect the social integration of rural older adults by limiting their ability to participate in a dominant social institution.
doi:10.1111/j.1748-0361.2007.00097.x
PMCID: PMC3653177  PMID: 17565525
rural aging; minority aging; chronic disease; diabetes; religious participation; religiosity; social integration
9.  Potential Impact of Accelerating the Primary Dose of Rotavirus Vaccine in Infants 
Vaccine  2012;30(17):2738-2741.
We estimated the potential impact of administering the first dose of rotavirus vaccine at 6 weeks (42 days of life) instead of 2 months of age, which is permissible for all U.S. vaccines recommended at 2 months of age, on rotavirus hospitalization rates. We used published data for hospitalization rates, vaccine coverage, and vaccine efficacy after one dose and assumed a two-week delay in seroconversion after vaccine administration in the United States. Administering the first dose of rotavirus vaccine at 6 weeks instead of 8 weeks of age should have prevented 1110, 1660, and 2210 rotavirus hospitalizations among U.S. infants <3 months of age in 2006 when the vaccine was first introduced. This estimated benefit represents a 2%-4% reduction in rotavirus hospitalizations among children <5 years of age.
doi:10.1016/j.vaccine.2012.02.032
PMCID: PMC3312978  PMID: 22374373
rotavirus vaccine; infants; rotavirus; hospitalizations; prevention; epidemiology
10.  Assessment of Parental Report for 2009–2010 Seasonal and Monovalent H1N1 Influenza Vaccines among Children in the Emergency Department or Hospital 
Academic Pediatrics  2011;12(1):36-42.
Objective
To assess the validity of parental report for seasonal and monovalent H1N1 influenza vaccinations among children 6 months-<18 years who were recommended to receive both vaccines in 2009–2010.
Methods
Children with fever or respiratory symptoms were prospectively enrolled in both emergency departments in Forsyth County, North Carolina and the only pediatric hospital in the region. Enrollment occurred from September 1, 2009 through April 12, 2010, during the H1N1 influenza pandemic. A parental questionnaire was administered by trained interviewers to ascertain the status of seasonal and monovalent H1N1 influenza vaccines. Parental report was compared to that documented in the medical record and/or the North Carolina immunization registry.
Results
Among 297 enrolled children 6 months -<18 years of age, 174 (59%) were 6 months-4 years, 67 (23%) were 5–8 years and 56 (19%) were 9-<18 years. Parents reported that 140 (47%) children had received ≥1 dose of 2009–2010 influenza vaccine-- 128 (43%) for seasonal vaccine and 63 (21%) for H1N1 vaccine. Confirmed vaccination data indicated that 156 (53%) children had received ≥1 dose of any 2009–2010 vaccine—120 (40%) for seasonal vaccine and 53 (18%) for H1N1 vaccine.
Parental report of any seasonal influenza vaccination was 92% sensitive and 86% specific and had a kappa of 0.76. Parental report for any H1N1 influenza vaccination was 88% sensitive and 92% specific with a kappa of 0.71.
Conclusion
Parental report of 2009–2010 seasonal and monovalent H1N1 influenza vaccinations was sensitive and specific and had reasonable agreement with the medical record and/or immunization registry.
What’s New
During the 2009–2010 H1N1 pandemic when seasonal and monovalent H1N1 vaccines were recommended for all children, we found that parental report for both influenza vaccines among children aged 6 months-<18 years had reasonable sensitivity, specificity and validity as compared to the medical record and/or immunization registry.
doi:10.1016/j.acap.2011.08.006
PMCID: PMC3261370  PMID: 22033102
influenza vaccine; parental report; child; validity; accuracy; seasonal influenza vaccine; monovalent H1N1 influenza vaccine
11.  Impact of Maternal Immunization on Influenza Hospitalizations in Infants 
American journal of obstetrics and gynecology  2011;204(6 Suppl 1):S141-S148.
Objective
To determine whether maternal vaccination during pregnancy was associated with a reduced risk of laboratory-confirmed influenza hospitalizations in infants <6 months old.
Study Design
Active population-based, laboratory-confirmed influenza surveillance was conducted in children hospitalized with fever and/or respiratory symptoms in 3 U.S. counties from November-April during the 2002–2009 influenza seasons. The exposure, influenza vaccination during pregnancy, and the outcome, positive/negative influenza testing among their hospitalized infants, were compared using logistic regression analyses.
Results
Among 1510 hospitalized infants <6 months old, 151 (10%) had laboratory-confirmed influenza and 294 (19%) mothers reported receiving influenza vaccine during pregnancy. Eighteen (12%) mothers of influenza-positive infants and 276 (20%) mothers of influenza-negative infants were vaccinated (unadjusted OR= 0.53, 95%CI 0.32–0.88 and adjusted OR=0.52, 95%0.30–0.91).
Conclusion
Infants of vaccinated mothers were 45%–48% less likely to have influenza hospitalizations than infants of unvaccinated mothers. Our results support the current influenza vaccination recommendation for pregnant women.
doi:10.1016/j.ajog.2011.02.042
PMCID: PMC3111909  PMID: 21492825
infants; influenza hospitalization; influenza vaccine; maternal vaccination; vaccine effectiveness
12.  A Meta-Analysis and Genome-Wide Association Study of Platelet Count and Mean Platelet Volume in African Americans 
PLoS Genetics  2012;8(3):e1002491.
Several genetic variants associated with platelet count and mean platelet volume (MPV) were recently reported in people of European ancestry. In this meta-analysis of 7 genome-wide association studies (GWAS) enrolling African Americans, our aim was to identify novel genetic variants associated with platelet count and MPV. For all cohorts, GWAS analysis was performed using additive models after adjusting for age, sex, and population stratification. For both platelet phenotypes, meta-analyses were conducted using inverse-variance weighted fixed-effect models. Platelet aggregation assays in whole blood were performed in the participants of the GeneSTAR cohort. Genetic variants in ten independent regions were associated with platelet count (N = 16,388) with p<5×10−8 of which 5 have not been associated with platelet count in previous GWAS. The novel genetic variants associated with platelet count were in the following regions (the most significant SNP, closest gene, and p-value): 6p22 (rs12526480, LRRC16A, p = 9.1×10−9), 7q11 (rs13236689, CD36, p = 2.8×10−9), 10q21 (rs7896518, JMJD1C, p = 2.3×10−12), 11q13 (rs477895, BAD, p = 4.9×10−8), and 20q13 (rs151361, SLMO2, p = 9.4×10−9). Three of these loci (10q21, 11q13, and 20q13) were replicated in European Americans (N = 14,909) and one (11q13) in Hispanic Americans (N = 3,462). For MPV (N = 4,531), genetic variants in 3 regions were significant at p<5×10−8, two of which were also associated with platelet count. Previously reported regions that were also significant in this study were 6p21, 6q23, 7q22, 12q24, and 19p13 for platelet count and 7q22, 17q11, and 19p13 for MPV. The most significant SNP in 1 region was also associated with ADP-induced maximal platelet aggregation in whole blood (12q24). Thus through a meta-analysis of GWAS enrolling African Americans, we have identified 5 novel regions associated with platelet count of which 3 were replicated in other ethnic groups. In addition, we also found one region associated with platelet aggregation that may play a potential role in atherothrombosis.
Author Summary
The majority of the variation in platelet count and mean platelet volume between individuals is heritable. We performed genome-wide association studies in more than 16,000 African American participants from seven population-based cohorts to identify genetic variants that correlate with variation in platelet count and mean platelet volume. We observed statistically significant evidence (p-value<5×10−8) that 10 genomic regions were associated with platelet count and 3 were associated with mean platelet volume. Of the regions that were significantly associated, we found 5 novel regions that were not reported previously in other populations. Three of these 5 regions were also associated with platelet count in European Americans and Hispanic Americans. All these regions contain genes that are either known to have or potentially may have a role in determining platelet count and/or mean platelet volume. We further found that one of these regions was also associated with agonist-induced platelet aggregation. Further studies will determine the exact role played by these genomic regions in platelet biology. The knowledge generated by this and other studies will not only help us better understand platelet biology but can also lead us to the discovery of new anti-platelet drugs.
doi:10.1371/journal.pgen.1002491
PMCID: PMC3299192  PMID: 22423221
13.  Reducing Farmworker Residential Pesticide Exposure: Evaluation of a Lay Health Advisor Intervention 
Health promotion practice  2008;10(3):447-455.
The goal of this analysis is to evaluate the effectiveness of a promotora program for teaching women in Latino farmworker families about pesticide safety and increasing pesticide safety behaviors. Volunteer promotoras delivered a pesticide safety curriculum (intervention) and nutrition curriculum (control) to farmworker women residing in western North Carolina and Virginia. Pre- and post-intervention interviews assessed differences in delivery of the intervention, recognition of the intervention, pesticide knowledge, pesticide exposures behaviors, and integrated pest management behaviors. Participants in the intervention group reported significantly more receipt of pesticide education and greater recognition of the key messages. However, their knowledge, pesticide exposure behaviors, and integrated pest management behaviors did not change. A more structured program is needed to be sure that the dose of interventions is large enough to overcome educational and cultural characteristics of immigrant communities. Policy changes are needed to address circumstances outside of farmworkers’ control that affect pesticide exposure.
doi:10.1177/1524839907301409
PMCID: PMC3088730  PMID: 18287581
14.  Screening for iron overload: Lessons from the HEmochromatosis and IRon Overload Screening (HEIRS) Study 
BACKGROUND:
The HEmochromatosis and IRon Overload Screening (HEIRS) Study provided data on a racially, ethnically and geographically diverse cohort of participants in North America screened from primary care populations.
METHODS:
A total of 101,168 participants were screened by testing for HFE C282Y and H63D mutations, and measuring serum ferritin concentration and transferrin saturation. In the present review, lessons from the HEIRS Study are highlighted in the context of the principles of screening for a medical disease as previously outlined by the World Health Organization.
RESULTS:
Genetic testing is well accepted, with minimal risk of discrimination. Transferrin saturation has high biological variability and relatively low sensitivity to detect HFE C282Y homozygotes, which limits its role as a screening test. Symptoms attributable to HFE C282Y homozygosity are no more common in individuals identified by population screening than in control subjects.
CONCLUSIONS:
Generalized population screening in a primary care population as performed in the HEIRS Study is not recommended. There may be a role for focused screening in Caucasian men, with some debate regarding genotyping followed by phenotyping, or phenotyping followed by genotyping.
PMCID: PMC2777090  PMID: 19893773
Haemochromatosis; Hemochromatosis; HFE; Iron overload
15.  Dietary Fat Reduction Behaviors among African American, American Indian, and White Older Adults with Diabetes 
Dietary self-management of diabetes is often difficult for older adults to practice, particularly in rural communities. We describe patterns and correlates of dietary fat reduction among older rural adults with diabetes of any type. In-home interviews were conducted with a multiethnic random sample of 701 adults ≥65 with diabetes from two North Carolina counties. The Fat and Fiber Behavior Questionnaire was used to measure dietary behaviors. Separate multiple linear regressions assessed effects of gender, ethnicity, and diabetes education. In general, scores were more favorable for practices that involved modifying food preparation (e.g., avoiding frying) and less favorable for practices that involved changing foods consumed (e.g., substituting fruits and vegetables as desserts or snacks). American Indians and African Americans had less favorable scores than whites, and diabetes education was associated with greater fat restriction for women than men. Older men and ethnic minorities with diabetes should be targeted for dietary change education.
doi:10.1080/01639360902950158
PMCID: PMC2854545  PMID: 20396599
diabetes; African Americans; American Indians; gender differences; diet; self-management
16.  Clinical manifestations of hemochromatosis in HFE C282Y homozygotes identified by screening 
BACKGROUND:
Patients with hemochromatosis may suffer organ damage from iron overload, often with serious clinical consequences.
OBJECTIVE:
To assess prevalences of self-reported symptoms and clinical signs and conditions in persons homozygous for the hemochromatosis gene (HFE) mutation (C282Y) identified by screening.
METHODS:
Participants were adults 25 years of age or older enrolled in the Hemochromatosis and Iron Overload Screening (HEIRS) Study. C282Y homozygotes (n=282) were compared with control participants without the HFE C282Y or H63D alleles (ie, wild type/wild type; n=364).
RESULTS:
Previously diagnosed C282Y homozygotes and newly diagnosed homozygotes with elevated serum ferritin levels had higher prevalences of certain symptoms such as chronic fatigue (OR 2.8; 95% CI 1.34 to 5.95, and OR 2.0; 95% CI 1.07 to 3.75, respectively), and had more hyperpigmentation on physical examination (OR 4.7; 95% CI 1.50 to 15.06, and OR 3.7; 95% CI 1.10 to 12.16, respectively) and swelling or tenderness of the second and third metacarpophalangeal joints (OR 4.2; 95% CI 1.37 to 13.03, and OR 3.3; 95% CI 1.17 to 9.49, respectively) than control subjects. Joint stiffness was also more common among newly diagnosed C282Y homozygotes with elevated serum ferritin than among control subjects (OR 2.7; 95% CI 1.38 to 5.30). However, the sex- and age-adjusted prevalences of self-reported symptoms and signs of liver disease, heart disease, diabetes and most other major clinical manifestations of hemochromatosis were similar in C282Y homozygotes and control subjects.
CONCLUSIONS:
Some symptoms and conditions associated with hemochromatosis were more prevalent among C282Y homozygotes identified by screening than among control subjects, but prevalences of most outcomes were similar in C282Y homozygotes and controls in this primary care-based study.
PMCID: PMC2661195  PMID: 19018338
Complications; Cross-sectional study; Hemochromatosis; HFE; Iron overload; Prevalence
17.  Complementary and Alternative Medicine Use and Diabetes Self-Management Among Rural Older Adults 
Complementary and alternative medicine (CAM) is a growing form of self-care and is related to other healthy behaviors. This study examines the relationship between CAM use and diabetes self-management. A survey of rural older African American, Native American, and White adults with diabetes was conducted. Data were collected on diabetes self-management domains and general and diabetes-specific CAM use. Some associations were observed, particularly for CAM use and following a healthy eating plan. CAM is part of the health maintenance strategy of rural older adults with diabetes. Further research should examine the health trajectory associated with CAM use in this population.
doi:10.1177/1533210106292461
PMCID: PMC2743492  PMID: 19756166
complementary and alternative medicine; diabetes mellitus; self-management; African Americans; Native Americans
18.  ETHNIC DISPARITIES IN HEALTH-RELATED QUALITY OF LIFE AMONG OLDER RURAL ADULTS WITH DIABETES 
Ethnicity & disease  2007;17(3):471-476.
Diabetes mellitus disproportionately affects ethnic minorities and has serious economic, social, and personal implications. This study examines the effect of diabetes disease burden and social resources on health-related quality of life (HRQOL) among older rural adults with diabetes. Data come from a population-based cross-sectional survey of 701 adults (age ≥65 years) with diabetes in North Carolina from three ethnic groups: African American, Native American, and White. HRQOL was assessed using the 12-item short-form health survey (SF-12). Mean scores were 35.1 ± 11.4 and 50.5 ± 10.8 for the physical and mental components of the SF-12, respectively. In bivariate analyses, scores were significantly lower for Native Americans than Whites for both components. In multivariate analyses, higher physical HRQOL was associated with male sex, greater mobility ability, fewer chronic conditions, exercising vs not exercising, fewer depressive symptoms, and not receiving process assistance. Higher mental HRQOL was associated with greater mobility ability, fewer chronic conditions, and a high school education or more. Diabetes appears to have a substantial effect on physical HRQOL. Physical disability associated with diabetes may have a greater impact in the rural environment than in other areas. Aspects of rural social milieu may help to keep mental HRQOL high, even in the face of severe chronic disease. Ethnic differences in HRQOL are largely accounted for by diabetes disease burden and, to a lesser extent, social resources. Strategies to reduce diabetes-related complications (long term) and assist mobility (short term) may reduce ethnic disparities in HRQOL. (Ethn Dis. 2007;17:471–476)
PMCID: PMC2621317  PMID: 17985500
African Americans; Diabetes; Quality of Life; Native Americans; Rural; Minority Health
19.  Ethnic and Sex Differences in Ownership of Preventive Health Equipment Among Rural Older Adults With Diabetes 
Context
Diabetes self-management is important for achieving successful health outcomes. Different levels of self-management have been reported among various populations, though little is known about ownership of equipment that can enhance accomplishment of these tasks.
Purpose
This study examined diabetes self-management equipment ownership among rural older adults.
Methods
Participants included African American, American Indian, and white men and women 65 years of age and older. Data included equipment ownership overall and by ethnicity and sex across diabetes self-management domains (glucose monitoring, foot care, medication adherence, exercise, and diet). Associations between equipment ownership and demographic and health characteristics were assessed using logistic regression.
Findings
Equipment ownership ranged from 85.0% for blood glucose meters to less than 11% for special socks, modified dishes, and various forms of home exercise equipment. Equipment ownership was associated with ethnicity, living arrangements, mobility, poverty status, and formal education.
Conclusions
Rural older adults with diabetes are at risk because they lack equipment to perform some self-management tasks. Providers should be sensitive to and assist patients in overcoming this barrier.
doi:10.1111/j.1748-0361.2007.00111.x
PMCID: PMC2612629  PMID: 17868240
20.  Predictors of Falls in a Multiethnic Population of Older Rural Adults With Diabetes 
Background
Falls are a recognized danger for older adults with diabetes. Persons in rural communities with diabetes may face additional risks from falling due to environmental and activity differences.
Methods
Data were obtained in a cross-sectional survey of a stratified random sample of 691 community-dwelling adults (42.7% white, 31.4% African American, and 25.9% Native American) at least 65 years old with two or more Medicare claims for diabetes in 1998–2000, living in two rural counties in North Carolina. Falls data were self-reported for the previous year. Demographic data, foot-related symptoms, diabetes medications, and other health characteristics were reported.
Results
Three hundred two persons (43.7%) reported falling at least once, including 171 (26.2%) who experienced two or more (frequent) falls. Frequent fallers were more likely to be male (odds ratio [OR] = 1.76; 95% confidence interval [CI] = 1.17, 2.66), report tingling or numbness in feet (OR = 1.75; 95% CI = 1.13, 2.70), have had a stroke (OR = 1.81; 95% CI = 1.19, 2.76), have longer duration of diabetes (OR = 1.21; 95% CI = 1.00, 1.47), have lower physical functioning (OR = 0.97; 95% CI = 0.96, 0.99) and mobility (OR = 0.89; 95% CI = 0.82, 0.96), and take a greater number of prescription medications (OR = 1.07; 95% CI = 1.01, 1.13).
Conclusions
For rural older adults with diabetes, falls history should be screened to identify those at risk. Further research should investigate unique environmental factors contributing to falls for rural elderly persons.
PMCID: PMC1592639  PMID: 16611707
21.  Complementary and Alternative Medicine Use as Health Self-Management: Rural Older Adults With Diabetes 
Objectives
This study describes complementary and alternative medicine (CAM) use among rural older adults with diabetes, delineates the relationship of health self-management predictors to CAM therapy use, and furthers conceptual development of CAM use within a health self-management framework.
Methods
Survey interview data were collected from a random sample of 701 community dwelling African American, Native American, and White elders residing in two rural North Carolina counties. We summarize CAM use for general use and for diabetes care and use multiple logistic modeling to estimate the effects of health self-management predictors on use of CAM therapies.
Results
The majority of respondents used some form of CAM for general purpose, whereas far fewer used CAM for diabetes care. The most widely used CAM categories were food home remedies, other home remedies, and vitamins. The following health self-management predictors were related to the use of different categories of CAM therapies: personal characteristics (ethnicity), health status (number of health conditions), personal resources (education), and financial resources (economic status).
Discussion
CAM is a widely used component of health self-management among rural among older adults with diabetes. Research on CAM use will benefit from theory that considers the specific behavior and cognitive characteristics of CAM therapies.
PMCID: PMC1622916  PMID: 16497962
22.  Ethnic Disparities in Glycemic Control Among Rural Older Adults with Type 2 Diabetes 
Ethnicity & disease  2005;15(4):656-663.
Glycemic control is a predictor of diabetes-related morbidity and mortality. However, little is known about how well older adults in rural communities, with limited access to self-care resources and specialty care practitioners, control their diabetes. Even less is known about whether minority, older, rural adults are at increased risk for poor glycemic control. We analyzed data from a cross-sectional survey of randomly selected older (≥65 years) adults with type 2 diabetes in rural North Carolina. Participants (N=693) were men and women from three ethnic groups: African American, Native American, and White. Capillary blood samples were collected for HbA1C analysis. HbA1C levels (<7%, 7%–<8%, and ≥8%) were compared across ethnic and gender groups. Two multiple logistic regression models (model 1: personal characteristics; model 2: personal and health characteristics) were used to evaluate potential predictors of HbA1C ≥7%. Overall, 36.4% had HbA1C ≥7%. Native Americans and African-American men had the highest proportion at levels of poor glycemic control (≥7%), and African-American women and White men had the lowest. In bivariate analysis, ethnicity, living arrangements, use of medications for diabetes, having a diabetes-related healthcare visit in the past year, and duration of diabetes were significantly associated with glycemic control. In multivariate analysis (model 1), being Native American, having low income without Medicaid, and being married were associated with poor glycemic control. Adding health characteristics (model 2), longer diabetes duration and diabetes medication therapy were significant predictors. These data indicate that older ethnic minorities in rural communities are at increased risk for diabetes complications and need diabetes management strategies to improve glycemic control.
PMCID: PMC1780265  PMID: 16259490
African Americans; Elderly; Diabetes; Ethnicity; Glycosylated Hemoglobin; Health Disparities; Native Americans; Rural
23.  Self-monitoring of Blood Glucose in a Multiethnic Population of Rural Older Adults With Diabetes 
The Diabetes educator  2005;31(1):84-90.
Purpose
The purpose of the study was to describe self-monitoring of blood glucose (SMBG) practices of 698 older adults with type 2 diabetes in the rural Southeast, to identify characteristics differentiating testers from nontesters, and to identify personal and support-related predictors of monitoring frequency.
Methods
The ELDER (Evaluating Long-term Diabetes Self-management Among Elderly Rural Adults) study was a population-based, cross-sectional survey of African American, Native American, and white Medicare recipients ≥65 years with diagnosed diabetes. Data were obtained through in-home interviews. Multiple logistic regression models were used to identify factors associated with SMBG and frequency of monitoring.
Results
Seventy-seven percent of respondents practiced SMBG in the previous week; 40% tested every day in that week. No ethnic differences were seen. Significant independent predictors of any SMBG were medication regimen (taking oral agents or insulin with or without oral agents) and health care provider (HCP) recommendation to test. Among those monitoring, significant independent predictors of SMBG frequency were medication regimen, HCP recommendation to test, duration of diabetes, and receiving help with testing, which was negatively associated with monitoring frequency.
Conclusions
Among rural older persons with diabetes, HCP recommendation significantly affected practicing SMBG and SMBG frequency. These findings suggest points of intervention by diabetes educators with this vulnerable population. Further research is needed to determine how older adults use SMBG data in their self-care regimen.
PMCID: PMC1630682  PMID: 15779249
24.  Physical Activity Among Rural Older Adults With Diabetes 
Purpose
This analysis describes physical activity levels and factors associated with physical activity in an ethnically diverse (African American, Native American, white) sample of rural older adults with diabetes.
Method
Data were collected using a population-based, cross-sectional stratified random sample survey of 701 community-dwelling elders with diabetes completed in 2 rural North Carolina counties. Outcome measures were as follows: first, physical activity in the past year, and second, days physically active in the prior week (0-7). Potential correlates included personal and health characteristics and were evaluated for statistical significance using logistic regression models.
Findings
About half (52.5%) of the participants stated that they had engaged in physical activity in the past year. Among those, 42.5% stated that they had no days with at least 30 minutes of continuous physical activity in the prior week, while 21.5% reported daily physical activity. Common activities were walking and housework. Correlates of physical activity in the past year and days active in the prior week included measures of physical health and mobility.
Conclusions
Physical activity in this ethnically diverse sample of rural elders with diabetes is limited. Effort must be invested to increase physical activity in these groups.
doi:10.1111/j.1748-0361.2006.00026.x
PMCID: PMC1613260  PMID: 16606429
25.  Diabetes Foot Self-care Practices in a Rural, Triethnic Population 
The Diabetes educator  2005;31(1):75-83.
Purpose
The purposes of this study were to assess the level of foot self-care performed in a rural, multiethnic population of older adults and to identify factors associated with foot self-care.
Methods
The Evaluating Long-term Diabetes Self-management Among Elder Rural Adults study included a random sample of 701 African American, Native American, and white adults from 2 rural North Carolina counties. Participants completed in-home interviews, 5 foot self-care practices from the Summary of Diabetes Self-Care Activities (SDSCA), functional status measures, and measures of education and support for foot care.
Results
Foot care practices/behaviors reported at least 6 days/week ranged from 35.6% for inspecting shoes to 79.2% for not soaking feet. Four independent predictors of the SDSCA summary foot care index score were observed: having been shown how to care for feet (P < .0001), female gender (P = .03), having had a doctor check nerves in feet in past year (P = .02), and not receiving support caring for feet (P = .0425).
Conclusions
These findings indicate that educating patients about foot self-care may encourage routine foot care but that those dependent on either formal or informal support to perform foot care do so less frequently than those who perform it independently.
PMCID: PMC1613259  PMID: 15779248

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