Objective. Earlier we found black-white contrast in insulin levels in adolescents. The purpose of this study is to assess whether this difference is attributable to alterations in insulin secretion and/or clearance. Methods. Fasting circulating insulin and C-peptide concentrations were examined in 1157 adolescents aged 11 to 18 years from a biracial community. Fasting plasma C-peptide, C-peptide to insulin ratio, and glucose to insulin ratio were used as indices of insulin secretion, hepatic insulin clearance, and insulin sensitivity, respectively. Results. After adjusting several covariates (age, sexual maturation, and obesity), black adolescents had higher insulin levels (14.99 vs 12.66 µU/mL in girls). However, they had lower C-peptide levels than their white counterparts, indicating lower insulin secretion by pancreatic beta cells in black adolescents. Moreover, black adolescents had lower levels of C-peptide to insulin ratio than white adolescents (0.14 vs 0.17), suggesting reduced hepatic insulin clearance in black adolescents. In addition, significantly lower levels of glucose to insulin ratio in black girls suggest a reduced insulin sensitivity in this group. Further, differences in insulin levels between white and black girls disappeared after adjusting for differences in C-peptide to insulin ratio. Conclusion. These data suggest that elevated insulin levels observed in black adolescents, especially in black girls, may be attributed to their decreased hepatic insulin clearance, not hypersecretion of insulin.
Either spontaneous or induced delivery before a gestational age of 39 weeks is associated with an increased risk of adverse neonatal outcomes. A significant proportion of induced early-term (37–38 weeks) deliveries are elective and not medically indicated. There has been a national effort to reduce early-term deliveries through implementation of a policy limiting elective delivery before 39 weeks of gestation. After implementation of this policy, several studies reported initial success at shifting the timing of elective delivery at individual hospitals and large regions. However, the effect of this policy on neonatal outcomes has not been fully evaluated. This retrospective cohort study investigated the effectiveness of a new institutional policy limiting elective delivery before 39 weeks of gestation on obstetric practice and neonatal outcomes at a large regional medical center. Outcomes for term singleton deliveries were compared for a period 2 years before and 2 years after implementation of the new policy. Data on medical risk factors for outcomes of interest were obtained from electronic obstetrical records. The study cohort included 12,015 term singleton live births that occurred before implementation and 12,013 after implementation of the policy. The overall percentage of deliveries before 39 weeks of gestation was decreased from 33.1% before to 26.4% after implementation (P < 0.001); the greatest difference was found among women with induced labor and repeat cesarean delivery. After intervention, there was also a significant reduction in the proportion of term live-birth infants admitted to the neonatal intensive care unit: 1116 admissions (9.29%) before and 1027 (8.55%) after (P = 0.044). However, after implementation, there was an 11% increase in the adjusted odds of birth weight >4000 g (odds ratio, 1.11; 95% confidence interval, 1.01–1.22), as well as an increase in stillbirths at 37 and 38 weeks' gestation, from 2.5 to 9.1 per 10,000 term pregnancies (relative risk, 3.67; 95% confidence interval, 1.02–13.15, P = 0.032). These findings demonstrate that implementation of an institutional policy limiting elective delivery before 39 weeks of gestation is effective in changing the timing of term deliveries. However, examination of the data reveals an increase in the rate of macrosomia and stillbirth in contrast to the reduction in neonatal intensive care unit admissions after the intervention.
The association between microalbuminuria and blood pressure levels was examined in young white and black adults (n = 1131) aged 19 to 32 years. Urinary ratio of albumin (mg/L) to creatinine (mmol/L) was used as an estimation of urinary albumin excretion. Black men and women compared with their white counterparts had higher levels of blood pressure. Significantly positive correlations between urinary albumin excretion and systolic and diastolic blood pressures were observed in black men (r = 0.20 and r = 0.24, P <.01) and black women (r = 0.15 and r = 0.14, P <.05). Similar correlations of significance were not seen in the white counterparts. Systolic and diastolic blood pressure levels were significantly higher in normotensive black subjects (<140/90 mm Hg) with increased urinary albumin excretion (≥90th percentile) than in those without increased urinary albumin excretion. After accounting for potential confounding by age, sex, and body mass index, blacks in the uppermost systolic and diastolic blood pressure group were 7.1 times (95% CI, 2.0 to 25.8) and 4.8 times (1.3 to 18.3), respectively, as likely to have elevated albumin/creatinine excretion as those in the lowest group. In contrast, the likelihood for elevated albumin/creatinine excretion were 0.9 times (95% CI, 0.5 to 2.2) and 1.1 times (0.5 to 2.3), respectively, in whites, which were not significant. These data suggest that a stronger association between blood pressure levels and urinary albumin excretion exists in young blacks than in whites, which supports the notion that blacks may be more susceptible to renal damage from relatively low levels of blood pressure increases. These observations have implications for prevention of progressive target organ changes to early hypertension. Am J Hypertens 1994;7:794–800
Postpartum hemorrhage remains one of the most significant maternal complications of childbirth in the United States, with peripartum transfusion the most commonly identified morbidity.We completed a retrospective cohort study of women delivering at 20+ weeks at a large regional obstetric hospital between 2000 and 2008. Data were extracted from the institutional data warehouse; women with a potential coagulopathy were excluded. The association of maternal and obstetric factors with odds of transfusion was explored using univariate and multivariable logistic regression.We identified 59,282 deliveries and 614 cases of transfusion, an incidence rate of 10.4/1,000 deliveries. Rates were highest for black (14.1/1,000 deliveries) and lowest for white (8.4/1,000 deliveries) women. Increased odds of perinatal transfusion were seen for women with anemia at entry to labor and delivery (odds ratio [OR] 3.03, 95% confidence interval [CI] 2.43-3.79 for hemoglobin (Hgb) 9.5-10.5 g/dL; OR 12.65, 95% CI 10.35-15.46 for Hgb<9.5 g/dL) and those undergoing a cesarean delivery (OR 4.28, 95% CI 3.62-5.05). The excess risk associated with black race was eliminated after adjusting for anemia and other covariates. A synergistic effect of anemia with delivery method was observed. Anemia was estimated to account for 31.7% of transfusions.Potentially modifiable factors most strongly associated with risk for transfusion were antenatal anemia and cesarean delivery, and their co-occurrence was synergistic. Anemia is an easily identified and treatable risk factor and warrants focus as part of preconception and interconception care in childbearing women.
To assess whether circulating insulin is a major contributor to adverse lipid profiles during the transition from adolescence to young adulthood.
Methods:
The association between fasting insulin levels and serum lipid and lipoprotein levels was examined in a cross-sectional survey of 4136 young individuals aged 5 to 30 years from a biracial community.
Results:
Fasting insulin levels were strongly and positively correlated with serum triglyceride and very-low-density lipoprotein cholesterol levels and negatively correlated with high-density lipoprotein cholesterol levels in all age groups (5 to 11, 12 to 17, 19 to 24, and 25 to 30 years). An increasing impact of insulin level on low-density lipoprotein cholesterol level was observed in young adults aged 25 to 30 years. In multivariate analysis, fasting insulin level was associated with very-low-density lipoprotein cholesterol level for most of the age groups in both races independently of age, sex, glucose levels, obesity, cigarette smoking, and alcohol intake. The independent relationship to low-density lipoprotein cholesterol level persisted in young adults aged 25 to 30 years. The independent and negative association with high-density lipoprotein cholesterol level remained in whites aged 5 to 24 years and blacks aged 19 to 24 years. When individuals were divided into tertiles according to insulin concentration and subscapular skinfold thickness, the independent effect of insulin level and obesity on lipoprotein fractions was also noted. Furthermore, a stronger association of insulin level with lipoprotein fractions was observed in obese than in lean white males.
Conclusions:
These data indicate that an increasing association of insulin levels with adverse lipoprotein levels in young adults, especially obese individuals, may have adverse consequence for adult cardiovascular diseases. (Arch Intern Med. 1995;155:190-196)
Background: The role of aggressive diabetic management in the prevention of macrovascular complications remains unclear. This study of longitudinal electronic medical records (EMR) examines the ris...
Because of concerns for propagating clots into pulmonary emboli by the placement of pneumatic compression boots (PCBs), the standard of care at our institution was to perform a duplex Doppler ultrasound with compression (DUSC) before applying PCBs. We sought to determine the rate of asymptomatic preexisting deep vein thrombosis (DVT) in hospitalized patients who underwent DUSC before PCB.We evaluated consecutive patients who underwent lower extremity DUSC within 48 hours of admission. All patients were assessed for DVT risk factors using the American College of Chest Physicians' criteria (American College of Chest Physicians Conference on Antithrombotic/Thrombolytic Therapy: Evidence-Based Guidelines, 9th Edition). A t test, Wilcoxon rank sum test, and χ(2) or Fisher exact test were used to compare patients characteristics according to DVT status. Logistic regression was used to determine the importance of each risk factor on the risk of DVT.DUSC was performed during 1136 hospitalizations; 1071 patients were included in the dataset. Of those, 19 patients (1.8%) had asymptomatic DVT and had at least 1 risk factor; 16 (84.2%) had more than 1 risk factor. The only risk factors that were statistically significant were ambulatory dysfunction and thromboembolic disease history.Few patients have asymptomatic DVT upon admission; all of these patients have at least 1 predisposing risk factor. There appears to be no need for DUSC prior to initiation of PCBs. DUSC evaluation for DVT may be of value if there is a history of previous DVT, ambulatory dysfunction, or more than 3 risk factors, as the information may change therapeutic approaches.
Pregnancy-induced hypertension (PIH) plays a major role in the perinatal outcome for mother and neonate. With the rising prevalence of obesity, the role of prepregnancy body mass index (BMI) as an independent risk factor for PIH and a target for preconception care is important to explore.We completed a retrospective cohort study of 16,582 women who received obstetrical care at a regional medical center and delivered a singleton pregnancy between 2003 and 2006. Clinical data were derived from the electronic medical record. Logistic regression was used to explore the association of demographic characteristics and medical risk factors with the outcome of PIH.Diagnoses of chronic hypertension, prepregnancy diabetes, and gestational diabetes were more likely in women with increasing prepregnancy maternal BMI (p < 0.0001). The odds of PIH also increased with BMI, ranging from an odds ratio (OR) of 1.99 (95% confidence interval [CI] 1.73-2.31) for overweight women through OR 4.26 (95% CI 3.37-5.38) for those with a BMI of ≥40 kg/m(2). Other risk factors for PIH included chronic hypertension (OR 6.57, 95% CI 5.43-7.95), nulliparity (OR 1.89, 95% CI 1.69-2.12), prepregnancy diabetes (OR 2.05, 95% CI 1.33-3.17), and gestational diabetes (OR 1.28, 95% CI 1.04-1.58). The presence of chronic hypertension modified the association between obesity and PIH; for women with chronic hypertension, obesity was not associated with PIH (adjusted OR [aOR] 1.39, 95% CI 0.77-2.50 for BMI 30-34.9; aOR 0.98, 95% CI 0.52-1.87 for BMI 35-39.9; and aOR 1.33, 95% CI 0.73-2.43 for BMI ≥40 kg/m(2)) compared with women with a BMI in the normal range.The risk of PIH rises with maternal prepregnancy BMI independent of other obesity-associated comorbidity. Women with chronic hypertension carry the greatest risk of PIH but incur no obesity-associated increase in risk.
Increased urinary activity of N-acetyl-β-D-glucosaminidase (NAG) has been reported in many clinical conditions, including essential hypertension. Since hypertension is increasingly recognized as beginning in childhood, we hypothesized that urinary NAG changes with increasing blood pressure may start early in life and may also be the evidence of the existence of early hypertensive disease. We analyzed the urinary NAG changes in 980 young adults, ages between 18 to 32, in relation to age, race, sex, and systolic and diastolic blood pressure. We observed that black women had the highest level of NAG, with or without adjustment for creatinine. With aging, urinary NAG significantly increased in men. As blood pressure increased, urinary NAG excretion appeared to increase, and this was more apparent in black women (P < .05). Significant correlations between NAG excretion and systolic (r = 0.12, P = .04) and diastolic (r = 0.18, P = .003) blood pressures existed in the oldest age group, 28 to 32 years old. These findings show that a significant association between urinary NAG and blood pressure exists in normal young adults and changes in urinary NAG may be evidence of early hypertensive disease.
