Phoenix Indian Medical Center

Hepatic secretions of biliary lipids were estimated in 43 patients with and without cholesterol gallstones. Studies were carried out by a marker dilution technique employing duodenal intubation with a three-lumen tube. Hourly secretion rates of cholesterol, bile acids, and phospholipids were determined during constant infusion with liquid formula. In 17 American Indian women with gallstones, hourly outputs of biliary bile acids were significantly less than those in 7 Indian men and 12 Caucasian women without gallstones. These findings suggest that a decreased hepatic secretion of bile acids contributes significantly to the production of a lithogenic bile in Indian women. However, in Indian women with gallstones, secretion of biliary cholesterol was also significantly increased, as compared with Caucasian women without stones. Therefore, lithogenic bile in Indian women was, in most cases, due to a combined decrease in bile acid output and increase in cholesterol secretion. In an attempt to determine the mechanisms for these abnormalities, cholesterol balance studies were done in Indian women with gallstones and normal Indian men. Balance data were compared with results reported previously in non-Indian patients studied by the same techniques, and in general, Indian women showed a slight increase in fecal excretion of bile acids. Since bile acids in the enterohepatic circulation were relatively depleted in Indian women, these patients had a reduced fractional reabsorption. However, previous studies have shown that Caucasians can rapidly replenish bile acid pools in the presence of much greater intestinal losses, and it is suggested that among Indian women with gallstones, reduced secretion rates of bile acids are primarily the result of defective homeostatic regulation of bile acid synthesis. In Indian women with gallstones, at least two factors may have contributed to an increased availability of cholesterol in the liver for secretion into bile. First, cholesterol was inadequately converted into bile acids, and secondly, an increased amount of cholesterol was synthesized, as shown by the balance technique. This enhanced production of cholesterol can partially be explained by obesity, but other factors may also play a role.

The goal of this report is to define an average size and size range for many of the skull's foramina and to determine in which paired foramina asymmetry is commonly found so that researchers and clinicians examining foramina may have an anatomical reference. The incidence of foraminal variations is also discussed. Information on skull foraminal size and symmetry is increasingly important because of the advancements in radiologic techniques such as magnetic resonance imaging (MRI) and computed tomography (CT). These methods are making difficult diagnoses of pathologic conditions of skull foramina possible. The foramina of 100 randomly selected dry skulls were measured and the symmetry of paired foramina was noted. The average, largest, and smallest sizes for 29 different foramina and the length of one canal are listed. Information regarding the symmetry of 27 paired foramina and the length symmetry of the infraorbital canal was also gathered. Specific data collected for paired foramina include the percent of skulls in which (1) neither foramen of the pair was present, (2) both foramina of a pair were present, (3) both foramina of the pair are present and were both the same size within 0.5 mm, and (4) both foramina of a pair are present but there was greater than 0.5 mm difference in size between them.

To investigate gallstone size, growth, and the relation between stone size and gallbladder cancer we have used cholecystectomy reports from 1676 female subjects (169 Whites, 531 Blacks, and 976 Native American Indians). Although the prevalence of gallstones differs markedly in these groups it appears that the estimated growth rate of gallstones in younger subjects, 2.0 mm per year (95% confidence interval: 1.7-2.3 mm) is homogeneous for all three groups. In both Indian and non-Indian populations the proportion of small stones diminished and the proportion of large stones increased over time. We found a strong relationship between gallstone size and gallbladder cancer. Large stones (greater than or equal to 3 cm) were found in 40% of patients with gallbladder cancer but in only 12% of all subjects of similar age. The relative risk for gallbladder cancer in subjects with stones greater than or equal to 3 cm was 9.2 compared with subjects with stones less than 1 cm. (95% confidence interval: 2.3-37). We estimate that one-third of all gallbladder cancers in subjects with calculi will be associated with large (greater than or equal to 3 cm) stones. We believe that stone size might be used to determine the risk of gallbladder cancer in patients with gallstones.

OBJECTIVE: This study aimed to evaluate the effects of varied lifestyle intervention programs designed to ameliorate excess gestational weight gain (GWG) in pregnant women with overweight or obesity compared with standard care, including effects on pregnancy outcomes. METHODS: Seven clinical centers conducted separate randomized clinical trials to test different lifestyle intervention strategies to modify GWG in diverse populations. Eligibility criteria, specific outcome measures, and assessment procedures were standardized across trials. The results of the separate trials were combined using an individual-participant data meta-analysis. RESULTS: For the 1,150 women randomized, the percent with excess GWG per week was significantly lower in the intervention group compared with the standard care group (61.8% vs. 75.0%; odds ratio [95% CI]: 0.52 [0.40 to 0.67]). Total GWG from enrollment to 36 weeks' gestation was also lower in the intervention group (8.1 ± 5.2 vs. 9.7 ± 5.4 kg; mean difference: -1.59 kg [95% CI:-2.18 to -0.99 kg]). The results from the individual trials were similar. The intervention and standard care groups did not differ in preeclampsia, gestational diabetes, cesarean delivery, or birth weight. CONCLUSIONS: Behavioral lifestyle interventions focusing primarily on diet and physical activity among women with overweight and obesity resulted in a significantly lower proportion of women with excess GWG. This modest beneficial effect was consistent across diverse intervention modalities in a large, racially and socioeconomically diverse US population of pregnant women.

Pima Indians have the highest reported prevalence rate of noninsulin-dependent diabetes mellitus (NIDDM) in the world, so that metabolic comparisons with caucasians, who have a much lower rate, should provide insights into the pathogenesis of NIDDM. We have compared 81 caucasians with 211 Pima Indian nondiabetic subjects similar in age, sex, degree of obesity, and glucose tolerance. During a hyperinsulinemic euglycemic clamp at physiological insulin concentrations, Pima Indians were 17% more insulin resistant than caucasians after accounting for any differences in degree of obesity (P less than 0.0001). During oral glucose tolerance testing, mean plasma insulin concentrations were 33% higher in the Pimas (P less than 0.0001), but these differences were largely explained by the greater insulin resistance in the Pimas. Insulin clearance did not differ between the races. However, early insulin responses were exaggerated in the Indians and not explained by insulin resistance. After accounting for differences in insulin action, plasma insulin concentrations in Pima Indians were 50% higher than those in caucasians 3-5 min after iv glucose (P less than 0.0001), 38% higher 10 min after the end of a meal (P less than 0.0001), and 20% higher 30 min after an oral glucose load (P less than 0.006). These data suggest that in addition to insulin resistance, Pima Indians have exaggerated early insulin release and either increased beta-cell mass or enhanced beta-cell sensitivity to glucose. The data argue against low or delayed insulin secretion as primary factors leading to NIDDM in Pima Indians and favor insulin resistance as the underlying and initiating cause of the disease.

Biliary lipid composition was determined on gallbladder bile and on hepatic bile during the diurnal cycle of feeding and fasting in American Indians with and without gallstones and in Caucasian women without gallstones. Fasting hepatic bile was consistently more lithogenic than gallbladder bile or hepatic bile obtained during feeding. Although lithogenicity was greater in Indians, even Caucasian women regularly produce more highly lithogenic bile during the fasting period, apparently because of an uncoupling of cholesterol and bile acid secretion. Although bile acids were sequestered in the gallbladder during late fasting, cholesterol secretion continued somewhat independently of bile acids, thus enhancing lithogenicity. This effect was more pronounced in Indian women, who have reduced pools of bile acids and increased cholesterol secretion. An increasing lithogenicity of hepatic bile throughout fasting might contribute to cholesterol gallstone formation if mixing in the gallbladder is incomplete so that levels of lithogenic bile become segregated.

OBJECTIVE: Few studies have investigated the epidemiology of systemic lupus erythematosus (SLE) in American Indian and Alaska Native populations. The objective of this study was to determine the prevalence and incidence of SLE in the Indian Health Service (IHS) active clinical population in 3 regions of the US. METHODS: For this population-based registry within the IHS, the denominator consisted of individuals in the IHS active clinical population in 2007, 2008, and/or 2009 and residing in a community in 1 of 3 specified regions. Potential SLE cases were identified based on the presence of a diagnostic code for SLE or related disorder in the IHS National Data Warehouse. Detailed medical record abstraction was performed for each potential case. The primary case definition was documentation in the medical record of ≥4 of the revised American College of Rheumatology criteria for the classification of SLE. Prevalence was calculated for 2007, and the mean annual incidence was calculated for the years 2007 through 2009. RESULTS: The age-adjusted prevalence and incidence of SLE according to the primary definition were 178 per 100,000 person-years (95% confidence interval [95% CI] 157-200) and 7.4 per 100,000 person-years (95% CI 5.1-10.4). Among women, the age-adjusted prevalence was 271, and the age-adjusted incidence was 10.4. The prevalence was highest in women ages 50-59 years and in the Phoenix Area IHS. CONCLUSION: The first population-based lupus registry in the US American Indian and Alaska Native population has demonstrated that the prevalence and incidence of SLE are high. Our estimates are as high as or higher than the rates reported in the US black population.

The offspring of Pima Indians with early onset type 2 diabetes are at high risk for developing diabetes at an early age. This risk is greater among those whose mothers were diabetic during pregnancy. To define the metabolic abnormalities predisposing individuals in these high-risk groups to diabetes, we conducted a series of studies to measure insulin secretion and insulin action in healthy adult Pima Indians. In 104 normal glucose-tolerant subjects, acute insulin secretory response (AIR) to a 25-g intravenous glucose challenge correlated with the age at onset of diabetes in the mother (r = 0.23, P = 0.03) and, in multiple regression analyses, the age at onset of diabetes in the father (P = 0.02), after adjusting for maternal age at onset and after allowing for an interaction between these terms. In contrast, insulin action (hyperinsulinemic glucose clamp) did not correlate with the age at onset of diabetes in the parents. To determine whether early onset diabetes in the parents affected insulin secretion in the offspring across a range of glucose concentrations, responses to a stepped glucose infusion were measured in 23 subjects. Insulin secretion rates were lower in individuals whose mothers had developed diabetes before 35 years of age (n = 8) compared with those whose parents remained nondiabetic until at least 49 years of age (n = 15) (average insulin secretory rates: geometric mean [95% CI] 369 [209-652] vs. 571 [418-780] pmol/min, P = 0.007). Finally, the AIR was lower in individuals whose mothers were diabetic during pregnancy (n = 8) than in those whose mothers developed diabetes at an early age but after the birth of the subject (n = 41) (740 [510-1,310] vs. 1,255 [1,045-1,505] pmol/l, P < 0.02). Thus, insulin secretion is lower in normal glucose tolerant offspring of people with early onset type 2 diabetes. This impairment may be worsened by exposure to a diabetic environment in utero.

BACKGROUND: This study determined the dose-response relation of intrathecal fentanyl for labor analgesia and described the onset, duration, and quality of analgesia when used as the sole analgesic. METHODS: Eighty-four parturients in active labor who requested analgesia were randomized to one of seven treatment groups. They received 5-45 microg intrathecal fentanyl as part of a combined spinal-epidural technique. Visual analog pain scores were recorded before and at intervals after injection patients requested additional analgesia. The occurrence and severity of pruritus, nausea, and vomiting were also recorded. Maternal blood pressure was recorded before injection and at intervals after injection. Fetal heart rate was recorded before and 30 min after injection. RESULTS: By 5 min after injection, pain scores were significantly different among groups (P < 0.001). Mean duration of analgesia increased to 89 min as the dose increased to 25 microg. Maternal diastolic blood pressure was significantly lower 10 and 30 min after injection. There was no difference among groups in the incidence of pruritus; nausea and vomiting were uncommon. Fetal heart rates did not change after injection. A dose-response curve indicates that the median effective dose of intrathecal fentanyl for labor analgesia is 14 microg (95% confidence interval, 13-15 microg). CONCLUSIONS: Intrathecal fentanyl produces rapid, profound labor analgesia with minimal side effects. These data indicate that there is little benefit to increasing the dose beyond 25 microg when it is used as the sole agent for intrathecal labor analgesia.

The factors responsible for variable susceptibility to diabetic nephropathy are not clear. According to the non-enzymatic glycation hypothesis, diabetes-related tissue damage occurs due to a complex mixture of toxic products, including alpha-oxoaldehydes, which are inherently toxic as well as serving as precursors for advanced glycation end-products. Protective mechanisms exist to control this unavoidable glycation, and these are determined by genetic or environmental factors that can regulate the concentrations of the reactive sugars or end-products. In diabetes these protective mechanisms become more important, since glycation stress increases, and less efficient defence systems against this stress could lead to diabetic complications. Some of these enzymatic control mechanisms, including those that regulate alpha-oxoaldehydes, have been identified. We have observed significant increases in production of the alpha-oxoaldehydes methylglyoxal and 3-deoxyglucosone in three human populations with biopsy-proven progression of nephropathy. The increase in methylglyoxal could be secondary to defects in downstream glycolytic enzymes (such as glyceraldehyde-3-phosphate dehydrogenase) that regulate its production, or in detoxification mechanisms such as glyoxalase. Other mechanisms, however, appear to be responsible for the observed increase in 3-deoxyglucosone levels. We present results of our studies on the mechanisms responsible for variable production of alpha-oxoaldehydes by measuring the activity and characteristics of these enzymes in cells from complication-prone and -resistant diabetic patients. New therapeutic interventions designed to control these endogenous mechanisms could potentially enhance protection against excessive glycation and prevent or reverse complications of long-term diabetes.

Second Edition Editorial Committee: Helen K. Li, MD (Chair), Mark Horton, OD, MD (Co-chair), Sven-Erik Bursell, PhD, Jerry Cavallerano, OD, PhD, Ingrid Zimmer-Galler, MD, Mathew Tennant, MD Writing Committees: Clinical: Jerry Cavallerano, OD, PhD (Chair), Ingrid Zimmer-Galler, MD Technology: Sven-Erik Bursell, PhD (Chair), Michael Abramoff, MD, PhD, Edward Chaum, MD, PhD, Debra Cabrera DeBuc, PhD Operations: Mark Horton, OD, MD (Chair), Helen K. Li, MD, Tom Leonard-Martin, PhD, MPH, Mathew Tennant, MD, Marc Winchester, BA Other Contributors: Reviewers [R], ATA Standard and Guidelines Committee Members [SG], ATA Staff [S] Nina Antoniotti, RN, MBA, PhD [Chair, SG] Jordana Bernard, MBA [S] David Brennan, MSBE [SG] Anne Burdick, MD, MPH [SG] Jerry Cavallerano, OD, PhD [SG] Brian Grady, MD [SG] Tom Hirota, DO [SG] Elizabeth Krupinski, PhD [Vice Chair, SG] Cindy K. Leenknecht, MS, APRN-CS, CCRP [SG] Jonathan Linkous, MPA [S] Lou Theurer [SG] Jill Winters, PhD, RN [SG] First Edition American Telemedicine Association, Ocular Telehealth Special Interest Group, and the National Institute of Standards and Technology Working Group American Telemedicine Association Executive Committee: Jonathan D. Linkous, Richard Bakalar, MD, Adam Darkins, MD, Col. Ronald K. Poropatich, MD American Telemedicine Association Ocular Telehealth Special Interest Group: Jerry Cavallerano, OD, PhD (Chair), Mary G. Lawrence, MD, M.P.H. (Vice Chair) Editorial Committee: Helen K. Li, MD (Co-chair), Mathew Tennant, MD (Co-chair), Sven Bursell, PhD, Jerry Cavallerano, OD, PhD, Mark Horton, OD, MD, Richard Bakalar, MD Writing Committees: Clinical: Jerry Cavallerano, OD, PhD (Chair), Mary G. Lawrence, MD, MPH, Ingrid Zimmer-Galler, MD, COL Wendall Bauman, MD Technology: Sven Bursell, PhD (Chair), W. Kelly Gardner Operations: Mark Horton, OD, MD (Chair), Lloyd Hildebrand, MD, Jay Federman, MD National Institute of Standards and Technology: Lisa Carnahan Veterans Administration: Peter Kuzmak, John M. Peters, Adam Darkins, MD At Large Group Participants: Jehanara Ahmed, MD, Lloyd M. Aiello, MD, Lloyd P. Aiello, MD, PhD, Gary Buck, Ying Ling Chen, PhD, Denise Cunningham, CRA, RBP, M.Ed., Eric Goodall, Ned Hope, Eugene Huang, PhD, Larry Hubbard, MAT, Mark Janczewski, MD, J.W.L. Lewis, PhD, Hiro Matsuzaki, COL Francis L. McVeigh, OD, Jordana Motzno, Diane Parker-Taillon, Robert Read, Peter Soliz, PhD, Bernard Szirth, PhD, COL Robert A. Vigersky, MD, COL Thomas Ward, MD American Telemedicine Association Administrative Contributor: Catherine Diver Table of Contents 1. PREAMBLE 2. INTRODUCTION 3. BACKGROUND a. The Diabetic Retinopathy Study b. Early Treatment Diabetic Retinopathy Study c. Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications d. The United Kingdom Prospective Diabetes Study e. The Diabetic Retinopathy Clinical Research Network 4. PRINCIPLES OF A TELEHEALTH DR PROGRAM a. Mission b. Vision c. Goals d. Guiding Principles 5. ETHICS 6. CLINICAL VALIDATION a. Category 1 b. Category 2 c. Category 3 d. Category 4 7. COMMUNICATION 8. PERSONNEL QUALIFICATIONS a. Medical Care Supervision b. Patient Care Coordinator c. Image Acquisition d. Image Review and Evaluation e. Information Systems 9. EQUIPMENT SPECIFICATIONS a. Interoperability b. Image Acquisition c. Compression d. Data Communication and Transmission e. Computer Display f. Archiving and Retrieval g. Security h. Reliability and Redundancy i. Documentation j. Image Analysis 10. LEGAL REQUIREMENTS a. Health Insurance Portability and Accountability Act b. Privileging and Credentialing c. Stark Act and Self-Referrals d. State Medical Practice Acts/Licensure e. Tort Liability f. Duty g. Standards of Care h. Consent 11. QUALITY CONTROL 12. OPERATIONS 13. CUSTOMER SUPPORT a. Originating Site b. Transmission c. Distant Site 14. FINANCIAL FACTORS a. Reimbursement b. Grants c. Federal Programs d. Other Financial Factors e. Equipment Cost 15. SUMMARY REFERENCES APPENDIX 1. Interoperability 2. Digital Imaging and Communications in Medicine (DICOM) Metadata 3. Computer-Aided Detection 4. Health Insurance Portability and Accountability Act 5. Privileging and Credentialing 6. Quality Control 7. Operational Specifications 8. Customer Support 9. Reimbursement ABBREVIATIONS GLOSSARY

OBJECTIVE: Digital retinal imaging is a relatively new technology that can be used to assess patients for diabetic retinopathy. We evaluated the impact of adding a primary care-based retinal imaging technology to an existing eye care professional referral process on the rate of surveillance and treatment of diabetic retinopathy in a large, well-defined patient population over a 5-year period. RESEARCH DESIGN AND METHODS: We performed systematic performance evaluations using a computerized patient information system and a comprehensive procedure log to describe annually the patient population, the number of patients with diabetes, and the proportion of patients with diabetes who received appropriate eye care services, including surveillance and laser treatment for diabetic retinopathy before and after implementation of a digital retinal imaging system at the Phoenix Indian Medical Center Primary Care Medical Clinic. RESULTS: The rate of annual retinal examinations increased from 50% (95% CI 44-56%) to 75% (70-80%; P < 0.000001), representing a 50% increase in the retinal examination rate. The rate of laser therapy increased from 19.6 per 1,000 patients with diabetes in 1999 to 29.5 per 1,000 in 2003 for a 51% increase in the laser treatment rate. CONCLUSIONS: Implementing retinal imaging technology in a primary care setting resulted in a significant increase in the rate of diabetic retinopathy surveillance and a proportional increase in the rate of laser treatment for diabetic retinopathy for a large patient population. Application of this technology in primary care settings holds the potential to extend sight-preserving care by increasing access to appropriate retinal care.

OBJECTIVE: American Indians and Alaska Natives are 2.3 times more likely to have diabetes than are individuals in the U.S. general population. The objective of this study was to compare morbidity among American Indian and U.S. adults with diabetes. RESEARCH DESIGN AND METHODS: We extracted demographic and health service utilization data for an adult American Indian population aged 18-64 years (n = 30,121) served by the Phoenix Service Unit from the Indian Health Service clinical reporting system. Similar data for a U.S. population (n = 1,500,002) with commercial health insurance, matched by age and sex to the American Indian population, were drawn from the MartketScan Research Database. We used Diagnostic Cost Groups to identify medical conditions for which each individual was treated and to assign a risk score to quantify his or her morbidity burden. We compared the prevalence of comorbidities and morbidity burden of American Indian and U.S. adults with diabetes. RESULTS: American Indians with diabetes had significantly higher rates of hypertension, cerebrovascular disease, renal failure, lower-extremity amputations, and liver disease than commercially insured U.S. adults with diabetes (P < 0.05). The American Indian prevalence rates were 61.2, 6.9, 3.9, 1.8, and 7.1%, respectively. The morbidity burden among the American Indian with diabetes exceeded that of the insured U.S. adults with diabetes by 50%. CONCLUSIONS: The morbidity burden associated with diabetes among American Indians seen at the Phoenix Service Unit far exceeded that of commercially insured U.S. adults. These findings point to the urgency of enhancing diabetes prevention and treatment services for American Indians/Alaska Natives to reduce diabetes-related disparities.

The effects of a four to six day fast on gallbladder bile lipid composition, bile acid pool size, bile acid composition, and cholic acid metabolism have been determined in normal human subjects. Total bile acid pool size and cholic acid pool size were measured before and after fasting by a one-sample technique previously validated in our laboratory. The rate of synthesis of cholic acid and its fractional turnover rate before fasting were measured using standard techniques. Estimates of fasting cholic acid synthesis rate and fractional turnover rate were calculated as daily averages from the change in cholic acid pool size, in combination with the change in cholic acid specific activity, during the fasting period. Since these estimates are approximate, a maximum value for cholic acid synthesis rate during fasting was also determined by assuming that the entire change in cholic acid specific activity during the fasting period occurred instantaneously. The molar percent of cholesterol in gallbladder bile was reduced in eight of nine subjects after a four to six day fast (p less than .01; mean reduction 30.5%). The molar percents of bile acid and phospholipid were not significantly altered by fasting. The cholesterol saturation index, calculated on the basis of these data, was reduced by an average of 31.0% after a four to six day fast (p less than .02). The average daily cholic acid synthesis rate and the fractional turnover rate were reduced in all six subjects on whom isotope kinetic studies were carried out. The mean decrease in synthesis rate was 68.5% (p less than .05; range 55.2-79.8%) while the mean decrease in fractional turnover rate was 64.4% (p less than .05; range 30.2-100%). Reduction in synthesis rate was confirmed by the determination of maximum fasting synthesis of cholic acid, which averaged 61.1% lower than synthesis in the fed period. Fasting had no consistent effect on total bile acid pool size, cholic acid pool size, or bile acid species composition.

. These guidelines were developed by the Diabetic Retinopathy Telehealth Practice Guidelines Working Group. This working group consisted of a large number of subject matter experts in clinical applications for telehealth in ophthalmology. The editorial committee consisted of Mark B. Horton, OD, MD, who served as working group chair and Christopher J. Brady, MD, MHS, and Jerry Cavallerano, OD, PhD, who served as cochairs. The writing committees were separated into seven different categories. They are as follows: 1.Clinical/operational: Jerry Cavallerano, OD, PhD (Chair), Gail Barker, PhD, MBA, Christopher J. Brady, MD, MHS, Yao Liu, MD, MS, Siddarth Rathi, MD, MBA, Veeral Sheth, MD, MBA, Paolo Silva, MD, and Ingrid Zimmer-Galler, MD. 2.Equipment: Veeral Sheth, MD (Chair), Mark B. Horton, OD, MD, Siddarth Rathi, MD, MBA, Paolo Silva, MD, and Kristen Stebbins, MSPH. 3.Quality assurance: Mark B. Horton, OD, MD (Chair), Seema Garg, MD, PhD, Yao Liu, MD, MS, and Ingrid Zimmer-Galler, MD. 4.Glaucoma: Yao Liu, MD, MS (Chair) and Siddarth Rathi, MD, MBA. 5.Retinopathy of prematurity: Christopher J. Brady, MD, MHS (Chair) and Ingrid Zimmer-Galler, MD. 6.Age-related macular degeneration: Christopher J. Brady, MD, MHS (Chair) and Ingrid Zimmer-Galler, MD. 7.Autonomous and computer assisted detection, classification and diagnosis of diabetic retinopathy: Michael Abramoff, MD, PhD (Chair), Michael F. Chiang, MD, and Paolo Silva, MD.

A simplified isotope dilution method for measurement of the bile acid pool size in normal subjects is described and compared with the traditional method of Lindstedt (Acta Physiol. Scand. 40: 1-9, 1957). Advantages of this simplified method include a four- to eightfold reduction of isotope dose, facilitation of analytical procedures, and a reduction in the required number of duodenal intubations. In 15 human subjects who had two separate estimates of pool size by this method, precision averaged 2.6 percent. In 16 comparisons, pool size measured by this method averaged 13.7 percent higher than simultaneous estimates by the Lindstedt method. Factors affecting accuracy (as opposed to precision) in both methods are discussed.

OBJECTIVE: Maternal mortality is underreported in the United States in part because traumatic deaths are not included in nationally reported maternal mortality ratios. The overall study goal was to compare women whose deaths had been reported to and investigated by a medical examiner and who had evidence of pregnancy to women without evidence of pregnancy in terms of socio-demographic information, toxicology results, and manner and cause of death. A secondary goal was to compare the pregnancy status and gestational age of women with evidence of pregnancy at the time of death in relation to the manner of death, with particular focus on women who died as a result of violent death. METHODOLOGY: Autopsy charts from 1988-1996 for 651 women aged 15 to 50 from the District of Columbia Office of the Chief Medical Examiner whose autopsies included examination of the uterus were reviewed. Medical examiners' classification of manner and specific causes of death were used as the main outcome measures. Overall, the sample reflected demographic characteristics of women of childbearing age in the District of Columbia, with 82% black, 74.6% unmarried, and 46.5% aged 20 to 34. RESULTS: Among the 651 autopsy charts evaluated, 30 (4.6%) documented evidence of pregnancy; 43.3% of the women who died due to homicide with evidence of pregnancy were not included in the 21 pregnancy-related deaths officially reported by the District of Columbia State Center for Health Statistics during the study period, and therefore, were also not included in national maternal mortality ratios. Although not statistically significant, 11% more homicides occurred among women with evidence of pregnancy as compared to non-pregnant women. Pregnant women who died a violent death were significantly more likely than non-pregnant women to have died due to gunshot trauma. A significant proportion of pregnant women were < 21 weeks gestation at the time of their death. Additionally, women in this sample with evidence of pregnancy were over 3 times more likely to have been teenagers compared to non-pregnant women. CONCLUSION: Medical examiner autopsy records identify violent pregnancy-associated deaths, many of which occur early in pregnancy and are missed by other enhanced case-finding techniques that require a record of a birth or fetal death. These deaths are usually excluded from reported maternal mortality ratios. Few studies have evaluated the prevalence of homicide in women of childbearing age, yet understanding the extent of less commonly associated causes of death during pregnancy such as homicide, may lead to improved identification of preventable problems that contribute to maternal morbidity and mortality. This study, which sheds new light on the identifying and reporting of maternal mortality, and specifically on homicide as a form of violence toward pregnant women, should be of particular interest for all women's health providers, as well as public health professionals, researchers, and advocates who are interested in the design, development, and evaluation of prevention programs, especially those directed toward preventable problems such as domestic violence.

We report a new disorder with diverse neurological problems resulting from abnormal brainstem function. Consistent features of this disorder, which we propose should be called the Atabascan brainstem dysgenesis syndrome, include horizontal gaze palsy, sensorineural deafness, central hypoventilation, and developmental delay. Other features seen in some patients include swallowing dysfunction, vocal cord paralysis, facial paresis, seizures, and cardiac outflow tract anomalies. All affected children described are of Athabascan Indian heritage, with eight children from the Navajo tribe and two patients who are of Apache background. The disorder can be distinguished from the Moebius syndrome by the pattern of central nervous system findings, especially the sensorineural deafness, horizontal gaze palsy, and central hypoventilation. Recognition of children with some features of Athabascan brainstem dysgenesis syndrome should prompt investigation for other related abnormalities. Published 2003 Wiley-Liss, Inc.

Prudent interventions for reducing selenium (Se) in groundwater and streams within an irrigated river valley must be guided by a sound understanding of current field conditions. An emerging picture of the nature of Se contamination within the Lower Arkansas River Valley in Colorado is provided by data from a large number of groundwater and surface water sampling locations within two study regions along the river. Measurements show that dissolved Se concentrations in the river are about double the current Colorado Department of Public Health and Environment (CDPHE) chronic standard of 4.6 microg L(-1) for aquatic habitat in the upstream region and exceed the standard by a factor of 2 to 4 in the downstream region. Groundwater concentrations average about 57.7 microg L(-1) upstream and 33.0 microg L(-1) downstream, indicating a large subsurface source for irrigation-induced dissolution and mobilization of Se loads to the river and its tributaries. Inverse correlation was found between Se concentration and the distance to the closest identified shale in the direction upstream along the principal groundwater flow gradient. The data also exhibited, among other relationships, a moderate to strong correlation between dissolved Se and total dissolved solids in groundwater and surface water, a strong correlation with uranium in groundwater, and power relationships with nitrate in groundwater. The relationship to nitrate, derived primarily from N fertilizers, reveals the degree to which dissolved Se depends on oxidation and inhibited reduction due to denitrification and suggests that there are prospects for reducing dissolved Se through nitrate control. Current and future results from these ongoing studies will help provide a foundation for modeling and for the discovery of best management practices (BMPs) in irrigated agriculture that can diminish Se contamination.

BACKGROUND: Diabetes and its complications are more common in American Indians and Alaska Natives (AI/AN) than other US racial/ethnic populations. Prior reports of diabetic retinopathy (DR) prevalence in AI/AN are dated, and research on diabetic macular edema (DME) is limited. This study characterizes the recent prevalence of DR and DME in AI/AN using primary care-based teleophthalmology surveillance. METHODS: This is a multi-site, clinic-based, cross-sectional study of DR and DME. The sample is composed of AI /AN patients with diabetes (n = 53,998), served by the nationally distributed Indian Health Service-Joslin Vision Network Teleophthalmology Program (IHS-JVN) in primary care clinics of US Indian Health Service (IHS), Tribal, and Urban Indian health care facilities (I/T/U) from 1 November 2011 to 31 October 2016. Patients were recruited opportunistically for a retinal examination using the IHS-JVN during their regular diabetes care. The IHS-JVN used clinically validated, non-mydriatic, retinal imaging and retinopathy assessment protocols to identify the severity levels of non-proliferative diabetic retinopathy (NPDR), proliferative diabetic retinopathy (PDR), DME, and sight threatening retinopathy (STR; a composite measure). Key social-demographic (age, gender, IHS area), diabetes-related health (diabetes therapy, duration of diabetes, A1c), and imaging technology variables were examined. The analysis calculated frequencies and percentages of severity levels of disease. RESULTS: Prevalence of any NPDR, PDR, DME, and STR among AI/AN patients undergoing DR teleophthalmology surveillance by IHS-JVN was 17.7%, 2.3%, 2.3%, and 4.2%, respectively. Prevalence was lowest in Alaska and highest among patients with A1c >/ = 8%, duration of diabetes > 10 years, or using insulin. CONCLUSIONS: Prevalence of DR in this cohort was approximately half that in previous reports for AI/AN, and prevalence of DME was less than that reported in non-AI/AN populations. A similar reduction in diabetes related end-stage renal disease in the same population and time period has been reported by other researchers. Since these two diabetic complications share a common microvasculopathic mechanism, this coincident change in prevalence may also share a common basis, possibly related to improved diabetes management.