White American Patients Research Articles

Effect of waist circumference on reference intervals of liver-related enzyme tests in apparently healthy adult Mexican Americans, black and white Americans

Background: We used a more comprehensible and more physiologically valid indicator of obesity-related liver disease, waist circumference (WC), rather than BMI to study the effect of obesity on liver enzymes, easily measurable surrogates of liver disease. Methods: WC, liver enzymes and pertinent demographic data were abstracted from NHANES III. After exclusion criteria were applied, we stratified the populations by sex and ethnicity and graphed the percentage of elevated enzymes per WC interval. Results: There was a significant relationship between enzyme activity and WC ( p < 0.001 for ALT, p < 0.01 for ALP, p < 0.01 for AST, p = 0.02 for GGT and p < 0.05 for LD), and the relationship was stronger in females ( p < 0.002) and Mexican Americans ( p < 0.001). The enzyme–WC relationship is much weaker in non-Hispanic black females and males. Conclusion: As increases in liver enzyme activity can indicate potentially reversible liver disease, our graphs should be used by physicians to motivate obese, apparently healthy Mexican American and non-Hispanic white patients with elevated liver enzymes to reduce their WC.

Race-ethnicity, crime, and other factors associated with adherence to inhaled corticosteroids

Previous studies have shown differences in adherence to inhaled corticosteroids (ICSs) by race-ethnicity, yet little is known about factors that contribute to adherence within these groups. Environmental stressors, such as crime exposure, which has been associated with asthma morbidity, might also predict ICS adherence. We sought to identify factors associated with ICS adherence among patients with asthma and among African American patients and white patients separately. Study patients with asthma were aged 18 to 50 years and were enrolled in a large southeast Michigan health maintenance organization between January 1, 1999, and December 31, 2001. The primary outcome, ICS adherence, was calculated by linking prescription-fill data with dosage information. Predictor variables included age, sex, race-ethnicity, measures of socioeconomic status (SES), average ICS copay, existing comorbidities, and crime rate in area of residence. Adherence information was available for 176 patients. ICS adherence was lower among African American patients (n = 75) when compared with white patients (n = 94; 40% vs 58%, respectively; P = .002). Among white patients, adherence was significantly lower for women when compared with men. Among African American patients, age and residential crime rates were positively and negatively associated with ICS adherence, respectively. Area crime remained a predictor of adherence in African American patients, even after adjusting for multiple measures of SES. This study suggests that an environmental stressor, area crime, provides additional predictive insight into ICS-adherent behavior beyond typical SES factors. Better understanding of environmental factors that influence ICS adherence might aid in efforts to improve it.

Clozapine Utilization and Outcomes by Race in a Public Mental Health System: 1994-2000

This study aimed to assess racial differences in clozapine prescribing, dosing, symptom presentation and response, and hospitalization status. This study extends previous studies of clozapine by examining patient- and treatment-related factors that may help explain or eliminate reasons for differential prescribing. Clozapine records for 373 white and African American patients with schizophrenia or schizoaffective disorder treated between March 1, 1994, and December 31, 2000, in inpatient mental health facilities in the state of Maryland were examined. Records for this study were derived from 3 state of Maryland databases: the Clozapine Authorization and Monitoring Program, the State of Maryland Antipsychotic Database, and the Health Maintenance Information System Database. A total of 10.3% of African Americans (150/1458) with schizophrenia received clozapine treatment compared with 15.3% of whites (223/1453) (chi2 = 16.74, df = 1, p < .001) during inpatient treatment in the public mental health system in Maryland. Clozapine doses were lower in African Americans relative to whites (385.3 +/- 200.6 vs. 447.3 +/- 230.3 mg/day) (t = -2.66, df = 366, p = .008). At the time of clozapine initiation, whites had more activating symptoms as measured by the Brief Psychiatric Rating Scale (BPRS) (t = -3.98, df = 301, p < .0001); however, African Americans had significantly greater improvements in BPRS total symptoms (F = 4.80, df = 301, p = .03) and in anxiety/ depressive symptoms during 1 year of treatment with clozapine (F = 10.04, df = 303, p = .002). The estimated rate of hospital discharge was not significantly different for African Americans compared to whites prescribed clozapine (log-rank chi2 = 0.523, df = 1, p = .470); however, African Americans were more likely than whites to discontinue clozapine during hospitalization (log-rank chi2 = 4.19, df = 1, p = .041). Our data suggest underutilization of clozapine in African American populations. This racial disparity in clozapine treatment is of special concern because of the favorable outcomes associated with clozapine in treatment-resistant schizophrenia and in the specific benefits observed in African American patients. More research is needed to determine why disparities with clozapine treatment occur and why African Americans may be discontinued from clozapine at a higher rate, despite potential indicators of equal or greater effectiveness among African Americans compared with whites.

Ahmed Glaucoma Valve Implantation in African American and White Patients

To evaluate the results of Ahmed Glaucoma Valve implantation in African American and white patients. In this retrospective, comparative case-control study, we reviewed 86 eyes of 86 patients, comparing the surgical outcomes in white patients (n = 43) with matched African American patients (n = 43). Success was defined as an intraocular pressure (IOP) between 6 mm Hg and 21 mm Hg with or without glaucoma medicines, without further glaucoma surgery, and without loss of light perception (definition 1) and an IOP between 6 mm Hg and 21 mm Hg and achievement of a 20% reduction in IOP from the preoperative level (definition 2). The mean follow-up was 2.3 years for white patients and 2.5 years for African American patients (P = .50). At the last follow-up, the mean +/- SD IOP was 15.3 +/- 3.3 mm Hg and 15.3 +/- 3.5 mm Hg (P = .77) in white and African American patients, respectively. Life table analysis showed a significantly lower success rate for African American patients compared with white patients by both definition 1 (P = .03) and definition 2 (P = .006). Cox proportional hazards regression analysis detected African American race as a risk factor for surgical failure by both definitions. Visual outcomes and complications were comparable between the 2 groups. African American patients have a greater risk of surgical failure after Ahmed Glaucoma Valve implantation compared with white patients.

Hepatitis C Virus Genotype 1a NS5A Pretreatment Sequence Variation and Viral Kinetics in African American and White Patients

In hepatitis C virus (HCV) infection, race is a determinant of treatment response and interferon (IFN) effectiveness. Here, we investigated whether there were differences in the pretreatment viral strains between African American patients and white patients and whether these differences correlated with viral kinetics. IFN effectiveness was calculated using a viral kinetic model. The HCV NS5A region from 21 treated patients with HCV genotype 1a was sequenced and analyzed. White patients displayed more mutations in the V3 region (mean+/-SD, 4.5+/-1.4 vs. 2.9+/-1.6; P=.016), and treatment responders tended to have more mutations in this region than did nonresponders. There was a significant positive correlation between IFN effectiveness and the number of mutations in the V3 region (P=.03). There was no clustering of strains by race, treatment response, or IFN effectiveness in phylogenetic analyses. The results of this study, in conjunction with those of a previous study illustrating the impaired IFN effectiveness in African Americans, suggest a role for host-related factors.

Perceived Adverse Effects of Antiretroviral Therapy

Adverse effects from antiretroviral therapy (ARV) for HIV are associated with medication nonadherence. The purposes of this study were to explore group differences in the reporting of adverse effects, identify individual adverse effects that are linked to nonadherence, and to explore the role of coping in the relationship between adverse effects and adherence. Cross-sectional interviews of 2,765 HIV-positive adults on ARV therapies in four U.S. cities were performed using a computerized assessment of self-reported adverse effects, coping self-efficacy, and adherence. There were no gender differences in the rate or severity of adverse effects reported. Latino respondents reported more adverse effects than either White or African Americans. Those taking a protease inhibitor (PI) reported a higher rate and greater severity of adverse effects. Older participants reported fewer adverse effects despite being more likely to be on a regimen containing a PI. Respondents with less than 90% adherence reported greater numbers and severity of adverse effects overall. In multivariate analyses, nausea, skin problems, vomiting, and memory adverse effects were independently related to less than 90% adherence over the prior three days. Coping moderated the relationship between nausea and adherence such that individuals who reported lower coping self-efficacy and experienced nausea were at increased risk for nonadherence, regardless of the length of time on the current ARV regimen. Women and men are similar in their overall reports of adverse effects, and Latinos report more adverse effects to ARVs than White or African American patients. Specific adverse effects (skin problems, memory problems, vomiting, and nausea) are more likely than others to be associated with missing ARV medications. Increasing adaptive coping self-efficacy among patients experiencing nausea may be a particularly effective strategy in increasing medication adherence.

Racial differences in cardiac catheterization as a function of patients' beliefs.

We examined racial differences in cardiac catheterization rates and reviewed whether patients' beliefs or other variables were associated with observed disparities. We did a prospective observational cohort study of 1045 White and African American patients at 5 Veterans Affairs (VA) medical centers whose nuclear imaging studies indicated reversible cardiac ischemia. There were few demographic differences between White and African American patients in our sample. African Americans were less likely than Whites to undergo cardiac catheterization. African Americans were more likely than Whites to indicate a strong reliance on religion and to report racial and social class discrimination and were less likely to indicate a generalized trust in people but did not differ from White patients on numerous other attitudes about health and health care. Neither sociodemographic or clinical characteristics nor patients' beliefs explained the observed disparities, but physicians' assessments of the procedure's importance and patients' likelihood of coronary disease seemed to account for differences not otherwise explained. Patients' preferences are not the likely source of racial disparities in the use of cardiac catheterization among veterans using VA care, but physicians' assessments warrant further attention.

Cancer survival in a southern African urban population.

This paper provides the first comprehensive population based cancer survival estimates from the African continent. Five-year absolute and relative survival estimates are presented for black and white Zimbabwean patients diagnosed with cancer in Harare, Zimbabwe between the years 1993 and 1997. The survival of black Zimbabwean cancer patients are among the lowest ever reported from population based cancer registries. For most cancer sites, white Zimbabwean patients have much higher survival than black Zimbabweans, except for lung and colorectal cancer, for which the estimates are similarly poor. Race specific comparisons to cancer patients in the United States show that Zimbabwean patients have much lower survival than American cancer patients and that the gap between black Zimbabwean patients and black American patients is broader than between white Zimbabwean and white American patients. Access to and the ability to pay for medical care may be a very important barrier to better survival for the majority of black Zimbabwean patients and the most important cause for the very low cancer survival in this population.

Shared decision making for older, poor, newly diagnosed prostate cancer patients may not be feasible

6086 Background: Shared decision making may be difficult for older prostate cancer patients of lower SES. Although physicians and patients make shared treatment decisions about the option of radiation, surgery, or watchful waiting, functional and psychosocial obstacles may limit the effectiveness of this process among older men of lower socioeconomic status with newly diagnosed prostate cancer. Methods: A cohort (n= 85) of lower socioeconomic status White (25%) and African American patients (75%), 65 year and older with newly diagnosed prostate cancer were queried on social support and evaluated for health literacy, hearing, vision, activities of daily living, nutrition, depressive mood, and cognitive and mobility function using validated tools including the Rapid Estimate for Adult Literacy in Medicine, Mini Nutritional Assessment Short Form, and the Vulnerable Elderly Survey. Results: Subjects were mainly low SES (29% within the poverty range) and African American (74.2%). Mean age was 72 years (SD = 5), and one third lived alone. Impairments identified included: <7th grade health literacy (30%); cognitive impairment (32%); vulnerable (increased risk of decline in activities of daily living and death) (15%); mobility (19%); poor nutrition (22%); visual impairment (8%); hearing impairment (21%); depressive mood (10%); and lack of social support (4%). Overall, 73% of patients had at least one impairment. Conclusions: We conclude that among older, lower SES prostate cancer patients, three quarters have functional and psychosocial impairments that may limit the feasibility of shared decision making approaches. No significant financial relationships to disclose.

Shared decision making for older, poor, newly diagnosed prostate cancer patients may not be feasible

6086 Background: Shared decision making may be difficult for older prostate cancer patients of lower SES. Although physicians and patients make shared treatment decisions about the option of radiation, surgery, or watchful waiting, functional and psychosocial obstacles may limit the effectiveness of this process among older men of lower socioeconomic status with newly diagnosed prostate cancer. Methods: A cohort (n= 85) of lower socioeconomic status White (25%) and African American patients (75%), 65 year and older with newly diagnosed prostate cancer were queried on social support and evaluated for health literacy, hearing, vision, activities of daily living, nutrition, depressive mood, and cognitive and mobility function using validated tools including the Rapid Estimate for Adult Literacy in Medicine, Mini Nutritional Assessment Short Form, and the Vulnerable Elderly Survey. Results: Subjects were mainly low SES (29% within the poverty range) and African American (74.2%). Mean age was 72 years (SD = 5), and one third lived alone. Impairments identified included: <7th grade health literacy (30%); cognitive impairment (32%); vulnerable (increased risk of decline in activities of daily living and death) (15%); mobility (19%); poor nutrition (22%); visual impairment (8%); hearing impairment (21%); depressive mood (10%); and lack of social support (4%). Overall, 73% of patients had at least one impairment. Conclusions: We conclude that among older, lower SES prostate cancer patients, three quarters have functional and psychosocial impairments that may limit the feasibility of shared decision making approaches. No significant financial relationships to disclose.

HLA-DQ Alleles in White and African American Patients With Juvenile-Onset Recurrent Respiratory Papillomatosis

To determine HLA-DQalpha and -DQbeta1 allele associations in juvenile-onset recurrent respiratory papillomatosis (RRP) for risk, disease course, and human papillomavirus type. A nonrandomized controlled study was performed on DNA extracted from papilloma specimens of children with a history of RRP, and from peripheral blood of African American and white children without RRP. The frequencies of DQalpha and DQbeta1 alleles were compared between patients and ethnically matched controls. Records of 48 children treated for RRP at Children's Hospital of Michigan in Detroit (26 African American and 22 white) were reviewed. Control subjects consisted of 80 African American and 80 white children seen at the hospital for conditions other than RRP. African American and white patients with DQbeta1*050X (not *0501, *0502, *0503, *0504, or *0505) were at higher risk to develop RRP than controls (P =.01 and.03, respectively). DQbeta1*0402 was protective for African Americans (P =.01). Whites with DQalpha*0102 were at risk for RRP (P =.03). This allele was associated with disease remission in African Americans (P =.03). DQalpha*0101/0104 conferred protection in whites (P =.047). No association was seen for allele frequency and human papillomavirus type. Whites with haplotype DQalpha*0501/DQbeta1*0201 were at high risk for RRP (P =.002). No relationships were seen for African Americans or whites between haplotype frequencies and disease course or human papillomavirus type. HLA-DQalpha and -DQbeta1 alleles occur at different frequencies in African American and white children with RRP than controls. Specific alleles influence risk for RRP. Allele and haplotype frequencies have some influence on disease course, but were independent of human papillomavirus type.

Access to care, acculturation, and risk factors for stroke in Mexican Americans: the Brain Attack Surveillance in Corpus Christi (BASIC) project.

Mexican Americans are the largest subgroup of Hispanic Americans, now the most numerous US minority population. We compared access to care, acculturation, and biological risk factors among Mexican American and non-Hispanic white stroke patients and the general population. The Brain Attack Surveillance in Corpus Christi project is a population-based stroke surveillance study conducted in southeast Texas. All stroke cases were ascertained through active and passive surveillance from January 2000 through April 2002 and compared with population estimates from a random-digit telephone survey. Compared with non-Hispanic white stroke patients (n=405), Mexican American stroke patients (n=403) were less likely to have graduated from high school (odds ratio [OR], 15.4; 95% confidence interval [CI], 10.6 to 22.4) and more likely to earn less than 20 000 dollars per year (OR, 6.5; 95% CI, 4.5 to 9.4). Mexican American stroke patients were more likely to have diabetes (OR, 2.7; 95% CI, 2.0 to 3.7) and less likely to have atrial fibrillation (OR, 0.5; 95% CI, 0.4 to 0.8). Compared with population estimates (n=719), stroke was associated with diabetes (Mexican Americans: OR, 3.6; 95% CI, 2.2 to 5.8; non-Hispanic whites: OR, 3.0; 95% CI, 1.7 to 5.5), hypertension (Mexican Americans: OR, 2.8; 95% CI, 1.8 to 4.3; non-Hispanic whites: OR, 3.3; 95% CI, 2.2 to 5.0), lower incomes (Mexican Americans: OR, 3.4; 95% CI, 2.1 to 5.4; non-Hispanic whites: OR, 3.0; 95% CI, 1.7 to 5.2), and lower educational attainment (Mexican Americans: OR, 5.1; 95% CI, 3.2 to 8.1; non-Hispanic whites: OR, 4.5; 95% CI, 2.2 to 9.3). Biological and social variables are associated with stroke to a similar extent in both Mexican Americans and non-Hispanic whites. Health behavior interventions for both populations may follow from this work. Stroke disparities between these populations may be explained only partially by differences in the prevalence of currently identified biological and social factors.

Survival rates are similar between African American and white patients with heart failure

Background The clinical characteristics of heart failure differ significantly between African American patients and white patients, apparently as a result of differences in the pathobiology of the condition in the races. We investigated the hypothesis that race also influences the survival of patients with heart failure. Methods Data from the University of North Carolina Heart Failure Database were analyzed for 853 patients (44% African American, 32% women) who had symptomatic heart failure (New York Heart Association class 2.8 ± 0.02 [mean ± SEM]) with a reduced left ventricular ejection fraction of 26% ± 0.5% and a body mass index of 27 ± 0.2. Data on vital status were available in 96.4% of these patients, with a mean length of follow-up of 3.8 ± 0.1 years. Results An unadjusted univariate proportional-hazards analysis suggested similar survival rates between African American patients and white patients in the study population (relative risk, 0.90; 95% CI, 0.73-1.10; P = .293). Adjusted analysis, taking into account the characteristics shown to be of prognostic importance, demonstrated no difference in survival rate between African American patients and white patients (relative risk,1.12; 95% CI, 0.89-1.42; P = .336). The adjusted relative risk of all-cause mortality in the respective races among patients with heart failure caused by ischemic heart disease was 1.21 (95% CI, 0.80-1.84; P = .367). Conclusion African American and white patients with symptomatic heart failure had similar survival rates in our database.

Sex, ethnicity, and antipsychotic medication use in patients with psychosis

Previous studies suggested that African–American patients with psychotic disorders receive higher doses of antipsychotic medication than white patients, are more likely to receive depot antipsychotics, and are less likely to be prescribed second-generation antipsychotics. African–American men in particular may be most likely to receive excessive doses of antipsychotics and depot antipsychotics, although this is less clear. Few studies have examined how sex and ethnicity interactions affect treatment of psychotic disorders. In this study, we examined whether the interaction of sex and ethnicity predicted the use of depot antipsychotics and the dosing of antipsychotics in a sample of inpatients with psychotic disorders. The inpatient records of 167 patients with psychotic disorders were evaluated for type and dose of medication at discharge. African–American men received depot antipsychotic medication more frequently than African–American women and white patients. This difference persisted after controlling for sociodemographic and clinical variables. African–American men and women with psychotic mood disorders were also more likely to be discharged on high antipsychotic doses compared with white patients. There were no ethnic or sex differences in the dosing of antipsychotics for the treatment of schizophrenia spectrum disorders. There were also no ethnic or sex differences in the use of second-generation antipsychotics.

Viral dynamics and response differences in HCV-infected African American and white patients treated with IFN and ribavirin

Studies have suggested that African American patients infected with hepatitis C virus (HCV) do not respond as well to treatment with interferon (IFN) as white patients. Here we analyzed the difference in the viral kinetic response between genotype 1 HCV-infected African American patients (n = 19) and white patients (n = 16). Patients were treated with 10 mIU IFN-α2b daily with or without ribavirin for 1 month followed by 3 mIU IFN-α2b 3 times a week with ribavirin. The kinetic parameters (ϵ, treatment effectiveness at inhibiting virion production; δ, loss rate of virus-producing cells; c, clearance rate of free virions; τ, delay until viral decline starts) were estimated from the viral load decay profiles using a previously described mathematical model. Differences in early kinetic parameters and viral negativity frequencies at weeks 4, 12, and 48 were compared. Ribavirin did not appear to enhance any of the viral kinetic parameters, although this may have been due to the high dose of IFN used. African American patients exhibited significantly ( P = .005) lower drug effectiveness (88.6% vs. 98.2%) compared with white patients, accounting for a 0.8 log lower HCV RNA decrease in the first 24 hours of treatment. Significant differences ( P = .006) were also noted for δ. There was no correlation between any of the viral kinetic parameters and either age, body mass index (BMI), or genotype 1 subtype. No patient achieved viral negativity at weeks 4, 12, or 48 without an ϵ greater than 90%. The mean viral decline and viral negativity rates were statistically different between the two races; however, when controlling for treatment effectiveness, these differences were no longer apparent. In conclusion, the failure of IFN response in African American patients infected with genotype 1 HCV is in part due to an impaired ability to inhibit viral production. (H epatology 2003;37:1343-1350.)

Differences in mortality among patients with community-acquired pneumonia in California by ethnicity and hospital characteristics

Purpose To determine ethnic disparities in mortality for patients with community-acquired pneumonia, and the potential effects of hospital characteristics on disparities, we compared the risk-adjusted mortality of white, African American, Hispanic, and Asian American patients hospitalized for community-acquired pneumonia. Methods We studied patients discharged with community-acquired pneumonia in 1996 from an acute care hospital in California (n = 54,874). Logistic regression models were used to examine the association between ethnicity and hospital characteristics and 30-day mortality after adjusting for clinical characteristics. Results The overall 30-day mortality was 12.2%. After adjustment for demographic, clinical, and hospital characteristics, Hispanic (odds ratio [OR] = 0.81; 95% confidence interval [CI]: 0.73 to 0.90) and Asian American patients (OR = 0.88; 95% CI: 0.77 to 1.00) had lower mortality than did white patients, whereas African Americans had a similar mortality to whites (OR = 0.93; 95% CI: 0.83 to 1.06). There were no overall differences in mortality by hospital characteristics (i.e., teaching status, rural location, and public or district hospital). Conclusion Hispanics and Asian Americans have a lower risk of death from community-acquired pneumonia than whites in California. No overall differences in mortality were observed by hospital characteristics.

Comparison of APF activity and epithelial growth factor levels in urine from Chinese, African-American, and white American patients with interstitial cystitis

Objectives Interstitial cystitis (IC) is a chronic bladder disorder for which the etiology is unknown. We have previously shown that antiproliferative factor (APF), heparin-binding epidermal growth factor-like growth factor (HB-EGF), and epidermal growth factor (EGF) are sensitive and specific biomarkers for IC in white American patients. Because little is known about the epidemiology of this disorder, it is unclear whether these factors would also be useful biomarkers for IC in patients from different racial groups and/or geographic locations. Methods Urine specimens were collected from Chinese, white American, and African-American women with IC and age and race-matched asymptomatic normal control women. APF activity was determined by 3H-thymidine incorporation into primary normal adult human bladder epithelial cells in vitro. The HB-EGF and EGF urine levels were determined by enzyme-linked immunosorbent assay. Results The Chinese, African-American, and white American women with IC had significantly greater urine APF activity ( P <0.000001, P = 0.0008, and P <0.000001, respectively), lower urine HB-EGF levels ( P <0.000001, P = 0.02, and P <0.000001, respectively), and greater urine EGF levels ( P <0.000001, P = 0.002, and P <0.000001, respectively), than their matched asymptomatic controls. Conclusions These findings confirm the utility of APF, HB-EGF, and EGF as biomarkers for IC in patients from three different racial groups and two different countries.

Duration of untreated psychosis, ethnicity and social isolation in the aesop (London) first onset psychosis study

Previous studies suggested that African–American patients with psychotic disorders receive higher doses of antipsychotic medication than white patients, are more likely to receive depot antipsychotics, and are less likely to be prescribed second-generation antipsychotics. African–American men in particular may be most likely to receive excessive doses of antipsychotics and depot antipsychotics, although this is less clear. Few studies have examined how sex and ethnicity interactions affect treatment of psychotic disorders. In this study, we examined whether the interaction of sex and ethnicity predicted the use of depot antipsychotics and the dosing of antipsychotics in a sample of inpatients with psychotic disorders. The inpatient records of 167 patients with psychotic disorders were evaluated for type and dose of medication at discharge. African–American men received depot antipsychotic medication more frequently than African–American women and white patients. This difference persisted after controlling for sociodemographic and clinical variables. African–American men and women with psychotic mood disorders were also more likely to be discharged on high antipsychotic doses compared with white patients. There were no ethnic or sex differences in the dosing of antipsychotics for the treatment of schizophrenia spectrum disorders. There were also no ethnic or sex differences in the use of second-generation antipsychotics.

Perceptions of Diabetes Among Patients in an Urban Health Care System

Objectives. A major problem facing health care providers today is adherence to treatment regimens by patients. Adherence is of even greater significance for patients with diabetes who shoulder a great deal of responsibility in their disease management. Perceptions of diabetes have been found to play a major role in adherence. The effects of race and socioeconomic status on the disease perceptions remain unclear. This exploratory study encompassed two themes: (1) assessing perceptions of diabetes among African American and white American adults with diabetes who were patients in 1994 in a large Midwestern urban health care system and (2) examining the psychometric properties of the measurement instruments used to study perceptions. Design. A stratified random sampling scheme (by race and socioeconomic status (SES)) was used. Diabetes perceptions were measured using three scales from the Meaning of Illness Questionnaire assessing the impact loss and stress associated with diabetes. Perceptions of physician efficacy were also measured. The study population consisted of 50 (68% response rate) African American and white American patients aged 18-65 years. Results. No differences in SES were found between the African American and white American participants ( p = 0.44). However the African Americans in the study indicated a greater sense of loss associated with diabetes than the white Americans in the study ( p < 0.05). In the combined racial group the reliability coefficients as measured by Cronbach's alpha were 0.76 0.78 0.68 and 0.68 for the Impact Loss Stress and Perceptions of Physician Efficacy scales respectively. However the results of within-racial-group analyses tell a different story. The Impact scale fitted the African American and white American subgroups although there was some item variation by racial group. The Loss scale did not fit the white American subgroup and the Stress and Perceptions of Physician Efficacy scales did not fit the African American subgroup.

HLA-DR15 (DR2) is overrepresented in myelodysplastic syndrome and aplastic anemia and predicts a response to immunosuppression in myelodysplastic syndrome

The extent and importance of autoimmune mechanisms in myelodysplastic syndrome (MDS) and the role of immunosuppression in the treatment of this disease are not well defined. We report overrepresentation of HLA-DR2 and its serologic split HLA-DR15 in both MDS and aplastic anemia (AA). Four clinically and ethnically defined patient groups were analyzed. The HLA-DR15 antigen frequencies among North American white MDS patients (n = 72) and AA patients (n = 59), who received immunosuppressive treatment at the National Institutes of Health (NIH), were 36% and 42%, respectively. These antigen frequencies were significantly higher than that of the control population of 240 North American white NIH blood donors typed for HLA antigens by the same molecular technique (HLA-DR15, 21.3%, P =.01 for MDS, P <.001 for AA). Among North American white patients reported in the International Bone Marrow Transplant Registry (IBMTR), 30% of 341 MDS patients and 33% of 364 AA patients were positive for HLA-DR2. These antigen frequencies were higher than those reported for the general North American white population (HLA-DR2, 25.3%, P =.089 for MDS, P =.01 for AA). The DR15 and DR2 frequencies were significantly increased in MDS refractory anemia (RA) (P =.036 and P =.01, respectively) but not MDS refractory anemia with excess blasts. In the NIH MDS patients, HLA-DR15 was significantly associated with a clinically relevant response to antithymocyte globulin (ATG) or cyclosporine immunosuppression (multivariate analysis, P =.008). In MDS with RA, DR15 may be useful as a guide to pathophysiology, prognosis, and treatment.