Showing papers in "Annals of Internal Medicine in 1998"
TL;DR: These Guidelines were developed by the Panel* on Clinical Practices for Treatment of HIV Infection convened by the Department of Health and Human Services and the Henry J. Kaiser Family Foundation.
Abstract: SUMMARY The availability of an increasing number of antiretroviral agents and the rapid evolution of new information has introduced extraordinary complexity into the treatment of HIV-infected persons. In 1996, the Department of Health and Human Services and the Henry J. Kaiser Family Foundation convened the Panel on Clinical Practices for the Treatment of HIV to develop guidelines for the clinical management of HIV-infected adults and adolescents. This report recommends that care should be supervised by an expert, and makes recommendations for laboratory monitoring including plasma HIV RNA, CD4 cell counts and HIV drug resistance testing. The report also provides guidelines for antiretroviral therapy, including when to start treatment, what drugs to initiate, when to change therapy, and therapeutic options when changing therapy. Special considerations are provided for adolescents and pregnant women. As with treatment of other chronic conditions, therapeutic decisions require a mutual understanding between the patient and the health care provider regarding the benefits and risks of treatment. Antiretroviral regimens are complex, have major side effects, pose difficulty with adherence, and carry serious potential consequences from the development of viral resistance due to non-adherence to the drug regimen or suboptimal levels of antiretroviral agents. Patient education and involvement in therapeutic
4,321 citations
TL;DR: This long-term follow-up of the Cholesterol Lowering Atherosclerosis Study cohort indicated that progression of coronary artery disease was predictive of coronary events, and the objective was to determine whether carotid arterial intima-media thickness predicts coronary events.
Abstract: Background: Carotid arterial intima-media thickness is used as a noninvasive surrogate end point to measure progression of atherosclerosis, but its relation to coronary events has not been fully ex...
1,226 citations
TL;DR: What makes interleukin-6 particularly interesting to physicians is its marked pleiotropy and its involvement not only in inflammation but in the regulation of endocrine and metabolic functions.
Abstract: Interleukin-6, an inflammatory cytokine, is characterized by pleiotropy and redundancy of action Apart from its hematologic, immune, and hepatic effects, it has many endocrine and metabolic actions Specifically, it is a potent stimulator of the hypothalamic-pituitary-adrenal axis and is under the tonic negative control of glucocorticoids It acutely stimulates the secretion of growth hormone, inhibits thyroid-stimulating hormone secretion, and decreases serum lipid concentrations Furthermore, it is secreted during stress and is positively controlled by catecholamines Administration of interleukin-6 results in fever, anorexia, and fatigue Elevated levels of circulating interleukin-6 have been seen in the steroid withdrawal syndrome and in the severe inflammatory, infectious, and traumatic states potentially associated with the inappropriate secretion of vasopressin Levels of circulating interleukin-6 are also elevated in several inflammatory diseases, such as rheumatoid arthritis Interleukin-6 is negatively controlled by estrogens and androgens, and it plays a central role in the pathogenesis of the osteoporosis seen in conditions characterized by increased bone resorption, such as sex-steroid deficiency and hyperparathyroidism Overproduction of interleukin-6 may contribute to illness during aging and chronic stress Finally, administration of recombinant human interleukin-6 may serve as a stimulation test for the integrity of the hypothalamic-pituitary-adrenal axis
1,121 citations
TL;DR: The Multicenter Study for Perioperative Ischemia (McSPI) Research Group studied 2400 patients who underwent myocardial revascularization with cardiopulmonary bypass to determine the incidence and characteristics of postoperative renal dysfunction and failure, the predictors of renal dysfunction [determined by the use of multivariate modeling techniques], and the effect of kidney dysfunction on in-hospital resource utilization and patient disposition after discharge.
Abstract: Background: Acute changes in renal function after elective coronary bypass surgery are incompletely characterized and represent a challenging clinical problem. Objective: To determine the incidence...
1,063 citations
TL;DR: The optimal strategy for investigating patients with suspected pulmonary embolism should combine clinical assessment, ventilation-perfusion scanning, and venous ultrasonography of the lower extremities, and the group developed a useful clinical model by reviewing the literature and coming to a consensus on a scoring system.
Abstract: Background: The low specificity of ventilation-perfusion lung scanning complicates the management of patients with suspected pulmonary embolism. Objective: To determine the safety of a clinical mod...
937 citations
TL;DR: This study examined factors associated with ventilator-associated pneumonia and explored baseline and time-dependent characteristics, including measures of illness severity, factors relating to mechanical ventilation, variables in the gastropulmonary route of infection, and drug exposure.
Abstract: Background: Understanding the risk factors for ventilator-associated pneumonia can help to assess prognosis and devise and test preventive strategies Objective: To examine the baseline and time-de
903 citations
TL;DR: This study examined the effect of incident vertebral fractures on back pain and back-related functional limitations in a large community-based sample of elderly women who underwent serial spinal radiography and annual assessments of backPain and disability over the same period.
Abstract: Background: Vertebral fractures are a hallmark of postmenopausal osteoporosis and an important end point in trials of osteoporosis treatment, but the clinical significance of these fractures remain...
799 citations
TL;DR: This report examines the temporal and dosage relations between intake of folate, both from supplements and from foods, and risk for colon cancer in women in the Nurses' Health Study and pays particular attention to the problem of possible confounding by multivitamin use.
Abstract: Background: High intake of folate may reduce risk for colon cancer, but the dosage and duration relations and the impact of dietary compared with supplementary sources are not well understood. Obje...
756 citations
TL;DR: This study prospectively investigated body mass index at 18 years of age and at midlife, as well as long-term and medium-term weight changes, in relation to subsequent risk for hypertension in a large cohort of U.S. female nurses without diagnosed hypertension.
Abstract: Background: Obesity increases the risk for hypertension, but the effects of modest long-term weight changes have not been precisely quantified. Objective: To investigate body mass index (BMI) and w...
684 citations
TL;DR: The female reproductive system is regulated by the hypothalamic-pituitary-adrenal axis, which is activated during stress and produces the clinical phenomenology of what Hans Selye described as the stress syndrome.
Abstract: The hypothalamic-pituitary-adrenal axis exerts profound, multilevel inhibitory effects on the female reproductive system. Corticotropin-releasing hormone (CRH) and CRH-induced proopiomelanocortin peptides inhibit hypothalamic gonadotropin-releasing hormone secretion, whereas glucocorticoids suppress pituitary luteinizing hormone and ovarian estrogen and progesterone secretion and render target tissues resistant to estradiol. The hypothalamic-pituitary-adrenal axis is thus responsible for the "hypothalamic" amenorrhea of stress, which is also seen in melancholic depression, malnutrition, eating disorders, chronic active alcoholism, chronic excessive exercise, and the hypogonadism of the Cushing syndrome. Conversely, estrogen directly stimulates the CRH gene promoter and the central noradrenergic system, which may explain adult women's slight hypercortisolism; preponderance of affective, anxiety, and eating disorders; and mood cycles and vulnerability to autoimmune and inflammatory disease, both of which follow estradiol fluctuations. Several components of the hypothalamic-pituitary-adrenal axis and their receptors are present in reproductive tissues as autacoid regulators. These include ovarian and endometrial CRH, which may participate in the inflammatory processes of the ovary (ovulation and luteolysis) and endometrium (blastocyst implantation and menstruation), and placental CRH, which may participate in the physiology of pregnancy and the timing of labor and delivery. The hypercortisolism of the latter half of pregnancy can be explained by high levels of placental CRH in plasma. This hypercortisolism causes a transient postpartum adrenal suppression that, together with estrogen withdrawal, may partly explain the depression and autoimmune phenomena of the postpartum period.
658 citations
TL;DR: Management strategies that use serial impedance plethysmography or venous ultrasonography, which detect proximal deep venous thrombosis at presentation and extending distal deep venOUS thromBosis with repeated testing, have been developed.
Abstract: Purpose: To review noninvasive methods for diagnosis of first and recurrent deep venous thrombosis and provide evidence-based recommendations for the diagnosis of deep venous thrombosis in symptoma...
TL;DR: In this paper, non-invasive pressure support ventilation during weaning reduces weaning time, shortens the time in the intensive care unit, decreases the incidence of nosocomial pneumonia, and improves 60-day survival rates.
Abstract: Background In patients with acute exacerbations of chronic obstructive pulmonary disease, mechanical ventilation is often needed. The rate of weaning failure is high in these patients, and prolonged mechanical ventilation increases intubation-associated complications. Objective To determine whether noninvasive ventilation improves the outcome of weaning from invasive mechanical ventilation. Design Multicenter, randomized trial. Setting Three respiratory intensive care units. Patients Intubated patients with chronic obstructive pulmonary disease and acute hypercapnic respiratory failure. Intervention A T-piece weaning trial was attempted 48 hours after intubation. If this failed, two methods of weaning were compared: 1) extubation and application of noninvasive pressure support ventilation by face mask and 2) invasive pressure support ventilation by an endotracheal tube. Measurements Arterial blood gases, duration of mechanical ventilation, time in the intensive care unit, occurrence of nosocomial pneumonia, and survival at 60 days. Results At admission, all patients had severe hypercapnic respiratory failure (mean pH, 7.18+/-0.06; mean PaCO2, 94.2+/-24.2 mm Hg), sensory impairment, and similar clinical characteristics. At 60 days, 22 of 25 patients (88%) who were ventilated noninvasively were successfully weaned compared with 17 of 25 patients (68%) who were ventilated invasively. The mean duration of mechanical ventilation was 16.6+/-11.8 days for the invasive ventilation group and 10.2+/-6.8 days for the noninvasive ventilation group (P = 0.021). Among patients who received noninvasive ventilation, the probability of survival and weaning during ventilation was higher (P = 0.002) and time in the intensive care unit was shorter (15.1+/-5.4 days compared with 24.0+/-13.7 days for patients who received invasive ventilation; P = 0.005). Survival rates at 60 days differed (92% for patients who received noninvasive ventilation and 72% for patients who received invasive ventilation; P = 0.009). None of the patients weaned noninvasively developed nosocomial pneumonia, whereas 7 patients weaned invasively did. Conclusions Noninvasive pressure support ventilation during weaning reduces weaning time, shortens the time in the intensive care unit, decreases the incidence of nosocomial pneumonia, and improves 60-day survival rates.
TL;DR: In this paper, a nurse case manager with considerable management responsibility can, in association with primary care physicians and an endocrinologist, help improve glycemic control in diabetic patients in a group-model HMO.
Abstract: Background: Control of hyperglycemia delays or prevents complications of diabetes, but many persons with diabetes do not achieve optimal control. Objective: To compare diabetes control in patients receiving nurse case management and patients receiving usual care. Design: Randomized, controlled trial. Setting: Primary care clinics in a group-model health maintenance organization (HMO). Patients: 17 patients with type 1 diabetes mellitus and 121 patients with type 2 diabetes mellitus. Intervention: The nurse case manager followed written management algorithms under the direction of a family physician and an endocrinologist. Changes in therapy were communicated to primary care physicians. All patients received ongoing care through their primary care physicians. Measurements: The primary outcome, hemoglobin A 1c (HbA 1c ) value, was measured at baseline and at 12 months. Fasting blood glucose levels, medication type and dose, body weight, blood pressure, lipid levels, patient-perceived health status, episodes of severe hypoglycemia, and emergency department and hospital admissions were also assessed. Results: 72% of patients completed follow-up. Patients in the nurse case management group had mean decreases of 1.7 percentage points in HbA 1c values and 43 mg/dL (2.38 mmol/L) in fasting glucose levels; patients in the usual care group had decreases of 0.6 percentage points in HbA 1c values and 15 mg/dL (0.83 mmol/L) in fasting glucose levels (P < 0.01). Self-reported health status improved in the nurse case management group (P = 0.02). The nurse case management intervention was not associated with statistically significant changes in medication type or dose, body weight, blood pressure, or lipids or with adverse events. Conclusions: A nurse case manager with considerable management responsibility can, in association with primary care physicians and an endocrinologist, help improve glycemic control in diabetic patients in a group-model HMO.
TL;DR: The art of medical care involves a continuing, individualized search in which the physician tries to match incomplete scientific knowledge of disease and treatment with incomplete local knowledge about particular patients at particular times in their lives, called the Plan-Do-Study-Act (PSA) cycle.
Abstract: Improving the daily practice of medicine requires making changes in processes of care.In many circumstances, the most powerful way to make such changes is to conduct small, local tests-Plan-Do-Stud...
Journal Article•
TL;DR: This study investigated whether protein supplements in vitamin D-replete patients with a recent hip fracture who were receiving calcium supplements could increase circulating IGF-I levels and favorably influence bone mineral density.
Abstract: Background: Elderly persons who have osteoporotic hip fracture are often undernourished, particularly with respect to protein. Protein malnutrition may contribute to the occurrence and outcome of h...
TL;DR: The CBT and supportive diabetes education is an effective nonpharmacologic treatment for major depression in patients with type 2 diabetes as discussed by the authors, which may also be associated with improved glycemic control.
Abstract: Results: The percentage of patients achieving remission of depression (Beck Depression Inventory score < 9) was greater in the CBT group than in the control group: posttreatment 850% of patients in the CBT group (17 of 20) compared with 273% of controls (6 of 22) achieved remis sion (difference, 577 percentage points [95% Cl# 33 to 82 percentage points]) (P < 0001); at follow-up f 700% of patients in the CBT group (14 of 20) compared with 333% of controls (7 of 21) achieved remission (difference, 367 percentage points [CI, 9 to 65 percentage points]) (P = 003) Post-treatment glycosylated hemoglobin levels were not different in the two groups, but follow-up mean gly cosylated hemoglobin levels were significantly better in the CBT group than in the control group (95% compared with 109%; P = 003) Conclusions: The combination of CBT and supportive diabetes education is an effective nonpharmacologic treatment for major depression in patients with type 2 diabetes It may also be associated with improved glycemic control
TL;DR: In this article, the authors investigated whether oral protein supplements benefit bone metabolism in patients with recent hip fracture and found that patients who received protein supplements had significantly greater increases in serum levels of insulin-like growth factor-I (85.6% +/- 14.8% and 34.1% +/- 7.2% at 6 months; difference, 51.5 percentage points [95% CI, 18.6 to 84.4 percentage points]; P = 0.003) and an attenuation of the decrease in proximal femur bone mineral density (-2.29%
Abstract: BACKGROUND Elderly persons who have osteoporotic hip fracture are often undernourished, particularly with respect to protein. Protein malnutrition may contribute to the occurrence and outcome of hip fracture. OBJECTIVE To investigate whether oral protein supplements benefit bone metabolism in patients with recent hip fracture. DESIGN 6-month, randomized, double-blind, placebo-controlled trial with a 6-month post-treatment follow-up. SETTING University orthopedic ward. PATIENTS 82 patients (mean age, 80.7 +/- 7.4 years) with recent osteoporotic hip fracture. Patients received calcium supplementation, 550 mg/d, and one dose of vitamin D, 200,000 IU (at baseline). INTERVENTION Protein supplementation, 20 g/d, or isocaloric placebo (among controls). MEASUREMENTS Bone mineral density, biochemical markers of bone remodeling, calciotropic hormone levels, biochemically evaluated nutritional and immunologic status, and muscle strength were measured every 6 months. RESULTS Compared with controls, patients who received protein supplements had significantly greater increases in serum levels of insulin-like growth factor-I (85.6% +/- 14.8% and 34.1% +/- 7.2% at 6 months; difference, 51.5 percentage points [95% CI, 18.6 to 84.4 percentage points]; P = 0.003) and an attenuation of the decrease in proximal femur bone mineral density (-2.29% +/- 0.75% and -4.71% +/- 0.77% at 12 months; difference, 2.42 percentage points [CI, 0.26 to 4.59 percentage points]; P = 0.029). Seven and 13 new vertebral deformities were found among patients who received protein supplements and controls, respectively (P > 0.2). Median stay in rehabilitation wards was shorter for patients who received protein supplements than for controls (33 days [CI, 29 to 56 days] and 54 days [CI, 44 to 62 days]; difference, 21 days [CI, 4 to 25 days]; P = 0.018). CONCLUSION Protein repletion after hip fracture was associated with increased serum levels of insulin-like growth factor-I, attenuation of proximal femur bone loss, and shorter stay in rehabilitation hospitals.
TL;DR: A prognostic model was developed that stratified patients into three levels of risk (low, intermediate, and high) for adverse clinical outcome and the prediction accuracy of the prognosticmodel was assessed.
Abstract: Background: Community-acquired bacterial meningitis causes substantial morbidity and mortality in adults. Objective: To create and test a prognostic model for persons with community-acquired bacter...
TL;DR: The scientific data on chemical (synthetic) and natural (plant-derived) insect repellent currently available are reviewed, some of the popular myths about alternative repellents are debunks, and effective techniques for reducing mosquito populations in the local environment are reviewed.
Abstract: This paper is intended to provide the clinician with the detailed and scientific information needed to advise patients who seek safe and effective ways of preventing mosquito bites.For this review,...
TL;DR: A clinical overview of botulism is provided and the U.S. Botulism Surveillance System is described to help clinicians recognize and treat patients with mechanical ventilation and early administration of antitoxin in the event of terrorist use of botulinum toxin.
Abstract: Botulism is caused by a neurotoxin produced from the anaerobic, spore-forming bacterium Clostridium botulinum. Botulism in humans is usually caused by toxin types A, B, and E. Since 1973, a median ...
TL;DR: Data from the Framingham Heart Study allowed us to evaluate the accuracy of the death certificate diagnosis of coronary heart disease as the underlying cause of death, and the influence of age, sex, calendar year in which death occurred, and prevalence of coronaryheart disease on the accuracy.
Abstract: Background: Death certificates are widely used in epidemiologic and clinical investigations and for national statistics. Objective: To examine the accuracy of death certificates for coding coronary...
TL;DR: The Cholesterol and Recurrent Events (CARE) trial investigated whether reducing average cholesterol levels by using pravastatin in patients who have had myocardial infarction would prevent recurrent cardiac events, and reported that patients who were older than the median age of 59 years had a reduced rate of coronary death, nonfatal myocardIAL infarctions, coronary artery bypass grafting, angioplasty, and stroke.
Abstract: Background: A majority of all myocardial infarctions occur in patients who are 65 years of age or older and have average cholesterol levels, but little information is available on whether cholester...
TL;DR: This work surveyed female and male faculty in all academic departments at 24 randomly selected medical schools across the United States to evaluate the extent of other dependent care responsibilities that might negatively affect women's academic careers.
Abstract: Background: Studies have found that female faculty publish less, have slower career progress, and generally have a more difficult time in academic careers than male faculty. The relation of family ...
TL;DR: The strengths and weaknesses of venous ultrasonography are considered in patients with the five clinical presentations of suspected venous thromboembolism and the criteria used to diagnose thrombosis often vary among examiners.
Abstract: This paper describes the role of venous ultrasonography in the diagnosis of suspected deep venous thrombosis and pulmonary embolism. Inability to compress the common femoral or popliteal vein is usually diagnostic of a first episode of deep venous thrombosis in symptomatic patients (positive predictive value of about 97%). Full compressibility of both of these sites excludes proximal deep venous thrombosis in symptomatic patients (negative predictive value of about 98%). In patients with suspected deep venous thrombosis or in those who present with suspected pulmonary embolism but have a nondiagnostic lung scan, the subsequent risk for symptomatic venous thromboembolism is very low (<2% during 6 months of follow-up) provided that ultrasonography of the proximal veins remains normal in the course of 1 week (suspected deep venous thrombosis) or 2 weeks (suspected pulmonary embolism). Anticoagulation and further diagnostic testing can usually be safely withheld in these situations. Venous ultrasonography is much less reliable for the diagnosis of asymptomatic, isolated distal, and recurrent deep venous thrombosis than for the diagnosis of a first episode of proximal deep venous thrombosis in symptomatic patients. Clinical evaluation of the probability of deep venous thrombosis or pulmonary embolism, preferably by using a validated clinical model, complements venous ultrasonographic findings and helps to identify patients who would benefit from additional (often invasive) diagnostic testing. Thus, venous ultrasonography is thought to be a very valuable test for the diagnosis and management of patients with suspected deep venous thrombosis or pulmonary embolism.
TL;DR: A population-based casecontrol study to evaluate and quantify risk factors for infective endocarditis, especially those considered by the American Heart Association to be indications for antibiotic prophylaxis.
Abstract: Background: Although antibiotic prophylaxis against infective endocarditis is recommended, the true risk factors for infective endocarditis are unclear. Objective: To quantitate the risk for endoca...
TL;DR: The numerous persons who presented with near-fatal classic heat stroke during the Chicago heat wave provided an opportunity to analyze the clinical course of this condition and prompted a 1-year follow-up to assess delayed functional outcome and mortality.
Abstract: Background: In July 1995, Chicago sustained a heat wave that resulted in more than 600 excess deaths, 3300 excess emergency department visits, and a substantial number of intensive care unit admiss...
TL;DR: On the basis of previous reports of increased risk for cancer in patients with the Peutz-Jeghers syndrome and the predisposition to cancer seen with other polyposis syndromes, this cohort of patients was followed to characterize the development of cancer.
Abstract: Background: Some reports describe an increased risk for cancer in patients with the Peutz-Jeghers syndrome. Objective: To characterize occurrences of cancer in a large cohort of patients with the P...
TL;DR: This systematic review analyzed all published reports of drug-induced thrombocytopenia by using explicit, a priori criteria for establishing levels of evidence of a causal relation to help clinicians better understand the likelihood that a drug will cause throm bocy topenia.
Abstract: Purpose To determine the strength of clinical evidence for individual drugs as a cause of thrombocytopenia. Data sources All English-language reports on drug-induced thrombocytopenia. Study selection Articles describing thrombocytopenia caused by heparin were excluded from review. Of the 581 articles reviewed, 20 were excluded because they contained no patient case reports. The remaining 561 articles reported on 774 patients. Data extraction Two of the authors used a priori criteria to independently review each patient case report. Two hundred fifty-nine patient case reports were excluded from further review because of lack of evaluable data, platelet count of 100000 cells/microL or more, use of cytotoxic or nontherapeutic agents, occurrence of drug-induced systemic disease, or occurrence of disease in children. For the remaining 515 patient case reports, a level of evidence for the drug as the cause of thrombocytopenia was assigned. Data on bleeding complications and clinical course were recorded. Data synthesis The evidence supported a definite or probable causal role for the drug in 247 patient case reports (48%). Among the 98 drugs described in these reports, quinidine was mentioned in 38 case reports, gold in 11, and trimethoprim-sulfamethoxazole in 10. Of the 247 patients described in the case reports, 23 (9%) had major bleeding and 2 (0.8%) died of bleeding. Conclusions Many reports of drug-induced thrombocytopenia do not provide evidence supporting a definite or probable causal relation between the disease and the drug. Future patient case reports should incorporate standard criteria to clearly establish the etiologic role of the drug.
TL;DR: This paper supports the contention that action that successfully decreases financial barriers across socioeconomic groups will go a long way toward the substantial reduction of socioeconomic disparities in health.
Abstract: Many health care professionals have sustained an almost single-minded conviction that disparities in access to health care across socioeconomic groups are the key reason for the major discrepancies in health status between wealthy persons and poor persons. Others, however, have argued that a host of factors work to create major impediments and that reducing or eliminating financial barriers to health care in particular will do little to reduce discrepancies in health status. This paper, while acknowledging the spectrum of contributing factors, argues that the elimination of financially based differences in access is central to any effort to create equity in outcomes across socioeconomic groups. Through selected review of the many studies on health insurance, access, outcomes, and socioeconomic status, it establishes that a core links affected populations, their difficulty in financing health care, and the threat to their well-being. In so doing, it cites findings that strongly associate lack of insurance (especially for persons who live in poverty), inability to obtain services, and adverse health outcomes. It also uses the example of Medicaid and other coverage for HIV-infected persons in particular as an important positive instance in which leveling the discrepancies in health care across socioeconomic groups can move toward creating quality in access and outcomes. The competitive pressures in today's health care environment threaten to drive socioeconomic groups further apart, especially insured and uninsured persons. However, the recent enactment of state actions, especially the State Child Health Insurance Program, represent powerful examples of health insurance expansion that have lessons for policymakers at all levels for the monitoring and reduction of socioeconomic disparities.
TL;DR: Clinical characteristics, time course until the onset of disease, response to treatment, and outcomes in 60 patients with ticlopidine-associated thrombotic throm bocytopenic purpura are described.
Abstract: Background: Thrombotic thrombocytopenic purpura, a life-threatening multisystem disease, has been infrequently associated with use of ticlopidine, a platelet anti-aggregating agent. Purpose: To rev...