Showing papers in "JAMA in 1988"
TL;DR: Assessing quality depends on whether one assesses only the performance of practitioners or also the contributions of patients and of the health care system, on how broadly health and responsibility for health are defined, and on whether the maximally effective or optimally effective care is sought.
Abstract: Before assessment can begin we must decide how quality is to be defined and that depends on whether one assesses only the performance of practitioners or also the contributions of patients and of the health care system; on how broadly health and responsibility for health are defined; on whether the maximally effective or optimally effective care is sought; and on whether individual or social preferences define the optimum. We also need detailed information about the causal linkages among the structural attributes of the settings in which care occurs, the processes of care, and the outcomes of care. Specifying the components or outcomes of care to be sampled, formulating the appropriate criteria and standards, and obtaining the necessary information are the steps that follow. Though we know much about assessing quality, much remains to be known. (JAMA1988;260:1743-1748)
5,353 citations
TL;DR: The association of low-density lipoprotein (LDL) subclass patterns with coronary heart disease was investigated in a case-control study of nonfatal myocardial infarction and multivariate logistic regression analyses showed that both high-density cholesterol and triglyceride levels contributed to the risk associated with the small, dense LDL subclass pattern.
Abstract: The association of low-density lipoprotein (LDL) subclass patterns with coronary heart disease was investigated in a case-control study of nonfatal myocardial infarction. Subclasses of LDL were analyzed by gradient gel electrophoresis of plasma samples from 109 cases and 121 controls. The LDL subclass pattern characterized by a preponderance of small, dense LDL particles was significantly associated with a threefold increased risk of myocardial infarction, independent of age, sex, and relative weight. Plasma levels of high-density lipoprotein cholesterol were decreased, and levels of triglyceride, very low—density lipoproteins, and intermediate-density lipoproteins were increased in subjects with this LDL subclass pattern. Multivariate logistic regression analyses showed that both high-density lipoprotein cholesterol and triglyceride levels contributed to the risk associated with the small, dense LDL subclass pattern. Thus, the metabolic trait responsible for this LDL subclass pattern results in a set of interrelated lipoprotein changes that lead to increased risk of coronary heart disease. (JAMA1988;260:1917-1921)
1,772 citations
TL;DR: Twenty-one percent of 292 patients with untreated borderline hypertension were found to have normal daytime ambulatory pressures, and patients with white coat hypertension were defined as having "white coat" hypertension, and they were more likely to be female and younger, to weigh less, and to be more recently diagnosed.
Abstract: Twenty-one percent of 292 patients with untreated borderline hypertension (clinic diastolic blood pressures persistently between 90 and 104 mm Hg) were found to have normal daytime ambulatory pressures (defined from a population of normotensive subjects). These patients were defined as having "white coat" hypertension, and they were more likely to be female and younger, to weigh less, and to be more recently diagnosed than patients whose pressure was elevated both in the clinic and during ambulatory monitoring. Patients with white coat hypertension did not show a generalized increase of blood pressure lability, nor an exaggerated pressor response while at work. The phenomenon is more pronounced when blood pressure is measured by a physician than by a technician. In such patients, the pressor response may be relatively specific to the physician's office and lead to significant misclassification of hypertension.
1,150 citations
TL;DR: It is suggested that, for appropriately selected patients, comprehensive cardiac rehabilitation has a beneficial effect on mortality but not on nonfatal recurrent myocardial infarction.
Abstract: Randomized clinical trials of cardiac rehabilitation following myocardial infarction have typically demonstrated a lower mortality in treated patients, but with a statistically significant reduction in only one trial. To overcome the problem of not being able to detect small but clinically important benefits in mortality in randomized clinical trials of exercise and risk factor rehabilitation after myocardial infarction with small numbers of patients, we carried out a meta-analysis on the combined results of ten randomized clinical trials that included 4347 patients (control, 2145 patients; rehabilitation, 2202 patients). The pooled odds ratios of 0.76 (95% confidence intervals, 0.63 to 0.92) for all-cause death and of 0.75 (95% confidence intervals, 0.62 to 0.93) for cardiovascular death were significantly lower in the rehabilitation group than in the control group, with no significant difference for nonfatal recurrent myocardial infarction. These results suggest that, for appropriately selected patients, comprehensive cardiac rehabilitation has a beneficial effect on mortality but not on nonfatal recurrent myocardial infarction. ( JAMA 1988;260:945-950)
1,082 citations
TL;DR: The results of this study suggest that both elevating HDL and lowering LDL cholesterol levels are effective in the primary prevention of CHD.
Abstract: In the Helsinki Heart Study, a randomized five-year, double-blind trial, a 34% reduction in the incidence of coronary heart disease (CHD) was observed in dyslipidemic men treated with gemfibrozil. Averaged over the five years of the trial, gemfibrozil therapy produced, compared with placebo, mean decreases of 10% in serum total cholesterol level, 14% in non-high-density lipoprotein (HDL) cholesterol level, 11% in low-density lipoprotein (LDL) cholesterol level, 35% in triglyceride level, and a mean increase of 11% in HDL cholesterol level from baseline levels measured prior to treatment. While changes in HDL cholesterol level were similar in all Fredrickson types, the effect on concentrations of total cholesterol and LDL cholesterol was largest in type IIA and on LDL minimal in type IV. The reduction of CHD incidence over placebo was largest in type IIB and smallest in type IIA. The lipid changes were dependent on lipid levels prior to treatment and on compliance with the medication regimen. When risk factors for CHD, including age, blood pressure, smoking and drinking habits, baseline lipid levels, and exercise and relative weight, were controlled by applying the Cox proportional hazards model, the changes in serum HDL and LDL cholesterol levels were both statistically significantly associated with the decline in CHD incidence within the gemfibrozil-treated group. The large decrease in serum triglyceride levels had relatively small effect on CHD incidence. Thus, the results of this study, together with earlier observations, suggest that both elevating HDL and lowering LDL cholesterol levels are effective in the primary prevention of CHD. (JAMA1988;260:641-651)
979 citations
TL;DR: Smoking was significantly related to stroke after age and hypertension were taken into account and even after pertinent cardiovascular disease risk factors were added to the Cox model, cigarette smoking continued to make a significant independent contribution to the risk of stroke generally and brain infarction specifically.
Abstract: The impact of cigarette smoking on stroke incidence was assessed in the Framingham Heart Study cohort of 4255 men and women who were aged 36 to 68 years and free of stroke and transient ischemic attacks. During 26 years of follow-up, 459 strokes occurred. Regardless of smoking status and in each sex, hypertensive subjects had twice the incidence of stroke. Using the Cox proportional hazard regression method, smoking was significantly related to stroke after age and hypertension were taken into account. Even after pertinent cardiovascular disease risk factors were added to the Cox model, cigarette smoking continued to make a significant independent contribution to the risk of stroke generally and brain infarction specifically. The risk of stroke increased as the number of cigarettes smoked increased. The relative risk of stroke in heavy smokers (>40 cigarettes per day) was twice that of light smokers (fewer than ten cigarettes per day). Lapsed smokers developed stroke at the same level as nonsmokers soon after stopping. Stroke risk decreased significantly by two years and was at the level of nonsmokers by five years after cessation of cigarette smoking. ( JAMA 1988;259:1025-1029)
814 citations
TL;DR: Meta-analysis predicted that a team of physicians and nonphysicians using multiple intervention modalities to deliver individualized advice on multiple occasions would produce the best result in controlled smoking cessation trials.
Abstract: Meta-analysis was used to examine 108 intervention comparisons in 39 controlled smoking cessation trials. Type of intervention (face-to-face advice being better than all others), type of intervenor (both physician and nonphysician counselors better than either alone), the number of reinforcing sessions, and the duration of reinforcing sessions were related to success six months after the initiation of intervention. The number of modalities used by the intervention predicted success with borderline statistical significance. Multivariate analysis predicted that a team of physicians and nonphysicians using multiple intervention modalities to deliver individualized advice on multiple occasions would produce the best result. Program success 12 months after the initiation of intervention was related to the type of intervention session (group and individual sessions combined better than either alone), the number of intervention modalities, and the number of reinforcing sessions. With multivariate adjustment for confounding, the number of intervention modalities alone had a positive association with intervention success. ( JAMA 1988;259:2882-2889)
761 citations
605 citations
TL;DR: The epidemic rise in S enteritidis infections due to Grade A shell eggs is unlike past problems of salmonellosis associated with cracked or soiled eggs and raises the possibility of trans-ovarian contamination of eggs with S Enteritidis.
Abstract: From 1976 to 1986, reported Salmonella enteritidis infections increased more than sixfold in the northeastern United States. From January 1985 to May 1987, sixty-five foodborne outbreaks of S enteritidis were reported in the Northeast that were associated with 2119 cases and 11 deaths. Twenty-seven (77%) of the 35 outbreaks with identified food vehicles were caused by Grade A shell eggs or foods that contained such eggs. National data from 1973 to 1984 showed that S enteritidis outbreaks (44%) were more frequently associated with egg-containing foods than were outbreaks of other Salmonella serotypes (15%). Reflecting the geographic distribution of human illness, cultures of bulk raw eggs from pasteurization plants in the Northeast more frequently yielded S enteritidis (10%) than did eggs from other regions of the United States (0%). The epidemic rise in S enteritidis infections due to Grade A shell eggs is unlike past problems of salmonellosis associated with cracked or soiled eggs and raises the possibility of transovarian contamination of eggs with S enteritidis . New techniques may therefore be needed to control resurgent egg-associated salmonellosis in the United States. ( JAMA 1988;259:2103-2107)
563 citations
TL;DR: A strong and consistent relationship between hyperglycemia and incidence and progression of retinopathy is suggested, after controlling for duration of diabetes, age, sex, and baselineretinopathy.
Abstract: The relationship between hyperglycemia, measured by glycosylated hemoglobin at the initial examination, and the four-year incidence and progression of diabetic retinopathy was examined in a population-based study in Wisconsin Younger- (n = 891) and older-onset (n = 987) persons participating in baseline and follow-up examinations were included Glycosylated hemoglobin was measured by microcolumn Retinopathy was determined from stereoscopic fundus photographs In the younger-onset group, comparing the highest with the lowest quartile of glycosylated hemoglobin, the relative risk for developing any diabetic retinopathy was 19; for proliferative retinopathy, 218; and for progression, 40 Among older-onset persons taking insulin, the corresponding relative risks were 19, 40, and 21 Among older-onset persons not taking insulin, relative risks were 40 for any retinopathy and 62 for progression A positive relationship between incidence and progression of retinopathy and glycosylated hemoglobin remained after controlling for duration of diabetes, age, sex, and baseline retinopathy These data suggest a strong and consistent relationship between hyperglycemia and incidence and progression of retinopathy ( JAMA 1988;260:2864-2871)
562 citations
TL;DR: Captopril treatment is significantly more effective than placebo and is an alternative to digoxin therapy in patients with mild to moderate heart failure who are receiving diuretic maintenance therapy.
Abstract: This multicenter, double-blind, placebo-controlled study compares the effects of captopril treatment with those of digoxin treatment during maintenance diuretic therapy in patients with mild to moderate heart failure. Compared with placebo, captopril therapy resulted in significantly improved exercise time (mean increase, 82 s vs 35 s) and improved New York Heart Association class (41% vs 22%), but digoxin therapy did not. Digoxin treatment increased ejection fraction (4.4% increase) compared with captopril therapy (1.8% increase) and placebo (0.9% increase). The number of ventricular premature beats decreased 45% in the captopril group and increased 4% in the digoxin group in patients with more than ten ventricular premature beats per hour. Treatment failures, increased requirements for diuretic therapy, and hospitalizations were significantly more frequent in patients receiving placebo compared with those receiving either active drug. Transitory hypotension occurred more frequently with administration of captopril. Captopril treatment is significantly more effective than placebo and is an alternative to digoxin therapy in patients with mild to moderate heart failure who are receiving diuretic maintenance therapy. ( JAMA 1988;259:539-544)
TL;DR: The high prevalence, persistence, and functional consequences of fatigue mandate a search for effective therapy.
Abstract: Although fatigue is one of the most common complaints in ambulatory care, research has been minimal Of the 1159 consecutive patients surveyed in two adult primary-care clinics, 276 (24%) indicated that fatigue was a major problem Fatigue was more prevalent in women than in men (28% vs 19%) Extensive clinical, laboratory, psychometric, and functional data were gathered for 102 fatigued patients and 26 controls Laboratory testing was not useful in detecting unsuspected medical conditions or in determining the cause of fatigue Depression or somatic anxiety or both were suggested by screening psychometric instruments in 82 fatigued patients (80%) compared with three controls (12%) Global dysfunction was marked, as reported by patients on the Sickness Impact Profile The mean score on the Sickness Impact Profile of 113 for fatigued patients is similar to that reported for patients with major medical illnesses After one year of follow-up, only 29 fatigued patients (28%) had improved The high prevalence, persistence, and functional consequences of fatigue mandate a search for effective therapy ( JAMA 1988;260:929-934)
TL;DR: Fourteen of the 15 patients who received tretinoin to the face had improvement in photoaging, whereas none of the vehicle-treated patients' faces improved, a statistically significant difference in response between the two groups.
Abstract: In a 16-week randomized, double-blind, vehicle-controlled study of topical tretinoin in the treatment of photoaging, all patients applied topical tretinoin to one forearm and vehicle cream to the other. Half of the patients received tretinoin to the face, and half received vehicle cream. All 30 patients who completed the study showed statistically significant improvement in photoaging on the tretinoin-treated forearms, but not on the vehicle-treated forearms. Fourteen of the 15 patients who received tretinoin to the face had improvement in photoaging, whereas none of the vehicle-treated patients' faces improved, a statistically significant difference in response between the two groups. Statistically significant histologic changes were seen in forearm skin treated with tretinoin, but not with vehicle cream. Side effects were limited to irritation of tretinoin-exposed skin. ( JAMA 1988;259:527-532)
TL;DR: Food-sensitive individuals must self-administer epinephrine promptly at the first sign of systemic reaction, and emergency care providers should be aware of cricothyrotomy as a life-saving procedure.
Abstract: Fatal food-induced anaphylaxis is rarely reported. In 16 months, we identified seven such cases involving five males and two females, aged 11 to 43 years. All victims were atopic with multiple prior anaphylactic episodes after ingestion of the incriminated food (peanut, four; pecan, one; crab, one; fish, one). In six cases the allergenic food was ingested away from home. Factors contributing to the severity of individual reactions included denial of symptoms, concomitant intake of alcohol, reliance on oral antihistamines alone to treat symptoms, and adrenal suppression by chronic glucocorticoid therapy for coexisting asthma. In no case was epinephrine administered immediately after onset of symptoms. Premortem or postmortem serum samples were available from six victims; in each case elevated levels of IgE antibodies to the incriminated food were demonstrated. Food-sensitive individuals must self-administer epinephrine promptly at the first sign of systemic reaction. Emergency care providers should be aware of cricothyrotomy as a life-saving procedure. ( JAMA 1988;260:1450-1452)
TL;DR: The evidence indicates that educational intervention strategies should begin as early as junior high school; the intervention should not be directed only toward those individuals who participate in school-based athletics.
Abstract: The use of anabolic-androgenic steroids (AS) is perceived by the media, by segments of the sports medicine and athletic communities, and by the public to have grown to epidemic proportions. Unfortunately, the incidence and prevalence of AS use among elite, amateur, and recreational athletes is poorly documented. This study was designed to help identify AS use patterns among the male portion of the general adolescent population. The overall participation rate on a schoolwide basis was 68.7% and on an individual basis reached 50.3%. Participants in this investigation were 12th-grade male students (N = 3403) in 46 private and public high schools across the nation who completed a questionnaire that established current or previous use of AS as well as user and nonuser characteristics. Results indicate that 6.6% of 12th grade male students use or have used AS and that over two thirds of the user group initiated use when they were 16 years of age or younger. Approximately 21% of users reported that a health professional was their primary source. The evidence indicates that educational intervention strategies should begin as early as junior high school; the intervention should not be directed only toward those individuals who participate in school-based athletics. (JAMA1988;260:3441-3445)
TL;DR: Daniel's attempt to demonstrate the superiority of his simple diet was criticized, because the sample size, four subjects on the experimental diet and a larger unspecified number on kingly fare, was too small to be likely to detect a difference in outcome.
Abstract: WHEN Daniel 1 requested that he and his compatriots be served pulse and water while Nebuchadnezzar's other young servants be served the king's food and wine, he was inaugurating the first recorded clinical trial. Today we would criticize Daniel's attempt to demonstrate the superiority of his simple diet. He failed to assign the two diets at random; neither the experimental subjects nor the eunuchs who were to measure the ten-day outcome, fairness of countenance, were blinded to the treatment; and the sample size, four subjects on the experimental diet and a larger unspecified number on kingly fare, was too small to be likely to detect a difference in outcome. Despite, or perhaps because of, the faulty design, the results supported Daniel's hypothesis. "And at the end of ten days their countenances appeared fairer, and they were fatter in flesh, than all the youths that did eat of the king's food."
TL;DR: It is concluded that in the diabetic patient who survives an MI, cardiac failure is a common occurrence, warranting early detection and vigorous management in periods of convalescence and follow-up, particularly in women, where its effect on survivorship is considerable.
Abstract: The impact of diabetes on recurrent myocardial infarction (MI) and fatal coronary heart disease was examined in survivors of an initial MI using 34-year follow-up data in the Framingham Study. Among nondiabetic patients, the risk of fatal coronary heart disease was significantly lower in women compared with men (relative risk, 0.6). In the presence of diabetes, however, the risk of recurrent MI in women was twice the risk in men. In addition, the effect of diabetes doubled the risk of recurrent MI in women (relative risk, 2.1) but had an insignificant effect in men. Increased susceptibility to cardiac failure among diabetic women was an important factor in determining survivorship. Women with diabetes developed cardiac failure four times more often (16%) than women without diabetes (3.8%). Furthermore, when cardiac failure developed, 25% of diabetic women experienced a recurrent MI or fatal coronary event, more than doubling the rate when diabetes was absent. We conclude that in the diabetic patient who survives an MI, cardiac failure is a common occurrence, warranting early detection and vigorous management in periods of convalescence and follow-up. In addition, when cardiac failure appears, control of diabetes assumes added importance, particularly in women, where its effect on survivorship is considerable. ( JAMA 1988;260:3456-3460)
TL;DR: Findings are highly suggestive of an important role of clonidine in smoking cessation, and warrant further studies to establish the long-term efficacy of this drug and to replicate the association between nicotine dependence and depression.
Abstract: Seventy-one heavy smokers who had failed in previous attempts to stop smoking participated in a randomized clinical trial to test the efficacy of clonidine as an aid in smoking cessation. The success rate in clonidine-treated subjects (verified by serum cotinine concentration) was more than twice that in the placebo-treated subjects. When the data were stratified by gender, a strong effect present in women was not apparent in men. After six months, cessation rates remained significantly higher among smokers treated with clonidine than those receiving placebo. The data also revealed an unexpectedly high prevalence (61%) of a history of major depression in this sample and a significant negative effect of such a history on cessation regardless of treatment. These findings, highly suggestive of an important role of clonidine in smoking cessation, warrant further studies to establish the long-term (≥12 months) efficacy of this drug and to replicate the association between nicotine dependence and depression. ( JAMA 1988;259:2863-2866)
TL;DR: The positive predictive values of the LNMP GA estimates decreased dramatically from term to preterm to postterm, and the systematic errors in menstrual GA estimates have profound implications for unnecessary induction, dysfunctional labor and cesarean section, and resultant neonatal and maternal morbidity.
Abstract: Despite recognition that estimation of gestational age (GA) based on maternal recollection of the last normal menstrual period (LNMP) is fraught with error, it is not generally appreciated that the magnitude and direction of this error vary as a function of the LNMP estimate Early second-trimester (16 to 18 weeks) ultrasound determinations of the fetal biparietal diameter were used as the "gold standard" to test the validity of LNMP-based GA estimates in 11 045 women The large majority of deliveries occurring at or near term showed LNMP estimates that were valid within plus or minus seven days of the ultrasound estimate As the LNMP GA deviated progressively toward earlier or later GAs, however, the discrepancies became quite marked, especially for postterm dates The positive predictive values of the LNMP GA estimates decreased dramatically from term (949) to preterm (775) to postterm (119) deliveries These systematic errors in menstrual GA estimates have profound implications for unnecessary induction, dysfunctional labor and cesarean section, and resultant neonatal and maternal morbidity ( JAMA 1988;260:3306-3308)
TL;DR: The multiplication of techniques for imaging and studying the bone and soft tissues has made choosing the best method for examination of the patient more difficult and, in an environment in which cost-effectiveness has become a byword, more important.
Abstract: The first edition (1981) of this comprehensive work weighed 25 lb and had 3300 pages. This entirely new third edition, published 14 years later, has grown to 45 lb and 4850 pages. This growth is not due to inflation but is the direct result of the information explosion. The multiplication of techniques for imaging and studying the bone and soft tissues has made choosing the best method for examination of the patient more difficult and, in an environment in which cost-effectiveness has become a byword, more important. An underlying principle of this work is to guide the physician in the choice of the technology to be employed to get essential information quickly and efficiently. Dr Resnick has called on a group of 40 contributors for special information, but he himself has played a major role in the writing and has been more than an editor, thereby ensuring a consistent and
TL;DR: An overall apparent protective effect of periconceptional multivitamin use on the occurrence of neural tube defects is found, with a crude estimated relative risk of 0.40 (95% confidence interval, 0.25 to 0.63).At this time, it is not possible to determine whether this apparently lower risk is the direct result of multiv vitamin use or the result of other characteristics of women who use multivitamins.
Abstract: We studied the association between multivitamin use during the periconceptional period and the occurrence of neural tube defects using data from the Atlanta Birth Defects Case-Control Study. There were 347 babies with neural tube defects who were live born or stillborn to residents of metropolitan Atlanta from 1968 through 1980. The 2829 control-babies born without birth defects were randomly selected through birth certificates. Periconceptional multivitamin use was defined as reported use for each of the three months before conception through the first three months of pregnancy. Mothers who reported not using multivitamins any time during the six-month period were defined as nonusers. Fourteen percent of mothers reported periconceptional multivitamin use and 40% reported nonuse. Multivitamin users were different from nonusers in a number of demographic, health-related, and life-style characteristics. We found an overall apparent protective effect of periconceptional multivitamin use on the occurrence of neural tube defects, with a crude estimated relative risk of 0.40 (95% confidence interval, 0.25 to 0.63). At this time, it is not possible to determine whether this apparently lower risk is the direct result of multivitamin use or the result of other characteristics of women who use multivitamins. ( JAMA 1988;260:3141-3145)
TL;DR: The operation was effective in reducing symptoms and improvement in indices of quality of life occurred only among patients with acute retention or severe symptoms prior to surgery, emphasizing the importance of patient participation in the decision to undergo prostatectomy.
Abstract: When prostatectomy is proposed as treatment for the symptoms of prostatism, the decision to operate should depend on how patients evaluate their symptoms and on objective information about the outcomes. We undertook a health interview study to determine the probabilities for symptom relief, improvement in the quality of life, and complications following surgery and to evaluate patient concern about the symptoms of prostatism. The operation was effective in reducing symptoms: 93% of severely and 79% of moderately symptomatic patients experienced improvement; however, a statistically significant improvement in indices of quality of life occurred only among patients with acute retention or severe symptoms prior to surgery. Short-term complications of varying severity occurred in 24% of patients; in addition, 4% reported persistent incontinence and 5%, impotence. Patients with similar symptoms reported considerable difference in the degree to which they were bothered by their symptoms. The result emphasizes the importance of patient participation in the decision to undergo prostatectomy. ( JAMA 1988;259:3018-3022)
TL;DR: It is suggested that genital ulcerative diseases are an important risk factor for the acquisition of HIV infection in homosexual men; measures directed at control of these diseases may reduce the transmission of HIV in this population.
Abstract: We analyzed the association of herpes simplex virus (HSV) infection and syphilis, the two most common causes of genital ulceration in homosexual men, with human immunodeficiency virus (HIV) infection in 200 men enrolled between 1983 and 1986 into a study evaluating the microbial causes of acute proctitis. Infection with HIV was independently associated with a history of syphilis, serologic evidence of syphilis, a history of HSV infection, and antibody to HSV-2. Antibody to HIV was not associated with a history of other genital infections or with antibody to Chlamydia trachomatis or HSV-1. Similar associations were observed in 111 asymptomatic homosexuals seen for HIV screening. Men who presented with primary HSV proctitis had a lower prevalence of HIV antibody than those with preexisting HSV-2 antibody (44% vs 68%); this suggests that HSV-2 infection antedated HIV infection. These data suggest that genital ulcerative diseases are an important risk factor for the acquisition of HIV infection in homosexual men; measures directed at control of these diseases may reduce the transmission of HIV in this population. ( JAMA 1988;260:1429-1433)
TL;DR: It is concluded that inpatient death rates depend on length-of-stay patterns and give a biased picture of mortality.
Abstract: To assess the meaning of hospital-associated death rates, we studied whether mortality within 30 days of hospital admission (30-day mortality) is more informative than inpatient mortality and whether detailed assessment of additional discharge diagnoses helps in understanding death rates. We examined hospitalizations for elderly Medicare patients with principal diagnoses of stroke, bacterial pneumonia, myocardial infarction, and congestive heart failure; these conditions account for 30.8% of Medicare 30-day mortality. Average hospital stays for these conditions were 99.0% longer, and inpatient mortality was 25.0% higher in New York than in California, but 30-day mortality was 1.6% higher in California. We conclude that inpatient death rates depend on length-of-stay patterns and give a biased picture of mortality. Additional diagnoses such as shock and pneumonia were strongly associated with increased mortality, but Medicare data do not reveal which patients had these conditions at the time of admission. Recorded diagnoses of chronic diseases such as hypertension, diabetes mellitus, obesity, benign prostatic hypertrophy, and osteoarthritis were commonly associated with reduced risk of death; such reduced risk is not clinically plausible. Several lines of evidence suggest that chronic disorders are underreported for patients with life-threatening disorders. We recommend great caution in using discharge diagnoses of comorbid conditions to adjust hospital death rates for clinical differences in the patient populations.
TL;DR: Cardiopulmonary resuscitation should be administered only to those who have the greatest potential benefit from this emotionally and physically traumatic procedure, and the presence of sepsis, cancer, increased age, increased number of medication doses administered, and absence of witness were all "predictive" of poor outcome.
Abstract: A retrospective review of 399 cardiopulmonary resuscitation (CPR) efforts in 329 veterans was performed to evaluate the observation that few geriatric patients were discharged alive after they underwent CPR. Cardiopulmonary resuscitation efforts with witnessed arrests were more frequently successful than efforts with unwitnessed arrests (47.7% vs 29.9%) and resulted in live discharge more often than efforts with unwitnessed arrests. Cardiopulmonary resuscitation efforts that resulted in a live discharge were more brief and involved a lower mean number of medication doses. Of the 77 CPR efforts in patients 70 years of age or older who had arrests, 24 (31%) were successful, and in 22 (92%), patients were alive after 24 hours. None lived to discharge. There were 322 CPR efforts in the younger cohort; 137 (43%) were successful, in 124 (91%) of these 137 efforts, patients were alive after 24 hours, and in 22 (16%), patients were discharged alive. Older patients were significantly less likely to live to discharge both at the time of arrest and 24 hours after successful resuscitation. When a multivariate analysis was used, the presence of sepsis, cancer, increased age, increased number of medication doses administered, and absence of witness were all "predictive" of poor outcome. Cardiopulmonary resuscitation should be administered only to those who have the greatest potential benefit from this emotionally and physically traumatic procedure.
TL;DR: Randy Shilts' engaging, horrifying, although ultimately frustrating book about the early years of the acquired immunodeficiency syndrome (AIDS) epidemic in the United States is an American morality play— isolated heroes against an indifferent system.
Abstract: It is no less true of reading than of eating: how things taste is not a perfect measure of nutritive value. So it is with Randy Shilts' engaging, horrifying, although ultimately frustrating book about the early years of the acquired immunodeficiency syndrome (AIDS) epidemic in the United States. Shilts, a San Francisco journalist with extensive experience reporting on the San Francisco homosexual community, has amassed an astonishing compendium of AIDS anecdotes from victims, politicians, medical researchers, gay newspapers, medical literature, and government documents. The book is organized chronologically, giving the exponentially mounting victim count, a count that compellingly compresses the months of the unfolding disaster. This is an American morality play— isolated heroes against an indifferent system. The heroes are gay activists, who struggled to have their community recognize the new link between an ideology of promiscuity and death, and astute epidemiologists, who diverted resources and their careers to track
TL;DR: Development of P carinii pneumonia was associated with the stage of Kaposi's sarcoma, B subtype disease, and the presence of 0.20 × 109/L (200/mm 3 ) or fewer CD4 cells at study entry.
Abstract: The safety and efficacy of sulfamethoxazole and trimethoprim in the prevention of Pneumocystis carinii pneumonia associated with the acquired immunodeficiency syndrome (AIDS) were evaluated. Sixty patients with a new diagnosis of Kaposi's sarcoma and no history of opportunistic infections were randomly assigned to receive 800 mg of sulfamethoxazole and 160 mg of trimethoprim twice per day or no therapy. None of the 30 patients receiving sulfamethoxazole and trimethoprim developed P carinii pneumonia. Sixteen of the 30 patients receiving no suppressive therapy developed P carinii pneumonia. Development of P carinii pneumonia was associated with the stage of Kaposi's sarcoma, B subtype disease, and the presence of 0.20 × 109/L (200/mm 3 ) or fewer CD4 cells at study entry. The proportion of patients surviving and the mean length of survival were significantly greater in the treatment group compared with the control group. Adverse reactions occurred in 15 patients (50%). ( JAMA 1988;259:1185-1189)
TL;DR: It is concluded that AIDS represents a significant risk factor for suicide in New York City residents diagnosed with the acquired immunodeficiency syndrome (AIDS) in 1985.
Abstract: The rate of suicide has been reported to be higher in persons with chronic and life-threatening illnesses (eg, cancer, Huntington's disease, and renal failure). We studied the rate of suicide in 1985 in New York City residents diagnosed with the acquired immunodeficiency syndrome (AIDS). There were 668 suicides in New York City residents in 1985, yielding a rate of 9.29 per 100000 personyears. In men aged 20 to 59 years without a known diagnosis of AIDS, the rate was 18.75 per 100000 person-years. There were 3828 individuals who lived with the diagnosis of AIDS for some part, or all, of 1985. There were 12 suicides in men aged 20 to 59 years from this group who lived 1763.25 person-years with a diagnosis of AIDS. This yields a suicide rate of 680.56 per 100000 person-years. Thus, the relative risk of suicide in men with AIDS aged 20 to 59 years was 36.30 times (95% confidence limits, 20.45 to 64.42) that of men aged 20 to 59 years without this diagnosis, and 66.15 times (95% confidence limits, 37.38 to 117.06) that of the general population. We conclude that AIDS represents a significant risk factor for suicide. ( JAMA 1988;259:1333-1337)
TL;DR: Total mortality was significantly lower for metoprolol than for thiazide diuretics because of fewer deaths from coronary heart disease and stroke and the benefit demonstrated in patients treated with metoprole seems to have important implications for clinical practice.
Abstract: The present study of primary prevention in white men aged 40 to 64 years attempts to investigate whether a β-blocker given as initial antihypertensive treatment would lower total mortality to a greater extent than thiazide diuretics. Patients were randomized to metoprolol (n = 1609, 8110 patient-years) or a thiazide diuretic (n = 1625, 8070 patient-years). The median follow-up time was 4.2 years. The mean dose of metoprolol was 174 mg/d, and of thiazide diuretics, 46 mg/d of hydrochlorothiazide or 4.4 mg/d of bendroflumethiazide. Identical control of blood pressure was achieved using a fixed therapeutic schedule. Total mortality was significantly lower for metoprolol than for thiazide diuretics because of fewer deaths from coronary heart disease and stroke. Total mortality was also significantly lower in smokers randomized to metoprolol. The benefit demonstrated in patients treated with metoprolol seems to have important implications for clinical practice. (JAMA1988;259:1976-1982)
TL;DR: F fluorouracil-containing regimens resulted in a small benefit of therapy in terms of overall survival, with a mortality odds ratio of 0.83 in favor of therapy, which would be far from negligible in a common case of malignancy with long survival expectancy.
Abstract: All randomized controlled trials of adjuvant therapy of colorectal cancer, published up to December 1986 in English, were reviewed. Eight trials compared radiotherapy groups with control groups in rectal cancer (3062 patients), and 17 trials compared chemotherapy groups with control groups in colorectal cancer (6791 patients). The results of trials testing radiotherapy or chemotherapy were combined. Fluorouracil-containing regimens resulted in a small benefit of therapy in terms of overall survival, with a mortality odds ratio of 0.83 in favor of therapy (95% confidence interval, 0.70 to 0.98). All other combinations of trials failed to show statistically significant differences between treated and control patients, even though the odds of death tended to be slightly lower in treated patients, especially those with rectal tumors. Some overall survival benefit from adjuvant therapy cannot be excluded, but it is likely small. Such small benefit, if real, would be far from negligible in a common case of malignancy with long survival expectancy. Trials much larger than those published up to now are needed. (JAMA1988;259:3571-3578)