Showing papers in "JAMA in 1990"
TL;DR: Comorbidity of addictive and severe mental disorders was highest in the prison population, most notably with antisocial personality, schizophrenia, and bipolar disorders.
Abstract: The prevalence of comorbid alcohol, other drug, and mental disorders in the US total community and institutional population was determined from 20 291 persons interviewed in the National Institute of Mental Health Epidemiologic Catchment Area Program. Estimated US population lifetime prevalence rates were 22.5% for any non—substance abuse mental disorder, 13.5% for alcohol dependence-abuse, and 6.1% for other drug dependence-abuse. Among those with a mental disorder, the odds ratio of having some addictive disorder was 2.7, with a lifetime prevalence of about 29% (including an overlapping 22% with an alcohol and 15% with another drug disorder). For those with either an alcohol or other drug disorder, the odds of having the other addictive disorder were seven times greater than in the rest of the population. Among those with an alcohol disorder, 37% had a comorbid mental disorder. The highest mental-addictive disorder comorbidity rate was found for those with drug (other than alcohol) disorders, among whom more than half (53%) were found to have a mental disorder with an odds ratio of 4.5. Individuals treated in specialty mental health and addictive disorder clinical settings have significantly higher odds of having comorbid disorders. Among the institutional settings, comorbidity of addictive and severe mental disorders was highest in the prison population, most notably with antisocial personality, schizophrenia, and bipolar disorders. (JAMA. 1990;264:2511-2518)
6,102 citations
TL;DR: Follow-up and angiography together suggest pulmonary embolism occurred among 12% of patients with low-probability scans, and clinical assessment combined with the ventilation/perfusion scan established the diagnosis or exclusion of pulmonary emblism only for a minority of patients--those with clear and concordant clinical and ventilation-perfusions scan findings.
Abstract: To determine the sensitivities and specificities of ventilation/perfusion lung scans for acute pulmonary embolism, a random sample of 933 of 1493 patients was studied prospectively. Nine hundred thirty-one underwent scintigraphy and 755 underwent pulmonary angiography; 251 (33%) of 755 demonstrated pulmonary embolism. Almost all patients with pulmonary embolism had abnormal scans of high, intermediate, or low probability, but so did most without pulmonary embolism (sensitivity, 98%; specificity, 10%). Of 116 patients with high-probability scans and definitive angiograms, 102 (88%) had pulmonary embolism, but only a minority with pulmonary embolism had high-probability scans (sensitivity, 41%; specificity, 97%). Of 322 with intermediate-probability scans and definitive angiograms, 105 (33%) had pulmonary embolism. Follow-up and angiography together suggest pulmonary embolism occurred among 12% of patients with low-probability scans. Clinical assessment combined with the ventilation/perfusion scan established the diagnosis or exclusion of pulmonary embolism only for a minority of patients--those with clear and concordant clinical and ventilation/perfusion scan findings.
2,468 citations
TL;DR: It is concluded that high-resistance weight training leads to significant gains in muscle strength, size, and functional mobility among frail residents of nursing homes up to 96 years of age.
Abstract: Muscle dysfunction and associated mobility impairment, common among the frail elderly, increase the risk of falls, fractures, and functional dependency. We sought to characterize the muscle weakness of the very old and its reversibility through strength training. Ten frail, institutionalized volunteers aged 90 ± 1 years undertook 8 weeks of high-intensity resistance training. Initially, quadriceps strength was correlated negatively with walking time (r= -.745). Fat-free mass (r=.732) and regional muscle mass (r=.752) were correlated positively with muscle strength. Strength gains averaged 174% ±31% (mean ± SEM) in the 9 subjects who completed training. Midthigh muscle area increased 9.0%± 4.5%. Mean tandem gait speed improved 48% after training. We conclude that high-resistance weight training leads to significant gains in muscle strength, size, and functional mobility among frail residents of nursing homes up to 96 years of age. (JAMA. 1990;263:3029-3034)
2,186 citations
TL;DR: Major changes were instituted to more clearly define when prophylaxis is or is not recommended, improve practitioner and patient compliance, reduce cost and potential gastrointestinal adverse effects, and approach more uniform worldwide recommendations.
Abstract: Objective. —To update recommendations issued by the American Heart Association last published in 1990 for the prevention of bacterial endocarditis in individuals at risk for this disease. Particpants. —An ad hoc writing group appointed by the American Heart Association for their expertise in endocarditis and treatment with liaison members representing the American Dental Association, the Infectious Diseases Society of America, the American Academy of Pediatrics, and the American Society for Gastrointestinal Endoscopy. Evidence. —The recommendations in this article reflect analyses of relevant literature regarding procedure-related endocarditis, in vitro susceptibility data of pathogens causing endocarditis, results of prophylactic studies in animal models of endocarditis, and retrospective analyses of human endocarditis cases in terms of antibiotic prophylaxis usage patterns and apparent prophylaxis failures. MEDLINE database searches from 1936 through 1996 were done using the root wordsendocarditis, bacteremia, andantibiotic prophylaxis. Recommendations in this document fall into evidence level III of the US Preventive Services Task Force categories of evidence. Consensus Process. —The recommendations were formulated by the writing group after specific therapeutic regimens were discussed. The consensus statement was subsequently reviewed by outside experts not affiliated with the writing group and by the Science Advisory and Coordinating Committee of the American Heart Association. These guidelines are meant to aid practitioners but are not intended as the standard of care or as a substitute for clinical judgment. Conclusions. —Major changes in the updated recommendations include the following: (1) emphasis that most cases of endocarditis are not attributable to an invasive procedure; (2) cardiac conditions are stratified into high-, moderate-, and negligible-risk categories based on potential outcome if endocarditis develops; (3) procedures that may cause bacteremia and for which prophylaxis is recommended are more clearly specified; (4) an algorithm was developed to more clearly define when prophylaxis is recommended for patients with mitral valve prolapse; (5) for oral or dental procedures the initial amoxicillin dose is reduced to 2 g, a follow-up antibiotic dose is no longer recommended, erythromycin is no longer recommended for penicillin-allergic individuals, but clindamycin and other alternatives are offered; and (6) for gastrointestinal or genitourinary procedures, the prophylactic regimens have been simplified. These changes were instituted to more clearly define when prophylaxis is or is not recommended, improve practitioner and patient compliance, reduce cost and potential gastrointestinal adverse effects, and approach more uniform worldwide recommendations.
1,468 citations
TL;DR: Publication bias is the tendency on the part of investigators, reviewers, and editors to submit or accept manuscripts for publication based on the direction or strength of the study findings.
Abstract: Publication bias is the tendency on the parts of investigators, reviewers, and editors to submit or accept manuscripts for publication based on the direction or strength of the study findings. Much of what has been learned about publication bias comes from the social sciences, less from the field of medicine. In medicine, three studies have provided direct evidence for this bias. Prevention of publication bias is important both from the scientific perspective (complete dissemination of knowledge) and from the perspective of those who combine results from a number of similar studies (meta-analysis). If treatment decisions are based on the published literature, then the literature must include all available data that is of acceptable quality. Currently, obtaining information regarding all studies undertaken in a given field is difficult, even impossible. Registration of clinical trials, and perhaps other types of studies, is the direction in which the scientific community should move. (JAMA. 1990;263:1385-1389)
1,326 citations
TL;DR: The threshold for identifying clinically significant depression may need to be reevaluated to include persons with fewer symptoms but measurable morbidity, only by changing the nosology can the societal impact of depression be adequately addressed.
Abstract: We describe the relationship of depression and depressive symptoms to disability days and days lost from work in 2980 participants in the Epidemiologic Catchment Area Study in North Carolina after 1 year of follow-up. Compared with asymptomatic individuals, persons with major depression had a 4.78 times greater risk of disability (95% confidence interval, 1.64 to 13.88), and persons with minor depression with mood disturbance, but not major depression, had a 1.55 times greater risk (95% confidence interval, 1.00 to 2.40). Because of its prevalence, individuals with minor depression were associated with 51% more disability days in the community than persons with major depression. This group was also at increased risk of having a concomitant anxiety disorder or developing major depression within 1 year. We conclude that the threshold for identifying clinically significant depression may need to be reevaluated to include persons with fewer symptoms but measurable morbidity. Only by changing our nosology can the societal impact of depression be adequately addressed. (JAMA. 1990;264:2524-2528)
1,241 citations
TL;DR: The association between cigarette smoking and major depression was not ubiquitous across all psychiatric diagnoses, and gender differences in rates of smoking and of smoking cessation observed in the larger population were not evident among the depressed group.
Abstract: A relationship between cigarette smoking and major depressive disorder was suggested in previous work involving nonrandomly selected samples. We conducted a test of this association, employing population-based data (n = 3213) collected between 1980 and 1983 in the St Louis Epidemiologic Catchment Area Survey of the National Institute of Mental Health. A history of regular smoking was observed more frequently among individuals who had experienced major depressive disorder at some time in their lives than among individuals who had never experienced major depression or among individuals with no psychiatric diagnosis. Smokers with major depression were also less successful at their attempts to quit than were either of the comparison groups. Gender differences in rates of smoking and of smoking cessation observed in the larger population were not evident among the depressed group. Furthermore, the association between cigarette smoking and major depression was not ubiquitous across all psychiatric diagnoses. Other data are cited indicating that when individuals with a history of depression stop smoking, depressive symptoms and, in some cases, serious major depression may ensue. ( JAMA . 1990;264:1546-1549)
1,196 citations
TL;DR: Results indicate that prediabetic subjects have an atherogenic pattern of risk factors (possibly caused by obesity, hyperglycemia, and especially hyperinsulinemia), which may be present for many years and may contribute to the risk of macrovascular disease as much as the duration of clinical diabetes itself.
Abstract: Although type II diabetes is associated with both microvascular and macrovascular complications, duration of diabetes and severity of glycemia are strongly associated only with the former. Since prediabetic individuals are hyperinsulinemia, and since hyperinsulinemia may be a cardiovascular risk factor, we hypothesized that prediabetic individuals might have an atherogenic pattern of risk factors even before the onset of clinical diabetes, thereby explaining the relative lack of an association of macrovascular complications with either glycemic severity or disease duration. We documented the cardiovascular risk factor status of 614 initially nondiabetic Mexican Americans who later participated in an 8-year follow-up of the San Antonio Heart Study, a population-based study of diabetes and cardiovascular disease. Individuals who were nondiabetic at the time of baseline examination, but who subsequently developed type II diabetes (ie, confirmed prediabetic subjects, n = 43), had higher levels of total and low-density lipoprotein cholesterol, triglyceride, fasting glucose and insulin, 2-hour glucose, body mass index, and blood pressure, and lower levels of high-density lipoprotein cholesterol than subjects who remained nondiabetic (n = 571). Most of these differences persisted after adjustment for obesity and/or level of glycemia, but were abolished after adjustment for fasting insulin concentration. When subjects with impaired glucose tolerance at baseline (n = 106) were eliminated, the more atherogenic pattern of cardiovascular risk factors was still evident (and statistically significant) among initially normoglycemic prediabetic subjects. These results indicate that prediabetic subjects have an atherogenic pattern of risk factors (possibly caused by obesity, hyperglycemia, and especially hyperinsulinemia), which may be present for many years and may contribute to the risk of macrovascular disease as much as the duration of clinical diabetes itself.
1,055 citations
TL;DR: Using the theory and practice of methods to improve physicians' clinical decision making to enhance the quality and cost-effectiveness of care and to reduce inappropriate prescribing as well as unnecessary health care expenditures are shown.
Abstract: With the efficacy and costs of medications rising rapidly, it is increasingly important to ensure that drugs be prescribed as rationally as possible. Yet, physicians' choices of drugs frequently fall short of the ideal of precise and cost-effective decision making. Evidence indicates that such decisions can be improved in a variety of ways. A number of theories and principles of communication and behavior change can be found that underlie the success of pharmaceutical manufacturers in influencing prescribing practices. Based on this behavioral science and several field trials, it is possible to define the theory and practice of methods to improve physicians' clinical decision making to enhance the quality and cost-effectiveness of care. Some of the most important techniques of such "academic detailing" include (1) conducting interviews to investigate baseline knowledge and motivations for current prescribing patterns, (2) focusing programs on specific categories of physicians as well as on their opinion leaders, (3) defining clear educational and behavioral objectives, (4) establishing credibility through a respected organizational identity, referencing authoritative and unbiased sources of information, and presenting both sides of controversial issues, (5) stimulating active physician participation in educational interactions, (6) using concise graphic educational materials, (7) highlighting and repeating the essential messages, and (8) providing positive reinforcement of improved practices in follow-up visits. Used by the nonprofit sector, the above techniques have been shown to reduce inappropriate prescribing as well as unnecessary health care expenditures. ( JAMA . 1990;263:549-556)
1,053 citations
TL;DR: Study of nonblack women aged 65 years and older who had measurements of bone mineral density using single-photon absorptiometry in the calcaneus, distal radius, and proximal radius concludes that decreased bone density in the appendicular skeleton is associated with an increased risk of hip fracture.
Abstract: To determine whether measurement of bone density predicts hip fracture in women, we prospectively studied 9703 nonblack women aged 65 years and older who had measurements of bone mineral density using single-photon absorptiometry in the calcaneus, distal radius, and proximal radius. During an average of 1.6 years of follow-up, 53 hip fractures occurred. The risk of hip fracture was inversely related to bone density at all three measurement sites. After adjusting for age, the relative risk of hip fracture was 1.66 for a decrease of 1 SD in the bone density at the calcaneus (95% confidence interval, 1.22 to 2.26), 1.55 (95% confidence interval, 1.13 to 2.11) at the distal radius, and 1.41 (95% confidence interval, 1.06 to 1.88) at the proximal radius. None of the three measurements was a significantly better predictor of hip fracture than the others. After adjusting for bone mineral density, the risk of hip fracture doubled for each 10-year increase in age (relative risk, 2.09; 95% confidence interval, 1.31 to 3.33). We conclude that decreased bone density in the appendicular skeleton is associated with an increased risk of hip fracture, but this accounts for only part of the age-related increase in risk of hip fracture among older women. ( JAMA . 1990;263:665-668)
965 citations
TL;DR: The polymorphic pattern of this receptor gene suggests that a gene that confers susceptibility to at least one form of alcoholism is located on the q22-q23 region of chromosome 11.
Abstract: In a blinded experiment, we report the first allelic association of the dopamine D2receptor gene in alcoholism. From 70 brain samples of alcoholics and nonalcoholics, DNA was digested with restriction endonucleases and probed with a clone that contained the entire 3' coding exon, the polyadenylation signal, and approximately 16.4 kilobases of noncoding 3' sequence of the human dopamine D2receptor gene (λhD2G1). In the present samples, the presence of A1 allele of the dopamine D2receptor gene correctly classified 77% of alcoholics, and its absence classified 72% of nonalcoholics. The polymorphic pattern of this receptor gene suggests that a gene that confers susceptibility to at least one form of alcoholism is located on the q22-q23 region of chromosome 11. (JAMA. 1990;263:2055-2060)
TL;DR: Of variables measured, maximal CPP was most predictive of ROSC, and all CPP measurements were more predictive than was aortic pressure alone, substantiates animal data that indicate the importance of CPP during cardiopulmonary resuscitation.
Abstract: Coronary perfusion pressure (CPP), the aortic-to-right atrial pressure gradient during the relaxation phase of cardiopulmonary resuscitation, was measured in 100 patients with cardiac arrest. Coronary perfusion pressure and other variables were compared in patients with and without return of spontaneous circulation (ROSC). Twenty-four patients had ROSC. Initial CPP (mean±SD) was 1.6 ± 8.5 mm Hg in patients without ROSC and 13.4 ± 8.5 mm Hg in those with ROSC. The maximal CPP measured was 8.4 ±10.0 mm Hg in those without ROSC and 25.6 ±7.7 mm Hg in those with ROSC. Differences were also found for the maximal aortic relaxation pressure, the compression-phase aortic-to— right atrial gradient, and the arterial Po 2 . No patient with an initial CPP less than 0 mm Hg had ROSC. Only patients with maximal CPPs of 15 mm Hg or more had ROSC, and the fraction of patients with ROSC increased as the maximal CPP increased. A CPP above 15 mm Hg did not guarantee ROSC, however, as 18 patients whose CPPs were 15 mm Hg or greater did not resuscitate. Of variables measured, maximal CPP was most predictive of ROSC, and all CPP measurements were more predictive than was aortic pressure alone. The study substantiates animal data that indicate the importance of CPP during cardiopulmonary resuscitation. ( JAMA . 1990;263:1106-1113)
TL;DR: The authors found no significant differences in the prevalence of reading disability in research identified boys compared with research-identified girls in either second (17 [8.7%] of 196 boys; 15 [6.9%] of 216 girls) or third grade (18 [9.0%] of 199 boys; 13 [6] of 215 girls).
Abstract: We hypothesized that results of previous investigations indicating an increased prevalence of reading disability in boys compared with girls reflected a bias in subject selection. In an epidemiologic sample of 215 girls and 199 boys, we identified two groups of reading-disabled children: research identified and school identified. Results indicated no significant differences in the prevalence of reading disability in research-identified boys compared with research-identified girls in either second (17 [8.7%] of 196 boys; 15 [6.9%] of 216 girls) or third grade (18 [9.0%] of 199 boys; 13 [6.0%] of 215 girls). In contrast, school identification resulted in the classification of 27 (13.6%) of 198 boys and seven (3.2%) of 216 girls in second grade and 20 (10.0%) of 199 boys and nine (4.2%) of 215 girls in third grade. Our data indicate that school-identified samples are almost unavoidably subject to a referral bias and that reports of an increased prevalence of reading disability in boys may reflect this bias in ascertainment. These findings caution against relying solely on schools for identification of reading-disabled children. (JAMA. 1990;264:998-1002)
TL;DR: Depressed smokers were 40% less likely to have quit compared with nondepressed smokers and adjusted for amount smoked, sex, age, and educational attainment by means of a Cox proportional hazards model found that depression plays an important role in the dynamics of cigarette smoking in the United States.
Abstract: Data from multiple studies suggest that depression plays a role in cigarette smoking. To obtain a national perspective on the role of depression in the dynamics of smoking, we analyzed data from the first National Health and Nutrition Examination Survey and the National Health and Nutrition Examination Survey Epidemiologic Follow-up Study. We used the Center for Epidemiologic Studies Depression Scale to assess symptoms of depression and used the standard cutoff (score, ≥16) for defining persons as depressed. The cross-sectional analysis of the first National Health and Nutrition Examination Survey showed that the prevalence of current smokers increased as the Center for Epidemiologic Studies Depression Scale score increased, whereas the quit ratio (former smokers/ever smokers) decreased as the Center for Epidemiologic Studies Depression Scale score increased. Among the cohort of smokers in the National Health and Nutrition Examination Survey Epidemiologic Follow-up Study, the estimated incidence of quitting after 9 years of follow-up was 9.9% for depressed smokers and 17.7% for nondepressed smokers. When we adjusted for amount smoked, sex, age, and educational attainment by means of a Cox proportional hazards model, we found that depressed smokers were 40% less likely to have quit compared with nondepressed smokers (relative risk, 0.6). These findings suggest that depression plays an important role in the dynamics of cigarette smoking in the United States. ( JAMA . 1990;264:1541-1545)
TL;DR: The increased mortality associated with delirium appears to be explained by greater severity of illness, and identifies elderly at risk for death, longer hospitalization, and institutionalization.
Abstract: The prevalence, risk factors, and outcomes of delirium were studied in 229 elderly patients. Fifty patients (22%) met criteria for delirium; nondelirious elderly constituted the control group. Abnormal sodium levels, illness severity, dementia, fever or hypothermia, psychoactive drug use, and azotemia were associated with risk of delirium. Patients with three or more risk factors had a 60% rate of delirium. Delirious patients stayed 12.1 days in the hospital vs 7.2 days for controls and were more likely to die (8% vs 1%) or be institutionalized (16% vs 3%). Illness severity predicted 6-month mortality, but the effect of delirium was not significant. Delirium occurs commonly in hospitalized elderly, is associated with chronic and acute problems, and identifies elderly at risk for death, longer hospitalization, and institutionalization. The increased mortality associated with delirium appears to be explained by greater severity of illness. (JAMA. 1990;263:1097-1101)
TL;DR: Reduction of low-density lipoprotein cholesterol levels can induce regression of atherosclerotic lesions of the coronary arteries in patients with familial hypercholesterolemia, and the anticipation of benefit from treatment applies to women and men alike.
Abstract: We conducted a randomized, controlled trial in 72 patients with heterozygous familial hypercholesterolemia to test whether reducing plasma low-density lipoprotein levels by diet and combined drug regimens can induce regression of coronary lesions. Four hundred fifty-seven lesions were measured before and after a 26-month interval by computer-based quantitative angiography. The primary outcome variable was within-patient mean change in percent area stenosis. Mean low-density lipoprotein cholesterol levels decreased from 7.32 +/- 1.5 to 4.45 +/- 1.6 mmol/L. The mean change in percent area stenosis among controls was +0.80, indicating progression, while the mean change for the treatment group was -1.53, indicating regression (P = .039 by two-tailed t test for the difference between groups). Regression among women, analyzed separately, was also significant. The change in percent area stenosis was correlated with low-density lipoprotein levels on trial. We conclude that reduction of low-density lipoprotein cholesterol levels can induce regression of atherosclerotic lesions of the coronary arteries in patients with familial hypercholesterolemia. The anticipation of benefit from treatment applies to women and men alike.
TL;DR: Clinical Methods, now in its third edition, reviews the history and physical examination in depth and offers brief discussions of selected laboratory methods used in diagnosis.
Abstract: In these times of burgeoning medical technology and runaway costs, it is a pleasure to find a medical textbook that emphasizes the more basic aspects of practice.Clinical Methods, now in its third edition, reviews the history and physical examination in depth. In addition, the book offers brief discussions of selected laboratory methods used in diagnosis. Compared with previous editions, this volume has undergone extensive revision both in content and organization. Following a brief overview, it is divided into sections based on organ systems. The introductory section includes a useful and well-written chapter on the sensitivity, specificity, and predictive value of laboratory tests, as well as a chapter that takes on the difficult task of articulating the thought processes that are used in the collection and interpretation of medical data. The bulk of the text comprises a detailed discussion of the history and physical examination as related to a particular
TL;DR: Children in the child and parent group showed significantly greater decreases in percent overweight after 5 and 10 years than children in the nonspecific control group, and child height was related strongly to the height of the parent of the same sex.
Abstract: Using a prospective, randomized, controlled design, we examined the effects of behavioral family-based treatment on percent overweight and growth over 10 years in obese 6- to 12-year-old children Obese children and their parents were randomized to three groups that were provided similar diet, exercise, and behavior management training but differed in the reinforcement for weight loss and behavior change The child and parent group reinforced parent and child behavior change and weight loss, the child group reinforced child behavior change and weight loss, and the nonspecific control group reinforced families for attendance Children in the child and parent group showed significantly greater decreases in percent overweight after 5 and 10 years (-112% and -75%, respectively) than children in the nonspecific control group ( + 79% and + 143%, respectively) Children in the child group showed increases in percent overweight after 5 and 10 years ( + 27% and +45%, respectively) that were midway between those for the child and parent and nonspecific groups and not significantly different from either At 10 years, child height was related strongly to the height of the parent of the same sex (r=78): children were 18 cm taller than their parents, with no differences in height between groups ( JAMA 1990;264:2519-2523)
TL;DR: After 30 to 64 months of education, significant net reductions in community averages favoring treatment occurred in plasma cholesterol level, blood pressure, resting pulse rate, and smoking rate of the cohort sample, which resulted in important decreases in composite total mortality risk scores and coronary heart disease risk scores.
Abstract: To test whether communitywide health education can reduce stroke and coronary heart disease, we compared two treatment cities (N = 122,800) and two control cities (N = 197,500) for changes in knowledge of risk factors, blood pressure, plasma cholesterol level, smoking rate, body weight, and resting pulse rate. Treatment cities received a 5-year, low-cost, comprehensive program using social learning theory, a communication-behavior change model, community organization principles, and social marketing methods that resulted in about 26 hours of exposure to multichannel and multifactor education. Risk factors were assessed in representative cohort and cross-sectional surveys at baseline and in three later surveys. After 30 to 64 months of education, significant net reductions in community averages favoring treatment occurred in plasma cholesterol level (2%), blood pressure (4%), resting pulse rate (3%), and smoking rate (13%) of the cohort sample. These risk factor changes resulted in important decreases in composite total mortality risk scores (15%) and coronary heart disease risk scores (16%). Thus, such low-cost programs can have an impact on risk factors in broad population groups.
TL;DR: The rapid growth of the oldest age groups will have a major impact on future health care costs, and future costs for Medicare, nursing homes, dementia, and hip fractures are projected.
Abstract: The rapid growth of the oldest age groups will have a major impact on future health care costs We use current US Census Bureau projections for the growth of our oldest age groups to project future costs for Medicare, nursing homes, dementia, and hip fractures Without major changes in the health of our older population, these health care costs will escalate enormously, in large part as a result of the projected growth of the "oldest old," those aged 85 years and above Medicare costs for the oldest old may increase sixfold by the year 2040 (in constant 1987 dollars) It is unlikely that these projected increases in health care costs will be restrained solely by cost-containment strategies Successful containment of these health care costs will be related to our ability to prevent and/or cure those age-dependent diseases and disorders that will produce the greatest needs for long-term care (JAMA 1990;263:2335-2340)
TL;DR: This report describes the first association (exclusive of drug overdose) of symptomatic torsades de pointes occurring with the use of terfenadine in a patient who was taking the recommended prescribed dose of this drug in addition to cefaclor, ketoconazole, and medroxyprogesterone.
Abstract: Torsades de pointes is a form of polymorphic ventricular tachycardia that is associated with prolongation of the QT interval. Although found in many clinical settings, torsades de pointes is most often drug induced. This report describes the first association (exclusive of drug overdose) of symptomatic torsades de pointes occurring with the use of terfenadine in a patient who was taking the recommended prescribed dose of this drug in addition to cefaclor, ketoconazole, and medroxyprogesterone. Measured serum concentrations of terfenadine and its main metabolite showed excessive levels of parent terfenadine and proportionately reduced concentrations of metabolite, suggesting inhibition of terfenadine metabolism. We believe that a drug interaction between terfenadine and ketoconazole resulted in the elevated terfenadine levels in plasma and in the cardiotoxicity previously seen only in cases of terfenadine overdose.
TL;DR: The hypothesis that lead impairs children's IQ at low dose is strongly supported by this quantitative review, and the effect is robust to the impact of any single study.
Abstract: We identified 24 modern studies of childhood exposures to lead in relation to IQ. From this population, 12 that employed multiple regression analysis with IQ as the dependent variable and lead as the main effect and that controlled for nonlead covariates were selected for a quantitative, integrated review or metaanalysis. The studies were grouped according to type of tissue analyzed for lead. There were 7 blood and 5 tooth lead studies. Within each group, we obtained jointPvalues by two different methods and average effect sizes as measured by the partial correlation coefficients. We also investigated the sensitivity of the results to any single study. The sample sizes ranged from 75 to 724. The sign of the regression coefficient for lead was negative in 11 of 12 studies. The negative partial r's for lead ranged from —.27 to —.003. The power to find an effect was limited, below 0.6 in 7 of 12 studies. The jointPvalues for the blood lead studies were (JAMA. 1990;263:673-678)
TL;DR: An extended use of prospective registration of trials at inception, as well as benefiting clinical research in other ways, could help people to play their respective roles in reducing underreporting of clinical trials.
Abstract: Substantial numbers of clinical trials are never reported in print, and among those that are, many are not reported in sufficient detail to enable judgments to be made about the validity of their results. Failure to publish an adequate account of a well-designed clinical trial is a form of scientific misconduct that can lead those caring for patients to make inappropriate treatment decisions. Investigators, research ethics committees, funding bodies, and scientific editors all have responsibilities to reduce underreporting of clinical trials. An extended use of prospective registration of trials at inception, as well as benefiting clinical research in other ways, could help people to play their respective roles in reducing underreporting of clinical trials. ( JAMA . 1990;263:1405-1408)
TL;DR: Patients with no history of transfusions were just as likely to be positive for antibody to hepatitis C virus as patients with transfusion-associated hepatitis, indicating that hepatitis Cirus is the major causative agent of all non-A, non-B hepatitis in the United States.
Abstract: The Centers for Disease Control conducted intensive surveillance for acute non-A, non-B hepatitis in four sentinel counties over a 7-year period. Testing for antibody to hepatitis C virus was performed with the newly developed enzyme immunoassay. The incidence of non-A, non-B hepatitis remained relatively stable (average, 7.1 cases per 100 000), but there were significant changes in disease transmission patterns. The proportion of patients with a history of blood transfusion declined from 17% to 6%, but the proportion with a history of parenteral drug use increased from 21% to 42%. The proportion of patients with histories of sexual exposure (6%), household exposure (3%), occupational exposure to blood (2%), or hemodialysis (0.6%) did not change over time. Antibody to hepatitis C virus was found in 45% of patients within 6 weeks of onset of illness and in 68% of patients followed up for at least 6 months. Patients with no history of transfusions were just as likely to be positive for antibody to hepatitis C virus as patients with transfusion-associated hepatitis, indicating that hepatitis C virus is the major causative agent of all non-A, non-B hepatitis in the United States. ( JAMA . 1990;264:2231-2235)
TL;DR: It is concluded that cessation programs serve a small, but important, population of smokers that includes heavier smokers, those most at risk for tobacco-related morbidity and mortality.
Abstract: Using data from the 1986 Adult Use of Tobacco Survey, we analyzed smoking-cessation methods used by adult smokers in the United States who tried to quit. About 90% of successful quitters and 80% of unsuccessful quitters used individual methods of smoking cessation rather than organized programs. Most of these smokers who quit on their own used a "cold turkey" approach. Multivariate analysis showed that women, middle-aged persons, more educated persons, persons who had made more quit-smoking attempts, and, particularly, heavier smokers were most likely to use a cessation program. Daily cigarette consumption, however, did not predict whether persons would succeed or fail during their attempts to quit smoking. Rather, the cessation method used was the strongest predictor of success. Among smokers who had attempted cessation within the previous 10 years, 47.5% of persons who tried to quit on their own were successful whereas only 23.6% of persons who used cessation programs succeeded. We conclude that cessation programs serve a small, but important, population of smokers that includes heavier smokers, those most at risk for tobacco-related morbidity and mortality. (JAMA. 1990;263:2760-2765)
TL;DR: The frontiers in atherosclerosis research are moving from lipoprotein metabolism and control of hyperlipidemia to the cellular events in the artery wall, and emerging hypotheses, including the oxidative modification hypothesis, are already suggesting new approaches that could complement and be additive to control ofhypercholesterolemia in the prevention of Atherosclerosis.
Abstract: The frontiers in atherosclerosis research are moving from lipoprotein metabolism and control of hyperlipidemia to the cellular events in the artery wall. Emerging hypotheses, including the oxidative modification hypothesis, are already suggesting new approaches that could complement and be additive to control of hypercholesterolemia in the prevention of atherosclerosis.
TL;DR: This study analyzes data from New York State's new Cardiac Surgery Reporting System to determine the set of significant clinical risk factors and to identify cardiac surgical centers most likely to have serious quality-of-care problems.
Abstract: This study analyzes data from New York State's new Cardiac Surgery Reporting System, which contains information about cardiac preoperative risk factors, postoperative complications, and hospital discharge. The purposes of the study were to determine the set of significant clinical risk factors and to identify cardiac surgical centers most likely to have serious quality-of-care problems. Significant risk factors for in-hospital death were age, gender, ejection fraction, previous myocardial infarction, number of open heart operations in previous admissions, diabetes requiring medication, dialysis dependence, disasters (acute structural defect, renal failure, cardiogenic shock, gunshot), unstable angina, intractable congestive heart failure, left main trunk narrowed more than 90%, and type of operation performed. Four of the 28 hospitals had significantly higher mortality rates than expected, given the risk factors of their patients. Subsequent site visits and medical record reviews confirmed that these facilities had high percentages of quality-of-care problems among cases resulting in mortality. ( JAMA . 1990;264:2768-2774)
TL;DR: A subgroup of 103 subjects treated for 4 years of combined colestipol-niacin therapy reaffirm the need for early initiation of vigorous long-term lipid lowering therapy in coronary bypass subjects and indicate that regression can continue for4 years.
Abstract: The Cholesterol Lowering Atherosclerosis Study (CLAS) was a randomized, placebo-controlled, angiographic trial testing combined colestipol-niacin therapy in 162 subjects. Two-year results (CLAS-I) showed decreased atherosclerosis progression and increased regression. We now describe a subgroup of 103 subjects treated for 4 years (CLAS-II). Changes in blood lipid, lipoproteincholesterol, and apolipoprotein levels were maintained, and at 4 years significantly more drug-treated subjects demonstrated nonprogression (52% drug- vs 15% placebo-treated) and regression (18% drug- vs 6% placebo-treated) in native coronary artery lesions. Significantly fewer drug-treated subjects developed new lesions in native coronary arteries (14% drug- vs 40% placebo-treated) and bypass grafts (16% drug- vs 38% placebo-treated). These results confirm CLAS-I findings and indicate that regression can continue for 4 years. They reaffirm the need for early initiation of vigorous long-term lipid lowering therapy in coronary bypass subjects. ( JAMA . 1990;264:3013-3017)
TL;DR: Neither changes in International Classification of Diseases coding nor improved recognition of asthma, as demonstrated by trends in autopsy rates or rates of in-hospital deaths, seems to explain the increasing mortality of the 1980s.
Abstract: Studies have suggested increases in hospitalization for asthma and in asthma mortality during the early 1980s. Using US Vital Records, we examined asthma mortality from 1968 through 1987 to describe the rates of change among children and young adults (aged 5 to 34 years) with time and in small geographic areas. During the 1970s, US asthma mortality declined by 7.8% per annum ( ± 1.0%), declining faster among women and nonwhites. During the 1980s, mortality increased by 6.2% per annum ( ± 1.2%), increasing faster among those aged 5 to 14 years than among those aged 15 to 34 years. Small-area geographic analysis revealed four areas with persistently high asthma mortality. Neither changes inInternational Classificationof Diseases coding nor improved recognition of asthma, as demonstrated by trends in autopsy rates or rates of in-hospital deaths, seems to explain the increasing mortality of the 1980s. (JAMA. 1990;264:1683-1687)
TL;DR: Thyroglobulin and thyroid peroxidase autoantibodies are an independent marker of "at-risk" pregnancy and the increase in miscarriages could not be explained by differences in thyroid hormone levels, the presence of cardiolipin autoantibia, maternal age, gestational age at the time of maternal entry into the study, or previous obstetric history.
Abstract: We screened 552 women who presented to their obstetrician in the first trimester of pregnancy using highly sensitive enzyme-linked immunosorbent assays for the presence of thyroglobulin and thyroid peroxidase autoantibodies and found an incidence of positivity of 19.6%. The tendency to secrete detectable levels of thyroid autoantibodies was significantly correlated with an increased rate of miscarriage. Thyroid autoantibody-positive women miscarried at a rate of 17%, compared with 8.4% for the autoantibody-negative women. Individual levels of thyroglobulin and thyroid peroxidase autoantibodies were similarly related to this increased miscarriage rate, with no evidence of autoantibody specificity in the relationship. Furthermore, the increase in miscarriages could not be explained by differences in thyroid hormone levels, the presence of cardiolipin autoantibodies, maternal age, gestational age at the time of maternal entry into the study, or previous obstetric history. We conclude that thyroid autoantibodies are an independent marker of "at-risk" pregnancy.