Showing papers in "JAMA in 1991"

Rising incidence of adenocarcinoma of the esophagus and gastric cardia.

Abstract: Analyses of cancer incidence data from nine areas of the United States revealed steadily rising rates from 1976 to 1987 of adenocarcinomas of the esophagus and gastric cardia. The increases among men in this period ranged from 4% to 10% per year, and thus exceeded those of any other type of cancer. In contrast, there were relatively stable trends for squamous cell carcinoma of the esophagus and slight declines for adenocarcinoma of more distal portions of the stomach. Adenocarcinomas of the esophagus and gastric cardia disproportionately affected white men and rarely occurred among women. By the mid-1980s. among white men, adenocarcinomas accounted for about one third of all esophageal cancers, while cardia cancers accounted for about one half of all stomach cancers with specified subsites. The rising incidence rates and similar demographic patterns point to the need for investigation into the causes of these poorly understood cancers. (JAMA. 1991;265:1287-1289)

Racial variations in the prevalence of primary open-angle glaucoma. The Baltimore Eye Survey.

Abstract: Objective. —To compare the prevalence of primary open-angle glaucoma between black and white Americans. Design, Setting, and Participants. —The design was a population-based prevalence survey of a noninstitutionalized black and white population aged 40 years or older from the eastern and southeastern health districts of Baltimore, Md. A multistage random sampling strategy was used to identify 7104 eligible participants, of whom 5308 (2395 blacks, 2913 whites) received an ophthalmologic screening examination. Those with abnormalities were referred for definitive diagnostic evaluation. Main Outcome Measure. —Primary open-angle glaucoma was defined based on evidence of glaucomatous optic nerve damage, including abnormal visual fields and/or severe optic disc cupping, and was independent of intraocular pressure. Main Results. —Age-adjusted prevalence rates for primary open-angle glaucoma were four to five times higher in blacks as compared with whites. Rates among blacks ranged from 1.23% in those aged 40 through 49 years to 11.26% in those 80 years or older, whereas rates for whites ranged from 0.92% to 2.16%, respectively. There was no difference in rates of primary open-angle glaucoma between men and women for either blacks or whites in this population. Based on these data, an estimated 1.6 million persons aged 40 years or older in the United States have primary open-angle glaucoma. Conclusions. —Black Americans are at higher risk of primary open-angle glaucoma than their white neighbors. This may reflect an underlying genetic susceptibility to this disease and indicates that additional efforts are needed to identify and treat this sight-threatening disorder in high-risk communities. ( JAMA . 1991;266:369-374)

Estrogen and coronary heart disease in women.

Abstract: We review herein the evidence that estrogen is protective against the development of cardiovascular disease in women To our knowledge, no studies in women have looked at endogenous estrogen levels as predictors of cardiovascular disease Studies of surrogate measures of endogenous estrogen such as parity, age at menarche, and age at menopause have provided inconsistent results Current use of oral contraceptives increases risk in older women who smoke cigarettes, but most studies of past use show no increased risk Most, but not all, studies of hormone replacement therapy in postmenopausal women show around a 50% reduction in risk of a coronary event in women using unopposed oral estrogen These important observations need to be confirmed in a double-blind, randomized clinical trial, since the protection is biologically plausible and the magnitude of the benefit would be quite large if selection factors can be excluded ( JAMA 1991;265:1861-1867)

Cardiac toxicity 4 to 20 years after completing anthracycline therapy.

Abstract: Objective. —To assess the cardiac status of long-term survivors of pediatric malignancies who received chemotherapy, including anthracyclines. Design and Method. —Patients were evaluated by echocardiogram from 4 to 20 years (median, 7 years) after completion of anthracyclines, with prospective and retrospective analysis. Patients. —The consecutive sample of 201 patients had received a total anthracycline dose of 200 to 1275 mg/m2(median, 450 mg/m2), and 51 patients had mediastinal radiotherapy. Main Outcome Measures. —The overall incidence and severity of abnormal systolic cardiac function were determined for the entire cohort. Risk factors of total anthracycline dose, mediastinal radiotherapy, age during treatment, and length of follow-up were examined. Results. —Twenty-three percent (47/201) of the cohort had abnormal cardiac function on noninvasive testing at long-term follow-up. Correlation between total cumulative dose, length of follow-up, and mediastinal irradiation with incidence of abnormalities was significant. Fifty-six patients were followed up for 10 years or more (median, 12 years), with a median anthracycline dose of 495 mg/m2, Thirty-eight percent (21/56) of these patients, compared with 18% (26/145) of patients evaluated after less than 10 years, had abnormal findings. Sixty-three percent of patients followed up for 10 years or more after receiving 500 mg/m2or more of anthracyclines had abnormal findings. Nine of 201 patients had late symptoms, including cardiac failure and dysrhythmia, and three patients died suddenly. Microscopic examination of the myocardium on biopsy and autopsy revealed fibrosis. Conclusion. —The 23% incidence of late cardiac abnormalities warrants continued evaluation of patients after anthracyclines to guide patient care and the design of future chemotherapeutic protocols. (JAMA. 1991;266:1672-1677)

Analysis and interpretation of treatment effects in subgroups of patients in randomized clinical trials.

Abstract: A key principle for interpretation of subgroup results is that quantitative interactions (differences in degree) are much more likely than qualitative interactions (differences in kind). Quantitative interactions are likely to be truly present whether or not they are apparent, whereas apparent qualitative interactions should generally be disbelieved as they have usually not been replicated consistently. Therefore, the overall trial result is usually a better guide to the direction of effect in subgroups than the apparent effect observed within a subgroup. Failure to specify prior hypotheses, to account for multiple comparisons, or to correct P values increases the chance of finding spurious subgroup effects. Conversely, inadequate sample size, classification of patients into the wrong subgroup, and low power of tests of interaction make finding true subgroup effects difficult. We recommend examining the architecture of the entire set of subgroups within a trial, analyzing similar subgroups across independent trials, and interpreting the evidence in the context of known biologic mechanisms and patient prognosis. ( JAMA . 1991;266:93-98)

Genital human papillomavirus infection in female university students as determined by a PCR-based method.

Abstract: The presence of genital human papillomavirus (HPV) was determined at cervical and vulvar sites using two methods, the Food and Drug Administration-approved ViraPap test and polymerase chain reaction (PCR) DNA amplification technology, in 467 women presenting to a university health service for a routine annual gynecologic examination. The PCR system afforded the sensitive detection of a broad spectrum of genital HPV types. Using PCR, we found that 46% of the study population was infected with HPV; the ViraPap test showed a prevalence of 11% infected. PCR analyses demonstrated that 69% of the HPV-positive women were infected at both genital sites. Subsequent HPV-type determination showed that 33% of the study population had HPV types 6, 11, 16, 18, 31, 33, 35, 39, 45, 51, 52, or other previously isolated types, and 13% had yet unidentified types. Almost all (92%) of the women diagnosed by Papanicolaou smear with condylomatous atypia or dysplasia (n = 12) were HPV positive. The PCR method proved to be an informative and rapid way to detect HPV in large numbers of clinical samples. Our results demonstrate that genital HPV infection is common among sexually active young women.

Carotid Endarterectomy and Prevention of Cerebral Ischemia in Symptomatic Carotid Stenosis

Abstract: Objective. —To determine whether carotid endarterectomy provides protection against subsequent cerebral ischemia in men with ischemic symptoms in the distribution of significant (>50%) ipsilateral internal carotid artery stenosis. Design. —Prospective, randomized, multicenter trial. Setting. —Sixteen university-affiliated Veterans Affairs medical centers. Patients. —Men who presented within 120 days of onset of symptoms that were consistent with transient ischemic attacks, transient monocular blindness, or recent small completed strokes between July 1988 and February 1991. Among 5000 patients screened, 189 individuals were randomized with angiographic internal carotid artery stenosis greater than 50% ipsilateral to the presenting symptoms. Forty-eight eligible patients who refused entry were followed up outside of the trial. Outcome Measures. —Cerebral infarction or crescendo transient ischemic attacks in the vascular distribution of the original symptoms or death within 30 days of randomization. Intervention. —Carotid endarterectomy plus the best medical care (n = 91) vs the best medical care alone (n=98). Results. —At a mean follow-up of 11.9 months, there was a significant reduction in stroke or crescendo transient ischemic attacks in patients who received carotid endarterectomy (7.7%) compared with nonsurgical patients (19.4%), or an absolute risk reduction of 11.7% (P=.011). The benefit of surgery was more profound in patients with internal carotid artery stenosis greater than 70% (absolute risk reduction, 17.7%;P=.004). The benefit of surgery was apparent within 2 months after randomization, and only one stroke was noted in the surgical group beyond the 30-day perioperative period. Conclusions. —For a selected cohort of men with symptoms of cerebral or retinal ischemia in the distribution of a high-grade internal carotid artery stenosis, carotid endarterectomy can effectively reduce the risk of subsequent ipsilateral cerebral ischemia. The risk of cerebral ischemia in this subgroup of patients is considerably higher than previously estimated. (JAMA. 1991;266:3289-3294)

Fetal alcohol syndrome in adolescents and adults

Abstract: Fetal alcohol syndrome is a specific recognizable pattern of malformation. Manifestations in 61 adolescents and adults suffering from alcohol teratogenesis are presented. After puberty, the faces of patients with fetal alcohol syndrome or fetal alcohol effects were not as distinctive. Patients tended to remain short and microcephalic, although their weight was somewhat closer to the mean. The average IQ was 68, but the range of IQ scores widely varied. Average academic functioning was at the second- to fourth-grade levels, with arithmetic deficits most characteristic. Maladaptive behaviors such as poor judgment, distractibility, and difficulty perceiving social cues were common. Family environments were remarkably unstable. Fetal alcohol syndrome is not just a childhood disorder; there is a predictable long-term progression of the disorder into adulthood, in which maladaptive behaviors present the greatest challenge to management. (JAMA. 1991;265:1961-1967)

Relationship Between Resistance to Insulin-Mediated Glucose Uptake, Urinary Uric Acid Clearance, and Plasma Uric Acid Concentration

Abstract: Objective. —To define the relationship, if any, between insulin-mediated glucose disposal and serum uric acid. Design. —Cross-sectional study of healthy volunteers. Setting.— General Clinical Research Center, Stanford (Calif) University Medical Center. Participants. —Thirty-six presumably healthy individuals, nondiabetic, without a history of gout. Measurements. —Obesity (overall and regional), plasma glucose and insulin responses to a 75-g oral glucose load, fasting uric acid concentrations, plasma triglyceride and high-density lipoprotein—cholesterol concentrations, systolic and diastolic blood pressure, insulin-mediated glucose disposal, and urinary uric acid clearance. Results. —Magnitude of insulin resistance and serum uric acid concentration were significantly related ( r =.69; P r =.57; P r = -.49; P r = -.61; P Conclusions. —Urinary uric acid clearance appears to decrease in proportion to increases in insulin resistance in normal volunteers, leading to an increase in serum uric acid concentration. Thus, it appears that modulation of serum uric concentration by insulin resistance is exerted at the level of the kidney. ( JAMA . 1991;266:3008-3011)

Opinion leaders vs audit and feedback to implement practice guidelines. Delivery after previous cesarean section.

Abstract: A randomized controlled trial with 76 physicians in 16 community hospitals evaluated audit and feedback and local opinion leader education as methods of encouraging compliance with a guideline for the management of women with a previous cesarean section. The guideline recommended clinical actions to increase trial of labor and vaginal birth rates. Charts for all 3552 cases in the study groups were audited. After 24 months the trial of labor and vaginal birth rates in the audit and feedback group were no different from those in the control group, but rates were 46% and 85% higher, respectively, among physicians educated by an opinion leader. Duration of hospital stay was lower in the opinion leader education group than in the other two groups. The overall cesarean section rate was reduced only in the opinion leader education group. There were no adverse clinical outcomes attributable to the interventions. The use of opinion leaders improved the quality of care. ( JAMA . 1991;265:2202-2207)

A Controlled Clinical Trial of E5 Murine Monoclonal IgM Antibody to Endotoxin in the Treatment of Gram-Negative Sepsis

Abstract: Objective. —To assess the efficacy of adjunctive monoclonal antibody antiendotoxin immunotherapy in patients with gram-negative sepsis. Design. —Double-blind, randomized, placebo-controlled trial. Setting. —Thirty-three university-affiliated centers, including Veterans Affairs, community, and municipal hospitals. Patients. —Hospitalized adults with signs of gram-negative infection and a systemic septic response. Intervention. —Patients were assigned to receive either 2 mg/kg of a murine monoclonal antibody directed against gram-negative endotoxin (E5) or placebo. A second infusion was administered 24 hours later. Main Outcome Measures. —Mortality over the 30-day study period, resolution of organ failures, and safety. Results. —Four hundred eighty-six patients were enrolled. Three hundred sixteen had confirmed gram-negative sepsis (54% bacteremic, 46% nonbacteremic). The survival difference was not statistically significant for all patients. Among patients with gram-negative sepsis who were not in shock at study entry (n = 137), E5 treatment resulted in significantly greater survival (relative risk, 2.3; P =.01). Resolution of individual organ failures was more frequent among these patients, occurring in 19 (54%) of 35 patients in the E5 group vs eight (30%) of 27 in the placebo group ( P =.05). Four reversible allergic reactions occurred among 247 patients (1.6%) receiving E5. No other toxicity was identified. Conclusions. —Treatment with E5 antiendotoxin antibody appears safe. It reduces mortality and enhances the resolution of organ failure among patients with gram-negative sepsis who are not in shock when treated. ( JAMA . 1991;266:1097-1102)

Why Is Diabetes Mellitus a Stronger Risk Factor for Fatal Ischemic Heart Disease in Women Than in Men?: The Rancho Bernardo Study

Abstract: We report here the 14-year sex-specific effect of non—insulin-dependent diabetes mellitus on the risk of fatal ischemic heart disease in a geographically defined population of men and women aged 40 through 79 years. There were 207 men and 127 women who had diabetes at baseline based on medical history or fasting hyperglycemia. They were compared with 2137 adults who had fasting euglycemia and a negative personal and family history of diabetes. The relative hazard of ischemic heart disease death in diabetics vs nondiabetics was 1.8 in men and 3.3 in women, after adjusting for age, and 1.9 and 3.3, respectively, after adjusting for age, systolic blood pressure, cholesterol, body mass index, and cigarette smoking using the Cox regression model. The sex difference in the independent contribution of diabetes to fatal heart disease was largely explained by the persistently more favorable survival rate of women (than men) without diabetes. ( JAMA . 1991;265:627-631)

A Meta-analysis of the Effect of Estrogen Replacement Therapy on the Risk of Breast Cancer

Abstract: To quantify the effect of estrogen replacement therapy on breast cancer risk, we combined dose-response slopes of the relative risk of breast cancer against the duration of estrogen use across 16 studies. Using this summary dose-response slope, we calculated the proportional increase in risk of breast cancer for each year of estrogen use. For women who experienced any type of menopause, risk did not appear to increase until after at least 5 years of estrogen use. After 15 years of estrogen use, we found a 30% increase in the risk of breast cancer (relative risk, 1.3; 95% confidence interval [CI], 1.2 to 1.6). The increase in risk was largely due to results of studies that included premenopausal women or women using estradiol (with or without progestin), studies for which the estimated relative risk was 2.2 (CI, 1.4 to 3.4) after 15 years. Among women with a family history of breast cancer, those who had ever used estrogen replacement had a significantly higher risk (3.4; CI, 2.0 to 6.0) than those who had not (1.5; CI, 1.2 to 1.7). (JAMA. 1991;265:1985-1990)

Computerized Surveillance of Adverse Drug Events in Hospital Patients

Abstract: Objective. —To develop a new method to improve the detection and characterization of adverse drug events (ADEs) in hospital patients. Design. —Prospective study of all patients admitted to our hospital over an 18-month period. Setting. —LDS Hospital, Salt Lake City, Utah, a 520-bed tertiary care center affiliated with the University of Utah School of Medicine, Salt Lake City. Patients. —We developed a computerized ADE monitor, and computer programs were written using an integrated hospital information system to allow for multiple source detection of potential ADEs occurring in hospital patients. Signals of potential ADEs, both voluntary and automated, included sudden medication stop orders, antidote ordering, and certain abnormal laboratory values. Each day, a list of all potential ADEs from these sources was generated, and a pharmacist reviewed the medical records of all patients with possible ADEs for accuracy and causality. Verified ADEs were characterized as mild, moderate, or severe and as type A (dose-dependent or predictable) or type B (idiosyncratic or allergic) reactions, and causality was further measured using a standardized scoring method. Outcome Measure. —The number and characterization of ADEs detected. Results. —Over 18 months, we monitored 36 653 hospitalized patients. There were 731 verified ADEs identified in 648 patients, 701 ADEs were characterized as moderate or severe, and 664 were classified as type A reactions. During this same period, only nine ADEs were identified using traditional detection methods. Physicians, pharmacists, and nurses voluntarily reported 92 of the 731 ADEs detected using this automated system. The other 631 ADEs were detected from automated signals, the most common of which were diphenhydramine hydrochloride and naloxone hydrochloride use, high serum drug levels, leukopenia, and the use of phytonadione and antidiarrheals. The most common symptoms and signs were pruritus, nausea and/or vomiting, rash, and confusion-lethargy. The most common drug classes involved were analgesics, anti-infectives, and cardiovascular agents. Conclusion. —We believe that screening for ADEs with a computerized hospital information system offers a potential method for improving the detection and characterization of these events in hospital patients. ( JAMA . 1991;266:2847-2851)

The Dopamine D2 Receptor Locus as a Modifying Gene in Neuropsychiatric Disorders

Abstract: Objective. —The A1 allele of the Taq I polymorphism of the dopamine D 2 receptor ( DRD2 ) gene has been earlier reported to occur in 69% of alcoholics, compared with 20% of controls. Other research has reported no significant difference in the prevalence of the A1 allele in alcoholics vs controls and no evidence that the DRD2 gene was linked to alcoholism. We hypothesized that these seemingly conflicting results might be because increases in the prevalence of the A1 allele may not be specific to alcoholism. Thus, we examined other disorders frequently associated with alcoholism or those believed to involve defects in dopaminergic neurotransmission. Design. —Case comparison study. To minimize the effect of racial differences in gene frequencies, the study was restricted to non-Hispanic whites. Setting. —Ambulatory and hospitalized patients. Results. —Among all known controls (n = 314), 77 (24.5%) carried the A1 allele. Of the 69 controls known not to be alcoholics, 10 (14.5%) carried the A1 allele. The prevalence of the A1 allele was significantly increased in patients with Tourette's syndrome (44.9%, n = 147), attention deficit hyperactivity disorder (46.2%, n = 104), autism (54.5%, n = 33), alcoholism (42.3%, n = 104), and posttraumatic stress disorder (45.7%, n = 35). After correction for multiple comparisons (requiring P Conclusion. —These results suggest the A1 allele of the DRD2 gene is associated with a number of behavior disorders in which it may act as a modifying gene rather than as the primary etiological agent. ( JAMA . 1991;266:1793-1800)

The interferons. Mechanisms of action and clinical applications.

Abstract: The interferons (IFN) are one of the body's natural defensive responses to such foreign components as microbes, tumors, and antigens. The IFN response begins with the production of the IFN proteins (α, β, and γ), which then induce the antiviral, antimicrobial, antitumor, and immunomodulatory actions of IFN. Recent advances have led to Food and Drug Administration approval of five clinical indications for IFN. Interferon alfa is approved for hairy-cell leukemia, condyloma acuminatum, Kaposi's sarcoma in the acquired immunodeficiency syndrome, and non-A, non-B (type C) viral hepatitis. Interferon gamma has properties distinctive from those of IFNs α and β and is approved as an immunomodulatory treatment for chronic granulomatous disease. Promising clinical results with IFNs have also been reported for basal cell carcinoma, chronic myelogenous leukemia, cutaneous squamous cell carcinoma, early human immunodeficiency virus infection, hepatitis B, and laryngeal papillomatosis. Future clinical uses of IFNs may emphasize combination therapy with other cytokines, chemotherapy, radiation, surgery, hyperthermia, or hormones. (JAMA. 1991;266:1375-1383)

Association of Chlamydia pneumoniae (strain TWAR) infection with wheezing, asthmatic bronchitis, and adult-onset asthma.

Abstract: Objective. —To study the clinical characteristics of respiratory tract illness caused by Chlamydia pneumoniae . Design. —Prospective clinical, bacteriologic, and serologic study. Secondarily, a matched comparison of patients with and without evidence of C pneumoniae infection (serologic titers ≥1:64 and Setting. —Four primary care (family practice) clinics in Madison, Wis, and nearby towns. Patients. —The study included 365 white males and females (mean age, 34.2 years). Main Outcome Measures. —Association of acute C pneumoniae infection with signs and symptoms of respiratory illness and the relationship of C pneumoniae antibody titer with wheezing at the time of enrollment in the study, and with the diagnosis of asthmatic bronchitis. Results. —Nine (47%) of 19 patients with acute C pneumoniae infection had bronchospasm during respiratory illness, and there was a strong quantitative association of C pneumoniae titer with wheezing at the time of enrollment in the study ( P =.01). In the matched study, C pneumoniae antibody was significantly associated with asthmatic bronchitis after, but not before, respiratory illness (odds ratio, 7.2; 95% confidence interval, 2.2 to 23.4). Four infected patients had newly diagnosed asthma after illness, and four others had exacerbation of previously diagnosed asthma. There was no serologic evidence of coexisting Mycoplasma pneumoniae, Chlamydia trachomatis , or respiratory viral infection in 96% of patients with asthmatic bronchitis and asthma. Conclusions. —Some Cpneumoniae antibody titers, although not diagnostic of chlamydial infection by present criteria, probably represent acute reinfection or ongoing chronic infection. Repeated or prolonged exposure to C pneumoniae may have a causal association with wheezing, asthmatic bronchitis, and asthma. ( JAMA . 1991;266:225-230)

Group- vs home-based exercise training in healthy older men and women. A community-based clinical trial.

Abstract: Objective. —To determine the effectiveness of group- vs home-based exercise training of higher and lower intensities among healthy, sedentary older adults. Design. —Year-long randomized, controlled trial comparing (1) higher-intensity group-based exercise training; (2) higher-intensity home-based exercise training; (3) lower-intensity home-based exercise training; or (4) assessment-only control. Setting. —General community located in northern California. Participants. —One hundred sixty women and 197 men 50 to 65 years of age who were sedentary and free of cardiovascular disease. One out of nine persons contacted through a community random-digit-dial telephone survey and citywide promotion were randomized. Interventions. —For higher-intensity exercise training, three 40-minute endurance training sessions per week were prescribed at 73% to 88% of peak treadmill heart rate. For lower-intensity exercise training, five 30-minute endurance training sessions per week were prescribed at 60% to 73% of peak treadmill heart rate. Main Outcome Measures. —Treadmill exercise test performance, exercise participation rates, and heart disease risk factors. Results. —Compared with controls, subjects in all three exercise training conditions showed significant improvements in treadmill exercise test performance at 6 and 12 months ( P P Conclusions. —We conclude that (1) this community-based exercise training program improved fitness but not heart disease risk factors among sedentary, healthy older adults; (2) home-based exercise was as effective as group exercise in producing these changes; (3) lower-intensity exercise training was as effective as higher-intensity exercise training in the home setting; and (4) the exercise programs were relatively safe. (JAMA. 1991;266:1535-1542)

The Impact of Obesity on Left Ventricular Mass and Geometry: The Framingham Heart Study

Abstract: Objective —To determine the relationship of varying degrees of obesity with left ventricular mass and geometry Design —Survey Setting —Population-based epidemiologic study Participants and Methods —M-mode echocardiograms, which were adequate for estimation of left ventricular mass, were obtained in 3922 healthy participants of the Framingham Heart Study Measured height and weight were used to calculate body-mass index, a measure of obesity Results —Body-mass index was strongly correlated with left ventricular mass After adjusting for age and blood pressure, body-mass index remained a strong independent predictor of left ventricular mass, left ventricular wall thickness, and left ventricular internal dimension ( P 2 Conclusions —Obesity is significantly correlated with left ventricular mass, even after controlling for age and blood pressure The increase in left ventricular mass associated with increasing adiposity reflects increases in both left ventricular wall thickness and left ventricular internal dimension ( JAMA 1991;266:231-236)

Contaminant blood cultures and resource utilization. The true consequences of false-positive results.

Abstract: To determine whether contaminant blood cultures increase resource utilization, we studied charge and length of stay data for episodes in which blood cultures were obtained from hospitalized adults. Compared with 1097 negative episodes, 94 false-positive episodes were associated with increased subsequent length of stay (median, 12.5 vs 8 days) and subsequent total charges (median, $13 116 vs $8731), pharmacy charges (median, $1456 vs $798), and laboratory charges (median, $2057 vs $1426). In multivariate analyses, contaminants were independently correlated with 20% and 39% increases in total subsequent laboratory charges and intravenous antibiotic charges, respectively. Thus, the true costs of contaminants may greatly exceed those of the test itself. Identifying patients at very low risk of bacteremia and attention to sterile technique may reduce costs by decreasing the frequency of contaminants. (JAMA. 1991;265:365-369)

Do House Officers Learn From Their Mistakes

Abstract: Mistakes are inevitable in medicine. To learn how medical mistakes relate to subsequent changes in practice, we surveyed 254 internal medicine house officers. One hundred fourteen house officers (45%) completed an anonymous questionnaire describing their most significant mistake and their response to it. Mistakes included errors in diagnosis (33%), prescribing (29%), evaluation (21%), and communication (5%) and procedural complications (11%). Patients had serious adverse outcomes in 90% of the cases, including death in 31% of cases. Only 54% of house officers discussed the mistake with their attending physicians, and only 24% told the patients or families. House officers who accepted responsibility for the mistake and discussed it were more likely to report constructive changes in practice. Residents were less likely to make constructive changes if they attributed the mistake to job overload. They were more likely to report defensive changes if they felt the institution was judgmental. Decreasing the work load and closer supervision may help prevent mistakes. To promote learning, faculty should encourage house officers to accept responsibility and to discuss their mistakes. (JAMA. 1991;265:2089-2094)

Depression and mortality in nursing homes.

Abstract: To determine the prevalence rates of major depressive disorder and of depressive symptoms and their relationship to mortality in nursing homes, research psychiatrists examined 454 consecutive new admissions and followed them up longitudinally for 1 year. Major depressive disorder occurred in 12.6% and 18.1% had depressive symptoms; the majority of cases were unrecognized by nursing home physicians and were untreated. Major depressive disorder, but not depressive symptoms, was a risk factor for mortality over 1 year independent of selected physical health measures and increased the likelihood of death by 59%. Because depression is a prevalent and treatable condition associated with increased mortality, recognition and treatment in nursing homes is imperative.

Setting health care priorities in Oregon. Cost-effectiveness meets the rule of rescue.

Abstract: The Oregon Health Services Commission recently completed work on its principal charge: creation of a prioritized list of health care services, ranging from the most important to the least important Oregon's draft priority list was criticized because it seemed to favor minor treatments over lifesaving ones This reaction reflects a fundamental and irreconcilable conflict between cost-effectiveness analysis and the powerful human proclivity to rescue endangered life: the "Rule of Rescue" Oregon's final priority list was generated without reference to costs and is, therefore, more intuitively sensible than the initial list However, the utility of the final list is limited by its lack of specificity with regard to conditions and treatments An alternative approach for setting health care priorities would circumvent the Rule of Rescue by carefully defining necessary indications for treatment Such an approach might be applied to Oregon's final list in order to achieve better specificity ( JAMA 1991;265:2218-2225)

Evidence for the effects of HIV antibody counseling and testing on risk behaviors.

Abstract: Objective. —To review published abstracts, journal articles, and presentations for evidence of the effects of human immunodeficiency virus (HIV) antibody counseling and testing on risk behaviors. Studies reviewed focused on homosexual men, intravenous drug users in treatment programs, pregnant women, and other heterosexuals. Data Sources. —Peer-reviewed journals (January 1986 through July 1990) and published abstracts and oral presentations from the second (1986) through the sixth (1990) International Conferences on AIDS. Study Selection. —We identified 66 studies that included data on the behavioral effects of HIV antibody counseling and testing. By consensus of the authors, 16 of these were excluded because of small sample size or inadequate study design. Data Extraction. —Studies were assessed by the authors according to methodological strength (sample selection, inclusion of appropriate comparison groups, and inclusion of statistical tests of significance). Data Synthesis. —All longitudinal studies of homosexual men reported reductions in risky behavior among both tested and untested men, and a few reported greater decreases among seropositive men than among seronegative men and those untested or unaware of their serostatus. For intravenous drug users in treatment, we found reductions in intravenous drug use and sexual risk behaviors regardless of counseling and testing experience. We found little evidence for the impact of counseling and testing on pregnancy and/or pregnancy termination rates for either seropositive or seronegative high-risk women. We noted substantial risk reduction among heterosexual couples with one infected partner. Findings among other heterosexuals at increased risk were scanty and mixed. Conclusions. —Further studies should specifically address the behavioral consequences of counseling and testing in various settings. (JAMA. 1991;266:2419-2429)

Continuous emotional support during labor in a US hospital. A randomized controlled trial.

Abstract: The continuous presence of a supportive companion (doula) during labor and delivery in two studies in Guatemala shortened labor and reduced the need for cesarean section and other interventions. In a US hospital with modern obstetric practices, 412 healthy nulliparous women in labor were randomly assigned to a supported group (n = 212) that received the continuous support of adoulaor an observed group (n = 200) that was monitored by an inconspicuous observer. Two hundred four women were assigned to a control group after delivery. Continuous labor support significantly reduced the rate of cesarean section deliveries (supported group, 8%; observed group, 13%; and control group, 18%) and forceps deliveries. Epidural anesthesia for spontaneous vaginal deliveries varied across the three groups (supported group, 7.8%; observed group, 22.6%; and control group, 55.3%). Oxytocin use, duration of labor, prolonged infant hospitalization, and maternal fever followed a similar pattern. The beneficial effects of labor support underscore the need for a review of current obstetric practices. (JAMA. 1991;265:2197-2201)

A multivariate analysis of risk factors for preeclampsia.

Abstract: Objective. —To determine, in a multivariate analysis, risk factors for preeclampsia that could be observed early in pregnancy and to establish whether these risk factors are different for nulliparas and multiparas. Design. —A case-control study of preeclampsia. Setting. —Women who gave birth at Northern California Kaiser Permanente Medical Centers in 1984 and 1985. Participants. —Preeclamptic cases (n =139) were determined from discharge diagnosis of severe preeclampsia and by confirmation of blood pressures and proteinuria from medical records. Controls (n = 132) were randomly selected women who had no discharge diagnosis of any hypertensive disorder of pregnancy and who had no evidence of hypertension or proteinuria from medical record review. Main Variables Examined. —Medical records were abstracted for information regarding maternal age, race, previous pregnancy history, family medical history, socioeconomic status, employment during pregnancy, body mass, and smoking and alcohol consumption. Results. —Multiple logistic regression analyses confirmed that case patients were more likely than control patients to be nulliparous (adjusted odds ratio [OR], 5.4; 95% confidence interval [CI], 2.8 to 10.3) and that preeclampsia in a previous pregnancy greatly increased the risk in a subsequent one (adjusted OR, 10.8; 95% CI, 1.2 to 29.1). However, regardless of parity, preeclamptic women were also more likely to be of high body mass (adjusted OR, 2.7; 95% CI, 1.2 to 6.2), to work during pregnancy (adjusted OR, 2.1; 95% CI, 1.1 to 4.4), and to have a family history of hypertension (adjusted OR, 1.7; 95% CI, 0.92 to 3.2). Having a previous history of a spontaneous abortion was protective but only in multiparous women (adjusted OR for multiparas, 0.09; 95% CI, 0.02 to 0.48). In contrast, being black was a significant risk for preeclampsia but only in nulliparous women (adjusted OR for nulliparas, 12.3; 95% CI, 1.6 to 100.8). Conclusions. —There are a number of risk factors for preeclampsia that may be determined early in a woman's pregnancy. Multiparas and nulliparas share certain risk factors but not others. A cohort investigation is needed to determine the ability of these risk factors to predict who develops preeclampsia. (JAMA. 1991;266:237-241)

Preconception care of diabetes. Glycemic control prevents congenital anomalies.

Abstract: To test the value of intensive management of diabetes before and during early pregnancy, 84 women recruited prior to conception were compared with 110 women who were already pregnant referred at 6 to 30 weeks' gestation. All underwent daily measurement of fasting and postprandial capillary blood glucose levels. Mean blood glucose levels during embryogenesis and organogenesis were within 3.3 to 7.8 mmol/L in 50% of preconception subjects and exceeded 10 mmol/L in 6.5%. One major congenital anomaly occurred in 84 infants (1.2%) of women treated before conception compared with 12 anomalies in 110 infants (10.9%) of mothers in the postconception group. Transient symptomatic hypoglycemia occurred during embryogenesis in 60% of women in the preconception group, with a median frequency of 2.7 episodes per week, but was not associated with excess malformations. We conclude that education and intensive management for glycemic control of diabetic women before and during early pregnancy will prevent excess rates of congenital anomalies in their infants.

Brand logo recognition by children aged 3 to 6 years. Mickey Mouse and Old Joe the Camel.

Abstract: Objective. —Little is known about the influence of advertising on very young children. We, therefore, measured product logo recognition by subjects aged 3 to 6 years. Design. —Children were instructed to match logos with one of 12 products pictured on a game board. Twenty-two logos were tested, including those representing children's products, adult products, and those for two popular cigarette brands (Camel and Marlboro). Setting. —Preschools in Augusta and Atlanta, Ga. Participants. —A convenience sample of 229 children attending preschool. Results. —The children demonstrated high rates of logo recognition. When analyzed by product category, the level of recognition of cigarette logos was intermediate between children's and adult products. The recognition rates of The Disney Channel logo and Old Joe (the cartoon character promoting Camel cigarettes) were highest in their respective product categories. Recognition rates increased with age. Approximately 30% of 3-year-old children correctly matched Old Joe with a picture of a cigarette compared with 91.3% of 6-year-old children. Conclusion. —Very young children see, understand, and remember advertising. Given the serious health consequences of smoking, the exposure of children to environmental tobacco advertising may represent an important health risk and should be studied further. (JAMA. 1991;266:3145-3148)

The J-curve phenomenon and the treatment of hypertension. Is there a point beyond which pressure reduction is dangerous?

Abstract: We critically appraised the medical literature to evaluate whether there is a point beyond which blood pressure reduction in hypertensive subjects is no longer beneficial and possibly even deleterious. Thirteen studies that stratified cardiovascular outcomes by level of achieved blood pressure in treated hypertensive subjects who had been followed up for at least 1 year were critiqued by four independent reviewers. Data addressing population, protocol, and methodological characteristics were evaluated. Studies did not show a consistent J-shaped relationship between treated blood pressure and stroke, but they did demonstrate a consistent J-shaped relationship for cardiac events and diastolic blood pressure. The beneficial therapeutic threshold point was 85 mm Hg. We conclude that low treated diastolic blood pressure levels, ie, below 85 mm Hg, are associated with increased risk of cardiac events. ( JAMA . 1991;265:489-495)

The variability of transfusion practice in coronary artery bypass surgery. Transfusion Medicine Academic Award Group.

Abstract: We audited 540 patients undergoing elective first-time coronary artery bypass grafts at 18 institutions. The purposes of the study were to describe the variability in transfusions among institutions and to determine factors that may account for variability. Mean homologous red blood cell use per patient was 2.9(+/- 0.1) U (institutional range, 0.4 to 6.3 U). One hundred seventy-seven patients (32%) received plasma (institutional range, 0% to 97%), and 119 (22%) received platelets (institutional range, 0% to 80%). After controlling for patient and surgical practice variables, transfusion practice factors still accounted for variation in red blood cell transfusions. Variation in patients receiving plasma and platelet transfusions among institutions was determined in part by prophylactic transfusions. We conclude that blood component usage for coronary artery bypass grafts differs widely among institutions. The variability in use of these components is accounted for in part by unnecessary transfusions in otherwise routine, uncomplicated coronary artery bypass graft procedures.