Showing papers in "JAMA in 1994"
TL;DR: In addition to intrinsic cardiac causes such as valve disease and congestive heart failure, risk factors for cardiovascular disease also predispose to atrial fibrillation.
Abstract: Objective. —To determine the independent risk factors for atrial fibrillation. Design. —Cohort study. Setting. —The Framingham Heart Study. Subjects. —A total of 2090 men and 2641 women members of the original cohort, free of a history of atrial fibrillation, between the ages of 55 and 94 years. Main Outcome Measures. —Sex-specific multiple logistic regression models to identify independent risk factors for atrial fibrillation, including age, smoking, diabetes, electrocardiographic left ventricular hypertrophy, hypertension, myocardial infarction, congestive heart failure, and valve disease. Results. —During up to 38 years of follow-up, 264 men and 298 women developed atrial fibrillation. After adjusting for age and other risk factors for atrial fibrillation, men had a 1.5 times greater risk of developing atrial fibrillation than women. In the full multivariable model, the odds ratio (OR) of atrial fibrillation for each decade of advancing age was 2.1 for men and 2.2 for women (P Conclusion. —In addition to intrinsic cardiac causes such as valve disease and congestive heart failure, risk factors for cardiovascular disease also predispose to atrial fibrillation. Modification of risk factors for cardiovascular disease may have the added benefit of diminishing the incidence of atrial fibrillation. (JAMA. 1994;271:840-844)
2,962 citations
TL;DR: Observed trends in overweight prevalence and body mass index of the US adult population suggest that the Healthy People 2000 objective of reducing the prevalence of overweight US adults to no more than 20% may not be met by the year 2000.
Abstract: Objective. —To examine trends in overweight prevalence and body mass index of the US adult population. Design. —Nationally representative cross-sectional surveys with an in-person interview and a medical examination, including measurement of height and weight. Setting/Participants. —Between 6000 and 13000 adults aged 20 through 74 years examined in each of four separate national surveys during 1960 to 1962 (the first National Health Examination Survey [NHES I]), 1971 to 1974 (the first National Health and Nutrition Examination Survey [NHANES I]), 1976 to 1980 (NHANESII), and 1988 to 1991 (NHANES III phase 1). Results. —In the period 1988 to 1991,33.4% of US adults 20 years of age or older were estimated to be overweight. Comparisons of the 1988 to 1991 overweight prevalence estimates with data from earlier surveys indicate dramatic increases in all race/sex groups. Overweight prevalence increased 8% between the 1976 to 1980 and 1988 to 1991 surveys. During this period, for adult men and women aged 20 through 74 years, mean body mass index increased from 25.3 to 26.3; mean body weight increased 3.6 kg. Conclusions. —These nationally representative data document a substantial increase in overweight among US adults and support the findings of other investigations that show notable increases in overweight during the past decade. These observations suggest that the Healthy People 2000 objective of reducing the prevalence of overweight US adults to no more than 20% may not be met by the year 2000. Understanding the reasons underlying the increase in the prevalence of overweight in the United States and elucidating the potential consequences in terms of morbidity and mortality present a challenge to our understanding of the etiology, treatment, and prevention of overweight. ( JAMA . 1994;272:205-211)
2,782 citations
TL;DR: Primary Care Evaluation of Mental Disorders appears to be a useful tool for identifying mental disorders in primary care practice and research.
Abstract: Objective. —To assess the validity and utility of PRIME-MD (Primary Care Evaluation of Mental Disorders), a new rapid procedure for diagnosing mental disorders by primary care physicians. Design. —Survey; criterion standard. Setting. —Four primary care clinics. Subjects. —A total of 1000 adult patients (369 selected by convenience and 631 selected by site-specific methods to avoid sampling bias) assessed by 31 primary care physicians. Main Outcome Measures. —PRIME-MD diagnoses, independent diagnoses made by mental health professionals, functional status measures (Short-Form General Health Survey), disability days, health care utilization, and treatment/ referral decisions. Results. —Twenty-six percent of the patients had a PRIME-MD diagnosis that met full criteria for a specific disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition . The average time required of the primary care physician to complete the PRIME-MD evaluation was 8.4 minutes. There was good agreement between PRIME-MD diagnoses and those of independent mental health professionals (for the diagnosis of any PRIME-MD disorder, κ=0.71; overall accuracy rate=88%). Patients with PRIME-MD diagnoses had lower functioning, more disability days, and higher rates of health care utilization than did patients without PRIME-MD diagnoses (for all measures, P Conclusion. —PRIME-MD appears to be a useful tool for identifying mental disorders in primary care practice and research. ( JAMA . 1994;272:1749-1756)
2,717 citations
TL;DR: The DSM-IV: Diagnostic and Statistical Manual of Mental Disorders , fourth edition, was developed with a great deal of input from mental health professionals and professional organizations and is a great improvement over thethird edition (DSM-III) and the third edition, revised (DSS-III-R).
Abstract: Diagnostic Criteria From DSM-IV, by the American Psychiatric Association, 358 pp, spiral-bound, $22.50, ISBN 0-89042-064-5, Washington, DC, American Psychiatric Press Inc, 1994. DSM-IV Sourcebook , vol 1, edited by Thomas A. Widiger, Allen J. Frances, Harold Alan Pincus, Michael B. First, Ruth Ross, and Wendy Davis, 768 pp, $112.50, ISBN 0-89042-065-3, Washington, DC, American Psychiatric Association, 1994. DSM-IV: Diagnostic and Statistical Manual of Mental Disorders , fourth edition, was developed with a great deal of input from mental health professionals and professional organizations. In addition, there was a significant collaboration between the American Psychiatric Association (APA) and the World Health Organization, as it developed the tenth revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) . As a result, DSM-IV is a great improvement over the third edition (DSM-III) and the third edition, revised (DSM-III-R) . The Task Force on DSM-IV and 13 work groups (each responsible for a section
2,630 citations
TL;DR: The article entitled "Actual Causes of Death in the United States" was misleading in a number of ways, and misleadingly suggests that heart disease and cancers are not leading causes of death.
Abstract: To the Editor. —The article entitled "Actual Causes of Death in the United States"1was misleading in a number of ways. First, the title should have been something like "Nongenetic Causes of Death" or "Potentially Preventable Nongenetic Causes of Premature Death," or adjustments should have been made so that ordinary causes of death not credited to one of Drs McGinnis and Foege's major external factors were kept in. Otherwise, listing nine or 10 leading "actual causes" misleadingly suggests that heart disease and cancers are not leading causes of death. In fact, subtract those cancers and heart diseases that McGinnis and Foege attribute to external causes, lifestyles, and the like, and heart disease remains comfortably in third place as a cause of death, and cancers not attributable to outside influences kill more than toxic agents do. Second, either some deaths are counted twice or virtually no firearm-related deaths are attributed
2,331 citations
TL;DR: Artificial neural network research began in the early 1940s, advancing in fits and starts, until the late 1960s when Minsky and Papert published Perceptrons, in which they proved that neural networks, as then conceived, can be proved.
Abstract: Neural Computing: Theory and Practice , by Philip Wasserman, 230 pp, $41.95, with illus, ISBN 0-442-20743-3, New York, NY, Van Nostrand Reinhold, 1989. Neural Networks: A Tutorial , by Michael Chester, 182 pp, $38, with illus, ISBN 0-13-368903-4, Englewood Cliffs, NJ, Prentice Hall, 1993. Neural Networks: Algorithms, Applications, and Programming Techniques , by James Freeman and David Skapura, 401 pp, $50.50, with illus, ISBN 0-201-51376-5, Reading, Mass, Addison-Wesley, 1991. Understanding Neural Networks: Computer Explorations , vol 1: Basic Networks , vol 2: Advanced Networks , 309, 367 pp, by Maureen Caudill and Charles Butler, paper, with illus, spiral-bound, with 1 diskette/vol, $39.95/vol, vol 1: ISBN0-262-53102-X (Macintosh), 0-262-53099-6 (IBM), vol 2: ISBN 0-262-53103-8 (Macintosh), 0-262-53100-3 (IBM), Cambridge, Mass, The MIT Press, 1992. Artificial neural network research began in the early 1940s, advancing in fits and starts, until the late 1960s when Minsky and Papert published Perceptrons , in which they proved that neural networks, as then conceived, can
2,216 citations
TL;DR: To evaluate how well quality of life is being measured in the medical literature and to offer a new approach to the measurement, original English-language articles having the term "quality of life" in their titles were identified.
Abstract: Objective. —To evaluate how well quality of life is being measured in the medical literature and to offer a new approach to the measurement. Data Sources. —Original English-language articles having the term "quality of life" in their titles were identified from a recent Quality-of-Life Bibliography and from two MEDLINE searches. Articles were eligible for review only if they described or used one or more "quality-of-life" instruments. Study Selection. —Twenty-five articles were randomly selected from each of the three data sources. Data Extraction. —Each article was reviewed for its compliance with two sets of criteria having several components, which are cited under "Data Synthesis." Data Synthesis. —(1) Investigators conceptually defined quality of life in only 11 (15%) of the 75 articles; identified the targeted domains in only 35 (47%); gave reasons for selecting the chosen quality-of-life instruments in only 27 (36%); and aggregated their results into a composite quality-of-life score in only 27 (38%) of 71 eligible articles. (2) No article distinguished "overall" quality of life from health-related quality of life; patients were invited to give their own separate rating for quality of life in only 13 articles (17%); and among 71 eligible articles, patients were asked to supplement the stipulated items with personal responses in only nine (13%) and to rate the importance of individual items in only six (8.5%). Conclusions. —Because quality of life is a uniquely personal perception, denoting the way that individual patients feel about their health status and/or nonmedical aspects of their lives, most measurements of quality of life in the medical literature seem to aim at the wrong target. Quality of life can be suitably measured only by determining the opinions of patients and by supplementing (or replacing) the instruments developed by "experts." (JAMA. 1994;272:619-626)
2,192 citations
TL;DR: The patient is a 28-year-old man whose acute onset of shortness of breath and vague chest pain began shortly after completing a 10-hour auto trip, and the physician is very apprehensive about his symptoms.
Abstract: CLINICAL SCENARIO You are back where we put you in the previous article1on diagnostic tests in this series on how to use the medical literature: in the library studying an article that will guide you in interpreting ventilation-perfusion (V/Q) lung scans. Using the criteria in Table 1, you have decided that the Prospective Investigation of Pulmonary Diagnosis (PIOPED) study2will provide you with valid information. Just then, another physician comes looking for an article to help with the interpretation of V/Q scanning. Her patient is a 28-year-old man whose acute onset of shortness of breath and vague chest pain began shortly after completing a 10-hour auto trip. He experienced several episodes of similar discomfort in the past, but none this severe, and is very apprehensive about his symptoms. After a normal physical examination, electrocardiogram and chest radiograph, and blood gas measurements that show a Pco2of
2,084 citations
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TL;DR: Evidence from a number of sources indicates that a substantial number of patients suffer treatment-caused injuries while in the hospital, and inappropriate use of drugs was the leading cause of injuries.
Abstract: FOR YEARS, medical and nursing students have been taught Florence Nightingale's dictum—first, do no harm. 1 Yet evidence from a number of sources, reported over several decades, indicates that a substantial number of patients suffer treatment-caused injuries while in the hospital. 2-6 In 1964 Schimmel 2 reported that 20% of patients admitted to a university hospital medical service suffered iatrogenic injury and that 20% of those injuries were serious or fatal. Steel et al 3 found that 36% of patients admitted to a university medical service in a teaching hospital suffered an iatrogenic event, of which 25% were serious or life threatening. More than half of the injuries were related to use of medication. 3 In 1991 Bedell et al 4 reported the results of an analysis of cardiac arrests at a teaching hospital. They found that 64% were preventable. Again, inappropriate use of drugs was the leading cause of
2,029 citations
TL;DR: You are back where you were in the previous article1 on diagnostic tests: in the library studying an article that will guide you in interpreting ventilation-perfusion (V/Q) lung scans.
Abstract: You are back where we put you in the previous article1 on diagnostic tests in this series on how to use the medical literature: in the library studying an article that will guide you in interpreting ventilation-perfusion (V/Q) lung scans. Using the criteria in Table 1, you have decided that the Prospective Investigation of Pulmonary Diagnosis (PIOPED) study2 will provide you with valid information. Just then, another physician
1,963 citations
TL;DR: Binge drinking is widespread on college campuses and programs aimed at reducing this problem should focus on frequent binge drinkers, refer them to treatment or educational programs, and emphasize the harm they cause for students who are not binge drinkers.
Abstract: Objective. —To examine the extent of binge drinking by college students and the ensuing health and behavioral problems that binge drinkers create for themselves and others on their campus. Design. —Self-administered survey mailed to a national representative sample of US 4-year college students. Setting. —One hundred forty US 4-year colleges in 1993. Participants. —A total of 17592 college students. Main Outcome Measures. —Self-reports of drinking behavior, alcohol-related health problems, and other problems. Results. —Almost half (44%) of college students responding to the survey were binge drinkers, including almost one fifth (19%) of the students who were frequent binge drinkers. Frequent binge drinkers are more likely to experience serious health and other consequences of their drinking behavior than other students. Almost half (47%) of the frequent binge drinkers experienced five or more different drinking-related problems, including injuries and engaging in unplanned sex, since the beginning of the school year. Most binge drinkers do not consider themselves to be problem drinkers and have not sought treatment for an alcohol problem. Binge drinkers create problems for classmates who are not binge drinkers. Students who are not binge drinkers at schools with higher binge rates were more likely than students at schools with lower binge rates to experience problems such as being pushed, hit, or assaulted or experiencing an unwanted sexual advance. Conclusions. —Binge drinking is widespread on college campuses. Programs aimed at reducing this problem should focus on frequent binge drinkers, refer them to treatment or educational programs, and emphasize the harm they cause for students who are not binge drinkers. (JAMA. 1994;272:1672-1677)
TL;DR: An aggressive smoking intervention program significantly reduces the age-related decline in FEV 1 in middle-aged smokers with mild airways obstruction and use of an inhaled anticholinergic bronchodilator results in a relatively small improvement inFEV 1 that appears to be reversed after the drug is discontinued.
Abstract: Objective. —To determine whether a program incorporating smoking intervention and use of an inhaled bronchodilator can slow the rate of decline in forced expiratory volume in 1 second (FEV1) in smokers aged 35 to 60 years who have mild obstructive pulmonary disease. Design. —Randomized clinical trial. Participants randomized with equal probability to one of the following groups: (1) smoking intervention plus bronchodilator, (2) smoking intervention plus placebo, or (3) no intervention. Setting. —Ten clinical centers in the United States and Canada. Participants. —A total of 5887 male and female smokers, aged 35 to 60 years, with spirometric signs of early chronic obstructive pulmonary disease. Interventions. —Smoking intervention: intensive 12-session smoking cessation program combining behavior modification and use of nicotine gum, with continuing 5-year maintenance program to minimize relapse. Bronchodilator: ipratropium bromide prescribed three times daily (two puffs per time) from a metered-dose inhaler. Main Outcome Measures. —Rate of change and cumulative change in FEV1over a 5-year period. Results. —Participants in the two smoking intervention groups showed significantly smaller declines in FEV1than did those in the control group. Most of this difference occurred during the first year following entry into the study and was attributable to smoking cessation, with those who achieved sustained smoking cessation experiencing the largest benefit. The small noncumulative benefit associated with use of the active bronchodilator vanished after the bronchodilator was discontinued at the end of the study. Conclusions. —An aggressive smoking intervention program significantly reduces the age-related decline in FEV1in middle-aged smokers with mild airways obstruction. Use of an inhaled anticholinergic bronchodilator results in a relatively small improvement in FEV1that appears to be reversed after the drug is discontinued. Use of the bronchodilator did not influence the long-term decline of FEV1. (JAMA. 1994;272:1497-1505)
TL;DR: Serum PSA level, PSA density, and needle biopsy pathologic findings are accurate predictors of tumor extent and it may be reasonable to follow up some patients whose tumors are most likely insignificant with serial PSA measurements and repeated biopsies.
Abstract: Objectives. —We examined preoperative clinical and pathologic parameters in men with clinical stage T1c disease who underwent radical prostatectomy and correlated these findings with the pathologic extent of disease in the surgical specimen in an attempt to identify a subset of patients with potentially biologically insignificant tumor who might be followed up without immediate treatment. Design and Patients. —A case series of 157 consecutive men who underwent radical prostatectomy for clinical stage T1c disease compared with 64 similarly treated clinical stage T1a cancers (incidental minimal cancers found on transurethral resection of prostate) and 439 clinical stage T2 (palpable) cancers. Main Outcome Measures. —Pathologic stage, grade, and margins; tumor volume; and tumor location. Results. —Sixteen percent of tumors were insignificant ( 0.5 cm3or capsular penetration, with a Gleason score Conclusions. —Eighty-four percent of nonpalpable prostate cancers diagnosed by screening techniques are significant tumors and warrant definitive therapy. However, 16% are insignificant. Serum PSA level, PSA density, and needle biopsy pathologic findings are accurate predictors of tumor extent. It may be reasonable to follow up some patients whose tumors are most likely insignificant with serial PSA measurements and repeated biopsies. (JAMA. 1994;271:368-374)
TL;DR: Protection against tuberculous death, meningitis, and disseminated disease is higher than for total TB cases, although this result may reflect reduced error in disease classification rather than greater BCG efficacy.
Abstract: Objective. —To quantify the efficacy of BCG vaccine against tuberculosis (TB). Data Sources. —MEDLINE with index termsBCG vaccine, tuberculosis, andhuman. Experts from the Centers for Disease Control and Prevention and the World Health Organization, among others, provided lists of all known studies. Study Selection. —A total of 1264 articles or abstracts were reviewed for details on BCG vaccination, concurrent vaccinated and unvaccinated groups, and TB outcome; 70 articles were reviewed in depth for method of vaccine allocation used to create comparable groups, equal surveillance and follow-up for recipient and concurrent control groups, and outcome measures of TB cases and/or deaths. Fourteen prospective trials and 12 case-control studies were included in the analysis. Data Extraction. —We recorded study design, age range of study population, number of patients enrolled, efficacy of vaccine, and items to assess the potential for bias in study design and diagnosis. At least two readers independently extracted data and evaluated validity. Data Synthesis. —The relative risk (RR) or odds ratio (OR) of TB provided the measure of vaccine efficacy that we analyzed. The protective effect was then computed by 1 —RR or 1 —OR. A random-effects model estimated a weighted average RR or OR from those provided by the trials or case-control studies. In the trials, the RR of TB was 0.49 (95% confidence interval [Cl], 0.34 to 0.70) for vaccine recipients compared with nonrecipients (protective effect of 51%). In the case-control studies, the OR for TB was 0.50 (95% CI, 0.39 to 0.64), or a 50% protective effect. Seven trials reporting tuberculous deaths showed a protective effect from BCG vaccine of 71% (RR, 0.29; 95% Cl, 0.16 to 0.53), and five studies reporting on meningitis showed a protective effect from BCG vaccine of 64% (OR, 0.36; 95% Cl, 0.18 to 0.70). Geographic latitude of the study site and study validity score explained 66% of the heterogeneity among trials in a random-effects regression model. Conclusion. —On average, BCG vaccine significantly reduces the risk of TB by 50%. Protection is observed across many populations, study designs, and forms of TB. Age at vaccination did not enhance predictiveness of BCG efficacy. Protection against tuberculous death, meningitis, and disseminated disease is higher than for total TB cases, although this result may reflect reduced error in disease classification rather than greater BCG efficacy. (JAMA. 1994;271:698-702)
Washington University in St. Louis1, Stanford University2, National Institutes of Health3, Pennsylvania State University4, Harvard University5, Vanderbilt University6, University of Tennessee Health Science Center7, University of Washington8, Case Western Reserve University9, George Washington University10, Johns Hopkins University11, Baylor College of Medicine12, Howard University13, University of California, Los Angeles14, University of Michigan15
TL;DR: It is concluded that ulcer patients with H. pylori infection require treatment with antimicrobial agents in addition to antisecretory drugs whether on first presentation with the illness or on recurrence.
Abstract: The National Institutes of Health Consensus Development Conference onHelicobacter pyloriin Peptic Ulcer Disease brought together specialists in gastroenterology, surgery, infectious diseases, epidemiology, and pathology, as well as the public to address the following questions: (1) What is the causal relationship ofH pylorito upper gastrointestinal disease? (2) How does one diagnose and eradicateH pyloriinfection? (3) Does eradication ofH pyloriinfection benefit the patient with peptic ulcer disease? (4) What is the relationship betweenH pyloriinfection and gastric malignancy? (5) WhichH pylori—infected patients should be treated? (6) What are the most important questions that must be addressed by future research inH pyloriinfections? Following 1½ days of presentations by experts and discussion by the audience, a consensus panel weighed the evidence and prepared their consensus statement. Among their findings, the consensus panel concluded that (1) ulcer patients withH pyloriinfection require treatment with antimicrobial agents in addition to antisecretory drugs whether on first presentation with the illness or on recurrence; (2) the value of treating of nonulcerative dyspepsia patients withH pyloriinfection remains to be determined; and (3) the interesting relationship betweenH pyloriinfection and gastric cancers requires further exploration. (JAMA. 1994;272:65-69)
TL;DR: Increasing the consumption of foods rich in certain carotenoids, in particular dark green, leafy vegetables, may decrease the risk of developing advanced or exudative AMD, the most visually disabling form of macular degeneration among older people.
Abstract: Objective. —To evaluate the relationships between dietary intake of carotenoids and vitamins A, C, and E and the risk of neovascular age-related macular degeneration (AMD), the leading cause of irreversible blindness among adults. Design. —The multicenter Eye Disease Case-Control Study. Setting. —Five ophthalmology centers in the United States. Patients. —A total of 356 case subjects who were diagnosed with the advanced stage of AMD within 1 year prior to their enrollment, aged 55 to 80 years, and residing near a participating clinical center. The 520 control subjects were from the same geographic areas as case subjects, had other ocular diseases, and were frequency-matched to cases according to age and sex. Main Outcome Measures. —The relative risk for AMD was estimated according to dietary indicators of antioxidant status, controlling for smoking and other risk factors, by using multiple logistic-regression analyses. Results. —A higher dietary intake of carotenoids was associated with a lower risk for AMD. Adjusting for other risk factors for AMD, we found that those in the highest quintile of carotenoid intake had a 43% lower risk for AMD compared with those in the lowest quintile (odds ratio, 0.57; 95% confidence interval, 0.35 to 0.92;Pfor trend=.02). Among the specific carotenoids, lutein and zeaxanthin, which are primarily obtained from dark green, leafy vegetables, were most strongly associated with a reduced risk for AMD (Pfor trend=.001). Several food items rich in carotenoids were inversely associated with AMD. In particular, a higher frequency of intake of spinach or collard greens was associated with a substantially lower risk for AMD (Pfor trend Conclusion. —Increasing the consumption of foods rich in certain carotenoids, in particular dark green, leafy vegetables, may decrease the risk of developing advanced or exudative AMD, the most visually disabling form of macular degeneration among older people. These findings support the need for further studies of this relationship. (JAMA. 1994;272:1413-1420)
TL;DR: Increased educational and occupational attainment may reduce the risk of incident AD, either by decreasing ease of clinical detection of AD or by imparting a reserve that delays the onset of clinical manifestations.
Abstract: Objective. —Several cross-sectional studies have found an association between Alzheimer's disease (AD) and limited educational experience. It has been difficult to establish whether educational experience is a risk factor for AD because educational attainment can influence performance on diagnostic tests. This study was designed to determine whether limited educational level and occupational attainment are risk factors for incident dementia. Design. —Cohort incidence study. Setting. —General community. Participants. —A total of 593 nondemented individuals aged 60 years or older who were listed in a registry of individuals at risk for dementia in North Manhattan, NY, were identified and followed up. Interventions. —We reexamined subjects 1 to 4 years later with the identical standardized neurological and neuropsychological measures. Main Outcome Measure. —Incident dementia. Results. —We used Cox proportional hazards models, adjusting for age and gender, to estimate the relative risk (RR) of incident dementia associated with low educational and occupational attainment. Of the 593 subjects, 106 became demented; all but five of these met research criteria for AD. The risk of dementia was increased in subjects with either low education (RR, 2.02; 95% confidence interval [CI], 1.33 to 3.06) or low lifetime occupational attainment (RR, 2.25; 95% CI, 1.32 to 3.84). Risk was greatest for subjects with both low education and low life-time occupational attainment (RR, 2.87; 95% CI, 1.32 to 3.84). Conclusions. —The data suggest that increased educational and occupational attainment may reduce the risk of incident AD, either by decreasing ease of clinical detection of AD or by imparting a reserve that delays the onset of clinical manifestations. (JAMA. 1994;271:1004-1010)
TL;DR: The attributable mortality from nosocomial bloodstream infection is high in critically ill patients and is associated with a doubling of the SICU stay, an excess length of hospital stay of 24 days in survivors, and a significant economic burden.
Abstract: Objective. —To determine the excess length of stay, extra costs, and mortality attributable to nosocomial bloodstream infection in critically ill patients. Design. —Pairwise-matched (1:1) case-control study. Setting. —Surgical intensive care unit (SICU) in a tertiary health care institution. Patients. —All patients admitted in the SICU between July 1,1988, and June 30, 1990, were eligible. Cases were defined as patients with nosocomial bloodstream infection; controls were selected according to matching variables in a stepwise fashion. Methods. —Matching variables were primary diagnosis for admission, age, sex, length of stay before the day of infection in cases, and total number of discharge diagnoses. Matching was successful for 89% of the cohort; 86 matched case-control pairs were studied. Main Outcome Measures. —Crude and attributable mortality, excess length of hospital and SICU stay, and overall costs. Results. —Nosocomial bloodstream infection complicated 2.67 per 100 admissions to the SICU during the study period. The crude mortality rates from cases and controls were 50% and 15%, respectively (P Conclusions. —The attributable mortality from nosocomial bloodstream infection is high in critically ill patients. The infection is associated with a doubling of the SICU stay, an excess length of hospital stay of 24 days in survivors, and a significant economic burden. (JAMA. 1994;271:1598-1601)
TL;DR: Because IL-2 does not have a direct effect on cancer cells but rather mediates its antitumor activity by altering host immune reactions, these data represent the best available evidence that immunologic therapy for cancer can be effective in selected patients.
Abstract: Objective. —To determine the efficacy of treatment using high-dose bolus Interleukin 2 (IL-2) in patients with metastatic melanoma or renal cell cancer. Design and Setting. —Consecutive series of all patients treated with high-dose IL-2 in the Surgery Branch of the National Cancer Institute from September 1985 through December 1992. Patients. —Two hundred eighty-three patients with metastatic melanoma or metastatic renal cell cancer who had failed standard treatment for their cancers. Interventions. —Patients received IL-2 at a dose of 720 000 lU/kg intravenously every 8 hours for a maximum of 15 doses per cycle. Two cycles constituted a treatment course, and patients with stable or responding disease received additional treatment courses. A total of 447 courses of treatment were administered. Main Outcome Measures. —Regression of measurable tumor, durability of response to treatment, and survival. Results. —Nine patients (7%) with metastatic melanoma achieved complete regression of all disease and 14 patients (10%) had partial regression. Ten patients (7%) with metastatic renal cell cancer experienced complete regression and 20 patients (13%) had partial regression. Of the 19 patients with complete regression, 15 have remained in complete remission from 7 to 91 months after treatment. Three treatment-related deaths (1.1%) occurred early in this series, but as experience with the administration of this IL-2 regimen increased, no treatment-related deaths occurred in 214 patients treated during the last 5 years of the study. Conclusion. —Biologic therapy with IL-2 can cause significant antitumor effects in patients with advanced metastatic melanoma or renal cell cancer. Because IL-2 does not have a direct effect on cancer cells but rather mediates its antitumor activity by altering host immune reactions, these data represent the best available evidence that immunologic therapy for cancer can be effective in selected patients. (JAMA. 1994;271:907-913)
TL;DR: Primary and retrospective analyses of efficacy suggest that treatment with rhIL-1ra results in a dose-related increase in survival time among patients with sepsis who have organ dysfunction and/or a predicted risk of mortality of 24% or greater.
Abstract: Objective. —To further define the safety and efficacy of recombinant human interleukin 1 receptor antagonist (rhIL-1ra) in the treatment of sepsis syndrome. Study Design. —Randomized, double-blind, placebo-controlled, multicenter, multinational clinical trial. Population. —A total of 893 patients with sepsis syndrome received an intravenous loading dose of rhIL-1ra, 100 mg, or placebo followed by a continuous 72-hour intravenous infusion of rhIL-1ra (1.0 or 2.0 mg/kg per hour) or placebo. Outcome Measure. —Twenty-eight—day all-cause mortality. Results. —There was not a significant increase in survival time for rhIL-1ra treatment compared with placebo among all patients who received the study medication (n=893; generalized Wilcoxon statistic, P =.22) or among patients with shock at study entry (n=713; generalized Wilcoxon statistic, P =.23), the two primary efficacy analyses specified a priori for this trial. Results from secondary analyses suggest an increase in survival time with rhIL-1ra treatment among patients with dysfunction of one or more organs (n=563; linear dose-response, P =.009). Retrospective analysis demonstrated an increase in survival time with rhIL-1ra treatment among patients with a predicted risk of mortality of 24% or greater (n=580; linear dose-response, P =.005) as well as among patients with both dysfunction of one or more organs and a predicted risk of mortality of 24% or greater (n=411; linear dose-response, P =.002). Conclusions. —There was not a statistically significant increase in survivial time for rhIL-1ra treatment compared with placebo among all patients who received the study medication or among patients with shock at study entry. Secondary and retrospective analyses of efficacy suggest that treatment with rhIL-1ra results in a dose-related increase in survival time among patients with sepsis who have organ dysfunction and/or a predicted risk of mortality of 24% or greater. ( JAMA . 1994;271:1836-1843)
TL;DR: High-intensity strength training exercises are an effective and feasible means to preserve bone density while improving muscle mass, strength, and balance in postmenopausal women.
Abstract: Objective. —To determine how multiple risk factors for osteoporotic fractures could be modified by high-intensity strength training exercises in postmenopausal women. Design. —Randomized controlled trial of 1-year duration. Setting. —Exercise laboratory at Tufts University, Boston, Mass. Population. —Forty postmenopausal white women, 50 to 70 years of age, participated in the study; 39 women completed the study. The subjects were sedentary and estrogen-deplete. Interventions. —High-intensity strength training exercises 2 days per week using five different exercises (n=20) vs untreated controls (n=19). Main Outcome Measures. —Dual energy x-ray absorptiometry for bone status, one repetition maximum for muscle strength, 24-hour urinary creatinine for muscle mass, and backward tandem walk for dynamic balance. Results. —Femoral neck bone mineral density and lumbar spine bone mineral density increased by 0.005±0.039 g/cm 2 (0.9%±4.5%) (mean±SD) and 0.009±0.033 g/cm 2 (10%±3.6%), respectively, in the strength-trained women and decreased by -0.022±0.035 g/cm 2 (-2.5%±3.8%) and -0.019±0.035 g/cm 2 (-1.8%±3.5%), respectively, in the controls ( P =.02 and.04). Total body bone mineral content was preserved in the strength-trained women (+2.0±68 g; 0.0%±3.0%) and tended to decrease in the controls (-33+77 g; -1.2%±3.4%, P =.12). Muscle mass, muscle strength, and dynamic balance increased in the strength-trained women and decreased in the controls ( P =.03 to Conclusions. —High-intensity strength training exercises are an effective and feasible means to preserve bone density while improving muscle mass, strength, and balance in postmenopausal women. ( JAMA . 1994;272:1909-1914)
Journal Article•
TL;DR: In this paper, a 78-year-old woman who had abdominal surgery was seen by a medical consultant, who was asked by a surgical colleague to see a 78 year old woman, now 10 days after abdominal surgery, who has become increasingly short of breath over the last 24 hours.
Abstract: CLINICAL SCENARIO You are a medical consultant asked by a surgical colleague to see a 78-year-old woman, now 10 days after abdominal surgery, who has become increasingly short of breath over the last 24 hours. She has also been experiencing what she describes as chest discomfort, which is sometimes made worse by taking a deep breath (but sometimes not). Abnormal findings on physical examination are restricted to residual tenderness in the abdomen and scattered crackles at both lung bases. Chest roentgenogram reveals a small right pleural effusion, but this is the first roentgenogram since the operation. Arterial blood gases show a Po 2 of 70 mm Hg, with a saturation of 92%. The electrocardiogram shows only nonspecific changes. You suspect that the patient, despite receiving 5000 U of heparin twice a day,
TL;DR: Tacrine produced statistically significant, dose-related improvements on objective performance-based tests, clinician- and caregiver-rated global evaluations, and measures of quality of life.
Abstract: Objective. —To evaluate the efficacy and safety of high-dose tacrine hydrochloride over 30 weeks in patients with probable Alzheimer's disease. Design. —A 30-week randomized, double-blind, placebo-controlled, parallel-group trial. Setting. —Outpatients at 33 US centers. Patients. —Men and women at least 50 years of age with mild to moderate Alzheimer's disease and otherwise in good health. Interventions. —Group 1 received placebo; group 2 received 40 mg/d of tacrine for 6 weeks, then 80 mg/d for 24 weeks; groups 3 and 4 received 40 mg/d of tacrine for 6 weeks, 80 mg/d for 6 weeks, and 120 mg/d for 6 weeks. Group 3 remained on a dosage of 120 mg/d for a total of 18 weeks; after 6 weeks at 120 mg/d, group 4 titrated to 160 mg/d for the last 12 weeks. Primary Outcome Measures. —Clinician Interview-Based Impression (CIBI), Alzheimer's Disease Assessment Scale—Cognitive subscale (ADAS-Cog), and Final Comprehensive Consensus Assessment (FCCA). Results. —A total of 663 patients entered the study; 653 patients were included in an intent-to-treat (ITT) analysis; 263 had evaluable data at 30 weeks. The results of the ITT analysis revealed significant (P≤.05) dose-response trends and between-group comparisons on CIBI and ADAS-Cog. In evaluable patients, significant dose-response trends were observed for all three primary measures (P≤.001). Significant differences in favor of 160 mg/d of tacrine vs placebo were observed on the CIBI (P≤.002) and ADAS-Cog and FCCA (P≤.001), as well as caregiver-global and quality-of-life assessments (P≤.05). On the CIBI, 23% and 42% of tacrine-treated patients in the ITT and evaluable-patient populations, respectively, were rated improved compared with 17% and 18% of placebo patients, respectively. The primary reasons for withdrawal of tacrine-treated patients were asymptomatic liver transaminase elevations (28%) and gastrointestinal complaints (16%). These adverse events were reversible on discontinuation of treatment, and many patients were able to restart tacrine. Conclusions. —Tacrine produced statistically significant, dose-related improvements on objective performance-based tests, clinician- and caregiver-rated global evaluations, and measures of quality of life. There was no evidence that the large number of patient withdrawals biased the overall conclusions of the study. (JAMA. 1994;271:985-991)
TL;DR: A 78-year-old woman, now 10 days after abdominal surgery, who has become increasingly short of breath over the last 24 hours, is seen by a medical consultant asked by a surgical colleague to see her.
Abstract: CLINICAL SCENARIO You are a medical consultant asked by a surgical colleague to see a 78-year-old woman, now 10 days after abdominal surgery, who has become increasingly short of breath over the last 24 hours. She has also been experiencing what she describes as chest discomfort, which is sometimes made worse by taking a deep breath (but sometimes not). Abnormal findings on physical examination are restricted to residual tenderness in the abdomen and scattered crackles at both lung bases. Chest roentgenogram reveals a small right pleural effusion, but this is the first roentgenogram since the operation. Arterial blood gases show a Po 2 of 70 mm Hg, with a saturation of 92%. The electrocardiogram shows only nonspecific changes. You suspect that the patient, despite receiving 5000 U of heparin twice a day,
TL;DR: The combination of standard antibiotics and S boulardii was shown to be an effective and safe therapy for these patients with recurrent CDD, and a history of CDD episodes dramatically increased the likelihood of further recurrences.
Abstract: Objective. —To determine the safety and efficacy of a new combination treatment for patients with Clostridium difficile —associated disease (CDD). The treatment combines the yeast Saccharomyces boulardii with an antibiotic (vancomycin hydrochloride or metronidazole). Design. —A double-blind, randomized, placebo-controlled, parallel-group intervention study in patients with active CDD. Patients received standard antibiotics and S boulardii or placebo for 4 weeks, and were followed up for an additional 4 weeks after therapy. Effectiveness was determined by comparing the recurrence of CDD in the two groups using multivariate analysis to control for other risk factors for CDD. Setting. —National referral study of ambulatory or hospitalized patients from three main study coordinating centers. Patients. —A total of 124 eligible consenting adult patients, including 64 who were enrolled with an initial episode of CDD, and 60 who had a history of at least one prior CDD episode. Patients who were immunosuppressed due to acquired immunodeficiency syndrome or cancer chemotherapy within 3 months were not eligible. Intervention. —Treatment with oral S boulardii (1 g/d for 4 weeks) or placebo in combination with a standard antibiotic. Main Outcome Measure. —Recurrence of active CDD. Results. —A history of CDD episodes dramatically increased the likelihood of further recurrences. Multivariate analysis revealed that patients treated with S boulardii and standard antibiotics had a significantly lower relative risk (RR) of CDD recurrence (RR, 0.43; 95% confidence interval, 0.20 to 0.97) compared with placebo and standard antibiotics. The efficacy of S boulardii was significant (recurrence rate 34.6%, compared with 64.7% on placebo; P =.04) in patients with recurrent CDD, but not in patients with initial CDD (recurrence rate 19.3% compared with 24.2% on placebo; P =.86). There were no serious adverse reactions associated with S boulardii . Conclusions. —The combination of standard antibiotics and S boulardii was shown to be an effective and safe therapy for these patients with recurrent CDD; no benefit of S boulardii was demonstrated for those with an initial episode of CDD. ( JAMA . 1994;271:1913-1918)
TL;DR: The consistent relationship of psychopathology and disability indicates the compelling personal and socioeconomic impact of common mental illnesses across cultures and suggests the importance of impairments of higher-order human capacities as determinants of functional disability.
Abstract: Objective. —To examine the impact of common mental illness on functional disability and the cross-cultural consistency of this relationship while controlling for physical illness. A secondary objective was to determine the level of disability associated with specific psychiatric disorders. Design. —A cross-sectional sample selected by two-stage sampling. Setting. —Primary health care facilities in 14 countries covering most major cultures and languages. Patients. —A total of 25916 consecutive attenders of these facilities were screened for psychopathology using the General Health Questionnaire (96% response). Screened patients were sampled from the General Health Questionnaire score strata for the second-stage Composite International Diagnostic Interview administered to 5447 patients (62% response). Main Outcome Measures. —Patient-reported physical disability, number of disability days, and interviewer-rated occupational role functioning. Results. —After controlling for physical disease severity, psychopathology was consistently associated with increased disability. Physical disease severity was an independent, although weaker, contributor to disability. A dose-response relationship was found between severity of mental illness and disability. Disability was most prominent among patients with major depression, panic disorder, generalized anxiety, and neurasthenia; disorder-specific differences were modest after controlling for psychiatric comorbidity. Results were consistent across disability measures and across centers. Conclusions. —The consistent relationship of psychopathology and disability indicates the compelling personal and socioeconomic impact of common mental illnesses across cultures. This suggests the importance of impairments of higher-order human capacities (eg, emotion, motivation, and cognition) as determinants of functional disability. (JAMA. 1994;272:1741-1748)
University of Texas Health Science Center at San Antonio1, Abbott Laboratories2, University of Texas Health Science Center at Houston3, Case Western Reserve University4, University of Illinois at Chicago5, University of Texas Southwestern Medical Center6, Indiana University7, Emory University8, University of Miami9
TL;DR: Divalproex was as effective in rapid-cycling manic patients as in other patients and appears to be independent of prior responsiveness to lithium, while lithium was significantly more effective than placebo in reducing the symptoms of acute mania.
Abstract: Objective. —To compare the effectiveness of divalproex sodium with that of lithium and placebo in patients with acute mania. Design. —Randomized, double-blind, parallel-group study of treatment outcomes in patients with manic-depressive illness. Patients. —A total of 179 hospitalized, acutely manic patients meeting the Research Diagnostic Criteria for manic disorder, approximately half of whom had been nonresponsive to lithium previously, were studied at nine university-affiliated hospitals. Interventions. —After a minimum 3-day washout period, random assignment for 21 days to divalproex, lithium, or placebo in a 2:1:2 ratio. Dosage of divalproex and lithium was increased if tolerated to a target concentration of 1041 μmol/L (150 μg/ mL) or 1.5 mmol/L (conventionally expressed as milliequivalents per liter), respectively. Main Outcome Measures. —Primary outcome measures were changes in the Mania Rating scale derived from the Schedule for Affective Disorders and Schizophrenia. Results. —Intent-to-treat analysis for efficacy was based on data from 68, 35, and 73 patients in the divalproex, lithium, and placebo groups, respectively. Groups were initially comparable except that all eight patients with four or more manic episodes in the previous year were in the divalproex group. In 30%, 33%, and 51% of the above groups, treatment was prematurely terminated due to lack of efficacy, with fewer premature terminations from divalproex than placebo (P=.017). The proportions of patients improving at least 50% were higher for divalproex and lithium groups than for the placebo group: 48% for divalproex (P=.004) and 49% for lithium (P=.025) vs 25% for placebo. Divalproex was as effective in rapid-cycling manic patients as in other patients. Conclusions. —Both divalproex and lithium were significantly more effective than placebo in reducing the symptoms of acute mania. The efficacy of divalproex appears to be independent of prior responsiveness to lithium. (JAMA. 1994;271:918-924)
TL;DR: In the elderly, influenza vaccination may halve the incidence of serological and clinical influenza (in periods of antigenic drift), which is less pronounced for self-reported influenza.
Abstract: Objective. —To determine the efficacy of influenza vaccination in elderly people. Design. —Randomized double-blind placebo-controlled trial. Setting. —Fifteen family practices in the Netherlands during influenza season 1991-1992. Participants. —A total of 1838 subjects aged 60 years or older, not known as belonging to those high-risk groups in which vaccination was previously given. Intervention. —Purified split-virion vaccine containing A/Singapore/6/86(H1N1), A/Beijing/353/89(H3N2), B/Beijing/1/87, and B/Panama/45/90 (n=927) or intramuscular placebo containing physiological saline solution (n=911). Main Outcome Measures. —Patients presenting with influenzalike illness up to 5 months after vaccination; self-reported influenza in postal questionnaires 10 weeks and 5 months after vaccination; serological influenza (fourfold increase of antibody titer between 3 weeks and 5 months after vaccination). Results. —The incidence of serological influenza was 4% in the vaccine group and 9% in the placebo group (relative risk [RR], 0.50; 95% confidence interval [CI], 0.35 to 0.61). The incidences of clinical influenza were 2% and 3%, respectively (RR, 0.53; 95% CI, 0.39 to 0.73). The effect was strongest for the combination of serological and clinical influenza (RR, 0.42; 95% CI, 0.23 to 0.74). The effect was less pronounced for self-reported influenza. Conclusion. —In the elderly, influenza vaccination may halve the incidence of serological and clinical influenza (in periods of antigenic drift). (JAMA. 1994;272:1661-1665)
TL;DR: A substantial decline in blood lead levels is demonstrated of the entire US population and within selected subgroups of the population and similar declines were found in population subgroups defined by age, sex, race/ethnicity, income level, and urban status.
Abstract: Objective. —To describe trends in blood lead levels for the US population and selected population subgroups during the time period between 1976 and 1991. Design. —Two nationally representative cross-sectional surveys and one cross-sectional survey representing Mexican Americans in the southwestern United States. Setting/Participants. —Participants in two national surveys that included blood lead measurements: the second National Health and Nutrition Examination Survey, 1976 to 1980 (n=9832), and phase 1 of the third National Health and Nutrition Examination Survey, 1988 to 1991 (n=12119). Also, Mexican Americans participating in the Hispanic Health and Nutrition Examination Survey, 1982 to 1984 (n=5682). Results. —The mean blood lead level of persons aged 1 to 74 years dropped 78%, from 0.62 to 0.14 μmol/L (12.8 to 2.8 μg/dL). Mean blood lead levels of children aged 1 to 5 years declined 77% (0.66 to 0.15 μmol/L [13.7 to 3.2 μg/dL]) for non-Hispanic white children and 72% (0.97 to 0.27 μmol/L [20.2 to 5.6 μg/dL]) for non-Hispanic black children. The prevalence of blood lead levels 0.48 μmol/L (10 μg/dL) or greater for children aged 1 to 5 years declined from 85.0% to 5.5% for non-Hispanic white children and from 97.7% to 20.6% for non-Hispanic black children. Similar declines were found in population subgroups defined by age, sex, race/ethnicity, income level, and urban status. Mexican Americans also showed similar declines in blood lead levels of a slightly smaller magnitude over a shorter time. Conclusions. —The results demonstrate a substantial decline in blood lead levels of the entire US population and within selected subgroups of the population. The major cause of the observed decline in blood lead levels is most likely the removal of 99.8% of lead from gasoline and the removal of lead from soldered cans. Although these data indicate major progress in reducing lead exposure, they also show that the same sociodemographic factors continue to be associated with higher blood lead levels, including younger age, male sex, non-Hispanic black race/ ethnicity, and low income level. Future efforts to remove other lead sources (eg, paint, dust, and soil) are needed but will be more difficult than removing lead from gasoline and soldered cans. (JAMA. 1994;272:284-291)
TL;DR: The importance and implications of placebo effects in pain treatment and research from the existing literature are estimated, with emphasis on their magnitude and duration, the conditions influencing them, and proposed explanations.
Abstract: Objective. —To estimate the importance and implications of placebo effects in pain treatment and research from the existing literature, with emphasis on their magnitude and duration, the conditions influencing them, and proposed explanations. Data Sources. —English-language articles and books identified through MEDLINE (1980 through 1993) and PsycLIT (1967 through 1993) database searching, bibliography review, and expert consultation. Study Selection. —Articles were included if they pertained to the review objectives. Results. —Placebo response rates vary greatly and are frequently much higher than the often-cited one third. Placebos have time-effect curves, and peak, cumulative, and carryover effects similar to those of active medications. As with medication, surgery can produce substantial placebo effects, and this possibility is commonly overlooked in case series reports on back surgery. Individuals are not consistent in their placebo responses, and a placebo-responder personality has not been identified. Models advanced to explain placebo effects emphasize the role of anxiety, expectations, and learning. Conclusions. —Placebo effects influence patient outcomes after any treatment, including surgery, that the clinician and patient believe is effective. Placebo effects plus disease natural history and regression to the mean can result in high rates of good outcomes, which may be misattributed to specific treatment effects. The true causes of improvements in pain after treatment remain unknown in the absence of independently evaluated randomized controlled trials. ( JAMA . 1994;271:1609-1614)