Showing papers in "JAMA Internal Medicine in 1992"

Serum Cholesterol, Blood Pressure, Cigarette Smoking, and Death From Coronary Heart Disease Overall Findings and Differences by Age for 316099 White Men

Abstract: To assess the combined influence of blood pressure (BP), serum cholesterol level, and cigarette smoking on death from coronary heart disease (CHD) and to describe how these associations vary with age, data on those factors and on mortality for 316 099 men screened for the Multiple Risk Factor Intervention Trial (MRFIT) were examined. Vital sta tus of participants has been determined after an average follow-up of 12 years; 6327 deaths from CHD have been identified. Strong graded relationships between serum cho lesterol levels above 4.65 mmol/L (180 mg/dL), systolic BP above 110 mm Hg, and diastolic BP above 70 mm Hg and mortality due to CHD were evident. Smokers with serum cholesterol and systolic BP levels in the highest quintiles had CHD death rates that were approximately 20 times greater than nonsmoking men with systolic BP and cholesterol lev els in the lowest quintile. Systolic and diastolic BP, serum cholesterol level, and cigarettes per day were significant predictors of death due to CHD in all age groups. Systolic BP was a stronger predictor than diastolic BP. These results, together with the findings of clinical trials, offer strong support for intensified preventive efforts in all age groups. (Arch Intern Med. 1992;152:56-64)

Serum cholesterol, blood pressure, cigarette smoking, and death from coronary heart disease. Overall findings and differences by age for 316,099 white men. Multiple Risk Factor Intervention Trial Research Group.

Abstract: To assess the combined influence of blood pressure (BP), serum cholesterol level, and cigarette smoking on death from coronary heart disease (CHD) and to describe how these associations vary with age, data on those factors and on mortality for 316,099 men screened for the Multiple Risk Factor Intervention Trial (MRFIT) were examined. Vital status of participants has been determined after an average follow-up of 12 years; 6327 deaths from CHD have been identified. Strong graded relationships between serum cholesterol levels above 4.65 mmol/L (180 mg/dL), systolic BP above 110 mm Hg, and diastolic BP above 70 mm Hg and mortality due to CHD were evident. Smokers with serum cholesterol and systolic BP levels in the highest quintiles had CHD death rates that were approximately 20 times greater than nonsmoking men with systolic BP and cholesterol levels in the lowest quintile. Systolic and diastolic BP, serum cholesterol level, and cigarettes per day were significant predictors of death due to CHD in all age groups. Systolic BP was a stronger predictor than diastolic BP. These results, together with the findings of clinical trials, offer strong support for intensified preventive efforts in all age groups.

A possible protective effect of nut consumption on risk of coronary heart disease. The Adventist Health Study.

Abstract: bkground.— Although dietary factors are suspected to be important determinants of coronary heart disease (CHD) risk, the direct evidence is relative-lse. Methods.— The Adventist Health Study is a prospective cohort investigation of 31 208 non-Hispanic white California Seventh-Day Adventists. Extensive dietary information was obtained at baseline, along with the values of traditional coronary risk factors. These were related to risk of definite fatal CHD or definite nonfatal- dial infarction. Results.— Subjects who consumed nuts frequently (more than four times per week) experienced substantially fewer definite fatal CHD events (relative risk, 0.52; 95% confidence interval [CI], 0.36 to 0.76) and definite nonfatal myocardial infarctions (relative risk, 0.49; 95% CI, 0.28 to 0.85), when compared with those who consumed nuts less than once per week. These findings persisted on covariate adjustment and were seen in almost all of 16 different subgroups of the population. Subjects who usually consumed whole wheat bread also experienced lower rates of definite nonfatal myocardial infarction (relative risk, 0.56; 95% CI, 0.35 to 0.89) and definite fatal CHD (relative risk, 0.89; 95% CI, 0.60 to 1.33) when compared with those who usually ate white bread. Men who ate beef at least three times each week had a higher risk of definite fatal CHD (relative risk, 2.31; 95% CI, 1.11 to 4.78), but this effect was not seen in women or for the nonfatal myocardial infarction end point. Conclusion.— Our data strongly suggest that the frequent consumption of nuts may protect against risk of CHD events. The favorable fatty acid profile of many nuts is one possible explanation for such an effect. (Arch Intern Med. 1992;152:1416-1424)

Serum cholesterol level and mortality findings for men screened in the Multiple Risk Factor Intervention Trial. Multiple Risk Factor Intervention Trial Research Group.

Abstract: Background.— With increased efforts to lower serum cholesterol levels, it is important to quantify associations between serum cholesterol level and causes of death other than coronary heart disease, for which an etiologic relationship has been established. Methods.— For an average of 12 years, 350 977 men aged 35 to 57 years who had been screened for the Multiple Risk Factor Intervention Trial were followed up following a single standardized measurement of serum cholesterol level and other coronary heart disease risk factors; 21 499 deaths were identified. Results.— A strong, positive, graded relationship was evident between serum cholesterol level measured at initial screening and death from coronary heart disease. This relationship persisted over the 12-year follow-up period. No association was noted between serum cholesterol level and stroke. The absence of an association overall was due to different relationships of serum cholesterol level with intracranial hemorrhage and nonhemorrhagic stroke. For the latter, a positive, graded association with serum cholesterol level was evident. For intracranial hemorrhage, cholesterol levels less than 4.14 mmol/L ( Conclusions.— The association of serum cholesterol with specific causes of death varies in direction, strength, gradation, and persistence. Further research on the determinants of low serum cholesterol level in populations and long-term follow-up of participants in clinical trials are necessary to assess whether inverse associations with noncardiovascular disease causes of death are consequences of noncardiovascular disease, whether serum cholesterol level and noncardiovascular disease are both consequences of other factors, or whether these associations are causal. ( Arch Intern Med . 1992;152:1490-1500)

Practice Guidelines, a New Reality in Medicine: II. Methods of Developing Guidelines

Abstract: Current methods for developing practice guidelines include informal consensus development, formal consensus development, evidence-based guideline development, and explicit guideline development. Informal consensus development is the oldest and most common approach, but guidelines produced in this manner are often of poor quality and lack adequate documentation of methods. Formal consensus development uses a systematic approach to assess expert opinion and to reach agreement on recommendations. Evidence-based guideline development links recommendations directly to scientific evidence of effectiveness; rules of evidence are emphasized over expert opinion in making recommendations. Explicit guideline development clarifies the rationale by specifying the potential benefits, harms, and costs of available interventions; estimating the possibility of the outcomes; and comparing the desirability of the outcomes based on patient preferences. Steps in the development of practice guidelines include introductory decisions (selection of topic and panel members, clarification of purpose); assessments of clinical appropriateness (review of scientific evidence and expert opinion); assessment of public policy issues (resource limitations, feasibility issues); and guideline document development and evaluation (drafting of document, peer review, and pretesting). (Arch Intern Med.1992;152:946-952)

Delirium. The occurrence and persistence of symptoms among elderly hospitalized patients.

Abstract: We evaluated the occurrence and persistence of delirium in 325 elderly patients admitted to a teaching hospital from either a defined community or a long-term care facility. Of the study participants, 34 (10.5%) had Diagnostic and Statistical Manual of Mental Disorders, Third Edition -defined delirium at initial evaluation; of the remaining patients, 91 (31.3%) developed new-onset delirium. An additional 110 patients also experienced individual symptoms of delirium without meeting full criteria. Preexisting cognitive impairment and advanced age were associated with increased risk of incident delirium in the community sample but not the institutional one. Delirium was not associated with an increased risk of mortality, but it was associated with a prolonged hospital stay and an increased risk of institutional placement among community-dwelling elderly. Only five patients (4%) experienced resolution of all new symptoms of delirium before hospital discharge, and only 20.8% and 17.7%, respectively, had resolution of all new symptoms by 3 and 6 months after hospital discharge. These data suggest that delirium is a common disorder that may be substantially less transient than currently believed and that incomplete manifestations of the syndrome may be frequent. ( Arch Intern Med. 1992;152:334-340)

Clinical relevance of nighttime blood pressure and of daytime blood pressure variability.

Abstract: Background.— The purpose of this study was to assess whether hypertensive target organ damage is related to average nighttime blood pressure (BP) and to BP variability. Methods.— Sixty-seven normotensive subjects and 171 borderline, 309 mild, 140 moderate, and 41 severe hypertensive patients were studied with noninvasive ambulatory BP monitoring. Each subject was assigned a target organ damage score of 0 to 5 on the basis of funduscopic changes and degree of left ventricular hypertrophy calculated from electrocardiogram and chest roentgenogram. Results.— When the 728 subjects were subdivided into five classes of increasing daytime BP, in each class a significantly higher degree of target organ damage was present in the subjects with higher nighttime diastolic BP. A similar, although nonsignificant, trend was observed in the subjects with higher nighttime systolic BP. In particular, higher night-time BP levels were accompanied by a more severe degree of left ventricular hypertrophy. As for variability, subjects with higher daytime systolic BP SD, but not with higher day-time diastolic SD, displayed a more severe degree of target organ damage; this was accounted for by a higher degree of retinal abnormalities. The association between target organ damage and systolic BP SD was present both in men and women, while that with nighttime BP was present only in men. No relationship was found between degree of cardiovascular complications and peaks of pressure. Conclusions.— These results suggest that a reduced day-night BP difference and an increased daytime BP variability, evaluated as the SD, are associated with a higher degree of hypertensive cardiovascular complications. Whether this BP profile is the cause or the consequence of target organ damage remains to be established. (Arch Intern Med.1992;152:1855-1860)

Predictors of cardiac rehabilitation participation in older coronary patients.

Abstract: Background— While older coronary patients have a lower exercise capacity than younger coronary patients and have been demonstrated to improve exercise capacity to a degree similar to younger coronary patients, they are less likely to be referred to an outpatient cardiac rehabilitation program The goal of this study was to determine demographic, medical, and psychosocial predictors of outpatient cardiac rehabilitation participation in hospitalized older post—coronary event patients Methods— An in-hospital—guided interview was performed by the clinical research nurse of the cardiac rehabilitation program with 226 hospitalized patients, aged 62 years and older, who had recently suffered a myocardial infarction or coronary bypass surgery Demographic, medical, and psychosocial data were analyzed Results — Overall cardiac rehabilitation participation rate in a population with a mean age of 704±6 years (range, 62 to 92 years) was 21% By multivariate analysis, the strength of the primary physician's recommendation for participation was the most powerful predictor of cardiac rehabilitation entry Also, significant predictors of participation included commute time, patient "denial" of severity of illness, and history of depression Medical factors such as cardiac diagnosis and left ventricular ejection fraction did not predict participation Conclusions— Demographic, medical, and psychosocial data, collected in hospitalized post—coronary event patients are powerful predictors of subsequent participation in cardiac rehabilitation (Arch Intern Med1992;152:1033-1035)

Serum albumin level on admission as a predictor of death, length of stay, and readmission.

Abstract: We studied the serum albumin level within 48 hours of hospitalization for acute illness to predict in-hospital death, length of stay, and readmission in 15,511 patients older than 40 years. Patients with low serum albumin levels (less than 34 g/L), who made up 21% of the population, were more likely to die, had longer hospital stays, and were readmitted sooner and more frequently than patients with normal albumin levels. The in-hospital mortality was 14% among patients with low albumin levels, as compared with 4% among patients with normal levels. Although the serum albumin level was a nonspecific marker, it was a stronger predictor of death, length of stay, and readmission than age. We conclude that the serum albumin level on admission is an important variable that should be incorporated in severity-of-illness measures based on physiologic indexes.

Inferior vena cava filters. Indications, safety, effectiveness

Abstract: Background.— Preventing pulmonary embolization by interrupting vena caval flow has been attempted since 1893. Inferior vena cava (IVC) filters have been available for 20 years, and currently there are five filters commercially available in the United States (Greenfield filter, Titanium Greenfield filter, Simon-Nitinol filter, Bird's Nest filter, and LGM or Vena Tech filter) and two other filters under development (Amplatz filter and Gunther filter). Although these devices are widely used, their clinical utility and safety have not been completely evaluated. Controlled clinical trials to determine the clinical role for IVC filters have not been attempted, but numerous case series describing the outcomes of the seven current filters have been published. We have systematically reviewed these studies to clarify what is known about the indications, safety, and effectiveness of IVC filters. Methods.— Using the MEDLINE database, all English-language publications since 1970 that included follow-up clinical information after filter insertion were reviewed and eight methodologic guidelines were employed to assess the scientific quality of the clinical information. Results.— Twenty-four case series were reviewed: 16 concerned the Greenfield filter (1632 patients), and eight dealt with newer designs (925 patients). Commonly noted methodologic problems included failure to report the initial extent of thromboembolic disease, incomplete description of the patient assembly process, and incomplete and potentially biased outcome assessment. Recurrent clinical pulmonary embolism was rare after filter placement, and only eight deaths from pulmonary embolism were reported. Filter complications were common but rarely life threatening; four (0.16%) deaths from filter complications were noted among the reviewed studies. Thrombotic complications following filter placement included insertion-site deep vein thrombosis and IVC obstruction. These events were rare, but they occurred with all filter types. Conclusions.— Inferior vena cava filters appear to be effective in preventing recurrent pulmonary embolism. Despite the large published experience with IVC filters, many questions remain about their indications, safety, and effectiveness. Anticoagulant therapy, if not contraindicated, should be used in conjunction with filters. While there is no ideal filter, some situations call for specific filters. Filter selection and insertion require experience, modern angiographic technique, and collaboration between clinicians caring for patients and the interventional radiologists or surgeons inserting the device. (Arch Intern Med. 1992;152:1985-1994)

Inquiry about victimization experiences. A survey of patient preferences and physician practices.

Abstract: • Background.— It is unknown whether patients want primary care physicians to inquire about physical abuse (PA) or sexual abuse (SA) or how frequently physicans make such inquiries. Methods.— To determine patient preferences and physician practices, we surveyed 164 patients and 27 physicians at private and public primary care sites. Data were collected using confidential, anonymous, written, multiple-choice questionnaires and were evaluated using univariate analysis. Results.— Among patients, routine PA inquiry was favored by 78% and routine SA inquiry was favored by 68%. Only 7% were ever asked about PA and 6% about SA. A history of PA was reported by 16% and a history of SA by 17%. Ninety percent believed physicians could help with problems from PA and 89% felt physicians could help with problems from SA. Among physicians, one third believed that PA and SA questions should be asked routinely. However, SA inquiries were never made by 89% at initial vi its or by 85% at annual visits. Physical abuse inquiries were never made by 67% at initial visits, or by 60% at annual visits. Eighty-one percent believed they could help with problems associated with PA and 74% with SA. Conclusions.— Most patients favor inquiries about physical and sexual abuse and believe physicians can help with these problems. Physicians believe they can help with these problems though they frequently do not inquire. (Arch Intern Med.1992;152:1186-1190)

The prevalence and incidence of lower extremity amputation in a diabetic population.

Abstract: Objective.—— To describe the incidence of lower extremity amputations and sores or ulcers and investigate risk factors for these complications. Design.— Cohort. Setting.— Primary care. Participants.— Population-based sample (N =1210) of younger-onset diabetic persons (diagnosed before age 30 years and taking insulin) and a stratified random sample (N =1780) of older-onset diabetic persons (diagnosed after age 30 years). Baseline and 4-year follow-up examinations were completed by 996 and 891 younger-onset persons, respectively, and by 1370 and 987 older-onset persons, respectively. Main Outcome Measures.—— Amputations and sores or ulcers of the lower extremities. Results. — Four-year incidence of amputations was 2.2% in both groups. Incidence of sores or ulcers was 9.5% in younger-onset and 10.5% in older-onset persons. In younger-onset persons, significant risk factors for amputation with odds ratios (and 95% confidence intervals) include age, 2.0 for 10 years (1.2 to 3.1), history of sores or ulcers, 10.5 (3.7 to 29.8), diastolic blood pressure, 2.1 for 10 mm Hg (1.3 to 3.5), and pack-years smoked, 1.3 for 10 years (1.0 to 1.6). Risk factors for sores or ulcers include glycosylated hemoglobin, 1.6 for 2% (1.3 to 2.0), retinopathy, 1.3 for two steps (1.1 to 1.6), and current smoking, 2.3 (1.0 to 5.6). In older-onset persons, risk factors for amputation are history of sores or ulcers, 4.6 (1.7 to 12.2), proteinuria, 4.3 (1.6 to 11.5), glycosylated hemoglobin, 1.5 for 2% (1.0 to 2.2), sex, 2.8 for males (1.0 to 7.5), and duration of diabetes, 1.8 for 10 years (1.0 to 3.2). For sores or ulcers, risk factors are glycosylated hemoglobin, 1.6 for 2% (1.3 to 2.0), duration, 1.5 for 10 years (1.0 to 2.1), proteinuria, 2.2 (1.1 to 4.3), and diastolic blood pressure, 0.8 for 10 mm Hg (0.6 to 1.0). Conclusions.— Several factors offer potential for modification for the prevention of amputations but require further study. These include blood pressure, glycosylated hemoglobin, and smoking. (Arch Intern Med. 1992;152:610-616)

Gender Differences in the Treatment and Outcome of Acute Myocardial Infarction: Results From the Myocardial Infarction Triage and Intervention Registry

Abstract: Background. The objective of this study was to compare treatment and outcome of acute myocardial infarction in women and men. Methods. In this survey, patient hospital records were reviewed, and information about patient characteristics, treatments, and hospital events was entered in the Myocar dial Infarction Triage and Intervention Registry. Between January 1988 and June 1990, a total of 4891 consecutive patients, including 1659 women, were hospitalized for acute myocardial infarction in 19 hospitals in the Seattle (Wash) metropolitan area. In-hospital thrombolytic ther apy, coronary angiography, angioplasty, and bypass surgery were examined, as were in-hospital complications and death. Results. Women were older and more often had histo ries of previous hypertension and previous congestive heart failure. Thrombolytic therapy was used less often in women, although information about eligibility for treatment was not available to detemine if this difference was due to treatment bias or differences in eligibility. Both coronary angiography and coronary angioplasty were used less frequently in women. However, of patients who had coronary angiogra phy, equal proportions of women and men received angio plasty and/or coronary bypass surgery. Hospital mortality was 16% for women and 11% for men, although this differ ence was diminished by age adjustment. Mortality was higher in women undergoing bypass surgery, but this difference, too, was less apparent after age adjustment. Conclusions. — Despite high levels of risk factors and mortality, coronary angiography and angioplasty were used less often in women, although among those who underwent coronary angiography, there were no gender differences in the use of angioplasty or bypass surgery. Clearly, more needs to be known about decision making for coronary an giography, as this process seems to differ for women and men with acute myocardial infarction. ( Arch Intern Med. 1992;152:972-976)

Factors impairing daytime performance in patients with sleep apnea/hypopnea syndrome.

Abstract: Patients with sleep apnea/hypopnea syndrome commonly demonstrate impaired daytime performance. In a prospective study, 29 patients with sleep apnea/hypopnea syndrome were assessed polysomnographically to determine the relationship of cognitive performance and daytime sleepiness with sleep disruption, hypoxemia, and mood. Deterioration of cognitive performance correlated significantly with increasing severity of nocturnal breathing irregularity, magnitude of nocturnal hypoxemia, and extent of sleep disruption. Multiple regression analysis identified frequency of apneas plus hypopneas and of arousal and the extent of nocturnal hypoxemia as the variables most strongly associated with cognitive deficits. Anxiety and depression also contributed to this impairment. Objective daytime sleepiness was not significantly associated with nocturnal variables. This study showed that the frequency of breathing irregularities and the extent of both sleep disruption and nocturnal hypoxemia are important in determining daytime function in patients with sleep apnea/hypopnea syndrome. All of these factors should be considered when deciding which patients require treatment. (Arch Intern Med. 1992;152:538-541)

Marital aggression. Impact, injury, and health correlates for husbands and wives.

Abstract: The overall aim of the current study was to comprehensively evaluate the prevalence, impact, and health correlates of marital aggression in a clinic sample of maritally discordant couples seeking psychological treatment. Participants were 93 consecutively presenting clinic couples and 16 maritally satisfied matched control couples from the community. Overall, 71% of clinic couples reported at least one act of marital aggression during the past year. Although 86% of the aggression reported was reciprocal between husbands and wives, impact and injuries sustained as a function of this aggression differed between husbands and wives. Specifically, wives were more likely than husbands to be negatively affected and to sustain severe injuries (eg, broken bones, broken teeth, or injury to sensory organs). Additionally, wives who experienced marital aggression reported clinical levels of depressive symptomatology. Recommendations are offered and risk markers are identified to improve detection by physicians of patients who may be involved in violent marriages. ( Arch Intern Med. 1992;152:1178-1184)

Results of the National Institute of Allergy and Infectious Diseases Collaborative Clinical Trial to test the predictive value of skin testing with major and minor penicillin derivatives in hospitalized adults.

Abstract: Background. — A history (or lack thereof) of penicillin allergy is known to be unreliable in predicting reactions on subsequent administration of the drug. This study tests the usefulness of four penicillin allergen skin tests in the prediction of IgE-mediated reactions subsequent to administration of penicillin. Methods. — Eight centers cooperated in the National Institute of Allergy and Infectious Diseases trial of the predictive value of skin testing with major and minor penicillin derivatives. Hospitalized adults were tested with a major determinant (octa-benzylpenicilloyl-octalysine) and a minor determinant mixture and its components (potassium benzylpenicillin, benzylpenicilloate, and benzylpenicilloyl-N-propylamine). Patients then received a therapeutic course of penicillin and were observed, for 48 hours, for adverse reactions compatible with an IgE-mediated immediate or accelerated allergy. Results.— Among 726 history-positive patients, 566 with negative skin tests received penicillin and only seven (1.2%) had possibly IgE-mediated reactions. Among 600 history-negative patients, 568 with negative skin tests received penicillin and none had a reaction. Only nine of the 167 positive skin test reactors received a penicillin agent and then usually by cautious incremental dosing. Two (22%) of these nine patients had reactions compatible with IgE-mediated immediate or accelerated penicillin allergy; both were positive to the two determinants. Conclusions.— These data corroborate previous data about the negative predictive value of negative skin tests to these materials. The reaction rate in skin test—positive patients was significantly higher than in those with negative skin tests, demonstrating the positive predictive value of positive tests to both major and minor determinants. The number of patients positive only to the major determinant or only to the minor determinant mix was too small to draw conclusions about the positive predictive value of either reagent alone. ( Arch Intern Med. 1992;152:1025-1032)

Fetal outcome after in utero exposure to cancer chemotherapy.

Abstract: Background.— Cancer is the second leading cause of death of women during the reproductive years, and its occurrence in pregnancy is between 0.07% and 0.1%. Methods.— To analyze the effect of cancer on pregnancy, we compared 21 pregnancies occurring during 30 years in women who received chemotherapy for their cancer with a control group matched for maternal age and composed of women not exposed to known teratogens or reproductive risks during pregnancy. Results.— Of 13 women exposed to chemotherapy during the first trimester, two of five whose pregnancies continued to term had major malformations in their infants, four had spontaneous abortions, and four had therapeutic abortions. Of four women with second-trimester exposure to chemotherapy, two had normal live births, one had a stillbirth, and one had a therapeutic abortion. All four pregnancies exposed to chemotherapy during the third trimester resulted in healthy live births. Infants exposed to chemotherapy had statistically significantly lower birth weights than their matched controls (2227±558 g vs 3519±272 g,P Conclusions.— This study confirms the increased likelihood of spontaneous abortions and major birth defects when chemotherapy is used during embryogenesis, whereas such a risk is not apparent beyond the first trimester. Because of the higher risk of stillbirth and intrauterine growth retardation, women with cancer should be monitored closely by a high-risk obstetric unit to define the optimal time of delivery. (Arch Intern Med.1992;152:573-576)

Risk factors associated with complaints of insomnia in a general adult population : influence of previous complaints of insomnia

Abstract: Background— Insomnia is a common complaint both in the general population and also in physician's offices However, risk factors for the development of insomnia complaints have not been completely identified Methods— To identify population characteristics associated with increased prevalence of insomnia complaints, we surveyed a large general adult population in 1984 through 1985 We evaluated the relationship among current complaints of initiating and maintaining sleep and obesity, snoring, concomitant health problems, socioeconomic status, and documented complaints of difficulty with insomnia 10 to 12 years previously Results— The strongest risk factor for complaints of initiating and maintaining sleep was previous complaints of insomnia (odds ratio, 35) In addition, female gender (odds ratio, 15), advancing age (odds ratio, 13), snoring (odds ratio, 13), and multiple types of concomitant health problems (odds ratios, 11 to 17) were all risk factors associated with an increased rate of complaints of initiating and maintaining sleep Conclusion— Complaints of insomnia tend to be a persistent or recurrent problem over long periods of time Female gender, advancing age, and concomitant health problems also are important risk factors ( Arch Intern Med 1992;152:1634-1637)

Epidemiology of Bacterial Endocarditis in the Netherlands: I. Patient Characteristics

Abstract: Background.— Studies of the epidemiology of bacterial endocarditis are usually based on a retrospective review of medical records from referral centers serving diverse patient populations. These studies are therefore likely to suffer from selection bias. We conducted a nationwide prospective epidemiologic study of endocarditis in the Netherlands. Methods.— During a 2-year period, all cases of consecutively hospitalized patients with suspected endocarditis in the Netherlands were reported to us. While hospitalized, patients were visited for an in-person interview and a review of the medical record. Results.— Of 559 episodes, 438 met the criteria for endocarditis; these included 89 episodes of prosthetic valve endocarditis and 349 episodes of native valve endocarditis. Adjusted for age- and sex-specific population figures, the incidence was 19 per million person-years. The incidence increased significantly with age, and men were more often affected than women (266 and 172 cases, respectively). Rheumatic and congenital cardiac lesions formed most of the underlying heart diseases. Mitral valve prolapse was present in only 29 patients with native valve endocarditis (8.3%). A history of intravenous drug abuse was present in 32 patients (7.3%). Viridans streptococci, staphylococci, and enterococci together constituted 86% of the isolated bacterial strains. Only 1.1 % of the patients had culturenegative endocarditis. Overall case fatality was 19.7% and varied widely according to causative microorganism. Conclusion. The distribution of causal microorganisms, the case fatality rate, and the incidence rate of endocarditis are age related. Therefore, a meaningful comparison of data is only possible between population-based cohorts of patients with endocarditis. ( Arch Intern Med. 1992;152:1863-1868)

Optimal therapeutic level of heparin therapy in patients with venous thrombosis.

Abstract: Background.— Audits of heparin sodium therapy suggest that heparin administration is fraught with difficulty. The literature indicates that the current clinical practice of intuitive ordering of heparin results in inadequate therapy because of fear of bleeding. The importance of exceeding the lower limit of the therapeutic range has been strongly supported by findings of prospective clinical trials. Firm evidence indicates that failure to exceed the lower limit is associated with unacceptably high rates of recurrent venous thromboembolism. By comparison, evidence supporting the risk of exceeding the upper limit of the therapeutic range is weak. Objectives.— The purposes of this study were (1) to validate prospectively an approach designed to minimize the proportion of patients receiving subtherapeutic doses of heparin and (2) to determine the effectiveness and safety of decreasing the heparin dosage infused on the basis of activated partial thromboplastin time (APTT) prolongation reflecting both heparin and warfarin sodium effects. Methods.— We performed a randomized double-blind study evaluating a prescriptive approach to heparin administration in patients receiving heparin or heparin with warfarin. Thromboembolic and bleeding complications were objectively documented. Results.— Only 1% and 2% of patients had subtherapeutic heparin levels for 24 hours or more in the heparin and combined groups, respectively. Recurrent venous thromboembolism occurred infrequently in both groups (7%). Sixty-nine (69%) of 99 patients receiving combined therapy had supratherapeutic values, compared with 24 (24%) of 100 receiving heparin; bleeding complications occurred in 9% and 12%, respectively. Conclusions.— Our findings demonstrate that no association exists between supratherapeutic APTT responses and bleeding, which is in direct contrast to the observed association between subtherapeutic APTT responses and recurrent venous thromboembolism. (Arch Intern Med.1992;152:1589-1595)

The prevalence of risk factors for venous thromboembolism among hospital patients.

Abstract: Background.— This study provides an estimate of the prevalence of risk factors for venous thromboembolism among hospital patients. Methods.— The presence of risk factors for venous thromboembolism was determined from a retrospective review of the medical records of 1000 randomly selected patients in 16 acute care hospitals in central Massachusetts. Results.— This most common risk factors for venous thromboembolism were age 40 years (59%) or more, obesity (28%), and major surgery (23%). The average number of risk factors increased with increasing age. One or more risk factors for venous thromboembolism were present in 78% of hospital patients, two or more in 48%, three or more in 19%, four or more in 6%, and five or more in 1%. Conclusion.— Risk factors for venous thromboembolism are common among hospital patients, suggesting that prophylaxis should be widely employed. The cost-effectiveness and risk benefit of prophylaxis is well established in patients undergoing major surgery. Further studies are needed to confirm the benefit of prophylaxis in patients with nonsurgical risk factors for venous thromboembolism. (Arch Intern Med. 1992;152:1660-1664)

Undiagnosed migraine headaches. A comparison of symptom-based and reported physician diagnosis.

Abstract: Background.— Although migraine headaches are a common cause of temporary disability, many people with migraine have not been diagnosed. In a sample of the US population, we sought to determine the proportion of migraineurs diagnosed by a physician and to identify the headache characteristics and sociodemographic profiles associated with undiagnosed migraine. Methods.— A mail questionnaire survey was sent to 15 000 US households, selected from a panel to be representative of the US population. Of a total study base population of 23 611, excluding 3043 subjects less than 12 years of age and respondents with unreported gender, we analyzed data for 20 468 subjects aged 12 to 80 years. Migraine diagnoses were assigned on the basis of reported symptoms by means of operational diagnostic criteria. Physician diagnosis of migraine was ascertained on the basis of self-report. Results. — Forty-one percent of female and 29% of male migraineurs reported having been diagnosed by a physician. Diagnosis was more likely in females, in people with high income levels, and in individuals who reported migraine associated with aura, vomiting, or disability. Of the undiagnosed subjects, 80% experienced at least some headacherelated disability. Conclusions. — Results of this survey indicate that the majority of people with migraine in the United States do not report having been diagnosed by a physician. Given the high proportion of undiagnosed subjects with headache-related disability, efforts to improve the diagnosis and treatment of migraine are recommended. ( Arch Intern Med . 1992;152:1273-1278)

Fever of unknown origin in the 1980s. An update of the diagnostic spectrum.

Abstract: Objective. To determine the relative proportions of the diagnostic categories in patients with fever of unknown origin who were examined in the 1980s. Study Design. Prospective case series. Setting. General Internal Medicine Service based at University Hospital, Leuven, Belgium. Patients. — One hundred ninety-nine consecutive patients meeting the classic criteria of fever of unknown origin who were treated in the 1980s Main Outcome Measurement. The final diagnosis es tablished at discharge or during follow-up. Results. Infections were found in 45 patients (22.6%), tumors were found in 14 (7%), multisystem diseases were found in 42 (21.5%), drug-related fever was found in six (3%), factitious fever was found in seven (3.5%), habitual hyperthermia was found in five (2.5%), miscellaneous dis eases were found in 29 (14.5%), and no diagnosis was reached in 51 (25.6%). Conclusions. Tumors were a less important cause of fe ver of unknown origin in the 1980s. The same holds true for some infectious diseases, such as abscesses and hepatobil iary disorders. Multisystem diseases were more frequently found, and the number of undiagnosed cases increased. Al though these shifts in the disease spectrum in fever of un known origin most probably resulted from a constellation of factors, we suspect that these changes are mainly due to easy and early diagnosis by new diagnostic modalities, such as ultrasonography and computed tomography, of previ ously common causes of fever of unknown origin. ( Arch Intern Med . 1992;152:51-55)

A Comparison of Imipenem to Ceftazidime With or Without Amikacin as Empiric Therapy in Febrile Neutropenic Patients

Abstract: Background.— Neutropenic patients with cancer are traditionally treated with empiric antibiotic combinations when they become febrile. The availability of broadspectrum antibiotics such as ceftazidime and imipenem has made it possible to initiate therapy with a single agent (monotherapy). The objectives of this trial were to compare ceftazidime and imipenem as single agents for the therapy of febrile episodes in neutropenic patients and to ascertain whether the addition of an aminoglycoside (amikacin) to either of these agents would provide an advantage. Methods.— A prospective clinical trial was conducted in which eligible neutropenic patients with cancer were randomized to one of four treatment arms: ceftazidime alone; imipenem alone; ceftazidime plus amikacin; and imipenem plus amikacin. Efficacy analysis was done for 750 assessable episodes. A multivariate logistic-regression analysis was also performed to examine the unique contribution of various prognostic factors. Results.— The overall response rates were 76% with imipenem plus amikacin, 72% with imipenem, 71% with ceftazidime plus amikacin, and 59% with ceftazidime alone. Single-organism gram-positive infections occurred in 101 of 750 episodes. Without a change in antibiotics, the response rates were 50% with imipenem, 40% with imipenem plus amikacin, 39% with ceftazidime plus amikacin, and 38% with ceftazidime. Most responded to vancomycin or other antibiotics, and the mortality associated with gram-positive infections was only 5%. Regardless of the antibiotic regimen, the majority of uncomplicated gramnegative infections responded to therapy and the majority of complicated gram-negative infections failed to respond. Multivariate logistic-regression analysis showed that recovery of the neutrophil count was the most favorable prognostic factor in a patient's response to infection, whereas the presence of gram-positive infection, acute leukemia, pulmonary or enteric infection, and therapy with ceftazidime were unfavorable factors. Conclusions.— Single-agent therapy with imipenem is as effective as more conventional combination antibiotic therapy for the empirical treatment of febrile episodes in neutropenic patients with cancer. ( Arch Intern Med . 1992;152:283-291)

A Study of Chest Compression Rates During Cardiopulmonary Resuscitation in Humans: The Importance of Rate-Directed Chest Compressions

Abstract: . A prospective, cross-over trial was performed comparing two different rates of precordial compression using endtidal carbon dioxide as an indicator of the efficacy of cardiopulmonary resuscitation in 23 adult patients. A second purpose of this study was to determine the effect of audioprompted, rate-directed chest compressions on the endtidal carbon dioxide concentrations during cardiopulmonary resuscitation. Patients with cardiac arrest received external chest compressions, initially in the usual fashion without rate direction and then with rhythmic audiotones for rate direction at either 80 compressions per minute or 120 compressions per minute. Nineteen of 23 patients had higher end-tidal carbon dioxide levels at the compression rate of 120 per minute. The mean end-tidal carbon dioxide level during compressions of 120 per minute was 15.0±1.8 mm Hg, slightly but significantly higher than the mean level of 13.0±1.8 mm Hg at a compression rate of 80 per minute. However, end-tidal carbon dioxide levels increased rather dramatically when audiotones were used to guide the rate of chest compressions. Mean end-tidal carbon dioxide concentration was 8.7±1.2 mm Hg during standard cardiopulmonary resuscitation immediately before audio-prompted, rate-directed chest compression and increased to 14.0±1.3 mm Hg after the first 60 seconds of audible tones directing compressions. Using end-tidal carbon dioxide as an indicator of cardiopulmonary resuscitation efficacy, we conclude that audible rate guidance during chest compressions may improve cardiopulmonary resuscitation performance. (Arch Intern Med. 1992;152:145-149)

Agreement between patients and their self-selected surrogates on difficult medical decisions.

Abstract: Background.— Several studies have demonstrated that surrogate decision makers often are unable to use substituted judgment when asked to make decisions for incompetent patients. This study further explored this question, using a relatively young, healthy sample of 50 patient/ surrogate pairs. Methods. — Patients were randomly recruited from a community family practice clinic and asked to select a surrogate. Five case vignettes were presented to patients and surrogates during separate interviews. Vignettes asked for decisions related to ventilation, resuscitation, and tube feeding for a patient in permanent coma, amputation as life-extending treatment for a mentally confused patient, and chemotherapy for a decisionally incapacitated patient with advanced cancer. Factors considered important to decision making were also investigated. Results. — As groups, patients and surrogates were similar as they chose to withdraw or continue treatment in the same proportions. However, within individual pairs, agreement on treatment occurred only 70% of the time even though surrogates were asked to base their treatment decisions on substituted judgment. The κ coefficients indicated that the rate of agreement in individual vignettes was low. Patients considered "burden on the family" and "time left to live" as the most important factors in choosing among difficult treatment options, while surrogates identified the patients' pain as the most important factor. Conclusions.— The high rate of discrepant decisions underscores the importance of effective patient-surrogate communication before medical decision-making incompetence occurs. The potential of increasing patient-surrogate agreement on difficult medical decisions by educational interventions should be explored. (Arch Intern Med.1992;152:1049-1054)

Body mass index and body girths as predictors of mortality in black and white women.

Abstract: Background.— The high prevalence of obesity in black women has been hypothesized to contribute to higher rates of coronary heart disease and total mortality. Investigators have recently refined the study of obesity by differentiating anatomic patterns of the physical location of adipose tissue on the body. We examined fat patterning as a predictor of mortality in black women. Methods. — Body mass index (BMI) and body girths were examined as predictors of all-cause and coronary heart disease mortality during 25 to 28 years of follow-up in black and white women in the Charleston Heart Study. Results. — The BMI was associated with all-cause and coronary heart disease mortality in white, but not black, women. After controlling for differences in BMI, the risk of all-cause mortality was greater in white women with larger chest and abdominal girths, while midarm girths were inversely associated with mortality. The hazard at the 85th percentile relative to the 15th percentile of abdomen/ midarm ratio was 1.44 in models that included BMI, education, and smoking as covariates. In black women, the girths were not predictive of either all-cause or coronary heart disease mortality. Conclusions. — The failure of BMI and fat patterning to predict mortality in black women challenges previously held assumptions regarding the role of overweight in the higher mortality experienced by black women. ( Arch Intern Med . 1992;152:1257-1262)

Clinical prognostic factors in lupus nephritis. The importance of hypertension and smoking.

Abstract: Background.— Many previous studies of the influence of sociodemographic and clinical factors on the development of renal failure in patients with lupus nephritis have been based on selected subgroups of patients and have yielded conflicting results. We sought to determine the prognostic importance of patient demographic characteristics (age, gender, race, and socioeconomic status), smoking status, and hypertension in the development of end-stage renal disease (ESRD) among patients with lupus nephritis. Methods.— This retrospective cohort study followed an inception cohort of 160 adults with lupus nephritis. The outcome measure was the development of ESRD, defined as the institution of maintenance dialysis or measurement of a creatinine clearance of 10 mL/min or less. Life-table analysis was used to determine differences between patient subgroups in the time to development of ESRD. Results.— End-stage renal disease developed in 41 (26%) of 160 patients followed up for a median of 6.4 years. Hypertension and smoking status at the onset of nephritis were strongly associated with differences in the time to development of ESRD. The median time to ESRD among patients with moderate to severe hypertension (diastolic blood pressure, ≥105 mm Hg) was 7 months, among patients with mild hypertension (diastolic blood pressure, 90 to 104 mm Hg) it was 146 months, and among normotensive patients it was greater than 273 months.The median time to ESRD among smokers was 145 months and among nonsmokers it was greater than 273 months. These effects persisted in multivariable analyses adjusting for differences among patients in age, gender, socioeconomic status, renal histology, and immunosuppressive treatment. The independent effects of hypertension and smoking resulted in shorter times to renal failure among patients who were both hypertensive and smoking, compared with nonsmoking hypertensive patients. The development of ESRD did not differ among patient demographic subgroups. Conclusion.— Patient demographic characteristics had no detectable impact on the rate of progression to ESRD in this cohort. Hypertension and smoking appear to be important, potentially modifiable, factors influencing the prognosis of patients with lupus nephritis. ( Arch Intern Med . 1992;152:2082-2088)

Operative risk in patients with severe obstructive pulmonary disease.

Abstract: Background.— We wanted to determine the risk of post-operative pulmonary complications and mortality in patients with severe chronic obstructive pulmonary disease. Methods.— We reviewed 107 consecutive operations performed in 89 patients with severe chronic obstructive pulmonary disease (forced expiratory volume in 1 second, Results.— Postoperative pulmonary complications occurred in 31 operations (29%) and were significantly related to the type and duration of surgery. Also, American Society of Anesthesiologists class approached significance as a predictor. Postoperative pulmonary complications occurred at higher rates in coronary artery bypass grafting and major abdominal procedures (60% and 56%) than in other operations involving general or spinal anesthesia (27%) or in procedures performed with the patient under regional or local anesthesia (16%). When the durations of the operations were classified as less than 1 hour, 1 to 2 hours, 2 to 4 hours, and more than 4 hours, the rates of postoperative pulmonary complications were 4%, 23%, 38%, and 73%, respectively. Regarding American Society of Anesthesiologists class, postoperative pulmonary complications occurred in 10% of patients in class II, 28% of those in class III, and 46% of those in class IV. In terms of life-threatening complications, there were six deaths and only two cases of nonfatal ventilatory failure. Notably, mortality clustered primarily in coronary artery bypass graft procedures. Five of 10 patients receiving coronary artery bypass grafts died, compared with one death after 97 non—coronary artery bypass graft operations (50% vs 1%). Conclusions.— Although the risk of coronary artery bypass grafting deserves further study, noncardiac surgery carries an acceptable operative risk in patients with severe chronic obstructive pulmonary disease. ( Arch Intern Med. 1992;152:967-971)

Rochalimaea henselae causes bacillary angiomatosis and peliosis hepatis.

Abstract: Background. — Recent studies have demonstrated that a newly described agent of persistent bacteremia, Rochalimaea henselae , and the agent of bacillary angiomatosis are both closely related to Rochalimaea quintana . Bacillary peliosis hepatis seemed likely to have the same etiologic agent as bacillary angiomatosis. We sought these pathologic changes in patients from whom R henselae was cultivated. Methods. — For two patients whose histopathologic findings we reviewed, additional light and electron microscopy were performed. Their bacterial isolates were compared by electrophoretic patterns of outer membrane proteins, restriction endonuclease digestion patterns of DNA, and reaction with murine antiserum. Results.—— A previously reported human immunodeficiency virus—infected man with persistent bacteremia due to R henselae was found to have bacillary peliosis hepatis. Rochalimaea henselae was also isolated from the spleen of a woman receiving immunosuppressive therapy after allogeneic renal transplantation. She had developed fever, liver and spleen nodules, and periaortic lymphadenopathy. Bacillary peliosis of her liver and spleen, as well as bacillary angiomatosis of liver, spleen, and a lymph node, were found. The bacterial isolates had comparable electrophoretic patterns of outer membrane proteins and of restriction endonuclease—digested DNA, which differed from the respective patterns of R quintana . Murine antisera raised to the first isolate reacted strongly with the second by means of immunoblot and immunofluorescence techniques, while reacting only weakly with R quintana . Conclusion.—— Rochalimaea henselae , recently recognized to cause persistent fever and bacteremia in immunocompetent and immunocompromised persons, also causes bacillary angiomatosis and parenchymal bacillary peliosis. ( Arch Intern Med . 1992;152:602-606)