Showing papers in "JAMA Internal Medicine in 1998"

The AUDIT Alcohol consumption questions (AUDIT-C) : An effective brief screening test for problem drinking

Abstract: cording to the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition, criteria; and (3) either. Results: Of 393 eligible patients, 243 (62%) completed AUDIT-C and interviews. For detecting heavy drinking, AUDIT-C had a higher AUROC than the full AUDIT (0.891 vs 0.881; P = .03). Although the full AUDIT performed better than AUDIT-C for detecting active alcohol abuse or dependence (0.811 vs 0.786; P<.001), the 2 questionnaires performed similarly for detecting heavy drinking and/or active abuse or dependence (0.880 vs 0.881).

Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study.

Abstract: Background The incidence of venous thromboembolism has not been well described, and there are no studies of long-term trends in the incidence of venous thromboembolism. Objectives To estimate the incidence of deep vein thrombosis and pulmonary embolism and to describe trends in incidence. Methods We performed a retrospective review of the complete medical records from a population-based inception cohort of 2218 patients who resided within Olmsted County, Minnesota, and had an incident deep vein thrombosis or pulmonary embolism during the 25-year period from 1966 through 1990. Results The overall average age- and sex-adjusted annual incidence of venous thromboembolism was 117 per 100000 (deep vein thrombosis, 48 per 100000; pulmonary embolism, 69 per 100000), with higher age-adjusted rates among males than females (130 vs 110 per 100000, respectively). The incidence of venous thromboembolism rose markedly with increasing age for both sexes, with pulmonary embolism accounting for most of the increase. The incidence of pulmonary embolism was approximately 45% lower during the last 15 years of the study for both sexes and all age strata, while the incidence of deep vein thrombosis remained constant for males across all age strata, decreased for females younger than 55 years, and increased for women older than 60 years. Conclusions Venous thromboembolism is a major national health problem, especially among the elderly. While the incidence of pulmonary embolism has decreased over time, the incidence of deep vein thrombosis remains unchanged for men and is increasing for older women. These findings emphasize the need for more accurate identification of patients at risk for venous thromboembolism, as well as a safe and effective prophylaxis.

Relationship of Functional Health Literacy to Patients' Knowledge of Their Chronic Disease A Study of Patients With Hypertension and Diabetes

Abstract: Background: Inadequate functional health literacy is common, but its impact on patients with chronic diseases is not well described. Objective: To examine among patients with hypertension or diabetes the relationship between their functional health literacy level and their knowledge of their chronic disease and treatment. Methods: We conducted a cross-sectional survey of patients with hypertension and diabetes presenting to the general medicine clinics at 2 urban public hospitals. Literacy was measured by the Test of Functional Health Literacy in Adults. Knowledge of their illness was assessed in patients with diabetes or hypertension using 21 hypertension and 10 diabetes questions based on key elements in educational materials used in our clinics.

Herbal Medicinals: Selected Clinical Considerations, Focusing on Known or Potential Drug-Herb Interactions

Abstract: Herbal medicinals are being used by an increasing number of patients who typically do not advise their clinicians of concomitant use. Known or potential drug-herb interactions exist and should be screened for. If used beyond 8 weeks, Echinacea could cause hepatotoxicity and therefore should not be used with other known hepatoxic drugs, such as anabolic steroids, amiodarone, methotrexate, and ketoconazole. However, Echinacea lacks the 1,2 saturated necrine ring associated with hepatoxicity of pyrrolizidine alkaloids. Nonsteroidal anti-inflammatory drugs may negate the usefulness of feverfew in the treatment of migraine headaches. Feverfew, garlic, Ginkgo, ginger, and ginseng may alter bleeding time and should not be used concomitantly with warfarin sodium. Additionally, ginseng may cause headache, tremulousness, and manic episodes in patients treated with phenelzine sulfate. Ginseng should also not be used with estrogens or corticosteroids because of possible additive effects. Since the mechanism of action of St John wort is uncertain, concomitant use with monoamine oxidase inhibitors and selective serotonin reuptake inhibitors is ill advised. Valerian should not be used concomitantly with barbiturates because excessive sedation may occur. Kyushin, licorice, plantain, uzara root, hawthorn, and ginseng may interfere with either digoxin pharmacodynamically or with digoxin monitoring. Evening primrose oil and borage should not be used with anticonvulsants because they may lower the seizure threshold. Shankapulshpi, an Ayurvedic preparation, may decrease phenytoin levels as well as diminish drug efficacy. Kava when used with alprazolam has resulted in coma. Immunostimulants (eg, Echinacea and zinc) should not be given with immunosuppressants (eg, corticosteroids and cyclosporine). Tannic acids present in some herbs (eg, St John wort and saw palmetto) may inhibit the absorption of iron. Kelp as a source of iodine may interfere with thyroid replacement therapies. Licorice can offset the pharmacological effect of spironolactone. Numerous herbs (eg, karela and ginseng) may affect blood glucose levels and should not be used in patients with diabetes mellitus.

Donepezil Improves Cognition and Global Function in Alzheimer Disease A 15-Week, Double-blind, Placebo-Controlled Study

Abstract: Methods: This was a 12-week, double-blind, placebocontrolled, parallel-group trial with a 3-week single-blind washout. Outpatients at 23 centers in the United States were randomized to receive placebo, 5 mg of donepezil hydrochloride, or 10 mg of donepezil hydrochloride (5 mg/d during week 1 then 10 mg/d thereafter) administered once daily at bedtime. Primary efficacy was measured using the Alzheimer’s Disease Assessment Scale‐Cognitive Subscale (ADAS-cog) and Clinician’s Interview˛Based Impression of Change including caregiver information (CIBIC plus). Results: A total of 468 patients entered the study, more than 97% of whom were included in the intention-totreat (end point) analyses. The use of donepezil produced statistically significant improvements in ADAS-cog, CIBIC plus, and Mini-Mental State Examination scores, relative to placebo. The mean drug-placebo differences, at end point, for the groups receiving 5 mg/d and 10 mg/d of donepezil hydrochloride were, respectively, 2.5 and 3.1 units for ADAS-cog (P,.001); 0.3 and 0.4 units for CIBIC plus (P#.008); and 1.0 and 1.3 units for Mini-Mental State Examination (P#.004). On the CIBIC plus scale, 32% and 38% of patients, respectively, treated with 5 mg/d and 10 mg/d of donepezil hydrochloride demonstrated clinical improvement (a score of 1, 2, or 3) compared with placebo (18%). The mean (± SEM) donepezil plasma concentrations at study end point were 25.9 ± 0.7 ng/mL and 50.6 ± 1.9 ng/mL in the groups receiving dosages of 5 mg/d and 10 mg/d, respectively. Corresponding mean (± SEM) percentages of inhibition of red blood cell acetylcholinesterase activity were 63.9% ± 0.9% and 74.7% ± 1.2% for these 2 dosages, respectively. There was a statistically significant positive correlation between plasma concentrations of donepezil and acetylcholinesterase inhibition; the EC50 (50% effect) was obtained at a concentration of 15.6 ng/mL. A plateau of inhibition (80%-90%) was reached at plasma donepezil concentrations higher than 50 ng/mL. The correlations between plasma drug concentrations and both ADAS-cog (P,.001) and CIBIC plus (P = .006) were also statistically significant, as were the correlations between red blood cell acetylcholinesterase inhibition and change in ADAScog (P,.001) and CIBIC plus (P = .005). The incidence of treatment-emergent adverse events with both dosages of donepezil (68%˛78%) was comparable with that observed with placebo (69%). The use of 10 mg/d of donepezil hydrochloride was associated with transient mild nausea, insomnia, and diarrhea. There were no treatmentemergent clinically significant changes in vital signs or clinical laboratory test results. More important, the use of donepezil was not associated with the hepatotoxic effects observed with acridine-based cholinesterase inhibitors. Conclusion: Donepezil hydrochloride (5 and 10 mg) administered once daily is a well-tolerated and efficacious agent for treating the symptoms of mild to moderately severe Alzheimer disease. Arch Intern Med. 1998;158:1021-1031

Impact of Atrial Fibrillation on Mortality, Stroke, and Medical Costs

Abstract: Background The impact of atrial fibrillation (AF) on mortality, stroke, and medical costs is unknown. Methods We conducted a prospective cohort study of hospitalized Medicare patients with AF and 1 other cardiovascular diagnosis (CVD) compared with a matched group without AF (n=26753), randomly selected in 6 age-sex strata from 1989 MedPAR files of more than 1 million patients diagnosed as having AF. Stroke rates were also determined in another cohort free of CVD (n=14267). Total medical costs after hospitalization were available from a 1991 cohort. Cumulative mortality, stroke rates, and costs following index admission were adjusted by multivariate and proportional hazard regression analyses. Results Mortality rates were high in individuals with CVD, ranging from 19.0% to 52.1% in 1 year. Adjusted relative mortality risk was approximately 20% higher in patients with AF in all age-sex strata during each of the 3 years studied ( P P P Conclusion Prevention of AF and treatment of patients with AF and associated CVD may yield benefits in reduced mortality and stroke as well as reducing health care costs.

Comparison of an Anticoagulation Clinic With Usual Medical Care: Anticoagulation Control, Patient Outcomes, and Health Care Costs

Abstract: Background The outcomes of an inception cohort of patients seen at an anticoagulation clinic (AC) were published previously. The temporary closure of this clinic allowed the evaluation of 2 more inception cohorts: usual medical care and an AC. Objective To compare newly anticoagulated patients who were treated with usual medical care with those treated at an AC for patient characteristics, anticoagulation control, bleeding and thromboembolic events, and differences in costs for hospitalizations and emergency department visits. Results Rates are expressed as percentage per patient-year. Patients treated at an AC who received lower-range anticoagulation had fewer international normalized ratios greater than 5.0 (7.0% vs 14.7%), spent more time in range (40.0% vs 37.0%), and spent less time at an international normalized ratio greater than 5 (3.5% vs 9.8%). Patients treated at an AC who received higher-range anticoagulation had more international normalized ratios within range (50.4% vs 35.0%), had fewer international normalized ratios less than 2.0 (13.0% vs 23.8%), and spent more time within range (64.0% vs 51.0%). The AC group had lower rates (expressed as percentage per patient-year) of significant bleeding (8.1% vs 35.0%), major to fatal bleeding (1.6% vs 3.9%), and thromboembolic events (3.3% vs 11.8%); the AC group also demonstrated a trend toward a lower mortality rate (0% vs 2.9%;P=.09). Significantly lower annual rates of warfarin sodium–related hospitalizations (5% vs 19%) and emergency department visits (6% vs 22%) reduced annual health care costs by $132086 per 100 patients. Additionally, a lower rate of warfarin-unrelated emergency department visits (46.8% vs 168.0%) produced an additional annual savings in health care costs of $29972 per 100 patients. Conclusions A clinical pharmacist–run AC improved anticoagulation control, reduced bleeding and thromboembolic event rates, and saved $162058 per 100 patients annually in reduced hospitalizations and emergency department visits.

Depression Is a Risk Factor for Coronary Artery Disease in Men: The Precursors Study

Abstract: Background Several studies have found that depression is an independent predictor of poor outcome after the onset of clinical coronary artery disease. There are few data concerning depression as a risk factor for the development of coronary artery disease. Objective To determine if clinical depression is an independent risk factor for incident coronary artery disease. Patients and Methods The Johns Hopkins Precursors Study is a prospective, observational study of 1190 male medical students who were enrolled between 1948 and 1964 and who continued to be followed up. In medical school and through the follow-up period, information was collected on family history, health behaviors, and clinical depression. Cardiovascular disease end points have been assessed with reviews of annual questionnaires, National Death Index searches, medical records, death certificates, and autopsy reports. Results The cumulative incidence of clinical depression in the medical students at 40 years of follow-up was 12%. Men who developed clinical depression drank more coffee than those who did not but did not differ in terms of baseline blood pressure, serum cholesterol levels, smoking status, physical activity, obesity, or family history of coronary artery disease. In multivariate analysis, the men who reported clinical depression were at significantly greater risk for subsequent coronary heart disease (relative risk [RR], 2.12; 95% confidence interval [CI], 1.24-3.63) and myocardial infarction (RR, 2.12; 95% CI, 1.11-4.06). The increased risk associated with clinical depression was present even for myocardial infarctions occurring 10 years after the onset of the first depressive episode (RR, 2.1; 95% CI, 1.1-4.0). Conclusion Clinical depression appears to be an independent risk factor for incident coronary artery disease for several decades after the onset of the clinical depression.

Incidence and Time Course of Thromboembolic Outcomes Following Total Hip or Knee Arthroplasty

Abstract: Background Little is known about the incidence and time course of clinical thromboembolic events after total hip or knee arthroplasty, particularly after hospital discharge. Methods We used a linked hospital discharge database provided by the State of California to identify cases diagnosed as having deep vein thrombosis or pulmonary embolism within 3 months of unilateral total hip or knee arthroplasty. Also, we surveyed orthopedic surgeons to estimate the frequency of postoperative thromboprophylaxis during July 1991 through June 1993. Medical charts were audited to determine the accuracy of the coded records. Results Among 19586 primary hip and 24059 primary knee arthroplasties, the cumulative incidence of deep vein thrombosis or pulmonary embolism within 3 months of surgery was 556 (2.8%) after hip arthroplasty and 508 (2.1%) after knee arthroplasty. The diagnosis of thromboembolism was made after hospital discharge in 76% and 47% of the total hip and total knee arthroplasty cases, respectively ( P P Conclusions There is a difference in the temporal patterns of clinically symptomatic thromboembolic complications after total hip and total knee arthroplasty, suggesting differences in pathogenesis or natural history. The findings suggest that to further reduce thromboembolic outcomes, earlier, more intense prophylaxis may be needed for total knee arthroplasty, and more prolonged prophylaxis may be required after total hip arthroplasty.

Health-Related Quality of Life in Patients Served by the Department of Veterans Affairs Results From the Veterans Health Study

Abstract: Background The Department of Veterans Affairs Health Care System (VA) is the largest integrated single payer system in the United States. To date, there has been no systematic measurement of health status in the VA. The Veterans Health Study has developed methods to assess patient-based health status in ambulatory populations. Objectives To describe the health status of veterans and examine the relationships between their health-related quality of life, age, comorbidity, and socioeconomic and service-connected disability status. Methods Participants in the Veterans Health Study, a 2-year longitudinal study, were recruited from a representative sample of patients receiving ambulatory care at 4 VA facilities in the New England region. The Veterans Health Study patients received questionnaires of health status, including the Medical Outcomes Study Short Form 36-Item Health Survey; and a health examination, clinical assessments, and medical history taking. Sixteen hundred sixty-seven patients for whom we conducted baseline assessments are described. Results The VA outpatients had poor health status scores across all measures of the Medical Outcomes Study Short Form 36-Item Health Survey compared with scores in non-VA populations (at least 50% of 1 SD worse). Striking differences also were found with the sample stratified by age group (20-49 years, 50-64 years, and 65-90 years). For 7 of the 8 scales (role limitations due to physical problems, bodily pain, general health perceptions, vitality, social functioning, role limitations due to emotional problems, and mental health), scores were considerably lower among the younger patients; for the eighth scale (physical function), scores of the young veterans (aged 20-49 years) were almost comparable with the levels in the old veterans (>65 years). The mental health scores of young veterans were substantially worse than all other age groups (P Conclusions The VA outpatients have substantially worse health status than non-VA populations. Mental health differences between the young and old veterans who use the VA health care system are sharply contrasting; the young veterans are sicker, suggesting substantially higher resource needs. Mental health differences may explain much of the worse health-related quality of life in young veterans. As health care systems continue to undergo a radical transformation, the Department of Veterans Affairs should focus on the provision of mental health services for its younger veteran.

Effects of a home-based intervention among patients with congestive heart failure discharged from acute hospital care

Abstract: Background: We examined the effect of a home-based intervention (HBI) on readmission and death among “high-risk” patients with congestive heart failure discharged home from acute hospital care.

Montelukast, a once-daily leukotriene receptor antagonist, in the treatment of chronic asthma: A multicenter, Randomized, double-blind trial

Abstract: Objectives To determine the clinical effect of oral montelukast sodium, a leukotriene receptor antagonist, in asthmatic patients aged 15 years or more. Design Randomized, multicenter, double-blind, placebo-controlled, parallel-group study. A 2-week, single-blind, placebo run-in period was followed by a 12-week, double-blind treatment period (montelukast sodium, 10 mg, or matching placebo, once daily at bedtime) and a 3-week, double-blind, washout period. Setting/Patients Fifty clinical centers randomly allocated 681 patients with chronic, stable asthma to receive placebo or montelukast after demonstrating a forced expiratory volume in 1 second 50% to 85% of the predicted value, at least a 15% improvement in forced expiratory volume in 1 second (absolute value) after inhaled β-agonist administration, a minimal predefined level of daytime asthma symptoms, and inhaled β-agonist use. Twenty-three percent of the patients used concomitant inhaled corticosteroids. Primary End Points Forced expiratory volume in 1 second and daytime asthma symptoms. Results Montelukast improved airway obstruction (forced expiratory volume in 1 second, morning and evening peak expiratory flow rate) and patient-reported end points (daytime asthma symptoms, "as-needed" β-agonist use, nocturnal awakenings) ( P P P Conclusions Montelukast, compared with placebo, significantly improved asthma control during a 12-week treatment period. Montelukast was generally well tolerated, with an adverse event profile comparable with that of placebo.

Benefits of influenza vaccination for low-, intermediate-, and high-risk senior citizens.

Abstract: Background: Vaccination rates for healthy senior citizens are lower than those for senior citizens with underlying medical conditions such as chronic heart or lung disease. Uncertainty about the benefits of influenza vaccination for healthy senior citizens may contribute to lower rates of utilization in this group. Objective: To clarify the benefits of influenza vaccination among low-risk senior citizens while concurrently assessing the benefits for intermediate- and high-risk senior citizens. Methods: All elderly members of a large health maintenance organization were included in each of 6 consecutive study cohorts. Subjects were grouped according to risk status: high risk (having heart or lung disease), intermediate risk (having diabetes, renal disease, stroke and/or dementia, or rheumatologic disease), and low risk. Outcomes were compared between vaccinated and unvaccinated subjects after controlling for baseline demographic and health characteristics. Results: There were more than 20 000 subjects in each of the 6 cohorts who provided 147 551 person-periods of observation. The pooled vaccination rate was 60%. There were 101 619 person-periods of observation for low-risk subjects, 15 482 for intermediate-risk, and 30 450 for highrisk subjects. Vaccination over the 6 seasons was associated with an overall reduction of 39% for pneumonia hospitalizations (P,.001), a 32% decrease in hospitalizations for all respiratory conditions (P,.001), and a 27% decrease in hospitalizations for congestive heart failure (P,.001). Immunization was also associated with a 50% reduction in all-cause mortality (P,.001). Within the risk subgroups, vaccine effectiveness was 29%, 32%, and 49% for high-, intermediate-, and low-risk senior citizens for reducing hospitalizations for pneumonia and influenza (for high and low risk, P#.002; for intermediate risk, P = .11). Effectiveness was 19%, 39%, and 33% (for each, P#.008), respectively, for reducing hospitalizations for all respiratory conditions and 49%, 64%, and 55% for reducing deaths from all causes (for each, P,.001). Vaccination was also associated with direct medical care cost savings of $73 per individual vaccinated for all subjects combined (P = .002). Estimates of cost savings within each risk group suggest that vaccination would be cost saving for each subgroup (range of cost savings of $171 per individual vaccinated for high risk to $7 for low risk), although within the subgroups these findings did not reach statistical significance (for each, P$.05). Conclusions: This study confirms that healthy senior citizens as well as senior citizens with underlying medical conditions are at risk for the serious complications of influenza and benefit from vaccination. All individuals 65 years or older should be immunized with this vaccine. Arch Intern Med. 1998;158:1769-1776

Clinical Correlates of Insomnia in Patients With Chronic Illness

Abstract: Background Patients with chronic insomnia are more likely to develop affective disorders, cardiac morbidity, and other adverse health outcomes, yet many clinicians tend to trivialize the complaint of insomnia or to attribute it only to psychiatric causes. Objectives To estimate the prevalence and longitudinal course of insomnia in patients with documented chronic medical illness and/or depression and to quantify the associations between specific chronic conditions and insomnia. Methods The presence of mild or severe insomnia was based on responses to a sleep questionnaire completed by 3445 patients with at least 1 of 5 physician-identified chronic conditions (hypertension, diabetes, congestive heart failure, myocardial infarction, or depression) at baseline; a subsample of 1814 patients completed follow-up questionnaires at 2 years. Using multivariate techniques, we evaluated the relationship between chronic conditions, patient-reported comorbidities, and insomnia (complaints of initiating and maintaining sleep), adjusting for sociodemographics and health habits. Results Sixteen percent of study patients had severe and 34% had mild insomnia at baseline. At 2-year follow-up, 59% (95% confidence interval, 55%-63%) of patients with mild insomnia and 83% (95% confidence interval, 78%-88%) of patients with severe insomnia at baseline still had sleep problems. Odds ratios corresponding to mild and severe insomnia for key risk factors were as follows: current depressive disorder, 2.6 and 8.2; subthreshold depression, 2.2 and 3.4; congestive heart failure, 1.6 and 2.5; obstructive airway disease, 1.6 and 1.5; back problems, 1.4 and 1.5; hip impairment, 2.2 and 2.7; and prostate problems, 1.6 and 1.4. The majority of insomnia-comorbidity associations observed at baseline persisted at 2-year follow-up. Conclusions Patients with insomnia require follow-up, as the majority continue to be bothered by difficulty initiating and maintaining sleep. In addition to detecting affective disorders in patients with insomnia, clinicians should focus on medical conditions that disturb sleep, especially cardiopulmonary disease, painful musculoskeletal conditions, and prostate problems.

The role of "colonization pressure" in the spread of vancomycin-resistant enterococci: an important infection control variable.

Abstract: Objective The spread of nosocomial multiresistant microorganisms is affected by compliance with infection control measures and antibiotic use. We hypothesized that "colonization pressure" (ie, the proportion of other patients colonized) also is an important variable. We studied the effect of colonization pressure, compliance with infection control measures, antibiotic use, and other previously identified risk factors on acquisition of colonization with vancomycin-resistant enterococci (VRE). Methods Rectal colonization was studied daily for 19 weeks in 181 consecutive patients who were admitted to a single medical intensive care unit. A statistical model was created using a Cox proportional hazards regression model including length of stay in the medical intensive care unit until acquisition of VRE, colonization pressure, personnel compliance with infection control measures (hand washing and glove use), APACHE (Acute Physiology and Chronic Health Evaluation) II scores, and the proportion of days that a patient received vancomycin or third-generation cephalosporins, sucralfate, and enteral feeding. Results With survival until colonization with VRE as the end point, colonization pressure was the most important variable affecting acquisition of VRE (hazard ratio [HR], 1.032; 95% confidence interval [CI], 1.012-1.052;P=.002). In addition, enteral feeding was associated with acquisition of VRE (HR, 1.009; 95% CI, 1.000-1.017;P=.05), and there was a trend toward association of third-generation cephalosporin use with acquisition (HR, 1.007; 95% CI, 0.999-1.015;P=.11). The effects of enteral feeding and third-generation cephalosporin use were more important when colonization pressure was less than 50%. Once colonization pressure was 50% or higher, these other variables hardly affected acquisition of VRE. Conclusions Acquisition of VRE was affected by colonization pressure, the use of antibiotics, and the use of enteral feeding. However, once colonization pressure was high, it became the major variable affecting acquisition of VRE.

Main Risk Factors for Nephropathy in Type 2 Diabetes Mellitus Are Plasma Cholesterol Levels, Mean Blood Pressure, and Hyperglycemia

Abstract: Background: The control of hyperglycemia is of major importance in the treatment of patients with type 1 diabetes mellitus. However, there is no consensus about the required degree of metabolic control in patients with type 2 diabetes mellitus and about the role of hyperglycemia in diabetic nephropathy and in the development of atherosclerosis in relation to other risk factors. Patients and Methods: A prospective, long-term follow-up study was conducted on 574 patients, aged 40 to 60 years, with recent onset of type 2 diabetes mellitus. Patients were initially normotensive and had normal renal function and a normal urinary albumin excretion rate (,30 mg/24 h). The patients were followed up for 2 to 9 years (mean ± SD, 7.8 ± 0.9 years). Levels of hemoglobin A1c and plasma lipids, mean blood pressure, and body mass index (calculated as the weight in kilograms divided by the square of the height in meters) were determined periodically. Cigarette smoking and socioeconomic status were recorded. Renal status was evaluated by the logarithm of the final urinary albumin excretion rate and by the decline in reciprocal creatinine values. Definite clinical events including death, nonfatal myocardial infarction, angina pectoris, congestive heart failure, and peripheral vascular disease were recorded. Results: At the end of the study the urinary albumin excretion rate remained normal (,30 mg/24 h) in 373 patients (65%), 111 (19%) had microalbuminuria (30-300 mg/24 h), and 90 (16%) had overt albuminuria (.300 mg/24 h). Logistic regression models demonstrated that the correlation between hemoglobin A1c levels and the risk of albuminuria is exponential. Multiple logistic regression analysis indicated that levels of total cholesterol, mean blood pressure, and hemoglobin A1c were the main factors associated with the decrease in renal function and with the increase in albuminuria. The combination of values higher than the 50th percentile of all 3 factors defined a high-risk patient population. These high-risk patients had an odds ratio of 43 (95% confidence interval, 25-106) for microalbuminuria and 15 (95% confidence interval, 9-25) for clinical events related to arteriosclerosis compared with the rest of the group. Low levels of high-density lipoprotein, body mass index, cigarette smoking, low socioeconomic status, and male sex were all significantly associated with diabetic nephropathy, as well as with the manifestations of arteriosclerosis. Conclusions: The combination of blood pressure values in the high-normal range with moderately elevated levels of total cholesterol and hemoglobin A1c defines a high-risk group for the progression to diabetic nephropathy and for clinical events related to arteriosclerotic cardiovascular disease. Arch Intern Med. 1998;158:998-1004

Practical criteria for screening patients at high risk for diabetic foot ulceration.

Abstract: years), foot deformities (hallux rigidus or hammer toes), male sex, poor diabetes control (glycosylated hemoglobin .9%), 1 or more subjective symptoms of neuropathy, and an elevated vibration perception threshold (.25 V) were significantly associated with foot ulceration. In addition, 59 patients (78%) with ulceration had a rigid deformity directly associated with the site of ulceration. No significant associations were noted between vascular disease, level of formal education, nephropathy, retinopathy, impaired vision, or obesity and foot ulceration on multivariate analysis. Conclusions: Neuropathy, foot deformity, high plantar pressures, and a history of amputation are significantly associated with the presence of foot ulceration. Although vascular and renal disease may result in delayed wound healing and subsequent amputation, they are not significant risk factors for the development of diabetic foot ulceration. Arch Intern Med. 1998;158:157-162

A review of the incorporation of complementary and alternative medicine by mainstream physicians.

Abstract: Background Studies suggest that between 30% and 50% of the adult population in industrialized nations use some form of complementary and/or alternative medicine (CAM) to prevent or treat a variety of health-related problems. Method A comprehensive literature search identified 25 surveys conducted between 1982 and 1995 that examined the practices and beliefs of conventional physicians with regard to 5 of the more prominent CAM therapies: acupuncture, chiropractic, homeopathy, herbal medicine, and massage. Six studies were excluded owing to their methodological limitations. Results Across surveys, acupuncture had the highest rate of physician referral (43%) among the 5 CAM therapies, followed by chiropractic (40%) and massage (21%). Rates of CAM practice by conventional physicians varied from a low of 9% for homeopathy to a high of 19% for chiropractic and massage therapy. Approximately half of the surveyed physicians believed in the efficacy of acupuncture (51%), chiropractic (53%), and massage (48%), while fewer believed in the value of homeopathy (26%) and herbal approaches (13%). Conclusions This review suggests that large numbers of physicians are either referring to or practicing some of the more prominent and well-known forms of CAM and that many physicians believe that these therapies are useful or efficacious. These data vary considerably across surveys, most likely because of regional differences and sampling methods, suggesting the need for more rigorous surveys using national, representative samples. Finally, outcomes studies are needed so that physicians can make decisions about the use of CAM based on scientific evidence of efficacy rather than on regional economics and cultural norms.

Impact of chronic cough on quality of life.

Abstract: Background Cough is the most common complaint for which adult patients seek medical care in the United States; however, the reason(s) for this is unknown. Objectives To determine whether chronic cough was associated with adverse psychosocial or physical effects on the quality of life and whether the elimination of chronic cough with specific therapy improved these adverse effects. Methods The study design was a prospective before-and-after intervention trial with patients serving as their own controls. Study subjects were a convenience sample of 39 consecutive and unselected adult patients referred for evaluation and management of a chronic, persistently troublesome cough. Baseline data were available for 39 patients and follow-up for 28 patients (22 women and 6 men). At baseline, demographic, Adverse Cough Outcome Survey (ACOS), and Sickness Impact Profile (SIP) data were collected and patients were managed according to a validated, systematic protocol. Following specific therapy for cough, ACOS and SIP instruments were readministered. Results The ages, sex, duration, and spectra and frequencies of the causes of cough were similar to multiple other studies. At baseline, patients reported a mean±SD of 8.6±4.8 types of adverse occurrences related to cough. There were significant correlations between multiple ACOS items and total, physical, and psychosocial SIP scores. Psychosocial score correlated with total number of symptoms (P Conclusions Chronic cough was associated with deterioration in patients' quality of life. The health-related dysfunction was most likely psychosocial. The ACOS and SIP appear to be valid tools in assessing the impact of chronic cough.

Attitude and self-reported practice regarding prognostication in a national sample of internists.

Abstract: Background Since prognostication appears increasingly important in clinical practice, especially in end-of-life care, we examined physicians' experiences and attitudes regarding it. Methods We mailed a survey to a national sample of 1311 internists, yielding 697 responses that were analyzed with multivariate models and other means. Findings were supplemented by qualitative comments from 162 physicians and by interviews with 20. Results On an annual basis, the typical internist addressed the question "How long do I have to live?" 10 times, withdrew or withheld life support 5 times, and referred 5 patients to hospice. Nevertheless, physicians disdain prognostication: 60.4% find it "stressful" to make predictions; 58.7% find it "difficult"; 43.7% wait to be asked by a patient before offering predictions; 80.2% believe patients expect too much certainty; 50.2% believe that if they were to make an error, patients might lose confidence; 89.9% believe they should avoid being too specific; and 56.8% report inadequate training in prognostication. With respect to the key concept of "terminal" illness, physicians on average believe that such patients should have 13.5±11.8 weeks to live, but responses varied substantially from 1 to 75 weeks. Conclusions Physicians (1) commonly encounter situations that require prognostication, (2) feel poorly prepared for prognostication, (3) find it stressful and difficult to make predictions, (4) believe that patients expect too much certainty and might judge them adversely for prognostic errors, and (5) vary in how they regard the key concept of being "terminally ill." These observations may have significant consequences for patient care.

Obesity, Health Services Use, and Health Care Costs Among Members of a Health Maintenance Organization

Abstract: Background Obesity is an independent risk factor for a variety of chronic diseases and is therefore a potential source of avoidable excess health care expenditures. Previous studies of obesity and health care costs have used group level data, applying estimates of population-attributable risks to estimates of US total costs of care for each obesity-related disease. Objective To quantify the association between body mass index (BMI) and health services use and costs stratified by age and use source at the patient level, a level of detail not previously reported. Methods In 17118 respondents to a 1993 health survey of members of a large health maintenance organization, we ascertained through computerized databases all hospitalizations, laboratory services, outpatient visits, outpatient pharmacy and radiology services, and the direct costs of providing these services during 1993. Results There was an association between BMI and annual rates of inpatient days, number and costs of outpatient visits, costs of outpatient pharmacy and laboratory services, and total costs ( P ≤.003). Relative to BMI of 20 to 24.9, mean annual total costs were 25% greater among those with BMI of 30 to 34.9 (rate ratio, 1.25; 95% confidence interval, 1.10-1.41), and 44% greater among those with BMI of 35 or greater (rate ratio, 1.44; 95% confidence interval, 1.22-1.71). The association between BMI and coronary heart disease, hypertension, and diabetes largely explained these elevated costs. Conclusion Given the high prevalence of obesity and the associated elevated rates of health services use and costs, there is a significant potential for a reduction in health care expenditures through obesity prevention efforts.

Tuberculous Pleurisy: A Study of 254 Patients

Abstract: Objectives To determine the age at which tuberculous pleural effusions occur, the radiological and biochemical characteristics of the effusions, the sensitivities of the various diagnostic tests, and the utility of combining clinical, radiological, and analytic data in diagnosis. Methods We studied the case histories of 254 patients in whom tuberculous pleural effusions were diagnosed with certainty between January 1, 1989, and June 30, 1997, in a Spanish university hospital in a region with a high incidence of tuberculosis. Results The mean (±SD) age of the patients was 34.1 ± 18.1 years, and 62.2% were younger than 35 years. The effusion was on the right side in 55.9% of patients, on the left side in 42.5% of patients, and on both sides in 1.6% of patients. In 81.5% of patients, less than two thirds of the hemithorax was affected. Associated pulmonary lesions were detected in 18.9% of patients, of whom 14.6% exhibited cavitation. In 93.3% of the effusions, more than 50% of leukocytes were lymphocytes, and almost all had the biologic characteristics of exudates (98.8% had high total protein contents, 94.9% had high cholesterol levels, and 82.3% had high lactate dehydrogenase levels). All but 1 effusion (99.6%) had an adenosine deaminase (ADA) concentration higher than 47 U/L, 96.8% (123/127) of the effusions had high ADA2levels, and 89% (73/82) of the effusions had high interferon gamma levels. Adenosine deaminase 2 contributed 72.2% ± 12.5% (mean ± SD) of total ADA activity. Total ADA activity was significantly correlated with ADA2(r=0.83) and with interferon gamma (r=0.30) levels. Definitive diagnosis was based on the observation of caseous granulomas in pleural biopsy tissue samples in 79.8% of patients, on the results of biopsy cultures in 11.7% of patients, and on pleural effusion cultures in the remaining 8.5% of patients. Results of the tuberculin skin test were positive in only 66.5% of patients. Conclusions In these patients, lymphocyte-rich exudative pleural effusions occurred, on average, at a young age, with no preference for either the right or the left side; normally affected no more than two thirds of the hemithorax; and were generally unaccompanied by pulmonary infiltrates. High ADA concentration was a highly sensitive diagnostic sign and was caused by a rise in ADA2concentration. The most sensitive criterion based on pleural biopsy was the observation of caseous granulomas, and culture of biopsy material further increased overall sensitivity. Negative skin test results were no guarantee of the effusion being nontuberculous. This, together with the low mean age of the patients and the low frequency of associated pulmonary lesions, suggests that tuberculous pleural effusion is a primary form of tuberculosis in this region.

Choosing a Practical Screening Instrument to Identify Patients at Risk for Diabetic Foot Ulceration

Abstract: Objective To evaluate the sensitivity and specificity of 3 sensory perception testing instruments to screen for risk of diabetic foot ulceration Methods This case-control study prospectively measured the degree of peripheral sensory neuropathy in diabetic patients with and without foot ulcers We enrolled 115 age-matched diabetic patients (40% male) with a case-control ratio of approximately 1:3 (30 cases and 85 controls) from a tertiary care diabetic foot specialty clinic Cases were defined as individuals who had an existing foot ulceration or a history of a recently ( Results A vibration perception threshold test using 25 V and lack of perception at 4 or more sites using the Semmes-Weinstein 10-g monofilament wire system had a significantly higher specificity than the neuropathy score used The neuropathy score was most sensitive when 1 or more answers were affirmative When modalities were combined, particularly the monofilament wire system plus vibration perception threshold testing and the neuropathy score plus the monofilament wire system, there was a substantial increase in specificity with little or no diminution in sensitivity Conclusions The early detection of peripheral neuropathy or loss of "protective sensation" is paramount to instituting a structured treatment plan to prevent lower extremity amputation The results of our study suggest that all 3 sensory perception testing instruments are sensitive in identifying patients at risk for ulceration Combining modalities appears to increase specificity with very little or no diminution in sensitivity

Homocysteine and Ischemic Heart Disease Results of a Prospective Study With Implications Regarding Prevention

Abstract: Results: Serum homocysteine levels were significantly higher in men who died of IHD than in men who did not (mean, 13.1 vs 11.8 µmol/L; P,.001). The risk of IHD among men in the highest quartile of serum homocysteine levels was 3.7 times (or 2.9 times after adjusting for other risk factors) the risk among men in the lowest quartile (95% confidence interval [CI], 1.8-4.7). There was a continuous dose-response relationship, with risk increasing by 41% (95% CI, 20%-65%) for each 5-µmol/L increase in the serum homocysteine level. After adjustment for apolipoprotein B levels and blood pressure, this estimate was 33% (95% CI, 22%-59%). In a metaanalysis of the retrospective studies of homocysteine level and myocardial infarction, the age-adjusted association was stronger: an 84% (95% CI, 52%-123%) increase in risk for a 5-µmol/L increase in the homocysteine level, possibly because the participants were younger; the relationship between serum homocysteine level and IHD seems to be stronger in younger persons than in older persons. Conclusions: Our positive results help resolve the uncertainty that resulted from previous prospective studies. The epidemiological, genetic, and animal evidence together indicate that the association between serum homocysteine level and IHD is likely to be causal. A general increase in consumption of the vitamin folic acid (which reduces serum homocysteine levels) would, therefore, be expected to reduce mortality from IHD. Arch Intern Med. 1998;158:862-867

Renal failure in multiple myeloma: presenting features and predictors of outcome in 94 patients from a single institution.

Abstract: Background Twenty percent of patients with multiple myeloma (MM) have renal failure. Objective To analyze the presenting features, the response to therapy, and the factors associated with renal function recovery and survival in 94 patients with MM and renal failure. Patients and Methods Medical records of patients from our institution with MM and renal failure diagnosed between January 1969 and December 1994 were reviewed. The statistical methods consisted of Kaplan-Meier survival curves, the log-rank test, logistic regression analysis, and the Cox proportional hazards model for survival analysis. Results Renal failure was observed in 94 (22.2%) of 423 patients. Patients with renal failure had more advanced disease than the others. Patients with renal failure had a lower response rate to chemotherapy than those with normal renal function (39% vs 56%; P P P =.003) and response to chemotherapy ( P Conclusions Renal failure was present in almost one fourth of patients with MM. Patients with reversible renal failure had longer survival than those not recovering renal function. When patients dying within the first 2 months of treatment were excluded, the response rate was not affected by renal function. Factors associated with renal function recovery were degree of renal failure, presence of hypercalcemia, and amount of proteinuria. Response to chemotherapy and severity of renal failure were the only independent factors associated with survival.

Dental surgery in anticoagulated patients.

Abstract: Continuous oral anticoagulant therapy has been used to decrease the risk of thromboembolism for more than half a century, prolonging the lives of thousands of patients. Many physicians recommend interrupting continuous anticoagulant therapy for dental surgery to prevent hemorrhage. In reviewing the available literature, there are no well-documented cases of serious bleeding problems from dental surgery in patients receiving therapeutic levels of continuous warfarin sodium therapy, but there were several documented cases of serious embolic complications in patients whose warfarin therapy was withdrawn for dental treatment. Many authorities state that dental extractions can be performed with minimal risk in patients who are at or above therapeutic levels of anticoagulation. There are sound legal reasons to continue therapeutic levels of warfarin for dental treatment. Although there is a theoretical risk of hemorrhage after dental surgery in patients who are at therapeutic levels of anticoagulation, the risk appears to be minimal, the bleeding usually can be easily treated with local measures, and this risk may be greatly outweighed by the risk of thromboembolism after withdrawal of anticoagulant therapy.

Herbs as Medicines

Abstract: Herbs and related products are commonly used by patients who also seek conventional health care. All physicians, regardless of specialty or interest, care for patients who use products that are neither prescribed nor recommended. Some herbs have been extensively studied, but little is known about others. When a patient asks for advice regarding the use of a particular herb, how should a physician respond? Similarly, how does a physician determine if a patient's symptoms are caused by a "remedy"? This review attempts to answer these questions by investigating pertinent definitions, the history of herbs in medicine, epidemiology and prevalence of herbal use, and relevant psychosocial issues.

Depressive Symptoms and Increased Risk of Stroke Mortality Over a 29-Year Period

Abstract: Background Several lines of evidence indicate that depression is importantly associated with cardiovascular disease end points. However, little is known about the role of depression in stroke mortality. Methods This study examined the association between depressive symptoms and stroke mortality in a prospective study of behavioral, social, and psychological factors related to health and mortality in a community sample of 6676 initially stroke-free adults (45.8% male; 79.1% white; mean age at baseline, 43.4 years) from Alameda County, California. Depressive symptoms were assessed by the 18-item Human Population Laboratory Depression Scale. Cox proportional hazards regression models were used to evaluate the impact of depressive symptoms after controlling for age, sex, race, and other confounders. Results A total of 169 stroke deaths occurred during 29 years of follow-up. Reporting 5 or more depressive symptoms at baseline was associated with increased risk of stroke mortality, after adjusting for age, sex, and race (hazard ratio, 1.66; 95% confidence interval, 1.16-2.39; P P Conclusions This population-based study provides the strongest epidemiological evidence to date for a significant relationship between depressive symptoms and stroke mortality. These results contribute to the growing literature on the adverse health effects of depression.

Death and End-of-Life Planning in One Midwestern Community

Abstract: Background The major health care organizations in a geographically defined area implemented an extensive, collaborative advance directive education program approximately 2 years prior to this study. Objectives To determine for a geographically defined population the prevalence and type of end-of-life planning and the relationship between end-of-life plans and decisions in all local health care organizations, including hospitals, medical clinics, long-term care facilities, home health agencies, hospices, and the county health department. Methods For more than 11 months, end-of-life planning and decisions were retrospectively studied for all adult decedents residing in areas within 5 ZIP codes. These decedents were mentally capable in the 10 years prior to death and died while under the care of the participating health care organizations. Data were collected from medical records and death certificates. Treating physicians and decedent proxies were also contacted for interviews. Results A total of 540 decedents were included in this study. The prevalence of written advance directives was 85%. Almost all these documents (95%) were in the decedent's medical record. The median time between advance directive documentation and death was 1.2 years. Almost all advance directive documents requested that treatment be forgone as death neared. Treatment was forgone in 98% of the deaths. Treatment preferences expressed in advance directives seemed to be consistently followed while making end-of-life decisions. Conclusions This study provides a more complete picture of death, end-of-life planning, and decision making in a geographic area where an extensive advance directive education program exists. It indicates that advance planning can be prevalent and can effectively guide end-of-life decisions.