Showing papers in "JAMA Internal Medicine in 2000"
TL;DR: Evidence of strong covariation of depression and medical noncompliance suggests the importance of recognizing depression as a risk factor for poor outcomes among patients who might not be adhering to medical advice.
Abstract: Background: Depression and anxiety are common in medical patients and are associated with diminished health status and increased health care utilization. This article presents a quantitative review and synthesis of studies correlating medical patients’ treatment noncompliance with their anxiety and depression.
3,882 citations
TL;DR: The results confirm that thyroid dysfunction is common, may often go undetected, and may be associated with adverse health outcomes that can be avoided by serum TSH measurement.
Abstract: Context: The prevalence of abnormal thyroid function in the United States and the significance of thyroid dysfunction remain controversial. Systemic effects of abnormal thyroid function have not been fully delineated, particularly in cases of mild thyroid failure. Also, the relationship between traditional hypothyroid symptoms and biochemical thyroid function is unclear. Objective: To determine the prevalence of abnormal thyroid function and the relationship between (1) abnormal thyroid function and lipid levels and (2) abnormal thyroid function and symptoms using modern and sensitive thyroid tests. Design: Cross-sectional study.
2,525 citations
TL;DR: Hospital or nursing home confinement, surgery, trauma, malignant neoplasm, chemotherapy, neurologic disease with paresis, central venous catheter or pacemaker, varicose veins, and superficial vein thrombosis are independent and important risk factors for VTE.
Abstract: Background Reported risk factors for venous thromboembolism (VTE) vary widely, and the magnitude and independence of each are uncertain Objectives To identify independent risk factors for deep vein thrombosis and pulmonary embolism and to estimate the magnitude of risk for each Patients and Methods We performed a population-based, nested, case-control study of 625 Olmsted County, Minnesota, patients with a first lifetime VTE diagnosed during the 15-year period from January 1, 1976, through December 31, 1990, and 625 Olmsted County patients without VTE The 2 groups were matched on age, sex, calendar year, and medical record number Results Independent risk factors for VTE included surgery (odds ratio [OR], 217; 95% confidence interval [CI], 94-499), trauma (OR, 127; 95% CI, 41-397), hospital or nursing home confinement (OR, 80; 95% CI, 45-142), malignant neoplasm with (OR, 65; 95% CI, 21-202) or without (OR, 41; 95% CI, 19-85) chemotherapy, central venous catheter or pacemaker (OR, 56; 95% CI, 16-196), superficial vein thrombosis (OR, 43; 95% CI, 18-106), and neurological disease with extremity paresis (OR, 30; 95% CI, 13-74) The risk associated with varicose veins diminished with age (for age 45 years: OR, 42; 95% CI, 16-113; for age 60 years: OR, 19; 95% CI, 10-36; for age 75 years: OR, 09; 95% CI, 06-14), while patients with liver disease had a reduced risk (OR, 01; 95% CI, 00-07) Conclusion Hospital or nursing home confinement, surgery, trauma, malignant neoplasm, chemotherapy, neurologic disease with paresis, central venous catheter or pacemaker, varicose veins, and superficial vein thrombosis are independent and important risk factors for VTE
2,069 citations
TL;DR: In this article, the authors explored the impact of depressive symptoms in primary care patients with diabetes on self-care, adherence to medication regimens, functioning, and health care costs.
Abstract: Background Depression is common among patients with chronic medical illness. We explored the impact of depressive symptoms in primary care patients with diabetes on diabetes self-care, adherence to medication regimens, functioning, and health care costs. Methods We administered a questionnaire to 367 patients with types 1 and 2 diabetes from 2 health maintenance organization primary care clinics to obtain data on demographics, depressive symptoms, diabetes knowledge, functioning, and diabetes self-care. On the basis of automated data, we measured medical comorbidity, health care costs, glycosylated hemoglobin (HbA 1c ) levels, and oral hypoglycemic prescription refills. Using depressive symptom severity tertiles (low, medium, or high), we performed regression analyses to determine the impact of depressive symptoms on adherence to diabetes self-care and oral hypoglycemic regimens, HbA 1c levels, functional impairment, and health care costs. Results Compared with patients in the low-severity depression symptom tertile, those in the medium- and high-severity tertiles were significantly less adherent to dietary recommendations. Patients in the high-severity tertile were significantly distinct from those in the low-severity tertile by having a higher percentage of days in nonadherence to oral hypoglycemic regimens (15% vs 7%); poorer physical and mental functioning; greater probability of having any emergency department, primary care, specialty care, medical inpatient, and mental health costs; and among users of health care within categories, higher primary (51% higher), ambulatory (75% higher), and total health care costs (86% higher). Conclusions Depressive symptom severity is associated with poorer diet and medication regimen adherence, functional impairment, and higher health care costs in primary care diabetic patients. Further studies testing the effectiveness and cost-effectiveness of enhanced models of care of diabetic patients with depression are needed.
1,491 citations
TL;DR: Leisure time physical activity was inversely associated with all-cause mortality in both men and women in all age groups, and benefit was found from moderate leisure timephysical activity, with further benefit from sports activity and bicycling as transportation.
Abstract: BACKGROUND: Physical activity is associated with low mortality in men, but little is known about the association in women, different age groups, and everyday activity. OBJECTIVE: To evaluate the relationship between levels of physical activity during work, leisure time, cycling to work, and sports participation and all-cause mortality. DESIGN: Prospective study to assess different types of physical activity associated with risk of mortality during follow-up after the subsequent examination. Mean follow-up from examination was 14.5 years. SETTING: Copenhagen University Hospital, Copenhagen, Denmark. PARTICIPANTS: Participants were 13,375 women and 17,265 men, 20 to 93 years of age, who were randomly selected. Physical activity was assessed by self-report, and health status, including blood pressure, total cholesterol level, triglyceride levels, body mass index, smoking, and educational level, was evaluated. MAIN OUTCOME MEASURE: All-cause mortality. RESULTS: A total of 2,881 women and 5,668 men died. Compared with the sedentary, age- and sex-adjusted mortality rates in leisure time physical activity groups 2 to 4 were 0.68 (95% confidence interval, 0.64-0.71), 0.61 (95% confidence interval, 0.57-0.66), and 0.53 (95% confidence interval, 0.41-0.68), respectively, with no difference between sexes and age groups. Within the moderately and highly active persons, sports participants experienced only half the mortality of nonparticipants. Bicycling to work decreased risk of mortality in approximately 40% after multivariate adjustment, including leisure time physical activity. CONCLUSIONS: Leisure time physical activity was inversely associated with all-cause mortality in both men and women in all age groups. Benefit was found from moderate leisure time physical activity, with further benefit from sports activity and bicycling as transportation.
1,044 citations
TL;DR: For example, this paper found that only 38% of patients achieved NCEP-specified LDL-C target levels; success rates were 68% among low-risk patients, 37% among high-risk patents, and 18% among patients with coronary heart disease (CHD).
Abstract: Methods: Adult patients with dyslipidemia, who had been receiving the same lipid-lowering therapy for at least 3 months, were assessed at investigation sites. Lipid levels were determined once in each patient at the time of enrollment. The primary end point was the success rate, defined as the proportion of patients who achieved their LDL-C target level as specified by NCEP guidelines. Results: A total of 4888 patients from 5 regions of the United States were studied. Of these, 23% had fewer than 2 risk factors for coronary heart disease (CHD) and no evidence of CHD (low-risk group), 47% had 2 or more risk factors and no evidence of CHD (high-risk group), and 30% had established CHD. Overall, only 38% of patients achieved NCEP-specified LDL-C target levels; success rates were 68% among low-risk patients, 37% among high-risk patents, and 18% among patients with CHD. Drug therapy was significantly (P#.001) more effective than nondrug therapy in all patient risk groups. However, many patients treated with lipid-lowering drugs did not achieve LDL-C target levels. Conclusions: Large proportions of dyslipidemic patients receiving lipid-lowering therapy are not achieving NCEP LDL-C target levels. These findings indicate that more aggressive treatment of dyslipidemia is needed to attain goals established by NCEP guidelines. Arch Intern Med. 2000;160:459-467
1,004 citations
TL;DR: A review of the large body of evidence indicating that higher levels of body weight and body fat are associated with an increased risk for the development of numerous adverse health consequences suggests efforts to prevent further weight gain in adults at risk for overweight and obesity are essential.
Abstract: More than half of adult Americans are overweight or obese, and public health recommendations call for weight loss in those who are overweight with associated medical conditions or who are obese. However, some controversy exists in the lay press and in the medical literature about the health risks of obesity. We review briefly the large body of evidence indicating that higher levels of body weight and body fat are associated with an increased risk for the development of numerous adverse health consequences. Efforts to prevent further weight gain in adults at risk for overweight and obesity are essential. For those whose present or future health is at risk because of their obesity and who are motivated to make lifestyle changes, a recommendation for weight loss is appropriate.
956 citations
TL;DR: The prevalence of restless legs in the general adult population is high and may be associated with decreased well-being, emphasizing the need for further research and greater medical recognition of this condition.
Abstract: Background Restless legs syndrome (RLS) is a disorder characterized by sleep-disrupting unpleasant leg sensations, often accompanied by daytime behavioral problems. Treatment for this condition is available, but it is suspected that most instances of RLS remain undiagnosed. The goal of this investigation was to assess the prevalence and health status correlates of restless legs symptoms (hereinafter referred to as restless legs) in the general population. Methods A question reflecting the clinical features of RLS was added to the 1996 Kentucky Behavioral Risk Factor Surveillance Survey. Data on the frequency of experiencing restless legs, self-rated general and mental health status, demographics, and behavioral risk factors were collected by telephone interview from 1803 men and women, 18 years and older. Results Experiencing restless legs 5 or more nights per month was reported by 3% of participants aged 18 to 29 years, 10% of those aged 30 to 79 years, and 19% of those 80 years and older. The age-adjusted prevalence for Kentucky adults is 10.0%; prevalence did not vary significantly by sex. The adjusted odds ratios (95% confidence intervals) for restless legs and diminished general health and poor mental health status were 2.4 (1.4-4.0) and 3.1 (2.0-4.6), respectively. Restless legs were significantly associated with increased age and body mass index, lower income, smoking, lack of exercise, low alcohol consumption, and diabetes. Conclusions The prevalence of restless legs in the general adult population is high. Restless legs may be associated with decreased well-being, emphasizing the need for further research and greater medical recognition of this condition.
739 citations
TL;DR: This study demonstrates that OLD is present in a substantive number of US adults, and many US adults have low lung function but no reported OLD diagnosis, which may indicate the presence of undiagnosed lung disease.
Abstract: Background Obstructive lung disease (OLD) is an important cause of morbidity and mortality in the US adult population. Potentially treatable mild cases of OLD often go undetected. This analysis determines the national estimates of reported OLD and low lung function in the US adult population. Methods We examined data from the Third National Health and Nutrition Examination Survey (NHANES III), a multistage probability representative sample of the US population. A total of 20,050 US adults participated in NHANES III from 1988 to 1994. Our main outcome measures were low lung function (a condition determined to be present if the forced expiratory volume in 1 second–forced vital capacity ratio was less than 0.7 and the forced expiratory volume in 1 second was less than 80% of the predicted value), a physician diagnosis of OLD (chronic bronchitis, asthma, or emphysema), and respiratory symptoms. Results Overall a mean (SE) of 6.8% (0.3%) of the population had low lung function, and 8.5% (0.3%) of the population reported OLD. Obstructive lung disease (age-adjusted to study population) was currently reported among 12.5% (0.7%) of current smokers, 9.4% (0.6%) of former smokers, 3.1% (1.1%) of pipe or cigar smokers, and 5.8% (0.4%) of never smokers. Surprisingly, 63.3% (0.2%) of the subjects with documented low lung function had no prior or current reported diagnosis of any OLD. Conclusions This study demonstrates that OLD is present in a substantive number of US adults. In addition, many US adults have low lung function but no reported OLD diagnosis, which may indicate the presence of undiagnosed lung disease.
739 citations
TL;DR: A strong association exists between acute increases in serum creatinine of up to 30% that stabilize within the first 2 months of ACEI therapy and long-term preservation of renal function and withdrawal of an ACEI in patients with preexisting renal insufficiency is recommended.
Abstract: Background Reducing the actions of the renin-angiotensin-aldosterone system with angiotensin-converting enzyme inhibitors (ACEIs) slows nephropathy progression in patients with or without diabetes. Post hoc analyses of many ACEI-based clinical trials demonstrate the greatest slowing of renal disease progression in patients with the greatest degree of renal insufficiency at study initiation. However, many physicians fail to use ACEIs or angiotensin receptor blockers in patients with renal insufficiency for fear that either serum creatinine or potassium levels will rise. Objective To determine if limited initial reduction in either glomerular filtration rate (GFR) or elevation in serum creatinine levels, associated with ACEI or angiotensin receptor blocker use, results in long-term protection against decline in renal function in patients with renal insufficiency. Methods We reviewed 12 randomized clinical trials that evaluated renal disease progression among patients with preexisting renal insufficiency. Six of these studies were multicenter, double-blinded, and placebo controlled, with the remainder being smaller randomized studies with a minimum 2-year follow-up on renal function. These investigations evaluated patients with and without diabetes or systolic heart failure. Average duration of follow-up for all studies was 3 years. Trials were examined in the context of changes in either serum creatinine levels or GFR in the group randomized to an ACEI (N=1102). Sixty-four percent of these individuals (705/1102) had renal function data at both less than 6 months and at the end of the study. Results Most trials demonstrated that patients with preexisting renal insufficiency manifested an acute fall in GFR, a rise in serum creatinine, or both. Those randomized to an ACEI with a serum creatinine level of 124 µmol/L or greater (≥1.4 mg/dL) demonstrated a 55% to 75% risk reduction in renal disease progression compared with those with normal renal function randomized to an ACEI. An inverse correlation was observed between the amount of renal function loss at baseline and the subsequent rate of annual decline in renal function following randomization to an antihypertensive regimen that contained an ACEI. Conclusions A strong association exists between acute increases in serum creatinine of up to 30% that stabilize within the first 2 months of ACEI therapy and long-term preservation of renal function. This relationship holds for persons with creatinine values of greater than 124 µmol/L (>1.4 mg/dL). Thus, withdrawal of an ACEI in such patients should occur only when the rise in creatinine exceeds 30% above baseline within the first 2 months of ACEI initiation, or hyperkalemia develops, ie, serum potassium level of 5.6 mmol/L or greater.
734 citations
TL;DR: The elderly and patients with a history of peptic ulcer could benefit the most from a reduction in NSAID gastrotoxicity, especially in the subgroup of patients with the greatest background risk.
Abstract: Background In the last decades, studies have estimated the upper gastrointestinal tract bleeding/perforation (UGIB) risk associated with individual nonsteroidal anti-inflammatory drugs (NSAIDs). Later analyses have also included the effect of patterns of NSAID use, risk factors for UGIB, and modifiers of NSAID effect. Methods Systematic review of case-control and cohort studies on serious gastrointestinal tract complications and nonaspirin NSAIDs published between 1990 and 1999 using MEDLINE. Eighteen original studies were selected according to predefined criteria. Two researchers extracted the data independently. Pooled relative risk estimates were calculated according to subject and exposure characteristics. Heterogeneity of effects was tested and reasons for heterogeneity were considered. Results Advanced age, history of peptic ulcer disease, and being male were risk factors for UGIB. Nonsteroidal anti-inflammatory drug users with advanced age or a history of peptic ulcer had the highest absolute risks. The pooled relative risk of UGIB after exposure to NSAIDs was 3.8 (95% confidence interval, 3.6-4.1). The increased risk was maintained during treatment and returned to baseline once treatment was stopped. A clear dose response was observed. There was some variation in risk between individual NSAIDs, though these differences were markedly attenuated when comparable daily doses were considered. Conclusions The elderly and patients with a history of peptic ulcer could benefit the most from a reduction in NSAID gastrotoxicity. Whenever possible, physicians may wish to recommend lower doses to reduce the UGIB risk associated with all individual NSAIDs, especially in the subgroup of patients with the greatest background risk.
TL;DR: Patients with depression following an acute MI are less likely to adhere to recommended behavior and lifestyle changes intended to reduce the risk of subsequent cardiac events, which could explain why depression in the hospital is related to long-term prognosis in patients recovering from an MI.
Abstract: Background Patients with depression are at greater risk of cardiac death in the first few months after a myocardial infarction (MI). This study was performed to determine whether depression affects adherence to recommendations intended to reduce the risk of cardiac events after an MI. Methods All consenting patients admitted to a university-affiliated teaching hospital during an 18-month period were interviewed 3 to 5 days following an acute MI using the Beck Depression Inventory to assess symptoms of depression and using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition , to determine the presence of major depression and/or dysthymia. Accessible survivors (n=204; 116 men and 88 women) were interviewed by telephone 4 months later using the Medical Outcomes Study Specific Adherence Scale to measure self-reported adherence to recommendations to modify cardiac risk. Results Patients who were found in the hospital to have symptoms of at least mild to moderate depression (Beck Depression Inventory score ≥10, n=35 [17.2%]) or to have major depression and/or dysthymia (n=31 [15.2%]) reported lower adherence to a low-fat diet, regular exercise, reducing stress, and increasing social support 4 months later. Those with major depression and/or dysthymia also reported taking medications as prescribed less often than those without major depression and/or dysthymia. Diabetic patients with major depression and/or dysthymia were less likely to follow a diet for patients with diabetes than diabetic patients without depression. Conclusions Patients with depression following an acute MI are less likely to adhere to recommended behavior and lifestyle changes intended to reduce the risk of subsequent cardiac events. This finding could explain why depression in the hospital is related to long-term prognosis in patients recovering from an MI.
TL;DR: The waist-hip ratio was the best anthropometric predictor of total mortality and was associated less consistently than BMI or waist circumference with cancer incidence, and all anthropometric indexes were associated with incidence of diabetes and hypertension.
Abstract: confidence interval, 11-14), compared with 091 (95% confidence interval, 08-10) for BMI and 11 (95% confidence interval, 10-13) for waist circumference The waist-hip ratio was also associated positively with mortality from coronary heart disease, other cardiovascular diseases, cancer, and other causes The waist-hip ratio was associated less consistently than BMI or waist circumference with cancer incidence All anthropometric indexes were associated with incidence of diabetes and hypertension For example, women simultaneously in the highest quintiles of BMI and waist-hip ratio had a relative risk of diabetes of 29 (95% confidence interval, 18-46) vs women in the lowest combined quintiles Conclusion: The waist-hip ratio offers additional prognostic information beyond BMI and waist circumference
TL;DR: Several risk factors for DVT were identified in medical outpatients presenting with DVT, and their comprehension may improve appropriateness and efficiency of the different methods available for thromboprophylaxis.
Abstract: Background Little information is available concerning risk factors for venous thromboembolism (VTE) in nonhospitalized patients. Participants and Methods An epidemiologic case-control study of deep vein thrombosis (DVT) risk factors was conducted in 1272 outpatients by general practitioners. The case population (636 patients presenting with DVT) was paired with the control population (636 patients presenting with influenzal or rhinopharyngeal syndrome) according to sex and age. Deep vein thrombosis was to be documented by at least 1 objective test. Risk factors were classified into "intrinsic" ("permanent") and "triggering" ("transient") factors and were evidenced using univariate analysis. Results In the medical population , defined as patients who had not undergone surgery or application of a plaster cast to the lower extremities within the 3 weeks preceding inclusion (494 cases and 494 controls), intrinsic factors such as history of VTE, venous insufficiency, chronic heart failure, obesity, immobile standing position, history of more than 3 pregnancies, and triggering factors such as pregnancy, violent effort, or muscular trauma, deterioration of general condition, immobilization, long-distance travel, and infectious disease were significantly more frequent in the case patients than in the controls (odds ratio, >1; P Conclusion Several risk factors for DVT were identified in medical outpatients presenting with DVT, and their comprehension may improve appropriateness and efficiency of the different methods available for thromboprophylaxis.
TL;DR: Thromboembolic prophylaxis of women with mechanical heart valves during pregnancy is best achieved with OA; however, this increases the risk of fetal embryopathy, and large prospective trials to determine the best regimen for these women are needed.
Abstract: Background: The management of women with pros- thetic heart valves during pregnancy poses a particular challenge as there are no available controlled clinical tri- als to provide guidelines for effective antithrombotic therapy. Oral anticoagulants such as warfarin sodium cause fetal embryopathy; subcutaneous administration of heparin sodium has been reported to be ineffective in preventing thromboembolic complications. Methods: We performed a systematic review of the lit- erature to determine pooled estimates of maternal and fe- tal risks associated with the 3 commonly used approaches: (1) oral anticoagulants (OA) throughout pregnancy, (2) replacing OA with heparin in the first trimester (from 6-12 weeks' gestation), and (3) heparin use throughout preg- nancy. Fetal outcomes included spontaneous abortions and fetopathic effects, and maternal outcomes were ma- jor bleeding, thromboembolic complications, and death. Results: The use of OA throughout pregnancy is asso- ciated with warfarin embryopathy in 6.4% (95% confi- dence interval (CI), 4.6%-8.9%) of livebirths. The sub- stitution of heparin at or prior to 6 weeks, and continued until 12 weeks, eliminated this risk. Overall risks for fe- tal wastage (spontaneous abortion, stillbirths, and neo- natal deaths) were similar in women treated with OA throughout, compared with women treated with hepa- rin in the first trimester. Maternal mortality was 2.9% (95% CI, 1.9%-4.2%). Major bleeding events occurred in 2.5% (95% CI, 1.7%-3.5%) of all pregnancies, most at the time of delivery. The regimen associated with the lowest risk of valve thrombosis (3.9%; 95% CI, 2.9-5.9%) was the use of OA throughout; using heparin only between 6 and 12 weeks' gestation was associated with an increased risk of valve thrombosis (9.2%; 95% CI, 5.9%-13.9%). Conclusions: Thromboembolic prophylaxis of women with mechanical heart valves during pregnancy is best achieved with OA; however, this increases the risk of fe- tal embryopathy. Substituting OA with heparin be- tween 6 and 12 weeks reduces the risk of fetopathic ef- fects, but with an increased risk of thromboembolic complications. The use of low-dose heparin is definitely inadequate; the use of adjusted-dose heparin warrants ag- gressive monitoring and appropriate dose adjustment. Large prospective trials to determine the best regimen for these women are needed. Arch Intern Med. 2000;160:191-196
TL;DR: Large differences in sociodemographic status, health status, and subsequent resource use exist between the VA and the general patient population, and comparisons of VA care with non-VA care need to take these differences into account.
Abstract: Background The Veterans Affairs (VA) health system has been criticized for being inefficient based on comparisons of VA care with non-VA care. Whether such comparisons are biased by differences between the VA patient population and the non-VA patient population is not known. Our objective is to determine if VA patients are different from non-VA patients in terms of health status and medical resource use. Method We analyzed 128,099 records from the National Health Interview Survey for the years 1993 and 1994. We compared the VA patient population with the general patient population for self report on health status, number of medical conditions, number of outpatient physician visits, number of hospital admissions, and number of hospital days each year. Results The VA patient population had poorer health status (odds ratio [OR], 14.7; 95% confidence interval [CI], 10.7-20.2), more medical conditions (OR, 14; 95% CI, 10.5-18.7), and higher medical resource use compared with the general patient population (OR, 3.7 for 3 or more physician visits per year; OR 5.4 for 3 or more hospital admissions per year; OR, 7.7 for 21 or more days spent in a hospital per year). However, after controlling for health and sociodemographic differences, VA patients had similar resource use compared with the general patient population. Conclusion Large differences in sociodemographic status, health status, and subsequent resource use exist between the VA and the general patient population. Therefore, comparisons of VA care with non-VA care need to take these differences into account. Furthermore, health care planning and resource allocation within the VA should not be based on data extrapolated from non-VA patient populations.
TL;DR: Age, smoking, family history of AAA, and atherosclerotic diseases remained the principal positive associations with AAAs, and female sex, diabetes, and black race remained the Principal negative associations.
Abstract: Background We previously reported the prevalence and associations of abdominal aortic aneurysm (AAA) in 73,451 veterans aged 50 to 79 years who underwent ultrasound screening. Objective To understand the prevalence of and principal positive and negative risk factors for AAA, and to assess reproducibility of our previous findings. Methods In the new cohort of veterans undergoing screening, 52,745 subjects aged 50 to 79 without history of AAA underwent successful ultrasound screening for AAA, after completing a questionnaire on demographics and potential risk factors. Results We detected AAA of 4.0 cm or larger in 613 participants (1.2%; compared with 1.4% in the earlier cohort). The direction and magnitude of the important associations reported in the first cohort were confirmed. Respective odds ratios for the major associations with AAA for the second and for the combined cohorts were as follows: 1.81 and 1.71 for age (per 7 years), 0.12 and 0.18 for female sex, 0.59 and 0.53 for black race, 1.94 and 1.94 for family history of AAA, 4.45 and 5.07 for smoking, 0.50 and 0.52 for diabetes, and 1.60 and 1.66 for atherosclerotic diseases. The excess prevalence associated with smoking accounted for 75% of all AAAs of 4.0 cm or larger in the total population of 126,196. Associations for AAA of 3.0 to 3.9 cm were similar but tended to be somewhat weaker. Conclusions Our findings confirm our previous cohort findings. Age, smoking, family history of AAA, and atherosclerotic diseases remained the principal positive associations with AAA, and female sex, diabetes, and black race remained the principal negative associations.
TL;DR: Delirium precipitated by opioids and other psychoactive medications and dehydration is frequently reversible with change of opioid or dose reduction, discontinuation of unnecessary psychoactive medication, or hydration, respectively, and patients with delirium had poorer survival rates than controls.
Abstract: Context Delirium impedes communication and contributes to symptom distress in patients with advanced cancer. There are few prospective data on the reversal of delirium in this population. Objectives To evaluate the occurrence, precipitating factors, and reversibility of delirium in patients with advanced cancer. Design Prospective serial assessment in a consecutive cohort of 113 patients with advanced cancer. Precipitating factors were examined using standardized criteria; 104 patients met eligibility criteria. Setting Acute palliative care unit in a university-affiliated teaching hospital. Main Outcome Measures Delirium occurrence and reversal rates, duration, and patient survival. Strengths of association of various precipitating factors with reversal were expressed as hazard ratios (HRs) in univariate and multivariate analyses. Results On admission, delirium was diagnosed in 44 patients (42%), and of the remaining 60, delirium developed in 27 (45%). Reversal of delirium occurred in 46 (49%) of 94 episodes in 71 patients. Terminal delirium occurred in 46 (88%) of the 52 deaths. In univariate analysis, psychoactive medications, predominantly opioids (HR, 8.85; 95% confidence interval [CI], 2.13-36.74), and dehydration (HR, 2.35; 95% CI, 1.20-4.62) were associated with reversibility. Hypoxic encephalopathy (HR, 0.39; 95% CI, 0.19-0.80) and metabolic factors (HR, 0.44; 95% CI, 0.21-0.91) were associated with nonreversibility. In mulitivariate analysis, psychoactive medications (HR, 6.65; 95% CI, 1.49-29.62), hypoxic encephalopathy (HR, 0.32; 95% CI, 0.15-0.70), and nonrespiratory infection (HR, 0.23; 95% CI, 0.08-0.64) had independent associations. Patients with delirium had poorer survival rates than controls ( P Conclusions Delirium is a frequent, multifactorial complication in advanced cancer.Despite its terminal presentation in most patients, delirium is reversible in approximately 50% of episodes. Delirium precipitated by opioids and other psychoactive medications and dehydration is frequently reversible with change of opioid or dose reduction, discontinuation of unnecessary psychoactive medication, or hydration, respectively.
TL;DR: The literature supports the use of formal screening instruments over other clinical measures to increase the recognition of alcohol problems in primary care and increased adherence to methodological standards for diagnostic tests.
Abstract: Background Primary care physicians can play a unique role in recognizing and treating patients with alcohol problems. Objective To evaluate the accuracy of screening methods for alcohol problems in primary care. Methods We performed a search of MEDLINE for years 1966 through 1998. We included studies that were in English, were performed in primary care, and reported the performance characteristics of screening methods for alcohol problems against a criterion standard. Two reviewers appraised all articles for methodological content and results. Results Thirty-eight studies were identified. Eleven screened for at-risk, hazardous, or harmful drinking; 27 screened for alcohol abuse and dependence. A variety of screening methods were evaluated. The Alcohol Use Disorders Identification Test (AUDIT) was most effective in identifying subjects with at-risk, hazardous, or harmful drinking (sensitivity, 51%-97%; specificity, 78%-96%), while the CAGE questions proved superior for detecting alcohol abuse and dependence (sensitivity, 43%-94%; specificity, 70%-97%). These 2 formal screening instruments consistently performed better than other methods, including quantity-frequency questions. The studies inconsistently adhered to methodological standards for diagnostic test research: 3 (8%) provided a full description of patient spectrum (demographics and comorbidity), 30 (79%) avoided workup bias, 12 (of 34 studies [35%]) avoided review bias, and 21 (55%) performed an analysis in pertinent clinical subgroups. Conclusions Despite methodological limitations, the literature supports the use of formal screening instruments over other clinical measures to increase the recognition of alcohol problems in primary care. Future research in this field will benefit from increased adherence to methodological standards for diagnostic tests.
TL;DR: To elucidate the clinical features, radiological classification, and prognostic factors of EPN; to compare the modalities of management and outcome among the various radiological classes; and to clarify the gas-forming mechanism and pathogenesis of EPM by gas analysis and pathological findings.
Abstract: Background Emphysematous pyelonephritis (EPN) is a rare, severe gas-forming infection of renal parenchyma and its surrounding areas. The radiological classification and adequate therapeutic regimen are controversial and the prognostic factors and pathogenesis remain uncertain. Objectives To elucidate the clinical features, radiological classification, and prognostic factors of EPN; to compare the modalities of management (ie, antibiotic treatment alone, percutaneous catheter drainage combined with antibiotic treatment, or nephrectomy) and outcome among the various radiological classes of EPN; and to clarify the gas-forming mechanism and pathogenesis of EPN by gas analysis and pathological findings. Patients and Methods Forty-eight EPN cases from our institution were enrolled between August 1,1989, and November 30, 1997. According to the radiological findings on computed tomographic scan, they were classified into the following classes: (1) class 1: gas in the collecting system only; (2) class 2: gas in the renal parenchyma without extension to extrarenal space; (3) class 3A: extension of gas or abscess to perinephric space; class 3B: extension of gas or abscess to pararenal space; and (4) class 4: bilateral EPN or solitary kidney with EPN. The clinical manifestations, management, and outcome were compared. The gas contents of specimens from 6 patients were analyzed. The pathological findings from 8 patients who received nephrectomy were reviewed. The statistical methods consisted of the Fisher exact test (2 tailed) for categorical variables and Wilcoxon rank sum test for continuous variables to test the predictors of poor prognosis. Results Forty-six patients (96%) had diabetes mellitus, and 10 (22%) of the 46 also had urinary tract obstruction in the corresponding renoureteral unit. The other 2 nondiabetic patients (4%) had severe hydronephrosis. Twenty-one (72%) of the 29 patients with diabetes mellitus also had a glycosylated hemoglobin A 1c level higher than 0.08. Escherichia coli (69%) and Klebsiella pneumoniae (29%) were the most common pathogens. The mortality rate in patients who received antibiotic treatment alone was 40% (2 of 5 patients). The success rate of management by percutaneous catheter drainage (PCD) combined with antibiotic treatment was 66% (27 of 41 patients). In classes 1 and 2 EPN, all the patients who were treated using a PCD or ureteral catheter combined with antibiotic treatment survived. In extensive EPN (classes 3 and 4), 17 (85%) of the 20 patients with fewer than 2 risk factors (ie, thrombocytopenia, acute renal function impairment, disturbance of consciousness, or shock) were successfully treated using PCD combined with antibiotic treatment; and the patients with 2 or more risk factors had a significantly higher failure rate than those with no or only 1 risk factors (92% vs 15%, P Conclusions Acute renal infection with E coli or K pneumoniae in patients with diabetes mellitus and/or urinary tract obstruction is the cornerstone for the development of EPN. Mixed acid fermentation of glucose by Enterobacteriaceae is the major pathway of gas formation. For localized EPN (classes 1 and 2), PCD combined with antibiotic treatment can provide a good outcome. For extensive EPN (classes 3 and 4) with a more benign manifestation (ie,
TL;DR: When influenza is circulating within the community, patients with an influenza-like illness who have both cough and fever within 48 hours of symptom onset are likely to have influenza and the administration of influenza antiviral therapy may be appropriate to consider.
Abstract: Background: New antiviral drugs are available for the treatment of influenza type A and type B infections. In clinical practice, antiviral use has rarely been guided by antecedent laboratory diagnosis. Defined clinical predictors of an influenza infection can help guide timely therapy and avoid unnecessary antibiotic use. Objective: To examine which clinical signs and symptoms are most predictive of influenza infection in patients with influenzalike illness using a large data set derived from clinical trials of zanamivir. Methods: This analysis is a retrospective, pooled analysis of baseline signs and symptoms from phase 2 and 3 clinical trial participants. It was conducted in mainly unvaccinated (mean age, 35 years) adults and adolescents who had influenzalike illness, defined as having fever or feverishness plus at least 2 of the following influenzalike symptoms: headache, myalgia, cough, or sore throat who underwent laboratory testing for influenza. Clinical signs and symptoms were evaluated in statistical models to identify those best predicting laboratory confirmation of influenza. Results: Of 3744 subjects enrolled with baseline influenzalike symptoms, and included in this analysis, 2470 (66%) were confirmed to have influenza. Individuals with influenza were more likely to have cough (93% vs 80%), fever (68% vs 40%), cough and fever together (64% vs 33%), and/or nasal congestion (91% vs 81%) than those without influenza. The best multivariate predictors of influenza infections were cough and fever with a positive predictive value of 79% (P,.001). The positive predictive value rose with the increase in the temperature at the time of recruitment. Conclusion: When influenza is circulating within the community, patients with an influenzalike illness who have both cough and fever within 48 hours of symptom onset are likely to have influenza and the administration of influenza antiviral therapy may be appropriate to consider. Arch Intern Med. 2000;160:3243-3247
TL;DR: Recommendations for the management of community-acquired pneumonia and the surveillance of drug-resistant Streptococcus pneumoniae (DRSP) are provided to limit the emergence of fluoroquinolone-resistant strains.
Abstract: Objective To provide recommendations for the management of community-acquired pneumonia and the surveillance of drug-resistant Streptococcus pneumoniae (DRSP). Methods We addressed the following questions: (1) Should pneumococcal resistance to β-lactam antimicrobial agents influence pneumonia treatment? (2) What are suitable empirical antimicrobial regimens for outpatient treatment of community-acquired pneumonia in the DRSP era? (3) What are suitable empirical antimicrobial regimens for treatment of hospitalized patients with community-acquired pneumonia in the DRSP era? and (4) How should clinical laboratories report antibiotic susceptibility patterns for, S pneumoniae and what drugs should be included in surveillance if community-acquired pneumonia is the syndrome of interest? Experts in the management of pneumonia and the DRSP Therapeutic Working Group, which includes clinicians, academicians, and public health practitioners, met at the Centers for Disease Control and Prevention in March 1998 to discuss the management of pneumonia in the era of DRSP. Published and unpublished data were summarized from the scientific literature and experience of participants. After group presentations and review of background materials, subgroup chairs prepared draft responses, which were discussed as a group. Conclusions When implicated in cases of pneumonia, S pneumoniae should be considered susceptible if penicillin minimum inhibitory concentration (MIC) is no greater than 1 µg/mL, of intermediate susceptibility if MIC is 2 µg/mL, and resistant if MIC is no less than 4 µg/mL. For outpatient treatment of community-acquired pneumonia, suitable empirical oral antimicrobial agents include a macrolide (eg, erythromycin, clarithromycin, azithromycin), doxycycline (or tetracycline) for children aged 8 years or older, or an oral β-lactam with good activity against pneumococci (eg, cefuroxime axetil, amoxicillin, or a combination of amoxicillin and clavulanate potassium). Suitable empirical antimicrobial regimens for inpatient pneumonia include an intravenous β-lactam, such as cefuroxime, ceftriaxone sodium, cefotaxime sodium, or a combination of ampicillin sodium and sulbactam sodium plus a macrolide. New fluoroquinolones with improved activity against S pneumoniae can also be used to treat adults with community-acquired pneumonia. To limit the emergence of fluoroquinolone-resistant strains, the new fluoroquinolones should be limited to adults (1) for whom one of the above regimens has already failed, (2) who are allergic to alternative agents, or (3) who have a documented infection with highly drug-resistant pneumococci (eg, penicillin MIC ≥4 µg/mL). Vancomycin hydrochloride is not routinely indicated for the treatment of community-acquired pneumonia or pneumonia caused by DRSP.
TL;DR: High levels of depressive symptoms are an independent risk factor for mortality in community-residing older adults, andMotivational depletion may be a key underlying mechanism for the depression-mortality effect.
Abstract: Background Studies of the association between depressive symptoms and mortality in elderly populations have yielded contradictory findings. To address these discrepancies, we test this association using the most extensive array of sociodemographic and physical health control variables ever studied, to our knowledge, in a large population-based sample of elderly individuals. Objective To examine the relation between baseline depressive symptoms and 6-year all-cause mortality in older persons, systematically controlling for sociodemographic factors, clinical disease, subclinical disease, and health risk factors. Methods A total of 5201 men and women aged 65 years and older from 4 US communities participated in the study. Depressive symptoms and 4 categories of covariates were assessed at baseline. The primary outcome measure was 6-year mortality. Results Of the 5201 participants, 984 (18.9%) died within 6 years. High baseline depressive symptoms were associated with a higher mortality rate (23.9%) than low baseline depression scores (17.7%) (unadjusted relative risk [RR], 1.41; 95% confidence interval [CI], 1.22-1.63). Depression was also an independent predictor of mortality when controlling for sociodemographic factors (RR, 1.43; 95% CI, 1.23-1.66), prevalent clinical disease (RR, 1.25; 95% CI, 1.07-1.45), subclinical disease indicators (RR, 1.35; 95% CI, 1.15-1.58), or biological or behavioral risk factors (RR, 1.42; 95% CI, 1.22-1.65). When the best predictors from all 4 classes of variables were included as covariates, high depressive symptoms remained an independent predictor of mortality (RR, 1.24; 95% CI, 1.06-1.46). Conclusions High levels of depressive symptoms are an independent risk factor for mortality in community-residing older adults. Motivational depletion may be a key underlying mechanism for the depression-mortality effect.
TL;DR: A literature review has identified patient-, physician-, and health care system-related barriers to warfarin prescription, however, the relative importance of these specific barriers remains unknown.
Abstract: Atrial fibrillation (AF) is a growing public health problem associated with significant morbidity and mortality. Numerous randomized controlled trials of warfarin have conclusively demonstrated that long-term anticoagulation therapy can reduce the risk for stroke by approximately 68% per year in patients with nonvalvular AF, and even more in patients with valvular AF. However, available data show that of those patients with AF and no contraindication to warfarin therapy, only 15% to 44% are prescribed warfarin. Our literature review has identified patient-, physician-, and health care system‐related barriers to warfarin prescription. However, the relative importance of these specific barriers remains unknown. Further work is needed to understand the discrepancy between the randomized controlled trial evidence and clinical practice patterns. Arch Intern Med. 2000;160:41-46
TL;DR: Patients with proximal DVT, diagnosed cancer, short duration of oral anticoagulation therapy, or a history of thromboembolic events had a higher risk of recurrent events, while patients with postoperative DVT had a lower recurrence rate.
Abstract: Background The recurrence rate after deep vein thrombosis (DVT) is high and the risk factors for recurrent thromboembolic events have only been investigated on a small scale. Objectives To estimate the cumulative incidence of recurrent venous thromboembolic events after a first or a second DVT and to identify possible risk factors for recurrent venous thromboembolism. Methods We prospectively followed up 738 consecutive patients with an objectively verified symptomatic DVT for 3.7 to 8.8 years. Medical records and death certificates for all patients were reviewed during follow-up and recurrent DVT and pulmonary embolism were registered. Results The 5-year cumulative incidence of recurrent venous thromboembolic events was 21.5% (95% confidence interval [CI], 17.7%-25.4%) after a first DVT and 27.9% (95% CI, 19.7%-36.1%) after a second DVT. The 5-year cumulative incidence of fatal pulmonary embolism was 2.6% (95% CI, 1.1%-4.1%) after a first DVT. Proximal DVT (relative risk [RR], 2.40; 95% CI, 1.48-3.88; P P P P P Conclusions The recurrence rate after a symptomatic DVT is high. Patients with proximal DVT, diagnosed cancer, short duration of oral anticoagulation therapy, or a history of thromboembolic events had a higher risk of recurrent events, while patients with postoperative DVT had a lower recurrence rate. This knowledge could help identify patients who might benefit most from prolonged prophylactic treatment in various risk situations.
TL;DR: In older hypertensive patients, pulse pressure not mean pressure is the major determinant of cardiovascular risk, according to a meta-analysis based on individual patient data.
Abstract: Background: Current guidelines for the management of hypertension rest almost completely on the measurement of systolic and diastolic blood pressure. However, the arterial blood pressure wave is more correctly described as consisting of a pulsatile (pulse pressure) and a steady (mean pressure) component. Objective: To explore the independent roles of pulse pressure and mean pressure as determinants of cardiovascular prognosis in older hypertensive patients. Methods: This meta-analysis, based on individual patient data, pooled the results of the European Working Party on High Blood Pressure in the Elderly trial (n = 840), the Systolic Hypertension in Europe Trial (n = 4695), and the Systolic Hypertension in China Trial (n = 2394). The relative hazard rates associated with pulse pressure and mean pressure were calculated using Cox regression analysis, with stratification for the 3 trials and with adjustments for sex, age, previous cardiovascular complications, smoking, and treatment group. Results: A 10-mm Hg wider pulse pressure increased the risk of major cardiovascular complications; after controlling for mean pressure and the other covariates, the increase in risk ranged from approximately 13% for all coronary end points (P = .02) to nearly 20% for cardiovascular mortality (P = .001). In a similar analysis, mean pressure predicted the incidence of cardiovascular complications but only after removal of pulse pressure as an explanatory variable from the model. Furthermore, the probability of a major cardiovascular end point increased with higher systolic blood pressure; at any given level of systolic blood pressure, it also increased with lower diastolic blood pressure, suggesting that the wider pulse pressure was driving the risk of major complications. Conclusions: In older hypertensive patients, pulse pressure not mean pressure is the major determinant of cardiovascular risk. The implications of these findings for the management of hypertensive patients should be further investigated in randomized controlled outcome trials in which the pulsatile component of blood pressure is differently affected by antihypertensive drug treatment. Arch Intern Med. 2000;160:1085-1089
TL;DR: Preliminary evidence is provided that patients with CFS, FM, and TMD share key symptoms, and it also is apparent that other localized and systemic conditions may frequently co-occur with C FS,FM, andTMD.
Abstract: Background Patients with chronic fatigue syndrome (CFS), fibromyalgia (FM), and temporomandibular disorder (TMD) share many clinical illness features such as myalgia, fatigue, sleep disturbances, and impairment in ability to perform activities of daily living as a consequence of these symptoms. A growing literature suggests that a variety of comorbid illnesses also may commonly coexist in these patients, including irritable bowel syndrome, chronic tension-type headache, and interstitial cystitis. Objective To describe the frequency of 10 clinical conditions among patients with CFS, FM, and TMD compared with healthy controls with respect to past diagnoses, degree to which they manifested symptoms for each condition as determined by expert-based criteria, and published diagnostic criteria. Methods Patients diagnosed as having CFS, FM, and TMD by their physicians were recruited from hospital-based clinics. Healthy control subjects from a dermatology clinic were enrolled as a comparison group. All subjects completed a 138-item symptom checklist and underwent a brief physical examination performed by the project physicians. Results With little exception, patients reported few past diagnoses of the 10 clinical conditions beyond their referring diagnosis of CFS, FM, or TMD. In contrast, patients were more likely than controls to meet lifetime symptom and diagnostic criteria for many of the conditions, including CFS, FM, irritable bowel syndrome, multiple chemical sensitivities, and headache. Lifetime rates of irritable bowel syndrome were particularly striking in the patient groups (CFS, 92%; FM, 77%; TMD, 64%) compared with controls (18%) (P Conclusions This study provides preliminary evidence that patients with CFS, FM, and TMD share key symptoms. It also is apparent that other localized and systemic conditions may frequently co-occur with CFS, FM, and TMD. Future research that seeks to identify the temporal relationships and other pathophysiologic mechanism(s) linking CFS, FM, and TMD will likely advance our understanding and treatment of these chronic, recurrent conditions.
TL;DR: The American Thyroid Association recommends that adults be screened for thyroid dysfunction by measurement of the serum thyrotropin concentration, beginning at age 35 years and every 5 years thereafter.
Abstract: Objective To define the optimal approach to identify patients with thyroid dysfunction. Participants The 8-member Standards of Care Committee of the American Thyroid Association prepared a draft, which was reviewed by the association's 780 members, 50 of whom responded with suggested revisions. Evidence Relevant published studies were identified through MEDLINE and the association membership's personal resources. Consensus Process Consensus was reached at group meetings. The first draft was prepared by a single author (P.W.L.) after group discussion. Suggested revisions were incorporated after consideration by the committee. Conclusions The American Thyroid Association recommends that adults be screened for thyroid dysfunction by measurement of the serum thyrotropin concentration, beginning at age 35 years and every 5 years thereafter. The indication for screening is particularly compelling in women, but it can also be justified in men as a relatively cost-effective measure in the context of the periodic health examination. Individuals with symptoms and signs potentially attributable to thyroid dysfunction and those with risk factors for its development may require more frequent serum thyrotropin testing.
TL;DR: Computerized physician order entry is a powerful and effective tool for improving physician prescribing practices and persisted at 1- and 2-year follow-up analyses.
Abstract: Background: Computerized order entry systems have the potential to prevent errors, to improve quality of care, and to reduce costs by providing feedback and suggestions to the physician as each order is entered. This study assesses the impact of an inpatient computerized physician order entry system on prescribing practices. Methods: A time series analysis was performed at an urban academic medical center at which all adult inpatient orders are entered through a computerized system. When physicians enter drug orders, the computer displays drug use guidelines, offers relevant alternatives, and suggests appropriate doses and frequencies. Result: For medication selection, use of a computerized guideline resulted in a change in use of the recommended drug (nizatidine) from 15.6% of all histamine2blocker orders to 81.3% (P,.001). Implementation of dose selection menus resulted in a decrease in the SD of drug doses by 11% (P,.001). The proportion of doses that exceeded the recommended maximum decreased from 2.1% before order entry to 0.6% afterward (P,.001). Display of a recommended frequency for ondansetron hydrochloride administration resulted in an increase in the use of the approved frequency from 6% of all ondansetron orders to 75% (P,.001). The use of subcutaneous heparin sodium to prevent thrombosis in patients at bed rest increased from 24% to 47% when the computer suggested this option (P,.001). All these changes persisted at 1and 2-year follow-up analyses. Conclusion: Computerized physician order entry is a powerful and effective tool for improving physician prescribing practices. Arch Intern Med. 2000;160:2741-2747
TL;DR: Education/feedback intervention and patient awareness programs failed to improve handwashing compliance, however, introduction of easily accessible dispensers with an alcohol-based waterless handwashing antiseptic led to significantly higher handwashing rates among health care workers.
Abstract: Context Under routine hospital conditions handwashing compliance of health care workers including nurses, physicians, and others (eg, physical therapists and radiologic technicians) is unacceptably low. Objectives To investigate the efficacy of an education/feedback intervention and patient awareness program (cognitive approach) on handwashing compliance of health care workers; and to compare the acceptance of a new and increasingly accessible alcohol-based waterless hand disinfectant (technical approach) with the standard sink/soap combination. Design A 6-month, prospective, observational study. Setting One medical intensive care unit (ICU), 1 cardiac surgery ICU, and 1 general medical ward located in a 728-bed, tertiary care, teaching facility. Participants Medical caregivers in each of the above settings. Interventions Implementation of an education/feedback intervention program (6 in-service sessions per each ICU) and patient awareness program, followed by a new, increasingly accessible, alcohol-based, waterless hand antiseptic agent, initially available at a ratio of 1 dispenser for every 4 patients and subsequently 1 for each patient. Main Outcome Measure Direct observation of handwashing for 1575 potential opportunities monitored over 120 hours randomized for both time of day and bed locations. Results Baseline handwashing compliance before and after defined events was 9% and 22% for health care workers in the medical ICU and 3% and 13% for health care workers in the cardiac surgery ICU, respectively. After the education/feedback intervention program, handwashing compliance changed little (medical ICU, 14% [before] and 25% [after]; cardiac surgery ICU, 6% [before] and 13% [after]). Observations after introduction of the new, increasingly accessible, alcohol-based, waterless hand antiseptic revealed significantly higher handwashing rates ( P Conclusions Education/feedback intervention and patient awareness programs failed to improve handwashing compliance. However, introduction of easily accessible dispensers with an alcohol-based waterless handwashing antiseptic led to significantly higher handwashing rates among health care workers.