Showing papers in "JAMA Internal Medicine in 2001"

Impact of overweight on the risk of developing common chronic diseases during a 10-year period.

Abstract: Background Overweight adults are at an increased risk of developing numerous chronic diseases. Methods Ten-year follow-up (1986-1996) of middle-aged women in the Nurses' Health Study and men in the Health Professionals Follow-up Study to assess the health risks associated with overweight. Results The risk of developing diabetes, gallstones, hypertension, heart disease, and stroke increased with severity of overweight among both women and men. Compared with their same-sex peers with a body mass index (BMI) (calculated as weight in kilograms divided by the square of height in meters) between 18.5 and 24.9, those with BMI of 35.0 or more were approximately 20 times more likely to develop diabetes (relative risk [RR], 17.0; 95% confidence interval [CI], 14.2-20.5 for women; RR, 23.4; 95% CI, 19.4-33.2 for men). Women who were overweight but not obese (ie, BMI between 25.0 and 29.9) were also significantly more likely than their leaner peers to develop gallstones (RR, 1.9), hypertension (RR, 1.7), high cholesterol level (RR, 1.1), and heart disease (RR, 1.4). The results were similar in men. Conclusions During 10 years of follow-up, the incidence of diabetes, gallstones, hypertension, heart disease, colon cancer, and stroke (men only) increased with degree of overweight in both men and women. Adults who were overweight but not obese (ie, 25.0≤BMI≤29.9) were at significantly increased risk of developing numerous health conditions. Moreover, the dose-response relationship between BMI and the risk of developing chronic diseases was evident even among adults in the upper half of the healthy weight range (ie, BMI of 22.0-24.9), suggesting that adults should try to maintain a BMI between 18.5 and 21.9 to minimize their risk of disease.

Glucose tolerance and cardiovascular mortality - Comparison of fasting and 2-hour diagnostic criteria

Abstract: BACKGROUND New diagnostic criteria for diabetes based on fasting blood glucose (FBG) level were approved by the American Diabetes Association. The impact of using FBG only has not been evaluated thoroughly. The fasting and the 2-hour glucose (2h-BG) criteria were compared with regard to the prediction of mortality. METHODS Existing baseline data on glucose level at fasting and 2 hours after a 75-g oral glucose tolerance test from 10 prospective European cohort studies including 15 388 men and 7126 women aged 30 to 89 years, with a median follow-up of 8.8 years, were analyzed. Hazards ratios for death from all causes, cardiovascular disease, coronary heart disease, and stroke were estimated. RESULTS Multivariate Cox regression analyses showed that the inclusion of FBG did not add significant information on the prediction of 2h-BG alone (P>.10 for various causes), whereas the addition of 2h-BG to FBG criteria significantly improved the prediction (P<.001 for all causes and P<.005 for cardiovascular disease). In a model including FBG and 2h-BG simultaneously, hazards ratios (95% confidence intervals) in subjects with diabetes on 2h-BG were 1.73 (1.45-2.06) for all causes, 1.40 (1.02-1.92) for cardiovascular disease, 1.56 (1.03-2.36) for coronary heart disease, and 1.29 (0.66-2.54) for stroke mortality, compared with the normal 2h-BG group. Compared with the normal FBG group, the corresponding hazards ratios in subjects with diabetes on FBG were 1.21 (1.01-1.44), 1.20 (0.88-1.64), 1.09 (0.71-1.67), and 1.64 (0.88-3.07), respectively. The largest number of excess deaths was observed in subjects who had impaired glucose tolerance but normal FBG levels. CONCLUSION The 2h-BG is a better predictor of deaths from all causes and cardiovascular disease than is FBG.

Risk factors for congestive heart failure in US men and women: NHANES I epidemiologic follow-up study.

Abstract: Background: The incidence of congestive heart failure (CHF) has been increasing steadily in the United States during the past 2 decades. We studied risk factors for CHF and their corresponding attributable risk in the First National Health and Nutrition Examination Survey Epidemiologic Follow-up Study. Participants and Methods: A total of 13643 men and women without a history of CHF at baseline examination were included in this prospective cohort study. Risk factors were measured using standard methods between 1971 and 1975. Incidence of CHF was assessed using medical records and death certificates obtained between 1982 and 1984 and in 1986, 1987, and 1992. Results: During average follow-up of 19 years, 1382 CHF cases were documented. Incidence of CHF was positively and significantly associated with male sex (relative risk [RR], 1.24; 95% confidence interval [CI], 1.10-1.39; P,.001; population attributable risk [PAR], 8.9%), less than a high school education (RR, 1.22; 95% CI, 1.04-1.42; P=.01; PAR, 8.9%), low physical activity (RR, 1.23; 95% CI, 1.09-1.38; P,.001; PAR, 9.2%), cigarette smoking (RR, 1.59; 95% CI, 1.39-1.83; P,.001; PAR, 17.1%), overweight (RR, 1.30; 95% CI, 1.12-1.52; P=.001; PAR, 8.0%), hypertension (RR, 1.40; 95% CI, 1.241.59; P,.001; PAR, 10.1%), diabetes (RR, 1.85; 95% CI, 1.51-2.28; P,.001; PAR, 3.1%), valvular heart disease (RR, 1.46; 95% CI, 1.17-1.82; P=.001; PAR, 2.2%), and coronary heart disease (RR, 8.11; 95% CI, 6.95-9.46; P,.001; PAR, 61.6%). Conclusions: Male sex, less education, physical inactivity, cigarette smoking, overweight, diabetes, hypertension, valvular heart disease, and coronary heart disease are all independent risk factors for CHF. More than 60% of the CHF that occurs in the US general population might be attributable to coronary heart disease. Arch Intern Med. 2001;161:996-1002

Relationship of depression to increased risk of mortality and rehospitalization in patients with congestive heart failure

Abstract: Background Patients with congestive heart failure (CHF) may have a high prevalence of depression, which may increase the risk of adverse outcomes. Objective To determine the prevalence and relationship of depression to outcomes of patients hospitalized with CHF. Methods We screened patients aged 18 years or older having New York Heart Association class II or greater CHF, an ejection fraction of 35% or less, or both, admitted between March 1, 1997, and June 30, 1998, to the cardiology service of one hospital. Patients with a Beck Depression Inventory score of 10 or higher underwent a modified National Institute of Mental Health Diagnostic Interview Schedule to identify major depressive disorder. Primary care providers coordinated standard treatment for CHF and other medical and psychiatric disorders. We assessed all-cause mortality and readmission (rehospitalization) rates 3 months and 1 year after depression assessment. Logistic regression analyses were used to evaluate the independent prognostic value of depression after adjustment for clinical risk factors. Results Of 374 patients screened, 35.3% had a Beck Depression Inventory score of 10 or higher and 13.9% had major depressive disorder. Overall mortality was 7.9% at 3 months and 16.2% at 1 year. Major depression was associated with increased mortality at 3 months (odds ratio, 2.5 vs no depression; P = .08) and at 1 year (odds ratio, 2.23; P = .04) and readmission at 3 months (odds ratio, 1.90; P = .04) and at 1 year (odds ratio, 3.07; P = .005). These increased risks were independent of age, New York Heart Association class, baseline ejection fraction, and ischemic etiology of CHF. Conclusions Major depression is common in patients hospitalized with CHF and is independently associated with a poor prognosis.

A prospective study of physical activity and cognitive decline in elderly women: women who walk.

Abstract: Background Several studies have suggested that physical activity is positively associated with cognitive function in elderly persons. Evidence about this association has been limited by the cross-sectional design of most studies and by the frequent lack of adjustment for potential confounding variables. We determined whether physical activity is associated with cognitive decline in a prospective study of older women. Methods We studied 5925 predominantly white community-dwelling women (aged ≥65 years) who were recruited at 4 clinical centers and were without baseline cognitive impairment or physical limitations. We measured cognitive performance using a modified Mini-Mental State Examination at baseline and 6 to 8 years later. Physical activity was measured by self-reported blocks (1 block ≈ 160 m) walked per week and by total kilocalories (energy) expended per week in recreation, blocks walked, and stairs climbed. Cognitive decline was defined as a 3-point decline or greater on repeated modified Mini-Mental State Examination. Results Women with a greater physical activity level at baseline were less likely to experience cognitive decline during the 6 to 8 years of follow-up: cognitive decline occurred in 17%, 18%, 22%, and 24% of those in the highest, third, second, and lowest quartile of blocks walked per week ( P Conclusions Women with higher levels of baseline physical activity were less likely to develop cognitive decline. This association was not explained by differences in baseline function or health status. This finding supports the hypothesis that physical activity prevents cognitive decline in older community-dwelling women.

Physical activity and television watching in relation to risk for type 2 diabetes mellitus in men.

Abstract: Background Television (TV) watching, a major sedentary behavior in the United States, has been associated with obesity. We hypothesized that prolonged TV watching may increase risk for type 2 diabetes. Methods In 1986, 37 918 men aged 40 to 75 years and free of diabetes, cardiovascular disease, and cancer completed a detailed physical activity questionnaire. Starting from 1988, participants reported their average weekly time spent watching TV on biennial questionnaires. Results A total of 1058 cases of type 2 diabetes were diagnosed during 10 years (347 040 person-years) of follow-up. After adjustment for age, smoking, alcohol use, and other covariates, the relative risks (RRs) for type 2 diabetes across increasing quintiles of metabolic equivalent hours (MET-hours) per week were 1.00, 0.78, 0.65, 0.58, and 0.51 ( P for trend, 40) were 1.00, 1.66, 1.64, 2.16, and 2.87, respectively ( P for trend, P for trend, .01). Conclusions Increasing physical activity is associated with a significant reduction in risk for diabetes, whereas a sedentary lifestyle indicated by prolonged TV watching is directly related to risk. Our findings suggest the importance of reducing sedentary behavior in the prevention of type 2 diabetes.

Nurses' recognition of delirium and its symptoms: comparison of nurse and researcher ratings.

Abstract: Background Nurses play a key role in recognition of delirium, yet delirium is often unrecognized by nurses. Our goals were to compare nurse ratings for delirium using the Confusion Assessment Method based on routine clinical observations with researcher ratings based on cognitive testing and to identify factors associated with underrecognition by nurses. Methods In a prospective study, 797 patients 70 years and older underwent 2721 paired delirium ratings by nurses and researchers. Patient-related factors associated with underrecognition of delirium by nurses were examined. Results Delirium occurred in 239 (9%) of 2721 observations or 131 (16%) of 797 patients. Nurses identified delirium in only 19% of observations and 31% of patients compared with researchers. Sensitivities of nurses' ratings for delirium and its key features were generally low (15%-31%); however, specificities were high (91%-99%). Nearly all disagreements between nurse and researcher ratings were because of underrecognition of delirium by the nurses. Four independent risk factors for underrecognition by nurses were identified: hypoactive delirium (adjusted odds ratio [OR], 7.4; 95% confidence interval [CI], 4.2-12.9), age 80 years and older (OR, 2.8; 95% CI, 1.7-4.7), vision impairment (OR, 2.2; 95% CI, 1.2-4.0), and dementia (OR, 2.1; 95% CI, 1.2-3.7). The risk for underrecognition by nurses increased with the number of risk factors present from 2% (0 risk factors) to 6% (1 risk factor), 15% (2 risk factors), and 44% (3 or 4 risk factors; P trend Conclusions Nurses often missed delirium when present, but rarely identified delirium when absent. Recognition of delirium can be enhanced with education of nurses in delirium features, cognitive assessment, and factors associated with poor recognition.

Religious struggle as a predictor of mortality among medically ill elderly patients: a 2-year longitudinal study.

Abstract: Background Although church attendance has been associated with a reduced risk of mortality, no study has examined the impact of religious struggle with an illness on mortality. Objective To investigate longitudinally the relationship between religious struggle with an illness and mortality. Methods A longitudinal cohort study from 1996 to 1997 was conducted to assess positive religious coping and religious struggle, and demographic, physical health, and mental health measures at baseline as control variables. Mortality during the 2-year period was the main outcome measure. Participants were 596 patients aged 55 years or older on the medical inpatient services of Duke University Medical Center or the Durham Veterans Affairs Medical Center, Durham, NC. Results After controlling for the demographic, physical health, and mental health variables, higher religious struggle scores at baseline were predictive of greater risk of mortality (risk ratio [RR] for death, 1.06; 95% confidence interval [CI], 1.01-1.11; χ 2 = 5.89; P = .02). Two spiritual discontent items and 1 demonic reappraisal item from the religious coping measure were predictive of increased risk for mortality: "Wondered whether God had abandoned me" (RR for death, 1.28; 95% CI, 1.07-1.50; χ 2 = 5.22; P = .02), "Questioned God's love for me" (RR for death, 1.22; 95% CI, 1.02-1.43; χ 2 = 3.69; P = .05), and "Decided the devil made this happen" (RR for death, 1.19; 95% CI, 1.05-1.33; χ 2 = 5.84; P = .02). Conclusions Certain forms of religiousness may increase the risk of death. Elderly ill men and women who experience a religious struggle with their illness appear to be at increased risk of death, even after controlling for baseline health, mental health status, and demographic factors.

Non-high-density lipoprotein cholesterol level as a predictor of cardiovascular disease mortality.

Abstract: Background: Non‐high-density lipoprotein cholesterol (non‐HDL-C) contains all known and potential atherogenic lipid particles. Therefore, non‐HDL-C level may be as good a potential predictor of risk for cardiovascular disease (CVD) as low-density lipoprotein cholesterol (LDL-C). Objectives: Todeterminewhethernon‐HDL-Clevelcould be useful in predicting CVD mortality and to compare the predictive value of non‐HDL-C and LDL-C levels. Methods: Data are from the Lipid Research Clinics Program Follow-up Study, a mortality study with baseline data gathered from 1972 through 1976, and mortality ascertained through 1995. A total of 2406 men and 2056 women aged 40 to 64 years at entry were observed for an average of 19 years, with CVD death as the main outcome measure. Results: A total of 234 CVD deaths in men and 113 CVD deaths in women occurred during follow-up. Levels of HDL-C and non‐HDL-C at baseline were significant and strong predictors of CVD death in both sexes. In contrast, LDL-C level was a somewhat weaker predictor of CVD death in both. Differences of 0.78 mmol/L (30 mg/ dL) in non‐HDL-C and LDL-C levels corresponded to increases in CVD risk of 19% and 15%, respectively, in men. In women, differences of 0.78 mmol/L (30 mg/dL) in non‐HDL-C and LDL-C levels corresponded to increases in CVD risk of 11% and 8%, respectively. Conclusions: Non‐HDL-C level is a somewhat better predictor of CVD mortality than LDL-C level. Screening for non‐HDL-C level may be useful for CVD risk assessment.

Prevalence of high blood pressure and elevated serum creatinine level in the United States: findings from the third National Health and Nutrition Examination Survey (1988-1994).

Abstract: Background The prevalence and incidence of end-stage renal disease in the United States are increasing, but milder renal disease is much more common and may often go undiagnosed and undertreated. Methods A cross-sectional study of a representative sample of the US population was conducted using 16 589 adult participants aged 17 years and older in the Third National Health and Nutrition Examination Survey (NHANES III) conducted from 1988 to 1994. An elevated serum creatinine level was defined as 141 µmol/L or higher (≥1.6 mg/dL) for men and 124 µmol/L or higher (≥1.4 mg/dL) for women (>99th percentile for healthy young adults) and was the main outcome measure. Results Higher systolic and diastolic blood pressures, presence of hypertension, antihypertensive medication use, older age, and diabetes mellitus were all associated with higher serum creatinine levels. An estimated 3.0% (5.6 million) of the civilian, noninstitutionalized US population had elevated serum creatinine levels, 70% of whom were hypertensive. Among hypertensive individuals with an elevated serum creatinine level, 75% received treatment. However, only 11% of all individuals with hypertension had their blood pressure reduced to lower than 130/85 mm Hg (the Sixth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure recommendation for hypertensive individuals with renal disease); 27% had a blood pressure lower than 140/90 mm Hg. Treated hypertensive individuals with an elevated creatinine level had a mean blood pressure of 147/77 mm Hg, 48% of whom were prescribed one antihypertensive medication. Conclusion Elevated serum creatinine level, an indicator of chronic renal disease, is common and strongly related to inadequate treatment of high blood pressure.

Prevalence of gastrointestinal symptoms associated with diabetes mellitus: a population-based survey of 15,000 adults.

Abstract: Background Gastrointestinal symptoms are reportedly common in diabetes, but a causal link is controversial and adequate population control data are lacking. Objective To determine whether gastrointestinal symptoms are more frequent in persons with diabetes, particularly in those with poor glycemic control. Methods Fifteen thousand adults were mailed a questionnaire (response rate, 60.0%) containing validated questions on the frequency of troublesome gastrointestinal symptoms within the past 3 months, diabetic status, and self-reported glycemic control. The prevalence of 16 symptoms and 5 symptom complexes, reported to occur often or very often, was compared using logistic regression analysis, adjusting for age and sex. Results Overall, 8657 eligible subjects responded; 423 (4.9%) reported having diabetes. Most (94.8%) had type 2 diabetes mellitus. Adjusting for age and sex, all 16 symptoms and the 5 symptom complexes were significantly more frequent in subjects with diabetes compared with controls. An increased prevalence rate of symptoms was significantly associated with poorer levels of glycemic control but not with duration of diabetes or type of diabetic treatment. Conclusions Diabetes mellitus is associated with an increased prevalence of upper and lower gastrointestinal symptoms. This effect may be linked to poor glycemic control but not to duration of diabetes or type of treatment.

Dietary patterns and the risk of coronary heart disease in women.

Abstract: Background Although substantial information on individual nutrients or foods and risk of coronary heart disease (CHD) is available, little is known about the role of overall eating pattern. Methods Using dietary information from a food frequency questionnaire in 1984 from the Nurses' Health Study, we conducted factor analysis and identified 2 major dietary patterns—"prudent" and "Western"—and calculated factor scores of each pattern for individuals in the cohort. We used logistic regression to examine prospectively the associations between dietary patterns and CHD risk among 69 017 women aged 38 to 63 years in 1984 without history of major chronic diseases. Results The prudent pattern was characterized by higher intakes of fruits, vegetables, legumes, fish, poultry, and whole grains, while the Western pattern was characterized by higher intakes of red and processed meats, sweets and desserts, french fries, and refined grains. Between 1984 and 1996, we documented 821 CHD cases. After adjusting for coronary risk factors, the prudent diet score was associated with a relative risk (RR) of 0.76 (95% confidence interval (CI), 0.60-0.98; P for trend test, .03) comparing the highest with lowest quintile. Extreme quintile comparison yielded an RR of 1.46 (95% CI, 1.07-1.99; P for trend test, .02) for the Western pattern. Those who were jointly in the highest prudent diet quintile and lowest Western diet quintile had an RR of 0.64 (95% CI, 0.44-0.92) compared with those with the opposite pattern profile. Conclusion A diet high in fruits, vegetables, whole grains, legumes, poultry, and fish and low in refined grains, potatoes, and red and processed meats may lower risk of CHD.

Assessing clinical probability of pulmonary embolism in the emergency ward: a simple score.

Abstract: Objective To develop a simple standardized clinical score to stratify emergency ward patients with clinically suspected pulmonary embolism (PE) into groups with a high, intermediate, or low probability of PE to improve and simplify the diagnostic approach. Methods Analysis of a database of 1090 consecutive patients admitted to the emergency ward for suspected PE in whom diagnosis of PE was ruled in or out by a standard diagnostic algorithm. Logistic regression was used to predict clinical parameters associated with PE. Results A total of 296 (27%) of 1090 patients were found to have PE. The optimal estimate of clinical probability was based on 8 variables: recent surgery, previous thromboembolic event, older age, hypocapnia, hypoxemia, tachycardia, band atelectasis, or elevation of a hemidiaphragm on chest x-ray film. A probability score was calculated by adding points assigned to these variables. A cutoff score of 4 best identified patients with low probability of PE. A total of 486 patients (49%) had a low clinical probability of PE (score ≤4), of which 50 (10.3%) had a proven PE. The prevalence of PE was 38% in the 437 patients with an intermediate probability (score of 5-8; n = 437) and 81% in the 63 patients with a high probability (score ≥9). Conclusions This clinical score, based on easily available and objective variables, provides a standardized assessment of the clinical probability of PE. Applying this score to emergency ward patients suspected of having PE could allow a more effective diagnostic process.

The Impact of Diabetes Mellitus on Mortality From All Causes and Coronary Heart Disease in Women: 20 Years of Follow-up

Abstract: Background Few data are available on the long-term impact of type 2 diabetes mellitus on total mortality and fatal coronary heart disease (CHD) in women. Methods We examined prospectively the impact of type 2 diabetes and history of prior CHD on mortality from all causes and CHD among 121 046 women aged 30 to 55 years with type 2 diabetes in the Nurses' Health Study who were followed up for 20 years from 1976 to 1996. Results During 20 years of follow-up, we documented 8464 deaths from all causes, including 1239 fatal CHD events. Compared with women with no diabetes or CHD at baseline, age-adjusted relative risks (RRs) of overall mortality were 3.39 (95% confidence interval [CI], 3.08-3.73) for women with a history of diabetes and no CHD at baseline, 3.00 (95% CI, 2.50-3.60) for women with a history of CHD and no diabetes at baseline, and 6.84 (95% CI, 4.71-9.95) for women with both conditions at baseline. The corresponding age-adjusted RRs of fatal CHD across these 4 groups were 1.0, 8.70, 10.6, and 25.8, respectively. Multivariate adjustment for body mass index and other coronary risk factors only modestly attenuated the RRs. Compared with nondiabetic persons, the multivariate RRs of fatal CHD across categories of diabetes duration (≤5, 6-10, 11-15, 16-25, >25 years) were 2.75, 3.63, 5.51, 6.38, and 11.9 ( P 15 years) was associated with a 30-fold (95% CI, 20.7-43.5) increased risk of fatal CHD. Conclusions Our data indicate that among women, history of diabetes is associated with dramatically increased risks of death from all causes and fatal CHD. The combination of diabetes and prior CHD identifies particularly high-risk women.

Total Cholesterol/HDL Cholesterol Ratio vs LDL Cholesterol/HDL Cholesterol Ratio as Indices of Ischemic Heart Disease Risk in Men: The Quebec Cardiovascular Study

Abstract: Background Total cholesterol (TC)/high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C)/HDL-C ratios are used to predict ischemic heart disease risk. There is, however, no consensus on which of these 2 indices is superior. The objective of the present study was to present evidence that the LDL-C/HDL-C ratio may underestimate ischemic heart disease risk in overweight hyperinsulinemic patients with high triglyceride (TG)–low HDL-C dyslipidemia. Methods A total of 2103 middle-aged men in whom measurements of the metabolic profile were performed in the fasting state were recruited from 7 suburbs of the Quebec metropolitan area. Results The relationship of LDL-C/HDL-C to TC/HDL-C ratios was examined among men in the Quebec Cardiovascular Study classified into tertiles of fasting TG levels. For any given LDL-C/HDL-C ratio, the TC/HDL-C ratio was higher among men in the top TG tertile (>168 mg/dL [>1.9 mmol/L]) than in men in the first and second TG tertiles. Adjustment of the TC/HDL-C ratio for LDL-C/HDL-C by covariance analysis generated significant differences in average TC/HDL-C ratios among TG tertiles ( P Conclusion Variation in the TC/HDL-C ratio may be associated with more substantial alterations in metabolic indices predictive of ischemic heart disease risk and related to the insulin resistance syndrome than variation in the LDL-C/HDL-C ratio.

Successful aging in the oldest old: Who can be characterized as successfully aged?

Abstract: Background Successful aging is a worldwide aim, but it is less clear which indicators characterize elderly persons as successfully aged. We explored the meaning of successful aging from 2 perspectives. Methods Analysis of data from the first cross-sectional part of the longitudinal Leiden 85-plus Study, conducted in Leiden, the Netherlands. All inhabitants of Leiden aged 85 years were eligible. Data were obtained from 599 participants (response rate, 87%). Successful aging from a public health perspective was defined as a state of being. All participants were classified as successful or not successful based on optimal scores for physical, social, and psychocognitive functioning and on feelings of well-being, using validated quantitative instruments. Qualitative indepth interviews on the perspectives of elderly persons were held with a representative group of 27 participants. Results Although 45% (267/599) of the participants had optimal scores for well-being, only 13% (79/599) had optimal scores for overall functioning. In total, 10% (58/599) of the participants satisfied all the criteria and could be classified as successfully aged. The qualitative interviews showed that most elderly persons viewed success as a process of adaptation rather than a state of being. They recognized the various domains of successful aging, but valued well-being and social functioning more than physical and psychocognitive functioning. Conclusions If successful aging is defined as an optimal state of overall functioning and well-being, only a happy few meet the criteria. However, elderly persons view successful aging as a process of adaptation. Using this perspective, many more persons could be considered to be successfully aged.

An Evidence-Based Assessment of Federal Guidelines for Overweight and Obesity as They Apply to Elderly Persons

Abstract: Background The US Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults set the body mass index (BMI; weight in kilograms divided by the square of height in meters) of 25 as the upper limit of ideal weight for all adults regardless of age. However, the prognostic importance of overweight and obesity in elderly persons (≥65 years) is controversial. We sought to analyze the guidelines in the context of currently available evidence that is relevant to older adults. Methods We searched MEDLINE for all English-language studies of the association between BMI and all-cause or cardiovascular mortality or coronary heart disease events from January 1966 through October 1999. Additional pertinent articles were identified through bibliographies of the MEDLINE articles. We selected studies for detailed review if they reported on the association between BMI and mortality for nonhospitalized subjects who were 65 years or older and had been followed up for at least 3 years. We controlled for age, smoking, and baseline health status. Of the 444 screened articles, 13 were selected to assess the guidelines. We extracted information regarding publication year, study design, population, recruitment period, follow-up duration, number of subjects, sex, age range, inclusion and exclusion criteria, and statistical models, including variables and end points. Results These data do not support the BMI range of 25 to 27 as a risk factor for all-cause and cardiovascular mortality among elderly persons. The results were not substantially different for men and women. Most studies showed a negative or no association between BMI and all-cause mortality. Three studies indicated overweight (BMI ≥27) as a significant prognostic factor for all-cause and cardiovascular mortality among 65- to 74-year-olds, and one study showed a significant positive association between overweight (BMI ≥28) and all-cause mortality among those 75 years or older. Higher BMI values were consistent with a smaller relative mortality risk in elderly persons compared with young and middle-aged populations. Conclusions Federal guideline standards for ideal weight (BMI 18.7 to

Hyperthermia After Cardiac Arrest Is Associated With an Unfavorable Neurologic Outcome

Abstract: Background Moderate elevation of brain temperature, when present during or after ischemia, may markedly worsen the resulting injury. Objective To evaluate the impact of body temperature on neurologic outcome after successful cardiopulmonary resuscitation. Methods In patients who experienced a witnessed cardiac arrest of presumed cardiac cause, the temperature was recorded on admission to the emergency department and after 2, 4, 6, 12, 18, 24, 36, and 48 hours. The lowest temperature within 4 hours and the highest temperature during the first 48 hours after restoration of spontaneous circulation were recorded and correlated to the best-achieved cerebral performance categories' score within 6 months. Results Over 43 months, of 698 patients, 151 were included. The median age was 60 years (interquartile range, 53-69 years); the estimated median no-flow duration was 5 minutes (interquartile range, 0-10 minutes), and the estimated median low-flow duration was 14.5 minutes (interquartile range, 3-25 minutes). Forty-two patients (28%) underwent bystander-administered basic life support. Within 6 months, 74 patients (49%) had a favorable functional neurologic recovery, and a total of 86 patients (57%) survived until 6 months after the event. The temperature on admission showed no statistically significant difference (P =.39). Patients with a favorable neurologic recovery showed a higher lowest temperature within 4 hours (35.8 degrees C [35.0 degrees C-36.1 degrees C] vs 35.2 degrees C [34.5 degrees C-35.7 degrees C]; P =.002) and a lower highest temperature during the first 48 hours after restoration of spontaneous circulation (37.7 degrees C [36.9 degrees C-38.6 degrees C] vs 38.3 degrees C [37.8 degrees C-38.9 degrees C]; P Conclusion Hyperthermia is a potential factor for an unfavorable functional neurologic recovery after successful cardiopulmonary resuscitation.

Randomized trial comparing Traditional Chinese medical acupuncture, therapeutic massage, and self-care education for chronic low back pain

Abstract: Background Because the value of popular forms of alternative care for chronic back pain remains uncertain, we compared the effectiveness of acupuncture, therapeutic massage, and self-care education for persistent back pain. Methods We randomized 262 patients aged 20 to 70 years who had persistent back pain to receive Traditional Chinese Medical acupuncture (n = 94), therapeutic massage (n = 78), or self-care educational materials (n = 90). Up to 10 massage or acupuncture visits were permitted over 10 weeks. Symptoms (0-10 scale) and dysfunction (0-23 scale) were assessed by telephone interviewers masked to treatment group. Follow-up was available for 95% of patients after 4, 10, and 52 weeks, and none withdrew for adverse effects. Results Treatment groups were compared after adjustment for prerandomization covariates using an intent-to-treat analysis. At 10 weeks, massage was superior to self-care on the symptom scale (3.41 vs 4.71, respectively; P = .01) and the disability scale (5.88 vs 8.92, respectively; P P = .01). After 1 year, massage was not better than self-care but was better than acupuncture (symptom scale: 3.08 vs 4.74, respectively; P = .002; dysfunction scale: 6.29 vs 8.21, respectively; P = .05). The massage group used the least medications ( P Conclusions Therapeutic massage was effective for persistent low back pain, apparently providing long-lasting benefits. Traditional Chinese Medical acupuncture was relatively ineffective. Massage might be an effective alternative to conventional medical care for persistent back pain.

Anaphylaxis in the United States: an investigation into its epidemiology

Abstract: Background Anaphylaxis is a severe, life-threatening allergic reaction that affects both children and adults in the United States. However, data regarding the incidence and prevalence of anaphylaxis and the number of deaths caused by it are limited. Objective To provide a better understanding of the magnitude of the problem of anaphylaxis in the United States. Methods A thorough review of the current medical literature was conducted to obtain prevalence estimates on each of the 4 major subtypes of anaphylaxis (food, drugs, latex, and insect stings). We calculated an overall estimate of the risk of anaphylaxis by using only estimates that are specifically derived from epidemiologic studies measuring anaphylaxis in the general population. Results Known rates or cases of anaphylaxis were 0.0004% for food, 0.7% to 10% for penicillin, 0.22% to 1% for radiocontrast media, and 0.5% to 5% after insect stings. There were 220 cases after latex exposure. Considering the 1999 US population of 272 million, the population at risk for anaphylaxis from food is 1099, from penicillin is 1.9 million to 27.2 million, from radiocontrast media is 22 000 to 100 000, from latex is 220, and from insect stings is 1.36 million to 13.6 million. These calculations yield a total of 3.29 million to 40.9 million individuals at risk of anaphylaxis. Conclusion The occurrence of anaphylaxis in the US is not as rare as is generally believed. On the basis of our figures, the problem of anaphylaxis may, in fact, affect 1.21% to 15.04% of the US population.

Association between blood pressure level and the risk of myocardial infarction, stroke, and total mortality: the cardiovascular health study.

Abstract: Background Recent reports have drawn attention to the importance of pulse pressure as a predictor of cardiovascular events. Pulse pressure is used neither by clinicians nor by guidelines to define treatable levels of blood pressure. Methods In the Cardiovascular Health Study, 5888 adults 65 years and older were recruited from 4 US centers. At baseline in 1989-1990, participants underwent an extensive examination, and all subsequent cardiovascular events were ascertained and classified. Results At baseline, 1961 men and 2941 women were at risk for an incident myocardial infarction or stroke. During follow-up that averaged 6.7 years, 572 subjects had a coronary event, 385 had a stroke, and 896 died. After adjustment for potential confounders, systolic blood pressure (SBP), diastolic blood pressure (DBP), and pulse pressure were directly associated with the risk of incident myocardial infarction and stroke. Only SBP was associated with total mortality. Importantly, SBP was a better predictor of cardiovascular events than DBP or pulse pressure. In the adjusted model for myocardial infarction, a 1-SD change in SBP, DBP, and pulse pressure was associated with hazard ratios (95% confidence intervals) of 1.24 (1.15-1.35), 1.13 (1.04-1.22), and 1.21 (1.12-1.31), respectively; and adding pulse pressure or DBP to the model did not improve the fit. For stroke, the hazard ratios (95% confidence intervals) were 1.34 (1.21-1.47) with SBP, 1.29 (1.17-1.42) with DBP, and 1.21 (1.10-1.34) with pulse pressure. The association between blood pressure level and cardiovascular disease risk was generally linear; specifically, there was no evidence of a J-shaped relationship. In those with treated hypertension, the hazard ratios for the association of SBP with the risks for myocardial infarction and stroke were less pronounced than in those without treated hypertension. Conclusion In this population-based study of older adults, although all measures of blood pressure were strongly and directly related to the risk of coronary and cerebrovascular events, SBP was the best single predictor of cardiovascular events.

Advance Directives as Acts of Communication A Randomized Controlled Trial

Abstract: Background Instructional advance directives are widely advocated as a means of preserving patient self-determination at the end of life based on the assumption that they improve surrogates' understanding of patients' life-sustaining treatment wishes. However, no research has examined whether instructional directives are effective in improving the accuracy of surrogate decisions. Participants and Methods A total of 401 outpatients aged 65 years or older and their self-designated surrogate decision makers (62% spouses, 29% children) were randomized to 1 of 5 experimental conditions. In the control condition, surrogates predicted patients' preferences for 4 life-sustaining medical treatments in 9 illness scenarios without the benefit of a patient-completed advance directive. Accuracy in this condition was compared with that in 4 intervention conditions in which surrogates made predictions after reviewing either a scenario-based or a value-based directive completed by the patient and either discussing or not discussing the contents of the directive with the patient. Perceived benefits of advance directive completion were also measured. Results None of the interventions produced significant improvements in the accuracy of surrogate substituted judgment in any illness scenario or for any medical treatment. Discussion interventions improved perceived surrogate understanding and comfort for patient-surrogate pairs in which the patient had not completed an advance directive prior to study participation. Conclusions Our results challenge current policy and law advocating instructional advance directives as a means of honoring specific patient wishes at the end of life. Future research should explore other methods of improving surrogate decision making and consider the value of other outcomes in evaluating the effectiveness of advance care planning.

Use of medications with anticholinergic effect predicts clinical severity of delirium symptoms in older medical inpatients.

Abstract: Background Use of anticholinergic (ACH) medications is a biologically plausible and potentially modifiable risk factor of delirium, but research findings are conflicting regarding its association with delirium. Objectives To evaluate the longitudinal association between use of ACH medications and severity of delirium symptoms and to determine whether this association is modified by the presence of dementia. Patients and Methods A total of 278 medical inpatients 65 years and older with diagnosed incident or prevalent delirium were followed up with repeated assessments using the Delirium Index for up to 3 weeks. Exposure to ACH and other medications was measured daily. The association between change in medication exposure in the 24 hours preceding a Delirium Index assessment was assessed using a mixed linear regression model. Results During follow-up (mean ± SD, 12.3 ± 7.0 days), 47 medications with potential ACH effect were used in the population (mean, 1.4 medications per patient per day). Increase in delirium severity was significantly associated with several measures of ACH medication exposure on the previous day, adjusting for dementia, baseline delirium severity, length of follow-up, and number of non-ACH medications taken. Dementia did not modify the association between ACH medication use and delirium severity. Conclusion Exposure to ACH medications is independently and specifically associated with a subsequent increase in delirium symptom severity in elderly medical inpatients with diagnosed delirium.

Legume Consumption and Risk of Coronary Heart Disease in US Men and Women: NHANES I Epidemiologic Follow-up Study

Abstract: Background Soybean protein and dietary fiber supplementation reduce serum cholesterol in randomized controlled trials. Consumption of legumes, which are high in bean protein and water-soluble fiber, may be associated with a reduced risk of coronary heart disease (CHD). Methods A total of 9632 men and women who participated in the First National Health and Nutrition Examination Survey Epidemiologic Follow-up Study (NHEFS) and were free of cardiovascular disease (CVD) at their baseline examination were included in this prospective cohort study. Frequency of legume intake was estimated using a 3-month food frequency questionnaire, and incidence of CHD and CVD was obtained from medical records and death certificates. Results Over an average of 19 years of follow-up, 1802 incident cases of CHD and 3680 incident cases of CVD were documented. Legume consumption was significantly and inversely associated with risk of CHD ( P = .002 for trend) and CVD ( P = .02 for trend) after adjustment for established CVD risk factors. Legume consumption 4 times or more per week compared with less than once a week was associated with a 22% lower risk of CHD (relative risk, 0.78; 95% confidence interval, 0.68-0.90) and an 11% lower risk of CVD (relative risk, 0.89; 95% confidence interval, 0.80-0.98). Conclusions Our study indicates a significant inverse relationship between legume intake and risk of CHD and suggests that increasing legume intake may be an important part of a dietary approach to the primary prevention of CHD in the general population.

The effect of age on pain, function, and quality of life after total hip and knee arthroplasty.

Abstract: Background As utilization rates for total joint arthroplasty increase, there is a hesitancy to perform this surgery on very old patients. The objective of this prospective study was to compare pain, functional, and health-related quality-of-life outcomes after total hip and total knee arthroplasty in an older patient group (≥80 years) and a representative younger patient group (55-79 years). Methods In an inception community-based cohort within a Canadian health care system, 454 patients who received primary total hip arthroplasty (n = 197) or total knee arthroplasty (n = 257) were evaluated within a month prior to surgery and 6 months postoperatively. Pain, function, and health-related quality of life were evaluated with the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index and the 36-Item Short-Form Health Survey (SF-36). Results There were no age-related differences in joint pain, function, or quality-of-life measures preoperatively or 6 months postoperatively. Furthermore, after adjusting for potential confounding effects, age was not a significant determinant of pain or function. Although those in the older and younger groups had comparable numbers of comorbid conditions and complications, those in the older group were more likely to be transferred to a rehabilitation facility than younger patients. Regardless of age, patients did not achieve comparable overall physical health when matched with the general population for age and sex. Conclusions With increasing life expectancy and elective surgery improving quality of life, age alone is not a factor that affects the outcome of joint arthroplasty and should not be a limiting factor when considering who should receive this surgery.

Risk factors for adverse drug events among nursing home residents.

Abstract: Background In a prospective study of nursing home residents, we found adverse drug events (ADEs) to be common, serious, and often preventable. To direct prevention efforts at high-risk residents, information is needed on resident-level risk factors. Methods Case-control study nested within a prospective study of ADEs among residents in 18 nursing homes. For each ADE, we randomly selected a control from the same home. Data were abstracted from medical records on functional status, medical conditions, and medication use. Results Adverse drug events were identified in 410 nursing home residents. Independent risk factors included being a new resident (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.5-5.2) and taking anti-infective medications (OR, 4.0; CI, 2.5-6.2), antipsychotics (OR, 3.2; CI, 2.1-4.9), or antidepressants (OR, 1.5; CI, 1.1-2.3). The number of regularly scheduled medications was associated with increased risk of ADEs; the OR associated with taking 5 to 6 medications was 2.0 (CI, 1.2-3.2); 7 to 8 medications, 2.8 (CI, 1.7-4.7); and 9 or more, 3.3 (CI, 1.9-5.6). Taking supplements or nutrients was associated with lower risk (OR, 0.42; CI, 0.27-0.63). Preventable ADEs occurred in 226 residents. Independent risk factors included taking opioid medications (OR, 6.6; CI, 2.3-19.3), antipsychotics (OR, 4.0; CI, 2.2-7.3), anti-infectives (OR, 3.0; CI, 1.6-5.8), antiepileptics (OR, 2.2; CI, 1.1-4.5), or antidepressants (OR, 2.0; CI, 1.1-3.5). Scores of 5 or higher on the Charlson Comorbidity Index were associated with increased risk of ADEs (OR, 2.6; CI, 1.1-6.0). The number of regularly scheduled medications was also a risk factor: the OR for 7 to 8 medications was 3.2 (CI, 1.4-6.9) and for 9 or more, 2.9 (CI, 1.3-6.8). Residents taking nutrients or supplements were at lower risk (OR, 0.27; CI, 0.14-0.50). Conclusions It is possible to identify nursing home residents at high risk of having an ADE. Particular attention should be directed at new residents, those with multiple medical conditions, those taking multiple medications, and those taking psychoactive medications, opioids, or anti-infective drugs.

Monotherapy may be suboptimal for severe bacteremic pneumococcal pneumonia

Abstract: Background Although monotherapy for pneumococcal pneumonia is standard, a survival benefit of combination β-lactam and macrolide therapy has been suggested. Hypothesis Initial empirical therapy with a combination of effective antibiotic agents would have a better outcome than a single effective antibiotic agent in patients with bacteremic pneumococcal pneumonia. Methods A review of adult bacteremic pneumococcal pneumonia within the Methodist Healthcare System, Memphis, Tenn, between January 1, 1996, and July 31, 2000. Empirical therapy was defined as all antibiotic agents received in the first 24 hours after presentation. On the basis of culture results, empirical therapy was classified as single effective therapy (SET), dual effective therapy (DET), or more than DET (MET). Acute Physiology and Chronic Health Evaluation II (APACHE II)–based predicted mortality, and Pneumonia Severity Index scores were calculated. Results Of the 225 patients identified, 99 were classified as receiving SET, 102 as receiving DET, and 24 as receiving MET. Compared with the other groups, patients who received MET had statistically significantly more severe pneumonia as measured by the Pneumonia Severity Index score ( P = .04) and predicted mortality ( P = .03). Mortality within the SET group was significantly higher than within the DET group ( P = .02, odds ratio, 3.0 [95% confidence intervals, 1.2-7.6]), even when the DET and MET groups ( P = .04) were combined. In a logistic regression model including antibiotic therapy and clinical risk factors for mortality, SET remained an independent predictor of mortality with a predicted mortality–adjusted odds ratio for death of 6.4 (95% confidence intervals, 1.9-21.7). All deaths occurred in patients with a Pneumonia Severity Index score higher than 90, and the predicted mortality–adjusted odds ratio for death with SET in this subgroup was 5.5 (95% confidence intervals, 1.7-17.5). Conclusions We found that SET is associated with a significantly greater risk of death than DET. Therefore, monotherapy may be suboptimal for patients with severe bacteremic pneumococcal pneumonia who have Pneumonia Severity Index scores higher than 90.

Acute Precipitants of Congestive Heart Failure Exacerbations

Abstract: Background Few studies have prospectively and systematically explored the factors that acutely precipitate exacerbation of congestive heart failure (CHF) in patients with left ventricular dysfunction. Knowledge of such factors is important in designing measures to prevent deterioration of clinical status. The objective of this study was to prospectively describe the precipitants associated with exacerbation of CHF status in patients enrolled in the Randomized Evaluation of Strategies for Left Ventricular Dysfunction Pilot Study. Methods We conducted a 2-stage, multicenter, randomized trial in 768 patients with CHF who had an ejection fraction of less than 40%. Patients were randomly assigned to receive enalapril maleate, candesartan cilexetil, or both for 17 weeks, followed by randomization to receive metoprolol succinate or placebo for 26 weeks. Investigators systematically documented information on clinical presentation, management, and factors associated with the exacerbation for any episode of acute CHF during follow-up. Results A total of 323 episodes of worsening of CHF occurred in 180 patients during 43 weeks of follow-up; 143 patients required hospitalization, and 5 died. Factors implicated in worsening of CHF status included noncompliance with salt restriction (22%); other noncardiac causes (20%), notably pulmonary infectious processes; study medications (15%); use of antiarrhythmic agents in the past 48 hours (15%); arrhythmias (13%); calcium channel blockers (13%); and inappropriate reductions in CHF therapy (10%). Conclusions A variety of factors, many of which are avoidable, are associated with exacerbation of CHF. Attention to these factors and patient education are important in the prevention of CHF deterioration.

Deep Vein Thrombosis and Its Prevention in Critically Ill Adults

Abstract: Background Our objective was to systematically review the incidence of deep vein thrombosis (DVT) and the efficacy of thromboprophylaxis in critically ill adults, including patients admitted to intensive care units and following trauma, neurosurgery, or spinal cord injury. Methods Two authors independently searched MEDLINE, EMBASE, abstract databases, and the Cochrane database. Data were extracted independently in triplicate. Results Ten percent to 30% of medical and surgical intensive care unit patients develop DVT within the first week of intensive care unit admission. The use of subcutaneous low-dose heparin reduced the rate by 50% compared with no prophylaxis. Approximately 60% of trauma patients developed DVT within the first 2 weeks of admission. Use of unfractionated heparin appears to decrease the incidence of DVT by only 20%, whereas low-molecular-weight heparin decreases the incidence by a further 30%. The estimated prevalence of DVT in neurosurgical patients not given prophylaxis is 22% to 35%. Mechanical prophylaxis is efficacious, with a pooled odds ratio in 5 randomized trials of 0.28. Use of low-molecular-weight heparin has been investigated as an adjunct to mechanical prophylaxis with a pooled odds ratio of 0.59 compared with graduated compression stockings alone. The incidence of DVT without prophylaxis in acute spinal cord injury patients is likely in excess of 50% to 80%. Studies of prophylaxis in these patients are too sparse to come to any definitive conclusion. Conclusions Critically ill patients commonly develop DVT, with rates that vary from 22% to almost 80%, depending on patient characteristics. Methods of prophylaxis proven in one group do not necessarily generalize to other critically ill patient groups. More potent prophylactic regimens other than unfractionated or low-molecular-weight heparins alone may be needed with higher-risk groups.