Vitamin E and coronary artery disease.

Various studies have evaluated the antioxidant effects of vitamin E in the prevention or treatment of coronary artery disease (CAD). In vitro data suggest that vitamin E protects against oxidation of low-density lipoprotein and decreases the deposition of atherogenic oxidized low-density lipoprotein in arterial walls. Various observational and epidemiological studies also suggest a relationship between vitamin E serum concentrations or intake and CAD. One prospective, randomized trial suggested that low-dosage vitamin E supplementation (50 IU/d) decreases the risk of angina in patients without previously diagnosed CAD. Another study, using high-dosage vitamin E supplementation (400 or 800 IU/d), demonstrated a decrease in the combined end point of nonfatal myocardial infarction and cardiovascular death in patients with established CAD. Discordant data, however, have been published that imply no cardiovascular benefit of low-dosage vitamin E supplementation (50 IU/d) and detrimental effects if vitamin E is combined with beta carotene. At this point, clinicians should emphasize a low-fat diet with high intake of fruits and vegetable sources containing vitamin E. Supplemental vitamin E may be considered in patients at high risk for CAD or with documented CAD, but the potential beneficial effects should be weighed against possible long-term adverse effects. If vitamin E supplementation is initiated, the literature suggests dosages of 100 to 400 IU/d, with the higher dosage considered in patients with documented CAD. Additional investigation is warranted to further define the role of vitamin E supplementation in CAD and to critically evaluate the optimal dosage, duration of use, and method of consumption (dietary vs supplemental).

Caucasian versus African-American differences in orosomucoid: potential implications for therapy.

We conducted a prospective, nonrandomized study in healthy volunteers to determine if racial differences exist in orosomucoid (ORM) and its variants, and to examine quinidine and lidocaine binding to the protein. Total ORM serum concentrations were measured by Laurell-Rocket immunoelectrophoresis. Allele types were determined by isoelectric focusing and immunoblotting. Total and unbound quinidine and lidocaine concentrations were measured with standard fluorescence polarization immunoassays after ultrafiltration. The frequency of the common ORM alleles was similar between 38 Caucasians and 67 African-Americans. Mean total ORM concentration was significantly lower in Caucasians (57.3 +/- 25.4 vs 73.2 +/- 33.9 mg/dl, p=0.01). However, more Caucasians took oral contraceptives, which may have decreased ORM concentrations. Quinidine unbound fraction (UF) was related to ORM phenotype. The highest UF was found with ORM 1-S (p=0.009). There were no significant relationships between ORM phenotype and lidocaine UF. Overall, African-Americans had higher ORM concentrations than Caucasians. Quinidine binding showed significant relationships to specific ORM variants.

Altered protein binding of quinidine in patients with atrial fibrillation and flutter.

STUDY OBJECTIVES: To determine if alpha1-acid glycoprotein (AAG) concentrations are altered in patients with atrial fibrillation and flutter (AFF), and to establish if fluctuations in AAG change the free fraction of quinidine. DESIGN: Prospective, controlled, nonrandomized. SETTING: Tertiary care medical center and outpatient clinics. PATIENTS: Thirty patients with AFF and 16 matched controls. INTERVENTIONS: Serial blood samples were collected from patients with AFF at baseline and for 28 days after cardioversion. The control group received no treatment and a single blood sample was obtained. MEASUREMENTS AND MAIN RESULTS: Concentrations of AAG were measured by Laurell-Rocket immunoelectrophoresis. Quinidine concentrations were determined by fluorescence polarization immunoassay using the Abbott TDx system. Baseline AAG concentrations in patients with AFF (122 +/- 55 mg/dl) were significantly increased compared with the control group (62 +/- 28 mg/dl, p<0.0005). Concentrations of AAG remained elevated after conversion to sinus rhythm and did not significantly change over the study period, regardless of method of cardioversion (p>0.2). In patients with AFF, the free fraction of quinidine at the highest AAG concentration was 8.5 +/- 2.3%. This was significantly reduced compared with the value in the control group (12.5 +/- 3.0%, p<0.05) as well as that in patients with AFF at the lowest AAG concentration (11.0 +/- 2.5%, p<0.05). Overall at the highest AAG concentration, patients with AFF had a relative reduction in the quinidine free fraction by 32% compared with controls. Regression analysis showed an indirect relationship between serum AAG concentration and the unbound fraction of quinidine (r=0.56) CONCLUSIONS: Concentrations of AAG are increased in patients with AFF and remain elevated for at least 28 days after cardioversion. Elevated AAG concentrations significantly reduce the free fraction of quinidine.

Warfarin resistance in a patient with short bowel syndrome.

Drug therapy in short bowel syndrome can be complicated by inadequate or incomplete absorption of drugs in the small intestine. Many case reports claim that warfarin absorption is not affected by the syndrome. We treated a patient with oral warfarin for recurring deep vein thrombosis; up to 20 mg/day was administered with no increase in the international normalized ratio. Drug-drug interactions that may prevent absorption, increase metabolism, or antagonize the effects of warfarin were ruled out. Intravenous lipid administration, which is anecdotally reported to precipitate warfarin resistance, may have contributed to the condition, but dosing was less frequent than in published reports. The most probable explanation of warfarin resistance is the reduced surface area for drug absorption secondary to surgical removal of the patient's duodenum and gastrojejunostomy.

Pharmacokinetic interaction between ketoconazole and amprenavir after single doses in healthy men.

STUDY OBJECTIVE: To determine the effects of coadministration of amprenavir and ketoconazole on the pharmacokinetics of both drugs, and to assess the utility of the erythromycin breath test (ERMBT) to predict and explain these effects. DESIGN: Open-label, randomized, balanced, single-dose, three-period crossover study. SETTING: University research center. SUBJECTS: Twelve healthy men. INTERVENTION: Subjects received amprenavir 1200 mg, ketoconazole 400 mg, and amprenavir 1200 mg plus ketoconazole 400 mg. Each treatment was separated by 14 days. MEASUREMENTS AND MAIN RESULTS: Serial plasma samples for amprenavir and ketoconazole concentrations were measured by high-performance liquid chromatography. Coadministration of the drugs increased amprenavir area under the curve extrapolated to infinity (AUCinfinity) by 31% and reduced its maximum concentration (Cmax) by 16%. Amprenavir increased the AUCinfinity of ketoconazole by 44% and increased the drug's half-life and Cmax by 23% and 19%, respectively. Both agents resulted in substantial inhibition of ERMBT. CONCLUSION: Coadministration of ketoconazole and amprenavir results in a statistically significant increase in AUC for both agents, but the changes are not likely to be clinically important.

Interviewing style and response to family information by family practice residents.

The visits of 50 new patients seeing 20 family practice residents were audiotaped. Analysis of transcripts of all conversation involving family-related content showed that the resident physicians used a high control interviewing style consisting mostly of closed-end questions and declarative statements. They rarely asked open-end questions. After eliciting family information, the residents missed numerous opportunities to express empathy or concern verbally. The physicians seldom connected family information obtained during the visit with the patient's ongoing or potential health problems. Of 12 patients reporting a life-threatening familial illness in a close relative, only one received any relevant patient education. The closed style of interviewing appeared to interfere with the physicians' gathering and responding to family information.

Screening depression in primary care: back to the basics with a new tool.

Two depression inventories were used to screen 377 family practice patients. One, the Self-Rating Depression Scale (SDS), assesses major symptomatology; it is the depression inventory most frequently used in family practice. The other, the Depression Adjective Checklist (DACL), assesses mood only and has not been previously reported in the family medicine literature. Forty-one percent of the patients who completed the SDS rated themselves at least mildly depressed; 37% scored in the same range on the DACL. Four percent of the patients scored in the severe depression range on the SDS, while 15% scored in the severe depression range on the DACL. Residents treating these patients, however, failed to diagnose depression in more than 85% of the patients who had rated themselves as at least mildly depressed on either inventory. The residents also failed to diagnose depression in more than 70% of those who had rated themselves as severely depressed. Teaching and research implications are discussed.

Rapid assessment of literacy levels of adult primary care patients.

Health education materials, medical instructions, consent forms, and self-report questionnaires are often given to patients with little regard for their ability to read them. Reading ability is rarely tested in medical settings. The Rapid Estimate of Adult Literacy in Medicine (REALM) was developed as a quick screening tool to assist physicians in identifying patients with limited reading skills and in estimating patient reading levels. This information can be used to tailor materials and instructions to patients' abilities. The REALM and the reading sections of the Peabody Individual Achievement Test-Revised and the Slosson Oral Reading Test were used to test reading ability in 207 adults in six public and private primary care clinics. REALM scores correlated highly with those of the standardized reading tests. The REALM, which takes three to five minutes to administer and score, appears to be a practical instrument to estimate patient literacy in primary care, patient education, and medical research.

Rapid estimate of adult literacy in medicine: a shortened screening instrument.

BACKGROUND: This study was conducted to validate a shortened version of the Rapid Estimate of Adult Literacy in Medicine (REALM). This screening instrument is designed to be used in public health and primary care settings to identify patients with low reading levels. It provides reading grade estimates for patients who read below a ninth-grade level. The REALM can be administered in one to two minutes by personnel with minimal training. METHODS: Two hundred and three patients in four university hospital clinics (internal medicine, family practice, ambulatory care, and obstetrics/gynecology) were given the REALM and three other standardized reading tests: the reading recognition section of the Peabody Individual Achievement Test-Revised (PIAT-R), the Wide Range Achievement Test-Revised (WRAT-R), and the Slosson Oral Reading Test-Revised (SORT-R). One hundred inmates at a state prison were also given the REALM twice, one week apart, to determine test-retest reliability. RESULTS: The REALM correlated well with the three other tests. (Correlation coefficients were 0.97 [PIAT-R], 0.96 [SORT-R], and 0.88 [WRAT-R].) All correlations were significant at P < .0001. Test-retest reliability was 0.99 (P < .001). CONCLUSIONS: The REALM provides an estimate of patient reading ability, displays excellent concurrent validity with standardized reading tests, and is a practical instrument for busy primary care settings.

Irritable bowel syndrome. Toward a biopsychosocial systems understanding.

The symptoms of irritable bowel syndrome (IBS) are usually a subset of a broader problem that meets DSM-III criteria for depression, anxiety disorder, somatization disorder, or adjustment disorder. A biopsychosocial perspective that addresses multigenerational family patterns of anxiety, depression, and somatization of stress suggests guidelines for understanding and treating patients with IBS symptoms. Effective treatment focuses primarily on helping patients cope with emotional disorders and psychosocial stressors, and secondarily on direct symptom relief. Psychotherapy is a valuable adjunct to medical treatment. The medications most likely to yield lasting benefits are the antidepressants.

Current concepts in autologous bone marrow transplantation.

BMT is the treatment of disease with high-dose chemotherapy and/or radiation therapy accompanied with bone marrow rescue. An autologous BMT is performed with marrow acquired from the patient. The marrow is obtained from the bone marrow or from peripheral blood progenitor cells (PBPCs), also known as stem cell transplants. Marrow purging of malignant cells and autologous BMT with only PBPC continues to be an area of active research.

Documentation of family health history in the outpatient medical record.

In a university-based family practice residency program, patients' computerized medical records were audited to determine how information about family health history was recorded. Family history items were listed on the problem lists for only 4.4 percent of all active patients and for only 2.7 percent of a systematic sample of 375 patients. A manual audit of 75 charts randomly selected from the systematic sample showed that the problem lists contained only 5.8 percent of the family history items reported by patients. Children's problem lists contained fewer family history items than did those of adults.

Family awareness demonstrated by family practice residents: physician behavior and patient opinions.

Audiotapes of the visits of 50 new patients with 20 family practice residents were analyzed to determine how aware the residents were of their patients' families. The same patients' opinions about family awareness were elicited by interviews. Residents exhibited only limited family awareness. Despite this, patients thought that the residents showed more interest in family matters than they usually expected from a family physician. Patients thought the physicians were most interested in their family situations when they asked more questions about family matters. Physicians were seen as least interested when they asked few family questions and when they were absent from the examination room for a relatively high proportion of the visit. Physicians were much less likely to discuss family matters with a patient during a short visit for an acute problem than during a longer visit for a chronic problem or for health maintenance. Most patients identified physician attitudes and behaviors as more important obstacles to the discussion of family matters than patient attitudes. Patients generally wanted substantially more help from their family physician for family problems than they expected to receive.

The gap between patient reading comprehension and the readability of patient education materials.

Patient education materials and hospital forms are given to patients with little regard for their ability to read them. Nationwide sampling and data from the 1980 census suggest that a high proportion of patients cared for in public hospitals are functionally illiterate. In this study, 151 adult primary care patients in five different ambulatory care settings were tested for reading comprehension. Patient education materials and forms from each clinic were analyzed for readability using a standard computer program. A large discrepancy was found between the average patient reading comprehension and the ability levels needed to read patient education materials. The average reading comprehension of public clinic patients was 6th grade 5th month. Most tested patient education materials required a reading level of 11th to 14th grade, and standard institutional consent forms required a college-level reading comprehension. In the public clinics there was a gap of more than 5 years between patient reading levels and the comprehension levels required by written patient materials.

Heparin-induced thrombocytopenia and thrombosis.

Heparin is one of the most frequently prescribed medications in the United States; yet, a significant number of patients receiving heparin develop heparin-induced thrombocytopenia and thrombosis syndrome. This detailed case report demonstrates the significant role nurses play in early detection and prevention of the numerous multisystem complications of this heparin toxicity.

Urokinase therapy in mesenteric venous thrombosis: a case study.

Mesenteric venous thrombosis is an emergency usually treated by bowel resection with an end-to-end anastomosis and in some cases anticoagulant therapy. The survival rate is low. The literature records many cases of mesenteric venous thrombosis and various treatment modalities. An 18-year-old man was successfully treated for mesenteric venous thrombosis by the placement of a femoral infusion catheter in the superior mesenteric artery for continuous infusion of urokinase (Abbot Laboratories, N. Chicago, Ill.). This case study and overview of the disease process reviews the nursing implications of this problem.