Does high weight loss in older adults with knee osteoarthritis affect bone-on-bone joint loads and muscle forces during walking?

OBJECTIVE: The aim of this study was to examine the effects of high weight loss on knee joint loads during walking in participants with knee osteoarthritis (OA). DESIGN: Data were obtained from a subset of participants enrolled in the Arthritis, Diet, and Activity Promotion Trial (ADAPT). Complete baseline and 18-month follow-up data were obtained on 76 sedentary, overweight or obese older adults with radiographic knee OA. Three-dimensional gait analysis was used to calculate knee joint forces and moments. The cohort was divided into high (>5%), low (<5%), and no (0% or gain) weight loss groups. RESULTS: From baseline body weight, the high weight loss group lost an average of 10.2%, the low weight loss group lost an average of 2.7%, and the no weight loss group gained 1.5%. Adjusted 18-month outcome data revealed lower maximum knee compressive forces with greater weight loss (P=0.05). The difference in compressive forces between the high weight loss and no weight loss groups was due primarily to lower hamstring forces (P=0.04). Quadriceps forces were similar between the groups at 18-month follow-up. There was no difference between the groups in 18-month joint space width or Kellgren-Lawrence scores. CONCLUSIONS: These results suggest that a 10% weight loss in an overweight and obese osteoarthritic population elicits positive changes in the mechanical pathway to knee OA by having lower knee joint compressive loads during walking compared to low and no weight loss groups. The difference in compressive forces was due, in large part, to reductions in hamstring co-contraction during the initial portion of the stance phase.

Effect of interleukin-1 alpha on lipoprotein lipids in cynomolgus monkeys: comparison to tumor necrosis factor.

Acute inflammation is associated with changes in lipoprotein metabolism. Cytokines are thought to mediate the metabolic effects of the inflammatory process. This study was undertaken to compare the effects of interleukin-1 alpha (IL-1 alpha) to tumor necrosis factor (TNF) on lipoprotein metabolism in non-human primates. Recombinant human IL-1 alpha (100 micrograms/kg), TNF alpha (20 micrograms/kg) and lipopolysaccharide (20 micrograms/kg) were injected into cynomolgus monkeys. Lipoprotein concentrations, plasma activities of post-heparin lipase (PHLA) and lecithin:cholesterol acyltransferase (LCAT) were measured prior to and 24 and 48 h after, injection. All three injections caused afebrile response in the animals. Interleukin-1 alpha had no effect on plasma lipoprotein concentrations, composition of lipoproteins or enzyme activity. In contrast, injection of TNF caused significant changes in lipoprotein concentrations. There was a 38% increase in plasma triacylglycerol and 30% decrease in plasma cholesterol at 48 h after injection. Concentrations of apolipoproteins A-I and B were decreased 20% and 44%, respectively, at 48 h. Compositional analyses of lipoprotein particles after TNF injection showed that both the LDL and HDL particles had decreased content of cholesterol ester and increased triacylglycerol after injection, and plasma activities of PHLA and LCAT were decreased. These changes were qualitatively similar to those seen after LPS injection. These data suggest that, unlike TNF, IL-1 alpha is not an important mediator of the inflammatory process on lipoprotein metabolism in cynomolgus monkeys.

Mortality in intensive care patients with respiratory disease. Is age important?

BACKGROUND: Age has been proposed as a criterion for health care rationing. However, the relationship of age and other prognostic factors to in-hospital mortality in older patients is unclear. The purpose of this study was to examine the effect of age on hospital mortality for patients admitted to the intensive care unit. METHODS: This historical prospective study examined 3050 admissions of patients aged 50 years and older with disease of the lower respiratory tract to intensive care units in 78 hospitals in the United States during an 18-month period (July 1987 through December 1988). The association of age with hospital mortality was examined by means of a multiple logistic regression model that included age, gender, primary discharge diagnosis, severity, and comorbid diseases. RESULTS: Variables significantly predictive of in-hospital mortality included age, severity of illness, diagnosis, and a history of chronic obstructive pulmonary disease. In contrast, gender, diabetes mellitus, congestive heart failure, angina, and stroke/transient ischemic attack were not significant predictors of mortality. Predicted mortalities varied from 0.7% to 40.7% in 50-year-old patients and from 5.5% to 78.6% in 90-year-old patients. CONCLUSIONS: Chronological age is independently associated with in-hospital mortality in patients with disease of the lower respiratory tract admitted to an intensive care unit. However, the clinical importance of this relationship is modulated by other variables, such as the primary diagnosis, the presence of comorbid conditions (chronic obstructive pulmonary disease), and the severity of the acute illness, such that use of age alone is not sufficient to predict hospital outcome.

Lack of age-related differences in the clinical presentation of digoxin toxicity.

BACKGROUND: Digoxin toxicity occurs most commonly among the elderly. While the clinical syndrome of digoxin toxicity is well understood, how toxic manifestations change with age is not known. METHODS: We performed secondary analysis of data from a postmarketing surveillance study of patients with life-threatening digoxin toxicity treated with digoxin antibody therapy. Patients receiving long-term maintenance digoxin therapy and aged 55 years or older were divided into four age groups: 55 to 64, 65 to 74, 75 to 84, and 85 years and older (n = 45, 167, 183, and 83, respectively) and compared with regard to presenting manifestations, digoxin dosing, serum potassium and digoxin levels, and renal function. RESULTS: The prevalence of high-degree atrioventricular block showed an increasing but nonsignificant trend with age (40%, 40%, 42%, and 47%, respectively). Age-related trends in high-degree atrioventricular block were stronger among men than women and even stronger among men with underlying cardiac ischemia. The proportion of subjects with nausea/vomiting as a toxic manifestation did not consistently change with age (42%, 48%, 48%, and 46%, respectively). There were no age-related differences in degree of renal impairment or maintenance dose, but maintenance dose decreased with increasing renal impairment. CONCLUSIONS: Among patients with life-threatening digoxin toxicity, there is no age-related difference in clinical presentation.

Elevated apolipoprotein-B levels in corticosteroid-treated patients with systemic lupus erythematosus.

Patients treated with corticosteroids often have a dyslipoproteinemia characterized by elevated plasma levels of triglyceride and low density lipoprotein cholesterol and/or decreased levels of the high density lipoprotein2 fraction of high density lipoprotein cholesterol. This study was undertaken to determine if such patients also have elevated apolipoprotein-B (apoB) levels and/or abnormalities of the activities of the triglyceride lipases in postheparin plasma. Plasma lipoprotein levels and the postheparin activities of hepatic lipase and lipoprotein lipase were measured in 28 women with systemic lupus erythematosus (SLE) who were treated with prednisone, 10 women with SLE not treated with prednisone, and 15 normal women. The prednisone-treated group had higher mean plasma levels of triglyceride [2.06 +/- 1.3 (+/- SD) vs. 1.15 +/- 0.35 and 0.95 +/- 0.46 mmol/L; P less than 0.01], low density lipoprotein cholesterol [3.41 +/- 1.4 (+/- SD) vs. 2.79 +/- 0.67 and 2.84 +/- 0.70 mmol/L; P less than 0.01], and apoB [1.16 +/- 0.35 (+/- SD) vs. 0.82 +/- 0.13 and 0.76 +/- 0.22 g/L] than the other 2 groups. Forty-three percent of the prednisone-treated group had apoB levels of 1.20 g/L or more compared to 7% of normal subjects and none of the untreated SLE group (P less than 0.05). However, of the 12 prednisone-treated patients with elevated plasma apoB levels 5 had normal plasma lipid levels. There were no differences in the postheparin lipase activities among the 3 groups. These data indicate that corticosteroid-treated patients have elevations in apoB as well as hyperlipidemia. The lipoprotein abnormalities may explain the increased risk of atherosclerosis reported in these patients.

Effect of short-term, low-dose corticosteroids on plasma lipoprotein lipids.

The effects of low-dose short-term corticosteroids on plasma lipid and lipoprotein cholesterol was measured in 23 subjects who received prednisone for active rheumatic disease. After 1 month, plasma cholesterol increased from 195 to 219 mg/dl (P less than 0.001), and high density lipoprotein cholesterol (HDL-C) from 52 to 70 mg/dl (P less than 0.001). Mean plasma triglyceride (TG) and low density lipoprotein cholesterol (LDL-C) did not show a significant change. There was a wide variation in individual response of plasma lipid values to corticosteroid treatment. There was also a strong relationship between change in plasma total cholesterol and change in LDL-C (r = 0.86) (P less than 0.001), and change in TG (r = 0.39, P less than 0.01), but not in HDL-C. Thus, short-term, low-dose corticosteroids markedly affect plasma lipid levels. In most subjects there is an increase in HDL-C; however, an increase in total cholesterol may be indicative of a change in VLDL-C and LDL-C as well.

Controlled double-blind trial of dazoxiben and nifedipine in the treatment of Raynaud's phenomenon.

The prostaglandin thromboxane A2 causes platelet aggregation and vasoconstriction and may be important in the pathogenesis of Raynaud's phenomenon. Therefore, a randomized, double-blind, placebo-controlled trial was conducted to assess the effectiveness of dazoxiben, a selective thromboxane synthetase inhibitor, in the treatment of Raynaud's phenomenon and to compare it with nifedipine, a calcium channel blocker. Twenty-two subjects who had at least one episode of Raynaud's phenomenon per day entered the study. Three patients withdrew from the study because of side effects while taking nifedipine. There was no difference among the subjects' subjective evaluation of the three treatments. Seven of 19 (44 percent) reported a moderate to marked improvement while taking placebo compared with 12 of 19 (63 percent) taking nifedipine and five of 19 (26 percent) taking dazoxiben (p = NS). Similarly, there was no difference in the mean two-week episode rate among the three treatments: placebo 30.4 +/- 4.5, nifedipine 24.7 +/- 5.6, dazoxiben 32.0 +/- 4.9 (p = NS). Twelve of 22 subjects experienced side effects while taking nifedipine as compared with two of 21 taking placebo and eight of 21 taking dazoxiben (p less than 0.005). These data show that dazoxiben is not effective in the treatment of Raynaud's phenomenon and suggest that thromboxane does not cause the vasoconstriction that characterizes this disorder.

Nifedipine in the treatment of Raynaud's phenomenon. Evidence for inhibition of platelet activation.

Platelet activation has been reported to occur in patients with Raynaud's phenomenon; however, the effect of calcium channel blockers and thromboxane synthetase inhibitors has not been previously studied. The effect of two drugs that potentially inhibit platelet activation were studied: nifedipine, a calcium channel blocker, and dazoxiben, a specific thromboxane synthetase inhibitor. Two platelet-specific proteins released during platelet activation, beta-thromboglobulin and platelet factor 4, were measured during a double-blind clinical trial of these two drugs in patients with Raynaud's phenomenon. The plasma beta-thromboglobulin level was significantly elevated in the patient population (53.8 +/- 7.6 ng/ml) during the placebo period compared with that in a normal control population (27.0 +/- 3.1 ng/ml) (p less than 0.01). The plasma platelet factor 4 level was 8.7 +/- 2.2 ng/ml in the patients compared with 6.5 +/- 1.0 ng/ml in the normal subjects (p = NS). These findings indicate the presence of in vivo platelet activation in patients with Raynaud's phenomenon. Nifedipine lowered the levels of beta-thromboglobulin to near the normal range (33.4 +/- 4.6 ng/ml). The inhibition of platelet activation by nifedipine was associated with clinical improvement in Raynaud's phenomenon with fewer and less intense episodes. Beta-thromboglobulin was not lowered by dazoxiben (58.1 +/- 9.0 ng/ml) compared with the placebo. The reduction of beta-thromboglobulin levels by nifedipine indicates that in vivo platelet activation was inhibited by this agent. Since this was associated with a reduced frequency of attacks, it is not clear whether this was a direct effect of the drug on platelet activation, leading to decreased frequency of vasospasm, or an effect on vascular smooth muscle leading to decreased vasospasm and a secondary decrease in platelet activation.

Dyslipoproteinemia in systemic lupus erythematosus. Effect of corticosteroids.

The increased incidence of atherosclerotic coronary artery disease in patients with systemic lupus erythematosus (SLE) may be due to a dyslipoproteinemia caused by corticosteroid administration. To determine whether lipoprotein lipid levels are abnormal in SLE and the relation of lipoprotein levels to corticosteroid use, lipid and apolipoprotein levels were measured in 46 female patients with SLE and 30 matched control subjects. The patients with SLE had higher levels of plasma triglyceride (134 versus 73 mg/dl; p less than 0.001), cholesterol (201 versus 168 mg/dl; p less than 0.001), and low-density lipoprotein cholesterol (121 versus 94 mg/dl; p less than 0.001) than control subjects. The levels of high-density lipoprotein cholesterol, high-density lipoprotein subfraction 3 cholesterol, and apolipoprotein Al were similar in the two groups, but high-density lipoprotein subfraction 2 cholesterol was lower in the patients with SLE (10.2 versus 18.2 mg/dl; p less than 0.001). When patients with SLE treated with prednisone (n = 32) were compared to patients with SLE not treated with prednisone (n = 14), the former had higher triglyceride (158 versus 87 mg/dl; p less than 0.001), cholesterol (214 versus 170 mg/dl; p less than 0.001), and low-density lipoprotein cholesterol (130 versus 103 mg/dl; p less than 0.001) levels. The patients with SLE not treated with prednisone had lipid levels similar to those in control subjects except that high-density lipoprotein cholesterol was lower (49.7 versus 59.0 mg/dl; p less than 0.05). The daily prednisone dosage in the treated patients with SLE correlated with levels of cholesterol (r = 0.38, p less than 0.02), high-density lipoprotein cholesterol (r = 0.40, p less than 0.02), and high-density lipoprotein subfraction 3 cholesterol (r = 0.47, p less than 0.01). Thus, female patients with SLE have a dyslipoproteinemia of the type that would place them at an increased risk for coronary artery disease. Corticosteroids, used in the treatment of SLE, seem to play a role in the pathogenesis of the observed lipoprotein abnormalities.

Absence of positional change in pulmonary diffusing capacity in systemic sclerosis.

Patients with systemic sclerosis frequently have pulmonary function abnormalities, and recent evidence suggests that pulmonary vascular involvement is a common manifestation. To test the hypothesis that patients with systemic sclerosis have impaired ability to recruit or distend the pulmonary vascular bed, the postural change in the coefficient of carbon monoxide diffusing capacity was measured in 11 patients with systemic sclerosis, and the results were compared with results from age-, smoking-, and sex-matched control subjects with rheumatoid arthritis and with results from healthy subjects. In normal subjects and patients with rheumatoid arthritis increased, the coefficient of diffusion by 9.4 percent (p less than 0.005) and 8.4 percent (p less than 0.01), respectively, when they moved from the sitting to the supine position. In contrast, patients with systemic sclerosis did not show a significant increase in coefficient of diffusion, even those who had otherwise normal pulmonary function. Regression analyses showed that the change in coefficient of diffusion decreased with increasing age (r = -0.57) in normal subjects, and that the change in coefficient of diffusion was a function of the percent predicted forced vital capacity, both in patients with systemic sclerosis (r = 0.59) and in those with rheumatoid arthritis (r = 0.70). Thus, these findings indicate that patients with systemic sclerosis have a nondistensible pulmonary capillary bed and that the absence of positional change in the coefficient of diffusion in systemic sclerosis is a subtle indicator of pulmonary involvement.

Associations of elevated interleukin-6 and C-reactive protein levels with mortality in the elderly.

PURPOSE: To investigate whether interleukin-6 and C-reactive protein levels predict all-cause and cause-specific mortality in a population-based sample of nondisabled older people. SUBJECTS AND METHODS: A sample of 1,293 healthy, nondisabled participants in the Iowa 65+ Rural Health Study was followed prospectively for a mean of 4.6 years. Plasma interleukin-6 and C-reactive protein levels were measured in specimens obtained from 1987 to 1989. RESULTS: Higher interleukin-6 levels were associated with a twofold greater risk of death [relative risk (RR) for the highest quartile (> or = 3.19 pg/mL) compared with the lowest quartile of 1.9 [95% confidence interval, CI, 1.2 to 3.1]). Higher C-reactive protein levels (> or = 2.78 mg/L) were also associated with increased risk (RR = 1.6; CI, 1.0 to 2.6). Subjects with elevation of both interleukin-6 and C-reactive protein levels were 2.6 times more likely (CI, 1.6 to 4.3) to die during follow-up than those with low levels of both measurements. Similar results were found for cardiovascular and noncardiovascular causes of death, as well as when subjects were stratified by sex, smoking status, and prior cardiovascular disease, and for both early (<2.3 years) and later follow-up. Results were independent of age, sex, body mass index, and history of smoking, diabetes, and cardiovascular disease, as well as known indicators of inflammation including fibrinogen and albumin levels and white blood cell count. CONCLUSIONS: Higher circulating levels of interleukin-6 and C-reactive protein were associated with mortality in this population-based sample of healthy older persons. These measures may be useful for identification of high-risk subgroups for anti-inflammatory interventions.

Relationship between corticosteroid exposure and plasma lipid levels in heart transplant recipients.

PURPOSE: Accelerated coronary atherosclerosis is a major cause of heart graft failure two years and more after heart transplantation, yet its etiology remains undetermined. We conducted this study to determine the prevalence of coronary risk-associated lipid abnormalities, and the relationship between lipid levels and exposure to corticosteroids and cyclosporine, in heart transplant recipients. PATIENTS AND METHODS: The records of 92 consecutive heart transplant recipients from three different transplantation centers were reviewed. Patients from the three centers varied in age, in corticosteroid regimens, and in the proportion undergoing transplantation for ischemic cardiomyopathy. Although 11 patients were not receiving corticosteroids at the time of the study, all patients had received them immediately after transplantation. In addition to information pertaining to demographics, pretransplant medical history, rejection episodes, drug doses, renal function, and blood glucose levels, data on dietary intake and body weight were collected and plasma lipid levels were measured at the time of record review. RESULTS: A significant number, 48 (52 percent), of heart transplant recipients were above the sex- and age-adjusted 75th percentile, and 35 (38 percent) were above the 90th percentile for total cholesterol in comparison with a general reference population. Similar elevations were found in low-density lipoprotein cholesterol, triglyceride, and high-density lipoprotein cholesterol levels. Bivariate analysis demonstrated cumulative prednisone exposure (r = 0.40, p = 0.0001) and cumulative cyclosporine exposure (r = 0.22, p = 0.04) but not diet or etiology of pretransplant heart disease to be significantly associated with age- or sex-adjusted total cholesterol percentiles. Low-density lipoprotein cholesterol percentiles were also correlated with cumulative prednisone (r = 0.37, p = 0.001) and cumulative cyclosporine exposure (r = 0.24, p = 0.02). Stepwise multiple linear regression analysis, however, demonstrated cumulative prednisone exposure to be the strongest predictor of both total and low-density lipoprotein cholesterol levels and percentiles (p = 0.0001), independent of cumulative cyclosporine exposure and other clinical variables. CONCLUSION: These data suggest that long-term corticosteroid exposure may result in an increased prevalence of unfavorable lipid profiles in heart transplant recipients.

Trial of Nonpharmacologic Intervention in the Elderly (TONE). Design and rationale of a blood pressure control trial.

National and international policy-making organizations advocate nonpharmacologic therapies to reduce blood pressure (BP). However, data to support such recommendations in older persons are virtually nonexistent. The Trials of Nonpharmacologic Intervention in the Elderly (TONE) is a randomized, controlled trial that will test whether weight loss or a reduced sodium (Na) intake or both can maintain satisfactory BP control, without unacceptable side effects, after withdrawal of antihypertensive drug therapy. Medication-treated hypertensives (aged 60 to 80 years) with a systolic BP less than 145 mm Hg and a diastolic BP less than 85 mm Hg who are taking one antihypertensive medication are randomly assigned to one of four groups: (1) weight loss alone, (2) reduced Na intake alone, (3) combined weight loss and reduced Na intake, or (4) usual life-style (control group). Overweight participants are randomized to one of these four groups, while nonoverweight individuals are assigned to either the reduced Na intake or the usual life-style group. The interventions, tailored to the needs of older persons, use behavioral approaches to accomplish intervention-specific goals (weight loss > or = 10 lb, daily Na intake < or = 80 mEqa). Three months after the start of intervention, antihypertensive drug therapy is withdrawn. The primary trial end point is a BP of 150/90 mm Hg or higher, resumption of antihypertensive drug therapy, or the occurrence of a BP-related clinical complication during 2 to 3 years of follow-up. It is anticipated that TONE findings may identify an effective and acceptable nonpharmacologic approach to control hypertension in the increasingly large number of older persons treated with antihypertensive drug therapy.

Obesity and osteoarthritis of the knee: evidence from the National Health and Nutrition Examination Survey (NHANES I).

The importance of systemic/metabolic factors in the association of obesity with radiographic knee osteoarthritis (OA) was examined for 3,905 adults aged 45 to 74 from the United States National Health and Nutrition Examination Survey, 1971 to 1975 (NHANES I). Obesity was associated with both bilateral and unilateral OA, but more strongly with bilateral OA. Obesity was also associated with both symptomatic and nonsymptomatic knee OA. Controlling for age, sex, serum cholesterol, serum uric acid, diabetes, body fat distribution, bone density, and blood pressure did not significantly reduce the association between obesity and knee OA. Findings from these data are not supportive of a metabolic link between obesity and knee OA.

Physical disability in older adults: a physiological approach. Cardiovascular Health Study Research Group.

Measures of physical function have been developed primarily to assess health status, prognosis, and service needs. They are now, increasingly, being used as outcome measures in studies seeking to determine the causes of disability. However, the extent to which these standardized measures, as they currently are constituted, are meaningful for the evaluation of underlying pathophysiology is not defined. To assess evidence for an etiologic rationale for these measures, we evaluated self-report of difficulty in physical function in the Cardiovascular Health Study, a study of 5201 men and women 65 years and older in four U.S. communities. We determined (by factor analysis) that self-reported difficulty with each of 17 tasks of daily life aggregates in four groups; i.e. difficulty in one task is associated with having difficulty in the other tasks in the group. These groups include (1) activities primarily dependent on mobility and exercise tolerance; (2) complex activities heavily dependent on cognition and sensory input; (3) selected basic self-care activities; and (4) upper extremity activities. Groups 2 and 3 are similar, but not identical, to Instrumental Activities of Daily Living (IADL) and Activities of Daily Living (ADL), respectively. We then tested whether these groupings were associated with different underlying impairments. Multiple logistic regression analyses indicate that there are constellations of physiologic and disease characteristics significantly (p < 0.01) associated with difficulty in each of these four groups of activities, among 15 chronic diseases and conditions ascertained. Some diseases are uniquely associated with difficulty in one group of tasks; some overlap, and are associated with 2, 3 or 4 groups of tasks. The associations found with difficulty in performing tasks in groups 2 and 3 were frequently stronger than those with the larger groups of ADL or IADL tasks, suggesting increased specificity of associations found with these new groupings. These results suggest that re-grouping of tasks of daily life may provide a more refined physiologically-based outcome measure for use in evaluating causes of disability. The ability to define risk factors for disability may be enhanced by choosing outcome measures with a demonstrated physiologic rationale.

Long-term physical functioning in persons with knee osteoarthritis from NHANES. I: Effects of comorbid medical conditions.

This study examined the effects of comorbid medical conditions (heart disease, pulmonary disease, hypertension and obesity) on the association of radiographic knee osteoarthritis (OA) with long-term difficulty in physical function. Data are from the National Health and Nutrition Examination Survey, 1971-1975 (NHANES I), a prospective epidemiologic cohort study, and the NHANES Epidemiologic Follow-up Study, 1982-1984 (NHEFS) and included 4059 persons who were 45-74 years old and participated in the detailed examination component of NHANES I. Knee OA was ascertained by anterior-posterior bilateral radiographs of the knee and self-report of knee pain, heart and pulmonary disease by self report of disease or symptoms, and hypertension and obesity by blood pressure and weight measurements. The presence of symptomatic knee OA at NHANES I was associated with reported difficulty at NHEFS 1982-84 in functions which used the lower extremity (ambulation and transfer). The presence of coexistent chronic conditions, particularly heart disease, pulmonary disease and obesity, increased the likelihood of subsequent disability. These findings suggest that knee OA is associated with long-term physical disability, and that the presence of coexistent chronic disease may increase the amount of long-term disability from knee OA.

The low cholesterol-mortality association in a national cohort.

The relationship of low serum cholesterol and mortality was examined in data from the NHANES I Epidemiologic Followup Study (NHEFS) for 10,295 persons aged 35-74, 5833 women with 1281 deaths and 4462 men with 1748 deaths (mean (followup = 14.1 years). Serum cholesterol below 4.1 mmol/l was associated with increased risk of death in comparison with serum cholesterol of 4.1-5.1 mmol/l (relative risk (RR) for women = 1.7, 95% confidence interval (CI) = (1.2, 2.3); for men RR = 1.4, CI = (1.1, 1.7)). However, the low serum cholesterol-mortality relationship was modified by time, age, and among older persons, activity level. The low serum cholesterol-mortality association was strongest in the first 10 years of followup. Moreover, this relationship occurred primarily among older persons (RR for low serum cholesterol for women 35-59 = 1.0 (0.6, 1.8), for women 70-74, RR = 2.1 (1.2, 3.7); RR for low serum cholesterol for men 35-59 = 1.2 (0.8, 2.0), for men 70-74, RR = 1.9 (1.3, 2.7)). Among older persons, however, the low serum cholesterol-mortality association was confined only to those with low activity at baseline. Factors related to underlying health status, rather than a mortality-enhancing effect of low cholesterol, likely accounts for the excess risk of death among persons with low cholesterol. The observed low cholesterol-mortality association therefore should not discourage public health programs directed at lowering serum cholesterol.

Consumer-perceived value: the key to a successful business strategy in the healthcare marketplace.

The Medicare market is becoming increasingly competitive and uncertain. To compete successfully for a share of the Medicare market, providers must: Have a cogent strategy that defines their customers and the value proposition for those customers Design their services to maximize the benefits of outcomes and service process that are important to consumers Determine the needed structure and infrastructure to put those services in place Marketing research is critical in this regard, as is effectiveness tracking. This approach is different from that usually taken by healthcare providers in the marketplace. It means being strategic rather than tactical and proactive rather than reactive. Most importantly, providers must shift their focus externally to the consumer's needs rather than their own. Finally, this approach requires working together in an integrated organization with common goals.

A study of the characteristics of the dementia patients and caregivers in dementia-nonspecific adult day care programs.

OBJECTIVE: To determine if basic differences exist between the patients and caregivers of a representative group of dementia-nonspecific medical versus social adult day care centers with specific programs for dementia patients. DESIGN: A telephone interview questionnaire survey. SETTING: North Central North Carolina. PARTICIPANTS: A total of 242 adult day care dementia patients and caregivers from three medical and three social nondementia-specific adult day care centers. MEASUREMENTS: Dementia patient variables: Day care subtype (medical or social); length of stay; number of days attended; age; sex; race; educational level; marital status; religious affiliation; income; living status; number of medical conditions; number of prescription medications; function; ADL status (walking, eating, bathing, dressing, grooming, toileting); continence status; number and type of abnormal behaviors; formal help status (hospitalization during day care, part or full-time nursing home attendance, or home healthcare assistance); transportation; and financial assistance. Caregiver variables: day care subtype; age; sex; race; educational level; marital status; religious affiliation; income; number of medical conditions; number of prescription medications; informal help (family friends or other non-paid help); paid help (friend, other, home health, or nursing home); relationship to patient; employment status; and level of caregiver burden. MAIN RESULTS: There were 144 medical and 62 social adult day care dementia patients and caregivers who agreed to participate. The average age of the patient was 77.9 years (SD +/- 8.4), and that of the caregiver was 57.7 years (SD +/- 13.9); 68.4% of the patients and 75.4% of the caregivers were females. Dementia patients in the medical subtype day care had a shorter length of stay than social day care patients; this did not reach statistical significance. There were significantly more white patients and caregivers in the medical than in the social subtype day care, 83.1% versus 50% and 83.3% versus 50.8%, respectively. Dementia patients of the medical subtype also had significantly more education, income, less function, and more symptoms of depression than dementia patients in the social subtype. Dementia patients of the medical subtype also had more abnormal psychological behaviors than their social subtype counterparts, with borderline significance (P = .071). There were more married caregivers in the medical subtype than in the social subtype day care. Caregivers of dementia patients in the medical subtype had significantly more paid help and caregiver burden than did caregivers of dementia patients in the social subtype. CONCLUSIONS: In this study, there appear to be key differences between the dementia patients and caregivers of medical versus social adult day care centers as to demographic and health-related variables. The differences in demographic variables appear to be associated with socioeconomic factors, whereas the decreased function and greater number of depressive symptoms of the medical dementia patients may reflect poorer health as reflected by the greater amount of paid help and increased caregiver burden experienced by the caregivers of medical dementia patients. These findings should be verified in prospective studies.

Characteristics and outcomes of hospitalized older patients who develop hypocholesterolemia.

OBJECTIVES: This research project was undertaken to determine the clinical characteristics, lipoprotein abnormalities, and outcomes of older hospitalized patients who develop hypocholesterolemia. METHODS: The project had two parts: (1) a retrospective, case-control study of 50 hospitalized patients greater than or equal to 65 years old whose serum cholesterol was normal on admission (greater than or equal to 160 mg/dL) and fell to less than or equal to 120 mg/dL during hospitalization; (2) a laboratory study of lipoproteins in 17 hospitalized patients greater than or equal to 65 years old whose cholesterol was normal on admission but fell to less than or equal to 120 mg/dL during hospitalization. RESULTS: Case-control Study--Nine percent of patients greater than or equal to 65 years old developed hypocholesterolemia while in the hospital, and these patients were more likely than controls to have undergone surgery and to have nothing by mouth for 5 days or longer. Cases had a longer length of stay, more complications, and were slightly more likely to die in the hospital than controls. LABORATORY STUDY--Hypocholesterolemic patients had low concentrations of all lipoproteins (VLDL, LDL, HDL), and the LDL and HDL were enriched in triglyceride and depleted of cholesterol ester. CONCLUSION: Acquired hypocholesterolemia is a common finding in hospitalized older patients and is associated with poor outcomes. Patients who became hypocholesterolemic in the hospital had both a low concentration of lipoprotein particles and abnormalities in lipoprotein particle composition.