Illicit drug use and cardiometabolic disease risk: an analysis of 2005-2008 National Health and Nutrition Examination Survey data.

PURPOSE: To explore the association between illicit drug use (IDU) and cardiometabolic disease risk factors (CDRF) in a nationally representative sample of adults. METHODS: The 2005-2008 National Health and Nutrition Examination Surveys data from 20- to 45-year-old adults (n = 8738) were utilised to analyze the relationship between IDU (ever used, repeated use and current use) and CDRF (hyperlipidemia, hyperinsulinemia, hypertension, elevated C-reactive protein, body mass index, waist circumference and cigarette use) via chi square and logistic regression analyses. Age, gender, race/ethnicity, education level, poverty to income ratio (PIR), and alcohol use were included as confounders in the models. RESULTS: Individuals who reported drug use (DU) at least once in lifetime were more likely to have CDRF than non-DU (NDU) (OR = 1.3, p = 0.004). Females with DU, IDU at least once in lifetime, and with repeated IDU were about 1.5 times more likely than their NDU counterparts to have CDRF (p < 0.0001, p = 0.02, p = 0.02, respectively). CONCLUSION: Results from this study suggest that healthcare professionals should be aware that patients with a history of DU may be at heightened risk for cardiometabolic disease. Females in particular have a heightened cluster of CDRF across drug-use categories.

Associations of age, gender and body mass with 1H MR-observed brain metabolites and tissue distributions.

Recent reports have indicated that a measure of adiposity, the body mass index (BMI), is associated with MR-observed brain metabolite concentrations and tissue volume measures. In addition to indicating possible associations between brain metabolism, BMI and cognitive function, the inclusion of BMI as an additional subject selection criterion could potentially improve the detection of metabolic and structural differences between subjects and study groups. In this study, a retrospective analysis of 140 volumetric MRSI datasets was carried out to investigate the value of including BMI in the subject selection relative to age and gender. The findings replicate earlier reports of strong associations of N-acetylaspartate, creatine, choline and gray matter with age and gender, with additional observations of slightly increased spectral linewidth with age and in female relative to male subjects. Associations of metabolite levels, linewidth and gray matter volume with BMI were also observed, although only in some regions. Using voxel-based analyses, it was also observed that the patterns of the relative changes of metabolites with BMI matched those of linewidth with BMI or weight, and that residual magnetic field inhomogeneity and measures of spectral quality were influenced by body weight. It is concluded that, although associations of metabolite levels and tissue distributions with BMI occur, these may be attributable to issues associated with data acquisition and analysis; however, an organic origin for these findings cannot be specifically excluded. There is, however, sufficient evidence to warrant the inclusion of body weight as a subject selection parameter, secondary to age, and as a factor in data analysis for MRS studies of some brain regions.

Aerobic training does not alter CRP in apparently healthy, untrained men.

AIM: Regular aerobic exercise may reduce cardiovascular disease (CVD) risk by lowering the concentration of inflammatory markers, such as C-reactive protein (CRP). While studies in diseased populations have shown significant decreases in CRP concentrations with regular aerobic training, little has been conclusively determined regarding the effects of aerobic training on CRP concentrations in apparently healthy, untrained populations. Aim of the study was to examine the effects of a 17-wk half marathon training program (TP) on CRP concentrations, aerobic fitness, and body composition in apparently healthy, untrained men. METHODS: Twenty men (29.3±1.0 y) enrolled as training subjects (TRN) in a 17-wk half marathon TP. An additional 22 men (27.8±1.4 y) served as controls (CON). Fasting blood samples were taken at four time points over the TP and were analyzed for CRP and interleukin-6 (IL-6) concentrations. Aerobic capacity (VO2max) and body fat percent (BF%) were measured before and after the TP. RESULTS: No significant post-training changes in CRP (P=0.70) or IL-6 concentrations (P=0.67) were seen in TRN as a result of the TP, despite significant improvements in VO2max (42.2±1.9 ml∙kg-1∙min⁻¹, P<0.0001) and significant reductions in resting heart rate (P=0.004), BF% (P=0.03), and body mass index (BMI, P=0.05). No significant changes in CRP, VO2max, BMI, or BF% were detected in CON over time. CONCLUSION: Regular aerobic training does not appear to affect CRP concentrations in apparently healthy, untrained men despite significant improvements in bodyweight, BF%, BMI, and VO2max.

Tricuspid valve surgery and intraoperative echocardiography: factors affecting survival, clinical outcome, and echocardiographic success.

BACKGROUND: The impact of echocardiographic-guided treatment on outcome after tricuspid valve (TV) surgery is not well defined. OBJECTIVES: The purpose of this study was to determine clinical and echocardiographic factors associated with adverse outcomes after TV surgery and determine the role of intraoperative echo (IOE) in facilitating successful outcomes after TV surgery. METHODS: Four hundred and one patients (279 females, mean age 60 years) underwent TV surgery and other concomitant cardiac surgery at a single institution and were followed clinically and by echocardiography during a 10-year period. RESULTS: Decreased survival after TV surgery was associated with: preoperative increased New York Heart Association (NYHA) functional classification (relative risk [RR]=2.02), increased left ventricular dysfunction by echocardiography (RR=1.28), and use of a TV replacement strategy (RR=2.92). Decreased event-free survival after TV surgery was associated with concomitant coronary artery bypass grafting (RR=2.97). Late echocardiographic failure (3 to 4+ tricuspid valve regurgitation [TR]) after TV surgery was associated with increased severity of TR on preoperative echocardiogram (odds ratio [OR]=1.91). Decreased late echocardiographic failure after TV surgery was associated with the use of a TV annuloplasty ring with a repair strategy (OR=0.40). The surgical plan was altered at the time of surgery to insure a successful outcome in 32 (10%) of 335 patients based on IOE findings. CONCLUSIONS: Adverse outcomes after TV surgery can be predicted by several preoperative clinical and echocardiographic variables. IOE is useful in improving immediate, but not late, outcomes after TV surgery.

Atrial fibrillation early postoperatively following minimally invasive cardiac valvular surgery.

We report a cohort of our first 100 minimally invasive cardiac valvular operations matched 1:1 by age and valvular surgery type with patients undergoing a traditional midline sternotomy approach. The prevalence of postoperative atrial fibrillation among patients with minimally invasive procedures versus traditional midline sternotomy was 26.3% versus 38.0%, respectively (p = 0.08). Neither multiple logistic regression nor Kaplan-Meier distribution analysis identified differences in postoperative atrial fibrillation between the 2 surgical techniques.

Comparison of mortality rates and progression of left ventricular dysfunction in patients with idiopathic dilated cardiomyopathy and dilated versus nondilated right ventricular cavities.

This study assesses the influence of right ventricular (RV) dilation on the progression of left ventricular (LV) dysfunction and survival in patients with idiopathic dilated cardiomyopathy (IDC). Using transthoracic echocardiography, we studied 100 patients with IDC aged 20 to 80 years (mean 55 +/- 14); 67% were men. In the apical 4-chamber view, diastolic LV and RV chamber area measurements classified patients into 2 groups: group RV enlargement+ (RV area/LV area > 0.5) included 54 patients; group RV enlargement- (no RV enlargement) had RV area/LV area < or = 0.5. Echocardiographic studies were repeated in all patients after a mean of 33 +/- 16 months. At the time of the initial study, the 2 groups did not differ in age, gender, incidence of atrial fibrillation and diabetes, left ventricular mass, and LV ejection fraction, but the RV enlargement+ group had more severe tricuspid regurgitation and less LV enlargement. After 47 +/- 22 months (range 12 to 96), patients in group RV enlargement+ had lower LV ejection fraction (29% vs 34%, p = 0.006) than patients with initial RV enlargement-. At clinical follow-up, mortality was higher (43%) in patients with initial RV enlargement+ than the RV enlargement- patients (15%), p = 0.002. For survivors, the mitral deceleration time averaged 157 +/- 36 ms; for nonsurvivors or patients who required transplant, the mitral deceleration time averaged 97 +/- 12 ms (p < 0.0001). With use of a multivariate Cox model adjusting for LV ejection fraction, LV size, and age, the relative risk ratio of mortality from initial RV enlargement+ was 4.4 (95% confidence limits 1.7 to 11.1) (p = 0.002). Thus, patients with significant RV dilation had nearly triple the mortality over 4 years and more rapidly deteriorating LV function than patients with less initial RV dilation. In IDC, RV enlargement is a strong marker for adverse prognosis that may represent a different morphologic subset.

Absence of increased in-hospital complications with reused balloon catheters.

A reanalysis of data from a prospective Canadian study suggests that catheter reuse is not associated with an increased rate of in-hospital complications. However, these results should be replicated in clinical trials before catheter reuse becomes routinely established.

A placebo-controlled trial of nadolol in the treatment of neuroleptic-induced akathisia.

BACKGROUND: Although propranolol has been documented to be useful in treatment of neuroleptic-induced akathisia, preliminary anecdotal reports on the efficacy of nadolol in treatment of this condition are contradictory. METHOD: To evaluate the efficacy of nadolol in treatment of this condition, a double-blind, placebo-controlled trial was conducted in 20 psychiatric inpatients. Patients with akathisia of at least moderate severity were randomly assigned to receive nadolol 40 to 80 mg/day or placebo. Patients were rated daily for 4 days, then every other day for 15 days by means of the Extrapyramidal Symptom Rating Scale. RESULTS: No significant differences were found between or within groups in subjective restlessness scores. In objective akathisia scores, there were no significant differences between groups; however, beginning at Day 9, both groups showed significant improvement compared with Day 1. There was no difference between groups in number of responders. CONCLUSIONS: The authors' data do not support the efficacy of nadolol in the treatment of neuroleptic-induced akathisia and do not provide support for a peripheral site of action for beta-blockers in treatment of this condition.

Efficacy of depot leuprolide in premenstrual syndrome: effect of symptom severity and type in a controlled trial.

OBJECTIVE: To determine whether depot leuprolide is effective in premenstrual syndrome (PMS) and whether symptom type or severity affects therapeutic or hormonal responses and the incidence of adverse events. METHODS: Twenty-five women who met strict diagnostic criteria for PMS completed a double-blind, placebo-controlled, 6-month crossover trial at a university medical center. Depot leuprolide (3.75 mg/month) or saline was administered intramuscularly for three consecutive treatment cycles. Efficacy, adverse events, and hormone concentrations were assessed at each visit. Repeated-measures analysis of variance was used to analyze continuous data, and ordinal and binary data were analyzed using nonparametric techniques. RESULTS: Depot leuprolide treatment was significantly more effective than placebo on all rating scales. Irritability, neurologic symptoms, breast tenderness, and fatigue were most responsive to treatment. Symptoms were reduced to follicular phase levels only in women without premenstrual depression. Those with moderate premenstrual depression improved but remained clinically symptomatic, whereas the group with severe premenstrual depression showed no improvement on any efficacy measure. Adverse events were lowest in those without premenstrual depression and highest in those with severe depression. Leuprolide suppressed estradiol and progesterone in most premenstrual depression groups but had varying effects on gonadotropins. CONCLUSIONS: Leuprolide treatment reduced both behavioral and physical symptoms and was well tolerated in the absence of severe premenstrual depression. Women should be evaluated for depression severity before receiving a GnRH agonist. The differential response to leuprolide suggests that it may possess diagnostic value in determining distinct subtypes of PMS.

Early and late intraventricular hemorrhage: the role of obstetric factors.

OBJECTIVE: To evaluate the influence of active phase labor and other obstetric factors on the development of periventricular-intraventricular hemorrhage in the neonate. METHODS: A total of 230 infants were studied. Antenatal enrollment was carried out when estimated fetal weight was 1750 g or less. Serial head ultrasound scans were performed to screen for periventricular-intraventricular hemorrhage, with the initial scan performed within minutes of birth. Scan findings and obstetric and neonatal variables collected prospectively at scheduled intervals were analyzed to determine the significant factors that predispose to intraventricular hemorrhage. RESULTS: In 47 infants (20%), intraventricular hemorrhage was detected within 1 hour of birth (early) and in another 49 (21%) at a later age (late). The overall incidence of hemorrhage was similar between vaginal and cesarean deliveries (41 and 44%, respectively). Early hemorrhage was more frequent in vaginal (28%) than cesarean deliveries (11%), whereas late hemorrhage was more frequent in cesarean deliveries. When the role of delivery mode and labor was analyzed by stepwise logistic regression, the odds ratios for development of early intraventricular hemorrhage increased in the following order: cesarean delivery with no labor, cesarean delivery with latent phase labor, vaginal delivery with forceps use, cesarean delivery with active phase labor, and vaginal delivery without forceps use. For late hemorrhage, the odds ratios increased in the following order: vaginal delivery with forceps, vaginal delivery without forceps, cesarean delivery with no labor, cesarean delivery with latent phase labor, and cesarean delivery with active phase labor. CONCLUSIONS: Active phase labor may predispose to early periventricular-intraventricular hemorrhage, but its influence may be attenuated by use of forceps or by abdominal delivery. The protective effect of forceps remains for late periventricular-intraventricular hemorrhage, but abdominal delivery does not seem to protect against late hemorrhage.

Aortic valve replacement for octogenarians: are small valves bad?

BACKGROUND: As the population ages, more octogenarians become candidates for aortic valve replacement. Many octogenarians, particularly women, have a small aortic annulus and there is uncertainty as to the optimal management of this situation in that age group. METHOD: To examine this issue, we reviewed 248 octogenarians (mean age, 82.6 +/- 2.3 years; 58% men) who underwent primary isolated aortic valve replacement (n = 99), or aortic valve replacement and coronary revascularization (n = 149), between 1980 and 1995. Nineteen-millimeter valves were used in 26% of the patients. RESULTS: In-hospital mortality was 8.9%, 5% for aortic valve replacement alone and 11.4% for aortic valve replacement and coronary revascularization. It was 12.5% for the 19-mm size valves compared with 7.7% for the bigger size valves (p = 0.24). Follow-up (mean interval, 4.4 years) demonstrated survival for all patients of 85%, 60%, and 30% and survival free from cardiovascular events of 80%, 45%, and 21% at 1, 5, and 10 postoperative years, respectively. Multivariate analysis identified triple-vessel disease and preoperative congestive heart failure as associated with increased risk for both in-hospital and late mortality (p < 0.05). Valve size did not influence late survival or event-free survival regardless of body surface area. CONCLUSIONS: The use of small aortic valve prostheses in octogenarians does not adversely affect the incidence of early or late mortality or cardiac events.

The fate of homograft conduits in children with congenital heart disease: an angiographic study.

The use of homograft conduits in the repair of congenital heart disease is widely accepted. We reviewed the catheterization and angiographic data from 20 patients with homograft conduits. All conduits were to the pulmonary arteries. The age at operation was 4.7 +/- 5.6 years (mean +/- standard deviation) and at follow-up catheterization, 7.8 +/- 6.7 years. At implantation, conduit cross-sectional area and Z value were 219 +/- 96 mm2 and 3.5 +/- 1.8, respectively. At subsequent catheterization, the conduit diameters were measured in two projections at the shaft, annulus, valve opening, and insertion into the pulmonary artery. The transconduit gradient was 47 +/- 26 mm Hg. The cross-sectional areas were 149 +/- 56 mm2 at the shaft, 151 +/- 92 mm2 at the annulus, 108 +/- 116 mm2 at the valve opening, and 127 +/- 84 mm2 at the pulmonary artery insertion. The Z values were -0.9 +/- 2.5, -0.9 +/- 2.8, -3.8 +/- 4.0, and -2.0 +/- 3.4, respectively. The cross-sectional areas and the Z values at the levels of measurement were significantly smaller than the corresponding values at implantation. The change in cross-sectional areas and Z values exceeded what would be expected from growth alone. These data indicate that there is a decrease, with time, in the functional lumen of homograft conduits, and this may have implications for follow-up strategy after implantation.

Single serum progesterone as a screen for ectopic pregnancy: exchanging specificity and sensitivity to obtain optimal test performance.

OBJECTIVE: To investigate the diagnostic accuracy of screening serum P in diagnosis of ectopic pregnancy (EP) and to identify a cutoff value that provides the best compromise between test sensitivity and specificity. DESIGN: Retrospective analysis. SETTING: University hospital. INTERVENTIONS: Observation only. PATIENTS: First trimester pregnant women at risk for EP. MAIN OUTCOME MEASURE: Single P measurements were obtained from 3,674 pregnancies with outcomes defined as EP, viable intrauterine pregnancy (IUP), and spontaneous abortion (SAB). Diagnostic accuracy of the test was analyzed by generating receiver operating characteristic (ROC) curves, which quantify the ability of the test to distinguish EP and SAB from IUP. RESULTS: Diagnostic accuracy for EP versus IUP was 88.7% +/- 0.1% (mean +/- SEM); for SAB versus IUP, 93.8% +/- 0.4%; and for SAB + EP versus IUP, 92.8% +/- 0.4%. Diagnostic accuracy for SAB versus EP was only 39.4% +/- 0.2%. In the interval of 15.0 to 19.9 ng/mL (47.7 to 63.3 nmol/L), P missed 5.3% of the EPs and incorrectly included 84.3% of the viable IUPs; in the interval of 20.0 to 24.9 ng/mL (63.6 to 79.2 nmol/L), sensitivity improved in that only 3.5% of the EPs were missed but 88.8% of viable IUPs were included incorrectly. A cutoff value of > or = 17.5 ng/mL (55.7 nmol/L), the median point of the 15.0 to 19.9 ng/mL (47.7 to 63.3 nmol/L) interval, missed only 35 of 423 (8.3%) total EPs in the study. CONCLUSION: Analysis of ROC curves demonstrates that single serum P has high diagnostic accuracy for differentiating accidents of pregnancy (SAB and EP) from viable IUP, both individually (SAB versus IUP and EP versus IUP) and collectively (SAB + EP versus IUP); it cannot efficiently discriminate SAB versus EP. We conclude that for P > or = 17.5 ng/mL (55.7 nmol/L), patients thought to be at risk for EP may be followed reasonably without ultrasound or further invasive diagnostic studies.

Left and right atrial transport function after the Maze procedure for atrial fibrillation: an echocardiographic Doppler follow-up study.

OBJECTIVES: We evaluated atrial transport function after the Maze procedure in long-term follow-up and compared left and right atrial function in Maze patients with that of healthy age-matched controls using echo Doppler techniques. BACKGROUND: The Maze procedure is designed to eliminate atrial fibrillation, restore normal sinus rhythm, and preserve atrial contraction. Initial data indicate that atrial transport function is restored in most patients undergoing the Maze procedure. The long-term echo Doppler evaluation of patients after the Maze procedure has not been well described. METHODS: We performed pulsed-wave Doppler and two-dimensional echocardiographic studies on 31 patients (24 men, mean age 53.8 years) who underwent the Maze procedure and who had a follow-up study greater than 3 months (mean 16.5 months) after the procedure. Measurements included peak left ventricular and right ventricular inflow A-wave velocity, maximum and minimum left atrial and right atrial areas, and fractional area change of the left and right atria. Results were compared with those obtained from 15 age-matched control subjects (11 men, mean age 53.8 years). RESULTS: Twenty-two patients (71%) had left atrial function shown by the presence of left ventricular inflow A-wave, and 25 patients (81%) had right atrial function shown by the presence of right ventricular inflow A-wave on Doppler echocardiography. The left ventricular inflow A-wave velocity was significantly lower than that of age-matched controls (37.5 +/- 15.5 versus 61.0 +/- 13.9 cm/sec; p < 0.001), whereas the right ventricular inflow A-wave velocity did not significantly differ between patients and control subjects (35.4 +/- 9.9 versus 35.3 +/- 4.9 cm/sec; p = Not significant). Although left and right atrial areas decreased significantly after the procedure, there was no significant change in the fractional area change which was smaller in Maze patients than control individuals. CONCLUSIONS: (1) In long-term follow-up of 16.5 months after the Maze procedure, left atrial systolic function was preserved in 71% of our patients and right atrial systolic function was preserved in 81%; (2) the left ventricular inflow peak A-wave velocity after Maze is considerably less than that in age-matched controls; and (3) left and right atrial sizes decreased after the procedure with no change in the fractional area change. These findings suggest that the Maze procedure is effective in restoring atrial function in the majority of patients; however, restored function is less than in control individuals.

Antibiotic therapy for preterm premature rupture of the membranes.

Amniotic fluid studies and placental histopathological evaluation have confirmed the association between intrauterine infection and preterm premature rupture of the membranes (pPROM). This association is increasingly strong with pPROM at early gestational ages. The organisms associated with pPROM include a broad spectrum of aerobic and anaerobic gram-positive and gram-negative bacteria. In many cases, the patient presenting with pPROM will have overt intrauterine infection necessitating delivery. For those amenable to expectant management, the clinical course is usually of brief latency between membrane rupture and delivery. A number of well-designed prospective clinical trials have evaluated the utility of antibiotic treatment during the expectant management of pPROM. Taken together, these studies suggest broad spectrum antibiotic treatment of this population to enhance pregnancy prolongation, and to reduce maternal and neonatal infectious morbidity. There are some data suggesting the potential for a reduction in neonatal gestational age-dependent morbidity. We recommend aggressive adjunctive antibiotic treatment to prolong pregnancy and reduce morbidity in patients with pPROM, at gestations remote from term, when a significant improvement in neonatal outcome can anticipated with expectant management.

Similarities and differences on five inventories among mood and anxiety disorder patients.

The Eysenck Personality Questionnaire (EPQ), BAROMAS, Leisure Interests Checklist (LIC), Mental Health Inventory (MHI) and a one-page checklist of Body Problems were given to 128 outpatients with serious mood or anxiety disorders. Compared to normative data published on the first four devices, the combined patients were far 'sicker' in nearly all comparisons (P less than or equal to 0.01). However, anxiety and mood patients did not differ on the EPQ, BAROMAS, or LIC. On Body Problems, strong contrasts emerged (P less than 0.04), especially when 'fringe' cases were excluded (e.g. dysthymics from mood, and obsessives from anxiety disorder diagnoses). Small anxiety subtype groups also differed (P less than 0.05). On the MHI, both global and core groups of mood--especially unipolar (depressed)--patients differed from the anxiety disorders (P less than 0.04).

The "differential diagnosis" for multiple diseases: comparison with the binary-truth state experiment in two empirical studies.

RATIONALE AND OBJECTIVES: In practice readers must often choose between multiple diagnoses. For assessing reader accuracy in these settings. Obuchowski et al have proposed the "differential diagnosis" method, which derives all pairwise estimates of accuracy for the various diagnoses, along with summary measures of accuracy. The current study assessed the correspondence between the differential diagnosis method and conventional binary-truth state experiments. MATERIALS AND METHODS: Two empirical studies were conducted at two institutions with different readers and diagnostic tests. Readers used the differential diagnosis format to interpret a set of cases. In subsequent readings they interpreted the cases in binary-truth state experiments. Spearman rank correlation coefficients and the percentages of agreement in scores were computed, and the areas under the receiver operating characteristic curves were estimated and compared. RESULTS: The between-format Spearman rank correlation coefficients were 0.697-0.718 and 0.750-0.780 for the two studies; the between-reader correlations were 0.417 and 0.792, respectively. The percentages of agreement between formats for the two studies were 50.0%-51.7% and 72.9%-78.8%; the percentages of agreement between readers were 45.0% and 80%, respectively. In the first study there were several significant differences in the areas under receiver operating characteristic curves; in the second study these differences were small. CONCLUSION: The differences observed between the two formats can be attributed to within-reader variability and inherent differences in the questions posed to readers in the multiple-diagnoses versus binary-truth state reading sessions. The differential diagnosis format is useful for estimating accuracy when there are multiple possible diagnoses.

Telephone medicine in a southern university private practice.

Routine, office-hour, patient-directed telephone calls to a general and multi-specialty-university, private-practice clinic were surveyed. The calls were short, averaging 1 to 2 minutes. Two-thirds of the calls concerned medications, and 13% were for new medical problems. Patients called with a variety of chronic conditions and less commonly for new problems. Medications such as antihypertensives, antibiotics, and diuretics were prescribed and refilled. The role of telephone medicine in providing access in some managed-care settings is yet to be studied.

Current physician screening and treatment of hypercholesterolemic patients.

To determine resident physician recognition and treatment of hypercholesterolemia, a retrospective chart audit was performed on 300 systematically selected patients seen in an internal medicine resident's continuity care clinic during the spring of 1992. A self-administered resident survey was given after completion of chart selection. Of the 300 patients, 64 (21%) did not have a cholesterol reading on the chart. The frequency of screening was unaffected by cardiac risk factors, patient race or sex, or resident level of training or specialty. Of the 96 patients who had a total cholesterol greater than 240 mg/dL documented in the chart, 48% received diet therapy, 46% received other nonpharmacologic therapy, 24% received drug therapy, 4% were referred to a lipidologist, and 30% received no treatment. Fasting lipid profiles were ordered for 57% of these patients. The frequency of therapy was unaffected by patient race or sex, resident level of training or specialty, or presence of two or more cardiac risk factors, although patients with a diagnosis of hypercholesterolemia and patients younger than age 65 were treated significantly more often. Resident action primarily involved evaluation rather than therapy. Efforts to improve the aggressiveness of treatment for hypercholesterolemia by resident physicians are necessary.

Comprehensive long-term management program for asthma: effect on outcomes in adult African-Americans.

To determine if a comprehensive long-term management program, emphasizing inhaled corticosteroids and patient education, would improve outcomes in adult African-American asthmatics a nonrandomized control trial with a 2-year intervention was performed in a university-based clinic. Inclusion criteria consisted of (> or = 5) emergency department (ED) visits or hospitalizations (> or = 2) during the previous 2 years. Intervention patients were volunteers; a comparable control group was identified via chart review at hospitals within the same area and time period as the intervention patients. Individualized doses of beclomethasone with a spacer, inhaled albuterol "as needed," and crisis prednisone were the primary therapies. Environmental control, peak flow monitoring, and a partnership with the patient were emphasized. Detailed patient education was an integral part of management. Control patients received usual care from local physicians. ED visits and hospitalizations for 2 years before and 2 years during the intervention period were compared. Quality of life (QOL) measurements were made at baseline and every 6 months in the intervention group. Study group (n = 21) had a significant reduction in ED visits (2.3 +/- 0.2 pre-intervention versus 0.6 +/- 0.2 post-intervention; P = 0.0001). Control group (n = 18) did not have a significant change in ED visits during the 2-year post-intervention period (2.6 +/- 0.2 pre-intervention versus 2.0 +/- 0.2 post-intervention; P = 0.11). Both groups had significant reductions in hospitalizations, but the study group had a greater reduction. Sixty-two percent of study patients had complete elimination of ED visits and hospitalizations, whereas no control patients had total elimination of the need for institutional acute care. QOL in the study patients revealed significant improvements for most parameters. A comprehensive long-term management program emphasizing inhaled corticosteroids combined with other state-of-the-art management, including intensive patient education, improves outcomes in adult African-American asthmatics.