Can asthmatic subjects dive?

Recreational diving with self-contained underwater breathing apparatus (scuba) has grown in popularity. Asthma is a common disease with a similar prevalence in divers as in the general population. Due to theoretical concern about an increased risk for pulmonary barotrauma and decompression sickness in asthmatic divers, in the past the approach to asthmatic diver candidates was very conservative, with scuba disallowed. However, experience in the field and data in the current literature do not support this dogmatic approach. In this review the theoretical risk factors of diving with asthma, the epidemiological data and the recommended approach to the asthmatic diver candidate will be described.

Carcinoid heart disease: current understanding and future directions.

Carcinoid tumors are rare and aggressive malignancies. A multitude of vasoactive agents are central to the systemic effects of these tumors. The additional burden of cardiac dysfunction heralds a steep decline in quality of life and survival. Unfortunately, by the time carcinoid syndrome surfaces clinically, the likelihood of cardiac involvement is 50%. Although medical therapies such as somatostatin analogues may provide some symptom relief, they offer no mortality benefit. On the other hand, referral to surgery following early detection has shown increased survival. The prompt recognition of this disease is therefore of the utmost importance.

Diving medicine.

Exposure to the undersea environment has unique effects on normal physiology and can result in unique disorders that require an understanding of the effects of pressure and inert gas supersaturation on organ function and knowledge of the appropriate therapies, which can include recompression in a hyperbaric chamber. The effects of Boyle's law result in changes in volume of gas-containing spaces when exposed to the increased pressure underwater. These effects can cause middle ear and sinus injury and lung barotrauma due to lung overexpansion during ascent from depth. Disorders related to diving have unique presentations, and an understanding of the high-pressure environment is needed to properly diagnose and manage these disorders. Breathing compressed air underwater results in increased dissolved inert gas in tissues and organs. On ascent after a diving exposure, the dissolved gas can achieve a supersaturated state and can form gas bubbles in blood and tissues, with resulting tissue and organ damage. Decompression sickness can involve the musculoskeletal system, skin, inner ear, brain, and spinal cord, with characteristic signs and symptoms. Usual therapy is recompression in a hyperbaric chamber following well-established protocols. Many recreational diving candidates seek medical clearance for diving, and healthcare providers must be knowledgeable of the environmental exposure and its effects on physiologic function to properly assess individuals for fitness to dive. This review provides a basis for understanding the diving environment and its accompanying disorders and provides a basis for assessment of fitness for diving.

Factors affecting frequency of patient use of Internet-based telemedicine to manage cardiovascular disease risk.

We examined the frequency of use by patients of a web-based reporting system to monitor and control cardiovascular disease (CVD) risk factors. A total of 192 patients with intermediate or high CVD risk were categorized into four quartiles based on their frequency of use of the telemedicine reporting system over one year. The lowest frequency users (Quartile I) averaged 17 reporting days in one year and the highest frequency users (Quartile IV) averaged 211 reporting days in one year. Factors associated with more frequent use were overall knowledge of CVD (P = 0.014), blood lipids (P = 0.017), smoking (P = 0.036), higher scores in medication self-efficacy (P = 0.016) and higher income (P = 0.002). All quartiles showed trends of decreasing systolic blood pressure from hypertensive (≥140 mm Hg) to pre-hypertensive (<140) ranges. Patients were able to lower CVD risk with as few as two transmissions per month using the telemedicine system. Telemedicine reporting coupled with self-assessment of health status can promote a strong patient-provider partnership for managing the chronic risk factors of CVD.

Managing hypertension in urban underserved subjects using telemedicine--a clinical trial.

BACKGROUND: We evaluated an Internet- and telephone-based telemedicine system for reducing blood pressure (BP) in underserved subjects with hypertension. METHODS: A total of 241 patients with systolic BP ≥140 mm Hg were randomized to usual care (C; n = 121) or telemedicine (T; n = 120). The T group reported BP, heart rate, weight, steps/day, and tobacco use twice weekly. The primary outcome was BP control at 6 months. RESULTS: Average age was 59.6 years, average body mass index was 33.7 kg/m(2), 79% were female, 81% were African American, 15% were white, 53% were at or below the federal poverty level, 18% were smokers, and 32% had diabetes. Six-month follow-up was achieved in 206 subjects (C: 107, T: 99). Goal BP was achieved in 52.3% in C and 54.5% in T (P = .43). Systolic BP change (C: -13.9 mm Hg, T: -18.2; P = .118) was similar in both groups. Subjects in the T group reported BP 7.7 ± 6.9 d/mo. Results were not affected by age, sex, ethnicity, education, or income. In nondiabetic T subjects, goal BP was achieved in 58.2% compared with 45.2% of diabetic T subjects (P = .024). Nondiabetic T subjects demonstrated a greater reduction in systolic BP (T: -19 ± 20 mm Hg, C: -12 ± 19 mm Hg; P = .037). No difference in BP response between C and T was noted in patients with diabetes. CONCLUSION: In hypertensive subjects, engagement in a system of care with or without telemedicine resulted in significant BP reduction. Telemedicine for nondiabetic patients resulted in a greater reduction in systolic BP compared with usual care. Telemedicine may be a useful tool for managing hypertension particularly among nondiabetic subjects.

Treatment of patients with intermediate cardiovascular risk: Are clinical measures enough?

AIM: Clinical measures of cardiovascular disease risk (CVD) are important tools for establishing therapy to lower CVD risk. Risk assessment has come under criticism because clinical measures can underestimate or overestimate CVD risk. We assessed CVD risk in 252 subjects without evidence of CVD to establish therapy of one or more risk factors from clinical indications. The subjects all had intermediate CVD risk using the Framingham score. RESULTS: Average age was 59.1 years. 23.8% were smokers, 59.1% were hypertensive, 65.1% had hyperlipidemia. BMI was greater than 30 kg/M(2) in 56% and diabetes was present in 43.7%. In this cohort, 86.9% required therapy for hypertension or hyperlipidemia, and this proportion increased to 95.6% when subjects with diabetes were included. Of the remaining 4.4% (11 subjects), 7 reached intermediate risk based on cigarette smoking and 4 based on age >65 years old. Among diabetics, 94/110 had another risk factor and would require statin and ACE or ARB therapy. CONCLUSIONS: Of subjects at intermediate risk for CVD, 98.4% would not require further testing to decide on therapy to lower CVD risk. Although 16 diabetic subjects had no other risk factors, current guidelines suggest that these subjects should be treated to reduce CVD risk.

Gender differences in cardiovascular risk factors and risk perception among individuals with diabetes.

PURPOSE: The purpose of this study was to examine gender-based differences in cardiovascular risk factors and risk perception among individuals with diabetes. METHODS: The sample consisted of patients with an established history of diabetes who were enrolled in a telemedicine trial to reduce cardiovascular disease (CVD) risk. All subjects had a 10% or greater risk on the Framingham risk index. Assessments included blood pressure, A1C, lipid profile, medication history, and knowledge and risk perception surveys. RESULTS: Data were available for 211 individuals with type 2 diabetes (88 men and 123 women). The women and men did not differ in age, body mass index, or Framingham risk. Only 37.4% of women and 40.9% of men were at an A1C target of <7%. Total cholesterol levels were significantly higher among women, and fewer women were at low-density lipoprotein or blood pressure targets. Knowledge of CVD was similar between the 2 sexes. However, women perceived their risk for CVD to be significantly higher than did men. CONCLUSION: Less favorable cardiovascular risk profiles are observed among women with diabetes as compared with their male counterparts. Multifaceted approaches to both diabetes management and education are needed to target CVD risk reduction among individuals with diabetes.

Using a telemedicine system to decrease cardiovascular disease risk in an underserved population: design, use, and interim results.

Cardiovascular disease is the leading cause of morbidity and mortality in the USA. Disease management programs, while successful, are intensive and expensive. Follow-up is often inadequate, incomplete, and inconsistent. To address these problems, we developed an Internet-Telemedicine system. Patients send/receive data to/from their care provider via the Internet. The system optimizes function and minimizes cost (all hardware is off the shelf and FDA approved). We are currently using this Telemedicine system in a prospective, randomized clinical trial, to reduce CVD risk in medically underserved populations. Over an 8-month time interval, we found very high rates of usage of the Telemedicine system (92%). This rate of self-monitoring greatly exceeded the self-monitoring rate in controls (48%). The patient-entered Telemedicine blood pressure values were similar to the meter recorded values and to the office values.

Cardiovascular disease prevention for underserved patients using the Internet: bridging the digital divide.

For underserved populations, telemedicine can address the high prevalence and suboptimal control of cardiovascular disease (CVD) risk factors. However, Internet access issues may limit the successful application of telemedicine. We tested the hypothesis that computer skills, and not access per se, was the main obstacle to using the Internet for health care. After informed consent, 44 participants with little or no computer experience received 2 hours of training covering 14 basic computer use skills, Internet access, and our telemedicine system. The telemedicine system enables reporting blood pressure, weight, physical activity, cigarette use, provider feedback, personal medication information, and educational information about CVD risk factors. The patient population included 12 males and 32 females. Of this total were 23 African Americans. The average patient age was 60.4 +/- 3 years, and 64% had annual family incomes under 25,000 dollars. Eighty-two percent of the participants averaged 4 or higher (on a scale of 1 to 5) on basic computer skills. Only 11% had an average score below 3. Thirty-seven of 44 participants reported on their health status from a local Internet access site within 10 days. Participants' successful use of the telemedicine system was not correlated with age, gender, education level, or ownership of a computer. Computer skill score had a positive effect on system use. Underserved populations without computer experience or skills and at increased risk for CVD can be educated to use an Internet telemedicine system to communicate health status to their health care providers. Ownership of a computer was not a factor that predicted system use.