Serum levels of tumor necrosis factor and IL-1 alpha and IL-1 beta in diabetic patients.

OBJECTIVE: To determine whether chronic hyperglycemia causes increased levels of serum tumor necrosis factor (TNF) and interleukin 1 alpha (IL-1 alpha) and IL-1 beta. RESEARCH DESIGN AND METHODS: Sera were obtained from 59 diabetic patients, 44 chronically ill nondiabetic patients, and 34 age-matched healthy control subjects. Mononuclear cells were isolated from a subgroup of diabetic patients and healthy control subjects. RESULTS: Except for a modest increase in the prevalence of detectable serum TNF levels in diabetic patients, the serum cytokines measured in this study did not appear to be altered in diabetes. In vitro TNF production by mononuclear cells was not altered in diabetic patients. However, in vitro IL-1 beta secretion, in response to lipopolysaccharides, was reduced. CONCLUSIONS: Diabetes mellitus is not associated with significant changes in serum levels of TNF, IL-1 alpha, or IL-1 beta. In vitro secretion of IL-1 beta in response to lipopolysaccharides may be reduced in diabetes.

Role of gamma-aminobutyric acid in antipanic drug efficacy.

All effective pharmacologic agents used to treat panic disorder augment gamma-aminobutyric acid (GABA) transmission. Anxiolytics and antidepressants that lack GABA activity are not effective in panic disorder. To test the hypothesis that GABA activity is a component of antipanic drug efficacy, the authors treated nine medication-free panic disorder subjects with oral baclofen (30 mg/day for 4 weeks) in a double-blind, placebo-controlled crossover trial. Baclofen, a selective GABA agonist, was significantly more effective than placebo in reducing the number of panic attacks and scores on the Hamilton anxiety scale, Zung scale, and Katz-R nervousness subscale. The authors discuss possible mechanisms of antipanic drug efficacy.

The relationship between muscle mass and muscle strength in the elderly.

To determine the extent that muscle mass is predictive of muscle strength in the elderly, anthropomorphic estimates of muscle area and impedance measurements of muscle mass and peak isometric muscle strength were obtained in a relatively healthy older population over 65 years of age (mean age = 71.7; n = 218). Midarm muscle area correlated strongly with upper arm strength (r = 0.68, P less than 0.0001) while midthigh muscle area had a much lower correlation with thigh muscle strength (r = 0.29, P less than 0.0001). These muscle area calculations also include bone area. Lean body mass calculated by bioelectric impedance correlated highly with cumulative muscle strength measured by summing all muscle groups (r = 0.79, P less than 0.0001). To determine whether aging alters muscle strength per unit of muscle mass, additional middle-aged subjects were included, and three groups, middle-aged (55-64) (n = 78), young-old (65-74) (n = 161), and old-old (75+) (n = 57), were compared. A significant age-related trend of decreasing muscle strength per unit of lean body mass was noted. It is concluded that although muscle mass correlates with muscle strength in a healthy older population, use of simple age-independent clinical measurements of body mass should not be used to predict muscle strength.

The interrelationship between physical exercise, muscle strength and body adiposity in a healthy elderly population.

OBJECTIVE: To determine the relationship between habitual physical exercise and body adiposity in a healthy elderly population. RESEARCH DESIGN AND METHODS: Physical exercise was measured by a questionnaire previously adapted for use with the healthy elderly. The level of exercise was converted into calories expended over the previous 14 days and was divided into tertiles. Body adiposity was measured at six sites by anthropometry, and overall percent body fat was measured by bioelectric impedence. PARTICIPANTS AND SETTING: Two hundred and thirteen healthy ambulatory subjects over the age of 60 (116 females and 97 males) were recruited from a large retirement community in Southern Arizona. The mean age of the subjects was 70.0 years. RESULTS: Percent body fat was similar in men with different levels of physical activity (27.9% for lowest tertile of activity, 28.1% for middle tertile of activity, and 28.5% for highest tertile of activity). The corresponding values of percent fat in women was 38.0%, 36.0%, and 37%, respectively. There was a statistically significant increase in muscle strength measured in five muscle groups with a hand-held dynamometer with increasing levels of activity. CONCLUSIONS: These data indicate that level of physical exercise, over the range of 0 to 1,528 Kcal/day, does not predict body adiposity in the healthy elderly population. To decrease body fat without a change in dietary habits would require a more intensive exercise regimen than currently being undertaken by most healthy elderly people.

Vascular disease risk factors, urinary free cortisol, and health histories in older adults: shyness and gender interactions.

We studied relationships between shyness and health during a health screening survey of older adults (ages 50-88) living in an active retirement community in the southwestern United States (n = 232). As in previous studies of infants, older individuals with hay fever, insomnia and constipation were more shy than those without these problems. Shy persons overall showed higher sitting systolic blood pressure and a larger fall in orthostatic systolic blood pressure on standing; shy men had a greater prevalence of hypertension histories than did low-shy men. Shy subjects of both sexes had lower HDL cholesterol and higher triglycerides than did low-shy subjects; shy women tended to have higher LDL cholesterol than did low-shy women. In contrast with findings of elevated salivary cortisol in extremely inhibited children of both sexes, only shy women had higher 24 h urinary free cortisol excretion than did low-shy women; men showed the opposite pattern, possibly related to suppression of aggression. Shy men also tended to report a higher prevalence of thyroid disease history than did low-shy men (20% versus 6%). Notably, autoimmune thyroiditis has previously been linked with panic and depression, disorders which in turn have been associated with shyness. Taken together with previous work in shy children and their families, the data raise the possibility of (a) increased risk for arteriosclerotic vascular disease; and (b) increased risk of adrenal- and/or thyroid-related diseases in certain shy older adults.

Pressure-equalization (PE) tubes in treatment of otitis media: national survey of otolaryngologists.

This study was designed to describe those indicators for the insertion of pressure-equalization (PE) tubes given highest priority by board-certified otolaryngologists. An original questionnaire was mailed to 1000 board-certified otolaryngologists practicing in the United States. The respondents rated the relative importance of 22 indicators on a 6-point scale. These indicators were grouped into four categories: Medical History, Physical Examination, Audiologic Evaluation, and Related Indicators. With a return rate of 52.7%, approximately 1 of every 9 board-certified, practicing otolaryngologists in the United States was represented in the study. The five indicators with the highest ratings were: "persistence of fluid for 3 or more months per episode," "presence of speech-language delay," "presence of bilateral conductive hearing loss of 20 dB or more," "total number of episodes of otitis media," and "lack of response to suppressive antibiotic therapy." Additional analyses of the data yielded information regarding characteristics of the responding physicians and the self-generated indicators.

Arthritis: preferred learning methods among Arizona therapists.

Arizona occupational and physical therapists were surveyed about their needs for education in arthritis. Responses to statements regarding attitudes, knowledge, willingness to learn, and preferred methods of learning were subjected to chi-square analysis. The results showed that a significant number of both occupational and physical therapists are deficient in knowledge about the disease and maintain negative attitudes about patients with rheumatoid arthritis. Both groups indicated a high interest in continuing education about arthritis. The preferred method of learning was self-study guides.

Assessing clinical judgment with standardized patients.

Family physicians and general practitioners see the majority of patients with uncomplicated rheumatic disease, yet information on database collection and clinical judgment in such practices is limited. Trained patients with uncomplicated rheumatic disease (standardized patients) were used to evaluate these abilities in 26 family physicians at the University of Arizona College of Medicine in blinded, but previously consented to, brief new encounters. Ability to formulate an assessment and to plan was evaluated as well as ability to collect diagnostic information. Few physicians explored the psychosocial impact of the illness (4 percent) or the role of depression (0 percent). In the brief encounter with a localized complaint, little inquiry was directed to systemic disease (46 percent). Physicians more uniformly asked about the chief complaint (96 percent) and time of onset (88 percent). Physical examination items most commonly omitted were evaluation of systemic joint involvement (69 percent) and muscle wasting in the involved area (59 percent). Referral occurred on 15 percent of encounters and patient education occurred in 62 percent. Three quarters of physicians developed an adequate assessment and virtually all developed an adequate patient care plan.

Family practice and internal medicine clinical judgment in a university setting.

There were no significant differences between family practice and internal medicine residents in the proportion of total diagnoses that were reasonable (72 percent and 77 percent, respectively) and unreasonable (14 percent and 15 percent, respectively) or average number of consultations requested per examination (.15 and .16, respectively). There was a significant difference between the two types of physicians in the average number of laboratory tests requested per examination (1.42 per family practice and 1.88 per internal medicine) and average number of x-ray examinations requested per examination (0.35 for family practice and 1.02 for internal medicine). The average length of examination for internal medicine tended to be longer than for family practice. Although generalizability of this study is limited, the results suggest that there may be important differences in the practice patterns of family practice and internal medicine with implications for training programs.

The effect of age on protein composition of rat cerebral microvessels.

The effect of age on protein composition of cerebral microvessels was investigated by examining the content of glycosylation endproducts in cerebral microvessels isolated from young (3-6 month old), intermediate age (18 month) and aged (24-26 month old) Fischer 344 male rats and by quantitating various protein spots identified with two dimensional (2D) electrophoresis. The results indicate that aging in rats is not associated with significant increase in glycosylation of microvessel proteins. Of the 26 proteins in cerebral microvessels identified on the 2-D gel, ten showed significant age-related changes (p less than 0.0004) and in two of these the changes were significant as early as 18-months of age. A large acidic protein with a molecular weight of 144,000 and isoelectric point (pI) of 5.4 (Spot #1) was found only in aged rats. The results indicate that aging is associated with significant quantitative changes in protein composition of cerebral microvessels. It is possible that Spot #1 may be a novel biochemical marker of aging blood-brain barrier.

Subjective and objective admissions factors as predictors of clinical clerkship performance.

Subjective and objective measures available at the time of medical school admission were related to subjective and objective clinical performance measures during medical school. Strategies were developed for coding narrative faculty comments from admissions interviews and clinical performance evaluations. Factor analysis was used to examine underlying structures for both admission and clinical performance measures. Summed scores were calculated to represent each factor, and multiple regression was used in predicting each of the clinical factors from the admission factors. Multiple regression showed that admission interview comments best predict narrative clerkship performance, while objective scores best predict an objective measure of clinical knowledge. Conclusions were: (a) narrative information can be coded reliably. (b) Objective and subjective measures are distinct, identifiable structures both at admission and during the third year of medical school. (c) Prediction formulas will vary depending on what outcome variables are chosen.

Decline of height with age in adults in a general population sample: estimating maximum height and distinguishing birth cohort effects from actual loss of stature with aging.

The decline in stature with age among adults is well documented. Although part of this represents a birth cohort effect, actual height declines among older individuals are known to contribute to the effect. In this study we used longitudinal changes in the heights of adults in a general population sample to determine the rate of decline in height over time in individuals of different ages. This allowed an estimation of the age at which decline in height begins, a value close to age 40 in both sexes. It also allowed derivation of equations from which the maximum height of subjects can be estimated on the basis of their sex, current height, and age. These equations should prove useful when examining the effect of aging per se on physiological measurements that are height dependent. The data also allow one to compare the magnitude of the effect of year of birth with that of the actual decline in height seen among the elderly. We estimate that approximately 60% of the smaller stature of older male subjects and 45% of the smaller stature of older female subjects is a birth cohort effect deriving from the secular trend toward greater stature; the remainder is a result of an actual decrement in height after the age of 40.

Attitudes of local VA leadership toward the VA health care system.

A nationwide survey of directors, associate directors, and chiefs of staff of Department of Veterans Affairs (VA) Medical Centers was conducted to (1) determine the attitudes of these local health care executives toward the public's perception of the VA health care system, their own job satisfaction, and the level of job support they receive; and (2) assess how these attitudes relate to the stated intention of the local leadership to leave the VA health care system before retirement. A total of 268 responses were analyzed. Significant differences between local executive positions were identified, including a less favorable perception of the public's attitude toward the VA system and less satisfaction with the VA system by chiefs of staff; and less general job satisfaction and satisfaction with the local VA facility by associate directors. Variables related to public perception, job satisfaction, and job support were significant predictors of plans for each group to leave the VA; 34 to 49 percent of the variance in a multiple linear regression model could be explained by these factors.

Impact of intensive education and interaction with health professionals on patient instructors.

The use of patients as instructors in teaching medical students and physicians the musculoskeletal examination has proven to be an effective method of learning. However, the effect on the patient instructors (PIs) of their intensive training and the numerous physical examinations made of them has been unknown. In this study, eight patients with stable rheumatoid arthritis were given the Taylor-Johnson Temperament Assessment (TJTA) when they were recruited as PIs and every six months thereafter for two years. Individual interviews focusing on the changes taking place in the patient instructors' lives were also conducted. Three PIs left the program early in their training. Observed changes in TJTA scores were frequently positive for the five who remained in the study. Interview results indicate positive changes in terms of confidence, competence, and emotional stability. All five PIs have continued in their role as PIs and have also expanded into other responsibilities. It is concluded that the patient instructor program was certainly not harmful to the individual PIs and, in fact, was mostly beneficial to them as well as to physicians and medical students.

The use of trained patient instructors for teaching and assessing rheumatologic care.

The training of professionals in rheumatologic care requires review and study. To improve teaching methods, 6 patients with stable rheumatic disease were trained to evaluate and teach medical students by using themselves as models for musculoskeletal examinations. Checklists for scoring performance and content were developed. Criteria established to give evidence of the validity of the checklists and of the reliability of the patient instructors in their scoring were met or exceeded. The patient instructors are now an integral part of the Preparation for Clinical Medicine curriculum at our institution and serve as resources for evaluation and teaching in the continuing education of practicing professionals.