Socioeconomic status, race and COPD health outcomes.

BACKGROUND: Although chronic obstructive pulmonary disease (COPD) is a common cause of death and disability, little is known about the effects of socioeconomic status (SES) and race-ethnicity on health outcomes. METHODS: The aim of this study is to determine the independent impacts of SES and race-ethnicity on COPD severity status, functional limitations and acute exacerbations of COPD among patients with access to healthcare. Data were used from the Function, Living, Outcomes and Work cohort study of 1202 Kaiser Permanente Northern California Medical Care Plan members with COPD. RESULTS: Lower educational attainment and household income were consistently related to greater disease severity, poorer lung function and greater physical functional limitations in cross-sectional analysis. Black race was associated with greater COPD severity, but these differences were no longer apparent after controlling for SES variables and other covariates (comorbidities, smoking, body mass index and occupational exposures). Lower education and lower income were independently related to a greater prospective risk of acute COPD exacerbation (HR 1.5; 95% CI 1.01 to 2.1; and HR 2.1; 95% CI 1.4 to 3.4, respectively). CONCLUSION: Low SES is a risk factor for a broad array of adverse COPD health outcomes. Clinicians and disease management programs should consider SES as a key patient-level marker of risk for poor outcomes.

Developing a prediction rule from automated clinical databases to identify high-risk patients in a large population with diabetes.

OBJECTIVE: To develop and validate a prediction rule for identifying diabetic patients at high short-term risk of complications using automated data in a large managed care organization. RESEARCH DESIGN AND METHODS: Retrospective cohort analyses were performed in 57,722 diabetic members of Kaiser Permanente, Northern California, aged > or =19 years. Data from 1994 to 1995 were used to model risk for macro- and microvascular complications (n = 3,977), infectious complications (n = 1,580), and metabolic complications (n = 316) during 1996. Candidate predictors (n = 36) included prior inpatient and outpatient diagnoses, laboratory records, pharmacy records, utilization records, and survey data. Using split-sample validation, the risk scores derived from logistic regression models in half of the population were evaluated in the second half. Sensitivity, positive predictive value, and receiver operating characteristics curves were used to compare scores obtained from full models to those derived using simpler approaches. RESULTS: History of prior complications or related outpatient diagnoses were the strongest predictors in each complications set. For patients without previous events, treatment with insulin alone, serum creatinine > or =1.3 mg/dl, use of two or more antihypertensive medications, HbA(1c) >10%, and albuminuria/microalbuminuria were independent predictors of two or all three complications. Several risk scores derived from multivariate models were more efficient than simply targeting patients with elevated HbA(1c) levels for identifying high-risk patients. CONCLUSIONS: Simple prediction rules based on automated clinical data are useful in planning care management for populations with diabetes.

Self-monitoring of blood glucose levels and glycemic control: the Northern California Kaiser Permanente Diabetes registry.

PURPOSE: We sought to evaluate the effectiveness of self-monitoring blood glucose levels to improve glycemic control. SUBJECTS AND METHODS: A cohort design was used to assess the relation between self-monitoring frequency (1996 average daily glucometer strip utilization) and the first glycosylated hemoglobin (HbA1c) level measured in 1997. The study sample included 24,312 adult patients with diabetes who were members of a large, group model, managed care organization. We estimated the difference between HbA1c levels in patients who self-monitored at frequencies recommended by the American Diabetes Association compared with those who monitored less frequently or not at all. Models were adjusted for age, sex, race, education, occupation, income, duration of diabetes, medication refill adherence, clinic appointment "no show" rate, annual eye exam attendance, use of nonpharmacological (diet and exercise) diabetes therapy, smoking, alcohol consumption, hospitalization and emergency room visits, and the number of daily insulin injections. RESULTS: Self-monitoring among patients with type 1 diabetes (> or = 3 times daily) and pharmacologically treated type 2 diabetes (at least daily) was associated with lower HbA1c levels (1.0 percentage points lower in type 1 diabetes and 0.6 points lower in type 2 diabetes) than was less frequent monitoring (P < 0.0001). Although there are no specific recommendations for patients with nonpharmacologically treated type 2 diabetes, those who practiced self-monitoring (at any frequency) had a 0.4 point lower HbA1c level than those not practicing at all (P < 0.0001). CONCLUSION: More frequent self-monitoring of blood glucose levels was associated with clinically and statistically better glycemic control regardless of diabetes type or therapy. These findings support the clinical recommendations suggested by the American Diabetes Association.

Hormone replacement therapy is associated with better glycemic control in women with type 2 diabetes: The Northern California Kaiser Permanente Diabetes Registry.

OBJECTIVE: In women with diabetes, the changes that accompany menopause may further diminish glycemic control. Little is known about how hormone replacement therapy (HRT) affects glucose metabolism in diabetes. The aim of this study was to examine whether HbA(1c) levels varied by current HRT among women with type 2 diabetes. RESEARCH DESIGN AND METHODS: In a cohort of 15,435 women with type 2 diabetes who were members of a health maintenance organization, HbA(1c) and HRT were assessed by reviewing records in the health plan's computerized laboratory and pharmacy systems. Sociodemographic and clinical information were collected by survey. RESULTS: The mean age was 64.7 years (SD +/- 8.7). The study cohort comprised 55% non-Hispanic whites, 14% non-Hispanic blacks, 12% Hispanics, 11% Asians, 4% "other" ethnic groups, and 4% with missing ethnicity data. Current HRT was observed in 25% of women. HbA(1c) levels were significantly lower in women currently using HRT than in women not using HRT (age-adjusted mean +/- SE: 7.9 +/- 0.03 vs. 8.5 +/- 0.02, respectively, P = 0.0001). No differences in HbA(1c) level were observed between women using unopposed estrogens and women using opposed estrogens. In a Generalized Estimating Equation model, which took into account patient clustering within physician and adjusted for age, ethnicity, education, obesity, hypoglycemic therapy, diabetes duration, self-monitoring of blood glucose, and exercise, HRT remained significantly and independently associated with decreased HbA(1c) levels (P = 0.0001). CONCLUSIONS: HRT was independently associated with decreased HbA(1c) level. Clinical trials will be necessary to understand whether HRT may improve glycemic control in women with diabetes.

Targeted testing of children for tuberculosis: validation of a risk assessment questionnaire.

OBJECTIVE: Given the directive of the American Academy of Pediatrics to test children for tuberculosis (TB) only if they are at high risk for the disease, we sought to determine how well a risk assessment questionnaire can predict a positive tuberculin skin test (TST) result among children seen in a medical office setting. METHODS: In a prospective observational study, we identified 31 926 children who received well-child care in 18 pediatric offices of the Kaiser Permanente Northern California Region from August 1996 through November 1998 and who were due to receive a routine TST (Mantoux method) as part of universal screening. Parents were asked to complete a questionnaire about risk factors for TB infection that included demographic information. The TST result at 48 to 72 hours was compared with questionnaire responses to identify responses that were most highly associated with a positive TST result at both the 10-mm and 15-mm cutoffs. A concurrent study was conducted to determine whether parents can recognize induration. RESULTS: This population was diverse in age (range: 0-18 years), race/ethnicity (white: 37%; Hispanic: 26.4%; Asian: 15.0%; black: 11.8%; other: 8.4%; not stated by parent: 1.6%), and household annual income (range: $10 524-$175 282). Overall incidence of positive TST results was 1.0% at the 10-mm cutoff and 0.5% at the 15-mm cutoff. Positive predictive value of selected individual risk factors at the 10-mm cutoff were: child born outside the United States, 10.4%; history of receiving bacille Calmette-Guérin vaccine, 5.5%; and child having lived outside the United States, 5.3%. Using multivariate analysis, we selected a subset of risk factors that were independently and significantly associated with a positive TST result >/=10 mm: history of receiving bacille Calmette-Guérin vaccine (odds ratio [OR]: 2.31; 95% confidence interval [CI]: 1.70-3.13); household member with history of positive TST result or TB disease (OR: 1.53; 95% CI: 1.14-2.04); child born outside the United States (OR: 8.63; 95% CI: 6.16-12.09); child having lived outside the United States (OR: 2.06; 95% CI: 1.49-2.85); and race/ethnicity reported by parent as Asian (OR: 2.28; 95% CI: 1.59-3.27) or Hispanic (OR: 1.57; 95% CI: 1.09-2.26). Several factors were not statistically significant predictors of a positive TST result: age, sex, household annual income, household member infected with human immunodeficiency virus or who had stayed in a homeless shelter, and being an adopted or foster child. Overall sensitivity of the 9 main items on the questionnaire was 80.9%; when a subset of 4 of these questions plus the race/ethnicity questions were used, sensitivity of responses was 83.5%. Parents failed to recognize positive TST results at a rate of 9.9% (for the 10-mm cutoff) and 5.9% (at the 15-mm cutoff). CONCLUSION: A 5-question risk assessment questionnaire completed by parents can be used to accurately identify risk factors associated with TB infection in children. In our population, some risk factors suggested by the American Academy of Pediatrics could not be validated. Parents cannot be relied on to read TST results accurately. Screening for TB can be enabled by using a standardized, validated questionnaire to identify children who should be given tuberculin skin testing.

Quality of life measurement clarifies the cost-effectiveness of Helicobacter pylori eradication in peptic ulcer disease and uninvestigated dyspepsia.

OBJECTIVES: Previous economic studies of Helicobacter pylori eradication in dyspepsia and peptic ulcer disease have not measured quality of life using utilities (preference probabilities), which are needed to compare the cost-effectiveness of such treatment to other health care interventions. The goals of this study were to measure quality of life in patients with dyspepsia or peptic ulcer and apply these measurements to published models of disease management to determine cost-effectiveness in dollars per quality-adjusted life year (QALY) gained. METHODS: Utilities for dyspepsia and peptic ulcer disease were measured in adult patients (n = 73) on chronic acid suppression for peptic ulcer or ulcer-like dyspepsia. Median utility values were applied to the results of published cost-effectiveness analyses and a previously validated dyspepsia model. Cost-utility ratios for early H. pylori eradication in uninvestigated dyspepsia and peptic ulcer disease were then computed. RESULTS: The total disutility, or lost quality of life, for an ulcer was 0.11 QALY, of which 0.09 QALY was attributed to dyspeptic symptoms. After these results were incorporated into published studies, cost-utility ratios for ulcer treatment varied from $3,100 to $12,500 per QALY gained, whereas estimates for uninvestigated dyspepsia management ranged from $26,800 to $59,400 per QALY. Sensitivity analyses indicated a range of $1,300 to $27,300 per QALY for management of duodenal ulcer and $15,000 to $129,700 per QALY for dyspepsia. CONCLUSIONS: Strategies that emphasize early H. pylori eradication were cost-effective for patients with peptic ulcer and possibly cost-effective for patients with uninvestigated dyspepsia, relative to other medical interventions. Dyspeptic symptoms cause significant disutility that should be incorporated in future cost-effectiveness analyses of treatment strategies.

Ultrasound availability in the evaluation of ectopic pregnancy in the ED: comparison of quality and cost-effectiveness with different approaches.

The liberal use of ultrasonography has been advocated in patients with first trimester cramping or bleeding to avoid misdiagnosis of ectopic pregnancy in the emergency department (ED). The cost-effectiveness of different approaches to ultrasound availability has not been previously reported. In this study, we investigated measures of quality and cost-effectiveness in detecting ectopic pregnancy in the ED over a 6-year period, divided into three approximately equal epochs with three distinct approaches to ultrasound availability. The study retrospectively identified 120 cases of ectopic pregnancy seen in the ED over 6 years. There was significant improvement in the percentage of patients with ectopic pregnancy who were documented to have absence of intrauterine pregnancy (IUP) at the first visit from 76% during Epoch 1, when there was limited availability of ultrasound through medical imaging (MI Sono), to 88% in Epoch 2, when MI Sono was readily available, to 96% in Epoch 3, when both MI Sono and ultrasound by emergency physicians (ED Sono) were readily available (P = .02). The estimated number of MI Sonos ordered by emergency physicians in patients at risk for ectopic pregnancy increased from 5.2 per ectopic pregnancy in Epoch 1 to 11.8 per ectopic pregnancy in Epoch 2, and declined to 5.5 per ectopic pregnancy in Epoch 3, when 19.9 ED Sonos per ectopic pregnancy were also done. The cost of ED Sono in Epoch 3 was more than offset by savings from avoiding calling in ultrasound technicians after regular medical imaging department hours. The specificity of ED Sono in ruling in an IUP was 100% (95% CI 98.3 to 100%), but analysis of secondary quality indicators reflecting times from first ED visit to treatment in Epoch 3 raised the possibility that an adnexal mass or signs of tubal rupture may have been missed on some ED Sonos. We conclude that increased availability of ultrasonography leads to improved quality in the detection of ectopic pregnancy in the ED, but at the expense of a disproportionate increase in the number of ultrasound studies done per ectopic pregnancy detected. Our study suggests that the most cost-effective strategy is for emergency physicians to screen all patients with first trimester cramping and bleeding with ED Sonos, and to obtain MI Sonos at the time of the initial ED visit in all cases in which the ED Sono is indeterminate or shows no IUP.

Self-monitoring of blood glucose: language and financial barriers in a managed care population with diabetes.

OBJECTIVE: Self-monitoring of blood glucose (SMBG) is a cornerstone of diabetes care, but little is known about barriers to this self-care practice. RESEARCH DESIGN AND METHODS: This cross-sectional study examines SMBG practice patterns and barriers in 44,181 adults with pharmacologically treated diabetes from the Kaiser Permanente Northern California Region who responded to a health survey (83% response rate). The primary outcome is self-reported frequency of SMBG. RESULTS: Although most patients reported some level of SMBG monitoring, 60% of those with type 1 diabetes and 67% of those with type 2 diabetes reported practicing SMBG less frequently than recommended by the American Diabetes Association (three to four times daily for type 1 diabetes, and once daily for type 2 diabetes treated pharmacologically). Significant independent predictors of nonadherent practice of SMBG included longer time since diagnosis, less intensive therapy, male sex, age, belonging to an ethnic minority, having a lower education and neighborhood income, difficulty communicating in English, higher out-of-pocket costs for glucometer strips (especially for subjects with lower incomes), smoking, and excessive alcohol consumption. CONCLUSIONS: Considerable gaps persist between actual and recommended SMBG practices in this large managed care organization. A somewhat reduced SMBG frequency in subjects with linguistic barriers, some ethnic minorities, and subjects with lower education levels suggests the potential for targeted, culturally sensitive, multilingual health education. The somewhat lower frequency of SMBG among subjects paying higher out-of-pocket expenditures for strips suggests that removal of financial barriers by providing more comprehensive coverage for these costs may enhance adherence to recommendations for SMBG.

Parents' preferences for outcomes associated with childhood vaccinations.

BACKGROUND: The number of shots in the childhood immunization schedule has been increasing and is likely to continue to increase in the coming years. Consideration of the psychologic costs of multiple injections, adverse events and vaccine-preventable disease is therefore growing in importance. METHODS: We assessed parent preferences, using both the time tradeoff (i.e. amount of parent time willing to trade) and willingness-to-pay (i.e. dollars willing to pay) metrics, for possible outcomes of vaccination among 206 parents of infants receiving care at Kaiser, Northern California Region. We also explored the relationship between preferences and subject characteristics. RESULTS: In general the amount of time subjects were willing to give up and the quantity of money they were willing to spend to avoid an outcome increased with the severity of the outcome. Preferences for our six main outcomes of interest all differed from one another (P < 0.0001, Tukey's multiple comparisons procedure). Rank correlation coefficients between time tradeoff and willingness-to-pay values for the six main outcomes ranged from 0.42 to 0.52 (all P < 0.004). Subject characteristics, including education, income, race/ethnicity and the child's birth order, did not explain the variation in parent preferences. CONCLUSIONS: In general subjects were willing to give up more money or time to avoid less desired outcomes. They were willing to give up only very small amounts of their own life expectancy or money to avoid minor, temporary outcomes (e.g. moderate fussiness, fever and pain) whereas they were willing to forego substantial lengths of their life or amounts of money to avoid a major, permanent outcome (i.e. permanent disability). Nonetheless much variation surfaced in the amount of time (or money) subjects were willing to trade to avoid outcomes. If this variation represents true differences in preferences, guideline developers must consider the role of individual parent preferences in decisions concerning vaccination.

Excess maternal transmission of type 2 diabetes. The Northern California Kaiser Permanente Diabetes Registry.

OBJECTIVE: To assess excess maternal transmission of type 2 diabetes in a multiethnic cohort. Previous studies have reported higher prevalence of diabetes among mothers of probands with type 2 diabetes than among fathers. This analysis is vulnerable to biases, and this pattern has not been observed in all populations or races. RESEARCH DESIGN AND METHODS: We assessed evidence for excess maternal transmission among 42,533 survey respondents with type 2 diabetes (probands) by calculating the prevalence of diabetes in their siblings and offspring. To assess data quality, we evaluated completeness of family history data provided. Accuracy of family information reported by probands was also evaluated by comparing survey responses in a subsample of 206 probands with family histories modified after further interviews with relatives. RESULTS: Siblings (n = 60,532) of probands with affected mothers had a greater prevalence of diabetes (20%) than those with affected fathers (17%) (P < 0.001 for adjusted odds ratios). Prevalence of diabetes was higher among the offspring (n = 72,087) of female (3.4%) versus male (2.2%) probands (P < 0.001 for adjusted odds ratios). These patterns were evident in all races and both sexes; however, the effect size was clinically insignificant in African-Americans and male offspring. In general, probands provided more complete data about diabetes status for the maternal arm of the pedigree than the paternal arm. Completeness of knowledge was not related to proband sex, but was related to education and race, and inversely to age. Accuracy of proband-reported family history was consistently good (kappa statistics generally > 0.70). CONCLUSIONS: Excess maternal transmission was observed in all races and both sexes, although the size of the excess was negligible in African-Americans and male offspring. Potential reporting and censoring biases are discussed.

Neonatal group B streptococcal infection in a managed care population. Perinatal Group B Streptococcal Infection Study Group.

OBJECTIVE: In a health maintenance organization population, we determined the incidence of early-onset (at less than or equal to 7 days) neonatal group B streptococcal (GBS) disease, the sensitivity and prevalence of labor risk factors, the adherence to a protocol for intrapartum antibiotics, and the costs for care of and outcomes of affected infants. METHODS: Mothers and infants at four health maintenance organization hospitals in northern California in 1989 to 1995 were studied retrospectively using computerized databases and chart review. In 1994, two of the four hospitals had adopted protocols similar to the ACOG recommendations for intrapartum antibiotics for women with labor risk factors (preterm, temperature 100.4F or higher, or rupture of membranes (ROM) 18 hours or more). RESULTS: Among the 79,940 live births, the incidence of early-onset neonatal GBS infection was higher among preterm than among term infants (3.1 compared with 0.9 per 1000). Before protocol adoption, 68% of 65 infants with GBS had mothers with labor risk factors. Approximately 18% of all mothers had labor risk factors: 7.7% had preterm delivery, and 10.6% had term delivery with fever and/or ROM 18 hours or more. At the two hospitals that adopted GBS protocols, GBS incidence was reduced from 1.3 per 1000 in the preprotocol period to 0.8 per 1000 in the postprotocol period (P=.08). Six cases of neonatal GBS occurred after protocol adoption. Of these, four were not preventable under the protocol and two might have been preventable if protocol had been followed. Three of the 19 preterm infants with group B streptococcal disease died. CONCLUSION: Risk factor-based protocols hold some promise to reduce GBS disease, but clinical strategies to promote protocol adherence are needed.

Lymphangioleiomyomatosis: the pathophysiology of diminished exercise capacity.

Dyspnea with exertion is nearly always present in patients with pulmonary lymphangioleiomyomatosis, but the mechanisms underlying exercise impairment have not been well defined. Spirometry, lung volumes, lung mechanics, and exercise physiology were performed on a cohort of 16 patients. We determined the relative contribution of airflow limitation, gas exchange abnormalities, and pulmonary vascular abnormalities to the exercise performance achieved. The patients had normal TLC and Vtg, but RV was elevated in 88% of the subjects. A moderate to severe obstructive pattern was present in 69% of the subjects, and the DLCO was reduced, often markedly, in 81% of the subjects. Exercise performance was limited (work load, 68% +/- 6) with abnormalities of ventilatory function and gas exchange present. Strong correlations between overall exercise performance (percent predicted VO2max and maximal work load achieved) and indices of airflow and vascular involvement were present. Poor exercise performance was due primarily to ventilatory limitation. The etiology of this ventilatory limitation appears twofold. First, subjects had a reduced ventilatory ceiling because of airflow limitation. Second, subjects demonstrated an excessive ventilatory response as a result of increased dead-space ventilation thought to be due to disease-associated cystic changes and associated pulmonary vascular dysfunction or destruction.

Pulmonary histiocytosis X: pulmonary function and exercise pathophysiology.

Pulmonary histiocytosis X (PHX) is a diffuse, smoking-related lung disease characterized pathologically by bronchocentric inflammation, cyst formation, and widespread vascular abnormalities and physiologically by exercise limitation. The major mechanism underlying exercise impairment in this disease has not been previously defined. Spirometry, lung volumes, lung mechanics, and exercise physiology were performed on 23 patients with PHX. Two subgroups were identified on the basis of elastic recoil: 12 subjects had an elevated coefficient of elastic recoil with 11 demonstrating a predominant pattern of restriction, and 10 subjects had normal elastic recoil and relatively normal lung function. Exercise performance was severely limited in both subgroups (workload 53 +/- 3%). Abnormalities of ventilatory function and gas exchange were present but did not appear to be exercise-limiting in the majority of subjects. Indices reflecting pulmonary vascular function (DLCO, baseline VD/VT, exercise VD/VT) were abnormal. Strong correlations between overall exercise performance (% predicted VO2max) and indices of vascular involvement were present: DLCO (r = 0.68, p = 0.0004), baseline VD/VT (-0.65, 0.001), exercise VD/VT (-0.67, 0.0004). Similar correlations were found when exercise performance was measured by maximal workload achieved. We conclude that (1) subjects with PHX present with either normal or predominantly restrictive pulmonary physiology and that (2) exercise impairment is common and appears to reflect pulmonary vascular dysfunction.

Chronotherapy of asthma with inhaled steroids: the effect of dosage timing on drug efficacy.

BACKGROUND: Studies in asthma with systemic corticosteroids given at 3:00 PM have shown a superior therapeutic benefit compared with dosing at other time points. OBJECTIVE: The study was designed to compare beneficial and systemic effects of 800 micrograms of inhaled triamcinolone once daily at 3:00 PM (QD group) versus 200 micrograms conventional four times a day dosing (QID group). METHODS: Efficacy outcome measures included forced expiratory volume in 1 second (FEV1), peak expiratory flow rates, bronchial responsiveness, and use of beta-agonist. Systemic effects were blood eosinophil and cortisol levels, 24-hour urinary cortisol, and evaluation for oral candidiasis and dysphonia. RESULTS: The baseline FEV1 was comparable in the two groups: QD = 67% +/- 2% and QID = 66% +/- 2% of predicted value. After 4 weeks of treatment, FEV1 increased similarly in the QD group to 77% +/- 4% and in the QID group to 74% +/- 4% of predicted value. Likewise, the improvement in morning and evening peak expiratory flow rates was not significantly different between the groups. Both QD and QID groups experienced comparable daily decrements in beta-agonist use. The systemic responses to the two regimens as assessed by eosinophil count, morning serum cortisol, and 24-hour urinary cortisol were also comparable. CONCLUSIONS: The single daily administration of inhaled triamcinolone at 3:00 PM has no increased systemic effects and produces similar improvement in efficacy variables. A dosing strategy based on once daily dosing should increase compliance of inhaled steroid use in the clinical setting.

Stability of the circadian alteration in lung function in asthma.

Although studies on pharmacologic interventions for nocturnal asthma are increasing, information about the long-term stability of circadian spirometric changes or bronchial responsiveness is not known. This study was undertaken to evaluate these variables in 10 patients with asthma measured quarterly during a 1-year period. We have found that the overnight decrease in peak expiratory flow rate measurements is stable (mean range, 13.8% to 16.4%) during the year, as are the quarterly 4 PM (1600-hour) and 4 AM (0400-hour) FEV1 values. The 4 PM provocative concentration of methacholine that produced a 20% fall in FEV1 (PC20) (range of geometric mean, 0.213 to 0.359 mg/ml) and the 4 AM PC20 (range, 0.057 to 0.152 mg/ml) for the group were also relatively stable. Individual variation was higher for the PC20 values than for the FEV1. We concluded that during a 1-year period, without acute respiratory events, (1) the overnight decrement in peak expiratory flow rate and the 4 AM and 4 PM FEV1 values were constant and (2) bronchial responsiveness demonstrated some individual variability, but for the group, it remained stable.

Pectus excavatum and scoliosis. Thoracic anomalies associated with pulmonary disease caused by Mycobacterium avium complex.

We studied the frequency of pectus excavatum or otherwise abnormally narrowed anterior-posterior thoracic dimension and of thoracic scoliosis among consecutive series of 67 patients with pulmonary disease due to Mycobacterium avium complex and 55 patients with pulmonary Mycobacterium tuberculosis. Among those with M. avium, pectus excavatum and abnormal narrowing was present in 27% and scoliosis was seen in 52%; overall, 47 of the 67 (70%) had one or both of these anomalies. By comparison, of those with M. tuberculosis only 5% had pectus excavatum or abnormal narrowing, only 13% had scoliosis; and none had both. The prevalence of pectus excavatum and abnormal narrowing among female M. avium complex patients was significantly greater than among female tuberculosis patients (p = 0.05) or in the general population (p less than 0.001). Among male M. avium complex patients, pectus excavatum and abnormal narrowing was significantly more common than in the general population (p less than 0.001) but not significantly different than among male tuberculosis patients (p = 0.264). For all M. avium complex versus all M. tuberculosis patients the prevalence of pectus excavatum abnormal narrowing was significantly greater (p = 0.013). Scoliosis was significantly more common among all M. avium complex patients than among M. tuberculosis patients or the general population. We believe that these anomalies, which are associated with a variety of heritable connective disorders, are phenotypic markers of patients who are at increased risk for pulmonary disease due to environmental mycobacteria, such as M. avium complex.

Lack of benefit of methotrexate in severe, steroid-dependent asthma. A double-blind, placebo-controlled study.

OBJECTIVE: To determine the effect of low-dose methotrexate in asthmatic patients on steroid use, asthma symptom scores, pulmonary function, airway reactivity, blood cellular components, and immunoglobulin E levels. DESIGN: A randomized, double-blind, parallel, placebo-controlled, 13-week clinical trial with follow-up of patients in an open trial of methotrexate at the conclusion of the double-blind study. SETTING: An asthma care outpatient clinic. PATIENTS: From February 1988 to March 1990, 19 patients with severe, steroid-dependent asthma were enrolled in the study. Two of these patients were excluded from analysis. INTERVENTIONS: Patients were administered methotrexate or placebo intramuscularly, to assure complete absorption, once weekly during the 13-week study. RESULTS: Patients on methotrexate and placebo both significantly decreased their steroid dose by 39.6% (95% CI, 25.1% to 54.1%, P = 0.001) and 40.2% (CI, 17.9% to 67.4%, P = 0.003), respectively. Pulmonary function did not differ significantly between the methotrexate and placebo groups. In addition, airway reactivity and symptom scores were unchanged on methotrexate or placebo. No significant toxicities were seen during the course of the 13-week blinded study, but one patient on methotrexate and prednisone in the follow-up period developed Pneumocystis carinii pneumonia and died. Despite continuing methotrexate for up to 1 year, and increasing methotrexate to 30 mg weekly, no significant benefit of methotrexate on asthma control could be shown. CONCLUSION: Our study does not support the use of methotrexate in the treatment of severe asthma.

Properties of the Inventory to Diagnose Depression in American Indian adolescents.

The Inventory to Diagnose Depression (IDD) was administered to 177 American Indian adolescents attending a tribally administered boarding school. The psychometric properties in this population were studied and compared to those obtained when the Center for Epidemiologic Studies-Depression Scale (CES-D) was administered to a similar population. Analyses were performed on the scale items individually as well as on the continuous summary score and the dichotomous diagnosis. The internal consistency was very good (0.94 to 0.96). There were relatively few gender effects at the item level and none with respect to the diagnosis. IDD prevalence estimates of depression were much closer to the expected rates suggested by epidemiological studies than those generated by other self-report measures like the CES-D. These findings recommend the IDD for additional investigation in terms of its use with adolescent populations.

Treatment outcome in a private-sector residential care program.

The treatment outcomes of 60 chronic mentally ill patients who received services at Community Care, a private-sector residential care program, were analyzed. In addition to psychiatric services, the program offers instruction in living skills and vocational preparation, helps patients find jobs and housing, and operates an outpatient support network. Forty-two percent of the patients discharged during the study period achieved independence or near independence in the program and functioned at that level during a three-year follow-up period. Patients' level of education, degree of participation in the program, levels of residential and vocational achievement at discharge, and discharge status were significantly related to outcome. Patients with good participation in the program who stayed with the outpatient support network at discharge had at least a 95 percent probability of good outcome.

High-frequency oscillations in human electromyograms during voluntary contractions.

Spectral analysis was used to identify correlated sinusoidal frequency components in left and right side diaphragm electromyographic (EMG) recordings from human subjects during voluntary deep inspirations. In 31 of 33 subjects bilaterally correlated high-frequency oscillations were found in broad or narrow bands in the range of 60-84 and 16-40 Hz. To determine if such oscillations were associated also with bilaterally symmetric, phasic, voluntary activation of nonrespiratory muscles, we obtained EMG signals from left and right masseter muscles during clenching of the jaw; left and right sternomastoid muscles during lifting of the head against gravity; and left and right biceps muscles during lifting of a weighted bar. Weakly correlated frequency components, mainly at frequencies below 60 Hz, were found in the left and right masseter EMGs on at least one trial from 12 of 17 subjects. No bilaterally correlated frequency components were found during phasic contraction of biceps and sternomastoid muscles. Power spectra of biceps EMGs, however, sometimes exhibited peaks indicative of oscillations that were not bilaterally correlated. In nine subjects, correlated frequency components in the 60-84 Hz range were found in intercostal EMGs from the axillary region of the fifth interspace during voluntary deep inspirations but not during postural contractions. We conclude that high-frequency oscillations in the range of 60-84 Hz in diaphragm and intercostal EMGs are associated particularly with respiratory activation of respiratory muscles. These results support the hypothesis that high-frequency oscillations may be a manifestation of control of muscular contraction via a central pattern generator.