Outcomes of Acute Pancreatitis in Hospitalized Patients With Generalized Anxiety Disorder.

Introduction Acute pancreatitis (AP) is a common cause of hospitalization in the United States. There is evidence that chronic stress increases the risk for more severe AP episodes. One common form of chronic stress is generalized anxiety disorder (GAD). The purpose of this research was to investigate the impact of GAD on the outcomes of adult patients admitted to the hospital with AP. Methods Utilizing the 2014 National Inpatient Sample database and International Classification of Diseases, Ninth Edition Revision (ICD) codes, AP patients were selected. Common inpatient outcomes of AP patients with and without GAD were examined. The outcomes studied were acute renal failure, acute respiratory failure, sepsis, acute deep vein thrombosis, myocardial infarction, intestinal perforation, and inpatient mortality. A multivariate logistic regression analysis was conducted to assess if GAD was an independent predictor for these outcomes. Results Among 82,156 adult patients hospitalized for AP during the 2014 year, 10,611 of them had coexisting GAD. AP patients with comorbid GAD were found to have an increased likelihood of acute renal failure (aOR = 1.19, 95% confidence interval (CI) = 1.11-1.28, p < 0.001), sepsis (aOR = 1.09, 95% CI = 1.01 -1.19, p = 0.037), acute deep vein thrombosis (aOR = 1.63, 95% CI = 1.06-2.50, p = 0.025), and inpatient mortality (aOR = 1.62, 95% C = I 1.27-2.08, p < 0.001). There was no statistically significant difference found between the two cohorts for the outcomes of myocardial infarction and intestinal perforation. Conclusion In patients hospitalized with AP, those with coexisting GAD were found to have an increased risk of developing acute renal failure, sepsis, acute deep vein thrombosis, and inpatient mortality. There may be benefits to identifying AP patients with comorbid GAD at the time of admission and monitoring them more carefully during their hospitalization to help identify early signs of complications or prevent the negative outcomes seen in this study.

Outcomes of Gastroparesis in Hospitalized Patients With Generalized Anxiety Disorder.

Background   Gastroparesis is a common gastrointestinal pathology that has been increasing in prevalence and represents a significant cost to the United States healthcare system. Gastroparesis is associated with psychological dysfunction, including generalized anxiety disorder (GAD). GAD is known to be a prevalent and chronic manifestation of anxiety, which has been increasing in prevalence since the year 2020. Despite the association between gastroparesis and GAD, there has been limited research on the possible impact GAD may have on the morbidity and mortality of patients hospitalized for gastroparesis, which is further evaluated in this study.   Methods   Using the Nationwide Inpatient Sample from the year 2014, a retrospective study was conducted to assess the outcomes of hospitalized gastroparesis patients with and without a history of GAD. In this study, the analyzed outcomes included acute kidney injury (AKI), acute respiratory failure, sepsis, acute deep vein thrombosis, myocardial infarction, intestinal obstruction, and inpatient mortality. To assess whether GAD is an independent risk factor for the outcomes, a multivariate logistic regression analysis was used.   Results   There were 22,150 patients with gastroparesis assessed in this study; GAD was found to be a comorbid diagnosis in 4,196 of those patients. In the GAD cohort, there was an elevated risk for AKI (adjusted odds ratio 1.24, p < 0.001). The adjusted odds ratios for acute respiratory failure, sepsis, acute deep vein thrombosis, myocardial infarction, intestinal obstruction, and inpatient mortality did not meet the threshold for statistical significance.   Conclusion   In hospitalized gastroparesis patients, GAD is a risk factor for AKI. This finding may be attributed to prerenal azotemia due to an increased risk of nausea and vomiting associated with GAD, as well as the medications used to treat GAD such as escitalopram and duloxetine. In addition, the dual inflammatory states caused by the co-existence of both GAD and gastroparesis may also have a role in increasing the risk for AKI. The results of this study may become increasingly relevant given the increasing prevalence of GAD. .

Outcomes of Patients Hospitalized for Acute Diverticulitis With Comorbid Generalized Anxiety Disorder.

Introduction Diverticular disease and anxiety disorders are common in the general population. Prior research on diverticular disease showed that these patients have an increased frequency of anxiety and depression. The objective of this study was to explore the impact of generalized anxiety disorder (GAD) on the outcomes of adult patients admitted with acute diverticulitis. Methods Using the National Inpatient Sample database from the year 2014 and International Classification of Diseases, Ninth Edition Revision, Clinical Modification (ICD-9 CM) codes, acute diverticulitis patients were selected. The outcomes of diverticulitis patients with and without GAD were explored. The outcomes of interest included inpatient mortality, hypotension/shock, acute respiratory failure, acute hepatic failure, sepsis, intestinal abscess, intestinal obstruction, myocardial infarction, acute renal failure, and colectomy. A multivariate logistic regression analysis was performed to determine if GAD is an independent predictor for the outcomes. Results Among 77,520 diverticulitis patients in the study, 8,484 had comorbid GAD. GAD was identified as a risk factor for intestinal obstruction (adjusted odds ratio (aOR) 1.22, 95% CI: 1.05-1.43, p<0.05), and intestinal abscess (aOR 1.19, 95% CI: 1.10-1.29, p<0.05). GAD was found to be a protective factor for hypotension/shock (aOR 0.83, 95% CI: 0.76-0.91, p<0.05) and acute respiratory failure (aOR 0.76, 95% CI: 0.62-0.93, p<0.05). The aORs of sepsis, inpatient mortality, myocardial infarction, acute renal failure, and colectomy were not statistically significant. Conclusions Patients with acute diverticulitis who are also diagnosed with GAD are at increased risk for intestinal obstruction and intestinal abscess, which may be due to the influence GAD has on the gut microbiota as well as the impact of GAD pharmacotherapy on gut motility. There was also a decreased risk for acute respiratory failure and hypotension/shock appreciated in the GAD cohort which may be attributable to the elevated healthcare resource utilization seen generally in GAD patients, which may allow for presentation to the emergency department, hospitalization, and treatment earlier in the diverticulitis disease course.

Outcomes of Patients Who Developed Clostridioides difficile Infection During Hospitalization and Had a History of Comorbid Post-Traumatic Stress Disorder.

INTRODUCTION: Clostridioides difficile (C. difficile), is a common cause of nosocomial diarrhea. Antibiotic use is a risk factor for developing C. difficile infection (CDI). Clinical presentations of CDI range from mild diarrhea to fulminant colitis. A history of anxiety increases the risk of developing irritable bowel syndrome following CDI. Post-traumatic stress disorder (PTSD) is a common form of anxiety and is associated with several medical comorbidities. This study explores the impact PTSD has on the outcomes of adult patients who develop CDI while hospitalized. METHODS: Hospitalized adults who had developed CDI were selected from the 2014 National Inpatient Sample database using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9) codes. The outcomes of CDI patients with and without comorbid PTSD were explored. The outcomes assessed in this study were inpatient mortality, sepsis, hypotension/shock, acute renal failure, acute respiratory failure, megacolon, colonic perforation, and intestinal abscess. Independent t-tests and chi-squared tests were used to compare means and proportions, respectively. A multivariate logistic regression analysis was utilized to determine whether PTSD is an independent predictor of the outcomes. RESULTS: Among 72,383 hospitalized adults who developed CDI in the year 2014, 465 also had a diagnosis of PTSD. PTSD was found to be an independent risk factor for inpatient mortality (adjusted odds ratio {aOR} 2.93, 95% confidence interval (CI): 1.39-6.21, p = 0.005), and sepsis (aOR 1.61, 95% CI: 1.24-2.07, p = 0.001). However, PTSD was not a risk factor for hypotension/shock (aOR 1.26, 95% CI: 0.97-1.63, p = 0.080), acute renal failure (aOR 1.02, 95% CI: 0.81-1.28, p = 0.895), or acute respiratory failure (aOR 1.15, 95% CI: 0.83-1.58, p = 0.412) in patients with CDI. Due to small sample sizes of patients who developed megacolon, colonic perforation, and intestinal abscess, further analysis of these outcomes was not performed. CONCLUSION: Inpatients who develop CDI with comorbid PTSD are at increased risk for sepsis and inpatient mortality. These findings may be due to the impact of PTSD's dysregulation of the hypothalamic-pituitary axis leading to low cortisol production, increased serum cytokine concentrations, and/or increased intestinal inflammation. Awareness of these increased risks when triaging CDI patients with PTSD and possibly increased psychiatric interventions to treat PTSD may be necessary to help reduce the risk of sepsis and inpatient mortality in this subgroup of patients.

Outcomes of Inflammatory Bowel Disease in Hospitalized Patients With Generalized Anxiety Disorder.

Background The development of inflammatory bowel disease (IBD), which encompasses ulcerative colitis and Crohn's disease, is multifactorial. Stress from anxiety is a risk factor for IBD. Generalized anxiety disorder (GAD) is twice as likely in IBD patients. This study explores the outcomes of patients hospitalized for IBD with comorbid GAD. Methods A retrospective analysis utilizing the 2014 USA National Inpatient Sample database was performed to assess the outcomes of hospitalized IBD patients with and without GAD. The outcomes analyzed were sepsis, acute hepatic failure, hypotension/shock, acute respiratory failure, acute deep vein thrombosis, acute renal failure, intestinal obstruction, myocardial infarction, ileus, inpatient mortality, colectomy, intestinal abscess, intestinal perforation, and megacolon. A multivariate logistic regression analysis was employed to explore whether GAD is a risk factor for these outcomes. Results Among 28,173 IBD hospitalized patients in the study, GAD was a comorbid diagnosis in 3,400 of those patients. IBD patients with coexisting GAD were found to be at increased risk for acute hepatic failure (adjusted odds ratio (aOR) 1.80, p = 0.006), sepsis (aOR 1.33, p < 0.001), acute respiratory failure (aOR 1.24, p = 0.018), inpatient mortality (aOR 1.87, p < 0.001), intestinal abscess (aOR 2.35, p = 0.013), and intestinal perforation (aOR 1.44, p = 0.019). The aORs for the remaining outcomes were not statistically significant. Conclusions In hospitalized IBD patients, GAD is a risk factor for sepsis, acute hepatic failure, acute respiratory failure, intestinal abscess, intestinal perforation, and inpatient mortality. IBD and GAD are becoming increasingly common, which will likely lead to a larger number of complications among inpatients with these comorbidities.

Conversations on Diagnostic Uncertainty and Its Management Among Pediatric Acute Care Physicians.

OBJECTIVE: Diagnosis is a complex, iterative, and nonlinear process, often occurring over time. When presenting signs, symptoms, and diagnostic testing cannot be integrated into a diagnosis, clinicians are confronted with diagnostic uncertainty. Our aim was to study the self-reported cognitive, communication, and management behaviors of pediatric emergency medicine (PEM) and pediatric hospital medicine (PHM) physicians regarding diagnostic uncertainty. METHODS: A qualitative study was conducted through focus groups with PEM and PHM physicians in a large academic pediatric medical center. Four focus groups were conducted. Interviews were recorded, deidentified, and transcribed by a team member. Thematic analysis was used to review the transcripts, highlight ideas, and organize ideas into themes. RESULTS: Themes were categorized using the model of the diagnostic process from the National Academy of Sciences. "Red flags" and "gut feelings" were prominent during the information, integration, and interpretation phases. To combat diagnostic uncertainty, physicians employed strategies such as "the diagnostic pause" and having a set of "fresh eyes" to review the data. It was important to all clinicians to rule out any "cannot miss" diagnoses. Interphysician communication was direct; communication with patient and families about uncertainty was less direct because of physician concern of being thought of as untrustworthy. Contingency planning, "disposition over diagnosis" by ensuring patient safety, the "test of time," and availability of resources were techniques used by physicians to manage diagnostic uncertainty. CONCLUSIONS: Physicians shared common mitigation strategies, which included consulting colleagues and targeting cannot miss diagnoses, but gaps remain regarding communicating diagnostic uncertainty to families.

Preparing for a Career in Pediatric Hospital Medicine: A Needs Assessment and Recommendations for Individualized Curricula.

OBJECTIVES: The individualized curriculum within residency programs allows residents to tailor their elective time toward future career goals and interests. Our objective was to identify experiences and activities that would foster resident interest and enhance preparation for a career in pediatric hospital medicine (PHM). METHODS: Electronic surveys were distributed to pediatric hospitalists, PHM fellowship directors, and graduating PHM fellows. These stakeholders were asked to identify key experiences for residents to explore before entering fellowship or practice. Descriptive statistics and thematic analysis were performed on survey responses. RESULTS: Forty-six percent of PHM fellows (16 of 35), 42% of pediatric hospitalists (149 of 356), and 58% of fellowship program directors (35 of 60) completed the survey. All 3 groups identified complex care as the most important clinical experience to gain in residency. Other highly valued clinical experiences included pain management, surgical comanagement, and palliative care. Lumbar puncture, electrocardiograph interpretation, and airway management were identified as essential procedural skills. Nonclinical experiences that were deemed important included quality improvement, development of teaching skills, and research methodology. All groups agreed that these recommendations should be supplemented with effective mentorship. CONCLUSIONS: Identification of key clinical experiences, nonclinical activities, and mentorship for residents interested in PHM may assist with tailoring the individualized curriculum to personal career goals. Incorporating these suggested experiences can improve preparedness of residents entering PHM.

Development of strategic social information seeking: Implications for cumulative culture.

Human learners are rarely the passive recipients of valuable social information. Rather, learners usually have to actively seek out information from a variety of potential others to determine who is in a position to provide useful information. Yet, the majority of developmental social learning paradigms do not address participants' ability to seek out information for themselves. To investigate age-related changes in children's ability to seek out appropriate social information, 3- to 8-year-olds (N = 218) were presented with a task requiring them to identify which of four possible demonstrators could provide critical information for unlocking a box. Appropriate information seeking improved significantly with age. The particularly high performance of 7- and 8-year-olds was consistent with the expectation that older children's increased metacognitive understanding would allow them to identify appropriate information sources. Appropriate social information seeking may have been overlooked as a significant cognitive challenge involved in fully benefiting from others' knowledge, potentially influencing understanding of the phylogenetic distribution of cumulative culture.

Comparing traditional, immersive simulation with Rapid Cycle Deliberate Practice in postgraduate year 2 anesthesiology residents.

BACKGROUND: Rapid Cycle Deliberate Practice (RCDP) is an increasingly popular simulation technique that allows learners to achieve mastery of skills through repetition, feedback, and increasing difficulty. This manuscript describes the implementation and assessment of RCDP in an anesthesia residency curriculum. METHODS: Researchers describe the comparison of RCDP with traditional instructional methods for anesthesiology residents' application of Emergency Cardiovascular Care (ECC) and communication principles in a simulated environment. Residents (n = 21) were randomly assigned to either Traditional or RCDP education groups, with each resident attending 2 days of bootcamp. On their first day, the Traditional group received a lecture, then participated in a group, immersive simulation with reflective debriefing. The RCDP group received education through an RCDP simulation session. On their second bootcamp day, all participants individually engaged in an immersive simulation, then completed the "Satisfaction and Self-Confidence in Learning" survey. Application of ECC and communication principles during the simulation was scored by a blinded reviewer through video review. Participants ended the bootcamp by ranking the experiences they found most valuable. RESULTS: No significant differences were found in the different group members' individual performances during the immersive simulation, nor in the experiences they deemed most valuable. However, the Traditional education group reported higher levels of satisfaction and self-confidence in learning in 5 areas (p = 0.004-0.04). CONCLUSIONS: Regardless of RCDP or Traditional education grouping, anesthesia residents demonstrated no difference in ECC skill level or perceived value of interventions. However, members of the Traditional education group reported higher levels of satisfaction and self-confidence in numerous areas. Additional RCDP opportunities in the anesthesia residency program should be considered prior to excluding it as an educational method in our program.

Should adult ventilated patients on the intensive care unit be fasted preoperatively?

In the absence of separate guidelines for critically unwell ventilated patients in the intensive care unit who are undergoing surgery, questions arise about whether patients in intensive care should be starved preoperatively, despite already having a protected airway.

Declaring Uncertainty: Using Quality Improvement Methods to Change the Conversation of Diagnosis.

BACKGROUND: Diagnostic uncertainty may be a sign that a patient's working diagnosis is incorrect, but literature on proactively identifying diagnostic uncertainty is lacking. Using quality improvement methodologies, we aimed to create a process for identifying patients with uncertain diagnoses (UDs) on a pediatric inpatient unit and communicating about them with the interdisciplinary health care team. METHODS: Plan-do-study-act cycles were focused on interdisciplinary communication, structured handoffs, and integration of diagnostic uncertainty into the electronic medical record. Our definition of UD was as follows: "you wouldn't be surprised if the patient had a different diagnosis that required a change in management." The primary measure, which was tracked on an annotated run chart, was percentage agreement between the charge nurse and primary clinician regarding which patients had a UD. Secondary measures included the percentage of patient days during which patients had UDs. Data were collected 3 times daily by text message polls. RESULTS: Over 13 months, the percentage agreement between the charge nurse and primary clinician about which patients had UDs increased from a baseline of 19% to a median of 84%. On average, patients had UDs during 11% of patient days. CONCLUSIONS: We created a novel and effective process to improve shared recognition of patients with diagnostic uncertainty among the interdisciplinary health care team, which is an important first step in improving care for these patients.

Uncertain diagnoses in a children's hospital: patient characteristics and outcomes.

BACKGROUND: A quality improvement initiative at our institution resulted in a new process for prospectively identifying pediatric hospital medicine (PHM) patients with uncertain diagnoses (UD). This study describes the clinical characteristics and healthcare utilization patterns of patients with UD. METHODS: This single center cross-sectional study included all PHM patients identified with UD during their admission. A structured chart review was used to abstract patient demographics, primary symptoms, discharge diagnoses, and healthcare utilization patterns, including consult service use, length of stay (LOS), escalation in care, and 30-day healthcare reutilization. Appropriate descriptive statistics were used for categorical and continuous variables. RESULTS: This study includes 200 PHM patients identified with UD. Gastrointestinal symptoms were the primary finding in 45% of patients with UD. Consult service use was highly variable, with a range of 0-8 consult services for individual patients. The median LOS was 1.6 days and only 5% required a rapid response team evaluation. As for reutilization, 7% of patients were readmitted within 30 days. CONCLUSIONS: This descriptive study highlights the heterogeneity of patients with uncertain diagnoses. Ongoing work is needed to further understand the impact of UD and to optimize the care of these patients.

Nutrition and Preventative Medicine Across the Lifespan: Implementation of a Physician Assistant Team-Based Learning Curriculum on Pediatric Preventative Medicine.

PURPOSE: Physician assistants (PAs) will increasingly fill an important primary care gap in pediatrics. This study implemented a pediatric preventative care curriculum using a team-based learning (TBL) strategy and then evaluated the effect on first-year PA students' knowledge and attitudes toward TBL as a teaching method. METHODS: The curriculum was developed and implemented during a one-semester course. Students completed knowledge-based questions precourse and postcourse; the mean scores for individual students were then compared using a paired t test. Descripted statistics were used to analyze the postcourse survey that evaluated students' attitudes toward TBL. RESULTS: Of the 31 PA students who participated, 27 (87%) completed the surveys and were included in the analysis. The mean correct pretest and posttest scores were 17/39 and 31/39, respectively, resulting in a change of 14 points (p < .05). The majority of students (85%) rated TBL as effective, and most students (75%) reported that it led to retention of the presented content. CONCLUSIONS: A TBL-based curriculum in pediatric preventative care was effective in increasing PA student knowledge, and the students reported it as effective. This strategy could be considered for other PA courses.

Saving the Male Breast: A Systematic Literature Review of Breast-Conservation Surgery for Male Breast Cancer.

BACKGROUND: Male breast cancer (MBC) management is extrapolated from female BC. Mastectomy remains the most frequently used surgical procedure for male breast cancer (MBC). We performed a literature review to assess the use of breast-conservation (BCS) in MBC as well as outcomes following BCS. METHODS: A systematic literature was performed, and articles screened to identify studies that measured overall survival (OS), disease-free survival (DFS), or local recurrence (LR) in patients undergoing BCS. Weighted averages based on study size were performed for LR, DFS, and 5-year OS. RESULTS: Eight studies met the inclusion criteria with male breast surgery cases, and 859 (14.7%) underwent BCS. The mean follow-up time was 53 months, and mean age was 62.6 years, with stage II as the most common presentation. Two studies reported that 50-71.4% of patients underwent sentinel lymph node biopsy, and four studies reported axillary lymph node dissection in 14.3-100%. Five studies reported on adjuvant radiation therapy in 12.0-100% of total patients undergoing BCS. Four studies reported use of hormonal therapy in 73.8-100% of patients. Four studies reported use of chemotherapy in 25-66.7% of patients. Seven studies reported LR among 116 patients, with a weighted average of 9.9%. Three studies reported on DFS in 14 patients, with a weighted average 85.6%. Two studies report OS in 143 patients with a weighted average of 84.4%. CONCLUSIONS: Breast conservation may be considered a safe alternative in the surgical treatment of MBC. Future research should focus on better standardization of local therapy for MBC and improved reporting of outcomes.

Neutropenic enterocolitis in a child with acute myeloid leukemia successfully treated with early surgical intervention.

Neutropenic entrocolitis (NE) is a life threatening complication of acute leukemia. The case presented here is of a 12 year old boy with acute myeloid leukemia, who developed neutropenic enterocolitis after induction with BFM-93 protocol. Patient underwent exploratory laparotomy during grade 4 neutropenia after failure on conservative line of management of NE. Patient withstood the procedure with supportive care and recovered. This case is reported because NE is a rare but potentially fatal complication and there are no clear guidelines for surgical intervention.

A retrospective study of central venous catheters GCRI experience.

BACKGROUND: The use of central venous catheters (CVCs) has greatly improved the quality-of-care in cancer patients, yet these catheters may cause serious infectious and thrombotic complications. The aim of this retrospective study was to study the various types of CVCs and their complications. MATERIALS AND METHODS: We studied retrospectively 213 cases of CVCs in our institute with their indications, type and complications from August 2010 to July 2011. RESULTS: A total of 213 CVCs were inserted in patients with hematological (62%) and solid organ malignancies (38%). Ninety-eight patients (46%) had peripheral inserted central catheter (PICC), 90 (42%) patients had Hickman catheters and 25 (12%) had a port. The median duration of retention of Hickman catheters was 104 days (3-365 days), for the peripherally inserted central catheters was 59 days (3-100 days) and for the port it was 280 days (45-365 days). Non-infective complications were more than infective (12% vs. 7%). The most common complication was non-infective occlusion and thrombophlebitis. In one patient with PICC thrombosis occurred in the cephalic, radial and ulnar vein and in one patient with port thrombosis occurred in the superior vena cava. Organisms were isolated in 60% (12 out of 20) of cultures. Common organisms isolated were Pseudomonas aeruginosa in 5 (42%), Staphylococcus aureus in 2 (16%), Escherichia coli in 2 (16%) and Aspergillus in 3 (25%) patients. 7 out of 12 infected patients had negative blood cultures within 7 days of antibiotic treatment, 5 patients remained positive for more than 7 days with antibiotics. In 155 patients (73%), the desired treatment protocol was completed and at present there are still 28 patients (13%) with catheters. 5 patients (2.3%) died of febrile neutropenia and septicemia with multi-organ failure. In 5 patients (2.3%), the catheters (1 Port, 1 Hickman and 3 PICC) were prematurely removed because of thrombosis. CONCLUSION: CVCs are better options to facilitate the long-term vascular access provided infection is prevented with meticulous care and treated promptly with proper antibiotics. Most CVCs is acceptable to patients.

Inverse correlation of serum paraoxonase and homocysteine thiolactonase activities and antioxidant capacity of high-density lipoprotein with the severity of cardiovascular disease in persons with type 2 diabetes mellitus.

Atherosclerotic risk is increased in diabetes partly because of increased plasma levels of the oxidized low-density lipoprotein and homocysteine, 2 independent and important cardiovascular disease (CVD) risk factors. Paraoxonase (PON) is a multifunctional antioxidant enzyme component of high-density lipoprotein (HDL), which can protect against low-density lipoprotein (LDL) oxidation. It also exhibits homocysteine thiolactonase (HCTL) activity that detoxifies homocysteine thiolactone, which can damage proteins by homocysteinylation of the lysine residues, thus leading to atherosclerosis. We conducted a cross-sectional study to correlate PON-1, HCTL activities, and the lag time of LDL oxidation in 15 healthy control subjects and in 55 subjects with type 2 diabetes mellitus with different degrees of CVD. Compared with healthy controls and diabetic subjects without evidence of overt CVD, we not only found 47% (P < .005) decrease in PON-1 activity, but also for the first time, 30% (P = .019) decrease in HCTL activity in subjects with a prior coronary artery bypass surgery. There was corresponding decreased effectiveness of HDLs from diabetic groups (with and without CVD) in protecting against LDL oxidation. Moreover, the PON-1 activity was significantly inversely correlated to the extent of intracoronary lesions determined at catheterization (ie, a high Gensini score). These decreases in PON-1 and HCTL activity were not due to any bias in preferential distribution of low-activity QQ homozygotes in the diabetic groups compared with the control group because QQ allele was equally distributed in all the experimental groups, whereas RR allele tended to increase in the diabetic subjects with coronary artery bypass surgery compared with the other groups. Therefore, clinical intervention to restore the impaired antiatherogenic activities of HDL should be considered an important goal in the treatment of persons with diabetes.