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IMPORTANCE: Although psychological distress is common among survivors of critical illness, there are few tailored therapies. OBJECTIVE: To determine the optimal method for delivering a mindfulness intervention via a mobile app for critical illness survivors. DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial used a 2 × 2 × 2 factorial design and was conducted at 3 sites among survivors of critical illness with elevated postdischarge symptoms of depression. The study was conducted between August 2019 and July 2023. INTERVENTIONS: Participants were randomized to 1 of 8 different groups as determined by 3 two-level intervention component combinations: intervention introduction method (mobile app vs therapist call), mindfulness meditation dose (once daily vs twice daily), and management of increasing symptoms (mobile app vs therapist call). MAIN OUTCOMES AND MEASURES: The primary outcome was the 9-item Patient Health Questionnaire (PHQ-9) depression scale score (range, 0-27) at 1 month. Secondary outcomes included anxiety (7-item Generalized Anxiety Disorder) and posttraumatic stress disorder (Posttraumatic Stress Scale) symptoms at 1 and 3 months, adherence, and feasibility. General linear models were used to compare main effects and interactions of the components among intervention groups. A formal decisional framework was used to determine an optimized intervention version. RESULTS: A total of 247 participants (mean [SD] age, 50.2 [15.4] years; 104 [42.1%] women) were randomized. Twice-daily meditation compared with once-daily meditation was associated with a 1.2 (95% CI, 0.04-2.4)–unit lower mean estimated PHQ-9 score at 1 month and a 1.5 (95% CI, 0.1-2.8)–unit lower estimated mean score at 3 months. The other 2 intervention components had no main effects on the PHQ-9. Across-group adherence was high (217 participants [87.9%] using the intervention at trial conclusion) and retention was strong (191 [77.3%] and 182 [73.7%] at 1 and 3 months, respectively). CONCLUSIONS AND RELEVANCE: A mindfulness intervention for survivors of critical illness that included an app-based introduction, twice-daily guided meditation, and app-based management of increasing depression symptoms was optimal considering effects on psychological distress symptoms, adherence, and feasibility. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04038567

IMPORTANCE: Vitamin C supplementation (500 mg/d) for pregnant smokers has been reported to increase offspring airway function as measured by forced expiratory flow (FEF) through age 12 months; however, its effects on airway function at age 5 years remain to be assessed. OBJECTIVE: To assess whether vitamin C supplementation in pregnant smokers is associated with increased and/or improved airway function in their offspring at age 5 years and whether vitamin C decreases the occurrence of wheeze. DESIGN, SETTING, AND PARTICIPANTS: This study followed up the Vitamin C to Decrease the Effects of Smoking in Pregnancy on Infant Lung Function (VCSIP) double-blind, placebo-controlled randomized clinical trial conducted at 3 centers in the US (in Oregon, Washington, and Indiana) between 2012 and 2016. Investigators and participants remain unaware of the treatment assignments. Forced expiratory flow measurements at age 5 years were completed from 2018 to 2021. INTERVENTIONS: Pregnant smokers were randomized to vitamin C (500 mg/d) or placebo treatment. MAIN OUTCOMES AND MEASURES: The primary outcome was the prespecified measurement of FEF between 25% and 75% expired volume (FEF25-75) by spirometry at age 5 years. Secondary outcomes included FEF measurements at 50% and 75% of expiration (FEF50 and FEF75), forced expiratory volume in 1 second (FEV1), and occurrence of wheeze. RESULTS: Of the 251 pregnant smokers included in this study, 125 (49.8%) were randomized to vitamin C and 126 (50.2%) were randomized to placebo. Of 213 children from the VCSIP trial who were reconsented into this follow-up study, 192 (90.1%) had successful FEF measurements at age 5 years; 212 (99.5%) were included in the analysis of wheeze. Analysis of covariance demonstrated that offspring of pregnant smokers allocated to vitamin C compared with placebo had 17.2% significantly higher mean (SE) measurements of FEF25-75 at age 5 years (1.45 [0.04] vs 1.24 [0.04] L/s; adjusted mean difference, 0.21 [95% CI, 0.13-0.30]; P < .001). Mean (SE) measurements were also significantly increased by 14.1% for FEF50 (1.59 [0.04] vs 1.39 [0.04] L/s; adjusted mean difference, 0.20 [95% CI, 0.11-0.30]; P < .001), 25.9% for FEF75 (0.79 [0.02] vs 0.63 [0.02] L/s; 0.16 [95% CI, 0.11-0.22]; P < .001), and 4.4% for FEV1 (1.13 [0.02] vs 1.09 [0.02] L; 0.05 [95% CI, 0.01-0.09]; P = .02). In addition, offspring of pregnant smokers randomized to vitamin C had significantly decreased wheeze (28.3% vs 47.2%; estimated odds ratio, 0.41 [95% CI, 0.23-0.74]; P = .003). CONCLUSIONS AND RELEVANCE: In this follow-up study of offspring of pregnant smokers randomized to vitamin C vs placebo, vitamin C supplementation during pregnancy resulted in significantly increased airway function of offspring at age 5 years and significantly decreased the occurrence of wheeze. These findings suggest that vitamin C supplementation for pregnant smokers may decrease the effects of smoking in pregnancy on childhood airway function and respiratory health. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03203603

Background: Antioxidant vitamins are thought to play a role in atherosclerosis. Supplementation of these nutrients has been explored as a means of reducing cardiovascular morbidity and mortality. Purpose: To assess the evidence of the effectiveness of vitamin supplementation, specifically vitamins A, C, and E; beta-carotene; folic acid; antioxidant combinations; and multivitamin supplements, in preventing cardiovascular disease. Data Sources: Cochrane Controlled Trials Registry and MEDLINE (1966 to September 2001), reference lists, and experts. Study Selection: The researchers selected English-language reports of randomized trials and cohort studies that assessed vitamin supplementation in western populations and reported incidence of or death from cardiovascular events. They also included reports of good- or fair-quality clinical trials of primary and secondary prevention and good- or fair-quality prospective cohort studies. Studies that examined only dietary nutrients or did not provide separate estimates for supplements were not included. Data Extraction: Two reviewers abstracted descriptive information and data on cardiovascular outcomes and mortality from included studies. The researchers assessed study quality using predetermined criteria. Data Synthesis: Evidence tables were constructed to summarize data from included studies. The researchers summarized the strength, level, and quality of the overall evidence for the effectiveness of each of the vitamin supplements in preventing or treating cardiovascular disease. Conclusions: Some good-quality cohort studies have reported an association between the use of vitamin supplements and lower risk for cardiovascular disease. Randomized, controlled trials of specific supplements, however, have failed to demonstrate a consistent or significant effect of any single vitamin or combination of vitamins on incidence of or death from cardiovascular disease. Understanding the sources of these differences will permit researches to better analyze the cohort study data and to better design long-term clinical trials.

Pregnant women who have blood in their urine have twice the risk of developing preeclampsia as other pregnant women, according to a study of 4,307 women. Preeclampsia is a serious complication of pregnancy.

Women who smoke but who quit when they learn they are pregnant do not have a lower risk of hypertension or preeclampsia during pregnancy. This is the conclusion of a study of 4,589 women, which contradicts other studies showing a reduced risk of hypertension and preeclampsia in pregnant women who smoke during pregnancy.

There appears to be no nutritional factor that can prevent preeclampsia, according to a study of 4,589 pregnant women. Preeclampsia is a serious complication of pregnancy.

Noncompliance with therapeutic diets remains a major obstacle to achieving improvements in cardiovascular disease (CVD) morbidity and mortality. This study compared dietary compliance and CVD risk factor response to two dietary interventions designed to treat hypertension, dyslipidemia, and diabetes mellitus. In a multicenter trial, 560 adults were randomly assigned to either a self-selected, mixed-food plan (n = 277), or a nutrient-fortified prepared meal plan (n = 283); each was designed to provide 15-20% of energy from fat, 55-60% from carbohydrate, and 15-20% from protein. Nutrient intake was estimated from 3-d food records collected biweekly throughout the 10-wk intervention. Compliance was determined by evaluating the participants' ability to meet specific criteria for energy intake [+ or -] 420 kJ (100 kcal) from the midpoint of the prescribed energy range], fat intake (< 20%, < 25%, or < 30% of energy from total fat), and the National Cholesterol Education Program/American Heart Association Step 1 and 2 diet recommendations. Compliance with energy, fat, and Step 1 and 2 criteria was better in participants who followed the prepared meal plan than in those who followed the self-selected diet (P < 0.0001). Compliant participants in both groups achieved greater reductions in body weight, systolic and diastolic blood pressure, and total and low-density-lipoprotein cholesterol than noncompliant participants (P < 0.05). In general, better endpoint responses were observed with lower fat intakes regardless of group assignment. The prepared meal plan is a simple and effective strategy for meeting the many nutrient recommendations for CVD risk reduction and improving dietary compliance and CVD endpoints. Am J Clin Nutr 1997;66:373-85.

Community intervention projects, efforts at single centers, and multicenter, prospective, dietary salt-restriction trials suggest that such an intervention is neither easy to achieve nor simple to maintain. Community-wide interventions based on advertisements, pamphlets, posters, radio messages, instructions in schools or other institutions, and cooperation from food suppliers such as butchers and bakers resulted in a slight decrease in salt consumption, mostly in normotensive women. A demonstration project at a single center showed that lowering salt intake longterm by 50% in hypertensive patients was feasible. That study included self-administered, positive-feedback devices to indicate adherence and a role for a household partner in achieving compliance. Multicenter intervention trials also indicate that reducing salt intake in the long term is feasible. However, in all intervention trials the subjects were highly selected, stable, generally married male volunteers. An elaborate training program involving many health care professionals was necessary and recidivism was common. Successful intervention requires specific goals and delegated responsibilities on the part of the health care team, careful assessment of the patient and the risk factors, as well as motivation for behavioral change, a specific plan for implementation, repetitive educational efforts, and a built-in monitoring mechanism.

Sodium restriction, widely prescribed for hypertensive persons and recommended for the broader US population, may result in nutrient alterations that could either beneficially or detrimentally affect overall diet quality. Most dietary sodium comes from meats (including poultry and fish), grains, and dairy products. These three groups also provide most dietary calcium, iron, magnesium, and vitamin B-6. Thus, reduced consumption of foods that are primary sodium sources could concurrently reduce the dietary content of these other nutrients below recommended daily intakes. This consequence of sodium restriction has not been specifically addressed in clinical trials. Although intake of most food groups was significantly reduced by a sodium-restricted diet in the Hypertension Prevention Trial, three other large clinical trials reported differing effects of sodium restriction on simultaneous energy and nutrient intakes. In the largest study of the effects of a sodium-restricted diet on intake of all major nutrients, sodium reduction was accompanied by lower energy intake and, concomitantly, lower intakes of total fat, saturated fat, protein, carbohydrate, and calcium. Present data are inadequate for determining the potential nutrient alterations of a broad prescription of sodium restriction. Difficulties in interpreting the available data result from the combination of sodium restriction with other interventions, intensive sodium reduction measures that do not reflect clinical implementation, poor compliance with sodium restriction, lack of analysis of changes in patterns of food intake, and interventions that are too short to reflect stable dietary patterns.

Background: Adherence to dietary recommendations for disease management is often hindered by the complexity of incorporating them into the daily diet. Nutrition and cardiovascular scientists and food technologists collaborated to develop a prepared meal plan that meets national dietary guidelines for cardiovascular risk reduction. Objective: To assess the clinical effects of this plan, which incorporates all National Academy of Sciences National Research Council recommended dietary allowances for vitamins, minerals, and macronutrients, compared with a patient-selected American Heart Association Step I and Step II diet plan. Methods: This multicenter, randomized, parallel-intervention trial was conducted at 10 medical centers in the United States and Canada and involved 560 men and women with hypertension, dyslipidemia, or diabetes. Following calculation of prescriptions to meet individual nutritional requirements based on the Harris-Benedict equation, participants were randomized to the Campbell's Center for Nutrition and Wellness (CCNW) plan, which is composed of prepackaged breakfast, lunch, and dinner meals provided to participants, or a nutritionist-guided American Heart Association Step I and Step II diet, in which participants self-selected foods to meet their nutrition prescription for 10 weeks. Main Outcome Measures: Blood pressure (BP); lipid, glucose, glycosylated hemoglobin ([HbA.sub.1c]), and insulin levels; body weight; dietary intake; and quality of life. Results: Patients' BP, lipid levels, carbohydrate metabolism, weight, and quality of life (P [equal to or less than] .001 for all findings except low-density lipoprotein-high-density lipoprotein ratio, P = .25) all improved on both nutrition plans. Mean differences ([plus or minus] SD) between baseline and treatment clinical values for the CCNW and the self-selected diet groups (between-group P values), respectively, were as follows: systolic BP, -6.4 [plus or minus] 9.2 mm Hg and -4.6 [plus or minus] 9.0 mm Hg (P = .02); diastolic BP, -4.2 [plus or minus] 5.7 mm Hg and -3.0 [plus or minus] 5.1 mm Hg (P = .006); cholesterol, -0.32 [plus or minus] 0.58 mmol/L and -0.27 [plus or minus] 0.56 mmol/L (-12.4 [plus or minus] 22.5 mg/dL and -10.4 [plus or minus] 21.9 mg/dL) (P = .30); glucose, -0.65 [plus or minus] 1.88 mmol/L and -0.75 [plus or minus] 2.03 mmol/L (-11.7 [plus or minus] 34.0 mg/dL and -13.5 [plus or minus] 36.6 mg/dL) (P = .10); and [HbA.sub,1c], -0.4% plus or minus] 0.8% and -0.3% [plus or minus] 0.7% (P = .66). Weight loss with the CCNW and self-selected plans, respectively, was as follows: men, -4.5 [plus or minus] 3.6 kg and -3.5 [plus or minus] 3.3 kg; and women, -4.8 [plus or minus] 3.0 kg and -2.8 [plus or minus] 2.8 kg. Quality of life was significantly improved for daily and work activities (P [is less than] .05) and nutritional health perceptions (P [is less than] .05) with the CCNW plan relative to the self-selected group. Overall nutrient intake and compliance were both significantly (P [is less than] .001) better with the CCNW plan. Conclusions: Nutritionally balanced meals that meet the recommendations of national health organizations improved multiple risk factors for patients with cardiovascular disease. The CCNW plan resulted in greater clinical benefits, nutritional completeness, and compliance than the self-selected diet. The CCNW is a comprehensive nutrition plan, convenient for both prescription and practice, and appears viable for effecting favorable dietary changes in patients at high risk for cardiovascular disease.

Current dietary recommendations for cardiovascular disease risk reduction and recommended dietary allowances (RDAs) were used to develop a nutritionally complete prepackaged prepared meal plan specifically designed to reduce the risk of cardiovascular disease. In the current study we tested patient acceptance of the diet as defined by measures of quality of life. In a randomized, parallel-design, multicenter clinical trial, 77 persons with hypertension, diabetes mellitus, dyslipidemia, or a combination of two or more of these conditions were recruited and randomly assigned to either a prepared meal plan (n = 39) or a comparable self-selected diet (n = 38) for 10 wk. The prepared meal plan met both the RDAs for all essential micronutrients and the dietary recommendations of national health organizations for macronutrients, cholesterol, sodium, and fiber. The prescribed self-selected diet was matched for macronutrients. Quality of life, as measured by a battery of instruments, was the major endpoint. Individuals consuming the prepared meal plan had significant improvements in mental health (P < 0.01), general perceived health (P < 0.005), daily activities (P < 0.05), work performance (P < 0.005), affect (P < 0.01), and nutritional health perceptions (P < 0.001), and reductions in nutrition hassles based on a standardized questionnaire (P < 0.001). The self-selected-diet group had significant improvements in nutritional health perceptions (P < 0.001) and affect (P < 0.001). There were significant improvements in weight (P < 0.001), blood pressure (P < 0.001), cholesterol (P < 0.002), low-density lipoproteins (P < 0.001), glucose (P < 0.014), and glycated hemoglobin (Hb [A.sub.1c]) (P < 0.004) that were comparable in both groups. In summary, this study shows that a nutritionally complete diet, whether prepackaged or self-selected, improves multiple risk factors for cardiovascular disease. The prepackaged prepared meal plan had the added benefit of a greater improvement in quality of life.

This study examined the feasibility of increasing food-derived calcium to 1500 mg d and the impact of this change on plasma lipids and nutrient consumption in hypertensive (n = 130) and normotensive (n = 196) participants. Three interventions were applied in a randomized, parallel, placebocontrolled fashion: 1) counseling to increase dietary calcium through food consumption to 1500 mg/d (n = 106), 2) a 1000-mg/d calcium supplement (n = 109), or 3) placebo (n = 111). Plasma lipids were measured before and after 12 wk of intervention whereas nutrient intake was monitored throughout the study. At baseline, hypertensive patients reported lower intakes of carbohydrates, calcium, magnesium, phosphorus, potassium, iron, vitamin D, thiamin, and riboflavin (all P < 0.05). They also had lower HDL (P = 0.014) and higher LDL (P < 0.05) compared with normotensive subjects. During intervention, calcium, magnesium, phosphorus, potassium, thiamin, riboflavin, and vitamins C and D increased (P < 0.01) in the group receiving food calcium but not in the placebo or supplement groups. No changes occurred in plasma lipids or lipoproteins after 12 wk of intervention.

Three hundred twenty-two consecutive operations between December 1985 and December 1989 for 10 types of low-risk congenital cardiac malformations were reviewed to determine the hospital charge and postoperative length of stay. Multiple regression analysis of variance was used to predict the influence of the primary diagnosis and various preoperative parameters. The average hospital charge was $27,262 [+ or -] $20,644 and the postoperative length of stay was 9.3 [+ or -] 8.3 days. Age at operation alone did not influence the dependent variables. The diagnosis of atrial septal defect (p = 0.002) or coarctation of the aorta (p = 0.002) decreased the mean charge, whereas the 8 other primary diagnoses did not significantly influence the mean charge. Other preoperative factors found to be predictive of increased hospital charge were: the date of operation (p 100 miles from home to hospital (p = 0.05). A primary diagnosis of atrial septal defect decreased the mean postoperative length of stay by 3.1 days (p

My grandfather was a near-victim of the 1918 outbreak ('Journal of the Plague Year'). Mistaken for dead, he was covered and placed near other bodies when he managed to blow [...]

We assess the productivity, outcomes, and experiences of participants in the National Institutes of Health/National Heart, Lung, and Blood Institute–funded K12 institutional research training programs in emergency care research.

Objective: To assess the long-term effects of a prepackaged, nutritionally complete, prepared meal plan compared with a usual-care diet (UCD) on weight loss and cardiovascular risk factors in overweight and obese persons. Design: In this randomized multicenter study, 302 persons with hypertension and dyslipidemia (n = 183) or with type 2 diabetes mellitus (n = 119) were randomized to the nutrient-fortified prepared meal plan (approximately 22% energy from fat, 58% from carbohydrate, and 20% from protein) or to a macronutrient-equivalent UCD. Main Outcome Measures: The primary outcome measure was weight change. Secondary measures were changes in blood pressure or plasma lipid, lipoprotein, glucose, or glycosylated hemoglobin levels; quality of life; nutrient intake; and dietary compliance. Results: After 1 year, weight change in the hypertension/ dyslipidemia group was -5.8 [+ or -] 6.8 kg with the prepared meal plan vs -1.7 [+ or -] 6.5 kg with the UCD plan (P [is less than] .001); for the type 2 diabetes mellitus group, the change was -3.0 [+ or -] 5.4 kg with the prepared meal plan vs - 1.0 [+ or -] 3.8 kg with the UCD plan (P [is less than] .001) (data given as mean [+ or -] SD). In both groups, both interventions improved blood pressure, total and low-density lipoprotein cholesterol levels, glycosylated hemoglobin level, and quality of life (P [is less than] .02); in the diabetic group, the glucose level was reduced (P [is less than] .001). Compared with those in the UCD group, participants with hypertension/dyslipidemia in the prepared meal plan group showed greater improvements in total (P [is less than] .01) and high-density lipoprotein (P [is less than] .03) cholesterol levels, systolic blood pressure (P [is less than] .03), and glucose level (P [is less than] .03); in participants with type 2 diabetes mellitus, there were greater improvements in glucose (P = .046) and glycosylated hemoglobin (P [is less than] .02) levels. The prepared meal plan group also showed greater improvements in quality of life (P [is less than] .05) and compliance (P [is less than] .001) than the UCD group. Conclusions: Long-term dietary interventions induced significant weight loss and improved cardiovascular risk in high-risk patients. The prepared meal plan simultaneously provided the simplicity and nutrient composition necessary to maintain long-term compliance and to reduce cardiovascular risk. Arch Intern Med. 2000;160:2150-2158

Background: Elevated blood homocysteine is a risk factor for cardiovascular disease. A 5-[micro]mol/L increase is associated with an [approximately equals] 70% increase in relative risk of cardiovascular disease in adults. For patients with established risk factors, this risk is likely even greater. Objective: Effects of increased dietary folate and recommended intakes of vitamins B-12 and B-6 on serum total homocysteine (tHcy) were assessed in individuals at high risk of cardiovascular disease. Design: This trial was conducted at 10 medical research centers in the United States and Canada and included 491 adults with hypertension, dyslipidemia, type 2 diabetes, or a combination thereof. Participants were randomly assigned to follow a prepared meal plan (PMP; n = 244) or a self-selected diet (SSD: n = 247) for 10 wk, which were matched for macronutrient content. The PMP was fortified to provide [is greater than or equal to] 100% of the recommended dietary allowances for 23 micronutrients, including folate. Results: Mean folate intakes at 10 wk were 601 [+ or -] 143 [micro]g/d with the PMP and 270 [+ or -] 107 [micro]g/d with the SSD. With the PMP, serum tHcy concentrations fell from 10.8 [+ or -] 5.8 to 9.3 [+ or -] 4.9 [micro]mol/L (P [is less than] 0.0001) between weeks 0 and 10 and the change was associated with increased intakes of folate, vitamin B-12, and vitamin B-6 and with increased serum and red blood cell folate and serum vitamin B-12 concentrations, tHcy concentrations did not change significantly with the SSD. Conclusions: The PMP resulted in increased intakes and serum concentrations of folate and vitamin B-12. These changes were associated with reduced serum tHcy concentrations in persons at high risk of cardiovascular disease. Am J Clin Nutr 1999:70:881-7. KEY WORDS Homocysteine, dietary folate, vitamin B-12, vitamin B-6, cardiovascular disease, randomized clinical trial, humans

Despite widely documented evidence that supports breastfeeding throughout the first year of life, many mothers quit breastfeeding earlier than intended. This retrospective review examined the effect of an International Board Certified Lactation Consultant (IBCLC) in the pediatric primary care setting on breastfeeding duration and exclusivity rates. In this study, access to an IBCLC in the pediatric primary care setting increased the odds of mothers breastfeeding longer than mothers who did not have such access. Neither term gestation nor previous history of childbirth affected the likelihood of mothers exclusively breastfeeding for 4–6 months or continuing breastfeeding for at least 1 year. Increasing maternal age did not increase the odds of exclusively breastfeeding until 4–6 months but did increase the odds of continuing to provide some breast milk for at least 1 year. The presence of an IBCLC in this setting was associated with increased breastfeeding duration even among women who had no direct interaction with the consultant. Integrating an IBCLC into the pediatric primary care setting may be a viable option to increase breastfeeding duration and exclusivity rates.

Populations at risk for esophageal adenocarcinoma remain poorly defined. Laryngeal symptoms can be secondary to laryngopharyngeal reflux (LPR) and can occur without associated gastroesophageal reflux symptoms such as heartburn and regurgitation.

HYPOTHESIS Screening for esophageal adenocarcinoma has focused on identifying Barrett esophagus (BE) in patients with severe, long-standing symptoms of gastroesophageal reflux disease (GERD). Unfortunately, 95% of patients who develop esophageal adenocarcinoma are unaware of the presence of BE before their cancer diagnosis, which means they never had been selected for screening. One possible explanation is that no correlation exists between the severity of GERD symptoms and cancer risk. We hypothesize that severe GERD symptoms are not associated with an increase in the prevalence of BE, dysplasia, or cancer in patients undergoing primary endoscopic screening. DESIGN Cross-sectional study. SETTING University hospital. PATIENTS A total of 769 patients with GERD. INTERVENTIONS Primary screening endoscopy performed from November 1, 2004, through June 7, 2007. MAIN OUTCOMES MEASURES Symptom severity, proton pump inhibitor therapy, and esophageal adenocarcinogenesis (ie, BE, dysplasia, or cancer). RESULTS Endoscopy revealed adenocarcinogenesis in 122 patients. An increasing number of severe GERD symptoms correlated positively with endoscopic findings of esophagitis (odds ratio, 1.05; 95% confidence interval, 1.01-1.09). Conversely, an increasing number of severe GERD symptoms were associated with decreased odds of adenocarcinogenesis (odds ratio, 0.94; 95% confidence interval, 0.89-0.98). Patients taking proton pump inhibitors were 61.3% and 81.5% more likely to have adenocarcinogenesis if they reported no severe typical or atypical GERD symptoms, respectively, compared with patients taking proton pump inhibitors, who reported that all symptoms were severe. CONCLUSIONS Medically treated patients with mild or absent GERD symptoms have significantly higher odds of adenocarcinogenesis compared with medically treated patients with severe GERD symptoms. This finding may explain the failure of the current screening paradigm in which the threshold for primary endoscopic examination is based on symptom severity.

Microorganisms are hypothesized to contribute to the pathogenesis of bronchopulmonary dysplasia (BPD) in very low birth weight (VLBW) infants. This hypothesis remains controversial. We sought to determine whether endotracheal colonization with Ureaplasmasp., adenovirus, or Chlamydiasp. increases the risk of BPD. Intubated VLBW infants were included. Polymerase chain reaction (PCR) analysis was used to detect Ureaplasmasp., adenovirus, and Chlamydiasp. The outcome measure was BPD or death due to lung disease. Detection of microorganisms was compared between subjects with and without BPD. Logistic regression was used to control for covariates. Of 139 subjects, 33 (25%) screened positive for Ureaplasmasp., 22 of 136 (16%) were positive for adenovirus; eight of 133 (6%) were positive for Chlamydiasp. At 36 wk postmenstrual age, 14 patients had died, 68 (57%) had BPD. Detection of Ureaplasma sp.was associated with BPD or death (p< 0.001); adenovirus (p0.52) and Chlamydia sp.(p0.33) were not. Controlling confounding factors, the odds ratio for Ureaplasma sp.and BPD or death was 4.2 (95% CI 1.03, 17). In our population, detection of Ureaplasma sp.,but not adenovirus or Chlamydia sp.was associated with BPD or death due to lung disease.

PTPN11 missense mutations cause approximately 50% of Noonan syndrome, an autosomal dominant disorder presenting with various congenital heart defects, most commonly valvar pulmonary stenosis, and hypertrophic cardiomyopathy. Atrioventricular septal defects and coarctation of the aorta occur in 15% and 9%, respectively. The aim of this study was to determine if PTPN11 mutations exist in non‐syndromic patients with these two relevant forms of congenital heart disease. The 15 coding PTPN11 exons and their intron boundaries from subjects with atrioventricular septal defects (n = 24) and coarctation of the aorta (n = 157) were analyzed using denaturing high performance liquid chromatography and sequenced if abnormal. One subject with an atrioventricular septal defect but no other known medical problems had a c.127C > T transition in exon 2, predicting a p.L43F substitution. This mutation affected the phosphotyrosine‐binding region in the N‐terminal src homology 2 domain and was close to a Noonan syndrome mutation (p.T42A). An otherwise healthy patient with aortic coarctation had a silent c.540C > T change in exon 5 corresponding to p.D180D. Our study showed that PTPN11 mutations are rarely found in two isolated forms of congenital heart disease that commonly occur in Noonan syndrome. The p.L43F mutation belongs to a rare class of PTPN11 mutations altering the phosphotyrosine‐binding region. These mutations are not predicted to alter the autoinhibition of the PTPN11 protein product, SHP‐2, which is the mechanism for the vast majority of mutations causing Noonan syndrome. Future studies will be directed towards understanding these rare phosphotyrosine binding region mutants. © 2005 Wiley‐Liss, Inc.

Restless legs syndrome (RLS) is a common entity affecting hemodialysis patients. Although the cause of RLS remains unclear, a number of therapies have been used successfully to treat the disorder. Gabapentin is an anticonvulsant shown to alleviate symptoms of RLS in two small studies of nonhemodialysis patients. Because it is excreted renally, gabapentin has a long half-life among hemodialysis patients and may be advantageous if proven effective. We conducted a randomized, double-blind, placebo-crossover study of gabapentin in the treatment of RLS among a population of hemodialysis patients. Sixteen patients identified with RLS were randomized to either gabapentin or placebo. After 6 weeks of treatment with 200 to 300 mg of gabapentin after each hemodialysis session, patients' RLS was reassessed. After a 1-week washout period, patients were switched from gabapentin to placebo or placebo to gabapentin. After another 6 weeks, patients' RLS was assessed again. Patient data were analyzed using both parametric and nonparametric means. Thirteen of the 16 original patients completed the study. Two patients dropped out because of lethargy (believed to be secondary to gabapentin), and 1 patient died secondary to myocardial infarction. Eleven patients responded to gabapentin, but not placebo (P< 0.01). One patient responded to both, and 1 patient responded to placebo, but not gabapentin. Gabapentin is an effective treatment for RLS in hemodialysis patients. © 2001 by the National Kidney Foundation, Inc.

OBJECTIVES

Objective: To determine maternal and perinatal outcomes in nulliparas with pregnancy-associated hypertension or preeclampsia.

Preterm birth (PTB), a pressing issue for US maternal-child health, disproportionately impacts women in Appalachia. Transvaginal ultrasound (TVU) cervical length (CL) screening is the most accurate PTB risk predictor but remains underutilized. This study characterizes the knowledge, attitudes and beliefs of patients with prior PTB concerning PTB prevention efforts and TVU CL screening.

To determine if eating between initial and delayed thallium images alters the appearance of the delayed thallium scan, a prospective study was performed; 184 subjects sent for routine thallium imaging were randomized into two groups, (1) those who ate a meal high in carbohydrates between initial and delayed thallium myocardial images (n=106), and (2) those who fasted (n = 78). The 021Tl images were interpreted in blinded fashion for global myocardial and pulmonary clearance of 201Tl and for the presence of transient or persistent 201Tl myocardial defects. The eating group had a significantly lower incidence of transient myocardial defects compared to the noneating group (7 percent vs 18 percent, respectively; p<0.05). The time between initial and delayed images and the incidence of exercise-induced ischemic ST-segment depression or pathologic Q waves on the electrocardiogram were not significantly different between the two groups. These data suggest that eating a high-carbohydrate meal between initial and delayed 201Tl images causes increased 201Tl myocardial clearance rates and may alter 201Tl myocardial redistribution over time.

From 1981 through June 1989, 59 children had surgery for a complete atrioventricular (AV) canal defect at Oregon Health Sciences University. We compared the morbidity, mortality, and hemodynamic status of 47 children with and 12 without Down's syndrome through review of operative, clinical, and cardiac catheterization records. Overall, 10 children with Down's syndrome have died, nine from cardiac cause within 90 days of surgery. The 2-year survival of these children was 77±6% as compared to 100% in children without Down's syndrome (p=0.08). Early age at surgery, the surgical anatomy of the AV canal, and gender had no significant effect on survival. Before surgery, the hemodynamic status of Down's syndrome and non-Down's syndrome children did not differ; in a small group of post-operative catheterization, right heart pressures and pulmonary vascular resistance remained significantly higher in the Down's syndrome as compared to non-Down's syndrome children. These trends to higher mortality and poorer postoperative hemodynamics in children with Down's syndrome may necessitate closer follow-up if confirmed in other cohorts.

Dietary calcium and sodium have been postulated to modify both bone mineral status and blood pressure regulation in humans and animals. The spontaneously hypertensive rat (SHR) manifests several defects in calcium metabolism that may contribute to its hypertension. Blood pressure and bone mineral status were measured in SHR and normotensive Wistar-Kyoto rats (WKY) as a marker of whole animal calcium metabolism. In addition, the effect of alterations in dietary calcium and sodium on bone status were examined. At 6 weeks of age, seven male SHR and seven male WKY were placed on a control diet. At the same age, 28 SHR and 28 WKY were randomized to four diets containing either 2.0% or 0.1% calcium and 1.0% or 0.25% sodium. Four markers of bone mineral status were analyzed; bone density measured by direct photon absorptiometry, and total bone calcium, phosphorus, and magnesium content measured by atomic absorption spectrophotometry. The SHR exhibited significantly lower levels (p < 0.001) of bone density and bone magnesium content than the WKY, whereas bone phosphorus and calcium did not differ between the two strains. The 2.0% calcium diets resulted in Increased bone density and bone calcium content, and lower bone magnesium in both strains. The 1.0% sodium diets were associated with decreased bone density in the SHR, but not in the WKY. These findings identify another indicator of disturbed calcium metabolism in the SHR that may be related to impaired renal calcium handling. They are consistent with previously reported reductions in renal calcium reabsorption and decreased intestinal calcium transport in older SHR.

Prologue:Despite the failure of government to act on comprehensive health system reform, the US, health care system is undergoing rapid and profound changes. Managed care plans continue to gain a foothold throughout the country. The security of many Americans' health care rises and falls with the fortunes of the U.S. economy, both here and abroad, because health care coverage is inextricably linked to employment status. Public programs such as Medicare and Medicaid are under unprecedented scrutiny by lawmakers intent on balancing the federal budget by sharply reducing their growth rates. Amid these changes, it is critical for health policymakers to know how Americans perceive their health care system and their coverage. The survey reported in this paper is an attempt to fill the information gap. Conducted by The Commonwealth Fund in 1994, the managed care survey examines the experiences with managed care by families who have employer health coverage in Boston, Los Angeles, and Miami. Karen Davis is president of The Commonwealth Fund, the nation s fourth-oldest private foundation. She holds a doctorate in economics from Rice University. Before joining Commonwealth, Davis chaired the Department of Health Policy and Management at the Johns Hopkins School of Hygiene and Public Health. Karen Scott Collins is a senior program officer at Commonwealth; she holds a medical degree from Cornell and a master of public health degree from Johns Hopkins. Cathy Schoen is director of special projects at the University of Massachusetts Labor Relations and Research Center; she holds a master s degree in economics from Boston University. Cynthia Morris is an associate in the office of communications at the Edna McConnell Clark Foundation; she holds a master of public health degree from Columbia University.Abstract:Enroliees' views of their health plans and physicians are important measures of the performance of the health care system. The Commonwealth Fund's 1994 survey of 3,000 adults in fee-for-service and managed care organizations documents enroliees' experiences with choosing a plan and satisfaction with that plan. Fee-for-service enroliees were more satisfied with their plan's access to and quality of care; managed care enroliees were more satisfied with their plan's cost, paperwork, and coverage of preventive care. The survey also found a high rate of involuntary plan changing, limited choice of physicians, and low levels of satisfaction among low-income managed care enroliees.

Objectives. The aim of this study was to determine the efficacy of implantable cardioverter-defibrillator (ICD) therapy in survivors of sudden cardiac death in whom no ventricular arrhythmias can be induced with programmed electrical stimulation.

General medical opinion has not accepted the contention that dietary sodium chloride causes hypertension. The findings of this report support the opinion that table salt is not as dangerous as the public has been led to think it is.

Objectives. This study sought to define 1) the risk of sudden death after operation for common congenital heart defects; and 2) factors associated with an increased risk of sudden death.

In order to characterize the day to day reproducibility of arrhythmias provoked during electrophysiologic stimulation, 114 patients with documented sustained clinical ventricular tachyarrhythmias were studied. Two baseline electrophysiologic tests were performed in the drugfree state and within 6 to 24 hours of one another. There was a significant increment (p ≤ 0.02) in the induction of sustained ventricular tachyarrhythmias as the number of programmed extrastimuli increased from one (10% induction) to four (64% induction). Provoked arrhythmias were observed to be more frequently nonreproducible (as reflected in a major change in rate or duration, or both, of an induced ventricular arrhythmia between baseline tests) as the number of extrastimuli increased from one (7%) to four (27%). Nonreproducibility with three and four extrastimuli was not significantly greater than when two extrastimuli were utilized. Electrophysiology-directed drug trials should be interpreted in light of this observed variability in induced arrhythmias.

Offspring of smokers who continue to smoke during pregnancy show adverse effects in their lung development, with lifelong decreases in pulmonary function. Clinical trials of smoking cessation during pregnancy have been ineffective. This randomized, double-blind, placebo-controlled study was performed to determine whether vitamin C supplementation decreases the effects of maternal smoking on newborn pulmonary function test (PFT) results.

Lipoic acid (alpha lipoic acid, thioctic acid) is a popular over-the-counter antioxidant and insulin-mimetic supplement under investigation in a variety of conditions including multiple sclerosis, diabetes, and schizophrenia. Unfortunately, high-grade proteinuria was an unexpected adverse event specific to the treatment arm of our clinical trial investigating lipoic acid supplementation in patients with multiple sclerosis. This observation led to detection of similar patients in our nephrology practice. Here, we describe four biopsy-proven cases of neural epidermal growth factor-like 1 (NELL1)-associated membranous nephropathy following lipoic acid supplementation and a fifth suspected case. Discontinuation of lipoic acid and supportive therapy resulted in remission.

Presents suggestions for hair care for African-Americans from hair care professionals in the United States. Includes Ali N. Syed, president of Avlon; Rudy Townsel, salon manager for Naomi Sims Beauty Centers; Importance of bonding ingredients in shampoos; Botanical shampoos.