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Background: Left ventricular ejection fraction (EF) is a valuable prognostic index in patients with congestive heart failure (CHF). Although EF can be readily measured, many clinicians use roentgenographic heart size as a clue to differentiate systolic from diastolic dysfunction, even in the absence of solid supportive data. Objective: To test the hypothesis that the cardiothoracic ratio (CTR) measured from the chest roentgenogram can be used to estimate left ventricular EF in individuals with CHF. Methods: To answer this question, the database of the Digitalis Investigation Group trial was used. The CTR, determined using the Danzer method, and quantitative EF, measured locally using angiographic, radionuclide, or 2-dimensional echocardiographic techniques, were compared in 7476 patients with clinical CHF (New York Heart Association functional classes I-IV) due to acquired left-sided cardiac disease of ischemic, hypertensive, idiopathic, and alcohol-related causes. Results: Mean ([+ or -] SD) CTR for the cohort was 0.53 [+ or -] .07. Mean ([+ or -] SD) EF was 31.7% [+ or -] 12.2%. A weak, negative correlation between CTR and EF was observed (r=-0.176). Similar findings were obtained when the results were stratified by cause of CHF, presence of clinically defined right ventricular dysfunction, and method of EF measurement. Categorical analysis failed to yield a CTR cutoff point that facilitated useful segregation of individuals with an EF greater than 35% or 35% and below; greater than 40% or 40% and below; and greater than 45% or 45% and below in any patient group. Conclusions: Although a weak, negative correlation exists between CTR and EF, this relationship does not allow for accurate determination of systolic function in individual patients with CHF. Considering the morbidity and mortality associated with CHF, and the clinical implications of systolic function in this syndrome, direct measurement of EF is recommended. Arch Intern Med. 1998;158:501-506

To assess the perceptions and attitudes of pharmacists and pharmacy technicians involved in an office-based opioid dependence treatment program using buprenorphine/naloxone.

We evaluate the efficacy of medical therapy on nocturia in men with benign prostatic hyperplasia (BPH).

The benefits of the long-term administration of oral anticoagulant therapy remain unclear in patients with lower extremity arterial bypass surgery. We studied the effect of warfarin plus aspirin therapy (WASA) versus aspirin therapy alone (ASA) on patient mortality, morbidity and bypass patency rates in a randomized clinical trial.

OBJECTIVES

• Nursing homes have played a major role in deinstitutionalization, and their increased use for the mentally ill has been questioned. We performed a controlled study of nursing homes as an alternative to continued psychiatric hospitalization. Men (N = 403) referred for nursing home placement from eight Veterans Administration medical centers were randomly assigned to community nursing homes (CNHs), Veterans Administration nursing care units, continued care on the same ward, or transfer to another psychiatric ward. Patients met defined criteria for schizophrenia or organic brain disease. Data were collected before random assignment and six and 12 months later, covering physical and mental function, psychopathology, mood, social adjustment, satisfaction with care, as well as drug use, characteristics of settings, and movement in and out of settings. Significant differences between settings were found in self-care, behavioral deterioration, mental confusion, depression, and satisfaction with care. Results were strikingly consistent, showing the group transferred to another ward doing better and the CNH group doing worse. Drug use did not differ from six months before entering the study or later between the settings. Cost showed a marked advantage for the CNH group. Thus, the less costly community nursing home alternative must be viewed in the context of the non-monetary costs of less favorable patient outcome.

Background/Aims:Few studies have compared the precision of various diagnostic tests used to determine the presence of Barrett's esophagus. The aim of this study was to compare the results of histological, endoscopic, and manometric tests for patients with Barrett's esophagus in two closely spaced examinations. Methods:In a Veterans Administration Cooperative Study, 192 patients with complicated gastroesophageal reflux disease had esophageal manometry and endoscopy performed at baseline and after 6 weeks. At each examination, the endoscopist localized the most proximal level of Barrett's epithelium and the lower esophageal sphincter and obtained esophageal biopsy specimens. Results:One hundred sixteen patients met the criteria for Barrett's esophagus on at least one of the two endoscopic examinations. Among patients with specialized columnar epithelium, 20% had specialized columnar epithelium found on only one of the two examinations. Although the mean lower esophageal sphincter level did not change, approximately 10% of patients had a change ≥4 cm on endoscopy and manometry between examinations. This led to an apparent change in the diagnosis in 18% of patients with Barrett's esophagus. Conclusions:From one endoscopic examination to another, inconsistencies in the ability to detect specialized columnar epithelium are common. This may lead to substantial problems in establishing an accurate diagnosis of Barrett's esophagus.

We assessed the relationship between changes in scores for the American Urological Association (AUA) symptom index and benign prostatic hyperplasia (BPH) impact index with patient global ratings of improvement in a large Veterans Affairs trial comparing different pharmacological therapies for BPH.

PurposeWe determine the effect of placebo, finasteride, terazosin and a combination of drugs on bother due to symptoms, quality of life and patient perception of improvement, and identify baseline clinical factors that predict clinical response to medical therapy.Materials and MethodsA total of 1,229 subjects with clinical benign prostatic hyperplasia (BPH) were randomized to 1 year of placebo, finasteride, terazosin or drug combination. The primary outcome measures were American Urological Association (AUA) symptom score and peak flow rate. Relevant secondary outcome measures were symptom problem score, BPH impact score and global rating of improvement.ResultsGroup mean differences in symptom problem and BPH impact scores between the finasteride versus placebo, and terazosin versus combination groups were not statistically or clinically significant. Group mean differences in all outcome measures were highly statistically significant between the terazosin and finasteride, and combination and finasteride groups. The percentage of subjects who rated improvement as marked or moderate with placebo, finasteride, terazosin and combination was 39, 44, 61 and 65%, respectively. In the subsets of men in the placebo, finasteride, terazosin and combination groups with prostates greater than 50 cm.3 group mean decrease from baseline in AUA symptom score was -2.5, -3.6, -6 and -7, group mean increase in peak flow rate was 0.6, 2.7, 3.6 and 3.7 ml. per second, group mean decrease in symptom problem score was -2.2, -1.9, -3.1 and -4.5, and group mean decrease in BPH impact score was -0.6, -0.3, -1.1 and -1.5, respectively. A correlational analysis failed to show a significant relationship between baseline prostate volume and treatment response to finasteride. There was a significant but weak relationship between change in AUA symptom score and peak flow rate in the finasteride and combination groups. The symptom responses with terazosin were independent of baseline peak flow rate.ConclusionsIn men with clinical BPH finasteride and placebo are equally effective, while terazosin and combination are significantly more effective. In men with clinical BPH and large prostates the advantage of finasteride over placebo in terms of symptom reduction, impact on bother due to symptoms and quality of life is small at best, while the advantage of terazosin and combination over finasteride and placebo is highly significant. Baseline prostate volume was not a predictor of response to finasteride in the overall study population. On the basis of our results alpha 1 blockers, such as terazosin, should be first line medical treatment for BPH.