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Aims: The purpose of this research was to characterize CYP2D6, GST-M1 and GST-T1 enzyme expression in human parathyroid tissue, and to determine whether or not there is any association between deficiencies in these enzymes and serum parathyroid hormone concentrations in patients with end-stage renal disease., Methods: Surgical human parathyroid tissue was obtained and evaluated by immunohistochemistry for cellular localization of CYP2D6, GST-M1 and GST-T1 and colocalization of CYP2D6 with parathyroid hormone. Blood samples were collected from 328 Caucasian patients with end-stage renal disease for genetic testing of CYP2D6*3, *4, *5, *6, *7 and GST-M1*0 and GST-T1*0 alleles. Clinical chemistry data and serum intact parathyroid hormone (iPTH) concentrations were obtained from patient medical records. In 277 of the patients, the same laboratory performed all clinical tests., Results: CYP2D6, GST-M1 and GST-T1 were present in human parathyroid tissue. CYP2D6 was colocalized with parathyroid hormone in parathyroid chief cells. Within the end-stage renal disease population, a nonfunctional CYP2D6 genotype was present in 18.2%[95% confidence interval (CI) 8.0, 28.4] of patients in the 1st iPTH concentration quintile (iPTH < 64 pg x mL(-1)), in 0% (95% CI 0, 7.5) of those in the 2nd quintile, in 1.8% (95% CI 0, 9.3) of those in the 3rd quintile, in 9.1% (95% CI 1.5, 16.7) of those in the 4th quintile, and in 16.7% (95% CI 6.8, 26.5) of those in the 5th quintile (iPTH > 347 pg x mL(-1)) (P = 0.001). Out of 12 CYP2D6-deficient females, seven were in the 1st iPTH concentration quintile and the remaining five were in the 5th quintile. Patients deficient in the GST-M1 and GST-T1 enzymes displayed a far more uniform frequency distribution relative to serum iPTH concentrations., Conclusions: The presence of CYP2D6, GST-M1 and GST-T1 in parathyroid cells was observed. An association is reported between a lack of CYP2D6 and iPTH concentrations in newly diagnosed end-stage renal disease patients. Gender and concomitant deficiency in GST-M1 and/or GST-T1 appear to define this association further. It remains to be established whether these associations reflect a cause-effect relationship between deficient expression of metabolizing enzymes and severity of secondary manifestation of renal failure.

Purpose: The aim of this study was to identify independent predictors of acquiring a nosocomial bloodstream infection (BSI) during extracorporeal membrane oxygenation (ECMO)., Methods: This retrospective cohort consisted of 202 neonates treated with ECMO from 1989 to 1998 at the author' institution. Data collected included patient demographics, primary and secondary diagnoses, white blood cell counts, antibiotic usage, presence of central lines, operative procedures, and outcome. Surveillance blood cultures were drawn daily from the circuit using sterile technique to identify acquired pathogens. Statistical analyses included logistic regression, Cox proportional regression analysis, and discriminate analysis., Results: There were 1,245 blood cultures drawn on 202 patients (6.2 cultures per patient), and a nosocomial BSI was identified in 7 patients (3.4%) during this 10-year span. These were infections that were neither present nor incubating on admission. Pre-ECMO diagnoses of patients who had a nosocomial BSI while on bypass included group B beta-hemolytic streptococcal sepsis (n = 2), herpes simplex viral sepsis (n = 1), congenital diaphragmatic hernia (n = 2), persistent pulmonary hypertension (n = 1), and congenital heart disease (n = 1). The median time on ECMO before obtaining a positive culture was 390 hours. The infectious agents responsible for these BSIs included Staphylococcus epidermidis (n = 5), Staphylococcus aureus (n = 1), and Escherichia coli (n = 1). The major factor associated with acquiring a nosocomial BSI on ECMO was the duration of bypass (391 v 141 hours, P =.002). Additionally, patients in the BSI group were more likely to have had an arterial catheter in place (16 v 7 days, P =.009) and to have received more screening blood cultures (16 v 6 cultures, P < 001). White blood cell counts, absolute neutrophil counts, and immature/total (I/T) ratios were not useful in predicting a nosocomial BSI. Of the 31 patients who required ECMO for more than 10 days, 7 (23%) had a positive blood culture, and 5 of these 7 infants (71%) died (P =.03)., Conclusions: The only predictor of acquiring a nosocomial BSI on ECMO was the duration of support for greater than 10 days. Because classical predictors of infection are unreliable while the patient is on ECMO, the authors suggest that obtaining daily surveillance blood cultures beginning on the tenth day should be performed with prolonged ECMO courses. The authors confirmed previous reports of the association between a prolonged ECMO course and a high mortality rate. However, the authors speculate that, in actuality, the primary diagnosis leads to the prolonged course of support and is the major factor in the infant' demise.

There are anecdotal reports of pulmonary edema after a night of recurrent obstructive apneas (OAs) in humans, but no data on lung water, gas exchange, filling pressure, or cardiac output (Q) exist in these patients. By clamping the endotracheal tube of eight intubated, anesthesized dogs, we created repetitive OAs of 45-s duration at 30-s intervals, for 8 h. Five additional dogs without apneas, but identically instrumented, were studied simultaneously, serving as nonapneic controls. Sa (O(2)) was measured by intraarterial catheter, pulmonary capillary wedge pressure (Pcw), continuous cardiac output (Q), and mixed venous oxygen saturation (Sv(O(2))) were measured by flotation catheter. Basal and hourly hemodynamics and blood gases (arterial and venous) under steady state respiration were measured. Venous admixture (Q S/Q T) was calculated by standard equations. Pa(O(2)) from the beginning to the end of the experiment fell from 89.6 to 82.8 mm Hg in apneic animals and from 92.2 to 85.5 mm Hg in controls. The Q S/Q T increased in both groups but more so in the apnea group (3.3 to 19.4%) than in nonapneic controls (3.1 to 7.9%). Neither Q nor Pcw changed significantly in either group. Lung wet/dry weight was 5.40 +/- 0.93 in apneic animals and 5.00 +/- 0.67 in controls. Light microscopy showed gross alveolar fluid in three apneic dogs, and electron microscopy showed interstitial fluid in two additional apneic dogs. One of the lung edema dogs expired of acute heart failure in the seventh hour of the experiment. Worsening of gas exchange and histology suggest that lung edema can result from recurrent OAs.

Objective: Esophageal adenocarcinoma is increasing in white men. We sought to identify trends in esophageal cancer in different patient groups in our region., Methods: We reviewed the records of all patients with esophageal cancer seen at two hospitals in Columbia, SC between 1981 and 1995. Patients were divided into three cohorts (1981-1985, 1986-1990, and 1991-1995). Demographic data, histological type, tumor stage, grade, and survival were recorded., Results: Histology was available in 371 of 386 patients (cohort 1, 113 patients; cohort 2, 144; and cohort 3, 114). Adenocarcinoma accounted for 24%, 27%, and 49% of esophageal cancer in white men in cohorts 1, 2, and 3, respectively (p = 0.03). Corresponding figures for African-Americans were 10%, 7%, and 3% (p = 0.22). Women comprised 8%, 14%, and 22% of patients with squamous carcinoma in the three cohorts (p = 0.03). Median survival for esophageal cancer was 6.0, 6.8, and 10.4 mo in cohorts 1, 2, and 3 (p = 0.0002)., Conclusion: Adenocarcinoma is increasing in whites. Squamous carcinoma remains the predominant type in this region, seen mainly in African-Americans. Esophageal squamous carcinoma is increasing in women. The mean age at diagnosis of squamous carcinoma has decreased in whites. There is a trend toward improved survival in patients with esophageal cancer.

Objective: To assess the relationship between ethnicity and decision-makers expressing healthcare wishes in a group of frail older persons enrolled in the Program of All-inclusive Care for the Elderly (PACE)., Design: A retrospective chart review of 1193 participants in the PACE program., Setting: Program of All-inclusive Care for the Elderly, a comprehensive managed care demonstration program serving frail older participants at 10 sites across the nation., Participants: A total of 1193 older adults, all of whom met state criteria for nursing home level of care. Three hundred were non-Hispanic whites, 364 were black, 156 were Hispanic, and 288 were Asian., Measurements: Demographic characteristics of the patients and the presence or absence of an alternative decision-maker; the characteristics of alternative decision-makers included the relationship to the participant as recorded in the patient's medical record., Results: Ninety-one percent of white patients expressed their own healthcare wishes in contrast to only 85% of Hispanic, 83% of Asian, and 67% of black patients. An alternative decision-maker was identified for about 15% of Asians and Hispanics and for one-third of blacks, but only about 8% of whites had an alternative decision-maker. Black and Hispanic patients were most likely to have a daughter as an alternative decision-maker, Asians were most likely to have a son, and whites patients were most likely to have a spouse as an alternative decision-maker. Blacks, particularly black men, were the most likely to have a relative other than a spouse or child as an alternative decision-maker., Conclusions: In this population, we found significant ethnic variation in the person identified to be the decision-maker in a group of frail older people. Ethnic variation reflected sociodemographic as well as cultural differences. However, there are important limitations to this study, and caution should be used in extrapolating the results to other populations or in attributing the results to ethnicity alone. An awareness of cross-cultural patterns in identified or de facto decision-makers can be significant for healthcare workers when they approach patients and their families about issues surrounding end of life decisions.

Higher complication rates and lower success rates for treatment of women compared with men have been reported in prior studies of coronary angioplasty and in most early reports of outcome with new coronary interventional devices. In multivariate analysis this has been attributed largely to older age and other unfavorable clinical characteristics. These results are reflected in the current guidelines for coronary angioplasty. Women in prior studies have also had different distributions of vessel and lesion characteristics, but the influence of these differences on the outcome of new-device interventions have not been adequately evaluated. This article evaluates the influence of gender on clinical and angiographic characteristics, interventional procedure and complications, angiographic success, and clinical outcomes at hospital discharge and 1-year follow-up, as observed in the New Approaches to Coronary Intervention (NACI) registry. The NACI registry methodology has been reported in detail elsewhere in this supplement. This study focuses on the 90% of patients-975 women and 1,880 men-who had planned procedures with a single new device and also had angiographic core laboratory readings. Women compared with men were older, had more recent onset of coronary ischemic pain that was more severe and unstable, and had more frequent histories of other adverse clinical conditions. The distributions of several but not all angiographic characteristics before intervention were considered more favorable to angioplasty outcome in women. Differences were observed in device use and procedure staging. Angiographically determined average gain in lumen diameter after new-device intervention, with or without balloon angioplasty, was significantly less in women (1.38 mm) than in men (1.53 mm; p < 0.001); this 0.15 mm difference is consistent with the 0.16-mm smaller reference vessel lumen diameter of women. However, final percent diameter stenoses and TIMI flow and lesion compliance characteristics were similar. Among procedural complications, only treatment for hypotension, blood transfusion, and vascular repair occurred more often in women. More women than men were clinically unstable (2.1% vs 1.1%) or went directly to emergent coronary artery bypass graft surgery (CABG; 1.2% vs 0.6%) on leaving the interventional laboratory. However, in-hospital death (1.4% vs 1.1%), Q-wave myocardial infarction (MI) (0.9% vs 1.1%), and emergent CABG (1.5% vs 1.0%, for women and men, respectively) were not significantly different. Nonemergent CABG was more frequent in women (1.8% vs 0.9%; p < 0.05) and length of hospital stay after device intervention was longer (4.4 days vs 3.8 days in men; p < 0.01). In both univariate and multivariate analyses gender did not emerge as a significant variable in relation to the combined endpoint, death, Q-wave MI, or emergent CABG at hospital discharge. At 1-year follow-up more women than men reported improvement in angina (70% vs 62%) and fewer women than men had had repeat revascularization (32% vs 36%). Similar proportions were alive and free of angina, Q-wave MI and repeat revascularization (46% of women vs 45% of men). Although several procedure-related complications were more frequent in women than men after coronary interventions with new devices, no important disadvantages were observed for women in the rates of major clinical events at hospital discharge and at 1-year clinical follow-up. Additional studies are needed to evaluate the complex interplay of clinical, vessel, and lesion characteristics on success and complications of specific interventional techniques and to determine whether gender, per se, is a risk factor and whether gender specific interventional strategies may be beneficial.

Directional coronary atherectomy (DCA) with the Simpson coronary atherocath seeks to debulk rather than simply displace obstructive tissue and is a means of enlarging the stenotic coronary lumen. This report from the New Approaches to Coronary Intervention (NACI) registry describes the experience of 1,196 patients who underwent DCA as the sole treatment for either native vessel or vein graft lesions. Device success (post-DCA residual stenosis <50% and > or =20% improvement) was achieved in 87.8%, with a lesion success rate (postprocedural residual stenosis <50% and > or =20% improvement) of 94.0%. The mean resultant stenosis after all interventions (by core laboratory) was 19%. Significant in-hospital complications occurred in 2.8% of patients with DCA attempts, including death 0.6%, Q-wave myocardial infarction (MI) 1.5%, and emergent coronary artery bypass graft surgery (CABG) 2.8%. At 1-year follow-up, cumulative mortality was 3.6%, with repeat revascularization in 28% (repeat percutaneous transluminal coronary angioplasty, 20.1%; CABG, 10.6%). This reflected percutaneous or surgical revascularization of the original lesion (target lesion revascularization) in 22.6% of patients. Subgroup analysis showed a lower lesion success rate and an increased complication rate for unplanned use, vein graft treatment, and treatment of a de novo (vs a restenotic) lesion. Multivariate analysis shows that diabetes mellitus, unstable angina, treatment of a restenotic lesion, and greater residual stenosis after the initial procedure were independent predictors of the composite endpoint of death/Q-wave MI/target lesion revascularization by 1-year follow-up. Among these generally favorable acute and 1-year results, the NACI directional atherectomy data confirm the "bigger is better" hypothesis: that lesions with a lower residual stenosis after a successful procedure had significantly fewer target lesion revascularizations between 30 days and 1 year, with no increase in major adverse events.

Objective: The health care system in many developing countries is less efficient compared with that in the industrialized world. The aim of the present study was to investigate the differences of the efficiency of the health care in obstetrics in Nigeria, Mali and Togo., Study Design: The data were collected in African district hospitals from Lomé/Togo (n = 1002), Bamako/Mali (n = 1462) and Kaduna/Nigeria (n = 1055) with a routinely applied questionnaire analyzed at the University Giessen and compared with the data from the Department of Obstetrics and Gynaecology Giessen (Germany) (referral hospital) (n = 1313) and the total data pool of the perinatal survey 1993 in Hesse (n = 58430)., Results: The medical history indicates important differences: the incidence of young mothers below 18 is highest in Mali (9.8%) compared with Nigeria (2.7%) and Togo (2.6%) (Hesse 0.6%). In general there is an increased rate of previous pregnancies of more than five: 13-28% (Hesse 2.1%). The rate of prenatal visits is also reduced: more than ten visits have 2% in Togo, 10.6% in Mali and 15.5% in Nigeria (Hesse 72%). Ultrasound examinations are very rare (1-12%) and tocolysis is nearly unknown. As a result the incidence of dead infants in the medical history is high: Mali 28%, Togo 18%, Nigeria 10.8% (Hesse 1.7%), as well as the rate of low birth weight infants. This is also reflected in the perinatal mortality which ranged from 115/1000 in Mali, 77/1000 in Togo and 68/1000 in Nigeria (Hesse 5.3/1000, Ob/Gyn Giessen 16.4/1000)., Conclusion: The improvement of perinatal and maternal health in the developing world can only be achieved if family planning, prenatal care, selection of high risk pregnancies goes in parallel with a sound organization implemented and supported by the government.

Objective: To assess the relationship between ethnicity and Health Care wishes, including Advance Directives, in a group of frail older persons in PACE (Program For All Inclusive Care Of The Elderly)., Design: Retrospective chart review of 1193 participants in the PACE program., Setting: Program of All Inclusive Care Of The Elderly (PACE), a comprehensive managed care demonstration program serving frail older participants at 10 sites across the nation., Participants: A total of 1193 older adults, all of whom met state criteria for nursing home level of care. There were 385 non-Hispanic whites, 364 blacks, 156 Hispanics, and 288 Asians., Measurements: Presence or absence of advance directives, type of health care wishes selected including living will, durable power of attorney, and health care proxy., Results: Frail older white, black, Hispanic and Asian Americans differ significantly in their health care wishes and how they choose to express them. Blacks were significantly more likely to select aggressive interventions and less likely than non-Hispanic whites and Hispanics to utilize a written instrument for expressing health care wishes. Whites were significantly more likely to utilize written documents for advance directives, whereas Asians were more likely to select less aggressive interventions but were unlikely to use written advance directives., Conclusions: In this population, we found significant ethnic variations in choice of health care wishes. Although health care wishes are an individual decision, an awareness of cross cultural patterns can assist practitioners in addressing the concerns of their patients, as well as assisting Health Care Policy Development.

Purpose: Fifty-one consecutive patients with premature lower extremity atherosclerosis were prospectively evaluated for atherogenic risk factors and primary or acquired hypercoagulability, which might contribute to early ischemia and revascularization failure., Methods: Laboratory tests included plasma assays of (1) natural anticoagulants (NAC), lipoprotein (a) (Lp[a]), and anticardiolipin antibodies, and (2) fibrinolytic activators and inhibitors at baseline and stimulated after 20 minutes of upper extremity venous occlusion., Results: Forty-six (90%) of these 51 patients had laboratory abnormalities. One or more NAC deficiencies were found in 15 (30%) patients and included antithrombin III (n = 5), protein C (n = 8), protein S (n = 4), and heparin cofactor II (n = 2). Hypofibrinolysis was identified as a deficiency of stimulated tissue plasminogen activator in 22 (45%) patients and elevated plasminogen activator inhibitor-1 (PAI-1) in 29 (59%). Elevated Lp(a) was found in 43 (86%) patients. Five (10%) patients had anticardiolipin antibodies. Ten patients had combined NAC deficiency and hypofibrinolysis. Five (10%) patients had no abnormality. NAC deficiencies, especially protein C deficiency, were associated with acute ischemia (p < 0.01), prior vascular intervention (p < 0.01), an increasing number of total vascular procedures (p < 0.01), and major amputation (p < 0.01). PAI-1 was associated with a history of heart disease (p < 0.05) and prior vascular procedures (p < 0.05). Elevated Lp(a) was associated with elevated PAI-1 (p < 0.05). Retesting in 20 patients suggested that 80% of NAC deficiencies were acquired, but abnormalities persisted in 66% of patients with elevated PAI-1 and in 93% of those with elevated Lp(a)., Conclusions: These data strongly support the hypothesis that the convergence of atherogenic risk factors and hypercoagulability play an important role in early ischemia and poor results reported for lower extremity vascular procedures in young adults.

Objective: Patients with Barrett's esophagus may be at increased risk of colon neoplasms, including cancer. However, different studies of this have yielded conflicting results. The objective of this analysis was to review all existing published data in an attempt to determine whether there is such an association and, if so, to estimate the level of risk., Methods: We have reviewed all of the published studies examining the prevalence of colon neoplasms in patients with Barrett's esophagus. We have compared these with a cohort of patients drawn from the general population and participating in colorectal cancer screening programs., Results: The prevalence of colon cancer in patients with Barrett's esophagus was 7.6% compared with 1.6% in the control group. The pooled odds ratio for colon cancer in Barrett's esophagus was 5.19 (p < 0.0001). In a small subgroup analysis, the odds ratio for colon cancer in patients identified as having Barrett's esophagus with specialized columnar epithelium was 8.71 (p < 0.0001)., Conclusions: We conclude that patients with Barrett's esophagus have an increased risk of colon cancer. This may be particularly true in those patients with specialized columnar epithelium.

Despite poor results reported with conventional vascular bypasses in young adults with ischemia from premature lower extremity atherosclerosis (PLEA), little attention has been given to alternative revascularization techniques. This study evaluated 32 patients (21 males and 11 females) < 45 years of age with PLEA who underwent 53 primary percutaneous transluminal angioplasty (PTA) procedures for treatment of 46 ischemic limbs. A residual arterial stenosis < 30% was achieved in 83% of PTA sites. Mean degree of stenosis decreased from 79.9% to 24.1% (p < 0.0001). Clinical improvement in ischemic symptoms was obtained in 39 (85%) limbs. Hemodynamic improvement was achieved in 31 (70%) of 40 limbs as documented by ankle/brachial indices. All criteria for early clinical success were met in 70%. Another 13% met all criteria except that the residual stenosis was < 50%. Hematoma and early restenosis were reported in two patients each. Mean follow-up was 27.3 months (range 1 to 84 months). Cumulative patency by life-table analysis was 81% at 1 year, 77% at 2 years, and 71% at 3 years. Thirteen (41%) patients required secondary PTA or bypass; 85% were performed within 1 year. Two patients had adjunctive bypasses; six (19%) were performed after PTA failure. Only one (3%) patient required major amputation. Neither cardiovascular risk factors, treatment indication, location of the diseased arterial segment, nor quality of distal runoff vessels predicted the need for secondary PTA or surgical procedures. PTA of the proximal arteries in young patients with PLEA is an effective primary revascularization technique with results comparable to those of conventional operative revascularization procedures.

Physicians routinely discuss pulmonary function and its impact on prognosis or operative risk. Although many studies have related various measures of pulmonary function to postoperative outcome, there has been no study designed to determine which of the spirometric measures of pulmonary function tests reflects the actual abstract idea of pure pulmonary function. A homogeneous population of 70 male patients was subjected to pulmonary function tests and a simple stair climb. Measures of pulmonary function (including FEV1, FEV1%, FVC, FVC%, and MVV%) were factor analyzed in a measurement model of pulmonary function to obtain reliability and validity estimates in predicting performance on a simple stair-climb test. The analysis revealed several interesting aspects concerning the relative importance of the various spirometric measures of pulmonary function tests. The validity estimates of the pulmonary function measures were as follows: FEV1% = 0.917; FEV1 = 0.886; MVV% = 0.769; FVC% = 0.715; FVC = 0.694. Analysis indicates that the FEV1% was the single best spirometric indicator of pulmonary function when predicting the physiologic outcome (followed closely by the FEV1). In addition, the various spirometric measures of pulmonary function were not equally valid nor interchangeable in such analysis. Although the number of stairs climbed correlates well with pulmonary function (r = 0.626), the coefficient of non-determination (i.e., 1-r2) suggests that about 61% of the performance on the stair climb may be explained by other parameters (i.e., cardiac function, determination, altitude, etc.).

A retrospective community-wide survey identified 109 patients younger than 40 years of age with lower extremity ischemia: 72 men and 37 women, mean age 36 years (range 25 to 40 years), black-to-white ratio-1:1. Initially, 66 patients had claudication and 43 had severe ischemia. Cardiovascular risk factors were smoking (85%), hypertension (47%), coronary artery disease (30%), hyperlipidemia (27%), diabetes (25%), and visceral arteriopathy (17%). Unique risk factors included hypercoagulability (15%) and clinical arterial hypoplasia (15%). Twenty-three (21%) patients were treated medically; 74 (68%) underwent primary revascularization and 12 (11%) primary major limb amputation. Forty-six (53%) patients required secondary procedures, of which 34 (74%) were performed within 1 year of primary intervention. A total of 29 (27%) patients ultimately required amputation (10 bilateral). Women had higher prevalence of diabetes (p < 0.01), arterial hypoplasia (p < 0.05), and tendency for more severe ischemia (p = 0.11). No racial differences in severity of symptoms or outcome of treatment were found. By multiple logistic regression analysis, typical cardiovascular risk factors did not predict severity of symptoms, need for surgical treatment, or outcome. However, diabetes was associated with tissue loss (p < 0.05) and primary amputation (p < 0.001). Further, adjusted odds ratios indicate that arterial hypoplasia had a protective effect on distal vasculature (p < 0.05) and predicting need for revascularization (p < 0.05), but not on treatment failure. Hypercoagulability had the highest predictive value for presence of severe ischemia (p < 0.05), need for primary amputation (p < 0.01), and early failure of surgical treatment (p < 0.05).

The results of routinely performed multigated blood pool studies (MUGA) were compared with the presence of postthoracotomy complications in 46 adult men in a retrospective chart review. Pulmonary function measurements were also examined in relation to the presence of complications experienced. There was only one death, but survivable complications were not predicted by the MUGA results. The addition of MUGA as a routine preoperative cardiac screening technique did not result in increased ability to predict postoperative cardiopulmonary complications.

A survey of USC/RMH Family Medicine alumni indicated that a large proportion have remained in South Carolina, providing primary care especially in small towns and rural areas. These physicians engage in a broad range of clinical activities and feel comfortable with treating a wide spectrum of patient problems. The alumni are active participants in religious, cultural and civic programs in their communities and they express satisfaction with their decision to practice Family Medicine in South Carolina.

National studies have documented an excessive rate of cigarette smoking in black men; however, a 1987 survey conducted in two urban areas in South Carolina documents a high rate of smoking in young white men with fewer than 12 years of education (67%; 95% confidence interval [CI] = 58.3, 75.7). Differences in smoking rates by educational level were significant only for those younger than 40. Young blacks were less likely to smoke and smoked fewer cigarettes than whites. As a result, the population burden of cigarettes in young black men with fewer than 12 years of education was only 27% of the burden carried by their white peers. Television, physicians, and radio were all seen as likely sources of health information to prevent heart disease, but newspapers were less likely to be cited by those younger than 40 or by those with fewer than 12 years of education. Reported physician counseling for smoking cessation did not differ significantly by race, sex, or educational level of the patient, but reported counseling was higher for individuals with a personal history of cardiovascular disease (odds ratio [OR] = 2.32, CI = 1.27, 4.25) and somewhat lower for the elderly. We highlight the population burden of cigarettes, a predictor of the eventual disease burden attributable to smoking, as a useful priority measure for smoking intervention efforts.

A sample of 28 rural and urban private practicing family physicians was compared on a number of attitudes and practice characteristics based on results from a mailed questionnaire. Results cross-validated previous findings and provided new ones. A number of self-report discriminators are discussed to better predict which physicians will locate in rural areas.

Serum bile acids have been shown to serve as useful indicators of liver disease. We have confirmed these findings and added an analysis of interleukin-1 beta (IL-1 beta) profiles to further differentiate viral hepatitis from toxic liver damage associated with exposure to vinyl chloride (VC) or trinitrotoluene (TNT). The frequency of elevated cholylglycine (CG) was 100%, 75%, and 37.5% in viral hepatitis, VC- and TNT-linked liver injury patients, respectively. The mean levels, expressed in micrograms/dL, were 578, 507, 142, and 65 in hepatitis B, hepatitis non-A non-B, VC and TNT liver injury patients, respectively. Thus, the CG test could detect viral hepatitis and, VC liver injury, and (less frequently) liver injury associated with exposure to TNT. The mean level of IL-1 beta in patients with hepatitis type B was 424 pg/mL and hepatitis non A non B was 384 pg/mL compared with a mean of 33-40 pg/mL in those with VC or TNT-linked liver disease. The IL-1 beta detection test proved further to be an important distinguishing parameter as it was 100% positive in patients with viral hepatitis but only 12.5% to 25% positive in patients with VC/TNT-induced liver damage.

A prospective, sequential study compared ease of use and bag-valve ventilation delivered by an endotracheal tube (ET) with that of the pharyngeotracheal lumen airway (PtL) for 111 victims of cardiac arrest in the pre-hospital setting. The PtL airway was found to be significantly easier to use as measured by the time required to intubate the patient and the number of attempts to place the device. Arterial blood gas determinations were made on arrival at the hospital and repeated 15 minutes later. No statistical significance could be found between the two airway devices for either the first or second blood gas determination. During PtL ventilation, the first arterial blood gas values were PaCO2, 58 +/- 32 mm Hg; PaO2, 163 +/- 180 mm Hg; pH, 7.15 +/- 0.22. During ET ventilation the first arterial blood gas values were PaCO2, 53 +/- 29 mm Hg; PaO2, 156 +/- 178 mm Hg; pH, 7.16 +/- 0.23. No adverse effects were reported. We conclude that the ability of the PtL to deliver effective ventilation is comparable with that of the ET as measured by arterial PCO2. When the ET method of airway control cannot be achieved, the PtL airway offers an effective alternative.

We studied relative changes of serum cholesterol in obese patients during and after weight loss to determine if they depend on initial cholesterol levels as classified by the National Cholesterol Education Program. Three groups of obese free-living outpatients with desirable (normal) (less than 5.17 mmol/l, n = 26), borderline-high (5.17-6.18 mmol/l, n = 29), and high (greater than 6.21 mmol/l, n = 32) initial total cholesterol completed a 26-week program employing a very low calorie diet. The program involved 12 weeks of supplemented fasting, followed by 6 weeks of refeeding and then 7 weeks consumption of step 1 diet that maintained the new reduced weight. The groups were similar in initial clinical characteristics and they also lost comparable percentages of initial weights. Relative reduction in total cholesterol throughout the study was significantly larger in both borderline-high and high cholesterol groups compared to normal. In patients of borderline-high and high cholesterol groups favourable and significant reduction of total cholesterol, LDL cholesterol, total cholesterol/HDL cholesterol, and LDL cholesterol/HDL cholesterol ratios were maintained at the end of the study. The percent decrease in total serum cholesterol at the end of the study positively correlated with the percent of weight loss in patients of the high cholesterol group. We conclude that obese hypercholesterolemic patients have favorable changes in cholesterol profile following weight loss, and that relative reduction of cholesterol levels depend on initial levels. However, specific roles of weight loss, change in diet and/or increased physical activity in observed changes in lipid profiles cannot be determined by this study.

We surveyed 178 orthopedic physicians in the Washington, DC, area to ascertain the effect on patient care of previous education in the area of drug and alcohol issues. The return rate was 75%. Of the respondents, 99% were male, average age was 46.7 years (+/- 9.3), and average number of years in practice was 15.2 (+/- 9.6). A majority of respondents indicated that they did not have training in the abuse potential of analgesics (92 [69%]), characteristics of benzodiazepine abuse (77 [58%]), or when to seek the assistance of an addiction medicine specialist for patients with chronic pain (106 [80%]). Only 41 (31%) of the orthopedists indicated that they inquire about alcohol and drug use before prescribing opiates for more than a week. We offer suggestions for self-education for interested physicians.

The results of a clinically performed preoperative stair climb was compared to the presence of postthoracotomy complications in the retrospective hospital record review of 54 adult men. The stair climb was a maximum of five flights (125 steps) performed at the patient's rate and terminated at his request. Pulmonary function measurements and facets of the stair climb physiology were also examined in reference to the presence, type, and severity of complications experienced. Most minor complications such as transient arrhythmias, atelectasis, and pneumonia were clearly not predicted by the stair climb performance. The ability to climb three flights preoperatively most clearly separated those patients having the longer postoperative intubation and hospital stay, greater frequency of complications, and cumulative complication score (p less than 0.005). This retrospective study did not have sufficient numbers of fatal cardiopulmonary complications to exclude the possibility that these may be predicted by the results of this simple test.

Although left ventricular (LV) aneurysm is associated with increased mortality, its independent prognostic significance is controversial. To determine the effect of LV aneurysm on risk, 121 patients with healed myocardial infarction (MI), 55 manifesting akinesia on ventriculography (MI group) and 66 with LV aneurysm characterized by diastolic deformity (eccentricity) and systolic dyskinesia (LV aneurysm group) were studied. At a mean follow-up of 5.7 years, there were 32 cardiac deaths (12 MI vs 20 LV aneurysm), including 9 sudden deaths (1 MI vs 8 LV aneurysm). Multivariate analysis revealed decreasing ejection fraction to be the best predictor of total cardiac death, and revascularization to be protective. Nonsudden cardiac death was predicted by ejection fraction, absence of revascularization and right coronary artery disease, whereas sudden cardiac death was predicted by LV aneurysm and the frequency of ventricular ectopic complexes on Holter monitoring. In the MI group, ejection fraction was the only significant predictor of total cardiac death and nonsudden cardiac death. In the LV aneurysm group, total cardiac death, as well as nonsudden cardiac death, were predicted by ejection fraction, ventricular tachycardia and right coronary artery disease, whereas ventricular tachycardia predicted sudden cardiac death. It is concluded that the risk profile for total cardiac death differs between LV aneurysm and MI patients, and that LV aneurysm constitutes an independent predictor of late sudden cardiac death after MI. Moreover, on a substrate of LV aneurysm, the risk factors for sudden cardiac death and nonsudden cardiac death differ, with ventricular tachycardia being the sole predictor of sudden cardiac death. Furthermore, Holter monitoring is valuable in identifying patients at persistent risk of sudden cardiac death.

Risk factor identification in the coronary heart disease/ myocardial infarction syndrome has failed to account for the epidemic pattern of increase in this century with recent decline. It is hypothesized that the true cause remains unidentified and that innovative application of traditional epidemiologic techniques, to correlate the identifiable peaks in different regions with possible agents, may prove successful.

Utilizing South Carolina live birth-infant death cohort files for the period 1975-80, this study examines the bivariate distribution of birth weight-gestational age (BW-GA), intrauterine growth curves, and BW-GA specific neonatal mortality rates (NMRs) by race. Comparison of BW-GA distributions revealed an appreciable shift between racial subgroups. Nonwhites, on the average, were born 1 week earlier and 270 grams lighter in weight than whites. In addition to racial differences in rates of intrauterine growth, nonwhites experienced lower BW-GA NMRs than whites in BW-GA categories less than 3,000 grams and less than 38 weeks. However, the improved mortality experience of nonwhites at more immature BW-GA categories was not consistently present when different cause-specific NMRs were considered. These persistent racial variations highlight continuing issues regarding both the use of a single norm for defining low birth weight or prematurity and the role of nonsocioeconomic factors related to racial BW-GA distribution and mortality disparities. As birth weight and gestational age represent empirical indicators of the maturity and survivability of an infant at birth, these data and previous supporting research raise further concerns regarding the ability of these indicators to accurately reflect equivalent fetal development and subsequent risk of mortality among racial groups.

In 1975 the American Medical Association was awarded a grant by the Law Enforcement Assistance Administration to conduct pilot projects to improve the quality of health care in jails. The medical societies of six states were selected as subgrantees and projects were initiated in thirty jails. The evaluation of these projects involved both process and impact components. The principle criterion for the process evaluation was the success of jails in meeting the standard of health care for jails that were established by the AMA as part of the project. The principle criterion employed in the impact assessment was the extent of improvement in the early detection of inmates' health problems. The project was determined to be successful in both the process and the impact evaluation, although notable improvements in jail health care are still to be made.

Seventy male patients with a mean age of 56.8 years scheduled for pulmonary function testing were subjected to a stair climb in order to determine the relationship, if any, between the number of steps climbed and the results of pulmonary function testing. The number of steps completed was plotted against the different parameters which may be used as predictors of post-thoracotomy outcome. The stair climb acts as a stress test and, although there is a strong relationship to pulmonary function tests, it also is an indicator of many other parameters including cardiovascular status, cooperation, and determination. Based on results of this study, the stair climb can be used as a reliable screening test of pulmonary function. Also, preoperative patients who are unable to perform pulmonary function tests can be evaluated accurately for lung resection by use of the stair climb test.

Lung resection in patients with cardiopulmonary dysfunction is associated with increased risk. We studied 52 elderly male patients with airflow obstruction and a lung mass. Studies were performed at rest with routine ventilatory tests and lung scan quantitation of right-left lung function. Cycle ergometry exercise was then performed at 2 submaximal work loads (25 and 40 watts). Data were obtained using systemic and pulmonary artery catheterization for blood pressures, thermal dilution cardiac output, and blood gases. Twenty-nine patients underwent lung resection and seven failed to tolerate the procedure (death within 60 days or prolonged ventilator dependence). Those parameters most clearly separating the group tolerating surgery (n = 22) from the intolerant group (n = 7) were obtained during exercise and included: cardiac index (tolerant 5.5 +/- 1.3 vs intolerant 3.9 +/- 0.3 L/min/m2, p less than .01), O2 delivery (p less than .01) and calculated VO2 ml/kg/min (tolerant 11.3 +/- 2.1 vs intolerant 7.8 +/- 1.5 ml/kg/min, p less than .001). Pulmonary vascular pressures and calculated resistance did not predict intolerance. Calculated VO2 at 40 watts did not separate those patients who had survivable complications from those who did not (p much greater than .05). Multivariate analysis suggests that exercise VO2 is an important predictor of tolerance of lung resection because it reflects the effects of cardiac function and O2 transport. In our patients with COPD, submaximal exercise testing predicted intolerance of lung resection better than calculation using quantitative lung scanning. Exercise testing may accomplish this goal by uncovering deficits in O2 transport.

To evaluate the risk factors for coronary disease, 345 women, aged 35 to 59 years, who had undergone coronary arteriography for suspected coronary disease completed a mail questionnaire, telephone interview, or both. Two hundred eight women with angiographically normal coronary arteries constituted the control group, and 137 with a 70% or more occlusion of one or more coronary vessels were classified as having severe coronary occlusive disease. Age-adjusted odds of severe coronary disease based on the logistic regression model for the risk factors evaluated were as follows: smoking, 5.73 (p less than 0.001); diabetes, 5.09 (p less than 0.001); cholesterol level greater than 240 mg/dl, 2.35 (p less than 0.05); a parental history of death from heart disease before age 60 years, 2.03 (p less than 0.05); and estrogen use for 6 months or longer, 0.50 (p less than 0.01). There were no differences with regard to the presence of obesity and a history of hypertension in women with and without coronary disease. These data support the hypothesis that use of noncontraceptive estrogen significantly reduces the risk of severe coronary disease, whereas smoking, an elevated cholesterol level, and a parental history of heart disease all increase the risk of ischemic heart disease in women.