Search

Tuberculosis (TB) is a leading cause of childhood mortality. Isoniazid preventive therapy significantly reduces progression to TB disease. The World Health Organization recommends that high TB burden countries conduct child contact management (CCM) to identify exposed child contacts aged5 years for screening and appropriate treatment. An active, clinic-based CCM strategy incorporating transport/screening reimbursement, monitoring and evaluation tools, and health care worker education was implemented in western Kenya. Among 169 identified child contacts aged5 years, 146 (86%) underwent successful screening, of whom 43 (29%) were diagnosed with active TB. We describe our CCM strategy and its potential for enhancing screening and treatment efforts.La tuberculose (TB) est une cause majeure de mortalité des enfants. Le traitement préventif par isoniazide réduit significativement la progression vers la TB maladie. L'Organisation Mondiale de la Santé recommande aux pays durement frappés par la TB de réaliser une prise en charge des enfants contacts (CCM) afin d'identifier les enfants contacts âgés de5 ans exposés en vue d'un dépistage et d'un traitement appropriés. Une stratégie active de CCM basée sur la clinique incorporant le transport/le remboursement du dépistage, les outils de suivi et évaluation et l'éducation du personnel de santé a été mise en œuvre dans l'Ouest du Kenya. Sur 169 enfants contacts identifies âgés de5 ans, 146 (86%) ont eu un dépistage réussi, dont 43 (29%) ont eu un diagnostic de TB active. Nous décrivons notre stratégie de CCM et son potentiel d'aMEacute;lioration des efforts de dépistage et de traitement.La tuberculosis (TB) es una causa mayor de mortalidad en la niñez. El tratamiento preventivo con isoniazida disminuye de manera considerable la progresión hacia la enfermedad activa. La Organización Mundial de la Salud recomienda a los países con alta carga de morbilidad por TB que practiquen la gestión de los contactos pediátricos (CCM), con el fin de reconocer a los niños menores de 5 años de edad expuestos, realizar la detección de la TB y ofrecer el tratamiento apropiado. En Kenya occidental se introdujo en los consultorios una estrategia activa de gestión de los contactos pediátricos, que comportaba el reembolso de los gastos de transporte y detección, instrumentos de supervisión y evaluación y educación de los profesionales de salud. De los 169 contactos pediátricos menores de 5 años de edad encontrados, se practicó una detección adecuada en 146 (86%) y se diagnosticó TB activa en 43 (29%). En el presente artículo se describe la estrategia CCM y se analiza su capacidad para fortalecer los esfuerzos de detección sistemática y tratamiento.

Objectives To determine whether statin treatment is associated with increased risk of haemorrhagic stroke (HS) in older women. A secondary objective was to evaluate HS risk in users of combined statin and antiplatelet treatment. Design Observational study: secondary data analysis from the Women's Health Initiative (WHI) clinical trials. Setting Women were recruited from 40 participating sites. Participants Cohort of 68 132 women followed through 2005 (parent study) and for an additional 5 years in the extension study. Main outcome measures Statin use was assessed at baseline and at follow-up visits (1, 3, 6 and 9 years). Women brought medications in original containers for inventory. Strokes were ascertained semiannually and centrally adjudicated. Risk of HS by statin use (time-varying covariate, with the ‘no use’ category as the referent) was estimated from Cox proportional hazard regression models adjusted for age (model 1); risk factors for HS (model 2); and possible confounders by indication (model 3). Prespecified subgroup analyses were conducted by use of antiplatelet medications. Results Final models included 67 882 women (mean age, 63±7 years). Over a mean follow-up of 12 years, incidence rates of HS were 6.4/10 000 person-years among statin users and 5.0/10 000 person-years among non-users (p=0.11). The unadjusted risk of HS in statin users was 1.21 (CI 0.96 to 1.53); after adjusting for age and HS risk factors the HR was 0.98 (CI 0.76 to 1.26). Risk of HS was higher among women on statins and antiplatelet agents versus women on antiplatelet medications alone (HR=1.59; CI 1.03 to 2.47); p for interaction=0.011. Conclusions This retrospective analysis did not show an association between statin use and HS risk among older women. HS risk was higher among women taking statins with antiplatelet agents. These findings warrant further investigation, given potential implications for clinical decision-making.

Elevated serum cholesterol is a major risk factor for CHD. Primary prevention through behavioral modification has been designated first-line treatment for patients with elevated cholesterol. In this study, we assessed the impact of a physician office visit after a worksite cholesterol screening on self-reported changes in diet, weight loss, exercise, and smoking. We hypothesized that those individuals who had a physician office visit regarding cholesterol would make more changes in CHD risk factors than those who did not have such a visit.A cohort of 4,928 participants from 33 work-sites in Massachusetts and Rhode Island had baseline CHD risk factors evaluated at a cholesterol screening and 4,473 were available at follow-up 6 months later by telephone interview. A total of 1,957 had elevated cholesterol levels (/=200 mg;/dl) and were instructed to visit their physician, in addition to receiving educational materials related to CHD risk factor modification.Most individuals with elevated cholesterol levels had other prevalent self-reported CHD risk factors at baseline: 58% consumed high-fat diets (30% fat), 43% were overweight, 60% had a sedentary lifestyle (sweat-related physical activity3 x per week), and 22% were cigarette smokers. After 6 months of follow-up, 74% of participants with high-fat diets reported eating a lower fat diet, 71% of overweight participants reported weight loss, 53% of sedentary participants attempted to increase physical activity, and 38% of smokers decreased or quit cigarette smoking. Thirty-five percent of participants completed the referral for a physician office visit to discuss their elevated cholesterol determined at the baseline worksite screening. However, these individuals showed only a modest change (which was not statistically significant) in self-reported CHD risk factors compared with those who did not have follow-up physician visits after adjusting for age, sex, race, education, occupation, medical insurance, time since last doctor visit, diabetes, and hypertension. Objective measurements of serum cholesterol, body mass index, and dietary score were likewise modestly improved and not statistically significant.In 6 months of follow-up, high absolute levels of CHD risk factor modification were observed after a worksite cholesterol screening. A physician office visit added only a modest but not statistically significant benefit for further CHD risk factor modification. These findings indicate that the follow-up cholesterol-related physician visit had little added clinical benefit over the screening intervention alone.

We were interested in studying whether a family history of coronary heart disease (CHD) persisted as a significant risk factor for premature coronary heart disease after adjusting for traditional and nontraditional risk factors.Ninety-five case patients with documented premature CHD (occurring in a person less than 60 years old and with greater than 50 percent occlusion of a major epicardial vessel or a documented myocardial infarction) and 95 community-based control patients were examined for risk factors including family history, hypertension, diabetes mellitus, sedentary lifestyle, smoking, body mass index, total cholesterol, high-density lipoprotein cholesterol, triglycerides, low-density lipoprotein cholesterol, lipoprotein(a), homocysteine, and fibrinogen.The risk of premature CHD for a positive family history ranged from an odds ratio (OR) of 3.25 for a standard family history of CHD in a first-degree relative, 5.9 for family history of early CHD in a first-degree relative before the age of 45 years, and 6.1 for a strong family history of CHD defined as CHD in at least two first-degree relatives. Family history persisted as a significant risk factor for premature CHD (OR = 3.9, 95 percent confidence interval [CI] 1.8-8.7) in multiple variable models that included traditional and nontraditional risk factors. It was rare, however, for a person with a positive family history not to have at least two other traditional or nontraditional risk factors.Family history of CHD should not be considered a simple binary risk factor for premature CHD, and a positive family history of CHD indicates that a person is at high risk for premature CHD independent of traditional and nontraditional risk factors.

Exercise can increase longevity and improve overall health and quality of life. Since a large proportion of Americans have a sedentary lifestyle, exercise counseling should be a part of routine health maintenance. Physicians need to provide patients with information about the specific benefits of exercise and motivate them to increase their physical activity. Physicians should encourage all adults, including those who elect not to participate in a formal exercise program, to accumulate 30 minutes or more of moderate-intensity physical activity on most days of the week. Before beginning an exercise program, selected higher risk patients may need to be evaluated with a physical examination and a treadmill test. Many patients benefit from a preexercise determination of fitness and specific instructions for monitoring their heart rate to maintain exercise within appropriate target ranges. A formal exercise prescription should include specific advice about the type, frequency, intensity, duration and progression of physical activity. Once an exercise regimen has begun, injury prevention and adherence to the program become important.

To determine the efficacy of high-dose ascorbate supplementation in lowering lipoprotein(a) [Lp(a)] levels in patients with premature coronary heart disease (CHD).Randomized, double-blind, placebo-controlled trial.Outpatient clinic.Forty-four patients with documented premature CHD, defined as confirmed myocardial infarction and/or angiographically determined stenosis of 50% or greater in at least one major coronary artery before age 60 years.Patients were block randomized on the basis of age, gender, and screening Lp(a) concentrations to receive ascorbate 4.5 g/day or placebo for 12 weeks.High-dose ascorbate was well tolerated and produced a marked elevation in mean plasma ascorbate levels (+1.2 mg/dl; p0.001). Multiple linear regression analysis revealed no significant effect of supplementation on postintervention Lp(a) levels (p = 0.39) in a model that included treatment group assignment, and baseline Lp(a) levels.Our findings do not support a clinically important lowering effect of high-dose ascorbate on plasma Lp(a) in patients with premature CHD.

The relationships between physical activity, physical fitness, and coronary heart disease risk factors measured in a large community sample were evaluated. Self-reported physical activity using a single question, maximal oxygen consumption estimates derived from the Pawtucket Heart Health Step Test, blood pressure, nonfasting lipids, and body mass index were cross-sectionally evaluated in 381 men and 556 women. The correlation of estimated maximal oxygen consumption and self-reported physical activity was modest but statistically significant (r = 0.13 in men and r = 0.19 in women). Blood pressure, body mass index, and HDL cholesterol were correlated with physical fitness (r = 0.24-0.65) and correlated to self-reported physical activity (r = 0.09-0.14). Evaluation of coronary heart disease risk factors using both physical activity and physical fitness revealed a complex relationship that generally showed a stronger relationship with measures of physical fitness than with physical activity. This study suggests that simultaneous measurement of physical activity and physical fitness may be useful in epidemiologic studies of habitual physical activity and chronic disease.

The risk of mortality from cardiovascular disease (CVD) is much higher in those with preexisting CVD than in those without it. Risk factor modification can reduce these risks. This study was designed to determine whether physicians manage risk factors differently in patients with and without overt CVD.Risk factor identification and management strategies after the diagnosis of CVD (secondary prevention) were analyzed by chart audit for 61 patients with premature CVD and 61 age-matched patients free of CVD (primary prevention). All of these patients had entered an academic family practice within 1 year of each other and had at least two physician visits between 1982-1992.In the majority of patients, risk factors for CVD were identified by family physicians. Few differences in counseling and management of risk factors were noted between patients with premature CVD and those free of CVD. Management of hypertension was performed with behavioral and pharmacologic therapy; more than 94% of the patients had at least one posttreatment blood pressure below 140/90. Lipid disorders, however, were managed primarily by diet; only 20% of cases with hyperlipidemia and premature CVD received pharmacologic therapy, and only 2.5% had a controlled blood cholesterol level (below 200 mg/dl).In an academic family practice, CVD risk factor identification was high but recommended management practices in the secondary prevention of CVD were suboptimal. Management of CVD risk factors was not more aggressive among secondary prevention cases compared to primary prevention controls.

It has been proposed that dyslipidemic hypertension is part of a distinct metabolic syndrome related to insulin resistance. This paper describes the prevalence and cross-sectional relations of dyslipidemic hypertension in a population-based sample of men and women.In two southeastern New England communities, 11,199 randomly selected participants were evaluated as part of a cross-sectional surveillance program of coronary heart disease risk factors between 1981 and 1990.The frequency of dyslipidemia was 38% and of hypertension was 26.5%; the conjoint frequency (dyslipidemic hypertension) was 15.0%, which is 1.49 times the expected value if the two diseases were independent P.05). Using a discrete multivariate model, dyslipidemia and hypertension were associated with sex, obesity, and diabetes mellitus. The excess association of dyslipidemic hypertension, compared with individual effects of dyslipidemia and hypertension, was not related to these factors.This study suggests that dyslipidemic hypertension is common but may not be a unique entity associated with a distinct metabolic syndrome.

We describe the predictors of change in physical activity in a population-derived sample of residents of two New England communities. In 1986-1987 and again in 1990-1991, we assessed the self-reported physical activity of 1,081 survey respondents using a single question concerning the frequency of exercise-induced sweating. We measured and analyzed sociodemographic variables, cardiovascular disease risk factors, health knowledge and beliefs, social support variables, and exercise performance variables at baseline as potential predictors of physical activity change. We defined physical activity change in subjects as follows: maintainers (12.2%) persisted withor = 3 times per week of activity, adopters (16.0%) increased activity toor = 3 times per week, quitters (11.9%) decreased activity to3 times per week, and sedentary (59.9%) individuals persisted with3 times per week of activity. Using polychotomous multiple logistic regression analysis, we found that short-term success with exercise and weight loss, school children's recommendation of exercise, and work outside the home predicted adoption or maintenance of increased physical activity in women. For men, short-term success with exercise and weight loss and health beliefs regarding the role of exercise in preventing heart attacks and stroke were the major determinants of maintaining or adopting increased physical activity. This identification of the predictors of physical activity change provides the rationale for future sex-specific strategies aimed at increasing regular physical activity and long-term adherence to an active lifestyle.

This paper is the second of two reports that together review the scientific evidence regarding the inverse relation between physical activity and cardiovascular fitness and coronary heart disease (CHD).Using a MEDLINE search with the key words exercise, physical fitness, coronary heart disease, and cardiovascular disease, more than 75 articles were reviewed, evaluating study design, measurement error, bias and confounding, the strength of associations, consistency of results, temporal and dose-response relation, and biologic plausibility.The relative risk in epidemiologic studies comparing the least to the most fit categories ranges from 1.2 to 4.8, which is greater than that for physical inactivity. The differences between cardiovascular fitness (an attribute) and physical activity (a behavior) are highlighted. The range of correlation (r = 0.02 to 0.44) between cardiovascular fitness and physical activity is discussed relative to measurement error and genetic and environmental factors. Studies reporting the safety of regular physical activity suggest an injury rate as high as 35 injuries per 100 persons per year. Efficacy studies limited to secondary prevention trials report a 66 percent compliance rate and 15 percent reduction in total mortality.The scientific evidence implying a causal relation between cardiovascular fitness and CHD is strongly positive, but the clinical and public health implications are unclear. Further research and clinical guidelines are suggested.

This paper is the first of two reports that together review the scientific evidence regarding the inverse relation between physical activity and cardiovascular fitness and coronary heart disease (CHD).In Part I, the evidence suggesting a causal link between physical activity and CHD protection independent of other CHD risk factors is reviewed, accounting for bias, confounding, and different study designs.A strong, consistent inverse relation is found. Using meta-analytic techniques, the relative risk of the independent relation of physical inactivity to CHD is 1.37, with a 95 percent confidence interval (1.27-1.48).A graded biologic response of CHD protection to physical activity is shown, but the intensity, duration, and frequency of activity necessary for CHD benefit remain unclear. Plausible biologic mechanisms for the inverse relation of physical activity to CHD are the risk factor modifications that accrue with physical activity.

Risk factors for cardiovascular disease are commonly obtained in freshman medical students for the purpose of increasing interest and awareness in preventive cardiology. What would be a normal range of values for this select group? This paper describes the major cardiovascular risk factors for 3,811 male and female freshman medical students from eight U.S. medical schools that were obtained in a standardized fashion as part of the Preventive Cardiology Academic Award (PCAA) programs at these institutions. The distributions of height, weight, Quetelet index, systolic and diastolic blood pressures, total cholesterol, triglycerides, high-density lipoprotein cholesterol, and calculated low-density lipoprotein cholesterol are presented for male and female medical students stratified by race into white, black, Asian, and Hispanic groups. The sex and race distributions of cardiovascular risk factors such as previously diagnosed hypertension, diabetes mellitus, smoking, lack of regular exercise (three times a week or more), oral contraceptive use in women, and family history of coronary heart disease are presented. The cardiovascular risk of freshman medical students is compared to other epidemiologic studies of young adults. The use and limitations of these race- and sex-specific data on cardiovascular risk, including physiologic measurements, are discussed in the context of educational programs for medical students and house staff in preventive cardiology.

N sub2 H sub4 derivatives: The f.p. of N sub2 H sub3 Me (I) wa s calculated as -56.08 deg. C; the eutectic for the system I-N sub2 H sub4 occured at 85 wt.-% I and -64 deg. C. Neutralizing I.H sub2 SO sub4 with KOH yielded 95. 6% I. The formation of trimethylazonium bromide in the reaction of N sub2 H sub4 and MeBr was not prevented by using 0.5 M Me Br to 1.0 M N sub2 H sub4 or by lowering the reaction temperature to 0 deg. C. The method adopted for seperating N sub2 H sub4, unsym-dimethylhydrazine, and I utilized the formation of complexes with BzH. Thermal decomposition of MeNO sub2: Analyzing the contents of heated ampoules with a mass spectrometer appeared a promising method for studying the decomposition mechanism. The apparatus for spectrometer determinations was completed. Engine spectrometer determination was completed. Engine test program: In fourteen 100-lb.-thrust tests, the 13% solution of LiBH sub4 in N sub2 H sub4 and O had a maximum I sub sp value of 256 lb.-sec./lb., which was 94% of the theoretical maximum. All runs were characterized by copious deposits of gray or white oxides, which almost covered the chamber, nozzle walls, turbulator, and injector face.