Biomedical subjects

P Lapuerta

Publications and source records attributed to P Lapuerta.

At least 19 recordsLinked to original sources

PubMed2005

[Adherence to guidelines in CHF therapy in Germany].

BACKGROUND AND OBJECTIVE: The MAHLER survey examined the impact of the European guidelines for the treatment of chronic heart failure (CHF). Especially, the trial addressed the question whether adherence to treatment guidelines leads to a reduction in the rate of CHF and cardiovascular (CV) hospitalization. The present sub-study presents the Germany specific data of the MAHLER study and compares the results with the results in other European countries. PATIENTS AND METHOD: The gobal adherence index (GAI) shows the proportion of correctly prescribed heart failure medications per patient. Class adherence indicators for angiotensin-converting enzyme (AC)-inhibitors, beta-blockers, spironolactone, diuretics and cardiac glycosides and general adherence indicators (GAI3 adherence to first three classes of heart failure medications, GAI5 adherence to five classes) were constructed. In the German sub-study, 251 patient were included, who were seen by 21 cardiologists in private practice (mean age 68,6 + 10,4 years; 173 man, 78 woman; 158 NYHA II; 91 NYHA III, 2 NYHA IV). RESULTS: Mean adherence to CHF therapy guidelines was 63 % for GAI3, 62 % for GAI5. Compared to the other MAHLER-study countries, Germany was on place two and three concerning GAI3 and GAI5, respectively. Strong adherence to treatment guidelines in Germany led to a reduction of CHF and CV hospitalization rate by 40 % (p < 0.033). Thus, the German data confirm the results of the international study indicating that a good GAI3 performance is an independent predictor of time to hospitalization. Hitherto, the relative risk for hospitalization was higher for CHF patients in Germany than for patients in all other European countries. CONCLUSIONS: In Germany like in other European countries, guideline adherence for CHF therapy leads to a reduction in hospitalization rate.

Aged↗

PubMed2004

A clinically meaningful difference was generated for a performance measure of recovery from hip fracture.

BACKGROUND AND OBJECTIVE: The Lower Extremity Gain Scale (LEGS) is a performance measure of tasks that are often impaired in hip fracture patients. This study was designed to determine a clinically meaningful difference in LEGS. METHODS: The population was 139 female patients (age >65 years) admitted to Baltimore hospitals. Recovery levels were estimated by fitting trajectory curves for the cohort for the 12 months post fracture. The clinically meaningful difference was evaluated using an anchor-based approach, examining the relationship between the LEGS recovery level and age. A second, distribution-based method used an effect size of .20. RESULTS: According to our model, a difference of 5 years in age corresponded to a difference of 1.6-3.6 points in LEGS scores. The standard deviation for LEGS at 12 months was 8.0; thus, Cohen's effect size of 0.2 would equate to a difference of 1.6 points. CONCLUSION: This suggests that a clinically meaningful difference in the LEGS scores for a population in this age range would be 2-3 points.

Activities of Daily Living↗

PubMed2001

A new approach for measuring quality of care for women with hypertension.

BACKGROUND: Guidelines for care of hypertensive patients have proliferated recently, yet quality assessment remains difficult in the absence of well-defined measurement systems. Existing systems have not always linked process measures to blood pressure outcomes. METHODS: A quality measurement system was developed and tested on hypertensive women in a West Coast health plan. An expert panel selected clinically detailed, evidence-explicit indicators using a modified Delphi method. Thirteen indicators (1 screening, 5 diagnostic, 5 treatment, and 2 follow-up indicators) were selected by this process. Trained nurses used a laptop-based tool to abstract data from medical records for the most recent 2 years of care. RESULTS: Of 15 004 eligible patients with hypertensive and other chronic disease codes, 613 patients were sampled, all eligible for the screening indicator. Of these, 234 women with an average blood pressure of 140/90 mm Hg or more, or a documented diagnosis of hypertension, were studied for the remaining indicators. The average woman received 64% of the recommended care. Most patients did not receive adequate initial history, physical examination, or laboratory tests. Only 37% of hypertensive women with persistent elevations to more than 160/90 mm Hg had changes in therapy or lifestyle recommended. The average adherence proportion to all indicators was lower in patients with uncontrolled blood pressure (>140/90 mm Hg) than in those with controlled blood pressure (54% vs 73%; P<.001). CONCLUSIONS: Quality of hypertensive care falls short of indicators based on randomized controlled trials and national guidelines. Poor performance in essential care processes is associated with poor blood pressure control.

Aged↗

PubMed2001

Assessment of the association between blood pressure control and health care resource use.

BACKGROUND: Several studies have reported increased health care resource use among hypertensive patients with uncontrolled blood pressure (BP). OBJECTIVE: The purpose of this study was to investigate the relationship between BP control and health care resource use. METHODS: Data were obtained from the Caring for Hypertension on Initiation: Costs and Effectiveness (CHOICE) study, a multicenter feasibility study of actual physician and patient behavior and clinical outcomes in a naturalistic setting. Adult patients with newly diagnosed hypertension were randomized to either Group 1 (treatment with diuretics or beta-blockers) or Group 2 (treatment with calcium channel blockers or angiotensin-converting enzyme inhibitors) and followed for 5 +/- 1 months. Physicians practiced standard care while documenting medications, BP measurements, and health care resource use for their patients. A subsequent analysis evaluating the relationship between BP and physician visits was performed for the whole population and for a subpopulation of patients with at least 4 months of follow-up data. Cox regression was used to model time to next visit. RESULTS: A total of 512 patients with newly diagnosed hypertension were followed: 399 had follow-up data for at least 4 months. Baseline demographic characteristics were similar in the 2 groups. Kaplan-Meier curves and a log-rank test showed that the time to next visit for patients with uncontrolled BP was significantly shorter than for patients whose BP was controlled (P < 0.05). On average, patients with uncontrolled BP (> or = 140/90 mm Hg) had follow-up office visits approximately 13 days earlier than patients with controlled BP (< 140/90 mm Hg). This association remained significant after adjustment for repeated measures, and after exclusion of the first return visit. Cox regression analysis showed that higher systolic and diastolic BP measurements were significantly associated with a shorter time to next visit, after adjustment for age and sex. Total estimated costs during the study period were $170 per patient for medications and $283 per patient for office visits. CONCLUSIONS: In the CHOICE study, higher BP was associated with a shorter time to next visit. Office visits were the main cost driver in the short-term management of hypertension.

Adrenergic beta-Antagonists↗

PubMed2001

A health perception score predicts cardiac events in patients with heart failure: results from the IMPRESS trial.

BACKGROUND: New York Heart Association (NYHA) class and treadmill exercise test variables are widely used for estimating prognosis and measuring the outcomes of treatment in patients with heart failure, but they do not take patients' perceptions into account. METHODS AND RESULTS: Five hundred forty-five patients enrolled in a multicenter 24-week comparison of the effects of omapatrilat and lisinopril on functional capacity in patients with heart failure reported a visual analog scale (VAS) score of their overall health perception at week 12 of the study. A total of 27 first events, defined as death or worsening heart failure (hospitalization, emergency room visit, or study discontinuation), occurred in the subsequent 12 weeks. The mean (+/-SD) health perception scores were 0.43 +/- 0.31 and 0.68 +/- 0.20 in patients with and without events, respectively (P =.0006). The risk ratio (RR) for an event associated with a decile change in the health perception score was 0.74 (95% confidence interval [CI], 0.61-0.88; P =.001). The RR was unaltered by adjustment for demographic variables, treadmill time, and NYHA functional class. Although the week 12 NYHA functional class was predictive of events (RR = 2.1; 95% CI, 1.2-4.6; P =.04), treadmill time was not (RR = 0.87; 95% CI, 0.73-1.03; P = 0.11). CONCLUSIONS: A patient-reported measure of perceived health predicts events in patients with heart failure.

Aged↗

PubMed2001

Predominance of isolated systolic hypertension among middle-aged and elderly US hypertensives: analysis based on National Health and Nutrition Examination Survey (NHANES) III.

The purpose of the present study was to examine patterns of systolic and diastolic hypertension by age in the nationally representative National Health and Nutrition Examination Survey (NHANES) III and to determine when treatment and control efforts should be recommended. Percentage distribution of 3 blood pressure subtypes (isolated systolic hypertension, combined systolic/diastolic hypertension, and isolated diastolic hypertension) was categorized for uncontrolled hypertension (untreated and inadequately treated) in 2 age groups (ages <50 and >/=50 years). Overall, isolated systolic hypertension was the most frequent subtype of uncontrolled hypertension (65%). Most subjects with hypertension (74%) were >/=50 years of age, and of this untreated older group, nearly all (94%) were accurately staged by systolic blood pressure alone, in contrast to subjects in the untreated younger group, who were best staged by diastolic blood pressure. Furthermore, most subjects (80%) in the older untreated and the inadequately treated groups had isolated systolic hypertension and required a greater reduction in systolic blood pressure than in the younger groups (-13.3 and -16.5 mm Hg versus -6.8 and -6.1 mm Hg, respectively; P:=0.0001) to attain a systolic blood pressure treatment goal of <140 mm Hg. Contrary to previous perceptions, isolated systolic hypertension was the majority subtype of uncontrolled hypertension in subjects of ages 50 to 59 years, comprised 87% frequency for subjects in the sixth decade of life, and required greater reduction in systolic blood pressure in these subjects to reach treatment goal compared with subjects in the younger group. Better awareness of this middle-aged and older high-risk group and more aggressive antihypertensive therapy are necessary to address this treatment gap.

Age Factors↗

PubMed2001

Impact of poorly controlled hypertension on healthcare resource utilization and cost.

OBJECTIVE: To examine the relation between blood pressure (BP) control and utilization and cost of healthcare resources. STUDY DESIGN: A retrospective database study of managed care patients in New Mexico from January 1, 1996, to December 31, 1997. PATIENTS AND METHODS: We stratified 1000 hypertensive patients into categories based on average and maximum BP. Antihypertensive medication use and cost, number of physician visits, and interval between hypertension-related physician visits were determined. RESULTS: Medication costs increased progressively across all BP categories from lowest to highest, and higher average systolic BP (SBP) was significantly correlated with increased cost (P < .001). There were significant correlations between higher maximum BP and greater number of hypertension-related physician visits (P < .001). Mean number of visits for BP groups was 5.5 for patients with a maximum diastolic BP (DBP) < 85 mm Hg and 10.0 for those with a maximum DBP > or = 100 mm Hg (P < .001). Patients with a maximum SBP > or = 180 mm Hg averaged 9.7 visits, whereas those with a maximum SBP < 120 mm Hg averaged 4.1 visits (P < .001). Both SBP and DBP were significantly correlated with time to next visit (P < .001). Mean visit intervals ranged from 44 days for patients with an SBP < 85 mm Hg to 25 days for those with an SBP > or = 180 mm Hg (P < .001). A similar association was found between DBP and visit interval. CONCLUSIONS: Poor control of hypertension is associated with higher drug costs and more physician visits. Aggressive treatment might help reduce managed care costs and resource utilization.

Angiotensin-Converting Enzyme Inhibitors↗

PubMed2000

Headache in mild-to-moderate hypertension and its reduction by irbesartan therapy.

BACKGROUND: Although it is generally acknowledged to be a problem in severe hypertension, headache has not been consistently associated with mild-to-moderate hypertension. PATIENTS AND METHODS: In 7 randomized, double-blind, placebo-controlled trials, which included 2,673 patients with mild-to-moderate hypertension (defined as seated diastolic blood pressure of 95-110 mm Hg), patients were randomized to receive once-daily treatment with irbesartan, an angiotensin II receptor blocker (n= 1,987), or placebo (n=686). The data were pooled and analyzed retrospectively to determine whether the level of hypertension was associated with headache and whether antihypertensive therapy reduced the incidence of headache. RESULTS: Factors found to be predictive of headache incidence were diastolic blood pressure, sex (female), and age (<50 years). In comparison with placebo, the use of irbesartan was associated with a significant reduction in the incidence of headache (P=.003). CONCLUSIONS: These data suggest that mild-to-moderate hypertension is not asymptomatic and that the incidence of headache can be reduced by antihypertensive treatment with a favorable adverse effect profile.

Adult↗

PubMed2000

Cost per millimeter of mercury lowering is a measure of economic value for antihypertensive agents.

The use of pharmacoeconomic analyses to evaluate the appropriateness of treatment regimens is increasing rapidly. Trials that study the efficacy of antihypertensive agents do not often measure long-term cardiovascular morbidity and mortality, so complementary methods are needed to evaluate the cost-effectiveness of these agents. One method is to compare agents on the basis of their costs and blood pressure-lowering efficacy, producing a ratio of cost per millimeter of mercury lowering, or cost/mm Hg. This provides a simple, transparent method with which to evaluate the cost-effectiveness of antihypertensive agents. It also allows the cost-effectiveness of a blood pressure treatment to be assessed in terms of ambulatory blood pressure data. The use of cost/mm Hg requires assumptions that tolerability of agents is comparable and that blood pressure lowering is a valid surrogate for cardiovascular risk reduction. Given the emergence of new treatments that have differences in blood pressure efficacy, cost/mm Hg is likely to become increasingly used as an indicator of economic value.

Antihypertensive Agents↗

PubMed1999

Neural networks in outcomes research.

Neural networks (NNs) are being used in the areas of prediction and classification of outcomes in medicine--areas in which regression models have traditionally been used. In this report, we summarize the steps in developing and testing an NN. Through applications in clinical research, we present several examples of NN development and evaluation. Through these applications we show that the performance of the NNs matched or exceeded the performance of traditional methods. We then discuss the advantages and disadvantages of NN models in comparison to traditional regression methods.

Health Services Research↗

PubMed1998

Psammoma bodies in fine-needle aspirates of the thyroid: predictive value for papillary carcinoma.

BACKGROUND: Although characteristic of thyroid papillary carcinoma, psammoma bodies occasionally arise in benign or nonpapillary lesions. Their predictive value in fine-needle aspirates (FNA), without other features suggestive of papillary carcinoma, is uncertain. METHODS: This retrospective study determined the frequency of psammoma bodies and other calcifications in 313 FNAs and 69 resected thyroids; positive predictive value, sensitivity, and specificity were calculated and compared with a triad of characteristic cytologic features (papillary fronds, nuclear ridges/grooves, and intranuclear inclusions). Psammoma bodies from benign and malignant conditions were assessed for differentiating architectural or staining characteristics. RESULTS: Psammoma bodies were found in only 8 of 313 FNAs. Their positive predictive value for papillary carcinoma was 50%, the rest arising from multinodular goiters. By contrast, the positive predictive value of combined cytologic features was 100%. These features were also much more sensitive, present in 80% of papillary carcinomas compared with 14% with psammoma bodies. The psammoma bodies of papillary carcinoma could not be differentiated from those of other lesions either by staining characteristics or by architecture. Other types of calcifications also were present in diverse conditions, and did not discriminate among them. CONCLUSIONS: Isolated psammoma bodies are an unreliable predictor of papillary carcinoma in the absence of cytologic features. In view of the relatively low aggressiveness of papillary carcinoma in most age groups, repeat fine-needle aspiration and clinical correlation are recommended prior to consideration of surgery.

Biopsy, Needle↗

PubMed1998

Electrocardiographic and clinical predictors of acute myocardial infarction in patients with unstable angina pectoris.

Among patients with unstable angina pectoris (UAP), those who have non-ST-elevation acute myocardial infarction (AMI) are at higher risk for subsequent adverse events. To determine predictors of AMI in patients with UAP, we studied consecutive nonreferral patients with UAP or AMI admitted from the emergency department to the intensive care or telemetry units of an urban teaching hospital over 1 year. There were 280 study patients (mean age 66 years, 1/3 women); 24% had AMI at presentation, whereas 76% had UAP without evidence of AMI. Thresholds of > or = 3 involved leads (odds ratio [OR] 3.3; 95% confidence intervals [CI] 1.6 to 6.9) and > or = 0.2 mV (OR 5.1; 95% CI 2.2 to 11.6) of ST depression on the presenting electrocardiogram were strongly associated with AMI. The multivariate predictors of AMI were reported duration of symptoms >4 hours (OR 3.8; 95% CI 1.9 to 7.3), absence of prior revascularization (OR 3.5; 95% CI 1.6 to 7.5), absence of beta-blocker use before presentation (OR 2.8; 95% CI 1.3 to 5.8), and presence of new ST depression (OR 2.8; 95% CI 1.4 to 5.7). Using the 4 multivariate predictors, a prediction rule was developed. The percentages of patients with AMI when 0, 1, 2, 3, or 4 characteristics were present, respectively, were 7%, 6%, 24%, 46%, and 83% (p <0.001). A similar prediction rule developed from the Thrombolysis In Myocardial Ischemia III trial was validated in our cohort. Among patients with UAP, electrocardiographic and clinical variables can help immediately identify those at high risk for AMI at presentation.

Aged↗

PubMed1998

Cytologic features of mycobacterial pleuritis: logistic regression and statistical analysis of a blinded, case-controlled study.

Tuberculous pleural effusions are characterized by lymphocytosis; the significance of mesothelial cells is uncertain, as are the cytologic features in concurrent human immunodeficiency virus (HIV) infection. This blinded study compared 38 culture-positive pleural fluids (6 HIV+) with 38 controls from benign exudative processes. Logistic regression analysis selected mature lymphocytes as most predictive of positive culture, and mesothelial cells and eosinophils as negative predictors. Mesothelial cells were scant (< 10% of nucleated cells) in 36/38 cases with mycobacteria (sensitivity 95%); if these cell were > 10%, tuberculosis was virtually ruled out in HIV- patients. Specificity was maximized (82%) when mesothelial cells < 10% were combined with lymphocytes > 50%; positive predictive value with this combination was 76%, but was raised to 96% if moderate/marked cellularity was also identified. Among tuberculosis cases, reactive mesothelial cells differentiated HIV+ from HIV- patients; there was no other significant difference.

Acquired Immunodeficiency Syndrome↗

PubMed1998

Fine needle aspiration (FNA) in HIV+ patients: results from a series of 655 aspirates.

There are many selected small series or case reports of FNAs in patients with HIV infection, but large series are rare and epidemic's characteristics have evolved over time. The current study, from a large public hospital in the USA, included women as well as men, hetero- and homosexuals, in-patients and out-patients, and deep radiologically guided aspirates as well as superficial masses. Of 655 FNAs, reactive or benign changes were present in 37% confirmed or suspected malignancy in 13%, specific infection with stainable organisms in 14%, and inflammation in 16%. Twenty percent of cases were inadequate for diagnosis. Most of the identifiable infections were associated with Mycobacterium tuberculosis, with fewer atypical mycobacteria, fungi and other bacteria. Clinically significant diagnoses were correlated with deep aspirate location and lesion size > 2 cm, confirming other studies which also identified tenderness and recent enlargement as important indicators. The liberal use of FNA in our HIV+ population has greatly reduced the necessity for surgical nodal resection, reassured clinicians in continuing observation of reactive lymphadenopathy, and allowed immediate therapy for specific infection, cyst or malignancy.

AIDS-Related Opportunistic Infections↗

PubMed1997

Neural networks as predictors of outcomes in alcoholic patients with severe liver disease.

We developed and evaluated neural networks as predictors of outcomes in alcoholic patients with severe liver disease using commonly available clinical and laboratory values. Hospital charts of 144 patients were reviewed. Nine variables (five laboratory, four clinical) were recorded along with in-hospital death or survival. Data were organized into separate development and validation sets. Neural network predictions of survival were compared with those of the Maddrey discriminant function and logistic regression models developed on the same data. Model performance was evaluated by comparing areas under receiver-operating characteristic (ROC) curves and the distributions of model scores. Survivors had significantly different laboratory and clinical characteristics, the most important being a higher prothrombin time, lower bilirubin, and lower incidence of encephalopathy. Neural network performance was significantly better than that of the Maddrey score (ROC areas, 81.5% vs. 73.8%; P = .04). The ROC area for neural networks was similar to that of logistic regression (ROC area 78.2%; P = .3), but the neural networks were more successful in classifying patients into low- and high-risk groups (P < .001). A neural network score with laboratory data from hospital-day 7 improved prognostic accuracy further to 84.3%. After adjusting for baseline risk, the neural network change in illness severity was still a significant predictor of mortality (P = .001). Neural networks using clinical and laboratory data showed a high prognostic accuracy for predicting mortality in alcoholic patients with severe liver disease.

Adult↗

PubMed1997

Fine-needle aspiration of peripheral lymph nodes in patients with tuberculosis and HIV.

Previous studies of fine-needle aspiration (FNA) specimens from lymph nodes of patients with tuberculosis (TB) and infection with the human immunodeficiency virus (HIV) have often involved small numbers of specimens and have produced conflicting results. We reviewed 93 FNA specimens from peripheral lymph nodes in a consecutive series of 79 patients with TB to compare results for patients with and without HIV infection. The 45 patients with HIV infection in the series were more frequently male, more likely to have negative results on a purified protein derivative tuberculin skin test, and they had more disseminated disease. Granulomatous inflammation, a positive result on a culture, acid-fast bacilli, or necrosis was found in 71% of the studies. Identification of granulomatous inflammation occurred at a similar rate in FNA specimens from patients with HIV infection (16%) and without HIV infection (21%; P = .56). Necrosis was the sole reported finding in a significant subset of cases (16%), occurring in patients with and patients without HIV infection. FNA of peripheral lymph nodes of patients with TB was an effective diagnostic test. Granulomatous inflammation and other FNA findings in peripheral lymph nodes of patients with TB were similar in those with and those without HIV infection.

Adult↗

PubMed1995

Use of neural networks in predicting the risk of coronary artery disease.

Artificial neural networks were created to predict the occurrence of coronary artery disease based on information from the serum lipid profile. The development of the networks involved a strategy which permitted learning from censored observations. The networks were developed with data from the Cholesterol Lowering Atherosclerosis Study, which followed serum lipoprotein levels and clinical events in 162 patients over a period of up to 10 years. Inputs consisted of seven different mean lipid values, and the desired output was the time period during which a complication of coronary artery disease was predicted to occur. Cross-validation was performed by splitting the data into separate training and testing sets, scoring the performance of the neural network strategy on the testing sets, and comparing scores with those obtained from Cox regression models developed on the same training data. Performance of the neural network strategy exceeded that of Cox regression in predicting clinical outcomes (66% vs 56%, McNemar's test P = 0.005). The network design provided an effective approach to predicting outcomes from a clinical trial with variable follow-up times.

Adult↗

PubMed1995

A four-surface schematic eye of macaque monkey obtained by an optical method.

Schematic eyes for four Macaca fascicularis monkeys were constructed from measurements of the positions and curvatures of the anterior and posterior surfaces of the cornea and lens. All of these measurements were obtained from Scheimpflug photography through the use of a ray-tracing analysis. Some of these measurements were also checked (and confirmed) by keratometry and ultrasound. Gaussian lens equations were applied to the measured dimensions of each individual eye in order to construct schematic eyes. The mean total power predicted by the schematic eyes agreed closely with independent measurements based on retinoscopy and ultrasound results, 74.2 +/- 1.3 (SEM) vs 74.7 +/- 0.3 (SEM) diopters. The predicted magnification of 202 microns/deg in one eye was confirmed by direct measurement of 205 microns/deg for a foveal laser lesion. The mean foveal retinal magnification calculated for our eight schematic eyes was 211 +/- (SEM) microns/deg, slightly less than the value obtained by application of the method of Rolls and Cowey [Experimental Brain Research, 10, 298-310 (1970)] to our eight eyes but just 4% more than the value obtained by application of the method of Perry and Cowey [Vision Research, 12, 1795-1810 (1985)].

Animals↗