Biomedical subjects

S Nessim

Publications and source records attributed to S Nessim.

At least 19 recordsLinked to original sources

PubMed1999

Actual failure rates: A method of assessing tissue valve reoperation rates.

BACKGROUND: Patients older than age 70 with coronary disease undergoing mitral valve replacement have a limited survival rate, suggesting that few of these patients will require reoperation if they receive a tissue mitral valve. However, traditional actuarial analysis of valve durability censors patients who die before valve failure and doesn't reflect the lower frequency of reoperation in patient subgroups with limited survival rates. METHODS: Actual or cumulative reoperation rates represent the rates of reoperation in patients without censoring for death and estimate the risk that the valve will fail before the patient dies. The actual rates of valve rereplacement were determined in 255 recipients of tissue mitral valves, categorizing patients by age and presence of coronary artery disease at 8 years after surgery and compared with standard actuarial estimates of valve durability. RESULTS: Operative mortality rates were 17.5% for patients with coronary artery disease and 6.0% for those without (P <.001). At 8 years, the actual reoperation rates for patients younger than age 70 with and without coronary artery disease were 9.2% (n = 76) and 10% (n = 90), respectively. In patients older than age 70 without coronary artery disease the reoperation rate was 9.4% (n = 32). In contrast, the actual reoperation rate was only 1.7% (n = 58) in patients older than age 70 with coronary artery disease. This rate was significantly lower (P =.05) than the other groups. The difference in reoperation rates was not significant if standard actuarial analysis was used. CONCLUSIONS: Actual reoperation rates are significantly lower in patients older than 70 years with CAD receiving mitral tissue valves than in younger patients or in patients without coronary artery disease. Calculation of actual reoperation rates provides a unique and clinically useful perspective in evaluating data on prosthetic valve reoperation rates.

Age Factors↗

PubMed1997

Cardiac operations in patients 90 years of age and older.

BACKGROUND: Growth of the elderly population worldwide, and specifically in the United States, will continue to accelerate and will have a profound impact on the cost and delivery of health care resources in the future. A medical strategy that allows the elderly to live independently is essential to most cost-effective use of our resources. The question remains as to what will be the future of surgical therapy for this increasing population. METHODS: We retrospectively studied the cases of 30 consecutive nonagenarians (mean age, 92.3 +/- 1.8 years) who underwent a cardiac operation within a 9-year period. All patients were in New York Heart Association class III or IV and underwent operation urgently or emergently. RESULTS: The 30-day mortality rate was 10%, and the actuarial survival rates were 81% +/- 8% and 75% +/- 9% at 1 year and 2 years, respectively. Seventy-eight percent of survivors were in New York Heart Association class I or II within 2 years after operation and had an improved quality of life. The cost of providing care in this age group was 24% higher than in octogenarians. CONCLUSIONS: Advanced age in and of itself (>90 years) should not be a contraindication to an open-heart operation, although morbidity, mortality, and cost may be higher. However, selective criteria identifying risks and benefits for individual patients should be applied. The aging of our population will have a profound impact on the cost and delivery of health care resources in the future. This issue must be addressed in the current debate on the provision of expensive procedures under a realigned national health-care system.

Actuarial Analysis↗

PubMed1997

Resting hemodynamics after total versus standard orthotopic heart transplantation in patients with high preoperative pulmonary vascular resistance.

OBJECTIVE: Pretransplant pulmonary vascular resistance > or = 4 Wood-units predisposes to right ventricular failure after heart transplantation. Total orthotopic heart transplantation with bicaval and pulmonary venous anastomoses offers synchronous contractions of the atria and a normal ventricular filling pattern, but requires longer ischemic time than standard orthotopic heart transplantation. To test if total orthotopic heart transplantation improves resting hemodynamics in pts with high preoperative pulmonary vascular resistance, we analyzed 65 pts with standard and 65 with total orthotopic heart transplantation transplanted between 12/88 and 7/94. Of these, 18 with total and 15 with standard orthotopic heart transplantation had a preoperative pulmonary vascular resistance > or = 4 Wood-units. METHODS: Right heart catheterization data were obtained at each endomyocardial biopsy. All data from biopsies at both 2 weeks and 1 year posttransplant that were free from humoral or greater than 1A cellular rejection (9 versus 13 pts) were included in a two way ANOVA. Pts with postop pacemakers, atrial fib or beta-blocker therapy at the time of biopsy were excluded. RESULTS: Ischemic time was different (172 +/- 44 versus 142 +/- 28 min, P = 0.03). Demographics, NYHA class, pre-TX hemodynamics, donor age and inotropes were similar. Cardiac output and index were higher in the total orthotopic group at 2 weeks (6.5 +/- 1.7 versus 5.1 +/- 1.0 l/min; 3.4 +/- 0.9 versus 2.8 +/- 0.6 l/min per m2) and 1 year (7.1 +/- 2.0 versus 4.9 +/- 1.1 l/min, P = 0.002; 3.6 +/- 1.1 versus 2.6 +/- 0.5 l/min per m2, P = 0.009). Right atrial and pulmonary arterial mean pressure (mmHg) were lower with total orthotopic heart transplantation at 2 weeks (6 +/- 4 versus 9 +/- 5, P = 0.04; 22 +/- 3 versus 25 +/- 7, P = 0.1) and 1 year (5 +/- 2 versus 7 +/- 3, P = 0.02; 19 +/- 4 versus 25 +/- 7, P = 0.03). Pulmonary capillary wedge pressure (mmHg) was borderline nonsignificant (11 +/- 4 versus 13 +/- 7 at 2 weeks, 8 +/- 3 versus 14 +/- 5 at 1 year, P = 0.055), as well as pulmonary vascular resistance (1.9 +/- 1 versus 2.5 +/- 1 at 2 weeks, 1.5 +/- 0.6 versus 2.7 +/- 1.7 WU at 1 year, P = 0.051). CONCLUSIONS: Total orthotopic heart transplantation improves cardiac output and index in pts with high preoperative pulmonary vacular resistance. There is a lower mean RA and PA pressure perhaps due to less tricuspid and mitral regurgitation. In view of the frequently observed restrictive filling pattern after cardiac transplantation, total orthotopic heart transplantation can be beneficial until this pattern has subsided by preserving atrioventricular synchrony and offering better atrial transport.

Aged↗

PubMed1997

Heart transplantation with bicaval and pulmonary venous anastomoses. A hemodynamic analysis of the first 117 patients.

BACKGROUND: A new surgical technique for orthotopic heart transplantation has been introduced into clinical practice. It accomplishes total atrioventricular transplantation as the recipient's atria are completely excised and the allograft is implanted using bicaval and pulmonary venous anastomoses. MATERIALS AND METHODS: We retrospectively analyzed post-transplant hemodynamic and patient survival in our first 117 patients transplanted with this new operative approach and compared them with 64 patients transplanted with the standard biatrial technique. RESULTS: Patients transplanted with the bicaval technique had a significantly lower right atrial mean, pulmonary arterial systolic, pulmonary arterial mean, and pulmonary capillary wedge pressures. In addition, a significant reduction in post-transplant tricuspid regurgitation and a trend towards less severe mitral regurgitation was observed. The need for permanent pacemaker implantation due to sinus node dysfunction after transplantation was completely eliminated with this new technique. Thirty-day operative survival and actuarial survival at 1, 2, 3, and 4 years was significantly greater in patients transplanted with the bicaval technique. CONCLUSIONS: Orthotopic heart transplantation performed with bicaval and pulmonary venous anastomoses offers improved post-transplant hemodynamics, eliminates the need for permanent pacemaker, and has improved patient survival when compared with the standard biatrial technique. These differences can be related in part to improved hemodynamic function of the cardiac allograft due to preservation of the anatomic configuration and physiologic function of the atria.

Adult↗

PubMed1996

Adverse 5-year outcome after coronary artery bypass surgery in blacks.

BACKGROUND: Coronary heart disease is the leading cause of death among blacks, but little is known about the late results of coronary artery bypass surgery in this population. It is not known whether differences in preoperative medical characteristics or medical health insurance affect outcome. We studied the effects of medical risk factors on survival outcome after coronary artery bypass surgery in a population of medically insured black and white patients. METHODS: Racial status and outcomes from surgery were determined in 3728 consecutive patients who had coronary artery bypass surgery at the authors' institution from January 1, 1984, to June 30, 1992. Coronary artery bypass surgery (excluding valve replacement) was performed in 115 black and 3113 white patients. RESULTS: Late survival probability was worse for blacks than whites at 1 year (84% vs 92%) and at 5 years (64% vs 82%, P=.001, Wilcoxon test). Most deaths were due to cardiac events in both groups (68% in blacks vs 67% in whites). Blacks had more hypertension (84% vs 54%), diabetes mellitus (36% vs 23%), and more were current smokers (21% vs 14%) (all P<.05, Fisher's exact test). Medical insurance coverage for blacks and whites was as follows: Medicare (60% vs 57%), private (38% vs 42%), and Medi-Cal (2% vs 2%). Operative mortality (30 days) was similar (5.2% for blacks vs 4.1% for whites; P=.48, Fisher's exact test). In a Cox regression model, race predicted long-term survival and persisted as an important risk factor after adjusting for preoperative factors related to patient survival (adjusted hazard ratio, 2.10; 95% confidence interval, 1.43 to 3.07). CONCLUSIONS: In this group of predominantly medically insured patients undergoing coronary artery bypass surgery, the risk of death in blacks at 5 years was twice that of whites.

Black or African American↗

PubMed1996

Heart transplantation in patients 65 years of age and older: a comparative analysis of 40 patients.

BACKGROUND: Advanced age has traditionally been considered a relative contraindication to heart transplantation because of the potential for increased morbidity and decreased long-term survival. METHODS: We analyzed the results in 40 patients 65 years of age and older who underwent heart transplantation and compared them with those in 138 patients younger than 65 years. RESULTS: The older age group had a higher incidence of diabetes mellitus (p = 0.01), donor-recipient weight mismatch (< 0.80) (p = 0.004), lower donor-recipient weight ratio (p = 0.02), and longer allograft ischemic time (p = 0.008), among other differences. However, the 30-day operative mortality was similar in both groups (2.5% in older versus 2.2% in younger patients). Actuarial survival at 12, 24, and 36 months was not statistically different between the older and younger patients (86% +/- 6% versus 93% +/- 2%, 78% +/- 8% versus 89% +/- 3%, and 72% +/- 9% versus 81% +/- 4%, respectively; p = 0.26). The posttransplantation intensive care unit stay, total hospital stay, and associated hospital costs were also similar. The incidence of rejection during the first posttransplantation year was similar in both groups. CONCLUSIONS: Heart transplantation in selected patients 65 years of age and older can be performed successfully, with a morbidity and mortality comparable with those seen in younger patients. Advanced age should not be an exclusion criterion for heart transplantation, but selective criteria should be applied that identify risks and benefits individually.

Actuarial Analysis↗

PubMed1996

The effect of thigh-length support stockings on the hemodynamic response to ambulation in pregnancy.

OBJECTIVE: Our purpose was to determine the effect of thigh-length support stockings on hemodynamic response when pregnant subjects change from the sitting to the lateral recumbent position and then after standing with ambulation. STUDY DESIGN: Eighteen subjects in the late second and early third trimester of pregnancy acted as their own controls. The cardiovascular status of the subjects was assessed by a noninvasive technique--thoracic electrical bioimpedance before and after wearing support stockings for 1 week. Urine catecholamines were measured in 13 patients before and after wearing support stocking to assess the release of catecholamines. Samples were collected after the subjects had been in the lateral recumbent position 40 minutes and again 40 minutes later after standing with ambulation. RESULTS: Heart rate and mean arterial blood pressure decreased significantly when subjects changed from the sitting to the lateral recumbent position and then increased with ambulation. Wearing compression stockings significantly increased mean arterial pressure and afterload in all three positions. Position change from lateral recumbent to standing and ambulation marginally increased urinary dopamine levels (p = 0.097) and significantly increased norepinephrine levels (p = 0.006). CONCLUSIONS: There are significant hemodynamic changes in pregnant subjects when they change from the sitting position to the lateral recumbent position and then change to standing with ambulation. Support stocking have a significant mechanical effect: they significantly increase afterload and systemic vascular resistance by preventing pooling of blood in the lower extremities. There may also be a biochemical effect that results in less catecholamine release. These results suggest that compression stockings could play an important role in supporting the circulation during ambulation.

Adult↗

PubMed1996

Clinical experience with one hundred consecutive patients undergoing orthotopic heart transplantation with bicaval and pulmonary venous anastomoses.

OBJECTIVE: Our objective was to assess survival, need for pacemaker insertion, and rejection frequency with a new surgical technique of orthotopic heart transplantation using bicaval and pulmonary venous anastomoses. METHODS: We retrospectively reviewed 100 consecutive patients who had orthotopic heart transplantation with this technique between July 1991 and September 1995. RESULTS: The mean age was 57.0 +/- 11.1 years, with 51 patients being 60 years or older. The mean donor/recipient weight ratio was 0.92, and in 28 patients the ratio was less than 0.8. The early (30-day) survival was 100% and the 1- and 2-year survivals were 98% +/- 2% and 96% +/- 2%, respectively. Survival was not affected by age or by the duration of the OKT3 therapy (p > 0.2 for each of these parameters). The seven late deaths were due to infection (n = 2), graft atherosclerosis (n = 3), acute rejection (n = 1), and nonspecific graft failure (n = 1). No permanent pacemaker was required in the first 6 months after the operation, and all the patients were discharged in normal sinus rhythm. Freedom from treated rejection was significantly greater in patients with 7 days of OKT3 therapy than in patients with 14 days of therapy (p < 0.0001). CONCLUSIONS: Orthotopic heart transplantation with bicaval and pulmonary venous anastomoses offers an improved alternative to the standard biatrial technique, with a 30-day mortality of 0,% in 100 consecutive patients, excellent intermediate-term survival, and elimination of the need for pacemaker insertion. More normal anatomic configuration and synchronous function of the atria may have contributed to these results.

Adolescent↗

PubMed1996

Resting hemodynamics after total versus standard orthotopic heart transplantation.

Total orthotopic heart transplantation (TOHT) requires longer surgery than standard orthotopic heart transplantation (SOHT), but offers normal anatomy and synchronous atrial contraction. We endeavored to test whether TOHT improves resting hemodynamics. We analyzed 60 patients with SOHT and 66 with TOHT transplanted between 12/89 and 7/94. Age, preoperative NYHA class, ejection fraction, and donor characteristics were similar. After applying exclusion criteria at 2 weeks postoperatively, 53 SOHT and 58 TOHT patients were accepted for further study. Right-heart hemodynamics were examined at 2 weeks and 6 months posttransplant. Despite a longer ischemic time (161 +/- 36 vs. 142 +/- 37 min, p = 0.004), cardiac output and index were higher in the TOHT group at 2 weeks (6.1 +/- 1.4 vs. 5.4 +/- 1.0 L/min, TOHT vs. SOHT, p = 0.01; and 3.3 +/- 0.7 vs. 2.9 +/- 0.6 L/min/m2, p = 0.005) but similar at 6 months (5.9 +/- 1.2 vs. 5.6 +/- 1.4 L/min; and 3.0 +/- 0.6 vs. 2.9 +/- 0.7 L/min/m2). Right-atrial pressure was lower with TOHT at both time points (7 +/- 4 vs. 9 +/- 4 mmHg, p = 0.02: and 5 +/- 2 vs. 7 +/- 3, p = 0.0006). Wedge pressure was similar at 2 weeks (12 +/- 5 vs. 13 +/- 5, p = 0.045). Heart rate (bpm) was higher at both time points with TOHT (84 +/- 10 vs. 75 +/- 12, p = 0.0003: and 90 +/- 12 vs. 82 +/- 9, p = 0.0006). Pulmonary vascular resistance was similar at both time points. Despite a longer ischemic time, total orthotopic heart transplantation does not impair postoperative cardiac function. There is an early improvement in cardiac output, a sustained higher heart rate reflecting preservation of donor sinus node function, and a lower right-atrial pressure.

Blood Pressure↗

PubMed1996

Heart transplantation in patients with diabetic end-organ damage before transplantation.

Diabetes mellitus with preexisting end-organ damage (EOD) is considered a contraindication for heart transplantation. The outcome of such patients has not been well characterized. Among 138 patients transplanted between 12/88 and 7/94, 29 were diabetic (11 insulin-dependent); of these, 12 had preexisting EOD, defined as a creatinine clearance < or = 50 ml/min, a 24-hour urine protein concentration > or = 500 mg/L or typical symptoms of peripheral or autonomic polyneuropathy, and 17 had no EOD. We compared diabetics with and without EOD and non-diabetics (n = 109) for operative mortality, length of stay, serum creatinine, fasting glucose levels, and postoperative prednisone doses at 1,6, and 12 months. Actuarial survival and freedom from rejection and infection were analyzed. Both diabetic groups were significantly older than nondiabetics, Ischemic time, operative mortality, surgical technique, ICU- and total length of stay were similar. Actuarial survival and freedom from rejection were similar among the three groups. Infection rates including CMV did not differ. Serum creatinine levels increased in all groups compared to pretransplant levels (p = 0.001), but without significant differences among the groups. Post-transplant glucose levels at 6 and 12 months were higher for diabetic patients with EOD than for those without or for nondiabetics (183, 153, and 94 mg/dl at 6 months, p = 0.01; 202, 161, and 102 mg/dl at 12 months, p = 0.0001). Prednisone dosage was lower in diabetics with EOD at 6 months, but did not differ among the three groups at 12 months. The incidence of angiographically proven transplant vasculopathy did not differ at 1 and 2 years. Diabetics with preexisting EOD undergoing heart transplantation experience similar short- and intermediate-term results when compared to diabetics without EOD and nondiabetics. Metabolic control is more difficult to achieve, as indicated by higher fasting glucose levels. Larger and longer-term prospective studies have to confirm our findings, since the shortage of donor organs would increase if such patients were transplanted routinely.

Actuarial Analysis↗

PubMed1995

A study of patient satisfaction and adherence to preventive care practice guidelines.

PURPOSE: Patient satisfaction ratings are being used to judge physicians' quality of care and to determine physician reimbursement. We therefore studied the association between patient satisfaction and the quality of medical care received by patients in physicians' offices. PATIENTS AND METHODS: Patient satisfaction was measured in a survey of patients cared for by 48 primary care physicians in a health maintenance organization in Southern California. Evidence that patients were offered or received preventive care services was determined by patient survey and medical record abstraction, respectively. The medical records of 3,249 randomly selected elderly patients (65 to 75 years old) were studied. Of these patients, 2,799 completed a patient satisfaction and preventive care services survey (response rate 86.1%), 2,654 completed a patient satisfaction survey (response rate 81.7%), and 2,258 completed a quality-of-life survey (response rate 69.5%). RESULTS: Patients were generally satisfied with their physicians' care (median satisfaction score 4.2; scale 1 to 5, 5 being most satisfied). Patients who received or were offered mammography, clinical breast examination, influenza vaccine, pneumococcal vaccine, tetanus vaccine, exercise counseling, and smoking cessation counseling were more satisfied with their medical care than those patients who did not (P < 0.001 for all tests). After controlling for the physician who was providing the medical care, there was still a statistically significant relationship between these factors and patient satisfaction. CONCLUSIONS: We found a significant association between patient satisfaction and the performance of some but not all preventive care services. However, we cannot be certain whether there is a relationship between patient satisfaction and quality of patient care.

Aged↗

PubMed1995

Lupus in the 1980s: III. Influence of clinical variables, biopsy, and treatment on the outcome in 150 patients with lupus nephritis seen at a single center.

Of 500 patients with systemic lupus erythematosus observed at our center, 150 fulfilled criteria for lupus nephritis. Of these 150 patients, 91% were female, and 67% were white. The mean age of onset was 26.2 years, and the mean follow-up duration was 11.7 years. Biopsies (n = 142) performed on 107 patients showed the following World Health Organization (WHO) class distribution: class I, n = 1; class II, n = 13; class III, n = 19; class IV, n = 69; class V, n = 17; class VI, n = 8; and class not determinable, n = 15. Ninety-five patients were nephrotic. Therapeutic intervention courses given to all patients (n = 356) included parenteral (IV) cyclophosphamide (n = 58), high-dose oral steroids (n = 126), pulse steroids (n = 49), apheresis (n = 39), azathioprine (n = 43), oral cyclophosphamide (n = 5), nitrogen mustard (n = 27), and chlorambucil (n = 6). In addition to examining the course of disease for various subsets, various predictors for fatality and end-stage renal disease (ESRD) were analyzed. Descriptive data for the short-term response to five therapies are provided for the complete patient sample, proliferative disease, and nephrotic syndrome. Twenty patients died, primarily from cardiovascular complications and sepsis, with 97% and 92% 5- and 10-year survival rates, respectively. Twenty-nine were dialyzed, and 11 were transplanted. Risk of ESRD by WHO class at 5 years was as follows: class III, 0%; IV, 9%; V, 16% (P = .04 for class V v other patterns).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1994

The West Los Angeles Preterm Birth Prevention Project. I. Program impact on high-risk women.

OBJECTIVE: The primary objective of this prospective study was to test whether preterm birth prevention education plus increased clinic visits and selected prophylactic interventions reduce preterm birth. STUDY DESIGN: Eight West Los Angeles prenatal county clinics, comparable with respect to selected demographics, were randomized to be either experimental or control clinics. High-risk patients in all clinics were identified with a risk scoring system derived from a similar population. High-risk patients (N = 1774) in experimental clinics were offered a program of education and more frequent visits and were randomized to receive various secondary intervention protocols in addition to the basic interventions of education and more frequent visits. Control clinic patients (N = 880) received standard county care. RESULTS: Preterm birth rates were 19% lower among the experimental high-risk patients (7.4% vs 9.1%), and differences were significant (p < 0.05) when preterm risk was taken into account. There was no evidence to suggest that the secondary interventions provided added benefit over the primary intervention protocol of preterm birth prevention education and increased visits. CONCLUSION: The 19% reduction in preterm birth rate observed in the experimental clinics suggest an overall program benefit from a protocol that offered education, more frequent visits, and greater attention given to patients while the selected interventions were applied.

Adult↗

PubMed1994

The West Los Angeles Preterm Birth Prevention Project: II. Cost-effectiveness analysis of high-risk pregnancy interventions.

OBJECTIVE: To examine the cost-effectiveness of the West Los Angeles Preterm Birth Prevention Project. METHODS: Maternal and neonatal care data were collected on all preterm deliveries (150) and a random sample of term deliveries (140) from high-risk patients at both experimental and control clinic sites. Costs were determined for prenatal care, inpatient preterm labor, delivery and postpartum care, and newborn care. Cost calculations, weighted by the actual proportions of term and preterm births, were confirmed with square-root transformation and trimmed mean (2%) values. RESULTS: When compared to control clinic high-risk patients, experimental clinic high-risk patients had an average cost savings of $2196 for newborn care (P = .02), resulting in a net savings of $1768 per high-risk mother-infant pair. Births before 32 weeks' gestation accounted for the greatest mean cost. CONCLUSION: Programs of comprehensive prenatal care and patient education may be highly cost-effective for prevention of prematurity.

Adult↗

PubMed1994

The St. Jude Medical valve. Experience with 1,000 cases.

We analyzed the long-term results of valve replacement with the St. Jude Medical bileaflet valve (St. Jude Medical, Inc., St. Paul, Minn.) in our first 1000 implantations between 1978 and 1992. A total of 399 patients had mitral valve replacement, 471 aortic valve, and 130 double (mitral and aortic) valve replacement. The average patient age was 64 +/- 15 years and the majority of patients (52%) had concomitant coronary disease. With 4328 patient-years of follow-up, 83% of the mitral group, 76% of the aortic group, and 77% of the double valve group were free of thromboembolism at 10 years after operation, and 87% of the mitral group, 82% of the aortic group, and 85% of the double valve group were free of valve-related hemorrhage. At 10 years, 91% of the mitral group, 84% of the aortic group, and 84% of the double valve group were free of valve-related death. However, overall survival at 10 years was only 42% +/- 4% for the mitral group, 43% +/- 4% for the aortic group, and 43% +/- 6% for the double valve group. For all three groups, age was a highly significant factor stratifying survival (p < 0.001), as was the presence of coronary disease (all p < 0.001). The excellent freedom from valve-related death at 10 years of 84% to 91% is in striking contrast to the overall survivals of 42% to 43% at 10 years. This difference suggests that the primary factors limiting long-term survival after valve replacement with the St. Jude Medical valve are not valve-related factors, but other patient factors such as age and concomitant coronary disease.

Aged↗

PubMed1993

Impact of family relocation on children's growth, development, school function, and behavior.

OBJECTIVE: The United States is a highly mobile society, with family relocation rates double those of Great Britain and Germany. The objective of this study was to describe the impact of frequent family moves on reported rates of delay in growth or development, learning disorders, school failure, and frequent behavioral problems in US school-age children. DESIGN AND SETTING: We analyzed data on 9915 six- to 17-year-old children of families responding to the 1988 National Health Interview Survey, a nationally representative sample of families and children. OUTCOME MEASURES: Parents were asked to report the total number of moves the index child had experienced during his or her lifetime. Total moves were adjusted for the child's age in years. Children were divided into two groups: never moved/infrequent relocation (below the 90th percentile for age-adjusted moves) and frequent relocation (above the 90th percentile for age-adjusted moves). The parent was asked if the child had ever had a learning disability or a delay in growth or development, had ever failed a grade, or had four or more frequently occurring behavioral problems as described by a behavioral problems checklist. RESULTS: The measures of both child dysfunction and family relocation were independently associated with multiple sociodemographic characteristics such as poverty, race, and family structure. Frequent relocation was associated with higher rates of all measures of child dysfunction; 23% of children who moved frequently had repeated a grade vs 12% of children who never or infrequently moved. Eighteen percent of children who moved frequently had four or more behavioral problems vs 7% of children who never or infrequently moved. Use of logistic regression to control for potential confounding covariates demonstrated that children who moved frequently were 77% more likely to be reported to have four or more behavioral problems (odds ratio, 1.77; 95% confidence interval, 1.37 to 2.29) and were 35% more likely to have failed a grade (odds ratio, 1.35; 95% confidence interval, 1.06 to 1.72), but no more likely to have had delays in growth or development or a learning disorder. CONCLUSIONS: After adjusting for other covariates, frequent family relocation was associated with an increased risk of children failing a grade in school and four or more frequently occurring behavioral problems.

Adjustment Disorders↗

PubMed1992

Cutaneous lupus erythematosus without systemic lupus erythematosus: clinical and laboratory features.

Sixty-seven patients with cutaneous lupus erythematosus (CLE) were followed up as part of a series of 570 lupus erythematosus patients seen in a private practice between 1980 and 1989. Clinical and laboratory features, treatment, and natural course were observed. Findings of interest included (1) a ratio of at least one CLE case for every seven cases of systemic lupus erythematosus (SLE); (2) occurrence of CLE in fewer women and apparently associated with an older age at diagnosis than SLE; (3) similar frequency of cutaneous lupus subsets in CLE and SLE; (4) strong family history for SLE but not CLE in CLE patients; (5) other cutaneous and musculoskeletal features in a majority of CLE patients and constitutional symptoms in 10%; (6) positive ANA titers, high sedimentation rates, and leukopenia common in CLE; (7) anticardiolipin antibody in 31% of CLE patients but not associated with systemic complications; (8) antimalarials required by 75% of patients and systemic steroids by 33%; and (9) an excellent prognosis associated with CLE, organ-threatening disease being rare.

Adult↗

PubMed1992

Department of pharmacy-initiated program for streamlining empirical antibiotic therapy.

The outcome of a department of pharmacy-initiated "streamlining" study designed to promote cost-conscious modifications of empirically selected antibiotic therapy is described. Two hundred forty-one evaluable adult patients started on restricted-use antibiotics at this university-affiliated community private teaching hospital were enrolled in a 9-week prospective streamlining study. Patients were alternately assigned to a Control (i.e., no pharmacist-initiated streamlining recommendations offered based on culture and susceptibility reports) or a Pharmacist Intervention group (i.e., pharmacist offers recommendations to streamline therapy). A statistically significant greater number of patients had their empiric antibiotic treatment courses modified to more appropriate antibiotic choices after receipt of culture and susceptibility reports among private prescribers in the Pharmacist Intervention group (83%) than in the Control group (38%) (p = .006). Additionally, pharmacists were overall successful in gaining prescriber acceptance for 64% of recommended changes of empiric antibiotic treatment courses before the receipt of culture and susceptibility reports (e.g., dose and/or frequency changes). There was no program effect observed with respect to improved physician response to microbiologic data that would allow streamlining empirical antibiotic choices in the Housestaff (i.e., medical or surgical residents), or infectious disease consultant prescriber groups. Projected overall annual cost savings that would be achieved as a result of continued efforts by pharmacists directed at streamlining empirical "restricted" antibiotic regimens is approximately +40,000.

Analysis of Variance↗