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PubMed1984

Asymptomatic carotid arterial disease in patients presenting with angiographically proven coronary artery disease.

Atherosclerosis is a systemic and progressive disease process. However, the patterns of disease and the sequence of arterial involvement need further definition. A select group of patients initially presenting with coronary arterial disease was evaluated for evidence of hemodynamically significant carotid arterial disease. Eight per cent of patients were found to have hemodynamically significant carotid arterial disease by the oculopneumoplethysmography (Gee OPG). This low incidence of carotid arterial disease is in contrast to patients who present with carotid arterial disease who are found to have a high incidence of coronary artery disease. This would suggest that either the coronary artery disease develops first or that there is a specific pattern of atherosclerotic vascular disease where patients have coronary artery disease without hemodynamically significant carotid disease. Long-term follow-up on patients initially presenting with coronary arterial disease will help further define this question.

Adult↗

PubMed2000

Awareness, perception, and knowledge of heart disease risk and prevention among women in the United States. American Heart Association Women's Heart Disease and Stroke Campaign Task Force.

CONTEXT: One of 2 women in the United States dies of heart disease or stroke, yet women are underdiagnosed and undertreated for these diseases and their risk factors. Informed decisions to prevent heart disease and stroke depend on awareness of risk factors and knowledge of behaviors to prevent or detect these diseases. OBJECTIVE: Assess (1) knowledge of risks of heart disease and stroke and (2) perceptions of heart disease and its prevention among women in the United States. DESIGN AND SETTING: Telephone survey conducted in 1997 of US households, including an oversample of African American and Hispanic women. PARTICIPANTS: One thousand respondents 25 years or older; 65.8% white, 13.0% African American, and 12.6% Hispanic. MAIN OUTCOME MEASURES: Knowledge of heart disease and stroke risks, perceptions of heart disease, and knowledge of symptoms and preventive measures. RESULTS: Only 8% of the respondents identified heart disease and stroke as their greatest health concerns; less than 33% identified heart disease as the leading cause of death. More women aged 25 to 44 years identified breast cancer as the leading cause of death than women 65 years or older. Women aged 25 to 44 years indicated they were not well informed about heart disease and stroke. Although 90% of the women reported that they would like to discuss heart disease or risk reduction with their physicians, more than 70% reported that they had not. CONCLUSIONS: Most women do not perceive that heart disease is a substantial health concern and report that they are not well informed about their risk. Age influenced knowledge to a greater extent than ethnicity. Programs directed at young women that address the effects of lifestyle behaviors on long-term health are needed. Better communication between physicians and patients is also warranted.

Adult↗

PubMed1999

Perforating ileocecal Crohn's disease does not carry a high risk of recurrence but usually re-presents as perforating disease.

PURPOSE: The aim of this study was to study the natural history of perforating and nonperforating ileocecal Crohn's disease. METHODS: One hundred sixty-five cases of primary ileocecal Crohn's disease operated on between 1975 and 1995 were reviewed. Perforating disease was defined as acute free perforation, subacute perforation with an abscess, or chronic perforation with an internal or external fistula. RESULTS: Perforating disease was identified in 72 patients (44 percent); 11 with acute free perforation, 18 with abscess formation, and 43 with fistulas. Postoperative complications occurred in 29 percent of perforating and in 23 percent of nonperforating disease (not a significant difference). There was no significant difference in the cumulative reoperation-free rate for recurrence at the ileocolonic anastomosis (perforating, 78 percent vs. nonperforating, 73 percent at 5 years and perforating, 61 percent vs. nonperforating, 55 percent at 10 years), or in the median time interval from the primary to the secondary operation (perforating, 49 vs. nonperforating, 37 months). Seventy percent of perforating disease re-presented with perforating recurrence. Likewise, 83 percent of nonperforating disease re-presented with nonperforating (P < 0.0001) recurrence. Re-reoperation rate for re-recurrence at the ileocolonic anastomosis and median duration from the second operation to the third operation did not differ between perforating and nonperforating disease. Seventy-nine percent of perforating disease re-presented again with perforating disease, and 87 percent of nonperforating disease re-presented again with nonperforating disease as before (P = 0.001). CONCLUSIONS: These data suggest that perforating ileocecal disease usually re-presents in the way it did originally but does not represent a high-risk group for recurrence.

Adult↗

PubMed1992

Pelvic inflammatory disease: findings during inpatient treatment of clinically severe, laparoscopy-documented disease.

OBJECTIVES: We evaluated the relationship between clinically severe pelvic inflammatory disease and laparoscopic diagnosis and grading, comparative treatment with clindamycin plus cefamandole or doxycycline, and a management protocol for inpatient pelvic inflammatory disease treatment. STUDY DESIGN: Thirty-three patients who met our clinical criteria for severe pelvic inflammatory disease underwent diagnostic laparoscopy. Pelvic inflammatory disease patients were randomized to double-blind treatment with clindamycin plus cefamandole or doxycycline within our management protocol; postdischarge oral antibiotics were omitted. RESULTS: Laparoscopy confirmed pelvic inflammatory disease in 23 (70%) patients; 10 (44%) had mild pelvic inflammatory disease by laparoscopic grading. Laparoscopic grade alone predicted necessary duration of therapy to response: mild pelvic inflammatory disease, 2.3 +/- 0.5 days; moderate pelvic inflammatory disease, 2.7 +/- 1.5 days; and severe pelvic inflammatory disease, 3.9 +/- 1.5 days (p less than 0.05). Using the management plan presented, response rates for both antibiotic regimens were 100%. CONCLUSIONS: Clinical diagnosis and grading of severe pelvic inflammatory disease has poor specificity. Laparoscopic grading of severity of pelvic inflammatory disease seems accurate. Both clindamycin plus cefamandole and clindamycin plus doxycycline are equally effective regimens for treatment of pelvic inflammatory disease and did not require supplementation after discharge. Our management plan is objective and practical; daily bimanual examination is the most sensitive indicator of persistent disease.

Adult↗

PubMed1999

Hyperhomocyst(e)inemia and the prevalence of atherosclerotic vascular disease in patients with end-stage renal disease.

Hyperhomocyst(e)inemia is now recognized as an independent risk factor for atherosclerotic cardiovascular disease in patients with normal renal function. Hyperhomocyst(e)inemia is common in patients with chronic renal failure. This study is designed to look for an association between hyperhomocyst(e)inemia and atherosclerotic vascular disease in patients with end-stage renal disease (ESRD). Two hundred eighteen patients undergoing hemodialysis were enrolled onto the study and had predialysis bloodwork performed for total homocyst(e)ine, red blood cell folate, and vitamin B(12) levels. A history of clinically significant atherosclerotic vascular disease (ischemic heart disease, cerebrovascular disease, or peripheral vascular disease) was elicited by patient questionnaire and verified by careful inpatient and outpatient chart review. Atherosclerotic vascular disease was present in 45.9% of patients. Mean homocyst(e)ine concentration was 26.7 micromol/L (95% confidence interval [CI], 25.0 to 28.4) overall. Mean homocyst(e)ine concentration was 28.6 micromol/L (95% CI, 25.6 to 31.7) and 25.0 micromol/L (95% CI, 23.2 to 26.8) in patients with and without atherosclerotic disease, respectively (P = 0.036). The adjusted odds ratio for atherosclerotic disease was 2.12 (95% CI, 1.03 to 4.39) for those subjects with a homocyst(e)ine level in the highest quartile compared with the lowest 3 quartiles. In the 126 men, the adjusted odds ratio for atherosclerotic disease was 3.4 (95% CI, 1. 24 to 9.42) for those with homocyst(e)ine levels in the highest quartile compared with the lowest 3 quartiles. No association was found between homocyst(e)ine level and atherosclerotic disease in women. In conclusion, there is an association between hyperhomocyst(e)inemia and atherosclerotic vascular disease in patients undergoing dialysis. Prospective studies need to further examine the relationship between homocyst(e)ine level and atherosclerosis in women with ESRD.

Aged↗

PubMed2003

Is Crohn's disease caused by a mycobacterium? Comparisons with leprosy, tuberculosis, and Johne's disease.

Although Crohn's disease is considered to be autoimmune in origin, there is increasing evidence that it may have an infectious cause. The most plausible candidate is Mycobacterium avium subspecies paratuberculosis (MAP). Intriguingly, Koch's postulates may have been fulfilled for MAP and Crohn's disease, even though they still have not been met for Mycobacterium leprae and leprosy. In animals MAP causes Johne's disease, a chronic wasting intestinal diarrhoeal disease evocative of Crohn's disease. Johne's disease occurs in wild and domesticated animals, including dairy herds. Viable MAP is found in human and cow milk, and is not reliably killed by standard pasteurisation. MAP is ubiquitous in the environment including in potable water. Since cell-wall-deficient MAP usually cannot be identified by Ziehl-Neelsen staining, identification of MAP in human beings requires culture or detection of MAP DNA or RNA. If infectious in origin, Crohn's disease should be curable with appropriate antibiotics. Many studies that argue against a causative role for MAP in Crohn's disease have used antibiotics that are inactive against MAP. However, trials that include macrolide antibiotics indicate that a cure for Crohn's disease is possible. The necessary length of therapy remains to be determined. Mycobacterial diseases have protean clinical manifestations, as does Crohn's disease. The necessity of stratifying Crohn's disease into two clinical manifestations (perforating and non-perforating) when interpreting the results of antibiotic therapy is discussed. Rational studies to evaluate appropriate therapies to cure Crohn's disease are proposed.

Animals↗

PubMed2001

Assessment of Crohn's disease activity by Doppler sonography of the superior mesenteric artery, clinical evaluation and the Crohn's disease activity index: a prospective study.

AIM: Recent data have shown that superior mesenteric artery (SMA) flow rates are significantly increased in active Crohn's disease, suggesting that SMA flow may be a useful, non-invasive index of disease activity. The aim of this prospective study was to evaluate the use of SMA Doppler sonography as an indicator of Crohn's disease activity and to compare with clinical evaluation and the Crohn's disease activity index (CDAI). MATERIALS AND METHODS: Patients with active Crohn's (n = 19), inactive Crohn's (n = 17) and control subjects (n = 17) were evaluated. Categorization of disease activity was based on a reference standard. CDAI scores were also calculated independently. The SMA flow parameters evaluated were resistive index, pulsatility index, end diastolic velocity, peak systolic velocity, time averaged maximum velocity, cross-sectional area and maximum flow volume. RESULTS: Using a three-group ANOVA for each of peak systolic velocity (PSV) (P = 0.01), end-diastolic velocity (EDV) (P = 0.04), pulsatility index (PI) (P = 0.003), time-averaged maximum velocity (TAMV) (P = 0.05), and maximum flow volume (TAMV.CSA) (P = 0.01), there was a significant effect of group. Using post-hoc tests, only EDV (P = 0.01), TAMV (P = 0.02) and TAMV.CSA (P = 0.003) were significantly different between active and inactive Crohn's disease, though with considerable overlap of values for EDV and TAMV. The mean CDAI scores were significantly different between patients with active Crohn's (287) and inactive Crohn's (71) (P = 0.0001) and correlated well with the reference standard. CONCLUSION: Only three of several parameters previously described as allowing Crohn's disease activity assessment actually did so in our study. However, for two of these parameters (EDV, TAMV), there was overlap between the measurements in the active and inactive groups, thus limiting the ability to discriminate disease activity in practice. The degree of overlap for maximum flow volume (TAMV.CSA) between active and inactive disease was considerably less and this parameter may be more discriminatory of disease activity. On the other hand, we found CDAI scores to be accurate in disease categorization. We agree that there appear to be hyperdynamic changes in active Crohn's disease but suggest that Doppler ultrasound assessment does not reliably assess disease activity in routine clinical practice.

Adult↗

PubMed1996

Crohn's disease: influence of age at diagnosis on site and clinical type of disease.

BACKGROUND & AIMS: Crohn's disease has a bimodal age distribution of disease onset diagnosis. The peaks (20 and 50 years) may represent different phenotypes or different genetic and/or environmental influences between younger- and older-onset individuals. The aim of this study was to examine the influences of age at diagnosis of Crohn's disease on disease site, type, and course. METHODS: Records of 552 consecutive patients with Crohn's disease were reviewed retrospectively. RESULTS: Younger age at diagnosis (younger than 20 years), compared with an older age (40 years or older), was associated with a greater prevalence of a family history of Crohn's disease (29.9% vs. 13.6%), greater small bowel involvement (88.7% vs. 57.5%), more stricturing disease (45.8% vs. 28.8%), and a higher frequency of surgery (70.6% vs. 55.3%). Older age at diagnosis was associated with a greater prevalence of colonic disease (84.8% vs. 71.2%) and the inflammatory subtype (54.5% vs. 34.4%). A conditional logistic regression analysis confirmed an independent effect of age at diagnosis on ileal disease and surgery for intractable disease. CONCLUSIONS: In Crohn's disease, early age at diagnosis is associated with more complicated disease and a greater likelihood of having affected relatives. Stratification of Crohn's disease by age at diagnosis provides support for the concept of genetic heterogeneity.

Adult↗

PubMed2002

Vulvar Paget disease of urothelial origin: a report of three cases and a proposed classification of vulvar Paget disease.

Extramammary Paget disease is generally considered a distinct entity that can involve the genital tract skin and may be associated with underlying adenocarcinoma. Evidence is presented that vulvar Paget disease represents a heterogeneous group of epithelial neoplasms that can be similar both clinically and histopathologically. Three cases of vulvar Paget-like disease that were manifestations of urothelial carcinoma are investigated. Vulvar Paget disease can be classified based on the origin of the neoplastic Paget cells as either primary (of cutaneous origin) or secondary (of noncutaneous origin). Each classification has 3 subtypes: primary, intraepithelial cutaneous Paget disease of the usual type; intraepithelial cutaneous Paget disease with invasion, and intraepithelial cutaneous Paget disease as a manifestation of underlying skin appendage adenocarcinoma; secondary, Paget disease of anorectal origin, Paget disease of urothelial origin, and Paget disease of other origin. This subclassification is based on a review of the literature and the current study of 3 patients with Paget-like disease of urothelial neoplastic origin. The 3 subtypes of vulvar Paget disease studied here can present similarly as eczematoid skin or vulvar mucosal lesions and may appear similar on routine hematoxylin and eosin-stained slides. Immunohistochemical studies can be used to help differentiate them. The distinction between these 3 types of Paget-like lesions is essential in that the specific diagnosis has a significant influence on current treatment. The difference in surgical approach to the subtypes of vulvar Paget disease justifies classifying them into distinct lesions to avoid potential confusion and unnecessary surgery.

Aged↗

PubMed2005

The goals of comprehensive and integrated disease state management for diabetic kidney-disease patients.

Diabetes, cardiovascular disease, and chronic kidney disease present many challenges to clinicians as separate disease entities. Management and optimization of care of diabetic kidney-disease patients requires a proactive and integrated approach for all 3 disease states. To optimize the assessment, monitoring, and intervention in this population, comprehensive and integrated disease state management medical care plans must be established. Medical nutrition therapy is another key component that must be coordinated with these disease-state management medical care plans. Coordination of integrated disease-state management and medical nutrition therapy for diabetes, cardiovascular disease, and chronic kidney disease will help to improve patient outcomes and allow for a proactive approach to the identification, prevention, and management of potential disease-state complications. Several programs and guidelines have been established to accomplish these goals: the K/DOQI Clinical Practice Guidelines, the American Diabetes Association Standards of Medical Care for Diabetes (developed by the American Diabetes Association, the National Institute of Diabetes and Digestive Kidney Diseases, and the Centers for Disease Control-Diabetes Foundation), the National Diabetes Education Program, and the National Cholesterol Education Program. The multidisciplinary medical care team assumes an integral role in the success and implementation of this integrated approach as well as the empowerment of the patient in their own care.

Cardiovascular Diseases↗

PubMed2000

Gallbladder motility in Crohn disease: influence of disease localization and bowel resection.

BACKGROUND: Patients with Crohn disease (CD) have an increased risk of developing gallstones. Among other factors, gallbladder motility may have a role in the pathogenesis of gallstone formation. We have evaluated whether gallbladder motor function is affected in Crohn disease with special emphasis on the influence of disease localization and previous bowel resection. METHODS: Thirty-seven patients (20 females and 17 males, age 36 +/- 2 years) with inactive Crohn disease (CDAI < 150) were studied: 15 patients after ileocecal resection and 22 non-operated patients; 12 had small bowel disease and 10 had large bowel disease. Nineteen healthy subjects (10 female; 9 male, age 30 +/- 2 years) served as controls. Gallbladder volumes were measured in the fasting state and at regular intervals for 2 h after ingestion of a solid meal (780 kcal). Blood samples were drawn at regular intervals for determination of cholecystokinin (CCK) and peptide YY (PYY). RESULTS: Fasting gallbladder volumes were significantly (P < 0.05) reduced in patients with large bowel disease (20.8 +/- 2.1 ml) or after ileocecal resection (18.3 +/- 2.4 ml) compared to patients with small bowel disease (28.0 +/- 2.1 ml) and controls (27.2 +/- 1.8 ml). Fasting plasma CCK levels were significantly (P < 0.05) higher in patients with large bowel disease or after ileocecal resection compared to patients with small bowel disease and controls. Postprandial gallbladder emptying and endogenous plasma CCK and PYY secretion in patients with Crohn disease were not different from controls. CONCLUSIONS: Fasting gallbladder volume is decreased and fasting plasma CCK levels are increased in patients with Crohn disease of the large bowel and patients after ileocecal resection. Postprandial gallbladder motility, CCK and PYY release were not affected in patients with Crohn disease.

Adult↗

PubMed1999

Titres of anti-neutrophil cytoplasmic antibodies in inflammatory bowel disease are not related to disease activity.

In the systemic vasculitides, serial measurement of titres of anti-neutrophil cytoplasmic autoantibodies (ANCA) is useful for follow-up of disease activity and prediction of relapses. ANCA have been detected in patients with inflammatory bowel disease, but their relation to disease activity in these diseases is unclear. We analysed the relation between disease activity and ANCA titres as determined by indirect immunofluorescence in paired samples obtained during active disease and at remission from individual patients with ulcerative colitis (n=60) and Crohn's disease (n=101). In addition, patients were followed prospectively, to study the fluctuations of ANCA with time in relation to disease activity. We did not detect a correlation between disease activity and ANCA titres, either in paired samples from active disease and remission, or in serial samples, either in ulcerative colitis or in Crohn's disease. In contrast to the ANCA-associated systemic vasculitides, serial measurement of ANCA titres is not useful in the monitoring of disease activity in patients with inflammatory bowel disease.

Adolescent↗

PubMed1997

Gold-induced pulmonary disease: clinical features, outcome, and differentiation from rheumatoid lung disease.

Gold-induced pulmonary disease is difficult to diagnose, especially, in the case in which interstitial pneumonia appears in the course of gold therapy for rheumatoid arthritis. We analyzed the literature to define the clinical features and prognosis of gold-induced pulmonary disease, and to identify those features that distinguish gold-induced pulmonary disease from pulmonary disease secondary to the underlying disease process of rheumatoid arthritis. Relevant articles from the medical literature were identified using a Mediline search, and the bibliographies of the articles were retrieved. These works were critically reviewed for information on the clinical, physiologic, radiographic, pathologic, and bronchoalveolar lavage (BAL) findings. A total of 140 cases of gold-induced pulmonary disease were identified from 110 reports. In 81% of the patients, gold was being used to treat rheumatoid arthritis, bronchial asthma (6%), pemphigus (5%), or other processes (9%). Side effects other than pulmonary toxicity were common, and included skin rash (38%), peripheral eosinophilia (38%), liver dysfunction (15%), and proteinuria (22%). Only the presence of pemphigus or liver dysfunction correlated with a bad prognosis. Gold-induced pulmonary disease most often followed improvement in rheumatoid arthritis, presumably induced by gold therapy. BAL lymphocytosis and computed tomography (CT) scan findings are useful in making a diagnosis of gold-induced pulmonary disease in an appropriate clinical setting. Features that distinguish gold-induced pulmonary disease from rheumatoid lung disease include female predominance, presence of fever or skin rash, absence of subcutaneous nodules or finger clubbing, low titers of rheumatoid factor at onset of lung disease, lymphocytosis in bronchoalveolar lavage fluid (BALF), and alveolar opacities along the bronchovascular bundles on chest CT scan. Gold-induced lung disease is a distinct entity that can be distinguished from rheumatoid lung disease. It usually improves with cessation of therapy or treatment with corticosteriods.

Arthritis, Rheumatoid↗

PubMed2001

Prevalence and relationship between allergic diseases and infectious diseases.

In order to determine the prevalence of childhood allergic diseases, infectious diseases, and the relationship between them, 8723 children from three junior high schools in Tou-Cheng City, Taipei County, were studied using questionnaires developed according to the International Study of Asthma and Allergies in Childhood (ISAAC) criteria combined with supplementary questions about infectious diseases. Students and their parents completed the questionnaires at home. The age of the children ranged from 10 to 18 years old (14.12 +/- 0.89 years), the majority (96.03%) was aged from 13 to 15 years old. The 12-month prevalences of self-reported allergic disease symptoms were: asthma symptom 8.2%, allergic rhinitis symptom 39.6%, and atopic dermatitis symptom 5.9%. The prevalences of diagnosis of the allergic diseases were: asthma 8.7%, allergic rhinitis 24.1%, and atopic dermatitis 3.9%. The 12-month prevalences of diagnosis of infectious diseases were: pneumonia 0.6%, bronchitis 7.2%, sinusitis 7.2%, purulent conjunctivitis 2.5%, otitis media 4.3%, encephalitis or meningitis 0.4%, gastroenteritis 14.5%, acne 23.9%, purulent dermatitis 1.3%, and other infectious diseases 1.2%. Lifetime admission rates of children due to infectious diseases were: pneumonia 1%, bronchitis 1.8%, sinusitis 0.3%, purulent conjunctivitis 0.2%, otitis media 0.3%, encephalitis or meningitis 0.3%, gastroenteritis 2.1%, and other infectious diseases 0.6%. The prevalence of infectious diseases was significantly higher in children with allergic disease symptoms (defined as asthma, allergic rhinitis, or atopic dermatitis). These results demonstrated the presence of a link between allergic diseases and infectious diseases, which may have some important clinical implications.

Adolescent↗

PubMed1986

Serum antibodies from patients with Crohn's disease and from their household members react with murine lymphomas induced by Crohn's disease tissue filtrates.

Injection into athymic nude mice (nu/nu) of filtrates of Crohn's disease tissue produces lymphoid hyperplasia and lymphomas, which react with serum antibody from other patients with Crohn's disease. We examined for such antibodies in sera of 14 patients with Crohn's disease and 25 of their household members and compared results with sera from 36 healthy unselected controls and from 14 patients with ulcerative colitis and 19 of their household members. Sera from all patients with Crohn's disease and ulcerative colitis and household members were collected in Michigan, coded, and examined by an indirect immunofluorescence assay against two primary nu/nu lymphomas and one transmitted lymphoma produced by three Crohn's disease tissue filtrates. Seven patients with Crohn's disease had antibodies against antigen(s) in the Crohn's disease lymphomas. Seven household members of patients with Crohn's disease and no household members of patients with ulcerative colitis (P less than 0.05) reacted with Crohn's disease lymphomas. However, none of the patients with ulcerative colitis (P less than 0.01) and no control healthy subjects (P less than 0.005) demonstrated immunoreactivity against nu/nu lymphomas. None of the sera reacted with a control nu/nu lymphoma. Five household members who had positive assay results were first-degree blood relatives, and the other two were spouses of patients with Crohn's disease. These results suggest that a common environmental factor may be associated with Crohn's disease, that there is a familial association in Crohn's disease, and that nu/nu mice are an important model to study the pathogenesis of Crohn's disease.

Adult↗

PubMed1991

Incidence of macrovascular disease in diabetes mellitus: the London cohort of the WHO Multinational Study of Vascular Disease in Diabetics.

We report on the incidence of new macrovascular disease among the 497 members of the London Cohort of the WHO Multinational Study of Vascular Disease in Diabetics (aged 35-54 years at recruitment) over a mean 8.33 year follow-up period. Overall at the end of the follow-up period the prevalence of macrovascular disease in the cohort was 45%; 43% of the subjects showed evidence of ischaemic heart disease, 4.5% of cerebrovascular disease and 4.2% of peripheral vascular disease. The incidence rates for new disease in those subjects who were free at baseline expressed per 1000 patient years of follow-up were: ischaemic ECG abnormality 23.6 (patients with insulin-dependent diabetes 19.8, patients with non-insulin-dependent diabetes 28.1), myocardial infarction 17.6 (patients with insulin-dependent diabetes 16.5, patients with non-insulin-dependent diabetes 18.8), all ichaemic heart disease 31.7 (patients with insulin-dependent diabetes 30.3, patients with non-insulin-dependent diabetes 33.4), cerebrovascular disease 5.9 and peripheral vascular disease 5.2. Incidence rates were generally similar among men and women except for myocardial infarction in patients with non-insulin-dependent diabetes where men had a significantly higher incidence rate. Macrovascular disease is a major problem in patients with diabetes and in this age group is mainly manifested as ischaemic heart disease.

Adult↗

PubMed2004

Does disease management improve clinical and economic outcomes in patients with chronic diseases? A systematic review.

PURPOSE: To assess the clinical and economic effects of disease management in patients with chronic diseases. METHODS: Electronic databases were searched for English-language articles from 1987 to 2001. Articles were included if they used a systematic approach to care and evaluated patients with chronic disease, reported objective measurements of the processes or outcomes of care, and employed acceptable experimental or quasi-experimental study designs as defined by the Cochrane Effective Practice and Organization of Care Group. RESULTS: Two reviewers evaluated 16,917 titles and identified 102 studies that met the inclusion criteria. Identified studies represented 11 chronic conditions: depression, diabetes, rheumatoid arthritis, chronic pain, coronary artery disease, asthma, heart failure, back pain, chronic obstructive pulmonary disease, hypertension, and hyperlipidemia. Disease management programs for patients with depression had the highest percentage of comparisons (48% [41/86]) showing substantial improvements in patient care, whereas programs for patients with chronic obstructive pulmonary disease (9% [2/22]) or chronic pain (8% [1/12]) appeared to be the least effective. Of the outcomes more frequently studied, disease management appeared to improve patient satisfaction (71% [12/17]), patient adherence (47% [17/36]), and disease control (45% [33/74]) most commonly and cost-related outcomes least frequently (11% to 16%). CONCLUSION: Disease management programs were associated with marked improvements in many different processes and outcomes of care. Few studies demonstrated a notable reduction in costs. Further research is needed to understand how disease management can most effectively improve the quality and cost of care for patients with chronic diseases.

Cardiovascular Diseases↗

PubMed1991

Thyroid diseases after treatment of Hodgkin's disease.

BACKGROUND AND METHODS: Thyroid disease, especially hypothyroidism, is common in patients with Hodgkin's disease who have been treated with irradiation. We reviewed the records of 1787 patients (740 women and 1047 men) with Hodgkin's disease who were treated with radiation therapy alone (810 patients), radiation and chemotherapy (920 patients), or chemotherapy alone (57 patients) at Stanford University between 1961 and 1989. Among these patients, 1533 were alive at the last follow-up, and 254 had died of causes other than Hodgkin's disease. (Four other patients were excluded from the analysis because they had undergone thyroidectomy before treatment for Hodgkin's disease. The thyroid was irradiated in 1677 patients. Follow-up averaged 9.9 years. RESULTS: A total of 573 patients had clinical or biochemical evidence of thyroid disease. Among the 1677 patients whose thyroid was irradiated, the actuarial risk of thyroid disease 20 years after treatment was 52 percent, and it was 67 percent at 26 years. Hypothyroidism was found in 513 patients. A total of 486 patients received thyroxine therapy for elevated serum thyrotropin concentrations and either low free thyroxine (208 patients) or normal free thyroxine values (278 patients); 27 had transient elevations of the serum thyrotropin level that were not treated. Graves' hyperthyroidism developed in 30 patients (2 of whom had not undergone thyroid irradiation), and ophthalmopathy developed in 17 of these patients. Ophthalmopathy developed in four other patients with Graves' disease during a period of hypothyroidism (n = 3) or euthyroidism (n = 1). The risk of Graves' disease was 7.2 to 20.4 times that for normal subjects. Silent thyroiditis with thyrotoxicosis developed in six patients. Forty-four patients were found to have single or multiple thyroid nodules, 26 of whom underwent thyroidectomy. Six of the 44 had papillary or follicular cancers. Among the patients who did not undergo operation, 12 had small functioning nodules, 4 had cysts, and 2 had multinodular goiters. The actuarial risk of thyroid cancer was 1.7 percent. The risk of thyroid cancer was 15.6 times the expected risk. CONCLUSIONS: High risks of thyroid disease persist more than 25 years after patients have received radiation therapy for Hodgkin's disease, reinforcing the need for continued clinical and biochemical evaluation. Prolonged follow-up confirms an elevated risk of thyroid cancer and Graves' disease as well as hypothyroidism in these patients.

Adolescent↗