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PubMed2006

Longitudinal associations between dietary protein intake and survival in hemodialysis patients.

BACKGROUND: Decreased dietary protein intake may be associated with increased mortality risk in individuals with kidney failure undergoing maintenance hemodialysis (MHD). We hypothesized that longitudinal changes in dietary protein intake have independent associations with survival in MHD patients. METHODS: The relation between urea kinetic-based normalized protein nitrogen appearance (nPNA) and all-cause and cardiovascular mortality was examined in a 2-year (July 2001 to June 2003) cohort of 53,933 MHD patients from virtually all DaVita dialysis clinics in the United States, using both conventional and time-dependent (repeated-measure) Cox models to estimate death hazard ratios for quarterly averaged nPNA categories controlled for case-mix, comorbidity, dialysis dose (Kt/V), and available markers of malnutrition-inflammation complex syndrome (MICS). RESULTS: The best survival was associated with nPNA between 1.0 and 1.4 g/kg/d, whereas nPNA less than 0.8 or greater than 1.4 g/kg/d was associated with greater mortality in almost all models. Adjustment for MICS mitigated the associations substantially. A decrease in protein intake during the first 6 months in patients with an nPNA in the 0.8- to 1.2-g/kg/d range was associated incrementally with greater death risks in the subsequent 18 months, whereas an increase in nPNA tended to correlate with reduced death risk. CONCLUSION: Low daily protein intake or decrease in its magnitude over time is associated with increased risk for death in MHD patients. Whether the association between time-varying protein intake and survival is causal or a consequence of anorexia secondary to MICS or other factors needs to be explored further in interventional trials.

Aged↗

PubMed1999

"Telestroke" : the application of telemedicine for stroke.

BACKGROUND: Time is of the essence for effective intervention in acute ischemic stroke. Efforts including stroke teams that are "on call" around-the-clock are emerging to reduce the time from emergency room arrival to evaluation and treatment. SUMMARY OF COMMENT: Based on the results of the NINDS rt-PA Stroke Trial, which demonstrated both clinical effectiveness in reducing neurological deficits and disability and cost savings to health care systems, many community hospitals and managed-care organizations are exploring methods to enhance and expedite acute stroke care in their local communities. Only a small fraction of acute stroke victims is currently treated with thrombolytics (<1.5% nationally), and few benefit from the expertise and experience of the stroke teams. It is essential to develop new paradigms to improve acute stroke care in all settings, rural and urban. Rapid linkages to expert stroke care can help the underserved areas. Telemedicine for stroke, "Telestroke, " uses state-of-the-art video telecommunications that may be a potential solution and may maximize the number of patients given effective acute stroke treatment across the country and across the world. Telestroke could facilitate remote cerebrovascular specialty consults from virtually any location within minutes of attempted contact, adding greater expertise to the care of any individual patient. This model also has the potential to enhance patient entry into clinical trials. Telestroke would enhance stroke education through the use of Internet-based interactives for health-care professionals and patients. Education would be facilitated through the creation of telecommunication-linked classes providing interactive information on stroke care and prevention to places where they are otherwise not available. Health-care professionals will gain experience and expertise through the interaction with a remote expert--telementoring. Telestroke provides an excellent medium for data collection and an unprecedented opportunity for quality assurance. Monitoring of an entire tele-interaction can offer real-time assessments, which can then be analyzed in-depth at a later date for unique insights into health-care delivery. Prehospital use of telemedicine for stroke is already being piloted, linking patients in the ambulance to the emergency department. Legal and economic parameters must be established for telemedicine in the areas of reimbursement, liability, malpractice insurance, licensing, and credentialing. Issues of protection of privacy and confidentiality, informed consent, product liability, and industry standards must be addressed to facilitate the use of this new and potentially useful technology. CONCLUSIONS: Computer-based technology can now be used to integrate electronic medical information, clinical assessment tools, neuroradiology, laboratory data, and clinical pathways to bring state-of-the-art expert stroke care to underserved areas.

Acute Disease↗

PubMed1996

[Translaryngeal tracheostomy. A new era?].

OBJECTIVE: Presentation of a new technique of dilation tracheostomy projected to offer a minimum risk of complication and tissue trauma. DESIGN: Prospective study carried out between July 1993 and December 1995, to evaluate the feasibility of the procedure, its possible advantages over other methods, and possible complications. SETTING: General ICU with a Paediatrics Section. PATIENTS: Uninterrupted series of 84 adults and 12 children with multifactorial respiratory insufficiency. INTERVENTION: Through a needle inserted in the trachea, a guide wire is retrogradely pushed out of the mouth and attached to a special device formed by a flexible plastic cone with pointed metal tip joined to an armoured tracheal cannula. This device is then pulled back through the oral cavity, larynx, trachea-hence the definition: TransLaryngeal Tracheostomy (TLT)- and outwards across the neck wall by applying traction on the wire with one hand and counterpressure on the neck wall with the fingers of the operator's other hand. When the cone and part of the cannula have emerged, the cone is separated from the cannula. The cannula is further extracted until its inside portion can be turned downwards to its final placement. RESULTS: A precise localisation of the stoma placement and the needle introduction are facilitated by the rigid tracheoscope and protrusion. Thanks to the very pointed cone, the piercing resistances are lowered. At the same time, every degree of traction power is allowed through the counterpressure practised by the fingers. The channel is very regular with a strong adherence to the cannula that secures a virtual lack of bleeding and local inflammation. We observed this in the fifty cases, in which the final version of our technique was applied. Trachea CT scan and endoscopic control did not show late lesions of the airway. CONCLUSIONS: TLT is characterised by highest inherent safety and lowest tissue traumatism, that it can also be performed in patients who would risk complications from any other tracheostomy techniques.

Adult↗

PubMed2002

Assessment and reporting of perioperative cardiac risk by Canadian general internists: art or science?

OBJECTIVE: Physicians may use several validated risk indices to estimate perioperative cardiac risk, but there is little evidence for interventions to reduce this risk. We were interested in evaluating how general internists assess, define, communicate, and attempt to modify perioperative cardiac risk. DESIGN: Cross-sectional survey of all 312 general internists in the Canadian Society of Internal Medicine with Canadian mailing addresses; 117 (38%) responded. RESULTS: Respondents' mean age was 46 years, 79% were male, and on average they did 17 preoperative consults per month. Of the 104 respondents who routinely performed preoperative assessments, 96% (100/104) informed patients of their perioperative cardiac risk, but 77% did so only subjectively (i.e., stating risk as low, moderate, or high). Respondents provided 8, 27, and 12 different definitions for low, moderate, and high risk, respectively, with marked variability in the range of definitions they provided: from <1% to < 20% for "low risk," from 1% to 2% to 20% to 50% for "moderate risk," and from >2% to >50% for "high risk." The 67% of respondents who reported using a perioperative cardiac risk index used a variety of indices and exhibited just as much variability in their risk estimates and definitions as those who didn't use risk indices. While virtually all advised perioperative beta blockade in patients with known coronary artery disease, they varied substantially in the recommended agent or dose; further, these internists were evenly split on whether antiplatelet agents should be held or continued perioperatively. CONCLUSIONS: These physicians differed widely in their assessment of perioperative cardiac risk and their definitions of low, moderate, or high risk. This raises concerns about whether patients (and surgeons) are provided with adequate information to make fully informed decisions about the potential risks of elective surgical operations.

Canada↗

PubMed2006

Drug residues store in the body following cessation of use: impacts on neuroendocrine balance and behavior--use of the Hubbard sauna regimen to remove toxins and restore health.

For decades, scientists have investigated the environmental and human health effects of synthetic chemicals. A growing body of research has illuminated the spectrum of consequences deriving from our reliance these substances and their proliferation in air, water, soil and the food chain. Of particular concern is the fact that residues of many man-made chemicals are now detectible in virtually every person. A key to a chemical's tendency to persist in tissues once it has entered the body is its lipophilicity. Substances that are poorly soluble in water and quite soluble in fat have relatively free access, via lipid-rich cellular membranes, to the cells of all organs including the ability to cross the blood-brain and placental barriers. Substantial data exist demonstrating that in addition to pollutants, drugs and their metabolites dispose to tissues high in fat content, including brain and adipose. While their characteristic lipophilicity permits drugs and medications to reach target tissues, thereby producing therapeutic effects in the present, current perceptions of risk may be ignoring the possibility that adipose accumulations of illicit drugs and pharmaceuticals may lead to future patterns of ill health similar to those associated with exposure to other categories of xenobiotic chemicals. Empirical data are beginning to characterize the myriad regulatory functions of adipose hormones, including roles in cravings, cognitive function, energy level, and inflammation as well as changes in adipose hormone levels associated with drug use. Included in this data are the observation that a rehabilitative treatment intervention introduced by L. Ron Hubbard in 1978 to aid in the broad elimination of chemicals from body stores improves symptoms common to both chemical exposure and drug addiction. The regimen, which includes exercise, sauna bathing, and vitamin and mineral supplementation, is utilized by nearly 70 drug rehabilitation and medical practices in over 20 countries. At present, much more is unknown than is known regarding long-term drug retention and effects. This subject deserves careful evaluation given its potential implications for health and chronic illnesses of poorly defined etiology (such as chronic fatigue syndrome), as well as drug abuse prevention, drug rehabilitation, forensic and legal areas.

Dietary Supplements↗

PubMed2005

Cross-sex hormone treatment does not change sex-sensitive cognitive performance in gender identity disorder patients.

Cognitive performance in untreated early onset gender identity disorder (GID) patients might correspond to their born sex and not to their perceived gender. As a current mode of intervention, cross-sex hormone treatment causes considerable physical changes in GID patients. We asked, as has been suggested, whether this treatment skews cognitive performance towards that of the acquired sex. Somatically healthy male and female early onset GID patients were neuropsychologically tested before, 3 and 12 months after initiating cross-sex hormone treatment, whereas untreated healthy subjects without GID served as controls (C). Performance was assessed by testing six cognitive abilities (perception, arithmetic, rotation, visualization, logic, and verbalization), and controlled for age, education, born sex, endocrine differences and treatment by means of repeated measures analysis of variance. GID patients and controls showed an identical time-dependent improvement in cognitive performance. The slopes were essentially parallel for males and females. There was no significant three-way interaction of born sex by group by time for the six investigated cognitive abilities. Only education and age significantly influenced this improvement. Despite the substantial somatic cross-sex changes in GID patients, no differential effect on cognition over time was found between C and GID participants. The cognitive performance of cross-sex hormone-treated GID patients was virtually identical to that of the control group. The documented test-retest effect should be taken into consideration when evaluating treatment effects generally in psychiatry.

Adult↗

PubMed1998

Chronic antiprogestin therapy produces a stable atrophic endometrium with decreased fibroblast growth factor: a 1-year primate study on contraception and amenorrhea.

OBJECTIVE: To describe the efficacy of mifepristone in the prevention of menstrual bleeding and ovulation, with similar observations in comparison groups. DESIGN: Prospective experimental study. Thirty-two cynomolgus monkeys were divided equally into four treatment groups (n = 8). Treatment lasted for 1 year. INTERVENTION(S): Group I received GnRH-agonist (GnRH-a) and in-sequence mifepristone, group II received mifepristone only, group III received GnRH-a only, and group IV received vehicle control. MAIN OUTCOME MEASURE(S): Serum estradiol and progesterone, menstrual bleeding, endometrial thickness, and endometrial expression of basic fibroblast growth factor (bFGF) as determined by immunohistochemistry. RESULT(S): Weekly progesterone determinations showed that mifepristone-treated monkeys seldom ovulated (6 ovulations in 8 years), compared with the controls (100 ovulations in 8 years), while maintaining early to midfollicular levels of circulating serum estradiol. The GnRH-a-only group also rarely ovulated, but was chronically and severely hypoestrogenic. The mifepristone-only group showed scant menstrual bleeding (5 days in 8 years) as compared with the menstrual frequency in control animals (422 days in 8 years). Endometrial proliferation, as determined by biopsy, was similarly minimal for both the GnRH-a and mifepristone groups, and statistically less than in control monkeys. Both the mifepristone and GnRH-a treatments suppressed endometrial gland expression of the angiogenesis polypeptide bFGF. CONCLUSION(S): Chronic mifepristone induced anovulation along with virtual amenorrhea, which suggests the worth of this novel hormonal contraceptive.

Amenorrhea↗

PubMed2000

Increased gene expression of components of the renin-angiotensin system in glomeruli of genetically hypertensive rats.

OBJECTIVE: The renin-angiotensin system (RAS) is implicated in the development of hypertensive glomerulosclerosis. However, no experimental evidence exists that clearly demonstrates activation of glomerular RAS in hypertensive nephropathy. We used stroke-prone spontaneously hypertensive rats (SHRSP) to examine whether RAS components are increased in glomeruli of SHRSP and whether this increase leads to an increase in mRNA levels for transforming growth factor-beta1 (TGF-beta1). METHODS: We examined the sequential changes of urinary albumin excretion (UAE), morphology, and glomerular mRNA expression for TGF-beta1 and fibronectin (FN) in relation to glomerular mRNA expression for angiotensinogen (ATN), angiotensin converting enzyme (ACE), angiotensin II type 1a (AT1a), and type 1b (AT1b) receptors, and intervention with angiotensin II type 1 receptor antagonist candesartan and equihypotensive hydralazine. RESULTS: In SHRSP, UAE was normal at 9 weeks of age, but became higher, beginning at 12 weeks of age, than that in the age-matched Wistar-Kyoto (WKY) rats, while SHRSP showed no glomerulosclerosis until 14 weeks of age; it was marked at 24 weeks. Plasma renin activity and plasma angiotensin II level was equivalent in the 9- and 12-week-old SHRSP and the WKY rats; both parameters, however, were elevated in 24-week-old SHRSP as compared with age-matched control. RNase protection assays showed that glomerular levels of ATN, ACE, and AT1a and AT1b receptors mRNA were significantly increased in 9-, 12-, and 14-week-old, but not in 24-week-old SHRSP, compared with age-matched WKY rats. Northern blot analysis showed that glomerular levels of TGF-beta1 and FN mRNA were higher in SHRSP than in WKY rats at all time points. Candesartan reduced UAE to control levels, whereas hydralazine reduced UAE but not to control levels. Candesartan administration for 12 weeks virtually prevented the progression of glomerulosclerosis. While candesartan reduced mRNA levels for RAS components, TGF-beta1, and FN to control levels, hydralazine was not effective in this respect. Conclusion Results suggest that increases in glomerular RAS components that occur independently of circulating RAS alter glomerular permselectivity and increase the glomerular expression of TGF-beta1 and FN in young SHRSP. Findings in old SHRSP suggest that altered glomerular permselectivity and an increased glomerular expression of TGF-beta1 and FN may be associated with the activation of systemic RAS.

Albuminuria↗

PubMed2001

Organising evidence on QT prolongation and occurrence of Torsades de Pointes with non-antiarrhythmic drugs: a call for consensus.

BACKGROUND: The growing list of non-antiarrhythmic drugs associated with QT prolongation and the relevant regulatory interventions have generated concern for two reasons. First, QT prolongation is sometimes viewed as an intrinsic effect of a whole therapeutic class (for example, antihistamines), whereas, in many cases, it is displayed only by some compounds within a given class of non-antiarrhythmic drugs because of an effect on cardiac repolarisation. Second, drug-induced Torsades de Pointes are still considered idiosyncratic, totally unpredictable adverse drug reactions, whereas a number of risk factors for their occurrence is now recognised. OBJECTIVES: In order to increase awareness among prescribing physicians that many non-antiarrhythmic drugs can affect cardiac repolarisation, we would like to propose a comprehensive and updated list of QT-prolonging drugs that should be a starting point to maintain a "consensus list" to be periodically updated. METHODS: The drug list was generated by performing a Medline search, by using published lists as starting points to retrieve the relevant references quoted in each article and by considering the International Registry for Drug-induced Arrhythmias maintained by the Georgetown University and mainly based on the FDA approved labelling. RESULTS: The drug list presented in this paper: (1) includes virtually all non-antiarrhythmic drugs with QT-prolonging potential, (2) organises the available information on each drug at different levels of clinical relevance and (3) is as up-to-date as possible in order to provide a fast track for the clinical pharmacologist to retrieve the original publications. CONCLUSIONS: This list should be considered as a starting point to call for consensus on: (1) the criteria used to generate the list, (2) possible ways to implement the use of this list as a quick reference for clinicians, for instance by providing a "proarrhythmic score" for each drug, and (3) inclusion/exclusion of a given agent into the list on the basis of evidence that may not be available to us.

Animals↗

PubMed2005

Effects of exercise training on insulin-like growth factor-I expression in the skeletal muscle of non-cachectic patients with chronic heart failure.

BACKGROUND: Chronic heart failure (CHF) is associated with progressive muscle atrophy and reduced local expression of insulin-like growth factor I (IGF-I). DESIGN: The present study was designed to test the hypothesis that the local deficiency of IGF-I in the skeletal muscle of patients with CHF would respond to a 6-months aerobic training intervention. Therefore, 18 patients [mean age 52.4 (SD 4.8) years, left ventricular ejection function (LVEF) 27 (SD 6)%] were prospectively randomized to either 6 months of training or sedentary lifestyle. METHODS: Serum levels of growth hormone (GH) were measured by immunofluorometric assay, IGF-I by competitive solid phase immunoassay. IGF-I expression was assessed in vastus lateralis biopsies by real-time PCR. RESULTS: Exercise training led to a significant increase in peak oxygen uptake by 26% [from 20.3 (SD 3.3) ml/kg per min to 25.5 (SD 5.7) ml/kg per min, P=0.003 versus control]. Local expression of IGF-I increased significantly after exercise training by 81% [from 6.3 (SE 0.8) to 11.4 (SE 1.4) relative units, P=0.007 versus control] while IGF-I receptor expression was reduced by 33% [from 20.0 (SE 2.1) to 13.8 (SE 1.7) relative units, P=0.008 versus control]. Serum growth hormone (GH) rose modestly from 0.12 (SE 0.07) to 0.65 (SE 0.37) ng/ml in the training group (P=0.043 versus baseline), however, this change was not significant compared to the control group (P=0.848). IGF-I serum levels remained virtually unchanged. CONCLUSIONS: Exercise training improves local IGF-I expression without significant changes of systemic parameters of the GH/IGF-I axis. These findings indicate that exercise training has the therapeutic potential to attenuate peripheral skeletal muscle alterations in particular with respect to local IGF-I expression in patients with moderate CHF.

Adult↗

PubMed1989

Pharmacotherapy of childhood obsessive-compulsive disorder.

OCD appears in children and adolescents in virtually the same form as adults. Antipsychotics, anxiolytics, and antidepressants (other than CMI and other serotonergic reuptake blockers) are not consistently helpful in treating OCD. Adult controlled studies have found that CMI, a serotonin reuptake blocker, is selectively and specifically effective for treating OCD. The two controlled studies of CMI in a pediatric sample found that CMI was significantly better than placebo and desipramine in ameliorating the symptoms of OCD. CMI appears to be safe, well tolerated, and effective for OCD at dosages targeting 3 mg per kg per day in children and adolescents. Further studies of its use in long-term maintenance are indicated. Based on anecdotal information, fluoxetine appears to be promising for use in OCD, although it is currently only approved for use as an antidepressant in adults. Fluvoxamine, which has not been tried in a pediatric population, appears to be efficacious for adult OCD. Controlled studies of their safety and efficacy in the pediatric population need to be done. The long-term prognosis for children with OCD is unknown. It appears that all treatment modalities should be utilized, including psychopharmacologic, behavioral, and other psychotherapeutic interventions.

Adolescent↗

PubMed2006

Novel virtual biopsy of the kidney with near infrared, reflectance confocal microscopy: a pilot study in vivo and ex vivo.

PURPOSE: Current diagnostic strategies for the kidney combine noninvasive imaging techniques with invasive procedures such as needle biopsy. However, renal needle biopsy is not devoid of risks, such as bleeding or infection. Additionally, histology studies are limited to ex vivo morphology and processing induces tissue artifacts, is time-consuming and limits the performance of further studies. Near infrared, reflectance CM is a novel technique that allows high resolution optical sectioning through intact tissues without using any exogenous fluorescent stains. Contrast between structures is based on the natural differences in refractivity. In this pilot study we assessed the usefulness of CM in the study of the kidney in vivo and ex vivo. MATERIALS AND METHODS: Kidneys of live rats were imaged with CM. Contrast in images is based on native properties of the tissue upon being shone with a near infrared laser. By convention hyperrefractile structures are seen as white and hyporefractile structures are seen as black. CM imaging planes varied along the x, y and z axes of space. Images of live kidney were compared with those from ex vivo CM imaging and standard histology procedures. RESULTS: The tubules, glomeruli, vessels and interstitium were readily identified, revealing intracellular detail. Differences between the kidney in vivo and ex vivo were also observed. Experimental contrast agents further highlighted the nuclei. CONCLUSIONS: CM is a useful noninvasive imaging technique that is an adjunct to current techniques for 3-dimensional study of the kidney in vivo and ex vivo. Future technical developments will provide key applications during surgical intervention, transplantation and rapid tissue assessment.

Animals↗

PubMed2001

Localisation of mRNA for h5-HT1B and h5-HT1D receptors in human dorsal raphe.

In the mammalian mesencephalon, virtually all serotoninergic neurons are located in the raphe nuclei and the adjacent reticular formation. Pharmacological evidence obtained in rodents suggests that terminal and somatodendritic autoreceptors controlling serotonin (5-hydroxytryptamine, 5-HT) release belong to the 5-HT1B/D subtype of receptors, whereas somatodendritic autoreceptors controlling neuronal cell firing are predominantly of the 5-HT1A subtype. This study investigated the presence of h5-HT1D and h5-HT1B receptor mRNA within the subdivisions of the dorsal raphe of post-mortem human brains by means of in situ hybridisation. Although differences in the labelling intensity, which may be caused by different pre- and/or post-mortem conditions, were obvious among the specimens, all brains expressed both the h5-HT1D and the h5-HT1B mRNA in dorsal raphe neurons. In comparison to h5-HT1D mRNA, expression of h5-HT1B mRNA was slightly more abundant. Information on the existence and localisation of h5-HT1D and h5-HT1B receptors in human dorsal raphe neurons confirms that both subtypes may serve an autoreceptor function in humans. This finding is of pharmacological relevance since these receptors are potential new targets for therapeutic interventions in psychiatric disorders such as depression and anxiety.

Aged↗

PubMed1993

Manpower deficiencies in cardiovascular pathology. Implications for medical care of cardiovascular diseases.

The general shortage of pathology manpower has been well documented, but virtually no published data are available on cardiovascular pathologists. To address this situation, the Society for Cardiovascular Pathology surveyed all chairpersons of academic pathology departments, chiefs of academic clinical cardiovascular programs, including adult and pediatric cardiology and cardiovascular surgery, in the United States and Canada, regarding their perceptions of cardiovascular pathology manpower and the training and areas of expertise necessary for a competent cardiovascular pathologist. Of total respondents, 41% stated that their institution's department of pathology needed to add a cardiovascular pathologist, 39% of respondents replied that money and funding were available to hire an additional cardiovascular pathologist, yet only 19% stated that their institution intended to add a cardiovascular pathologist. In regard to career orientation, 77% of respondents wanted a cardiovascular pathologist capable of both diagnostic work and basic research. The survey results show a significant discrepancy between apparent institutional needs for cardiovascular pathologists and hiring plans, implying that there is a substantial shortage of cardiovascular pathologists. This deficiency in cardiovascular pathology manpower has important ramifications for the amount and quality of medical services that can be provided to clinical cardiovascular colleagues in an era of increasingly complex pathobiological information and interventional strategies in the prevention and treatment of cardiovascular diseases.

Cardiovascular Diseases↗

PubMed1995

The clinical and financial impact of non-invasive vascular testing in the USA.

Health care costs in the USA have increased dramatically during the past 10 years, and it is widely believed that they have reached crisis dimensions. Vascular laboratories are a segment of the USA health care industry that has experienced particularly rapid growth in the last decade. In 1992, USA Medicare payments (for patients > or = 65 years) totalled US$304,492,588 for 3,673,695 non-invasive vascular studies. This figure represents only one segment of USA health care costs and, if all segments were considered, the 1992 total for vascular laboratory services would probably approach one billion USA dollars. The expansion of vascular laboratory utilization is attributed to a number of factors: (i) increased recognition of the clinical value of non-invasive vascular studies; (ii) replacement of invasive (angiographic) procedures; (iii) expanded surveillance application; (iv) the verification of carotid endarterectomy for treatment of carotid stenosis; (v) widespread, unlimited access; (vi) over-utilization; (vii) greed. Widespread awareness of the crisis in USA health care funding has imposed cost-containment pressure where virtually none existed previously. The vascular laboratory is no exception to this trend, and the following measures have been suggested for controlling vascular laboratory costs: (i) demonstration of the clinical and cost effectiveness of non-invasive vascular studies; (ii) utilization review; (iii) pre-approval of requests for vascular studies; (iv) linkage of vascular study reimbursement with clinical diagnosis; (v) limitations on self-referral; (vi) reduced reimbursement; (vii) capitation; (viii) diagnosis-related reimbursement; (ix) accreditation. This article summarizes the factors that have led to increased utilization of vascular laboratory services, and discusses methods proposed for containing vascular laboratory expenditure.

Accreditation↗

PubMed1999

Physical activity for preventing and treating obesity-related dyslipoproteinemias.

PURPOSE: The clinical trial data were reviewed on effects of physical activity on obesity-related dyslipoproteinemias (specifically low HDL-cholesterol (HDL-C), elevated triglycerides (TG), and high total and LDL-cholesterol (TC and LDL-C)) in adult men and women. METHODS: Effort was made to identify all randomized clinical trials (RCT), with exercise intervention programs of at least 4 months' duration, which had lipoprotein outcomes. Those that had both an exercise only intervention and control groups or both a diet plus exercise and identical diet only intervention groups were reviewed. Tables were developed of baseline characteristics and weight and lipoprotein changes for aerobic exercise trials by body mass index: 1) < 25.0 kg x m(-2), 2) 25.0-29.9 kg x m(2), and 3) > or = 30.0 kg x m(-2)and for studies involving resistance exercise or increased energy expenditure from daily activities versus structured exercise programs. RESULTS: Very few RCT were found that specifically addressed the role of physical activity in preventing or treating obesity-related adverse lipoprotein levels. There was essentially no evidence found in lean or overweight men or women to support a specific role for exercise in improving undesirable lipoprotein levels; however, trial data strongly suggest that the addition of exercise to a hypocaloric, reduced-fat diet improves HDL-C and TG in men and women with generally desirable initial levels and reduces LDL-C in men and women with initially elevated LDL-C levels. The evidence is also reasonably strong that weight loss, including that achieved solely by exercise, improves HDL-C and TG in obese men, without reducing LDL-C, whereas it remains weak for women. There are also virtually no trial data to support a role for resistance exercise or an increase in daily living activities for improving obesity-related lipoproteins. CONCLUSIONS: Current evidence from RCT is too limited to determine whether physical activity can raise low HDL-C or lower high TG or LDL-C levels in overweight and obese individuals.

Adult↗

PubMed1991

Preclinical diagnosis of familial hypertrophic cardiomyopathy by genetic analysis of blood lymphocytes.

BACKGROUND: The clinical diagnosis of familial hypertrophic cardiomyopathy is usually made on the basis of the physical examination, electrocardiogram, and echocardiogram. Making an accurate diagnosis can be particularly difficult in children, who may not have cardiac hypertrophy until adulthood. Recently, we demonstrated that mutations in the cardiac myosin heavy-chain genes cause familial hypertrophic cardiomyopathy in some families. We report a diagnostic test for familial hypertrophic cardiomyopathy that relies on the detection of mutations in the beta myosin heavy-chain gene in circulating lymphocytes that we used to evaluate three generations of a family, including the children. METHODS AND RESULTS: Using the polymerase chain reaction, we found that normal and mutant beta cardiac myosin heavy-chain genes are transcribed in circulating lymphocytes. This allowed us to examine beta cardiac myosin heavy-chain messenger RNA from blood lymphocytes, even though ordinary expression of the gene is virtually restricted to the heart. Base sequences amplified from this messenger RNA were analyzed with a ribonuclease protection assay to identify small deletions, abnormal splicing, or missense mutations. Using this technique we identified a novel missense mutation in a patient with familial hypertrophic cardiomyopathy. We evaluated 15 of the patient's adult relatives and found perfect agreement with the clinical diagnosis (8 affected and 7 not affected). Clinical analysis of 14 of the children (age, 1 to 20 years) of these affected family members revealed 1 child with echocardiographic findings diagnostic of familial hypertrophic cardiomyopathy. However, genetic analyses showed that six other children had also inherited the missense mutation and might later manifest the disease. CONCLUSIONS: Transcripts of beta cardiac myosin heavy-chain gene can be detected in blood lymphocytes and used to screen for mutations that cause familial hypertrophic cardiomyopathy. This approach makes practical the identification of mutations responsible for this disorder and may be applicable to other diseases in which direct analysis is difficult because the mutated gene is expressed only in certain tissues. Preclinical or prenatal screening in an affected family will make it possible to study the disease longitudinally and to develop preventive interventions.

Adolescent↗

PubMedDate not supplied

The main end points in human hypertension.

Prospective data from Western populations show a fairly steady increase in the incidence of total mortality as well as of myocardial infarction (MI) and sudden coronary death (SD) with increasing blood pressure levels. In the age groups up to 70 years, stroke is much less common than MI and SD at virtually all blood pressure levels, but for older men and also for somewhat younger women, stroke is as common as MI and SD at the highest blood pressure levels. The incidence of MI and SD is strongly dependent on serum lipid abnormalities and smoking habits, whereas stroke appears to depend very little on lipid levels and in only a few studies appears related to smoking habits. Thus, the effect of blood pressure is appreciably modified by the presence of some other abnormalities that are believed to enhance coronary arteriosclerosis. There are major differences between populations with respect to the incidence of MI, SD, and stroke. MI mortality and SD have, for example, been very high in the United States, whereas stroke mortality has been low. In Japan, on the other hand, stroke mortality has been high and MI mortality and SD have been low. Sweden has occupied an intermediate position with respect to MI mortality and SD, which have been increasing slightly while they have been decreasing in the United States, whereas stroke mortality in Sweden and in the other Scandinavian countries has been very low and is even showing a slight decrease. Both prospective epidemiologic studies and intervention trials indicate some influence of blood pressure on noncardiovascular mortality, such as that from cancer.

Blood Pressure↗