Blood lead level and blood pressure during pregnancy in South Central Los Angeles

In many studies in which the relationship between blood pressure and blood lead level has been examined, investigators have found significant--but small--associations. There was only one previous report of a significant association of blood lead with blood pressure in pregnant women. We measured blood lead level and sitting blood pressure of 1,627 women in their third trimester of pregnancy. We eliminated subjects with known causes of hypertension. Most women (98.4%) were normotensive. We controlled for body mass index, age, and stress--among other factors--and constructed multiple-regression models of lead association with diastolic and systolic blood pressures. Immigrants (73% of total) had significantly higher blood lead levels and different blood pressures than nonimmigrants, suggesting that analysis be stratified by "immigrant, nonimmigrant" status. Positive relationships between blood lead level and blood pressure were found only for immigrants (p < or = .001). From the 5th to 95th blood-lead percentiles (0.9-6.2 microg/dl) in immigrants, systolic blood pressure increased 2.8 mm Hg, and diastolic blood pressure increased 2.4 mm Hg. Higher prior lead exposure of immigrants (97.7% from Latin countries) than nonimmigrants might explain the differential effect of these low levels of blood lead on blood pressure in nonimmigrants. Perhaps some immigrants are at higher risk than nonimmigrants for lead-associated elevated blood pressure during pregnancy, despite blood lead levels within the currently considered acceptable range.

Effect of ambulatory 24-hour esophageal pH monitoring on reflux-provoking activities

Ambulatory 24-hr esophageal pH monitoring is considered the gold standard for diagnosing gastroesophageal reflux disease (GERD). The current approach is to encourage patients to pursue their everyday activity in order to obtain near-physiological recordings. However, the effect of the test itself on reflux-provoking activities has never been evaluated. Thus, the aim of our study was to assess daily food consumption, habits, symptoms, sleep, and perceived experience of patients undergoing pH testing as compared to an off test (normal) day. Patients reported type and time spent in each activity pursued, food ingested and length of each meal, habits, frequency and severity of GERD and other related symptoms, sleep disturbances, side effects, and overall perceived experience during pH testing and four weeks later, during a normal day. Fifty-four patients enrolled. pH testing significantly reduced time spent being active, number of meals and cups of coffee consumed, and frequency of GERD symptoms. Almost half of the patients reported having dysphagia during the test. Most patients experienced side effects and stated that the test bothered them most of the time. In conclusion, pH testing has a significant effect on decreasing reflux-provoking activities-patients tend to assume a more sedentary lifestyle. This may influence the reliability of the test as a physiologic measure of acid reflux.

Use of the selective oral neuraminidase inhibitor oseltamivir to prevent influenza

BACKGROUND

Safe and effective antiviral agents are needed to prevent infection with influenza A and B virus. Oseltamivir (GS4104), which can be administered orally, is the prodrug of GS4071, a potent and selective inhibitor of influenzavirus neuraminidases. We studied the use of oseltamivir for long-term prophylaxis against influenza in two placebo-controlled, double-blind trials at different U.S. sites during the winter of 1997-1998.

METHODS

We randomly assigned 1559 healthy, nonimmunized adults 18 to 65 years old to receive either oral oseltamivir (75 mg given once or twice daily, for a total daily dose of 75 or 150 mg) or placebo for six weeks during a peak period of local influenzavirus activity. The primary end point with respect to efficacy was laboratory-confirmed influenza-like illness (defined as a temperature of at least 37.2 degrees C accompanied by at least one respiratory and at least one systemic symptom).

RESULTS

In the two studies combined, the risk of influenza among subjects assigned to either once-daily or twice-daily oseltamivir (1.2 percent and 1.3 percent, respectively) was lower than that among subjects assigned to placebo (4.8 percent; P<0.001 and P=0.001 for the comparison with once-daily and twice-daily oseltamivir, respectively). The protective efficacy of oseltamivir in the two active-treatment groups combined was 74 percent (95 percent confidence interval, 53 to 88 percent) at all the sites combined and 82 percent (95 percent confidence interval, 60 to 93 percent) at sites in Virginia, where the rate of influenza infection was higher than the overall rate. For culture-proved influenza, the rate of protective efficacy in the two oseltamivir groups combined was 87 percent (95 percent confidence interval, 65 to 96 percent). The rate of laboratory-confirmed influenza infection was lower with oseltamivir than with placebo (5.3 percent vs. 10.6 percent, P<0.001). Oseltamivir was well tolerated but was associated with a greater frequency of nausea (12.1 percent and 14.6 percent in the once-daily and twice-daily groups, respectively) and vomiting (2.5 percent and 2.7 percent, respectively) than was placebo (nausea, 7.1 percent; vomiting, 0.8 percent). However, the frequency of premature discontinuation of drug or placebo was similar among the three groups (3.1 to 4.0 percent).

CONCLUSIONS

Oseltamivir administered daily for six weeks by the oral route is safe and effective for the prevention of influenza.

Clinical and economic assessment of the omeprazole test in patients with symptoms suggestive of gastroesophageal reflux disease

OBJECTIVE

To evaluate the diagnostic accuracy of a trial of a high-dose proton pump inhibitor (the omeprazole test) in detecting gastroesophageal reflux disease (GERD) in patients with heartburn symptoms.

DESIGN

A randomized, double-blind, placebo-controlled, crossover trial.

PATIENTS AND SETTING

Forty-three consecutive patients with symptoms suggestive of GERD were enrolled at a Veterans Affairs medical center.

MAIN OUTCOME MEASURES

Symptom response to the omeprazole test vs placebo in GERD-positive and GERD-negative patients; sensitivity, specificity, and positive and negative predictive values of the omeprazole test; and cost per correct diagnosis achieved with the omeprazole test compared with traditional diagnostic strategies.

RESULTS

Of 42 patients (98%) who completed the study, 35 (83%) were classified as GERD positive and 7 (17%) as GERD negative. Twenty-eight GERD-positive and 3 GERD-negative patients responded to the omeprazole test, providing a sensitivity of 80.0% (95% confidence interval, 66.7%-93.3%) and a specificity of 57.1% (95% confidence interval, 20.5%-93.8%). Economic analysis revealed that the omeprazole test saves $348 per average patient evaluated, and results in a 64% reduction in the number of upper endoscopies performed and a 53% reduction in the use of pH testing.

CONCLUSIONS

The omeprazole test is sensitive and fairly specific for diagnosing GERD in patients with typical GERD symptoms. This strategy could result in significant cost savings and decreased use of invasive diagnostic tests.

National perspective on iron therapy as a clinical performance measure for maintenance hemodialysis patients

The Health Care Financing Administration (HCFA) End-Stage Renal Disease (ESRD) Core Indicators Project collects clinical information on prevalent adult patients receiving in-center hemodialysis care in the United States to assess the quality of care delivered. Although hematocrit values, transferrin saturations (TSATs) and iron prescription practices have improved over the last 5 years, we sought to determine whether there are continued opportunities for improvement of this domain of care. A random sample of 7,292 adult in-center hemodialysis patients was selected for the period October through December 1996. Hematocrit values, TSATs, serum ferritin concentrations, epoetin-alfa dosing, and iron prescriptions were abstracted from 4,991 patient medical records to assess anemia management practices. The mean hematocrit for this cohort was 32.6% +/- 3.5%, and 72% of patients had hematocrit values greater than 30%. Ninety-four percent of patients received epoetin alfa intravenously, with a mean weekly epoetin dose of 202.4 +/- 137.2 U/kg. The mean TSAT was 27.4% +/- 12.6%; 73% of patients had TSATs >/= 20%. The mean serum ferritin concentration was 386 +/- 422 ng/mL; 79% and 12% of patients had serum ferritin concentrations greater than 100 ng/mL and greater than 800 ng/mL, respectively. Nine percent of the sample had TSATs less than 20% and serum ferritin concentrations less than 100 ng/mL. Regardless of the TSAT, approximately three fourths of patients received iron; only about half received IV iron. Of the subset of patients with TSATs less than 20% and serum ferritin concentration less than 800 ng/mL, only 53% were prescribed IV iron. Although substantial improvements have been made in anemia management in hemodialysis patients over the last 5 years, significant opportunities persist to improve iron prescription practices.

A new class of selective and potent inhibitors of neuronal nitric oxide synthase

The synthesis and SAR of a series of 6-(4-(substituted)phenyl)-2-aminopyridines as inhibitors of nitric oxide synthase are described. Compound 3a from this series shows potent and selective inhibition of the human nNOS isoform, with pharmacokinetics sufficient to provide in vivo inhibition of nNOS activity.

Benign breast disease

The author presents an overview of benign breast disease. History, epidemiology, risk factors, hormonal influence, and clinical features are discussed. Appropriate treatment for mastalgia, diffuse nodularity, mastitis, and dominant lumps is presented. The importance of patient education, clinical breast examination, mammography, and patient reassurance is stressed. Benign breast disease in men is also discussed.

Adolescent substance use disorders: findings from a 14-year follow-up of speech/language-impaired and control children

Intervening on the development of adolescent addiction requires an understanding of the role of precursors. In a community sample of youth with and without early childhood speech/language (S/L) impairments, 12.7% of participants had a substance use disorder (SUD). Among these participants, 42.0% met criteria for more than 1 SUD. Interestingly, rates of SUDs did not differ by S/L status. However, S/L-impaired participants did show greater psychiatric comorbidity and poorer functioning. A total of 80% of S/L participants with SUDs had a concurrent diagnosis of antisocial personality disorder, compared with 43.8% of SUDs controls. In a logistic regression analysis, we found age 5 mother-rated problem behavior scores and an interaction between S/L status and teacher-rated conduct problem scores were predictive of SUDs. High conduct scores were predictive of SUDs development among control participants but not among S/L-impaired participants. First substance use and initial SUDs symptoms suggest that a window of opportunity exists to reach these troubled young people before they spiral into addiction.

Athletes and eating disorders: the National Collegiate Athletic Association study

OBJECTIVE

To present findings from a collaborative study with the National College Athletic Association regarding the prevalence of disordered eating among student athletes.

METHOD

1,445 student athletes from 11 Division 1 schools were surveyed using a 133-item questionnaire.

RESULTS

Results indicated that 1.1% of the females met DSM-IV criteria for bulimia nervosa versus 0% for males. None of the student athletes met DSM-IV criteria for anorexia nervosa. 9.2% of the females were identified as having clinically significant problems with bulimia versus .01% of the males. 2.85% of the females were identified as having a clinically significant problem with anorexia nervosa versus 0% for males. 10.85% of the females reported binge eating on a weekly or greater basis versus 13.02% of the males 5.52% of the females reported purging behavior (vomiting, laxatives, diuretics) on a weekly or greater basis versus 2.04% for the males.

DISCUSSION

Results from the current investigation are more conservative than previous studies of student athletes, but comparable to another large study of elite Norwegian athletes. Reasons for these differences are discussed. Clearly female athletes report more difficulty with disordered eating than male athletes. Some specific risk factors for female athletes are discussed.

Asystole during inadvertent high spinal anesthesia in a high risk patient without morbidity

Sudden cardiac arrest following high spinal anesthesia (SA) in young and healthy patients with poor outcome has been reported. Extreme bradycardia, hypotension and/or asystole during SA has recently received worldwide attention. We report a high risk patient who developed cardiac arrest associated with two other episodes of extreme bradycardia, hypotension and verbal unresponsiveness during SA without adverse outcome.

[Quality of life assessment in pancreatic carcinoma: results of an European multicentric study]

Quality of life (Qol) assessment is a mandatory endpoint of cancer clinical trials. Little research has been conducted on pancreatic cancer (Pc) and no disease specific Qol questionnaire exists. We report on the development of the European Organization for Research and Treatment of Cancer (EORTC) Pc Qol module to supplement the core cancer module (QLQ-C30). Literature research and qualitative interviews with 6 specialists and 34 patients in the UK were followed by construction of a questionnaire, a peer review by international specialists and EORTC. Administration of the QLQ-C 30, a provisional Pc module and a qualitative debriefing interview was performed on 78 patients in 8 countries stratified into groups by disease stage and treatment intention. Pretesting identified that 23/26 questions had an adequate internal reliability (Cronbach's alpha > 0.7) and construct validity (Pearson's r 0.4-0.6). The median time of completion was 12 mins. Qualitative analysis indicates that the module is easy to complete and cross culturally applicable. The EORTC QLO-PAN 26 includes 26 items covering symptoms, body image, sexuality and the emotional and social consequences of Pc. It is intended for use in patients undergoing clinical trials for pancreatic cancer including surgery, chemotherapy and radiotherapy and will allow the detection of small but clinically meaningful differences in clinical trials for Pc.

Stages of change for increasing fruit and vegetable consumption among adults and young adults participating in the national 5-a-Day for Better Health community studies

Higher fruit and vegetable consumption is associated with a reduced risk of certain cancers and chronic diseases. The 5-a-Day for Better Health community studies are evaluating population-based strategies to achieving dietary behavior change using the stages-of-change model and associated theories. The authors present baseline comparisons of stages of change for fruit and vegetable consumption among adults and young adults in eight study sites representing diverse regions of the United States and diverse populations and settings. Three dominant stages, precontemplation, preparation, and maintenance, were found across sites. Women and those with college degrees were more likely to be in action/maintenance. Fruit and vegetable consumption, self-efficacy, and knowledge of the 5-a-Day recommendation were positively associated with more advanced stages of change in all study sites. The authors discuss the findings in relation to possible limitations of this and other dietary stages-of-change measures and suggest directions for future research.

Three-year maintenance of improved diet and physical activity: the CATCH cohort. Child and Adolescent Trial for Cardiovascular Health

OBJECTIVE

To assess differences through grade 8 in diet, physical activity, and related health indicators of students who participated in the Child and Adolescent Trial for Cardiovascular Health (CATCH) school and family intervention from grades 3 through 5.

DESIGN

Follow-up of the 4-center, randomized, controlled field trial with 56 intervention and 40 control elementary schools.

PARTICIPANTS

We studied 3714 (73%) of the initial CATCH cohort of 5106 students from ethnically diverse backgrounds in California, Louisiana, Minnesota, and Texas at grades 6, 7, and 8.

RESULTS

Self-reported daily energy intake from fat at baseline was virtually identical in the control (32.7%) and intervention (32.6%) groups. At grade 5, the intake for controls remained at 32.2%, while the intake for the intervention group declined to 30.3% (P<.001). At grade 8, the between-group differential was maintained (31.6% vs 30.6%, P = .01). Intervention students maintained significantly higher self-reported daily vigorous activity than control students (P = .001), although the difference declined from 13.6 minutes in grade 5 to 11.2, 10.8, and 8.8 minutes in grades 6, 7, and 8, respectively. Significant differences in favor of the intervention students also persisted at grade 8 for dietary knowledge and dietary intentions, but not for social support for physical activity. No impact on smoking behavior or stages of contemplating smoking was detected at grade 8. No significant differences were noted among physiologic indicators of body mass index, blood pressure, or serum lipid and cholesterol levels.

CONCLUSION

The original CATCH results demonstrated that school-level interventions could modify school lunch and school physical education programs as well as influence student behaviors. This 3-year follow-up without further intervention suggests that the behavioral changes initiated during the elementary school years persisted to early adolescence for self-reported dietary and physical activity behaviors.

A study of 'crisis cards' in a community psychiatric service

OBJECTIVE

'Crisis cards' state patients' treatment details and preferences in anticipation of a later occasion when the patient might be too ill to express them directly. We assessed the feasibility of introducing 'crisis cards', or a collaborative form of them, 'joint crisis plans', into a sectorized community psychiatric service.

METHOD

All patients with a psychosis and at high risk of crisis were invited to participate. Follow-up examined patients' satisfaction and how the cards were used.

RESULTS

In total, 106 eligible patients were identified and offered a card, and 40% agreed to participate. Patients with an affective psychosis, past suicide attempts and less frequent admissions were over-represented among those who agreed to take part. Patients chose to include a wide range of information. For participants, admissions fell by 30% in the follow-up year.

CONCLUSION

Crisis cards serve both a 'manifest', practical function (to provide important information when the patient is too ill to do so) and a 'latent' psychological one (positive effects on the patient's attitude to self, their illness and treatment, and their relationship with the clinical team).

Screening high-risk patients for methicillin-resistant Staphylococcus aureus on admission to the hospital: is it cost effective?

OBJECTIVES

To determine the cost-effectiveness of a policy of screening high-risk patients for methicillin-resistant Staphylococcus aureus (MRSA) colonization on admission to hospital.

SETTING

980-bed university-affiliated tertiary-care hospital.

PATIENTS

Between June 1996 and May 1997, patients directly transferred from another hospital or nursing home, or who had been hospitalized in the previous 3 months, were screened for MRSA within 72 hours of hospital admission.

DESIGN

Nasal, perineal, and wound swabs were obtained for MRSA screening using standard laboratory methods. Laboratory and nursing costs associated with screening patients for MRSA on admission to hospital were calculated. The costs associated with the implementation of recommended infection control measures for patients with MRSA also were determined.

RESULTS

3,673 specimens were obtained from 1,743 patients. MRSA was found on admission in 23 patients (1.3%), representing 36% of the 64 patients with MRSA identified in the hospital during the year. MRSA-colonized patients were more likely to have been transferred from a nursing home (odds ratio [OR], 6.4; P =.04) or to have had a previous history of MRSA colonization (OR, 13.1; P =.05). Laboratory and nursing costs were found to be $8.34 per specimen, for a total cost of $30,632 during the year. The average cost of implementing recommended infection control measures for patients colonized with MRSA was approximately $5,235 per patient.

CONCLUSION

If early identification of MRSA in colonized patients prevents nosocomial transmission of the organism to as few as six new patients, the screening program would save money.

Physical and pharmacologic restraints in long-term care facilities

This study examined the effects of education on the attitudes and practices of long-term care staff toward use of restraints. The intervention, a 1-day educational seminar, used a collaborative team of speakers from the Utah Survey Agency and medical professions. Seminar goals were threefold: first, to provide information about best practices for managing behaviors of individuals with dementia in long-term care settings; second, to provide an explanation of the Omnibus Budget Reconciliation Act regulations pertaining to restraint use; and third, to present alternative strategies to link best practice guidelines to the provision of care. Results showed significant changes in participants' attitudes toward use of restraints. Participants reported replicating the seminar for nursing home staff, revisiting facility policies on restraints, and modifying resident care plans.

Exposure to traumatic incidents and prevalence of posttraumatic stress symptomatology in urban firefighters in two countries

Urban firefighters are at risk for posttraumatic stress disorder (PTSD) due in part to their exposure to duty-related trauma. This study compared duty-related trauma exposures and the prevalences of posttraumatic stress in U.S. and Canadian firefighters. Both samples reported relatively numerous and frequent posttrauma symptoms, and the rates of self-reported PTSD prevalence did not differ significantly. However, analysis of departmental records for respondents' previous year on duty revealed significant differences in both frequencies and categories of traumatic incident exposures. Some of the vulnerability and moderating risk factors associated with PTSD caseness differed between the U.S. and Canadian samples. Potential explanations for the observed differences in risk factors for PTSD in these 2 firefighter samples are considered.

Spinal anesthesia for cesarean section: isobaric versus hyperbaric solution

BACKGROUND

The present study was undertaken to compare the outcomes of hyperbaric versus isobaric spinal anesthesia in Cesarean delivery.

METHODS

The anesthetic solution was administered in sitting position as this posture is commonly used in this clinical setting. Except for the baricity of the anesthetic solution, identical technique was employed for every parturient in the study. Following administration of anesthetic solution the parturient immediately resumed horizontal supine position. The solutions used were 2.0 mL of 0.5% tetracaine in 5% dextrose (hyperbaric) for Group H (n = 30) and in cerebrospinal fluid (isobaric) for Group I (n = 30).

RESULTS

Both hyperbaric and isobaric tetracaine given in sitting position provided adequate analgesic levels. However, hyperbaric tetracaine solution produced a slightly higher median peak level of wilder range, and caused a higher incidence of hemodynamic changes and subjective sensation of "feeling sick" than isobaric tetracaine. Additionally, the duration of surgical anesthesia was shorter and the sacral block was longer for hyperbaric tetracaine solution than for isobaric tetracaine solution at same dose and concentration. Only one mother in Group H needed supplemental inhalation anesthesia for a subsequent hysterectomy due to uncontrollable bleeding. There were no complications, including postpuncture headache in either group.

CONCLUSIONS

Our results indicated that numerous variables must be taken into consideration in predicting the outcome of a spinal anesthesia. Alternation in the technique and individual patient factor may individually or collectively produce different results.

Extraction and high-performance liquid chromatographic separation of selected pyrene and benzo[a]pyrene sulfates and glucuronides: preliminary application to the analysis of smokers' urine

In the study of the complex mixture of urinary metabolites derived from polycyclic aromatic hydrocarbon compounds, it is desirable to simplify the analysis through separation of classes of compounds. We have developed a liquid chromatography (LC) method for the separation of selected sulfate and glucuronide conjugate isomers derived from hydroxybenzo[a]pyrenes (OH-BaP) and hydroxypyrenes. This LC method was utilized in the preliminary analysis of the urine of smokers by combining it with an extraction technique employing tetra-n-butyl-ammonium ion as a coupling agent to generate a 1:1 complex, extractable in chloroform at low pH prior to LC analysis.

An audit of postoperative analgesia after pyloromyotomy

Seventy-two cases of pyloric stenosis treated in our institution in the last five years were reviewed in an attempt to determine the need for postoperative analgesia after pyloromyotomy in infants. All children had their wound infiltrated with a mean dose of 2.16+/-1.43 mg x kg(-1) of bupivacaine, and first analgesia was required 9.12+/-8.04 h after surgery. Paracetamol was the main analgesic administered (average of two doses of approximately 20 mg x kg(-1)). Only three patients required postoperative opioids. In conclusion, there was a low consumption of analgesics after pyloromyotomy. Furthermore, infiltration of the wound appeared to be beneficial since time to administration of first postoperative analgesia was delayed.