[Prevalence of immediate-type hypersensitivity to latex in a hospital employee population in Israel]

BACKGROUND

Different studies reported a prevalence of latex allergy among health care workers ranging between 5-22%. The prevalence of an allergy to latex in public hospitals in Israel has been reported in selected, non-heavily exposed populations in Israeli hospitals.

METHODS

Two hundred and three health care workers from the Rambam Medical Center volunteered to participate in this study. They completed a questionnaire including demographic data, personal, family allergic conditions and symptoms related to latex exposure. Blood samples were taken to determine the serum concentration of total IgE and latex-specific IgE antibodies.

RESULTS

Thirty workers (14.8%) were found to have latex-specific IgE antibodies. The principal findings accompanying workers with latex-specific IgE antibodies are profession, positive personal and family history of allergic conditions and elevated total IgE. Approximately half of the health care workers allergic to latex were physicians, most of them from the departments of intensive care, surgery and internal medicine.

Trends in acute coronary heart disease mortality, morbidity, and medical care from 1985 through 1997: the Minnesota heart survey

BACKGROUND

Coronary heart disease (CHD) mortality continued to decline from 1985 to 1997.

METHODS AND RESULTS

We tabulated CHD deaths (ICD-9 codes 410 through 414) in the Minneapolis/St Paul, Minnesota, area. For 1985, 1990, and 1995, trained nurses abstracted the hospital records of patients 30 to 74 years old with a discharge diagnosis of acute CHD (ICD-9 codes 410 or 411). Acute myocardial infarction (AMI) events were validated and followed for 3-year all-cause mortality. Between 1985 and 1997, age-adjusted CHD mortality rates in Minneapolis/St Paul fell 47% and 51% in men and women, respectively; the comparable declines in US whites were 34% and 29%. In-hospital mortality declined faster than out-of-hospital mortality. The rate of AMI (ICD-9 code 410) hospital discharges declined almost 20% between 1985 and 1995, whereas the discharge rate for unstable angina (ICD-9 code 411) increased substantially. The incidence of hospitalized definite AMI declined approximately 10%, whereas recurrence rates fell 20% to 30%. Three-year case fatality rates after hospitalized AMI decreased consistently by 31% and 41% in men and women, respectively. In-hospital administration of thrombolytic therapy, emergency angioplasty, ACE inhibitors, beta-blockers, heparin, and aspirin increased greatly.

CONCLUSIONS

Declining out-of-hospital death rates, declining incidence and recurrence of AMI in the population, and marked improvements in the survival of AMI patients all contributed to the 1985 to 1997 decline of CHD mortality in the Minneapolis/St Paul metropolitan area. The effects of early and late medical care seem to have had the greatest contribution to rates during this time period.

Absence seizures aggravated by valproic acid

PURPOSE

To report on pediatric patients with absence epilepsy who experienced absence seizure aggravation while receiving valproic acid (VPA).

METHODS

The charts of all children from four pediatric epilepsy clinics receiving VPA for absence epilepsy were reviewed. Patients were evaluated and followed up between 1994 and 2000.

RESULTS

Eight cases (six boys) of absence seizure aggravation were detected. Mean age at seizure onset was 5.8 years (range, 3-12 years). Six patients had simple absence seizures, one had myoclonic absences, and one had absences with automatisms. The electroencephalogram in all cases depicted generalized 3-Hz spike-and-wave activities. All eight patients experienced an increase in the frequency of absence seizures within days of VPA introduction. Dose increments resulted in further seizure aggravation. Serum levels of VPA were within therapeutic range in all patients. No case was attributed to VPA-induced encephalopathy. All patients improved on VPA discontinuation. In five children, VPA was reintroduced, resulting in further seizure aggravation.

CONCLUSIONS

VPA can occasionally provoke absence seizure aggravation in patients with absence epilepsy.

Prevalence of self-reported allergic conditions in an adult population in Israel

BACKGROUND

Asthma, allergic rhinitis, and atopic dermatitis are leading causes of chronic diseases in developed countries, with at least one allergic condition troubling 10 to 20% of the general population. The few studies performed in Israel determined the prevalence of allergic conditions in selected populations (schoolchildren and soldiers); no study representative of the general population has previously been done.

OBJECTIVES

To determine the prevalence of allergic conditions in the general population in Israel and the differences between ethnic and socioeconomic groups.

METHOD

Using a computer-assisted telephone interview, a telephone questionnaire was conducted in a representative sample of the general Israeli population.

RESULTS

Of the population studied, 14% claimed to have bronchial asthma, 14% allergic rhinitis, and 6% other allergic conditions. Prevalence rates were higher in the Israeli Arab population and in those with low income and low education levels. Of those with allergic conditions, 58% were treated by a primary physician, 32% were not treated at all, and only 10% were treated by a different specialist physician.

CONCLUSIONS

The prevalence of allergic conditions in this study concurs with that found by other studies in developed countries. Allergic conditions are higher in the Israeli Arab population and in those with low income and low education level.

Congenital subependymal pseudocysts: own data and meta-analysis of the literature

BACKGROUND

Congenital subependymal pseudocysts are incidental findings that are found in 0.5-5.2% of neonates during postmortem examination or head ultrasonography. In our institution we detected 10 neonates with CSEPC.

OBJECTIVE

To investigate associated etiological factors, morphologic characteristics and outcome of CSEPC.

METHODS

We performed a meta-analysis of the literature on CSEPC (1967-98), including our 10 cases.

RESULTS

A total of 256 cases of CSEPC were analyzed. Ultrasound diagnosed 77.6% of CSEPC; 48.8% were bilateral and 53.4% were located in the caudothalamic groove or head of caudate nucleus. Altogether, 93.5% resolved during 1-12 months of ultrasonographic follow-up. Compared to the general neonatal population, the following features were more prevalent in the CSEPC population: prematurity, maternal vaginal bleeding, preeclamptic toxemia, intrauterine growth restriction, asphyxia, fetal cytomegalovirus and rubella infections, congenital malformations, chromosomal aberrations, infant mortality, and neurodevelopmental handicap. The risk for neurodevelopmental handicap was significantly higher when CSEPC were associated with fetal infections, IUGR, malformations and chromosomal aberrations, or persistence of CSEPC during follow-up. CSEPC infants without any of these four conditions had a low risk for neurodevelopmental handicap.

CONCLUSIONS

CSEPC are morphologic features of various underlying conditions encountered in the fetus. Association of CSEPC with IUGR, fetal infections, malformations and chromosomal aberrations or persistence of CSEPC indicates a higher risk for future neurodevelopmental handicaps, probably because of the deleterious effects on the fetal brain that are inherent in these conditions. A favorable outcome is expected in the absence of these risk factors.

Neurodevelopmental delay associated with nonconvulsive status epilepticus in a toddler

Nonconvulsive status epilepticus is a prolonged and continuous state of increased unawareness without overt motor seizures linked with repetitive generalized epileptic discharges. In children, it may occur de novo but more commonly may complicate a preexisting epileptic disorder. We report on a 2-year-old female who presented with global developmental delay as the main manifestation of nonconvulsive status epilepticus. Following valproic acid treatment, her motor, cognitive, and speech delays had gradually subsided and nearly completely resolved, in concert with normalization of electroencephalography (EEG). Hence, given a possible, albeit rare, presentation of nonconvulsive status epilepticus with global developmental delay, we suggest that EEG should be recommended in any infant who manifests neurodevelopmental delay.

Prolonged epileptic blindness in an infant associated with cortical dysplasia

We report a female infant with status epilepticus amauroticus and intractable focal motor seizures associated with congenital cortical dysplasia. EEG demonstrated persistent epileptiform discharges over the right parieto-temporal regions extending to occipital areas. She required cortical resection of the epileptic zone at age 8 months given failure of very high dose antiepileptic combinations. Histological analysis of a sample of cortex resected from the right central parieto-temporal region, identified by electrocorticography as the focus of epileptic activity, showed cortical dysplasia. The seizures ceased and the infant gained full vision after 48 hours. During an 8-year follow-up period she has had a few short-lived seizures, currently controlled with carbamazepine and vigabatrin. Her cognition and speech are intact. This case demonstrates that: (1) resection of a central temporo-parietal focus, which may have spread to the occipital regions, may result in complete visual recovery and cessation of seizures; and (2) EEG should be considered in every infant with alleged delayed visual maturation, to rule out concealed epileptic activity.

Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study

Disordered breathing during sleep is associated with acute, unfavorable effects on cardiovascular physiology, but few studies have examined its postulated association with cardiovascular disease (CVD). We examined the cross-sectional association between sleep- disordered breathing and self-reported CVD in 6,424 free-living individuals who underwent overnight, unattended polysomnography at home. Sleep-disordered breathing was quantified by the apnea-hypopnea index (AHI)-the average number of apneas and hypopneas per hour of sleep. Mild to moderate disordered breathing during sleep was highly prevalent in the sample (median AHI: 4.4; interquartile range: 1.3 to 11.0). A total of 1,023 participants (16%) reported at least one manifestation of CVD (myocardial infarction, angina, coronary revascularization procedure, heart failure, or stroke). The multivariable-adjusted relative odds (95% CI) of prevalent CVD for the second, third, and fourth quartiles of the AHI (versus the first) were 0.98 (0.77-1.24), 1.28 (1.02-1.61), and 1.42 (1.13-1.78), respectively. Sleep-disordered breathing was associated more strongly with self-reported heart failure and stroke than with self-reported coronary heart disease: the relative odds (95% CI) of heart failure, stroke, and coronary heart disease (upper versus lower AHI quartile) were 2.38 (1.22-4.62), 1.58 (1.02- 2.46), and 1.27 (0.99-1.62), respectively. These findings are compatible with modest to moderate effects of sleep-disordered breathing on heterogeneous manifestations of CVD within a range of AHI values that are considered normal or only mildly elevated.

Extra-pyramidal parkinsonism complicating organophosphate insecticide poisoning

We present a 1 7-year-old female with acute extra-pyramidal parkinsonism complicating a suicidal attempt with the organophosphate insecticide chlorpyrifos, who was initially suspected to have developed severe depression or psychosis. On admission she was stupurous, with diarrhoea and massive salivation lapsing into respiratory failure and coma. Following atropine and toxogonin treatment along with mechanical ventilation she developed overt extrapyramidal parkinsonism and encephalopathy, characterized by impaired sensorium and agitation, mask facies along with a muffled voice and swallowing impairment, a resting tremor with cogwheel rigidity switching to bradykinetic choreoathetotic movements. Once a parkinsonian syndrome was diagnosed, she was given amantadine therapy with complete recovery. The patient is presently maintained on amantadine therapy; there was mild worsening of her extrapyramidal signs following unplanned discontinuation of this medication, and on follow-up assessments after 9 months she is virtually asymptomatic. A parkinsonian extrapyramidal syndrome, complicating organophosphate intoxication, should therefore also be taken into account in any patient with organophosphate poisoning, presenting with marked behavioural alterations, rigidity or akinetic mutism, and beneficial response to amantadine.

Severe migraine associated with coarctation of aorta: complete recovery following balloon dilation

We report on a rare association of severe migraine headaches associated with coarctation of aorta that completely resolved following dilation of the constricted aorta. A 6-year-old girl presented with severe pounding headaches accompanied with recurrent vomiting, associated with photophobia and phonophobia. She experienced frequent awakenings with severe headaches and vomiting. The described excruciating, prolonged, and practically persistent headaches were not relieved by analgesics and ergotamines. Neurologic assessment and brain computed tomography were both normal. A systolic murmur at the third right intercostal space prompted a cardiac echocardiogram, which demonstrated coarctation of the ascending aorta beyond the orifice of the left common carotid artery. Catheterization revealed a systolic gradient of 54 mm Hg, and the constricted lumen of the aorta was then dilated by a balloon. The excruciating vascular headaches and associated symptoms had abated instantaneously following this procedure. To the best of our knowledge, this is the first report associating severe migraine headaches in a child with coarctation of the aorta. Given complete recovery following balloon dilation of the aorta, cardiac echocardiogram should be added to the diagnostic battery of children with severe unresponsive migraine.

Correlates of cognitive function in middle-aged adults. Atherosclerosis Risk in Communities (ARIC) Study Investigators

The Atherosclerosis Risk in Communities Study administered cognitive function tests to more than 14,000 middle-aged adults in 1990-1992. The battery included the Delayed Word Recall test, the Digit Symbol Subtest of the Wechsler Adult Intelligence Scale-Revised, and the Controlled Oral Word Association (Word Fluency) test. Test performance was correlated positively with education level, negatively with age, was better in women than in men, and better in managers/professionals compared with other occupations. After controlling for these factors, race and community, the findings most consistent for both sexes were that Delayed Word Recall was negatively associated with depressive symptoms, diabetes, and fibrinogen level; the Digit Symbol Subtest was associated with marital status, negatively associated with depressive symptoms, smoking status, fibrinogen level, and carotid intima-media thickness, and positively associated with alcohol drinking and FEV1; and the Word Fluency test was positively associated with marital status, alcohol drinking, sports participation, and FEV1. Most of these cross-sectional results were in the predicted direction and have biologic plausibility, but mean differences between extreme categories were small (generally on the order of 0.1 to 0.2 of a standard deviation). Longitudinal study is warranted to evaluate whether small differences in middle-age lead to larger, clinically meaningful deficits with aging.

Melatonin improves sleep-wake patterns in psychomotor retarded children

Five children with severe psychomotor retardation (mean age 8.2+/-3.6 years) and irregular sleep-wake patterns underwent 1 week of wrist actigraphic monitoring before and after treatment with 3 mg melatonin. Three underwent multiple measurements of urinary sulfatoxymelatonin levels. Urine sulfatoxymelatonin levels were abnormally low, without any significant day/night differences. Melatonin treatment increased nighttime sleep from 5.9+/-0.8 to 7.3+/-0.5 hours (paired t test, P<0.01) and sleep efficiency from 69.3%+/-6.2% to 88.3%+/-2.3% (P<0.01). Daytime sleep decreased from 3.2+/- 1.2 to 1.7+/-1.2 hours (P<0.05). Thus, no change in 24-hour total sleep time (9.1+/-1.5 vs. 9.0+/-1.6 hours) occurred. Administration of 3 mg melatonin to five severely psychomotor retarded children resulted in a significant improvement in their sleep-wake patterns.

A prospective study of cytomegalovirus, herpes simplex virus 1, and coronary heart disease: the atherosclerosis risk in communities (ARIC) study

BACKGROUND

Conflicting evidence exists implicating infectious disease in the pathological processes leading to coronary heart disease (CHD). The objective of this article is to describe the relationship of previous infection with cytomegalovirus (CMV) and herpes simplex virus 1 to incident CHD in a population-based cohort study.

METHODS

Using a nested case-cohort design from the Atherosclerosis Risk in Communities Study, antibody levels to CMV and herpes simplex virus 1 were determined in serum samples that had been frozen at the baseline examination in participants free of CHD. Determinations were made in those who developed incident CHD (n=221) during follow-up of up to 5 years from baseline and in a stratified random sample of all participants (n=515).

RESULTS

The population with the highest antibody levels of CMV (approximately the upper 20%) showed an increased relative risk (RR) of CHD of 1.76 (95% confidence interval, 1.00-3.11), adjusting for age, sex, and race. After adjustment for additional covariates of hypertension, diabetes, years of education, cigarette smoking, low-density lipoprotein and high-density lipoprotein cholesterol levels, and fibrinogen level, the RR increased slightly. Based on a priori hypotheses, the RR of CHD at the highest antibody levels in individuals with diabetes was particularly large but with wide confidence intervals (RR, 9.2; 95% confidence interval, 1.8-47.0), and the interaction between high levels of antibody to CMV and diabetes was statistically significant (P=.05). There was no association of CHD with the highest herpes simplex virus 1 antibody levels (adjusted RR, 0.77; 95% confidence interval, 0.36-1.62).

CONCLUSIONS

High levels of CMV antibodies are significantly associated with incident CHD. Infection with CMV, particularly in more susceptible disease states such as diabetes, may be an important risk factor for CHD.

Visual impairment in children with epilepsy treated with vigabatrin

Vigabatrin is an anti-epileptic drug particularly useful for drug-resistant partial seizures and infantile spasms. Recently, vigabatrin-induced visual field constriction (VFC) and abnormal ocular electrophysiological studies were reported. In this study, we assessed visual fields, visual evoked potentials (VEPs), and electroretinography (ERG) in children treated with vigabatrin. Twenty-four visually asymptomatic children underwent a clinical ophthalmological examination, perimetry when appropriate, and VEP and ERG. Thirteen patients had at least one abnormal study. VFC was seen in 11 of 17 patients who had perimetry; 5 of 15 patients who underwent VEP testing and 4 of 11 who underwent ERG testing had abnormal examinations. For the most part, abnormal VEPs and ERGs were found in children who also had VFC. There was a consistent trend for longer treatment periods to correlate with VFC, abnormal ERGs, and VEPs. In summary, over half of the children treated with vigabatrin demonstrated VFC or abnormal ocular electrophysiological studies. Perimetry seemed to be the most sensitive modality for identifying vigabatrin toxicity. Abnormal ERGs and VEPs were primarily seen in children with VFC and may be useful in monitoring children who are not appropriate candidates for perimetry. Although the incidence of vigabatrin-induced VFC is worrisome, in the context of intractable seizures or infantile spasms, therapeutic benefits must be weighed against risks.

Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study. Sleep Heart Health Study

CONTEXT

Sleep-disordered breathing (SDB) and sleep apnea have been linked to hypertension in previous studies, but most of these studies used surrogate information to define SDB (eg, snoring) and were based on small clinic populations, or both.

OBJECTIVE

To assess the association between SDB and hypertension in a large cohort of middle-aged and older persons.

DESIGN AND SETTING

Cross-sectional analyses of participants in the Sleep Heart Health Study, a community-based multicenter study conducted between November 1995 and January 1998.

PARTICIPANTS

A total of 6132 subjects recruited from ongoing population-based studies (aged > or = 40 years; 52.8% female).

MAIN OUTCOME MEASURES

Apnea-hypopnea index (AHI, the average number of apneas plus hypopneas per hour of sleep, with apnea defined as a cessation of airflow and hypopnea defined as a > or = 30% reduction in airflow or thoracoabdominal excursion both of which are accompanied by a > or = 4% drop in oxyhemoglobin saturation) [corrected], obtained by unattended home polysomnography. Other measures include arousal index; percentage of sleep time below 90% oxygen saturation; history of snoring; and presence of hypertension, defined as resting blood pressure of at least 140/90 mm Hg or use of antihypertensive medication.

RESULTS

Mean systolic and diastolic blood pressure and prevalence of hypertension increased significantly with increasing SDB measures, although some of this association was explained by body mass index (BMI). After adjusting for demographics and anthropometric variables (including BMI, neck circumference, and waist-to-hip ratio), as well as for alcohol intake and smoking, the odds ratio for hypertension, comparing the highest category of AHI (> or = 30 per hour) with the lowest category (< 1.5 per hour), was 1.37 (95% confidence interval [CI], 1.03-1.83; P for trend = .005). The corresponding estimate comparing the highest and lowest categories of percentage of sleep time below 90% oxygen saturation (> or = 12% vs < 0.05%) was 1.46 (95% CI, 1.12-1.88; P for trend <.001). In stratified analyses, associations of hypertension with either measure of SDB were seen in both sexes, older and younger ages, all ethnic groups, and among normal-weight and overweight individuals. Weaker and nonsignificant associations were observed for the arousal index or self-reported history of habitual snoring.

CONCLUSION

Our findings from the largest cross-sectional study to date indicate that SDB is associated with systemic hypertension in middle-aged and older individuals of different sexes and ethnic backgrounds.

Hypertension and antihypertensive therapy as risk factors for type 2 diabetes mellitus. Atherosclerosis Risk in Communities Study

BACKGROUND

Previous research has suggested that thiazide diuretics and beta-blockers may promote the development of type 2 diabetes mellitus. However, the results of previous studies have been inconsistent, and many studies have been limited by inadequate data on outcomes and by potential confounding.

METHODS

We conducted a prospective study of 12,550 adults 45 to 64 years old who did not have diabetes. An extensive health evaluation conducted at base line included assessment of medication use and measurement of blood pressure with a random-zero sphygmomanometer. The incidence of new cases of diabetes was assessed after three years and after six years by measurement of serum glucose concentrations while the subjects were fasting.

RESULTS

After simultaneous adjustment for age, sex, race, education, adiposity, family history with respect to diabetes, physical-activity level, other health-related behavior, and coexisting illnesses, subjects with hypertension who were taking thiazide diuretics were not at greater risk for the subsequent development of diabetes than were subjects with hypertension who were not receiving any antihypertensive therapy (relative hazard, 0.91; 95 percent confidence interval, 0.73 to 1.13). Likewise, subjects who were taking angiotensin-converting-enzyme inhibitors and calcium-channel antagonists were not at greater risk than those not taking any medication. In contrast, subjects with hypertension who were taking beta-blockers had a 28 percent higher risk of subsequent diabetes (relative hazard, 1.28; 95 percent confidence interval, 1.04 to 1.57).

CONCLUSIONS

Concern about the risk of diabetes should not discourage physicians from prescribing thiazide diuretics to nondiabetic adults who have hypertension. The use of beta-blockers appears to increase the risk of diabetes, but this adverse effect must be weighed against the proven benefits of beta-blockers in reducing the risk of cardiovascular events.

Carotid wall thickness is predictive of incident clinical stroke: the Atherosclerosis Risk in Communities (ARIC) study

Few studies have determined whether carotid artery intima-media thickness (IMT) is associated prospectively with risk of first ischemic stroke. In the Atherosclerosis Risk in Communities Study, carotid IMT, an index of generalized atherosclerosis, was defined as the mean of IMT measured by B-mode ultrasonography at six sites of the carotid arteries. The authors assessed the relation of mean IMT to stroke incidence over 6-9 years' follow-up (1987-1995) among 7,865 women and 6,349 men aged 45-64 years without prior stroke at baseline in four US communities. There were 90 incident ischemic stroke events for women and 109 for men. In sex-specific Cox proportional hazards models adjusting only for age, race, and community, the hazard rate ratios comparing extreme mean IMT values (> or =1 mm) to values less than 0.6 mm were 8.5 for women (95% confidence interval: 3.5, 20.7) and 3.6 for men (95% confidence interval: 1.5, 9.2). The relation was graded, and models with cubic splines indicated significant nonlinearity, with hazards increasing more rapidly at lower IMTs than at higher IMTs. Thus, models using linear IMT values substantially underestimate the strength of the association at lower IMTs. The strength of the association was reduced by the inclusion of putative stroke risk factors, but it remained elevated at higher IMTs. Hence, mean carotid IMT is a noninvasive predictor of future ischemic stroke incidence.

Serum albumin level as a predictor of incident coronary heart disease: the Atherosclerosis Risk in Communities (ARIC) study

Various studies have reported an inverse association between serum albumin level and incident coronary heart disease (CHD), though biologic mechanisms have not been established. The authors examined the association between serum albumin level and CHD in the Atherosclerosis Risk in Communities cohort, comprising 14,506 White and African-American middle-aged men and women. The mean albumin level in this population was 3.9 g/dl (standard deviation 0.3). During 5.2 years of follow-up, 470 incident CHD events occurred. The hazard ratio for incident CHD associated with a 1-standard deviation decrease in serum albumin level was 1.26 (95% confidence interval (CI): 1.15, 1.38) after adjustment for age, gender, and ethnicity and 1.18 (95% CI: 1.07, 1.30) after additional adjustment for covariates related to CHD. Hazard ratios were similar across gender and ethnic groups. However, there was statistically significant effect modification by smoking status, with hazard ratios of 1.01 (95% CI: 0.84, 1.22) among never smokers, 1.09 (95% CI: 0.92, 1.30) among former smokers, and 1.35 (95% CI: 1.17, 1.54) among current smokers. Further adjustment for factors related to renal disease, nutrition, platelet aggregation, inflammation, use of angiotensin-converting enzyme inhibitors, and hemostasis factors attenuated the albumin-CHD relation only slightly. In this study, serum albumin was inversely associated with incident CHD at the baseline examination in current smokers but not in never or former smokers. Albumin level may be a marker of susceptibility to the inflammatory response that results from smoking.

HMO membership and patient age and the use of specialty care for hospitalized patients with acute stroke: The Minnesota Stroke Survey

BACKGROUND

The number of older patients enrolling in health maintenance organizations (HMOs) is increasing. Concerns have been raised that older patients may be targeted by HMOs for more stringent cost-containment mechanisms, including reduced access to expensive specialty care.

OBJECTIVES

We investigated the relationship between membership in an HMO and the decision to consult with a neurologist or admit to a neurology ward for patients hospitalized with acute stroke. We then compared 1-year mortality of patients who received neurology care to the 1-year mortality of those who did not receive neurology care.

DESIGN

Retrospective medical record review.

SUBJECTS

A sample of hospitalized acute stroke patients (age range, 30-79 years) who were discharged from Minneapolis-St. Paul metropolitan hospitals with a diagnosis code of acute cerebrovascular disease from 1991 to 1993.

MEASURES

Trained nurses abstracted the medical records. Stroke events (n = 2,320) were validated using clinical criteria and neuroimaging reports. Mortality data were obtained from the Minnesota Death Index.

RESULTS

Among patients enrolled in HMOs, 30% of validated stroke patients did not receive neurology care in comparison with 19% of patients not enrolled in HMOs. After adjusting for patient mix and hospital characteristics, the odds of receiving neurology care were half as great for patients enrolled in HMOs as compared with patients not enrolled in HMOs (odds ratio [OR] = 0.52, 95% confidence interval [CI] 0.36-0.74). The association of membership in HMOs with lower use of neurology care was concentrated in older patients. Within each age group, the odds ratios and 95% CI of receiving neurology care for patients enrolled in HMOs versus patients not enrolled in HMOs were: < 55 years (1.06, 0.42-2.67), 55 to 64 years (0.54, 0.34-0.87), 65 to 74 years (0.51, 0.36-0.71), and >75 years (0.40, 0.24-0.68). Using Cox regression, 30-day mortality did not differ between patients who received neurology care and those who did not. Among 30-day survivors, the mortality hazards ratio (HR) during the next 11 months for patients who received neurology care was 71% of the hazard for patients who did not receive neurology care (HR = 0.71, 95% CI = 0.55-0.91).

CONCLUSIONS

These data suggest that membership in an HMO was associated with reduced access to neurology care for older patients with acute stroke and that patients who received neurology care had a lower risk of death during the year after their stroke. It remains to be determined if these differences in outcome are caused by true differences in stroke management or by unmeasured characteristics.

Effective acute desensitization for immediate-type hypersensitivity to human granulocyte-monocyte colony stimulating factor

BACKGROUND

Granulocyte-monocyte colony stimulating factor (GM-CSF) is the treatment of choice for patients with life threatening neutropenias. Hypersensitivity to GM-CSF may lead to cessation of treatment. Acute desensitization is an alternative mode of managing drug hypersensitivity, especially when other common modes like substitution of offending drug or premedication with antihistamines and/or corticosteroids are not available or fail.

CASE REPORT

A 42-year-old woman with a 17-year history of severe chronic mucocutaneous candidal infections became resistant to all common antifungal drugs. As her disorder was associated with defective functions of monocytes and granulocytes, GM-CSF treatment was started yielding a very good clinical effect. After a short period of treatment, however, the patient developed anaphylactic reactions which could not be abolished by preadministration of antihistamines and/or corticosteroids. Replacement of therapy by G-CSF caused identical hypersensitivity phenomena.

METHODS

Prick skin tests with 100, 200, or 400 microg/mL of GM-CSF or G-CSF, using also negative and positive controls, were performed on the patient and three healthy control subjects. A positive local reaction was observed only in patient at the prick point of 200 microg/mL GM-CSF or 400 microg/mL G-CSF. Acute desensitization to GM-CSF was initiated adopting a protocol used for parenteral desensitization to penicillin.

RESULTS

The patient tolerated the desensitization procedure very well and we could resume the administration of GM-CSF. For the past 30 months the patient has been treated uneventfully by subcutaneous administration of GM-CSF, 500 microg twice weekly, and is free of candidal infections. Skin prick tests were repeated 1 month postdesensitization and resulted in a very weak response to GM-CSF compared with the predesensitization response.

CONCLUSIONS

Acute desensitization can be utilized in patients who develop drug hypersensitivity reactions to GM-CSF. As GM-CSF is a very unique agent and in most cases cannot be replaced by another one, acute desensitization may play a very important role in managing failure of GM-CSF treatment due to hypersensitivity reactions.

Prospective study of markers of hemostatic function with risk of ischemic stroke. The Atherosclerosis Risk in Communities (ARIC) Study Investigators

BACKGROUND

Several markers of hemostatic function and inflammation have been associated with increased risk of coronary heart disease, but prospective evidence for their role in ischemic stroke is scant.

METHODS AND RESULTS

The Atherosclerosis Risk in Communities (ARIC) Study measured several of these markers in more than 14 700 participants 45 to 64 years old who were free of cardiovascular disease and were followed up for 6 to 9 years for occurrence of ischemic stroke (n=191). There was no apparent association between ischemic stroke incidence and factor VIIc, antithrombin III, platelet count, or activated partial thromboplastin time. After adjustment for multiple cardiovascular risk factors, von Willebrand factor, factor VIIIc, fibrinogen, and white blood cell count were positively associated and protein C was negatively but nonsignificantly associated with ischemic stroke incidence in regression analyses based on either continuous variables or fourths of the variable distributions. The adjusted relative risk (and 95% CI) for ischemic stroke in those in the highest versus lowest fourth were: von Willebrand factor, 1.71 (1.1 to 2.7); factor VIIIc, 1.93 (1.2 to 3.1); white blood cell count, 1.50 (0.9 to 2.4); fibrinogen, 1.26 (0.8 to 2.0); and protein C, 0.65 (0.4 to 1.0).

CONCLUSIONS

This study offers modest support for the hypothesis that some markers of hemostatic function and inflammation can identify groups of middle-aged adults at increased risk of stroke. These factors may play a role in the pathogenesis of ischemic stroke.

A community-based study of explanatory factors for the excess risk for early renal function decline in blacks vs whites with diabetes: the Atherosclerosis Risk in Communities study

CONTEXT

The explanation for the excess risk for diabetic renal disease in blacks is uncertain.

OBJECTIVES

To compare the incidence of early renal function decline in black and white adults with diabetes and to examine possible explanatory factors for racial differences.

DESIGN

Prospective cohort study.

SETTING

Four US communities participating in the Atherosclerosis Risk in Communities study.

PARTICIPANTS

Community-based sample of 1434 diabetic adults aged 45 to 64 years.

MEASUREMENTS

Detailed baseline assessment using structured interview, results of physical examination, and laboratory measurements.

MAIN OUTCOME

Development of early renal function decline defined by an increase in serum creatinine of at least 35.4 micromol/L (0.4 mg/dL) during 3 years of follow-up.

RESULTS

During 3 years of follow-up, early renal function decline developed in 45 blacks (28.4 per 1000 person-years [PY]) and 25 whites (9.6 per 1000 PY). After adjustment for age, sex, and baseline serum creatinine level, early renal function decline was more than 3 times as likely to develop in blacks than whites (odds ratio, 3.15; 95% confidence interval, 1.86-5.33). Additional adjustment for education, household income, health insurance, fasting glucose level, mean systolic blood pressure, smoking history, and physical activity level reduced the relative odds in blacks to 1.38 (95% confidence interval, 0.71-2.69), corresponding to a 82% reduction in excess risk.

CONCLUSIONS

These data suggest that early renal function decline is 3 times more likely to develop in blacks than whites and that potentially modifiable factors, including lower socioeconomic status, suboptimal health behaviors, and suboptimal control of glucose level and blood pressure, account for more than 80% of this disparity.

Physical activity and ischemic stroke risk. The atherosclerosis risk in communities study

BACKGROUND AND PURPOSE

The relationship between physical activity and stroke is inconclusive according to the 1996 US Surgeon General's Report on Physical Activity and Health. Therefore, this study examined the relationship between physical activity and ischemic stroke risk among 14 575 Atherosclerosis Risk in Communities Study participants aged 45 to 64 years free of self-reported stroke and coronary heart disease at baseline.

METHODS

Eligible potential stroke hospitalizations were identified from ongoing hospital surveillance and from hospitalizations reported by the cohort study participants. All strokes were validated by hospitalization records. Physical activity was measured as sport, leisure (nonsport), and work with the use of the Baecke questionnaire. Multivariable Poisson and Cox proportional hazards models were used to determine the association of differing levels of physical activity with ischemic stroke incidence.

RESULTS

During an average of 7.2 years of follow-up, 189 incident ischemic strokes occurred. Ischemic stroke incidence rates were highest in the lowest quartile of sport, leisure, and work scores. The hazard rate ratios with 95% CIs for ischemic stroke for the highest quartile compared with the lowest quartile of activity adjusted for age, sex, race-center, education, and smoking, were sport 0.83 (0.52, 1.32), leisure 0.89 (0.57, 1.37), and work 0.69 (0.47, 1.00). Further adjustment for factors that likely were intermediate variables (hypertension, diabetes, fibrinogen, and body mass index) between physical activity and stroke attenuated the associations.

CONCLUSIONS

Our findings suggest that physical activity was weakly associated with a reduced risk of ischemic stroke among middle-aged adults. The association may be due to links between physical activity and other risk factors or due to chance.