Perceived adequacy of tangible social support and health outcomes in patients with coronary artery disease

OBJECTIVE

Health outcomes of patients with chronic disease might be influenced by assistance from others in performing daily activities. We examined whether perceived adequacy of such tangible support was associated with prognosis in a cohort of patients with coronary artery disease.

DESIGN

Longitudinal cohort study.

SETTING/PARTICIPANTS

In spring 1993, a cohort of 1,468 patients with chronic artery disease was identified using claims data. The cohort consisted of all surviving residents of Manitoba, Canada, who had been hospitalized for acute myocardial infarction from 1991 to 1992: 820 patients completed the initial survey, and 734 completed a follow-up survey approximately 1 year later.

MEASUREMENTS AND MAIN RESULTS

Adequacy of tangible support was assessed by asking if respondents needed help at home because of health problems, and whether these needs were met. We examined the association between perceived adequacy of tangible support and health outcomes at 1 year (mortality, physical function). Of 820 participants, 74% perceived no need for help, 13% had sufficient help, 9% needed more help, and 5% needed much more help; 31 patients died during follow-up. After adjustment for age and initial health status, odds ratios (95% confidence interval) for death were: sufficient help 1.8 (0.61, 5.8); need more help 3.2 (1.1, 9.4); and need much more help 6.5 (2.0, 21.6) compared with respondents with no perceived need. Decline in physical function was also linearly related to perceiving less-adequate tangible support. Sensitivity analyses indicated it is highly improbable that results were due to selection bias.

CONCLUSIONS

Perceived lack of needed assistance was related to mortality and to decline in physical functioning. Adequacy of tangible support was an important prognostic factor for these patients with coronary artery disease and may be a determinant of health outcomes.

Bioanalysis of p-trifluoromethylmandelic acid and Mosher's acid by chiral gas chromatography and fluorine nuclear magnetic resonance to study chiral inversion: application to rat urine samples

Methods for the nuclear magnetic resonance and gas chromatographic analysis of the enantiomers of p-trifluoromethylmandelic acid (p-TFM) and Mosher's acid (alpha-methoxy-alpha-(trifluoromethyl)phenylacetic acid) present in rat urine samples are described. Gas chromartography was performed using cyclodextrin capillary columns with both compounds analysed following derivatisation with methanolic HCl. Nuclear magnetic resonance was performed directly on the untreated urine samples following addition of beta-cyclodextrin. The methods were suitable for the determination of the individual enantiomers of the analytes in urine. Analysis of the rat urine samples indicated that the p-TFM had undergone a unidirectional enantiomeric interconversion in vivo, while the enantiomers of Mosher's acid were excreted unchanged.

Treatment and health outcomes of women and men in a cohort with coronary artery disease

BACKGROUND

Women with coronary artery disease are treated differently than men. Although mortality has been studied, functional outcomes for women and men have not been prospectively compared.

METHODS

The Manitoba Health Reform Impact Study used hospital databases to identify all residents aged 45 years and older in Manitoba who were hospitalized for a myocardial infarction between October 1, 1991, and September 30, 1992. Cohort members were interviewed twice, an average of 16 and 25 months after hospitalization. Baseline and follow-up measures included treatments (eg, physician visits, diagnostic testing, revascularization, and cardiac medications), physical health status (physical component summary [PCS] score derived from the Medical Outcomes Study Short Form 36), reinfarction, and mortality.

RESULTS

Of the 820 patients who completed the initial survey, 31 died during the follow-up period, and 734 completed the follow-up survey. Data were complete for the primary outcome (PCS score) and all relevant covariates for the 677 patients who were included in this study Women constituted 34% of this cohort. Although women had more physician visits during follow-up, they were less likely to have undergone treadmill testing or angiography (odds ratio, 0.68; 95% confidence interval, 0.46-0.99). Women were equally likely to report taking beta-adrenergic blocking agents, but were less likely than men to report the use of aspirin (odds ratio, 0.69; 95% confidence interval, 0.48-0.98). After adjusting for baseline differences in PCS scores, age, income, social supports, and the levels of angina and dyspnea, the PCS score for women declined by 1.4 points, while the score for men improved by 0.2 points (P = .03). During the follow-up period, reinfarction and mortality rates were low overall, but were not different in men and women.

CONCLUSIONS

In this cohort of patients with known coronary artery disease, we found less aggressive treatment of coronary artery disease and less use of aspirin among women than among men during 1 year of observation. After controlling for baseline differences, women with coronary artery disease experienced a more rapid decline in physical health status than did men during 1 year of follow-up.

Depression in North India comparison of symptoms and life events with ocher patient groups

Cross-cultural studies of depression have raised interesting issues in terms of symptoms and diagnosis in patients seeking treatment. To understand the symptom patterns of depression in a clinic population in north India, we studied 75 consecutive patients diagnosed as suffering from depression. They were asked to describe their symptoms, life events in the year before the onset of depression, and family history. Sleep disturbances, low mood and irritability were common symptoms. Suicidal intent was reported by 54% of the sample, and guilt by 56%. Study of family history and life events suggests that in those with a negative family history, the onset of depression was more likely to be related to a significant life event the commonest being family conjunct. The symptoms of this patient group are compared with the symptoms of depression reported from clinical samples in south India, Bombay and the West. North Indian samples have low rates of delusions, whereas Bombay samples reveal low levels of hypochondriasis, agitation, guilt and suicidal thoughts. The roles of cultural factors, family responsibilities and expectations are discussed in relation to depression across cultures. These findings also have implications for the clinical management of patients from the North Indian diaspora presenting with depression.

Structure of a combination of Functional Independence Measure and Instrumental Activity Measure items in community-living persons: a study of individuals with cerebral palsy and spina bifida

OBJECTIVE

To analyze the structure of a combination of physical items from the Functional Independence Measure (FIM) and seven instrumental activity items using ratings of dependence and perceived difficulty.

DESIGN

Disability in terms of dependence and subject's perceived difficulty was studied in patients with cerebral palsy (CP) and spina bifida (SB). Rasch analysis was used to construct calibrated linear measure and to identify suitable models with respect to rating steps.

SETTING

Interviews were performed at home with patients from an outpatient university rehabilitation unit for young disabled persons.

PATIENTS

Fifty-three CP and 20 SB patients (including 5 with other early acquired spinal cord lesions), 20 to 39 years of age, participated and represented 62% and 80%, respectively, of available patients. All had fulfilled an elementary school program.

RESULTS

The best scoring model using Rasch analysis was achieved using 5 levels for dependence and 4 levels for perceived difficulty. Hierarchic orders for all items are presented. The FIM items Bowel and Bladder showed different characteristics in the two groups of patients, especially for perceived difficulty, and were excluded in the joint calibrations. There was close overall agreement between the ratings of dependence and perceived difficulty. Person measure values from the Rasch analyses were separated between wheelchair users and walkers.

CONCLUSION

The combination of physical items from FIM and instrumental activity measure (IAM) are useful for disability assessment in community-living persons and should be further studied in other impairment groups.

The structure of an instrument for assessing the effects of assistive devices and altered working methods in women with rheumatoid arthritis

OBJECTIVE

To use Rasch analysis to transform the ordinal score from a newly developed instrument, the Evaluation of Daily Activities Questionnaire (EDAQ), in order to obtain unidimensional linear measures; to analyze whether items change in difficulty with interventions; and to follow changes in subjects' degree of ability.

METHODS

Twenty-one women with rheumatoid arthritis rated their perceived difficulty without and with assistive devices or altered working methods using the EDAQ; the EDAQ consists of 102 items of daily activities, divided into 11 dimensions.

RESULTS

All items in the EDAQ could be structured into an acceptable model from "hard" to "easy" with the subjects overall measures ranging from "more able" to "less able." Forty-one items showed a significant reduction of difficulty with interventions. For some items results indicated that easier initial difficulty led to greater effect of interventions. In general, difficulty without assistive devices could not predict difficulty with interventions. Twenty women demonstrated a significant increase in activities of daily living (ADL) ability after interventions.

CONCLUSION

The EDAQ analyzed with the Rasch model, demonstrated a hierarchical order of difficulty in 102 items showing that it was possible to evaluate the effect of using assistive devices or altered working methods.

CD30 ligand expression in nonmalignant and Hodgkin's disease-involved lymphoid tissues

The CD30 ligand (CD30L) is a type II transmembrane glycoprotein of the tumor necrosis factor ligand superfamily. Recent cloning of CD30L has enabled studies to explore its function and tissue distribution. For instance, recombinant CD30L has been shown to co-stimulate T cells and to act as mitogen for Hodgkin's disease (HD)-derived cell lines. The counter-receptor for CD30L, ie, CD30, is a type I cytokine receptor that is highly expressed by activated T cells, Hodgkin and Reed-Sternberg (H-RS) cells, and anaplastic large cell lymphoma cells. In the present study, recombinant membrane-bound and soluble human CD30L were instrumental to raise a monoclonal antibody (M80) recognizing membrane-bound CD30L on transfected and native cells. With this reagent, a panel of cultured lymphoma-derived cell lines as well as primary normal, reactive, and HD-involved lymphoid tissues were examined for expression of CD30L by immunostaining and flow cytometry. In reactive lymphnodes and tonsils, CD30L was expressed by a small subset of lymphoid cells, histiocytes, and granulocytes. Higher levels of CD30L expression were noted in HD lesions among bystander cells; ie, T cells and granulocytes that surrounded H-RS cells. Native CD30L displayed at the cell surface was functionally active as shown by the ability of fixed granulocytes to interact with CD30+ cell lines. Moreover, CD30L was detectable, although to a lower staining intensity, in primary H-RS cells of all HD tissues investigated regardless of the histological subtype and the phenotype of H-RS cells (ie, CD30+/CD40+ versus CD30-/CD40+). Co-expression of CD30 and CD30L that was seen on H-RS cells of all, except the CD30- nodular lymphocyte predominant, subtypes of HD may point to the use of this pair of molecules in paracrine and/or autocrine mitogenic cell interactions. Monoclonal antibody M80 may thus represent a useful tool for studying CD30L expression on cultured cell lines and primary cells from normal, reactive, and malignant tissues.

Computers, communication and confidentiality: tales of Baron Munchausen

The aim was to examine the use of computer and paper based systems in accident and emergency (A&E) departments in the management of patients who are frequent attenders. More than half of the A&E consultants in the Thames regions who were sent a questionnaire responded (44 of the 80). 82% of the respondents use such systems predominantly to monitor violent patients, those with Munchausen syndrome, and children on the "at risk" register. Systems currently in use fail to fulfil many of the functions that would be required of an ideal system. When using computers to store and communicate clinical data, several ethical problems were identified but these appeared to be outweighed by the practical need and were also present with paper based systems. Safeguards could also be built into computer based systems to reduce some of the ethical problems. Computer systems should be deliberately chosen and implemented in response to a specific management problem. The potential benefits should be weighed against possible damaging side effects, such as a breach of confidentiality.

Measuring the fetal kidney with ultrasonography

OBJECTIVES

To establish a normal range of measurements for the external and internal dimensions of the fetal kidney and, if possible, to correlate these measurements with gestational age.

SUBJECTS AND METHODS

The external and internal dimensions of the fetal kidney were measured in 810 women selected on the grounds of obstetric, fetal or technical risk factors from a consecutive series of 1136 women attending the ante-natal ultrasonography clinic of a district general hospital. Post-natal data were obtained from medical records on 1122 newborns. The maximum of pairs of renal measurements was used for analysis. Measurements were cross-sectional in 347 cases and longitudinal in 463. The total number of measurement episodes was 2294.

RESULTS

External renal dimension and gestational age were closely related, enabling accurate growth centile charts to be constructed. The correlation between renal pelvic dimension and gestational age was weak. The maximum dimension of the renal pelvis at any gestational age in 92.7% of fetuses was < 5 mm. Using longitudinal measurements, 6.5% of cases with a renal pelvic dimension of < 5 mm at the first scan measured > or = 5 mm at a subsequent scan, but 53.3% with a dimension of > or = 5 mm at the first scan also measured > or = 5 mm at the subsequent scan.

CONCLUSION

It is possible to assess the growth and size of the fetal kidney according to gestational age but this does not apply to the renal pelvis. A renal pelvic dimension of > 5 mm at any gestational age is unusual and dilatation beyond this level should prompt a detailed post-natal urological investigation.

Pharmacokinetics of single- and multiple-dose bupropion in elderly patients with depression

A study of a dopaminergic antidepressant that may have an advantageous profile for use in elderly patients, bupropion, was conducted to determine the pharmacokinetics of bupropion in the elderly. Pharmacokinetics of single- and multiple-dose bupropion were examined in six elderly patients (five women and one man) diagnosed with depression. Mean (+/- SD) CL app of bupropion was 1.6 +/- 0.4 L/hr/kg, approximately 80% of the corresponding value reported for younger patients. Mean bupropion t1/2 was 34.2 +/- 8.7 hours, and average apparent Vd (Vd app) was 79.3 +/- 29.4 L/kg. Apparent half-lives (t1/2 app) of the metabolites hydroxybupropion, erythrobupropion, and threohydrobupropion were 34.2 +/- 4.6 hours, 61.4 +/- 21.6 hours, and 38.8 +/- 7.6 hours, respectively. After multiple dosing, the mean t1/2 for bupropion and its metabolites did not change significantly, although in some patients the t1/2 app of the metabolites was substantially prolonged. There was also evidence of inordinate accumulation of metabolites. The elderly are at risk for accumulation of bupropion and its metabolites. Specification of therapeutic drug monitoring parameters for bupropion treatment of the elderly is needed.