Docosahexaenoic acid and smoking-related chronic obstructive pulmonary disease. The Atherosclerosis Risk in Communities Study Investigators

If the inflammatory response to inhalation of cigarette smoke causes chronic obstructive pulmonary disease (COPD), suppression of that natural response might be beneficial. We hypothesized that a smoker's risk of developing COPD is inversely related to physiologic levels of two fatty acids that have antiinflammatory properties: eicosapentaenoic acid (EPA, C20:5) and docosahexaenoic acid (DHA, C22:6). The proportion of each fatty acid in plasma lipids was measured in 2,349 current or former smokers. COPD was identified and defined by clinical symptoms and/or spirometry. After adjustment for smoking exposure and other possible confounders, the prevalence odds of COPD were inversely related to the DHA (but not to the EPA) content of plasma lipid components in most of the models. For example, as compared with the first quartile of the DHA distribution, the prevalence odds ratios (ORs) for chronic bronchitis were 0.98, 0.88, and 0.69 for the second, third, and fourth quartiles, respectively (p for linear trend = 0.09). The corresponding ORs for COPD as defined spirometrically, were 0.65, 0.51, and 0.48 (p < 0. 001). Among 543 current heavy smokers, adjusted mean values of FEV1 (lowest to highest DHA quartile) were 2,706, 2,785, 2,801, and 2,854 ml. DHA may have a role in preventing or treating COPD and other chronic inflammatory conditions of the lung. Pilot testing of that hypothesis in experimental models seems warranted.

[Clinical and immunological characteristics of HIV-positive AIDS in children in Northern Israel]

We are treating 11 children in our AIDS clinic. All were infected by vertical transmission from carrier mothers. However, among 31 HIV-carrier AIDS patients who were under follow-up during pregnancy, supposedly taking zidovudine prophylaxis, only 1 (3.3%) gave birth to a baby infected with HIV. Our children with HIV and AIDS are 3 months to 12 years of age (average 4.5 years); mean age at diagnosis was 18 months. All are either symptomatic or have laboratory evidence of progressive immunodeficiency, 1 is asymptomatic (N2), 1 has mild symptoms (A2) and the rest present significant symptoms or AIDS-defining disease. All have moderate to severe immunodeficiency, as evidenced by CD4+ cells counts. 60% have rapidly progressive disease, based on their symptomatology and immune state, whereas clinical reports in the literature point to only 10-15%. However, the average CD4 + cell count was 22% (749/mm3) at diagnosis and 22% (759/mm3) at last follow-up. These stable findings during an average follow-up of 28 months probably reflect the effect of medical and supportive treatment. All received antiretroviral medication consisting of a combination of 2 or 3 drugs. 8 of 11 also received prophylactic treatment against opportunistic infections and 8 of 11 are clinically well. Routine follow-up and a good relationship with the patient's family increase cooperation and promote optimal medical treatment, and consequently improve the clinical condition and quality of life.

Stroke incidence and survival among middle-aged adults: 9-year follow-up of the Atherosclerosis Risk in Communities (ARIC) cohort

BACKGROUND AND PURPOSE

Although stroke mortality rates in the United States are well documented, assessment of incidence rates and case fatality are less well studied.

METHODS

A cohort of 15 792 men and women aged 45 to 64 years from a population sample of households in 4 US communities was followed from 1987 to 1995, an average of 7. 2 years. Incident strokes were identified through annual phone contacts and hospital record searching and were then validated.

RESULTS

Of the 267 incident definite or probable strokes, 83% (n=221) were categorized as ischemic strokes, 10% (n=27) were intracerebral hemorrhages, and 7% (n=19) were subarachnoid hemorrhages. The age-adjusted incidence rate (per 1000 person-years) of total strokes was highest among black men (4.44), followed by black women (3.10), white men (1.78), and white women (1.24). The black versus white age-adjusted rate ratio (RR) for ischemic stroke was 2.41 (95% CI, 1.85 to 3.15), which was attenuated to 1.38 (95% CI, 1.01 to 1.89) after adjustment for baseline hypertension, diabetes, education level, smoking status, and prevalent coronary heart disease. There was a tendency for the adjusted case fatality rates to be higher among blacks and men, although none of the case fatality comparisons across sex or race was statistically significant.

CONCLUSIONS

After accounting for established baseline risk factors, blacks still had a 38% greater risk of incident ischemic stroke compared with whites. Identification of new individual and community-level risk factors accounting for the elevated incidence of stroke requires further investigation and incorporation into intervention planning.

Reliability of scoring respiratory disturbance indices and sleep staging

STUDY OBJECTIVES

Unattended, home-based polysomnography (PSG) is increasingly used in both research and clinical settings as an alternative to traditional laboratory-based studies, although the reliability of the scoring of these studies has not been described. The purpose of this study is to describe the reliability of the PSG scoring in the Sleep Heart Health Study (SHHS), a multicenter study of the relation between sleep-disordered breathing measured by unattended, in-home PSG using a portable sleep monitor, and cardiovascular outcomes.

DESIGN

The reliability of SHHS scorers was evaluated based on 20 randomly selected studies per scorer, assessing both interscorer and intrascorer reliability.

RESULTS

Both inter- and intrascorer comparisons on epoch-by-epoch sleep staging showed excellent reliability (kappa statistics >0.80), with stage 1 having the greatest discrepancies in scoring and stage 3/4 being the most reliably discriminated. The arousal index (number of arousals per hour of sleep) was moderately reliable, with an intraclass correlation (ICC) of 0.54. The scorers were highly reliable on various respiratory disturbance indices (RDIs), which incorporate an associated oxygen desaturation in the definition of respiratory events (2% to 5%) with or without the additional use of associated EEG arousal in the definition of respiratory events (ICC>0.90). When RDI was defined without considering oxygen desaturation or arousals to define respiratory events, the RDI was moderately reliable (ICC=0.74). The additional use of associated EEG arousals, but not oxygen desaturation, in defining respiratory events did little to increase the reliability of the RDI measure (ICC=0.77).

CONCLUSIONS

The SHHS achieved a high degree of intrascorer and interscorer reliability for the scoring of sleep stage and RDI in unattended in-home PSG studies.

Rapid recovery from transverse myelopathy in children treated with methylprednisolone

Acute transverse myelopathy is an uncommon disease that manifests with gradually developing weakness of the lower extremities associated with bladder or bowel dysfunction, sensory deficits, and pain localized in the back, legs, or abdomen. There are controversies in the literature regarding the role of steroids in the treatment of acute transverse myelopathy. Recently, a pilot open study of five children with acute transverse myelopathy treated with high-dose methylprednisolone demonstrated significant shortening of motor recovery when compared with an historic control group receiving either no treatment or low-dose steroids. The authors add their experience of 10 children with acute transverse myelopathy treated with high-dose methylprednisolone as soon as the diagnosis was confirmed. The median time of motor recovery in the present series was 5.5 compared with 23 days in the other study. No significant side effects were observed after treatment. This study provides further support that this treatment modality is safe and efficient and should be suggested for all children with acute transverse myelopathy after establishing the diagnosis.

Trends in cigarette smoking: the Minnesota Heart Survey, 1980 through 1992

OBJECTIVES

The purpose of this study was to describe trends in the prevalence of cigarette smoking between 1980 through 1982 and 1990 through 1992 in Minneapolis and St. Paul, Minn.

METHODS

Three population-based surveys were conducted among adults 25 to 74 years of age in 1980 through 1982, 1985 through 1987, and 1990 through 1992.

RESULTS

Overall age-adjusted prevalences of cigarette smoking declined significantly between 1980-1982 and 1985-1987 and between 1985-1987 and 1990-1992. Serum thiocyanate, a biochemical marker for tobacco use, also declined significantly over the 3 periods.

CONCLUSIONS

Favorable trends in smoking prevalence and cigarette consumption among smokers were observed, but disturbing trends in some smoking behaviors were also noted.

Delayed hospital arrival for acute stroke: the Minnesota Stroke Survey

BACKGROUND

Although recent advances have been made in the treatment of acute stroke, patients often arrive at the hospital too late to receive the maximum benefit from these new therapies.

OBJECTIVE

To investigate characteristics that influence the time from symptom onset to hospital arrival (delay time) for patients with acute stroke.

DESIGN

Retrospective medical record review.

SETTING

Minneapolis-St. Paul metropolitan hospitals.

PATIENTS

A 50% random sample of all patients 30 to 79 years of age who were hospitalized with acute stroke from 1991 to 1993.

MEASUREMENTS

Patients were identified through discharge diagnosis lists by using the International Classification of Diseases, 9th Revision. Trained nurses abstracted the medical records. Stroke events were validated by using neuroimaging reports and additional clinical criteria (1895 patients). An accelerated failure time model was used to identify patient characteristics that independently predicted delay time. For 70% of patients (n = 1334), delay time was calculated from the medical record by subtracting the recorded time of symptom onset from the admission time. For the remaining 30% of patients (n = 561), the time of symptom onset was not recorded, and an approximate delay time was estimated from all available information.

RESULTS

Among patients with a calculated delay time, half arrived within 3 hours of symptom onset and 90% arrived within 24 hours. Patients with approximated delay times tended to have longer delays, and less than 40% of these patients arrived within 24 hours of symptom onset. Some characteristics associated (P < 0.05) with longer delay included Asian/Pacific Islander ethnicity, dependence in any activities of daily living before stroke, and several symptoms at stroke onset. Characteristics associated (P < 0.05) with shorter delay included admission through the emergency department, presence of syncope or seizures at stroke onset, previous myocardial infarction, abnormal mental status, and greater disability at presentation (measured by the Rankin scale).

CONCLUSIONS

Most patients arrive at the hospital too late to receive the maximum benefit from emerging stroke therapies. Efforts to reduce delays in hospital arrival after acute stroke can maximize the effectiveness of these therapies by specifically targeting persons at risk for longer delay.

Melatonin treatment in an institutionalised child with psychomotor retardation and an irregular sleep-wake pattern

An institutionalised 13 year old girl with psychomotor retardation suffered from an irregular sleep-wake pattern. Multiple measurements of urinary sulphatoxy-melatonin (aMT6) concentrations were abnormally low, without any significant day-night differences. Administration of exogenous melatonin (3 mg) at 18:00 resulted in increased nocturnal urinary aMT6 concentrations and improvements in her sleep-wake pattern. Melatonin may help disabled children suffering from sleep disorders.

Parkinsonian syndrome complicating systemic lupus erythematosus

Two girls with florid extrapyramidal parkinsonism complicating systemic lupus erythematosus (SLE) are reported. One patient (15 years old) presented with extreme rigidity, irritability, and mutism initially diagnosed as acute psychosis. Examination revealed severe extrapyramidal akinetic mutism, along with marked restlessness. CT and MRI imaging of the brain were unremarkable. EEG revealed moderate generalized disturbance of background activity. 99mTc-HmPAO SPECT cerebral scanning detected decreased regional cerebral blood flow at the basal ganglia. Dopamine-agonist drugs led to complete recovery after 3 months, along with normalization of EEG and SPECT alterations. The second patient (16 years old) was assessed for progressive bradykinesia and apathy impeding her active daily activities, and she was suspected to have developed depression. Neurologic assessment revealed a parkinsonian syndrome that was less severe than that of the first patient. The EEG showed mild disturbance of background activity, and 99mTc-HmPAO SPECT demonstrated impaired regional cerebral blood flow over the basal ganglia. A parkinsonian extrapyramidal syndrome complicating SLE should therefore be taken into account in any patient with SLE presenting with marked behavioral alterations, rigidity, or akinetic mutism.

Weight-loss induced changes in plasma factor VII coagulant activity and relation to the factor VII Arg/Gln353 polymorphism in moderately obese adults

Elevated plasma factor VII coagulant activity (factor VIIc) may be an independent risk factor for coronary heart disease. Several cross-sectional studies suggest that a polymorphism of the factor VII gene (Arg-Gln353) interacts with plasma triglyceride level in determining factor VIIc, but prospective data are lacking. Factor VII genotype, factor VIIc, and triglyceride level were measured in moderately obese adults aged 25 to 45 who underwent a six-month clinical trial to evaluate strategies for weight loss. A total of 48 men and 50 women who experienced substantial weight loss (mean: 10 kg) provided samples for genetic analysis. Overall, 78% of participants were homozygous for the Arg353 allele, while the remaining 22% were heterozygous (Arg/Gln353). At the baseline examination, heterozygotes had lower mean factor VIIc than Arg353 homozygotes (92% vs. 112%; p<0.001), and genotype explained 18% of the variance of factor VIIc. Average six-month weight loss was similar in both genotypes; mean reductions in factor VIIc following weight loss were greatest among Arg353 homozygotes with high initial values (> 120%). Cross-sectional and longitudinal associations between plasma factor VIIc and triglyceride level were not dependent on genotype. These data confirm that the Gln353 allele is associated with lower factor VII coagulant activity in moderately obese adults, but they do not support the hypothesis that the Arg-Gln353 polymorphism interacts with plasma triglyceride level in determining factor VIIc.

High incidence of hypoglycemic episodes with neurologic manifestations in children with insulin dependent diabetes mellitus

Hypoglycemia is a serious frequent complication of insulin therapy in type 1 diabetes.

PATIENTS AND METHODS

We surveyed 139 IDDM patients.

RESULTS

Forty-four patients (32%) reported at least one severe hypoglycemic episode. All patients with severe hypoglycemia experienced neurological manifestations. Symptoms included confusion and abnormal behavior, convulsions, coma, transient hemiparesis and one case of permanent hemiparesis. Most episodes occurred at night or during morning hours. 44% of episodes were related to delayed meal or snack, 11% to excess insulin administration and 13% to extra physical activity. HbA1c was significantly lower in patients with severe hypoglycemia compared with diabetic controls (7.33 +/- 1.09% and 9.45 +/- 4.32%, respectively).

Electrocardiographic findings in a healthy biracial population. Atherosclerosis Risk in Communities (ARIC) Study Investigators

It has been well documented that the prevalence of certain electrocardiographic (ECG) findings among individuals free of coronary heart disease (CHD) differs by race. However, it is not known whether these differences exist independently of CHD risk factors (e.g., hypertension). We examined the ECG tracings of 2,686 apparently healthy, middle-aged African-American and white men and women who participated in the Atherosclerosis Risk in Communities Study and were at low risk of CHD. Using the Minnesota Code, among men, 46% of African-Americans, but only 25% of whites, had a minor ECG finding (p < 0.001). In women, 32% of African-Americans and 23% of whites had a minor ECG finding (p < 0.01). Specifically, the age-adjusted prevalences of high-amplitude R wave, ST elevation, T-wave findings, and prolonged P-R interval were statistically significantly higher in African-Americans. As for continuous ECG measurements, the R wave in leads V5 and V6, the S wave in V1, the J-point amplitude in leads V2 and V5, the P-R interval, and the Cornell voltage (¿S V3¿ + R aVL) for left ventricular hypertrophy were all significantly greater in African-Americans than in whites. However, in both men and women, the heart rate corrected QT interval was shorter in African-Americans than in whites. All of these findings remained statistically significant after further adjustment for traditional CHD risk factors. These results suggest that racial differences in electrocardiograms may not be explained entirely by differences in established CHD risk factors, and because current diagnostic ECG criteria are largely based on data from middle-aged white men and women, race should be considered in the interpretation of ECG findings.

Trends in medical care of hospitalized stroke patients between 1980 and 1990: The minnesota stroke survey

Recent decades have seen several advances in medical care for acute stroke patients, but there has been little systematic documentation of these changes. This study examined changes in technology use and medical therapies for hospitalized acute stroke during the 1980s. For 1980, 1985, and 1990, we obtained discharge diagnosis lists from Minneapolis-St Paul metropolitan hospitals, identified hospitalizations for acute stroke of patients aged 30 to 74 years, and selected a 50% random sample. Trained nurses abstracted the medical records. Strokes were classified as hemorrhagic or ischemic based on discharge diagnosis code (using the International Classification of Diseases, 9th Revision) and findings from computed tomography (CT) or magnetic resonance imaging (MRI). Strokes classified as ischemic totaled 459 in 1980, 549 in 1985, and 657 in 1990. There were approximately 100 hemorrhagic stroke patients in each survey year. Throughout the 1980s, there was a trend toward both greater and earlier use of CT and MRI to diagnose stroke. By 1990, only 3% of patients did not receive CT or MRI during the acute hospital stay, and the percentage of patients scanned on the first day of hospitalization almost doubled from 43% in 1980 to 76% in 1990 (P=.0001). For ischemic stroke patients, the use of carotid ultrasound doubled from 24% to 48% between 1985 and 1990 (P<.0005), and the probability of identifying a possibly embolic source increased from 27% in 1980 to 40% in 1990 (P<.0005). The use of anticoagulants to treat ischemic stroke decreased from 1985 to 1990 (heparin, 53% to 47%, P=.030; coumadin, 37% to 31%, P=.032), whereas the use of aspirin increased by over 50% (from 27% to 41%, P<.0005). Finally, the mean length of stay was halved from 20 days in 1980 to 10 days in 1990 (P=.0001). This study documented several significant time trends in acute stroke care. Whether these trends account for some of the improvement in stroke survival during the 1980s is uncertain.

Trends in cholesterol knowledge and screening and hypercholesterolemia awareness and treatment, 1980-1992. The Minnesota Heart Survey

BACKGROUND

National cholesterol education initiatives were implemented in the middle to late 1980s. This study examines whether there were significant increases in population cholesterol knowledge and screening and hypercholesterolemia awareness and treatment from 1980 to 1992.

METHODS

Three population-based surveys were conducted among adults aged 25 to 74 years in 1980-1982 (N = 4086), 1985-1987 (N = 5735) and 1990-1992 (N = 6305) in the Minneapolis-St Paul, Minn, metropolitan area as part of the Minnesota Heart Survey. Personal interviews about knowledge of cholesterol level and hypercholesterolemia awareness and treatment were conducted. Total serum cholesterol was measured; hypercholesterolemia was defined as having a total cholesterol level of 6.21 mmol/L or more (> or = 240 mg/dL) or current use of cholesterol-lowering medications. Hypercholesterolemia awareness was defined as the belief of a participant with hypercholesterolemia that her or his total cholesterol was high.

RESULTS

Knowledge increased from 15% in 1980-1982 to 17% in 1985-1987 to 55% in 1990-1992 (P < .001) in women; similar trends were observed for men (19%, 22%, and 47%, respectively; P < .001). Hypercholesterolemia awareness doubled during the decade (women: 17%, 1980-1982; 24%, 1985-1987; 60%, 1990-1992; P < .001; men: 25%, 30%, and 55%, respectively; P < .001). Among participants who reported physician-diagnosed hypercholesterolemia, the prevalence of current pharmacological treatment increased from 9% in 1980-1982 to 14% in 1990-1992 in women, and from 7% to 13%, respectively, in men.

CONCLUSIONS

Cholesterol knowledge and hypercholesterolemia awareness and treatment increased substantially during the 1980s, concurrent with educational initiatives of the National Cholesterol Education Program and other efforts.

Assessment of endocrine functions in children following severe head trauma

The goal of the present study was to assess endocrine functions in children following severe head trauma. Subjects included 21 children between the ages of 3 years and 18 years 6 months, referred to the Pediatric Rehabilitation Unit at Sheba Medical Center, Israel, between 1984 and 1995. Each was examined 4 months to 11 years following the first admission, undergoing a complete physical examination, including neurologic assessment, biochemical and baseline endocrine profiles, and bone age determination. A GnRH stimulation test was performed in prepubescent children who had advanced bone age. Sixteen children had experienced the head trauma before, or at onset of puberty, according to their chronologic ages. Two children had completed puberty before the head trauma. A 12-year-old male who sustained head trauma at 10 years 6 months of age was found to have Tanner grade 3 pubertal stage and advanced bone age. In addition, 3 prepubescent children also had advanced bone age with no other signs of precocious puberty and a normal GnRH test. For all children studied, the biochemical and hormonal laboratory measurements were in the normal range. Endocrine abnormalities were not found in children examined 4 months or more following severe head trauma. We conclude that clinical monitoring of endocrine status after severe head trauma is sufficient; specific hormonal measurements are not required unless warranted by abnormal physical signs.

Familial history of stroke and stroke risk. The Family Heart Study

BACKGROUND AND PURPOSE

Although familial history of stroke is generally perceived to be an important marker of stroke risk, very few epidemiological studies have been published to address this hypothesis. We sought to examine whether familial history of stroke is associated with the prevalence of stroke in the Family Heart Study, a National Heart, Lung, and Blood Institute-supported multicenter study of the familial, genetic, and nongenetic determinants of cardiovascular disease in populations.

METHODS

The personal and familial histories of stroke were assessed in 3168 individuals (probands) who were at least 45 years old and 29,325 of their first-degree relatives with the use of a standardized questionnaire.

RESULTS

The age-, ethnicity-, and sex-adjusted stroke prevalences were 4.8%, 4.9%, and 3.9% in probands with a positive familial, paternal, and maternal history of stroke, respectively, in comparison with 2.0% in probands without any positive familial history (P < .01). The age-, ethnicity-, and sex-adjusted odds ratios (95% confidence interval) of stroke were 2.00 (1.13, 3.54) for a positive paternal and 1.41 (0.80, 2.50) for a positive maternal history of stroke. Additional statistical adjustment for the proband's history of elevated cholesterol level, cigarette smoking status, history of coronary heart disease, hypertension, and diabetes did not alter the associations. A similar pattern was seen for African Americans and European Americans.

CONCLUSIONS

The increased risk of stroke among persons with a positive familial history of stroke compared with those without a familial history of stroke is consistent with the expression of genetic susceptibility, a shared environment, or both in the etiology of stroke.

Autoimmune progesterone dermatitis: effective prophylactic treatment with danazol

BACKGROUND

Autoimmune progesterone dermatitis is a rare condition appearing during the perimenstrual period or following progesterone treatment. Various treatment modalities have been suggested, but most have proved to be ineffective.

METHODS

We used the anabolic androgen danazol as a preventive treatment for recurrent episodes of autoimmune progesterone dermatitis in two young women. The treatment regimen consisted of 200 mg danazol twice daily, starting 1-2 days before the expected date of each menses and continuing for 3 days thereafter.

RESULTS

This treatment regimen proved to be highly effective in preventing the eruptions in these two patients.

CONCLUSIONS

Patients with autoimmune progesterone dermatitis may benefit from prophylactic treatment with danazol.

Glycosylated hemoglobin level and carotid intimal-medial thickening in nondiabetic individuals. The Atherosclerosis Risk in Communities Study

OBJECTIVE

People with diabetes are at increased risk for cardiovascular events. However, questions remain about what role, if any, homeostatic glucose control plays in the development of cardiovascular disease among nondiabetic individuals. We investigated the relationship between HbA1c level and carotid intimal-medial thickening in normoglycemic individuals.

RESEARCH DESIGN AND METHODS

We conducted a case-control study among 208 normoglycemic individuals (fasting glucose < or = 6.4 mmol/l and no history of diabetes) who had carotid initial-medial thickening (case subjects) and 208 normoglycemic control subjects individually matched for age, sex, race, field center, and date of exam. Subjects were free-living men and women, aged 45-64 years at baseline, who participated in the Atherosclerosis Risk in Communities (ARIC) Study.

RESULTS

HbA1c levels, expressed as percent of total hemoglobin, ranged from 4 to 7% and correlated only modestly with single measurements of fasting glucose (r = 0.16) and fasting insulin (r = 0.14). The mean level of HbA1c was 5.18% among case subjects and 5.07% among control subjects (P = 0.004, paired t test). As compared with the first quartile of HbA1c the matched relative odds of being a case were 1.15, 1.33, and 2.30 for the second, third, and fourth quartiles, respectively (P = 0.005 for linear trend). After multivariate adjustment for age, fasting glucose, fasting insulin, BMI, smoking status, hypertension, LDL cholesterol, HDL cholesterol, fibrinogen, and education level, the respective relative odds estimates were 0.98, 1.07, and 1.88 (P = 0.16 for linear trend). When modeled linearly as a continuous variable and after adjustment for the above-mentioned covariates, a 1% point increment in HbA1c level was associated with 1.77 greater odds of being a case (95% CI, 0.9-3.5).

CONCLUSIONS

These data provide some support to the hypothesis that in the absence of diabetes, homeostatic glycemic control is a risk factor for atherosclerosis.

Comparison of medical care and one- and 12-month mortality of hospitalized patients with acute myocardial infarction in Minneapolis-St. Paul, Minnesota, United States of America and Göteborg, Sweden

We compared medical care and mortality through 1-year of hospitalized acute myocardial infarction (AMI) patients in 2 large metropolitan areas in the United States and Sweden. All hospitalized AMI discharges (International Classification of Diseases, 9th revision [ICD9] codes 410) occurring among 30 to 74-year-old residents of the Minneapolis-St. Paul metropolitan area in 1990 and Göteborg, Sweden, in 1990 to 1991 were identified and their medical records examined. There were dramatic differences in medical care during the index hospitalization of AMI patients between Minneapolis-St. Paul and Göteborg. Use of thrombolytic therapy, coronary angioplasty, bypass surgery, calcium antagonists and lidocaine was more common in Minneapolis-St. Paul; beta blockers were more frequently used in Göteborg, and aspirin use was similar. Despite these large differences, neither 28-day nor 1-year mortality of hospitalized AMI patients differed significantly. The marked differences found in the early treatment of AMI between Minneapolis-St. Paul and Göteborg, combined with the negligible differences observed in short- and long-term mortality, raise questions about the most effective and efficient allocation of medical resources.

Neighborhood environments and coronary heart disease: a multilevel analysis

The authors investigated whether neighborhood socioeconomic characteristics are associated with coronary heart disease prevalence and risk factors, whether these associations persist after adjustment for individual-level social class indicators, and whether the effects of individual-level indicators vary across neighborhoods. The study sample consisted of 12,601 persons in four US communities (Washington County, Maryland; Forsyth County, North Carolina; Minneapolis, Minnesota; and Jackson, Mississippi) participating in the baseline examination of the Atherosclerosis Risk in Communities Study (1987-1989). Neighborhood characteristics were obtained from 1990 US Census block-group measures. Multilevel models were used to estimate associations with neighborhood variables after adjustment for individual-level indicators of social class. Living in deprived neighborhoods was associated with increased prevalence of coronary heart disease and increased levels of risk factors, with associations generally persisting after adjustment for individual-level variables. Inconsistent associations were documented for serum cholesterol and disease prevalence in African-American men. For Jackson African-American men living in poor neighborhoods, coronary heart disease prevalence decreased as neighborhood characteristics worsened. Additionally, in African-American men from Jackson, low social class was associated with increased serum cholesterol in "richer" neighborhoods but decreased serum cholesterol in "poorer" neighborhoods. Neighborhood environments may be one of the pathways through which social structure shapes coronary heart disease risk.

A Popperian perspective of the term 'evidence-based medicine'

If the term 'evidence-based medicine' conveys more than is conveyed by the word medicine, then there must be a way to distinguish between evidence-based medicine and non-evidence-based medicine. In particular, there must be a logically acceptable way to classify medical decisions as justified or unjustified by scientific evidence. In this essay I examine the nature of medical theories, the nature of the evidence that is produced by empirical tests of medical theories, and the relation of medical decisions to both. I conclude that attempts to classify medical decisions as justified or unjustified by scientific evidence have no foundation in logic and that the term 'evidence-based medicine' is logically indistinguishable from the term 'medicine'. The use of the term 'evidence-based medicine' calls for a new type of authoritarianism in medical practice.