Underutilization of reperfusion therapy in eligible African Americans with acute myocardial infarction: Role of presentation and evaluation characteristics

BACKGROUND

Immediate reperfusion therapy to restore coronary blood flow is recommended for all eligible patients with acute myocardial infarction. However, reperfusion therapy is reportedly underutilized among African Americans, even when they are eligible. Reasons for the lack of use have not been fully explored.

METHODS

We examined the demographic, clinical, and treatment data of 10,469 African Americans with acute myocardial infarction who were eligible for reperfusion therapy, enrolled in the National Registry of Myocardial Infarction-2 from June 1994 through March 1998.

RESULTS

The mean age was 62.58 (+/-14.4) years, and 44.7% were female. Although eligible, 47% of the African Americans in this study did not receive reperfusion therapy. In a multivariate analysis, the absence of chest pain at presentation (odds ratio [OR] 0.31, 95% CI 0.26-0.37) and initial admission diagnoses other than definite myocardial infarction (OR for receipt of reperfusion <0.12) were the strongest predictors of lack of early reperfusion therapy. Progressive delays in hospital arrival and hospital evaluation predicted a lower likelihood of early reperfusion. Prior stroke (OR 0.63, 95% CI 0.50-0.78), myocardial infarction (OR 0.75, 95% CI 0.65-0.86), and congestive heart failure (OR 0.49, 95% CI 0.40-0.60) were all associated with lack of reperfusion therapy.

CONCLUSION

Almost half of eligible African American patients with myocardial infarction did not receive reperfusion therapy. Potential reasons may include atypical presentation, patient and institutional delay, and underappreciation of myocardial infarction by care providers. Strategies to address these factors may improve the rate of use of reperfusion therapy.

Atypical presentation of Acanthamoeba keratitis

PURPOSE

To present two cases of minimal pain Acanthamoeba keratitis to alert clinicians to remember Acanthamoeba when evaluating atypical cases of keratitis.

METHODS

The histories of two cases were reviewed with attention to clinical presentation subjective complaints, treatment, and long-term outcome.

RESULTS

In case 1, a 24-year-old man presented with decreased vision and an irritated feeling in his eye. He did not wear contact lenses. His initial diagnosis was adenoviral conjunctivitis. One month later, he was diagnosed with atypical herpes simplex keratitis and started on acyclovir. Two weeks later, he was referred to the Cornea Service. Further history revealed the patient to be a professional triathlete who trained by swimming in a fresh water pond. He was found to have an unusually high pain tolerance. Biopsy revealed Acanthamoeba. He was admitted for intensive therapy with neomycin, propamidine isethionate, and polyhexamethylene biguanide. Two years after diagnosis, he has best-corrected visual acuity of 20/100. In case 2, a 28-year-old man with known herpes simplex keratitis presented with decreased vision. He was started on topical trifluridine. After 6 weeks without improvement, he was referred for corneal evaluation. His eye always remained comfortable. Corneal sensation was markedly decreased. Further history revealed that he swam in fresh water. Biopsy was positive for Acanthamoeba. After 1 year of therapy with polyhexamethylene biguanide and neomycin, visual acuity was 20/200, and the patient underwent a corneal transplant.

CONCLUSION

Acanthamoeba keratitis must be considered in the differential diagnosis of keratitis, even without the classic presentation of severe pain and predisposing corneal trauma, including contact lens wear.

The importance of providing good patient information

Having recognised the importance of looking at health care provision from the patient's perspective, a district general hospital's acute pain service revised its policy on providing patient information by involving patients in the development process. The service went on to achieve the Government's mark of excellence in public service, the Charter Mark.

Histone variant H2A.Z is required for early mammalian development

Fundamental to the process of mammalian development is the timed and coordinated regulation of gene expression. This requires transcription of a precise subset of the total complement of genes. It is clear that chromatin architecture plays a fundamental role in this process by either facilitating or restricting transcription factor binding [1]. How such specialized chromatin structures are established to regulate gene expression is poorly understood. All eukaryotic organisms contain specialized histone variants with distinctly different amino acid sequences that are even more conserved than the major core histones [2]. On the basis of their highly conserved sequence, histone variants have been assumed critical for the function of mammalian chromatin; however, a requirement for a histone variant has not been shown in mammalian cells. Mice with a deletion of H1 degrees have been generated by gene targeting in ES cells, but these mice show no phenotypic consequences, perhaps due to redundancy of function [3]. Here we show for the first time that a mammalian histone variant, H2A.Z, plays a critical role in early development, and we conclude that this histone variant plays a pivotal role in establishing the chromatin structures required for the complex patterns of gene expression essential for normal mammalian development.

Using insurance to enhance nitrogen fertilizer application to reduce nitrogen losses to the environment

The advantage of using insurance to help a farmer adopt a best nitrogen management plan (BNMP) that reduces the impact of agricultural production on the environment is analytically and empirically demonstrated. Using an expected value analysis, it is shown that an insurance program can be structured so as to reduce a farmer's cost of bearing the adoption risk associated with changing production practices and, thus, to improve the farmer's certainty equivalent net return thereby promoting the adoption of a BNMP. Using the adoption of growing-season only N fertilizer application in Iowa as a case study, it is illustrated how insurance may be used to promote the adoption of this practice to reduce N fertilizer use. It is shown that it is possible for a farmer and an insurance company both to have an incentive to develop an insurance adoption program that will benefit both the farmer and the insurance company, increasing net social welfare and improving environmental quality in Iowa.

Neurobehavioral symptoms in childhood closed-head injuries: changes in prevalence and correlates during the first year postinjury

OBJECTIVE

To examine changes in the prevalence and correlates of neurobehavioral symptoms during the first year following childhood closed-head injuries (CHIs).

METHODS

Participants included 31 children with severe CHIs, 38 with moderate CHIs, and 53 with orthopedic injuries (OIs). Children and their families were assessed shortly after injury and at 6- and 12-month follow-ups. Parents rated 15 symptoms classified as either cognitive/somatic (C/S) or emotional/behavioral (E/B).

RESULTS

Both kinds of symptoms were more common in the CHI groups than in the OI group. C/S symptoms declined in the CHI groups over time, whereas E/B symptoms became relatively more common. Measures of injury severity, children's premorbid behavioral adjustment, and concurrent cognitive functioning predicted C/S symptoms. E/B symptoms were predicted by injury severity, concurrent cognitive functioning soon after the injury, and concurrent parent and family functioning later in time. Both types of symptoms contributed to the prediction of perceived family burden, with the relationships strengthening over time.

CONCLUSIONS

The findings indicate that the prevalence and correlates of neurobehavioral symptoms in childhood CHIs vary as a function of symptom type and time since injury.

Assessment of adult stereopsis using the Lang 1 Stereotest: a pilot study

BACKGROUND AND PURPOSE

To assess the use of the Lang 1 Stereotest as a vision-screening test for adults, for which little is known or reported.

METHOD

The Lang 1 Stereotest was administered to 292 consecutive participants of the Visual Impairment Project (VIP) five year followup study, which is a population based study of eye disease in Melbourne, Australia. 56.9% were female. The mean age was 59.4 years, range 44-90 years. A "positive" stereoscopic response was recorded where the stereoscopic target image was correctly named; a "partial positive" response where depth was appreciated but the shape could not be named; and a "negative" response where there was no appreciation of a stereo effect. The responses were further categorized so that the test was either "passed" or "failed". A "pass" score was 3/3 positive responses; 3/3 partial positive responses or 2/3 positive and/or partial positive responses where the negative response was at the 550" of arc stereoacuity level. "Failure" was 3/3 negative responses and 2/3 negative responses where the positive or partial positive response as at the 1200" level.

RESULTS

Of the 292 participants tested, 19 (6.5%) participants "failed" the test. In addition to strabismus and anisometropia, failure was associated significantly (p<0.001) with reduced distance visual acuity (<6/12) irrespective of the ocular morbidity.

CONCLUSION

The Lang 1 Stereotest correctly identified people with vision defects associated with reduced stereopsis. This suggests the Lang 1 Stereotest is an appropriate for the vision screening of adults as it is for children.

Cataract blindness--challenges for the 21st century

Cataract prevalence increases with age. As the world's population ages, cataract-induced visual dysfunction and blindness is on the increase. This is a significant global problem. The challenges are to prevent or delay cataract formation, and treat that which does occur. Genetic and environmental factors contribute to cataract formation. However, reducing ocular exposure to UV-B radiation and stopping smoking are the only interventions that can reduce factors that affect the risk of cataract. The cure for cataract is surgery, but this is not equally available to all, and the surgery which is available does not produce equal outcomes. Readily available surgical services capable of delivering good vision rehabilitation must be acceptable and accessible to all in need, no matter what their circumstances. To establish and sustain these services requires comprehensive strategies that go beyond a narrow focus on surgical technique. There must be changes in government priorities, population education, and an integrated approach to surgical and management training. This approach must include supply of start-up capital equipment, establishment of surgical audit, resupply of consumables, and cost-recovery mechanisms. Considerable innovation is required. Nowhere is this more evident than in the pursuit of secure funding for ongoing services.

An inter-disciplinary approach to swallowing problems in acute stroke

Many speech and language therapy (SLT) departments are in danger of being swamped with dysphagia referrals, often to the detriment of other work. At the same time surveys have shown that large numbers of patients with acute stroke have swallowing problems which are poorly managed during the critical early phase, not referred or missed altogether. The Collaborative Dysphagia Audit (CODA) study, carried out in six British hospitals, showed that nurses could quickly be trained to carry out basic screening assessments for dysphagia and that implementation of a co-ordinated inter-disciplinary dysphagia management policy (DMP) could substantially improve the proportion of dysphagic patients in whom appropriate feeding precautions were taken. These early DMPs were limited by the need for ward staff to keep all patients with suspected swallowing impairment nil by mouth until assessed by SLT, so in some acute stroke units nurses have been trained to a higher level which allows them to manage most routine transient swallowing problems, leaving only complex or persistent cases for referral to SLT. This approach has been used successfully in our unit in Gateshead, where a dysphagia nurse specialist post has been set up to act as a link between ward staff and SLTs, to ensure that the necessary training levels are maintained and to co-ordinate the DMP.

Increased incidence of corneal perforation after topical fluoroquinolone treatment for microbial keratitis

PURPOSE

To compare the incidence of corneal perforation in eyes treated with topical fluoroquinolone or fortified antibiotics for microbial keratitis.

METHODS

A retrospective medical record review of patients hospitalized for bacterial keratitis from January 1991 through November 1999.

RESULTS

Two hundred seventy-seven cases of bacterial keratitis were identified. The incidence of corneal perforations was significantly higher in fluoroquinolone-treated eyes (18 out of 142, 12.7%) compared with eyes treated with fortified antibiotics (1 out of 135, 0.7%) (chi-square = 13.6, degrees of freedom (df) = 2, P <.001). Within the fluoroquinolone-treated group, all corneal perforations occurred in those eyes treated with ofloxacin (18 out of 125, 14.4%). Corneal perforations that occurred in the ofloxacin-treated eyes were not associated with any particular microbial isolate.

CONCLUSION

Our data suggest an increased risk of corneal perforation after fluoroquinolone treatment for bacterial keratitis compared with treatment with fortified antibiotics. Further studies are warranted to verify this association and establish possible mechanisms by which topical fluoroquinolones may alter corneal collagen or keratocyte function.

Fat distribution and cardiovascular disease risk in African-American women

We have previously shown that in Caucasian men and women fat in the trunk, and especially visceral fat, was related to cardiovascular disease (CVD) risk even after adjusting for fat in other depots. We also found that leg fat was negatively related to CVD. In order to determine if these relationships also exist in African-American women, blood lipids, insulin, and blood pressure in 26 pre-menopausal African-American women were evaluated. In addition, magnetic resonance imaging measured fat distribution was evaluated from the lateral malleolus to top of the shoulder. Percent fat was related to VLDL cholesterol, VLDL3 cholesterol, triglycerides, insulin, and diastolic blood pressure. Inclusion of visceral and trunk fat together in multiple regression did little to improve the relationship with CVD risk. Leg fat, however, tended to be negatively related to CVD risk after adjusting for trunk fat and visceral fat. Partial correlations indicated that leg fat was negatively related to VLDL cholesterol (r = -0.36), triglycerides (r = -0.36), insulin (r = -0.46), and diastolic blood pressure (r = -0.43). These results indicate that in African-American women, visceral fat may be less atherogenic than in Caucasian men and women since it was poorly related to CVD risk after adjusting for fat in the trunk. In addition, consistent with results from Caucasians, leg fat is inversely related to CVD risk after adjusting for fat in other parts of the body. Caution must be made in the interpretation of correlational data. Further research is warranted to explore these intriguing relationships.

Delayed conception and active and passive smoking. The Avon Longitudinal Study of Pregnancy and Childhood Study Team

OBJECTIVE

To determine whether passive as well as active smoking by women or smoking by men is associated with delayed conception, after adjustment for confounding factors.

DESIGN

Population study of couples expecting a baby. Logistic regression was performed to identify factors associated with delayed conception.

SETTING

The Avon Health Authority area, United Kingdom.

PATIENT(S)

All couples expected to deliver between April 1991 and December 1992.

INTERVENTION(S)

Questionnaires administered early in pregnancy.

MAIN OUTCOME MEASURE(S)

Time taken to conceive, categorized as <6 months, 6-11 months, 1-3 years, and >3 years.

RESULT(S)

After correction for confounding factors, delayed conception was statistically significantly associated with both active smoking by the woman (odds ratio [OR] 1.23 [95% CI 0.98-1.49] for > 6 months and 1.54 [95% CI 1.19-2.01] for >12 months) and her exposure to passive smoking (OR 1.17 [95% CI 1.02-1.37] and 1.14 [95% CI 0.92-1.42]) compared with women with no exposure to tobacco smoke (referent). Heavy smoking by men was independently associated with delayed conception. In active smokers, the effect increased with the number of cigarettes.

CONCLUSION(S)

Smoking by men and passive and active smoking by women are associated with delayed conception.

Schistosoma mansoni gene GP22 encodes the tegumental antigen sm25: (1) antibodies to a predicted B-cell epitope of Sm25 cross-react with other candidate vaccine worm antigens; (2) characterization of a recombinant product containing tandem-repeats of this peptide as a vaccine

Monospecific antibodies against two putative epitopes of schistosome protein encoded by gene GP22 (182 codons, no introns) were used to probe worm extracts fractionated by lentil-lectin affinity chromatography or by electrophoresis. Anti-peptide-alpha (codons 70-84) exclusively identifies the N-glycanase-sensitive, 25 kDa tegumental glycoprotein Sm25 in the lectin-bound fraction of detergent-solubilized adult worm extract S3. In contrast, antipeptide-delta (codons 151-162) does not react with Sm25 but cross-reacts with other schistosome proteins, including candidate vaccine antigens paramyosin (Sm97) and glutathione-S-transferases (Sm26, Sm28, Sj26). Recombinant protein r4 x 47, constructed to express multiple copies of codon sequence 117-163 (containing delta), reacts with anti-delta and is uniquely recognized by protective Fischer twice-infected (F-2x) rat antiserum. Immunization with r4 x 47 induces antibodies with cross reactivities similar to anti-delta, but which also recognize Sm25. Despite these cross-reactivities with protective antigens, rodents vaccinated with r4 x 47 were not protected against cercarial infection. On the basis of these data, two hypotheses are proposed: (1) antigenic epitopes other than delta are present within the r4 x 47 sequence which induce antibodies reactive with Sm25 and/or (2) peptide-delta assumes alternative antigenic conformations, dependent upon the context of neighbouring sequences, some of which mimic epitopes of proteins encoded by other schistosome genes. These mimotopes are not targets of protective antibodies.

Increasing paternal age is associated with delayed conception in a large population of fertile couples: evidence for declining fecundity in older men. The ALSPAC Study Team (Avon Longitudinal Study of Pregnancy and Childhood)

The impact of male age on fecundity remains controversial. Here, a large population study was used to investigate the effect of paternal age on time to conception. All couples in the Avon Health district expecting a baby between 1 April 1991 and 31 December 1992 were eligible. Questionnaires completed by both the man and the woman at 18 weeks gestation covered specific fertility factors, e.g. parity, paternity, cohabitation and oral contraception; and non-specific factors, e.g. educational achievement, housing, cigarette smoking, alcohol consumption, obesity. Logistic regression was used to identify factors independently related to conception in < or =6 or < or =12 months. Of 8515 planned pregnancies, 74% were conceived in < or =6 months, 14% in the second 6 months and 12% after more than a year. Nine variables, including the age of the woman, were independently related to time to conception. After adjustment for these, the likelihood of conception within 6 or 12 months was lower in older men. Compared to men <25 years old, the adjusted odds ratios (95% confidence interval) for conception in < or =12 months were 0.62 (0.40, 0.98), 0.50 (0.31, 0.81) and 0.51 (0.31, 0.86) in men aged 30-34, 35-39 and > or =40 years respectively.

Management of anaemia in United Kingdom renal units: a report from the UK Renal Registry

BACKGROUND

Morbidity and mortality of patients undergoing renal replacement therapy is influenced by the adequacy of correction of renal anaemia. The Renal Association has set standards for attainment of a target haemoglobin of 10 g/dl. This study compared the management of anaemia in dialysis patients in nine renal units in the UK.

METHODS

A cross-sectional analysis was carried out on data submitted electronically to the UK Renal Registry. There were 1449 haemodialysis patients and 741 peritoneal dialysis patients in the nine renal centres analysed. Individual patient data were collected on haemoglobin, ferritin, erythropoietin prescription, and pre- and post-dialysis urea concentrations.

RESULTS

None of the centres achieved the standard of more than 80% of haemodialysis patients with a haemoglobin of greater than 10 g/dl. Three centres achieved this standard for peritoneal dialysis. There was wide variation between centres in the percentage reaching the target. Differences in ferritin, erythropoietin prescription, and dialysis doses between centres could not entirely explain the variations between centres. Females had lower haemoglobin than males despite a greater proportion being treated with erythropoietin. There was a trend of increasing haemoglobin concentration during the study period in haemodialysis but not in peritoneal dialysis patients.

CONCLUSIONS

The Renal Association standards for management of anaemia are not being met. The data allow renal centres to compare their practices with others to identify areas that might be improved. Further analysis may allow a benchmark to be determined of what it is possible to achieve by best practice.

Epidemiology and ecology of enterococci, with special reference to antibiotic resistant strains, in animals, humans and the environment. Example of an ongoing project within the European research programme

The objectives of the present study are to generate knowledge of the ecology and epidemiology of enterococci in the food chain by studying the following: (1) the population structure (in measures of abundance, number of vancomycin resistant strains, antibiotic resistance patterns, diversity, and stability) among enterococcal populations in different geographical regions and in different links of the food chain (2) possible transmission of strains through the food chain and between hospital environments and the food chain (3) the association between vancomycin resistance and individual strains of enterococci and (4) the diversity of the drug resistance genes in enterococci. So far, 1578 samples have been collected from different countries within the EU (Sweden, Denmark, UK and Spain), and from different habitats (pig farms, carcasses in slaughter houses, soil, manure, water, sewage, and humans). Total and vancomycin resistant enterococcal populations in each sample have been enumerated and more than 12000 isolates have been characterised by phenotyping. Representative isolates are further species identified and characterised by genotyping and MIC determination and from antibiotic resistant isolates the resistance genes are characterised.

Managing hypertension in the southeastern United States: applying the guidelines from the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI)

The southeastern United States has the highest occurrence of heart disease and stroke and among the highest rates of congestive heart failure and renal failure in the country. The Consortium for Southeastern Hypertension Control (COSEHC) is cooperating with other organizations in implementing initiatives to reduce morbidity and mortality from hypertension-related conditions in the southeastern United States. This article outlines for clinicians special consideration for implementation of the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) in the southeastern United States. Clinicians are encouraged to adapt the recommendations of JNC VI to their own patient groups, paying attention to these specific areas: (1) Ensure screening for hypertension in your practice and community. (2) Evaluate all patients for accompanying risk factors and target organ damage. (3) Promote lifestyle management for individual patients and populations for prevention and treatment of hypertension. (4) Set a goal blood pressure for each patient, and monitor progress toward that goal. (5) Recognize that many patients will be candidates for blood pressure goals of <130/85 mm Hg. (6) Pay attention to compelling and special indications such as diabetes, congestive heart failure, and renal dysfunction. (7) Consider combination therapy. (8) Maximize staff contributions to enhance patient adherence. (9) Encourage patient, family, and community activities to promote healthy lifestyles and blood pressure control.

The sleep of older people in hospital and nursing homes

Disturbed sleep can affect personal wellbeing and impede the rehabilitation and recovery of older people from illness. This paper reports the findings of a pilot study which included examination of sleep quality and sleep patterns of older people in community hospital and nursing home settings. A marked proportion of older people reported sleeping well in nursing care settings, and those in nursing homes slept better than those in the community hospital. The main causes of sleep disturbance in both settings were: needing to go to the toilet, noise, pain, and discomfort; a similar pattern was seen across the different settings. No discernible difference was found in quality of sleep and whether patients felt rested or not between those patients on hypnotic medication and those who were not. The implications of the findings for practice and future research are discussed.

Phytoestrogens alter hypothalamic calbindin-D28k levels during prenatal development

Calbindin-D28K (CALB) in the medial basal hypothalamic (MBH) and preoptic area (POA) of male and female fetuses from pregnant rats fed different phytoestrogens diets during gestation was examined by Western analysis. In animals fed a phytoestrogen containing diet (Phyto-200), males displayed significantly higher CALB levels compared to females. Whereas, in animals fed a phytoestrogen-free diet (Phyto-free), females exhibited significantly higher CALB levels compared to Phyto-200 female values. The present data have far reaching implications where phytoestrogen content in diets apparently influence MBH-POA CALB levels prenatally. The altered CALB levels may in turn modify sexually dimorphic brain structures during neuronal development by buffering Ca2+ that is associated with programmed cell death.