Evaluation of arterial compliance in patients with carotid arterial atherosclerosis

BACKGROUND

High-resolution peripheral vascular sonography has the capability to determine vessel compliance. A number of factors affect compliance in humans, including age, hypertension and atherosclerosis. However, compliance in patients with coronary artery disease (CAD) combined with carotid artery lesions has not been well studied. The objectives of this study were: 1) to determine whether carotid artery compliance is reduced in patients with CAD and carotid artery lesions, and 2) to determine whether decreased arterial compliance is related to an abnormality in vascular wall structure.

METHODS

The study participants included 12 patients with CAD and carotid artery disease (group III), 13 patients with CAD only (group II) and 13 age-matched normal subjects who served as controls (group I). High-resolution peripheral vascular ultrasonography was performed to directly visualize the common carotid artery and to measure its diameter and wall thickness. Carotid artery elastic properties were determined relative to arterial diameter and pressure generated within the heart.

RESULTS

Carotid artery walls were thicker in Group II and III patients than in normal subjects (1.49 +/- 0.03 mm, 1.98 +/- 0.04 mm, vs 1.22 +/- 0.03 mm, p < 0.05 and p < 0.01). There were significant differences in wall thickness between subgroups of CAD patients (p < 0.01). Carotid distensibility was lower (21.8 +/- 1.2 x 10(-6).N-1.m2, 14.8 +/- 1.7 x 10(-6).N-1.m2, vs 25.6 +/- 1.5 x 10(-6).N-1.m2; p < 0.05 and p < 0.01) and Young's modulus of elasticity was higher (3.12 +/- 0.43 x 10(5).Nm-2, 4.18 +/- 0.30 x 10(5).Nm-2, vs 2.34 +/- 0.23 x 10(5).Nm-2; p < 0.05 and p < 0.01) in group II and III patients than in normal subjects. These two indices of carotid artery compliance also differed between subgroups of CAD (p < 0.01). Increased wall thickness may occur secondary to changes in the architectural structure of the vessel wall, and these atherosclerotic changes lead to decreased compliance of arteries.

CONCLUSION

The mechanical properties of the carotid arteries provide reliable information regarding changes caused by atherosclerosis.

Systemic correction of the muscle disorder glycogen storage disease type II after hepatic targeting of a modified adenovirus vector encoding human acid-alpha-glucosidase

This report demonstrates that a single intravenous administration of a gene therapy vector can potentially result in the correction of all affected muscles in a mouse model of a human genetic muscle disease. These results were achieved by capitalizing both on the positive attributes of modified adenovirus-based vectoring systems and receptor-mediated lysosomal targeting of enzymes. The muscle disease treated, glycogen storage disease type II, is a lysosomal storage disorder that manifests as a progressive myopathy, secondary to massive glycogen accumulations in the skeletal and/or cardiac muscles of affected individuals. We demonstrated that a single intravenous administration of a modified Ad vector encoding human acid alpha-glucosidase (GAA) resulted in efficient hepatic transduction and secretion of high levels of the precursor GAA proenzyme into the plasma of treated animals. Subsequently, systemic distribution and uptake of the proenzyme into the skeletal and cardiac muscles of the GAA-knockout mouse was confirmed. As a result, systemic decreases (and correction) of the glycogen accumulations in a variety of muscle tissues was demonstrated. This model can potentially be expanded to include the treatment of other lysosomal enzyme disorders. Lessons learned from systemic genetic therapy of muscle disorders also should have implications for other muscle diseases, such as the muscular dystrophies.

Seborrheic keratosis of conjunctiva simulating a malignant melanoma: an immunocytochemical study with impression cytology

OBJECTIVE

Seborrheic keratosis on the conjunctiva appears to have never been reported in the literature. The authors report here a well-documented case of seborrheic keratosis of conjunctiva clinically simulating a malignant melanoma.

DESIGN

Case report.

METHODS

A 66-year-old man presented with a juxtalimbal pigmented tumor involving the temporal conjunctiva of his left eye. Because of the rapid enlargement of the mass within a period of 5 months, a clinical diagnosis of malignant melanoma was made. Cytopathologic examinations were performed by impression cytology before the patient underwent a wide en-block excision of the tumor.

MAIN OUTCOME MEASURES

Cytologic features were studied by impression cytology with periodic acid-Schiff-Papanicolaou stain. Immunochemical characteristics of tumor cells were studied by immunochemical stain of cytokeratin and HMB-45. Tumor morphology was observed by histopathologic examination.

RESULTS

Impression cytology disclosed basaloid cells intermixing with squamoid cells, and these cells demonstrated positive immunoreactivity to cytokeratin and no reactivity to HMB-45. Histopathologic examination of the tumor specimen established the diagnosis of seborrheic keratosis, and the results of immunohistochemical staining were consistent with those of the impression cytology with immunocytochemical staining.

CONCLUSION

The authors describe the first case report of conjunctival seborrheic keratosis and present its immunocytochemical and immunohistochemical characteristics. Such a benign lesion can clinically mimic a malignant melanoma.

Gender differences in relation to leptin concentration and insulin sensitivity in nondiabetic Chinese subjects

OBJECTIVE

To investigate the relationship between fasting plasma leptin concentrations and insulin resistance in Chinese men and women.

DESIGN

Cross-sectional study design.

SUBJECTS

Ninety-six nondiabetic Chinese (51 men and 45 women) with body mass index (BMI) between 18.4-35.8 kg/m2 were studied.

MEASUREMENTS

Plasma glucose and insulin concentrations were measured every 30 min for 2 h after a 75 g oral glucose load. The degree of insulin resistance was assessed using a modified insulin suppression test. Plasma leptin values were determined by radioimmunoassay.

RESULTS

Fasting plasma glucose, glucose areas, fasting insulin, insulin areas, most of the lipoprotein concentrations and steady state plasma glucose (SSPG) concentrations were relatively similar between men and women. Despite the fact that men had higher BMI values (26.1 +/- 0.5 vs 24.7 +/- 0.5 kg/m2, P < 0.05), fasting plasma leptin concentrations were significantly lower in men than in women (4.9 +/- 0.5 vs 9.0 +/- 0.8 ng/ml, P < 0.001). Fasting leptin values were positively related to SSPG concentrations by simple correlation analysis in both sexes. However, this relationship persisted in men (r = 0.513, P < 0.01) but not in women (r = 0.119, P = NS) after adjustment for BMI. Multiple regression analysis showed that SSPG concentrations, BMI, glucose and insulin responses together accounted for 62.5% and 52.2% of the variation in plasma leptin concentrations in Chinese men and women respectively.

CONCLUSION

Fasting plasma leptin concentrations were lower in Chinese men than in Chinese women despite the higher BMI observed in men. After adjustment for BMI, plasma leptin values correlated with the degree of insulin resistance in men but not in women.

Comparing AMI mortality among hospitals in patients 65 years of age and older: evaluating methods of risk adjustment

BACKGROUND

Interest in the reporting of risk-adjusted outcomes for patients with acute myocardial infarction is growing. A useful risk-adjustment model must balance parsimony and ease of data collection with predictive ability.

METHODS AND RESULTS

From our analysis of 82 359 patients >/=65 years of age admitted with acute myocardial infarction to 2401 hospitals, we derived a parsimonious model that predicts 30-day mortality. The model was validated on a similar group of 78 699 patients from 2386 hospitals. Of the 73 candidate predictor variables examined, 7 variables describing patient characteristics on arrival were selected for inclusion in the final model: age, cardiac arrest, anterior or lateral location of myocardial infarction, systolic blood pressure, white blood cell count, serum creatinine, and congestive heart failure. The area under the receiver-operating characteristic curve for the final model was 0.77 in the derivation cohort and 0.77 in the validation cohort. The rankings of hospitals by performance (in deciles) with this model were most similar to a comprehensive 27-variable model based on medical chart review and least similar to models based on administrative billing codes.

CONCLUSIONS

A simple 7-variable risk model performs as well as more complex models in comparing hospital outcomes for acute myocardial infarction. Although there is a continuing need to improve methods of risk adjustment, our results provide a basis for hospitals to develop a simple approach to compare outcomes.

Quality of care for patients hospitalized with heart failure at academic medical centers

BACKGROUND

The purpose of this study was to determine the standard of care provided by academic medical centers for the management of congestive heart failure (CHF).

METHODS AND RESULTS

The standard of care was estimated by assessing adherence to the treatment guidelines published by the US Agency for Health Care Policy and Research among 522 patients hospitalized at 7 university hospitals with a diagnosis of CHF. Data were abstracted by retrospective chart review. Of the 522 patients analyzed, 435 (83%) had a left ventricular ejection fraction (LVEF) measured or documented. Among these patients, 192 were considered "ideal" candidates for angiotensin-converting enzyme (ACE) inhibitor therapy (ie, with systolic dysfunction [LVEF <40%] and no contraindications to ACE inhibitors). In this cohort of "ideal" candidates, 138 (72%) were receiving ACE inhibitors at hospital discharge, including 60 (44%) who were prescribed doses recommended in large clinical trials. Compliance with patient education guidelines was assessed in all 487 patients who were alive at the time of discharge. Of these patients, 365 (75%) received dietary counseling, 404 (83%) were educated about exercise, 54 (11%) were instructed to follow daily weights, and 468 (96%) were counseled regarding medication compliance. Among the 87 smokers who were alive at time of discharge, 8 (9%) had documented advice to quit smoking.

CONCLUSIONS

This study indicates that academic medical centers performed fairly well on the assessment of LVEF, the prescription of ACE inhibitors at discharge, and on education regarding diet, exercise, and compliance with medications. However, the results suggest opportunities for improvement in ACE inhibitor dosing and patient education regarding the importance of monitoring daily weights and smoking cessation.

Risk factors for heart failure in the elderly: a prospective community-based study

PURPOSE

The risk factors for the development of heart failure are not clearly defined, particularly for older adults. We undertook the current investigation to examine the associations of traditional cardiovascular risk factors, comorbidity, and psychosocial factors with the risk of heart failure during 10 years of follow-up in a community-based elderly population.

SUBJECTS AND METHODS

We evaluated 1,749 subjects, 65 years of age or older, free of heart failure, myocardial infarction, and angina at baseline, who were participating in the New Haven, Connecticut cohort of the Established Population for Epidemiologic Studies of the Elderly program. Cox proportional hazards regression models were used to determine risk ratios (RR) and 95% confidence intervals (CI).

RESULTS

During 13,811 person-years of follow-up, 173 subjects developed incident heart failure, as confirmed by chart review. Five factors were independent predictors of heart failure: male sex (RR = 1.7; CI, 1.3 to 2.4), older age (RR = 1.9; CI, 1.3 to 2.7 for age 75 to 84 years, RR = 3.0; CI, 1.7 to 5.5 for age 85 years and older, compared with < or = 74 years), diabetes (RR = 2.9; CI, 2.0 to 4.3), pulse pressure > or = 70 mm Hg (RR = 2.3; CI, 1.3 to 4.3, compared with <50 mm Hg), and body mass index > or = 28 kg/m2 (RR = 1.6; CI, 1.0 to 2.4, compared with <24 kg/ m2). Myocardial infarction occurred during follow-up in 8% of the cohort and was also an important predictor of heart failure (RR = 21; CI, 15 to 31).

CONCLUSIONS

Age and traditional cardiovascular risk factors are associated with the development of heart failure in the elderly. Preventive strategies should focus on the management of diabetes, blood pressure, and weight, in addition to the prevention and management of myocardial infarction.

Variations in and correlates of length of stay in academic hospitals among patients with heart failure resulting from systolic dysfunction

OBJECTIVE

Given the high cost of caring for patients with congestive heart failure, there are strong incentives to decrease hospital costs by shortening length of hospital stay. We sought to identify factors associated with length of stay among patients admitted for the treatment of heart failure resulting from systolic dysfunction.

STUDY DESIGN

Retrospective cohort study.

METHODS

We examined data from patients with a principal discharge diagnosis of congestive heart failure who had been admitted to 1 of the 49 academic hospitals across the United States that participated in the CHF Benchmark Project, a large collaborative quality improvement project coordinated by the University HealthSystem Consortium. Patients were discharged between January 1 and June 30, 1996. We obtained patient characteristics and hospitalization data by retrospectively reviewing medical records. We used linear regression models to identify major determinants of length of stay.

RESULTS

Among the 1046 patients eligible for the study, 59% were women, 55% were white, and 58% were aged 65 years or older. Adjusting for patient demographic and admission clinical characteristics, the mean length of stay was 4.9 +/- 0.9 days. Length of stay varied significantly among hospitals, even after adjusting for differences in patient characteristics. In multivariate regression models, factors that were independently associated with a significantly longer length of stay were prior renal failure, peripheral edema, atrial fibrillation, hyponatremia, urinary catheter on admission, initiation of an antiarrhythmic or warfarin, and major complications. Patient characteristics and hospital events combined explained 16% of the variation in the length of stay. Adjusting for the individual hospitals explained an additional 10% of the variation in the length of stay.

CONCLUSIONS

Although a number of patient and hospitalization factors were associated with length of stay in patients with congestive heart failure resulting from systolic dysfunction, much unexplained variation remained. Clinical factors alone explained about 50% more variation than did factors specific to the individual hospitals.

Lack of association between genetic variation in the beta3-adrenergic receptor gene and insulin resistance in patients with coronary heart disease

The beta-adrenergic system plays a critical role in regulating lipolysis and thermogenesis. Recent studies have suggested that a missense Trp64Arg mutation in the beta3-adrenergic receptor gene is involved in visceral obesity and insulin resistance. We investigated the effect of this mutation on insulin resistance in patients with angiographically documented coronary heart disease ([CHD]n = 137) and normal subjects (n = 188). Plasma glucose and insulin responses to a 75-g oral glucose tolerance test and insulin resistance measured by the insulin suppression test, were determined in 58 (42%) patients with CHD and 121 (64%) controls. The genotype and allele frequency of the beta3-adrenergic receptor did not differ between patients with CHD and controls. The blood pressure, body mass index (BMI), waist to hip ratio, fasting plasma glucose, insulin, and lipid, and plasma glucose and insulin responses to the glucose load were relatively similar in subjects with and without the mutation in CHD and normal groups. The degree of insulin sensitivity, ie, the steady-state plasma glucose concentration, was not significantly different between subjects with and without the mutation in the CHD group (11.3 +/- 1.2, n = 11 v 11.9 +/- 0.6 mmol/L, n = 47, P = NS) and control group (8.4 +/- 0.7, n = 30 v 8.2 +/- 0.4 mmol/L, n = 91, P = NS). We conclude that Trp64Arg polymorphism of the beta3-adrenergic receptor gene does not likely play a major role in the development of CHD in the Chinese population. In addition, it appears to have no association with the insulin resistance syndrome in either CHD or non-CHD subjects.

Expression of melanocyte-associated markers gp-100 and Melan-A/MART-1 in angiomyolipomas. An immunohistochemical and rt-PCR analysis

Angiomyolipomas are tumours of uncertain histogenesis, most often occurring in association with the kidney. A characteristic finding is their reactivity with HMB-45, a monoclonal antibody to the melanocyte-associated antigen gp-100. We tested 18 angiomyolipomas for their reactivity with A103, a monoclonal antibody to Melan-A (MART-1), another melanocyte-associated marker, and compared it with HMB-45. All cases were positive with both antibodies, yet most cases showed a more homogeneous staining pattern with A103. Normal kidney was immunohistochemically negative for both antibodies. We also performed RT-PCR assays for gp-100 and Melan-A in 4 of the 18 angiomyolipoma samples and in three normal kidney samples. All 4 angiomyolipoma specimens revealed mRNA for both melanocyte differentiation markers. gp-100 mRNA was found in the samples of normal kidney, but Melan-A mRNA was not. Our study shows that angiomyolipomas express the melanocyte-associated antigens Melan-A and gp-100 at the protein and at the mRNA level, suggesting a true expression of these antigens rather than cross-reacting epitopes. Based on the mRNA expression pattern, immunohistochemical analysis is the preferred method for the detection of gp-100, while Melan-A can be used at the protein and mRNA levels. Our study demonstrates that A103 is a useful marker for the diagnosis of angiomyolipomas.

Isoforms of the human PDZ-73 protein exhibit differential tissue expression

Patients with renal and colon cancer frequently develop IgG autoantibodies toward the NY-CO-38/PDZ-73 antigen, a protein of 652 amino acids (73 kDa) which contains three copies of the PDZ protein-protein interaction domain. The gene encoding PDZ-73 mapped to chromosome 11p15.4-p15.1. Additional tissue-specific isoforms were identified: PDZ-45, which lacks the third PDZ domain and the putative PEST protein degradation motif, is expressed in kidney, colon, small intestine, brain and testis; PDZ-54 and PDZ-59, which also lack the third PDZ domains, have unique carboxyl terminal amino acids and are expressed in brain, kidney, bladder, colon cancer and renal cancer; and a putative PDZ-37 isoform, containing only the third PDZ domain, that is expressed in the central nervous system. Immunohistochemical staining with anti-PDZ 73 monoclonal antibodies showed strong cytoplasmic reactivity in epithelial cells of the small intestine, colon and kidney tubules, with a prominent apical staining pattern in cells of the small intestine. The reactivity pattern of the antibodies with various tissues correlated with the mRNA expression pattern of the PDZ-45 isoform. The existence of multiple PDZ-73 isoforms with variations in tissue distribution, PDZ domains, protein degradation sequences and carboxyl terminal structure indicate that these isoforms have distinct tissue-specific functions.

Coupling assembly of the E-cadherin/beta-catenin complex to efficient endoplasmic reticulum exit and basal-lateral membrane targeting of E-cadherin in polarized MDCK cells

The E-cadherin/catenin complex regulates Ca++-dependent cell-cell adhesion and is localized to the basal-lateral membrane of polarized epithelial cells. Little is known about mechanisms of complex assembly or intracellular trafficking, or how these processes might ultimately regulate adhesion functions of the complex at the cell surface. The cytoplasmic domain of E-cadherin contains two putative basal-lateral sorting motifs, which are homologous to sorting signals in the low density lipoprotein receptor, but an alanine scan across tyrosine residues in these motifs did not affect the fidelity of newly synthesized E-cadherin delivery to the basal-lateral membrane of MDCK cells. Nevertheless, sorting signals are located in the cytoplasmic domain since a chimeric protein (GP2CAD1), comprising the extracellular domain of GP2 (an apical membrane protein) and the transmembrane and cytoplasmic domains of E-cadherin, was efficiently and specifically delivered to the basal-lateral membrane. Systematic deletion and recombination of specific regions of the cytoplasmic domain of GP2CAD1 resulted in delivery of <10% of these newly synthesized proteins to both apical and basal-lateral membrane domains. Significantly, >90% of each mutant protein was retained in the ER. None of these mutants formed a strong interaction with beta-catenin, which normally occurs shortly after E-cadherin synthesis. In addition, a simple deletion mutation of E-cadherin that lacks beta-catenin binding is also localized intracellularly. Thus, beta-catenin binding to the whole cytoplasmic domain of E-cadherin correlates with efficient and targeted delivery of E-cadherin to the lateral plasma membrane. In this capacity, we suggest that beta-catenin acts as a chauffeur, to facilitate transport of E-cadherin out of the ER and the plasma membrane.

Cadherin function in junctional complex rearrangement and posttranslational control of cadherin expression

The role of E-cadherin, a calcium-dependent adhesion protein, in organizing and maintaining epithelial junctions was examined in detail by expressing a fusion protein (GP2-Cad1) composed of the extracellular domain of a nonadherent glycoprotein (GP2) and the transmembrane and cytoplasmic domains of E-cadherin. All studies shown were also replicated using an analogous cell line that expresses a mutant cadherin construct (T151) under the control of tet repressor. Mutant cadherin was expressed at approximately 10% of the endogenous E-cadherin level and had no apparent effect on tight junction function or on distributions of adherens junction, tight junction, or desmosomal marker proteins in established Madin-Darby canine kidney cell monolayers. However, GP2-Cad1 accelerated the disassembly of epithelial junctional complexes and delayed their reassembly in calcium switch experiments. Inducing expression of GP2-Cad1 to levels approximately threefold greater than endogenous E-cadherin expression levels in control cells resulted in a decrease in endogenous E-cadherin levels. This was due in part to increased protein turnover, indicating a cellular mechanism for sensing and controlling E-cadherin levels. Cadherin association with catenins is necessary for strong cadherin-mediated cell-cell adhesion. In cells expressing low levels of GP2-Cad1, protein levels and stoichiometry of the endogenous cadherin-catenin complex were unaffected. Thus effects of GP2-Cad1 on epithelial junctional complex assembly and stability were not due to competition with endogenous E-cadherin for catenin binding. Rather, we suggest that GP2-Cad1 interferes with the packing of endogenous cadherin-catenin complexes into higher-order structures in junctional complexes that results in junction destabilization.

Productivity and some properties of immunoglobulin specific against Streptococcus mutans serotype c in chicken egg yolk (IgY)

Hens were immunized on thighs by using whole cells of Streptococcus mutans MT8148 serotype c strain as antigen through intramuscular (im) and subcutaneous (sc) routes to investigate the difference of immunization reactions and the changes in yolk antibody activities against antigen after initial immunization. Several properties of crude IgY were examined to evaluate the stability during food processing. Results showed that the specificity of IgY of im treated hens was nearly 10 times as high as those of sc treated antibody. IgY from the hens immunized with the serotype c strain showed significant cross-reactions against serotypes e and f, while minor reactions against serotypes a, b, d, and g were observed. In thermal stability tests, IgY activity in both yolk and crude IgY decreased with the increasing temperature, from 70 to 80 degrees C, but the thermal denaturation rates between those two samples were not significantly different. The addition of high levels sucrose, maltose, glycerol, or 2% glycine displayed effective protection against thermal denaturation of IgY. Lyophilized yolk-5% gum arabic powder showed better stability against proteases.

A prognostic rule for elderly patients admitted with community-acquired pneumonia

PURPOSE

We sought to identify admission characteristics predicting mortality in elderly patients hospitalized with community-acquired pneumonia and to develop a prognostic staging system and discriminant rule.

PATIENTS AND METHODS

We retrospectively analyzed data from 2,356 patients aged > or = 65 years admitted with community-acquired pneumonia. Multivariable analyses of a derivation cohort (n = 1,000) identified characteristics associated with hospital mortality. A staging system and discriminant rule based on these characteristics were tested in a validation cohort (n = 1,356). Our discriminant rule was compared with a rule formulated from a heterogeneous adult population with community-acquired pneumonia.

RESULTS

Hospital mortality rates were 9% (derivation cohort) and 12% (validation cohort). We identified five independent predictors of mortality: age > or = 85 years [odds ratio 1.8 (95% confidence interval 1.1-3.1)], comorbid disease [odds ratio 4.1 (2.1-8.1)], impaired motor response [odds ratio 2.3 (1.4-3.7)], vital sign abnormality [odds ratio 3.4 (2.1-5.4)], and creatinine level > or = 1.5 mg/dL [odds ratio 2.5 (1.5-4.2)]. These variables stratified patients into four distinct stages with increasing mortality in the derivation cohort (Stage 1, 2%; Stage 2, 7%; Stage 3, 22%; Stage 4, 45%; P = 0.001) as well as in the validation cohort (Stage 1, 4%; Stage 2, 11%; Stage 3, 23%; Stage 4, 41%; P = 0.001). The discriminant rule developed from the derivation cohort had greater overall accuracy (77.1%) in the validation cohort than a rule formulated from a heterogeneous adult population (68.0%, P = 0.001).

CONCLUSION

Elderly patients with community-acquired pneumonia have characteristics at admission that can predict mortality. Our staging system and discriminant rule improve prognostic stratification of these patients.

Improving cephalogram analysis through feature subimage extraction

An MLP with a GA was proposed to extract feature subimages containing orthodontic landmarks. Simulated images and cephalograms were used to investigate its performance in comparison with the cross-correlation method. From the results of simulated image containing shapes with different geometrical conditions, it was shown that the fault tolerance of the MLP for rotation, scaling, brightness variety, and other anomalous deformations is good enough to overcome the clinical application problems. It was also shown that the stability, accuracy, and speed of this proposed algorithm are very promising. Moreover, the performance of the MLP can be significantly improved by collecting, more "representative" false patterns. The GA is a good approach to speed up the process of feature subimage extraction based on the fitness evaluated using the MLP.

Trends in costs of percutaneous transluminal coronary angioplasty

OBJECTIVE

To evaluate recent trends in the cost of percutaneous transluminal coronary angioplasty (PTCA), particularly the impact of newer technology and changing patient profile.

STUDY DESIGN

Retrospective study with a 6-month follow up.

PATIENTS AND METHODS

We compared the data on two groups of 100 consecutive patients admitted for elective PTCA at Yale-New Haven Hospital in 1995 and 1996. Hospital records, cineangiograms, and hospital cost accounting system were reviewed, and 6-month clinical outcomes were obtained from telephone interviews and medical chart review.

RESULTS

Demographic and clinical characteristics did not differ between the 1995 and 1996 groups of patients, nor was a difference detected in in-hospital and 6-month clinical outcomes between 1995 and 1996. Angiographic features of treated lesions were different between the two groups, with a significantly higher frequency of type C and totally occluded lesions in 1996 (p = 0.002 and p = 0.04, respectively). The total hospital costs were higher in 1996 compared with 1995 ($11,799 +/- $6189 vs $10,087 +/- $5608; p = 0.04). This difference persisted after adjustment for changes in patient population. The major factor responsible for escalating costs was a 45% increase in catheterization laboratory costs ($8575 +/- $4524 in 1996 vs $5916 +/- $3030 in 1995; P < 0.0001). In contrast, the noncatheterization costs decreased substantially during this period, largely as a result of an approximately 33% decrease in length of stay (3.75 +/- 2.66 days in 1995 vs 2.57 +/- 1.99 days in 1996; P = 0.0005). In a multiple linear regression model, the most important determinants of cost were lesion characteristics, stent use, and radiographic contrast volume.

CONCLUSIONS

Despite cost reduction efforts, the costs of PTCA are rising because of increased consumption of resources in the catheterization laboratory.

Factors related to delayed treatment and posttreatment symptom severity in Taiwanese patients with benign prostatic hyperplasia

We evaluated the sociodemographic and clinical factors of delayed treatment and posttreatment symptom severity in outpatients with benign prostatic hyperplasia (BPH). The study included 146 BPH patients treated at the National Taiwan University Hospital in early 1997. All patients were treated with alpha-adrenergic antagonists or finasteride for at least 2 weeks. A questionnaire based on Andersen's Health Behavior Model was used to assess various sociodemographic features, while the pre- and posttreatment symptoms severity was rated according to the International Prostate Symptom Score (IPSS). Multiple logistic regression was used to assess the associations of these factors with delayed treatment and posttreatment symptom severity. Subjects who had recently quit smoking or were blue-collar workers tended to delay treatment, while those who chose a medical center as the care provider for chronic diseases tended to be less likely to delay treatment. However, none of these associations were statistically significant. No enabling factors (income, insurance) or need factors (symptom scores) evaluated were associated with delayed treatment. Predisposing factors associated with higher posttreatment symptom severity were delayed treatment (over 12 months) (adjusted odds ratio [OR]: 2.67, 95% confidence interval [CI]: 1.16-6.16), quitting smoking (adjusted OR: 4.47, 95% CI: 1.34-14.94), and having never smoked (adjusted OR: 3.73, 95% CI: 1.15-12.11). Subjects with severe pretreatment symptoms were far more likely than subjects with mild pretreatment symptoms to have severe symptoms after treatment (adjusted OR: 52.69, 95% CI: 54.46-621.90). Our findings, though based on a limited number of subjects, suggest sociodemographic factors rather than objective clinical attributes (prostate specific antigen level, prostate volume, and urodynamic results) are associated with delayed treatment in Taiwanese men with BPH. Both pretreatment symptom severity and sociodemographic factors are related to posttreatment symptom severity.