Increasing acceptability and uptake of voluntary male medical circumcision in Zambia: implementing and disseminating an evidence-based intervention

Voluntary medical male circumcision (VMMC) uptake in Africa could prevent 3.4 million HIV infections across a 10 year span. In Zambia, however, ~80 per cent of uncircumcised men report no interest in undergoing VMMC. The Spear & Shield (S&S) intervention has been shown to be more effective than control or observation of only conditions at increasing the number of VMMCs. This study identified predictors of S&S implementation success or failure to create an "early warning" system to enable remedial action during implementation. Participants were n = 48 staff members from 12 community health facilities conducting the S&S program in Lusaka Province, Zambia. Quantitative assessments included demographics, provider attitudes, barriers to research uptake, staff burnout, and organizational readiness. Qualitative interviews were also conducted and quantified for analysis using the Consolidated Framework for Implementation Research (CFIR). Two-thirds (66%) of staff were women with a mean age of 37.67 years (SD = 7.51). Quantitatively, staff performance (p = .033) and decreased levels of staff burnout (p = .025) were associated with S&S implementation success. Qualitatively, constructs such as improved planning, executing, and self-reflection and evaluation were associated with S&S implementation success (p = .005). Identifying these factors facilitated remedial action across health facilities. This study illustrates the utility of the CFIR to guide program decision making in VMMC implementation in the Zambian context. Early identification of challenges to implementation may enable remedial action to enhance the likelihood of program sustainability. Effective monitoring strategies for HIV prevention interventions may thus enhance dissemination, implementation, and sustainability goals to bridge research and practice.

The Role of Artificial Intelligence in Diagnostic Radiology: A Survey at a Single Radiology Residency Training Program

PURPOSE

Advances in artificial intelligence applied to diagnostic radiology are predicted to have a major impact on this medical specialty. With the goal of establishing a baseline upon which to build educational activities on this topic, a survey was conducted among trainees and attending radiologists at a single residency program.

METHODS

An anonymous questionnaire was distributed. Comparisons of categorical data between groups (trainees and attending radiologists) were made using Pearson χ² analysis or an exact analysis when required. Comparisons were made using the Wilcoxon rank sum test when the data were not normally distributed. An α level of 0.05 was used.

RESULTS

The overall response rate was 66% (69 of 104). Thirty-six percent of participants (n = 25) reported not having read a scientific medical article on the topic of artificial intelligence during the past 12 months. Twenty-nine percent of respondents (n = 12) reported using artificial intelligence tools during their daily work. Trainees were more likely to express doubts on whether they would have pursued diagnostic radiology as a career had they known of the potential impact artificial intelligence is predicted to have on the specialty (P = .0254) and were also more likely to plan to learn about the topic (P = .0401).

CONCLUSIONS

Radiologists lack exposure to current scientific medical articles on artificial intelligence. Trainees are concerned by the implications artificial intelligence may have on their jobs and desire to learn about the topic. There is a need to develop educational resources to help radiologists assume an active role in guiding and facilitating the development and implementation of artificial intelligence tools in diagnostic radiology.

Evaluation of an Immunosuppressant Side Effect Instrument

Background

Clinicians continue to be compelled to evaluate the impact of immunosuppressive medication side effects on the quality of life of transplant recipients. We were asked to develop an instrument to measure side effects in immunosuppressed transplant recipients.

Objective

To construct an instrument that measures the impact and severity of side effects of immunosuppressive medications used in transplantation and to assess the reliability and validity of the newly developed instrument called the Memphis Survey.

Design

The instrument was constructed by a panel of physicians, nurses, and pharmacists with experience in treating transplant recipients. A small group of kidney transplant recipients (n=13) provided pilot data for refining and testing the instrument. A national sample of kidney, liver, and heart transplant recipients (n=505) provided data that were used to further develop the instrument.

Analysis

Factor analysis was used to determine the psychological dimensions underlying the instrument and to guide the construction of scales from the survey items. The instrument scales were then computed from the dataset of 505 transplant recipients to quantify the impact of immunosuppressant side effects on the quality of life of transplant recipients.

Results and Conclusion

Analyses showed the final instrument scales to be valid and reliable. Exploratory analysis suggests the need for further testing of the instrument to determine gender differences.

Implementation of Lifestyle Modification Program Focusing on Physical Activity and Dietary Habits in a Large Group, Community-Based Setting

BACKGROUND

Lifestyle modification programs improve several health-related behaviors, including physical activity (PA) and nutrition. However, few of these programs have been expanded to impact a large number of individuals in one setting at one time. Therefore, the purpose of this study was to determine whether a PA- and nutrition-based lifestyle modification program could be effectively conducted using a large group format in a community-based setting.

METHOD

One hundred twenty-one participants enrolled in a 16-week, community-based lifestyle modification program and separated in small teams of 13 to 17 individuals. Height, weight, fruit and vegetable (FAV) consumption, physical fitness, and several psychosocial measures were assessed before and after the program.

RESULTS

Significant improvements in 6-minute walk distance (+68.3 m; p < .001), chair stands (+6.7 repetitions; p < .001), FAV servings (+1.8 servings/day; p < .001), body weight (-3.2 lbs; p < .001), as well as PA social support and eating habits self-efficacy were observed. Our lifestyle modification program was also successful in shifting participants to higher levels of stages of change for nutrition and PA, increasing overall levels of self-efficacy for healthy eating, and improving levels of social support for becoming more active.

CONCLUSIONS

A lifestyle modification program can be successfully implemented in a community setting using a large group format to improve PA and FAV attitudes and behaviors.

A cross-sectional survey of cadmium biomarkers and cigarette smoking

Cadmium contamination of tobacco may contribute to the health hazards of cigarette smoking. The 2005-2012 United States National Health and Nutrition Examination Survey data provided a unique opportunity to conduct a cross-sectional survey of cadmium biomarkers and cigarette smoking. Among a sample of 6761 participants, we evaluated mean differences and correlations between cadmium biomarkers in the blood and urine and characteristics of never, former and current smokers. We found statistically significant differences in mean cadmium biomarker levels between never and former smokers as well as between never and current smokers. In current smokers, duration in years had a higher correlation coefficient with urinary than blood cadmium levels. In contrast, number of cigarettes smoked per day had a higher correlation coefficient with blood than urinary cadmium levels. These data suggest that blood and urine cadmium biomarker levels differ by duration and dose. These findings should be considered in evaluating any association between cadmium and smoking related diseases, especially cardiovascular disease.

A Wellness Program for Cancer Survivors and Caregivers: Developing an Integrative Pilot Program with Exercise, Nutrition, and Complementary Medicine

The Integrative Wellness Program (IWP) at the University of Miami Sylvester Comprehensive Cancer Center (SCCC) sought to provide integrative wellness education to cancer patients, survivors, and caregivers by offering instruction in exercise, nutrition, and complementary and alternative medicine. The objective of this study was to assess the impact of the IWP on the overall wellness of the individuals participating in the program. Three different 10-week versions of the IWP were conducted over a 1-year period. Each session focused on a different wellness topic presented through interactive lectures and applied activities. A series of self-report questionnaires were administered at baseline and again at the completion of the program to assess improvements in physical activity levels, dietary habits, sleep hygiene, and quality of life. Participants were generally older, Caucasian, female, had higher levels of education, and still currently receiving treatment. Significant changes were observed in two measures: Starting the Conversation (-2.0 ± 2.40, p = .037) and the Sticking To It subscale of the Self-Efficacy and Eating Habits Survey (1.7 ± 1.22, p = .0013). A trend for improvement in the Reducing Fat subscale of the Self-Efficacy Eating Habits (0.44 ± 0.60, p = .056) was also observed. Participant satisfaction surveys indicated high levels of satisfaction and applicability of the material presented. The significant improvements detected related to dietary habits, combined with the responses from the participant satisfaction surveys, suggest that the IWP was well received and can positively impact the overall wellness of cancer patients, survivors, and their caregivers.

Implementation of HIV prevention interventions in resource limited settings: the partner project

Evidence-based HIV prevention interventions have been translated to a variety of contexts across sub-Saharan Africa. Non-specialized community health center (CHC) staff members have been successfully engaged to deliver the interventions, which can be integrated into pre-existing HIV service programs in community-based health care delivery sites. This manuscript describes the process of implementing the Partner Project, a couples HIV risk reduction intervention, and examines the ability of CHC staff to achieve risk reduction outcomes comparable to those of the highly-trained research staff. The Partner Project was implemented within the HIV Counseling and Testing program in 6 urban community health clinics in Lusaka, Zambia. One hundred ninety-seven HIV-seroconcordant and -discordant couples were sequentially enrolled to the control group or to receive the intervention from partner research or CHC staff members. Couple members completed assessments on condom use, alcohol use, and intimate partner violence (IPV) at baseline, 6, and 12 months follow-up. Sexual barrier use outcomes achieved by the CHC staff were comparable to or better than those achieved by the Partner Project research staff, and both were superior to the control group. A reduction in IPV was observed for the entire sample, although no change in alcohol use was observed. Implementation of HIV prevention interventions at the community level should take advantage of existing resources available within the CHC staff. This is especially relevant in resource limited settings as consideration of the financial and clinical requirements of intervention programs is essential to the achievement of successful program implementation.

Acceptability, knowledge, beliefs, and partners as determinants of Zambian men's readiness to undergo medical male circumcision

There is limited information about the influence of partners on medical male circumcision (MMC) uptake. This study aimed to evaluate attitudes, knowledge, and preferences about MMC among men and their partners, and their relative impact on male readiness to undergo the MMC procedure. Male participants (n = 354) and their partners (n = 273) were recruited from community health centers in Lusaka, Zambia. Men reported their readiness to undergo MMC, and both men and women were assessed regarding their attitudes and knowledge regarding MMC. Men who had discussed MMC with their partners, those who endorsed MMC for HIV risk reduction, and those viewing MMC as culturally acceptable reported increased readiness to undergo MMC. Additionally, endorsement of MMC by female partners was associated with increased men's readiness. Results support promotion of cultural acceptability of MMC, and efforts to increase MMC uptake may benefit from incorporating partners in the decision making process.

Duration of analgesia and pruritus following intrathecal fentanyl for labour analgesia: no significant effect of A118G μ-opioid receptor polymorphism, but a marked effect of ethnically distinct hospital populations

BACKGROUND

Genetic polymorphism (A118G) in the μ-opioid receptor has been reported to affect systemic opioid analgesia. However, reported pharmacogenetic effects on spinal opioid analgesia, particularly in labour, have been equivocal.

METHODS

We prospectively assessed effects of the μ-opioid receptor A118G single nucleotide polymorphism (SNP) on analgesia after 20 μg of spinal fentanyl. We studied two ethnically distinct hospital populations (Miami and Jerusalem). Independent variables were A118G, ethnicity, and hospital. Primary outcome was time from spinal analgesia until analgesic request. Secondary outcomes were pain and pruritus, assessed at repeated intervals until analgesia request.

RESULTS

One hundred and twenty-five nulliparous parturients in early labour were analysed. The allelic frequency of A118G was 14.8% (14.4% in Miami; 15.5% in Jerusalem). Time to analgesia request (sd) in Miami was 122 (44) min and in Jerusalem was 87 (32) min, P<0.001; Hispanic 123 (46) min vs Jew/Arab 87 (32) min, P<0.001; Black 121 (41) min vs Jew/Arab 87 (32) min, P=0.015. There was no significant effect of A118G. Survival analysis showed Miami > Jerusalem, P<0.001; Hispanics and Black > Jew/Arab, P<0.001; no effect of A118G. Within hospital groups, A118G had no effect on time to analgesic request; within genomic groups there was a significant difference between hospitals. The time-course for pruritus exactly paralleled the time-course for analgesia and was affected by hospital (P=0.006) and by ethnic group (P=0.03), but not by A118G.

CONCLUSIONS

We found no significant effect for the A118G single nucleotide polymorphism (SNP) on analgesic duration after spinal fentanyl for labour. In contrast, ethnically distinct hospital population groups exerted a marked effect on the time-course of both analgesia and pruritus.

Ultrasound assessment of the vertebral level of the intercristal line in pregnancy

BACKGROUND

The intercristal line is known to most frequently cross the L4 spinous process or L4-5 interspace; however, it is speculated to be positioned higher during pregnancy because of the exaggerated lumbar lordosis. Clinical estimation of vertebral levels relying on the use of the intercristal line has been shown to often be inaccurate. We hypothesized that the vertebral level of the intercristal line determined by palpation would be higher than the level determined by ultrasound in pregnant women.

METHODS

Fifty-one term pregnant patients were recruited. Two experienced anesthesiologists performed estimates of the position of the intercristal line by palpation. Using ultrasound, another anesthesiologist who was blinded to the clinical estimates, determined the position of the superior border of the iliac crest in the transverse and longitudinal planes and then identified the lumbar vertebral levels. The vertebral level at which the clinical estimates of the intercristal line crossed the spine was recorded and compared with the ultrasound-determined level of the superior border of the iliac crest.

RESULTS

The clinical estimates of the spinal level of the intercristal line agreed with the ultrasound measurement 14% of the time (14 of 101; 95% confidence interval [CI]: 8%, 22%). The clinical estimates were 1 level higher than the ultrasound measurement 23% of the time (23 of 101; 95% CI: 16%, 32%) and >1 level higher 25% of the time (25 of 101; 1-tailed 95% CI: >18%). The distribution of the clinical estimates found clinicians locating the intercristal line at L3 or L3-4 54% of the time (54 of 101; 95% CI: 44%, 63%) and at L2-3 or higher 27% of the time (27 of 101; 1-tailed 95% CI: >20%).

CONCLUSION

The anatomical position of the intercristal line was at L3 or higher in at least 6% of term pregnant patients using ultrasound. Clinical estimates were found to be ≥1 vertebral level higher than the anatomical position determined by ultrasound at least 40% of the time. This disparity may contribute to misidentification of lumbar interspaces and increased risk of neurologic injury during neuraxial anesthesia.

Increasing rates of melanoma among nonwhites in Florida compared with the United States

OBJECTIVE

To compare melanoma trends within Florida with national melanoma trends from 1992 through 2004. An analysis of state and national melanoma trends is critical for the identification of high-risk regions of the country.

DESIGN

Data from the Florida Cancer Data System (FCDS) and Surveillance, Epidemiology, and End Results (SEER) were evaluated to determine age-adjusted and race/ethnicity- and sex-specific invasive cutaneous melanoma incidence trends for 1992 through 2004 using joinpoint regression analysis. Standardized incidence rate ratios (SIRRs) were computed to compare Florida with the United States.

PATIENTS

A population of 109 633 patients with invasive melanoma was evaluated: 73 206 (66.8%) from SEER and 36 427 (33.2%) from FCDS.

MAIN OUTCOME MEASURES

Melanoma incidence and change in melanoma rates over time.

RESULTS

The incidence of melanoma among male Hispanic patients residing in Florida was 20% higher than that of their male counterparts in the SEER catchment areas (SIRR, 1.2; 95% confidence interval [CI], 1.1-1.4). Conversely, the incidence of melanoma among female Hispanic patients residing in Florida was significantly lower than that in SEER (SIRR, 0.7; 95% CI, 0.7-0.8). Differences in melanoma incidence were identified in female non-Hispanic black (NHB) patients in Florida who had a 60% significantly higher incidence of melanoma compared with female NHB patients in SEER (SIRR, 1.6; 95% CI, 1.3-2.0).

CONCLUSION

These findings suggest an emerging public health concern in race/ethnic subgroups that were previously understudied.

Mapping of brain metabolite distributions by volumetric proton MR spectroscopic imaging (MRSI)

Distributions of proton MR-detected metabolites have been mapped throughout the brain in a group of normal subjects using a volumetric MR spectroscopic imaging (MRSI) acquisition with an interleaved water reference. Data were processed with intensity and spatial normalization to enable voxel-based analysis methods to be applied across a group of subjects. Results demonstrate significant regional, tissue, and gender-dependent variations of brain metabolite concentrations, and variations of these distributions with normal aging. The greatest alteration of metabolites with age was observed for white-matter choline and creatine. An example of the utility of the normative metabolic reference information is then demonstrated for analysis of data acquired from a subject who suffered a traumatic brain injury. This study demonstrates the ability to obtain proton spectra from a wide region of the brain and to apply fully automated processing methods. The resultant data provide a normative reference for subsequent utilization for studies of brain injury and disease.

Reliability of histopathologic assessment for the differentiation of recurrent hepatitis C from acute rejection after liver transplantation

Histopathologic assessment is considered essential for the differentiation of recurrent hepatitis C (RHC) from acute cellular rejection (ACR) after liver transplantation (LT); however, there is limited information regarding its reliability. The aim of this study was to determine the interobserver and intraobserver agreement of the histopathologic diagnosis of RHC vs. ACR, and to determine the reliability of specific histopathologic features for the differentiation of RHC from ACR. Liver biopsy specimens from 105 consecutive patients transplanted for hepatitis C virus (HCV)-related liver disease were studied retrospectively. All the biopsies were performed for evaluation of abnormal liver enzymes within the 1st year after LT. The slides were blindly coded and assessed by 5 liver-transplant pathologists, practicing at 3 medical centers. The pathologists were asked to render a diagnosis, and determine the severity of the disease. Four of the pathologists were asked to determine the presence and severity of 36 histopathologic features. A total of 34 of the samples were then blindly resubmitted to each of the 4 pathologists to determine the intraobserver agreement. There was a slight agreement (kappa = .12) among the 5 pathologists on the histopathologic diagnosis. All 5 pathologists were in agreement on the diagnosis of RHC in only 5 patients (5%) and on the diagnosis of ACR in only 2 patients (2%). The best agreement among any 4 pathologists was fair (kappa = .20). Slight to moderate agreement occurred on the main histological features considered to be important in the diagnosis of ACR. Intraobserver agreement ranged from slight (kappa = .19) to moderate (kappa = .42) among 4 pathologists. In conclusion, the histopathologic differentiation of RHC from ACR after LT had relatively low interobserver and intraobserver agreement rates, and hence showed low reliability. Histopathologic assessment should be used cautiously for the differentiation of RHC from ACR post-LT.

Chronic prenatal exposure to cocaine alters cerebrovascular responses in newborn pigs

Maternal cocaine abuse may increase the incidence of perinatal asphyxia. In nonexposed asphyxiated neonates, decreased cerebrospinal fluid (CSF) cAMP concentrations are associated with poor neurological outcome. On the other hand, cocaine increases central nervous system (CNS) cAMP. Therefore, we hypothesized that in utero cocaine exposure may increase brain cAMP and thereby preserve cerebrovascular responses to cAMP-dependent stimuli following asphyxia. Pregnant pigs received either cocaine (1 mg/kg, i.v.) twice weekly during the last trimester or normal saline vehicle (sham-control) and were allowed to deliver vaginally at term. Cranial windows were implanted in the newborn pigs within the first week of life and used to collect CSF for cAMP determinations and to assess changes in pial arteriolar diameters (PAD). In the first part of the study, pial arteriolar responses to different vasodilator and vasoconstrictor stimuli were evaluated in piglets prior to asphyxia (n = 20). In newborn pigs exposed to cocaine, cerebrovascular responses to hypercapnia and norepinephrine were significantly exaggerated compared to controls. Then, piglets were randomly selected for the second part of the study that involved prolonged asphyxia (n = 12). In cocaine-exposed but not sham-control piglets, CSF cAMP increased markedly during asphyxia. In the sham piglets, but not the cocaine-exposed piglets, CSF cAMP fell progressively below the baseline during recovery. Cerebrovascular reactivity to cAMP-dependent stimuli (hypercapnia and isoproterenol) was preserved during recovery from asphyxia in the cocaine-exposed piglets but significantly attenuated in the sham controls. We conclude that piglets with chronic prenatal exposure to cocaine show exaggerated cerebrovascular responses to vasogenic stimuli and preserved cAMP-dependent cerebral vasoreactivity following asphyxia.

Prevalence and determinants of hyperhomocysteinemia in hemodialysis and peritoneal dialysis

BACKGROUND

Hyperhomocysteinemia is an independent risk factor for atherosclerotic complications in patients with end-stage renal disease, although the mechanisms remain unclear. The major determinants of plasma homocysteine concentration are usually folate, vitamin B12, pyridoxal 5'-phosphate (vitamin B6), and glomerular filtration rate.

METHODS

We measured factors, including plasma folate, vitamin B12, vitamin B6, creatinine, as well as the dose and duration of dialysis, that might affect plasma homocysteine concentrations in 130 patients on hemodialysis (HD) and compared these observations with those in 46 patients on peritoneal dialysis (PD). Independent determinants of total homocysteine were identified using a multiple logistical regression analysis.

RESULTS

Total homocysteine values averaged 29.8 mumol/liter in HD patients, significantly higher than the mean value of 19.9 mumol/liter observed in patients on PD (P < 0.001). The prevalence of hyperhomocysteinemia was 90.8% among HD patients, significantly higher than the prevalence of 67.4% among PD patients. Folate values in HD patients averaged 45.5 nmol/liter and were significantly lower than in PD patients (104.2 nmol/liter, P < 0.001). For patients on HD, the only determinant of total homocysteine concentration was plasma folate (r = -0.31, P < 0.001). In contrast, for PD patients, total homocysteine did not correlate with plasma folate, vitamin B12, or vitamin B6.

CONCLUSIONS

Hyperhomocysteinemia is more prevalent and intense in HD patients compared with those on PD. The homocysteine response may become refractory to excess folate supplementation in PD patients.

Reduction of homocysteine levels in coronary artery disease by low-dose folic acid combined with vitamins B6 and B12

An increased plasma homocysteine concentration is a risk factor for atherosclerosis. Folic acid lowers homocysteine but the optimal dose in patients with coronary artery disease (CAD) is unclear. This placebo-controlled, single-blind, dose-ranging study evaluates the effect of low-dose folic acid on homocysteine levels in 95 patients aged 61 +/- 11 years (mean +/- SD) with documented CAD. Patients in each group were given either placebo or 1 of 3 daily supplements of folic acid (400 microg, 1 mg, or 5 mg) for 3 months. Each active treatment arm also received 500 microg vitamin B12 and 12.5 mg vitamin B6. Total plasma homocysteine levels were measured after 30 and 90 days. Folic acid 400 microg reduced homocysteine levels from 13.8 +/- 8.8 to 9.6 +/- 2.0 micromol/L at 90 days (p = 0.001). On 1- and 5-mg folic acid, levels decreased from 13.0 +/- 6.4 to 9.8 +/- 4.0 micromol/L (p = 0.001) and from 14.8 +/- 6.9 to 9.7 +/- 3.3 micromol/L (p < 0.001), respectively. The decrease was similar in all treatment groups. There was no significant change with placebo. Although the sample size is small, these findings suggest that daily administration of 400 microg/day folic acid combined with vitamin B12 and vitamin B6 may be equivalent to higher doses in reducing homocysteine levels in patients with CAD.

Prognosis of patients with vascular disease after clinical evaluation and dobutamine stress echocardiography

BACKGROUND

Coronary disease is an important cause of long-term morbidity in patients needing major vascular surgery. We sought to assess the efficacy of preoperative clinical evaluation and the detection of inducible ischemia for prediction of immediate and long-term cardiac outcomes of patients undergoing vascular surgery.

METHODS

In 233 patients undergoing vascular procedures, we assessed risk clinically on the basis of Eagle's criteria. Dobutamine echocardiography was performed with a standard protocol and results were classified as showing ischemia, scar, or a normal response. Patients were observed perioperatively, and late follow-up (28 +/- 13 months) was completed in all surgical survivors. A composite end point of cardiac death, myocardial infarction, and unstable and progressive angina requiring late revascularization was used to judge event-free survival.

RESULTS

Of 233 patients undergoing preoperative dobutamine echocardiography, 39 (17%) had inducible ischemia and 36 (15%) had scar. Perioperative events occurred in 8 patients (3%). None of the patients with ischemia had perioperative events, reflecting the effect of revascularization in 9 patients. Late events occurred in 36 patients; ischemia on preoperative stress testing was a predictor of these events even after adjusting for clinical variables and left ventricular dysfunction (relative risk = 3.3; 95% confidence interval 1.6 to 6.8; P =.001). The association of ischemia with clinical predictors was associated with incrementally worse outcome.

CONCLUSION

In addition to perioperative assessment, the combined use of clinical and dobutamine echocardiographic evaluation may stratify the risk of late cardiac events.

Low circulating folate and vitamin B6 concentrations: risk factors for stroke, peripheral vascular disease, and coronary artery disease. European COMAC Group

BACKGROUND

A high plasma homocysteine concentration is a risk factor for atherosclerosis, and circulating concentrations of homocysteine are related to levels of folate and vitamin B6. This study was performed to explore the interrelationships between homocysteine, B vitamins, and vascular diseases and to evaluate the role of these vitamins as risk factors for atherosclerosis.

METHODS

In a multicenter case-control study in Europe, 750 patients with documented vascular disease and 800 control subjects frequency-matched for age and sex were compared. Plasma levels of total homocysteine (before and after methionine loading) were determined, as were those of red cell folate, vitamin B12, and vitamin B6.

RESULTS

In a conditional logistic regression model, homocysteine concentrations greater than the 80th percentile for control subjects either fasting (12.1 micromol/L) or after a methionine load (38.0 micromol/L) were associated with an elevated risk of vascular disease independent of all traditional risk factors. In addition, concentrations of red cell folate below the lowest 10th percentile (<513 nmol/L) and concentrations of vitamin B6 below the lowest 20th percentile (<23.3 nmol/L) for control subjects were also associated with increased risk. This risk was independent of conventional risk factors and for folate was explained in part by increased homocysteine levels. In contrast, the relationship between vitamin B6 and atherosclerosis was independent of homocysteine levels both before and after methionine loading.

CONCLUSIONS

Lower levels of folate and vitamin B6 confer an increased risk of atherosclerosis. Clinical trials are now required to evaluate the effect of treatment with these vitamins in the primary and secondary prevention of vascular diseases.

Use of exercise echocardiography for prognostic evaluation of patients with known or suspected coronary artery disease

OBJECTIVES

This study prospectively compared the incremental prognostic benefit of exercise echocardiography with that of exercise testing in a large cohort.

BACKGROUND

Exercise echocardiography is widely accepted as a diagnostic tool, but the prognostic information provided by this test, incremental to clinical and stress testing evaluation, is ill-defined.

METHODS

Clinical, exercise and echocardiographic variables were studied in a consecutive group of 500 patients undergoing exercise echocardiography. After exclusion of patients who underwent revascularization within 3 months of the stress test (n = 16, 3%) and those lost to follow-up (n = 21, 4%), the remaining 463 patients (mean [+/-SD] age 57 +/- 12 years, 302 men) were followed-up for 44 +/- 11 months. Outcome was related to the exercise and echocardiographic findings, and the incremental prognostic benefit of exercise echocardiography was compared with that of standard exercise testing.

RESULTS

Cardiac events occurred in 81 patients (17%), including 33 (7%) with spontaneous events (cardiac death, myocardial infarction and unstable angina) and 48 with late revascularizations due to progressive symptoms. In a multivariate Cox proportional hazards model, the likelihood of any cardiac event was increased in the presence of ischemia (relative risk [RR] 5.06, 95% confidence interval [CI] 3.09 to 8.29, p < 0.001) and lessened by more maximal stress, measured as percent age-predicted maximal heart rate (RR per 5% increment 0.84, 95% CI 0.77 to 0.92, p < 0.001). Spontaneous events were more strongly predicted by ischemia (RR 8.20, 95% CI 3.41 to 19.71, p < 0.001) and percent age-predicted maximal heart rate (RR per 5% increment 0.78, 95% CI 0.67 to 0.91, p < 0.001). An interactive logistic regression model showed that the addition of echocardiographic to exercise and clinical data offered incremental predictive value.

CONCLUSIONS

The presence of ischemia on the exercise echocardiogram can predict whether patients will experience an event. This relation is independent of, and incremental to, clinical and exercise data.

Left atrial appendage "stunning" after electrical cardioversion of atrial flutter: an attenuated response compared with atrial fibrillation as the mechanism for lower susceptibility to thromboembolic events

OBJECTIVES

This study sought to determine whether left atrial appendage stunning occurs in patients with atrial flutter and to compare left atrial appendage function in the pericardioversion period with that in patients with atrial fibrillation.

BACKGROUND

Left atrial appendage stunning has recently been proposed as a key mechanistic phenomenon in the etiology of postcardioversion thromboembolic events in atrial fibrillation. Atrial flutter is thought to be associated with a negligible risk of thromboembolic events; therefore, anticoagulation is commonly withheld before and after cardioversion in these patients.

METHODS

Sixty-three patients with atrial flutter (n = 19) or atrial fibrillation (n = 44) underwent transesophageal echocardiography immediately before and after electrical cardioversion. In addition to assessing the presence of thrombus and spontaneous echo contrast, we measured left atrial appendage emptying velocity and calculated shear rates by pulsed wave Doppler and two-dimensional echocardiography.

RESULTS

Patients with atrial flutter exhibited greater left atrial appendage flow velocities before cardioversion than those with atrial fibrillation (42 +/- 19 vs. 28 +/- 15 cm/s [mean +/- SD], p < 0.001). Left atrial appendage shear rates were also higher in patients with atrial flutter (103 +/- 82 vs. 59 +/- 37 s-1, p < 0.001). After cardioversion, left atrial appendage flow velocities decreased compared with precardioversion values in patients with atrial fibrillation (28 +/- 15 before to 15 +/- 14 cm/s after cardioversion, p < 0.001) and atrial flutter (42 +/- 19 to 27 +/- 18 cm/s, respectively, p < 0.001). Shear rates decreased from 59 +/- 37 before cardioversion to 30 +/- 31 s-1 after cardioversion in atrial fibrillation (p < 0.001), and from 103 +/- 82 s to 65 +/- 52 s-1, respectively (p < 0.001), in atrial flutter. This decrease in flow velocity from before to after cardioversion occurred in 36 (82%) of 44 patients with atrial fibrillation and 14 (74%) of 19 with atrial flutter. The impaired left atrial appendage function after cardioversion was less pronounced in the group with atrial flutter (27 +/- 18 cm/s for atrial flutter vs. 15 +/- 14 cm/s for atrial fibrillation, p < 0.001). New or increased spontaneous echo contrast occurred in 22 (50%) of 44 patients with atrial fibrillation versus 4 (21%) of 19 with atrial flutter (p < 0.05).

CONCLUSIONS

Left atrial appendage stunning also occurs in patients with atrial flutter, although to a lesser degree than in those with atrial fibrillation. These data suggest that patients with atrial flutter are at risk for thromboembolic events after cardioversion, although this risk is most likely lower than that in patients with atrial fibrillation because of better preserved left atrial appendage function.

Hyperhomocysteinemia confers an independent increased risk of atherosclerosis in end-stage renal disease and is closely linked to plasma folate and pyridoxine concentrations

BACKGROUND

A high level of total plasma homocysteine is a risk factor for atherosclerosis, which is an important cause of death in renal failure. We evaluated the role of this as a risk factor for vascular complications of end-stage renal disease.

METHODS AND RESULTS

Total fasting plasma homocysteine and other risk factors were documented in 176 dialysis patients (97 men, 79 women; mean age, 56.3 +/- 14.8 years). Folate, vitamin B12, and pyridoxal phosphate concentrations were also determined. The prevalence of high total homocysteine values was determined by comparison with a normal reference population, and the risk of associated vascular complications was estimated by multiple logistic regression. Total homocysteine concentration was higher in patients than in the normal population (26.6 +/- 1.5 versus 10.1 +/- 1.7 mumol/L; P < .01). Abnormally high concentrations (> 95th percentile for control subjects, 16.3 mumol/L) were seen in 149 patients (85%) with end-stage renal disease (P < .001). Patients with a homocysteine concentration in the upper two quintiles (> 27.8 mumol/L) had an independent odds ratio of 2.9 (CI, 1.4 to 5.8; P = .007) of vascular complications. B vitamin levels were lower in patients with vascular complications than in those without. Vitamin B6 deficiency was more frequent in patients than in the normal reference population (18% versus 2%; P < .01).

CONCLUSIONS

A high total plasma homocysteine concentration is an independent risk factor for atherosclerotic complications of end-stage renal disease. Such patients may benefit from higher doses of B vitamins than those currently recommended.

Race and sex differences in health locus of control beliefs and cardiovascular reactivity

Examined the effects of race, sex, health locus of control (HLC), and the interactions of these variables on cardiovascular reactivity in 214 children. Participants completed the Multidimensional HLC scales for children. Systolic and diastolic blood pressures were measured at rest and during a reactivity task. Black boys had significantly higher scores on the powerful others (external HLC) subscale (p < 0.01) than white boys and girls. Furthermore, black boys showed greater systolic blood pressure reactivity when they were low on internality (vs. high) as compared to the other race-sex groups. Social and cultural factors may explain these differential findings across race and sex.

The presentation of adenocarcinoma of the uterine cervix

BACKGROUND

Among malignancies of the uterine cervix, the percentage of adenocarcinomas seems to have increased in recent reports.

METHODS

The clinical presentation of adenocarcinoma of the uterine cervix during the past 25 years was examined by review of charts and pathologic specimens. The data of a total of 124 patients with cervical adenocarcinoma treated between 1964 and 1988 were evaluated.

RESULTS

During the 25-year period, the percentage of adenocarcinoma among all cervical malignancies increased from 9% to 25%. In addition, the average number of new cases per year increased from 3.7 to 10.8. The percentage of women young than 35 years with adenocarcinoma increased from 16% in 1964 to 24% in 1989. Of these younger women, 74% had disease discovered by cytopathology, in comparison with 27% of the patients who were older than 35 years. The overall percentage of patients with disease diagnosed by cytology increased from 24% in the first half to 39% in the second half of the study period. Vaginal bleeding was the most common symptom. In the entire period, 57% of patients had International Federation of Gynecology and Obstetrics (FIGO) Stage I disease, with a median tumor diameter of 1 cm in patients with no symptoms and 3 cm in patients with symptoms. Outcome was inversely related to stage, tumor volume, and the presence of lymph node metastasis but not to histologic tumor type.

CONCLUSION

The frequency of adenocarcinoma of uterine cervix is increasing in patients 35 years or younger. Cytopathology is a good screening tool for these patients, leading to earlier diagnosis and improved outcome.

Emergency department asthma treatment protocol

OBJECTIVE

The purpose of this study was to determine if a brief educational intervention (INT) on the treatment of acute asthma improved prescribing patterns of internal medicine residents in an emergency department (ED). Additional objectives were to determine if optimal therapy reduced length of stay (LOS) in the ED and to determine if discharge prescribing patterns could be improved.

DESIGN

Nonrandomized, single-blind INT study.

SETTING

A large, urban, county-owned, university-affiliated ED.

PATIENTS AND OTHER PARTICIPANTS

Eight internal medicine residents in each of three study periods; numbers of adult asthmatics for each period were: control group, 129 (Nov-Dec 1989); INT group A, 82 (Jan-Feb 1990); and INT group B, 139 (Nov-Dec 1990).

INTERVENTIONS

INT consisted of a ten-minute verbal presentation, a three-page summary of the literature, and a posted protocol in the ED. Control data were collected prior to any INT. Prescribing patterns were covertly evaluated in each of the three study periods. Because discharge prescribing of long-term antiinflammatory therapy with inhaled corticosteroids was not improved in group A, emphasis on this point was added for group B.

MAIN OUTCOME MEASURES

Percentage of patients who received desired acute and discharge therapies and LOS for each study period.

RESULTS

Increased prescribing of desired acute therapy in the ED was seen in both INT groups. For discharge prescribing, the INT was partially successful. Reduced LOS was not found for the INT groups.

CONCLUSIONS

A brief INT effectively improves prescribing of optimal acute therapy of asthma in the ED, yet does not appear to reduce LOS. Further strategies are needed to impact on therapy prescribed at discharge from the ED.

Asthma in the emergency department: impact of a protocol on optimizing therapy

The objective of this study was to evaluate the impact of a simple educational intervention on the prescribing habits of internal medicine residents in the treatment of acute asthma in a busy emergency department (ED). Prescribing habits for 16 residents were documented for 4 months. The first 2 months served as a control period during which eight residents managed asthma patients without the benefit of any specific educational intervention beyond standard department protocols. A total of 129 patients treated by the residents during this initial phase were assessed. During the second 2-month period, a 10-minute verbal presentation and explicit written treatment protocol were provided to another eight residents, and their treatment of 83 patients was covertly evaluated. Increased prescribing of desired therapy was significantly improved in every area except that of prescribing an inhaled steroid metered dose inhaler for use as a discharge medication. The 10-minute verbal presentation given in conjunction with a three-page handout was found to be highly effective for eliciting improvement in treatment practices during short clinical rotations. The duration of this effect beyond each rotation is unknown. This educational intervention should be presented by the ED medical director, clinical pharmacist, or other appropriate clinician in virtually any ED as quality of patient care can be dramatically improved.

The role of handwashing in prevention of endemic intensive care unit infections

Handwashing is believed to be the most important means of preventing nosocomial infections. Previous studies of healthcare workers (HCWs) have shown that handwashing practices are poor. No one has shown that handwashing practices can be easily improved and that this prevents endemic (nonepidemic) nosocomial infection. Handwashing and infection rates were studied in two intensive care units (ICUs) of a community teaching hospital. Handwashing rates were monitored secretly throughout the study. After six months of observation, we started interventions to increase handwashing. Handwashing increased gradually, but overall rates before (22.0%) and after (29.9%) interventions were not significantly different (p = .071). Handwashing never occurred before intravenous care, whereas it occurred 67.5% for all other indications (p less than .0001). When questioned, nurses felt they were washing appropriately nearly 90% of the time. Infection rates seemed unrelated to handwashing throughout the study, and no clusters of infection were detected. We conclude that handwashing rates, when measured against arbitrary but reasonable standards, are suboptimal, difficult to change and not closely related to evidence of cross-infection. Further, nurses wash hands selectively, depending on the indication for handwashing, and generally believe they are washing much more frequently than an objective observer believes they are.

Blood pressure increases, birth weight-dependent stability boundary, and intraventricular hemorrhage

The blood pressure (BP) and transcutaneous PO2 (TcPO2) changes associated with intensive care procedures were evaluated to determine whether responses differ between babies with and without periventricular-intraventricular hemorrhage (PV-IVH). Fifty-three inborn babies less than or equal to 1500 g were studied using a microcomputer-based monitoring system. With almost any procedure including a seemingly benign one such as a diaper change, peak systolic BP increased and TcPO2 decreased. However, responses to interventions did not differ between babies with PV-IVH and those without PV-IVH. Neither did these responses differ between those with birth weight less than or equal to 1000 g and greater than 1000 g. When each baby's record was scanned for the highest peak systolic BP before diagnosis of PV-IVH or within 48 hours in those with no PV-IVH and their BP points plotted against birth weight, a stable region was evident wherein PV-IVH occurred at a lower incidence (13%). When peak systolic BP was beyond this stable region, the incidence of PV-IVH was significantly higher, 70% (P less than .0001). The stability boundary for the maximum systolic BP is birth weight-dependent; the limit for the highest tolerable peak systolic BP is lower for the low-birth-weight infant. In over 70% of instances the highest peak systolic BP was associated with motor activities either induced by nursery procedures or spontaneous. We speculate that decreasing the frequency of intensive care interventions may decrease episodic BP increases to levels beyond the birth weight-dependent stability boundary where PV-IVH is likely to occur.

Indomethacin reduces the risks of severe intraventricular hemorrhage

A prospective, random selection, double-blind clinical trial was carried out to determine the efficacy of indomethacin in preventing periventricular-intraventricular hemorrhage (PV-IVH). Babies who were born in our institution, had birth weights less than or equal to 1500 gm, and had no PV-IVH or grade 1 PV-IVH were given either placebo (n = 70) or indomethacin (n = 71), 0.2 mg/kg intravenously at 6 hours of age and 0.1 mg/kg at 18 and 30 hours. Two major outcomes were determined: the development of grades 2 to 4 PV-IVH and the development of severe PV-IVH (i.e., hemorrhages with blood filling greater than 50% of the ventricles and in some cases with associated parenchymal echodensities). Grades 2 to 4 PV-IVH occurred in 16 (23%) of the indomethacin group and 27 (39%) of the placebo group (p less than 0.03). The incidence of severe PV-IVH was 3% in the indomethacin-treated babies and 14% in the control group (p less than 0.02). The influence of other perinatal factors on the incidence of grades 2 to 4 or severe PV-IVH was determined by stepwise logistic regression. Placebo use, early grade 1 PV-IVH, lower birth weight, and higher fraction of inspired oxygen at 6 hours of life were associated with higher estimated odds of the development of grades 2 to 4 PV-IVH. Placebo use, male gender, lower 5-minute Apgar score, and a large base deficit were predictive of severe PV-IVH. Estimated odds ratios of severe PV-IVH with placebo use and male gender were 11.25:1 and 9:1, respectively. Thus indomethacin prophylaxis reduced the relative risk of grades 2 to 4 PV-IVH and severe PV-IVH, but other perinatal variables contributed significantly to the overall risk of PV-IVH.

Pneumocystis carinii serologic study in pediatric acquired immunodeficiency syndrome

Pneumocystis carinii antigen and IgG antibody profiles were prepared on 17 pediatric patients with acquired immunodeficiency syndrome (AIDS) with pneumonia who were examined by a variety of invasive methods for P carinii organisms. Overall, the accuracy of the antigen assay in invasively examined pediatric patients with AIDS with pneumonia was 94% (sensitivity, 100%; specificity, 90%), as antigen and invasive test results agreed in 16 of 17 patients. No statistically significant differences in IgG titer were observed between controls and patients invasively examined for P carinii, whether the organism was observed in the specimen or not. Since 38% of all serum samples referred were derived from "blood-borne" cases of AIDS, including patients who contracted AIDS as a result of both transfusion and hemophilia A, this suggests that P carinii pneumonia or P carinii pneumonia- like pneumonias may be more common in these individuals.

Controlled supplemental oxygenation during tracheobronchial hygiene

The effect of controlled supplemental oxygenation without bag ventilation on transcutaneous partial pressure of oxygen (TcPO2) measurements during tracheobronchial hygiene was evaluated. Procedure A, no supplemental oxygenation, was compared to Procedure B, in which controlled supplemental oxygenation was used. For controlled supplemental oxygenation, the FiO2 was increased until TcPO2 measurements rose to levels between 90 and 100 torr. Sixteen premature infants who required mechanical ventilation were studied in the neonatal center. Both procedures were performed on each patient in random order. In both procedures, a precipitous decrease in TcPO2 was observed during chest vibration, and further decrease in TcPO2 was noted with endotracheal suctioning. Except for baseline readings, throughout the tracheobronchial hygiene TcPO2 measurements were significantly higher and more subjects maintained TcPO2 values greater than 40 torr in Procedure B. In Procedure A corresponding TcPO2 measurements were 40 torr or less. Mean recovery time was shorter in Procedure B, 2.1 +/- 2.3 minutes, than in Procedure A, 4.9 +/- 2.8 minutes, p less than .003. Thus, in most patients, controlled supplemental oxygenation without manual bag ventilation seems sufficient to prevent hypoxia during tracheobronchial hygiene; it also shortens recovery time from hypoxemia as a result of the bronchopulmonary hygiene procedure.