Chronic heart failure in the United States: a manifestation of coronary artery disease

BACKGROUND: Hyperhomocysteinemia occurs in renal failure and may increase the risk for cardiovascular disease, possibly by damaging the endothelium. Folic acid and betaine are required in two separate homocysteine conversion pathways and may therefore lower plasma homocysteine. OBJECTIVE: To study the therapeutic role of betaine and the effect on endothelial function of long-term homocysteine-lowering therapy with folic acid, in peritoneal dialysis (PD) patients. PATIENTS AND DESIGN: Thirty PD patients were randomized to a 12-week treatment with 5 mg folic acid and 4 g betaine daily, or to 5 mg folic acid alone daily. They were then rerandomized to treatment with 1 or 5 mg folic acid daily for 40 weeks. MEASUREMENTS: At baseline and after 52 weeks, endothelial function was assessed by determination of endothelium-dependent vasodilatation and biochemical markers. RESULTS: Plasma total homocysteine (tHcy) was elevated at baseline: 42.6 (5.8) micromol/L. Only 1 patient (3%) had a normal plasma homocysteine (i.e., < or = 15 micromol/L) before therapy. Normalization of plasma homocysteine occurred in 39% of the patients at 12 weeks. Betaine had no additional homocysteine-lowering effect. Plasma tHcy levels were similar during treatment with 1 or 5 mg folic acid daily. Endothelial function was impaired at baseline and had not improved after 52 weeks of treatment. CONCLUSIONS: Peritoneal dialysis patients have hyperhomocysteinemia, which can be normalized with folic acid alone in about 40% of patients. Betaine does not further lower plasma homocysteine. A maintenance dose of 1 or 5 mg folic acid daily results in equivalent plasma homocysteine levels. Long-term reduction in plasma homocysteine did not result in improvement of endothelial function as assessed by our methods.     

Estimating the costs of occupational injury in the United States

This article estimates workplace injury costs in the U.S. These costs have been studied in less detail than most injury costs. Our methods, which mostly use regularly published data, produce order-of-magnitude estimates. Overall, workplace injuries cost the U.S. an estimated $140 billion annually. This estimate includes $17 billion in medical and emergency services, $60 billion in lost productivity, $5 billion in insurance costs, and $62 billion in lost quality of life. One sixth of the societal costs result from the 3% of workplace injuries in motor vehicle crashes. Motor vehicle costs per injury are almost 6 times the workplace injury average.     

Long-term results of the medical treatment of coronary artery disease

The natural history of patients with ischemic heart disease varies widely depending upon the anatomic lesion and extent of left ventricular dysfunction. Several clinical variables may also be used to help determine the likelihood of long-term survival. Individuals with high-grade isolated disease of the left anterior descending coronary artery, without significant impairment of ventricular function, have little morbidity and mortality for the 2-year period after arteriography. At the other end of the spectrum, medically treated patients with stenosis of the left main coronary artery or three-vessel disease without such involvement have a reduced life expectancy compared with patients treated surgically. Global judgments on long-term results of the medical treatment of coronary artery disease are meaningless. Efforts should be made to delineate optimal treatment for various subgroups of patients under the broad rubric of ischemic heart disease.     

Primary prevention of coronary heart disease: role of cholesterol control in the United States

The benefit of cholesterol-lowering drug therapy in patients with existing coronary heart disease (CHD) is well established through clinical trials. Prevention of recurrent coronary morbidity and mortality in CHD patients is called secondary prevention. In contrast, primary prevention is delaying or preventing altogether new-onset-CHD. There are three categories of primary prevention: high-risk, moderate-risk, and long-term (life-time). A recent clinical trial has documented benefit of cholesterol-lowering drugs for prevention of coronary morbidity and mortality and total mortality in hyper-cholesterolemic, middle-aged men. This trial lends support for including aggressive cholesterol reduction in high-risk primary prevention. However, for such therapy to be cost effective at present-day prices of cholesterol-lowering drugs, only those patients in the higher ranges of risk can be selected for treatment. This leaves a large number of people at moderately high risk for premature CHD because of high cholesterol levels. These persons deserve increased professional attention to risk reduction. In general the nondrug approach is indicated. The latter approach includes eliminating other risk factors, e.g. cigarette smoking and hypertension, and reducing serum cholesterol levels by decreased intakes of saturated fatty acids, cholesterol, and excess total calories. Some moderate-risk patients may require low doses of cholesterol-lowering drugs to achieve the goals for cholesterol reduction. Finally, public health strategies need to be developed for applying the same nondrug approach for the general population for reducing the overall incidence of CHD.     

Comparison of long-term efficacy of medical treatment versus coronary artery bypass grafting (CABG) in multivessel coronary artery disease

The long-term results of medical therapy and coronary artery bypass grafting (CABG) were compared in patients with multivessel disease. All patients were confirmed to have > or = 75% luminal narrowing of major coronary arteries by coronary arteriogram. When multivessel disease was stratified into double- and triple- vessel disease, the outcomes varied. In triple-vessel disease, the outcome with CABG was good, but the outcome was unfavorable in those employing medical therapy, particularly in patients with decreased left ventricular (LV) function. In patients with double-vessel disease with good LV function, the long-term results with medical therapy were just as favorable as those with CABG. However, double-vessel disease complicated by reduced LV function (ejection faction < or = 40%) had a clearly less favorable outcome when treated with medical therapy than with CABG. Thus, it is important for patients with multivessel disease to undergo revascularization if indicated, to improve their prognosis. On the other hand, the incidence of cardiac events arising from vein graft occlusions tended to increase in CABG patients after 5 years or more following surgery.     

Clinical features of moyamoya disease in the United States

BACKGROUND AND PURPOSE: We report the clinical features and longitudinal outcome of the largest cohort of patients with moyamoya disease described from a single institution in the western hemisphere. Moyamoya disease in Asia usually presents with ischemic stroke in children and intracranial hemorrhage in adults. METHODS: Our study population included all patients with moyamoya disease evaluated at a university hospital in Houston, Texas from 1985 through 1995 (n = 35). We used Kaplan-Meier methods to estimate individual and hemispheric stroke risk by treatment status (medical versus surgical). Predictors of neurological outcome were assessed. RESULTS: The ethnic background of our patients was representative of the general population in Texas. The mean age at diagnosis was 32 years (range, 6 to 59 years). Ischemic stroke or transient ischemic attack was the predominant initial symptom in both adults and children. Of the 6 patients with intracranial hemorrhage, 5 had an intraventricular site of hemorrhage. The crude stroke recurrence rate was 10.3% per year in 116 patient-years of follow-up. Twenty patients underwent surgical revascularization, the most common procedure being encephaloduroarteriosynangiosis. The 5-year risk of ipsilateral stroke after synangiosis was 15%, compared with 20% for medical treatment and 22% overall for surgery. CONCLUSIONS: Our observations indicate that moyamoya disease may have a different clinical expression in the United States than in Asia, and may demonstrate a trend toward a lower stroke recurrence rate and better functional outcome after synangiosis.     

Comparison of sudden and nonsudden coronary deaths in the United States

BACKGROUND: The present study was designed to compare risk factor prevalences in coronary heart disease deaths in persons dying within 1 hour of onset of cardiovascular symptoms (sudden coronary death), those dying without such sudden symptoms (nonsudden coronary death), and those with unknown duration of symptoms before death (other coronary death). METHODS AND RESULTS: Data from the 1986 National Mortality Followback Survey and the US Bureau of the Census were examined to assess death rates for sudden, nonsudden, and other coronary deaths. Multivariate logistic regression methods were used to calculate the odds ratio (OR), compared with nonsudden and other coronary deaths, for sudden coronary death associated with socioeconomic status variables, the person's location at death, and coronary heart disease risk factors. Mortality rates for all coronary deaths increased with age, were higher for men than women, and increased with decreasing years of schooling. The rate of sudden coronary death was highest for Hispanics. In 1986, an estimated 251,000 sudden coronary deaths (95% CI = 238,000 to 263,000) occurred in the United States. Sudden coronary deaths were less likely than nonsudden coronary deaths to occur at home (OR = 0.5, 95% CI = 0.4 to 0.6), but individuals who died of sudden coronary death were more likely to have been current cigarette smokers (OR = 1.3, 95% CI = 1.0 to 1.8). No other modifiable risk factors for coronary heart disease distinguished sudden coronary deaths from nonsudden coronary deaths. CONCLUSIONS: Contrary to the commonly held view, coronary deaths in the home are more likely to be nonsudden than sudden. Cigarette smoking more likely results in sudden than nonsudden coronary death, perhaps because of nicotine-induced ventricular arrhythmias.     

Psychology in United States medical schools: 1983.

Compared results from a survey of 108 chief psychologists at medical schools to the results of a previous survey by the 2nd author and colleagues (see record 1978-32394-001). The current survey revealed considerable progress in changing the bylaws of university-affiliated hospitals to enable psychologists to be members of the active medical staff. Some progress has also been made achieving departmental status for psychology. These developments are discussed in the context of the maturation of psychology in medical schools. (15 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Mental disorders and access to medical care in the United States

OBJECTIVE: The authors examined the barriers to receipt of medical services among people reporting mental disorders in a representative sample of U.S. adults. METHOD: The sample was drawn from adults who responded to the 1994 National Health Interview Survey (N=77,183). The authors studied the association between report of a mental disorder and 1) access to health insurance and a primary provider, and 2) actual receipt of medical care. Multivariate techniques were used to model problems with access as a function of mental disorders, controlling for demographic, insurance, and health variables. RESULTS: While people who reported mental disorders showed no difference from those without mental disorders in likelihood of being uninsured or of having a primary care provider, they were twice as likely to report having been denied insurance because of a preexisting condition or having stayed in their job for fear of losing their health benefits. Among respondents with insurance, those who reported mental illness were no less likely to have a primary care provider but were about two times more likely to report having delayed seeking needed medical care because of cost or having been unable to obtain needed medical care. CONCLUSIONS: People who reported mental disorders experienced significant barriers to receipt of medical care. Efforts to measure and improve access to health care for this population may need to go beyond simply providing insurance benefits or access to general medical providers.     

Ventricular remodeling in coronary artery disease

OBJECTIVE: To examine knowledge and practices in relation to sexually transmissible diseases (STDs) of general practitioners (GPs) in Victoria, Australia. METHOD: A questionnaire was distributed to 520 Victorian GPs randomly selected from the Australian Medical Publishing Company (AMPCo) database of Australian medical practitioners. RESULTS: A response rate of 85% was obtained. While sexual health consultations were common for Victorian GPs, STD caseloads were generally low. Knowledge of clinical features of symptomatic STDs and of important STD epidemiology was generally good although there was a lower awareness of the asymptomatic nature of the most prevalent STDs in Victoria. Diagnostic tests were generally selected appropriately although many GPs did not perform the gold standard combination of tests required for adequate differential diagnosis. Level of STD STD knowledge was related to frequency of advising about safe sex, diagnosing STDs, and younger practitioner age. Attendance at any of a number of postgraduate courses of relevance to the management of STDs was not related to better STD knowledge overall. CONCLUSIONS: Prevention and detection of STDs in general practice involve risk assessment and screening of asymptomatic patients as well as effective treatment of symptomatic patients and their contacts. Results presented here suggest that GPs have good knowledge and use appropriate investigations for patients presenting with symptoms of an STD. The low levels of awareness of the asymptomatic nature of many STDs and other particular aspects of STD knowledge and practice should be addressed in undergraduate and postgraduate medical education programmes.     

Evaluation of coronary artery disease in women

Sepsis syndrome and septic shock remain significant causes of morbidity and mortality. To date, clinical trials of novel agents to treat sepsis have failed to demonstrate clinical efficacy despite considerable animal data to suggest a positive therapeutic benefit. This article reviews the recent major clinical trials on sepsis and discusses the hypotheses on which these therapies are based and the critical issues associated with clinical sepsis. Recommendations for future clinical trials on sepsis are made.     

Risk factors in the pathogenesis of coronary artery disease

In men, plaque rupture is strongly correlated with total cholesterol, and smoking is a predictor of acute thrombosis. In women younger than 50, plaque erosion correlates with smoking, whereas in women older than 50, thrombosis is secondary to plaque rupture and correlates with total cholesterol.