Prognostic relevance of transforming growth factor alpha (TGF-alpha) and tumor necrosis factor alpha (TNF-alpha) detected in breast cancer tissues by immunohistochemistry

BACKGROUND: Reducing inappropriate hospital admissions could lead to lower total health care costs without compromising the quality of care. Research suggests that a sizeable portion of hospital admissions are inappropriate. Other studies indicate that family physicians use health care resources, including hospitalizations, less often than other primary care physicians. To gain additional insight into family physicians' decisions to admit patients, we performed an exploratory study using the Appropriateness Evaluation Protocol, a validated, clinically based utilization review instrument. METHODS: We assessed admissions by community-based and residency-based family physicians to a single university-affiliated hospital during calendar year 1988. A total of 905 patients were admitted to the hospital by family physicians during the study period. Of these, 889 records had complete data. Each was reviewed for appropriateness of admission. We calculated percentages of inappropriate admissions and used logistic regression to ascertain variables that were significant predictors of inappropriateness. RESULTS: Overall, 5.4 percent of admissions were categorized as inappropriate. Omitting obstetric cases, the rate was 10.5 percent. Inappropriate admissions did not cluster around a small number of diagnoses or diagnosis-related groups. Using logistic regression, we found that urgency of admission, patient insurance status, and residency-based physician admission versus community-based physician admission were significant predictors of inappropriate hospital use. Of the inappropriate admissions, 70 percent were so rated because diagnostic procedures or treatments could have been performed on an outpatient basis. CONCLUSIONS: In contrast with other studies for which physician specialty was not controlled, family physicians less frequently admitted patients inappropriately. Predictors of inappropriateness differed from those found in other studies. Changes in hospital systems, in addition to educational efforts directed toward individual physicians, hold promise as a strategy for reducing inappropriate hospital use.     

Comparison of pediatric hospitalization using the pediatric appropriateness evaluation protocol at three diverse hospitals in Louisiana

The purpose of this study was to compare the number of inappropriate pediatric admissions and hospital days in three hospitals in Louisiana using Pediatric Appropriateness Evaluation Protocol (PAEP) criteria. The hospitals studied included an urban, nontertiary care, teaching hospital with 20 inpatient, pediatric beds (A); a private, tertiary care hospital with 30 beds (B); and a tertiary care, regional referral center with 133 pediatric beds (C). The study prospectively observed all nonintensive care pediatric admissions (> six months of age) between May 1 and June 30, 1993. Admissions and subsequent hospital days were labeled as appropriate or inappropriate based on PAEP criteria. A significantly shorter hospital stay (days) was demonstrated at hospital C (4.41 +/- 1.01, p < .05) compared to A (5.98 +/- 4.95) or B (5.78 +/- 1.21). Similarly, hospital B had significantly more patients admitted electively (19%, p < .05) compared to A (4%) or C (15%). The percentage of inappropriate admissions for hospitals A, B, and C were 11.0, 10.0, and 2.0 (p < .05) and hospital days 18.0, 22.0, and 12.0 (p < .05), respectively. A significant proportion of inappropriate hospital days came from trauma admissions in hospital A (18%, p < .05) and elective admissions in hospital B (36%, p < .05). Hospital A had 99% of patients with either Medicaid or uninsured payor status compared to 35% and 84% at hospital B and C, respectively. Significant differences in the rate of inappropriate admission or subsequent hospital days were demonstrated in the three hospitals studied. Finally, the rates of inappropriate hospitalization demonstrated in this study of Louisiana hospitals were similar to previous studies using the PAEP in other regions.     

Hospital utilization reviews under field conditions: potential and improvements

Hospital reviews based on an adaptation of Gertman and Restuccia's Appropriateness Evaluation Protocol were performed by acute care hospitals and the canton of Vaud (Switzerland) public health department in three settings during a six-month period in 1990-91. Interrater agreement between hospital and public health department reviewers was measured on 1,847 days of consecutively admitted patients during the last weeks of the reviews.     

Appropriateness of admission and the last 24 hours of hospital care in medical wards in an east London teaching group hospital

OBJECTIVE: To assess the rates of inappropriateness of admission and last day of care on adult medical wards in an east London hospital, to identify associations with any inappropriateness and to assess what services need to be improved or provided if patients assessed as "inappropriate" are to be more appropriately placed in the future. DESIGN: From the patients' medical notes, nursing notes and ward charts, a trained reviewer with nursing and university qualifications collected concurrent information about each patient's first 24 hours as an in-patient and about the last 24 hours of care preceding discharge. Patients were also interviewed before discharge and 7-10 days after discharge, and their health status and level of satisfaction about the discharge process assessed. SETTING: The three adult medical wards at the Homerton Hospital in Hackney, east London. This hospital is within the St Bartholomew's Hospital Teaching Hospital Group. SUBJECTS: The case-notes of a random sample of 625 adult in-patients were reviewed. END POINTS: Appropriateness of admission and last day of care. MAIN OUTCOME MEASURES: The main instrument used was the Appropriateness Evaluation Protocol (AEP). This is an instrument devised to assess the appropriateness of adult patient admission to, and specific days of care in, acute hospital beds through case-note review against a structured set of criteria. RESULTS: The study presented here reported that 31% of in-patient admissions to adult medical wards in an east London hospital were inappropriate, and also that 66% of the last days of stay were inappropriate. CONCLUSIONS: There is clearly considerable room for improvement in relation to cooperation between service providers in order to maximise efficient bed use. Delays due to waiting for medications from pharmacy, and the combination of more "inappropriate" cases wanting help from social services after discharge with the fact that many of them were still in hospital because they were waiting for these services to be organized, suggest that inappropriateness could be reduced through increased efficiency or increased provision in these areas. The study reported here is unique in its inclusion of patient interview data.     

Why patients use alternative medicine: results of a national study

CONTEXT: Research both in the United States and abroad suggests that significant numbers of people are involved with various forms of alternative medicine. However, the reasons for such use are, at present, poorly understood. OBJECTIVE: To investigate possible predictors of alternative health care use. METHODS: Three primary hypotheses were tested. People seek out these alternatives because (1) they are dissatisfied in some way with conventional treatment; (2) they see alternative treatments as offering more personal autonomy and control over health care decisions; and (3) the alternatives are seen as more compatible with the patients' values, worldview, or beliefs regarding the nature and meaning of health and illness. Additional predictor variables explored included demographics and health status. DESIGN: A written survey examining use of alternative health care, health status, values, and attitudes toward conventional medicine. Multiple logistic regression analyses were used in an effort to identify predictors of alternative health care use. SETTING AND PARTICIPANTS: A total of 1035 individuals randomly selected from a panel who had agreed to participate in mail surveys and who live throughout the United States. MAIN OUTCOME MEASURE: Use of alternative medicine within the previous year. RESULTS: The response rate was 69%. The following variables emerged as predictors of alternative health care use: more education (odds ratio [OR], 1.2; 95% confidence interval [CI], 1.1-1.3); poorer health status (OR, 1.3; 95% CI, 1.1-1.5); a holistic orientation to health (OR, 1.4; 95% CI, 1.1-1.9); having had a transformational experience that changed the person's worldview (OR, 1 .8; 95% CI, 1 .3-2.5); any of the following health problems: anxiety (OR, 3.1; 95% CI, 1.6-6.0); back problems (OR, 2.3; 95% CI, 1 .7-3.2); chronic pain (OR, 2.0; 95% CI, 1.1 -3.5); urinarytract problems (OR, 2.2; 95% CI, 1.3-3.5); and classification in a cultural group identifiable by their commitment to environmentalism, commitment to feminism, and interest in spirituality and personal growth psychology (OR, 2.0; 95% CI, 1.4-2.7). Dissatisfaction with conventional medicine did not predict use of alternative medicine. Only 4.4% of those surveyed reported relying primarily on alternative therapies. CONCLUSION: Along with being more educated and reporting poorer health status, the majority of alternative medicine users appear to be doing so not so much as a result of being dissatisfied with conventional medicine but largely because they find these health care alternatives to be more congruent with their own values, beliefs, and philosophical orientations toward health and life.     

Health literacy and the risk of hospital admission

OBJECTIVE: To determine the association between patient literacy and hospitalization. DESIGN: Prospective cohort study. SETTING: Urban public hospital. PATIENTS: A total of 979 emergency department patients who participated in the Literacy in Health Care study and had completed an intake interview and literacy testing with the Test of Functional Health Literacy in Adults were eligible for this study. Of these, 958 (97.8%) had an electronic medical record available for 1994 and 1995. MEASUREMENTS AND MAIN RESULTS: Hospital admissions to Grady Memorial Hospital during 1994 and 1995 were determined by the hospital information system. We used multivariate logistic regression to determine the independent association between inadequate functional health literacy and hospital admission. Patients with inadequate literacy were twice as likely as patients with adequate literacy to be hospitalized during 1994 and 1995 (31. 5% vs 14.9%, p <.001). After adjusting for age, gender, race, self-reported health, socioeconomic status, and health insurance, patients with inadequate literacy were more likely to be hospitalized than patients with adequate literacy (adjusted odds ratio [OR] 1.69; 95% confidence interval [CI] 1.13, 2.53). The association between inadequate literacy and hospital admission was strongest among patients who had been hospitalized in the year before study entry (OR 3.15; 95% CI 1.45, 6.85). CONCLUSIONS: In this study population, patients with inadequate functional health literacy had an increased risk of hospital admission.     

A rude awakening: post-take ward round in the department of medicine for the elderly

This paper describes the post-take ward round of a department of medicine for the elderly (DME), to portray the nature of the medical admissions and their immediate management. The data concern the patients seen by one consultant in 28 such ward rounds during the last four months of 1997, in a teaching hospital where the DME is separate from the department of general internal medicine. 254 patients were seen, 107 men and 147 women, with an average age of 82.4 years (range 73-102). The decisions taken included diagnosis, further investigations, treatment, referral, discharge, and resuscitation status. Very few admissions were judged inappropriate, particularly among the majority referred by general practitioners. 101 patients were thought suitable for transfer to the department of general internal medicine, 109 definitely unsuitable. These findings support the view that, if medical beds are to be freed, the initiative must come from facilitating discharge rather than curtailing admission. Generalists are needed to sort and manage these patients. In the UK, these will often be general internal medicine consultant geriatricians, while the younger patients are seen by consultants practising general internal medicine in addition to one of the specialties. Sizeable numbers of these consultants are needed if the post-take ward round is to be efficient and not conflict with their fixed commitments.     

Use of emergency departments by elder patients: a five-year follow-up study

OBJECTIVE: To compare the use of emergency medical care by elders in the United States in 1995 with that previously described for 1990. METHODS: A computerized billing database of 88 EDs in 21 states was retrospectively reviewed for 1995, comparing elder and nonelder patients, estimating national use of emergency medical services by elders, and comparing the 1995 data with previously published results for 1990. RESULTS: From 1990 to 1995, the number of ED visits in the United States increased from 92 million to 100 million. The number of visits made by patients aged 65 years or older increased from 13,639,400 (15%) to 15,666,300 (15.7%), but this increase did not reach statistical significance (p = 0.17). The admission rate for elder ED patients increased from 32% to 46% over the five-year interval (p<0.01). This represents more than 7 million hospital admissions for elder patients in 1995. The rate of intensive care unit (ICU) admission for elders decreased from 7% to 6% over the five-year interval (p = 0.56), compared with 1.3% for nonelder patients for both years. Thirty percent of elder ED patients arrived by ambulance in 1990, compared with 33% in 1995 (p = 0.02). Based on 1995 data, elders comprised 39% of patients arriving by ambulance [odds ratio (OR) 4.75, 95% confidence interval (CI) = 4.71 to 4.79], 43% of all admissions (OR 6.59, 95% CI = 6.54 to 6.64), and 47% of ICU admissions (OR 5.00, 95% CI = 4.91 to 5.09). The comparable ORs in 1990 were 4.4, 5.6, and 5.5, respectively. CONCLUSIONS: From 1990 to 1995, the overall number of ED visits increased. The rate of increase was somewhat greater for elder patients. The use of ambulance services also disproportionately grew among elder patients, as did the rate of hospital admission. The overall rate of ICU admission was stable, but actually fell modestly for elder patients. Of these changes, only the increase in the rate of hospital admission for elders reached statistical significance.     

Quantification of alterations in structure and function of elastin in the arterial media

The effect of environmental tobacco smoke (ETS) exposure on adults with asthma has not been well characterized. In a prospective cohort study of 451 nonsmoking adults with asthma, we evaluated the impact of ETS exposure on asthma severity, health status, and health care utilization over 18 mo. There were 129 subjects (29%; 95% CI, 25-33%) who reported regular ETS exposure, falling into three categories: exposure at baseline but none at follow-up (n = 43, 10%), no baseline exposure and new exposure at follow-up (n = 56, 12%), and exposure at both baseline and follow-up (n = 30, 7%). In cross-sectional analyses, subjects with baseline ETS exposure had greater severity-of-asthma scores (score difference, 1.7; 95% CI, 0. 2-3.1), worse asthma-specific quality of life scores (score difference, 3.5; 95% CI, 0.03-7.0), and worse scores on the Medical Outcomes Study SF-36 physical component summary (score difference, 3. 0; 95% CI, 0-6.0) than unexposed subjects. They also had greater odds of emergency department visits (odds ratio [OR] = 2.1; 95% CI, 1.2-3.5), urgent physician visits (OR = 1.9; 95% CI, 1.1-3.3), and hospitalizations (OR = 1.9; 95% CI, 1.02-3.6). In longitudinal follow-up, subjects reporting ETS cessation showed improvement in severity-of-asthma scores (score reduction, -3.2; 95% CI, -4.4 to -2. 0) and physical component summary scores (score increase, 5.3; 95% CI, 2.6-8.1). Environmental tobacco smoke cessation decreased the odds of emergency department visits (OR = 0.4; 95% CI, 0.2-0.97) and hospitalizations (OR = 0.2; 95% CI, 0.04-0.97) after adjustment for covariates. Environmental tobacco smoke initiation was associated with greater asthma severity only in subjects with high-level (>= 3 h/wk) exposure (score increase, 1.4; 95% CI, 0.03-2.7). In conclusion, self-reported ETS exposure is associated with greater asthma severity, worse health status, and increased health care utilization in adults with asthma.     

Effects of prenatal cocaine exposure on embryonic expression of sonic hedgehog

PURPOSE: To estimate the impact of visual impairment in older Australians on the use of community support services. METHODS: In the Blue Mountains Eye Study, 3654 people aged 49 or older were examined- 82.4% of eligible residents in an area west of Sydney, Australia. Presenting and best-corrected visual acuities were measured using a LogMAR chart. Subjects were categorized as having visual impairment if their better eye read 40 or fewer letters (20/40 or worse). Interview data included marital and other socioeconomic status measures, living status (alone or with spouse or other person), use of community support services, reliance on regular help from nonspouse family members or friends, and perceived ability to go out alone. RESULTS: After adjusting for age, gender, education, living status, walking disability, and health-related factors, for each one-line (five-letter) decrease in best-corrected visual acuity, there was a corresponding increase in reliance on community support services (odds ratio [OR], 1.17; 95% confidence interval, [CI] 1.07-1.28) or combined community and family support (OR 1.22; 95% CI, 1.12-1.32). Visually impaired persons were three times as likely to use regular support services provided by the municipality (OR 3.1; 95% CI, 1.8-5.1). A similar increased reliance on regular help from community, nonspouse family members, or friends was found. Visually impaired persons were also much more likely to state that they thought they were unable to go out alone (OR 6.2; 95% CI, 2.6-14.3). The findings were similar when presenting visual acuity was used to define visual impairment or after subjects with walking disabilities were excluded. Visual impairment seemed to have a greater effect on use of community support services in women than in men. CONCLUSIONS: After adjustment was made for confounding factors, visual impairment was found to affect significantly and negatively the independence of elderly people, particularly older women. Presenting visual acuity closely approximated best-corrected visual acuity in its impact on the use of community support services.     

Cognitive and affective assessment of the geriatric patient

Allocation of limited resources in the Canadian health care system is hampered by a lack of studies addressing the appropriateness of the pediatric patient days in hospital. The authors retrospectively reviewed one hospital day per month in 1988, using a Pediatric Appropriateness Evaluation Protocol previously used in the United States. Of 878 inpatients, 852 charts were reviewed, and 26 charts were unavailable for study. The patients ranged in age from premature newborns to 20 years old. There were 475 medical days, 359 surgical days, and 18 patients to other services. Statistical significance was tested using the chi 2 test for contingency tables. Twenty-four percent of patient days were inappropriate. Younger children and shorter lengths of stay were more likely to result in appropriate hospital days. For infants younger than 60 days, 11% of days in hospital were inappropriate, 21% of days for infants between 2 months and 1 year of age, 25% for children between 1 and 5 years, and 36% for children older than 5 years of age. Children hospitalized 2 days or less had inappropriate hospital days accounting for 16% of the reviewed days. This increased to 33% for 3 to 14 days of hospitalization. Inappropriate hospital days did not vary significantly from month to month. Surgical patients had more appropriate hospital days than medical patients. Admission route (elective, emergency, or transferred from another hospital) did not affect the appropriateness of the subsequent day reviewed. It is concluded that inappropriate hospitalization in a Canadian pediatric hospital occurs only slightly more frequently than in an American pediatric hospital.(ABSTRACT TRUNCATED AT 250 WORDS)     

Differences in risk factors for being either a hepatitis B carrier or anti-hepatitis C+ in a hepatoma-hyperendemic area in rural Taiwan

This is a study of the differences in the risk factors for being either hepatitis B surface antigen positive [HBsAg(+)] or antibody to hepatitis C virus positive [Anti-HCV(+)] in A-Lein, a rural area in southern Taiwan, an area which also has a high hepatoma mortality rate. Three hundred eighty-five patients age > or =40 years participated in hepatoma screening at the A-Lein Community Health Center during 1995. Those who were HBsAg(-) and anti-HCV(-) or had coinfection of HBsAg(+) and anti-HCV(+) were excluded, leaving 293 patients: 109 HBsAg(+) and 184 anti-HCV(+). The anti-HCV(+) patients had a lower socioeconomic status (as defined by level of education and type of occupation) and were older than HBsAg(+) patients (P < 0.05). Those with higher alanine aminotransferase levels (ALT) also had a higher anti-HCV(+) to HBsAg(+) odds ratio (OR), and a dose response relationship was found, P < 0.0001. Anti-HCV(+) patients were more likely than HBsAg(+) patients to have a spouse who shared the infection, OR = 5.11; 95% CI, 2.30-11.28. Anti-HCV(+) patients were more likely than HBsAg(+) patients to have had blood transfusions (OR = 2.66; 95% CI, 1.20-5.89), frequent medical injections (OR = 2.64; 95% CI, 1.62-4.31), or injections by non-licensed medical providers (OR = 1.91; 95% CI, 1.18-3.09). Multiple logistic regression analysis showed that the significant factors for anti-HCV(+) patients vs. HBsAg(+) patients are drinking habit (OR = 3.45; 95% CI, 1.02-11.60), age (OR = 6.33; 95% CI, 2.93-13.68), and frequent medical injections (OR = 2.88; 95% CI, 1.65-5.03). The transmission of hepatitis C in A-Lein is closely related to low socioeconomic status, age, alcohol abuse, spouses being anti-HCV(+), and frequent medical injections, especially from non-licensed medical providers, including both pharmacists and those with no medical licensing whatsoever. These nonlicensed medical providers sometimes reuse needles to save money, which is a likely route of infection.     

Value of acute rest sestamibi perfusion imaging for evaluation of patients admitted to the emergency department with chest pain

OBJECTIVES: This study sought to determine the ability of early perfusion imaging using technetium-99m sestamibi to predict adverse cardiac outcomes in patients who present to the emergency department with possible cardiac ischemia and nondiagnostic electrocardiograms (ECGs). BACKGROUND: Evaluation of patients presenting to the emergency department with possible acute coronary syndromes and nondiagnostic ECGs is problematic. Accurate risk stratification is necessary to prevent serious adverse outcomes. Initial results suggest that early perfusion imaging using technetium-99m sestamibi enables reliable risk stratification. METHODS: Patients presenting to the emergency department with a low to moderate probability of acute coronary syndromes underwent rapid sestamibi injection with gated single-photon emission computed tomographic imaging. Studies showing perfusion defects with associated wall motion abnormalities were considered positive. RESULTS: A total of 532 consecutive patients underwent serial myocardial marker analysis and rest perfusion imaging. Of these patients, perfusion imaging was positive in 171 (32%). Positive perfusion imaging was the only multivariate predictor of myocardial infarction (MI) (p < 0.0001, odds ratio [OR] 33, 95% confidence interval [CI] 7.7 to 141) and was the most important independent predictor of MI or revascularization (p < 0.0001, OR 14, 95% CI 7.3 to 25), followed by diabetes (p < 0.01, OR 2.8, 95% CI 1.5 to 5.1), typical angina (p = 0.01, OR 2.1, 95% CI 1.2 to 3.7) and male gender (p = 0.03, OR 1.9, 95% CI 1.1 to 3.5). The sensitivity of positive perfusion imaging for MI was 93% (95% CI 77% to 98%), and for MI or revascularization it was 81% (95% CI 71% to 88%), with negative predictive values of 99% (95% CI 98% to 100%) and 95% (95% CI 92% to 97%), respectively. CONCLUSIONS: Positive rest perfusion imaging accurately identified patients at high risk for adverse cardiac outcomes, whereas negative perfusion imaging identified a low risk patient group. Early perfusion imaging allows for rapid and accurate risk stratification of emergency department patients with possible cardiac ischemia and nondiagnostic ECGs.     

Physicians disciplined by a state medical board

CONTEXT: State medical boards discipline several thousand physicians each year. Although certain subgroups, such as those disciplined for malpractice, substance use, or sexual abuse, have been studied, little is known about disciplined physicians as a group. OBJECTIVE: To assess the offenses, contributing factors, and type of discipline of a consecutive series of disciplined physicians. DESIGN: Case-control study on publicly available data matching 375 disciplined physicians with 2 groups of control physicians, one matched solely by locale, and a second matched for sex, type of practice, and locale. SUBJECTS: All disciplined physicians publicly reported by the Medical Board of California from October 1995 through April 1997. MAIN OUTCOME MEASURES: Characteristics of disciplined physicians, offenses leading to discipline, and type of discipline. RESULTS: A total of 375 physicians licensed by the Medical Board of California (approximately 0.24% per year) were disciplined for 465 offenses. The most frequent causes for discipline were negligence or incompetence (34%), abuse of alcohol or other drugs (14%), inappropriate prescribing practices (11%), inappropriate contact with patients (10%), and fraud (9%). Discipline imposed was revocation of medical license (21%), actual suspension of license (13%), stayed suspension of license (45%), and reprimand (21%). Type of offense was significantly associated with severity of discipline (P=.03). In logistic regression models comparing disciplined physicians with controls matched by locale, board discipline was significantly associated with physicians' sex (odds ratio [OR] for women, 0.44; 95% confidence interval [CI], 0.28-0.70) and involvement in direct patient care (OR, 2.56; 95% CI, 1.75-3.75). In the regression model with additional matching criteria, disciplinary action was negatively associated with specialty board certification (OR, 0.42; 95% CI, 0.29-0.60) and positively associated with being in practice more than 20 years (OR, 2.02; 95% CI, 1.39-2.92). CONCLUSIONS: A small but substantial proportion of physicians is disciplined each year for a variety of offenses. Further study of disciplined physicians is necessary to identify physicians at high risk for offenses leading to disciplinary action and to develop effective interventions to prevent these offenses.     

ACE inhibitor use is associated with hospitalization for severe hypoglycemia in patients with diabetes. DARTS/MEMO Collaboration. Diabetes Audit and Research in Tayside, Scotland. Medicines Monitoring Unit

OBJECTIVE: To evaluate the association between the use of ACE inhibitors and hospital admission for severe hypoglycemia and to explore the effects of potential confounding variables on this relationship. RESEARCH DESIGN AND METHODS: The association between the use of ACE inhibitors and the incidence of hypoglycemia is controversial. A recent study reported that 14% of all hospital admissions for hypoglycemia might be attributable to ACE inhibitors. We performed a nested case-control study, using a cohort of 6,649 diabetic patients taking insulin or oral antidiabetic drugs, on the Diabetes Audit and Research in Tayside, Scotland (DARTS) database. From 1 January 1993 to 30 April 1994, we identified 64 patients who had been admitted to Tayside hospitals with hypoglycemia and selected 440 control patients from the same cohort. RESULTS: Hypoglycemia was associated with the use of ACE inhibitors (odds ratio [OR] 3.2, 95% CI 1.2-8.3, P = 0.023), whereas use of beta-blockers and calcium antagonists was not associated with an increased risk of hospitalization for hypoglycemia with ORs of 0.9 (95% CI 0.3-3.3) and 1.7 (95% CI 0.2-2.1), respectively. There were significant differences between case and control patients in type of diabetes treatment, diabetes duration, place of routine diabetes care, and congestive cardiac failure. These differences did not confound the relationship between ACE inhibitors and hypoglycemia (adjusted OR 4.3, 95% CI 1.2-16.0). CONCLUSIONS: The results show that the association between ACE inhibitor therapy and hospital admission for severe hypoglycemia is not explained by these confounding factors. Although ACE inhibitors have distinct advantages over other antihypertensive drugs in diabetes, the risk of hypoglycemia should be considered.     

Fundus autofluorescence in patients with macular holes imaged with a laser scanning ophthalmoscope

BACKGROUND: Because of a strong association between health maintenance visits (HMVs) and cancer screening, knowledge of the predictors of an HMV have implications for screening. OBJECTIVE: To examine the association of an HMV with patient, physician, and practice characteristics in the primary care setting. DESIGN: A statewide study of cancer screening was conducted in Colorado to determine concordance with the National Cancer Institute's guidelines for screening for breast, cervical, prostate, and skin cancer. Medical records form patients were randomly chosen from primary care practices. Predictors of an HMV were determined by fitting a logistic model to baseline data, adjusting for the cluster sampling of patients within practices. SETTING: Nonacademic primary care practices in Colorado. PARTICIPANTS: A total of 5746 patients aged 42 to 74 years from 132 primary care practices. MAIN OUTCOME MEASURE: Whether a patient had an HMV in the previous year. RESULTS: Of all patients, 31% had an HMV in the previous year. Patient characteristics associated with having HMVs included nonsmoking status, odds ratio (OR) (95% confidence interval [CI]) of 1.27 (1.11-1.46), age, and sex. Women aged 50 to 69 years were significantly more likely to have an HMV than men aged 50 to 69 years (OR, 1.30; 95% CI, 1.10-1.54). Among adults aged 70 years and older, there were no significant sex differences in receiving HMVs. Physician and practice characteristics associated with providing HMVs included practice size (> or = 3 full-time physicians) (OR, 1.34; 95% CI, 1.01-1.77), physician contemplation of changing approaches to cancer screening (OR, 1.33; 95% CI, 1.04-1.70), and physician female sex (OR, 1.33; 95% CI, 1.04-1.70). Physician age and specialty (general internist or family physician) were not associated with the level of health maintenance delivery. CONCLUSION: Certain subgroups, such as smokers, patients in smaller practices, and physicians not yet considering changing their approach to cancer screening, could be targeted in future intervention studies designed to provide preventive services in primary care settings.     

Use of the acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI) to assist with triage of patients with chest pain or other symptoms suggestive of acute cardiac ischemia. A multicenter, controlled clinical trial

BACKGROUND: Approximately 6 million U.S. patients present to emergency departments annually with symptoms suggesting acute cardiac ischemia. Triage decisions for these patients are important but remain difficult. OBJECTIVE: To test whether computerized prediction of the probability of acute ischemia, used with electrocardiography, improves the accuracy of triage decisions. DESIGN: Controlled clinical trial. SETTING: 10 hospital emergency departments in the midwestern, southeastern, and northeastern United States. PATIENTS: 10689 patients with chest pain or other symptoms suggestive of acute cardiac ischemia. INTERVENTION: The probability of acute ischemia predicted by the acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI), either automatically printed or not printed on patients' electrocardiograms. MEASUREMENTS: Emergency department triage to a coronary care unit (CCU), telemetry unit, ward, or home. Other measurements were the bed capacity of the CCU relative to that of the telemetry unit; training or supervision status of the triaging physician; and patient diagnoses and outcomes based on clinical, electrocardiographic, and creatine kinase data. RESULTS: For patients without cardiac ischemia, in hospitals with high-capacity CCUs and relatively low-capacity cardiac telemetry units, use of ACI-TIPI was associated with a reduction in CCU admissions from 15% to 12%, a change of -16% (95% CI, -30% to 0%), and an increase in emergency department discharges to home from 49% to 52%, a change of 6% (CI, 0% to 14%; overall P=0.09). Across all hospitals, for patients evaluated by unsupervised residents, use of ACI-TIPI was associated with a reduction in CCU admissions from 14% to 10%, a change of -32% (CI, -55% to 3%); a reduction in telemetry unit admissions from 39% to 31%, a change of -20% (CI, -34% to -2%); and an increase in discharges to home from 45% to 56%, a change of 25% (CI, 8% to 45%; overall P=0.008). Among patients with stable angina, in hospitals with high-capacity CCUs, use of ACI-TIPI was associated with a reduction in CCU admissions from 26% to 13%, a change of -50% (CI, -70% to -17%), and an increase in discharges to home from 20% to 22%, a change of 10% (CI, -29% to 71%; overall P=0.02). At hospitals with high-capacity telemetry units, use of ACI-TIPI was associated with a reduction in telemetry unit admissions from 68% to 59%, a change of -14% (CI, -27% to 1%), and an increase in emergency department discharges to home from 10% to 21%, a change of 100% (CI, 22% to 230%; overall P=0.02). Among patients with acute myocardial infarction or unstable angina, use of ACI-TIPI did not change appropriate admission (96%) to the CCU or telemetry unit at hospitals with high-capacity CCUs or telemetry units. CONCLUSIONS: Use of ACI-TIPI was associated with reduced hospitalization among emergency department patients without acute cardiac ischemia. This result varied as expected according to the CCU and cardiac telemetry unit capacities and physician supervision at individual hospitals. Appropriate admission for unstable angina or acute infarction was not affected. If ACI-TIPI is used widely in the United States, its potential incremental impact may be more than 200000 fewer unnecessary hospitalizations and more than 100000 fewer unnecessary CCU admissions.     

Prevalence of risk factors in spontaneous intracerebral hemorrhage and aneurysmal subarachnoid hemorrhage

OBJECTIVE: To evaluate whether differences exist in the occurrence of modifiable risk factors between aneurysmal subarachnoid hemorrhage and spontaneous intracerebral hemorrhage, since these stroke subtypes have frequently been combined in epidemiological studies and labeled hemorrhagic stroke. DESIGN: Cross-sectional survey. SETTING: Helsinki University Central Hospital in Helsinki, Finland. PATIENTS: One hundred fifty-six consecutive patients with spontaneous intracerebral hemorrhage aged 16 to 60 years (96 males and 60 females) and 281 patients with aneurysmal subarachnoid hemorrhage (145 males and 136 females) who were admitted to an emergency department. MAIN OUTCOME MEASURES: Prevalence of several health habits, previous diseases, and medication of patients with spontaneous intracerebral hemorrhage were compared with that of patients with subarachnoid hemorrhage using multiple logistic regression. RESULTS: Hypertension (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.6-4.3), diabetes mellitus (OR, 26.4; 95% CI, 3.1-221.6), alcohol intake within the preceding week (for 1-150 g of alcohol: OR, 2.0; 95% CI, 1.1-3.6; for 151-300 g of alcohol: OR, 1.7; 95% CI, 0.8-3.8; and for > 300 g of alcohol: OR, 4.4; 95% CI, 2.1-9.1), and anticoagulant treatment (OR, 21.8; 95% CI, 2.3-207.3) were all significantly more common, but current cigarette smoking (OR, 0.3; 95% CI, 0.2-0.5) was less common in patients with intracerebral hemorrhage than in those with subarachnoid hemorrhage simultaneously after adjustment for sex, age, and body mass index. In males, hypertension (OR, 2.3; 95% CI, 1.1-4.5) and alcohol intake (for > 300 g/wk: OR, 5.8; 95% CI, 2.2-15.7) were more common, but current smoking (OR, 0.2; 95% CI, 0.1-0.4) was less common in patients with intracerebral hemorrhage than in those with subarachnoid hemorrhage after adjustment for age, body mass index, and diabetes mellitus. In females, hypertension (OR, 2.9; 95% CI, 1.4-5.8) and anticoagulant treatment (OR, 10.0; 95% CI, 1.0-100.2) were more common in patients with intracerebral hemorrhage after adjustment for age and body mass index. In univariate statistics, patients with intracerebral hemorrhage were also older, more often had previous symptoms of cerebral ischemia, and had higher values for body mass index and gamma-glutamyltransferase than did those with subarachnoid hemorrhage. CONCLUSIONS: Hypertension, diabetes mellitus, anticoagulant treatment, and amount of alcohol taken within 1 week seem more commonly to be associated with intracerebral hemorrhage than with subarachnoid hemorrhage, which is, however, associated more frequently with cigarette smoking.     

Leptospirosis: prognostic factors associated with mortality

To determine the prognostic factors for leptospirosis, we conducted a retrospective study of data collected in the emergency department of our hospital between 1989 and 1993. Sixty-eight patients, for whom the diagnosis of leptospirosis was based on pertinent clinical and epidemiological data and positive serology, were included in this study. Fifty-six patients (82%) were discharged from the hospital, and 12 (18%) died. Multivariate logistic regression demonstrated that five factors were independently associated with mortality: dyspnea (odds ratio [OR], 11.7; 95% confidence interval [CI], 2.8-48.5; P < .05), oliguria (OR, 9; CI, 2.1-37.9; P < .05); white blood cell count, >12,900/mm3 (OR, 2.5; CI, 1.8-3.5; P < or = .01), repolarization abnormalities on electrocardiograms (OR, 5.9; CI, 1.4-24.8; P < or = .01), and alveolar infiltrates on chest radiographs (OR, 7.3; CI, 1.7-31.7; P < or = .01). Identification of these factors on admission might provide useful selection criteria for patients who need early transfer to the intensive care unit.     

Asthma, employment status, and disability among adults treated by pulmonary and allergy specialists

STUDY OBJECTIVE: Identify risk factors for work disability among adults with asthma treated by pulmonary and allergy specialists. DESIGN: Cross-sectional survey, including retrospective work history data. PARTICIPANTS: Sixty-eight pulmonary and 16 allergy internal medicine subspecialists maintaining a registry of patient visits for asthma; 698 registered patients aged 18 to 50 years, of whom 601 (86%) were studied. MEASURES: Computer-assisted, telephone-administered structured interview assessing asthma severity, perceived general health status, asthma quality of life, demographics, and work history. Complete work disability defined as total work cessation attributed to asthma; partial work disability defined as change in job, duties, or reduction in work hours attributed to asthma. RESULTS: Complete cessation of work due to asthma was reported by 40 (7%; 95% confidence interval [CI], 5 to 9%) and partial work disability by 53 (10%; 95% CI, 7 to 12%) of 550 subjects with a history of labor force participation. Severity of asthma score predicted both complete disability (odds ratio [OR], 7.9; 95% CI, 4.2 to 15 per 10-point increment) and partial disability (OR 2.6; 95% CI, 1.6 to 4.2). Taking illness severity into account, job conditions, occupation, and work exertion carried a combined disability OR of 3.9 (95% CI, 1.7 to 8.6). CONCLUSIONS: Work disability is common among adults with asthma receiving specialist care. Severity of disease is a powerful predictor, but not the sole predictor of disability in this group. Working conditions, including job-related exposures, are associated with added disability risk even after taking illness severity into account.