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C K Francis

Publications and source records attributed to C K Francis.

At least 19 recordsLinked to original sources
PubMed2001

Medical ethos and social responsibility in clinical medicine.

The medical profession will face many challenges in the new millenium. As medicine looks forward to advances in molecular genetics and the prospect of unprecedented understanding of the causes and cures of human disease, clinicians, scientists, and bioethicists may benefit from reflection on the origins of the medical ethos and its relevance to postmodern medicine. Past distortions of the medical ethos, such as Nazism and the Tuskegee Syphilis Study, as well as more recent experience with the ethical challenges of employer-based, market-driven managed care, provide important lessons as medicine contemplates the future. Racial and ethnic disparities in health status and access to care serve as reminders that the racial doctrines that fostered the horrors of the Holocaust and the Tuskegee Syphilis Study have not been removed completely from contemporary thinking. Inequalities in health status based on race and ethnicity, as well as socioeconomic status, attest to the inescapable reality of racism in America. When viewed against a background of historical distortions and disregard for the traditional tenets of the medical ethos, persistent racial and ethnic disparities in health and the prospect of genetic engineering raise the specter of discrimination because of genotype, a postmodern version of "racist medicine" or of a "new eugenics." There is a need to balance medicine's devotion to the well-being of the patient and the primacy of the patient-physician relationship against the need to meet the health care needs of society. The challenge facing the medical profession in the new millennium is to establish an equilibrium between the responsibility to ensure quality health care for the individual patient while effecting societal changes to achieve "health for all."

Black or African American↗
PubMed2001

The medical ethos and social responsibility in clinical medicine.

The medical profession will face many challenges in the new millennium. As medicine looks forward to advances in molecular genetics and the prospect of unprecedented understanding of the causes and cures of human disease, clinicians, scientists and bioethicists may benefit from reflection upon the origins of the medical ethos and its relevance to postmodern medicine. Past distortions of the medical ethos, such as Nazism and the Tuskegee Syphilis Study, as well as more recent experience with the ethical challenges of employer-based market driven managed care, provide important lessons as medicine contemplates the future. Racial and ethnic disparities in health status and access to care serve as a reminders that the racial doctrines that fostered the horrors of the Holocaust and the Tuskegee Syphilis Study have not been completely removed from contemporary thinking. Inequalities in health status based on race and ethnicity, as well as socioeconomic status, attest to the inescapable reality of racism in America. When viewed against a background of historical distortions and disregard for the traditional tenets of the medical ethos, persistent racial and ethnic disparities and health and the prospect of genetic engineering raise the specter of discrimination because of genotype, a postmodern version of "racist medicine" or of a "new eugenics." There is a need to balance medicine's devotion to the wellbeing of the patient and the primacy of the patient-physician relationship against with the need to meet the health care needs of society. The challenge facing the medical profession in the new millennium is to establish an equilibrium between the responsibility to assure quality health care for the individual patient while affecting societal changes to achieve "health for all."

Black People↗
PubMed2000

Plasma sphingomyelin level as a risk factor for coronary artery disease.

Only a fraction of the clinical complications of atherosclerosis are explained by known risk factors. Animal studies have shown that plasma sphingomyelin (SM) levels are closely related to the development of atherosclerosis. SM carried into the arterial wall on atherogenic lipoproteins may be locally hydrolyzed by sphingomyelinase, promoting lipoprotein aggregation and macrophage foam cell formation. A novel, high-throughput, enzymatic method to measure plasma SM levels has been developed. Plasma SM levels were related to the presence of coronary artery disease (CAD) in a biethnic angiographic case-control study (279 cases and 277 controls). Plasma SM levels were higher in CAD patients than in control subjects (60+/-29 versus 49+/-21 mg/dL, respectively; P:<0. 0001). Moreover, the ratio of SM to SM+phosphatidylcholine (PC) was also significantly higher in cases than in controls (0.33+/-0.13 versus 0.29+/-0.10, respectively; P:<0.0001). Similar relationships were observed in African Americans and whites. Plasma SM levels showed a significant correlation with remnant cholesterol levels (r=0.51, P:<0.0001). By use of multivariate logistic regression analysis, plasma SM levels and the SM/(SM+PC) ratio were found to have independent predictive value for CAD after adjusting for other risk factors, including remnants. The odds ratio (OR) for CAD was significantly higher for the third and fourth quartiles of plasma SM levels (OR 2.81 [95% CI 1.66 to 4.80] and OR 2.33 [95% CI 1.38 to 3. 92], respectively) as well as the SM/(SM+PC) ratio (OR 1.95 [95% CI 1.10 to 3.45] and OR 2.33 [95% CI 1.34 to 4.05], respectively). The findings indicate that human plasma SM levels are positively and independently related to CAD. Plasma SM levels could be a marker for atherogenic remnant lipoprotein accumulation and may predict lipoprotein susceptibility to arterial wall sphingomyelinase.

Case-Control Studies↗
PubMed2000

High levels of Lp(a) with a small apo(a) isoform are associated with coronary artery disease in African American and white men.

Elevated levels of lipoprotein(a) [Lp(a)] and the presence of small isoforms of apolipoprotein(a) [apo(a)] have been associated with coronary artery disease (CAD) in whites but not in African Americans. Because of marked race/ethnicity differences in the distribution of Lp(a) levels across apo(a) sizes, we tested the hypothesis that apo(a) isoform size determines the association between Lp(a) and CAD. We related Lp(a) levels, apo(a) isoforms, and the levels of Lp(a) associated with different apo(a) isoforms to the presence of CAD (>/=50% stenosis) in 576 white and African American men and women. Only in white men were Lp(a) levels significantly higher among patients with CAD than in those without CAD (28.4 versus 16.5 mg/dL, respectively; P:=0.004), and only in this group was the presence of small apo(a) isoforms (<22 kringle 4 repeats) associated with CAD (P:=0.043). Elevated Lp(a) levels (>/=30 mg/dL) were found in 26% of whites and 68% of African Americans, and of those, 80% of whites but only 26% of African Americans had a small apo(a) isoform. Elevated Lp(a) levels with small apo(a) isoforms were significantly associated with CAD (P:<0.01) in African American and white men but not in women. This association remained significant after adjusting for age, diabetes mellitus, smoking, hypertension, HDL cholesterol, LDL cholesterol, and triglycerides. We conclude that elevated levels of Lp(a) with small apo(a) isoforms independently predict risk for CAD in African American and white men. Our study, by determining the predictive power of Lp(a) levels combined with apo(a) isoform size, provides an explanation for the apparent lack of association of either measure alone with CAD in African Americans. Furthermore, our results suggest that small apo(a) size confers atherogenicity to Lp(a).

Black or African American↗
PubMed1998

Hypertensive vascular disease as a cause of death in blacks versus whites: autopsy findings in 587 adults.

Cardiovascular disease is the major cause of excess mortality among urban US blacks, but autopsy data comparing black-white differences in underlying pathological causes of cardiovascular death are lacking. We reviewed all 720 adult cases autopsied in 1991 in the New York City Medical Examiner's Office in which the coded cause of death was cardiovascular disease (International Classification of Diseases, 9th Revision, codes 391, 393 to 398, 401 to 404, 410, 411, 414 to 417, 420 to 438, and 440 to 444). After exclusion of 133 cases because race was missing or coded as other than black or white, gender was not coded, or there was an unusual circumstances of death or extreme obesity, 587 cases were available for analysis. There were 314 black and 273 white subjects. Black women were younger than white women at time of death (mean age, 54.7 versus 61.5 years; P<.001), whereas black and white men did not differ in mean age at death. Hypertensive vascular disease was the autopsy cause of death in 42% of blacks compared with 23% of whites (P<.001). Conversely, atherosclerotic heart disease was the autopsy cause of death in 64% of white subjects but only 38% of blacks. These patterns were consistent in both sexes and after adjustment for age. Hypertensive vascular disease was far more common than atherosclerotic heart disease as the cause of death at autopsy among blacks compared with whites in New York City, whereas atherosclerotic heart disease was more common in whites. These findings suggest that ineffective control of hypertension is a major factor contributing to excess cardiovascular mortality among urban blacks.

Adult↗
PubMed1997

Coronary revascularization and cardiac catheterization in the United States: trends in racial differences.

OBJECTIVES: We sought to determine whether racial differences in rates of coronary artery bypass graft surgery (CABG), percutaneous transluminal coronary angioplasty (PTCA) and cardiac catheterization decreased after 1980. BACKGROUND: Many reports of racial differences in utilization of CABG have been published since 1982. However, changes in the relative utilization of revascularization over time have received little attention. METHODS: Data from the National Hospital Discharge Survey were examined for the years 1980 through 1993. Estimated numbers of procedures performed in nonfederal U.S. hospitals were used to compute age-adjusted rates per 100,000 population by year and race for patients 35 to 84 years old. RESULTS: In patients 35 to 84 years old, the rate of CABG increased in blacks and whites between 1980 and 1993. Between 1986 and 1993, there was little change in the black/white ratio of age-adjusted rates (0.23 in 1980 through 1985 combined, 0.38 in 1986 and 0.43 in 1993). An apparent increase from 0.23 in 1980 through 1985 combined may have been due to sampling variation. Despite rapid increases in rates of PTCA in both races, no increase in the black/white ratio was noted (0.57 in 1993). However, the rate of inpatient cardiac catheterization increased more rapidly in blacks than in whites. This resulted in an increase in the black/white ratio of age-adjusted rates from 0.42 in 1980 to 0.91 in 1993. CONCLUSIONS: Rates of CABG, cardiac catheterization and especially PTCA increased between 1980 and 1993, a period during which racial disparities in the procedures became widely known. Despite apparent increases in the black/white ratio for inpatient cardiac catheterization, large racial disparities in the utilization of CABG and PTCA persist and require further evaluation and possible intervention.

Adult↗
PubMed1997

Research in coronary heart disease in blacks: issues and challenges.

Research on coronary heart disease (CHD) has contributed to the decline in cardiovascular disease morbidity and mortality during the past three decades. However, life expectancy and rates of illness and death from CHD have not improved for blacks as for whites. Blacks have not experienced the full benefit of research advancements for a variety of reasons, including insufficient scientific data, lack of research focused on minority populations, and limited access to health care resources and technology. In order to address these disparities in prevention, diagnosis, treatment, and outcomes of CHD in blacks, the National Heart, Lung, and Blood Institute converted a Working Group on Research in Coronary Heart Disease in Blacks. In its deliberations, the working group identified 10 priority research areas, which are treatment, epidemiology (data collection and analysis), evaluation of chest pain and diagnosis of CHD, prevention and behavior, risk factors, genetics, vascular biology, left ventricular hypertrophy, coronary microvasculature, and sudden cardiac death.

Black or African American↗
PubMed1996

Hemodynamic correlates of spontaneous echo contrast in the descending aorta.

To identify the hemodynamic association of spontaneous echo contrast (SEC) in the descending aorta (DA), we measured aortic flow parameters in 102 consecutive patients studied with transesophageal echocardiography. SEC in the DA was identified in 19 of 102 patients (19%). Patients with SEC in the DA were older (67 +/- 9 vs 57 +/- 17 years; p = 0.001), had a higher proportion of chronic atrial arrhythmia (13 of 19 vs 11 of 83; p = 0.000001), and had a higher frequency of decreased left ventricular performance (10 of 19 vs 19 of 83; p = 0.01). Patients with SEC in the DA had larger aortic diameters (2.9 +/- 0.5 vs 2.3 +/- 0.4 cm; p = 0.0001), lower maximal velocity in the DA (42.6 +/- 12.8 vs 75.6 +/- 34.4 cm/s; p = 0.0001), and lower maximal shear rate (61.6 +/- 20.3 vs 139.9 +/- 78.8 s-1; p = 0.0001). There was no difference in volumetric flow in the DA between groups. In multivariate analysis, only arrhythmia (p = 0.008) and maximal shear rate (p = 0.002) were identified as significant independent predictors of SEC in the DA. We conclude that SEC in the DA is related to chronic atrial arrhythmia and shear rate but not to volumetric flow.

Adult↗
PubMed1996

New staging system of the fifth Joint National Committee report on the detection, evaluation, and treatment of high blood pressure (JNC-V) alters assessment of the severity and treatment of hypertension.

The fifth Joint National Committee report on the detection, evaluation, and treatment of high blood pressure (JNC-V) introduced a new system of blood pressure classification that incorporated systolic blood pressure (SBP) and established new diastolic blood pressure (DBP) cut points. With the previous JNC classification, subjects were classified according to DBP alone. In this study, our purpose was to assess the effect of the new staging system on the assessment of hypertension severity and to determine whether' the new JNC-V staging system better identifies individuals at risk for hypertensive target-organ damage. We compared the assessment of hypertension severity using JNC-IV with that using JNC-V in 1158 subjects enrolled in the Harlem Hospital Hypertension Clinic database from 1975 to 1992. We used pretreatment DBP to classify subjects according to JNC-IV criteria. These subjects were reclassified into one of the four stages of JNC-V. The assessment of hypertension severity and prevalence of organ damage in subjects who remained in the same category of severity in both systems was compared with damage in subjects who were upstaged. With the JNC-V classification, 321 subjects remained in the same category, and 837 were upstaged. Six hundred and four subjects moved up because of the new cut points of DBP, and 275 were upstaged because of higher SBP. Upstaged subjects had more manifestations of hypertensive target-organ damage. With the new JNC-V classification system, hypertension is assessed as severe or very severe in more individuals than with JNC-IV. Subjects who are upstaged in JNC-V are more likely to have evidence of renal disease and other target-organ damage.

Adult↗
PubMed1994

Task Force 1: The underserved.

The ACC has affirmed its commitment to universal access to health care. Underserved populations exist in urban and rural centers. Common to each is a paucity of personnel trained in cardiovascular care and a lack of access to preventive and highly technologic services. These factors contribute to a poor health outcome (75). Part of the rural problem can be corrected by the transfer of information to local providers by the use of new information systems. Included would be real-time electronic consultation, on-site subspecialty visits and the appropriate use of nonphysician providers (15). The urban problem requires changes in priorities and responsibilities of the academic health centers toward the communities they serve. Curricula changes of cardiovascular specialists, internists, generalists and nonphysician health care personnel must include diversity in training, physician training of ethnically matched providers in addition to technical excellence and research into methods of patient education and motivation for a healthier life-style (51). Reimbursement must appropriately reward those caring for underserved patients and those providing evaluation and management services (43,52).

Academic Medical Centers↗
PubMed1993

Effect of thrombolysis on acute mitral regurgitation during evolving myocardial infarction. Experience from the Thrombolysis in Myocardial Infarction (TIMI) Trial.

OBJECTIVES: This study was undertaken to determine whether early successful thrombolysis can reverse infarct-associated mitral valve dysfunction. BACKGROUND: Mitral regurgitation is a common complication of acute myocardial infarction and has been shown to adversely affect both short- and long-term prognosis. Although anecdotal reports have suggested that reperfusion of the infarct-related artery may restore normal function to the mitral valve, this theory has not been subjected to formal investigation. METHODS: Patients with total or partial obstruction of the infarct-related artery received intravenous thrombolytic therapy with either streptokinase or recombinant tissue-type plasminogen activator within 7 h of symptom onset (mean 4.8 h) as part of the Thrombolysis in Myocardial Infarction (TIMI) Phase I trial. Repeat coronary angiography assessed arterial patency at 90 min and 10 days after attempted reperfusion. The presence and severity of mitral regurgitation were determined by contrast ventriculography both before thrombolysis and before hospital discharge. RESULTS: Overall, 21 (16%) of the 132 study patients exhibited mitral regurgitation on either their initial or their predischarge ventriculogram. The proportion of infarct-related arteries found to be patent (TIMI flow grade 2 or 3) was statistically similar in patients with and without mitral regurgitation during each angiographic evaluation period (initial, 90 min and 10 days). Although coronary artery perfusion increased overall during sequential measurement (mean TIMI grade was 0.4 +/- 0.6 initially, 1.5 +/- 1.3 at 90 min and 2.2 +/- 1.0 at 10 days), the pattern of reperfusion observed could not predict an increase or decrease in regurgitant severity (p = NS). Early mitral regurgitation resolved in 57% of patients by 10 days, but this resolution appeared independent of the presence or absence of improved coronary perfusion (60% vs. 50%). The development of new regurgitation during the recovery period (6%) was also unrelated to improved perfusion (7% vs. 4%). CONCLUSIONS: Acute mitral regurgitation developing during myocardial infarction shows frequent changes in its presence or severity during the 1st 10 days, appears independent of coronary artery patency both early and late after thrombolysis and cannot be reliably treated by improving arterial perfusion with thrombolytic agents.

Acute Disease↗
PubMed1992

Predisposing factors for severe, uncontrolled hypertension in an inner-city minority population.

BACKGROUND: Hypertensive emergency and urgent hypertension are the most severe forms of uncontrolled hypertension and are now seen predominantly in poor, minority populations. We studied the characteristics of the medical care received by patients with these conditions in order to identify risk factors for severe, uncontrolled hypertension. METHODS: Using a case-control study design, we interviewed 93 patients with severe, uncontrolled hypertension who presented in the hospital emergency room and 114 control patients with hypertension; both groups were seen at two New York City hospitals from 1989 through 1991. All the patients were black or Hispanic. Multiple logistic-regression models were used to adjust for age, sex, race or ethnic background, education, smoking status, alcohol-related problems, and use of illicit drugs during the previous year. RESULTS: After additional adjustment for lack of health insurance, severe, uncontrolled hypertension was found to be more common among patients who had no primary care physician (adjusted odds ratio, 3.5; 95 percent confidence interval, 1.6 to 7.7) and among those who did not comply with treatment for their hypertension (adjusted odds ratio, 1.9; 95 percent confidence interval, 1.4 to 2.5). Lack of health insurance was marginally associated with severe, uncontrolled hypertension (adjusted odds ratio, 1.9; 95 percent confidence interval, 0.8 to 4.6) after adjustment for lack of a primary care physician and noncompliance with antihypertensive treatment. Patients without a primary care physician and without health insurance were more likely to have their blood pressure checked and receive prescriptions for blood-pressure medications in emergency rooms than in physicians' offices or clinics. CONCLUSIONS: Characteristics of both the health care system and patients' behavior are associated with severe, uncontrolled hypertension. Improving access to primary care physicians, through health insurance or other means, may be an effective strategy for improving control of hypertension in disadvantaged minority populations.

Adult↗
PubMed1992

Mitral regurgitation in early myocardial infarction. Incidence, clinical detection, and prognostic implications. TIMI Study Group.

OBJECTIVE: To investigate mitral regurgitation occurring early in the course of acute myocardial infarction with respect to its incidence, the impact of infarct size and location, the accuracy of clinical detection, the contribution of global and regional left ventricular performance, and its influence on prognosis. DESIGN: Prospective observational study derived from patients entering Phase I of the Thrombolysis in Myocardial Infarction (TIMI) trial. SETTING: Multicenter trial involving 13 university-affiliated medical centers. PATIENTS: A total of 206 patients studied within 7 hours of symptom onset during their first myocardial infarction. MEASUREMENTS: Contrast left ventriculography was used to document mitral regurgitation. RESULTS: Mitral regurgitation was present in 27 patients (13%). Although the presence of regurgitation correlated with the site of infarction (20 of 27 had anterior infarctions) and the number of akinetic chords, it was not statistically related to the peak creatine kinase value or to left ventricular chamber size or filling pressure. A murmur of mitral regurgitation was heard in only 2 patients (1 incorrectly). The presence of early mitral regurgitation predicted cardiovascular mortality at 1 year by univariate (relative risk, 12.2; 95% Cl, 3.5 to 42; P less than 0.0001) and multivariate (relative risk, 7.5; Cl, 2.0 to 28.6; P = 0.0008) analyses. CONCLUSIONS: Mitral regurgitation in early myocardial infarction is generally clinically "silent," is more common in anterior infarction, is associated with regional dysfunction but not early ventricular dilation or peak enzyme release, and is an important predictor of cardiovascular mortality.

Adult↗
PubMed1992

Correlates of nonadherence to hypertension treatment in an inner-city minority population.

OBJECTIVE: Adherence to treatment is a key factor in achieving blood pressure control among hypertensives. We examined correlates of nonadherence to hypertension treatment in an inner-city minority population. METHODS: Subjects (n = 202) were interviewed as part of a case-control study of severe, uncontrolled hypertension conducted in two New York City hospitals in 1989-91. All subjects were African American or Hispanic. Self-reported nonadherence to drug treatment for hypertension was measured using a five-item scale, and the sample was dichotomized as more (n = 87) or less (n = 115) adherent. Multiple logistic regression analysis was used to adjust for demographic and other covariates. RESULTS: Nonadherence was associated with having blood pressure checked in an emergency room (adjusted odds ratio [OR] = 7.9; 95% confidence interval [CI] = 1.75, 35.77; P < .01), lack of a primary care physician (adjusted OR = 2.9; 95% CI = 1.37, 6.02; P < .01), current smoking (adjusted OR = 2.4; 95% CI = 1.10, 5.22; P = .03), and younger age (adjusted OR = 1.03, 95% CI = 1.00, 1.06; P = .03). CONCLUSIONS: Changing the locus of care for hypertension from emergency rooms to primary care physicians may improve adherence to hypertension treatment in minority populations.

Adult↗
PubMed1991

Hypertension, cardiac disease, and compliance in minority patients.

In minorities, as in the general population, hypertension is taken seriously because it is a risk factor for cardiovascular disease. Until recently, our understanding of the role that hypertension plays in the heart disease seen in minorities has been limited by a paucity of prospective data regarding the prevalence, natural history, and pathophysiology of the disease process in minority populations. In the last few years large-scale epidemiologic studies and well-controlled clinical studies alike have confirmed usually high rates of hypertension-related morbidity and mortality in minorities, particularly blacks and Hispanics. The severity of end-organ damage, both cardiac and renal, that is seen in these patients--especially when coupled with the severe cerebrovascular damage that is also more common in black and Hispanic hypertensives--mandate that more effective public health measures be taken to reduce the incidence of hypertension in these patient populations. Because hypertension is usually without significant clinical symptoms, noncompliance with drug therapy and high dropout rates are common in all patient populations. They are strikingly higher in inner-city populations, however, where illiteracy, poverty, homelessness, and high rates of chemical dependency combine to exacerbate an already serious problem in treating hypertensive patients. Inner-city patients are, increasingly, black and Hispanic patients, and these patients are more likely to be underinsured or uninsured, to be functionally illiterate in English, to be disinclined to seek health care, and to be less capable of following a prescribed regimen than the populace as a whole. The nature of the therapeutic regimen itself is probably the most important determinant of compliance, and compliance with drug therapy will be improved if the clinic chooses a simplified drug regimen and avoids drugs that produce intolerable side effects. Once-a-day--or, with transdermal clonidine, one-a-week--single-drug therapy may not be possible in all patients, but multiple drug therapy and multiple daily dosing schedules should be avoided wherever possible.

Black or African American↗