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Biomedical subjects

J P Burke

Publications and source records attributed to J P Burke.

At least 19 recordsLinked to original sources
PubMed2003

Surgical correction of large-angle exotropia in adults.

AIM: A retrospective and longitudinal review of the outcome of strabismus surgery for adults with large- and very-large-angle manifest exodeviations, using two-, three- and four muscle horizontal recti surgery with adjustable sutures. METHODS: A total of 26 consecutive adult patients undergoing surgery for socially noticeable strabismus comprising five primary, 16 consecutive, and five secondary constant exotropias with a mean near deviation of 58 prism dioptres and a mean distance deviation of 55Delta were evaluated preoperatively and at various time intervals postoperatively. Surgery involved two muscles in seven cases, three muscles in 13 cases, and four muscles in six cases; and 25 of 26 had adjustable sutures. There was a horizontal preoperative ocular movement deficit in 17 that was asymmetrical in four cases. RESULTS: Binocularity was restored in eight patients (31%), 20 (77%) were within 10Delta of orthotropia, and 24 (92%) were happy with their cosmesis. Two had symptomatic asymmetrical ocular motility deficits postoperatively following a two-muscle procedure and one required reoperation. A total of 19 patients undergoing three- or four-muscle surgery were asymptomatic postoperatively. A total of 22 patients had follow-up of 8 months or more. CONCLUSION: In adults with large-angle manifest exodeviations, adjustable suture surgery involving three or more horizontal recti successfully restores primary position alignment, a high degree of patient satisfaction, and can be expected to be associated with a low incidence of symptomatic postoperative asymmetrical ocular movement deficits.

Adolescent↗
PubMed2001

Maximizing appropriate antibiotic prophylaxis for surgical patients: an update from LDS Hospital, Salt Lake City.

Errors in antimicrobial prophylaxis for surgical patients remain one of the most frequent types of medication errors in hospitals. Failure to administer the first dose of antimicrobial prophylaxis within the 2-h window of time before incision is associated with 2- to 6-fold increases in rates of surgical site infection. Optimal use of antimicrobial prophylaxis includes proper case selection; use of appropriate agents; proper dosing, route of administration, timing, and duration; and intraoperative dosing when appropriate. Effective use of antimicrobial prophylaxis also requires monitoring of and feedback on patterns of use. Programs to improve antimicrobial prophylaxis should be multidisciplinary and should aim to improve use of medications, not simply to change physician practice patterns. The LDS Hospital experience demonstrates the clinical and financial benefits of such a program and also shows the pitfalls of and great difficulties associated with changing systems of care.

Anti-Infective Agents↗
PubMed2001

The epidemiology of nephrotoxicity associated with conventional amphotericin B therapy.

PURPOSE: We sought to quantify the incidence of, define risk factors for, and examine the relation between renal functional impairment and treatment with conventional amphotericin B. SUBJECTS AND METHODS: We performed a 9-year retrospective analysis of amphotericin B-associated nephrotoxicity in 494 adult inpatients who received > or = 2 doses of amphotericin B. Nephrotoxicity was classified according to two nonmutually exclusive severity categories (50% increase or doubling in the baseline creatinine level). RESULTS: The median cumulative dosage of amphotericin B was 240 mg (interquartile range, 113 to 500 mg), with the majority of patients (n = 361) receiving it for empiric treatment. Overall, 139 (28%) patients experienced renal toxicity, including 58 (12%) with moderate-to-severe nephrotoxicity. The rate of nephrotoxicity was relatively constant during amphotericin B treatment. For each 10-mg increase in the mean daily amphotericin B dose, the adjusted rate of renal toxicity increased by a factor of 1.13 (95% confidence interval: 1.02 to 1.25). We defined 5 categorical risk factors: mean daily amphotericin B dose > or = 35 mg, male sex, weight > or = 90 kg, chronic renal disease, and use of amikacin or cyclosporine. The incidence of moderate-to-severe nephrotoxicity was 4% (6 of 137) in patients with none of these risk factors, 8% (14 of 181) in those with 1 risk factor, 18% (21 of 117) in those with 2 risk factors, and 29% (17 of 59) in patients with > or = 3 risk factors. Nephrotoxicity rarely led to hemodialysis (n = 3); however, at the time of discharge or death, 70% of patients with moderate-to-severe nephrotoxicity had a serum creatinine level that was > or = 0.5 mg/dL above baseline. CONCLUSION: Amphotericin B-related nephrotoxicity is an important dose-dependent and duration-dependent toxicity that is accentuated by certain nephrotoxic drugs and patient characteristics. Patients with more than two risk factors for nephrotoxicity are potential candidates for alternative antifungal therapy.

Adult↗
PubMed2001

Menopause in type 1 diabetic women: is it premature?

Women with type 1 diabetes have a delayed menarche and a greater prevalence of menstrual disorders than women without diabetes. However, little is known about the menopause transition among type 1 diabetic women. The Familial Autoimmune and Diabetes (FAD) Study recruited both adult individuals who were identified from the Children's Hospital of Pittsburgh Type 1 Diabetes Registry for the years 1950-1964 and their family members. Unrelated nondiabetic control probands and their relatives were also evaluated. Women with type 1 diabetes (n = 143) compared with nondiabetic sisters (n = 186) or unrelated control subjects (n = 160) were more likely to have an older age at menarche (13.5, 12.5, and 12.6 years, respectively, P < 0.001), more menstrual irregularities before 30 years of age (45.7, 33.3, and 33.1%, respectively, P = 0.04), and a younger age at menopause (41.6, 49.9, and 48.0 years, respectively, P = 0.05). This resulted in a 6-year reduction in the number of reproductive years (30.0, 37.0, and 35.2 years, respectively, P = 0.05) for women with type 1 diabetes. Risk factors univariately associated with earlier menopause included type 1 diabetes (hazard ratio [HR] 1.99, P = 0.04), menstrual irregularities before 30 years of age (HR 1.87, P = 0.04), nulliparity (HR 2.14, P = 0.01), and unilateral oophorectomy (HR 6.51, P < 0.0001). Multivariate analysis confirmed that type 1 diabetes (HR 1.98, P = 0.056), menstrual irregularities by 30 years of age (HR 2.36, P = 0.01), and unilateral oophorectomy (HR 9.76, P < 0.0001) were independent determinants of earlier menopause in our cohort. We hypothesize that an earlier menopause, which resulted in a 17% decrease in reproductive years, is a major unstudied complication of type 1 diabetes.

Adult↗
PubMed2001

Elevated incidence of type 2 diabetes in San Antonio, Texas, compared with that of Mexico City, Mexico.

OBJECTIVE: To compare the incidence of type 2 diabetes between low-income Mexican-Americans residing in San Antonio, Texas, and low-income residents in Mexico City, Mexico. RESEARCH DESIGN AND METHODS: Using data from the San Antonio Heart Study and the Mexico City Diabetes Study, we compared the incidence of type 2 diabetes in 35- to 64-year-old low-income Mexican-American residents of San Antonio with similarly aged low-income residents of Mexico City. Because of the different follow-up times in the two studies, Poisson regression was used to compare the rates of diabetes. Potential risk factors for diabetes were also analyzed to determine whether they explained or contributed to a difference in incidence. RESULTS: The age- and sex-adjusted incidence of type 2 diabetes was significantly higher in San Antonio (RR 2.01) compared with Mexico City. This difference was seen primarily in the oldest age group (55-64 years of age) and remained statistically significant after adjusting for a number of diabetes risk factors, including demographic, anthropometric, and metabolic variables. Follow-up rates were similar in both cities. CONCLUSIONS: We conclude that there was a higher incidence of type 2 diabetes in San Antonio than in Mexico City, and that difference occurred primarily in individuals in the oldest age group. The potential mediating factors we examined did not account for this difference. Other factors, such as exercise and diet, which were not available for analysis in this study, in addition to a cohort effect, may have contributed to the difference in incidence of type 2 diabetes in the two cities. In addition, there was no evidence of a higher case fatality among diabetic individuals from Mexico City compared with San Antonio.

Adult↗
PubMed2001

Cerebral revascularization in trauma and carotid occlusion.

Cerebrovascular disruption frequently results from head and neck trauma. Injury to the extra- and intracranial carotid artery is uncommon but is associated with a high rate of death and permanent neurologic deficit. In this article, injuries to the carotid artery are reviewed with emphasis on the mechanisms, clinical manifestations, radiologic evaluation, and management of these traumatic lesions.

Adult↗
PubMed2000

Insulin-resistant prediabetic subjects have more atherogenic risk factors than insulin-sensitive prediabetic subjects: implications for preventing coronary heart disease during the prediabetic state.

BACKGROUND: Subjects who convert to type 2 diabetes mellitus have increased cardiovascular risk factors relative to nonconverters. However, it is not known whether these atherogenic changes in the prediabetic state are predominantly due to insulin resistance, decreased insulin secretion, or both. METHODS AND RESULTS: We examined this issue in the 7-year follow-up of the San Antonio Heart Study, in which 195 of 1734 subjects converted to type 2 diabetes. At baseline, converters had significantly higher body mass index, waist circumference, triglyceride concentration, and blood pressure and lower HDL cholesterol than nonconverters. Atherogenic changes in converters were markedly attenuated (and no longer significant) after adjustment for the homeostasis model assessment of insulin resistance (HOMA IR, a surrogate for insulin resistance); in contrast, the differences in risk factors between converters and nonconverters increased after adjustment for the ratio of early insulin increment to early glucose increment (DeltaI(30-0)/DeltaG(30-0)) during an oral glucose tolerance test (a surrogate for insulin secretion). We also compared converters who had a predominant insulin resistance (high HOMA IR and high DeltaI(30-0)/DeltaG(30-0)) (n=56) and converters who had a predominant decrease in insulin secretion (low HOMA IR and low DeltaI(30-0)/DeltaG(30-0)) (n=31) with nonconverters (n=1539). Only the converters who were insulin resistant had higher blood pressure and triglyceride levels and lower HDL cholesterol levels than nonconverters. CONCLUSIONS: Our data suggest that atherogenic changes in the prediabetic state are mainly seen in insulin-resistant subjects and that strategies to prevent type 2 diabetes might focus on insulin-sensitizing interventions rather than interventions that increase insulin secretion because of potential effects on cardiovascular risk.

Adult↗
PubMed2000

Genetic basis of acanthosis nigricans in Mexican Americans and its association with phenotypes related to type 2 diabetes.

Acanthosis nigricans (AN) is a skin condition associated with hyperinsulinemia and insulin resistance and has been shown to be a risk factor for type 2 diabetes. The influence of genetic factors on AN and the basis of its association with type 2 diabetes and its risk factors are unknown. Using data from 397 participants from two Mexican American family studies, we investigated the heritability of AN and its genetic correlation with other diabetes risk factors. AN was examined as both a continuous trait and a dichotomous trait by means of a previously described validated scale. The results indicated that the heritability (h2) for AN, when examined as a continuous trait, was high (0.58+/-0.10) and statistically significant (P<0.001). The h2 for AN as a dichotomous trait was estimated to be moderate (0.23+/-0.05) and was also significant (P=0.018). The additive genetic correlations between AN (either as a continuous trait or a dichotomous trait) and type 2 diabetes and its risk factors, including body mass index and fasting insulin, were high or moderately high and statistically significant. The random environmental correlations, by contrast, were low and statistically insignificant. These data suggest that genes that influence AN have pleiotropic effects on diabetes and its risk factors.

Acanthosis Nigricans↗
PubMed2000

Rising trend in obesity in Mexican Americans and non-Hispanic whites: is it due to cigarette smoking cessation?

OBJECTIVE: Several studies have examined the influence of smoking cessation on weight gain. However, to date no study has examined this association in Mexican Americans (MA). DESIGN: Using data collected from the San Antonio Heart Study, a population-based study of diabetes and cardiovascular disease, we examined the association between smoking cessation and weight gain in 1930 Mexican Americans and 1126 non-Hispanic whites (NHW). Smoking cessation was defined as self-reported smoking at baseline but not at follow-up. RESULTS: Although there was no significant ethnic difference in the prevalence of smoking at baseline (27.2% in MA and 25.4% in NHW, P = 0.309), a greater proportion of MA smoked at follow-up compared to NHW (19.7% vs 16.5%, P = 0.037). However, there was no significant ethnic difference in the percentage of individuals who stopped smoking during the follow-up period. A two-fold greater percentage of MA quitters than NHW quitters became overweight or obese, defined as a body mass index greater than or equal to 25 kg/m2 (7.4% vs 3.1%). However, this difference did not quite reach statistical significance (P = 0.072). Using linear regression to predict change in weight or body mass index from baseline to follow-up, smoking cessation was predictive of either weight gain or BMI gain in both ethnic groups. However, smoking status accounted for only 1.0% of the variance in these outcomes, and the estimated risk of becoming overweight or obese attributable to smoking cessation was only 7.4% in MA and 3.1% in NHW. CONCLUSION: We conclude that there is an ethnic difference in the influence of smoking cessation on weight gain in MA and NHW. However, in both ethnic groups this effect is quite small and makes only a slight contribution to the overall increase in prevalence of obesity in this population.

Adult↗
PubMed1999

Rapid rise in the incidence of type 2 diabetes from 1987 to 1996: results from the San Antonio Heart Study.

BACKGROUND: The prevalence of type 2 diabetes has increased in the early part of the 20th century, particularly in developing countries. There is now evidence that the prevalence also continues to increase in developed countries, including the United States. However, it is unknown whether this increase is due to a rise in the incidence of diabetes or to decreasing diabetic mortality or both. METHODS: Participants in the San Antonio Heart Study, who were nondiabetic at baseline and who returned for a 7- to 8-year follow-up examination, were examined for secular trends in the incidence of type 2 diabetes. Risk factors for diabetes, such as obesity, were also examined. Patients were enrolled in the San Antonio Heart Study from 1979 to 1988 and 7- to 8-year incidence of diabetes was determined from 1987 to 1996. RESULTS: A significant secular trend in the 7- to 8-year incidence of type 2 diabetes was observed in Mexican Americans (5.7% for participants enrolled in 1979 to 15.7% for participants enrolled in 1988). In non-Hispanic whites, the incidence increased from 2.6% for participants enrolled in 1980 to 9.4% for participants enrolled in 1988 (P = .07) . After adjusting for age and sex, the secular trend remained significant in Mexican Americans and borderline significant in non-Hispanic whites. This indicates that between 1987 and 1996 the 7- to 8-year incidence of type 2 diabetes approximately tripled in both ethnic groups. The overall secular trend also remained significant after adjusting for additional risk factors for diabetes, such as obesity. A rising secular trend in obesity was also observed. CONCLUSIONS: There has been a significant increasing secular trend in the incidence of type 2 diabetes in Mexican Americans and a borderline significant trend in non-Hispanic whites participating in the San Antonio Heart Study. Unlike other cardiovascular risk factors such as lipid levels, cigarette smoking, and blood pressure, which are either declining or under progressively better medical management and control, and unlike cardiovascular mortality, which is also declining, obesity and type 2 diabetes are exhibiting increasing trends. Thus, obesity and diabetes could easily become the preeminent US public health problem.

Adult↗
PubMed1999

Temporal trends in spontaneous abortion associated with Type 1 diabetes.

The objective of this study was to investigate temporal changes in the reported rates of spontaneous abortion associated with Type 1 diabetes. Individuals from the Children's Hospital of Pittsburgh Type 1 Diabetes Registry for 1950-1964 (n=495) completed a self-report reproductive history questionnaire in 1981 that was updated in 1990. Data from both surveys, which proved to be valid and reliable, were utilized for this report. More spontaneous abortions (26.8 vs. 7.7%, P<0.001), stillbirths (4.7 vs. 1.2%, P<0.001) and induced abortions (7.0 vs. 0.9%, P<0.001) were reported for Type 1 diabetic women than for the non-diabetic partners of Type 1 diabetic men. A significant temporal decline in the rates of spontaneous abortion for Type 1 diabetic women was observed (< or = 1969: 26.4%; 1970-1979: 31.0%; 1980-1989: 15.7%; P<0.05). No differences were apparent for the non-diabetic partners of Type 1 diabetic men (< or = 1969: 4.2%; 1970-1979: 9.5%; 1980-1989: 5.7%; P>0.05). Temporal changes in medical care for women with diabetes (i.e. self-monitoring of glycemic control) may have contributed to a recent reduction in spontaneous abortions associated with maternal Type 1 diabetes.

Abortion, Spontaneous↗
PubMed1999

Antibiotic use and microbial resistance in intensive care units: impact of computer-assisted decision support.

As part of our integrated hospital information system (the HELP system), we developed computer-assisted decision support programs for antimicrobial prescribing that are available at bedside terminals throughout our 520-bed community hospital. Recently, options have been added to allow direct physician order entry of anti-infective agents in the shock-trauma intensive care unit (STRICU). Physicians prescribed the computer-suggested regimens for 46% but followed the suggested dose and interval for 93% of the orders during a 1-year study period. In comparison to a 2-year pre-intervention period, improved drug selection and reductions in adverse drug events and costs were seen. Antimicrobial resistance patterns for nosocomial gram-negative isolates remained stable or improved in the STRICU over an 11-year period of computer-assisted antibiotic management. We conclude that strategies for optimizing antimicrobial prescribing have the potential to stabilize resistance and reduce costs by encouraging heterogeneous prescribing patterns, use of local antimicrobial susceptibility patterns to inform empiric drug selection, and reduced "tonnage" of antibiotic use.

Algorithms↗
PubMed1999

Clinical and financial impact of intravenous erythromycin therapy in hospitalized patients.

OBJECTIVE: To determine the economic consequences of intravenous erythromycin use in hospital patients in a variety of clinical circumstances. DESIGN: Retrospective cohort study of patients with specified primary diagnosis-related group discharge diagnoses treated from January 1, 1990, to December 31, 1994, who received erythromycin, and a matched cohort group from the same period who did not receive erythromycin. SETTING: LDS Hospital, Salt Lake City, UT, a 520-bed teaching hospital. PATIENTS: A long-term archive of clinical and financial data from a computerized hospital information system was searched for patients meeting a strict case definition. This archive contained information on erythromycin exposure as well as concurrent drug therapy and adverse drug events that had been prospectively evaluated during hospitalization throughout the study and cohort periods. Detailed costs were available for each patient. MAIN OUTCOME MEASURE: Attributable differences in lengths of stay and total costs determined using linear regression modeling. RESULTS: For 797 erythromycin patients and 2771 cohort patients, we found an attributable increased length of stay of 2.14 days and an increased cost of hospitalization of $6061 for erythromycin case patients. Case patients also had a significantly increased risk of adverse drug events. Linear regression modeling showed that erythromycin use was significantly related to increased length of stay and cost of hospitalization. CONCLUSIONS: Intravenous erythromycin use has been associated with significant increases in hospital length of stay and total hospital cost.

Adolescent↗
PubMed1999

Evaluation of a computer-assisted antibiotic-dose monitor.

OBJECTIVE: To examine the effect of a computer-assisted antibiotic-dose monitor used to reduce the number of days that patients receive excessive dosages of antibiotics and the number of adverse drug events (ADEs) secondary to antibiotics. DESIGN: Descriptive epidemiologic study of a two-year preintervention period and one-year intervention period. SETTING: The LDS Hospital, a tertiary care center in Salt Lake City, UT. PATIENTS: All patients aged > or = 18 years, admitted to LDS Hospital from April 1, 1993, to March 31, 1996, who received at least one of five targeted antibiotics (vancomycin, gentamicin, imipenem, cefazolin, cefuroxime), who had a serum creatinine or a urine creatinine clearance test result before antibiotic therapy, and who were never admitted or transferred to the shock/trauma/respiratory intensive care unit. METHODS: Each morning during the 12-month intervention period, the antibiotic-dose monitor checked the renal function of all patients who were receiving any of the five antibiotics. Pharmacists received a computer listing of patients who may have been receiving excessive dosages. The antibiotic-dose monitor suggested an alternate dosage and a pharmacist contacted the patient's physician if the suggested change in the dosage was appropriate. RESULTS: During the intervention period, 4483 patients received at least one of the five study antibiotics and 1974 (44%) were identified as receiving an excessive dosage, compared with 4494 (50%) of 8901 patients during the preintervention period (p < 0.001). The patients receiving excessive dosages received an excessive dosage for an average of 2.9 days during the intervention period, compared with 4.7 days (p < 0.001) during the preintervention period. In addition, these same patients during the intervention period received fewer doses of antibiotics (10.9 vs. 13.4; p < 0.001), fewer grams of antibiotics (10.4 vs. 12.0; p < 0.02), at less cost ($98 vs. $128; p < 0.004) than the patients during the preintervention period. Moreover, there were 14 ADEs (0.3%) secondary to the five study antibiotics during the intervention period, compared with 82 (0.9%; p < 0.001) for the two-year preintervention period. The study also found that significantly more patients identified as receiving excessive dosages had experienced decreases in renal function, compared with patients who were not identified as receiving excessive dosages (25% vs. 12% during preintervention period and 23% vs. 16% during intervention period; p < 0.001). CONCLUSIONS: Many patients experience decreases in renal function after antibiotics are ordered. The use of the computer-assisted antibiotic-dose monitor appears to be a promising method to help reduce the excessive use and cost of antibiotic therapy and reduce the number of ADEs secondary to antibiotics.

Adverse Drug Reaction Reporting Systems↗
PubMed1999

A quantitative scale of acanthosis nigricans.

OBJECTIVE: To develop and validate a scale for acanthosis nigricans (AN). RESEARCH DESIGN AND METHODS: Subjects were participants from the San Antonio Family Diabetes Study and the San Antonio Family Heart Study. A total of 406 subjects were independently examined for AN by at least two observers. Five locations were examined: the neck, axilla, elbows, knuckles, and knees. Interobserver concordance and kappa statistics were calculated to determine replicability of the scale. Comparisons of diabetes-related risk factors by AN score were also calculated. RESULTS: Only the neck had consistently high kappa statistics, and thus, other locations were excluded from further analyses. Elevated AN was strongly associated with elevated fasting insulin and BMI in both diabetic and nondiabetic subjects. Elevated AN was also strongly associated with elevated fasting glucose, systolic blood pressure, and diastolic blood pressure, and with decreased HDL in nondiabetic subjects. In diabetic subjects, elevated AN was associated with elevated total cholesterol. CONCLUSIONS: We have developed a scale for AN that is easy to use, has high interobserver reliability in Mexican Americans, and correlates well with fasting insulin and BMI. This scale will permit longitudinal and cross-sectional evaluation of AN and will permit the evaluation of AN as a trait in genetic studies.

Acanthosis Nigricans↗