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PubMed1985

Mortality findings for stepped-care and referred-care participants in the hypertension detection and follow-up program, stratified by other risk factors. The Hypertension Detection and Follow-up Program Cooperative Research Group.

Analyses of 5-year mortality data from the Hypertension Detection and Follow-up Program (HDFP) were performed with stratification according to several baseline traits. The HDFP participants were 10,940 white and black men and women ages 30-69 at baseline who were randomized to either stepped-care (SC) or referred-care (RC) groups. All-causes mortality rates were lower for the SC than the RC group, both overall and for the 90-104 mm Hg stratum, for both cigarette smokers and nonsmokers, and for persons with and without hypercholesterolemia, hyperglycemia, diagnosed diabetes, hyperuricemia, or rapid pulse rate. The SC group also fared better than RC for all strata of body mass index, with an apparent trend toward an inverse relationship between body mass index and degree of benefit. Several of the traits--cigarette smoking, fasting hyperglycemia, and hyperuricemia--were associated with significantly higher 5-year mortality rates in both SC and RC participants, in both univariate and multivariate analyses, and a significant U-shaped relationship was recorded between body mass index and mortality for both SC and RC groups. These findings indicate the broad benefit of vigorous antihypertensive stepped-care treatment for hypertensive patients regardless of the presence or absence of the other major risk factors. They also underscore the need for comprehensive management of persons with high blood pressure to control not only their hypertension but also other risk factors associated with negative impact on long-term prognosis.

Adult↗
PubMedDate not supplied

RECPAM: a computer program for recursive partition and amalgamation for censored survival data and other situations frequently occurring in biostatistics. I. Methods and program features.

The methodology of recursive partition and amalgamation in biostatistics is presented and a FORTRAN program for its implementation, RECPAM, is described. RECPAM can be used to obtain classifications of patients according to several criteria commonly occurring in clinical biostatistics: an example is prognostic classification based on survival data. Classes are defined by simple statements, expressed in clinical terms, about predictor variables (e.g. prognostic factors). Special features of RECPAM are: the possibility of implementing a variety of classification criteria, the integration of recursive partition and amalgamation, and the availability of several strategies for constructing classification trees. A simple example to illustrate input and output features is given. The scope and flexibility of RECPAM will be illustrated in greater detail in a subsequent paper.

Algorithms↗
PubMedDate not supplied

The Beech Hill Hospital Eating Disorders Treatment Program for Drug Dependent Females: program description and case analysis.

The association of eating disorders and substance abuse has increasingly been noted among chemically dependent women. Without diagnosis and focused interventions around the disordered eating, female substance abusers are vulnerable to chemical relapse and continued out of control eating. This paper describes an eating disorder treatment program for drug-dependent females during the inpatient phase of chemical dependency treatment. The interrelationship and need to treat both addiction and eating disorder at the beginning of early sobriety is emphasized.

Adult↗
PubMedDate not supplied

Nicotine treatment at the Drug Dependency Program of the Minneapolis VA Medical Center. A program director's perspective.

Nicotine addiction treatment has been integrated with inpatient chemical dependency treatment in the Drug Dependency Treatment program (DDTP) of the Minneapolis VA Medical Center since June 1988. The process of addressing this "new" drug (nicotine) is described. It has required significant changes in staff awareness and attitudes and several years to melt denial of nicotine addiction and develop new habits that address nicotine in therapeutic interactions with patients. Nicotine recovery has gradually been incorporated into all educational and therapeutic activities as well as the traditional recovery tools. Six weeks postdischarge 58% of patients who were smokers upon admission were nicotine-free or had greatly reduced use, and 98% of these were abstinent from drugs/alcohol. Nicotine use produces frequent and intense addictive urges/cravings that are a central issue in treatment. We believe that including nicotine in chemical dependency treatment supports fuller freedom from addictive urges and abstinence from drugs/alcohol.

Adolescent↗
PubMed1998

Epigenetic control of programmed cell death: inhibition by 5-azacytidine of 1,25-dihydroxyvitamin D3-induced programmed cell death in C6.9 glioma cells.

In mammalian DNA cytosine methylation occurs specifically at CpG dinucleotide. Although the full array of function of DNA methylation is yet to be elucidated, it is well established that DNA methylation is an important mechanism involved in gene expression, DNA replication and cancer. Rat glioma C6.9 cells undergo programmed cell death (PCD) after treatment with 1,25-dihydroxyvitamin D3 (1,25-D3). Hence, these cells were used to study whether DNA methylation was involved in the control of PCD. We found that 1,25-D3-mediated PCD of C6.9 cells was suppressed by exposure of the cells to the DNA demethylating agents 5-azacytidine (5-AzaC) and 5-aza-2'-deoxycytidine. This effect remains detectable several cell divisions following removal of 5-AzaC and, therefore, involves DNA methylation as an epigenetic regulatory mechanism of PCD. Accordingly, internucleosomal fragmentation, a feature of apoptosis that is detected in 1,25-D3-treated cells, is no longer observable after treatment of these cells with 5-AzaC. However, 5-AzaC does not totally suppress the responsiveness of C6.9 cells to 1,25-D3 since the induction of the c-myc gene remains unaffected. These results suggest that a change in DNA methylation pattern could suppress 1,25-D3-mediated PCD through the expression of previously hypermethylated genes such as proto-oncogenes with death-repressor activity, endogenous virus sequences or even genes inducing change in the differentiated state of these cells.

Animals↗
PubMed1998

An assessment of the influence of clinical breast examination reports on the interpretation of mammograms in a breast screening program. Ontario Breast Screening Program Radiologists Research Group.

The population-based Ontario Breast Screening Program (OBSP) provides two-yearly screening by both nurse examiner clinical breast examination (CBE) and two-view mammography to women aged 50 to 69. CBE alone accounts for about 5% of cancer detection. The purpose of this study was to determine whether CBE information affects radiologists' interpretation of mammography. Interpretation was defined by 1) radiologists' referral rates for diagnostic evaluation and 2) radiologists' accuracy in distinguishing cancer from non-cancer on mammograms. Mammograms were obtained from women randomly selected from those screened in the OBSP between 1990 and 1992. Selection was stratified by whether or not the nurse examiner had independently referred for diagnostic evaluation. Additional women diagnosed with breast cancer were selected to increase the precision of the receiver-operating characteristic (ROC) curve. Each participating OBSP radiologist read a set of mammograms twice, approximately three weeks apart. The first reading was based on mammograms alone. At the second reading, the CBE report was included on the reporting form. Among 620 women referred by the nurse, radiologist referral rate increased from 37.7% to 40.8% (p = 0.079) when CBE information was available. Among the 637 not referred by the nurse, radiologist referral rate decreased from 29.8% to 25.6% (p = 0.005). There was little effect on the sensitivity and specificity of radiologist referral and the areas under the two ROC curves (with and without CBE information) were not significantly different (p = 0.571). Although there was some effect of CBE information on radiologists' pattern of referral, there was no effect on accuracy of cancer detection.

Breast Neoplasms↗
PubMed2000

Neurocognitive functioning in children with mild and moderate asthma in the childhood asthma management program. The Childhood Asthma Management Program (CAMP) Research Group.

BACKGROUND: The Childhood Asthma Management Program (CAMP) is a multicenter double-blind, randomized, placebo-controlled, clinical trial of two anti-inflammatory agents and placebo in children with mild and moderate asthma. OBJECTIVE: The interrelationship between asthma severity and neurocognitive functioning among 1041 children (age range, 5-12 years) enrolled in the CAMP trial was examined. METHODS: Asthma severity was established at baseline with a clinical history of asthma symptomatology and measures of lung function (spirometry and methacholine challenge). Diary cards were used in a screening to record nighttime awakenings and doctor contacts caused by asthma symptoms, symptom severity, and number of puffs from a rescue inhaler. All children received a comprehensive neurocognitive assessment at the end of the 28-day screening period (before randomization), including measures of intelligence, attention, memory, and academic achievement. RESULTS: Significant differences were found between children with mild and moderate asthma on lung function and symptom outcome variables (log(e)FEV(1)PC(20), DeltaFEV(1) percent predicted, change in peak flow percent predicted, nighttime awakenings caused by asthma, average symptom severity score, and average daily number of puffs from a rescue inhaler) but not on neurocognitive variables. Multiple regression analyses revealed that asthma outcomes could not be predicted by neurocognitive variables despite controlling for socioeconomic status. The prevalence of neurocognitive dysfunction, as indicated by the use of psychostimulant medication, was found to be consistent with that found in the existing literature. CONCLUSION: Mild and moderate asthma symptoms are not related to neurocognitive functioning in the children enrolled in CAMP. Mean performance on neurocognitive variables was found to be similar to that of national normative data.

Asthma↗
PubMedDate not supplied

PROTOTYPES: an urban model program of treatment and recovery services for dually diagnosed perinatal program participants.

PROTOTYPES, a women's treatment program located in Los Angeles, is described in terms of its services for pregnant and parenting women with coexisting substance abuse and mental health disorders. The philosophy of treatment, goals and objectives, treatment planning process, and treatment content are discussed. Management of the milieu, relational model considerations and staff self-care issues are presented in addition to future directions in treatment and research on women with coexisting disorders.

Diagnosis, Dual (Psychiatry)↗
PubMed1999

Effects of the National Cholesterol Education Program's Step I and Step II dietary intervention programs on cardiovascular disease risk factors: a meta-analysis.

BACKGROUND: Plasma lipid and lipoprotein responses have been variable in dietary intervention studies. OBJECTIVE: The objective of this study was to evaluate the effects of the National Cholesterol Education Program's Step I and Step II dietary interventions on major cardiovascular disease risk factors using meta-analysis. DESIGN: MEDLINE was used to select 37 dietary intervention studies in free-living subjects published from 1981 to 1997. RESULTS: Step I and Step II dietary interventions significantly decreased plasma lipids and lipoproteins. Plasma total cholesterol (TC), LDL cholesterol, triacylglycerol, and TC:HDL cholesterol decreased by 0.63 mmol/L (10%), 0.49 mmol/L (12%), 0.17 mmol/L (8%), and 0.50 (10%), respectively, in Step I intervention studies, and by 0.81 mmol/L (13%), 0.65 mmol/L (16%), 0.19 mmol/L (8%), and 0.34 (7%), respectively, in Step II intervention studies (P < 0.01 for all). HDL cholesterol decreased by 7% (P = 0.05) in response to Step II but not to Step I dietary interventions. Positive correlations between changes in dietary total and saturated fatty acids and changes in TC and LDL and HDL cholesterol were observed (r = 0.59, 0.61, and 0.46, respectively; P < 0.001). Multiple regression analyses showed that for every 1% decrease in energy consumed as dietary saturated fatty acid, TC decreased by 0.056 mmol/L and LDL cholesterol by 0.05 mmol/L. Moreover, for every 1-kg decrease in body weight, triacylglycerol decreased by 0.011 mmol/L and HDL cholesterol increased by 0.011 mmol/L. Exercise resulted in greater decreases in TC, LDL cholesterol, and triacylglycerol and prevented the decrease in HDL cholesterol associated with low-fat diets. CONCLUSION: Step I and Step II dietary interventions have multiple beneficial effects on important cardiovascular disease risk factors.

Body Weight↗
PubMedDate not supplied

Guidelines for clinical engineering programs--Part I: guidelines for electrical isolation; Part II: performance evaluation of clinical engineering programs.

This series presents guidelines for: electrically isolated inputs and outputs; measuring the performance of hospital biomedical engineering programs; evaluating the risk of electric shock in hospitals; and for isolated power in anesthetizing locations. In Part I, specific recommendations are given for the use of insulated approach, battery-powered monitors in surgery, and for isolation requirements for devices connected to cardiac leads. In Part II, checklists are provided for the self-evaluation of an in-house, biomedical engineering staff. Parts III and IV, in future issues of this Journal, will include discussion of the theoretical electrical hazard potential in reference to the use of isolated power systems. The question of whether isolated power should be required in all anesthetizing locations will be discussed in Part IV.

Accident Prevention↗
PubMedDate not supplied

A clinical internship program in biomedical engineering, Part II: Administration of the program.

This paper discusses the administration of a clinical internship for biomedical engineering students. The interns rotate through sequences of hospital services, divided into four sets, separated by intervening elective periods, and spread over different clinical facilities. Rotations include orientation conferences, counseling sessions with staff personnel, and on-the-job training in each hospital service. Students keep logs of their experiences and submit service reports summarizing each rotation. They also write brief reports illustrating engineering contributions to health care delivery. The reports are graded and serve, together with staff and faculty evaluations, to rate the students' overall performance in the program.

Biomedical Engineering↗
PubMed2000

Physician orders for life-sustaining treatment (POLST): outcomes in a PACE program. Program of All-Inclusive Care for the Elderly.

OBJECTIVES: To evaluate whether terminal care was consistent with Physician Orders for Life-Sustaining Treatment (POLST), a preprinted and signed doctor's order specifying treatment instructions in the event of serious illness for CPR, levels of medical intervention, antibiotics, IV fluids, and feeding tubes. DESIGN: Retrospective chart review. SETTING: ElderPlace, a Program of All-Inclusive Care for the Elderly (PACE) site in Portland, Oregon. PARTICIPANTS: All ElderPlace participants who died in 1997 were eligible (n = 58). Reasons for exclusion were no POLST (1), missing POLST (1), and insufficient documentation of care (2). MEASUREMENTS: POLST instructions for each participant and whether or not each of the treatments addressed by the POLST was administered in the final 2 weeks of life. RESULTS: The POLST specified "do not resuscitate" for 50 participants (93%); CPR use was consistent with these instructions for 49 participants (91%). "Comfort care" was the designated level of medical intervention in 13 cases, "limited interventions" in 18, "advanced interventions" in 18, and "full interventions" in 5. Interventions administered were at the level specified in 25 cases (46%); at a less invasive level in 18 (33%), and at a more invasive level in 11 (20%). Antibiotic administration was consistent with POLST instructions for 86% of 28 subjects who had infections in the last 2 weeks of life, and less invasive for 14%. Care matched POLST instructions in 84% of cases for IV fluids and 94% for feeding tubes. CONCLUSIONS: POLST completion in ElderPlace exceeds reported advance directive rates. Care matched POLST instructions for CPR, antibiotics, IV fluids, and feeding tubes more consistently than previously reported for advance directive instructions. Medical intervention level was consistent with POLST instructions for less than half the participants, however. We conclude that the POLST is effective for limiting the use of some life-sustaining interventions, but that the factors that lead physicians to deviate from patients' stated preferences merit further investigation.

Advance Directives↗
PubMed1989

Prognostic value of serum creatinine and effect of treatment of hypertension on renal function. Results from the hypertension detection and follow-up program. The Hypertension Detection and Follow-up Program Cooperative Group.

The Hypertension Detection and Follow-up Program followed up 10,940 persons for 5 years in a community-based, randomized, controlled trial of treatment for hypertension. Participants were randomized to one of two treatment groups, stepped care and referred care. The primary end point of the study was all-cause mortality, with morbid events involving the heart, brain, and kidney as secondary end points. Loss of renal function, ascertained by a change in serum creatinine, was among these secondary events. Baseline serum creatinine concentration had a significant prognostic value for 8-year mortality. For persons with a serum creatinine concentration greater than or equal to 1.7 mg/dl, 8-year mortality was more than three times that of all other participants. The estimated 5-year incidence of substantial decline in renal function was 21.7/1,000 in the stepped-care group and 24.6/1,000 in the referred-care group. Among persons with a baseline serum creatinine level between 1.5 and 1.7 mg/dl, the 5-year incidence of decline was 113.3/1,000 (stepped care) and 226.6/1,000 (referred care) (p less than 0.01). The incidence of decline in renal function was greater in men, blacks, and older adults, as well as in those with higher entry diastolic blood pressure. Among persons with a baseline serum creatinine level greater than or equal to 1.7 mg/dl, serum creatinine concentration declined by 25% or more in 28.6% of stepped-care and 25.2% of referred-care participants. Although the incidence of clinically significant hypercreatininemia in a hypertensive population is low, an elevated serum creatinine concentration is a very potent independent risk factor for mortality. The slightly lower rate of development of hypercreatininemia and the higher rate of improvement in stepped-care compared with referred-care participants is consistent with the belief that aggressive treatment of hypertension may reduce renal damage and the associated increased risk of death.

Adult↗
PubMed1999

Impact of robustness of program implementation on outcomes of clients in dual diagnosis programs.

Three types of treatment-behavioral skills training, a 12-step recovery model, and intensive case management-provided to 132 clients at four facilities were identified as being robustly or not robustly implemented, depending on whether core elements of these treatments were emphasized. Outcomes and costs of services to clients were examined over 18 months. Clients receiving robustly implemented behavioral skills training had significantly higher psychosocial functioning and lower costs for supportive services than those receiving nonrobustly implemented training. Clients receiving robustly implemented case management also exhibited significantly higher psychosocial functioning and lower costs for intensive services than those in the nonrobust intervention. To be effective, dual diagnosis programs should better manage the robustness of implementation of planned interventions.

Adolescent↗
PubMed1990

Development of a collaborative geriatric program between the legal system and a social work-directed program of a community hospital.

This paper details the development of a unique program developed between a social work-directed service of a community hospital and the probate system. It documents the value of combining the skills of these two systems to enhance the care, service delivery and quality of life of older persons involved in conservatorship matters. It suggests that such models will become increasingly necessary as the American population ages.

Aged↗
PubMed1987

Survival analysis in drug program evaluation. Part I. Overall program effectiveness.

Survivorship analysis is a statistical technique used here in a summative evaluation that compares outcome data from multiple-site methadone maintenance programs in three California counties. Multiple outcome measures were obtained from retrospective interviews with 297 heroin addicts 6-8 years after admission to treatment. These measures were rates of retention, incarceration, addiction, crime, dealing, and loss of employment. Survival curves for all six measures are consistent in showing that Los Angeles County had the best outcomes, followed by San Bernardino County and then Orange County.

Adult↗
PubMed1999

The International Health Program: the fifteen-year experience with Yale University's Internal Medicine Residency Program.

The purpose of this study was to assess the impact of international health electives on physicians-in-training. A retrospective study was conducted using an anonymous, self-administered mailed survey to internal medicine residents who trained at Yale from 1982 to 1996 based on their experience with our International Health Program (IHP). The response rate was 61%, with 96 completed surveys in the participant group and 96 completed surveys in the nonparticipant group. Participants were more likely than nonparticipants to care for patients on public assistance (77 versus 49; P < 0.001) and immigrant patients (41 versus 23; P = 0.006). Among residents who changed their career plans, participants (22) were more likely than nonparticipants (14) to switch from subspecialty medicine to general medicine (P = 0.02). Participants were significantly more likely to have a positive view of health care delivery in developing countries. Compared with nonparticipants (64), IHP participants (74) believed that the physical examination is under-used by physicians from the United States as a diagnostic skill (P = 0.03). International health experiences appeared to have an important impact on the decisions and attitudes of residents.

Adult↗
PubMed1999

The Childhood Asthma Management Program (CAMP): design, rationale, and methods. Childhood Asthma Management Program Research Group.

The Childhood Asthma Management Program (CAMP) is a multicenter, randomized, double-masked clinical trial designed to determine the long-term effects of three inhaled treatments for mild to moderate childhood asthma: budesonide (a glucocorticoid used daily) and albuterol (a short-acting beta-agonist bronchodilator used as needed); nedocromil (a nonsteroid anti-inflammatory agent used daily) and albuterol; and placebo and albuterol. One thousand forty-one children (32% from ethnic minority groups), aged 5 to 12 years at screening, are currently participating. The primary outcome measure is lung growth as indicated by postbronchodilator forced expiratory volume in 1 second (FEV1) percent of predicted, observed over 5- to 6-year period. The trial also assesses differences between treatment groups with respect to airway responsiveness, morbidity, physical growth and development, and psychological growth and development. This report describes the design of the trial, the rationale for the design choices made, and the methods used to carry out the trial.

Albuterol↗