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PubMed1990

Voluntary HIV antibody testing among STD clinic patients: a pilot study.

A pilot study was conducted with the aim of measuring the acceptability of voluntary testing for human immunodeficiency virus (HIV) antibody among patients attending sexually transmissible disease (STD) clinics. Three STD clinics, two public and one private, participated in the study which was conducted over a three-month period beginning in November 1988. For each patient attending the clinics, sex, date of birth, HIV transmission category and previous HIV test result were recorded. Patients who did not request the HIV antibody test were offered testing. Of the 2356 patients who were included in the analyses, 784 (34%) requested testing. For almost all patients (97%) who requested testing, a serum sample was collected and testing completed. Approximately half (55%) of those patients who were offered the test accepted testing. Overall, 70% of patients completed HIV antibody testing. Of the major transmission categories, the acceptance rate for those offered the test was lowest among homosexual men (45%), who also had the highest rate of HIV antibody seropositivity (11%) among those tested. Of patients who reported themselves to be HIV antibody seronegative prior to the pilot study, 78% were retested during the study and seven had a positive test for HIV antibody. We conclude that voluntary HIV antibody testing is acceptable in both public and private STD clinic settings, although a substantial amount of additional resources would need to be allocated to counselling if voluntary testing is to be introduced on a routine basis.

Acquired Immunodeficiency Syndrome↗
PubMed1994

Spectrum of hypertensive target organ damage in Africa: a review of published studies.

This paper reviews the evidence of hypertensive target organ damage (HTOD) in Africa, and the difficulties of its assessment, with a focus on implications for further research and prevention. Specific examples of HTOD reviewed include left ventricular hypertrophy, heart failure, ischaemic heart disease, arrhythmias and sudden death, kidney failure, cerebrovascular accidents, retinopathy and central as well as peripheral vascular disease. There is evidence that the prevalence of hypertension is increasing in some parts of Africa, thus increasing the number of people who suffer from fatal and nonfatal complications. Analysis of the type, frequency and distribution of HTOD is critical to the design of interventions to prevent and manage hypertension, and in the design of future clinical research. As would be expected, the frequency of atherosclerotic complications, particularly involving the heart, is lower in Africa than in developed countries. Stroke, renal failure and heart failure appear to be the principal adverse outcomes and are likely to be associated with a high case fatality rate. Community-based data on these issues are limited, however, and hospital series cannot estimate the population burden and may be unreliable in describing the case mix. Improved data on HTOD will more accurately reflect the health impact of hypertension, provide the basis for aggressive efforts at prevention, detection and control of high BP and establish their relevance in the overall scheme of resource allocation during fiscal austerity and limited healthcare spending. Additionally, knowledge of the prevalence and relative frequencies of HTOD has direct and important implications for clinical outcomes research in hypertension.

Africa↗
PubMed1998

Angiotensin converting enzyme inhibition and calcium antagonism attenuate streptozotocin-diabetes-associated mesenteric vascular hypertrophy independently of their hypotensive action.

OBJECTIVES: To investigate the relative roles of angiotensin II, bradykinin, and calcium-dependent pathways in the genesis of mesenteric vascular hypertrophy in experimental diabetes. DESIGN: Streptozotocin-induced diabetic Sprague-Dawley rats were randomly allocated to these treatments for 24 weeks: no treatment; ramipril at a hypotensive dose; ramipril plus the bradykinin type 2 receptor blocker icatibant; icatibant alone; ramipril at a low dose; the angiotensin II type 1 receptor antagonist, valsartan; the dihydropyridine calcium antagonist, lacidipine; and the nondihydropyridine calcium antagonist mibefradil. METHODS: Systolic blood pressure was serially measured every 4 weeks by tail-cuff plethysmography. We assessed the vascular architecture in sections of mesenteric arteries obtained after in-vivo perfusion, which were stained with an antibody to alpha-smooth muscle actin. RESULTS: Both blood pressure and the mesenteric arterial wall: lumen ratio were reduced by administration of ramipril, at the high dose, either alone or in combination with icatibant, and also by valsartan. Treatment either with the low dose of ramipril or with the calcium antagonists lacidipine and mibefradil was associated with a decrease in the wall : lumen ratio of the mesenteric arteries without influencing blood pressure. CONCLUSIONS: These findings demonstrate that blockade both of angiotensin II-dependent and of calcium-dependent pathways attenuates mesenteric vascular hypertrophy in experimental diabetes. Furthermore, the antitrophic effects of these antihypertensive agents may be independent of their hypotensive effects.

Actins↗
PubMed1994

Administration of prostaglandin E1 after lung transplantation improves early graft function.

Early graft dysfunction continues to be a major clinical problem after lung transplantation. The objective of this experiment was to determine whether continuous administration of prostaglandin E1 (PGE1) after lung transplantation has a beneficial effect on early graft function. Left lung allotransplantation was performed in 10 size-matched mongrel dogs (weight, 24.4 to 31.4 kg). Lung preservation consisted of a bolus injection of PGE1 (250 micrograms) into the pulmonary artery, followed by a pulmonary artery flush with 50 mL/kg of 4 degrees C modified Euro-Collins solution. The lungs were then stored at 1 degree C for 12 hours. Left lung transplantation was performed using standard technique. The right pulmonary artery and right bronchus were ligated prior to chest closure. Animals were placed in the supine position and ventilated for 6 hours with 100% oxygen at a rate of 20 breaths/min, a tidal volume of 550 mL, and a positive end-expiratory pressure of 5 cm H2O. Animals were randomly allocated to one of two groups. Group I animals (n = 6) received continuous PGE1 infusion from the onset of implantation. The dose was gradually increased and fixed when mean systemic pressure showed a 10% decrease (mean PGE1 dose, 31.7 +/- 6.9 ng.kg-1.min-1). Group II animals (n = 4) received no PGE1. After the 6-hour assessment period, arterial oxygen tension and alveolar-arterial oxygen pressure difference were preserved in group I compared with group II (group I versus group II: arterial oxygen tension, 255.8 +/- 37.6 mm Hg versus 64.7 +/- 7.9 mm Hg [p < 0.05]; alveolar-arterial oxygen pressure difference, 411.1 +/- 70.5 mm Hg versus 597.5 +/- 1.3 mm Hg [p < 0.05]).(ABSTRACT TRUNCATED AT 250 WORDS)

Alprostadil↗
PubMed1989

The effect of high-dose short-term ibuprofen on antihypertensive control with hydrochlorothiazide.

The effect of high-dose ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), on the blood pressure of treated hypertensive patients was evaluated in a randomized, placebo-controlled, double-blind, crossover trial with 24-hour ambulatory blood pressure monitoring. Twelve middle-aged black women with essential hypertension, controlled with 50 mg hydrochlorothiazide per day, randomly received 3200 mg ibuprofen and a placebo for 8 days. Each treatment phase was separated by a 1-week washout period. Ambulatory blood pressure monitoring (ABPM), body weight, and 24-hour urinary excretion of sodium, creatinine, and prostaglandin E2 (PGE2) were determined at the end of each treatment phase. Mean (+/- SEM) 24-hour systolic and diastolic blood pressures were 122/85 (+/- 2.9/1.7) and 125/85 (+/- 3.0/1.1) during the placebo and ibuprofen phases, respectively. Mean ABPM during six consecutive 4-hour periods also revealed no significant differences between placebo and ibuprofen. We conclude that 3200 mg ibuprofen per day for up to 1 week induced little change in blood pressure in hypertensive who are receiving hydrochlorothiazide.

Adult↗
PubMed2000

Older boys benefit from higher initial prednisolone therapy for nephrotic syndrome. The West Japan Cooperative Study of Kidney Disease in Children.

BACKGROUND: A long course of the initial prednisolone therapy has been shown to be more effective than standard-course therapy in reducing relapse rates in children with idiopathic nephrotic syndrome, but it is commonly accompanied by corticosteroid toxicities. There has been no study on prednisolone dosage for the effective treatment of nephrotic syndrome. METHODS: Sixty-eight children (42 boys and 26 girls) with an initial attack of nephrotic syndrome were randomly allocated into two different long-course treatment groups. Patients in Group 1 received a daily prednisolone dose of 60 mg/m2 for six weeks, followed by an alternate-day dose of 40 mg/m2 for six weeks. Patients in Group 2 had a daily dose of 40 mg/m2 instead of 60 mg/m2. RESULTS: Four children in each group did not respond within six weeks. Group 1 was associated with a significantly earlier response but more frequent corticosteroid toxicities than Group 2. Boys in Group 1 had a higher rate of sustained remission than boys in Group 2 (P = 0.0073), especially boys four years old or more (P = 0.0027), but girls did not show a significant difference (P = 0.863). Boys four years old or more in Group 1 had a course of frequent relapsing less often than those in Group 2 (2 of 13 vs. 6 of 8, P = 0.0075). CONCLUSION: These findings indicate that efficient prednisolone doses may vary between sexes and ages, and that a higher initial prednisolone therapy may be of greater benefit to older boys.

Adolescent↗
PubMed1989

Muscle strength, activity, housing and the risk of falls in elderly people.

In a national survey in Britain, 983 elderly people randomly selected from eight areas were asked about falls they had had in the past. The independent association of social and physical variables with a history of one or more falls was analysed by multiple logistic regression. Those who had fallen one or more times had reduced grip strength and were less mobile than those who had not fallen. More of them used non-phenothiazine tranquilizers, lived alone, had recently lost weight or were physically disabled. Independent of these influences, a history of having fallen was strongly related to place of residence. Part of this relationship was explained by differences in housing, in particular the percentage of houses without indoor lavatories.

Accidents, Home↗
PubMedDate not supplied

More quality bang for your healthcare buck.

The quality management department at North Shore-Long Island Jewish Health System has designed a collaborative process that improves patient safety, is accountable to the public, and increases efficiency on the basis of sound data management. By forging strategic alliances between the quality, finance, and materials support services departments at the health system level, a quality economic business model was developed that led to greater efficiencies in length-of-stay management, improved resource utilization in critical care, and standardization of skin care products and equipment. This article describes these quality initiatives.

Cooperative Behavior↗
PubMed2006

Allocating treatment options to patient profiles: clinical art or science?

BACKGROUND: For many researchers, the disappointing results of Project MATCH were the death blow for any further activities in the field of patient-treatment interactions. On the other hand, we have an increased knowledge of patient heterogeneity and a greater variety of treatment options than before, and allocation guidelines for an ongoing process of patient-placement decisions are of high practical relevance. AIMS: To analyse deficits in the current research and to provide suggestions for future action. FINDINGS: It is argued that (1) certain major design aspects of Project MATCH and other research studies--such as stringent patient exclusion criteria and low treatment 'dosage'-minimize the chances of detecting possible patient-treatment interactions and (2) Project MATCH obscures our view of previous treatment-allocation research findings. CONCLUSIONS: Several research strategies and specific research topics are suggested for (1) improving the theoretical and methodological basis for detecting possible patient-treatment interactions and (2) stimulating research on major treatment decision needs, such as site, setting, time in treatment (extensiveness and intensity), service components and specific treatment modules. More international research cooperation is needed to clarify the inconsistent findings.

Behavior, Addictive↗
PubMed2001

Intravenous immune globulins in patients with Guillain-Barré syndrome and contraindications to plasma exchange: 3 days versus 6 days.

Plasma exchange is contraindicated in 10 to 20% of patients with Guillain-Barré syndrome (GBS). The optimal schedule for intravenous immune globulin (IVIg) therapy has not yet been established in these patients. The objective was to compare the efficacy and safety of two IVIg treatment durations in patients with GBS with contraindications for plasma exchange. In this randomised, double blind, multicentre phase II trial conducted in seven French centres, patients with GBS with severe haemostasis, unstable haemodynamics, or uncontrolled sepsis were randomly assigned to 0.4 g/kg/day IVIg for 3 or 6 days. The primary outcome measure was the time needed to regain the ability to walk with assistance. Thirty nine patients were included from March 1994 to May 1997, 21 in the 3 day group and 18 in the 6 day group. Time to walking with assistance was non-significantly shorter in the 6 day group (84 (23-121) v 131 days (51-210), p=0.08); the difference was significant in ventilated patients (86 days (13-151) in the 6 day group v 152 days (54-332) in the 3 day group; p=0.04). The prevalence and severity of IVIg related adverse effects were comparable between the two groups. In conclusion, in patients with GBS and contraindications for plasma exchange, especially those who need ventilatory assistance, IVIg (0.4 g/kg/day) may be more beneficial when given for 6 days rather than 3 days.

Aged↗
PubMedDate not supplied

Angiotensin-converting enzyme inhibition reduces diabetes-induced vascular hypertrophy: morphometric studies.

Angiotensin-converting enzyme (ACE) activity and vascular mass are both increased in the mesenteric arteries of diabetic rats. As vascular hypertrophy may result from smooth muscle growth following increased formation of angiotensin II, we have examined the histological nature of the increase in mesenteric arterial mass and the role of elevated ACE activity in diabetic vascular hypertrophy by administration of an ACE inhibitor (perindopril). Cross-sectional area of the media was measured in perfusion-fixed mesenteric vessels of diabetic rats 3 weeks after streptozotocin injection. The media was significantly larger (63%) in mesenteric vessels of diabetic rats compared to age-matched control animals. Medial hypertrophy in these vessels was not associated with increased blood pressure or plasma renin activity but there was evidence for increased hemodynamic load due to hyperphagia and intestinal enlargement. Increased mesenteric ACE activity was involved in this process as there was significant inhibition of medial hypertrophy by perindopril. Other markers of cardiovascular hypertrophy such as left ventricular weight and aortic medial area were less affected, but increased in the diabetic group when corrected for significant body weight effects, consistent with a systemic influence of diabetes on cardiovascular mass. These data provide new insights into the mechanisms of vascular complications of diabetes and may have implications for the use of ACE inhibitors in preventing or arresting diabetes-associated vascular pathology.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed1991

Integrated delivery can ally physician and hospital plans.

Hospitals trying for successful business cooperation with physicians have become frustrated with risky joint ventures, quick-fix recruiting plans, and management service organizations. An integrated delivery system (IDS), however, may succeed where other approaches have failed. An IDS can align physician and hospital strategic planning, command more favorable contract terms from payers, and meet community needs in recruiting physicians and allocating capital. With the healthcare payment system likely to remain chaotic, however, the value of IDS improvements to healthcare delivery remains to be seen.

Capital Financing↗
PubMed1988

Lessons from the European Cooperative recombinant tissue-type plasminogen activator (rt-PA) versus placebo trial.

A new European Cooperative Study Group trial of 721 patients has recently found recombinant tissue-type plasminogen activator (rt-PA) to positively affect infarct size, left ventricular function, cardiovascular morbidity and early survival. In this 26 center trial, patients were randomized to receive either placebo or 100 mg rt-PA intravenously over 3 h. Heparin (5,000 U bolus injection and then 1,000 U/h) and aspirin (250 mg initially, then 75 to 125 mg every other day) were given to all patients until angiography was performed (10 to 22 days after allocation). Enzymatic infarct size was found to be 20% smaller in the rt-PA group (2p = 0.0018) than in the control group. At angiography, 83% of rt-PA-treated patients had a patent infarct-related vessel compared with 77% of the placebo-treated patients. Ejection fraction was 2.2% points higher (2p = 0.04) and end-diastolic and end-systolic volumes were +/- 6 ml smaller (2p = 0.003) than in the control group, indicating an improved left ventricular pump function in the thrombolysis group. Cardiovascular complications such as shock, ventricular fibrillation and pericarditis were markedly fewer in patients treated with rt-PA, but bleeding complications occurred more frequently. An intracranial hemorrhage within 3 days after the infusion of rt-PA was observed in five patients (1.4%). None of these bleeding episodes was causally related to death. Although this European Cooperative trial was not designed primarily as a mortality study, important reductions in early mortality rates were observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1991

Short-course chemotherapy for pulmonary tuberculosis under routine programme conditions: a comparison of regimens of 28 and 36 weeks duration in Algeria. Algerian Working Group/British Medical Research Council Cooperative Study.

Two chemotherapy regimens of 28 weeks (6M) and 36 weeks (8M) duration were compared in patients with previously untreated pulmonary tuberculosis in 30 health districts of Algeria. In the 6M regimen, patients received isoniazid plus rifampicin daily throughout with streptomycin and pyrazinamide in addition for the first 8 weeks. In the 8M regimen patients received isoniazid daily throughout plus rifampicin for the first 16 weeks and streptomycin and pyrazinamide as well for the first 8 weeks. The districts were allocated to apply either the 6M or the 8M regimen to all eligible patients. However, 22% of eligible patients were not admitted, the most common reason being oversight on the part of the personnel in the local health centres. A total of 2218 (977 6M, 1241 8M) patients was admitted and the results were assessed 2 years after the due date of completion of chemotherapy, irrespective of whether or not management had deviated from the study protocol. An appreciable proportion of patients (25% of 6M, 29% of 8M) could not be assessed because they failed to attend for follow-up or the collection of specimens was overlooked or because of difficulties in the transport of specimens to the reference laboratory in Algiers, and a further 5% and 4% of patients died. Of those who were assessable 7 (1%) of 731 6M and 15 (2%) of 875 8M were classified as having an unfavourable response during or after chemotherapy because they had one or more positive cultures. In addition 16 (2%) 6M and 18 (2%) 8M patients had received additional chemotherapy for failure, relapse or the development of non-pulmonary lesions but had achieved a favourable status. Of 1018 (488 6M, 530 8M) patients assessed who had fully sensitive strains pretreatment and completed treatment as planned, 97% in both series had a favourable status 2 years after their chemotherapy was due to be completed. In patients with initial strains resistant to isoniazid the results were less good in the 8M than the 6M series: none of the 19 6M compared with 5 of 26 in the 8M series having an unfavourable outcome suggesting that the duration of rifampicin may have been important in patients with initial isoniazid resistance. A slightly higher proportion of patients on the 8M regimen defaulted during chemotherapy (9.3% compared with 6.7% in the 6M regimen) but there was no difference between the regimens in other measures of compliance.(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗