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PubMed1999

Beta-blockers after myocardial infarction: do benefits ever outweigh risks in asthma?

beta-Blockers are well documented to prolong life in patients after myocardial infarction (MI), yet patients who also have asthma are frequently and understandably denied this therapy. We reviewed the literature (via MEDLINE) for the past 35 years for beta-blocker-induced asthma, and reexamined potential beta-blocker use in the context of NIH guidelines for asthma classification and management. Because beta-blockers can cause fatal or life-threatening asthma, their use should be avoided in moderate to severe persistent asthmatics. Benefits of low-dose beta(1)-blockers (e.g. atenolol 50 mg daily) may outweigh risks in some patients with mild intermittent or well-controlled mild persistent asthma. Further study is needed to verify that low doses of beta(1)-blockers are effective in prolonging life after MI, and that use specifically in mild intermittent or mild persistent asthma per NIH classification is safe.

Adrenergic beta-1 Receptor Antagonists↗
PubMed2004

Preventive therapy for asthmatic children under Florida Medicaid: changes during the 1990s.

BACKGROUND: In response to the increasing prevalence and severity of asthma in this country, the National Institutes of Health in 1991 published an expert consensus report Guidelines for the Diagnosis and Management of Asthma. An important aspect of the report included the recommendation that children with moderate asthma may benefit from daily treatment with anti-inflammatory drugs such as inhaled corticosteroids and cromolyn. OBJECTIVES: The objective of this article is to examine changes in prescribing of daily anti-inflammatory drugs for children covered by Florida Medicaid during two 2-year periods, the first just after publication of the Guidelines and the second 7 years later; and to estimate adherence to treatment by children who received one of them. DESIGN: The study groups for each of the two 2-year periods included only children 2 to 18 years old who had medical or institutional claims to Medicaid for asthma and who were continuously covered during the period. From outpatient claims files, a record was assembled for each child containing the number of prescriptions in each category of asthma drugs during each interval. For each child who had received a prescription for any daily preventative drug, the number of such prescriptions and the time after the first were used to calculate availability of medication. RESULTS: The proportion of children receiving at least one prescription for a preventive drug rose from 26.9 per cent of children in 1990-1992 to 52.6 per cent in 1997-1998. African-American children were less likely to receive a preventive in the earlier period, but the difference narrowed by 1997. Assuming that one refill provided a month's supply of drug, the percentage of children who had enough drug dispensed to treat for more than half of the time following the initial prescription rose from 6.1 to 11.2 per cent. For children with the highest use of beta-agonist (11 or more prescriptions over 2 years), the percentage rose from 25.3 to 35.8; in those with 5 or more courses of a systemic steroid, the proportion rose from 36.6 to 40.2. During the second interval, adherence to use of oral montelukast was no better than to inhaled daily medications. CONCLUSION: In the 7 years after the publication of the NIH Guidelines, asthmatic children covered by Florida Medicaid had an approximate doubling in the proportion who received a prescription for a daily anti-inflammatory drug. However, during both intervals the adherence to treatment once prescribed remained low even among those with the severest asthma. Effective strategies to improve adherence will be needed before these drugs can realize their potential.

Adolescent↗
PubMed2000

Exercise, methacholine, and adenosine 5'-monophosphate challenges in children with asthma: relation to severity of the disease.

Bronchial hyperreactivity is a characteristic feature of asthma and can be evaluated by different challenges. The aim of this study was to compare exercise, methacholine (MCH), and adenosine 5'-monophosphate (AMP) challenges in 135 children and young adults (mean age +/- SD, 12.4+/-3.9 years) with asthma, and to examine the utility of the different challenges in predicting those children with asthma likely to require prophylactic antiinflammatory treatment. The sensitivity of MCH challenge in detecting bronchial hyperreactivity (at or below 8 mg/mL) was 98%, that of AMP challenge (at or below 200 mg/mL) 95.5%, and that of exercise (more than 8.2% fall in FEV(1)) was 65%. There was a significant difference between mild asthmatic children (85 patients, intermittent asthma, step 1 of NIH guidelines) and moderate asthmatics (50 patients, steps 2 and 3 of guidelines) in relation to the logarithmic mean provocation concentration to elicit a 20% fall in FEV(1) (PC(20)) to MCH (0.49 mg/mL vs. 0.15 mg/mL, P<0.00001), that to AMP (7.67 mg/mL vs. 3.60 mg/mL, P = 0.001), and in relation to the mean percent fall in FEV(1) after exercise (13.9% vs. 22.0%, P = 0.001). Sensitivity and specificity curves between the two severity groups of asthma were constructed, and the intersection point of the two curves for each type of challenge was determined. When mild asthmatics were compared to moderate asthmatics, the intersection points for MCH, AMP, and exercise were 66%, 63%, and 61%, respectively. Logistic regression analysis and receiver operating characteristic (ROC) curves of the three challenges for the two severity groups of asthma showed that methacholine was a better discriminating challenge between the severity groups than the other two challenges. We conclude that the sensitivities of AMP and MCH challenges in the detection of bronchial hyperreactivity in children and young adults with asthma are very similar and higher than that of exercise. There is a significant difference between mild and moderate asthmatics within the three bronchial challenges, with MCH discriminating better than AMP or exercise between groups.

Adenosine Monophosphate↗
PubMed2006

Defining "success" in recruitment of underrepresented populations to cancer clinical trials: moving toward a more consistent approach.

Although medically underserved groups bear a heavy burden of cancer disease and governmental agencies have required inclusion of minorities and women in cancer clinical trials since 1993, many of these groups are underrepresented in cancer prevention or treatment clinical trials. To assess and enhance recruitment of underrepresented populations into cancer-related clinical trials, investigators and governmental agencies need consistent measurement approaches for recruitment that can be applied to diverse settings where trials are conducted. We conducted a systematic review to evaluate what measurement approaches were used to evaluate the success of recruitment of underrepresented groups into cancer prevention or treatment trials, and whether these recruitment goals were stated a priori. Only two articles reported an a priori recruitment goal. The recruitment measurement approaches varied considerably, with no consistent standard, especially for individual trials. By using the empiric evidence from this review in conjunction with the National Institutes of Health (NIH) guidelines, we constructed a framework for choosing consistent a priori recruitment goals for underrepresented groups based on the research question and study location. Using consistent measurement approaches for underrepresented groups will improve comparability of recruitment strategies across trials, improve equity in distribution of benefits and burdens of cancer-related clinical trials, and may improve applicability of trial results to multiple populations.

Clinical Competence↗
PubMed2002

T-cell subset counting and the fight against AIDS: reflections over a 20-year struggle.

The story of T-lymphocyte subset immunophenotyping technology is reviewed on the occasion of the 20th anniversary of CD4 T-cell enumeration. Over time, immunophenotyping has evolved into precise, reliable, but complicated and expensive technology requiring fresh blood samples. The gating technologies that were universally adapted for clinical flow cytometry for the past decade relied on rapidly deteriorating morphological scatter characteristics of leukocytes. This special issue dedicated to CD4 T-cell enumeration features most of the available new options that will have a significant impact on how this technology will be implemented within the first decade of the 21st century. In a series of original publications, including the new NIH guideline for T-cell subset enumeration, contemporary gating protocols that use immunologically logical parameters are presented as part of the more reliable and affordable immunophenotyping alternative. Some of the improvements addressed here include the costs of the assays and the capacity to monitor interlaboratory and intralaboratory performances. It is clear that an effective attack on the human immunodeficiency virus (HIV) epidemic has to embrace resource-poor regions. Reducing the cost of the assay while improving reliability and durability is a move in the right direction.

Acquired Immunodeficiency Syndrome↗
PubMed2006

The College Health and Wellness Study: baseline correlates of overweight among African Americans.

Overweight and obesity are epidemic in the United States, particularly among minority populations. This epidemic contributes to the development of chronic conditions that occur later in life such as type 2 diabetes and hypertension. Therefore, it is important to identify factors associated with the development of obesity during young adulthood. We conducted a cross-sectional survey among students graduating from a Historically Black College or University (HBCU) in the Mid-Atlantic region. Participants were 392 predominantly African American seniors graduating in the spring of 2003. Data were collected using a self-administered paper and pencil questionnaire which focused on weight, weight management activities, individual and familial weight history, and health status indicators. Participants were on average 24 +/- 5 years of age and 69% female; over 90% identified as African American or Black. According to NIH guidelines, about 30% of males and 28% of females were considered overweight, 12% of males and 7% of females were considered obese, and 7% of males and females were considered extremely obese. Significant correlates of being more overweight were being married, having children, lower socio-economic status, weight-loss attempts, personal and family history of overweight, and poorer health status. These data suggest that among this sample, the prevalence of overweight and obesity is similar to other populations of young African American adults. Familial factors such as socio-economic status and family weight history were important correlates of overweight. Overweight is a significant problem in this population, and these data should be useful for developing weight loss interventions aimed at young adults.

Adult↗
PubMed1979

Isolation of human germ-line DNA suitable for recombinant DNA studies.

Dna from human sperm cells can be isolated with size and purity sufficient for use in recombinant DNA research. The DNA averages 100 000 base pairs (bp) in size (about 70.10(6) daltons) and is free of somatic cell, bacterial, and viral DNA. It can therefore be cloned under P2 + EK2 conditions as stipulated in the 1978 NIH Guidelines for recombinant DNA research.

Centrifugation, Density Gradient↗
PubMed1995

Educational and long-term therapeutic intervention in the ED: effect on outcomes in adult indigent minority asthmatics.

Minorities have increased morbidity and mortality rates resulting from asthma. The segment of minorities that is socioeconomically depressed often uses the emergency department (ED) as their primary site of medical care. For these reasons, we provided major long-term therapeutic intervention as well as intensive education in the ED for indigent adult African American asthmatics. We intervened in the cases of 30 patients who were frequent visitors to the ED over the previous 2 years. The intervention consisted of 1 hour of education in the ED before discharge regarding the prevention of asthma, the importance of decreasing inflammation as a means of improving asthma control, self-monitoring with a peak flow meter, and a demonstration of correct inhalation technique with metered-dose inhalers and a spacer device. Further, the intervention included management consistent with recent NIH Guidelines, stressing inhaled corticosteroids. After the intervention in the ED, patients were scheduled for follow-up asthma clinic visits. Outcome measures were ED visits and hospitalizations for 1 year after the ED intervention. Using the same inclusion/exclusion criteria, a retrospective control group of 22 patients for the same time period was compared with the intervention group. Before our intervention, the mean number of ED visits per patient for the previous 2 years was 4.4 +/- 2.7, and after the intervention, 2.6 +/- 2.6 (P < .01). The control group did not show a difference in the number of ED visits (3.4 +/- 2.6 before and 3.5 +/- 2.7 after, P = .96). After the intervention, the mean number of hospitalizations decreased significantly in the study group (P < .01).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1995

Mucositis management practices for hospitalized patients: national survey results.

The optimal management strategies for cancer chemotherapy and radiotherapy-induced mucositis have not been identified. In 1989, the National Institutes of Health (NIH) published a consensus statement outlining a standardized approach for the prevention and treatment of oral complications. The purpose of this survey was to identify the national treatment practices for oral mucositis, mucocutaneous Herpes simplex virus infections, and oral candidiasis, and to compare them to the NIH guidelines. Surveys were mailed to clinical pharmacists at 200 hospitals throughout the United States. Sixty-two of the 200 questionnaires were completed and returned. Institutions used a diversity of agents, generating substantial variability in mucositis prophylaxis and treatment protocols. Many of these therapies included products or combinations of ingredients that lack proven clinical efficacy. Mucositis management strategies for hospitalized patients vary widely at US hospitals. Coordinated, controlled studies are needed to identify optimal therapies for these patients.

Antineoplastic Agents↗
PubMed2000

Primary hyperparathyroidism. When to observe and when to operate.

The decision to recommend parathyroid surgery in patients with symptomatic primary hyperparathyroidism is clear. The decision to recommend parathyroid surgery in patients with asymptomatic primary hyperparathyroidism is clearer than it was 10 years ago. In addition to the NIH guidelines, the author believes that patients who have vertebral osteopenia, patients who have vitamin D deficiency, and patients who are in their perimenopausal years should undergo surgery. Although surgery may be an acceptable option even for patients who do not meet these guidelines, many patients can be safely managed without surgery. For these patients, monitoring is essential because a small number will show progression of disease over time.

Female↗
PubMed2001

The association of perceived health, clinical status, and initiation of HAART (highly active antiretroviral therapy) in adolescents.

PURPOSE: To examine factors associated with the initiation of highly active antiretroviral therapy (HAART) in adolescents to understand better how current National Institutes of Health (NIH) Guidelines are being used in practice. METHODS: HIV infected and HAART-naive adolescents seen at 15 REACH clinical sites were selected. Repeated measures methodology using generalized estimating equations was applied to identify associations between subject demographic characteristics, risk behaviors, perceived health, and clinical status with the outcome measure of HAART initiation during the first 24 study months. RESULTS: A total of 219 subjects were eligible for analysis; HAART was prescribed in 115 (53%). Significant univariate associations with HAART prescription included lower CD4(+) T cell counts (OR = 1.7, 95% CI: 1.1-2.6), higher viral loads (OR = 2.7, 95% CI: 1.5-5.0), and calendar year of HAART prescription (OR as high as 2.4, 95% CI: 1.1-5.2). Multivariate results showed that after controlling for CD4(+) T cell counts below 500 cells/mm(3), higher plasma HIV-1 RNA (<or=10,000 copies per ml), and temporal factors, having a high school diploma/GED but no further education (OR = 2.7, 95% CI: 1.3-5.5) and subject's perception of poor health status (OR = .987; 95% CI: .975- .999) were independently associated with prescription of HAART. HAART was most likely to be prescribed during the first half of 1998 in this cohort (OR = 10.8; 95% CI: 4.0-29.0). CONCLUSIONS: In this first ever study of HAART prescription in adolescents infected with HIV, perception of poor health status and having a high school diploma/GED were independently associated with prescription of HAART suggesting that the personal decision to accept therapy is related to the belief that one's health is deteriorating and that the decision to prescribe therapy may be linked in some fashion to the prescriber's assessment of the patient's ability to master the regimen as well as clinical status.

Adolescent↗
PubMed2006

Is the current BMI obesity classification appropriate for black and white postmenopausal women?

OBJECTIVE: To evaluate the relation between body fatness (%Fat) and body mass index (BMI) and to evaluate the validity of the BMI standards for obesity established by the NIH in older black and white postmenopausal women. RESEARCH METHODS: Height, weight, BMI, and %Fat, assessed by DXA, were determined for 296 healthy, independently living women ranging in age from 50 to 80 years (M+/-s.d.; 64.4+/-7.8 years). RESULTS: Per NIH guidelines, 32% were classified as obese (> or = 30 kg/m2, mean BMI = 28.1+/-5.5 kg/m2). In contrast, using the %Fat criterion of 38% advocated by Lohman to define obesity, 47% of our sample was obese (mean %Fat=37.3+/-6.2%). A moderately high curvilinear relation existed between BMI and %Fat (R = 0.82, SEE = 3.57 %Fat, P<0.05). Race added meaningfully to the prediction of %Fat (P<0.05) such that for the same BMI, black women will have 1% lower body fatness than white women. Based on a %Fat > or = 38 as the criterion for obesity, receiver operating characteristic (ROC) analysis, performed separately by race, indicated that the currently accepted BMI cutpoint for obesity produced low sensitivity (69% and 61% for black and white women, respectively). Alternatively, BMI values > or = 28.4 kg/m2 for black women and > or = 26.9 kg/m2 for white women to define obesity maximized classification accuracy. CONCLUSION: We conclude that current BMI categories may not be appropriate for identifying obesity among postmenopausal women. Furthermore, the relation between BMI and %Fat is different in black compared to white women but remains constant from the sixth through the eighth decade of life.

Absorptiometry, Photon↗
PubMed2005

A controlled, prospective study of neuropsychological outcomes post parathyroidectomy in primary hyperparathyroid patients.

BACKGROUND: There is an increasing number of primary hyperparathyroidism (PHPT) patients with neuropsychological or psychiatric symptoms. Many of these patients do not have osseous or renal complications to satisfy the criteria for parathyroidectomy according to the NIH guidelines. OBJECTIVE: To assess whether there is any improvement in neuropsychological and mood symptoms following parathyroidectomy. PATIENTS AND DESIGN: Twenty PHPT patients undergoing parathyroidectomy and 20 orthopaedic controls matched for age, gender and estimated intelligence were subjects to pre and postoperative assessment of cognition and mood with a mean surgery-retest interval of 3 months. RESULTS: Using two tests of attentional flexibility [the Stroop test, the Digit symbol test of the Wechsler Adult Intelligence Scale-Revised (WAIS-R)], and two memory tests for prose and nonverbal material, no significant change was found between the groups when comparing scores before and after surgery. There was no improvement between pre and postoperative measures of verbal (dominant hemisphere) as opposed to visuo-spatial (nondominant hemisphere) function when compared to controls. There was no relationship between the reduction in serum calcium and the change in the neuropsychological measures postoperatively. CONCLUSION: This controlled, prospective study demonstrates no significant improvement in neuropsychological indices using objective, validated psychometric tools in an unselected cohort of PHPT patients. No relationship was found between serum calcium level and the degree of neuropsychological deficit. More studies are needed to assess whether the effect of parathyroidectomy is beneficial and sustainable in PHPT patients with neuropsychological symptoms alone.

Adult↗
PubMed2006

Positive effect of parathyroidectomy on bone mineral density in mild asymptomatic primary hyperparathyroidism.

OBJECTIVES: Patients with mild primary hyperparathyroidism (pHPT) often appear asymptomatic, and have previously been regarded as not requiring treatment. However, increased cardiovascular morbidity and dyslipidaemia have also been recognized in mild pHPT, which also seem to be normalized after parathyroidectomy. The present study explores whether postmenopausal women with mild pHPT have decreased bone mineral density (BMD) compared with age-matched healthy controls, and the effects on BMD of parathyroidectomy. DESIGN, SUBJECTS AND INTERVENTION: A population-based health screening of 5202 postmenopausal women identified 87 overtly asymptomatic patients with mild pHPT as well as age-matched healthy controls. A 5-year follow-up included 49 cases who had undergone parathyroidectomy. BMD was measured with DXA at the femoral neck, the lumbar spine and the total body. RESULTS: At study entry, BMD was 5-6% lower in the lumbar spine (L2-L4) and femoral neck in cases compared with matched controls. After the 5-year follow-up, BMD increased in L2-L4 by 2.9% (P = 0.002) in the parathyroidectomized cases and remained stable in the femoral neck. However, femoral neck BMD increased 4.1% (P = 0.013) for cases <67 years old (50% of the cohort). CONCLUSION: In accordance with recent NIH guidelines for pHPT treatment, the level of BMD per se in the investigated group of patients justifies parathyroidectomy in almost half of the cases with mild pHPT. Surgery could be expected to increase BMD in L2-L4 to the level of the controls, to increase femoral neck BMD in patients <67 years of age and to preserve femoral neck BMD in the elderly population.

Absorptiometry, Photon↗
PubMedDate not supplied

The mammography controversy: a case for breast self-examination.

More and more nurses are held legally accountable for their practice. The mammography controversy and the directives in the NIH guidelines must be taken into account by nurses because of their implications for preventive health care and early detection of breast cancer. Mortality rates from breast cancer are high enough that the importance of regular, competent BSE by women cannot be overestimated. Nursing is in an ideal position within the health care delivery system to promote BSE. In the meantime, the answer to the question of whether to use mammography as a routine screening device for asymptomatic women under age 50 can only come from research that is designed to demonstrate the relative risks and benefits of the procedure for this age group.

Adult↗
PubMed2003

Accuracy of three dry-chemistry methods for lipid profiling and risk factor classification.

The purpose of this project was to determine the accuracy in lipids measurement and risk factor classification using Reflotron, Cholestech, and Ektachem DT-60 dry-chemistry analyzers. Plasma and capillary venous blood from fasting subjects (n = 47) were analyzed for total cholesterol (TC), high density lipoprotein (HDL-C), and triglycerides (TG) using these analyzers and a CDC certified laboratory. Accuracy was evaluated by comparing the results of each portable analyzer against the CDC reference method. One-way ANOVAs were performed for TC, HDL-C, and TG between all portable analyzers and the reference method. Chi-square was used for risk classification (2001 NIH Guidelines). Compared to the reference method, the Ektachem and Reflotron provided significantly lower values for TC (p < .05). In addition, the Cholestech and Ektachem values for HDL-C were higher than the CDC (p < .05). The Reflotron and Cholestech provided higher values of TG than the CDC (p < .05). Chi-squares analyses for risk classification were not significant (p > .45) between analyzers. According to these results, the Ektachem and Cholestech analyzers met the current NCEP III guidelines for accuracy in measurement of TC, while only Ektachem met guidelines for TG. All 3 analyzers provided a good overall risk classification; however, values of HDL-C should be only used for screening purposes.

Adult↗
PubMed2006

Six steps to fast-track insurance approval for bariatric surgery.

Most of the health-insurers approve bariatric surgery for patients according to the NIH standards, while others only approve the surgery if the patient has a BMI >50. Therefore, it is important for the physician to know and carefully follow the various criteria of different insurance companies. We suggest 6 steps to fast-track insurance approval: 1) a multidisciplinary team; 2) 6-month diet; 3) comprehensive medical evaluation; 4) flexibility and consistency; 5) analysis of each patient indication; 6) quality of cost-effectiveness and long-term monitoring and benefits. In the event that an insurance company rejects the request for surgery, a blueprint of an appeal letter is very important. The appeal letter should stress the indications and benefits of surgery for your patients. Insurance company criteria may differ from the NIH guidelines. Irrespective of this, the steps outlined will help speed the insurance approval process and reduce paperwork and confusion. Most often, rejections stem from letters that were not written clearly or that lacked one or more of the elements delineated above. If the surgeon follows the 6 steps described, he/she should meet less disappointment, as in our experience that went from 50% to 90% success because of better communication with insurance and more appropriate paperwork.

Bariatric Surgery↗