Racial bias in federal nutrition policy, Part II: Weak guidelines take a disproportionate toll.
(33/4783)
Many diet-related chronic diseases take a disproportionate toll among members of racial minorities. Research shows the prevalence of diabetes, hypertension, cancer, and heart disease is higher among various ethnic groups compared with whites. The Guidelines and the Food Guide Pyramid, however, promote the use of multiple servings of meats and dairy products each day and do not encourage replacing these foods with vegetables, legumes, fruits, and grains. The Dietary Guidelines for Americans encourage a 30% caloric reduction in fat intake and make no provision for further reductions for those who wish to minimize health risks. Abundant evidence has shown that regular exercise combined with diets lower in fat and richer in plant products than is encouraged by the Dietary Guidelines for Americans are associated with reduced risk of these chronic conditions. While ineffective Dietary Guidelines potentially put all Americans at unnecessary risk, this is particularly true for those groups hardest hit by chronic disease. (+info)
Mortality and hormone-related exposures in women with diabetes.
(34/4783)
OBJECTIVE: Hormone-related events and exposures are related to mortality and especially to cardiovascular disease in women. We evaluated whether such exposures influenced risk in a well-defined group of women with diabetes. RESEARCH DESIGN AND METHODS: Women with younger- and older-onset diabetes who were identified during a population-based study were queried about number of pregnancies, age at menarche, use of oral contraceptives, use of estrogen replacement therapy, and menopausal status at examinations in 1984-1986. Analyses are limited to women aged > or = 18 years (n = 398 and 542 in those with younger- and older-onset diabetes, respectively). Cohort mortality was monitored carefully, and causes of death were abstracted from death certificates. RESULTS: There were 58 deaths in the first group and 338 deaths in the second group since the 1984-1986 examination. The number of pregnancies was significantly associated with all-cause mortality (hazard ratio, 0.96 [95% CI 0.92-1.00]) in older-onset women only. CONCLUSIONS: These data suggest and are compatible with the notion that the hormone exposures examined are unrelated to cardiovascular mortality in women with diabetes, with the exception of a minimal effect of the number of pregnancies in older-onset women. Whether there is a difference in these exposure-outcome relationships between women with diabetes and those without diabetes is uncertain and requires further investigation. (+info)
Death on the waiting list for cardiac surgery in The Netherlands in 1994 and 1995.
(35/4783)
OBJECTIVE: To describe the causes and circumstances of death regarding patients who died in 1994 and 1995 while on a waiting list for cardiac surgery in the Netherlands. DESIGN: Retrospective multicentre case study. SETTING: 11 Dutch cardiac surgery centres. PATIENTS: All patients reported as dying while on the waiting list for cardiac surgery in 1994 and 1995. MAIN OUTCOME MEASURES: Classification of death by an independent adjudication committee into "erroneously reported", "waiting list related" or "not waiting list related". Death was judged as "waiting list related" if the clinical course would have been substantially different if there had been unrestricted surgical capacity. RESULTS: 138 and 129 deaths were reported in 1994 and 1995, respectively. 43 deaths (16%) were considered as erroneously reported. 181 of the remaining 224 cases were adjudicated as waiting list related. Median time from acceptance for surgery to death was 35 days (interquartile range 14-75 days). 97 of 181 deaths occurred within six weeks following addition to the waiting list. The estimated incidence of death ranged from 1.33 per 1000 patient-weeks during weeks 2-4 to 0.68 per 1000 patient-weeks after 12 weeks. CONCLUSIONS: The causes and circumstances of death are waiting list related for approximately 100 patients per year in the Netherlands. At least half of the deaths may occur within the first six weeks. Waiting lists for cardiac surgery engender high risks for the patients involved. (+info)
Does professional advice influence aspirin use to prevent heart disease in an HMO population?
(36/4783)
OBJECTIVE: Aspirin use seems to reduce coronary artery disease events in some groups of patients. Factors associated with use of aspirin to prevent heart disease in an HMO population were examined. DESIGN: A population-based survey. SETTING: A large HMO in the midwestern United States. PARTICIPANTS: 8000 health plan members 40 years of age and older. MAIN OUTCOME MEASURES: The survey assessed use of aspirin, professional advice to use aspirin, and coronary heart disease risk factors and status. The sample was stratified by whether members had none, one, or more than one of the following chronic conditions: diabetes, hypertension, lipid disorder, or heart disease. The mailed survey had a corrected response rate of 82.4%. RESULTS: Overall, 38% of respondents reported using aspirin at least three times a week to prevent heart disease. Aspirin use did not vary in owned versus contracted clinics. Aspirin use was 71.3% in patients with and 27.7% in patients without diagnosed coronary heart disease (P < 0.001). In logistic regression models, professional advice to take aspirin was strongly associated with self-reported use of aspirin (odds ratio, 13.86) (P < 0.001) after adjustment for age, sex, level of education, and chronic disease status. CONCLUSIONS: Aspirin is widely used by HMO members with coronary artery disease to prevent subsequent coronary artery disease events. Professional advice to use aspirin seems to be strongly related to aspirin use. (+info)
Assessing public health capacity to support community-based heart health promotion: the Canadian Heart Health Initiative, Ontario Project (CHHIOP).
(37/4783)
This paper presents initial findings of the Canadian Heart Health Initiative, Ontario Project (CHHIOP). CHHIOP has two primary objectives. The programmatic objective is to coordinate and refine a system for supporting effective, sustained community-based heart health activities. This paper addresses the scientific objective: to develop knowledge of factors that influence the development of predisposition and capacity to undertake community-based heart health activities in public health departments. A systems theory framework for an ecological approach to health promotion informs the conceptualization of the key constructs, measured using a two-stage longitudinal design which combines quantitative and qualitative methods. This paper reports the results of the first round of quantitative survey data collected from all health departments in Ontario (N = 42) and individuals within each health department involved in heart health promotion (n = 262). Results indicate low levels of implementation of heart health activities, both overall and for particular risk factors and settings. Levels of capacity are also generally low, yet predisposition to undertake heart health promotion activities is reportedly high. Analyses show that implementation is positively related to capacity but not predisposition, while predisposition and capacity are positively related. Overall, results suggest predisposition is a necessary but not sufficient condition for implementation to occur; capacity-related factors appear to be the primary constraint. These findings are used to inform strategies to address CHHIOP's programmatic objective. (+info)
Renal insufficiency and altered postoperative risk in carotid endarterectomy.
(38/4783)
PURPOSE: Higher complication rates have been reported in patients with renal insufficiency (RI) undergoing peripheral vascular surgery. Little attention has been paid specifically to carotid endarterectomy (CEA) in patients with RI where the risk/benefit considerations are very sensitive to small increases in postoperative complications. METHODS: One thousand one consecutive CEAs performed since 1990 were reviewed from our vascular registry, and 73 CEAs on patients with RI were identified. For comparison, two groups were established: group I (n = 928), normal renal function (creatinine level, <1.5 mg/dL); and group II (n = 73), RI (creatinine level, >/=1.5 mg/dL). RESULTS: Differences in the nonfatal stroke rates and combined stroke and death rates were statistically significant (P <.02) between the groups: group I (1. 08% and 1.18%) and group II (5.56% and 6.94%) respectively. Both groups were similar in regard to operative indications. In addition with the comparison of group I to group II, there was a statistically significant increase in hematoma rate, 1.61% versus 12. 5% ( P <.001), total cardiac morbidity, 1.72% versus 6.94% (P =.003), and total complications, 6.24% versus 36.1% (P =.001). Multivariate analysis demonstrated pre-existing RI to be the only significant predictor for perioperative stroke and hematoma. CONCLUSION: Patients with preoperative RI are at a higher, but not prohibitive, risk for stroke and death after CEA than patients with normal renal function. They are also at risk for hematoma formation, cardiac morbidity, and overall complications. Care in selection of these patients for CEA must be emphasized. (+info)
Angiographic anatomy of the inferior right atrial isthmus in patients with and without history of common atrial flutter.
(39/4783)
BACKGROUND: Although most ablative procedures undertaken for common atrial flutter target the inferior right atrial isthmus, comparative studies of the morphology of this area are lacking. Our study examines its angiographic anatomy, making correlations with postmortem specimens, to provide a better understanding of the anatomic substrate of this arrhythmia. METHODS AND RESULTS: The gross morphological features and dimensions of the area between the orifice of the inferior caval vein and the attachment of the septal leaflet of the tricuspid valve were determined from angiograms made in 23 patients with documented atrial flutter and 30 control subjects. For comparison, we studied 20 normal heart specimens. When viewed in right anterior oblique projection, 2 morphologically distinct areas were identified. In the specimens, the inferior isthmus measured a mean length of 30+/-4 mm, not significantly different from the dimensions obtained from angiograms of control subjects. The mean length of the isthmus, however, was greater in patients with common atrial flutter than those without (37+/-8 versus 28+/-6 mm). Patients with atrial flutter and structural heart disease had an even longer isthmus than those with flutter alone (39. 6+/-8 versus 33+/-7 mm). Compared with those without flutter, the atrial diameter was also larger in patients with flutter (57.6+/-9 versus 48.5+/-6 mm). Reevaluation carried out at follow-up 10+/-2 months after ablation did not show any reduction in atrial size, although contractility improved. CONCLUSIONS: The inferior isthmus and right atrium in patients with common atrial flutter were significantly larger than those in a control population. (+info)
Paclitaxel by 24-hour infusion with doxorubicin by 48-hour infusion as initial therapy for metastatic breast cancer: phase I results.
(40/4783)
PURPOSE: We and others have demonstrated the antineoplastic efficacy of paclitaxel as a single agent in metastatic breast cancer. We performed this phase I trial to evaluate the combination of paclitaxel with doxorubicin. PATIENTS AND METHODS: Eligible patients had measurable or evaluable metastatic breast cancer for which this was the initial cytotoxic treatment. They may have received adjuvant chemotherapy with other drugs. The study had four parts. In part 1, the patients received paclitaxel by 24-hour infusion followed by doxorubicin by 48-hour infusion. The paclitaxel dose was to be escalated from a starting dose of 125 mg/m2, and the doxorubicin dose was to remain constant at 60 mg/m2 with treatment repeated every three weeks. The results of part 1 prompted part 2 which was a study of the reverse sequence. Part 3 was a formal study of pharmacology and has been reported (J Clin Oncol 14: 2713-21, 1996). In part 4, patients received doxorubicin 50 mg/m2 by bolus followed by paclitaxel 150 mg/m2 by 24-hour infusion for courses 1 and 2. In all subsequent courses doxorubicin was administered by 48-hour infusion. All patients in all four parts of the study had baseline cardiac scans. All patients received standard premedication for paclitaxel. RESULTS: Forty-eight patients were treated in all four parts of the study. In part 1 (10 patients), the maximum tolerated dose (MTD) was paclitaxel 125 mg/m2/24 hours followed by doxorubicin 48 mg/m2/48 hours as defined by dose-limiting mucositis and neutropenic fever which occurred at the starting dose. For part 2 (21 patients), the MTD was doxorubicin 60 mg/m2/48 hours followed by paclitaxel 160 mg/m2/24 hours. In part 4 (seven patients), the MTD was doxorubicin 50 mg/m2/bolus followed by paclitaxel 135 mg/m2/24 hours. In parts 2 and 4, the dose-limiting toxic effect was neutropenia. Of the entire cohort of 48 patients, seven (15%) had a complete response (one persists at five years without intervening therapy), 26 (54%) had a partial response for an objective response rate of 69% (95% confidence interval (95% CI): 54%-81%). The median follow-up of all living patients is 38+ months (range 20+ to 62+); the median response duration is seven months (range 2-33.7+); the median overall survival is 20.5 months (range 5-54+). The median time to progression is 9.6 months (range 1-33.7+ months). Two patients developed congestive heart failure, one at 24 months after her final dose of doxorubicin which amounted to a cumulative lifetime total doxorubicin dose of 870 mg/m2, one after a total of 660 mg/m2. In both, cardiac symptoms were controlled with medications. CONCLUSIONS: The combination of paclitaxel/24 hours with doxorubicin/48 hours is an effective antineoplastic treatment for metastatic breast cancer. However, the incidence of complete response, the median overall survival, and time to progression were not greater than for standard doxorubicin-based combinations. Additionally, a sequence-dependent interaction between paclitaxel and doxorubicin, given in the schedule described here, was defined. Other strategies and schedules should be evaluated to maximize the antineoplastic efficacy of these two potent agents. (+info)