MB's Articles of Interest - September '98

ARTICLE TITLE: Preemptive epidural analgesia and recovery from radical prostatectomy: a randomized controlled trial [see comments]
COMMENTS: Comment in: JAMA 1998 Apr 8; 279(14):1114-5
ARTICLE SOURCE: JAMA (United States), Apr 8 1998, 279(14) p1076-82
AUTHOR(S): Gottschalk A; Smith DS; Jobes DR; Kennedy SK; Lally SE; Noble VE; Grugan KF; Seifert HA; Cheung A; Malkowicz SB; Gutsche BB; Wein AJ
AUTHOR'S ADDRESS: Department of Anesthesia, School of Medicine, University of Pennsylvania, Philadelphia 19104, USA. ag@network3.entropy.upenn.edu.
MAJOR SUBJECT HEADING(S): Analgesia, Epidural; Pain, Postoperative [prevention & control]; Prostatectomy
MINOR SUBJECT HEADING(S): Aged; Analgesics; Analysis of Variance; Anesthesia, General; Bupivacaine; Double-Blind Method; Fentanyl; Middle Age; Pain Measurement; Statistics, Nonparametric; Time Factors
INDEXING CHECK TAG(S): Human; Male; Support, Non-U.S. Gov't
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: CONTEXT: Preemptive analgesia can decrease the sensitization of the central nervous system that would ordinarily amplify subsequent nociceptive input, but a clear demonstration of its clinical efficacy is necessary for it to become a routine component of acute pain therapy. OBJECTIVE: To determine the impact of preemptive epidural analgesia on postoperative pain and other clinically important outcome variables after radical retropubic prostatectomy. DESIGN AND SETTING: A block randomized double-blind clinical trial lasting 20 months at a single academic medical center. PATIENTS: A total of 100 generally healthy and neurologically intact patients scheduled for radical retropubic prostatectomy for the treatment of prostate cancer in whom an epidural catheter for treating postoperative pain was to be placed prior to the induction of general anesthesia. INTERVENTIONS: Epidural bupivacaine, epidural fentanyl, or no epidural drug was administered prior to induction of anesthesia and throughout the entire operation, followed by aggressive postoperative epidural analgesia for all patients. MAIN OUTCOME MEASURES: Daily pain scores during hospitalization and pain scores obtained 3.5, 5.5, and 9.5 weeks after hospital discharge. RESULTS: The patients who received epidural fentanyl or bupivacaine prior to surgical incision (preemptive analgesia) experienced 33% less pain while hospitalized (P=.007). Pain scores in those receiving preemptive analgesia were significantly lower at 9.5 weeks (P=.02), but were not significantly different at 3.5 or 5.5 weeks. At 9.5 weeks, 32 (86%) of 37 patients receiving preemptive analgesia were pain-free compared with 9 (47%) of 19 control patients (P=.004). Patients receiving preemptive analgesia were more active 3.5 weeks after surgery (P=.01), but not at 5.5 or 9.5 weeks. CONCLUSIONS: Even in the presence of aggressive postoperative pain management, preemptive epidural analgesia significantly decreases postoperative pain during hospitalization and long after discharge, and is associated with increased activity levels after discharge.
MEDLINE INDEXING DATE: 199806
ISSN: 0098-7484
LANGUAGE: English
UNIQUE NLM IDENTIFIER: 98206642
CAS REGISTRY/EC NUMBER(S): 0 (Analgesics); 2180-92-9 (Bupivacaine); 437-38-7 (Fentanyl)

ARTICLE TITLE: Why review articles on the health effects of passive smoking reach different conclusions.
ARTICLE SOURCE: JAMA (United States), May 20 1998, 279(19) p1566-70
AUTHOR(S): Barnes DE; Bero LA
AUTHOR'S ADDRESS: Department of Public Health Biology and Epidemiology, School of Public Health, University of California, Berkeley, USA.
MAJOR SUBJECT HEADING(S): Publishing; Tobacco Smoke Pollution
MINOR SUBJECT HEADING(S): Analysis of Variance; Authorship; Conflict of Interest; Health Status Indicators; Logistic Models; Publication Bias; Publishing [standards]; Tobacco Smoke Pollution [adverse effects]
INDEXING CHECK TAG(S): Human; Support, Non-U.S. Gov't
PUBLICATION TYPE: JOURNAL ARTICLE; META-ANALYSIS
ABSTRACT: OBJECTIVE: To determine whether the conclusions of review articles on the health effects of passive smoking are associated with article quality, the affiliations of their authors, or other article characteristics. DATA SOURCES: Review articles published from 1980 to 1995 were identified through electronic searches of MEDLINE and EMBASE and from a database of symposium proceedings on passive smoking. ARTICLE SELECTION: An article was included if its stated or implied purpose was to review the scientific evidence that passive smoking is associated with 1 or more health outcomes. Articles were excluded if they did not focus specifically on the health effects of passive smoking or if they were not written in English. DATA EXTRACTION: Review article quality was evaluated by 2 independent assessors who were trained, followed a written protocol, had no disclosed conflicts of interest, and were blinded to all study hypotheses and identifying characteristics of articles. Article conclusions were categorized by the 2 assessors and by one of the authors. Author affiliation was classified as either tobacco industry affiliated or not, based on whether the authors were known to have received funding from or participated in activities sponsored by the tobacco industry. Other article characteristics were classified by one of the authors using predefined criteria. DATA SYNTHESIS: A total of 106 reviews were identified. Overall, 37% (39/106) of reviews concluded that passive smoking is not harmful to health; 74% (29/39) of these were written by authors with tobacco industry affiliations. In multiple logistic regression analyses controlling for article quality, peer review status, article topic, and year of publication, the only factor associated with concluding that passive smoking is not harmful was whether an author was affiliated with the tobacco industry (odds ratio, 88.4; 95% confidence interval, 16.4-476.5; P .001). CONCLUSIONS: The conclusions of review articles are strongly associated with the affiliations of their authors. Authors of review articles should disclose potential financial conflicts of interest, and readers of review articles should consider authors' affiliations when deciding how to judge an article's conclusions.

ARTICLE TITLE: Are beta-blockers efficacious as first-line therapy for hypertension in the elderly? A systematic review.
ARTICLE SOURCE: JAMA (United States), Jun 17 1998, 279(23) p1903-7
AUTHOR(S): Messerli FH; Grossman E; Goldbourt U
AUTHOR'S ADDRESS: Department of Internal Medicine, Ochsner Clinic and Alton Ochsner Medical Foundation, New Orleans, LA 70121, USA. Fmesserli@aol.com.
MAJOR SUBJECT HEADING(S): Adrenergic beta-Antagonists [therapeutic use]; Antihypertensive Agents [therapeutic use]; Hypertension [drug therapy]
MINOR SUBJECT HEADING(S): Aged; Cardiovascular Diseases [mortality] [prevention & control]; Diuretics [therapeutic use]; Hypertension [mortality]; Models, Statistical; Morbidity; Randomized Controlled Trials
INDEXING CHECK TAG(S): Comparative Study; Human
PUBLICATION TYPE: JOURNAL ARTICLE; META-ANALYSIS
ABSTRACT: OBJECTIVE: To assess antihypertensive efficacy of beta-blockers and their effects on cardiovascular morbidity and mortality and all-cause morbidity compared with diuretics in elderly patients with hypertension. DATA SOURCE: A MEDLINE search of English-language articles published between January 1966 and January 1998 using the terms hypertension (drug therapy) and elderly or aged or geriatric, and cerebrovascular or cardiovascular diseases, and morbidity or mortality. References from identified articles were also reviewed. DATA SELECTION: Randomized trials lasting at least 1 year, which used as first-line agents diuretics and/or beta-blockers, and reported morbidity and mortality outcomes in elderly patients with hypertension. DATA SYNTHESIS AND RESULTS: Ten trials involving a total of 16164 elderly patients ( or =60 years) were included. Two thirds of the patients assigned to diuretics were well controlled on monotherapy, whereas less than a third of the patients assigned to beta-blockers were well controlled on monotherapy. Diuretic therapy was superior to beta-blockade with regard to all end points and was effective in preventing cerebrovascular events (odds ratio [OR], 0.61; 95% confidence interval [CI], 0.51-0.72), fatal stroke (OR, 0.67; 95% CI, 0.49-0.90), coronary heart disease (OR, 0.74; 95% CI, 0.64-0.85), cardiovascular mortality (OR, 0.75; 95% CI, 0.64-0.87), and all-cause mortality (OR, 0.86; 95% CI, 0.77-0.96). In contrast, beta-blocker therapy only reduced the odds for cerebrovascular events (OR, 0.75; 95% CI, 0.57-0.98) but was ineffective in preventing coronary heart disease, cardiovascular mortality, and all-cause mortality (ORs, 1.01, 0.98, and 1.05, respectively). CONCLUSIONS: In contrast to diuretics, which remain the standard first-line therapy, beta-blockers, until proven otherwise, should no longer be considered appropriate first-line therapy of uncomplicated hypertension in the elderly hypertensive patient.

ARTICLE TITLE: The case for "presumed consent" in organ donation. International Forum for Transplant Ethics.
ARTICLE SOURCE: Lancet (England), May 30 1998, 351(9116) p1650-2
AUTHOR(S): Kennedy I; Sells RA; Daar AS; Guttmann RD; Hoffenberg R; Lock M; Radcliffe-Richards J; Tilney N
AUTHOR'S ADDRESS: School of Public Policy, University College, London University, UK.
MAJOR SUBJECT HEADING(S): Informed Consent [legislation & jurisprudence]; Organ Procurement [legislation & jurisprudence] [standards]; Organ Transplantation [legislation & jurisprudence]; Tissue Donors [legislation & jurisprudence]
MINOR SUBJECT HEADING(S): Belgium; Civil Rights; Ethics, Medical; Europe; Morals; World Health Organization

ARTICLE TITLE: Rugby and spinal injury: what can be done? [editorial; comment]
COMMENTS: Comment on: Med J Aust 1998 Apr 20; 168(8):379-81
ARTICLE SOURCE: Med J Aust (Australia), Apr 20 1998, 168(8) p372-3
AUTHOR(S): Yeo JD
MAJOR SUBJECT HEADING(S): Football [injuries]; Spinal Cord Injuries [etiology]
MINOR SUBJECT HEADING(S): Athletic Injuries [complications] [prevention & control]; Spinal Cord Injuries [prevention & control]

ARTICLE TITLE: Primary pulmonary hypertension: new reasons for optimism? [editorial]
ARTICLE SOURCE: Med J Aust (Australia), Apr 6 1998, 168(7) p316-7
AUTHOR(S): Williams TJ
MAJOR SUBJECT HEADING(S): Hypertension, Pulmonary [diagnosis] [therapy]
MINOR SUBJECT HEADING(S): Diagnosis, Differential; Hypertension, Pulmonary [epidemiology] [etiology]; Lung Transplantation; Prognosis; Survival Analysis; Vasodilator Agents [therapeutic use]

ARTICLE TITLE: The death of a healthy volunteer in a human research project: implications for Australian clinical research.
ARTICLE SOURCE: Med J Aust (Australia), May 4 1998, 168(9) p449-51
AUTHOR(S): Day RO; Chalmers DR; Williams KM; Campbell TJ
AUTHOR'S ADDRESS: Clinical Pharmacology, St Vincent's Hospital, Sydney, NSW. R.Day@unsw.edu.au.
MAJOR SUBJECT HEADING(S): Anesthetics, Local [adverse effects]; Bronchoscopy; Clinical Protocols [standards]; Lidocaine [adverse effects]; Voluntary Workers
MINOR SUBJECT HEADING(S): Adult; Australia; Ethics, Medical; Fatal Outcome; Informed Consent; New York
INDEXING CHECK TAG(S): Case Report; Female; Human
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: A healthy 19-year-old United States college student volunteer in a clinical research program underwent a bronchoscopy and died as a result of acute lignocaine toxicity. The major contributing factor in the tragedy was that the research protocol failed to specify an upper dose limit for lignocaine spray, although previous versions of the protocol had done so. We look at the implications of this case for Australian institutional ethics committees.

ARTICLE TITLE: Asthma and other atopic diseases in Australian children. Australian arm of the International Study of Asthma and Allergy in Childhood.
ARTICLE SOURCE: Med J Aust (Australia), May 4 1998, 168(9) p434-8
AUTHOR(S): Robertson CF; Dalton MF; Peat JK; Haby MM; Bauman A; Kennedy JD; Landau LI
AUTHOR'S ADDRESS: Department of Thoracic Medicine, Royal Children's Hospital, Melbourne. cfrob@cryptic.rch.unimelb.edu.au.
MAJOR SUBJECT HEADING(S): Asthma [epidemiology]; Eczema [epidemiology]; Hay Fever [epidemiology]
MINOR SUBJECT HEADING(S): Adolescence; Asthma [therapy]; Australia [epidemiology]; Child; Eczema [therapy]; Hay Fever [therapy]; Prevalence; Questionnaires
INDEXING CHECK TAG(S): Female; Human; Male; Support, Non-U.S. Gov't
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: OBJECTIVE: To determine the prevalence of asthma, eczema and allergic rhinitis in Australian schoolchildren using the protocol of the International Study of Asthma and Allergy in Childhood (ISAAC). DESIGN: Questionnaire-based survey. SETTING: Melbourne, Sydney, Adelaide (in winter-spring, 1993) and Perth (in winter-spring, 1994). SUBJECTS: All children in school years 1 and 2 (ages 6-7 years) or in year 8 (ages 13-14 years), attending a random sample of 272 schools, stratified by age and city. MAIN OUTCOME MEASURES: Parent-reported (for 6-7 year olds) or self-reported (for 13-14 year olds) symptoms of atopic disease in the previous 12 months, or ever; treatment of asthma; and country of birth. RESULTS: 10,914 questionnaires were completed for 6-7 year olds and 12,280 for 13-14 year olds (84% and 94% response rates, respectively). Prevalence of wheeze in the past 12 months was 24.6% for the 6-7 year olds and 29.4% for the 13-14 year olds, and, among 6-7 year olds, was significantly higher in boys (27.4%) than girls (21.7%). Children born in Australia were more likely to report current wheeze than those born elsewhere (6-7 year olds: odds ratio [OR], 1.82; 95% confidence interval [CI] 1.55-2.15; and 13-14 year olds: OR, 1.88; 95% CI, 1.68-2.11). Prevalences of current eczema and allergic rhinitis were 10.9% and 12.0%, respectively, for the 6-7 year olds, and 9.7% and 19.6%, respectively, for the 13-14 year olds. Asthma, eczema and rhinitis coexisted in 1.8% of 6-7 year olds and 2.8% of 13-14 year olds. CONCLUSION: This study provides evidence that asthma prevalence in Australian schoolchildren is continuing to increase and is higher among Australian-born children than among those born elsewhere. Asthma, eczema and allergic rhinitis coexist to a lesser extent than expected. These results form the basis for future Australian and international comparisons.

ARTICLE TITLE: An epidemic of renal failure among Australian Aboriginals [see comments]
COMMENTS: Comment in: Med J Aust 1998 Jun 1; 168(11):532-3
ARTICLE SOURCE: Med J Aust (Australia), Jun 1 1998, 168(11) p537-41
AUTHOR(S): Spencer JL; Silva DT; Snelling P; Hoy WE
AUTHOR'S ADDRESS: Menzies School of Health Research, Casuarina, NT.
MAJOR SUBJECT HEADING(S): Aborigines [statistics & numerical data]; Kidney Failure, Chronic [epidemiology] [etiology]
MINOR SUBJECT HEADING(S): Adolescence; Adult; Age Distribution; Aged; Australia [epidemiology]; Incidence; Kidney Failure, Chronic [therapy]; Middle Age; Risk Factors; Sex Distribution; Survival Rate
INDEXING CHECK TAG(S): Female; Human; Male; Support, Non-U.S. Gov't
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: OBJECTIVE: To define recent trends (1993-1996) in incidence of endstage renal disease (ESRD) among Australian Aboriginal people in the Top End of the Northern Territory (NT). DESIGN: Analysis of hospital and clinical records of the Darwin-based ESRD treatment program from 1993 to 1996 and comparison with data accumulated since 1978. PARTICIPANTS: All people entering the ESRD treatment program from 1978 to 1996. MAIN OUTCOME MEASURES: Number of patients treated for ESRD; their ethnicity, age and sex; comorbidities in Aboriginal patients; treatment methods and outcomes. RESULTS: More Aboriginal people presented with ESRD between 1993 and 1996 (87) than in the previous 15 years of the program (68). The incidence of ESRD in Aboriginals reached 838 per million in 1996, and is doubling every 4 years. Aboriginal people presenting with ESRD are younger than non-Aboriginal people with ESRD, and, in contrast to non-Aboriginals, ESRD rates are higher in women than men. The numbers and proportions of Aboriginal ESRD patients who have hypertension, type 2 diabetes and cardiac disease are rising. Haemodialysis remains the most common form of treatment, and the number of dialysis treatments is doubling every 2.5 years. Only 9% of Aboriginal patients entering the program in 1993-1996 were treated with chronic ambulatory peritoneal dialysis and only 3% received transplants. Despite their younger age, survival of Aboriginal people on dialysis is low (median 3.3 years v. 6.5 years in non-Aboriginals), and graft survival after transplant is poor (37% at 5 years v. 88% in non-Aboriginals). Survival has not improved in the past 4 years, with fewer deaths from infection offset by more deaths from cardiovascular disease. CONCLUSIONS: The predicted doubling of ESRD incidence among Aboriginal people by the year 2000 will add an enormous burden to limited resources. Risk factors for renal disease underlie all the excess morbidity and mortality in NT Aboriginal adults, and arise out of accelerated lifestyle changes and socioeconomic disadvantage. Better living conditions and education, robust and integrated primary healthcare programs, and systematic screening for early renal disease and treatment of those with established disease are all matters of urgency.

ARTICLE TITLE: Reexploration for hemorrhage following coronary artery bypass grafting: incidence and risk factors. Northern New England Cardiovascular Disease Study Group.
ARTICLE SOURCE: Arch Surg (United States), Apr 1998, 133(4) p442-7
AUTHOR(S): Dacey LJ; Munoz JJ; Baribeau YR; Johnson ER; Lahey SJ; Leavitt BJ; Quinn RD; Nugent WC; Birkmeyer JD; O'Connor GT
AUTHOR'S ADDRESS: Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA. lawrence.j.dacey@hitchcock.org.
MAJOR SUBJECT HEADING(S): Coronary Artery Bypass; Postoperative Hemorrhage [epidemiology] [surgery]
MINOR SUBJECT HEADING(S): Aged; Cohort Studies; Hospital Mortality; Incidence; Length of Stay [statistics & numerical data]; Logistic Models; Maine [epidemiology]; Middle Age; New Hampshire [epidemiology]; Prospective Studies; Reoperation [statistics & numerical data]; Risk Factors; Vermont [epidemiology]
INDEXING CHECK TAG(S): Female; Human; Male
PUBLICATION TYPE: JOURNAL ARTICLE; MULTICENTER STUDY
ABSTRACT: OBJECTIVE: To assess mortality and risk factors associated with reexploration for hemorrhage in patients undergoing coronary artery bypass grafting (CABG). DESIGN: Regional cohort study. Patient characteristics, treatment variables, and outcome measures were collected prospectively. SETTING: All 5 centers performing cardiac surgery in Maine, New Hampshire, and Vermont. PATIENTS: A consecutive cohort of 8586 patients undergoing isolated CABG between 1992 and 1995. MAIN OUTCOME MEASURES: Postoperative hemorrhage leading to reexploration, in-hospital mortality, and length of stay. RESULTS: A total of 305 patients (3.6%) underwent reexploration for bleeding. In these patients, in-hospital mortality was nearly 3 times higher (9.5% vs 3.3% for patients not requiring reoperation, P .001) and average length of stay from surgery to discharge was significantly longer (14.5 days vs 8.6 days, P .001). High rates of reexploration for hemorrhage were observed in patients with prolonged ( 150 minutes) cardiopulmonary bypass (39 [11.1%] of 351) and in those requiring an intra-aortic balloon pump intraoperatively (12 [8%] of 139). In multivariate analysis, older age, smaller body surface area, prolonged cardiopulmonary bypass, and number of distal anastomoses were associated with increased bleeding risks. The use of thrombolytic therapy within 48 hours of surgery was weakly but not significantly associated with the need for reexploration. Factors not significantly associated with reexploration included patient sex, preoperative ejection fraction, surgical priority, history of liver disease, myocardial infarction, prior CABG, renal failure, and diabetes mellitus. CONCLUSIONS: Hemorrhage requiring reexploration after CABG is associated with markedly increased mortality and length of stay. Patients predicted to have increased risks of bleeding may benefit from prophylactic use of aprotinin, aminocaproic acid, or other agents shown to reduce hemorrhage.

ARTICLE TITLE: Preemptive pain control in patients having laparoscopic hernia repair: a comparison of ketorolac and ibuprofen.
ARTICLE SOURCE: Arch Surg (United States), Apr 1998, 133(4) p432-7
AUTHOR(S): Mixter CG 3rd; Meeker LD; Gavin TJ
AUTHOR'S ADDRESS: Department of Surgery, Exeter Hospital, NH, USA.
MAJOR SUBJECT HEADING(S): Analgesics, Non-Narcotic [therapeutic use]; Anti-Inflammatory Agents, Non-Steroidal [therapeutic use]; Hernia, Inguinal [surgery]; Ibuprofen [therapeutic use]; Pain, Postoperative [prevention & control]; Surgical Procedures, Laparoscopic; Tolmetin [analogs & derivatives]; Tromethamine [analogs & derivatives]
MINOR SUBJECT HEADING(S): Administration, Oral; Analgesics, Non-Narcotic [administration & dosage]; Anti-Inflammatory Agents, Non-Steroidal [administration & dosage]; Double-Blind Method; Ibuprofen [administration & dosage]; Injections, Intravenous; Intraoperative Care; Middle Age; Pain Measurement; Preoperative Care; Prospective Studies; Tolmetin [administration & dosage] [therapeutic use]; Tromethamine [administration & dosage] [therapeutic use]
INDEXING CHECK TAG(S): Human
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: OBJECTIVES: To determine if nonsteroidal anti-inflammatory drugs provide adequate pain control for patients having laparoscopic hernia repair and to compare the effectiveness of ketorolac tromethamine with ibuprofen in reducing postoperative laparoscopic hernia pain. DESIGN AND SETTING: Prospective double-blind randomized study at a 100-bed community hospital. PATIENTS: Seventy patients ranging in age from 16 to 83 years scheduled for elective laparoscopic inguinal hernia repair. INTERVENTIONS: Patients undergoing laparoscopic hernia repair were enrolled in a double-blind randomized study to compare the 2 treatments. Group 1 received a placebo capsule 1 hour before surgery and ketorolac tromethamine, 60 mg intravenously, at the time of trocar insertion. Group 2 received ibuprofen, 800 mg an hour before surgery, and isotonic sodium chloride solution, 2 mL intravenously, at the time of trocar insertion. In addition, all patients received local infiltration of 30 mL of bupivacaine hydrochloride into their trocar sites. All patients were discharged within 5 hours of the operation and were instructed to take 400 mg of ibuprofen orally every 4 hours for 24 hours whether or not they were experiencing pain. A 24-hour supply of ibuprofen was provided to all study patients. Pain was assessed using the Visual Analog Pain Scale with a maximum pain rating of 100. Assessments were done at the time of and 18 hours after discharge. MAIN OUTCOME MEASURE: Postoperative pain 18 and 24 hours after discharge was assessed using a standardized questionnaire in a telephone interview by a registered nurse from the Outpatient Surgical Unit. RESULTS: There was no significant difference in the level of pain experienced by 35 patients who received ketorolac intravenously and 35 who received ibuprofen orally. There was no significant difference between the 2 treatment groups in the amount of pain experienced at discharge and 18 hours after discharge. CONCLUSIONS: Pain relief from ibuprofen, 800 mg, administered orally an hour before laparoscopic hernia repair was not statistically different from that obtained with intravenous ketorolac, 60 mg, administered intraoperatively when comparing the hospital discharge pain score and the mean and highest pain scores 18 hours after discharge. Ibuprofen offers equivalent pain control at a lower cost and reduced potential for adverse drug events compared with intravenous ketorolac in patients having laparoscopic hernia repair. No patient required narcotic supplementation, and pain control was judged satisfactory by all the patients.

ARTICLE TITLE: A randomized, prospective, blinded comparison of postoperative pain, metabolic response, and perceived health after laparoscopic and small incision cholecystectomy.
ARTICLE SOURCE: Surgery (United States), May 1998, 123(5) p485-95
AUTHOR(S): Squirrell DM; Majeed AW; Troy G; Peacock JE; Nicholl JP; Johnson AG
AUTHOR'S ADDRESS: Department of Surgical and Anaesthetic Sciences, University of Sheffield, U.K.
MAJOR SUBJECT HEADING(S): Attitude to Health; Blood Glucose [metabolism]; Cholecystectomy, Laparoscopic; Cholecystectomy; Health Status Indicators; Pain, Postoperative; Respiratory Function Tests
MINOR SUBJECT HEADING(S): Adult; Aged; Analgesics [therapeutic use]; Antiemetics [therapeutic use]; C-Reactive Protein [analysis]; Double-Blind Method; Emotions; Hydrocortisone [blood]; Inflammation; Length of Stay; Middle Age; Pain Measurement; Pain, Postoperative [drug therapy]; Prospective Studies
INDEXING CHECK TAG(S): Comparative Study; Female; Human; Male; Support, Non-U.S. Gov't
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE; RANDOMIZED CONTROLLED TRIAL
ABSTRACT: BACKGROUND: We have previously shown that in a randomized comparison of laparoscopic (LC) versus small incision (SC) cholecystectomy, postoperative hospital stay is comparable. This randomized prospective study compares the postoperative pain, analgesic and antiemetic consumption, perceived health, and metabolic and respiratory responses after these two procedures. METHODS: Two hundred patients were recruited; postoperative stay, pain scores, analgesic and antiemetic consumption were recorded. Nottingham Health Profile questionnaires were completed by a subgroup of 100 patients, and the metabolic and respiratory responses were also compared in a further subgroup of 20 patients. RESULTS: Pain scores in both groups were low. LC, however, was associated with lower postoperative pain scores and analgesic requirements compared with SC, but the antiemetic requirements were greater after LC. The duration of hospital stay and the perceived health after operation were the same in both groups, and both procedures were associated with a similar reduction of respiratory function. Twenty-four hours after operation the inflammatory (C-reactive protein, CRP) response to LC (22 +/- 20 mg/L) was significantly lower than after SC (68 +/- 30 mg/L), but the neuroendocrine (cortisol) response was similar (LC, 475 +/- 335 nmol/L, compared with SC, 710 +/- 410 nmol/L). Independent of the technique used, the duration of postoperative hospital stay correlated significantly with the magnitude of both the 24-hour postoperative cortisol and CRP responses (cortisol: rs = 0.678, p 0.001; CRP: rs = 0.566, p = 0.011). CONCLUSIONS: LC appears to be associated with less tissue destruction and pain than SC, but this did not confer any advantage in the degree of postoperative respiratory impairment, length of hospital stay, or postoperative perceived health. The neuroendocrine component of the metabolic response evoked by each procedure was similar and had a significant correlation to patient's postoperative hospital stay. This finding may explain the similar postoperative recovery after LC and SC.

ARTICLE TITLE: The life and death of Professor Alexander P. Borodin: surgeon, chemist, and great musician.
ARTICLE SOURCE: Surgery (United States), Jun 1998, 126(6) p606-16
AUTHOR(S): Konstantinov IE
AUTHOR'S ADDRESS: Department of Thoracic and Cardiovascular Surgery, Carolinas Heart Institute, Charlotte, N.C., USA.
MAJOR SUBJECT HEADING(S): Famous Persons; Music [history]
MINOR SUBJECT HEADING(S): Chemistry [history]; History of Medicine, 19th Cent.; Military Medicine [history]; Portraits; Russia; Surgery [history]

ARTICLE TITLE: Endoluminal abdominal aortic aneurysm surgery.
ARTICLE SOURCE: Br J Surg (England), Apr 1998, 85(4) p435-43
AUTHOR(S): Woodburn KR; May J; White GH
AUTHOR'S ADDRESS: Department of Vascular Surgery, Royal Prince Alfred Hospital, University of Sydney, Australia.
MAJOR SUBJECT HEADING(S): Angioplasty [methods]; Aortic Aneurysm, Abdominal [surgery]
MINOR SUBJECT HEADING(S): Angioplasty [adverse effects] [mortality]; Blood Vessel Prosthesis; Forecasting; Radiography, Interventional; Treatment Outcome
INDEXING CHECK TAG(S): Human; Support, Non-U.S. Gov't
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (69 references); REVIEW LITERATURE
ABSTRACT: BACKGROUND: The development of devices designed for the endoluminal repair of abdominal aortic aneurysm has led to the emergence of new endovascular techniques. METHODS: Articles and case reports obtained from a Medline search of the English language literature from 1989 to 1997 are reviewed. This search was carried out using the MeSH heading 'aortic aneurysm, abdominal' and the keywords 'endovascular' and 'endoluminal'. RESULTS: Reported mortality and complication rates for endoluminal aneurysm repair are similar to those following conventional repair, with the exception of continued perfusion of the aneurysm sac which remains a major problem following endoluminal repair. CONCLUSION: Successful endoluminal aneurysm exclusion is associated with reduced aneurysm diameter. However, longer term results of endoluminal repair, in particular of sealed endoleaks, are required before randomized controlled trials of endoluminal versus conventional repair can be undertaken.

ARTICLE TITLE: Effect of graft reperfusion on intracellular calcium levels in mononuclear leucocytes during human orthotopic liver transplantation.
ARTICLE SOURCE: Br J Surg (England), May 1998, 85(5) p673-6
AUTHOR(S): Enright SM; Srinivasa R; Bellamy MC
AUTHOR'S ADDRESS: Department of Anaesthesia, St James's University Hospital, Leeds, UK.
MAJOR SUBJECT HEADING(S): Calcium [metabolism]; Leukocytes, Mononuclear [metabolism]; Liver Transplantation [methods]; Reperfusion Injury [metabolism]
MINOR SUBJECT HEADING(S): Adult; Extracellular Space [metabolism]; Intracellular Fluid [metabolism]; Liver Transplantation [immunology]; Lymphocyte Transformation; Middle Age
INDEXING CHECK TAG(S): Female; Human; Male
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Orthotopic liver transplantation (OLT) is accompanied by local and systemic manifestations of the ischaemia-reperfusion syndrome. Local effects are mediated in part through changes in intracellular calcium levels in Kupffer cells. Arachidonic acid metabolites mediate increases in intracellular calcium concentration and thus potentiate the effect of free radicals. This study was carried out to characterize white blood cell (WBC) calcium changes as a mediator for white cell activation in human OLT. METHODS: Twenty consecutive patients had OLT using standard surgery and anaesthesia techniques. Blood samples were drawn for estimation of WBC cytosolic calcium content at induction of anaesthesia, 5 min before graft reperfusion and 15 min after reperfusion. The rate of rise in intracellular calcium concentration after the addition of a calcium chloride 1 mmol L(-1) solution to the extracellular milieu was used as an estimate of membrane calcium permeability. RESULTS: Both extracellular (P = 0.0002) and intracellular (P = 0.0008) calcium concentrations rose with time. However, at no time was there a correlation between extracellular and intracellular calcium levels or rate of calcium influx (r2 = 0.002, P = 0.78). There was a significant increase in intracellular calcium concentration (P = 0.0008) and in the rate of rise of intracellular calcium levels (P = 0.0009) after reperfusion. CONCLUSION: There was a significant increase in circulating monocyte membrane permeability for calcium and cytosolic calcium concentration following reperfusion in human OLT. This was independent of extracellular calcium concentration. These results are consistent with WBC activation by reperfusion and could be implicated in the systemic reperfusion syndrome

ARTICLE TITLE: Effect of dopamine on renal function after arteriography in patients with pre-existing renal insufficiency.
ARTICLE SOURCE: Am Surg (United States), May 1998, 64(5) p432-6
AUTHOR(S): Hans SS; Hans BA; Dhillon R; Dmuchowski C; Glover J
AUTHOR'S ADDRESS: Department of Surgery, Macomb Hospital Center, Warren, Michigan, USA.
MAJOR SUBJECT HEADING(S): Angiography; Aortography; Contrast Media [adverse effects]; Dopamine [administration & dosage]; Kidney Failure, Chronic [chemically induced]; Kidney Function Tests
MINOR SUBJECT HEADING(S): Aged, 80 and over; Aged; Creatinine [blood]; Infusions, Intravenous; Kidney Failure, Chronic [diagnosis] [prevention & control]; Kidney [blood supply]; Leg [blood supply]; Middle Age; Premedication; Prospective Studies; Vascular Resistance [drug effects]
INDEXING CHECK TAG(S): Female; Human; Male; Support, Non-U.S. Gov't
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: Contrast media-induced nephropathy is one of the leading causes of hospital-acquired renal failure, occurring most frequently in patients with pre-existing renal insufficiency. We prospectively studied 55 patients with chronic renal insufficiency (serum creatinine concentration 1.4 to 3.5 mg/dl) who underwent abdominal aortography and arteriography of the lower extremities. The patients were randomized into two groups. Group 1, 28 patients, received dopamine 2.5 mcg/kg beginning 1 hour before arteriography and continuing for 12 hours. Group 2 received an equal volume of saline for the same period of time. Serum creatinine and 12-hour creatinine clearance were measured before arteriography and for 4 consecutive days afterward. Acute contrast-induced decrease in renal function was defined as increase in the baseline serum creatinine concentration or = 0.5 mg/dl. On day 1 postarteriography the serum creatinine increased from baseline .193 mg/dl for controls while the dopamine group decreased slightly from baseline .018 mg/dl (p = 0.002). Excepting day 1 postarteriography, there was no statistical difference between groups, and serum levels for both groups increased linearly from baseline across time (dopamine p = 0.028, control p = 0.025). In patients with pre-arteriography baseline serum levels greater than or equal to 2.0 mg/dl, however, the increase in serum creatinine from baseline levels was consistently and significantly greater in the control group through the fourth day (0.012 or = p or = 0.049). Creatinine clearance did not change significantly from baseline after arteriography in the dopamine group (baseline versus days 1 through 4, 0.238 or = p or = 0.968); however, the control group showed a significant linear decrease in creatinine clearance from baseline through the fourth day after arteriography (p = 0.016). Dopamine infusion prevented a rise in serum creatinine 24 hours after angiography in patients with pre-existing renal insufficiency, and protected against contrast-induced decrease in renal function in patients whose baseline serum creatinine was or = 2.0 mg/dl.

ARTICLE TITLE: Task performance in endoscopic surgery is influenced by location of the image display.
ARTICLE SOURCE: Ann Surg (United States), Apr 1998, 227(4) p481-4
AUTHOR(S): Hanna GB; Shimi SM; Cuschieri A
AUTHOR'S ADDRESS: Department of Surgery, Ninewells Hospital & Medical School, University of Dundee, Tayside, Scotland.
MAJOR SUBJECT HEADING(S): Clinical Competence; Data Display; Surgical Procedures, Endoscopic [instrumentation]; Task Performance and Analysis
MINOR SUBJECT HEADING(S): Time Factors
INDEXING CHECK TAG(S): Human; Support, Non-U.S. Gov't
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: OBJECTIVE: To investigate the influence of image display location on endoscopic task performance in endoscopic surgery. SUMMARY BACKGROUND DATA: The image display system is the only visual interface between the surgeon or interventionist and the operative field. Several factors influence the correct perceptual processing and endoscopic manipulation from images. One of these is location of the image display with respect to the surgeon and to the operative site. The present study was conducted to investigate whether endoscopic task performance improves under two conditions: when the surgeon-to-monitor visual axis is aligned with the forearm-instrument motor axis and when the image display is close to the operator's manipulation workspace. METHODS: An endoscopic task (tying an intracorporeal surgeon's knot) was performed under standardized conditions except for varying monitor locations. These altered the direction of view--in front of, to the left, and to the right of the operator's head and hands. In each of these view directions, the monitor was placed at the surgeon's eye level and lower down, at the level of the operator's hands. The outcome measures were the execution time, knot quality score and performance quality score. RESULTS: Task performance was better with frontal view direction: execution time was shorter (p 0.0001) and the performance score was higher (p 0.005) than with side viewing, with no significant difference between right and left viewing directions. With frontal view direction, hand-level "gaze-down" viewing resulted in a shorter execution time (p 0.01) and a higher performance score (p 0.01) than eye-level viewing. CONCLUSIONS: Task performance improves when the image display is placed in front of the operator, at a level below the head and close to the hands.

ARTICLE TITLE: "Renal dose" dopamine in surgical patients: dogma or science?
ARTICLE SOURCE: Ann Surg (United States), Apr 1998, 227(4) p470-3
AUTHOR(S): Perdue PW; Balser JR; Lipsett PA; Breslow MJ
AUTHOR'S ADDRESS: Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
MAJOR SUBJECT HEADING(S): Dopamine [pharmacology]; Kidney Failure [prevention & control]; Kidney [drug effects]; Postoperative Complications [prevention & control]; Surgical Procedures, Operative
MINOR SUBJECT HEADING(S): Critical Illness; Dopamine [therapeutic use]; Heart Failure, Congestive [complications]; Hemodynamics [drug effects]; Kidney Failure [complications]; Preoperative Care; Vasodilation
INDEXING CHECK TAG(S): Animal; Human
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (38 references); REVIEW, TUTORIAL
ABSTRACT: OBJECTIVE: "Renal dose" dopamine is widely used in the perioperative period to provide renal protection. A comprehensive review of the literature was performed to determine whether dopamine does in fact confer protection on the kidneys of surgical patients. SUMMARY BACKGROUND DATA: Studies in healthy animals and human volunteers reveal that dopamine causes diuresis and natriuresis, as well as some degree of renal vasodilatation. RESULTS: Studies of the perioperative use of dopamine fail to demonstrate any benefit of dopamine in preventing renal failure. Studies in congestive heart failure, critical illness, and sepsis also fail to show any benefit of dopamine other than diuresis. Further, dopamine administration is not completely without risk, because of dopamine's catecholamine and neuroendocrine functions. CONCLUSIONS: Routine use of prophylactic "renal dose" dopamine in surgical patients is not recommended.

ARTICLE TITLE: Trauma service cost: the real story.
ARTICLE SOURCE: Ann Surg (United States), May 1998, 227(5) p720-4; discussion 724-5
AUTHOR(S): Taheri PA; Wahl WL; Butz DA; Iteld LH; Michaels AJ; Griffes LC; Bishop G; Greenfield LJ
AUTHOR'S ADDRESS: Department of Surgery, University of Michigan Health System, Ann Arbor, USA.
MAJOR SUBJECT HEADING(S): Hospital Costs; Trauma Centers [economics]
MINOR SUBJECT HEADING(S): Cost Allocation; Cost Control; Delivery of Health Care, Integrated [economics]; Health Services Research; Hospitals, University [economics]; Michigan
INDEXING CHECK TAG(S): Human
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: OBJECTIVE: The objective was to define and characterize the costs associated with trauma care at a level I trauma center. Once the costs were identified, attending physician-led teams were designed to reduce costs within each cost center. SUMMARY BACKGROUND DATA: The location and magnitude of the costs on a trauma service remain largely unknown. Focused cost-containment strategies remain difficult to implement because the expected return on these interventions is unknown. METHODS: Cost center data were reviewed for the 40 major DRGs admitted for the first 6 months of the fiscal years 1996 and 1997. Data were obtained from the hospital finance department using the Transition Systems Inc. accounting system. We focused on variable direct costs, those that vary with patient volume (e.g., staff nursing expense and medical/surgical supplies). To address issues of inflation, pay raises, and changing costs, a proxy value was created for 1996 and costs were held constant for the 1997 calculation. The major services that constitute cost centers identified in the system were nursing, surgical, pharmacy, laboratory, radiology, and emergency services. Attendings were assigned to develop and oversee customized cost-reduction modalities specific to each cost center. The cost-reduction modalities used to achieve significant savings were as follows: nursing, case management approach focusing on early discharge; surgical, meeting with operating room (OR) purchasing to modify expensive behavior patterns; pharmacy, integrating clinical pharmacist with direct attending support; laboratory, enforcing protocol for lab draws; radiology, increasing the use of emergency room ultrasound and accepting outside x-rays; and emergency services, 24-hour in-house attending staff to reduce emergency room time. The surgical and emergency services cost centers predominately generate costs by the length of time care is delivered in that area. RESULTS: For each period, data from 363 patients were compared. Mean length of stay decreased between the study periods from 8.72 to 7.06 days, while the average injury severity score was unchanged. Together, these cost centers constituted 87.4% of the total cost of care delivered. Significant cost reduction was achieved in all six variable cost centers: nursing (24%), surgical (5%), pharmacy (57%), laboratory (27), radiology (7%), and emergency (36). The mean cost per case was reduced by 25%. CONCLUSIONS: Identification of the true cost centers and directed attending surgeon involvement are essential to the development and implementation of a successful cost-reduction process.

ARTICLE TITLE: A national survey of physician-assisted suicide and euthanasia in the United States.
ARTICLE SOURCE: N Engl J Med (United States), Apr 23 1998, 338(17) p1193-201
AUTHOR(S): Meier DE; Emmons CA; Wallenstein S; Quill T; Morrison RS; Cassel CK
AUTHOR'S ADDRESS: Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York, NY 10029, USA.
MAJOR SUBJECT HEADING(S): Attitude of Health Personnel; Euthanasia [statistics & numerical data]; Specialties, Medical; Suicide, Assisted [statistics & numerical data]
MINOR SUBJECT HEADING(S): Adult; Data Collection; Injections; Middle Age; Odds Ratio; Physician's Practice Patterns [statistics & numerical data]; Physicians [psychology]; Questionnaires; Terminally Ill; United States
INDEXING CHECK TAG(S): Female; Human; Male; Support, Non-U.S. Gov't; Support, U.S. Gov't, P.H.S.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Although there have been many studies of physician-assisted suicide and euthanasia in the United States, national data are lacking. METHODS: In 1996, we mailed questionnaires to a stratified probability sample of 3102 physicians in the 10 specialties in which doctors are most likely to receive requests from patients for assistance with suicide or euthanasia. We weighted the results to obtain nationally representative data. RESULTS: We received 1902 completed questionnaires (response rate, 61 percent). Eleven percent of the physicians said that under current legal constraints, there were circumstances in which they would be willing to hasten a patient's death by prescribing medication, and 7 percent said that they would provide a lethal injection; 36 percent and 24 percent, respectively, said that they would do so if it were legal. Since entering practice, 18.3 percent of the physicians (unweighted number, 320) reported having received a request from a patient for assistance with suicide and 11.1 percent (unweighted number, 196) had received a request for a lethal injection. Sixteen percent of the physicians receiving such requests (unweighted number, 42), or 3.3 percent of the entire sample, reported that they had written at least one prescription to be used to hasten death, and 4.7 percent (unweighted number, 59), said that they had administered at least one lethal injection. CONCLUSIONS: A substantial proportion of physicians in the United States report that they receive requests for physician-assisted suicide and euthanasia, and about 7 percent of those who responded to our survey have complied with such requests at least once.

ARTICLE TITLE: Ten-year risk of false positive screening mammograms and clinical breast examinations [see comments]
COMMENTS: Comment in: N Engl J Med 1998 Apr 16; 338(16):1145-6
ARTICLE SOURCE: N Engl J Med (United States), Apr 16 1998, 338(16) p1089-96
AUTHOR(S): Elmore JG; Barton MB; Moceri VM; Polk S; Arena PJ; Fletcher SW
AUTHOR'S ADDRESS: Department of Medicine, University of Washington School of Medicine, Seattle 98195-6429, USA.
MAJOR SUBJECT HEADING(S): Breast Neoplasms [diagnosis]; False Positive Reactions; Mammography; Physical Examination
MINOR SUBJECT HEADING(S): Adult; Aged; Bayes Theorem; Breast Neoplasms [psychology] [radiography]; Cohort Studies; Mammography [economics] [statistics & numerical data]; Mass Screening [economics] [statistics & numerical data]; Middle Age; Physical Examination [economics] [statistics & numerical data]; Retrospective Studies; Risk
INDEXING CHECK TAG(S): Female; Human; Support, Non-U.S. Gov't
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: The cumulative risk of a false positive result from a breast-cancer screening test is unknown. METHODS: We performed a 10-year retrospective cohort study of breast-cancer screening and diagnostic evaluations among 2400 women who were 40 to 69 years old at study entry. Mammograms or clinical breast examinations that were interpreted as indeterminate, aroused a suspicion of cancer, or prompted recommendations for additional workup in women in whom breast cancer was not diagnosed within the next year were considered to be false positive tests. RESULTS: A total of 9762 screening mammograms and 10,905 screening clinical breast examinations were performed, for a median of 4 mammograms and 5 clinical breast examinations per woman over the 10-year period. Of the women who were screened, 23.8 percent had at least one false positive mammogram, 13.4 percent had at least one false positive breast examination, and 31.7 percent had at least one false positive result for either test. The estimated cumulative risk of a false positive result was 49.1 percent (95 percent confidence interval, 40.3 to 64.1 percent) after 10 mammograms and 22.3 percent (95 percent confidence interval, 19.2 to 27.5 percent) after 10 clinical breast examinations. The false positive tests led to 870 outpatient appointments, 539 diagnostic mammograms, 186 ultrasound examinations, 188 biopsies, and 1 hospitalization. We estimate that among women who do not have breast cancer, 18.6 percent (95 percent confidence interval, 9.8 to 41.2 percent) will undergo a biopsy after 10 mammograms, and 6.2 percent (95 percent confidence interval, 3.7 to 11.2 percent) after 10 clinical breast examinations. For every 100 dollars spent for screening, an additional 33 dollars was spent to evaluate the false positive results. CONCLUSIONS: Over 10 years, one third of women screened had an abnormal test result that required additional evaluation, even though no breast cancer was present. Techniques are needed to decrease false positive results while maintaining high sensitivity. Physicians should educate women about the risk of a false positive result from a screening test for breast cancer.

ARTICLE TITLE: Should we accept mediocrity?
ARTICLE SOURCE: N Engl J Med (United States), Apr 9 1998, 338(15) p1067-9
AUTHOR(S): Manian FA
AUTHOR'S ADDRESS: Infectious Diseases Consultants, St. Louis, MO 63141, USA.
MAJOR SUBJECT HEADING(S): Managed Care Programs [standards]; Patient Care [standards]; Quality of Health Care
MINOR SUBJECT HEADING(S): Clinical Competence; Cost Control; Insurance, Health, Reimbursement; Managed Care Programs [organization & administration]; Personnel Staffing and Scheduling; Quality of Health Care [economics] [organization & administration] [trends]

ARTICLE TITLE: Acid-base disorders [letter]
ARTICLE SOURCE: N Engl J Med (United States), May 28 1998, 338(22) p1626-7; discussion 1628-9
AUTHOR(S): Marik P; Varon J
MAJOR SUBJECT HEADING(S): Acidosis [drug therapy]; Sodium Bicarbonate [therapeutic use]
MINOR SUBJECT HEADING(S): Acidosis [etiology]; Anoxia [complications]; Vasoconstrictor Agents [therapeutic use]
INDEXING CHECK TAG(S): Human
PUBLICATION TYPE: LETTER
MEDLINE INDEXING DATE: 199807

ARTICLE TITLE: The treatment of unrelated disorders in patients with chronic medical diseases [see comments]
COMMENTS: Comment in: N Engl J Med 1998 May 21; 338(21):1541-2
ARTICLE SOURCE: N Engl J Med (United States), May 21 1998, 338(21) p1516-20
AUTHOR(S): Redelmeier DA; Tan SH; Booth GL
AUTHOR'S ADDRESS: Department of Medicine, University of Toronto, Sunnybrook Health Science Centre, ON, Canada.
MAJOR SUBJECT HEADING(S): Arthritis [drug therapy]; Chronic Disease; Estrogen Replacement Therapy; Hyperlipidemia [drug therapy]; Polypharmacy
MINOR SUBJECT HEADING(S): Aged; Arthritis [complications]; Diabetes Mellitus [drug therapy]; Hyperlipidemia [complications]; Ontario; Psychotic Disorders [complications] [drug therapy]; Pulmonary Emphysema [complications] [drug therapy]
INDEXING CHECK TAG(S): Comparative Study; Female; Human; Male; Support, Non-U.S. Gov't
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Patients can have several illnesses concurrently, yet some of these diseases may be neglected if one problem consumes attention. We conducted a population-based analysis in Ontario, Canada - where universal health insurance is provided - to determine whether unrelated disorders are less likely to be treated in patients with chronic diseases. METHODS: We studied the 1,344,145 residents of Ontario in 1995 who were 65 or older and eligible to receive prescription medications free of charge as part of the Ontario Drug Benefit program. Patients with diabetes mellitus were identified by prescriptions for insulin, pulmonary emphysema by prescriptions for ipratropium bromide, and psychotic syndromes by prescriptions for haloperidol. For each chronic disease, we selected an unrelated treatment: estrogen-replacement therapy for patients with diabetes mellitus, lipid-lowering medications for those with pulmonary emphysema, and medical treatment of arthritis for those with psychotic syndromes. RESULTS: The 30,669 patients with diabetes mellitus were less likely to receive estrogen-replacement therapy than the other subjects in the study (2.4 percent vs. 5.9 percent, P 0.001). The disease was associated with a 60 percent reduction in the odds of estrogen treatment (odds ratio, 0.40; 95 percent confidence interval, 0.37 to 0.43). Findings were similar for the 56,779 patients with pulmonary emphysema, who were less likely to receive lipid-lowering medications (odds ratio, 0.69; 95 percent confidence interval, 0.67 to 0.72; P 0.001), and the 17,336 patients with psychotic syndromes, who were less likely to receive medical treatments for arthritis (odds ratio, 0.59; 95 percent confidence interval, 0.57 to 0.62; P 0.001). CONCLUSIONS: In patients 65 or older who have chronic medical diseases and who receive prescription medications free of charge, unrelated disorders are undertreated. Clinicians caring for patients with chronic diseases should remain alert to other disorders and minimize the number of missed opportunities for treating them.

ARTICLE TITLE: Patients with multiple chronic conditions--how many medications are enough? [editorial; comment]
COMMENTS: Comment on: N Engl J Med 1998 May 21; 338(21):1516-20
ARTICLE SOURCE: N Engl J Med (United States), May 21 1998, 338(21) p1541-2
AUTHOR(S): Steinbrook R
MAJOR SUBJECT HEADING(S): Arthritis [drug therapy]; Chronic Disease; Estrogen Replacement Therapy; Hyperlipidemia [drug therapy]; Polypharmacy
MINOR SUBJECT HEADING(S): Aged; Arthritis [complications]; Diabetes Mellitus; Hyperlipidemia [complications]; Psychotic Disorders [complications]; Pulmonary Emphysema [complications]
INDEXING CHECK TAG(S): Human
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: Alcohol consumption and mortality in U.S. adults [letter]
ARTICLE SOURCE: N Engl J Med (United States), May 7 1998, 338(19) p1385; discussion 1385-6
AUTHOR(S): Urbach DR; Bell CM
MAJOR SUBJECT HEADING(S):
MINOR SUBJECT HEADING(S): Bias (Epidemiology); Deception; Questionnaires; United States [epidemiology]

ARTICLE TITLE: Rating the appropriateness of coronary angiography--do practicing physicians agree with an expert panel and with each other? [see comments]
COMMENTS: Comment in: N Engl J Med 1998 Jun 25; 338(26):1918-20
ARTICLE SOURCE: N Engl J Med (United States), Jun 25 1998, 338(26) p1896-904
AUTHOR(S): Ayanian JZ; Landrum MB; Normand SL; Guadagnoli E; McNeil BJ
AUTHOR'S ADDRESS: Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA.
MAJOR SUBJECT HEADING(S): Coronary Angiography [utilization]; Delphi Technique; Myocardial Infarction [radiography]; Utilization Review
MINOR SUBJECT HEADING(S): Aged; Cardiology; Data Collection; Family Practice; Internal Medicine; Multivariate Analysis; Regression Analysis; Reproducibility of Results; Utilization Review [methods]
INDEXING CHECK TAG(S): Human; Support, Non-U.S. Gov't; Support, U.S. Gov't, P.H.S.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Evaluations of the appropriateness of medical care are important to monitor the quality of care and to contain costs and enhance safety by reducing inappropriate care. Experts' views are usually incorporated into evaluations of appropriateness. However, practicing physicians may not concur with these views, and physicians' clinical backgrounds may influence their beliefs. METHODS: We asked 1058 internists, family practitioners, and cardiologists in California, Florida, New York, Pennsylvania, and Texas to rate the appropriateness of coronary angiography after acute myocardial infarction for 20 common indications. Nine clinical experts also rated these indications using an established consensus method. RESULTS: For 17 of the 20 indications, median ratings of surveyed physicians and the expert panel agreed within 1 unit on a 9-unit scale. Patients' older age had a negative effect on ratings by the expert panel but not on ratings by surveyed physicians. In multivariable analyses of surveyed physicians, cardiologists rated angiography as significantly more appropriate than did primary care physicians for complicated indications, and for uncomplicated indications cardiologists who performed invasive procedures gave higher appropriateness ratings for angiography than did cardiologists who did not perform such procedures and primary care physicians. For uncomplicated indications, physicians from hospitals providing coronary angioplasty and bypass surgery rated angiography as more appropriate than physicians from other hospitals. Physicians from New York and those employed by health maintenance organizations rated angiography as less appropriate than other physicians. CONCLUSIONS: Surveyed physicians agreed with clinical experts about the appropriateness of coronary angiography after myocardial infarction for most indications, indicating that well-designed expert panels can closely reflect the views of practicing physicians. Variations in beliefs among practicing physicians suggest that evaluations of medical practice should incorporate the views of a range of relevant types of physicians.

ARTICLE TITLE: Use and overuse of angiography and revascularization for acute coronary syndromes [editorial; comment]
COMMENTS: Comment on: N Engl J Med 1998 Jun 18; 338(25):1785-92
ARTICLE SOURCE: N Engl J Med (United States), Jun 18 1998, 338(25) p1838-9
AUTHOR(S): Lange RA; Hillis LD
MAJOR SUBJECT HEADING(S): Coronary Angiography [utilization]; Myocardial Infarction [therapy]; Myocardial Revascularization [utilization]
MINOR SUBJECT HEADING(S): Health Services Misuse; United States
INDEXING CHECK TAG(S): Human
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: Conflict of interest in the debate over calcium-channel antagonists [letter]
ARTICLE SOURCE: N Engl J Med (United States), Jun 4 1998, 338(23) p1697-8
AUTHOR(S): Strandgaard S
MAJOR SUBJECT HEADING(S): Authorship; Calcium Channel Blockers [therapeutic use]; Conflict of Interest; Drug Industry; Research Support
MINOR SUBJECT HEADING(S): Drug Industry [economics]; Physicians [economics]

ARTICLE TITLE: Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. HIV Outpatient Study Investigators [see comments]
COMMENTS: Comment in: N Engl J Med 1998 Mar 26; 338(13):906-8
ARTICLE SOURCE: N Engl J Med (United States), Mar 26 1998, 338(13) p853-60
AUTHOR(S): Palella FJ Jr; Delaney KM; Moorman AC; Loveless MO; Fuhrer J; Satten GA; Aschman DJ; Holmberg SD
AUTHOR'S ADDRESS: Northwestern University Medical School, Chicago, IL 60611-0949, USA.
MAJOR SUBJECT HEADING(S): AIDS-Related Opportunistic Infections [epidemiology]; Acquired Immunodeficiency Syndrome [mortality]; Anti-HIV Agents [therapeutic use]; HIV Protease Inhibitors [therapeutic use]
MINOR SUBJECT HEADING(S): Acquired Immunodeficiency Syndrome [drug therapy]; Adult; Cytomegalovirus Infections [epidemiology]; Drug Therapy, Combination; Drug Utilization [economics] [statistics & numerical data]; Incidence; Insurance, Health; Middle Age; Mycobacterium avium-intracellulare Infection [epidemiology]; Pneumonia, Pneumocystis carinii [epidemiology]; United States [epidemiology]
INDEXING CHECK TAG(S): Female; Human; Male; Support, Non-U.S. Gov't; Support, U.S. Gov't, P.H.S.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND AND METHODS: National surveillance data show recent, marked reductions in morbidity and mortality associated with the acquired immunodeficiency syndrome (AIDS). To evaluate these declines, we analyzed data on 1255 patients, each of whom had at least one CD4+ count below 100 cells per cubic millimeter, who were seen at nine clinics specializing in the treatment of human immunodeficiency virus (HIV) infection in eight U.S. cities from January 1994 through June 1997. RESULTS: Mortality among the patients declined from 29.4 per 100 person-years in the first quarter of 1995 to 8.8 per 100 in the second quarter of 1997. There were reductions in mortality regardless of sex, race, age, and risk factors for transmission of HIV. The incidence of any of three major opportunistic infections (Pneumocystis carinii pneumonia, Mycobacterium avium complex disease, and cytomegalovirus retinitis) declined from 21.9 per 100 person-years in 1994 to 3.7 per 100 person-years by mid-1997. In a failure-rate model, increases in the intensity of antiretroviral therapy (classified as none, monotherapy, combination therapy without a protease inhibitor, and combination therapy with a protease inhibitor) were associated with stepwise reductions in morbidity and mortality. Combination antiretroviral therapy was associated with the most benefit; the inclusion of protease inhibitors in such regimens conferred additional benefit. Patients with private insurance were more often prescribed protease inhibitors and had lower mortality rates than those insured by Medicare or Medicaid. CONCLUSIONS: The recent declines in morbidity and mortality due to AIDS are attributable to the use of more intensive antiretroviral therapies.

ARTICLE TITLE: Progress and problems in the fight against AIDS [editorial; comment]
COMMENTS: Comment on: N Engl J Med 1998 Mar 26; 338(13):853-60
ARTICLE SOURCE: N Engl J Med (United States), Mar 26 1998, 338(13) p906-8
AUTHOR(S): Hirschel B; Francioli P
MAJOR SUBJECT HEADING(S): Anti-HIV Agents [therapeutic use]; HIV Infections [drug therapy]
MINOR SUBJECT HEADING(S): Acquired Immunodeficiency Syndrome [drug therapy] [mortality]; Anti-HIV Agents [economics]; Drug Costs; HIV Protease Inhibitors [therapeutic use]; United States [epidemiology]
INDEXING CHECK TAG(S): Human
PUBLICATION TYPE: COMMENT; EDITORIAL

ARTICLE TITLE: Ethics of placebo-controlled trials of zidovudine to prevent the perinatal transmission of HIV in the Third World [letter]
ARTICLE SOURCE: N Engl J Med (United States), Mar 19 1998, 338(12) p839-40; discussion 840-1
AUTHOR(S): Lallemant M; McIntosh K; Jourdain G; Le Coeur S; Vithayasai V; Lee TH; Hammer S; Prescott N; Essex M
MAJOR SUBJECT HEADING(S): Anti-HIV Agents [therapeutic use]; Clinical Trials [methods]; Developing Countries; Disease Transmission, Vertical [prevention & control]; Ethics, Medical; HIV Infections [prevention & control]
MINOR SUBJECT HEADING(S): HIV Infections [transmission]; Pregnancy Complications, Infectious [drug therapy]; Pregnancy; Thailand; Zidovudine [therapeutic use]
INDEXING CHECK TAG(S): Female; Human
PUBLICATION TYPE: LETTER

ARTICLE TITLE: Ethical issues in studies in Thailand of the vertical transmission of HIV [see comments]
COMMENTS: Comment in: N Engl J Med 1998 Mar 19; 338(12):843-4; Comment in: N Engl J Med 1998 Mar 19; 338(12):844
ARTICLE SOURCE: N Engl J Med (United States), Mar 19 1998, 338(12) p834-5
AUTHOR(S): Phanuphak P
AUTHOR'S ADDRESS: Thai Red Cross Society, Bangkok.
MAJOR SUBJECT HEADING(S): Anti-HIV Agents [therapeutic use]; Clinical Trials [methods]; Disease Transmission, Vertical [prevention & control]; Ethics, Medical; HIV Infections [prevention & control]; Placebos; Zidovudine [therapeutic use]
MINOR SUBJECT HEADING(S): Developing Countries; HIV Infections [transmission]; Pregnancy Complications, Infectious [drug therapy]; Pregnancy; Thailand

ARTICLE TITLE: Anesthesiology [letter]
ARTICLE SOURCE: N Engl J Med (United States), Mar 5 1998, 338(10) p686; discussion 686-7
AUTHOR(S): Blumberg N
MAJOR SUBJECT HEADING(S): Blood Transfusion, Autologous [economics]
MINOR SUBJECT HEADING(S): Blood Transfusion, Autologous [utilization]; Blood Transfusion [economics]; Cost-Benefit Analysis
INDEXING CHECK TAG(S): Human
PUBLICATION TYPE: LETTER

ARTICLE TITLE: Reduction in pulmonary vascular resistance with long-term epoprostenol (prostacyclin) therapy in primary pulmonary hypertension [see comments]
COMMENTS: Comment in: N Engl J Med 1998 Jan 29; 338(5):321-2
ARTICLE SOURCE: N Engl J Med (United States), Jan 29 1998, 338(5) p273-7
AUTHOR(S): McLaughlin VV; Genthner DE; Panella MM; Rich S
AUTHOR'S ADDRESS: Section of Cardiology, Rush Medical College, Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL 60612-3824, USA.
MAJOR SUBJECT HEADING(S): Antihypertensive Agents [therapeutic use]; Epoprostenol [therapeutic use]; Hypertension, Pulmonary [drug therapy]; Vascular Resistance [drug effects]
MINOR SUBJECT HEADING(S): Adult; Antihypertensive Agents [adverse effects] [pharmacology]; Epoprostenol [adverse effects] [pharmacology]; Follow-Up Studies; Hemodynamics [drug effects]; Hypertension, Pulmonary [physiopathology]; Infusions, Intravenous; Pulmonary Artery [drug effects]
INDEXING CHECK TAG(S): Female; Human; Male
PUBLICATION TYPE: CLINICAL TRIAL; JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Primary (idiopathic) pulmonary hypertension is a progressive, fatal disease. Conventional therapy with anticoagulant and vasodilator drugs may improve symptoms and survival among selected patients, but there is no evidence that the disease can be reversed. METHODS: We evaluated the effects of long-term therapy (i.e., for more than one year) with intravenous epoprostenol (prostacyclin) in patients with advanced primary pulmonary hypertension. The base-line evaluation included an assessment of pulmonary vascular dilation in response to intravenous adenosine. The epoprostenol dose was increased monthly to the maximum tolerated. Long-term therapy was evaluated by measuring improvement in symptoms, exercise capacity, and hemodynamic measures. RESULTS: We evaluated 27 patients with primary pulmonary hypertension over a mean (+/-SD) period of 16.7+/-5.2 months. Intravenous adenosine had a variable effect on pulmonary vascular resistance (mean reduction, 27 percent; range, 0 to 56; P 0.001). Epoprostenol therapy was initiated and the rate of infusion was increased by an average of 2.4 ng per kilogram of body weight per minute each month. Twenty-six of the 27 patients had improvement in symptoms and hemodynamic measures, and overall, pulmonary vascular resistance declined by 53 percent to 7.9+/-3.8 resistance units (P 0.001) at the time of restudy. The long-term effects of epoprostenol exceeded the short-term pulmonary vasodilator response to adenosine in all but one patient. Seven of the eight patients who had minimal pulmonary vasodilation in response to adenosine (mean reduction in resistance units, 20 percent) still had a significant reduction in pulmonary vascular resistance when treated with epoprostenol (mean, 39+/-14 percent; P=0.002). CONCLUSIONS: In primary pulmonary hypertension, long-term therapy with epoprostenol lowers pulmonary vascular resistance beyond the level achieved in the short term with intravenous adenosine. Epoprostenol appears to have sustained efficacy in this disorder.

ARTICLE TITLE: Pulmonary hypertension--beyond vasodilator therapy [editorial; comment]
COMMENTS: Comment on: N Engl J Med 1998 Jan 29; 338(5):273-7
ARTICLE SOURCE: N Engl J Med (United States), Jan 29 1998, 338(5) p321-2
AUTHOR(S): Fishman AP
MAJOR SUBJECT HEADING(S): Antihypertensive Agents [therapeutic use]; Epoprostenol [therapeutic use]; Hypertension, Pulmonary [drug therapy]
MINOR SUBJECT HEADING(S): Antihypertensive Agents [pharmacology]; Epoprostenol [pharmacology]; Infusions, Intravenous; Vascular Resistance [drug effects]
INDEXING CHECK TAG(S): Human
PUBLICATION TYPE: COMMENT; EDITORIAL
TITLE: Effects of walking on mortality among nonsmoking retired men.
ARTICLE SOURCE: N Engl J Med (United States), Jan 8 1998, 338(2) p94-9
AUTHOR(S): Hakim AA; Petrovitch H; Burchfiel CM; Ross GW; Rodriguez BL; White LR; Yano K; Curb JD; Abbott RD
AUTHOR'S ADDRESS: Division of Biostatistics, University of Virginia School of Medicine, Charlottesville 22908, USA.
MAJOR SUBJECT HEADING(S): Mortality; Walking
MINOR SUBJECT HEADING(S): Aged, 80 and over; Aged; Cardiovascular Diseases [mortality]; Exercise; Follow-Up Studies; Longevity; Middle Age; Neoplasms [mortality]; Risk
INDEXING CHECK TAG(S): Human; Male; Support, U.S. Gov't, P.H.S.
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: The potential benefit of low-intensity activity in terms of longevity among older men has not been clearly documented. We examined the association between walking and mortality in a cohort of retired men who were nonsmokers and physically capable of participating in low-intensity activities on a daily basis. METHODS: We studied 707 nonsmoking retired men, 61 to 81 years of age, who were enrolled in the Honolulu Heart Program. The distance walked (miles per day) was recorded at a base-line examination, which took place between 1980 and 1982. Data on overall mortality (from any cause) were collected over a 12-year period of follow-up. RESULTS: During the follow-up period, there were 208 deaths. After adjustment for age, the mortality rate among the men who walked less than 1 mile (1.6 km) per day was nearly twice that among those who walked more than 2 miles (3.2 km) per day (40.5 percent vs. 23.8 percent, P=0.001). The cumulative incidence of death after 12 years for the most active walkers was reached in less than 7 years among the men who were least active. The distance walked remained inversely related to mortality after adjustment for overall measures of activity and other risk factors (P=0.01). CONCLUSIONS: Our findings in older physically capable men indicate that regular walking is associated with a lower overall mortality rate. Encouraging elderly people to walk may benefit their health.

ARTICLE TITLE: Conflict of interest in the debate over calcium-channel antagonists.
ARTICLE SOURCE: N Engl J Med (United States), Jan 8 1998, 338(2) p101-6
AUTHOR(S): Stelfox HT; Chua G; O'Rourke K; Detsky AS
AUTHOR'S ADDRESS: Department of Medicine, University of Toronto, ON, Canada.
MAJOR SUBJECT HEADING(S): Calcium Channel Blockers [therapeutic use]; Conflict of Interest; Drug Industry; Physicians [economics]; Research Support
MINOR SUBJECT HEADING(S): Calcium Channel Blockers [adverse effects]; Drug Industry [economics]
INDEXING CHECK TAG(S): Human; Support, Non-U.S. Gov't
PUBLICATION TYPE: JOURNAL ARTICLE
ABSTRACT: BACKGROUND: Physicians' financial relationships with the pharmaceutical industry are controversial because such relationships may pose a conflict of interest. It is unknown to what extent industry support of medical education and research influences the opinions and behavior of clinicians and researchers. The recent debate over the safety of calcium-channel antagonists provided an opportunity to examine the effect of financial conflicts of interest. METHODS: We searched the English-language medical literature published from March 1995 through September 1996 for articles examining the controversy about the safety of calcium-channel antagonists. Articles were reviewed and classified as being supportive, neutral, or critical with respect to the use of calcium-channel antagonists. The authors of the articles were asked about their financial relationships with both manufacturers of calcium-channel antagonists and manufacturers of competing products (i.e., beta-blockers, angiotensin-converting-enzyme inhibitors, diuretics, and nitrates). We examined the authors' published positions on the safety of calcium-channel antagonists according to their financial relationships with pharmaceutical companies. RESULTS: Authors who supported the use of calcium-channel antagonists were significantly more likely than neutral or critical authors to have financial relationships with manufacturers of calcium-channel antagonists (96 percent, vs. 60 percent and 37 percent, respectively; P 0.001). Supportive authors were also more likely than neutral or critical authors to have financial relationships with any pharmaceutical manufacturer, irrespective of the product (100 percent, vs. 67 percent and 43 percent, respectively; P 0.001). CONCLUSIONS: Our results demonstrate a strong association between authors' published positions on the safety of calcium-channel antagonists and their financial relationships with pharmaceutical manufacturers. The medical profession needs to develop a more effective policy on conflict of interest. We support complete disclosure of relationships with pharmaceutical manufacturers for clinicians and researchers who write articles examining pharmaceutical products.

ARTICLE TITLE: Management of life-threatening acid-base disorders. First of two parts.
ARTICLE SOURCE: N Engl J Med (United States), Jan 1 1998, 338(1) p26-34
AUTHOR(S): Adrogue HJ; Madias NE
AUTHOR'S ADDRESS: Department of Medicine, Baylor College of Medicine and Methodist Hospital, Houston, USA.
MAJOR SUBJECT HEADING(S): Acid-Base Imbalance
MINOR SUBJECT HEADING(S): Acid-Base Imbalance [etiology] [physiopathology] [therapy]; Acidosis; Alkalosis; Carbonates [therapeutic use]; Drug Combinations; Sodium Bicarbonate [therapeutic use]; Tromethamine [therapeutic use]
INDEXING CHECK TAG(S): Human
PUBLICATION TYPE: JOURNAL ARTICLE; REVIEW (68 references); REVIEW, TUTORIAL