Housing Dependence and Intimate Relationships in the Lives of Low-Income Puerto Rican Mothers

Using longitudinal ethnographic data from the Three-City Study, we examined the relationship between sixteen low-income Puerto Rican mothers' housing dependencies and their intimate partner relations. We traced mothers' dependent housing arrangements and entrée to marital or cohabiting relationships from their teens through their procurement of independent housing while entering and maintaining intimate partner unions as adults. Findings indicated that various trigger factors led women out of their natal homes and into expedited cohabitation with romantic partners which frequently resulted in unstable unions in which mothers had little power and autonomy. As mothers became eligible for housing subsidies they obtained housing independent from their male partners, potentially increasing the propensity for greater relationship power. Housing independence, however, was not without problems. Spillover effects, such as shadowing partners, threatened housing stability and mothers' independence. The relevance of these findings for future research is discussed.     

Acute upper gastrointestinal bleeding in elderly persons

We have seen that UGI bleeding is a serious and apparently growing problem for seniors. Of special concern in the older patient are the frequency with which serious peptic disease presents silently, the limitation frequently imposed on adequate pain relief from NSAIDs, and the higher complication rates from most of the causes of UGI bleeding. Care of the elderly would be enhanced by research focused on defining those older patients most at risk of experiencing NSAID-induced peptic complications, improved methods for preventing or treating NSAID-induced ulceration that are well tolerated and cost-effective, and better regimens for preventing the recurrence of ulcers and UGI bleeding in these patients. In regard to the last, future investigation of the role of H. pylori, methods for successfully eliminating the organism, and the effect of eradication on patients' subsequent course may be particularly helpful.     

The split radial technique: an alternative to the Y-graft for total arterial myocardial revascularisation

There is evidence that the use of Y-grafts attached to the left internal mammary artery - to - left anterior descending artery graft may compromise the patency of the distal limb of the left internal mammary artery. We describe a technique (split radial technique) that avoids the use of Y-grafts by constructing two aorto-coronary grafts from a single radial artery. The split radial technique requires the harvesting of the radial artery in its entirety from the brachial bifurcation to the radial styloid. The first radial artery distal anastomosis is performed and the required length of conduit is determined. The conduit is transected, leaving a sufficiently long radial segment for a second aorto-coronary graft. A clinical follow-up 41 weeks after surgery of the first 37 patients in whom the split radial technique was used showed no deaths or major complications. This suggests that the split radial technique is a useful and safe way to maximise the use of radial artery conduit and to avoid the potential risk of compromising internal mammary artery patency with Y-grafts. There is evidence that the use of Y-grafts attached to the left internal mammary artery may compromise the patency of the distal limb of the left internal mammary artery. We describe the split radial technique of constructing two aorto-coronary graft segments from a single radial artery that can be used to avoid the use of Y-grafts.     

A pharmacy discharge plan for hospitalized elderly patients--a randomized controlled trial

OBJECTIVES: to investigate the effectiveness of a pharmacy discharge plan in elderly hospitalized patients. DESIGN: randomized controlled trial. SUBJECTS AND SETTINGS: we randomized patients aged 75 years and older on four or more medicines who had been discharged from three acute general and one long-stay hospital to a pharmacy intervention or usual care. INTERVENTIONS: the hospital pharmacist developed discharge plans which gave details of medication and support required by the patient. A copy was given to the patient and to all relevant professionals and carers. This was followed by a domiciliary assessment by a community pharmacist. In the control group, patients were discharged from hospital following standard procedures that included a discharge letter to the general practitioner listing current medications. OUTCOMES: the primary outcome was re-admission to hospital within 6 months. Secondary outcomes included the number of deaths, attendance at hospital outpatient clinics and general practice and proportion of days in hospital over the follow-up period, together with patients' general well-being, satisfaction with the service and knowledge of and adherence to prescribed medication. RESULTS: we recruited 362 patients, of whom 181 were randomized to each group. We collected hospital and general practice data on at least 91 and 72% of patients respectively at each follow-up point and interviewed between 43 and 90% of the study subjects. There were no significant differences between the groups in the proportion of patients re-admitted to hospital between baseline and 3 months or 3 and 6 months. There were no significant differences in any of the secondary outcomes. CONCLUSIONS: we found no evidence to suggest that the co-ordinated hospital and community pharmacy care discharge plans in elderly patients in this study influence outcomes.     

Methotrexate (MTX) plus ursodeoxycholic acid (UDCA) in the treatment of primary biliary cirrhosis

This placebo-controlled, randomized, multicenter trial compared the effects of MTX plus UDCA to UDCA alone on the course of primary biliary cirrhosis (PBC). Two hundred and sixty five AMA positive patients without ascites, variceal bleeding, or encephalopathy; a serum bilirubin less than 3 mg/dL; serum albumin 3 g/dL or greater, who had taken UDCA 15 mg/kg daily for at least 6 months, were stratified by Ludwig's histological staging and then randomized to MTX 15 mg/m2 body surface area (maximum dose 20 mg) once a week while continuing on UDCA. The median time from randomization to closure of the study was 7.6 years (range: 4.6-8.8 years). Treatment failure was defined as death without liver transplantation; transplantation; variceal bleeding; development of ascites, encephalopathy, or varices; a doubling of serum bilirubin to 2.5 mg/dL or greater; a fall in serum albumin to 2.5 g/dL or less; histological progression by at least two stages or to cirrhosis. Patients were continued on treatment despite failure of treatment, unless transplantation ensued, drug toxicity necessitated withdrawal, or the patient developed a cancer. There were no significant differences in these parameters nor to the time of development of treatment failures observed for patients taking UDCA plus MTX, or UDCA plus placebo. The trial was conducted with a stopping rule, and was stopped early by the National Institutes of Health at the advice of our Data Safety Monitoring Board for reasons of futility. In conclusion, methotrexate when added to UDCA for a median period of 7.6 years had no effect on the course of PBC treated with UDCA alone.     

Comparative effects of lidocaine and procainamide on acutely impaired hemodynamics

Controversy exists regarding the relative safety of intravenously administered lidocaine and procainamide to patients with acutely impaired hemodynamics. Accordingly, their effects were studied in 15 such patients, 14 with acute myocardial infarction and one with cardiomyopathy and severe congestive heart failure. All had elevated levels of pulmonary capillary wedge pressure (>15 mm Hg) and/or low cardiac index (<2.5 liters/min/m²). Patients were given lidocaine, a 100 mg bolus followed by a 3 mg/min infusion and, after at least a 30 minute recovery period, procainamide, a 100 mg bolus over 2 minutes followed by a 20 mg/min infusion for 20 to 25 minutes. Hemodynamic measurements were compared early and late in the infusion of each drug. Small, clinically insignificant differences were observed in the hemodynamic responses to the drugs, and no clinically significant deterioration occurred with either. Conventional therapeutic doses of intravenous procainamide can be administered by this regimen, to patients with acute myocardial infarction complicated by cardiac failure or low cardiac output, without producing deleterious hemodynamic effects.     

The relationship between hepatic immunoglobulin production and CD154 expression in chronic liver diseases.

BACKGROUND: CD40-CD154 is a receptor-ligand pair that provides key communication signals between cells of the adaptive immune system in states of inflammation and autoimmunity. The CD40 receptor is expressed constitutively on B lymphocytes, for which it provides important signals regulating clonal expansion and antibody production. CD154 is a member of the tumor necrosis factor superfamily, which is primarily expressed by activated T cells. METHODS: Because many chronic liver diseases are characterized by lymphocytic infiltration of the liver and several have increased immunoglobulin (Ig) production, the role of CD40-CD154 in hepatic Ig production was investigated in patients with primary biliary cirrhosis (PBC), primary sclerosing cholangitis, autoimmune hepatitis (AIH), hepatitis C, hepatitis B, alcoholic and non-alcoholic steatohepatitis, as well as normal controls. RESULTS: Soluble CD154 levels in the serum were found to be no different in chronic liver diseases vs normal controls. Likewise, CD154 mRNA levels in peripheral blood mononuclear cells did not differ. However, mRNA for CD154 was significantly increased in the liver of individuals with PBC and AIH as compared with the other groups. The quantity of CD154 mRNA in the liver correlated positively with the quantity of mRNA for secretory Ig. CONCLUSION: These findings suggest that CD40-CD154 signals may be involved in Ig production within the liver of autoimmune liver diseases.