The Internet as a newly emerging risk environment for sexually transmitted diseases

CONTEXT: Transmission of sexually transmitted diseases (STDs) such as human immunodeficiency virus (HIV) infection is associated with unprotected sex among multiple anonymous sex partners. The role of the Internet in risk of STDs is not known. OBJECTIVE: To compare risk of STD transmission for persons who seek sex partners on the Internet with risk for persons not seeking sex partners on the Internet. DESIGN: Cross-sectional survey conducted September 1999 through April 2000. SETTING AND PARTICIPANTS: A total of 856 clients of the Denver Public Health HIV Counseling and Testing Site in Colorado. MAIN OUTCOME MEASURES: Self-report of logging on to the Internet with the intention of finding sex partners; having sex with partners who were originally contacted via the Internet; number of such partners and use of condoms with them; and time since last sexual contact with Internet partners, linked to HIV risk assessment and test records. RESULTS: Of the 856 clients, most were white (77. 8%), men (69.2%), heterosexual (65.3%), and aged 20 to 50 years (84. 1%). Of those, 135 (15.8%) had sought sex partners on the Internet, and 88 (65.2%) of these reported having sex with a partner initially met via the Internet. Of those with Internet partners, 34 (38.7%) had 4 or more such partners, with 62 (71.2%) of contacts occurring within 6 months prior to the client's HIV test. Internet sex seekers were more likely to be men (P<.001) and homosexual (P<.001) than those not seeking sex via the Internet. Internet sex seekers reported more previous STDs (P =.02); more partners (P<.001); more anal sex (P<.001); and more sexual exposure to men (P<.001), men who have sex with men (P<.001), and partners known to be HIV positive (P<.001) than those not seeking sex via the Internet. CONCLUSIONS: Seeking sex partners via the Internet was a relatively common practice in this sample of persons seeking HIV testing and counseling (representative of neither Denver nor the overall US population). Clients who seek sex using the Internet appear to be at greater risk for STDs than clients who do not seek sex on the Internet. JAMA. 2000;284:443-446     

Regional brain volume abnormalities and long-term cognitive outcome in preterm infants

CONTEXT: Preterm infants have a high prevalence of long-term cognitive and behavioral disturbances. However, it is not known whether the stresses associated with premature birth disrupt regionally specific brain maturation or whether abnormalities in brain structure contribute to cognitive deficits. OBJECTIVE: To determine whether regional brain volumes differ between term and preterm children and to examine the association of regional brain volumes in prematurely born children with long-term cognitive outcomes. DESIGN AND SETTING: Case-control study conducted in 1998 and 1999 at 2 US university medical schools. PARTICIPANTS: A consecutive sample of 25 eight-year-old preterm children recruited from a longitudinal follow-up study of preterm infants and 39 term control children who were recruited from the community and who were comparable with the preterm children in age, sex, maternal education, and minority status. MAIN OUTCOME MEASURES: Volumes of cortical subdivisions, ventricular system, cerebellum, basal ganglia, corpus callosum, amygdala, and hippocampus, derived from structural magnetic resonance imaging scans and compared between preterm and term children; correlations of regional brain volumes with cognitive measures (at age 8 years) and perinatal variables among preterm children. RESULTS: Regional cortical volumes were significantly smaller in the preterm children, most prominently in sensorimotor regions (difference: left, 14.6%; right, 14.3% [P<.001 for both]) but also in premotor (left, 11.2%; right, 12.6% [P<.001 for both]), midtemporal (left, 7.4% [P =.01]; right, 10.2% [P<.001]), parieto-occipital (left, 7.9% [P =.01]; right, 7.4% [P =.005]), and subgenual (left, 8.9% [P =.03]; right, 11.7% [P =.01]) cortices. Preterm children's brain volumes were significantly larger (by 105. 7%-271.6%) in the occipital and temporal horns of the ventricles (P<. 001 for all) and smaller in the cerebellum (6.7%; P =.02), basal ganglia (11.4%-13.8%; P相似文献   

Using Internet technology to deliver a behavioral weight loss program

CONTEXT: Rapid increases in access to the Internet have made it a viable mode for public health intervention. No controlled studies have evaluated this resource for weight loss. OBJECTIVE: To determine whether a structured Internet behavioral weight loss program produces greater initial weight loss and changes in waist circumference than a weight loss education Web site. DESIGN: Randomized, controlled trial conducted from April to December 1999. SETTING AND PARTICIPANTS: Ninety-one healthy, overweight adult hospital employees aged 18 to 60 years with a body mass index of 25 to 36 kg/m(2). Analyses were performed for the 65 who had complete follow-up data. INTERVENTIONS: Participants were randomly assigned to a 6-month weight loss program of either Internet education (education; n = 32 with complete data) or Internet behavior therapy (behavior therapy; n = 33 with complete data). All participants were given 1 face-to-face group weight loss session and access to a Web site with organized links to Internet weight loss resources. Participants in the behavior therapy group received additional behavioral procedures, including a sequence of 24 weekly behavioral lessons via e-mail, weekly online submission of self-monitoring diaries with individualized therapist feedback via e-mail, and an online bulletin board. MAIN OUTCOME MEASURES: Body weight and waist circumference, measured at 0, 3, and 6 months, compared the 2 intervention groups. RESULTS: Repeated-measures analyses showed that the behavior therapy group lost more weight than the education group (P =.005). The behavior therapy group lost a mean (SD) of 4.0 (2.8) kg by 3 months and 4.1 (4.5) kg by 6 months. Weight loss in the education group was 1.7 (2.7) kg at 3 months and 1.6 (3.3) kg by 6 months. More participants in the behavior therapy than education group achieved the 5% weight loss goal (45% vs 22%; P =.05) by 6 months. Changes in waist circumference were also greater in the behavior therapy group than in the education group at both 3 months (P =.001) and 6 months (P =.005). CONCLUSIONS: Participants who were given a structured behavioral treatment program with weekly contact and individualized feedback had better weight loss compared with those given links to educational Web sites. Thus, the Internet and e-mail appear to be viable methods for delivery of structured behavioral weight loss programs.     

Novel risk factors for systemic atherosclerosis: a comparison of C-reactive protein, fibrinogen, homocysteine, lipoprotein(a), and standard cholesterol screening as predictors of peripheral arterial disease

CONTEXT: Several novel risk factors for atherosclerosis have recently been proposed, but few comparative data exist to guide clinical use of these emerging biomarkers. OBJECTIVE: To compare the predictive value of 11 lipid and nonlipid biomarkers as risk factors for development of symptomatic peripheral arterial disease (PAD). DESIGN, SETTING, AND PARTICIPANTS: Nested case-control study using plasma samples collected at baseline from a prospective cohort of 14 916 initially healthy US male physicians aged 40 to 84 years, of whom 140 subsequently developed symptomatic PAD (cases); 140 age- and smoking status-matched men who remained free of vascular disease during an average 9-year follow-up period were randomly selected as controls. MAIN OUTCOME MEASURE: Incident PAD, as determined by baseline total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), total cholesterol-HDL-C ratio, triglycerides, homocysteine, C-reactive protein (CRP), lipoprotein(a), fibrinogen, and apolipoproteins (apo) A-I and B-100. RESULTS: In univariate analyses, plasma levels of total cholesterol (P<.001), LDL-C (P =.001), triglycerides (P =.001), apo B-100 (P =.001), fibrinogen (P =.02), CRP (P =.006), and the total cholesterol-HDL-C ratio (P<.001) were all significantly higher at baseline among men who subsequently developed PAD compared with those who did not, while levels of HDL-C (P =.009) and apo A-I (P =.05) were lower. Nonsignificant baseline elevations of lipoprotein(a) (P =.40) and homocysteine (P =.90) were observed. In multivariable analyses, the total cholesterol-HDL-C ratio was the strongest lipid predictor of risk (relative risk [RR] for those in the highest vs lowest quartile, 3.9; 95% confidence interval [CI], 1.7-8.6), while CRP was the strongest nonlipid predictor (RR for the highest vs lowest quartile, 2.8; 95% CI, 1.3-5.9). In assessing joint effects, addition of CRP to standard lipid screening significantly improved risk prediction models based on lipid screening alone (P<.001). CONCLUSIONS: Of 11 atherothrombotic biomarkers assessed at baseline, the total cholesterol-HDL-C ratio and CRP were the strongest independent predictors of development of peripheral arterial disease. C-reactive protein provided additive prognostic information over standard lipid measures.     

Changes in youth cigarette use and intentions following implementation of a tobacco control program: findings from the Florida Youth Tobacco Survey, 1998-2000

CONTEXT: Many states are developing tobacco use prevention and reduction programs, and current data on tobacco use behaviors and how these change over time in response to program activities are needed for program design, implementation, and evaluation. OBJECTIVES: To assess changes in youth cigarette use and intentions following implementation of the Florida Pilot Program on Tobacco Control. DESIGN, SETTING, AND PARTICIPANTS: Self-administered survey conducted prior to program implementation (1998), and 1 and 2 years (1999, 2000) later among a sample of Florida public middle school and high school students who were classified as never users, experimenters, current users, and former users of cigarettes based on survey responses. MAIN OUTCOME MEASURES: Changes in cigarette use status, intentions, and behaviors among students over a 2-year period. RESULTS: Surveys were completed by 22,540, 20,978, and 23, 745 students attending 255, 242, and 243 Florida public middle and high schools in 1998, 1999 and 2000, respectively. Response rates for the 3 survey years ranged from 80% to 82% and 72% to 82% for the middle school and high school surveys, respectively. After 2 years, current cigarette use dropped from 18.5% to 11.1% (P<.001) among middle school students and from 27.4% to 22.6% (P =.01) among high school students. Prevalence of never use increased from 56.4% to 69. 3% (P<.001) and from 31.9% to 43.1% (P =.001) among middle school and high school students, respectively. Prevalence of experimenting decreased among middle school and high school students from 21.4% to 16.2% (P<.001) and from 32.8% to 28.2% (P<.001), respectively. Among never users, the percentage of committed nonsmokers increased from 67.4% to 76.9% (P<.001) and from 73.7% to 79.3% (P<.001) among middle school and high school students, respectively. Among experimenters, the percentage of students who said they will not smoke again increased from 30.4% to 42.0% (P<.001) in middle school and from 44.4% to 51.0% (P<.001) in high school. CONCLUSIONS: Progress toward reduction of youth tobacco use was observed in each of the 2 years of Florida's Pilot Program on Tobacco Control. Our results suggest that a comprehensive statewide program can be effective in preventing and reducing youth tobacco use. JAMA. 2000;284:723-728     

Effect of improved glycemic control on health care costs and utilization

CONTEXT: Because of the additional costs associated with improving diabetes management, there is interest in whether improved glycemic control leads to reductions in health care costs, and, if so, when such cost savings occur. OBJECTIVE: To determine whether sustained improvements in hemoglobin A(1c) (HbA(1c)) levels among diabetic patients are followed by reductions in health care utilization and costs. DESIGN AND SETTING: Historical cohort study conducted in 1992-1997 in a staff-model health maintenance organization (HMO) in western Washington State. PARTICIPANTS: All diabetic patients aged 18 years or older who were continuously enrolled between January 1992 and March 1996 and had HbA(1c) measured at least once per year in 1992-1994 (n = 4744). Patients whose HbA(1c) decreased 1% or more between 1992 and 1993 and sustained the decline through 1994 were considered to be improved (n = 732). All others were classified as unimproved (n = 4012). MAIN OUTCOME MEASURES: Total health care costs, percentage hospitalized, and number of primary care and specialty visits among the improved vs unimproved cohorts in 1992-1997. RESULTS: Diabetic patients whose HbA(1c) measurements improved were similar demographically to those whose levels did not improve but had higher baseline HbA(1c) measurements (10.0% vs 7.7%; P<.001). Mean total health care costs were $685 to $950 less each year in the improved cohort for 1994 (P =.09), 1995 (P =.003), 1996 (P =.002), and 1997 (P =.01). Cost savings in the improved cohort were statistically significant only among those with the highest baseline HbA(1c) levels (>/=10%) for these years but appeared to be unaffected by presence of complications at baseline. Beginning in the year following improvement (1994), utilization was consistently lower in the improved cohort, reaching statistical significance for primary care visits in 1994 (P =.001), 1995 (P<.001), 1996 (P =.005), and 1997 (P =.004) and for specialty visits in 1997 (P =.02). Differences in hospitalization rates were not statistically significant in any year. CONCLUSION: Our data suggest that a sustained reduction in HbA(1c) level among adult diabetic patients is associated with significant cost savings within 1 to 2 years of improvement.     

Resource utilization in liver transplantation: effects of patient characteristics and clinical practice. NIDDK Liver Transplantation Database Group

CONTEXT: Liver transplantation is among the most costly of medical services, yet few studies have addressed the relationship between the resources utilized for this procedure and specific patient characteristics and clinical practices. OBJECTIVE: To assess the association of pretransplant patient characteristics and clinical practices with hospital resource utilization. DESIGN: Prospective cohort of patients who received liver transplants between January 1991 and July 1994. SETTING: University of California, San Francisco; Mayo Clinic, Rochester, Minn; and the University of Nebraska, Omaha. PATIENTS: Seven hundred eleven patients who received single-organ liver transplants, were at least 16 years old, and had nonfulminant liver disease. MAIN OUTCOME MEASURE: Standardized resource utilization derived from a database created by matching all services to a single price list. RESULTS: Higher adjusted resource utilization was associated with donor age of 60 years or older (28% [$53813] greater mean resource utilization; P=.005); recipient age of 60 years or older (17% [$32795]; P=.01); alcoholic liver disease (26% [$49596]; P=.002); Child-Pugh class C (41% [$67 658]; P<.001); care from the intensive care unit at time of transplant (42% [$77833]; P<.001); death in the hospital (35% [$67 076]; P<.001); and having multiple liver transplants during the index hospitalization (154% increase [$474 740 vs $186 726 for 1 transplant]; P<.001). Adjusted length of stay and resource utilization also differed significantly among transplant centers. CONCLUSIONS: Clinical, economic, and ethical dilemmas in liver transplantation are highlighted by these findings. Recipients who were older, had alcoholic liver disease, or were severely ill were the most expensive to treat; this suggests that organ allocation criteria may affect transplant costs. Clinical practices and resource utilization varied considerably among transplant centers; methods to reduce variation in practice patterns, such as clinical guidelines, might lower costs while maintaining quality of care.     

Involvement in caregiving and adjustment to death of a spouse: findings from the caregiver health effects study.

CONTEXT: Most deaths in the United States occur among older persons who have 1 or more disabling conditions. As a result, many deaths are preceded by an extended period during which family members provide care to their disabled relative. OBJECTIVE: To better understand the effect of bereavement on family caregivers by examining predeath vs postdeath changes in self-reported and objective health outcomes among elderly persons providing varying levels of care prior to their spouse's death. DESIGN AND SETTING: Prospective, population-based cohort study conducted in 4 US communities between 1993 and 1998. PARTICIPANTS: One hundred twenty-nine individuals aged 66 to 96 years whose spouse died during an average 4-year follow-up. Individuals were classified as noncaregivers (n = 40), caregivers who reported no strain (n = 37), or strained caregivers (n = 52). MAIN OUTCOME MEASURES: Changes in depression symptoms (assessed by the 10-item Center for Epidemiological Studies-Depression [CES-D] scale), antidepressant medication use, 6 health risk behaviors, and weight among the 3 groups of participants. RESULTS: Controlling for age, sex, race, education, prevalent cardiovascular disease at baseline, and interval between predeath and postdeath assessments, CES-D scores remained high but did not change among strained caregivers (9.44 vs 9.19; P =.76), while these scores increased for both noncaregivers (4.74 vs 8.25; F(1,116) = 14.33; P<.001) and nonstrained caregivers (4.94 vs 7.13; F(1,116) = 4.35; P =.04). Noncaregivers were significantly more likely to be using nontricyclic antidepressant medications following the death than the nonstrained caregiver group (odds ratio [OR], 12.85; 95% confidence interval [CI], 1.02-162.13; P =.05). The strained caregiver group experienced significant improvement in health risk behaviors following the death of their spouse (1.47 vs 0.66 behaviors; F(1,118) = 20.23; P<.001), while the noncaregiver and nonstrained caregiver groups showed little change (0.27 vs 0.27 [P =.99] and 0.46 vs 0.27 [P =.39] behaviors, respectively). Noncaregivers experienced significant weight loss following the death (149.1 vs 145.3 lb [67.1 vs 65.4 kg]; F(1,101) = 8.12; P =.005), while the strained and nonstrained caregiving groups did not show significant weight change (156.2 vs 155.2 lb [70.3 vs 69.8 kg] [P =.41] and 156.2 vs 154.0 lb [70.3 vs 69.3 kg] [P =.12], respectively). CONCLUSIONS: These data indicate that the impact of losing one's spouse among older persons varies as a function of the caregiving experiences that precede the death. Among individuals who are already strained prior to the death of their spouse, the death itself does not increase their level of distress. Instead, they show reductions in health risk behaviors. Among noncaregivers, losing one's spouse results in increased depression and weight loss.     

同性交友平台上青年学生的艾滋病知识和艾滋病相关行为现状

目的：了解同性交友平台上青年学生的获得性免疫缺陷综合征（acquired immune deficiency syndrome,AIDS,艾滋病）知识及相关行为现状,为今后通过网络开展艾滋病宣传教育提供依据。方法：采用滚雪球抽样方法,使用自行设计的自填式问卷调查同性交友平台上青年学生的艾滋病知识及其相关行为,并采用卡方检验分析不同特征青年学生的艾滋病知识知晓水平,用Logistic回归分析人类免疫缺陷病毒（human Immunodeficiency virus,HIV）检测情况的影响因素。结果：共调查同性交友平台上的青年学生469人,问卷有效率为94.2%（442）。研究发现,同性交友平台上青年学生的“大众人群艾滋病知识”知晓率为83.9%（371）,“青年学生艾滋病知识”知晓率为77.1%（341）,HIV抗体检测率为52.0%（230）。不同年龄段（P＝0.001）、不同婚姻状态（P＜0.001）、不同性取向（P＜0.001）和首次性行为对象的不同性别（P＜0.001）的青年学生,“大众人群艾滋病知识”知晓率差异有统计学意义。不同年龄段（P＝0.010）、不同婚姻状态（P＝0.004）、不同性取向（P＜0.001）和首次性行为对象的不同性别（P＜0.001）的青年学生“青年学生艾滋病知识”知晓率差异有统计学意义。同性交友平台上青年学生性行为发生率为75.1%（332）,多性伴发生率为41.3%（137）。相比于同性性取向的学生,性取向为异性（OR＝0.282,95%CI：0.151~0.528）和性取向不确定（OR＝0.175,95%CI：0.035~0.885）是HIV抗体检测的阻碍因素,多性伴（OR＝2.103,95%CI：1.278~3.462）是HIV抗体检测的促进因素。结论：同性交友平台上的青年学生的高危行为发生率较高,需要关注有同性性行为倾向的异性恋男生,积极探索通过同性交友平台开展艾滋病防治教育,提高青年学生自我保护意识。     

Effect of weight loss and lifestyle changes on vascular inflammatory markers in obese women: a randomized trial

CONTEXT: Obesity is an independent risk factor for cardiovascular disease, which may be mediated by increased secretion of proinflammatory cytokines by adipose tissue. OBJECTIVE: To determine the effect of a program of changes in lifestyle designed to obtain a sustained reduction of body weight on markers of systemic vascular inflammation and insulin resistance. DESIGN AND SETTING: Randomized single-blind trial conducted from February 1999 to February 2002 at a university hospital in Italy. PATIENTS: One hundred twenty premenopausal obese women (body mass index > or =30) aged 20 to 46 years without diabetes, hypertension, or hyperlipidemia. INTERVENTIONS: The 60 women randomly assigned to the intervention group received detailed advice about how to achieve a reduction of weight of 10% or more through a low-energy Mediterranean-style diet and increased physical activity. The control group (n = 60) was given general information about healthy food choices and exercise. MAIN OUTCOME MEASURES: Lipid and glucose intake; blood pressure; homeostatic model assessment of insulin sensitivity; and circulating levels of interleukin 6 (IL-6), interleukin 18 (IL-18), C-reactive protein (CRP), and adiponectin. RESULTS: After 2 years, women in the intervention group consumed more foods rich in complex carbohydrates (9% corrected difference; P<.001), monounsaturated fat (2%; P =.009), and fiber (7 g/d; P<.001); had a lower ratio of omega-6 to omega-3 fatty acids (-5; P<.001); and had lower energy (-310 kcal/d; P<.001), saturated fat (-3.5%; P =.007), and cholesterol intake (-92 mg/d; P<.001) than controls. Body mass index decreased more in the intervention group than in controls (-4.2; P<.001), as did serum concentrations of IL-6 (-1.1 pg/mL; P =.009), IL-18 (-57 pg/mL; P =.02), and CRP (-1.6 mg/L; P =.008), while adiponectin levels increased significantly (2.2 microg/mL; P =.01). In multivariate analyses, changes in free fatty acids (P =.008), IL-6 (P =.02), and adiponectin (P =.007) levels were independently associated with changes in insulin sensitivity. CONCLUSION: In this study, a multidisciplinary program aimed to reduce body weight in obese women through lifestyle changes was associated with a reduction in markers of vascular inflammation and insulin resistance.     

Tracing a syphilis outbreak through cyberspace

CONTEXT: A recent outbreak of syphilis among users of an Internet chat room challenged traditional methods of partner notification and community education because locating information on sexual partners was limited to screen names and privacy concerns precluded identifying sexual partners through the Internet service provider. OBJECTIVES: To determine the association of Internet use and acquisition of syphilis and to describe innovative methods of partner notification in cyberspace. DESIGN, SETTING, AND PATIENTS: Outbreak investigation conducted at the San Francisco (Calif) Department of Public Health (SFDPH) in June-August 1999 of 7 cases of early syphilis among gay men linked to an online chat room; case-control study of 6 gay men with syphilis reported to SFDPH in July-August 1999 (cases) and 32 gay men without syphilis who presented to a city clinic in April-July 1999 (controls). MAIN OUTCOME MEASURES: Association of syphilis infection with Internet use, Internet use among cases vs controls, and partner notification methods and partner evaluation indexes. RESULTS: During the outbreak, cases were significantly more likely than controls to have met their sexual partners through use of the Internet (67% vs 19%; odds ratio, 8.7; P =.03). We notified and confirmed testing for 42% of named partners; the mean number of sexual partners medically evaluated per index case was 5.9. CONCLUSIONS: In this study, meeting sexual partners through the Internet was associated with acquisition of syphilis among gay men. Public health efforts must continually adapt disease control procedures to new venues, carefully weighing the rights to privacy vs the need to protect public health. JAMA. 2000;284:447-449     

Complicated left-sided native valve endocarditis in adults: risk classification for mortality

CONTEXT: Complicated left-sided native valve endocarditis causes significant morbidity and mortality in adults. Lack of valid data regarding estimation of prognosis makes management of this condition difficult. OBJECTIVE: To derive and externally validate a prognostic classification system for adults with complicated left-sided native valve endocarditis.Design, Setting, and PATIENTS: Retrospective observational cohort study conducted from January 1990 to January 2000 at 7 Connecticut hospitals among 513 patients older than 16 years who experienced complicated left-sided native valve endocarditis and who were divided into derivation (n = 259) and validation (n = 254) cohorts. MAIN OUTCOME MEASURE: All-cause mortality at 6 months after baseline. RESULTS: In the derivation and validation cohorts, the 6-month mortality rates were 25% and 26%, respectively. Five baseline features were independently associated with 6-month mortality (comorbidity [P =.03], abnormal mental status [P =.02], moderate to severe congestive heart failure [P =.01], bacterial etiology other than viridans streptococci [P<.001 except Staphylococcus aureus, P =.004], and medical therapy without valve surgery [P =.002]) and were used to create a prognostic classification system. In the derivation cohort, patients were classified into 4 groups with increasing risk for 6-month mortality: 5%, 15%, 31%, and 59% (P<.001). In the validation cohort, a similar risk among the 4 groups was observed: 7%, 19%, 32%, and 69% (P<.001). CONCLUSIONS: Adults with complicated left-sided native valve endocarditis can be accurately risk stratified using baseline features into 4 groups of prognostic severity. This prognostic classification system might be useful for facilitating management decisions.     

Sex differences in cardiac catheterization: the role of physician gender.

CONTEXT: Many studies indicate that women are less likely than men to undergo cardiac procedures after an acute myocardial infarction (AMI), raising concerns of sexual bias in clinical care. However, no data exist regarding the relationship between patient sex, physician sex, and use of cardiac procedures. OBJECTIVE: To determine whether sex differences in cardiac catheterization after AMI were greater when patients were treated by male attending physicians compared with female attending physicians. DESIGN, SETTING, AND PATIENTS: Analysis of data from the Cooperative Cardiovascular Project, a retrospective medical record review. A total of 104 >231 Medicare fee-for-service beneficiaries who were hospitalized in US acute care hospitals for an AMI between January 1994 and February 1995. MAIN OUTCOME MEASURE: Use of cardiac catheterization within 60 days of admission, compared between the 4 groups of patient sex-physician sex combinations. RESULTS: Women underwent fewer cardiac catheterizations than men when treated by either male physicians (38.6% vs 50.8%; P =.001) or female physicians (34.8% vs 45.8%; P =.001). Sex differences in procedure use were not greater when a patient and physician were of different sexes (P for interaction =.85). After potential confounders in multivariable analysis were accounted for, women were less likely to undergo cardiac catheterization (risk ratio, 0.90 [95% confidence interval (CI), 0.88-0.92]), regardless of the treating physician's sex. Patients treated by male physicians were more likely to undergo cardiac catheterization (risk ratio, 1.06 [95%CI, 1.02-1.10]) than those treated by female physicians, regardless of patient sex. CONCLUSIONS: Women who have had an AMI undergo a cardiac catheterization less often than men, whether treated by a male or female physician. These results suggest that factors other than sexual bias by male physicians toward women account for sex differences in cardiac procedure use.     

Has misdiagnosis of appendicitis decreased over time? A population-based analysis

CONTEXT: Misdiagnosis of presumed appendicitis is an adverse outcome that leads to unnecessary surgery. Computed tomography, ultrasonography, and laparoscopy have been suggested for use in patients with equivocal signs of appendicitis to decrease unnecessary surgery. OBJECTIVE: To determine if frequency of misdiagnosis preceding appendectomy has decreased with increased availability of computed tomography, ultrasonography, and laparoscopy. DESIGN, SETTING, AND PATIENTS: Retrospective, population-based cohort study of data from a Washington State hospital discharge database for 85 790 residents assigned International Classification of Diseases, Ninth Revision procedure codes for appendectomy, and United States Census Bureau data for 1987-1998. MAIN OUTCOME MEASURE: Population-based age- and sex-standardized incidence of appendectomy with acute appendicitis (perforated or not) or with a normal appendix. RESULTS: Among 63 707 nonincidental appendectomy patients, 84.5% had appendicitis (25.8% with perforation) and 15.5% had no associated diagnosis of appendicitis. After adjusting for age and sex, the population-based incidence of unnecessary appendectomy and of appendicitis with perforation did not change significantly over time. Among women of reproductive age, the population-based incidence of misdiagnosis increased 1% per year (P =.005). The incidence of misdiagnosis increased 8% yearly in patients older than 65 years (P<.001) but did not change significantly in children younger than 5 years (P =.17). The proportion of patients undergoing laparoscopic appendectomy who were misdiagnosed was significantly higher than that of open appendectomy patients (19.6% vs 15.5%; P<.001). CONCLUSION: Contrary to expectation, the frequency of misdiagnosis leading to unnecessary appendectomy has not changed with the introduction of computed tomography, ultrasonography, and laparoscopy, nor has the frequency of perforation decreased. These data suggest that on a population level, diagnosis of appendicitis has not improved with the availability of advanced diagnostic testing.     

Safety of early discharge for Medicaid newborns.

CONTEXT: Neonates are being discharged from the hospital more rapidly, but the risks associated with this practice, especially for low-income populations, are unclear. OBJECTIVE: To determine the impact of decreasing postnatal length of stay on rehospitalization rates in the immediate postdischarge period for Medicaid neonates. DESIGN AND SETTING: Retrospective, population-based cohort study using Ohio Medicaid claims data linked to vital statistics files from July 1, 1991, to June 15, 1995. PARTICIPANTS: A total of 102 678 full-term neonates born to mothers receiving Medicaid for at least 30 days after birth. MAIN OUTCOME MEASURES: Rehospitalization rates within 7 and 14 days of discharge, postdischarge health care use, and regional variations in length of stay and rehospitalization. RESULTS: The proportion of neonates who were discharged following a short stay (less than 1 day after vaginal delivery, less than 2 days after cesarean birth) increased 185%, from 21% to 59.8% (P<.001) and the mean (SD) length of stay decreased 27%, from 2.2 (1.0) to 1.6 (0.9) days (P<.001), over the course of the study. The proportion of neonates who received a primary care visit within 14 days of birth increased 117% (P = .001). Rehospitalization rates within 7 and 14 days of discharge decreased by 23%, from 1.3% to 1.0% (P=.01), and by 19%, from 2.1% to 1.7% (P=.03), respectively. Short stay across the 6 regions of the state varied significantly over time (P<.001). Factors significantly associated with increased likelihood of rehospitalization within both 7 and 14 days of discharge were white race, shorter gestation, primiparity, earlier year of birth, lower 5-minute Apgar score, vaginal delivery, married mother, and region of the state. CONCLUSION: Our data suggest that reductions in length of stay for full-term Medicaid newborns in Ohio have not resulted in an increase in rehospitalization rates in the immediate postnatal period.     

Leg symptoms in peripheral arterial disease: associated clinical characteristics and functional impairment

CONTEXT: Persons with lower-extremity peripheral arterial disease (PAD) are often asymptomatic or have leg symptoms other than intermittent claudication (IC). OBJECTIVE: To identify clinical characteristics and functional limitations associated with a broad range of leg symptoms identified among patients with PAD. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional study of 460 men and women with PAD and 130 without PAD, who were identified consecutively, conducted between October 1998 and January 2000 at 3 Chicago-area medical centers. MAIN OUTCOME MEASURES: Ankle-brachial index score of less than 0.90; scores from 6-minute walk, accelerometer-measured physical activity over 7 days, repeated chair raises, standing balance (full tandem stand), 4-m walking velocity, San Diego claudication questionnaire, Geriatric Depression Score Short-Form, and the Walking Impairment Questionnaire. RESULTS: All groups with PAD had poorer functioning than participants without PAD. The following values are for patients without IC vs those with IC. Participants in the group with leg pain on exertion and rest (n = 88) had a higher (poorer) score for neuropathy (5.6 vs 3.5; P<.001), prevalence of diabetes mellitus (48.9% vs 26.7%; P<.001), and spinal stenosis (20.8% vs 7.2%; P =.002). The atypical exertional leg pain/carry on group (exertional leg pain other than IC associated with walking through leg pain [n = 41]) and the atypical exertional leg pain/stop group (exertional leg pain other than IC that causes one to stop walking [n = 90]) had better functioning than the IC group. The group without exertional leg pain/inactive (no exertional leg pain in individual who walks 相似文献   

Association of noninvasive ventilation with nosocomial infections and survival in critically ill patients

CONTEXT: Invasive life-support techniques are a major risk factor for nosocomial infection. Noninvasive ventilation (NIV) can be used to avoid endotracheal intubation and may reduce morbidity among patients in intensive care units (ICUs). OBJECTIVE: To determine whether the use of NIV is associated with decreased risk of nosocomial infections and improved survival in everyday clinical practice among patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) or hypercapnic cardiogenic pulmonary edema (CPE). DESIGN AND SETTING: Matched case-control study conducted in the medical ICU of a French university hospital from January 1996 through March 1998. PATIENTS: Fifty patients with acute exacerbation of COPD or severe CPE who were treated with NIV for at least 2 hours and 50 patients treated with mechanical ventilation between 1993 and 1998 (controls), matched on diagnosis, Simplified Acute Physiology Score II, Logistic Organ Dysfunction score, age, and no contraindication to NIV. MAIN OUTCOME MEASURES: Rates of nosocomial infections, antibiotic use, lengths of ventilatory support and of ICU stay, ICU mortality, compared between cases and controls. RESULTS: Rates of nosocomial infections and of nosocomial pneumonia were significantly lower in patients who received NIV than those treated with mechanical ventilation (18% vs 60% and 8% vs 22%; P<.001 and P =.04, respectively). Similarly, the daily risk of acquiring an infection (19 vs 39 episodes per 1000 patient-days; P =.05), proportion of patients receiving antibiotics for nosocomial infection (8% vs 26%; P =.01), mean (SD) duration of ventilation (6 [6] vs 10 [12] days; P =.01), mean (SD) length of ICU stay (9 [7] vs 15 [14] days; P =.02), and crude mortality (4% vs 26%; P =.002) were all lower among patients who received NIV than those treated with mechanical ventilation. CONCLUSIONS: Use of NIV instead of mechanical ventilation is associated with a lower risk of nosocomial infections, less antibiotic use, shorter length of ICU stay, and lower mortality. JAMA. 2000;284:2361-2367.     

Association of coffee and caffeine intake with the risk of Parkinson disease

CONTEXT: The projected expansion in the next several decades of the elderly population at highest risk for Parkinson disease (PD) makes identification of factors that promote or prevent the disease an important goal. OBJECTIVE: To explore the association of coffee and dietary caffeine intake with risk of PD. DESIGN, SETTING, AND PARTICIPANTS: Data were analyzed from 30 years of follow-up of 8004 Japanese-American men (aged 45-68 years) enrolled in the prospective longitudinal Honolulu Heart Program between 1965 and 1968. MAIN OUTCOME MEASURE: Incident PD, by amount of coffee intake (measured at study enrollment and 6-year follow-up) and by total dietary caffeine intake (measured at enrollment). RESULTS: During follow-up, 102 men were identified as having PD. Age-adjusted incidence of PD declined consistently with increased amounts of coffee intake, from 10.4 per 10,000 person-years in men who drank no coffee to 1.9 per 10,000 person-years in men who drank at least 28 oz/d (P<.001 for trend). Similar relationships were observed with total caffeine intake (P<.001 for trend) and caffeine from non-coffee sources (P=.03 for trend). Consumption of increasing amounts of coffee was also associated with lower risk of PD in men who were never, past, and current smokers at baseline (P=.049, P=.22, and P=.02, respectively, for trend). Other nutrients in coffee, including niacin, were unrelated to PD incidence. The relationship between caffeine and PD was unaltered by intake of milk and sugar. CONCLUSIONS: Our findings indicate that higher coffee and caffeine intake is associated with a significantly lower incidence of PD. This effect appears to be independent of smoking. The data suggest that the mechanism is related to caffeine intake and not to other nutrients contained in coffee. JAMA. 2000;283:2674-2679.     

Comprehensive follow-up care and life-threatening illnesses among high-risk infants: A randomized controlled trial

CONTEXT: Inner-city high-risk infants often receive limited and fragmented care, a problem that may increase serious illness. OBJECTIVE: To assess whether access to comprehensive care in a follow-up clinic is cost-effective in reducing life-threatening illnesses among high-risk, inner-city infants. DESIGN: Randomized controlled trial. SETTING AND PARTICIPANTS: A total of 887 very-low-birth-weight infants born in a Texas county hospital between January 1988 and March 1996 and followed up in a children's hospital clinic. One hundred four infants who became ineligible or died after randomization but before nursery discharge were excluded from the analysis. INTERVENTIONS: Infants were randomly assigned to receive routine follow-up care (well-baby care and care for chronic illnesses; n = 441) or comprehensive care (which included the components of routine care plus care for acute illnesses, with 24-hour access to a primary caregiver; n = 446). MAIN OUTCOME MEASURES: Life-threatening illnesses (ie, causing death or hospital admission for pediatric intensive care) occurring between nursery discharge and age 1 year, assessed by blinded evaluators from inpatient charts and state Medicaid and vital statistics records; and hospital costs (estimated from department-specific cost-to-charge ratios). RESULTS: Comprehensive care resulted in a mean of 3.1 more clinic visits and 6.7 more telephone conversations with clinic staff (P<.001 for both). One-year outcomes were unknown for fewer comprehensive-care infants than routine-care infants (9 vs 28; P =.001). Identified deaths were similar (11 in comprehensive care vs 13 in routine care; P =.68). The comprehensive-care group had 48% fewer life-threatening illnesses (33 vs 63; P<.001), 57% fewer intensive care admissions (23 vs 53; P =.003), and 42% fewer intensive care days (254 vs 440; P =.003). Comprehensive care did not increase the mean estimated cost per infant for all care ($6265 with comprehensive care and $9913 with routine care). CONCLUSION: Comprehensive follow-up care by experienced caregivers can be highly effective in reducing life-threatening illness without increasing costs among high-risk inner-city infants. JAMA. 2000;284:2070-2076.