Lower standing systolic blood pressure as a predictor of falls in the elderly: a community-based prospective study.

OBJECTIVES: We investigated prospectively the relationships among falls, physical balance, and standing and supine blood pressure (BP) in elderly persons. BACKGROUND: Falls occur often and adversely affect the activities of daily living in the elderly; however, their relationship to BP has not been clarified thoroughly. METHODS: A total of 266 community-dwelling elderly persons age 65 years or over (123 men and 143 women, mean age of 76 years) were selected from among residents of Coop City, Bronx, New York. Balance was evaluated at baseline using computerized dynamic posturography (DPG). During a one-year follow-up, we collected information on subsequent falls on a monthly basis by postcard and telephone follow-up. RESULTS: One or more falls occurred in 60 subjects (22%) during the one-year follow-up. Women fell more frequently than men (28% vs. 16%, p < 0.03), and fallers were younger than nonfallers. Fallers (n = 60) had lower systolic BP (SBP) levels when compared with nonfallers (n = 206) (128 +/- 17 vs. 137 +/- 22 mm Hg for standing, p < 0.006; 137 +/- 16 vs. 144 +/- 22 mm Hg for lying, p < 0.02), whereas diastolic BP was not related to falls. Falls occurred 2.8 times more often in the lower BP subgroup (<140 mm Hg for standing SBP) than in the higher BP subgroup (> or =140 mm Hg, p < 0.0003), and gender-related differences were observed (p = 0.006): 3.4 times for women (p < 0.0001) versus 1.9 times for men (p = 0.30). Loss of balance, as detected by DPG, did not predict future falls and was also not associated with baseline BP levels. Multiple logistic regression analysis demonstrated that female gender (relative risk [RR] = 2.1, p = 0.02), history of falls (RR = 2.5, p = 0.008) and lower standing SBP level (RR = 0.78 for 10 mm Hg increase, p = 0.005) were independent predictors of falls during one year of follow-up. CONCLUSIONS: Lower standing SBP, even within normotensive ranges, was an independent predictor of falls in the community-dwelling elderly. Elderly women with a history of falls and with lower SBP levels should have more attention paid to the prevention of falls and related accidents.

Age-associated changes in diastolic filling: Doppler E/A ratio is not associated with congestive heart failure in the elderly.

Although left ventricular filling tends to occur in late diastole in the elderly, the clinical significance of this change is unclear. To determine the prevalence of diastolic filling delay and its relationship to congestive heart failure (CHF) in the elderly, we studied 114 community-living elderly volunteers (median age 75, 37% male). Clinical history, physical examination, chest x-ray film, and Doppler echocardiogram were obtained in blinded fashion. CHF was diagnosed by a previously validated clinico-radiographic scoring system. Diastolic filling was assessed by the Doppler ratio of early to late transmitral flow velocity (E/A). The standard clinical definition of diastolic filling delay (E/A < 1) was met by 94 subjects (82%), and median E/A was 0.72; for this study, diastolic filling delay was defined at the median, although both approaches yielded similar results. Systolic function was normal (ejection fraction > or = 0.5) in 97%. There were 22 subjects (19%) with definite or possible CHF. Older subjects were more likely to have CHF, but not more likely to have an E/A ratio below the median. Subjects with diastolic filling delay were no more likely to have CHF than those without. Mean E/A was not different between CHF groups, and there was no significant correlation between E/A and CHF score. There was still no association after controlling for age, history of hypertension, and other potential confounders by multiple logistic regression. Although diastolic filling delay is common in the elderly, it does not correlate with signs and symptoms of CHF. Determination of its prognostic significance requires a prospective follow-up study.

Low incidence of stroke in ambulatory patients with heart failure: a prospective study.

The current study was undertaken to determine prospectively the risk of cerebral thromboembolism and the prognostic significance of left ventricular thrombus in ambulatory patients with chronic congestive heart failure. A total of 264 ambulatory patients (mean age 62 years, mean left ventricular ejection fraction 27%) were followed prospectively for 24 +/- 9 months to determine the incidence of nonhemorrhagic stroke, transient ischemic attack, and mortality. Two-dimensional echocardiographic studies, performed for clinical indications other than previous systemic thromboembolism in 109 patients, were analyzed to relate the presence of left ventricular thrombus to subsequent outcome. Nine cerebral thromboembolic events occurred in 264 patients during the two-year mean follow-up period, yielding a rate of 1.7 thromboembolic events per 100 patient-years of follow-up. Known risk factors for stroke (hypertension, diabetes mellitus, and/or atrial fibrillation) were present in all nine patients with cerebral thromboembolic events. The 109 patients with echocardiographic studies had more severe heart failure than patients without echocardiographic studies (functional class 2.6 vs 2.1, p < 0.01), greater risk of a thromboembolic event (2.4 vs 1.4 events/100 patient-years of follow-up, p < 0.01), and higher mortality (21.3 vs 5.5 deaths/100 patient-years, p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Lung cancer in patients with immunodeficiency syndrome.

We report adenocarcinoma of the lung in seven patients with human immunodeficiency virus (HIV) infection. We compared age, clinical findings and survival data with a sex-matched control group of HIV-negative patients with adenocarcinoma of the lung. Median age of HIV-infected patients with lung cancer was lower than in control patients with lung cancer. The HIV-infected patients had more systemic symptoms and abnormal physical findings than control subjects. Both groups had smoking histories. Laboratory data were similar but control subjects had lower blood oxygen tensions than did HIV patients; HIV patients had more abnormalities on chest roentgenograms and computed tomography scans than did control subjects. All HIV-infected patients were stage IV. Median survival was 4 weeks. For control patients, 50 percent had stage IV disease; median survival was 25.5 weeks. Thus, patients with HIV infection develop lung cancer at a younger age than sex-matched control subjects and undergo a more fulminant course with shortened survivals.

Prognosis in ischemic heart disease. Can you tell as much at the bedside as in the nuclear laboratory?

BACKGROUND--While the resting left ventricular ejection fraction (LVEF) predicts prognosis in ischemic heart disease, clinical evaluation is also useful. METHODS--To compare the prognostic value of LVEF by resting radionuclide ventriculography with that of clinical signs and symptoms of congestive heart failure (CHF), 170 patients with suspected ischemic heart disease were followed up in this prospective study. Patients had a standardized history and physical examination performed by a study cardiologist immediately before the nuclear scan. Chest roentgenography and radionuclide ventriculography were performed in a standard manner. The diagnosis of CHF was made by validated clinicoradiographic criteria based on the Framingham study. Mortality was determined by means of the National Death Index; median follow-up time was 3 years. RESULTS--There was CHF at baseline in 70 patients, and baseline LVEF was low (< or = 0.4) in 63 patients. Low LVEF was significantly associated with CHF. During follow-up, 55 of the subjects died (overall mortality, 32%). Subjects with CHF had a significantly higher risk of death than those without CHF, and subjects with low LVEF had a higher mortality than those with preserved LVEF. Both CHF and LVEF were independent predictors of mortality. In a Cox model, each percentage increase in LVEF was associated with a 2% decreased mortality, while subjects with CHF had a mortality 2.5 times higher than that of those without CHF. Also, CHF with preserved LVEF had a better prognosis than CHF with depressed LVEF, but this prognosis was worse than that in subjects without CHF. CONCLUSIONS--The clinical diagnosis of CHF, based on clinical evaluation and chest roentgenogram, is a valid predictor of mortality and provides information independent of the radionuclide LVEF in determining prognosis in patients with ischemic heart disease.

Left ventricular hypertrophy in black and white hypertensives. Standard electrocardiographic criteria overestimate racial differences in prevalence.

OBJECTIVE: To assess racial differences in the accuracy of standard electrocardiographic (ECG) criteria in the diagnosis of left ventricular hypertrophy (LVH). DESIGN: The sensitivity and specificity of standard ECG criteria were compared in blacks and whites using echocardiographic LVH as the reference standard. SETTING: Eight worksite-based hypertension clinics in New York, NY. PATIENTS: A sample of 122 black and 148 white hypertensive patients. RESULTS: The prevalence of ECG-LVH was two to six times higher in blacks than in whites, depending on the criteria used (range, 6% to 24% in blacks vs 1% to 7% in whites; P = .0005 to .19 for black-white comparisons). The difference in prevalence of echocardiographic LVH [corrected], however, was less striking and did not attain statistical significance (26% in blacks and 20% in whites; P greater than .2). The sensitivity of the ECG was low (range, 3% to 17%) and did not differ significantly between the two races for any of the conventional criteria; specificity, however, was lower in blacks for all criteria (range, 73% to 94% vs 95% to 100% for whites; P = .0001 to .09). The predictive value of a positive ECG was consistently, although not significantly, lower in the black subjects. Black race was the strongest independent predictor of decreased ECG specificity in multiple logistic regression analysis that also considered age, gender, body mass index, left ventricular mass index, and smoking. CONCLUSIONS: Commonly used ECG criteria for the detection of LVH have a poor sensitivity in both black and white hypertensives and a lower specificity in blacks than in whites; this may lead to a greater number of false-positive diagnoses in black patients, as well as to an overestimation of black-white difference in LVH prevalence.

Teaching clinical epidemiology to medical students using a collaborative learning model.

Epidemiology and biostatistics are difficult to teach in medical school. To determine the feasibility of applying a collaborative learning model, we randomly assigned one section of an epidemiology and biostatistics class to use this teaching model. Students in this section did not attend lectures or follow the regular curriculum but instead learned epidemiologic concepts by identifying clinical problems of interest to them and reviewing relevant journal articles, with the group leader functioning as facilitator. All students took an identical examination and anonymously evaluated the course. Examination performance was comparable between the study group (mean 72.1%) and the other students (mean 73.5%). However, the students' evaluation of the study group method was more favorable, especially in their perceived mastery of specific cognitive skills. The data suggest that this model can be successfully applied in teaching epidemiology and biostatistics to medical students.

Clinical diagnosis of congestive heart failure in patients with acute dyspnea.

The validity and utility of physical examination maneuvers were determined in diagnosing congestive heart failure (CHF) in patients with acute dyspnea. Fifty one patients presented to the emergency room with the chief complaint of shortness of breath. History and physical examination were obtained independently, and the physical examination included hepatojugular reflux and the Valsalva maneuver. The diagnosis of CHF was made by predetermined criteria, and was compared with the diagnosis of the emergency room (ER) physician and with the response to bedside maneuvers. The hepatojugular reflux and Valsalva maneuvers were valid in the diagnosis of congestive heart failure in acutely dyspneic patients. Although these maneuvers rarely added to the routine assessment of patients in this study, they may provide a useful, noninvasive adjunct to clinical diagnosis in problematic cases.

Zidovudine therapy in an inner city population.

To determine the compliance and tolerance with zidovudine (azidothymidine or AZT) therapy among poor, minority, and intravenous drug-using patients, data were collected on all AIDS and ARC patients followed for at least 4 weeks in a New York City Human Immunodeficiency Virus clinic. Ninety-nine patients received zidovudine, of whom 75% were males, 92% were minorities, and 59% had a history of intravenous drug use. Of the 99 patients, 72 had AIDS and 27 had ARC with T-helper (CD4) lymphocytes less than or equal to 500 mm3. Eighty-seven of the 99 patients (88%) were compliant with zidovudine therapy. Fifty-seven percent of these had at least one adverse drug reaction requiring dose reduction (44%) or cessation (13%). Adverse reactions were similar to those reported in other populations with HIV-related illness, although headache and nausea were less common. Twenty opportunistic infections (OIs) or HIV-related malignancies occurred in 15 of 82 (18%) patients who were on zidovudine for at least 4 weeks (7.6 OIs/1,000 patient weeks). Seven of the 82 died (9%), compared to 9 of the 17 patients (53%) who did not complete 4 weeks of zidovudine therapy (p less than 0.05). There were no significant differences in any of these measures when intravenous drug users were compared with other risk groups. We conclude that zidovudine can be administered to intravenous drug users and others in an inner city clinic with acceptable compliance and tolerance.

Diagnostic heterogeneity in clinical trials for congestive heart failure.

There are no uniform diagnostic criteria for congestive heart failure. To determine the pattern of diagnostic criteria used, reports of 51 randomized, double-blind, placebo-controlled, clinical drug trials published between 1977 and 1985 were reviewed. Only 23 (45%) of the trials specified objective diagnostic criteria beyond treatment history, clinical diagnosis, or functional class. Of these, there were two trials each for digoxin, hydralazine, amrinone, and metoprolol; for each pair, only one study showed therapy beneficial. Of the amrinone pair, the positive study required a lower ejection fraction (less than 30% compared with less than 45%) and selected patients with more clinical severity. Conversely, for metoprolol, the positive study specified a higher ejection fraction (less than 49% compared with less than 35%) and selected patients with clinically milder disease, suggesting that conflicting results may relate to differences in study population. Many studies of congestive heart failure are done without explicit diagnostic criteria. Criteria lack uniformity, and such discrepancies may explain conflicting results.

The relationship between left ventricular systolic function and congestive heart failure diagnosed by clinical criteria.

There is no uniformly accepted clinical definition for congestive heart failure (CHF), although criteria have been published by various groups. There is also no reference standard for CHF, although left ventricular ejection fraction (LVEF) gives a quantitative assessment of systolic function and is useful in predicting prognosis. To determine the relationship between LVEF and clinically diagnosed CHF, we compared resting LVEF determined by radionuclide ventriculography with diagnosis of CHF by clinical criteria in 407 patients, based on clinical data collected by a cardiology fellow. Of 153 patients with a low LVEF (less than or equal to 0.40), 30 (20%) met none of the criteria for CHF. Conversely, of 204 patients with normal LVEF (greater than or equal to 0.50), 105 (51%) met at least one of the criteria. We conclude that different criteria for CHF will have varying utility depending on the population being examined, and that a combination of clinical features and an objective measure of cardiac performance is needed to diagnose CHF.

Inability to predict diagnosis in febrile intravenous drug abusers.

Although hospitalization is recommended for all febrile intravenous drug abusers, this practice has not been tested and validated. To determine the distribution of disease and the predictive value of clinical information available in the emergency room for diagnosis in these patients, we prospectively evaluated the clinical and laboratory data for 87 consecutive admissions involving 75 intravenous drug abusers with temperature of 38.1 degrees C or more, emergency room physicians' diagnostic predictions, and final diagnosis. Final diagnoses were pneumonia in 38% of the patients, trivial illness (viral syndrome, pharyngitis, or pyrogen reaction) in 26%, infective endocarditis in 13%, and other conditions in 23%. Neither emergency room physicians' diagnostic predictions nor clinical data correlated with a final diagnosis of endocarditis. Although physicians' prediction of trivial illness was associated with a final diagnosis of trivial illness (p less than 0.05), 29% of these patients had a more serious final diagnosis. These data confirm the need to hospitalize all intravenous drug abusers presenting with fever at an emergency room.

Diffuse lymphadenopathy as a manifestation of ankylosing spondylitis.

Diffuse lymphadenopathy has not been previously described in association with ankylosing spondylitis. A 22-year-old man who presented with anorexia, weight loss, shoulder pain, and diffuse lymphadenopathy is described. Lymph node biopsy showed a nonspecific pattern of reactive hyperplasia with sinus histiocytosis. Clinical evaluation disclosed active spondylitis with HLA-B27 positivity. No other cause for the lymphadenopathy was found. The association between lymphadenopathy and connective tissue diseases is discussed. Ankylosing spondylitis should be added to the differential diagnosis of patients with generalized lymphadenopathy of uncertain cause.