Impact of availability of hospital-based invasive cardiac services on racial differences in the use of these services.

BACKGROUND: Reports indicate that black patients are less likely than white patients to receive invasive cardiac services after hospitalization for acute myocardial infarction (AMI). There is still uncertainty as to why racial differences exist and how they affect patient outcomes. This is the first study to focus on the availability of invasive cardiac services and racial differences in procedure use. Study objectives were to (1) document whether racial differences existed in the use of invasive cardiac procedures, (2) study whether these racial differences were related to availability of hospital-based invasive cardiac services at first admission for AMI, and (3) determine whether there were racial differences in long-term mortality rates. METHODS: A historical cohort study was conducted with discharge records from all acute care hospitals in New Jersey for 1993 linked to death certificate records for 1993 and 1994. There were 13,690 black and white New Jersey residents hospitalized with primary diagnosis of AMI. Use of cardiac catheterization within 90 days, revascularization within 90 days (percutaneous transluminal coronary angioplasty [PTCA] or coronary artery bypass graft surgery [CABG]), and death within 1 year after admission for AMI were the main outcome measures. Patterns for PTCA and CABG as separate outcomes were also studied. Hospital-based cardiac services available were described as no invasive cardiac services, catheterization only, or PTCA/CABG. To account for payer status and comorbidity differences, patients 65 years and older with Medicare coverage were analyzed separately from those younger than 65 years. RESULTS: Black patients aged 65 and older were generally less likely to receive catheterization and revascularization than white patients, regardless of facilities available at first admission. For patients younger than 65 years, the greatest differences between black and white patients in catheterization and PTCA/CABG use within 90 days after AMI occurred when no hospital-based invasive cardiac services were available. However, use of invasive cardiac procedures within 90 days after AMI was substantially increased if the first hospital offered catheterization only or PTCA/CABG services, among all patients, especially among blacks younger than age 65. No significant racial differences or interactions with available services were found in 1-year mortality rates. CONCLUSIONS: Availability of invasive cardiac services at first hospitalization for AMI was associated with increased procedure use for both races. However, use of invasive cardiac procedures was generally lower for black patients than for white patients, regardless of services available. Long-term mortality rates after hospitalization for AMI did not differ between blacks and whites.

Medical partnerships with community-based organizations in violence prevention.

Youth violence is an important public health issue. The magnitude of youth violence in New Jersey is defined along with innovative community projects. The authors present recommendations for health professionals involved in youth violence behavior.

Sex differences in the management and long-term outcome of acute myocardial infarction. A statewide study. MIDAS Study Group. Myocardial Infarction Data Acquisition System.

BACKGROUND: We wished to evaluate whether differences in the rate of invasive cardiac procedures between men and women with acute myocardial infarction are associated with different short- and long-term mortality. METHODS AND RESULTS: The database (Myocardial Infarction Data Acquisition System, MIDAS) included all discharges for the years 1986 and 1987 with the diagnosis of acute myocardial infarction in New Jersey, based on the New Jersey hospital discharge data system (MIDS/UB-82). Accuracy of the data was evaluated by auditing 726 randomly selected charts. The variables examined included age, sex, race, comorbidity (anemia, chronic liver disease, cancer, chronic obstructive pulmonary disease, diabetes, hypertension, prior myocardial infarction), complications (left ventricular dysfunction, arrhythmias, conduction defects), insurance status, performance of cardiac catheterization, percutaneous transluminal coronary angioplasty, or coronary artery bypass graft surgery, and survival up to 3 years. Women were older, had longer hospital stay, and were more likely than men to have anemia, diabetes, hypertension, left ventricular dysfunction, and Medicare or Medicaid insurance coverage. They were less likely than men to be admitted to a hospital equipped to perform invasive procedures or to have chronic obstructive pulmonary disease, chronic liver disease, prior myocardial infarction, or arrhythmias. After adjustment for these differences, women were less likely than men to have cardiac catheterization. Cardiac catheterization was associated with lower mortality. Women up to age 70 had higher 3-year death rates than men after adjustment for age, race, comorbidity, complications, and insurance type. This difference between men and women was somewhat diminished after the performance of cardiac catheterization and revascularization was taken into account. Unadjusted mortality was high in this study group. CONCLUSIONS: Women with acute myocardial infarction are less likely to have invasive cardiac procedures and have higher 3-year adjusted death rate up to age 70 than men.

Exogenous calciferol (vitamin D) and vitamin D endocrine status among elderly nursing home residents in the New York City area.

OBJECTIVE: To determine the role and relative importance of sources of exogenous calciferol (vitamin D) in maintaining vitamin D endocrine status in the mid-winter and early spring in a representative sample of institutionalized elderly persons in the New York City area. DESIGN: Cross-sectional survey. SETTING: A privately-run urban nursing home and the long-term care unit of a suburban public hospital. PARTICIPANTS: Residents aged 60 years and older scheduled for a routine annual physical examination and an additional group of individuals ascertained by random sampling. Those with a history of anti-convulsant or glucocorticoid use, liver disease, chronic renal disease (or serum creatinine > 1.5 mg/dL), parathyroid disease, Paget's disease, gastric surgery, or pharmacological vitamin D use were excluded. Of 301 sampled individuals, 221 were found eligible to participate, and 109 were successfully enrolled. RESULTS: The average vitamin D intake was 379 IU/day (range 55-1006 IU/day) and total vitamin D intake was below the Recommended Dietary Allowance in 16% of subjects. Fifty percent of total vitamin D intake came from fortified milk, and 26% came from vitamin supplements. Vitamin supplement use was not associated with low dietary intake. Among subjects taking a supplement containing 400 IU/day, none had serum calcidiol levels below 15 ng/mL, while among subjects with vitamin D intake between 200 and 400 IU/day, 46% had serum calcidiol levels below 15 ng/mL and 14% had calcidiol levels below 10 ng/mL. Vitamin D intake from non-supplement sources (but not from supplements) appeared to have a negative association with serum calcitriol levels. CONCLUSIONS: Many nursing home residents may require vitamin supplements in order to achieve optimal levels of calciferol replacement. The choice of a vehicle for calciferol replacement may affect calcitriol levels.

Protein binding, sister chromatid exchange and expression of oncogene proteins in patients treated with cisplatinum (cisDDP)-based chemotherapy.

The aim of this pilot was to evaluate the feasibility of incorporating several complementary biologic markers into a molecular epidemiologic study of chemotherapy patients. Thirty-two cancer patients being treated with cis-DDP-based chemotherapy for the first time were enrolled in the study and donated a baseline sample and at least one post-treatment sample of blood. Sister Chromatid Exchange (SCEs) and plasma protein and hemoglobin binding by cisDDP were significantly increased in samples drawn at various timepoints following treatment. The pattern of nine different oncogene protein products (including those of ras, fes, and myc) remained unchanged in sera of six patients followed over the course of their treatment. However, the levels of ras P21 product were significantly elevated above normal, control levels in all six cancer patients--both prior to and throughout the course of chemotherapy. These results suggest the usefulness of utilizing a battery of markers to evaluate biologic response to cisplatinum-based chemotherapy.