Pegfilgrastim for the prevention of febrile neutropenia in patients with epithelial ovarian carcinoma--a cost-effectiveness analysis.

The objective is to assess the cost-effectiveness of pegfilgrastim for the prevention of hospitalization due to febrile neutropenia (FN) in patients with epithelial ovarian carcinoma (EOC) receiving taxane/platinum-based chemotherapy. A decision analysis model evaluated a hypothetical cohort of 10,000 patients receiving six cycles of taxane/platinum-based chemotherapy for EOC. Three strategies were analyzed for the prevention of hospitalization due to FN: 1) dose modifications and delays after a hospitalization for FN without the use of granulocyte-colony stimulating factors (G-CSF) (NO G-CSF); 2) all patients receive G-CSF with each chemotherapy cycle (1 degrees PROPHYLAXIS); 3) patients receive G-CSF for all subsequent chemotherapy cycles after a hospitalization for FN (2 degrees PROPHYLAXIS). The model was applied to two patient populations: 1) an average-risk population (FN hospitalization rate = 5%); 2) a high-risk population (FN hospitalization rate = 16%). Using baseline assumptions in an average-risk population, NO G-CSF was the least expensive strategy with a cost of $68 million and resulted in 2,860 hospitalizations for FN. 2 degrees PROPHYLAXIS resulted in 141 fewer hospitalizations than NO G-CSF at a cost of $76,288 per hospitalization prevented. 1 degrees PROPHYLAXIS was the most effective and resulted in 1,689 fewer hospitalizations for FN compared to NO G-CSF at a cost of $47,343 per hospitalization prevented. When this model is applied to a high-risk patient population, 1 degrees PROPHYLAXIS is more effective and less expensive than both NO G-CSF and 2 degrees PROPHYLAXIS. We conclude that in average-risk patients receiving chemotherapy for EOC the use of pegfilgrastim is effective at reducing hospitalizations due to FN, but at a significant cost. However, in high-risk patients, primary prophylaxis is the only cost-effective strategy and should be strongly considered.

Randomized controlled trial of clarithromycin and ethambutol in the treatment of Crohn's disease.

BACKGROUND: A mycobacterial infection may be the cause of Crohn's disease in some patients. Measurement of intestinal permeability may identify Crohn's disease patients with a high likelihood of relapse and may quantify the severity of intestinal injury. AIM: To assess the effect of 3 months of clarithromycin and ethambutol on the disease activity and intestinal permeability in patients with Crohn's disease at high risk of relapse. METHODS: Patients with Crohn's disease, with a lactulose-mannitol permeability test above 0.03, were randomly assigned to receive either clarithromycin, 500 mg twice daily, and ethambutol, 15 mg/kg daily, or identically appearing placebo for 3 months in addition to their regular therapy. The Harvey-Bradshaw index and the lactulose-mannitol test were assessed in a blind fashion every 3 months for 12 months. RESULTS: Thirty-one patients were randomized to receive either drugs (n=15) or placebo (n=16). The groups were similar in age, sex, duration of disease, location of disease, past complications and disease severity. Specifically, there was no difference between the drug or placebo groups in the mean Harvey-Bradshaw index (4.8 vs. 4.4), number with active disease (33% vs. 44%) and mean lactulose-mannitol test (0.06 vs. 0.10). During the 12-month follow-up period, there were no consistent, statistically significant differences in the mean Harvey-Bradshaw index or lactulose-mannitol test between treatment and placebo groups. Individual patients showed either improvement or worsening of these indices, but these were not related to study medication. Specifically, no 'cures' were noted with anti-mycobacterial treatment. CONCLUSIONS: Three months of treatment with clarithromycin and ethambutol does not benefit Crohn's disease patients who are receiving standard medical therapy.

Variable practice with lenses improves visuo-motor plasticity.

Novel sensorimotor situations present a unique challenge to an individual's adaptive ability. Using the simple and easily measured paradigm of visual-motor rearrangement created by the use of visual displacement lenses, we sought to determine whether an individual's ability to adapt to visuo-motor discordance could be improved through training. Subjects threw small balls at a stationary target during a 3-week practice regimen involving repeated exposure to one set of lenses in block practice (x 2.0 magnifying lenses), multiple sets of lenses in variable practice (x 2.0 magnifying, x 0.5 minifying and up-down reversing lenses) or sham lenses. At the end of training, adaptation to a novel visuo-motor situation (20-degree right shift lenses) was tested. We found that (1) training with variable practice can increase adaptability to a novel visuo-motor situation, (2) increased adaptability is retained for at least 1 month and is transferable to further novel visuo-motor permutations and (3) variable practice improves performance of a simple motor task even in the undisturbed state. These results have implications for the design of clinical rehabilitation programs and countermeasures to enhance astronaut adaptability, facilitating adaptive transitions between gravitational environments.

Blood pressure and symptoms of depression and anxiety: a prospective study.

This study investigated whether symptoms of depression and anxiety were related to the development of elevated blood pressure in initially normotensive adults. The study's hypothesis was addressed with an existing set of prospective data gathered from an age-, sex-, and weight-stratified sample of 508 adults. Four years of follow-up data were analyzed both with logistic analysis, which used hypertension (blood pressure > or =140 mm Hg systolic or 90 mm Hg diastolic) as the dependent variable, and with multiple regression analysis, which used change in blood pressure as the dependent variable. Five physical risk factors for hypertension (age, sex, baseline body mass index, family history of hypertension, and baseline blood pressure levels) were controlled for in the regression analyses. Use of antidepressant/antianxiety and antihypertensive medications were controlled for in the study. Of the 433 normotensive participants who were eligible for our study, 15% had missing data in the logistic regression analysis focusing on depression (n = 371); similarly, 15% of the eligible sample had missing data in the logistic regression using anxiety as the psychological variable of interest (n = 370). Both logistic regression analyses showed no significant relationship for either depression or anxiety in the development of hypertension. The multiple regression analyses (n = 369 for the depression analysis; n = 361 for the anxiety analysis) similarly showed no relationship between either depression or anxiety in changes in blood pressure during the 4-year follow-up. Thus, our results do not support the role of depressive or anxiety symptoms in the development of hypertension in our sample of initially normotensive adults.

Evaluation of Lp[a] and other independent risk factors for CHD in Asian Indians and their USA counterparts.

Conventional risk factors for coronary heart disease (CHD) do not completely account for the observed increase in premature CHD in people from the Indian subcontinent or for Asian Indians who have immigrated to the USA. The objective of this study was to determine the effect of immigration to the USA on plasma levels of lipoprotein [a] (Lp[a]) and other independent risk factors for CHD in Asian Indians. Three subject groups were studied: group 1, 57 subjects living in India and diagnosed with CHD (CHD patients); group 2, 46 subjects living in India and showing no symptoms of CHD (control subjects); group 3, 206 Asian Indians living in the USA. Fasting blood samples were drawn to determine plasma levels of triglyceride (TG), total cholesterol (TC), low density lipoprotein [LDL cholesterol (LDL-Chol)], high density lipoprotein [HDL cholesterol (HDL-Chol)], apolipoprotein B-100 (apoB-100), and Lp[a]. Apolipoprotein [a] (apo[a]) size polymorphism was determined by immunoblotting. Plasma TG, apoB-100, and Lp[a] concentrations were higher in CHD patients than in control and USA groups. CHD patients had higher levels of TC and LDL-Chol and lower HDL-Chol than control subjects. However, the USA population had higher levels of TC, LDL-Chol, and apoB-100 and lower HDL-Chol than control subjects. Plasma Lp[a] levels were inversely correlated with the relative molecular weight of the more abundant of each subject's two apo[a] isoforms (MAI), and CHD patients showed higher frequencies of lower relative molecular weights among MAI. Our observed changes in lipid profiles suggest that immigrating to the USA may place Asian Indians at increased risk for CHD. This study suggests that elevated plasma Lp[a] confers genetic predisposition to CHD in Asian Indians, and nutritional and environmental factors further increase the risk of CHD. This is the first report implicating MAI size as a predictor for development of premature CHD in Asian Indians. Including plasma Lp[a] concentration and apo[a] phenotype in screening procedures may permit early detection and preventive treatment of CHD in this population.

Application of the vestibular disorders activities of daily living scale.

OBJECTIVE: Existing scales of functional performance are either insufficiently sensitive or omit some important daily life tasks. This paper demonstrates that a new scale of self-perceived disablement in the vestibularly impaired population-the Vestibular Disorders Activities of Daily Living Scale (VADL)-differentiates between disabled and healthy persons and evaluates the associations of this assessment with other measures of vestibular disorders. STUDY DESIGN: Prospective. METHODS: Subjects were 1) asymptomatic, healthy adults, 2) patients with benign paroxysmal positional vertigo, 3) patients with chronic vestibulopathy excluding Meniere's disease, postsurgical vertigo, and postconcussion vertigo, and 4) family members. Patient were assessed on the VADL, the Dizziness Handicap Inventory, level of vertigo, and computerized dynamic posturography. Healthy subjects and family members completed the VADL. RESULTS: The VADL differentiates healthy persons from patients but does not differentiate between patient groups. Patients perceived themselves as more independent than their spouses perceived them to be. Scores are weakly correlated with vertigo frequency and posturography scores for conditions with unreliable kinesthesia and absent or unreliable vision. The VADL is more responsive to higher levels of impairment than the Dizziness Handicap Inventory. CONCLUSIONS: This well-normed, self-administered scale of self-perceived disablement is useful for evaluating the functional status of patients with peripheral vestibular disorders. Perceptions of patients and significant others vary, but scores are moderately correlated with some standard measures of vestibular function. As it assesses a different domain of function than do standard diagnostic tests, the VADL will augment these tests during initial evaluation and may be useful for assessing posttreatment change.

Development of the vestibular disorders activities of daily living scale.

BACKGROUND: Existing scales of self-perceived disablement in patients with vestibular impairment either are too broad to detect the subtle deficits in this population or omit some important daily life tasks. OBJECTIVES: To develop a scale to assess self-perceived disablement in patients with vestibular impairment and to describe the development and initial testing of this new assessment tool. DESIGN: A list of items was developed, sent to a panel of expert therapists for review, and then revised to yield the preliminary 31-item, 10-point scale that was administered to subjects. The scale was revised again, yielding the final 28-item scale, which was administered to a new group of subjects. SETTING: Data were collected from patients in an outpatient clinic of a tertiary care center. PARTICIPANTS: Patients diagnosed as having benign paroxysmal positional vertigo and patients diagnosed as having chronic vestibulopathy, excluding Ménière disease, postsurgical vertigo, and postconcussion vertigo. RESULTS: The final scale has 3 subscales: functional, ambulation, and instrumental. It has good face validity, high internal consistency (alpha> or =.90), and high test-retest reliability (r(c)> or =0.87). Scale ratings ranged from 1 (independent) to 10 (ceasing to participate in the activity), but median scores for most subjects were 4 or less. From 41% (39/94) to 44% (41/94) of subjects considered themselves to be independent on those tasks. CONCLUSIONS: This scale has good face validity, high internal consistency, and high test-retest reliability. It may be useful for evaluating functional limitation and perceived handicap or disability before and after intervention and for helping patients become more realistic in understanding their own capabilities.

Long-term vestibulo-ocular reflex changes in patients with vestibular ablation.

Long-term changes in the parameters of the vestibulo-ocular reflex (VOR) were evaluated using recently developed multilevel statistical modelling techniques in a group of patients who had undergone ablative inner ear procedures. Data from 84 patients were available for study. The most dramatic recovery in the VOR occurred during the first 60 postoperative days, however, slow changes continued, levelling off at about 120 days. While frequency was a highly significant predictor of outcomes in all parameters, age showed significant predictive value only to phase measures (p = 0.006) and gender had no effect. Sum gain at the lowest frequency tested remained below the 5th percentile and at the higher frequencies remained below the 50th percentile for normal subjects. Phase decreased exponentially, but remained above the 95th percentile for normal subjects, except at the highest frequency where it remained above the 50th percentile. DC bias decreased exponentially, dropping to the 50th percentile by day 146. Asymmetry stayed between the 50th and 95th percentile, except at the highest frequency, where it was at the 50th percentile by day 125.

Binge eating severity, self-concept, dieting self-efficacy and social support during treatment of binge eating disorder.

OBJECTIVE: In treatment of binge eating, measures of self-concept, eating self-efficacy, and social support were examined at 0, 6, and 18 months to determine if improvements in these variables were associated with reductions in binge eating severity. METHOD: Obese adult females (N = 125) were treated for 6 months, with 12 months of maintenance meetings. The Binge Eating Scale (BES), Tennessee Self-Concept Scale (TSC), Dieter's Inventory of Eating Temptations (DIET), and a social support measure (SocSup) were used. RESULTS: Over the first 6 months, improvements in BES were associated with improvements in the TSC and DIET. Over 18 months, improvements in BES were associated with improvements in the TSC, DIET, and SocSup. DISCUSSION: Therapy for binge eating should result in improvement in self-concept and eating self-efficacy, as well as reductions in binge eating. This study showed that self-concept and eating self-efficacy were associated with improvement in binge eating severity. The association with social support did not appear until long-term follow-up. Improvement in self-concept and eating self-efficacy may be processes leading to clinical improvement in this eating disorder, or they may result from changes in binge eating.

Effect of moderate alcohol consumption on hypertriglyceridemia: a study in the fasting state.

BACKGROUND: Patients with hypertriglyceridemia (HTG) are generally advised to avoid alcohol, even though moderate alcohol consumption is cardioprotective. Alcohol increases plasma triglyceride concentration transiently in normolipidemic subjects, but whether alcohol consumption per se increases triglyceride concentrations in patients with HTG is unclear. OBJECTIVE: To assess whether baseline fasting triglyceride concentration determines plasma triglyceride concentration after acute oral alcohol intake. METHODS: Twelve persons with fasting triglyceride concentrations of 2.3 to 8.5 mmol/L (200-750 mg/dL) and 12 persons as a non-HTG group were enrolled. Obesity, current smoking, and history of hypertension, diabetes, or excessive alcohol use were exclusionary. Fasted subjects consumed 38 mL of ethanol in water (equivalent, 2 alcoholic drinks); blood samples were collected at baseline and at intervals thereafter for 10 hours. No less than 1 week later, the subjects consumed water alone in a control test. RESULTS: Mean triglyceride values were 4.04+/-0.41 mmol/L (358+/-36.9 mg/dL) and 1.00+/-0.11 mmol/L (89+/-10.2 mg/dL) for the HTG and non-HTG groups, respectively. Despite similar changes with alcohol feeding in plasma ethanol, nonesterified fatty acid, and acetate concentrations, the groups differed in triglyceride response. At 6 hours (peak) compared with baseline, triglyceride concentration increased only 3% in the HTG group but 53% in the non-HTG group. The former change was not significantly different from the effect with water alone (-9.2% from baseline; P = .43), whereas the latter was (-8.0%; P = .003). CONCLUSIONS: Acute alcohol intake alone is not an important determinant of plasma triglyceride concentration in individuals with HTG. Other factors, such as the contemporaneous consumption of fat and alcohol, known to increase triglyceride concentrations synergistically in non-HTG individuals, may be more important.

A prospective, population-based study of the demographics, epidemiology, management, and outcome of out-of-hospital pediatric cardiopulmonary arrest.

STUDY OBJECTIVES: To perform a population-based study addressing the demography, epidemiology, management, and outcome of out-of-hospital pediatric cardiopulmonary arrest (PCPA). METHODS: Prospective, population-based study of all children (17 years of age or younger) in a large urban municipality who were treated by EMS personnel for apneic, pulseless conditions. Data were collected prospectively for 3(1/2) years using a comprehensive data collection tool and on-line computerized database. Each child received standard pediatric advanced cardiac life support. RESULTS: During the 3(1/2)-year period, 300 children presented with PCPA (annual incidence of 19. 7/100,000 at risk). Of these, 60% (n=181) were male (P =.0003), and 54% (n=161) were patients 12 months of age or younger (152,500 at risk). Compared with the population at risk (32% black patients, 36% Hispanic patients, 26% white patients), a disproportionate number of arrests occurred in black children (51.6% versus 26.6% in Hispanics, and 17% in white children; P <.0001). Over 60% of all cases (n=181) occurred in the home with family members present, and yet those family members initiated basic CPR in only 31 (17%) of such cases. Only 33 (11%) of the total 300 PCPA cases had a return of spontaneous circulation, and 5 of the 6 discharged survivors had significant neurologic sequelae. Only 1 factor, endotracheal intubation, was correlated positively with return of spontaneous circulation (P =.032). CONCLUSION: This population-based study underscores the need to investigate new therapeutic interventions for PCPA, as well as innovative strategies for improving the frequency of basic CPR for children.

The predictive validity of the Diet Readiness Test in a clinical population.

OBJECTIVE: To evaluate the psychometric properties, including the factorial and predictive validity, of the Diet Readiness Test (DRT) in a clinical population. METHOD: The DRT was administered to 132 women who participated in an obesity and binge eating treatment study. RESULTS: The DRT demonstrated adequate internal consistency. The DRT's proposed factor structure was not supported. Neither the DRT subscales nor the derived factors predicted changes in weight, binge eating, or exercise. DISCUSSION: The DRT did not demonstrate factorial or predictive validity in this study. Based on the DRT's cutoff criteria, 100% of the sample was considered not ready to begin a weight loss program, suggesting that the DRT may have limited utility with clinical populations.

Soluble cell adhesion molecules in hypertriglyceridemia and potential significance on monocyte adhesion.

Hypertriglyceridemia may contribute to the development of atherosclerosis by increasing expression of cell adhesion molecules (CAMs). Although the cellular expression of CAMs is difficult to assess clinically, soluble forms of CAMs (sCAMs) are present in the circulation and may serve as markers for CAMs. In this study, we examined the association between sCAMs and other risk factors occurring with hypertriglyceridemia, the effect of triglyceride reduction on sCAM levels, and the role of soluble vascular cell adhesion molecule-1 (sVCAM-1) in monocyte adhesion in vitro. Compared with normal control subjects (n=20), patients with hypertriglyceridemia and low HDL (n=39) had significantly increased levels of soluble intercellular adhesion molecule-1 (sICAM-1) (316+/-28.8 versus 225+/-16.6 ng/mL), sVCAM-1 (743+/-52.2 versus 522+/-43.6 ng/mL), and soluble E-selectin (83+/-5.9 versus 49+/-3.6 ng/mL). ANCOVA showed that the higher sCAM levels in patients occurred independently of diabetes mellitus and other risk factors. In 27 patients who received purified n-3 fatty acid (Omacor) 4 g/d for > or =7 months, triglyceride level was reduced by 47+/-4.6%, sICAM-1 level was reduced by 9+/-3.4% (P=.02), and soluble E-selectin level was reduced by 16+/-3.2% (P<.0001), with the greatest reduction in diabetic patients. These results support previous in vitro data showing that disorders in triglyceride and HDL metabolism influence CAM expression and treatment with fish oils may alter vascular cell activation. In a parallel-plate flow chamber, recombinant sVCAM-1 at the concentration seen in patients significantly inhibited adhesion of monocytes to interleukin-1-stimulated cultured endothelial cells under conditions of flow by 27.5+/-7.2%. Thus, elevated sCAMs may negatively regulate monocyte adhesion.

Nondieting versus dieting treatment for overweight binge-eating women.

This study evaluated the effectiveness of nondieting versus dieting treatments for overweight, binge-eating women. Participants (N = 219) were randomly assigned to 1 of 3 groups: diet treatment (DT), nondiet treatment (NDT), or wait-list control (WLC). DT received a balanced-deficit diet reinforced with behavioral strategies. NDT received therapy designed to help participants break out of their dieting cycles. Treatment in both conditions was administered in weekly groups for 6 months, followed by 26 biweekly maintenance meetings, for a total of 18 months of contact. At 6 months posttreatment, DT lost 0.6 kg while NDT gained 1.3 kg. Both treatment groups reduced their Binge Eating Scale scores significantly more than WLC. At 18-month follow-up, both treatment groups experienced weight gain but maintained similar reductions in binge eating. Results indicate that neither intervention was successful in producing short- or long-term weight loss. Therapist biases, which may have affected treatment integrity, and other methodological issues are discussed in relation to the small weight losses achieved.

Structural and functional differences between glycosylated and non-glycosylated forms of human interferon-beta (IFN-beta).

PURPOSE: Two recombinant IFN-beta products have been approved for the treatment of multiple sclerosis, a glycosylated form with the predicted natural amino acid sequence (IFN-beta-1a) and a non-glycosylated form that has a Met-1 deletion and a Cys-17 to Ser mutation (IFN-beta-1b). The structural basis for activity differences between IFN-beta-1a and IFN-beta-1b, is determined. METHODS: In vitro antiviral, antiproliferative and immunomodulatory assays were used to directly compare the two IFN-beta products. Size exclusion chromatography (SEC), SDS-PAGE, thermal denaturation, and X-ray crystallography were used to examine structural differences. RESULTS: IFN-beta-1a was 10 times more active than IFN-beta-1b with specific activities in a standard antiviral assay of 20 x 10(7) IU/mg for IFN-beta-1a and 2 x 10(7) IU/mg for IFN-beta-1b. Of the known structural differences between IFN-beta-1a and IFN-beta-1b, only glycosylation affected in vitro activity. Deglycosylation of IFN-beta-1a produced a decrease in total activity that was primarily caused by the formation of an insoluble disulfide-linked IFN precipitate. Deglycosylation also resulted in an increased sensitivity to thermal denaturation. SEC data for IFN-beta-1b revealed large, soluble aggregates that had reduced antiviral activity (approximated at 0.7 x 10(7) IU/mg). Crystallographic data for IFN-beta-1a revealed that the glycan formed H-bonds with the peptide backbone and shielded an uncharged surface from solvent exposure. CONCLUSIONS: Together these results suggest that the greater biological activity of IFN-beta-1a is due to a stabilizing effect of the carbohydrate on structure.

Effects of ozone and other pollutants on the pulmonary function of adult hikers.

This study evaluated the acute effects of ambient ozone (O3), fine particulate matter (PM2.5), and strong aerosol acidity on the pulmonary function of exercising adults. During the summers of 1991 and 1992, volunteers (18-64 years of age) were solicited from hikers on Mt. Washington, New Hampshire. Volunteer nonsmokers with complete covariates (n = 530) had pulmonary function measured before and after their hikes. We calculated each hiker's posthike percentage change in forced expiratory volume in 1 sec (FEV1), forced vital capacity (FVC), the ratio of these two (FEV1/FVC), forced expiratory flow between 25 and 75% of FVC(FEF25-75%), and peak expiratory flow rate (PEFR). Average O3 exposures ranged from 21 to 74 ppb. After adjustment for age,sex, smoking status (former versus never), history of asthma or wheeze, hours hiked, ambient temperature, and other covariates, there was a 2.6% decline in FEV1 [95% confidence interval (CI), 0.4-4.7; p = 0.02] and a 2.2% decline in FVC (CI, 0.8-3.5; p =0.003) for each 50 ppb increment in mean O3. There were consistent associations of decrements in both FVC (0.4% decline; CI,0.2-0.6, p = 0.001) and PEFR (0.8% decline; CI, 0.01-1.6; p = 0.05) with PM2.5 and of decrements in PEFR (0.4% decline; CI, 0.1-0.7; p = 0.02) with strong aerosol acidity across the interquartile range of these exposures. Hikers with asthma or a history of wheeze (n = 40) had fourfold greater responsiveness to ozone than others. With prolonged outdoor exercise, low-level exposures to O3, PM2.5, and strong aerosol acidity were associated with significant effects on pulmonary function among adults. Hikers with a history of asthma or wheeze had significantly greater air pollution-related changes in pulmonary function.

Fat-gram counting and food-record rating are equally effective for evaluating food records in reduced-fat diets.

OBJECTIVE: To compare rates of adherence to low-fat diets using food-record rating and fat-gram counting, to evaluate dietary adherence using the fat-gram counting method, and to assess correlations between food-record rating and fat-gram counting. DESIGN: A diet monitoring and observation study was conducted to compare the effectiveness of food-record rating and fat-gram counting to evaluate dietary adherence. Subjects were randomly assigned to the food-record rating group of the fat-gram counting group. Each participant was asked to complete four 3-day food records. Food records were evaluated by food-record rating for one group and by fat-gram counting for the other. Each record was then scored using the alternate system. For a subset, manually calculated fat-gram values were compared for accuracy with values from the Nutrient Data Systems database. STATISTICAL ANALYSES PERFORMED: Mantel-Haenszel chi 2, regression, and K analyses were used to evaluate adherence rates and within-subject agreement between fat-gram counting and food-record rating. SUBJECTS/SETTING: Seventy-eight participants were recruited from a lipid-lowering research trial conducted in Houston, Tex. RESULTS: Strong correlations were found between fat-gram values calculated manually and those calculated using the Nutrient Data Systems. No significant differences in adherence rates were found between the food-record rating and fat-gram counting groups. CONCLUSIONS: Fat-gram counting is at least as effective as food-record rating in monitoring dietary fat content. Dietitians can use it as an alternative dietary fat-monitoring procedure for clinical practice and research.

Prognostic value of exercise 201Tl tomography in patients treated with thrombolytic therapy during acute myocardial infarction.

BACKGROUND: Although myocardial perfusion scintigraphy is of proven value in the risk stratification of patients with a recent myocardial infarction who receive conventional therapy, its value in patients undergoing thrombolytic therapy remains controversial. METHODS AND RESULTS: Seventy-one patients who received thrombolytic therapy for acute myocardial infarction had exercise 201Tl tomography and coronary angiography before hospital discharge. Eleven (15%) of 71 patients had ischemic ST-segment depression during exercise, whereas 27 patients (38%) had scintigraphic ischemia. Twenty-five (37%) of 68 patients had a cardiac event consisting of either death (n = 2), recurrent myocardial infarction (n = 5), congestive heart failure (n = 7), or unstable angina (n = 11) during a follow-up of 26 +/- 18 months. Univariate predictors of cardiac events were as follows: Killip class (P = .04); left ventricular ejection fraction (P < .0005); total (P = .002) and ischemic (P < .0005) perfusion defect size; percent thallium lung uptake (P = .001); presence of infarct-zone redistribution (P = .02); and multivessel coronary artery disease (P = .01). By multivariate analysis, the significant joint predictors of risk were ejection fraction (P < .0005) and ischemic perfusion defect size (P = .005). The combination of ejection fraction and thallium tomography added significant incremental prognostic information to the clinical data, whereas angiography did not further improve a model that included clinical, ejection fraction, and tomographic variables. CONCLUSIONS: Quantitative exercise 201Tl tomography provides important incremental, long-term prognostic information in patients receiving thrombolytic therapy for acute myocardial infarction.

Effect of gemfibrozil on levels of lipoprotein[a] in type II hyperlipoproteinemic subjects.

Plasma lipoprotein[a] (Lp[a]) levels are highly correlated with angiographically demonstrable coronary heart disease, and elevated Lp[a] is an independent risk factor for atherosclerosis. Previous studies have provided evidence that the levels of Lp[a] and triglyceride are related, suggesting that Lp[a] might be altered by gemfibrozil, a drug well known for its efficacy in reducing plasma triglycerides. Accordingly, 18 type IIa and 16 type IIb hyperlipoproteinemic males aged 35-58 were treated for 3 months with 600 mg of gemfibrozil twice daily. The efficacy of the drug in altering lipid and lipoprotein levels was different in the two type groups. In type IIa and IIb subjects the respective changes in median levels were: total cholesterol, -7.5 and -8.5% triglycerides, -35.6 and -54.4%; HDL-cholesterol, +9.0 and +11.0%; and Lp[a], -17.2 and +6.1%. Before and after gemfibrozil treatment, 7 type IIa and 10 type IIB subjects were given a 100 g/2 m2 oral-fat load; triglycerides and Lp[a] were measured post-prandially at 0, 2, 4, 6, 8, and 10 h. The differences between before- and after-gemfibrozil post-prandial curve integrated areas (PPCIA) were compared for triglycerides and Lp[a]. The changes in median PPCIA for triglycerides in types IIa and IIB were -54% and -53%, and for Lp[a] were -8% and +8%, respectively. These results indicate i) that the levels of Lp[a] are about 2 times higher in type IIa than IIb subjects, and ii) that although gemfibrozil elicits a rather uniform decrease in fasting and post-prandial triglyceride levels in type IIa and IIb patients, the drug causes heterogeneous changes in Lp[a], suggesting that different metabolic mechanisms may be dominant in subjects showing opposing effects.

Outcome of mechanical ventilation for adults with hematologic malignancy.

BACKGROUND: Patients with hematologic malignancy who develop respiratory failure generally have a very poor prognosis. A few such patients, however, enjoy long-term survival. The objective of this study was to identify clinical characteristics of patients with hematologic malignancy and respiratory failure that are predictive of outcome. METHODS: We performed a retrospective chart review of all patients who required mechanical ventilation for acute respiratory failure while on the leukemia or bone marrow transplantation units at the Johns Hopkins Oncology Center between January 1985 and October 1991 (n = 157). RESULTS: Overall hospital mortality was 83%. Major organ system dysfunction, as measured by the acute physiology score (APS) of the APACHE III prognostic system, was significantly (P < 0.05) related to hospital mortality. Three disease-specific clinical characteristics were predictive of mortality: 1) stage beyond first complete remission, 2) duration of neutropenia greater than 30 days, and 3) treatment with bone marrow transplantation, especially if HLA-mismatched. None of the 15 (10%) patients with neutropenia greater than 30 days or the four patients who underwent HLA-mismatched transplantation survived to discharge. Age was also a significant predictor of hospital mortality. CONCLUSIONS: Overall outcome of patients with hematologic malignancy and acute respiratory failure is poor. A larger prospective study will be required to confirm the relative value of disease-specific variables identified in this study when combined with established predictive variables. In the future, it may be possible to develop a predictive instrument that is specifically tailored for patients with hematologic malignancy who develop respiratory failure.