RESUMO
Background: Daytime sleepiness is common in older adults and may result from poor nighttime sleep due to sleep disordered breathing, fragmented sleep, or other sleep disorders. Daytime sleepiness may be associated with cognition in older adults. Objectives: We investigated the association between self-reported daytime sleepiness and cognitive function in the Look AHEAD clinical trial. Design: Observational follow-up of a randomized clinical trial of an intensive lifestyle intervention. Setting: Clinic. Participants: Participants (n=1,778) aged 45-76 years at baseline with type 2 diabetes and overweight or obesity. Interventions: Participants were randomized to an intensive lifestyle intervention for weight loss or a control condition of diabetes support and education. Measurements: Participants provided self-reported levels of daytime sleepiness at baseline and years 12-13. Cognitive function was assessed with a neurocognitive battery at years 12-13 and 18-20. Results: Participants who reported having frequent daytime sleepiness (often or always) performed significantly worse than others on the cognitive composite (-0.35; p-value=0.014) after controlling for covariates. When stratified by intervention arm, participants assigned to the intensive lifestyle intervention who reported often/always having daytime sleepiness performed worse on Digit Symbol Coding (-0.63; p-value=0.05) and Trail Making Part-B (-0.56; p-value=0.02) after controlling for covariates. Statistical interactions revealed associations between daytime sleepiness and the following covariates: race and ethnicity, APOE ε4 carrier status, baseline history of cardiovascular disease, and depression. Conclusions: Daytime sleepiness over ~13 years predicted poorer cognitive performance in older individuals who, by virtue of having diabetes and overweight/obesity, are at high risk for sleep disorders and cognitive impairment.
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Hemoglobin (Hb) levels and mean corpuscular volume (MCV) are abnormal in some persons with hemochromatosis or thyroid disorders. We sought to determine whether serum free thyroxine (T4) affects erythrocyte measures in euthyroid adults with or without C282Y homozygosity. We evaluated 488 white HFE C282Y homozygotes and controls (no HFE C282Y or H63D; normal serum iron measures) identified in screening; we excluded those with thyroid disorders, anemia, erythrocytosis, or serum ferritin (SF) <34 pmol/l. In the remaining 141 C282Y homozygotes and 243 controls, we evaluated correlations of log(10) free T4 with Hb, RBC, MCV, and red blood cell distribution width (RDW). C282Y homozygotes had lower mean age, higher mean Hb, MCV, and log(10) SF, and lower mean RBC and RDW than controls; mean log(10) free T4 did not differ significantly. In HFE C282Y homozygotes, there was no significant correlation of log(10) T4 with erythrocyte measures. In controls, there was a positive correlation of log(10) T4 with Hb (P = 0.0096) and a negative correlation with RDW (P = 0.0286). Among euthyroid white adults without iron deficiency, there are significant correlations of log(10) free T4 with Hb and RDW in controls, but not in HFE C282Y homozygotes.
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Contagem de Eritrócitos , Hemocromatose , Antígenos de Histocompatibilidade Classe I/genética , Homozigoto , Sobrecarga de Ferro , Proteínas de Membrana/genética , Tiroxina/sangue , População Branca/etnologia , Adulto , Tamanho Celular , Feminino , Genótipo , Hemocromatose/genética , Hemocromatose/metabolismo , Proteína da Hemocromatose , Humanos , Sobrecarga de Ferro/genética , Sobrecarga de Ferro/metabolismo , Masculino , Pessoa de Meia-Idade , Padrões de Referência , População Branca/genéticaRESUMO
Hemochromatosis has often been associated with progressive iron overload, but the natural history of iron accumulation in untreated C282Y homozygotes has been reported infrequently. The Hemochromatosis and Iron Overload Screening (HEIRS) Study screened 101 168 primary care participants for iron overload using transferrin saturation, unbound iron-binding capacity, Serum ferritin (SF), and HFE C282Y and H63D genotyping. SF was measured at initial screening (IS) and again when selected participants returned for a clinical examination (CE). The change in SF over the observation period (defined as ferritin rate of change) was analyzed according to age, gender, initial SF, initial SF/age, transferrin saturation, and iron removed by phlebotomy in C282Y homozygotes. Seventy-four male and 133 female untreated C282Y homozygotes were observed over a median of 112 days (34-924 days) between IS and CE. In men, SF increased in 54% and decreased in 46%. In women, SF increased in 50% and decreased in 50%. The significant variables affecting the SF rate were initial log SF (P = 0.0027) and transferrin saturation (P < 0.0001). Male C282Y homozygotes with higher SF rates (n = 27, upper 50th percentile) had significantly greater iron removed by phlebotomy (mean 4.93 g, range 1.0-17 g) than those with lower SF rates (n = 26, lower 50th percentile) (mean 2.6 g, 0.42-7.1, P < 0.05). SF was as likely to decrease as increase in untreated C282Y homozygotes over this relatively brief observation period. Incremental increases in SF are not inevitable in untreated C282Y homozygotes.
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Ferritinas/sangue , Hemocromatose/sangue , Hemocromatose/genética , Antígenos de Histocompatibilidade Classe I/genética , Proteínas de Membrana/genética , Polimorfismo de Nucleotídeo Único/genética , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Proteína da Hemocromatose , Homozigoto , Humanos , Ferro/metabolismo , Masculino , Pessoa de Meia-IdadeRESUMO
We compared initial screening transferrin saturation (TfSat) and serum ferritin (SF) phenotypes and HFE C282Y and H63D genotypes of 645 Native American and 43,453 white Hemochromatosis and Iron Overload Screening Study participants who did not report a previous diagnosis of hemochromatosis or iron overload. Elevated measurements were defined as TfSat >50% in men and >45% in women and SF >300 ng/ml in men and >200 ng/ml in women. Mean TfSat was 31% in Native American men and 32% in white men (p = 0.0337) and 25% in Native American women and 27% in white women (p < 0.0001). Mean SF was 153 microg/l in Native American and 151 microg/l in white men (p = 0.8256); mean SF was 55 microg/l in Native American women and 63 microg/l in white women (p = 0.0015). The C282Y allele frequency was 0.0340 in Native Americans and 0.0683 in whites (p < 0.0001). The H63D allele frequency was 0.1150 in Native Americans and 0.1532 in whites (p = 0.0001). We conclude that the screening TfSat and SF phenotypes of Native Americans are similar to those of whites. The allele frequencies of HFE C282Y and H63D are significantly lower in Native Americans than in whites.
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Ferritinas/metabolismo , Hemocromatose/genética , Antígenos de Histocompatibilidade Classe I/genética , Indígenas Norte-Americanos/genética , Sobrecarga de Ferro/genética , Proteínas de Membrana/genética , Transferrina/metabolismo , População Branca/genética , Adulto , Idoso , Feminino , Ferritinas/genética , Frequência do Gene , Genótipo , Hemocromatose/diagnóstico , Hemocromatose/metabolismo , Proteína da Hemocromatose , Humanos , Sobrecarga de Ferro/sangue , Sobrecarga de Ferro/diagnóstico , Masculino , Pessoa de Meia-Idade , Fenótipo , Transferrina/genéticaRESUMO
OBJECTIVE: To examine the effect of short-term improvements in glycaemic control on brachial artery endothelial function as a marker of cardiovascular health. METHODS: Persons with Type 2 diabetes who were poorly controlled on oral therapy were randomly assigned to monotherapy with repaglinide or combination therapy with repaglinide plus metformin. Brachial artery flow-mediated vasodilation was assessed by ultrasonography at randomization and following 16 weeks of therapy. The primary outcome was change in brachial artery endothelial function from baseline. Comparison of randomized groups was a secondary aim. RESULTS: Eighty-six participants were randomized, and 83 were followed to study completion. Post occlusion brachial artery vasodilation was 3.74% at baseline and 3.82% following 16 weeks of therapy (P = 0.77). The treatment effect was 0.08% (95% CI: -0.48%, 0.64%). No difference was seen between treatment groups (P = 0.69). Overall, A1C was reduced from 8.3% to 7.0%, with a greater reduction in the combination therapy group (from 8.4% to 6.7%) than in the monotherapy group (from 8.3% to 7.3%, p for difference between groups = 0.01). Statistically significant reductions were observed in fasting glucose, and plasminogen activator inhibitor-1. Statistically significant increases were observed for fasting insulin, uric acid, weight and BMI. CONCLUSIONS: Brachial artery endothelial function was not influenced by short-term improvements in glycaemic control. The CONTROL DM group was successful in lowering A1C. Future research should explore more intensive and longer-lasting improvements in glycaemic control on endothelial function. Some data previously published in abstract form (Diabetes 2001; 50 (Suppl. 2): A217).
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Carbamatos/administração & dosagem , Diabetes Mellitus Tipo 2/tratamento farmacológico , Hipoglicemiantes/administração & dosagem , Metformina/administração & dosagem , Piperidinas/administração & dosagem , Administração Oral , Adulto , Idoso , Artéria Braquial/efeitos dos fármacos , Terapia Combinada/métodos , Diabetes Mellitus Tipo 2/dietoterapia , Quimioterapia Combinada , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Vasodilatação/efeitos dos fármacosRESUMO
AIM: Previous clinical studies suggest hormone replacement therapy (HRT) alleviates menopausal symptoms and may improve health-related quality of life (HRQL). Most studies on HRT and HRQL were limited in duration (12 months or less) and scope (few and non-standard HRQL measures). The aim of this paper is to assess HRQL in the Estrogen Replacement and Atherosclerosis (ERA) trial. METHODS: A subset of women within a randomized, blinded, placebo-controlled secondary prevention trial has been studied in outpatient and community settings at 5 US sites. A total of 246 postmenopausal women with angiographically documented heart disease (mean age 66 years, 83% Caucasian) were enrolled in the ERA trial. Participants received either 0.625 mg/day conjugated equine estrogen only, estrogen plus 2.5 mg/day medroxyprogesterone acetate, or placebo. HRQL was assessed using validated questionnaire instruments at baseline and follow-up (mean 3.2 years of trial). Physical and mental functioning, life satisfaction, depressive symptoms, urinary incontinence, sleep disturbance, and frequency and intensity of physical symptoms were evaluated. RESULTS: In this group of women with established coronary disease, active therapy was not significantly associated with more favorable outcomes for any HRQL. The estrogen-only group reported more urinary incontinence than the placebo group (p<0.05). Analyses restricted to adherent women (those who took > or = 80% of pills) showed a similar pattern of results, showing that the estrogen only group reported significantly higher urinary incontinence compared to placebo (p<0.01). CONCLUSION: The hormone replacement regimens in the ERA trial did not improve HRQL of postmenopausal women with heart disease.
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Terapia de Reposição de Estrogênios/psicologia , Qualidade de Vida/psicologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Método Duplo-Cego , Feminino , Humanos , Pessoa de Meia-Idade , Inquéritos e QuestionáriosRESUMO
Dietary recalls and urine assays provide different metrics for assessing sodium and potassium intakes. Means, variances, and correlations of data obtained from these two modes of measurement differ. Pooling of these data is not straightforward, and results from studies employing the different modes may not be comparable. To explore differences between these metrics, the authors used data from the Trial of Nonpharmacologic Intervention in the Elderly (TONE), which included repeated standardized 24-hour dietary recalls and 24-hour urine collections administered over 3 years of follow-up, to estimate sodium and potassium intakes. The authors examined data from 341 control participants assigned to usual care that were collected between August 1992 and December 1995. Dietary recalls yielded estimates of sodium intake that averaged 22% less than those from urine assays and estimates of potassium intake that averaged 16% greater than those from urine assays. Sodium intake estimates were less repeatable (r = 0.22 for diet; r = 0.30 for urine) than potassium intake estimates (r = 0.49 for diet; r = 0.50 for urine), making relations with outcomes more difficult to characterize. Overall, the performance of the two measurement modes was fairly similar across demographic subgroups. Errors in separate estimations of long term sodium and potassium intakes using short term data were strongly correlated, more strongly than the underlying long term intakes of these electrolytes. Because of the correlated measurement error, estimated regression coefficients for linear models including both electrolytes as predictors may be confounded such that the separate relations between these nutrients and outcomes such as blood pressure cannot be reliably estimated by common analytical strategies.
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Memória , Potássio na Dieta , Sódio na Dieta , Idoso , Fatores de Confusão Epidemiológicos , Estudos Epidemiológicos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Teóricos , Estado Nutricional , Potássio/urina , Reprodutibilidade dos Testes , Sódio/urina , Inquéritos e Questionários , UrináliseRESUMO
OBJECTIVE: To examine the relationship between cognitive variables and time until suicide attempts among 180 adolescents who were monitored for as much as 6.9 years after discharge from an inpatient psychiatry unit. METHOD: In a prospective naturalistic study, adolescents were assessed at the time of their psychiatric hospitalization and semiannually thereafter. Suicidal behavior at index hospitalization and over the follow-up period was assessed with semistructured psychiatric diagnostic interviews. At hospitalization, cognitive risk factors were assessed with a problem-solving task and with questionnaires assessing hopelessness, expectations for posthospitalization suicidal behavior, reasons for living, and dysfunctional attitudes. RESULTS: Expectations about future suicidal behavior were related to posthospitalization suicide attempts. Among youths with previous suicide attempts, higher levels of hopelessness were associated with increased risk, and greater survival and coping beliefs were associated with decreased risk for posthospitalization suicide attempts. Hopelessness and survival and coping beliefs were not related to posthospitalization attempts among adolescents without prior suicidal behavior, and hopelessness was not predictive after controlling for overall severity of depression. CONCLUSIONS: Expectations for suicidal behavior, hopelessness, and survival and coping beliefs provide important prognostic information about later suicidal behavior and should be targeted in interventions with suicidal youths.
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Cognição , Resolução de Problemas , Tentativa de Suicídio/psicologia , Adolescente , Adulto , Afeto , Criança , Feminino , Hospitalização , Humanos , Masculino , Alta do Paciente , Estudos Prospectivos , Fatores de RiscoRESUMO
This paper documents recruitment for the Estrogen Replacement and Atherosclerosis trial, a multicenter, placebo-controlled, double-blind angiographic trial of the effects of opposed and unopposed estrogen on coronary atherosclerosis in postmenopausal women (average scheduled duration of follow-up 3.2 years). We compare costs, yields, and participant characteristics between community-based and hospital-based recruitment strategies. We further compare community-based enriched sources (i.e., those that allowed self-selection or targeted women with known health characteristics) and nonenriched sources. Data gathered on potential participants include method of contact, clinical site, eligibility, completion of screening visits, and randomization rates. Demographic data on participants include age, race, education, marital status, and income. Self-reported health status, smoking status, lipid level, ejection fraction as well as history of chest pain, hypertension, and diabetes were recorded at baseline. Recruitment costs were estimated from employee salaries and costs of screening tests and procedures. Yields were compared by clinical site and by method of contact. Enriched sources of recruitment yielded higher percentages of enrolled participants than nonenriched sources. Both types of source resulted in demographically similar participants. Costs of community-based recruitment were less than hospital-based recruitment; however, screening costs were higher. Overall, screening and recruitment averaged $2508 per randomized participant. Control Clin Trials 2001;22:13-25
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Doença da Artéria Coronariana/prevenção & controle , Terapia de Reposição de Estrogênios/estatística & dados numéricos , Seleção de Pacientes , Meio Social , Idoso , Angiografia Coronária/economia , Angiografia Coronária/estatística & dados numéricos , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/economia , Doença da Artéria Coronariana/epidemiologia , Custos e Análise de Custo , Método Duplo-Cego , Terapia de Reposição de Estrogênios/economia , Estrogênios Conjugados (USP)/administração & dosagem , Estrogênios Conjugados (USP)/efeitos adversos , Feminino , Humanos , Programas de Rastreamento/economia , Programas de Rastreamento/estatística & dados numéricos , Acetato de Medroxiprogesterona/administração & dosagem , Acetato de Medroxiprogesterona/efeitos adversos , Pessoa de Meia-IdadeRESUMO
PURPOSE: To characterize the distribution of errors in self-reported sodium and potassium dietary intakes relative to more objective urine measures among participants receiving lifestyle interventions. METHODS: We analyzed longitudinal data from 900 individuals with hypertension who had been enrolled in a randomized controlled clinical trial to establish whether usual care or three lifestyle interventions (weight loss, sodium reduction, and combined weight loss and sodium reduction) could effectively substitute for phamacotherapy. Repeated standardized 24-hour diet recalls and 24-hour urine collections were collected over up to three years of follow-up to estimate sodium and potassium intakes. By contrasting self-reported and urine-based sodium and potassium data collected before and during interventions, we examined the relative impact of intervention assignment on estimated intakes, repeatability, and multivariate measurement error. RESULTS: Relative to urine-based measures, mean self-reported sodium intakes were biased about 10% lower among participants assigned to combined weight loss and sodium reduction, but were unaffected by the other interventions. The repeatability of self-report measures increased slightly with time, particularly among participants assigned to sodium interventions. Errors in self-reported sodium and potassium intakes were correlated before the start of the intervention, but became uncorrelated among individuals assigned to sodium restriction interventions. CONCLUSIONS: Lifestyle interventions may influence not only diet intake, but also the measurement of diet intake.
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Hipertensão/terapia , Estilo de Vida , Estado Nutricional , Potássio na Dieta/administração & dosagem , Sódio na Dieta/administração & dosagem , Idoso , Viés , Pressão Sanguínea , Feminino , Humanos , Hipertensão/urina , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Potássio/urina , Autorrevelação , Sódio/urina , Redução de PesoRESUMO
BACKGROUND: Heart disease is a major cause of illness and death in women. To understand better the role of estrogen in the treatment and prevention of heart disease, more information is needed about its effects on coronary atherosclerosis and the extent to which concomitant progestin therapy may modify these effects. METHODS: We randomly assigned a total of 309 women with angiographically verified coronary disease to receive 0.625 mg of conjugated estrogen per day, 0.625 mg of conjugated estrogen plus 2.5 mg of medroxyprogesterone acetate per day, or placebo. The women were followed for a mean (+/-SD) of 3.2+/-0.6 years. Base-line and follow-up coronary angiograms were analyzed by quantitative coronary angiography. RESULTS: Estrogen and estrogen plus medroxyprogesterone acetate produced significant reductions in low-density lipoprotein cholesterol levels (9.4 percent and 16.5 percent, respectively) and significant increases in high-density lipoprotein cholesterol levels (18.8 percent and 14.2 percent, respectively); however, neither treatment altered the progression of coronary atherosclerosis. After adjustment for measurements at base line, the mean (+/-SE) minimal coronary-artery diameters at follow-up were 1.87+/-0.02 mm, 1.84+/-0.02 mm, and 1.87+/-0.02 mm in women assigned to estrogen, estrogen plus medroxyprogesterone acetate, and placebo, respectively. The differences between the values for the two active-treatment groups and the value for the placebo group were not significant. Analyses of several secondary angiographic outcomes and subgroups of women produced similar results. The rates of clinical cardiovascular events were also similar among the treatment groups. CONCLUSIONS: Neither estrogen alone nor estrogen plus medroxyprogesterone acetate affected the progression of coronary atherosclerosis in women with established disease. These results suggest that such women should not use estrogen replacement with an expectation of cardiovascular benefit.
Assuntos
Doença das Coronárias/tratamento farmacológico , Terapia de Reposição de Estrogênios , Estrogênios Conjugados (USP)/uso terapêutico , Acetato de Medroxiprogesterona/uso terapêutico , Adulto , Idoso , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/mortalidade , Colesterol/sangue , Angiografia Coronária , Doença das Coronárias/mortalidade , Doença das Coronárias/fisiopatologia , Progressão da Doença , Método Duplo-Cego , Quimioterapia Combinada , Terapia de Reposição de Estrogênios/efeitos adversos , Estrogênios Conjugados (USP)/efeitos adversos , Estrogênios Conjugados (USP)/farmacologia , Feminino , Terapia de Reposição Hormonal/efeitos adversos , Humanos , Acetato de Medroxiprogesterona/farmacologia , Pessoa de Meia-Idade , Pós-Menopausa , Triglicerídeos/sangueRESUMO
BACKGROUND: The antidepressant and cognitive side effects of right unilateral (RUL) electroconvulsive therapy (ECT) are reported to depend on the magnitude of the electrical stimulus relative to the seizure threshold. The stimulus doses explored in previous clinical trials of RUL ECT have generally been limited to 1 to 2.5 times the convulsive threshold and the antidepressant efficacy has been low compared with bilateral (BL) ECT. The present study compares the antidepressant and cognitive side effects of 2 RUL dosing strategies: titrated moderately suprathreshold and fixed high dose. METHODS: Seventy-two adult patients with major depression were randomized to either titrated RUL ECT at 2.25 times initial seizure threshold (mean dose, 136 millicoulombes [mC]), or RUL ECT at a fixed dose of 403 mC. Primary outcome measures were antidepressant response and cognitive status 1 or 2 days after the course of ECT. RESULTS: The 2 treatment groups were comparable in demographic and clinical characteristics prior to ECT. Both groups received a mean of 5.7 sessions of RUL ECT. Patients receiving fixed-dose ECT were more likely to have an antidepressant response at the end of the protocol (n = 49 [67%]) compared with those receiving titrated dosing (n = 28 [39%]). Furthermore, the likelihood of both antidepressant response and cognitive deficits increased as stimulus dose increased relative to initial seizure threshold, up through 8 to 12 times the threshold. CONCLUSIONS: The antidepressant efficacy and cognitive side effects of RUL ECT are dependent on the magnitude of the stimulus dose relative to the seizure threshold, and a dose-response relationship extends through at least 12 times the seizure threshold.
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Transtornos Cognitivos/epidemiologia , Transtorno Depressivo/terapia , Eletroconvulsoterapia/métodos , Adulto , Transtornos Cognitivos/diagnóstico , Transtornos Cognitivos/etiologia , Transtorno Depressivo/diagnóstico , Eletroconvulsoterapia/efeitos adversos , Eletroconvulsoterapia/estatística & dados numéricos , Feminino , Lateralidade Funcional/fisiologia , Humanos , Masculino , Transtornos da Memória/diagnóstico , Transtornos da Memória/epidemiologia , Transtornos da Memória/etiologia , Pessoa de Meia-Idade , Análise de Regressão , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
We describe an interactive Fortran program which performs computations related to the design and analysis of group sequential clinical trials using Lan-DeMets spending functions. Many clinical trials include interim analyses of accumulating data and rely on group sequential methods to avoid consequent inflation of the type I error rate. The computations are appropriate for interim test statistics whose distribution or limiting distribution is multivariate normal with independent increments. Recent theoretical results indicate that virtually any design likely to be used in a clinical trial will fall into this category. Interim analyses need not be equally spaced, and their number need not be specified in advance. In addition to determining sequential boundaries using an alpha spending function, the program can perform power computations, compute probabilities associated with a given set of boundaries, and generate confidence intervals.
Assuntos
Ensaios Clínicos como Assunto/economia , Interpretação Estatística de Dados , Modelos Estatísticos , SoftwareRESUMO
The Estrogen Replacement and Atherosclerosis (ERA) trial is a three-arm, randomized, placebo-controlled, double-blind trial to evaluate the effects of estrogen replacement therapy (0.625 mg/day oral conjugated estrogen) with or without continuous low-dose progestin (2.5 mg oral medroxyprogesterone acetate/day) versus placebo on progression of atherosclerosis. A total of 309 postmenopausal women at five sites underwent baseline coronary angiography and were randomized. Participants will have repeat coronary angiography after an average of 3.25 years of treatment. The primary outcome of interest will be change in minimum diameter of the major epicardial segments, as assessed by quantitative coronary angiography. The primary aim is to test the hypothesis that either form of hormone therapy will slow the progression or induce regression of coronary atherosclerosis compared to placebo. The secondary aims are to assess the effects of the two treatments versus placebo on endothelial function (measured using flow-mediated vasodilator responses), on several presumed mediators of estrogen's effect on atherosclerosis (i.e., plasma lipids and lipoproteins, blood pressure, glucose metabolism, hemostatic factors, and antioxidant activity), on other factors that influence the development of coronary heart disease (i.e., diet, smoking status, exercise, weight, and health-related quality of life issues), and on clinical cardiovascular events. The ERA trial is the first angiographic endpoint clinical trial to examine the effects of postmenopausal hormone replacement on coronary atherosclerosis in women. It will provide an unparalleled opportunity to determine if either regimen of hormone therapy is effective in slowing the progress of angiographically defined coronary atherosclerosis. This study will complement other estrogen replacement trials, such as the PEPI, HERS, and Women's Health Initiative studies, to provide a more comprehensive examination of the effects of estrogen replacement on cardiovascular risk factors, anatomic and functional manifestations of atherosclerosis, and risk for coronary heart disease in postmenopausal women. Control Clin Trials 2000;21:257-285
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Arteriosclerose/diagnóstico , Terapia de Reposição de Estrogênios , Estrogênios/uso terapêutico , Medroxiprogesterona/uso terapêutico , Congêneres da Progesterona/uso terapêutico , Projetos de Pesquisa , Idoso , Angiografia Coronária , Método Duplo-Cego , Quimioterapia Combinada , Exercício Físico , Feminino , Seguimentos , Humanos , Lipídeos/sangue , Pessoa de Meia-Idade , Pós-Menopausa , Qualidade de Vida , Fumar , Resultado do TratamentoRESUMO
BACKGROUND AND PURPOSE: Echo-planar diffusion-weighted and fluid-attenuated inversion-recovery (FLAIR) imaging have both proved valuable for detecting acute ischemic infarcts, but little is known about the value of diffusion-weighted imaging beyond the acute infarct period. Furthermore, no direct comparison of the techniques has been published. We compared the diagnostic utility of diffusion-weighted, FLAIR, and T2-weighted fast spin-echo (FSE) imaging for detecting cerebral infarctions up to 10 days old. METHODS: FSE, FLAIR, and diffusion-weighted MR sequences were obtained prospectively over a 6-month period in 212 patients with suspected cerebral infarctions. Seventy patients with nonhemorrhagic ischemic infarcts less than 10 days old whose symptoms lasted longer than 48 hours were identified. The three sequences were compared for detectability and conspicuity of abnormalities that correlated with the neurologic deficit. RESULTS: Seventy-two symptomatic infarcts were found in the 70 patients. Diffusion-weighted imaging detected 70 (97%), FLAIR, 69 (96%), and FSE, 64 (89%) of the 72 lesions. Only the difference between diffusion-weighted and FSE imaging approached statistical significance. There was no difference in the number of lesions detected in the patients imaged 48 hours or more after infarction. Lesion conspicuity on diffusion-weighted images was judged superior to that on FSE and FLAIR images in 55 (77%) and 47 (67%) of the cases, respectively. FLAIR images were judged superior to FSE in 34 (48%) of the cases. CONCLUSION: Diffusion-weighted images showed more infarcts than FLAIR and FSE images, and FLAIR images showed more than FSE images, but the differences were not statistically significant. Lesion conspicuity, however, was consistently better on diffusion-weighted images than on either FLAIR or FSE images throughout the 10-day period. Acquisition of diffusion-weighted images in the late acute and subacute periods after ischemic cerebral infarction appears to be beneficial.
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Infarto Cerebral/diagnóstico , Imagem Ecoplanar , Aumento da Imagem , Processamento de Imagem Assistida por Computador , Imageamento por Ressonância Magnética , Doença Aguda , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Sensibilidade e EspecificidadeRESUMO
BACKGROUND: Little is known about how the health-related quality of life (HRQL) associated with psoriasis compares with that of other patient populations. OBJECTIVE: We describe HRQL associated with psoriasis and compare it with HRQL of patients with other major chronic health conditions. A second aim is to identify which specific aspects of psoriasis contribute most to HRQL. METHODS: A total of 317 patients completed a non-disease-specific measure of HRQL. Responses were compared with those of patients with 10 other chronic health conditions. HRQL was regressed on ratings of 18 aspects of psoriasis. RESULTS: Patients with psoriasis reported reduction in physical functioning and mental functioning comparable to that seen in cancer, arthritis, hypertension, heart disease, diabetes, and depression. Six aspects of psoriasis predicted physical functioning, and 5 different disease aspects predicted mental functioning. CONCLUSION: The impact of psoriasis on HRQL is similar to that of other major medical diseases. Different aspects of psoriasis are related to the different dimensions of HRQL supporting the need for multidimensional treatment models.
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Pessoas com Deficiência , Psoríase/complicações , Adulto , California/epidemiologia , Doença Crônica , Comorbidade , Pessoas com Deficiência/psicologia , Pessoas com Deficiência/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , North Carolina/epidemiologia , Prognóstico , Psoríase/epidemiologia , Psoríase/psicologia , Qualidade de Vida , Índice de Gravidade de Doença , Inquéritos e QuestionáriosRESUMO
OBJECTIVE: To examine risk for suicide attempts among 180 consecutively referred adolescents during the first 5 years after discharge from an inpatient psychiatry unit. METHOD: In a prospective naturalistic study, adolescents were assessed at psychiatric hospitalization and semiannually thereafter for up to 5 years with semistructured psychiatric diagnostic interviews and self-report questionnaires. RESULTS: Approximately 25% of the adolescents attempted suicide and no adolescents completed suicide within the first 5 years after discharge. The first 6 months to 1 year after discharge represented the period of highest risk. The number of prior attempts was the strongest predictor of posthospitalization attempts. Affective disorders by themselves did not predict later suicide attempts but were related to posthospitalization attempts when accompanied by a history of past suicide attempts. Independent of psychiatric diagnoses, severity of depressive symptoms and trait anxiety also predicted suicide attempts. Similar to the effect with affective disorders, depressive symptoms were most strongly related to posthospitalization suicidality among adolescents with a prior history of suicide attempts. CONCLUSIONS: Particularly among youths with prior suicidal behavior, clinicians should be alert to the above constellation of psychiatric predictors of posthospitalization suicidal behavior.
Assuntos
Comportamento do Adolescente , Hospitalização/estatística & dados numéricos , Tentativa de Suicídio/estatística & dados numéricos , Adolescente , Feminino , Seguimentos , Previsões , Humanos , Masculino , North Carolina/epidemiologia , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Estatística como Assunto , Virginia/epidemiologiaRESUMO
This paper proposes a two-part model for studying transitions between health states over time when multiple, discrete health indicators are available. The includes a measurement model positing underlying latent health states and a transition model between latent health states over time. Full maximum likelihood estimation procedures are computationally complex in this latent variable framework, making only a limited class of models feasible and estimation of standard errors problematic. For this reason, an estimating equations analogue of the pseudo-likelihood method for the parameters of interest, namely the transition model parameters, is considered. The finite sample properties of the proposed procedure are investigated through a simulation study and the importance of choosing strong indicators of the latent variable is demonstrated. The applicability of the methodology is illustrated with health survey data measuring disability in the elderly from the Longitudinal Study of Aging.