Prospective risk stratification in renal transplant candidates for cardiac death

In previous studies to predict future cardiac death of patients undergoing evaluation for renal transplantation, noninvasive or invasive testing of all, or nearly all, patients has been used. In an attempt to decrease the cost of cardiac risk assessment, we prospectively used a two-tiered cardiac risk assessment algorithm on 189 consecutive patients referred for renal transplant evaluation. First, patients were stratified by clinical characteristics of age > or = 50 years, history of angina, insulin-dependent diabetes, congestive heart failure, or abnormal electrocardiogram (excluding left ventricular hypertrophy). Patients having none of these risk factors (n = 94) were considered at low risk for cardiac events and underwent no further cardiac evaluation. Patients with one or more of the cardiac risk factors (n = 95) were considered to be in a high-risk group and were required to undergo further evaluation with thallium myocardial scintigraphy. Follow-up of patients was for 46 +/- 16 months. Cardiac mortality was significantly higher in the clinical high-risk group compared with the clinical low-risk group (17% v 1%, respectively; P < 0.001). Further cardiac risk stratification was evident by thallium myocardial scintigraphy. Patients with reversible thallium defects had significantly higher cardiac mortality rates than patients with no thallium defects (23% v 5%, respectively; P < 0.05). Fixed thallium defects also had predictive value for cardiac mortality (29%,; P < 0.05), but deaths in this fixed defect group tended to occur later in the follow-up period. The initial clinical stratification obviated the need for further noninvasive or invasive testing in nearly half of the renal transplant candidates.(ABSTRACT TRUNCATED AT 250 WORDS)

Prevalence of HIV and associated risk behaviour in attendees at a Dublin needle exchange

The aim of this study was to measure the prevalence of HIV infection and assess the level of equipment-sharing and unsafe sexual activity among attendees at a Dublin needle exchange. Using an anonymous unlinked approach, attendees were asked to complete a brief questionnaire and provide a sample of saliva for HIV testing. Of the 144 attendees eligible for inclusion during the study period, 106 agreed to participate and complete a questionnaire, a response rate of 74%. Of the 81 respondents who submitted a usable saliva sample, 14.8% were HIV positive. Half of the respondents claimed that they had not shared equipment during the preceding 28 days, but a third had shared with multiple partners. Half of the respondents claimed that they had multiple sexual partners during the preceding year, but only a quarter said that they always used condoms. The prevalence of HIV infection is similar to that found in routine linked testing of drug users in Ireland. The high level of unsafe injecting and sexual activity makes clear the need for more effective health promotion among drug users in Dublin.

Serve Our Seniors, Inc.--a demonstration program for proposed California menu guidelines for senior nutrition. California Department of Aging

Revised menu guidelines, written by the California Department of Aging (CDA) for senior nutrition programs, were tested by Serve Our Seniors, Inc. in a demonstration program from January '91 through June '92. Results showed improved nutrient value of the meals through increasing fiber, and decreasing sugar and fat. New menus were accepted by senior participants with little resistance. Project food costs increased 4%. Guidelines were used in a variety of project kitchens, with minimal staff training. Limited storage was a problem. Vendors were encouraged to identify appropriate foods and control costs.

Usefulness of Holter monitoring for detecting myocardial ischemia in patients with nondiagnostic exercise treadmill test

To determine if Holter monitoring can predict cardiac risk in patients when the exercise test is nondiagnostic, a total of 90 eligible patients were monitored for 24 hours after their exercise test without alterations in baseline medications. Prospective follow-up was obtained and events were confirmed by investigators unaware of subjects' clinical data. Nineteen patients (21%) had a total of 71 episodes of ST depression, all of which were asymptomatic. During a mean follow-up of 719 days, there were 10 patients with adverse events: 3 with cardiac deaths, 3 with nonfatal myocardial infarctions, and 4 with admissions for unstable angina. Of the 10 adverse events, 9 occurred in the group of 19 with ST depression detected by Holter (relative risk 34, 95% confidence interval 10 to 114). The sensitivity of ST depression was 90%, the specificity 88%, the predictive positive value 47%, and the predictive negative value 99%. In a multivariate Cox proportional-hazards model that controlled for prior history of coronary artery disease, hypercholesterolemia, and all exercise test variables, the presence of ST depression detected by Holter was the only independent predictor of outcome. In patients with nondiagnostic exercise tests, ST depression detected by Holter monitoring identified those with an increased risk of adverse cardiac events. The absence of ST depression detected by Holter was a useful predictor of low risk.

Changing vasomotor responses of coronary arteries to nifedipine

Coronary vasomotion is influenced by a variety of factors, including atherosclerosis and diurnal variations in alpha-adrenergic tone. The effect of such factors on the coronary response to vasodilator drugs is unknown. To determine whether there is a diurnal variation to the response of coronary arteries to nifedipine, and whether this response is altered by atherosclerosis, we studied 11 patients with smooth coronary arteries, six in the morning and five in the afternoon, and 12 patients with irregular coronary arteries, six in the morning and six in the afternoon. Changes in coronary blood flow and the vasomotor response of an epicardial coronary artery were measured before and after a 2 mg intracoronary infusion of nifedipine. There were no appreciable differences in epicardial vessel dilator response or coronary blood flow in the morning and afternoon among patients with smooth coronary arteries. By contrast, patients with irregular coronary arteries had a significantly diminished dilator response in the afternoon, without an appreciable change in coronary blood flow. We postulate that normal coronary arteries maintain basal tone throughout the day. By contrast, atherosclerotic coronary arteries cannot do the same, increasing tone in the morning in response to catecholamines. When catecholamine levels drop in the afternoon, basal tone decreases in atherosclerotic vessels, and the dilator response to nifedipine is blunted. This observation may have an important impact on the expected benefits and timing of vasodilator therapy in patients with coronary artery disease.

Alcohol use in post-primary school children

The prevalence of alcohol use of Irish post-primary schoolchildren has been reported on numerous occasions over the past five years. A study of drinking patterns in 294 schoolchildren aged 14 to 17 from single sex and mixed sex schools is presented. The age at first drink for boys was 11.7 years, and for girls 12.3 years. Eighty percent of boys had ever drank compared to 66% of girls. 59% of boys were regular drinkers compared to 54% of girls. Both these parameters were equal for boys from single sex and mixed schools but girls from mixed sex schools had a higher prevalence of drinking than girls from single sex schools. Beer was by far the favourite drink of boys whereas wine was the favourite drink of girls. Girls were more likely to drink at home than boys. The results of the present study will be compared with other recent prevalence studies of teenage alcohol use in Ireland. Many findings are similar but the separate analysis of single and mixed sex schools is new.

Facing the powers that be

Lobbyists, entrenched forces in congress and self-interested friends will try to stymie Clinton's efforts. A look at four key arenas of combat.

"Avoidable mortality" as an index of health care outcome: results from the European Community Atlas of "Avoidable Death"

The history of the European Community Atlas of "Avoidable Death" is given. Data from the second Atlas are presented. For all causes of death except asthma there was a decrease in mortality in the period 1980-1984 with respect to 1974-1978. Taking the EC as a whole as the standard (100) population the standardised mortality ratio (SMR) in Ireland in the period 1980-1984 for tuberculosis was 160, for asthma 180 and maternal mortality 58. Ireland had the highest mortality for tuberculosis in both time periods. Asthma mortality increased in all countries except Scotland between 1974-1978 and 1980-1984. Ireland had one of the highest declines in maternal mortality over the two time periods. Within Ireland tuberculosis mortality was highest in the Mid-Western Health Board and lowest in the North-Western Health Board. Asthma mortality was highest in the Western Health Board and lowest in the Mid-Western Health Board. Maternal mortality was highest in the Midland Health board and lowest in the Southern Health Board.

Detection and significance of intraoperative and postoperative myocardial ischemia in peripheral vascular surgery

OBJECTIVE

To determine the incidence and significance of intraoperative and postoperative myocardial ischemia and their relationship to preoperative ischemia and postoperative cardiac events in patients undergoing peripheral arterial surgery.

DESIGN

Prospective cohort trial.

PATIENTS

One hundred fifteen patients undergoing elective vascular surgery who met predefined eligibility criteria and were thought to have acceptable cardiac risk as assessed by independent cardiologists.

INTERVENTIONS

Ambulatory electrocardiographic monitoring preoperatively, intraoperatively, and up to 72 hours postoperatively.

MEASUREMENTS

Preoperative clinical characteristics and laboratory data were collected. Predefined adverse cardiac events were identified by an investigator who was "blinded" to monitoring results. Monitor recordings were interpreted for ST-segment depression by investigators blinded to patient information.

MAIN RESULTS

Intraoperative ischemia was present in 21 patients (18%), and postoperative ischemia was present in 35 (30%). There were 16 postoperative cardiac events. The relative risk of suffering a cardiac event was 2.7 in patients with intraoperative ischemia and was 16 in patients with postoperative ischemia. Preoperative ischemia closely correlated with intraoperative and postoperative ischemia. Preoperative and postoperative ischemia preceded cardiac events in 14 of 16 patients.

CONCLUSIONS

Preoperative ischemia appears to identify high-risk patients, and subsequent perioperative monitoring detects silent ischemia that commonly precedes clinical events and that may be treatable with anti-ischemia therapy.

Words and actions: a study in nurse wastage

This paper examines whether a group of nurses' stated intentions to leave were subsequently transformed into actual leaving actions. We argue that establishing the truth of relationships between words and actions is of fundamental importance in social science research. Nurses broadly did what they said they would do. Hence, definite intentions to leave were generally acted upon while less strong leaving intentions were not acted upon to any practically significant degree. We further investigate the link between the nurses' words and actions by reporting on a small interview study where nurses were asked why they did or did not do as they stated. The importance of these findings in terms of health authorities planning their labour force is discussed.

Laboring to manage care

What happened at AT&T is an example of the possibilities when labor and management cooperate. Both sides contributed their input, and the result was a health care plan that was acceptable to everyone involved.

Nursing: just a job? Do statistics tell us what we think?

This study considers the value of classifying attitudinal statements given by nurses in a questionnaire by the statistical procedure of latent class analysis. It demonstrates with the use of qualitative data derived from in-depth interviews how precarious are the groups derived from statistical analysis. However, it is argued that the apparent discrepancies between responses 'objectively' derived by a statistical approach and those 'subjectively' declared by respondents may focus on different levels of meaning and may well provide a useful resource. Most importantly, it is stressed that a dynamic model is needed which recognizes change and the consequences of change.