Division Of Internal Medicine Research Articles

Clinical inertia: errors of omission in drug therapy.

P harmacists are trained to be vigilant about identifying and correcting medication-related problems, including prescription errors, contraindications, and drug interactions, as well as managing adverse drug reactions. However, certain prescribing problems, particularly in chronic illness management, are often overlooked or have not received appropriate attention and contribute to failure to achieve treatment goals. The causes of these problems are often errors of omission and errors in prescribing a drug therapy of sufficient intensity. By classifying these therapeutic problems as errors, we can draw on the tools used in the error literature, such as root-cause analysis and failure-mode and effects analysis, to better understand and analyze them. We must first define what we mean by error. In the highly publicized Institute of Medicine report To Err Is Human: Building a Safer Health System, James Reason’s definition of an error was adopted: a “failure of a planned action to be completed as intended (i.e., error of execution) or the use of a wrong plan to achieve an aim (i.e., error of planning).” Our reference to the word “error” in this discussion refers to the above definition. An error of omission is “a failure to carry out the necessary steps in the performance of a task.” An example of an omission error would be for a physician to recognize a high AMANDA G. KENNEDY, PHARM.D., BCPS, is Research Assistant Professor of Medicine and CHARLES D. MACLEAN, M.D., is Associate Professor of Medicine, Division of General Internal Medicine, College of Medicine, University of Vermont, Burlington. Address correspondence to Dr. Kennedy at the Division of General Internal Medicine, College of Medicine, University of Vermont, 371 Pearl Street, Burlington, VT 05401 (amanda.kennedy@vtmednet.org). The following individuals participated in the root-cause analysis of diabetes and contributed to the authors’ understanding of clinical inertia: Anupam Goel, M.D., Dana Walrath, Ph.D., Alan S. Rubin, M.D., Dryver R. Huston, Ph.D., Benjamin Littenberg, M.D., Marilee C. Jones, M.A., Tracey Niquette, M.S., and Robert W. Beardall, M.D., M.P.H.

Desire for information and participation in therapeutic decisions concerning severe diseases, in patients of a university hospital

The purpose of our study was to evaluate the desire of the patients on being informed about diagnosis of severe diseases, the desire to have their families informed about this situation and to participate in therapeutic decisions. 363 patients (outpatients and inpatients) of a General Internal Medicine division of a University Hospital were interviewed. The questionnaire contained specific questions on their desire to be informed of the diagnosis in case of cancer or AIDS and on their desire to have their families informed as well. Specific questions on whether they wanted to be informed of and participate of the therapeutic discussion process in case of abdominal tumors were also included. 96.1% of men and 92.6% of women showed the desire of being informed in case of cancer diagnosis and 87.7% of men and 84.2% of women wanted to have their families informed, 94.2% of men and 91% of women wanted to know the diagnosis of AIDS. While 86% of women and 76.6% of men wanted be informed in the case of a diagnosis of an abdominal tumor, only 58.5% of women and 39.6% of men wanted to give their opinion about in the case of different therapeutic alternatives. The desire to participate in therapeutic decisions was significantly lower (p<0.05) in men, people older than 60 years and inpatients. Our results showed that the great majority of the population that seeks for medical support in a Brazilian university hospital wishes to be informed on this health condition, even in case of serious illness. In addition, there are intense familiar bonds that make patients want to have their families also informed.

Editorial overview

Division of Infectious Diseases and Internal Medicine, Division of Clinical Microbiology, Mayo Clinic, College of Medicine, Rochester, Minnesota, USA Correspondence to Robin Patel, MD, Division of Infectious Diseases and Internal Medicine, Division of Clinical Microbiology, Mayo Clinic, College of Medicine, Rochester, MN 55905, USA Tel: 507 255 6482; fax: 507 255 7767; e-mail: [email protected]

A 6-month prospective survey of cutaneous drug reactions in a hospital setting.

Few prospective studies are available on the incidence and analysis of the characteristics of adverse cutaneous drug reactions in hospital settings. A 6-month prospective study was managed in our hospital among hospitalized patients to: (i) evaluate the incidence of cutaneous allergic reactions from systemic drugs; (ii) study characteristics of patients with cutaneous drug reactions; (iii) describe the adverse cutaneous reactions; and (iv) evaluate drug reaction imputability and preventability. All suspected allergic cutaneous reactions to systemic drugs were collected during a 6-month period (November 2000 to May 2001). Exhaustivity of recording was ensured by regular dissemination of information about this study to the practitioners; a simple method for inclusion by fax was established. Inclusion criteria were suspected cutaneous allergic reactions induced by systemic drugs responsible for hospitalization or developed during hospitalization. A physical examination was done by a dermatologist who completed a standardized questionnaire. Requested information included patient characteristics (associated disorders, severity score), drug intake (list and chronology of the drug intake during the 3 weeks preceding the adverse reaction) and characteristics of the skin reaction (type, course). A group comprising dermatologists and pharmacologists evaluated the drug imputability and preventability. Forty-eight cases were collected. A prevalence of 3.6/1000 among hospitalized patients was estimated. The prevalence rate was higher in patients hospitalized in medical departments (0.5%) than in surgical departments (0.01%) (P < 0.001). The cases were mostly recruited in departments of infectious diseases and dermatology. The most frequent associated disorders were: human immunodeficiency virus (HIV) infection (19%), connective tissue disease (10%) and viral or autoimmune hepatitis (12%). Of these patients, 31% had had a previous immunological drug reaction. Adverse cutaneous drug reactions were principally exanthematous (56%). Reactions were considered severe in 34% of cases because they were responsible for hospitalization (18%), increased the duration of hospitalization (14%) or were life threatening (2%). Principal imputable drugs were antibiotics, mainly penicillins. An imputability score was likely in 56% of cases, but it was only possible to conclude definitively in 44% of patients. In 15% of the cases, the side-effect was considered to be preventable. This study finds a lower incidence than other studies that reported an incidence of 2% of cutaneous drug reactions in hospitalized patients, but only allergic adverse cutaneous reactions induced by systemic drugs were collected in this study. The previous studies were principally done in selected patients hospitalized only in general internal medicine or medical divisions. Our results confirm some data already known about skin drug reactions: HIV infection as a risk factor (P < 0.0001), high prevalence of adverse cutaneous reactions due to antibiotics, and difficulty in ascertaining the imputability of a drug. A high proportion (34%) of these reactions was severe and 15% were avoidable; these two facts justify the development of an intensive programme of clinical pharmacology.

From observing the relationship between volume and outcome to making policy recommendations: comments on Sheikh.

From the Institute for Health Policy Studies, and the Division of General Internal Medicine, University of California San Francisco, San Francisco, California. Address correspondence and reprint requests to: Harold S. Luft, PhD, Caldwell B. Esselstyn Professor of Health Policy and Health Economics, Director, Institute for Health Policy Studies, University of California San Francisco, 3333 California Street, Suite 265, San Francisco, CA 94118. E-mail: [email protected]

Evaluation of myocardial blood flow reserve in patients with chronic congestive heart failure due to non-ischemic cardiomyopathy

Evaluation of Myocardial Blood Flow Reserve in Patients with Chronic Congestive Heart Failure Due to Non-Ischemic Cardiomyopathy Mohammed W. Akhter, Menahem Canetti, Amir Lerman, Ilyas S. Karaalp, Jason A. Zell, Harpreet Singh, Anilkumar Mehra, Uri Elkayam1—Division of Cardiovascular Medicine, University of Southern California, Los Angeles, CA; Division of Cardiovascular Medicine & Internal Medicine, Mayo Clinic Rochester, Rochester, MN

American internal medicine in the 21st century: can an Oslerian generalism survive?

American internal medicine suffers a confusion of identity as we enter the 21st century. The subspecialties prosper, although unevenly, and retain varying degrees of connection to their internal medicine roots. General internal medicine, identified with primary care since the 1970s, retains an affinity for its traditional consultant-generalist ideal even as primary care further displaces that ideal. We discuss the origins and importance of the consultant-generalist ideal of internal medicine as exemplified by Osler, and its continued appeal in spite of the predominant role played by clinical science and accompanying subspecialism in determining the academic leadership of American internal medicine since the 1920s. Organizing departmental clinical work along subspecialty lines diminished the importance of the consultant-generalist ideal in academic departments of medicine after 1950. General internists, when they joined the divisions of general internal medicine that appeared in departments of medicine in the 1970s, could sometimes emulate Osler in practicing a general medicine of complexity, but often found themselves in a more limited role doing primary care. As we enter the 21st century, managed care threatens what remains of the Oslerian ideal, both in departments of medicine and in clinical practice. Twenty-first century American internists will have to adjust their conditions of work should they continue to aspire to practice Oslerian internal medicine.

Summary of pneumocystis research presented at the 8th International Workshop on Opportunistic Protists.

Journal of Eukaryotic MicrobiologyVolume 50, Issue s1 p. 602-604 Summary of Pneumocystis Research Presented at the 8th International Workshop on Opportunistic Protists ANDREW H. LIMPER, Corresponding Author ANDREW H. LIMPER Thoracic Diseases Research Unit, Division of Pulmonary, Critical Cure and Internal Medicine, Mayo Clinic, Kocheste6 MN 55005, andCorresponding author: A.H. Limper. Telephone: (507) 284-2964; Fax: (507) 284-4521; Email: Limper.Andrew@Mayo.eduSearch for more papers by this authorSALIM MERALI, SALIM MERALI Department of Medical and Molecular Parasitology, New York University School of Medicine, New York, NYSearch for more papers by this author ANDREW H. LIMPER, Corresponding Author ANDREW H. LIMPER Thoracic Diseases Research Unit, Division of Pulmonary, Critical Cure and Internal Medicine, Mayo Clinic, Kocheste6 MN 55005, andCorresponding author: A.H. Limper. Telephone: (507) 284-2964; Fax: (507) 284-4521; Email: Limper.Andrew@Mayo.eduSearch for more papers by this authorSALIM MERALI, SALIM MERALI Department of Medical and Molecular Parasitology, New York University School of Medicine, New York, NYSearch for more papers by this author First published: 11 July 2005 https://doi.org/10.1111/j.1550-7408.2003.tb00645.xCitations: 2Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume50, Issues1July 2003Pages 602-604 RelatedInformation

Teaching women's health skills: confidence, attitudes and practice patterns of academic generalist physician.

This study assesses the readiness of academic general internists to perform and precept a commonly utilized women's health examination, and procedural and management skills. Full-time faculty from divisions of general internal medicine and departments of family practice in 9 states reported their encounter frequency with, comfort precepting, and the importance they ascribe to several examination, procedural, and management skills relevant to women's health care; and their attitudes toward performing the pelvic exam and obtaining a Pap smear. A total of 331 general internal medicine physicians (GIMs) and 271 family medicine physicians (FPs) completed questionnaires, with response rates of 57% and 64%, respectively. More than 90% of GIMs and FPs indicated they were confident precepting the breast and Pap/pelvic examinations. A relatively small percentage of GIMs expressed confidence precepting the management of dysfunctional uterine bleeding (22%), initiating Depo-Provera (21%), and initiating oral contraceptives (45%), while a substantially larger percentage indicated that these skills were important to primary care practice (43%, 44%, and 85%, respectively). Although GIMs indicated they were confident precepting the Pap/pelvic exam, they were less likely than FPs to agree with the following statements: "Performing routine Pap smears is a good use of my time" (GIMs 65%, FPs 84%); "It is a waste of health care dollars for primary care physicians to refer patients to gynecologists for routine Pap/pelvic exams" (GIMs 69%, FPs 90%); "I feel very well trained to do a routine bimanual exam" (GIMs 71%, FPs 98%), and "The clinic where I practice is well equipped to do a Pap smear" (GIMs 78%, FPs 94%). Although most academic GIMs are confident precepting the breast and pelvic examination, only a minority are confident precepting the management of dysfunctional uterine bleeding, initiating Depo-Provera, and initiating oral contraceptives. These findings suggest that a number of academic GIMs may not be prepared or willing to perform or precept important women's health skills.

Effect of changing referral mode to C–L Psychiatry for noncognitively impaired medical inpatients with emotional disorders

Objective: To test the effect of changing referral mode to Consultation–Liaison Psychiatry (C–L Psychiatry) by implementing early screening with systematic multidisciplinary management for emotional disorders in noncognitively impaired medical inpatients. Method: A prospective pre- and postintervention controlled study in the internal medicine division of a university hospital. Results: Out of 515 patients admitted to the internal medicine ward during the study period, 176 were included in the study and gave their informed consent (male=63%); 81 in the control group and 95 in the intervention group. Except for the increase in referral rate to the C–L Psychiatry service (4–32%), there were no significant differences between the baseline and intervention periods either in terms of length of stay in the internal medicine ward and of use and costs of medical resources, or in terms of patients' satisfaction as regards attention paid to psychosocial issues during hospitalization. Conclusion: As a result of changing referral mode to C–L Psychiatry, the lack of effect on length of stay and on medical consumption of medically ill inpatients should be considered in the context of the briefness of the hospitalization periods encountered. Furthermore, the change in referral process does not seem to increase patients' perception of the quality of care provided.

Point of View

From the Division of General Internal Medicine, University of Washington, Seattle, Washington. Supported by grant no. P60 AR48093 from the National Institute for Arthritis, Musculoskeletal and Skin Diseases. The manuscript submitted does not contain information about medical device(s)/drug(s). No benefits of any kind have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript. Address correspondence and reprint requests to Richard A. Deyo, MD, MPH, Division of General Internal Medicine, University of Washington, Box 356420, Seattle, WA 98195, USA; E-mail: [email protected]

National and regional rates and variation of cervical discectomy with and without anterior fusion, 1990-1999. Point of view

From the Division of General Internal Medicine, University of Washington, Seattle, Washington. Supported by grant no. P60 AR48093 from the National Institute for Arthritis, Musculoskeletal and Skin Diseases. The manuscript submitted does not contain information about medical device(s)/drug(s). No benefits of any kind have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript. Address correspondence and reprint requests to Richard A. Deyo, MD, MPH, Division of General Internal Medicine, University of Washington, Box 356420, Seattle, WA 98195, USA; E-mail: [email protected]

Prognostic value of Doppler-derived myocardial performance index in patients with left ventricular systolic dysfunction

S studies have attempted to identify the prognostic factors of patients with heart failure and left ventricular (LV) systolic dysfunction.1–4 In this population, echocardiographic parameters have been described to predict a poor outcome including LV enlargement, low LV ejection fraction or fractional shortening, high mitral flow E/A ratio, and short deceleration time of mitral E flow.1–4 Early reports have shown that isovolumic intervals can be used to analyze cardiac dysfunction in patients with heart failure.5–11 Recently, a Doppler-derived interval index including systolic and diastolic performance of the left ventricle was reported to be a useful, sensitive, and reproducible parameter to detect myocardial dysfunction in many clinical situations.12–14 This index, which is easy to obtain, was defined as the ratio of the summation of isovolumic contraction and relaxation time to ejection time. However, the prognostic value of this index in patients with heart failure and LV systolic dysfunction remains unclear and has not been previously prospectively studied. Therefore, we decided to record, in a prospective study, this index in patients with LV systolic dysfunction to analyze its prognostic value. • • • Between February 1996 and February 1998, we prospectively included 100 consecutive patients (79 men and 21 women, aged 65 11 years) in sinus rhythm, hospitalized with clinical congestive heart failure and LV ejection fraction 40% at echocardiographic examination, and without any valvular heart disease. Patients were clinically stable for at least 3 weeks. All echocardiographic measurements were analyzed without knowledge of clinical data. The entire echocardiography and Doppler examination was completed for each patient (Sonos 2000 or 5500, Philips Ultrasound System, probe 2.5 MHz, Andover, Massachusetts) including measurements of LV diastolic and systolic diameters, diastolic and systolic volumes using Simpson’s method,15 and right ventricular end-diastolic diameter. LV ejection fraction and shortening fraction were calculated. On mitral flow, we measured maximum velocity of E and A waves and the deceleration time of the E wave, and we calculated E/A ratio. The myocardial performance index (MPI) was calculated as previously described by Tei et al.14 Briefly, using pulsed Doppler, we recorded mitral and aortic flow from 4 and 5 apical chamber views, with a 1-mm sample placed at the level of mitral tips during diastole and at the level of the aortic annulus during systole. Ejection time b was measured from the opening to the closure of the aortic valve on the LV outflow velocity profile. The interval a was obtained from mitral flow recordings from the cessation to the onset of mitral inflow, which was equal to the sum of isovolumic relaxation and contraction time and ejection time. Thus, a b represented the sum of isovolumic relaxation and contraction time. Therefore, the MPI was calculated as: MPI (a b)/b . Tricuspid regurgitation was recorded and pulmonary systolic artery pressure was calculated. All reported parameters are the average of 5 measurements. Follow-up information was obtained from the family physician or by direct-mail questionnaires or interviews. Results are presented as mean SD. A 2-sample t test was performed to compare continuous variables. The chi-square test was used to compare categorical variables. A p value 0.05 was considered statistically significant. The Kaplan-Meier method was used for cumulative survival analysis, with the log-rank test for assessing statistical differences between curves. Univariate analysis was applied to define differences between survivors and deaths. Multivariate Cox proportional-hazards regression (toward stepwise procedure) was used to investigate whether the variables identified with a p value 0.10 in the univariate analysis were independent predictors of mortality. The previously mentioned variables were treated as dichotomous variables. Analysis was done with STATVIEW computer version 5 software (Abacus Concepts, Inc., Berkeley, California). • • • Most patients were men (79%), in New York Heart Association (NYHA) functional class III to IV (77%). Etiology of heart failure was coronary artery disease in 65% and idiopathic-dilated cardiomyopathy in 35%. The baseline clinical and echocardiographic characteristics of patients are listed in Table 1. Mean LV ejection fraction was 33 6% and mean MPI was 0.69 0.30 (range 0.10 to 1.70). There was a significant correlation between the index and the ejection fraction (r 0.35, p 0.0043), the shortening fraction (r 0.34, p 0.006), LV end-diastolic (r 0.40, p 0.0008) and end-systolic (r 0.42, p 0.0005) diameters, and LV end-diastolic (r 0.31, p 0.013) From the Department of Cardiology and the UPRES Unit, South Hospital, University of Picardie, Amiens, France; and the Division of Cardiovascular and Internal Medicine, Mayo Clinic, Rochester, Minnesota. Dr. Slama’s address is: Unite de reanimation, Service de Nephrologie, Hopital Sud, 80054 Amiens Cedex 1, France. E-mail: MSlama0508@aol.com. Manuscript received May 14, 2002; revised manuscript received and accepted July 29, 2002.

Five things oculoplastic surgeons should know about the preoperative assessment of hemostasis.

From the Division of Hematology and Internal Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A. Accepted July 1, 2002. Address correspondence and reprint requests to Dr. R.K. Pruthi, Mayo Clinic, 200 First Street SW, Rochester, MN 55905. E-mail: [email protected]

What is an academic general internist? Career options and training pathways.

Academic divisions of general internal medicine have developed and flourished in the last 2 decades. Young faculty can join these divisions in 1 of 3 possible career paths: clinical educator, clinical researcher, and, most recently, the "hospitalist." This article describes the typical job description, training pathway, and rewards and challenges for each path for students and residents considering a career in academic general internal medicine.

Management of occupational allergy to natural rubber latex in a medical center: the importance of quantitative latex allergen measurement and objective follow-up.

When our employees began coming to the Occupational Health Service, Dermatology, and Allergy Clinics with symptoms of allergy to rubber gloves 12 years ago, the Mayo Clinic initiated 3 responses. (1) The Allergic Disease Research Laboratory adapted well-established technology to measure both the IgE antibody specific to natural rubber allergens, and by use of this IgE antibody, the allergens in rubber products and in the air of the workplace. (2) The Division of Allergic Diseases and Internal Medicine reviewed the prevalence and severity of the problem. (3) The Clinical Practice Committee appointed a multidisciplinary task force to implement measures to reduce exposure. The 3 sections of this article describe the Mayo Clinic's experience of successful control of this occupational health problem. Use of only gloves with low or undetectable allergen content greatly reduced the concentration of allergen in the work site, reduced the number of new cases of occupational allergy to rubber, and allowed individuals with latex allergy to work at their usual jobs.

The subspecialty fellowship training program director: essentials and expectations

Fellowship training programs should be an integral component of every successful academic subspecialty division of internal medicine. It is hoped that, by knowing the attributes of the program director and the expectations of the institution that are reasonable precursors to success, academic subspecialty divisions can review their fellowship programs and enhance the quality of these programs, and thereby enhance the quality of future subspecialists.

Predictors of unsuccessful electrical cardioversion in atrial fibrillation

R of sinus rhythm improves functional capacity and alleviates palpitations in patients with atrial fibrillation (AF). The advantages of direct-current cardioversion include the immediate restoration of sinus rhythm, as opposed to the unpredictable time to cardioversion in pharmacologic intervention, and the avoidance of potential adverse drug reactions. Although direct-current cardioversion is thought to have a higher success rate than pharmacologic intervention, it may fail to restore sinus rhythm in 5% to 30% of procedures. Few data are available regarding the association between clinical variables and the failure of direct-current cardioversion. Also, the relation between abnormalities of cardiac function and the success of direct-current cardioversion has not been studied in a large number of patients. This study assesses the success rate of direct-current cardioversion in patients with AF and the relation between clinical and echocardiographic variables and the success of direct-current cardioversion. • • • We studied 692 patients (459 men [66%] and 233 women [34%], mean age SD 67 13 years) with AF who had a first elective direct-current cardioversion at Mayo Clinic (Rochester, Minnesota). This study was approved by the Institutional Review Board of the Mayo Foundation. The duration of AF was 48 hours in 653 patients (94%) and 48 hours in 39 patients (6%). All patients underwent transthoracic echocardiography before cardioversion. Transesophageal echocardiography was performed in 201 patients (29%) before cardioversion. A history of coronary artery disease was considered present if the patient had had a previous myocardial infarction, myocardial revascularization, significant coronary artery stenosis on angiography, or typical anginal complaints. Valvular heart disease was considered present if the patient had more than mild stenosis or regurgitation of 1 cardiac valve. Idiopathic dilated cardiomyopathy was defined as left ventricular dilatation and global hypokinesia without significant coronary artery disease. The duration of AF was determined by the time of documentation of AF on the electrocardiogram or the onset of symptoms, whichever occurred earlier. Two-dimensional and M-mode imaging were performed with commercially available echocardiographic machines equipped with 2.5and 3.5-MHz phased-array transducers. M-mode echocardiography was used to measure cardiac dimensions and wall thickness. A left atrial diameter of 40 mm defined left atrial dilatation. This was considered mild for values 50 mm and marked for values 50 mm. Ejection fraction at rest was measured using a previously validated modification of the method of Quinones in Dujardin et al or by visual estimation. Structural heart disease was defined as any of the following: valvular heart disease, coronary heart disease, cardiomyopathy, or ejection fraction 50%. All procedures were performed with electrocardiographic monitoring and full equipment for cardiopulmonary resuscitation. Digitalis preparations were withheld for 24 to 48 hours before the procedure. After administration of intravenous sedation, synchronized direct-current monophasic shock was administered using the anteroposterior paddle position (sternal body angle of the left scapula). If sinus rhythm was not restored after the first shock, the procedure was repeated (up to 4 times) using a larger number of joules (up to 360 J). The number of joules with which cardioversion was initiated was determined for each patient according to physician discretion. Electrocardiography was performed before and after the procedure to verify cardiac rhythm. Successful cardioversion was defined as restoration of sinus rhythm after administration of direct-current shock. Unless specified, data are presented as mean values SD or as frequency percentages. The rank sum and chi-square tests were used to compare differences between continuous variables and proportions, respectively. Univariate and multivariate stepwise logistic regression models were used to identify individual and joint predictors of unsuccessful cardioversion. Analyses of success were done using both the patient and the individual shock as the unit of observation to harvest information when multiple shocks were needed. Differences were considered significant if the null hypothesis could be rejected at the 0.05 probability level. These diseases were present in the study population: systemic hypertension in 355 patients (51%), coronary artery disease in 233 patients (34%), valvular heart disease in 227 patients (33%), and cardiomyopathy (idiopathic dilated, restrictive, or hypertrophic) in 125 patients (18%). Cardioversion was successful in 592 patients (86%) and unsuccessful in 100 (14%). The mean number of shocks was 2.1 1.2/patient. The mean number of joules was 222 100. In 74 patients, 50 J was used initially, with success achieved From the Division of Cardiovascular Diseases and Internal Medicine and the Section of Biostatistics, Mayo Clinic, Rochester, Minnesota. Dr. Khandheria’s address is: Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905. Manuscript received June 13, 2001; revised manuscript received and accepted September 6, 2001.

The large increase in incidence of Type I diabetes mellitus in Poland.

A rising incidence of Type I (insulin-dependent) diabetes mellitus in different countries in Europe during the last decade has been recently reported. However, in the early 1990s, Poland was reported to have a stable low incidence of this disease. This study aimed to estimate the annual incidence of Type I diabetes in a north-eastern region of Poland (Białystok region) and investigate if it is associated with age, sex, urban rural differences and the season of disease onset. A register of patients with Type I diabetes using two independent sets of data sources was established in 1994 as part of the EURODIAB TIGER programme. The primary data sources were paediatric and internal medicine divisions of the hospitals in the Białystok province and the secondary were outpatient diabetic clinics in the region. The degree of ascertainment was 98.5 % for the combinated data sources. We found a significant rising trend in the incidence of Type I diabetes in children under 15 years of age (in 1998 the incidence was approximately twice as high as in 1994). Increasing incidence rates were observed in the rural areas but not in urban populations. Seasonal variation in the incidence was also found, with a peak in winter and nadir in summer. These results show that the north-eastern region of Poland is an area with a moderate rather than a low risk of Type I diabetes. Our observations confirm the important role of environmental and socio-economic factors or both in the pathogenesis of Type I diabetes.

Pulmonary Function in Non-Insulin-Dependent Diabetes mellitus

Background: In type I diabetes mellitus, lung function has been investigated in several clinical studies, but there are few data concerning pulmonary function abnormalities in patients with non-insulin-dependent diabetes mellitus (NIDDM). Objectives: The aim of this study was to assess the presence of pulmonary function abnormalities in patients with NIDDM and to verify the possible associations between diabetic renal microangiopathy, retinopathy and diabetes control. Method and Patients: Thirty patients with NIDDM were collected and divided into two similar groups: subjects with retinopathy and/or diabetic glomerulopathy (group 1, n = 15) and patients without any complications (group 2, n = 15). 17 were males and 13 females, aged from 45 to 81 years. They had had diabetes for 3–23 years and were studied at the Division of Internal Medicine, with an outpatient service for diabetic patients. All patients were non-smokers. The presence of diabetic glomerulopathy was determined by measuring the 24-hour protein excretion rate using the nephelometric method. The presence of retinopathy was determined by using ophthalmoscopy. Glycosylated hemoglobin was measured as an indicator of glycemic control. We performed a global spirometry and measured pulmonary diffusion capacity by the single-breath method corrected by alveolar volume. Results: We found a significant reduction in lung diffusion capacity for carbon monoxide (DL_CO) in the group of patients with other signs of diabetic microangiopathy (p < 0.005) and a significative correlation between DL_COand the grade of albuminuria (r = –0.83, p < 0.001). Conclusions: Pulmonary function abnormalities, in particular a reduction in diffusion capacity, are common in patients with NIDDM and signs of diabetic microangiopathy. A possible explanation is related to an impaired pulmonary microvasculature and alveolar epithelial basal lamina.