UC Groups Research Articles

2585 Effects of a nurse-led, clinic and home-based intervention on recurrent hospital use in chronic heart failure

Background: Chronic heart failure (CHF) exerts a significant burden on the health care system in the UK. A recent study concluded that it contributes to almost 4% of total National Health Service expenditure with recurrent hospitalisation in typically older patients (pts) being a major cost component. Nurse-led programs of care to reduce recurrent hospitalisation in such pts have proven to be particularly cost-effective. To date they have predominantly focussed on either home or clinic-based follow-up. Aim: In a randomised controlled study, we examined the effectiveness of a nurse-led, CHF program, involving a composite of clinic plus home-based follow-up, in reducing recurrent hospital stay. Methods: A total of 113 typically older pts admitted to two hospitals in York and Scunthorpe were recruited to the study. The majority were aged > 65 years and 70% were male. All pts had a history of at least one admission with acute HF and evidence of systolic left ventricular dysfunction. Most pts also had concurrent disease states likely to complicate treatment for their CHF. A total of 62 and 51 pts, respectively, were randomised to clinic plus home-based intervention (C+HBI) lasting 6 months post-discharge or to usual, post-discharge care (UC). In this preliminary analysis we compared morbidity and mortality rates within 6 months of their index admission. Results: During 6 months follow-up, a total of 13 (21%) versus 21 (41%) of pts in the C+HBI and UC groups, respectively, had an emergency hospital admission (P = 0.024: OR 0.38, 95% CI 0.17 - 0.87). Pts in the HBI group had fewer emergency admissions (15 vs. 33 admissions) and days of reccurrent hospital stay (108 vs. 351 days). On an adjusted basis, therefore, C+HBI was associated with a lower rate of emergency admission (0.24 vs. 0.59 admissions/pt: P = 0.007) and recurrent hospital stay (1.7 vs. 6.9 days/pt: P = 0.003) relative to UC. During the same follow-up period, 9 (15%) versus 8 (16%) pts died (NS). Conclusions: We have previously speculated that the combination of home and clinic based follow-up would be most practical and, potentially, most effective effective in optimising the management of high pts with CHF. To date, there have been few studies specifically examining this approach. In this randomised study, involving pts from two independent hospitals in the North of England, we found that C+HBI was associated with significant reductions in recurrent readmissions and associated stay. As such, this represents another form of postdischarge management that can be implemented widely to reduce the overall burden of CHF.

Effects of ACE inhibitor therapy on derived central arterial waveforms in hypertension

Large artery properties constitute an important component of left ventricular afterload in hypertension. The present study examined whether such properties were particularly responsive to angiotensin converting enzyme inhibitor therapy. A prospective, randomized, 12-week study in 138 previously treated hypertensive subjects, in 67 of whom usual treatment (UC) was replaced with perindopril (P) therapy. Large artery properties were assessed as central arterial pressure augmentation determined by applanation tonometry of the radial artery and a transfer function. At baseline both augmentation index (AI, %) and pressure (AP, mm Hg) were related to body size, heart rate, and gender. In addition AP was related to age and systolic blood pressure (BP). After 12 weeks of treatment AP decreased significantly in both perindopril and UC groups, whereas AI only decreased significantly (151.7% ± 2.3% to 144.9% ± 2.6%) in those treated with perindopril. Decreases in AP (−4.2 ± 0.9 mm Hg v-1.9 ± 0.7 mm Hg) and AI (−6.8% ± 2.2% v-2.2% ± 2.5%) from week 0 to week 12 were greater in the perindopril-treated group, but differences between groups failed to reach statistical significance ( P = .05 and .09, respectively). The change in AI during the 12-week treatment period was dependent on the initial heart rate ( P < .001), systolic BP ( P < .05), weight ( P < .001), and sex ( P < .001), but not on treatment group ( P > .5). AI at 12 weeks was negatively correlated with heart rate but regression slopes for the association were virtually identical for perindopril and UC groups. Perindopril treatment produces a greater decrease in AI than continuation with previous therapy, but this can be largely explained by hemodynamic changes rather than direct arterial effects.

Achieving National Cholesterol Education Program Goals for Low-Density Lipoprotein Cholesterol in Cardiac Patients: Importance of Diet, Exercise, Weight Control, and Drug Therapy

Achieving National Cholesterol Education Program Goals for Low-Density Lipoprotein Cholesterol in Cardiac Patients: Importance of Diet, Exercise, Weight Control, and Drug TherapyAllison TG, Squires RW, Johnson BD, Gau GT Mayo Clin Proc 1999;74:466-473 Background. The National Cholesterol Education Program (NCEP) guidelines recommend a low-density lipoprotein cholesterol (LDL) of ≤ 100 mg/dl in patients with coronary artery disease. Data on the attainment of these goals in clinical practice are limited. Methods. Consecutive patients who completed cardiac rehabilitation and were not on lipid-lowering drug therapy (LLD) were randomized to follow-up care with nurse lipid specialists (RN) or preventive cardiologists (UC). All patients received diet and exercise recommendations and were treated with LLD in accordance with NCEP guidelines. Results. The baseline LDL level in all 152 patients was 130 ± 29 mg/dl and did not differ between the groups. After a mean of 526 days of follow-up, 39% of all the patients had an LDL level ≤ 100 mg/dl and 35% of these patients were not receiving LLD therapy. Independent predictors of a final LDL level ≤ 100 mg/dl included LLD therapy (P < 0.001), baseline LDL level (P < 0.001), and amount of exercise in minutes/week (P < 0.05). There was no difference between the RN and UC groups in the percentage of patients reaching the target LDL levels. Conclusion. The authors conclude that nurses manage lipids as effectively as preventive cardiologists and that LLD therapy is the most important factor in achieving the target LDL level. Comments. The results of this study indicate modest success in attainment of NCEP goals within an academic preventive cardiology setting. Reasons for lack of attainment of these goals in the majority of patients and ways to improve compliance deserve further study.

The Effect of Intensive Coronary Risk Reduction on Psychosocial and Health-Related Quality of Life Responses

Popular sentiment suggests that patients undertaking risk factor and lifestyle behavior changes may experience negative mood states and quality of life decrements. Women, and men (n = 41 and 259) with known coronary artery disease (CAD) were randomly assigned to an intensive risk reduction group (RR) or the usual care of their physician (UC). Risk factor and psychosocial profiles were measured at baseline and annually. HQOL profiles were measured at one year in a subset of UC and RR patients (n = 67 and 63). Comparisons of psychosocial profiles did not differ for the UC and RR groups at baseline or afier one year, although the RR group achieved significant reductions in risk factors. Baseline mood states did not differ for women and men, however women had lower Type A behavior scores. After one year, HQOL gender comparisons revealed significantly lower scores for women in the physical hnctioning domain. Multivariate analysis found that the presence of angina was negatively related to physical functioning,...

Reactance theory and alcohol consumption laws: further confirmation among collegiate alcohol consumers.

By the late 1980s, the United States legal drinking age had increased to 21 years. Based on psychological reactance theory, one would predict that these law changes would cause underage collegiate consumers to drink more alcohol because of the belief that their behavioral freedom was being reduced. It was hypothesized that underage collegiate alcohol consumers (UC) would drink more than their legal-age peers (LC) if psychological reactance was a contributing factor to consumption, whereas no differences would be present between the UC and LC groups' usage of illicit drugs, as these had not been affected by recent law changes. To test this hypothesis, a sample of 2,142 college students from 10 midwestern postsecondary educational facilities responded to the Alcohol and Other Drug Use Needs Assessment Survey in the spring of 1990. Mann-Whitney U analyses revealed significant differences between groups on alcohol use measures, but no differences were present on illicit substance use measures. These results are interpreted as supporting reactance theory.

Baseline factors associated with smoking cessation and relapse

Background. Data on smoking cessation and relapse for 6 years of the Multiple Risk Factor Intervention Trial were evaluated in univariate and multivariate analyses to determine the relationship between variables measured at the beginning of the trial and smoking cessation and relapse for special intervention and usual care participants. Results. The variables positively associated with smoking cessation in both the SI and the UC groups included age, education, and past success in quitting; there was a negative association with the number of cigarettes smoked per day. The expectation of quitting was positively associated with cessation in the special intervention group only, while life events, alcohol, and the presence of a wife who smokes were significant predictors of reduced cessation for the usual care group. The special intervention program may have overcome obstacles which interfered with cessation among the usual care participants. Associations with relapse were generally stronger in the usual care group than in the special intervention group. For usual care participants, multivariate analyses showed that education, past success in quitting smoking, alcohol, and life events were associated with relapse rates. For special intervention participants, only alcohol emerged as a significant predictor. Conclusion. The data are relevant in terms of factors that govern smoking cessation and relapse for adult smokers who take part in formal intervention programs and for those who are left to modify their behavior on their own.

Quality control in the multiple risk factor intervention trial nutrition modality

One of the principal objectives of the MRFIT was to teach and motivate participants assigned to the SI group to adhere to a fat-controlled dietary regimen over the course of the trial. The magnitude of the trial (with more than 12,000 participants, half of them assigned to the SI protocol, to be followed for at least 6 years in 22 separate centers) presented new challenges for maintenance of quality control over a nutrition intervention program. Collection of data to monitor changes in dietary intake over time in SI and UC groups, as well as information to assess dietary adherence levels in SI participants also presented large-scale challenges in maintenance of quality control. The MRFIT formulated many of its initial nutrition intervention and data collection decisions based on experience of the earlier National Diet Heart Study (NDHS). In order to avoid coding 7-day dietary records by local clinic nutritionists (as in NDHS), the trial opted for collection of 24-hour dietary recalls that were coded centrally at the Nutrition Coding Center. It necessitated extra attention to training and certification of clinic nutritionist-interviewers to be certain that NCC coders had sufficiently precise information about all foods entered on dietary recall forms. Since dietary intake data were collected over a time span of approximately 10 years, procedures for updating the food composition database and coding rules were a necessity. Continuing attention to training and monitoring of performance of clinic nutritionist-interviewers also was important. The MRFIT nutrition intervention program was designed with the need for interclinic comparability of intervention techniques in mind. This required not only development of study-wide nutrition intervention materials, but also necessitated ongoing attention to staff training and monitoring procedures in order to ensure intercenter comparability of efforts. The success of the nutrition intervention modality depended upon the continuing efforts of the nutrition counselors not only to achieve dietary adherence but also to monitor levels of dietary adherence over time. The NDHS experience served as a springboard for designing the MRFIT nutrition intervention and data collection procedures. It is hoped that techniques for maintaining and monitoring quality control over the MRFIT nutrition modality as outlined in this chapter may prove useful to future planners.

Coronary heart disease death, nonfatal acute myocardial infarction and other clinical outcomes in the multiple risk factor intervention trial

The Multiple Risk Factor Intervention Trial was a randomized clinical study to test whether a special intervention (SI) program aimed at reducing serum cholesterol levels, blood pressure and cigarette smoking would prevent coronary heart disease (CHD) in middle-aged men. The main endpoint reported here is the percentage of participants experiencing first major CHD events (either nonfatal acute myocardial infarction [AMI] or CHD death) during 7 years of follow-up. This outcome was slightly less frequent in the 6,428 SI men than in the 6,438 men assigned to their usual source of care (UC). However, the relative difference—either 1% (95% confidence interval −17% to 16%) or 8% (95% confidence interval −5% to 20%), depending on how AMI was classified—was not statistically significant. Regression analyses within the SI and UC groups suggested that the cholesterol and cigarette smoking interventions reduced the number of first major CHD events: the associations between lowering the levels of these 2 factors and reductions in CHD rates were significant (p < 0.001) and of the anticipated magnitude. A similar analysis of antihypertensive treatment in the SI group revealed no favorable association between lowering blood pressure and CHD rate, and other subgroup comparisons suggested that a mixture of beneficial and adverse effects may underlie this finding. Thus, the nonsignificant overall UC/SI contrast in CHD rates may reflect a combination of the expected beneficial effects of the cholesterol and smoking interventions with unexpected heterogeneous effects of the antihypertensive intervention. Seven of 8 other prespecified cardiovascular endpoihts occurred less frequently among SI than among UC men, the difference being nominally significant (p < 0.05) for angina pectoris, congestive heart failure and peripheral arterial disease.

Observations on cattle schistosomiasis in the Sudan, a study in comparative medicine. V. The effect of praziquantel therapy on naturally acquired resistance to Schistosoma bovis.

Studies in the White Nile area of the Sudan have shown that Zebu cattle acquire a high degree of resistance to Schistosoma bovis as a result of repeated natural exposures without, however, being able to eliminate their populations of adult schistosomes, although these do show greatly suppressed fecundity. To test whether these adult worms are necessary for the maintenance of resistance we cured six "naturally resistant" cattle (TC group) with a double treatment of 25 mg/kg praziquantel and compared their response to a 70,000 cercariae challenge with groups of "naturally resistant" but untreated cattle (UC group) and with previously unexposed, challenged cattle (CC group). Challenge was carried out 7 weeks after the second dose of praziquantel. The results confirmed that untreated cattle are "naturally resistant" and also showed that resistance was not abrogated by cure of the naturally-acquired infections. Thus, fecal egg counts after challenge reached mean maxima of 2,432 eggs per gram (epg) in the CC, but only 5 epg and 28 epg in the TC and UC groups, respectively. Similarly, mean worm counts were 85% and 69% lower in the TC and UC groups, respectively, and mean tissue egg densities were reduced by 72-99%, and 56-80%. Histopathologically, the TC and UC groups were also far less affected than the CC. Effective praziquantel treatment does therefore not destroy naturally acquired resistance to S. bovis, and may benefit infected livestock even in the absence of transmission control. The situation in human schistosomiasis is less clear, but there are several epidemiological and experimental indications of a similar conclusion for S. mansoni.

Histopathology of nasopharyngeal carcinoma.Correlations with epidemiology, survival rates and other biological characteristics

A total of 363 cases of nasopharyngeal carcinoma (NPC) in Singapore were classified into squamous cell carcinoma (SCC; 73 cases), non-keratinizing carcinoma (NKC; 178 cases) and undifferentiated carcinoma (UC; 172 cases). Possible biological differences between these histologic types and between tumors with and without lymphocytic infiltration were investigated by correlations with survival rates and with selected epidemiologic, immunovirologic, and immunogenetic data on the disease. The 5-year survival rates following radiotherapy were 25.3% for all cases and 58.8% for tumors restricted to the nasopharynx. The 5-year survival rate for SCC was poorer than for the combined NKC and UC groups (p less than 0.05). The 3-year survival rate was better for tumors with lymphocytic infiltration (p less than 0.05), but there were no differences in the 5-year survivals. The survival rates were better in females (p less than 0.01) and in the younger age groups (p less than 0.01). There were no significant correlations between histopathology of NPC and the distributions of cases by age, sex, HLA antigen profiles, or cell-mediated immune status. Squamous cell carcinoma was associated with lower levels of antibodies to the Epstein-Barr nuclear antigen (p less than 0.05), but there were no differences with respect to antibodies against other EBV related antigens. These findings support the view that SCC, NKC, and UC of the nasopharynx, as defined in the WHO classification, are variants of a fairly homogeneous group of neoplasms in the Singapore population.