Lifestyle habits and compression of morbidity Hubert, Helen B; Bloch, Daniel A; Oehlert, John W ...
The journals of gerontology. Series A, Biological sciences and medical sciences,
06/2002, Volume:
57, Issue:
6
Journal Article
Peer reviewed
Open access
There has been much debate regarding the degree to which healthy lifestyles can increase longevity and whether added years will be offset by increased morbidity at older ages. This study was designed ...to test the compression of morbidity hypothesis, proposing that healthy lifestyles can reduce and compress disability into a shorter period toward the end of life.
Functional status in 418 deceased members of an aging cohort was observed between 1986 and 1998 in relationship to lifestyle-related risk factors, including cigarette smoking, physical inactivity, and under- or overweight. Three risk groups were created based on the number of these factors at study entry. Disability scores prior to death were modeled for each risk group to compare levels and rates of change, as well as to determine if and when acceleration in functional decline occurred.
The risk-factor-free group showed average disability scores near zero 10-12 years before death, rising slowly over time, without evidence of accelerated functional decline. In contrast, those with two or more factors maintained a greater level of disability throughout follow-up and experienced an increase in the rate of decline 1.5 years prior to death. For those at moderate risk, the rate of decline increased significantly only in the last 3 months of life. Other differences between groups provided no alternative explanations for the findings.
These results make a compelling argument for the reduction and postponement of disability with healthier lifestyles as proposed by the compression of morbidity hypothesis.
Objective: The objective was to review the current results of endovascular abdominal aortic aneurysm repair with the AneuRx stent graft and to determine the effectiveness of the device in achieving ...the primary objective of preventing aneurysm rupture. Methods: The outcome of all patients treated during the past 4 years in the U.S. AneuRx clinical trial was determined, and the worldwide clinical experience was reviewed. Results: A total of 1192 patients were treated with the AneuRx stent graft during all phases of the U.S. Clinical Trial from June 1996 to November 1999, with follow-up extending to June 2000. Ten (0.8%) patients have had aneurysm rupture, with most ruptures (n = 6) occurring in 174 (3.4%) patients treated with an early stiff bifurcation stent graft design used in phase I and in the initial stages of phase II. Since the current, flexible, segmented bifurcation stent graft design was introduced, four (0.4%) ruptures have occurred among 1018 patients treated. Of these, one was during implantation, two were placed too far below the renal arteries, and one patient refused treatment of a type I endoleak. Kaplan-Meier analysis of all 1192 patients treated with the AneuRx stent graft including both stent graft designs revealed the patient survival rate to be 93% at 1 year, 88% at 2 years, and 86% at 3 years, freedom from conversion to open repair to be 98% at 1 year, 97% at 2 years, and 93% at 3 years, and freedom from secondary procedure to be 94% at 1 year, 92% at 2 years, and 88% at 3 years. Freedom from aneurysm rupture with the commercially available segmented bifurcation stent graft was 99.7% at 1 year, 99.5% at 2 years, and 99.5% at 3 years. The presence or absence of endoleak on contrast computed tomography scanning after stent graft placement was not found to be a significant predictor of long-term outcome measures. Worldwide experience with the AneuRx device now approaches 10,000 patients. Conclusions: Endovascular management of abdominal aortic aneurysms with the AneuRx stent graft has markedly reduced the risk of aneurysm rupture while eliminating the need for open aneurysm surgery in 98% of patients at 1 year and 93% of patients at 3 years. The device was effective in preventing aneurysm rupture in 99.5% of patients over a 3-year period. The overall patient survival rate was 93% at 1 year and 86% at 3 years. (J Vasc Surg 2001;33:S135-45.)
ABSTRACT
Aims To conduct a preliminary evaluation of the safety and efficacy of tiagabine, sertraline or donepezil versus an unmatched placebo control as a treatment for cocaine dependence.
Design ...A 10‐week out‐patient study was conducted using the Cocaine Rapid Efficacy and Safety Trial (CREST) study design.
Setting This study was conducted at the Cincinnati Medication Development Research Unit (MDRU) and at an affiliated site in Dayton, Ohio.
Participants Participants met Diagnostic and Statistical Manual version IV (DSM‐IV) criteria for cocaine dependence. Sixty‐seven participants were enrolled with 55 completing final study measures.
Intervention The targeted daily doses of medication were tiagabine 20 mg, sertraline 100 mg and donepezil 10 mg. All participants received 1 hour of manualized individual cognitive behavioral therapy on a weekly basis.
Measurements Primary outcome measures of efficacy included urine benzoylecgonine (BE) level, Cocaine Clinical Global Impression Scale–Observer and self‐report of cocaine use. Safety measures included adverse events, ECGs, vital signs and laboratory tests.
Findings Subjective measures of cocaine dependence indicated significant improvement for all study groups. Generalized estimating equations analysis indicated that the tiagabine group showed a trend toward a significant decrease in urine BE level from baseline to weeks 5–8 (P = 0.10) and non‐significant changes for the other study groups. No pattern of physical or laboratory abnormalities attributable to treatment with any of the medications was identified. There were three serious adverse events reported, none of which were related to study procedures.
Conclusions The present findings suggest that tiagabine may be worthy of further study as a cocaine dependence treatment.
Background. The unique pharmacological properties of buprenorphine may make it a useful maintenance therapy for opiate addiction. This meta‐analysis considers the effectiveness of buprenorphine ...relative to methadone.
Methods. A systematic literature search identified five randomized clinical trials comparing buprenorphine to methadone. Data from these trials were obtained. Retention in treatment was analyzed with a Cox proportional hazards regression. Urinalyses for opiates were studied with analysis of variance and a common method of handling missing values. A meta‐analysis was used to combine these results.
Results. Subjects who received 8‐12 mg/day buprenorphine had 1.26 times the relative risk of discontinuing treatment (95% confidence interval 1.01‐1.57) and 8.3% more positive urinalyses (95% confidence interval 2.7‐14%) than subjects receiving 50‐80 mg/day methadone. Buprenophrine was more effective than 20‐35 mg/day methadone. There was substantial variation in outcomes in the different trials.
Conclusions. The variation between trials may be due to differences in dose levels, patient exclusion criteria and provision of psychosocial treatment. The difference in the effectiveness of buprenorphine and methadone may be statistically significant, but the differences are small compared to the wide variance in outcomes achieved in different methadone treatment programs. Further research is needed to determine if buprenorphine treatment is more effective than methadone in particular settings or in particular subgroups of patients.
We reviewed the structural findings of explanted AneuRx stent grafts used to treat abdominal aortic aneurysms, and relate the findings to clinical outcome measures.
We reviewed data for all ...bifurcated AneuRx stent grafts explanted at surgery or autopsy and returned to the manufacturer from the US clinical trial and worldwide experience of more than 33,000 implants from 1996 to 2003. Devices implanted for more than 1 month with structural analysis are included in this article. Explant results were analyzed in relation to cause of explantation and pre-explant evidence of endoleak, enlargement, or device migration.
One hundred twenty explanted stent grafts, including 37 from the US clinical trial, were analyzed. Mean implant duration was 22 ± 13 months (range, 1-61 months). Structural abnormalities included stent fatigue fractures, fabric abrasion holes, and suture breaks. The mean number of nitinol stent strut fractures per explanted device was 3 ± 4, which represents less than 0.2% of the total number of stent struts in each device. The mean number of fabric holes per explanted device was 2 ± 3, with a median hole size of 0.5 mm
2. Suture breaks were seen in most explanted devices, but composed less than 1.5% of the total number of sutures per device. “For cause” explants (n = 104) had a 10-month longer implant duration (
P = .007) compared with “incidental” explants (n = 16). “For cause” explants had more fractures (3 ± 5;
P = .005) and fabric holes (2 ± 3;
P = .008) per device compared with “incidental” explants, but these differences were not significant (
P = .3) when adjusted for duration of device implantation. Among clinical trial explants the number of fabric holes in grafts in patients with endoleak (2 ± 3 per device) was no different from those without endoleak (3 ± 4 per device;
P = NS). The number of fatigue fractures or fabric holes was no different in grafts in clinical trial patients with pre-explant aneurysm enlargement compared with those without enlargement. Pre-explant stent-graft migration was associated with a greater number of stent strut fractures (5 ± 7 per device;
P = .04) and fabric holes (3 ± 3 per bifurcation;
P = .03) compared with explants without migration. Serial imaging studies revealed inadequate proximal, distal, or junctional device fixation as the probable cause of rupture or need for conversion to open surgery in 86% of “for cause” explants. Structural device abnormalities were usually remote from fixation sites, and no causal relationship between device findings and clinical outcome could be established.
Nitinol stent fatigue fractures, fabric holes, and suture breaks found in explanted AneuRx stent grafts do not appear to be related to clinical outcome measures. Longer term studies are needed to confirm these observations.
Recent technological developments provide easy access to use an artificial oxygen supply (hyperoxia) during exercise training. The aim of this study was to assess the efficacy of a commercially ...available oxygen compressor inducing low-dose hyperoxia, on limiting factors of endurance performance. Thirteen active men (age 24 ± 3 years) performed a high-intensity interval exercise (HIIE) session (5 × 3 min at 80% of W
, separated by 2 min at 40% W
) on a cycle ergometer, both in hyperoxia (4 L∙min
, 94% O
, HYP) or ambient conditions (21% O
, NORM) in randomized order. The primary outcome was defined as red blood cell deformability (RBC-D), while our secondary interest included changes in muscle oxygenation. RBC-D was expressed by the ratio of shear stress at half-maximal deformation (SS
/
) and maximal deformability (EI
) and muscle oxygenation of the rectus femoris muscle was assessed by near-infrared spectroscopy. No statistically significant changes occurred in SS
/
and EI
in either condition. The ratio of SS
/
to EI
statistically decreased in NORM (
< 0.01; Δ: -0.10; 95%CI: -0.22, 0.02) but not HYP (
> 0.05; Δ: -0.16; 95%CI: -0.23, -0.08). Muscle oxygenation remained unchanged. This study showed that low-dose hyperoxia during HIIE using a commercially available device with a flow rate of only 4 L·min
may not be sufficient to induce acute ergogenic effects compared to normoxic conditions.
Prior studies have demonstrated inefficacy among dopamine receptor antagonists for treating cocaine dependence. An alternative approach would be to investigate the ability of indirect inhibitors of ...cortico-mesolimbic dopamine release, such as the 5-HT
3 receptor antagonist ondansetron, to reduce cocaine's reinforcing effects. We hypothesized that ondansetron might be more efficacious than placebo at reducing cocaine intake and promoting abstinence in cocaine-dependent individuals. In a pilot randomized, double-blind, 10-week controlled trial, 63 treatment-seeking, cocaine-dependent men and women received ondansetron (0.25
mg, 1.0
mg, or 4.0
mg twice daily) or placebo. Up to three times per week, participants were assessed on several measures of cocaine use, including urine benzoylecgonine. Cognitive behavioral therapy was administered weekly. Ondansetron was well tolerated, causing no serious adverse events. The ondansetron 4.0
mg group had the lowest dropout rate among all treatment groups and a greater rate of improvement in percentage of participants with a cocaine-free week compared with the placebo group (
p
=
0.02), whereas the ondansetron 1.0
mg group had a lower rate of improvement in percentage of weekly mean non-use days than did placebo recipients (
p
=
0.04). These results suggest the possibility of a non-linear dose–response function, with evidence supporting efficacy for the 4.0
mg group.
The Challenger space shuttle explosion in January 1986 offered an opportunity to determine what, if any, symptoms of posttraumatic stress disorder (PTSD) and bereavement normal latency-age children ...and adolescents would develop after a distant, horrifying event.
With a structured interview, the authors assessed the symptoms of 153 randomly selected children from Concord, N.H., and Porterville, Calif. Responses were statistically compared between East Coast children, who saw the event on television and who generally cared more about the teacher aboard Challenger, and West Coast children, who heard about it first; between latency-age children and adolescents; and between children seen 5-7 weeks later and those same children seen 14 months later.
More than 60% of the subjects feared at least one stimulus related to Challenger within the first 5-7 weeks of the explosion. The East Coast and latency-age groups appeared significantly more symptomatic than did the West Coast and adolescent groups. Over the 14-month study period, most symptoms dramatically faded. However, adolescents' diminished expectations for the future in general increased, and latency-age children's changed approach to space careers held relatively steady. Three East Coast latency-age children met the DSM-III-R symptom requirements for PTSD in 1986; no children met these in 1987.
Children's symptomatic patterns after Challenger relate to the patterns for PTSD listed in diagnostic manuals and to three symptoms not in the DSM-IV list. To the authors, distant traumas appear to be one of a newly defined spectrum of trauma-related conditions that include relatively evanescent symptoms and a few longer-lasting ones. These symptoms may affect large numbers of normal children.
Postural balance in children with cerebral palsy Rose, Jessica; Wolff, Don R; Jones, Vincent K ...
Developmental medicine and child neurology,
January 2002, 2002-01-00, Volume:
44, Issue:
1
Journal Article
Peer reviewed
Postural control deficits have been suggested to be a major component of gait disorders in cerebral palsy (CP). Standing balance was investigated in 23 ambulatory children and adolescents with ...spastic diplegic CP, ages 5 to 18 years, and compared with values of 92 children without disability, ages 5 to 18 years, while they stood on a force plate with eyes open or eyes closed. The measurements included center of pressure calculations of path length per second, average radial displacement, mean frequency of sway, and Brownian random motion measures of the short‐term diffusion coefficient, and the long‐term scaling exponent. In the majority of children with CP (14 of 23) all standing balance values were normal. However, approximately one‐third of the children with CP (eight of 23) had abnormal values in at least two of the six center of pressure measures. Thus, mean values for path length, average radial displacement, and diffusion coefficient were higher for participants with CP compared with control individuals with eyes open and closed (p<0.05). Mean values for frequency of sway and the long‐term scaling exponent were lower for participants with CP compared with control participants (p<0.05). Increased average radial displacement was the most common (nine of 23) postural control deficit. There was no increase in abnormal values with eyes closed compared with eyes open for participants with CP, indicating that most participants with CP had normal dependence on visual feedback to maintain balance. Identification of those children with impaired standing balance can delineate factors that contribute to the patient's gait disorder and help to guide treatment.
To assess if joint damage at 2 years after diagnosis in patients with systemic juvenile idiopathic arthritis (SJIA) can be predicted by clinical or laboratory features assessed up to 3 or 6 months ...after diagnosis.
Medical records from 70 children were retrospectively reviewed. The primary outcome measure was presence of joint damage at 2 years after diagnosis (JD2) as defined by presence of erosions or fusion in one or more joints. Potential predictor variables for JD2 in the first 3 and 6 months after diagnosis consisted of the highest observed white blood cell count, platelet count, erythrocyte sedimentation rate, active joint count, and presence of symptomatic pulmonary or cardiac disease or macrophage activation syndrome, and treatment data.
The outcome of interest, JD2, was identified in 15/70 patients. Classification-tree analysis identified a pair of variables (highest observed platelet count and number of active joints) measured within the first 3 months after diagnosis that together predicted progression to JD2 with an estimated sensitivity of 87%, specificity of 82%, and positive predictive value of 57%. Multivariate logistic regression analyses at 3 months found that higher quantities of joints with active arthritis and early use of methotrexate (MTX) were factors significantly associated with increased odds of progression to JD2 (active joints odds ratio = 1.08, 95% CI 1.00-1.16, p = 0.04; MTX OR = 11.85, 95% CI 1.89-74.26, p = 0.01). Unsupervised cluster analysis identified 2 major phenotypes of patients at 3 months characterized by different ages at onset, acute phase markers, active joint counts, and presence of serositis. These phenotypes differed 3-fold in proportion of subjects progressing to JD2 (p < 0.05).
By 3 months after diagnosis, a clinical phenotype based on active joint count and platelet count may be prognostic of an increased risk of progression to JD2. Use of corticosteroids did not appear to change the risk of joint damage. In contrast, the presence of serositis appeared to be associated with decreased risk of joint damage.
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