bluuebunny/crossref_metadata_2025 huggingface dataset:
Effect of Antireflux Treatment on Asthma Exacerbations in Nonatopic Children
Authors: Khoshoo Vikram , Haydel Robert
Published: February 2007

Objective:

To evaluate the asthma outcome of treatment with ranitidine or esomeprazole plus metoclopramide in older children with moderate‐persistent asthma and gastroesophageal reflux disease (GERD).

Patients and Methods:

The study patients included 44 patients with asthma and GERD who had received 1 year of treatment with a proton pump inhibitor/prokinetic combination and had shown significant clinical improvement in asthma symptoms and no exacerbations for more than 3 months. For further treatment, 30 of the 44 patients continued treatment with esomeprazole/metoclopramide (group A), and 14 switched to ranitidine (group B). Nine patients with GERD and asthma who had previously undergone fundoplication were used as control individuals (group C). All patients were followed up closely for exacerbation of asthma symptoms and treated according to a standardized protocol.

Results:

During the 6‐month follow‐up, group B patients experienced significantly more exacerbations per patient (2.2) than did those in group A (0.33) or group C (0.77) (P < 0.05).

Conclusions:

Fundoplication or continued treatment with esomeprazole and metoclopramide is associated with significantly fewer exacerbations of asthma symptoms in children with moderate‐persistent asthma and concomitant GERD in comparison with treatment with ranitidine.
Right-handed snakes: convergent evolution of asymmetry for functional specialization
Authors: Hoso Masaki , Asami Takahiro , Hori Michio
Published: February 2007

External asymmetry found in diverse animals bears critical functions to fulfil ecological requirements. Some snail-eating arthropods exhibit directional asymmetry in their feeding apparatus for foraging efficiency because dextral (clockwise) species are overwhelmingly predominant in snails. Here, we show convergence of directional asymmetry in the dentition of snail-eating vertebrates. We found that snakes in the subfamily Pareatinae, except for non-snail-eating specialists, have more teeth on the right mandible than the left. In feeding experiments, a snail-eating specialist
Pareas iwasakii
completed extracting a dextral soft body faster with fewer mandible retractions than a sinistral body. The snakes failed in holding and dropped sinistral snails more often owing to behavioural asymmetry when striking. Our results demonstrate that symmetry break in dentition is a key innovation that has opened a unique ecological niche for snake predators.
Social cognition by food-caching corvids. The western scrub-jay as a natural psychologist
Authors: Clayton Nicola S , Dally Joanna M , Emery Nathan J
Published: February 2007

Food-caching corvids hide food, but such caches are susceptible to pilfering by other individuals. Consequently, the birds use several counter strategies to protect their caches from theft, e.g. hiding most of them out of sight. When observed by potential pilferers at the time of caching, experienced jays that have been thieves themselves, take further protective action. Once the potential pilferers have left, they move caches those birds have seen, re-hiding them in new places. Naive birds that had no thieving experience do not do so. By focusing on the counter strategies of the cacher when previously observed by a potential pilferer, these results raise the intriguing possibility that re-caching is based on a form of mental attribution, namely the simulation of another bird's viewpoint. Furthermore, the jays also keep track of the observer which was watching when they cached and take protective action accordingly, thus suggesting that they may also be aware of others' knowledge states.
Insights into neural stem cell biology from flies
Authors: Egger Boris , Chell James M , Brand Andrea H
Published: February 2007

Drosophilaneuroblasts are similar to mammalian neural stem cells in their ability to self-renew and to produce many different types of neurons and glial cells. In the past two decades, great advances have been made in understanding the molecular mechanisms underlying embryonic neuroblast formation, the establishment of cell polarity and the temporal regulation of cell fate. It is now a challenge to connect, at the molecular level, the different cell biological events underlying the transition from neural stem cell maintenance to differentiation. Progress has also been made in understanding the later stages of development, when neuroblasts become mitotically inactive, or quiescent, and are then reactivated postembryonically to generate the neurons that make up the adult nervous system. The ability to manipulate the steps leading from quiescence to proliferation and from proliferation to differentiation will have a major impact on the treatment of neurological injury and neurodegenerative disease.
Dobutamine Stress Echocardiography in Preoperative and Long‐Term Postoperative Risk Assessment of Elderly Patients
Authors: Dhond Milind R. , Nguyen Than T. , Sabapathy Raju , Patrawala Rob A. , Bommer William J.
Published: February 2007

The authors reviewed all negative preoperative dobutamine stress echocardiograms (DSEs) performed over a 3‐year period to determine the value of negative DSE for preoperative risk assessment in elderly patients. All patients with negative DSE performed for preoperative evaluation were followed. Cardiac event rates during and after the operative procedure were determined for hard end points (nonfatal myocardial infarction, cardiac death) and soft end points (emergency room visits, hospitalization for unstable angina, congestive heart failure, coronary angioplasty, coronary artery bypass graft surgery). Results noted that DSEs were negative for ischemia in 82 preoperative evaluations. Group 1 (age=65; n=41) had hard and soft event rates per patient/year of 0.97% and 7.3%, while group 2 (age <65; n=41) had hard and soft event rates per patient/year of 0.81% and 10.8%. There were no significant differences in event rates between the two groups (p=NS). In conclusion, the authors found that negative DSEs predict low cardiac event rates in elderly patients during the perioperative and long‐term postoperative periods, which are not significantly different from the cardiac event rates in a younger cohort.
Heart Failure in the Elderly: Strategies to Optimize Outpatient Control and Reduce Hospitalizations
Authors: Rich Michael W.
Published: February 2007

Heart failure is a disorder that disproportionately affects the elderly, and over 50% of heart failure hospitalizations in the United States occur in persons over 75 years of age. Moreover, despite recent advances in heart failure therapy, optimal treatment of elderly patients remains undefined. In addition, heart failure management in older persons is often complicated by the presence of multiple comorbid conditions, polypharmacy, psychosocial and behavioral concerns, dietary issues, and economic considerations. As a result, management of heart failure in the elderly requires a coordinated, multidisciplinary approach, and a series of recent studies have documented the efficacy of heart failure disease management programs in reducing readmissions, enhancing medication and dietary compliance, and lowering cost of care. Ongoing studies will provide insights into the feasibility and effectiveness of implementing heart failure disease management programs on a population‐wide basis, and on the effects of such programs on long‐term clinical outcomes and costs.
Ventricular Resynchronization: A Promising Therapy for Heart Failure
Authors: Kumar Uday N. , Saxon Leslie A.
Published: February 2007

Primarily a disease of the elderly, heart failure continues to be an ever‐increasing health care problem given the growth in the number of individuals over age 65. Although there have been many advances in the pharmacologic management of heart failure, there continues to be a significant number of patients with persistent symptoms despite maximal therapy and it is likely that this group of patients will only continue to increase in number. Given this, significant research has gone into exploring new modalities, such as device therapies, to treat heart failure. Of these, ventricular resynchronization has emerged as one of the most promising. This review will examine the most important aspects of ventricular resynchronization therapy including: the significance of ventricular dyssynchrony, the role of traditional pacemakers, the effects on contractile function and reverse remodeling, and the currently accepted indications for resynchronization devices. Additionally, various aspects of completed and ongoing trials will be discussed.
Outcomes of Treating Hypertension in the Elderly: A Short Commentary on Current Issues
Authors: Weber Michael A.
Published: February 2007

Because treating hypertension in the elderly so effectively reduces major cardiovascular events, it is vital to diagnose this very common condition early. Much of the hypertension that occurs with aging results from stiffening of the major capacitance arteries, typically marked by high systolic and low diastolic blood pressures. Pulse pressure, derived by subtracting diastolic from systolic values, is a useful index of stiffness, but new noninvasive techniques for measurement of arterial compliance have shown that blood pressures cannot reliably predict the state of the arteries in older people. The Systolic Hypertension in the Elderly Program (SHEP) and the Systolic Hypertension in Europe (Syst‐Eur) trial demonstrated that treating hypertension in the elderly with diuretics or calcium channel blockers reduces strokes and cardiac events; these results are also clearly evident in high‐risk groups like diabetics. Further analysis of Syst‐Eur has suggested that a calcium channel blocker reduces new‐onset dementia, while follow‐up data from SHEP indicate that a diuretic provides survival and stroke benefits in obese or overweight elderly hypertensives, but not in the lean. In general, comparisons of antihypertensive agents, including diuretics, βblockers, angiotensin‐converting enzyme inhibitors, and calcium channel blockers have found similar clinical end point effects. But recently, the Losartan Intervention For End Point Reduction in Hypertension (LIFE) study, performed in patients (average age, 67) with left ventricular hypertrophy and predominant systolic hypertension, showed that the angiotensin receptor blocker losartan was significantly more effective than the β blocker atenolol in reducing such key outcomes as strokes and new‐onset diabetes. Even so, careful but effective control of blood pressure in elderly patients, including those over age 80, still remains a critical factor in preventing major cardiovascular events.
Noninvasive Cardiac Testing in the Geriatric Patient
Authors: Fleischmann Kirsten E.
Published: February 2007

The use and interpretation of noninvasive cardiac testing in the elderly may differ from that in younger patients due to changes in disease prevalence, normal values, comorbidities, or patient and physician preferences. This paper reviews the experience with several commonly used noninvasive tests such as electrocardiography, exercise testing, and stress imaging with echocardiography or with scintigraphy in geriatric patients. Most commonly used noninvasive tests remain feasible and safe. Data suggest that exercise stress testing is feasible in many elderly patients with a good safety profile and should be considered as a first‐line test due to the extra information provided by the duration and hemodynamic response to exercise. Adjunctive imaging may be particularly helpful when the electrocardiogram is uninterpretable or suspect due to underlying baseline abnormalities or when determining the extent or distribution of ischemia is felt to be important.
Circadian and Orthostatic Blood Pressure Is Abnormal in the Carotid Sinus Syndrome
Authors: Mulcahy Ríona , Jackson Stephen H.D. , Richardson David A. , Lee David R. , Kenny Rose Anne
Published: February 2007

The authors' objective was to determine circadian blood pressure behavior and the prevalence of orthostatic hypotension in patients with cardioinhibitory carotid sinus syndrome. A prospective consecutive series of 160 patients (mean age, 72 [65–83]) with recurrent syncope attributed to cardioinhibitory carotid sinus syndrome was recruited. Mean maximal slowing of heart rate was 4.5 seconds (3.0–5.5 seconds) during carotid sinus massage. Patients had cardiovascular assessments, including 24‐hour ambulatory blood pressure measurements (recordings every half‐hour during daytime, hourly at night) and morning orthostatic blood pressures before pacemaker implants. Ambulatory measurements were compared with those of 98 age‐and sex‐matched controls. Nocturnal systolic blood pressure (130.0±21.0 vs. 122.1±16.7 mm Hg; p<0.005), diastolic blood pressure (72.8±12.5 vs. 68.7±9.7 mm Hg; p<0.005), and heart rate (66.5±9.4 vs. 65.2±9.7 bpm; p<0.005), were significantly higher in patients and independent of cardiovascular medication, cardiovascular diagnoses, and orthostatic hypotension. Almost one half of carotid sinus syndrome patients also had orthostatic hypotension. Blood pressure behavior is abnormal in patients with carotid sinus syndrome as represented by altered nocturnal blood pressures and high prevalence of orthostatic hypotension.
The Prevalence of Falls in Older Persons Paced for Atrioventricular Block and Sick Sinus Syndrome
Authors: Seifer Colette , Kenny Rose Anne
Published: February 2007

Falls are a major health priority. Eight percent of persons over age 70 present to emergency departments each year due to a fall; fall‐related injuries account for 6% of all medical expenditures for persons age 65 and older in the United States. Pacing reduces falls by 70% in patients with cardioinhibitory carotid sinus hypersensitivity. The prevalence of falls in other bradyarrhythmic disorders is not known. The purpose of the following study was to compare the prevalence of falls in older adults with atrioventricular block and sick sinus syndrome with case controls. Consecutive subjects who had pacemakers implanted for atrioventricular block and sick sinus syndrome were assessed. Age and gender‐matched admissions to the coronary care unit were similarly studied. Eighty‐one subjects were included in the study, 31 paced and 50 controls. There were 134 falls in the bradyarrhythmic group and 12 in the control group. The authors conclude that this is the first series that clearly shows a significant association between atrioventricular block, sick sinus syndrome, and falls. Further prospective studies are needed to substantiate these results.
Short‐Term Efficacy and Safety of Extended‐Release Fluvastatin in a Large Cohort of Elderly Patients
Authors: Bruckert Eric , Lièvre Michel , Giral Philippe , Crepaldi Gaetano , Masana Luis , Vrolix Matthias , Leitersdorf Eran , Dejager Sylvie
Published: February 2007

The efficacy and safety of lipid‐lowering agents in elderly individuals have not been extensively assessed. This population generally takes more drugs concurrently than middle‐aged patients, and are therefore at higher risk of drug‐drug interactions. This large‐scale, randomized, double‐blind, placebo‐controlled study investigated the efficacy and safety of extended‐release (XL) fluvastatin 80 mg once daily for up to 1 year in elderly patients with primary hypercholesterolemia. A total of 1229 patients (mean age, 75.5 years) were randomized. After 2 months of treatment, fluvastatin XL 80 mg significantly decreased plasma lipid levels from baseline compared with placebo; fluvastatin reduced total cholesterol by 25% compared with a decrease of 2.5% in the placebo group, low‐density lipoprotein cholesterol was −33% vs. −2.5%, respectively, and triglycerides were −13.3% vs. 2.9%, respectively (p<0.00001). The safety profile of fluvastatin XL was similar to that of placebo. Fluvastatin XL 80 mg once daily was well tolerated and effectively managed plasma lipid profiles in a large cohort of elderly patients. These findings are consistent with data obtained previously in younger recipients of fluvastatin XL 80 mg, and reinforce the safety of fluvastatin in a population at high risk of drug‐drug interactions.
Anticoagulation in the Elderly
Authors: Dhond Abhay J. , Michelena Hector I. , Ezekowitz Michael D.
Published: February 2007

This review will address the general approach to the management of the typical elderly patient requiring anticoagulation. Most of the data has been derived from studies of patients with non‐valvular atrial fibrillation. Data from postmyocardial infarction trials have also been included. A practical clinical approach to anticoagulation in the elderly is described. Emphasis has been placed on maximizing the benefit and reducing the risk of anticoagulation in the rapidly expanding group of elderly patients aged ≥75 who are at the greatest risk of stroke and are likely to benefit the most from antithrombotic therapy.
Diagnosis of Aortic Stenosis in the Elderly: Role of Echocardiography
Authors: Alipour Massoud S. , Shah Pravin M.
Published: February 2007

Doppler echocardiography provides accurate hemodynamic information for the diagnosis, assessment and follow‐up of patients with aortic stenosis, making diagnostic cardiac catheterization redundant in most cases. Considering the rapid growth of the aging population and the high incidence of aortic stenosis, as the most common valvular heart disease in the age group, the authors have described the utility of the Doppler technique with a brief discussion of the clinical evaluation of these patients. Close observation of patients with asymptomatic aortic stenosis has been emphasized. Decision‐making about the appropriate timing for aortic valve replacement is of immense clinical significance, which may be facilitated and achieved by the periodic follow‐up and the use of this noninvasive method. Following a comprehensive echo‐Doppler evaluation, the patient would only need coronary arteriography prior to surgery. The utility of hemodynamic and anatomic information by echocardiography in this type of surgery is emphasized.
Is There Any Indication for Aortic Valvuloplasty in the Elderly?
Authors: Dauterman Kent W. , Michaels Andrew D. , Ports Thomas A.
Published: February 2007

Elderly patients with severe symptomatic calcific aortic stenosis do poorly with medical management. The optimal treatment for this group of patients is surgical valve replacement. Balloon valvuloplasty may be useful as a bridge to aortic valve replacement in hemodynamically unstable patients, in patients undergoing emergent noncardiac surgery, and in patients with severe comorbidities who are too ill to undergo cardiac surgery. Balloon valvuloplasty often results in symptomatic improvement; however, the postvalvuloplasty valve area is usually <1.0 cm2, the major periprocedural complication rate is roughly 5%, and the 6‐month restenosis rate is quite high. There is no evidence that balloon valvuloplasty alters the natural history of aortic stenosis, although no randomized study has been performed.
Calcific Aortic Stenosis in the Elderly: A Brief Overview
Authors: Sawhney Neil , Hassankhani Alborz , Greenberg Barry H.
Published: February 2007

Aortic stenosis is the most common valvular lesion in patients above the age of 65. The etiology, presentation, and management of aortic stenosis differs in the elderly compared to younger patients in many ways. Many of the classic physical findings are absent in the elderly, making the diagnosis of critical aortic stenosis more difficult. Due to coexisting morbidity in many elderly patients, there is often a reluctance to recommend aortic valve replacement despite the dismal prognosis of medical therapy. In the following review, the authors discuss the pathophysiology, presentation, and management of aortic stenosis in the elderly.
Infective Endocarditis in the Elderly: Diagnosis and Management
Authors: Gregoratos Gabriel
Published: February 2007

Infective endocarditis is seen with increasing frequency in older patients. This increase is due to the general aging of the population, improved survival of patients with congenital and valvular heart disease, and the increasing use of catheters and other prosthetic devices with resulting higher incidence of nosocomial endocarditis. In older patients, infective endocarditis frequently develops in the absence of underlying structural heart disease; atheromatous deposits and mitral annular calcification are two important risk factors in this population. Infective organisms in older patients are frequently enterococci and other gastrointestinal tract bacteria. A marked febrile response is uncommon whereas central nervous system symptoms are more common in older patients. Transesophageal echocardiography can be performed safely and is a major diagnostic tool with sensitivity of more than 90% in detecting vegetations as small as 2–5 mm. Appropriately drawn blood cultures provide bacteriologic diagnosis in 80%–99% of patients. Prolonged antibiotic therapy may be required in many instances depending on the infective organism. Early surgical therapy is advisable for patients who develop heart failure as a result of severe acute aortic valvular regurgitation. Valve replacement surgery can be performed with acceptable mortality and morbidity even in very elderly patients.
Percutaneous Coronary Intervention in the Elderly: Procedural Success and 1‐Year Outcomes
Authors: Eckart Robert E. , Shry Eric A. , Simpson Daniel E. , Stajduhar Karl C.
Published: February 2007

Clinical trials have found increased morbidity in elderly persons presenting for percutaneous coronary intervention for chronic stable angina. Long‐term follow‐up is limited for the elderly following percutaneous coronary intervention. The authors reviewed all coronary interventions performed from January 1998 to August 2001. One year following the procedure, subjects were screened for death, need for revascularization, and myocardial infarction. There were 401 subjects aged ≥65years (mean 73.4±6.0years) and 479 subjects aged <65years (mean 55.6±6.7 years). Although there was no difference in 1‐year rate of subsequent myocardial infarction or in revascularization, the elderly were more likely to die during hospitalization (4.7% vs. 1.0%, p<0.01), and at 1 year (10.2% vs. 4.0%, p<0.01). When controlled for ejection fraction, age was no longer significant in either predischarge mortality or in 1‐year mortality. Excess postpercutaneous coronary intervention mortality in the elderly may be due to underlying comorbidities and not due to subsequent myocardial infarction or revascularization.
Thrombolytic Therapy Is Indicated for Patients Over 75 Years of Age With ST‐Elevation Acute Myocardial Infarction: Antagonist Viewpoint
Authors: Aronow Wilbert S.
Published: February 2007

From the available data, one cannot conclude whether thrombolytic therapy is beneficial or detrimental in patients older than age 75 years with acute myocardial infarction. Data favor the use of primary percutaneous transluminal coronary angioplasty rather than thrombolysis in eligible patients older than age 75 years with acute myocardial infarction to reduce mortality, recurrent myocardial infarction, stroke, and intracranial hemorrhage. High‐risk elderly patients with acute myocardial infarction, such as those with a large anterior myocardial infarction complicated by heart failure and hypotension, those with persistent ischemic pain or marked ST‐segment changes, those with hemodynamic instability, and those at high risk for stroke or bleeding complications, should, especially, be treated with percutaneous transluminal coronary angioplasty.
Willingness to Participate in Cardiac Trials
Authors: Peterson Eric D. , Lytle Barbara L. , Biswas Mimi S. , Coombs Laura
Published: February 2007

The elderly, women, and minorities are all less likely to be enrolled in randomized clinical trials (RCTs). Whether differential patient interest in RCTs contributes to these disparities is unclear. The authors surveyed 660 patients' willingness to consider two potential cardiac RCTs of medical therapy vs. percutaneous coronary angioplasty or coronary artery bypass surgery, respectively. The cohort's mean age was 67 years (43% aged ≥70 years; 35% women; and 28% nonwhite). Compared with younger patients, those aged ≥70 years were equal or more likely to consider both the percutaneous coronary angioplasty (46% vs. 41%) and coronary artery bypass surgery RCTs (35% vs. 31%). Race also had no significant impact on trial enrollment, yet women were significantly less likely than men to participate in either RCT. In conclusion, patient willingness to consider RCT participation does not explain underenrollment of elderly and minority patients. Women, however, were more reluctant to consider RCTs, an area requiring further study.
Chronic Angina Pectoris: Inadequacies of Current Therapy
Authors: Parker John O.
Published: February 2007

Chronic angina is a major medical problem in the United States with more than 6 million patients affected, a number that will increase substantially because of the progressive aging of the population. The annual mortality rate for patients with chronic angina is approximately 2%, but is much higher in certain subsets of patients, particularly the elderly. Angina is also associated with major social and economic burdens. Because of poor symptom control and hemodynamic, as well as other drug side effects, angina is commonly associated with a poor quality of life. No new class of drug has been available for angina treatment in more than two decades, and current medications frequently fail to provide adequate symptom control. Thus, the majority of patients are taking two or three antianginal medications. New agents that modulate myocardial metabolism have shown antianginal efficacy, a favorable side‐effect profile, and an absence of hemodynamic effects.
Effect of a Long‐Term, Community‐Based Cardiac Rehabilitation Program on Middle‐Aged and Elderly Cardiaac Patients
Authors: Lee SoJung , Naimark Barbara , Porter Michelle M. , Ready A. Elizabeth
Published: February 2007

The purpose of this retrospective study was to compare the effects of a 2‐year, community‐based cardiac rehabilitation exercise program on cardiovascular fitness, body fatness, and blood lipids in middle‐aged (≤65 years, n=42) and elderly (>65 years, n=40) male cardiac patients. Estimated maximal metabolic equivalents increased in both groups; however, the increase was greater for middle‐aged patients (p =0.003). High‐density lipoprotein cholesterol level increased significantly after 1 year in both groups, but the change was greater for the middle‐aged subjects by Year 2 (p=0.02). The total cholesterol/high‐density lipoprotein cholesterol ratio and serum triglyceride levels decreased in both groups, whereas total cholesterol and low‐density lipoprotein cholesterol levels decreased only in the elderly group (p <0.01). Body fatness did not change in either group. These findings reinforce the importance of referring elderly as well as middle‐aged patients to community‐based cardiac rehabilitation exercise programs.
The Prognostic Value of Vasodilator Myocardial Perfusion Imaging in Octogenarians
Authors: Curtis Jeptha P. , Ko Dennis T. , Wang Yun , Wackers Frans J.T. , Foody JoAnne M.
Published: February 2007

The ability of single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) to stratify risk in octogenarians is poorly defined. The authors identified 439 octogenarians who underwent vasodilator SPECT MPI between 1994 and 2000. Over a mean 2.5 years of follow‐up, moderate and large stress defects were associated with increased crude mortality (normal: 24.5%, small defect: 21.9%, moderate or large stress defect: 41.4%, p for trend <0.001). The degree of defect reversibility was also strongly associated with increased mortality (normal: 24.5%, no reversibility: 22.0%, small reversible defect: 36.5%, moderate or large reversible defect: 50.0%, p for trend <0.001). In multivariable analysis, stress defects were the strongest predictor of mortality (hazard ratio, 2.39; 95% confidence interval, 1.56–3.65). The mortality of octogenarians with moderate or large perfusion defects is nearly double that of patients with normal or mildly abnormal MPI. Appropriately selected octogenarians with abnormal vasodilator SPECT imaging may benefit from more aggressive management of their cardiac disease.
Impact of Aging on Hostility in Coronary Patients and Effects of Cardiac Rehabilitation and Exercise Training in Elderly Persons
Authors: Lavie Carl J. , Milani Richard V.
Published: February 2007

Hostility is a coronary artery disease (CAD) risk factor affecting recovery after major CAD events. Yet, few data exist on the impact of aging on hostility in CAD patients or the effects of cardiac rehabilitation on elderly patients with high hostility. The authors studied 500 consecutive patients following CAD events to determine the impact of aging on hostility scores, the prevalence of hostility symptoms, and the response of elderly persons with hostility symptoms to cardiac rehabilitation programs. Overall hostility scores (p<0.01) and prevalence of hostility symptoms (8% in 268 elderly vs. 28% in 81 younger patients [aged <50 years]) were inversely related to age (p<0.01). Elderly persons with hostility symptoms had greater weight (p=0.02), four times higher anxiety and depression scores (p<0.0001), two times higher scores for somatization (p<0.0001), and 17% lower scores for quality of life (p<0.001) compared with elderly persons without hostility symptoms. Marked reduction in hostility and improvements in other risk factors occurred following rehabilitation. These results demonstrate the inverse relationship between age and hostility symptoms in patients with CAD. Although hostility symptoms are relatively uncommon in elderly persons with CAD, these patients have more adverse CAD risk profiles and still have marked improvements following cardiac rehabilitation and exercise training programs.
Mode of Death From Congestive Heart Failure: Implications for Clinical Management
Authors: Derfler Mary Clare , Jacob Mark , Wolf Robert E. , Bleyer Frank , Hauptman Paul J.
Published: February 2007

The care of the end‐stage patient has not been extensively studied, and little is known about best care practices. Therefore, using new definitions for mode of death due to heart failure, we performed a retrospective chart review of records from a university‐based heart failure disease management program to characterize the population of patients dying from heart failure and to define clinical predictors that identify patients who will likely die of metabolic and/or progressive causes. Of 74 deaths recorded over a 60‐month period, 17.6% and 21.3% were deemed to be metabolic or progressive, respectively. Utilization of resources was considerable, and only a small number of patients died while in hospice. Patients who required continuous inotropic support and those with preexisting renal failure were at highest risk for non‐sudden cardiac death. We conclude that prospective identification of patients at risk for metabolic and progressive heart failure death is possible. The numbers of these patients is likely to increase in an era of implantable cardioverter‐defibrillators. Intervention studies designed to evaluate and improve strategies that emphasize symptom control should target this group.
“Tako‐Tsubo‐Like Left Ventricular Dysfuntion”: A clinical Entity Mimicking Acute Myocardial Infarction With a Favorable Prognosis
Authors: Farouque H. M. Omar , Kaltenbach Tonya , Ako Junya , Tremmel Jennifer A. , Fearon William F. , Yeung Alan C. , Vagelos Randall H.
Published: February 2007

An emotionally‐distressed, elderly Caucasian woman presented with chest pain and hypertension. Electrocardiogram showed inferior ST‐segment elevation, and an urgent cardiac catheterization was performed. Coronary angiography revealed normal appearing coronary arteries; however, left ventriculography showed extensive left ventricular apical akinesis. The patient had a mild rise in cardiac enzyme levels indicative of myocardial injury. She was discharged after an uncomplicated in‐hospital course. One month later, the left ventricular wall motion abnormality had improved. In this report, the authors discuss this compilation of findings known as tako‐tsubo‐like left ventricular dysfunction.
Better Late Than Never: How Congestive Heart Failure Patients Die
Authors: Basta Lofty L.
Published: February 2007

While you do not know life, how can you know about death? Confucius 551–479 BC

The Confucian Analects bk 11:11
End‐of‐Life Medical Treatment of Older Cardiac Patients
Authors: Basta Lofty L.
Published: February 2007

The last decade saw breathtaking advances in the science and technology of heart disease. Fewer patients die from an acute myocardial infarction or acute stroke, or have a sudden death. Thanks to modern technology, people live much longer, but more than half still die of heart disease, mostly chronic. Training programs concentrate on mastery of procedures; the discipline of cardiology has become fragmented into noninvasive, nuclear, invasive, interventional, electrophysiology, heart failure, transplantation, and research. Dying persons expect to receive attention to their spiritual and psychosocial, as well as their physical needs. Ordinary people speak of lack of suffering, no unnecessary interventions that postpone the moment of an inevitable dying, not being a burden on others, and having a sense of control. Their assessment of quality may not match that of doctors who speak in terms of science and technology. Review of the limits of modern technology; understanding of existing laws; the near irrelevance of living wills; the role of the physician in the diagnosis of medical futility; the early indications of depression; and, more importantly, better communication with the patient and his/her loved ones are essential components of the practice of medicine. Cardiologists should differentiate between what should be done and what could be done for their patients.
Advance Care Planing
Authors: Lo Bernard
Published: February 2007

Advance directives allow patients to have some control over decisions even when they are no longer able to make decisions themselves. All states authorize written advance directives, such as the appointment of a health care proxy, but commonly impose procedural requirements. Some states have restricted the use of oral advance directives, although they are frequently used in everyday practice. Advance directives are limited because they are infrequently used, may not be informed, and may conflict with the patient's current best interests. Moreover, surrogates often cannot state patients' preferences accurately. Furthermore, discussions among physicians and patients about advance directives are flawed. Physicians can improve discussions about advance directives by asking the patient who should serve as proxy and by ascertaining the patient's values and general preferences before discussing specific clinical situations.
Severity of heroin use in Israel: comparisons between native Israelis and former Soviet Union immigrants
Authors: Isralowitz Richard , Reznik Alexander , Spear Suzanne E. , Brecht Mary Lynn , Rawson Richard A.
Published: February 2007

Aims  This study examined drug use patterns and severity among native‐Israeli and former Soviet Union (FSU) immigrants in Israel who reported heroin use.

Design, setting and participants  a total of 272 native Israelis and 300 FSU heroin users were interviewed from 2002 to 2006 as part of a large drug use surveillance study in Israel. Individuals were sampled at an intake centre, a methadone clinic and a day‐treatment facility in the Negev region of Israel. Participants were assessed using the Addiction Severity Index, fifth edition. Native Israeli and FSU users were compared within two groups: those interviewed at intake and those interviewed in treatment.

Findings  Overall, ASI composite scores suggested generally comparable levels of addiction severity between the two ethnic groups. Native‐born Israelis reported more years of heroin use; however, the FSU immigrants reported longer use of other opiates. The FSU reported significantly more heroin use by injection, and a significantly higher rate of hepatitis C and other chronic medical problems. Comparisons by gender within each group revealed higher drug severity scores for females (native‐born Israeli and FSU combined). Females in the intake group had significantly higher severity scores in the areas of employment and psychiatric status when compared to individuals who had been in treatment for some time.

Conclusions  Except for higher levels of alcohol use, the FSU did not have more severe drug problems than the native Israelis as measured by ASI severity scores. Injection use among FSU, however, is a critical public health problem, especially given the well‐established link between injection drug use, hepatitis C and HIV/AIDS.
Discrepancies in estimates of prevalence and correlates of substance use and disorders between two national surveys
Authors: Grucza Richard A. , Abbacchi Anna M. , Przybeck Thomas R. , Gfroerer Joseph C.
Published: February 2007

Aim  To assess the degree to which methodological differences might influence estimates of prevalence and correlates of substance use and disorders by comparing results from two recent surveys administered to nationally representative US samples.

Methods  Post‐hoc comparison of data from the 2002 National Survey on Drug Use and Health (NSDUH) with data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) administered in 2001–02.

Results  Prevalence estimates for all substance use outcomes were higher in the NSDUH than in the NESARC; ratios of NSDUH to NESARC prevalences ranged from 2.1 to 5.7 for illegal drug use outcomes. In the NSDUH, past‐year substance use disorder (SUD) prevalence estimates were higher for cocaine and heroin, but were similar to NESARC estimates for alcohol, marijuana and hallucinogens. However, prevalence estimates for past‐year SUD conditional on past‐year use were substantially lower in the NSDUH for marijuana, hallucinogens and cocaine. Associations among drug and SUD outcomes were substantially higher in the NESARC. Total SUD prevalence did not differ between surveys, but estimates for blacks and Hispanics were higher in the NSDUH.

Conclusion  A number of methodological variables might have contributed to such discrepancies; among plausible candidates are factors related to privacy and anonymity, which may have resulted in higher use estimates in the NSDUH, and differences in SUD diagnostic instrumentation, which may have resulted in higher SUD prevalence among past‐year substance users in the NESARC.
Genes, time to first cigarette and nicotine dependence in a general population sample of young adults
Authors: Haberstick Brett C. , Timberlake David , Ehringer Marissa A. , Lessem Jeffrey M. , Hopfer Christian J. , Smolen Andrew , Hewitt John K.
Published: February 2007

Aim  To examine variation in nicotine dependence scores and covariation between different dependence symptoms.

Design  A 12‐year, nationally representative, probability‐based survey of adolescent health‐related behaviors and their outcomes during young adulthood in the United States. The genetic contribution to nicotine dependence was evaluated in the sibling‐pairs sample of the US National Longitudinal Study of Adolescent Health.

Measurements  Nicotine dependence (ND) was assessed using the Fagerström Test for Nicotine Dependence (FTND) and Heaviness of Smoking Index (HSI) in 1154 young adults, between the ages of 18 and 25 years, who were from twin, full sibling and half‐sibling pairs.

Findings  Dependence in this sample was common and varied in degree. Total HSI scores evidenced moderate to large heritable contributions (61%, 95% confidence interval (CI): 0.46–0.72), as did the quantity of cigarettes smoked (52%, 95% CI: 0.39–0.63) and urgency to smoke (55%, 95% CI: 0.38–0.68). Multivariate modeling identified a highly heritable underlying factor (76%, 95% CI: 0.56–0.91) that influenced the covariation of dependence symptoms and loaded most heavily on how soon after waking a smoker uses his or her first cigarette. The quantity of cigarettes smoked per day also evidenced residual genetic influences that were not common to other dependence‐related behaviors.

Conclusions  In this sample of young adults from the general population, both genes and individual‐specific environments are important etiological factors in ND. The urgency to smoke, as measured by the time to first cigarette, may be the most informative measure on the FTND for genetic studies of nicotine dependence.
Risk factors for methadone outside treatment programs: implications for HIV treatment among injection drug users
Authors: Vlahov D. , O'Driscoll P. , Mehta S. H. , Ompad D. C. , Gern R. , Galai N. , Kirk G. D.
Published: February 2007

Background  Diversion of methadone outside treatment programs occurs, yet reasons for use of ‘street methadone’ are characterized poorly. Self‐medication for withdrawal symptoms is one plausible hypothesis. Among HIV‐infected drug users, some antiretroviral medications can reduce potency of methadone, yet any association between such effects and the use of supplemental methadone sources remains undetermined.

Objective  To estimate the frequency and risk factors for use of street methadone.

Methods  Injection drug users (IDUs) recruited through extensive community outreach in 1988–89 and 1994 were followed semi‐annually with questionnaires about health history, use of licit and illicit drugs including methadone and HIV‐related assays. Analyses were performed using generalized estimating equation logistic regression.

Results  Of 2811 IDUs enrolled and eligible for analysis, 493 people reported use of street methadone over 12 316 person‐years of follow‐up (4.0/100 person‐years). In multivariate analyses, street methadone use was more common among women, whites, those 40–59 years old, those who reported withdrawal symptoms, past methadone program attendance (6–12 months before visit), recent heroin injection with or without cocaine (but not cocaine alone), smoking or sniffing heroin and reported trading sex. Street methadone was not associated with HIV infection or treatment.

Conclusion  The results suggest that older IDUs still using heroin may be using street methadone to treat signs of withdrawal. The absence of a higher rate of street methadone use in HIV seropositive IDUs reveals that antiretroviral/methadone interactions are not a primary determinant of use outside of treatment settings.
Tolerance in banana to Fusarium wilt is associated with early up‐regulation of cell wall‐strengthening genes in the roots
Authors: VAN DEN BERG NOËLANI , BERGER DAVE K. , HEIN INGO , BIRCH PAUL R. J. , WINGFIELD MICHAEL J. , VILJOEN ALTUS
Published: February 2007

Fusarium wilt, caused by the fungal pathogen Fusarium oxysporum f. sp. cubense (Foc), is one of the most destructive diseases of bananas. In the tropics and subtropics, Cavendish banana varieties are highly susceptible to Foc race 4 (VCG 0120). Cavendish selection GCTCV‐218 was shown to have significantly lower disease severity and incidence compared with susceptible cultivar Williams in replicated greenhouse and field trials. Suppression subtractive hybridization (SSH) was previously carried out to identify genes induced in roots of GCTCV‐218, but not in Williams, after infection with Foc‘subtropical’ race 4. Seventy‐nine SSH clones were sequenced and revealed 13 non‐redundant gene fragments, several of which showed homology to defence‐associated genes, including cell wall‐strengthening genes. Quantitative RT‐PCR was used to confirm up‐regulation and differential expression of a number of genes throughout a time‐course, following Foc infection in the tolerant GCTCV‐218 when compared with susceptible cv. Williams. Tolerance of GCTCV‐218 was linked to significantly increased induction of cell wall‐associated phenolic compounds.
Planned telephone support for disadvantaged parents in North Wales: perceptions of service users
Authors: Madoc‐Jones Iolo , Warren Emily , Ashdown‐Lambert Joan , Williams Elaine , Parry Odette
Published: February 2007

This paper draws on the findings of a qualitative evaluation to examine user perceptions of a planned telephone support intervention based in a disadvantaged area in North Wales. Telephone support services are tailored differentially to offer information, advice and/or counselling on a crisis‐led or planned‐intervention basis. Research focusing on telephone support, for the most part (and particularly in the UK) has examined crisis‐led as opposed to planned support services. The findings of our study resonate with earlier research findings about telephone support that suggest provision of non‐visual support in social care can overcome some practical and financial difficulties for users with little discernible loss to their experience of satisfaction with the service. In addition, the paper suggests that planned support may provide a valuable service to users who are most disadvantaged and marginalized and who have found traditional forms of support unsatisfactory. For such users, planned telephone support can offer one‐to‐one communication tailored to specific client needs. Moreover, it can enable the development of user trust in the service which empowers users to operationalize strategies in the context of a reliable, sustained, unthreatening (and thus minimal risk) relationship.
Discordance of ZAP‐70 in patients with chronic lymphocytic leukemia
Authors: CHAAR B. T. , SCHERGEN A. K. , GROSSO L. E.
Published: February 2007

B‐cell chronic lymphocytic leukemia has a highly variable clinical course with behavior ranging from indolent to aggressive. Identified prognostic markers include IgVH mutational status, and CD38 and ZAP‐70 expression. In several studies, ZAP‐70 expression correlated with IgVH mutational status, and predicted disease progression and overall survival. In addition to its prognostic utility, ZAP‐70 expression was found to be constant over time, and did not vary between peripheral blood, bone marrow or lymph node specimens in individual patients. In contrast to these reports, we present three CLL patients with discordant ZAP‐70 levels. One demonstrated a change in expression with time; the second and third cases had discordant results in blood, lymph node and bone marrow and between blood and bone marrow specimens, respectively, obtained at the same time.
Severe antibody‐mediated agranulocytosis
Authors: JOHNSEN H. , HUSEBEKK A. , SKJELBAKKEN T.
Published: February 2007

A 56‐year‐old female with Crohn's disease was admitted to the hospital with malaise, fever, and a low white blood cell count (0.8 × 109/l) with no granulocytes or myeloid precursor cells in the bone marrow. The leucopenia was initially thought to be the result of an infection and she was treated with antibiotics and granulocyte colony‐stimulating factor (G‐CSF, filgrastim). However, the bacterial cultures and viral tests were all negative. The patient's condition deteriorated and she became morbidly ill, but recovered after high dose steroid treatment. Six weeks later she relapsed whilst receiving 7.5 mg daily dose of prednisolone. She recovered quickly after being given high dose methylprednisolone in combination with filgrastim. A high maintenance dose of prednisolone was tapered over 5 months. She has not relapsed since and is currently well.

Antibodies to the human neutrophil antigen (HNA)‐3a were detected, but these antibodies could not easily explain her agranulocytosis as she had a HNA‐3a negative phenotype. It seems plausible that her agranulocytosis was immune mediated through autoantibodies directed towards the early myeloid cells.