bluuebunny/crossref_metadata_2025 huggingface dataset:
Using clinical tests of colour vision to predict the ability of colour vision deficient patients to name surface colours
Authors: Cole Barry L. , Lian Ka‐Yee , Lakkis Carol
Published: June 2007

Purpose:  To determine the predictive power of commonly used tests for abnormal colour vision to identify patients who can or cannot name surface colours without error.

Methods:  The colour vision of 99 subjects with colour vision deficiency (CVD) was assessed using the Ishihara, the Richmond HRR (2002), the Farnsworth D15, the Medmont C100 and the Nagel anomaloscope. They named 10 surface colours (red, orange, brown, yellow, green, blue, purple, white, grey and black), which were presented in two shapes (lines and dots) and three sizes. The surface colours were also named by an age‐matched group of 20 subjects with normal colour vision. The performance of the clinical tests to predict the CVD subjects who made no colour naming errors and those who made errors is expressed in terms of the predictive value of a pass P(P) and the predictive value of a fail P(F).

Results:  The P(P) values of the tests were between 0.59 and 0.70 and P(F) values were between 0.77 and 1.00.

Conclusions:  A ‘mild’ classification with the Richmond HRR test, especially if no more than two errors are made on the HRR diagnostic plates, identifies patients with abnormal colour vision who are able to name surface colour codes without error or only the occasional error. A pass of the Farnsworth D15 test identifies patients who will make no or few (up to 6%) errors with a 10 colour code, but who will be able to name the colours of a seven colour code that does not include orange, brown and purple. If protans are excluded, the predictive value for a pass P(P) for the Farnsworth D15 is improved from 0.59 to 0.70. The anomaloscope is not an especially good predictor of those who can recognise surface colour codes. However, an anomaloscope range >35 units identifies those who have difficulty in recognising surface colour codes, as does a fail at the Farnsworth D15 test.
Graphics Based Humour: Its Contribution to Learning and Understanding
Authors: BLYTHE‐LORD ROBIN
Published: June 2007

The educational use of humour, when it is used during live teaching, appears to be mainly that of maintaining attention and improving audience attitude. It may be unplanned, opportunist and driven by events, or consciously worked into a presentation, lecture or demonstration, nevertheless the quality, pertinence and effectiveness of the humour is very much due to the individual's sense of humour, timing and sensibilities.

Some teacher's views on humour are that it is in some way divorced from learning (which is a properly serious thing) and only useful to alleviate boredom and stress. A typical response might run as follows:

1. Humour is flippant, deconstructive and diverts from the true path of knowledge, 2. If this paper is about humour then it is going to be terribly dull, 3. OK then, make me laugh.

This current research, which is at an early stage, is concerned with applications of textual and illustrative humour in teaching materials for 18–22 year old undergraduate students. It will consider the possibility that humour can positively contribute to understanding, creativity and learning, and whether an application model can be constructed to help teachers, authors and learners.
Art Education in Initial Teacher Education: A Negotiated Education
Authors: ROGERS MAGGIE , PLASTER JACKY
Published: June 2007

In this article we aim to highlight the issues we have encountered in teaching art curriculum courses on the primary BAEd degree programme. The main issues addressed are student self‐confidence and the conditions which form barriers to active engagement in art activities. These we have addressed in the context of the wide changes taking place since the Education Reform Act of 1988. Our concern is that students develop the confidence to implement change in accord with their own convictions. We describe how we support them in their developing autonomy through the various strategies we have developed including the recognition and transfer of prior knowledge and reflection on the process of their own learning.
Art Education for Understanding: Goodman, Arts PROPEL, and DBAE
Authors: LINDSTROM LARS
Published: June 2007

‘What is art for?’ This provocative question was the motto of the 31st Annual Convention of the National Art Education Association (NAEA) held in Atlanta, Georgia, 1991. As a visiting scholar for a semester at Harvard Project Zero, I had rich opportunities to study art education programmes in higher education and public schools all over the United States. As a consequence, I felt complelled to reformulate the NAEA question, and ask ‘What is art education for?’

This essay argues for the importance of understanding and meaning‐making in art education. It starts with a review of some common rationales for the teaching of art that stress both the alleged ability of the arts to promote ‘good’– i.e. creative, harmonious, and civilised – characters and the instrumental value of the arts as a means of communication. These rationales are then evaluated within the context of Nelson Goodman's philosophy, which emphasises the primary role of curiosity in the arts.

The following two sections discuss the rationales, contributions and limitations of two art programmes that are currently being carried out in the United States: Arts PROPEL and Discipline‐Based Art Education (DBAE). Arts PROPEL has introduced long‐term, open‐ended projects that integrate production (making) with perception (learning to ‘read’ art works and observe the world closely) and reflection (thinking about one's work and the works of others). The DBAE curricula are sequentially organised and integrate content from the disciplines of art creation, art criticism (learning what to look for and how to interpret), art history (studying contexts and alternatives of taste and style), and aesthetics (building a personal philosophy of art).

In the final section, Arts PROPEL and DBAE are compared. In the context of previous rationales for the teaching of art, the similarity in aims of these programmes stand out as more important than the differences in approach. Neither do these programmes overstate the humanising power of art, nor do they focus on visual literacy per se. Instead, both programmes emphasise the role of reflection, interpretation, and understanding in art. Productive and analytic art activities are used as important vehicles in making sense of the world and of ourselves. It is concluded that Arts PROPEL and DBAE offer promising and supplementary approaches to promote curiosity and to teach art for the sake of understanding.
Croatian and Bosnian Children's Art in Times of War
Authors: TANAY EMIL ROBERT
Published: June 2007

This paper looks at the effect of the destruction of homes, displacement of families, and ‘ethnic cleansing’ on the artistic expression of thirty five children aged 4 to 12 who were ‘deposited’ in Zagreb in September 1991. The children are mainly from Croatia with a few from Bosnia, and they have been with us for almost three years. In an attempt to offer them some form of control over their negative experiences (and the dreams, memories and traumas these occasion), a supportive climate of trust and discussion was offered, in which drawing and painting materials were available and used. The results of their experiences are apparent in their social relationships, and most movingly and tellingly in their pictorial images and the verbal descriptions which accompany these. Although the work is being studied by focusing on two age groups ‐ 4 to 7 and 7 to 11 ‐ in order to examine the Intuitive‐Symbolic level of cognitive development in the former, and the Concrete‐Operative level of cognitive development in the latter, we are very much aware of trying to give them the means by which they can rediscover a positive self image in order to battle against their self‐destructive and negative sense of self. In the totality of this experience which is a mixture of the social, educational, psychological, therapeutic and artistic, I feel we are learning as much as we are helping.
The Reform of Support Mechanisms for Upland Farming: Paying for Public Goods in the Severely Disadvantaged Areas of England
Authors: Hanley Nick , Colombo Sergio , Mason Pamela , Johns Helen
Published: June 2007

The incomes of hill‐farmers in ‘Less Favoured Areas’ of the UK have traditionally been supported by payments related to their production levels. Reform of the Common Agricultural Policy and changes in policy objectives within the UK imply a need to change this basis of support. We investigate the option of paying for public goods produced, focusing on landscape features and habitats. A choice experiment study is used to estimate willingness to pay for different landscape features in four Severely Disadvantaged Areas of England. We find significant differences in the value of landscape features, both within and across regions, and parallel differences in the aggregate value of different policy options for upland areas. We discuss briefly how this information could be included in a spatially differentiated payments scheme.
Plant Stanol Ester: Review of Cholesterol‐Lowering Efficacy and Implications for Coronary Heart Disease Risk Reduction
Authors: Cater Nilo B.
Published: June 2007

Plant stanol ester has been shown in over 20 studies to be an effective and safe cholesterol‐lowering substance. Randomized, placebo‐controlled studies indicate that 2–3 g/day of plant stanol ester significantly reduces low density lipoprotein cholesterol levels by about 10%–20%. These results have been consistently found in various groups, including young adult and elderly men, pre‐ and postmenopausal women, children with and without familial hypercholesterolemia, type II diabetics, and patients with coronary heart disease. Plant stanol ester has also been shown to significantly augment the cholesterol‐lowering effect of statins. No clinically significant adverse effects have been detected in studies or in general use in Finland, where foods fortified with plant stanol ester have been available since 1995. Results of studies with plant stanol ester have important implications for both the clinical and public health approaches to coronary heart disease risk reduction.
Premenopausal Black Women Are Uniquely at Risk for Coronary Heart Disease Compared to White Women
Authors: Gerhard Glenn T. , Sexton Gary , Malinow M. René , Wander Rosemary C. , Connor Sonja L. , Pappu Anuradha S. , Connor William E.
Published: June 2007

Premenopausal black women have a two to threefold greater rate of coronary heart disease than premenopausal white women. This study was designed to provide greater insight into the reasons for this difference which is currently unclear. Coronary heart disease risk factors were compared in 100 black and 100 white, healthy premenopausal women, ages 18–45 years, and of relatively advantaged socioeconomic status. Compared to white women, black women had a higher body mass index (32.0±9.2 vs. 29.0±9.4 kg/m2, p=0.021), and higher systolic (124±17 vs. 115±14 mm Hg, p<0.0001) and diastolic (79±14 vs. 75±11 mm Hg, p=0.048) blood pressures. The mean plasma lipoprotein(a) concentration was markedly higher in the black women (40.2±31.3 mg/dL) than in the white women (19.2±23.7 mg/dL, p<0.0001). The plasma total homocysteine level was also higher in the black women (8.80±3.38 vs. 7.81±2.58 mmol/L, p=0.013). The black women, however, had lower plasma triglyceride levels (0.91±0.46 vs. 1.22±0.60 mmol/L, p<0.0001) and a trend toward higher high density lipoprotein cholesterol levels (1.37±0.34 vs. 1.29±0.31 mmol/L, p=0.064) than the white women. Plasma total and low density lipoprotein cholesterol levels were similar. Black women consumed more saturated fat and cholesterol. Rates of cigarette smoking and alcohol intake were low and similar between the races. In summary, compared to white women, black women had a higher mean body mass index, higher blood pressures, higher lipoprotein(a) and plasma total homocysteine levels, and greater consumption of saturated fat and cholesterol. The differences in coronary risk factors between these two premenopausal groups may explain the higher incidence of coronary heart disease in black women.
Risk Factors for Ischemic Stroke in Older Persons in an Academic Hospital Based Geriatrics Practice
Authors: Ness Jose , Aronow Wilbert S. , Ahn Chul
Published: June 2007

We performed a retrospective analysis of charts investigating risk factors for ischemic stroke in 467 men (mean age 80±8 years) and 1444 women (mean age 81±8 years) seen in an academic geriatrics practice. Ischemic stroke was present in 126 of 467 men (27%) and in 296 of 1444 women (20%) (p=0.003). Stepwise logistic regression analysis showed that significant independent risk factors for ischemic stroke were age (p=0.005 in men and 0.010 in women, odds ratio=1.04 in men and 1.03 in women); cigarette smoking (p=0.006, odds ratio=1.7 in women); hypertension (p<0.001 in men and women, odds ratio=4.6 in men and 3.9 in women); diabetes mellitus (p=0.018 in men and <0.001 in women, odds ratio=1.9 in men and 2.0 in women); serum low density lipoprotein cholesterol (p<0.001 in men and women, odds ratio=1.02 in men and 1.01 in women); and serum high density lipoprotein cholesterol (p<0.001, odds ratio=0.97 in women). Significant independent risk factors for ischemic stroke in both sexes were: age, hypertension, diabetes mellitus, and serum low density cholesterol; and in older women: cigarette smoking and serum high density lipoprotein cholesterol (inverse association).
The Antilipidemic Effects of Plain and Extended‐Release Niacin
Authors: Robinson Anne White , Sloan Helen L , Arnold Gary
Published: June 2007

The extensive antihyperlipidemic effects of niacin are well known. Cardiac doses of niacin are effective in lowering low density lipoprotein, triglyceride, and lipoprotein(a) levels and in elevating high density lipoprotein levels. Adverse reactions to niacin range from annoying cutaneous flushing to hepatic toxicity. A new extended‐release form of niacin (Niaspan®) has been found to have relatively mild hepatic effects. Nighttime dosing of Niaspan® appears to attenuate cutaneous flushing. Regardless of the form of drug prescribed, patients advised to use niacin should be carefully screened and monitored. Adverse effects of niacin are emphasized because of their particular importance in the provision of primary care. The dosing schedules for both plain niacin and extended‐release niacin are discussed.
Hypertension and the Risk of Acute Myocardial Infarction in Argentina
Authors: Ciruzzi Mario , Pramparo Palmira , Rozlosnik Jorge , Zylberstjn Horatio , Delmonte Hernán , Haquim Mónica , Abecasis Blanca , De La Cruz Ojeda Juan , Mele Eduardo , La Vecchia Carlo , Schargrodsky Herman , On Behalf Of The Argentine Factores de Riesgo Coronario en A
Published: June 2007

The relationship between a history of hypertension and the quality of its control in routine clinical practice and the risk of acute myocardial infarction was examined in a multicenter, casecontrol study conducted in Argentina between November 1991 and August 1994, within the framework of the FRICAS study. The cases were 939 patients with acute myocardial infarction and without a history of ischemic heart disease. The controls were 949 subjects identified in the same centers as the cases and admitted with a wide spectrum of acute disorders unrelated to known or suspected risk factors for acute myocardial infarction. The odds ratios and the 95% confidence intervals were derived from multiple logistic regression equations, including terms for age, gender, education, social status, exercise, smoking status, cholesterolemia, history of diabetes, body mass index, and family history of myocardial infarction. The quality of hypertension control was assessed with the most recent blood pressure reading reported by the subjects. Seventy‐two percent of hypertensive cases and 62.6% of hypertensive controls had a history of antihypertensive therapy by self‐report, when admitted to the medical center. The adjusted odds ratio for acute myocardial infarction due to hypertension was 2.58 (95% confidence interval, 2.08–3.19). The odds ratio was 2.42 (95% confidence interval, 1.88–3.11) when hypertensives reported that their greatest systolic value was below 200 mm Hg (moderate status) and 4.12 (95% confidence interval, 2.87–5.89) when it was above 200 mm Hg (severe status). When the highest diastolic blood pressure value was below 120 mm Hg (moderate status), the risk increased to 2.48 (95% confidence intervals, 1.90–3.24) and to 4.12 (95% confidence interval, 2.83–5.99) when it was above 120 mm Hg (severe status). If the most recent systolic blood pressure was ≥140 mm Hg, the odds ratio was 2.59 (95% confidence interval, 1.96–3.41), and it was 3.42 (95% confidence interval, 2.40–4.87) when the value was >140 mm Hg. If the most recent diastolic blood pressure was ≤90 mm Hg, the risk increased more than two fold (odds ratio=2.48; 95% confidence interval, 1.91–3.22), and if it was >90 mm Hg, it increased nearly four‐fold (odds ratio=3.72; 95% confidence interval, 2.33–5.96). In smokers, the odds ratio was 2.28 in the absence of hypertension and increased to 7.51 when hypertension was present. In this Argentine population, hypertension is a strong and independent risk factor for acute myocardial infarction. In routine clinical practice, the control of blood pressure to levels below 140/90 seems to be required in order to reduce part (but not all) of the risk of acute myocardial infarction in hypertensive patients.
Focus on Statins: Lipid‐Lowering Mechanisms and Beyond
Authors: Auer Johann , Berent Robert , Eber Bernd
Published: June 2007

Recent large‐scale clinical trials have confirmed that statin‐induced lipid modification can significantly reduce cardiovascular morbidity and mortality. Statins are now the drugs of choice in lipid management but fail to meet the criteria for an ideal therapy in several respects. Therefore, the search continues for lipid modifying treatments that meet even higher standards. Lipid‐lowering drugs currently in development may meet these more exacting standards and together with complementary methods could ultimately form ideal combination therapy.
Estrogen Levels and Lipid Peroxidation Following Exercise
Authors: Baer Janine T. , Ayres Stacey A.
Published: June 2007

Recent large‐scale clinical trials have confirmed that estrogens are powerful antioxidants that effectively prevent lipid peroxidation. In particular, estrogen decreases oxidative modification of low‐density lipoprotein both in vitro and in vivo. Estrogen levels fluctuate during the menstrual cycle and during perimenopause, and they are permanently depressed at menopause. Thus, it is of interest to evaluate the lipid peroxidation response under conditions of low estrogen status. It is of additional interest to evaluate lipid peroxidation under such conditions in response to situations that augment free radical production, such as exercise. Aerobic exercise, and more recently anaerobic exercise regimens, are reported to variably affect free radical production and lipid peroxidation. In addition to the exercising woman's estrogen status and menstrual history, other factors to consider when evaluating an exercising woman's risk for increased lipid peroxidation include the intensity of exercise and/or the woman's fitness level as well as her current dietary antioxidant status.
Aerobic Exercise and Resting Blood Pressure: A Meta‐Analytic Review of Randomized, Controlled Trials
Authors: Kelley George A. , Kelley Kristi A. , Vu Tran Zung
Published: June 2007

In this study the authors used the meta‐analytic approach to examine the effects of aerobic exercise on resting systolic and diastolic blood pressure in adults. Forty‐seven clinical trials representing a total of 72 effect sizes in 2543 subjects (1653 exercise, 890 control) met the criteria for inclusion. Statistically significant exercise‐minus‐control decreases were found for changes in resting systolic and diastolic blood pressure in both hypertensive (systolic, −6 mm Hg, 95% CI, −8 to −3; diastolic, −5 mm Hg, 95% CI, −7 to −3) and normotensive (systolic, −2 mm Hg, 95% CI, −3 to −1; diastolic, −1 mm Hg, 95% CI, −2 to −1) groups. The differences between groups were statistically significant (systolic, p=0.008; diastolic, p=0.000). Relative decreases were approximately 4% (systolic) and 5% (diastolic) in hypertensives, and 2% (systolic) and 1% (diastolic) in normotensives. It was concluded that aerobic exercise reduces resting systolic and diastolic blood pressure in adults.
Determination of Risk for Atrial Fibrillation Utilizing Precise P Wave Duration‐Measuring Methodology
Authors: Uhley Herman
Published: June 2007

Increased duration of the P wave has been shown to be an indicator of increased risk for atrial fibrillation. This paper describes a method of obtaining the “true P wave duration” from previously recorded six‐channel electrocardiograms, using readily available personal computers and software instead of more expensive P wave signal averaging devices. P wave duration in the atrial fibrillation group was significantly greater than in the nonfibrillation group. Measuring true P wave duration has greater sensitivity and specificity than measuring “conventional P wave duration.” Precise measurement of P wave duration may prove to be an important factor in determining the risk of atrial arrhythmias.
Resolving the Coronary Artery Disease Epidemic Through Plant‐Based Nutrition
Authors: Esselstyn Caldwell B.
Published: June 2007

The world's advanced countries have easy access to plentiful high‐fat food; ironically, it is this rich diet that produces atherosclerosis. In the world's poorer nations, many people subsist on a primarily plant‐based diet, which is far healthier, especially in terms of heart disease. To treat coronary heart disease, a century of scientific investigation has produced a device‐driven, risk factor‐oriented strategy. Nevertheless, many patients treated with this approach experience progressive disability and death. This strategy is a rear‐guard defensive one. In contrast, compelling data from nutritional studies, population surveys, and interventional studies support the effectiveness of a plant‐based diet and aggressive lipid lowering to arrest, prevent, and selectively reverse heart disease. In essence, this is an offensive strategy. The single biggest step toward adopting this strategy would be to have United States dietary guidelines support a plant‐based diet. An expert committee purged of industrial and political influence is required to assure that science is the basis for dietary recommendations.
An Association Between Varying Degrees of Hypothyroidism and Hypercholesterolemia in Women: The Thyroid‐Cholesterol Connection
Authors: Feld Stanley , Dickey Richard A.
Published: June 2007

Evidence of an association between subclinical hypothyroidism and cardiovascular disease is mounting. The impact of thyroid hormone on lipid levels is primarily mediated through triiodothyronine (T3)‐bound thyroid protein binding and activation of the promoter regions of the low‐density lipoprotein receptor and 3‐hydroxy‐3‐methylglutaryl coenzyme A‐reductase genes, leading to a reduction in serum cholesterol levels. Thus, the decreased T3 seen in hypothyroidism may result in increased serum cholesterol. Although a clear correlation exists between overt hypothyroidism and clinically significant hypercholesterolemia, there is a logarithmic relationship between thyroid‐stimulating hormone and cholesterol, and the effects of subclinical hypothyroidism on cardiovascular disease are under debate. However, current data suggest that normalizing even modest thyroid‐stimulating hormone elevations may result in improvement in the lipid profile.
Effects of Hatha Yoga Practice on the Health‐Related Aspects of Physical Fitness
Authors: Tran Mark D. , Holly Robert G. , Lashbrook Jake , Amsterdam Ezra A.
Published: June 2007

Ten healthy, untrained volunteers (nine females and one male), ranging in age from 18–27 years, were studied to determine the effects of hatha yoga practice on the health‐related aspects of physical fitness, including muscular strength and endurance, flexibility, cardiorespiratory fitness, body composition, and pulmonary function. Subjects were required to attend a minimum of two yoga classes per week for a total of 8 weeks. Each yoga session consisted of 10 minutes of pranayamas (breath‐control exercises), 15 minutes of dynamic warm‐up exercises, 50 minutes of asanas (yoga postures), and 10 minutes of supine relaxation in savasana (corpse pose). The subjects were evaluated before and after the 8‐week training program. Isokinetic muscular strength for elbow extension, elbow flexion, and knee extension increased by 31%, 19%, and 28% (p<0.05), respectively, whereas isometric muscular endurance for knee flexion increased 57% (p<0.01). Ankle flexibility, shoulder elevation, trunk extension, and trunk flexion increased by 13% (p<0.01), 155% (p<0.001), 188% (p<0.001), and 14% (p<0.05), respectively. Absolute and relative maximal oxygen uptake increased by 7% and 6%, respectively (p<0.01). These findings indicate that regular hatha yoga practice can elicit improvements in the health‐related aspects of physical fitness.
Dietary Counseling for High Blood Cholesterol in Families at Risk of Coronary Disease
Authors: Moy Taryn F. , Yanek Lisa R. , Raqueño Judith V. , Bezirdjian Pamela J. , Blumenthal Roger S. , Wilder Lora B. , Becker Diane M.
Published: June 2007

A positive family history of coronary heart disease alone confers an increased risk, which may be affected by untreated hypercholesterolemia. Dietary counseling is a first‐line treatment approach. To determine whether nurse counseling can provide additional benefits over usual physician efforts to lower dietary fat in high‐risk persons, 117 apparently healthy adult siblings of persons with premature coronary heart disease were counseled by a registered nurse using adapted national guidelines. Reductions in total fat, saturated fat, and cholesterol were significantly greater in the nurse group compared to those in the usual care group. Total fat intake decreased by 14 g in the nurse group, compared with an increase of 5 g in the usual care group (p=0.0001). Assignment to the nurse group was also a significant predictor of a greater reduction in the percentage of total fat calories (p=0.008). The authors conclude that a registered nurse may serve as a complement to usual care in efforts to lower dietary fat and cholesterol in high‐risk families.
A Practical Approach to the Dietary Treatment of Hypertriglyceridemia
Authors: Mueller‐Cunningham Wendy M. , Hyson Dianne
Published: June 2007

Reducing high plasma triglyceride (TG) levels is an important step in the treatment and prevention of coronary artery disease. The rise in plasma TGs seen after subjects consume low‐fat, high‐carbohydrate diets for a period of time may be due to the simple form of carbohydrate provided and/or prevention of weight loss in these studies. Ad libitum low‐fat, high‐carbohydrate intake often results in weight loss and decreases in plasma TGs. Replacing dietary carbohydrate with monounsaturated fat lowers serum TG levels and maintains serum high‐density lipoprotein levels but fails to result in weight loss. Low fat, high complex carbohydrate intake reduces incidence rates of coronary artery disease. On the basis of the evidence, a lowfat, high‐complex carbohydrate diet combined with limited alcohol and sugar intake is recommended for the treatment of hypertriglyceridemia.
The Evolving Role of High‐Density Lipoprotein in Reducing Cardiovascular Risk
Authors: Ballantyne Christie M. , Rangaraj Gopikishan R.
Published: June 2007

In many patients with coronary artery disease, a low level of high‐density lipoprotein cholesterol (HDL‐C), rather than substantially elevated lowdensity lipoprotein cholesterol (LDL‐C), is often the predominant lipid abnormality. Although the National Cholesterol Education Program treatment guidelines include HDL‐C concentration as a major risk factor for primary prevention, the guidelines' emphasis on LDL‐C as the primary target of therapy may cause uncertainty as to whether risk reduction strategies should focus on lowering LDL‐C or raising HDL‐C in high‐risk patients with low HDL‐C. Recent clinical trial evidence and epidemiologic data suggest that HDL‐C should play a more important role in risk assessment, and that the definition of low HDL‐C may need adjustment from the current National Cholesterol Education Program definition of <35 mg/dL to perhaps <40 mg/dL in men and <45 mg/dL in women. Patients with low HDL‐C should receive aggressive risk factor modification, and more emphasis on increasing HDL‐C may be warranted in addition to lowering LDL‐C.
The Chest Pain Center Strategy for Delivering Community Heart Attack Care by Shifting the Paradigm of Heart Attack Care to Earlier Detection and Treatment
Authors: Bahr Raymond D.
Published: June 2007

Heart attack remains the number one health problem in the United States and throughout the world. It has been that way for more than 100 years. Unless we change our course, heart attack will continue to exert its horrendous casualties, not only in the United States but also throughout the world. Our present strategy in dealing with this problem needs both leadership and a change in direction. In an effort to search “outside the box” for the solution to this problem, this symposium is a call to action that challenges us to approach the heart attack problem with a mindset bent on winning this war against heart disease, and not coexisting and accepting the problem as an inescapable fate.
A Comparison Trial for Stratifying Intermediate‐Risk Chest Pain: Benefits of Emergency Department Observation Centers
Authors: Robinson David J. , Woods Patrick G. , Snedeker Cynthia A. , Lynch James H. , Chambers Kimberly
Published: June 2007

Chest pain of uncertain etiology (intermediate‐risk chest pain [IR‐CP]) constitutes a majority of acute chest pain presentations to emergency departments (EDs). A before‐and‐after trial of 2197 IR‐CP patients transferred from the hospital's ED to one of three units—ED‐based observation center (ED‐OC), inpatient observation center (IN‐OC), and inpatient units—compared mean cost, length of stay, and safety over a 2‐year period. The mean per patient cost for management of IR‐CP was lower in the ED‐OC ($1642) than the IN‐OC ($1910) or the inpatient units ($2785). The mean length of stay was shorter in the ED‐OC (0.75 days) than in the IN‐OC (1.18 days) or the inpatient units (2.16 days). Return rates were lower in the ED‐OC at 7 days (0%) and at 6 months (0.45%) than the IN‐OC (0% and 1.22%) or the inpatient units (0.77% and 3.67%). Overall hospital costs for managing IR‐CP dropped significantly (12.5%) after the ED‐OC was opened. ED‐OCs provide a safe and cost‐effective alternative to admission of IR‐CP patients.
Dialing 911: A Call to Action
Authors: Smaha Lynn A.
Published: June 2007

Cardiovascular disease and stroke are the nation's leading causes of disability and death. Scientific advances have provided newer treatments that, when applied effectively and in time, save a significant number of lives. Multiple factors in our system of delivery impede our ability to apply effective treatments, but with an analysis of the components of care, each of us can take leadership roles in our communities to improve the chain of survival. These elements and the science supporting each are briefly reviewed.
Reducing the Knowledge‐Practice Gap in the Management of Patients With Cardiovascular Disease
Authors: Amsterdam Ezra A. , Laslett Lawrence , Diercks Deborah , Kirk J. Douglas
Published: June 2007

Despite major progress in the development of effective therapy to reduce mortality and morbidity from cardiovascular disease, it remains the leading cause of mortality in this country. One aspect of this problem is represented by the lag in adoption of treatments with documented efficacy in large clinical trials. This “knowledge‐practice gap” has been attributed to factors at multiple levels of the health care system that impede implementation of optimal therapy. Although there is evidence of progress in the use of recommended therapeutic modalities in the past decade, this has been modest. Recent approaches to assessment of patient care by physicians, health plans, and institutions through the tracking of clinical performance have been instituted to promote optimal patient care. They are being increasingly utilized for purposes of accreditation and will also provide guidance for consumer purchasing of health care. Such methods have the potential to promote increased adherence to current standards of care.
Conquering Heart Disease: A Call to Action
Authors: Morosco Gregory J.
Published: June 2007

Despite 20th century scientific and technologic advances in the area of cardiovascular medicine and public health and associated benefits in terms of significant declines in mortality, heart disease remains as the dominant cause of death for all Americans. Tremendous geographic variation in age‐adjusted coronary heart disease mortality, varying over two‐fold between the highest and lowest states, provides troubling evidence that this epidemic is raging unrelentingly in many communities across our country. Also disturbing are signs that the significant decline in coronary heart disease mortality observed since the 1960s may have slowed in recent years. The coronary heart disease epidemic continues to hit hard among certain racial and ethnic minorities, prompting the Healthy People 2010 national call for action to eliminate cardiovascular disease disparity.
C‐Reactive Protein, Statins, and the Primary Prevention of Atherosclerotic Cardiovascular Disease
Authors: Bermudez Edmund A. , Ridker Paul M.
Published: June 2007

Emerging data implicate inflammation as integral to atherosclerosis and its complications. From a clinical perspective, the inflammatory biomarker C‐reactive protein has demonstrated consistent predictive value in the detection of individuals at high risk for cardiovascular disease. Therapy with 3‐hydroxy‐3‐methylglutaryl coenzyme A reductase inhibitors (statins) reduces C‐reactive protein as well as low‐density lipoprotein cholesterol, thus providing a potential additional mechanism for the reduction in cardiovascular events associated with the use of these agents. Evidence from the Air Force/Texas Coronary Atherosclerosis Prevention Study suggests that statin therapy may be effective in reducing incident coronary events among those with elevated levels of C‐reactive protein but normal levels of low‐density lipoprotein cholesterol. These data, along with accumulating laboratory data, support a potential anti‐inflammatory benefit of statins. Large‐scale, randomized trials in the primary prevention of acute coronary events among individuals without overt hyperlipidemia but with evidence of elevated C‐reactive protein are now needed to directly test this hypothesis.
Lipid Management and the Elderly
Authors: Davidson Michael H. , Kurlandsky Sara B , Kleinpell Ruth M , Maki Kevin C.
Published: June 2007

Advancing age is an independent risk factor for the development of coronary heart disease. However, the significance of hypercholesterolemia as a cardiovascular risk factor in the elderly, has been widely debated. While no large‐scale, randomized clinical trial has been conducted to evaluate cholesterol lowering solely in the elderly, evidence from older subgroups in several intervention trials supports the efficacy of lowering elevated low‐density lipoprotein cholesterol for reducing cardiovascular risk in the elderly. Furthermore, although the relative risk of hypercholesterolemia for coronary heart disease incidence may be attenuated with advancing age, the population‐wide impact of treating elevated cholesterol levels in the elderly would be large, due to the high frequency of coronary heart disease in the elderly. This article reviews key issues in the management of hypercholesterolemia with respect to coronary heart disease risk reduction in the elderly.
Sleep‐Disordered Breathing: Implications in Cerebrovascular Disease
Authors: Mohsenin Vahid
Published: June 2007

Stroke and sleep‐disordered breathing (SDB) are both common and are associated with significant morbidity and mortality. Several recent large epidemiologic studies have shown a strong association between these two disorders independent of known risk factors for stroke. This review will outline the scientific basis for this relationship and suggest SDB as a modifiable risk factor for stroke. Several studies have shown a characteristic circadian rhythmicity in stroke. The authors discussed the influence of normal sleep states as well as the effect of SDB on cerebral hemodynamics. The hemodynamic, metabolic, and hematologic changes during SDB in the form of decreased cerebral perfusion and increased coagulability are the possible pathogenetic mechanisms for stroke. There are accumulating lines of evidence that SDB may indeed cause diurnal hypertension. However, the increased risk of stroke in patients with SDB appears to be independent of coexisting hypertension, but the presence of hypertension would greatly increase the risk even further. Furthermore, several studies have documented high prevalence of sleep apnea in patients with transient ischemic attacks and stroke. SDB appears to contribute as a risk factor for stroke through hemodynamic and hematologic changes. Because of high prevalence of SDB in this population, patients with transient ischemic attacks and stroke should be screened for these disorders.
Should the Patient With Coronary Artery Disease Use Sildenafil?
Authors: Cheitlin Melvin D.
Published: June 2007

Since the etiology of erectile dysfunction is frequently related to endothelial dysfunction, a problem in common with much vascular disease, erectile dysfunction disproportionately affects patients with cardiovascular disease. With the development of phosphodiesterase 5 inhibitors, the first of which was sildenafil (Viagra), an effective oral medication became available. The question of safety of these drugs, especially in patients with latent or overt coronary artery disease, is of concern. Sildenafil relaxes smooth muscle and therefore lowers systolic and diastolic blood pressure slightly. With organic nitrates, the drop in blood pressure is potentiated, at times dangerously, thereby making it contraindicated to take nitrates within 24 hours of using sildenafil. In double‐blind, placebo‐controlled trials, there was no difference between sildenafil subjects and control patients in the incidence of myocardial infarction, cardiovascular, and total deaths. Coronary disease patients with stable angina, controlled on medications, were included in the trials. Therefore, sildenafil, as a drug, is safe in such patients. With a patient with coronary artery disease suddenly engaging in the physical exercise associated with sexual intercourse, there is the danger of increased risk of precipitating myocardial infarction or death. The cardiovascular metabolic cost of sexual activity is reviewed and appears to be approximately at the level of 3–5 metabolic equivalents of exercise. Sexual activity occurs within 2 hours of the onset of an acute myocardial infarction in <1.0% of patients. Although sexual intercourse is estimated to increase the risk of myocardial infarction by a factor of 2×, there is still only a very small increase in risk, a risk acceptable to patients who feel their quality of life will be markedly improved by their ability to engage in sexual activity.
Forty‐Year Follow‐Up of Coronary Heart Disease Mortality and Its Predictors: The Corfu Cohort of the Seven Countries Study
Authors: Pitsavos Christos , Panagiotakos Demosthenes B. , Menotti Alessandro , Chrysohoou Christina , Skoumas John , Stefanadis Christodoulos , Dontas Anastasios , Toutouzas Pavlos
Published: June 2007

The authors examined the effect of several risk factors in relation to coronary heart disease (CHD) mortality in the Corfu cohort of the Seven Countries Study. The population studied in this analysis consisted of 529 rural men (age 40–59 years) enrolled in 1961. Multivariate analysis was performed with CHD death as the end point; age, blood pressure, heart rate, serum total cholesterol, smoking, physical activity, body mass index, skinfold thickness, vital capacity, and forced expiratory volume were the predictors. The 40‐year CHD survival rate was 63% (108 deaths). Age (hazard ratio [HR]=1.093; p<0.001), smoking (HR=1.79; p<0.05), body mass index (HR=1.05; p<0.1), and serum total cholesterol (HR=1.004; p<0.2) were independently associated with 40‐year CHD mortality. Conclusively, in men from the Corfu cohort, age, lifestyle habits (expressed as smoking and body mass index), and serum cholesterol levels were consistently associated with 40‐year CHD mortality. In addition, the current status of men in the Corfu cohort is marked by long‐term adoption of a Mediterranean type of diet, physical activity, and optimism.
Assessment of Risk Factors in Coronary Patients Being Followed by Cardiologists: Control of Risk Factors in Coronary Patients
Authors: Ladeia Ana Marice , Guimarães Armênio C.
Published: June 2007

Control of risk factors for coronary heart disease secondary prevention is still very unsatisfactory. This study assessed 104 patients referred by cardiologists to discover how carefully National Cholesterol Education Program II recommendations were being followed. Average age of the cohort was 60.9±10.8 years, and 67.3% were men. A total of 57(54.8%) experienced a previous myocardial infarction and 83 (80.3%) a revascularization procedure. They saw their doctors 4.4±2.9 times a year and had blood tests 2.8±1.7 times a year. Blood pressure was =140/90 mm Hg in 57.8%, body mass index =25 kg/m2 in 62.5%, and the weight‐to‐hip ratio =0.95 in 42.9% of men, and =0.85 in 47.0% of women. Total, low‐density lipoprotein, and high‐density lipoprotein cholesterol and triglyceride values were 222.9±47.3 mg/dL, 144.9 mg/dL, 44.8±11.5 mg/dL, and 176±119.41 mg/dL, respectively. Low‐density lipoprotein cholesterol was <100 mg/dL in 8.1%, and <130 mg/dL in 47.1%; the total cholesterol/high‐density lipoprotein cholesterol ratio was 5.1±1.5 (=5 in 51%). In these patients, the control of major risk factors like high blood pressure, overweight, and high low‐density lipoprotein cholesterol was poor.
Beyond the Mediterranean Diet: The Role of Omega‐3 Fatty Acids in the Prevention of Coronary Heart Disease
Authors: Harper Charles R. , Jacobson Terry A.
Published: June 2007

Evidence from epidemiologic and clinical secondary prevention trials suggest that the omega‐3 polyunsaturated fatty acids (n‐3 PUFAs) may have a significant role in the prevention of coronary heart disease. Dietary sources of n‐3 PUFAs include fish oils, rich in eicosapentaenoic acid and docosahexaenoic acid, along with plants rich in α‐linolenic acid. Randomized secondary prevention clinical trials with fish oils (eicosapentaenoic acid, docosahexaenoic acid) and α‐linolenic acid have demonstrated reductions in risk that compare favorably to those seen in landmark secondary prevention trials with lipid‐lowering drugs. Several mechanisms explaining the cardioprotective effect of the n‐3 PUFA have been suggested including antiarrhythmic and antithrombotic roles. Although official US guidelines for the dietary intake of n‐3 PUFA are not available, several international guidelines have been published. Fish is an important source of the n‐3 PUFA in the US diet; however, vegetable sources including grains and oils offer an alternative source for those who are unable to regularly consume fish.
Randomized Trial to Improve Prescribing Safety in Ambulatory Elderly Patients
Authors: Raebel Marsha A. , Charles Jeanya , Dugan Jennifer , Carroll Nikki M. , Korner Eli J. , Brand David W. , Magid David J.
Published: June 2007

OBJECTIVES: To determine whether a computerized tool that alerted pharmacists when patients aged 65 and older were newly prescribed potentially inappropriate medications was effective in decreasing the proportion of patients dispensed these medications.

DESIGN: Prospective, randomized trial.

SETTING: U.S. health maintenance organization.

PARTICIPANTS: All 59,680 health plan members aged 65 and older were randomized to intervention (n=29,840) or usual care (n=29,840). Pharmacists received alerts on all patients randomized to intervention who were newly prescribed a targeted medication.

INTERVENTION:
Prescription and age information were linked to alert pharmacists when a patient aged 65 and older was newly prescribed one of 11 medications that are potentially inappropriate in older people.

MEASUREMENTS: Physicians and pharmacists collaborated to develop the targeted medication list, indications for medication use for which an intervention should occur, intervention guidelines and scripts, and to implement the intervention.

RESULTS: Over the 1‐year study, 543 (1.8%) intervention group patients aged 65 and older were newly dispensed prescriptions for targeted medications, compared with 644 (2.2%) usual care group patients (P=.002). For medication use indications in which an intervention should occur, dispensings of amitriptyline (P<.001) and diazepam (P=.02) were reduced.

CONCLUSIONS: This study demonstrated the effectiveness of a computerized pharmacy alert system plus collaboration between healthcare professionals in decreasing potentially inappropriate medication dispensings in elderly patients. Coupling data available from information systems with the knowledge and skills of physicians and pharmacists can improve prescribing safety in patients aged 65 and older.
Depressive Symptoms in Older African‐American and White Adults with Functional Difficulties: The Role of Control Strategies
Authors: Gitlin Laura N. , Hauck Walter W. , Dennis Marie P. , Schulz Richard
Published: June 2007

OBJECTIVES: To examine whether control‐oriented strategies buffer effects of functional difficulties on depressive symptoms over time in older African‐American and white adults with disability.

DESIGN: Community‐based, prospective study.

SETTING: Baseline and 12‐month data from a randomized trial.

PARTICIPANTS: One hundred twenty‐nine African‐American and 151 white older adults with 12‐month data from 319 participants in the trial.

MEASUREMENTS: Data were obtained for functional difficulties, the extent that respondents reported using control (cognitive and behavioral) strategies to enhance and maintain independence, and baseline and 12‐month depressive symptoms (Center for Epidemiologic Studies Depression Scale; CES‐D).

RESULTS: African Americans reported greater baseline functional difficulty (P=.009), fewer depressive symptoms (P=.002) and higher control strategy use (P=.001) than whites. Functional difficulty was associated with depressive symptoms for both groups at baseline and 12 months. Living alone for whites and low spirituality for African Americans predicted higher 12‐month depressive symptom scores. African Americans with baseline functional difficulty and high strategy use had lower 12‐month depression than those with similar difficulty levels but low strategy use (P=.04 for interaction), representing a 28.5‐point CES‐D score differential. Control strategies did not buffer the function–depression relationship over time for whites.

CONCLUSION: Control‐oriented strategies moderated the experience of depressive symptomatology over time for African Americans with disability but not for whites. This may explain the paradox of greater functional disparities but less reported emotional distress in African Americans than whites. Results suggest that the use and benefits of adaptive resources to attain functional goals and determinants of depression differ by race. Depression prevention programs should be modified to be suitable for different cultural groups.