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Objective: To evaluate the subsequent rate of thrombosis among women with obstetric antiphospholipid syndrome (Ob-APS) in a multicentre database of antiphospholipid antibody (aPL)-positive patients, and the clinical utility of the adjusted Global Antiphospholipid Syndrome Score (aGAPSS), a validated tool to assess the likelihood of developing new thrombosis, in this group of patients.Design: Retrospective study.Setting: The Antiphospholipid Syndrome Alliance for Clinical Trials and International Networking Clinical Database and Repository.Population: Women with Ob-APS.Methods: Comparison of clinical and laboratory characteristics and measurement of aGAPSS in women with Ob-APS, with or without thrombosis, after initial pregnancy morbidity (PM).Main Outcome Measures: Risk factors for thrombosis and aGAPSS.Results: Of 550 patients, 126 had Ob-APS; 74/126 (59%) presented with thrombosis, and 47 (63%) of these women developed thrombosis after initial PM, in a mean time of 7.6 ± 8.2 years (4.9/100 patient years). Younger age at diagnosis of Ob-APS, additional cardiovascular risk factors, superficial vein thrombosis, heart valve disease, and multiple aPL positivity increased the risk of first thrombosis after PM. Women with thrombosis after PM had a higher aGAPSS compared with women with Ob-APS alone [median 11.5 (4-16) versus 9 (4-13); P = 0.0089].Conclusion: Based on a retrospective analysis of our multicentre aPL database, 63% of women with Ob-APS developed thrombosis after initial obstetric morbidity; additional thrombosis risk factors, selected clinical manifestations, and high-risk aPL profile increased the risk. Women with subsequent thrombosis after Ob-APS had a higher aGAPSS at entry to the registry. We believe that aGAPSS is a valid tool to improve risk stratification in aPL-positive women.Tweetable Abstract: More than 60% of women with obstetric antiphospholipid syndrome had thrombosis after initial pregnancy morbidity. [ABSTRACT FROM AUTHOR]

Objective: To determine the predictive value of gadolinium enhancement on MRI in differentiating atypical lipomatous tumor (ALT)/well-differentiated (WD) liposarcoma from benign fatty tumors.Design: All histologically proven fatty tumors with preoperative gadolinium-enhanced MRI were reviewed. Only those tumors with predominantly fatty signal were included. Sensitivity, specificity, and positive and negative predictive values for both gadolinium enhancement and biopsy as predictors for the final diagnosis of ALT/WD liposarcoma were calculated.Patients: From 129 patients evaluated for fatty tumors between 1994 and 2002, the patient population was narrowed to 32 excised fatty tumors with preoperative gadolinium-enhanced MRI.Results: As a predictor of ALT/WD liposarcoma, the presence of gadolinium enhancement showed 100% sensitivity, 71% specificity, 53% positive predictive value and 100% negative predictive value. Needle or incisional biopsy yielded 57% sensitivity, 100% specificity, 100% positive predictive value and 63% negative predictive value for a diagnosis of ALT/WD liposarcoma.Conclusions: Gadolinium enhancement of a homogeneous fatty soft tissue tumor is a sensitive screening tool to determine possible diagnosis of ALT/WD liposarcoma. Biopsy, on the other hand, is specific but insensitive. [ABSTRACT FROM AUTHOR]

The primary hypothesis of this study was that contraceptive methods that prevent exposure to sperm and seminal fluid (condoms, diaphragms, spermicides, withdrawal) are associated with an increased risk of developing preeclampsia during the subsequent pregnancy. A case-control study was conducted comparing the contraceptive and reproductive histories of 110 primiparous women with preeclampsia with 115 pregnant women without preeclampsia, aged 15 to 35 years, who gave birth at North Carolina Memorial Hospital, Chapel Hill, between 1984 and 1987. Controls were frequency matched to cases by age, race, and distance from the hospital. Unconditional logistic regression analysis indicated a 2.37-fold (95% confidence interval, 1.01 to 5.58) increased risk of preeclampsia for users of contraceptives that prevent exposure to sperm. A dose-response gradient was observed, with increasing risk of preeclampsia for those with fewer episodes of sperm exposure. These results were supportive of the hypothesis that birth control methods that prevent sperm exposure may play a role in the etiology of preeclampsia. [ABSTRACT FROM AUTHOR]

Cytocidal activity of a drug is dependent on both drug dosage and duration of exposure. In contrast to the 'conventional" 6-h infusion and in an attempto to improve its efficacy, the high-dose methotrexate therapeutic regimen was given over a 24-h period with 10% of the dose administered in the first hour. Citrovorum factor was initiated at hour 24 and continued for 72 h. Treatment was administered every 2-3 weeks. 57 infusions were performed in twelve patients aged 7-20 years (six with osteogenic sarcoma and six with acute lymphoblastic leukemia). Determinations of serum methotrexate levels revealed that the levels were dependent on the dose. Levels assayed at 24 h revealed the following results: 4.4 +/- 1.4 x 10(-5) molar with 4.5 g/m(2), 2.04 +/- 0.34 x 10(-4) molar with 7.5 g/m(2) and 4.59 +/- 0.80 x 10(-4) molar with 12.5 g/m(2). Major toxicity was myelosuppression in 12 of 57 patients. There were no responses. The study demonstrates that 24-h infusions of high-dose methotrexate can be tolerated every 2-3 weeks in patients without bone marrow involvement and levels of at least 10(-4) molar can be maintained during the infusion. [ABSTRACT FROM AUTHOR]

The authors conducted a clinical trial to examine the efficacy and safety of nortriptyline in the treatment of major depression in elderly medical inpatients. The diagnosis of major depression was made by a psychiatrist in 41 of 680 patients 65 years of age or older. The study was balted at the midpoint because of inadequate patient recruitment, primarily a consequence of medical illnesses that prevented more than 80% of eligible patients from participating in or completing the clinical trial. Major or minor medical contraindications to the use of antidepressants were present in over 90% of depressed patients. Short-term follow-up was conducted on untreated depressed patients, those receiving antidepressants at the time of assessment, and those in whom antidepressant treatment was initiated after assessment. Non-randomized exposure to antidepressants did not predict remission of depression at follow-up due to spontaneous remission in the untreated group. Given the prevalence of medical contraindications to antidepressant use among depressed elderly patients and the problems with side effects in treated patients, there were few depressed, elderly hospitalized patients who were candidates for antidepressant therapy. [ABSTRACT FROM AUTHOR]

Objective: This study was designed to establish whether a ratio of three units of Dysport is equivalent to one unit of Botox for the treatment of cervical dystonia.Methods: Patients with predominantly rotational cervical dystonia, and a minimum of four previous Botox treatments, were randomised to receive either the clinically indicated dose of Botox or three times that dose in Dysport units. Study botulinum toxin was administered in a double blind fashion, to one or more clinically indicated muscles, at one or more sites per muscle. Patients returned for assessment two, four, eight, and 12 weeks after treatment.Results: A total of 73 patients (Dysport, 38; Botox, 35) were entered. The Dysport group received a mean (SD) dose of 477 (131) (range 240-720) Dysport units, and the Botox group received a mean (SD) dose of 152 (45) (range 70-240) Botox units. The mean (SEM) post-treatment Tsui scores for the Dysport group (4.8 (0.3)) and the Botox group (5.0 (0.3)) were not statistically different (p=0.66). The study had 91% power to detect a clinically significant difference of two points. Both groups showed substantial improvement in Tsui score by week 2 (mean (SD); Dysport, 46 (28)%; Botox, 37 (28)%), with a peak effect at week 4 (mean (SD); Dysport, 49 (29)%; Botox, 44 (28)%). A similar response profile was seen for other assessments of efficacy. The duration of effect, assessed by time to retreatment, was also similar (mean (SD); Dysport, 83.9 (13.6) days; Botox, 80.7 (14.4) days; p=0.85). During the study 22 of 38 (58%) Dysport patients reported 39 adverse events, and 24 of 35 (69%) Botox patients reported 56 adverse events (p=0.35). A global assessment of efficacy and safety considered that 29 of 38 (76%) Dysport patients and 23 of 35 (66%) Botox patients were treatment successes (p=0.32).Conclusion: Patients with predominantly rotational cervical dystonia treated with the clinically indicated dose of Botox or three times that dose in Dysport units show similar improvements and do not have significantly different safety profiles. [ABSTRACT FROM AUTHOR]

Study Objective: To evaluate the impact of a geriatric consultation team on the functional status of hospitalized elderly patients.Design: Randomized controlled clinical trial.Setting: University-affiliated referral Veterans Administration Medical Center.Patients: One hundred and seventy-eight hospitalized elderly men 75 years or older admitted to medical, surgical, and psychiatry services, but excluding patients admitted to intensive care units.Intervention: Eighty-eight intervention group patients received multidimensional evaluation by an interdisciplinary geriatric consultation team composed of a faculty geriatrician, geriatrics fellow, geriatric clinical nurse specialist, and a social worker trained in geriatrics. Results of the evaluation, including problem identification and recommendations, were given to the patients' physicians. Ninety control group patients received only usual care.Measurements and Main Results: Intervention and control groups were comparable initially. The major outcome variable was the Index of Independence in the Activities of Daily Living (ADL) (Katz). Thirty-nine percent of the total study population was functionally independent on admission, 27% required assistance with one to three ADL, 22% required assistance with four to six ADL, and 12% were completely dependent. Many patients remained unchanged from admission to discharge: intervention group, 38%; control group, 39%. In the intervention group, 34% improved and 28% declined; in the control group, 26% improved and 36% declined. Although these changes reflected a trend toward greater improvement in the intervention group, the results were not statistically significant.Conclusions: Among elderly patients entering an acute-care hospital, approximately 60% had some degree of, and one third had serious functional disability. Such patients are at risk for further decline during hospitalization. A geriatric consultation team was unable to alter the degree of functional decline. Geriatric units or consultation teams may have to offer direct preventive or restorative services in addition to advice if improvements are to be made. [ABSTRACT FROM AUTHOR]

To examine the relationship between degree of treatment-induced blood pressure (BP) reduction and myocardial infarction, the experience of 1765 previously untreated, mild to moderate hypertensives (initial BP greater than or equal to 160 and/or greater than or equal to 95 mm Hg) in a systematic treatment program was reviewed. Over an average of 4.2 years, there were 39 morbid or fatal myocardial infarctions. Three types of fall in diastolic BP (final minus pretreatment) were defined: small (less than or equal to 6 mm Hg), moderate (7 to 17 mm Hg), and large (greater than or equal to 18 mm Hg). By Cox regression, an association was observed between myocardial infarctions and both a large and a small fall, relative to a moderate decline. Age and sex were independent risk factors. Body mass index, cholesterol level, electrocardiogram, race, prior cardiovascular disease, smoking status, initial and final revisit BP, total intreatment BP, and systolic BP were not. Since both a large and small reduction in diastolic BP were associated with a higher incidence of myocardial infarction (relative to a moderate fall), perhaps a moderate reduction in diastolic BP should be the goal of treatment for mild and moderate hypertensives. [ABSTRACT FROM AUTHOR]

Discusses the development of geriatric medicine in the United States. Inclusion of an offer of a certifying examination signifying special competence under the joint sponsorship of the American Board of Internal Medicine and the American Academy of Family Physicians; Finding that osteoporosis is a major cause of morbidity and mortality in elderly patients.

We sought to determine the rate of target vessel revascularization (TVR) after percutaneous transluminal coronary angioplasty (PTCA) and to determine factors that predispose to its occurrence. The 10-year outcome of 2,262 patients in the National Heart, Lung, and Blood institute PTCA Registry was analyzed to determine the incidence and characterize predictors of TVR. TVR was performed in 30.4% of patients. Male gender (relative risk [RR] 1.26; p <0.05), diabetes (RR 1.57; p <0.001), multiple discrete lesions (RR 1.38, p <0.01), diffuse lesions (RR 1.27; p <0.05), and calcium at the lesion site (RR 1.25; p <0.05) were predictors for TVR. TVR was performed early (< or = 1 year) in 18.3% and late (> 1 year) in 12.2%. Age > or = 65 years (RR 1.24; p <0.05), congestive heart failure (RR 1.70; p <0.05), acute coronary insufficiency (RR 1.28; p <0.05), and left anterior descending lesion location (RR 1.34, p <0.01) were significant predictors of early versus late TVR by multivariate analysis. Coronary artery bypass grafting (CABG) rather than PTCA was the TVR procedure in 21% of patients undergoing early TVR and 58% of those undergoing late TVR. Significant independent predictors of CABG as the TVR procedure were multivessel disease (RR 1.97; p <0.001), presence of collateral vessels (RR 1.81; p <0.05), diffuse (RR 1.89; p <0.01), or occluded (RR 1.82; p <0.05) target lesions, and a greater residual stenosis after the initial PTCA (RR 1.19; p <0.001). Age > or = 65 years (RR 0.65; p <0.05) conferred a lower risk for CABG. [ABSTRACT FROM AUTHOR]