Search

night can manage to sleep longer without taking medication, and whether those who succeed lose weight. Researchers also will assess whether additional sleep lowers prevalence of the metabolic syndrome and alters levels of appetite-control hormones (http:// clinicalstudies.info.nih.gov/detail /A_2006-DK-0036.html). “This is a proof-of-concept study,” said Giovanni Cizza, MD, PhD, the study’s principal investigator and staff clinician in the clinical endocrine section of the NIDDK. The researchers plan to enroll approximately 150 men and premenopausal women aged 22 to 50 years (100 in the intervention group and 50 controls), living in the Baltimore-Washington metropolitan area. They also hope to enroll the participants’ partners. Participants will be randomly assigned to either try to increase their sleep up to a limit of 7.5 hours or continue to sleep their usual amount. “Even if only a modest change in BMI occurs,” Cizza said, “that finding would have a huge impact from a population perspective.”

mmol/L). If levels are 190 mg/dL (4.92 mmol/L) or higher after an adequate period of dietary therapy, drug therapy should be considered. If levels are between 160 mg/dL (4.14 mmol/L) and 189 mg/dL (4.92 mmol/L) and a severe risk factor is present, drug therapy is an option, the guidelines said. Beyond refining cholesterol guidelines, Cleeman hopes the update will serve to remind everyone that even though at least 36 million individuals should be receiving drug therapy, less than half that number are taking medication. “The hope is that by paying attention to the update and trial results, we can get the public and physicians to pay attention and turn a picture of undertreatment into a picture of appropriate care,” Cleeman said. The update may not be the final word on low-cholesterol targeting. Cleeman said some researchers are suggesting that lowering LDL-C levels to 40 mg/dL (1.04 mmol/L) may provide substantial additional cardiovascular protection. Clinical trials that may prove the hypothesis are under way. The update is available online at http://www.nhlbi.nih.gov/guidelines /cholesterol/atp3upd04.htm.

To the Editor. —In their article, Drs Kaplan and Gifford 1 make the point that certain antihypertensive drugs have unique advantages for certain patients and that rigid adherence to the recommendations of the fifth report of the Joint National Committee for the Detection, Evaluation, and Treatment of High Blood Pressure (JNC V) might not optimally serve the interests of all patients. It is our view that additional considerations should be given to women of childbearing age. The possibility of future conception and the safety of specific antihypertensive drugs during pregnancy should be discussed with all women of childbearing age. Because many women do not plan their pregnancies, patients with hypertension may conceive while taking medication that could adversely affect the fetus. It is not uncommon for uninformed patients to abruptly discontinue their antihypertensive medication(s) when pregnancy is discovered because of their concerns about the fetus. Because these patients may thus

Background: Previous studies have shown the effectiveness of tilt table testing in establishing the diagnosis ofneurocardiogenic syncope and in dictating therapy in patients with syncope of unknown origin. Most studies have been limited by small numbers of patients and brief follow-up. Tilt table testing was performed with and without isoproterenol hydrochloride in 94 patients, and therapy was determined by the test findings. The patients were followed up for at least 10 months (mean, 17.8 months). Methods: The 80° tilt table test was performed in 94 consecutive patients who presented with syncope (n=74) or presyncope (n=20) and in whom neurologic and cardiac causes were ruled out. Therapy was determined by the tilt test findings. Sixty-seven patients were followed up for 17.8±5.3 months (mean±SD) (range, 10 to 27 months). Results: Forty-nine patients had positive results of tilt studies and received therapy. Of these 49 patients, 36 returned for second tilt studies while they were taking medication, and 30 had negative results. Six patients had medication changes and had negative results of follow-up tilt studies. No symptoms were noted on follow-up in the 24 patients who presented with syncope and who had positive results of tilt tests that responded to therapy. Of those 35 patients presenting with syncope who had negative results of initial tilt studies and who did not receive any therapy, syncope recurred in four patients. Three of 10 patients contacted who presented with presyncope and had negative results of tilt studies reported symptoms. Conclusions: Tilt table testing is an excellent tool for diagnosing neurocardiogenic syncope in adults and in determining effective therapy in patients presenting with syncope of unknown origin. (Arch Intern Med. 1994;154:1613-1617)

To the Editor. —As someone who has devoted a good part of the past 19 years to the health care needs of New York City prisoners, I was intrigued by your excellent and provocative article 1 and Editorial 2 concerning the medical problems of newly arrested diabetic patients with no access to medication. It is my impression (at least with regard to epilepsy, the illness that I deal with) that the main cause for the sudden interruption of medical treatment in this setting is the police confiscating the patients' medication at the time of arrest. I doubt, in fact, whether the people taking medication for diabetes, epilepsy, asthma, and the like keep this information to themselves as the article suggests. What my patients tell me is that they complain vociferously but to no avail. In other words, I question the statement: "In order to receive any medication, recently arrested prisoners

In Reply.— I would like to thank Chapdelaine for his interest in my study. 1 Some of his concerns have already been expressed in the editorial by Grundy 2 that accompanied my article. I would, however, like to respond to some of the concerns. While it is true that most of the subjects of my study were from a select population (upper class, white, highly motivated), the results show that most individuals do, indeed, respond to lifestyle modification with major reductions in serum lipid levels. Of the 4587 subjects, 91% reduced their total cholesterol levels and 88% reduced their triglyceride levels. This would indicate that many individuals presently taking medication to lower lipid levels, with long-term side effects unknown, could use life style modification as recommended by the National Cholesterol Education Program. Chapdelaine states that the validity of my statistics is suspect because all parameters were not obtained from all

In Reply.—I thank Dr Lee for his thoughtful comments. He raised several issues related to our study about the use of anabolic steroids in high school students.1He suggested that students with medical conditions, such as growth disorders, allergies, and asthma may be taking steroids or other similar medications and may be confused by the termanabolic steroids. The number of students taking medication for growth disorders is likely to be extremely small. It also seems reasonable to conclude that those students would be very likely to know they were taking growth hormone and would be unlikely to confuse them with anabolic steroids. While it is estimated that 5% to 10% of children will have signs and symptoms of asthma during childhood,2the number of adolescents with asthma severe enough to necessitate long-term corticosteroid therapy is extremely small. It again appears likely that this select group would

Aneurysms of the extracranial portions of the internal carotid artery are rare, and, of the 85 cases reported, in all but 2 the patients were less than 15 years old. We are adding to the reported cases that of a woman aged 50 years who made a complete recovery after surgical extirpation of the aneurysm. The patient, a Negro woman 50 years of age, had been seen in the Medical Clinic since 1949 because of epileptic seizures. She had been having these seizures since the age of 23 years, at which time she was involved in an accident and became unconscious. She had been taking medication regularly and her last seizure was Dec. 10, 1955. An electroencephalogram revealed an abnormal tracing suggesting epilepsy. On her visit to the clinic on Dec. 10 the patient complained of a lump in her throat, which she stated had been present for seven years.

• The "nonspecific" and nonpharmacologic aspects of taking medication are important in several clinical situations: when patients insist on a medicine that is not clinically indicated; when they refuse an appropriate medication; when they are repeatedly troubled by side effects from a variety of drugs; and when they do not adhere to the regimen. The patient's behavior in these situations may be motivated by the psychological meanings, interpersonal communications, or social consequences of taking pills. The physician may be able to identify these psychosocial factors by learning about the patient's prior experiences with medications, by eliciting his views of physicians and medical care, and by understanding the consequences of becoming a patient. (Arch Intern Med1983;143:1544-1548)

• Using precise infrared recording instrumentation, we measured the eye-movement patterns in six schizophrenic patients who were taking medication and found saccadic intrusions and saccadic smooth-pursuit tracking in three. This defined some of the eye-movement irregularities reported previously by many investigators. A variety of eye-movement functions in addition to smooth pursuit exhibited these abnormalities, including fixation, vergence, and head-eye pursuit. Saccadic intrusions or saccadic pursuit also occurs in a number of neuro-ophthalmologic disorders, and occasionally In healthy normal subjects. Thus, these eye-movement abnormalities do not occur exclusively in schizophrenia.

To the Editor.— In a conceptually important study, Gur et al 1 measured with the xenon Xe 133 inhalation technique the blood flow in the grey matter of the superficial cortex. Their subjects were schizophrenic patients who were taking medication and control subjects at rest and during verbal and spatial tasks that were designed to explore hemispheric asymmetries in processing. The authors concluded that patients and control subjects did not differ at rest, but differences emerged with cognitive activation such that in patients the verbal task induced symmetric increases in blood flow and the spatial task induced greater left hemispheric increases, whereas in control subjects changes were compatible with hemispheric specializations. When sex differences were examined, schizophrenic women showed minimal changes that were greatest when performing the verbal task and not the spatial task as in other groups. Some of these results are open to question because group differences all

The Hypertension Detection and Follow-up Program (HDFP) previously described a significant reduction in five-year, all-cause mortality in its intensively treated stepped care (SC) group relative to its referred care (RC) control group. At the time this finding was described, a proportion of the SC cohort had been treated for periods as long as 6.7 years, but comparable RC and SC mortality data beyond five years were not available. These data, which are described herein, indicate that the 6.7-year life-table mortality rates were 95.1/1000 participants for SC vs 116.3/1000 participants for RC, a larger mortality difference than was observed at five years. This favorable finding for SC extended to all major subgroups, including white women and those aged 30 to 49 years at trial entry. Six months after the close of the treatment trial, a two-year posttrial surveillance study, which extended mortality follow-up to 8.3 years, was conducted. The posttrial use of antihypertensive medication declined in SC and increased in RC participants so that by the end of the posttrial period, there was little difference in the percentages of SC and RC participants taking medication. Control of blood pressure, indicated by mean diastolic blood pressure and by percent of participants with a pressure of 90 mm Hg or less, was slightly better for SC than for RC participants (SC group, 86.5 mm Hg and 68% controlled; RC group, 87.8 mm Hg and 62% controlled). The absolute mortality advantage found at 6.7 years persisted and increased throughout the posttrial period of follow-up despite discontinuation of the formal SC therapy program. It is postulated that regression of hypertensive end-organ changes brought about by the more effective SC treatment caused this favorable outcome. (JAMA1988;259:2113-2122)

• We sought to determine whether such state-related factors as neuroleptic treatment and facio-oral tardive dyskinesia (TD) influence smooth-pursuit eye movement (SPEM) in chronic schizophrenics. The design Involved 100 schizophrenics, 64 of whom showed "abnormal" eye tracking. Experimentally drug-withdrawn patients, some of whom were clinically relapsed, were compared with control patients who continued taking medication in prewithdrawal and postwithdrawal SPEM tests. All groups showed a slight worsening in eye-tracking performance on two postwithdrawal tests, but significant group-by—test session "interactions" were not demonstrable. We also determined that patients with TD tend to substitute large, nontracking saccades for SPEM to a significantly greater extent than nondyskinetic patients. Our findings strengthen the supposition that impaired SPEM is a trait in many schizophrenics but suggest that patients with TD be excluded in future studies of SPEM addressed to trait issues.

The authors of Facilitating Treatment Adherence are medical psychologists who have worked for more than 20 years with a variety of clinical populations who manifest medical, psychological, and behavioral problems such as chronic pain, diabetes, smoking, and psychotic disorders. The purpose of their book is to review the important issue of treatment adherence, describe adherence enhancement procedures, and exhibit the integration of adherence procedures and impediments to their use. The authors clarify the terminology, or jargon, of the adherence literature and point out the difference between adherence and compliance—a distinction more semantic than real. The first part of the book is rich with information regarding the problem of patients not following treatment directions, not taking medication, and not changing unhealthy behaviors or life-styles. They focus on factors that affect treatment adherence, such as patients' beliefs, the complexity of a treatment regimen, and the severity of symptoms. The second part of