Alan C. Wilson

Effect of diabetes mellitus on short- and long-term mortality rates of patients with acute myocardial infarction: A statewide study

We studied the effect of diabetes mellitus (DM) on mortality rate in 42,595 patients in the statewide Myocardial Infarction Data Acquisition System (MIDAS), which included patients with myocardial infarction from 90 nonfederal hospitals in New Jersey during the years 1986 and 1987. Of these patients 9695 (22.8%) had DM. DM was more prevalent among female, black, and older patients. DM was associated with higher mortality rates, both in-hospital (21.5% vs 19.2%, p < 0.001) and during 3-year follow-up (46.7% vs 37.8%, p < 0.001). This relation persisted in both men and women, blacks and whites, and all age groups. DM was an independent predictor of mortality by multivariate Cox proportional hazards regression analysis after adjustments were made for gender, race, age, hypertension, left ventricular dysfunction, chronic pulmonary disease, chronic liver disease, and anemia. This effect of DM was most pronounced in the younger age groups. Relative risk was 1.87 for age group 30 to 49, 1.36 for 50 to 69, and 1.17 for 70 to 89 years (p < 0.0001).

Lipid risk profile and weight stability after gastric restrictive operations for morbid obesity.

There are no longitudinal data that address weight loss stability and lipid levels in bariatric surgical patients. The goal of this study was to determine whether weight regain adversely affected reduction in lipid levels after gastric bariatric operations. Of 651 consecutive patients undergoing gastric restrictive surgery for morbid obesity, 227 (35%) had increased serum levels of total cholesterol (TC), triglycerides, or both preoperatively. High-density lipoprotein cholesterol (HDL-C) levels were subnormal (≤35 mg/dl) in 45 (20%) of the hyperlipidemic patients. Fasting lipid profiles were determined at 6-month intervals postoperatively. This series included the following three operations: gastroplasty (GP; N = 13), standard Roux-en-Y gastric bypass (RYGB; N = 205), and distal Roux-en-Y gastric bypass (DRY; N = 9). By 6 months postoperatively, patients had a ≥15% mean reduction in TC and a ≥50% mean reduction in triglycerides, both of which were significant in comparison with preoperative levels (P ≤0.05). Mean HDL-C levels had increased significantly vs. preoperative levels by 12 months postoperatively (P <0.05) and continued to increase through 5 years. By 18 months both HDL-C and TC were significantly lower after DRY than after GP or RYGB. In 91 patients who were followed for 2 years or longer (mean 48 ± 25 months), mean excess weight loss was 55% with mean body mass index reduced from 48 to 33 kg/m2. This group was divided into patients whose weight remained stable (N = 54) and patients who regained ≥l5% of their lost weight or lost less than 50% of excess weight (N = 3 7). Although mean excess weight loss and body mass index were significantly different between the two groups (P <0.0001) at 2 years, there was no difference in the lipid profile (TC/HDL) between the two groups at any interval through 5 years. These results show that abnormal lipid profiles can be permanently improved after gastric bariatric surgery and are not adversely affected by mediocre weight loss or regaining ≥15% of lost weight. DRY appears to be a superior operation for TC reduction in comparison with GP and RYGB.

The Effectiveness of Outpatient Appointment Reminder Systems in Reducing No-Show Rates

BACKGROUND Patients who do not keep physician appointments (no-shows) represent a significant loss to healthcare providers. For patients, the cost includes their dissatisfaction and reduced quality of care. An automated telephone appointment reminder system may decrease the no-show rate. Understanding characteristics of patients who miss their appointments will aid in the formulation of interventions to reduce no-show rates. METHODS In an academic outpatient practice, we studied patient acceptance and no-show rates among patients receiving a clinic staff reminder (STAFF), an automated appointment reminder (AUTO), and no reminder (NONE). Patients scheduled for appointments in the spring of 2007 were assigned randomly to 1 of 3 groups: STAFF (n=3266), AUTO (n=3219), or NONE (n=3350). Patients in the STAFF group were called 3 days in advance by front desk personnel. Patients in the AUTO group were reminded of their appointments 3 days in advance by an automated, standardized message. To evaluate patient satisfaction with the STAFF and AUTO, we surveyed patients who arrived at the clinic (n=10,546). RESULTS The no-show rates for patients in the STAFF, AUTO, and NONE groups were 13.6%, 17.3%, and 23.1%, respectively (pairwise, P<.01 by analysis of variance for all comparisons). Cancellation rates in the AUTO and STAFF groups were significantly higher than in the NONE group (P<.004). Appointment reminder group, age, visit type, wait time, division specialty, and insurance type were significant predictors of no-show rates. Patients found appointment reminders helpful, but they could not accurately remember whether they received a clinic staff reminder or an automated appointment reminder. CONCLUSIONS A clinic staff reminder was significantly more effective in lowering the no-show rate compared with an automated appointment reminder system.

Association of increased pulse pressure with the development of heart failure in shep

The aim of this study was to assess the relationship between pulse pressure (PP) and the occurrence of heart failure (HF) in older persons with isolated systolic hypertension. Data from a prospective, multicenter, randomized, double-blind, placebo-controlled clinical trial were analyzed. A total of 4736 persons aged > or = 60 years with systolic blood pressure (SBP) between 160 and 219 mm Hg and diastolic blood pressure (DBP) < 90 mm Hg who participated in the Systolic Hypertension in the Elderly Program (SHEP) were studied. The main outcome measures were fatal and nonfatal HF. During 4.5 years average follow-up, fatal or nonfatal HF occurred in 160 of 4736 patients. The SBP, PP, and mean arterial pressure (MAP) were strong predictors of the development of HF (P < .0002). Cox proportional hazards regression using time-dependent covariates and controlling for MAP indicated that HF was inversely related to DBP (P = 0.002) and was directly related to pulse pressure (P = 0.002). Data were similar when patients who developed myocardial infarction during follow up were excluded. These data indicate that, in older persons with isolated systolic hypertension, high pulse pressure is associated with increased risk of heart failure independently of MAP and of the occurrence of acute myocardial infarction during follow-up.

Superiority of nonpharmacologic therapy compared to propranolol and placebo in men with mild hypertension: A randomized, prospective trial

We compared the effects of nonpharmacologic therapy, propranolol monotherapy, and placebo on blood pressure, metabolic, exercise, and quality of life variables in a 12-week, randomized, placebo-controlled trial of 79 male patients with hypertension. A significant reduction in diastolic blood pressure was observed with both nondrug therapy (-8.0 +/- 1.08 mm Hg) and propranolol (-9.5 +/- 1.46 mm Hg) compared to placebo (-0.1 +/- 2.01 mm Hg). However, only patients receiving nonpharmacologic therapy showed a reduced body mass index, lower total and low-density lipoprotein serum cholesterol levels, and increased exercise tolerance compared to both propranolol and placebo. Patients receiving propranolol felt less anxious and unsure but showed a significant decrement in nocturnal penile tumescence compared to both placebo and nondrug therapy. Patients receiving nondrug therapy felt more energetic and reported improved sexual arousal and greater sexual satisfaction after treatment. Reductions in blood pressure in the nondrug treatment group were related to both weight reduction and improved fitness. We conclude that nondrug therapy is effective in controlling blood pressure in men with mild hypertension and is associated with improvements in weight, lipoprotein levels, and exercise tolerance compared to both propranolol and placebo. Quality of life assessments further support the use of nondrug therapy in this context.

Suppression of aortic atherosclerosis in cholesterol-fed rabbits by purified rabbit interferon.

The effectiveness of rabbit interferon in suppressing atherosclerosis was evaluated in rabbits fed a diet containing 1% cholesterol. Ten male New Zealand White rabbits received intramuscular injections of 1 million units of interferon twice a week, while a control group of 10 rabbits received injections of buffer. Both groups had average serum cholesterol levels of over 2000 mg/dl during the 8-week experimental period. Interferon treatment resulted in no significant hypolipidemic effect or changes in lipoprotein composition. Atherosclerotic lesions in aortas were quantified both macroscopically and microscopically. Interferon treatment decreased the grossly visible lesion area significantly from 25 +/- 4% to 8 +/- 1% (mean +/- SEM, p less than 0.005) compared to the untreated group. Microscopic analysis of serial cross-sections of aortic segments revealed significant (p less than 0.01) reductions in both lesion size and frequency in the interferon-treated group. Electron microscopy also showed that interferon treatment reduced the pathological effects of cholesterol feeding. Tissue analysis showed that total aortic cholesterol was reduced by 28% by interferon treatment, while the aortic phospholipid concentration was increased by 25%. The possibility exists that the interferon preparation used contained other biological response modifiers and that the observed effects may be totally unrelated with interferon. These results suggest that the mechanism of atherosclerosis suppression in these cholesterol-fed rabbits is not related to the lowering of serum cholesterol but may be associated with inhibition of lesion initiation.

Effects of combined probucol-colestipol treatment for familial hypercholesterolemia and coronary artery disease

To evaluate the effect of hypercholesterolemic treatment on coronary artery disease in patients known to be susceptible to disease progression, 44 patients with familial hypercholesterolemia and coronary artery disease were started on a lipid-lowering diet and either probucol (1 g/day) or colestipol (30 g/day). After 5 months of monotherapy, all patients went on a regimen of diet and 2-drug therapy. To date, combination therapy has continued for 3.4 to 4.1 years, and has resulted in the following changes from baseline in mean serum lipid levels: -48.5% in total cholesterol, -53.3% in low density lipoprotein cholesterol, -30.0% in high density lipoprotein cholesterol and +14.5% in triglycerides. The reduction in low density lipoprotein cholesterol apparently improved the clinical status of these patients despite the associated drop in high density lipoprotein cholesterol. In the 19 patients who underwent coronary arteriography before admission to the study, follow-up arteriograms showed that combined treatment stabilized the progression of established lesions and prevented the formation of new ones. Side effects occurred mainly with monotherapy and during the early phase of combination therapy. Reactions included diarrhea, constipation, other vague abdominal symptoms, headache and joint stiffness. In all instances, the side effects gradually subsided after the institution of combination therapy. The combination of probucol and colestipol plus diet appears to be effective in treating most patients with familial hypercholesterolemia.

Treatment of type III hyperlipoproteinemia with gemfibrozil to retard progression of coronary artery disease

Eight type III hyperlipoproteinemic (type III HLP), homozygous E 2/2 patients were enrolled in two periods of long-term diet-gemfibrozil treatment. The combined therapy resulted in highly significant decreases in their low-density lipoprotein cholesterol, very-low density lipoprotein cholesterol, very-low density lipoprotein triglycerides, and increases in their high-density lipoprotein cholesterol during the first treatment period of 24 to 28 months. Type III HLP reasserted itself following an 8-week interruption of gemfibrozil therapy. Resumption of gemfibrozil therapy again lowered the high lipid-lipoprotein concentrations of these patients toward normal. Tuboeruptive xanthomata, palmar xanthoma, and xanthoma striata palmare subsided with treatment. Follow-up coronary arteriograms performed 2.5 to 3.0 years after initiation of diet-drug treatment showed stabilization of coronary arterial lesions, which was associated with improvement in exercise tolerance.

Persistence of normotension after discontinuation of lifestyle intervention in the Trial of TONE

BACKGROUND Weight loss and sodium reduction programs are effective in treating hypertension, but there is little information about the persistence of the benefit after discontinuation of the intervention. METHODS The Trial of Nonpharmacologic Interventions in the Elderly (TONE) was a four-center controlled clinical trial of weight loss, reduced sodium intake, or both in maintaining normotension after withdrawal of antihypertensive drug therapy in older men and women whose hypertension was controlled with a single antihypertensive medication. Information on maintenance of normotension without need for drug therapy was obtained on 222 of 223 participants at the Robert Wood Johnson Medical School clinical center on average of 48.4 months (range 45 to 54 months) after the end of TONE. RESULTS At the end of TONE follow-up, 43% of participants in the combined intervention group were off medication compared with 25% in the usual care group (P = .011). At 48 months after the end of TONE and discontinuation of contact of the participants with the clinical center, 23% of the combined intervention group v 7% in the usual care group were off medication (P = .012). CONCLUSIONS Some benefits of structured dietary intervention appears to persist long term in a significant number of patients after discontinuation of the intervention.

Suppression of experimental atherosclerosis in rabbits by interferon-inducing agents

The effects of two chemically different interferon inducers on the suppression of atherosclerosis were studied in rabbits fed an atherogenic chow diet. One group (10 rabbits per group) was fed normal rabbit chow, and three groups were fed an atherogenic chow. One of the latter groups received the atherogenic feeding alone; the other two were treated with either polyinosinic-polycytidylic acid (poly I:C) or 2-amino-5-bromo-6-phenyl-4-pyrimidinone (ABPP). Neither of the drugs reduced significantly the hypercholesterolemia induced by the feeding. However, both poly I:C and ABPP treatment significantly reduced the percent area of the aortic intimal surface lesions, stained for lipid with Sudan IV, compared with that in untreated rabbits fed atherogenic chow. Microscopic sections of typical aortic plaques showed that both drug treatments significantly reduced the size and number of intimal lipid deposits compared with those observed in the aortas of untreated animals. Chemical analysis for cholesterol and collagen content revealed that interferon-inducing agents significantly reduced cholesterol deposits in the aorta, with little effect on fibrous protein deposition. The results indicate that two unrelated interferon-inducing drugs suppressed atherogenesis without reducing serum cholesterol and low density lipoprotein levels. Whether the protection against atherosclerosis is exerted by endogenous interferon production remains to be determined.