David C. Parish

Racial Differences in Plasma Endothelin-1 Concentrations in Individuals With Essential Hypertension

Hypertension is more prevalent in blacks than whites, and the reasons for this difference remain unclear. To test whether endothelin may play a role in these racial variations, we analyzed plasma samples from black and white women and men with high blood pressure by an enzyme-linked immunoassay specific for endothelin-1 (ET-1), a potent vasoconstrictor, and compared them with those obtained from similar subjects with normal blood pressure. Both female and male hypertensive blacks had elevated levels of immunoreactive ET-1 (11.3 +/- 1.0 and 12.3 +/- 1.3 pmol/L, respectively) compared with values in normotensive control blacks (1.5 +/- 0.2 and 1.4 +/- 0.2 pmol/L). Corresponding values in female and male hypertensive whites were 3.8 +/- 0.6 and 3.8 +/- 0.6 pmol/L, respectively, compared with respective values of 1.4 +/- 0.1 and 2.8 +/- 0.4 pmol/L in normotensive control whites. These results indicate that plasma concentrations of immunoreactive ET-1 levels differ significantly between black and white individuals with high blood pressure. This finding may be an important factor in the etiology of racial differences in the prevalence and severity of hypertension and deserves further study [corrected].

Medicare Financing of Graduate Medical Education: Intractable Problems, Elusive Solutions

The past decade has seen ongoing debate regarding federal support of graduate medical education, with numerous proposals for reform. Several critical problems with the current mechanism are evident on reviewing graduate medical education (GME) funding issues from the perspectives of key stakeholders. These problems include the following: substantial interinstitutional and interspecialty variations in per-resident payment amounts; teaching costs that have not been recalibrated since 1983; no consistent control by physician educators over direct medical education (DME) funds; and institutional DME payments unrelated to actual expenditures for resident education or to program outcomes. None of the current GME reform proposals adequately address all of these issues. Accordingly, we recommend several fundamental changes in Medicare GME support. We propose a re-analysis of the true direct costs of resident training (with appropriate adjustment for local market factors) to rectify the myriad problems with per-resident payments. We propose that Medicare DME funds go to the physician organization providing resident instruction, keeping DME payments separate from the operating revenues of teaching hospitals. To ensure financial accountability, we propose that institutions must maintain budgets and report expenditures for each GME program. To establish educational accountability, Residency Review Committees should establish objective, annually measurable standards for GME program performance; programs that consistently fail to meet these minimum standards should lose discretion over GME funds. These reforms will solve several long-standing, vexing problems in Medicare GME funding, but will also uncover the extent of undersupport of GME by most other health care payers. Ultimately, successful reform of GME financing will require “all-payer” support.

Success changes the problem: Why ventricular fibrillation is declining, why pulseless electrical activity is emerging, and what to do about it

BACKGROUND Programs for research and practice in resuscitation have focused on identification and reversal of ventricular fibrillation (VF). While substantial progress has been achieved, evidence is accumulating that clinical death is less likely to be caused by fibrillation now than in the 1960s and 1970s. Pulseless electrical activity (PEA) has emerged as the most common rhythm found in arrests in the hospital and is rapidly rising in pre-hospital reports. PURPOSE To identify the magnitude of changes occurring, search for potential explanations from population and clinical epidemiology and present the data available regarding etiology and treatment of PEA. DATA SOURCES Synthesis of material from population epidemiology, clinical epidemiology, animal and human research on VF and PEA. CONCLUSIONS VF is a manifestation of severe, undiagnosed coronary artery disease (CAD). Rates of death from CAD increased from rare in 1930 to become the most common cause of death in the US. CAD death rates peaked in the early 1960s and had declined over 50% by the late 1990s. Primary and secondary prevention, early diagnosis and aggressive, successful treatment have contributed to this decline. PEA is a brief phase in clinical death that occurs after losses in consciousness, ventilatory drive and circulation but before decay to asystole; survival rates are poor. PEA is a common stage in clinical death from any of a variety of tissue hypoxic/anoxic insults. Research on PEA is needed; 50 years of attention to CAD and VF have resulted in improved survival and changed the disease spectrum. Similar attention to animal and clinical research on PEA may have the potential to improve survival.

Effect of Advanced Cardiac Life Support Training on Resuscitation Efforts and Survival in a Rural Hospital

STUDY OBJECTIVE To determine the impact of an Advanced Cardiac Life Support (ACLS) training program on resuscitation and survival in a rural hospital. METHODS Retrospective review of arrests in a 119-bed rural community hospital before, during, and after organization of an ACLS teaching program. ICU logs, death logs, and code review sheets were used to determine resuscitation efforts and outcomes; these were cross-checked with medical and administrative records. From 1980 through 1984, resuscitation attempts were conducted only in the ICU. By 1985, after the training program was instituted, resuscitation efforts were conducted throughout the hospital. Data are presented on resuscitations in the ICU only and on total hospital resuscitations. To assess effort, resuscitation attempts and successes were compared with total death events (ie, total number of hospital deaths plus total number surviving a resuscitation effort). RESULTS From 1980 through 1984, before ACLS training was instituted, 42 patients were resuscitated and 15 (36%) survived to discharge. From 1985 through 1987, 113 ICU patients were resuscitated and 29 (26%) survived. From 1988 through 1990, after ACLS protocol and code review procedures were established, 81 ICU patients were resuscitated and 23 (28%) survived. The number of attempted resuscitations throughout the hospital increased from 42 in the early period to 179 in the final period, with 15 (36%) and 52 (29%) survivors, respectively. Rates of ICU or hospital-wide resuscitation success were not significantly different over time (P > .3). There were 893 total death events in the early period and 485 in the final period. The percentage of death events with an intervention rose from 5% to 37% (P < .001), and the percentage reversed by intervention increased from 2% to 11% (P < .001). CONCLUSION After widespread ACLS training and code team organization, there was a significant increase in resuscitation efforts and reversal of death events despite a slight decline in the percentage of patients surviving resuscitation attempts. An ACLS training program in a rural hospital can contribute to increased overall survival.

Resuscitation in the hospital: Differential relationships between age and survival across rhythms

OBJECTIVE Assess the frequency and outcome of inhospital resuscitation and determine the relationship between patient age and survival and whether it is affected by initial rhythm. DESIGN Retrospective, single-institution, registry study of inhospital resuscitation. SETTING A 550-bed, tertiary-care, teaching hospital in Macon, GA. PATIENTS All admissions for which a resuscitation was attempted in the Medical Center of Central Georgia during the period of January 1, 1987 through December 31, 1993. The registry sample included 2,394 admissions, for which 2,813 resuscitation attempts were made; only the first resuscitation attempt during an admission was analyzed. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Rates of survival to discharge steadily increased from 24.4% in 1987 to 38.6% in 1993; the overall survival rate was 26.8%. Age, used as a continuous variable, was strongly related to survival (odds ratio = 0.984; p < .0001). Categorically, overall survival rates for pediatric, adult, and geriatric patients were 56.4%, 29.0%, and 24.0%, respectively. Survival rates also varied significantly (odds ratio = 0.469; p < .0001) among initial rhythms, i.e., supraventricular tachycardia (60.7%), ventricular tachycardia (57.6%), perfusing rhythms (49.84%), ventricular fibrillation (32.0%), pulseless electrical activity (14.6%), and asystole (9.1%). The relationship between age and survival did not change across the years included in the study, but did vary as a function of initial rhythm (p < .0001). Age was positively related to survival when initial rhythm was supraventricular tachycardia (p = .04), negatively related to survival when the initial rhythm was perfusing (p < .0001) or pulseless electrical activity (p = .0002), and not related to survival when the initial rhythm was ventricular tachycardia (p = .98), ventricular fibrillation (p = .14), or asystole (p = .21). CONCLUSIONS The relationship between patient age and a successful resuscitation attempt is not as simple as reported earlier. Whether age is related to increased or decreased survival, or is unrelated to survival, depends on the rhythm extant when resuscitation attempts begin. Survival rates were higher than most reported elsewhere and improved significantly over time. Multicentered studies are needed to determine whether these results are unique to the institution studied.

Long-Term Follow-Up of Participants With Heart Failure in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT)

Background— In the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), a randomized, double-blind, practice-based, active-control, comparative effectiveness trial in high-risk hypertensive participants, risk of new-onset heart failure (HF) was higher in the amlodipine (2.5–10 mg/d) and lisinopril (10–40 mg/d) arms compared with the chlorthalidone (12.5–25 mg/d) arm. Similar to other studies, mortality rates following new-onset HF were very high (≥50% at 5 years), and were similar across randomized treatment arms. After the randomized phase of the trial ended in 2002, outcomes were determined from administrative databases. Methods and Results— With the use of national databases, posttrial follow-up mortality through 2006 was obtained on participants who developed new-onset HF during the randomized (in-trial) phase of ALLHAT. Mean follow-up for the entire period was 8.9 years. Of 1761 participants with incident HF in-trial, 1348 died. Post-HF all-cause mortality was similar across treatment groups, with adjusted hazard ratios (95% confidence intervals) of 0.95 (0.81–1.12) and 1.05 (0.89–1.25), respectively, for amlodipine and lisinopril compared with chlorthalidone, and 10-year adjusted rates of 86%, 87%, and 83%, respectively. All-cause mortality rates were also similar among those with reduced ejection fractions (84%) and preserved ejection fractions (81%), with no significant differences by randomized treatment arm. Conclusions— Once HF develops, risk of death is high and consistent across randomized treatment groups. Measures to prevent the development of HF, especially blood pressure control, must be a priority if mortality associated with the development of HF is to be addressed. Clinical Trial Registration— http://www.clinicaltrials.gov. Unique identifier: NCT00000542.

Relation of the pre-employment drug testing result to employment status: a one-year follow-up.

All employees hired over a six-month period at a large hospital underwent pre-employment urinary toxicology screening. Results of the screening were kept confidential. After a year of employment, the personnel folders of all employees studied were reviewed. Twenty-two of 180 employees (12%) had tested positive for drug use. Employees in clerical/aide positions were significantly more likely to test positive than were employees in professional positions (17% vs. 6%). Drug-positive employees were also more likely to be young and male. Comparison of job performance variables, job retention, supervisor evaluations, and reasons for termination showed no difference between drug-positive and drug-negative employees. Eleven drug-negative employees were fired during the study; no drug-positive employee was fired. There was a strongly significant difference between clerical and professional employees on each of these variables. This study did not find a relation between drug use and job performance. The widespread use of drug screening prior to employment makes further studies of this issue important.All employees hired over a six-month period at a large hospital underwent pre-employment urinary toxicology screening. Results of the screening were kept confidential. After a year of employment, the personnel folders of all employees studied were reviewed. Twenty-two of 180 employees (12%) had tested positive for drug use. Employees in clerical/aide positions were significantly more likely to test positive than were employees in professional positions (17% vs. 6%). Drug-positive employees were also more likely to be young and male. Comparison of job performance variables, job retention, supervisor evaluations, and reasons for termination showed no difference between drug-positive and drug-negative employees. Eleven drug-negative employees were fired during the study; no drug-positive employee was fired. There was a strongly significant difference between clerical and professional employees on each of these variables. This study did not find a relation between drug use and job performance. The widespread use of drug screening prior to employment makes further studies of this issue important.

Problem-based ACLS instruction: A model approach for undergraduate emergency medical education

The optimal format for teaching advanced cardiac life support (ACLS) to medical students and other groups with little emergency medicine experience has not been studied extensively. We report an ACLS provider course that was taught to sophomore medical students using a self-directed, problem-based learning model. The traditional two-day provider course format was replaced by a series of clinical problems that emphasized various aspects of the ACLS curriculum. Students then met weekly with an ACLS instructor who served as a tutor to discuss the problem. A specific set of learning objectives for the entire ACLS curriculum was developed into a study unit index and given to students at the beginning of the course. Enhanced practice time was offered to students in the form of traditional teaching stations and skills laboratories. Students were tested using standard ACLS criteria. The students in the problem-based course achieved a higher pass rate on the written test and skills stations than senior medical students did in a standard two-day course during the same time period. The problem-based format with enhanced practice time would appear to be an effective alternative for groups that need to acquire the basic skills needed in a resuscitation attempt but have little previous experience in this area.

Resuscitation in the hospital: relationship of year and rhythm to outcome

OBJECTIVE determine the frequency of initial rhythms in in-hospital resuscitation and examine its relationship to survival. Assess changes in outcome over time. METHODS retrospective cohort (registry) including all admissions to the Medical Center of Central Georgia in which a resuscitation was attempted between 1 January, 1987 and 31 December, 1996. RESULTS the registry includes 3327 admissions in which 3926 resuscitations were attempted. Only the first event is reported. There were 961 hospital survivors. Survival increased from 24.2% in 1987 to 33.4% in 1996 (chi(2)=39.0, df=1, P<0.0001). Survival was affected strongly by initial rhythm (chi(2)=420.0, df=1, P<0.0001) and decreased from 63.2% for supraventricular tachycardia (SVT) to 55.3% for ventricular tachycardia (VT), 51.0% for perfusing rhythms (PER), 34.8% for ventricular fibrillation (VF), 14.3% for pulseless electrical activity (PEA) and 10.0% for asystole (ASYS). PEA was the most frequent rhythm (1180 cases) followed by perfusing (963), asystole (580), VF (459), VT (94) and SVT (38). DISCUSSION the powerful effect of initial rhythm on survival has been reported in pre-hospital and in-hospital resuscitation. VF is considered the dominant rhythm and generally accounts for the most survivors. We report good outcome for each; however, VF represents only 13.8% of events and 16.7% of survivors. PEA accounts for more survivors (169) than does VF (160). Our improved outcome is partially explained by changes in rhythms, but other institutional variables need to be identified to fully explain the results. Further studies are needed to see if our findings can be sustained or replicated.

The effect of regulation of high blood pressure on plasma endothelin-1 levels in blacks with hypertension

Plasma concentrations of immunoreactive endothelin-1 (irET-1) are significantly elevated in blacks with hypertension. In the present study, we investigated the effect of the regulation of high blood pressure on plasma irET-1 levels in black hypertensive individuals. After the initial blood samples were collected from 20 black patients with uncontrolled high blood pressure (Day 1), an intensive antihypertensive treatment was initiated, and the blood pressure and plasma irET-1 levels were monitored on days 2, 8, and 22. When the high blood pressure was brought under control with commonly used antihypertensive medications, plasma irET-1 concentrations dropped dramatically, suggesting that ET-1 concentrations rise as a consequence of high blood pressure in this study group.