Joel Steinberg

Prevalence of clinically occult cardiomyopathy in chronic alcoholism

The mean absolute heart weight and mean heart weight to body weight ratio of a group of 43 alcoholics, screened from 1,970 consecutive autopsy reports at the Detroit General Hospital by selecting alcoholics with only ethyl alcohol abuse as an etiology of heart disease, are compared to those of a group of similarity selected age-matched nonalcoholic controls. None of the alcoholics was clinically suspected of having had cardiomyopathy. The statistically significant increased mean absolute heart weight and heart weight to body weight ratio of the alcoholic group reflected the presence of subclinical alcoholic cardiomyopathy. In addition, several of the patients in the alcoholic group displayed gross and microscopic cardiac pathologic changes consistent with alcoholic cardiomyopathy occurring in the absence of cardiomegaly.

Telemedicine for recently discharged older patients.

Congestive heart failure, chronic obstructive pulmonary disease, diabetes, and hypertension are common causes of hospitalization in the elderly. Short-term postdischarge clinical outcomes regarding compliance, symptom control, readmission, functional status, and mortality rates are in need of improvement. This observational study documents the results of a home-based case-managed telemedicine (CMTM) program delivered over a 2-month period postdischarge. A population of 851, predominantly elderly (over age 60), recently discharged patients were enrolled in the program. They received a nurse visit up to 3 times/week and home telemedicine monitoring (weight, blood pressure, pulse rate, blood glucose, and oximeter recordings) on a daily basis. Patient education was provided by the nurse and reinforced through telemedicine. Compliance rates, quality of life parameters, patient satisfaction with telemedicine, and data regarding nine quality of care measures (QCM), hospital readmission, and mortality rates were documented. Patient demographics and outcomes of care were analyzed. There were 68% females and 56% African Americans. The readmission rate was 13% and mortality 2%. Treatment goals were met in 67%, patient compliance rate was 77%, and the average improvement in the nine QCM indicators was 66%. A majority of patients showed improved quality of health perception, better disease understanding, and high satisfaction rates with telemedicine. This is one of the larger observational studies in a predominantly elderly patient population enrolled in a CMTM program, to date. This model of care was well accepted by the elderly and produced excellent short-term clinical outcomes.

Racial differences in drug response: Isoproterenol effects on heart rate following intravenous metoprolol

Healthy young black men and white men received single intravenous doses of metoprolol (0.07 mg/kg) or participated in an isoproterenol sensitivity study before and after metoprolol (0.07 mg/kg followed by 50 µg/min) in a randomized, crossed‐over fashion. Noncompartmental pharmacokinetic parameters were calculated. The dose of isoproterenol versus change in heart rate response curves were constructed, and comparisons of dose ratio, ED50, Emax, and Ka, with the apparent association constant for metoprolol binding to β1receptors, were made. There were no pharmacokinetic differences observed between the groups. The predicted Emax for the black group was 52.7 ± 8.7 beats/mm at a metoprolol concentration of 29.8 ± 6.1 ng/ml, which was higher (p < 0.05) than that in the white group, i.e., 43.7 ± 7.3 beats/min at a concentration of 27.6 ± 9.1 ng/ml. There were no differences in dose ratio, ED50, or Ka. The racial differences in β1‐receptor responses to exogenous isoproterenol following metoprolol can simply be explained by an increase in β1‐receptor activity in the black subjects, assuming homogeneity in cardiac β2‐receptor responses.

Racial Differences in Drug Response: Isoproterenol Effects on Heart Rate in Healthy Males

It was the purpose of this study to investigate racial alterations in β-adrenoceptor response. Two groups of healthy, male volunteers gave their consent. There were eight black Americans (mean age, 26.1 ± 2.5 years) and eight white/Caucasian Americans (mean age, 24.4 ± 1.8 years). Each subject underwent an isoproterenol sensitivity test. There was a significant (P < 0.05) decrease in the ratio of Emax to ED50 in the white group (25.3 ± 6.4) compared with the black group (37.1 ± 12.4). Over the dose range of 0.1 to 1.0 µg there was a significant increase in response at both the 0.25- and the 0.5-µg dose (P < 0.05), with the black American group appearing to respond with a greater rate of rise in heart rate following the initial doses.

Implementing a clinical pathway for congestive heart failure: experiences at a teaching hospital.

Clinical pathways are processes of care that use a multidisciplinary team effort to move patients toward a designed outcome. This article details the challenges of a Quality Enhancement and Clinical Resource Management Team in designing and implementing a successful congestive heart failure pathway at a teaching hospital. Academic institutions have the resources as part of their research mission, to enhance the development of clinical pathways and assess their outcomes.

Racial Differences in Drug Response: Isoproterenol Effects Before and After Propranolol

The aim of this study was to determine in young, healthy men the relative contribution of pharmacodynamic factors inherent between two groups known to respond differently to hypertensive therapy. Black (n = 10) and white (n = 10) men received an isoproterenol sensitivity test before and after propranolol (0.1 mg/kg, then 50 µg/min). There were greater increases (twofold) in systolic BP following the 1.0- and 1.5-µg isoproterenol dose (P < 0.05) in the black group. During propranolol there were no differences in free (1)-propranolol concentrations between the groups; however, propranolol decreased resting heart rate in the white group more than in the black group (P < 0.05). Cardiac index decreased less in the black group compared to the white group (P < 0.05). Following the second isoproterenol challenge, there again were greater increases in systolic BP in the black group at both the 10- and the 20-µg isoproterenol dose (P < 0.05). Our study has highlighted the importance of cross-racial studies in evaluating drug effects.

Effect of Age on Lymphocyte Beta2-Adrenergic Responsiveness

Beta-adrenergic receptor agonists and antagonists are among the most widely used classes of agents in the US today. Heterogeneity in pharmacologic response among humans exists. This article reviews the influence of age on lymphocyte beta2-adrenergic receptor responses. Evidence obtained in humans indicates that beta-adrenergic receptor numbers on peripheral blood cells may differ, although the direction of the change is not consistent among laboratories. Drug-induced regulation of receptors either up or down appears to be similar among age groups. The affinity of beta-adrenoceptor binding sites for isoproterenol decreases with aging. Events distal to the receptor recognition site itself exhibit age-related differences, presumably due to a decrease in the coupling of beta-adrenoceptors to adenylate cyclase. Mechanisms of decreased catecholamine responsiveness during aging remain to be defined. The precise definition of these alterations may contribute useful insights into the changes that occur with aging in response to catecholamines, other hormones, and neurotransmitters.

Preliminary Data from a Pharmacist-Managed Anticoagulation Clinic Embedded in a Multidisciplinary Patient-Centered Medical Home: A Coordinated Quality, Cost-Savings Model

Patient-centered, comprehensive, team-based, coordinated care models are a focal point of healthcare reform. The patient-centered medical home (PCMH) model aims to provide better primary care and health outcomes at a lower cost. To become a PCMH, a set of standards must be met that includes coordination of care transitions.

Metabolic and Cardiovascular Manifestations of Hypertension in the Elderly

Aging in industrialized societies is associated with an increasing prevalence of hypertension, type II diabetes mellitus, renal disease and atherosclerotic vascular disease. This increase in chronic disease processes in industrialized societies is related, in part, to increasing obesity, reduced physical activity, medications such as non-steroidal anti-inflammatory agents, and other environmental influences. Hypertension in the elderly is characterized by high peripheral vascular resistance, reduced baroreflex sensitivity, a low renin state with reduced cardiac output / increased hypertrophy, reduced intravascular volume, and an increased propensity to salt-sensitivity. Type II diabetes commonly accompanies hypertension in the elderly, in part related to reduction in lean body mass and relative increase in adiposity. Lipid abnormalities are also relatively common in the elderly and should generally be treated in a similar fashion to those in the middle-aged individual.

The impact of patient autonomy on older adults with asthma

BACKGROUND Understanding patient preferences and desire for involvement in making medical decisions is important when managing chronic conditions. Previous studies have used the Autonomy Preference Index (API) in younger patients with asthma to evaluate these preferences. OBJECTIVE To identify factors associated with autonomy and to determine whether autonomy is related to asthma outcomes among older adults. METHODS A total of 189 older adults (>55 years old) with persistent asthma were included. Preferences for autonomy were assessed using the API, with a higher score indicating higher desire for autonomy. Scores were separated into 2 domains of information-seeking and decision-making preferences. The separated scores were correlated with asthma outcomes and demographic variables. To control for confounding factors, a linear regression analysis was performed. RESULTS Higher decision-making preference scores correlated with female sex (P = .007), higher educational level (P = .01), and lower depression scores (P = .04). Regarding outcomes, decision-making scores positively correlated with Mini Asthma Quality of Life Questionnaire (Mini-AQLQ) scores (P = .01). On linear regression analysis, the Mini-AQLQ score remained significantly associated with decision-making preference scores (P = .03). There was no association with asthma control test scores, spirometry values, and health care use. Information-seeking preference scores correlated with educational level (P = .03), but there was no correlation with asthma outcomes. CONCLUSION Older adults with asthma and a greater desire for involvement in decision making have better asthma-related quality of life. Future studies with the intention to increase patient autonomy may help establish a causal relationship.