John T. Wulu

Iliofemoral Deep Vein Thrombosis: Conventional Therapy Versus Lysis and Percutaneous Transluminal Angioplasty and Stenting

ObjectiveTo compare conventional treatment (heparin and warfarin) of iliofemoral venous thrombosis with multimodality treatment (lysis and stenting). Summary Background DataSeveral studies have reported on conventional therapy for iliofemoral venous thrombosis with disappointing results. However, more recent studies have reported better results with multimodality treatment. MethodsFifty-one consecutive patients with extensive iliofemoral venous thrombosis were treated during a 10-year period. If there were no contraindications, patients were given the option to choose between conventional therapy (group 1) and multimodality therapy (group 2). The multimodality treatment strategy included catheter-directed lysis followed by percutaneous transluminal balloon angioplasty (PTA) and stenting for residual iliac stenoses. All patients underwent routine venous duplex imaging at 30 days, 3 months, 6 months, and every 6 months thereafter. ResultsThere were 33 patients in group 1 and 18 patients in group 2. Demographic and clinical characteristics were comparable for both groups. Initial lysis was achieved in 16 of 18 patients (89%) in group 2. Ten of 18 patients in group 2 had residual stenosis after lysis (8 primary and 2 secondary to malignancy), and they were treated with PTA/stenting with an initial success rate of 90%. Two patients in group 1 (6%) had a symptomatic pulmonary embolism (none in group 2). At 30 days, venous patency and symptom resolution were achieved in 1 of 33 patients (3%) in group 1 versus 15 of 18 (83%) in group 2. Kaplan-Meier analysis showed primary iliofemoral venous patency rates at 1, 3, and 5 years of 24%, 18%, and 18% and 83%, 69%, and 69% for groups 1 and 2, respectively. Long-term symptom resolution was achieved in 10 of 33 patients (30%) in group 1 versus 14 of 18 (78%) in group 2. Kaplan-Meier life table analysis showed similar survival rates at 1, 3, and 5 years of 100%, 93%, and 85% for group 1 and 100%, 93%, and 81% for group 2. ConclusionsLysis/stenting treatment was more effective than conventional treatment in patients with iliofemoral vein thrombosis.

Income inequality and health: a critical review of the literature.

This article critically reviews published literature on the relationship between income inequality and health outcomes. Studies are systematically assessed in terms of design, data quality, measures, health outcomes, and covariates analyzed. At least 33 studies indicate a significant association between income inequality and health outcomes, while at least 12 studies do not find such an association. Inconsistencies include the following: (1) the model of health determinants is different in nearly every study, (2) income inequality measures and data are inconsistent, (3) studies are performed on different combinations of countries and/or states, (4) the time period in which studies are conducted is not consistent, and (5) health outcome measures differ. The relationship between income inequality and health is unclear. Future studies will require a more comprehensive model of health production that includes health system covariates, sufficient sample size, and adjustment for inconsistencies in income inequality data.

Primary care, infant mortality, and low birth weight in the states of the USA

Study objective: The study tests the extent to which primary care physician supply (office based primary care physicians per 10 000 population) moderates the association between social inequalities and infant mortality and low birth weight throughout the 50 states of the USA. Design: Pooled cross sectional, time series analysis of secondary data. Analyses controlled for state level education, unemployment, racial/ethnic composition, income inequality, and urban/rural differences. Contemporaneous and time lagged covariates were modelled. Setting: Eleven years (1985–95) of data from 50 US states (final n = 549 because of one missing data point). Main results: Primary care was negatively associated with infant mortality and low birth weight in all multivariate models (p<0.0001). The association was consistent in contemporaneous and time lagged models. Although income inequality was positively associated with low birth weight and infant mortality (p<0.0001), the association with infant mortality disappeared with the addition of sociodemographic covariates. Conclusions: In US states, an increased supply of primary care practitioners—especially in areas with high levels of social disparities—is negatively associated with infant mortality and low birth weight.

Primary care, social inequalities, and all-cause, heart disease, and cancer mortality in US counties, 1990

OBJECTIVES We tested the association between the availability of primary care and income inequality on several categories of mortality in US counties. METHODS We used cross-sectional analysis of data from counties (n=3081) in 1990, including analysis of variance and multivariate ordinary least squares regression. Independent variables included primary care resources, income inequality, and sociodemographics. RESULTS Counties with higher availability of primary care resources experienced between 2% and 3% lower mortality than counties with less primary care. Counties with high income inequality experienced between 11% and 13% higher mortality than counties with less inequality. CONCLUSIONS Primary care resources may partially moderate the effects of income inequality on health outcomes at the county level.

Early Postsurgical Carotid Restenosis: Redo Surgery versus Angioplasty/Stenting:

PURPOSE To compare the results of balloon angioplasty/stenting (BA/S) versus redo surgery in patients with early carotid restenosis. METHODS Sixty-one patients (35 women; mean age 69 years, range 46-82) with early restenosis (<24 months from the primary endarterectomy) in 63 carotid arteries were treated during a 5-year period; 41 patients (41 arteries) had redo surgery (group A) and 20 patients (22 arteries) had BA/S (group B). Patients were followed regularly with duplex ultrasound to detect >or=50% recurrent restenosis (RRS) after redo surgery or BA/S. Kaplan-Meier life-table analysis was used to estimate the stroke-free survival rates and freedom from >or=50% RRS. RESULTS The demographic and clinical characteristics were comparable for both groups, as were the perioperative stroke and death rates (2.4% and 0% for group A, respectively, versus 4.5% and 0% for group B, p=0.46). Group A had a 12% incidence of cranial nerve injury (all transient) versus 0% for group B (p=0.11); however, group B had a higher incidence of >or=50% RRS than group A (32% versus 0%, p=0.0003). The stroke-free survival rates for redo surgery at 6, 12, 24, 36, and 48 months were 100%, 100%, 100%, 100%, and 88% versus 95%, 95%, 84%, 84%, and 63% for BA/S (p=0.067). Redo surgery had a 100% freedom from >or=50% RRS at the same time intervals, while recurrent restenosis rates for the BA/S patients were 95%, 86%, 69%, 52%, and 52% (p<0.0001). CONCLUSIONS BA/S and redo surgery have comparable stroke and death rates in the treatment of early RCS; however, redo surgery is associated with cranial nerve injuries (transient), while stent patients have a higher incidence of recurrent lesions. These considerations should be kept in mind when selecting the appropriate treatment for patients with early postsurgical restenosis.

Immunization Coverage of Vulnerable Children: A Comparison of Health Center and National Rates

Serving a predominantly poor and minority population, health centers are positioned to address national immunization disparities in the context of comprehensive primary care. Having demonstrated success in eliminating disparities for other preventive services, this study evaluates health center effectiveness in mitigating immunization disparities. Up-to-date health center and national immunization rates were obtained from the 1995 User and the 1995 National Health Interview Surveys. For the most part, national immunization disparities were not found among health center children. However, black children served at health centers were still significantly less likely to be vaccinated for polio and Medicaid children significantly less likely for measles. Health center outreach and enabling services are hypothesized to facilitate regular access to care and thus timely immunization. Additional health center analysis is necessary to establish factors responsible for the relative absence of disparities, uncover persistent barriers to immunization, and identify structural attributes that may further raise immunization coverage.