Archives of Internal Medicine

Dalen, James E.

doi: 10.1001/archinte.1993.00410120005001pmid: N/A

Abstract OBJECTIVE TESTS are needed to confirm or exclude the diagnosis of venous thromboembolism because the accuracy of the clinical diagnosis is less than 50%.1,2 The most accurate tests available for the diagnosis of pulmonary embolism and deep venous thrombosis (DVT) are pulmonary angiography1 and contrast venographhy.3 With technically adequate studies, false-negative tests are rare. Therefore, a normal pulmonary angiogram is sufficient evidence to withhold treatment in patients with suspected pulmonary embolism,4 and a normal venogram precludes the need for therapy in patients with suspected DVT.5 Unfortunately, pulmonary angiography and venography are expensive, invasive tests that have associated morbidity, and are not available at all hospitals. Therefore, noninvasive tests play a critical role in the evaluation of patients with suspected venous thromboembolism. Two noninvasive tests for deep venous thromboembolism, impedance plethysmography (IPG) and ultrasonography have an excellent correlation with venograms in patients with proximal DVT of References 1. Dalen JE, Brooks HL, Johnson LW, Meister SG, Szucs M Jr, Dexter L. Pulmonary angiography in acute pulmonary embolism: indications, techniques, and results in 367 patients . Am Heart J. 1971;81:175-185.Crossref 2. Wheeler HB, Anderson FA Jr, Cardullo PA, Patwardhan NA, Jian-Ming L, Cutler BS. Suspected deep vein thrombosis . Arch Surg. 1982;117: 1206-1209.Crossref 3. Rabinov K, Paulin S. Roentgen diagnosis of venous thrombosis in the leg . Arch Surg. 1972;104:134-144.Crossref 4. Novelline RA, Baltarowich OH, Athanasoulis CA, Waltman AC, Greenfield AJ, McKusick KA. The clinical course of patients with suspected pulmonary embolism and a negative pulmonary arteriogram . Radiology . 1978;126:561-567.Crossref 5. Hull R, Hirsh J, Sackett DL, et al. Clinical validity of a negative venogram in patients with clinically suspected venous thrombosis . Circulation . 1981;64:622-624.Crossref 6. Hull RD, Secker-Walker RH, Hirsh J. Diagnosis of deep vein thrombosis . In: Colman RW, Hirsh J, Marder VJ, Salzman EW, eds. Hemostasis and Thrombosis . Philadelphia, Pa: JB Lippincott Co; 1987:1220-1239. 7. Polak JF. Doppler ultrasound of the deep leg veins . Chest . 1991;99:165S-172S.Crossref 8. Anderson DR, Lensing AWA, Wells PS, Levine MN, Weitz JI, Hirsh J. Limitations of impedance plethysmography in the diagnosis of clinically suspected deep-vein thrombosis . Ann Intern Med. 1993;118:25-30.Crossref 9. Kipper MS, Moser KM, Kortman KE, Ashburn WL. Long-term follow-up of patients with suspected embolism and a normal lung scan . Chest . 1982; 82:411-415.Crossref 10. Hull RD, Raskob GE, Coates G, Panju AA. Clinical validity of a normal perfusion lung scan in patients with suspected pulmonary embolism . Chest . 1990;97:23-26.Crossref 11. PIOPED Investigators. Value of the ventilation/ perfusion scan in acute pulmonary embolism . JAMA . 1990;263:2753-2795.Crossref 12. Hull RD, Raskob GE, Coates G, Panju AA, Gill GJ. A new noninvasive management strategy for patients with suspected pulmonary embolism . Arch Intern Med. 1989;149:2549-2555.Crossref 13. Oudkerk M, Van Beek EJR, Van Putten WLJ, Buller HR. Cost-effectiveness analysis of various strategies in the diagnostic management of pulmonary embolism . Arch Intern Med. 1992. 14. Dalen JE, Alpert JS. Natural history of pulmonary embolism . Progr Cardiovasc Dis. 1975;17: 259-270.Crossref 15. Moser KM, LeMoine JR. Is embolic risk conditioned by location of deep venous thrombosis? Ann Intern Med. 1981;94(pt (1) ):439-444.Crossref 16. Hull RD, Raskob GE, Carter CJ. Serial impedance plethysmography in pregnant patients with clinically suspected deep-vein thrombosis . Ann Intern Med. 1990;112:663-667.Crossref 17. Huisman MV, Buller HR, Ten Cate JW, Vreeken J. Serial impedance plethysmography for suspected deep venous thrombosis in outpatients . N Engl J Med. 1986;314:823-828.Crossref 18. Kruit WHJ, De Boer AC, Sing AK, Van Roon F. The significance of venography in the management of patients with clinically suspected pulmonary embolism . J Intern Med. 1991;230:333-339.Crossref

Psaty, Bruce M.;Heckbert, Susan R.;Atkins, David;Siscovick, David S.;Koepsell, Thomas D.;Wahl, Patricia W.;Longstreth, W. T.;Weiss, Noel S.;Wagner, Edward H.;Prentice, Ross;Furberg, Curt D.

doi: 10.1001/archinte.1993.00410120009002

Appel, Lawrence J.;Miller, Edgar R.;Seidler, Alexander J.;Whelton, Paul K.

doi: 10.1001/archinte.1993.00410120017003pmid: N/A

Abstract Background: Several lines of evidence suggest that supplementation of diet with omega-3 polyunsaturated fatty acids (ω-3) PUFA), commonly referred to as fish oils, may reduce blood pressure (BP). However, most clinical trials of ω-3 PUFA supplementation have been of insufficient size to detect relevant BP changes. Methods: We conducted a meta-analysis of 17 controlled clinical trials of ω-3 PUFA supplementation. To estimate an overall effect of ω-3 PUFA supplementation on BP, we calculated the net BP change in each trial (BP A in ω-3 PUFA group minus BP A in control group), which was then weighted according to the inverse of the variance. Results: In the 11 trials that enrolled normotensive individuals (n=728), ω-3 PUFA supplementation led to significant reductions of systolic BP (SBP) and diastolic BP (DBP) in two and one trials, respectively. In the six studies that enrolled untreated hypertensives (n=291), significant reductions of SBP and DBP were present in two and four trials, respectively. Weighted, pooled estimates of SBP and DBP change (mm Hg) with 95% confidence intervals were —1.0 (—2.0 to 0.0) and —0.5 (—1.2 to +0.2) in the trials of normotensives, and —5.5 (—8.1 to —2.9) and —3.5 (—5.0 to —2.1) in the trials of untreated hypertensives. In 13 of 17 studies, trial duration was less than 3 months. Doses of ω-3 PUFA tended to be high (average dose >3 g/d in 11 trials). The magnitude of BP reduction was greatest at high BP but was not significantly associated with dose of ω-3 PUFA. Side effects, most commonly eructation and a fishy taste, occurred more frequently in ω-3 PUFA participants than in control participants (28% vs 13%, P<.001). Conclusions: Our analyses indicate that diet supplementation with a relatively high dose of ω-3 PUFA, generally more than 3 g/d, can lead to clinically relevant BP reductions in individuals with untreated hypertension. However, use of ω-3 PUFA as antihypertensive therapy will require demonstration of long-term efficacy and patient acceptability of lower doses.(Arch Intern Med. 1993;153:1429-1438) References 1. Bang HO, Dyerberg J, Sinclair HM. The composition of the Eskimo food in north western Greenland . Am J Clin Nutr. 1980;33:2657-2661. 2. Kagawa Y, Nishizawa M, Suzuki M, et al. Eicosapolyenoic acids of serum lipids of Japanese islanders with low incidence of cardiovascular diseases . J Nutr Sci Vitaminol (Tokyo) . 1982;28:441-453.Crossref 3. Kromhout D, Bosschieter EB, Coulander CDL. The inverse relation between fish consumption and 20-year mortality from coronary heart disease . N Engl J Med. 1985;312:1205-1209.Crossref 4. Shekelle RB, Missell LV, Paul 0, Shryock AM, Stamler J. Fish consumption and mortality from coronary heart disease . N Engl J Med. 1985;313:820.Crossref 5. Norell SE, Ahlbom A, Feychting M, Pedersen NL. Fish consumption and mortality from coronary heart disease . BMJ . 1986;293:426.Crossref 6. Burr ML, Fehily AM, Gilbert JF, et al. Effects of changes in fat, fish, and fibre intakes on death and myocardial reinfarction: diet and reinfarction trial (DART) . Lancet . 1989;2:757-761.Crossref 7. Simopoulos AP. Omega-3 fatty acids in health and disease and in growth and development . Am J Clin Nutr. 1991;54:438-463. 8. Bonaa K. Epidemiological and intervention studies on the effect of marine polyunsaturated fatty acids on blood pressure . J Intern Med. 1989;225( (suppl 1) ): 105-110.Crossref 9. Radack K, Deck C. The effects of omega-3 polyunsaturated fatty acids on blood pressure: a methodologic analysis of the evidence . J Am Coll Nutr. 1989;8: 376-385.Crossref 10. Greenland S. Quantitative methods in the review of epidemiologic literature . Epidemiol Rev. 1987;9:1-30. 11. Gill JS, Zezulka AV, Beevers DG, Davies P. Relationship between initial blood pressure and its fall with treatment . Lancet . 1985;1:567-569.Crossref 12. Wing LMH, Nestel PJ, Chalmers JP, et al. Lack of effect of fish oil supplementation on blood pressure in treated hypertensives . J Hypertens. 1990;8: 339-343.Crossref 13. Singer P, Melzer S, Goschell M, Augustin S. Fish oil amplifies the effect of propranolol in mild essential hypertension . Hypertension . 1990;16:682-691.Crossref 14. Margolin G, Huster G, Glueck CJ, et al. Blood pressure lowering in elderly subjects: a double-blind crossover study of ω-3 and ω-6 fatty acids . Am J Clin Nutr. 1991;53:562-572. 15. Sanders TAB, Vickers M, Haines AP. Effect on blood lipids and haemostasis of a supplement of cod-liver oil, rich in eicosapentaenoic and docosahexaenoic acids, in healthy young men . Clin Sci. 1981;61:317-324. 16. Lorenz R, Spengler U, Fischer S, Duhm J, Weber PC. Platelet function, thromboxane formation and blood pressure control during supplementation of the western diet with cod liver oil . Circulation . 1983;67:504-511.Crossref 17. Hamazaki T, Nakazawa R, Tateno S, et al. Effects of fish oil rich in eicosapentaenoic acid on serum lipid in hyperlipidemic hemodialysis patients . Kidney Int. 1984;26:81-84.Crossref 18. Olivieri O, Negri M, De Gironcoli M. Effects of dietary fish oil on malondialdehyde production and glutathione peroxidase activity in hyperlipidemic patients . Scand J Clin Lab Invest. 1988;48:659-665.Crossref 19. Urakaze M, Hamazaki T, Yano S. Fish oil and hypertension . J Hum Hypertens. 1989;3:277-278. 20. Singer P, Jaeger W, Wirth M, et al. Lipid and blood pressure-lowering effect of mackerel diet in man . Atherosclerosis . 1983;49:99-108.Crossref 21. Singer P, Wirth M, Berger I, et al. Influence on serum lipids, lipoproteins and blood pressure of mackerel and herring diet in patients with type IV and V hyperlipoproteinemia . Atherosclerosis . 1985;56:111-118.Crossref 22. Singer P, Wirth M, Voigt S, et al. Blood pressure- and lipid-lowering effect of mackerel and herring diet in patients with mild essential hypertension . Atherosclerosis . 1985;56:223-235.Crossref 23. Kristensen SD, Schmidt EB, Anderson HR, Dyerberg J. Fish oil in angina pectoris . Atherosclerosis . 1987;64:13-19.Crossref 24. Kasim SE, Stern B, Khilnani S, McLin P, Baciorowski S, Jen KLC. Effects of omega-3 fish oils on lipid metabolism, glycemic control, and blood pressure in type II diabetic patients . J Clin Endocrinol Metab. 1988;67:1-5.Crossref 25. Jensen T, Stender S, Goldstein K, Holmer G, Deckert T. Partial normalization by dietary cod-liver oil of increased microvascular albumin leakage in patients with insulin-dependent diabetes and albuminuria . N Engl J Med. 1989;321: 1572-1577.Crossref 26. Mehta JL, Lopez LM, Lawson D, Wargovich TJ, Williams LL. Dietary supplementation with omega-3 polyunsaturated fatty acids in patients with stable coronary heart disease . Am J Med. 1988;84:45-52.Crossref 27. Urakaze M, Hamazaki T, Yano S, Kashiwabara H, Oomori K, Yokoyama T. Effect of fish oil concentrate on risk factors of cardiovascular complications in renal transplantation . Transplant Proc. 1989;21:2134-2136. 28. Gans ROB, Bilo HJG, Weersink EGL, et al. Fish oil supplementation in patients with stable claudication . Am J Surg. 1990;160:490-495.Crossref 29. Homan van der Heide JJ, Bilo HJG, Tegzess AM, Donker AJM. The effects of dietary supplementation with fish oil on renal function in cyclosporine-treated renal transplant recipients . Transplantation . 1990;49:523-527.Crossref 30. Bairati I, Roy L, Meyer F. Effects of a fish oil supplement on blood pressure and serum lipids in patients treated for coronary artery disease . Can J Cardiol. 1992; 8:41-46. 31. Norris PG, Jones CJH, Weston MJ. Effect of dietary supplementation with fish oil on systolic blood pressure in mild essential hypertension . BMJ . 1986;293: 104-105.Crossref 32. Bach R, Schmidt U, Jung F, et al. Effects of fish oil capsules in two dosages on blood pressure, platelet functions, haemorrheological and clinical chemistry parameters in apparently healthy subjects . Ann Nutr Metab. 1989;33:359-367.Crossref 33. Hughes GS, Ringer TV, Watts KC, DeLoof JJ, Francom SF, Spillers CR. Fish oil produces an atherogenic lipid profile in hypertensive men . Atherosclerosis . 1990; 84:229-237.Crossref 34. Cobiac L, Nestel PJ, Wing LMH, Howe PRC. Effects of dietary sodium restriction and fish oil supplements on blood pressure in the elderly . Clin Exp Pharmacol Physiol. 1991;18:265-268.Crossref 35. Mortensen JZ, Schmidt EB, Nielsen AH, Dyerberg J. The effect of N-6 and N-3 polyunsaturated fatty acids on hemostasis, blood lipids and blood pressure . Thromb Haemost. 1983;50:543-546. 36. Bruckner G, Webb P, Greenwell L, Chow C, Richardson D. Fish oil increases peripheral capillary blood cell velocity in humans . Atherosclerosis . 1987;66: 237-245.Crossref 37. Rogers S, James KS, Butland BK, Etherington MD, O'Brien JR, Jones JG. Effects of a fish oil supplement on serum lipids, blood pressure, bleeding time, haemostatic and rheological variables . Atherosclerosis . 1987;63:137-143.Crossref 38. Van Houwelingen R, Nordoy A, van der Beek E, Houtsmuller U, de Metz M, Hornstra G. Effect of a moderate fish intake on blood pressure, bleeding time, hematology, and clinical chemistry in healthy males . Am J Clin Nutr. 1987; 46:424-436. 39. Demke DM, Peters GR, Linet 01, Metzler CM, Klott KA. Effects of a fish oil concentrate in patients with hypercholesterolemia . Atherosclerosis . 1988;70: 73-80.Crossref 40. Blonk MC, Bilo HJG, Nauta JJP, Popp-Snijders C, Mulder C, Donker AJM. Dose-response effects of fish-oil supplementation in healthy volunteers . Am J Clin Nutr. 1990;53:120-127. 41. Flaten H, Hostmark AT, Kierulf P, et al. Fish-oil concentrate: effects on variables related to cardiovascular disease . Am J Clin Nutr. 1990;52:300-306. 42. Kestin M, Clifton P, Belling GB, Nestel PJ. n-3 Fatty acids of marine origin lower systolic blood pressure and triglycerides but raise LDL cholesterol compared with n-3 and n-6 fatty acids from plants . Am J Clin Nutr. 1990;51:1028-1034. 43. Cobiac L, Clifton PM, Abbey M, Belling GB, Nestel PJ. Lipid, lipoprotein, and hemostatic effects of fish vs fish-oil n-3 fatty acids in mildly hyperlipidemic males . Am J Clin Nutr. 1991;53:1210-1216. 44. Oh SY, Ryue J, Hsieh CH, Bell DE. Eggs enriched in ω-3 fatty acids and alterations in lipid concentrations in plasma and lipoprotein and in blood pressure . Am J Clin Nutr. 1991;54:689-695. 45. The Trials of Hypertension Prevention Collaborative Research Group (TOHP). The effects of nonpharmacologic interventions on blood pressure of persons with high normal levels: results of the Trials of Hypertension Prevention, phase 1 . JAMA . 1992;267:1213-1220.Crossref 46. Singer P, Berger I, Luck K, Taube C, Naumann E, Godicke W. Long-term effect of mackerel diet on blood pressure, serum lipids and thromboxane formation in patients with mild essential hypertension . Atherosclerosis . 1986;62:259-265.Crossref 47. Knapp HR, Fitz-Gerald GA. The antihypertensive effects of fish oil: a controlled study of polyunsaturated fatty acid supplements in essential hypertension . N Engl J Med. 1989;320:1037-1043.Crossref 48. Meland E, Fugelli P, Laerum E, Ronneberg R, Sandivk L. Effect of fish oil on blood pressure and blood lipids in men with mild to moderate hypertension . Scand J Prim Health Care. 1989;7:131-135.Crossref 49. Bonaa KH, Bjerve KS, Straume B, Gram IT, Thelle D. Effect of eicosapentaenoic and docosahexaenoic acids on blood pressure in hypertension . N Engl J Med. 1990;322:795-801.Crossref 50. Levinson PD, Iosiphidis AH, Saritelli AL, Herbert PN, Steiner M. Effects of n-3 fatty acids in essential hypertension . Am J Hypertens. 1990;3:754-760. 51. Radack K, Deck C, Huster G. The effects of low doses of n-3 fatty acid supplementation on blood pressure in hypertensive subjects . Arch Intern Med. 1991;151:1173-1180.Crossref 52. Cutler JA, Follmann D, Elliott P, Suh I. An overview of randomized trials of sodium reduction and blood pressure . Hypertension . 1991;17( (suppl 1) ):127-133.Crossref 53. Law MR, Frost CD, Wald NJ. By how much does dietary salt reduction lower blood pressure? Ill: analysis of data from trials of salt reduction . BMJ . 1991; 302:819-824.Crossref 54. MacMahon S, Cutler J, Brittain E, Higgins M. Obesity and hypertension: epidemiological and clinical issues . Eur Heart J. 1987;8:57-70.Crossref 55. Cutler JA. Randomized clinical trials of weight reduction in nonhypertensive persons . Ann Epidemiol. 1991;1:363-370.Crossref 56. Hepburn FN, Exler J, Weihrauch JL. Provisional tables on the content of omega-3 fatty acids and other fat components of selected foods . J Am Diet Assoc. 1986;86:788-793. 57. The Medical Letter Inc. Fish oil for the heart . Med Lett. 1987;29:7-9.

Anderson, David R.;Harrison, Linda;Hirsh, Jack

doi: 10.1001/archinte.1993.00410120027004pmid: N/A

Abstract Background: The anticoagulant activity of warfarin sodium is monitored by the prothrombin time (PT). The introduction of a portable PT monitor has raised the possibility that patients could reduce the inconvenience of anticoagulant therapy by measuring their PT at home. We performed this study to determine the feasibility and accuracy of home use of the portable PT monitor. Methods: A prospective cohort study was performed in consecutive eligible patients who required long-term anticoagulant therapy. Patients performed multiple measurements of their PT at home by means of the portable monitor and at their usual laboratory within a 4-hour interval. The accuracy of the portable monitor was evaluated by two criteria for agreement. Standard agreement was achieved if the portable monitor and laboratory results were both either within or outside the patient's targeted therapeutic range or if the two results were within 0.4 international normalized ratio units of each other. Expanded agreement was achieved if both the portable monitor and laboratory results were within ±0.4 international normalized ratio units of the targeted therapeutic range. Results: Forty patients (19 men and 21 women, aged 25 to 74 years) were followed up for 6 to 24 months by means of the portable PT monitor. The mean level of agreement achieved per patient was 83% (95% confidence interval, 79% to 87%) by the standard criteria and 96% (95% confidence interval, 94% to 98%) by the expanded criteria. Twenty-seven patients (68%) and 39 patients (98%) achieved more than 80% agreement by the standard and the expanded criteria, respectively. Questionnaire results revealed that 97% of the patients preferred using the portable monitor to measure their PT. Conclusions: Patients receiving long-term anticoagulant therapy achieved a high rate of clinically important agreement between self-measurements of the PT with the use of a portable monitor and laboratory PT results. Patients strongly preferred using the portable monitor to measure their PT levels. The use of the portable monitor as the primary method for measuring the PT can be recommended in selected patients receiving long-term anticoagulant treatment.(Arch Intern Med. 1993;153:1441-1447) References 1. Hirsh J. Oral anticoagulant drugs . N Engl J Med. 1991;324:1865-1875.Crossref 2. Hirsh J, Poller L, Deykin D, Levine MN, Dalen JE. Optimal therapeutic range for oral anticoagulants . Chest. 1989;95( (suppl 2) ):5S-11S. 3. Hull R, Hirsh J, Jay R, et al. Different intensities of oral anticoagulant therapy in the treatment of proximal-vein thrombosis . N Engl J Med. 1982;307:1676-1681.Crossref 4. Turpie AGG, Gunstensen J, Hirsh J, Nelson H, Gent M. Randomised comparison of two intensities of oral anticoagulant therapy after tissue heart valve replacement . Lancet . 1988;1:1242-1245.Crossref 5. Saour JN, Sieck JO, Mamo LAR, Gallus AS. Trial of different intensities of anticoagulation in patients with prosthetic heart valves . N Engl J Med. 1990;322: 428-432.Crossref 6. Lucas FV, Duncan A, Jay RM, et al. A novel whole blood capillary technique for measuring the prothrombin time . Am J Clin Pathol. 1987;88:442-446. 7. White RH, McCurdy SA, van Marensdorff H, Woodruff DE Jr, Leftgoff L. Home prothrombin time monitoring after the initiation of warfarin therapy: a randomized prospective study . Ann Intern Med. 1989;111:730-737.Crossref 8. Ansell J, Holden A, Knapic N. Patient self-management of oral anticoagulation guided by capillary (fingerstick) whole blood prothrombin times . Arch Intern Med. 1989;149:2509-2511.Crossref 9. Ansell J, Hamke K, Holden A, Knapic N. Cost effectiveness of monitoring warfarin therapy using standard versus capillary prothrombin times . Am J Clin Pathol. 1989;91:587-589.

Ippolito, Giuseppe;Puro, Vincenzo;De Carli, Gabriella

doi: 10.1001/archinte.1993.00410120035005pmid: N/A

Abstract Background: More than 50 cases of occupationally acquired human immunodeficiency virus (HIV) infection in health care workers (HCWs) have been reported world-wide. Determinants of injuries and of infection are important to investigate to design effective prevention programs. Methods: In Italy, 29 acute-care public hospitals were enrolled in a multicenter study between 1986 and 1990. At each facility, all HCWs were enrolled who reported percutaneous, mucous-membrane, or nonintact-skin exposure to the body fluids and tissues to which universal precautions apply from an HIV-infected patient. Data were collected at the time of the incident on clinical status of the HIV-infected source, circumstance and type of exposure, and use of infection control precautions. The HCWs were followed up clinically and serologically for HIV infection at 1, 3, 6, and 12 months. Results: A total of 1592 HIV exposures were reported in 1534 HCWs; most exposures (67%) occurred in nurses, followed by physicians and surgeons (17.5%). Needlesticks were the most common source of exposure (58.4%), followed by nonintact-skin and mucous-membrane contamination (22.7% and 11.2%, respectively) and cuts (7.7%). At the time of exposure, 77.5% of the HCWs knew or suspected that the source patient was HIV infected. Two seroconversions were observed among a total of 1488 HCWs followed up for at least 6 months: one occurred in a student nurse who had been stuck with a needle used for an HIV antibody—negative, p24 HIV antigen—positive drug addict; the other was in a nurse who experienced mucousmembrane contamination with a large quantity of blood from an HIV-positive hemophilic patient. The seroconversion rate was 0.10% after percutaneous exposure (1/ 1003; 95% confidence interval, 0.006% to 0.55%) and 0.63% after mucous-membrane contamination (1/158; 95% confidence interval, 0.018% to 3.47%). Conclusions: The study demonstrates a small but real risk of HIV infection after percutaneous and mucousmembrane exposure to blood of HIV-infected patients and that transmission can occur during the "window period" of infection. Furthermore, exposures to HIV are not infrequent, and many exposures could be prevented with the use of barrier precautions, appropriate behaviors, and safer devices and techniques.(Arch Intern Med. 1993;153:1451-1458) References 1. Marcus R, Kay K, Mann JM. Transmission of human immunodeficiency virus (HIV) in health-care settings worldwide . Bull World Health Organ. 1989;67: 577-582. 2. Gerberding JL. Current epidemiologic evidence and case report of occupationally acquired HIV and other bloodborne diseases . Infect Control Hosp Epidemiol. 1990;11( (suppl 1) ):558-560.Crossref 3. Beekmann SE, Fahey BJ, Gerberding JL, Henderson DK. Risky business: using necessarily imprecise casualty counts to estimate occupational risk for HIV-1 infection . Infect Control Hosp Epidemiol. 1990;11:371-379.Crossref 4. Henderson DK, Fahey BJ, Willy M, et al. Risk for occupational transmission of human immunodeficiency virus type 1 (HIV-1) associated with clinical exposure: a prospective evaluation . Ann Intern Med. 1990;113:740-746.Crossref 5. Ippolito G, Atlattordir A, Ayres L, et al. HIV infection in healthcare workers: the European experience . PAACNOTES . 1990;2:273-275. 6. McCray E, Cooperative Needlestick Surveillance Group. Occupational risk of the acquired immunodeficiency syndrome among health care workers . N Engl J Med. 1986;314:1127-1132.Crossref 7. Marcus R, CDC Cooperative Needlestick Surveillance Group. Surveillance of health care workers exposed to blood from patients infected with the human immunodeficiency virus . N Engl J Med. 1988;319:1118-1123.Crossref 8. Tokars JI, Marcus R, Culver DH, McKibben PS, Bell DM, CDC Cooperative Needlestick Surveillance Group. Zidovudine use after occupational exposure to HIV-infected blood . In: Program and abstracts of the Seventh International Conference on AIDS; June 16-21, 1991 ; Florence, Italy. Abstract WD4184. 9. Marcus R, Tokars JI, Culver DH, McKibben PS, Bell DM, Cooperative Needlestick Surveillance Group. Zidovudine use after occupational exposure to HIV-infected blood . In: Program and abstracts of the International Conference on Antimicrobial Agents and Chemotherapy; September 29-October 2, 1991 ; Chicago, III. Abstract 979. 10. Gerberding JL, Bryant-LeBlanc CE, Nelson K, et al. Risk of transmitting the human immunodeficiency virus, cytomegalovirus, and hepatitis B virus to health care workers exposed to patients with AIDS and AIDS-related conditions . J Infect Dis. 1987;156:1-8.Crossref 11. Fahey BJ, Schmitt JM, Saah AJ, Lane HC, Henderson DK. Assessment of risk for occupational/nosocomial transmission of human immunodeficiency virus, type I in health care workers . In: Program and abstracts of the Fifth International Conference on AIDS; June 4-9, 1989 ; Montreal, Quebec. Abstract MDP 88. 12. Kuhls TL, Viker S, Parris NB, Garakian A, Sullivan Bolyai J, Cherry J. Occupational risk of HIV, HBV and HSV-2 infections in health care personnel caring for AIDS patients . Am J Public Health. 1987;77:1306-1309.Crossref 13. Ramsey KM, Smith EN, Reinarz JA. Prospective evaluation of 44 health care workers exposed to human immunodeficiency virus with one seroconversion . Clin Res. 1988;36:361. Abstract. 14. Josephson A, Bottone M, Gerber M, Oppermann N. Blood and body fluid exposure follow-up in the HIV era: a two year experience . Am J Infect Control. 1990;18:136. Abstract.Crossref 15. Hirsch MS, Wormser GP, Schooley RT, et al. Risk of nosocomial infection with human T-cell lymphotropic virus III (HTLV-III) . N Engl J Med. 1985;312:1-4.Crossref 16. Wormser GP, Joline C, Sivak S, Arlin ZA. Human immunodeficiency virus infection: considerations for health care workers . Bull N Y Acad Med. 1988;64: 203-215. 17. McCormick RD, Meisch MG, Ircink FG, Maki DG. Epidemiology of hospital sharps injuries: a 14-year prospective study in the pre-AIDS and AIDS eras . Am J Med. 1991;91( (suppl 3B) ):301-307.Crossref 18. Elmslie K, Mulligan L, O'Shaughnessy M. National surveillance program: occupational exposure to human immunodeficiency virus (HIV-1) infection in Canada . In: Program and abstracts of the Fifth International Conference on AIDS; June 4-9, 1989 ; Montreal, Quebec. Abstract TAP 46. 19. Strickler AC. Occupational exposure to HIV infection among health care workers at the Toronto General Hospital . Can Dis Weekly Rep. 1988;32:141-146. 20. Abreu ES, Fernandes ME. Risk of acquiring HIV infection at Emilio Ribas Hospital . In: Program and abstracts of the Sixth International Conference on AIDS; June 20-24, 1990 ; San Francisco, Calif. Abstract SC 565. 21. Cavalcante NJF, Abreu ES, Fernandes MEL, et al. Risk of health care professionals acquiring HIV infection in Latin America . AIDS Care . 1991;3:311-316.Crossref 22. Pereira LIA, Souza LCS, Souza MA, Silva AB, Oliveira AN. Acidentes profissionais com material biologico de pacientes com sindrome da imunodeficiencia adquirida-acompanhamento clinico-serologico . Rev Soc Bras Med Trop. 1991;24:169. Abstract 169.Crossref 23. Arva P, Doblug JH, Lystad A, Vatn S. Risk of HBV and HIV from injuries by needles and sharp objects among employees in three Norwegian hospitals . In: Program and abstracts of the International Conference on Blood-Borne Infections in the Work-place; August 28-30, 1989 ; Stockholm, Sweden. Page 120, abstract 5. 24. Jorbeck H, Skoglund G, Backstrom B, Persson M, Hallqvist J. Blood exposures in health care workers: a report on incidence and risk procedures . In: Program and abstracts of the International Conference on Blood-Borne Infections in the Work-place; August 28-30, 1989 ; Stockholm, Sweden. Page 125, abstract 10. 25. Shanson DC, Evans R, Lai L. Incidence and risk of transmission to staff at London Hospital, 1982-85 . J Hosp Infect. 1985;6( (suppl C) ):15-22.Crossref 26. McEvoy M, Porter K, Mortimer P, Simmins N, Shanson D. Prospective study of clinical, laboratory, and ancillary staff with accidental exposures to blood or body fluids from patients infected with HIV . BMJ. 1987;294:1595-1597.Crossref 27. Porter K, Heptonstall J, Gill ON. Outcome of needlestick HIV exposure: UK HCWs . In: Program and abstracts of the Sixth International Conference on AIDS; June 20-24, 1990 ; San Francisco, Calif. Abstract FC 650. 28. Abiteboul D, Fourrier A, Azoulay S, et al. Occupational exposure to blood: a descriptive survey of risk management in public assistance hospitals in Paris . In: Program and abstracts of the Seventh International Conference on AIDS; June 16-21, 1991 ; Florence, Italy. Abstract WD4174. 29. Francioli P, Saghafi L, Raselli P. Exposures of Health care workers (HCW) to blood during various procedures: results of two surveys before and after the implementation of universal precautions (UP) . In: Program and abstracts of the Sixth International Conference on AIDS; June 20-24, 1990 ; San Francisco, Calif. Abstract TC 602. 30. Hernandez E, Gatell JM, Puyudo T, Barrera JM, Pumarola T. Risk of infection by human immunodeficiency virus in health care workers (HCW) In: Program and abstracts of the Fifth International Conference on AIDS; June 4-9, 1989 ; Montreal, Quebec. Abstract A 618. 31. Comunidad de Madrid. Vigilancia epidemiologica del SIDS y de la infeccion por VIH. Informe n.2-Octubre. 1988:37-46. 32. Arranz M, Bueno R, Cavanillas R, et al. Assessing the risk of HIV transmission after accidental exposure to blood and/or body fluids of patients infected with HIV in health care personnel in Madrid . In: Program and abstracts of the International Conference on Blood-Borne Infections in the Work-place; August 28-30, 1989 ; Stockholm, Sweden. Page 127, abstract 12. 33. De Juanes JR. Sindrome de inmunodeficiencia adquirida y accidentes en el personal sanitario: tres anos de seguimento . Rev Esp Microbiol Clin. 1988;3: 399-403. 34. St Louis ME, Rauch KJ, Petersen LR, et al. Seroprevalence of human immunodeficiency virus infection at sentinel hospitals in the United States . N Engl J Med. 1990;323:213-218.Crossref 35. Brennan T. Transmission of the human immunodeficiency virus in the health care setting: time for action . N Engl J Med. 1991;21:1505-1509. 36. Ippolito G, Cadrobbi P, Carosi G, et al. Risk of transmission among health care workers: a multicenter study . Scand J Infect Dis. 1990;22:245-246.Crossref 37. Lazzarato M, Carlini E, Mandini A, et al. Rischio occupazionale da HIV: sorveglianza degli operatori sanitari nel servizio ospedaliero della USL N31 di Ferrara . Igiene Mod. 1987;88:890-897. 38. Pizzocolo G, Stellini R, Cadeo GP, Cesari S, Zampini PL. Risk of HIV and HBV after accidental needlestick . In: Program and abstracts of the Fourth International Conference on AIDS; June 12-16, 1988 ; Stockholm, Sweden. Abstract 9010. 39. Rastrelli M, Ferrazzi D, Vigo B, Giannelli F. Risk of HIV transmission to health care workers and comparison with viral hepatitis . In: Program and abstracts of the Fifth International Conference on AIDS; June 4-9, 1989 ; Montreal, Quebec. Abstract A 503. 40. Francavilla E, Cadrobbi P, Scaggiante R, De Silvestro G, Bortolotti F, Bertaggia A. Surveillance on occupational exposure to HIV among health care workers in Italy . In: Program and abstracts of the Fifth International Conference on AIDS; June 4-9, 1989 ; Montreal, Quebec. Abstract D 623. 41. Puro V, Ranchino M, Profili F. Occupational exposures to blood and risk of HIV transmission in a general hospital (1986-1988) . Eur J Epidemiol. 1990;6:67-70.Crossref 42. Perna MC, Bragonzi G, Rigotti A, et al. Frequency of parenteral and mucocutaneous exposure of an infectious disease staff to patient body fluids . In: Program and abstracts of the Seventh International Conference on AIDS; June 16-21, 1991 ; Florence, Italy. Abstract WD 4171. 43. Di Vito G, Rizzo F, Poli A, et al. HIV infection and health care workers: results of five years of epidemiologic surveillance in two general hospitals in Genova . In: Program and abstracts of the Seventh International Conference on AIDS; June 16-21, 1991 ; Florence, Italy. Abstract WD 4172. 44. Centers for Disease Control. Update: universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health care settings . MMWR. 1988;37:377-382, 387-388. 45. Puro V, Ippolito G, Guzzanti E, et al. Zidovudine prophylaxis after accidental exposures to HIV: the Italian experience . AIDS. 1992;6:963-969.Crossref 46. Italian Ministry of Health. Central Service for Health . Attivitá Gestionali ed Economiche delle USL . Rome, Italy: Italian Ministry of Health; 1990. (Originally published in Italian.) 47. National AIDS Commission. Aggiornamento dei casi di AIDS al Dicembre 1990 . Rome, Italy: Italian Ministry of Health; 1991. (Originally published in Italian.) 48. Lima G, Traina C. Considerazioni su un caso di sindrome correlata all'AIDS (ARC/LAS) in una operatrice sanitaria . Minnerva Med. 1988;108:141-143. 49. Gioannini P, Sinicco A, Cariti G, Lucchini A, Paggi G, Giachino O. HIV infection acquired by a nurse . Eur J Epidemiol. 1988;4:119-120.Crossref 50. Imagawa DT, Lee MH, Wolinsk SM, et al. Human immunodeficiency virus type 1 infection in homosexual men who remain seronegative for prolonged periods . N Engl J Med. 1989;320:1458-1462.Crossref 51. Ensoli F, Fiorelli V, Mezzaroma I, et al. Plasma viraemia in seronegative HIV-1-infected individuals . AIDS. 1991;5:1195-1200.Crossref 52. Koup RA, Ho DD. Immunosilent HIV-1 infection: intrigue continues . AIDS. 1991; 5:1263.Crossref 53. Lee T, El-Amad Z, Reis M, et al. Absence of HIV-1 DNA in high-risk seronegative individuals using high-input polymerase chain reaction . AIDS. 1991;5: 1201-1207.Crossref 54. Imagawa D, Detels R. HIV-1 in seronegative homosexual men . N Engl J Med. 1991;325:1250-1251.Crossref 55. Wormser GP, Joline C, Bittker S, Forseter G. Polymerase chain reaction for seronegative health care workers with parenteral exposure to HIV-infected patients . N Engl J Med. 1989;321:1681-1682.Crossref 56. Henry K, Campbell S, Jackson B, et al. Long-term follow-up of health care workers with work-site exposure to human immunodeficiency virus . JAMA. 1990;263:1765-1766.Crossref 57. Marcus R, Bell DM, Jaffe HW. Exposure of health care workers to the blood of patients infected with the human immunodeficiency virus . N Engl J Med. 1989; 320:1351.Crossref 58. Centers for Disease Control. Apparent transmission of human T-lymphotropic virus type III/lymphadenopathy-associated virus from a child to a mother providing health care . MMWR. 1986;35:76-79. 59. Centers for Disease Control. Update: AIDS and HIV infection among health care workers . MMWR. 1988;37:229-239. 60. Weiss SH, Goedert JJ, Gartner S, et al. Risk of human immunodeficiency virus (HIV-1) infection among laboratory workers . Science. 1988;239:68-71.Crossref 61. Fahey BJ, Koziol DE, Banks SM, Henderson DK. Frequency of nonparenteral occupational exposures to blood and body fluids before and after universal precautions training . Am J Med. 1991;90:145-153.Crossref 62. Jagger J, Hunt EH, Brand-Elnaggar J, Pearson RD. Rates of needle-stick injury caused by various devices in a university hospital . N Engl J Med. 1988;319: 284-288.Crossref 63. Wong ES, Stotka JL, Chinchilli VM, Williams DS, Stuart CG, Markowitz SM. Are universal precautions effective in reducing the number of occupational exposures among health care workers? a prospective study of physicians on a medical service . JAMA. 1991;265:1123-1128.Crossref 64. Jagger J, Pearson RD. Universal precautions: still missing the point on needle-sticks . Infect Control Hosp Epidemiol. 1991;12:45-47.Crossref 65. Jagger J, Hunt EH, Pearson RD. Sharp object injuries in the hospital: causes and strategies for prevention . Am J Infect Control. 1990;18:227-231.Crossref 66. Fournier AM, Zeppa R. Preoperative screening for HIV infection: a balanced view for the practicing surgeon . Arch Surg. 1989;124:1038-1040.Crossref 67. Elford J, Cockroft A. Compulsory HIV antibody testing, universal precautions and the perceived risk of HIV: a survey among medical students and consultant staff at a London teaching hospital . AIDS Care. 1991;3:151-158.Crossref 68. Shanson DC, Cockroft A. Testing patients for HIV antibodies is useful for infection control purposes (pro and against the proposition) . Rev Med Virol. 1991; 1:5-9.Crossref 69. Gerberding JL, Littell C, Tarkington A, Brown A, Schecter PW. Risk of exposure of surgical personnel to patients' blood during surgery at San Francisco General Hospital . N Engl J Med. 1990;322:1788-1793.Crossref

Soma, Maurizio R.;Osnago-Gadda, Iolanda;Paoletti, Rodolfo;Fumagalli, Remo;Morrisett, Joel D.;Meschia, Michele;Crosignani, Piergiorgio

doi: 10.1001/archinte.1993.00410120044006pmid: N/A

Abstract Objective: To evaluate whether estrogen plus progesterone replacement therapy influences the plasma lipoprotein[a] (Lp[a]) levels in postmenopausal women. Design: Fifty-five women who had been menopausal for at least 1 year were followed up for 12 months. Twenty-four subjects served as the control group and 31 subjects served as the therapy group. The therapy consisted of conjugated estrogen (1.25 mg/d) and medroxyprogesterone acetate (10 mg/d for 10 days a month). Blood samples were obtained before the start of therapy and at 6 months and 12 months after therapy. Nine subjects in the therapy group were followed up for an additional year after the treatment was suspended (washout group). Settings: All subjects were healthy women (mean age, 52 years) who had natural menopause at least 1 year before the beginning of recruitment. None of the women had received exogenous sex steroids or drugs known to influence lipid and lipoprotein metabolism in the previous 12 months. Main Results: In the control group, no change was noted in the plasma Lp[a] concentrations during the study. In the treatment group, the mean plasma Lp[a] concentrations decreased 50% after 6 months (P<.01) and remained at this level 12 months after treatment was started. In the washout group, mean plasma Lp[a] levels tended to return to pretherapy values. In addition, estrogen plus progesterone treatment significantly lowered total cholesterol levels by 15% and low-density lipoprotein cholesterol levels by 30%; it increased high-density lipoprotein cholesterol levels by 19%. Conclusion: The results suggest that in estrogen plus progesterone-treated postmenopausal women, the lipid profile is improved not only by lowering low-density lipoprotein cholesterol levels and raising high-density lipoprotein levels, but also by lowering plasma Lp[a] concentrations.(Arch Intern Med. 1993;153:1462-1468) References 1. Lipoprotein[a] . Lancet. 1991;337:397-398. Editorial.Crossref 2. Scanu AM, Gunther MF. Lipoprotein[a] . J Clin Invest. 1990;85:1709-1715.Crossref 3. Loscalzo J. Lipoprotein[a]: a unique risk factor for atherothrombotic disease . Arteriosclerosis. 1990;10:672-679.Crossref 4. Utermann G. Lipoprotein[a]: a genetic risk factor for premature coronary heart disease . Nutr Metab Cardiovasc Dis. 1991;1:7-9. 5. Utermann G. The mysteries of lipoprotein[a] . Science. 1989;246:904-910.Crossref 6. Boerwinkle E, Leffert CC, Lin J, Lackner C, Chiesa G, Hobbs HH. Apolipoprotein[a] gene accounts for greater than 90% of the variation in plasma lipoprotein[a] concentrations . J Clin Invest. 1992;90:52-60.Crossref 7. Scott J. Lipoprotein[a] . BMJ. 1991;303:663-664.Crossref 8. Miles LA, Fless GM, Levin EG, Scanu AM, Plow EF. A potential basis for the thrombotic risk associated with lipoprotein[a] . Nature. 1989;339:301-305.Crossref 9. Hoefler G, Harnoncourt F, Paschke E, Mirtl W, Pfeiffer KH, Kostner GM. Lipoprotein[a] a risk factor for myocardial infarction . Arteriosclerosis. 1988;8:398-401.Crossref 10. Lp[a] joins other serum cholesterol lipoproteins as risk determinant . JAMA. 1989;261:2013-2014.Crossref 11. Dahlen GH, Guyton JR, Attar M, Farmer JA, Kautz JA, Gotto AM Jr. Association of levels of lipoprotein Lp[a], plasma lipids, and other lipoproteins with coronary artery disease documented by angiography . Circulation. 1986;74:758-765.Crossref 12. Guyton JR, Dahlen GH, Patsch W, Kautz JA, Gotto AM Jr. Relationship of plasma lipoprotein Lp[a] levels to race and to apolipoprotein B . Arteriosclerosis. 1985; 5:264-272. 13. Morrisett JD, Guyton JR, Gaubatz JW, Gotto AM Jr. Lipoprotein[a]: structure, metabolism and epidemiology . In: Gotto AM Jr, ed. Plasma Lipoproteins . New York, NY: Elsevier Science Publishing Co Inc; 1987:129-151. 14. Albers JJ, Marcovina SM, Lodge MS. The unique lipoprotein[a]: properties and immunochemical measurement . Clin Chem. 1990;36:2019-2026. 15. Sandkamp M, Assmann G. Lipoprotein[a] in PROCAM participants and young myocardial infarction survivors . In: Scanu AM, ed. Lipoprotein[a]: 25 Years of Progress . Orlando, Fla: Academic Press Inc; 1990:205-210. 16. LaRosa JC. Women, lipoproteins and cardiovascular disease risk . Can J Cardiol. 1990;6( (suppl B) ):23B-30B. 17. Knopp RH. Effect of sex steroid hormones on lipoprotein levels in pre and post menopausal women . Can J Cardiol. 1990;6( (suppl B) ):31B-35B. 18. Meade TW, Berra A. Hormone replacement therapy and cardiovascular disease . Br Med Bull. 1992;48:276-308. 19. Stampfer MJ, Colditz GA. Estrogen replacement therapy and coronary heart disease: a quantitative assessment of the epidemiological evidence . Prev Med. 1991;20:47-63.Crossref 20. Stampfer MJ, Colditz GA, Willet WC, et al. Postmenopausal estrogen therapy and cardiovascular disease . N Engl J Med. 1991;325:756-762.Crossref 21. Stampfer MJ, Willett WC, Colditz GA. A prospective study of postmenopausal estrogen therapy and coronary heart disease . N Engl J Med. 1975;313:1044-1049.Crossref 22. Bush TL, Barrett-Connor E, Cowan LD. Cardiovascular mortality and noncontraceptive use of estrogen in women: results from the Lipid Research Clinics Program follow-up study . Circulation. 1987;75:1102-1109.Crossref 23. Barrett-Connor E. Hormone replacement and cancer . Br Med Bull. 1992;48: 345-355. 24. Mack TM, Pike MC, Henderson BE, Pfeffer RI, Gerkins V. Estrogens and endometrial cancer in a retirement community . N Engl J Med. 1976;294:1262-1267.Crossref 25. Smith DC, Prentice R, Thompson DJ, Herrman WL. Association of exogenous estrogens and endometrial cancer . N Engl J Med. 1975;293:1164-1167.Crossref 26. Ettinger B, Golditch IM, Friedman G. Gynecologic consequences of long-term unopposed estrogen replacement therapy . Maturitas. 1988;10:271-282.Crossref 27. Criqui MH, Suarez L, Barrett-Connor E, McPhilips J, Wingard DL. Postmenopausal estrogen use and mortality: results from a prospective study in a defined, homogeneous community . Am J Epidemiol. 1988;128:606-614. 28. Persson I, Adami H-O, Bergkvist L, et al. Risk of endometrial cancer after treatment with oestrogens alone or in conjunction with progestogens: results of a prospective study . BMJ. 1989;298:147-156.Crossref 29. Lipid and lipoprotein analysis . In: Lipid Research Clinic Program: Manual of Laboratory Operations . Washington, DC: 1974. US Dept of Health, Education, and Welfare publication NIH 75-628. 30. Friedewald WT, Levy RI, Fredrikson DS. Estimation of the concentration of low-density lipoprotein cholesterol in plasma without the use of the preparative ultracentrifuge . Clin Chem. 1972;18:499-502. 31. Gaubatz JW, Heideman C, Gotto AM Jr, Morrisett JD, Dahlen GH. Human plasma lipoprotein[a] . J Biol Chem. 1983;258:4582-4589. 32. Armitage P. ANOVA analysis . In: Armitage P, ed. Statistical Methods in Medical Research. Boston, Mass: Blackwell Scientific Publications Inc; 1971:215-263. 33. Huitson A. A 2-way analysis two crossed classification with no replication . In: Kendall MG, ed. The Analysis of Variance: Griffin's Statistical Monographs and Courses . 1966:17-18. 34. Applebaum-Bowden D, McLean P, Steinmetz A, et al. Lipoprotein, apolipoprotein, and lipolytic enzyme changes following estrogen administration in postmenopausal women . J Lipid Res. 1989;30:1895-1906. 35. Wallentin L, Larsson-Cohn U. Metabolic and hormonal effects of postmenopausal estrogen replacement treatment, II: plasma lipids . Acta Endocrinol. 1977;86:597-604. 36. Colvin PL, Auerbach BJ, Applebaum-Bowden D, Hazzard WR. Effect of estrone versus 17 beta-estradiol on lipoproteins in postmenopausal women . Clin Res. 1988;36:269A-278A. 37. Wahl P, Walden C, Knopp RH, et al. Effect of estrogen/progestogin potency on lipid/lipoprotein cholesterol . N Engl J Med. 1983;308:862-867.Crossref 38. Tikkanen MJ, Nikkila EA, Kuusi T, Sipinen S. Effects of oestradiol and levonor-gestrel on lipoprotein lipids and postheparin plasma lipase activities in normolipoproteinaemic women . Acta Endocrinol. 1982;99:630-635. 39. Knopp RH. Cardiovascular effects of endogenous and exogenous sex hormones over a woman's lifetime . Am J Obstet Gynecol. 1988;158:1630-1643.Crossref 40. Nanjee NM, Koritnik DR, Thomas J, Miller NE. Hormonal determinants of apolipoprotein B,E receptor expression in human liver: positive association of receptor expression with plasma estrone concentration in middle-aged/elderly women . Biochim Biophys Acta. 1990;1046:151-158.Crossref 41. Hunt K, Vessey M, McPherson K. Mortality in a cohort of long-term users of hormone replacement therapy: an updated analysis . Br J Obstet Gynecol. 1990; 97:1080-1086.Crossref 42. Gurkar A, Hoeg JM, Kostner GM. Levels of lipoprotein[a] decline with neomycin and niacin treatment . Atherosclerosis. 1985;57:293-301.Crossref 43. Jones PH, Gotto AM Jr, Pownall HJ, et al. Effect of gemfibrozil on plasma lipoprotein[a] levels in type Ila hyperlipoproteinemic subjects . Arteriosclerosis Thromb. 1991;11:1423a. Abstract. 44. Albers JJ, Taggart HMCA, Applebaum-Bowden D, Haffner S, Chestnut CH, Hazzard WR. Reduction of lecithin-cholesterol acyltransferase, apolipoprotein D and the Lp[a] lipoprotein with the anabolic steroid stanazolol . Biochim Biophys Acta. 1984;795:293-296.Crossref 45. Zechner R, Desoye G, Schweditsch MO, Pfeiffer KP, Kostner GM. Fluctuations of plasma lipoprotein[a] concentrations during pregnancy and post partum . Metabolism. 1986;35:333-336.Crossref 46. Farish E, Rolton HA, Barnes JF, Hart DM. Lp[a] concentrations in postmenopausal women taking norethisterone . BMJ. 1991;303:694.Crossref 47. Henriksson P, Angelin B, Berglund L. Hormonal effects on serum Ip[a] levels: marked reduction during estrogen treatment in males with prostatic cancer . Arteriosclerosis Thromb. 1991;11:1423a. Abstract.

Ganzini, Linda;Casey, Daniel E.;Hoffman, William F.;McCall, Anthony L.

doi: 10.1001/archinte.1993.00410120051007pmid: N/A

Abstract Background: Metoclopramide hydrochloride, a neuroleptic dopamine receptor antagonist used to treat gastric ailments, is reported to cause extrapyramidal movement disorders. The goals of this study were (1) to determine the prevalence and severity of tardive dyskinesia and acute extrapyramidal movement syndromes including akathisia, acute dystonia, and drug-induced parkinsonism in metoclopramide-treated patients and (2) to compare the prevalence and severity of tardive dyskinesia in metoclopramide-treated diabetics and nondiabetics. Methods: From a list of metoclopramide-treated patients received from the Portland (Ore) Veterans Affairs Medical Center pharmacy, 53 patients met inclusion criteria and 51 (96%) agreed to participate. Controls consisted of a convenience sample drawn from the Portland Veterans Affairs Medical Center Outpatient Clinic who were matched to subjects on age (±10 years), gender, and presence or absence of diabetes. Of 61 potential controls contacted, 51 (84%) agreed to participate. Metoclopramide-treated subjects and controls were seen by a rater who was "blind" to all diagnoses and treatments. The rater performed a standardized examination used to elicit signs and symptoms of tardive dyskinesia and acute extrapyramidal movement syndromes. Results: The relative risk for tardive dyskinesia was 1.67 (95% confidence interval, 0.93 to 2.97), and the relative risk for drug-induced parkinsonism was 4.0 (95% confidence interval, 1.5 to 10.5). Metoclopramide-treated patients had significantly greater severity of tardive dyskinesia, drug-induced parkinsonism, and subjective akathisia than controls. Use of metoclopramide was associated with impairment in ambulation and increased use of benzodiazepines. Metoclopramidetreated diabetics had significantly greater severity of tardive dyskinesia than metoclopramide-treated nondiabetics. Conclusions: Metoclopramide use is associated with a significantly increased prevalence and severity of several extrapyramidal movement disorders.(Arch Intern Med. 1993;153:1469-1475) References 1. Albibi R, McCallum RW. Metoclopramide: pharmacology and clinical application . Ann Intern Med. 1983;98:86-95.Crossref 2. Casey DE. Metoclopramide side effects . Ann Intern Med. 1983;98:673-674.Crossref 3. Miller LG, Jankovic J. Metoclopramide-induced movement disorders: clinical findings with a review of the literature . Arch Intern Med. 1989;149:2486-2492.Crossref 4. Orme ML'E, Tallic RC. Metoclopramide and tardive dyskinesia in the elderly . BMJ. 1984;289:397-398.Crossref 5. Grimes JD, Hassan MN, Preston DN. Adverse neurologic effects of metoclopramide . Can Med Assoc J. 1982;126:23-25. 6. Wiholm BE, Mortimer O, Boethius G, Haggstrom JE. Tardive dyskinesia associated with metoclopramide . BMJ. 1984;288:545-547.Crossref 7. Ganzini L, Heintz RT, Hoffman WF, Keepers G, Casey DE. Acute extrapyramidal syndromes in neuroleptic-treated elderly: a pilot study . J Geriatr Psychiatry Neurol. 1991;4:222-226.Crossref 8. Adler LA, Angrist B, Reiter S, Rotrosen J. Neuroleptic-induced akathisia: a review . Psychopharmacology. 1989;97:1-11.Crossref 9. Addonizio G, Alexopoulos GS. Drug-induced dystonia in young and elderly patients . Am J Psychiatry. 1988;145:869-871. 10. American Psychiatric Association. Tardive Dyskinesia: A Task Force Report of the American Psychiatric Association . Washington, DC: American Psychiatric Association; 1992. 11. Smith JM, Baldessarini RJ. Changes in prevalence, severity, and recovery of tardive dyskinesia with age . Arch Gen Psychiatry. 1980;37:1368-1373.Crossref 12. Ganzini L, Heintz RT, Hoffman WF, Casey DE. The prevalence of tardive dyskinesia in neuroleptic-treated diabetics: a controlled study . Arch Gen Psychiatry. 1991;48:259-263.Crossref 13. Harrington RA, Hamilton CW, Brogden RN, Linkewich JA, Romankiewicz JA, Heel RC. Metoclopramide: an updated review of its pharmacologic properties and clinical use . Drugs. 1983;25:451-494.Crossref 14. Bateman DN, Rawlins MD, Simpson JM. Extrapyramidal reactions with metoclopramide . BMJ. 1985;291:930-932.Crossref 15. Physicians' Desk Reference . 45th ed. Montvale, NJ: Medical Economics Data; 1991. 16. National Diabetes Data Group. Classification and diagnosis of diabetes mellitus and other categories of glucose intolerance . Diabetes. 1979;28:1039-1057.Crossref 17. Guy W. ECDEU Assessment Manual for Psychopharmacology . Washington, DC: US Dept of Health, Education, and Welfare; 1976:534-537. 18. Schooler N, Kane JM. Research diagnoses for tardive dyskinesia . Arch Gen Psychiatry. 1982;39:486-487. 19. Gerlach J. Tardive dyskinesia . Dan Med Bull. 1979;25:209-244. 20. Folstein MF, Folstein SE, McHugh PR. Mini-Mental State: a practical method for grading the cognitive state of patients for the clinician . J Psychiatr Res 1975;12:189-198.Crossref 21. Fleiss JL. Statistical Methods for Rates and Proportions . 2nd ed. New York, NY: John Wiley & Sons Inc; 1981. 22. Stevens J. Applied Multivariate Statistics for the Social Scenes . Hillsdale, NJ: Lawrence Erlbaum Associates; 1986. 23. Kramer S. Clinical Epidemiology and Biostatistics . New York, NY: Springer-Verlag NY Inc; 1988. 24. Cohen J, Cohen P. Applied Multiple Regression/Correlation Analysis for the Behavioral Sciences . 2nd ed. Hillsdale, NJ: Lawrence Erlbaum Associates; 1983. 25. Bateman DN, Darling WM, Boys R, Rawlins MD. Extrapyramidal reactions to metoclopramide and prochlorperazine . Q J Med. 1989;264:307-311. 26. Weiden PJ, Mann JJ, Haas G, Mattson M, Frances A. Clinical nonrecognition of neuroleptic-induced movement disorders: a cautionary study . Am J Psychiatry . 1987;144:1148-1153. 27. McCall AL. The impact of diabetes on the CNS . Diabetes. 1992;41:557-570.Crossref 28. McCall AL. Cerebral microvascular transport and metabolism: implications for diabetes . In: Ruderman N, Williamson J, Brownlee M, eds. Hyperglycemia, Diabetes, and Vascular Disease . New York, NY: Oxford University Press Inc; 1992: 59-106. 29. Waddington JL. Schizophrenia, affective psychoses and other disorders treated with neuroleptic drugs: the enigma of tardive dyskinesia, its neurobiological determinants and the conflict of paradigms . Int Rev Neurobiol. 1989;31:297-353. 30. Schoenberg BS, Anderson DW, Haerer AF. Prevalence of Parkinson's disease in the biracial population of Copiah County, Mississippi . Neurology . 1985;35: 841-845.Crossref

Sullivan, Mark;Clark, Michael R.;Katon, Wayne J.;Fischl, Mark;Russo, Joan;Dobie, Robert A.;Voorhees, Richard

doi: 10.1001/archinte.1993.00410120059008pmid: N/A

Abstract Background: Dizziness is a common and disabling symptom in primary care practice, especially among the elderly. Though there are many organic causes of dizziness, the results of medical workups are negative in the majority of patients. Methods: A total of 75 patients with dizziness who were referred to a community otolaryngology practice received a structured psychiatric diagnostic interview (National Institute of Mental Health Diagnostic Interview Schedule) and questionnaires that assessed psychological distress as well as a complete otologic evaluation, including electronystagmogram. Patients with evidence of a peripheral vestibular disorder were compared with those without such evidence. Results: While psychiatric diagnoses were present in both those with and without evidence of a peripheral vestibular disorder, those without such evidence had a greater mean number of lifetime psychiatric diagnoses as defined by the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition, and specifically, a greater life-time prevalence of major depression and panic disorder. This group also more frequently met criteria for somatization disorder, had more current and lifetime unexplained medical symptoms, and had more severe current depressive, anxiety, and somatic symptoms. Conclusions: Psychiatric diagnoses are common among patients with dizziness referred for otologic evaluation who do not show evidence of a peripheral vestibular disorder. Specific psychiatric disorders should be part of the differential diagnosis of patients who present with dizziness.(Arch Intern Med. 1993;153:1479-1484) References 1. National Center for Health Statistics. National Ambulatory Medical Care Survey, 1980-1: Vital and Health Statistics . Washington, DC: Public Health Service; 1984. US Dept of Health and Human Services publication PHS 84-1741. Series 13, No. (80) . 2. Kroenke K, Arrington ME, Manglesdorff AD. The prevalence of symptoms in medical outpatients and the adequacy of therapy . Arch Intern Med. 1990;150: 1685-1689.Crossref 3. Luxon LM. Disturbances of balance in the elderly . Br J Hosp Med. 1991;45: 22-26. 4. Sloane P, Blazer D, George LK. Dizziness in a community elderly population . J Am Geriatr Soc. 1989;37:101-108. 5. Kroenke K, Mangelsdorff AD. Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome . Am J Med. 1989;86:262-266.Crossref 6. Drachman DA, Hart CW. An approach to the dizzy patient . Neurology. 1982; 22:323-330.Crossref 7. Simpson RB, Nedzelski JM, Barber HO, Thomas MR. Psychiatric diagnoses with psychogenic dizziness or severe tinnitus . J Otolaryngol. 1988;17:325-330. 8. Rigatelli M, Casolari L, Bergamini G, Guidetti G. Psychosomatic study of 60 patients with vertigo . Psychother Psychosom. 1984;41:91-99.Crossref 9. Coker NJ, Coker RR, Jenkins HA, Vincent KR. Psychological profile of patients with Meniere's disease . Arch Otolaryngol Head Neck Surg. 1989;115:1355-1357.Crossref 10. Hallam RS, Stephens SDG. Vestibular disorder and emotional distress . J Psychosom Res. 1985;29:407-413.Crossref 11. O'Connor KP, Hallam R, Beyts J, Hinchcliffe R. Dizziness: behavioral, subjetive and organic aspects . J Psychosom Res. 1988;32:291-302.Crossref 12. Robins LN, Helzer JE, Croughan J, Ratcliff JS. National Institute of Mental Health Diagnostic Interview Schedule: its history, characteristics, and validity . Arch Gen Psychiatry. 1981;38:381-389.Crossref 13. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders , Revised Third Edition. Washington, DC: American Psychiatric Press Inc; 1987. 14. Hamilton M. A rating scale for depression . J Neurol Neurosurg Psychiatry. 1960;23:56-62.Crossref 15. Hamilton M. The assessment of anxiety states by rating . Br J Med Psychol. 1959;32:50-56.Crossref 16. Derogatis LR, Lipman RS, Rickels K, Uhlenhuth EH, Covi L. The Hopkins Symptom Checklist—a self-report symptom inventory . Behav Sci. 1974;19:1-15.Crossref 17. Barsky AJ, Wyshak G, Klerman GL. The Somatosensory Amplification Scale and its relationship to hypochondriasis . J Psychiatr Res. 1990;24:323-334.Crossref 18. Escobar Jl, Golding JM, Hough RL, Darno M, Burnam MA, Wells KB. Somatization in the community: relationship to disability and use of services . Am J Public Health. 1987;77:837-840.Crossref 19. Clark MR, Sullivan MD, Katon WJ, et al. Psychiatric and medical factors associated with disability in patients with dizziness . Psychosomatics . In press. 20. Jacob RG. Panic disorder and the vestibular system . Psychiatr Clin North Am. 1988;11:361-374. 21. Cwikel J, Kaplan G, Barell V. Falls and subjective health rating among the elderly: evidence from two Israeli samples . Soc Sci Med. 1990;31:485-490.Crossref 22. Linzer M, Pontinen M, Gold D, Divine G, Felder A, Brooks W. Impairment in physical and psychosocial function in recurrent syncope . J Clin Epidemiol. 1991; 44:1037-1043.Crossref 23. Clark MR, Sullivan MD, Fischl M, Katon WJ, Russon JE, Dobie RA, Voorhees RD. Dizziness symptoms as clues to otologic and psychiatric diagnosis . Psychosom Med. In press. 24. Pilgrim JA, Stansfield S, Marmot M. Low blood pressure, low mood? BMJ. 1992;304:75-78.Crossref 25. Katon W, Egan K, Miller D. Chronic pain: lifetime psychiatric diagnoses and family history . Am J Psychiatry. 1985;142:1156-1160. 26. Katon WJ, Buchwald DS, Simon GE, Russo JE, Mease PJ. Psychiatric illness in patients with chronic fatigue and those with rheumatoid arthritis . J Gen Intern Med. 1991;6:277-285.Crossref 27. Regier DA, Goldberg ID, Taube CA. The de facto US mental health service system: a public health perspective . Arch Gen Psychiatry. 1988;35:685-693.Crossref 28. Drossman DA, Sandler RS, Mckee DC, Lovitz AJ. Bowel patterns among subjects not seeking health care . Gastroenterology. 1982;83:529-534. 29. Broadhead WE, Blazer DG, George LK, Tse CK. Depression, disability days, and days lost from work in a prospective epidemiologic survey . JAMA. 1990;264: 2524-2528.Crossref 30. Johnson J, Weissman MM, Klerman GL. Service utilization and social morbidity associated with depressive symptoms in the community . JAMA. 1992; 267:1478-1483.Crossref 31. Wells KB, Stewart A, Hays RD, Burnam MA, Rogers W, Daniels M. The functioning and well-being of depressed patients . JAMA. 1989;262:914-919.Crossref

Woodruff, Tracey J.;Rosbrook, Brad;Pierce, John;Glantz, Stanton A.

doi: 10.1001/archinte.1993.00410120065009pmid: N/A

Abstract Objective: We examined the relationship between workplace smoking policies and smoking prevalence and cigarette consumption. Methods: California residents were questioned by telephone with the 1990 California Tobacco Survey. All respondents (11 704) above age 18 years who were employed indoors were used. Respondents were asked about smoking status, workplace smoking policy, desire to quit, and smoking history. Logistic regression was used to determine the relationship of workplace smoking policy to smoking status, accounting for demographic variables. Results: Prevalence of regular smokers was significantly lower in smoke-free workplaces than in those with no restrictions (13.7% vs 20.6%, P<.001). Continuing regular smokers in smoke-free workplaces smoked fewer cigarettes than those in workplaces with no restrictions (296 vs 341 packs per year, P<.001). More comprehensive smoking policies were associated with smokers more likely to contemplate quitting (P=.014). Conclusions: Employees in smoke-free workplaces have a lower smoking prevalence and, among continuing smokers, lower cigarette consumption than individuals working where smoking is permitted. We estimate cigarette consumption among employees indoors is 21% below that if there were no smoking restrictions in California workplaces. Furthermore, if all California workplaces were smoke-free, cigarette consumption among employees would be 41% below that if there were no workplace smoking restrictions, approximately a $406 million annual loss in sales to the tobacco industry. This study supports the hypothesis that smoke-free workplace policies are an effective public health measure for decreasing smoking prevalence and cigarette consumption among continuing smokers.(Arch Intern Med. 1993;153:1485-1493) References 1. Reducing the Health Consequences of Smoking: 25 Years of Progress, a Report of the Surgeon General . Rockville, Md: US Dept of Health and Human Services; 1989. Publication CDC 89-8411. 2. National Research Council. Environmental Tobacco Smoke: Measures of Exposure and Assessing Health Effects . Rockville, Md: National Academy Press; 1986. Publication CDC 87-8398. 3. The Health Consequences of Involuntary Smoking: A Report of the Surgeon General . Washington, DC: US Dept of Health and Human Services; 1986. 4. Glantz S. Passive smoking and heart disease epidemiology, physiology, and biochemistry . Circulation. 1991;83:1-12.Crossref 5. Steenland K. Passive smoking and the risk of heart disease . JAMA. 1992;267: 94-99.Crossref 6. Taylor A, Johnson D, Kazemi H. Environmental tobacco smoke and cardiovascular disease: a position paper from the Council on Cardiopulmonary and Critical Care, American Heart Association . Circulation. 1992;86:1-4.Crossref 7. Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders . Washington, DC: Environmental Protection Agency; 1992. Publication EPA/600/6-90/006F. 8. Emmons K, Abrams D, Marshall R, et al. Exposure to environmental tobacco smoke in naturalistic settings . Am J Public Health. 1992;82:24-28.Crossref 9. Becker DM, Conner HF, Waranch HR, et al. The impact of a total ban on smoking in The Johns Hopkins Children's Center . JAMA. 1989;262:799-802.Crossref 10. Beiner L, Abarms D, Follick M, Dean L. A comparative evaluation of a restrictive smoking policy in a general hospital . Am J Public Health. 1989;79:192-195.Crossref 11. Borland R, Pierce JP, Burns DM, Gilpin E, Johnson M, Bal D. Protection from environmental tobacco smoke in California: the case for a smoke-free workplace . JAMA. 1992;268:749-752.Crossref 12. Gottlieb N, Eriksen M, Lovato C, Weinstein R, Green L. Impact of a restrictive work site smoking policy on smoking behavior, attitudes, and norms . J Occup Med. 1990;32:16-23.Crossref 13. Sorensen G, Rigotti N, Rosen A, Pinney J, Prible R. Effects of a worksite nonsmoking policy: evidence for increased cessation . Am J Public Health. 1991; 81:202-204.Crossref 14. Stillman FA, Becker DM, Swank RT, et al. Ending smoking at The Johns Hopkins Medical Institutions: an evaluation of smoking prevalence and indoor air pollution . JAMA. 1990;264:1565-1569.Crossref 15. Borland R. Changes in prevalence of and attitudes to restrictions on smoking in the workplace among indoor workers in the state of Victoria, Australia, 1988-90 . Tobacco Control. 1992;1:19-24.Crossref 16. Stave GM, Jackson GW. Effect of a total work-site smoking ban on employee smoking and attitudes . J Occup Med. 1991;33:884-890.Crossref 17. Borland R, Chapman S, Owen N, Hill D. Effects of workplace smoking bans on cigarette consumption . Am J Public Health. 1990;80:178-180.Crossref 18. Petersen L, Helgerson S, Gibbons C, Calhoun C, Ciacco K, Pitchford K. Employee smoking behavior changes and attitudes following a restrictive policy on worksite smoking in a large company . Public Health Rep. 1988;103:115-120. 19. Rosenstock I, Stergachis A, Heaney C. Evaluation of smoking prohibition policy in a health maintenance organization . Am J Public Health. 1986;76:1014-1015.Crossref 20. Kristein M. How much can business expect to profit from smoking cessation? Prev Med. 1983;12:385-381.Crossref 21. Ryan J, Zwerling C, Orav E. Occupational risks associated with cigarette smoking: a prospective study . Am J Public Health. 1992;82:29-32.Crossref 22. Waksberg J. Sampling methods for random digit dialing . J Am Stat Assoc. 1978;73:40-46.Crossref 23. Fiore M, Novotny T, Pierce J, Hatziandreu E, Patel K, Davis R. Trends in cigarette smoking in the United States: the changing influence of gender and race . JAMA. 1989;261:49-55.Crossref 24. Efron B. The Jack-knife, the Bootstrap and Other Resampling Plans . Philadelphia, Pa: Society for Industrial and Applied Mathematics; 1982. 25. Hosmer D, Lemeshow S. Applied Logistic Regression. New York, NY: John Wiley & Sons Inc; 1989. 26. Burns D, Pierce J. Tobacco Use in California 1990-1991 . Sacramento: California Dept of Health Services; 1992. 27. The Tax Burden on Tobacco. Washington, DC: The Tobacco Institute; 1991: 183. 28. Hatziandreu E, Pierce J, Fiore M, Grise V, Novotny T, Davis R. The reliability of self-reported cigarette consumption in the United States . Am J Public Health. 1989;79:1020-1023.Crossref 29. Pertschuk M. Shopland D. Major Local Smoking Ordinances in the United States . Washington, DC: US Dept of Health and Human Services; 1989. Publication NIH 90-479. 30. Pierce J, Naquin M, Gilpin E, Giovino G, Mills S, Marcus S. Smoking initiation in the United States: a role for worksite and college smoking bans . J Natl Cancer Inst. 1991;83:1009-1013.Crossref 31. Begay M, Glantz S. Political Expenditures by the Tobacco Industry in California State Politics From 1976 to 1991 . San Francisco, Calif: Institute for Health Policy Studies, University of California, San Francisco; 1991. 32. Samuels B, Glantz SA. The politics of local tobacco control . JAMA. 1991;266: 2110-2117.Crossref

Mahaffey, Kenneth W.;Hippenmeyer, Carol L.;Mandel, Richard;Ampel, Neil M.

doi: 10.1001/archinte.1993.00410120076010pmid: N/A

Abstract Coccidioidomycosis is becoming increasingly recognized as an opportunistic infection among patients infected with the human immunodeficiency virus. We treated two cases of concomitant coccidioidomycosis and Pneumocystis carinii pneumonia. In each case, the diagnosis of coccidioidomycosis was delayed despite appropriate examination of bronchoalveolar lavage fluid. Both patients were treated with antimicrobial therapy directed against P carinii and given adjuvant corticosteroid therapy. In both cases, this led to clinical worsening and was associated with the development of a reticulonodular pulmonary infiltrate on chest roentgenograms. When coccidioidomycosis and Pneumocystis pneumonia occur concomitantly in patients with human immunodeficiency virus infection, the diagnosis of coccidioidomycosis may be delayed or missed. In such cases, corticosteroids may lead to overwhelming coccidioidomycosis. Development of a reticulonodular pulmonary pattern on chest roentgenograms is suggestive of this complication. (Arch Intern Med. 1993;153:1496-1498) References 1. Bozzette SA, Sattler FR, Chiu J, et al. A controlled trial of early adjunctive treatment with corticosteroids for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome. N Engl J Med. 1990;323:1451-1457.Crossref 2. Gagnon S, Boota AM, Fischl MA, et al. Corticosteroids as adjunctive therapy for severe Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome: a double-blind, placebo-controlled trial . N Engl J Med. 1990;323:1444-1450.Crossref 3. MacFadden DK, Edelson JD, Hyland RH, et al. Corticosteroids as adjunctive therapy in treatment of Pneumocystis carinii pneumonia in patients with acquired immunodeficiency syndrome . Lancet. 1987;1:1477-1479.Crossref 4. Montaner JS, Lawson LM, Levitt N, et al. Corticosteroids prevent early deterioration in patients with moderately severe Pneumocystis cariniipneumonia and the acquired immunodeficiency syndrome (AIDS) . Ann Intern Med. 1990;113:14-20.Crossref 5. Bronnimann DA, Adam RD, Galgiani JN, et al. Coccidioidomycosis in the acquired immunodeficiency syndrome . Ann Intern Med. 1987; 106:372-379.Crossref 6. Fish DG, Ampel NM, Galgiani JN, et al. Coccidioidomycosis during human immunodeficiency virus infection: a review of 77 patients . Medicine. 1990;69:384-391.Crossref 7. Abrams Dl, Robia M, Blumenfeld W, et al. Disseminated coccidioidomycosis in AIDS . N Engl J Med. 1984;310:986-987.Crossref 8. Vartivarian SE, Coudron PE, Markowitz SM. Disseminated coccidioidomycosis: unusual manifestations in a cardiac transplantation patient . Am J Med. 1987;83:949-952.Crossref 9. Deresinski SC, Stevens DA. Coccidioidomycosis in compromised hosts: experience at Stanford University Hospital . Medicine. 1974;54:377-395.Crossref 10. Weldon-Linne CM, Rhone DP, Bourassa R. Bronchoscopy specimens in adults with AIDS: comparative yields of cytology, histology and culture for diagnosis of infectious agents . Chest. 1990;98:24-28.Crossref 11. Sobonya RE, Barbee RA, Wiens J, Trego D. Detection of fungi and other pathogens in immunocompromised patients by bronchoalveolar lavage in an area endemic for coccidioidomycosis. Chest. 1990;97:1349-1355.Crossref 12. Consensus statement on the use of corticosteroids as adjunctive therapy for Pneumocystis pneumonia in the acquired immunodeficiency syndrome . N Engl J Med. 1990;323:1500-1504.Crossref 13. Lambertus MW, Goetz MB, Murthy AR, Mathisen GE. Complications of corticosteroid therapy in patients with the acquired immunodeficiency syndrome and Pneumocystis cariniipneumonia . Chest. 1990;98:38-43.Crossref 14. Ampel NM, Ryan KJ, Carry PJ, Wieden MA, Schifman RB. Fungemia due to Coccidioides immitis: an analysis of 16 episodes in 15 patients and a review of the literature . Medicine. 1986;65:312-321.Crossref