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In This Issue of Archives of Internal Medicine
September 08, 2003

In This Issue of Archives of Internal Medicine

Arch Intern Med. 2003;163(16):1877. doi:10.1001/archinte.163.16.1877
Adverse Childhood Experiences and Self-reported Liver Disease: New Insights Into the Causal Pathway

To assess whether adverse childhood experiences will increase risk of liver disease, a retrospective study of 17 337 adult health plan members was conducted. The results support that childhood abuse, neglect, and forms of household dysfunction are significantly associated with the risk of liver disease, and this association appears to be mediated substantially by behaviors such as substance abuse and high-risk sexual activity, which increase the risk of viral and alcohol-induced liver disease.

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Clinical Spectrum and Prevalence of Neurologic Events Provoked by Tilt Table Testing

Motor activity occurring during neurocardiogenic syncope can mimic true neurologic events. In this retrospective study of 222 patients with syncope and a positive tilt table test result, 18 patients (8%) had apparent neurologic events during testing. Patients with tonic-clonic seizure–like activity had a significantly lower systolic blood pressure at the termination of tilt testing than all other patients whose tilt table test results were positive. Heart rate at the time of test termination was significantly lower in patients with tonic-clonic seizure–like activity and non–tonic-clonic neurologic events than in patients with positive tilt table test results with no provoked neurologic events, and asystole was provoked more frequently in these 2 patient populations. Neurologic events are common during episodes of neurocardiogenic syncope, and the diagnosis should be considered in the evaluation of unexplained seizurelike activity.

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The Ankle-Brachial Index in the Elderly and Risk of Stroke, Coronary Disease, and Death: The Framingham Study

Murabito et al examined 251 men and 423 women (mean age, 80 years), who attended a Framingham Study examination from 1994-1995. A low ankle-brachial index (ABI) was defined as less than 0.9. Persons were followed up for 4 years for the occurrence of stroke or transient ischemic attack (TIA), coronary disease, and death. Cox proportional hazards models were used to assess the relation between a low ABI and each outcome after adjusting for age, sex, and prevalent coronary disease. A low ABI was detected in 20% of the sample, among whom only 18% reported symptoms of claudication. Results of multivariable Cox proportional hazards analyses demonstrated a statistically significant increased risk for stroke or TIA in persons with a low ABI (hazards ratio, 2.0; 95% confidence interval, 1.1-3.7). No significant relation between a low ABI and coronary disease or death was observed. A low ABI is associated with risk for stroke or TIA in the elderly. These results need to be confirmed in larger studies.

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Role of Environmental Contamination as a Risk Factor for Acquisition of Vancomycin-Resistant Enterococci in Patients Treated in a Medical Intensive Care Unit

Environmental reservoirs for vancomycin-resistant enterococci, in which contamination is persistent despite cleaning, may be associated with transmission in an intensive care unit. This case-control study demonstrated a high-risk room to be an independent predictor of vancomycin-resistant enterococci acquisition in a medical intensive care unit.

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Lifetime Risk of Coronary Heart Disease by Cholesterol Levels at Selected Ages

Using data from the Framingham Heart Study, the authors examined lifetime risk for coronary heart disease (CHD) by cholesterol levels for men and women at selected ages. At all ages, there was a 1.5- to 2-fold greater lifetime risk for CHD in subjects with total cholesterol (TC) level of 240 mg/dL or greater (≥6.20 mmol/L) vs less than 200 mg/dL (<5.20 mmol/L). At age 40 years, the lifetime risks for CHD through age 80 years for men with TC level less than 200 mg/dL (<5.20 mmol/L), 200 to 239 mg/dL (5.20-6.19 mmol/L), and 240 mg/dL or greater (≥6.20 mmol/L) were 31%, 43%, and 57%, respectively; for women, the lifetime risks were 15%, 26%, and 33%, respectively. Lifetime risks contrasted sharply with shorter-term risks: at age 40 years, the 10-year cumulative risks for CHD were 3%, 5%, and 12% for men and 1%, 2%, and 5% for women, respectively. Lifetime risk was also stratified well by cholesterol subfractions that included high-density lipoprotein cholesterol. These data support routine cholesterol screening in younger patients, who may have low short-term but high lifetime risks for CHD, and they may help target high-risk patients for lifestyle modification or drug therapy.

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