CHICAGO—Having an electron beam tomography scan performed to detect evidence of coronary disease is not associated with an improvement in modifiable cardiovascular risk one year later, according to an article in the May 7 issue of The Journal of the American Medical Association (JAMA).

Evidence exists that cardiovascular risk screening-and its feedback-has mild but non-sustained beneficial effects on serum cholesterol levels, diet, and predicted risk, according to background information in the article. However, concerns also exist that such interventions may have adverse consequences, such as the effects of disease labeling on quality of life.

Electron beam tomography (EBT) is a specialized scan of the heart and blood vessels to detect calcium deposits in the coronary arteries. This new technology is being used for the detection of subclinical coronary artery disease and been validated as a tool to predict cardiovascular risk, although its incremental value is controversial. a# Although the use of EBT as a motivational tool to change behavior is practiced, its efficacy has not been studied.

Patrick G. O'Malley, M.D., M.P.H., of Walter Reed Army Medical Center, Washington, D.C., and colleagues conducted a randomized controlled trial to test the added effect of anatomically based coronary heart disease detection with EBT compared with conventional risk prediction alone in the context of either intensive risk factor modification or usual care. The researchers hypothesized that showing patients a picture of their coronary artery anatomy with EBT, whether with or without evidence of underlying coronary calcification, would generally enhance motivation to modify risk factors to reduce risk of developing clinical coronary heart disease.

The study included 450 asymptomatic active-duty U.S. Army personnel aged 39 to 45 years stationed within the Washington, D.C., area and scheduled to undergo a periodic Army-mandated physical examination. They were enrolled between January 1999 and March 2001(average age, 42 years; 79 percent male; 15 percent had coronary calcification; average predicted 10-year coronary risk, 5.85 percent). Patients were randomly assigned to 1 of 4 intervention arms: EBT results provided in the setting of either intensive case management (ICM) (n = 111) or usual care (n = 119) or EBT results withheld in the setting of either ICM (n = 124) or usual care (n = 96). There was 1 year of follow-up. The primary outcome measure was change in a composite measure of risk, the 10-year Framingham Risk Score (FRS).

"Comparing the groups who received EBT results with those who did not, the mean absolute risk change in 10-year FRS was +0.30 vs. +0.36. Comparing the groups who received ICM with those who received usual care, the mean absolute risk change in 10-year FRS was ?-0.06 vs. +0.74," the authors write. "In multivariable analyses predicting change in FRS, after controlling for knowledge of coronary calcification, motivation for change, and multiple psychological variables, only the number of risk factors and receipt of ICM were associated with improved or stabilized projected risk."

"Our findings show that in an asymptomatic population at an appropriate age for cardiovascular risk screening, the addition of anatomically based subclinical coronary disease diagnosis using EBT does not substantially affect coronary risk profile. We measured change in modifiable behaviors at 1 year, a reasonable period after attempting to activate a patient to change lifestyle. We also found that this lack of effect was not modified by the setting in which the information was given (ICM of risk factors or usual care)," the researchers write.

CHICAGO—The amount of blood donated in the week following the September 11 terrorist attacks was about 2.5 times greater than normal, without a substantial increase in the risk of transfusion-transmissible viral infections, according to an article in the May 7 issue of The Journal of the American Medical Association (JAMA).

According to background information in the article, better understanding of characteristics of blood donors who donate in times of crisis may help predict long-term impact on blood supply safety and future donor return patterns.

Simone A. Glynn, M.D., M.Sc., M.P.H., of Westat, Rockville, Md., and colleagues conducted a study to characterize the volume of donations and prevalence of infectious disease markers in blood donated by U.S. donors responding to the September 11, 2001, attacks, and to evaluate return rates in those who donated for the first time. Data were gathered by investigators in the National Heart, Lung, and Blood Institute Retrovirus Epidemiology Donor Study for the 4 weeks before and the 4 weeks starting with September 11, 2001, and the corresponding 8-week period in 2000. The study included 327,065 volunteer blood donors making 373,628 blood donations at 5 large regional U.S. blood centers.

The authors found: "Approximately 20,000 [blood] donations were collected weekly in the four weeks preceding September 11, whereas about 49,000 (2.5-fold increase) and approximately 26,000 to 28,000 (1.3-fold to 1.4-fold increases) donations were made per week in the first and in the second through fourth weeks starting with September 11, respectively. All demographic groups donated more than usual after the attacks, and after adjusting for seasonal and annual variation there was a 5.2-fold increase in the number of first-time donations vs. a 1.5-fold increase in the number of repeat donations made in the first week starting on September 11 vs. the 4 weeks before," they write. "First-time donor 12-month return rates for 2000 and 2001 were similar, about 28 percent for donors in the first week starting with September 11 (or September 12, 2000) and 30 percent for the second to fourth weeks."

The researchers add that the absolute risk of transfusion-transmissible viral infections did not increase substantially.

"The dramatic increase in first-time donations after a national disaster and subsequent relatively low return rates warrant further consideration," they write. "It is clear that a large population of eligible donors can be mobilized after a national disaster and that, in the United States, most eligible people do not regularly donate."

CHICAGO—The incidence rate for mild to moderately severe sleep-disordered breathing, such as sleep apnea, is approximately 16 percent over five years, according to an article in the May 7 issue of The Journal of the American Medical Association (JAMA).

Sleep disordered breathing (SDB) is a prevalent condition that is associated with serious chronic illness, according to background information in the article. The incidence of SDB and the effect of risk factors on this incidence are unknown. Peter V. Tishler, M.D., of Brigham and Women's Hospital and Harvard Medical School, Boston, and colleagues conducted a study to determine the 5-year incidence of SDB overall and the risk factors.

The study included participants in the Cleveland Family Study, those aged 18 years or older, from either case or control families, who had 2 in-home sleep studies 5 years apart. The first had to be performed before June 30, 1997, and had to have normal results. Data included questionnaire information on medical and family history, SDB symptoms; measurement of height, weight, blood pressure, waist and hip circumference, and serum cholesterol concentration; and overnight sleep monitoring.

The researchers measured results using the apnea hypopnea index (AHI). It was defined as the number of apnea episodes (frequent stoppage or disruption of breathing during sleep) and hypopnea episodes (breathing that is shallower, and/or slower, than normal) per hour of sleep. Sleep-disordered breathing was defined by an AHI of at least 10 (mild to moderate) or of at least 15 (moderate).

"Forty-seven (16 percent) of 286 eligible participants had a second-study AHI of at least 10 and 29 (10 percent) participants had a second-study AHI result of at least 15. For the AHI results of at least 15, we estimate that about 2.5 percent may represent test variability," the authors write. "By ordinal logistic regression analysis, AHI was significantly associated with age [79 percent increased risk per 10-year increase], body mass index [BMI, 14 percent increased risk per unit increase], sex [four times the risk for men vs. women], waist-hip ratio [61 percent increased risk per 0.1 unit increase], and serum cholesterol concentration [11 percent increased risk per 10 mg/dL (0.25 mmol/L) increase]."

The authors add that the predominance in men diminishes with increasing age, and by age 50 years, incidence rates among men and women are similar. The effect of BMI also decreases with age and may be negligible at age 60 years.

CHICAGO—Patients enrolled in Medicare managed care programs had consistently higher rates of hospice use and significantly longer hospice stays than those enrolled in Medicare fee-for-service (FFS) plans, according to a new study in the May 7 issue of The Journal of the American Medical Association (JAMA).

Ellen P. McCarthy, Ph.D., M.P.H., from Harvard Medical School, Boston, and colleagues analyzed data from 260,090 Medicare patients aged 66 years or older diagnosed with eight types of cancer (lung, colorectal, prostate, female breast, bladder, pancreatic, gastric and liver) between January 1, 1973 and December 31, 1996 and who died between January 1, 1988 and December 31, 1998. The researchers evaluated the time from diagnosis to hospice entry and hospice length of stay for patients enrolled in FFS versus managed care plans.

In background information the authors write, "Cancer is a common cause of morbidity and mortality among men and women aged 65 years or older. For patients with many types of cancer, effective treatment exists but for others palliative therapies may remain the only option when treatment fails." The authors state that hospice has become a standard of care for patients with life-threatening illnesses. "Hospice care has been shown to improve symptom management and quality of life for patients at the end of life. Hospice patients are more likely to die at home and are generally more satisfied with their care."

In this study, McCarthy et al found that only 21 percent (54,937) of the 260,090 patients received hospice care before death. "Hospice use varied by type of primary cancer ranging from 31.8 percent of patients with pancreatic cancer to 15.6 percent with bladder cancer. Managed care patients were more likely to use hospice than FFS patients (32.4 percent vs. 19.8 percent). Among hospice patients, median length of stay was longer for managed care vs. FFS patients (32 days vs. 25 days)."

"We found that patients with managed care insurance were less likely to enroll in hospice care within 7 days of death and more likely to be enrolled in hospice for 2 or more months before death than patients with FFS insurance. These findings suggest that patients with managed care insurance have a greater opportunity to benefit from hospice care," the authors write.

NEW STUDY IDENTIFIES RISK FACTORS AND LIKELIHOOD OF DEVELOPING SLEEP APNEA