Abstracts
of Articles Authored
or Coauthored by Permanente Clinicians
Selected
by Louise Williams, PhD, Center for Health Research
From
the Northwest and Hawaii:
Nulliparity
and fracture risk in older women: the study of osteoporotic fractures
Hillier TA, Rizzo JH, Pedula KL, et al. J Bone Miner Res 2003 May;18(5):893-9.
Whether
nulliparity increases fracture risk is unclear from prior studies, which
are limited by small samples or lack of measured bone mineral density.
No study has evaluated whether the effect of parity differs by skeletal
site. We prospectively analyzed the relationship of parity to the risk
of incident nontraumatic hip, spine, and wrist fractures in 9704 women
aged 65 years or older participating in the Study of Osteoporotic Fractures
to determine if parity reduces postmenopausal fracture risk, and if
so, if this risk reduction is 1) greater at weight-bearing skeletal
sites and 2) independent of bone mineral density. Parity was ascertained
by self-report. Incident hip and wrist fractures were determined by
physician adjudication of radiology reports (mean follow-up, 9.8 years)
and spine fractures by morphometric criteria on serial radiographs.
The relationship of parity to hip and wrist fracture was assessed by
proportional hazards models. Spine fracture risk was evaluated by logistic
regression. Compared with parous women, nulliparous women (n = 1835,
19%) had an increased risk of hip and spine, but not wrist, fractures.
In multivariate models, parity remained a significant predictor only
for hip fracture. Nulliparous women had a 44% increased risk of hip
fractures independent of hip bone mineral density (hazards ratio, 1.44;
95% CI, 1.17-1.78). Among parous women, each additional birth reduced
hip fracture risk by 9% (p = 0.03). Additionally, there were no differences
in mean total hip, spine, or radial bone mineral density values between
nulliparous and parous women after multivariate adjustment. In conclusion,
childbearing reduces hip fracture risk by means that may be independent
of hip bone mineral density.
Reproduced
from J Bone Miner Res 2003;18:893-9 with permission of the American
Society for Bone and Mineral Research.
From
Southern California:
Design
and evaluation of interventions promoting periconceptional multivitamin
use
Lawrence JM, Watkins ML, Ershoff D, et al. Am J Prev Med 2003 Jul;25(1):17-24.
background:
Periconceptional folic acid use reduces the risk of neural tube defects
and possibly other birth defects. The effectiveness of two interventions
to increase the use of multivitamins among women of childbearing ages
was evaluated.
methods:
Quasi-experimental interrupted time series design with a nonequivalent
control group. Participants included female members of Kaiser Foundation
Health Plan aged 18 to 39 years residing in the three geographic service
areas of California under study from 1998 through 2000. The central
component of the direct mail/pharmacy information intervention was the
mailing of "starter kits" of 100 multivitamins, while the
provider education intervention used primary care providers to deliver
the study message. Main outcomes included the use of multivitamins containing
folic acid at least four times per week ("regularly"), intention
to use multivitamins regularly, and knowledge and attitudes about multivitamins.
Outcomes were measured via telephone interviews of nonpregnant women
of childbearing age.
results:
A total of 3438 women were interviewed. There was a small but significant
increase in the percentage of women using multivitamins in the direct
mail/pharmacy information intervention group at the beginning of the
intervention period (p = 0.006), but this increase was not sustained
after the interventions ended. No other significant change was observed.
conclusions:
Despite our ability to reach many women of childbearing age with multiple
messages about regularly using multivitamins, only a small temporary
increase was found in the percentage of women using multivitamins who
received the messages in the mail. Other interventions and further evaluation
of the impact of food fortification with folic acid should be considered.
Reprinted
from The American Journal of Preventive Medicine, Volume 25, Lawrence
JM, Watkins ML, Ershoff D, Petitti DB, Chiu V, Postlethwaite D, Erickson
JD, Design and evaluation of interventions promoting periconceptional
multivitamin use, p 17-24, Copyright 2003, with permission from The
American Journal of Preventive Medicine.
clinical
implication: Although approximately 75% of neural tube defects
(NTDs) are preventable by consuming 400 mcg of folic acid (FA) daily
during the periconceptional period, the proportion of childbearing-age
women taking these vitamins has increased only slightly in the past
ten years. Our direct mail campaign was only marginally successful
in increasing the proportion of women using multivitamins and education
by physicians and other health care providers showed no effect. However,
our postimplementation survey showed that only a small proportion
of providers implemented the educational intervention in the context
of their clinical visits. Women of childbearing age should be encouraged
to take a vitamin containing FA every day and to consume foods rich
in FA, including foods fortified with FA (cereals, pasta, bread, etc).
--JL
From
the Northwest:
Fetal
fibronectin: the impact of a rapid test on the treatment of women with
preterm labor symptoms
Plaut MM, Smith W, Kennedy K. Am J Obstet Gynecol 2003 Jun;188(6):1588-93;
discussion 1593-5.
objective:
The purpose of this study was to determine whether knowledge of the
results of a rapid fetal fibronectin test affects treatment decisions
during the evaluation and treatment of possible preterm labor. Previous
observational studies have suggested that a negative test might help
to avoid unnecessary intervention.
study
design: This was a randomized study of women who were between 24
weeks and 34 weeks six days of gestation with symptoms of preterm labor
and who were seen in three community hospitals. A rapid fetal fibronectin
test was performed on all subjects. Patients were assigned randomly
to a group whose results were known to physician or to a group whose
results were not known. Treatment decisions were at the discretion of
the physician.
results:
One hundred eight samples were collected between September 2000 and
December 2001. There were ten positive fetal fibronectin tests. The
overall prevalence of delivery within two weeks for the study population
was 2.8%. For women who had negative fetal fibronectin test results,
the hospital stay was not significantly shorter when the result was
known (6.8 hours) than when it was not known (8.1 hours, p = .35). However,
when the physician knew the fetal fibronectin status of women with a
negative test result who were observed for >6 hours, the hospital
stay was shortened 40%, to 22.7 hours from 37.8 hours (p = .04).
conclusion:
Fetal fibronectin testing may be able to supplement clinical judgment
in the evaluation of the condition of patients with symptoms of preterm
labor. The greatest benefit of fetal fibronectin testing might be for
the patient whom the physician judges to be at high risk for imminent
delivery. In such patients, the knowledge of a negative fetal fibronectin
may shorten the hospital stay.
Reprinted
from the American Journal of Obstetrics and Gynecology, Volume 188,
Plaut MM, Smith W, Kennedy K, Fetal fibronectin: the impact of a rapid
test on the treatment of women with preterm labor symptoms, p1588-93,
Copyright 2003, with permission from Elsevier.
clinical
implication: Fetal fibronectin testing cannot definitely determine
whether a patient with preterm labor symptoms will deliver within
the next one to two weeks, but the possibility is moderately increased
by a positive test. Prior studies showing a very low likelihood (<2%)
of imminent delivery in patients with a negative test were biased
by the already low prevalence of imminent delivery in those populations
(3%-4%). Our study suggests that testing is probably not needed in
most patients presenting with symptoms of preterm labor. For the subgroup
of patients whom we now treat aggressively, testing might be helpful
in shortening hospital stays. --MP
From
Colorado:
Femoral
endarteritis associated with percutaneous suture closure: new technology,
challenging complications
Whitton Hollis H Jr, Rehring TF. J Vasc Surg 2003 Jul;38(1):83-7.
objective:
Use of percutaneous suture closure devices after catheter-based interventions
is increasing. We recently have seen several severe femoral arterial
wall infections after use of such devices. The purpose of this study
was to examine the incidence, comorbid associations, and management
of femoral arterial infections associated with percutaneous suture closure
devices.
methods:
We retrospectively reviewed all infectious complications that occurred
after 2223 consecutive cardiac catheterization procedures performed
over 12 months in a university-affiliated community teaching hospital.
Outcome variables included demographics, procedural details, infection,
type of arterial reconstruction required, mortality, and limb loss.
results:
During this study, 822 patients received percutaneous suture devices.
Infection developed in six patients (0.7%). The incidence of diabetes
in the population undergoing percutaneous suture closure was 219 of
822 patients (26.6%). Three comorbid conditions, noted in multiple patients
with infectious complications, included diabetes mellitus, obesity,
and placement of a percutaneous suture closure device within the past
six months. Invasive femoral endarteritis developed in four patients.
Gram-positive cocci predominated in four patients. In one patient with
polymicrobial infection catastrophic complications developed, including
multiple anastomotic ruptures and hemorrhage. A new method of repair
that incorporated double-thickness everted saphenous vein was used in
two patients, and safe arterial closure was achieved. There was one
late fatality on postoperative day 36. Limb salvage was achieved in
all patients.
conclusions:
Femoral endarteritis complicating percutaneous suture closure is a challenging
new problem for vascular surgeons and can result in catastrophic complications.
Customary techniques that use saphenous vein patch or interposition
grafting are not adequate in all circumstances. Successful outcome requires
operative exploration in patients with suspected infection. Removal
of the percutaneous suture closure device and debridement to normal
arterial wall is recommended in all patients with suspected femoral
endarteritis, based on positive intraoperative Gram stains or abnormal
appearance of the adjacent femoral artery. Early success with an autologous
bolstered repair is reported. Caution is advised when considering the
use of a percutaneous suture closure device in patients with comorbid
conditions including diabetes, obesity, and previously implanted devices.
Reprinted
from Journal of Vascular Surgery, Volume 38, Copyright 2003, Whitton
Hollis H Jr, Rehring TF, Femoral endarteritis associated with percutaneous
suture closure: new technology, challenging complications, p 83-7, with
permission from The Society for Vascular Surgery and the American Association
for Vascular Surgery.
From
Northern California:
Use
of antibiotics is not associated with decreased risk of myocardial infarction
among patients with diabetes
Karter AJ, Thom DH, Liu J, Moffet HH, Ferrara A, Selby JV. Diabetes
Care 2003 Jul;26(7):2100-6.
objective:
To study the relationship between exposure to antibiotic treatment and
risk of subsequent myocardial infarction (MI) in patients with diabetes.
research
and design methods: A case-control design was used to assess the
effect of previous antibiotic exposure in diabetes patients with acute,
nonfatal or fatal MI (case subjects) and individually matched control
subjects (four control subjects to one case subject, matched on sex,
age, and index date). Subjects were sampled from the Northern California
Kaiser Permanente Diabetes Registry, a well-characterized, ethnically
diverse diabetic population from Kaiser Permanente Medical Care Program,
Northern California Region. MI events were ascertained during a two-year
observation period (1998-1999). Separate conditional logistic regression
models were specified to assess antibiotic exposure history (cephalosporins
only, penicillins only, macrolides only, quinolones only, sulfonamides
only, tetracyclines only, as well as more than one, any, or no antibiotic)
for three nested windows before the index date (0-6 months, 0-12 months,
0-24 months), facilitating assessment of whether the potential effect
was dependent on the timing of the exposure.
results:
A total of 1401 MI case subjects were observed. Odds ratios were calculated
in models adjusted for age, sex, race, education attainment, time since
diabetes diagnosis, diabetes type and treatment, use of diet and exercise,
total cholesterol, HDL cholesterol, triglyceride levels, hypertension,
elevated urinary albumin excretion, serum creatinine, BMI, and smoking.
We found no evidence of a protective effect of any of these therapeutic
classes of antibiotics during any of the three time frames.
conclusions:
Our study does not support the hypothesis that use of antibiotics has
a protective effect for prevention of coronary heart disease in diabetic
patients.
Copyright
© 2003 American Diabetes Association. From Diabetes Care, V 26,
2003;2100-6. Reprinted with permission from The American Diabetes Association.
clinical
implication: Some studies suggest potential benefit of antibiotic
use for CHD, but this has not been investigated among diabetics. This
case-control study assessed the effect of previous antibiotic exposure
among 1401 diabetics with acute, non-fatal or fatal myocardial infarction,
with four individually age-sex-matched controls for each case. After
adjusting for age, sex, race, and 11 other factors, we found no evidence
of a protective effect of any therapeutic antibiotic class during
any of three time frames. Our study does not support the hypothesis
that use of antibiotics reduces CHD risk in diabetic patients. --AK
From
Northern California:
Psychiatric
symptoms, impaired function, and medical care costs in an HMO setting
Hunkeler EM, Spector WD, Fireman B, Rice DP, Weisner C. Gen Hosp
Psychiatry 2003 May-Jun;25(3):178-84.
More information
is needed regarding the medical care utilization and costs of individuals
who report depressed mood, persistent anxiety, brief anxiety, panic,
and trouble controlling violent behavior. We present findings from a
one-year prospective follow-up study of a stratified random sample of
adult HMO enrollees (n = 10,377) originally interviewed by telephone.
A strong association was observed between these psychiatric symptoms,
associated impaired function, and general medical care costs during
the year following the interview. After controlling for age, gender,
race, medical conditions, and smoking, the mean costs of general medical
care were $1948 for respondents who reported none of the psychiatric
symptoms or impaired function: $3006 for respondents with all five symptoms
but no impaired function; and $3906 for those with all five symptoms
and pervasive functional impairment. Persistent anxiety and depressed
mood had the greatest impact on total general medical costs, while impaired
function was associated with increased likelihood of hospital admission
and emergency room use. We conclude that depressed mood, persistent
anxiety, and related impaired function are associated with substantial
increases in the use and cost of general medical care.
Reprinted
from General Hospital Psychiatry, Volume 25, Hunkeler EM, Spector WD,
Fireman B, Rice DP, Weisner C, Psychiatric symptoms, impaired function,
and medical care costs in an HMO setting, p 178-84, Copyright 2003,
with permission from Elsevier.
