Abstracts
of Articles Authored or Coauthored by Permanente Physicians
Selected by Daphne Plaut, MLS, Librarian, Center for Health Research
| to
pdf >>
From
Georgia
The
relationship of cardiovascular risk factors to microalbuminuria in older
adults with or without diabetes mellitus or hypertension: the cardiovascular
health study.
Barzilay
JI, Peterson D, Cushman M, et al. Am J Kidney Dis 2004 Jul;44(1):25-34.
background:
Microalbuminuria is a risk factor for coronary heart disease (CHD).
It occurs most commonly in the settings of diabetes and hypertension.
The mechanisms by which it increases CHD risk are uncertain.
methods:
We examined the cross-sectional association of microalbuminuria with
a broad range of CHD risk factors in three groups of adults aged 65
years or older with and without microalbuminuria: those with 1) no diabetes
or hypertension (n = 1098), 2) hypertension only (n = 1450), and 3)
diabetes with or without hypertension (n = 465).
results:
Three factors were related to microalbuminuria in all three groups:
age, elevated systolic blood pressure, and markers of systemic inflammation.
In patients with neither diabetes nor hypertension, increasing C-reactive
protein levels were associated with microalbuminuria (odds ratio per
1-mg/L increase, 1.46; 95% confidence interval [CI], 1.15 to 1.84).
Among those with diabetes, an increase in white blood cell (WBC) count
was associated with microalbuminuria (odds ratio per 1000-cell/mL increase,
2.57; 95% CI, 1.12 to 5.89). Among those with hypertension, an increase
in WBC count (odds ratio per 1000-cell/mL increase, 1.83; 95% CI, 1.04
to 3.23) and fibrinogen level (odds ratio per 10-mg/dL increase, 1.02;
95% CI, 1.00 to 1.05) were significantly associated with microalbuminuria.
In all three groups, prevalent CHD was related to an elevated WBC count.
In none of the three groups was brachial artery reactivity to ischemia,
an in vivo marker of endothelial function, related to microalbuminuria.
conclusion:
Microalbuminuria is associated with age, systolic blood pressure, and
markers of inflammation. These associations reflect potential mechanisms
by which microalbuminuria is related to CHD risk.
Reprinted
from the American Journal of Kidney Diseases, 44(1), Barzilay JI, Peterson
D, Cushman M, Heckbert SR, Cao JJ, Blaum C, Tracy RP, Klein R, Herrington
DM, The relationship of cardiovascular risk factors to microalbuminuria
in older adults with or without diabetes mellitus or hypertension: the
cardiovascular health study, 25-34, Copyright 2004, with permission
from the National Kidney Foundation.
|
clinical
implication: In this study, we show that coronary heart disease
(CHD) and microalbuminuria share three common factors--elevated
systolic blood pressure, advanced age, and the presence of increased
levels of inflammatory markers. These associations--whether in
the presence or absence of diabetes or hypertension--provide a
mechanism to explain why the exudation of a small amount of protein
in the urine is associated with an increased risk of CHD. JB
|
From
Southern California
The
relationship of asthma medication use to perinatal outcomes.
Schatz
M, Dombrowski MP, Wise R, et al. J Allergy Clin Immunol 2004 Jun;113(6):1040-5.
background:
Maternal asthma has been reported to increase the risk of preeclampsia,
preterm deliveries, and lower-birth-weight infants, but the mechanisms
of this effect are not defined.
objective:
We sought to evaluate the relationship between the use of contemporary
asthma medications and adverse perinatal outcomes.
methods:
Asthmatic patients were recruited from the 16 centers of the National
Institute of Child Health and Human Development Maternal Fetal Medicine
Units Network from December 1994 through February 2000. Gestational
medication use was determined on the basis of patient history at enrollment
and at monthly visits during pregnancy. Perinatal data were obtained
at postpartum chart reviews. Perinatal outcome variables included gestational
hypertension, preterm births, low-birth-weight infants, small-for-gestational-age
infants, and major malformations.
results:
The final cohort included 2123 asthmatic participants. No significant
relationships were found between the use of inhaled beta-agonists (n
= 1828), inhaled corticosteroids (n = 722), or theophylline (n = 273)
and adverse perinatal outcomes. After adjusting for demographic and
asthma severity covariates, oral corticosteroid use was significantly
associated with both preterm birth at less than 37 weeks' gestation
(odds ratio, 1.54; 95% CI, 1.02-2.33) and low birth weight of less than
2500 g (odds ratio, 1.80; 95% CI, 1.13-2.88).
conclusions:
Use of inhaled beta-agonists, inhaled steroids, and theophylline do
not appear to increase perinatal risks in pregnant asthmatic women.
The mechanism of the association between maternal oral corticosteroid
use and prematurity remains to be determined.
Reprinted
from the Journal of Allergy and Clinical Immunology, 113(6), Schatz
M, Dombrowski MP, Wise R, Momirova V, Landon M, Mabie W, Newman RB,
Hauth JC, Lindheimer M, Caritis SN, Leveno KJ, Meis P, Miodovnik M,
Wapner RJ, Paul RH, Varner MW, O'Sullivan MJ, Thurnau GR, Conway DL;
Maternal-Fetal Medicine Units Network, The National Institute of Child
Health and Development; The National Heart, Lung and Blood Institute,
1040-5, Copyright 2004, with permission from the American Academy of
Allergy, Asthma and Immunology.
From
Georgia
The association
of fasting glucose levels with congestive heart failure in diabetic
adults > or =65 years: the Cardiovascular Health Study.
Barzilay
JI, Kronmal RA, Gottdiener JS, et al. J Am Coll Cardiol 2004 Jun 16;43(12):2236-41.
objectives:
The purpose of this study was to determine if fasting glucose levels
are an independent risk factor for congestive heart failure (CHF) in
elderly individuals with diabetes mellitus (DM) with or without coronary
heart disease (CHD).
background:
Diabetes mellitus and CHF frequently coexist in the elderly. It is not
clear whether fasting glucose levels in the setting of DM are a risk
factor for incident CHF in the elderly.
methods:
A cohort of 829 diabetic participants, age > or = 65 years, without
prevalent CHF, was followed for five to eight years. The Cox proportional
hazards modeling was used to determine the risk of CHF by fasting glucose
levels. The cohort was categorized by the presence or absence of prevalent
CHD.
results:
For a one standard deviation (60.6 mg/dl) increase in fasting glucose,
the adjusted hazard ratios for incident CHF among participants without
CHD at baseline, with or without an incident myocardial infarction (MI)
or CHD event on follow-up, was 1.41 (95% confidence interval 1.24 to
1.61; p < 0.0001). Among those with prevalent CHD at baseline, with
or without another incident MI or CHD event on follow-up, the corresponding
adjusted hazard ratio was 1.27 (95% confidence interval 1.02 to 1.58;
p < 0.05).
conclusions:
Among older adults with DM, elevated fasting glucose levels are a risk
factor for incident CHF. The relationship of fasting glucose to CHF
differs somewhat by the presence or absence of prevalent CHD.
Reprinted
from the Journal of the American College of Cardiology, 43, Barzilay
JI, Kronmal RA, Gottdiener JS, Smith NL, Burke GL, Tracy R, Savage PJ,
Carlson M, The association of fasting glucose levels with congestive
heart failure in diabetic adults > or =65 years: the Cardiovascular
Health Study: 2236-41: Copyright 2004, with permission from the American
College of Cardiology Foundation.
|
clinical
implication: Diabetic patients have more than twice the burden
of heart failure (HF) as compared to nondiabetic individuals.
In this article we demonstrate that CHF risk in people with diabetes
has a strong association with glucose control. This is especially
so in the absence of coronary heart disease (ie, "diabetic
cardiomyopathy"). These findings offer one more reason that
the clinician should attempt tight glucose control in diabetic
patients. JB
|
From
Southern California
Irritable
bowel syndrome and surgery: a multivariable analysis.
Longstreth
GF, Yao JF. Gastroenterology 2004 Jun;126(7):1665-73.
background
and aims: Patients with irritable bowel syndrome (IBS) have high
surgical rates. We investigated the demographic and medical factors
independently associated with surgical histories of health examinees.
methods:
We applied multiple stepwise logistic regression analysis to self-completed
questionnaire data from 89,008 examinees, assessing six surgeries as
outcomes. We assessed questionnaire/physician record agreement of physician-diagnosed
IBS and surgical history on 201 randomly selected examinees with 3 years
of records.
results:
Questionnaire/record agreement for IBS and surgery was 83.6% (kappa
= 0.68) and 95.5%-100.0% (kappa = 0.82-1), respectively. IBS was reported
by 4587 examinees (5.2%) (1382 men [3.0%] and 3205 women [7.5%]). Subjects
with and without IBS, respectively, reported the following surgical
procedures: cholecystectomy, 569 (12.4%) versus 3428 (4.1%), p <
0.0001; appendectomy, 967 (21.1%) versus 9906 (11.7%), p < 0.0001;
hysterectomy, 1063 (33.2%) versus 6751 (17.0%), p < 0.0001; back
surgery, 201 (4.4%) versus 2436 (2.9%), p < 0.0001; coronary artery
surgery, 127 (2.8%) versus 2033 (2.4%), p > 0.05; peptic ulcer surgery,
22 (0.5%) versus 277 (0.3%), p > 0.05. Among independent surgery
associations, IBS was associated with cholecystectomy (adjusted odds
ratio [OR], 2.09; 95% confidence interval [CI], 1.89-2.31; p < 0.0001),
appendectomy (OR, 1.45; 95% CI, 1.33-1.56; p < 0.0001), hysterectomy
(OR, 1.70; 95% CI, 1.55-1.87;
p < 0.0001), and back surgery (OR, 1.22; 95% CI, 1.05-1.43; p = 0.0084).
conclusions:
Health examinees with physician-diagnosed IBS report rates of cholecystectomy
three-fold higher, appendectomy and hysterectomy two-fold higher, and
back surgery 50% higher than examinees without IBS; IBS is independently
associated with these surgical procedures.
Reprinted
from Gastroenterology, 126(7), Longstreth GF, Yao JF, Irritable bowel
syndrome and surgery: a multivariable analysis, 1665-73, Copyright 2004,
with permission from the American Gastroenterological Association.
|
clinical
implication: To minimize unnecessary abdominal surgery in
IBS patients, physicians should diagnose IBS unequivocally, explain
to patients that it can cause severe pain, and avoid unnecessary
tests. For example, gallstones are common (especially in women),
but biliary pain can usually be distinguished from bloating, fatty
food intolerance and other types of dyspepsia that are common
in IBS patients but not of biliary origin. By limiting gallbladder
sonography to patients with biliary-type pain, asymptomatic gallstones
will remain undiscovered and untreated by mistaken surgery. "Chronic
pelvic pain" is often due to IBS, whether or not gynecological
pathology is present, and collaboration of gynecologists with
other physicians can reduce unnecessary hysterectomy. GL
|
From
The Northwest
An
evaluation of one-on-one advanced proficiency training in clinicians'
use of computer information systems.
Kirshner
M, Salomon H, Chin H. Int J Med Inform 2004 May;73(4):341-8.
objective:
We examined the effectiveness of a one-on-one training strategy for
advanced proficiency in computer information systems (CIS) by clinicians
in a large health maintenance organization (HMO). Specifically, this
study assessed the level of self-reported improvement in CIS efficiency
following one-on-one training, and assessed the perceived value of one-on-one
training compared to other teaching methods.
design:
We performed a cross-sectional study using a paper-based survey of 129
clinicians practicing in the HMO.
measurements:
We used a multi-item satisfaction index to measure clinician satisfaction
with the one-on-one training. We measured whether clinicians thought
they were more efficient using the system after training.
results:
The one-on-one method was significantly preferred over other teaching
methods. Compared to other CIS components, use of the electronic medical
record (EMR) improved most following one-on-one training. Sixty-one
percent of the clinicians reported major improvements (ie, >3 on
a 5-point Likert scale; 5 being the highest score) in using the EMR.
conclusion:
Perceived effectiveness of one-on-one training and overall satisfaction
were ranked high by clinicians. The findings support the assumption
that clinicians value one-on-one training and value this training method
above other methods.
Reprinted
from International Journal of Medical Informatics, 73(4), Kirshner M,
Salomon H, Chin H, An evaluation of one-on-one advanced proficiency
training in clinicians' use of computer information systems, 341-38,
Copyright 2004, with permission from Elsevier.
|
clinical
implication: Becoming proficient in use of clinical information
systems (CIS), such as Hyperspace, requires training and practice.
When compared to small groups, classrooms, and e-learning, one-on-one
personalized training is favored by most primary care providers
studied. Clinicians reported improved satisfaction, effectiveness,
and efficiency with CIS following one-on-one training. Offering
multiple venues, however, may be necessary to provide appropriate
opportunities for individual learning styles and the apparent
benefits must be weighed against associated time and financial
costs. Despite these limitations, one-on-one CIS training is viewed
as providing high value to Permanente clinicians. MK
|
From
Northern California
Smoking,
coffee, and pancreatitis.
Morton
C, Klatsky AL, Udaltsova N. Am J Gastroenterol 2004 Apr;99(4):731-8.
objectives:
We studied relationships of cigarette smoking and coffee drinking to
risk of pancreatitis.
methods:
This was a cohort study among 129,000 prepaid health plan members who
supplied data about demographics and habits in 1978-85. Among 439 persons
subsequently hospitalized for pancreatitis, probable etiologic associations
were cholelithiasis (168/439 = 38%), alcohol (125/439 = 29%), idiopathic
(110/430 = 25%), and miscellaneous (36/439 = 8%). Cox proportional hazards
models with seven covariates (including alcohol intake) yielded relative
risk estimates for smoking and coffee use.
results:
Increasing smoking was strongly related to increased risk of alcohol-associated
pancreatitis, less related to idiopathic pancreatitis, and unrelated
to gallstone-associated pancreatitis. Relative risks (95% confidence
intervals, CI) of one pack per day (vs never) smokers for pancreatitis
groups were: alcohol = 4.9 (2.2-11.2, p < 0.001), idiopathic = 3.1
(1.4-7.2, p < 0.01), and gallstone = 1.3 (0.6-3.1). The relationship
of smoking to alcohol-associated pancreatitis was consistent in sex
and race subsets. Drinking coffee, but not tea, was weakly inversely
related to risk only of alcohol-associated pancreatitis, with relative
risk (95% CI) per cup per day = 0.85 (0.77-0.95; p = 0.003). Male sex,
black ethnicity, and lower-educational attainment were other predictors
of alcohol-associated pancreatitis.
conclusions: Cigarette smoking is an independent risk factor for
alcohol-associated and idiopathic pancreatitis. Coffee drinking is associated
with reduced risk of alcohol-associated pancreatitis. The data are compatible
with the hypotheses that smoking may be toxic to the pancreas or may
potentiate other pancreatic toxins while some ingredient in coffee may
have a modulating effect.
Reprinted
from the American Journal of Gastroenterology with permission from Blackwell
Publishing, Ltd.
|
clinical
implication: Since these data strongly suggest that cigarette
smoking promotes or causes pancreatitis, they mandate that especially
strong advice to stop smoking be given to persons at risk of pancreatitis
or recurrence of the condition. On the other hand, there is no
reason to prohibit or discourage coffee drinking among such persons,
in view of the apparent protective role of coffee drinking. --CM
|
To
abstracts contents list >>
