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Permanente
Abstracts
Abstracts of Articles Authored or Coauthored by Permanente Clinicians
Selected by Daphne Plaut, MLS, Librarian, Center for Health Research
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From
Colorado:
Effectiveness of the 2003-2004 influenza vaccine among children six
months to eight years of age, with 1 vs 2 doses.
Ritzwoller
DP, Bridges CB, Shetterly S, Yamasaki K, Kolczak M, France EK. Pediatrics
2005 Jul;116(1):153-9.
objective:
To evaluate the effectiveness of one and two doses of the 2003-2004
influenza vaccine in preventing medically attended influenza-like
illness (ILI) among children six to 23 months and six months to eight
years of age.
design
and methods: Outpatient and Emergency Department visits and immunization
records were used to conduct a retrospective cohort study among children
six months to eight years of age. ILI and pneumonia and influenza
(P&I) outcomes were defined on the basis of International Classification
of Diseases, Ninth Revision, codes. Influenza vaccine effectiveness
(VE) was calculated as (1 - hazard rate ratio) x 100.
results:
A total of 29,726 children were included in the analyses; 17.3% were
6 to 23 months of age. By November 19, 2003, the start of peak influenza
activity, 7.5% and 9.9% of children six months to eight years were
fully or partially vaccinated against influenza, respectively. For
fully vaccinated children six to 23 months of age, VE against ILI
and P&I was 25% and 49%, respectively. No statistically significant
reduction in ILI or P&I rates was observed for partially vaccinated
children six to 23 months of age (-3% and 22%, respectively). For
fully vaccinated children six months to eight years of age, VE against
ILI and P&I was 23% and 51%, respectively. For partial vaccination,
VE was significant only for P&I (23%).
conclusions:
Despite a suboptimal match between the influenza vaccine and predominant
circulating strains, influenza vaccination provided substantial protection
for fully vaccinated children and possibly some protection for partially
vaccinated children <9 years of age. These findings support vaccinating
targeted children even when the vaccine match is suboptimal, and they
highlight the need to vaccinate previously unvaccinated children with
two doses for optimal protection.
Reproduced
with permission from Pediatrics, Vol. 116(1), Page(s) 153-9, Copyright
2005 by the AAP.
clinical
implication: Minimal literature exists associated with the effectiveness
of the influenza vaccine in very young children, especially during
a year when the vaccine match is suboptimal. Our study demonstrated
that the influenza vaccine was effective in children, especially
those six months to 23 months of age. We demonstrated how important
a double dose of the shot is for children from six months to 23
months of age and how important it is to vaccinate previously unvaccinated
children with two doses for optimal protection. As a result of this
research, parents now should plan to schedule their children's first
flu shots four weeks apart. --DR
From
Southern California:
Shoulder
dystocia: are historic risk factors reliable predictors?
Ouzounian
JG, Gherman RB. Am J Obstet Gynecol 2005 Jun;192(6):1933-5; discussion
1935-8.
objective:
Our purpose was to determine the rate of associated risk factors for
shoulder dystocia from a large cohort of patients delivered within
our Southern California perinatal program.
study
design: A retrospective analysis was performed of patients delivered
from January 1991 to June 2001. Patients with and without shoulder
dystocia were identified from our computer-stored perinatal database
and compared. Statistical methods used included: c2 test,
t test, calculation of odds ratios, and Fisher exact test, as indicated.
results:
Among the 267,228 vaginal births during the study period, there were
1686 cases of shoulder dystocia (rate 0.6%). Rates for operative vaginal
delivery, diabetes, epidural use, multiparity, and postdatism were
similar among cases with and without shoulder dystocia. The clinical
triad of oxytocin use, labor induction, and birth weight greater than
4500 g yielded a cumulative odds ratio of 23.2 (95% CI 17.3-31.0)
for shoulder dystocia, but its sensitivity and positive predictive
value were only 12.4% and 3.4%, respectively.
conclusion:
Historic obstetric risk factors for shoulder dystocia are not useful
predictors for the event. Furthermore, although shoulder dystocia
was observed more frequently with increasing birth weight, current
limitations in estimating birth weight antenatally with accuracy preclude
its practical use as a reliable predictor.
Reprinted
from the American Journal of Obstetrics and Gynecology, 192(6), Ouzounian
JG, Gherman RB, Shoulder dystocia: are historic risk factors reliable
predictors?, 1933-5; discussion 1935-8 Copyright 2005, with permission
from Elsevier.
clinical
implication: The occurrence of shoulder dystocia historically
has been described in conjunction with various risk factors (maternal
diabetes, epidural use, operative vaginal delivery, macrosomia, etc).
Our study demonstrates that these risk factors have a very poor predictive
value for shoulder dystocia. While increasing birth weight was associated
with increasing rates of shoulder dystocia, our limited ability in
predicting true birthweight accurately limits its practical use in
planning route of delivery. JO
From
Colorado and Ohio:
Effect
of a centralized clinical pharmacy anticoagulation service on the
outcomes of anticoagulation therapy.
Witt
DM, Sadler MA, Shanahan RL, Mazzoli G, Tillman DJ. Chest 2005 May;127(5):1515-22.
context:
A growing body of reports has documented the ability of anticoagulation
management services to help patients receiving warfarin therapy achieve
better outcomes compared to the care provided by their personal physicians
(ie, usual care).
objective: To compare clinical outcomes associated with anticoagulation
therapy provided by a clinical pharmacy anticoagulation service (CPAS)
to usual care.
design: Retrospective, observational cohort study, six months
in duration.
setting: Large nonprofit, group-model health maintenance organization.
patients: A total of 6645 patients receiving warfarin therapy
were included in the final analyses (intervention group, 3323 patients;
control group, 3322 patients).
intervention: Anticoagulation therapy for patients in the intervention
group was managed by a centralized, telephonic CPAS. Therapy for patients
in the control group was managed in the usual manner by their personal
physicians.
main outcome measures: The primary outcome was the occurrence
of anticoagulation therapy-related complications. A secondary outcome
was the proportion of time spent in the target international normalized
ratio (INR) range for each patient. Cox proportional hazards regression
analyses were used to examine the risk of complications in relation
to the study group.
results: Patients in the CPAS were 39% less likely to experience
an anticoagulation therapy-related complication than were patients
in the control group (hazard ratio, 0.61; 95% confidence interval,
0.42 to 0.88). The number of patients needed to treat to prevent an
anticoagulation therapy complication was 52. Additional analyses revealed
that improved outcomes associated with CPAS were mediated largely
through improved therapeutic INR control. Patients in the CPAS group
spent 63.5% of study period days within their target INR range compared
to 55.2% in the control group (p < 0.001).
conclusions: A centralized, telephonic, pharmacist-managed anticoagulation
monitoring service reduced the risk of anticoagulation therapy-related
complications compared to that with usual care. The cumulative evidence
supporting the superior care associated with implementing a pharmacist-managed
anticoagulation monitoring service was sufficient to recommend widespread
implementation.
From
Northern California:
Obesity
in middle age and future risk of dementia: a 27-year longitudinal
population-based study.
Whitmer
RA, Gunderson EP, Barrett-Connor E, Quesenberry CP Jr, Yaffe K. BMJ
2005 Jun 11;330(7504):1360. Epub 2005 Apr 29.
objective:
To evaluate any association between obesity in middle age, measured
by body mass index and skinfold thickness, and risk of dementia later
in life.
design: Analysis of prospective data from a multiethnic population
based cohort.
setting: Kaiser Permanente Northern California Medical Group,
a health care delivery organization.
participants: Ten thousand two hundred seventy-six men and women
who underwent detailed health evaluations from 1964 to 1973 when they
were aged 40-45 and who were still members of the health plan in 1994.
main outcome measures: Diagnosis of dementia from January 1994
to April 2003. Time to diagnosis was analyzed with Cox proportional
hazard models adjusted for age, sex, race, education, smoking, alcohol
use, marital status, diabetes, hypertension, hyperlipidaemia, stroke,
and ischaemic heart disease.
results: Dementia was diagnosed in 713 (6.9%) participants. Obese
people (body mass index 30) had a 74% increased risk of dementia (hazard
ratio 1.74, 95% confidence interval 1.34 to 2.26), while overweight
people (body mass index 25.0-29.9) had a 35% greater risk of dementia
(1.35, 1.14 to 1.60) compared with those of normal weight (body mass
index 18.6-24.9). Compared with those in the lowest fifth, men and
women in the highest fifth of the distribution of subscapular or tricep
skinfold thickness had a 72% and 59% greater risk of dementia, respectively
(1.72, 1.36 to 2.18, and 1.59, 1.24 to 2.04).
conclusions: Obesity in middle age increases the risk of future
dementia independently of comorbid conditions.
Reprinted from British Medical Journal, 2005, 330(7504), 1360, with
permission from the BMJ Publishing Group.
From
Southern California:
Short-term
and long-term asthma control in patients with mild persistent asthma
receiving montelukast or fluticasone: a randomized controlled trial.
Zeiger
RS, Bird SR, Kaplan MS, et al. Am J Med 2005 Jun;118(6):649-57.
purpose:
To determine whether montelukast is as effective as fluticasone in
controlling mild persistent asthma as determined by rescue-free days.
subjects and methods: Participants aged 15 to 85 years with mild
persistent asthma (n = 400) were randomized to oral montelukast (10
mg once nightly) or inhaled fluticasone (88 mug twice daily) in a
year-long, parallel-group, multicenter study with a 12-week, double-blind
period, followed by a 36-week, open-label period.
results: The mean percentage of rescue-free days was similar between
treatments after 12 weeks (fluticasone: 74.9%, montelukast: 73.1%;
difference = 1.8%, 95% confidence interval [CI]: -3.2% to 6.8%) but
not during the open-label period (fluticasone: 77.3%, montelukast:
71.1%; difference = 6.2%, 95% CI: 0.8% to 11.7%). Although both fluticasone
and montelukast significantly improved symptoms, quality of life,
and symptom-free days during both treatment periods, greater improvements
occurred with fluticasone in lung function during both periods and
in asthma control during open-label treatment. Post hoc analyses revealed
a difference in rescue-free days favoring fluticasone in participants
in the quartiles for lowest lung function and greatest albuterol use
at baseline.
conclusion: In patients with mild persistent asthma, rescue-free
days and most asthma control measures improved similarly with fluticasone
or montelukast over the short term, but with prolonged open-label
treatment, asthma control improved more with fluticasone. Improved
asthma control with fluticasone appeared to occur in those with decreased
lung function and greater albuterol use at baseline. In the remaining
patients, the two treatments appeared to be comparable. These results
suggest that classification criteria for mild persistent asthma may
need to be re-evaluated.
Reprinted from American Journal of Medicine, 118(6), Zeiger RS, Bird
SR, Kaplan MS, Schatz M, Pearlman DS, Orav EJ, Hustad CM, Edelman
JM, Short-term and long-term asthma control in patients with mild
persistent asthma receiving montelukast or fluticasone: a randomized
controlled trial, 649-57, Copyright 2005, with permission from Excerpta
Medica Inc.
From Colorado:
The
frequency and behavioral outcomes of goal choices in the self-management
of diabetes.
Estabrooks
PA, Nelson CC, Xu S, et al. Diabetes Educ 2005 May-Jun;31(3):391-400.
purpose:
The purpose of this study was to determine the frequency and effectiveness
of behavioral goal choices in the self-management of diabetes and
to test goal-setting theory hypotheses that self-selection and behavioral
specificity of goals are key to enhancing persistence.
methods:
Participants with type 2 diabetes in a randomized controlled trial
(n = 422) completed baseline behavioral assessments using a clinic-based,
interactive, self-management CD-ROM that allowed them to select a
behavioral goal and receive mail and telephone support for the initial
six months of the trial followed by additional behavioral assessments.
Frequency of behavioral goal selection and six-month behavioral data
were collected.
results:
Approximately 49%, 27%, and 24% of the participants, respectively,
set goals to increase physical activity (PA), reduce fat intake, or
increase fruits and vegetables (F&V) consumed. At baseline, participants
who selected PA, reduced fat consumption, or F&V were significantly,
and respectively, less active, consumed more dietary fat, and ate
fewer F&V regardless of demographic characteristics. Participants
who selected a reduced-fat goal showed a significantly larger decrease
than did those that selected PA or F&V goals. Participants who
selected an F&V goal showed significant changes in F&V consumption.
Participants who selected a PA goal demonstrated significant changes
in days of moderate and vigorous physical activity.
conclusions:
When participants are provided with information on health behavior
status and an option of behavioral goals for managing type 2 diabetes,
they will select personally appropriate goals, resulting in significant
behavioral changes over a six-month period.
From
Northern California:
Abdominal
obesity predicts declining insulin sensitivity in non-obese normoglycaemics:
the Insulin Resistance Atherosclerosis Study (IRAS).
Karter
AJ, D'Agostino RB Jr, Mayer-Davis EJ, et al. Diabetes Obes Metab 2005
May;7(3):230-8.
aim:
Cross-sectional studies have demonstrated a relationship between obesity
and insulin sensitivity (S(I)); however, there is a lack of evidence
from longitudinal studies.
methods:
The Insulin Resistance Atherosclerosis Study (IRAS) estimated S(I)
(x10(-4)/min.microU/ml) directly using a frequently sampled intravenous
glucose tolerance test with minimal model analysis in 504 normoglycaemic
subjects. Partial correlation coefficients (r) were calculated to
compare the relationship of change in S(I) from baseline to five years
later (DeltaS(I)) with baseline waist circumference (waist) as a measure
of abdominal obesity and body mass index (BMI) as a measure of overall
obesity. Mean DeltaS(I) was -1.06 (SD = 1.85).
results:
Higher baseline waist (r = -0.16; p = 0.0005), but not BMI (r = -0.005;
p = 0.91), was associated with (-) DeltaS(I) in models including sex,
ethnicity, clinical centre and baseline S(I), BMI, waist, age and
physical activity. The waist-DeltaS(I) relationship differed across
the levels of baseline BMI, being significant only in normal weight
(r = -0.21) and overweight subjects (r = -0.16), but not in obese
subjects. DeltaS(I) was correlated with a five-year change in either
obesity measure (Deltawaist: r = -0.22 and DeltaBMI: r = -0.20; p
= 0.0001).
conclusions:
Among non-diabetics, waist circumference was a strong predictor of
declining S(I) among lean subjects, a modest predictor among overweight
subjects, but was not predictive among obese individuals. Waist circumference
should be considered, in addition to BMI, when identifying individuals
at high risk of diabetes or the insulin resistance syndrome.
clinical
implication: This study demonstrated that, among non-diabetics,
waist circumference was a strong predictor of declining insulin sensitivity
among lean subjects, a modest predictor among overweight subjects,
but was not predictive among obese individuals. The most important
practical lesson is that lean individuals with central obesity (ie,
a big waist) should be considered at high risk of developing diabetes
or the insulin resistance syndrome even though they are not technically
considered obese (based on body mass index). AK
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