From
the Northwest:
The
DASH diet and blood pressure
Craddick
SR, Elmer PJ, Obarzanek E, Vollmer WM, Svetkey LP, Swain MC. Curr Atheroscler
Rep 2003 Nov;5(6):484-91.
High blood
pressure (also called hypertension) is one of the most important and
common risk factors for atherosclerotic cardiovascular disease (CVD)
and other chronic diseases. National guidelines recommend that all individuals
with blood pressure readings of 120/80 mm Hg or higher adopt healthy
lifestyle habits, including the Dietary Approaches to Stop Hypertension
(DASH) diet, to manage their blood pressure. The DASH diet, which is
high in fruits, vegetables, and low-fat dairy products and reduced in
fat, has been shown in large, randomized, controlled trials to reduce
blood pressure significantly. The DASH diet also has been shown to reduce
blood cholesterol and homocysteine levels and to enhance the benefits
of antihypertensive drug therapy. The DASH diet should be promoted,
along with maintaining healthy weight, reducing sodium intake, increasing
regular physical activity, and limiting alcohol intake, for lowering
blood pressure and reducing the risk of CVD.
From
Southern California:
Risk
factors for asthma hospitalizations in a managed care organization:
development of a clinical prediction rule
Schatz
M, Cook EF, Joshua A, Petitti D. Am J Manag Care 2003 Aug;9(8):538-47.
objective:
To use a computerized administrative database to develop and validate
a clinical prediction rule for the occurrence of asthma hospitalizations.
study
design: Retrospective cohort.
methods:
Subjects included asthmatic patients ages 3 to 64 who were continuously
enrolled in the Southern California Kaiser Permanente managed care organization
in both 1998 and 1999. Data were based on linkage of a hospital discharge
database, diagnosis and procedures database, membership database, and
prescription database. The outcome was any 1999 hospitalization with
a primary diagnosis of asthma. The outcome was evaluated and modeled
separately for children (ages 3-17) and adults (ages 18-64).
results:
Univariate analyses showed that hospitalized children were younger than
nonhospitalized children. Adults and children hospitalized in 1999 had
lower mean household incomes, were more likely to have required an emergency
department visit or hospitalization in 1998, used more beta-agonists
and oral corticosteroids in 1998, and had more 1998 prescribers than
nonhospitalized patients. In multivariable analysis, independent predictors
of 1999 hospitalization in children included age and 1998 hospitalizations,
beta-agonist dispensings, total anti-inflammatory dispensings, and number
of prescribers. Among adults, 1998 hospitalizations and oral steroid
dispensings as well as income were independent predictors of hospitalization
in 1999. The prediction rules developed in this study identified the
11% to 13% of adults or children with an approximately six-fold higher
likelihood for being hospitalized in the following year.
conclusion:
These models can be used to identify high-risk asthmatic patients in
whom targeted intervention might reduce asthma morbidity and cost of
care.
clinical
implication: A prior asthma hospitalization is the strongest risk
factor for a future asthma hospitalization in both children and adults.
Other easily identifiable risk factors include increased beta agonist
use in children and oral steroid use in adults. Inhaled steroids could
be shown to significantly reduce the risk, at least in children. Patients
with these risk factors should be aggressively managed and closely
followed. MS
From
the Northwest:
The
primary prevention of heart disease in women through health behavior
change promotion in primary care
Whitlock
EP, Williams SB. Womens Health Issues 2003 Jul-Aug;13(4):122-41.
purpose:
To summarize recent evidence-based recommendations for physical activity
promotion, dietary improvement, and tobacco cessation from the US Preventive
Services Task Force (USPSTF) and the Task Force on Community Preventive
Services (CTF), and examine their applicability to the primary prevention
of cardiovascular disease (CVD) in women through primary care interventions.
methods: For the behaviors cited, USPSTF and CTF recommendations
and their associated systematic evidence reviews (SERs) were retrieved.
Individual articles from the USPSTF healthy diet and physical activity
SERs that met our inclusion criteria were systematically examined to
determine the applicability of this research to women. We supplemented
findings from these sources with comprehensive federal research summaries
and SERs from focused searches of systematic review databases relevant
to primary CVD prevention in women through healthy behavior change.
main
findings: The USPSTF strongly recommends primary care interventions
for tobacco cessation. Strong CTF recommendations for multicomponent
systems supports for clinicians, telephone support for quitters, and
reduced patient costs for effective cessation therapies guide complementary
approaches to assist clinicians. The USPSTF recommends intensive behavioral
dietary counseling by specialists for high-risk CVD patients, but found
insufficient evidence to recommend for routine healthy diet or physical
activity promotion in primary care. The evidence base for these recommendations
generally applies to women. Better reporting of gender and minority
subgroup outcomes will assist more in-depth understanding of potential
differences in either the processes or outcomes of behavior change interventions.
conclusions:
Primary care clinicians, including obstetrician-gynecologists, can contribute
to preventing CVD in women through implementing credible evidence-based
recommendations for clinical interventions in tobacco and healthy diet.
Researchers can further our understanding of gender-specific issues
in healthy behavior interventions by reporting process and outcome data
for gender and minority subgroups.
Reprinted
from Journal of Women's Health Issues, V 13, Whitlock EP, Williams SB,
The primary prevention of heart disease in women through health behavior
change promotion in primary care, 122-41, Copyright 2003, with permission
from Jacobs Institute of Women's Health.
From
Northern California:
Improvement
of gastroesophageal reflux symptoms after radiofrequency energy: a randomized,
sham-controlled trial
Corley
DA, Katz P, Wo JM, et al, Gastroenterology 2003 Sep;125(3):668-76.
background
and aims: Gastroesophageal reflux disease is a prevalent disorder
that often requires long-term medical therapy or surgery. The United
States Food and Drug Administration recently cleared new endoluminal
gastroesophageal reflux disease treatments; however, no controlled trials
exist.
methods:
We randomly assigned 64 gastroesophageal reflux disease patients to
radiofrequency energy delivery to the gastroesophageal junction (35
patients) or to a sham procedure (29 patients). Principal outcomes were
reflux symptoms and quality of life. Secondary outcomes were medication
use and esophageal acid exposure. After six months, interested sham
patients crossed over to active treatment.
results:
At six months, active treatment significantly and substantially improved
patients' heartburn symptoms and quality of life. More active vs sham
patients were without daily heartburn symptoms (n = 19 [61%] vs n =
7 [33%]; p = 0.05), and more had a >50% improvement in their gastroesophageal
reflux disease quality of life score (n = 19 [61%] vs n = 6 [30%]; p
= 0.03). Symptom improvements persisted at 12 months after treatment.
At six months, there were no differences in daily medication use after
a medication withdrawal protocol (n = 17 [55%] vs n = 14 [61%]; p =
0.67) or in esophageal acid exposure times. There were no perforations
or deaths.
conclusions:
Radiofrequency energy delivery significantly improved gastroesophageal
reflux disease symptoms and quality of life compared with a sham procedure,
but it did not decrease esophageal acid exposure or medication use at
six months. This procedure represents a new option for selected symptomatic
gastroesophageal reflux disease patients who are intolerant of, or desire
an alternative to, traditional medical therapies.
Reprinted
from Gastroenterology, Vol 125, Corley DA, Katz P, Wo JM, et al, Improvement
of gastroesophageal reflux symptoms after radiofrequency energy: a randomized,
sham-controlled trial, 668-76, Copyright 2003, with permission from
American Gastroenterological Association.
From
the Northwest:
Diabetic
retinopathy: contemporary prevalence in a well-controlled population
Brown
JB, Pedula KL, Summers KH. Diabetes Care 2003 Sep;26(9):2637-42.
objective:
To measure the extent to which modern intensified risk factor control
has lessened the duration-specific prevalence of diabetic retinopathy
and, therefore, has decreased the risk of blindness in Americans with
type 2 diabetes.
research
and design methods: Intensified control of blood glucose and blood
pressure has prevented diabetic retinopathy in randomized controlled
trials. There is as yet no confirmation that subsequent treatment intensification
in the community has had the same result. We identified all 6993 members
of a health maintenance organization, Kaiser Permanente Northwest (KPNW),
who, in 1997-1998, had dilated retinal examinations and verifiable data
of diagnosis of type 2 diabetes. We plotted prevalence by time since
diagnosis for background diabetic retinopathy (BDR) and proliferative
diabetic retinopathy (PDR) and compared these results to identically
derived 1980-1982 results from the Wisconsin Epidemiologic Study of
Diabetic Retinopathy (WESDR). We estimated multivariate predictive models.
results:
Mean (± SD) HbA1c in KPNW was 7.84 ± 1.26% versus
10.37% (standardized) in the WESDR. KPNW blood pressure averaged 138.6
± 13.8/79.5 ± 7.4 mmHg compared with 147.0/79.0 in the WESDR.
BDR was much less prevalent in KPNW, but PDR prevalence appeared unchanged.
BDR preceded diagnosis in 20.8% of the WESDR subjects but only 2.0%
of KPNW subjects. However, in both populations, the first cases of PDR
appeared similarly, soon after diagnosis.
conclusions:
Earlier diagnosis and more aggressive control of blood glucose and blood
pressure decreased the duration-adjusted prevalence of background, but
not of sight-threatening proliferative retinopathy. More population-based
research is needed to replicate and explain this unexpected finding.
Detecting and treating PDR should not be neglected on the assumption
that risk-factor control has minimized its prevalence.
Copyright
2003 American Diabetes Association from Diabetes Care, Vol 26, 2003;2637-42.
Reprinted with permission from The American Diabetes Association.
clinical
implication: First, even in well-controlled diabetics we should
re-emphasize the importance of annual and biennial retinopathy screening
exams and make sure that members with pathology are treated and closely
followed. Second, we should initiate antihyperglycemic treatments
at <7.0% HbA1c, rather than at the ADA-recommended 8.0%.
This will reduce risk of post-treatment "accelerated diabetic
retinopathy," and the long-term glycemic burden of our members.
Long-term burden is growing thanks to aggressive CVD prevention, providing
more years for development of blindness and renal failure. Third,
we should consider rapid, office-based HbA1c assays, or
have members come in for tests before their visits. Rapid testing
reduces mean HbA1c and glycemic control may deteriorate
quickly as treatments fail. It is hard to respond quickly when the
HbA1c result arrives after the patient is out the door.
JB
From
Northern California:
The early repolarization
normal variant electrocardiogram: correlates and consequences
Klatsky
AL, Oehm R, Cooper RA, Udaltsova N, Armstrong MA. Am J Med. 2003 Aug
15;115(3):171-7.
purpose:
We compared the characteristics and outcomes of patients with "early
repolarization" electrocardiograms (ECGs) with those who had normal
ECGs.
methods: In 1983 to 1985, we collected photocopies of 2234 selected
ECGs from 73,088 patients undergoing health examinations. Excluding
153 ECGs with missing data or that were judged to be abnormal, the remaining
ECGs were reinterpreted in 2000 by cardiologists as showing early repolarization
(n = 670), or being borderline (n = 330) or normal (n = 1081). Characteristics
and outcomes of persons with early repolarization ECGs were compared
with those who had normal ECGs using analysis of variance, logistic
regression, or proportional hazards models. Information on exercise
was available in 325 patients.
results: Patients with early repolarization were more likely to
be male (81% [n = 583] vs 33% [n = 360]), <40 years old (60% [n =
441] vs 37% [n = 403]), black (48% [n = 384] vs 26% [n = 280]), and
more athletically active (mean [± SD], 10.4 ±1.3 hours per
week of activity vs 6.4 ±1.2 hours per week of activity) than those
with normal ECGs. Patients with early repolarization were not more likely
to be hospitalized (hazard ratio [HR] = 1.0; 95% confidence interval
[CI]: 0.9 to 1.2) or to die (HR = 0.8; 95% CI: 0.6 to 1.2) during follow-up
than those with normal ECGs. Outpatient diagnoses were not more common
in those with early repolarization; arrhythmias were actually less common
(p < 0.01).
conclusion: Although especially prevalent in young, athletic, black
men, early repolarization is not rare in other patients. The long-term
prognosis of early repolarization is benign.
Reprinted from American Journal of Medicine, Vol 115, Klatsky AL,
Oehm R, Cooper RA, Udaltsova N, Armstrong MA, The early repolarization
normal variant electrocardiogram: correlates and consequences, 171-7.
Copyright 2003, with permission from Excerpta Medica, Inc.
From
Northern California:
Meconium-stained
amniotic fluid is associated with puerperal infections
Tran
SH, Caughey AB, Musci TJ. Am J Obstet Gynecol. 2003 Sep;189(3):746-50.
objective:
The purpose of this study was to determine whether meconium-stained
amniotic fluid is associated with puerperal infection and whether the
quality of the meconium is further associated with this risk.
study
design: We designed a retrospective cohort study of all deliveries
beyond 37 weeks gestational age from 1992 to 2002 at a single community
hospital. Data were collected on rates of chorioamnionitis, endomyometritis,
quality of amniotic fluid, and length of labor and analyzed with bivariate
and multivariate analyses.
results:
We found that, among the 43,200 women who were delivered at term, 18.9%
of the women had meconium staining (8.8% thin, 5.5% moderate, 4.6% thick).
Compared with deliveries with clear amniotic fluid, those with meconium-stained
amniotic fluid had higher rates of chorioamnionitis (2.3% vs 4.1%, p
< .001) and endomyometritis (1.0% vs 1.7%, p < .001). Further,
the severity of meconium staining was associated with increased rates
of infection.
conclusion:
We found that the presence and severity of meconium-stained amniotic
fluid is associated with puerperal infection even when being controlled
for confounders.
Reprinted
from American Journal of Obstetrics and Gynecology, Tran SH, Caughey
AB, Musci TJ, Meconium-stained amniotic fluid is associated with puerperal
infections, 746-50, Copyright 2003, with permission from Elsevier.
From
the Northwest:
The problem
is getting us to stop. What teens say about smoking cessation
Vuckovic
N, Polen MR, Hollis JF. Prev Med. 2003 Sep;37(3):209-18.
background:
Low participation and high dropout in many teen cessation programs may
be due to lack of fit between teens' needs and the way programs are
delivered. Qualitative studies, designed to identify and understand
preferences of intervention participants and barriers to participation,
offer opportunities to customize programs and improve their reach and
effectiveness.
methods: Two sets of focus groups with high school students were
held in the Portland, OR, metropolitan area to elicit reactions to two
smoking cessation programs and discuss motivations for and experiences
with quitting. Thirty-three students (15 girls, 18 boys) participated
in the first set of four focus groups; 40 students (21 girls, 19 boys)
in the five focus groups for the second.
results: Participants preferred programs that respect the challenges
that teens face in quitting, and acknowledge their choice in making
the decision to quit. Teens wanted nonjudgmental and confidential support
from cessation counselors, and preferred counselors who are ex-smokers,
give useful quit tips, and can provide support for quit attempts. Private,
computer-based programs and personalized telephone services were options
for delivering cessation information and support.
conclusion: Teen smokers can supply valuable information to improve
youth cessation programs to fit teen lifestyles, respect the challenges
teens face, and acknowledge their choice in making the decision to quit.
Reprinted from Preventive Medicine, Vol 37, Vuckovic N, Polen MR,
Hollis JF, The problem is getting us to stop. What teens say about smoking
cessation, 209-18, Copyright 2003, with permission from Elsevier.
clinical
implication: Teen smokers value smoking cessation support that
respects their choices about when and how to quit and acknowledges
the challenges they face during cessation. Providing confidential,
nonjudgmental support and offering cessation strategies and resources
that have worked for others are important ways to support teens as
they consider and undertake cessation. Many teens liked the idea of
using interactive computer-based programs and multi-session telephone-based
cessation approaches because of their convenience and confidentiality.
Referring teens to such programs provides them with continued support
beyond the office visit. NV
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