PRACTICAL POINTERS

FOR

PRIMARY CARE







MEDICAL SUBJECT HEADINGS

AND

HIGHLIGHTS-INDEX

1999

JAMA, NEJM, LANCET	PUBLISHED BY PRACTICAL POINTERS INC.
BRITISH MEDICAL JOURNAL	EDITED BY RICHARD T. JAMES JR., M.D.
ARCHIVES OF INTERNAL MEDICINE	FIRST CHARLOTFE PHYSICIANS
ANNALS OF INTERNAL MEDICINE	300 BILLINGSLEY ROAD
ODDS AND ENDS	CHARLOTTE NC 28211 USA

A public service publication. Copies on file in Charlotte AHEC library.

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MEDICAL SUBJECT HEADINGS 1999

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ABCIXIMAB (See ANTIPLATLET DRUGS)	ABORTION
ACUTE PHASE PROTEINS	AIDS (See HIV)
ALCOHOL	ALENDRONATE (See OSTEOPOROSIS)
ALLERGIC RHINITIS	ALTERNATIVE MEDICINE (See also INTEGRATIVE MEDICINE)
ALZHEIMER'S DISEASE	ANEMIA
ANGINA (See also UNSTABLE ANGINA)	ANTIBIOTICS
ANTICOAGULATION	ANTIPHOSPHOLIPID ANTIBODIES
ANTIPLATELET DRUGS	APPENDICITIS
ASTHMA	ATHEROSCLEROSIS
ATRIAL FIBRILLATION
BACK PAIN	BAYESIAN METHODS
BENZODIAZEPINES	BETA BLOCKERS (See HEART FAILURE)
BEREAVEMENT	BISPHOSPHONATES (See 0STEOPOROSIS)
BITES (ANIMAL)	BLACK WIDOW SPIDER BITES (See BITES, ANIMAL)
BLOOD PRESSURE	BODY MASS INDEX (BMI ) (See OBESITY)
BONE MINERAL DENSITY (See OSTEOPOROSIS)	BRAIN ACTIVATION
BREAST CANCER	BREAST CYSTS
CAFFEINE	CANCER (See organ, eg, BREAST CANCER, CERVICAL CANCER)
CARBOHYDRATES	CARDIOVASCULAR DISEASE
CAREGIVING	CARING FOR PATIENTS
CARPAL TUNNEL SYNDROME	CELIAC DISEASE
CERVICAL CANCER	CHEWING GUM
CHOLESTEROL (See LIPIDS)	CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
CIGAR SMOKING	CIGARETTES (See SMOKING)
CLINICAL EPIDEMIOLOGY (See also BAYESIAN METHODS)	CLONING
CLOSTRIDIUM DIFFICILE	COLORECTA L ADENOMAS
COMMON COLD	CONTRACEPTION
CORONARY ARTERY DISEASE	CORONARY HEART DISEASE (See CORONARY ARTERY DISEASE)
COX-2 INHIBITORS	C-REACTIVE PROTEIN
CROHN'S DISEASE	CYTOKINES (See RHEUMATOLOGY)
DEATH AND DYING	DEMENTIA (See ALZHEIMER;S DISEASE)
DEPRESSION	DIABETES
DIFFICULT PATIENT	DISSEMINATED INTRAVASCULAR COAGULATION
DOMESTIC VIOLENCE	DOUBLE EFFECT (See ETHICS)
DRUG ABUSE	DRUG METABOLISM
DYING (See TERMINAL CARE)
EFFICIENCY	ELECTROCARDIOGRAM
EPIDEMIOLOGY — CLINICAL EPIDEMIOLOGY	ERECTAL DYSFUNCTION (See DIABETES)
ESOPHAGEAL VARICES	ESTROGEN (See also HORMONE REPLACEMENT THERAPY)
ETHICS	EUTHANASIA (See DEATH AND DYING)
EVIDENCE-BASED MEDICINE	EXERCISE (See also FITNESS)
FAMILIES	FIBER
FIBROMYALGIA	FITNESS
FOLATE – FOLIC ACID	FRACTURES
FUNCTIONAL FOODS	FUNGAL INFECTIONS
FUTILITY (See ETHICS)
GASTRO-ESOPHAGEAL REFLUX DISEASE (GERD)	GERIATRICS
GLYCEMIC INDEX (See CARBOHYDRATES)	GLYCOPROTEIN IIb IIIa RECEPTOR BLOCKERS (See ANTIPLATELET DRUGS)
GRAPEFRUIT JUICE
HEALTH CARE	HEALTH LITERACY
HEARTBURN (SEE GASTRO-ESPOHAGEAL REFLUX DISEASE)	HEART FAILURE
HELICOBACTER PYLORI	HEPATIC ENCEPHALOPATHY
HERPES ZOSTER (See VARICELLA-ZOSTER VIRUS)	HIV
HMOs	HOMOCYSTEINE
HORMONE REPLACEMENT THERAPY	HOSPICE
HUMAN PAPILLOMA VIRUS	HYPERPARATHYROIDISM
HYPERTENSION
IMMUNITY - IMMUNOTHERAPY (See also ALLERGIC RHINITIS)	IMMUNIZATION
IMPAIRED FASTING GLUCOSE (See DIABETES)	INCONTINENCE
INFECTIOUS DISEASE	INFORMED CONSENT (See ETHICS)
INFLAMMATION	INFLUENZA
INTEGRATIVE MEDICINE	INTENSIVE CARE
KIDNEY DISEASE
LIFE EXPECTANCY	LIFESTYLE
LIPIDS AND LIPID DISORDERS	LITERACY (See HEALTH LITERACY)
LUNG CANCER	LUPUS ANTICOAGULANT (See ANTIPHOSPHOLIPID ANTIBODIES)
LYING FOR PATIENTS
MAMMOGRAPHY	MELATONIN
MEMORY	MENINGOCOCCAL DISEASE
MITRAL VALVE PROLAPSE	MONOCLONAL ANTIBODIES
MYOCARDIAL INFARCTION
NARRATIVE IN MEDICINE	NEURALGIA
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDs) (See also COX-2 INHIBITORS)
OBESITY	ONYCHOMYCOSIS (See FUNGAL INFECTIONS)
ORAL HEALTH	ORLISTAT (See OBESITY)
ORTHOSTATIC HYPOTENSION	OSTEOPOROSIS
PAIN CONTROL	PALLIATIVE CARE
PATERNALISM	PATIENT CARE (See CARING FOR PATIENTS)
PHYSICAL FITNESS (See EXERCISE)	PHYSICIAN-ASSISTED SUICIDE (See EUTHANASIA)
POISONING	POSTHERPETIC NEURALGIA (See NEURALGIA)
PROFESSIONALISM	PROBABILITY
PROSTATE CANCER	PSA (See PROSTATE CANCER)
PULSE PRESSURE
QUALITY OF LIFE
RANDOMIZED, CONTROLLED TRIALS	RAYNAUDS'S SYNDROME
RECOMMENDED READING	REFERENCE ARTICLES
RENAL DISEASE	RHEUMATOLOGY
RHINOVIRUS INFECTION (See COMMON COLD)
SCIATICA	SCREENING
SILDENAFIL (See DIABETES)	SMOKING
SNAKE BITES	SOCIOLOGY AND HEALTH CARE
SOMATIZATION	STATISTICS
STRESS	SRESS INCONTINENCE (See INCONTINENCE)
STEATOHEPATITIS	STROKE
SUBSTANCE ABUSE	SURGERY
SUFFERING	"SUPPORT" STUDY (See PALLIATIVE CARE)
SURROGATE MARKERS
TENDINITIS	TERMINAL CARE (See also PALLIATIVE CARE)
THROMBOEMBOLIC DISEASE	THYROID DISEASE
TOBACCO (See SMOKING)	TRACHOMA
TRAVELER'S DIARRHEA	TROPONIN
TUBE FEEDING
UNSTABLE ANGINA
VACCINES-VACCINATION (See IMMUNIZATION)	VALULAR HEART DISEASE (See MITRAL VALVE PROLAPSE)
VARICELLA-ZOSTER VIRUS	VARICOSE VEINS
VENOUS THROMBOEMBOLISM	VENTRICULAR HYPERTROPHY
VITAMINS
WEIGHT (See OBESITY)	WHITE COAT NORMOTENSION (See HYPERTENSION)
WRITING

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A

ABORTION
11-20 CAFFEINE – FILTERING THE FACTS
      Reports a risk of spontaneous abortion in women who consume up to 6 cups of coffee a day. NEJM November 25, 1999; 341: 1688-89

ACUTE PHASE PROTEINS
2-9 ACUTE PHASE PROTEINS AND OTHER SYSTEMIC RESPONSES TO INFLAMMATION
      "Acute phase changes reflect the presence and intensity of inflammation. They have long been used as a clinical guide to diagnosis and management. For this purpose, determination of serum C-reactive protein has advantages over the traditional strategy of measuring the erythrocyte sedimentation rate." NEJM February 11, 1999; 340: 448-54

ALCOHOL
1-13 THE PROTECTIVE EFFECT OF MODERATE ALCOHOL CONSUMPTION ON ISCHEMIC STROKE
      Moderate alcohol consumption was independently associated with a decreased risk of ischemic stroke. Heavy alcohol consumption was deleterious. JAMA January 6, 1999; 281: 53-60

7-9 ALCOHOL INTAKE AND THE RISK OF CORONARY HEART DISEASE MORTALITY IN PERSONS WITH OLDER-ONSET DIABETES MELLITUS
      This study suggests an overall beneficial effect of alcohol consumption on decreasing risk of death from CHD in people with older-onset diabetes. JAMA July 21, 1999; 282: 239-46

7-10 SHOULD PATIENTS WITH DIABETES DRINK TO THEIR HEALTH?
      What is true for most patients with diabetes is true for other patients at high risk for CHD — light to moderate alcohol consumption likely provides benefit, but is contraindicated in anyone who, for whatever reason, cannot restrict his or her drinking to light or moderate levels. Judicious recommendations can be made in individual cases when the patient is well known to the clinician. But, the recommendation to drink should not be generalized. JAMA July 21, 1999; 282: 279-80

8-9 HAZARDOUS AND HARMFUL ALCOHOL CONSUMPTION IN PRIMARY CARE
      The article defines hazardous and harmful drinking which are recognized as common, distinct entities. And do not yet reach the definition of abuse or dependence. Routine screening is recommended. Brief physician counseling is effective therapy Archives Int Med August 9/23, 1999; 159: 1681-89

9-6 ASSOCIATION BETWEEN ALCOHOL CONSUMPTION AND MORTALITY, MYOCARDIAL INFARCTION, AND STROKE IN 25 YEAR FOLLOW UP OF 49 618 YOUNG SWEDISH MEN
      Alcohol clearly had a negative net effect on health up to age 45. This supports a restrictive alcohol policy with recommendations for little or no alcohol consumption by young men. BMJ September 25, 1999; 319: 821-22

10-16 BRIEF PHYSICIAN- AND NURSE PRACTITIONER- DELIVERED COUNSELING FOR HIGH-RISK DRINKERS: Does it work?
      Screening and very brief (5 to 10 minute) advice and counseling delivered by a physician or nurse practitioner as part of routine primary care significantly reduced alcohol consumption by high-risk drinkers. Archives Int. Med. October 11, 1999; 159: 2198-2295

11-14 EARLY ONSET DRUNK DRIVING, VIOLENT CRIMINALITY, AND MENTAL DISORDERS
      “The younger the drunk driver is, the greater the probability is of the driver being a violent offender with co-morbid mental disorder.” Lancet November 20, 1999; 354: 1788

ALLERGIC RHINITIS
8-19 LONG-TERM CLINICAL EFFECTIVENESS OF GRASS-POLLEN IMMUNOTHERAPY
      Immunotherapy for grass-pollen allergy induced prolonged clinical remission which continued for at least 3 years after discontinuation of therapy. NEJM August 12, 1999; 341: 468-75

8-20 IMMUNOTHERAPY FOR ALLERGIC RHINITIS
      Immunotherapy continues to be an attractive therapeutic option for selected patients because it provides benefits that cannot be achieved with pharmacotherapy. NEJM August 12, 1999; 341: 522-24

ALTERNATIVE MEDICINE
7-18 USE OF ALTERNATIVE MEDICINE BY WOMEN WITH EARLY-STAGE BREAST CANCER
      Among women with newly diagnosed early-stage breast cancer who had been treated with standard therapies, new-use of alternative medicine was a marker of greater psychosocial distress and worse quality of life. NEJM June 3, 1999; 340: 1733-39

ALZHEIMER'S DISEASE
5-22 A CONSENSUS-BASED APPROACH TO PROVIDING PALLIATIVE CARE TO PATIENTS WHO LACK DECISION-MAKING CAPACITY
      The palliative care strategy described by the authors is grounded in the theory that decisions are the result of dialogue and consensus building. The physician's duty is to teach all participants that the patient has a chronic, irreversible, and ultimately fatal disease, at the same time learning from those who participate about the patient's values and quality of life. This frames decisions about hospitalization, antibiotics, and enteral nutritional support as medical choices that ultimately shape the way the patient will live in the last phase of life. Annals Int. Med. May 18, 1999; 130 835-40

ANEMIA
4-11 RECENT ADVANCES IN HAEMATOLOGY
      Now, a new test (the serum transferrin receptor assay) is available, enabling more accurate differentiation. Transferrin is a protein that carries plasma iron. In iron deficiency anemia, the number of receptors increases. In anemia of chronic disease the number of receptors remains normal. BMJ April 10, 1999; 318: 991-94

5-12 THE DEFINITION OF ANEMIA IN OLDER PERSONS
      Anemia (hemoglobin concentrations below 12 g/dL for women and below 13 g/dL for men) was associated with increased mortality in individuals over age 85. These criteria for diagnosing anemia are appropriate for older persons. A lower hemoglobin at old age signifies disease. JAMA May 12, 1999; 281: 1714-17

11-12 REVERSAL OF IRON DEFICIENCY ANEMIA AFTER HELICOBACTER PYLORI ERADICATION IN PATIENTS WITH ASYMPTOMATIC GASTRITIS
      In this cohort of adult patients with iron deficiency associated with chronic pangastritis due to H pylori, cure of the infection cured the anemia. Annals Int Med November 2, 1999; 131: 668-72

ANGINA (See also UNSTABLE ANGINA)
5-10 META-ANALYSIS OF TRIALS COMPARING BETA-BLOCKERS, CALCIUM ANTAGONISTS, AND NITRATES FOR STABLE ANGINA
      In this meta-analysis of randomized trials of patients who had stable angina, beta-blockers provided similar clinical outcomes — and they were associated with fewer adverse effects than calcium blockers. JAMA May 26, 1999; 281: 1927-36

7-1 AGGRESSIVE LIPID-LOWERING THERAPY COMPARED WITH ANGIOPLASTY IN STABLE CORONARY ARTERY DISEASE
      In low-risk patients with stable coronary artery disease, aggressive lipid lowering is at least as effective as angioplasty and usual care in reducing incidence of ischemic events. NEJM July 8, 1999; 341:70-76

ANTIBIOTICS
12-13 QUINUPRISTIN/DALFOPRISTIN, A NEW ADDITION TO THE ANTIMICROBIAL ARSENAL
      A new drug, quinupristin/dalfopristin (Synercid), is now licensed in the US. It is active against gram-positive bacteria, including difficult organisms such as methicillin-resistant Staphylococcus aureus , and vancomycin-resistant Enterococcus faecium, and penicillin-resistant and macrolide-resistant pneumococci. Its activity is exclusively against gram-positive pathogens.
      The drug is specifically indicated when no other antibacterial agents are suitable. When mixed infections are suspected, quinupristin/dalfopristin should be used in combination with one or more agents active against nosocomial gram-negative bacteria. Lancet December 11, 1999; 354: 2012-13

ANTICOAGULATION
3-9 A COMPARISON OF THREE MONTHS OF ANTICOAGULATION WITH EXTENDED ANTICOAGULATION FOR A FIRST EPISODE OF IDIOPATHIC VENOUS THROMBOEMBOLISM
      Patients with a first episode of idiopathic thromboembolism should be treated with anticoagulation for longer than 3 months. How long? – to be determined later. NEJM March 25, 1999; 340: 901-07

ANTIPHOSPHOLIPID ANTIBODIES
4-20 ANTIPHOSPHOLIPID ANTIBODIES AND THROMBOSIS
      Autoantibodies specific for phospholipids (antiphospholipid antibodies) have long been recognized in systemic lupus erythematosis. They are associated with thrombotic complications and miscarriage. The terms are "lupus anti-coagulant" and "anticardiolipin" are used to describe these antibodies. The autoantibodies are heterogeneous. Their pathogenic role is not clear. Lancet April 17, 1999; 353: 1348-53

ANTIPLATELET DRUGS
5-14 BENEFIT OF ABCIXIMAB IN PATIENTS WITH REFRACTORY UNSTABLE ANGINA IN RELATION TO SERUM TROPONIN T LEVELS
      Troponin T may serve as a surrogate marker of active thrombus formation. Patients with unstable angina and high levels are at high risk for cardiac events. They benefited from abciximab therapy. (an antiplatelet drug — monoclonal antibody to platelet glycoprotein IIb/IIIa receeptor)
      A new diagnostic test (troponin T) and a therapeutic advance (abciximab) can be combined to benefit patients with acute coronary syndromes. NEJM May 2, 1999; 340" 1623-29

APPENDICITIS
9-8 ULTRASONOGRAPHY AND LIMITED COMPUTED TOMOGRAPHY IN THE DIAGNOSIS AND MANAGEMENT OF APPENDICITIS
      CT following a negative or indeterminate ultrasound was highly accurate in the diagnosis of appendicitis. JAMA September 15, 1999; 282: 1041-46

ASTHMA
7-8 RANDOMIZED, PLACEBO CONTROLLED TRIAL OF EFFECT OF LEUKOTRIENE RECEPTOR ANTAGONIST, MONTELUKAST, ON TAPERING INHALED CORTICOSTEROIDS IN ASTHMATIC PATIENTS.
      Montelukast reduced the need for inhaled corticosteroids among patients with chronic asthma who required moderate to high doses of corticosteroids.
      Leukotriene receptor antagonists such as montelukast may be useful for long term treatment. BMJ July 10, 1999; 319: 87-90

9-12 HOME MADE SPACERS FOR BRONCHODILATOR THERAPY IN CHILDREN WITH ACUTE ASTHMA
      A 500 mL plastic bottle is an effective alternative to a conventional spacer. It may be a valuable application in developing countries. Lancet September 18, 1999; 354: 979-82

12-17 TREATMENT OF ALLERGIC ASTHMA WITH MONOCLONAL ANTI-IGE ANTIBODY
      A recombinant humanized monoclonal antibody directed against IgE has potential as a treatment for patients with asthma. NEJM December 23, 1999; 341: 1966-73

ATHEROSCLEROSIS
2-2 PREVALENCE AND EXTENT OF ATHEROSCLEROSIS IN ADOLESCENTS AND YOUNG PEOPLE: Implications for Prevention from the Pathobiological Determinants of Atherosclerosis in Youth (PADY) Study
      Atherosclerosis begins in youth. Fatty streaks and clinically significant raised lesions increase rapidly in prevalence and extent during the 15 to 34-year age span. Primary prevention of clinically manifest atherosclerotic disease must begin in childhood or adolescence. JAMA February 24, 1999; 281: 727-35

12-11 SMOKING AND ATHEROSCLEROTIC CARDIOVASCULAR DISEASE IN MEN WITH LOW LEVELS OF CHOLESTEROL
      Current cigarette smoking was a major, independent risk factor for ASCVD in Korea despite the relatively low levels of cholesterol in the population. A low cholesterol conferred no protection against risks of smoking JAMA December 8, 1999; 282: 2149-55

ATRIAL FIBRILLATION
4-10 MANAGING ATRIAL FIBRILLATION IN ELDERLY PEOPLE
      The most effective way of minimizing the increased thromboembolic risk and treating symptoms is to return the rhythm to sustained sinus rhythm by electrical or chemical cardioversion. Restoration of sinus rhythm and maintenance of sinus rhythm after successful cardioversion may be enhanced by anti-arrhythmic drug therapy. "The optimal drug therapy has yet to be determined."BMJ April 24, 1999; 318: 1088-89

9-13 DIGOXIN IN THE TREATMENT OF PAROXYSMAL ATRIAL FIBRILLATION
      1. In the absence of HF, digoxin has no effect on the conversion rate of AF of recent (< 7 days) onset.
      2. Digoxin has a significant, albeit clinically modest, effect on reducing mean ventricular rate in symptomatic attacks. (Eg, reduction to 125 beats/min compared with 138 for placebo.) However, digoxin does not slow heart rate during moderate exercise.
      3. Digoxin reduces the frequency of symptomatic paroxysmal attacks to a modest extent.
      During a 24 hour period, heart rate control is insufficient and may not protect the heart against potential risks of HF or cardiomyopathy associated with a persistent tachycardia. Lancet September 11, 1999; 882-83

B

BACK PAIN
7-11 RANDOMISED CONTROLLED TRIAL OF EXERCISE FOR LOW BACK PAIN
      For subacute and recurrent low back pain, exercise class was more clinically effective than traditional general practitioner management and was cost effective. BMJ July 31, 1999; 319: 279-83

BAYESIAN METHODS
8-22 AN INTRODUCTION TO BAYESIAN METHODS IN HEALTH TECHNOLOGY ASSESSMENT.
      The authors suggest a definition of the Bayesian method: "The explicit quantitative use of external evidence in the design, monitoring, analysis, interpretation, and reporting of a health technology assessment." BMJ August 21, 1999; 508-12

BENZODIAZEPINES
11-5 FACILITATION OF BENZODIAZEPINE DISCONTINUATION BY MELATONIN
      Controlled-release melatonin may effectively facilitate discontinuation of benzodiazepine therapy while maintaining good sleep quality. Archives Intern Med November 8, 1999; 159: 2456-60

11-6 MELATONIN THERAPY: FROM BENZODIAZEPINE-DEPENDENT INSOMNIA TO AUTHENTICITY AND AUTONOMY
      “Choosing benzodiazepine-free treatment for insomnia can help patients sleep, dream, remember, and continue to have access to both the continuity of autobiographical memories relevant to authenticity and the procedural memories essential to autonomy.” Archives Int Med November 8, 1999; 159: 2393-95

BEREAVEMENT
7-17 GENERAL PRACTITIONERS' BELIEFS AND ATTITUDES ABOUT HOW TO RESPOND TO DEATH AND BEREAVEMENT: Qualitative Study
      GPs need support and learning methods to manage their own and their patients' bereavement. BMJ July 31, 1999; 319: 293-96

BITES (ANIMAL)
1-5 BACTERIOLOGIC ANALYSIS OF INFECTED DOG AND CAT BITES
      Infected dog and cat bites have a complex microbiologic mix that usually includes pasteurella species and may include many other organisms not previously recognized as bite-wound pathogens. NEJM January 14, 1999; 340: 85-92

1-6 THE MANAGEMENT OF BITE WOUNDS
      Whether antibiotics prevent infection remains controversial. Five of 8 studies reported prophylactic antibiotics reduced rate of infection, but in only 1 (amoxicillin-clavulanate [Augmentin] was the difference statistically significant. A meta-analysis found the relative risk of infection after prophylactic antibiotics was 0.56. "Currently antibiotics are not given routinely, but they are almost always recommended for high-risk wounds (deep punctures, and those requiring surgical repair and those involving the hands). "
      For empirical treatment of infection, in most cases a beta-lactam combined with a beta-lactamase inhibitor [eg, amoxicillin-clavulanate] should be the appropriate choice. NEJM January 14, 1999; 340: 138-40

2-19 SUCCESSFUL TREATMENT OF LATRODECTISM WITH ANTIVENIN AFTER 90 HOURS
      Anecdotal report which reminds us of the availability and use of antivenin. NEJM February 25, 1999: 340: 657

BLOOD PRESSURE
10-1 CARDIAC AND ARTERIAL TARGET ORGAN DAMAGE IN ADULTS WITH ELEVATED AMBULATORY AND NORMAL OFFICE BLOOD PRESSURE
      White coat normotension is the converse of white coat hypertension – in the former, clinic (office) BP is higher than ambulatory BP; in the latter, clinic BP is higher than the ambulatory BP.
      White coat normotension was associated with increased left ventricular mass and carotid wall thickness. The association of white coat normotension with prognostically important target organ damage may partly explain the ability of high normal clinic BP to predict subsequent hypertension and cardiovascular events. Annals Int Med October 19, 1999; 131: 564-72

BRAIN ACTIVATION
4-15 EFFECT OF ESTROGEN ON BRAIN ACTIVATION PATTERNS IN POSTMENOPAUSAL WOMEN DURING WORKING MEMORY TESTS.
      Therapeutic doses of estrogen altered activation of specific brain regions during the performance of the sorts of memory function that are called upon frequently during any given day. JAMA April 7, 1999; 281: 1197-1202

BREAST CANCER
5-5 RISK OF BREAST CANCER IN WOMEN WITH PALPABLE BREAST CYSTS
      Women with breast cysts were at increased risk of breast cancer, especially at ages below 45. This may be a reasonable indication for screening in age 40-49.Lancet May 22, 1999; 353: 1742-45

6-9 THE EFFECT OF RALOXIFENE ON RISK OF BREAST CANCER IN POSTMENOPAUSAL WOMEN: Results of the MORE Randomized Trial
      Among postmenopausal women with osteoporosis, the risk of invasive breast cancer was decreased by 76% during 3 years of primary preventive treatment with raloxifene. JAMA June 16, 1999; 281: 2189-97

6-10 TAMOXIFEN IN TREATMENT OF INTRADUCTAL BREAST CANCER: National Surgical Adjuvant Breast and Bowel Project B-24 Randomised Controlled Trial
      Tamoxifen, added to lumpectomy and radiation therapy, was more beneficial than lumpectomy plus radiation. Lancet June 12, 1999; 353:1993-2000

6-11 TAMOXIFEN HITS THE TARGET IN SITU
      Tamoxifen reduces incidence of metastatic disease from breast cancer. It is effective in primary prevention of breast cancer. Now, effectiveness is reported for use in reducing recurrent DCIS. Lancet June 12, 1999; 353: 1986-87

7-18 USE OF ALTERNATIVE MEDICINE BY WOMEN WITH EARLY-STAGE BREAST CANCER
      Among women with newly diagnosed early-stage breast cancer who had been treated with standard therapies, new-use of alternative medicine was a marker of greater psychosocial distress and worse quality of life. NEJM June 3, 1999; 340: 1733-39

BREAST CYSTS
5-5 RISK OF BREAST CANCER IN WOMEN WITH PALPABLE BREAST CYSTS
      Women with breast cysts were at increased risk of breast cancer, especially at ages below 45. This may be a reasonable indication for screening in age 40-49.Lancet May 22, 1999; 353: 1742-45

C

CAFFEINE
11-20 CAFFEINE – FILTERING THE FACTS
      Reports a risk of spontaneous abortion in women who consume up to 6 cups of coffee a day. NEJM November 25, 1999; 341: 1688-89

CARBOHYDRATES
3- 19 GLYCEMIC INDEX AS A DETERMINANT OF SERUM HDL-CHOLESTEROL CONCENTRATION
      High glycemic index carbohydrate diets (increasing postprandial blood glucose concentrations) were associated with lower HDL-cholesterol concentrations; low glycemic index diets (lower postprandial blood glucose) with higher HDL-cholesterol concentrations.
      The glycemic index was a stronger predictor of HDL-cholesterol concentrations than was dietary fat intake. Lancet March 27, 1999; 353: 1045-48

3-20 ARE THERE GOOD AND BAD CARBOHYDRATES FOR HDL CHOLESTEROL?
      Diets low in fat necessarily have a high carbohydrate content. Low fat, high carbohydrate diets lower HDL-c (an adverse outcome) as well as LDL-c. Thus the recommendation to decrease fat and increase carbohydrate have come under scrutiny. The study suggests that not all carbohydrates lower HDL-c. Those with a low glycemic index may preserve HDL-c concentrations. Lancet March 27, 1999; 353: 1029-30

CARDIOVASCULAR DISEASE
8-6 CARDIOVASCULAR DISEASE IN OLDER ADULTS WITH GLUCOSE DISORDERS: Comparison of American Diabetes Association Criteria for Diabetes Mellitus with WHO Criteria
      "If the purpose of screening for diabetes mellitus is to identify the maximum number of people at risk of cardiovascular disease events or death when glucose is slightly raised, then it would seem that the WHO criteria are superior to the fasting ADA criteria." Lancet August 21, 1999; 354: 622-25

9-15 ARE SURROGATE MARKERS ADEQUATE TO ASSESS CARDIOVASCULAR DISEASE DRUGS?
      Surrogate end points are thus neither consistent successes nor consistent failures. The safety concerns left unanswered by reliance on a surrogate need to be satisfied in some other way. JAMA August 25, 1999;282: 790-91

10-7 DIETARY FIBER, WEIGHT GAIN, AND CARDIOVASCULAR DISEASE RISK FACTORS IN YOUNG ADULTS.
      Dietary fiber was inversely associated with insulin levels, weight gain, and other risk factors for CVD in young adults. JAMA October 27, 1999; 282: 1539-46

12-11 SMOKING AND ATHEROSCLEROTIC CARDIOVASCULAR DISEASE IN MEN WITH LOW LEVELS OF CHOLESTEROL
      Current cigarette smoking was a major, independent risk factor for ASCVD in Korea despite the relatively low levels of cholesterol in the population. A low cholesterol conferred no protection against risks of smoking. (Smoking presents its own increased risk by its adverse effects on the endothelium. ) JAMA December 8, 1999; 282: 2149-55

12-10 DIETARY SODIUM INTAKE AND SUBSEQUENT RISK OF CARDIOVASCULAR DISEASE IN OVERWEIGHT ADULTS
      High sodium intake was strongly and independently associated with an increased risk of cardiovascular disease and all-cause mortality in overweight persons. Moderate reductions in sodium intake are recommended. JAMA December 1, 1999; 282: 2027-34

12-7 LOW RISK-FACTOR PROFILE AND LONG-TERM CARDIOVASCULAR AND NON-CARDIOVASCULAR MORTALITY AND LIFE EXPECTANCY
      In this very large cohort study, individuals with total cholesterol < 200, BP = 120/80, and who did not smoke, experienced lower long-term mortality and longer life expectancy than those with any one of these risk factors. JAMA December 1, 1999; 282: 2012-18

12-4 THE EFFECT OF BISOPROLOL ON PERIOPERATIVE MORTALITY AND MYOCARDIAL INFARCTION IN HIGH-RISK PATIENTS UNDERGOING VASCULAR SURGERY
      Bisoprolol (Zebeta) was associated with a marked reduction of perioperative death from cardiac causes and non-fatal MI in high-risk patients undergoing major vascular surgery. NEJM December 9, 1999; 1789-94

12-5 REDUCING CARDIAC RISK IN NONCARDIAC SURGERY
      In summary, the preceding study suggests that perioperative care will be characterized by fewer tests, fewer coronary revascularization procedures, more use of beta-blockers – and fewer complications. NEJM December 9, 1999; 1838-40

12-6 IS SIMPLE CLINICAL ASSESSMENT ADEQUATE FOR CARDIAC RISK STRATIFICATION BEFORE ELECTIVE NON-CARDIAC SURGERY?
      “For most patients cardiac risk stratification before elective non-cardiac surgery requires only a knowledge of the risk associated with the procedure and simple clinical assessment.” Patients undergoing high-risk abdominal and thoracic surgery and who have a history of ischemic heart disease, heart failure, insulin-treated diabetes and/or elevated plasma creatinine have increased risks of major cardiovascular complications. Lancet November 27, 1999; 354: 1837-38

12-1 REDUCED CORONARY EVENTS IN SIMVASTATIN-TREATED PATIENTS WITH CORONARY HEART DISEASE AND DIABETES OF IMPAIRED FASTING GLUCOSE LEVELS.
      In patients with established CHD, lowering cholesterol with simvastatin benefited patients with impaired fasting blood glucose (110 to 125) as well as patients with diabetes (FBG = 126). Total and coronary mortality and major coronary events were reduced in both groups. Archives Int Med December 13/27 1999; 2661-67

CAREGIVING
12-2 CAREGIVING AS A RISK FACTOR FOR MORTALITY
      Elderly spouses acting as caregivers to their spouse were at increased risk for death. JAMA December 15, 1999; 282: 2215-19

CARING FOR PATIENTS
1-17 THE TROUBLE WITH FAMILIES: Toward an Ethic of Accommodation
      A system that saves lives or prolongs lives only to cast patients and families into the abyss of fragmented chronic care and financial and emotional ruin, while at the same time criticizing them for being "too emotional", is unjust. Many families are willing to make enormous sacrifices, but martyrdom is not a good basis for health care policies or practice.
      When families are pushed beyond their limits, the patient's care is jeopardized, the caregiver's health is at risk, professionals are frustrated, and the health care system is burdened by greater costs. "Our recommendations focus on human relationships, not technology." A health care system that depends so heavily on the patient care provided by families should involve families as partners rather than define them as problems. Annals Int. Med. January 19, 1999; 130:148-52

1-3 QUALITY END-OF-LIFE CARE: Patient's Perspectives
      From a patient's perspective, quality end-of-life includes: receiving adequate pain and symptom management, avoiding inappropriate prolongation of dying, achieving a sense of control, relieving burden, and strengthening relationships with loved ones. JAMA January 13, 1999; 281: 163-68

1-4 PATIENT'S PRIORITIES
      “A revolution is underway in health care. After decades of patriarchal provision of services, governments are now accepting that patients should have a say in what they are provided." Patients now demand information. Providing patients with accurate, high quality up-to-date information is a priority.
      Patients hold remarkably similar views about what they want from primary care. Top of the list are: 1) having enough time in the consultation, 2) being able to get quick service in an emergency, and 3) having a general practitioner who listens and provides helpful information about their illnesses and treatment, and encourages them to discuss all their problems. They also want their physicians to keep up to date, and meet their need for confidentiality and advocacy. BMJ January 30, 1999; 277

1-1 SOLICITING THE PATIENT'S AGENDA
      Physicians often redirect patients' initial descriptions of their concerns before the description is fully completed. Once redirected, the list of concerns are rarely completed. Soliciting the patients' complete agenda at the outset of the interview can improve interview efficiency and yield increased data.
      Ask — "What concerns do you have" and then "Anything else" to complete the agenda. JAMA January 20, 1999; 381: 283-87

2-18 CHRONIC STRESS IN ELDERLY CARERS OF DEMENTIA PATIENTS AND ANTIBODY RESPONSE TO INFLUENZA VACCINE
      Elderly carers of spouses with dementia have increased activation of the hypothalamic-pituitary-adrenal axis and a poor response to influenza vaccine.
      Carers may be more vulnerable to infectious disease. Lancet February 20, 1999; 353: 627-31

2-14 LOOKING BEYOND THE NEXT PATIENT: Sociology and Modern Health Care
      Exclusion, isolation, and helplessness can be harmful to health. An assault must be made on factors that affect the human psyche — those that make people feel undervalued and excluded. Lancet February 6, 1999; 353: 486-89

5-6 THE LONELINESS OF THE LONG-TERM CARE GIVER
      Care givers want better communication with professionals, education and training, emotional support, and advocacy. They want help in negotiating the impenetrable thicket of financing mechanisms, and the inconsistent interpretations of policies and eligibility. They want respite, too. They want professionals to appreciate how much fear and anxiety complicate the learning of new tasks. They need relief from their suffering. NEJM May 20, 1999; 340: 1587-90

8-15 BRIEF ENCOUNTERS: Speaking With Patients
      "The foundation of good medical care . . . is a comfortable, evolving relationship between patient and physician." For new physicians, learning this art requires a prolonged relationship with a role-model, then adapting the art to their own personalities and practices.
      The editorialist recommends 4 books to aid in learning the art. Annals Int Med August 3, 1999; 131: 231-34

9-16 PATERNALISM OR PARTNERSHIP?
      Partners work together to achieve common goals. Their relationship is based on respect for each other's skills and competencies and recognition of the advantages of combining these resources to achieve beneficial outcomes.
      Doctors are, or should be, experts in medical knowledge and applications. "The key to successful doctor-patients partnerships is recognizing that patients are experts too. Only the patient knows about his or her experience of illness, social circumstances, habits and behavior, attitudes to risk, values, and preferences." BMJ September 14, 1999; 319: 719-20

9-17 INSTILLING PROFESSIONALISM IN MEDICAL EDUCATION
      The 3 essential characteristics of a profession:
      1. Expert knowledge ( as distinguished from a practical skill).
      2. Self-regulation
      3. Responsibility to place the needs of the client ahead of the self-interest of the practitioner. JAMA September 1, 1999; 282: 881-82

10-11 DIAGNOSING SUFFERING: A PERSPECTIVE
      The language that describes and defines suffering is different from the language of medicine.1 There is too often a disconnect between our case history and the patient's narrative. “Herein lies one of the reasons for the inadequate relief of suffering.” Physicians are trained primarily to find out what is wrong with the body in terms of diseases or pathophysiology. They do not examine what is wrong with persons. “When physicians attend to the body rather than to the person, they fail to diagnose suffering.”
      The care of the suffering patient (attending to the person) means more than caring about the patient or being compassionate. Lack of recognition of suffering does not come about only because of the absence of compassion, it is also the result of physicians' poor diagnostic and therapeutic knowledge and skills about persons –- that is, an inability to focus on the person rather than the disease. Annals Int. Med. October 5, 1999; 131; 531-34

11-22 THE YOUNG WOMAN WITH A WART ON HER NOSE
      An Anecdote of a Tragedy “A Memorable Patient” A narrative of a poignant personal experience. BMJ November 20, 1999; 319: 1349

CARPAL TUNNEL SYNDROME
11-21 INJECTION WITH METHYLPREDNISOLONE PROXIMAL TO THE CARPAL TUNNEL: RANDOMIZED, DOUBLE BLIND TRIAL
      A single injection of methylprednisolone close to (not into) the carpal tunnel may result in long-term improvement and should be considered before surgical decompression. BMJ October 2, 1999; 319: 884-86

CELIAC DISEASE
7-27 COELIAC DISEASE
      This reviews symptoms and signs, epidemiology, pathogenesis, diagnosis, treatment, prognosis, and complications. BMJ July 24, 1999; 319:236-40

CERVICAL CANCER
11-7 PERNICIOUS PAPILLOMA INFECTION
      “In sum, cervical cancer often begins with the sexual transmission of HPV infection to a woman who is susceptible to persistent infection. Over time, the HPV lesions progress to invasive cervical cancer.” NEJM November 25, 1999; 341: 1687-88

CHEWING GUM
12-14 THE ENERGY EXPENDED IN CHEWING GUM
      Chewing led to a mean increase in energy expenditure of 11 kcal per hour, a 19% increase over baseline. In the same subjects, standing was associated with a mean increase of 11%, and walking 1 mile per hour with a mean increase of 106% above baseline.
      If a person chewed gum during waking hours and changed no other component of energy balance, a yearly loss of over 10 pounds of body fat might be anticipated. NEJM December 30, 1999; 341: 2100

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
6-14 GLUCOCORTICOID THERAPY FOR CHRONIC OBSTRUCTIVE PULMONARY DISEASE
      Two studies concerning COPD in the issue of NEJM reported slight to moderate transient improvement in lung function with oral and inhaled corticoids.
      At times patients with acute exacerbations of COPD will have increased numbers of eosinophiles in bronchial biopsy specimens. This may be caused by a respiratory virus infection which attracts eosinophiles and results in a more favorable response to corticosteroids. NEJM June 24, 1999; 340: 1990-91

8-18 ORAL CORTICOSTEROIDS IN PATIENTS ADMITTED TO HOSPITAL WITH EXACERBATIONS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE.
      The data support the current practice of prescribing low-dose oral corticosteroids to all patients with non-acidotic exacerbations of COPD who require hospitalization. Lancet August 7, 1999; 354: 456-60

CIGAR SMOKING
6-15 EFFECT OF CIGAR SMOKING ON THE RISK OF CARDIOVASCULAR DISEASE, CHRONIC OBSTRUCTIVE PULMONARY DISEASE, AND CANCER IN MEN.
      Independent of other risk factors, regular cigar smoking can increase risk of coronary heart disease, COPD, and cancers of the lung and upper aero-digestive tract. NEJM June 10, 1999, 340: 1773-80

CLINICAL EPIDEMIOLOGY (See also BAYESIAN METHODS)
9-14 CAN IT WORK? DOES IT WORK? IS IT WORTH IT?
      1. Efficacy is the extent to which an intervention does more good than harm under ideal circumstances in a well designed, controlled trial. (Ie, can it work?)
      2. Effectiveness assesses whether an intervention does more good than harm when provided under usual circumstances in health care practice. (Does it work in practice?)
      3. Efficiency measures the effect of an intervention in relation to the resources it consumes. (Is it worth it?) BMJ September 11, 1999; 319: 652-53

CLONING
2-10 WOULD CLONED HUMANS REALLY BE LIKE SHEEP?
      Why a clone cannot be a clone. Read the original! NEJM February 11, 1999; 340: 471-75

CLOSTRIDIUM DIFFICILE
11-19 ANTIBIOTICS AND CLOSTRIDIUM DIFFICILE
      In addition to the second- and third-generation cephalosporins and clindamycin, ampicillin and amoxicillin are associated with the highest incidence. Quinolones, aminoglycosides, macrolides (especially the newer agents clarithromycin and azithromycin), vancomycin, and extended spectrum penicillins (ticarcillin, mezlocillin, and piperacillin) are associated with the lowest risk. Trimethoprim, tetracycline, and imipenem seem to carry an intermediate risk. NEJM November 25, 1999; 341: 1690-91

COLORECTA L ADENOMAS
1-21 CALCIUM SUPPLEMENTS FOR THE PREVENTION OF COLORECTAL ADENOMAS
      Calcium supplementation was associated with a significant — though moderate— reduction in risk of recurrent colorectal adenomas. NEJM January 14, 1999; 340: 101-07

COMMON COLD
5-23 EFFICACY OF TREMACAMRA, A SOLUBLE INTERCELLULAR ADHESION MOLECULE 1, FOR EXPERIMENTAL RHINOVIRUS INFECTION
      Tremacamra, a rhinovirus receptor blocker, reduced the frequency and severity of experimental rhinovirus colds. Clinical usefulness is not yet established. JAMA May 19, 1999; 281: 1797-1804

CONTRACEPTION
1-11 ORAL CONTRACEPTION AND HEALTH
      The evidence suggests that women who do not smoke, who have their blood pressure checked, and do not have hypertension, have no increased risk of myocardial infarction and little risk of stroke when they use combined OCs. (BP should be always measured before starting OCs.) BMJ January 9, 1999; 318: 69-70

CORONARY ARTERY DISEASE
2-11 IMPROVED DETECTION OF CORONARY ARTERY DISEASE BY EXERCISE ELECTROCARDIOGAPHY WITH USE OF RIGHT PRECORDIAL LEADS
      Exercise electrocardiography incorporating the combination of right leads along with the standard left leads greatly improved sensitivity for the diagnosis of coronary artery disease. NEJM February 4,1999; 340; 340-45

2-12 THE VALUE OF THE RIGHT PRECORDIAL LEADS OF THE ELECTROCARDIOGRAM
      Right ventricular infarction carries a marked increase in mortality during hospitalization. Identification of right ventricular infarction by right chest leads may select those who would benefit most from reperfusion. NEJM February 4, 1999; 340: 381-83

6-5 LONG-TERM INTAKE OF DIETARY FIBER AND DECREASED RISK OF CORONARY HEART DISEASE IN WOMEN
      High fiber intake, particularly from cereal sources, reduced the risk of CHD. JAMA June 2, 1999; 281: 1998-2004

6-12 TRANS FATTY ACIDS AND CORONARY HEART DISEASE
      The adverse effect of trans fats on the LDL-c / HDL-c ratio is clinically significant. The average intake of 2% of calories as trans fat in the US wold be predicted to account for a substantial number of deaths from coronary heart disease. (2% of a 2000 cal diet = 40 cal = about 4 g fat. One doughnut contains 3.2 g trans fat; one large french fries, 10 g.) NEJM June 24, 1999; 340: 1994-98

8-12 A PROSPECTIVE STUDY OF WALKING AS COMPARED WITH VIGOROUS EXERCISE IN THE PREVENTION OF CORONARY HEART DISEASE IN WOMEN
      Both walking and vigorous exercise were associated with substantial reductions in the risk of coronary events. There was a strong, graded inverse relation between energy expenditure, either walking or vigorous exercise and the incidence of coronary events. Risk was reduced equally in women who walked briskly for at least 3 hours per week and women who exercised vigorously for 1.5 hours per week.
      Enormous public health benefits would accrue from the adoption of moderate intensity exercise by those who are currently sedentary. NEJM August 26, 1999; 650-58

8-10 GEMFIBROZIL FOR THE SECONDARY PREVENTION OF CORONARY HEART DISEASE IN MEN WITH LOW LEVELS OF HIGH-DENSITY LIPOPROTEIN CHOLESTEROL
      For secondary prevention in patient with demonstrated coronary heart disease whose primary lipid abnormality is a low HDL-c level (a finding commonly occurring in the context of central obesity, diabetes, and other features of the metabolic syndrome), gemfibrozil effectively prevented recurrence of myocardial infarction and death from coronary heart disease. NEJM August 5, 1999; 410-18

COX-2 INHIBITORS
1-14 COX-2 INHIBITORS
      1. COX-1 acts constantly (not inducible). It predominates in the stomach. It is the predominant source of the gastric mucosal prostaglandins which protect the stomach. NSAIDs tend to selectively inhibit COX-1, reducing the protective effect of the prostaglandin, leading to acid-producing gastric mucosal injury.
      2. COX-2 is inducible by inflammation. Its prostaglandin is associated with pain, swelling, and stiffness.
      The idea then is to inhibit the "bad guy" — COX-2 while preserving the "good guy" — COX-1. Inhibiting COX- will relieve some symptoms of inflammation. Lancet January 23, 1999; 353; 307-14

11-8 ANTI-INFLAMMATORY AND UPPER GASTROINTESTINAL EFFECTS OF CELECOXIB IN RHEUMATOID ARTHRITIS: A Randomized Controlled Trial
      Celecoxib (Celebrex, a COX-2 inhibitor) was efficacious in treatment of rheumatoid arthritis and did not affect COX-1 activity in the upper GI tract mucosa as evidenced by less frequent ulcers compared with naproxin. JAMA November 24, 1999; 282: 1921-28

11-9 COX-1-SPARING NSAIDs – Is the Enthusiasm Justified?
      Costs are high for the new COX-1-sparing NSAIDs. The extra protection they offer the stomach must be balanced against the cost on an individual basis. JAMA November 24, 1999; 282: 1961-63

C-REACTIVE PROTEIN
2-9 ACUTE PHASE PROTEINS AND OTHER SYSTEMIC RESPONSES TO INFLAMMATION
      "Acute phase changes reflect the presence and intensity of inflammation. They have long been used as a clinical guide to diagnosis and management. For this purpose, determination of serum C-reactive protein has advantages over the traditional strategy of measuring the erythrocyte sedimentation rate." NEJM February 11, 1999; 340: 448-54

CROHN'S DISEASE
5-13 INFLIXIMAB FOR THE TREATMENT OF FISTULAS IN PATIENTS WITH CROHN'S DISEASE
      Infliximab was efficacious in treatment of enterocutaneous fistulas complicating Crohn's disease. NEJM May 6, 1999; 340: 1398-1405

D

DEATH AND DYING
1-3 QUALITY END-OF-LIFE CARE: Patient's Perspectives
      From a patient's perspective, quality end-of-life includes: receiving adequate pain and symptom management, avoiding inappropriate prolongation of dying, achieving a sense of control, relieving burden, and strengthening relationships with loved ones. JAMA January 13, 1999; 281: 163-68

7-26 FREUD'S PHYSICIAN-ASSISTED DEATH
      "Freud's choice of physician-assisted suicide was not merely an interesting historical event, but one of paramount rationality, and one that is relevant to our contentious contemporary debates concerning euthanasia and physician-assisted suicide. Archives Int Med July 26, 1999; 159: 1521-23

7-17 GENERAL PRACTITIONERS' BELIEFS AND ATTITUDES ABOUT HOW TO RESPOND TO DEATH AND BEREAVEMENT: Qualitative Study
      GPs need support and learning methods to manage their own and their patients' bereavement. BMJ July 31, 1999; 319: 293-96

DEPRESSION
3-21 THE PHYSICAL CONSEQUENCES OF DEPRESSIVE ILLNESS
      There is important and accumulating evidence that the physical consequences of depression are far from benign. In particular, increased risk of coronary artery disease and osteoporosis have received attention. The most consistent biologic abnormality in major depression is increased activation of the hypothalamic-pituitary-adrenal axis.
      Depression is an illness with physical as well as social and psychological consequences. BMJ March 27,1999; 318: 826

8-2 SOCIAL DISENGAGEMENT AND INCIDENT COGNITIVE DECLINE IN COMMUNITY-DWELLING ELDERLY PERSONS
      At 12 years, the odds ratio of experiencing cognitive decline was approximately twice as great in the most disengaged group as in the most engaged group. Continued mental stimulation staves off cognitive deterioration in old age possibly by maintaining a critical density of neocortical synapses. Annals Int Med August 3, 1999; 131: 165-73

DIABETES
1-2 THE ASSOCIATION BETWEEN CARDIORESPIRATORY FITNESS AND IMPAIRED FASTING GLUCOSE AND TYPE 2 DIABETES MELLITUS IN MEN
      Poor cardiorespiratory fitness was associated with increased risk for developing impaired fasting glucose and type 2 diabetes. A sedentary lifestyle may contribute to progression from normal fasting glucose to impaired fasting glucose, to diabetes. Annals Int. Med. January 19, 1999; 130: 89-96

2-20 THE NATIONAL DIABETES EDUCATION PROGRAM: Changing the Way Diabetes is Treated.
      These emerging findings have prompted the National Institutes of Health and the Centers for Disease Control and Prevention to sponsor a major national initiative, the National Diabetes Education Program. This will develop strategies to improve diabetes care, promote early detection, and ultimately prevent the onset of the disease.
      The Web site: http://NDEP.NIH.gov Annals Int. Med. February 16, 1999; 130: 324-26

2-4 SILDENAFIL FOR THE TREATMENT OF ERECTILE DYSFUNCTION IN MEN WITH DIABETES
      Oral sildenafil was an effective and well-tolerated treatment for ED in men with diabetes. JAMA February 3, 1999; 281: 421-26

3-5 COMPARISON OF BEDTIME INSULIN REGIMENS IN PATIENTS WITH TYPE 2 DIABETES MELLITUS
      A simple bedtime insulin regimen in patients whose type 2 diabetes was poorly controlled with sulfonylurea achieved better control. This was attributed to education and self-adjusting insulin dose. The combination of bedtime insulin and metformin gave the best results. Annals Int. Med. March 2,1999; 130: 389-96

3-6 TREATING TYPE 2 DIABETES WITH RESPECT
      Intensive control of hypoglycemia can be achieved with relatively low risk of hypoglycemia or weight gain. Annals Int. Med. March 2, 1999; 120: 440-41

3-7 EFFECTS OF CALCIUM-CHANNEL BLOCKADE IN OLDER PATIENTS WITH DIABETES AND SYSTOLIC HYPERTENSION
      Treatment of isolated systolic hypertension with the calcium-channel blocker, nitrendipine, was beneficial in older patients, especially in older patients with diabetes. These findings do not support the hypothesis that long acting calcium-channel blockers may be harmful in diabetic patients. NEJM March 4, 1999; 340: 67-84

4-1 RELATION BETWEEN FASTING PLASMA GLUCOSE AND GLYCOSYLATED HEMOGLOBIN
      About 60% of a large cohort of patients newly diagnosed as having "diabetes", had a normal HbA1c. If this degree of glycemia persists, they would not be at risk of microvascular complications.
      "We believe that diabetes should not be diagnosed in those with FPG levels less than 140 unless excessive glycosylation is present. Individuals without excessive glycosylation but with moderate elevations of FPG (110-139) should be treated with an appropriate diet and exercise. This diagnostic labeling achieves the goal of early intervention, without subjecting individuals to potentially negative labeling." JAMA April 7, 1999; 281: 1203-1210

4-2 WHEN IS DIABETES DIABETES?
      If we agree that a FPG under 110 eliminates the risk of "diabetes" (at least for the immediate future), and that a FPG over 140 is diagnostic of "diabetes" with its risk of complications, this leaves a wide "grey zone" of 110 to 126 to 130. Where should the predictive cutpoint be set? The investigators suggest performing 2 diagnostic tests — FPG and HbA1c. This adds a measure of pathophysiologic abnormality (protein glycosylation) to the prediction of future complications. JAMA April 7, 1999; 281: 1222-24

5-2 TYPE 2 DIABETES MELLITUS: Greater Cardiovascular Risks and Greater Benefits of Therapy
      This brief editorial stresses an important clinical point. Diabetic persons are much more likely to suffer myocardial infarction and stroke than non-diabetics — and at a lower level of BP and at lower levels of LDL-cholesterol. Treatment of hypertension and lipids results in more benefit than in non-diabetics. Decisions to treat with drugs should start at lower cut points for BP and LDL-cholesterol. Archives Int. Med. May 24, 1999; 159: 1033-34

6-6 GLYCEMIC CONTROL WITH DIET, SULFONYLUREA, METFORMIN, OR INSULIN IN PATIENTS WITH TYPE 2 DIABETES MELLITUS Progressive Requirement for Multiple Therapies (UKPDS 49)
      Type 2 diabetes is characterized by a steady deterioration of glucose control over the years due to progressive beta-cell dysfunction. It becomes more difficult to attain near-normal glycemic control.
      Compared with diet alone, insulin, sulfonylurea, or metformin as monotherapy increased by 2- to 3-fold the proportion of patients who attained HbA1c below 7%. However, the progressive deterioration of diabetes control was such that after 9 years only about 25% of patients could be controlled on monotherapy.
      The majority of patients need multiple therapies to attain satisfactory glycemic control over the long-term. JAMA June 2, 1999; 281: 2005-12

7-9 ALCOHOL INTAKE AND THE RISK OF CORONARY HEART DISEASE MORTALITY IN PERSONS WITH OLDER-ONSET DIABETES MELLITUS
      This study suggests an overall beneficial effect of alcohol consumption on decreasing risk of death from CHD in people with older-onset diabetes. JAMA July 21, 1999; 282: 239-46

7-10 SHOULD PATIENTS WITH DIABETES DRINK TO THEIR HEALTH?
      What is true for most patients with diabetes is true for other patients at high risk for CHD — light to moderate alcohol consumption likely provides benefit, but is contraindicated in anyone who, for whatever reason, cannot restrict his or her drinking to light or moderate levels. Judicious recommendations can be made in individual cases when the patient is well known to the clinician. But, the recommendation to drink should not be generalized. JAMA July 21, 1999; 282: 279-80

7-3 RANDOMISED CONTROLLED TRIAL OF LONG TERM EFFICACY OF CAPTOPRIL ON PRESERVATION OF KIDNEY FUNCTION IN NORMOTENSIVE PATIENTS WITH INSULIN DEPENDENT DIABETES AND MICROALBUMINURIA
      The effect of ACE inhibition in preserving renal function in patients with NIDDM lasts at least 8 years. BMJ July 3, 1999; 319: 24-25

8-25 PHARMACOLOGIC THERAPY FOR TYPE 2 DIABETES
      For those who would enjoy a comprehensive view of therapy. Annals Int Med August 17, 1999; 131: 281-303

8-16 HYPOGLYCEMIA AND THE DECISION TO DRIVE A MOTOR VEHICLE BY PERSONS WITH DIABETES.
      Persons with type 1 diabetes may not judge correctly when their blood glucose levels are too low to permit safe driving. Many continue to drive when they are aware of low levels. Health care workers should be aware of the possible dangers and so counsel patients. JAMA August 25,1999; 282: 750-54

8-5 GLUCOSE TOLERANCE AND MORTALITY: Comparison of WHO and American Diabetes Association Diagnostic Criteria
      Fasting glucose concentrations alone do not identify individuals at increased risk of death associated with hyperglycemia. An oral glucose tolerance test, measuring the 2-hour glucose, enables detection of individuals with impaired glucose tolerance, as well as diabetes, who have the greatest attributable risk of death. Lancet August 21, 1999; 354: 617-21

8-6 CARDIOVASCULAR DISEASE IN OLDER ADULTS WITH GLUCOSE DISORDERS: Comparison of American Diabetes Association Criteria for Diabetes Mellitus with WHO Criteria
      "If the purpose of screening for diabetes mellitus is to identify the maximum number of people at risk of cardiovascular disease events or death when glucose is slightly raised, then it would seem that the WHO criteria are superior to the fasting ADA criteria." Lancet August 21, 1999; 354: 622-25

8-7 NEW DIAGNOSTIC CRITERIA FOR DIABETES—Are They Doing What They Should?
      The ADA and the WHO criteria do not identify the same groups of individuals. Among people with diabetes according to the ADA criteria, only 46% had a 2 hour post-glucose concentration that met the WHO criterion. And impaired fasting glucose by ADA (glucose of 110-125) was present in only 48% of individuals classified as having impaired glucose tolerance by WHO (140-199).
      The ADA criteria were much less sensitive than the WHO criteria in predicting CVD mortality (sensitivity 28% vs 54%). Lancet August 21, 1999; 354: 610-11

8-8 EFFECTS OF METFORMIN IN PATIENTS WITH POORLY CONTROLLED INSULIN-TREATED TYPE 2 DIABETES.
      The addition of metformin to insulin in type 2 diabetics who were poorly controlled by insulin alone resulted in better glycemic control, with a substantial decrease in HbA1c. The combination allowed insulin dose to be reduced with no weight gain.
      "Metformin is an effective adjunct to insulin therapy in patients with type 2 diabetes. Annals Int Med August 3, 1999;131: 182-188

10-13 WALKING COMPARED WITH VIGOROUS PHYSICAL ACTIVITY AND RISKS OF TYPE 2 DIABETES IN WOMEN.
      These data suggest that greater physical activity is associated with substantial reduction of risk for type 2 diabetes. JAMA October 20, 1999: 282: 1433-39

11-17 NEPHROPATHY IN PATIENTS WITH TYPE 2 DIABETES
      This article reviews epidemiology, pathology, genetic basis, risk factors, renal failure, and treatment. NEJM October 7, 1999; 341: 1127-33

11-10 TWICE DAILY VERSUS FOUR TIMES DAILY INSULIN DOSE REGIMES FOR DIABETES IN PREGNANCY
      Giving insulin four times daily rather than twice daily improved glycemic control in pregnancy and perinatal outcome without further risking the mother. BMJ November 6, 1999; 319: 1223-27

11-11 AN UPDATE ON PERIOPERATIVE MANAGEMENT OF DIABETES
      A review of pre- intra- and post-operative care. Perioperative management is generally more of an art than a clinical science. There are many protocols for management. Homeostasis during this period is highly variable and often unpredictable. Clinical judgement remains the key. Archives Int Med November 8, 1999; 159: 2405-11

12-12 NONINVASIVE GLUCOSE MONITORING
      An automatic, non-invasive glucose-monitoring machine (Glucowatch) which makes frequent measurements demonstrated close agreement with blood glucose measurements obtained by finger stick. The machine provided more information about glucose levels than the current standard of care. (The FDA has given the machine a conditional approval.) JAMA November 17, 1999; 282: 1839-44

12-1 REDUCED CORONARY EVENTS IN SIMVASTATIN-TREATED PATIENTS WITH CORONARY HEART DISEASE AND DIABETES OF IMPAIRED FASTING GLUCOSE LEVELS.
      In patients with established CHD, lowering cholesterol with simvastatin benefited patients with impaired fasting blood glucose (110 to 125) as well as patients with diabetes (FBG = 126). Total and coronary mortality and major coronary events were reduced in both groups. Archives Int Med December 13/27 1999; 2661-67

DIFFICULT PATIENT
5-7 DIFFICULT PATIENT ENCOUNTERS IN THE AMBULATORY CLINIC
      "Poor physician psychosocial attitude was strongly predictive of experiencing more encounters as difficult." Archives Int. Med. May 24, 1999; 159: 1069-75

DISSEMINATED INTRAVASCULAR COAGULATION
8-23 DISSEMINATED INTRAVASCULAR COAGULATION
      This article reviews incidence, associated causal clinical conditions, pathogenesis, diagnosis, clinical relevance, prognosis, and management. NEJM August 19, 1999; 341: 586-92

DOMESTIC VIOLENCE
10-9 A QUALITATIVE ANALYSIS OF HOW PHYSICIANS WITH EXPERTISE IN DOMESTIC VIOLENCE APPROACH THE IDENTIFICATION OF VICTIMS
      This sample of physicians' experience may help others navigate around barriers to try to help victims. Screening questions should be carefully framed. Reassure patients that asking about intimate relationships is part of the physician's job. Help the patient to understand that domestic violence is prevalent. This approach aims to normalize the process of identification and disclosure. It minimizes fear of offending patients, patient shame and denial, and fears of being identified. It places domestic violence squarely in the domain of public health. Annals Int. Med. October 19, 1999; 131: 578-84

10-10 INTEGRATING ROUTINE INQUIRY ABOUT DOMESTIC VIOLENCE INTO DAILY PRACTICE.
      The Joint Commission for Accreditation of Health Care Organizations now requires hospitals and clinics to institute protocols and training to help providers identify victims of abuse, assess their needs, provide interventions, and make referrals to community-based advocacy services. “Because domestic violence is so prevalent and its presentations are so varied, inquiring only when abuse is suspected is no longer considered adequate. It is essential that questions about abuse be fully integrated into the medical history rather than viewed as optional components to be added when there is time.” Annals Int. Med. October 19,1999; 131: 619-20

DRUG ABUSE
4-19 ACUTE HEROIN OVERDOSE
      This reviews pharmacology, epidemiology, diagnosis, treatment, complications, and prevention.
      "The concept of 'take home' naloxone as a method of preventing overdose-related deaths has recently been discussed. Despite misgivings, the potential opportunity to prevent thousands of heroin-related deaths warrants the dispassionate exploration of this option." Annals Int Med April 6, 1999; 130: 584-90

DRUG METABOLISM
4-13 GRAPEFRUIT JUICE FOUND TO CAUSE HAVOC WITH DRUG UPTAKE
      Grapefruit can both enhance absorption, perhaps to toxic levels, and reduce absorption, and lower effectiveness. No way to predict except by trial and error. Lancet April 17, 1999; 353: 1335

E

EFFICIENCY
4-16 DEFINITIONS OF EFFICIENCY
      In healthcare, efficiency measures whether resources are being used to get the best value for the money.
      "Adopting the criterion of economic efficiency implies that society makes choices which maximize the health outcomes gained from the resources allocated to healthcare. Inefficiency exists when resources could be reallocated in a way which would increase the health outcomes produced. " BMJ April 24, 1999; 318: 1136

ELECTROCARDIOGRAM
2-11 IMPROVED DETECTION OF CORONARY ARTERY DISEASE BY EXERCISE ELECTROCARDIOGAPHY WITH USE OF RIGHT PRECORDIAL LEADS
      Exercise electrocardiography incorporating the combination of right leads along with the standard left leads greatly improved sensitivity for the diagnosis of coronary artery disease. NEJM February 4,1999; 340; 340-45

2-12 THE VALUE OF THE RIGHT PRECORDIAL LEADS OF THE ELECTROCARDIOGRAM
      Right ventricular infarction carries a marked increase in mortality during hospitalization. Identification of right ventricular infarction by right chest leads may select those who would benefit most from reperfusion. NEJM February 4, 1999; 340: 381-83

EPIDEMIOLOGY — CLINICAL EPIDEMIOLOGY
4-12 PROBABILITY AT THE BEDSIDE: The Knowing of Chances or the Chances of Knowing
      "Uncertainty is inherent in medical practice because patients present individual and complex medical circumstances. Physicians can never be certain how to transpose a biomedical theory or a clinical research finding to a particular case. In an act of interpretation, not application, physicians make clinical sense of a case, rather than placing it in a general category of cases. As interpreters, physicians draw on all their knowledge, including their own experience of patients, and laboratory-science models of cause and effect." Annals Int. Med. April 6, 1999; 130: 604-06

ESOPHAGEAL VARICES
4-17 COMPARISON OF ENDOSCOPIC LIGATION AND PROPANOLOL FOR PRIMARY PREVENTION OF VARICEAL BLEEDING.
      In patients with high-risk varices, endoscopic ligation was safe and more effective than propanolol in the primary prevention of bleeding. Propanolol is modestly effective medical therapy. NEJM April 1, 1999; 340; 988-93

ESTROGEN (See also HORMONE REPLACEMENT THERAPY)
4-15 EFFECT OF ESTROGEN ON BRAIN ACTIVATION PATTERNS IN POSTMENOPAUSAL WOMEN DURING WORKING MEMORY TESTS.
      Therapeutic doses of estrogen altered activation of specific brain regions during the performance of the sorts of memory function that are called upon frequently during any given day. JAMA April 7, 1999; 281: 1197-1202

ETHICS
1-17 THE TROUBLE WITH FAMILIES: Toward an Ethic of Accommodation
      A system that saves lives or prolongs lives only to cast patients and families into the abyss of fragmented chronic care and financial and emotional ruin, while at the same time criticizing them for being "too emotional", is unjust. Many families are willing to make enormous sacrifices, but martyrdom is not a good basis for health care policies or practice.
      When families are pushed beyond their limits, the patient's care is jeopardized, the caregiver's health is at risk, professionals are frustrated, and the health care system is burdened by greater costs. "Our recommendations focus on human relationships, not technology." A health care system that depends so heavily on the patient care provided by families should involve families as partners rather than define them as problems. Annals Int. Med. January 19, 1999; 130:148-52

1-15 NARRATIVE IN MEDICAL ETHICS
      Narrative ethics focuses on the patient as narrator of his of her own story, including the ethical choices that belong to their story. The doctor must work as co-author with the patient to construct a joint narrative of illness and medical care. "Narrative practice is relational and requires the doctor to be an empathic witness to the patient's suffering. "BMJ January 23, 1999; 318: 253-56

3-12 MEDICAL FUTILITY IN END-OF-LIFE CARE
      The council finds great difficulty in assigning an absolute definition to the term futility since it is inherently a value-laden determination. A fair process approach is favored for determining and subsequently withholding or withdrawing what is felt to be futile care, without recourse to the court system. JAMA March 10, 1999; 281; 937-41

3-13 THE RULE OF DOUBLE EFFECT
      The rule of double effect is the philosophical underpinning for the critically important concept of a side effect. "Clinicians opposed to euthanasia and assisted suicide can understand that they might conscientiously use potent drugs to treat terminally ill patients under circumstances in which hastening the death of a patient can be considered a morally permissible side effect." Archives Int Med March 22, 1999; 159: 545-50

5-4 WHEN DOCTORS MIGHT KILL THEIR PATIENTS: Foreseeing is Not Necessarily the Same as Intending
      There is a practical test of the difference between foreseeing and intending:
      A. If, having relieved the patient's pain and distress, one ceases to give morphine until and unless the pain or distress recur, then one's intention has clearly not been to kill the patient.
      B. If, despite relieving the pain and distress, one goes on giving more morphine until the patient does die (or gives a much higher dose than one thinks necessary) then clearly one not only foresees the patient's death — one intends it.
      According to the principle of "double effect", if the patient dies after A, the intervention can be considered a side effect of treatment. If the patient dies after B, death is intended and not a side effect, and not considered ethical under the principle of "double effect". BMJ May 29, 1999; 318: 1431-32

9-18 GAINING INFORMED CONSENT FOR SCREENING
      "Because of the combination of benefit and harm in all procedures, the individuals being screened must receive full and accurate information about the procedure and must give their informed consent." "Failure to obtain informed consent for many current preventive interventions is clearly unethical." BMJ September 18, 1999; 319: 722-23

10-12 LYING FOR PATIENTS: Physician Deception of Third Party Payers
      Many physicians sanction the use of deception to secure a third-party payers' approval of medically indicated care. A new ethic of cost control in the use of limited resources conflicts with the old ethic of patient advocacy. Although using deception to solve impasses may succeed in the interim, the long-term costs in loss of integrity are high. Archives Int Med October 25, 1999; 2263-70

EVIDENCE-BASED MEDICINE
1-16 NARRATIVE BASED MEDICINE IN AN EVIDENCE BASED WORLD
      Appreciating the narrative nature of illness and the intuitive and subjective aspects of the clinical method does not require us to reject the principles of evidence-based medicine. Genuine evidence- based practice actually presupposes an interpretive paradigm in which patients experience illness in a unique and contextual way.
      It is only within such an interpretive paradigm that a clinician can reach an integrated clinical judgement and meaningfully draw on all aspects of evidence — his or her own case based experience, the patient's individual and cultural perspectives, and the results of rigorous clinical research trials and observational studies. BMJ January 30, 1999; 318: 32325

3-17 EVIDENCE AND ETHICS
      "Evidence-based medicine and the clinical pathways derived from it can aid, but should never supercede or replace, the judgement of a clinician who knows both the patient and the evidence." Lancet March 6,1999; 353: 829-31

3-18 EVIDENCE-BASED INTERVENTIONS AND COMPREHENSIVE TREATMENT
      "The complexity of clinical practice can be clarified by distinguishing the disease dimension from the personal dimension. In general practice, the personal dimension predominates. In general practice the personal dimension offers a particularly rich potential for intervention." Lancet March 13, 1999; 353: 916-18

EXERCISE (See also FITNESS)
11-16 PLATELET ACTIVATION WITH EXERCISE AND RISK OF CARDIAC EVENTS
      An individual unaccustomed to habitual physical activity has about a 50-fold increase in the risk of sudden death and a 100-fold increase in risk of acute myocardial infarction when undertaking vigorous exercise – as compared with remaining at rest. Although physical fitness does not completely remove the risk of an event associated with vigorous exertion, it greatly reduces risk. Lancet November 20, 1999; 354: 1747-48

F

FAMILIES
1-17 THE TROUBLE WITH FAMILIES: Toward an Ethic of Accommodation
      A system that saves lives or prolongs lives only to cast patients and families into the abyss of fragmented chronic care and financial and emotional ruin, while at the same time criticizing them for being "too emotional", is unjust. Many families are willing to make enormous sacrifices, but martyrdom is not a good basis for health care policies or practice.
      When families are pushed beyond their limits, the patient's care is jeopardized, the caregiver's health is at risk, professionals are frustrated, and the health care system is burdened by greater costs. "Our recommendations focus on human relationships, not technology." A health care system that depends so heavily on the patient care provided by families should involve families as partners rather than define them as problems. Annals Int. Med. January 19, 1999; 130:148-52

FIBER
10-7 DIETARY FIBER, WEIGHT GAIN, AND CARDIOVASCULAR DISEASE RISK FACTORS IN YOUNG ADULTS.
      Dietary fiber was inversely associated with insulin levels, weight gain, and other risk factors for CVD in young adults. JAMA October 27, 1999; 282: 1539-46

FIBROMYALGIA
3-16 FIBROMYALGIA FALLS FOUL OF A FALLACY
      "Fibromyalgia, the neurasthenia of the late 20th century, is about to follow its 19th century namesake (neurasthenia), paying yet again the penalty of a failure to distinguish between cause and effect." Lancet March 27,1999; 353: 1092-93

FITNESS
1-10 BENEFITS OF LIFESTYLE ACTIVITY VS STRUCTURED EXERCISE.
      Two randomized clinical trials in the issue of JAMA 1, 2 compared the effects of lifestyle physical activity vs structured exercise on fitness, body composition, and risk factors for cardiovascular disease. The studies demonstrated that a lifestyle approach to increasing activity among previously sedentary persons can be effective and has similar effects on fitness, body composition, and blood pressure as a traditional structured exercise program. JAMA January 27, 1999, 281: 375-76

1-2 THE ASSOCIATION BETWEEN CARDIORESPIRATORY FITNESS AND IMPAIRED FASTING GLUCOSE AND TYPE 2 DIABETES MELLITUS IN MEN
      Poor cardiorespiratory fitness was associated with increased risk for developing impaired fasting glucose and type 2 diabetes. A sedentary lifestyle may contribute to progression from normal fasting glucose to impaired fasting glucose, to diabetes. Annals Int. Med. January 19, 1999; 130: 89-96

10-13 WALKING COMPARED WITH VIGOROUS PHYSICAL ACTIVITY AND RISKS OF TYPE 2 DIABETES IN WOMEN.
      These data suggest that greater physical activity is associated with substantial reduction of risk for type 2 diabetes. JAMA October 20, 1999: 282: 1433-39

FOLATE – FOLIC ACID
6-20 LABORATORY DIAGNOSIS OF VITAMIN B12 AND FOLATE DEFICIENCY
A Guide for the Primary Care Physician
      “The accurate diagnosis of deficiencies is a complex task. No easily performed test can reliably serve as a diagnostic gold standard." Archives Int Med., June 28, 1999; 159: 1289-98

FRACTURES
4-7 OCCULT VITAMIN D DEFICIENCY IN POSTMENOPAUSAL U. S. WOMEN WITH ACUTE HIP FRACTURE
      Many postmenopausal community-dwelling women presenting with hip fracture showed occult vitamin D deficiency. JAMA April 24, 1999; 281: 1505-11

FUNCTIONAL FOODS
7-22 FUNCTIONAL FOODS: Health Boon or Quackery?
      "The dividing line between foods and drugs is becoming increasingly blurred, In the United States a canned split pea soup features the herb St.John's Wort to 'give your mood a natural lift' and a chewing gum with phosphatidyl serine claims it 'improves concentration'. In Japan a soft drink named VegitaBeta is fortified with beta-carotene 'to support a healthy lifestyle'. And in the United Kingdom MD Foods claimed that its butter-like spread made with fish oil would benefit the heart. What is our food supply turning to?"BMJ July 24, 1999; 319: 205-06

9-7 FUNCTIONAL FOODS
      "'Functional food' has become a buzz word both in nutrition research and the food industry. The term hints of a future in which specially developed foods will protect consumers from a variety of diseases and discomforts. How realistic is this expectation?" Lancet September 4, 1999; 354: 794

FUNGAL INFECTIONS
4-8 DOUBLE BLIND, RANDOMISED STUDY OF CONTINUOUS TERBINAFINE COMPARED WITH INTERMITTENT ITRACONAZOLE IN TREATMENT OF TOENAIL ONYCHOMYCOSIS
      Continuous terbinafine was significantly more effective than intermittent itraconazole in the treatment of toenail onychomycosis. It "should be the current treatment of choice for onychomycosis". BMJ April 17, 1999;318: 1031-35

7-12 SYSTEMATIC REVIEW OF TOPICAL TREATMENTS FOR FUNGAL INFECTIONS OF THE SKIN AND NAILS OF THE FEET.
      There is little evidence to differentiate between popular over-the-counter topical treatments for fungal skin infections. The most effective strategy is to initially use an over-the-counter drug and save the prescription drug to treat failures. BMJ July 10, 1999; 319: 79-82

7-13 SKIN AND NAIL FUNGI — Almost Beaten
      The editorialist believes "that the most effective treatment for a topical dermatophyte infection is topical terbinafine, and for onychomycosis is oral terbinafine." BMJ July 10, 1999; 319: 71-72

G

GASTRO-ESOPHAGEAL REFLUX DISEASE (GERD)
3-11 HEARTBURN – A SERIOUS SYMPTOM
      Heartburn is the hallmark of gastroesophageal reflux, a disorder that may lead to esophagitis, progressing to metaplastic columnar mucosal changes (Barrett's esophagus), and ultimately to adenocarcinoma. Many patients with heartburn receive short-term treatment, which allows frequent relapses. "Physicians need to be aware that gastroesophageal reflux is a chronic disorder that usually calls for maintenance therapy." NEJM March 18, 1999; 340: 878-79

GERIATRICS
3-2 ANTIHYPERTENSIVE DRUGS IN VERY OLD PEOPLE: A Subgroup Meta-analysis of Randomised Controlled Trials
      An age limit beyond which hypertension should not be treated cannot be justified. Lancet March 6, 1999; 353: 793-96

3-3 HOW SHOULD AGE AFFECT MANAGEMENT OF ACUTE MYOCARDIAL INFARCTION?
      Elderly patients with acute MI were treated less vigorously than younger patients. The prognosis was substantially influenced by left ventricular failure. Some elderly patients have better outlooks than younger patients with adverse clinical factors. Considering age independently of clinical status is inappropriate. Lancet March 20, 1999; 353: 955-59

3-4 IS INTENSIVE DRUG THERAPY APPROPRIATE FOR OLDER PATIENTS?
      The evidence from clinical trials that included older patients, however, did not support restriction of beta-blockers or thrombolytic agents from the elderly. A statistical model has shown that thrombolysis administered to patients over age 75 was cost-effective. And beta-blocker use in elderly patients was associated with lower mortality at 2 years.
      "Owing to the greater incidence of comorbid illness in the elderly, physicians will have to be especially diligent in screening older patients for treatment with thrombolysis, beta-blockers, and other agents." Lancet March 20, 1999; 353: 940

4-3 GERIATRICS AND THE LIMITS OF MODERN MEDICINE
      The editorial comments on 3 problems for old people:
      1) Possible harm from treatment of proto-illness — risk factors which produce no symptoms or disease but thought to possibly cause subsequent disease. 2) Overtesting to establish a diagnosis, 3) Overtreatment by multiple specialists, all feeding on Medicare. NEJM April 22, 1999; 340: 1283-85

5-16 ORAL HEALTH OF ELDERLY OCCUPANTS IN RESIDENTIAL HOMES
      This study reports poor dental health was the standard in nursing homes. There was no systematic approach to arranging dental care. Care was arranged only when the resident or family complained of acute dental problems. Few had seen a dentist in the past 2 years.
      Poor dental health may contribute to eating problems, and the low nutrient and vitamin C levels found in this group — and cause weight loss, dehydration, and debility Lancet May 23, 1999; 353: 1721

5-12 THE DEFINITION OF ANEMIA IN OLDER PERSONS
      Anemia (hemoglobin concentrations below 12 g/dL for women and below 13 g/dL for men) was associated with increased mortality in individuals over age 85. These criteria for diagnosing anemia are appropriate for older persons. A lower hemoglobin at old age signifies disease. JAMA May 12, 1999; 281: 1714-17

8-1 POPULATION BASED STUDY ON SOCIAL AND PRODUCTIVE ACTIVITIES AS PREDICTORS OF SURVIVAL AMONG ELDERLY AMERICANS
      Social and productive activities that involve little or no enhancement of fitness lowered the risk of all cause mortality as much as physical fitness. Activities other than physical (which increases cardiopulmonary fitness) may confer survival benefits through psychosocial pathways. Social and productive activities that require less physical exertion may constitute alternative interventions for frail elderly people. An exclusive emphasis on physical fitness activity may be overly narrow. BMJ August 21, 1999; 319: 478-83

8-2 SOCIAL DISENGAGEMENT AND INCIDENT COGNITIVE DECLINE IN COMMUNITY-DWELLING ELDERLY PERSONS
      At 12 years, the odds ratio of experiencing cognitive decline was approximately twice as great in the most disengaged group as in the most engaged group. Continued mental stimulation staves off cognitive deterioration in old age possibly by maintaining a critical density of neocortical synapses. Annals Int Med August 3, 1999; 131: 165-73

8-11 CHOLESTEROL LOWERING IN THE ELDERLY POPULATION
      The National Cholesterol Education Program emphasizes the need to include the elderly (age 75-80+) in clinical management of high cholesterol. The elderly carry the highest risk for CHD and the highest burden of atherosclerotic heart disease. Archives Int Med August 9/23 1999; 159: 1670-78

GRAPEFRUIT JUICE
4-13 GRAPEFRUIT JUICE FOUND TO CAUSE HAVOC WITH DRUG UPTAKE
      Grapefruit can both enhance absorption, perhaps to toxic levels, and reduce absorption, and lower effectiveness. No way to predict except by trial and error. Lancet April 17, 1999; 353: 1335

H

HEALTH CARE
5-21 PATIENT-PHYSICIAN RACIAL CONCORDANCE AND THE PERCEIVED QUALITY AND USE OF HEALTH CARE
      Black respondents with black physicians were more likely than those with non-black physicians to rate their physicians as excellent, to report receiving preventive care, and all needed care. Hispanics with Hispanic physicians were more likely than those with non-Hispanic physicians to be very satisfied with their care. Physicians who are able to overcome this lack of concordance are indeed expert clinicians. Archives Int. Med. May 10, 1999; 997-1004

6-4 GENERAL PRACTITIONERS' PERCEPTIONS OF EFFECTIVE HEALTH CARE
      "The findings of our study suggest that the central assumptions of the evidence based medicine paradigm may not be shared by many general practitioners, making its application to general practice problematic."
      "The suggested routes to practicing evidence-based medicine fail to comprehend the complex nature of general practice." BMJ June 5, 1999; 318:1532-35

HEALTH LITEERACY
2-3 HEALTH LITERACY AMONG MEDICARE ENROLLEES IN A MANAGED CARE ORGANIZATION
      Elderly managed care enrollees may not have the literacy skills necessary to function adequately in the health care environment. This may limit ability to care for their health problems. JAMA February 10, 1999; 281: 545-51

HEART FAILURE
1-7 THE CARDIAC INSUFFICIENCY BISOPROLOL STUDY II (CIBIS II)
      Beta-blocker therapy with bisoprolol had benefits for survival in stable heart-failure patients. Lancet January 2, 1999; 353; 9-13

2-17 INCREASED PULSE PRESSURE AND RISK OF HEART FAILURE IN THE ELDERLY
      In this prospective study of community-based elderly, PP was independently and linearly associated with risk of HF. JAMA February 17, 1999; 281: 634-39

3-8 THE EVIDENCE FOR BETA-BLOCKERS IN HEART FAILURE
      Benefit of beta-blockers equals or surpasses that for ACE inhibitors. Most patients in the trials of beta-blockers were already taking ACE inhibitors, so the benefits of beta-blockade appear additional to those of ACE inhibitors. "The evidence that beta-blockers reduce mortality in patients with left ventricular systolic dysfunction is now compelling."
      They are most effectively and safely used in patients with milder symptoms to retard deterioration and increase the length and quality of life. BMJ March 27, 1999; 824-25

6-2 EFFECT OF METOPROLOL CR/XL IN CHRONIC HEART FAILURE:The MERIT-HF Trial
      Metoprolol controlled release/long-acting once daily in addition to optimum standard therapy improved survival in patients with stable chronic heart failure. Lancet June 12, 1999; 353: 2001-07

6-3 BENEFIT OF BETA-BLOCKERS FOR HEART FAILURE: Proven in 1999
      "The benefit of beta-blocker treatment for heart failure is now certain and substantial and should be incorporated into modern practice guidelines." Lancet June 12, 1999; 353: 1988-89

9-1 THE EFFECT OF SPIRONOLACTONE ON MORBIDITY AND MORTALITY IN PATIENTS WITH SEVERE HEART FAILURE
      Blockade of aldosterone receptors by spironolactone, in addition to standard therapy with ACE inhibitors, loop diuretics, and digoxin substantially reduced risk of both morbidity and mortality among patients with severe HF. NEJM September 2, 1999; 341: 709-17

9-2 ALDOSTERONE AND SPIRONOLACTONE IN HEART FAILURE
      The study indicates that the beneficial effects of spironolactone in blocking aldosterone receptors are additive to those of ACE inhibitors. This is an important therapeutic advance. Therapy of HF should be broadened to include spironolactone as long as renal function is adequate. NEJM September 2, 1999; 341: 753-54

HELICOBACTER PYLORI
11-12 REVERSAL OF IRON DEFICIENCY ANEMIA AFTER HELICOBACTER PYLORI ERADICATION IN PATIENTS WITH ASYMPTOMATIC GASTRITIS
      In this cohort of adult patients with iron deficiency associated with chronic pangastritis due to H pylori, cure of the infection cured the anemia. Annals Int Med November 2, 1999; 131: 668-72

HEPATIC ENCEPHALOPATHY
5-17 DIETARY MANAGEMENT OF HEPATIC ENCEPHALOPATHY
      The myth of protein restriction persists. Protein restriction continues to be advised. Perhaps more alarmingly, restriction therapy is used in patients with cirrhosis who have no neuropsychiatric impairment.
      At the current state of knowledge it seems sensible to give enough protein (up to 1.5 g/kg/d) to maintain a good nutritional state. BMJ May 22, 1999; 318: 1364-65

HIV
3-22 POSTEXPOSURE CHEMOPROPHYLAXIS FOR OCCUPATIONAL EXPOSURES TO THE HUMAN IMMUNODEFICIENCY VIRUS
      This article considers: safety and efficacy of antiretroviral chemoprophylaxis and suggested clinical management. A table (p 934) presents the US Public Health Service recommendations for postexposure regimens. JAMA March 10, 1999; 281: 931-36
12-18 1999 USPHS/IDSA GUIDELINES FOR THE PREVENTION OF OPPORTUNISTIC INFECTIONS IN PERSONS INFECTED WITH THE HUMAN IMMUNODEFICIENCY VIRUS
      In August 1999, the US Public Health Service and the Infectious Disease Society of America published these updated guidelines. They are intended primarily for health care providers who care for HIV-infected persons. The document is long and inclusive. Annals Int Med December 7, 1999; 131: 873-908

HMOs
10-12 LYING FOR PATIENTS: Physician Deception of Third Party Payers
      Many physicians sanction the use of deception to secure a third-party payers' approval of medically indicated care. A new ethic of cost control in the use of limited resources conflicts with the old ethic of patient advocacy. Although using deception to solve impasses may succeed in the interim, the long-term costs in loss of integrity are high. Archives Int Med October 25, 1999; 2263-70

HOMOCYSTEINE
9-11 HOMOCYSTEINE IN HEALTH AND DISEASE
      The epidemiological evidence connecting risk with elevated levels is consistent, strong, and biologically plausible. The risk is also independent of other risk factors. But data from prospective studies are weaker, with some conflicting results. Causality has not been proven. Annals Int Med September 7, 1999; 131: 387-88

HORMONE REPLACEMENT THERAPY
6- 8 THE EFFECT OF LOW-DOSE CONTINUOUS ESTROGEN AND PROGESTERONE THERAPY WITH CALCIUM AND VITAMIN D IN ELDERLY WOMEN
      Continuous oral administration of conjugated equine estrogen 0.3 mg/d and medroxyprogesterone 0.25 mg/d, combined with adequate calcium and vitamin D produced a significant bone-sparing effect in elderly women. The combination was well tolerated by most women. Annals Int. Med. June 1, 1999; 130: 897-904

7-23 HORMONE REPLACEMENT THERAPY
      In June 1999, the European Institute of Oncology met at Milan Italy with the aim of synthesizing clinical data on hormone replacement therapy (HRT). Much of the data came from women who used conjugated equine estrogens or estradiol, often given with a progestagen.
      Users tend to be healthier, better educated, more physically active, leaner, and to more often drink moderate amounts of alcohol than other women in the same region. Thus, data must be interpreted with caution. Bias probably influences results of studies. Lancet July 19, 1999; 354: 152-55

HOSPICE
11-3 EVALUATION OF PROGNOSTIC CRITERIA FOR DETERMINING HOSPICE ELIGIBILITY IN PATIENTS WITH ADVANCED LUNG, HEART, AND LIVER DISEASE.
      For seriously ill patients with chronic obstructive pulmonary disease, congestive heart failure, and end-stage liver disease, the recommended clinical prediction criteria were not effective in identifying individuals with a survival prognosis of 6 months or less. JAMA November 3, 1999; 282: 1638-45

11-4 HOW GRAVELY ILL BECOMES DYING: The Key to End-of-Life Care
      The preceding study concluded that we cannot accurately predict duration of remaining life in seriously ill persons, many of whom “never experience a time during which they were clearly dying of their disease”. “The sickest patients are not necessarily the ones who die first.” JAMA November 3, 1999; 282: 1670-72

HUMAN PAPILLOMA VIRUS
11-7 PERNICIOUS PAPILLOMA INFECTIONM
      “In sum, cervical cancer often begins with the sexual transmission of HPV infection to a woman who is susceptible to persistent infection. Over time, the HPV lesions progress to invasive cervical cancer.” NEJM November 25, 1999; 341: 1687-88

HYPERPARATHYROIDISM
10-14 A 10-YEAR PROSPECTIVE STUDY OF PRIMARY HYPERPARATHYROIDISM WITH OR WITHOUT PARATHYROID SURGERY
      In patients with primary hyperparathyroidism, parathyroidectomy resulted in the normalization of biochemical values and increased BMD. Most asymptomatic patients who did not undergo surgery, did not have progression of the disease over 10 years, although about 1/4 of them did. NEJM October 21, 1999; 341: 1249-55

10-15 TREATMENT OF PRIMARY HYPERPARATHYROIDISM
      Most patients with primary hyperparathyroidism probably have symptoms of the disease. The symptoms may be subjective, or may be due to nephrolithiasis or osteopenia. Surgery improves both types of symptoms, as well as preventing recurrent stones and reversing osteopenia. Surgical treatment is now much simpler and faster than in the past. “It should now be recommended for nearly all patients.” NEJM October 21, 1999; 341: 13011-02

HYPERTENSION
3-7 EFFECTS OF CALCIUM-CHANNEL BLOCKADE IN OLDER PATIENTS WITH DIABETES AND SYSTOLIC HYPERTENSION
      Treatment of isolated systolic hypertension with the calcium-channel blocker, nitrendipine, was beneficial in older patients, especially in older patients with diabetes. These findings do not support the hypothesis that long acting calcium-channel blockers may be harmful in diabetic patients. NEJM March 4, 1999; 340: 67-84

3-2 ANTIHYPERTENSIVE DRUGS IN VERY OLD PEOPLE: A Subgroup Meta-analysis of Randomised Controlled Trials
      An age limit beyond which hypertension should not be treated cannot be justified. Lancet March 6, 1999; 353: 793-96

4-21 MINERALCORTICOID HYPERTENSION
      "A high index of suspicion is needed in every hypertensive patient. Hypertensive patients with hypokalemia, together with those with severe hypertension (eg, those on triple therapy), or a family history of hypertension or stroke, should be screened for mineralcortocoid excess." Indeed, all patients with hypertension should have their electrolyte concentrations measured. Lancet April 17, 1999; 353: 1341-47

4-9 LEFT VENTRICULAR HYPERTROPHY IN HYPERTENSION
      When ECG evidence of left ventricular hypertrophy is present, the hypertrophy is advanced. This confers a risk of cardiac involvement several times greater than that attributed to the associated blood pressure level. Indeed, the risk is similar to that associated with a history of myocardial infarction. NEJM April 22, 1999; 340: 1221-27

6-19 OPTIMISATION OF ANTIHYPERTENSIVE TREATMENT BY CROSSOVER ROTATIONS OF FOUR MAJOR CLASSES
      Essential hypertension is a heterogeneous disorder. It would be surprising if the variable pathogenesis did not cause detectable variability in individual responses to different agents.
      There is a marked variability in hypertensive patients' response to different antihypertensive drugs. Optimization of treatment requires systematic rotation through several therapies. An AB/CD rule is proposed in which one of each of the two pairs is initially selected to abbreviate the rotation in routine practice. "We found significant variability in the response of most patients to the four main classes of antihypertensive agents. This variability was such that only a minority of patients were likely to receive their best drug first, or to reach a conventional target for blood pressure treatment without the process of systematic rotation. " Lancet June 12, 1999; 353: 2008-13

6-1 THE LONG-TERM PROGNOSTIC SIGNIFICANCE OF REPEATED BLOOD PRESSURE MEASUREMENTS IN THE ELDERLY.
      The study found a strong, positive, continuous, and independent association in elderly people between total and cardiovascular mortality and systolic BP, but not diastolic BP.
      This suggests that diastolic BP is still overstressed in the diagnosis and treatment of older patients.
      Any benefit in treatment of hypertension in the elderly might be attributed more to lowering systolic BP than to lowering diastolic BP. Indeed, effectiveness of therapy of isolated systolic hypertension is well documented. Archives Int. Med. June 14,1999, 1203-12

7-2 WALKING TO WORK AND RISK FOR HYPERTENSION IN MEN: The Osaka Health Survey
      Walking to work and other types of physical activity decreased the risk for hypertension in Japanese men. Annals Int Med July 6, 1999; 130: 21-26

9-5 BRITISH HYPERTENSION SOCIETY GUIDELINES FOR HYPERTENSION MANAGEMENT 1999: Summary
      This article summarizes guidelines for management of hypertension. Since previous British guidelines (1989 and 1993), new evidence has emerged on optimal BP targets; management of hypertension in diabetic persons; treatment of isolated systolic hypertension; comparison of the antihypertensive efficacy and tolerability of different drug classes; the role of non-pharmacological measures for prevention and treatment of hypertension; and additional benefits associated with the use of aspirin and statins. BMJ September 4, 1999; 319: 630-35

10-1 CARDIAC AND ARTERIAL TARGET ORGAN DAMAGE IN ADULTS WITH ELEVATED AMBULATORY AND NORMAL OFFICE BLOOD PRESSURE (WHITE COAT NORMOTENSION)
      White coat normotension is the converse of white coat hypertension – in the former, clinic (office) BP is higher than ambulatory BP; in the latter, clinic BP is higher than the ambulatory BP.
      White coat normotension was associated with increased left ventricular mass and carotid wall thickness. The association of white coat normotension with prognostically important target organ damage may partly explain the ability of high normal clinic BP to predict subsequent hypertension and cardiovascular events. Annals Int Med October 19, 1999; 131: 564-72

11-1 RANDOMISED TRIAL OF OLD AND NEW ANTI-HYPERTENSIVE DRUGS IN ELDERLY PATIENTS: Cardiovascular Mortality and Morbidity: The Swedish Trial in Old Patients with Hypertension-2 Study
      Old (diuretic and beta-blockers) and new (ACE inhibitors and calcium blockers) anti-hypertensive drugs were equally effective in preventing cardiovascular mortality or major events over 5 years in elderly patients with hypertension. Lancet November 20, 1999; 354: 1751-56

11-2 CONVENTIONAL VERSUS NEWER ANTIHYPERTENSIVE THERAPIES – A DRAW
      The prudent cost-effective prescriber who has decided that thiazide diuretics should be first-line treatment for elderly hypertensive people, will be further encouraged by this and other studies. LANCET November 20, 1999; 1744-45

I

IMMUNITY - IMMUNOTHERAPY (See also ALLERGIC RHINITIS)
2-18 CHRONIC STRESS IN ELDERLY CARERS OF DEMENTIA PATIENTS AND ANTIBODY RESPONSE TO INFLUENZA VACCINE
      Elderly carers of spouses with dementia have increased activation of the hypothalamic-pituitary-adrenal axis and a poor response to influenza vaccine.
      Carers may be more vulnerable to infectious disease. Lancet February 20, 1999; 353: 627-31

IMMUNIZATION
12-8 NEW RECOMMENDATIONS FOR ADULT IMMUNIZATION
      The Advisory Committee on Immunization Practices recommends the age for receiving flu vaccine be lowered from 65 to 50, in part because morbidity and mortality for influenza start to rise at age 50. JAMA December 15, 1999; 282: 2199

INCONTINENCE
2-8 SINGLE BLIND, RANDOMISED, CONTROLLED TRIAL OF PELVIC FLOOR EXERCISES, ELECTRICAL STIMULATION, VAGINAL CONES, AND NO TREATMENT IN MANAGEMENT OF GENUINE STRESS INCONTINENCE IN WOMEN
      Training of the pelvic floor muscles with exercise was superior to electrical stimulation and vaginal cones in treatment of genuine stress incontinence. BMJ February 20, 1999; 318: 487-93

INFECTIOUS DISEASE
12-13 QUINUPRISTIN/DALFOPRISTIN, A NEW ADDITION TO THE ANTIMICROBIAL ARSENAL
      A new drug, quinupristin/dalfopristin (Synercid), is now licensed in the US. It is active against gram-positive bacteria, including difficult organisms such as methicillin-resistant Staphylococcus aureus , and vancomycin-resistant Enterococcus faecium, and penicillin-resistant and macrolide-resistant pneumococci. Its activity is exclusively against gram-positive pathogens.
      The drug is specifically indicated when no other antibacterial agents are suitable. When mixed infections are suspected, quinupristin/dalfopristin should be used in combination with one or more agents active against nosocomial