10-1 BODY MASS INDEX, WAIST CIRCUMFERENCE, AND HEALTH RISK
      Health risk is greater in individuals with high WC (> 40 inches in men and > 35 Inches in women) regardless of BMI category, including individuals with normal weight. A high WC independently predicts obesity-related disease.

10-2 THE NEW NATIONAL CHOLESTEROL EDUCATION PROGRAM GUIDELINES
      The new NCEP-III guidelines present new clinical challenges to health care providers and their patients. They recommend stricter target lipid levels as well as a broader approach to risk assessment.

10-3 COMPLICATIONS OF DIABETES IN ELDERLY PEOPLE
      As diabetes increasingly becomes a disease of elderly people, some of its unappreciated complication must be addressed. These include:

Cognitive disorders
Physical disability
Falls and fractures
Other geriatric syndromes

10-4 WHY MEN WITH PROSTATE CANCER WANT WIDER ACCESS TO PROSTATE SPECIFIC ANTIGEN TESTING: Qualitative Study
      Most men with established or suspected PC received little information about risks and benefits of screening beforehand. Most thought that universal screening should be available.
      Many men are ill prepared for test results, and for the possible iatrogenic effects of treatment.

10-5 NATURAL EXPERIMENT EXAMINING IMPACT OF AGGRESSIVE SCREENING AND TREATMENT ON PROSTATE CANCER MORTALITY IN TWO FIXED COHORTS FROM SEATTLE AREA AND CONNECTICUT
      More intensive screening and treatment for PC was not associated with a lower PC-specific mortality over 11 years.

10-6 PROSTATE SPECIFIC ANTIGEN TESTING FOR PROSTATE CANCER
      “If a patient asks a medical practitioner for help, the doctor does the best possible. The doctor is not responsible for defects in medical knowledge. If, however, the practitioner initiates screening procedures, the doctor is in a very different situation. The doctor should, in our view, have conclusive evidence that screening can alter the natural history of disease in a significant proportion of those screened.”
      The difficulty remains – who and when to screen, or not to screen at all. All men who choose screening should be adequately informed about risks and benefits beforehand.

10-7 HOME BASED EXERCISE PROGRAMME FOR KNEE PAIN AND KNEE OSTEOARTHRITIS
      A simple home-based exercise program can produce significant reductions in knee pain and stiffness, and improvement in physical functioning over 2 years.

10-8 UNDERTREATMENT OF OSTEOPOROSIS IN MEN WITH HIP FRACTURE
      The burden of hip fracture is high in old men as well as women. Few men receive antiresorptive therapy. Men should be tested for osteoporosis before fracture closes the door of effective therapy.

10-9 GLUCOSAMINE SULFATE USE AND DELAY OF PROGRESSION OF KNEE OSTEOARTHRITIS.
      Long-term treatment with glucosamine sulfate retarded the progression of knee OA.

10-10 PRIMARY PREVENTION OF HYPERTENSION
      Current recommendations for primary prevention involve a population-based approach and an intensive strategy targeted on individuals at high risk for hypertension. The 2 strategies are complementary. They emphasize 6 approaches with proven efficacy for prevention:

Engage in moderate physical activity
Maintain normal body weight
Limit alcohol consumption
Reduce sodium intake
Maintain adequate intake of potassium
Consume a diet rich in fruits, vegetables, and low-fat dairy products with reduced saturated and total fat.

10-11 THE SCOFF QUESTIONNAIRE AND CLINICAL INTERVIEW FOR EATING DISORDERS IN GENERAL PRACTICE.
      Do you ever make yourself SICK because you feel uncomfortably full?
      Do you worry you have lost CONTROL over how much you eat?
      Have you recently lost more than ONE stone (14 pounds)?
      Do you believe yourself to be FAT?
      Would you say that FOOD dominates your life?
      The predictive value of a positive test was low; predictive value of a negative test was high. (Ie, if the test is positive, a definite diagnosis cannot be made – further observation is needed. If the test is negative, it is highly likely that the patient does not have A-B. )

10-12 GLUCOCORTICOID AND BETA-RECEPTOR AGONIST INTERACTIONS IN ASTHMA
      The preferred approach in asthma management combines a low-dose corticosteroid with an LABA. “It is notable that current management is based on pharmacological modification of two molecules that the adrenal glands produce in response to stress, namely adrenaline and hydrocortisone. It would make biological sense for these agents to potentiate each other’s effects, therefore maximizing the benefits that can be obtained from smaller quantities of either agent alone.”

10-13 ELECTRODE POSITIONING FOR CARDIOVERSION OF ATRIAL FIBRILLATION
      If control by cardioversion to sinus rhythm is chosen, positioning the electrodes anterior-posterior is more effective.
      For management of AF, two alternative strategies have emerged: 1) attempts to cardiovert and maintain sinus rhythm, or 2) attempts to maintain ventricular rate control while AF continues and is treated with long-term anticoagulation.
      Cumulatively, the data suggest that, compared with heart-rate control, maintaining sinus rhythm does not confer risk-benefits for mortality or thromboembolic events, or for major quality-of-life improvements.

10-14 HEPARIN PLUS ALTEPLASE COMPARED WITH HEPARIN ALONE IN PATIENTS WITH SUBMASSIVE PULMONARY EMBOLISM
      Treatment with alteplase + heparin improved the clinical course of stable patients with acute submassive PE. It prevented further clinical and hemodynamic deterioration which would have required escalation of treatment.

10-15 DIGOXIN – NEW PERSPECTIVE ON AN OLD DRUG.
      Digoxin has a narrow therapeutic window. In patients with normal cardiac rhythm, the beneficial hemodynamic, neuro-hormonal, and clinical effects are found with a low concentration of approximately 0.7 ng/mL. Additional benefits are not seen with higher doses traditionally considered therapeutic (with serum concentrations of 1.0 to 1.5 ng/mL). These higher concentrations may predispose to arrhythmias.
      Since digoxin may result in adrenergic stimulation at higher concentrations, or in patients with ischemia, the combination of digoxin with beta-blockade may have theoretical advantages
      We should not abandon a therapy that may help patients with heart failure. Rather we should use a dose that will result in a serum concentration lower than 1.0 ng per milliliter.

10-16 SCREENING AND BRIEF INTERVENTION OF EXCESSIVE ALCOHOL USE: Qualitative Interview Study Of Experiences Of General Practitioners.
      Screening and brief intervention programs may fail to detect harmful drinkers, while requiring considerable resources for primary prevention in groups of hazardous drinkers. Screening-based brief interventions left the practitioners with a sense of failure in achieving rapport and compliance, and was not congruent with contemporary approaches to dealing with lifestyle issues.
      Screening for excessive alcohol use created more problems than it solved.

10-17 PREVENTION OF DEMENTIA WITH ANTIHYPERTENSIVE TREATMENT
New Evidence from the Systolic Hypertension in Europe (Syst-Eur) Trial
      A 4-year follow-up study extending antihypertension therapy reinforced the evidence that BP-lowering therapy initiated with a long-acting dihydropyridine calcium blocker (nitrendipine) protects against dementia in older patients with systolic hypertension.

10-18 FISH, MEAT, AND RISK OF DEMENTIA: A Cohort Study
      Regular consumption of fish was associated with a lower risk of future development of dementia.

10-19 STATIN-ASSOCIATED MYOPATHY WITH NORMAL CREATININE LEVELS
      “Some patients who develop muscle symptoms while receiving statin therapy have demonstrable weakness and histopathologic findings of myopathy despite normal serum creatinine kinase levels.” Symptoms and histologic features reverted to normal on withdrawal of the drug.

10-20 XIMELAGATRAN VERSUS WARFARIN FOR PREVENTION OF VENOUS THROMBOEMBOLISM AFTER TOTAL KNEE ARTHROPLASTY
      Introducing a new anticoagulant. More confirmatory studies will be required before it can be entered into primary care practice. If it pans out, its fixed dose, oral administration, absence of interactions with food and drugs, and the fact that it requires no anticoagulation monitoring will be great advantages. RTJ

Men: Normal < 102 cm (< 40 inches) ; high > 102 cm (> 40 inches)
Women: Normal < 88 cm (35 inches); high > 88 cm (> 35 inches).

1. The Third National Health and Nutrition Examination consisted of over 14 500 adult participants considered to be a cross-sectional survey of the population.
2. Calculated BMI. Measured WC at a point half way between lower ribs and iliac crest with the patient at minimal inspiration. (I presume this was standing and not supine, although the study did not state. RTJ)
3. Compared risk factors in individuals within each of 3 BMI categories:

   Normal weight with normal WC vs normal weight with high WC
   Overweight with normal WC vs overweight with high WC
   Class I obese with normal WC vs class I obese with high WC.

1. Considering only the normal weight subjects and comparing those with normal vs those with high WC for both men and women:

   Age and BMI were higher in the high WC group. BP, fasting glucose, total cholesterol, LDL-cholesterol, and triglycerides were also higher
   Prevalence of hypertension, type 2 diabetes, high LDL-c, low HDL-c, hypertriglyceridemia and the metabolic syndrome was higher in the high WC group.

2. In the overweight and class I obese, these factors varied in the same way.

1. Health risks were greater in individuals with a high WC regardless of their BMI category.
2. “These observations underscore the importance of incorporating BMI and WC evaluation into routine clinical practice and provide substantive evidence that the sex-specific NIH cutoff points for the WC help to identify those at increased health risk within various BMI categories.”
3. The additional health risk explained by the WC likely reflects its ability to act as a surrogate for abdominal and, in particular, visceral fat.
4. Those with high WC were older than those with normal WC independent of sex and BMI. A high WC remained a significant predictor of obesity-related comorbidity after adjusting for age and other confounding variables.
5. This does not imply the dichotomous approach to WC values (40 inches in men and 35 inches in women) is the ideal threshold to denote increased health risk. The relation between WC and visceral fat is influenced by race and age. The ideal threshold values are not known.

Cognitive disorders
Physical disability
Falls and fractures
Other geriatric syndromes

1. Recruited 52 men with suspected or confirmed PC. All had received a PSA test.
2. Interviewers asked the men to tell their story, from when they first noted their symptoms and had the test.

1. Almost all remembered their PSA, but recalled being given little information beforehand.
2. Arguments in favor of increased access to testing included the belief that early diagnosis would reduce mortality, improve quality of life, and save the health care system money.
3. The men also thought that a national screening program should be available because symptoms can be ambiguous. A national program would encourage men to be screened. They felt screening would be responsible health behavior.
4. The majority of men were keen about others having a PSA tests for various reasons:

   Belief that early diagnosis is important to cure PC or to prevent it from spreading.
   Regarding screening as a responsible behavior similar to women’s cancer screening.
   Saving the health services money.
   A right to information and improved access.
   Equitability (ie, rights and parity with other health care spending).
   

5. Concerns about the accuracy of the PSA were mentioned, but not considered a convincing deterrent.
6. Only 4 men opposed screening. They had gathered information alerting them to uncertainty about the benefits of treatment. Two regretted that they had been tested. They emphasized that those who seek a PSA test should have pretest counseling. One man who was not in favor believed that total screening would terrify so many people that it would do more harm than good. One regretted having received the screen. If he had not known the results he would have happily lived on in ignorance. Another became intensely anxious and expected to die.

1. The study looked at PSA testing from the unique view point of men with suspected or confirmed PC. Many followed a different set of principles from those intended to guide screening programs. They did not dwell on the lack of a clear treatment choice.
2. The fact that PSA screening is offered routinely to men with private health insurance in the UK may promote the notion that it is valuable.
3. Practitioners in the UK are been advised to ensure that men who have PSA testing are making an informed choice. A key component in this information should be the uncertainty about benefits and risks of treatments. “However, arguments based on principles such as the ‘right to information’ about one’s health, equality, and the ‘imperative to avoid regret’ will persuade some men to have the test, even if they understand that no treatment in known to prolong life.”
4. Doctors and policy makers need to understand why people want wider access to PSA testing, so they can find better ways of communicating information about risk.

1. Population-based, natural experiment compared two fixed cohorts of men from 1987 to 1997.
2. Subjects were male Medicare beneficiaries age 65-79 drawn from Seattle (n > 94 000) and Connecticut (n > 120 000). All were without PC as of January 1987.
3. Determined rates of screening and treatment with radical prostatectomy with surgery and radiation.
4. Determined PC-specific mortality 1987 to 1999.

1. PSA testing rates in Seattle was over 5 times that of Connecticut. Biopsy rate was over twice that of Connecticut.
2. Ten year cumulative incidence of radical prostatectomy and external beam radiotherapy was higher in Seattle. (2.7% and 3.9% of the cohort compared with 0.5% and 3.1%)
3. No significant difference in PC-specific mortality existed between the cohorts over the entire 11 years of follow-up. Adjusted rate ratio of PC mortality was 1.03 in Seattle compared with Connecticut. (Confidence interval = 0.95 to 1.11)

1. The authors stress that the study included only men over age 65. Screening younger men may have resulted in different conclusions.
2. The follow-up of 11 years may not have been long enough to see a difference in mortality.

1. Pragmatic, randomized, controlled trial in two general practices followed over 750 patients (age > 45) with self-reported knee pain for most days for at least a month.
2. Randomized to: 1) exercise therapy; 2) monthly telephone contact; 3) exercise therapy + telephone contact; and 4) no intervention.
3. The exercise program was simple and applicable for all age groups. It was designed to maintain and improve the strength of muscles around the knee, the range of motion at the knee, and locomotive function. The program was self-paced and became progressively more challenging. Graded exercise bands were used to increase the resistance against which the muscles worked. The initial training period, taught in the patients’ homes by a trained researcher, consisted of 4 visits lasting about 30 minutes in the first 2 months, with follow-up at intervals of 6 months. Participants were encouraged to perform the program for 20-30 minutes a day, increasing the number of repetitions up to a maximum of 20 per leg.
4. The primary outcome was self-reported knee pain at 2 years on a knee-specific osteoarthritis index. The score could range for 0 to 20, with higher scores indicating more pain. Baseline score in exercise group = 6.9
5. Other outcomes were self-reported knee-specific physical function and stiffness, psychological outlook and depression, and isometric muscle strength.
6. Follow-up = 2 years.

1. Forty eight % of the exercise group completed the study.
2. At 24 months highly significant reductions in knee pain were apparent in the pooled exercise groups, compared with the non-exercise groups. Mean difference in pain score was -1.12 favoring the exercise group. (Number needed to treat to achieve > 50% improvement in knee pain = 13.)
3. Similar improvements were evident at 6, 12, and 18 months. The reduction in pain was greater the closer patients adhered to the exercise plan.
4. Regular telephone contacts alone did not reduce pain.
5. Scores of stiffness and physical function also showed significant improvement in the exercise groups.
6. General physical function, anxiety and depression were not improved.

1. A simple home-based exercise program produced small but significant reductions in knee pain. The program was generally well tolerated. Adherence was moderate.
2. Social support alone produced no benefit. The beneficial effects could reasonably be attributed to exercise alone.

1. Reviewed data from medical records of 363 patients (110 men, 253 women; mean age = 80) age 50 and over who sustained a low-energy hip fracture.
2. Main outcome = osteoporosis treatments prescribed at discharge and current treatments over a 5-year follow-up.

1. Most fractures resulted from falls from a standing height.
2. At hospital discharge, 5% of men received treatment of any kind for osteoporosis, compared with 27% of women.
3. At 1 to 5 year follow-up, 27% of men were taking any kind of osteoporosis treatment vs 71% of women. Treatment for men consisted of calcium-vitamin D only in 18% vs 23% of women. Only 3 men received bisphosphonates vs 35 women; 17% of women received estrogen.
4. Twelve month mortality for men was 32% for men vs 17% for women.

1. Attention to treatment of men with osteoporosis has been minimal.
2. In this study, over a 5-year period after hip fracture only about ¼ of men were taking any treatment for osteoporosis. Of these, most were taking non-aggressive therapy with only calcium-vitamin D.
3. “We suggest that the problem is not the lack of available treatment, but rather a lack of physician awareness of the lifetime risk of osteoporosis and fracture in men.”
4. Few old men receive bone-density measurements.
5. The urgency of the situation is illustrated by the high mortality and disability (especially for men) after hip fracture.
6. Older men (as well as women) should be evaluated for osteoporosis long before the first fracture event.
7. Responsibility for long-term therapy with bisphosphonates and calcium/vitamin D in both men and women , with and without fracture, rests primarily on the primary care clinician. Identification of risk and prophylactic therapy should begin early, before a fracture begins to close the door of effective therapy.

1. Randomized and followed to completion 121 patients with knee OA (mean age = 62) to: 1) glucosamine sulfate 1500 mg once daily, or 2) placebo. OA had been present a mean of 10 years.
2. Crystalline glucosamine was used. It is available by prescription in Europe, and as a nutritional supplement in the USA. (Rotta Pharmaceuticals, Wall, NJ.)
3. Determined changes in the radiographic joint space width in the medial compartment of the tibio-femoral joint Also assessed symptom change by indices – pain, maximum distance walked, stiffness, and limitation of physical function.
4. Follow-up = 3 years.

1. OA was of mild or moderate severity at enrollment. Average joint space widths were slightly less than 4 mm, and an index score less than 9 points. All patients were able to extend the knee.
2. Over 3 years, joint narrowing progressed in the placebo group (-0.19 mm). There was no average change with glucosamine (+0.4 mm) -- a significant difference between groups.
3. Fewer patients in the glucosamine group experienced predefined severe narrowing (> 0.5mm -- 5% vs 14%).
4. Symptoms improved modestly with placebo, but as much as 25% with glucosamine. Final differences in the symptom-indexes were significant. Benefit was evident at one year.
5. The drug was safe – no difference in adverse effects between groups.

1. Long-term oral glucosamine sulfate for 3 years can delay progression of knee OA. Symptoms and limitation of motion were improved compared with the placebo group.
2. On average, glucosamine patients did not undergo progressive joint structure changes.
3. The authors calculate that 11 patients needed to be treated to prevent one from experiencing clinically substantial joint space loss.
4. After oral administration, glucosamine is bioavailable, and reaches the articular cartilage. It is preferentially incorporated by the chondrocytes into the components of the glycol-amino-glycan chains in the intact cartilage. It stimulates the synthesis of proteoglycans, and decreases the activity of catabolic enzymes.
5. “Glucosamine sulfate is the first agent that meets the current requirements to be classified as a symptom and structure-modifying drug in osteoarthritis.”

Engage in moderate physical activity
Maintain normal body weight
Limit alcohol consumption
Reduce sodium intake
Maintain adequate intake of potassium
Consume a diet rich in fruits, vegetables, and low-fat dairy products with reduced saturated and total fat.

Do you ever make yourself SICK because you feel uncomfortably full?
Do you worry you have lost CONTROL over how much you eat?
Have you recently lost more than ONE stone (14 pounds)?
Do you believe yourself to be FAT?
Would you say that FOOD dominates your life?

      Sensitivity of a test = the percentage of patients with the target disorder who have a positive test. (The true positive test %) (The number of true positive tests / total number of subjects with the target disorder.) Of all patients in this study who actually had A-B (n = 13), 11 had a positive test ( 11/13 = 85%)
      Sensitivity of this test = 85% (85% were true positives; 15% false negatives).

      Specificity of a test = the percentage of subjects who do not have the target disorder who have a negative test. (The number of true negative tests / total number of negative tests.) Of all patients in this study who did not have A-B (n = 328), 294 had a negative test (294/328 = 90%) Specificity of this test = 90%. (90% true negatives; 10% false positives)

      Predictive value of positive tests = ratio of true positive tests to all positive tests. Of all patients in this study who had positive tests (n = 45), 11 were true positives, 34 false positives). Positive predictive value = 11/45 = 24% Thus, in this study, even if 2 or more questions are answered positively, there is still considerable doubt that anorexia-bulimia is present. (Too many false positives.)

      Predictive value of negative tests = ratio of true negative tests to total of all negative tests. Of all patients in this study who had negative tests (n = 296), 294 were true negatives; 2 were false negative. 294/294 = 99%. Thus, in this study, if 4 or 5 questions were answered negatively, the probability of A-B was very low.

Upside: If successful, no need for warfarin prophylaxis; exercise tolerance better.
Downside: Requires drug or electrical conversion. Both may fail. Adverse effects of drugs to maintain sinus rhythm (eg, amiodarone). (High rate of withdrawal due to adverse effects.) Reversion to AF common (about 50% revert to AF within one year). Hospitalizations more frequent. Higher costs.

Upside: Simpler -- avoidance of cardioversion. Fewer adverse drug reactions. Fewer hospitalizations. Exercise tolerance lower. Lower costs.
Downside: Continued drug therapy (calcium blocker; digoxin; warfarin)

1. Followed patients with acute PE who had pulmonary hypertension or right ventricular dysfunction, or both. None had arterial hypotension or shock.
2. Randomized 256 patients (mean age = 61). All patients received an intravenous bolus of 5000 U unfractionated heparin before undergoing further work up. They were then randomized to: 1) 100 mg alteplace as a 10 mg bolus followed by 90 mg over two hours, + heparin 1000 U per hour adjusted to activated partial thromboplastin time of 2.0 to 2.5 times upper limits of normal, or 2) heparin only. Heparin was continued for at least 4 days. Overlapping warfarin started on day 3.
3. Patients had at least one of the following: echocardographically detected right ventricular dysfunction defined as: 1) right ventricular enlargement combined with loss of inspiratory collapse of the inferior vena cava and without left ventricular or mitral valve disease); 2) echocardographically detected pulmonary artery hypertension (defined as tricuspid regurgitant jet velocity greater than 2.8 m per second), followed by confirmation by ventilation-perfusion lung scan, spiral computed CT, or pulmonary arteriography; 4) a mean pulmonary artery pressure > 20 mm Hg combined with a pulmonary wedge pressure below 18mm Hg followed by confirmation of a PE; or 5) new ECG signs of right ventricular strain (complete or incomplete right bundle branch block, S waves in lead 1 combined with Q waves in lead III or inverted T waves in precordial leads, followed by confirmation of PE. (Ie, diagnostic criteria were strict.)
4. Primary outcome = in-hospital death or clinical deterioration requiring an escalation of treatment (catecholamine injection, “rescue” thrombolysis due to worsening symptoms, cardiopulmonary resuscitation, or emergency embolectomy or thrombus fragmentation by catheter).

1. A higher incidence of escalation of therapy occurred in the heparin-alone group (25% vs 10%).
2. Mortality was low in both groups (3.4% in the heparin-alteplase group vs 2.2% in the heparin alone group). Heparin alone was associated with almost three times the risk of treatment escalation as was combined therapy. (Ie, event-free survival was much higher in the combined group.)
3. No fatal bleeding occurred in the combined group.

1. In treatment of massive PE, thrombolytic agents dissolve PE and improve pulmonary perfusion and right ventricular function. The present study assessed whether submassive PE would respond favorably to thrombolysis.
2. Results indicate that alteplase, given with heparin, improves the clinical course of hemodynamically stable patients with acute submassive PE with a low risk of hemorrhagic complications.
3. The clinical course and prognosis of acute PE vary widely, depending on the clinical and hemodynamic status at the time of diagnosis . Right ventricular dysfunction is a predictor of adverse outcomes.
4. The current trial focused on patients with evidence of pulmonary hypertension and right ventricular dysfunction. Patients with persistent arterial hypotension or shock resulting from overt right ventricular failure were excluded. (In this subset, immediate thrombolysis is indicated.)
5. Although in-hospital mortality was similar (and low) in the two randomized groups, the incidence of clinical deterioration requiring escalation of treatment was much higher in the heparin-alone group.
6. “It seems reasonable to assume that delayed resolution (or lack of resolution), or recurrence of pulmonary embolism with heparin alone, resulted in persistence or deterioration of pulmonary hypertension and right-sided heart failure.”

1. Conducted qualitative interviews with primary care clinicians who had participated in a pragmatic study of a combined program of screening and a brief intervention for excessive alcohol use. Over 6500 patients age 18-64 had been screened.
2. Screening was done using the AUDIT alcohol use disorders identification test. About 15% of patients drank excessively (over 12 units per week.). Alcohol dependence was suspected in 3%.
3. The study then interviewed the general practitioners who had conducted the screen and attempted intervention. Doctors in 24 practices volunteered for the study. They were interviewed in focus groups and individually to investigate the suitability, validity, and effectiveness of such a program.

1. Doctors were surprised at how difficult it was to establish rapport with the patients who had a positive result on screening and to ensure compliance with the intervention.
2. Doctors often failed to follow-up on initial interventions. Some expressed a lack of confidence in their ability to counsel patients effectively on lifestyle issues.
3. Doctors questioned the rationale of screening in young drinkers who may grow out of excessive drinking behaviors. A large number of young hazardous drinkers was identified. Many doctors felt that the prevention of alcohol problems in young people should chiefly take place earlier and elsewhere in the community and in their families. They felt that systematic interventions for young drinkers were not a natural part of their job, and questioned the rationale of screening in young drinkers.
4. The program needed considerable resources. It interrupted the natural course of consultations and was inflexible.
5. The doctors could not recommend the screening and intervention program, although they thought it important to counsel their patients on drinking.
6. Most doctors were convinced that some patients did not respond honestly to the questionnaire. Many drinkers declined screening or gave poor excuses for not being able to participate.
7. Almost all doctors experienced negative reactions from some patients, ranging from uneasiness or embarrassment, lying about their drinking behaviors, or to finding another doctor. However, most doctors felt their relationships with patients were robust enough for them to give advice on sensible drinking.
8. Most patients in the intervention group who revisited their primary care clinician had not been followed up on their drinking,
9. Some doctors said that a few patients may have been encouraged to take steps to modify their drinking behavior, but in general they were deeply skeptical about the effects of the intervention on behavior.
10. Lack of time and lack of training were considered by doctors to be important barriers to the effectiveness of the program. Ten minutes of intervention several times a day was experienced as stressful. Some believed that 10 to 15 minutes was too little time anyway, as alcohol problems were often part of a much more complex problems.
11. Both focus groups and 4 of the 5 doctors who were interviewed individually concluded that they could not recommend screening, nor would they screen their patients in the future.

1. Brief interventions on lifestyle matters are efficacious. They can work in ideal conditions and for selected patients. However, how doctors actually feel, think, and perform with respect to such programs may diverge from the official rhetoric on health promotion programs in primary care practice.
2. Clinical health promotion programs should take account of the professional, practical, technical, and ethical factors.
3. These results underline the value of pragmatic studies of the suitability of apparently efficacious programs before they are implemented on a wider scale.

1. Over 2000 patients entered in the original study. All were at least 60 years old at baseline. Systolic BP was between 160 and 219, with diastolic below 95. None had dementia..
2. Drug treatment was continued in the active group and started in the previous control group.
3. Treatment was based on the dihydropyridine calcium-blocker nitrendipine (10-40 mg/d) with possible addition of the ACE inhibitor enalapril (Vasotec; 5- 20 mg), hydrochlorothiazide 12.5 -25 mg, or both add-on drugs.
4. The original study covered 2 years. The add-on study continued treatment for an additional 2 years (4 years overall).

1. Incidence of dementia doubled in the 3rd and 4th years from 32 to 64 cases, 41 of whom had Alzheimer disease.
2. During the 3rd and 4th years, BP in the previous control group (n = 1400) was 7/3.2 mm Hg higher than in the subjects first randomized to active treatment.
3. At last examination, fewer patients in the previous control group were taking the active drugs than in the previous active treatment group.
4. Compared with previous controls, long-term antihypertension treatment was associated with a reduction in incidence of dementia from 7.4 to 3.3 cases per 1000 patient-years; (43 vs 21 total cases of dementia; 29 vs 12 cases of Alzheimer disease).
5. After adjustment for sex, age, education, and entry BP, the relative hazard rate of dementia associated with the use of nitrendipine was 0.38.
6. Treatment of 100 patients for 5 years was calculated to prevent 2 cases of dementia.

1. The present study demonstrated a high degree of consistency with the original study in the reduction of risk of dementia associated with antihypertension therapy based on nitrendipine.
2. The original hypothesis was that treatment of hypertension would protect mainly against vascular dementia. Recent studies suggest that hypertension, and more generally, all risk factors involved in arteriosclerosis, may contribute to the incidence of degenerative dementias.
3. “There is a growing awareness that the distinction between Alzheimer disease and vascular dementia is less clear than initially envisaged, both conditions sharing similar mechanisms and lesions albeit to different degrees.”
4. In this study, benefit was predominantly attributable to the prevention of degenerative dementia rather than dementia occurring in association with cardiovascular events such as stroke.
5. Some reports suggest that calcium channel blockers may confer specific neuroprotection. The aging brain loses its ability to regulate intracellular calcium, leading to a cascade of cellular impairments and ultimately to cell death. Calcium channel blockers might provide better protection against stroke than treatment based on diuretics and beta-blockers. 2

1. Obtained data from the PAUID (Personnes Agees QUID) epidemiological study of cognitive and functional ageing.
2. In 1991-92 visited over 1600 persons, all aged over 68. All were without dementia and living at home in southwestern France.
3. Determined frequency of consumption of fish or seafood: daily, at least once a week (but not every day), from time to time (but not every week), and never.
4. Followed participants for up to 7 years for onset of dementia.
5. Incidence of dementia was confirmed by a visited by a neurologist to confirm the diagnosis. (DSM-III-R)
6. Calculated incidence of dementia per 100 person-years.

1. During 7 years, 170 new cases of dementia occurred, including 135 cases of Alzheimer’s disease.
2. Risk of dementia decreased as consumption of fish or seafood increased:

   	Incidence per 100 patient-years
   Fish or seafood consumption	Dementia	Alzheimer’s
   Once a day	1.00	1.00
   At least once a week	2.05	1.64
   From time to time	2.90	2.24
   Never	6.61	5.29

3. Participants who ate fish or seafood at least once a week had a significantly lower risk of being diagnosed as having dementia in the 7 subsequent years. (Hazard ratio = 0.66) The hazard ratio for Alzheimer’s was 0.69)

1. Elderly persons who ate fish or seafood at least once a week were at lower risk of developing dementia, including Alzheimer’s disease over a period of 7 years.
2. The Rotterdam study reported similar results over a period of 2 years.
3. In addition to providing vascular protection,, the n-3 fatty acids contained in fish oils could reduce inflammation in the brain and may have a specific role in brain development and regeneration of nerve cells.