Review

Journal rack: new evidence for primary care

From BMJ USA 2003;May:285

This section calls attention to new studies and systematic reviews selected by the Editor from journals published just as this issue went into production (approximately 2 months before publication). Studies are noted that might directly influence clinical practice decisions in primary care. The journals hand-searched for the Journal rack are: American Journal of Medicine, American Journal of Preventive Medicine, Annals of Internal Medicine, Circulation, JAMA, Journal of General Internal Medicine, Journal of the American Board of Family Practice, JNCI, Lancet, New England Journal of Medicine, Obstetrics and Gynecology, Pediatrics.

Cardiovascular — A modeling analysis by the World Health Organization estimated that "non-personal" interventions to lower systolic blood pressure (eg, government efforts to reduce salt content of foods) could avert more than 21 million disability-adjusted life-years (DALYs) per year worldwide. A combination of personal and non-personal interventions for individuals whose 10-year risk of a cardiovascular event is greater than 35% would avert an additional 63 million DALYs per year (Murray et al. Lancet March 1, 2003;361:717-725).

Cardiovascular — A Canadian randomized trial involving 24 patients with obstructive sleep apnea and heart failure found that continuous positive airway pressure had a salutary lowering effect on systolic blood pressure and heart rate, and it increased the left ventricular ejection fraction from an average of 25% to 34% (Kaneko et al. N Engl J Med March 27, 2003;348:1233-1241).

Cardiovascular — A Swiss randomized trial involving 282 patients with chronic angina found that 1-year outcomes were similar for those treated with optimized medical therapy or with coronary angiography followed by revascularization. Subsequent hospitalization with revascularization was less likely among patients who underwent invasive therapy (Pfisterer et al. JAMA March 5, 2003;289:1117-1123).

Cardiovascular — A randomized trial involving 1439 patients with unstable angina or acute myocardial infarction found that treatment with azithromycin did not lower the incidence of recurrent events. Serological and epidemiological evidence had suggested an association between Chlamydia pneumoniae infection and coronary artery disease (Cercek et al. Lancet March 8, 2003;361:809-813).

Cardiovascular — Prospective data from the Framingham Heart Study found that an increased plasma homocysteine level almost doubled the risk of congestive heart failure within 8 years (Vasan et al. JAMA March 12, 2003;289:1251-1257).

Cardiovascular — A systematic review of 8 trials concluded that implantable cardioverter defibrillators reduced the risk of sudden cardiac death by 57% compared with usual care (most commonly, amiodarone therapy). The benefits of the device persisted regardless of baseline risk (Ezekowitz et al. Ann Intern Med March 18, 2003;138:445-452).

Cardiovascular — Analysis of trial data for 1929 patients with chronic heart failure found that a weight loss of 6% or more doubled the risk of impaired survival, but treatment with enalapril reduced that risk by 19% (Anker et al. Lancet March 29, 2003;361:1077-1083).

Endocrinologic — A randomized trial involving 130 adults age 45 and older, 39% of whom had type 2 diabetes, found that those taking daily multivitamin and mineral supplements had lower rates of self-reported infection and infection-related absenteeism than did those taking placebo (Barringer et al. Ann Intern Med March 4, 2003;138:365-371).

Endocrinologic — A prospective study of 6391 overweight and obese adults age 35 and older found that attempting to lose weight was associated with a 20% reduction in mortality, even if there was no change in weight (Gregg et al. Ann Intern Med March 4, 2003;138:383-389).

Endocrinologic — A systematic review of 117 studies found that ephedra and ephedrine promoted modest short-term weight loss (approximately 0.9 kg/month more than with placebo) but increased the risk of psychiatric, autonomic, gastrointestinal, and cardiac complications by a factor of 2.2 to 3.6 (Shekelle et al. JAMA March 26, 2003;289:1537-1545).

Endocrinologic — An analysis of adverse reactions reported to poison control centers found that products containing ephedra accounted for 64% of all adverse reactions to herbs in the United States, yet these products represented only 0.82% of herbal product sales (Bent et al. Ann Intern Med March 18, 2003;138:468-471).

Mental health — A British systematic review of 6 trials found that electroconvulsive therapy was significantly more effective in the short-term treatment of depressive symptoms than either sham electroconvulsive therapy or pharmacotherapy (The UK ECT Review Group. Lancet March 8, 2003;361:799-808).

Neurologic — A Dutch prospective study of 1015 non-demented adults age 60 to 90 found that those with silent brain infarcts on baseline imaging were 2.3 times more likely to develop dementia within 4 years (Vermeer et al. N Engl J Med March 27, 2003;348:1215-1222).

Neurologic — A randomized trial involving 81 patients with neuropathic pain refractory to treatment found that 8 weeks of high-strength (0.75 mg) levorphanol, a potent opioid agonist, reduced pain by 36%, compared with a 21% reduction for those receiving the low-strength preparation (0.15 mg). The higher strength had no additional effect on affective distress or functional status (Rowbotham et al. N Engl J Med March 27, 2003;348:1223-1232).

Oncologic — A randomized trial involving 635 patients with previously diagnosed colorectal cancer found that daily aspirin reduced the incidence of new adenomas by 35% over 13 months. Another trial involving 1121 patients with recent adenomas reported a more modest reduction in risk, which was statistically significant for patients taking 81 mg but not 325 mg of daily aspirin (Sandler et al. N Engl J Med March 6, 2003;348:883-890; Baron et al. N Engl J Med March 6, 2003;348:891-899).

Oncologic — A meta-analysis of 13 studies concluded that screening for prostate cancer with the prostate-specific antigen test was more accurate than digital rectal examination in terms of sensitivity (72% versus 53%), specificity (93% versus 84%), and positive predictive value (25% versus 18%) (Mistry and Cable. J Am Board Fam Pract March-April 2003;16:95-101).

Pediatric — Cross-sectional analysis of national survey data has revealed an association between pediatric dental caries and passive exposure to tobacco smoke. Children with elevated cotinine levels had twice the risk of decayed and filled tooth surfaces on their deciduous teeth (Aligne et al. JAMA March 12, 2003;289:1258-1264).

Pediatric — A British retrospective cohort study found that children who had been exposed to skin products containing peanut oil were 7 times more likely to develop peanut allergy (Lack et al. N Engl J Med March 13, 2003;348:977-985).

Pediatric — An analysis of child safety seat installation instructions revealed that they were written at a 7th to 12th grade reading level (mean readability grade level, 10.3). Almost half of Americans read at or below the 8th grade level (Wegner and Girasek. Pediatrics March 2003;111:588-591).

Primary care practice — A cohort study of the ambulatory care among Medicare beneficiaries identified 13.8 preventable adverse drug events per 1000 person-years of observation, 38% of which were serious or life threatening. Most errors associated with such events occurred at the prescribing or monitoring stage. The serious events were most likely to be preventable (Gurwitz et al. JAMA March 5, 2003;289:1107-1116).

Primary care practice — A survey of 700 prospective jurors at a county courthouse found that 26% condoned physician deception of insurance companies (misrepresenting a patient's condition) to obtain coverage for a desired service (Alexander et al. Ann Intern Med March 18, 2003;138:472-475).

Renal — Prospective data on 1624 women enrolled in the Nurses' Health Study suggest that high protein intake by women with mild renal insufficiency may accelerate their loss of renal function Knight et al. Ann Intern Med March 18, 2003;138:460-467).

Rheumatologic — A meta-analysis of 7 studies of the treatment of de Quervain's tenosynovitis reported an 83% cure rate with injection alone, 61% for injection and splint, 14% for splint alone, and 0% for rest or non-steroidal anti-inflammatory drugs (Richie and Briner. J Am Board Fam Pract March-April 2003;16:102-106).

Substance abuse — A randomized trial involving 41 primary care physicians found that giving providers the results of alcohol screening questions and recommendations for their patients was associated with increased rates of alcohol counseling by physicians and decreased rates of alcohol consumption by patients 6 months later (Saitz et al. Ann Intern Med March 4, 2003;138:372-382).

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