Reviews

From BMJ USA 2003;Jan:52

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. 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 Family Practice, Journal of General Internal Medicine, Journal of the American Board of Family Practice, JNCI, Lancet, New England Journal of Medicine, Obstetrics and Gynecology, Pediatrics

CardiovascularA randomized trial involving 111 sedentary, overweight adults with dyslipidemia revealed that the salutary effect of exercise on lowering lipids had more to do with the amount of exercise (eg, jogging a total of 20 versus 12 miles per week) than with the intensity of the sessions (65-80% versus 40-55% of peak oxygen consumption). (Kraus et al. N Engl J Med Nov 7, 2002;347:1483-1492.)

CardiovascularAn Indian randomized trial involving 1000 patients with coronary artery disease or surrogate risk factors found that an Indo-Mediterranean diet (emphasizing whole grains, fruits, vegetables, walnuts, and almonds) achieved significantly lower serum cholesterol levels and a 52% reduction in total cardiac end points over 2 years than did the conventional step I National Cholesterol Education Program diet (emphasizing reduced total and saturated fat intake). (Singh et al. Lancet Nov 9, 2002;360:1455-1461.)

CardiovascularA cohort study of 27 939 healthy women revealed that the 8-year risk of cardiovascular events and death was more strongly predicted by an elevated level of C-reactive protein than by an elevated level of LDL cholesterol. The differences in risk were modest, however: Relative risks for women in the highest quintile of C-reactive protein and LDL cholesterol levels were 2.3 and 1.5, respectively. (Ridker et al. N Engl J Med Nov 14, 2002;347:1557-1565.)

CardiovascularA European randomized trial involving 5804 patients age 70-82 with vascular disease or related risk factors found that those who took pravastatin (40 mg daily) reduced their 3-year risk of coronary artery and stroke events by 15% compared with those taking placebo. (Shepherd et al. Lancet Nov 23, 2002;360:1623-1630.)

CardiovascularA review of 33 practice guidelines on hypertension and hyperlipidemia found that those guidelines that were less adherent to 8 criteria for guideline quality were more likely to promote aggressive treatment thresholds, drug selection, and screening. The criteria were less likely to be met in guidelines developed by specialty societies. (Fretheim et al. J Fam Pract Nov 2002;51:963-968.)

CardiovascularA systematic review of 19 trials found that patients with mild to moderate reactive airway disease do not experience adverse respiratory effects from cardioselective -blockers. (Salpeter et al. Ann Intern Med Nov 5, 2002;137:715-725.)

CardiovascularA cohort study of 35 520 patients age 65 and older who had been hospitalized for myocardial infarction found that the subsequent 2-year mortality rate was 18.3% if patients' follow-up care was managed by an internist or family physician, 14.6% if they saw a cardiologist, and 11.1% if they received concurrent care involving both specialties. (Ayanian et al. N Engl J Med Nov 21, 2002;347:1678-1686.)

CardiovascularA British randomized trial involving 67 800 men age 65-74 found that those who underwent a single abdominal ultrasound examination (followed by a protocol for scan-detected aortic aneurysms) had a 42% reduction in aneurysm-related deaths compared to those who did not undergo screening. There were 65 such deaths in the screened group and 113 in the control group. See editorial on page 10. (The Multicentre Aneurysm Screening Study Group. Lancet Nov 16, 2002;360:1531-1539.)

EndocrineA Canadian randomized trial involving 105 women with diabetes and asymptomatic bacteriuria found that 6 weeks of antibiotic therapy was no more effective than placebo in preventing symptomatic urinary tract infections over 3 years. (Harding et al. N Engl J Med Nov 14, 2002;347:1576-1583.)

GeriatricA cohort study of 422 adults over age 75 without dementia found that those with gait abnormalities were twice as likely to develop dementia in the ensuing 6 years. (Verghese et al. N Engl J Med Nov 28, 2002;347:1761-1768.)

GynecologicA randomized trial involving 2392 women age 16-23 found that treatment with 3 doses of HPV-16 virus-like particle vaccine was more effective than placebo in reducing the incidence of persistent HPV-16 infection. No women in the vaccination group developed cervical intraepithelial neoplasia, whereas the control group experienced 9 cases. (Koutsky et al. N Engl J Med Nov 21, 2002;347:1645-1651.)

GynecologicA prospective cohort study of 44 187 postmenopausal women found that the risk of breast cancer among those who had taken hormone replacement therapy for at least 5 years was increased, but that the increased risk was magnified even further in proportion to the amount of alcohol the women consumed. (Chen et al. Ann Intern Med Nov 19, 2002;137:798-804.)

GynecologicA trial involving 875 postmenopausal women found that conjugated equine estrogen plus micronized progesterone cyclical was associated with fewer excess episodes of bleeding than was conjugated equine estrogen plus medroxyprogesterone acetate continuous in the first 6 months. (Lindenfeld and Langer. Obstet Gynecol Nov 2002;100(5 pt 1):853-863.)

GynecologicA systematic review of 29 trials of complementary and alternative medicine therapies for menopausal symptoms suggested that black cohosh and foods that contain phytoestrogens (eg, soy) offer modest benefit in controlling hot flashes, but it found little supporting evidence for using other herbs (eg, dong quai), vitamin E, or acupuncture for this purpose. (Kronenberg and Fugh-Berman. Ann Intern Med Nov 19, 2002;137:805-813.)

Infectious diseasesA prospective observational study of 504 adults with bloodstream infections occurring in the community found that the profile of pathogens and comorbid conditions for infections acquired in outpatient health care (eg, home health care, hospitalization within 3 months of infection) more closely resembled that for nosocomial infections than that for true community-acquired infections. The authors argue for a revised definition of community-acquired infections. (Friedman et al. Ann Intern Med Nov 19, 2002;137:791-797.)

Infectious diseasesA Dutch randomized trial involving 301 patients with bacterial meningitis revealed that treatment with 10 mg of dexamethasone in conjunction with the first dose of antibiotics resulted in lower rates of neurologic impairment and death at 8 weeks than did the antibiotic with placebo. (de Gans et al. N Engl J Med Nov 14, 2002;347:1549-1556.)

OrthopedicA Finnish study of 45 male monozygotic twin pairs who had greatly different lifetime occupational driving patterns revealed no differences in lumbar disk degeneration on magnetic resonance imaging, suggesting that driving itself does not damage the disks. (Battié et al. Lancet Nov 2, 2002;360:1369-1374.)

PediatricA Danish cohort study of 537 303 children who had received the measles-mumps-rubella vaccine reported that their relative risk for developing autism was 0.92 (confidence interval of 0.68-1.24), suggesting that vaccination plays no causal role. (Madsen et al. N Engl J Med Nov 7, 2002;347:1477-1482.)

Substance abuseA Russian cohort study of 6502 men found that mortality rates were not increased among those who engaged in alcohol binge drinking but were increased among heavy drinkers (men who consumed at least 120 g of ethanol, equivalent to 380 mL of vodka, three times a week). (Malyutina et al. Lancet Nov 9, 2002;360:1448-1454.)

Urgent careA randomized trial involving 156 adults who visited the emergency department and met criteria for one of three symptom complexes (which account for 33% of adult US emergency department visits) found that outcomes were similar whether the patients received usual care that day in the emergency department or were referred for next-day care at a primary care center. (Washington et al. Ann Intern Med Nov 5, 2002;137:707-714.)