Consider The Evidence: Med/Peds Journal Roundup

April 17, 2008

Yes, Statins do everything – even lower BP

Filed under: archives of internal medicine, hypertension — medblog @ 5:02 pm

What could be crazy enough to end a 4 month hibernation of CTE?

Archives Int Med 4/08 – The UCSD Statin study yielded further evidence that statin treatment reduces blood pressure (although not by much) The RCT enrolled over 900 subjects without known CVD or diabetes. The idea was to independently assess the effect on BP. There was no inclusion / exclusion criteria regarding baseline BP. Subjects were randomized to pravastatin, simvastatin, or placebo.

Treatment with a statin resulted in about a 2-2.5 point drop in SBP and DBP. The treatment was stopped at 6 months, and the blood pressures returned to baseline by month 8 – further suggesting that this was a true effect.



November 20, 2006

Thiazides increase Diabetes, ALLHAT says dont worry

Filed under: archives of internal medicine, diabetes, hypertension — medblog @ 11:08 pm

Archives IM 11/13- ALLHAT data first made news with the conclusion that older, thiazide type diuretics were just as effective at reducing hypertension related disease as newer types of anti-hypertensives. One result of the study that is less well known is that thiazides appeared to increase the risk of incident diabetes. In the last issue of Archives, the ALLHAT investigators addressed this issue more directly.[Article]

The investigators performed post hoc analyses on the subgroups assigned to Ca-channel blockers, ACE-Is, and thiazides. Patients with known diabetes prior to start of therapy were excluded from analysis, as were those without baseline fasting blood glucose(FG) levels.

The data shows that all subjects had an increase in FG, but the thiazide group had a significantly greater increase in fasting glucose levels than the other groups. In addition, subjects in the thiazide group had significantly greater odds of developing diabetes.

Is this a problem? The investigators state that the increase in DM did not result in a greater rate of adverse events compared to the other groups. Are they trying to sweep the issue under the rug? Or are they postulating that the diabetic state induced by thiazides is less malignant than naturally occuring DM? Adverse events data was only 2 years out – not long enough to show effects from new onset DM. The increased risk may have also been partially washed out by the increase in DM among all groups, and the lack of comparison with placebo. I’m not sure I would dismiss the risk as easily as they suggest – but I guess I dont have to worry about grant money…

With both beta-blockers and thiazides being linked to decreased glucose tolerance, the choice of anti-hypertensives is becoming much more complicated.

September 28, 2006

zzzzzz….all about sleep

Filed under: archives of internal medicine, Uncategorized — medblog @ 8:43 pm

So I’m an issue behind, but I had to blog on the sleep-themed Sept 18th issue of Archives of Int Med. (one of my favorite subjects). Just how important is it?

Steptoe et al. found that young adult subjects that slept less than 6 hours per night were almost twice as likely to report their health as being poor – even after adjustment for socioeconomic factors, physical activity, BMI and Beck Depression Inventory scores. However, I cant help be a little cautioned by the fact that both sleep time and health status were based on self-report.

From the basic science side, Irwin et al. found that monocyte production of the proinflammatory cytokines IL-6 and TNF-alpha was significantly higher on the morning after sleep deprivation. (sounds like a bad thing)

Arzt et al warn of a condition that may obscure the diagnosis of obstructive sleep apnea. Their research found that comorbid heart failure resulted in less daytime sleepiness in sufferers of OSA. Unfortumately, the detrimental effects of poor sleep remained present. Because excessive daytime sleepyness is often the presenting symptom leading to the diagnosis of OSA, the researchers caution that physicians may miss the presence of OSA in HF patients.

And in the midst of the obesity epidemic, Kothatsu et al. show that a significant inverse relationship between sleep duration and BMI also exists in a rural population. Other researchers have already shown the same to be true in the urban and suburban populations. But watch out for that giant 70% confidence interval.

August 3, 2006

Actually useful research on dieting?

Filed under: archives of internal medicine, diet, obesity — medblog @ 12:46 pm

ArchIM 6/24 – It is rare enough to see an RCT involving diets, but rarer still to see one with useful results. A study by McMillan-Price in last week’s Archives addressed the issue of diet content. Favor has recently fallen on low glycemic index foods and high protein content. But does this strategy make a difference in weight loss? Yes and No.

The study design divided subjects into 4 groups. Two were high in protein, and two high in carbohydrates. Each pair consisted of a high and low glycemic index group. The overall weight lost was similar in all groups. Bummer, this is starting to look like every other diet trial…

However, LDL levels declined the most in the high-carb, low-glycemic index group, and increased in the high protein, high – GI group. BUT the women in that group (high-protein, high GI) had the greatest number of subjects that lost more than 5% of body weight.

So maybe for women there is something to the Atkins idea as far as weight loss, but this is offset by an increase in cardivascular risk factors(LDL).

July 13, 2006

Dont Re-Invent the Wheel with CRP

Filed under: archives of internal medicine, CHD, CRP — medblog @ 8:08 pm

ArchivesIM 7/10 – Ever since it was shown that CRP levels are strong predictors of CHD, the controversy has been whether it is really any better than the risk predictors we already have. Several articles have concluded that CRP in some way is a “better” method of stratifying CHD risk.

A paper by Fulstrom et al. addressing this issue presents data from the Atherosclerosis Risk in Communities (ARIC) Study. This was a prospective case cohort study. They looked at the reciever-operator curve using traditional risk factors, and then calculated the improvement of this curve once novel risk markers such as CRP, IL-6, pLA2, etc were added. They found that these fancy-schmancy molecules did not add significantly to the accuracy of the old prediction model.

So maybe CRP levels are a solution without a cause… but there is still a camp that believes that using that measure will include a group of higher-risk individuals that is not identified by the traditional risk factors…

July 10, 2006

Decaf Drinkers Deftly Dodge Diabetes

Filed under: archives of internal medicine, caffeine, Coffee, diabetes, diet — medblog @ 11:02 am

ArchivesIM 5/26 – While there has been some recent controversy over the risks and benefits of coffee consumption for diseases such as diabetes and MI, the exact cause for these effects is unknown.

In the current Archives, Pereira et al. present further investigation of this phenomenon using data from an 11-year, 28,000 patient observational trial of post-menopausal women. They found a significant inverse relationship between coffee consumption and incidence of diabetes. In the most comprehensively adjusted model, the results were only significant for decaf drinkers. Unfortunately for the majority, the difference in this model was only significant for drinkers of 4-5, and 6+ cups a day.

Now if they can only explain the purpose of drinking decaf coffee at all, let alone more than six cups of it per day??

May 9, 2006

Corticosteroids and Atrial Fibrillation

Filed under: archives of internal medicine, Cardiology — medblog @ 11:48 am

Archives IM 5/9 – van der Hooft et al. investigate the theory, based mostly on case reports, that high-dose pulse steroid are associated with in an increased risk of Atrial-fibrillation (AF).

The study was a case-control design, with patient data from the Rotterdam Study. Subjects were categorized as receiving either high dose or low/moderate dose steroids.
The odds ratio for developing new onset AF with 1 month of starting therapy was 6.07 compared to controls, whereas the odds from the low/moderate dose group was not significantly different.

The risk was independent of indication, which is reassuring. However, I wonder whether the use of high-dose steroids indicates a greater severity of disease which may be correlated with a generally increased risk of cardiac complications?

February 23, 2006

bathtime fun and killing VRE, CRP for HTN?

Archives 2/13 – Why didnt anyone think of this earlier? Apparently a study by Vernon, et al. cleaning ICU patients with Chlorhexidine cloths effectively lowers patient colonization and contamination of healthcare workers’ hands and hospital surfaces. The intervention does a much better job than soap and water, or cloths alone. Anything to keep me from having to wear those stupid isolation gowns….

In another article – apparently you cant use CRP to measure risk all things cardiovascular. Unlike in older adults, CRP is not associated with risk of incident hypertension in young adults when adjusted for BMI – not suprising considering the two are probably strongly related…. (more…)

January 31, 2006

Treat and Street the PE

Filed under: archives of internal medicine, pulmonary — medblog @ 9:14 pm

ArchIM 1/23 – Now that we have LMWH in our toolbox, maybe patients can get treatment for pulmonary emboli in the comfort of their own home. Michael Fine, who helped create the mortality prediction rule for CAP, contributes on this Archives article that attempts to find the low-mortality risk subset of patients with PE. Maybe we can start treating these patients as outpatients as well? (more…)

D-dimer Value in Recurrent VTE

Filed under: archives of internal medicine, VTE — medblog @ 8:27 pm

ArchIM 1/23 – This weeks Archives features 3 articles focusing on PE/ VTE.
D-dimer can help us rule out PE due to its high sensitivity, but will the presence of prior VTE result in too many false-positives to make it useful? In Le Gal, et al report that PE was ruled out by negative D-dimer in about 16% of pts with previous VTE, vs about 32% of of those without previous VTE. (more…)

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