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Issue 178 - 18 April, 2011

Easter without the calories

Extravagant Easter eggs, some with a calorie intake so high it would take 26 hours of jogging to burn off, have been criticised by nutritionists. Registered dietician Fiona Boyle, of Food Solutions, advises choosing quality over quantity when it comes to Easter eggs.

Articles: Annals of Internal Medicine

1. Treatment of Chronic Rhinosinusitis With Nasal Polyposis With Oral Steroids Followed by Topical Steroids
By Vaidyanathan, Sriram et al. Annals of Internal Medicine, 3/1/2011, Vol. 154 Issue 5: p293-W92
Chronic rhinosinusitis (CRS) with nasal polyposis is common. The long-term efficacy and safety of approaches to medical management are not well-known.
Objective: To evaluate the efficacy and safety of a 2-week regimen of oral steroid therapy followed by 26 weeks of sequential topical steroid maintenance therapy.
Design: Parallel randomized trial with computer-generated block randomization and central allocation. Patients and investigators were blinded to group assignment. ( registration number: NCT00788749)
 Setting: A specialty rhinology clinic in Tayside, Scotland.
Patients: 60 adults with CRS and moderate-sized or larger nasal polyps who were referred by their primary physicians for specialty care.
 Interventions: Patients were randomly assigned in a 1:1 ratio to receive oral prednisolone, 25 mg/d, or placebo for 2 weeks, followed in both groups by fluticasone propionate nasal drops, 400 μg twice daily, for 8 weeks and then fluticasone propionate nasal spray, 200 μg twice daily, for 18 weeks.
Measurements: Polyp grading (primary outcome), hyposmia score, quality of life, symptoms, nasal patency, adrenal function, and bone turnover.
Results: The mean decrease in polyp grade from baseline to 2 weeks was 2.1 units (SD, 1.1) in the prednisolone group and 0.1 unit (SD, 1.0) in the placebo group (mean difference between groups, -1.8 units [95% CI, -2.4 to -1.2 units]; P = 0.001). The difference between groups was -1.08 units (CI, -1.74 to -0.42 unit; P = 0.001) at 10 weeks and -0.8 unit (CI, -1.8 to 0.2 unit; P = 0.11) at 28 weeks. The mean decrease in hyposmia score from baseline to 2 weeks was 31.12 mm (SD, 30.1) in the prednisolone group and 1.41 mm (SD, 30.6) in the placebo group (mean difference between groups, -28.33 mm [CI, -42.71 to -13.96 mm]; P = 0.002). The difference between groups was -16.06 mm (CI, -30.99 to -1.13 mm; P = 0.03) at 10 weeks and -12.13 mm (CI, -30.55 to 6.29 mm; P = 0.19) at 28 weeks. Prednisolone therapy resulted in transient suppression of adrenal function and increase in bone turnover after 2 weeks, with a return to baseline at 10 and 28 weeks.
Limitations: Patients were referred from primary care to a singlecenter rhinology clinic, which limits the generalizability of results. Serial measurements of surrogates of nasal inflammation (such as nitric oxide or cytokine levels) were not performed. Conclusion: Initial oral steroid therapy followed by topical steroid therapy seems to be more effective over 6 months than topical steroid therapy alone in decreasing polyp size and improving olfaction in patients referred for specialty care of CRS with at least moderate nasal polyposis.
Primary Funding Source: Chief Scientist Office, Scotland; National Health Service Tayside Small Grants Scheme; and an Anonymous Trust grant from University of Dundee. [ABSTRACT FROM AUTHOR]

2. Racial Differences in Glycemic Markers: A Cross-sectional Analysis of Community-Based Data
By Selvin, Elizabeth et al. Annals of Internal Medicine, 3/1/2011, Vol. 154 Issue 5: p303-W93
Although differences between black and white persons in hemoglobin A1c (HbA1c) values are well established, recent studies suggest that this might not reflect differences in glycemia.
Objective: To investigate racial disparities in glycemic markers, including those that reflect biological processes independent of hemoglobin glycation and erythrocyte turnover.
Design: Cross-sectional. Setting: Community-based.
Participants: 1376 nondiabetic and 343 diabetic adults in a substudy of the Atherosclerosis Risk in Communities Study.
Measurements: Hemoglobin A1c, fasting glucose, glycated albumin, fructosamine, and 1,5-anhydroglucitol levels. Results: Among persons with and without diabetes, black persons had significantly higher HbA1c, glycated albumin, and fructosamine levels than white persons before and after adjustment for covariates and fasting glucose concentration. Serum 1,5-anhydroglucitol levels, which are reduced in the setting of hyperglycemia-induced glycosuria, were lower in black persons than in white persons, although this difference was statistically significant only in nondiabetic adults.
Limitation: The design was cross-sectional, a limited number of participants with a history of diabetes was included, and the study did not include integrated measures of circulating nonfasting glycemia.
Conclusion: Differences between black and white persons in glycated albumin, fructosamine, and 1,5-anhydroglucitol levels parallel differences between these groups in HbA1c values. Racial differences in hemoglobin glycation and erythrocyte turnover cannot explain racial disparities in these serum markers. The possibility that black persons have systematically higher levels of nonfasting glycemia warrants further study. Primary Funding Source: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. [ABSTRACT FROM AUTHOR]

3. Estimated Glomerular Filtration Rate and Albuminuria as Predictors of Outcomes in Patients With High Cardiovascular Risk
By Clase, Catherine al. Johannes F.E. Annals of Internal Medicine, 3/1/2011, Vol. 154 Issue 5: p310-W97
: Glomerular filtration rate and albuminuria are risk factors for cardiovascular disease and markers of renal function. Objective: To examine the contribution of estimated glomerular filtration rate (eGFR) and urinary albumin-creatinine ratio beyond that of traditional cardiovascular risk factors to classification of patient risk for cardiovascular and renal outcomes.
Design: Prospective cohort study that pooled all patients of ONTARGET (ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial) and TRANSCEND (Telmisartan Randomized Assessment Study in Angiotensin-Converting-Enzyme- Inhibitor Intolerant Subjects with Cardiovascular Disease).
Patients: 27 620 patients older than 55 years with documented cardiovascular disease, who were followed for a mean of 4.6 years.
Measurements: Baseline eGFR, urinary albumin-creatinine ratio, and cardiovascular risk factors. Outcomes were all-cause mortality; a composite of cardiovascular death, myocardial infarction, stroke, and hospitalization for heart failure; long-term dialysis; and a composite of long-term dialysis and doubling of serum creatinine level.
Results: Lower eGFRs and higher urinary albumin-creatinine ratios were associated with the primary cardiovascular composite outcome (for example, an adjusted hazard ratio of 2.53 [95% CI, 1.61 to 3.99] for an eGFR <30 mL/min per 1.73 m2 and a very high urinary albumin-creatinine ratio). However, adding information about eGFR and urinary albumin-creatinine ratio to the risk reclassification analyses led to no meaningful decrease in the proportion of patients assigned to the intermediate-risk category (31% without vs. 32% with renal information). In contrast, eGFR and urinary albumin-creatinine ratio were strongly associated with risk for longterm dialysis and greatly improved both model calibration and risk stratification capacity when added to traditional cardiovascular risk factors (65% assigned to intermediate-risk categories without renal information vs. 18% with renal information).
Limitation: Creatinine levels were not standardized.
Conclusion: In patients with high vascular risk, eGFR and urinary albumin-creatinine ratio add little to traditional cardiovascular risk factors for stratifying cardiovascular risk but greatly improve risk stratification for renal outcomes.
Primary Funding Source: Boehringer Ingelheim, Population Health Research Institute, and the European Commission. [ABSTRACT FROM AUTHOR]

4. Hepatitis B Virus in the United States: Infection, Exposure, and Immunity Rates in a Nationally Representative Survey
By Ioannou, George N. Annals of Internal Medicine, 3/1/2011, Vol. 154 Issue 5: p319-W98
: Up-to-date estimates of the prevalence of hepatitis B virus (HBV) infection, exposure, and immunity are necessary to assess the effectiveness of ongoing programs aimed at preventing HBV transmission.
Objective: To determine the prevalence and associations of chronic HBV infection, past exposure, and immunity in the United States from 1999 to 2008.
Design: Nationally representative, cross-sectional household survey.
Setting: U.S. civilian, noninstitutionalized population.
Participants: 39 787 participants in the National Health and Nutrition Examination Survey (1999 to 2008) aged 2 years or older.
Measurements: Chronic HBV infection was defined by presence of serum HBV surface antigen and past exposure by serum antibody to hepatitis B core antigen among persons aged 6 years or older. Infant immunity was defined by presence of serum antibody to hepatitis B surface antigen among children aged 2 years.
Results: Among persons aged 6 years or older, 0.27% (95% CI, 0.20% to 0.34%) had chronic HBV infection (corresponding to approximately 704 000 persons nationwide), and 4.6% (CI, 4.1% to 5.0%) had been exposed to HBV (approximately 11 993 000 persons). These estimates are lower (P = 0.001) than estimates of HBV infection (0.42%) and exposure (5.1%) in the United States reported from 1988 to 1994. Infection and past exposure were very uncommon among persons aged 6 to 19 years. Children aged 2 years have high rates of immunity (68.6% [CI, 64.1% to 73.2%]). Adults, including those at high risk for infection, have much lower rates of immunity.
Limitations: Incarcerated and homeless persons were not sampled. Categorization of race or ethnicity did not identify high-risk groups, such as persons of Asian and Pacific Islander descent.
Conclusion: A cohort of children and adolescents is growing up in the United States with high rates of immunity against HBV and very low rates of infection. Vaccination of high-risk adults should continue to be emphasized.
Primary Funding Source: The Veterans Affairs Research Enhancement Award Program. [ABSTRACT FROM AUTHOR]

5. Narrative Review: Tetanus--A Health Threat After Natural Disasters in Developing Countries
By Afshar, Majid et al. Annals of Internal Medicine, 3/1/2011, Vol. 154 Issue 5: p329-W99
Tetanus is an expected complication when disasters strike in developing countries, where tetanus immunization coverage is often low or nonexistent. Collapsing structures and swirling debris inflict numerous crush injuries, fractures, and serious wounds. Clostridium tetani infects wounds contaminated with dirt, feces, or saliva and releases neurotoxins that may cause fatal disease. Clusters of infections have recently occurred after tsunamis and earthquakes in Indonesia, Kashmir, and Haiti. The emergency response to clusters of tetanus infections in developing countries after a natural disaster requires a multidisciplinary approach in the absence of an intensive care unit, readily available resources, and a functioning cold-chain system. It is essential that injured people receive immediate surgical and medical care of contaminated, open wounds with immunization and immunoglobulin therapy. Successful treatment of tetanus depends on prompt diagnosis of clinical tetanus, treatment to ensure neutralization of circulating toxin and elimination of C. tetani infection, control of spasms and convulsions, maintenance of the airway, and management of respiratory failure and autonomic dysfunction. [ABSTRACT FROM AUTHOR]

6. Systematic Review: The Effect on Surrogates of Making Treatment Decisions for Others
By Wendler, David; Rid, Annette. Annals of Internal Medicine, 3/1/2011, Vol. 154 Issue 5: p336-W104
Clinical practice relies on surrogates to make or help to make treatment decisions for incapacitated adults; however, the effect of this practice on surrogates has not been evaluated. Purpose: To assess the effect on surrogates of making treatment decisions for adults who cannot make their own decisions.
Data Sources: Empirical studies published in English and listed in MEDLINE, EMBASE, CINAHL, BIOETHICSLINE, PsycINFO, or Scopus before 1 July 2010. Study Selection: Eligible studies provided quantitative or qualitative empirical data, by evaluating surrogates, regarding the effect on surrogates of making treatment decisions for an incapacitated adult. Data Extraction: Information on study location, number and type of surrogates, timing of data collection, type of decisions, patient setting, methods, main findings, and limitations.
Data Synthesis: 40 studies, 29 using qualitative and 11 using quantitative methods, provided data on 2854 surrogates, more than one half of whom were family members of the patient. Most surrogates were surveyed several months to years after making treatment decisions, the majority of which were end-of-life decisions. The quantitative studies found that at least one third of surrogates experienced a negative emotional burden as the result of making treatment decisions. The qualitative studies reported that many or most surrogates experienced negative emotional burden. The negative effects on surrogates were often substantial and typically lasted months or, in some cases, years. The most common negative effects cited by surrogates were stress, guilt over the decisions they made, and doubt regarding whether they had made the right decisions. Nine of the 40 studies also reported beneficial effects on a few surrogates, the most common of which were supporting the patient and feeling a sense of satisfaction. Knowing which treatment is consistent with the patient's preferences was frequently cited as reducing the negative effect on surrogates.
Limitations: Thirty-two of the 40 articles reported data collected in the United States. Because the study populations were relatively homogenous, it is unclear whether the findings apply to other groups. In some cases, the effect of making treatment decisions could not be isolated from that of other stressors, such as grief or prognostic uncertainty. Nine of the studies had a response rate less than 50%, and 9 did not report a response rate. Many of the studies had a substantial interval between the treatment decisions and data collection.
Conclusion: Making treatment decisions has a negative emotional effect on at least one third of surrogates, which is often substantial and typically lasts months (or sometimes years). Future research should evaluate ways to reduce this burden, including methods to identify which treatment options are consistent with the patient's preferences.
Primary Funding Source: National Institutes of Health. [ABSTRACT FROM AUTHOR]

7.Screening Adults Aged 50 Years or Older for Hearing Loss: A Review of the Evidence for the U.S. Preventive Services Task Force
By Chou, Roger et al. Annals of Internal Medicine, 3/1/2011, Vol. 154 Issue 5: p347-W118
Hearing loss is common in older adults. Screening could identify untreated hearing loss and lead to interventions to improve hearing-related function and quality of life.
Purpose: To update the 1996 U.S. Preventive Services Task Force evidence review on screening for hearing loss in primary care settings in adults aged 50 years or older.
 Data Sources: MEDLINE (1950 and July 2010) and the Cochrane Library (through the second quarter of 2010).
Study Selection: Randomized trials, controlled observational studies, and studies on diagnostic accuracy were selected.
Data Extraction: Investigators abstracted details about the patient population, study design, data analysis, follow-up, and results and assessed quality by using predefined criteria.
Data Synthesis: Evidence on benefits and harms of screening for and treatments of hearing loss was synthesized qualitatively. One large (2305 participants) randomized trial found that screening for hearing loss was associated with increased hearing aid use at 1 year, but screening was not associated with improvements in hearing-related function. Good-quality evidence suggests that common screening tests can help identify patients at higher risk for hearing loss. One good-quality randomized trial found that immediate hearing aids were effective compared with wait-list control in improving hearing-related quality of life in patients with mild or moderate hearing loss and severe hearing-related handicap. We did not find direct evidence on harms of screening or treatments with hearing aids.
Limitation: Non-English-language studies were excluded, and studies of diagnostic accuracy in high-prevalence specialty settings were included.
Conclusion: Additional research is needed to understand the effects of screening for hearing loss compared with no screening on health outcomes and to confirm benefits of treatment under conditions likely to be encountered in most primary care settings. Primary Funding Source: Agency for Healthcare Research and Quality. [ABSTRACT FROM AUTHOR]

8. Screening for Osteoporosis: U.S. Preventive Services Task Force Recommendation Statement
Annals of Internal Medicine, 3/1/2011, Vol. 154 Issue 5: p356-W119
 Update of the 2002 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for osteoporosis.
Methods: The USPSTF evaluated evidence on the diagnostic accuracy of risk assessment instruments for osteoporosis and fractures, the performance of dual-energy x-ray absorptiometry and peripheral bone measurement tests in predicting fractures, the harms of screening for osteoporosis, and the benefits and harms of drug therapy for osteoporosis in women and men.
Recommendations: The USPSTF recommends screening for osteoporosis in women aged 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman who has no additional risk factors. (Grade B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis in men. (I statement) [ABSTRACT FROM AUTHOR]

9. Combined Oral and Intranasal Corticosteroid Therapy: An Advance in the Management of Nasal Polyposis?
By Mullol, Joaquim; Alobid, Isam. Annals of Internal Medicine, 3/1/2011, Vol. 154 Issue 5: p365-W120
The authors reflect on the efficiency of combined oral and intranasal corticosteroid therapy in nasal polyposis management. They note that corticosteroids exert anti-inflammatory effect by acting on particular receptors in human cells. They mention studies demonstrating that patients with nasal polyps who are sensitive to aspirin are susceptible to resist steroid treatment without glucocorticoid receptors' downregulation

10. Brave New EMR.
By Lewis, Stuart. Annals of Internal Medicine, 3/1/2011, Vol. 154 Issue 5: p368-369
The author offers his insights on the innovative program toward a totally electronic medical record (EMR) in the U.S. He shares his own decision of advancing to electronic in his profession as a physician. He considers his template-driven notes inaccurate as patients to not speak template. However, he realizes his task to accurately and comprehensively understand his patients rather than merely documenting them.

11. The Effect of Financial Incentives on Hospitals That Serve Poor Patients
By Mansi, Ishak al. Annals of Internal Medicine, 3/1/2011, Vol. 154 Issue 5: p370-371
A letter to the editor and a response to the article on the impact of financial incentives on hospitals serving poor patients is presented.

12. Limitations of the MEDLINE Database in Constructing Meta-analyses
By Leclercq, Edith et al. Annals of Internal Medicine, 3/1/2011, Vol. 154 Issue 5: p371-372
A letter to the editor is presented in response to the article on the limitations of MEDLINE database in the establishment of meta-analyses.

Journals - Table of Contents

13. From  Nursing Standard, Volume 25, No 31 - April 6-12, 2011
Person-centred care: Principle of Nursing Practice D [This is the fifth article in a nine-part series describing the Principles
of Nursing Practice developed by the Royal College of Nursing (RCN) in collaboration with patient and service organisations, the
Department of Health, the Nursing and Midwifery Council, nurses and other healthcare professionals]
13B. Patient empowerment and choice in chronic pain management [ Service provision and access to pain services vary considerably in the UK, with only a small percentage of people with chronic pain accessing specialist services].
13C. Identification, assessment and management of pleurisy [This article explores the underlying aetiology of pleurisy, including identification, assessment and management of the condition.
13D. Best practice in the provision of nebuliser therapy [Nebulisation is an important and common method of administering medication to patients with respiratory disease.
13E. Learning zone assessment - Managing sepsis [Sepsis is characterised by a systemic inflammatory response caused by an infective process (viral, bacterial or fungal).

14. From Nursing Times, Vol 107 No 13 - 5-11 April, 2011
. Nursing Practice: Nutritious meals count for nothing if they are cold
14A. Who do patients fail to follow long term treatment? [Trying to stick to diabetes regimens for six weeks gave members of a paediatric diabetes team insight into why patients find adherence to treatment difficult]
14B. Using A & E data to prevent violence in communities
14C. How to manage the diabetic foot
14D. Adverse reactions: know the risks [Be aware of when you need to report a drug reaction]
14E. Using the skills of public volunteers to steer services [Appointing 'critical friends' helped a cardiac unit gain practice development unit status]

15. From The Tube, NZNO Gastroenterology Nurses Section, Volume 26, issue 1, March 2011
Bowel Preparation: A nurse sensitive indicator
15B. Bowel preparation for colonoscopy at Waikato Hospital
15C. Jejunal feeding
15D. A lot to swallow - Achalasia balloon dilatation

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