Judith M. E. Walsh

Effect of 5-Aminosalicylate Use on Colorectal Cancer and Dysplasia Risk: A Systematic Review and Metaanalysis of Observational Studies

OBJECTIVES:We performed a systematic review with metaanalysis of observational studies evaluating the association between 5-ASA use and colorectal cancer (CRC) or dysplasia among patients with ulcerative colitis.METHODS:We conducted a search of Medline Embase Biosis, Web of Science, Cochrane Collaboration, manually reviewed the literature, and consulted with experts. Studies were included if they 1) evaluated and clearly defined exposure to 5-aminosalicylates in patients with ulcerative colitis, 2) reported CRC or dysplasia outcomes, 3) reported relative risks or odds ratio or provided data for their calculations. Quantitative analysis using a random-effects model is presented.RESULTS:Nine studies (3 cohort, 6 case–control) containing 334 cases of CRC, 140 cases of dysplasia, and a total of 1,932 subjects satisfied all inclusion criteria. Five studies reported CRC outcomes alone, two studies reported separate cancer and dysplasia outcomes, and two studies reported a combined outcome of CRC or dysplasia. All primary estimates are homogenous. Pooled analysis showed a protective association between use of 5-aminosalicylates and CRC (OR = 0.51; 95% confidence interval (CI): 0.37–0.69) or a combined endpoint of CRC/dysplasia (OR 0.51; 95% CI: 0.38–0.69). 5-ASA use was not associated with a lower risk of dysplasia, although only two studies evaluated this outcome (OR = 1.18; 95% CI: 0.41–3.43).CONCLUSION:Pooled results of observational studies support a protective association between 5-aminosalicylates and CRC or a combined endpoint of CRC/dysplasia in patients with ulcerative colitis. Additional studies analyzing the effect of 5-ASA on risk of dysplasia are needed.

Gastric banding or bypass: a systematic review comparing the two most popular bariatric procedures

OBJECTIVE Bariatric surgical procedures have increased exponentially in the United States. Laparoscopic adjustable gastric banding is now promoted as a safer, potentially reversible and effective alternative to Roux-en-Y gastric bypass, the current standard of care. This study evaluated the balance of patient-oriented clinical outcomes for laparoscopic adjustable gastric banding and Roux-en-Y gastric bypass. METHODS The MEDLINE database (1966 to January 2007), Cochrane clinical trials database, Cochrane reviews database, and Database of Abstracts of Reviews of Effects were searched using the key terms gastroplasty, gastric bypass, laparoscopy, Swedish band, and gastric banding. Studies with at least 1 year of follow-up that directly compared laparoscopic adjustable gastric banding with Roux-en-Y gastric bypass were included. Resolution of obesity-related comorbidities, percentage of excess body weight loss, quality of life, perioperative complications, and long-term adverse events were the abstracted outcomes. RESULTS The search identified 14 comparative studies (1 randomized trial). Few studies reported outcomes beyond 1 year. Excess body weight loss at 1 year was consistently greater for Roux-en-Y gastric bypass than laparoscopic adjustable gastric banding (median difference, 26%; range, 19%-34%; P < .001). Resolution of comorbidities was greater after Roux-en-Y gastric bypass. In the highest-quality study, excess body weight loss was 76% with Roux-en-Y gastric bypass versus 48% with laparoscopic adjustable gastric banding, and diabetes resolved in 78% versus 50% of cases, respectively. Both operating room time and length of hospitalization were shorter for those undergoing laparoscopic adjustable gastric banding. Adverse events were inconsistently reported. Operative mortality was less than 0.5% for both procedures. Perioperative complications were more common with Roux-en-Y gastric bypass (9% vs 5%), whereas long-term reoperation rates were lower after Roux-en-Y gastric bypass (16% vs 24%). Patient satisfaction favored Roux-en-Y gastric bypass (P=.006). CONCLUSION Weight loss outcomes strongly favored Roux-en-Y gastric bypass over laparoscopic adjustable gastric banding. Patients treated with laparoscopic adjustable gastric banding had lower short-term morbidity than those treated with Roux-en-Y gastric bypass, but reoperation rates were higher among patients who received laparoscopic adjustable gastric banding. Gastric bypass should remain the primary bariatric procedure used to treat obesity in the United States.

Meta-analysis: effect of hormone-replacement therapy on components of the metabolic syndrome in postmenopausal women

Aim:  To quantify the effects of hormone‐replacement therapy (HRT) on components of the metabolic syndrome in postmenopausal women.

Quality improvement strategies for hypertension management: a systematic review.

Background:Care remains suboptimal for many patients with hypertension. Purpose:The purpose of this study was to assess the effectiveness of quality improvement (QI) strategies in lowering blood pressure. Data Sources:MEDLINE, Cochrane databases, and article bibliographies were searched for this study. Study Selection:Trials, controlled before–after studies, and interrupted time series evaluating QI interventions targeting hypertension control and reporting blood pressure outcomes were studied. Data Extraction:Two reviewers abstracted data and classified QI strategies into categories: provider education, provider reminders, facilitated relay of clinical information, patient education, self-management, patient reminders, audit and feedback, team change, or financial incentives were extracted. Data Synthesis:Forty-four articles reporting 57 comparisons underwent quantitative analysis. Patients in the intervention groups experienced median reductions in systolic blood pressure (SBP) and diastolic blood pressure (DBP) that were 4.5 mm Hg (interquartile range [IQR]: 1.5 to 11.0) and 2.1 mm Hg (IQR: −0.2 to 5.0) greater than observed for control patients. Median increases in the percentage of individuals achieving target goals for SBP and DBP were 16.2% (IQR: 10.3 to 32.2) and 6.0% (IQR: 1.5 to 17.5). Interventions that included team change as a QI strategy were associated with the largest reductions in blood pressure outcomes. All team change studies included assignment of some responsibilities to a health professional other than the patients physician. Limitations:Not all QI strategies have been assessed equally, which limits the power to compare differences in effects between strategies. Conclusion:QI strategies are associated with improved hypertension control. A focus on hypertension by someone in addition to the patients physician was associated with substantial improvement. Future research should examine the contributions of individual QI strategies and their relative costs.

Brief report: Coronary heart disease events associated with hormone therapy in younger and older women. A meta-analysis.

AbstractOBJECTIVE: To assess the effect of hormone therapy (HT) on coronary heart disease (CHD) events in younger and older postmenopausal women. DESIGN: A comprehensive database search identified randomized-controlled trials of HT of at least 6 months’ duration that reported CHD events, defined as myocardial infarction or cardiac death. MEASUREMENTS: The pooled odds ratios (ORs) for CHD events were reported separately for younger and older women, defined as participants with mean time from menopause of less than or greater than 10 years, or mean age less than or greater than 60 years. MAIN RESULTS: Pooled data from 23 trials, with 39,049 participants followed for 191,340 patient-years, showed that HT significantly reduced CHD events in younger women (OR 0.68 [confidence interval (C I), 0.48 to 0.96]), but not in older women (OR 1.03 [CI, 0.91 to 1.16]). Hormone therapy reduced events in younger women compared with older women (OR 0.66 [CI, 0.46 to 0.95]). In older women, HT increased events in the first year (OR 1.47 [CI, 1.12 to 1.92]), then reduced events after 2 years (OR 0.79 [CI, 0.67 to 0.93]). CONCLUSIONS: Hormone therapy reduces the risk of CHD events in younger postmenopausal women. In older women, HT increases, then decreases risk over time.

Mortality Associated with Hormone Replacement Therapy in Younger and Older Women: A Meta-analysis

OBJECTIVE: To assess mortality associated with hormone replacement in younger and older postmenopausal women.DESIGN: A comprehensive search of medline, cinahl, and embase databases was performed to identify randomized controlled trials of hormone replacement therapy from 1966 to September 2002. The search was augmented by scanning selected journals through April 2003 and references of identified articles. Randomized trials of greater than 6 months’ duration were included if they compared hormone replacement with placebo or no treatment, and reported at least 1 death.MEASUREMENTS: Outcomes measured were total deaths and deaths due to cardiovascular disease, cancer, or other causes. Odds ratios (OR) for total and cause-specific mortality were reported separately for trials with mean age of participants less than and greater than 60 years at baseline.MAIN RESULTS: Pooled data from 30 trials with 26,708 participants showed that the OR for total mortality associated with hormone replacement was 0.98 (95% confidence interval [CI], 0.87 to 1.12). Hormone replacement reduced mortality in the younger age group (OR, 0.61; CI, 0.39 to 0.95), but not in the older age group (OR, 1.03; CI, 0.90 to 1.18). For all ages combined, treatment did not significantly affect the risk for cardiovascular or cancer mortality, but reduced mortality from other causes (OR, 0.67; CI, 0.51 to 0.88).CONCLUSIONS: Hormone replacement therapy reduced total mortality in trials with mean age of participants under 60 years. No change in mortality was seen in trials with mean age over 60 years.

Barriers to Colorectal Cancer Screening in Latino and Vietnamese Americans (Compared with Non-Latino White Americans)

AbstractOBJECTIVE: To identify current colorectal cancer (CRC) screening practices and barriers to screening in the Latino, Vietnamese, and non-Latino white populations. METHODS: We conducted a telephone survey of Latino, non-Latino white, and Vietnamese individuals living in San Jose, California. We asked about demographics, CRC screening practices, intentions to be screened, and barriers and facilitators to screening. RESULTS: Seven hundred and seventy-five individuals (40% white, 29.2% Latino, and 30.8% Vietnamese) completed the survey (Response Rate 50%). Overall, 23% of respondents reported receipt of fecal occult blood test (FOBT) in the past year, 28% reported sigmoidoscopy (SIG) in the past 5 years, and 27% reported colonoscopy (COL) in the past 10 years. Screening rates were generally lower in Latinos and Vietnamese. Vietnamese were less likely than whites to have had SIG in the past 5 years (odds ratio [OR], 0.26; 95% confidence interval [CI], 0.09 to 0.72), but ethnicity was not an independent predictor of FOBT or COL. Only 22% of Vietnamese would find endoscopic tests uncomfortable compared with 79% of whites (P<.05). While 21% of Latinos would find performing an FOBT embarrassing, only 8% of whites and 3% of Vietnamese felt this way (P<.05). Vietnamese were more likely than whites to plan to have SIG in the next 5 years (OR, 2.24; 95% CI, 1.15 to 4.38), but ethnicity was not associated with planning to have FOBT or COL. CONCLUSIONS: Rates of CRC screening are lower in ethnic minority populations than in whites. Differences in attitudes and perceived barriers suggest that culturally tailored interventions to increase CRC screening will be useful in these populations

EXERCISE COUNSELING BY PRIMARY CARE PHYSICIANS IN THE ERA OF MANAGED CARE

BACKGROUND Recommendations from the Centers for Disease Control and Prevention (CDC) and the American College of Sports Medicine (ACSM) advise all adults to accumulate at least 30 minutes of moderate intensity physical activity on most, if not all, days of the week, but many U.S. adults engage in no leisure-time physical activity. Since primary care providers can play an important role in exercise counseling and prescription, we wanted to assess the proportion of primary care physicians from four hospitals who asked about exercise habits, counseled about exercise, and prescribed exercise; and the factors that were associated with their counseling and prescription habits. DESIGN Survey of 326 internists, family practitioners, and internal medicine and family practice residents. RESULTS One hundred seventy-five physicians completed the questionnaire (54% response rate). Two thirds of physicians reported asking more than half of their patients about exercise, 43% counseled more than half of their patients about exercise, but only 14% prescribed exercise for more than half of their patients. Only 12% of physicians were familiar with the new ACSM recommendations. Physicians aged 35 and over were more likely than physicians less than 35 year old to ask about (82% versus 60%), counsel about (58% versus 37%), and prescribe (30% versus 8%) exercise. Family practitioners were more likely to ask about (85% versus 62%) and counsel about (59% versus 39%) exercise than internists. Physicians who felt they had adequate exercise knowledge were more likely to ask about (72% versus 49%) and counsel about (48% versus 29%) exercise than those who felt their knowledge was inadequate. Finally, physicians who felt that they were successful in changing behavior were more likely to ask about and counsel about exercise. The most important barriers to exercise counseling were not having enough time and needing more practice in effective counseling techniques. CONCLUSION Many primary care physicians are not asking about, counseling about, or prescribing exercise for their patients. Since primary care physicians are in the best position to provide individualized exercise prescriptions for their patients, future research should focus on training physicians in effective counseling techniques that can be done as brief interventions.

Detection, Evaluation, and Treatment of Eating Disorders: The Role of the Primary Care Physician

OBJECTIVE: To describe how primary care clinicians can detect an eating disorder and identify and manage the associated medical complications.DESIGN: A review of literature from 1994 to 1999 identified by a MEDLINE search on epidemiology, diagnosis, and therapy of eating disorders, including anorexia nervosa and bulimia nervosa.MEASUREMENTS AND MAIN RESULTS: Detection requires awareness of risk factors for, and symptoms and signs of, anorexia nervosa (e.g., participation in activities valuing thinness, family history of an eating disorder, amenorrhea, lanugo hair) and bulimia nervosa (e.g., unsuccessful attempts at weight loss, history of childhood sexual abuse, family history of depression, erosion of tooth enamel from vomiting, partoid gland swelling, and gastroesophageal reflux). Providers must also remain alert for disordered eating in female athletes (the female athlete triad) and disordered eating in diabetics. Treatment requires a multidisciplinary team including a primary care practitioner, nutritionist, and mental health professional. The role of the primary care practitioner is to help determine the need for hospitalization and to manage medical complications (e.g., arrhythmias, refeeding syndrome, osteoporosis, and electrolyte abnormalities such as hypokalemia).CONCLUSION: Primary care providers have an important role in detecting and managing eating disorders.

Predictors of physical activity in community-dwelling elderly white women

OBJECTIVE: To describe patterns of physical activity and to determine factors associated with engaging in regular exercise, especially walking, in elderly white women. DESIGN: Cross-sectional study of 9,442 independently living elderly white women aged 65 years and over participating in the Study of Osteoporotic Fractures. MEASUREMENTS AND MAIN RESULTS: We studied the association between lifestyle habits, social factors, health status and self-reported physical activity (assessed by modified Paffenbarger scale) during the past twelve months. Walking was the most common form of exercise: 4,837 (51%) women reported doing so a mean of 12 (SD=10) blocks per day, 3.9 (SD=2.9) times per week. Other common activities were gardening (35%), swimming (16%), and bicycling (13%). Less than a third of women reported engaging in medium- or high-intensity exercise in the past year. In a multivariate age-adjusted analysis, factors independently (P<.01) associated with walking for exercise included greater than high school education (52% vs 48%), history of physical activity for exercise at ages 30 years (51% vs 46%) and 50 years (51% vs 45%), and stronger social network (51% vs 47%). Women who were current smokers, obese, or depressed were less likely to take walks for exercise. Marital status, self-reported arthritis, current estrogen use, and a history of falls in the past year were not independently associated with taking walks for exercise. CONCLUSIONS: In this healthy cohort, walking for exercise is associated with other positive health behaviors. Given the mounting evidence about the health benefits of walking, and since many of these community dwelling women can and do walk for exercise, but rarely engage in other common prescribed physical activities, clinicians might best focus their efforts on encouraging walking.