Low Levels of Vitamin D Increase Risk of Heart Disease and Death and May Account for Higher Cardiovascular Risk Among Blacks
Fiscella and Franks add to the increasing evidence that a low level of vitamin D is an independent risk factor for cardiovascular disease. And they show that the higher cardiovascular risk observed among blacks may be partly related to lower vitamin D levels, which the researchers point out are very prevalent among blacks because of lower absorption of vitamin D due to darker skin, lower dietary intake, and decreased sun exposure. Analyzing nationally representative data on more than 15,000 U.S. adults, researchers found that those with serum vitamin D, specifically 25 hydroxyvitamin D, or 25(OH)D, levels in the lowest quartile compared with those in the three higher quartiles had a 40 percent adjusted higher cardiovascular risk for death after accounting for other factors. Notably, they also found that the 38 percent higher cardiovascular mortality observed in blacks versus whites was attenuated by accounting for differences in 25(OH)D levels and fully eliminated with further adjustment for lower income. Specifically, they found that accounting for 25(OH)D levels reduced blacks' higher risk of cardiovascular mortality by 60 percent, and inclusion of both 25(OH)D and poverty reduced the race risk to zero. The authors call for further research to determine whether vitamin D supplementation might improve cardiovascular outcomes and reduce existing racial health disparities.
Vitamin D, Race, and Cardiovascular Mortality: Findings From a National US Sample
By Kevin Fiscella, M.D., M.P.H., University of Rochester School of Medicine and Dentistry, New York, and Peter
Franks, M.D., University of California, Davis
Incidence of Hypertension Accelerating Among Rural Chinese Adults
A study out of China documents a high incidence of hypertension among rural Chinese adults, with most newly developed cases left untreated and uncontrolled. Data from a large population-based sample of 24,360 rural adults aged 35 years and older from China's Liaoning Province show that during a follow-up period of 28 months from 2004-2006 to 2008, more than one in four adults developed hypertension. Moreover, the researchers find that the great majority of cases of incident hypertension were untreated (80 percent) and uncontrolled (98 percent). They identify predictors of incident hypertension, including several modifiable risk factors in an environment of increasing urbanization and westernization of diet and health behaviors. The authors point out that the annual hypertension incidence of 11.4 percent is higher than that previously reported in China, Canada or the United States. They conclude the increases in hypertension are probably related to rapid social changes in China and may apply to other areas of the developing world. They call for urgent public health intervention to prevent and control hypertension.
Incidence and Predictors of Hypertension Among Rural Chinese Adults: Results From Liaoning Province
By Zhaoqing Sun, M.S., et al
First Affiliated Hospital, China Medical University, Shenyang
Superficial Blood Clots not Associated With Increased Incidence of Cancer
Researchers from The Netherlands debunk the belief that superficial venous thrombophlebitis (SVTP), or superficial blood clots, are associated with concomitant cancer. Analyzing records for 250 SVTP patients from five primary care centers in Amsterdam, researchers found no increased incidence of cancer after a first episode of unprovoked SVTP. Specifically, during the two-year observation period after an episode of unprovoked SVTP, the cumulative incidence of cancer was 2 percent, compared with 2 percent in a control group of Dutch patients. Recurrent SVTP was not common in the study sample (observed only in 18 of the 250 patients), allowing no conclusion about whether repeat episodes are associated with cancer, as case reports have suggested.
Idiopathic Superficial Thrombophlebitis and the Incidence of Cancer in Primary Care Patients
By F. F. van Doormaal, M.D., et al
Academic Medical Center of Amsterdam, The Netherlands
Paucity of Evidence to Support Male Circumcision, the World's Most Common Surgical Procedure
Although approximately 30 percent of the global male population is circumcised, this systematic review of the evidence on the safety and efficacy of circumcision for prophylactic, religious or cultural reasons finds a paucity of evidence demonstrating clinical benefit from the procedure. The eight studies included in the review did provide evidence for the efficacy of adult male circumcision in preventing HIV/AIDS acquisition in sub-Saharan African men, however the authors point out that these findings cannot necessarily be extrapolated to males in other countries. Moreover, they conclude that current evidence is unclear on the efficacy of adult circumcision in preventing sexually transmitted infections, urinary tract infections and penile cancer. The authors call for additional research to strengthen the evidence base and allow for more informed conclusions on nontherapeutic male circumcision.
Safety and Efficacy of Nontherapeutic Male Circumcision: A Systematic Review
By Caryn L. Perera, B.A., Grad. Cert. E.B.P., et al
Royal Australasian College of Surgeons, Adelaide, South Australia
Steroids Safe and Effective for Sore Throat Pain Relief, But Risks Must Be Considered
A systematic review of evidence from eight randomized controlled trials finds that steroids are effective in relieving sore throat pain in adult and pediatric patients. The review noted no serious adverse effects from the different steroids administered (dexamethasone, betamethasone, and prednisone); however, the authors point out that the benefits must be weighed against possible rare adverse drug effects and the further medicalization of a condition for which most people do not seek medical attention. They also point out that there are safe and effective over-the-counter medications to relieve sore throat pain. Notably, most patients studied also received concomitant antibiotics, and the authors point out that reducing prescription antibiotics for frequently benign upper respiratory tract infections is a public health goal. They therefore recommend further studies to establish the safety of steroid use without antibiotic coverage and the added benefits of steroids when used with regular administration of over-the-counter analgesic medications.
Steroids as Adjuvant Therapy for Acute Pharyngitis in Ambulatory Patients: A Systematic Review
By Katrin Korb, M.D., et al
University of Goettingen, Germany
Preventing Drug Errors: Physicians Disagree About How to Manage Patients' Drug Lists
Interviews with 20 Swedish physicians revealed a diversity of opinion as to whose responsibility it is to manage a patient's drug list to ensure drugs prescribed by different physicians do not interact negatively or cause harm. The researchers identified five different strategies used by physicians to manage this responsibility: 1) imposed responsibility, 2) responsible for own prescriptions, 3) responsible for all drugs, 4) different but shared responsibility, and 5) patient responsible for transferring drug information. They note that technical solutions, like electronic health records, alone are unlikely to be sufficient for preventing drug errors, and physicians should be made aware of variations in understanding responsibility so that health care quality can be improved.
Whose Job Is It Anyway? Swedish General Practioners' Perception of Their Responsibility for the Patient's Drug List
By Pia Bastholm Rahmner, et al
Stockholm County Council, Sweden
Do Physician and Patient Gender Affect how Cardiovascular Disease Risk Factors are Managed in Primary Care?
Tabenkin and colleagues look at the role sex of the physician and the patient plays in the management of cardiovascular disease risk factors. Chart audits of 4,195 patients cared for by 39 male and 19 female physicians in 30 primary care practices reveal that women physicians provide more preventive counseling for risk factors, including diet, weight loss, and physical activity. Additionally, they found that women patients, regardless of the sex of their physician, were less likely to receive drug therapy for diabetes management, including glucose-lowering medications, ACE inhibitor therapy and aspirin therapy. The authors point out, however, that the modest differences in cardiovascular disease risk factor management have little effect on the frequency with which patients meet guideline-specific goals for cardiovascular disease during a 2- 5-year period. They call for future research to explore whether the stylistic differences in cardiovascular disease risk factor management have any long-term impact on clinically relevant outcomes, such as heart attacks, strokes, heart failure and death.
Differences in Cardiovascular Disease Risk Factor Management in Primary Care by Sex of Physician and Patient
By Hava Tabenkin, M.D., M.S., L.L.B., et al
HaEmek Medical Center, Afula, Israel
Realizing the Potential of the Information Age by Considering Different Ways of Knowing
The sixth in a seven-part series of commentaries to understand health and health care With the January/February issue, Annals of Family Medicine editor Kurt Stange, M.D., Ph.D., continues his seven-part series of commentaries designed to help make sense of the problems and opportunities we face for understanding and fostering health. The series' sixth installment explores four different ways of knowing, learning and developing. Stange asserts that our understanding of the world has become more and more fragmented as information is generated in ever-smaller segments and for increasingly narrow purposes, leaving us with limited understanding and a paucity of wisdom. He posits that researchers can realize the potential of the information age and achieve a higher level of understanding by considering other, complementary ways of knowing the phenomena under study. Using the hypothetical story of a patient with diabetes, Stange illustrates how each way of knowing, when considered together, has the potential to evolve from data to information to knowledge to understanding. He calls on readers to imagine the symbiosis, synthesis and synergy that could be created if personalized medicine were understood not just from the perspective of biomedicine, but also from systems and ecological, community and family, and person perspectives.
Ways of Knowing, Learning and Developing
By Kurt C. Stange, M.D., Ph.D.
Case Western Reserve University, Ohio
Public Health Slogans About Healthy Diet Don't Necessarily Translate to Healthy Eating
While basic public health slogans and messages about a healthy diet may reach the lay public, this study illustrates that awareness does not necessarily translate to understanding and application in daily life. Interviews with 46 women from a Welsh working class community revealed that although the main public health messages about a healthy eating – like eating five a day and eating a balanced diet – were known by mothers and had been adopted into everyday language, the messages were being interpreted in a superficial way and appeared ineffective at achieving lasting behavior change. The authors assert that confused interpretations limit people's ability to bring about lifestyle change. What many of the women described as a healthy diet would not satisfy official definitions, and they described many barriers to making changes, including time, money, family preferences and a desire to enhance the quality of life through the enjoyment of food. The researchers conclude that while generic slogans are useful starting points, clinicians must offer patients more personalized, detailed advice on how changes can be positively achieved and sustained.
A Question of Balance: A Qualitative Study of Mothers' Interpretations of Dietary Recommendations
By Fiona Wood, PhD, et al
Cardiff University, Wales
Suicide Inquiry in Primary Care Sensitive and Straightforward
Noting that one-half of people who die by suicide have seen a primary care physician within a month of death, researchers from the University of Washington take a closer look at how primary care physicians inquire about suicide, recognizing the inherent challenges of suicide risk assessment given that physicians are often forced to probe for an unstated concern. The detailed qualitative analysis of 91 audio-recorded primary care visits found that most primary care physicians' suicide inquiries were sensitive and straightforward. Researchers found that generally, physicians seamlessly wove the topic of suicide into the conversational fabric that was focused on psychosocial functioning. Additionally, they found that physicians rarely responded to the standardized patients' denial of suicide ideation by jumping to a fresh topic. Most responded by probing for more information or by expressing supportive statements aimed at reassuring that the physician is concerned for their safety. In only a few instances (4) did physicians use language that might inhibit suicide disclosure.
Suicide Inquiry in Primary Care: Creating Context, Inquiring and Following Up
By Steven D. Vannoy, Ph.D., M.P.H., et al
University of Washington, Seattle
An Up-Close Look at New Mexico's Successful Rural Health Extension Program
Researchers from the University of New Mexico describe a statewide program aimed at improving community health and local capacity in rural New Mexico by identifying community health priorities and linking them with resources from the University of New Mexico Health Services Center. Modeled after the Agricultural Cooperative Extension Service, the Health Extension Rural Offices (HEROs) program enables health extension agents to attend to more than just immediate, strictly medical needs by addressing underlying social determinants of disease, such as school retention, food insecurity, and local economic development through community engagement. They conclude that programs similar to HEROs could be reproduced in other cities and towns.
Health Extension in New Mexico: An Academic Health Center and the Social Determinants of Disease
By Arthur Kaufman, M.D., et al
University of New Mexico, Albuquerque
Annals of Family Medicine is a peer-reviewed, indexed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care disciplines. Launched in May 2003, Annals is sponsored by seven family medical organizations, including the American Academy of Family Physicians, the American Board of Family Medicine, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the North American Primary Care Research Group, and the College of Family Physicians of Canada. Annals is published six times each year and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials. Complete editorial content and interactive discussion groups for each published article can be accessed free of charge on the journal's Web site, www.annfammed.org.
Journal
The Annals of Family Medicine