Chronic obstructive pulmonary disease megatrials: taking the results into office practice

Primary care specialists provide first-line care of chronic obstructive pulmonary disease (COPD), characterized by progressive, partially reversible airflow limitation induced mainly by smoking. Spirometry and questionnaires are important for COPD diagnosis, staging and prognosis. Smoking cessation, immunizations, pulmonary rehabilitation and self-management action plans comprise nonpharmacologic COPD management. The Understanding Potential Long-term Impacts on Function with Tiotropium (UPLIFT?) and Towards a Revolution in COPD Health (TORCH) megatrials provide evidence for maintenance pharmacotherapy to reduce exacerbations and improve patient symptoms and health-related quality of life. Although the primary outcomes--lung function decline (UPLIFT?) and mortality (TORCH)--were negative, long-acting bronchodilators in both trials reduced exacerbation rates and improved health status. Tiotropium added to usual care (in UPLIFT?) and salmeterol/fluticasone therapy (in TORCH) improved key patient-centered outcomes with no significant mortality risk or excess in serious cardiac adverse events associated with the study drugs. These results provide strong evidence of efficacy and acceptable safety profiles of maintenance pharmacotherapies in patient-centered outcomes and support combination drug regimens in patients with moderate to very severe COPD.     

Cardioprotection requires taking out the trash

Autophagy is a critical cellular housekeeping process that is essential for removal of damaged or unwanted organelles and protein aggregates. Under conditions of starvation, it is also a mechanism to break down proteins to generate amino acids for synthesis of new and more urgently needed proteins. In the heart, autophagy is upregulated by starvation, reactive oxygen species, hypoxia, exercise, and ischemic preconditioning, the latter a well-known potent cardioprotective phenomenon. The observation that upregulation of autophagy confers protection against ischemia/reperfusion injury and inhibition of autophagy is associated with a loss of cardioprotection conferred by pharmacological conditioning suggests that the pathway plays a key role in enhancing the heart’s tolerance to ischemia. While many of the antecedent signaling pathways of preconditioning are well-defined, the mechanisms by which preconditioning and autophagy converge to protect the heart are unknown. In this review we discuss mechanisms that potentially underlie the linkage between cardioprotection and autophagy in the heart.     

Tips and tools for people taking HAART

Suggestions for managing potential complications of fat abnormalities when using HAART are summarized. People should have body cell mass, blood lipid, and glucose levels monitored before beginning anti-HIV therapy. Recommendations include various screening tests, keeping track of body shape and body changes, and considering making lifestyle changes. Contact information to access Internet resources about fat abnormalities and protease inhibitors is provided.     

Anthrax and the mail: the making of an educational video for mail workers

The anthrax bioterrorist attacks in 2001 affected millions of people who process, sort, and deliver mail. To more effectively communicate information intended to protect the health of these workers, the Centers for Disease Control and Prevention produced a short-format educational video in December 2001 that targets this diverse group. This report illustrates how an educational video can be rapidly produced to translate and disseminate public health recommendations as part of a public health emergency response.     

Using out of office blood pressure monitoring in the management of hypertension

Self-measurement of blood pressure (BP) and 24-hour ambulatory BP monitoring (ABPM) are increasingly used in order to improve cardiovascular risk stratification over and beyond traditional methods, including sphygmomanometric BP measurement. Self-measured BP has the advantage of being cheap, quite representative of the usual BP over long periods of time, and devoid of the "white coat" effect. Only a few data exist on the prognostic value of self-measured BP. Most of the outcome studies with 24-hour ABPM have been conducted in patients with essential hypertension who were untreated at the time of execution of ABPM. Cardiovascular risk showed a direct association with ambulatory BP and an inverse association with the degree of BP reduction from day to night. White coat hypertension versus ambulatory hypertension and dippers versus nondippers are two classifications based on arbitrary operational risk categories. ABPM may be valuable for refining cardiovascular risk stratification in untreated subjects with office hypertension, as well as those with resistant hypertension.     

Primary care geriatrics: making a living taking care of old people the old-fashioned way

Delivering geriatric care in a community-based practice is a physical, mental and financial challenge. These challenges are described, followed by caveats for practicing physicians of all ages.     

Boarding out as an option for the care of elderly people

There has been some experiment in Ireland in recent years with boarding out of elderly persons. This comprises the placement, usually with a non-relative in a private household, of an elderly person, with the carer receiving some reward. This study assesses the cost of care for a small group of elderly persons in boarding-out care compared with a similarly dependent group of elderly persons in welfare home institutional care. The cost of boarding out care is less than half the cost of care in the welfare home. This result is encouraging given the feeling that quality of care in boarding out is not below that of institutional care.     

Bringing gait analysis out of the laboratory and into the clinic

The potential value of objective assessment of gait in geriatric medicine cannot be explored fully whilst gait analysis remains a laboratory research tool, imposing special conditions which often preclude its use in the elderly. We describe a method of gait analysis suitable for the geriatric clinic and illustrate its use in documenting the response to interventions in three patients presenting with falls due to parkinsonism. Irregularity between gait cycles was noted, a finding previously described in Parkinson's disease, dementia and normal old men at a fast walking speed. Such irregularity may prove to be a major risk factor for falls. Where multiple pathologies which disturb gait coexist, measurement of changes in gait in response to treatment may provide a much needed means of audit.