Cardiovascular disease and lipids. Issues and evidence for the management of dyslipidaemia in primary care

The commonest manifestations of cardiovascular disease, namely coronary heart disease (CHD) and stroke, represent the two most common causes of death in the world today. Furthermore, cardiovascular diseases have the highest healthcare utilisation costs in most countries. Both primary and secondary prevention management strategies are essential. Although more than 200 risk factors for CHD have now been identified, the single most powerful predictor of CHD risk is abnormal lipid levels. The relative risk influences of the various lipid sub-fractions are described, with particular emphasis on LDL cholesterol, which represents the principal target for treatment in most management guidelines. Unfortunately, there remains considerable evidence of continued under-management of patients with elevated cholesterol and cardiovascular risk who are eligible for secondary prevention. The barriers contributing to such physician under-performance are numerous. The more recent recognition of the importance of identifying patients at enhanced risk, but without established disease (primary prevention), will require greatly familiarity with the clinical use of CHD risk scoring systems, most of which are based upon the Framingham equation. Special reference is made to groups at particular risk of CHD. In summary, the application of the enormous evidence-base for interventions in cardiovascular disease, especially over the treatment of elevated cholesterol, pose a huge challenge to primary and secondary care in most healthcare systems.     

Interpreting office radiographs. A guide to systematic evaluation

Office radiographs are important diagnostic tools for most family physicians, and most family physicians believe that they should be capable of interpreting 90% of these films without referral to a radiologist. Optimal use of these radiographs requires that patients are appropriately selected, that the examination is adequately conducted, and that the films are accurately interpreted. Interpretive accuracy is enhanced if radiographs are analyzed by physicians skilled in observing and interpreting them and if the images are examined in a logical, systematic manner to minimize observer bias. A systematic search pattern is proposed to facilitate family physicians' interpretations for the most common office radiographs: chest, extremities, abdomen, skull, and spine.     

Promoting physical activity among children and adolescents: the strengths and limitations of school‐based approaches

Paediatric overweight and obesity is recognised as one of Australia's most significant health problems and effective approaches to increasing physical activity and reducing energy consumption are being sought urgently. Every potential approach and setting should be subjected to critical review in an attempt to maximise the impact of policy and program initiatives. This paper identifies the strengths and limitations of schools as a setting for promoting physical activity. The strengths are: most children and adolescents attend school; most young people are likely to see teachers as credible sources of information; schools provide access to the facilities, infrastructure and support required for physical activity; and schools are the workplace of skilled educators. Potential limitations are: those students who like school the least are the most likely to engage in health‐compromising behaviours and the least likely to be influenced by school‐based programs; there are about 20 more hours per week available for physical activity outside schools hours than during school hours; enormous demands are already being made on schools; many primary school teachers have low levels of perceived competence in teaching physical education and fundamental movement skills; and opportunities for being active at school may not be consistent with how and when students prefer to be active.     

Gastrointestinal surgery and gastroenterology. XIII. Classification and diagnosis of perianal fistulas

Intersphincteric abscesses due to inflammation of an anal gland are the origin of most perianal fistulas. Perianal fistulas are classified into four types. Intersphincteric and transsphincteric fistulas are the most common. The appropriate surgical treatment of perianal fistulas is dependent upon their correct classification. Despite new imaging-techniques, physical examination of the perianal region remains of paramount importance for the preoperative classification of perianal fistulas. At present, endoanal ultrasound with the injection of hydrogen peroxide into the fistulous tract, is advocated as the most suitable method for the preoperative imaging of perianal fistulas.     

Comparative study of the attitudes of students and nurses to physician-assisted suicide--first results

While the popular media and the professional literature deal with the topic of euthanasia intensively, the problems of physician-assisted suicide received insufficient attention in Hungary. The authors review the most important details of the physician-assisted suicide. A twelve-item scale to measure attitude toward PAS (constructed and validated by G. Domino) was administered to the samples of Hungarian social science, medical students and nurses. The distributions of responses for the 12 items for the social and medical samples are compared and discussed. Also a cross-cultural comparison was made with an American student sample examined by Domino. The social science students who have the fewest personal experiences with serious, or terminally ill patients are the most liberal group, characterised by the most permissive attitudes toward PAS. Nurses who have everyday contact and experience with these patients are the most conservative; they show more or less conclusively the lowest acceptability rate of PAS. The attitudes of medical student's group, of the would-be physicians are between them, and they are the most controversial and ambivalent. Future research is necessary to get more information about attitudes toward physician-assisted suicide.     

Man-made mineral fibers (MMMF): human exposures and health risk assessment

MMMF are made by spraying or extruding molten glass, furnace slag, or mineral rock. Health concerns are based on the morphological and toxicological similarities between MMMF and asbestos, and the well-documented evidence that asbestos fibers can cause lung fibrosis (asbestosis), bronchial cancer, and mesothelioma in humans. Epidemiological evidence for human disease from inhalation exposures to fibrous glass is largely negative. Some positive associations have been reported for slag and rockwools. Most of the toxicological evidence for MMMF toxicity in laboratory animals is based on non-physiological exposures such as intratracheal instillation or intraperitoneal injection of fiber suspensions. The risks for lung fibrosis, lung cancer, and mesothelioma for industrial exposures to most fibrous glass products are either low or negligible for a variety of reasons. First, most commercial fibrous glass products have mean fiber diameters of approximately 7.5 microns, which results in mean aerodynamic diameters greater than 22 microns. Thus, most glass fibers, even if dispersed into the air, do not penetrate into the lung to any great extent. Second, the small fraction of smaller diameter fibers which do penetrate into the lungs are not persistent within the lungs for most fibrous glass products, due to mechanical breakage into shorter lengths and dissolution. Dissolution is most rapid for the smaller diameters (less than 0.1 micron) capable of producing mesothelioma. The greater hazards for slag and rockwools, in comparison to conventional fibrous glass, appear to be related to their smaller diameters and greater durability within the lungs.     

血液肿瘤患者医院获得性感染细菌病原学研究

目的 探讨血液肿瘤患者化疗后粒细胞缺乏期，医院感染的细菌病原学特点及体外对抗生素的敏感性，为临床抗生素应用提供参考。方法 化疗后粒细胞缺乏期出现感染性发热患者，在应用抗生素前留取血，痰、尿及分泌物标本，体外分离细菌菌株并测定对抗生素的敏感性。结果 医院感染细菌以G^-杆菌多见，大肠埃希菌，肺炎克雷伯菌，铜绿假单胞菌是最常见的致病菌，鲍曼不动杆菌有逐年增加的趋势；G^ 球菌感染主要为肠球菌属；体外药敏试验显示耐药菌株近年来有增加趋势，大多数G^-杆菌对半合成青霉素耐药，5%左右肠球菌对万古霉素耐药。结论 在化疗后粒细胞缺乏的患者医院感染的细菌主要为内源性菌，耐药菌株增加，其原因与大量广谱抗生素应用及医院交叉感染有关。     

Using imiquimod for genital warts in female patients

Genital warts (GW) are the manifestation of infection with specific types of human papillomavirus (HPV), one of the most common sexually transmitted viral infections in the world. Genital warts can be either raised (exophytic) or flat. Exophytic genital warts are most commonly secondary to inoculation of the basal epithelium with nononcogenic HPV types 6 and 11, whereas flat warts are usually secondary to potentially oncogenic HPV types 16 and 31. Genital warts can occasionally cause irritation and discomfort, particularly during intercourse, although most cases are asymptomatic. It is the psychosocial effects of infection, such as a sense of shame, depression, and anxiety, that represent the more significant toll for most patients with GW. Current therapies for GW are mainly ablative and do not directly enhance the immune response to HPV. Therefore, recurrence is a problem for many patients. Imiquimod 5% cream is a patient-applied therapy that directly enhances the immune response to HPV and is safe and effective for the treatment of GW. A reduction in viral load is observed following treatment. Low recurrence rates compared to other treatment modalities may be due to the stimulation of the cell-mediated immune response by imiquimod.     

Community Variation in Risk and Protective Factors and Substance Use Outcomes

Communities are the context in which many prevention activities take place. One approach to community prevention is to identify the most elevated risk factors and most depressed protective factors for substance use in a community and then to select and implement preventive interventions to address the most elevated risk factors and most depressed protective factors in the community. This approach presumes that there are reliable differences between communities in risk and protection and that these differences relate to differences in substance use across communities. This paper addresses these issues using data from 28,091 students in 41 communities across the U.S. Intraclass correlation coefficients are used to assess the degree to which there are reliable and meaningful differences between communities in levels of risk and protective factors. The community means of the risk and protective factors are then correlated with levels of substance use. Findings indicate that there are meaningful differences between communities in levels of specific risk and protective factors, and that those differences are related to different levels of substance use in these communities. These results provide an empirical foundation for tailoring community-wide efforts to prevent substance abuse to the specific profiles of risk and protective factors experienced by youths in different communities.     

Defining “Rural” for Veterans’ Health Care Planning

Purpose: The Veterans Health Administration (VHA) devised an algorithm to classify veterans as Urban, Rural, or Highly Rural residents. To understand the policy implications of the VHA scheme, we compared its categories to 3 Office of Management and Budget (OMB) and 4 Rural-Urban Commuting Area (RUCA) geographical categories. Method: Using residence information for VHA health care enrollees, we compared urban-rural classifications under the VHA, OMB, and RUCA schemes; the distributions of rural enrollees across VHA health care networks (Veterans Integrated Service Networks [VISNs]); and how each scheme indicates whether VHA standards for travel time to care are met for the most rural veterans. Results: VHA's Highly Rural and Urban categories are much smaller than the most rural or most urban categories in the other schemes, while its Rural category is much larger than their intermediate categories. Most Highly Rural veterans live in VISNs serving the Rocky Mountains and Alaska. Veterans defined as the most rural by RUCA or OMB are distributed more evenly across most VISNs. Nearly all urban enrollees live within VHA standards for travel time to access VHA care; so do most enrollees defined by RUCA or OMB as the most rural. Only half of Highly Rural enrollees, however, live within an hour of primary care, and 70% must travel more than 2 hours to acute care or 4 hours to tertiary care. Conclusions: VHA's Rural category is very large and broadly dispersed; policy makers should supplement analyses of Rural veterans’ health care needs with more detailed breakdowns. Most of VHA's Highly Rural enrollees live in the western United States where distances to care are great and alternative delivery systems may be needed.     

Obstructive Sleep Apnea in North American Commercial Drivers

The most common medical cause of excessive daytime sleepiness (EDS) is obstructive sleep apnea (OSA). Specifically, among an estimated 14 million US commercial drivers, 17–28% or 2.4 to 3.9 million are expected to have OSA. Based on existing epidemiologic evidence, most of these drivers are undiagnosed and not adequately treated. Untreated OSA increases the risk of vehicular crashes as documented in multiple independent studies and by meta-analysis. Therefore, identifying commercial drivers with OSA and having them effectively treated should decrease crash-related fatalities and injuries. Several strategies are available for screening and identifying drivers with OSA. The simplest and most effective objective strategies use body mass index (BMI) cutoffs for obesity. Functional screens are promising adjuncts to other objective tests. The most effective approach will likely be a combination of a good questionnaire; BMI measures; and a careful physician-obtained history complemented by a functional screen.     

膳食营养素与高血压关系的研究进展

高血压是最常见的慢性非传染性疾病和最重要的心脑血管病危险因素。膳食因素是高血压患病率持续升高的最重要环境因素之一,研究膳食营养与高血压的关系,可以帮助人们了解膳食营养物质对高血压的影响,从而更加合理有效的干预以控制血压的升高。     

Neuroprotective and neurorestorative therapies for the treatment of Parkinson's disease

Parkinson's disease is the second most common neurodegenerative disorder after Alzheimer's disease. Current therapies are symptomatic and, although these therapies are efficacious during the early stages of the disease, they present important side effects when they are used for a long time. The ideal therapy would be the one that would slow down or stop the progression of the disease. This can be achieved, for instance, with neuroprotective and neurorestorative therapies. Among them, cell therapy and therapy with trophic factors such as glial cell line derived neurotrophic factor (GDNF) are the most challenging and promising ones for the scientific community. Although the use of GDNF as a treatment for Parkinson s disease was proposed several years ago, it is necessary to develop alternative strategies to deliver GDNF appropriately to concrete areas of the brain. Here, the use of microspheres as the most suitable tool for the administration of this neurotrophic factor is discussed.     

Are you up to date with new immunization recommendations?

Vaccines are one of the most important and effective tools for protecting the health of the public and family physicians are instrumental in insuring that vaccine recommendations are implemented. With the development of new vaccines come increasingly complex recommendations. Staying current is challenging. This column describes the most recent changes to the immunization schedules made by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC).     

Outpatient management of pelvic inflammatory disease

Pelvic inflammatory disease (PID) is a spectrum of inflammatory disorders of the female genital tract involving at least the endrometrium and may include the fallopian tubes, ovaries, and pelvic cavity. Over 1 million women each year are treated for PID in the United States, and it is one of the most serious infections diagnosed in women due to its sequelae. Women with PID acutely experience pain and are at risk for sepsis; however, the significant increases in ectopic pregnancy and infertility are the most disturbing long-term complications. It most often is initiated with an infection by a sexually transmitted disease, but can also involve a variety of pathogenic aerobes and anaerobes secondarily.     

Accidental injuries in agriculture in the UK

The rate of occupational accidents in British agriculture is higher than in most other industries. The most common fatal accidents are those involving vehicles and machinery, falls from a height and electrocution. A substantial proportion of reported non-fatal injuries in agricultural employees is attributable to manual handling, but among self-employed farmers the contribution is much smaller. Few data are available on longer-term determinants of risk, but accidental deaths are most frequent in July, August and September. The main approaches to preventing agricultural accidents are through engineering improvements, and education and training of the workforce. The introduction of roll-over protection structures for tractors has been an important development in recent decades. Other engineering controls include guards for power take off shafts, guard rails to prevent falls, better handling facilities for animals and closed transfer systems for pesticides. Training on safety is available from several sources, but its effectiveness in reducing accidents is uncertain.     

Differential diagnosis of headache in a neurological department

Headache is one of the most common symptoms patients attending a neurological department present. Although the overwhelming majority of these headaches are benign and self-limited, headache can be the initial symptom of life-threatening disorders. It is important for physicians to differentiate primary from symptomatic headaches. There are 3 types of primary headaches: migraine, tension-type headache, cluster headache. Symptomatic headaches are numerous and in most cases are not the consequence of serious diseases, however a tumour or a different cerebral disease can be taken into account. Accurate anamnesis and accurate physical examination will help in diagnosing the aetiology of headache. In most cases, neurological and physical exams are normal. Anamnesis is therefore the key to a correct diagnosis.     

A Study of Consumers' Attitudes Toward Veterinarian Advertising

This study identifies consumers' views regarding veterinarian advertising, the types of media they consult and the factors they use to choose a veterinarian, along with the most used services. The study used a telephone survey of 100 randomly chosen pet owners from a metropolitan area of a Southern state. Response analysis using a Liken scale for opinions along with precentages and cross-tabulations reveal that consumers' desire more information about service quality and type and are favorable toward veterinarian advertising. Results also indicate that in the absence of advertising, word of mouth recomemendations are the most frequent source for choosing a veterinarian; quality issues are more important than price; immunizations are the most used service; and advertising will not lower consumers' views of veterinarians' professionalism.     

Relative survival computation. Comparison of methods for estimating expected survival

Relative survival is the most commonly used method to determine survival in patients diagnosed with cancer. This method takes into account estimation of expected survival in cancer patients based on the observed mortality in the geographical area to which they belong. The most frequently used methods for estimation of expected survival are the Ederer (I and II) and Hakulinen methods. Survival tables for the geographical areas stratified by age and calendar year are required for these calculations. The present article presents an example of how to perform these estimations and how to choose the most appropriate method for the type of analysis to be performed. This article shows that if the follow-up of the cohort is less than 10 years, any of these methods should give similar results. However, the Hakulinen method is preferred, since it accounts for heterogeneity due to potential withdrawals.