Increasing physician involvement In cholesterol-lowering practices: The role of knowledge,attitudes and perceptions

The study evaluated a multifaceted educational intervention systematically designed to increase physician involvement in cholesterol-lowering practices. We hypothesized that knowledge, perceptions and behaviours would be enhanced in participating physicians, compared with controls. Method: Fifty-one family physicians were assigned randomly to three groups; the two experimental groups attended a training workshop, received physician and patient education materials and ongoing consultant support. One experimental group also received a “cuing” intervention. The control group received no interventions. Outcome measures included knowledge and attitude scores, self-efficacy perceptions, and physician dietary counselling behaviour. Measures were taken at pretest, 6 weeks and 15 months later. Results: Intervention group physicians achieved significantly higher knowledge scores than the control group at the six-week test; the differences disappeared at 15 months. Attitudes, self-reported practices and overall self-efficacy scores were similar across groups. Within group variation was highly significant. Physician dietary counselling scores were significantly higher in the intervention groups (p = 0.0001). Some associations were seen among knowledge, attitude, self-efficacy and dietary counselling scores. Conclusion: Physician behaviour change in cholesterol reduction may not depend entirely upon knowledge, attitudes and perceptions. This revised version was published online in June 2006 with corrections to the Cover Date.     

Aspects of the aetiology of congenital heart disease

A concise overview of current knowledge on the aetiology ofcongenital heart disease is provided. At present, only 10 to20% of the cases occurring in neonates can be attributed toknown risk factors. Recurrence within relatives, chromosomalanomalies, genetic disorders, maternal diseases and teratogenexposure are addressed briefly; contemporary research modelsand methods, e.g. embryology and genetics and molecular biology,are referred to. A major innovation has been the introductionof the concept of common pathogenetic pathways. Thus, differentteratogenic factors or risk-factors may affect normal developmentat an identical stage and cause similar malformations. Also,the importance of timing of an event is stressed. If the timeframe of exposure does not coincide with embryogenesis any teratogeniceffect may be missed. Large-scale epidemiological studies on fetuses and neonateswith congenital heart disease are introduced as a third modeof research on the aetiology, although this approach is notused efficiently at present; cases of intra-uterine death canbe considered a valuable source of information that needs furtherattention. Combined, the above three lines of research may proveproductive, but the design of a comprehensive research projectwould need to be handled carefully. Possibilities for preventionof the occurrence of cardiovascular malformations are reported.Through lack of knowledge of causality, at present, only secondaryprevention may be possible and hence deserves attention. However,there appears to be no provision for thorough pre-natal screeningtests for congenital heart disease in an unselected population.     

Electrocardiological profile and proarrhythmic effects of quinidine,verapamil and their combination: a mapping study

Quinidine and verapamil are widely used as antiarrhythmic agents and their combination is often used in the treatment of supraventricular tachycardia. This study was undertaken to clarify, whether these drugs exert proarrhythmic effects on the ventricles in therapeutic concentrations and whether possible arrhythmogenic effects might be enhanced by combination. Isolated rabbit hearts perfused according to the Langendorff technique were treated with increasing concentrations of quinidine (0.05 to 3.5 M) or verapamil (5 to 50 M) or of their combination (70:1 or 10:1; quinidine:verapamil) corresponding to common low, medium and high free therapeutic concentrations. The epicardial activation process was measured using a computer assisted mapping system for unipolar multichannel recording (256 channels simultaneously).Both substances prolonged the atrioventricular conduction time PQ. This effect was even more pronounced if the 70:1 combination was administered. The activation pattern was altered by both drugs and their combination to the same extent as became obvious from analysis of local activation vectors and of localisation of breakthroughpoints of epicardial activation for heart beats under control conditions and under drug treatment. The epicardial potential durations were prolonged by quinidine and to the same degree by the combinations, but not by verapamil alone. The total activation time was prolonged under the influence of quinidine and if the 70:1 combination was given. Both substances exerted a negative inotropic effect which was enhanced in an additive manner if both drugs were combined. In parallel the coronary flow was diminished.From these results it is concluded that (1) in this therapeutic concentration range quinidine possess a greater proarrhythmic risk than verapamil, (2) that both drugs' PQ prolonging effect can be enhanced by combination, (3) that combination does not enhance the proarrhythmic effects but the negative inotropic effects.     

A dose-response study of the effects of alcohol on the perceptions of pain and discomfort due to electric shock in men at high familial-genetic risk for alcoholism

Alcoholics have previously been found to be more sensitive to painful stimulation than controls, and more sensitive to the pain-reducing effects of alcohol. The present study was designed to examine these effects in men at high familial-genetic risk for alcoholism and controls. Subjects were assigned to one of four alcohol doses [0.135 (active placebo), 0.50, 0.75, or 1.00 ml 95% USP alcohol/kg body weight]. Ratings of the amount of discomfort and pain experienced during an aversive shock procedure were taken immediately post-shock, both while subjects were sober and after they had consumed one of the four alcohol doses. High risk men were found to rate the experience of the shock as more uncomfortable and painful overall than the low risk controls. Pharmacologically significant levels of alcohol were found to reduce or eliminate these group differences, suggesting that alcohol has a normalizing effect on pain and discomfort perceptions in high risk men. Only the higher doses of alcohol were found significantly to dampen subjects' shock rating scores. High risk males' increased sensitivity to pain and discomfort, combined with the negatively reinforcing effects of reducing these perceptions at moderate to high alcohol doses, may play a role in predisposing high risk males for the development of alcoholism.     

我国消除丙型肝炎的普通人群HCV检测策略的成本效果分析

目的 分析我国消除丙型肝炎（丙肝）的普通人群HCV检测策略的成本效果,明确最佳成本效果的HCV检测年龄。方法 运用TreeAge pro 2019软件构建决策树马尔科夫模型,以1年为周期,模拟10万名20~59岁各年龄组人群HCV检测和治疗结果,以全社会角度分析策略间比较的成本效果和效益。效果指标为增量成本效果比（ICER）,效益指标为净货币效益（NMB）,以我国2022年人均国内生产总值（85 698元）为意愿支付阈值。通过单因素敏感性分析和概率敏感性分析评估结果可靠性。结果 在20~59岁人群HCV检测有成本效果,在40~49岁年龄组进行HCV检测成本效果最佳。20~59岁年龄组人群HCV检测策略与未HCV检测策略比较,增量成本为161.24元/人,增量效用为0.003 6质量调整寿命年（QALYs）/人,ICER为45 197.26元/QALY,ICER小于意愿支付阈值,具有成本效果。各年龄组人群HCV检测策略与未HCV检测策略比较,ICER为42 055.06~53 249.43元/QALY,NMB为96.52~169.86元/人,其中40~49岁年龄组的ICER最低,NMB最高。单因素敏感性分析结果显示,贴现率、丙肝抗体（抗-HCV）检测成本、人群抗-HCV阳性率和直接抗病毒药物治疗成本对经济学评价影响较大,但改变参数取值,结论不变。概率敏感性分析结果表明模型分析结果稳定。结论 医疗机构探索动员20~59岁普通人群进行HCV检测具有较好的成本效果,以40~49岁年龄组人群的HCV检测成本效果最佳。在我国普通人群中实施HCV检测的“愿检尽检”策略,能降低人群丙肝疾病负担。     

职业人群不健康行为生活方式与高尿酸血症的关系及高血压、血脂异常的效应修饰作用

目的 探索不健康行为生活方式与高尿酸血症的关系,以及高血压、血脂异常的效应修饰作用,为预防高尿酸血症提供理论依据。方法 采用横断面调查研究设计,基于2021年10-12月来自四川省、贵州省28个地级市和重庆市33个区（县）中国铁路成都局集团有限公司的西南职业人群队列基线数据,通过问卷调查、体格测量及实验室生化检测收集研究对象的人口学特征、行为生活方式、慢性非传染性疾病患病情况。不健康行为生活方式得分根据吸烟、饮酒、膳食模式、体力活动和低体重/超重状况进行评分,分值越高不健康行为生活方式越多。采用多因素logistic回归模型分析不健康行为生活方式评分、吸烟状况、饮酒状况等与高尿酸血症的关系,采用分层分析探索高血压等疾病对不健康行为生活方式与高尿酸血症之间关系的修饰效应。结果 共纳入11 748名研究对象,高尿酸血症患病率为34.4%。多因素logistic回归分析显示,现在吸/既往吸烟、现在饮/既往饮酒及BMI异常是高尿酸血症患病的危险因素,不健康行为生活方式对高尿酸血症患病风险呈现累积效应,随着得分的升高,高尿酸血症患病风险升高,OR值由1.64（95%CI：1.34~2.00）上升至2.89（95%CI：2.39~3.50）。分层分析结果显示,在高血压及血脂异常人群中,不健康行为生活方式对高尿酸血症患病风险影响更大。结论 多种不健康行为生活方式的共存会升高高尿酸血症患病风险,这一效应在高血压、血脂异常人群中更明显。及时纠正不健康行为生活方式,并控制高血压和血脂异常,降低患高尿酸血症的风险。     

A study on how a 6-month aerobic exercise program can modify coronary risk factors depending on their severity in middle-aged sedentary women

It is well known that physical exercise can reduce coronary risk factors. But how an aerobic exercise modifies coronary risk factors in relation to severity and physical fitness is still controversial. Fifty-four middle-aged women (mean age, 55 years) completed a 6-month on-site and home-based anaerobic threshold-level exercise program. The changes in coronary risk factor profiles were observed during the pre-intervention and intervention periods. Before the intervention (during control period), most coronary risk factors showed a rather unfavorable trend. After the program, their mean body weight decreased from 56.7 to 55.7 kg (p>0.05) and the proportion of body fat from 30.9 to 27.9% (p>0.05) without any reduction in lean body mass. Systolic blood pressure (SBP) decreased from 129.0 to 125.0 mm Hg (p>0.05) and diastolic blood pressure from 79.5 to 76.6 mm Hg (p>0.05). Fasting plasma glucose (FPG) declined from 109.6 to 103.4 mg/dl (p>0.05). Changes in SBP and FPG were most remarkable in their respective worst tertile. Serum lipids improved only modestly. Maximum oxygen uptake increased from 23.6 to 26.1 ml/kg/min (p>0.01). However, no significant correlations were found between changes in coronary risk factors and those in physical fitness. We conclude that the 6-month aerobic exercise program would modify women’s coronary risk factors depending on their initial values, probably independently of the changes in physical fitness.     

Regulating the gene: From genetic consumption to regulatory trust

In this article, we examine the changing terms on which genetics-based technologies in two areas agriculture (Genetically Modified Organism, GMOs) and health (genetic diagnostics) have been regulated. These are used to illustrate and examine the proposition that shifts in the politics of governance and regulation (associated in part with the advent of the negotiation state) have meant that the responsibility for the social management of new technology is increasingly shared between the state and the consumer. However, this redistribution of the social management of risk, we argue, fails to establish a sufficient basis for a legitimate regulatory trust. We suggest that trust will depend on embedding broad social values and a self-critical agenda within the regulatory regime itself.     

Different pattern of risk factors for atopic and nonatopic asthma among children – report from the Obstructive Lung Disease in Northern Sweden Study

BACKGROUND: A cross-sectional study was performed among 78-year-old schoolchildren during the winter of 1996 in three municipalities in the most northern province of Sweden, Norrbotten. The study was the starting point of a longitudinal study of asthma, rhinitis, eczema, and type-1 allergy, and provided data on prevalence and risk factors for these conditions. The aim of the present study was to validate the classification of asthma based on a parental questionnaire, and to examine risk factors for atopic and nonatopic asthma. METHODS: The ISAAC questionnaire with additional questions was distributed by the schools to the parents. The response rate was 97%, and 3431 completed questionnaires were returned. The children in Kiruna and Lule? were also invited to be skin tested, and 2149 (88%) were tested with 10 common airborne allergens. A structured interview was administered by pediatricians in stratified samples of the children to test the validity of the diagnosis of asthma based on the questionnaire. RESULTS: After the validation study, the prevalence of "ever asthma" was estimated to be 8.0%. The specificity of the question, "Has your child been diagnosed as having asthma by a physician?", was high, >99%, while the sensitivity was around 70%. The strongest risk factor for "ever asthma" was a positive skin test (OR 3.9). Risk factors for asthma in the asthmatics who were not sensitized were family history of asthma, OR 3.6; breast-feeding less than 3 months, OR 1.8; past or present dampness at home, OR 1.8; smoking mother, OR 1.7; and male sex, OR 1.6. Among the sensitized asthmatics, only a family history of asthma was a significant risk factor (OR 3.0), while breast-feeding less than 3 months was not associated with an increased risk (OR 1.0). A synergistic effect between genetic and environmental factors was found especially in the nonatopic asthmatics; the children with a family history of asthma who had a smoking mother and past or present dampness at home had an OR for "ever asthma" of 13. CONCLUSIONS: Different risk-factor patterns were found for asthma and type-1 allergy. In addition, the risk factors for atopic or allergic asthma diverged from those for nonatopic asthma.     

Reflex testing I: algorithm for lipid and lipoprotein measurement in coronary heart disease risk assessment

We reviewed the current literature in order to construct a reflex testing algorithm that maximizes clinical utility and cost-effectiveness of lipid and lipoprotein testing. The algorithm was based on the 2nd Report of the National Cholesterol Education Program Adult Treatment Panel guidelines for use of total cholesterol (TC), triglycerides (TG), HDL-C, and LDL-C, and published reports describing the clinical use of apolipoprotein B and lipoprotein (a). The success of this algorithm was tested in a low-risk general and a high-risk hyperlipidemic patient population. Lipid data and non-lipid risk factors were obtained from a national database and from patients seen at two lipid clinics. A total of 16 968 individuals from the National Health and Nutrition Examination Survey III database comprised the low-risk group, and 239 patients examined in the Hartford Hospital and Washington University Lipid Clinics comprised the high-risk group. We found a solid scientific base to support the NCEP guidelines and reasonable support for limited testing of apoB and Lp(a). According to the algorithm, the direct LDL-C assay was deemed unnecessary in 98% and 91% of low- and high-risk subjects, respectively, if one assumes that the Friedewald equation is adequate with TG≤4.00 g/l. With a more conservative cutoff of TG≤2.50 g/l, the algorithm canceled 92% and 81% of direct LDL tests, respectively. The algorithm also limited TG to 20 and 64%, apoB to 6 and 20%, and Lp(a) to 15 and 56%, of low- and high-risk groups, respectively. Use of a comprehensive, reflex algorithm for coronary heart disease risk assessment will substantially reduce the utilization of laboratory services without diminishing the clinical value of these tests. The algorithm will prevent the overuse of certain expensive tests (direct LDL) while promoting the limited use of underutilized tests [apoB and Lp(a)].