The JNC 7 approach compared to conventional treatment in diabetic patients with hypertension: a double-blind trial of initial monotherapy vs. combination therapy

The JNC 7 states that persons with blood pressure (BP) more than 20/10 mm Hg above goal should be started on combination drug therapy. This criterion includes patients with BP >160/100 mm Hg and diabetics with hypertension. The goal BP for persons with diabetes mellitus is <130/80 mm Hg. A randomized, double-blind trial force titrated initial combination therapy utilizing an angiotensin receptor blocker (ARB) combination (losartan/hydrochlorothiazide [LOS/HCTZ]) compared with an angiotensin-converting enzyme (ACE) inhibitor (ramipril), for 8 weeks, and tested the hypothesis that combination therapy is more likely to achieve goal BP vs. monotherapy. At 4 weeks, 30.5% of LOS/HCTZ and 14.4% of ramipril recipients achieved goal diastolic BP (p<0.001). More participants achieved goal systolic BP in the ARB/HCTZ group at 4 weeks (29.8% vs. 14.4%; p<0.001). At 4 weeks, mean diastolic BP had decreased 10.2+/-7.4 mm Hg in the LOS/HCTZ group compared with 6.4+/-6.8 mm Hg in the ramipril group (p<0.001), and systolic BP had fallen 15.4+/-13.1 mm Hg in the ARB/HCTZ compared with 9.2+/-10.2 mm Hg in the ACE-inhibitor group (p<0.001). Significant differences favoring the combination were also noted at 8 weeks. Drug-related adverse experiences were 10.3% for the combination compared with 12.7% for the monotherapy group. Initial combination therapy with an ARB/HCTZ was more effective than ACE-inhibitor monotherapy in achieving BP goals in participants with diabetes with no significant differences in the incidence of adverse experiences. These observations confirm other studies of combination therapies, such as b blocker/diuretic, ACE inhibitor/diuretic, or ACE inhibitor/calcium channel blocker. The use of two medications will achieve goal BP in more patients than monotherapy. This observation is important in treatment of high-risk patients with diabetes.     

Factors associated with colonoscopy performed in nonhospital settings

BACKGROUND:

Colonoscopy is being increasingly performed in facilities outside of hospitals. Regulation of these facilities is variable, and concerns regarding the quality of procedures in nonhospital (NH) settings have been raised. Further study is needed to better understand endoscopic practice in these facilities.

OBJECTIVES:

To describe NH-based colonoscopy practice in Ontario from 1993 to 2005, and to identify patient (age, sex, income quintile and comorbidity) and physician (specialty and colonoscopy volume) factors associated with this practice.

METHODS:

The present study was a population-based, cross-sectional analysis using health administrative data from Ontario adults who underwent at least one outpatient colonoscopy between 1993 and 2005. A total of 1,240,781 patients underwent 1,917,714 colonoscopies. The main outcome measure was the receipt of colonoscopy in an NH facility.

RESULTS:

An increase in NH-based colonoscopy from 10.0% in 1993 to 15.1% in 2005 (P<0.0001) was found. In the multivariate model, younger, healthier men living in higher income areas were significantly more likely to undergo NH-based colonoscopy. Surgeons and other practitioners (eg, nongastroenterologists and noninternists) were significantly more likely to practice in NH settings. Physicians in the highest colonoscopy volume quintile were 25 times more likely to practice in NH settings than those in the lowest volume quintile (P<0.0001).

CONCLUSION:

Rates of NH-based colonoscopy are rising in Ontario. High-volume endoscopists and surgeons are most likely to practice in NH settings. Given its increasing use, further study of the practice and the regulation of NH colonoscopy is warranted.     

Comparative study on methotrexate and hydroxychloroquine in the treatment of rheumatoid arthritis

This study was done to see the efficacy and tolerability of methotrexate and hydroxychloroquine in the Treatment of Rheumatoid Arthritis. It was an open label controlled clinical trial, done in Mymensingh Medical college hospital. Fifty six patients were selected by random sampling method, 28 were included in methotrexate group and another 28 for hydroxychloroquine group using inclusion & exclusion criteria. Primary efficacy variables (DAS28, daily naproxen), secondary efficacy variables, and safety measurement variables studied both clinically & laboratory investigations. The data were analyzed by computer with the help of SPSS. The student's t test was used as test of significant. The mean age of the patients at diagnosis was almost identically distributed between methotrexate and hydroxychloroquine group (41.7±12.2 vs. 42.9±9.2 years, p=0.659). Disease activity at baseline was found to be almost homogeneous to each group except CRP which was observed to be significantly higher in methotrexate group than hydroxychloroquine group (p<0.001). Disease activity at 1 month of treatment reduced in the methotrexate group than those in hydroxychloroquine group (p<0.05 in each case). After 3 and 6 months of treatment, disease activity decreased significantly in both groups (p<0.001 and p<0.05 respectively). The average daily dose of NSAID (Naproxen) decreased significantly (p<0.001). Safety variables at 6 month were within normal physiological ranges and did not differ in groups (p>0.05) indicating that both methotrexate and hydroxychloroquine were effective and safe to use in rheumatoid arthritis. The difference in the incidence of adverse effects, total or individual, was almost nil.     

Cardiovascular complications of chronic renal failure - an updated review

Chronic kidney disease (CKD) is a worldwide public health problem. Cardiovascular disease (CVD) is frequently associated with CKD, which is important because individuals with CKD are more likely to die from CVD than to develop kidney failure. CVD in CKD is treatable and potentially preventable and CKD appears to be a risk factor for CVD. In order of incidence and frequency systemic hypertension, left ventricular failure, congestive cardiac failure, ischemic heart disease, anaemic heart failure, rhythm disturbances, pericarditis with or without effusion, cardiac tamponade, uraemic cardiomyopathy are various cardiovascular complications encountered in patients with chronic renal failure. A patient may present with one or more complications of cardiovascular system. The survival rate and prognosis to a great extent depends on proper management of these complications. Use of regular dialysis and renal transplant has changed the death pattern in developed countries but it is still a major problem in developing country. The aim of this article is early detection of CKD and proper management of it thereby preventing the major cardiovascular complications.     

Modeling the Longitudinal Transitions of Performance Status in Cancer Outpatients: Time to Discuss Palliative Care

ContextUnderstanding the longitudinal transitions of performance status among persons with cancer can assist providers in determining the appropriate time to initiate palliative care support.ObjectivesTo model longitudinal transitions of performance status in cancer outpatients, to determine the probabilities of improvement and deterioration in performance status over time, and to evaluate the factors associated with rates of transitions.MethodsThis population-based, retrospective, cohort study comprised adult outpatients diagnosed with any type of cancer and assessed for performance status throughout their observation period using the Palliative Performance Scale (PPS; scale 0–100; 0 indicates death). At every PPS assessment, patients were assigned to one of four states: stable state (PPS score 70–100), transitional state (PPS score 40–60), end-of-life state (PPS score 10–30), or dead. A Markov multistate model under the presence of interval censoring was used to examine the rate of state-to-state transitions.ResultsThere were 11,374 patients representing nearly 71,000 assessments. Patients with lung cancer in the transitional state had a 27.7% chance of being dead at the end of one month vs. 17.5% in patients with breast cancer. The average time spent in the transitional state was 6.6 weeks for patients diagnosed with gastrointestinal cancer vs. 8.8 weeks for patients with breast cancer. The rate at which one moves from the transitional state to death was higher for patients with lung cancer than those with breast cancer.ConclusionWe estimated the probability and direction of change in performance status in cancer outpatients. Entry into the transitional state may serve as an indicator for referral for palliative care support. Mean end-of-life sojourn times are too short to allow meaningful integration of palliative care.     

Combined occurrence of hyperthyroid Graves' and Hashimoto's thyroiditis

A 40 years old, married Govt. servant from Sadar upazila, Mymensingh was admitted in Mymensingh Medical College Hospital on 9(th) February, 2005 with the complaints of excessive sweating for 1 year, gradual loss of weight for 6 months, swelling in front of the neck for 1(1/2) months, and hoarseness of voice for 1 month. He was nervous, irritable, emotionally labile. Thyroid gland was symmetrically enlarged, firm in consistency with scalloped surface. Palms were warm and sweaty with fine tremor in outstretched hands. Lid lag, lid retraction and proptosis were the occular manifestations. All the reflexes were exaggerated. Radioactive iodine uptake showed enlarged gland with homogenously increased radiotracer concentration, ultrasonogram findings were enlarged gland with hypoechoic parenchyma with fibrous septa, T(3), T(4), TSH values were 6.56 nmol/L, 241.09 nmol/L and 0.14 mIU/L respectively. Thyroid microsomal antibody level was 32.87%. Thyroid FNAC findings were sheets of regular follicular cells, some large cells with granular basophilic cytoplasm, macrophages, a few inflammatory cells and giant cells. All the above findings were in favour of a diagnosis of hyperthyroid Graves' with Hashimoto's thyroiditis.     

Open-access colonoscopy in Ontario: Associated factors and quality

BACKGROUND

Open-access (OA) colonoscopy may increase efficiency and decrease wait times; however, because the patient is seen for the first time at the endoscopy appointment, previous processes, such as information about the procedure, preparation and appropriate triage, may be suboptimal.

OBJECTIVE:

To identify factors associated with OA colonoscopy and to determine the relationship between OA colonoscopy and an important quality measure, incomplete colonoscopy.

METHODS:

A population-based analysis of all adult outpatients undergoing a first-time colonoscopy between 1997 and 2007 in Ontario was performed. Colonoscopy was considered to be OA if there were no visits in the preceding five years with the physician performing the colonoscopy. Using logistic regression, patient, physician and institution factors associated with OA colonoscopy were identified. Using propensity score matching, the relationship between OA colonoscopy and incomplete colonoscopy in 2006 was examined.

RESULTS:

A total of 1,079,259 colonoscopies were performed. Of these, 14% were OA in 1997 compared with 26% in 2007. Patients 50 to 69 years of age, those from higher-income neighbourhoods and those with less comorbidity were more likely to undergo OA colonoscopy. The odds of receiving OA colonoscopy were six times greater in a nonhospital clinic compared with a community hospital. Colonoscopy was more likely to be complete if the procedure was OA (OR 1.3 [95% CI 1.2 to 1.4]; P<0.0001).

CONCLUSIONS:

Rates of OA colonoscopy have increased substantially since 1997. Institution type was most strongly associated with OA colonoscopy. Colonoscopy completeness, a recognized quality indicator, does not appear to be compromised by OA colonoscopy.