1.
Suboptimal use of evidence-based medical therapy in patients with acute myocardial infarction from the Korea Acute Myocardial Infarction Registry: prescription rate, predictors, and prognostic value.
Lee, JH, Yang, DH, Park, HS, Cho, Y, Jeong, MH, Kim, YJ, Kim, KS, Hur, SH, Seong, IW, Hong, TJ, et al
American heart journal. 2010;(6):1012-9
Abstract
BACKGROUND Only limited data are available for the recent trend of optimal evidence-based medical therapy at discharge after acute myocardial infarction (AMI) in Asia. We evaluated the predictors for the use of optimal evidence-based medical therapy at discharge and the association between discharge medications and 6-month mortality after AMI. METHODS Between November 2005 and January 2008, we evaluated the discharge medications among 9,294 post-MI survivors who did not have any documented contraindications to antiplatelet drugs, beta-blockers, angiotensin-converting enzyme inhibitors (ACE-Is)/angiotensin II receptor blockers (ARBs), or statins in the Korea Acute Myocardial Infarction Registry. Optimal evidence-based medical therapy was defined as the use of all 4 indicated medications. RESULTS Of these patients, 4,684 (50.4%) received all 4 medications at discharge. The discharge prescription rates of antiplatelet drugs, beta-blockers, ACE-Is/ARBs, and statins were 99.0%, 72.7%, 81.5%, and 77.2%, respectively. In multivariate analysis, advanced age, lower systolic blood pressure, higher Killip class at admission, left ventricular systolic dysfunction, higher blood creatinine level, lower total cholesterol levels, and coronary artery bypass grafting during hospitalization were independently associated with less use of optimal evidence-based medical therapy. In contrast, patients who underwent percutaneous coronary intervention were more likely to use optimal medications. In Cox proportional hazards model, optimal evidence-based medical therapy was an independent predictor of 6-month mortality after adjusting clinical characteristics and angiographic and procedural data. CONCLUSIONS The optimal evidence-based medical therapy is prescribed at suboptimal rates, particularly in patients with high-risk features. New educational strategies are needed to increase the use of these secondary preventive medical therapies.
2.
Multifactorial intervention to prevent recurrent cardiovascular events in patients 75 years or older: the Drugs and Evidence-Based Medicine in the Elderly (DEBATE) study: a randomized, controlled trial.
Strandberg, TE, Pitkala, KH, Berglind, S, Nieminen, MS, Tilvis, RS
American heart journal. 2006;(3):585-92
Abstract
OBJECTIVE We aimed to examine whether better use of preventive methods and treatments of cardiovascular disease would reduce recurrent events in home-dwelling patients 75 years or older. METHODS This was a randomized, controlled trial (a practical clinical trial, the DEBATE), conducted in 2000 to 2003 in Helsinki, Finland. We recruited 400 vascular patients with mean age of 80 years from the community, and they were randomly assigned to the intervention group (n = 199) where both nonpharmacological and pharmacological cardiovascular treatments were optimized by a geriatrician according to current guidelines. The control group (n = 201) received the usual care. Main outcome measures were major cardiovascular disease events and total mortality and changes in risk factors and medications. RESULTS The groups were balanced at baseline. Mean duration of follow-up was 3.4 years. At 3 years, drug treatments had become more evidence-based in the intervention group. Consequently, total and low-density lipoprotein cholesterol levels (P < .0001) and systolic (P = .005) and diastolic (P = .009) blood pressure were significantly improved in the intervention group. However, neither primary end points (52 and 53 events in the intervention and control groups, respectively) nor total mortality (36 and 35 deaths) were significantly different between the two groups. No special adverse effects were encountered. CONCLUSION It was possible and safe to institute evidence-based cardiovascular treatments and improve risk factors in patients 75 years or older in a pragmatic setting. During 3.4 years, however, this was not converted to clinical benefits.
3.
Central nervous system tumours in children: epidemiology and risk factors.
McKinney, PA
Bioelectromagnetics. 2005;:S60-8
Abstract
In children, a variety of distinct tumour types arise in the central nervous system (CNS) but they are frequently considered by epidemiologists as a single entity. CNS tumours are the second most common childhood malignancy and occur more frequently in developed countries than developing nations. Approximately 50% of paediatric CNS tumours are gliomas, with astrocytomas of the piloctyic type predominating. Distributions of subtypes by age show that primitive neuroectodermal tumours (PNET) and ependymomas mainly occur in children less than 10 years. There is an ongoing debate with regard to the apparent increases in incidence over recent decades, which, it has been suggested, are accounted for by improved diagnostic technologies implemented in the mid 1980s. CNS tumours differ between children and adults with respect to the proportion of all cancers (20% in children, less than 2% in adults), their cellular origins, classification scheme, the proportions of pathological subtypes, and anatomic site. The causes of childhood CNS tumours are largely unknown; and although an estimated 5% or more may be explained by genetic predisposition, investigations of environmental aetiology have not been fruitful. Whilst high dose ionising radiation is an established risk factor for this group of tumours, reported associations with dietary N-nitroso compounds have not been consistent. Exposure to ELF EMF, at any level, has not been associated with childhood CNS tumours, but the current evidence base is inadequate for complete evaluation. The rarity of childhood CNS tumours necessitates careful attention being paid to the design of future aetiological studies.
4.
The relation between methods and recommendations in clinical practice guidelines for hypertension and hyperlipidemia.
Fretheim, A, Williams, JW, Oxman, AD, Herrin, J
The Journal of family practice. 2002;(11):963-8
Abstract
OBJECTIVE To assess the association between methods used to develop clinical practice guidelines and the recommendations that are made. STUDY DESIGN Systematic review of clinical practice guidelines for hypertension or hyperlipidemia. OUTCOMES MEASURED Two people independently appraised guideline methods by using 8 criteria and the aggressiveness of recommendations for treatment thresholds, initial drug selection, and screening. RESULTS We identified 33 guidelines. Only 6 fulfilled 5 or more of the 8 criteria. For 5 of the criteria, fewer than 50% of the guidelines fulfilled those criteria. There was wide variation in recommendations for treatment thresholds, drug selection, and cholesterol screening. Guidelines that did not fulfill the criteria tended to suggest more aggressive recommendations than did guidelines that met the criteria. For 6 of the 8 criteria, guidelines published by specialty societies were less likely to fulfill them compared with guidelines not published by specialty societies. CONCLUSIONS Guideline developers who did not use rigorous methods tended to promote intervening more aggressively for hypertension and hyperlipidemia.