Selected Abstracts [*].

ENALAPRIL THERAPY SIGNIFICANTLY REDUCES THE RISK OF HOSPITALIZATION FOR HEART FAILURE AMONG WHITE BUT NOT BLACK PATIENTS WITH LEFT VENTRICULAR DYSFUNCTION 

Exner DV, Dries DL, Domanski MJ, et al: Lesser response to angiotensin-converting-enzyme inhibitor therapy in black as compared with white patients with left ventricular dysfunction. N Engl J Med 2001; 344:1351-1357

This matched-cohort design study included up to four white patients matched with one black patient according to trial, treatment assignment, sex, left ventricular ejection fraction, and age. A total of 1,196 white patients (580 from the prevention trial and 616 from the treatment trial) were included. The average length of follow-up was 35 months in the prevention trial and 33 months in the treatment trial. The black patients and the matched white patients had similar demographic and clinical characteristics. However, the black patients had higher rates of death from any cause (12.2 vs 9.7 per 100 person-years) and of hospitalization for heart failure (13.2 vs 7.7 per 100 person-years). Enalapril therapy, when compared with a placebo, was associated with a 44% reduction (95% confidence interval, 27%-57%) in the risk of hospitalization for heart failure among the white patients (P [less than] .001). However, there was not a significant reduction among black patients (P =.74). After 1 year, enalapril therapy w as associated with significant reductions from base-line in systolic blood pressure (by a mean [[+ or -]SD) of 5.0 [+ or -] 17.1 mm Hg) among the white but not the black patients. No significant change in the risk of death was seen in association with enalapril therapy in either group.

ANTIREFLUX SURGERY SHOULD NOT BE RECOMMENDED WITH THE EXPECTATION THAT PATIENTS WITH GASTROESOPHAGEAL REFLUX DISEASE (GERD) WILL NO LONGER NEED ANTISECRETORY MEDICATIONS OR THAT ESOPHAGEAL CANCER WILL BE PREVENTED AMONG THOSE WITH GERD AND BARRETT ESOPHAGUS

Spechler SJ, Lee E, Ahnen D, et al: Long-term outcome of medical and surgical therapies for gastroesophageal reflux disease. JAMA 2001; 285:2331-2338

From October 1997 through October 1999, follow-up study was done of a prospective, randomized trial of medical and surgical antireflux treatments in patients with complicated GERD. The mean (median) duration of follow-up was 10.6 years (7.3 years) for medical patients and 9.1 years (6.3 years) for surgical patients. A total of 129 patients participated (91 in the medical treatment group and 38 in the surgical treatment group). The main outcome measures included the use of antireflux medication, Gastroesophageal Reflux Disease Activity Index (GRACI) scores, grade of esophagitis, frequency of treatment of esophageal stricture, frequency of subsequent antireflux operations, 36-item Short Form health survey (SF-36) scores, satisfaction with antireflux therapy, and survival and incidence of esophageal adenocarcinoma, compared between the medical antireflux therapy group and the fundoplication surgery group. Eighty-three (92%) of the 90 medical patients and 23 (62%) of 37 surgical patients said they used antireflu x medications regularly (P [less than].001). Following a 1-week period after discontinuation of medication, mean (SD) GRACI symptom scores were significantly lower in the surgical treatment group (82.6 [17.5] vs 96.7 [21.4] in the medical treatment group; P = .003). No significant differences between the groups were found in grade of esophagitis, frequency of treatment of esophageal stricture and subsequent antireflux operations, SF-36 standardized physical and mental component scale scores, and overall satisfaction with antireflux therapy. In patients with Barrett esophagus at baseline, esophageal adenocarcinomas developed at an annual rate of 0.4%, whereas these cancers developed in patients without Barrett esophagus at an annual rate of 0.07%. There was no substantial difference between the groups in the incidence of esophageal cancer.

ATRIAL FIBRILLATION IS COMMON IN OLDER ADULTS IN THE UNITED STATES, AND THE NUMBER OF CASES IS EXPECTED TO INCREASE 2.5- FOLD DURING THE NEXT 50 YEARS

Go AS, Hylek EM, Phillips KA, et al: Prevalence of diagnosed atrial fibrillation in adults. JAMA 2001; 285:23702375

This cross-sectional study included adults aged 20 years or older who were enrolled in a large health maintenance organization in California and had atrial fibrillation diagnosed between July 1, 1996, and December 31, 1997. The main outcome measures were the prevalence of atrial fibrillation in the study population of 1.89 million and the projected number of people in the US with atrial fibrillation from 1995 to 2050. A sum of 17,974 adults with diagnosed atrial fibrillation were identified during the study period; 45% were 75 years old or older. The prevalence of atrial fibrillation was 0.95% (95% confidence interval, 0.94%-0.96%). Atrial fibrillation was more common in men than in women (1.1% vs 0.8%; P [less than] .001). The prevalence increased from 0.1% among adults younger than 55 years to 9.0% in those aged 80 years or older. Among individuals aged 50 years or older, the prevalence of atrial fibrillation was higher in whites than in blacks (2.2% vs 1.5%; P [less than] .001).

THE CONTRACEPTIVE PATCH IS COMPARABLE TO A COMBINATION ORAL CONTRACEPTIVE IN CONTRACEPTIVE EFFECTIVENESS AND CYCLE CONTROL

Audet MC, Moreau M, Koltun WD, et al: Evaluation of contraceptive efficacy and cycle control of a transdermal contraceptive patch versus an oral contraceptive. JAMA 2001; 285:2347-2354

This randomized, open-label, parallel-group trial was conducted from October 1997 to June 1999 in 45 clinics in the United States and Canada and included 1,417 healthy adult women of child-bearing potential. The outcome measures included overall and methodfailure Pearl Indexes (number of pregnancies/100 person-years of use), and life-table estimates of the probability of pregnancy were calculated. Cycle control, compliance, patch adhesion, and adverse effects were assessed. Overall and method-failure Pearl Indexes were numerically lower with the patch (1.24 and 0.99, respectively) compared with the oral contraceptive (OC) (2.18 and 1.24, respectively). This difference was not statistically significant (P = .57 and 0.80, respectively). The incidence of breakthrough bleeding and/or spotting was significantly higher only in the first two cycles in the group using the patch, but the incidence of breakthrough bleeding alone was comparable between treatments in all cycles. The mean proportion of individuals' cycles with perfect compliance was 88.2% (811 total participants; 5,141 total cycles) with the p atch and 77.7% (605 total participants; 4,134 total cycles) with the OC (P [less than] .001). Only 1.8% (300/16,673) of the patches completely detached. Both treatments were similarly well-tolerated, but application site reactions, breast discomfort, and dysmenorrhea were significantly more common in the group with the patch.

A TRAFFIC SIGN RECOGNITION TEST (TSRT) SUCCESSFULLY IDENTIFIES OLDER DRIVERS WITH A RECENT MOTOR VEHICLE CRASH (MVC), BUT LACKS SENSITIVITY AND SPECIFICITY

MacGregor JM, Freeman DH, Zhang D: A traffic sign recognition test can discriminate between older drivers who have and have not had a motor vehicle crash. JAm Geriatr Soc 2001; 49:466-469

This retrospective, matched, case control study included 60 crash and 60 control individuals from Galveston, Tex, who were matched for age and sex. The cases were identified from accident records, and the controls were selected from a] randomize'd list of licensed drivers in Galveston. The main measurements were the Folstein Mini-Mehtal State Examination (MMSE) and the Traffic Sign Recognition Test (TSRT). The TSRT significandy distinguished between case and control groups (P = .01), but the MMSE did not (P = .61). A TSRT predicted motor vehicle crash (MVC) in a multivariate analysis controlling for education, MMSE score, race/ethnicity, and mileage driven per year (odds ratio, 0.88; 95% confidence interval, 0.77-1.00).

SLEEP APNEA IS COMMON IN STROKE PATIENTS AND IS ASSOCIATED WITH DELIRIUM, DEPRESSED MOODS, LATENCY IN REACTIONS AND RESPONSE TO VERBAL STIMULI, AND IMPAIRED ACTIVITIES OF DAILY LIVING

Sandberg O, Franklin KA, Bucht G, et al: Sleep apnea, delirium, depressed mood, cognition, and ADL after stroke. J Am Geriatr Soc 2001; 49:391-391

This cross-sectional study included 133 patients (78 women and 55 men; mean age, 77.1 [+ or -] 7.7 years) who were consecutively admitted to a geriatric stroke rehabilitation unit. All the participants had overnight respiratory sleep recordings at 23 [+ or -] 7 days (range, 11 to 4l days) after having a stroke. The patients were assessed by the Organic Brain Syndrome Scale, Montgomery-Asberg Depression-Rating Scale, Mini-Mental State Examination (MMSE), and the Barthel-ADL (activities of daily living) Index. Sleep apnea was defined as an apnea-hypopnea index (AHI) of 10 or higher. The average of the AHI for the studied sample (N = 133) was 13 (range, 0-79; interquartile range, 6-28). Fifty-nine percent fulfilled the criteria for sleep apnea. Fifty-two percent with first-ever stroke had sleep apnea. More individuals with sleep apnea than without were delirious, depressed, or more ADL-dependent. The sleep apnea patients also had a higher frequency of ischemic heart disease and had more often had an earlier cer ebral infarction. A multivariate analysis showed that obesity, low ADL scores, ischemic heart disease, and depressed moods were independently associated with sleep apnea. Low ADL scores, apnea-related hypoxemia, a body mass index 27, and impaired vision were independently affiliated with delirium. Sleep apnea was not associated with any specific type of stroke or location of the brain lesion.

TYPE 2 DIABETES CAN BE PREVENTED WITH CHANGES IN THE LIFE-STYLES OF HIGH-RISK PEOPLE

Tuomilehto J, Lindstrom J, Eriksson JG, et al: Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 2001; 344:1343-1350

The study randomly assigned 522 middle-aged, overweight people (172 men and 350 women; mean age, 55 years; mean body mass index, 31) with impaired glucose tolerance to either the intervention group or the control group. Each individual in the intervention group received individualized counseling for weight reduction, total intake of fat, intake of saturated fat, increasing the intake of fiber, and physical activity. An oral glucose-tolerance test was done yearly, and the diagnosis of diabetes was confirmed by a second test. The average duration of follow-up was 3.2 years. The mean ([+ or -]SD) amount of weight lost between baseline and the end of 1 year was 4.2 [+ or -] 5.1 kg in the intervention group and 0.8 [+ or -] 3.7 kg in the control group. The net loss by the end of the second year was 3.5 [+ or -] 5.5 kg in the intervention group and 0.8 [+ or -] 4.4 kg in the control group (P [less than] .001 for both comparisons between the groups). The cumulative incidence of diabetes after four years was 11% (95 % confidence interval [CI], 6%-15%) in the intervention group and 23 % (95% CI, 17%-29%) in the control group. During the trial, the risk of diabetes was reduced by 58% (P[less than] .001) in the intervention group. The reduction in the incidence of diabetes was directly associated with the changes in lifestyle.

(*.) Originally prepared for presentation on Southern Medical Association's Web site (http://ivww.sma.org) by Elaine McClellan-Holm.