Primary prevention of cardiovascular disease: Communitywide strategies for youth.

National interest in health promotion and disease prevention has led naturally to a concern with primary prevention and with youth. This attention to youth has been particularly notable in efforts to prevent injuries and chronic diseases. Specific behavior patterns that are learned in childhood and adolescence are implicated in the development of chronic diseases. These behavior patterns logically become the targets for early intervention. Over the past two decades, studies on the prevention of cardiovascular disease (CVD), the primary cause of mortality in the Western world, have become numerous and comprehensive and have included substantial work with youth. This article provides a rationale for that focus. We review promising communitywide strategies for youth and argue that communitywide strategies ought to be most efficient and efficacious for primary prevention. Both interest in and research on communitywide strategies are relatively recent; consequently, few strategies can be recommended unequivocally. The need for future research in this area by multidisciplinary teams is identified. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Primary prevention of cardiovascular disease risk factors: review and implications for population-based practice

This review analyzed the results of population-based intervention studies targeting primary prevention of cardiovascular disease risk factors among children and adolescents in the United States. In general, the findings indicate that cardiovascular disease risk factors may be amenable to interventions in school-based programs. Although the interventions have small effects on risk factor outcomes, they should be interpreted within the context of population-based approaches that ultimately may have a greater impact on disease prevention than much larger effects among the small proportion of individuals at the highest levels of risk.     

Vitamin C and cardiovascular disease: a systematic review

BACKGROUND: Laboratory studies suggest that antioxidants, such as Vitamin C, are important inhibitors of atherosclerotic lesions. Most epidemiological reviews have considered all antioxidants together. This review seeks to clarify the current state of knowledge specifically concerned with vitamin C. METHODS: All ecological studies, case-control studies, prospective studies and trials in humans that examined the association between vitamin C intake or blood levels of vitamin C and cardiovascular disease were included. Relevant references were located by MEDLINE search for articles published from 1966 to 1996, by an EMBASE search for articles published from 1980 to 1996, by searching personal bibliographies, books and reviews and from citations in located articles. RESULTS: For coronary heart disease four of seven ecological studies, one of four case-control studies and three of 12 cohort studies found a significant protective association with vitamin C intake or status. For strokes two of two ecological studies, none of one case-control study and two of seven cohort studies found a significant protective association. For total circulatory disease, two of three cohort studies reported a significant protective association. CONCLUSIONS: The evidence, albeit limited, is consistent with vitamin C having protective effect against stroke whereas the evidence that vitamin C is protective against coronary heart disease is less consistent. The lack of an association for coronary heart disease could be explained in terms of there being a true lack of effect, dietary measurement error, a threshold effect, and effect of seasonal variations in intake, an interaction with other dietary constituents or a relatively short duration of follow-up.     

The gynecologist and cardiovascular disease: a window of opportunity for prevention

OBJECTIVE: We present current concepts and assess the quality of information available for the prevention of cardiovascular disease in women. METHODS: This article reviews research bearing on the prevention of cardiovascular disease in women, with particular attention to modifiable risk factors. We describe the magnitude of the problem and assess the quality of the data with respect to the classic risk factors. The concept is emphasized that changes at menopause, states of endocrine aberration, and benefits and risks of hormone substitution and oral contraception must be understood in conjunction with all other potentially modifiable and nonmodifiable risk factors. CONCLUSIONS: Primary care physicians, especially obstetrician/gynecologists, have a pivotal role to play in the reduction of this disease. Behavior modification is the key to integrating prevention into the regular annual visit.     

Compliance with primary prevention in private practice: creating a tobacco-free environment

A sample of private orthodontic practices (n = 40) from a controlled trial for clinician-initiated tobacco-use prevention was used to test the effectiveness of preventive medicine representative (PMR) visits in creating and maintaining an anti-tobacco office environment. Clinical staff of 20 offices, randomly assigned to the experimental group, were trained by a PMR on the use of anti-tobacco materials (no-smoking signs, posters, and print materials). Twenty control-group offices did not receive any training or special treatment. Subsequently, experimental-group offices were visited by a PMR once every three months and were telephoned six weeks after each visit over a 12-month period. During visits and phone calls, PMRs prompted offices to order anti-tobacco materials. Visits served to introduce offices to new materials and to encourage their continued use. Data from direct observations and self-report measures showed significant differences between experimental and control offices for display of anti-tobacco materials at 1.5 months and 12 months (P < .001). Results suggest that PMR visits may serve as an effective method of introducing and maintaining preventive medicine procedures in clinical environments.     

Primary prevention of cardiovascular disease: implications of lipid-lowering trials

AVAILABLE LIPID-LOWERING TREATMENT: Aggressive cholesterol-lowering with 3-hydroxy-3-methylglutaryl (HMG)-coenzyme A reductase inhibitors has proved to be more effective than drugs available in the past. This treatment is safe and reduces morbidity and mortality from coronary heart disease substantially in all categories of patients at risk. The effect of treatment on clinical events is proportional to the reduction in low-density-lipoprotein cholesterol. FUTURE PROSPECTS: In the future, even more effective drugs will become available that may yield even greater benefit than has been observed in trials until now. At present, this therapy is too expensive for use in mass strategy to prevent coronary heart disease. Therefore, it should be limited to patients with a high risk. When further development brings newer drugs with a lower cost, drug treatment for cholesterol-lowering may become as widespread as antihypertensive treatment is today in order to prevent cardiovascular disease.     

Specialty differences in cardiovascular disease prevention practices

OBJECTIVES: The aim of this study was to examine physician specialty differences in cardiovascular disease prevention practices. BACKGROUND: Despite the importance of cardiovascular disease prevention, little is known about current national practices, particularly physician specialty differences. METHODS: Using a national survey of office visits, we evaluated differences in the propensity of physicians of different specialties to provide prevention services. We analyzed 30,929 adult visits to 1,521 physicians selected by stratified random sampling in the 1995 National Ambulatory Medical Care Survey. Standard and ordinal multiple logistic regression models were employed to estimate the independent effects of physician and patient characteristics. RESULTS: A variety of cardiovascular disease prevention services were provided during an estimated 547 million adult office visits to US physicians in 1995, including blood pressure measurement (50% of visits), cholesterol testing (5%) and counseling for exercise (12%), weight (6%), cholesterol (4%) and smoking (3%). In addition, medication management was reflected by the report of antihypertensives in 12% of visits and lipid-lowering medications in 2%. Across these eight services, propensity to provide services varied consistently with specialty. Controlling for patient and visit characteristics and compared to general internists, the likelihood of providing services was higher for cardiologists (adjusted odds ratio 1.65, 95% confidence interval 1.44 to 1.89) but lower for obstetrician/gynecologists (0.75, 0.68 to 0.82), family physicians (0.69, 0.64 to 0.74), general practitioners (0.58, 0.53 to 0.63), other medical specialists (0.65, 0.59 to 0.72) and surgeons (0.06, 0.05 to 0.06). CONCLUSIONS: Cardiologists have the greatest propensity to provide cardiovascular disease prevention services, while primary care physicians vary substantially in their practices. These findings suggest a need to address variations in cardiovascular disease prevention.     

Contributions of health-related biobehavioral research to the prevention of cardiovascular diseases.

Discusses the roles that biobehavioral, psychosocial, and neurobiological approaches can have in epidemiologic studies, development and application of preventive measures, and use of therapeutic interventions for diseases within the purview of the US National Heart, Lung, and Blood Institute. Progress in interdisciplinary research is considered as it pertains to heart, lung, and blood diseases. Efforts to prevent progression of the disease process, once it has begun and to rehabilitate those already afflicted are also addressed. (20 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Outcomes research: a review

PURPOSE: The purpose of this article is to review the history of the medical outcomes movement as well as the methodologies used in outcomes research. CONCEPT: Outcomes research refers to a genre of clinical investigation that emphasizes the measurement of patient health outcomes, including the patient's symptoms, functional status, quality of life, satisfaction with treatment, and health care costs. RATIONALE: Outcomes research evolved from studies that demonstrated the presence of wide geographic variations in the practice of medicine and surgery. Such differences in utilization were unaccompanied by any discernible difference in patient outcomes. With escalating health care costs, there has been a growing interest in measuring the outcomes of medical intervention to determine the quality and appropriateness of medical care. DISCUSSION: Outcomes may be measured both directly and indirectly, over differing periods of time, and with varying degrees of objectivity, reliability, and validity. Current research has focused on quality of life issues, which include the extent to which a patient's usual or expected physical, emotional, and social well-being have been affected by a medical condition or treatment. The true value of health care can be determined only by a systematic examination of patient outcomes. To accomplish this goal, methods are required that are relatively unfamiliar to many clinical researchers. Future clinical research should include patient-oriented outcome measures that would otherwise focus solely on physiological or anatomic outcomes. Such information will be essential in determining which medical and surgical treatment strategies should be abandoned and which will gain acceptance in the future.     

Job stress and cardiovascular disease: A theoretic critical review.

During the last 15 yrs, the research on job stress and cardiovascular diseases has been dominated by the job strain model developed by R. Karasek (1979) and colleagues (R. Karasek & T. Theorell, 1990). In this article the results of this research are briefly summarized, and the theoretical and methodological basis is discussed and criticized. A sociological interpretation of the model emphasizing theories of technological change, qualifications of the workers, and the organization of work is proposed. Furthermore, improvements with regard to measuring the job strain dimensions and to sampling the study base are suggested. Substantial improvements of the job strain research could be achieved if the principle of triangulation were used in the measurements of stressors, stress, and sickness and if occupation-based samples were used instead of large representative samples. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Celiac disease: a review

Celiac disease is relatively rare in the United States and many of the facets of this complex disorder are not completely understood. In the gluten-sensitive individual, celiac disease is activated by ingestion of cereal glutens. An abnormal immune system response to dietary gluten causes damage to the small bowel mucosa, which results in nutrient malabsorption. When gluten is removed from the diet, malabsorption resolves. Nursing intervention in celiac disease requires careful nutritional assessment and dietary instruction.     

Exercise and cardiovascular disease: a new perspective

The oxidation of low density lipoprotein (LDL) has been suggested as a key event in atherogenesis. Paradoxically, exercise, which imposes an oxidative stress, is an important deterrent of cardiovascular disease. In study 1 the oxidizability of LDL was enhanced in exercisers compared with sedentary controls. The lag time of isolated LDL subjected to copper-induced in vitro oxidation was significantly shortened in the exercisers compared with sedentary subjects. This increased sensitivity was not due to a decreased presence of vitamin E. Instead, these findings suggested that the LDL of exercisers may contain increased amounts of preformed lipid peroxides, which account for the increased oxidizability. In study 2, a group x sex ANOVA revealed that male exercisers had a significantly longer mean lag time than male sedentary subjects and that females had similar mean lag times regardless of exercise group. This remained the case when statistical adjustment was made for age, body mass index, blood lipid levels, LDL, and plasma alpha-tocopherol levels. Study 1 exercisers had been in training for a shorter time (< 1 year) than study 2 exercisers (> 2 years). These findings suggest that truly "chronic" exercise (aerobic intensity over several months) decreases the susceptibility of a male exerciser's LDL to undergo oxidation. Conversely, regular aerobic stress during an overall shorter time span creates a more oxidative environment in the body, thus increasing the susceptibility of LDL to undergo oxidation. The oxidative stress of aerobic exercise does not appear to adversely affect the oxidizability of LDL in women.     

Central venous catheter replacement strategies: a systematic review of the literature

OBJECTIVE: To evaluate the effect of guidewire exchange and new-site replacement strategies on the frequency of catheter colonization and infection, catheter-related bacteremia, and mechanical complications in critically ill patients. DATA SOURCES: We searched for published and unpublished research by means of MEDLINE and Science Citation Index, manual searching of Index Medicus, citation review of relevant primary and review articles, review of personal files, and contact with primary investigators. STUDY SELECTION: From a pool of 151 randomized, controlled trials on central venous catheter management, we identified 12 relevant randomized trials of catheter replacement over a guidewire or at a new site. DATA EXTRACTION: In duplicate and independently, we abstracted data on the population, intervention, outcome, and methodologic quality. DATA SYNTHESIS: As compared with new-site replacement, guidewire exchange is associated with a trend toward a higher rate of catheter colonization (relative risk 1.26, 95% confidence interval 0.87 to 1.84), regardless of whether patients had a suspected infection. Guidewire exchange is also associated with trends toward a higher rate of catheter exit-site infection (relative risk 1.52, 95% confidence interval 0.34 to 6.73) and catheter-related bacteremia (relative risk 1.72, 95% confidence interval 0.89 to 3.33). However, guidewire exchange is associated with fewer mechanical complications (relative risk 0.48, 95% confidence interval 0.12 to 1.91) relative to new-site replacement. Exchanging catheters over guidewires or at new sites every 3 days is not beneficial in reducing infections, compared with catheter replacement on an as-needed basis. CONCLUSIONS: Guidewire exchange of central venous catheters may be associated with a greater risk of catheter-related infection but fewer mechanical complications than new-site replacement. More studies on scheduled vs. as-needed replacement strategies using both techniques are warranted. If guidewire exchange is used, meticulous aseptic technique is necessary.     

Sulphonylurea treatment of NIDDM patients with cardiovascular disease: a mixed blessing?

Non-insulin-dependent diabetic (NIDDM) patients show a high incidence of cardiovascular disease, with greater risk of recurrent myocardial infarction and a less favourable clinical outcome than non-diabetic patients. The majority of NIDDM patients are treated with sulphonylurea (SU) derivatives. In the 1970's the University Group Diabetes Program concluded that tolbutamide treatment caused increased cardiovascular mortality; the study, which led to curtailment of oral antidiabetic treatment in the USA, was received with scepticism in Europe. Later criticism of its methodology reduced the impact of the study; however, the question of the safety of SU in NIDDM patients with cardiovascular disease has been re-opened in the face of new experimental data. The heart and vascular tissues do have prerequisites for SU action, i.e. SU receptors and ATP-dependent K+ (K+ATP) channels. These channels play an important role in the protection of the myocardium against ischaemia-reperfusion damage, and their closure by SU could lead to amplified ischaemic damage. Here we review evidence from animal and human studies for deleterious SU effects on ischaemia-induced myocardial damage, either by direct action or through diminished cardioprotective preconditioning. Closure of K+ATP channels by SU can lead to reduction of post-infarct arrhythmias; the drug has also been claimed to improve various atherosclerosis risk factors. The evidence for these beneficial effects of SU is also reviewed. We look at the major difficulties that hamper transfer of information from experimental studies to clinical decision-making: a) The affinity of SU for heart K+ATP channels is orders of magnitude lower than for beta-cell channels; is it reasonable to expect in vivo cardiac effects with therapeutic 'pancreatic' SU doses? b) Most studies utilized high doses of acutely administered SU; are effects similar in the chronic steady-state of the SU-treated diabetic patient? c) Convincing SU effects have been demonstrated in acutely induced ischaemia by acutely administering the drug; do such effects persist in the clinical situation of gradually progressive ischaemia? d) Ischaemia and modification of K+ATP channel activity induce complex events, some with opposing effects; what is the net result of SU action, and do different SU derivatives lead to different outcomes? e) In the chronic (and hence clinically relevant) situation, how can direct (deleterious or beneficial) SU effects be separated from beneficial effects mediated by the metabolic action of the drug? Only large prospective clinical studies, making use of advanced technology for assessment of cardiovascular function, can answer these questions. Millions of NIDDM patients are treated with SU derivatives; many are in the age group where cardiovascular risks are extremely high. The question of whether SU derivatives are beneficial or deleterious for these patients must finally be settle unequivocally.     

Immersion scald burns: strategies for prevention

Tap water scald burns are common injuries to persons with disabilities, young children, and the elderly. A case is reported of an elderly woman with a physical and neurological handicap who while bathing received partial and full thickness (tap water) scald burns covering 20% of her total body surface area. This life-threatening injury could have been prevented with a Shower Safe, Inc. temperature-controlling water valve.     

Osteoporotic fractures: background and prevention strategies

To assess the effects of the novel sigma ligand JO 1994 on behavioural, histological and autoradiographical changes following global ischaemia, the Mongolian gerbil was used. Three experiments were carried out and in each case ischaemia was induced by bilateral carotid occlusion (BCO) for 5 min. In the first experiment we examined the effects of JO 1994 administered at doses of 0.25, 0.5 and 1 mg/kg i.p. 1 h before 5 min BCO on histological parameters 96 h after surgery. In the second experiment the effects of JO 1994 administered at doses of 2.5, 5, 10 and 20 mg/kg i.p. 1 h before 5 min BCO on locomotor activity 24, 48 and 72 h after surgery and on histological parameters 96 h after surgery was examined. In the third experiment the effects of JO 1994 (2.5 and 5 mg/kg i.p.), BMY 14802 (1 and 10 mg/kg i.p.) and MK-801 (2.5 mg/kg i.p.) administered 30 min, 6, 24, 48, 72, 96 and 120 h post-surgery on the densities of M1 and M2 muscarinic receptors in 35 brain regions, 7 days after surgery was examined. Results indicated that 5 min bilateral carotid occluded animals were hyperactive 24, 48 and 72 h after surgery. JO 1994 attenuated this hyperactivity. Extensive neuronal death was observed in the CA1 layer of the hippocampus in 5 min BCO animals 96 h after surgery. The low doses of JO 1994 (0.25, 0.5 and 1 mg/kg) had no effect on the ischaemia-induced cell death. However JO 1994 (2.5, 5, 10 and 20 mg/kg i.p.) protected against the neuronal death of cells in the CA1 layer (P < 0.01-0.03). There was a large loss of M1 and M2 receptors in the CA1 regions of the hippocampus. MK-801, BMY 14802 and JO 1994 provided significant (P < 0.01) protection against this ischaemia-induced receptor loss.