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In This Issue of Archives of Internal Medicine
Arch Intern Med. 2002;162:2029.
Patients' Ratings of Quality and Satisfaction With Care at the End
of Life
The authors interviewed 84 seriously ill medical inpatients with poor
prognoses about their satisfaction with care and their ratings of the quality
of care they received using a recently developed and validated instrument
called the Quality of End-of-Life Care and Satisfaction with Treatment scale.
Patients gave physicians higher quality ratings than nurses (4.39 vs 4.24; P = .01). In ANOVA models, those with do-not-resuscitate
orders and cared for by the house-staff service were the most likely to give
physicians lower ratings of quality and satisfaction. Nurses were rated lower
by patients who were depressed and by those cared for by the house-staff service.
Although preliminary, these findings offer initial insight into experiences
of hospitalized patients at the end of life.
(SEE ARTICLE)
Preservation of Cognitive Function With Antihypertensive Medications
The authors examined the effect of antihypertensive s on incident cognitive
impairment. Older adult African Americans (N = 1900) with preserved cognition
at baseline were screened for dementia using the Community Screening Instrument
for Dementia at 2 and 5 years. Within a year of screening, participants with
a high likelihood of cognitive impairment had physical and neuropsychological
examinations. Antihypertensives reduced the odds of incident cognitive impairment
by 38% (OR, 0.62; 95% CI, 0.45-0.84). The authors conclude that use of antihypertensives
is associated with preservation of cognitive function in older African Americans.
Although the favorable effect of antihypertensives is likely moderated by
blood pressure lowering, future studies are needed to confirm this.
(SEE ARTICLE)
The New National Cholesterol Education Program Guidelines: Clinical
Challenges for More Widespread Therapy of Lipids to Treat and Prevent Coronary
Heart Disease
The recently published National Cholesterol Education Program (NCEP)
III guidelines expands the number of US adults eligible for drug therapy to
treat or prevent coronary heart disease from 13 million to 36 million. This
is largely owing to an expansion of the definition of prior cardiovascular
disease to include all occlusive events of the heart, brain, and peripheral
arteries; the use of global risk assessment rather than just lipid parameters;
and elevation of diabetes mellitus to a coronary heart disease risk equivalent.
For patients with prior events as well as those with diabetes or a 10-year
risk of 20% or greater, the low-density lipoprotein cholesterol (LDL-C) goal
is less than 100 mg/dL (<2.59 mmol/L). For those without a prior event
or diabetes and 10-year risk of 10% to 19%, the LDL-C goal is less than 130
mg/dL (<3.36 mmol/L), and for those with a 10-year risk less than 10%,
the LDL-C goal is less than 160 mg/dL (<4.14 mmol/L). Drug therapy, primarily
using statins, either alone or in combination, should be an adjunct, not alternative,
to therapeutic lifestyle changes. The statin drugs decrease risk of myocardial
infarction, stroke, cardiovascular death, and total mortality. Statins have
the most conclusive body of evidence to support their use to favorably alter
lipid levels, including their benefit-to-risk and benefit-to-cost ratios,
so their increased use in accordance with the new NCEP III guidelines could
avoid tens of thousands of premature deaths in the United States each year.
(SEE ARTICLE)
The Prevention of Dementia With Antihypertensive Treatment: New Evidence
From the Systolic Hypertension in Europe (Syst-Eur) Study
After the double-blind placebo-controlled Systolic Hypertension in Europe
(Syst-Eur) Trial ended in February 1997, randomized patients were offered
active study medication for a further period of observation. Throughout the
follow-up period (median, 3.9 years), systolic/diastolic pressure was 7.0/3.2
mm Hg higher in 1417 control patients than in 1485 subjects randomized to
active treatment. Compared with control, long-term antihypertensive therapy
reduced the risk of dementia by 55% from 7.4 to 3.3 cases per 1000 patient-years
(P<.001). Treatment of 1000 patients for 5 years
can prevent 20 (95% confidence interval, 7-33) cases of dementia.
(SEE ARTICLE)
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Cumulative rate of dementia by treatment group.
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