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In This Issue of Archives of Internal Medicine
Arch Intern Med. 2009;169(20):1828.
Primary Care Visit Duration and Quality
It is unclear if increasing pressure on primary care physicians to deliver more efficient care has had an impact on outpatient visit duration or quality of care. In this study, the authors use the National Ambulatory Medical Care Survey to examine national trends in primary care visit duration between 1997 and 2005, performance on select quality metrics, and the association between visit duration and quality indicator performance.
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Treatment of Polymyalgia Rheumatica
Polymyalgia rheumatica (PMR) treatment is based on low-dose glucocorticoids. Lately, glucocorticoid-sparing agents have been tested with conflicting results. Hernández-Rodríguez et al investigate the treatment of PMR by systematically examining the peer-reviewed English-language literature on PMR therapy of all studies with 20 or more patients with PMR. Thirty studies (13 randomized trials and 17 observational studies) were finally analyzed. No meta-analyses or systematic reviews were found. Although this review remarks on the scarcity of randomized trials and the high level of heterogeneity among studies on PMR therapy, hence not allowing firm conclusions to be drawn, findings suggest that PMR remission may be achieved with prednisone treatment at a dose of 15 mg/d in most patients, and reductions below 10 mg/d should preferably follow a tapering rate of less than 1 mg/mo. Among all the glucocorticoid-sparing agents tested, an initial addition of oral or intramuscular methotrexate provided efficacy at doses of 10 mg/wk or higher.
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APOA2, Dietary Fat, and Body Mass Index
Translation of nutrigenomic research into practical applications aimed to provide personalized dietary advice has been hampered by the low replication level achieved in this field. Corella et al have identified a new gene-diet interaction between a functional promoter polymorphism (–265T>C) in the APOA2 gene and saturated fat intake in determining body mass index and obesity. This interaction has been replicated in 3 independent American populations: Framingham (1454 whites), Genetics of Lipid Lowering Drugs and Diet Network (1078 whites), and Boston–Puerto Rican (930 Hispanics of Caribbean origin) studies. Subjects with the CC genotype (11%-15% of the population) are more susceptible to increased body mass index and to becoming obese compared with T-carriers when consuming a high–saturated fat diet, but not when consuming a low–saturated fat diet. This is the first time that a gene-diet interaction involving obesity has been replicated in 3 independent populations. The consistency provided by this study supports the need for further research using intervention studies to corroborate this finding at the highest level of evidence. These results represent one step toward the practical implementation of genome-based personalized nutrition advice.
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Percentage of US Emergency Department Patients Seen Within the Recommended Triage Time
Wait times to see a health care provider in US emergency departments (EDs) have been steadily increasing. Horwitz and Bradley examined data from 151 999 ED visits in the National Hospital Ambulatory Medical Care Survey between 1997 and 2006. They found that the adjusted odds ratio (OR) of being seen within the time frame recommended at ED triage was 30% lower in 2006 than in 1997 (OR, 0.70; 95% confidence interval, 0.55-0.89). The adjusted OR of being seen within the triage target time was 87% lower (OR, 0.13; 95% confidence interval, 0.11-0.15) for emergent patients compared with semiurgent patients. Patients in the ED are increasingly unlikely to be evaluated by a health care provider within the time recommended at triage, and the most acutely ill are the least likely to be seen on time.
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Long-term Effects of a Very Low-Carbohydrate Diet and a Low-Fat Diet on Mood and Cognitive Function
A randomized clinical study was undertaken to examine the effects of the consumption of an energy-reduced, very-low-carbohydrate, high-fat diet (LC) or an isocaloric high- carbohydrate, low-fat diet (LF) on mood and cognitive function over 12 months in obese patients. Both diets achieved a similar reduction in body weight of approximately 14 kg. Compared with the LC diet, the LF diet had greater improvements in psychological mood state and affect. Both diets had similar effects on cognitive functioning (working memory and speed of processing). These findings suggest that although dietary macronutrient composition may have little influence on long-term weight loss, some aspects of the LC diet may have detrimental effects on mood that may negate any positive mood effects following weight loss.
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The asterisk indicates that the score is significantly higher compared with the LF diet (P < .05).
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