CONTEXTHigh diabetes prevalence among low-income and urban African American populations. OBJECTIVES & MAIN OUTCOME MEASURES: This study aimed to determine associations between neighborhood-level food sources and socioeconomic status (SES), and dietary patterns and body-mass index (BMI). The hypotheses were that the presence of food stores in neighborhoods would be associated with better dietary habits and BMI, and that the presence of convenience stores, and lower neighborhood SES, would be associated with poorer dietary habits and BMI. DESIGN, SETTING, & PATIENTS: Black adults (n = 132) with type 2 diabetes in Project Sugar 2 (Baltimore, Maryland) underwent the Ammerman dietary assessment: total dietary risk score and subscores for meat, dairy, starches, and added fat. Food source availability (food stores, convenience stores, other food stores, restaurants, and other food service places) and SES data from the 2000 US census at the tract-level were linked to individual-level data. Linear mixed-effects regression models with random intercepts were used to account for neighborhood clustering and for individual-level SES and potential confounders.RESULTSThe presence of restaurants and other food service places in census tracts were associated with better dietary patterns (adjusted added fat subscore beta = -1.1, 95% confidence interval [CI] = -1.8, -0.4, and beta = -1.0, 95% CI = -1.7, -0.3, respectively). The presence of convenience stores and lower neighborhood SES was not significantly associated with worse dietary patterns or body-mass index, although trends were in the hypothesized direction.CONCLUSIONSThese findings provide some evidence for structural improvements to food environments in urban and low-income black neighborhoods.
BACKGROUND:Clear cell adenocarcinoma of the vagina and cervix were previously shown to be tumors occurring in female offspring exposed prenatally to diethylstilbestrol. This report describes the first clinical case of clear cell adenocarcinoma of the ovary linked to early diethylstilbestrol exposure in utero.CASE:A 45-year-old woman presented with a self-discovered lump in the lower abdominal quadrant. She underwent surgery and staging that revealed clear cell adenocarcinoma confined to the left ovary. Foci of high-grade squamous neoplastic proliferation, inflammation, and a paratubal cyst were also present on the pathology specimen. Medical records established unequivocally that the patient's mother received diethylstilbestrol therapy throughout the pregnancy.CONCLUSION:Our case is consistent with clear cell adenocarcinoma, probably related to diethylstilbestrol exposure in utero. It reinforces the need for continued vigilance in individuals prenatally exposed to this drug.
To the Editor: Chronic kidney disease (CKD) is an emerging public health problem and is rapidly transforming in to an epidemic. A recent study reported that nearly 26 million Americans suffer from CKD.[1] Additionally 20 million Americans are at risk of developing CKD. CKD eventually can progress to end-stage renal disease (ESRD) requiring expensive therapies such as regular dialysis therapy and renal transplantation. Currently 485,000 Americans have been diagnosed with ESRD and are undergoing dialysis therapy. The number of Americans needing dialysis therapy is expected to grow to 700,000 by 2020.[2] The predicted increase in the CKD population coupled with ever-increasing ratio between the CKD patients and nephrologists places greater demands on the primary care physicians. To provide optimal care to patients with CKD, the primary care physician will remain an important team player along with the nephrologist. Patients with CKD need timely planning to be ready for dialysis when they reach ESRD. A normal vein cannot supply an adequate volume of blood required for the dialysis therapy. A surgeon connects an artery and vein in the upper extremity to create a fistula, which then can accommodate a large needle required for dialysis therapy. The dialysis vascular access (or fistula) becomes a lifeline when patients with CKD eventually start dialysis. Typically, these patients have several other comorbidities requiring frequent hospitalizations and blood draws, which can damage the superficial and deep veins in the arms that are used for creating a fistula. Patients are often discharged from a hospital with a peripherally placed intravenous central catheter, which can really ruin the veins for future use. It is essential that both patients with CKD and their primary care physicians are aware of this potential need to preserve the veins whenever possible for future fistula creation. Ideally, patient education should be started long before the patient is seen by a nephrologist. Patients with stage 3 or higher CKD should be made aware of this possibility and should be prepared accordingly, both mentally and physically. Recently, the American Society of Diagnostic and Interventional Nephrology released guidelines for venous access placement in patients with CKD with emphasis on vein preservation and timely planning and education.[3] As part of the education a simple intervention that the primary care physicians can implement while seeing patients with CKD stage 3 or higher is providing a “Medic Alert” bracelet. The bracelet can have the diagnosis and simple instruction engraved on it, such as “CKD- NO NEEDLE STICKS OR BP” and can be worn on 1 arm by the patient at all times. The advantage of using this bracelet is multifold. First and foremost the patient has enough time to think and educate himself about the disease process and be mentally prepared for the eventual change in life. It provides an avenue for primary care physicians to discuss the relevance of close monitoring and prognosis of CKD. And finally, the veins on at least 1 extremity would be preserved for future fistula placement, if and when needed. The fistula, which is the lifeline for patients with ESRD, is also an “Achilles heel.” If placed in a timely fashion with good well-preserved veins, the fistula can last forever, but if placed late in the disease process can be fraught with multiple interventions to keep it flowing. And sometimes, despite several interventions, the fistula may not remain patent to provide adequate dialysis therapy. The expense of maintaining these fistulae is a tremendous economic burden on the healthcare system. Currently, the annual cost of treating patients with ESRD patients is more than $32 million and a significant portion of this is spent on dialysis access-related issues. A healthy fistula created in a timely fashion can avoid some of the associated morbidities and expenses, benefiting both the patient as well as society. Vascular access guidelines from National Kidney Foundation - Kidney/Dialysis Outcome and Quality Initiative have suggested use of a medic alert bracelet for vein preservation, but unless these guidelines are widely publicized among the primary care physicians, who are more likely to see patients with early CKD, the issue will remain unresolved.[4] The primary care physician's role is equally important and their inclusion in the team to fight against this epidemic of CKD is vital.
CONTEXT:Published reports to date have failed to demonstrate a decrease in abortion rates with increased dispersal of levonorgestrel emergency contraception (LNG EC).OBJECTIVE:To evaluate whether there is an association between statewide increases in LNG EC use and birth, fertility, and abortion rates.DESIGN:Ecological study. The number of LNG EC doses dispensed at all Planned Parenthood Association of Utah (PPAU) sites (n = 6) were obtained for 2000-2006. For this time period, birth and abortion data were obtained from the Utah Department of Health.SETTING:State of Utah.PATIENTS:Women of childbearing age.MAIN OUTCOME MEASURES:Birth rates were calculated as the number of live births per 1000 population; general fertility rates, abortion rates, and LNG EC rates were calculated per 1000 women of childbearing age (15-44 years).RESULTS:Between 2000 and 2006, yearly distribution of LNG EC increased from 11,263 to 52,083 doses. Over this period, the rate of Plan B use per 1000 women age 15-44 years increased from 21.30 doses/1000 to 87.82 doses/1000, an increase of 312%. During the same period, there were corresponding changes in the statewide birth rate (-2.94%), general fertility rate (0.73%), and abortion rate (-6.36%). Pearson correlation coefficients were statistically significant for the association between the LNG EC rate and the birth rate (-0.9053; P = .0050) and the abortion rate (-0.8749; P < .001), but not between the Plan B rate and the general fertility rate (0.2446; P = .5970).CONCLUSION:This ecological study represents, to the authors' knowledge, the first statistically significant association between increasing rates of LNG EC distribution and decreasing abortion rates.
Endometrial stromal sarcoma (ESS) is a rare neoplasm of uterine origin. Intracardiac metastasis from this tumor is extremely infrequent. This report describes a 24-year-old woman from Yemen who had irregular vaginal bleeding shortly after spontaneous abortion. She developed left-lower-limb swelling, diagnosed by duplex scanning and magnetic resonance imaging as deep venous thrombosis in the inferior vena cava (IVC) that extended into the iliac veins on both sides, as well as the left femoral vein and right atrium. She developed acute respiratory distress, from which she recovered after transfer to the intensive care unit. Transesophageal echocardiography showed a large mass occupying the right atrium and ventricle and another mass in the right ventricular outflow tract with areas of cavitations. The tumor appeared to come from the IVC and extended through the right atrium and right ventricle into the pulmonary artery, ending in several digit-like projections. After surgical resection of the intracardiac mass, pathologic examination revealed a low-grade ESS that was confirmed by immunohistochemistry. The patient underwent panhysterectomy and IVC debridement. Pathologic examination revealed infiltrating low-grade endometrial sarcoma invading the myometrium and left adnexa, with intravenous extension into the pelvic veins and the IVC to the right side of the heart. This case shows that despite its well-known good prognostic nature, low-grade ESS may behave as an aggressive malignancy.
CONTEXTAsthma and chronic obstructive pulmonary disease (COPD) are prevalent respiratory conditions with overlapping disease characteristics. Differentiation between asthma and COPD is important because several aspects of the guideline-recommended management strategies differ for these conditions. This review identifies the epidemiologic, etiologic, and clinical distinctions of these diseases to assist physicians and other clinicians in differentiating between asthma and COPD. Key components of the guideline-recommended management approaches for these conditions are also reviewed.SEARCH STRATEGIESRelevant articles were found by searching the MEDLINE database for "asthma" and "chronic obstructive pulmonary disease OR COPD" in association with the terms "diagnostic criteria" and "differential diagnosis". Recent statistical summaries (meta-analyses), reviews, and consensus-type documents were also included.SYNTHESISA review of relevant articles found that, although asthma and COPD may occur simultaneously, differences between these diseases are frequently recognized in terms of age at onset, prevalence in relation to age and sex, potential for reversibility of airway obstruction, pathophysiology, and typical symptom presentation. A thorough clinical history in conjunction with lung function testing usually aids in diagnostic distinction and choice of therapeutic interventions. Radiologic imaging and inflammatory marker testing may also aid in the differentiation of these conditions. Over time, disease progression often differs between asthma and COPD.CONCLUSIONSAlthough overlaps exist in the disease characteristics of asthma and COPD, careful history, physical examination, and lung function testing often reveal information that facilitates distinction between these diseases, allowing physicians and other clinicians to better tailor their therapy.
CONTEXT:HIV infection and cervical cancer are common in Nigeria. HIV-positive women have a higher risk for cervical neoplasm; therefore, counseling and regular cervical cancer screening are recommended. After post-HIV testing counseling, HIV-positive women should be aware of the Papanicolaou (Pap) smear. OBJECTIVE:To determine the coverage of cervical cancer screening information for HIV-positive women by the post-HIV testing counseling. METHODS:Questionnaires were administered to 150 HIV-positive women and 150 HIV-negative controls after post-HIV testing counseling at the voluntary counseling and testing clinic of University of Nigeria Teaching Hospital, Enugu, Nigeria. Proportions of responses were compared by using a chi-square test at a 95% confidence level. RESULTS:Thirty-three (22.0%) HIV-positive women and 57 (38%) HIV-negative women were aware of cervical cancer. The awareness of the Pap smear among HIV-positive women (4.0%) was lower than that of HIV-negative women (21.3%) (P < .001). However, this finding became insignificant after adjustment for educational status groups (P > .05). No respondent agreed to being informed of Pap smears during post-HIV testing counseling. After counseling on cervical cancer, 96.0% of the HIV-positive group and 98.7% of the HIV-negative group expressed willingness to undergo routine Pap screening. CONCLUSIONS:Cervical cancer screening information is not part of post-HIV testing counseling for women in Enugu, southeastern Nigeria.
CONTEXT:Fruit and vegetable intake is an important part of a healthy diet and is associated with numerous positive health outcomes. MyPyramid provides recommendations for fruit and vegetable consumption based on individual calorie requirements as determined by an individual's age, sex, and physical activity level.OBJECTIVES:To determine (1) median fruit and vegetable consumption from all dietary sources among adolescent and adult consumers and the percentage of adolescents and adults meeting individual recommended intake levels based on caloric requirements and (2) consumption levels among various demographic groups, intake levels from subtypes of fruits and vegetables, and primary contributors to fruit and vegetable intake.DESIGN:Analysis of 2-day, 24-hour recall data from the 2003-2004 National Health and Nutrition Examination Survey (NHANES), a continuous, nationally representative, cross-sectional survey.RESULTS:This study included dietary contributions of fruits and vegetables from all dietary sources. Fewer than 1 in 10 Americans meet their calorie-specific MyPyramid fruit or vegetable recommendations. Higher intake was not observed in subgroups with higher recommendations for fruit and vegetable consumption based on caloric requirements. The primary contributors to total fruit intake were whole fruits among adults and fruit juices among adolescents. The largest single contributor to overall fruit intake was orange juice. Potatoes dominated vegetable consumption, particularly among adolescents, in whom fried potatoes increased the median vegetable intake from 0.72 cup to 1.21 cups per day. Dark green and orange vegetables and legumes accounted for a small portion of vegetable intake, and few people met the recommendations.CONCLUSIONS:Few American adolescents or adults reported consuming the recommended amounts of fruits or vegetables. Increasing consumption will probably require multifaceted approaches that augment educational campaigns with policy and environmental strategies aimed at the food system at large, from farm to plate, including schools, worksites, and retail establishments. Increasing America's fruit and vegetable consumption is an important public health strategy for weight management and reduction of risk for chronic disease.
To the Editor: The use of printed patient material has been a tool that I have used for 30 years in practice. Although I have only anecdotal results to back me up, I have dealt with many thousand patients in that time, and I always follow up with printed material on subsequent visits. My personal observations: Passive dissemination is useless. It is as effective to give away blank paper. At an early stage in my practice, we gave patients preprinted handouts, prepared by other doctors or by pharmaceutical companies. Almost without exception, when patients were asked on a subsequent visit how they had managed to assimilate the written material, there had been no attempt to read it. Compliance in reading and understanding the material increased when the doctor personally handed the patient the written material, although pharmaceutical company material was still rarely read. Compliance was the highest when the printed material was: Written by a doctor within the practice. We presumed this because the information was based on the practice's viewpoint on the information supplied; On lightly colored paper. The assumption was that colored paper was easier to find on a table among other mail on white paper; and Highlighted [by the practitioner, with] more relevant text within the material in front of the patient. When the printed material was given in this active way vs simple passive dissemination, subsequent visits with the patient showed that a majority of the patients were familiar with the contents of the printed handouts, were more responsive to lifestyle changes and to medication use where necessary, and were better able to report on treatment outcomes. My personal experience: Active dissemination of material is an extremely useful tool; passive dissemination is dangerously useless.
To the Editor: The immune system's response to precipitation of monosodium urate (MSU) crystals from serum uric acid into a joint is well established as a cause of the severe pain and inflammation of gout. Sleep apnea leading to the precipitation of MSU explains why so many gout flares begin while the gout sufferer is asleep. Pulmonology journal literature[1,2] describes 2 mechanisms by which the hypoxemia of sleep apnea leads to MSU precipitation. First, the cellular reaction to the hypoxemia initiates a catabolic process in which adenosine triphosphate decomposition undergoes a chain of chemical transitions that culminate irreversibly in the generation of excess uric acid that is fed into the blood. Because the transition to uric acid is irreversible, with each apneic episode more and more uric acid accumulates in the blood – faster than the kidneys can dispose of it. The second gout-producing mechanism from the hypoxemia is hypercapnia and acidosis, which increases the likelihood of MSU precipitation. Other pulmonology journal literature has confirmed that hyperuricemia is a result of sleep apnea.[3–5] About 30% of patients with sleep apnea and gout are not overweight. Screening patients with gout for sleep apnea is an important tool for treating their gout, even if they are not overweight. Using their gout as an indicator leading to diagnosis and treatment, if warranted, of the sleep apnea not only may prevent further gout flares, but more importantly will greatly lower their risks for the very serious – even life-threatening – cardiovascular, neurologic, and metabolic consequences of sleep apnea. The lifestyle focus for treating gout needs to consider not only how the patient eats or drinks, but also how the patient sleeps.
Keloids are a common presenting complaint in the primary care clinic. This condition presents a formidable challenge, as recurrence is often difficult to prevent despite use of multiple therapeutic interventions. Part of the reason for the absence of a definitive treatment is the incomplete understanding of the pathogenesis of keloid formation, which creates a frustrating situation for both physician and patient. Here we review the most recent literature on the clinical features, pathogenesis, and management of keloids, with special emphasis on the unique challenges faced by primary care physicians.
