Journals

New Regimens to Prevent Tuberculosis in Adults with HIV Infection.

A Hemodynamic Study of Pulmonary Hypertension in Sickle Cell Disease.

Origins of the E. coli Strain Causing an Outbreak of Hemolytic–Uremic Syndrome in Germany.

Primary Isoniazid Prophylaxis against Tuberculosis in HIV-Exposed Children.

Febrile Urinary Tract Infections in Children.

The Coagulopathy of Chronic Liver Disease.






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Vegetarian Diet Reduces Risk for Bowel Disorder

News Author: Laurie Barclay, MD
CME Author: Charles P. Vega, MD

CME Released: 07/22/2011; Valid for credit through 07/22/2012

Clinical Context

Most patients in the United Kingdom do not receive the recommended daily allowance for dietary fiber, and the authors of the current study describe how this might contribute to rising rates of diverticular disease. High levels of consumption of dietary fiber are associated with more rapid bowel transit times and increased frequency of bowel movements. This leads to less water reabsorption from the stools and softer, larger stools that are easier to pass. The overall effect of these actions is less pressure on the colonic wall and, possibly, less diverticular disease.

The current study by Crowe and colleagues examines the effects of vegetarianism and the amount of dietary fiber on the risk for diverticular disease.

Study Synopsis and Perspective

Following a vegetarian diet and having a high intake of dietary fiber are associated with a lower risk for diverticular disease, according to the results of a prospective cohort study reported online July 19 in the BMJ.

"Diverticular disease has been termed a 'disease of western civilisation' because of its high prevalence in countries like the United Kingdom and United States compared with certain parts of Africa," write Francesca L. Crowe, nutritional epidemiologist at the Cancer Epidemiology Unit, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom, and colleagues. "We examined the associations of vegetarianism and the intake of dietary fibre (defined as non-starch polysaccharides) with the risk of diverticular disease using information from hospital admission data and death certificates for England and Scotland in men and women taking part in the European Prospective Investigation into Cancer and Nutrition (EPIC)-Oxford cohort."

The study cohort consisted of 47,033 men and women living in England or Scotland and enrolled in EPIC-Oxford, a cohort of predominantly health-conscious participants recruited throughout the United Kingdom. Of these, 15,459 (33%) reported consuming a vegetarian diet at baseline. A 130-item, validated food frequency questionnaire was used to estimate dietary fiber intake.

Linkage with hospital records and death certificates allowed identification of cases of diverticular disease. Multivariate Cox proportional hazards regression models allowed estimation of hazard ratios (HRs) and 95% confidence intervals (CIs) for the risk for diverticular disease by diet group and quintiles of dietary fiber intake.

Of 812 cases of diverticular disease identified during follow-up (mean duration, 11.6 years), 806 were hospital admissions and 6 were deaths. Compared with meat eaters, vegetarians had a 31% lower risk for diverticular disease, after adjustment for confounding variables including smoking, alcohol use, and body mass index (relative risk, 0.69; 95% CI, 0.55 - 0.86). Meat eaters between the ages of 50 and 70 years had a 4.4% cumulative probability of hospitalization or death from diverticular disease vs 3.0% for vegetarians.

The risk for diverticular disease was also inversely associated with dietary fiber intake. Compared with participants in the lowest quintile of dietary fiber intake (< 14 g/day for both women and men), those in the highest quintile (≥ 25.5 g/day for women and ≥ 26.1 g/day for men) had a 41% lower risk for diverticular disease (HR, 0.59; 95% CI, 0.46 - 0.78; P < .001 trend).

Vegetarian diet and higher fiber intake were each significantly associated with a lower risk for diverticular disease, after mutual adjustment.

"Consuming a vegetarian diet and a high intake of dietary fibre were both associated with a lower risk of admission to hospital or death from diverticular disease," the study authors write.

Limitations of this study include unmeasured confounding, possible lack of generalizability, the possibility that vegetarians would undergo fewer tests and/or that meat eaters would have more gastrointestinal tract symptoms resulting in a diagnosis of diverticular disease, and undetermined validity of a diagnosis of diverticular disease from hospital records.

In an accompanying editorial, David J. Humes and Joe West, from Nottingham University Hospital, in Nottingham, United Kingdom, note that the findings must be interpreted in the light of these limitations.

"At a population level, if the available absolute risks are converted into a number needed to treat, about 71 meat eaters would have to become vegetarians to prevent one diagnosis of diverticular disease as measured in this study," Drs. Humes and West write. "...Overall the opportunity for preventing the occurrence of diverticular disease and other conditions, such as colorectal cancer, probably lies in the modification of diet, at either a population or an individual level. However, far more evidence is needed before dietary recommendations can be made to the general public."

Cancer Research UK funded the EPIC study. One of the study authors reports being a member of the Vegan Society. Drs. Humes and West have disclosed no relevant financial relationships.

BMJ. 2011;343:d4115, d4131.

Study Highlights

• Study data were drawn from the EPIC-Oxford cohort. All participants were at least 20 years old and resided in the United Kingdom.
• Participants completed a questionnaire at baseline that estimated the intake of 130 different foods and beverages during the past year. Vegetarians were defined as individuals who did not eat meat or fish. Participants who did not consume meat, fish, eggs, or dairy products were considered vegans.
• The questionnaire also inquired regarding demographic, health habit, and past medical data.
• The main study outcome was the relationship between vegetarianism, the amount of dietary fiber, and the incidence of diverticular disease, which was ascertained from hospital admission billing or death codes for diverticulosis, diverticulitis, and diverticulum of the small or large intestine.
• 47,033 adults provided study information, and 76% of participants were women. The mean follow-up period was 11.6 years.
• 35% of men and 32% of women were vegetarians. Vegetarians were younger than nonvegetarians, and nonvegetarians had higher body mass index values.
• Rates of diabetes, hypertension, or hyperlipidemia were 2 to 3 times higher among nonvegetarians vs vegetarians.
• There were 812 cases of diverticular disease during the follow-up period.
• Smoking was associated with a higher risk for diverticular disease, including an 86% increased risk for diverticular disease among heavy smokers vs nonsmokers.
• Higher body mass index was also associated with a higher risk for diverticular disease, as was hypertension, hyperlipidemia, and the use of female hormone therapy.
• The overall rates of hospitalization or death from diverticular disease were 4.4% among nonvegetarians and 3.0% among vegetarians and vegans.
• Compared with nonvegetarians, vegetarians had a relative risk for 0.69 for the development of diverticular disease (95% CI, 0.55 - 0.86). Vegans had an even lower risk for diverticular disease vs nonvegetarians (relative risk, 0.28; 95% CI, 0.10 - 0.74).
• The duration of vegetarianism had no significant effect on the risk for diverticular disease.
• The quantity of meat consumed among nonvegetarians also failed to affect the risk for diverticular disease.
• In contrast, there was a significant inverse association between the consumption of dietary fiber and the risk for diverticular disease. Participants in the highest fifth of dietary fiber consumption (at least 25.5 g/day among women and 26.1 g/day among men) had a 41% lower risk for diverticular disease (relative risk, 0.59; 95% CI, 0.46 - 0.78; P < .001 trend) vs participants in the lowest fifth of dietary fiber consumption (< 14 g/day).
• The main study results were similar in subgroup analyses based on participants' sex and age.

Clinical Implications

• Rates of diverticular disease have increased, as recommendations for intake of dietary fiber are not met. High levels of consumption of dietary fiber are associated with more rapid bowel transit times, less water reabsorption from the stool, and increased frequency of bowel movements.
• The current study suggests that vegetarianism and higher degrees of dietary fiber intake are associated with a lower risk for diverticular disease.

From : medscape

regards, taniafdi ^_^

Milk and Soy Protein Intake Reduce Systolic BP

News Author: Lisa Nainggolan
CME Author: Désirée Lie, MD, MSEd

CME Released: 07/21/2011; Valid for credit through 07/21/2012

Clinical Context

According to He and colleagues, hypertension is highly prevalent, and a 2-mm Hg reduction in systolic blood pressure (BP) could lead to a 6% reduction in stroke mortality rates, a 4% reduction in coronary artery mortality rates, and a 3% reduction in all-cause mortality rates. A diet rich in dairy products has been shown to reduce BP in clinical trials, perhaps because of the high content of potassium and calcium in these diets.

This randomized, double-blind, crossover trial compares the effect of soy protein, milk protein, and refined carbohydrates on systolic and diastolic BP in adults with prehypertension or stage I hypertension.

Study Synopsis and Perspective

Both soy protein and milk reduce systolic BP compared with carbohydrates, according to the first randomized controlled trial to directly compare the effects of these two proteins with carbohydrate [1].

The trial found that 40 g/day of soy protein and 40 g/day of milk protein both reduced systolic BP by approximately 2 mm Hg compared with 40 g/day of carbohydrate over eight weeks. While this is a small change for an individual, at a population level such a drop would translate into a 6% reduction in stroke mortality, a 4% cut in coronary heart disease deaths, and a 3% fall in all-cause mortality, say Dr Jiang He (Tulane University School of Public Health and Tropical Medicine, New Orleans, LA) and colleagues in their paper published inCirculation.

"Our study suggests that partially replacing carbohydrate with soy or milk protein might be an important component of nutrition intervention strategies for the prevention and treatment of hypertension," He told heartwire. He added that increasing intake of low-fat milk and other low-fat dairy products, soy milk, and beans would help achieve this goal.

First Study to Show Milk Lowers BP in Pre- and Early Stage Hypertension

He, an epidemiologist, and colleagues note that prior observational epidemiologic studies that looked at the relationship between dietary protein intake and BP have reported inconsistent findings. They also note that there are very limited data from randomized controlled trials to assess the effect of dietary protein on BP, and in most of these trials, change in BP was not the primary outcome and sample sizes were small.

In their study, they compared the effect of soy protein, milk protein, and complex carbohydrate supplementation on BP in a randomized, double-blind crossover trial in 352 adults with pre- or stage 1 hypertension between 2003 and 2008.

Participants were randomized to 40 g/day of soy protein, milk protein, or carbohydrate each, taken as powder supplements dissolved in water, for eight weeks in random order, and with a three-week washout period between interventions. The supplements used were formulated in a way that ensured they had the same sodium, potassium, and calcium content, so that the changes observed were not due to changes in the intake of these minerals.

BP readings were taken three times at each of two clinic visits--two before and two after each eight-week phase--to give a net BP change for each supplement period.

Compared with carbohydrate controls, soy protein and milk protein were significantly associated with a 2.0 mm Hg (p=0.002) and 2.3 mm Hg (p=0.0007) net decrease in systolic BP, respectively.

"The present study provides further evidence that soy protein supplementation reduces BP [and] to the best of our knowledge, this is the first clinical trial to document that milk protein lowers BP in prehypertension and stage 1 hypertension," the researchers note.

Despite these encouraging findings, further long-term randomized controlled trials are needed to examine the effects of various dietary proteins on BP, and to make specific recommendations for dietary changes, they conclude.

The authors report no conflicts of interest.

References

1. He J, Wofford MR, Reynolds K, et al. Effect of dietary protein supplementation on blood pressure. A randomized controlled trial. Circulation 2011; doi:10.1161/circulationaha.110.009159. Available at:http://circ.ahajournals.org/

Study Highlights

• The Protein and Blood Pressure study was a randomized, double-blind, placebo-controlled phase 3 clinical trial to test whether soy or milk protein supplementation would reduce BP compared with a complex carbohydrate.
• A crossover design was used with 3 intervention phases.
• Between 2003 and 2008, participants were allocated to either 40 g of soy protein, 40 g of milk protein, or 40 g of complex carbohydrate, each for 8 weeks, after a 2-week washout, with random sequence and 3 weeks between each intervention.
• 3 groups of participants received the 3 dietary interventions in 3 different orders.
• Inclusion criteria were age 22 years or older, and a mean systolic BP of 120 to 159 mm Hg and a diastolic BP of 80 to 95 mm Hg at 6 readings during 2 screening visits.
• Excluded were patients receiving antihypertensive medication; those with a systolic BP of 160 mm Hg or higher or a diastolic BP of 95 mm Hg or higher; those who reported kidney disease, diabetes mellitus, or cardiovascular disease; those with body mass index of more than 40 kg/m²; those who consumed more than 14 alcoholic drinks per week; or those with a current or intended pregnancy.
• The participants were recruited by mass mailing, worksite, and community-based BP screenings in 2 cities.
• The soy protein, milk protein, and complex carbohydrate supplements were provided by a single producer. There were comparable amounts of sodium, potassium, and calcium in each supplement.
• 2 baseline and 2 termination visits were made for each of the phases of intervention and 3 BP measurements at each visit.
• Mean age of the participants was 47 years, 58% were men, one third were black, 45% reported alcohol intake, and 5% to 11% were current smokers.
• Mean systolic/diastolic BP was 126.7/82.4 mm Hg.
• 18.5% of patients had hypertension.
• 80.7% had BP measured at the end of supplementation with soy protein, 81.3% after supplementation with milk protein, and 81.5% after carbohydrate supplementation.
• On average, dietary protein intake was significantly increased in both the soy (30.5 g/day) and milk protein (32.8 g/day) groups but not in the carbohydrate group.
• Carbohydrate intake was significantly decreased in the soy protein (by 30.7 g/day) and milk protein (30.6 g/day) supplementation phases but was increased in the carbohydrate phase.
• Urinary excretion of urea was significantly increased during the soy and milk protein phases but not in the carbohydrate phase.
• Mean systolic BP was reduced by 1.5 mm Hg from baseline during the soy protein phase and by 1.8 mm Hg during the milk protein phase but not during the carbohydrate phase.
• Diastolic BP was not significantly different during the 3 phases.
• Compared with the carbohydrate phase, the soy protein phase was associated with a 2.0-mm Hg reduction in systolic BP (P = .002), and the milk protein phase was associated with a 2.3-mm Hg lower systolic BP (P = .0007).
• No significant difference in BP reductions were seen for the soy protein phase vs the milk protein phase.
• Adverse effects were similar among the 3 phases and consisted of appetite change, nausea, and stomach pains.
• The authors concluded that dietary supplementation with soy or milk protein compared with complex carbohydrates was associated with a clinically significant reduction in systolic BP in patients with prehypertension or stage I hypertension.

Clinical Implications

• Supplementation with soy protein or milk protein compared with complex carbohydrates is associated with a reduction of 2 to 2.3 mm Hg in systolic BP in patients with prehypertension or stage I hypertension.
• Supplementation with soy protein or milk protein compared with complex carbohydrates is not associated with a reduction in diastolic BP in patients with prehypertension or stage I hypertension.

http://www.medscape.org/viewarticle/746757?src=cmemp

regards, taniafdi ^_^

CDC Releases New Guidelines for Infection Prevention in Outpatients

News Author: Laurie Barclay, MD
CME Author: Charles P. Vega, MD

CME/CE Released: 07/20/2011; Valid for credit through 07/20/2012

Clinical Context

The majority of medicine is practiced in ambulatory settings, and the authors of the current recommendations provide a review of this care. They state that the total number of office medical visits in the United States reached 1 billion in 2007. The average person makes approximately 3 visits to a clinician's office per year. In addition, more than three quarters of all operations in the United States are performed in settings outside of the hospital.

Ambulatory care facilities may not always maintain the same rigor in infection control practices as hospitals. The current recommendations by the US Centers for Disease Control and Prevention (CDC) describe systemic and personal means to implement effective infection control in ambulatory health centers.

Study Synopsis and Perspective

Each outpatient practice should identify an infection prevention leader, according to a new concise guide and checklist issued by the CDC and reported online July 13. The new recommendations, which aim to protect patients by informing clinicians about minimal expectations of safe care, target healthcare providers in outpatient care settings.

Despite the recent dramatic rise in medical care in outpatient settings, compliance with standard infection prevention practices is often poor in these facilities, which include endoscopy clinics, surgery centers, primary care offices, pain management clinics, urgent care centers, public health clinics, imaging centers, oncology clinics, outpatient behavioral health and substance abuse clinics, physical therapy and rehabilitation centers, and also hospital-based outpatient departments and clinics.

"Patients deserve the same basic levels of protection in a hospital or any other health care setting," said Michael Bell, MD, deputy director of CDC's Division of Healthcare Quality Promotion, in a news release. "Failure to follow standard precautions, such as correct injection practices, cannot be tolerated. Repeated outbreaks resulting from unsafe practices, along with breaches of infection control noted in ambulatory surgical centers during inspections by the Centers for Medicare and Medicaid, indicate the need for better infection prevention across our entire health care system, including outpatient settings."

In the United States, clinicians at outpatient facilities currently perform more than 75% of all surgical procedures. Between 1995 and 2007, the average number of outpatient visits to physician offices was 3 per person per year, resulting in a total of nearly 1 billion physician office visits by 2007.

Because a significant proportion of outpatients come from vulnerable patient populations, it is essential that clinicians offer care under conditions that minimize the risk for healthcare-associated infections (HAIs).

On the basis of currently available, evidence-based CDC guidelines mostly used by hospitals but applicable to a variety of healthcare settings, the easy-reference guide uses Standard Precautions as the foundation to prevent transmission of infectious agents during patient care in all healthcare settings. Accompanying materials include an Infection Prevention Checklist for Outpatient Settings and supporting materials.

Among the supporting materials is a new, no-cost, certified continuing medical education video course for clinicians in all healthcare settings, titled Unsafe Injection Practices: Outbreaks, Incidents, and Root Causes . The video course, which is offered on the Medscape Education Web site, was developed by the CDC in collaboration with the Safe Injection Practices Coalition, a partnership of healthcare-related organizations convened to facilitate safe injection practices in all US healthcare settings.

For internal evaluation, a facility or practice can use these materials, which complement ongoing CDC and Centers for Medicare and Medicaid efforts to integrate CDC recommendations into Centers for Medicare and Medicaid surveys used while inspecting ambulatory surgery centers and other outpatient settings.

One of the leading recommendations in the new guide is that all outpatient practices should designate 1 or more persons specifically trained in infection control to be on staff or regularly available. The infection control leader(s) should play an important role in developing a written policy to prevent and contain infection and should regularly communicate with the other healthcare providers regarding specifically identified issues or concerns.

Other Recommendations

Other recommendations for outpatient facilities and practices include the following:

• Infection prevention and occupational health programs should be developed, implemented, and maintained.
• Written infection prevention policies and procedures, based on evidence-based guidelines, regulations, or standards, should be developed to address services provided by each facility.
• All healthcare personnel, including those employed by outside agencies and available by contract or on a volunteer basis to the facility, should receive job- or task-specific infection prevention education and training focusing on principles of both healthcare provider safety and patient safety.
• Sufficient and appropriate supplies needed to comply with standard precautions should always be available. These precautions should include hand hygiene, use of personal protective equipment, safe injection practices, respiratory precautions, cough etiquette, and environmental cleaning and maintenance of reusable medical equipment according to the maker's instructions.
• Staff's compliance with infection prevention practices should be monitored regularly with audits and competency evaluations.
• To evaluate infection control practices, facilities should use CDC's infection prevention checklist for outpatient settings.
• Facilities should comply with local, state, and federal requirements regarding HAI surveillance, reportable diseases, and outbreak reporting.
• Healthcare personnel should always follow procedures to ensure safe handling of medical equipment that may be contaminated.
• Healthcare personnel should always follow safe medical injection practices.

Additional resources, including the guide, checklist, continuing medical education course, CDC and external commentary about the guide, clinician and patient education materials, a CDC Safe Surgery feature, and other supporting materials are available in the guidelines.

"The majority of ambulatory care settings are not designed to implement all of the isolation practices and other Transmission-Based Precautions (e.g., Airborne Precautions for patients with suspected tuberculosis, measles or chicken pox) that are recommended for hospital settings," the guide states. "Nonetheless, specific syndromes involving diagnostic uncertainty (e.g., diarrhea, febrile respiratory illness, febrile rash) are routinely encountered in ambulatory settings and deserve appropriate triage. Facilities should develop and implement systems for early detection and management of potentially infectious patients at initial points of entry to the facility."

"To the extent possible, this includes prompt placement of such patients into a single-patient room and a systematic approach to transfer when appropriate," the guide concludes. "When arranging for patient transfer, facilities should inform the transporting agency and the accepting facility of the suspected infection type."

CDC. Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care. Published online July 13, 2011.

Study Highlights

• The ambulatory facility should have access to at least 1 individual trained in infection control practices. This person should establish and communicate standards for infection control, which might vary based on the type of ambulatory practice.
• The infection control administrator should also ensure compliance with safety practices such as vaccinations for healthcare workers and post-exposure prophylaxis in case of unintended injuries.
• Finally, the infection control expert should coordinate and evaluate efforts to train healthcare personnel in habits to prevent the spread of infection, such as hand hygiene.
• Infection control training for healthcare personnel should focus on the safety of both practitioners and patients.
• Training should be repeated regularly, and all trainees should demonstrate competency in the practice of infection control germane to their responsibilities.
• At a minimum, ambulatory sites should adhere to established requirements for reporting communicable diseases. Regular surveys may help to ensure compliance with recommended protocols to prevent the spread of infection.
• Standard practices in infection control expected of all healthcare facilities include hand washing, use of personal protective equipment, safe injection practices, safe handling of contaminated surfaces in a patient care environment, and respiratory/cough hygiene.
• Alcohol-based hand rubs should be the primary means of hand hygiene in practice, given their ease of use and efficacy against most pathogens. Hand rubs are also faster and less irritating to the hands vs hand washing with soap and water.
• Nonetheless, soap and water should be used when the provider's hands are visibly soiled or after caring for a patient with a known communicable disease.
• The provider should practice hand hygiene before touching a patient, even if wearing gloves, and on leaving the patient care area. Hands should also be cleansed after gloves are removed.
• Vials of injected medications should ideally be assigned to only 1 patient. Similarly, fluid and infusion equipment should be used for only 1 patient.
• A syringe should never be reused to enter a medication vial or solution.
• The healthcare facility should attempt to control the possible transmission of infections via aerosol or droplets from the moment a patient enters that facility. Signs should alert patients to cover their mouths and noses when coughing and sneezing. Tissues should be provided, with no-touch receptacles to discard them after use.
• Hand hygiene should be available in patient waiting areas, and masks should be offered to patients who cough or sneeze.
• The facility may consider a separate waiting area for patients with possible infectious respiratory tract illness.

Clinical Implications

• Alcohol-based hand rubs should be the primary means of hand hygiene in practice. They are faster and less irritating to the hands vs hand washing with soap and water. The provider should practice hand hygiene before touching a patient, even if wearing gloves, and on leaving the patient care area.
• Means to reduce the spread of infectious respiratory tract illness in healthcare facilities include the provision of tissues, hand hygiene available in patient waiting areas, masks for patients who cough or sneeze, and a separate waiting area for patients with possible infectious respiratory tract illness.

http://www.medscape.org/viewarticle/746666?src=cmemp

regards, taniafdi ^_^