Soul of the Healer

s of Articles Authored or Coauthored by Permanente Clinicians minority subgroup outcomes will assist more in-depth understanding of potential differences in either the processes or outcomes of behavior change interventions. CONCLUSIONS: Primary care clinicians, including obstetrician-gynecologists, can contribute to preventing CVD in women through implementing credible evidence-based recommendations for clinical interventions in tobacco and healthy diet. Researchers can further our understanding of gender-specific issues in healthy behavior interventions by reporting process and outcome data for gender and minority subgroups. Reprinted from Journal of Women’s Health Issues, V 13, Whitlock EP, Williams SB, The primary prevention of heart disease in women through health behavior change promotion in primary care, 122-41, Copyright 2003, with permission from Jacobs Institute of Women’s Health. From Northern California: Improvement of gastroesophageal reflux symptoms after radiofrequency energy: a randomized, sham-controlled trial Corley DA, Katz P, Wo JM, et al, Gastroenterology 2003 Sep;125(3):668-76. BACKGROUND AND AIMS: Gastroesophageal reflux disease is a prevalent disorder that often requires long-term medical therapy or surgery. The United States Food and Drug Administration recently cleared new endoluminal gastroesophageal reflux disease treatments; however, no controlled trials exist. METHODS: We randomly assigned 64 gastroesophageal reflux disease patients to radiofrequency energy delivery to the gastroesophageal junction (35 patients) or to a sham procedure (29 patients). Principal outcomes were reflux symptoms and quality of life. Secondary outcomes were medication use and esophageal acid exposure. After six months, interested sham patients crossed over to active treatment. RESULTS: At six months, active treatment significantly and substantially improved patients’ heartburn symptoms and quality of life. More active vs sham patients were without daily heartburn symptoms (n = 19 [61%] vs n = 7 [33%]; p = 0.05), and more had a >50% improvement in their gastroesophageal reflux disease quality of life score (n = 19 [61%] vs 1980-1982 results from the Wisconsin Epidemiologic Study of Diabetic Retinopathy (WESDR). We estimated multivariate predictive models. RESULTS: Mean (± SD) HbA1c in KPNW was 7.84 ± 1.26% versus 10.37% (standardized) in the WESDR. KPNW blood pressure averaged 138.6 ± 13.8/79.5 ± 7.4 mmHg compared with 147.0/79.0 in the WESDR. BDR was much less prevalent in KPNW, but PDR prevalence appeared unchanged. BDR preceded diagnosis in 20.8% of the WESDR subjects but only 2.0% of KPNW subjects. However, in both populations, the first cases of PDR appeared similarly, soon after diagnosis. CONCLUSIONS: Earlier diagnosis and more aggressive control of blood glucose and blood pressure decreased the duration-adjusted prevalence of background, but not of sightthreatening proliferative retinopathy. More population-based research is needed to replicate and explain this unexpected finding. Detecting and treating PDR should not be neglected on the assumption that risk-factor control has minimized its prevalence. Copyright 2003 American Diabetes Association from Diabetes Care, Vol 26, 2003;2637-42. Reprinted with permission from The American Diabetes Association. CLINICAL IMPLICATION: First, even in well-controlled diabetics we should re-emphasize the importance of annual and biennial retinopathy screening exams and make sure that members with pathology are treated and closely followed. Second, we should initiate antihyperglycemic treatments at <7.0% HbA1c, rather than at the ADA-recommended 8.0%. This will reduce risk of posttreatment “accelerated diabetic retinopathy,” and the long-term glycemic burden of our members. Long-term burden is growing thanks to aggressive CVD prevention, providing more years for development of blindness and renal failure. Third, we should consider rapid, office-based HbA1c assays, or have members come in for tests before their visits. Rapid testing reduces mean HbA1c and glycemic control may deteriorate quickly as treatments fail. It is hard to respond quickly when the HbA1c result arrives after the patient is out the door. –JB n = 6 [30%]; p = 0.03). Symptom improvements persisted at 12 months after treatment. At six months, there were no differences in daily medication use after a medication withdrawal protocol (n = 17 [55%] vs n = 14 [61%]; p = 0.67) or in esophageal acid exposure times. There were no perforations or deaths. CONCLUSIONS: Radiofrequency energy delivery significantly improved gastroesophageal reflux disease symptoms and quality of life compared with a sham procedure, but it did not decrease esophageal acid exposure or medication use at six months. This procedure represents a new option for selected symptomatic gastroesophageal reflux disease patients who are intolerant of, or desire an alternative to, traditional medical therapies. Reprinted from Gastroenterology, Vol 125, Corley DA, Katz P, Wo JM, et al, Improvement of gastroesophageal reflux symptoms after radiofrequency energy: a randomized, sham-controlled trial, 668-76, Copyright 2003, with permission from American Gastroenterological Association. From the Northwest: Diabetic retinopathy: contemporary prevalence in a well-controlled population Brown JB, Pedula KL, Summers KH. Diabetes Care 2003 Sep;26(9):2637-42. OBJECTIVE: To measure the extent to which modern intensified risk factor control has lessened the duration-specific prevalence of diabetic retinopathy and, therefore, has decreased the risk of blindness in Americans with type 2 diabetes. RESEARCH AND DESIGN METHODS: Intensified control of blood glucose and blood pressure has prevented diabetic retinopathy in randomized controlled trials. There is as yet no confirmation that subsequent treatment intensification in the community has had the same result. We identified all 6993 members of a health maintenance organization, Kaiser Permanente Northwest (KPNW), who, in 1997-1998, had dilated retinal examinations and verifiable data of diagnosis of type 2 diabetes. We plotted prevalence by time since diagnosis for background diabetic retinopathy (BDR) and proliferative diabetic retinopathy (PDR) and compared these results to identically derived