1) Despite advances in antibiotics, death rates from infections have increased 58% from 1980 to 1992, partially due to HIV. Pneumococcal pneumonia is becoming increasingly resistant to antibiotics. 2) Studies found that a high dietary fiber intake and fish oil supplements can decrease the risk of heart disease, while coffee and beta carotene supplementation alone do not affect heart disease risk. 3) Early treatment of strokes and heart attacks within 1-4 hours improves outcomes, while smoking and not taking aspirin after a heart attack increases risks. Dog ownership may benefit heart attack survival.

1. The Internet Medical Journal
Clinical Pearls 1997 #2
These one sentence comments on recent articles in the medical literature are intended to direct the
reader to the source article. They provide medical information NOT ADVICE. Please consult with your
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Despite advances in antibiotics, age adjusted death rates from infections have increased 58%
over the 12 year period of 1980 to 1992; HIV disease alone was only partially responsible for this
increase. (JAMA 1996 01/17;275:0189)
Pneumococcal pneumonia, a major cause of pneumonia in the US, is becoming increasingly
resistant to antibiotics (14% to penicillin, 12% to ceftazidime, 24% to tri-sulfa); increased use of
the pneumococcal vaccine is urged. (JAMA 1996 01/17;275:0194)
Coffee was not associated with the development of heart disease in a study of 85,747 American
women. (JAMA 1996 02/14;275:0458)
A high dietary fiber intake was associated with a decreased risk of heart disease, independent of
fat intake, in a study of 43,757 men. (JAMA 1996 02/14;275:0447)
The National Center for Health Statistics has defined overweight as a body mass index (BMI) of
over 27.7 kg/m2 in men, and over 27.2 kg/m2 women (BMI = wt in kilograms / height in meters
squared) (Ann Intern Med 1993 ;119:0646)
Although a high plasma beta carotene level was associated with a lower death rate,
supplementation alone did not lower the death rate in a study of 1720 people (implying other
factors were more important than the beta carotene?). (JAMA 1996 03/06;275:0699)
Supplementation with vitamin E decreased the incidence of angina in a study of 29133 male
smokers; those taking supplements had a 9% decreased risk of developing angina during the
average 5 yr follow-up period. (JAMA 1996 03/06;275:0693)
Final infarct size among patients treated within 1 hour of symptom onset were only 40% as large
as the infarct size among a similar group of heart attact patients who waited 4 - 6 hours before
thrombolytic therapy. (Circulation 1996 01/01;93:0048)
Drinking caffeinated beverages either before or during exercise is not recommended due to the
abnormal increase in blood pressure caused by the caffeine, according to a study of 30 men.
(Amer J Hypertension 1995 12/01)
One year after coronary artery bypass surgery, those who continued to smoke had more than
twice the heart attack and reoperation risk compared to those who quit, in a study of 415
patients. (Circulation 1996 01/01;)
In a study of women who previously had delivered a preterm baby, 250 mg of Flagyl TID x 7d
with erythro 333 mg TID x 14 d decreased a second preterm delivery in those women with active
bacterial vaginosis. (NEJM 1995 12/28;333:1732)
An early fever after a stroke increases the mortality rate; a temperature of 100.2 F or more raised

2. the odds of dying 3.4 times suggesting the need to aggressively treat fevers (even low grade) in
acute stroke patients. (Stroke 1995 11/01;26:2040)
Dog owners were significantly more likely to be alive 1 year after a heart attack in a study of 369
patients; cat owners did not benefit, suggesting that the need to walk the dog (in contrast to cats)
was a important factor in their survival. (Am J Cardiol 1995 12/15;76:1213)
The use of a pacifier increased the risk of ear infections in children, causing an estimated 25% of
all cases of ear infections. (Pediatrics 1995 11/01;96:0884)
High doses of acetaminophen (>1000 mg) should be avoided in aspirin sensitive asthmatics,
according to a study of 70 asthmatics; 34% of aspirin sensitive pts were also sensitive to high dose
acetaminophen. (J Allergy Clin Immunol 1995 ;96:0480)
The death rate during the 6 months after a heart attack was cut 50% by aspirin (from 17% to
8.4%); unfortunately, a full 25% of patients were NOT prescribed aspirin (even though NO
contraindications existed) in this study of 5490 medicare patients. (Ann Intern Med 1996
02/01;124:0292)
In pts with proven, symptomatic coronary artery disease, vitamin E (400 - 800 IU per day)
reduced the rate of subsequent fatal and/or nonfatal myocardial infarction by 45% during a
mean follow-up period of 510 days in a study of 2002 pts. (Lancet 1996 03/23;347:0781)
Although both are important in decreasing heart disease, weight loss without exercising was
better than exercising without weight loss in this study of 170 nonsmoking, sedentary, obese men.
(JAMA 1995 ;274:1915)
Postmenopausal women who engaged in leisure-time physical activities (e.g. gardening, walking)
were found to have a 50% decreased risk of heart attack. (Arch Intern Med 1995 ;155:2302)
In a study of 49 patients who recently suffered a heart attack, giving fish oil supplements
increased the heart rate variability, supporting the hypothesis that fish oil may have a protective
antiarrhythmic effect (by raising the fibrillation threshold). (BMJ 1996 03/16;312:0677)
Air pollution, especially ozone, was shown to be strongly associated with acute episodes of
wheezing in children in a study of 5315 children. (BMJ 1996 03/16;312:0661)
Air polution, especially ozone, was associated with a significant increase in all cause, cardiac, and
respiratory death. (BMJ 1996 03/16;312:0665)
As of January, 1993, about 630,000 to 897,000 adults and adolescents in the US had HIV (107,000
to 150,000 were female); about 1% of white men, 3% of black men, and 1% of black women in
their 4th decade were infected. (Science 1995 ;270:1372)
There is insufficient evidence to recommend routine PAP smears for women who have had a
hysterectomy for benign disease. (JAMA 1996 03/27;275:0940)
Among women who take birth control pills, smokers are 10 times more likely than nonsmokers to
suffer a heart attack. (BMJ 1996 01/13;312:0068)
Out of 25 men with heart disease (CAD), 4 were free of angina but still had EKG changes
indicative of angina (suggesting a high rate of silent ischemia). (Am J Cardiol 1995 08/15;76:0337)
Newly diagnosed diabetic children are more likely to be depressed at 2 years after than diagnosis
than immediately after diagnosis. (Diabetes Care 1995 10/95;18:1330)
Balloons are the most common toy causing death by suffocation in children (29%), followed by
balls (13%) then marbles (6%). (JAMA 1995 12/13;274:1763)

3. Breastfeeding for 1 month or more offers significant and prolonged protection against food and
respiratory allergies, up to age 17 yrs old. (Lancet 1995 10/21;346:1065)
Regardless of folic acid intake, prepregnancy weight was positively associated with an increased
risk of neural tube defects. (JAMA 1996 04/10;275:1089)
The rate of UNRECOGNIZED pernicious anemia among Americans over 60 yrs old is estimated
to be about 2%, i.e. about 800,000 Americans have unrecognized pernicious anemia. (Arch Intern
Med 1996 ;156:1097)
Because of the risk of infection (mainly from cryptosporidium), the CDC now recommends all
AIDS patients boil their water, install filters on faucets, or drink only bottled water; municipal
water supplies are too unreliable in several large cities. (American Medical News 1996 05/20;)
In women undergoing a c-section after 4+ hours of labor or 4+ hours of ruptured membranes,
14% had bacteremia (13 of 93 pts studied) putting them at a theoretical risk for endocarditis.
(Obstet Gynecol 1996 ;87:0779)
Walking more than 4 hours per week versus less than 1 per week was associated with a 31%
decrease in hospitalization for cardiovascular disease in this study of 1,645 Americans over 65. (J
Am Geriatr Soc 1996 ;44:0113)
Among 30-69 year old Finns, the highest quartile of flavonoid intake had a 46% lower risk for
coronary mortality and a 31% reduced total mortality (foods high in flavonoids: apples, onions,
tea, read wine). (BMJ 1996 ;312:0478)
Enteric-coated fish oil capsules (containing 2.7 grams of omega-3 fatty acids) reduced by about
50% the frequency of relapse in a study of 78 pts with Crohn's disease. (NEJM 1996 06;334:1557)
Simple advice and encouragement from a physician to stop smoking was as or more effective
than nonspecific behavior modification therapy, group therapy, or the use of health promotion
clinics; nicotine replacement therapy is also highly effective. (Arch Intern Med 1995
10/9;155:1933)
In elderly patients with chronic rheumatoid arthritis requiring nonsteroidal anti-inflammatory
drugs (e.g. ibuprofen), taking misoprostol as well reduced the risk of gastrointestinal
complications by 38% in this study of 8843 patients. (Ann Intern Med 1995 08/15;123:0241)
Transcendental Meditation, 20 minutes 2x/day, enabled pts with coronary artery disease to
increase exercise capacity by 15% greater than the control group; TM was considered helpful in
the prevention and treatment of coronary artery disease. (Am J Cardiol 1996 04/15;77:0867)
Thrombolysis with tPA within 7 hours of the onset of a stroke was found both safe and benefitial;
tPA was given with heparin to a group of 43 pts with a mean age of 65. (Stroke 1996 ;27:0882)
In a study of 382 Swedes, hypertension at age 70 was associated with an increased risk of
dementia, including Alzheimer's type dementia. (Lancet 1996 ;347:1141)
In 125 pts with suspected acute myocardial infarction, the pts given a daily regimen of
antioxidant vitamins did better than the other pts in terms of cardiac death and reinfarction (vit
A-50,000 IU/d, vit C-1 g/d, vit E-400 mg/d, b-carotene-25mg/d). (Am J Cardiol 1996
02/01;77:0232)
The CDC reported that nearly 1 million illnesses and almost 1,000 deaths each year are the result
of tap water that fails to meet federal standards (report issued by the Environmental Working
Group & the Natural Resources Defense Council). ( 1996)

4. Postmenopausal women with diabetes on hormone replacement therapy should be monitored
closely for elevated triglyceride levels; they are at an increased risk of acute pancreatitis.
(Diabetes Care 1996 ;19:0480)
Treating hypertension is important in preventing congestive heart failure and other
cardiovascular complications; this entire issue of JAMA covers a broad range of hypertension
topics. (JAMA 1996 05/22;275(20))
Vitamin E supplementation may be useful in preventing macrovascular disease in diabetics. (Am
J Clin Nutr 1996 ;63:0753)
Simvastatin, a cholesterol lowering drug, can significantly reduce healthcare costs; the net effect
is a cost of $0.28 per day for simvastatin, a drug shown to decrease total mortality by 30% in a
select group of pts. (Circulation 1996 ;93:1796)
Aspirin plus low-molecular-weight heparin was superior to aspirin plus regular heparin (weight
based protocol) in reducing the occurence of acute myocardial infarction, the need for
revascularization, and recurrent angina. (J Am Coll Cardiol 1995 08/26;26:0313)
In selected postmenoposal women with osteoporosis (women on estrogens were excluded),
alendronate reduced new vertebral fractures and increased bone mineral density. (NEJM 1995
11/30;333:1437)
Sharing a bedroom with one or more adults was associated with a decrease in the rate of sudden
infant death syndrome; these authors recommend infants sleep in the same room as their parents
for the 1st 6 months of life. (Lancet 1996 ;347:0007)
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