Volume 14: Issue 1 June 1999

A Comparison of Multiple Doses of Fluticasone Propionate and Beclomethasone Dipropionate in Subjects with Persistent Asthma. G.D. Raphael, et al. Journal of Allergy and Clinical Immunology 103 (May 1999): 796-803.
Fluticasone propionate in low doses is superior to beclomethasone dipropionate in high doses to relieve the symptoms of asthma.

The anti-inflammatory actions of inhaled corticosteroids are effective in relieving asthma symptoms. Two corticosteroids, fluticasone propionate and beclomethasone dipropionate, are recommended for the treatment of persistent asthma, but few clinical studies have compared them.

This randomized, double-blind, parallel group clinical study compared the effect of multiple doses of fluticasone propionate and beclomethasone dipropionate in patients (N=399) with persistent asthma. Patients kept a daily record of symptoms, albuterol usage, and peak expiratory flows.

Patients treated with fluticasone propionate showed considerably greater improvement (P .034) in objective pulmonary function, significantly greater reductions in daily albuterol use (P .010), and greater relief from asthma symptoms (P .027) than those receiving beclomethasone dipropionate. Low and medium doses of fluticasone propionate improved forced expiratory volume in one second (FEV1) by 0.31 L (14 percent) and 0.36 L (15 percent) compared with low and medium doses of beclomethasone dipropionate, 0.18 L (8 percent) and 0.21 L (9 percent).

Nocturnal Asthma: Effect of Salmeterol on Quality of Life and Clinical Outcomes. R.F. Lockey, et al. Chest 115 (March 1999): 666-73.
Salmeterol improves the quality of life in patients who experience nocturnal asthma symptoms.

Nocturnal asthma symptoms have been linked to reduced pulmonary function, poor sleep quality, and poor daytime cognitive performance. Salmeterol, a long-acting inhaled beta-2 agonist bronchodilator, has been used to treat nocturnal asthma symptoms. It is designed to be used with an inhaled corticosteroid to prevent breathing problems.

This randomized, double-blind, placebo-controlled clinical trial evaluated the effect of 42 g of salmeterol or a placebo given twice daily to nonsmokers (N=474, 12 years old) experiencing significant asthma symptoms at night. Patients continued to use theophylline, inhaled corticosteroids, and, "as needed," albuterol and completed an Asthma Quality of Life Questionnaire (AQLQ). Other outcome measures included peak expiratory flow (PEF), nighttime awakenings, asthma symptoms, and supplemental albuterol use.

Change in AQLQ scores was considerably greater (p 0.005) with salmeterol compared with the placebo. After 12 weeks, salmeterol significantly increased the mean change from baseline (p<0.001, compared with the placebo) in forced expiratory volume in one second (FEV1), morning and evening PEF, percentage of symptom-free days, nights without awakening due to asthma, and days and nights without supplemental albuterol use.

A Program to Increase the Number of Family Physicians in Rural and Underserved Areas. H.K. Rabinowitz, et al. Journal of the American Medical Association 281 (January 20, 1999): 255-60.
National and state policies, and medical schools, can have a considerable impact on increasing the supply of family physicians to rural and underserved areas.

This retrospective cohort study examined 206 Physician Shortage Area Program (PSAP) graduates practicing family medicine in rural and underserved areas in Pennsylvania for more than 22 years. They were compared with their non-PSAP peers, all allopathic medical school graduates in the state of Pennsylvania, and all allopathic graduates, nationally and internationally.

Overall, PSAP graduates were more likely to practice in a rural area of the United States (34 percent versus 11 percent; relative risk [RR], 3.0), in an underserved area (30 percent versus 9 percent, RR, 3.2), and family medicine (52 percent versus. 13 percent; RR, 4.0), than their non-PSAP classmates. Many were also more likely to have combined a career in family practice and practice in a rural area. PSAP graduates were more likely (84 percent) to practice in either a rural or small metropolitan area, or one of the primary care specialties. Program retention has remained high. The number of PSAP graduates currently practicing rural family medicine is equal to 87 percent of those practicing 5 to 10 years ago, and 94 percent of those practicing in underserved areas.

Breast-Feeding and Infant Illness: A Dose-Response Relationship? J. Raisler, et al. American Journal of Public Health 89 (January 1999): 25-30.
Full breast-feeding in the first 6 months of life, without any other types of feeding, protects against infant illness and provides the same health benefits to all, regardless of income.

This study used regression techniques to analyze the association between breast-feeding dose and illnesses in the first 6 months of life. Infants (7,092) from the National Maternal and Infant Health Survey had their ratio of breast-feedings to other feedings categorized as full, most, equal, less, or no breast-feeding. Mothers were asked how many times a day they fed breast milk, formula, cow’s milk, fruits or vegetable, cereal, and meat to their infants during the first 6x months of life.

Full breast-feeding was practiced by 27 percent of mothers in month 1, almost 13 percent in month 3, and fewer than 2 percent in month six. Full breast-feeding infants had lower odds ratios of diarrhea, cough or wheeze, and vomiting, and lower mean ratios of illness months and sick baby medical visits compared with infants who had not been breast-fed. Infants who were mostly breast-fed also had lower odds ratio of cough and wheeze. Less breast-fed infants had no reduced odds ratios of illness. Results were similar for all economic classes.

HIV Infection

The Mode of Delivery and the Risk of Vertical Transmission of Human Immunodeficiency Virus Type 1—A Meta-Analysis of 15 Prospective Cohort Studies. The International Perinatal HIV Group The New England Journal of Medicine 340 (April 1, 1999): 977-87.
Elective cesarean section can lower the risk of mother to child transmission of human immunodeficiency virus type 1 (HIV-1).

This analysis comprised data on 8,533 mother-child pairs, which included North American and European studies of at least 100 mother-child pairs. Elective cesarean sections were those performed before labor onset and rupture of membranes. Adjustments for receipt of antiretroviral therapy, maternal stage of disease, and infant birth weight were made using multivariate logistic regression analysis.

It was noted that the probability of vertical transmission of HIV-1 was reduced by 50 percent with elective cesarean section as compared to other modes of delivery (adjusted odds ratio, 0.43; 95 percent confidence interval, 0.33 to 0.56). Transmission was also reduced by roughly 87 percent when elective cesarean section was coupled with receipt of antiretroviral therapy during the prenatal, intrapartum, and neonatal periods (adjusted odds ratio, 0.13; 95 percent confidence interval, 0.09 to 0.19).

Nutrition

Is Whole Grain Intake Associated With Reduced Total and Cause-Specific Death Rates in Older Women? The Iowa Women’s Health Study. D.R. Jacobs, et al. American Journal of Public Health 89 (March 1999): 322-29.
Using whole grain in place of refined can reduce the risk of chronic disease in the United States.

The study obtained data on grain intake from a food frequency questionnaire answered by 38,740 women, aged 55 to 69 years.

Women with a higher whole grain intake had healthier lifestyles and less baseline disease. Median whole grain, intake quintiles ranged from 0.2 to more than three servings a day. Total death rates and deaths associated with cancer, cardiovascular disease, and other causes decreased. When adjusted for lifestyle and baseline disease, the relative risk ratio for total death was 0.85 in those women who consumed whole grain daily. Total mortality rates—but not cardiovascular disease mortality—were higher among those women who frequently consumed refined grain.

Tobacco

Tobacco Use Among Middle and High School Students—Florida, 1998 and 1999. Morbidity and Mortality Weekly Report 48 (April 2, 1999): 248-53.
Effective state smoking programs can reduce chronic youth smoking.

Tobacco use is the leading preventable cause of death in the United States. The Centers for Disease Control and Prevention estimates that every day 3,000 children become regular smokers. However, promising new results from The Florida Pilot Program on Tobacco Control (a Florida, youth anti-smoking program) indicate that in just one year, smoking declined by 19 percent among middle school students and 8 percent among high school students.

To establish baseline parameters, students completed a questionnaire that included questions about tobacco use, exposure to environmental tobacco smoke, ability to purchase or obtain tobacco products, knowledge and attitudes about tobacco, and familiarity with tobacco-related media messages and school curriculum programs. Progress was monitored for one year in seven geographical regions. Program activities included community partnerships (in all 67 Florida counties), an education and training initiative, and enhanced enforcement of youth tobacco access laws. The program’s major component was a media campaign developed to reduce the allure of smoking and tobacco’s attractiveness to youth.

Smokeless Tobacco Cessation Intervention for College Athletes: Results After 1 Year. M.M. Walsh, et al. American Journal of Public Health 89 (February 1999): 228-34.
An intervention program that focuses on quitting smokeless tobacco is effective among college athletes who are frequent users of smokeless tobacco products.

Baseball and football teams from 16 colleges across the country were randomly selected in pairs for either the intervention or control group. Analysis of the two groups involved using a weighted version of the Fisher one-sided permutation test for paired samples. Intervention included oral soft tissue examination, counseling, and 2-mg nicotine gum to counteract withdrawal symptoms. Dental hygienists also met with nonusers to explain the quitting process and to ask them to encourage their teammates. The dental hygienists also made follow-up telephone calls to answer questions and offer support on the date designated for quitting. Prevalences of quitting smokeless tobacco use were based on self-reporting.

Colleges with intervention programs reported that 35 percent of athletes who had used smokeless tobacco quit, compared with 16 percent in the control group. Results of cessation after intervention increased with level of smokeless tobacco use.

Educational and Community-Based Programs

A Comparison Study of an Elementary School-Based Health Center. D.W. Kaplan, et al. Archives of Pediatrics and Adolescent Medicine 153 (March 1999): 235-43.
School-based health centers (SBHC) provide underserved minority children, 4 to 13 years old, with better access to and use of physical and mental health services than children without SBHC access.

This retrospective cohort analysis compared surveys of parents at two urban elementary schools—one with SBHC, and a comparison or control school without SBHC.

Parents whose children had access to SBHC had less difficulty (P = .01) receiving physical health care—treatment of illnesses and injuries, immunizations, and physical examinations—for their children (odds ratio, 0.66; 95 percent confidence interval, 0.48-0.91). SBHC access was independently and significantly related to less emergency department use (odds ratio, 0.63; 95 percent confidence interval, 0.40-0.99; P < .05). Access also meant a greater likelihood of having had a physician’s visit since the school year began (odds ratio, 1.92, 95 percent confidence interval, 1.39-2.65; P < .01), and a greater likelihood of having had an annual dental examination (odds ratio, 1.36; 95 percent confidence interval, 1.01-1.83; P < .05). Parents also reported the SBHC as their most-used health service and were significantly more satisfied with their service than those who mostly used community clinics (z = -5.21; P < .01) or hospital clinics (z = -4.03; P < .01).

Heart Disease and Stroke

Use of Aspirin, b-Blockers, and Lipid-Lowering Medications Before Recurrent Acute Myocardial Infarction. D. McCormick, et al. Archives of Internal Medicine 159 (March 22, 1999): 561-67.
Patients with previous myocardial infarction (MI) can prevent recurrent acute MI (AMI) by increasing their use of aspirin, b-blockers, and lipid-lowering medications.

This study examined 1,710 patients with previous MI hospitalizations and validated recurrent AMI during 1986, 1988, 1990, 1991, 1993, and 1995. The effect of demographic, clinical, and temporal factors on the receipt of aspirin, b-blockers, and lipid-lowering medication before hospitalization for recurrent AMI was assessed using logistic regression analyses.

Significant increases for aspirin (from 13.5 percent to 52.6 percent), b-blockers (from 33.2 percent to 44.4 percent), and lipid-lowering medications (from 0.8 percent to 11.7 percent) were noted over time. Advancing age was related to not receiving aspirin (odds ratio [OR], 0.67; 95 percent confidence interval [CI], .051-0.89), lipid-lowering medications (OR, 0.14; 95 percent CI, 0.08-0.25), and b-blockers (OR, 0.75; 95 percent CI, 0.57-1.00). Women were associated with not receiving aspirin (OR, 0.78; 95 percent CI, 0.62-0.98) but were associated with receiving lipid-lowering medications (OR, 1.59; 95 percent CI, 1.04-2.43). Medical conditions that existed simultaneously and simultaneous use of other cardiovascular remedies were also associated with receiving the three medications.

Sexually Transmitted Diseases

Is the Routine Pelvic Examination Needed with the Advent of Urine-Based Screening for Sexually Transmitted Diseases? M.A. Shafer, et al. Archives of Pediatrics and Adolescent Medicine 153 (February 1999): 119-25.
Urine-based screening for sexually transmitted diseases can prevent many cases of pelvic inflammatory disease (PID) and be more cost-effective than routine pelvic examinations.

The purpose of this study was to determine the most cost-effective method of screening for chlamydia and gonorrhea to prevent pelvic inflammatory disease (PID) in asymptomatic sexually active adolescent females.

Four strategies using decision analysis were compared for a potential cohort of 100,000 asymptomatic sexually active 15- to 19-year-old adolescent females: 1) pelvic examination screening in 100 percent; 2) urine screening in 100 percent; 3) actual predicted pelvic examination screening in 70 percent; and 4) actual predicted urine screening in 90 percent.

An estimated 1,750 cases of PID will occur every year with no screening. Strategy 1 would prevent the most cases of PID (1,283) at a mean cost of $10,230; Strategy 2 would prevent 1,215 cases of PID at a mean cost of $5,093. The marginal cost to prevent an additional case of PID by strategy 1 is $101,454. Strategy 3 would prevent 898 cases of PID and 1,093 cases of PID would be prevented with urine screening in strategy 4.

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