Sustain Weight Loss to Downregulate Inflammation
Weight loss in obese women downregulates the inflammatory state that increases risk of heart disease, according to Italian researchers reporting in this week’s issue of Circulation (Circulation. 2002;105:804–809OpenUrl). In this study, Patrizia Ziccardi, MD, PhD, and colleagues in the Department of Geriatrics and Metabolic Diseases at the Policlinico della Seconda Universita di Napoli in Naples, Italy, compared the levels of tumor necrosis factor α, interleukin-6, P-selectin, intercellular adhesion molecule 1and vascular adhesion molecule 1 in 56 healthy, premenopausal obese women, aged 25 to 44, to those of 40 age-matched normal women.
The obese women had a body mass index, on average, of 37.2 and a waist-to-hip ratio of 0.78 to 0.92. They had increased basal concentrations of the inflammatory cytokines and adhesion molecules that were measured in both groups.
After a year of counseling, the obese women had lost at least 10% of their original weight—a sustained weight loss that also resulted in reductions of the cytokine and adhesion concentrations. In addition, they showed an improved vascular response to l-arginine, the natural precursor to nitric oxide.
The authors conclude that because of the “powerful association with obesity, weight loss may be another safe method for downregulating the inflammatory status of obese subjects with the goal to reduce their cardiovascular risk.”
The Viagra Dilemma
A major concern about the use of sildenafil citrate (Viagra) has been its effect on men with coronary artery disease—arguably a group that might be among those most interested in using the medication to treat erectile problems.
In a study in the February 13, 2002, issue of the Journal of the American Medical Association, researchers from the Mayo Clinic conducted a prospective, randomized, double-blind, placebo-controlled trial of the medication in 105 men who were, on average, 66 years of age, with known or expected coronary artery disease and erectile dysfunction (JAMA. 2002;287:719–725OpenUrlCrossRefPubMed).
All patients received a single dose of sildenafil at 50 or 100 mg or a placebo an hour before undergoing 2 symptom-limited supine bicycle electrocardiograms. The tests were done 1 to 3 days apart.
The researchers found that there was no difference in symptoms, exercise duration, or the presence or absence of exercise-induced ischemia between the treated and placebo groups.
“In our study subjects, there was a slight decrease in blood pressure at rest after sildenafil administration, without changes in heart rate,” the authors wrote. Resting systolic blood pressure was reduced from an average of 135 to 128 mm Hg after sildenafil use, and from 135 to 133 mm Hg after placebo use.
“In patients who have stable coronary artery disease and are not taking nitrates [a drug used for treatment of angina], sildenafil did not potentiate myocardial ischemia,” the authors wrote. However, they advised that patients “with known or suspected coronary artery disease and erectile dysfunction should have an individualized assessment before sildenafil prescriptions are issued.” They suggested that more research be undertaken to determine which patients with coronary artery disease should take the drug, taking into account the extent of disease and the degree of exercise they can achieve without symptoms.
In an editorial that accompanied the report, Thomas H. Marwick, MD, PhD, of the University of Queensland, Brisbane, Australia, noted that the “novel finding” of the report was that there was no influence of sildenafil on the development of ischemia (JAMA. 2002; 287:766–767).
Although the evidence indicates that sildenafil does not provoke ischemia and related problems, “it seems more likely that the ischemia and cardiac events reported with sildenafil are related more to the performance of sexual activity in a patient with coronary disease than the risk of the drug. The important clinical issue is how to assess risk when patients with established coronary disease request treatment for erectile dysfunction,” he noted.
“The history should focus on the assessment of functional capacity of the patient,” he suggests. “Patients who have coronary artery disease and ischemia provoked by sexual activity also experience ischemia during an exercise electrocardiogram protocol and therefore during daily activity.”
“Although the current study cannot address the risk of events when sexual activity is combined with sildenafil therapy, previous studies have suggested that the drug is safe in unselected patients and in patients with a history of cardiac disease.”
“For clinicians considering prescribing sildenafil for patients with coronary artery disease, careful evaluation of functional capacity and thorough discussion with the patient about the risks of physical and sexual activity are essential,” he warned.
New Pamphlet Gives Guidelines for Medicine by Telephone
Nearly one quarter of patient-physician interactions occur over the telephone—the ubiquitous medium of modern life. Yet physicians are often unsure and dissatisfied when practicing such telephone medicine.
The issues that arise when patients ask questions about their care over telephone lines are addressed in a new informational booklet Telephone Medicine: A Guide for the Practicing Physician (Reisman, Anna B., MD, and David L. Stevens, MD. Telephone Medicine: A Guide for the Practicing Physician. American College of Physicians–American Society of Internal Medicine; 2002). The book is an attempt to help physicians improve the medical care they provide over the telephone, according to its editors.
“Most patients are happy with the telephone care they receive, yet physicians are generally dissatisfied with their performance on the phone,” said Dr Reisman, an assistant professor at the Yale University School of Medicine. “Nearly 25% of patient encounters will involve the phone. Yet only 6% of national residency programs teach telephone medicine.”
Although Drs Reisman and Stevens coauthored many of the chapters on the basis of a curriculum they have developed on the same topic, 16 other writers contributed to the book. Covered in the volume are medicolegal considerations as well as the challenges of the telephone interview. A chapter on the difficult patient is also included.
The book also includes electronic advances such a telemedicine, e-mail with patients, and using the Internet for patient information. The book, which costs members of the two organizations $32 and nonmembers $40, can be obtained from American College of Physicians–American Society of Internal Medicine Customer Service, 800-523-1546, extension 2600, product number 330301000. The table of contents and other information can be obtained online by visiting www.acponline.org/catalog/books or by e-mailing firstname.lastname@example.org.