Quote of the Week
The Top Three

The Journal Club
Last week (Feb. 28, 2000) and this week's (Mar. 6, 2000) Journal Club provided some interesting material for Dr T'S WEB LETTER. It also allowed me to interview Dr. Stephen Eppstein for the new feature of THE WEBLETTER. Each week I am going to present THE TOP THREE. I will interview a Physician who is currently in the Private Practice of Medicine and I will pose a question to him/her regarding Preventive Medicine related subjects. The answers ranked in order of frequency or importance will constitute THE TOP THREE for that week. This should be fun and I hope that it will be interesting for our Web site users and will bring you back weekly to check what is new and which Physician was quoted.

This first article is from the Feb 17, 2000 issue of The New England Journal of Medicine and is entitled EFFECT OF EXERCISE ON CORONARY ENDOTHELIAL FUNCTION IN PATIENTS WITH CORONARY ARTERY DISEASE by Rainer Hambrect, M.D. et al. from Leipzig, Germany. Don't let the terminology scare you off. Endothelial merely relates to the type of cells lining the arteries that supply blood to the heart muscle. Acute blockage of one of these vessels is what causes a heart attack or myocardial infarction. This is a small study but what they were able to demonstrate was that exercise training improved the ability of endothelial cells to control dilatation of the coronary arteries and also the smaller blood vessels of the heart.
     Ed. It has been known for a long time that exercise helped patients with coronary artery disease but the mechanism was not clear. This study shows that exercise actually dilates the blood vessels thus increasing the vital blood flow to the heart. It must be done under control so that the diseased heart is not over stressed thus negating the long-term benefits.

From Rotterdam, the Netherlands comes an article by A. Elizabeth Hak, M.D., et al. This was published in the Feb 15, 2000 issue of The Annals of Internal Medicine, Vol. 132, number 4. The authors were able to demonstrate that elderly women who demonstrate under function of the thyroid gland or sub clinical hypothyroidism as determined by certain laboratory tests were at increased risk for the development atherosclerosis (hardening of the arteries) and myocardial infarction.
     Ed. This article stimulated a brisk discussion by our group. The primary care Physicians present stated that they had made the observation of the frequency of sub-clinical hypothyroidism and that they treated most of these patients with thyroid hormone. They were not aware however of the relationship to atherosclerosis and subsequent myocardial infarction. This immediately brings up the question of whether treating these patients earlier in life will thereby reduce the incidence of this type of heart disease. They all thought that they would start ordering appropriate lab work in order to identify this high-risk group so that early therapy could be started. This is a classical example of the benefit of periodic physical exams and appropriate screening lab work that will direct preventive medicine. The indications will of course vary by age and gender and this problem was addressed in last week's DR. T'S WEB LETTER.

An abstract published in the American College of Physicians Journal Club January/February 2000 by Dr. N. Freemantle reviewed an article that was designed to answer the question of whether long term Beta Blocker use reduced the mortality after myocardial infarction. The original article by Dr. Freemantle et al was published in The British Medical Journal Jun 26 1999; 318:1730-7. It was their conclusion that indeed the long term use (6-48 months) did reduce subsequent mortality in patients who have had a previous myocardial infarct.
     Ed. This is nothing new. This conclusion has been demonstrated in many previous trials, yet it is amazing Beta Blockers continue to be under utilized in this group of patients. Managed Care Organizations can't be blamed for this since they utilize the incidence of their use as an outcome measure for appropriate therapy in this group of patients. Another example of the benefits of Preventive Medicine.

There was an interesting article in Diabetes Care, volume 22, number 10, October 1999 by Satish K. Garg, M.D., et al. They wanted to compare measurements of blood sugar that were obtained by iontophoretic extraction with the Gluco Watch automatic glucose measurer (Cygnus, Inc., Redwood City, CA) with those obtained by the finger stick method both in an outpatient setting and at home. The study concluded that the Gluco Watch was as accurate as the finger stick method in both settings.
     Ed. This is an important study. I don't know how many of our readers have to monitor their blood sugar by repeated daily fingersticks but the ability to obtain accurate values by a non-invasive technique is a major technical advance.

"There is no short cut to longevity. To win it is the work of a lifetime, and the promotion of it is a branch of Preventive Medicine"
     - Sir James Crichton-Browne (1840-1938)

As I stated in the first part of this week's WEB LETTER. This is to be a new weekly feature. This week I interviewed Dr. Stephen Eppstein who is a noted Internist at The Medical Clinic of North Texas. Dr. Eppstein and I go back a long way. We both started our practice at the late Lorimer Clinic. Dr Eppstein has a clinical teaching appointment at the Southwestern University Medical School in Dallas and is of course in private practice in Ft.Worth.

I asked him one question this week. What are THE TOP THREE lifestyle problems that he sees in his Medical Practice that contribute to illness in his patients ranked in order of their incidence or frequency? He did not hesitate. They are:
  1. Cigarette smoking
  2. Sedentary lifestyle
  3. Obesity
I think this speaks for itself.

Take care until next time,
RJT, Editor.

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