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By Louis Kuritzky, MD
Reduction in cholesterol through diet is a tool commonly used in persons who suffer stroke, myocardial infarction (MI), or peripheral vascular events, as well as in those persons felt to be at risk of such end points. Nonetheless, not all persons respond well to dietary intervention. Indeed, as many as 15-20% of persons counseled on diet do not demonstrate significant cholesterol reductions, despite adherence. This study investigated familial differences on effect of cholesterol-lowering diet upon LDL over two five-week periods.
Of the 56 initial families selected from the Dallas-Ft. Worth area, 46 completed the trial during which subjects used either butter (80% fat by weight) or margarine (since regular commercial margarine contains 60% fat by weight, subjects consumed specially compounded 80% fat by weight margarine). Family compliance to monitored ingestion of butter or margarine was excellent.
On average, adults experienced an 11% reduction in LDL by margarine substitution for butter. In concordance with earlier data, 19% of subjects experienced no LDL lowering. No single genetic factor was determined to account for individual variability in response to diet. Clinicians may anticipate that despite dietary compliance, a substantial minority of individuals will not enjoy cholesterol lowering.
Denke MA, et al. JAMA 2000;284: 2740-2747.
Low back pain (lbp) and its consequent disability have been our nation’s single largest source of disability dollar expenditure for many years. Numerous avenues of investigation seek to find effective tools to prevent, treat, or shorten the disability related to LBP. Wassell et al investigated the effect of low back support belts (BSB) in reducing the incidence of back injury claims or LBP among 110 supermarket-merchandise stores of a single corporation.
Of 144,469 corporate employees, 10% were identified as involved in "material handling tasks." Study data come from those individuals who successfully completed baseline interviews, divided equally among stores that required belt use for material handlers, compared to those in which belt use was voluntary.
There was no discernible effect of using a BSB. This same nil effect persisted in a variety of subgroups, including persons with or without history of previous back injury, persons with highly consistent belt wearing habits, and employees with the most strenuous jobs. This study demonstrates that BSB use does not favorably affect LBP.
Wassell JT, et al. JAMA 2000;284: 2727-2732.
There is, as yet, no clearly defined evidence-based path for best acute management of migraine. Lipton and colleagues describe "step care" as a process in which the patient usually initiates treatment with a nonspecific treatment such as simple analgesics; if resolution is inadequate, treatment escalation is used. In their description of "stratified care," the choice of initial treatment is based upon headache-related disability (i.e., activity limitations in various domains of function). Lipton et al compared step care with stratified care (n = 1062).
Step care treatment began with aspirin (800-1000 mg) plus metoclopramide (10 mg); unsatisfactory resolution indicated escalation to a triptan (zolmitriptan 2.5 mg). Patients with Migraine Disability Assessment Scale (MIDAS) scores of I-II were treated initially with the same aspirin plus metoclopramide regimen; MIDAS scores II-IV received the triptan as initial therapy.
The proportion of responders was significantly greater in the stratified care than in the step care groups. Lipton et al conclude that the stratified care strategy is superior to step care, suggesting that the patient’s headache disability score may be used to enhance the likelihood of success of initial therapy.
Lipton RB, et al. JAMA 2000;284: 2599-2605.