High use of specialist physicians and specialized procedures coupled with low exposure to primary care are distinguishing traits of the US health care system. Although the tasks of the primary care medical home are well established, consensus on the normative clinical roles of specialist physicians has not been achieved, which makes it unlikely that the specialist workforce is being used most effectively and efficiently. This article describes a typology of specialists' clinical roles and discusses the implications of the typology for improving the effectiveness and efficiency of the primary-specialty care interface.
This study examined associations between objectively measured sleep and blood pressure in 578 African Americans and whites aged 33 to 45 years. Results indicated that shorter sleep duration and lower sleep quality significantly predicted higher systolic and diastolic blood pressure cross-sectionally and more adverse changes in systolic and diastolic blood pressure over 5 years (all P < .05). Short sleep duration also significantly predicted increased odds of incident hypertension (odds ratio, 1.37; 95% confidence interval, 1.05-1.78). Furthermore, sleep duration appeared to mediate the difference between African Americans and whites in diastolic blood pressure change over time (P = .02). Reduced sleep duration and consolidation predicted higher blood pressure levels and adverse changes in blood pressure, suggesting the need for studies of whether interventions to optimize sleep may reduce blood pressure.
Therapies that can retard the progression of chronic kidney disease are needed to prevent the morbidity and mortality associated with reduced renal function. Although multiple studies published in the past 10 years have supported the combination use of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers to decrease proteinuria and delay disease progression, Ku et al advise that combinations of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers should be used with great caution in patients with chronic kidney disease because, in combination, the risks of adverse effects, including hyperkalemia, hypotension, and worsening renal failure, could outweigh the purported benefits of dual blockade.
Recurrent acute pancreatitis (RAP) and chronic pancreatitis (CP) are generally considered to be diseases of alcoholism. However, this assumption is challenged by new data showing that a threshold of 5 drinks per day or more is required before alcohol use becomes statistically associated with CP. These data also point to cigarette smoking as an independent, dose-dependent risk for chronic pancreatitis, and a trend for an interaction with drinking was observed. Among 1000 patients with pancreatitis and 695 control subjects studied at 20 academic medical centers across the United States, only a minority were alcoholic. In light of these new data, Yadav et al suggest that RAP and CP should be classified as complex inflammatory disorders rather than diseases of alcoholism. Finally, these data point to the need to screen for cigarette use and offer smoking cessation counseling to patients with RAP and CP, particularly among those who also meet or exceed the 5-drink threshold of alcohol consumption.
Low-carbohydrate diets are traditionally high in animal products but despite weight loss may not lower serum low-density cholesterol concentration. Jenkins et al therefore assessed the effect, over 1 month, of provision of a calorie-reduced, high–vegetable protein and vegetable oil diet on body weight and serum lipid concentrations as a novel approach to a low-carbohydrate diet. This diet was compared with a high-carbohydrate therapeutic diet based on low-fat dairy and whole grain cereal products. Compared with a high-carbohydrate diet, the low-carbohydrate diet significantly reduced low-density lipoprotein cholesterol concentrations and total cholesterol–high-density lipoprotein cholesterol and apolipoprotein B–apolipoprotein AI ratios, together with diastolic blood pressure. These reductions were achieved despite a similar drop in body weight with both diets of approximately 4 kg. Jenkins et al conclude that although weight loss may be little influenced by the nature of the diet, the inclusion of plant food components in weight loss regimens may have important properties in reducing cardiovascular risk factors.
In This Issue of Archives of Internal Medicine. Arch Intern Med. 2009;169(11):1014. doi:10.1001/archinternmed.2009.134