In This Issue of Archives of Internal Medicine

Kaltenbach et al used an evidence-based approach to determine the efficacy of lifestyle measures for management of gastroesophageal reflux disease (GERD). While there was physiologic evidence that tobacco, alcohol, chocolate, and high-fat meals decreased lower esophageal sphincter pressure, there was no published evidence for the efficacy of dietary measures and tobacco or alcohol cessation on esophageal pH or GERD symptoms. Head of bed elevation and left lateral decubitus position improved the overall time that the esophageal pH was less than 4.0, while weight loss improved both pH profiles and symptoms. Therefore weight loss and head of bed elevation are effective lifestyle interventions for GERD, whereas there is no evidence of improvement in GERD outcomes after dietary interventions.

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This 9-year follow-up study examined the relationship between heart failure and risk of dementia and Alzheimer disease in a community-based cohort of 1301 individuals 75 years or older. During the 6534 person-years of follow-up, 440 subjects developed dementia, including 333 with Alzheimer disease. Heart failure was significantly associated with a more than 80% increased risk of dementia and Alzheimer disease. Use of antihypertensive drugs (83% diuretics) could reduce dementia risk due to heart failure. Heart failure and low diastolic pressure (<70 mm Hg) had an additive effect on dementia risk. These findings suggest that heart failure is a risk factor for dementia and Alzheimer disease and that appropriate antihypertensive therapy may partially counteract the risk effect of heart failure on dementia in the elderly.

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Obstructive sleep apnea/hypopnea is a common disease that results in reduced quality of life and an increased risk of motor vehicle crashes; first-line therapy for obstructive sleep apnea/hypopnea is usually continuous positive airway pressure (CPAP). The purpose of this study was to calculate the incremental cost-effectiveness ratio in terms of US dollars per quality-adjusted life-year gained of a CPAP strategy compared with no CPAP in the treatment of obstructive sleep apnea/hypopnea. From a third-party payer perspective, the incremental cost-effectiveness ratio was $3354 per quality-adjusted life-year. Ayas et al conclude that when quality of life, costs of therapy, and motor vehicle crashes are considered, CPAP therapy in patients with obstructive sleep apnea/hypopnea is an economically attractive use of health care resources.

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Chen et al evaluated the relationship between longer-term use of unopposed estrogen and breast cancer risk. The study population included 11 508 postmenopausal women within the Nurses' Health Study who had a hysterectomy before 1980 and was expanded through 2002 to include women who subsequently became postmenopausal and had a hysterectomy, to eventually include 28 835 women. Breast cancer risk was not increased among shorter-term users of estrogen but increased with duration of unopposed estrogen use among longer-term users. For example, women who currently used estrogen alone for 20 or more years had a 42% increased risk of breast cancer compared with women who never used estrogen. The risk was highest for estrogen- and progesterone-receptor positive cancers. In conclusion, users of unopposed estrogen were still at increased risk of breast cancer but only after longer-term use.

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This study evaluated the effectiveness of electronic medical record alerts and group academic detailing to reduce the coprescription of warfarin and interacting medications. Participants were 239 primary care providers at 15 primary care clinics and 9910 patients taking warfarin. All 15 primary care clinics received electronic medical record alerts for warfarin interactions, and 7 clinics were randomly assigned to receive group academic detailing. The primary outcome was the interacting prescription rate—the number of coprescriptions of warfarin-interacting medications per 10 000 warfarin users per month. At baseline, nearly a third of patients taking warfarin had an interacting prescription. Coinciding with the alerts, there was an immediate and continued reduction in the interacting prescription rate, resulting in a 14.9% relative reduction (95% confidence interval, −19.5% to −10.2%) at 12 months. Group academic detailing did not enhance alert effectiveness.

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