What is the best way to diagnose GERD?

The Buzz: A simple point-of-care tool can help with the diagnosis of GERD
Citation: "Diagnosis of Gastroesophageal Reflux Disease" AFP  2010 May 15;81(10):1278-1280.
Summary: Upper abdominal symptoms are common in primary care, and this article presents two clinically-validated point-of-care tools for the diagnosis of GERD. The first, called "GerdQ", is a 5-item survey which predicts the likelihood of the diagnosis of GERD. This can be given to the patient at registration and was shown to be comparable to diagnosis by a specialist. The second is a clinical scoring guide which uses BMI and a few other data points to predict response to omeprazole. While calculating the score is slightly more time-consuming, the authors point out that in patients of average or increased weight, nighttime pain or recent antacid use predicts a good response to omeprazole*, a rule which provides an even more efficient way to decide if its use is worth recommending.
Commentary: Any shortcuts to the diagnosis and management of this common condition are welcome. *See recent post on PPIs.
By: Spencer Blackman MD

What are the most effective lifestyle changes for improvements in lipid profiles?

The Buzz: Various lifestyle modifications can benefit lipid profiles

Citation: "Diet and Exercise in the Management of Hyperlipidemia" AFP, 81;9 May 1, 2010 1097-1101

Summary: This review article is a compilation of various primary studies and meta analysis regarding specific life style modifications and their affect on lipids. Data summarized below:

• Limit saturated fats to < 7% of calories and eliminate trans fats = LDL ↓9-12%
• Increase intake of soluble fiber (3 oz oats per day, psyllium supplement) = LDL  ↓ 5 mg/dL  
• Isocalorically increase consumption of tree nuts ( .5 oz almonds, walnuts, or pecans per day) = LDL ↓ 2-19%
• 1.5 oz soy protein per day - tofu and soy foods to replace meats = ↓ LDL 5mg/dL
  ↑ HDL 0.8 mg/dL 
•  One alcoholic drink for females, two for males = ↓  LDL 7.8 mg/dL
  ↑ HDL 9-13 mg/dL 
• 1 oz Promise, Active, or Benecol spread per day  = ↓ LDL 10% 
• Increase intake of marine omega-3 fatty acids (EPA/DHA) = ↓ Triglycerides in a dose-dependant fashion
• Mediterranian Diet = ↓ total cholesterol:HDL ratio > 12% 
• Portfolio Diet  = ↓ LDL 29-35% 
• Aerobic exercise >120 min/week = ↓ LDL 4mg/dL
  ↑ HDL 1.9 - 2.5 mg/dL

Other pearls include:

• Dietary advice from physicians results in ↓ cholesterol 6.2/ mg/dL and ↓ LDL 7.0 mg/dL.
• Dietary advice from a dietitian results in and additional ↓ cholesterol 9.7 mg/dL.
• The greatest reduction results from avoidance of saturated and trans fats, increase in polyunsaturated and monunsaturated fats, moderate ETOH intake, supplementation with plant sterols or stanols (eg Promise spread), and isocalorically increasing consumption of tree nuts

Commentary: This study helps to quantify the effects of commonly recommended lifestyle modifications on lipid levels. Some of the recommendations, although showing impressive reductions in lipids, require a motivated patient. 

By: Steven Winiarski D.O.

Cochrane: Opioids for OA?

The Buzz: In OA of the hip and knee, opioids provide modest benefits that do not outweigh the risks
Citation: "Cochrane for Clinicians: Opioids for Osteoarthritis of the Knee or Hip" AFP May 1, 2010 81:9 1094-95 
Summary: The study authors reviewed ten outpatient trials involving 2,268 patients, reporting a response rate of 35% of patients in the treatment group, vs 31% in the control group (number needed to treat [NNT] = 25), as defined by a reduction of at least half of their pain. This was offset by adverse effects, though major adverse events were rare. No one opioid was found to be superior. The article authors recommend clinicians consider other interventions as outlined  by the Osteoarthritis Research Society International. They also recommended tramadol, as well as codeine, in patients with refractory pain.
Commentary: This seemingly focused review brings up a number of larger issues, including the overuse of narcotic medications (hydrocodone is the most prescribed medication in the US), and the approach to chronic pain. In addition, it points out a very useful resource available to California clinicians, the California Prescription Drug Monitoring Program (register here), which allows real-time controlled prescription reports on individual patients.
By: Spencer Blackman MD

Hgba1c as an independent risk factor for diabetes, CVD and death?

The Buzz: Glycated hemoglobin may be a useful marker for predicting development of diabetes, cardiovascular risk and death
Citation:  "Glycated Hemoglobin, Diabetes and Cardiovascular Risk in Nondiabetic Adults." NEJM 362;9 March 4, 2010 800-11

Summary: This multi-center study followed 11,092 middle-aged adults without diabetes over a 15 year period in order to study the use of glycated hemoglobin to predict risk of diabetes, coronary heart disease and death. Using thawed blood samples taken during subjects' earlier visits, researchers calculated adjusted hazard ratios for those with HgbA1c values below 7.0%, ie nondiabetics. HgbA1c values were as good as fasting glucose values for predicting risk of developing diabetes, and appeared to be better than fasting glucose as a predictor of long-term macrovascular event risk. For A1c values of <5.0%, 5.0%-<5.5%, 5.5%-<6.0%, 6.0%-<6.5% and >6.5%, the multivariable-adjusted hazard ratios were 0.52, 1.00, 1.86, 4.48 and 16.47, respectively for developing diabetes, and 0.96, 1.00, 1.23, 1.78, and 1.95, respectively for coronary heart disease (all values significant). Similar findings were reported for stroke and death from any cause.The authors concluded that not only does this study further support the use of glycated hemoglobin values to predict diabetes risk, but that values over 6.0% may be an independent risk factor for cardiovascular disease and death.
Commentary: This study, while observational, suggests we have another tool to help establish risk for developing diabetes, heart disease and death. However, the authors do not suggest which patients this would be useful for, nor do these findings change the approach to patients at elevated risk. Modifying lifestyle factors is still key in this battle.
By: Spencer Blackman MD