Thursday, August 15, 2013
QD: News Every Day--Look into the eyes to predict stroke risk
Retinal photographic assessment of hypertensive retinopathy may be useful for assessing stroke risk, as people with it were more than twice as likely to develop stroke, a study found.
Researchers reviewed data from the Atherosclerosis Risk in Communities (ARIC) Study to consider nearly 3,000 participants with hypertension ages 50 to 73 years, who had gradable retinal photographs; no history of diabetes, stroke or coronary heart disease; and subsequent data on stroke.
Experienced reviewers assessed retinal photographs for hypertensive retinopathy signs and classified them as none, mild, and moderate/severe. Results appeared online at Hypertension on Aug. 14.
The most common sign of hypertensive retinopathy were focal arteriolar narrowing (22.3%; 95% confidence interval [CI], 20.8% to 23.8%), arteriovenous nicking (17.5%; 95% CI, 16.1% to 18.9%]), and other retinopathy signs such as microaneurysms, soft exudates, blot hemorrhages and flamed-shaped hemorrhages (5.1%; 95% CI, 4.3% to 5.9%).
Slightly more than 1,400 people (48.4%; 95% CI, 46.5% to 50.2%]) had no retinal hypertension. More than 1,350 (46.6% 95% CI, 44.8% to 48.4%) had mild cases and 146 (5%) had moderate cases. One person had severe hypertensive retinopathy and was included in the moderate group (5.1%; 95% CI, 4.3% to 5.9%).
After a mean follow-up of 13 years, there were 146 cerebral infarctions and 15 hemorrhagic strokes.
For the entire study population there were 0.436 (95% CI, 0.42 to 0.45) strokes per 100 person-years. Among those with no retinopathy, the rate was 0.322 (95% CI, 0.305 to 0.339) per 100 person-years, among those with mild retinopathy, he rate was 0.493 (95% CI, 0.466 to 0.519) per 100 person-years, and among those with moderate retinopathy, the rate was 1.073 (95% CI, 0.899 to 1.246) per 100 person-years.
Patients with moderate hypertensive retinopathy were more likely to have stroke compared to no retinopathy (hazard ratio [HR], 2.37; 95% CI, 1.39 to 4.02). Among patients with good control of blood pressure through medication, hypertensive retinopathy was associated with an increased risk of cerebral infarction for mild retinopathy (HR, 1.96; 95% CI, 1.09 to 3.55) and moderate retinopathy (HR, 2.98; 95% CI, 1.01 to 8.83).
Researchers noted that because medical control of blood pressure may not be sufficient for stroke prevention in patients with hypertension, retinal assessment may be useful.
An editorial noted the advantages to ophthalmoscopy: “Although ophthalmoscopy is a skill that takes time, practice, and perseverance to master, proficiency pays dividends in the hypertension clinic and the stroke prevention clinic, as this study and others clearly show. The retina is the one place in the body where the physician can actually directly inspect the body’s microvasculature, the tissue most directly at risk from hypertension. ... It is a skill that can be relearned (when lost), particularly when retinal photographs are available for comparison with one’s own ophthalmoscopic examination.”
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Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
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Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
Controversies in Hospital
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
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Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
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David Katz, MD
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Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
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Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.
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Other blogs of note:
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Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.
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The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.