This Week in The New England Journal of Medicine

January 4, 2001

Effects on Blood Pressure of Reduced Sodium and the DASH Diet

The DASH diet emphasizes fruits, vegetables, and low-fat dairy products, and it is low in total and saturated fat. A previous study has shown that this diet lowers blood pressure in people with and without hypertension. The current study extends the previous one by showing that the restriction of sodium intake, in addition to the DASH diet, further lowers systolic and diastolic blood pressure. The effect is greater in people with hypertension than in those without hypertension.

Dietary change is an important initial approach to the treatment and prevention of hypertension. This study provides an important advance in the dietary treatment of hypertension by showing the benefit of restricting sodium intake, in conjunction with the DASH diet, for the control of blood pressure. Patients with hypertension will need to be instructed in how to select low-salt foods, since most daily salt intake comes from the salt in processed foods; adherence to this part of the diet is achievable but will not come easily.

Related Editorial

"A substantial
proportion of cases of
S. aureus bacteremia . . .
originate from colonies
in the nasal mucosa."

Nasal Carriage and Staphylococcus aureus Bacteremia

Of 219 patients with S. aureus bacteremia, 180 were found to have identical strains of this organism in their anterior nares. Of 1278 patients colonized with S. aureus, 14 later had bacteremia. In 12 of these 14 patients, the strains in the bloodstream were identical to those documented earlier in the nares. Hence, in most cases of S. aureus bacteremia, the source of the organisms appears to be endogenous.

The data from this study provide strong support for the anterior nares as the source of S. aureus leading to bacteremia. Thus, strategies to prevent systemic infections in high-risk patients by the elimination of nasal carriage of S. aureus could be worthwhile.

Related Editorial

The Pathogenesis of Hypertensive Pulmonary Edema

Patients with acute pulmonary edema often have elevated blood pressure. This study used echocardiography to examine whether hypertensive pulmonary edema is caused by systolic or diastolic dysfunction of the left ventricle. Since there was little or no echocardiographic evidence of systolic dysfunction at the time of pulmonary edema, the authors concluded that the principal cause of hypertensive pulmonary edema is diastolic dysfunction precipitated by elevated blood pressure.

This study underscores the important role of diastolic ventricular dysfunction in the pathogenesis of hypertensive pulmonary edema. The clinical implication is that intervention to lower blood pressure may improve diastolic dysfunction and the associated pulmonary congestion.

Related Editorial

"The combination of
vapreotide and
endoscopic treatment is
more effective than
endoscopic treatment
alone."

Vapreotide for Variceal Bleeding

Patients with bleeding from esophageal varices may be treated with somatostatin or endoscopy. In this study patients with cirrhosis and variceal bleeding were treated with the somatostatin analogue vapreotide or placebo for five days; all underwent endoscopic treatment within 12 hours. At endoscopy, 31 percent of the vapreotide group were actively bleeding, as compared with 46 percent of the placebo group. During the five-day treatment period the rates of survival with control of bleeding in the two groups were 66 percent and 50 percent, respectively.

Achieving hemostasis and preventing recurrent bleeding in patients with cirrhosis who have variceal bleeding is a difficult clinical problem. The combined approach used in this study seems to offer benefits, with respect to immediate cessation of bleeding and prevention of recurrence. However, the short-term mortality rates were similar in the two groups.

Advances in Immunology: Allergy and Allergic Diseases

This article, which is part of the Journal's Immunology series, is the first of a comprehensive two-part review of the pathogenesis and treatment of allergic diseases.

Drug Therapy: Misoprostol and Pregnancy

Misoprostol has important uses in pregnant women. These uses include induction of abortion in conjunction with mifepristone or methotrexate, treatment of missed abortion, induction of cervical ripening and of labor, and prevention and treatment of postpartum hemorrhage. This article summarizes the results of studies of the efficacy and side effects of misoprostol in obstetrical practice.

Related Editorial

Clinical Problem-Solving: High Time for Action

A 58-year-old man receiving hemodialysis after failed renal transplantation presents with unstable angina. He also reports malaise, nausea and vomiting since repair of an intraabdominal aortic aneurysm and removal of the renal graft less than four weeks earlier. The prothrombin time and activated partial- thromboplastin time are checked before planned cardiac catheterization. Although previously normal, these values are prolonged at 88 seconds and 77 seconds, respectively.

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