Ezetimibe/simvastatin 10/20 mg versus simvastatin 40 mg in coronary heart disease patients

BACKGROUND: Reducing low-density lipoprotein cholesterol (LDL-C) is the primary goal of therapy in patients with hypercholesterolemia and coronary heart disease (CHD). METHODS: This double blind placebo-controlled study enrolled patients 18 to 75 years of age with primary hypercholesterolemia and establishedCHDwhowere taking a stable daily dose of simvastatin 20 mg. Patients were randomized to ezetimibe/simvastatin 10/20 mg (eze/simva; n 5 56) or simvastatin 40 mg (simva; n 5 56) for 6 weeks. Percent change from baseline in LDL-C, total cholesterol, high-density lipoprotein cholesterol (HDL-C), and triglycerides were assessed by use of the Student t test. The percent of patients achieving LDL-C less than 100 mg/dL (,2.6mmol/L) or less than 80 mg/dL (,2.0 mmol/L) was analyzed via logistic regression with terms for treatment, baseline LDL-C, age, and gender. RESULTS: Baseline characteristics were similar between groups. Treatment with eze/simva combination resulted in significantly greater reductions in LDL-C, total cholesterol, and triglycerides versus doubling the dose of simva to 40 mg (all P , .01). Significantly more patients achieved LDL-C less than 100 mg/dL (,2.6mmol/L) and less than 80 mg/dL (,2.0mmol/L) with ezetimibe/simvastatin versus doubling the dose of simva to 40 mg (73.2% vs 25.0%; P,.001) for simvastatin. Changes in HDL-C were similar between treatments. Both treatments were generally well tolerated. CONCLUSION: In high-risk CHD patients with hypercholesterolemia, treatment with eze/simva combination resulted in significantly greater reductions inLDL-C, total cholesterol and triglycerides, as well as greater achievement of recommended LDL-C targets, compared with doubling the simvastatin dose to 40 mg over the 6-week period

Full integration of teaching 'Medical Humanities' in the medical curriculum: the challenge of the florence medical school.

Mankind has always longed to preserve and improve health. However, inherent in the practice of medicine lies the possibility of danger. Overlying the problem is the role of the medical profession, the skills it proclaims to profess and its relationship with the patient. Members of the medical profession are often criticized for overriding the wishes of the patient or for acting without informed consent [1]. The role of informed consent is one of the great challenges to the ethics and practice of modern medicine. The aim of this letter is to point out how education in Medical Humanities can enhance physicians' education and facilitate a different approach towards the relationship with the patient. Medicine began by espousing a paternalistic attitude towards medical treatments, which were continued in spite of the patient's disapproval or ignorance. In recent times the concept of informed consent, based on information given to the patient regarding the means of treatment, its benefits and risks, has come to the fore. Very often, however, the patient may not clearly understand the situation, due to the inaccessibility of medical language to the great majority of the population. Furthermore, the great expansion of the Internet and of the media in general has produced an undesired effect: patients very often arrive in the outpatient clinic having already looked for alternative sources of information. This can place strains on the physicianpatient relationship since patients do not possess the medical knowledge needed to evaluate the quality of the information they have already obtained and doctors have difficulties in countering misinformation in their patients. Consequently, it is first necessary to clear away prejudices that can endanger the decision making process; thus physicians must spend more time in reaching increased patient involvement. However, a subjective approach is not enough to obtain the generalized satisfaction of patients: the establishment of a partnership between physician and patient is the winning choice, but it has to face the constant pressure of time. Time is therefore a fundamental key in facilitating the passage from compliance to concordance [2]. The other basic problem is that of language. Medical language has always been the expression of a closed social class: even the Hippocratic oath places emphasis on the fact that medical education is to be directed to the doctor's sons, the sons of his mentor and to the students who are going to swear the medical oath, but to nobody else. Not surprisingly, while other languages for special purposes have become institutionalized only in recent times, medical language was already shaped in the 13th century, confirming the ancient attitude of considering the medical class a privileged entity that acted as a repository of knowledge which could not be shared [3]. The in-depth study of the History of Medicine can be of aid in fully understanding current linguistic medical patterns and, most importantly, in avoiding the repetition of the errors of the past in the patient-physician relationship. A comprehensive awareness of medical ethics and professional deontology includes a correct attitude towards the patient, an attitude that begins from a clear and understandable language. With regard to this, recent deliberations on the medical profession have emphasized that the incorrect use of jargon has widened the distance between doctor and patient, creating a discontinuity between them, while, on the contrary, this distance should be bridged by the avoidance of ambiguous words, complicated expressions and complex concepts. To give some examples: the Salk vaccination for poliomyelitis has been abbreviated in so many ways that any reader may have difficulties in identifying them all; similarly, idiopathic myeloid splenomegaly has 12 synonyms in English, 13 in German and 31 in French [4]. The international classification of diseases, published by the World Health Organization, is ignored by the greater part of the medical community. It is also rejected by some medical schools, that follow their own local traditions of terminology. It is therefore necessary to put some order into medical language, to allow clarity of communication with the general public. Physicians must know how to speak with the patient and not to the patient and therefore they must abandon their jargon and their superior attitude. If their language is to be understood, it must be adapted to the specific needs of the patient. The doctor's code must correspond to that of the patient, particularly with respect to risks and benefits, and this can be the result only of a precise management of the relationship. How may these aims be reached? We think that Medical Humanities can play a fundamental role in the education of physicians. The History of Medicine, that has become a specific academic discipline in many European countries during the 20th century, has endowed itself with a triad of basic principles, which deal with its relevance in helping physicians to acquire clinical and epidemiological knowledge, its role in legitimatizing the rise of professional experts, and its function as a school of ethics, proposing a continuous reflection on the everyday profession and favouring the development of the exercise of criticism