Clinical Briefs in Primary Care
HBP and Sexual Function in Women
Source: Duncan LE, et al. Am J Hypertens 2000;13:640-647.
Defining sexual dysfunction in women is a more difficult task than in men. Objectively measured end points of sexual dysfunction are not as readily assessable, nor is there a prominent objective background database on female sexual function and dysfunction with which to make a comparison. Similarly, there is little information based upon controlled population-based studies of women examining the relationship between hypertension, its treatment, and sexual function.
The study population reported in this article includes a review of 3312 medical records from premenopausal, heterosexual women. Of these, 224 women completed a self-administered questionnaire on sexuality and multiple telephone interviews, including determination of their blood pressure status and treatment methods if hypertensive.
Analysis of questions addressing quality of relationship, desire, physical pain, frequency of intercourse, and overall sexual satisfaction, did not demonstrate any significant difference between controls and hypertensives (treated or untreated). On the other hand, hypertensive women (treated or not) had lower scores in response to inquiry about ease of achieving orgasm, vaginal lubrication, and dyspareunia. Of additional note, smokers were also found to have lower scores for orgasm than nonsmokers.
ACE inhibitors, beta blockers, calcium channel blockers, and diuretics, both alone and in combination, were analyzed, without evidence of a detrimental effect upon sexual function. Duncan and associates suggest that sexual dysfunction be sought in hypertensive women, in order that it is appropriately managed; antihypertensive therapy in this population did not appear to worsen likelihood of sexual dysfunction.
Statins and the Risk of Fractures
Source: Meier CR, et al. JAMA 2000;283:3205-3210.
Statins are well-established treatment for lipid disorders, and enjoy significant use for reduction of major cardiovascular end points. Some data have suggested that statins have an effect upon bone mass in animals and may be bone-protective in the face of systemic steroid treatment. A recent trial in diabetic men demonstrated improved femoral bone density, yet whether this improved bone density will be reflected by reduction in fractures has never been shown. Meier and associates analyzed the population of the United Kingdom General Practice Research Databases (n ³ 3 million) to examine the relationship between lipid lowering agents (including statins, fibrates, etc.) and fracture risk.
The analysis addressed three separate groups. Group 1 (n = 28,340) included persons aged 50-89 who had been treated with lipid-lowering agents; group 2 (n = 13,271) included only hyperlipidemic patients who did not receive pharmacotherapy; and group 3 included only patients without a diagnosis of hyperlipidemia and without lipid-lowering agents (n = 50,000).
Fracture risk among hyperlipidemic patients not on therapy was similar to that of persons without hyperlipidemia. Current or past use of statins was associated with a significant 0.51-0.79 odds ratio of fracture. Fibrates and other lipid-lowering agents did not demonstrate any significant reduction in fracture risk. Benefits of statin use in reference to fractures appears to occur quickly, as even short exposure (1-4 months) was associated with reduced fracture risk in a variety of skeletal sites.
Meier et al conclude that their data suggest a favorable effect of statins in men and women older than 50 upon risk of fracture, though confirmatory controlled trials will be needed.
Proteinuria as a Risk for CVD in the Elderly
Source: Culleton BF, et al. Am J Med 2000;109:1-8.
The presence of albuminuria is a harbinger of end-stage renal disease, both in diabetic and nondiabetic patients. Additionally, albuminuria is associated with cardiovascular morbid and mortal end points, and all-cause mortality. It has been theorized that albuminuria is a surrogate indicator of such abnormalities as insulin resistance, hyperhomocysteinemia, and the coagulation aberrations, which result in adverse effects on cardiovascular complications.
Despite the compelling data in diabetics associating cardiovascular end points with albuminuria, information about the proteinuria in unselected persons older than age 68 has not been well described. To that end, Culleton and colleagues report men and women older than 68 (n = 2586) who are participants in the Framingham Heart Study.
At baseline, proteinuria was found in 17.4% of men, and 12.9% of women (proteinuria defined by ³ 1+ dipstick testing). Over 10.5 years of follow-up, persons with proteinuria demonstrated a significant increase in risk (1.3-1.4 hazard ratio) of cardiovascular mortality as well as all-cause mortality, when compared to those without proteinuria. Culleton et al conclude that proteinuria is a significant risk factor in older adults for cardiovascular mortality and all-cause mortality in both genders.
Health Food Store Recommendations for Breast Cancer
Source: Gotay CC, Dumitriu D. Arch Fam Med 2000;9:692-698.
As many as two-thirds of cancer patients may turn to complementary or alternative medicine. Unfortunately, not only can some of these agents have significant toxic effects, but also they might interact with traditional allopathic treatments. It is of some concern that quality control and adverse effect surveillance are not on parity with prescription drugs.
Health food store personnel generally do not possess a license to diagnose or prescribe, yet may not infrequently be called upon to consider giving such advice. The purpose of this study was to observe, by means of a simulated medical scenario, the personnel response to a young woman who posed as the daughter of a metastatic breast cancer patient. The details of the "case" included that the diagnosis had been made five years prior, lumpectomy had been performed, and radiation therapy had been done. Complaints of the patient (the mother) included bone pain, despite her medication regimen of tamoxifen. The story also included the detail that the mother wished to consider alternative treatment, since traditional treatment had not cured her cancer.
Of the 40 stores in which the scenario was enacted, only four stores did not make recommendations. The other 36 store employees suggested one or more products, and 20% of the personnel suggested participation in a structured program (usually provided by the store), such as consultation with their store specialist, a program of their products, or diagnostic tests (e.g., iridology, muscle testing). It was fairly common (35%) for indirect recommendations to be given by offering input that certain products were popular with cancer patients, for instance shark cartilage or maitake mushrooms.
Clinicians must be aware that cancer patients or their families may seek the advice of health food store personnel, and be prepared to respond in such a way as to best avoid potential adverse effects of such interventions, while not disallowing the possibility that some tools used in health food stores may be of benefit.
Rabies Postexposure Prophylaxis
Source: Moran GJ, et al. JAMA 2000;284:1001-1007.
In that there has been but a single confirmed rabies survivor in the United States in the last three decades, rabies may be acknowledged as a uniformly fatal disease. Thanks primarily to control of rabies in domestic animals, the number of annual cases has dropped from more than 100 at the beginning of the 20th century, to only 1-3 yearly.
Rabies among animals, especially raccoons, has increased almost 20% since 1996. No cases of human rabies have ever been documented subsequent to exposure to raccoon rabies. Appropriate administration of rabies prophylaxis treatment is important not only to prevent rabies, but also to avoid unnecessary administration to persons not at risk, since the process is not without discomfort, and is costly ($1500 for a treatment course alone, without physician or office/hospital fees). This trial is the first prospective one to assess appropriateness of rabies prophylaxis administration.
Of 2030 patients with rabies exposure, 6.7% received prophylaxis. Of 136 patients who received prophylaxis, 40% were considered inappropriate, most commonly due to the fact that the culprit animal was available for observation or testing, which could obviate intervention. Of 1894 persons not receiving prophylaxis, 6.3% were considered inappropriate, most commonly because the culprit animal was not available for observation.
The authors conclude that enhanced adherence to appropriate use of rabies prophylaxis is needed, and may be advanced by provision of easy access to and availability of suggested locale-specific and circumstance-specific guidance, through health department assistance and guideline promulgation.
Ondansetron for Reduction of ETOH
Source: Johnson BA, et al. JAMA 2000;284:963-971.
The serotonin 5ht-3 receptor is important in mediating alcohol effects, and blockade of this receptor in a variety of animals has reduced alcohol consumption. There has been some support for the concept that early-onset alcoholism might be responsive to intervention with ondansetron, due to its modulation of serotonin.
This placebo-controlled trial of 321 persons suffering alcoholism (at least 3 drinks daily at the time of enrollment) used either 1, 4, or 16 mcg/kg of ondansetron twice daily, in addition to cognitive behavioral therapy for a total of 12 weeks (including run-in).
Early-onset alcoholism patients who were treated with ondansetron demonstrated a significantly decreased amount of alcohol consumption, and improved number of days abstinent. The most effective dose of ondansetron was 4 mcg/kg. Early-onset alcoholism is characterized by earlier onset of problem drinking behavior and antisocial behavior. Patients with late-onset alcoholism did not respond to ondansetron treatment.
Adverse effects of the treatment were infrequent, and none were serious. The most common side effects were gastrointestinal. A single fatality in the trial was not attributed to the medication: the subject fell down a flight of stairs at home.
The biology of early-onset alcoholism appears to be different from late-onset alcoholism, and responds differently to ondansetron modulation.
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