Clinical Briefs in Primary Care
Increase in Blood Glucose Concentration During Antihypertensive Treatment as a Predictor of Myocardial Infarction
Source: Dunder K, et al. BMJ. 2003;326:681-684.
Release of the ALLHAT trial, the largest antihypertensive trial ever performed, has suggested that chlorthalidone, amlodipine, and lisinopril all provide favorable cardiovascular risk reduction. Additionally, this trial demonstrated that chlorthalidone, in addition to being less expensive, has a slightly more favorable cardiovascular risk reduction than its comparators. On the other hand, even modest doses of chlorthalidone were associated with an increase in glucose.
The Uppsala longitudinal study of men began in 1970-1974, and included 2322 men younger than age 50 at that time. In this population, Dunder and colleagues studied men (n = 1860) who were seen at baseline and 10 years later, and grouped them into participants who had or had not received antihypertensive treatment. Hypertensive treatments include beta blockers, thiazides, or both, with a small subset of individuals having been treated with hydralazine also. Subjects were evaluated for incidence of myocardial infarction, metabolic syndrome, and glucose derangements.
Subjects with an MI had a significantly higher fasting blood sugar than those who did not suffer an MI but only in the group receiving antihypertensive treatment. Whether the metabolic effect of antihypertensive therapy upon glucose mitigates some of the beneficial effects upon cardiovascular mortality remains uncertain, given the favorable results of studies like the ALLHAT trial.
Adverse Drug Events in Ambulatory Care
Source: Gandhi TK, et al. N Engl J Med. 2003;348:1556-1564.
Adverse events (AE) from medications have been well studied among hospital inpatients. It has been reported that as many as 6.5% of hospitalized patients have one or more AE, of which more than one-fourth are considered preventable. AE in the ambulatory setting have been less studied, but have been estimated to occur 5-35% of the time.
Gandhi and colleagues prospectively studied patients (n = 661) from Boston-area primary care practices. Any person older than age 18 who received a prescription was eligible. Telephone survey at 10, 14, and 90 days, chart review, and patient input were used to discern possible AE.
Twenty-five percent of patients experienced AE, of which approximately half were rated serious,’ including symptomatic bradycardia, symptomatic hypotension, and GI bleeding. Eleven percent of AE were considered preventable, and more than twice that number were "ameliorable" (ie, steps could have been taken to mitigate or reverse the AE).
AE are common in the outpatient setting and offer substantial room for clinicians to obviate (or mitigate) burden to our patients.
Prevention of Hip Fracture by External Hip Protectors
Source: Van Schoor NM, et al. JAMA. 2003;289:1957-1962.
In the year following a hip fracture (HIP), as many as one-third of persons die, and an equal number suffer inability to walk, or severe disability. One of the interventions intended to reduce HIP is use of external hip protectors (EHP), cushion-like devices worn during daily activity, which are intended to diminish the effect of a fall. Based upon the 10 randomized trials published to date, clinicians may be left with some degree of uncertainty concerning the efficacy of HIP, since 5 studies showed a statistically significant HIP impact, 2 studies found a favorable trend, and 3 studies showed no effect.
Van Schoor and associates enrolled 561 persons older than age 70 who resided in nursing homes or other assisted living facilities. Subjects wore hip protectors for approximately 15 months.
Two different varieties of hip protector were used: the Safehip and the Tytex devices.
Time to first hip fracture did not differ between those who wore an EHP and the control group. Compliance (monitored by unannounced visit) with EHP was imperfect: 61% at 1 month, 45% at 6 months, and 37% at 1 year. Whether greater compliance with EHP might have altered the outcome is unknown, but Van Schoor et al also mention that protectors with greater impact-effectiveness are to be desired, since 4 of 18 fractures in the intervention group occurred while the subject was wearing the protective device.
Rapid MRI vs Radiographs for Patients with Low Back Pain
Source: Jarvik JG, et al. JAMA. 2003;289:2810-2818.
The role of radiologic evaluation for acute low back pain (LBP) has been plagued with uncertainty, since as many as one-third of asymptomatic persons examined by MRI have signs consistent with herniated disk, and a substantially greater number manifest disk bulges or degeneration, despite an absence of symptoms. On the other hand, the high sensitivity of MRI might provide an opportunity for early diagnosis of problems that could benefit from prompt intervention. Making the possible use of MRI more attractive has been the recent evolution of rapid MRI, which requires only about 2 minutes of scanner activity.
Jarvik and colleagues compared plain x-rays with rapid MRI in subjects older than age 18 (n = 380) suffering acute LBP. Outcomes included functional disability, pain frequency, days of reduced or lost work, and patient satisfaction with care. Patients were interviewed at 1, 3, 6, 9, and 12 months after randomization.
Study results indicated that rapid MRI did not provide any statistically significant long-term advantage over plain films. Indeed, rapid MRI was associated with more frequent use of specialist consultants and more frequent invasive management techniques. Based upon these data, as well as cost considerations, Jarvik et al suggest that rapid MRI does not offer demonstrable long-term advantage over plain films.
Effectiveness of Anticholinergic Drugs Compared with Placebo in the Treatment of Overactive Bladder
Source: Herbison P, et al. BMJ. 2003;326:841-844.
Overactive bladder (OAB) comprises a syndrome that may include urgency, urge incontinence, frequency and/or nocturia. Incontinence troubles as many as one-third of all overactive bladder patients, but even symptoms of frequency or nocturia may cause substantial negative effect upon quality of life.
The most commonly offered treatment for OAB is anticholinergic pharmacotherapy, which provides reduction of detrusor muscle contraction through blockade of the parasympathetic (cholinergic) pathway. To date, impact upon detrusor contraction has been afforded at the cost of adverse drug effects such as dry mouth, dry eyes, and constipation. Herbison and associates posited that the efficacy of anticholinergic medications is uncertain and sought to provide further insight by performing a systematic review of anticholinergic drug treatment provided in randomized trials.
On the basis of 32 randomized trials (n = 6800), Herbison et al determined that for persons with incontinence, likelihood of an incontinent episode was reduced approximately once in 48 hours; frequency of urination was reduced by approximately 1 micturition per 24 hours.
Herbison et al observe that improvements in treated patients, despite being statistically significant, are clinically modest compared to placebo. Additionally, they comment that bladder training may provide similar magnitude of benefit.
A Randomized Trial of a Low Carbohydrate Diet for Obesity
Source: Foster GD, et al. N Engl J Med. 2003;348:2082-2090.
At the current time in America, almost half of women and a substantial minority of men (30%) are dieting to lose weight. Unfortunately, diet interventions have had surprisingly little favorable effect upon the weight of the nation, as manifest by a doubling of the prevalence of obesity in the past 20 years.
Much contention surrounds what is the "best" diet for persons trying to lose weight, and a diversity of suggested methodologies abound. If sales of diet books are in any way indicative of public interest, the Atkins diet (low carbohydrate) has been the most popularly addressed, with a readership 4 times greater than any other diet book. Although popular, no randomized controlled trial of the Atkins diet vs, for instance, a high-carbohydrate, low-fat diet has been performed.
Foster and associates report upon subjects who were randomly assigned to either a low-carbohydrate diet (like Atkins) or a "conventional" diet (low calorie, high carbohydrate, low fat) and followed for 12 months.
Although an early difference in favor of the low carbohydrate diet was evident in the first 3 months, there was no statistically significant difference in weight lost at 12 months. Similarly, there were no significant enduring differences in frequency of urinary ketones, blood pressure, glucose tolerance, or LDL. The low-carbohydrate diet did produce more favorable changes in HDL and triglycerides, but Foster et al question whether even these changes would remain beneficial over the long term, in the face of high fat intake associated with chronic adherence to the Atkins diet.
Increase in Blood Glucose Concentration During Antihypertensive Treatment as a Predictor of Myocardial Infarction; Adverse Drug Events in Ambulatory Care; Prevention of Hip Fracture by External Hip Protectors; Rapid MRI vs Radiographs for Patients with Low Back Pain; Effectiveness of Anticholinergic Drugs Compared with Placebo in the Treatment of Overactive Bladder; A Randomized Trial of a Low Carbohydrate Diet for ObesitySubscribe Now for Access
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