Clinical Briefs-By Louis Kuritzky, MD
Clinical Briefs-By Louis Kuritzky, MD
Seasonal Allergic Rhinitis
Seasonal allergic rhinitis sufferers often choose histamine blockade as their preferred treatment, usually a second-generation nonsedating agent. Recent data suggest that leukotriene modulation is also effective in allergic rhinitis. This report details the outcome of a study comparing loratadine, montelukast, the combination, or placebo in a large (n = 460), double-blind, randomized, parallel-group trial.
Subjects were assigned to receive montelukast 10 or 20 mg PO, loratadine 10 mg PO, or the combination of montelukast 10 mg + loratadine 10 mg (or placebo) each morning for two weeks. Each subject was required to have positive skin tests to at least one of eight allergens (Bermuda grass, Johnson grass, rye grass, olive tree, oak tree, elm tree, sycamore tree, or walnut tree). Daily allergic rhinitis symptom scores were calculated based upon nasal stuffiness, runny nose, itch, sneeze, teary eyes, itchy, red, or puffy eyes, and sleep difficulties related to allergic rhinitis manifestations.
Montelukast 20 mg was not more effective than 10 mg. All active treatments were more effective than placebo for rhinoconjuntivitis quality-of-life scores. The combination of montelukast and loratadine concomitantly were at least additive in efficacy scores when compared with either agent alone. Combining leukotriene modulation with antihistamine therapy may provide a logical therapeutic choice for patients who respond inadequately to either agent alone.
Meltzer EO, et al. J Allergy Clin Immunol 2000;105:917-922.
Does Acute Bronchitis Really Exist?
Upper respiratory infections (URIs) occupy a prominent role in the ambulatory caseload of most primary care physicians. It has been suggested that the diagnosis of acute bronchitis may be stimulated by such factors as clinician desire to justify antibiotic administration, difficult differentiation between acute bronchitis and other URIs, and variable criteria by which the diagnosis is made. The current study was devised to ascertain if any particular clinical signs or symptoms differentiate or predict acute bronchitis rather than URI. Hueston and colleagues hypothesized that there would not be clinical differentiation of bronchitis from other URIs, except that those designated as acute bronchitis would receive antibiotics with significantly greater frequency.
Study subjects comprised the 48,000 population of ambulatory visits at the Medical University of South Carolina Family Medicine Department. ICD-9-CM coding identified subjects.
Analysis of the patients identified as having either acute bronchitis or URI indicated a significant overlap for such signs as cough, chest pain, shortness of breath, runny nose, sore throat, and wheezing. When considering all factors, cough and wheezing were the strongest independent predictors of acute bronchitis. Hueston et al conclude that the respiratory infection entities might be more simply reconceptualized under a single diagnostic umbrella as acute viral respiratory infections, rather than trying to distinguish anatomically distinct disorders.
Hueston WJ, et al. J Fam Pract 2000; 49:401-406.
White-Coat Normotension
White coat hypertension is a well-recognized phenomenon consisting of abnormal blood pressure (BP) measurements in the office setting, in the face of normal measurements by ambulatory or home monitoring. Conventional wisdom ascribes such medical setting-associated BP increases to anxiety induced in the office setting. Whether there exists a cohort of individuals whose BP elevations might be pathologic on ambulatory monitoring, yet normal in the office setting (i.e., white-coat normotension), has not been examined.
To this end, Selenta and colleagues measured (by ambulatory monitoring) the BP of 319 individuals and compared this with office BP measurements in the same persons. All subjects were ostensibly in good health, not known to have or have had any BP problems, and were excluded if they were taking any medications known to have cardiovascular impact.
Using a definition of hypertension on ambulatory monitoring as greater than 135/85, 23% of the subjects manifest systolic hypertension, and 24% diastolic hypertension that was not captured by office BP measurement (5 office BP measurements were taken for comparison).
Office BP measurement may not be sufficient to address all those at risk of consequences of hypertension. As yet, there is no easily accessible application of ambulatory monitoring in office settings with sufficient economic feasibility that we can routinely use such monitoring to reduce white-coat hypertension and white-coat normotension.
Selenta C, et al. Arch Fam Med 2000; 9:533-540.
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