Clinical Briefs in Primary Care
November 1, 2001 6 minutes read
Doxazosin Added to Single-Drug Therapy in Hypertensive Patients with Benign Prostatic Hypertrophy
Source: Martell N, Luque M. J Clin Hypertens. 2001;3:218-223.
In middle age and beyond, both hypertension and benign prostatic hyperplasia (BPH) become increasingly common. Treatment of normotensive BPH patients can usually be accomplished using alpha-blockers without problematic episodes of hypotension. For hypertensive BPH patients, there has been some concern that addition of doxazosin to the antihypertensive regimen might produce hypotension or other untoward effects. This study evaluated the effect of 2-4 mg QD doxazosin added to the regimen of patients who had a achieved a diastolic blood pressure < 95 on nonalpha blocker monotherapy.
Patients (n = 2363, Spanish men > age 40) were followed for 14 weeks, and evaluated by a quality-of-life scale, prostatism symptom scale, blood pressure measurement, and recording of adverse events.
Doxazosin treatment resulted in a mean blood pressure reduction of 10.7/6.1 over baseline treatment with an ACE inhibitor, calcium channel blocker, or diuretic. Favorable effects for prostatism scores were consistently seen. Symptoms of dizziness, vertigo, hypotension, or syncope were seen uncommonly (2.7%, 0.4%, 0.8%, 0.3%, respectively). Martell and Luque conclude that addition of an alpha-blocker to the treatment regimen of hypertensive BPH patients is generally effective and well tolerated.
One-Time Screening for Colorectal Cancer with Combined FOBT and Examination of the Distal Colon
Source: Lieberman DA, Weiss DG. N Engl J Med. 2001;345:555-560.
Fecal occult-blood testing (FOBT) and sigmoidoscopy (SIGM), alone or in combination, have been shown to reduce colorectal cancer (CCA) mortality. Some evidence suggests that the combination may be superior. The current trial reports results from a study of the combination of one-time FOBT and colonoscopy (COL) in asymptomatic subjects (n = 2885, all male), in comparison with one-time FOBT and SIGM. All subjects underwent only COL; SIG was "defined" as the experience gained during COL that evaluated the rectum and sigmoid colon, but not beyond.
Advanced neoplasia (an adenoma > 10 mm diameter, with at least 25% villous involvement, high-grade dysplasia, or actual carcinoma) was found in almost one-fourth of persons with positive FOBT. Alone, SIGM detected 70% of neoplasia cases, enhanced by adding FOBT to 76%.
Though these results are encouraging, it is disheartening to think that as many as one-fourth of advanced neoplasia may be missed by the FOBT+SIGM combination. Since the level of penetration clinically attained in SIGM may be substantially less than described in this study, the actual sensitivity of SIGM may be even less than suggested by this trial. Whether COL should become the screening tool of choice remains a matter of some debate.
Bone Mineral Density Response to Estrogen Replacement in Frail Elderly Women
Source: Villareal DT, et al. JAMA. 2001;286:815-820.
The role of estrogen and progesterone replacement (HRT) for osteoporosis (OSPS) prevention is well established. Most data have accrued from relatively younger women, (ie, < 75 years old). Whether HRT provides equally beneficial OSPS effects for more senior women has not been well documented, since most data in older women is from observational studies.
In this placebo-controlled trial, Villareal and associates randomized 67 women who were considered especially high risk because of their relative frailty, to combination therapy with conjugated estrogens (0.625 mg QD) plus medroxyprogesterone acetate (5 mg QD for 13 consecutive days every third month) for 9 months. Bone mineral density (BMD) was measured at the lumbar spine and femur. Bone turnover markers were also measured. More than 90% of the women were osteopenic or osteoporotic at baseline.
BMD at the lumbar spine, and femoral neck, were statistically significantly improved in women who received HRT (eg, at the femoral neck) BMD increased 2.5%, as compared with a decrease in BMD in the placebo group. Bone turnover markers were similarly favorably affected. These data encouragingly support the concept that age should not be a barrier for consideration of HRT in at-risk menopausal women.
Severe Pulmonary Embolism Associated with Air Travel
Source: Lapostolle F, et al. N Engl J Med. 2001;345:779-783.
The relative immobility associated with air travel has long been suspected as causative in some cases of pulmonary embolism (PE), but until the current report, definitive data did not exist to prove the relationship. To study the relatedness of air travel and PE, Lapostolle and colleagues reviewed data from 135 million passengers arriving at Paris’ Charles de Gaulle Airport from 1993-2000. In this population, 56 cases of PE were confirmed; case confirmation required appropriate clinical symptomatology coupled with a positive ventilation-perfusion scan, pulmonary angiogram, or high-resolution helical CT angiography. PE clinical syndromes were included in the study analysis only if they occurred within 1 hour of landing at the airport.
There was a direct and linear relationship between the frequency of PE and the distance traveled. The incidence of PE in passengers traveling less than 3100 miles was more than 100-fold less common than that among passengers traveling more than 3100 miles. For persons traveling more than 6200 miles, the incidence of PE was 3-fold greater still than those traveling more than 3100 miles.
PE after long air travel remains extremely uncommon. Lapostolle et al have demonstrated that, as intuition would anticipate, longer travel increases PE risk. Though not studied in this population, they suggest that simple measures such as adequate hydration, position change, or support stockings might reduce risk for PE.
Effect of Levodopa in Combination with Physiotherapy on Functional Motor Recovery After Stroke
Source: Scheidtmann K, et al. Lancet. 2001;358:787-790.
In addition to the ominous impact of stroke mortality in our nation (no. 3 cause of death), many at-risk individuals view the specter of poststroke impairment as worse than death. Animal studies have demonstrated that use of amphetamines in poststroke models is additive to physiotherapy in benefit for motor rehabilitation. The mechanism by which amphetamines enhance motor recovery is uncertain, the norepinephrine (NE) is the proposed candidate mediator.
Because of the cardiovascular toxicity of NE, it is unfeasible to administer NE poststroke. Another way to augment central nervous system NE is to administer levodopa, which is converted in the brain and metabolized in sparing amounts (about 5%) to NE. Scheidtmann and colleagues studied the effect of levodopa 100 mg/d as a single dose for 3 weeks vs. placebo in 53 ischemic stroke patients. All patients received traditional physiotherapy. Effects were measured by the Rivermead motor assessment (RMA) tool.
Administration of levodopa was associated with a statistically significant improvement in RMA over physiotherapy alone. At the second study observation point (3 weeks after active drug cessation), levodopa recipients still maintained an advantage over the placebo group. No patient experienced problematic side effects.
Levodopa appears to enhance the motor rehabilitation response to traditional physiotherapy.
Antibiotic Treatment of Adults with Sore Throat by Community Primary Care Physicians: A National Survey
Source: Linder JA, Stafford RS. JAMA. 2001;286:1181-1186.
Despite the fact that a diversity of suggested management plans for acute upper respiratory infections abounds, clinicians often use methods that reflect practice contrary to such guidance. Linder and Stafford propose that in cases of sore throat, the only bacteria that merits treatment is Group A beta-hemolytic streptococci (GABHS), for which first-line treatment recommendations generally include penicillin and erythromycin.
Linder and Stafford performed a retrospective analysis of 2244 adult primary care visits for sore throat over a 10-year period (1989-1999). Almost three-fourths of patients received antibiotic treatment, though it has been repeatedly demonstrated that the majority of adult pharyngitis cases are viral. Additionally, less than one-third of the antibiotic prescriptions were for penicillin or erythromycin.
Over the 10-year study period, use of nonrecommended antibiotics actually increased. On the other hand, in the most recent year surveyed, overall antibiotic prescribing was reduced by almost one-third, though there was no diminution of nonrecommended antibiotic use, most common of which was prescription of aminopenicillins. They have demonstrated that community-based primary care physicians commonly overprescribe antibiotics, and often choose agents which are not traditionally recommended as first-line.
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