Clinical Briefs
By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is a consultant for GlaxoSmithKline and is on the speaker's bureau of GlaxoSmithKline, 3M, Wyeth-Ayerst, Pfizer, Novartis, Bristol-Myers Squibb, AstraZeneca, Jones Pharma, and Boehringer Ingelheim.
Diagnosis of Pulmonary Embolism by Multidetector CT
Because the consequence of missed pulmonary embolism (PEM) is so grave, it is essential to continue our evolution of tools which maximize diagnostic sensitivity, offer clinical expedience, and minimize risk for the patient. Recently, the combination of clinical probability assessment (CPA) with d-dimer, venous compression ultrasound (v-US), and helical CT has enjoyed advocacy, but multislice CT (MSCT) provides even better vascular visualization down to the level of segmental and subsegmental vessels.
Righini, et al compared a strategy of d-dimer plus either MSCT alone or d-dimer plus MSCT and v-US in a study population (n = 1,819) all of whom had undergone clinical probability assessment because of suspicion of PEM.
The frequency of PEM confirmation was the same in both groups: 20.6%. During a 3-month follow-up of persons who had screened negative for PE, the incidence of documented episodes of thromboembolism was 0.3% in both groups.
These data suggest that the combination of d-dimer with MSCT is as effective as a diagnostic plan incorporating v-US to both confirm the diagnosis of PEM and effectively exclude those without it.
Eighini M, et al. Lancet. 2008;371:1343-1352.
The Impact of Medicare Part D on Medication Nonadherence Among Seniors
One of the goals of the Medicare Prescription Drug Improvement and Modernization Act of 2003 (MPD) was to provide more universal coverage for essential medications for senior citizens and the disabled. Because of the expense of medications and consistency of polypharmacy among seniors, medication behaviors such as dose-skipping, dose reduction, or frank medication omission occur all too often.
Prior to MPD as many as 38% of Medicare beneficiaries did not have a source of prescription coverage, but that number has now been reduced to about 10%. Did the MPD reduce cost-related medication nonadherence?
To determine the answer, a representative sample of Medicare enrollees (n = 15,700) responded to questions addressing cost-related nonadherence such as "did you skip doses/take smaller doses of medicine to make it last longer." Because behaviors such as skimping on food, heat, or other basic needs to afford medicine has also been commonly seen in the past, these behaviors were also addressed on questionnaires.
Since MPD, spending less on basic needs decreased from 10.6% to 7.6%. There was also a 15% reduction in cost-related nonadherence overall. Unfortunately, the least healthy individuals (rated as fair to poor health) did not demonstrate the same reductions.
MPD has benefitted Medicare beneficiaries overall. The sickest beneficiaries still experience unabated cost-related nonadherence behaviors.
Madden JM, et al. JAMA. 2008;299(16):1922-1928.
Liberty, Justice, and Hypertension Treatment for ALL
The benefits of treatment of hypertension (HTN) include meaningful reductions in stroke, MI, CHF, and overall mortality. Typically, HTN treatment trials enroll adults from middle-aged and early geriatric groups, without a large representation of advanced seniors (> age 80). The gap in knowledge about advanced seniors has been closed by HYVET (Hypertension in the Very Elderly Trial).
A large population (n=3,845) of advanced senior subjects (mean age =83.6) was randomized to indapamide or placebo for 2 years. If BP was not controlled on indapamide monotherapy, perindopril was added (BP target = 150/80). The primary endpoint of the trial was fatal or nonfatal stroke.
Indapamide treatment reduced the primary endpoint by 30%. Additionally, treatment provided a 21% reduction in all-cause mortality and 64% reduction in heart failure (all statistically significant). Differences between placebo and active treatment became visible within as little as 12 months time. Remarkably, the frequency of serious adverse events was lower in the active treatment group than the placebo group. Even change in potassium, a well recognized adverse effect of thiazide diuretics, was not significantly more common in the indapamide treatment group than in the placebo group.
These data support that concept that advanced age should not be a limiting factor in the decision to treat hypertension
Beckett NS, et al. N Engl J Med. 2008;358:1887-1898.
Because the consequence of missed pulmonary embolism (PEM) is so grave, it is essential to continue our evolution of tools which maximize diagnostic sensitivity, offer clinical expedience, and minimize risk for the patient.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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