Clinical Briefs
February 15, 2018
Statins for COPD?
SOURCE: Zhang W, et al. Chest 2017;152:1159-1168.
Depending on what one reads, COPD is now the third or fourth leading cause of death in the United States. Unfortunately, even though numerous pharmacologic treatments are available to mollify symptoms, none of the currently available treatments can be classified as “disease-modifying.” That is, mortality and disease progression do not appear to be altered by pharmacologic treatment. Why someone thought that statins might be beneficial for patients with COPD escapes me, although certainly it is not surprising that the same commonplace toxin that leads to COPD (smoking) also commonly leads to concomitant cardiovascular consequences in COPD patients.
At any rate, Zhang et al performed a systematic review of clinical trials in COPD patients in which comparison groups of statins vs. placebo were reported (n = 1,471). They found statistically significant benefits for exercise capacity, lung function, and St. George’s Respiratory Questionnaire (a 51-item questionnaire specific to how pulmonary function affects the patient’s life). In contrast, the 2014 STATCOPE trial of simvastatin (n = 884) in COPD patients did not demonstrate improvements in outcomes. Putative benefits from statins in COPD are attributed to the “pleotropic actions” of statins, including decreases in C-reactive proteins and inflammation. Since the population that showed the most benefit in the Zhang et al study were those with pre-existing cardiovascular disease, hyperlipidemia, and elevated C-reactive proteins at baseline, it seems reasonable to ensure that such patients receive appropriate statin treatment so they might enjoy both the expected cardiovascular risk reduction as well as possible pulmonary quality of life improvements.
An Overlooked Disability Burden
SOURCE: Cunningham LL, Tucci DL. N Engl J Med 2017;377;25:2465-2475.
The burden of hearing loss in later life may surprise some. According to Cunningham and Tucci, half of persons 60-69 years of age and 80% of those ≥ 85 years of age suffer sufficiently severe hearing loss that affects daily communication. Age-related hearing loss (presbycusis) generally is bilateral and typified by high-frequency (> 2,000 Hz) sound deficits. Causes include death of cochlear sensory hair cells with aging (termed “sensory presbycusis”) and “metabolic presbycusis,” which is characterized by impaired function of the stria vascularis (vascular ligament to the cochlear duct).
In addition to straightforward causes of hearing loss (e.g., external canal occlusion with cerumen, noise-induced hearing loss, trauma, ototoxic meds), there are strong associations between cardiovascular risk factors (smoking, diabetes mellitus, obesity) and hearing loss, although the mechanisms by which these associations might be causative are not clear.
The sudden loss of hearing (defined as onset within ≤ 72 hours) is considered an otologic emergency, requiring prompt evaluation. Only a few patients with identified hearing loss take advantage of hearing aids (< 15%), perhaps daunted by issues like cost (> $1,000), potential stigma associated with wearing a hearing-assistive device, or comfort. Disconcertingly, in contrast to most developed nations, the U.S. government does not provide economic subsidies for hearing aids. In Denmark, which provides assistance, approximately half of affected persons use hearing aids.
Educating Patients About ‘Ugly Duckling Sign’
SOURCE: Ilyas M, et al. J Am Acad Dermatol 2017;77:1088-1095.
Patients or their partners detect most malignant melanomas first. Enhancing public awareness of malignant melanomas and enabling patients’ ability to promptly and accurately identify at-risk lesions is important.
The ABCDE rule (Asymmetry, Border irregularity, Color variegation, Diameter > 6 mm, and Evolution) has gained widespread utility among health professionals as well as the lay public since its introduction in 1985; however, there are limitations to the rule. Ilyas et al suggested that adding an additional tool to patient self-identification of lesions could be helpful: the Ugly Duckling Sign (UDS).
The UDS simply asks that the examiner identify whether a lesion in question is distinctly different from other skin lesions on his or her body. Ilyas et al performed a randomized, controlled trial to compare the accuracy of malignant melanoma identification in two groups of subjects: one educated in the ABCDE method and one in the UDS method. After brief instruction in only one method, participants (n = 101) were shown photographs of skin lesions.
Although both methods of identification proved to be highly accurate, the UDS demonstrated a statistically significant advantage over ABCDE. The authors encouraged more widespread sharing of the UDS as a method to help patients self-identify risky lesions.
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