Clinical Briefs-By Louis Kuritzky, MD
September 15, 2000 4 minutes read
Clinical Briefs-By Louis Kuritzky, MD
Is There a Persian Gulf War Syndrome?
A diversity of symptoms, including myalgia, fatigue, cognitive difficulty, and mood dysfunction, have been reported among persons returning from Gulf War deployment. There has been some suggestion that a Gulf War syndrome, representing a new disorder, accounts for some of these symptoms, but much controversy exists about the veracity of such a syndrome. Doebbeling and colleagues use a statistical technique called factor analysis on a large population (n = 29,010) of Iowa National Guard or Reserve soldiers, comparing data on those deployed to the Persian Gulf, with those not so deployed.
A survey research group used computer-assisted telephone surveys to assess almost 80 different symptoms and the severity of such symptoms. Ultimately, interviews included 3695 subjects, approximately half who had been deployed to the Persian Gulf. Demographic data indicated no substantial differences between the groups, including race, income, smoking, etc.
Half of the deployed veterans, vs. 14% of nondeployed controls, reported current health problems. Polyarthralgia, fatigue, joint stiffness, headaches, and memory problems were the symptoms reported differentially most frequently by deployed veterans. Factor analysis did not demonstrate the existence of a unique Gulf War syndrome. Additionally, the diversity of symptoms reported by deployed Gulf War personnel reduces the likelihood of a single disorder explanation. Though the inability to distinguish a distinct Gulf War syndrome may present frustration to those suffering a variety of symptom-complexes, it should provide reassurance that the likelihood of some new "mystery illness" is small.
Doebbeling BN, et al. Am J Med 2000; 108:695-704.
Treatment of Low Back Pain Exacerbations with Willow Bark Extract
Salicin, a prodrug for salicylate, appears to be the primary active ingredient of willow bark extract (WBE). It has been used to treat fever, rheumatologic symptoms, headache, and other pain. European data about optimum dosing are unclear, as doses ranging from less than 120 mg up to 240 mg of salicin per day have been suggested. Chrubasik and associates tried two different doses of WBE in acute exacerbations of chronic low back pain. Rescue analgesia was allowed with tramadol. The measured outcome was proportion of persons free of pain without rescue medication for at least five days at the final week of treatment. Secondary outcomes included number of persons requiring rescue medication, and score on a back pain index.
The study was placebo controlled. An analysis of 110 features analyzed during the trial indicated little in the way of clinically relevant demographic differences in the three groups (placebo, low-dose WBE, and high-dose WBE) at baseline. Areas in which there were detectable differences would tend to minimize the benefit of active drug (e.g., duration of persistent pain and higher back pain scores were more often found in recipients of active drug).
There was a statistically significant difference between groups for the primary outcome of pain-free status with no rescue tramadol: 6% in the placebo group, 21% in the low-dose group, and 39% in the high-dose group. In the group of patients with baseline neurological deficits, differences between placebo and WBE were intensified: one of 18 placebo recipients vs. 25 of 43 active WBE recipients had a favorable response.
The active agent was well tolerated with few side effects. Traditional agents used to treat low back pain are not without risk, adverse events, and substantial cost. Chrubasik et al suggest that WBE may be an effective alternative to such traditional therapies.
Chrubasik S, et al. Am J Med 2000; 109:9-14.
Intermediate Doses of Aspirin Can Suppress ACEI-Induced Cough
The most frequent, and arguably troublesome, side effect of angiotensin-converting enzyme inhibitors (ACEIs) is cough. Changing to another class of agents resolves cough promptly, but clinicians would enjoy a tool to reduce or resolve ACEI-induced cough, short of drug discontinuation.
Nonsteroidal anti-inflammatory drugs (NSAIDs) and thromboxane antagonists have been found to attenuate or resolve ACEI cough, but optimum dosing has been unclear. The current study evaluated aspirin (ASA) in doses of either 100 mg or 500 mg daily for nonsmoking persons suffering ACEI cough (n = 14). In order to ensure other primary disease processes were not responsible for cough, exclusion criteria included asthma, heart failure, or pre-existing NSAID treatment.
Cough was rated on a 4-point scale, from no cough to severe cough. Subjects underwent discontinuation of ACEI, upon which cough disappeared, and then rechallenge, which did again induce cough.
Low-dose ASA (100 mg) did not affect cough. Higher dose ASA (500 mg) reduced cough in all patients, resolving it in all but one. Beneficial effects occurred as quickly as 24 hours and persisted unabated through the two weeks of the trial. Though this study was brief, Tenenbaum and associates include commentary on six patients with successful cough-control enduring up to one year.
Tenenbaum A, et al. Am J Hypertens 2000;13:776-782.
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