Clinical Briefs
By Louis Kuritzky, MD
Severe Pulmonary Embolism Associated with Air Travel
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.
Lapostolle F, et al. N Engl J Med. 2001;345:779-783.
Effect of Levodopa in Combination with Physiotherapy on Functional Motor Recovery After Stroke
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.
Scheidtmann K, et al. Lancet. 2001; 358:787-790.
Antibiotic Treatment of Adults with Sore Throat by Community Primary Care Physicians: A National Survey
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.
Linder JA, Stafford RS. JAMA. 2001; 286:1181-1186.
Dr. Kuritzky, Clinical Assistant Professor, University of Florida, Gainesville, is Associate Editor of Internal Medicine Alert.
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