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.
Should Empiric Treatment be Given to women with UTI Sx but negative U/A?
Women with a history of urinary tract infection (UTI) quickly learn to identify recurrences. Not uncommonly, women present with typical UTI Sx, but normal dipstick urinalysis results may discourage antibiotic treatment. Whether on-treatment is appropriate in this clinical scenario is called into question by this study.
Adult women (59) with acute onset dysuria and frequency plus negative dipstick (normal leukocytes and negative nitrite) were randomly assigned in a placebo-controlled double-blind fashion to trimethoprim (TRI) or placebo for 7 days.
Median time to dysuria resolution was significantly shorter for TRI than placebo (3 days vs 5 days). Constitutional symptomatology was also significantly reduced by 4 days with active treatment.
Only 5 women with UTI symptoms had positive bacterial culture results, and these women were equally distributed between treatment and placebo groups (3 and 2, respectively).
United States clinicians may be somewhat unfamiliar with prescription of trimethoprim as monotherapy. Oral TMP-SMX (eg, Bactrim, Septra) has been removed from the market in England except for inpatient parenteral therapy based upon the UK experience that the commonplace utilization of sulfonamides for UTI is responsible for an unacceptable burden of Steven’s-Johnson syndrome and agranulocytosis.
The authors conclude that symptom-driven empiric treatment of UTI is with trimethoprim is appropriate even in the face of a normal dipstick result.
Richards D, et al. BMJ. 331:143.
Is Routine Fundoscopy Worth the Bother in Hypertension?
Common wisdom suggests that fundoscopy (FND) should be a routine examination among patients with hypertension. Although findings at FND may shape management choices in situations of hypertensive urgency or emergency, whether meaningful impact is achieved by FND in other settings is poorly defined. To that end, van den Born et al addressed data from 5 different trials (n ≥ 23,000) that provided information on retinal changes and blood pressure.
Because of the low prevalence of hypertensive retinopathy (HTN-R) in hypertension, the sensitivity of HTN-R was found to be only 3-21%. On the other hand, specificity (the percent of normal patients without HTN-R) was very high: 88-98%.
The predictive value of hemorrhages/exudates, AV nicking, and focal arteriolar narrowing as well as the association between HTN-R and LVH were each examined. Overall, the authors derive that there is limited value of fundoscopy in routine HTN management. Indeed, more than half of the time when hypertensive patients have retinal changes, it is not the HTN that is responsible for those changes.
van den Born BJ, et al. BMJ. 2005;331:73.
Autoantibody Signatures in Prostate Cancer
The value of routine psa screening continues to be debated. Despite convincing evidence that PSA-screened patients enjoy a reduced prostate cancer related mortality, no major trial has demonstrated that overall mortality is favorably effected by PSA screening. Hence, at this point, it is unknown whether the benefits outweigh the risks of PSA screening. Additionally, a not-insubstantial group of men with confirmed prostate cancerperhaps as many 15-20%do not have an elevated PSA at the time of diagnosis.
Cancer patients may produce plasma autoantibodies against tumor antigens. For instance, of persons proven to have prostate cancer, as many as 62% have plasma autoantibodies against alpha-methylacyl-coenzyme A racemase (AMCAR).
Use of a 22-phage-peptide panel in persons with confirmed prostate CA demonstrated 80-90% sensitivity to discriminate between patients with prostate cancer and controls. Interestingly, when prostate cancer subjects were analyzed for autoantibodies post-prostatectomy, many fewer positive tests were seen, suggesting that when the immunologic stimulus for autoantibody development is removed (ie, prostate cancer mass is excised), autoantibodies regress or disappear. Whether such a methodology will prove useful in large-scale screening remains to be determined.
Wang X, et al N Engl J Med. 2005;353:1224-1235.
Should Empiric Treatment be Given to women with UTI Sx but negative U/A?; Is Routine Fundoscopy Worth the Bother in Hypertension?; Autoantibody Signatures in Prostate CancerYou have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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