Clinical Briefs



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Am Fam Physician. 1998 Nov 1;58(7):1688-1691.

Update on Maternal Mortality

Since 1982, no progress has been made in reducing the rate at which American women die of pregnancy and childbirth complications, according to a report in the September 4, 1998, issue of Morbidity and Mortality Weekly Report. Having declined substantially in the previous 40 years, the annual maternal mortality rate fluctuated between seven and eight maternal deaths per 100,000 live births from 1982 to 1996. Trends by race were similar to trends in the overall mortality ratio, and no rate decreases were observed in either black or white women. Ratios were between 18 and 22 per 100,000 live births for black women and between five and six per 100,000 live births for white women. The proposed Healthy People 2000 goal for maternal mortality remains 3.3 maternal deaths per 100,000 live births.

The report notes that about one half of these maternal deaths are preventable. Interventions to reduce rates of maternal mortality include providing all women with access to family planning services, because unintended pregnancies are associated with higher risks for both mother and infant. Women should also know how to prevent sexually transmitted diseases, and women with sexually transmitted diseases need effective and early treatment. All women need access to culturally appropriate and quality prenatal, delivery and postpartum care. In 1996, approximately 10 percent of all pregnant women had little or no prenatal care.

Drug for Heparin-Induced Thrombocytopenia

The first product in the United States to treat patients with thromboembolic complications associated with heparin-induced thrombocytopenia and associated thromboembolic disease has been approved by the U.S. Food and Drug Administration. Lepirudin rDNA for injection (Refludan) is a recombinant hirudin belonging to a class of anticoagulants known as direct thrombin inhibitors. Lepirudin has a different chemical structure than heparin so there is no risk of cross-reaction between the two agents.

Lepirudin is administered by injection or infusion. Bleeding from puncture sites and wounds has been the most common side effect. Concomitant use with thrombolytics can result in intracranial bleeding. Other adverse events include anemia, hematoma, hematuria, fever and abnormal liver function.

Efficacy of Treatment for Substance Abuse

The Substance Abuse and Mental Health Services Administration has released study results indicating that both substance use and criminal behavior are reduced for at least five years following inpatient, outpatient and residential substance abuse treatment. The study included interviews with 1,799 persons who underwent substance abuse treatment at 99 treatment facilities. Five years after treatment, there was a 21 percent reduction in the use of any illicit drug; a 14 percent decrease in alcohol use; a 28 percent decrease in marijuana use; a 45 percent decrease in cocaine use; a 17 percent reduction in crack use; and a 14 percent decrease in heroin use. Criminal activity declined by at least 23 percent and as much as 38 percent following treatment.

Results of the Services Research Outcomes Study are available on the Internet at http://www.samhsa.gov or http://www.health.org or by calling the National Clearinghouse for Alcohol and Drug Information at 800-729-6686. The publication is free of charge.

New Indication for Pravastatin

A new indication for pravastatin sodium (Pravachol) has been approved by the U.S. Food and Drug Administration. Pravastatin is now approved for use in reducing the risk of stroke or transient ischemic attacks (TIAs) in patients who have had a previous myocardial infarction and have normal cholesterol levels. In 1996, pravastatin was approved for use in reducing the risk of a first myocardial infarction in patients with elevated cholesterol levels and no history or symptoms of coronary artery disease.

In the Cholesterol and Recurrent Events trial, the risk of stroke or TIAs was reduced by 26 percent in the patients receiving pravastatin, and the risk of recurrent myocardial infarction and death from coronary disease was reduced by 24 percent. The subjects in this study had an average total cholesterol level of 209 mg per dL (5.40 mmol per L).

Pravastatin is well tolerated in most patients. The most common adverse effects include mild skin irritation and transient rash, and gastrointestinal upset. It should not be used in persons with active liver disease or liver problems, in women who are pregnant or nursing, or in persons who are allergic to any component of the drug. Muscle pain or weakness could be a sign of a serious side effect.

Creatine Supplementation

The American College of Sports Medicine (ACSM) has issued a position statement on the use of creatine supplementation. According to the statement, research indicates that creatine enhances the ability to maintain power output during short-term maximal bouts of exercise, including cycling, sprinting, jumping and weightlifting protocols. Another finding often reported in studies on the short-term use of creatine is an increase in body mass. Limited data exist on the long-term benefits and risks of creatine supplementation. Creatine supplementation (5 g per day) during 10 to 12 weeks of resistance training enhances maximal strength, body mass and fat-free mass.

Nearly all research examining creatine supplementation has been obtained in the laboratory. There are few field studies documenting beneficial effects of creatine supplementation during specific sports and competitions. ACSM notes that the verdict is still out on the safety of creatine supplementation, especially when used over long periods. More research is needed to thoroughly evaluate any potential value and risks associated with creatine supplementation, especially in light of the increasing use of nutritional supplements by athletes of all ages.

Lowering Cholesterol in Persons with Coronary Disease

The National Cholesterol Education Program has published a booklet to help persons with coronary artery disease lower their cholesterol levels. “Live Healthier, Live Longer—Lowering Cholesterol for the Person with Heart Disease” discusses coronary artery disease, the role of cholesterol in coronary artery disease, how to obtain a cholesterol level, cholesterol-lowering medications, medications prescribed for coronary artery disease and the importance of diet and exercise. Person with coronary artery disease should aim for a low-density lipoprotein level of 100 mg per dL (2.6 mmol per L) or less. The booklet can be ordered for $3 plus shipping charges from the National Heart, Lung, and Blood Institute Information Center, P.O. Box 30105, Bethesda, MD 20824-0105; telephone: 301-251-1222; fax: 301-251-1223.

The complete statement can be obtained by writing ACSM, P.O. Box 1440, Indianapolis, IN 46206 or calling 317-637-9200.

Combined Triple Therapy for H. pylori Infection

The U.S. Food and Drug Administration (FDA) has approved a 10-day, triple therapy regimen combining the antisecretory medication omeprazole (Prilosec) for use with the antibiotics clarithromycin (Biaxin) and amoxicillin to treat Helicobacter pylori infection in patients with duodenal ulcer disease. This triple combination regimen is the only 10-day treatment option in the eradication of H. pylori that has been approved by the FDA.

The recommended dosage for eradication of H. pylori infection associated with active and inactive duodenal ulcers is 20 mg of omeprazole, 500 mg of clarithromycin and 1,000 mg of amoxicillin, each given twice a day for 10 days. The combination regimen is generally well tolerated. The most common side effects include diarrhea, taste perversion and headache. For patients with active duodenal ulcers, an additional course of therapy with omeprazole, 20 mg once daily for 18 days, is recommended following the initial treatment.


Copyright © 1998 by the American Academy of Family Physicians.
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