Clinical Briefs



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Am Fam Physician. 1999 Sep 15;60(4):1248-1254.

Brief Intervention for Alcohol Problems

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) has published a research update on brief intervention for alcohol problems (Alcohol Alert No. 43). The report notes that a brief intervention can reduce patients' risk for alcohol problems and is more effective than no intervention at all. Brief intervention is generally most effective for those with less severe alcohol problems. It consists of four or fewer sessions, each session lasting up to an hour, and is designed to be used by health care professionals who are not specialists in addictions treatment.

“The finding that brief intervention can be an effective means of intervening in alcohol problems adds an important tool to the clinician's repertoire of treatment options,” states NIAAA director Enoch Gordis, M.D.

Six elements have been identified as key ingredients in a brief intervention. These are feedback, responsibility, advice, menu of strategies, empathy and self-efficacy (summarized by the acronym FRAMES). Goal-setting, follow-up and timing also have been identified as factors that are important for the effectiveness of brief intervention. The drinking goal is usually negotiated between the patient and the physician and may be in the form of a prescription from the physician or as a contract signed by the patient.

The full report can be found on the NIAAA Web site (http://www.niaaa.nih.gov). Copies may also be obtained from NIAAA Publications Distribution Center, attn.: Alcohol Alert, P.O. Box 10686, Rockville, MD 20849-0686.

Update on Hantavirus Pulmonary Syndrome

An update on the status of hantavirus pulmonary syndrome in the United States appears in the June 25, 1999, issue of Morbidity and Mortality Weekly Report. Hantavirus, a rodent-borne viral disease, has a case-fatality ratio of 43 percent. The report emphasizes that the number of cases of hantavirus pulmonary syndrome has increased in 1999 and discusses the importance of physician awareness and early detection in the treatment of patients with the infection.

As of May 1999, the Centers for Disease Control and Prevention (CDC) had confirmed 217 cases of hantavirus pulmonary syndrome in 30 states, with the largest concentration of cases occurring in New Mexico, Arizona and California. The illness most often begins with a prodrome of headache, fever and myalgia that is followed by pulmonary edema, which often leads to severe respiratory compromise.

The CDC report discusses the need for renewed awareness to reduce the risk for hantavirus exposure. Illness can occur after inhaling infectious aerosols from rodent saliva or excreta. Risk for the disease is greatest in areas where people are more likely to come in contact with the infectious rodents. The CDC recommends increased efforts to educate the public, especially residents of rural areas in the southwestern United States. The report divides the measures to prevent hanta-virus into four areas: eliminating rodent harborage, controlling rodent populations, properly cleaning up rodent infestation and avoiding rodents in outdoor settings.

Additional information on hanta-virus syndrome is available by calling the hantavirus hotline at 877-232-3322. Information is also available on the CDC Web site (http://www.cdc.gov/ncidod/diseases/hanta/hps/index.htm) and can be obtained by mail at CDC's Special Pathogens Branch, Division of Viral and Rickettsial Diseases, National Center for Infectious Diseases, Mailstop A-26, 1600 Clifton Rd., N.E., Atlanta, GA 30333.

Substance Abuse Services Guide for Clinicians

The Bureau of Primary Health Care (BPHC) of the Health Resources and Services Administration and the Center for Substance Abuse Treatment of the Substance Abuse and Mental Health Services Administration are offering a desk reference to help health care professionals conduct brief intervention for patients in the early stages of substance abuse and to make referrals for patients with severe addictive disorders. The “Guide to Substance Abuse Services for Primary Care Clinicians” summarizes a larger treatment improvement protocol (TIP) recently developed by a panel of substance abuse clinicians, researchers and educators. The TIP gives primary care clinicans specific guidance to recognize indications of substance abuse, select screening and assessment instruments and discuss the subject with a patient, and show how to perform a brief intervention. A Spanish version of the guide is also available. The TIP and guide can be obtained by calling the BPHC Clearinghouse at 800-400-2742. The TIP is also found on the National Library of Medicine's Web site (http://text.nlm.nih.gov).

Second COX-2 Inhibitor

The U.S. Food and Drug Administration (FDA) has approved rofecoxib (Vioxx) for the treatment of patients with osteoarthritis or menstrual pain, and for the management of acute pain in adults. Rofecoxib is a nonsteroidal anti-inflammatory drug that exhibits anti-inflammatory, analgesic and antipyretic activities and is the second drug to be approved in the class referred to as COX-2 inhibitors (cyclooxygenase-2 inhibitors). COX-2 inhibitors do not inhibit cyclooxygenase-1 (COX-1), an enzyme that protects the normal lining of the stomach.

In clinical trials of about 3,600 persons, rofecoxib was compared with ibuprofen (2,400 mg daily) and with placebo to determine the incidence of stomach and upper intestinal ulcerations following the use of these products. Treatment with 25 to 50 mg of rofecoxib daily was associated with a significantly lower percentage of gastroduodenal ulcers than treatment with ibuprofen. There were a few cases of serious gastrointestinal bleeding and one case of obstruction in the patients who received rofecoxib. The FDA recommends that patients who receive rofecoxib be told to report symptoms of gastrointestinal ulceration or bleeding, skin rash, unexplained weight gain or swelling to their physicians.

Guidelines for Treatment of Obstructive Sleep Apnea

New guidelines for the treatment of patients with obstructive sleep apnea have been released by the American College of Chest Physicians. The guidelines, published in the March 1999 issue of Chest, were written by a panel of experts who based their recommendations on peer-reviewed studies and widely accepted clinical practice. Treatment modalities for obstructive sleep apnea with positive airway pressure include continuous positive airway pressure, bilevel or variable positive airway pressure and autotitrating positive airway pressure.

The guidelines cover the following topics: which patients should undergo standard diagnostic techniques (polysomnography, the continuous recording of a number of physiologic functions and events during sleep), what criteria should be met to appropriately define apnea and hypoxia, what conditions warrant use of which type of positive airway pressure therapy, and what efforts should be undertaken to help patients comply with therapy.

According to the panel, the recommendations are meant as an interim guideline until results from research such as the Sleep Heart Health Study and other evidence outcome studies can provide data for more formal consensus recommendations.

Report on Genetic Testing for Susceptibility to Breast Cancer

The Health Technology Advisory Committee (HTAC) has published a report on genetic testing for susceptibility to breast cancer. HTAC was established in 1992 by the Minnesota state legislature. It is an independent, non-partisan advisory body that evaluates new and emerging health care technologies based on existing scientific research and technology assessments.

The report provides information on the available tests for breast cancer susceptibility, who is tested, the effectiveness of tests, sensitivity and specificity, and genetic testing and patient outcome. The background and risk factors of breast cancer, cost-effectiveness of genetic testing and unresolved issues in genetic testing are also discussed. An appendix lists recommendations from professional organizations.

HTAC recommends that clinicians make information available to their patients on the benefits and limitations of genetic testing, emphasizing that genetic testing is not a replacement for medical checkups and breast self-examinations no matter what the test results may be. Women should also be advised to check to see if their health plans cover genetic testing. The following three-tier process is recommended by HTAC for genetic testing for susceptibility to breast cancer:

  • Women considering genetic testing should receive evaluation and guidance from a genetic counselor or a physician with formal training in cancer genetics prior to being tested.

  • Genetic testing should be done only after a genetic counselor or a physician with formal training in cancer genetics determines that testing is indicated based on a strong family history of breast cancer.

  • Women who choose to be tested should receive follow-up counseling with a genetic counselor or a physician with formal training in cancer genetics.

This report (document no. 980601) and other reports published by HTAC may be obtained by request (telephone: 651-282-6374; e-mail: htac@health.state.mn.us). There is no charge for the reports. All HTAC reports are also available through the World Wide Web (http://www.health.state.mn.us/htac/index.htm).

Launch of Web Site to Help Women Remember to Schedule Papanicolaou Smears

The College of American Pathologists (CAP) has launched a free Internet service designed to help women remember to schedule their annual Papanicolaou (Pap) smear. Women can access the Web site (http://www.papsmear.org), select a day to be reminded, and, on the day selected, an e-mail will be sent reminding the woman to call her physician to schedule an appointment.

“Many women are so busy with their careers and families, they don't take time for their own health—including receiving a Pap smear each year. This Web site takes only seconds to set up the reminder, but those seconds could save a woman's life,” says Mary E. Kass, M.D., chair of CAP's Council on Public Affairs. “It's our goal to register at least 4,000 women this year so that they will remember and schedule this important annual screening.”

CAP has also developed free fliers and statement stuffers that physicians can provide to their patients to tell them about the site. The fliers and statement stuffers can be obtained by contacting CAP at 800-323-4040, ext. 7538.

Nonoccupational HIV Postexposure Prophylaxis Registry

The National Nonoccupational HIV Postexposure Prophylaxis (PEP) Registry has been established to monitor isolated episodes of potential exposure to human immunodeficiency virus (HIV) through sexual activity, injecting-drug use and other nonoccupational events. Information is collected about the type of exposure, the decision to use or not use PEP, drugs taken, risk-reduction referrals made and results of HIV-antibody tests. No names or other identifying information will be collected. More information about the registry is available by calling the toll-free number (877-448-1737). Information can also be found on the registry's Web site (http://www.HIVpepregistry.org).

FDA Warning About Diabetes Medication

Troglitazone (Rezulin), a medication used to treat patients with type 2 diabetes mellitus (formerly known as non–insulin-dependent diabetes mellitus), should only be used in patients whose disease is not adequately controlled by other therapies, and it should never be used as initial single-agent therapy, according to new labeling and use changes established by the U.S. Food and Drug Administration (FDA). These labeling changes also include recommendations for more extensive monitoring of liver function in patients using troglitazone. New safety data have shown that serious and sometimes fatal liver injury can occur in patients receiving troglitazone. The labeling will also include a patient education sheet with information about the safe and effective use of this drug.

Any adverse reactions associated with the use of troglitazone should be reported to the FDA through MedWatch. Reports can be made by telephone (800-332-1088), by fax (800-332-0178) or by mail to Med-Watch, HF-2, FDA, 5600 Fishers Lane, Rockville, MD 20857. Reports can also be filed on the Web site of the FDA (http://www.fda.gov/medwatch).



Copyright © 1999 by the American Academy of Family Physicians.
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