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Tips from Other Journals
Thromboxane Antagonist for ACE InhibitorInduced Cough
Persistent cough can be a troublesome side effect of angiotensin converting enzyme (ACE) inhibitors and may lead to discontinuation of therapy. Although the etiology of ACE inhibitorinduced cough remains unknown, accumulation of bradykinin in the bronchial tissues is believed to be an essential feature. Malini and colleagues evaluated the use of the thromboxane synthesis inhibitor picotamide in the management of ACE inhibitorinduced cough.
Nine Italian patients who developed cough during treatment with enalapril for essential hypertension were included in the study. Following a full assessment to establish cardiac status and exclude pulmonary disease, the four men and five women stopped taking all medications for two weeks. They then began therapy with enalapril, 20 mg daily, until cough developed. While continuing enalapril, the patients were randomly assigned to receive either picotamide, 600 mg twice daily, or an identical placebo for two weeks. The patients receiving picotamide were then switched to placebo for two more weeks, and the patients receiving placebo were switched to picotamide for two weeks. Patients kept a daily "cough diary" during the four weeks of treatment and completed assessments of cough and six other symptoms at their weekly clinic visits. Pill counts and measures of urinary excretion of drug metabolites were used to assess compliance.
Cough recurred within nine to 31 days after enalapril was restarted. When picotamide was given, cough was suppressed within 72 hours of initiation of the medication and was effectively controlled in all but one patient. In this patient, the patient's history and pill counts suggested compliance but urine sampling was consistent with nonabsorption of the medication. Patients who switched from picotamide to placebo reported the recurrence of cough within 48 to 72 hours of discontinuing picotamide.
The authors conclude that picotamide effectively prevented ACE inhibitorinduced cough in this small group of patients. Since agents such as sulindac and indomethacin also may partially suppress this cough response, they speculate that the etiology depends on tissue thromboxane levels. Picotamide may be more effective because it has the dual action of decreasing the production of thromboxane and antagonizing thromboxane receptors.
ANNE D. WALLING, M.D.
Malini PL, et al. Thromboxane antagonism and cough induced by angiotensin-converting-enzyme inhibitor. Lancet 1997;350:15-8.
Significance of Serum Amylase Levels After Pancreatic Injury
Although serum amylase levels are used in the diagnosis of traumatic injury of the pancreas, recent studies have questioned the value of this determination in cases of acute injury. Factors such as the type of pancreatic injury and the interval between the time of the injury and amylase determination might have an influence on serum amylase levels. Takishima and associates evaluated the significance and limitations of serum amylase levels in the diagnosis of blunt pancreatic injury in 73 patients with pancreatic injuries caused by penetrating abdominal trauma.
The patients ranged in age from three to 68 years. Associated intra-abdominal injuries were present in 47 of the 73 patients (64.4 percent). The type of pancreatic injury was identified by computed tomography, endoscopic retrograde pancreatography or gross findings at laparotomy. Type I injury (contusion) was found in 35 cases (47.9 percent); type II injury (laceration) was present in 10 cases (13.7 percent) and type III injury (ductal injury) was documented in 28 cases (38.4 percent). Serum amylase levels were determined on admission in all of the patients.
Relationship Between Serum Amylase Levels and Time of Determination After Blunt Pancreatic Injury Time elapsed from injury until admission (hours) Number of patients Patients without elevated serum amylase (%) Patients with elevated serum amylase (%)
< or=1.0
1.0 to 2.0
2.0 to 3.0
3.0 to 4.0
4.0 to 5.0
5.0 to 6.0
>6.0
Total14
23
13
3
1
2
17
735 (35.1)
5 (21.7)
2 (15.4)
0
0
0
0
12 (16.4)9 (64.3)
18 (78.3)
11 (84.6)
3 (100)
1 (100)
2 (100)
17 (100)
61 (83.6)
Reprinted with permission from Takishima T, Sugimoto K, Hirata M, Asari Y, Ohwada T, Kakita A. Serum amylase level on admission in the diagnosis of blunt injury to the pancreas: its significance and limitations. Ann Surg 1997; 226:70-6.The serum amylase level was already elevated at the time of admission in 61 of the 73 patients (83.6 percent). Of the 50 patients admitted within three hours after trauma, 38 patients (76 percent) had elevated serum amylase levels at the time of admission. All of the 23 patients admitted more than three hours after trauma had elevated serum amylase levels. The serum amylase level in patients with type III injury was approximately twice that in patients with type I or type II injury. Patients with type I or type III injury who were admitted more than three hours after they sustained trauma had significantly higher serum amylase levels than those admitted within three hours of sustaining trauma.
Regulation of the serum amylase level is multifactorial, and elevated levels can develop in association with decreased renal clearance (e.g., chronic renal failure, macroamylasemia), perforation of the abdominal hollow viscus and pancreatitis. In this study, the interval between injury and serum amylase determination appeared to be the most important factor influencing serum amylase levels in patients with blunt injury to the pancreas. The longest time during which the serum amylase level remains in the normal range might be a three-hour period following trauma (see the accompanying table).
The authors conclude that a normal serum amylase level taken within three hours after blunt abdominal trauma does not eliminate the possibility of pancreatic injury. However, a serum amylase determination more than three hours after trauma may be useful in detecting pancreatic injury.
RICHARD SADOVSKY, M.D.
Takishima T, et al. Serum amylase level on admission in the diagnosis of blunt injury to the pancreas: its significance and limitations. Ann Surg 1997;226:70-6.
Adenoidectomy and Relief of Sinusitis in Children
Chronic sinusitis in children is characterized by persistent nasal congestion, rhinorrhea, cough, headache and mouth breathing. These symptoms may not abate despite repeated and, often, extended courses of oral antibiotics. Moreover, the diagnosis of chronic sinusitis is often clinical, and the role of adjunctive therapies such as antihistamines and decongestants has not been firmly established. The symptom complex attributed to chronic sinusitis overlaps considerably with that of adenoidal hypertrophy. The adenoids are believed to cause mechanical obstruction and stasis of nasal secretions, and may serve as a bacterial reservoir as well. Vandenberg and Heatley evaluated the efficacy of adenoidectomy in relieving symptoms of chronic sinusitis in children.
The authors retrospectively reviewed the medical records of 48 children who underwent adenoidectomy for symptoms of chronic sinusitis. The patients ranged in age from one to 12 years (median age: 4.4 years). All of the children received extensive antibiotic therapy before surgical referral. Children with a history of cystic fibrosis or those who underwent concurrent endoscopic sinus surgery were excluded from the study.
Preoperative clinical notes were reviewed for the presence of comorbid conditions, including asthma, allergy, otitis media and obstructive sleep apnea. Symptoms of chronic sinusitis, such as rhinorrhea, cough, nasal congestion, headache, halitosis and irritability were also recorded. A telephone interview with each child's caregiver was conducted five to 24 months after surgery to assess long-term symptom control and overall improvement. Four patients were not available for follow-up and did not complete the study.
The patients were divided into three groups: those with complete or nearly complete resolution of symptoms, those with some improvement and those with minimal or no improvement. Complete or nearly complete resolution of symptoms was reported in 25 of 43 children (58 percent). Of the remaining 18 children, some improvement was noted in nine (21 percent), and another nine had no improvement. The average number of symptoms experienced by each patient decreased from 5.3 to 2.9. Also, 29 of 39 patients (74 percent) with a history of frequent antibiotic therapy were able to reduce or completely eliminate the use of antibiotics after surgery. Only three patients subsequently required endoscopic sinus surgery.
The authors conclude that adenoidectomy is an effective treatment in the majority of children with symptoms of chronic sinusitis. A reduction in the use of antibiotics and improvement in quality of life may also be considered benefits.
JEFFREY T. KIRCHNER, D.O.
Vandenberg SJ, Heatley DG. Efficacy of adenoidectomy in relieving symptoms of chronic sinusitis in children. Arch Otolaryngol Head Neck Surg 1997;123:675-8.
Benzodiazepines, Automobile Accidents and the Elderly
Benzodiazepines are among the most frequently prescribed classes of medications in elderly patients, primarily for treatment of anxiety and insomnia. The many adverse side effects of benzodiazepines, including drowsiness, sedation, confusion and impaired motor function, may have a serious effect on a patient's ability to operate a motor vehicle. Hemmelgarn and colleagues reviewed the association between the type of benzodiazepine used (long- or short-acting) and the risk of injury in a motor vehicle accident.
Individuals were included in the study if they had been driving when an accident occurred that injured at least one person. All study subjects lived in Quebec and were between the ages of 67 and 84 years. Prescription use of a benzodiazepine was confirmed by a review of Quebec province health care service records. Benzodiazepines were classified as having a long half-life (clonazepam, diazepam, clorazepate, chlordiazepoxide, flurazepam or nitrazepam) or a short half-life (alprazolam, bromazepam, lorazepam, oxazepam, temazepam or triazolam). Study subjects were selected from a cohort of those who met the criteria, and 10 control subjects were randomly selected for each study subject. A total of 5,579 study subjects and 18,490 control subjects were selected for the study.
Regardless of the duration of use, individuals who were currently taking long-acting benzodiazepines had an increased risk of involvement in a motor vehicle accident with injury. However, for those who had just begun taking long-acting benzodiazepines within the last seven days, the risk was even higher (risk ratio: 1.45). The risk dropped to nonsignificant levels if the individual had been taking the drug between eight and 30 days. The risk significantly increased again in study subjects who had used a benzodiazepine for more than 61 days. Those taking short-acting benzodiazepines had no similar risk of involvement in motor vehicle accidents with injury.
The authors conclude that use of long-acting benzodiazepines, particularly within seven days of initiation of treatment, is associated with a significantly high risk of involvement in a motor vehicle accident with injury. Tolerance to the psychomotor effects of long-acting benzodiazepine use does not seem to develop, as had previously been proposed.
GRACE BROOKE HUFFMAN, M.D.
Hemmelgarn B, et al. Benzodiazepine use and the risk of motor vehicle crash in the elderly. JAMA 1997;278:27-31.
Guidelines for Low Back Pain and Utilization of Radiographs
The Agency for Health Care Policy and Research (AHCPR) guidelines for the management of acute low back pain recommend obtaining radiographs in the evaluation of certain patients. Specifically, the recommendations for use of radiographs relate to the presence of potential "red flags" for spinal fracture, cancer or infection. Red flags for spinal fracture include a history of major trauma, minor trauma or strenuous lifting in an older patient or in a patient with possible osteoporosis, prolonged steroid use, the presence of osteoporosis and age greater than 70 years. Red flags for tumor or infection include a history of cancer, age under 20 or over 50 years, constitutional symptoms and back pain that is worse in the supine position or severe at night. Suarez-Almazor and colleagues performed a retrospective study to examine the potential impact of the recommendations for radiographs among patients with back pain who visit family physicians.
Four family practice clinics in Edmonton, Alberta, participated in the study. Adult patients were included if they presented with a complaint of low back pain and had had no similar complaint in the past year. Patients were excluded if the complaint was ascribed to a visceral condition or if the patient was pregnant or had ankylosing spondylitis. Medical records were reviewed to determine whether lumbar radiographs were obtained and to determine what, if any, red flags were present. Follow-up for at least two years established whether vertebral fracture, tumor or infection was subsequently diagnosed.
A total of 963 patients met AHCPR guideline criteria for acute low back pain. Lumbar radiographs were obtained at the first visit in 127 patients (13.2 percent). The radiographs revealed degenerative changes in 64 of the 127 patients (50.4 percent), and findings were normal in 44 of these patients (34.6 percent). Fracture was identified in four patients and possible metastatic disease was found in one patient.
AHCPR guidelines would have required 44 percent of the patients to have radiographs. At least one AHCPR criterion for radiographic examination was present in 346 patients who did not undergo radiographic examination, indicating underutilization according to the guidelines. Thirteen patients had active cancer during the follow-up period, but spinal infiltrates were found in only three of these patients.
The authors conclude that adherence to the AHCPR guidelines would cause overutilization of radiographs, with a concomitant increase in health care costs. Even if all of the patients with subsequent serious disease had been identified through the use of radiographs at the initial visit, it is not clear that the outcome of the disease would have changed. The authors state that adherence to the age criterion would have substantially increased utilization of radiographs and that the patient's age had a low specificity. They recommend that age not be used to screen patients in the absence of other red flags. Deferring radiographs for two to three weeks would probably not be harmful unless the likelihood of serious disease is high.
GRACE BROOKE HUFFMAN, M.D.
Suarez-Almazor ME, et al. Use of lumbar radiographs for the early diagnosis of low back pain: proposed guidelines would increase utilization. JAMA 1997;277:1782-6.
Efficacy of Self-Application
of Protective CreamsIrritant contact dermatitis of the hands, particularly in the finger webs and on the fingertips, is an occupational exposure for which some protective creams have been shown to be effective. However, before these creams can reduce the risk of contact dermatitis, they must be applied frequently and in sufficient amounts to all areas that need protection. Wigger-Alberti and associates prospectively studied the effectiveness of protective cream in reducing contact dermatitis.
A total of 150 volunteers were recruited from a metalworking factory, several construction sites and a university hospital housekeeping department. The study subjects' hands underwent constant exposure to irritating substances such as metalworking fluid, cement or painting colors. The protective cream used in the study was mixed with vitamin A acetate to obtain fluorescence under Wood's lamp so that the amount of coverage could be evaluated. Under normal light, the preparation was invisible. At least 51 of 56 areas of the hands had to be covered for the hands to be considered sufficiently protected. Volunteers also answered a questionnaire about their history and knowledge of the use of protective creams.
Results of the study showed that almost 100 percent of the volunteers had applied a sufficient amount of cream to the palms of the hands. However, considerable differences were apparent in the amounts applied to the dorsal aspects of the hands and wrists. All volunteers had incomplete application on the dorsal aspects of the fingers and in the interdigital spaces, except for the area between the thumb and the index finger.
Metalworkers had the highest rate of coverage but, even in this group, coverage in the interdigital spaces ranged only from 54 to 70 percent. Hospital cleaners and construction workers had only 50 to 60 percent coverage and 34 to 42 percent coverage, respectively, in the interdigital spaces. Most volunteers were surprised to see how many areas they had missed. The volunteers' hands seemed to be protected comparably to workers wearing gloves with many holes.
Data from the questionnaire showed that 38 percent of hospital cleaners and metalworkers reported a history of irritant contact dermatitis, compared with 24 percent of construction workers. Sixty-four percent of the metalworkers stated that they had been informed about the use of skin protection at their workplace, but 78 percent stated they were occasional or regular users of a protective cream. Differences in coverage may reflect the influence of previous information given about the necessity and the correct use of protective creams. However, regardless of information received by all three groups, the application was less than satisfactory. The dorsum of the hands was particularly underprotected.
The authors conclude that education appears to be one of the basic elements in preventing occupational irritant contact dermatitis. Physicians and individuals who provide job training should give specific instructions on the use of occupational skin protection for workers at high risk for contact dermatitis.
BARBARA APGAR, M.D., M.S.
Wigger-Alberti W, et al. Self-application of a protective cream. Pitfalls of occupational skin protection. Arch Dermatol 1997;133:861-4.
Maternal HPV Infection and Risk of Exposure to Newborns
Maternal human papillomavirus (HPV) infection is implicated as a cause of laryngeal papillomas in children. Children born to mothers infected with HPV appear to have the same type of HPV in their buccal mucosa as their mothers have in their cervix. Puranen and colleagues conducted a long-term prospective cohort study to determine the frequency of vertical exposure of an infant to the cervical HPV infection of the mother.
Cervical scrapings from 105 mothers and nasopharyngeal aspirate fluids from their 106 infants (including one pair of twins) were collected at the time of delivery. Either cytologic or histologic evidence of HPV infection was used to identify cervical HPV infection in 18 mothers. The DNA of HPV was identified by polymerase chain reaction and subsequent Southern blot hybridization.
Among 15 mothers who were DNA positive and had clinical signs of cervical HPV infection and were undergoing vaginal delivery, the samples of 13 (87 percent) of the mother-infant pairs showed the same type of HPV. A total of 60 mothers had no history or current clinical signs of cervical HPV infection. The same DNA type of HPV was found in both the mothers and their infants in 11 pairs, with different types of HPV found in two pairs. Results of DNA detection in infants born by cesarean section to the 26 mothers with no signs or history of HPV infection showed that five pairs had the same type of HPV infecton and two pairs had a different type. In 15 pairs, both mother and infant were DNA negative for HPV.
The overall concordance between HPV types in the mother and her infant was 69 percent. Regardless of match in type of HPV, 37 percent of infants were DNA positive for HPV infection. When the mode of delivery was separated, DNA of HPV was found in nine (35 percent) of the 26 infants born by cesarean section and in 30 (38 percent) of the 78 infants born by vaginal delivery. In the group of mothers with no history or signs of cervical HPV infection, DNA detection of HPV did not differ significantly between mothers and infants regardless of mode of delivery. The most frequent type of HPV found in both infant and mother was HPV-16 (10 pairs) followed by HPV-33 (three pairs).
Results demonstrated the possibility of exposure of the infant to HPV infection in utero. Data showed that five infants born by cesarean section were DNA-positive for HPV and harbored the same viral type as the mother. Because of the transient nature of HPV, it was not unexpected for the authors to find six infants whose nasopharyngeal aspirates proved DNA-positive for HPV even when the mother's cervical sample was DNA negative at the time of delivery.
The authors conclude that an infant is exposed to the cervical HPV infection of the mother even when there are no signs or history of infection and that transplacental exposure of an infant to HPV infection may be possible as well.
BARBARA APGAR, M.D., M.S.
Puranen MH, et al. Exposure of an infant to cervical human papillomavirus infection of the mother is common. Am J Obstet Gynecol 1997;176:1039-45.
EDITOR'S NOTE: Long-term studies relating prenatal or intrapartum exposure to maternal HPV infection and subsequent development of respiratory papillomatosis in the infant are being conducted. Because there is high morbidity associated with respiratory papillomatosis, pregnant patients with clinical signs of HPV infection may request a cesarean section. On the basis of this study and others, a cesarean section does not appear to prevent the transmission of HPV infection to the infant. Long-term studies of infants positive for HPV are needed to further elucidate the mechanism of transmission and possible adverse sequelae.
B.A.
Rates of Death Associated with Use of Bedrails
Bedrails are used extensively in hospitals and nursing homes for restraint or safety. In hospitals, the use of bedrails is typically a nursing decision. In nursing homes, federal guidelines mandate a physician's order when bedrails are used as restraints. Bedrails have been associated with a number of deaths despite the fact that they are often thought to be an innocuous safety feature. Parker and Miles reviewed the ways that bedrails may cause death and offered suggestions for preventing these types of deaths.
United States Product Safety Commission files were reviewed for deaths occurring in adults who were in bed and whose death was related to the use of bedrails. Patients were excluded if other restrictive devices, such as chest or pelvic restraints, were used. Demographic data and descriptive information were collected for cases occurring from 1966 through 1996, and illustrations were made to recreate the mechanism of injury in order to categorize the types of death.
Safety Recommendations to Prevent Bedrail-Related Deaths Design specifications Clinical change
Bed
- Specify that bed must lower to a height that allows a patient to be sitting with upper legs parallel to floor for standing up and exiting bed.
- Close the head-trapping triangular space created by the right angle formed by the headboard and bedrails and the rounded corner of the mattress by curving the headboard (or rails) in at the ends of the bed.
- There should be a standard anchoring location and system for string-type position alarms.
- There should be a place on all beds for retrofitting weight-based position sensors.
- Beds should be maximally lowered except during direct medical care.
- Alarms that detect a decrease in the amount of a confused or restless patient's weight that is centered on the mattress should be turned on at all times.
- Alarms that detect a patient being out of position should also be used for all persons who are confused, or restless and in restraints, or incapable of ambulating independently when awake.
Mattress
- Label mattresses for specific beds.
- Specify maximum lateral distance between mattress sides and siderails and between mattress sides and head/foot boards.
- Specify that mattress and bed must be designed so that mattress cannot move toward either side or head or foot of bed.
- Clearly mark minimal mattress width and length on bed.
- Specify minimum vertical distance from mattress top to bedrail top and clearly mark this on bedrails.
- Specify refurbishing method that will not shrink mattresses.
- Confirm that mattress is matched and fitted in relation to width and height of rails.
- Pending revisions of mattress design, consider placing hook and loop or other antiskid material between the mattress and the mattress deck to reduce mattress slippage to one side or toward foot of bed.
Bedrails
- Label rails for specific beds.
- Specify latch strength and durability.
- Require latch switch so that patients who, when awake, can ambulate independently, can operate latch to lower bedrails themselves to prevent falls from climbing over rails.
- Specify headrails bar spacing so that head cannot go between bars.
- Specify space between head and foot rails and lateral space between rails and bed frame so that a 90-lb patient cannot slip through them. This may require curving the lower edge of the rails inward to the mattress frame.
- Confirm proper selection and fitting of bedrails to bed and in relation to mattress.
- Use padded bedrail covers to reduce trauma and to obscure bar spaces for any agitated patient or when patient's head can pass between head rail bars.
Bedrail covers
- Specify which covers go with which rails and beds and performance standards for softness and for strength at blocking a person sliding a limb between or through rails.
- Bedrail covers should be used as part of the emergency management of patients who are undergoing seizure or who are extremely agitated and who are restrained and who require that both head and foot rails be in the up position. If so indicated, they should be used to close any space between head and foot rails that is greater than 6 cm.
Reprinted with permission from Parker K, Miles SH. Deaths caused by bedrails. J Am Geriatr Soc 1997;45:797-802.Fifty-one of the 74 deaths recorded occurred in patients older than 70 years of age, with 26 deaths occurring in patients between 81 and 90 years of age. Women were involved more than twice as often as men, with 69 percent of the deaths occurring in women and 28 percent occurring in men. Deaths were categorized into three groups. Most deaths (70 percent) were caused by suffocation resulting from entrapment between the rail and the mattress and/or the bed itself. Latch failure that resulted in the bedrail falling on the patient's head occurred in 18 percent of deaths. In these cases, the patient's head was caught between the vertical rails. The third group of patients (12 percent) died after sliding on either the abdomen or the back through the space between the head and foot rails and becoming lodged with the neck either hypoextended or hyperextended by the floor. In four patients, the exact mechanism of injury could not be determined.
The authors conclude that bedrails should not be used in ambulatory patients. Use of bedrails may be appropriate in patients who are sedated and on life-sustaining systems. Design recommendations include limiting the space between the head and the foot rails to no more than 6 cm to prevent entrapment injuries. Other design recommendations are listed in the accompanying table.
GRACE BROOKE HUFFMAN, M.D.
Parker K, Miles SH. Deaths caused by bedrails. J Am Geriatr Soc 1997;45:797-802.
Value of Follow-up Screening of Patients with Lung Cancer
The goal of frequent follow-up in patients with a history of cancer has been to detect early recurrence of cancer, allowing institution of chemotherapy or radiation therapy to improve the chance of survival. However, no data are available to suggest that follow-up testing of patients who achieve clinical remission after treatment for small-cell lung carcinoma has an impact on the natural history of this disease. Perez and colleagues studied the value of screening procedures in patients who were enrolled in one of several Phase III clinical trials through the North Central Cancer Treatment Group (NCCTG).
The trials included patients with limited and extensive small-cell lung cancer. All had achieved a complete clinical response and were considered to be in remission from their original cancer. The follow-up protocol for these patients included a clinical history, physical examination, hematologic studies, chemistry studies and chest radiographs every four months for the first year and every six months thereafter.
A total of 1,044 patients originally were enrolled in the NCCTG studies, of whom 276 achieved clinical remission initially but subsequently had cancer recurrence. The authors attempted to obtain a random sample of 150 of these patients but ultimately were left with only 115 patients who could be appropriately included in the study. About 55 percent were men, and the median age was 62 years.
Cancer recurred within the first year after treatment in 49 percent of the study subjects. It occurred by the second follow-up year in 44 percent. In the remaining 7 percent, cancer recurred more than two years after the initial diagnosis. The median time until progression was 322 days in the 57 patients with extensive disease at the time of diagnosis and 443 days in those with limited disease.
The most common site of recurrence was the lung/pleura (44 percent of patients), followed by the lymph nodes (30 percent), the liver (26 percent) and the brain (22 percent). Disease recurrence was signaled by the clinical history alone in 71 percent of patients. Symptoms included headache, abdominal pain, bone pain, emesis and dyspnea. Physical examination uncovered disease recurrence in another 10 percent of patients who were without symptoms but were found to have hepatomegaly or lymphadenopathy. In the remaining patients, recurrence of cancer was found by chest radiography in 12 percent and by chemistry evaluations in 6 percent. Hematologic studies were never the sole indicator of disease recurrence.
In patients whose symptoms signaled recurrent cancer, 59 percent were seen at a time other than the scheduled four- or six-month interval appointment. Recurrence was detected at a scheduled visit in only 41 percent. All 115 patients died after recurrence of small-cell cancer. The duration of survival after recurrence ranged from one day to 793 days.
The authors conclude that the clinical history and physical examination are the best ways to detect recurrence of lung cancer. Since 12 percent of patients were diagnosed by follow-up chest radiographs, they believe it is reasonable to continue this practice. However, blood tests were not helpful in detecting recurrent disease, and the authors believe that blood tests could be omitted from follow-up protocols. They also state that while some patients may respond to a second regimen of chemotherapy, no satisfactory evidence indicates that instituting cytotoxic drug therapy early, before the development of symptoms, will improve the patient's quality of life or length of survival.
JEFFREY T. KIRCHNER, D.O.
Perez EA, et al. Utility of screening procedures for detecting recurrence of disease after complete response in patients with small cell lung carcinoma. Cancer 1997;80: 676-80.
Pitfalls in Diagnosing Obturator Hernia
Obturator hernia is a rare condition, accounting for approximately 1.5 percent of all hernias and up to 2 percent of all cases of mechanical intestinal obstruction. However, this condition is associated with high rates of morbidity and mortality. The poor prognosis is attributed to a delay in diagnosis and complications of surgery in patients of advanced age and debilitated condition. Two recent articles emphasize the importance of early diagnosis of obturator hernia.
Both articles report small case series of patients with symptomatic obturator hernia. In one of the series (six cases), the patients were all elderly women (average age: 78 years) of low body weight (average weight: 88 lb). In all patients, a delay of several days occurred between the onset of symptoms and hospital admission, and a further delay occurred in some of the patients between hospital admission and definitive diagnosis and surgery. Conditions such as deafness, dementia and other medical or communication disorders made diagnosis more difficult in a significant proportion of patients.
All of the patients presented with symptoms of intestinal obstruction. The classic tests for obturator hernia--the Howship-Romberg and Hannington-Kiff signs--were not consistently helpful, and hernial sacs could not be palpated in all cases. The authors of one of the articles report that ultrasound of the inguinal region and inner thigh reliably confirmed the diagnosis.
The obturator canal in the pelvis is 1 to 2 cm long and 1 cm wide. With significant weight loss, the normal fat padding of the canal disappears, and increased intra-abdominal pressure can produce herniation. The hernia compresses the obturator nerve, producing pain and paresthesia of the anterior thigh. Abdominal contents may traverse the obturator canal and may be located behind the pectineus muscle in the thigh, where the hernia may be difficult to see or feel. A mass may be felt on vaginal or rectal examination.
With the Howship-Romberg test, extension and abduction of the thigh produce pain along the medial thigh to the knee. The more specific Hannington-Kiff sign is characterized by loss of the adductor reflex with retention of the patellar reflex on the side of the herniation. The hernia is usually small and located on the right side but is frequently complicated by strangulated and gangrenous bowel. Although barium studies, computed tomography and other investigations may be helpful in the diagnosis of this condition, it appears that a high index of suspicion and early use of appropriate ultrasonography may reduce delay in diagnosis and definitive treatment.
ANNE D. WALLING, M.D.
Naude G, Bongard F. Obturator hernia is an unsuspected diagnosis. Am J Surg 1997;174:72-5, and Yokoyama T, et al. Preoperative diagnosis of strangulated obturator hernia using ultrasonography. Am J Surg 1997;174:76-8.
EDITOR'S NOTE: When patients achieve significant and appropriate weight loss, the role of the physician is principally one of encouragement to sustain the new, healthier lifestyle. Substantial weight loss, however, appears to make patients slightly more vulnerable to a few conditions, such as symptomatic gallstones. One wonders if patients who lose significant weight are also at increased risk of obturator hernia. This diagnosis is certainly worth consideration if a woman who has recently lost substantial weight presents with what appears to be intestinal obstruction. Early diagnosis is the key to a good outcome for this rare condition.
A.D.W.
Eating Disorders and Diabetic Retinopathy in Young Women
Type 1 diabetes mellitus (insulin-dependent diabetes mellitus) is one of the most common chronic diseases of childhood and adolescence. Previous studies suggest that as many as one third of young women with diabetes have eating disturbances. Rydall and colleagues studied the natural history of eating disorders in adolescent girls with type 1 diabetes and the association between eating disorders and microvascular complications.
In 1988, the authors contacted 121 adolescent girls aged 12 to 18 years and invited them to participate in a self-reported survey of eating attitudes and behavior. Eight did not return the questionnaire and six subsequently refused to participate. A total of 107 girls (88.4 percent) participated in the study at that time. For the present study, the authors attempted to contact these patients during 1992 and 1993 to obtain follow-up information; 91 (85 percent) of the 107 agreed to participate in the follow-up study. One of the 11 patients who did not participate in the follow-up study was in the group with highly disordered eating behavior at baseline and two of the 11 were in the group with moderately disordered eating behavior. One of the five patients lost to follow-up was in the group with highly disordered eating at baseline.
Nine of the 91 women in the current study met the criteria for highly disordered eating at baseline, and 17 met the criteria for moderately disordered eating. Ten of the 26 patients with highly or moderately disordered eating behavior at baseline were found to have improved at the time of the follow-up study. Fourteen of the 65 patients without evidence of an eating disorder at baseline had acquired disordered eating behavior in the intervening years. Patients with highly disordered eating behavior had a significantly higher mean hemoglobin A1c value at baseline than did those in the groups with moderately disordered eating behavior or no disordered eating behavior.
Ophthalmologic examinations were performed in 71 patients who participated in the follow-up study. Diabetic retinopathy was present in 24 (33 percent) of the patients. Retinopathy was found in six (86 percent) of the seven patients with highly disordered eating behavior at baseline and in six (43 percent) of the 14 patients with moderately disordered eating behavior at baseline. In contrast, 12 (24 percent) of the 50 patients without disordered eating behavior at baseline had evidence of retinopathy. Disordered eating accounted for more of the variance in predicting retinopathy than did the duration of diabetes or the hemoglobin A1c level.
The patients in the study demonstrated less well-recognized features of an eating disorder. Other studies have shown that such patients may not comply with diabetes treatment and may have unstable metabolic control, hyperglycemia, recurrent ketoacidosis and an earlier onset of microvascular complications. Bulimia and purging were uncommon. Aside from dieting to lose weight, intentional omission of an insulin dose and underdosing of insulin were the most common means of inducing weight loss. These two methods for losing weight were reported by one third of the women at follow-up.
The authors conclude that disordered eating behavior is common and persists in young women with type 1 diabetes. The findings suggest that routine screening for eating disturbances may be indicated in young women with diabetes.
KATHRYN M. ANDOLSEK, M.D., M.P.H.
Rydall AC, et al. Disordered eating behavior and microvascular complications in young women with insulin-dependent diabetes mellitus. N Engl J Med 1997;336:1849-54.
Estrogen Therapy and the Risk of Alzheimer's Disease
The bone-preserving and cardiovascular benefits of estrogen replacement therapy in postmenopausal women are well documented. Recent evidence also suggests that estrogen therapy may exert a protective effect against Alzheimer's disease. Kawas and associates reviewed data from the Baltimore Longitudinal Study of Aging (BLSA) to determine whether estrogen replacement therapy confers a protective effect against the development of Alzheimer's disease.
The BLSA is a prospective, multidisciplinary study of aging conducted by the National Institute on Aging. It began in 1978. Data were gathered for 514 post- and perimenopausal women over a 16-year period. All of the study subjects underwent extensive testing every two years, including physical and neurologic examinations and neuropsychologic testing. Past and present use of estrogen therapy was assessed to determine the duration of estrogen use. The relative risk of development of Alzheimer's disease associated with estrogen use was calculated.
Forty-five percent of the 514 women eligible for the study reported estrogen use. A total of 34 cases of Alzheimer's disease occurred among 472 women in whom estrogen replacement status was known. Nine of these women had a history of estrogen replacement therapy. The relative risk for the development of Alzheimer's disease in estrogen users compared with nonusers was 0.46. Other variables, including age at menopause, age at menarche, years of natural cyclic estrogen exposure and duration of menopause, were not found to be significant factors. The protective effect did not increase with an increased duration of estrogen use.
The authors conclude that these results support previous case-control studies that have demonstrated a protective effect of estrogen replacement therapy against the development of Alzheimer's disease. An increased duration of use was not associated with an increase in the protective effect. Estrogen replacement therapy may become a tool in preventing or slowing the progression of Alzheimer's disease, but randomized clinical trials are necessary to confirm this association. A study of estrogen replacement in women with Alzheimer's disease is now in progress under the sponsorship of the Alzheimer's Disease Cooperative Study Unit, funded by the National Institute on Aging.
JAMES NUOVO, M.D.
Kawas C, et al. A prospective study of estrogen replacement therapy and the risk of developing Alzheimer's disease: the Baltimore Longitudinal Study of Aging. Neurology 1997;48:1517-21.
Use of Lovastatin in Blacks with Hypercholesterolemia
Black patients have almost twice the age-adjusted risk of dying from coronary heart disease as do white patients. Lipid-lowering drugs are known to have a beneficial effect on risk factors such as hypercholesterolemia. However, few studies have evaluated the efficacy of the use of lipid-lowering drugs in this population. Fong and Ward conducted a double-blind controlled trial to evaluate the efficacy of lovastatin in black patients with primary hypercholesterolemia.
Patients were included in the study if they had a diagnosis of hypercholesterolemia and met National Cholesterol Education Program (NCEP II) guidelines for the use of medication to treat elevated cholesterol levels. Patients with diabetes mellitus, hypothyroidism and liver or renal disease were excluded from the study. Recent myocardial infarction and coronary artery bypass surgery were also exclusion criteria. A total of 41 patients completed the study. Lipid profiles and other blood chemistries were performed for each patient. Patients were then randomized to receive either placebo or 20 mg of lovastatin daily. All of the patients were counseled about the American Heart Association Step One Diet for lowering serum cholesterol.
Total cholesterol was reduced by 14.7 percent in the lovastatin group, compared with no reduction in cholesterol in the placebo group. Low-density lipoprotein levels decreased by 20 percent in the treatment group, and triglyceride levels decreased 10.5 percent in the treatment group. Several patients in the treatment group reached their target low-density lipoprotein levels (as established by the NCEP II guidelines), but none of the placebo-treated group reached the NCEP II goal. Neither group experienced any serious side effects, although four patients in the treatment group discontinued their medication for various reasons, including gastrointestinal upset. Previous studies have shown that black patients are less likely than white patients to be treated for hypercholesterolemia (odds ratio: 0.81).
The authors conclude that lovastatin and probably other HMG-CoA reductase inhibitors are efficacious in the treatment of hypercholesterolemia, and should be used more frequently in the black population when indicated for the treatment of hypercholesterolemia.
GRACE BROOKE HUFFMAN, M.D.
Fong RL, Ward HJ. The efficacy of lovastatin in lowering cholesterol in African Americans with primary hypercholesterolemia. Am J Med 1997;102:387-91. *
"Tips from Other Journals" are written by the medical editors of American Family Physician.
Copyright © 1998 by the American Academy of Family Physicians.
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