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Effect of Cancer on Physical Function in the Elderly
The diagnosis of cancer can cause a significant physical burden for patients. Such a diagnosis may have an even greater impact on elderly patients. At the present time, the question of whether a diagnosis of cancer decreases the functional status of elderly patients is a matter of controversy. Stafford and Cyr assessed the specific impact that a diagnosis of cancer may have on elderly patients and what parameters may be used to identify high-risk groups.
A stratified random sample of 9,745 Medicare benificiaries were evaluated. The study subjects underwent a personal interview that included questions about demographics, medical conditions, current health status, issues related to health care access, satisfaction with medical care and an evaluation of the patient's ability to perform activities of daily living (ADL) and independent activities of daily living (IADL).
Results of the study indicated that the self-reported health status of patients with cancer was worse than that of patients without a chronic condition. The diagnosis of lung cancer produced the worst results in self-reported health status. Patients with cancer reported more limitations in ADL and IADL capabilities than those without cancer. Health care utilization was higher in the cancer group as well. Cancer patients with lower socioeconomic status were more likely to report poor health status, functional limitations, increased health care costs and dissatisfaction with their health care.
The authors conclude that when the diagnosis of cancer is established in elderly patients, physicians must be aware of the difficulties facing these patients. Physicians should establish a care plan that addresses the treatment of the cancer as well as interventions to reduce the impact on elderly patients' functional status.
KARL MILLER, M.D.
Stafford RS, Cyr PL. The impact of cancer on the physical function of the elderly and their utilization of health care. Cancer 1997 November 15;80:1973-80.
Antibacterial Activity of Azithromycin in Children
Azithromycin is an azilide antimicrobial agent similar to the widely used macrolide antibiotics, such as erythromycin. The acid stability of azithromycin provides highly favorable pharmacokinetic properties and patient tolerance. This azilide compound interferes with bacterial protein synthesis, giving it bactericidal activity against Streptococcus pyogenes, Streptococcus pneumoniae and Haemophilus influenzae. Reed and Blumer reviewed the pharmacokinetics and spectrum of antibacterial activity of azithromycin, noting that many pathogens responsible for infections in infants and children are within the scope of antibacterial activity of this agent.
Most strains of staphylococci and streptococci, with the exception of enterococci, are susceptible to azithromycin. Concentrations of the drug in tissue and cells are far in excess of concentrations in the blood. The authors report that the primary advance that azithromycin offers in the spectrum of antibacterial activity is against gram-negative pathogens, most notably Haemophilus species. Azithromycin and most newer macrolide antibiotics have demonstrated good to excellent activity against beta-lactamasepositive or beta-lactamasenegative organisms. Azithromycin is also highly active against Chlamydia, Mycoplasma, Bordetella and Borrelia, although azithromycin's activity against Borrelia burgdorferi (Lyme disease) requires further study. Resistance to erythromycin is highly suggestive of resistance to azithromycin.
Pharmacokinetic studies demonstrate better gastrointestinal absorption, greater tissue penetration and a longer elimination half-life with azithromycin than with erythromycin. These characteristics allow once-daily dosing and a shortened duration of therapy, features that distinguish azithromycin from all other orally administered antibiotics used in infants and children.
Most macrolide antibiotics, but not the azilides, seem to have the capacity to interfere with the hepatic metabolism of certain hepatically metabolized drugs, including theophylline, terfenidine and carbamazepine.
Decreased gastrointestinal side effects have been noted with azilides, providing a high degree of patient acceptability. There seems to be no basis for concern about prolonged drug-induced reactions secondary to the longer elimination half-life of azithromycin.
A five-day course of azithromycin has been widely used for the treatment of acute otitis media and streptococcal pharyngitis in children. Therapy is initiated with a loading dose. Recent studies show similar efficacy with a three-day course for otitis media, which may greatly improve compliance. The palatability of the liquid form also enhances acceptability in children.
The authors note that azithromycin appears to have significant advantages over erythromycin, including improved tolerance and less frequent dosing. Although a three-day course of treatment has been shown to be efficacious in otitis media, this short course has not demonstrated such efficacy in the treatment of streptococcal pharyngitis.
RICHARD SADOVSKY, M.D.
Reed MD, Blumer JL. Azithromycin: a critical review of the first azilide antibiotic and its role in pediatric practice. Pediatr Infect Dis J 1997 November;16:1069-83.
Efficacy of Ginkgo Biloba in Treating Dementia
An extract of the dried leaves of the Ginkgo biloba tree is used in Europe to alleviate symptoms associated with a range of cognitive problems and has recently been approved in Germany for the treatment of dementia. Ginkgo is thought to have antioxidant properties, although its exact mechanism of action is unclear. Le Bars and colleagues conducted a randomized, double-blind, placebo-controlled trial to test the efficacy of ginkgo in the management of patients with Alzheimer's disease and multi-infarct dementia.
Patients were included in the study if they were at least 45 years old and had been diagnosed with Alzheimer's disease or multi-infarct dementia, and had a Mini-Mental State Examination score of nine to 26 and a Global Deterioration Scale score of three to six. Patients with significant medical problems such as type 1 diabetes or cardiac disease were excluded from the study. Changes in medication regimens were not allowed during the study period. Data from 202 patients were compared for the one-year study. Each patient underwent a 14-day, single-blind run-in period. Patients were reevaluated at four, 12, 26, 39 and 52 weeks. Extensive medical, neurologic and psychiatric examinations were performed at baseline and at the end of the study. Patients were randomized to receive either placebo or 40 mg of ginkgo three times daily before meals. The three primary outcomes assessed changes in the following areas: cognitive impairment, daily living and social behavior, and general psychopathology.
A total of 166 patients were randomized to the ginkgo treatment group, and 161 were randomized to the placebo group. Patients receiving ginkgo demonstrated no worsening of their cognitive impairment at end point, compared with a 1.5 point worsening (based on the Alzheimer's Disease Assessment Scale--Cognitive subscale [ADAS-Cog]) in the placebo group. The Geriatric Evaluation by Relative's Rating Instrument (GERRI), a caregiver-rated assessment, showed mild improvement in the treatment group and significant worsening in the placebo group. At the halfway point of the study, patients in the ginkgo group showed a slight improvement on both the ADAS-Cog and GERRI scales, whereas the placebo group showed significant worsening. Adverse events were not significantly different between the treatment and placebo groups, and were considered to be mild to moderate in intensity.
The authors conclude that treatment with extract of Ginkgo biloba is safe for up to one year in patients with dementia and can improve cognitive performance and functioning. The improvement was significant enough to be identified by the patient's caregiver.
GRACE BROOKE HUFFMAN, M.D.
Le Bars PL, et al. A placebo-controlled, double-blind, randomized trial of an extract of ginkgo biloba for dementia. JAMA 1997 October 22/29;278:1327-32.
Prevention of Wound Infection After Appendectomy
Wound sepsis remains a common problem following surgery on the gastrointestinal tract. Infection of the incision site associated with appendectomy has been reduced but still approaches 7.2 percent. While many strategies aimed at minimizing the infection rate have been explored, most notably the use of oral or parenteral antibiotics, the results are less than satisfactory. Postoperative infection affects length of hospital stay and recovery time. Shubing and Litian investigated the impact of infusing metronidazole into the subcutaneous muscle and tissue around the incision site to reduce the incidence of wound infection following acute appendectomy.
Between 1991 and 1995, 260 patients who underwent acute appendectomy at a Mongolian hospital were evaluated for inclusion in the study. Twenty-one patients with diabetes, intestinal tuberculosis, tumor or a history of lengthy steroid treatment were excluded. The remaining 239 patients were randomized to a treatment group that received metronidazole injection at the incision site or to a control group that received intravenous metronidazole and cephazolin. After induction of anesthesia, patients in the treatment group received 60 to 80 mL of metronidazole solution (0.915 g metronidazole disodium phosphate or 25 percent metronidazole glucose solution in 100 mL of 0.9 percent normal saline solution) injected by layers. Patients in both groups received intravenous metronidazole and 4 g of cephazolin daily postoperatively. Patients were monitored for infection at the incision site for one month following surgery.
Patients were comparable in age, sex, type of surgery and average time from onset of symptoms until surgery. The severity of appendicitis was almost identical in the two groups of patients (see accompanying table). Infection developed in only one patient (0.8 percent) in the treatment group. In the control group, 14 patients (11.6 percent) had clinical wound infection. In addition, patients in the control group stayed in the hospital 10 days longer than those in the treatment group.
Infection Rate of Two Groups After Appendectomy Group A (treatment group)
Group B (control group)
Pathologic
type
Number of
cases
Number of
infections
Number of
cases
Number of
infections
Simple 13 1 15 1 Suppurative 28 0 30 3 Gangrenous 39 0 36 2 Perforative 39
0
39
8
Total 119 1 (0.8%) 120 14 (11.6 %)
Reprinted with permission from Shubing W, Litian Z. Preventing infection of the incision after appendectomy by using metronidazole preoperatively to infiltrate tissues at the incision. Am J Surg 1997;174:423.The authors conclude that preoperative local infiltration of metronidazole into the muscle tissue resulted in a significant reduction in the incidence of infection at the incision site following appendectomy for acute appendicitis. They attribute much of this effect to the direct exposure of anaerobic bacteria to an appropriate antimicrobial medication in areas of limited perfusion.
ANNE D. WALLING, M.D.
Shubing W, Litian Z. Preventing infection of the incision after appendectomy by using metronidazole preoperatively to infiltrate tissues at the incision. Am J Surg 1997 October;174:422-4.
Iron Deficiency in Children One toThree Years of Age
Iron deficiency anemia is now uncommon in children during the first year of life. The promotion of breast feeding, along with the increased use of iron-fortified formulas and foods, has greatly curtailed this problem. These nutritional interventions came in response to earlier studies which showed delayed mental and psychomotor development in children who were deficient in iron. Studies of iron deficiency between the first and third years of life have reported a prevalence of 3 to 15 percent. Eden and Mir attempted to determine the prevalence of iron deficiency in children one to three years of age who were followed from July 1995 through June 1996.
Children between 12 and 36 months of age who visited the offices of four pediatricians in the New York City area were enrolled in the study. All children were from urban lower or middle socioeconomic groups. Racial distribution was 40 percent black, 40 percent Hispanic and 20 percent white. Excluded were children with a history of chronic illness, blood dyscrasia, prematurity or a febrile illness at the time of the visit. Venous blood samples were obtained, from which hemoglobin, ferritin, free erythrocyte protoporphyrin (FEP) and lead levels were measured. A hemoglobin level less than 11 g per dL (110 g per L) was used to define anemia. Ferritin levels less than 10 ng per mL (10 mg per L) represented iron depletion, and FEP levels greater than 35 mg per dL (0.62 mmol per L) demonstrated iron deficiency.
A total of 504 children were initially enrolled in the study. However, after excluding children with hemoglobin levels less than 11 g per dL (110 g per L) but normal ferritin and FEP levels, 485 children remained in the final analysis. Of this group, 86 children (18 percent) were iron depleted, 32 (7 percent) were iron deficient without anemia, and 48 (10 percent) had iron deficiency anemia. These results demonstrated that 35 percent of the children from the study population had some degree of iron insufficiency.
The authors conclude that there is a significant prevalence of iron deficiency in children between one and three years of age. They believe that possible explanations for this include switching children from breast milk or iron-fortified formulas to regular cow's milk, using adult-type non-iron-fortified cereals rather than iron-fortified infant cereals, and a decreased appetite for solid foods paired with an increased intake of juices. The authors cite data showing that iron deficiency during the second year of life prevents adequate brain growth and adversely affects development. They recommend that some form of supplemental iron be given to all children through at least the second year of life.
JEFFREY T. KIRCHNER, D.O.
Eden AN, Mir MA. Iron deficiency in 1- to 3-year-old children: a pediatric failure? Arch Pediatr Adolesc Med 1997 October;151:986-8.
Influence of Fluoxetine on Length of Menstrual Cycle
Changes in the length of the menstrual cycle are not typically monitored or identified as adverse effects during trials of medications, although shortening and lengthening of the menstrual cycle have been noted occasionally during studies of fluoxetine. Steiner and colleagues studied the effect of fluoxetine on menstrual patterns in women who previously reported having stable cycle lengths.
Women 20 to 45 years of age were recruited from seven Canadian university clinics. All participants had mood-change symptoms associated with premenstrual syndrome (PMS) that failed to respond to lifestyle, dietary and exercise interventions. Women were excluded if they were pregnant or lactating, taking psychoactive or contraceptive medications, had ever taken fluoxetine, had seizure disorders or other medical conditions, or reported having irregular menstrual cycles. After extensive clinical and laboratory testing, all patients received a placebo for two cycles. Those who did not respond to the placebo were randomly assigned to receive fluoxetine, in a dosage of 20 or 60 mg daily, or placebo. All treatment began on the first day of the menstrual cycle. Compliance was verified by pill counts, reports by the participants and, in 15 percent of the group, by measurement of serum fluoxetine levels. Patients kept records of menstrual flow as part of the data gathered on PMS symptoms.
A total of 313 women entered the treatment phase of the study, and 193 of these were randomized into one of three groups. Sixty-one women were given placebo, 70 were given 20 mg of fluoxetine daily and 62 were given 60 mg of fluoxetine daily. The mean age of the participants was 36 years. All of the women were high school graduates, approximately one half were married, and 70 percent had at least one child. At the end of the first treatment cycle, 11 (18 percent) of those receiving the 60-mg dosage and seven (10 percent) of those receiving the 20-mg dosage reported cycle lengthening or shortening of at least four days compared with baseline. Only one woman in the placebo group reported such a change. Over the three cycles studied, nine women (15 percent) taking the 60-mg dosage and four women (6 percent) taking the 20-mg dosage reported changes in cycle length, compared with two women (3 percent) taking placebo. Fluoxetine lengthened the cycles of eight women and shortened the cycles of 10 women by at least four days. The differences were statistically significant, showing a dose-dependent effect on menstrual cycle length. This effect disappeared within one to two cycles when the medication was discontinued.
The authors conclude that fluoxetine can cause changes in menstrual patterns, and they propose several explanations for the fluctuations. Since this drug is widely used in women of reproductive age, further research into its effects on menstruation, fertility and sexual behavior is indicated.
ANNE D. WALLING, M.D.
Steiner M, et al. Effect of fluoxetine on menstrual cycle length in women with premenstrual dysphoria. Obstet Gynecol 1997 October;90:590-5.
Risk of Influenza Infection in Infants From Birth to One Year
The highest attack rate for influenza virus infection occurs in school-age children. Live attenuated viruses administered by nasal spray promise to be the preferred route of vaccination for children; however, the age for first administration remains to be determined. Influenza vaccination of pregnant women who will be in the second or third trimester during influenza season not only protects the woman but should provide increased protection for the newborn by increased vertical transmission of antibody. Glezen and associates followed children from birth to one year to assess the risk of influenza during the first year of life and to determine the most effective time for initiation of active immunization.
A total of 209 infants were enrolled in the study at the time of birth. Only 26 infants were infected with influenza virus infection during the first six months of life (infection rate: 12.4 per 100 infants) compared with 43 infections occurring during the second six months of life (infection rate: 20.6 per 100 infants). About 45 percent of the infections were asymptomatic or manifested by afebrile upper respiratory illness only. Illnesses of greater severity were more likely to occur in the second six months of life. Infection rates varied significantly according to the number of older siblings, with the highest rate occurring among infants with three or more siblings.
The infection rate for influenza virus during the first year of life was less than one half the rate for respiratory syncytial virus or parainfluenza virus type 3. Lower respiratory tract illness was also less frequent in infants with influenza. The immunogenicity of influenza vaccines administered to infants at less than six months of age may not be immunologically efficient, probably because of the immaturity of the infant's immune system and the presence of maternal antibodies.
The authors conclude that routine immunization against influenza before six months of age is unnecessary for most infants. Annual immunization for infants more than six months of age offers the most promise of reducing the risk of infection in infants. Maximal protection is obtained by vaccinating older contacts until younger children receive the second annual dose. This is probably more efficient than the alternative schedule of two doses eight weeks apart for the first immunization of naive subjects.
RICHARD SADOVSKY, M.D.
Glezen WP, et al. Influenza virus infections in infants. Pediatr Infect Dis J 1997 November;16:1065-8.
Impact of Race and Gender on Location of Colorectal Cancer
The utilization of flexible sigmoidoscopy as a screen for colorectal cancer has been shown to be cost effective for patients with average risk factors for this cancer. The impact of variables on the location of colon cancer has not been completely studied. Nelson and colleagues explored age, gender and race as variables that may influence the site for colorectal cancer.
The site for colorectal cancer was defined as distal (sigmoid, rectosigmoid and rectum) or proximal (cecum through descending colon). The study consisted of a review of 38,391 patients with colorectal cancer enrolled in the tumor registry in one state. When controlled for age, the incidence of proximal colorectal cancer was higher in the black population than in the white population. Distal colorectal cancer rates were higher for male patients than for female patients in both races.
The authors conclude that offering flexible sigmoidoscopy as a screen is appropriate for white male patients. However, in black female patients, a barium enema would be a better screen because of the increased incidence in that population of proximal colorectal cancers that are beyond the range of a sigmoidoscope. The authors also conclude that the poorer survival rate for colorectal cancer in the black population might be explained by the tendency for these patients to have a higher incidence of proximal tumors.
KARL MILLER, M.D.
Nelson RL, et al. The relation of age, race, and gender to the subsite location of colorectal carcinoma. Cancer 1997 July;80:193-7.
Diagnosis of Osteomyelitis of the Foot in Diabetic Patients
Establishing a diagnosis of osteomyelitis of the foot in patients with diabetes is often problematic because of the difficulty in determining whether the infection involves the bone or only the soft tissue. In addition, diabetes is a common cause of noninfectious bone disease, such as neuropathic osteoarthropathy, which can have the radiographic appearance of osteomyelitis. Lipsky reviewed the diagnostic and management approach to foot infections in patients with diabetes.
The first step in establishing the diagnosis is a careful clinical examination. Patients with soft tissue infection or skin ulceration over a bony prominence are at risk for osteomyelitis. The risk is significantly increased if the wound has been present for more than two weeks.
Several other clinical findings have been shown to be predictive of osteomyelitis. One study showed that an ulcer area of more than 2 cm2 has a sensitivity of 56 percent and a specificity of 92 percent for the diagnosis of osteomyelitis. If the depth of the ulcer is more than 3 mm, the likelihood of bony infection is much greater. A positive "probe-to-bone" test (making contact with bone when the ulcer is probed) has been reported to have a sensitivity of 66 percent, a specificity of 85 percent and a positive predictive value of 89 percent in the diagnosis of osteomyelitis.
One study showed that an erythrocyte sedimentation rate (ESR) greater than 70 mm per hour was present in 100 percent of patients with osteomyelitis. However, the same study showed that the ESR had a sensitivity of only 28 percent. The white blood cell count has not been found to be useful in diagnosing osteomyelitis.
The author notes that bony changes that are due to infection are not evident on plain films until 10 to 20 days after the onset of infection, when 40 to 70 percent of bone has been resorbed. Previous studies have shown that plain radiographs are about 60 percent sensitive and 66 percent specific for the diagnosis of osteomyelitis.
Bone scanning with technetium-99m can demonstrate abnormal uptake two weeks before changes are seen on plain films. The sensitivity of 99mTc bone scans in identifying osteomyelitis has been found to be about 86 percent, but the specificity has been noted to be poor, at only 45 percent. The explanation is that any preexisting osseous condition that causes bone turnover will result in a positive bone scan.
Indium-111labeled leukocyte scanning is quite specific for infection, showing a 78 percent specificity in previous studies. Limitations of this study include leukocyte scanning's poor resolution in differentiating bony infection from adjacent soft tissue infection and the fact that it requires the withdrawal and reinfusion of blood.
Magnetic resonance imaging (MRI) provides excellent tissue contrast, making it an extremely sensitive test for osteomyelitis. A 99 percent sensitivity rate has been demonstrated in previous studies. However, false-positive results may occur in the presence of osteoarthropathy. Poor cortex resolution may result in false-negative results in patients with isolated cortical infection and no bone marrow involvement. Overall, several recent studies have shown MRI to be the best diagnostic imaging study for osteomyelitis. MRI has also been reported to be useful for monitoring the response to antimicrobial treatment. The primary limitation of MRI is cost.
The definitive diagnostic study for osteomyelitis is a bone biopsy. This procedure is reported to be 95 percent sensitive and 99 percent specific for identifying osteomyelitis. Bone specimens can be obtained percutaneously, but surgery may be necessary. The advantage of performing a bone biopsy is that it provides specific identification of the organism and its antimicrobial sensitivities. Disadvantages include cost (approximately $800) and patient discomfort.
The author refers to a recent decision and cost-effectiveness analysis of diabetic foot infections by other investigators which revealed that noninvasive testing adds significant expense to the evaluation of patients with diabetic foot ulcers but does little to change the patient's outcome. He notes that these investigators advocated surgical debridement followed by a 10-week course of antibiotic therapy based on the results of soft tissue culture. He disagrees with the conclusions of these investigators and advocates the thoughtful use of noninvasive diagnostic studies (see algorithm).
Suggested approach to the diagnostic evaluation and treatment of cutaneous ulceration or soft tissue infection of the foot in patients with diabetes. (MRI=magnetic resonance imaging)
*--Antibiotic therapy based on results of bone culture, if available; otherwise, based on results of culture of overlying infected soft tissue.
†--Antibiotic therapy based on results of soft tissue culture.
Reprinted with permission from Lipsky BA. Osteomyelitis of the foot in diabetic patients. Clin Infect Dis 1997;25:1321.
JEFFREY T. KIRCHNER, D.O.
Lipsky BA. Osteomyelitis of the foot in diabetic patients. Clin Infect Dis 1997 December;25:1318-26.
Diagnosis and Management of Idiopathic Pulmonary Fibrosis
Idiopathic pulmonary fibrosis is a progressive lung disease of unknown etiology characterized by thickening of alveolar walls and the presence of large mononuclear cells in the alveolar space. Although idiopathic pulmonary fibrosis is believed to be underdiagnosed, the prevalence in the United States has been estimated to be 29 per 100,000 men and 26 per 100,000 women. A recent review by Chan-Yeung and Müller provides diagnostic and treatment guidelines.
The typical patient with idiopathic pulmonary fibrosis is 40 to 70 years of age and presents with a one- to three-year history of nonproductive cough and increasing breathlessness. Physical examination usually reveals bilateral basilar crackles and clubbed fingers. Approximately one third of patients have an autoimmune condition, such as polyarthritis. Although chest radiographs typically show a diffuse reticular pattern predominately in the lower zones, in up to 16 percent of patients the chest radiograph may appear normal. High-resolution computed tomographic (CT) scan shows linear opacities and honeycombing with areas of ground-glass attenuation. Tests of lung function show restrictive results such as low lung volumes and impaired gas transfer.
The diagnosis is based on exclusion of other causes of fibrosing alveolitis. A thorough occupational and environmental exposure history is particularly important. High-resolution CT scan is crucial in confirming the diagnosis. Since patients with ground-glass attenuation are more likely to respond to corticosteroids, the CT scan also guides choice of therapy. Transbronchial lung biopsy and bronchoalveolar lung lavage do not contribute directly to the diagnosis of idiopathic pulmonary fibrosis but are useful in identifying other potential diagnoses such as sarcoidosis, hypersensitivity pneumonitis, cryptogenic organizing pneumonia and malignancy. Lung biopsy using either open or transbronchial routes confirms the diagnosis; samples should be obtained from at least two sites.
The treatment of idiopathic pulmonary fibrosis is controversial and is hampered by a lack of understanding of the natural history of the disease. Only 10 to 15 percent of patients improve with corticosteroid therapy, and 26 percent of patients develop serious complications from the steroid therapy. Indicators of good response to steroid therapy include young age, female sex, ground-glass lesions on CT scan and active inflammation on lung biopsy samples. Azathioprine, cyclophosphamide and other cytotoxic drugs have been used either as second-line agents or in combination with steroids as first-line therapy. Although the general prognosis was poor, combined treatment improved three-year survival rates. Selected patients with idiopathic pulmonary fibrosis have been treated with lung transplantation.
ANNE D. WALLING, M.D.
Chan-Yeung M, Müller NL. Cryptogenic fibrosing alveolitis. Lancet 1997 August;350:651-6.
Domestic Violence and Women's Expectations of Physicians
Women are more likely to experience violence delivered by a current or former partner than by all other assailants. Domestic violence is the most common cause of injuries among women, exceeding injuries caused by motor vehicle accidents and muggings combined. Despite the prevalence of domestic violence, victims of abuse often are not identified during physician visits. Caralis and Musialowski interviewed women attending ambulatory clinics at a Veterans Affairs Medical Center to obtain information about their experiences with domestic violence and their attitudes and expectations regarding medical care.
A total of 406 participants were interviewed by trained persons using a standardized 50-item questionnaire. The survey included questions about personal experiences with domestic violence, and preferences and expectations about physician screening for domestic violence and treatment of victims.
The mean age of the study participants was 50.4 years. Forty percent reported emotional or physical abuse by a partner at some time during their lives. Seven percent were in an abusive relationship at the time of the interview.
Most of the women believed that physicians should routinely screen for domestic violence in their patients; 85 percent "agreed" and 50 percent "strongly agreed" that routine screening for domestic violence should be incorporated into medical practice. Only 12 percent of the total group stated that their physicians had inquired about domestic violence, although 23 percent of the women who had been abused reported that physicians or nurses had asked them about abuse. Sixty-eight percent of the women "strongly agreed" that they would admit to experiencing domestic violence if their physicians asked them about it. Twenty percent of the victims said that their physicians, even when informed of abuse, did nothing with the information. The majority of the women believed that physicians should provide information concerning community and legal resources if violence affects their patients and should assist patients in finding protective services.
The authors conclude that women expect physicians to address the issue of domestic violence. They also expect physicians and other health care professionals to take an active role in providing services for victims and perpetrators of abuse. Women recognize that physicians and other professionals can work together to coordinate the range of community services that are available to victims of domestic violence
KARL MILLER, M.D.
Caralis PV, Musialowski R. Women's experiences with domestic violence and their attitudes and expectations regarding medical care of abuse victims. South Med J 1997 November;90:1075-80.
Effect of Smoking Cessation on Levels of Anxiety
Controversy exists regarding anxiety levels in patients who stop smoking. Some studies have demonstrated that patients experience an increased level of anxiety when attempting to stop smoking, while others suggest a decrease in the level of anxiety. Most of these trials have not featured complete abstinence from smoking during the studies. It is possible that the increase in anxiety levels is more closely related to the failure of complete cessation than to withdrawal from smoking. West and Hajek studied the impact of complete cessation of smoking on levels of anxiety.
Study subjects were recruited from family physician offices and from the general public. To be eligible for inclusion in the study, patients had to have smoked at least 15 cigarettes per day for at least five years. Strict criteria for lapse-free abstinence was established, with patient reporting and saliva sampling to ensure compliance. Anxiety levels were evaluated by the State-Trait Anxiety Inventory--State Form X at one and two weeks before the stop date, then again at 24 hours and one, two, three and four weeks after the stop date.
Seventy of 101 patients who entered the study completely abstained during the four-week study, as established by report and saliva sampling. Members of this group had no increase in anxiety levels following smoking cessation and had a decrease in anxiety levels after the first week.
The authors conclude that smoking may cause chronic anxiety and that smoking cessation may reduce anxiety levels in these persons. This finding may be used when counseling patients who voice concern about the impact of tobacco abstinence on their anxiety levels.
KARL MILLER, M.D.
West R, Hajek P. What happens to anxiety levels on giving up smoking? Am J Psychiatry 1997 November;154:1589-92.
Underutilization of Beta Blockers After Infarction in the Elderly
Beta-adrenergic blockers are known to reduce rates of mortality after myocardial infarction in older patients. Mendelson and Aronow conducted a retrospective study to investigate the use of beta blockers in elderly patients with a history of myocardial infarction or coronary artery disease.
The medical records of patients attending a hospital-based geriatrics clinic from January 1996 through March 1997 were reviewed to identify patients with a history of myocardial infarction or coronary artery disease. Physicians and consultants provided care to 233 patients (149 women and 84 men) with a history of myocardial infarction or coronary artery disease. The patients ranged in age from 67 to 96 years.
A total of 162 study subjects (70 percent) had a history of myocardial infarction, and 71 (30 percent) had documented coronary artery disease and atypical angina without a history of infarction. Only 38 (23 percent) of the 162 patients with a history of myocardial infarction were receiving beta blockers. Of the 124 patients not receiving beta blockers, only 19 (15 percent) had a contraindication to this medication. Thus, the prevalence of beta-blocker use in the patients with a history of myocardial infarction and no contraindications to beta blockers was 27 percent. Of 233 patients with documented coronary artery disease, 53 (23 percent) were receiving beta blockers. Beta blockers were contraindicated in 34 (19 percent) of these patients. The prevalence of beta-blocker use in the overall group with no contraindications was 27 percent.
The authors conclude that beta blockers are greatly underused in elderly patients who have a history of myocardial infarction. The authors note that beta blockers are known to decrease mortality in this population, as well as in elderly patients with complex ventricular arrhythmias associated with a history of myocardial infarction and normal or abnormal left ventricular ejection fraction. Data from the Beta-Blocker Heart Attack Trial showed that use of propranolol was associated with a 27 percent reduction in mortality in patients with congestive heart failure and a 25 percent reduction in mortality in patients without heart failure. The authors also note that the Beta-Blocker Pooling Project, which compiled data from nine studies involving 3,519 patients with heart failure at the time of an acute myocardial infarction, revealed that beta blockers produced a 25 percent reduction in mortality. The authors emphasize that beta blockers should be used instead of calcium channel blockers in patients with a history of myocardial infarction.
RICHARD SADOVSKY, M.D.
Mendelson G, Aronow WS. Underutilization of beta-blockers in older patients with prior myocardial infarction or coronary artery disease in an academic, hospital-based geriatrics practice. J Am Geriatr Soc 1997 November;45:1360-1.
Ulcer Recurrence After Eradication of H. pylori
The pathogenic role of Helicobacter pylori in chronic active gastritis and duodenal ulcer disease is well documented. Ulcer relapse has been reported despite treatment or eradication of H. pylori infection. However, concomitant use of nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin, or incomplete eradication of H. pylori may account for these recurrences. Van der Hulst and colleagues conducted a prospective review of patients after active ulcer healing and eradication of H. pylori infection to assess the long-term incidence of ulcer relapse.
Active ulcer healing was confirmed by endoscopy, and eradication of H. pylori was confirmed by culture and histology. A total of 247 patients were enrolled in the study, and 186 patients (141 with duodenal ulcers and 45 with gastric ulcers) met the criteria. Patients were excluded if they had evidence of infection or were taking NSAIDs, aspirin or maintenance therapy with histamine H2 antagonists. Study subjects underwent a series of endoscopic examinations with biopsy every three months for one year. Eradication of H. pylori was accomplished with a variety of therapies. Recurrence was defined as confirmed peptic ulcer disease based on endoscopic examination in patients whose initial ulcer had been healed as confirmed by an initial endoscopic examination.
None of the patients with an original duodenal ulcer had a relapse for a median follow-up period of 2.6 years. In patients with an original gastric ulcer, none had a recurrence for a median follow-up period of 2.5 years. This complete absence of relapse after successful eradication of H. pylori was consistent even in patients with a maximum follow-up of 9.8 years in the gastric ulcer group and 9.2 years in the duodenal ulcer group. Infection did not recur in any of the patients.
The authors conclude that ulcer relapse does not occur after complete eradication of H. pylori, even after a follow-up period of up to 9.8 years. Their results differ from other studies in that their patients did not take NSAIDs or aspirin during the study. Eradication of H. pylori should be mandatory in patients with duodenal or gastric ulcer disease, since eradication helps prevent recurrence.
RICHARD SADOVSKY, M.D.
Van der Hulst RW, et al. Prevention of ulcer recurrence after eradication of Helicobacter pylori: a prospective long-term follow-up study. Gastroenterol 1997 October; 113;1082-6.
Adolescent Diabetes and Use of Insulin-like GrowthFactor-1
Recent studies have emphasized the importance of sustained glycemic control to prevent long-term microvascular complications in patients with type 1 (insulin-dependent) diabetes mellitus. Such control is difficult to achieve in adolescents, partly because the hormonal changes of puberty substantially influence insulin sensitivity. Even with intensive insulin therapy, good glycemic control may be difficult to achieve in adolescents, particularly during the night. Acerini and colleagues conducted a randomized, double-blind, placebo-controlled trial to determine if adding insulin-like growthfactor-1 to insulin therapy in adolescents with type 1 diabetes would improve insulin sensitivity and glycemic control.
The authors studied 53 patients from 10 to 20 years of age (median age: 16 years) with type 1 diabetes mellitus of at least two years' duration who received insulin therapy three to four times a day. The 26 males and 27 females were randomly assigned to one of three groups. Eighteen patients in each of the two treatment groups self-administered insulin-like growthfactor-1 in dosages of 20 or 40 µg per kg daily for 24 weeks. A control group of 17 patients self-administered placebo. Patients were asked to test blood glucose levels twice daily and to adjust insulin dosage accordingly to achieve and maintain ideal blood sugar levels. The investigators maintained close contact with study patients through patient visits and telephone calls every two to four weeks. Routine biochemical measures, including glycated hemoglobin (HbA1c) were assessed every four weeks. Glomerular filtration rates and retinal photographs were taken at the beginning of the study and at 24 weeks, after completion of treatment. Patients were followed for an additional eight weeks after completion of treatment.
The patients in the three groups were comparable in age, body mass index and baseline HbA1c. Six patients withdrew from the study, mainly because of difficulty in following the protocol, leaving 15 patients in the placebo group, 14 patients who received 20 mg per kg of insulin-like growthfactor-1 and 18 patients who received 40 mg per kg of insulin-like growthfactor-1. Concentrations of serum insulin-like growthfactor-1 increased in a dose-response manner in the treatment groups, peaking at week 12. HbA1c levels in patients treated with 40 mg per kg were significantly lower compared with the placebo group, without any associated change in body-mass index, insulin dosage, rate of hypoglycemia or evidence of adverse effect on retinal vasculature or glomerular filtration rate. The greatest change occurred within the first 12 weeks of therapy.
By week 24, levels of insulin-like growth factor-1 had declined, possibly as a result of compliance problems, and HbA1c levels were not significantly different among the three groups. No significant differences were found among the groups in total daily insulin dosage, body mass index, glomerular filtration rate, number of adverse effects or other biochemical variables.
The authors conclude that insulin-like-growthfactor-1 in a dosage of 40 mg per kg per day as an adjunct to insulin therapy can improve HbA1c values in adolescent patients with type 1 diabetes without obvious adverse effects. They call for further studies to identify patients who can benefit most from this treatment approach and also to identify the optimal dosage of insulin-like growthfactor-1 and duration of treatment. Although the loss of therapeutic effect toward the end of this trial may have been related to compliance problems, the possibility of problems with long-term bioavailability or effectiveness of insulin-like growthfactor-1 cannot be ruled out.
ANNE D. WALLING, M.D.
Acerini CL, et al. Randomised placebo-controlled trial of human recombinant insulin-like growth factor 1 plus intensive insulin therapy in adolescents with insulin-dependent diabetes mellitus. Lancet 1997 October 25;350:1199-204.
Strength Training in Cardiac Rehabilitation Patients
Traditional cardiac rehabilitation programs do not consistently address both the physical and the psychologic well-being of patients. The addition of high-intensity strength training (which has been reported to decrease depression and improve mood in other patients) to traditional cardiac rehabilitation programs may offer an opportunity to improve mood as well as physical function in these patients. Beniamini and associates evaluated the effect of added strength and flexibility training on self-efficacy, mood states and psychologic well-being in cardiac rehabilitation patients.
Thirty-eight patients enrolled in a cardiac rehabilitation program were randomized to undergo either high-intensity strength training or flexibility training in addition to regular aerobic exercise. Patients completed standardized questionnaires to measure self-efficacy, mood states and perception of health status two weeks before and two weeks after the training programs.
Clinical characteristics of both groups were similar at the beginning of the study. Patients in the high-intensity strength training group experienced significant improvements (30 to 100 percent) in self-efficacy scores for areas such as lifting, pushing, climbing, walking and jogging. These patients also had significantly improved mood states and overall perceptions of physical and emotional well-being. Patients in the flexibility group showed no significant changes. In addition, patients in the strength training group showed improvements in physical function, perception of pain, vitality and role emotional-health domains.
The authors conclude that high-intensity strength training is a safe, effective and relatively inexpensive addition to traditional cardiac rehabilitation programs, especially when supervised by a professional exercise specialist or physical therapist. Actual improvements in strength and perceived self-efficacy appeared to be responsible for improvements in mood in patients in the strength training group.
RICHARD SADOVSKY, M.D.
Beniamini Y, et al. Effects of high-intensity strength training on quality-of-life parameters in cardiac rehabilitation patients. Am J Cardiol 1997 October 1;80:841-6.
Phyto-estrogens in the Etiology of Breast Cancer
Strong epidemiologic evidence implicates diet as a factor in the development of breast cancer. Recent theories have focused on the phyto-estrogens (isoflavonoids and lignans) that are found in many edible plants. When consumed, phyto-estrogens are metabolized by bowel microflora, and the resulting compounds have antiangiogenic, estrogenic and antiestrogenic properties, as well as the ability to inhibit several enzymes. In cell culture and animal experiments, these compounds have also been shown to inhibit tumor development. Further evidence of a possible protective effect comes from the observation that populations consuming large quantities of phyto-estrogens from soy-rich diets have lower rates of breast and other cancers. Ingram and colleagues studied the association of dietary phyto-estrogen and breast cancer in Australian women.
A total of 144 women with breast cancer were matched with control subjects selected according to age and area of residence. Women in both the study group and the control group were interviewed using a standardized questionnaire to elicit detailed information regarding demographic, reproductive and lifestyle characteristics. Participants also provided three consecutive 24-hour urine specimens and a blood sample. The urine samples were analyzed for lignans and isoflavonoid phyto-estrogens, and for urea and ammonia so that a measure of total nitrogen excretion could be obtained as an index of total food intake.
Initial analyses showed a substantial reduction in the risk of developing breast cancer in women with increasing excretion of phyto-estrogen metabolites, particularly equol (an isoflavin). This substantial effect persisted for equol and enterolactone (a lignan) after adjusting for age at menarche, parity and nutritional variables such as alcohol intake and total fat intake. For equol, the risk of developing breast cancer for women in the highest quartile of excretion (after adjusting for confounding variables) was one quarter that of women in the lowest quartile of excretion. For enterolactone, the comparable reduction in risk was one third. Other phyto-estrogens were associated with reductions in risk that did not reach significance.
The authors conclude that their findings support earlier studies that show increased excretion of phyto-estrogens is associated with a substantial reduction in the risk of developing breast cancer. This theory also has biological plausibility as these compounds inhibit the growth and development of hormone-dependent cells. Because the compounds are weakly estrogenic, it is suggested that they reduce the amount of circulating estrogen. However, the exact mechanisms of the suggested anticarcinogenic effect are not understood. In the absence of other primary prevention for breast cancer, the cultural movement toward increased consumption of foods containing phyto-estrogens appears to be potentially beneficial.
ANNE D. WALLING, M.D.
Ingram D, et al. Case-control study of phyto-oestrogens and breast cancer. Lancet 1997 October 4;350:990-4.
Olestra in Patients With Inflammatory Bowel Disease
The fat substitute olestra is a mixture of hexa-, hepta- and octaesters of sucrose that are formed from any edible oil. It is not absorbed from the intestines and therefore contributes no calories to the diet. It has been shown to be safe for consumption in healthy volunteers. However, other food additives, such as sorbitol, have been found to be associated with gastrointestinal distress in patients with certain types of bowel disease. Zorich and colleagues prospectively evaluated changes caused by olestra in the disease state of patients who were undergoing remission of certain types of chronic inflammatory bowel disease.
Adult patients were included in the study if they had a history of mild to moderate Crohn's disease or ulcerative colitis for at least two years and if the disease was in remission at the beginning of the study period. Patients who had had more than three relapses in the past year were excluded. Patients in the study group were not currently receiving oral or topical (rectal) steroid therapy or mesalamine suppositories and were not taking more than 3.5 g of sulfasalazine treatment per day. Patients were randomized to eat either 20 g of olestra-containing snacks and cookies or conventional vegetable triglyceride-containing snacks and cookies daily for 28 to 31 days. Patients were evaluated weekly by telephone or at the study site and were also interviewed four weeks after they last consumed the study product or conventional product. Patients kept track of their consumption of the assigned product and their well-being and disease state.
Forty-three patients with ulcerative colitis and 46 patients with Crohn's disease were included in the study, and 83 of these patients were available for inclusion in the final analysis. Forty-four patients were assigned to the olestra group and 45 were assigned to the triglyceride group. There was no significant difference in the number of patients who relapsed or had worsening symptoms. Three patients in the olestra group (7 percent) versus four patients in the triglyceride group (10 percent) had worsening symptoms without relapse. One patient in the olestra group (2 percent) relapsed, compared with no relapses in the triglyceride group. A few patients experienced increases in stool frequency or other gastrointestinal symptoms several weeks after the consumption period, but none of these symptoms appeared to be related to the ingestion of olestra. A total of 27 patients in the olestra group (61 percent) had adverse events, compared with 64 percent of the triglyceride group.
The authors conclude that 20 g of olestra ingested daily for one month does not affect the disease activity of patients with quiescent inflammatory bowel disease.
RICHARD SADOVSKY, M.D.
Zorich NL, et al. A randomized, double-blind study of the effect of olestra on disease activity in patients with quiescent inflammatory bowel disease. Am J Med 1997 November;103:389-99.
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