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Source: Hawker GA, et al. N Engl J Med 2000;342:1016-1022.
Gender discrimination has been suggested to have played a role in the use of a variety of medical and surgical procedures, including coronary revascularization and renal transplantation, but the data are inconclusive since gender differences for disease prevalence, contraindications to surgery, and personal preference are scanty and may have an important effect.
Hip and knee arthroplasty (HNA) improve symptoms and reduce disability in persons with advanced arthritic disease. Although more women than men undergo HNA, these data are confounded by the fact that women demonstrate a higher incidence of hip and knee arthritis, as well as osteoporotic hip fracture. The intention of this report was to evaluate whether gender differences exist as far as need for, or willingness to undergo, arthroplasty are concerned.
Women were slightly more likely than men to report chronic hip or knee problems (OR = 1.16). Despite the greater self-reported osteoporosis and arthritis among women, they were less likely than men to have undergone HNA (OR = 0.78). Women reported having discussed HNA with their physician less often than men (32% vs 42%), and this gender disparity persisted when adjusted for age and disease severity.
In Hawker and colleagues’ final analysis, they conclude that although HNA is underused by both genders, underuse is more substantial for men than women. The fact that women appear to initiate discussion about their arthritis or seek a surgical solution less often than men may be part of the explanation for the observed disparities.
Source: Wong JB, et al. Am J Med 2000;108:366-373.
Although interferon (ifn) can transiently eliminate virus from the serum in almost half of hepatitis C-infected individuals, most relapse, with or without sustained treatment. Fortunately, combining ribavirin (RBV) with interferon (RBV/IFN) is able to produce undetectable virus levels in almost half of patients who relapse after IFN monotherapy. Unfortunately, RBV/IFN costs almost three times as much as IFN alone, calling into question the cost-effectiveness of this regimen.
Using short-term clinical trial data to predict short-term events, and a long-term model based upon the natural history of chronic hepatitis C, Wong and colleagues evaluated the cost-effectiveness of RBV/IFN vs. IFN alone, including patients who relapse after IFN monotherapy. Estimates below reflect model projections.
RBV/IFN would decrease lifetime major hepatic consequences (e.g., cirrhosis, CA, hepatic failure/death) by up to 20%, thereby reducing lifetime medical costs by almost $5000, and increasing life expectancy by 4.2 quality-adjusted life years. Patients with moderate hepatitis (as compared with mild) would be anticipated to enjoy greater cost efficacy, since they are inherently more likely to suffer progression of disease.
Wong et al conclude that their analysis supports a six-month course of RBV/IFN for patients who have relapsed after IFN monotherapy, both on a cost and mortality reduction basis.
Source: Balluz LS, et al. Arch Fam Med 2000;9:258-262.
Vitamin and mineral supplements (V&M) represent the third largest over-the-counter (OTC) drug category used in America, yet there are scant data to define the frequency, type, and diversity of use of this class of product. A dietary supplement is defined as "a product other than tobacco intended to supplement the diet that bears or contains one or more of the following dietary ingredients: a vitamin, a mineral, an herb or other botanical, an amino acid, or a dietary substance for use by man to supplement the diet" (adapted from the Dietary Supplement Health and Education Act of 1994). Household questionnaires were administered to almost 34,000 persons with inquiry about V&M administration.
Approximately 40% of respondents reported V&M use over the past month. In this group of products, vitamin C was the most commonly used ingredient, followed by vitamin B12, B6, niacin, thiamin, B2, vitamin E, vitamin A, vitamin D, and folic acid. Persons with higher levels of education were more likely to take V&M, as did persons with higher income and those living in the western regions of the United States.
The dramatically high frequency of V&M use by patients suggests that clinicians might routinely inquire about habits of their patients in this sphere, lest potential toxicity go undetected.
Source: Pulmonary Embolism Prevention Trial Collaborative Group. Lancet 2000;355:1295-1302.
A variety of tools have been evaluated for their efficacy in reducing deep vein thrombosis (DVT) postsurgically and in other high-risk circumstances. Although heparin subcutaneously has been shown to reduce DVT risk by at least half, the benefit of this intervention remits once heparin is discontinued, usually at the time of hospital discharge. Despite the fact that antiplatelet therapies have been shown to reduce risk of myocardial infarction (MI) and stroke, they have not been generally embraced as effective DVT prevention. Meta-analysis of antiplatelet therapy postsurgically indicates a 40% reduction in DVT and a 66% reduction of pulmonary embolism (PE). The current trial was devised to confirm (or refute) in a single prospective trial whether low-dose aspirin would reduce DVT in an at-risk population, specifically, persons undergoing orthopedic surgical procedures.
From 1992 to 1998, 13,356 patients were randomized to 160 mg/d of aspirin (begun the day of surgical intervention in 82% of cases, preoperatively) or placebo. Patients were followed up to 35 days.
Aspirin treatment was associated with a 29% reduction in DVT and a 43% reduction in PE, compared with placebo. The frequency of fatal bleeding among hip fracture patients was the same in aspirin and placebo recipients. The only demonstrated bleeding consequence detected more often in aspirin subjects was the frequency of postoperative bleeding requiring transfusion (2.9% vs 2.4%). The authors conclude that low-dose aspirin reduces risk of PE, fatal PE, and DVT.
Source: Jen A, et al. J Allergy Clin Immunol 2000;105:732-738.
It is likely that most clinicians anticipate chronic daily administration of nasal steroid (NS) therapy for many of their patients who are established as sufferers of seasonal allergic rhinitis. On the other hand, since NS pathophysiologically prevents inflammation from developing, prevents allergic priming, and blocks the late allergic response, dose administration for mild disease may have a somewhat durable effect. In contrast, antihistamines block only the immediate allergic response and have less effect as allergy season becomes more established and the late allergic response more activated. This placebo-controlled study evaluated the use of fluticasone nasal spray (FNS) taken as needed for allergic rhinitis symptoms during allergy season (n = 56).
Over the course of 28 days, as-needed dosing resulted in an average of 14-16 dose administrations (placebo or FNS). Symptom scores among active drug recipients were dramatically lower (mean = 4.5) than placebo recipients (mean = 8.5), despite the fact that active medication was administered on only approximately half of the study days.
Jen and associates point out that it is likely that many patients administer NS less often than directed, or on an as-needed basis. This study suggests that even as-needed NS provides substantial relief to allergic rhinitis sufferers.
Source: Brady K, et al. JAMA 2000; 283:1837-1844.
Although post-traumatic stress disorder (PTSD) used to be commonly considered a disorder of soldiers exposed to combat stressors, we now recognize that physical and sexual assault may result in the same chronic symptoms. Literally, more than half of the entire U.S. population experiences at least one major traumatic event in their life, when one includes experiences like natural disasters, serious motor vehicle accidents, and witnessing serious injury to another.
The three characteristic domains of PTSD symptoms include re-experienced thoughts, avoidance of things associated with the trauma, and altered states of arousal when confronted with PTSD-associated factors. These symptoms may be chronic, with a median duration of 3-5 years. Few trials have addressed the efficacy of pharmacotherapy for PTSD. Since animal models of PTSD suggest that sertraline has some efficacy, and other SSRIs have shown some benefit, this large trial (n = 187) of men and women examined the effect of sertraline 50-200 mg q.i.d.
After 12 weeks of active treatment, three of four primary outcome measures were statistically significantly improved. Additionally, sertraline treatment was associated with improvement in social and occupational function and improved quality of life. Overall, more than half of patients were much improved, experiencing a 79% reduction in symptom severity. Brady and colleagues conclude that sertraline is an effective treatment for PTSD.