Prevention of Hip Fracture in Elderly People with Use of a Hip Protector

Source: Kannus P, et al. N Engl J Med 2000;343:1506-1513.

Despite enhanced pharmaco-logic therapies for osteoporosis prevention and treatment, hip fractures remain an important individual and public health problem. Since the mean age of the population continues to increase, it is likely that management of hip fracture will become even more pertinent. In this study, Kannus and associates report on the use of a hip protector (specifically, KPY Hip Protector, Respecta, Helsinki, Finland) worn to reduce the effect of trauma upon the hip. Each patient in the treatment group (n = 653) wore bilateral 19 cm conical padded hip protectors daily.

During the study period, compliance with the device was a modest 48% (i.e., treatment group participants actually wore the devices only half the days). Nonetheless, almost three-quarters of the falls that occurred in this group happened while wearing protectors. There were 13 treatment group patients who had a hip fracture vs. 67 control subjects (relative hazard = 0.4). Similarly, the pelvic fracture rate was halved by use of the hip protector, despite the fact that some fractures occurred in the treatment group while they were not wearing their protectors. Adverse reactions attributable to wearing the protectors were few and generally inconsequential. Protective padding, for those willing to use it, offers an effective preventive for hip fracture.

The Effect of Fecal Occult-Blood Screening on the Incidence of Colorectal Cancer

Source: Mandell JS, et al. N Engl J Med 2000;343:1603-1607.

As demonstrated by both randomized and observational studies, the mortality rate of colorectal cancer (CRC) is reduced by fecal occult blood testing (FOBT). The favorable effect of FOBT upon CRC mortality has been attributed to earlier stage of tumor at time of detection, surgical excision of tumors, and removal of premalignant lesions. This report details the results at 18 years of follow-up for participants in the Minnesota Colon Cancer Control Study (n = 46,551), which used annual, biennial, or "usual care" for FOBT screening. Persons with any positive FOBT were offered colonoscopy.

The cumulative incidence of CRC in both screening groups was significantly (17-20%) less than in the control group. Mandell and colleagues challenge the theory suggested by others that mortality reduction is a consequence of chance tumor detection at colonoscopy; they suggest that it is the sensitivity of FOBT testing that is responsible for the improved outcome. No significant difference was found between yearly vs. every two years of FOBT screening.

Patient Preferences for Laboratory Test Results Notification

Source: Meza JP, Webster DS. Am J Manag Care 2000;6:1297-1300.

Smooth and successful functioning of clinical care depends upon appropriately informing patients of laboratory test results. In recent studies, less than one-third of physicians routinely notified patients of normal results. Perhaps surprisingly, these same data reflected that more than one-third of physicians do not always notify patients even if results of laboratory tests are abnormal. This study investigated by telephone questionnaire (n = 49) patient responses to inquiry about lipid testing as part of their hypercholesterolemia evaluation. Inquiry detailed if they had been informed of results, the method used for informing, their level of satisfaction, and their personal preference for notification.

Most patients (85%) were notified about results by phone, mail, or at a subsequent visit. A resounding concordance of patients (93.9%) indicated that they believed that patients should be informed of all results, normal or abnormal, generally preferring notification by mail (63%) or telephone (13%). Patients who did receive notification of lab results were statistically significantly more satisfied than those who did not. The increased level of satisfaction was true whether results were abnormal or not. Meza and Webster conclude that patient satisfaction may be improved by routinely informing patients of laboratory test results.

Short-term Prognosis After Emergency Department Diagnosis of Transient Ischemic Attack

Source: Johnston SC, et al. JAMA 2000;284:2901-2906.

Short-term outcome after transient ischemic attack (TIA) has been a topic investigated in only a few settings. Confirmation of TIA diagnosis may be contentious, since seizure, syncope, migraine, and other etiologies can be mistaken for TIA. This study evaluated persons presenting to emergency departments (EDs) in a single health maintenance organization over one year with a diagnosis of TIA (n = 1707).

Within 90 days after presentation to the ED, 10.5% of patients suffered a completed stroke. Although TIA patients who received anticoagulation at discharge from the ED were subsequently more likely to suffer a completed stroke, it has been suggested that perhaps those individuals were perceived to have been at greater stroke risk at the time of ED presentation. A favorable trend toward stroke reduction was seen in antiplatelet recipients (e.g., aspirin, ticlopidine). Five items were determined to be independent risk factors for stroke within 90 days: age older than 60, diabetes, TIA enduring over 10 minutes, weakness with TIA, and speech impairment with TIA. n

A Comparison of Moxifloxacin and Azithromycin in the Treatment of Acute Exacerbations of Chronic Bronchitis

Source: Kreis SR, et al. Journal of Clinical Outcomes Management 2000;7(12):33-37.

Optimum treatment for acute exacerbations of chronic bronchitis (AECB) remains a matter of heated debate. Because AECB are common and a substantial minority of such cases result in hospitalization, refining treatment choices may help clinicians improve outcomes.

The trial enrolled 401 patients with AECB, defined as increased sputum purulence plus increased sputum volume, cough, or dyspnea. Patients were randomized to receive a five-day course of moxifloxacin (n = 203) 400 mg qd, or azithromycin (n = 198) 500 mg day 1, then 250 mg qd ´ 4. At the test of cure visit, patient outcomes were examined including the number of days until symptom relief, days until resuming normal activity, and hours of work missed.

Both regimens were highly effective for clinical resolution. Patients in the moxifloxacin group had a slightly more rapid recovery (symptomatic relief by day 3: moxifloxacin = 40%, azithro-mycin = 27%). Kreis and associates conclude that moxifloxacin is as effective for AECB resolution and may offer more rapid return to normal activities for some individuals.

Urine Detection of Survivin and Diagnosis of Bladder Cancer

Source: Smith SD, et al. JAMA 2001;285:324-328.

Bladder cancer accounts for more than 10,000 deaths annually in the United States. Recently, survivin (SVN), a dysregulator of apoptosis, has been implicated in a variety of cancers, including bladder cancer. SVN prolongs apoptosis. It has been theorized that by abnormally prolonging cell life, mutation accumulation occurs. Normal tissue does not have SVN, but it is prominent in a number of cancers, and its presence is associated with worse outcome. Since SVN has been found in almost 80% of bladder cancers, its use as a screening tool for bladder cancer was the subject of this investigation.

Abnormal levels of urine SVN were found in all 46 patients with a diagnosis of new or recurrent bladder cancer. Among healthy volunteers, and persons with other urologic cancers, urinary SVN levels were normal. Dramatizing the potential case-finding value of the tool in three patients with hematuria who were urine SVN positive, one demonstrated bladder cancer by cytology, and another developed bladder cancer within six months of evidencing an elevated urinary SVN level. Urinary SVN had a sensitivity for new or recurrent bladder cancer of 100%. Smith and associates comment that the single-antibody urine test for SVN is now commercially available and may function well in a number of clinical settings for detection and monitoring of bladder cancer.