Identification and Fracture Outcomes of Undiagnosed Low BMD in Postmenopausal Women

Clinical Briefs by
Louis Kuritzky, MD

Bone mineral density (BMD) measurement by dual-energy x-ray absorptiometry (DEXA) is currently the gold standard for identification of osteoporosis (OSPS) and osteopenia (OSPN). Measuring BMD at the hip and spine is expensive, and often not covered as a screening test for young women, many of whom may be suffering silent, but substantial, loss of bone. This report shares results from the National Osteoporosis Risk Assessment, which examined 200,160 ambulatory women older than age 50 who had no prior history of reduced BMD. BMD was obtained using a portable peripheral BMD assessment device that measures at the heel, finger, or forearm. Historical data obtained from the population of women included risk factors for osteoporosis; all women were postmenopausal.

Almost 40% of these women had OSPN, and 7.2% had OSPS (WHO criteria). Risk factors for reduced BMD were determined to be concordant with those already established in traditional literature: family history, age, ethnicity, smoking, use of glucocorticoids, lack of exercise, and low body mass.

That peripheral measurement of BMD is a functional method substantiated by the 4-fold increased rate of fractures subsequently found in women with peripheral DEXA-determined OSPS when compared with normal BMD women. This study is the largest ever conducted in United States, and adds substantially to our body of knowledge about minority women, since 18,000 of the population were minority women. Though the relative risk of OSPS and OSPN among African-American women was less than others, the fact that 32% had OSPN and 4% had OSPS mandates renewed clinician awareness of low BMD disorders in minorities.

Siris ES, et al. JAMA. 2001;286: 2815-2822.

Comparison of Cefuroxime With or Without Intranasal Fluticasone for the Treatment of Rhinosinusitis

The use of intranasal steroids (INS) is appropriate foundation therapy for many patients with allergic rhinitis. Since INS produce reduction in inflammation and edema of the nasal mucosa and turbinates, it is plausible that they might enhance drainage and function of sinuses involved with acute rhinosinusitis (ARS). To determine whether INS enhances recovery from ARS, Dolor and colleagues performed a double-blind, randomized, placebo-controlled study comparing cefuroxime axetil alone (250 mg b.i.d.) with cefuroxime plus intranasal fluticasone (2 puffs, 100 mcg/puff QD); all patients in both groups also received xylometazoline, a nasal decongestant. The diagnosis of sinusitis was confirmed by radiography as well as symptom criteria as established by the Task Force on Rhinosinusitis of the American Academy of Otolaryngology-Head and Neck Surgery.

Use of fluticasone resulted in both a higher proportion of clinical success and a more rapid time to clinical success, when compared with cefuroxime alone. The number needed to treat (NNT) with fluticasone to gain 1 additional cure was 6 patients.

Dolor et al conclude that fluticasone is beneficial when added to background antibiotic and decongestant therapy for ARS.

Dolor RJ, et al. JAMA. 2001;286: 3097-3105.

Lack of Clinical Significance of Early Ischemic Changes on Computed Tomography in Acute Stroke

It has been recommended, largely based upon the National Institute of Neurological Disorders and Stroke (NINDS) study, that patients presenting within 3 hours of stroke onset be considered for thrombolytic therapy with recombinant tissue plasminogen activator (rt-PA). In order to exclude stroke patients with cerebral hemorrhage as the cause of their acute stroke, baseline head CT is recommended. Although CT is highly effectively in ruling out hemorrhage, the subgroup of patients with edema or mass effect on CT has demonstrated in some studies a worsened risk of hemorrhage subsequent to rt-PA. Overall, despite this finding, nonhemorrhagic patients with edema or mass effect on CT who receive rt-PA still fared better than those who did not. Patel and colleagues analyzed CT early ischemic changes which have been brought to light since the NINDS by re-examining CT scans obtained in that study, and trying to determine if such changes are associated with response to rt-PA, clinical outcome, or development of post-rt-PA hemorrhage.

CT scans were evaluated in 616 patients. Early ischemic changes were not associated with any alteration in response to rt-PA, clinical outcome, or subsequent hemorrhage. Patel et al conclude that early ischemic changes do not add substantial impact to the criteria currently used for treatment decisions.

Patel SC, et al. JAMA. 2001;286: 2830-2838.

Dr. Kuritzky, Clinical Assistant Professor, University of Florida, Gainesville, is Associate Editor of Internal Medicine Alert.