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By Louis Kuritzky, MD
A Strategy to Reduce Cardiovascular Disease by More Than 80 Percent
Despite impressive results in cardiovascular risk reduction by applying an individual treatment (eg, statin, antihypertensive), the effect of multiple risk factor reduction has been much more elusive to quantify. Wald and Law suggest that the literature supports consideration of a combination product they call the Polypill which is a multicomponent pill containing treatments which have demonstrated efficacy to reduce CV end points by means of LDL reduction, blood pressure control, attenuation of platelet aggregability, and reduction of homocysteine (although data referable to homocysteine is predominantly observational at this time). They base their suggested composition of the Polypill upon numerous large randomized, controlled trials and metaanalyses.
Their suggested Polypill would contain either atorvastatin 10 mg or simvastatin 40 mg, 3 different antihypertensives at half-standard dose (thiazide + ARB + CCB would be best tolerated, but thiazide + beta blocker + ACE would be less expensive, albeit at almost triple that adverse effect incidence profile), folic acid 800 mg and 75 mg of ASA. Wald and Law are remarkably optimistic in their anticipation of benefits for persons older than 55 without previous CV end points: They claim, "As 96% of deaths from IHD or stroke occur in people aged 55 and over, treating everyone in this group would prevent nearly all such deaths." They go on to opine that risk factor measurement prior to institution of the Polypill would be unnecessary, since risk reduction has been demonstrated regardless of initial risk level. Wald and Law acknowledge the radical nature of their suggestions, but support the rationale with highly attractive potential benefits.
Wald NJ, Law MR. Prog Cardiovasc Dis. 2003;46:31-38.
Pearly Penile Papules: Still No Reason for Uneasiness
It is not uncommon for adult men to present to clinicians with lesions on their penis, which ultimately turn out to be pearly penile papules (PPP). These lesions appear around the margins of the glans and have been sometimes mistaken for condylomata from human papilloma virus (HPV). Indeed, some early reports misattributed PPP to HPV. Recent polymerase chain reaction specimens have failed to demonstrate HPV in PPP. Pathologic and histologic studies have shown that these small, punctuate lesions are angiofibromata, are covered with normal squamous epithelium, and may occur on the glans or corona of the penis. Because these are normal structures, patients who present with PPP should be reassured that no treatment is required.
In this trial, Hogewoning et al assayed PPP lesions in adult men (n = 71) and were unable to find any association between PPP and HPV. In the occasional case where HPV was detected in other, non-PPP skin lesions, the HPV varieties were those of low risk for carcinogenesis. PPP is an innocent cutaneous lesion, which does not have precancerous potential, nor does it predict involvement with HPV. Clinicians should reassure concerned patients about the benignity of the disorder.
Hogewoning C, et al. J Am Acad Dermatol. 2003;49:50-54.
The Epidemiology of Major Depressive Disorder
The first major national population survey to establish the demographics of depression using DSM III criteria occurred 1990-1992 and reported a lifetime prevalence of 14.9%, with 12 month prevalence of 8.6%. Since that report, an evolution of diagnostic criteria (ie, DSM IV) coupled with an enhanced public and professional awareness of the seriousness, prevalence, and treatability of depression, have occurred. These changes were pertinent for a new national survey to update prior information. The National Comorbidity Survey (NCS) is data collected from face-to-face interviews with a representative cross-section of the adult American public (n = 9090) in 2001-2002.
According to NCS data, the lifetime prevalence for major depressive disorder was 16.2%, which equates to 32-35 million Americans affected during their lifetime. Disturbingly, the number of days "out of role" because of depression was more than twice that seen for most other chronic conditions. Of all the persons who had suffered depression within the last 12 months, slightly more than half had received treatment for it. Depression remains a prevalent and costly condition in America.
Kessler RC, et al JAMA. 2003;289:3095-3105.
Dr. Kuritzky, Clinical Assistant Professor, University of Florida, Gainesville, is Associate Editor of Internal Medicine Alert.