Clinical Briefs
Clinical Briefs
By Louis Kuritzky, MD
Syncope, Driving Recommendations, and Clinical Reality: Survey of Patients
Patients who suffer syncope disorders, similarly to those who have seizures, are at increased risk for themselves and others when driving. Detailed guidance has been devised for clinicians to assist patients in making decisions about the appropriateness of driving when seizure-free, and some countries have provided recommendations about driving for persons with syncope. For instance, the European task force guidelines state " . . . a person with recurrent syncope should be advised not to drive until a cause has been identified and symptoms are controlled." Whether patients choose to follow health professional guidance on such matters has been little studied.
Maas and colleagues studied patients (n = 104) from their cardiology practice who had been referred for consultation about syncope for a 28-month period. Patients were advised about driving in accordance with the European task force guideline, and were followed for 1 year. At contact 6 months after the initial consultation, the great majority of patients (78%) recalled receiving advice about driving. Remarkably, all (100%) of the patients who had been counseled not to drive had nonetheless continued to do so, unless they had already stopped driving prior to their arrival at the cardiologists’ office (n = 7). A substantial minority of patients (18%) did suffer recurrence of syncope during the study period, one incurring injury, and another suffering a driving misadventure that did not culminate in injury.
Adherence to clinician recommendations about driving appears inadequate, and new measures for enhancing compliance merit investigation.
Maas R, et al. BMJ. 2003;326:21.
Combination Treatment of Angiotensin-II Receptor Blocker and Angiotensin-Converting-Enzyme Inhibitor in Non-Diabetic Renal Disease (COOPERATE): A Randomized Controlled Trial
Angiotensin-converting-enzyme inhibitors (ACE) and angiotensin-II receptor blockers (ARB) have been demonstrated to provide significant benefits for persons with both diabetic and hypertensive nephropathy. Whether ACE + ARB will provide greater renal protection than either agent alone is an area of intensive study, with initial data suggesting that combination therapies will provide greater benefit.
Nakao and colleagues prospectively studied patients (n = 263) with nondiabetic nephropathy, with at least 300 mg/24 hr microalbuminuria. Patients were randomly assigned to ARB (losartan 100 mg/d), ACE (trandolapril 6 mg/d), or ACE + ARB. The primary end point was the combination of doubling of serum creatinine or end stage renal disease; secondary end points were changes in blood pressure, proteinuria, and adverse effects.
At 3 years’ follow-up, the combination therapy had performed substantially better than either monotherapy: primary end point was reached by 11% (ACE + ARB), 23% (ARB), and 23% (ACE). Similar benefits were seen in patients whether they were at the stage of microalbuminuria or had progressed to overt proteinuria. No severe adverse reactions were seen. Nakao et al have demonstrated substantial efficacy enhancement of ACE + ARB over either agent alone.
Nakao N, et al. Lancet. 2003;361: 117-124.
Early Onset of Action and Efficacy of a Combination of Calcipotriene and Betamethasone Dipropionate in the Treatment of Psoriasis
Both calcipotriene (dovonex®) and topical steroids (STR) have been proven effective in management of psoriasis. Calcipotriene (CPT) has been demonstrated to be more effective than steroids, and safe over long-term use (up to 1 year). The currently available delivery systems for topical CPT and topical steroids are not compatible. Since CPT and STR appear to work by different, potentially complementary mechanisms, the concept of combination therapy is appealing. Papp and colleagues assessed the efficacy of a new formulation containing both agents administered simultaneously.
This prospective, randomized, double-blind trial (n = 1028) compared CPT + STR vs CPT alone, STR alone, or vehicle alone. Subjects were followed for 4 weeks and assessed by the Psoriasis Area and Severity Index.
CPT + STR was statistically significantly more effective than either agent alone or vehicle. Additionally, onset of benefit was seen sooner with combination therapy. There was no increase in adverse events noted with application of the combination agent vs individual components. A combination CPT + STR product will be a welcome addition to psoriasis therapy.
Dr. Kuritzky is Clinical
Assistant Professor at the University of Florida in Gainesville.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.