Clinical Briefs

By Louis Kuritzky, MD

Peripheral Arterial Disease Detection, Awareness, and Treatment in Primary Care

Peripheral arterial disease (PAD) causes substantial morbidity, and is associated with significant mortality, particularly referable to cardiovascular events. Compared to other vasculopathies like stroke and myocardial infarction (MI), which are associated with high levels of public awareness and commonplace incorporation of risk factor reduction on the part of the clinical community, PAD is relatively neglected. The PARTNERS program evaluated detection of PAD in the office setting, hypothesizing that PAD is underdiagnosed and undertreated in primary care.

Patients (n = 6979) from 350 primary care sites older than age 70 (> age 50, if a smoker or diabetic) were screened for PAD using a Doppler device to obtain the ankle-brachial index (ankle systolic blood pressure divided by brachial systolic blood pressure). Since ankle blood pressure should be equal to or greater than brachial, an ABI less than 0.9 is indicative of clinically relevant PAD.

PAD was found in 29% of study subjects, of which the majority had not been previously diagnosed. Less than 10% of PAD subjects were symptomatic. Only half of physicians were aware of the PAD diagnosis in persons previously diagnosed.

Attending to cardiovascular risk factor analysis, Hirsch and colleagues note that smoking cessation had been applied to only half of PAD subjects, and management of both hypertension and hyperlipidemia were less intensive than in comparable patients with cardiovascular disease. PAD, a harbinger of other cardiovascular mortal and morbid end points, has been demonstrated to be underdiagnosed and less intensively managed than other comparable vasculopathies.

Hirsch AT, et al. JAMA. 2001;286: 1317-1324.

Widespread Distribution of UTIs Caused by a Multidrug-Resistant E coli Clonal Group

The majority of American women will experience a urinary tract infection (UTI) in their lifetime, and as many as 11% of women report at least 1 UTI per year. Although most Escherichia coli strains involved in UTI are susceptible to trimethroprim-sulfamethoxazole, currently more than 15% of isolates are resistant. Since certain clonal strains of E coli have caused outbreaks of cystitis and pyleonephritis in Europe, the question has been raised whether there is a specific clone of E coli in the United States that has been etiologic in TMP-SMX-resistant UTI.

Study subjects were obtained from a population of California women with symptoms of UTI who cultured positive for E coli resistant to TMP-SMX over a 14-week period beginning October 1999; the results were compared with analyses of E coli from women with UTI in Michigan and Minnesota.

Considering isolates from all 3 states, 38-50% TMP-SMX resistant E coli belonged to a single clonal group. The method of spread of this clonal group is unknown, but the suggestion has been made that contaminated food could harbor such strains.

Manges AR, et al. N Engl J Med. 2001;345:1007-1013.

Selective Postoperative Inhibition of GI Opioid Receptors

Major abdominal surgery consistently produces some degree of ileus, which not only may cause pain, nausea, and vomiting, but also delays return to oral feeding. Ultimately, ileus prolongs hospitalization. The common causes of ileus include the mechanical effects of surgical bowel manipulation, and opioids used in pain management. Opioid analgesia results in anticholinergically derived reductions in bowel motility.

ADL 8-2698 (ADL) is an investigational agent that blocks the gastrointestinal effects of opioid analgesics; because it is poorly absorbed when administered orally, and does not cross the blood-brain, coadministration with opioid analgesics is possible without blockade of opioid-induced centrally-mediated analgesia. The current study included 78 patients who underwent significant abdominal surgery. Patients were randomly assigned to ADL or placebo, both administered orally twice daily.

Participants who received ADL enjoyed shorter time to first passage of flatus (49 vs 70 hours), earlier first bowel movement (70 vs 111 hours), and earlier discharge from the hospital (68 vs 91 hrs). No serious adverse events were reported; indeed, ADL was associated with reduced nausea and vomiting. ADL offers promise as a tool to circumvent anticholinergic effects of postoperative opioid analgesia.

Taguchi A, et al. N Engl J Med. 2001; 345:935-940.

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