Clinical Briefs
By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville
Dr. Kuritzky is a consultant for GlaxoSmithKline and is on the speaker’s bureau of GlaxoSmithKline, 3-M, Wyeth-Ayerst, Pfizer, Novartis, Bristol-Myers Squibb, AstraZeneca, Jones Pharma, and Boehringer Ingelheim.
Screening for Abdominal Aortic Aneurysms: Single-Center Randomized Controlled Trial
Recent guidance from the United States Preventive Services Task Force has affirmed the evidence-based value of screening male current/ex-smokers older than age 65 for abdominal aortic aneurysm (AAA). There remains some debate about whether screening should be offered to a broader patient population, for instance to include women, male non-smokers, or younger individuals. Lindholt et al studied a Danish population of men older than age 65 independent of smoking status to determine the value of AAA screening.
The study population included all men born in Viborg County, Denmark, between 1921-1929 (n = 12,639). In this cohort, half were ultrasound screened, and the other half served as the control group. An aneurysm was defined as an infra-renal aortic diameter > 3 cm. Identified aneurysms > 5 cm were referred to a vascular surgeon for elective repair; aneurysms < 5 cm were re-scanned on an annual basis. All subjects were followed for 5 years.
Ultrasound scanning identified 191 AAA subjects (4%). Screened subjects enjoyed 75% fewer emergency interventions for AAA, and an overall 67% reduction in AAA-related mortality.
These data encourage consideration of more widespread screening for AAA, to include non-smoking subjects.
Lindholt JS, et al. BMJ USA. 2005;5:222-224.
Comparison of Physical Treatments vs a Brief Pain-Management Program for Back Pain in Primary Care
Finding the optimum management plan to improve outcomes in low back pain (LBP) remains problematic. Generally, active treatments such as exercise and manual medicine have been found to be superior to no treatment. Increasingly, cognitive behavioral techniques have been used in an effort to enhance mobilization, reduce disability, and improve return-to-work status. Usually, cognitive behavioral techniques are applied in secondary care or referral settings.
A British patient population from 28 general practices provided adult study subjects (n = 402) with LBP of < 12 weeks duration. Subjects were randomly assigned to a brief pain management program (BPMP) or traditional physiotherapy (which functioned as the control) consisting of exercise and manual medicine interventions. Components of the BPMP included addressing psychosocial risk factors for persistent disability, an emphasis upon returning to normal activity by means of goal setting, and strategies to overcome psychosocial barriers to recovery. Positive coping strategies—including “hurt does not mean you are inducing harm” were encouraged.
At 12 months, outcomes in both groups were equivalent. Hay and colleagues point out that providing the BPMP required fewer sessions than traditional therapy, and fewer referrals to secondary care.
Hay EM, et al. Lancet. 2005;365: 2024-2030.
Visit Frequency and Hypertension
Despite a plethora of highly effective antihypertensive agents and lifestyle modulations (eg, diet, exercise) which can favorably affect blood pressure (BP), only a minority of hypertensive individuals in America are identified, on treatment, and controlled to < 140/90. One of the factors which might influence BP control is visit frequency (VF); that is, do patients who are seen more (or less) frequently obtain better BP control?
Literature on warfarin management might provide a precedent: the more often patients are seen, the better control of INR is achieved, albeit at greater cost and inconvenience to the patient. JNC VII guidance on hypertension (HTN) suggested monthly visits until stable, then 3-6 monthly; patients with stage 2 HTN or comorbidities are suggested to be seen more frequently than monthly.
To study the relationship between VF and HTN control, data from 2 family practice patient populations were reviewed (n = 429 patients, visit n = 7,910). The median interval to return visit was 45 days. Interval to return visit was shorter if BP was uncontrolled.
Overall, there was a significant correlation between shorter return visit intervals and percent change in BP.
Although these data come from an observational study, it suggests that shorter intervals between visits may favorably affect likelihood of good BP control.
Guthmann R, et al. J Clin Hypertens. 2005;7:327-332.
Recent guidance from the United States Preventive Services Task Force has affirmed the evidence-based value of screening male current/ex-smokers older than age 65 for abdominal aortic aneurysm.
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