Clinical Briefs

By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville, and Associate Editor of Internal Medicine Alert.

Folate and Mecobalamin on Hip Fx in Stroke Patients

Hip fractures (HIP) occur 2-4 times more commonly in persons who have sustained a stroke than in an age-matched population. Amongst these individuals, fractures occur more commonly on the same side as the stroke; bone mineral density (BMD) studies have shown a corresponding decline in BMD on the paretic side, compared with the non-involved side.

Homocysteine levels have been associated with risk for ischemic stroke; indirect evidence indicates that elevated homocysteine levels may also be related to osteoporosis, since individuals with homocysteinuria (and concomitant marked elevations in homocysteine) demonstrate increased osteoporosis. Whether modulation of homocysteine by means of folate and B12 administration might effect HIP was the clinical question posed by this study.

Patients (n = 628) who had suffered an ischemic stroke resulting in hemiplegia at least 1 year prior to enrollment and were aged 65 or older were randomized in a double-blind fashion to folate and B12 vs placebo. Subjects were followed for 2 years.

The baseline homocysteine level was elevated in both groups. Folate/B12 supplementation resulted in a 38% decline in plasma homocysteine (compared with a 31% increase in the control group), and was associated with a dramatic 80% risk reduction in hip fractures (10 fractures in the treatment group, 43 in the placebo group)! No adverse effects of folate/B12 were identified. This is the first such study to demonstrate these highly favorable results, but many clinicians may be sufficiently impressed with the efficacy (combined with safety) that they consider inclusion of folate and B12 for persons who have suffered a hemiplegic ischemic stroke.

Sato Y, et al. JAMA. 2005;293: 1082-1088.

Accuracy of Clinical BP Measurement?

Benefits accrued as a result of hypertension (HTN) treatment are based upon results of large, randomized, clinical trials, some of which do not provide thorough details about the method in which blood pressure (BP) was measured. Such issues as posture, timing, and time in repose have been reported to influence BP, but there are little data that specifically addresses variation in BP based upon these parameters obtained from a large population.

Sala and colleagues selected 540 consecutive male and female patients with essential HTN who were attending an Italian hospital clinic for a routine visit. BP was measured as follows: 1) seated in a chair, after 5-10 minutes had elapsed during history taking, with the arm supported on a desk at mid-sternum level, feet on the floor; 2) supine, after 5 minutes, at the end of the visit; 3) seated on the side of a bed for 3-5 minutes with the back unsupported, arm supported by the operator at mid-sternum level, feet on a foot stool; and 4) after standing for 3-5 minutes. A mercury-based sphygmomanometer was used.

Mean BP was statistically significantly lower when chair-seated (143.5/87.2) than BP measured supine (153.4/89.7), sitting on a bed (148.9/90.9), or standing (144.8/91.7). Other methods of measurement may produce meaningful deviations from BP that would be obtained using the guidelines recommended methodology.

Sala C, et al. Am J Hypertens. 2005;18:244-248.

Sexual Problems Among Women and Men Aged 40-80

The Global Study of Sexual Attitudes and Behaviors is a database of 13,882 women and 13,618 men from 29 countries. Data were obtained in a variety of methods, including in-person or telephone interview (Westernized nations) or mail-in questionnaire (Middle-East, some countries in Asia, Africa). The population includes adults aged 40-80, regardless of marital status or gender orientation.

Worldwide, sexual problems were most frequent in Eastern and Southeast Asia. The most common problem for women was lack of interest in sex (ranging from 26-43% among different nations), followed by inability to reach orgasm (range, 18-41%). Amongst men, premature ejaculation was the most common difficulty (12.4% in the Middle East, 30.5% in Southeast Asia). Erectile dysfunction was next most common in men, with similar prevalence of lubrication difficulties in women.

Financial problems and depression were consistently associated with sexual dysfunction in women. Erectile dysfunction was associated with lower educational achievement. Sexual dysfunction is commonplace in American men and women; this global vantage point provides a perspective about the worldwide burden of sexual dysfunction.

Laumann EO, et al. Int J Impotence Research. 2005;17(1):39-57.