8-1 COMPARISON OF AGREEMENT BETWEEN DIFFERENT MEASURES OF BLOOD PRESSURE IN PRIMARY CARE AND DAYTIME AMBULATORY BLOOD PRESSURE.
      The white coat effect is important in diagnosing and assessing control of hypertension. If ambulatory machine measurement is not available, repeated measurement by nurses or by patients themselves will result in fewer patients receiving unnecessary treatment or change in treatment.
      “It is time to stop using high blood pressure readings documented by general practitioners to make treatment decisions.”

8-2 OBESITY AND THE RISK OF HEART FAILURE
      Elevated BMI was associated with an increased risk of HF without evidence of a threshold
      Increased BMI was independently associated with an increased risk of HF. Given the high rates of obesity in the USA, strategies to promote optimal body weight may reduce the population burden of HF.

8-3 OBESITY AND HEART FAILURE – RISK FACTOR OR MECHANISM?
      Overweight and obesity are associated with increased rates of hypertension, coronary heart disease, left ventricular hypertrophy, diabetes, and the “metabolic syndrome”. All of these are important causes of HF. Nonetheless, BMI emerged as a significant independent and graded predictor of HF and remained so when other factors were analyzed together with BMI.
      The editorialist suggests some drug treatment preferences for obese patients: renin-angiotensin inhibitors, metformin, statins, and aspirin.

8-4 U.S CENTERS FOR DISEASE CONTROL AND PREVENTION GUIDELINES FOR THE TREATMENT OF SEXUALLY TRANSMITTED DISEASES: 2002 Guidelines
      Primary care clinicians may wish to file and consult this article to obtain the latest information. A table of selected recommendations for treatment of STDs appears on page 257. The authors include several new guidelines.

8-5 EFFECT OF HOMOCYSTEINE-LOWERING THERAPY WITH FOLIC ACID, VITAMIN B12, AND VITAMIN B6 ON CLINICAL OUTCOME AFTER PERCUTANEOUS CORONARY INTERVENTION.
      Homocysteine-lowering therapy with folic acid, vitamin B12, and vitamin B6 significantly reduced incidence of major adverse events after percutaneous coronary intervention. This strengthens the evidence linking the beneficial effects of folic acid, B12, and B6 in lowering homocysteine and the risk of atherosclerotic disease.

8-6 A PRIMARY CARE HOME FOR AMERICANS
      “It is clear that primary care in the United States is not designed to deliver the accessible, comprehensive, longitudinal and coordinated care required by a 21st century health care system.”
      “It is time for primary care to get its house in order. New ideas are needed”
      Suggestions for improvement are made. Economic factors constrain application.

8-7 WITHHOLDING ANTIBIOTIC TREATMENT IN PNEUMONIA PATIENTS WITH DEMENTIA
      In the Netherlands, antibiotic treatment is commonly withheld in severely demented nursing home patients with pneumonia. Especially if they are very frail.

8-8 HERPES ZOSTER: Clinical Review
      Treatment of pain in the acute phase: Pain can be very severe and should not be underestimated. Sympathetic blockade can provide rapid, temporary relief. Scheduled short-acting narcotics should be prescribed. For acute pain which persists, long-acting controlled release opioids (oral or transdermal) are preferred. Early attenuation of the pain may prevent initiation of central mechanisms of chronic pain, thereby reducing severity of post-herpetic neuralgia.
      Prevention of post-herpetic neuralgia: Antiviral therapy does not reliably prevent it. Hypothetically, combining antivirals with analgesics, tricyclic antidepressants, or anticonvulsants at onset of HZ could reduce the risk.
      Suggestions for treatment of post-herpetic neuralgia.

8-9 EFFICACY OF HANDRUBBING WITH ALCOHOL BASED SOLUTION VERSUS STANDARD HANDWASHING WITH ANTISEPTIC SOAP
      The rapid efficacy of alcohol solutions and their availability at the bedside make them an ideal substitute for conventional handwashing. Compliance is increased.

8-10 HAND-RUBBING WITH AN AQUEOUS ALCOHOL SCRUBBING SOLUTION VS SURGICAL HAND-SCRUBBING AND 30-DAY SURGICAL SITE INFECTION RATES
      Hand-rubbing with aqueous alcohol solution before surgical procedures was as effective as the traditional hand-scrubbing.
      It was better tolerated and improved compliance.
      “Hand rubbing with liquid aqueous alcoholic solutions can thus be safely used as an alternative to traditional hand-scrubbing.”

8-11 EMERGENCY CONTRACEPTION
      A review article. The public and patients should be educated about the difference between emergency contraception and abortion.
      Hormonal emergency contraception can substantially reduce the burden of unintended pregnancies. It does not interrupt a pregnancy. It prevents a pregnancy from starting.

8-12 NEW STRAINS OF BACTERIA AND EXACERBATIONS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE
      Isolation of new strains of bacteria are associated with acute exacerbations. This strengthens the use of antibiotics to treat exacerbations.

8-13 ORAL VITAMIN K LOWERS THE INTERNATIONAL NORMALIZED RATIO MORE READILY THAN SC VITAMIN K IN THE TREATMENT OF WARFARIN-ASSOCIATED COAGULOPATHY.
      In asymptomatic patients with supra-therapeutic INR values (4.5 to 10) while receiving warfarin, 1 mg oral vitamin K lowered INR more rapidly to a therapeutic level than subcutaneous K.
      The day after administration of oral K, the INRs remained within therapeutic range in many patients, allowing reinstitution of warfarin therapy.

8-14 LOCAL TREATMENTS FOR CUTANEOUS WARTS
      Compared with other topicals, salicylic acid has a more favorable therapeutic effect

8-15 EFFECTIVE PAIN TREATMENT PROMOTES ACTIVITIES
      “Pain is whatever the patient says it is, and exists whenever the patients says it does.”
      “The patient’s self-report is the single most reliable indicator of pain and its intensity.”
      Physical dependence and tolerance are expected responses to prolonged treatment. Some patients show reluctance about using pain medication, fearing addiction or uncontrollable adverse effects. Some think use of medication will hide other aspects of the disease, or that they should reserve medications until the pain is unbearable. Patient education aimed at these concerns is integral to therapy.
      When prescribing opioids, individualized dosage is the key. There is no way to know in advance what a patient will require. Medication should be taken around the clock, rather than as needed.
      Tricyclic antidepressants raise levels of serotonin and norepinephrine, particularly at the level of the spinal cord, thereby shutting off nocioceptive signals from the periphery. Nortriptyline (generic) and desipramine (Norpramin; generic) are preferred because they have fewer adverse effects.
      “Physicians can promote use of cognitive-behavioral techniques by educating patients about mind/body interactions and reassuring them that the pain is real and that psychologic therapies complement other medical care.”
      Multidisciplinary pain treatment centers don’t see pain cessation as their primary goal. Instead, they seek to help people return to normal activities and improve quality of life.
      The article pertains mainly to pain-specialists. Primary care clinicians may help their patients with chronic pain to understand the approaches to treatment.

8-16 LOCAL WARMING AND INSERTION OF PERIPHERAL VENOUS CANNULAS.
      Local warming of the hand facilitated the insertion of cannulas, reducing both the time and number of attempts required. This application may help primary care clinicians more easily start routine i.v. fluids in patients with difficult veins.

1. General practices in England followed over 200 patients with newly diagnosed high or borderline hypertension, and patients with poor control while receiving treatment. Management changes were being considered in all.
2. Determined BP as recorded by a variety of methods: 1) readings by MDs, 2) readings recorded on the chart in recent clinic visits, 3) by nurses, 4) home measurement, and 5) self-measurement in the clinic.
3. These were compared with daytime ambulatory monitoring with an expensive automated machine.¹
4. Main outcome = overall agreement with ambulatory BP.

1. Determinations of systolic BP by doctors and recent clinic readings were much higher than systolic BP measured by ambulatory BP machine (difference = 19 mmHg). The difference from ambulatory monitoring increased as BP increased. Doctor-measured and recent BPs recorded in the clinic were not specific in predicting treatment thresholds.
2. Higher readings were also recorded by nurses (+4 to +8 mmHg), by self-measurement in the clinic (+10), and home measurement (+ 5). (Compared with daytime ambulatory machine measurements.)
3. The white coat effect was attenuated with repeat visits to nurses – from + 11 mmHg in the first visit to + 3 in follow-ups.

1. Exact BP management thresholds will always be debated. Nevertheless, agreement exists that poor control in routine clinic readings for most patients is > 140/90. Ambulatory BP < 135/85 represents good control. Those with additional risk factors (eg, diabetes) may need tighter control.
2. The differences between measurements are likely due to different alerting responses.
3. The estimates of the white coat effect in this study are similar to those in previous work. It is not an artifact of research studies. It applies equally to new diagnosis and assessment of control.
4. Patients with white coat hypertension are at considerably reduced risk compared with those with higher ambulatory pressures.²
5. Overzealous initiation and maintenance of treatment for white coat hypertension represents an enormous cost for professionals and for patients, in addition to the associated iatrogenesis – particularly unnecessary anxiety and side effects of drugs.
6. Repeated readings by a nurse in primary care provides better assessment than readings by doctors.
7. Patients can accurately measure their pressure at home with the potential advantages of lower costs compared with ambulatory measurement. Self measurement in the clinic may provide similar levels of agreement, but more visits to the clinic are required, and suitable rooms must be made available.

1. Framingham Heart Study followed over 5800 participants (mean age = 55).
2. Evaluated BMI both as a continuous variable and as a categorical variable (BMI = 18.5 to 25.9; 25.0 to 29.9; and obese 30.0 or more).
3. Criteria for diagnosis of HF:

   A.	Major criteria:       Paroxysmal nocturnal dyspnea or orthopnea; jugular vein distention; pulmonary rales; radiographic cardiomegaly; acute pulmonary edema; a third heart sound; central venous pressure above 16 cm of water; hepatojugular reflux, and weight loss of 10 pounds or more in response to treatment for HF.
   B.	Minor criteria:       Bilateral ankle edema; nocturnal cough; dyspnea on ordinary exertion; hepatomegaly; pleural effusion; and a heart rate of at least 120. These were acceptable only if they could not be attributed to any other medical condition.
   C.	Diagnosis required simultaneous presence of at least two major criteria, or one major criterion and two minor criteria.

4. Primary outcome = first episode of HF. Follow-up a mean of 14 years.

1. HF developed in 496 subjects. (8%)
2. A graded increase in risk was observed across categories of BMI. After adjustment for established risk factors, there was an increase in the risk of HF in about 6% for each increment in BMI (18.5 to 25.9; 25.0 to 29.9; >30.0). Hazard ratios per increase in category of BMI were 1.5 in women and 1.4 in men.
3. Obese subjects (BMI 30 or above) had a doubling of the risk.

1. Elevated BMI was associated with an increased risk of HF without evidence of a threshold. The increase was evident in both sexes and was not limited to persons with extreme obesity.
2. There was evidence of a continuous gradient of HF risk with increasing BMI.
3. The strength of the association, the stepwise increase in risk, the demonstration of a temporal sequence (obesity preceded HF), and the consistency of results in multiple analyses suggest a causal relationship.
4. Plausible mechanism: Increased BMI is a risk for hypertension, diabetes, and dyslipidemia, all of which augment risk of myocardial infarction, an important antecedent of HF. Hypertension and diabetes independently increase risk.
5. Elevated BMI is associated with altered left ventricular remodeling, possible owing to increased hemodynamic load, neurohormonal activation, and increased oxidative stress.
6. The authors calculate that about 11% to 14% of cases of HF in the community are attributable to obesity alone.
7. “Our findings suggest that obesity is an important risk factor for heart failure.”

1. Re-evaluation of chlamydial infections to be done at 3 to 4 months because of the high rate of re-infection. Routine screening for clamydia is recommended for all sexually active women over age 25. Selective screening and treatment has been shown to greatly reduce incidence of pelvic inflammatory disease. Treatment with a single dose of azithromycin is effective.
2. Emergence of quinolone-resistant gonorrhea and implications for treatment. Several single-dose regimens are effective treatment. Concomitant empiric treatment for clamydia is still recommended because of the frequency of this co-infection.
3. Alternative treatment regimens for early syphilis and neurosyphilis in persons allergic to penicillin.
4. Commercial availability of type-specific tests for genital herpes.
5. Screening and treatment for bacterial vaginosis.
6. Nucleic acid testing for human papilloma virus in women with atypical squamous cells of undetermined significance on Pap smears. HPV plays a central role in the pathogenesis of squamous cell cancer of the cervix, vagina, vulva, and penis. Although no specific treatment is available, results may guide the need for colposcopic evaluation.

1. Randomized, double-blind, placebo-controlled trial entered over 550 patients (mean age = 62). All had undergone a successful angioplasty of at least one significant coronary stenosis.
2. Randomized to: 1) combined folic acid (1 mg), cyanocobalamin (B12; 400 ug/d), and pyridoxine (B6; 10 mg daily), or 2) placebo.
3. Composite endpoint = death, non-fatal myocardial infarction, and need for revascularization.
4. Active therapy was discontinued after 6 months. Observation continued for a year.

1. Baseline homocysteine levels correlated with age.
2. Mean homocysteine levels were significantly lowered at 6 months in the treatment group: placebo group = 1.36 mg/L; treatment group = 1.01 mg/L.
3. At one year, the composite endpoint was significantly lower in patients receiving the active treatment (15% vs 23%; absolute difference = 8%; NNT(benefit 1 patient over 1 year) = 12). This was despite discontinuation of homocysteine-lowering therapy at 6 months.
4. Efficacy was primarily due to a reduced rate of target revascularization. A non-significant trend was seen toward fewer deaths, and non-fatal MI.

1. “This study provides strong evidence that homocysteine-lowering therapy . . . improves outcome after percutaneous coronary intervention by reducing need for repeat revascularization and decreasing the overall incidence of major adverse events one year after successful PCI.”
2. The results are consistent with those of recent randomized trials with homocysteine-lowering therapy showing decreased coronary events among healthy patients, halting the progression of carotid plaques, and improving arterial endothelial function.
3. The therapy is inexpensive and has minimal adverse effects. (The benefit/harm-cost ratio is high.)
4. Increasing evidence suggests that the primary mechanism may be a decrease in oxidative endothelium injury.

1. Observational cohort study identified over 700 patients with pneumonia who lived in Dutch psychogeriatric nursing homes. Almost all had dementia and were to stay in the home for the rest of their lives.
2. Physicians were explicitly instructed to include terminal patients in the study.
3. Patients were assigned to treatment or no-treatment solely on the basis of the decision of the physician.¹
4. Patients were followed for up to 3 months.

1. In about one out of four patients, antibiotics were withheld. The other patients received antibiotics with palliative (8%) or curative (69%) intent. (Most received amoxicillin by mouth.)
   Fewer than 1% were admitted to a hospital. ²
2. Patients for whom treatment was withheld had more severe dementia (most with mini-mental exam score = 0), had more severe pneumonia, had lower food and fluid intake, had more history of aspiration, and were more often dehydrated. The strongest association with the decision to withhold was the clinical judgment of the severity of illness at the time of the decision.
3. Considerable variation in decisions occurred when considering how rapidly the patient was aging, on whether the patient had aspirated, and whether there was a past history of pneumonia.
4. Opiates were instituted more often in those for whom antibiotics were withheld. ³
5. Ninety percent of the antibiotic-withheld group died within 1 month (median time = 6 days); 27% of the patients for whom antibiotics were aimed at cure died despite the treatment.

1. Antibiotics were withheld in about 25% of seriously ill, frail, demented patients.
2. Physicians thought antibiotics could save the lives of about 1/3 of these patients. Almost 2/3 were expected to die despite antibiotics.
3. Some physicians were inclined to treat patients who had survived pneumonia before. Others were inclined to withhold if the patient had recurrent pneumonia. Similarly, physicians and families differed in their approach if the patients aspirated, and if they were relatively young.
4. The authors comment that variation might be expected to be greater in the USA, where there is less legal and ethical clarity about initiating a strictly palliative approach. Although sometimes antibiotics were given for palliative reasons, evidence of benefit of palliative effects is lacking.
5. The occurrence of pneumonia may have been used as an opportunity to let the patient die a natural death. (“The old man’s friend”)
6. Advanced care planning was common in the nursing homes studied. Re-consultation with families is recommended in the acute situation.

1. Followed over 4300 consecutive patients undergoing clean and clean-contaminated surgery.
2. Used the 2 methods of hand cleaning alternately every other day.
3. Measured 30 day surgical site infection rates.
4. Follow-up to 14 months.

1. The 2 protocols were comparable in regard to surgical site infections. (2.44% vs 2.48%)
2. Compliance with the recommended duration of hand antisepsis was better in the hand-rubbing with AS. (44% vs 28%)
3. There was less skin dryness and less skin irritation with the AS protocol.

1. In the routine surgical setting, hand rubbing with AS was equivalent to the traditional method of hand-scrubbing. It improved compliance with hand antisepsis protocol.
2. Some previous studies have shown that AS reduces nosocomial infection rates and improves compliance with hand hygiene when implemented throughout a hospital, particularly at the bedside in medical wards. Some studies, however, were less favorable.
3. For presurgery antisepsis, the critical end point for compliance is how well and how long it is performed (at least 30 s). Better compliance with the AS protocol was noted throughout 14 months.

1. Prospective study of 81 patients assessed clinical information and collected sputum samples for culture each month and during exacerbations.
2. Performed molecular typing of sputum isolates of 4 different pathogens (H influenzae, M catarrhalis, S pneumoniae, and P aeruginosa.)

1. Over 56 months, the 81 patients with COPD made over 1900 clinic visits; over 375 for exacerbations. (About 2 per patient per year.)
2. Isolation of a new strain of the 4 pathogens was associated with a significantly increased risk of an exacerbation -- 33% of exacerbations were associated with a new strain vs 15% associated with isolation of an old strain.

1. This finding contributes to the growing body of evidence that bacteria cause a substantial proportion of exacerbations.
2. The investigators speculate that a strain-specific protective immune response develops after an exacerbation.. Acquisition of a new strain to which the patient is susceptible leads to an exacerbation.
3. Some patients had a new bacterial strain in the absence of an exacerbation. Possibly these strains were less virulent. Or the new strain may have caused symptoms which were not severe enough to prompt the patient to seek medical help.
4. Some exacerbations occur in the absence of bacteria in sputum. Some may be due to viral infections; some due to bacteria not tested for in the study.

1. Randomized, controlled trial entered over 50 patients. All were receiving warfarin and were considered over-coagulated (INR 4.5 to 10; mean = 6.0 ) None had bleeding.
2. Risk of hemorrhage in patients with INR less than 4.5 was not considered to warrant intervention with vitamin K.
3. Randomized to: 1) 1 mg oral vitamin K1, or 2) 1 mg sc vitamin K1. Either phytonadione¹ or phytomenadione was used. Warfarin was stopped.
4. Primary outcome = INR on the day after administration. Goal was to reduce INR to between 1.8 and 3.2, thus maintaining a therapeutic ratio.

1. Fifteen of 26 (57%) in the oral group achieved a therapeutic INR (1.8 to 3.2) on the next day , vs 6 of 25 (24%) in the sc group. (NNT to benefit one patient with oral therapy vs sc = 3)
2. Three patients in the oral group had INR less than 1.8 the next day vs none in the sc group. Sixteen patients in the oral group were able to safely restart warfarin on the day after oral therapy vs 7 in the sc group.

1. Oral vitamin K was more effective than sc vitamin K in re-establishing a therapeutic INR in asymptomatic patients with warfarin-associated coagulopathy and an INR 4.5 to 10.
2. Currently, it is common practice not to treat patients receiving warfarin who present with excessively increased INR. This may be due in part because of the perception that these patients have a low risk of bleeding. The risk has probably been underestimated.

1. Fifty trials were identified. Only two were classified as high quality. Thus, evidence from these studies was generally weak. Despite this, some useful pooling of data was possible.
2. Main outcome was complete disappearance of the warts.

1. Placebo: 17 trials with placebo reported a cure rate of 30% after an average 10 weeks.
2. Salicylic acid: 13 trials used various preparations (15% to 26%). Pooled data from 6 controlled trials showed a cure rate of 75% vs 48% with placebo. Minor skin irritation was reported occasionally, but generally there were no harmful effects.
3. Cryotherapy: 16 trials assessed cryotherapy. 2 small trials compared cryotherapy with placebo or with no treatment. There was no significant difference in cure rate. Four trials showed “aggressive” treatment (various definitions) was more effective than “gentle” therapy, with cure rates of 52% and 31%. Pain and blistering seemed to be more common with aggressive cryotherapy. Some participants withdrew.
4. Topical treatment with topical dinitrochlorobenzene: showed some evidence of efficacy. No precise data reported on adverse effects. Some reported sensitization after a second application with major local irritation with and without blistering.
5. Intralesional bleomycin: no consistent evidence found for effectiveness in 5 trials. Some trials reported pain in most participants.
6. A variety of other treatments (fluorouracil, intralesional interferons, photodynamic therapy, pulsed laser) reported various efficacy and adverse effects.

1. Most trials were of low quality. Study designs were heterogeneous. The dearth of high quality evidence prevents the rational use of treatments. Simple salicylic acid seems to be both effective and safe.
2. No clear evidence that any other treatments have a particular advantage of either higher cure rates or fewer adverse effects than salicylic acid.

1. Followed 40 patients on chemotherapy or with leukemia, and 100 neurosurgical patients.
2. Randomized to: 1) warmed hands and forearms with a heating unit for 15 minutes, or 2) passive insulation (heater not turned on). The cannula was to be inserted on the back of the hand.
   
3. Main outcome: Success rate of insertion.

1. It took 30 seconds to insert the cannula in the warmed group vs 62 seconds in the non-warmed group.
2. Three first attempts failed in the warmed group vs 14 in the passive group.

1. Cannulation is easier when the veins are more visible. This can be helped by having the arm hanging down, or warming.