Journal Watch summaries for May 27, 1994 
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 Journal Watch summaries for May 27, 1994

  This is Journal Watch, a medical-literature
survey produced by the Massachusetts Medical
Society.
  Twice a week, our physician-editors summarize
important new clinical research from a group
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  Contents copyright 1994, Mass. Medical Society.

Journal Watch Summaries for May 27, 1994

URSODIOL FOR PRIMARY BILIARY CIRRHOSIS.
   In 1991, a French randomized study of 145 patients
showed that the bile acid ursodiol slows the short-term
progression of primary biliary cirrhosis. At the end of the
two-year study, all ursodiol recipients continued their
treatment and 79 percent of placebo recipients agreed to
take ursodiol in an open trial. This report presents the
four-year outcome of these patients.
   The patients who had taken ursodiol for all four years
had significantly fewer treatment failures
(hyperbilirubinemia, variceal bleeding, ascites, or
encephalopathy) than the patients initially assigned to
placebo (9 vs. 20); they also had significantly fewer liver
transplantations or referrals for transplantations (4 vs.
13).
   Comment: The differences between these two groups are
impressive, since most placebo recipients took ursodiol
during the third and fourth years. An editorialist concludes
that most patients with primary biliary cirrhosis who do not
have advanced disease should receive ursodiol. However,
ongoing studies are testing combinations of {*filter*} (e.g.,
ursodiol, methotrexate, and colchicine) because no single
agent reliably halts progression of the disease. --AS Brett.
   Citation: Poupon RE; et al. Ursodiol for the long-term
treatment of primary biliary cirrhosis. N Engl J Med 1994 May 12;
330:1342-7.
   Citation: Kaplan MM. Primary biliary cirrhosis -- a first step
in prolonging survival. N Engl J Med 1994 May 12; 330:1386-7.

ESTROGEN PLUS CONTINUOUS VS. SEQUENTIAL PROGESTIN.
   Progestin is usually added to estrogen therapy in
postmenopausal women to decrease the risk for endometrial
hyperplasia. However, this combination can produce
menstrual-like bleeding that some women find unacceptable.
This one-year double-blind, multicenter study of 1724
postmenopausal women compared the bleeding patterns
associated with four different combined regimens.
   All women received conjugated estrogens (0.625 mg daily).
In addition, they also received either continuous daily
doses of medroxyprogesterone (either 2.5 or 5 mg), or
sequential doses of medroxyprogesterone (either 5 or 10 mg)
during the last half of each 28-day cycle, or placebo. There
was no bleeding during 75 percent of the cycles of women
taking estrogen plus placebo, 73 percent of cycles of women
on the high-dose continuous regimen, and 61 percent of
cycles of women on the low-dose continuous regimen. In
contrast, most of the women on the sequential progesterone
regimens had regular withdrawal bleeding (81 percent of
cycles in the low-dose group and 77 percent in the high-dose
group).
   Comment: Both unopposed estrogen and estrogen plus
continuous progestin markedly reduced the incidence of
withdrawal bleeding as compared with regimens using
sequential progestin. The latter are associated with regular
rather than irregular withdrawal bleeding. --CD Mulrow.
   Citation: Archer CD; et al. Bleeding patterns in
postmenopausal women taking continuous combined or sequential
regimens of conjugated estrogens with medroxyprogesterone
acetate. Obstet Gynecol 1994 May; 83:686-92.

ECZEMA: CURSE OF THE AFFLUENT?.
   Children from higher socioeconomic classes have been
found to have an increased prevalence of eczema, but some
observers have wondered whether this finding is real or the
result of increased reporting. This study used direct
examination by a physician to clarify the issue.
   The study involved 8279 children from England, Wales, and
Scotland who were born during one week in 1958 and followed-
up at ages 7, 11, and 16 by both questionnaire and direct
physical examination. At age 7, the actual prevalence of
eczema in the six socioeconomic strata, from highest to
lowest, was 4.8, 3.6, 3.6, 2.4, 2.2, and 2.4 percent. The
pattern was similar at other ages, persisted after
adjustment for region and family size, and was not found for
psoriasis or acne. Surprisingly, overreporting of eczema
appeared to be more common in the lower socioeconomic
classes.
   Comment: The reasons for the two-fold difference in
eczema prevalence between the highest and lowest classes are
unknown; they may include a variety of environmental factors
such as differential use of showers and soaps. For now,
socioeconomic class should be included as a risk factor for
eczema in any study of that condition. --KI Marton.
   Citation: Williams HC; et al. Childhood eczema: disease of the
advantaged? BMJ 1994 Apr 30; 308:1132-5.

PROPHYLACTIC PROPRANOLOL IN MARFAN'S SYNDROME.
   During the past two decades some authorities have
recommended prophylactic beta-blockers to reduce the risk
for aortic dissection in patients with Marfan's syndrome. A
randomized trial now provides indirect evidence to support
this practice.
   The study involved 70 patients with Marfan's syndrome
(mean age, 15 years); 32 received propranolol (mean daily
dose, 212 mg) and 38 received no treatment. During 10 years
of follow-up, the propranolol group had a significantly
lower rate of increase in their aortic diameter than the
placebo group. Two propranolol-treated patients had aortic
dissection, versus four controls; two patients in each group
had aortic regurgitation; and two patients in the control
group died for reasons unrelated to the aorta.
   Comment: Because aortic size is known to correlate with
the occurrence of dissection and regurgitation, this study
strongly suggests that prophylactic propranolol can benefit
Marfan's patients. However, the small sample size precludes
a definitive statement about the ultimate clinical effect of
prophylactic beta-blockade. --AS Brett.
   Citation: Shores J; et al. Progression of aortic dilatation
and the benefit of long-term beta-adrenergic blockade in Marfan's
syndrome. N Engl J Med 1994 May 12; 330:1335-41.

URINARY INCONTINENCE IS POORLY ADDRESSED BY
GERIATRICIANS.
   Though common, urinary incontinence in the elderly is
often overlooked or dismissed as an expected part of aging.
Do geriatric assessment units (GAUs) do a better job of
identifying and treating incontinence than primary-care
physicians?
   To find out, investigators studied 364 frail elderly
people (86 percent women; mean age, 75) who underwent
structured in-home interviews during which 151 reported
urinary incontinence. Subjects were then randomized to an
outpatient assessment by either a practicing community
physician or a GAU (a team including a geriatrician, nurse,
and social worker). GAUs were significantly better than
community physicians at recognizing urinary incontinence as
detected by home interview or record review: recognition
rates were 59 vs. 16 percent. This difference held for both
mild incontinence (44 vs. 2 percent) and incontinence
occurring three times weekly or more (86 vs. 44 percent).
However, once a case was identified, there was no difference
in the rate of recorded intervention or referral (31 vs. 27
percent). GAUs tended to refer patients to continence
programs, while community physicians referred more to
urologists.
   Comment: GAUs were much better than community physicians
in identifying urinary incontinence. However, a 59 percent
recognition rate is still low, and the majority of patients
with recognized incontinence were not appropriately treated
or referred, regardless of who assessed them. --JC Puffer.
   Citation: McDowell BJ; et al. Identification and intervention
for urinary incontinence by community physicians and geriatric
assessment teams. J Am Geriatr Soc 1994 May; 42:501-5.

DETECTING DEPRESSION IN THE NURSING HOME.
   The 30-question Geriatric Depression Scale (GDS) is
widely used and has been validated in the outpatient
setting, but it is less helpful in nursing-home patients
because of the high prevalence of dementia. To improve the
utility of the GDS in nursing homes, this study sought the
lowest cognitive level at which the GDS is valid.
   The authors screened 166 patients newly admitted to two
New York nursing homes and found 66 (average age, 83) who
were willing and able to be studied. Psychiatric interviews
using DSM-III-R criteria found 30 of these patients (45
percent) to be depressed or to have depressive symptoms.
Overall, the GDS had 63 percent sensitivity and 83 percent
specificity in detecting depression as compared with the
psychiatric interview. However, when analysis was restricted
to the 42 patients scoring 15 or higher on the Folstein
Mini-Mental Status Exam (MMSE), sensitivity and specificity
rose to 84 and 91 percent, versus only 27 and 69 percent in
patients with MMSE scores below 15.
   Comment: Depression is known to be underdiagnosed in the
nursing home. Selectively administering the GDS only to
patients with relatively intact cognitive function should
increase the diagnosis of depression in this group.
--JC Puffer.
   Citation: McGivney SA; et al. Validating the GDS depression



Wed, 13 Nov 1996 02:12:59 GMT
 
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 Relevant Pages 

1. Journal Watch Summaries for September 27, 1994

2. Journal Watch Summaries for December 27, 1994

3. Journal Watch Summaries for December 27, 1994

4. Journal Watch Summaries for September 27, 1994

5. Journal Watch summaries for May 24, 1994

6. Journal Watch summaries for May 20, 1994

7. Journal Watch Summaries for August 30, 1994

8. Journal Watch Summaries for June 3, 1994

9. Journal Watch Summaries for June 28, 1994

10. Journal Watch Summaries for June 17, 1994

11. Journal Watch Summaries for July 1, 1994

12. Journal Watch Summaries for Aug 5, 1994


 
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