Family Practice

Therapeutics



Rosen T, Schell
BJ, Orengo I [Baylor
College of Medicine, Houston]

Anti
–inflammatory Activity of Antifungal Preparations

Int
J Dermatol 36: 788-792, 1997

    

This study compares the results of
several antifungal creams with 2.5% hydrocortisone
to determine their anti-inflammatory properties. UVB
induced erythema of non-exposed sites were used for
evaluation.

    

1%
terbinafine, 1% ciclopirox olamine, and 1% naftifine
hydrochloride were shown to possess
anti-inflammatory effects that were greater than hydrocortisone. 
Other creams used were 2% ketoconazole, 1%
oxiconazole nitrate and 1% econazole nitrate. These
were less effective.

    

The  use 
of an antifungal agent with anti-inflammatory
activity thus takes 
care of the inflammatory component of fungal
infections. Side effects of a steroid of the
combination preparation are thus avoided.

    

Bornstein
J Heifetz S, Kellner Y, et al [Carmel Med Ctr,
Haifa, Israel]

Clobetasol
Dipropionate 0.05% Versus Testosterone Propionate 2%
Topical Application for Severe Vulvar Lichen
Sclerosus

Am
J Obstet Gynecol 178: 80-84, 1998

    

20
postmenopausal women were treated with 0.05%
clobetasol propionate and 20 with 2% testosterone
propionate. Mean age group was 64 years and follow
up was carried out at three months and 1 year,
between 1988 and 1993. Short and long terms were
thus covered.

   

Clobetasol
was more effective than testosterone. 
Side effects such as skin atrophy [as would
be expected with a corticosteroid ointment] were not
seen. Patient compliance was better with clobetasol
than with testosterone. 
One in the steroid group and six in the
testosterone had side effects.

    

Burks
AW, James JM, Hiegel A, et al [Univ of Arkansas,
Little Rock; Arkansas Children’s Hosp Research
Inst, Little Rock]

Atopic
Dermatitis and Food Hypersensitivity Reactions

J
Pediatr 132: 132-136, 1998

    

This
is a double-blind, placebo-controlled study of 165
subjects of atopic dermatitis [AD] between the ages
of 4 months and 21.9 years. On the basis of prick test positivity to
common foods elimination and challenges were
performed. Foods included milk, eggs, peanuts,
wheat, soy, fish and tree-nuts. 98 subjects were
positive to one food on prick testing. Of these 64
revealed a positive response on challenge.

     

The
importance of this article lies in its bringing out
necessity of testing for commonly used foods in the
management of AD. Foods to be tested for, depends on
the food habits of the individual hence the value of
dietary amnesis.

     

Levi
F, La Vecchia C, Te V-C, et al [ Centre Hospitalier
Universitaire Vaudois, Lausanne, Switzerland;
Registre Neuchatelois des Tumeurs, Neuchatel,
Switzerland; Universita degli Studi Milano, Italy]

Incidence
of Invasive Cancers Following Basal Cell Skin Cancer

Am
J Epidemiol 147: 722-726, 1998

   

A
total of 11,878 basal cell carcinoma subjects
between the ages of 15 years and 100 years were
followed up for 20 years. 
All were confirmed by histology. In the
period of follow-up lip cancers, melanomas, squamous
cell carcinomas and lymphomas other than Hodgkin’s
were found to be more common.

   

Once
an individual has had a basal cell carcinoma he
should be examined for other skin cancers and
lymphomas, as a long term follow up measure.

     

Kang
S, Fisher GJ, Voorhees JJ [Univ of Michigan, Ann
Arbor]

Photoaging
and Topical Tretinoin : Therapy, Pathogenesis, and
Prevention

Arch
Dermatol 133: 1280-1284, 1997

   

Dry,
rough finely wrinkled and dyspigmented skin with
loss of normal tension characterize skin aging. Such
changes developing on sun exposed skin constitute
photoaging. They result from loss of collagen in the
upper dermis induced by metalloproteinases, a group
of enzymes causing collagen breakdown. Ultraviolet
light especially the B component [UVB] is
responsible for this effect.

   

Application
of Tretinoin cream reverses such damage. The
earliest sign of improvement is reduction of
wrinkling.

                        
    

Prostate Disease

McConnell JD, for the Finasteride Long-Term Efficacy and Safety Study Group [ Univ of Texas, Dallas; Univ of Wisconsin, Madison; The Johns Hopkins Med Institutions, Baltimore, Md; et al]

The Effect of Finasteride on the Risk of Acute Urinary Retention and the Need for Surgical Treatment Among Men With Benign Prostatic Hyperplasia
.

N Engl J Med 338: 557-563, 1998

    


Men with benign prostatic hyperplasia [BPH] invariably present with urinary symptoms, often improving with the use of finasteride. Long term administration of 5 mgm per day of finasteride was evaluated in 3040 men over a period of 4 years. All had BPH of moderate to severe degree and were evaluated every 4 months. They were studied for urinary flow, symptomatology prostatic MRI and volume as well as serum prostate-specific antigen levels. The last were done for 1 year and later once in 8 months.

    


In this double-blind, randomized and placebo-controlled study data for 2760 was available at the end of 4 years. 10% in the placebo group and 5% in the finasteride sample needed prostatic surgery. Acute retention of urine was observed in 7% of controls and 3% on active therapy. Finasteride treated patients revealed symptomatic improvement as well as a better flow of urine: reduction in prostate volume was also observed.

   


This study suggests that finasteride is a useful agent in managing patients with B.P.H. and may help in delaying surgery.

   

Goldstein I, for the Slidenafil Study Group [ Boston Univ; Univ of California, San Francisco; Univ of Southern California, Los Angeles; et al]

Oral Slidenafil in the Treatment of Erectile Dysfunction

N Engl J Med 338: 1397-1404, 1998

   

Erectile dysfunction is a problem faced by aging males. Sidenafil [Viagra] prevents catabolism of cyclic -GMP. This leads to relaxation of smooth muscle in the corpus cavernosum leading erection on sexual stimulation but not in the absence of the latter. Being administered orally, it is more acceptable than injections or surgery. The drug, in this study was taken 1 hour before planned sexual activity. Organic, psychogenic or mixed causes constituted the 861 men studied. They were 18 years of age or older and had the problem for 6 months or longer. Of these 532 received 25, 50 or 100 mgm of the drug or a placebo on a random selection, for 24 weeks. Another group of 329 men randomly received 50 mgm of the drug or a placebo. They were allowed to double the dose or reduce it by 50% depending on the response during the 12 week period of study.

  

Better erection and its maintenance after penetration was observed when the dose was gradually increased from 25 mgm to 100 mgm. Flushing headache and gastrointestinal disturbances were noticed. The drug was generally well tolerated.

    

Combs JA, Caskey PM [Shriner’s Hosp for Crippled Children, Spokane, Wash]

Back Pain in Children and Adolescents : A Retrospective Review of 648 Patients

South Med J 90: 789-792, 1997



A complaint of back-ache in children being unusual is looked upon as a serious problem needing investigation.



648 children with complaints related to the spine were reviewed during a 2.5 year period. 265 subjects complained of pain and comprised 167 girls and 98 boys [ average age 14 years]. 1 child in this group had malignant disease. In the rest of this group infections were not present and the etiology was related to psychosocial causes, including depression, and family instability.



The no pain group comprised 383 subjects [ 245 girls and 138 boys with an average age of 12 years]. 44% in this group had spinal asymmetry and 40% scoliosis.



Though the pattern of the etiology of symptoms referred to the spine in children is changing to a form simulating adults it should be taken seriously and investigated. 

Brynhildsen J, Hansson A, Persson A, et al [ Univ Hosp Linkoping, Sweden]

Follow-up of Patients With Low Back Pain During Pregnancy

Obstet Gynecol 91: 182-186, 1998



Up to 75% of pregnant women complain of low back pain. To establish morbidity over a long period questionnaire were designed and sent. 79 such women had been studied during a period of 1 year. [ 1983-84] at Linkoping in Sweden. 62 of these were included in the present study. Women who did not have back pain and were attending the same antenatal clinic during 1983-1984 were used as controls. Data included parity, age, weight, height occupation, low back pain, smoking habits and was sent to both groups in 1996. 84% of those with pain and 80% of those without it responded.



10 women with back pain at the first pregnancy avoided a second pregnancy. 94% of those with severe backache experienced it in subsequent pregnancies. 44% of the control group also developed backache in later pregnancies. The pain group continued to suffer from it later in the absence of pregnancy.



Low back pain during the first pregnancy tends to recur with subsequent ones and may end up as chronic back pain in later life.



The cause is not known and exercises to keep muscles in good condition are advised.

Barbalias GA, Nikiforidis G, Liatsikos EN [Univ of Patras, Greece]

a-Blockers for the Treatment of Chronic Prostatitis in Combination With Antibiotics 

J Urol 159: 883-887, 1998



For this study three groups were created. Group 1 comprised 134 subjects with prostatodynia and abacterial prostatitis; group 2, 72 participants had prostatodynia and the third group, 64 individuals had bacterial prostatitis. Group 1 and 2 and half of the group three received a-blockers. Dose was built up gradually to reach a maximum of 5 mgm of terazocin or 7.5 mg of alfuzocin daily. All patients with bacterial prostatitis and 67 of the abacterial group with more than 10 white cells per high-power field in prostatic secretion were given antibiotics.



At the end of 22 months of follow-up marked symptomatic improvement was observed with a-blockers. In the abacterial group greater improvement was observed in those on a combination regime. In the group of bacterial as well as abacterial prostatitis recurrences were reduced.



a-blockers are thus useful in treatment of symptoms arising out of benign prostatic hyperplasia.

Yamanishi T, Yasuda K, Sakakibara R, et al [ Chiba Univ, Japan]

Pelvic Floor Electrical Stimulation in the Treatment of Stress Incontinence : An Investigational Study and a Placebo Controlled Double-blind Trial

J Urol 158: 2127-2131, 1997

  


Forty-four subjects [mean age, 63 years] with stress as well as mild urge incontinence comprising 6 men and 38 women were studied. A vaginal electrode was used for women and anal for men. 

  


Maximal urethral closing pressure were used for evaluation. This was measured before, during a stimulation period of 15 minutes and after treatment. Figures of 44.4, 64.5 and 46.8 cm of water were noted respectively.

   


Electrical stimulation of the pelvic floor is thus a useful alternative to surgery. Evaluation at the end of 4 weeks revealed 45% cure and 60% improvement rates.


   

Barton DL, Loprinzi CL, Quella SK, et al (Mayo Clinic and Found, Rochester, Minn; Carle Cancer Ctr, Urbana III; IIIinois Oncology Research Assoc Community Clinical Oncology Program, Peoria III; et al)

Prospective Evaluation of Vitamin E for Hot Flashes in Breast Cancer Survivors

J Clin Oncol 16: 495-500, 1998

      

Estrogen and progesterone usually control hot flashes complained of by breast cancer patients after treatment.

      

The authors used 800 IU/day of vitamin E in a controlled study. Patients did not improve.

     

Skjeldestad FE, Hadgu A, Eriksson N (Norwegian
Univ, Trondheim, Norway; Natl Ctrs for Disease Control and Prevention, Atlanta,
Ga; Orkdal Hosp, Orkanger, Norway)

Epidemiology of Repeat Ectopic Pregnancy: A Population-based Prospective Cohort Study 

Obstet Gynecol 91: 129-135, 1998

       


Women below the age of 37 years (37 included) without prior tubal surgery were studied. In normal subjects chance of a second ectopic after a first episode decreased by a third up to 3 pregnancies. With infection as the etiology the risk increased by 3 times.

      


At age 24 years or less an ectopic followed by work-up for infertility, including a surgical procedure did not cause an ectopic pregnancy. An intrauterine device may lead to an ectopic event. After 2 ectopics the possibility of intrauterine pregnancy to term is reduced to 4 per cent. The authors recommend assisted pregnancy for the last group.

  

Malleson PN, Sailer M, Mackinnon MJ (Univ of British Columbia, Vancouver, Canada; British Columbia’s Children Hosp, Vancouver, Canada)

Usefulness of Antinuclear Antibody Testing to Screen for Rheumatic Diseases 

Arch Dis Child 77: 299-304, 1997



Indirect immunofluorescence antinuclear antibody (FANA), with human laryngeal epithelial cells representing nuclear material is evaluated in this paper.



As a screening test for rheumatic disease the test if negative can be interpreted thus, but a positive result may represent a false positive result.



If used it should be to confirm a clinical suspicion and not as a screening procedure. Its replacement with anti-DNA test is suggested by the authors.

        

Walter W. Rosser 

Aspirin for Primary Prevention of Cardiovascular Events 

Lancet Vol.357, January 13, 2001, Pg. 84-85

         

Summary : Whether general practitioners should recommend aspirin to their patients to reduce the risk of heart attack and other cardiovascular events has been confusing. The report on the Primary Prevention Project (PPP) in Lancet provides general practitioners with some evidence.

        

The PPP study was stopped after about 3.5 years of follow-up because 2 other studies of low doses of aspirin showed a significant beneficial effect of drug. PPP results showed that 100 mg daily of enteric coated aspirin had a protective effect in people with one or more cardiovascular risk factors.

         

All 3 studies highlight the fact that in hypertensive patients blood pressure must be well controlled because higher the blood pressure greater the risk of haemorrhagic strokes, and aspirin should be prescribed in low doses to avoid bleeding complications.

        

The 2^nd segment of PPP, that of the effect of vitamin E did not provide evidence that the vitamin reduces cardiovascular risk. General practitioners can advise their patients that any beneficial effect that vitamin E might have is weak and awaits discovery.

        
 

Ann M Arvin

Varicella Vaccine – The First Six Years

NEJM, Vol.344(13), March 29, 2001, pg.1007

      

The live attenuated varicella vaccine is the only vaccine licensed for the prevention of a disease caused by a human herpes virus. Vazquez et al have reported that the varicella vaccine prevented chickenpox in 85 percent of immunized children, with 97 percent protection against moderately severe and severe disease. The 85 percent clinical effectiveness of the varicella vaccine indicates that most children acquire protective immunity when they are immunized in the clinical care setting.

      

Whether a second dose of vaccine will be needed as a substitute for contact with wild-type varicella zoster virus remains unknown. Assuming that immunologic memory reflects the magnitude of initial response, increasing the amount of infectious virus in the varicella vaccine might enhance the primary response and reduce the incidence of breakthrough disease. Another question is whether herpes zoster would become less common if the viral load of latent varicella-zoster virus in the ganglia of vaccinated persons were lowered.

      

The varicella vaccine is being evaluated for its potential to prevent herpes zoster caused by wild-type varicella-zoster virus, which would benefit older people and further disrupt the cycle of transmission of the virus.

      

Proof of the clinical effectiveness of the varicella vaccine provides further support for the broad implementation of the current recommendations that healthy children and susceptible adults be immunized against varicella-zoster virus.        

                                                                             

Sander Koning, Lisette WA van Suijlekom-Smit, Jan L Nouwen, et al             

Fusidic acid cream in the treatment of impetigo in general practice: double blind randomized placebo controlled trial.    

BMJ, vol.324, 26 Jan.2002, pg.203             

                                                                        

Fusidic acid cream is an effective treatment for impetigo. The combination of topical fusidic acid and povidone iodine shampoo was found to be much more effective than placebo and povidone-iodine shampoo in treating impetigo in children. In a   
randomised controlled tiral, Koning et al also found more adverse effects in the children who were given placebo cream.  
Staph.aureus was the most common cause of the
infection, and none of the strains isolated were
resistant to fusidic acid