Selected abstracts. (*) (Special Feature).

EFFECT OF LEVODOPA IN COMBINATION WITH PHYSIOTHERAPY ON FUNCTIONAL MOTOR RECOVERY AFTER STROKE: A PROSPECTIVE, RANDOMISED, DOUBLE-BLIND STUDY

Scheidtmann K, Fries W, Muller F, et al. Lancet 2001; 358:787-790

A single dose of levodopa is well tolerated and enhances motor recovery in patients with hemiplegia when given in combination with physiotherapy. This prospective, randomized, placebo-controlled, double-blind study included 53 primary stroke patients. During the first three weeks the patients were given single doses of levodopa 100 mg or a placebo daily in combination with physiotherapy. During the second three weeks the patients had only physiotherapy. Motor function was quantitatively assessed every week with Rivermead motor assessment (RMA). Motor recovery was substantially improved following three weeks of drug intervention in patients taking levodopa (RMA improved by 6.4 points) when compared to those taking a placebo (4.1), and the result was independent of the initial degree of impairment (P < .004). The advantage of the levodopa group was maintained at study endpoint three weeks after levodopa was discontinued. At the end of the study the total RMA score gain for the levodopa group was 8.2 points whe n compared with 5.7 in the group taking a placebo (P= .020).

A SCORE FOR PREDICTING RISK OF DEATH FROM CARDIOVASCULAR DISEASE IN ADULTS WITH RAISED BLOOD PRESSURE, BASED ON INDIVIDUAL PATIENT DATA FROM RANDOMISED CONTROLLED TRIALS

Pocock SJ, McCormack V, Gueyffier F, et al. BMJ 2001;

A risk score is useful in assessing an individual's risk of cardiovascular disease, including stroke and coronary heart disease. Data was collected from eight randomized, controlled trials that included 47,088 men and women with various ages and eligibility criteria for blood pressure. Deaths from cardiovascular causes (1,639) during a mean 5.2 years of follow-up were the main outcome measures. Using a multivariate Cox model, baseline factors were related to the risk of death from cardiovascular disease. A risk score was developed from the following 11 factors: age, sex, systolic blood pressure, serum total cholesterol concentration, height, serum creatinine concentration, cigarette smoking, diabetes, left ventricular hypertrophy, history of stroke, and history of myocardial infarction. The risk score is an integer, with points added for each factor according to its relationship to risk. Smoking contributed to risk more in women and in younger age groups. Total cholesterol concentration counted less in women than in men, whereas diabetes had more of an effect. Antihypertensive treatment also reduced the score. A five-year risk of death from cardiovascular disease for scores of 10, 20, 30, 40, 50, and 60 was 0.1%, 0.3%, 0.8%, 2.3%, 6.1%, and 15.6%, respectively. The risk score is useful when determining a patient's need for antihypertensive treatment and other management strategies for cardiovascular risk.

ANTIBIOTIC TREATMENT OF ADULTS WITH SORE THROAT BY COMMUNITY PRIMARY CARE PHYSICIANS. A NATIONAL SURVEY, 1989-1999

Linder JA, Stafford RS. JAMA 2001; 1181-1186

More than half of the adults seen by a community primary care physician are prescribed an antibiotic. Nonrecommended, more costly, broader-spectrum antibiotics are also frequently prescribed. This retrospective analysis of 2,244 visits to primary care physicians in office-based practices in the national Ambulatory Medical Care Survey included adults with a chief complaint of a sore throat. The rate of treatment with antibiotics and with nonrecommended antibiotics was the main outcome measure. There were about 6.7 million annual visits in the United States by adults with sore throats between the years 1989 and 1999. Antibiotics were prescribed in 73% (95% confidence interval [CI], 70%-76%) of the visits. Patients were administered nonrecommended antibiotics in 68% (95% CI, 64%-72%) of the visits. From 1989 to 1999, there was a substantial decrease in the use of penicillin and erythromycin, and there was an increase in the use of nonrecommended antibiotics, especially extended-spectrum macrolides and extended- spectrum fluoroquinolones (P< .001 for all trends). In multivariable modeling, increasing patient age (odds ratio [OR], 0.86 per decade; 95% CI, 0.79-0.94) and general practice specialty (OR, 1.54 compared to family practice specialty; 95% CI, 1.10-2.14) were independent predictors of the use of antibiotics. In those patients receiving antibiotics, nonrecommended antibiotic use increased over time (OR, 1.17 per year, 95% CI, 1.11-1.24).

CAROTID SINUS HYPERSENSITIVITY IS COMMON IN OLDER PATIENTS PRESENTING TO AN ACCIDENT AND EMERGENCY DEPARTMENT WITH UNEXPLAINED FALLS

Davies AJ, Steen N, Kenny RA. Age and Ageing 2001; 30:289-293

Approximately half of cognitively normal older patients with non-accidental falls have carotid sinus hypersensitivity. This prospective case-controlled, non-randomized study is based on data collected from semi-structured interviews, physical examinations, and neuro-cardiovascular investigations. The study included 26 consecutive patients with non-accidental falls and 54 controls matched for age, sex, and cognitive function presenting to the same accident and emergency department because of an accidental fall or for another reason. Orthostatic blood pressure responses did not alter between the groups. The heart rate and blood pressure responses to carotid sinus massage were abnormal in patients with non-accidental falls when compared with the controls (P = .002). Asystolic responses were seen in 12 (46%) of 26 cases and seven (13%) of the 54 controls.

ASPIRIN USE AND ALL-CAUSE MORTALITY AMONG PATIENTS BEING EVALUATED FOR KNOWN OR SUSPECTED CORONARY ARTERY DISEASE. A PROPENSITY ANALYSIS

Gum PA, Thamilarasan M, Watanabe J, et al. JAMA 2001; 286:1187-1194

Aspirin use in patients undergoing stress echocardiography is independently associated with reduced long-term all-cause mortality, especially with older patients, those with known coronary artery disease, and patients with impaired exercise capacity. This prospective, nonrandomized, observational cohort study was conducted between 1990 and 1998 at an academic medical institution including 6,174 adults undergoing stress echocardiography for evaluation of known or suspected coronary disease. Of these adults, 2,310 (37%) were taking aspirin. The main outcome measure was all-cause mortality according to aspirin use. During 3.1 years of follow-up, 276 individuals (4.5%) died. In a simple univariable analysis, there was no affiliation between aspirin use and mortality (4.5% vs 4.5%). However, after adjusting for age, sex, standard cardiovascular risk factors, the use of other medications, coronary disease history, ejection fraction, exercise capacity heart rate recovery, and echocardiographic ischemia, the use of aspirin was associated with reduced mortality (hazard ratio [HR], 0.67, 95% confidence interval [CI], 0.51-0.87; P = .002). In a further analysis using matching by propensity score, 1,351 individuals taking aspirin were found to be at lower risk for death than 1,351 patients not taking aspirin (4% vs 8%, respectively; HR 0.53; 95% CI, 0.38-0.74; P=.002). After adjusting for the propensity for using aspirin, as well as other possible confounders and interactions, the use of aspirin was still associated with a lower risk for death (adjusted HR, 0.56; 95% CI, 0.40-0.78; P<.001). Most aspirin-related reductions in mortality were seen in older patients, those with known coronary artery disease, and those with impaired exercise capacity.

CLINICAL PREDICTORS OF PROLONGED DELAY IN RETURN OF THE INTERNATIONAL NORMALIZED RATIO TO WITHIN THE THERAPEUTIC RANGE AFTER EXCESSIVE ANTICOAGULATION WITH WARFARIN

Hylek EM, Regan S, Go AS, et al. Ann Intern Med 2001; 135:393-400

Sensitivity to warfarin, advanced age, and an extreme elevated international normalized ratio (INR) are independent risk factors for prolonged delay to return of the INR to within the therapeutic range. This retrospective cohort study included outpatients with an INR > 6.0 from August 1993 to September 1998. Two doses of warfarin were withheld and a follow-up INR was obtained on the second calendar day. The INR was measured two days following a recorded INR > 6.0. Of the 633 individuals with a beginning INR > 6.0, 232 (37%) still had an INR of [greater than or equal to] 40 after two doses of warfarin were withheld. Those who needed larger weekly maintenance doses of warfarin were less apt to have an INR of [greater than or equal to] 4.0 on the second day (adjusted odds ratio per 10 mg of warfarin, 0.87 [95% confidence interval {CI}, 0.79-0.97]). Additional risk factors for having an INR of [greater than or equal to] 4.0 on the second day included age (odds ratio per decade of life, 1.18 [CI, 1.01-1.38]), ind ex INR (odds ratio per unit, 1.25; CI, 1.14-1.37), decompensated congestive heart failure (odds ratio, 2.79; CI, 1.30-5.98), and active cancer (odds ratio, 2.48; CI, 1.11-5.57).

DIAGNOSTIC TESTS FOR RENAL ARTERY STENOSIS IN PATIENTS SUSPECTED OF HAVING RENOVASCULAR HYPERTENSION: A META-ANALYSIS

Vasbinder GBC, Nelemans P, Kessels AGH, et al. Ann Intern Med 2001; 135:401-411

Patients evaluated for renovascular hypertension prefer computed tomography angiography and gadolinium-enhanced three-dimensional magnetic resonance angiography. This literature search compared the validity of computed tomography angiography, magnetic resonance angiography, ultrasonography, captopril renal scintigraphy, and the captopril test in diagnosing renal artery stenosis in patients suspected of having renovascular hypertension. The studies met the following criteria: suspicion of renovascular hypertension was the reason for the test; intra-arterial x-ray angiography was used as the gold standard; a cutoff point for a positive test was expressly defined; and absolute numbers of true-positive, false-negative, true-negative, and false-positive results were available or could be obtained from the data. Even though accuracy varied greatly for all diagnostic modalities, summary receiver-operating characteristic curves showed computed tomography angiography and gadolinium-enhanced, three-dimensional magneti c resonance angiography performed substantially better than other diagnostic tests.

THIRD GENERATION ORAL CONTRACEPTIVES AND RISK OF VENOUS THROMBOSIS: META-ANALYSIS

Kemmeren JM, Algra A, Grobbee DE. BMJ 2001; 323:131-134

Third generation oral contraceptives are associated with an increased risk of venous thrombosis. This meta-analysis included cohort and case controlled studies that assessed the risk of venous thromboembolism in women using oral contraceptives before October 1995. The main outcome measures were pooled adjusted odds ratios calculated by a general variance based random effects method. The overall adjusted odds ratio for third compared to second generation oral contraceptives was 1.7 (95% confidence interval, 1.4-2.0; 7 studies). Similar risks were seen when oral contraceptives containing desogestrel or gestodene were compared with contraceptives containing levonorgestrel. In first time users, the odds ratio for third compared to second generation preparations was 3.1 (2.0-4.6; 4 studies). The odds ratio was 2.5 (1.6-4.1; 5 studies) for short-term users when compared with an odds ratio of 2.0 (1.4-2.7; 5 studies) for long-term users. The odds ratio was 1.3 (1.0-1.7) in studies that were funded by the pharmaceut ical industry and was 2.3 (1.7-3.2) in other studies. Any differences in age and certainty of diagnosis of venous thrombosis did not alter the results.

(*.) Originally prepared for presentation on Southern Medical Association's Web site (http://www.sma.org) by Elaine McClellan-Holm.