PEARLS/STROKE RECOVERY
From the American Academy of Family Physicians’ 2006 Scientific Assembly, Washington DC
| EVIDENCE-BASED PEARLS —Frank J. Domino, MD, Associate Professor of Family Medicine, University of Massachusetts
Medical School, Worcester
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| Acute sinusitis: etiology usually viral; resolves spontaneously most of time; diagnosis—based on symptoms of upper
respiratory infection (URI); purulent rhinorrhea, postnasal drip, cough, congestion, facial pain, headache, fever;
treatment—consider antibiotic if symptoms last >10 days and no improvement with nasal decongestants; amoxicillin
500 mg tid or trimethoprim–sulfamethoxazole (Bactrim DS) bid just as effective as newer antibiotics, with fewer side effects;
comparator bias—comparing new treatment to no treatment rather than to current standard of care; eg, levofloxacin
(Levaquin) and azithromycin (Zithromax) claimed superiority to placebo in treatment of acute sinusitis; implied Levaquin
and Zithromax as effective as amoxicillin and Bactrim, but no published study; publication bias—few randomized controlled
trials published when outcome not clinically significant; Levaquin may be as effective as amoxicillin and Bactrim,
but associated with greater cost, resistance, and side effects
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| Tinea versicolor: superficial infection developing from normal skin flora, resulting in spots; treatment for recurrences—
fluconazole (Diflucan) had 90% cure rate (similar to ketoconazole) without hepatotoxicity associated with ketoconazole and at
lower cost; topical antifungals unlikely to be effective; initial treatment—400 mg of fluconazole ($20) most effective treatment
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| Medroxyprogesterone (Depo-Provera): according to World Health Organization (WHO), causes clinically insignificant
decrease in bone mineral density (<1 SD); benefits outweigh risks
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| Donepezil (Aricept): randomized controlled trial concluded that donepezil significantly improves cognition and preserves
function in patients with severe Alzheimer’s disease in nursing homes; activities of daily living (ADLs) and cognitive
function improved 4% to 5%, but caregivers found no difference in patient needs; statistically significant but
clinically insignificant; unnecessary medication can increase cost and side effects
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| Preventing end-stage renal disease in type 2 diabetes: calcium channel blockers and angiotensin-converting enzyme
(ACE) inhibitors equally effective in decreasing proteinuria; only thiazide diuretics found effective in decreasing
rate of end-stage renal disease in type 2 diabetes; follow-up study found ACE inhibitors more effective than thiazides in
preventing albuminuria, but not more effective at preventing renal failure; in type 2 diabetes, blood pressure (BP) control
paramount for preventing renal disease; reasonable to use ACE inhibitor with thiazide or start with thiazide and add ACE
inhibitor if no microalbuminuria
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| Immunization: rotavirus vaccine—removed from market because of increased risk for intussusception; new 2-dose
vaccine (Rotarix) coming out; 3-dose vaccine (RotaTeq) now available; 85% relative risk reduction in gastroenteritis and
hospitalization with Rotarix; 95% relative risk reduction in gastroenteritis, hospitalizations, and emergency department
(ED) visits with RotaTeq; may have large impact on health care worldwide; quadrivalent human papillomavirus
(HPV) recombinant vaccine (Gardasil)—partially effective against HPV subtypes 6 and 11 (known to cause low-
grade squamous intraepithelial lesions [SIL]) and 16 and 18 (high-grade SIL); other uses may include men, eg, condyloma
acuminatum and protection from common wart; herpes zoster vaccine—relative risk reduction ≈51%; postherpetic
neuralgia reduced by 66%; live vaccine; indicated in patients ≥60 yr of age, but contraindicated in
immunosuppressed patients and during pregnancy
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| Developmental dysplasia: Ortolani and Barlow maneuvers no longer needed on newborns; insufficient data about usefulness
of screening; most abnormal hip examinations resolve spontaneously in 8 wk; triple diapering can worsen condition;
risk factors include female sex, breech birth, positive family history, and American Indian ethnicity; incidence of
serious developmental dysplasia 0.5%
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| Abdominal aortic aneurysm (AAA): ultrasonography recommended for men 65 to 75 yr of age with history of tobacco
smoking (reduces risk of AAA mortality by nearly 50%); send to high-volume centers (low mortality rates from intraoperative
events)
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| Hemachromatosis: screening not recommended; only small percentage of patients have genotype that causes disease;
no evidence that taking weekly blood samples improves outcomes
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| Iron deficiency anemia: 2006 United States Preventive Services Task Force stated insufficient evidence for routine
screening in asymptomatic children; using hematocrit or ferritin not sufficiently predictive
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| Avian influenza: “forget about amantadine”; oseltamivir (Tamiflu) and zanamivir (Relenza) slightly prevented and reduced
symptoms if started shortly after onset; Tamiflu minimally but significantly decreased lower respiratory tract infections;
both drugs reduced but did not stop viral shedding; use of Tamiflu found to prevent seroconversion (ie,
prevented patients from developing immune resistance), and may result in patients harboring and possibly spreading resistant
virus; in event of pandemic, Centers for Disease Control and Prevention (CDC) recommends cautious use of Tamiflu
|
| Heart disease: homocysteine—high levels correlate with increased risk for heart disease; vitamin B can lower homocysteine
levels; study of 6000 patients found no reduction in cardiovascular disease risk after 5 yr when patients with
high homocysteine levels given vitamin B; no significant difference in primary end point of myocardial infarction (MI),
stroke, or cardiovascular death; C-reactive protein (CRP)—CDC and American Heart Association (AHA) recommend
using CRP as marker only in patients with moderate degree of risk (ie, 10%-20% risk for MI over next 10 yr); no data
that using CRP more effective than looking at traditional risk factors (eg, hypertension, diabetes, positive family history
of premature heart disease, low levels of low-density lipoprotein [LDL]); cocoa study—group with highest cocoa consumption
had slightly lower BP, and relative risk for death from heart disease of 0.67 (33% reduction in risk); only men
studied; cohort study (does not prove cause and effect); people who ate cocoa more likely to consume large amounts of
alcohol, nuts, and seeds; cocoa intake inversely associated with consumption of red meat and coffee
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| Premenstrual syndrome (PMS): may be effective—vitamin E for 5 days around menses, continuing for a few cycles;
chaste tree berry (20 mg daily); calcium supplementation daily for 3 mo; vitamin B6 supplementation (100 mg
daily); definitely effective—selective serotonin reuptake inhibitors (SSRIs) improve discomfort and provide behavioral
benefits, but must be taken throughout month; ibuprofen and application of heating pad safe and effective
|
| Gastroesophageal reflux disease (GERD): coffee intake improves asthma and GERD symptoms; study found esomeprazole
(Nexium), 40 mg bid, did not improve morning expiratory flow rates, decrease use of rescue inhalers, or improve
quality of life scores in patients with nocturnal asthma and/or GERD; functional dyspepsia—epigastric pain or
burning; postprandial fullness; early satiation; no evidence of disease on esophagogastroduodenoscopy (EGD); heartburn;
indigestion; study comparing omeprazole (20 mg daily), ranitidine (Zantac; 150 mg bid), cisapride, and placebo found patients
on proton pump inhibitor (PPI) had best outcomes at 4 wk, but no significant difference in outcomes thereafter; if patient
does not improve after 4 wk of PPI, consider H2 -antagonist (eg, ranitidine)
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| Unnecessary prescriptions: study by Veterans Administration found nearly 50% of veteran patients had ≥1 unnecessary
unjustified prescription, nearly 20% had 2; gastrointestinal (GI) agents most common agent added at discharge
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| Child issues: coughing—no good evidence of efficacy of over-the-counter cough agents; most studies small and low
quality; codeine may not be helpful; pacifiers—data show pacifiers decrease length of breast feeding; benefits include
90% relative risk reduction for sudden infant death syndrome (SIDS); effects of media—1) 2-yr study showed that adolescents
12 to 14 yr of age who viewed highest amount of sexually explicit material on television at higher risk for early
sexual intercourse; parental disapproval of teenaged sex lowered risk for early intercourse; hands-on parenting most effective
in blacks at lowering risk for early sexual activity; 2) teenagers who watched 2 hr of television daily at higher risk for
sexual intercourse over next year, compared to those who watched <2 hr daily; 3) for every 1-hr of television watched,
children consumed extra 167 calories
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| Vitamin D: chronic musculoskeletal pain—study found 93% of patients with chronic myalgias had low vitamin D levels,
28% had severely low levels; Women’s Health Initiative—study of 36,000 women found no difference between all-fracture
rate and hip fractures in those taking calcium (1000 mg daily) and vitamin D (400 IU daily); vitamin D (10,000 IU
weekly or 1000 IU daily) significantly decreased fall rate; study of women >65 yr of age who received 700 IU of vitamin D
and calcium found number needed to treat to prevent fall, 5; current recommendation for vitamin D, 400 IU daily; many endocrinologists
recommend 800 IU daily; consider vitamin D deficiency in patients with chronic musculoskeletal complaints;
give at-risk patients ≥800 IU of vitamin D daily
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| FAMILY PHYSICIAN’S STROKE RECOVERY STORY —Thomas T. Gilbert, MD, Assistant Professor of Family Medicine
(Retired), Boston University School of Medicine, and Margaret (“Peggy”) R. Gilbert, BA, North Haven, ME
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Dr. Gilbert
| Introduction: family physician for 25 yr; while vacationing in Maine in August 1999, Dr. Gilbert awoke with severe
headache; then noticed inability to raise right arm or leg, and inability to speak clearly; within 2 hr, conscious but “slipping
fast” due to massive brain hemorrhage; affected left side of brain and right side of body; Dr. Gilbert lost consciousness;
flown to Massachusetts General Hospital in Boston; remained unconscious for 1 wk in intensive care unit;
transferred to Spaulding Rehabilitation Hospital; disoriented and unable to follow simple directions; body “floppy as a
rag doll”; could not swallow correctly or speak clearly
|
| 10 wk after stroke: discharged from Spaulding; able to walk across room with assistance but primarily used wheelchair;
speech limited to single words and he often used wrong words (eg, called dog by wife’s name); continued therapy
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| Recovery: gradual; milestones included being able to walk and passing driver’s license examination; began sailing again
with help of family; attended support groups with wife, Peggy; realized that interacting with other stroke victims and families
gave hope for future; continued speech therapy at home; encouraged to interact with community as much as possible;
began volunteering at library and on stroke floor at Spaulding; applied skills from family medicine practice to volunteer
work; continued to listen to patients and family members, answer questions, and share experiences; “as a stroke victim I
know that there is no end point to one’s recovery”
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| 7 yr after stroke: Dr. Gilbert continues to improve “though the rate is much slower”; continues volunteer work; meets
regularly with family medicine fellow and attends family medicine grand rounds and research meetings; goes to gym
twice weekly; “my life is very different than before the stroke and yet it is very much the same”; developed sense of purpose
and pride from interacting with other stroke patients
|
Mrs. Gilbert
| Initial reaction to husband’s stroke: disbelief and shock at disability; wondered whether lives would ever be normal
again; realized husband’s recovery would take place in increments, not giant leaps
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| Emotions: feelings of defeat; loneliness; extreme despair; terrified of future; received support from family, friends, and
colleagues; daughter encouraged exercise to release tension; son wrote inspirational letters; exchanged messages and
shared fond memories with friends through E-mail; encouraged by Dr. Gilbert’s expression of pleasure from daughter’s
reading of letters (first sign that comprehension intact); uncertain about ability to care for husband
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| Life at home: during walk outside of home, Dr. Gilbert stumbled and fell; Peggy felt out of control and called 911; had
feelings of failure but was reminded “it’s okay to ask for help”; met with social worker and felt relief to have changes in
life acknowledged; Peggy resigned from work to care for husband; feeling isolated and lonely; instead of equal partnership
with husband, she felt in charge and more like parent than wife; gradually began to relax as Dr. Gilbert did things for
himself; communication—difficult; feelings of guilt when chatting with friends while husband sat isolated in wheelchair;
noticed slow but tremendous strides in husband’s improvement; relaxed conversations most meaningful; worst
conversations occurred when Peggy tried to speed things up by finishing husband’s sentences
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| Physician: sadness and comfort from meeting with family physician; smart and kind like her husband; physician listened to
concerns about antiseizure drugs; made time to interpret test results; returned telephone calls promptly; during check-ups,
encouraged Dr. Gilbert to report on his own progress; open to exploring alternative therapies (eg, hypnosis); “I felt blessed
to have a compassionate physician who listened carefully and offered meaningful advice”; discussed difference between depression
and grief; encouraged Peggy to grieve
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| Life after husband’s stroke: Dr. Gilbert continues to progress; can process complex information well and communicate
effectively; returning to work—Peggy felt good to be back in school community; able to connect immediately with
students experiencing loss; became more effective college counselor; overall effects—deepened love for each other,
family, and friends; Peggy in awe of husband’s determination; stroke no longer defines or overshadows them, but catalyst
to find new direction and meaning in their lives
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Educational Objectives
| The goal of this program is to educate the listener about recent and significant medical findings (evidence-based “pearls”)
in primary care and about personal experiences with stroke recovery. After hearing and assimilating this program, the participant
will be better able to:
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 | 1. Critically analyze literature about the treatment of acute sinusitis.
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| 2. Select appropriate drugs for end-stage renal disease in type 2 diabetes.
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| 3. Discuss the efficacy of oseltamivir (Tamiflu) in avian influenza.
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| 4. Implement current recommendations for screening for heart disease, functional dyspepsia, and vitamin D supplementation.
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| 5. Counsel patients and family members about stroke recovery and therapy.
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Discussed on This Program
Amantadine HCl [Symmetrel]
Amoxicillin [Amoxil, several others]
Azithromycin [Zithromax, Zmax]
Calcium carbonate and elemental calcium [several trade names]
Cisapride [Propulsid]
Codeine PO4
Donepezil HCl [Aricept, Aricept ODT]
Esomeprazole magnesium [Nexium]
Fluconazole [Diflucan]
Human papillomavirus recombinant vaccine [Gardasil]
Ibuprofen [several trade names]
Ketoconazole [Nizoral, Nizoral Cream Shampoo]
Levofloxacin [Levaquin, Quixin]
Medroxyprogesterone acetate [Depo–Provera, several others]
Omeprazole [Prilosec, Prilosec OTC, Rapinex]
Oseltamivir phosphate [Tamiflu]
Ranitidine HCl [Zantac, Zantac 75, Zantac EFFERdose]
Rotavirus vaccine live [Rotarix (investigational), Rotateq]
Trimethoprim-sulfamethoxazole (co-trimoxazole; TMP-SMZ) [Bactrim, several others]
Vitamin D
Vitamin E [several trade names]
Zanamivir [Relenza]
Suggested Reading
Bischoff-Ferrari HA et al: Effect of cholecalciferol plus calcium on falling in ambulatory older men and women: a 3-
year randomized controlled trial. Arch Intern Med 166:424, 2006; Brown JD et al: Sexy media matter: exposure to sexual
content in music, movies, television, and magazines predicts black and white adolescents' sexual behavior. Pediatrics
117:1018, 2006; Buijsse B et al: Cocoa intake, blood pressure, and cardiovascular mortality: the Zutphen Elderly Study.
Arch Intern Med 166:411, 2006; Clark MS et al: A randomized controlled trial of an education and counselling intervention
for families after stroke. Clin Rehabil 17:703, 2003; Curtis KM et al: Progestogen-only contraception and bone
mineral density: a systematic review. Contraception 73:470, 2006; Farschian M et al: Fluconazole versus ketoconazole
in the treatment of tinea versicolor. J Dermatolog Treat 13:73, 2002; Flicker L et al: Should older people in residential
care receive vitamin D to prevent falls? Results of a randomized trial. J Am Geriatr Soc 53:1881, 2005; Hajjar ER et al:
Unnecessary drug use in frail older people at hospital discharge. J Am Geriatr Soc 53:1518, 2005; Hauck FR et al: Do
pacifiers reduce the risk of sudden infant death syndrome? A meta-analysis. Pediatrics 116:e716, 2005; Jefferson T et
al: Antivirals for influenza in healthy adults: systematic review. Lancet 367:303, 2006; Kiljander TO et al: Effects of
esomeprazole 40 mg twice daily on asthma: a randomized placebo-controlled trial. Am J Respir Crit Care Med 173:1091,
2006; Legg LA et al: Occupational therapy for patients with problems in activities of daily living after stroke. Cochrane
Database Syst Rev:CD003585, 2006; Lonn E et al: Homocysteine lowering with folic acid and B vitamins in vascular
disease. N Engl J Med 354:1567, 2006; Luft AR et al: Stroke recovery--moving in an EXCITE-ing direction. JAMA
296:2141, 2006; Miller M et al: High attributable risk of elevated C-reactive protein level to conventional coronary heart
disease risk factors: the Third National Health and Nutrition Examination Survey. Arch Intern Med 165:2063, 2005; Plotnikoff
GA et al: Prevalence of severe hypovitaminosis D in patients with persistent, nonspecific musculoskeletal pain.
Mayo Clin Proc 78:1463, 2003; Ruiz-Palacios GM et al: Safety and efficacy of an attenuated vaccine against severe
rotavirus gastroenteritis. N Engl J Med 354:11, 2006; Snow V et al: Principles of appropriate antibiotic use for acute sinusitis
in adults. Ann Intern Med 134:495, 2001; Veldhuyzen van Zanten SJ et al: A randomized trial comparing
omeprazole, ranitidine, cisapride, or placebo in helicobacter pylori negative, primary care patients with dyspepsia: the CADET-HN
Study. Am J Gastroenterol 100:1477, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. The following has been disclosed:
Dr. Domino is Chief Communications Officer and Editor at RxPalm, Inc.
Dr. Domino, Dr. Gilbert, and Mrs. Gilbert spoke in Washington DC, at the American Academy of Family Physicians’
(AAFP) 2006 Scientific Assembly, presented September 27 to October 1, 2006. The Audio-Digest Foundation thanks
the speakers and the AAFP for their cooperation in the production of this program.
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