VALUE OF BELOW-KNEE ELASTIC COMPRESSION STOCKINGS

Incidence of postthrombotic syndrome is reduced by half.

Applying below-knee elastic compression stockings daily for two years following the first episode of symptomatic proximal deep venous thrombosis (DVT) may reduce by half the incidence of postthrombotic syndrome.

Patients (N = 180) who suffered their first episode of symptomatic proximal DVT were randomly assigned to wear below-knee elastic compression stockings (provided to the patients) for two years (n = 90). A control group (n = 90) didn't wear the stockings, which were available in several standard sizes and applied 30 to 40 mmHg of pressure at the ankle. Patients also received heparin and oral anticoagulant therapy. Information such as the amount of time the approved stockings were worn and the development of adverse effects, such as itching, erythema, and the use of nonsteroidal antiinflammatory drugs, were recorded daily by the patients, who were clinically assessed at three months, six months, and biannually for up to five years. Researchers assessed for postthrombotic signs and symptoms, such as pretibial edema, skin induration, hyperpigmentation, new venous ectasia, redness and pain during calf compression, pain, cramps, heaviness, pruritus, and paresthesia.

Forty-nine percent of the control group developed postthrombotic syndrome compared with only 26% in the elastic-stockings group, with most of the incidences occurring during the first two years. The risk of postthrombotic syndrome was reduced by 50% in patients who were assigned to wear the stockings. The control group experienced more cumulative incidences of severe postthrombotic syndrome than did the elastic-stockings group (11.7% versus 3.5%). Recurrent ipsilateral DVT was associated with a three-times-greater risk of postthrombotic syndrome, whereas increasing age (10-year increments) was associated with a 1.36-times-greater risk.

Ready-made elastic compression stockings are widely available, inexpensive, and well tolerated. Researchers suggest their use during the first year after an initial acute DVT episode to decrease the risk of postthrombotic sequelae. -JC

Prandoni P, et al. Ann Intern Med 2004;141(4):249-56.

ADVANCED CARDIAC LIFE SUPPORT IN THE COMMUNITY SETTING

It doesn't improve survival rate.

Providing advanced cardiac life support (ACLS) to an optimally functioning emergency response system of rapid defibrillation and cardiopulmonary resuscitation in the prehospital setting doesn't improve survival rates among individuals who suffer cardiac arrest in this setting.

Eleven hospitals in 17 communities of Ontario, Canada, participated in the Ontario Prehospital Advanced Life Support Study, a controlled trial that evaluated the survival and morbidity benefits of adding an ACLS program performed by emergency medical system personnel to an already operating system of bystander-initiated cardiopulmonary resuscitation (CPR) and rapid defibrillation. During the rapid-defibrillation phase, which was conducted for 12 months, 1,391 patients were enrolled; during the advanced-life-support phase, which was conducted for 36 months, 4,247 patients were enrolled. A run-in period of six to 36 months separated the two phases to allow for proficiency of new skills. Only patients who were 16 years of age or older and who hadn't suffered trauma or obvious noncardiac cause of arrest were enrolled. Researchers were primarily interested in measuring survival to hospital discharge.

Although significantly more patients returned to spontaneous circulation (increased from 12.9% to 18.0%) and were admitted to the hospital in greater numbers (increased from 10.9% to 14.6%) in the advanced-life-support phase, the change in survival rate to discharge between the two phases wasn't significant statistically.

The study showed that the first three links in the chain of survival (early access, CPR and early defibrillation) remain important and most beneficial to survival. Researchers believe that CPR performed by bystanders and rapid defibrillation should be stressed in the community. Nurses can encourage others to learn CPR and be involved in teaching this vital skill. -JC

Stiell IG, et al. N Engl J Med 2004;351 (7):647-56.

BREAST CANCER STUDIES

Increasing patient awareness and education has positive results.

Two studies revealed that increasing the awareness and education of patients with breast cancer using either a computer program or personal one-on-one counselors or both shows positive results.

From November 1999 to April 2002, McMaster University reported that general surgeons in Hamilton, Ontario, and surrounding communities recruited 201 patients to participate in one of two groups-experimental and control. In the experimental group, the surgeon used a decision board, an aid that presents written and visual information to patients regarding their treatment options, which include short-and long-term effects with treatment, effects of treatment on the patient's breast, long-term survival, and quality of life. The surgeon in the control group discussed treatment options with patients without using the decision board.

In the Pennsylvania State University study, which took place from May 2000 to September 2002, 211 women with a personal or family history of breast cancer were recruited from six different study sites. Patients were randomly divided into two groups, one assigned to a counselor group, the other assigned to a computer group followed by one-on-one counseling. Within the two groups were subgroups of low- and high-risk patients.

The results of both studies showed an increase in patients' knowledge and satisfaction after participating in the McMaster study, reporting that the decision board group had greater knowledge and better satisfaction about their less-invasive treatment options (66.9% versus 58.7%).

The Penn State study reported that knowledge scores increased in both groups, regardless of their risk status. The women in the low-risk computer group had a greater increase in their knowledge scores. The overall perception of absolute risk of breast cancer decreased significantly in both groups.

Although both groups showed increased awareness, education, and satisfaction of the patient's decision making in their breast cancer treatment, the amount of time needed to help every patient requesting information greatly outnumbers the supply of practitioners who can provide it. Continued training and education of both medical personnel and patients at perceived risk should be maintained. -PWF

Whelan T, et al. JAMA 2004;292(4):435-41; Green M, et al. JAMA 2004;292(4):442-52.

ERECTILE DYSFUNCTION AND SILENT CAD

Patients with uncomplicated type 2 diabetes and ED are more susceptible.

Patients with uncomplicated type 2 diabetes who also had erectile dysfunction (ED) are more likely to have silent coronary artery disease (CAD), a recent study found.

In a study conducted by Gazzaruso and colleagues in 2004 at the University of Pavia, Italy, 260 men, 127 of whom had diabetes but had no myocardial ischemia at exercise electrocardiography (ECG), 48-hour ambulatory ECG, and stress echocardiography, and 133 men who had uncomplicated diabetes and who had silent CAD as verified per angiography, were studied.

Factored into the study were subjects' ages and length of diagnosis of diabetes. Each group was screened for ED using the validated International Index of Erectile Function (IIEF-5) questionnaire. Family history of heart disease, lipid profile, smoking history and drug abuse or both, body mass index, and history of hypertension were additional variables calculated into the final outcome.

The results presented a strong association between ED and silent CAD in men with uncomplicated type 2 diabetes who were at low risk for developing CAD. Additionally, the study noted that men with uncomplicated type 2 diabetes who did not have CAD had an incidence of ED no more than the general population.

This is essential because guidelines of the American Diabetes Association and the American College of Cardiology currently recommend noninvasive screening for silent CAD in men with uncomplicated type 2 diabetes when two or more common cardiovascular risk factors are present.¹ ED could become an indicator for silent myocardial ischemia in diabetic patients who were considered low risk for a diagnosis of silent CAD. -PWF

Gazzaruso C, et al. Circulation 2004; 110:22-6. American Diabetes Association. Diabetes Care 1998;21:1551-9.

COUGH MEDICATIONS AND SLEEP QUALITY

OTC medications don't necessarily help nocturnal cough.

Administering an over-the-counter (OTC) medication for nocturnal cough is no more effective than a placebo, according to a recent study from the Penn State College of Medicine.

From June 2002 to May 2003, patients with upper respiratory infection (URI) symptoms were recruited by two pediatric practices in Hershey, Pennsylvania. There were 105 eligible patients between the ages of 2 and 18 who had coughed for less than seven days because of URI symptoms. In the double-blind study, one-third of the patients were given dextromethorphan, a popular OTC cough suppressant; one-third were given diphenhydramine, a popular OTC antihistamine; and one-third were given a placebo for one night.

Symptom scores were obtained the day after medication wasn't administered. Scores were then were compared to follow-up calls the day after a single-dose administration.

The results indicated that parents reported that they and their children slept better the night of the study, but no significant improvement of symptoms was found when any of the treatments were compared. In all three groups, parents reported that once the medication was given, the cough was less bothersome to their children and therefore less bothersome to themselves.

Although there was no significant difference between the three groups, the study failed to research the effect of these treatments over several days and several doses of medication, which may change the outcome significantly.

Despite the perceived alleviation of symptoms, parents and practitioners should be educated and encouraged to allow children's illnesses to run their course without involving unnecessary, and possibly risky, medications.-PWF

Paul, IM, et al. Pediatrics 2004;114(1):e85-90.

ACUTE CORONARY SYNDROMES

Which heparin works best?

Low-molecular-weight heparins offer some advantages, in comparison with unfractionated heparin, to patients with acute coronary syndromes (either unstable angina or myocardial infarction without ST segment elevation but with elevated cardiac enzyme levels).

Seven randomized, controlled clinical trials involving 11,092 patients were reviewed for evidence comparing treatment with unfractionated heparin, the standard of care, with four different low-molecular-weight heparins. The latter were found to be superior to unfractionated heparin in decreasing the risk of subsequent myocardial infarction and the necessity of revascularization procedures, and they also showed a tendency toward the prevention of recurrent angina and carried less risk of the development of thrombocytopenia. The mortality rate was the same with each treatment, as was the risk of either major or minor bleeding.

Low-molecular-weight heparins cost more than un-fractionated heparin, but the administration of the latter is complicated and costly in terms of nursing time and laboratory testing. With fewer revascularization procedures, decreased nursing time, and decreased laboratory testing, the administration of low-molecular-weight heparins may be less financially costly in the end. And of course, the better outcomes associated with low-molecular-weight heparins significantly reduce the cost in terms of the burden of disease.

More research is needed to determine which low-molecular-weight heparins produce the best results, whether or not they can be used safely with glycoprotein IIb/IIIa inhibitors, and what the optimal timing of administration is. Patients with a history of angina or coronary disease should go to the ED as soon as symptoms of either begin. When patients present with chest pain and a history of angina, or chest pain without ST elevation but with elevated cardiac enzyme levels, treatment should be initiated immediately or as soon as possible. -FM

Brown MD. Ann Emerg Med 2004;44 (1):76-8.