Urinary Tract Infections in Paralyzed Persons

Available evidence is insufficient to recommend regular use of oral antibiotics for the prevention of urinary tract infections (UTIs) in adults and adolescents who have abnormal bladder function because of spinal cord damage, according to an evidence-based report/technology assessment from the Agency for Health Care Policy and Research (AHCPR). The report was prepared by the Southern California Evidence-based Practice Center/RAND (one of 12 AHCPR Evidence-based Practice Centers [EPCs]) in collaboration with the University of California, Los Angeles. It is part of a new series of evidence reports and technology assessments sponsored by the AHCPR to provide comprehensive, science-based information on common medical conditions and health care technologies.

The report discusses prevention and management of UTIs in the two populations most commonly affected—persons who have spinal cord injuries and persons who have multiple sclerosis.

Diseases of the urinary system are the fifth most common cause of death in persons with spinal cord injuries. According to the report, bladder dysfunction develops in nearly 90 percent of persons with multiple sclerosis, which increases their chance of UTIs and other complications. Because the incidence of UTIs among persons with spinal cord injuries and multiple sclerosis is high, every person with bladder dysfunction caused by problems of the central or peripheral nervous system should be considered at high risk for infection. The EPC based its report on 1,278 studies involving patients 13 years of age or older.

A summary of the report titled “Prevention and Management of Urinary Tract Infections in Paralyzed People” (AHCPR Publication No. 99-E007) is available on the AHCPR Web site at http://www.ahcpr.gov. The full report may be obtained free from the AHCPR Publications Clearinghouse by calling 800-358-9295. Faxed copies are available from AHCPR InstantFAX by calling 301-594-2800 from a fax machine with a telephone.

Other EPC reports and technology assessments already released examine sleep apnea, persons with traumatic brain injury, alcohol dependence, testosterone suppression treatment of prostate cancer and cervical cytology.

Interim Guidelines for Anthrax Exposure

In response to reports of a series of bioterroristic threats of anthrax exposure in the United States, the Centers for Disease Control and Prevention (CDC) has issued interim guidelines for the management of anthrax exposure. The interim guidelines appear in the February 5, 1999, issue of Morbidity and Mortality Weekly Report (MMWR). Although all of the threats alleging use of anthrax that were described in the report turned out to be hoaxes, the CDC believes they point to settings where bioterrorism might occur and suggest the potential public health impact. These threats required immediate action by health care professionals, law enforcement officials and laboratory personnel.

Postexposure prophylaxis for exposure to Bacillus anthracis consists of chemoprophylaxis and vaccination. Oral fluoroquinolones are standard therapy for all adults. If fluoroquinolones are not available or are contraindicated, doxycycline is used. Children should receive prophylaxis with oral ciprofloxacin or oral doxycycline. Use of tetracyclines and fluoroquinolones in children has adverse effects that need to be considered carefully against the risk for life-threatening disease. Prophylaxis should be continued until B. anthracis exposure has been excluded. If exposure is confirmed, prophylaxis should continue for four weeks and until three doses of anthrax vaccine have been given or for eight weeks if vaccine is not available.

Vaccination is indicated in conjunction with chemoprophylaxis following a proven biologic incident. Postexposure vaccination consists of three injections, with one given as soon as possible after exposure and the others given at two and four weeks after exposure. Anthrax vaccine can be requested through the CDC.

The report in MMWR summarizes the findings of the investigations of the recent threats of anthrax exposure. It also covers the methods by which health professionals and public health departments should address bioterrorism and develop locality-specific response plans.

New Treatment Device for Rheumatoid Arthritis

A new therapeutic device has been approved by the U.S. Food and Drug Administration (FDA) for use in the treatment of patients with rheumatoid arthritis. The device, Prosorba column, is indicated for use in the therapeutic reduction of the signs and symptoms of moderate to severe rheumatoid arthritis in adults with longstanding disease and who have failed or are intolerant of disease-modifying antirheumatic drugs.

In this treatment, the patient's blood is removed and passed through a machine that separates the blood cells from the plasma. The plasma is passed through the Prosorba column and then recombined with the blood cells and returned to the patient. According to the manufacturer, the Prosorba column is a polycarbonate (plastic) cylinder that contains highly purified protein A immobilized on an inert silica matrix. The protein A binds to and removes antibodies, including clusters of circulating immune complexes and antigens. The standard course of treatment involves 12 weekly outpatient apheresis sessions. Each session lasts about two hours.

In clinical trials, about one half of patients who completed all 12 treatments showed significant clinical improvement. The patients in the trials had rheumatoid arthritis for an average of 15.5 years and had failed treatment with an average of five different drug regimens. In some patients, the effects of the Prosorba column lasted up to 75 weeks.

Report on Health Literacy

Patients with an inadequate ability to read and comprehend information have problems communicating their health care needs and understanding information about their medical conditions, which may adversely affect their health outcomes, according to a report of the Council on Scientific Affairs of the American Medical Association (AMA). The report, from the Council's Ad Hoc Committee on Health Literacy, was published in the February 10, 1999, issue of JAMA. It discusses the consequences of inadequate health literacy, implications for practicing physicians, communicating with patients, future research issues and health literacy as a policy issue.

In today's medical environment, patients are expected to be responsible for self-management of chronic conditions and other aspects of the spectrum of health care. According to the report, there is often a gap between what patients actually understand and what health care professionals expect their patients to know. Many patients with the greatest health care needs have the least ability to understand health concepts and basic health-related materials. Studies cited in the report note that these patients have worse health status and little understanding about their medical conditions and treatments.

The AMA committee recommends development of education programs for medical students and physicians to improve patient-physician communication skills. Future research should focus on optimal methods of screening patients to identify those with poor health literacy, effective health education techniques, and outcomes and costs associated with poor health literacy.

New Test for Lyme Disease

The U.S. Food and Drug Administration (FDA) has approved a new blood test for Lyme disease that can be performed in a physician's office. The test (PreVue Borrelia burgdorferi antibody detection assay) provides results in an hour. It is intended to be used as the first step in testing persons suspected of having Lyme disease. Positive results must still be confirmed with a Western blot test.

According to the FDA, the test uses antigenic proteins developed by recombinant DNA techniques rather than the whole-cell B. burgdorferi preparations used in current laboratory tests. In clinical trials, PreVue accurately detected Lyme disease in 72 percent of one group of 120 blood samples and 95 percent in another group of 42 blood samples.

Cardiovascular Disease Risk Reduction

Patients are significantly more likely to exercise and follow good dietary habits if they are advised to do so by their physicians, according to a report from the Centers for Disease Control and Prevention (CDC) published in the February 5, 1999, issue of Morbidity and Mortality Weekly Report. The CDC analyzed data from the 1997 Behavioral Risk Factor Surveillance System for seven states and Puerto Rico. A total of 20,847 adults responded to questions about cardiovascular disease risk-reduction behaviors and physician counseling. Persons over the age of 35 years were asked if they took aspirin every day or every other day and whether they did so to reduce their chance of having a myocardial infarction or stroke.

Overall, 42.3 percent of the participants reported receiving physician advice to exercise more and 41.5 percent reported receiving physician advice to follow good dietary habits. Women were more often given exercise or dietary advice than men, and middle-aged persons were more likely than younger or older persons to report receiving such advice.

Nearly 75 percent of the participants in the survey who reported being counseled by their physicians to increase their level of exercise did so, compared with 50.5 percent of those who had not received advice from their physician. Similarly, 82.8 percent of those who received counseling to change dietary habits had done so, compared with 55.6 percent who had not received physician advice.

Physicians were more likely to give dietary and exercise advice to persons with a history of cardiovascular disease. About 20 percent of persons over the age of 35 years reported taking aspirin daily or every other day to reduce their risk of myocardial infarction or stroke.

The CDC recommends that physicians counsel their patients about primary and secondary prevention of heart disease.

Statement on Interpreting Echocardiograms

A joint policy statement issued by the American Society of Echocardiography (ASE) and the American College of Cardiology (ACC) provides recommendations for emergency medicine physician training in echocardiography. The 12-member Task Force on Echocardiography in Emergency Medicine concluded that minimum training in echocardiography for emergency medicine, as defined in a 1994 report published in Annals of Emergency Medicine (23:95-102), is not adequate for physicians interpreting emergency medicine cardiographic studies today.

The 1994 study recommended a training period of 40 hours, including a total of 150 ultrasound examinations, with cardiac studies comprising approximately 25 to 50 examinations. The new ASE and ACC guidelines recommend, at a minimum, three months of echocardiography training, including 150 studies in the areas of cardiac, echocardiographic and Doppler research. To reach a competent reader level in echocardiography, physicians should have a minimum of six months of echocardiography education, involving 300 studies; and to achieve level 3 training, 12 months of study are needed with 750 cardiac, echocardiographic and Doppler studies.

ASE and ACC also recommend that high-quality echocardiographic equipment be readily available in all emergency departments. Copies of the policy statement are available by calling 800-253-4636 or writing the ACC, Educational Services, 9111 Old Georgetown Rd., Bethesda, MD 20814-1699.