Medicine Digest
mild with either treatment. Single-dose azithromycin is simpler
than intramuscular benzathine benzyl- penicillin. It may encourage the elimi- nation of yaws through mass treatment campaigns.
Mitjà O et al. Single-dose azithromycin versus ben- zathine benzylpenicillin for treatment of yaws in chil- dren in Papua New Guinea: an open-label, non-in- feriority, randomised trial. Lancet 2012; 379: 342–7; Mabey D. Oral azithromycin for treatment of yaws. Ibid: 295–7 (comment).
Genotyping was performed on 11 Cardiology
Antihypertensive drugs and gout Up to 74% of people with gout are also hypertensive. A study based on a UK general practice database has provided data about the risk of gout with various antihypertensive drugs. Data for 2000–2007 included 24768 incident cases of gout and 50000 matched controls. Among people with hypertension, diuretics were associated with a significant 2.4-fold increase in risk of gout. β-blockers significantly in- creased the risk by 48%, non-losartan angiotensin II receptor blockers were as- sociated with a significant 29% increase in risk, and ACE inhibitors with a signifi- cant 24% increase. By contrast, calcium channel blockers were associated with a significant 13% reduction in risk, and losartan with a significant 19% reduc- tion. Each of the latter drugs has urate- lowering properties. Among people with hypertension,
diuretics, β-blockers, ACE inhibitors, and non-losartan angiotensin II recep- tor blockers increase the risk of gout but calcium channel blockers and losartan reduce the risk.
Choi HK et al. Antihypertensive drugs and risk of inci- dent gout among patients with hypertension: popu- lation based case-control study. BMJ 2012; 344 (11 Feb): 18 (d8190); Ruilope LM. Antihypertensives in people with gout or asymptomatic hyperuricaemia. Ibid: 9 (d7961) (editorial).
The Y chromosome and coronary disease
Genes on the Y chromosome may be re- lated to cardiovascular disease. The XYY karyotype is associated with increased cardiovascular mortality and a common polymorphism in the male-specific re- gion (MSY) of the Y chromosome is as- sociated with cardiovascular risk factors. A genetic study has illustrated the con- nection between the Y chromosome and coronary disease in men.
56 Africa Health
markers of the MSY in 3233 unrelated British men from three established co- horts. Each Y chromosome was tracked back to one of 13 ancient lineages (haplogroups) and the risk of coronary disease was related to haplogroup. Two haplogroups (R1b162 and I) accounted for 90% of Y chromosome variants. Car- riers of haplogroup I had a 56% increase in risk of coronary disease compared with other haplogroups, independently of common cardiovascular and socio- economic risk factors. Studies on mac- rophage transcriptome in men from one of the cohorts pointed to common genes related to inflammation and immunity. The Y chromosome may play an im- portant part in determining cardiovascu-
lar risk in men. Charchar FJ et al. Inheritance of coronary artery dis- ease in men: an analysis of the role of the Y chromo- some. Lancet 2012; 379: 915–22; Miller VM. Family matters: sexual dimorphism in cardiovascular disease. Ibid: 873–5 (comment).
and mortality: a systematic review and meta-analysis. Lancet 2012; 379: 905–14; McManus RJ, Mant J. Do differences in blood pressure between arms matter? Ibid: 872–3 (comment).
Obs & Gyn Ulipristal acetate for fibroids
Ulipristal acetate is a selective proges- terone-receptor modulator that acts on myometrial and endometrial tissue and inhibits ovulation. Two small trials have suggested that ulipristal acetate might benefit patients with uterine fibroids. Now two successive reports in the New England Journal of Medicine have shown that ulipristal acetate is more effective than placebo and non-inferior to leup- rolide acetate, a gonadotropin-releasing hormone (GnRH) agonist, with a lesser tendency to cause hot flushes. In a placebo-controlled trial, a total
Inter-arm difference in
systolic blood pressure and cardiovascular risk
A reduced ankle-brachial pressure index is taken as evidence of peripheral vas- cular disease. Similarly, a difference in systolic blood pressure between the two arms of >15mmHg may be evidence of atherosclerosis. Guidelines recommend measuring the blood pressure in both arms in patients presenting with hyper- tension but it is rarely done in UK general practice. A systematic review and meta- analysis has included 20 studies. In five angiographic studies subclavian stenosis of >50% was associated with a mean dif- ference in systolic pressure between the arms of 36.9mmHg and a difference of 10mmHg or greater was associated with a nine-fold increase in likelihood of sub- clavian stenosis. Pooled data from non- invasive studies showed that a between- arms difference of 15mmHg or greater was associated with a 2.5-fold increase in peripheral vascular disease, a 60% increase in pre-existing cerebrovascular disease, a 70% increase in cardiovascu- lar mortality, and a 60% increase in all- cause mortality. A difference of 10mmHg or greater was associated with a 2.4-fold increase in peripheral vascular disease. A difference in systolic blood pressure
of 10mmHg or more between arms may be an indicator of vascular disease need-
ing investigation and treatment. Clark CE et al. Association of a difference in systolic blood pressure between arms with vascular disease
of 242 women with fibroids, excessive uterine bleeding, and anaemia (haemo- globin 10.2g/dl or less) were randomised (2:2:1) to oral ulipristal acetate 5mg per day, or 10mg per day, or placebo, for 13 weeks, together with iron supplementa- tion. At 13 weeks, uterine bleeding was controlled in 91% (ulipristal acetate 5mg), 92% (10mg), and 19% (placebo). Amenorrhea occurred in 73%, 82%, and 6% respectively. Median total fibroid volume decreased by 21% and 12% in the treated groups and increased by 3% in the placebo group. Ulipristal acetate induced benign changes in endometrial histology that resolved within 6 months of stopping treatment. One patient in the ulipristal 10mg group developed uterine haemorrhage and one in the placebo group had a fibroid protruding through the cervix. Headache and breast tender- ness occurred at the same rates in both treatment and placebo groups. In an active-control trial a total of 307
patients with symptomatic fibroid and excessive uterine bleeding were ran- domised to oral ulipristal acetate 5mg daily oral ulipristal acetate 10mg daily, or i.m. leuprolide acetate 3.75mg once a month, for 3 months. Uterine bleeding was controlled in 90% (ulipristal 5mg), 98% (ulipristal 10mg), and 89% (leup- rolide). Amenorrhea occurred after an average of 7 days, 5 days, and 21 days respectively and moderate to severe hot flushes were reported by 11%, 10%, and 40%.
Ulipristal acetate is effective for the treatment of uterine fibroids prior to surgery.
July 2012
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