Antihistamines: the old and the new.

Several pharmacologic agents provide antihistamine effects by acting at the H1 histamine receptor site. The classic agents are relatively nonselective, resulting in a wide range of effects, both therapeutic and undesirable. The newer agents preferentially block peripheral H1 receptor sites and, consequently, have fewer side effects, including sedation. Antihistamines are useful in the treatment of allergic conditions, Parkinson's disease, insomnia and some forms of nausea, and provide symptomatic relief of cough and other conditions associated with respiratory tract infections. Certain agents may play a role in the treatment of asthma and anorexia. Selection of a specific agent should be based on cost and the minimization of side effects. The classic antihistamines provide an inexpensive and highly effective means of treating histamine-mediated symptoms. The bothersome central nervous system side effects can be alleviated by taking the drugs at bedtime; their prolonged tissue half-life allows dosing once or twice a day for 24-hour clinical relief. The newer, more expensive nonsedating antihistamines are acceptable alternatives for patients who are incapable of tolerating the effects of classic agents.

Urinary incontinence in the elderly: pharmacologic therapies.

Treatment of acute urinary incontinence should be directed toward the underlying cause, such as infection, medication side effect, atrophic vaginitis, anxiety, depression and restricted mobility. Pharmacologic treatment depends on identification of one of the four subtypes of chronic urinary incontinence: stress, urge, overflow or mixed. Stress incontinence responds to alpha-adrenergic agents, which increase sphincter tone. Urge incontinence is the most common type of incontinence in the elderly; it can be treated with anticholinergic agents, smooth muscle relaxants, estrogen replacement therapy in women and, possibly, calcium antagonists. Overflow incontinence is caused by neurologic deficits, such as diabetes, or outflow obstruction, such as from prostatic enlargement, urethral stricture and tumors. Anticholinergic agents and alpha-adrenergic agents should be considered only after existing outflow obstruction is surgically corrected or intermittent catheterization is unsuccessful.

Calcitonin in the treatment of osteoporotic bone pain.

Calcitonin has been observed to have an analgesic effect on painful bone conditions. A case illustrating the antinociceptive effect of calcitonin on bone pain caused by osteoporotic vertebral compression fracture is presented. There is increasing clinical evidence supporting this phenomenon, though few rigorously controlled studies exist. Calcitonin may have an advantage over other analgesics in the treatment of bone pain resulting from an osteoporotic compression fracture, because, in addition to the observed analgesic effect, it is useful in treating the underlying disorder.

A criterion-based review of preventive health care in the elderly. Part 2. A geriatric health maintenance program.

Although the geriatric population is growing rapidly and using an increasing portion of health care dollars, no consensus exists about the best approach to preventive medicine in this age group. The most comprehensive review to date is the 1989 United States Preventive Services Task Force (USPSTF) recommendations. However, the USPSTF did not specifically address the unique situation of the elderly. Consequently, we have evaluated numerous screening tests and preventive interventions for the elderly by systematically applying the geriatric-specific criteria for preventive services proposed in Part 1 of this article (J Fam Pract 1992; 34: 205-224). Tests and interventions were measured against specific screening criteria and put into one of three categories: those that have been proven effective, those that may be effective but about which more research is needed, and those that are not effective. Recommendations were compared with those of the USPSTF. Proof of the efficacy of most screening tests and interventions in the current literature was found to be lacking, pointing to the need for substantial future research in this area.

The relationship between self-esteem and physical health in a family practice population.

This study explored the relationship between self-esteem and physical health in a primary care setting. Sixty-eight adult patients (33 males and 35 females) at a Family Practice Center completed a questionnaire assessing self-esteem and physical health. Multiple regression analysis was used in exploring the effects of self-esteem, and the control variables age, gender, employment and marital status on health status, as assessed from the patient's chart, and on number of symptoms, as assessed through patient self-report. The regression on health status was significant overall (F = 4.12, p less than .001) with each of the predictors yielding significant coefficients. Those with high self-esteem, younger people, men, and employed people had significantly higher health status scores as assessed from the patient's chart. The regression on number of symptoms was marginally significant overall (F = 2.28, p less than .06) with self-esteem emerging as a significant predictor (p less than .05). Those with high self-esteem had significantly fewer symptoms as reported on the Hopkins Symptom Check List. These results support the existence of a positive relationship between self-esteem and physical health in a family practice patient population.

Obstetric ultrasound training for family physicians. Results from a multi-site study.

A practical program to train family physicians in obstetric ultrasound was tested with 13 family physicians. Each physician completed 6.5 days of course work and ultrasound laboratory apprenticeship prior to beginning a clinical preceptorship of approximately 14 months' duration. During the clinical preceptorship the physicians performed ultrasound studies in their own offices. All studies were reviewed by a local consultant radiologist utilizing examination data sheets and videotapes. At the conclusion of the training program, the physicians took a combined practical and written proficiency examination administered by an independent sonographer. Eight physicians completed the training, performing during the preceptorship an average of 78 examinations. The rated performance of the physicians improved markedly over the course of the preceptorship. During the last segment of the preceptorship the radiologist preceptors rated 94 percent of the ultrasound studies as acceptable, compared with 79 percent rated acceptable at the beginning of the preceptorship. Seven of the eight physicians completing the protocol took the proficiency examination: all passed. This study can provide a blueprint for an individual family physician to design his own training, or it can guide an academic department of family medicine in developing and evaluating ultrasound training programs for residents and practicing physicians.

A systematic approach to identifying and reducing medication-related problems in family practice patients.

Because of the existence of multiple medical diseases and the concurrent use of multiple medications, many elderly patients present a therapeutically complex picture to clinicians. This pilot study evaluates a systematic approach to identifying and reducing medication-related problems in a population averaging five chronic medical problems and taking an average of eleven medications. The approach is unique in its use of an in-depth home medication history and a comprehensive review of therapy. In spite of close medical supervision, an average of ten potentially medication-related problems were identified among seventeen therapeutically complex patients. Recommendations to eliminate these problems were developed by pharmacists who reviewed the patient information. These recommendations were presented to the patient's physician who accepted 67% of the suggestions.