Clinical Shorts

Incontinence after prostatectomy

Teaching behavioural therapy to men who are incontinent after prostatectomy is worthwhile even in those who have tried it before and even when the surgery was done several years ago. In a randomized controlled trial in the United States, of 208 men with incontinence ranging from 1–17 years after prostatectomy, the number needed to treat to achieve complete continence in one patient was 10. A third of the men were assigned to delayed treatment (control group), a third to an eight week course of behavioural therapy, and a third to behavioural therapy plus biofeedback and pelvic floor electrical stimulation. Complete continence was achieved in 15.7% and 17.1% of the two treatment groups and 5.9% of the control group. Improvement in continence was reported in 55% (95% CI [confidence interval] 44%–66%), 51% (95% CI 51%–65%) and 24% (95% CI 10%–39%) of these groups respectively. Half the men in the trial had tried pelvic floor exercises before. See JAMA 2011;305:151–9.

Incontinence episodes per week in seven-day bladder diary. Analysis was based on multiple imputations of data for all patients as randomized. The change in scores from baseline to eight weeks was statistically significantly different among groups (p = 0.001). Reprinted with permission from JAMA, Jan. 12, 2011—Vol. 305, No. 2. p. 156.

Image courtesy of © 2011 American Medical Association. All rights reserved.

Stories for people with hypertension

Telling stories to African Americans with uncontrolled hypertension might help them control their blood pressure. Researchers from an inner-city clinic in the southern United States gave 147 patients interactive DVDs that contained narratives from three storytellers with hypertension that described how they had learned to interact with their physicians and suggested ways to improve compliance. The video also had a “learn more” section. Patients in the control group (n = 152) received DVDs that covered health topics not related to hypertension. Among patients with baseline uncontrolled hypertension, reduction favoured the intervention group, at three months for both systolic (11.21 mm Hg, 95% CI 2.51–19.9 mm Hg) and diastolic pressure (6.43 mm Hg, CI 1.49–11.45 mm Hg). This study was carried out at just one site over six months and had a 23% loss to follow up. See Ann Intern Med 2011;154:77–84.

Do e-health technologies improve the quality and safety of health care?

A lack of good quality research on the cost-effectiveness and risks of implementing e-health technologies was documented in a synthesis of 100 systematic reviews. A large gap exists between postulated and empirically demonstrated benefits of digital solutions, conclude the authors. We often do not know how and why certain interventions work and others fail. One wonders if all e-health technology launches, whether in individual practices or national projects, should include comprehensive evaluations with special attention to social and technical factors. See PLoS Med 2011;8:e1000387 doi:10.1371/journal.pmed.1000387.

HPV vaccination in boys and men

Should we be vaccinating all young men against human papillomavirus (HPV) to prevent genital warts? One industry-sponsored multicentre double-blind randomized trial involved 4065 men aged 16–26 years. The quadrivalent HPV vaccine reduced the number of men affected by external genital lesions from 89 among the 2032 men treated with a placebo to 36 among the 2033 men who received the vaccine (a relative efficacy of 60.2%; 95% CI 40.8%–73.8%). Persistent infections with the relevant HPV strains were decreased by 47.8% (95% CI 36.0%–57.6%). There were no serious adverse events related to the vaccine, but pain at the site of injection or mild fever was more common in the men who received a vaccine.

Based on the published results, the absolute risk reduction is calculated at 2.6% (95% CI 1.6%–3.5%) or a number needed to vaccinate of 38 (95% CI 28.69–63.32). These data point to HPV vaccination being effective in young men as well as women. The question remains whether this study, performed with a selected group of participants, provides sufficient information to justify incorporating male HPV vaccination into organized population-based programs. See N Engl J Med 2011;364:401–11.

Automated measurement of blood pressure in primary care

Poor technique, chatting during the procedure and lack of a rest period before manual blood pressure measurement can contribute to imprecise and inconsistent measurement of blood pressure in primary care. In a Canadian multicentre trial involving over 550 patients with systolic hypertension, 67 practices were randomly allocated to either ongoing use of manual or automated office blood pressure measurements. Automated office blood pressure readings did not appear to provoke the white coat response frequently seen with manual measurement. Automated readings correlated better with ambulatory blood pressure monitoring than manual measurement. However, we still do not know the accuracy of the readings at predicting future cardiovascular events. See BMJ 2011;342:d286 doi:10.1136/bmj.d286.