Letters to the Editor: November 2007
Using C-Reactive Protein to Predict Cardiovascular Risk
To The Editor:
Dr. Blaine presented an excellent analysis of C-reactive protein usage in the elderly population for cardiovascular risk reduction.1 My question concerns the myeloperoxidase level and its assessment. Should this level be checked, and under what circumstances would it prove useful?
(Dr.) Frank M. Shanley, PA, FACC
1. Blaine JM. Using C-reactive protein to predict cardiovascular risk in older patients. Clinical Geriatrics 2007;15(8):20-25.
Dr. Blaine responds:
Thank you for your question about another biomarker for cardiovascular disease: myeloperoxidase (MPO). MPO is contained in leukocytes and is released when leukocytes are activated. There is abundant evidence linking MPO to clinical atherosclerotic disease. Among its many activities, it appears to convert low-density lipoprotein (LDL) by oxidation into a more atherogenic form. So far, its clinical use seems to be limited to patients with acute coronary syndromes, where it can be very predictive. Whether it adds anything in the clinical management of patients above and beyond current clinical practice remains to be proven. MPO measurement has no utility in the management of patients with either stable coronary artery disease, or for patients at risk for coronary artery disease.
Jerry M. Blaine, MD
Lahey Clinic Medical Center
Clinical Assistant Professor in Medicine, Tufts University School of Medicine;
Clinical Instructor in Medicine, Harvard Medical School
Brennan ML, Penn MS, Van Lente F, et al. Prognostic value of myeloperoxidase in patients with chest pain. N Engl J Med 2003;349(17):1595-1604.
Nicholls SJ, Hazen SL. Myeloperoxidase and cardiovascular disease. Arterioscler Thromb Vasc Biol 2005;25(6):1102-1111. Epub 2005 Mar 24.
A Practical Rapid Clinical Examination of Multiple Functions
To the Editor:
As a part of the medical examination that I have been teaching students, the following procedure has been found to be useful to both diagnosis and total therapeutic planning with patients:
Ask a pharmacist to sell you two dark-colored cylindrical prescription pill containers:
• One 6.5 x 4.0-cm container, with several labels attached, if possible of different colors, with the icons and directions regarding usage (eg, “This medication may be taken with or without food,” “Do not crush, swallow whole”), and a non–child-resistant cap on it. Then you fill it with a common aromatic substance, such as cinnamon.
• One 7.5 x 3.0-cm container, with several labels attached, and a child-resistant safety cap on it. Fill it with a different aromatic substance, such as instant coffee. (The reason for the taller/narrower container is so the patient can use at least three fingers and a thumb to grip it with one hand, using the other to remove the cap.)
(Note: We know that for many people illiteracy is the secret of their life. Whatever the reason—deprivation of various types, cerebral/mental disorder, immigration—it is an area that must be explored for the patient’s welfare.)
Unless it has already been determined that the patient is severely visually impaired, the following procedure is suggested:
1. Tell the patient that you want to examine her vision and ability to properly take her medication.
2. Hand the patient the containers, and ask her what color they are and what color the labels are.
3. Ask the patient to read aloud some labels. If she says, “I can’t read without my glasses, and I don’t have them,” offer a good magnifying glass. If the patient then says she cannot read it, ask whether she is unable to read English but can read another language. If she cannot read English, ask if there is someone where she lives who can read for her. Ask if she can see the pictures on the labels, and if so, ask her to explain what they mean.
4. If the patient can read, ask her which one has a child-resistant cap. If she cannot read, ask her if she knows the difference between the two caps. If she does not, then demonstrate how to open the child-resistant top.
5. Ask the patient to open the non–child-resistant container and describe the smell.
6. Ask the patient to open the child-resistant container and describe the smell.
This brief examination affords observation of the following: patient’s ability to hear, comprehend, and execute spoken instructions; patient’s visual acuity and color perception; patient’s literacy in healthcare English; some understanding of patient’s family/social support system; patient’s cognitive/inferential ability (ie, if she cannot read English, determine what message she infers from the pictures on the labels; if demonstration of how to open a child-resistant cap is necessary, there is further opportunity to observe the patient’s ability to watch and recall a procedural activity); patient’s hand/arm functional strength/weakness; patient’s speech patterns; and patient’s olfactory sense and ability to name what she smells. All are important functions for activities of daily living.
Joseph Robert Cowen, MD