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Content 7


The Doctor and the Pharmacist

Radio Show Articles:
January 22, 2011

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Warning: increase in fever-related seizures in young children receiving the flu shot
Colonoscopy, Time of Day, and Polyp Yield
Book Review: Honest Medicine. A local author and friend of the radio program
Cranberry Juice Is No Better Than Placebo for Preventing UTIs
Prophylactic Antibiotics at Catheter Removal After Prostatectomy?
Selective Serotonin Reuptake Inhibitors and Peptic Ulcers
Gait Speed Predicts 10-Year Survival in Elders
A Comprehensive Guide to Food Allergy

Just Thursday the FDA announced that they and the CDC are investigating an increase in fever-related seizures in young children receiving the flu shot. There have been 36 confirmed reports of seizures recently in children ages 6 months to 2 years. The FDA announcement resembles a previous one issued by the agency in July 2010 about increased rates of febrile seizures among Australian and New Zealand children who were vaccinated with another trivalent inactivated vaccine, Afluria (CSL Limited). The children involved in that announcement were mostly younger than 5 years. They were immunized during the 2010 influenza season of the Southern Hemisphere with the same trivalent formula now in use in the Northern Hemisphere.
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Gastrointest Endosc 2010 Dec; 72:1233
Colonoscopy, Time of Day, and Polyp Yield
An informational poster in the endoscopy room did not stop hour-by-hour reduction in polyp yields.

     Some studies have shown that as the endoscopy day and shift proceed, polyp and adenoma yields decline, presumably because of operator fatigue or rushing. One research group that previously reported this finding has now studied an intervention designed to reverse the trend.
     Informational posters showing the negative relation between time of day and polyp yield were placed in endoscopy rooms at a California hospital. The intervention did not work: The drop-off in polyp and adenoma yields during the day was similar between the 3-month intervention period and an earlier control period.
     Comment: Some studies reported at Digestive Disease Week in 2010 showed no appreciable reduction in polyp and adenoma detection during the day, indicating that the problem might not be present in all settings. In other studies, the phenomenon was seen, but not with all endoscopists. The current findings indicate that additional work will be needed to find a solution.
Douglas K. Rex, MD Published in Journal Watch Gastroenterology January 21, 2011
     Citation(s): Kaneshiro M et al. Colonoscopy yields fewer polyps as the day progresses despite using social influence theory to reverse the trend. Gastrointest Endosc 2010 Dec; 72:1233.PMID: 21111873
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Book Review - A local author and friend of the radio program.
Honest Medicine
Schopick J.
Oak Park, IL: Innovative Health Publishing; 2011: 308 pages

     The frustrations of the author with the way her husband was medically treated and the resistance to effective, time-tested, inexpensive treatments for life-threatening diseases that were not FDA approved or supported by Big PHARMA, is presented in a very informative, easy-to-read and interesting book.
     This book is well documented with case histories written by physicians. The treatments described have been used for many years, but many patients are sent home with no hope by physicians trained in the traditional methods that seem to be "closed-minded" or uninformed of other options available to them. Some say they are just "too busy" to look at other options! Drugs described in this book include Silverlon, alpha lipoic acid, and low dose naltrexone; the ketogenic diet is also described. A "very good read" that will support a lot of the recommendations by pharmacists and physicians who are open to other treatment when traditional methods fail. Available at Amazon.com.
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Clin Infect Dis 2011 Jan 1; 52:23
Cranberry Juice Is No Better Than Placebo for Preventing UTIs
Or, alternatively, placebo helped too. Surprisingly, we have seen reproducible positive results with D-mannose in either capsule or powdered form. These have been in men, women and children as well at patients with in-dwelling urethral catheters, a high risk group for recurrent UTI’s.
Cranberry juice for the prevention of urinary tract infections (UTIs) is one of the most durable folk remedies around, but attempts to prove its value have yielded results scattered all over the map. Some researchers have found it is worthless, whereas others have found it to be almost as potent as an antibiotic.
     In a randomized double-blind trial from Michigan, researchers assigned 155 healthy college-age women who sought medical care for UTIs to ingest low-calorie cranberry juice (8 oz twice daily) for 6 months after completion of antibiotic treatment. Another 164 women received placebo liquid carefully formulated to mimic real juice in all ways, except that it contained no proanthocyanidin, the moiety in cranberry juice that is thought to lower Escherichia coli adherence to uroepithelial cells.
     At 6 months, UTI recurrence rates were 19% in the cranberry group and 15% in the placebo group — a nonsignificant difference — with both rates strikingly lower than the expected recurrence rate of 30%. Further, although E. coli accounted for initial infections in about 80% of both groups, it accounted for far more recurrent infections in the cranberry group than the placebo group (93% vs. 58%) — exactly the opposite of what one might have expected if proanthocyanidin was involved.
     Comment: Here stands another negative study for the cranberry, although this one raises the intriguing possibility that the cranberry's active ingredient in fact might not be proanthocyanidin but another compound that, in this study, was present in both juice and placebo. And so the strange saga of the little berry that defied science continues.
Abigail Zuger, MD Published in Journal Watch General Medicine January 20, 2011
     Citation(s): Barbosa-Cesnik C et al. Cranberry juice fails to prevent recurrent urinary tract infection: Results from a randomized placebo-controlled trial. Clin Infect Dis 2011 Jan 1; 52:23. (http://dx.doi.org/10.1093/cid/ciq073)
PMID: 21148516
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Urol Int 2010 Dec; 85:415
Prophylactic Antibiotics at Catheter Removal After Prostatectomy?
Prophylactic ciprofloxacin started the day before catheter removal appears to reduce the risk for postprostatectomy urinary tract infection.
     Patients undergoing radical prostatectomy require short-term catheterization to allow bladder emptying while the urethra heals. Urinary tract infections (UTIs) often develop around the time of catheter removal. Some urologists prescribe prophylactic antibiotics at catheter removal to prevent this complication, but does this strategy work?
     To address this question, investigators at a New York City hospital retrospectively analyzed the incidence of UTIs after laparoscopic radical prostatectomies performed by two surgeons: one who routinely gave patients a 3-day course of ciprofloxacin (500 mg twice daily) starting the day before catheter removal and one who did not. Patients who received postoperative antibiotics for any other reason were excluded from the analysis.
     During the 34-month study period, 261 of 713 eligible patients received prophylactic ciprofloxacin. General characteristics of patients who did and did not receive ciprofloxacin were comparable, but the incidence of symptomatic UTIs within 6 weeks after catheter removal was significantly lower in the patients who received ciprofloxacin than in those who did not (3.1% vs. 7.3%; P=0.019).
     Comment: As the authors acknowledge, this study had several limitations, including a retrospective, nonrandomized design; a lack of systematic patient follow-up; and the potential for confounding linked to the different surgeons that could have contributed to the observed infection rates. Nonetheless, given the increasing concerns regarding healthcare-associated infections today, this and other potential approaches to preventing postprostatectomy UTIs should be evaluated in well-designed prospective trials.
Richard T. Ellison III, MD Published in Journal Watch Infectious Diseases January 19, 2011
     Citation(s): Pinochet R et al. Role of short-term antibiotic therapy at the moment of catheter removal after laparoscopic radical prostatectomy. Urol Int 2010 Dec; 85:415.PMID: 21099192
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Aliment Pharmacol Ther Dec; 32:1383
Selective Serotonin Reuptake Inhibitors and Peptic Ulcers
People with uncomplicated ulcers were 50% more likely to be using SSRIs, suggesting a possible direct ulcerogenic effect.
     Selective serotonin reuptake inhibitors (SSRIs) have been associated with increased risk for bleeding peptic ulcers in large population-based studies. One suggested mechanism for this association is the inhibition of platelets by SSRIs, resulting in bleeding from preexisting ulcers. However, the possibility that these drugs could directly cause ulcers has not yet been explored.
     To investigate this issue, researchers conducted a case-control study in a county in Denmark, using population-based data to select 4862 patients with a diagnosis of an uncomplicated peptic ulcer and 19,448 controls matched by age and gender. They collected data on current, recent, and past exposure to SSRIs, as well as potential confounding factors.
     Patients had a 50% higher likelihood of SSRI use than did controls (adjusted odds ratio, 1.50; 95% confidence interval, 1.18–1.90). The use of tricyclic antidepressants was similar in the two groups. Proton-pump inhibitor (PPI) use in people taking SSRIs eliminated the association between SSRI use and uncomplicated peptic ulcer.
     Comment: These results suggest that SSRI use is linked with uncomplicated peptic ulcer disease and that higher doses and more-recent exposure increase the association. However, this relationship might be overstated because of an underestimation of uncomplicated peptic ulcers in control patients because of higher likelihood of care seeking — and, consequently, discovery of ulcers — among patients taking SSRIs. The magnitude and mechanism of this relationship requires further investigation. In the meantime, PPI use to mitigate the effect of SSRIs should be considered in high-risk patients.
David J. Bjorkman, MD, MSPH (HSA), SM (Epid.) Published in Journal Watch Gastroenterology January 7, 2011
     Citation(s): Dall M et al. There is an association between selective serotonin reuptake inhibitor use and uncomplicated peptic ulcers: A population-based case-control study. Aliment Pharmacol Ther 2010 Dec; 32:1383. PMID: 21050241
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AMA 2011 Jan 5; 305:50
Gait Speed Predicts 10-Year Survival in Elders
Predictive value roughly equaled that of more complex clinical assessments.
    Assessment of life expectancy often is an important factor in decisions about whether to continue screening and treatment regimens, but no well-established predictive models are available. Researchers used data from nine cohort studies to assess the value of walking speed as a predictor of life expectancy in about 35,000 community-dwelling older adults (mean age at baseline, 74; predominantly white women). The studies used various walking distances (8–20 feet), and a range of mean baseline walking speeds were reported (roughly 5–11 seconds to walk 20 feet). About 18,000 deaths occurred during median follow-ups of 6 to 15 years.
     A significant association was noted between gait speed and 10-year survival, particularly for participants older than 75. Ten-year survival increased by roughly 12% for each 0.1-m/second increase in walking speed. Predictive value of walking speed was as accurate as the combined predictive value of age, sex, weight, smoking status, blood pressure, chronic disease burden, and prior hospitalizations.
     Comment: Walking speed is a readily accessible piece of clinical data that modestly predicts 10-year survival, and it is as accurate as more-complicated predictive models. The authors suggest that a gait speed of 0.6 m/second (10 seconds to walk 20 feet) is a threshold below which risk for early mortality is high, but the greater clinical value probably is in following change in gait speed over time. Substantial decline might trigger discussion about the appropriateness of continued aggressive care.
Thomas L. Schwenk, MD Published in Journal Watch General Medicine January 20, 2011     Citation(s): Studenski S et al. Gait speed and survival in older adults. JAMA 2011 Jan 5; 305:50. (http://dx.doi.org/10.1001/jama.2010.1923) PMID: 21205966
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J Allergy Clin Immunol 2010 Dec; 126:S1
A Comprehensive Guide to Food Allergy
NIAID guidelines include 43 recommendations for diagnosis and management of food allergy.
    Food allergy (FA) affects approximately 5% of young children and 4% of teens and adults in the U.S. The National Institute of Allergy and Infectious Diseases (NIAID) has released a guideline with 43 recommendations for diagnosis and management of FA derived from 348 articles reviewed by an expert panel. Highlights of the guideline include the following:
Definition, Prevalence, Epidemiology
• FA is defined as "an adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a given food."
• Mechanisms of FA reactions can be IgE mediated (acute urticaria, oral allergy syndrome), non–IgE mediated (food protein–induced enteropathy), mixed IgE and non–IgE mediated, or cell mediated.
• Prevalence is uncertain; FA is overreported by patients on the basis of symptoms alone (e.g., 3% of patients report symptoms of milk allergy, but only 0.9% are confirmed by food challenge).
Natural History
• Most infants with egg or milk allergy develop tolerance at a young age. Lower levels of allergen-specific IgE (sIgE) at diagnosis are associated with more-rapid development of tolerance. Decreases in sIgE level often are associated with tolerance.
• About one third of children <5 years with moderate-to-severe atopic dermatitis also have FA.
• FA should be suspected in any individual who presents with anaphylaxis or any combination of 37 listed symptoms that occur within minutes to hours after ingesting food.
• All reports of presumed FA should be confirmed (50%–90% of cases are not allergies).
• The double-blind placebo-controlled food challenge is the gold standard for diagnosing FA; a negative test rules out FA.
• Skin-prick test (SPT) and sIgE measurement should be used to assist in the diagnosis of FA, but neither test alone can be considered diagnostic.
• Intradermal tests, total serum IgE measurement, and atopy patch tests are not recommended.
• The type of diagnostic testing should be selected based on medical history and not comprise large general panels of food allergens.
• The guideline includes lengthy discussion of many non–IgE-mediated FAs.
Management and Prevention
• Individuals with documented FA should avoid the offending food.
• The frequency of follow-up testing (e.g., SPT or sIgE) depends on the offending food, age of the child, and intervening medical history.
• No medications prevent the development of FA.
• MMR and MMRV vaccines are safe for children with egg allergy, even for those with a history of severe reaction. The guideline includes extensive information regarding the administration of influenza vaccine in children with egg allergy.
• Routine testing for FA before introduction of highly allergic foods is not recommended, even in high-risk children.
• Children with atopic dermatitis that is unresponsive to therapy and those with atopic dermatitis and a reliable history of an immediate reaction after ingestion of a specific food should be tested for FA.
• Maternal diet during pregnancy should not be restricted to prevent FA.
• Soy milk should not be substituted for cow's milk as a strategy for preventing or modifying the development of FA.
• Use of hydrolyzed infant formulas in infants at risk for the development of FA who are not exclusively breast-fed might help delay or prevent FA (consistent with recent American Academy of Pediatrics recommendations [JW Pediatr Adolesc Med Feb 20 2008]).
• Introduction of solids, including allergenic foods, should not be delayed beyond age 4 to 6 months.
Diagnosis and Management of Food-Induced Anaphylaxis
• Anaphylaxis is "a serious allergic reaction that is rapid in onset and may cause death." The guideline includes detailed diagnostic criteria and pharmacologic management.
• Up to 20% of individuals with anaphylaxis have biphasic reactions.
• Lab tests, including plasma histamine and serum or plasma total tryptase, are rarely diagnostic.
• Epinephrine is the mainstay of treatment and should be administered as soon as anaphylaxis is recognized.
• Prior to discharge, all patients with anaphylaxis should receive (1) an emergency action plan, (2) two prescriptions for epinephrine autoinjectors, (3) a plan for monitoring expiration dates, (4) follow-up appointments, and (5) printed information about anaphylaxis and treatment.
     Comment: I like to use sIgE testing to guide diagnosis and treatment, although the ease of interpretation depends on the presence of symptoms and level of sIgE; the predictive value improves as levels rise above >3K IU. My practice is to test children with hard-to-control atopic dermatitis and those with histories consistent with FA before we institute an elimination diet, because the diet is so difficult to maintain in young children. The recommendation to provide two epinephrine autoinjectors for all children with anaphylaxis is better practice than the recent recommendation to provide two autoinjectors for all children with food allergy (JW Pediatr Adolesc Med Apr 7 2010). I am disappointed that the expert panel did not include a primary care pediatrician (PCP) because recommendations from specialists often do not translate well to the primary care setting, and PCPs cannot refer every child with suspected FA to specialists. See JW Pediatr Adolesc Med Jan 19 2011 for additional commentary on the NIAID guidelines.
Howard Bauchner, MD Published in Journal Watch Pediatrics and Adolescent Medicine January 19, 2011
     Citation(s): Boyce JA et al. Guidelines for the diagnosis and management of food allergy in the United States: Report of the NIAID-Sponsored Expert Panel. J Allergy Clin Immunol 2010 Dec; 126:S1.PMID: 21134576

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