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Content 7


The Doctor and the Pharmacist

Radio Show Articles:
February 22, 2013

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Eardrops More Effective Than Oral Antibiotics for Tympanostomy - Tube Ottorrhea
ACOG Guidelines Focus on Reducing Primary Cesarean Deliveries
Misconceptions about Conception
Subcuticular Suture versus Staples for C-section Skin Repairs
Adhesive versus Subcuticular Sutures for Epidermal Closure
Has Creating Personalized Stem Cells Just Become easier?
Prolonged Opioid Use is Uncommon After Major Surgery in Older Adults
Low Dose Opioids Safe in severe COPD, Benzodiazepines Less So
PDE-5 Inhibitors (Viagra-like products) for Treatment of Raynaud Phenomenon
Smoking Cessation's Mental Health Benefits Rival Those of Antidepressants
Dental Association recommends Fluoride Toothpaste for Infants and Toddlers
Yoga and Breast Cancer Survivor Quality of Life
Menopausal Hormone Therapy and the Pancreas
Cardioprotective Aspirin Is Associated with Elevated Risk for Gout
Children with Food Allergy: What's the Risk for Fatal Anaphylaxis?
Oral Antibiotics versus Topical Decolonization to Prevent Surgical Site Infections

MM: Here is an example of less is more. Keeping a treatment localized may be more effective and render fewer potential adverse reactions compared to systemic antibiotics. We have found the same approach to be true when treating localized joint and muscle pain as well as neuropathic pain and have tremendous success with our various Keto-R-A-G gels and Neuropathic pain creams. These get much greater local concentrations of medicine while limiting systemic presence and subsequent adverse reactions such as GI discomfort or potential dose related drug-drug interactions.
Eardrops More Effective Than Oral Antibiotics for Tympanostomy - Tube Ottorrhea
By Amy Orciari Herman
Eardrops containing antibiotics and hydrocortisone are more effective than oral antibiotics for managing uncomplicated otorrhea in children with tympanostomy tubes, a New England Journal of Medicine study finds.
Some 230 children (aged 1-10 years) in the Netherlands with tympanostomy-tube otorrhea were randomized to hydrocortisone-bacitracin-colistin eardrops for 7 days, oral amoxicillin-clavulanate for 7 days, or initial observation. At 2 weeks, otorrhea persisted in just 5% of children in the eardrop group, versus 44% in the oral antibiotic group and 55% in the observation group. In addition, during 6 months' follow-up, the median number of days of otorrhea was 5, 13.5, and 18, respectively.
In NEJM Journal Watch, pediatrician F. Bruder Stapleton notes: "This combination of agents in eardrops is not currently approved by the FDA. However, a ciprofloxacin and dexamethasone suspension (Ciprodex) has also been shown to be effective for this indication and is FDA approved for use in children aged 6 months and older." Careful cleaning of the ear canal is necessary for ear drops to be effective in the middle ear
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MM: I must applaud ACOG on this seemingly new attitude towards elective C-section. Allowing a normal vaginal delivery provides long term benefits to the newborn by allowing direct contact with mom's friendly bacteria upon entry to the outside world. This helps with immune and inflammatory functions throughout the body that have a lifelong effect on disease susceptibility and environmental sensitivity.
ACOG Guidelines Focus on Reducing Primary Cesarean Deliveries
By Kelly Young
To reduce the number of first-time cesarean deliveries, women should be encouraged to undergo longer labor, according to new guidelines from the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine.
Here are some of the key recommendations:

OB/GYN Allison Bryant, with NEJM Journal Watch, comments: "This evidence-based blueprint is much welcomed, emphasizing safe means to reduce first cesareans; the greatest yield will require rethinking longstanding paradigms of labor disorders and fetal heart rate abnormalities."

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MM: As Health Care Providers we must not assume that our patients and clients are simply aware of healthcare issues and information. That is a mistake that people tend to make about the fields that they are intimately associated with. I know that when I was looking at phone systems for my business, the vendors simply assumed that I was aware of all the ins and outs of phone systems but since that is not my field, I was predominantly ignorant and had to insist that they explained all the options so that I could make an informed decision. Our patients are entitled to receive information that we may consider obvious or commonplace yet may be foreign to them.
Fertil Steril 2014 Jan 30
Misconceptions about Conception
Even the highly educated have limited knowledge of key reproductive health concepts.
Optimal reproductive outcomes require a solid understanding of women's ability to conceive. Investigators used data from an online survey of 1000 U.S. women (age range, 18–40 years) to analyze knowledge and attitudes about conception and fertility. Participants were generally representative of the U.S. population, with the exception that 80% attended college.
Among women who had or wanted children, 75% reported that their leading source of information about reproductive health was their women's health provider, and 42% said pregnancy-focused websites were their second preferred source. Although half of respondents acknowledged discussing reproductive issues with a health care provider, the proportion discussing each issue was low. For example, only 13% of smokers had discussed the effects of smoking on reproductive health.
One third of respondents were unaware that past sexually transmitted infections, obesity, or irregular menses might reduce the chances of pregnancy, and 20% were unaware that fertility wanes with age. Forty percent did not know that ovulation usually occurs 14 days before menses. Sixty percent believed that intercourse should occur after ovulation to maximize chances of conception and 40% believed that women should remain supine with an elevated pelvis after intercourse to maximize chances of pregnancy.
Comment: The authors conclude that we need “strategies to improve patient-provider interaction and targeted educational efforts,” but they do not offer any concrete guidance about how to expand patients' knowledge in this area. Clearly, there is room to improve the health curricula offered in schools. In addition, clinicians have a responsibility to ensure their patients understand fundamental concepts of reproductive health.
Citation(s): Lundsberg LS et al. Knowledge, attitudes, and practices regarding conception and fertility: A population-based survey among reproductive-age United States women. Fertil Steril 2014 Jan 30; [e-pub ahead of print].
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MM: Patients seem to prefer the aesthetic result of staples when compared to sutures and many clinicians seem to like the ease and speed of the stapler compared to the suture. A question always arises when activities requiring greater skill such as suturing are replaced by a mechanical operation. That question is whether the skills that may be required on an occasional basis that are extremely important will be reduced by a lack of practice and a subsequent loss of muscle memory in the name of speed and ease.
Obstet Gynecol 2013 Oct; 122:878
Subcuticular Suture versus Staples for C-section Skin Repairs
Traditional epidermal repairs with running or simple interrupted sutures are being rethought.
Approximately one third of pregnant women in the U.S. have a cesarean delivery. To compare the risks for adverse effects related to wound closure after this procedure, investigators enrolled 32 women who had epidermal closure with subcutaneous sutures on one side of their incision and staples on the other side. Where the subcutaneous fat layer was more than 2.5 cm deep, subcutaneous 3.0 polyglactin 910 sutures (e.g., Vicryl) preceded the epidermal repairs.
At 6 months, more women preferred the scar on the stapled side (odds ratio, 2.55; 95% confidence interval: 1.18–5.52), as did one of two blinded plastic surgeon raters.
Comment: As patients and physicians become ever more concerned about improving the aesthetic appearance of skin repairs, traditional epidermal repairs with running or simple interrupted sutures are being rethought. Such repairs can leave epidermal markings (e.g., “track marks”). Subcuticular repairs can avoid such markings, but other investigators and Cochrane reviewers have noted a slightly greater risk for dehiscence with such repairs. When large epidermal repairs are accomplished with minimal subcutaneous sutures (e.g., when the fat layer is <2.5 cm thick), subcuticular sutures alone are inadequate to hold the skin together with a thin scar, and even the skin markings of staples are aesthetically preferable. Apart from aesthetics, other considerations can include time and cost. Researchers comparing tissue adhesive with subcuticular sutures for epidermal closure (NEJM JW Dermatol Jan 20 2014) found that adhesives can require significantly less surgeon time than even subcuticular repairs, but they also note that the cost of adhesives can be substantial. Staples are very speedy to apply, seldom permit dehiscence, but are associated with increased costs, and may be aesthetically adequate mostly in areas like the hair-bearing scalp, where staple-related skin markings are well-concealed.
Citation(s): Aabakke AJ et al. Subcuticular suture compared with staples for skin closure after cesarean delivery: A randomized controlled trial. Obstet Gynecol 2013 Oct; 122:878.

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MM: Just another look and a continued thought from the preceding article.
J Oral Maxillofac Surg 2013 Dec; 71:2152.e1
Adhesive versus Subcuticular Sutures for Epidermal Closure
Adhesive repairs remain attractive because they offer the prospect of healed skin without visible suture marks.
How effective is tissue glue for wound closure? These investigators compared cyanoacrylate adhesive and subcuticular skin sutures for closure of maxillofacial incisions. They evaluated time to closure, associated morbidity, patient satisfaction, and cosmetic outcome in 29 patients. Following similar placement of subcutaneous sutures, 20 approximated facial wounds in 14 patients received epidermal closure with octyl-2-cyanoacrylate adhesive, and 20 wounds in 15 patients were repaired with standard subcuticular sutures.
Cosmetic outcome was assessed after 3 months by an independent plastic surgeon using validated scales. Patient satisfaction was evaluated by a visual analog scale. Both expert-rated cosmetic outcome and patient satisfaction at 3 months were comparable for the two epidermal closure groups, but the application of adhesive required significantly less time than subcuticular sutures (slightly >1 minute vs. slightly >6 minutes). There was no significant difference in the dehiscence of wounds with either method.
Comment: There are now many articles comparing epidermal adhesive closures to epidermal suture closures. The primary parameters of comparison are function and aesthetics. Some studies suggest that adhesive closures may be slightly more susceptible to dehiscence, although that was not seen in this study. Adhesive repairs remain attractive because they offer the prospect of healed skin without visible suture marks, and because closures without epidermal sutures are less alarming for patients. Speed and costs are other considerations, which may vary based on circumstances, including operator technique. In dermatology, adhesives are still only used in a minority of repairs because they are perceived as less able to provide the precise approximation and eversion often needed for facial wounds.
Citation(s): Soni A et al. Comparing cyanoacrylate tissue adhesive and conventional subcuticular skin sutures for maxillofacial incisions—A prospective randomized trial considering closure time, wound morbidity, and cosmetic outcome. J Oral Maxillofac Surg 2013 Dec; 71:2152.e1.
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MM: As many of you know, I periodically take a "geek moment" to enjoy the latest hi-tech info that used to be considered science fiction. This new technique of creating stem cells and possibly new organs for transplant or tissue repair potentially eliminates graft rejection and possibly the need for potent and dangerous supplemental drug therapy following transplant.
Nature 2014 Jan 30; 505:641
Has Creating Personalized Stem Cells Just Become easier?
A new technique does away with genetic manipulation.
In 2007, researchers created the first induced pluripotent stem (iPS) cells. This labor-intensive technique allowed for construction of genetically identical embryonic-like stem cells for any person — without ever having to produce and destroy an embryo (NEJM JW Gen Med Dec 29 2008). As originally developed, the technique required introduction of a small number of genes into a differentiated adult cell (a fibroblast from a skin biopsy). This process was inefficient, and the altered cells were hypothesized to have malignant potential. Subsequently, modifications to the technique have lowered malignancy risk and increased efficiency greatly (NEJM JW Gen Med Nov 12 2013).
A new report from research teams in Boston and Kobe, Japan, makes a remarkable claim: Without any genetic manipulation, brief exposure of differentiated adult mouse cells to an acidic environment transforms them into the equivalent of iPS cells. Cells transformed in this way are called STAP cells. Like iPS cells, STAP cells reproduce themselves indefinitely and can be transformed into any differentiated cell type. Additionally, they can be introduced into a blastocyst and can be incorporated into a newborn animal, including that animal's germ cells. In fact, STAP cells also become part of placental tissue: They are more plastic than embryonic stem cells or iPS cells.
Comment:In mice, a simple technique that does not involve genetic manipulation can produce stem cell scientists' (and science fiction writers') dreams: an animal's own genetically identical embryonic stem cells. These and other investigators are racing to confirm these findings and to see if the technique also works in human cells. If so, these reports will be regarded as landmarks in the history of stem cell research.
Citation(s): Obokata H et al. Stimulus-triggered fate conversion of somatic cells into pluripotency. Nature 2014 Jan 30; 505:641.

Obokata H et al. Bidirectional developmental potential in reprogrammed cells with acquired pluripotency. Nature 2014 Jan 30; 505:676.
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MM: There is a great deal of anxiety about the use of opioid analgesics, addiction and pain. The appropriate short term use of these products for acute pain does not typically increase the likelihood of a patient becoming dependent upon or addicted to them. Where the problem tends to arise is when treatment is not sufficiently monitored and the pain is inadequately treated. Pain is associated with inflammation and while opiates will dull the short term presence of pain they will actually increase the amount of inflammation surrounding the nerves that transmit the pain information to the brain by inflaming the glial cells that surround these nerves. Dr Chopra from Brown medical Center and University has demonstrated the incidence of this glial cell inflammation and the use of Low Dose Naltrexone (LDN) in attacking this inflammation, reducing pain and eliminating the need for chronic use of opiate medications.
Prolonged Opioid Use is Uncommon After Major Surgery in Older Adults
By Kelly Young
Only about 1 in 30 older patients undergoing major elective surgery continued to use opioids more than 90 days post-surgery, according to a BMJ study.
Using Canadian databases, researchers studied nearly 40,000 patients (aged 66 years and older) without preexisting pain disorders who underwent coronary artery bypass graft surgery, lung or colon resection, prostatectomy, or hysterectomy. Both open and minimally invasive procedures were considered. Half the patients were prescribed opioids within 90 days after surgery. After 90 days, 3% were still taking opioids.
The highest risks for prolonged opioid use were associated with intrathoracic procedures, whether open (8.5%) or minimally invasive (6.3%).
The authors note that patients can "be reassured that when people receive opioids appropriately to treat acute pain after major surgery, the majority do not experience prolonged use." They add: "Patients' understandable fears about opioid dependence may be an important barrier to achieving adequate acute postsurgical pain relief."
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MM: Although I am not a great fan of the chronic general use of opioids due to their secondary inflammatory effects, there is a place in treatment for them and for those with chronic COPD there has been a substantial amount of literature that supports the use of this class of drugs to ease the discomfort of breathing. Chronic addiction or dependence does not generally appear to be an issue with these patients.
Low Dose Opioids Safe in severe COPD, Benzodiazepines Less So
By Amy Orciari Herman
Low-dose opioids may be safely used to reduce breathlessness in patients with severe chronic obstructive pulmonary disease, a BMJ study finds.
Using Swedish registries, researchers followed roughly 2200 patients starting long-term oxygen therapy for COPD. Some 40% were using benzodiazepines, opioids, or both at baseline.
During a median 2.5 months' follow-up, three-quarters of all patients were hospitalized. Use of benzodiazepines or opioids was not associated with increased admission rates. After 1 year, half of all patients had died. Benzodiazepines were associated with a 20% increase in mortality, as were high-dose opioids. Lower-dose opioids (30 mg or less of oral morphine equivalents/day), however, did not increase mortality.
The researchers say their research "supports the safety of regular low dose systemic opioids to reduce breathlessness in severely ill patients with respiratory compromise." They add that "benzodiazepines should not be the first line treatment ... given the unclear evidence of net clinical benefit."
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MM: We have had tremendous success ameliorating the symptoms of Raynaud with transdermal Nifedipine cream. Unlike nitroglycerin, there is rarely any incidence of headache and typically no significant lowering of blood pressure. This approach tends to be superior to the oral use of CCB's for raynaud phenomenom.
Ann Rheum Dis 2013 Oct; 72:1696
PDE-5 Inhibitors (Viagra-like products) for Treatment of Raynaud Phenomenon
Added to existing therapy, these oral agents could boost efficacy.
 Raynaud phenomenon (RP) may be primary (idiopathic) or secondary, usually in conjunction with a collagen vascular disorder. The initial treatment of RP consists of measures aimed at avoidance of triggers, including wearing of gloves to avoid cold. Topical nitroglycerin might help some patients, but the initial pharmacologic intervention is usually a calcium channel blocker (CCB). Oral angiotensin-converting enzyme inhibitors (ACE-Is) might also be effective. Recently, interest in the use of phosphodiesterase (PDE)-5 inhibitors has arisen due to their effect on nitric oxide, believed to be involved in RP pathogenesis.
The authors conducted a systematic review of randomized, controlled trials involving sildenafil, tadalafil, or vardenafil for treatment of secondary RP. Six trials involving a total of 244 patients met the inclusion criteria; most patients (>90%) had scleroderma-associated RP. In all instances, the comparator was placebo. The measures of efficacy were a Raynaud condition score, frequency of daily attacks, and duration of the attacks. All measures were significantly improved by the use of a PDE-5 inhibitor. There was some heterogeneity in these studies, as some allowed the use of a CCB or ACE-I.
Comment Oral PDE-5 inhibitors might benefit patients with secondary Raynaud phenomenon. The authors note that their efficacy may not be significantly better than that of calcium channel blockers, but they observe that when a PDE-5 inhibitor was an add-on to existing therapy, the efficacy was significantly better than with placebo. Perhaps PDE-5 inhibitors alone or in combination will allow patients to avoid injections of iloprostCitation(s): Roustit M et al. Phosphodiesterase-5 inhibitors for the treatment of secondary Raynaud's phenomenon: Systematic review and meta-analysis of randomised trials. Ann Rheum Dis 2013 Oct; 72:1696.
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MM: Lifestyle modification, although more difficult to achieve than the use of medication is frequently a preferable approach to achieving a better or healthier status. Smoking is a powerful addiction and typically very difficult to overcome as noted by the extremely high recidivism rate among those who have tried to quit. But, it appears that there are multiple organ system benefits to quitting. Young people rarely identify with the aspects of diminished mortality associated with smoking tobacco but perhaps if this information is coupled with the recent dermatological information associated with smoking and wrinkles, and the effects on mental health, a greater impact may be made upon this demographic.
Smoking Cessation's Mental Health Benefits Rival Those of Antidepressants
By Amy Orciari Herman
Smoking cessation is associated with improved mental health, even among patients with psychiatric conditions, according to a BMJ meta-analysis.
Researchers examined data from 26 longitudinal studies that measured mental health immediately before smoking cessation and at least 6 weeks afterward. Median follow-up ranged from 6 to 12 months.
Compared with participants who continued to smoke, those who quit had significant improvements in anxiety, depression, stress, psychological quality of life, and positive affect. Findings were similar across subgroups, including patients with physical or psychiatric disorders.
The researchers note that the mental health benefits seen with cessation were at least as large as those seen with antidepressants in previous meta-analyses. They conclude: "Whether or not smoking cessation directly causes the observed improvement in mental health, there are direct clinical implications. Smokers can be reassured that stopping smoking is associated with mental health benefits."
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MM: I am not a big fan of introducing fluoride to toddlers. Here is why... Fluorine is in the same chemical class as Iodine and Iodine effects metabolism and thyroid function. One of the greatest, if not the greatest challenge to healthcare and wellness is obesity. An increased challenge to weight and wellness represents a greater risk to the overall welfasre and well-being of the U.S. population than do cavities in America.
Dental Association recommends Fluoride Toothpaste for Infants and Toddlers
By Kelly Young
The American Dental Association is recommending that caregivers start brushing children's teeth with fluoride toothpaste as soon as the first tooth comes in. Previously, caregivers were instructed to use water to clean the teeth of children ages 2 years and younger.
The new recommendation is for a smear of fluoride toothpaste — roughly the size of a grain of rice — to be used in children under 3 years old. For children aged 3 to 6, the amount can be increased to the size of a pea. These small amounts are unlikely to lead to fluorosis, according to the association. Children should spit out the toothpaste as soon as they are able to do so.
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J Clin Oncol 2014 Jan 27
Yoga and Breast Cancer Survivor Quality of Life
Yoga exercise reduced fatigue and inflammation associated with decreased physical function.
Breast cancer survivors frequently cite myriad symptoms, including fatigue, deconditioning, and depression. In addition, their cardiorespiratory fitness is about 30% lower than that of their sedentary, age-matched, cancer-free counterparts. Survivors benefit from regular exercise but often limit their physical activity because of pain and fatigue. Would less vigorous yoga exercise provide health benefits for such individuals?
To find out, investigators conducted a 3-month, randomized, controlled trial in which 200 breast cancer survivors were assigned to a yoga program (twice-weekly, 90-minute, hatha yoga workouts for 12 weeks) or to usual activities (controls). The primary outcomes were measures of inflammation associated with decreased physical function — interleukin (IL)-6, tumor necrosis factor (TNF)-α), and interleukin (IL)-1β — as well as scores on validated assessments of vitality, fatigue, and depression. Women reporting more than 5 hours of vigorous exercise per week or prior or current yoga practice were excluded.
Immediately after treatment, vitality was higher in the yoga group than in controls (P=0.01), but fatigue was not diminished. At 3 months after treatment, fatigue was lower in the yoga group (P=0.002), vitality was higher (P=0.01), and inflammatory measures were lower: IL-6 (P=0.027), TNF-α (P=0.027), and IL-β (P=0=.037). Measures of depression did not differ between groups.
Comment: Modest exercise of any sort has been shown in prior studies to improve functional status, physiologic fitness, and many common symptoms that cancer survivors experience. Yoga appears to have similar effects on sedentary breast cancer survivors. Encouraging patients and survivors to exercise, even with modest exertion, can provide significant benefits and should be part of a survivorship plan.
Citation(s): Kiecolt-Glaser JK et al. Yoga's impact on inflammation, mood, and fatigue in breast cancer survivors: A randomized controlled trial. J Clin Oncol 2014 Jan 27; [e-pub ahead of print].
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MM: This information is further support for transdermal and local vaginal administration of estrogen and/or testosterone for menopausal women. Whether the reason for increased risk of pancreatitis is hepatic metabolites that are produced in greater amounts with oral HT or some other related source, this information tends to support the supposition that oral hormones are typically not the best approach to treatment.
CMAJ 2014 Jan 27
Menopausal Hormone Therapy and the Pancreas
HT increased risk for acute pancreatitis, particularly when administered systemically or for >10 years.
Hormone therapy (HT) for postmenopausal symptoms has been associated with acute pancreatitis in a number of case reports, but epidemiologic data are lacking. Investigators conducted a prospective study of postmenopausal women (age range, 48–83 years) from the population-based Swedish Mammography Cohort who completed baseline questionnaires about HT use in 1997 and were followed until 2010. At baseline, 42% of 31,000 participants were current users and 12% were past users of HT.
Using the Swedish National Patient Register, investigators identified 237 cases of incident acute pancreatitis during a total follow-up of 400,000 person-years. Incidence rates, standardized to the cohort's age distribution, were 71 cases per 100,000 person-years among women who had ever used HT, compared with 52 cases per 100,000 person-years among never users. Ever users had a multivariable-adjusted relative risk (RR) for acute pancreatitis of 1.57. The risk was greater among women who used systemic HT than among those who used local therapy. Risk rose with duration of therapy: RR increased by 1.09 for each 2 years of use. Among women who used systemic therapy for >10 years, RR was 2.44. Adjustment for baseline history of cholelithiasis did not change the association between use of HT and acute pancreatitis.
Comment: One epidemiologic study does not prove causation, but clinicians should be aware of this possible connection (especially given the known effect of estrogens in raising triglyceride levels, which have been associated with acute pancreatitis). These findings indicate the need for additional studies to determine whether the association between hormone therapy and pancreatitis is real. If a cause-and-effect relation exists, it would provide another reason to use transdermal rather than oral HT for menopausal symptoms.
Citation(s): Oskarsson V et al. Postmenopausal hormone replacement therapy and risk of acute pancreatitis: A prospective cohort study. CMAJ 2014 Jan 27; [e-pub ahead of print].
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MM: For those who are interested in a more natural means of preventing gout attack while using low dose aspirin for cardioprotection, Our All-Flex Pro product may be used at 2 capsules once daily and/or the use of concentrated sour cherry juice will also tend to reduce the likelihood of a gout attack.
Ann Rheum Dis 2014 Feb; 73:385
Cardioprotective Aspirin Is Associated with Elevated Risk for Gout
But concomitant use of urate-lowering agents might minimize the effect.
Aspirin's dual effects on urate handling are well known: High-dose aspirin is uricosuric and lowers serum uric acid, whereas low-dose aspirin (≤2 g daily) blocks urate secretion and raises serum uric acid. Anecdotally, low-dose aspirin use has been associated with gout attacks. In this observational study, investigators examined the association between low-dose aspirin use and recurrent gout attacks in 724 patients (median age, 54; 78% men; 18% with renal insufficiency) with gout who were enrolled in a gout study and followed for 1 year. Participants provided data on exposure to risk factors, including aspirin use, during the 2 days prior to gout attacks (hazard periods) and during 2-day control periods every 3 months.
Compared with no aspirin use, aspirin use at usual cardiovascular doses (i.e., ≤325 mg daily or ≤81 mg daily) on 2 consecutive days during hazard periods was associated with roughly twofold higher risk for recurrent gout. Concomitant use of allopurinol neutralized these effects.
Comment: These results are consistent with anecdotal observations and with our understanding of aspirin's effects on renal handling of urate. The findings are not a reason to change cardioprotective use of low-dose aspirin, but they should alert clinicians and patients to recurrent gout as a possible side effect of low-dose aspirin use and might expand uric acid monitoring and treatment in aspirin-treated patients who have recurrent gout attacks.
Citation(s): Zhang Y et al. Low-dose aspirin use and recurrent gout attacks. Ann Rheum Dis 2014 Feb; 73:385.
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MM: As parents and grandparents we are always interested in the safety of our children and grandchildren. This information serves to open our eyes to the realistic threat and true danger of food allergies. Although we should be vigilant, we need not constantly be in fear for our children's safety.
Clin Exp Allergy 2013 Dec; 43:1333
Children with Food Allergy: What's the Risk for Fatal Anaphylaxis?
Risk for fatal anaphylaxis in food-allergic children is more than 10 times lower than the risk for accidental death in the general population.
Food allergy affects up to 10% of children and is the most frequent cause of anaphylaxis. Persistent fear of a food-related anaphylactic reaction (especially to peanuts) is associated with parental anxiety and lower quality of life. Researchers examined the risk for fatal food-related anaphylaxis in a meta-analysis of 13 international registry, database, or cohort studies.
During an estimated 165 million food-allergic person-years, 240 deaths from food anaphylaxis were reported. In food-allergic people of all ages, the incidence rate of fatal food anaphylaxis was 1.81 per million person-years. Among children and adolescents, the incidence rate was 3.25 per million person-years (10 studies), and 2.13 per million person-years for peanut allergy (7 studies). In four studies that recorded nonfatal food anaphylaxis rates in the same population and time period, fatality rates ranged from 33% of patients admitted to an intensive care unit to 0.14% of patients admitted to a hospital. The authors calculated that the incidence of fatal food anaphylaxis in a food-allergic person is ≥100 times lower than the incidence of accidental death in the general population. Incidence is ≥10 times lower in food-allergic children and adolescents aged 0–19 years.
Comment: The authors note the possibility that specific groups of food-allergic people have higher incidences of fatal food anaphylaxis, but these patients have not been identified in clinical practice. The finding that the rate of fatal food anaphylaxis in food-allergic children is lower than the rate of accidental death might be reassuring to parents who are anxious about their child developing a severe allergic reaction to a food. Pediatricians can use the results to allay excessive fear among parents of food-allergic children.
Citation(s): Umasunthar T et al. Incidence of fatal food anaphylaxis in people with food allergy: A systematic review and meta-analysis. Clin Exp Allergy 2013 Dec; 43:1333.

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MM: It would seem that local pre- treatment with an antibiotic may be superior to systemic pre-treatment in prevention of a secondary infection following a surgical procedure. This is exciting news for patients and clinicians alike. This approach could decrease the likelihood of creating an antibiotic induced dysbiosis and possibly reduce the incidence of super-infections.In fact, taken to the next level, should dentists use this approach with antibiotic mouth rinses as a pre-treatment in at risk patients vs. systemic use of antibiotics?
Dermatol Surg 2013 Oct; 39:1486
Oral Antibiotics versus Topical Decolonization to Prevent Surgical Site Infections
Murad Alam, MD, MSCI reviewing Cherian P et al. Dermatol Surg 2013 Oct. Murad Alam, MD, MSCI
The relative superiority of topical prophylaxis to oral prophylaxis for patients colonized with S. aureus was striking. Murad Alam, MD, MSCI
To determine the best method of preventing surgical site infections after Mohs micrographic surgery, investigators compared topical therapy and oral antibiotics in patients with nasal carriage of Staphylococcus aureus.
In this randomized, controlled trial, of 693 surgical patients undergoing Mohs at a single center, 179 were found to have S. aureus colonization preoperatively by nasal swab. The colonized patients were divided into two groups. One group received topical mupirocin to the nose twice daily plus once-daily body wash with chlorhexidine solution; the other group ingested 2000 mg of oral cephalexin 1 hour before the procedure and another 1000 mg dose 6 hours after. The overall rate of culture positive surgical site infections (SSIs) in all patients was 5.6% (39/693). Among the colonized patients, the rates of SSIs were 9% in oral antibiotic recipients (8/89) and 0% in patients who received topical cleansing – a statistically significant difference (P=0.003).
Comment: Limitations of this study include that it is from a single-center and that the 5.6% overall rate of surgical site infections was substantially higher than the <1% rate typically seen after Mohs surgery. Still, the relative superiority of topical prophylaxis to oral prophylaxis for patients colonized with S. aureus was striking. Even if the degree of protection were merely comparable, topical regimens may be preferred due to the lower risk for induction of antibiotic resistance. While no type of antibiotic prophylaxis is required perioperatively for Mohs surgery, when such prophylaxis is considered, topical regimens can be considered, keeping in mind that these may require greater patient effort and compliance.
Citation(s): Cherian P et al. Oral antibiotics versus topical decolonization to prevent surgical site infection after Mohs micrographic surgery — A randomized, controlled trial. Dermatol Surg 2013 Oct; 39:1486.

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