First New York resident dies from swine flu complications.
In a front-page story, the New York Times (5/18, A1, Hartocollis) reports that Mitchell Wiener, “an assistant principal at a New York City public school died of complications from swine flu in an intensive care unit of a Queens hospital on Sunday night, the first death in New York State of the flu strain that has swept across much of the world since it was first identified in April.” Earlier in the day, “city officials announced that five more Queens schools had closed.” Dr. Daniel Jernigan, head of flu epidemiology for CDC, said Friday that “there had been 173 hospitalizations and five deaths reported to the agency. But he emphasized that most cases in the United States — possibly ‘upwards of 100,000’ — were mild.” On Sunday, health officials said that Weiner’s “death was not surprising, since even in a normal flu season, thousands of victims die of complications from the disease.”
While the Times reports five deaths before Weiner, CNN (5/18) notes only four US deaths the CDC has attributed to H1N1, adding that “all had preexisting medical problems.”
The AP (5/18) calls it “the sixth linked to swine flu in the United States. Most of the other victims were suffering from other health problems.” Still, “besides Wiener, no one else in New York City has become seriously ill from the virus.”
Nonetheless, “health officials warned to expect new severe cases,” the New York Daily News (5/18, Yaniv, Kennedy) reports. New York Health Commissioner Thomas Frieden said, “It is entirely possible that in the coming days there will be people with severe illness from flu, particularly among people who have underlying health problems.” Reuters (5/18, Michaud) and AFP (5/18) also cover the story.
Study indicates vitamin D deficiency in elderly may contribute to metabolic syndrome.
BBC News (5/16) reported that, according to a study published online Apr. 14 in the journal Diabetes Care, “spending more time in the sun could help older people cut their risk of heart disease and diabetes.” That is because “sun exposure helps the skin make vitamin D — a vitamin older people are generally deficient in due to their lifestyles and aging processes.” For the study, researchers from the UK’s Warwick University examined data on more than 3,000 “50 to 70-year-olds living in China,” and found that “94 percent had a vitamin D (25-hydroxyvitamin D) deficiency or insufficiency, and 42 percent also had metabolic syndrome.” The investigators said that “the same can be seen in British and American populations too,” because “vitamin D deficiency is becoming a condition that is causing a large burden of disease across the globe with particular deleterious impact among the elderly.” The authors explained that as people age, the skin becomes “less efficient at forming vitamin D,” and the “diet may also become less varied, with a lower natural vitamin D content.”
Researchers say home phototherapy may be safe, effective for treating psoriasis.
Following a BBC News story, Medscape (5/15, Barclay) reported that, according to a study published May 7 in the BMJ, “ultraviolet B phototherapy administered at home for the treatment of psoriasis is equally safe and effective as ultraviolet B phototherapy administered in an outpatient setting.” For the study, researchers from University Medical Center Utrecht, the Netherlands, randomly assigned “196 patients with psoriasis who were clinically eligible for narrowband (TL-01) ultraviolet B phototherapy…to receive” that therapy “at home using a TL-01 home phototherapy unit,” or undergo that therapy “in an outpatient setting.” The “primary efficacy endpoint” was defined as “the proportion of patients with a 50 percent or more reduction of the baseline psoriasis area and severity index (PASI) or self-administered psoriasis area and severity index (SAPASI), which was termed the PASI 50 and SAPASI 50.” The team found that “SAPASI 50 was achieved in 82 percent of patients treated at home and 79 percent of patients treated as outpatients,” with “patients treated at home” having “a significantly lower burden of undergoing ultraviolet B phototherapy.”
Researchers compare PDL, Nd:YAG laser treatments for facial acne scars.
MedWire (5/15, Wilkinson) reported that, according to a study published in the May issue of the Journal of the American Academy of Dermatology, “pulsed dye laser (PDL) and 1064-nm long-pulsed neodymium: yttrium-aluminum-garnet (Nd:YAG) laser treatments are similarly effective for treating facial acne scars.” For the study, researchers from Korea’s Seoul National University College of Medicine compared “a 585-nm PDL and a 1064-nm Nd:YAG laser in the same” 18 patients, all of whom were “affected by acne scars.” The “patients received four sessions of PDL or Nd:YAG laser treatment at two-week intervals in a randomized split-face manner, and were followed up at four-week intervals for eight weeks after the final session.” The team found that both “treatments resulted in similar, mild, atrophic acne scar improvements at eight weeks after treatment that were statistically significant.” The authors noted, however, that “ice-pick scars tended to respond better to PDL, while deep boxcar scars tended to benefit more with the Nd:YAG lasers, although these differences were not significant.”
Clinical presentation of HS may differ strongly in women and men, research suggests.
MedWire (5/15, Wilkinson) reported that, according to a study published online Apr. 30 in the Journal of the American Academy of Dermatology, “the clinical presentation of hidradenitis suppurativa (HS) differs strongly in women and men.” For the study, researchers from France’s Hôpital Henri Mondor examined “the clinical characteristics of the disease in 302 consecutive French patients referred to a single hospital between 1998 and 2006.” The team found that “atypical locations, such as the ear, chest, abdomen, or legs, were significantly more common in men than in women, at 47.1…versus 14.8 percent.” Moreover, “disease severity rated according to the Sartorius score, which takes into account disease extent, and the number and severity of individual lesions, was also greater in men, at a median of 20.5 compared with 16.5 in women.” Notably, “patients with a family history of HS tended to have less severe disease…a result the researchers called ‘unexpected.'”
Organized medicine, legal experts urge physicians to comply with “red flags” rules.
American Medical News (5/18, Sorrel) reports that the “‘red flags’ rules, which require creditors to implement a formal policy for detecting and preventing identity theft,” also apply to the healthcare industry starting Aug. 1. The rules were authorized under “the 2003 Fair and Accurate Credit Transitions Act, which” covers “entities that regularly extend credit, or defer payment for services.” The FTC contends that “physicians are considered creditors under the rules,” but, “the American Medical Association and several medical organizations continue to challenge what they believe is an overly broad legal interpretation.” Meanwhile, “organized medicine and legal experts urge doctors to get in compliance.” Specifically, “the rules require physician practices to identify red flags, or warning signs, of potential identity theft occurrences, create a corporate policy for responding to such risks, and train staff on the new policy.” Healthcare lawyer John S. Mulhollan says that “FTC rules require distinct security policies that focus more on financial data than medical data.”
Researchers identify quality of care indicators for psoriasis treatment.
MedWire (5/15, Piper) reported that, according to a study published online in the journal Dermatology, researchers from Germany’s University Medical Center Hamburg-Eppendorf “have identified eight guideline-based indicators of quality of care in psoriasis” by extracting “indicators of process and outcome quality from the international research literature and from the German Board of Scientific Medical Societies guideline for the treatment of psoriasis vulgaris.” Next, the investigators validated “a refined list of eight indicators…with data from two nationwide studies on psoriasis care carried out in 2005 and 2007, involving 1,511 and 2,009 patients, respectively.” They identified “eight indicators,” including “mean Psoriasis Severity and Area Index (PASI) score, mean score on the Dermatology quality of life Index,” the “proportion of patients with PASI >20, proportion with DLQI>10, proportion who had received treatment with systemics, proportion with PASI >20 and concurrently treated with systemics, proportion who received inpatient treatment in the past five years, and mean number of working days lost.”
Obama names New York City health commissioner to head CDC.
The New York Times (5/16, Harris, Hartocollis) reported that President Obama announced he has “chosen Dr. Thomas R. Frieden, the New York City health commissioner, as the next director of the Centers for Disease Control and Prevention.”
The AP (5/16, Caruso) reported that Frieden has for “seven years…been the nagging conscience of the nation’s biggest city, the man who made sure New Yorkers couldn’t smoke in bars or eat French fries cooked in artery-clogging trans fats. Now, the city’s health commissioner will be taking his crusade against unhealthy living national.”
The Washington Post (5/16, A3, Wilgoren, Shear) noted, “In a statement, Obama called Frieden, 48, ‘an expert in preparedness and response to health emergencies’ who in seven years as the city health commissioner has ‘been at the forefront of the fight against heart disease, cancer and obesity, infectious diseases such as tuberculosis and AIDS, and in the establishment of electronic health records.'” Acting CDC Director Richard Besser, who has steered the CDC “through the current global swine flu outbreak, will return to his role as head of the CDC’s emergency response unit. Two sources with knowledge of the process said Frieden was on a shortlist of prospects long before Besser made a name for himself by his handling of the swine flu crisis.”
The Wall Street Journal (5/16, A3, McKay) added that Frieden “is known for aggressive and controversial measures to improve New Yorkers’ health,” and “now, the question is whether the physician will risk the controversy almost certain to follow if he tries to push the same types of measures on all 50 states.” The New York Daily News (5/16, Lombardi, McAuliff) similarly reported, “The man who banned smoking in bars and trans fats in New York may get the chance to push those policies on the nation.”
The Los Angeles Times (5/16, Levey) added that Frieden is best known “as an advocate of government action in preventive medicine, which many experts say is crucial to the health system overhaul envisioned by Obama and his congressional allies.” Now, “Frieden will take over an agency that is working to repair its reputation after criticism that CDC science was politicized under President George W. Bush.”
According to NPR’s All Things Considered (5/15, Knox), “There’s no more activist public health official in the land than Tom Frieden. Here’s how he set out his philosophy on NPR’s Talk Of The Nation back in 2006.” Frieden said, “The way public health works best is by changing the context so that people don’t have to think twice to drink water that’s fluoridated, or use paint that doesn’t have lead in it. In the same way, we want to make the environment such that the healthy choice is the default value.”
CQ HealthBeat (5/16, Reichard) noted that Frieden’s appointment brings “a hard-nosed public health official to the helm of the sometimes troubled agency.” Frieden is expected to “begin his new duties at the CDC in early June.”
Senators fail to resolve differences on public health insurance.
The Wall Street Journal (5/16, A4, Adamy) reported, “Senators couldn’t resolve differences this past week over whether to create a public health-insurance plan, suggesting an uphill struggle in meeting their goal of passing a bipartisan healthcare bill by August. An 8 1/2-hour meeting that ended Thursday night featured ‘an awful lot of conflict,'” Sen. Charles Grassley (R-IA) said. Aides who were present “said even some Democrats expressed concern about creating a public insurance option as part of a broad plan to revamp the nation’s healthcare system.”
Senate considering controls on health insurers. The New York Times (5/16, A9, Pear) reported, “The government could rein in aggressive marketing practices of health insurance companies, regulate their premiums and allow workers to drop out of group health plans to seek a better deal on their own under legislation being developed by leading Democratic senators. The Senate proposals, which emerged this week, are broadly similar to ones being drafted by the chairmen of three House committees.”
FDA Warns About Disetronic Insulin Pump Failure
Emma Hitt, PhD
May 5, 2009 — ACCU-CHEK Spirit insulin pumps (Disetronic) with serial numbers from SN02119552 through SN10006093 may have a potential defect in the “up” and/or “down” buttons, the US Food and Drug Administration (FDA) has announced.
The serial numbers affected were all shipped in the United States. Pumps with serial numbers including and above SN10006094 are not affected, and no action is required by users of these pumps, noted the manufacturer, which is owned by Roche Diagnostics, in a news release.
According to an alert sent from MedWatch, the FDA’s safety information and adverse event reporting program, the defect in the “up” and/or “down” buttons may present as an intermittent or complete loss of function of the “up” and/or “down” buttons, which may impair users’ ability to change any programmed setting on the pump.
“If this failure occurs, the pump may not respond with a vibration or acoustic confirmation signal to a button press and the display will remain unchanged,” the company notes. “This defect was discovered through the company’s normal quality control monitoring process,” they add.
The company advises that if a pump appears to have this defect, the user should disconnect the pump and use an alternate method of insulin delivery. Users should contact the ACCU-CHEK Spirit hotline to receive a replacement pump, which will be issued within 1 to 2 business days.
“We are telling our customers to continue to use their ACCU-CHEK Spirit insulin pumps, but monitor the functioning of the “up” and “down” buttons,” stated Dr. Mathias Neumann, head of Global Quality Management Diabetes Care, Roche Diagnostics. “In addition, customers are to continue to monitor their blood glucose as directed by their healthcare professional.”
The manufacturer has isolated the cause of the problem — an interrupted electronic contact in the flexible board of the “up” and “down” button module caused over time by stress of this board during repeated pressing of the button.
Users of these insulin pumps who are experiencing failure of the “up” and/or “down” buttons should immediately contact the hotline by telephone at 1-800-778-5095. This number is available 24 hours a day, 7 days a week.
Any adverse or serious events associated with the insulin pump should be communicated to the FDA’s MedWatch reporting program by telephone at 1-800-FDA-1088, by fax at 1-800-FDA-0178, online at http://www.fda.gov/medwatch, or by mail to 5600 Fishers Lane, Rockville, Maryland 20852-9787.
Authors and Disclosures
Emma Hitt, PhD
Emma Hitt is a freelance editor and writer for Medscape.
Medscape Medical News © 2009 Medscape, LLC
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Family Docs and Internists Mistakenly Think They Do Fine Treating High Blood Pressure
May 5, 2009 (Columbus, Ohio) — Family physicians and general internists feel that they are doing a good job treating hypertension–the most common diagnosis in primary-care practice–and that failure to reach blood-pressure goals is due to patient factors such as noncompliance and not to their management, according to the results of a small survey published online April 2, 2009 in BMC Family Practice .
However, their good opinion of their performance does not quite jibe with what has been published in the literature, lead author Dr Randy Wexler (Ohio State University College of Medicine, Columbus) and colleagues write. “Physicians often overestimate their effectiveness of the care they provide. . . . One possibility for such thinking is a lack of education and training on how to reach therapeutic goals, which hinders the ability of physicians to achieve desired treatment targets.”
Indeed, half of the physicians in this survey said they would not intensify treatment of poorly controlled hypertension even in patients with underlying heart disease, diabetes, or kidney disease, despite recommendations to do so by the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7).
The survey asked 28 family- and internal-medicine physicians who were attending a monthly clinical meeting at Ohio State University College of Medicine to rate their response to six statements using a standard Likert scale (strongly disagree, disagree, undecided, agree, strongly agree).
The physicians were asked about their perceived barriers to hypertension control, their ability to adequately treat hypertension, and their knowledge of hypertension treatment guidelines. They were also asked when they would intervene to step up treatment of hypertension when blood pressure was above recommended levels in patients with essential hypertension, heart disease, diabetes, and renal disease.
Poor Blood-Pressure Control Is the Patient’s Fault
Eighteen physicians agreed and eight strongly agreed that a significant barrier to blood-pressure control was patient noncompliance; two said they were undecided. Twenty-five agreed and three strongly agreed that they do a good job of treating their patients’ hypertension. Only one physician was unfamiliar with the JNC guidelines–“this is probably because all of the physicians in our sample were board certified,” Wexler told heartwire .
But despite their familiarity with JNC guidelines, only 53% said they would intensify treatment according to the levels set in the JNC recommendations.
Blood-Pressure Levels at Which to Intensify Treatment
|Systolic/diastolic blood pressure levels||Median (mm Hg)|
|In patients with heart disease||130/85|
|In patients with diabetes||130/85|
|In patients with renal disease||130/80|
|In patients with essential hypertension||140/90|
Wexler told heartwire that the fact that half the respondents said they would treat to established targets is a distinct improvement over a survey that was done in 2000, where only a small minority said they would do so. “There are more physicians now who would treat to goal, who would pursue tighter control, and this is appropriate, but there is still a lot of room for improvement.”
Can’t See the Forest for the Trees
Physicians know which antihypertensive agents to use in different scenarios, such as diabetes and heart failure, because so much has been written about this in the literature, Wexler said. He thinks that there may be too much emphasis placed on selecting a particular drug for a particular condition, when the emphasis should be on getting the blood pressure down. Simplification of blood-pressure recommendations into an easily digestible one- or two-page bulleted summary would be a big help in this regard.
“The JNC guidelines are 60 to 70 pages long. In primary care, we treat a vast variety of diseases, all of which come with their own guidelines, and we then run into the problem of competing demands. The reality is that if primary-care physicians did all the screening and preventive recommendations that are out there, there would be about 20 to 30 minutes left in the day to do everything else. So it becomes a matter of focus. And in our attempts to focus on a lot of things, we’re not seeing the forest for the trees,” said Wexler.
Survey Results a Cause for Concern
Asked to comment on this study by heartwire , Dr Stephen Nicholls (Cleveland Clinic, OH), said the survey raises a concern, “and the concern is that we need to be vigilant about the way we try to manage our patients’ risk factors. It is somewhat concerning that we are tending to be complacent in trying to achieve the blood-pressure goals that already exist, particularly given the evidence that is starting to emerge to suggest that we perhaps need to be even more aggressive with blood-pressure control.”
Nicholls coauthored a study that was recently published in the Journal of the American College of Cardiology  and reported in heartwire, which found that patients with coronary artery disease who reduced their LDL cholesterol to very low levels and also achieved a normal systolic blood pressure of 120 mm Hg or less had the slowest progression of atherosclerosis.
In answer to Wexler’s plea for more concise recommendations for the treatment of blood pressure, Nicholls said more evidence-based studies to answer the “really important question–what is the ideal blood pressure that our patients at various levels of risk should be at?” are essential.
“If we do those studies, and we get more and more evidence, the blood-pressure guidelines will become a lot clearer, and then, I think, clinicians will feel that they are in a much more comfortable position to be able to embrace the guidelines and follow them.”
Getting Blood Pressures to Goal a Challenge for Patients and Doctors
Weighing in on the subject, Dr Joseph Stubbs, a general internist practicing in Albany, GA and current president of the American College of Physicians, told heartwire that he takes issue with the survey’s results. “We don’t think that poor blood pressure control is because of the patients,” he insists.
“Even in the best of circumstances, trying to get particularly older patients’ blood pressures to goal is a very difficult thing that often takes adding two or three medicines to their already seven or 10 medicines, and it’s a challenge for the patient and for the doctor. The doctors are trying their best, and the patients are trying their best, and it just doesn’t get done,” he said.
Wexler receives research funding from Pfizer and CVRx and is a speaker for CVRx and a data safety monitoring board member for Cardiomems. Disclosures for the coauthors are listed in the paper. Nicholls disclosed that he has received honoraria, consulting fees, and research support from Pfizer, AstraZeneca, Novartis, Takeda, Roche, and Merck/Schering-Plough.
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- Wexler R, Elton T, Taylor CA, et al. Physician reported perception in the treatment of high blood pressure does not correspond to practice. BMC Fam Pract 2009; 10:23. Abstract
- Chhatriwalla AK, Nicholls SJ, Wang TH, et al. Low levels of low-density lipoprotein cholesterol and blood pressure and progression of coronary atherosclerosis. J Am Coll Cardiol 2009; 53:1110-1115. Abstract
Authors and Disclosures
is a freelance writer for Medscape.
Heartwire © 2009 Medscape, LLC
Vitamin C Supplementation May Help Prevent Gout CME
News Author: Laurie Barclay, MD
CME Author: Charles Vega, MD, FAAFP
CME Released: 03/10/2009; Valid for credit through 03/10/2010
March 10, 2009 — Vitamin C supplementation may help prevent gout, according to the results of a prospective study reported in the March 9 issue of the Archives of Internal Medicine.
“Several metabolic studies and a recent double-blind, placebo-controlled, randomized trial have shown that higher vitamin C intake significantly reduces serum uric acid levels,” write Hyon K. Choi, MD, DrPH, from Vancouver General Hospital and University of British Columbia in Vancouver, Canada, and colleagues. “Yet the relation with risk of gout is unknown.”
From 1986 through 2006, the investigators evaluated the association between vitamin C intake and the risk for incident gout in 46,994 male participants who had no history of gout at baseline. American College of Rheumatology criteria for gout were determined by a supplementary questionnaire, and validated questionnaires administered every 4 years examined vitamin C intake.
There were 1317 confirmed incident cases of gout during 20 years of follow-up. Compared with vitamin C intake less than 250 mg/day, the multivariate relative risk (RR) for gout associated with total vitamin C intake of 500 to 999 mg/day was 0.83 (95% confidence interval [CI], 0.71 – 0.97). For intake of 1000 to 1499 mg/day, RR was 0.66 (95% CI, 0.52 – 0.86), and for 1500 mg/day or greater, it was 0.55 (95% CI, 0.38 – 0.80; P < .001 for trend). Per 500-mg increase in total daily vitamin C intake, the multivariate RR was 0.83 (95% CI, 0.77 – 0.90).
These associations were independent of dietary and other risk factors for gout, such as body mass index, age, hypertension, diuretic use, alcohol use, and chronic renal failure, and they persisted across subgroups stratified by body mass index, alcohol use, and dairy intake.
Compared with lack of vitamin C supplementation, the multivariate RR for gout associated with supplemental vitamin C intake of 1000 to 1499 mg/day was 0.66 (95% CI, 0.49 – 0.88), and it was 0.55 (95% CI, 0.36 – 0.86) for 1500 mg/day or greater (P < .001 for trend).
“Higher vitamin C intake is independently associated with a lower risk of gout,” the study authors write. “Supplemental vitamin C intake may be beneficial in the prevention of gout.”
Limitations of this study include dietary consumption self-reported by questionnaire; observational design; lack of confirmation of gout diagnosis by observation of urate crystals in joint fluid; and restriction to health professionals, limiting generalizability.
The National Institutes of Health and TAP Pharmaceuticals supported this study in part. The study authors have disclosed no relevant financial relationships.
Arch Intern Med. 2009;169:502-507.
Vitamin C may lower serum levels of uric acid, primarily through a uricosuric effect. Vitamin C induces competition for renal reabsorption of uric acid in the proximal tubule of the nephron, and vitamin C may also help reduce levels of uric acid by increasing the overall glomerular filtration rate.
Research into the effects of vitamin C on uric acid has focused on supplements, and there are limited data as to whether vitamin C actually reduces the incidence of gout. The current study examines the effects of dietary vitamin C consumption plus vitamin C supplements on the risk for incident gout in men.
- The study cohort was derived from the Health Professionals Follow-up Study, which consisted of male health professionals between the ages of 40 and 75 years in 1986. Participants with gout at baseline were excluded from the current analysis.
- Participants completed a semiquantitative food frequency questionnaire, which inquired regarding consumption of more than 130 foods and beverages in the last year. These questionnaires were completed every 4 years. Previously, the food questionnaires were demonstrated to correlate well with 1-week intake of vitamin C.
- Study participants also reported the use of vitamin C supplements.
- Participants completed questionnaires regarding their health every 2 years during the study period.
- The main outcome of the study was the effect of vitamin C intake on the incidence of gout, which was recorded after participant self-report and verified with a supplementary questionnaire focused on criteria for the diagnosis of gout.
- The main outcome was adjusted to account for potential confounding factors, including age, total energy intake, alcohol use, body mass index, other dietary factors, the use of diuretics, and the presence of hypertension or chronic kidney disease.
- 46,994 men provided data for analysis. The mean age was 55 years, the mean body mass index was 24.8 kg/m2. 91% of participants were white.
- The mean daily dietary vitamin C intake was 164 mg, and 53% of participants reported using vitamin C supplements. Men who consumed more vitamin C ate less meat, drank less coffee, and ate more seafood.
- 1317 new cases of gout were diagnosed during 20 years of follow-up.
- Compared with men with a total daily vitamin C intake less than 250 mg, the multivariate RRs for gout were as follows for different levels of total daily vitamin C intake:
- 500 – 999 mg: RR, 0.83
- 1000 – 1499 mg: RR, 0.66
- 1500 mg or more: RR, 0.55
- The trend toward a reduced risk for gout with higher levels of total vitamin C intake was statistically significant.
- Supplemental vitamin C also reduced the risk for gout. Compared with men who did not use supplements, participants who consumed supplements at a daily dose of 1000 to 1499 mg experienced a RR of 0.66 for gout. The respective RR associated with vitamin C supplementation of 1500 mg or more per day was 0.55.
- Each 500-mg increase in supplemental vitamin C intake reduced the risk for incident gout by 15%.
- Higher vitamin C intake remained significantly associated with a reduction in the risk for gout in subgroup analyses based on body mass index and the consumption of alcohol and dairy products.
Pearls for Practice
- Vitamin C may reduce serum uric acid levels through a uricosuric effect.
- In the current study, total vitamin C intake and the consumption of vitamin C supplements were associated with a reduced risk for incident gout in middle-aged men.
This article is a CME certified activity. To earn credit for this activity visit:
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As an organization accredited by the ACCME, Medscape, LLC requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines “relevant financial relationships” as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner, that could create a conflict of interest.
Medscape, LLC encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.
Laurie Barclay, MD
Laurie Barclay, MD, is a freelance reviewer and writer for Medscape LLC.
Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.
Brande Nicole Martin
Brande Nicole Martin is the News CME editor for Medscape Medical News.
Disclosure: Brande Nicole Martin has disclosed no relevant financial information.
Charles P. Vega, MD, FAAFP
|Associate Professor; Residency Director, Department of Family Medicine, University of California, IrvineDisclosure: Charles Vega, MD, FAAFP, has disclosed an advisor/consultant relationship to Novartis, Inc.|
Medscape Medical News © 2009 Medscape, LLC
The material presented here does not necessarily reflect the views of Medscape or companies that support educational programming on http://www.medscape.com. These materials may discuss therapeutic products that have not been approved by the US Food and Drug Administration and off-label uses of approved products. A qualified healthcare professional should be consulted before using any therapeutic product discussed. Readers should verify all information and data before treating patients or employing any therapies described in this educational activity.
This article is a CME certified activity. To earn credit for this activity visit:
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CME Released: 03/10/2009; Valid for credit through 03/10/2010
This article is intended for primary care clinicians, rheumatologists, and other specialists who care for patients at risk for gout.
The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.
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- Identify how vitamin C consumption may reduce serum uric acid levels.
- Describe the effect of vitamin C intake on the risk for gout.
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AGS 2009: High-Dose Vitamin E Slows Functional Decline in Alzheimer’s Disease
May 5, 2009 (Chicago, Illinois) — Patients with Alzheimer’s disease who receive high-dose vitamin E combined with a cholinesterase inhibitor have less long-term deterioration in their ability to perform activities of daily living than those who do not receive vitamin E, a new study found. The results were presented here at the American Geriatrics Society (AGS) Annual Scientific Meeting.
Treatment benefit increased with time over 5 years, the authors report. This result may explain why some previous studies of vitamin E in patients with Alzheimer’s disease showed no effect at only 1 year, lead author Michael Flaherty said in an interview with Medscape Internal Medicine. Mr. Flaherty performed the research during a research fellowship at Massachusetts General Hospital in Boston and is now a second-year medical student at the University of New England College of Osteopathic Medicine in Biddeford, Massachusetts.
“Many neurologists continue to prescribe vitamin E for their Alzheimer’s patients, but whether it slows progression of dementia is unclear,” Mr. Flaherty said. “We found out there is promise for vitamin E in this disease.”
The clinical-effectiveness study enrolled 540 patients with probable Alzheimer’s disease (324 women) who had a mean age of nearly 74 years. All were receiving 1 of the following cholinesterase inhibitors: donepezil, rivastigmine, or galantamine (800 to 1000 U twice daily). In addition, 208 patients received vitamin E (800 to 2000 IU/day); 49 received anti-inflammatory medications, mainly nonsteroidal anti-inflammatory drugs, but no vitamin E; 177 patients received both vitamin E and anti-inflammatory drugs; and 106 received neither.
Every 6 months, the patients had a cognitive assessment using the Blessed Dementia Scale’s Information-Memory-Concentration subscale and an evaluation of their function with the Weintraub Activities of Daily Living (ADL) Scale. The mean follow-up was 3.1 years. The authors annually calculated Cohen’s d effect sizes for 5 years based on mixed-effects regression analyses.
Vitamin E treatment showed small to medium effect sizes in slowing functional decline, the abstract reports. For vitamin E, the ADL Cohen’s d significantly increased, from 0.20 in year 1 (P = .02) to 0.42 by year 5 (P < .001).
Anti-inflammatory drugs showed a small effect size in slowing cognitive decline, with the Cohen’s d for the dementia scale going from 0.12 in year 1 to 0.22 by year 5 (P = .006).
The study did not assess safety. Mr. Flaherty said further studies are needed to determine the risks and benefits of high-dose vitamin E and anti-inflammatory treatment, as well as the appropriate doses.
Safety a Concern
However, because some studies have shown an increased risk for death with vitamin E doses greater than 400 IU/day, high-dose vitamin E therapy for Alzheimer’s disease fell out of favor a few years ago, according to an expert on Alzheimer’s disease. That expert, Sharon Brangman, MD, director of the Central New York Alzheimer’s Disease Center and chief of the Division of Geriatric Medicine at SUNY Upstate Medical University in Syracuse, told Medscape Internal Medicine in a phone interview, “We don’t know if the benefit is worth the risks of high-dose vitamin E. We suggest taking no more than 400 IU per day.”
Dr. Brangman, who is president-elect of AGS and who was not involved with the study, said: “I don’t think this study alone gives enough information to drive clinical therapy. We need more research.”
However, she added that most research on therapies for Alzheimer’s disease is focusing on new agents, such as “amyloid busters.”
This study was funded by the National Institutes of Health, Massachusetts Alzheimer’s Disease Research Center, and the American Federation for Aging Research. Mr. Flaherty has disclosed no relevant financial relationships, but 1 of his coauthors, Alireza Atri, MD, PhD, from Massachusetts General Hospital in Boston, reported receiving payment for lectures or consulting from Eisai, Forest, Merck, Novartis, and Pfizer. Dr. Brangman has disclosed no relevant financial relationships.
American Geriatrics Society (ASG) 2009: Abstract A117. Presented April 30, 2009.
Authors and Disclosures
Kathleen Louden is a freelance writer for Medscape
Management of Common Childhood Poisonings Reviewed
News Author: Laurie Barclay, MD
CME Author: Hien T. Nghiem, MD
CME/CE Released: 03/11/2009; Valid for credit through 03/11/2010
March 11, 2009 — Practice recommendations to evaluate and treat common childhood poisonings are reviewed in the March 1 issue of American Family Physician. The review highlights the evaluation and treatment of children younger than 12 years who unintentionally ingest toxins.
“Poison control centers in the United States received more than 2.4 million reports of toxin exposures in 2003,” write Tamara McGregor, MD, from the University of Texas Southwestern Family Medicine Residency Program in Dallas, and colleagues. “Most exposures involved oral ingestion (76 percent), occurred in the home (93 percent), and were unintentional (more than 80 percent). Children younger than six years accounted for 51 percent of the exposures. Of these, 38 percent involved children three years or younger.”
In the family practice setting, clinicians often have to treat children who have ingested substances, most of which are nontoxic. Therefore, clinicians should have the telephone number of the poison control center available and be familiar with the appropriate initial evaluation of suspected toxin ingestion.
In case of poisoning, initial management must include rapid triage and stabilization of airway, respiration, and circulation, followed by appropriate supportive or toxin-specific treatment as indicated.
Clinicians should be able to recognize and treat significant toxidromes resulting from acetaminophen; anticholinergic agents including antihistamines and psychoactive drugs; anticoagulants such as warfarin or rat poison; cardiac medications including calcium channel blockers, beta-blockers, and digoxin; muscarinic cholinergic agents including carbamates, some mushrooms, and organophosphates; nicotinic cholinergic agents such as insecticides and nicotine; cyanide; ethylene glycol or methanol from antifreeze or rubbing alcohol; iron-containing products such as deferoxamine; opioids such as morphine, hydrocodone, or methadone; salicylate (aspirin-containing products); sulfonylurea; and sympathomimetic agents such as amphetamines, caffeine, cocaine, or ephedrine.
“If physical examination or laboratory findings suggest a specific toxidrome, the physician should consider toxin-specific treatments, such as an antidote,” the review authors write. “Antidotes are usually given after the patient is stable, preferably within a few hours of ingestion, and may require multiple doses because of short durations of action. The physician should consult with the local poison control center before administering an antidote unless he or she has ample experience with specialized poison treatment.”
Initial laboratory testing may include bicarbonate level, electrolytes, serum urea nitrogen, and serum creatinine levels to evaluate for renal failure and electrolyte imbalance; blood glucose levels for hypoglycemic ingestion; electrocardiography for cardiotoxicity; prothrombin time for coagulopathy; pulse oximetry for hypoxia; serum acetaminophen level for acetaminophen toxicity; and urine human chorionic gonadotropin levels in female patients of childbearing age.
Depending on clinical and initial laboratory findings, other tests that may be useful include arterial blood gas or pulse oximetry to evaluate for hypoxemia, creatine kinase for nephrotoxicity or rhabdomyolysis, serum osmolality, specific drug levels (eg, salicylates, iron, digoxin, anticonvulsants, or alcohol), urine drug screen for opioid or street drug ingestion, and urinalysis for nephrotoxicity or renal failure.
Except for the most severe cases, gastric decontamination (eg, activated charcoal and gastric lavage) is no longer routinely recommended. When decontamination is deemed necessary, it should be done with poison control center support. Similarly, the use of ipecac is no longer recommended.
Although a child with few symptoms or a witnessed toxin exposure may be monitored at home, some long-acting medications have delayed toxin effects and require additional surveillance. In addition to enteric-coated or sustained-release preparations, some other toxins have delayed absorption, such as carbamazepine; concretions from iron, meprobamate, aspirin, or theophylline; and diphenoxylate/atropine.
Other toxins have a delayed mechanism of action, including anticoagulants, monoamine oxidase inhibitors, sulfonylureas, thyroid hormones, or toxic mushrooms. Delayed toxin effects may also result from toxic metabolites, as is the case with acetaminophen, acetonitrile, dapsone, or toxic alcohols. The toxicity of lithium may also be delayed, requiring additional surveillance after ingestion.
Specific key clinical recommendations for practice, all with level of evidence rating C, are as follows:
- After possible or known toxin ingestion, patients with respiratory, circulatory, or neurologic symptoms should be transported by ambulance to the nearest emergency department.
- When evaluating patients with suspected toxin ingestions, the clinician should document the age and sex of the patient, time and type of probable exposure, and all medications present in the home.
- A child who is asymptomatic at first after suspected toxin ingestion may have ingested a delayed-action medication or other substance and should therefore be monitored for a longer period.
- Gastric lavage is only recommended when performed within 1 hour of the ingestion by a clinician experienced in placing orogastric tubes.
- Except when given within 1 hour of ingestion, the routine use of activated charcoal is discouraged.
- For the treatment of suspected toxin ingestions, syrup of ipecac is no longer recommended.
“Childhood poisonings require supportive treatment, including monitoring and continued observation,” the review authors conclude. “Low-risk patients with minimal symptoms, nontoxic ingestions, and no expected sequelae may be discharged to caregivers after a short observation period. High-risk patients (e.g., intentional ingestions, patients who exhibit continued toxidromes or prolonged symptoms) should be admitted to the hospital for ongoing treatment and extended observation.”
The review authors have disclosed no relevant financial relationships.
Am Fam Physician. 2009;79:397-403.
In 2003, more than 2.4 million reports of toxin exposures were received by poison control centers in the United States. Children younger than 6 years accounted for 51% of exposures; of these, 38% involved children 3 years or younger. Most exposures involved oral ingestion (76%), occurred in the home (93%), and were unintentional (> 80%). In addition, most ingestions involved nontoxic substances and were managed at home.
The aim of this article was to review the evaluation and treatment of unintentional toxin ingestions in children younger than 12 years.
- The history of patients with suspected toxin ingestions should include age and sex, time and type of probable exposure, and all medications present in the home (evidence rating, C).
- Initial evaluation involves determining whether the patient is symptomatic; any patient who has ingested a toxin and who has respiratory, circulatory, or neurologic symptoms should be transported by ambulance to the nearest emergency department (evidence rating, C).
- If the ingestion was witnessed, a nontoxic substance was involved, and the patient appears asymptomatic, a prompt examination by the clinician in the office or a period of observation at home may be appropriate; otherwise, poison control should be consulted, and the patient should be evaluated in the clinician’s office or in the emergency department.
- In the emergency department, rapid triage is crucial, including airway, respiration, and circulation stabilization.
- The most toxic substances to a child include iron, antidepressants, hypoglycemics, cardiovascular drugs, salicylates, anticonvulsants, and illicit drugs.
- Iron poisoning is one of the most fatal in children younger than 6 years, especially because as few as 5 to 10 adult ferrous fumarate tablets can kill or seriously harm a child.
- An asymptomatic child with suspected toxin ingestion may have ingested a delayed-action medication and should be monitored for a longer period (evidence rating, C).
- Identifying toxidromes or symptoms that point to toxin exposure is crucial; therefore, the patient’s mental status, vital signs, pupil reactivity, skin moisture and color, bowel sounds, powder or vomit around the mouth, and any unusual breath odors should be noted.
- Useful laboratory tests usually include bicarbonate levels, blood glucose levels, electrocardiography, electrolytes, prothrombin time, pulse oximetry, serum acetaminophen levels, and urine human chorionic gonadotropin levels in women of childbearing age.
- Appropriate supportive or toxin-specific treatment should be initiated with all childhood poisonings.
- Gastric decontamination, such as activated charcoal and gastric lavage, is no longer routinely recommended. It is only recommended when performed by a clinician with experience placing orogastric tubes and when administered within 1 hour of the ingestion (evidence rating, C).
- Activated charcoal decreases the absorption of toxins in the stomach and intestinal tract. It is most likely to help children who have ingested carbamazepine, dapsone, phenobarbital, quinine, theophylline, salicylates, phenytoin, or valproic acid.
- The American Academy of Clinical Toxicology discourages the routine use of activated charcoal except within 1 hour of ingestion (evidence rating, C). If used, a charcoal-to-drug ratio of 10:1 is recommended or a dose of 1 to 2 g/kg is recommended for children with ingestions of an unknown quantity. Sorbitol is used to improve taste and transit through the intestinal tract.
- Syrup of ipecac is no longer recommended (evidence rating, C).
- Hemodialysis may be appropriate for lithium, salicylate, theophylline, methanol, atenolol, phenobarbital, or valproic acid toxicity.
- Psychiatric consultation is appropriate in the setting of intentional ingestion.
Pearls for Practice
- In 2003, reports of toxin exposure usually involved children younger than 6 years, were unintentional, involved oral ingestion, and occurred in the home.
- Gastric decontamination, such as activated charcoal and gastric lavage, is no longer routinely recommended and should be reserved for the most severe cases, with poison control center support. Management options should consider the type and amount of substance ingested, potential toxicity, time elapsed since ingestion, and symptoms exhibited.
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