• Concomitant Use of TMP-SMX and Common BP Drugs Linked to Sudden Death
• Ibuprofen Better than Morphine for Kids with Fracture
• Probiotics Do Not Prevent Eczema at Age 2 Years
• Oral Fecal Microbiota Capsules Show Early promise for C.difficile Infection
• Spinal Manipulation for Chronic Back-Related Leg Pain: Short-Term Relief Only
• A Guide to Polycystic Ovary Syndrome
• Polycystic Ovary Syndrome: Diagnosis and Management
• Ten Tips on Celiac Disease
• Antibiotic Monotherapy Not as Effective as Dual Therapy in Community Acquired Pneumonia
MM: The reason that we should take note of this article is that many older patients tend to get MRSA infections and a very common antibiotic for MRSA is TMP-SMX, also known as Bactrim. It is relatively inexpensive, has a long track record and is fairly effective for MRSA. It is also on most formularies that elderly patients are required to receive medication treatments from.
Concomitant Use of TMP-SMX and Common BP Drugs Linked to Sudden Death
By Amy Orciari Herman, Edited by André Sofair, MD, MPH, and William E. Chavey, MD, MS
Among older patients taking angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), concomitant use of the antibiotic trimethoprim-sulfamethoxazole is associated with increased risk for sudden death, according to a case-control study in BMJ.
Using prescription drug databases, researchers identified Ontario residents aged 66 and older who were using ACE inhibitors or ARBs. Within this cohort, roughly 1000 cases who died within 7 days of being prescribed antibiotics commonly used for urinary tract infections (e.g., TMP-SMX, amoxicillin, ciprofloxacin, or nitrofurantoin) were matched with about 3700 controls who also received antibiotics but didn't die.
Compared with amoxicillin, TMP-SMX was associated with significantly increased risk for sudden death within 7 days (adjusted odds ratio, 1.38) — corresponding to roughly three sudden deaths with TMP-SMX versus one with amoxicillin per 1000 prescriptions.
The researchers write: "We speculate that the increased risk of sudden death during treatment with [TMP-SMX] reflects unrecognized arrhythmic death due to hyperkalemia, a well described complication of the use of trimethoprim in this setting." However, they acknowledge that they did not have access to patients' potassium or creatinine concentrations.
http://www.bmj.com/content/349/bmj.g6196
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MM: Challenges for acute pain relief have increased significantly as products have been removed from the market or greater stumbling blocks have been established to decrease drug diversion. It is reassuring that a product that is readily available such as ibuprofen can provide significant pain relief for specific acute situations like a pediatric fracture. Unfortunately, ibuprofen is not without adverse effects if used for an extended period of time and it can certainly be over-dosed. Many people are familiar with the advent of upset stomach or ulcer from ibuprofen but fewer are aware that kidney failure can also be a result. Natural products such as Arnica, Boswelia, Cetyl myristoleate, Glucosamine and others may work as well and be less dangerous for chronic pain or post treatment pain. All Flex Pro is a combination of several of these items and is available at Mark Drugs.
Ibuprofen Better than Morphine for Kids with Fracture
Ibuprofen looks to be just as effective as morphine for pain control in children with uncomplicated fractures and has significantly fewer adverse effects, according to a study published online October 27 in the Canadian Medical Association Journal. In a parallel-group, randomized, blinded superiority trial involving 134 children treated for fracture in the emergency department of Children's Hospital in London, the authors recorded no significant difference in pain scores between the two drugs.
http://www.medscape.com/viewarticle/833895
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MM: Point of view is everything. This commentator dismisses a significant response to a safe and inexpensive product. No adverse effects are noted and a relatively small number are required to be treated to demonstrate beneficial effects. He as much as states that his compelling argument against recommending probiotics is his own ignorance and the fact that the FDA has not approved an over the counter product for a medical condition.
Arch Dis Child 2014 Nov; 99:1014
Probiotics Do Not Prevent Eczema at Age 2 Years
They do decrease allergic sensitization but not accompanying allergic disease.
One hypothesis proposed to explain the recent increase in allergic disease is a reduction in microbial exposure during the first year of life. Meta-analyses suggest that probiotics might modestly reduce eczema (but not asthma or food allergy) in children, but randomized trials have yielded conflicting results.
To assess the efficacy of perinatal exposure to probiotics in preventing clinically diagnosed eczema in infants until age 2 years (primary endpoint), investigators conducted an industry-supported trial in the U.K. They randomized 454 pregnant women to receive a daily capsule of probiotic therapy (a mixture of 2 lactobacilli strains and 2 bifidobacteria strains) or placebo starting at 36 weeks' gestation. After birth, the capsule was opened and given directly to the child until age 6 months.
Incidences of eczema, asthma, allergic rhinitis, and food allergy were similar between groups at age 2 years, but the probiotic group had lower frequencies of allergic sensitization and atopic eczema (eczema with ≥1 positive skin test) compared with the placebo group. For every 13 children treated, sensitization was prevented in one child. No adverse effects were reported from probiotic administration.
Comment: Parents frequently ask me if they should give their newborns probiotics to prevent allergic disease. Although probiotics are very safe, there is not enough evidence to recommend them for the prevention of allergic disease. To complicate matters, the FDA has not approved any probiotics, and numerous strains and strengths are available but with little concrete information to guide selection.
Citation(s): Allen SJ et al. Probiotics in the prevention of eczema: A randomised controlled trial. Arch Dis Child 2014 Nov; 99:1014.
(http://dx.doi.org/10.1136/archdischild-2013-305799)
http://adc.bmj.com/content/99/11/1014?ijkey=8abab943b9a1296ece3a199b3eac4af89
48c65cd&keytype2=tf_ipsecsha
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MM: It wasn't all that long ago that very few clinicians had even heard of probiotics or prebiotics and certainly it was only the rare person who had any familiarity at all with fecal transplantation. The field of working with microorganisms rather than trying to completely defy them has grown so much in the past decade that it would be hard pressed to find someone who had not heard of probiotics and their benefits. Unfortunately, there remains a great deal of missing or simply inaccurate information about probiotics, which ones to take and how much is an appropriate amount. With more than a decade of experience on this topic, the staff at Mark Drugs can help to direct and instruct patients with all their probiotic and prebiotic needs.
Oral Fecal Microbiota Capsules Show Early promise for C.difficile Infection
By Kelly Young, Edited by David G. Fairchild, MD, MPH, and Jaye Elizabeth Hefner, MD
Oral capsules of frozen fecal material appeared to improve symptoms in patients with recurrent Clostridium difficile infection in a small, preliminary study published in JAMA.
Twenty patients with recurrent or refractory C. difficile infections received capsules containing frozen stool from healthy donors on 2 consecutive days. The donations had been screened for pathogens. None of the recipients experienced serious adverse events, but about a third had abdominal cramping and bloating. Ninety percent of patients saw their diarrhea resolve within 8 weeks. Fourteen of the twenty patients had symptom resolution after the first round of treatment, while another four had resolution with another treatment 7 days later.
The authors note: "If reproduced in future studies with active controls, these results may help make [fecal microbiota transplantation] accessible to a wider population of patients, in addition to potentially making the procedure safer."
http://jama.jamanetwork.com/article.aspx?articleid=1916296
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MM: Pain relief is largely subjective. Each person has a unique response and tolerance to pain and its many manifestations. I am not denying that any person who states that they have pain is faking it. No, rather that everyone responds to and reflects upon pain differently. What is mild pain to one person may be severe to another and vice versa. Additionally, there is not a single, most effective treatment for pain. It is commonly a combination of modalities that achieve the best results. These may include allopathic, chiropractic, acupuncture, physical therapy, stretching and a number of other modalities; none of which are mutually exclusive. I would recommend that anyone with chronic lower back pain or back related leg pain, investigate a wide range of treatment options before considering surgery.
Ann Intern Med 2014 Sep 16; 161:381
Spinal Manipulation for Chronic Back-Related Leg Pain: Short-Term Relief Only
After 1 year, leg pain was no better after chiropractic care than after exercise alone.
Treatment options are limited for patients with back-related leg pain. Researchers in Minnesota and Iowa randomized 192 adults (mean age, 57) who had radiating pain from the lumbar spine into a lower extremity (duration, ≥4 weeks) to 12 weeks of either home exercise and advice alone, or exercise and advice plus spinal manipulative therapy. Spinal-manipulation patients received ≤20 sessions with chiropractors who delivered high-velocity, low-amplitude thrust procedures or low-velocity, variable-amplitude mobilization maneuvers to the lumbar vertebral or sacroiliac joints, plus adjunctive therapies (e.g., soft-tissue stretching) as needed. Patients in both groups received four 1-hour home exercise and advice visits, designed to help them manage pain and improve mobility.
At baseline, mean scores on the primary outcome — patient-rated leg pain during the past week on a scale of 0 to 10 — were about 6 in both groups. At 12 weeks, mean leg-pain scores were 2.9 in the spinal-manipulation group and 3.9 in the exercise-alone group (a significant difference); at 52 weeks, the difference between groups was no longer significant. Similarly, subjectively measured secondary outcomes (e.g., lower back pain, disability) favored spinal manipulative therapy at 12 weeks but not at 52 weeks.
Comment: At 12 weeks, patients who were randomized to spinal manipulative therapy showed greater improvements than did controls. However, the spinal-manipulation group was seen by clinicians far more frequently and received additional, adjunctive therapies. Still, adverse outcomes did not differ between groups; so, for patients inclined to undergo lumbar spinal manipulative therapy, we probably have no reason to discourage them.
Citation(s): Bronfort G et al. Spinal manipulation and home exercise with advice for subacute and chronic back-related leg pain: A trial with adaptive allocation.
Ann Intern Med 2014 Sep 16; 161:381.
(http://dx.doi.org/10.7326/M14-0006)
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MM: PCOS is a very troubling condition. Although not life threatening, it can make a person very uncomfortable and even infertile. These can be both physically and psychologically tormenting. A thorough understanding of the condition, its diagnosis and some possible treatment approaches may help a person cope with the condition.
A Guide to Polycystic Ovary Syndrome
PCOS is a complex hormonal problem, but many treatments are available.
Polycystic ovary syndrome (PCOS) is a medical condition that, despite its name, affects more than just your ovaries. Recent research has improved our understanding of this condition, which affects about 5 million U.S. women. If you have signs or symptoms of PCOS as described below, see a clinician (doctor, nurse practitioner or midwife, physician assistant), because PCOS can affect your current and future health.
Diagnosing PCOS: Three factors are considered in the diagnosis of PCOS:
- Hyperandrogenism (too much male hormone). In addition to producing female hormones, all women produce small amounts of male hormones, primarily testosterone. Women with PCOS produce unusually large amounts, often leading to hirsutism (excessive body hair, especially on the upper lip, chin, chest, and stomach) and acne. Blood tests can tell if you have excessive androgens.
- Irregular or infrequent menstrual periods. Most women's menstrual cycles (counted from day 1 of one period to day 1 of the next) are about 28 days long, although a little variation is normal. If your cycles are 35 days or longer, or if you sometimes skip periods for a few months, PCOS may be the cause.
- Presence of many follicles in the ovaries (determined with pelvic ultrasound). Ovarian follicles are fluid-filled sacs containing cells destined to become eggs. Normally one follicle enlarges and develops into an egg, which is released in monthly ovulation. Because of the hormonal shifts in PCOS, eggs are not released and small follicles accumulate inside the ovaries.
If you have two or three of the above features, the diagnosis of PCOS is clear. If you have only one factor, further testing is needed. For instance, if you have excessive body hair but regular periods, a pelvic ultrasound showing multiple ovarian cysts confirms the diagnosis. If you have few periods but aren't overly hairy, a blood test for male hormone levels and a pelvic ultrasound can be performed.
Additional Health Issues: Because women with PCOS have a higher likelihood of developing diabetes, blood tests for diabetes when you are first diagnosed (and then periodically) are a good idea. PCOS also makes heart disease more likely. You should have your cholesterol levels checked regularly and discuss with your clinician what you can do to avoid or delay heart problems.
If you are having few or no periods, tests can determine possible causes other than or in addition to PCOS. A pituitary adenoma (small tumor in the pituitary gland of the brain), early menopause, or an underactive thyroid gland can all interfere with your period; blood tests can reveal them.
PCOS Treatments: If you're not ready to get pregnant, the first-line treatment for PCOS is birth control pills containing estrogen and progestin (similar to progesterone). The pills benefit you by:
- Protecting against overgrowth of the endometrium (tissue lining the uterus), which can lead to endometrial cancer. Women with PCOS produce estrogen like other women — but because they're not ovulating, they don't make progesterone, a hormone produced only after ovulation. Without progesterone to balance out estrogen's effects, endometrial overgrowth can occur. Birth control pills provide both estrogen and progestin, preventing this overgrowth.
- Lowering androgen levels, which improves acne and excessive body hair.
Some women (for example, those who have had blood clots in their legs or lungs) cannot safely use dual-hormone birth control pills. Alternative treatments for such women include a progestin-releasing intrauterine device that prevents endometrial overgrowth, along with metformin (a diabetes medication) with or without spironolactone (an androgen-blocking medication that is also a diuretic [“water pill”]). Spironolactone can also be taken with birth control pills if the pills alone don't improve hirsutism. Spironolactone is known to cause birth defects. If you take this medication and are of reproductive age (between 15 and 49), you must use an effective method to prevent pregnancy. Other prescription and nonprescription treatments for hirsutism and acne are also available.
Why use a diabetes medication to treat PCOS? Insulin produced by your body allows you to get energy from food. Insulin resistance can develop in PCOS as in diabetes. With insulin resistance, your body cannot effectively use this insulin, so it makes more, resulting in too much. The excessive insulin stimulates your ovaries to make testosterone, blocking ovulation. Metformin decreases insulin resistance, improving these problems.
Birth control pills will also protect you from unintended pregnancy. Although women with PCOS usually don't ovulate as frequently, many still ovulate a few times a year. So don't count on PCOS as a birth control method.
PCOS and Pregnancy: At the time you are diagnosed with PCOS, it's helpful to discuss your thoughts about and plans for future pregnancy. Because women with PCOS don't ovulate regularly or at all, they may have difficulty becoming pregnant and having babies. The good news is that ovulation stimulation with clomiphene or other fertility medications works for most women with PCOS. Clomiphene triggers the pituitary gland to secrete follicle-stimulating hormone, signaling the follicles to grow. Other fertility medication may be suggested, particularly if you are obese or do not get pregnant after trying clomiphene.
Pregnant women with PCOS are at risk for gestational diabetes (which starts during pregnancy and generally goes away after the baby is born), so they should be checked regularly. Gestational diabetes can be treated — and you can have a healthy baby.
PCOS and Weight: About half of all U.S. women with PCOS are obese. For such women (especially those with extreme obesity), weight loss can result in more-regular periods, an easier time getting pregnant, and improvement in hirsutism. Weight loss needn't be drastic. Even if you don't reach your ideal body weight, losing just 10% of your current weight can help. For example, if you weigh 200 pounds, losing 20 pounds may improve PCOS. Most types of weight-loss diets, coupled with regular physical exercise, are helpful in achieving and maintaining weight loss. Following a low-carbohydrate diet (while also eating some “good fats”) may be particularly helpful for losing weight and keeping it off. If you're not sure how your weight measures up, check the body-mass index (BMI) calculator in the Resources below.
If you need to lose weight, you may want to consult a dietitian for advice or join a support group. There are even mobile apps to help with weight loss. In addition to managing your PCOS, you will be improving your general health and lowering your risk for other health problems.
In Conclusion: PCOS is a complex problem. If you have symptoms of PCOS, see a clinician to find out if you have this condition. If you're obese, work on losing weight. Once a diagnosis is made, consider your treatment options to control current and prevent future problems.
Resources :
PCOS
http://www.womenshealth.gov/publications/our-publications/fact-sheet/polycystic-ovary-syndrome.html#b
http://www.pcosupport.org
BMI calculator
http://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm
Weight Loss
http://www.womenshealth.gov/publications/our-publications/fact-sheet/overweight-weight-loss.html
http://www.webmd.com/women/guide/womens-health-healthy-eating
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MM: Many of the treatments below are used commonly for PCOS but what has been left out is bio-identical progesterone cream. The use of bio-identical progesterone was discussed by Dr. John Lee as early as the 1980's and before him by Dr. Katarina Dalton. These pioneers of using bio-identical progesterone for PMS, PCOS and menopausal symptoms led the way for the clinicians of today who treat patients with compassion by recognizing these conditions and coax the body back to an appropriate place rather than trying to overcome it and obtain numerous adverse drug effects while addressing only a limited number of symptoms that have been identified. There is no denying that this author is quite learned and has a host of highly respected references, but in my opinion, she is missing the boat when it comes to overall patient care.
Polycystic Ovary Syndrome: Diagnosis and Management
Diagnosis of PCOS typically requires two steps, and treatment is usually multifaceted.
Case: A 16-year-old girl visited a dermatologist for acne and moderate hirsutism. The patient reported experiencing menarche at age 14 followed by two menses yearly. The dermatologist initiated minocycline treatment, which improved the acne; however, the hirsutism progressed. Two years later, before starting college, the patient visited an internist, who recognized the dyad of hirsutism and oligomenorrhea. What diagnosis did the internist make? What is the first-line treatment?
Diagnosis of PCOS: A Two-Step Process Polycystic ovary syndrome (PCOS) is typically diagnosed using the Rotterdam criteria, which require the presence of two of the following three manifestations: (1) hyperandrogenism as indicated by hirsutism or elevated serum androgen levels (testosterone, androstenedione, or dehydroepiandrosterone); (2) oligomenorrhea as manifested by cycle length ≥35 days; and (3) multifollicular ovaries on ultrasound (≥12 small follicles in an ovary).1 The first diagnostic step is to determine if both hirsutism and oligomenorrhea are present based on physical examination and history. If both symptoms are observed, the diagnosis of PCOS is established and treatment can be initiated. Approximately 95% of women with hirsutism and oligomenorrhea have multifollicular ovaries on ultrasound.
If only hirsutism or only oligomenorrhea is present, the second step is to obtain additional studies. If hirsutism is the sole presenting symptom, a pelvic ultrasound should be obtained; if this reveals multifollicular ovaries, the diagnosis of PCOS is established. If oligomenorrhea is the only symptom, serum androgens should be measured and a pelvic ultrasound obtained. If elevated serum androgens, a multifollicular ovary, or both are identified, the diagnosis of PCOS is established. Women with PCOS and amenorrhea should undergo measurement of serum prolactin, thyroid-stimulating hormone (TSH), and follicle-stimulating hormone (FSH) to rule out amenorrhea's other causes. Overweight and obese women with PCOS should be evaluated for the metabolic syndrome. Professional societies recommend screening women with PCOS for diabetes using an oral glucose tolerance test.1 I prefer measuring hemoglobin A1c to screen for diabetes.
Etiology: Most women with PCOS have increased pituitary secretion of luteinizing hormone (LH) and many have insulin resistance with compensatory hyperinsulinemia. LH and insulin both stimulate secretion of ovarian testosterone and androstenedione, thereby blocking the growth of a large (dominant) follicle that can trigger ovulation. Follicles are frozen in their development at 2 mm to 9 mm in diameter and cannot grow to the size of 20 mm to 25 mm necessary to elicit ovulation. The increased ovarian secretion of androgens causes hirsutism and, in some women, acne.2 Women with PCOS have midfollicular serum estradiol levels but low progesterone levels, increasing their risk for developing endometrial hyperplasia and cancer.
Management: Women with PCOS typically require a multifaceted approach to treatment because they present with one or more of the following chief complaints1,2:
Oligomenorrhea
Hirsutism
Ovulatory infertility
Weight problems and concern about developing diabetes
Oligomenorrhea and Hirsutism: Estrogen-progestin contraceptives are first-line therapy for both oligomenorrhea and hirsutism. Although few comparative data address the pros and cons of different progestin formulations of oral contraceptives for treating women with PCOS, I do not prescribe norgestrel-containing contraceptives in this setting because this progestin is highly androgenic. After 6 months of estrogen-progestin therapy, if the hirsutism has not improved, spironolactone can be initiated.1 I often begin therapy for moderate-to-severe hirsutism with a combination of an estrogen-progestin contraceptive and spironolactone. For all my patients I use a fixed, 100-mg daily dose of spironolactone (near the top of the dose-response curve for this agent). Because of spironolactone's teratogenic effects, any woman of reproductive age who is receiving this agent should also use highly effective contraception. Finasteride and flutamide are two other antiandrogens that have been used to treat hirsutism in women with PCOS. I recommend against these agents because finasteride carries an FDA black box warning advising against its use in women and flutamide has been associated with rare instances of liver damage.
Estrogen-progestin contraceptives are contraindicated in women with histories of venous thromboembolism (VTE) and those with deficiencies of antithrombin, protein C, or protein S. PCOS itself, as well as the associated obesity, may also be a risk factor for VTE.4,5 For women with PCOS and contraindications to estrogen-progestin treatment, I recommend multimodal therapy with second-line agents. One option is to place a levonorgestrel-releasing intrauterine device to prevent endometrial hyperplasia and heavy menstrual bleeding, while also initiating treatment with metformin (1500–2250 mg daily) and spironolactone (100 mg daily). Another option is to initiate therapy with an oral progestin such as norethindrone acetate (5 mg daily [one tablet] or 2.5 mg daily [one-half tablet]) to prevent heavy bleeding, while also prescribing metformin plus spironolactone.Anovulatory
Infertility: Clomiphene (an estrogen antagonist) and letrozole (an aromatase inhibitor) are first-line agents for inducing ovulation. Both agents increase pituitary secretion of FSH, which stimulates small follicles to grow, thereby triggering ovulation. Recent results of two large randomized trials can guide fertility treatment in women with PCOS. In one trial, clomiphene was much more effective than metformin for inducing ovulation and achieving live birth. In the second trial, in women with body-mass index (BMI) ≥30 kg/m2, letrozole was superior to clomiphene for inducing ovulation and live birth, but in women with BMI <30, letrozole and clomiphene were equally effective.8 Because letrozole is not FDA approved for ovulation induction, I recommend clomiphene for inducing ovulation in PCOS patients with BMI <30. However, because letrozole is more effective than clomiphene in PCOS patients with BMI ≥30, I recommend letrozole in this situation.
Although most women with PCOS who undergo ovulation induction go on to conceive and bear children, counseling is recommended. In particular, adolescents with PCOS should be advised that they might have difficulty conceiving in the future and therefore might require assistance to achieve pregnancy.
Weight Problems and Risk for Diabetes: About half of U.S. women with PCOS are obese. Weight loss of about 10% of body mass can improve cycle regularity and lower serum testosterone, although if the obesity is extreme, ovulation may not resume without other treatment9; nonetheless, women with PCOS and obesity still benefit from increased physical activity and initiation of weight-loss diets. All diets can be effective for achieving weight loss — but compared with low-fat diets, low-carbohydrate diets (with recommendations to consume healthy fats) may help women with PCOS lose more weight and maintain that weight loss over a longer period of time. Women with PCOS are at excess risk for developing gestational diabetes (GDM) and type 2 diabetes mellitus (T2DM). Many women with PCOS are insulin resistant, and long-term metformin treatment may help obese women with PCOS reduce their risk for developing GDM or T2DM.
Case Conclusion: Based on the presence of both hirsutism and oligomenorrhea, the internist made the diagnosis of PCOS, initiated therapy with an estrogen-progestin contraceptive, and continued the minocycline. The patient developed regular withdrawal menses, reported a reduction in her hirsutism, and was optimistic that her hormonal problems could be effectively managed. Dr. Barbieri is Chair, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, and Kate Macy Ladd Professor, Harvard Medical School, Boston, MA. Citation(s):
1. Legro RS et al. Diagnosis and treatment of polycystic ovary syndrome: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2013 Dec; 98:4565. (http://dx.doi.org/10.1210/jc.2013-2350)
http://www.ncbi.nlm.nih.gov/pubmed/24151290?access_num=24151290&link_
type=MED&dopt=Abstract
2. Ehrmann DA.Polycystic ovary syndrome. N Engl J Med 2005 Mar 24; 352:1223. (http://dx.doi.org/10.1056/NEJMra041536)
3. Domecq JP et al. Adverse effects of the common treatments for polycystic ovary syndrome: A systematic review and meta-analysis. J Clin Endocrinol Metab 2013 Dec; 98:4646. (http://dx.doi.org/10.1210/jc.2013-2374)
4. Okoroh EM et al. Is polycystic ovary syndrome another risk factor for venous thromboembolism? United States, 2003–2008. Am J Obstet Gynecol 2012 Nov 1; 207:377.e1. (http://dx.doi.org/10.1016/j.ajog.2012.08.007)
5. Bird ST et al. Risk of venous thromboembolism in women with polycystic ovary syndrome: A population-based matched cohort analysis. CMAJ 2013 Feb 5; 185:E115. (http://dx.doi.org/10.1503/cmaj.120677)
6. Nestler JE.Metformin for the treatment of the polycystic ovary syndrome. N Engl J Med 2008 Jan 3; 358:47. (http://dx.doi.org/10.1056/NEJMct0707092)
7. Legro RS et al. Clomiphene, metformin, or both for infertility in the polycystic ovary syndrome. N Engl J Med 2007 Feb 8; 356:551. (http://dx.doi.org/10.1056/NEJMoa063971)
8. Legro RS et al. Letrozole versus clomiphene for infertility in the polycystic ovary syndrome. N Engl J Med 2014 Jul 10; 371:119. (http://dx.doi.org/10.1056/NEJMoa1313517)
9. Moran LJ et al. Lifestyle changes in women with polycystic ovary syndrome. Cochrane Database Syst Rev 2011 Jul 6; CD007506. (http://dx.doi.org/10.1002/14651858.CD007506.pub3)
10. Bazzano LA et al. Effects of low-carbohydrate and low-fat diets: A randomized trial. Ann Intern Med 2014 Sep 2; 161:309. (http://dx.doi.org/10.7326/M14-0180)
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Clin Gastroenterol Hepatol 2014 Jul 19
Ten Tips on Celiac Disease
A helpful tune-up for clinicians on diagnosing and managing patients
Two experts on celiac disease have provided 10 things that every gastroenterologist should know.
Excerpts include the following:
- The best screening serology is still immunoglobulin A (IgA) tissue transglutaminase (TTG) plus total serum IgA. IgG TTG performs well in patients with known IgA deficiency.
- Water immersion in the duodenum can target biopsies and permits evaluation in patients without a prior indication for biopsy.
- Take four biopsies from the postbulbar duodenum and two biopsies from the bulb at the 9 o'clock and 12 o'clock positions.
- Consider serologic testing in all first-degree relatives of patients with celiac disease and in second-degree relatives if sibling pairs are affected.
- Test patients with type 1 diabetes.
- Do HLA testing for patients on a gluten-free diet, and if HLA markers are present, serologic testing can be done after a low-dose (3 g daily) gluten challenge for 6 weeks.
- Test all newly diagnosed patients with complete blood count, ferritin, B12, folate, copper, zinc, calcium, and vitamin D, and conduct bone-density measurement in adults.
- Patients who do not respond to a gluten-free diet should have the original diagnosis assessed; look for gluten exposure and if not present, obtain duodenal and colonic biopsies.
Comment: This article is in a great teaching format and should be useful to any gastroenterologist who wants a celiac tune-up.
Citation(s): Oxentenko AS and Murray JA.Celiac disease: Ten things that every gastroenterologist should know. Clin Gastroenterol Hepatol 2014 Jul 19;
[e-pub ahead of print].
(http://dx.doi.org/10.1016/j.cgh.2014.07.024)
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MM: Antibiotics should be reserved for the most dangerous of conditions but when they are prescribed it is important the most effective treatments are being used and in the case of community acquired pneumonia (CAP) strains of infectious bacteria have been increasing their potency and have become more resistant to single antibiotics. This necessitates a new approach and it appears that multiple antibiotics being prescribed simultaneously may be an appropriate answer for the time being.
Antibiotic Monotherapy Not as Effective as Dual Therapy in Community Acquired Pneumonia
By Kelly Young, Edited by David G. Fairchild, MD, MPH, and Jaye Elizabeth Hefner, MD
Treating community-acquired pneumonia with only a beta-lactam antibiotic does not appear to be as effective as treating with a beta-lactam and a macrolide antibiotic, according to an open-label, noninferiority study in JAMA Internal Medicine.
Swiss researchers randomized nearly 600 adults presenting to the hospital with community-acquired pneumonia to either monotherapy with a beta-lactam (usually amoxicillin–clavulanic acid) or dual therapy with a beta-lactam and a macrolide (clarithromycin).
At day 7 of treatment, 41% of patients in the monotherapy group were not clinically stable (the primary outcome), versus 34% in the combination group. While the difference between the groups was not significant, monotherapy could not be considered noninferior to dual therapy. In patients with an atypical pathogen, dual therapy was superior.
Until future trials are completed, commentators write, "dual therapy should remain the recommended treatment for patients hospitalized for CAP."
http://archinte.jamanetwork.com/article.aspx?articleid=1910547
