4/15/10

Antipsychotic use in elderly patients linked to pneumonia

NEW YORK (Reuters Health) - Elderly patients who use antipsychotic agents are at increased risk for community-acquired pneumonia, a report from The Netherlands indicates. Moreover, as the drug dosage increases, so does the risk of pneumonia.

"Clinicians who start treatment with both atypical and typical antipsychotic drugs should closely monitor patients, particularly at the start of therapy and if high doses are given, with respect to the risk for community-acquired pneumonia," lead author Dr. Gianluca Trifiro, from Erasmus University Medical Center, Rotterdam, and colleagues advise.

Exactly how antipsychotics may promote pneumonia is unclear, the report indicates, but their antihistaminergic, extrapyramidal, and anticholinergic actions could promote aspiration pneumonia through effects on swallowing and mouth dryness.

For their study, reported in the Annals of Internal Medicine for April 5, the authors gathered data from the Dutch Integrated Primary Care Information database from 1996 to 2006. They compared 258 antipsychotic drug users with incident pneumonia (age 65 years or older) to 1686 control subjects matched by age, gender, and date of onset.

Current use of typical and atypical antipsychotics increased the odds of community-acquired pneumonia in a dose-dependent fashion (adjusted OR, 1.76 and 2.61, respectively). Further analysis showed that only use of atypical antipsychotics increased the risk of fatal pneumonia (adjusted OR, 5.97).

The risk of pneumonia was greater for agents with higher H1-histaminergic receptor affinity, according to the paper.

"In light of the potential role of the antihistaminergic effect in the antipsychotic-induced pneumonia and the differential receptor-binding profile of antipsychotic drugs, larger population-based studies should better evaluate the comparative risk for community-acquired pneumonia for individual atypical and typical antipsychotic drugs," the authors conclude.

A similar report from The Netherlands, published 2 years ago, used national pharmacy data from 1986 to 2003 to evaluate the risk of pneumonia in elderly users of antipsychotics (see Reuters Health story, April 25, 2008). In that study, the risk of pneumonia nearly quintupled during the first 7 days of antipsychotic use but then declined over the next few weeks. Those authors too cited aspiration as an important etiology in their elderly subjects, and they advised physicians to evaluate patients' ability to swallow before prescribing antipsychotics.

Reference:
Ann Intern Med 2010;152:418-425.

http://www.thedoctorschannel.com/go/reuters/3114.html
regards, taniafdi ^_^

Pacemaker upgrade improves systolic function

NEW YORK (Reuters Health) - Upgrading traditional 2 chamber cardiac pacemakers to modern 3 chamber pacemakers -- cardiac resynchronization therapy (CRT) devices -- improves left ventricular ejection fraction (LVEF), researchers reported online March 16th in the European Heart Journal.

Chronic right ventricular (RV) pacing with the older devices produces ventricular dyssynchrony, leading to LV remodeling and associated morbidity and mortality, the researchers note.

"The important clinical finding in our study is that even after a long period (up to 8 years) of 2 chamber pacing and subsequently very reduced LVEF, upgrading to CRT can improve systolic heart function," senior author Dr. Johannes Holzmeister told Reuters Health by email.

Dr. Holzmeister of University Hospital Zurich and colleagues studied 102 patients after primary CRT implantation and 70 after a CRT upgrade.

After a mean follow-up of close to 2 years, the researchers saw significant absolute increases in LVEF of 10% in the primary group and 11% improvement in the upgrade group.

Both sets of patients had significant and similar reductions in LV end-systolic diameter and diameter index. The response to CRT upgrade was independent of the underlying rhythm, QRS duration, duration of prior RV pacing, or LV function and size at baseline.

Moreover, 7 of 9 patients with older devices in place for more than 12 years responded favorably to CRT.

"In other words," concluded Dr. Holzmeister, this means "that a pacing induced cardiomyopathy is reversible even at a late stage."

Reference:
Eur Heart J 2010. 


regards, taniafdi ^_^

Ultrasound useful in infants with first urinary tract infection

NEW YORK (Reuters Health) - Ultrasound can be useful in the work-up of infants with a first urinary tract infection, researchers from Sweden report in the May issue of The Journal of Urology.

The most appropriate way to evaluate infants with a first urinary tract infection - ultrasonography, or voiding cystourethrography, or renal scanning with dimercaptosuccinic acid (DMSA), or some combination of those - has been controversial, according to senior author Dr. Sverker Hansson and colleagues from the University of Gothenburg.

To learn more about the role of ultrasound, the investigators obtained scans in 290 infants (161 males) with a first urinary tract infection. Along with ultrasonography, the babies underwent DMSA scintigraphy during the initial evaluation, followed within 2 months by cystourethrography.

One hundred twenty infants (41%) had 183 abnormal findings on ultrasound, including important structural abnormalities in 21 boys and 19 girls.

Ultrasound identified 17 of 27 children with dilating vesicoureteral reflux (grades III to V), but only 5 of 13 children with grade III reflux. Overall, ultrasound was 63% sensitive and 61% specific in identifying vesicoureteral reflux.

Abnormality on ultrasound was significantly associated with the presence and severity of abnormality on DMSA scan, with ultrasound showing 48% sensitivity and 66% specificity in detecting DMSA abnormalities.

The length of the longer kidney on ultrasound (expressed as the standard deviation) was directly related to the presence of inflammatory parameters such as body temperature and C-reactive protein level, and to the presence of DMSA scan abnormalities. For instance, among babies with the longest kidney length in the reference range, 22% had DMSA scan findings, compared to 67% of babies whose longest kidney was more than 2 standard deviations above the norm.

Outside the study, an additional 28 infants were diagnosed with dilatation on ultrasound prenatally (15 infants) and postnatally (13 infants).

Since it is nonvasive, ultrasonography is "an attractive alternative or complement to DMSA scan" for first line imaging in infants with urinary tract infection, "especially in the absence of prenatal ultrasound during late pregnancy," the researchers conclude.

Reference:
J Urol 2010;183:1984-1988
http://www.thedoctorschannel.com/video/3130.html

regards, taniafdi ^_^

4/13/10

Warfarin plus antibiotic can cause stomach bleed: study.

The Canadian Press
Date: Tuesday Apr. 13, 2010 8:53 AM ET

TORONTO — Researchers say people taking the blood-thinning drug warfarin should avoid a popular antibiotic that's often used to treat urinary tract infections. A study by the Institute for Clinical Evaluative Sciences found that warfarin can be dangerous when combined with the antibiotic cotrimoxazole, sold under such brand names as Bactrim and Septra. Principal investigator Hadas Fischer says some antibiotics boost the risk of bleeding in patients prescribed warfarin to prevent blood clots that could cause a heart attack or stroke. 

The study found patients on warfarin who were prescribed cotrimoxazole had an almost four-fold greater risk of an upper-gastrointestinal hemorrhage compared to those not given the antibiotic. The researchers say the risk of bleeding is considerably higher than that from other antibiotics. Fischer says that in rare instances when the two drugs must be used together, doctors should monitor patients very closely. 

Urinary-tract infections are extremely common among the elderly and often are treated with antibiotics that have a significant potential for interacting with warfarin, sold under brand names such as Coumadin. About 34 per cent of the 135,000 patients in the 10-year study, all of whom were taking warfarin, had at least one prescription for antibiotics to treat a urinary-tract infection. Seven per cent received at least one prescription for cotrimoxazole. 

Overall, more than 2,000 patients taking warfarin were hospitalized with gastrointestinal bleeding. "This is a completely avoidable problem," says co-author Dr. David Juurlink, a scientist at ICES. "Whenever possible, clinicians should prescribe alternative antibiotics to cotrimoxazole in patients receiving warfarin."

source :
http://www.ctv.ca/servlet/ArticleNews/story/CTVNews/20100413/warafarin_100413/20100413?hub=Health&s_name=

regards, taniafdi ^_^

4/12/10

Cases and Answer

A 10 year old boy presented with generalized swelling. This had been present for 4 days and included swollen ankles and puffiness of the face. It started a few days after a mild cold with a runny nose. His only past medical history was of mild eczema. On examination, there were no abnormalities apart from the swelling, which included pitting edema around both ankles.

Urinalysis showed protein +++ and 24-h urine collection contained 10 g protein/24h (10.000 mg/24h). His serum creatinine was normal at 60umol/L (0,7 mg/dL), but his serum albumin was low at 20 g/L (2.0 g/dL).

- What clinical syndrome does he have?
- What is the prbable pathological diagnosis ?
- What is the usual treatment ?

Answer :

1. This boy has nephrotic syndrome with heavy proteinuria (>3,5 g/24h), hypoalbuminemia, and peripheral edema causing the swelling.
2. In children, the most common cause of the nephrotic syndrome is minimal change nephropathy. This typically follows an upper respiratory infection and is more common in children with atopy (allergic, eczema, asthma, and hay fever).
3. Minimal change nephropathy responds well to steroids. Proteinuria usually resolves completely and does not leave permanent renal damage. If the disease does relapse, ciclosporin is sometimes used to prevent further relapse.

Source : The Renal System at a Glance, 3rd edition, Chris O'Callaghan, Willey-Blackwell.

regards, taniafdi ^_^

Therapy of Diabetes

1. Metformin is recommended first line for most type 2 patients.

2. Sulphonylureas have a more immediate effect at reducing blood glucose levels in symptomatic patients and   may also be first choice for insulin-deficient individuals.

3. Sulphonylureas, glitazones and insulin may all cause weigth gain and obesity is often already a problem.

4. Sulphonylureas may put the patient at risk of hypoglicemia with implications for driving. 

5. There appears to be increased risk of distal fractures in women using glitazones.

6. Glitazones may cause fluid retention, exacerbating or precipitating heart failure.

7. Exenatide may assist with weight reduction.

8. Sitaglipin is licensed for triple therapy (with metformin and a sulphonylurea) but vildagliptin is currently only licensed for use in combination with one of these other agents.

9. Failure of the HbA1c to respond to exenatide of a gliptin after an appropriate interval requires withdrawal of the drug.


regards, taniafdi ^_^

Botox in Urology


Pertama kali saya mengetahui tentang penggunaan botox untuk urologi adalah dari dr. Leticia de Kort. Beliau adalah salah satu urologis wanita dari Rumah Sakit Pendidikan Utrecht (UMC). Cukup kaget juga, karena yang saya tahu waktu itu, bahwa pemakaian botox sering digunakan pada bedah plastik..

Menurut dr. De Kort, pemakaian botox sering pada pasien-pasien Overreactive Bladder. Dosis yang diberikan bisa 200-300 unit untuk sekali pemakaian. Beliau juga mengaku, bahwa pemakaian botox memang relatif baru. Botox disuntikkan dengan bantuan sitoskopi ke seluruh otot vesika urinaria secara random. Suntikkan diusahakan untuk menjauhi daerah otot spinchter. Menurut beliau, jika disuntikkan pada daerah tersebut, ditakutkan berujung pada retensi urine. 

Dr. De Kort berpendapat bahwa pemakaian botox cukup efektif pada pasien over reactive bladder dan sangat membantu. Biasanya pemberian suntikan akan diulangi beberapa kali dengan jeda lebih kurang 6 bulan.

Operasi yang saya ikuti ini cukup menambah pengalaman dan pengetahuan. Beliau sangat informatif kepada saya. It's really cool... 

regards, taniafdi ^_^

Topical menthol 10% solution (peppermint oil) may abort acute migraine.

Clinical Question:

Is topical menthol 10% solution effective as an abortive treatment of acute migraine headache in adults?

Bottom Line:

Topical menthol 10% solution applied as described below may be more effective than placebo solution in alleviating acute migraine headache pain in adults.?Topical menthol 10% solution applied as described below may be more effective than placebo solution?? There?s a typo in Table 2 ? the n for migraine attacks in the placebo group should be 58, not 8. (LOE = 2b)

Reference:

Study Design:

Cross-over trial (randomized)

Funding:

Foundation

Setting:

Outpatient (specialty)

Allocation:

Concealed

Synopsis:

These investigators identified 44 adults, aged 18 to 65 years, who met standard international criteria for migraine headache and had at least a 1-year history of migraines and 1 to 6 migraine attacks per month. Eligible patients randomly received (concealed allocation assignment) either menthol for the first 2 of 4 migraine atttacks followed by placebo for the second 2 attacks, or the same treatment in the opposite order. Patients and all investigators who assessed outcomes remained masked to treatment order. Active study medication was prepared as a 10% solution of menthol crystals in ethanol. A solution of 0.5% ethanol menthol solution with the same color and odor served as the placebo. At the onset of a migraine, patients intitially cleansed the forehead and temporal area of the most painful side of the head with tap water. After drying, 1 mL of active drug or placebo was applied with a sponge on a surface area of 5 cm x 5 cm. The same treatment was reapplied after 30 minutes. Participants were allowed to take rescue medication if needed after 2 hours. Follow-up occurred for 79% of patients for 4 migraine attacks. Patients reported no pain at 2 hours after attacks significantly more often when treated with menthol 10% than when treated with placebo (38.3% vs 12.1%; number needed to treat [NNT] = 4; 95% CI, 2.5-9.4). Similarly, patients reported a greater than 50% decrease in pain scores compared with baseline significantly more often when treated with menthol 10% than with placebo (58.3% vs 17.2%; NNT = 2.4; 2-4). No recurrence of headache at 24 hours also occurred signifcantly more often in patients when using menthol 10% than when using placebo (33.3% vs 12.1%; NNT = 5; 3-17). Two patients (5.7%) dropped out of the trial because of a severe burning sensation on the temporal area and an aggravation of headache. 

Copyright © 2010 by Wiley Subscription Services, Inc. All rights reserved.

regards, taniafdi ^_^

Journal of The Day 5



A Step Forward in the Treatment of Advanced Biliary Tract Cancer.

regards, taniafdi ^_^

Dutasteride Decreases Prostate Cancer Risk

Results from a large, randomized clinical trial indicate that men at an increased risk for prostate cancer reduced their risk with regular use of the drug dutasteride (Avodart). The results came from the REDUCE trial, which is the second largest clinical trial to demonstrate a decreased risk of prostate cancer in men taking an agent from the class of drugs known as 5-α reductase inhibitors (5-αRIs). Previously, the Prostate Cancer Prevention Trial (PCPT) showed that the drug finasteride had a risk reduction similar to what has now been seen in REDUCE.

Findings from this trial suggest “that the major effect of dutasteride is the shrinkage of prostate tumors or inhibition of their growth,” wrote the study’s lead investigator Dr. Gerald Andriole, of the Washington University School of Medicine in St. Louis, and his colleagues in the April 1 New England Journal of Medicine. GlaxoSmithKline, which funded the trial and manufactures dutasteride, has resubmitted an application with the FDA to market the drug for the prevention of prostate cancer in men at increased risk. Dutasteride is already approved to treat men with benign prostatic hyperplasia, or BPH.

The international trial involved more than 6,700 men between ages 50 and 75 who, at enrollment, had a prostate-specific antigen (PSA) test score between 2.5 and 10 and a negative biopsy in the prior 6 months. Participants, the large majority of who were white, also received biopsies 2 and 4 years after enrollment. After 4 years of follow up, there was a nearly 23 percent reduction in the relative risk of prostate cancer in men who took dutasteride compared with those who took a placebo (659 cancers versus 858 cancers).

Side effects, including erectile dysfunction and decreased libido, were similar to those typically seen with dutasteride use. The only exception was an increased risk of cardiac failure, although it was rare: 30 cases were reported in men taking dutasteride (0.7 percent of men taking the drug) compared with 16 (0.4 percent) of men in the placebo arm. Cardiac failure was more likely in men who were taking both dutasteride and drugs known as alpha blockers, which are commonly used to treat high blood pressure, as well as BPH.

The reduction in prostate cancer risk was found mostly for men diagnosed with Gleason score 6 (intermediate grade prostate cancer) on biopsy. As was the case with finasteride in the PCPT trial, more high-grade cancers (Gleason scores 8–10) were detected among men who received dutasteride than men who received a placebo. This was likely due in part, the authors explained, to the drug’s ability to reduce the volume of the prostate, which in turn improves the ability to identify high-grade tumors in biopsy samples. They did not exclude the possibility, though, that the drug could be responsible for some high-grade tumors.

In an accompanying editorial, Dr. Patrick Walsh of Johns Hopkins University called it “somewhat disappointing” that dutasteride “was ineffective in reducing these high-grade tumors.” Based on the evidence from the REDUCE and PCPT trials, he also argued that neither of the drugs prevents prostate cancer, but “merely temporarily shrink tumors that have a low potential for being lethal,” because their effect seems to be relegated to tumors with Gleason scores in the 5 to 6 range.

“The ‘prevention’ versus ‘delay’ argument is a distinction without a difference,” noted Dr. Howard Parnes of NCI’s Division of Cancer Prevention. “We now have two independent, randomized clinical trials showing that 5-αRIs decrease a man’s risk of being diagnosed with prostate cancer.” The benefit of reducing the incidence of Gleason score (GS) 6 prostate cancer should not be discounted, Dr. Parnes continued. “These are the most common prostate cancers and more than 90 percent of men with GS 6 prostate cancer are treated with radical surgery or radiation, both of which are associated with substantial morbidity.”

The higher incidence of cardiac failure associated with dutasteride is not of significant concern, said Dr. Brantley Thrasher, chair of the Department of Urology at the University of Kansas Medical Center. “We’ve been using this class of drugs for a long time and rarely see these types of problems,” he said.

In February 2009, the American Society of Clinical Oncology and the American Urological Association issued guidelines on 5-αRIs for prostate cancer prevention. The guidelines suggested that healthy older men who are already taking a 5-αRI for BPH or are being regularly screened for prostate cancer should discuss the possible long-term use of the treatment for prostate cancer prevention with their doctors.

Dr. Thrasher is already having those discussions with his patients, he said, and a number of them who are at an increased risk for prostate cancer because of factors such as family history or elevated PSA are taking finasteride or dutasteride. FDA approval of dutasteride for a prevention indication, he believes, would prompt many clinicians and patients to use it for that purpose. “I think the average clinician would have confidence to speak with their patients about using [5-αRIs] for prevention.”

—Carmen Phillips

regards, taniafdi ^_^

PJK (Penyakit Jantung Koroner)

 PJK (Penyakit Jantung Koroner) merupakan penyebab berkurangnya kapasitas kerja penderita, meningkatnya biaya pelayanan kesehatan dan juga kematian premature. Kita ketahui juga aterosklerosis merupakan keadaan yang berjalan kronis dan umumnya tidak diketahui penderita sampai pada suatu saat terjadi bencana vaskuler. Dilain pihak, penglolaan faktor resiko yang baik telah terbukti menurunkan angka kejadian dan angka kematian akibat penyakit kardiovaskuler, terutama pada subjek dengan resiko tinggi. Guideline dari European Society of Cardiology menganjurkan “0 3 5 140 5 3 0” yang berarti :
 
0 : tanpa tembakau
3 : berjalan 3 km atau 30 menit
5 : 5 porsi sayur dan buah
140 : tekanan darah kurang dari 140 mmHg
5 : kadar kolestero total < 190 mg/dl
3 : kadar kolesterol LDL < 115 mg/dl
0 : tanpa overweight
Melalui anjuran di atas, untuk mencapai tujuan “tetap hidup sehat”, ESC menganjurkan :

-          Tidak merokok
-          Memilih makanan sehat
-          Aktivitas fisik sedang minimal dilakukan 30 menit
-          BMI < 25 kg/m2
-          Tekanan darah kurang dari 140/90mmHg
-          Kadar total kolesterol tidak lebih dari 190mg/dl dan LDL <115mg/dl
-          Kadar gula darah < 110 mg/dl

Kapan saatnya melakukan penentuan faktor resiko PJK

-          Penderita dengan usia menengah dan merokok
-          Obesitas terutama central obesity
-          Terdapat 1 atau lebih faktor resiko PJK konvensional
-          Terdapat faktor resiko PJK premature pada keluarga
-          Adanya gejala yang mengarah pada PJK.

Deteksi dini faktor resiko, khususnya dislipidemia serta penatalaksanaan yang baik akan menurunkan angka kejadian dan kematian. Statin merupakan obat pilihan dalam memperbaiki profil lipid dan diantara statin yang ada, rosuvastatin saat ini merupakan salah satu statin yang mempunyai performance yang baik dalam mencegah progresifitas aterosklerosis dan berperan dalam pencegahan primer penyakit kardiovaskuler.

regards, taniafdi ^_^

OAINS Fact's


Faktor resiko untuk kejadian gangguan saluran cerna akibat AINS adalah (Gabriel et al., 1991) :
-          Usia di atas 65 tahun
-          Comorbid
-          Penggunaan Glukokortikoid
-          Riwayat tukak peptic atau perdarahan saluran cerna
Faktor resiko terjadinya gangguan ginjal akibat penggunaan AINS adalah (Garella & Matarese, 1984) :
-          Usia diatas 65 tahun
-          Peninggian kadar serum kreatinin
-          Hipertensi
-          Payah jantung
-          Penggunaan ACE inhibitor
-          Penggunaan diuretic
Pengkajian meta-analisis sebelumnya oleh Pope dkk (1993) menunjukkan peninggian MAP (Mean Arterial Pressure) pada penderita hipertensi pasca pemberian berbagai jenis OAINS, penelitian ini mendapatkan bahwa OAINS diclofenac, sulindac dan ibuprofen tidak mempengaruhi tekanan darah penderita.
Menurut Scharf (1998) menunjukkan bahwa AINS dengan waktu paruh pendek (diclofenac) memberikan toksisitas saluran cerna yang rendah dibandingkan dengan AINS dengan waktu paruh lebih panjang (naproxen dan piroxicam).
Khasiat analgetika parasetamol akan makin meningkat bila ditambahkan OAINS diclofenac (Breivik dkk, 1999) atau ibuprofen (Pickering dkk, 2002).
Penggabungan kodein dengan diklofenac akan meningkatkan khasiat analgetik (Breivik dkk, 1999).
Sumber :
1. Gabriel SE, Jaakkimainen L, Bomberdier C. Risk for serious gastrointestinal complications related to the use of nonsteroidal anti-inflammatory drugs: a metaanalysis. Ann Intern Med 1991; 115: 787-96.
2.  Garella S, Matarese RA. Renal effects of prostaglandins and clinical adverse effects of nonsteroidal anti-inflammatory agents. Medicine (Baltimore) 1984; 63: 165-81.
3.  Pope JE, Anderson JJ, Felson DT. A meta-analysis of the effects of nonsteroidal anti-inflammatory drugs on blood pressure. Arch Intern Med. 1993; 153: 477-84.
4.   Scharf S, Kwiatek R, Ugoni A, Christophidis N. NSAIDs and faecal blood loss in elderly patients with osteoarthritis : is plasma half-life relevant? Aust N Z J Med 1998; 28(4):436-9.
5. Breivik K, Barkvoll P, Skovlund E. Combining diclofenac with acetaminophen or acetaminophen-codeine after oral surgery; a randomized, double blind single dose study. Clin Pharmacol Ther 1999; 66: 625-35.

regards, taniafdi ^_^

4/5/10

Adherence to Guidelines Varies in Treatment of Pediatric Asthma.

by Norra MacReady

March 15, 2010 (Anaheim, California) — Clinicians vary widely in their adherence to evidence-based guidelines for treating children with asthma, Angeline Ti reported in a poster session here at the American Medical Student Association 60th Annual Convention.

In some cases, following the guidelines had no impact on clinical outcomes, said Ms. Ti, a second-year student at the University of Michigan Medical School in Ann Arbor. For her study, Ms. Ti reviewed the records of 200 randomly selected children, aged 2 to 18 years, admitted to the University of Michigan Hospital System for asthma exacerbations from January 1, 2007 to June 30, 2009.

To evaluate quality of care, each case was examined for inpatient use of systemic corticosteroids, short-acting beta-agonists (SABAs), and asthma action plans. All of these are listed as quality measures for pediatric asthma treatment by Hospital Compare, which Ms. Ti defined as "a national dataset provided by Medicare for patients to compare the quality of patient care across hospitals." She hypothesized that adherence to these measures would be associated with better outcomes, defined as fewer revisits and readmissions.

Virtually all of the children (99%) received a SABA at some time during their hospital stay, and nearly as many (92.5%) received a systemic corticosteroid. However, only 46% of the patients were discharged with a written asthma action plan. Furthermore, 36% of the patients revisited their asthma clinician or the emergency department within 1 year of hospitalization for an acute asthma exacerbation, and 16% of the patients required readmission.

"Failure to receive a SABA or oral corticosteroids was perfectly associated with not being readmitted to the hospital," Ms. Ti reported in her poster. Keeping follow-up appointments with the child's primary asthma care provider significantly reduced their chances of revisits or readmission, whereas admission to the pediatric pulmonary care unit or intensive care unit increased the risk for subsequent readmission.

In addition to showing a wide variation in adherence to the guidelines, these findings suggest that better outcomes do not necessarily result when the guidelines are observed, Ms. Ti said. "This could be less a problem with the guidelines and more a problem with having good measurable outcomes," she told Medscape Med Students. She also pointed out that, as a chronic illness, asthma is managed largely by patients and their families themselves, so that "many of the outcomes depend less on what the doctor does and more on the home environment and what the patient does."

It is also possible that the few children who did not receive steroids were less seriously ill, said Henry Milgrom, MD, professor of pediatrics at National Jewish Health in Denver, Colorado. "There is no question that patients with asthma who receive steroids do better than those who don't. Most doctors would give steroids during and after hospital admission, so the kids who did not get them may not have had asthma at discharge."

The guidelines do have their flaws, although they are always being improved, said Dr. Milgrom, who was not involved in this study. Currently, the guidelines are too long and too difficult to wade through during a busy clinical consultation. They do not include management of important cases, such as patients with allergies, and they do not pay enough attention to conditions that can mimic or coexist with asthma. "But overall, people with asthma need steroids. There's nothing else that's better."

"Initially, I was disappointed" at the spotty adherence to the guidelines, Ms. Ti admitted. Ultimately, however, she realized that many other variables are involved. "There's a lot more that goes into how well a child can control their asthma than whether or not they receive a certain medication."

American Medical Student Association (AMSA) 60th Annual Convention: Abstract 25. Presented March 11, 2010.

Source :

regards, taniafdi ^_^

Preop chlorhexidine-alcohol more effective than povidone-iodine in preventing surgical-site infections.

Clinical Question:
Is preoperative skin cleansing with chlorhexidine-alcohol superior to cleansing with povidone-iodine in preventing surgical-site infections?

Bottom Line:
In patients undergoing clean-contaminated surgery, preoperative skin cleansing with chlorhexidine-alcohol is more effective than cleansing with povidone-iodine in reducing the rate of surgical-site infections. (LOE = 1b)

Reference:
Darouiche RO, Wall MJ Jr, Itani KM, et al. Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med 2010;362:18-26.

Study Design:
Randomized controlled trial (double-blinded)

Funding:
Industry

Allocation:
Concealed

Setting:
Inpatient (ward only)

Synopsis:
Chlorhexidine baths have been shown to reduce bloodstream infections in medical intensive care unit patients; however, a previous systematic review did not show a clear benefit of this treatment in reducing surgical-site infections. Using concealed allocation, these study authors randomized patients undergoing clean contaminated surgery -- either abdominal, thoracic, gynecologic, or urologic procedures -- to receive preoperative skin cleansing with 2% chlorhexidine gluconate plus 70% isopropyl alcohol (n = 409) or with 10% povidone-iodine (n = 440). All patients received preoperative systemic antibiotic prophylaxis. Only the operating surgeon was aware of the treatment assignment. Investigators followed up patients for 30 days after surgery for development of surgical-site infection. In both groups, patients had a mean age of 53 years, a mean duration of surgery of 3 hours, and similar underlying comorbidities. Analysis was by intention to treat. Patients in the chlorhexidine-alcohol group had a decreased rate of surgical-site infection compared with those in the povidone-iodine group (9.5% vs 16.1%; P = .004; relative risk = 0.59; 95% CI, 0.41-0.85). You would have to treat 15 patients with chlorhexidine-alcohol to prevent 1 additional surgical-site infection (number needed to treat = 15; 11-41). This treatment significantly reduced both superficial and deep incisional infections (superficial: 4.2% vs 8.6%; P = .008; deep: 1% vs 3%; P = .05), but not organ-space
infections. The per-protocol analysis, which excluded patients who had clean surgery instead of clean-contaminated surgery and those who did not complete 30-day follow-up, resulted in similar findings. Study-drug-related adverse events were minor and included pruritus and erythema at the surgical site. There was no difference in number of adverse events between the 2 groups.

PMID: 20054046
Delivered as Daily POEM: 2010-03-29

Copyright © 2010 by Wiley Subscription Services, Inc. All rights reserved. www.essentialevidenceplus.com.


regards, taniafdi ^_^

Corticosteroids possibly effective in decreasing pain from pharyngitis

Clinical Question:
Are corticosteroids effective in decreasing pain when used as an adjunct to antibiotics in patients with acute
pharyngitis?

 
Bottom Line:
If these authors have identified all the relevant data, corticosteroids are associated with a reduction in pain severity and duration when used as an adjunct to antibiotics in patients with pharyngitis. Since the included studies have the potential for bias in favor of steroids, and since none of the studies assessed steroids as monotherapy, the jury is still out as to whether the use of steroids should become common practice. (LOE = 1a-)

 
Reference:
Korb K, Scherer M, Chenot JF. Steroids as adjuvant therapy for acute pharyngitis in ambulatory patients: a systematic review. Ann Fam Med 2010;8(1):58-63.

 
Study Design:
Meta-analysis (randomized controlled trials)

 
Funding:
Unknown/not stated

 
Setting:
Outpatient (any)

 
Synopsis:

These authors searched several databases to find randomized trials of adjuvant corticosteroids in patients with acute pharyngitis. Two authors independently determined study eligibility and resolved disagreements by consensus. They don't describe searching for unpublished data. The authors assessed the quality of the studies but don't report if the assessment was independently made by 2 or more reviewers. They wound up with 8 trials, 7 of which occurred in emergency departments. Five trials studied 413 adults, and 3 studied 393 children. The studies of adults were fairly different in their design and conduct, so the authors appropriately decided not to pool the data. In all these studies, patients also received antibiotics and other treatments for pain. All the studies reported decreases in pain intensity or duration, and the average time to complete pain relief was approximately 24 hours. The studies of children were similarly heterogeneous and also allowed co-interventions. All the studies of children also found a reduction in pain. The data on subgroups of patients with confirmed streptococcal infection were inconsistent. A key threat to the validity of the individual studies is the lack of intention-to-treat analysis in all but one of the included trials. The lack of intention-to-treat analysis has been shown to introduce bias in favor of interventions (in this case, it may make the steroids look better than they really are). Additionally, the authors did not look for unpublished studies and do not formally assess the possibility of publication bias. Since negative studies are more likely to remain unpublished, this oversight also has the potential to make steroids look more effective.
 
PMID: 20065280
Delivered as Daily POEM: 2010-03-16

 
Copyright © 2010 by Wiley Subscription Services, Inc. All rights reserved. www.essentialevidenceplus.com.


regards, taniafdi ^_^

MTX associated with decreased CVD risk in patients with RA

Clinical Question:
Since patients with rheumatoid arthritis are at higher risk of developing cardiovascular disease than the general
population, does methotrexate modify this risk?

Bottom Line:
No high-quality studies exist that can definitively say that methotrexate (MTX) decreases cardiovascular disease (CVD) risk in patients with rheumatoid arthritis. Several studies have found an association, however, between MTX use and decreased risk. (LOE = 2a-)

Reference:
Westlake SL, Colebatch AN, Baird J, et al. The effect of methotrexate on cardiovascular disease in patients with rheumatoid arthritis: a systematic literature review. Rheumatology (Oxford) 2010;49(2):295-307.

Study Design:
Systematic review

Funding:
Industry

Setting:
Various (meta-analysis)

Synopsis:
These authors searched multiple databases, the reference lists of included articles, and conference proceedings for studies that evaluated the relationship between MTX and CVD in patients with rheumatoid arthritis. They also contacted authors about potential unpublished studies. They didn't restrict their search to randomized trials. Two reviewers independently determined which studies to include and assessed study quality. They found no randomized trials, 8 cohort studies, 6 case-control studies, and 4 cross-sectional studies. In other words, enough to evaluate associations and develop hypotheses, but not really enough to "prove" that MTX is the cause of the outcomes. Two cohort studies with more than 2100 patients (one with 6 years and one with 11 years of follow-up) evaluated the association between MTX and CVD mortality. In one study, MTX was associated with a reduced risk of deathfrom CVD; there was no significant association in the other. Five studies -- 3 cohort studies, 1 case-control study and 1 cross-sectional study -- evaluated all CVD events (symptoms, myocardial infarction, procedures, and so forth). All but one found an association between MTX use and a lower risk of CVD. Several studies assessed other outcomes -- myocardial infarction, congestive heart failure, lipids, hypertension, and so forth -- with no firm conclusions.

PMID: 19946022
Delivered as Daily POEM: 2010-03-12

Copyright © 2010 by Wiley Subscription Services, Inc. All rights reserved. www.essentialevidenceplus.com.

regards, taniafdi ^_^

Journal of The Day 4



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4/15/10

Antipsychotic use in elderly patients linked to pneumonia

NEW YORK (Reuters Health) - Elderly patients who use antipsychotic agents are at increased risk for community-acquired pneumonia, a report from The Netherlands indicates. Moreover, as the drug dosage increases, so does the risk of pneumonia.

"Clinicians who start treatment with both atypical and typical antipsychotic drugs should closely monitor patients, particularly at the start of therapy and if high doses are given, with respect to the risk for community-acquired pneumonia," lead author Dr. Gianluca Trifiro, from Erasmus University Medical Center, Rotterdam, and colleagues advise.

Exactly how antipsychotics may promote pneumonia is unclear, the report indicates, but their antihistaminergic, extrapyramidal, and anticholinergic actions could promote aspiration pneumonia through effects on swallowing and mouth dryness.

For their study, reported in the Annals of Internal Medicine for April 5, the authors gathered data from the Dutch Integrated Primary Care Information database from 1996 to 2006. They compared 258 antipsychotic drug users with incident pneumonia (age 65 years or older) to 1686 control subjects matched by age, gender, and date of onset.

Current use of typical and atypical antipsychotics increased the odds of community-acquired pneumonia in a dose-dependent fashion (adjusted OR, 1.76 and 2.61, respectively). Further analysis showed that only use of atypical antipsychotics increased the risk of fatal pneumonia (adjusted OR, 5.97).

The risk of pneumonia was greater for agents with higher H1-histaminergic receptor affinity, according to the paper.

"In light of the potential role of the antihistaminergic effect in the antipsychotic-induced pneumonia and the differential receptor-binding profile of antipsychotic drugs, larger population-based studies should better evaluate the comparative risk for community-acquired pneumonia for individual atypical and typical antipsychotic drugs," the authors conclude.

A similar report from The Netherlands, published 2 years ago, used national pharmacy data from 1986 to 2003 to evaluate the risk of pneumonia in elderly users of antipsychotics (see Reuters Health story, April 25, 2008). In that study, the risk of pneumonia nearly quintupled during the first 7 days of antipsychotic use but then declined over the next few weeks. Those authors too cited aspiration as an important etiology in their elderly subjects, and they advised physicians to evaluate patients' ability to swallow before prescribing antipsychotics.

Reference:
Ann Intern Med 2010;152:418-425.

http://www.thedoctorschannel.com/go/reuters/3114.html
regards, taniafdi ^_^

Pacemaker upgrade improves systolic function

NEW YORK (Reuters Health) - Upgrading traditional 2 chamber cardiac pacemakers to modern 3 chamber pacemakers -- cardiac resynchronization therapy (CRT) devices -- improves left ventricular ejection fraction (LVEF), researchers reported online March 16th in the European Heart Journal.

Chronic right ventricular (RV) pacing with the older devices produces ventricular dyssynchrony, leading to LV remodeling and associated morbidity and mortality, the researchers note.

"The important clinical finding in our study is that even after a long period (up to 8 years) of 2 chamber pacing and subsequently very reduced LVEF, upgrading to CRT can improve systolic heart function," senior author Dr. Johannes Holzmeister told Reuters Health by email.

Dr. Holzmeister of University Hospital Zurich and colleagues studied 102 patients after primary CRT implantation and 70 after a CRT upgrade.

After a mean follow-up of close to 2 years, the researchers saw significant absolute increases in LVEF of 10% in the primary group and 11% improvement in the upgrade group.

Both sets of patients had significant and similar reductions in LV end-systolic diameter and diameter index. The response to CRT upgrade was independent of the underlying rhythm, QRS duration, duration of prior RV pacing, or LV function and size at baseline.

Moreover, 7 of 9 patients with older devices in place for more than 12 years responded favorably to CRT.

"In other words," concluded Dr. Holzmeister, this means "that a pacing induced cardiomyopathy is reversible even at a late stage."

Reference:
Eur Heart J 2010. 


regards, taniafdi ^_^

Ultrasound useful in infants with first urinary tract infection

NEW YORK (Reuters Health) - Ultrasound can be useful in the work-up of infants with a first urinary tract infection, researchers from Sweden report in the May issue of The Journal of Urology.

The most appropriate way to evaluate infants with a first urinary tract infection - ultrasonography, or voiding cystourethrography, or renal scanning with dimercaptosuccinic acid (DMSA), or some combination of those - has been controversial, according to senior author Dr. Sverker Hansson and colleagues from the University of Gothenburg.

To learn more about the role of ultrasound, the investigators obtained scans in 290 infants (161 males) with a first urinary tract infection. Along with ultrasonography, the babies underwent DMSA scintigraphy during the initial evaluation, followed within 2 months by cystourethrography.

One hundred twenty infants (41%) had 183 abnormal findings on ultrasound, including important structural abnormalities in 21 boys and 19 girls.

Ultrasound identified 17 of 27 children with dilating vesicoureteral reflux (grades III to V), but only 5 of 13 children with grade III reflux. Overall, ultrasound was 63% sensitive and 61% specific in identifying vesicoureteral reflux.

Abnormality on ultrasound was significantly associated with the presence and severity of abnormality on DMSA scan, with ultrasound showing 48% sensitivity and 66% specificity in detecting DMSA abnormalities.

The length of the longer kidney on ultrasound (expressed as the standard deviation) was directly related to the presence of inflammatory parameters such as body temperature and C-reactive protein level, and to the presence of DMSA scan abnormalities. For instance, among babies with the longest kidney length in the reference range, 22% had DMSA scan findings, compared to 67% of babies whose longest kidney was more than 2 standard deviations above the norm.

Outside the study, an additional 28 infants were diagnosed with dilatation on ultrasound prenatally (15 infants) and postnatally (13 infants).

Since it is nonvasive, ultrasonography is "an attractive alternative or complement to DMSA scan" for first line imaging in infants with urinary tract infection, "especially in the absence of prenatal ultrasound during late pregnancy," the researchers conclude.

Reference:
J Urol 2010;183:1984-1988
http://www.thedoctorschannel.com/video/3130.html

regards, taniafdi ^_^

4/13/10

Warfarin plus antibiotic can cause stomach bleed: study.

The Canadian Press
Date: Tuesday Apr. 13, 2010 8:53 AM ET

TORONTO — Researchers say people taking the blood-thinning drug warfarin should avoid a popular antibiotic that's often used to treat urinary tract infections. A study by the Institute for Clinical Evaluative Sciences found that warfarin can be dangerous when combined with the antibiotic cotrimoxazole, sold under such brand names as Bactrim and Septra. Principal investigator Hadas Fischer says some antibiotics boost the risk of bleeding in patients prescribed warfarin to prevent blood clots that could cause a heart attack or stroke. 

The study found patients on warfarin who were prescribed cotrimoxazole had an almost four-fold greater risk of an upper-gastrointestinal hemorrhage compared to those not given the antibiotic. The researchers say the risk of bleeding is considerably higher than that from other antibiotics. Fischer says that in rare instances when the two drugs must be used together, doctors should monitor patients very closely. 

Urinary-tract infections are extremely common among the elderly and often are treated with antibiotics that have a significant potential for interacting with warfarin, sold under brand names such as Coumadin. About 34 per cent of the 135,000 patients in the 10-year study, all of whom were taking warfarin, had at least one prescription for antibiotics to treat a urinary-tract infection. Seven per cent received at least one prescription for cotrimoxazole. 

Overall, more than 2,000 patients taking warfarin were hospitalized with gastrointestinal bleeding. "This is a completely avoidable problem," says co-author Dr. David Juurlink, a scientist at ICES. "Whenever possible, clinicians should prescribe alternative antibiotics to cotrimoxazole in patients receiving warfarin."

source :
http://www.ctv.ca/servlet/ArticleNews/story/CTVNews/20100413/warafarin_100413/20100413?hub=Health&s_name=

regards, taniafdi ^_^

4/12/10

Cases and Answer

A 10 year old boy presented with generalized swelling. This had been present for 4 days and included swollen ankles and puffiness of the face. It started a few days after a mild cold with a runny nose. His only past medical history was of mild eczema. On examination, there were no abnormalities apart from the swelling, which included pitting edema around both ankles.

Urinalysis showed protein +++ and 24-h urine collection contained 10 g protein/24h (10.000 mg/24h). His serum creatinine was normal at 60umol/L (0,7 mg/dL), but his serum albumin was low at 20 g/L (2.0 g/dL).

- What clinical syndrome does he have?
- What is the prbable pathological diagnosis ?
- What is the usual treatment ?

Answer :

1. This boy has nephrotic syndrome with heavy proteinuria (>3,5 g/24h), hypoalbuminemia, and peripheral edema causing the swelling.
2. In children, the most common cause of the nephrotic syndrome is minimal change nephropathy. This typically follows an upper respiratory infection and is more common in children with atopy (allergic, eczema, asthma, and hay fever).
3. Minimal change nephropathy responds well to steroids. Proteinuria usually resolves completely and does not leave permanent renal damage. If the disease does relapse, ciclosporin is sometimes used to prevent further relapse.

Source : The Renal System at a Glance, 3rd edition, Chris O'Callaghan, Willey-Blackwell.

regards, taniafdi ^_^

Therapy of Diabetes

1. Metformin is recommended first line for most type 2 patients.

2. Sulphonylureas have a more immediate effect at reducing blood glucose levels in symptomatic patients and   may also be first choice for insulin-deficient individuals.

3. Sulphonylureas, glitazones and insulin may all cause weigth gain and obesity is often already a problem.

4. Sulphonylureas may put the patient at risk of hypoglicemia with implications for driving. 

5. There appears to be increased risk of distal fractures in women using glitazones.

6. Glitazones may cause fluid retention, exacerbating or precipitating heart failure.

7. Exenatide may assist with weight reduction.

8. Sitaglipin is licensed for triple therapy (with metformin and a sulphonylurea) but vildagliptin is currently only licensed for use in combination with one of these other agents.

9. Failure of the HbA1c to respond to exenatide of a gliptin after an appropriate interval requires withdrawal of the drug.


regards, taniafdi ^_^

Botox in Urology


Pertama kali saya mengetahui tentang penggunaan botox untuk urologi adalah dari dr. Leticia de Kort. Beliau adalah salah satu urologis wanita dari Rumah Sakit Pendidikan Utrecht (UMC). Cukup kaget juga, karena yang saya tahu waktu itu, bahwa pemakaian botox sering digunakan pada bedah plastik..

Menurut dr. De Kort, pemakaian botox sering pada pasien-pasien Overreactive Bladder. Dosis yang diberikan bisa 200-300 unit untuk sekali pemakaian. Beliau juga mengaku, bahwa pemakaian botox memang relatif baru. Botox disuntikkan dengan bantuan sitoskopi ke seluruh otot vesika urinaria secara random. Suntikkan diusahakan untuk menjauhi daerah otot spinchter. Menurut beliau, jika disuntikkan pada daerah tersebut, ditakutkan berujung pada retensi urine. 

Dr. De Kort berpendapat bahwa pemakaian botox cukup efektif pada pasien over reactive bladder dan sangat membantu. Biasanya pemberian suntikan akan diulangi beberapa kali dengan jeda lebih kurang 6 bulan.

Operasi yang saya ikuti ini cukup menambah pengalaman dan pengetahuan. Beliau sangat informatif kepada saya. It's really cool... 

regards, taniafdi ^_^

Topical menthol 10% solution (peppermint oil) may abort acute migraine.

Clinical Question:

Is topical menthol 10% solution effective as an abortive treatment of acute migraine headache in adults?

Bottom Line:

Topical menthol 10% solution applied as described below may be more effective than placebo solution in alleviating acute migraine headache pain in adults.?Topical menthol 10% solution applied as described below may be more effective than placebo solution?? There?s a typo in Table 2 ? the n for migraine attacks in the placebo group should be 58, not 8. (LOE = 2b)

Reference:

Study Design:

Cross-over trial (randomized)

Funding:

Foundation

Setting:

Outpatient (specialty)

Allocation:

Concealed

Synopsis:

These investigators identified 44 adults, aged 18 to 65 years, who met standard international criteria for migraine headache and had at least a 1-year history of migraines and 1 to 6 migraine attacks per month. Eligible patients randomly received (concealed allocation assignment) either menthol for the first 2 of 4 migraine atttacks followed by placebo for the second 2 attacks, or the same treatment in the opposite order. Patients and all investigators who assessed outcomes remained masked to treatment order. Active study medication was prepared as a 10% solution of menthol crystals in ethanol. A solution of 0.5% ethanol menthol solution with the same color and odor served as the placebo. At the onset of a migraine, patients intitially cleansed the forehead and temporal area of the most painful side of the head with tap water. After drying, 1 mL of active drug or placebo was applied with a sponge on a surface area of 5 cm x 5 cm. The same treatment was reapplied after 30 minutes. Participants were allowed to take rescue medication if needed after 2 hours. Follow-up occurred for 79% of patients for 4 migraine attacks. Patients reported no pain at 2 hours after attacks significantly more often when treated with menthol 10% than when treated with placebo (38.3% vs 12.1%; number needed to treat [NNT] = 4; 95% CI, 2.5-9.4). Similarly, patients reported a greater than 50% decrease in pain scores compared with baseline significantly more often when treated with menthol 10% than with placebo (58.3% vs 17.2%; NNT = 2.4; 2-4). No recurrence of headache at 24 hours also occurred signifcantly more often in patients when using menthol 10% than when using placebo (33.3% vs 12.1%; NNT = 5; 3-17). Two patients (5.7%) dropped out of the trial because of a severe burning sensation on the temporal area and an aggravation of headache. 

Copyright © 2010 by Wiley Subscription Services, Inc. All rights reserved.

regards, taniafdi ^_^

Journal of The Day 5



A Step Forward in the Treatment of Advanced Biliary Tract Cancer.

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Dutasteride Decreases Prostate Cancer Risk

Results from a large, randomized clinical trial indicate that men at an increased risk for prostate cancer reduced their risk with regular use of the drug dutasteride (Avodart). The results came from the REDUCE trial, which is the second largest clinical trial to demonstrate a decreased risk of prostate cancer in men taking an agent from the class of drugs known as 5-α reductase inhibitors (5-αRIs). Previously, the Prostate Cancer Prevention Trial (PCPT) showed that the drug finasteride had a risk reduction similar to what has now been seen in REDUCE.

Findings from this trial suggest “that the major effect of dutasteride is the shrinkage of prostate tumors or inhibition of their growth,” wrote the study’s lead investigator Dr. Gerald Andriole, of the Washington University School of Medicine in St. Louis, and his colleagues in the April 1 New England Journal of Medicine. GlaxoSmithKline, which funded the trial and manufactures dutasteride, has resubmitted an application with the FDA to market the drug for the prevention of prostate cancer in men at increased risk. Dutasteride is already approved to treat men with benign prostatic hyperplasia, or BPH.

The international trial involved more than 6,700 men between ages 50 and 75 who, at enrollment, had a prostate-specific antigen (PSA) test score between 2.5 and 10 and a negative biopsy in the prior 6 months. Participants, the large majority of who were white, also received biopsies 2 and 4 years after enrollment. After 4 years of follow up, there was a nearly 23 percent reduction in the relative risk of prostate cancer in men who took dutasteride compared with those who took a placebo (659 cancers versus 858 cancers).

Side effects, including erectile dysfunction and decreased libido, were similar to those typically seen with dutasteride use. The only exception was an increased risk of cardiac failure, although it was rare: 30 cases were reported in men taking dutasteride (0.7 percent of men taking the drug) compared with 16 (0.4 percent) of men in the placebo arm. Cardiac failure was more likely in men who were taking both dutasteride and drugs known as alpha blockers, which are commonly used to treat high blood pressure, as well as BPH.

The reduction in prostate cancer risk was found mostly for men diagnosed with Gleason score 6 (intermediate grade prostate cancer) on biopsy. As was the case with finasteride in the PCPT trial, more high-grade cancers (Gleason scores 8–10) were detected among men who received dutasteride than men who received a placebo. This was likely due in part, the authors explained, to the drug’s ability to reduce the volume of the prostate, which in turn improves the ability to identify high-grade tumors in biopsy samples. They did not exclude the possibility, though, that the drug could be responsible for some high-grade tumors.

In an accompanying editorial, Dr. Patrick Walsh of Johns Hopkins University called it “somewhat disappointing” that dutasteride “was ineffective in reducing these high-grade tumors.” Based on the evidence from the REDUCE and PCPT trials, he also argued that neither of the drugs prevents prostate cancer, but “merely temporarily shrink tumors that have a low potential for being lethal,” because their effect seems to be relegated to tumors with Gleason scores in the 5 to 6 range.

“The ‘prevention’ versus ‘delay’ argument is a distinction without a difference,” noted Dr. Howard Parnes of NCI’s Division of Cancer Prevention. “We now have two independent, randomized clinical trials showing that 5-αRIs decrease a man’s risk of being diagnosed with prostate cancer.” The benefit of reducing the incidence of Gleason score (GS) 6 prostate cancer should not be discounted, Dr. Parnes continued. “These are the most common prostate cancers and more than 90 percent of men with GS 6 prostate cancer are treated with radical surgery or radiation, both of which are associated with substantial morbidity.”

The higher incidence of cardiac failure associated with dutasteride is not of significant concern, said Dr. Brantley Thrasher, chair of the Department of Urology at the University of Kansas Medical Center. “We’ve been using this class of drugs for a long time and rarely see these types of problems,” he said.

In February 2009, the American Society of Clinical Oncology and the American Urological Association issued guidelines on 5-αRIs for prostate cancer prevention. The guidelines suggested that healthy older men who are already taking a 5-αRI for BPH or are being regularly screened for prostate cancer should discuss the possible long-term use of the treatment for prostate cancer prevention with their doctors.

Dr. Thrasher is already having those discussions with his patients, he said, and a number of them who are at an increased risk for prostate cancer because of factors such as family history or elevated PSA are taking finasteride or dutasteride. FDA approval of dutasteride for a prevention indication, he believes, would prompt many clinicians and patients to use it for that purpose. “I think the average clinician would have confidence to speak with their patients about using [5-αRIs] for prevention.”

—Carmen Phillips

regards, taniafdi ^_^

PJK (Penyakit Jantung Koroner)

 PJK (Penyakit Jantung Koroner) merupakan penyebab berkurangnya kapasitas kerja penderita, meningkatnya biaya pelayanan kesehatan dan juga kematian premature. Kita ketahui juga aterosklerosis merupakan keadaan yang berjalan kronis dan umumnya tidak diketahui penderita sampai pada suatu saat terjadi bencana vaskuler. Dilain pihak, penglolaan faktor resiko yang baik telah terbukti menurunkan angka kejadian dan angka kematian akibat penyakit kardiovaskuler, terutama pada subjek dengan resiko tinggi. Guideline dari European Society of Cardiology menganjurkan “0 3 5 140 5 3 0” yang berarti :
 
0 : tanpa tembakau
3 : berjalan 3 km atau 30 menit
5 : 5 porsi sayur dan buah
140 : tekanan darah kurang dari 140 mmHg
5 : kadar kolestero total < 190 mg/dl
3 : kadar kolesterol LDL < 115 mg/dl
0 : tanpa overweight
Melalui anjuran di atas, untuk mencapai tujuan “tetap hidup sehat”, ESC menganjurkan :

-          Tidak merokok
-          Memilih makanan sehat
-          Aktivitas fisik sedang minimal dilakukan 30 menit
-          BMI < 25 kg/m2
-          Tekanan darah kurang dari 140/90mmHg
-          Kadar total kolesterol tidak lebih dari 190mg/dl dan LDL <115mg/dl
-          Kadar gula darah < 110 mg/dl

Kapan saatnya melakukan penentuan faktor resiko PJK

-          Penderita dengan usia menengah dan merokok
-          Obesitas terutama central obesity
-          Terdapat 1 atau lebih faktor resiko PJK konvensional
-          Terdapat faktor resiko PJK premature pada keluarga
-          Adanya gejala yang mengarah pada PJK.

Deteksi dini faktor resiko, khususnya dislipidemia serta penatalaksanaan yang baik akan menurunkan angka kejadian dan kematian. Statin merupakan obat pilihan dalam memperbaiki profil lipid dan diantara statin yang ada, rosuvastatin saat ini merupakan salah satu statin yang mempunyai performance yang baik dalam mencegah progresifitas aterosklerosis dan berperan dalam pencegahan primer penyakit kardiovaskuler.

regards, taniafdi ^_^

OAINS Fact's


Faktor resiko untuk kejadian gangguan saluran cerna akibat AINS adalah (Gabriel et al., 1991) :
-          Usia di atas 65 tahun
-          Comorbid
-          Penggunaan Glukokortikoid
-          Riwayat tukak peptic atau perdarahan saluran cerna
Faktor resiko terjadinya gangguan ginjal akibat penggunaan AINS adalah (Garella & Matarese, 1984) :
-          Usia diatas 65 tahun
-          Peninggian kadar serum kreatinin
-          Hipertensi
-          Payah jantung
-          Penggunaan ACE inhibitor
-          Penggunaan diuretic
Pengkajian meta-analisis sebelumnya oleh Pope dkk (1993) menunjukkan peninggian MAP (Mean Arterial Pressure) pada penderita hipertensi pasca pemberian berbagai jenis OAINS, penelitian ini mendapatkan bahwa OAINS diclofenac, sulindac dan ibuprofen tidak mempengaruhi tekanan darah penderita.
Menurut Scharf (1998) menunjukkan bahwa AINS dengan waktu paruh pendek (diclofenac) memberikan toksisitas saluran cerna yang rendah dibandingkan dengan AINS dengan waktu paruh lebih panjang (naproxen dan piroxicam).
Khasiat analgetika parasetamol akan makin meningkat bila ditambahkan OAINS diclofenac (Breivik dkk, 1999) atau ibuprofen (Pickering dkk, 2002).
Penggabungan kodein dengan diklofenac akan meningkatkan khasiat analgetik (Breivik dkk, 1999).
Sumber :
1. Gabriel SE, Jaakkimainen L, Bomberdier C. Risk for serious gastrointestinal complications related to the use of nonsteroidal anti-inflammatory drugs: a metaanalysis. Ann Intern Med 1991; 115: 787-96.
2.  Garella S, Matarese RA. Renal effects of prostaglandins and clinical adverse effects of nonsteroidal anti-inflammatory agents. Medicine (Baltimore) 1984; 63: 165-81.
3.  Pope JE, Anderson JJ, Felson DT. A meta-analysis of the effects of nonsteroidal anti-inflammatory drugs on blood pressure. Arch Intern Med. 1993; 153: 477-84.
4.   Scharf S, Kwiatek R, Ugoni A, Christophidis N. NSAIDs and faecal blood loss in elderly patients with osteoarthritis : is plasma half-life relevant? Aust N Z J Med 1998; 28(4):436-9.
5. Breivik K, Barkvoll P, Skovlund E. Combining diclofenac with acetaminophen or acetaminophen-codeine after oral surgery; a randomized, double blind single dose study. Clin Pharmacol Ther 1999; 66: 625-35.

regards, taniafdi ^_^

4/5/10

Adherence to Guidelines Varies in Treatment of Pediatric Asthma.

by Norra MacReady

March 15, 2010 (Anaheim, California) — Clinicians vary widely in their adherence to evidence-based guidelines for treating children with asthma, Angeline Ti reported in a poster session here at the American Medical Student Association 60th Annual Convention.

In some cases, following the guidelines had no impact on clinical outcomes, said Ms. Ti, a second-year student at the University of Michigan Medical School in Ann Arbor. For her study, Ms. Ti reviewed the records of 200 randomly selected children, aged 2 to 18 years, admitted to the University of Michigan Hospital System for asthma exacerbations from January 1, 2007 to June 30, 2009.

To evaluate quality of care, each case was examined for inpatient use of systemic corticosteroids, short-acting beta-agonists (SABAs), and asthma action plans. All of these are listed as quality measures for pediatric asthma treatment by Hospital Compare, which Ms. Ti defined as "a national dataset provided by Medicare for patients to compare the quality of patient care across hospitals." She hypothesized that adherence to these measures would be associated with better outcomes, defined as fewer revisits and readmissions.

Virtually all of the children (99%) received a SABA at some time during their hospital stay, and nearly as many (92.5%) received a systemic corticosteroid. However, only 46% of the patients were discharged with a written asthma action plan. Furthermore, 36% of the patients revisited their asthma clinician or the emergency department within 1 year of hospitalization for an acute asthma exacerbation, and 16% of the patients required readmission.

"Failure to receive a SABA or oral corticosteroids was perfectly associated with not being readmitted to the hospital," Ms. Ti reported in her poster. Keeping follow-up appointments with the child's primary asthma care provider significantly reduced their chances of revisits or readmission, whereas admission to the pediatric pulmonary care unit or intensive care unit increased the risk for subsequent readmission.

In addition to showing a wide variation in adherence to the guidelines, these findings suggest that better outcomes do not necessarily result when the guidelines are observed, Ms. Ti said. "This could be less a problem with the guidelines and more a problem with having good measurable outcomes," she told Medscape Med Students. She also pointed out that, as a chronic illness, asthma is managed largely by patients and their families themselves, so that "many of the outcomes depend less on what the doctor does and more on the home environment and what the patient does."

It is also possible that the few children who did not receive steroids were less seriously ill, said Henry Milgrom, MD, professor of pediatrics at National Jewish Health in Denver, Colorado. "There is no question that patients with asthma who receive steroids do better than those who don't. Most doctors would give steroids during and after hospital admission, so the kids who did not get them may not have had asthma at discharge."

The guidelines do have their flaws, although they are always being improved, said Dr. Milgrom, who was not involved in this study. Currently, the guidelines are too long and too difficult to wade through during a busy clinical consultation. They do not include management of important cases, such as patients with allergies, and they do not pay enough attention to conditions that can mimic or coexist with asthma. "But overall, people with asthma need steroids. There's nothing else that's better."

"Initially, I was disappointed" at the spotty adherence to the guidelines, Ms. Ti admitted. Ultimately, however, she realized that many other variables are involved. "There's a lot more that goes into how well a child can control their asthma than whether or not they receive a certain medication."

American Medical Student Association (AMSA) 60th Annual Convention: Abstract 25. Presented March 11, 2010.

Source :

regards, taniafdi ^_^

Preop chlorhexidine-alcohol more effective than povidone-iodine in preventing surgical-site infections.

Clinical Question:
Is preoperative skin cleansing with chlorhexidine-alcohol superior to cleansing with povidone-iodine in preventing surgical-site infections?

Bottom Line:
In patients undergoing clean-contaminated surgery, preoperative skin cleansing with chlorhexidine-alcohol is more effective than cleansing with povidone-iodine in reducing the rate of surgical-site infections. (LOE = 1b)

Reference:
Darouiche RO, Wall MJ Jr, Itani KM, et al. Chlorhexidine-alcohol versus povidone-iodine for surgical-site antisepsis. N Engl J Med 2010;362:18-26.

Study Design:
Randomized controlled trial (double-blinded)

Funding:
Industry

Allocation:
Concealed

Setting:
Inpatient (ward only)

Synopsis:
Chlorhexidine baths have been shown to reduce bloodstream infections in medical intensive care unit patients; however, a previous systematic review did not show a clear benefit of this treatment in reducing surgical-site infections. Using concealed allocation, these study authors randomized patients undergoing clean contaminated surgery -- either abdominal, thoracic, gynecologic, or urologic procedures -- to receive preoperative skin cleansing with 2% chlorhexidine gluconate plus 70% isopropyl alcohol (n = 409) or with 10% povidone-iodine (n = 440). All patients received preoperative systemic antibiotic prophylaxis. Only the operating surgeon was aware of the treatment assignment. Investigators followed up patients for 30 days after surgery for development of surgical-site infection. In both groups, patients had a mean age of 53 years, a mean duration of surgery of 3 hours, and similar underlying comorbidities. Analysis was by intention to treat. Patients in the chlorhexidine-alcohol group had a decreased rate of surgical-site infection compared with those in the povidone-iodine group (9.5% vs 16.1%; P = .004; relative risk = 0.59; 95% CI, 0.41-0.85). You would have to treat 15 patients with chlorhexidine-alcohol to prevent 1 additional surgical-site infection (number needed to treat = 15; 11-41). This treatment significantly reduced both superficial and deep incisional infections (superficial: 4.2% vs 8.6%; P = .008; deep: 1% vs 3%; P = .05), but not organ-space
infections. The per-protocol analysis, which excluded patients who had clean surgery instead of clean-contaminated surgery and those who did not complete 30-day follow-up, resulted in similar findings. Study-drug-related adverse events were minor and included pruritus and erythema at the surgical site. There was no difference in number of adverse events between the 2 groups.

PMID: 20054046
Delivered as Daily POEM: 2010-03-29

Copyright © 2010 by Wiley Subscription Services, Inc. All rights reserved. www.essentialevidenceplus.com.


regards, taniafdi ^_^

Corticosteroids possibly effective in decreasing pain from pharyngitis

Clinical Question:
Are corticosteroids effective in decreasing pain when used as an adjunct to antibiotics in patients with acute
pharyngitis?

 
Bottom Line:
If these authors have identified all the relevant data, corticosteroids are associated with a reduction in pain severity and duration when used as an adjunct to antibiotics in patients with pharyngitis. Since the included studies have the potential for bias in favor of steroids, and since none of the studies assessed steroids as monotherapy, the jury is still out as to whether the use of steroids should become common practice. (LOE = 1a-)

 
Reference:
Korb K, Scherer M, Chenot JF. Steroids as adjuvant therapy for acute pharyngitis in ambulatory patients: a systematic review. Ann Fam Med 2010;8(1):58-63.

 
Study Design:
Meta-analysis (randomized controlled trials)

 
Funding:
Unknown/not stated

 
Setting:
Outpatient (any)

 
Synopsis:

These authors searched several databases to find randomized trials of adjuvant corticosteroids in patients with acute pharyngitis. Two authors independently determined study eligibility and resolved disagreements by consensus. They don't describe searching for unpublished data. The authors assessed the quality of the studies but don't report if the assessment was independently made by 2 or more reviewers. They wound up with 8 trials, 7 of which occurred in emergency departments. Five trials studied 413 adults, and 3 studied 393 children. The studies of adults were fairly different in their design and conduct, so the authors appropriately decided not to pool the data. In all these studies, patients also received antibiotics and other treatments for pain. All the studies reported decreases in pain intensity or duration, and the average time to complete pain relief was approximately 24 hours. The studies of children were similarly heterogeneous and also allowed co-interventions. All the studies of children also found a reduction in pain. The data on subgroups of patients with confirmed streptococcal infection were inconsistent. A key threat to the validity of the individual studies is the lack of intention-to-treat analysis in all but one of the included trials. The lack of intention-to-treat analysis has been shown to introduce bias in favor of interventions (in this case, it may make the steroids look better than they really are). Additionally, the authors did not look for unpublished studies and do not formally assess the possibility of publication bias. Since negative studies are more likely to remain unpublished, this oversight also has the potential to make steroids look more effective.
 
PMID: 20065280
Delivered as Daily POEM: 2010-03-16

 
Copyright © 2010 by Wiley Subscription Services, Inc. All rights reserved. www.essentialevidenceplus.com.


regards, taniafdi ^_^

MTX associated with decreased CVD risk in patients with RA

Clinical Question:
Since patients with rheumatoid arthritis are at higher risk of developing cardiovascular disease than the general
population, does methotrexate modify this risk?

Bottom Line:
No high-quality studies exist that can definitively say that methotrexate (MTX) decreases cardiovascular disease (CVD) risk in patients with rheumatoid arthritis. Several studies have found an association, however, between MTX use and decreased risk. (LOE = 2a-)

Reference:
Westlake SL, Colebatch AN, Baird J, et al. The effect of methotrexate on cardiovascular disease in patients with rheumatoid arthritis: a systematic literature review. Rheumatology (Oxford) 2010;49(2):295-307.

Study Design:
Systematic review

Funding:
Industry

Setting:
Various (meta-analysis)

Synopsis:
These authors searched multiple databases, the reference lists of included articles, and conference proceedings for studies that evaluated the relationship between MTX and CVD in patients with rheumatoid arthritis. They also contacted authors about potential unpublished studies. They didn't restrict their search to randomized trials. Two reviewers independently determined which studies to include and assessed study quality. They found no randomized trials, 8 cohort studies, 6 case-control studies, and 4 cross-sectional studies. In other words, enough to evaluate associations and develop hypotheses, but not really enough to "prove" that MTX is the cause of the outcomes. Two cohort studies with more than 2100 patients (one with 6 years and one with 11 years of follow-up) evaluated the association between MTX and CVD mortality. In one study, MTX was associated with a reduced risk of deathfrom CVD; there was no significant association in the other. Five studies -- 3 cohort studies, 1 case-control study and 1 cross-sectional study -- evaluated all CVD events (symptoms, myocardial infarction, procedures, and so forth). All but one found an association between MTX use and a lower risk of CVD. Several studies assessed other outcomes -- myocardial infarction, congestive heart failure, lipids, hypertension, and so forth -- with no firm conclusions.

PMID: 19946022
Delivered as Daily POEM: 2010-03-12

Copyright © 2010 by Wiley Subscription Services, Inc. All rights reserved. www.essentialevidenceplus.com.

regards, taniafdi ^_^

Journal of The Day 4



regards, taniafdi ^_^