Archive for the '[Medicine&Pharma]' category

Will finding sex partners online make you sick?

Jul 01 2011 Published by under [Medicine&Pharma], Medicine

Today seemed like a good day for a repost.  This piece gets lots of hits, albeit probably not what the searcher was hoping for.  --PalMD

To people who grew up before the internet, the debate about whether Craigslist should be allowed to post “erotic services” must seem bizarre. But meeting people online, whether for romance, friendship, collegiality, or anonymous sex is becoming not only common, but has lost its novelty. This isn’t going anywhere. The most compelling argument I’ve heard for asking Craigslist to abandon its lucrative paid sex ads is that it helps perpetuate an oppressive and violent sex trade, one that essentially enslaves women and turns them into chattel for the profit of others. That’s pretty damned compelling.

But should those of us who care about public health focus only on the "sex work” section of online bulletin boards? People meeting not only for romance but also for consensual, sometimes anonymous sex has become increasingly common. Like the bath houses of the 1970s, could online sex encounters possibly encourage the risk of sexually transmitted infections?

Data from before the late 1990s are hard to find, since broadband internet services were not widely available. In 2000, a study of a small syphilis outbreak among men who have sex with men (MSM) found that the men who had syphilis were much more likely to have met partners in an online chat room than men without syphilis. This made notification of contacts (for control of the outbreak) more difficult. Of note, when public health authorities launched an informational campaign about the phenomenon, gay online chat rooms were flooded with anti-gay hate messages, perhaps interfering with effective outreach.

Since that initial report, further studies seemed to confirm that meeting sex partners online conferred an increased risk for sexually transmitted diseases, especially among men who have sex with men. A more recent study from the journal Sexually Transmitted Infections aimed to clarify this risk.

The authors combed the records of a sexual health clinic in Denver for patients with a history of chlamydia or gonorrhea confirmed by laboratory testing. They then looked for a history of having sex with someone met online (this was a question asked of all the patients). Neither the group with these infections nor those without were more likely to have met sex partners online, arguing against what has become common knowledge. Earlier data suggested any effect might be more prominent among MSM, but while they found MSM to be significantly more likely to find sex partners online, there was no significant difference in infection rates between MSM and other groups.

The authors discuss possible weaknesses of this study, but there a few critical problems left undiscussed. Chlamydia and gonorrhea are not terribly rare in men who have sex with men, but left out were syphilis, HIV, and HPV infections. These infections have been implicated in earlier reports of online sexual behavior. While it is encouraging that sexual encounters that originate online may not be a unique risk factor for gonorrhea and chlamydia, these other diseases can be pretty devastating.

If the internet may increase the risk of STIs, it may also give us unique opportunities to reach out to people at risk. There are services that allow you to anonymously email a sexual partner to inform them of “bad news”. Internet sites that are used for finding sexual partners sometimes have links to websites with sexual health information (although how effective this might be at mitigating risky behavior is a big unknown).

Ten years ago, not many Americans had internet access, and even fewer had broadband access. Human ingenuity inserted sex into online interactions early, and increasing penetrance of the internet into our lives may increase the frequency of risky sexual encounters. In And the Band Played On, journalist Randy Shilts reported the difficult work of teasing out the origins of the AIDS pandemic, including the sociopolitical challenges of telling a despised minority that some of their behaviors were risky. Studies like the one one on chlamydia and gonorrhea will hopefully help flesh out the interaction between internet hook-ups and health risks so that we can better target at risk groups for preventative education.

Selected References

Klausner JD, Wolf W, Fischer-Ponce L, Zolt I, & Katz MH (2000). Tracing a syphilis outbreak through cyberspace. JAMA : the journal of the American Medical Association, 284 (4), 447-9 PMID: 10904507

Mary McFarlane, PhD; Sheana S. Bull, PhD, MPH; Cornelis A. Rietmeijer, MD, MPH (2000). The Internet as a Newly Emerging Risk Environment for Sexually Transmitted Diseases JAMA, 244 (4), 443-446 DOI: 10.1001/jama.284.4.443

Kim AA, Kent C, McFarland W, & Klausner JD (2001). Cruising on the Internet highway. Journal of acquired immune deficiency syndromes (1999), 28 (1), 89-93 PMID: 11579282

McFarlane M, Bull SS, & Rietmeijer CA (2002). Young adults on the Internet: risk behaviors for sexually transmitted diseases and HIV(1). The Journal of adolescent health : official publication of the Society for Adolescent Medicine, 31 (1), 11-6 PMID: 12090960

Centers for Disease Control and Prevention (CDC) (2003). Internet use and early syphilis infection among men who have sex with men--San Francisco, California, 1999-2003. MMWR. Morbidity and mortality weekly report, 52 (50), 1229-32 PMID: 14681596

A A Al-Tayyib1, M McFarlane, R Kachur, C A Rietmeijer1 (2009). Finding sex partners on the internet: what is the risk for sexually transmitted infections? Sexually Transmitted Infections, 85, 216-220 DOI: 10.1136/sti.2008.032631

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The death and rebirth of vitalism (repost)

Sep 02 2010 Published by under [Medicine&Pharma], Medicine

While we get our servers ramped up to handle our increasing traffic we have cut back on commenting. This should be fixed soon. Meanwhile, here's a piece from last year for you. --PalMD

One of the common themes in biology and medicine is the feeling that somehow there must be more. Creationists simply know that life must be more than matter, and mind-body dualists (which includes most alternative medicine advocates) are certain that humans are more than just "ugly bags of mostly water" (sorry for the geek reference). If you can stick with me here, I'll explain to you a bit of the history surrounding this fallacy.

Most of us intuitively feel that we are both a body and a person. In every day life, it makes a certain operational sense to think of our "mind" as being something distinct. From a biological standpoint, however, this doesn't work as well.

Biology was one of the last of the "natural philosophies" to become a science. It was clear to those who studied chemistry and physics that certain principles seemed to explain the natural world, but those who studied living things were mostly involved in description. Still, biology has become a science in its own right.  According to Ernst Mayr, one of the greatest biologists of the last century, a number of events preceded biology being recognized as a legitimate science. One vital event (sorry) was the recognition that all biological processes were constrained by the laws of physics and chemistry. Another important step was the rejection of two erroneous principles: vitalism, and teleology.

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Real patients, real people

Sep 01 2010 Published by under [Medicine&Pharma], Medicine

My medical students and residents are a pretty smart bunch.  They are from several different countries, and from all parts of the U.S.  Many grew up in families of modest means, and their parents have diverse educational backgrounds.  One fact that unites them is the group they have been with for the ten to twenty years: their peers have had the intellectual and economic resources to get into medical school.  By the time they enter their residencies, they have been surrounded by (generally) smart, academically successful, socially able young people.

When confronted for the first time by patients, the true diversity of humanity can come as a real shock.  Many patients have no idea what diabetes is or what the real risks of hypertension are.  They don't know what "Sig: 1 tab p.o. BID" means.  Nor should they.  Medical jargon is very useful, but it can be a significant barrier to patient care if the physician forgets that the patient did not spend the last eight years learning the lingo.

Being a physician means being an educator. It means gauging the knowledge level of your patient and communicating essential information in a way the patient can understand and use.  It may mean calling something a "tube" or a "gland" instead of using a more technically correct word.  The smartest doctor in the world is useless unless he or she can give a patient information they can use.

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How can we answer important questions?

Aug 31 2010 Published by under [Medicine&Pharma], Medicine

A recent commenter asked the following question:

If you are a clinical researcher, how do you test a treatment for recurring body-wide pain and extreme fatigue that has lasted more than a year? How do you use science to test whether X treatment works? What measurement(s) do you make pre- and post-treatment to produce a clinical study that supports or indicates the underlying reality?

In this hypothetical, let’s say the reality is that the treatment produces significant reductions in the body-wide pain and fatigue in 98% the afflicted. How do you produce a legitimate, science-based study that supports this?

For someone who is suffering, the details of designing a clinical study may not be the first thing on their mind.  But for researchers, it must be.  Clinicians must then be able to assimilate relevant data to use in treating their patients.

The first task in looking at this question is, "what is the question?"  In this case, we need a disease or syndrome with a useful operational definition.  Since the commenter hasn't given us one, we'll choose "fibromyalgia".  This syndrome is difficult but not impossible to study.  It's difficult because it is syndromic; we can define a list of signs and symptoms and create an operational definition, but we cannot pathologically define the illness.

In this case, we can measure exactly what the commenter asks.  We can choose an intervention, say, a sleep aid called Miraculum, and design a randomized controlled trial.  Patients can be recruited, randomized to placebo or Miraculum, and outcomes of interest can be measured.  There are many tools to measure these outcomes including visual analog pain scales and quality of life measures.  The numbers can be crunched and interpreted, and voila, we have an answer (and usually more questions as well).

I hope this helps our curious commenter.

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Cannabis for chronic pain: Are we there yet?

Aug 31 2010 Published by under [Medicine&Pharma], Medicine

Marijuana is pretty popular stuff, and for good reason.  It is a potent drug, capable of both making someone feel good and of reinforcing dependence pathways in the brain.  Cannabis has been lauded for its ability to treat nearly any unpleasant symptom (except perhaps dry mouth), but so far evidence other than the anecdotal has been meager.

One of the areas where research has been a bit promising is in the treatment of certain types of nerve pain.  Small studies have shown some possible benefit in certain groups of patients, but robust studies are lacking.  In the U.S., this is certainly due at least in part to restrictions on cannabis research, but only in part.

Still, chronic nerve pain is an important problem, with imperfect treatments.  Opiates such as morphine are effective but come with significant side-effects.  Some anti-seizure medications such as gabapentin and pregabalin have shown some promise, but they are relatively expensive (although the price on gabapentin is dropping) and only somewhat effective.  Finding effective drugs, to be used either alone or in combinations, would help people suffering from a frustrating and sometimes disabling problem. Continue Reading »

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Which food has more fairy dust, and which journalist will report it?

Aug 27 2010 Published by under [Medicine&Pharma], Medicine

In his now-famous New York Times magazine piece, Michael Pollan told us to "Eat food. Not too much. Mostly plants."  What is often forgotten is that this was not a prescription for eating as much as it was an admonition against "nutritionism", the idea that foods are nothing more than a vehicle for the delivery of certain nutrients.  While it is not entirely incorrect to view food this way, it is incomplete.  Food is more than the sum of its parts.  Some of the vitamins present in foods are necessary in small amounts to maintain health, a fact that has over the years led us to think that there are more magic substances in food.  This has not been borne out by science.  None of the myriad “antioxidants” and other magical substances discovered in foods has ever been found to provide some sort of revolutionary health benefit.

Antioxidants are probably the most commonly cited magic nutrients in foods, despite the lack of evidence of their ability to miraculously affect health.  The idea that antioxidants can perform important physiologic functions is not implausible, but it appears to be a naive and incomplete belief.

This is one of the reasons I let out a big yawn every time the latest food source of antioxidants is discovered.  There is little evidence that any single food performs significant health miracles.  What has been noted in studies is that diets lower in calories, and higher in plants seem to be beneficial.  Studies on flavinoids and other substances are interesting and may eventually lead to medical advances, but no one should rush to start a high-chocolate diet. 

This is one of the several reasons I was disappointed to read the following headline on the CBS website:

Black Rice: Low-Cost Grain Packs Bigger Antioxidant Punch than Blueberries.

What does this even mean?  If this is true, does it even matter?  The “writer” of the piece states that black rice might be a good source of antioxidants for health-conscious consumers who are tired of the high price of berries.  “Writer” is in scare quotes because, as you may have surmised, the article is cribbed directly from a press release.

What is left unasked and unanswered is “what is the clinical relevance of these findings?”  Does it matter that black rice has more fairy dust than blueberries?  Should this finding affect consumer behavior?  

These unanswered questions distract from a potentially interesting science and health story, an opportunity to raise the level of dialog about nutrition. 

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How sleepy are you?

Aug 26 2010 Published by under [Medicine&Pharma]

I've been reading a terrific book called The Twenty-four Hour Mind by Dr. Rosalind Cartwright.  Dr. Cartwright is one of the giants of sleep research, and for years ran the sleep program at my medical school.  But this isn't a book of simply parochial interest.  It's a fascinating longitudinal history of sleep research in the U.S., a history that I'd guess many physicians know little about.  I hope to get a full review up sometime soon. (I received a free copy of the book from the publisher at my request.)

Anyway, I've been thinking about sleepiness a lot lately, and I'd like to share a fun little tool with you.  The Epworth Sleepiness Scale is a commonly used tool to evaluate---you guessed it---sleepiness.  A high score may indicate a severe sleeping disorder, one that puts the patient at risk not only for medical problems such as hypertension, but also decreased work performance, and auto accidents.  One of the most common sleep disorders is "obstructive sleep apnea", an easily diagnosed and treated problem.  The Epworth scale is not a test for sleep apnea, but a high score may indicate a serious sleep problem of one sort or another, depending on a number of factors.  Try it.

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You gotta have heart---Just ask PZ

Aug 25 2010 Published by under [Medicine&Pharma], Medicine

(Updated)

About a year and a half ago I injured my back fairly severely. I was relatively immobile for several days (although I continued to work), and one night the pain became so unbearable that I took a (appropriately-prescribed) narcotic pain reliever. A short while later I was able to move around a bit better, but as I was climbing down the stairs I began to experience some shortness of breath and a pressure sensation in my mid-chest.

I've been putting off writing about certain aspects of heart disease for a long time. I'm very comfortable writing about the medical prevention and treatment of heart disease---this is a big part of my practice, and I'm pretty familiar with the literature. But when medication either fails or is not the optimal treatment, the literature explodes with huge, well-done studies often with conflicting conclusions.

Over the last several days, well-known blogger PZ Myers of Pharyngula has written of his new journey into the world of heart disease. He's written a very humorous and human account of his own angioplasty (contributing to the evidence against the claim that he is demon-spawn).   This seems a unique opportunity to try to shed a bit of light on the invasive treatment of coronary heart disease.

The Disease

The heart requires an uninterrupted source of oxygen in order to function properly.  This is supplied by the coronary arteries, which take off from the aorta immediately after it exits the heart.  These vessels receive blood when it is at it's highest pressure and highest oxygen content (more or less).

Anterior view of coronary arteries and veins

Over time, these arteries can develop plaques on their inner surfaces (atherosclerosis).  These plaques are caused by a combination of factors, including inherited an genetic predisposition, hypertension, diabetes, and tobacco use.  All of these can contribute to inflammation of the plaque, which can rupture, blocking the artery and cutting off the blood/oxygen supply to part of the heart muscle. Without oxygen,  this part of the muscle will soon stop beating and die.   We call that a myocardial infarction, or heart attack.

Prevention

We know a great deal about primary and secondary prevention of heart disease.  The risk factors we can control (i.e., not the patient's genetics) can be treated aggressively with life style modification and medication. (I've addressed this extensively in earlier posts.) But acute and established heart disease can also be treated invasively.

Treatment

It's not unusual for the first recognized symptoms of coronary heart disease to be a heart attack, but often their are warnings such as chest pain or difficulty breathing with physical activity.  These symptoms often lead to some sort of intervention.

"Angioplasty"

This is a procedure that can be used either in a heart attack or in symptomatic heart disease that hasn't yet resulted in a heart attack.  The current terminology, preferred because it is a general term, is "percutaneous coronary intervention" (PCI).  In PCI, the procedure that PZ just underwent, a catheter is placed in an artery in the arm or groin, and threaded into the heart.

http://commons.wikimedia.org/wiki/File:Hk_coronary_bionerd.jpg

Coronary Arteries seen during PCI

If blockages are identified, the cardiologist can inflate a balloon to open the artery and (usually) place stent, a sort of metal scaffolding.

Bypass

Coronary artery bypass grafting (CABG, or "cabbage") is a procedure where the chest is cut open and the blockages are bypassed by placing a vein or artery to take blood from above the blockage and deliver it below.

From the description, it's pretty clear that CABG is far more invasive than than PCI, but these procedure have different roles, and as I mentioned earlier, the data are often conflicting.

Heart Attacks

In places were angioplasty is not available, clot-dissolving drugs can be given to stop a heart attack in progress.  Both procedures effectively halt a heart attack, but a follow up intervention such as PCI or CABG is usually needed for more definitive therapy.  CABG is occasionally done in this setting, but that's another story.

Symptomatic Coronary Heart Disease

In patients having symptoms caused by blocked arteries, the data become more difficult.  Often, medical therapy alone is as good as PCI.  In cases where intervention seems more appropriate, there are several factors to consider in choosing PCI vs. CABG.  Part of this depends on the outcome you look at.  If you look at the need for re-intervention, you get one answer; mortality, another answer; future heart attack, yet another answer.  Also important is the extent of the disease and concurrent risk factors.  Some patients simply don't have an anatomy amenable to PCI.  If they have multiple vessels involved or are diabetic, there is evidence that CABG is a better choice (once again, depending on the outcome we're looking at).

PZ described having been called to the hospital for an angiogram, after a visit to the hospital for an episode of suspicious chest pain.  He told us that several stents were placed.  These may have been placed in a single vessel or multiple vessels.  These days, chances are the stents are coated with drugs that help prevent re-occlusion of the artery, and these types of stents require prolonged use of anti-platelet drugs.  These drugs are very both useful and necessary, but come with their own set of problems.

Our understanding of heart disease, its prevention, and treatment has expanded rapidly over the last three decades.  We have never had so many useful tools available for the treatment and prevention of heart disease, and despite the inconsistencies in the data, people are doing much better than they ever have.  In the year 2000 alone, approximately 340,000 heart disease deaths were prevented by the modern approach to heart disease, even with the uncertainties.

On the night I had trouble breathing, I thought I was having a panic attack.  It seemed logical that the narcotic---a drug I'm not accustomed to taking---was contributing to my "not feeling right".  But I couldn't talk myself down from my symptoms.  My relative inactivity put me at risk for developing a blood clot in my leg which could travel to my lung, and my high cholesterol put me at risk for heart disease.  I spent the evening at the ER, and a number of tests confirmed my original hypothesis---my heart an lungs were fine, so I was probably having a panic attack, an experience I hadn't had either before or since.

Selected References

Hlatky, M., Boothroyd, D., Bravata, D., Boersma, E., Booth, J., Brooks, M., Carrié, D., Clayton, T., Danchin, N., & Flather, M. (2009). Coronary artery bypass surgery compared with percutaneous coronary interventions for multivessel disease: a collaborative analysis of individual patient data from ten randomised trials The Lancet, 373 (9670), 1190-1197 DOI: 10.1016/S0140-6736(09)60552-3

Hansson, G. (2005). Inflammation, Atherosclerosis, and Coronary Artery Disease New England Journal of Medicine, 352 (16), 1685-1695 DOI: 10.1056/NEJMra043430

Serruys, P., Morice, M., Kappetein, A., Colombo, A., Holmes, D., Mack, M., Ståhle, E., Feldman, T., van den Brand, M., Bass, E., Van Dyck, N., Leadley, K., Dawkins, K., & Mohr, F. (2009). Percutaneous Coronary Intervention versus Coronary-Artery Bypass Grafting for Severe Coronary Artery Disease New England Journal of Medicine, 360 (10), 961-972 DOI: 10.1056/NEJMoa0804626

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Every patient is an experiment

Aug 24 2010 Published by under [Medicine&Pharma], Medicine

Mrs. Charbin's blood pressure just kept going up.  She felt fine---no chest pain, no shortness of breath, no headaches---but the numbers put her at risk.  At 55, her risk of developing heart disease at some point in her life is high, and is made even higher by her hypertension.  For each 20 mm Hg rise in systolic blood pressure (the "top" number), the risk of heart disease doubles.  Her systolic blood pressure has consistently been in the 160's.  She did a great job cutting down on salt, and she was already exercising as much as her arthritis would allow. It was time to try medication.

The data on the treatment of hypertension is extensive.  We not only have a wide range of medication options, but we know the risks and benefits of treatment. We also know that most people with high blood pressure will need at least two medications to bring their blood pressure to goal, a goal based on decreasing the risk of complications such as heart attack and stroke.

Based on this data, I started Mrs. Charbin on a thiazide-type diuretic.  These are inexpensive, effective, and well-tolerated.  Except in her.  When she came to see me two weeks later, her blood pressure was much better, but she was feeling a bit weak, and a little dizzy.   I drew some blood and found that her sodium level was pretty low.  This is a known complication of thiazide diuretic therapy, so I changed her to a dihydropyridine calcium channel blocker.  Two weeks later her blood pressure was fine, but her legs were uncomfortably swollen---once again, a known complication of the medication.  So I again changed her therapy, this time to an ACE inhibitor.  Any physicians reading will know what happened next---she developed a dry, nagging cough, a side effect requiring cessation of therapy.

Finally, I changed her to an ARB.  This class of drugs is related to ACE-I's.  I had to call her insurance company and explain why a more expensive drug was required (including the fact that I did not try beta blockers because of a resting low heart rate).  Once it was approved, she did great.  About two months after deciding to start drug therapy for her blood pressure, we'd found a regimen that worked.

Science-based medicine relies on data from large studies, but these data do not create a cookie-cutter approach to medicine.  The data tell me what is likely to happen when I fail to control blood pressure, and guide me toward success at reducing the risks of hypertension.  What the data don't tell me is how much my patient can afford to spend on medicine, how well they're able to remember their medicine, whether they will tolerate a particular medicine or not.  Each patient is an experiment, but one based on an extensive and living repository of data.

One of the lessons we've learned from science is that it works.  A failure of one particular science-based intervention does not invalidate all of science.  Science embraces failure, explains it in a way that makes sense and helps one improve.  I'm always fascinated by the argument that goes, roughly, "my medicine is different, and not susceptible to your science."  The argument often goes with a pitch for some alternative medicine technique that hasn't managed to get itself validated by scientific investigation.

One of these techniques is acupuncture, a technique that in aggregate has not been found to work better than placebo.  But true believers will not be deterred by the absence of supportive data (there are lots of good data, just not supportive data).  At the New York Times Well Blog, Tara Parker-Pope had a piece yesterday that repeats some of the misunderstandings of these true believers.

The most telling quote is the one from Dr. Alex Moroz, a trained acupuncturist:

There is a body of literature that argues that the whole approach to studying acupuncture doesn’t lend itself to the Western reductionist scientific method.

This is a common refuge for those who hold to practices that cannot be scientifically validated.  Rather than admit that acupuncture is no more effective than randomly poking someone with toothpicks, they argue that we Westerners and our fancy science are the real failure.  And it is fundamentally bad thinking.  Science is a technique for investigating and understanding the world, one that works.  One of the basic tenets of the scientific method is that we do not get to change the rules to suit our beliefs.  If engineers design a bridge and testing shows that it will collapse under real-life conditions, they don't just change the calculations, because physics doesn't change.

Biology doesn't either.  There are no "meridians of energy" in the human body.  They don't exist, and therefore, they cannot be manipulated.  Ignoring this fact does not change it.

Every patient is an experiment, but one that obeys certain basic physical laws, and is informed by data.  But as Parker-Pope reports:

[a]cupuncture believers say it doesn’t really matter whether Western scientific studies find that the treatment has a strong placebo effect. After all, the goal of what they call integrative medicine, which combines conventional and alternative treatments like acupuncture, is to harness the body’s power to heal itself. It doesn’t matter whether that power is stimulated by a placebo effect or by skillful placement of needles.

It actually matters quite a bit.  Knowingly prescribing a treatment that is no better than placebo is not harmless.  Worse, this mindset that allows one to ignore science when it is inconvenient is dangerous.  Mrs. Charbin's blood pressure didn't get better through judicious application of placebo.  It got better through an understanding of the pathophysiology and pharmacology of the treatment of high blood pressure.   If I found these facts to be inconvenient, my patient would be the one to suffer for my arrogance.

References

Aram V. Chobanian, MD; George L. Bakris, MD; Henry R. Black, MD; William C. Cushman, MD; Lee A. Green, MD, MPH; Joseph L. Izzo, Jr, MD; Daniel W. Jones, MD; Barry J. Materson, MD, MBA; Suzanne Oparil, MD; Jackson T. Wright, Jr, MD, PhD; Edward J. Roccella (2003). The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 Report--Correction JAMA: The Journal of the American Medical Association, 290 (2), 197-197 DOI: 10.1001/jama.290.2.197

The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group, . (2002). Major Outcomes in High-Risk Hypertensive Patients Randomized to Angiotensin-Converting Enzyme Inhibitor or Calcium Channel Blocker vs Diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) JAMA: The Journal of the American Medical Association, 288 (23), 2981-2997 DOI: 10.1001/jama.288.23.2981

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Sinus infections: what we do and don't know

Aug 22 2010 Published by under [Medicine&Pharma], Medicine

Acute sinusitis---a "sinus infection"---is one of the most common problems seen by primary care physicians.  The current preferred terminology is "acute rhinosinusitis", a term which is more descriptive of how the disease works (its "etiology").  In most cases, a patient will first develop cold or allergy symptoms including a runny, congested nose ("rhinitis").  The swelling in the nose will block off the holes ("ostia") that drain the sinuses.   Both cold viruses and allergies can cause inflammation in the nose and sinuses which will increase the flow of mucus.  As the mucus builds up in the sinuses with nowhere to go, the pressure increases causing pain in the face, forehead, and teeth.

Paranasal Sinuses

As the cold or allergies improve, the swelling decreases, allowing the mucus to flow back out of the sinuses.  But the longer the mucus pools in the sinuses without draining, the higher the chance that this nutritious fluid will become colonized and then infected with bacteria.  But most cases of sinusitis are primarily viral, and go away on their own without specific intervention, and only about 2% of colds go on to become bacterial sinusitis.

Deciding which sinus infections are viral and which bacterial is quite simple: we can puncture a sinus with a large needle, withdraw its contents, and send it to the lab for analysis.  Not surprisingly, most patients and physicians are resistant to such an approach.   Sinus X rays are abnormal in many patients with viral infections, so X rays don't help us much either, and are not recommended.  Patients who have had one-sided facial pain or tenderness, tooth pain, and thick green or yellow nasal discharge for more than a week are more likely to have bacterial sinusitis.  All of these folks should be given antibiotics immediately, right?

Not so much. Most of these patients can be treated with tylenol, decongestants, or anti-inflammatories such motrin, and they will get better on their own.  Patients who have significant symptoms that will not go away are the ones who should be treated with antibiotics.  Since most cases of acute sinusitis are caused by Streptococcus pneumoniae or Haemophilus influenzae, these can be targeted with narrow spectrum antibiotics to help prevent antibiotic resistance.

That's what the best science currently tells us.  But what is the worst science currently telling us?

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