Stig Östlund

torsdag, november 01, 2012

NEJM



 
NEJM Resident E-Bulletin
TEACHING TOPICS from the New England Journal of Medicine
Teaching Topics | November 1, 2012
Topical Ivermectin Lotion for Head Lice: What were the results of the study published in this week’s NEJM which compared a single application of 0.5% ivermectin lotion with vehicle control for the elimination of head louse infestations in patients 6 months of age or older?
Complex Cause of Pleuritic Chest Pain: What is the typical presentation and method of diagnosis of primary sclerosing cholangitis?
Teaching Topic
Topical Ivermectin Lotion for Head Lice
Original Article
D.M. Pariser and Others
CME Exam Comments
Infestations of head lice (Pediculus humanus capitis) lead to social disruption by stigmatizing infested children and causing parental anxiety, loss of parental income because of the need to care for the child at home, and absenteeism from school or day care.
Clinical Pearls
Clinical Pearl What is the most frequent clinical manifestation of pediculosis?
The most frequent sign of pediculosis is pruritus; other common manifestations include excoriations, cervical adenopathy, and conjunctivitis.
Clinical Pearl What are the current first- and second-line treatments for pediculosis?
The first-line pediculosis treatments, pyrethroids (e.g., permethrin), belong to a chemical class to which there is now increasing resistance. The established second-line treatments, lindane and malathion, have limitations related to safety and concerns about flammability and unpleasant odor. Investigations of benzyl alcohol and spinosad, both recently approved by the Food and Drug Administration for the treatment of head lice, indicate that up to two treatments with either agent are effective in eliminating infestations. However, the short generation time of head lice and the exposure of all life-cycle stages to any applied treatment are predisposing factors to the emergence of resistance; therefore, new therapies are needed.
Morning Report Questions
Q. What were the results of the study published in this week’s NEJM that compared a single application of 0.5% ivermectin lotion with vehicle control for the elimination of head louse infestations in patients 6 months of age or older?
A. Significantly more patients in the ivermectin group than in the vehicle-control group were free of live lice at the first post-application observation on day 2 (1 day after use of the study drug) and at the subsequent observations through day 15 (P<0 .001=".001" 10-minute="10-minute" 14="14" 1="1" 2="2" 7="7" a="a" after="after" and="and" application="application" as="as" at-home="at-home" at="at" authors="authors" baseline="baseline" comparison="comparison" conclude="conclude" control="control" day="day" days="days" each="each" effective="effective" eliminating="eliminating" for="for" from="from" greater="greater" group="group" had="had" head-louse="head-louse" in="in" infestation.="infestation." infestations="infestations" ivermectin="ivermectin" mean="mean" more="more" new="new" of="of" p="p" potential="potential" pruritus="pruritus" reduction="reduction" score="score" shows="shows" significantly="significantly" single="single" than="than" that="that" the="the" to="to" treatment="treatment" vehicle="vehicle" was="was">
Q. What reason do the authors postulate for the efficacy of a single treatment of topical ivermectin?
A. The authors postulate that continued efficacy of treatment with topical ivermectin through the final assessment 2 weeks after a single treatment suggests that this formulation has activity against louse eggs, although systemic ivermectin appears to have no such activity. The activity of topical treatment is probably due to the direct exposure of eggs to ivermectin that occurs with topical application. A recent report described laboratory studies in which ivermectin was applied to head louse ova; although the ova subsequently hatched, all the released nymphs quickly died. The nymphal mortality was attributed to ivermectin-induced mouthpart paralysis, which severely limited or completely prevented feeding.

Teaching Topic
Complex Cause of Pleuritic Chest Pain
Clinical Problem-Solving
L.Y. King and Others
CME Exam Comments
Ulcerative colitis is the most common form of inflammatory bowel disease and is associated with many extraintestinal manifestations, including primary sclerosing cholangitis. Primary sclerosing cholangitis is characterized by progressive inflammation, fibrosis, and destruction of the intrahepatic and extrahepatic bile ducts.
Clinical Pearls
Clinical Pearl What are the diagnostic criteria and typical causes of nephrotic syndrome?
The diagnostic criteria for the nephrotic syndrome include proteinuria (>3.5 g of protein per liter in 24 hours), hypoalbuminemia, peripheral edema, and hyperlipidemia. Most cases of the nephrotic syndrome, other than those caused by diabetic nephropathy, are caused by a primary glomerular disease, such as membranous nephropathy, focal segmental glomerulosclerosis, minimal-change disease, or membranoproliferative glomerular disease. Secondary causes of the nephrotic syndrome include systemic diseases (e.g., diabetes mellitus, systemic lupus erythematosus, and amyloidosis), cancer, medications (e.g., nonsteroidal anti-inflammatory drugs), and infections (e.g., human immunodeficiency virus, hepatitis B and C, and syphilis).
Clinical Pearl What is the association between primary sclerosing cholangitis and inflammatory bowel disease (IBD) as well as malignancy?
Primary sclerosing cholangitis eventually develops in up to 7% of patients with IBD, and approximately 70 to 80% of patients with primary sclerosing cholangitis have IBD. Primary sclerosing cholangitis is more prevalent in patients with ulcerative colitis than in those with Crohn’s disease. It is also associated with an increased risk of colonic dysplasia, colorectal carcinoma, cholangiocarcinoma, and pancreatic cancer. Patients with both ulcerative colitis and primary sclerosing cholangitis have a risk of colon cancer that is four times as high as that among patients with ulcerative colitis only.
Morning Report Questions
Q. What is the typical presentation and method of diagnosis of primary sclerosing cholangitis?
A. Patients are often asymptomatic at diagnosis. Typical symptoms include fatigue, jaundice, pruritus, and weight loss. The diagnosis is based on characteristic changes in the biliary tree seen on MRCP, ERCP, or both. A liver biopsy is not necessary for diagnosis. For patients with a new diagnosis of primary sclerosing cholangitis, the 2010 guidelines from the American Association for the Study of Liver Diseases (AASLD) recommend colonoscopy with random biopsies, followed by surveillance colonoscopies every 1 to 2 years in those with IBD.
Q. What treatments are available for primary sclerosing cholangitis?
A. There is no standard medical therapy for primary sclerosing cholangitis. Data from randomized controlled trials indicate that ursodeoxycholic acid does not alter the natural progression of the disease, and high doses may lead to an increase in adverse events, including death and the need for liver transplantation. Because immunosuppressive therapy has also failed to prove beneficial in patients with primary sclerosing cholangitis, AASLD guidelines do not recommend glucocorticoids or other immunosuppressive therapies for this condition. Endoscopic intervention may be necessary for patients with rapidly progressive disease, biliary obstruction, or cholangitis, both to treat the biliary condition and to evaluate the patient for the possibility of cholangiocarcinoma. The treatment of choice for end-stage primary sclerosing cholangitis is orthotopic liver transplantation.
quote of the week
Quote of the Week
“Over a 2-year period, two annual infusions of zoledronic acid significantly reduced the risk of new morphometric vertebral fractures by 67% among men with osteoporosis. This reduction was similar to that reported in postmenopausal women with osteoporosis who received zoledronic acid (relative reduction in the risk of vertebral fracture, 71% at 2 years), suggesting that the antifracture effect of zoledronic acid is independent of sex . . . These results provide support for the value of antiresorptive therapy in men with osteoporosis.”

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