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March: The Lion That Won't Quit!
Will this winter ever quit!? I sometimes wonder if the icy Atlantic sucks the warmth out of the air as Spring feebly spreads northward. Anyway, we still have March Madness, the NIT, Passover, and Easter to look forward to while Spring takes its time returning to the Jersey Shore. Go Temple Owls!
John A. Schmidt, MD
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Might Early Consumption Prevent Peanut Allergy?
As reported in the New England Journal of Medicine on February 26, the prevalence of peanut allergy among children in Western countries has doubled in the past ten years and peanut allergy is becoming apparent in Africa and Asia. Peanut allergy is the leading cause of anaphylaxis and death due to food allergy and imposes substantial psychosocial and economic burdens on patients and their families. For example, children are prohibited from taking PB&J to school! Peanut allergy occurs early in life and is rarely outgrown. Elimination of peanuts from the diets of infants and breast feeding mothers has proven unsuccessful. In this landmark study called LEAP (Learning Early about Peanut Allergy), early consumption of a peanut snack three times a week by infants with eczema, egg allergy, or both led to a five-fold reduction in peanut allergy by the age of five! What are parents with allergic infants to do? The authors of the accompanying editorial suggest that at-risk children be skin tested between four and eight months of age by an allergist and if negative (or slightly positive), consume two grams of peanut protein three times a week for at least three years. Whether this oral desensitization approach will work for other food allergies remains to be seen.
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C-diff: The New Household Word!
C. difficile (C-diff or C. diff.) is an increasingly common cause of bacterial diarrhea. Most cases are thought to be acquired in a hospital. However a survey conducted by the Centers for Disease Control and Prevention (CDC) in 2011 and published in the February 26 issue of the New England Journal of Medicine suggests that as many as 46 percent of cases were community-associated. Overall, the authors estimated that there were half a million cases with approximately 29,000 deaths. There have been three cases of C. diff in my practice in the past twelve months. Two were clearly hospital acquired but the third was not leaving me to scratch my head as to its origins. We know that C-diff is spread by hearty, alcohol-resistant spores and that there are carriers who shed spores in their stools without evidence of infection or diarrhea. Thus it is reasonable to speculate that a shared bathroom or kitchen is the place where community acquired infections occur and that anything that goes into our mouth, such as a toothbrush, drinking glass, or fingers could transmit the infection. This may also explain how C. diff recurs even after patients have been cured with antibiotics. I therefore recommend that previously hospitalized patients use disposable hand towels, disposable drinking cups, soap in pump dispensers, and discard their tooth brushes for new ones when they go home. Removal of reading materials from the "library" is also wise. Washing with soap and water, not alcohol-based hand sanitizers after toileting, is essential. Probiotics have proven ineffective in preventing or treating C. diff.
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| Should Obese Mothers Have Bariatric Surgery Before or After Pregnancy?
Obstetricians are seeing more and more moms who have undergone bariatric surgery. The American College of Obstetricians and Gynecologists recommends that such women be advised to delay conceiving until 12-24 months after surgery, the period when the most rapid weight loss occurs. As discussed in an editorial published in the February 26 issue of the New England Journal of Medicine, the kind of bariatric surgery also needs to be taken into account. For example the traditional Roux-en-Y gastric bypass surgery is more likely to lead to protein, iron, vitamin B12, vitamin D, and calcium deficiencies, all of which could have a negative impact on the fetus if not carefully monitored and addressed.
But what if an obese woman is contemplating bariatric surgery? About a third of women entering pregnancy in the United States are obese (Body Mass Index or BMI >40) and an increasing number are super-obese (BMI >50). Obesity is associated with poor outcomes for both the pregnant woman and the fetus. Such outcomes include fetal anomalies, gestational diabetes, preeclampsia, preterm birth, post-term birth, cesarean delivery, fetal growth restriction, and fetal macrosomia. Longer-term risks for offspring include childhood obesity and metabolic syndrome. Now comes a study published in the same issue of the Journal showing that pregnant women with prior bariatric surgery had significantly lower incidence of gestational diabetes and fewer large-for-gestational-age neonates. However, they also had significantly higher rates of small-for-gestational-age neonates and most worrisome, a higher rate of perinatal mortality. There were no significant differences in preterm birth or congenital anomalies. Thus there are clear benefits to having had bariatric surgery before pregnancy but, as mentioned, such patients should work closely with their obstetricians and nutritionists to make sure they are adequately and properly nourished without excessive weight gain.
Calculate your BMI on the Healthy Links page on www.ScmidtMD.com.
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Cholesterol Back in the News: Hope for High Risk Patients Who Fail to Reach LDL Goals on Statins
Two company funded studies, published online in The New England Journal of Medicine on March 15, suggest that self-injected monoclonal antibodies targeting PCSK9, the protease that removes LDL receptors from liver cells, not only dramatically reduce LDL cholesterol levels but also appear to halve the incidence of cardiovascular events (death from coronary artery disease, myocardial infarction, fatal or nonfatal ischemic stroke, or angina requiring hospitalization) after only 12-18 months of therapy. The antibodies were generally well tolerated. Interestingly, there was no increase in muscle related complaints. Neurocognitive adverse events (confusion, amnesia, delirium, and dementia) occurred in less than one percent of treated patients but were more common among treated patients raising a potential red flag to be addressed in future studies. Nevertheless, the author of the accompanying editorial concluded by saying, "PCSK9 inhibitors appear on track to become an important arrow in our quiver for reduction of cardiovascular events among higher-risk patients when statins are not enough." All going well, these antibodies will receive market approval by FDA in the next 12 months.
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| Cardiac Screening in Low Risk Adults
With heart attack still the number one killer of Americans, many of my patients are understandably curious about the value of cardiac screening tests such as ECG (resting or exercise), stress echocardiography ("stress ECHO"), and myocardial perfusion imaging ("nuclear stress test"). These tests have become a huge industry for the companies that manufacture them and the doctors and hospitals that perform them. Most patient interest comes from knowing that coronary artery disease can be silent and that the first event may be catastrophic. Everyone knows of someone who died suddenly and unexpectedly presumably from a myocardial infarction ("heart attack") and wonders if the event could have been prevented. (An informal survey, however, reveals that most of these sudden deaths occurred in patients who ignored early warning signs of angina (chest pain), smoked, or "didn't take care of themselves" meaning they never saw a doctor and decided against taking medication for high blood pressure, elevated cholesterol, etc.) Thus we have a perfect scenario for waste and abuse: terrified consumers and highly motivated providers (with lots of encouragement from their malpractice insurers!).
Now comes advice on this important topic from the High Value Care Task Force of the American College of Physicians, the professional organization to which I and most internists belong. Their advice, as published in the March 17 issue of the Annals of Internal Medicine, is clear: "Clinicians should not screen for cardiac disease in asymptomatic, low risk adults with resting or stress electrocardiography ("ECG"), stress echocardiography ("ECHO") or stress myocardial perfusion imaging ("nuclear stress test")." The reason is simple: harms outweigh benefits in this group of patients. Rather, they recommend that patients and doctors identify risk factors (hypertension, diabetes, elevated cholesterol, smoking, positive family history, obesity, sedentary lifestyle) and modify risk factors with change in diet, medication as appropriate, abstinence from smoking, and vigorous exercise. This approach is cheaper, safer, and more effective. For the minority of patients with multiple, long standing, and uncontrolled risk factors with symptoms, additional screening is warranted.
Valerie, Morgan, and I wish you a wonderful Passover and Easter Season! Let's hope that the crocuses are brave enough to bloom by then!
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Internist
One of the leading Internists in Monmouth County offering Medical Home Services.
"No winter lasts forever; no spring skips its turn."
-Hal Borland
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